- Email: [email protected]
paclitaxel chemotherapy for epithelial ovarian cancer
CARO 2002 - Innovative Technology in Radiation Medicine
25-27 October 2002 $3
one was neoplasia-related. Hematological toxicity was due mainly to anemia and leucopenia and predominantly of grade 1-2 (18 patients vs. 7 patients with grade 3-4) Ten patients had nephrotoxicity (grade 1) and none had oto- or neurotoxicity. Grade 1-2 nausea and vomitting was seen in 17 patients with no cases of grade 3-4 toxicity. Conclusion: Concomitant weekly low-dose (40 mg/m2)cisplatin with radiotherapy for squamous cell carcinoma of the head and neck shows an excellent response rate (CR 93%). The incidence of high grade (>3) toxicity is lower than that seen with standard regimens of concurrent cisplatin. These promising results would be of particular interest for patients whose performance status would preclude a full compliance to a higher dose regimen. Data will be updated for the meeting.
pareunia. The 2-year actuarial disease-free survival was 66%, and overall survival was 96% Conclusion: APRT is a safe adjuvant treatment for carefully selected patients with ovarian cancer and does not significantly increase the risk of long-term treatment complications. Consolidative APRT following cytoreductive surgery and chemotherapy warrants further investigation for patients who are at moderate to high risk of abdominal recurrence.
lO THE VALUE OF RE-STAGING INVESTIGATIONS IN ADJUVANT AND SALVAGE RADIOTHERAPY FOR CLINICALLY LOCALIZED PROSTATE CANCER
Lallv. BE.. Yue, N., Fischer, DB., Kimmett, J., Picone, J., Knisely, JPS. Yale Cancer Center, Yale University, New Haven, CT, USA
Dinniwe//. R.. Lock, M., F/eshner, N., Lob/aw, D.A. Toronto-Sunnybrook Regiona/ Cancer Centre, University of Toronto, Toronto, ON, Canada Purpose: To evaluate the frequency and utility of re-staging investigations in adjuvant and salvage radiotherapy (RT) after radical prostatectomy (RP) for clinically localized prostate cancer. Methods and Materials: Between April 2000 and May 2001, 101 hormonally naive and node negative patients were referred to the Toronto Sunnybrook Regional Cancer Centre for radiotherapy consultation for either adjuvant or salvage radiotherapy. The frequencies of false positive (FP) and true positive (TP) results of the re-staging chest x-rays (CXR), computed tomography (CT) scans and bone scans are reported. Results: Seventy patients were referred with positive margins and 30 had a rising PSA post RP. One patient had negative margins but a detectable PSA post-op. Patient age ranged from 45.8 - 77.1 years (mean 64.4 y). The median specimen Gteason score was 7 and the mean pre-op PSA was 10.9 ng/ml. At the time of re-staging, the mean PSA was 0.52 ng/ml (range 0 5.2 ng/ml). Re-staging investigations were performed in the majority of referred patients. Fifty-one CXRs were performed and 2 FPs (4%) occurred. Significant findings were apparent in 7/42 patients who had a CT abdomen/pelvis performed: 1 CT was indeterminate (2.4%) and of the 6 .FPs (14.3%), two incidental malignancies were diagnosed. Nine of the 63 bone scans performed had positive findings; 8 FPs (12.7% - 1 positive for bone metastases from a synchronous lung primary) and I TP (1.6%). Overall, in the 156 re-staging studies, there were 1 TP (0.6%), 16 FPs (11.5%) and 139 negative studies (87.9%). Three (1.9%) incidental tumors were found. The patient with a TP scan had a pT2, G7, tumor with negative margins a post-op PSA = 0.9 ng/ml and relapse PSA = 1.96 ng/ml. Conclusion In our experience, re-staging investigations are of limited utility in the setting of adjuvant and salvage RT for prostate cancer. 11 ABDOMINO-PELVIC RADIOTHERAPY (APRT) FOLLOWING SURGERY AND CARBOPLATIN/PACLITAXEL CHEMOTHERAPY FOR EPITHELIAL OVARIAN CANCER
Dinniwell. R., Lock, M., Fyles, A., Levin, W., Manchu/, L., Pintilie, M., Rosen, B., Sturgeon, J, Oza, A., Milosevic, M. Princess Margaret Hospital University of Toronto, Toronto, ON, Canada Purpose: To assess the feasibility of APRT following cytoreductive surgery and 6 cycles of carboplatin/paclitaxel chemotherapy in ovarian cancer. Methods and Materials: Between 1997 and 2001, 34 patients were treated with TAH-BSO and surgical staging, chemotherapy, and APRT as part of a prospective treatment protocol. There were 12 FIGO stage 1, 11 stage 2, and 11 stage 3 tumors. Grade was not recorded for I tumor and there were 2 grade 1 tumors, 13 grade 2 tumors, and 18 grade 3 tumors. Visible residual tumor in the abdomen was present at the completion of surgery in 7 patients, 3 of whom also had residual pelvic disease. The median abdominal dose was 2300 cGy in 23 daily fractions, and the pelvic dose was 4500 cGy in 30 fractions. Results: Most patients experienced RTOG Grade I or 2 nausea and/or diarrhea during APRT that responded to medication. One patient developed nausea and vomiting that was refractory to anti-emetics, and another severe diarrhea There were 3 cases of Grade 3 neutropenia, and 3 cases of" Grade 3-4 thrombocytopenia. Unplanned breaks in APRT were necessary in 8 patients (9.7%). APRT was abandoned prematurely in 3 patients: in 2 because of low blood counts and in the third at the patient's request. Late toxicity occurred in 4 patients. There was 1 small bowel obstruction which resolved with conservative management. Symptomatic sacral insufficiency fractures occurred in 2 cases, and there was 1 case of severe dys-
12 ACCURATE AND LABOR EFFICIENT TUMOR LOCALIZATION AND FAILURE ANALYSIS FOR PATIENTS WITH HIGH-GRADE GLIOMAS UTILIZING AN AUTOMATED MUTUAL-INFORMATION BASED IMAGE FUSION PROGRAM
This analysis was performed to determine how failure patterns were impacted by an image fusion program (IFP) developed at our institution based on mutual information principles that improved target definition for patients with high-grade gliomas who were treated with 3-D conformal radiotherapy (3DCRT). Between 1/1998 and 9/2001, 47 consecutive patients with high-grade gliomas were treated with 3DCRT. For treatment planning, a peri-surgical MRI was automatically fused with a treatment planning CT. GTVs were determined directly from the T2 and TIC weighted reformatted MR scans. The initial PTV was the T2 weighted GTV with a margin of 2 cm except where anatomic barriers to spread existed. For conedowns, the PTV included the TIC weighted GTV and 1.5-2 cm margins, or less depending on the proximity of radiosensitive structures. The patients were then followed to determine the time of local failure and overall survival. The MR images at the time of failure were then fused with the original treatment planning CT, so that the original plan could be superimposed upon that MR. This allowed us to determine the minimum isodose curve encompassing the failure site. As of 3/2002, the one year overall survival was 81%. The median disease free survival was 13.1 months. 23/47 patients had disease progression; 19/23 patients had follow-up imaging available for image registration. Fifteen patients failed within the volume encompassed by the 90% isodose surface. One patient failed within the 80% isodose surface volume. Two patients failed within the 90% isodose surface volume and also failed in the contraiateral hemisphere or spine. One patient failed only in the contralateral hemisphere. In conclusion, our results show that our IFP can accurately define the area at highest risk for tumor recurrence in patients with high-grade glioma. Analysis of failure patterns is also facilitated with IFP. 13 DETERMINATION OF PROSTATE MOTION AND TREATMENT SET UP ERROR BY FIDUCIAL MARKERS DURING CONFORMAL PROSTATE IRRADIATION Kerba. M.. Wu, JSY., Pate/, M., Corbett, T., Poon, I., Ostapiak, O., Chan,
J., Russell, D., Cosman, C., Sathya, J., Lukka, H. Hamilton Regional Cancer Centre, McMaster University, Hamilton, ON, Canada Purpose: To quantity the degree of prostate motion, isocentre set up variability, total positioning error (TPE) and potential geographic miss associated with the introduction of a new conformal radiotherapy technique at a single institution. Methods: 20 patients with localized prostate cancer had TRUS-guided insertion of 3 gold seeds (basal, mid, apical) into the prostate prior to CT treatment planning. PTV was obtained by 10mm volumetric expansion of contoured prostate gland. Patients were treated supine with empty bladder, ankles strapped, with no pelvic immobilization nor regimented bowel instructions, to total isocentre dose of 74 Gy/37 fractions/7.5 weeks using 6field MLC beam arrangement on 18 MV. Kodak ECL-TM portal films were taken from the right lateral port on days 1,3,5,7 and weekly thereafter. Isocentre variability and prostate motion were measured using pelvic bony landmarks as reference. TPE was measured for each gold seed. Results (Preliminary): 163 portal films on 15 patients have been analysed. 7/15 patients had mean isocentre error of > 2mm (range 2.2-3.4mm). Prostate base motion, determined as an average of the standard deviations (SD) of basal seed locations, was 2.4mm in the ant-post direction, and 1.8mm in the sup-inf direction. The averaged SD of basal seed TPE was 3.1mm in the ant-post direction, and 1.9mm in the sup-inf direction. The average TPE of basal seed measured on the first 3 portal films correlated well with the overall average TPE (r = 0.90, p 8.5mm in any direction for any seed, was evident in 9/163 films. Significant changes in rectal filling were noticed in two of six patients demonstrating geographic miss.
25-27 October 2002 $3
one was neoplasia-related. Hematological toxicity was due mainly to anemia and leucopenia and predominantly of grade 1-2 (18 patients vs. 7 patients with grade 3-4) Ten patients had nephrotoxicity (grade 1) and none had oto- or neurotoxicity. Grade 1-2 nausea and vomitting was seen in 17 patients with no cases of grade 3-4 toxicity. Conclusion: Concomitant weekly low-dose (40 mg/m2)cisplatin with radiotherapy for squamous cell carcinoma of the head and neck shows an excellent response rate (CR 93%). The incidence of high grade (>3) toxicity is lower than that seen with standard regimens of concurrent cisplatin. These promising results would be of particular interest for patients whose performance status would preclude a full compliance to a higher dose regimen. Data will be updated for the meeting.
pareunia. The 2-year actuarial disease-free survival was 66%, and overall survival was 96% Conclusion: APRT is a safe adjuvant treatment for carefully selected patients with ovarian cancer and does not significantly increase the risk of long-term treatment complications. Consolidative APRT following cytoreductive surgery and chemotherapy warrants further investigation for patients who are at moderate to high risk of abdominal recurrence.
lO THE VALUE OF RE-STAGING INVESTIGATIONS IN ADJUVANT AND SALVAGE RADIOTHERAPY FOR CLINICALLY LOCALIZED PROSTATE CANCER
Lallv. BE.. Yue, N., Fischer, DB., Kimmett, J., Picone, J., Knisely, JPS. Yale Cancer Center, Yale University, New Haven, CT, USA
Dinniwe//. R.. Lock, M., F/eshner, N., Lob/aw, D.A. Toronto-Sunnybrook Regiona/ Cancer Centre, University of Toronto, Toronto, ON, Canada Purpose: To evaluate the frequency and utility of re-staging investigations in adjuvant and salvage radiotherapy (RT) after radical prostatectomy (RP) for clinically localized prostate cancer. Methods and Materials: Between April 2000 and May 2001, 101 hormonally naive and node negative patients were referred to the Toronto Sunnybrook Regional Cancer Centre for radiotherapy consultation for either adjuvant or salvage radiotherapy. The frequencies of false positive (FP) and true positive (TP) results of the re-staging chest x-rays (CXR), computed tomography (CT) scans and bone scans are reported. Results: Seventy patients were referred with positive margins and 30 had a rising PSA post RP. One patient had negative margins but a detectable PSA post-op. Patient age ranged from 45.8 - 77.1 years (mean 64.4 y). The median specimen Gteason score was 7 and the mean pre-op PSA was 10.9 ng/ml. At the time of re-staging, the mean PSA was 0.52 ng/ml (range 0 5.2 ng/ml). Re-staging investigations were performed in the majority of referred patients. Fifty-one CXRs were performed and 2 FPs (4%) occurred. Significant findings were apparent in 7/42 patients who had a CT abdomen/pelvis performed: 1 CT was indeterminate (2.4%) and of the 6 .FPs (14.3%), two incidental malignancies were diagnosed. Nine of the 63 bone scans performed had positive findings; 8 FPs (12.7% - 1 positive for bone metastases from a synchronous lung primary) and I TP (1.6%). Overall, in the 156 re-staging studies, there were 1 TP (0.6%), 16 FPs (11.5%) and 139 negative studies (87.9%). Three (1.9%) incidental tumors were found. The patient with a TP scan had a pT2, G7, tumor with negative margins a post-op PSA = 0.9 ng/ml and relapse PSA = 1.96 ng/ml. Conclusion In our experience, re-staging investigations are of limited utility in the setting of adjuvant and salvage RT for prostate cancer. 11 ABDOMINO-PELVIC RADIOTHERAPY (APRT) FOLLOWING SURGERY AND CARBOPLATIN/PACLITAXEL CHEMOTHERAPY FOR EPITHELIAL OVARIAN CANCER
Dinniwell. R., Lock, M., Fyles, A., Levin, W., Manchu/, L., Pintilie, M., Rosen, B., Sturgeon, J, Oza, A., Milosevic, M. Princess Margaret Hospital University of Toronto, Toronto, ON, Canada Purpose: To assess the feasibility of APRT following cytoreductive surgery and 6 cycles of carboplatin/paclitaxel chemotherapy in ovarian cancer. Methods and Materials: Between 1997 and 2001, 34 patients were treated with TAH-BSO and surgical staging, chemotherapy, and APRT as part of a prospective treatment protocol. There were 12 FIGO stage 1, 11 stage 2, and 11 stage 3 tumors. Grade was not recorded for I tumor and there were 2 grade 1 tumors, 13 grade 2 tumors, and 18 grade 3 tumors. Visible residual tumor in the abdomen was present at the completion of surgery in 7 patients, 3 of whom also had residual pelvic disease. The median abdominal dose was 2300 cGy in 23 daily fractions, and the pelvic dose was 4500 cGy in 30 fractions. Results: Most patients experienced RTOG Grade I or 2 nausea and/or diarrhea during APRT that responded to medication. One patient developed nausea and vomiting that was refractory to anti-emetics, and another severe diarrhea There were 3 cases of Grade 3 neutropenia, and 3 cases of" Grade 3-4 thrombocytopenia. Unplanned breaks in APRT were necessary in 8 patients (9.7%). APRT was abandoned prematurely in 3 patients: in 2 because of low blood counts and in the third at the patient's request. Late toxicity occurred in 4 patients. There was 1 small bowel obstruction which resolved with conservative management. Symptomatic sacral insufficiency fractures occurred in 2 cases, and there was 1 case of severe dys-
12 ACCURATE AND LABOR EFFICIENT TUMOR LOCALIZATION AND FAILURE ANALYSIS FOR PATIENTS WITH HIGH-GRADE GLIOMAS UTILIZING AN AUTOMATED MUTUAL-INFORMATION BASED IMAGE FUSION PROGRAM
This analysis was performed to determine how failure patterns were impacted by an image fusion program (IFP) developed at our institution based on mutual information principles that improved target definition for patients with high-grade gliomas who were treated with 3-D conformal radiotherapy (3DCRT). Between 1/1998 and 9/2001, 47 consecutive patients with high-grade gliomas were treated with 3DCRT. For treatment planning, a peri-surgical MRI was automatically fused with a treatment planning CT. GTVs were determined directly from the T2 and TIC weighted reformatted MR scans. The initial PTV was the T2 weighted GTV with a margin of 2 cm except where anatomic barriers to spread existed. For conedowns, the PTV included the TIC weighted GTV and 1.5-2 cm margins, or less depending on the proximity of radiosensitive structures. The patients were then followed to determine the time of local failure and overall survival. The MR images at the time of failure were then fused with the original treatment planning CT, so that the original plan could be superimposed upon that MR. This allowed us to determine the minimum isodose curve encompassing the failure site. As of 3/2002, the one year overall survival was 81%. The median disease free survival was 13.1 months. 23/47 patients had disease progression; 19/23 patients had follow-up imaging available for image registration. Fifteen patients failed within the volume encompassed by the 90% isodose surface. One patient failed within the 80% isodose surface volume. Two patients failed within the 90% isodose surface volume and also failed in the contraiateral hemisphere or spine. One patient failed only in the contralateral hemisphere. In conclusion, our results show that our IFP can accurately define the area at highest risk for tumor recurrence in patients with high-grade glioma. Analysis of failure patterns is also facilitated with IFP. 13 DETERMINATION OF PROSTATE MOTION AND TREATMENT SET UP ERROR BY FIDUCIAL MARKERS DURING CONFORMAL PROSTATE IRRADIATION Kerba. M.. Wu, JSY., Pate/, M., Corbett, T., Poon, I., Ostapiak, O., Chan,
J., Russell, D., Cosman, C., Sathya, J., Lukka, H. Hamilton Regional Cancer Centre, McMaster University, Hamilton, ON, Canada Purpose: To quantity the degree of prostate motion, isocentre set up variability, total positioning error (TPE) and potential geographic miss associated with the introduction of a new conformal radiotherapy technique at a single institution. Methods: 20 patients with localized prostate cancer had TRUS-guided insertion of 3 gold seeds (basal, mid, apical) into the prostate prior to CT treatment planning. PTV was obtained by 10mm volumetric expansion of contoured prostate gland. Patients were treated supine with empty bladder, ankles strapped, with no pelvic immobilization nor regimented bowel instructions, to total isocentre dose of 74 Gy/37 fractions/7.5 weeks using 6field MLC beam arrangement on 18 MV. Kodak ECL-TM portal films were taken from the right lateral port on days 1,3,5,7 and weekly thereafter. Isocentre variability and prostate motion were measured using pelvic bony landmarks as reference. TPE was measured for each gold seed. Results (Preliminary): 163 portal films on 15 patients have been analysed. 7/15 patients had mean isocentre error of > 2mm (range 2.2-3.4mm). Prostate base motion, determined as an average of the standard deviations (SD) of basal seed locations, was 2.4mm in the ant-post direction, and 1.8mm in the sup-inf direction. The averaged SD of basal seed TPE was 3.1mm in the ant-post direction, and 1.9mm in the sup-inf direction. The average TPE of basal seed measured on the first 3 portal films correlated well with the overall average TPE (r = 0.90, p 8.5mm in any direction for any seed, was evident in 9/163 films. Significant changes in rectal filling were noticed in two of six patients demonstrating geographic miss.