- Email: [email protected]
213 Brain metastasis: Fitness to drive
CARO 2005
Results: Between September 1988 and March 2004, 163 patients underwent radiosurgical treatment of recurrent brain metastases following previous whole brain irradiation (WBI). Thereafter 18/163 underwent surgical resection of a radiologically progressive radiosurgically treated target at a median of 46 (95% CI 35-57) weeks following radiosurgery. The thirty day surgical mortality rate was 0/18. Pathology reports are available in 17 patients and describe tumour in 15 (88%) and radiation necrosis only in 2 (12%). A redo craniotomy in 1 radiation necrosis patient revealed tumour. As of 31 March 2005, 3 patients remain alive with 1 lost to followup. Median survival following surgical resection of the radiosurgical target is 51 (95% CI 27-75) weeks and is 132 (95% CI 106-158) weeks from the original WBI. Conclusions: In this selected group of patients tumour regrowth rather than radiation necrosis appears to be the principal cause of radiosurgical target progression. This observation questions the justification for using resection as an endpoint for radiation toxicity. Surgical resection, if feasible, may provide a further worthwhile period of survival without incurring unacceptable perioperative mortality. 213 Brain Metastasis: Fitness to Drive 7". Stuckless Cancer Centre of Southeastern Ontario, Queen's University, Kingston, Ontario I n t r o d u c t i o n : CanMEDS2000 "Skills for the New Millennium" was developed by the Royal College of Physicians and Surgeons of Canada as a means of outlining a competency framework by which residents should be trained. One such competency identifies the physician as a "health advocate" and requires the physician be able to "identify important determinants of health affecting patients, contribute effectively to improved health of patients and communities and recognize and respond to those issues where advocacy is appropriate". An example of where oncologists can function as health advocates in the community is by assessing fitness to drive in the management of patients with brain metastasis, a diagnosis seen in 20%-40% of cancer patients. An estimated 98,000 - 170,000 new cases are diagnosed in the United States annually. This number is climbing, due to both increased diagnosis secondary to improved imaging techniques and prolonged survival as a result of improved treatment options. Approximately 33% of patients with brain metastasis will experience seizures, 18% at first presentation. This identifies approximately 50,000 patients per year at risk for seizure. As health advocates, we have a responsibility to society to report those individuals with brain metastasis to the Ministry of Transportation. Objectives: 1. To review the reporting practices of oncologists at the Cancer Center of Southeastern Ontario, with respect to fitness to drive in patients with brain metastasis. 2. To promote awareness of the issue of fitness to drive amongst oncology health care professionals. Methods: A survey is currently underway that asks oncologists at the CCSO what the incidence of newly diagnosed brain metastasis are in their practice, how often they report these patients to the Ministry of Transportation and what factors influence their decision to do so. The results will be presented in this poster publication. 214 Hit or Miss: I s T h e r e a Role for C T / M R I Fusion in Sarcoma R a d i o t h e r a p y Planning? P-A, Gfeller, C. Candish, C. Marlowe, C. Keogh, L. Weir, C. Grafton, K. Goddard British Columbia Cancer Agency, Vancouver, British Columbia Background: Optimal radiotherapy planning for sarcomas relies on the accurate delineation of tumor volumes. Current planning techniques utilize CT based imaging. With CT alone it can be difficult to define tumor volumes. MRI imaging is superior for tumor delineation and differentiation. The purpose
September 7-10
$63
of this study is to compare CT with CT/MRI fusion images and the impact on target volume delineation for sarcomas. Methods: Patients with sarcomas previously treated using CT/MRI fusion were identified. Patients had undergone CT and MRI simulation in the treatment position with immobilization devices. CT and MRI were co-registered to produce fusion images. Two 3-D image sets were created for each patient. Three radiation oncologists independently contoured the gross tumor volume (GTV) and the planning target volume (PTV) on each data set. There was a minimum 1-week break between contouring on fusion or CT sets. Analysis of volumes was performed to assess for interobserver variability. Observers repeated contours for intraobserver variability. Results: 11 sarcoma patients were identified. Histology was fibromatosis (n=5), Ewing's sarcoma (n=3) and soft tissue sarcoma (n=3). Treatment regions were pelvis (n=5), extremities (n=5), and trunk ( n = l ) . 66 image sets were created. The original mean CT/MRI fusion GTV was 329.3 cc (range 28-1176 cc). The mean CT/MR! PiV was 1000.4 cc (range 223-2964 cc). The benefit of fusion was most notable for patients receiving pre-radiotherapy chemotherapy allowing radiotherapy to be planned accurately to the pre-chemotherapy volume and for improved delineation of tumor margins and edema. Complete analysis of CT and CT/MRI plans including inter and intraobserver variability will be presented. Conclusions: Modern radiotherapy techniques rely on accurate imaging. Preliminary results show that with CT images alone tumor extent may be underestimated. CT/NRI fusion is useful in sarcoma radiotherapy planning. 215 D o s i m e t r i c Comparison of 3 D C o n f o r m a l Radiation T h e r a p y (3DoCRT) to T o m o t h e r a p y for P e r i p h e r a l SoftTissue Sarcoma C. Holloway, C. Field, G. Dundas Cross Cancer Institute, University of Alberta, Edmonton, Alberta I n t r o d u c t i o n : Treatment planning of STS of the proximal lower limb poses many challenges including large treatment fields and non-uniform tissue planes. Consequently, the dose to the planning target volume (PTV) in conventional plans in inhomogenoeous. We propose a study to compare plans from 3D-CRT and tomotherapy in patients already treated for peripheral STS by 3D-CRT. The primary goal is to achieve dose homogeneity throughout the PTV in accordance with ICRU Report 50 (-5% + 7%) while minimizing dose to the organs at risk (OAR). We present the results of the first 5 patients, M a t e r i a l s and Methods: 5 patients with STS treated with 3D CRT were selected based on the location of the tumour in the proximal lower limb. A "PTV study" volume was defined as the volume to receive 66 Gy prescribed to the isocentre. OAR included: Femur, hip joint, knee joint, gonads and perineum. Dose volume histograms (DVH) for the volumes of interest were evaluated for the 3DCRT plans. The volumes and CT images were then exported to TomoTherapy HiArt planning system. Dose constraints were defined as follows: PTV study 66 Gy to the 90% isodose, Hip and Knee joint 80% of volumes receiving <52 Gy, gonads <3 Gy, femur 80% volume <50 Gy, normal tissue 50% volume <30 Gy, perineum 50% volume <20 Gy. Results: 3DCRT and tomotherapy plans were evaluated for dose homogeneity to the PTV study volume. Volume of PTV study receiving > 66 Gy:tomotherapy >90%; 3DCRT 300/0. 83%. Volume of PTV study outside of the ICRU reference range: tomotherapy <1% - 4% ; 3DCRT 2%-33% . Despite the improved dose homogeneity throughout the treatment volume the dose to the OAR did not increase dramatically and in some instances improved. Conclusion: Tomotherapy has significant benefits in allowing one to deliver homogeneous doses to the target volumes in patients with proximal lower extremity STS without compromising the OAR.
Results: Between September 1988 and March 2004, 163 patients underwent radiosurgical treatment of recurrent brain metastases following previous whole brain irradiation (WBI). Thereafter 18/163 underwent surgical resection of a radiologically progressive radiosurgically treated target at a median of 46 (95% CI 35-57) weeks following radiosurgery. The thirty day surgical mortality rate was 0/18. Pathology reports are available in 17 patients and describe tumour in 15 (88%) and radiation necrosis only in 2 (12%). A redo craniotomy in 1 radiation necrosis patient revealed tumour. As of 31 March 2005, 3 patients remain alive with 1 lost to followup. Median survival following surgical resection of the radiosurgical target is 51 (95% CI 27-75) weeks and is 132 (95% CI 106-158) weeks from the original WBI. Conclusions: In this selected group of patients tumour regrowth rather than radiation necrosis appears to be the principal cause of radiosurgical target progression. This observation questions the justification for using resection as an endpoint for radiation toxicity. Surgical resection, if feasible, may provide a further worthwhile period of survival without incurring unacceptable perioperative mortality. 213 Brain Metastasis: Fitness to Drive 7". Stuckless Cancer Centre of Southeastern Ontario, Queen's University, Kingston, Ontario I n t r o d u c t i o n : CanMEDS2000 "Skills for the New Millennium" was developed by the Royal College of Physicians and Surgeons of Canada as a means of outlining a competency framework by which residents should be trained. One such competency identifies the physician as a "health advocate" and requires the physician be able to "identify important determinants of health affecting patients, contribute effectively to improved health of patients and communities and recognize and respond to those issues where advocacy is appropriate". An example of where oncologists can function as health advocates in the community is by assessing fitness to drive in the management of patients with brain metastasis, a diagnosis seen in 20%-40% of cancer patients. An estimated 98,000 - 170,000 new cases are diagnosed in the United States annually. This number is climbing, due to both increased diagnosis secondary to improved imaging techniques and prolonged survival as a result of improved treatment options. Approximately 33% of patients with brain metastasis will experience seizures, 18% at first presentation. This identifies approximately 50,000 patients per year at risk for seizure. As health advocates, we have a responsibility to society to report those individuals with brain metastasis to the Ministry of Transportation. Objectives: 1. To review the reporting practices of oncologists at the Cancer Center of Southeastern Ontario, with respect to fitness to drive in patients with brain metastasis. 2. To promote awareness of the issue of fitness to drive amongst oncology health care professionals. Methods: A survey is currently underway that asks oncologists at the CCSO what the incidence of newly diagnosed brain metastasis are in their practice, how often they report these patients to the Ministry of Transportation and what factors influence their decision to do so. The results will be presented in this poster publication. 214 Hit or Miss: I s T h e r e a Role for C T / M R I Fusion in Sarcoma R a d i o t h e r a p y Planning? P-A, Gfeller, C. Candish, C. Marlowe, C. Keogh, L. Weir, C. Grafton, K. Goddard British Columbia Cancer Agency, Vancouver, British Columbia Background: Optimal radiotherapy planning for sarcomas relies on the accurate delineation of tumor volumes. Current planning techniques utilize CT based imaging. With CT alone it can be difficult to define tumor volumes. MRI imaging is superior for tumor delineation and differentiation. The purpose
September 7-10
$63
of this study is to compare CT with CT/MRI fusion images and the impact on target volume delineation for sarcomas. Methods: Patients with sarcomas previously treated using CT/MRI fusion were identified. Patients had undergone CT and MRI simulation in the treatment position with immobilization devices. CT and MRI were co-registered to produce fusion images. Two 3-D image sets were created for each patient. Three radiation oncologists independently contoured the gross tumor volume (GTV) and the planning target volume (PTV) on each data set. There was a minimum 1-week break between contouring on fusion or CT sets. Analysis of volumes was performed to assess for interobserver variability. Observers repeated contours for intraobserver variability. Results: 11 sarcoma patients were identified. Histology was fibromatosis (n=5), Ewing's sarcoma (n=3) and soft tissue sarcoma (n=3). Treatment regions were pelvis (n=5), extremities (n=5), and trunk ( n = l ) . 66 image sets were created. The original mean CT/MRI fusion GTV was 329.3 cc (range 28-1176 cc). The mean CT/MR! PiV was 1000.4 cc (range 223-2964 cc). The benefit of fusion was most notable for patients receiving pre-radiotherapy chemotherapy allowing radiotherapy to be planned accurately to the pre-chemotherapy volume and for improved delineation of tumor margins and edema. Complete analysis of CT and CT/MRI plans including inter and intraobserver variability will be presented. Conclusions: Modern radiotherapy techniques rely on accurate imaging. Preliminary results show that with CT images alone tumor extent may be underestimated. CT/NRI fusion is useful in sarcoma radiotherapy planning. 215 D o s i m e t r i c Comparison of 3 D C o n f o r m a l Radiation T h e r a p y (3DoCRT) to T o m o t h e r a p y for P e r i p h e r a l SoftTissue Sarcoma C. Holloway, C. Field, G. Dundas Cross Cancer Institute, University of Alberta, Edmonton, Alberta I n t r o d u c t i o n : Treatment planning of STS of the proximal lower limb poses many challenges including large treatment fields and non-uniform tissue planes. Consequently, the dose to the planning target volume (PTV) in conventional plans in inhomogenoeous. We propose a study to compare plans from 3D-CRT and tomotherapy in patients already treated for peripheral STS by 3D-CRT. The primary goal is to achieve dose homogeneity throughout the PTV in accordance with ICRU Report 50 (-5% + 7%) while minimizing dose to the organs at risk (OAR). We present the results of the first 5 patients, M a t e r i a l s and Methods: 5 patients with STS treated with 3D CRT were selected based on the location of the tumour in the proximal lower limb. A "PTV study" volume was defined as the volume to receive 66 Gy prescribed to the isocentre. OAR included: Femur, hip joint, knee joint, gonads and perineum. Dose volume histograms (DVH) for the volumes of interest were evaluated for the 3DCRT plans. The volumes and CT images were then exported to TomoTherapy HiArt planning system. Dose constraints were defined as follows: PTV study 66 Gy to the 90% isodose, Hip and Knee joint 80% of volumes receiving <52 Gy, gonads <3 Gy, femur 80% volume <50 Gy, normal tissue 50% volume <30 Gy, perineum 50% volume <20 Gy. Results: 3DCRT and tomotherapy plans were evaluated for dose homogeneity to the PTV study volume. Volume of PTV study receiving > 66 Gy:tomotherapy >90%; 3DCRT 300/0. 83%. Volume of PTV study outside of the ICRU reference range: tomotherapy <1% - 4% ; 3DCRT 2%-33% . Despite the improved dose homogeneity throughout the treatment volume the dose to the OAR did not increase dramatically and in some instances improved. Conclusion: Tomotherapy has significant benefits in allowing one to deliver homogeneous doses to the target volumes in patients with proximal lower extremity STS without compromising the OAR.