- Email: [email protected]
Intensity Modulated Radiotherapy for Adenocarcinoma of the Pancreas
I. J. Radiation Oncology d Biology d Physics
S272
Volume 75, Number 3, Supplement, 2009
Results: Fifty-seven patients with esophageal cancer underwent F18-FDG PET scans as part of their initial staging and post-radiation restaging workups, followed by esophagectomy. The pathologic complete response (pCR) rate was 25%. The presence of a focal component on post CRT PET predicted residual disease on univariate analysis (86% vs 64%), with a trend towards statistical significance (p = 0.07). This trend achieved significance when controlling for SUV and presence of diabetes on MVA (OR = 5.59, p = 0.028). There was no statistically significant relationship between pre or post CRT SUV, tumor histology, or length of increased F18-FDG uptake and presence of residual disease. SUV and focality did not interact significantly to predict the presence of residual disease. Conclusions: Qualitative PET imaging can be used to predict for increased likelihood of residual tumor in esophageal cancer patients following chemoradiation, however it is not sensitive enough to rule out the presence of residual disease. Author Disclosure: T.L. Klayton, None; T. Li, None; J.Q. Yu, None; J.D. Cheng, None; S.J. Cohen, None; N.J. Meropol, None; W.J. Scott, None; M. Xu-Welliver, None; A.A. Konski, None.
2202
WITHDRAWN
2203
Differences between Planned and Delivered Bowel Dose in Tomotherapy for Hepatocellular Carcinoma Patients
S. Lee, J. Kim, J. Cho, J. Kim, K. Jeong, Y. Kim, I. Lee, J. Seong Yonsei University Health System, Seoul, Republic Of Korea Purpose/Objective(s): To evaluate changes of delivered bowel dose due to organ movement during tomotherapy for hepatocellular carcinoma. Materials/Methods: We selected hepatocellular carcinoma patient whose tumor was located in segment V and VI. Fifty-one Gy in 20 fractions was prescribed to the high-risk planning target volume by Tomotherapy Hi-Art planning system (Wisconsin, USA). The organ at risk volume containing stomach, duodenum and small bowel at levels between upper margin of the first lumbar vertebrate and the lower margin of the third lumbar vertebrate was defined as a bowel region. After each treatment session, mega-voltage computed tomography (MVCT) images were fused with the planning CT images and a bowel region was contoured and compared with the initial bowel region. Congruity between bowel regions for 20 treatment sessions were analyzed(co-volume^2/ (volume 1 * volume 2). Using adaptive planning software from the Tomotherapy planning system, verification doses to bowel regions were analyzed, and high-dose volume (1.82.7 Gy/fr), mid-dose volume (1.01.8 Gy/fr) and low-dose volume (01.0 Gy/ fr) were defined. Results: The mean value of congruity between bowel region from the planning CT and bowel regions from MVCT was 88.99 ± 5.5%. Assessment of differences between planned and delivered bowel dose resulted in high-dose, mid-dose and low-dose volumes of 7.75 ± 4.45%, 2.91 ± 1.4% and 9.85 ± 3.43%, respectively. High-dose, mid-dose, low-dose volumes seemed to correspond to peri-hepatic, para-vertebral and peri-splenic bowel regions, repectively. Large discrepancy in the high-dose volume may have resulted from motion of GTV in the liver, while diaphragmatic movement and peristalsis in the peri-splenic free space may have contributed to discrepancy in the low-dose volume. Conclusions: The changes of delivered bowel dose due to organ movement for hepatocellular carcinoma were substantial at Highdose and Low-dose volume area. Helical tomotherapy, MVCT, Adaptive radiotherapy, Hepatoma, Organ motion. Author Disclosure: S. lee, None; J. kim, None; J. cho, None; J. kim, None; K. jeong, None; Y. kim, None; I. lee, None; J. seong, None.
2204
Intensity Modulated Radiotherapy for Adenocarcinoma of the Pancreas
J. A. Abelson, G. A. Fisher, J. M. Ford, P. Kunz, J. A. Norton, B. Visser, A. C. Koong, D. T. Chang Stanford Medical Cancer Center, Stanford, CA Purpose/Objective(s): To report the outcome using intensity modulated radiotherapy (IMRT) for pancreas adenocarcinoma. Materials/Methods: Fifty patients with adenocarcinoma of the pancreas were treated with IMRT from 2003 to 2008 at Stanford University. Thirty patients were treated adjuvantly, and 20 patients were treated for locally advanced disease. All patients received concurrent 5-FU chemotherapy. Median follow up was 17.8 months (range 5.3 - 66.0) among resectable and 6.8 months (range 2.5 - 20.7) among unresectable patients. Of patients who underwent resection, 57% had positive margins and 73% had positive lymph nodes. Treatment plans were optimized such that 95% of the planning target volume (PTV) received the prescription dose. The median delivered dose for adjuvant patients was 50.2 Gy (range 18.0 - 55.8), and for locally advanced patients, it was 54.0 Gy (range 18.0 - 59.4). Respiratory gating was utilized in 33% of resectable and 25% of unresectable patients. For the duodenum, the median mean dose was 38.1 Gy and median volume that received $45 Gy (V45) was 36.1%. Small bowel within 3 cm of the PTV median mean dose was 33.7 Gy and median V45 was 18.4%. Stomach median mean dose was 17.5 Gy and median V45 was 0.4%. Left and right kidney median V20 were 13.4% and 14.9% respectively. Liver median V30 was 10.4%. Spinal cord median maximum dose was 36.2 Gy. Results: Median age at diagnosis was 63.7 yrs (range 45 - 82 yrs). At last follow-up, all unresectable patients died, and of resectable patients, 21 died. For adjuvant patients, the 1 and 2 year overall survival (OS) was 80% and 42%, respectively. The 1-year and 2year recurrence free survival (RFS) was 59% and 20%, respectively. The OS at 1 and 2 years for positive margins was 71% and 31% versus 92% and 56% for negative/close margins (p-value = 0.37). Locoregional RFS at 1 and 2 years was 92% and 74%, respectively. For unresectable patients, 1 year OS, RFS, and locoregional RFS were 21%, 14% and 39%, respectively. One patient experienced paralytic ileus/ radiation enteritis and died. Four patients developed Grade 3 acute toxicity, including biliary stent blockage, pancreatitis requiring surgery, cholangitis, and small bowel obstruction requiring surgery. Four patients ended treatment early. Four patients developed Grade 3 late toxicity, including perforation of a stented common bile duct, two biliary strictures requiring drain placement, and small bowel obstruction requiring stent.
Proceedings of the 51st Annual ASTRO Meeting Conclusions: IMRT for pancreatic cancer is effective, well tolerated, and provides excellent sparing of adjacent critical organs, making dose escalation feasible. Author Disclosure: J.A. Abelson, None; G.A. Fisher, None; J.M. Ford, None; P. Kunz, None; J.A. Norton, None; B. Visser, None; A.C. Koong, None; D.T. Chang, None.
2205
Cardiac Contouring for the Assessment of Cardiac Toxicity after Chemoradiotherapy for Patients with Esophageal Cancer
T. Hashimoto, H. Asakura, A. Kanemoto, S. Kubota, H. Ogawa, H. Harada, K. Furutani, H. Fuji, S. Murayama, T. Nishimura Shizuoka Cancer Center Hospital, Nagaizumi, Japan Purpose/Objective(s): The clinical significance of long-term cardiac or pulmonary toxicity secondary to chemoradiotherapy for patients with esophageal cancer has been increasing. For radiotherapeutic management of esophageal cancer patients, it is prudent to delineate the lung or the heart precisely and reduce radiation exposure as much as possible in radiation treatment planning (RTP). There is little difficulty in contouring the lung, whereas contouring the heart is ambiguous and time-consuming work because there is no standard definition of the cardiac contour until now. We report on the contour of the heart in RTP to assess the risk of late cardiac toxicities in esophageal cancer patients treated with chemoradiotherapy. Materials/Methods: Between September 2002 and December 2004, 37 patients with squamous cell carcinoma of the thoracic esophagus received definitive radiotherapy and chemotherapy with 5-fluorouracil and cisplatin and followed-up at least one year. Typically, radiotherapy was delivered with 40 Gy in 20 fractions using anterior-posterior opposed fields, followed by bilateral oblique fields to a total dose of 60 Gy. All patients underwent three-dimensional RTP. We defined two ways of contouring the heart and compared: (A) the entire myocardium and the interior chambers (left and right atriums and ventricles) and the pulmonary trunk, ascending aorta, and root of the superior and inferior vena cava were included, but bilateral pulmonary arteries and veins, and pericardial fat were excluded from the heart volume; (B) under the level of the caudal border of the right pulmonary artery to the apex of (A). Mean heart dose (MHD) was calculated using dose-volume histogram analysis, and relationship between MHD and incidence of Grade 3# cardiac toxicities were evaluated for each way of cardiac contouring. Results: Ninety-two percent (34/37) of patients had middle or lower thoracic esophageal cancer, and 65% (24/37) had stage III or IV cancers. The median follow-up period was 38 (13-69) months. Of them, Grade 3# cardiac toxicity were observed in 10 (27%) patients. Median MHD was 3755 (312-5273) cGy in (A), and 3663 (26-5222) cGy in (B), respectively. Incidences of Grade 3# cardiac toxicity were 50% (8/16) and 54% (7/13) in patients with a MHD of $40 Gy in (A) and (B), respectively. By univariate analysis, MHD of $40 Gy were found to be significantly associated with Grade 3# cardiac toxicity in each way of cardiac contouring (p = 0.009, and p = 0.017, respectively). Conclusions: As the range of the contour of the heart for the assessment of the risk of cardiac toxicities, the contouring from the caudal border of the right pulmonary artery to the apex as well as from the ascending aorta to the apex could be useful in RTP for esophageal cancer patients treated with chemoradiotherapy. Author Disclosure: T. Hashimoto, None; H. Asakura, None; A. Kanemoto, None; S. Kubota, None; H. Ogawa, None; H. Harada, None; K. Furutani, None; H. Fuji, None; S. Murayama, None; T. Nishimura, None.
2206
Neo-adjuvant Chemotherapy versus Neo-adjuvant Chemoradiation Therapy followed by Esophagectomy versus Definitive Chemoradiation Therapy in Management of Locally-advanced Esophageal Carcinoma: A Single Institution Experience
S. G. DeFoe, A. Pennathur, J. C. Flickinger, D. E. Heron, M. K. Gibson, J. D. Luketich, J. S. Greenberger University of Pittsburgh Medical Center, Pittsburgh, PA Purpose/Objective(s): Management of locally-advanced esophageal cancer is controversial. Treatment options include neoadjuvant chemotherapy or chemoradiation (CRT) followed by definitive surgery or definitive chemoradiation. A single-center experience was reviewed to determine which treatment practices could predict survival and recurrence. Materials/Methods: Records of patients with adenocarcinoma or squamous cell carcinoma of the esophagus treated between the January 1992 and December 2004 were retrospectively reviewed. Univariate and Multivariate analyses were performed using logrank and Cox proportional hazards models and survival curves were estimated using Kaplan-Meier method. Results: Of the 100 patients with invasive cancer, 22 underwent preoperative chemotherapy, 49 preoperative CRT and 18 definitive CRT. The average age was 62.1 years, most patients were male (84%). Fifty-two percent of patients were staged with endoscopic ultrasound (EUS). Majority of patients underwent minimally invasive esophagectomy (MIE) (74%). Median overall survival of the entire group was 23.8 months and 2-year overall survival was 47.9%. Patients who underwent preoperative chemotherapy or preoperative CRT had 5-year survivals of 18% compared to 0% for definitive CRT patients, p = 0.058. Patients who received preoperative CRT were more likely to have a pathologic complete response (pCR) compared to patients who had preoperative chemotherapy, 20% versus 0% p = 0.04. The 3-year overall survival of these patients was 63%. The dose of radiation did not influence survival, time-to-disease progression or local progression-free survival. Conclusions: No significant difference seen in overall survival and failure pattern between the three treatment modalities however, patients who received preoperative CRT were more likely to have a pCR and thus are more likely to benefit from curative surgery. Author Disclosure: S.G. DeFoe, None; A. Pennathur, None; J.C. Flickinger, None; D.E. Heron, None; M.K. Gibson, None; J.D. Luketich, None; J.S. Greenberger, None.
S273
S272
Volume 75, Number 3, Supplement, 2009
Results: Fifty-seven patients with esophageal cancer underwent F18-FDG PET scans as part of their initial staging and post-radiation restaging workups, followed by esophagectomy. The pathologic complete response (pCR) rate was 25%. The presence of a focal component on post CRT PET predicted residual disease on univariate analysis (86% vs 64%), with a trend towards statistical significance (p = 0.07). This trend achieved significance when controlling for SUV and presence of diabetes on MVA (OR = 5.59, p = 0.028). There was no statistically significant relationship between pre or post CRT SUV, tumor histology, or length of increased F18-FDG uptake and presence of residual disease. SUV and focality did not interact significantly to predict the presence of residual disease. Conclusions: Qualitative PET imaging can be used to predict for increased likelihood of residual tumor in esophageal cancer patients following chemoradiation, however it is not sensitive enough to rule out the presence of residual disease. Author Disclosure: T.L. Klayton, None; T. Li, None; J.Q. Yu, None; J.D. Cheng, None; S.J. Cohen, None; N.J. Meropol, None; W.J. Scott, None; M. Xu-Welliver, None; A.A. Konski, None.
2202
WITHDRAWN
2203
Differences between Planned and Delivered Bowel Dose in Tomotherapy for Hepatocellular Carcinoma Patients
S. Lee, J. Kim, J. Cho, J. Kim, K. Jeong, Y. Kim, I. Lee, J. Seong Yonsei University Health System, Seoul, Republic Of Korea Purpose/Objective(s): To evaluate changes of delivered bowel dose due to organ movement during tomotherapy for hepatocellular carcinoma. Materials/Methods: We selected hepatocellular carcinoma patient whose tumor was located in segment V and VI. Fifty-one Gy in 20 fractions was prescribed to the high-risk planning target volume by Tomotherapy Hi-Art planning system (Wisconsin, USA). The organ at risk volume containing stomach, duodenum and small bowel at levels between upper margin of the first lumbar vertebrate and the lower margin of the third lumbar vertebrate was defined as a bowel region. After each treatment session, mega-voltage computed tomography (MVCT) images were fused with the planning CT images and a bowel region was contoured and compared with the initial bowel region. Congruity between bowel regions for 20 treatment sessions were analyzed(co-volume^2/ (volume 1 * volume 2). Using adaptive planning software from the Tomotherapy planning system, verification doses to bowel regions were analyzed, and high-dose volume (1.82.7 Gy/fr), mid-dose volume (1.01.8 Gy/fr) and low-dose volume (01.0 Gy/ fr) were defined. Results: The mean value of congruity between bowel region from the planning CT and bowel regions from MVCT was 88.99 ± 5.5%. Assessment of differences between planned and delivered bowel dose resulted in high-dose, mid-dose and low-dose volumes of 7.75 ± 4.45%, 2.91 ± 1.4% and 9.85 ± 3.43%, respectively. High-dose, mid-dose, low-dose volumes seemed to correspond to peri-hepatic, para-vertebral and peri-splenic bowel regions, repectively. Large discrepancy in the high-dose volume may have resulted from motion of GTV in the liver, while diaphragmatic movement and peristalsis in the peri-splenic free space may have contributed to discrepancy in the low-dose volume. Conclusions: The changes of delivered bowel dose due to organ movement for hepatocellular carcinoma were substantial at Highdose and Low-dose volume area. Helical tomotherapy, MVCT, Adaptive radiotherapy, Hepatoma, Organ motion. Author Disclosure: S. lee, None; J. kim, None; J. cho, None; J. kim, None; K. jeong, None; Y. kim, None; I. lee, None; J. seong, None.
2204
Intensity Modulated Radiotherapy for Adenocarcinoma of the Pancreas
J. A. Abelson, G. A. Fisher, J. M. Ford, P. Kunz, J. A. Norton, B. Visser, A. C. Koong, D. T. Chang Stanford Medical Cancer Center, Stanford, CA Purpose/Objective(s): To report the outcome using intensity modulated radiotherapy (IMRT) for pancreas adenocarcinoma. Materials/Methods: Fifty patients with adenocarcinoma of the pancreas were treated with IMRT from 2003 to 2008 at Stanford University. Thirty patients were treated adjuvantly, and 20 patients were treated for locally advanced disease. All patients received concurrent 5-FU chemotherapy. Median follow up was 17.8 months (range 5.3 - 66.0) among resectable and 6.8 months (range 2.5 - 20.7) among unresectable patients. Of patients who underwent resection, 57% had positive margins and 73% had positive lymph nodes. Treatment plans were optimized such that 95% of the planning target volume (PTV) received the prescription dose. The median delivered dose for adjuvant patients was 50.2 Gy (range 18.0 - 55.8), and for locally advanced patients, it was 54.0 Gy (range 18.0 - 59.4). Respiratory gating was utilized in 33% of resectable and 25% of unresectable patients. For the duodenum, the median mean dose was 38.1 Gy and median volume that received $45 Gy (V45) was 36.1%. Small bowel within 3 cm of the PTV median mean dose was 33.7 Gy and median V45 was 18.4%. Stomach median mean dose was 17.5 Gy and median V45 was 0.4%. Left and right kidney median V20 were 13.4% and 14.9% respectively. Liver median V30 was 10.4%. Spinal cord median maximum dose was 36.2 Gy. Results: Median age at diagnosis was 63.7 yrs (range 45 - 82 yrs). At last follow-up, all unresectable patients died, and of resectable patients, 21 died. For adjuvant patients, the 1 and 2 year overall survival (OS) was 80% and 42%, respectively. The 1-year and 2year recurrence free survival (RFS) was 59% and 20%, respectively. The OS at 1 and 2 years for positive margins was 71% and 31% versus 92% and 56% for negative/close margins (p-value = 0.37). Locoregional RFS at 1 and 2 years was 92% and 74%, respectively. For unresectable patients, 1 year OS, RFS, and locoregional RFS were 21%, 14% and 39%, respectively. One patient experienced paralytic ileus/ radiation enteritis and died. Four patients developed Grade 3 acute toxicity, including biliary stent blockage, pancreatitis requiring surgery, cholangitis, and small bowel obstruction requiring surgery. Four patients ended treatment early. Four patients developed Grade 3 late toxicity, including perforation of a stented common bile duct, two biliary strictures requiring drain placement, and small bowel obstruction requiring stent.
Proceedings of the 51st Annual ASTRO Meeting Conclusions: IMRT for pancreatic cancer is effective, well tolerated, and provides excellent sparing of adjacent critical organs, making dose escalation feasible. Author Disclosure: J.A. Abelson, None; G.A. Fisher, None; J.M. Ford, None; P. Kunz, None; J.A. Norton, None; B. Visser, None; A.C. Koong, None; D.T. Chang, None.
2205
Cardiac Contouring for the Assessment of Cardiac Toxicity after Chemoradiotherapy for Patients with Esophageal Cancer
T. Hashimoto, H. Asakura, A. Kanemoto, S. Kubota, H. Ogawa, H. Harada, K. Furutani, H. Fuji, S. Murayama, T. Nishimura Shizuoka Cancer Center Hospital, Nagaizumi, Japan Purpose/Objective(s): The clinical significance of long-term cardiac or pulmonary toxicity secondary to chemoradiotherapy for patients with esophageal cancer has been increasing. For radiotherapeutic management of esophageal cancer patients, it is prudent to delineate the lung or the heart precisely and reduce radiation exposure as much as possible in radiation treatment planning (RTP). There is little difficulty in contouring the lung, whereas contouring the heart is ambiguous and time-consuming work because there is no standard definition of the cardiac contour until now. We report on the contour of the heart in RTP to assess the risk of late cardiac toxicities in esophageal cancer patients treated with chemoradiotherapy. Materials/Methods: Between September 2002 and December 2004, 37 patients with squamous cell carcinoma of the thoracic esophagus received definitive radiotherapy and chemotherapy with 5-fluorouracil and cisplatin and followed-up at least one year. Typically, radiotherapy was delivered with 40 Gy in 20 fractions using anterior-posterior opposed fields, followed by bilateral oblique fields to a total dose of 60 Gy. All patients underwent three-dimensional RTP. We defined two ways of contouring the heart and compared: (A) the entire myocardium and the interior chambers (left and right atriums and ventricles) and the pulmonary trunk, ascending aorta, and root of the superior and inferior vena cava were included, but bilateral pulmonary arteries and veins, and pericardial fat were excluded from the heart volume; (B) under the level of the caudal border of the right pulmonary artery to the apex of (A). Mean heart dose (MHD) was calculated using dose-volume histogram analysis, and relationship between MHD and incidence of Grade 3# cardiac toxicities were evaluated for each way of cardiac contouring. Results: Ninety-two percent (34/37) of patients had middle or lower thoracic esophageal cancer, and 65% (24/37) had stage III or IV cancers. The median follow-up period was 38 (13-69) months. Of them, Grade 3# cardiac toxicity were observed in 10 (27%) patients. Median MHD was 3755 (312-5273) cGy in (A), and 3663 (26-5222) cGy in (B), respectively. Incidences of Grade 3# cardiac toxicity were 50% (8/16) and 54% (7/13) in patients with a MHD of $40 Gy in (A) and (B), respectively. By univariate analysis, MHD of $40 Gy were found to be significantly associated with Grade 3# cardiac toxicity in each way of cardiac contouring (p = 0.009, and p = 0.017, respectively). Conclusions: As the range of the contour of the heart for the assessment of the risk of cardiac toxicities, the contouring from the caudal border of the right pulmonary artery to the apex as well as from the ascending aorta to the apex could be useful in RTP for esophageal cancer patients treated with chemoradiotherapy. Author Disclosure: T. Hashimoto, None; H. Asakura, None; A. Kanemoto, None; S. Kubota, None; H. Ogawa, None; H. Harada, None; K. Furutani, None; H. Fuji, None; S. Murayama, None; T. Nishimura, None.
2206
Neo-adjuvant Chemotherapy versus Neo-adjuvant Chemoradiation Therapy followed by Esophagectomy versus Definitive Chemoradiation Therapy in Management of Locally-advanced Esophageal Carcinoma: A Single Institution Experience
S. G. DeFoe, A. Pennathur, J. C. Flickinger, D. E. Heron, M. K. Gibson, J. D. Luketich, J. S. Greenberger University of Pittsburgh Medical Center, Pittsburgh, PA Purpose/Objective(s): Management of locally-advanced esophageal cancer is controversial. Treatment options include neoadjuvant chemotherapy or chemoradiation (CRT) followed by definitive surgery or definitive chemoradiation. A single-center experience was reviewed to determine which treatment practices could predict survival and recurrence. Materials/Methods: Records of patients with adenocarcinoma or squamous cell carcinoma of the esophagus treated between the January 1992 and December 2004 were retrospectively reviewed. Univariate and Multivariate analyses were performed using logrank and Cox proportional hazards models and survival curves were estimated using Kaplan-Meier method. Results: Of the 100 patients with invasive cancer, 22 underwent preoperative chemotherapy, 49 preoperative CRT and 18 definitive CRT. The average age was 62.1 years, most patients were male (84%). Fifty-two percent of patients were staged with endoscopic ultrasound (EUS). Majority of patients underwent minimally invasive esophagectomy (MIE) (74%). Median overall survival of the entire group was 23.8 months and 2-year overall survival was 47.9%. Patients who underwent preoperative chemotherapy or preoperative CRT had 5-year survivals of 18% compared to 0% for definitive CRT patients, p = 0.058. Patients who received preoperative CRT were more likely to have a pathologic complete response (pCR) compared to patients who had preoperative chemotherapy, 20% versus 0% p = 0.04. The 3-year overall survival of these patients was 63%. The dose of radiation did not influence survival, time-to-disease progression or local progression-free survival. Conclusions: No significant difference seen in overall survival and failure pattern between the three treatment modalities however, patients who received preoperative CRT were more likely to have a pCR and thus are more likely to benefit from curative surgery. Author Disclosure: S.G. DeFoe, None; A. Pennathur, None; J.C. Flickinger, None; D.E. Heron, None; M.K. Gibson, None; J.D. Luketich, None; J.S. Greenberger, None.
S273