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EP-1901: Locally advanced cervical cancer in renal transplant patients: A dilemma between control and toxicity
ESTRO 33, 2014 EP-1901 Locally advanced cervical cancer in renal transplant patients: A dilemma between control and toxicity P. Maroun1, E. Rivin1, I. Dumas1, M. Mondini2, C. Clémenson2, J. Brahim1, C. Haie-Meder1, R. Mazeron1 1 Institut Gustave Roussy, Department of Radiation Oncology, Villejuif, France 2 Institut Gustave Roussy, Inserm U1030 - Université Paris XI, Villejuif, France Purpose/Objective: Treatment of locally advanced cervical cancer in patients with a renal graft requires precautions. The graft is usually in a pelvic position, close to the clinical target volume (CTV). Preserving the graft while ensuring local control is a challenge we have faced in two occasions. We report our experience. Materials and Methods: We report the cases of two patients treated at our institution with a modified work up and therapeutic approach compared to our standard approach. The clinical and technical aspects of both treatments were systematically reviewed and contrasted with reports previously cited in the literature.
S323 Results: Looking for unification the technical advantages of MUPIT and Utrech applicator and MRI T2 image we have developed a perineal template adaptable to manufactured devices (SIU, and titanium needles). This template has been developed with the aid of Lorca Marín S.A, Murcia, Spain, in the manufacturing process. It has several rows to introduce straight and angled titanium needles to allow cover distal parametrium and the totality of the vagina, and a vaginal cylinder (several sizes are available, for different anatomic lengths of the vagina), where the intrauterine tube is fixed. It allows rectify the position the uterus. So that, coverage of the whole volume of CTV is more adequately with the SIU and the needles in all directions. In the MRI (General Eletric 1,5 tesla) we use a T2 sequence for delineation of CTV and organ at risk following the recommendations of GEC-ESTRO and a 3D radio-frequency Spoiled Gradient recalled Echo (SPGR) sequence to recognize the applicator and Titanium needles (Figure).
Conclusions: This new template allows increasing the CTV coverage ofthe BT procedures in locally advanced cervical tumors in 4D MRI based BT, improving the possibilities for a more adaptative dosimetry. Results: The first patient received external beam conformal radiotherapy (total dose: 30 Gy in the pelvis) followed by two sessions of MRI-guided brachytherapy [2x15 Gy to 90% of the intermediate risk CTV (IR-CTV)]. The second one received pelvic IMRT (total dose: 45Gy) followed by MRI-guided brachytherapy delivering 15 Gy to 90% of the IRCTV. Both patients had a complete response and were still in remission more than two years after treatment while retaining their graft. No severe late toxicity was reported.> Conclusions: External beam radiotherapy followed by brachytherapy is feasible in locally advanced cervical cancer, despite the presence of a kidney graft near the targets. Image guided adaptive brachytherapy allowed an accurate evaluation of the dose distribution, reaching the recommended treatment thresholds with optimal protection of the graft. EP-1902 A new mixed intracavitary and interstitial perineal template compatible with GEC-ESTRO recommendations approach S. Rodríguez Villalba1, J. Richart1, A. Otal1, M. Depiaggio1, J. Perez Calatayud2, M. Santos Ortega1 1 Hospital Clinica Benidorm, Radiotherapy Department, Benidorm, Spain 2 Hospital La Fe, Radiotherapy Department, Valencia, Spain Purpose/Objective: To present a novel MRI compatible perineal template, able to support both: an intrauterine probe (SIU) (intracavitary component) and titanium needles (interstitial component) for 4D MRI-Guided brachytherapy (BT) applications, in locally advanced cervical cancer. Materials and Methods: From January 2006 to November 2013, 89 interstitial treatments employing Martinez Universal Perineal Interstitial Templete (MUPIT) have been done at our institution. Sixty-five have been employed in locally advanced cervical cancer as a primary treatment. MUPIT template has well known advantages: possibility of treating medial and distal parametrium (avoiding the dosimetric sum with external radiotherapy), medial and distal vagina and tumoral affectation of rectal and bladder wall. But it has some limitations too: impossibility to add the intrauterine component limiting the BT CTV in cranial direction which does specially difficult with the uterus is in ante or in retro positions, and the need of use CT for the dosimetry with the additional difficulty of recognize the total cervix, parametrium and relationship of the tumor with organ at risk due in part to the artifact produced by the stainless steel needles. From 2006 we began to employ MRI following the recommendations of GEC-ESTRO in the BT procedures of early stages of cérvix carcinoma and in 2009 we incorporate Utrech applicator to these patients.
EP-1903 The effect of rectal volume on rectum dose-volume metrics during cervical high dose-rate brachytherapy A. Martos Casado1, S. Sabater1, M. Gutierrez-Perez1, M.M. Sevillano1, I. Andres1, R. Berenguer1, M. Arenas2 1 Hospital General de Albacete, Radiation Oncology, Albacete, Spain 2 Hospital Sant Joan de Reus, Radiation Oncology, Reus, Spain Purpose/Objective: Intracavitary brachytherapy is an essential part in the treatment of cervical cancer patients. Higher doses at organs at risk (OAR) are associated with higher morbidity. Rectum lay in close proximity of the cervix, in the high dose region, so rectal toxicity is common. Our purpose was to study rectal dose related to patient factors. Materials and Methods: A retrospective analysis of 61 intracavitary highdose rate (HDR) brachytherapy applications with a Fletcher applicator, belonging to 13 patients, was carried out. A CT planning scan was performed at every application. For the purposes of the study resegmentation and re-planning were performed under the same conditions and regardless of the actual delivered treatment in order to improve statistical comparisons. Rectum was defined from 1 cm superior to the tip of the intrauterine catheter to 1.5 cm below the caudal border of the ovoids. All plans were calculated in order to deliver 4.5 Gy to point A regardless of the actual dose delivered in the treatment. Rectum DVH values (D0.1cc,D1cc, D2cc and, D5cc) were extracted and expressed as the dose percentage related to point A dose. a regression analysis was carried out. Variables analysed included: age, body mass index (BMI) and rectal volume. Results: Mean rectal volume was 49.7cc. Mean rectal dose metric parameters (expressed as a percentage of the prescribed dose) were: D01cc, 78.4%; D1cc, 62.6%; D2cc,55.9%; D5cc, 45.9%. Mean age, 52 years. Mean BMI, 29.9. Only rectal volume reached significance on regression analysis, explaining from 14% to 23% of the variance (p values, 0.0343, 0.0105, 0.0049 and, 0.001 for D01cc, D1cc, D2cc and, D5ccrespectively. Fig 1).
S323 Results: Looking for unification the technical advantages of MUPIT and Utrech applicator and MRI T2 image we have developed a perineal template adaptable to manufactured devices (SIU, and titanium needles). This template has been developed with the aid of Lorca Marín S.A, Murcia, Spain, in the manufacturing process. It has several rows to introduce straight and angled titanium needles to allow cover distal parametrium and the totality of the vagina, and a vaginal cylinder (several sizes are available, for different anatomic lengths of the vagina), where the intrauterine tube is fixed. It allows rectify the position the uterus. So that, coverage of the whole volume of CTV is more adequately with the SIU and the needles in all directions. In the MRI (General Eletric 1,5 tesla) we use a T2 sequence for delineation of CTV and organ at risk following the recommendations of GEC-ESTRO and a 3D radio-frequency Spoiled Gradient recalled Echo (SPGR) sequence to recognize the applicator and Titanium needles (Figure).
Conclusions: This new template allows increasing the CTV coverage ofthe BT procedures in locally advanced cervical tumors in 4D MRI based BT, improving the possibilities for a more adaptative dosimetry. Results: The first patient received external beam conformal radiotherapy (total dose: 30 Gy in the pelvis) followed by two sessions of MRI-guided brachytherapy [2x15 Gy to 90% of the intermediate risk CTV (IR-CTV)]. The second one received pelvic IMRT (total dose: 45Gy) followed by MRI-guided brachytherapy delivering 15 Gy to 90% of the IRCTV. Both patients had a complete response and were still in remission more than two years after treatment while retaining their graft. No severe late toxicity was reported.> Conclusions: External beam radiotherapy followed by brachytherapy is feasible in locally advanced cervical cancer, despite the presence of a kidney graft near the targets. Image guided adaptive brachytherapy allowed an accurate evaluation of the dose distribution, reaching the recommended treatment thresholds with optimal protection of the graft. EP-1902 A new mixed intracavitary and interstitial perineal template compatible with GEC-ESTRO recommendations approach S. Rodríguez Villalba1, J. Richart1, A. Otal1, M. Depiaggio1, J. Perez Calatayud2, M. Santos Ortega1 1 Hospital Clinica Benidorm, Radiotherapy Department, Benidorm, Spain 2 Hospital La Fe, Radiotherapy Department, Valencia, Spain Purpose/Objective: To present a novel MRI compatible perineal template, able to support both: an intrauterine probe (SIU) (intracavitary component) and titanium needles (interstitial component) for 4D MRI-Guided brachytherapy (BT) applications, in locally advanced cervical cancer. Materials and Methods: From January 2006 to November 2013, 89 interstitial treatments employing Martinez Universal Perineal Interstitial Templete (MUPIT) have been done at our institution. Sixty-five have been employed in locally advanced cervical cancer as a primary treatment. MUPIT template has well known advantages: possibility of treating medial and distal parametrium (avoiding the dosimetric sum with external radiotherapy), medial and distal vagina and tumoral affectation of rectal and bladder wall. But it has some limitations too: impossibility to add the intrauterine component limiting the BT CTV in cranial direction which does specially difficult with the uterus is in ante or in retro positions, and the need of use CT for the dosimetry with the additional difficulty of recognize the total cervix, parametrium and relationship of the tumor with organ at risk due in part to the artifact produced by the stainless steel needles. From 2006 we began to employ MRI following the recommendations of GEC-ESTRO in the BT procedures of early stages of cérvix carcinoma and in 2009 we incorporate Utrech applicator to these patients.
EP-1903 The effect of rectal volume on rectum dose-volume metrics during cervical high dose-rate brachytherapy A. Martos Casado1, S. Sabater1, M. Gutierrez-Perez1, M.M. Sevillano1, I. Andres1, R. Berenguer1, M. Arenas2 1 Hospital General de Albacete, Radiation Oncology, Albacete, Spain 2 Hospital Sant Joan de Reus, Radiation Oncology, Reus, Spain Purpose/Objective: Intracavitary brachytherapy is an essential part in the treatment of cervical cancer patients. Higher doses at organs at risk (OAR) are associated with higher morbidity. Rectum lay in close proximity of the cervix, in the high dose region, so rectal toxicity is common. Our purpose was to study rectal dose related to patient factors. Materials and Methods: A retrospective analysis of 61 intracavitary highdose rate (HDR) brachytherapy applications with a Fletcher applicator, belonging to 13 patients, was carried out. A CT planning scan was performed at every application. For the purposes of the study resegmentation and re-planning were performed under the same conditions and regardless of the actual delivered treatment in order to improve statistical comparisons. Rectum was defined from 1 cm superior to the tip of the intrauterine catheter to 1.5 cm below the caudal border of the ovoids. All plans were calculated in order to deliver 4.5 Gy to point A regardless of the actual dose delivered in the treatment. Rectum DVH values (D0.1cc,D1cc, D2cc and, D5cc) were extracted and expressed as the dose percentage related to point A dose. a regression analysis was carried out. Variables analysed included: age, body mass index (BMI) and rectal volume. Results: Mean rectal volume was 49.7cc. Mean rectal dose metric parameters (expressed as a percentage of the prescribed dose) were: D01cc, 78.4%; D1cc, 62.6%; D2cc,55.9%; D5cc, 45.9%. Mean age, 52 years. Mean BMI, 29.9. Only rectal volume reached significance on regression analysis, explaining from 14% to 23% of the variance (p values, 0.0343, 0.0105, 0.0049 and, 0.001 for D01cc, D1cc, D2cc and, D5ccrespectively. Fig 1).