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Comparison of the Planning Target Volume Based on 3-dimensional CT and 4-dimensional CT Images of Thoracic Esophageal Cancer
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Volume 84 Number 3S Supplement 2012 Purpose/Objective(s): 18F-FDG PET is used widely in clinical diagnosis, staging, and response assessment for esophageal squamous cell carcinoma (ESCC). The aim of this study is to evaluate new PET image parameters, FDG uptake heterogeneity obtained by texture analysis, and its impact on various approaches of target volume delineation for ESCC. Materials/Methods: Twenty-five patients with newly diagnosed and pathologically proved ESCC were included in this study. All the patients were treated definitive chemo-radiation therapy and received whole body FDG PET/CT scanning before treatments. Intra-tumor 18F-FDG uptake heterogeneity was accessed by three-dimensional image texture feature (entropy) using a software algorithm. Tumor volumes were delineated on the CT (VCT) and the corresponding PET images, using a fixed threshold at 40% of the SUVmax (VPET40%) or the absolute SUV cut-off values of 2.5 (VPET2.5). The correlation between the uptake heterogeneity parameter and the differences among VCT, VPET40% and VPET2.5 was analyzed. Results: VCT (45.41 37.87 cm3) was significantly larger than VPET40% (13.20 12.27cm3) or VPET2.5 (32.13 26.31 cm3). Larger tumors were more heterogeneous. The significant correlations were found between FDG uptake heterogeneous and tumor volume (VCT:r Z 0.59, VPET40:r Z 0.60 and VPET2.5: r Z 0.57, p < 0.01). Moreover, the uptake heterogeneity parameter was correlated strongly with the difference between VCT and VPET40 (r Z 0.54, p Z 0.006), VCT and VPET2.5 (r Z 0.59, p Z 0.002), or VPET40 and VPET2.5 (r Z 0.44, p Z 0.029). Conclusions: FDG uptake heterogeneity has an impact on thresholdbased delineation of ESCC, especially for large heterogeneous tumors. An accurate delineation of target volumes using PET imaging in ESCC needs further research with consideration of tumor heterogeneity. Author Disclosure: P. Wu: None. X. Dong: None. L. Xing: None. H. Wan: None. Z. Fu: None. Y. Yin: None. X. Sun: None. J. Yu: None.
2249 Neoadjuvant Concurrent Chemoradiation Therapy Followed by Definitive High-dose Radiation Therapy or Surgery for Operable T3 Squamous Cell Carcinoma of Thoracic Esophagus Y. Ishida,1 Y. Negoro,1 T. Fujii,1 F. Kusumi,2 and Y. Asao3; 1Department of Radiology, Tenri Hospital, Tenri-City, Nara Prefecture, Japan, 2 Department of Gastroenterology, Tenri Hospital, Tenri-City, Nara Prefecture, Japan, 3Department of Abdominal Surgery, Tenri Hospital, Tenri-City, Nara Prefecture, Japan Purpose/Objective(s): To evaluate neoadjuvant chemoradiation therapy followed by surgery or followed by definitive high-dose radiation therapy for operable T3 squamous cell carcinoma of thoracic esophagus. Materials/Methods: Between January 1991 and January 2008, 81 patients with operable T3 squamous cell carcinoma of the thoracic esophagus were enrolled. Median age of the patients was 64 years (range: 41 to 82 years); 68 were men and 13 were women. They were treated with neoadjuvant concurrent chemoradiation therapy (CRT) followed by surgery (CRT-S group) or definitive high-dose radiation therapy (CRT group). Neoadjuvant CRT consisted of concurrent 1-2 courses of cisplatin (80-100 mg/body, Day 1, bolus injection) and 5fluorouracil (500-1000 mg/body/day, Days 1-4, continuous infusion) and radiation therapy of 44 Gy in 40 fractions for 4 weeks (2.2 Gy/2 fraction / day). Patients were then divided into 2 groups - either of CRT group or CRT-S group - according to an intermediate clinical response at completion of neoadjuvant CRT, evaluated by barium swallow, endoscopy, EUS, thoracic and upper abdominal CT scan, and cervical ultrasound. Surgery was performed for those of less than 75% regression at the evaluation with/without intraoperative radiation therapy for abdominal lymphatics. Definitive high-dose radiation
therapy, a cumulative dose of 59.4-75.6 Gy (median 66 Gy), was performed for those of more than 75% regression or those who refused surgery. In addition, some of them were added high-dose-rate intraluminal brachytherapy. Failure was confirmed by findings of progressive disease on serial imaging studies and endoscopy with/ without histological diagnosis. Overall survival (OS), cause specific survival (CSS) and relapse free survival (RFS) rates were calculated by the Kaplan-Meier method. Toxicities were evaluated by the CTCAE version 4.0. Results: Forty patients were treated with definitive CRT and 41 were treated CRT followed by surgery. OS and CSS at 5 years were 29.4% and 33.5% in CRT group, and 47.6% and 52.8% in CRT-S group. There was no statistical significance (p Z 0.29 and 0.13). However, RFS at 5 years were 22.3% in CRT group and 47.9% in CRT-S group, there was a statistical significance (p Z 0.005). In CRT-S group, 9 patients had grade 2 anastomotic leak, 1 patient was died by surgical complications, and 1 patient had grade 2 recurrent laryngeal nerve palsy. Conclusions: For T3 esophageal carcinoma, CRT-S group was superior to CRT group in RFS at 5 years. However, there was no statistical significance at OS and CSS between 2 groups. With considering the patient selection, definitive high-dose CRT might be a reasonable treatment, at least for the responder of neoadjuvant CRT. Author Disclosure: Y. Ishida: None. Y. Negoro: None. T. Fujii: None. F. Kusumi: None. Y. Asao: None.
2250 Comparison of the Planning Target Volume Based on 3-dimensional CT and 4-dimensional CT Images of Thoracic Esophageal Cancer W. Wang, J. Li, Y. Zhang, T. Fan, H. Qi, and J. Xing; Shandong Cancer Hospital, Jinan, China Purpose/Objective(s): To compare the centroid position, volumetric differences and dice similarity coefficient (DSC) of planning target volume (PTV) based on three-dimensional CT (3DCT) and fourdimensional CT (4DCT) for the thoracic primary tumor of esophageal cancer. Materials/Methods: Forty-three patients with esophageal cancer underwent 3DCT and 4DCT simulation scans of the thorax during normal free breathing. The motion of primary tumors located in the proximal (group A), mid-(group B), and distal (group C) thoracic esophagus were obtained from the 4DCT scans. PTV3D was defined on 3DCT using the tumor motion measured by 4DCT scans; PTV4D was defined as the union of the target volume contoured on the 10 phases of 4DCT images. The differences in target centroid position, volume, DSC, and degree of inclusion (DI) between PTV3D and PTV4D were evaluated for tumors in different groups respectively. Results: The mean centroid shifts between PTV3D and PTV4D in the three dimensional directions were less than 0.3 cm, for all the three groups. However, the target centroid shift was demonstrated significant difference in lateral direction for group C (Z Z -2.355, p Z 0.019). The median size ratio of PTV4D to PTV3D was 0.79 0.07, 0.91 0.25, and 0.70 0.07 for group A, B and C. There was no significant correlation between the ratio of PTV4D to PTV3D and the target motion for the three groups. The DSC between the PTV4D and PTV3D were 0.87 0.04, 0.88 0.06, and 0.81 0.03. The median DI of PTV3D in PTV4D was 0.78, 0.85, 0.69 for group A, B and C, and the median DI of PTV4D in PTV3D was 0.98, 0.97, and 0.99 for group A, B and C, respectively. Conclusions: The 3DCT-based PTV provides a good coverage of the 4DCT-based PTV, especially for middle esophageal tumors, but for proximal and distal esophageal tumors, PTV3D also encompasses relatively large normal tissues. Author Disclosure: W. Wang: None. J. Li: None. Y. Zhang: None. T. Fan: None. H. Qi: None. J. Xing: None.
Volume 84 Number 3S Supplement 2012 Purpose/Objective(s): 18F-FDG PET is used widely in clinical diagnosis, staging, and response assessment for esophageal squamous cell carcinoma (ESCC). The aim of this study is to evaluate new PET image parameters, FDG uptake heterogeneity obtained by texture analysis, and its impact on various approaches of target volume delineation for ESCC. Materials/Methods: Twenty-five patients with newly diagnosed and pathologically proved ESCC were included in this study. All the patients were treated definitive chemo-radiation therapy and received whole body FDG PET/CT scanning before treatments. Intra-tumor 18F-FDG uptake heterogeneity was accessed by three-dimensional image texture feature (entropy) using a software algorithm. Tumor volumes were delineated on the CT (VCT) and the corresponding PET images, using a fixed threshold at 40% of the SUVmax (VPET40%) or the absolute SUV cut-off values of 2.5 (VPET2.5). The correlation between the uptake heterogeneity parameter and the differences among VCT, VPET40% and VPET2.5 was analyzed. Results: VCT (45.41 37.87 cm3) was significantly larger than VPET40% (13.20 12.27cm3) or VPET2.5 (32.13 26.31 cm3). Larger tumors were more heterogeneous. The significant correlations were found between FDG uptake heterogeneous and tumor volume (VCT:r Z 0.59, VPET40:r Z 0.60 and VPET2.5: r Z 0.57, p < 0.01). Moreover, the uptake heterogeneity parameter was correlated strongly with the difference between VCT and VPET40 (r Z 0.54, p Z 0.006), VCT and VPET2.5 (r Z 0.59, p Z 0.002), or VPET40 and VPET2.5 (r Z 0.44, p Z 0.029). Conclusions: FDG uptake heterogeneity has an impact on thresholdbased delineation of ESCC, especially for large heterogeneous tumors. An accurate delineation of target volumes using PET imaging in ESCC needs further research with consideration of tumor heterogeneity. Author Disclosure: P. Wu: None. X. Dong: None. L. Xing: None. H. Wan: None. Z. Fu: None. Y. Yin: None. X. Sun: None. J. Yu: None.
2249 Neoadjuvant Concurrent Chemoradiation Therapy Followed by Definitive High-dose Radiation Therapy or Surgery for Operable T3 Squamous Cell Carcinoma of Thoracic Esophagus Y. Ishida,1 Y. Negoro,1 T. Fujii,1 F. Kusumi,2 and Y. Asao3; 1Department of Radiology, Tenri Hospital, Tenri-City, Nara Prefecture, Japan, 2 Department of Gastroenterology, Tenri Hospital, Tenri-City, Nara Prefecture, Japan, 3Department of Abdominal Surgery, Tenri Hospital, Tenri-City, Nara Prefecture, Japan Purpose/Objective(s): To evaluate neoadjuvant chemoradiation therapy followed by surgery or followed by definitive high-dose radiation therapy for operable T3 squamous cell carcinoma of thoracic esophagus. Materials/Methods: Between January 1991 and January 2008, 81 patients with operable T3 squamous cell carcinoma of the thoracic esophagus were enrolled. Median age of the patients was 64 years (range: 41 to 82 years); 68 were men and 13 were women. They were treated with neoadjuvant concurrent chemoradiation therapy (CRT) followed by surgery (CRT-S group) or definitive high-dose radiation therapy (CRT group). Neoadjuvant CRT consisted of concurrent 1-2 courses of cisplatin (80-100 mg/body, Day 1, bolus injection) and 5fluorouracil (500-1000 mg/body/day, Days 1-4, continuous infusion) and radiation therapy of 44 Gy in 40 fractions for 4 weeks (2.2 Gy/2 fraction / day). Patients were then divided into 2 groups - either of CRT group or CRT-S group - according to an intermediate clinical response at completion of neoadjuvant CRT, evaluated by barium swallow, endoscopy, EUS, thoracic and upper abdominal CT scan, and cervical ultrasound. Surgery was performed for those of less than 75% regression at the evaluation with/without intraoperative radiation therapy for abdominal lymphatics. Definitive high-dose radiation
therapy, a cumulative dose of 59.4-75.6 Gy (median 66 Gy), was performed for those of more than 75% regression or those who refused surgery. In addition, some of them were added high-dose-rate intraluminal brachytherapy. Failure was confirmed by findings of progressive disease on serial imaging studies and endoscopy with/ without histological diagnosis. Overall survival (OS), cause specific survival (CSS) and relapse free survival (RFS) rates were calculated by the Kaplan-Meier method. Toxicities were evaluated by the CTCAE version 4.0. Results: Forty patients were treated with definitive CRT and 41 were treated CRT followed by surgery. OS and CSS at 5 years were 29.4% and 33.5% in CRT group, and 47.6% and 52.8% in CRT-S group. There was no statistical significance (p Z 0.29 and 0.13). However, RFS at 5 years were 22.3% in CRT group and 47.9% in CRT-S group, there was a statistical significance (p Z 0.005). In CRT-S group, 9 patients had grade 2 anastomotic leak, 1 patient was died by surgical complications, and 1 patient had grade 2 recurrent laryngeal nerve palsy. Conclusions: For T3 esophageal carcinoma, CRT-S group was superior to CRT group in RFS at 5 years. However, there was no statistical significance at OS and CSS between 2 groups. With considering the patient selection, definitive high-dose CRT might be a reasonable treatment, at least for the responder of neoadjuvant CRT. Author Disclosure: Y. Ishida: None. Y. Negoro: None. T. Fujii: None. F. Kusumi: None. Y. Asao: None.
2250 Comparison of the Planning Target Volume Based on 3-dimensional CT and 4-dimensional CT Images of Thoracic Esophageal Cancer W. Wang, J. Li, Y. Zhang, T. Fan, H. Qi, and J. Xing; Shandong Cancer Hospital, Jinan, China Purpose/Objective(s): To compare the centroid position, volumetric differences and dice similarity coefficient (DSC) of planning target volume (PTV) based on three-dimensional CT (3DCT) and fourdimensional CT (4DCT) for the thoracic primary tumor of esophageal cancer. Materials/Methods: Forty-three patients with esophageal cancer underwent 3DCT and 4DCT simulation scans of the thorax during normal free breathing. The motion of primary tumors located in the proximal (group A), mid-(group B), and distal (group C) thoracic esophagus were obtained from the 4DCT scans. PTV3D was defined on 3DCT using the tumor motion measured by 4DCT scans; PTV4D was defined as the union of the target volume contoured on the 10 phases of 4DCT images. The differences in target centroid position, volume, DSC, and degree of inclusion (DI) between PTV3D and PTV4D were evaluated for tumors in different groups respectively. Results: The mean centroid shifts between PTV3D and PTV4D in the three dimensional directions were less than 0.3 cm, for all the three groups. However, the target centroid shift was demonstrated significant difference in lateral direction for group C (Z Z -2.355, p Z 0.019). The median size ratio of PTV4D to PTV3D was 0.79 0.07, 0.91 0.25, and 0.70 0.07 for group A, B and C. There was no significant correlation between the ratio of PTV4D to PTV3D and the target motion for the three groups. The DSC between the PTV4D and PTV3D were 0.87 0.04, 0.88 0.06, and 0.81 0.03. The median DI of PTV3D in PTV4D was 0.78, 0.85, 0.69 for group A, B and C, and the median DI of PTV4D in PTV3D was 0.98, 0.97, and 0.99 for group A, B and C, respectively. Conclusions: The 3DCT-based PTV provides a good coverage of the 4DCT-based PTV, especially for middle esophageal tumors, but for proximal and distal esophageal tumors, PTV3D also encompasses relatively large normal tissues. Author Disclosure: W. Wang: None. J. Li: None. Y. Zhang: None. T. Fan: None. H. Qi: None. J. Xing: None.