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62 Results of external beam radiation and IR-192 HDR implants in patients with anal canal carcinomas
S16 61
62
MONTE CARLO SIMULATION OF laSl SEED (MODEL 6 7 1 1 ) IN A COMS 20 MM EYE PLAQUE
RESULTS OF EXTERNAL BEAM RADIATION AND IR-192 HDR IMPLANTS IN PATIENTS WITH ANAL CANAL CARCINOMAS
A. Sl,,dvs-Reyu*, C. Clnm s, I~L B m ' d p ' , A. R e v i r m a ' , J M Feratsde~
Vu~" and F. ~dvst',
E.Geyer, KKapp, G.F. Stuecklschweiger,F.Gebhart,A.Hackl
* Serv de O,,celollla Radloler~Ipi¢.a. HCI'. BarcdoM. Spaia. ' S e r v de l r i ~ y PP. I.C.O. L'Hmplt~kt d d U o b ~ t . S p ~ "Dep~ F.C1~4.Fa¢~tJt de F/,Squa UJI. B a r c d e u . Sipa~. Introduction: The use of '~1 plaqu~
for rediadon ~rapy
Division of Radiology.Department of Radiotherapy,Graz.Austria
of
eye tumors bss been incrtming continuously ia r e c e n t y c a r s . I n view o f ' h e i m l m r t o n ~ o f uceurste dmimelry to the evaluation of COMS rceulL we have performed Monte Carlo simuindom a n d c o m p a r e d t h e r e m d l s w i ' h . h m e from . h e c e m m e r c l a l ~IuRut pannilEg | D I I m l B E B I G Version 2.16. M a t e r i a l a n d M e t h o d s : A n"! model 6711 source hm b e e n u s e d , i n w h i c h . h e r e d i a c d v e t ~ l is e d m r b e d o n . h e s u r f e c e o f
• silver wire contoined wi.hin • ~ ~ capeude, The M o n t e C a r l o cede P E N E L O P E h s = b e e n w e d to compute the dose dblribufion for lille seed placed in .he central and lateral slot, o f • COMS eye plaque. In .he Monte Carlo shnulafion the d e t ~ b of .he Ileemelry (seed, |old Imekinll and |htsti¢ s4~lcarrier insert) Imve been carefully reproduced. Simubtlon cut-
off enert.ks were 2 k e V m u l 2S k e V for photom and election=, r e s p e c t i v e l y . T h e M o n t e C a r l o c o d e w a s r u n o n • 166 M h a PENTIUM, each simulation involved mort dum 70,000,000 primary photon histories. Results a n d D i s c u s l o n : M o n t e C a r l o r e s u l t s h a v e b e e u
comlutrsd with ttmee obtained by • BEBIG Plaque Simulator Version 2.16. Signilkalive differences have been f o u n d • a i r . h e s o u r c e . S m a l l e r d e v i a t i o n s ( i m m o f i s o d o a s displacement)
occur a t a b o u t 2 cm and far.her form source. ~ b work lut; beew ~ e ~ l ~ I by a Flg Gma N" 9 7/211L
63 INTERSTITIAL BRACHYTHER.-kPY BOOST WITH 1921r IN THE TREATMENT OF ANAL CANCER
PURPOSE:Evaluation of the efficacy and toxicity of primary radiotherapy +/-chemotherapy in patients with squamous cell cancer of the anal canal, stage T1-1"4 MATERIALS:Between July 1987- December 1997, 40 patients with squamous cell cardnoma of the anal canal received primary radiation treatment consisting of external beam radiation to the pelvis and groins in a split course fashion ( 30-50 Gy) with 1-2 Iridium 192 HDR implants (6Gy) scheduled after 30 Gy +/cconcomittant 5-FU and MMC chemotherapy. RADIATION THERAPY TECHNIQUE:External Beam Radiation was delivered with 8 MeV photons.Through individually shaped AP/PA portals encompassing the whole pelvis and the gmins.CTassisted treatment planning was employed in all cases.A dose of 6 Gy was prescribed to the is,dose curve encompassing the target volume.The implant geometry was preplanned based on the clinical and radiological findings and calculated on a computer program that enables display of isedosis of any orthooonal plan.Customized templates made out of plexiglas( with needle spacings of 8-12 mm) were used to assure a strictly parallel order of the needles. RESULTS:32 patients achieved a complete response.Treatment failures occured in 7 patients of whom 5 had denied systemic therapy as part of their treatment.The overall sphincter preservation rate was 83%.Radiation induced ulcers of which all healed spontaneously,occured in 4 patients. There was no severe toxicity requinng interrruption of treatment. CONCLUSION: Primary radiotherapy yielded excellent results in stage T1-T3 lesions.Treatment toxicity was transient and acceptable.The overall results with a sphincter preservation rate of 83% encourage us to continue with the pmtocel.
64 H D R B R A C H Y T H E R A P Y IN T H E T R E A T M E N T CARCINOMA OF THE ANAL CANAL
OF
O Manelli. F Bunkheila. G F r ~ A Galuppi. S Neff. C Parmeggiani. F Salvi, R Vannini. L Babini Istiruto di Eadioterapia Babini Bologna Italia
Seewald D.H., H a m m e r J., Zoidl L, Track Chr., Putz E., G r a y B. Department of Radiation - O n c o l o g y , Barmherzige S c h w e s t e m Hospital, Seilerstiitte4, A-4010 Linz, Austria
From July 1994 to July 1997 25 panents (Pls) were refecred to our Institute with histologically proven ¢pidermold cancer of the anal canal 6 of them were male and 19 females Age rmaged from 30 to 85 years (mean age 65 years) The period of observation after treatment ranged from 6 to 39 months (mean follow-up 20.6 months) TNM stage at diagnosis was the following: TI I PIs, T2 13 Pls. T3 8 l~s. T4 3 Pls. Ultrasonography was
Sphincter preservation by radiation therapy with or without simultaneous chemotherapy has become a widely accepted standard treatment for patients with anal cancer. Papillon and Montbarbon emphasized the role of interstitial LDR brachytherapy as a boost following external radiation therapy. In 1986 we introduced H D R - Iridium 192 as a boost in combination with external beam therapy to yield good local results. Between January 1986 and December 1995, twentynine patients were treated. There were 25 female and 4 male patients, mean age was 68. T w o patients received only H D R Iridium implantation. In the first 2 patients we observed severe toxicity and so we abandoned this method. W e changed our treatment set up completely, we constructed new templates as well as a special fixation device and patient positioning set. The implantation can be done by simultaneous rectal digital control and by using our fixation device there will be no displacement. W e can visualize the implanted needles by the means of CT, the i s , d o s e distribution can be visualized. Considering external beam dose and tumor stage, a dose of 5 to 7 Gy is prescribed to the is*dose encompassing the tumor. Boosting patients by H D R - Iridium implantation, we achieved excellent local results,there are only 2 local recurrences. Late toxicity seems to be correlated to the treated volume. Late toxicity grade 3 (Eschwege score) has been only observed in 2 patients, which were the first patientes treated by H D R implantation. Our results indicate that external beam therapy combined with interstitial H D R brachytherapy as a boost is highly effective in achieving local control without severe grade 3 toxicity.
performed in all Pts. Enlarged penrental nodes were detected with echography in 7 Pls Metastases in inguinal nodes were present in 3 Pts (T2 1113, "['3 1/8, T4 1/3) Treatment consisted in extermd beam radiation
therapy(EBRT) to primary and inguinalnodesfollowedby EBRT boostto anal canal and petirectal tissues to mean total dose of 4650 cGy (range 3000 - 5600 cC~) Concomitant chemotherapy with Mitomicyn C (10 mg/mq IV dl) and 5FU (1000 mg/mq/24h.r IV c i d 1-4) was given in 19/25 Pts (76*/0) during the first and the fifth week At~er 4-6 weeks all Pls were submitted l* 192 Iridium boost to the site of primary A single plan implant was performed with 4-7 needles and a perineaJ template, length of Iridium wires was comprised beetwenn 5 and $ cm and dose rate range was 0,450.98 Gy/hs" Boost dose specified according to Paris System after reconstruction of the geometry of the implant from two orthogonal films was 10-20 Gy (mean dose 15 Gyl according to the size of primatry and of the residual disease as assessed clitucally or with transartal uhrasonography Local failures were observed in 325 Pts (12°/o• 2 T2, I T3) after a mean interval of 9.3 months All these Pts were treated surgically with abdominoperineal resection ofthe rectum Local control was obtained in 2/3 of them Regional failures (iliac i'm,des)were observed in 1/25 Pts (4°/,; I T3N0) after an interval of 6 months Distant metastasis were observed in 1/25 Pls (4%; I T3N0) after an interval of 25 months Late complications in the boost volume were observed in 9 cases. 8 Pts presemed episodic bleeding from the rectum In I PI a small necrosis of the anal mucose was observed after 8 months and healed spontaneously after I year Interstitial brachytherapy boost with 1921r has an important role in the treatment of anal cancer, since it, administerin~ an higher dose tailored to the target volume, allows to achieve an excdlent local control (22/25 Pts, 88%) with an acceptable incidence of complications wich in our experience were never
severe
62
MONTE CARLO SIMULATION OF laSl SEED (MODEL 6 7 1 1 ) IN A COMS 20 MM EYE PLAQUE
RESULTS OF EXTERNAL BEAM RADIATION AND IR-192 HDR IMPLANTS IN PATIENTS WITH ANAL CANAL CARCINOMAS
A. Sl,,dvs-Reyu*, C. Clnm s, I~L B m ' d p ' , A. R e v i r m a ' , J M Feratsde~
Vu~" and F. ~dvst',
E.Geyer, KKapp, G.F. Stuecklschweiger,F.Gebhart,A.Hackl
* Serv de O,,celollla Radloler~Ipi¢.a. HCI'. BarcdoM. Spaia. ' S e r v de l r i ~ y PP. I.C.O. L'Hmplt~kt d d U o b ~ t . S p ~ "Dep~ F.C1~4.Fa¢~tJt de F/,Squa UJI. B a r c d e u . Sipa~. Introduction: The use of '~1 plaqu~
for rediadon ~rapy
Division of Radiology.Department of Radiotherapy,Graz.Austria
of
eye tumors bss been incrtming continuously ia r e c e n t y c a r s . I n view o f ' h e i m l m r t o n ~ o f uceurste dmimelry to the evaluation of COMS rceulL we have performed Monte Carlo simuindom a n d c o m p a r e d t h e r e m d l s w i ' h . h m e from . h e c e m m e r c l a l ~IuRut pannilEg | D I I m l B E B I G Version 2.16. M a t e r i a l a n d M e t h o d s : A n"! model 6711 source hm b e e n u s e d , i n w h i c h . h e r e d i a c d v e t ~ l is e d m r b e d o n . h e s u r f e c e o f
• silver wire contoined wi.hin • ~ ~ capeude, The M o n t e C a r l o cede P E N E L O P E h s = b e e n w e d to compute the dose dblribufion for lille seed placed in .he central and lateral slot, o f • COMS eye plaque. In .he Monte Carlo shnulafion the d e t ~ b of .he Ileemelry (seed, |old Imekinll and |htsti¢ s4~lcarrier insert) Imve been carefully reproduced. Simubtlon cut-
off enert.ks were 2 k e V m u l 2S k e V for photom and election=, r e s p e c t i v e l y . T h e M o n t e C a r l o c o d e w a s r u n o n • 166 M h a PENTIUM, each simulation involved mort dum 70,000,000 primary photon histories. Results a n d D i s c u s l o n : M o n t e C a r l o r e s u l t s h a v e b e e u
comlutrsd with ttmee obtained by • BEBIG Plaque Simulator Version 2.16. Signilkalive differences have been f o u n d • a i r . h e s o u r c e . S m a l l e r d e v i a t i o n s ( i m m o f i s o d o a s displacement)
occur a t a b o u t 2 cm and far.her form source. ~ b work lut; beew ~ e ~ l ~ I by a Flg Gma N" 9 7/211L
63 INTERSTITIAL BRACHYTHER.-kPY BOOST WITH 1921r IN THE TREATMENT OF ANAL CANCER
PURPOSE:Evaluation of the efficacy and toxicity of primary radiotherapy +/-chemotherapy in patients with squamous cell cancer of the anal canal, stage T1-1"4 MATERIALS:Between July 1987- December 1997, 40 patients with squamous cell cardnoma of the anal canal received primary radiation treatment consisting of external beam radiation to the pelvis and groins in a split course fashion ( 30-50 Gy) with 1-2 Iridium 192 HDR implants (6Gy) scheduled after 30 Gy +/cconcomittant 5-FU and MMC chemotherapy. RADIATION THERAPY TECHNIQUE:External Beam Radiation was delivered with 8 MeV photons.Through individually shaped AP/PA portals encompassing the whole pelvis and the gmins.CTassisted treatment planning was employed in all cases.A dose of 6 Gy was prescribed to the is,dose curve encompassing the target volume.The implant geometry was preplanned based on the clinical and radiological findings and calculated on a computer program that enables display of isedosis of any orthooonal plan.Customized templates made out of plexiglas( with needle spacings of 8-12 mm) were used to assure a strictly parallel order of the needles. RESULTS:32 patients achieved a complete response.Treatment failures occured in 7 patients of whom 5 had denied systemic therapy as part of their treatment.The overall sphincter preservation rate was 83%.Radiation induced ulcers of which all healed spontaneously,occured in 4 patients. There was no severe toxicity requinng interrruption of treatment. CONCLUSION: Primary radiotherapy yielded excellent results in stage T1-T3 lesions.Treatment toxicity was transient and acceptable.The overall results with a sphincter preservation rate of 83% encourage us to continue with the pmtocel.
64 H D R B R A C H Y T H E R A P Y IN T H E T R E A T M E N T CARCINOMA OF THE ANAL CANAL
OF
O Manelli. F Bunkheila. G F r ~ A Galuppi. S Neff. C Parmeggiani. F Salvi, R Vannini. L Babini Istiruto di Eadioterapia Babini Bologna Italia
Seewald D.H., H a m m e r J., Zoidl L, Track Chr., Putz E., G r a y B. Department of Radiation - O n c o l o g y , Barmherzige S c h w e s t e m Hospital, Seilerstiitte4, A-4010 Linz, Austria
From July 1994 to July 1997 25 panents (Pls) were refecred to our Institute with histologically proven ¢pidermold cancer of the anal canal 6 of them were male and 19 females Age rmaged from 30 to 85 years (mean age 65 years) The period of observation after treatment ranged from 6 to 39 months (mean follow-up 20.6 months) TNM stage at diagnosis was the following: TI I PIs, T2 13 Pls. T3 8 l~s. T4 3 Pls. Ultrasonography was
Sphincter preservation by radiation therapy with or without simultaneous chemotherapy has become a widely accepted standard treatment for patients with anal cancer. Papillon and Montbarbon emphasized the role of interstitial LDR brachytherapy as a boost following external radiation therapy. In 1986 we introduced H D R - Iridium 192 as a boost in combination with external beam therapy to yield good local results. Between January 1986 and December 1995, twentynine patients were treated. There were 25 female and 4 male patients, mean age was 68. T w o patients received only H D R Iridium implantation. In the first 2 patients we observed severe toxicity and so we abandoned this method. W e changed our treatment set up completely, we constructed new templates as well as a special fixation device and patient positioning set. The implantation can be done by simultaneous rectal digital control and by using our fixation device there will be no displacement. W e can visualize the implanted needles by the means of CT, the i s , d o s e distribution can be visualized. Considering external beam dose and tumor stage, a dose of 5 to 7 Gy is prescribed to the is*dose encompassing the tumor. Boosting patients by H D R - Iridium implantation, we achieved excellent local results,there are only 2 local recurrences. Late toxicity seems to be correlated to the treated volume. Late toxicity grade 3 (Eschwege score) has been only observed in 2 patients, which were the first patientes treated by H D R implantation. Our results indicate that external beam therapy combined with interstitial H D R brachytherapy as a boost is highly effective in achieving local control without severe grade 3 toxicity.
performed in all Pts. Enlarged penrental nodes were detected with echography in 7 Pls Metastases in inguinal nodes were present in 3 Pts (T2 1113, "['3 1/8, T4 1/3) Treatment consisted in extermd beam radiation
therapy(EBRT) to primary and inguinalnodesfollowedby EBRT boostto anal canal and petirectal tissues to mean total dose of 4650 cGy (range 3000 - 5600 cC~) Concomitant chemotherapy with Mitomicyn C (10 mg/mq IV dl) and 5FU (1000 mg/mq/24h.r IV c i d 1-4) was given in 19/25 Pts (76*/0) during the first and the fifth week At~er 4-6 weeks all Pls were submitted l* 192 Iridium boost to the site of primary A single plan implant was performed with 4-7 needles and a perineaJ template, length of Iridium wires was comprised beetwenn 5 and $ cm and dose rate range was 0,450.98 Gy/hs" Boost dose specified according to Paris System after reconstruction of the geometry of the implant from two orthogonal films was 10-20 Gy (mean dose 15 Gyl according to the size of primatry and of the residual disease as assessed clitucally or with transartal uhrasonography Local failures were observed in 325 Pts (12°/o• 2 T2, I T3) after a mean interval of 9.3 months All these Pts were treated surgically with abdominoperineal resection ofthe rectum Local control was obtained in 2/3 of them Regional failures (iliac i'm,des)were observed in 1/25 Pts (4°/,; I T3N0) after an interval of 6 months Distant metastasis were observed in 1/25 Pls (4%; I T3N0) after an interval of 25 months Late complications in the boost volume were observed in 9 cases. 8 Pts presemed episodic bleeding from the rectum In I PI a small necrosis of the anal mucose was observed after 8 months and healed spontaneously after I year Interstitial brachytherapy boost with 1921r has an important role in the treatment of anal cancer, since it, administerin~ an higher dose tailored to the target volume, allows to achieve an excdlent local control (22/25 Pts, 88%) with an acceptable incidence of complications wich in our experience were never
severe