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28 Intraoperative single fraction high dose rate brachytherapy for head and neck cancers
Proffered Papers
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fistula. Grade 5 complications include 3 cases of pelvic bleeding, all of them in previously irradiated patients treated with 40Gy of PHDRB alone. After a median follow-up of 18.2 months (249+), the 4-year local control rate was 87.4% (22 of 24 patients), the 4-year pelvic control rate 80.1% (21 of 24 patients) and the systemic control rate 40.5% (18 of 24 patients). Four-year overall survival rate was 35% (group 1 14.3%, group 2=52.0%; p=0.001). Conclusions: 1.Group i patients had an excessive vascular toxicity and therefore, PHDRB dose has been decreased to the closest lower level. 2.Group 2 patients present excellent 4-year locoregional (>80%) and survival (>50%) rates. 27 MRI-guided treatment of cervical cancer patients; comparing brachytherapy with an IMRT-boost technique.
M. Ketelaars:~ L. van de Bunt:, G.A.P. de Korf, C. Ceylan:, 1.M. Jiirgenliemk-Schulz I, U.A. van der Heide: :Department of Radiation Oncology 2Department of Radiology, University Medical Center, Utrecht, The Netherlands Introduction: The golden standard in the treatment of advanced cervical cancer consists of a combination of external beam irradiation (EBRT) and brachytherapy (BT). BT is administered to boost the dose to the primary tumor. In this prospective planning study we evaluated and optimized the dose coverage of the primary tumor and the dose to the organs at risk (OAR) of this combined treatment. Additionally, we explored if intensitymodulated radiotherapy (IMRT) would make it possible to integrate the boost dose into the external treatment. Materials and methods: In 10 patients treatment response was monitored with a series of three T2-weighted M R / s c a n s taken before, during- and after the treatment. In addition, two MR/ scans were taken with the BT applicators in situ. The primary gross tumor volumes and OAR were delineated on the MRI data sets and the 3-D dose distributions were calculated. IMRT-boost plans were generated using the delineation of the pre-treatment MRI scans. Because of the internal organ motions, margins of up to 15 mm around the target were used to ensure a proper coverage. Results: The tumors were diverse in size (11 to 188 cc) and showed different regression rates after having delivered the first 30 Gy of EBRT (6 to 75% of the initial size). These rates did not correlate with the initial tumor size. The tumor coverage that could be achieved by the first BT application was satisfactory for small tumors, especially after 3D optimization (coverage of 95-99 %). Tumors with a larger volume (more than 40 cc) at the time of the first BT treatment could not be irradiated adequately, not even after 3D optimization (coverage of 50-70 %). The IMRT-boost technique offered an improvement of the tumor coverage only when very small margins for internal motion were applied (up to 5 mm). In case of clinically more appropriate margins (up to 15 mm) only the large tumors maintained an improvement of the amaor coverage compared to the BT-boost technique. Conclusions: With BT small cervical cancers and cancers that regress quickly during the cottrse of EBRT can be covered satisfactory, especially when 3D MR/ optimization is used. In case of large tumor volumes and slow regression during the course of treatment the coverage is poor. An IMRT-boost technique can improve the target coverage substantially only when margins for positioning uncertainties are small. HEAD AND NECK CANCER 28 lntraoperative Single Fraction High Brachytherapy For H e a d a n d Neck Cancers
Dose
Rate
S. NagJ, 3/L Koc:, D.E. Sehuller 2, D. Tippin l, ~LC. Greeuld 1Division of Radiation Oncology and ;Department of Otolaryngology, Head and Neck Surgery The Arthur G. James Cancer Hospital and Research Institute, The Ohio State University, Columbus, OH 43210, US
Purpose: To report the results of the use of single fraction high dose rate (HDR) brachytherapy to deliver Iocalized intraoperative radiation therapy at sites in the head and neck region inaccessible to intraoperative electron beam radiotherapy. Methods: After maximal surgical resection, 7.5 to 20 Gy intraoperative high dose rate brachytherapy (IOHDR) was delivered in a shielded operating room to 65 patients using custom made foam or silicon surface applicators with plastic catheters embedded 1 cm apart. Results: The median follow up was 65 months (range 3 to 133 months). The 1, 3, mad 5-year local control rates for the entire group were 77%, 69%, and 59% respectively. The presence of gross disease after surgical resection was the strongest prognosticator, with 5-year survival and local control rates of 17% and 33% respectively, compared to 45% and 64% for microscopic disease, (p<0.01). Patients with IOHDR plus EBRT and close/micro margins had significantly increased local control rates (p<0.05 and p<0.01). The 1, 3, and 5-year overall survival rates were 83%, 63%, and 42% respectively with a median overall survival of 50 months (range 3-133). The disease free survival l, 3, and 5-year results are 72%, 65%, and 52% respectively. The 5-year sm'vival was worse in those with recurrent disease (30%) compared to those with primary disease (45%). Patients with grossly negative margins had significantly increased disease-free survival compared to those with grossly positive margins. (p<0.01). The addition of EBRT to IOHDR significantly increased overall survival (48% and 28%) (p<0.05) and increased the disease-free survival from 53% to 63%. There were no major intraoperative or postoperative complications. Conclusions: IOHDR can be used to treat selected locally advanced head and neck tumors arising at sites inaccessible to IOERT or at institutions not having IOERT. A randomized study with larger number of patients is needed to firmly establish its efficacy in this population group. 29 Exclusive brachytherapy for T1 and T2 squamous cell carcinomas of the velotonsillar area: results in 44 patients
R. Le Scodan:, P. Pommier:~ J.A/L Ardiet 4, ~ Montbarbon:, C. Maid, E Favrel4, P, Zrounba:, 3/[ Poupart 6, P. COruse5, C. Ferlaj, S. Clippe l 1Department of Radiation Oncology, Centre LOon Bdrard, Lyon, France :Head and Neck Oncology, Centre L~on BOrard, Lyon, France 3Medical Statistics, Centre L~on Bdrard, Lyon, France 4Department of Radiation Oncology, Centre Hospitalier LyonSud, Pierre-BOnite, France 5Head and neck Oncology, Centre Hospitalier Lyon-Sud, PierreB~nite, France 6Department of Head and Neck Oncology, H@ital de la Croix Rousse, Lyon, France Purpose: To evaluate the role of interstitial brachytherapy (BT) as an exclusive radiotherapy modality for primary TI-T2 squamous cell carcinomas (SCC) of the velotonsillar area. Methods and Materials: Between 1992 and 2000, 44 patients (40 males; mean age: 57 years; range: 41-83) with T1-T2 SCC of the tonsil (36) and soft palate (8) were treated to the primary with brachytherapy alone (37 pts) or after a limited resection (7 pts). According to the UICC classification, there were 29 T1N0, 1 T1N1, 1 T1N2, 12 T2N0 and 1 T2NI minors. Eight patients had prior external beam radiation therapy (EBRT) for previous head and neck carcinoma (HNC). Nineteen patients had initial neck dissection. Two patients with histological node involvement underwent additional ipsilateral celwical irradiation. The mean brachytherapy prescribed dose was 58.7 Gy (median: 60, range: 50-65). The mean linear activity was 1.51 m C i / c m (median: 1.53, range: 0.91-2.36) and the mean reference dose rate was 58.2 cGy/hnur (median: 55.6, range: 26-104). Results: With a 75 months median follow-up, one patient recurred locally. Isolated nodal relapses occurred in 4 patients, none of whom had initial neck dissection, and salvage therapy was successful in two. Five-year overall and progression-free survival rates were 76% and 68%. A definitive EBRT was possible in 7 of 12 patients who developed a second primary HNC (mean dose: 63.2 Gy, range: 60-70 Gy). Late toxicity was limited to 6 mild soft-tissue necroses, and was significantly
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fistula. Grade 5 complications include 3 cases of pelvic bleeding, all of them in previously irradiated patients treated with 40Gy of PHDRB alone. After a median follow-up of 18.2 months (249+), the 4-year local control rate was 87.4% (22 of 24 patients), the 4-year pelvic control rate 80.1% (21 of 24 patients) and the systemic control rate 40.5% (18 of 24 patients). Four-year overall survival rate was 35% (group 1 14.3%, group 2=52.0%; p=0.001). Conclusions: 1.Group i patients had an excessive vascular toxicity and therefore, PHDRB dose has been decreased to the closest lower level. 2.Group 2 patients present excellent 4-year locoregional (>80%) and survival (>50%) rates. 27 MRI-guided treatment of cervical cancer patients; comparing brachytherapy with an IMRT-boost technique.
M. Ketelaars:~ L. van de Bunt:, G.A.P. de Korf, C. Ceylan:, 1.M. Jiirgenliemk-Schulz I, U.A. van der Heide: :Department of Radiation Oncology 2Department of Radiology, University Medical Center, Utrecht, The Netherlands Introduction: The golden standard in the treatment of advanced cervical cancer consists of a combination of external beam irradiation (EBRT) and brachytherapy (BT). BT is administered to boost the dose to the primary tumor. In this prospective planning study we evaluated and optimized the dose coverage of the primary tumor and the dose to the organs at risk (OAR) of this combined treatment. Additionally, we explored if intensitymodulated radiotherapy (IMRT) would make it possible to integrate the boost dose into the external treatment. Materials and methods: In 10 patients treatment response was monitored with a series of three T2-weighted M R / s c a n s taken before, during- and after the treatment. In addition, two MR/ scans were taken with the BT applicators in situ. The primary gross tumor volumes and OAR were delineated on the MRI data sets and the 3-D dose distributions were calculated. IMRT-boost plans were generated using the delineation of the pre-treatment MRI scans. Because of the internal organ motions, margins of up to 15 mm around the target were used to ensure a proper coverage. Results: The tumors were diverse in size (11 to 188 cc) and showed different regression rates after having delivered the first 30 Gy of EBRT (6 to 75% of the initial size). These rates did not correlate with the initial tumor size. The tumor coverage that could be achieved by the first BT application was satisfactory for small tumors, especially after 3D optimization (coverage of 95-99 %). Tumors with a larger volume (more than 40 cc) at the time of the first BT treatment could not be irradiated adequately, not even after 3D optimization (coverage of 50-70 %). The IMRT-boost technique offered an improvement of the tumor coverage only when very small margins for internal motion were applied (up to 5 mm). In case of clinically more appropriate margins (up to 15 mm) only the large tumors maintained an improvement of the amaor coverage compared to the BT-boost technique. Conclusions: With BT small cervical cancers and cancers that regress quickly during the cottrse of EBRT can be covered satisfactory, especially when 3D MR/ optimization is used. In case of large tumor volumes and slow regression during the course of treatment the coverage is poor. An IMRT-boost technique can improve the target coverage substantially only when margins for positioning uncertainties are small. HEAD AND NECK CANCER 28 lntraoperative Single Fraction High Brachytherapy For H e a d a n d Neck Cancers
Dose
Rate
S. NagJ, 3/L Koc:, D.E. Sehuller 2, D. Tippin l, ~LC. Greeuld 1Division of Radiation Oncology and ;Department of Otolaryngology, Head and Neck Surgery The Arthur G. James Cancer Hospital and Research Institute, The Ohio State University, Columbus, OH 43210, US
Purpose: To report the results of the use of single fraction high dose rate (HDR) brachytherapy to deliver Iocalized intraoperative radiation therapy at sites in the head and neck region inaccessible to intraoperative electron beam radiotherapy. Methods: After maximal surgical resection, 7.5 to 20 Gy intraoperative high dose rate brachytherapy (IOHDR) was delivered in a shielded operating room to 65 patients using custom made foam or silicon surface applicators with plastic catheters embedded 1 cm apart. Results: The median follow up was 65 months (range 3 to 133 months). The 1, 3, mad 5-year local control rates for the entire group were 77%, 69%, and 59% respectively. The presence of gross disease after surgical resection was the strongest prognosticator, with 5-year survival and local control rates of 17% and 33% respectively, compared to 45% and 64% for microscopic disease, (p<0.01). Patients with IOHDR plus EBRT and close/micro margins had significantly increased local control rates (p<0.05 and p<0.01). The 1, 3, and 5-year overall survival rates were 83%, 63%, and 42% respectively with a median overall survival of 50 months (range 3-133). The disease free survival l, 3, and 5-year results are 72%, 65%, and 52% respectively. The 5-year sm'vival was worse in those with recurrent disease (30%) compared to those with primary disease (45%). Patients with grossly negative margins had significantly increased disease-free survival compared to those with grossly positive margins. (p<0.01). The addition of EBRT to IOHDR significantly increased overall survival (48% and 28%) (p<0.05) and increased the disease-free survival from 53% to 63%. There were no major intraoperative or postoperative complications. Conclusions: IOHDR can be used to treat selected locally advanced head and neck tumors arising at sites inaccessible to IOERT or at institutions not having IOERT. A randomized study with larger number of patients is needed to firmly establish its efficacy in this population group. 29 Exclusive brachytherapy for T1 and T2 squamous cell carcinomas of the velotonsillar area: results in 44 patients
R. Le Scodan:, P. Pommier:~ J.A/L Ardiet 4, ~ Montbarbon:, C. Maid, E Favrel4, P, Zrounba:, 3/[ Poupart 6, P. COruse5, C. Ferlaj, S. Clippe l 1Department of Radiation Oncology, Centre LOon Bdrard, Lyon, France :Head and Neck Oncology, Centre L~on BOrard, Lyon, France 3Medical Statistics, Centre L~on Bdrard, Lyon, France 4Department of Radiation Oncology, Centre Hospitalier LyonSud, Pierre-BOnite, France 5Head and neck Oncology, Centre Hospitalier Lyon-Sud, PierreB~nite, France 6Department of Head and Neck Oncology, H@ital de la Croix Rousse, Lyon, France Purpose: To evaluate the role of interstitial brachytherapy (BT) as an exclusive radiotherapy modality for primary TI-T2 squamous cell carcinomas (SCC) of the velotonsillar area. Methods and Materials: Between 1992 and 2000, 44 patients (40 males; mean age: 57 years; range: 41-83) with T1-T2 SCC of the tonsil (36) and soft palate (8) were treated to the primary with brachytherapy alone (37 pts) or after a limited resection (7 pts). According to the UICC classification, there were 29 T1N0, 1 T1N1, 1 T1N2, 12 T2N0 and 1 T2NI minors. Eight patients had prior external beam radiation therapy (EBRT) for previous head and neck carcinoma (HNC). Nineteen patients had initial neck dissection. Two patients with histological node involvement underwent additional ipsilateral celwical irradiation. The mean brachytherapy prescribed dose was 58.7 Gy (median: 60, range: 50-65). The mean linear activity was 1.51 m C i / c m (median: 1.53, range: 0.91-2.36) and the mean reference dose rate was 58.2 cGy/hnur (median: 55.6, range: 26-104). Results: With a 75 months median follow-up, one patient recurred locally. Isolated nodal relapses occurred in 4 patients, none of whom had initial neck dissection, and salvage therapy was successful in two. Five-year overall and progression-free survival rates were 76% and 68%. A definitive EBRT was possible in 7 of 12 patients who developed a second primary HNC (mean dose: 63.2 Gy, range: 60-70 Gy). Late toxicity was limited to 6 mild soft-tissue necroses, and was significantly