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164 Relation between cumulative doses and early complications in patients with transperineal Ir 192 wire implants
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162
Phase II Trial 01 Combined Surgical Resection. lntraoperative High Dose rate brachytherapy (IORT). and External Beam Radiation Therapy (EBRT) lor Malignant Pleural Mesothelioma (MPM) ARaben, V Rusch. B. Mychakzak. K. Schupak R. Ginsburg. M. Burt, M. Barns and L.E. Hamson Department 01 Radiation Oncology. Brachytherapy Section and Department 01 Surgery Thoracic Secbon. Memorial Sloan-Kettering Cancer Center, NY, USA
FRACTIONATED PEROPERATIVE INTERSTITIAL HDRIPDR-BRACHYTHERAPY USING THE PLASTIC TUBE TECHNIQUE AND CONFORMAL TREATMENT PLANNING: THE KIEL EXPERIENCE.
The purpose 01 this study was to determme the teasiblhty ot combining extrapleural pneumonectomy (EPP) or pteurectomy/decortlcatmn (PD), IORT and postoperabve EERT to treat MPM From 3/94 through 9/94. 16 pabents (pts) were enrolled on this tnat: 2 females and 14 mates wth a medw age of 59 (range:45 -75). Eligibility criteria included biopsy proven MPM. no evidence of T4 or N3 disease,by exatiCT scan, no evidence ot metastatic disease, no prewous treatment, and a Karnofsky performance status of z 80%. Pts wth pulmonary lunction tests permilmg EPP, underwent EPP and IORT (15 Gy prescribed to a depth 01 5 mr in bssue to the mediasbnum, diaphragm and chestwall) with postoperabve EBRT (54 Gy to entire hemlthorax. surgical scar and surgical drain site). Pts mellgible for EPP due to marglnal pulmonary funcbon underwent PD and IORT (15 Gy to mediastinum. diaphragm and chestwall). wth EBRT (54 Gy to entw hemithorax with customized lung btocklng). The median surgw. procedure time, median IORT time and median overall operating time was 554 mmutes, 240 mmutes and 649 minutes respectively. The median dose of EBRT was 50 4 Gy (range 50-54 Gy). The medtan lollow-up tome is 8 months (range: 3 . 17 months). Four of 16 pts had unresectable disease at the bme of surgery and were taken oft study. Eight pts underwent EPP/ IORT and 4 pahents underwent PD/IORT A complete resectton of all gross disease was obtained in t lpts One pt had a single locus 01 gross residual disease (less than 5 mm in sire) left behlnd. The overall actuarial local control at 1 year for resected patients is 66% The crude local contw rate and d,sts”t c~ntml rate lor pts ““dergwg EPP was 75% and 50% respectwety The crude local control rate end dtstant control rate lor PD pts was 50% and 75% The overall distant metastasis rate et 1 year was 42%. The overall comphcation rate wss 58% (7112). 01 the a pts undergong EPP and IORT, 1 patlent developed postoperatwe acute respiratov distress and expired. Two pts developed a postoperabve empyema wth bronchial stump leak; wth 1 pt developing bleeding from medwstinal vessels et 7 months. This was felt to be related to late radiation towlty. Wound dehiscence of the thoracotomy lnclsion occurred in 1 pt. Of the 4 pts undergoing PD. 1 pt developed a tracheoesophageal tistula. and 1 developed a postoperatwe chest tube leak. IORT in conjunction with EPP led to prohibitive local complications and has been discontinued. Although follow-up is short. IORT wth PO shows no improvement in local control compared to our historlcat experience. Local control wth EPP/ EBRT has thus far been excellent with mast patients relapsing outside of the EBRT field, in distinct contrast to the reported pattern of disease progression in MPM. emphasizing the need lor Improved systemic therapy
163
Material and Methods: In Ocober 1992 we started IO USC the peroperative plastic tube technique for mterstttal implants tn the Kiel University. Advantage of this method is the possibiliry of a fractionated brachytherapy (BT) with the option of a CT-simulation based conformal tretament planning. Fourty patients /pts/ (base of skull and orbIt exluded) in six different regions were treated in a combined schedule of external beam treatment (EBT) and BT (19 of head & neck, I3 of recNm recurrence. 4 of soft tissue sarcoma. as welJ as 3 of bile duct and one of bladder cancer). The “boost” implant had in 15 cases curative intention the rest was palliation with/without EBT. Twenty-w patlents were treated by the Kiel PDR protocol (5 pulses m IO hours. each I Gy, 5 x week). The HDR protocol was 2x 2.5 Gy with a stx-hours-mterval. 5x week. Applied total dose depending from the mdicatlon and EBT dose was between 15-40 Gy. Follow-up 3-33 months (mean I2 months). Results: Head & d: two out of I9 pts were treated with curative Intention: both are tumorfree after I6 as well as 8 months follow-up. We observed at mean 8 months (l-33 months) tumor free survival in the I7 palliative cases. Rectum recwrenc~: 7 out of I3 pts are tumor free with a mean follow-up of I4 months .Three patients died. one of them because of lung metastasis but local tumor free. the others by local and distant metastasis. ‘Ibree patients with a local recurrence two out of 4 pts have a local recurrence. are alive. Soft: one of them also distant metastasis. Two out of 4 are tumor free with 7 and I2 months follow-up. Both recurrences were observed aher 7 months. Bile duct: all three patients died after a mean follow-up of six months, one of them because of intercurrent disease after 3 months follow-up. The other two pts had a recurrence. m: the patient died after 10 months cancer related. In this case the implant geometry was very poor because of the loss of two oul of initially six implanted tubes. The Nbes were in place for 7-31 days (mean I8 days). We did not observed plastic tube related side effects. BT related side effect after two tmunts in one base of tongue cancer: superficial necrosis. healed by laser resection. Peroperative plastic tube BT technique seems to be an advanced treatment method. especially because of the possible conformal planning and fractionation.
164 BRACHY
Carpio
R. Gala& G. Kov&zs, P. Kohr, B. Schmid*, .I. Werner#, T. Kreusch**, R. Wilhelm, B. Kimmig, Clinics for Radtatlon Therapy (Radiooncolo8y). ‘Surgery. #OLR 8: Head and Neck Surgery. “Ore-Maxilla-Facial Surgev of the CAU. Kiel. German)
C: MttiUo
THERAPY
MT:
RELATION BETWEEN CUMULATIVE DOSES AND EARLY COMPLICATIONS IN PATIENTS WITB TRANSPERINEAL in I92 Wtw IMP~.ANTs
FOR PENIS CANCER
Pkez-Regadera
J. Caheza
ht4,
Ram&t
A,
De la CNZ J. Sinchez G. Sancho S, Femindez de Let& P, Lads E. Hospital
12 de Ochthre.
Madrid.
Spain.
Kuhel~ J, Zaletel-KragelJ L lnstltute of @w.ology LJubiJan.3,Slovema
On the basis of the relation between cumulattve doses and acute compllcattons m patients who, m additton to other radmtherapies, wewed also the therapy wth transpenneal Ir 192 net Implants, the authors of this study were trying to s&e the pnnc~ples that affect the occurrence of early comphcattons m these patteots A year aRer the posttlonmg of the transpenneal Ir 192 square net Implants, the authors were trytng to detemune the relattonshtp between acute comphcatmns and cumulatwe doses m 3 I pattents The distance between the wres of the square net Implants was rangmg from 0 5-l 0 cm, whereas the activity of the wes was rangmg from 0 5-1 5 mC per catlmeter Out of the total number of patwmts, only three were treated excluswely wth Implants, the rest of them, 28 pattents, received addtttonal percutaneous lrradttatton Both doses, the one apphed percutaneously and the other dehvered wth implants, were added up In pattents who rexwed doses from 41 to 60 Gy, no comphcattons occurred, at higher doses from 61 to 100 Gy, 25% of pattents had comphcatmns, and at the doses from 101 to 160, the comphcattons were observed m 75-100% ofthepattents. At the dosages of 73,50 Gy, 84.34 Gy, 91.73 Gy, 97.57 Gy and at lO2,58 Gy, the probabthty that compbcattons will occur IS 5%, IO%, 15%, 20% and 25%. respectwely On the basts of the obtamed study results It IS posstble to assess appropriate doses for the pattents who are recetvmg radmthetapy and are treated wth transpenneal Implants ather as the only therapy or as supponwe therapy It could be concluded that a simple adding up of both doses deltvered percutaneously and wtth tmplants may provide some onentatmns m assessmg the posstblhty of early negatne Irradmtmn effkcts
161
162
Phase II Trial 01 Combined Surgical Resection. lntraoperative High Dose rate brachytherapy (IORT). and External Beam Radiation Therapy (EBRT) lor Malignant Pleural Mesothelioma (MPM) ARaben, V Rusch. B. Mychakzak. K. Schupak R. Ginsburg. M. Burt, M. Barns and L.E. Hamson Department 01 Radiation Oncology. Brachytherapy Section and Department 01 Surgery Thoracic Secbon. Memorial Sloan-Kettering Cancer Center, NY, USA
FRACTIONATED PEROPERATIVE INTERSTITIAL HDRIPDR-BRACHYTHERAPY USING THE PLASTIC TUBE TECHNIQUE AND CONFORMAL TREATMENT PLANNING: THE KIEL EXPERIENCE.
The purpose 01 this study was to determme the teasiblhty ot combining extrapleural pneumonectomy (EPP) or pteurectomy/decortlcatmn (PD), IORT and postoperabve EERT to treat MPM From 3/94 through 9/94. 16 pabents (pts) were enrolled on this tnat: 2 females and 14 mates wth a medw age of 59 (range:45 -75). Eligibility criteria included biopsy proven MPM. no evidence of T4 or N3 disease,by exatiCT scan, no evidence ot metastatic disease, no prewous treatment, and a Karnofsky performance status of z 80%. Pts wth pulmonary lunction tests permilmg EPP, underwent EPP and IORT (15 Gy prescribed to a depth 01 5 mr in bssue to the mediasbnum, diaphragm and chestwall) with postoperabve EBRT (54 Gy to entire hemlthorax. surgical scar and surgical drain site). Pts mellgible for EPP due to marglnal pulmonary funcbon underwent PD and IORT (15 Gy to mediastinum. diaphragm and chestwall). wth EBRT (54 Gy to entw hemithorax with customized lung btocklng). The median surgw. procedure time, median IORT time and median overall operating time was 554 mmutes, 240 mmutes and 649 minutes respectively. The median dose of EBRT was 50 4 Gy (range 50-54 Gy). The medtan lollow-up tome is 8 months (range: 3 . 17 months). Four of 16 pts had unresectable disease at the bme of surgery and were taken oft study. Eight pts underwent EPP/ IORT and 4 pahents underwent PD/IORT A complete resectton of all gross disease was obtained in t lpts One pt had a single locus 01 gross residual disease (less than 5 mm in sire) left behlnd. The overall actuarial local control at 1 year for resected patients is 66% The crude local contw rate and d,sts”t c~ntml rate lor pts ““dergwg EPP was 75% and 50% respectwety The crude local control rate end dtstant control rate lor PD pts was 50% and 75% The overall distant metastasis rate et 1 year was 42%. The overall comphcation rate wss 58% (7112). 01 the a pts undergong EPP and IORT, 1 patlent developed postoperatwe acute respiratov distress and expired. Two pts developed a postoperabve empyema wth bronchial stump leak; wth 1 pt developing bleeding from medwstinal vessels et 7 months. This was felt to be related to late radiation towlty. Wound dehiscence of the thoracotomy lnclsion occurred in 1 pt. Of the 4 pts undergoing PD. 1 pt developed a tracheoesophageal tistula. and 1 developed a postoperatwe chest tube leak. IORT in conjunction with EPP led to prohibitive local complications and has been discontinued. Although follow-up is short. IORT wth PO shows no improvement in local control compared to our historlcat experience. Local control wth EPP/ EBRT has thus far been excellent with mast patients relapsing outside of the EBRT field, in distinct contrast to the reported pattern of disease progression in MPM. emphasizing the need lor Improved systemic therapy
163
Material and Methods: In Ocober 1992 we started IO USC the peroperative plastic tube technique for mterstttal implants tn the Kiel University. Advantage of this method is the possibiliry of a fractionated brachytherapy (BT) with the option of a CT-simulation based conformal tretament planning. Fourty patients /pts/ (base of skull and orbIt exluded) in six different regions were treated in a combined schedule of external beam treatment (EBT) and BT (19 of head & neck, I3 of recNm recurrence. 4 of soft tissue sarcoma. as welJ as 3 of bile duct and one of bladder cancer). The “boost” implant had in 15 cases curative intention the rest was palliation with/without EBT. Twenty-w patlents were treated by the Kiel PDR protocol (5 pulses m IO hours. each I Gy, 5 x week). The HDR protocol was 2x 2.5 Gy with a stx-hours-mterval. 5x week. Applied total dose depending from the mdicatlon and EBT dose was between 15-40 Gy. Follow-up 3-33 months (mean I2 months). Results: Head & d: two out of I9 pts were treated with curative Intention: both are tumorfree after I6 as well as 8 months follow-up. We observed at mean 8 months (l-33 months) tumor free survival in the I7 palliative cases. Rectum recwrenc~: 7 out of I3 pts are tumor free with a mean follow-up of I4 months .Three patients died. one of them because of lung metastasis but local tumor free. the others by local and distant metastasis. ‘Ibree patients with a local recurrence two out of 4 pts have a local recurrence. are alive. Soft: one of them also distant metastasis. Two out of 4 are tumor free with 7 and I2 months follow-up. Both recurrences were observed aher 7 months. Bile duct: all three patients died after a mean follow-up of six months, one of them because of intercurrent disease after 3 months follow-up. The other two pts had a recurrence. m: the patient died after 10 months cancer related. In this case the implant geometry was very poor because of the loss of two oul of initially six implanted tubes. The Nbes were in place for 7-31 days (mean I8 days). We did not observed plastic tube related side effects. BT related side effect after two tmunts in one base of tongue cancer: superficial necrosis. healed by laser resection. Peroperative plastic tube BT technique seems to be an advanced treatment method. especially because of the possible conformal planning and fractionation.
164 BRACHY
Carpio
R. Gala& G. Kov&zs, P. Kohr, B. Schmid*, .I. Werner#, T. Kreusch**, R. Wilhelm, B. Kimmig, Clinics for Radtatlon Therapy (Radiooncolo8y). ‘Surgery. #OLR 8: Head and Neck Surgery. “Ore-Maxilla-Facial Surgev of the CAU. Kiel. German)
C: MttiUo
THERAPY
MT:
RELATION BETWEEN CUMULATIVE DOSES AND EARLY COMPLICATIONS IN PATIENTS WITB TRANSPERINEAL in I92 Wtw IMP~.ANTs
FOR PENIS CANCER
Pkez-Regadera
J. Caheza
ht4,
Ram&t
A,
De la CNZ J. Sinchez G. Sancho S, Femindez de Let& P, Lads E. Hospital
12 de Ochthre.
Madrid.
Spain.
Kuhel~ J, Zaletel-KragelJ L lnstltute of @w.ology LJubiJan.3,Slovema
On the basis of the relation between cumulattve doses and acute compllcattons m patients who, m additton to other radmtherapies, wewed also the therapy wth transpenneal Ir 192 net Implants, the authors of this study were trying to s&e the pnnc~ples that affect the occurrence of early comphcattons m these patteots A year aRer the posttlonmg of the transpenneal Ir 192 square net Implants, the authors were trytng to detemune the relattonshtp between acute comphcatmns and cumulatwe doses m 3 I pattents The distance between the wres of the square net Implants was rangmg from 0 5-l 0 cm, whereas the activity of the wes was rangmg from 0 5-1 5 mC per catlmeter Out of the total number of patwmts, only three were treated excluswely wth Implants, the rest of them, 28 pattents, received addtttonal percutaneous lrradttatton Both doses, the one apphed percutaneously and the other dehvered wth implants, were added up In pattents who rexwed doses from 41 to 60 Gy, no comphcattons occurred, at higher doses from 61 to 100 Gy, 25% of pattents had comphcatmns, and at the doses from 101 to 160, the comphcattons were observed m 75-100% ofthepattents. At the dosages of 73,50 Gy, 84.34 Gy, 91.73 Gy, 97.57 Gy and at lO2,58 Gy, the probabthty that compbcattons will occur IS 5%, IO%, 15%, 20% and 25%. respectwely On the basts of the obtamed study results It IS posstble to assess appropriate doses for the pattents who are recetvmg radmthetapy and are treated wth transpenneal Implants ather as the only therapy or as supponwe therapy It could be concluded that a simple adding up of both doses deltvered percutaneously and wtth tmplants may provide some onentatmns m assessmg the posstblhty of early negatne Irradmtmn effkcts