- Email: [email protected]
71 Therapy for choroidal melanoma using Ruthenium-106 plaque
$18 3-5 October 2003
The median overall survival was 12.5 months with a mean of 19.4 months. In patients who had chemotherapy and radiation as primary treatment (n=3), the median survival was 13 months versus 16.5 months (p=0.97) for those who had surgery with or without adjuvant treatment (n =6). Patients who had tumours with a high mitotic rate (n=3) had lower overall survival (median = 7 months) versus those who had tumours without a high mitotic rate (n=7,median survival = 21 months, p= 0.0008). Similarly, time to detection of metastases was shorter in patients with tumours displaying a high mitotic rate (median time to metastases: 2 months versus 12 months, p= 0.0008). Liver, lung and bone were the most common sites of metastases detected at a median time of 11 months from diagnosis. Conclusion: There is no standard management of patients with primary cardiac sarcomas. Surgical resection appears to be important for local control of the primary tumour, relief of obstructive symptoms, and potentially improved survival although in our series there were no long-term survivors. The use of postoperative radiation and chemotherapy may improve local control but survival benefit is difficult to assess in our series. In patients with unresectable tumour, as suggested by our case report, combined chemotherapy and radiation may provide some degree of local control and may prolong survival. 70
Small cell carcinoma of the head and neck: experience of a single comprehensive cancer centre R. Dinniwell, J. Ringash, M. Lock, B. O'Sullivan, A. Bayley, B. Cummings, J. Kim, J. Waldron Princess Margaret Hospital, University of Toronto, Toronto, Ontario, Canada PurDose: To review the experience of a single comprehensive cancer centre with small cell carcinoma originating in the head and neck. Methods and Materials: Patient records were reviewed for demographics, presenting site and symptoms, disease stage, pathology, treatment and outcome. ResultS: Between 1971 and 2002, 11 patients had a pathologic diagnosis of extra-pulmonary small cell carcinoma. Median age was 63 years (range: 20 to 93). The primary sites were: 5 salivary gland (4 parotid; 1 submandibular); 2 larynx; 1 oral cavity; 1 nasopharynx; 1 sphenoid sinus; and 1 unknown primary. There were 2 AJCC (6th ed) / UICC stage 3, 6 stage 4A, and 2 stage 4B tumours. One patient (sphenoid sinus primary) tumour could not be staged. Five of 11 presented with pain and 1/11 with a paraneoplastic syndrome (SIADH). Nine patients had nodal metastases at diagnosis. Definitive surgical resection of primary and regional disease was performed on 6/11. Radical or adjuvant radiotherapy was delivered in 6/11 cases with a median dose of 50 Gy (range 35 to 70). Radiotherapy was not delivered in 3 patients due to post-operative death (1), development of metastases (1) or patient preference (1). Two patients were treated with palliative intent. Five patients received chemotherapy as part of their initial management. Failure was documented locally in 5/11, in regional lymph nodes in 2/11 and distantly in 5/11. For all patients, the median survival was 1 year with a 28% 5 year overall survival. Two patients received both chemotherapy and radiation, each achieved Iocoregional control; one patient is alive and disease free at 8 years of follow-up. Conclusion: Extra-thoracic small cell carcinoma of the head and neck often presents in advanced stage and has a poor prognosis. A propensity for rapid local growth and distant metastatic spread, suggests a need for aggressive local and effective systemic treatment. 71
Therapy for choroidal melanoma using Ruthenium-106 plaque G. Shenouda, M. Evans, C. Edelstein, M. Mansour, E. Podgorsak McGill University Health Centre, Montreal, Quebec, Canada Backoround: Radioactive episcleral plaque therapy is an option for selected group of patients with choroidal melanoma. Iodine-125 plaques using conventional gold shells are used to treat different size choroidal melanoma and have been used in our institution since 1987. However, Ruthenium-106 plaques can be used to treat choroidal melanoma equal to or less then 5 mm in height. Since October 2001, 14 consecutive patients were treated using Ruthenium-106 plaque at our institution. Experimental design: Ruthenium-106 plaque thickness is 1 mm it does not require custom preparation and can be re-used for up to 18 months by accounting for its half-life of 366 days. While iodine-125 is a photon emitter of average energy 29 keV, Ruthenium-106 are beta emitters and decay with an average electron of about 1.3 MeV. 85 Gy was prescribed to 5 mm depth. Three different plaques were used and include 2 un-notched with basal chord lengths of 18 and 20 ram, and a 20 mm notched plaque for
CARO 2003
tumours close to the optic nerve. Results: The median age of the patients treated was 65 (range 40 to 87). Assessed by ultrasound, the median tumour basal size was (11.3 x 10.9 mm) and the median height was 3.2 cm (range 2.5 to 5.2 mm). The mean dose received was 82.2 Gy at 5 mm, 154.6 to the tumour apex and 488.1 Gy to the inner sclera. Conclusion: The treatment of selected patients with choroidal melanoma using Ruthenium-106 plaque has been easy to implement. Ruthenium-106 plaques are easy to insert surgically and are readily available. We continue using Iodine-125 for choroidal melanoma greater then 5 mm in height. 72
Development and evaluation of a web-based Research Ethics Board (REB) review template H. Sampson, T. Panzarella, 7". Michaelson Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada Purpose: To develop and evaluate a web-based intranet Research Ethics Board (REB) protocol and consent template for REB members to review clinical research protocols systematically. Backaround: The three REBs at the institution review approximately 900 new protocols, plus annual reviews and amendments annually. The review principles are founded on the same tenets across all three REBs. Each study, consent and Investigator's Brochure is assessed and evaluated by a primary and secondary reviewer in detail, discussed by the entire board with comments, concerns and queries relayed to the Principal Investigator. It was identified that the members required a standardized method to review trials to improve quality, promote consistency and provide uniform responses for investigators to answer. A more formal accountability of the REB and the individual reviewers was also desirable. If a review template could be developed that was electronically accessible, the reviews would be transparent, uniform, and able to be submitted and filed electronically to the REB to improve uniformity and tracking. Methods: Building on an existing sophisticated information technology platform in the Radiation Medicine Program, we have initiated a web-based tool for reviewers to download and work from. The template has prompters to remind the reviewer to respond to areas such as study design, consent appropriateness etc. Results: Systematic assessment of clinical research studies and subsequent electronic filing improves ethics review techniques. Presumably, this provides safer and more efficacious delivery of experimental therapy to patients. Conclusion: Respecting the dynamic clinical research environment, the REB study review template must evolve with regulatory changes and research advances such as gene transfer technology; the process cannot be static. The electronic template will need to be updated routinely from the REB and patient perspective. We plan to invite REBs outside the institution to pilot this template for collaboration, criticism and standardization purposes. 73
Interobserver variability in Electronic Portal Imaging (EPI) registration in the treatment of prostate cancer E. Berthelet, P. Czaykowski,J. Runkel, B. Bendorffe, R. Kirby, D. Locke, L. McGovem, R. McLean, D. Sayers Radiation Oncology, British Columbia Cancer Agency, Victoria, British Columbia, Canada. Medical Oncology, Cancer Care Manitoba, Winnipeg, Manitoba, Canada Backaround: A protocol of EPI registration for the verification of treatment fields has been implemented at our institution. A template is generated using the reference images which is then registered with the EPI for verification. This study examines the impact of interobserver variability on the registration process. Methods: 20 patients were selected for the study. The EPIs from the initial 10 fractions were registered independently by 6 observers. For each fraction, an anterior-posterior (AP) and right lateral (LAT) EPIs were generated. These were registered with the reference images. Two values of displacement for the AP EPI in the superior-inferior (SI) and right left (RL) directions and 2 values for the LAT EPI in the AP and SI directions were established. A total of 2400 images and 4800 variables were analyzed. The relationships between the measurements and the patients, observers, and fraction number were examined using linear regression analysis. The proportion of measurements within -3mm to +3mm, was evaluated using the Chi-2 test. Multivariate analyses were conducted to examine sources of variation and potential interactions. Results: Linear regression analysis showed no statistically significant
The median overall survival was 12.5 months with a mean of 19.4 months. In patients who had chemotherapy and radiation as primary treatment (n=3), the median survival was 13 months versus 16.5 months (p=0.97) for those who had surgery with or without adjuvant treatment (n =6). Patients who had tumours with a high mitotic rate (n=3) had lower overall survival (median = 7 months) versus those who had tumours without a high mitotic rate (n=7,median survival = 21 months, p= 0.0008). Similarly, time to detection of metastases was shorter in patients with tumours displaying a high mitotic rate (median time to metastases: 2 months versus 12 months, p= 0.0008). Liver, lung and bone were the most common sites of metastases detected at a median time of 11 months from diagnosis. Conclusion: There is no standard management of patients with primary cardiac sarcomas. Surgical resection appears to be important for local control of the primary tumour, relief of obstructive symptoms, and potentially improved survival although in our series there were no long-term survivors. The use of postoperative radiation and chemotherapy may improve local control but survival benefit is difficult to assess in our series. In patients with unresectable tumour, as suggested by our case report, combined chemotherapy and radiation may provide some degree of local control and may prolong survival. 70
Small cell carcinoma of the head and neck: experience of a single comprehensive cancer centre R. Dinniwell, J. Ringash, M. Lock, B. O'Sullivan, A. Bayley, B. Cummings, J. Kim, J. Waldron Princess Margaret Hospital, University of Toronto, Toronto, Ontario, Canada PurDose: To review the experience of a single comprehensive cancer centre with small cell carcinoma originating in the head and neck. Methods and Materials: Patient records were reviewed for demographics, presenting site and symptoms, disease stage, pathology, treatment and outcome. ResultS: Between 1971 and 2002, 11 patients had a pathologic diagnosis of extra-pulmonary small cell carcinoma. Median age was 63 years (range: 20 to 93). The primary sites were: 5 salivary gland (4 parotid; 1 submandibular); 2 larynx; 1 oral cavity; 1 nasopharynx; 1 sphenoid sinus; and 1 unknown primary. There were 2 AJCC (6th ed) / UICC stage 3, 6 stage 4A, and 2 stage 4B tumours. One patient (sphenoid sinus primary) tumour could not be staged. Five of 11 presented with pain and 1/11 with a paraneoplastic syndrome (SIADH). Nine patients had nodal metastases at diagnosis. Definitive surgical resection of primary and regional disease was performed on 6/11. Radical or adjuvant radiotherapy was delivered in 6/11 cases with a median dose of 50 Gy (range 35 to 70). Radiotherapy was not delivered in 3 patients due to post-operative death (1), development of metastases (1) or patient preference (1). Two patients were treated with palliative intent. Five patients received chemotherapy as part of their initial management. Failure was documented locally in 5/11, in regional lymph nodes in 2/11 and distantly in 5/11. For all patients, the median survival was 1 year with a 28% 5 year overall survival. Two patients received both chemotherapy and radiation, each achieved Iocoregional control; one patient is alive and disease free at 8 years of follow-up. Conclusion: Extra-thoracic small cell carcinoma of the head and neck often presents in advanced stage and has a poor prognosis. A propensity for rapid local growth and distant metastatic spread, suggests a need for aggressive local and effective systemic treatment. 71
Therapy for choroidal melanoma using Ruthenium-106 plaque G. Shenouda, M. Evans, C. Edelstein, M. Mansour, E. Podgorsak McGill University Health Centre, Montreal, Quebec, Canada Backoround: Radioactive episcleral plaque therapy is an option for selected group of patients with choroidal melanoma. Iodine-125 plaques using conventional gold shells are used to treat different size choroidal melanoma and have been used in our institution since 1987. However, Ruthenium-106 plaques can be used to treat choroidal melanoma equal to or less then 5 mm in height. Since October 2001, 14 consecutive patients were treated using Ruthenium-106 plaque at our institution. Experimental design: Ruthenium-106 plaque thickness is 1 mm it does not require custom preparation and can be re-used for up to 18 months by accounting for its half-life of 366 days. While iodine-125 is a photon emitter of average energy 29 keV, Ruthenium-106 are beta emitters and decay with an average electron of about 1.3 MeV. 85 Gy was prescribed to 5 mm depth. Three different plaques were used and include 2 un-notched with basal chord lengths of 18 and 20 ram, and a 20 mm notched plaque for
CARO 2003
tumours close to the optic nerve. Results: The median age of the patients treated was 65 (range 40 to 87). Assessed by ultrasound, the median tumour basal size was (11.3 x 10.9 mm) and the median height was 3.2 cm (range 2.5 to 5.2 mm). The mean dose received was 82.2 Gy at 5 mm, 154.6 to the tumour apex and 488.1 Gy to the inner sclera. Conclusion: The treatment of selected patients with choroidal melanoma using Ruthenium-106 plaque has been easy to implement. Ruthenium-106 plaques are easy to insert surgically and are readily available. We continue using Iodine-125 for choroidal melanoma greater then 5 mm in height. 72
Development and evaluation of a web-based Research Ethics Board (REB) review template H. Sampson, T. Panzarella, 7". Michaelson Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada Purpose: To develop and evaluate a web-based intranet Research Ethics Board (REB) protocol and consent template for REB members to review clinical research protocols systematically. Backaround: The three REBs at the institution review approximately 900 new protocols, plus annual reviews and amendments annually. The review principles are founded on the same tenets across all three REBs. Each study, consent and Investigator's Brochure is assessed and evaluated by a primary and secondary reviewer in detail, discussed by the entire board with comments, concerns and queries relayed to the Principal Investigator. It was identified that the members required a standardized method to review trials to improve quality, promote consistency and provide uniform responses for investigators to answer. A more formal accountability of the REB and the individual reviewers was also desirable. If a review template could be developed that was electronically accessible, the reviews would be transparent, uniform, and able to be submitted and filed electronically to the REB to improve uniformity and tracking. Methods: Building on an existing sophisticated information technology platform in the Radiation Medicine Program, we have initiated a web-based tool for reviewers to download and work from. The template has prompters to remind the reviewer to respond to areas such as study design, consent appropriateness etc. Results: Systematic assessment of clinical research studies and subsequent electronic filing improves ethics review techniques. Presumably, this provides safer and more efficacious delivery of experimental therapy to patients. Conclusion: Respecting the dynamic clinical research environment, the REB study review template must evolve with regulatory changes and research advances such as gene transfer technology; the process cannot be static. The electronic template will need to be updated routinely from the REB and patient perspective. We plan to invite REBs outside the institution to pilot this template for collaboration, criticism and standardization purposes. 73
Interobserver variability in Electronic Portal Imaging (EPI) registration in the treatment of prostate cancer E. Berthelet, P. Czaykowski,J. Runkel, B. Bendorffe, R. Kirby, D. Locke, L. McGovem, R. McLean, D. Sayers Radiation Oncology, British Columbia Cancer Agency, Victoria, British Columbia, Canada. Medical Oncology, Cancer Care Manitoba, Winnipeg, Manitoba, Canada Backaround: A protocol of EPI registration for the verification of treatment fields has been implemented at our institution. A template is generated using the reference images which is then registered with the EPI for verification. This study examines the impact of interobserver variability on the registration process. Methods: 20 patients were selected for the study. The EPIs from the initial 10 fractions were registered independently by 6 observers. For each fraction, an anterior-posterior (AP) and right lateral (LAT) EPIs were generated. These were registered with the reference images. Two values of displacement for the AP EPI in the superior-inferior (SI) and right left (RL) directions and 2 values for the LAT EPI in the AP and SI directions were established. A total of 2400 images and 4800 variables were analyzed. The relationships between the measurements and the patients, observers, and fraction number were examined using linear regression analysis. The proportion of measurements within -3mm to +3mm, was evaluated using the Chi-2 test. Multivariate analyses were conducted to examine sources of variation and potential interactions. Results: Linear regression analysis showed no statistically significant