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34 Brachytherapy in head and neck tumors with mould technique. A new development
s30 33 Comparison of three boost techniques (intra-operative, postoperative brachytherapy and external irradiation) in conservative treatment of breast cancer C. HENNEQUIN, M. ESPIE, E. BOURSTYN, M.LEVARDON, P. CLOT, L. MIGNOT, M. MARTY, C.MAYLIN Service de Cancerologie-Radiotherapie, Hbpital Saint-Louis, Paris Conservative treatment of breast cancer consist in tumorectomy and external irradiation (45 to 50 Gy) of the mammary gland. Many physician add a boost dose (15 to 20 Gy) on the tumoricidal bed, arguing that local relapse frequently occur at this place. Technique for this boost depends of the localisation, size and histological type of the tumor and of the habit of the radiation oncologist. Brachytherapy usually irradiated a lesser volume than external irradiation, and offer a dose distribution which could improve the local control. Irma-operative settlement of plastic tubes (TP) have some technical advantages (better determination of the target volume, quickness of the local adjuvant treatment, easy placement of the TP) and practical advantage (only one general anesthesia, decrease of the radiation treatment duration). We have compared the outcome of the three technics used in Saint-Louis hospital on . local control and esthetic. Pooulatlon: 1002 pts have been treated for an early breast cancer beetween l/1/1980 and 31/12/91 with a conservative aDDroach. All have received 45 Gy on mammary gland. Boost technique (20 Gy) was: intra-operative brachytherapy (IOB): 796 pts; post-operative brachytherapy (POB): 146 pts; Small photons fields (Ph): 37; electrons (E): 9, no boost: 14. Median follow-up was similar for the five groups (5 1 months) Local relapses occured in 80 pts (8%) and was influenced by age, extensive intra-ductal component and tumor size. Prognosis factors are equally disributed beetween all the groups Results: Local relapses have occured in: IOB: 8,2%; POB: 5,4%; Ph: 8.1% ; E: 11.1%; no boost: 14.2%. These differences are not sienificant. Esthetical results as iudaed bv the Dhvsician in charee of ths patients are considered good 0; excellent’i& IOB: 73%; P’OB: 71%: Ph: 62%: E: 44%: No boost: 64%. These results aDDrOaCh 11 significance in favor of brachytherapy. Conclusion: Intra-operative brachytherapy offers many practical advantages over others techniques, with a similar efficiency and maybe better esthetical results.
34 BRACHYTHERAPY IN HEAD AND NECK TUMORS MOULD TECHNIQUE. A NEW DEVELOPMENT.
WITH
Blank, L.E.C.M., Schouwenburg, P.F., Gonzalez Gonzalez, D., De Boer, J.B., VoiIte, P.A. and Kupperman, D. Academisch Medisch Centrum, Amsterdam, The Netherlands. The preliminary findings in 9 patients treated with local excision and a brachytherapy mould technique in head and neck, rhabdomyosarcoma f7), a recurrent angiomafl) and a recurrent squamous cell carcinoma(l) are presented. The age of the patients with rhabdomyosarcoma ranged from 2 to 8 years, the other patients 41 and 50 years of age. All patients were pretreated with chemotherapy (7) and/or radiation (1) or surgery and radiation therapy (1). The tumor dimension at the time of excision ranged from 1x1 to 8x6 cm. The treatment consisted of local excision and the application of a mould of Gutta Percha loaded with brachytherapy catheters in the surgical bed during operation. Gutta Percha is a natural rubber compound which can be shaped to fit the operation cavity after heating in water. The subcutis and skin are closed over the mould. After recovery (2-3 days) and dose calculation treatment was started using the MicroSelectron LDR. The prescribed dose was 40-50 Gy at 5 mm from the surface of the mould. Dose rate ranged 55-l 10 cGy h-l. After treatment the mould is removed and a vascularized free muscle transplant is used for reconstruction by the plastic surgeon. Despite the large volumes treated this way, treatment was well tolerated. The mould caused little or no mechanical trauma to the soft tissue. The muscle transplant for reconstruction is not damaged by radiotherapy and helps to diminish radiation effect on normal surrounding tissue. The irregular treatment volume can be adequately covered by the mould. Follow up ranged 1-l 2 months with no local recurrence. Technique and acute toxicity will be discussed.
36 35 INTRAOPERATIVB HIGH DOSE RATE BRACHYTHERAPY FOR HEAD AND NECK CANCER S. Nag, S. Diit, R. Mountain, D. Schuller ArthurG. JamesCancer Hospitaland Research Institute The Ohio State University, Cohunbus, OH, USA Local control of advanced Stage III and Stage IV head and neck cancer remains a problem. Intraoperative electron beam radiotherapy (IOEBRT) has been used to boost radiation doses. However, many sites, especially in the base of the skull and sinuses, are inaccessible to IOEBRT. To overcome the limitations of IOBBRT and conventional brachytherapy, we used intraoperative high dose rate brachytherapy (IOHDR) to boost external beam doses after resection of all clinically detectable disease, but with close margins, in 20 anesthetized patients with head and neck cancer. Because the high dose rata brachytherapy machine was easily transported from the radiation oncology department into the shielded operadng room, it was not necessary to move tbe anesthetized patient nor was a dedicated radiation machine required. Doses of 7.5-20 Gy (dependant on residual tumor volume) were given to the tumor bed after resection, using newly developed intraoperative applicators and preplanned dosimetry. Treatment time averaged from 4560 minutes. Doses to normal tissues were reduced by shielding with lead or displacing using gauze. Local tumor control was 80% (92% in primary cases versus 62% in recurrent cases). Overall disease-free survival was 70%) with a median follow-up of 10 months (range 3-17 months). No intraoperative complications were noted. One patient developed an orocutaneous fistula after reconstruction. Although the follow-up has been short, we feel that IOHDR is a safe and effective modality of treatment in advanced and recurrent bead and neck cancers and is particularly useful in sites that are not easily accessible to intraoperative electron beam radiation therapy.
SOFT TISSUE SARCOMAS. THE ROLE OF INTRAOPERATIVE BRACHYTHERAPY
L. Cionini , P. Olmi, S. Marzano, S. Mussari Radiotherapy Unit - University of Florence - Italy
From 211979to 61199367 pts (m = 34, f = 27, age range = 8-77, median age = 50) with non metastatic soft tissue sarcomas (STS) were treated by surgery and post-operative radiotherapy. Site of the tumor: upper limb 14 cases, thigh 26, gluteal region 5, thoracic or abdominal wall 22. Thirty-seven patients were previously untreated and 30 presented with locally recurrent disease. Tumor size; 44~5 cm 15~5 cm and cl0 cm, 8>10 cm. Histoloey: malignant fibrous histiocytoma (14), liposarcoma (25), fibrosarcoma (1 l), synovialsarcoma (5), leiomyosarcoma (5). others (7). Treatment: Surgery: radical conservative excision 56; non radical excision 1I; Radiotherapy: in all patients after tumor removal intraoperative implant of plastic guides for afterloading Iridium 192 wires brachytherapy; in 53 cases the implant was followed by external irradiation. &: implant 15 Gy - 40 Gy; external irradiation 20 Gy - 60 Gy, implant only 35 Gy - 70 Gy. No patient underwent amputation. No patient had functional sequelae; four patients with tumor localized in the lower limb had a mild oedema; three had a post-treatment pain. Results: 7 local recurrences, 7 distant metastases: 4 both events. Five pts with local recurrence were salvaged by surgery +/- further radiotherapy. One patient with lung metastases was salvaged by chemotherapy and lung metastasectomy. Conclusions: intraoperative brachytherapy in combination with external irradiation as adjuvant treatment to surgery in soft tissue sarcomas is a simple technique allowing the delivery of high radiation doses with minimal morbidity and the advantage of a shorter overall [reatment time.
34 BRACHYTHERAPY IN HEAD AND NECK TUMORS MOULD TECHNIQUE. A NEW DEVELOPMENT.
WITH
Blank, L.E.C.M., Schouwenburg, P.F., Gonzalez Gonzalez, D., De Boer, J.B., VoiIte, P.A. and Kupperman, D. Academisch Medisch Centrum, Amsterdam, The Netherlands. The preliminary findings in 9 patients treated with local excision and a brachytherapy mould technique in head and neck, rhabdomyosarcoma f7), a recurrent angiomafl) and a recurrent squamous cell carcinoma(l) are presented. The age of the patients with rhabdomyosarcoma ranged from 2 to 8 years, the other patients 41 and 50 years of age. All patients were pretreated with chemotherapy (7) and/or radiation (1) or surgery and radiation therapy (1). The tumor dimension at the time of excision ranged from 1x1 to 8x6 cm. The treatment consisted of local excision and the application of a mould of Gutta Percha loaded with brachytherapy catheters in the surgical bed during operation. Gutta Percha is a natural rubber compound which can be shaped to fit the operation cavity after heating in water. The subcutis and skin are closed over the mould. After recovery (2-3 days) and dose calculation treatment was started using the MicroSelectron LDR. The prescribed dose was 40-50 Gy at 5 mm from the surface of the mould. Dose rate ranged 55-l 10 cGy h-l. After treatment the mould is removed and a vascularized free muscle transplant is used for reconstruction by the plastic surgeon. Despite the large volumes treated this way, treatment was well tolerated. The mould caused little or no mechanical trauma to the soft tissue. The muscle transplant for reconstruction is not damaged by radiotherapy and helps to diminish radiation effect on normal surrounding tissue. The irregular treatment volume can be adequately covered by the mould. Follow up ranged 1-l 2 months with no local recurrence. Technique and acute toxicity will be discussed.
36 35 INTRAOPERATIVB HIGH DOSE RATE BRACHYTHERAPY FOR HEAD AND NECK CANCER S. Nag, S. Diit, R. Mountain, D. Schuller ArthurG. JamesCancer Hospitaland Research Institute The Ohio State University, Cohunbus, OH, USA Local control of advanced Stage III and Stage IV head and neck cancer remains a problem. Intraoperative electron beam radiotherapy (IOEBRT) has been used to boost radiation doses. However, many sites, especially in the base of the skull and sinuses, are inaccessible to IOEBRT. To overcome the limitations of IOBBRT and conventional brachytherapy, we used intraoperative high dose rate brachytherapy (IOHDR) to boost external beam doses after resection of all clinically detectable disease, but with close margins, in 20 anesthetized patients with head and neck cancer. Because the high dose rata brachytherapy machine was easily transported from the radiation oncology department into the shielded operadng room, it was not necessary to move tbe anesthetized patient nor was a dedicated radiation machine required. Doses of 7.5-20 Gy (dependant on residual tumor volume) were given to the tumor bed after resection, using newly developed intraoperative applicators and preplanned dosimetry. Treatment time averaged from 4560 minutes. Doses to normal tissues were reduced by shielding with lead or displacing using gauze. Local tumor control was 80% (92% in primary cases versus 62% in recurrent cases). Overall disease-free survival was 70%) with a median follow-up of 10 months (range 3-17 months). No intraoperative complications were noted. One patient developed an orocutaneous fistula after reconstruction. Although the follow-up has been short, we feel that IOHDR is a safe and effective modality of treatment in advanced and recurrent bead and neck cancers and is particularly useful in sites that are not easily accessible to intraoperative electron beam radiation therapy.
SOFT TISSUE SARCOMAS. THE ROLE OF INTRAOPERATIVE BRACHYTHERAPY
L. Cionini , P. Olmi, S. Marzano, S. Mussari Radiotherapy Unit - University of Florence - Italy
From 211979to 61199367 pts (m = 34, f = 27, age range = 8-77, median age = 50) with non metastatic soft tissue sarcomas (STS) were treated by surgery and post-operative radiotherapy. Site of the tumor: upper limb 14 cases, thigh 26, gluteal region 5, thoracic or abdominal wall 22. Thirty-seven patients were previously untreated and 30 presented with locally recurrent disease. Tumor size; 44~5 cm 15~5 cm and cl0 cm, 8>10 cm. Histoloey: malignant fibrous histiocytoma (14), liposarcoma (25), fibrosarcoma (1 l), synovialsarcoma (5), leiomyosarcoma (5). others (7). Treatment: Surgery: radical conservative excision 56; non radical excision 1I; Radiotherapy: in all patients after tumor removal intraoperative implant of plastic guides for afterloading Iridium 192 wires brachytherapy; in 53 cases the implant was followed by external irradiation. &: implant 15 Gy - 40 Gy; external irradiation 20 Gy - 60 Gy, implant only 35 Gy - 70 Gy. No patient underwent amputation. No patient had functional sequelae; four patients with tumor localized in the lower limb had a mild oedema; three had a post-treatment pain. Results: 7 local recurrences, 7 distant metastases: 4 both events. Five pts with local recurrence were salvaged by surgery +/- further radiotherapy. One patient with lung metastases was salvaged by chemotherapy and lung metastasectomy. Conclusions: intraoperative brachytherapy in combination with external irradiation as adjuvant treatment to surgery in soft tissue sarcomas is a simple technique allowing the delivery of high radiation doses with minimal morbidity and the advantage of a shorter overall [reatment time.