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46 Endovascular brachytherapy for de-novo and recurrent femoropopliteal lesions
Proffered Papers
endosonographic (TRUS) guided target definition volume optimized treatment planning and radiation delivery. Aim of this prospective study was to obtain a better local tumor control and keeping toxicity low. Material and Methods: 50 patients (pts.) with histological stated primary cancer of the anal canal without distant metastases were treated. Before treatment in all pts. TRUS and sphincter function measurements were performed. A complementary course of 45 Gy EBRT to the pelvic region with conventional fraction and in case of N+ or T3-T4 in combination with chemotherapy was applied. Within 2-4 weeks after EBRT a high dose-rate IMBT boost was administered to the tumor bed/residual tumor using two fractions of 4-6 Gy. Fraction dose was defined at the surface of the TRUS visible target volume, needle geometry followed the rules of the Paris system. For positioning of the 2-7 needles a special applicator (RASHAapplicator) was used, which contained also the TRUS unit. Results: Ninety-two per cent of the pts. demonstrated a complete tumor remission after treatment was completed. Local recurrence occurred in one patient 15 months posttherapeutically. The disease specific 5 year survival rate was 82 %. 5 pts. had a abdominn-perineal resection (3 with persistent tumor, 1 with a local recurrence and 1 because suspected recurrence). Because of the observed mild proctitis (2pts) and severe sphincter necrosis (3pts) we reduced the initial 6 Gy HDR fraction dose to 2x4 Gy. In the following there were no acute severe side effects due to brachytherapy. Two out of forty-five tumor free patients underwent colostomy because of incontinence and one out of 45 patients suffers under mild incontinence. Conclusions: TRUS-guided HDR-BT boost using the RASHAapplicator enables a excellent rumor control rate aud results in acceptable long term treatment toxicity. Image guided treatment planning and brachytherapy delivery improves the target definition and allows a better dose optimization within the target volume. 44 Interstitial PDR brachytherapy in locally inoperable primary or recurrent rectal cancer J.C. Lindegaar~ P.C. Rasmussen 2, K. Tanderup l, S.IC. Nielsen l, H. Kjeldsen 3, N.C. Langkilde 4, S. Laurberg 2 1Aarhus University Hospital - Department of Oncology, Aarhus Denmark 2Aarhus University Hospital Department of Abdominal Surgery, Aarhus - Denmark 3Aarhus University Hospital Department of Plastic Surgery, Aarhus - Denmark 4Aarhus University Hospital Department of Urology, Aarhus Denmark Aim: To evaluate outcome of extensive surgery combined with interstitial pulsed dose rate (PDR) brachytherapy (BT) in locally inoperable primary or recurrent rectal cancer. Methods and material: 20 patients (7 primary, 13 recurrent) consecutively operated and treated with BT in the period 20012004 were evaluated with regard to tumor control and morbidity (CTCAE v3.0). Patients were screened for disseminated disease by CT, US and MR. PET was not routinely used. Patients were selected for BT when R0 resection close to muscle and bone in the posterior pelvis was thought doubtful based on pelvic MR and palpation in general anaesthesia performed before treatment. Previously mlirradiated patients were treated with preoperative pelvic external beam radiotherapy (EBRT) at a dose of 52-60 Gy/26-30 fx. Previously irradiated patients were given postoperative EBRT at a dose of 25 Gy/15 fx. to the tumor bed around 3 weeks after BT. Following resection of tumor and involved pelvic organs (13 pts. received Bricker bladder), 3-7 soft catheters were sutured in parallel at a distance of 1-1.5 cm and the tumor bed was marked with silver clips. A pediculated myocutaneous flap (Rectus Abdominis 19, Gracilis 1) was used to cover the catheters and the perineal defect. Prescribed PDR dose at 0.5 mm from the catheters was 25-30 Gy, 0.5-0.6 Gy/pulse, 1 pulse/hr. BT was initiated between 4-7 days after the operation. Results: R0 resection was possible in 8, R1 in i1 and R2 resection in 1 patient, respectively. Acute complications were
$20
found in 10 patients, with 7 experiencing grade 3-4 wound infection, 2 pneumonia and 6 septicaemia. However, mortality within 30 days or beyond 30 days during hospitalization was zero. So far limited late toxicity has been encountered with grade 2 neuropathy in 2 patients, soft tissue necrosis in 1, bladder retention in 1 and grade 3 hy&'onephrosis in 1 patient. At present 2 year overall-survival is 59% (+/-14 SE), local control 64% (+/15 SE) and disease free survival of 53% (+/-14 SE). Conclusion: Meaningful disease control and survival can be obtained at an acceptable rate of morbidity in selected patients with inoperable primary or recurrent rectal cancer by employing extensive surgery and interstitial PDR BT. The treatment program continues and is now recruiting patients from all of Denmark. Supported by the Aarhus University Hospital Research Initiative 45 Dose optimization in interstitial brachytherapy of rectal cancer K. Tanderuy, D.R. Olsen 2, C. Grau l, J. Lindegaard, t'L Honord 3, S.K. Nielsen 3 lAarhus University Hospital - Dept. of Oneology Aarhus Denmark 2The Norwegian Radium Hospital Dept. o3" Biophysics, Oslo Norway 3Aarhus University Hospital Dept. of Medical Physics, Aarhus Denmark Purpose: Brachytherapy dose distributions can be optimized by modulation of source dwell times. The purpose of this study was to evaluate dwell time optimized dose distributions in planar interstitial implants in rectal cancer. Materials and methods: Ten consecutive patients with rectal cancer were treated with postoperative interstitial pulsed dose rate brachytherapy. Braehytherapy was delivered by use of the Gammamedl2i afterloader (Varian). Flexible catheters were sutured intra-operatively to the tumor bed in areas with compromised surgical margin. For each patient both optimized and non-optimized CT based dose plans were made. Optimization was performed using the graphical optimization tool of the dose planning system (Brachyvision, Varian). Nonoptimized dose plans were based on equal dwell times in all source channels. The dose plans were normalised such that 95% of the target voIume was covered by the prescribed dose (PD). The homogeneity (homogeneity index, HI), conformity (conformal index, COIN), minirnnm target dose, and high dose volumes (dose larger than 200% PD) were evaluated from dose volume histograms. Mean central doses and mean catheter distances in the central plane were also calculated. Results: The mean catheter distance was 13.5~1.0 mm averaged over all patients. Optimized dose plans showed a significant decrease of 19%±11% in the size of high dose volumes (p 0.006). The homogeneity index and the confm'mal index were significantly improved from 0.49i0.05 to 0.60±0.05 and from 0.63±0.04 to 0.69±0.04, respectively (p=0.001 and p 0.005, respectively). Moreover, the minimum target dose increased significantly from 73%i5% to 80%-k5% of the prescribed dose (p-0.006). Also the ratio of prescribed dose to mean central dose was increased from 0.67±0.07 to 0.76~0.07, indicating that by optimization this dose ratio approaches the value of 0.85 required in the Paris Dosimetry System. In optimized dose plans the mean central dose varied from 120% to 152% of prescribed dose, and it was dependent on the mean distance between sources in the central plane. Conclusion: Dwell time optimization significantly improves the dose distribution for planar implants regarding homogeneity, conformity, minimum target dose, and size of high dose volumes.
46 Endovascular brachytherapy for de-novo and recurrent femoropopliteal lesions. B. Pokra/ac, R. P6tter, R. Wolfram, E. Minar Vienna Medical University - Radiotherapy, Vienna - Austria Background: Endovascular brachytherapy efficiently improves patency in patients with restenosis after angioplasty. This
$21
analysis was designed to evaluate the efficacy of the Iridium-192 brachytherapy for the prevention of restenosis in the femoropopliteal arteries treated for de-nnvo and recurrent lesions. Methods and Results: A total of 199 patients, treated after femoropopliteal angioplasty with either brachytherapy (N=100) or placebo therapy (N=99) within the prospective randomized trials Vienna-2 and Vienna-3 were analyzed according to the stratification criteria of a de-novo or recurrent disease. A total of 66/134 patients with de-novo lesions and 34/65 patients with recurrent lesions had been randomized into the brachytherapy arm. Outcolnes were compared to that of 68 patients with de-novo and 31 patients with recurrent lesions treated as placebo. The incidence of recurrence at 12-months was not significantly different between the brachytherapy and the placebo group for patients with de-nnvo lesions (36.4% and 44.1%, respectively; p=0.32).However, the 12-months recurrence rate was significantly lower in the irradiated group for recurrent lesions compared to the non-irradiated group (26.5% vs. 71.0%; p=0.004). Conclusion: Endovascular brachytherapy with Iridium-192 significantly reduces restenosis after femoropopliteal angioplasty of recurrent, but not of de-novo lesions. 47 A survey of brachytherapy accidents in Japan T. Nishimura Z Hirokawa, T. Yamashita Shizuoka Cancer Center, Juntendo University, Cancer Institute Hospital, Japan
Purpose: To show results of the first whole country survey of medical events in brachytherapy facilities in Japan. Methods and Materials: The questionnaire about medical events of brachytherapy which occurred between September 2002 and August 2004 was sent to 254 facilities in Japan. The cri~.eria of reporting is shown as follows: 1) the total dose delivered differs from the prescribed dose by 20 % or more, 2) the fractionated dose delivered differs from the prescribed dose by 50 % or more, 3) a wrong radioactive source was used, 4) a wrong patient was treated, 5) a wrong mode of treatment was carried out, 6) a wrong site was treated, 7) a sealed source was leaked, 8) a dose to the sites other than the treatment site, 9) an unexpected radiation exposure to an medical personnel. Results: There were 14 reports of medical events from 224 responders. By source type, there were 10 events of H D R 192Iridinm, 3 of HDR 60Co and 1 of LDR 192Iridium. By sites of treatment, there were 10 events o f the cervix or vagina (HDR intracavitary), 1 of the esophagus (HDR), 1 of the bile duct, 1 o f the prostate (HDR interstitial) and 1 of non-treatment. By type o f medical events, there were 6 events o f fractionated dose delivered by >50% of prescribed dose, 3 of treatments not to be started after completion of application, 2 of trouble in source transfer, 1 of a LDR source left in the body, 1 o f an unexpected exposure to medical personnel and 1 of a mistake in operation. There were no cases with serious illness reported in this survey. Discussion: It is the most useful to learn from actual cases to prevent medical events. Until now, medical events of brachytherapy have not been understood well in Japan. Although the number o f reported cases was limited, this survey provided fruitful informations. Human error was considered to be a main cause in the majority of reported medical events. Fish bone analysis revealed that medical events tended to occur in a specific part of the process o f brachytherapy. For example, misadministration was reported in 6 cases in which all events occurred in the process of dose specification o f treatment planning. Lack of communication between a physicians and a physicist was considered as a main cause. For this reason, staffs are recommended to make effort to communicate each other in prevention of medical events. Conclusion: The first whole country survey in Japan provided useful, informations to prevent the medical events in brachytherapy. The survey is expected to be continued in the future.
Proffered Papers
endosonographic (TRUS) guided target definition volume optimized treatment planning and radiation delivery. Aim of this prospective study was to obtain a better local tumor control and keeping toxicity low. Material and Methods: 50 patients (pts.) with histological stated primary cancer of the anal canal without distant metastases were treated. Before treatment in all pts. TRUS and sphincter function measurements were performed. A complementary course of 45 Gy EBRT to the pelvic region with conventional fraction and in case of N+ or T3-T4 in combination with chemotherapy was applied. Within 2-4 weeks after EBRT a high dose-rate IMBT boost was administered to the tumor bed/residual tumor using two fractions of 4-6 Gy. Fraction dose was defined at the surface of the TRUS visible target volume, needle geometry followed the rules of the Paris system. For positioning of the 2-7 needles a special applicator (RASHAapplicator) was used, which contained also the TRUS unit. Results: Ninety-two per cent of the pts. demonstrated a complete tumor remission after treatment was completed. Local recurrence occurred in one patient 15 months posttherapeutically. The disease specific 5 year survival rate was 82 %. 5 pts. had a abdominn-perineal resection (3 with persistent tumor, 1 with a local recurrence and 1 because suspected recurrence). Because of the observed mild proctitis (2pts) and severe sphincter necrosis (3pts) we reduced the initial 6 Gy HDR fraction dose to 2x4 Gy. In the following there were no acute severe side effects due to brachytherapy. Two out of forty-five tumor free patients underwent colostomy because of incontinence and one out of 45 patients suffers under mild incontinence. Conclusions: TRUS-guided HDR-BT boost using the RASHAapplicator enables a excellent rumor control rate aud results in acceptable long term treatment toxicity. Image guided treatment planning and brachytherapy delivery improves the target definition and allows a better dose optimization within the target volume. 44 Interstitial PDR brachytherapy in locally inoperable primary or recurrent rectal cancer J.C. Lindegaar~ P.C. Rasmussen 2, K. Tanderup l, S.IC. Nielsen l, H. Kjeldsen 3, N.C. Langkilde 4, S. Laurberg 2 1Aarhus University Hospital - Department of Oncology, Aarhus Denmark 2Aarhus University Hospital Department of Abdominal Surgery, Aarhus - Denmark 3Aarhus University Hospital Department of Plastic Surgery, Aarhus - Denmark 4Aarhus University Hospital Department of Urology, Aarhus Denmark Aim: To evaluate outcome of extensive surgery combined with interstitial pulsed dose rate (PDR) brachytherapy (BT) in locally inoperable primary or recurrent rectal cancer. Methods and material: 20 patients (7 primary, 13 recurrent) consecutively operated and treated with BT in the period 20012004 were evaluated with regard to tumor control and morbidity (CTCAE v3.0). Patients were screened for disseminated disease by CT, US and MR. PET was not routinely used. Patients were selected for BT when R0 resection close to muscle and bone in the posterior pelvis was thought doubtful based on pelvic MR and palpation in general anaesthesia performed before treatment. Previously mlirradiated patients were treated with preoperative pelvic external beam radiotherapy (EBRT) at a dose of 52-60 Gy/26-30 fx. Previously irradiated patients were given postoperative EBRT at a dose of 25 Gy/15 fx. to the tumor bed around 3 weeks after BT. Following resection of tumor and involved pelvic organs (13 pts. received Bricker bladder), 3-7 soft catheters were sutured in parallel at a distance of 1-1.5 cm and the tumor bed was marked with silver clips. A pediculated myocutaneous flap (Rectus Abdominis 19, Gracilis 1) was used to cover the catheters and the perineal defect. Prescribed PDR dose at 0.5 mm from the catheters was 25-30 Gy, 0.5-0.6 Gy/pulse, 1 pulse/hr. BT was initiated between 4-7 days after the operation. Results: R0 resection was possible in 8, R1 in i1 and R2 resection in 1 patient, respectively. Acute complications were
$20
found in 10 patients, with 7 experiencing grade 3-4 wound infection, 2 pneumonia and 6 septicaemia. However, mortality within 30 days or beyond 30 days during hospitalization was zero. So far limited late toxicity has been encountered with grade 2 neuropathy in 2 patients, soft tissue necrosis in 1, bladder retention in 1 and grade 3 hy&'onephrosis in 1 patient. At present 2 year overall-survival is 59% (+/-14 SE), local control 64% (+/15 SE) and disease free survival of 53% (+/-14 SE). Conclusion: Meaningful disease control and survival can be obtained at an acceptable rate of morbidity in selected patients with inoperable primary or recurrent rectal cancer by employing extensive surgery and interstitial PDR BT. The treatment program continues and is now recruiting patients from all of Denmark. Supported by the Aarhus University Hospital Research Initiative 45 Dose optimization in interstitial brachytherapy of rectal cancer K. Tanderuy, D.R. Olsen 2, C. Grau l, J. Lindegaard, t'L Honord 3, S.K. Nielsen 3 lAarhus University Hospital - Dept. of Oneology Aarhus Denmark 2The Norwegian Radium Hospital Dept. o3" Biophysics, Oslo Norway 3Aarhus University Hospital Dept. of Medical Physics, Aarhus Denmark Purpose: Brachytherapy dose distributions can be optimized by modulation of source dwell times. The purpose of this study was to evaluate dwell time optimized dose distributions in planar interstitial implants in rectal cancer. Materials and methods: Ten consecutive patients with rectal cancer were treated with postoperative interstitial pulsed dose rate brachytherapy. Braehytherapy was delivered by use of the Gammamedl2i afterloader (Varian). Flexible catheters were sutured intra-operatively to the tumor bed in areas with compromised surgical margin. For each patient both optimized and non-optimized CT based dose plans were made. Optimization was performed using the graphical optimization tool of the dose planning system (Brachyvision, Varian). Nonoptimized dose plans were based on equal dwell times in all source channels. The dose plans were normalised such that 95% of the target voIume was covered by the prescribed dose (PD). The homogeneity (homogeneity index, HI), conformity (conformal index, COIN), minirnnm target dose, and high dose volumes (dose larger than 200% PD) were evaluated from dose volume histograms. Mean central doses and mean catheter distances in the central plane were also calculated. Results: The mean catheter distance was 13.5~1.0 mm averaged over all patients. Optimized dose plans showed a significant decrease of 19%±11% in the size of high dose volumes (p 0.006). The homogeneity index and the confm'mal index were significantly improved from 0.49i0.05 to 0.60±0.05 and from 0.63±0.04 to 0.69±0.04, respectively (p=0.001 and p 0.005, respectively). Moreover, the minimum target dose increased significantly from 73%i5% to 80%-k5% of the prescribed dose (p-0.006). Also the ratio of prescribed dose to mean central dose was increased from 0.67±0.07 to 0.76~0.07, indicating that by optimization this dose ratio approaches the value of 0.85 required in the Paris Dosimetry System. In optimized dose plans the mean central dose varied from 120% to 152% of prescribed dose, and it was dependent on the mean distance between sources in the central plane. Conclusion: Dwell time optimization significantly improves the dose distribution for planar implants regarding homogeneity, conformity, minimum target dose, and size of high dose volumes.
46 Endovascular brachytherapy for de-novo and recurrent femoropopliteal lesions. B. Pokra/ac, R. P6tter, R. Wolfram, E. Minar Vienna Medical University - Radiotherapy, Vienna - Austria Background: Endovascular brachytherapy efficiently improves patency in patients with restenosis after angioplasty. This
$21
analysis was designed to evaluate the efficacy of the Iridium-192 brachytherapy for the prevention of restenosis in the femoropopliteal arteries treated for de-nnvo and recurrent lesions. Methods and Results: A total of 199 patients, treated after femoropopliteal angioplasty with either brachytherapy (N=100) or placebo therapy (N=99) within the prospective randomized trials Vienna-2 and Vienna-3 were analyzed according to the stratification criteria of a de-novo or recurrent disease. A total of 66/134 patients with de-novo lesions and 34/65 patients with recurrent lesions had been randomized into the brachytherapy arm. Outcolnes were compared to that of 68 patients with de-novo and 31 patients with recurrent lesions treated as placebo. The incidence of recurrence at 12-months was not significantly different between the brachytherapy and the placebo group for patients with de-nnvo lesions (36.4% and 44.1%, respectively; p=0.32).However, the 12-months recurrence rate was significantly lower in the irradiated group for recurrent lesions compared to the non-irradiated group (26.5% vs. 71.0%; p=0.004). Conclusion: Endovascular brachytherapy with Iridium-192 significantly reduces restenosis after femoropopliteal angioplasty of recurrent, but not of de-novo lesions. 47 A survey of brachytherapy accidents in Japan T. Nishimura Z Hirokawa, T. Yamashita Shizuoka Cancer Center, Juntendo University, Cancer Institute Hospital, Japan
Purpose: To show results of the first whole country survey of medical events in brachytherapy facilities in Japan. Methods and Materials: The questionnaire about medical events of brachytherapy which occurred between September 2002 and August 2004 was sent to 254 facilities in Japan. The cri~.eria of reporting is shown as follows: 1) the total dose delivered differs from the prescribed dose by 20 % or more, 2) the fractionated dose delivered differs from the prescribed dose by 50 % or more, 3) a wrong radioactive source was used, 4) a wrong patient was treated, 5) a wrong mode of treatment was carried out, 6) a wrong site was treated, 7) a sealed source was leaked, 8) a dose to the sites other than the treatment site, 9) an unexpected radiation exposure to an medical personnel. Results: There were 14 reports of medical events from 224 responders. By source type, there were 10 events of H D R 192Iridinm, 3 of HDR 60Co and 1 of LDR 192Iridium. By sites of treatment, there were 10 events o f the cervix or vagina (HDR intracavitary), 1 of the esophagus (HDR), 1 of the bile duct, 1 o f the prostate (HDR interstitial) and 1 of non-treatment. By type o f medical events, there were 6 events o f fractionated dose delivered by >50% of prescribed dose, 3 of treatments not to be started after completion of application, 2 of trouble in source transfer, 1 of a LDR source left in the body, 1 o f an unexpected exposure to medical personnel and 1 of a mistake in operation. There were no cases with serious illness reported in this survey. Discussion: It is the most useful to learn from actual cases to prevent medical events. Until now, medical events of brachytherapy have not been understood well in Japan. Although the number o f reported cases was limited, this survey provided fruitful informations. Human error was considered to be a main cause in the majority of reported medical events. Fish bone analysis revealed that medical events tended to occur in a specific part of the process o f brachytherapy. For example, misadministration was reported in 6 cases in which all events occurred in the process of dose specification o f treatment planning. Lack of communication between a physicians and a physicist was considered as a main cause. For this reason, staffs are recommended to make effort to communicate each other in prevention of medical events. Conclusion: The first whole country survey in Japan provided useful, informations to prevent the medical events in brachytherapy. The survey is expected to be continued in the future.
Proffered Papers