63 Evaluation of MDR brachytherapy and teletherapy results in patients with advanced cervical cancer

Posters

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calculated by the 3-D treatment planning system with in vivo measurements in selected points on the breast surface. Materials and methods: since 1998 in the Brachytherapy Department of the Centre of Oncology in Warsaw the HDR brachytherapy is used as the boost after the external beam radiotherapy in conservative treatment of breast cancer. After tumourectomy the whole breast is external beam radiotherapy the patients receive a 10-12 Gy HDR brachytherapy boost to the tumour bed. The position of the tumour bed is established on the basis of postoperative mammography. The treatment planning is based on the surgeon's reporl and mammograms. The number of brachytherapy needles and distances between them and also the rantge and length of Ir-192 source path (GAMMAMED from Sauerwein Gmbh) in the needles is established on the basis of the tumour bed volume and on its distance from the skin surface. The close distribution calculation and optimization is performed by the 3-D treatment planning system (ABACUS from Sauerwein Gmbh). The preliminary measurements were carried out on the Alderson phantom with mosfet dosimeters and TLD. The doses to the specific points markes on the patient's skin were measured with the thermoluminescent dosimeters (Harshaw JTLD pellets). Results and conclusions: in our group of patients the doses to the points in the skin ranged between 2-40% of the prescribed dose far less than commonly accepted value of 60%. The value of the dose to the skin has a great impact on the overall cosmetic effect of the treatment. The comparison of the doses measured in vivo and calculated allowed for the modification of the brachytherapy technique and optimization of the active length of the catheters and of the distance between the skin base and the distal and proximal dwell positions of the source.

or LDR brachytherapy sources. It is designed for intracavitary (intralum-pectomy cavity) implantation. Our team has implanted the spherical device (4 cm diameter) in 4 patients of the group enrolled nationally. Ages ranged from 65 to 84 years. Axial CT images of the patients with the applicator were taken at 3 mm intervals and imported into the 3 D treatment planning system, TPS, (BrachyVision 6.0 TPS, Varian Medical Systems Inc.). CT based planning allowed 3dimensional positioning of the breast tissue which varied from the 2-dimensional views available from orthogonal views on the simulator. A single position of the HDR source, in the center of the balloon, allowed good coverage of a concentric volume 1 cm around the implanted device by the 340 cGy isodose line. Results: All our patients tolerated the procedure well and had no complications during the 5 days of treatment, with 2 treatments a day given 6 hours apart. The only patient complaint was a sensation of pressure at the balloon site during the 5 day course. The device itself functioned well, with only 1 mm variation from concentric expansion of the balloon. After treatment, the device deflated well, with recovery of all but - 2 cc of the saline used for inflation of the balloon at the time of insertion. The device did deflate with redundant material making sedation at the time of removal a reasonable measure for patient comfort. One patient developed an abscess 5 days post removal necessitating surgical drainage but not debridement. The other patients were treated with prophylactic antibiotics at the time of removal and developed no evidence of infection. Conclusions: The MammoSite device performs well for brachytherapy treatment for early stage breast cancer patients. Complications to date have been low with this procedure and patient tolerance has been good.

59 poster B r a c h y t h e r a p y b o o s t in b r e a s t c a n c e r : d o s e , v o l u m e , fractionation relationships9 F. Piro, P. Guerrieri, A. Destito, I. Ziccarefli, C. Bianco, P. Ziccarelli, A. Molinaro. R. Mole, P. Montemaggi Radiotherapy, Mariano Santo, Cosenza, Italy Aims and background: In breast cancer the boost of tumor bed after conservative surgery is a widely accepted clinical practice, even if not completely clarified in its theoretic aspects. In this work we will analize our experience in out patients base. Methods: From April 1999 to December 2000, 75 consecutive patients with breast cancer were enrolled in this perspective study: Conservative surgery, Whole Breast Radiotherapy (50 Gy/5 weeks), 3-6 days after the completion of these. Brachytherapy (BRT) High Dose Rate (HDR) implant consisting of 3 fractions of 350 cGy each, 6 hour apart, over 24 hours; if intraoperative BRT was used, external radiotherapy was done 1-2 weeks after the reverse boost. Patients N received chemotherapy /- hormones. BRT boost was generally done as a multiplanes implant (MI) to provide the maximum coverage of the tumor bed, singleplane (SI) was performed in very small breast, in clearly identifiable tumor bed and in anatomic configuration of the breast not suitable for a MI. Results: 75 patients treated with BRT boost: 36 (48%) MI (4 intraoperative, 32 as out patients). The Volume Reference Isodose (350 cGy/fraction) was: median 106.2cc (range 13-516); the High Dose Volume (700 cGy/fraction): median 29.5cc (range 5-130); the Dose Homogeneity Index: median 0.74 (range 0.24-1 ); the 350/700 Volumes Ratio: median 3.8 (range 1.32-16.61 ); only 7 patients (9.3 %) of SI group did not receive an adequate treatment (normal ratio 2); cosmetics results, as variation of the surgical cosmetic results, were excellent in 65% of cases evaluated by the patients, 60% by the physicians. Only 5 patients had moderate infectious complication (no hospitalisation), no further toxicities has been observed. Conclusions: BRT is an effective method to boost tumor bed, MI seem to be more reliable, HDR can be used in out patients, complications and cosmetics results are similar to Low Dose Implants. Key words: Brachytherapy, breast cancer, high dose rate

61 poster F o u r - y e a r s e x p e r i e n c e in t h e t u m o u r b e d I o c a l i s a t i o n f o r HDR brachytherapy during BCT procedure. J. Lyczek, A. Kulik. M. Kawczynska, W. Bulski Cancer Center Institute of Oncology, Warsaw, Poland From 1996 almost 150 pts were treated with BCT procedure in brachytherapy department in cancer center in Warsaw. In all cases cancer was previously biopsy proven. T1-2NOM0 patients were qualified to the procedure with tumorectomy, external beam irradiation up to 50 Gy in conventional regime and then selected to electron boost or when the turnout was deeper than 1 cm under the skin to HDR boost. HDR therapy was given 5-10 days (m. 7 d) after external irradiation. In all cases 10 Gy was given in a single fraction in out-patient regime. "Bridge" applicator was used as a routine way of steel needle immobilisation. As a treatment unit Gammamed 12i was used. For planning ABACUS 1.6 Treatment Planning System with 3D reconstruction was used. Primary tumour bed was defined by titanium clips located during operation. Before HDR session mammography and CT exam was done. In 15% cas~'s tumour bed was unclear because of clips migration. Secondly ultrasound and mammography was done just before HDR therapy. In both groups no clear evidence of tumour bed margin gave an effect to implant 10 to 16 needles to be sure that prescribed isodose covered tumour bed with 1 cm margin. Now ultrasound and mammographyl is done before external irradiation in treatment position. In that way tumour bed is well defined and number of needles decrease to 5 to 8 always in rain 2 planes. In all groups there is difference in local recurrence and overall survival. Strongly differences are cosmetic results depending from number of insert neeldes.

60 poster Initial e x p e r i e n c e w i t h n o v e l b r a c h y t h e r a p y d e v i c e f o r e a r l y stage breast cancer t r e a t m e n t M. Hebert, R. Alecu, M. Alecu US Oncology. Texas Cancer Center. Sherman, TX. USA Purpose: To discuss our initial clinical experience with a novel brachytherapy applicator (The MammoSiteTM RTS, Proxima Therapeutics, Inc.) used for Ir-192 HDR intracavitary radiation treatment in the breast cancer. Problems encountered in meeting the national protocol's requirements due to variations in patients'; breast size and tissue firmness will be presented along with our solutions and clinical outcome. Materials and Methods: A novel brachytherapy device, MammoSite, is under trial for FDA approval. The MammoSite device is an inflatable spherical balloon catheter with a central lumen that may be used with either HDR

GYNAECOLOGICAL 62

TUMOURS

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Radical r a d i o t h e r a p y o f c a r c i n o m a of t h e e n d o m e t r i u m u s i n g e x t e r n a l b e a m r a d i o t h e r a p y a n d o p t i m i s e d s i n g l e line s o u r c e brachytherapy

B. Jones 1 M. Churn 2 1imperial College School of Medicine, Hammersmith Hospital, London W12 OHS & 2New Cross Hospital, Wolverhampton, UK Introduction: concurrent medical conditions, gross obesity or advanced stage confer inoperability in a small proportion of patients with adenocarcinoma of the endometrium. These patients can be treated with primary radiotherapy with either curative or palliative intent. Methods: we report 37 such patients treated at Clatterbridge Centre for Oncology (Liverpool) by a combination of external beam radiotherapy and intracavitary brachytherapy using a single line source technique. Optimisation of the dose distribution of the brachytherapy by means of variation of treatment length, radioactive source positions and prescription point (e.g. the use of the uterine serosal surface rather than point A) according to tumour bulk and individual anatomy were achieved in most patients studied.

$20

Posters

Results: the 5-year disease specific survival for non-surgically staged patients was 64% for FIGO stages 1 and 2 and 33% for stages 3 and 4. The incidence of late morbidity was acceptably low. Using the Franco-ltalian glossary there was 27.0% grade 1, but no grade 2-4 bladder toxicity. For the rectum the rates were 18.9% grade 1, 5.4% grade 2, 2.7% grade 3 and no grade 4 toxicity. It has been recommended that the BED for the rectum does not exceed 100 Gy3 (20) in general ghough for a small volume, a BED of 110 Gy3 may be well tolerated. The prescribed BED Gy3 values of our patients mostly fall withint these limits and may help to explain the low morbidity when compared to other larger series in the literature. 63

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Evaluation of MDR brachytherapy and teletherapy results in patients with advanced cervical cancer. A. Rembielak B. Bialas, K. Nowakowski, T. Rutkowski 1. B. Lukaszczyk, K. Slosarek Brachytherapy Department, Center of Oncology - Institute, Gfiwice, Poland 11st Radiotherapy Clinic, Center of Oncology - Institute, Gliwice, Poland 20ncological Gynaecology Clinic, Center of Oncology - Institute, Gliwice, Poland 3Treatment Planning Unit, Center of Oncology - Institute, Gliwice, Poland Introduction: definitive radiation therapy has been established as an effective treatment in patients with advanced cervical cancer. The aim of the study is to evaluate the results of MDR brachytherapy and external beam radiation in patients with cervical cancer stage lib and III. This method constituted an essential transition period in implementing of HDR 8T in clinical practice in our brachytherapy department. There are only few studies in medical literature concerning MDR brachytherapy in cervical cancer treatment. Material and meethods: from 1981 till 1986, 161 patients with advanced cervical cancer were treated in Center of Oncology - Institute in Gliwice: 34 patients with stage lib disease and 127 patients with stage III according to FIGO scale. Patients were treated with the combined radiotherapy: external beam radiation (Co-60 photons) and original MDR brachytherapy based on individually selected applicators and fractionation schedule. Results: the 5-year disease-free survival rate for patients with stage lib tumors was 60% with stage III - 41%. In fifty four patients (33.5%) clinical examination after completing the treatment revealed persistent disease, 28 patients (18%) developed local recurrence, 11 patients (7%) - distant metastases. Treatment tolerance in analyzed group was good. Severe postradiation complications were noted in 2 cases (1%). Conclusion: the efficiency and tolerance of the cervical cancer treatment combined with MDR brachytherapy was good and comparable to data from literature. 64

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Local control and t o x i c i t y in locally advanced cervical c a r c i n o m a treated with MDR-brachytherapy. O. Coza, C. Ordeanu, S. Gavris, I. Todor, O. Burghelea Cancer Institute 'l.Chiricuta", Brachytherapy. Cluj-Napoca, Romania Introduction: in the treatment of cervical carcinoma brachytherapy is a standard method. Since early 1996 we used a LDR/MDR Selectron unit; between january 1997 - december 1998 184 patients with locally advanced cervical carcinoma were treated. End-points were local control and late toxicity. Material and methods: 96 patients were treated prior to surgery by external beam and MDR-brachytherapy and 88 patients with exclusive radiotherapy. MDR-brachytherapy was performed with an LDR/MDR Selectron unit and consisted in one or two fractions to a total dose of 14 Gy/A (in preoperative treatment) and 18 Gy/A (in exclusive radiotherapy). Two types of utero-vaginal applicators were used: Manchester-type and a ring-type vaginal one. Dose rate varried from 3.53 Gy/hr. in 1997 to 3.15 Gy/hr. in 1998. Median follow-up was 18.2 months. Results and discussion: global local control was 81% at two years, slightly increased in 1998 (83.51%) vs. 1997 (78.17%), probably due to the increased use of a linear accelerator (43% vs.33%) vs. a Co60 machine. Global late toxicity appeared in 39 patients (21%): 23.7% in 1997 vs. 18.39% in 1998 and followed the dose rate reduction from 3.53 Gy/hr. to 3.15 Gy/hr. (X2=3.81). Vagina was found the most common site for late toxicity in 20 patients (51.2%) followed by urinary bladder (25.6%) and rectum (23%). Using the French-Italian glossary we found GI toxicity in 24 patients (13%), GII - 12 patients (6.52%), Gill in two patients (1.08%) and only one GIV (0.54%). Conclusions: MDR-brachytherapy is a valid option for the treatment of locally advanced cervical carcinoma. The local control was not influenced by the dose rate reduction in the two years studied; further, late toxicity was reduced (near statistic significance) due to dose rate reduction.

65 poster A comparison

o f three groups of patients w i t h e n d o m e t r i a l

cancer treated in period

Greatpoland cancer centre in the 30 years'

K. Bratos, A. Roszak, E. Cikowska-Wozniak Greatpoland Cancer Centre, Gynaecological Radiotherapy Department, Poznan, Poland The patient's profile: age, clinical stage, operability and results of treatment in three groups of women treated because of endometrial cancer were compared. Material and methods: Three groups of patients were analysed. The first one treated in 1971-80 ( 367 women), the second in 1986-89 (163 women), and the third between 1990-94 (160 women). All patients had surgery and then were irradiated. Megavoltage teletherapy- the doses from teletherapy were similar for all groups and were about 40-44 Gy/whole pelvis, manual brachytherapy with Ra 226- first group and after-loading method with Cs 137- in the rest groups. Results: The characteristic of patients were described below 1971-1980 (1) 1986-89(2) 1990-94 (3). patients operated 54%(1) 65%(2) 78 %(3), only radiotherapy treated 46%(1) 35%(2) 22 %(3). mean age of treated women 60 years(l) 58 years(2) 60 years(3). young women up to 40 years 3,1%(1) 1,3%(2) 1.3%(3). FIGO stage characteristic I la Ib Ic II III

89,2%(1) 17.7%(1) 54,9%(1) 27.4%(1) 5,4%(1 ) 5,4%(1 )

79,8%(2) 7,7%(2) 62,3%(2) 30,0%(2) 15,3%(2) 4,9%(2)

60.0%(3). 7.6%(3). 53.4%(3). 38,0%(3). 21,0%(3). 19,0%(3).

5 year survival (OS) all stages 77,6%(1) 84,0%(2) 89,4%(3). depended on depth of myometrium involvment la 93,1%(1) 100%(2) 100%(3). Ib 88.8%(1) 92%(2) 100%(3). Ic 66,7%(1) 80%(2) 91%(3). Conclusion: The number of patients treated by surgery and radiotherapy systematicaly increased. The age of patients was similar in compared groups. We observed improvement in the results of endornetrial cancer treatment. 66

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The influence of dose rate changes on the late m o r b i d i t y in patients with stage lib and IIIB uterine cervix cancer P. Rodrigus, J. Venselaar, K. De Winter Dr B. Verbeeten Institute, Tilburg, The Netherlands Purpose: to analyse the influence of the dose rate on late complications for patients with cervical cancer treated with 3 different brachytherapy schemes. Material and methods: from 1977-1986, 63 patients (27 liB, 36 IIIB) were treated with an external radiation dose of 40 Gy (2Gy/fx) followed by 2 intracavitary insertions with a dose of 25 Gy/application to point A. For this group the Gynatron afterloader was used with Cs-137 sources, with an average dose rate at point A of 0.54 Gy.h-1 (GYN). Then, the equipment was changed and a Selectron-LDR afterloader was used for all new patients. Dose rate was raised to an average value of 1.07 Gy.h-1 at point A. The dose prescription for the brachytherapy part was therefore reduced by 20% according to radiobiological models: from 1986-1994, 68 patients (36 liB, 32 IIIB) were treated with an external dose of 40 Gy combined with 2 insertions of 20 Gy (SEL-I). An increased incidence of G2-G3 complications, using the French Italian Glossary (see the table) led to a change of the treatment schedule: from 1994 onwards, 26 patients were treated with a dose of 45 Gy (1.8 Gy/fx) external radiation followed by 2 applications of 17.5 Gy (SEL-II). Thirteen patients of the latter group also received concurrent chemotherapy. Results: the actuarial freedom from all grade 2 or grade 3 (G2-G3) complications at 3 years is 60%, 66%, and 70% for the three schemes, respectively. Group Gastro-intestinal All G2-G3 GYN 29 10 (46%) (16%) SEL-I 31 14 (45%) (21%) SEL-II 15 5 (57%) (19%)

Urinary All 11 (17%) 15 (22%) 4 (15%)

G2-G3 4 (6%) 8 (12%) 1 (4%)

Other All G2-G3 12 10 (63) (19%) (16%) 10 7 (68) (15%) (10%) 7 5 (26) (27%) (19%)

Conclusions: in an earlier publication (R&0 42: 137, 1997) we analysed the data of the group GYN and SEL-I for all stages and concluded that the initial 20% dose reduction to account for the dose rate change was insuffi-