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58 Post-treatment visual aculty in patients treated with eplscleral plaque therapy for choroidal melanoma: Dose and dose rate effects
s15
57
58
HIGH-DOSE
RATE
INTRA-OPERATIVE
THERAPY FOR LOCAL COLORECTAL CANCER
ADVANCED
Harrison
B, Enker
LB,
Minsky NY,
B
Mychalczak
Memorial
RADIATION AND
W, Anderson
Sloan-Kettering
Post-Trea,meo, Pt.q~e Ther.P,
RECURRENT
Cancer
L. Cohen
Center,
AE.
New
York,
Tre.lcd Wttb Eptseler., Dose and Dose Rate E,Tec,a
Robert Jones. Etiubeth Gore. Wittinm Mieter. Michael Gillin. Katkaine Atband, and Beth Erickson Radiation Oncology, Medical College of Wisconsin, Mitwvaukee. Wt. VSA
U S A.
In an effort to improve the local control for advanced and recurrent cancers of the rectum, we have integrated high-dose rate intra-operative radiation therapy (HDR-IORT) into the treatment program Between I l/92 and 10195. 47 patients (pm) were treated Ther were 26 males and 21 females whose ages ranged There were 19 pts with primary from 30-80 (median = 62) years unresectable rectal cancer, and 28 pts who were treated for recurrent rectal mous
Histology
cancer
cancer
was adenocarcinoma
- 45 pts, squa-
(median
The range of follow-up is I-34 months The majority of primary unresectable = I4 months)
received
pre-operative
- 2 pts
radiation
chemotherapy (S-FU underwent resection
therapy
(4SOO-5040
cGy)
pts with
with Leucovorin) 4-6 weeks later. they For the 28 pts + HDR-IORT (1200 cGy)
with recurrent cancer, the majority received surgery and HDRIORT alone because they had received prior RT For the pts with primary unresectable disease. actuarial 2-year local control was 77%.
Acuky ,a Path@ Cboroidal Melsaoma:
Vlrunl
For
actuarial
free survival pts with
distant
metastasis-free
was 66%.
and overall
recurrent
659’0, distant
disease.
metastasis-free
actuarial survival
survival survival 2-year
was 71%.
local
disease For those
was 84% control
rate was
was 65%.
disease free Complications survival was 47%. and overall survival was 6 I% occurred in 36% There were no cases where the anatomical distribution of disease, or technical limitations prevented the We conclude that this technique adequate delivery of HDR-IORT was most versatile, and enabled all appropriate IORT The preliminary data in terms of local encouraging, even for the poor recurrent cancer
prognostic
pts to receive control are
sub-group
of pts with
59 COMBINED INTERSTITIAL AND PERCUTANEOUS FOR LOCALIZED PROSTATE CANCER
Purpprr: To determine the relationship belween Lbe long-knm visust fun&on and Le dose and dose raks delivered 10 criticat cculv suuf,u~s in padents with cboroidal melmama lmakd with lz* I cpirckrd plaque nadiotbexapy. Melbods From 1987 IO 1993, 63 paljenln un&nvent 1251episcleral plaque applicluion for the kecnbnen, of cbomidat melanoma. Mean ,umor beigh, was 4.6 nun Wage 1.7-8.3 mm). Ptaquc~ utihzed were of COMS design. Doses and dose rates at Lbe tumor apex. macuk. and optic disc were obtiained Visual achy da,= prior u) and af,er ptque appttcalion was available for 52 patienls. 9 padems were excluded fmm anllyeis secondary Lo co-marbiditier or disespe progression. 43 records were scored 10 assess if a decrease in visvat acuity of Z 2 tines on a standard Snekn eye cbti had occurred Statislical analysis was performed using chi-square tests of significance. &t&t&s Of ,be 63 total pstien& 59 (93.7%) were she at a median follow-up of 36 months Local progression occumd in 7/63 (tt.t%). Median dose and dose rate to the tumor spa were 90 Gy and 97.2 EGyh. respectively. Of Ihe 43 patients with post-lrcnlment visual acuity mslyrir, 28 (65.1%) experienced visual toss of Z 2 tines on a slandard eye chart. Median dme LOaltered visull acui,y WBF20 months. Median dose and dose E&S 10 the macula in patients wirh a significan, wsuat toss were t23 3 Gy and 122.5 ffiyihr. respecdvety. compared wilh 38 Gy and 51.9 cGyh in those widmut nalPble visuat change. ‘&se differences reached statistical significance a, a dose axl dose rate ID the macula al 82.0 Gy (p< .O,) and 72 diyh, (p SW,), respectively. Medim dose and dose races lo he oplic disc in patients wlh visual toss ad lbo.se wilb &able eyesight were 68.3 Gyl69 cGyh and 34.7 Gy 01.6 cGyhr. respzc,ively. The difference in dose ,o Lhe oplic disc WBSs+ficanl a, 43 Gy (p< .0X); dose rak Lo the disc demonsw’a(ed a Lrend toward rigniticancc a, 63 cGy/hr (p= ,051. Conclusion: Patienw in our series Ire&d with 12*1 plaque brachydxrapy for cbomidal melanoma eroerienced favorable Nmor contlot. but wilh a measurable incidence of decreased ksusl acuify. Bolb totll dose and dose ratis 10 Ihe macuta and optic disc colxtati s~angty with post-ecalmen, visual outcome. This information may be vetuabtc in decisions &.xL the dose and dose rates wed to &eat cboroidal melanomas and the risk of visual decline.
RADIOTHERAPY
S. Dinaes ; El. Boehmer ‘, S Deger ‘, T Wiegel ‘, SA Loening ‘, W V Budach ‘. ‘Dept. of Radrotherapy. ‘Dept. of Urology, Hinkelbein University Hdsprtal Charite, 3Un~vers~ty Hospital Sentamin-Franklrn, Berlin. FRG. Obieclives: To test the feasibrlrty and effectrveness 01 a combrned tnterstrttal and percutaneous radtotherapy approach for localtzed prostate cancer a prospectwe phase II trral was carned out. Methods: Between lo/92 and 12/94 69 evaluable p&rents (pts.) were treated. All of the patients were pathologically proven node negatrve by laparoscoprc node dissecbon of the fossa obturatona regron. Tic-3 tumours accordrng to the classrfrcation system of 1992 were one. 24 and 64, respectively. During the first and second week 9Gy each (10/9212/93: 1OGy each) were gwen rntersktial wrth htgh-dose-rate ‘921rrdrum brachytherapy to the prostate and tumour exterwon beyond the capsule. After thus a percutaneous 4 field box wradratron was gtven to the prostate to a dose of 45Gy/25 frackons (10192.12/93: 40Gy/20 lx). Results: A PSA value above 3 nglml before starhng treatment was found rn 65% (74167) with a median PSA of 15 rig/ml. Medtan PSA three and 12 months (mos.) after completton of therapy was 1 17 and 065 nglml. respecbvely. A PSA relapse was found rn 16.6% (13f703. 31 of 45 pts. (69%) had negative punch bropsres 12 months alter therapy, 8 of 10 pts. had negatwe bropsres after 24 mos. A posttrve bropsy combrned with a PSA value above 3 nglml were scheduled as local fadure and were observed tn 15.6% (7/45). Acute stde effects were as tallows: no grade 3 or 4 cystitis/diarrhoea. bladder tamponade (completely healed after rinsing) 2.2% (2/69). prochtrs grade 1 13 7% (10173) and grade 2 1.4% (l/73) and no grade 3 or 4 reactton. Late side effects. no cystihs nor urethral stricture. procbtis (12 mos. after treatment) grade 1 13 6X (g/66). no grade 2 or 3. Severe srde effects were observed tn two pts wrth addtttonally risk factors (colttts ulcerosa. diabetes mellrtus)they were temporary lost in follow-up and have bropstes of the anterror rectal wall elsewhere for late proctttis and developed a rectourethral ftstula requrnng colostomy both, but not in the htgh dose area of the anterror rectal wall Conclusion: The method IS feastble and well tolerable The two complications are not only caused by rrradiatton alone. Taktng of bropstes from the anterior rectal wall after definrtwe hrgh dose radrotherapy for prostate cancer has to be scheduled as contratndrcated The rate 01 negatwe prostate biopstes of 66% after 12 months represents an encouraging result.
60 LDR 192lr Brachytherapy(BRA) for Locally Advanced Prostatic Adenocarcinoma.Pilot Study P Nickers, C Mitine, MT Hoornaert, M Beauduin. Jolimont Hospital, La Louviere BELGIUM. From I/91 to 4/95. 24 patients have been treated with combated BRA and External Beam Radrotherapy(EBRT) The mean age ofthe patients was 68 Y .A2.BI.B2,CandDIstageswerepresentrespectivelyml,l,l4,6and 2 patients The mean pretreatment PSA value was 22 &m/ml BRA consisted rn the placement of intrapmstatic Plastic Catheters with the aid of the Manrnez Applicator(MA), under laparotomy for 18 patients or under echographic control for the last 6 The MA was then retracted and the Tubes sutured to the permeum so the patients could walk rn the treatment The next day, after a CT Scan control, the Tubes were room thereafter. loaded with 192Ir. The Paris System(PS) of dosimetry was used The mean In reality the mean Maumum Peripheral Basal Dose was I I .48Gy/day Dose(MPD) was 52Gy, while the 8S% and 70% iscdoses of the PS were surmmding the target whune in 50% of the patients each. The mean dose delivered to the antenor rectal wall was 46Gy 5 days latter. EBRT was commenced for delivering SCGy ICRU(25X2 Gy in 5 W) in the pelvis while shrelding at 26Gy the volume of the 35Gy BRA isodose. The mean followup is 26 months. The mean time for PSA to decrease to values < 3ng/mI is 5.4 months and it normahzcdat I8 months in 9l%ofcases 13114 biopsres realmed systematrcally at 18 months were negative. Until now. 4 recurrences were diagnosed The patimt whose biopsy was posrtrve at I8 months as well as one patient whose cancer nodule never disappeared were considered having local recurrence The other 2 develcpped bone The second patrent treated in our study developped a grade IV rnetastases rrectrtis explarned by the too small vicinity behveee a catheter and the rectal rnucosa(5nrm). The 8th patient implanted under laparcxomy developped a postoperative bleeding inducing a grade III urinary complicatron .AAerwards, no major problem was met This technrc combrning BRA and EBRT allows to deliver t&al cumulated MPD of 75Gy rn the prostate whrle treatrng more aggressively the base of the seminal vesrcles and penprostatrc trssues compared to BRA alone We plan to rncrease it to 8OGy as the placement of catheters under echography IS more precrse and secure
57
58
HIGH-DOSE
RATE
INTRA-OPERATIVE
THERAPY FOR LOCAL COLORECTAL CANCER
ADVANCED
Harrison
B, Enker
LB,
Minsky NY,
B
Mychalczak
Memorial
RADIATION AND
W, Anderson
Sloan-Kettering
Post-Trea,meo, Pt.q~e Ther.P,
RECURRENT
Cancer
L. Cohen
Center,
AE.
New
York,
Tre.lcd Wttb Eptseler., Dose and Dose Rate E,Tec,a
Robert Jones. Etiubeth Gore. Wittinm Mieter. Michael Gillin. Katkaine Atband, and Beth Erickson Radiation Oncology, Medical College of Wisconsin, Mitwvaukee. Wt. VSA
U S A.
In an effort to improve the local control for advanced and recurrent cancers of the rectum, we have integrated high-dose rate intra-operative radiation therapy (HDR-IORT) into the treatment program Between I l/92 and 10195. 47 patients (pm) were treated Ther were 26 males and 21 females whose ages ranged There were 19 pts with primary from 30-80 (median = 62) years unresectable rectal cancer, and 28 pts who were treated for recurrent rectal mous
Histology
cancer
cancer
was adenocarcinoma
- 45 pts, squa-
(median
The range of follow-up is I-34 months The majority of primary unresectable = I4 months)
received
pre-operative
- 2 pts
radiation
chemotherapy (S-FU underwent resection
therapy
(4SOO-5040
cGy)
pts with
with Leucovorin) 4-6 weeks later. they For the 28 pts + HDR-IORT (1200 cGy)
with recurrent cancer, the majority received surgery and HDRIORT alone because they had received prior RT For the pts with primary unresectable disease. actuarial 2-year local control was 77%.
Acuky ,a Path@ Cboroidal Melsaoma:
Vlrunl
For
actuarial
free survival pts with
distant
metastasis-free
was 66%.
and overall
recurrent
659’0, distant
disease.
metastasis-free
actuarial survival
survival survival 2-year
was 71%.
local
disease For those
was 84% control
rate was
was 65%.
disease free Complications survival was 47%. and overall survival was 6 I% occurred in 36% There were no cases where the anatomical distribution of disease, or technical limitations prevented the We conclude that this technique adequate delivery of HDR-IORT was most versatile, and enabled all appropriate IORT The preliminary data in terms of local encouraging, even for the poor recurrent cancer
prognostic
pts to receive control are
sub-group
of pts with
59 COMBINED INTERSTITIAL AND PERCUTANEOUS FOR LOCALIZED PROSTATE CANCER
Purpprr: To determine the relationship belween Lbe long-knm visust fun&on and Le dose and dose raks delivered 10 criticat cculv suuf,u~s in padents with cboroidal melmama lmakd with lz* I cpirckrd plaque nadiotbexapy. Melbods From 1987 IO 1993, 63 paljenln un&nvent 1251episcleral plaque applicluion for the kecnbnen, of cbomidat melanoma. Mean ,umor beigh, was 4.6 nun Wage 1.7-8.3 mm). Ptaquc~ utihzed were of COMS design. Doses and dose rates at Lbe tumor apex. macuk. and optic disc were obtiained Visual achy da,= prior u) and af,er ptque appttcalion was available for 52 patienls. 9 padems were excluded fmm anllyeis secondary Lo co-marbiditier or disespe progression. 43 records were scored 10 assess if a decrease in visvat acuity of Z 2 tines on a standard Snekn eye cbti had occurred Statislical analysis was performed using chi-square tests of significance. &t&t&s Of ,be 63 total pstien& 59 (93.7%) were she at a median follow-up of 36 months Local progression occumd in 7/63 (tt.t%). Median dose and dose rate to the tumor spa were 90 Gy and 97.2 EGyh. respectively. Of Ihe 43 patients with post-lrcnlment visual acuity mslyrir, 28 (65.1%) experienced visual toss of Z 2 tines on a slandard eye chart. Median dme LOaltered visull acui,y WBF20 months. Median dose and dose E&S 10 the macula in patients wirh a significan, wsuat toss were t23 3 Gy and 122.5 ffiyihr. respecdvety. compared wilh 38 Gy and 51.9 cGyh in those widmut nalPble visuat change. ‘&se differences reached statistical significance a, a dose axl dose rate ID the macula al 82.0 Gy (p< .O,) and 72 diyh, (p SW,), respectively. Medim dose and dose races lo he oplic disc in patients wlh visual toss ad lbo.se wilb &able eyesight were 68.3 Gyl69 cGyh and 34.7 Gy 01.6 cGyhr. respzc,ively. The difference in dose ,o Lhe oplic disc WBSs+ficanl a, 43 Gy (p< .0X); dose rak Lo the disc demonsw’a(ed a Lrend toward rigniticancc a, 63 cGy/hr (p= ,051. Conclusion: Patienw in our series Ire&d with 12*1 plaque brachydxrapy for cbomidal melanoma eroerienced favorable Nmor contlot. but wilh a measurable incidence of decreased ksusl acuify. Bolb totll dose and dose ratis 10 Ihe macuta and optic disc colxtati s~angty with post-ecalmen, visual outcome. This information may be vetuabtc in decisions &.xL the dose and dose rates wed to &eat cboroidal melanomas and the risk of visual decline.
RADIOTHERAPY
S. Dinaes ; El. Boehmer ‘, S Deger ‘, T Wiegel ‘, SA Loening ‘, W V Budach ‘. ‘Dept. of Radrotherapy. ‘Dept. of Urology, Hinkelbein University Hdsprtal Charite, 3Un~vers~ty Hospital Sentamin-Franklrn, Berlin. FRG. Obieclives: To test the feasibrlrty and effectrveness 01 a combrned tnterstrttal and percutaneous radtotherapy approach for localtzed prostate cancer a prospectwe phase II trral was carned out. Methods: Between lo/92 and 12/94 69 evaluable p&rents (pts.) were treated. All of the patients were pathologically proven node negatrve by laparoscoprc node dissecbon of the fossa obturatona regron. Tic-3 tumours accordrng to the classrfrcation system of 1992 were one. 24 and 64, respectively. During the first and second week 9Gy each (10/9212/93: 1OGy each) were gwen rntersktial wrth htgh-dose-rate ‘921rrdrum brachytherapy to the prostate and tumour exterwon beyond the capsule. After thus a percutaneous 4 field box wradratron was gtven to the prostate to a dose of 45Gy/25 frackons (10192.12/93: 40Gy/20 lx). Results: A PSA value above 3 nglml before starhng treatment was found rn 65% (74167) with a median PSA of 15 rig/ml. Medtan PSA three and 12 months (mos.) after completton of therapy was 1 17 and 065 nglml. respecbvely. A PSA relapse was found rn 16.6% (13f703. 31 of 45 pts. (69%) had negative punch bropsres 12 months alter therapy, 8 of 10 pts. had negatwe bropsres after 24 mos. A posttrve bropsy combrned with a PSA value above 3 nglml were scheduled as local fadure and were observed tn 15.6% (7/45). Acute stde effects were as tallows: no grade 3 or 4 cystitis/diarrhoea. bladder tamponade (completely healed after rinsing) 2.2% (2/69). prochtrs grade 1 13 7% (10173) and grade 2 1.4% (l/73) and no grade 3 or 4 reactton. Late side effects. no cystihs nor urethral stricture. procbtis (12 mos. after treatment) grade 1 13 6X (g/66). no grade 2 or 3. Severe srde effects were observed tn two pts wrth addtttonally risk factors (colttts ulcerosa. diabetes mellrtus)they were temporary lost in follow-up and have bropstes of the anterror rectal wall elsewhere for late proctttis and developed a rectourethral ftstula requrnng colostomy both, but not in the htgh dose area of the anterror rectal wall Conclusion: The method IS feastble and well tolerable The two complications are not only caused by rrradiatton alone. Taktng of bropstes from the anterior rectal wall after definrtwe hrgh dose radrotherapy for prostate cancer has to be scheduled as contratndrcated The rate 01 negatwe prostate biopstes of 66% after 12 months represents an encouraging result.
60 LDR 192lr Brachytherapy(BRA) for Locally Advanced Prostatic Adenocarcinoma.Pilot Study P Nickers, C Mitine, MT Hoornaert, M Beauduin. Jolimont Hospital, La Louviere BELGIUM. From I/91 to 4/95. 24 patients have been treated with combated BRA and External Beam Radrotherapy(EBRT) The mean age ofthe patients was 68 Y .A2.BI.B2,CandDIstageswerepresentrespectivelyml,l,l4,6and 2 patients The mean pretreatment PSA value was 22 &m/ml BRA consisted rn the placement of intrapmstatic Plastic Catheters with the aid of the Manrnez Applicator(MA), under laparotomy for 18 patients or under echographic control for the last 6 The MA was then retracted and the Tubes sutured to the permeum so the patients could walk rn the treatment The next day, after a CT Scan control, the Tubes were room thereafter. loaded with 192Ir. The Paris System(PS) of dosimetry was used The mean In reality the mean Maumum Peripheral Basal Dose was I I .48Gy/day Dose(MPD) was 52Gy, while the 8S% and 70% iscdoses of the PS were surmmding the target whune in 50% of the patients each. The mean dose delivered to the antenor rectal wall was 46Gy 5 days latter. EBRT was commenced for delivering SCGy ICRU(25X2 Gy in 5 W) in the pelvis while shrelding at 26Gy the volume of the 35Gy BRA isodose. The mean followup is 26 months. The mean time for PSA to decrease to values < 3ng/mI is 5.4 months and it normahzcdat I8 months in 9l%ofcases 13114 biopsres realmed systematrcally at 18 months were negative. Until now. 4 recurrences were diagnosed The patimt whose biopsy was posrtrve at I8 months as well as one patient whose cancer nodule never disappeared were considered having local recurrence The other 2 develcpped bone The second patrent treated in our study developped a grade IV rnetastases rrectrtis explarned by the too small vicinity behveee a catheter and the rectal rnucosa(5nrm). The 8th patient implanted under laparcxomy developped a postoperative bleeding inducing a grade III urinary complicatron .AAerwards, no major problem was met This technrc combrning BRA and EBRT allows to deliver t&al cumulated MPD of 75Gy rn the prostate whrle treatrng more aggressively the base of the seminal vesrcles and penprostatrc trssues compared to BRA alone We plan to rncrease it to 8OGy as the placement of catheters under echography IS more precrse and secure