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243 oral Radiosurgery and fractionated stereotactic radiotherapy for acoustic neurinoma
Proffered papers
240
oral
Role of combined extended field external XRT and transperineal interstitial implant in stage C and D1 ca of ¢rostate, 9 t o 28 year follow up outcome study to date. K. Charvulu, A. Markoe, N. Block, L. Dowlen, M. AbdeI-Wahab, W. Raub U. of Miami, Rad. Onc., Miami, USA The aim of the study is to enhance survival and preserve quality of life in this group of patients who have unfavorable outcome. A prospecive study was designed in 1972 to treat patients with Ca of Prostate Stages C and D1 with initial widefield external XRT to treat the primary and the lymph node echelons en bloc(pelvis and para aortic) to dose 4320cGy in 24 fr. Additional upto 1400 cGy in 7 fr. was given to prostate and pelvic nodes by lateral ports. After a 4 week rest boost dose to prostate(3200 cGy) was given by transperineal Au198 seed implant. This is a report on100 consecutive patients followed 9 to 28 yrs. The product limit method of Kaplan-Meir and multi-variate analysis were used for this study. The range of age is 52 to 81 yrs with median of 66 yrs.The 5, 10,and I5 yr overall survival in this study were 82%, 50% and 33% respectively. The overall 5, 10, & 15 yr disease free survival for all ages were 70%, 42%, and 23% respectively. This compares favourably with historical data.Age and grade of the tumour have no adverse influence in this study. The local control rate for 5 and 10 yr were 87%& 82% respectively. The patients in this study were all diagnosed by needle biopsy only. The study indicates that En Bloc treatment of the prostate and the lymph node echelons and boost dose by transperineal radioactive seed implant yields enhanced survival while preserving the quality of life. When wide field techniques are used as in this study with combined boost dose to the prostate, age of patients,and the tumour histological gradehave no adverse influence on the survival of patients.
STEREOTACTIC RADIOTHERAPY 241
oral
Chordomas and ehondrosarcomas of the skull base: results of combined proton and photon radiation therapy H. Mammarl,2~ G. No#l 1,3, D. Pontvert 4, C. Haie-Medet 5, R. Ferrand 1, M. Schlienger2, J. Habrand 5 J. Mazeron 1,3 1Centre de Protontherapie d'Orsay, Protonth6rapie, Orsay, France 2H6pital Tenon, Radioth6rapie, Paris, France 3H6pital Piti6-Salp#triere, Radioth6rapie, Pads, France 41nstitut Curie, Radioth6rapie, Paris, France 51nstitut Gustave Roussy, Radiotherapie, Villejuif, France Purpose : To evaluate in terms of probabilities of local control and survival, as well as treatment-related toxicity, results of combined proton and photon radiation therapy for chordoma and chondrosarcoma of the skull base. Materials and Methods : Between December 1995 and December 1999, 40 male and 31 female patients were treated at the centre de Protontherapie d'Orsay, for primary or recurrent chordoma (52 patients) or chondrosarcoma (19 patients). Age ranged from 12 to 85 years (median 53). Radiation treatment was given postoperatively in 63 patients (47 with chordoma and 16 with chondrosarcoma). Patients were given 45 Gy / 25 fractions / 33 days with 6 - 25 MV photons, and 22 CGE / 11 fractions/13 days with 201 MeV protons. (CGE: Cobalt Gray Equivalent: proton Gy x 1.1) Results : One chordoma and one chondrosarcoma recurred locally, at 46 and 36 months, respectively. Probability of local control at 3 years was 86%. Four patients died at 6, 11, 12, and 39 months, respectively. Causes of death included intercurrent disease (2), pulmonary embolus following salvage surgery (1), and unknown cause (1). Probability of overall survival at 40 months was 84 %. Treatment morbidity included: diabetes insipidus (1), cerebral hemorrhage (1), visual loss (1) and Lhermitte syndrome (1). Conclusion : Combined photon and proton, following in most cases complete or subtotal surgical resection, provided high preliminary local control and survival rates with acceptable toxicity. Results will be updated. 242
oral
Stereotactic radiosurgery of acoustic neuromas with a linear accelerator R.-P. Muelle_r1, M. Bendel 1, M. /(ocher 1, V. Sturm 2 1University Cologne, Radiotherapy, Cologne, Germany 2University Cologne, Stereotactic Neurosurgery, Cologne, Germany
Friday, 2 February 2001
$69
Introduction: Treatment of acoustic neuromas by stereotactic radiosurgery has been established in the last decade, but experience with linac based techniques in this disease is limited. Patients and Methods: Ninety-two patients with acoustic neuromas were treated with stereotactic radiosurgery using a linear accelerator between 199t and 1999. The median dose was t2 Gy to the lesion margin, with a range of 9 - 20 Gy. The mean tumour volume was 1.75 ml (range: 0.1 23.7 ml). Results: At a median follow-up period of 19 months (range: 6 - 76 months), 87 patients (95%) had local tumour control. In 27 patients, who underwent surgery as an initial treatment, actuarial tumour control rate (56%) was significantly worse (p = 0.0073). Only 10/59 patients (29%) with prior useful hearing experienced progressive hearing loss. Moderate facial paresis (House Grade IV) was observed in four of sixty-seven patients (6%). In patients, who had undergone MRI for treatment planning, actuarial preservation of facial function was significantly better than in patients, who received only CT for treatment planning (100% vs. 78%, p = 0.0061). Conclusion: Stereotactic radiosurgery with a linear accelerator is a highly effective treatment of acoustic neuromas with a low rate of side-effects. 243
oral
Radiosurgery and fractionated stereotactic radiotherapy for acoustic neurinoma. O.W.M. Meijer 1, J.G. Wolbers2, J.C. Baayen 2, B.J. Slotman 1 1VU-Ziekenhuis, Radiation Oncology, Amsterdam, The Netherlands 2VU-Ziekenhuis, Neurosurgery, Amsterdam, The Netherlands Purpose: To prospectively assess the local control and treatment related toxicity rate in acoustic neurinoma patients treated with linear accelerator based radiosurgery and fractionated stereotactic radiation therapy. Methods and materials: We evaluated 37 consecutive patients treated with stereotactic irradiation for acoustic neurinoma, All patients had progressive tumors, progressive symptoms or both. Mean tumor diameter was 2.3 cm (range 0.8-3.3 cm) on MR-scan. Dentate patients were given a fractionated treatment using a dental impression based stereotactlc head frame and received a dose of 5x4.00 Gy or 5x5.00 Gy in 1 week. Edentate patients were given a single fraction treatment using a scull screw based stereotactic head frame and received a dose of lx10.00 Gy or lx12.50 Gy. The dose was prescriped to the 80% isodose encompassing the tumor with a margin of 1 mm. All patients were treated with 1 isocenter and 5 non-ceplanar arcs of 140 degrees each. Results: With a mean follow-up period of 40 months (range 24-86 months) the actuarial local control rate at 5 years was 95% (only 1 patient failed). The actuarial rate of freedom from hearing loss at 5 years was 73% in all hearing patients and 80% in hearing patients given the fractionated treatment. The actuarial rate of freedom from trigeminal nerve toxicity was 97% at 5 years. No patient developed facial nerve toxicity or other complications. Conclusion: In this unselected series fractionated stereotactic radiation therapy and linear accelerator based radiosurgery give excellent local control in acoustic neurinoma. Although follow-up is still short it combines a high rate of preservation of hearing, especially in fractionated treated patients, with a very low rate of treatment related toxicity. 244
oral
Fractionated stereotactic radiotherapy in the paediatric population R. Smee M. Schneider, P. Hoban Prince of Wales Hospital, Radiation Oncology, Sydney, Australia Aim: The aim in the management of paediatric brain tumours is to deliver an effective therapeutic dose whilst minimising that delivered to surrounding normal brain. This review will demonstrate how this can be achieved in a paediatric population. Materials and Methods: Over the last 5 years out of a total of 205 patients who have had fractionated stereotactic radiotherapy 32 we less than 18 years old at the time of treatment. Within this population the diagnoses were: 12 tow grade gliomas (including 4 arising within the optic pathways), 5 craniopharyngiomas, 5 intermediate to high grade gliomas (including 1 recurrent lesion), 3 ependymomas (2 recurrent), 3 medullo-blastomas/ PNET (2 recurrent), 2 vestibular schwannomas, 1 germinoma, and 1 (malignant) meningioma. Five were done under general anaesthetic, the remainder awake. The SRS was the only treatment delivered in 24, and as a boost/palliative in 8 patients. The Minimultileaf Collimator was used for "field shaping" in 6 patients. Results: By the use of more defined treatment fields, and aided by dose volume histogram assessment for the tumour and adjacent normal tissue, more effective treatment is delivered. None of the low grade gliomas have progressed with maintenance of the pretreatment visual acuity in the 4
240
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Role of combined extended field external XRT and transperineal interstitial implant in stage C and D1 ca of ¢rostate, 9 t o 28 year follow up outcome study to date. K. Charvulu, A. Markoe, N. Block, L. Dowlen, M. AbdeI-Wahab, W. Raub U. of Miami, Rad. Onc., Miami, USA The aim of the study is to enhance survival and preserve quality of life in this group of patients who have unfavorable outcome. A prospecive study was designed in 1972 to treat patients with Ca of Prostate Stages C and D1 with initial widefield external XRT to treat the primary and the lymph node echelons en bloc(pelvis and para aortic) to dose 4320cGy in 24 fr. Additional upto 1400 cGy in 7 fr. was given to prostate and pelvic nodes by lateral ports. After a 4 week rest boost dose to prostate(3200 cGy) was given by transperineal Au198 seed implant. This is a report on100 consecutive patients followed 9 to 28 yrs. The product limit method of Kaplan-Meir and multi-variate analysis were used for this study. The range of age is 52 to 81 yrs with median of 66 yrs.The 5, 10,and I5 yr overall survival in this study were 82%, 50% and 33% respectively. The overall 5, 10, & 15 yr disease free survival for all ages were 70%, 42%, and 23% respectively. This compares favourably with historical data.Age and grade of the tumour have no adverse influence in this study. The local control rate for 5 and 10 yr were 87%& 82% respectively. The patients in this study were all diagnosed by needle biopsy only. The study indicates that En Bloc treatment of the prostate and the lymph node echelons and boost dose by transperineal radioactive seed implant yields enhanced survival while preserving the quality of life. When wide field techniques are used as in this study with combined boost dose to the prostate, age of patients,and the tumour histological gradehave no adverse influence on the survival of patients.
STEREOTACTIC RADIOTHERAPY 241
oral
Chordomas and ehondrosarcomas of the skull base: results of combined proton and photon radiation therapy H. Mammarl,2~ G. No#l 1,3, D. Pontvert 4, C. Haie-Medet 5, R. Ferrand 1, M. Schlienger2, J. Habrand 5 J. Mazeron 1,3 1Centre de Protontherapie d'Orsay, Protonth6rapie, Orsay, France 2H6pital Tenon, Radioth6rapie, Paris, France 3H6pital Piti6-Salp#triere, Radioth6rapie, Pads, France 41nstitut Curie, Radioth6rapie, Paris, France 51nstitut Gustave Roussy, Radiotherapie, Villejuif, France Purpose : To evaluate in terms of probabilities of local control and survival, as well as treatment-related toxicity, results of combined proton and photon radiation therapy for chordoma and chondrosarcoma of the skull base. Materials and Methods : Between December 1995 and December 1999, 40 male and 31 female patients were treated at the centre de Protontherapie d'Orsay, for primary or recurrent chordoma (52 patients) or chondrosarcoma (19 patients). Age ranged from 12 to 85 years (median 53). Radiation treatment was given postoperatively in 63 patients (47 with chordoma and 16 with chondrosarcoma). Patients were given 45 Gy / 25 fractions / 33 days with 6 - 25 MV photons, and 22 CGE / 11 fractions/13 days with 201 MeV protons. (CGE: Cobalt Gray Equivalent: proton Gy x 1.1) Results : One chordoma and one chondrosarcoma recurred locally, at 46 and 36 months, respectively. Probability of local control at 3 years was 86%. Four patients died at 6, 11, 12, and 39 months, respectively. Causes of death included intercurrent disease (2), pulmonary embolus following salvage surgery (1), and unknown cause (1). Probability of overall survival at 40 months was 84 %. Treatment morbidity included: diabetes insipidus (1), cerebral hemorrhage (1), visual loss (1) and Lhermitte syndrome (1). Conclusion : Combined photon and proton, following in most cases complete or subtotal surgical resection, provided high preliminary local control and survival rates with acceptable toxicity. Results will be updated. 242
oral
Stereotactic radiosurgery of acoustic neuromas with a linear accelerator R.-P. Muelle_r1, M. Bendel 1, M. /(ocher 1, V. Sturm 2 1University Cologne, Radiotherapy, Cologne, Germany 2University Cologne, Stereotactic Neurosurgery, Cologne, Germany
Friday, 2 February 2001
$69
Introduction: Treatment of acoustic neuromas by stereotactic radiosurgery has been established in the last decade, but experience with linac based techniques in this disease is limited. Patients and Methods: Ninety-two patients with acoustic neuromas were treated with stereotactic radiosurgery using a linear accelerator between 199t and 1999. The median dose was t2 Gy to the lesion margin, with a range of 9 - 20 Gy. The mean tumour volume was 1.75 ml (range: 0.1 23.7 ml). Results: At a median follow-up period of 19 months (range: 6 - 76 months), 87 patients (95%) had local tumour control. In 27 patients, who underwent surgery as an initial treatment, actuarial tumour control rate (56%) was significantly worse (p = 0.0073). Only 10/59 patients (29%) with prior useful hearing experienced progressive hearing loss. Moderate facial paresis (House Grade IV) was observed in four of sixty-seven patients (6%). In patients, who had undergone MRI for treatment planning, actuarial preservation of facial function was significantly better than in patients, who received only CT for treatment planning (100% vs. 78%, p = 0.0061). Conclusion: Stereotactic radiosurgery with a linear accelerator is a highly effective treatment of acoustic neuromas with a low rate of side-effects. 243
oral
Radiosurgery and fractionated stereotactic radiotherapy for acoustic neurinoma. O.W.M. Meijer 1, J.G. Wolbers2, J.C. Baayen 2, B.J. Slotman 1 1VU-Ziekenhuis, Radiation Oncology, Amsterdam, The Netherlands 2VU-Ziekenhuis, Neurosurgery, Amsterdam, The Netherlands Purpose: To prospectively assess the local control and treatment related toxicity rate in acoustic neurinoma patients treated with linear accelerator based radiosurgery and fractionated stereotactic radiation therapy. Methods and materials: We evaluated 37 consecutive patients treated with stereotactic irradiation for acoustic neurinoma, All patients had progressive tumors, progressive symptoms or both. Mean tumor diameter was 2.3 cm (range 0.8-3.3 cm) on MR-scan. Dentate patients were given a fractionated treatment using a dental impression based stereotactlc head frame and received a dose of 5x4.00 Gy or 5x5.00 Gy in 1 week. Edentate patients were given a single fraction treatment using a scull screw based stereotactic head frame and received a dose of lx10.00 Gy or lx12.50 Gy. The dose was prescriped to the 80% isodose encompassing the tumor with a margin of 1 mm. All patients were treated with 1 isocenter and 5 non-ceplanar arcs of 140 degrees each. Results: With a mean follow-up period of 40 months (range 24-86 months) the actuarial local control rate at 5 years was 95% (only 1 patient failed). The actuarial rate of freedom from hearing loss at 5 years was 73% in all hearing patients and 80% in hearing patients given the fractionated treatment. The actuarial rate of freedom from trigeminal nerve toxicity was 97% at 5 years. No patient developed facial nerve toxicity or other complications. Conclusion: In this unselected series fractionated stereotactic radiation therapy and linear accelerator based radiosurgery give excellent local control in acoustic neurinoma. Although follow-up is still short it combines a high rate of preservation of hearing, especially in fractionated treated patients, with a very low rate of treatment related toxicity. 244
oral
Fractionated stereotactic radiotherapy in the paediatric population R. Smee M. Schneider, P. Hoban Prince of Wales Hospital, Radiation Oncology, Sydney, Australia Aim: The aim in the management of paediatric brain tumours is to deliver an effective therapeutic dose whilst minimising that delivered to surrounding normal brain. This review will demonstrate how this can be achieved in a paediatric population. Materials and Methods: Over the last 5 years out of a total of 205 patients who have had fractionated stereotactic radiotherapy 32 we less than 18 years old at the time of treatment. Within this population the diagnoses were: 12 tow grade gliomas (including 4 arising within the optic pathways), 5 craniopharyngiomas, 5 intermediate to high grade gliomas (including 1 recurrent lesion), 3 ependymomas (2 recurrent), 3 medullo-blastomas/ PNET (2 recurrent), 2 vestibular schwannomas, 1 germinoma, and 1 (malignant) meningioma. Five were done under general anaesthetic, the remainder awake. The SRS was the only treatment delivered in 24, and as a boost/palliative in 8 patients. The Minimultileaf Collimator was used for "field shaping" in 6 patients. Results: By the use of more defined treatment fields, and aided by dose volume histogram assessment for the tumour and adjacent normal tissue, more effective treatment is delivered. None of the low grade gliomas have progressed with maintenance of the pretreatment visual acuity in the 4