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711 poster Prognostic factors of combined modality treatment in patients with laryngeal cancer basing on scale of risk of recurrence
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Posters
709 poster
710 poster
Concomitant chemoradiotherapy with weekly Cisplatin and subcutaneous Amifostin in the treatment of advanced head and neck cancer
Comparison of clinical target volume in PET-CT and CTscan based treatment planning in patients with head and neck cancer
M. Pala 1, P. Holeckova ~, P. Vitek ~, J. Kubes ~, J. VeselS, A. Svobodnik 3 ~lnstitute of Radiation Oncology University Hospital Bulovka, Department of Radiation Oncology, Prague, Czech Republic 2University Hospital Bulovka, Department of Otorhinolaryngology, Prague, Czech Republic 3Center for Information Science and Analysis Masaryk Memorial Cancer Institute, Brno, Czech Republic
A. van Baardwijk 1, F. Koppe ~, P. van den Ende 1, J. de Jong ~, B. Kremer2, M. van Kroonenburgh 3, B. de Bondt4, M. Oellers ~, P. Lamb#) ~, D. de Ruysscher1 I MAASTRO cfinic, Radiation Oncology, Maastricht, The Netherlands 2Academic Hospital Maastricht, Otorhinolaryngology and Head and Neck Surgery, Maastricht, The Netherlands 3Academic Hospital Maastricht, Nuclear Medicine, Maastricht, The Netherlands 4Academic Hospital Maastricht, Radiology, Maastricht, The Netherlands
Purpose: To demonstrate the efficacy and feasibility of chemoradiotherapy with weekly cisplatin and subcutaneous amifostin in the treatment of Ioco(regional) advanced head and neck cancer. Patients and Methods: Between February 2002 and April 2004, 54 consecutive patients (pts.) [WHO < 2, male to female ratio 46/8, median age 56 years (35-68)] with head and neck cancer were treated. Tumours of the oropharynx (53%) and hypopharynx (13%) were most frequent and stage IV (TNM 1997) was predominant (89%). Radiotherapy consisted of 70Gy/7weeks/35 fraction without (41 pts.) or after R1/2 resection (6 pts.) or 60Gy/6 weeks/30 fraction after R0 resection (5 pts.) or in a case of reirradiation (2 pts.). In most of cases we used the three field radiation technique with two lateral opposite wedged fields and a direct posterior field with central shielding block protecting spinal cord. All patients received concurrent chemotherapy with cisplatin 40mg/m 2 weekly and amifostin 500mg subcutaneously 20-30 min. prior to each radiotherapy fraction. The radiotherapy was combined with hyperthermia in 26% (14pts.). Prophylactic percutane0us endoscopic gastrostomy was itroduced in 87% (47 pts.). The endpoints of the study included initial tumor response (according to WHO), toxicity to radiochemotherapy and subcutaneous amifostin (according to RTOG and NCI-CTT) and survival. Results: The median duration of follow up was 15 months (228). Median total tumor dose was 70Gy (26-74), median number of chemotherapy courses 5 (1-8), median radiotherapy duration 51 days (18-68). Of the 48 pts. evaluable for response 77% (37 pts.) achieved complete response and 10% (5 pts.) partial response. Median overall survival is 12,9 months. Acute mucositis grade 3 were reported in 43% (23 pts.), acute dermatitis grade 3/4 in 17% (9 pts.), acute xerostomy grade 2 in 69% (37 pts.), acute dysphagia grade 3 in 43% (23 pts.). One case of larynx toxicity grade 4 was recorded. Median loss of weight was 7kg (10% of pretreatment value) (20-2). Grade 3/4 neutropenia occurred in 35% (19 pts.) and it was the most frequent reason for termination of concomitant chemotherapy. Renal toxicity was in general mild. 13% (7 pts.) discontinued radiotherapy due to treatment-related toxicity. Skin :rush grade 2/3 developed in 19% (10 pts.), 19% (10 pts.) interrupted administration of amifostine due to toxicities. The late toxicities were mild, predominantly subcutaneous fibrosis grade 1/2 and xerostomia grade 1/2 in most of cases. Conclusion: Concomitant chemoradiotherapy with weekly cisplatin and subcutaneous amifostin is toxic, but tolerable and highly active in term of initial response. Despite that, the overall survival of patients with Ioco(regional) advanced head and neck cancer evaluated in this study remains poor. For definitive conclusion long term follow-up is necessary.
Introduction: Combined PET-CT with FDG has recently shown to have a high diagnostic accuracy for head and neck cancer. We therefore investigated prospectively the potential gain of PET-CT delineation using a dedicated combined PET-CT-simulator in head and neck cancer patients referred for radical radiotherapy. Materials and Methods: From February 2004 onwards, all patients referred for radical radiotherapy for head and neck ,cancer have undergone a pre-treatment simulation on a dedicated combined PET-CT-simulator (Biograph TM , Siemens). For each patient two delineations of clinical target volume (CTV) were made: one on base of CT information alone and one on base of PET-CT information. Results: Out of 18 patients, 5 had significant FDG uptake in their primary tumour. In 13 patients no FDG uptake was seen: 3 patients with carcinoma in situ, 4 with a cT1 lesion, and 6 with microscopically positive margins postoperatively. Of the remaining 5 the CT based CTV was 376 ml + 66.7 ml vs. 369 ml + 74.7 ml for the PET-CT based CTV (p=0.76). The CTV on PET-CT extended beyond the CTV CT in 4 out of 5 patients for a mean volume of 48 ml + 22.6 ml. There was an overlap between CTV CT and CTV PET-CT in 84.4 % + 5.6 % of the volume. Conclusions: The first data suggest that target volumes will change according to PET-CT information compared with CT in case of macroscopic disease. As accrual of patients continues, more mature data will be presented at the meeting.
711 poster Prognostic factors of combined modality treatment in patients with laryngeal cancer basing on scale of risk of recurrence
A. Mucha-Malecka, K. Skladowski Center of Oncology, Radiotherapy Department, Cracow, Poland Purpose: The evaluation of prognostic value of clinical and histopathological factors and assessment of clinical usefulness of modified Peters' scale of risk of recurrence. Material and methods: Between 1994-96 197 pts were irradiated after surgery. Partial resections of the larynx were performed in 42(21%) of patients (pts), total resections in 155 pts (79%). Preoperative analysis revealed advanced laryngeal cancer (T3-4) in 67% of pts and absence of neck nodes metastases (NO) in 63% of pts and respectively 72% and 65% in postoperative analysis. Macroscopic nonradicalism was noted in 4 pts (10%) after partial resections and in 11 pts (7%) after total resections. Microscopic nonradicalism was noted in 13 pts (31%) after partial resections and in 31 pts (20%) after total resections. In 16 pts (28%)
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with node metastases extracapsular extension was noted. Only 12 pts (29%) after partial resection and radiotherapy did not require tracheostomy. Emergency tracheostomy was done before surgery in 29 pts (15%). The risk of postoperative recurrence was established according to modified Peters' criteria. In 118 of pts (60%) risk of local recurrence was low (0-2), in 59 (30%) moderate (3-5) and in 20 (10%) high (>5). In 53 of pts (51%) risk of nodal recurrence was low, in 33 (32%) moderate and in 13 (13%) high. Results: 5-year actuarial LC, DFS and OS were 88%, 68% and 73%, respectively. Along with increasing clinical stage DFS decreases from 79% in Stage I to 62% in stage IV. 5year DFS was 33% and 25% lower in the case of macroscopic or microscopic non-radicalism, respectively comparing to pts after radical resections. 5-year DFS was 29% lower in pts with extracapsular extension. 5-year LC was 83% after partial resection comparing to 90% after total resection. 5-year DFS in pts with pretreatment tracheostomy was 47% comparing to 71% in pts with tracheostomy performed during surgery. The most significant influence on treatment results was observed for particular groups of risk recurrence: 5-year LC and DFSwas 93% and 76% respectively for pts with low risk of local recurrence, 86% and 57% for moderate risk and 63% and 42% for high risk. Similar, highly significant correlation was observed for groups of risk of nodal recurrence: 5-year LC and DFS was 94% and 88% respectively for pts with low risk of local recurrence, 88% and 88% for moderate risk and 79% and 42% for high risk. Conclusions: Most important negative prognostic factors influencing combined modality treatment are: macro- or microscopical surgical non-radicalism, presence of node metastases, extracapsular extension and emergency tracheostomy. The most important influence on efficacy of combinetl modality treatment has the degree of risk recurrence established according to modified Peters' scale 712 poster Combined treatment of head and neck in children
K. Ficek ~, S. Blamek ~, W. Madziara 2, R. Tarnawski~, L. Miszczyk ~ ~Oncology Center Institute, Department of Radiotherapy, Gliwice, Poland 2Institute of Paediatric Oncology, Surgery Department, Katowice, Poland Introduction: Head and neck tumours rarely occur in children but a wide variety of neoplasm can arise in that Iocalisation. Multimodality treatment based on surgery, chemotherapy and radiotherapy improved the outcome on this group. Purpose: The purpose of this study was to evaluate the results of combined treatment in children with head and neck tumours. Material: The analysis was based on 19 patients treated in Department of Radiotherapy from 1993 to 2003. Children were 4 to 18 Years old (13yr. med.). There were 12 cases (63%) children with rhabdomyosarcoma and 7 (37%) nasopharyngeal carcinomas. 12 patients underwent surgery and then were treated with chemotherapy and postoperative radiotherapy. Second group (7 cases) were treated only with radiotherapy and chemotherapy. Most of patients were irradiated with the conventional schedule, only three patients with nasopharyngeal carcinoma were given hyperfractionated radiotherapy.
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Results: The overall survival was 84%. Four patients died, one from metastatic disease, three had local relapse, two patients with disseminated nasopharyngeal carcinoma are still alive. Only one patient with orbit RMS developed a postirradiation cataract. Others did not show ant late side effects or developmental disturbances. Conclusions: Combined treatment in head and neck tumours is an effective schedule in children. Radiotherapy can be successful treatment in non operable cases and as post-operative treatment. 713 poster Thyroid gland medullar cancer-outcome of combined treatment and prognostic factors
V. Stankovic 1, N. Borojevic 1, R. Dzodic2, I. Golubicic ~ 1Institute for oncology and radiology of Serbia, Radiotherapy, Belgrade, Serbia and Montenegro 2Institute for oncology and radiology of Serbia, Surgery, Belgrade, Serbia and Montenegro Introduction: Aim of the study was to evaluate results of combined treatment of thyroid gland meduliar cancer/ TGMC/determining probability of total survival, probability of survival without local recurrence and to investigate influence of prognostic parameters on treatment outcome. Methods: Non-randomized, retrospective, prospective study, including 36 patients with sporadic form of TGMC was conducted at Institute for oncology and radiology of Serbia. Median age of the group was 49,5 years/27-75years/. Incidence of both sexes was even/18;18/.27 patients were in third clinical stage and nine ones in the second clinical stage. After initial surgical treatment, all the patients were treated with postoperative transcutaneous irradiation therapy. The radiation therapy was conducted on megavoltage machines, with conventional regime of fractioning and total tumor dose of 55-65Gy. Median follow-up of the group was 37,75months. Results: probability of total 5-year survival for the group of 36 patients with sporadic form of TGMC, treated with surgery and postoperative irradiation therapy was 62, 61% and ofl0year survival 23, 48%. Probability of 5-year survival without local recurrence for the same group was 59, 54%. Here was no local recurrence after 5 years. Analysing influence of prognostic factors on treatment outcome, statistically significant difference was found regarding local recurrence in relation to disease clinical stage and time passed from operation to beginning of irradiation therapy. Cox's multivariant analysis showed statistical significance only for clinical stage of disease. Conclusions: Analysing obtained results of combined treatment we concluded that post-operative irradiation therapy did not contribute total survival, but, it was important in maintaining local control. Good treatment results were obtained owing to radical surgical treatment. 714 poster Intravenous administration of amifostine in bolus prior to radiotherapy in head and neck cancer
L. Gutierrez Bayard, C. Salas Buzon, P. Roman Rodriguez Puerta de/Mar Hospital, Radiotherapy, Cadiz, Spain Purpose: To present and defend the safety and tolerability advantage in administering amifostine in a rapid, 30 second intravenous in bolus administration of amifostine, versus the traditional 28 minute administration of this drug. In our experience, the traditional 28 minutes administration of amifostine has so severe negative side effects that 6.2% of
Posters
709 poster
710 poster
Concomitant chemoradiotherapy with weekly Cisplatin and subcutaneous Amifostin in the treatment of advanced head and neck cancer
Comparison of clinical target volume in PET-CT and CTscan based treatment planning in patients with head and neck cancer
M. Pala 1, P. Holeckova ~, P. Vitek ~, J. Kubes ~, J. VeselS, A. Svobodnik 3 ~lnstitute of Radiation Oncology University Hospital Bulovka, Department of Radiation Oncology, Prague, Czech Republic 2University Hospital Bulovka, Department of Otorhinolaryngology, Prague, Czech Republic 3Center for Information Science and Analysis Masaryk Memorial Cancer Institute, Brno, Czech Republic
A. van Baardwijk 1, F. Koppe ~, P. van den Ende 1, J. de Jong ~, B. Kremer2, M. van Kroonenburgh 3, B. de Bondt4, M. Oellers ~, P. Lamb#) ~, D. de Ruysscher1 I MAASTRO cfinic, Radiation Oncology, Maastricht, The Netherlands 2Academic Hospital Maastricht, Otorhinolaryngology and Head and Neck Surgery, Maastricht, The Netherlands 3Academic Hospital Maastricht, Nuclear Medicine, Maastricht, The Netherlands 4Academic Hospital Maastricht, Radiology, Maastricht, The Netherlands
Purpose: To demonstrate the efficacy and feasibility of chemoradiotherapy with weekly cisplatin and subcutaneous amifostin in the treatment of Ioco(regional) advanced head and neck cancer. Patients and Methods: Between February 2002 and April 2004, 54 consecutive patients (pts.) [WHO < 2, male to female ratio 46/8, median age 56 years (35-68)] with head and neck cancer were treated. Tumours of the oropharynx (53%) and hypopharynx (13%) were most frequent and stage IV (TNM 1997) was predominant (89%). Radiotherapy consisted of 70Gy/7weeks/35 fraction without (41 pts.) or after R1/2 resection (6 pts.) or 60Gy/6 weeks/30 fraction after R0 resection (5 pts.) or in a case of reirradiation (2 pts.). In most of cases we used the three field radiation technique with two lateral opposite wedged fields and a direct posterior field with central shielding block protecting spinal cord. All patients received concurrent chemotherapy with cisplatin 40mg/m 2 weekly and amifostin 500mg subcutaneously 20-30 min. prior to each radiotherapy fraction. The radiotherapy was combined with hyperthermia in 26% (14pts.). Prophylactic percutane0us endoscopic gastrostomy was itroduced in 87% (47 pts.). The endpoints of the study included initial tumor response (according to WHO), toxicity to radiochemotherapy and subcutaneous amifostin (according to RTOG and NCI-CTT) and survival. Results: The median duration of follow up was 15 months (228). Median total tumor dose was 70Gy (26-74), median number of chemotherapy courses 5 (1-8), median radiotherapy duration 51 days (18-68). Of the 48 pts. evaluable for response 77% (37 pts.) achieved complete response and 10% (5 pts.) partial response. Median overall survival is 12,9 months. Acute mucositis grade 3 were reported in 43% (23 pts.), acute dermatitis grade 3/4 in 17% (9 pts.), acute xerostomy grade 2 in 69% (37 pts.), acute dysphagia grade 3 in 43% (23 pts.). One case of larynx toxicity grade 4 was recorded. Median loss of weight was 7kg (10% of pretreatment value) (20-2). Grade 3/4 neutropenia occurred in 35% (19 pts.) and it was the most frequent reason for termination of concomitant chemotherapy. Renal toxicity was in general mild. 13% (7 pts.) discontinued radiotherapy due to treatment-related toxicity. Skin :rush grade 2/3 developed in 19% (10 pts.), 19% (10 pts.) interrupted administration of amifostine due to toxicities. The late toxicities were mild, predominantly subcutaneous fibrosis grade 1/2 and xerostomia grade 1/2 in most of cases. Conclusion: Concomitant chemoradiotherapy with weekly cisplatin and subcutaneous amifostin is toxic, but tolerable and highly active in term of initial response. Despite that, the overall survival of patients with Ioco(regional) advanced head and neck cancer evaluated in this study remains poor. For definitive conclusion long term follow-up is necessary.
Introduction: Combined PET-CT with FDG has recently shown to have a high diagnostic accuracy for head and neck cancer. We therefore investigated prospectively the potential gain of PET-CT delineation using a dedicated combined PET-CT-simulator in head and neck cancer patients referred for radical radiotherapy. Materials and Methods: From February 2004 onwards, all patients referred for radical radiotherapy for head and neck ,cancer have undergone a pre-treatment simulation on a dedicated combined PET-CT-simulator (Biograph TM , Siemens). For each patient two delineations of clinical target volume (CTV) were made: one on base of CT information alone and one on base of PET-CT information. Results: Out of 18 patients, 5 had significant FDG uptake in their primary tumour. In 13 patients no FDG uptake was seen: 3 patients with carcinoma in situ, 4 with a cT1 lesion, and 6 with microscopically positive margins postoperatively. Of the remaining 5 the CT based CTV was 376 ml + 66.7 ml vs. 369 ml + 74.7 ml for the PET-CT based CTV (p=0.76). The CTV on PET-CT extended beyond the CTV CT in 4 out of 5 patients for a mean volume of 48 ml + 22.6 ml. There was an overlap between CTV CT and CTV PET-CT in 84.4 % + 5.6 % of the volume. Conclusions: The first data suggest that target volumes will change according to PET-CT information compared with CT in case of macroscopic disease. As accrual of patients continues, more mature data will be presented at the meeting.
711 poster Prognostic factors of combined modality treatment in patients with laryngeal cancer basing on scale of risk of recurrence
A. Mucha-Malecka, K. Skladowski Center of Oncology, Radiotherapy Department, Cracow, Poland Purpose: The evaluation of prognostic value of clinical and histopathological factors and assessment of clinical usefulness of modified Peters' scale of risk of recurrence. Material and methods: Between 1994-96 197 pts were irradiated after surgery. Partial resections of the larynx were performed in 42(21%) of patients (pts), total resections in 155 pts (79%). Preoperative analysis revealed advanced laryngeal cancer (T3-4) in 67% of pts and absence of neck nodes metastases (NO) in 63% of pts and respectively 72% and 65% in postoperative analysis. Macroscopic nonradicalism was noted in 4 pts (10%) after partial resections and in 11 pts (7%) after total resections. Microscopic nonradicalism was noted in 13 pts (31%) after partial resections and in 31 pts (20%) after total resections. In 16 pts (28%)
Posters
with node metastases extracapsular extension was noted. Only 12 pts (29%) after partial resection and radiotherapy did not require tracheostomy. Emergency tracheostomy was done before surgery in 29 pts (15%). The risk of postoperative recurrence was established according to modified Peters' criteria. In 118 of pts (60%) risk of local recurrence was low (0-2), in 59 (30%) moderate (3-5) and in 20 (10%) high (>5). In 53 of pts (51%) risk of nodal recurrence was low, in 33 (32%) moderate and in 13 (13%) high. Results: 5-year actuarial LC, DFS and OS were 88%, 68% and 73%, respectively. Along with increasing clinical stage DFS decreases from 79% in Stage I to 62% in stage IV. 5year DFS was 33% and 25% lower in the case of macroscopic or microscopic non-radicalism, respectively comparing to pts after radical resections. 5-year DFS was 29% lower in pts with extracapsular extension. 5-year LC was 83% after partial resection comparing to 90% after total resection. 5-year DFS in pts with pretreatment tracheostomy was 47% comparing to 71% in pts with tracheostomy performed during surgery. The most significant influence on treatment results was observed for particular groups of risk recurrence: 5-year LC and DFSwas 93% and 76% respectively for pts with low risk of local recurrence, 86% and 57% for moderate risk and 63% and 42% for high risk. Similar, highly significant correlation was observed for groups of risk of nodal recurrence: 5-year LC and DFS was 94% and 88% respectively for pts with low risk of local recurrence, 88% and 88% for moderate risk and 79% and 42% for high risk. Conclusions: Most important negative prognostic factors influencing combined modality treatment are: macro- or microscopical surgical non-radicalism, presence of node metastases, extracapsular extension and emergency tracheostomy. The most important influence on efficacy of combinetl modality treatment has the degree of risk recurrence established according to modified Peters' scale 712 poster Combined treatment of head and neck in children
K. Ficek ~, S. Blamek ~, W. Madziara 2, R. Tarnawski~, L. Miszczyk ~ ~Oncology Center Institute, Department of Radiotherapy, Gliwice, Poland 2Institute of Paediatric Oncology, Surgery Department, Katowice, Poland Introduction: Head and neck tumours rarely occur in children but a wide variety of neoplasm can arise in that Iocalisation. Multimodality treatment based on surgery, chemotherapy and radiotherapy improved the outcome on this group. Purpose: The purpose of this study was to evaluate the results of combined treatment in children with head and neck tumours. Material: The analysis was based on 19 patients treated in Department of Radiotherapy from 1993 to 2003. Children were 4 to 18 Years old (13yr. med.). There were 12 cases (63%) children with rhabdomyosarcoma and 7 (37%) nasopharyngeal carcinomas. 12 patients underwent surgery and then were treated with chemotherapy and postoperative radiotherapy. Second group (7 cases) were treated only with radiotherapy and chemotherapy. Most of patients were irradiated with the conventional schedule, only three patients with nasopharyngeal carcinoma were given hyperfractionated radiotherapy.
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Results: The overall survival was 84%. Four patients died, one from metastatic disease, three had local relapse, two patients with disseminated nasopharyngeal carcinoma are still alive. Only one patient with orbit RMS developed a postirradiation cataract. Others did not show ant late side effects or developmental disturbances. Conclusions: Combined treatment in head and neck tumours is an effective schedule in children. Radiotherapy can be successful treatment in non operable cases and as post-operative treatment. 713 poster Thyroid gland medullar cancer-outcome of combined treatment and prognostic factors
V. Stankovic 1, N. Borojevic 1, R. Dzodic2, I. Golubicic ~ 1Institute for oncology and radiology of Serbia, Radiotherapy, Belgrade, Serbia and Montenegro 2Institute for oncology and radiology of Serbia, Surgery, Belgrade, Serbia and Montenegro Introduction: Aim of the study was to evaluate results of combined treatment of thyroid gland meduliar cancer/ TGMC/determining probability of total survival, probability of survival without local recurrence and to investigate influence of prognostic parameters on treatment outcome. Methods: Non-randomized, retrospective, prospective study, including 36 patients with sporadic form of TGMC was conducted at Institute for oncology and radiology of Serbia. Median age of the group was 49,5 years/27-75years/. Incidence of both sexes was even/18;18/.27 patients were in third clinical stage and nine ones in the second clinical stage. After initial surgical treatment, all the patients were treated with postoperative transcutaneous irradiation therapy. The radiation therapy was conducted on megavoltage machines, with conventional regime of fractioning and total tumor dose of 55-65Gy. Median follow-up of the group was 37,75months. Results: probability of total 5-year survival for the group of 36 patients with sporadic form of TGMC, treated with surgery and postoperative irradiation therapy was 62, 61% and ofl0year survival 23, 48%. Probability of 5-year survival without local recurrence for the same group was 59, 54%. Here was no local recurrence after 5 years. Analysing influence of prognostic factors on treatment outcome, statistically significant difference was found regarding local recurrence in relation to disease clinical stage and time passed from operation to beginning of irradiation therapy. Cox's multivariant analysis showed statistical significance only for clinical stage of disease. Conclusions: Analysing obtained results of combined treatment we concluded that post-operative irradiation therapy did not contribute total survival, but, it was important in maintaining local control. Good treatment results were obtained owing to radical surgical treatment. 714 poster Intravenous administration of amifostine in bolus prior to radiotherapy in head and neck cancer
L. Gutierrez Bayard, C. Salas Buzon, P. Roman Rodriguez Puerta de/Mar Hospital, Radiotherapy, Cadiz, Spain Purpose: To present and defend the safety and tolerability advantage in administering amifostine in a rapid, 30 second intravenous in bolus administration of amifostine, versus the traditional 28 minute administration of this drug. In our experience, the traditional 28 minutes administration of amifostine has so severe negative side effects that 6.2% of