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294 oral RUTHENIUM PLAQUE BRACHYTHERAPY FOR UVEAL MELANOMA
S 116
P ROFFERED PAPER
293 oral EFFICACY AND SAFETY OF HIGH DOSE RATE INTERSTITIAL BRACHYTHERAPY BOOST IN 88 PATIENTS WITH HEAD NECK CANCERS. A. Budrukkar1 , N. Khanna1 , R. Bhalavat1 , V. Murthy1 , S. Ghosh-Laskar1 , T. Gupta1 , R. R. Upreti2 , S. Jamema2 , J. P. Agarwal1 1 TATA M EMORIAL H OSPITAL, Department of Radiation Oncology, Mumbai, India 2 TATA M EMORIAL H OSPITAL, Department of Medical Physics, Mumbai, India Purpose: To study the outcome of patients with cancers of Oropharynx and oral cavity treated with external beam radiation therapy (EBRT) and high dose rate (HDR) interstitial brachytherapy (BRT) boost. Materials: Between January 1996 to December 2007, 88 patients with oral and oropharyngeal cancers were treated with radical intent using combination of EBRT and BRT. All patients after confirmation of histopathology received EBRT to a median dose 46 Gy/ 23# @ 2 Gy/# daily fractionation schedule. BRT was accomplished with HDR 192 Iridium to a median dose of 21 Gy (range 10-36 Gy) with dose per fraction of 4.5Gy and a median activity of 6 Curie (range 2-10 Curie). Median number of catheters used in implant was 9 (range 3-20). The median gap between EBRT and BRT was 20 days (range 6-99 days). Results: There were 77 males and 11 females with a median age of 54 years. Primary site of disease was predominantly oropharynx in 70 (80%) patients and oral cavity in 18 (20%). The most common subsites were base of tongue in 25 (28%), tonsil in 21 (24%), oral tongue in 14 (16%) and soft palate in 12 (14%) patients. Majority (N=62, 71%) patients had T2-T3 primary tumor with median T size of 3cm. Node negative disease was observed clinically in 74 patients (84%). Histopathology was squamous carcinoma in all the patients. Type of growth was proliferative in 36 (41%), ulcerative in 46 (52%) and infiltrative in 6 (7%). Response to EBRT was evaluated under anesthesia at the time of BRT and showed complete response in 65(74%) and partial response in 23 (26%).With a median follow up of 43 months (2-168 months) for surviving patients, 31 patients developed recurrence of which 24 had local recurrence with 3 and 5 year local control rates of 68% and median time to recurrence being 8.4 months (3-29 months). The 3 and 5 year disease free survival was 61% and 60% respectively. The 3 and 5 year overall survival was 70% and 61% respectively. On univariate analysis site of primary (p<0.001), type of growth (p<0.007) and response to EBRT (p<0.001) were the significant factors affecting disease free survival. Mild xerostomia as evaluated by physicians was observed in 65 (74%) patients. Mild to moderate soft tissue fibrosis was seen in 48 (54%) patients. Six patients developed mucosal atrophy and 4 patients had telengectasia. None of them had bone, cartilage or soft tissue necrosis. Conclusions: HDR BRT boost in patients with relatively large oropharyngeal cancers yielded encouraging results for local control and survival with very low complication and xerostomia rates. However the disease free survival was significantly inferior in patients with oral cavity tumors. Based on this data we have launched a randomized trial of comparing intensity modulated radiation therapy boost vs BRT boost for oraopharyngeal tumors . 294 oral RUTHENIUM PLAQUE BRACHYTHERAPY FOR UVEAL MELANOMA D. Smaniotto1 , B. Diletto1 , S. Fersino1 , L. Azario1 , M. G. Sammarco2 , M. Pagliara2 , M. C. Caputo2 , A. Scupola2 , G. D’ Amico2 , L. Tagliaferri1 , S. Luzi1 , E. Balestrazzi2 , M. A. Blasi2 , N. Cellini1 C ATHOLIC U NIVERSITY OF S ACRED H EART, Department of Bioimaging and Radiologic Science, Radiotherapy Institute, Rome, Italy 2 C ATHOLIC U NIVERSITY OF S ACRED H EART, Department of Ophthalmology, Rome, Italy
1
Purpose: Radiotherapy is still the most widely used treatment for uveal melanoma, and the most commonly used form of radiotherapy is brachytherapy, using a radioactive plaque. Ru-106 or I-125 plaques have been proven to be highly efficient in small and medium-sized tumours. A spherically curved plaque containing radioactive sources is sutured onto the sclera underling the tumor, where it remains for 3 to 10 days. A highly localized and intense dose of irradiation is delivered to the tumor, allowing normal tissue sparing. Often, brachytherapy is combined with some form of local ophthalmologic treatment, which is mostly laser coagulation. We evaluated the best treatment with Ru 106 brachyterapy of choroidal and ciliary body melanomas in terms of plaque type and energy according to localization and size of tumour. Materials: Between December 2006 and November 2010, 118 patients with choroidal or ciliary body melanoma were treated by Ruthenium plaque brachytherapy in the Ocular Oncology Centre of Catholic University of Rome. Each case was evaluated in a weekly multidisciplinary meeting with ophthalmologists, radiotherapists and clinical physicists, and it was assessed the best treatment taking into account the following parameters: tumor size, its localization (choroidal or ciliary body), proximity to macula or ocular nerve. Treatment planning was performed by physicists and validated by radiotherapists and ophthalmologists. The dose prescribed to the apix of tumor was 100%.
T UESDAY, M AY 10, 2011 Results: : The median age of patients was 63 years (range:18-91); 60 tumors were localized into the right eye, 22 lesions were localized into the ciliary body and 96 into the choroid. The diameters of the lesions before treatment were: medium height 3,7 mm (median: 3,49; range:2,1-8,8), medium trasversal diameter 8,8 mm (median:8,4; range:5,09-15), medium longitudinal diameter 9,3 (median: 9,4; range:4,16-14,9). We used spherically curved plaques of Ru 106 (BEBIG PLAQUES, in particularly: CCA in 40 cases (34%), COB in 32 cases (27%), CCB in 28 cases (24%) and CCD in 18 cases (15%), with this active zone diameter of plaques: CCA 13 mm, CCB 18 mm, COB 17 mm (notched for tumors near macula or optical nerve). The mean value of dose rate was 164.17 cGy/h (median 153.77, range 286.57 - 84.31). No patients had acute toxicity; 22 patients had a reduction of visual acuity > 3/10 at 1 year. Two patients had retinal detachment and one had haemovitreous. Conclusions: Brachytherapy with Ru 106 plaques is an easily implementable technique, able to treat tumors of choroidal and ciliary body, moreover is a well tolerated treatment with a low toxicity profile. 295 oral BRACHYTHERAPY IN CHILDREN WITH RHABDOMYOSARCOMAS OF THE NASOLABIAL FOLD: TREATMENT RESULTS OF 16 CASES R. Mazeron1 , O. Oberlin1 , I. Dumas1 , F. Kolb1 , C. Haie-Meder1 1 I NSTITUT G USTAVE R OUSSY, Villejuif, France Purpose: Rhabdomyosarcomas (RMS) are rare, accounting for about 2-4% of all malignancies in children and can occur in nearly all parts of the body. The nasolabial fold is difficult to manage due to cosmetic considerations and functional role. Therefore, brachytherapy (BT) has been proposed to improve local control and limit irradiated volumes or excisions. A retrospective study was conducted to assess the role of BT in the management of RMS of nasolabial fold. Materials: The medical reports of 16 patients treated for RMS with brachytherapy between 1971 and 2005 were identified from the registries of the BT department and retrospectively reviewed. At the time of diagnosis, patients age ranged from 5 months to 13.5 years. Ten were younger than 3 years. Half of the patients were male. Histological subtypes included 10 embryonal RMS and 6 alveolar. At diagnosis, the tumour diameter was 20 mm (6-45). For all children the treatment began with chemotherapy (1 to 12 cycles, median: 6), and 11 children received IVA (ifosfamide, vincristine, actinomycin D). In two cases, BT was used as part of a salvage treatment after chemotherapy. In four cases, BT was the sole local treatment offered. In most cases, the local treatment was followed by chemotherapy (12/16 cases). Results: Median follow-up was 4.4 years (1.7-33). Two lesions were classified IIA and the remaining III, according to the IRS. At the time of local treatment, median tumour diameter was 11 mm (0-26), and 6 children were in complete clinical remission. In 12 cases, BT was used in combination with surgery. For those children, a complete resection was achieved in 4 cases, positive microscopic margins for 7, and macroscopic tumour remnant in 1 case. Implantations were performed according to the Paris system rules, and the treatment delivered by low dose rate (median: 0.48 Gy/h, 0.32-0.66) with 192 I wires (median length 3.5 cm) and a median number of sources of 3 (2 to 7). Two plans were needed to cover 6 volumes. The doses delivered ranged from 50 to 70 Gy, depending on the residual tumour volume after chemotherapy and the status of the margins in case of surgery. The median volume of 100% isodose (V100%) was 6 cm3 (2.7-18.1). 6 children never relapsed. Of them, 5 had embryonal RMS. Out of the 6 patients treated for alveolar RMS, 5 relapsed. Ten patients experienced relapses. 5 local failures (31%) were reported from which 4 were in the irradiated volume. Among the 8 patients with incomplete resection, 3 local relapses were observed. 6 regional (cervical lymph nodes) and 2 metastatic relapses (bone and muscles) were also reported. The median time to relapse was 6.5 months and all except one occurred within 9 months. Only two relapses were salvaged: one local with chemotherapy intensification and surgery, and one regional with chemo and EBRT. At the time of analysis, 8 patients were alive, 1 dead. 7 were lost to follow up but were receiving palliative care at their last follow-up or had returned to their native country because of the terminal nature of their disease. Therefore, overall survival at 5 years was 50%. Conclusions: In this particular site, BT gives a local control lower than in pelvic sites (vagina or bladder/prostate) but the patients in this series also had a poor regional prognosis. This data raises the question of a more aggressive local treatment and the management of cervical lymph nodes.
P ROFFERED PAPER
293 oral EFFICACY AND SAFETY OF HIGH DOSE RATE INTERSTITIAL BRACHYTHERAPY BOOST IN 88 PATIENTS WITH HEAD NECK CANCERS. A. Budrukkar1 , N. Khanna1 , R. Bhalavat1 , V. Murthy1 , S. Ghosh-Laskar1 , T. Gupta1 , R. R. Upreti2 , S. Jamema2 , J. P. Agarwal1 1 TATA M EMORIAL H OSPITAL, Department of Radiation Oncology, Mumbai, India 2 TATA M EMORIAL H OSPITAL, Department of Medical Physics, Mumbai, India Purpose: To study the outcome of patients with cancers of Oropharynx and oral cavity treated with external beam radiation therapy (EBRT) and high dose rate (HDR) interstitial brachytherapy (BRT) boost. Materials: Between January 1996 to December 2007, 88 patients with oral and oropharyngeal cancers were treated with radical intent using combination of EBRT and BRT. All patients after confirmation of histopathology received EBRT to a median dose 46 Gy/ 23# @ 2 Gy/# daily fractionation schedule. BRT was accomplished with HDR 192 Iridium to a median dose of 21 Gy (range 10-36 Gy) with dose per fraction of 4.5Gy and a median activity of 6 Curie (range 2-10 Curie). Median number of catheters used in implant was 9 (range 3-20). The median gap between EBRT and BRT was 20 days (range 6-99 days). Results: There were 77 males and 11 females with a median age of 54 years. Primary site of disease was predominantly oropharynx in 70 (80%) patients and oral cavity in 18 (20%). The most common subsites were base of tongue in 25 (28%), tonsil in 21 (24%), oral tongue in 14 (16%) and soft palate in 12 (14%) patients. Majority (N=62, 71%) patients had T2-T3 primary tumor with median T size of 3cm. Node negative disease was observed clinically in 74 patients (84%). Histopathology was squamous carcinoma in all the patients. Type of growth was proliferative in 36 (41%), ulcerative in 46 (52%) and infiltrative in 6 (7%). Response to EBRT was evaluated under anesthesia at the time of BRT and showed complete response in 65(74%) and partial response in 23 (26%).With a median follow up of 43 months (2-168 months) for surviving patients, 31 patients developed recurrence of which 24 had local recurrence with 3 and 5 year local control rates of 68% and median time to recurrence being 8.4 months (3-29 months). The 3 and 5 year disease free survival was 61% and 60% respectively. The 3 and 5 year overall survival was 70% and 61% respectively. On univariate analysis site of primary (p<0.001), type of growth (p<0.007) and response to EBRT (p<0.001) were the significant factors affecting disease free survival. Mild xerostomia as evaluated by physicians was observed in 65 (74%) patients. Mild to moderate soft tissue fibrosis was seen in 48 (54%) patients. Six patients developed mucosal atrophy and 4 patients had telengectasia. None of them had bone, cartilage or soft tissue necrosis. Conclusions: HDR BRT boost in patients with relatively large oropharyngeal cancers yielded encouraging results for local control and survival with very low complication and xerostomia rates. However the disease free survival was significantly inferior in patients with oral cavity tumors. Based on this data we have launched a randomized trial of comparing intensity modulated radiation therapy boost vs BRT boost for oraopharyngeal tumors . 294 oral RUTHENIUM PLAQUE BRACHYTHERAPY FOR UVEAL MELANOMA D. Smaniotto1 , B. Diletto1 , S. Fersino1 , L. Azario1 , M. G. Sammarco2 , M. Pagliara2 , M. C. Caputo2 , A. Scupola2 , G. D’ Amico2 , L. Tagliaferri1 , S. Luzi1 , E. Balestrazzi2 , M. A. Blasi2 , N. Cellini1 C ATHOLIC U NIVERSITY OF S ACRED H EART, Department of Bioimaging and Radiologic Science, Radiotherapy Institute, Rome, Italy 2 C ATHOLIC U NIVERSITY OF S ACRED H EART, Department of Ophthalmology, Rome, Italy
1
Purpose: Radiotherapy is still the most widely used treatment for uveal melanoma, and the most commonly used form of radiotherapy is brachytherapy, using a radioactive plaque. Ru-106 or I-125 plaques have been proven to be highly efficient in small and medium-sized tumours. A spherically curved plaque containing radioactive sources is sutured onto the sclera underling the tumor, where it remains for 3 to 10 days. A highly localized and intense dose of irradiation is delivered to the tumor, allowing normal tissue sparing. Often, brachytherapy is combined with some form of local ophthalmologic treatment, which is mostly laser coagulation. We evaluated the best treatment with Ru 106 brachyterapy of choroidal and ciliary body melanomas in terms of plaque type and energy according to localization and size of tumour. Materials: Between December 2006 and November 2010, 118 patients with choroidal or ciliary body melanoma were treated by Ruthenium plaque brachytherapy in the Ocular Oncology Centre of Catholic University of Rome. Each case was evaluated in a weekly multidisciplinary meeting with ophthalmologists, radiotherapists and clinical physicists, and it was assessed the best treatment taking into account the following parameters: tumor size, its localization (choroidal or ciliary body), proximity to macula or ocular nerve. Treatment planning was performed by physicists and validated by radiotherapists and ophthalmologists. The dose prescribed to the apix of tumor was 100%.
T UESDAY, M AY 10, 2011 Results: : The median age of patients was 63 years (range:18-91); 60 tumors were localized into the right eye, 22 lesions were localized into the ciliary body and 96 into the choroid. The diameters of the lesions before treatment were: medium height 3,7 mm (median: 3,49; range:2,1-8,8), medium trasversal diameter 8,8 mm (median:8,4; range:5,09-15), medium longitudinal diameter 9,3 (median: 9,4; range:4,16-14,9). We used spherically curved plaques of Ru 106 (BEBIG PLAQUES, in particularly: CCA in 40 cases (34%), COB in 32 cases (27%), CCB in 28 cases (24%) and CCD in 18 cases (15%), with this active zone diameter of plaques: CCA 13 mm, CCB 18 mm, COB 17 mm (notched for tumors near macula or optical nerve). The mean value of dose rate was 164.17 cGy/h (median 153.77, range 286.57 - 84.31). No patients had acute toxicity; 22 patients had a reduction of visual acuity > 3/10 at 1 year. Two patients had retinal detachment and one had haemovitreous. Conclusions: Brachytherapy with Ru 106 plaques is an easily implementable technique, able to treat tumors of choroidal and ciliary body, moreover is a well tolerated treatment with a low toxicity profile. 295 oral BRACHYTHERAPY IN CHILDREN WITH RHABDOMYOSARCOMAS OF THE NASOLABIAL FOLD: TREATMENT RESULTS OF 16 CASES R. Mazeron1 , O. Oberlin1 , I. Dumas1 , F. Kolb1 , C. Haie-Meder1 1 I NSTITUT G USTAVE R OUSSY, Villejuif, France Purpose: Rhabdomyosarcomas (RMS) are rare, accounting for about 2-4% of all malignancies in children and can occur in nearly all parts of the body. The nasolabial fold is difficult to manage due to cosmetic considerations and functional role. Therefore, brachytherapy (BT) has been proposed to improve local control and limit irradiated volumes or excisions. A retrospective study was conducted to assess the role of BT in the management of RMS of nasolabial fold. Materials: The medical reports of 16 patients treated for RMS with brachytherapy between 1971 and 2005 were identified from the registries of the BT department and retrospectively reviewed. At the time of diagnosis, patients age ranged from 5 months to 13.5 years. Ten were younger than 3 years. Half of the patients were male. Histological subtypes included 10 embryonal RMS and 6 alveolar. At diagnosis, the tumour diameter was 20 mm (6-45). For all children the treatment began with chemotherapy (1 to 12 cycles, median: 6), and 11 children received IVA (ifosfamide, vincristine, actinomycin D). In two cases, BT was used as part of a salvage treatment after chemotherapy. In four cases, BT was the sole local treatment offered. In most cases, the local treatment was followed by chemotherapy (12/16 cases). Results: Median follow-up was 4.4 years (1.7-33). Two lesions were classified IIA and the remaining III, according to the IRS. At the time of local treatment, median tumour diameter was 11 mm (0-26), and 6 children were in complete clinical remission. In 12 cases, BT was used in combination with surgery. For those children, a complete resection was achieved in 4 cases, positive microscopic margins for 7, and macroscopic tumour remnant in 1 case. Implantations were performed according to the Paris system rules, and the treatment delivered by low dose rate (median: 0.48 Gy/h, 0.32-0.66) with 192 I wires (median length 3.5 cm) and a median number of sources of 3 (2 to 7). Two plans were needed to cover 6 volumes. The doses delivered ranged from 50 to 70 Gy, depending on the residual tumour volume after chemotherapy and the status of the margins in case of surgery. The median volume of 100% isodose (V100%) was 6 cm3 (2.7-18.1). 6 children never relapsed. Of them, 5 had embryonal RMS. Out of the 6 patients treated for alveolar RMS, 5 relapsed. Ten patients experienced relapses. 5 local failures (31%) were reported from which 4 were in the irradiated volume. Among the 8 patients with incomplete resection, 3 local relapses were observed. 6 regional (cervical lymph nodes) and 2 metastatic relapses (bone and muscles) were also reported. The median time to relapse was 6.5 months and all except one occurred within 9 months. Only two relapses were salvaged: one local with chemotherapy intensification and surgery, and one regional with chemo and EBRT. At the time of analysis, 8 patients were alive, 1 dead. 7 were lost to follow up but were receiving palliative care at their last follow-up or had returned to their native country because of the terminal nature of their disease. Therefore, overall survival at 5 years was 50%. Conclusions: In this particular site, BT gives a local control lower than in pelvic sites (vagina or bladder/prostate) but the patients in this series also had a poor regional prognosis. This data raises the question of a more aggressive local treatment and the management of cervical lymph nodes.