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82 poster Combined treatment of cervical cancer: the role of contact radiotherapy
Posters
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was revealed the best values of parameters in II group with CRMT by cisplatin on 12.4% comparatively with I group (per stages of CC: II =77,3:L-6.1%, III =53.1+7.0%). In III group results of treatment appeared a few (5.6%) below than in I group that was most likely caused by the reduced immune status patients which did not fall for correction. 82
poster
Combined treatment of cervical cancer: the role of contact radiotherapy V. Y. Strakhov, M./. Nechushkin, L.A. L.A. Marjina N. B/okhin Russian Cancer Research Center, Department of Radiosurgery, Moscow, Russia In the Department of Radiosurgery (Cancer Research Center, Moscow) the cervical cancer management programme using contact radiotherapy has been devised. The aim is to affect the micrometastasis and tumor cells in the lymphatic vessels and nodes along lilac vessels, in parametrim and vagina stump. At the first stage of management we perform the Wertheim' operation and insert flexible applicators. The applicator proximal ends are posed at 2 cm above the common lilac vessels bifurcation. The applicator distal ends are led out of vagina. The radiotherapy is performed at the "MicroSelectron HDR" (Nucletron-Oldelft, Holland) with Ir-192 radioactive sourses. The irradiation zone cuts across the vagina stump, paracervical trigonum, lilac regions. We deliver 3-5 Gr/day to a total dose 24 iGr in 2-4 fractions. The interval between fractions is 24 h. Then the following distant irradiation plan is devised. It depends upon the tumor morphology and the presense of metastasis in lymphnodes and the contact radiotherapy dose. According to this management plan 50 patients were treated in our Department. 6 patients were with la stage of disease, 19 - Ib stage, 6 - lla stage, 1 - lib stage, 19 - III stage (T1 aN 1-T2bN 1). Three-year disease-free su rvival was for la stage - 100%, for tb stage - 92.3%, for II stage - 71.4%, for Ill stage - 50%, for all stages - 80%.
84
M.G. Fabrini 1, A. Gennai2, F. Perrone 3 B. Manfredi 1, M. Panichi 1, V. Marchetti 1, S. Santi2, M. Rossi 2, L. Cionini 1 1U.O. Radioterapia, Dpt. Oncologia - UniversitY, Pisa, Italy 2U.O. Chirurgia IV, Az. Ospedaliera Pisana, Pisa, Italy 3U.O. Fisica Sanitaria, Az. Ospedaliera Pisana, Pisa, Italy The current technique for brachytherapy treatment planning in oesophageal cancer is routinely in 2D: following applicator placement with the dummy source inserted, anterior-posterior and lateral radiographs are taken at the time of simulation to verify the adequate tumour coverage. The dose prescription is done according to the American Brachytherapy Society, considering the diameter of the applicator and the geometry of the source. To verify the adequacy target volume coverage, we developed a simple method that uses Endoscopic Ultra Sonography (E.U.S.) images to obtain a three dimensional (3D)-treatment planning. We performed a 3D- CT based and -E.U.S. based treatment planning for HDR intraluminal brachytherapy in 6 patients. Dose at reference point, reference volume, dose-volume histograms were calculated for C.T. and E.U.S. assisted 3D-treatment planning. The E.U.S. and the C.T. images assisted 3D-TP, for the same patients have been compared and we don't find significant difference in the parameters analysed. In all patients a median of only 61% of the tumour volume received the prescribed dose to the reference point (500 cGy). The E.U.S. assisted 3D-TP allows a better definition of the target and produces less discomfort for the patients. Above we will describe the technique and indications, vantages, advantages and results respect to traditional and CT techniques. 85
GASTRO-INTESTINAL
TUMOURS
83 poster Metal stent and intraluminal HDR Ir-192 brachytherapy in the p a l l i a t i o n o f m a l i g n a n t bile duct obstructions
T. Lahtinenl~ E. Kaukanen 2, M. Turunen 1, E. Kumpulainen 1, hi. Manninen 2 • 1Kuopio University Hospital, Department of Oncology, Kuopio, Finland 2Kuopio University Hospital, Department of Radiology, Kuopio, Finland Purpose: To evaluate the effect of a single palliative dose of 10 Gy with intraluminal brachytherapy (BT) using high dose rate Ir-192 on stent patency and survival in patients treated with metal stent for bitiary obstructions. Material and Methods: The study included a total of 20 patients during 1998-2001. At the time of drainage procedure13 patients had a biopsyproven malignant extrahepatic disease while 7 patients were suspected of a malignant obstructive disease. A self-expanding metal stent (diameter 10 mm) was inserted with a drainage procedure using a percutaneous transhepatic catheterisation (PTC) as a palliation to biliary obstruction and/or pain. An intraluminal dose of 10 Gy at the depth of 1 cm from the center of the non-centering 6F afterloading catheter inserted through the 8F percutaneous introducer sheath was administered using HDR BT. In one patient the radiation treatment could not be performed due to a steep angle of the afterloading catheter. Results: The median and mean survival were 3.6 and 5.9 months (range 8 days - 27.4 months). Only 1 patient required a repeated drainage procedure at 18.0 months due to a stent occlusion of the biliary tract. Late morbidity related to BT was not detected. Conclusions: A baseline study during 1996-1997 with similar indications from our hospital in 16 patients without BT indicated a median and mean survival of 1.7 and 2.7 months and one stent occlusion at 2.8 months after stent placement. Although factors responsible for the improved survival are not yet known, intraluminal HDR BT combined with PTC-inserted metal stents yields a high stent patency rate and appears to extend survival without adding procedure-related late morbidity. Since the use of BT is simple and patients are hospitalized for a PTC drainage procedure, a combinedmodality therapy in patients with malignant bitiary obstructions is recommended.
poster
Endoscopic ultrasonography (E.U.S.) assisted vs C.T. assisted-3D treatment planning in HDR brachytherapy f o r oesophageal cancer
poster
Palliative radiotherapy in the treatment of carcinomas of the extrahepatic bile duct: a retrospective analysis of 24 patients E. Riedmann. H. Vedovelli, L. Pichler, N. Hdlbling, R. Hawliczek Institute of Radiooncology, SMZ-Ost/Donauspital, Vienna, Austria Puroose: to evaluate the benefit of radiation therapy in unresectabte or residual extrahepatic biliary cancer. A retrospective analysis of 24 patients with carcinoma of the extrahepatic biliary duct, treated with HD 192-1r brachytherapy alone or combined with external beam irradiation. Methods and materials: From 1996 to 2001,24 patients (15 female, 9 mate, median age 64 years) with carcinoma of the extrahepatic bile duct (16 Klatskin, 6 gallbladder, 2 metastases of gastrointestinal tumors) underwent palliative radiation therapy. 14 of the 24 patients had locally advanced unresectable tumor, 5 patients were treated for their residual tumor after resection, and 5 patients after recurrence. First all patients received a Wallstent-implantation via PTC-drainage. 23 patients received intraluminal brachytherapy, followed by additional external beam radiation for 10 of the 23 patients. One patient was treated with external beam radiation only. In the first year the brachytherapy dose was 15 Gy given in 3 separate fractions. Since 1997 we treated our patients with hyperfractionated (2 times a day) brachytherapy with a median dose of 20 Gy (5 times a single dose of 4 Gy). The median dose of external beam irradiation was 40 Gy (range 22 to 60 Gy). Results: for all patients the median survival rate was 7.7 months. The patients who received hyperfractionated brachytherapy showed a trend towards improved survival with a median of 11.6 months compared with 5.7 months for those in the conventionally treated group. The acute side effects were moderate. There were no complications observed. Conqtusion: our data suggest that hyperfractionated brachytherapy may improve survival. The therapy is well tolerated and shows a good palliation. In any case it improves quality of life in a patient group with only poor prognosis. 86
poster
The pitfalls and complications of palliative brachytherapy for esophageal cancer J. Skowronek 1, K. Adamska 1, G. Zwierzchowski 2, A. Jodda 2 1Greatpoland Cancer Center, Ist Radiotherapy, Poznan, Poland 2Greatpoland Cancer Center, Medical Physics, Poznan, Poland Introduction: The aim of palliative brachytherapy is to reduce dysphagia, diminish pain and bleeding, as well as improve the patient's well-being
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was revealed the best values of parameters in II group with CRMT by cisplatin on 12.4% comparatively with I group (per stages of CC: II =77,3:L-6.1%, III =53.1+7.0%). In III group results of treatment appeared a few (5.6%) below than in I group that was most likely caused by the reduced immune status patients which did not fall for correction. 82
poster
Combined treatment of cervical cancer: the role of contact radiotherapy V. Y. Strakhov, M./. Nechushkin, L.A. L.A. Marjina N. B/okhin Russian Cancer Research Center, Department of Radiosurgery, Moscow, Russia In the Department of Radiosurgery (Cancer Research Center, Moscow) the cervical cancer management programme using contact radiotherapy has been devised. The aim is to affect the micrometastasis and tumor cells in the lymphatic vessels and nodes along lilac vessels, in parametrim and vagina stump. At the first stage of management we perform the Wertheim' operation and insert flexible applicators. The applicator proximal ends are posed at 2 cm above the common lilac vessels bifurcation. The applicator distal ends are led out of vagina. The radiotherapy is performed at the "MicroSelectron HDR" (Nucletron-Oldelft, Holland) with Ir-192 radioactive sourses. The irradiation zone cuts across the vagina stump, paracervical trigonum, lilac regions. We deliver 3-5 Gr/day to a total dose 24 iGr in 2-4 fractions. The interval between fractions is 24 h. Then the following distant irradiation plan is devised. It depends upon the tumor morphology and the presense of metastasis in lymphnodes and the contact radiotherapy dose. According to this management plan 50 patients were treated in our Department. 6 patients were with la stage of disease, 19 - Ib stage, 6 - lla stage, 1 - lib stage, 19 - III stage (T1 aN 1-T2bN 1). Three-year disease-free su rvival was for la stage - 100%, for tb stage - 92.3%, for II stage - 71.4%, for Ill stage - 50%, for all stages - 80%.
84
M.G. Fabrini 1, A. Gennai2, F. Perrone 3 B. Manfredi 1, M. Panichi 1, V. Marchetti 1, S. Santi2, M. Rossi 2, L. Cionini 1 1U.O. Radioterapia, Dpt. Oncologia - UniversitY, Pisa, Italy 2U.O. Chirurgia IV, Az. Ospedaliera Pisana, Pisa, Italy 3U.O. Fisica Sanitaria, Az. Ospedaliera Pisana, Pisa, Italy The current technique for brachytherapy treatment planning in oesophageal cancer is routinely in 2D: following applicator placement with the dummy source inserted, anterior-posterior and lateral radiographs are taken at the time of simulation to verify the adequate tumour coverage. The dose prescription is done according to the American Brachytherapy Society, considering the diameter of the applicator and the geometry of the source. To verify the adequacy target volume coverage, we developed a simple method that uses Endoscopic Ultra Sonography (E.U.S.) images to obtain a three dimensional (3D)-treatment planning. We performed a 3D- CT based and -E.U.S. based treatment planning for HDR intraluminal brachytherapy in 6 patients. Dose at reference point, reference volume, dose-volume histograms were calculated for C.T. and E.U.S. assisted 3D-treatment planning. The E.U.S. and the C.T. images assisted 3D-TP, for the same patients have been compared and we don't find significant difference in the parameters analysed. In all patients a median of only 61% of the tumour volume received the prescribed dose to the reference point (500 cGy). The E.U.S. assisted 3D-TP allows a better definition of the target and produces less discomfort for the patients. Above we will describe the technique and indications, vantages, advantages and results respect to traditional and CT techniques. 85
GASTRO-INTESTINAL
TUMOURS
83 poster Metal stent and intraluminal HDR Ir-192 brachytherapy in the p a l l i a t i o n o f m a l i g n a n t bile duct obstructions
T. Lahtinenl~ E. Kaukanen 2, M. Turunen 1, E. Kumpulainen 1, hi. Manninen 2 • 1Kuopio University Hospital, Department of Oncology, Kuopio, Finland 2Kuopio University Hospital, Department of Radiology, Kuopio, Finland Purpose: To evaluate the effect of a single palliative dose of 10 Gy with intraluminal brachytherapy (BT) using high dose rate Ir-192 on stent patency and survival in patients treated with metal stent for bitiary obstructions. Material and Methods: The study included a total of 20 patients during 1998-2001. At the time of drainage procedure13 patients had a biopsyproven malignant extrahepatic disease while 7 patients were suspected of a malignant obstructive disease. A self-expanding metal stent (diameter 10 mm) was inserted with a drainage procedure using a percutaneous transhepatic catheterisation (PTC) as a palliation to biliary obstruction and/or pain. An intraluminal dose of 10 Gy at the depth of 1 cm from the center of the non-centering 6F afterloading catheter inserted through the 8F percutaneous introducer sheath was administered using HDR BT. In one patient the radiation treatment could not be performed due to a steep angle of the afterloading catheter. Results: The median and mean survival were 3.6 and 5.9 months (range 8 days - 27.4 months). Only 1 patient required a repeated drainage procedure at 18.0 months due to a stent occlusion of the biliary tract. Late morbidity related to BT was not detected. Conclusions: A baseline study during 1996-1997 with similar indications from our hospital in 16 patients without BT indicated a median and mean survival of 1.7 and 2.7 months and one stent occlusion at 2.8 months after stent placement. Although factors responsible for the improved survival are not yet known, intraluminal HDR BT combined with PTC-inserted metal stents yields a high stent patency rate and appears to extend survival without adding procedure-related late morbidity. Since the use of BT is simple and patients are hospitalized for a PTC drainage procedure, a combinedmodality therapy in patients with malignant bitiary obstructions is recommended.
poster
Endoscopic ultrasonography (E.U.S.) assisted vs C.T. assisted-3D treatment planning in HDR brachytherapy f o r oesophageal cancer
poster
Palliative radiotherapy in the treatment of carcinomas of the extrahepatic bile duct: a retrospective analysis of 24 patients E. Riedmann. H. Vedovelli, L. Pichler, N. Hdlbling, R. Hawliczek Institute of Radiooncology, SMZ-Ost/Donauspital, Vienna, Austria Puroose: to evaluate the benefit of radiation therapy in unresectabte or residual extrahepatic biliary cancer. A retrospective analysis of 24 patients with carcinoma of the extrahepatic biliary duct, treated with HD 192-1r brachytherapy alone or combined with external beam irradiation. Methods and materials: From 1996 to 2001,24 patients (15 female, 9 mate, median age 64 years) with carcinoma of the extrahepatic bile duct (16 Klatskin, 6 gallbladder, 2 metastases of gastrointestinal tumors) underwent palliative radiation therapy. 14 of the 24 patients had locally advanced unresectable tumor, 5 patients were treated for their residual tumor after resection, and 5 patients after recurrence. First all patients received a Wallstent-implantation via PTC-drainage. 23 patients received intraluminal brachytherapy, followed by additional external beam radiation for 10 of the 23 patients. One patient was treated with external beam radiation only. In the first year the brachytherapy dose was 15 Gy given in 3 separate fractions. Since 1997 we treated our patients with hyperfractionated (2 times a day) brachytherapy with a median dose of 20 Gy (5 times a single dose of 4 Gy). The median dose of external beam irradiation was 40 Gy (range 22 to 60 Gy). Results: for all patients the median survival rate was 7.7 months. The patients who received hyperfractionated brachytherapy showed a trend towards improved survival with a median of 11.6 months compared with 5.7 months for those in the conventionally treated group. The acute side effects were moderate. There were no complications observed. Conqtusion: our data suggest that hyperfractionated brachytherapy may improve survival. The therapy is well tolerated and shows a good palliation. In any case it improves quality of life in a patient group with only poor prognosis. 86
poster
The pitfalls and complications of palliative brachytherapy for esophageal cancer J. Skowronek 1, K. Adamska 1, G. Zwierzchowski 2, A. Jodda 2 1Greatpoland Cancer Center, Ist Radiotherapy, Poznan, Poland 2Greatpoland Cancer Center, Medical Physics, Poznan, Poland Introduction: The aim of palliative brachytherapy is to reduce dysphagia, diminish pain and bleeding, as well as improve the patient's well-being