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66 Brachytherapy for treatment of vulvar cancer
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65 P E R I N E A L B R A C H Y T H E R A P Y IN A N A L C A N A L A N D R E C T A L MALIGNANT DISEASES
G. T u r c ato , M.D. , G.B. Pizzi, M.D., Department of Radiation O n c o l o g y , Mestre Hospital. Venice-Mestre, Italy
66 BRACHYTHERAPY FOR TREATMENT OF V U L V A R CANCER_ A. Vitturini, Torcia.
N.
Raffetto,
M.
Valeriani
e
P.
Introduction : Sphincter preservation was the goal in distal rectum and anal malignancies by combining conservative surgery or external beam irradiation with interstitial Brachythcrapy. Patients & methods : Between October 1992 and December 1997, 54 patients received a Brachytberapy (BRT) perineal implant : 37 with anal canal carcinoma ( stage I: 7, stage 2 : 22. stage 3 A : 5 . stage 3 B : 3 ) , 16 with distal rectal adenocarcinoma (stage I : 14, stage 2 : l, stage 3 ; / ) and I rectal melanoma stage 1. The median follow-up was of 28 months (range I - 61 ). Seven patients where treated after exeisional surgery (Ri - R2) by BRT : 2 anal canal (I with local failure) and 5 rectal (2 with local failure and I melanoma) with a median dose of 52,14 Gy (range 40-60 Gy) . Exclusive BRT was performed in 6 anal canal and 4 rectal carcinoma with doses ranging from 50 to 60 Gy (median dose of 53.3 Gy) . After external beam pelvic and perineal field irradiation 38 (70.3 %) patients where boosted by BRT, generally two months after its completion: 29 anal canal cancers with a median dose of 19.78 Gy (range 15-25 Gy) and 8 low rectal with a median dose of 20,62 Gy (range 15-30 Gy) in accordance with the tumour regression after the external beam irradiation. For implantation 4 - I I needles were used. The anal applicator consist of a Teflon open ring with two concentric rows of holes, 8 holes t cm apart in the inner row and 9 holes 1,35 cm apart in the outer row. 26 patients underwent LDR implant and 28 underwent PDR implant (from June 1995) by a PDR micro-Selectron (Nucletron International) with a dose-rate of about 90 cGyth. The pulse width in PDR implant was around 10 minutes with a pulse period of about I hour, theoretically equivalent to the continuous LDR irradiation. Results : Them were no local failure in the rectal cancer while four (10,8 %) were observed in the anal canal carcinoma, all in the post external beam irradiation group ( 13.8 %). Eight patients were died, 6/37 patients with anal canal (3 with local failure, 2 with distant metastasis and I for other causes) and 2/t6 patients wilh rectal cancer ( I due to pancreatic cancer, I for other causes) No differences in immediate complications were observed in LDR and PDR implanted patients. The sphincter preservation obtained in the series treated with exclusive radiation therapy - external beams and BRT implant - in anal canal cancer was 86.2 % with a median follow-up of 28.8 months (range 1-62 months) Conclusions : The satisfactory sphincter preservation obtained, in respect to results reported in literature, may be due to the limited follow up time It is possible that more patients may experience recurrent disease.
External beam radiotherapy and brachytherapy can be the radical treatment for carcinoma of the vulva. Brachytherapy alone is reported, in few studies, to be effeciveve in managing the disease. Seventy patients with carcinoma of the vulva were treated at Istitute of Radiology of the University "La Sapienza" of Rome, between 19751995. Brachytherapy alone was performed in 8 stage II-III inoperable patients and in 11 postoperative local recurrences. All cases were clinically negative for limphnode involvement. Patients were treated by 1921r wires (LDR) using afterloading technique and single or double plane implant. Total brachytherapy dose was 45-65 Gy at a median dose rate of 45 cGy/h. Two of the 8 patients treated at first presentation recurred locally after 2 years and 3 years respectively. Of the 11 cases treated for recurrence, 2 had local and inguinal recurrence, 1 inguinal and 4 local recurrence. Overall 5-year survival was 50% for patients at first presentation and 30% for recurrents. In our study 1921r brachytherapy has allowed a high local control for patients treated at first presentation, without inguinal recurrence. Patients treated for postoperative recurrence ltave a satisfying local control but a poorer outcome.
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68
P O S T O P E R A T I V E RADIOTHERAPY WITH EXTERNAl. BF.AM I"IIERAPY AND HDR BRACHYTHERAPY IN T I l E T R E A T M E N T O F U T E R I N E C E R V I X CANCER. Frezza P.. Silvestro G., Ehno M. Deparlment of Radiotherapy - Nalional Cancer [nSliltae "Fond. G Pascale" NapoLi. The role of postoperative irradiation in palienl, with cervical czlrclnollla has hal yet been clearly established. Mosl invesligalors have been reported thai postoperative irradiation decrease Ih¢ risk of pelvic recurrence. The aim of this sludy is to determine Ihe incidence ol late complications and treatment tailures of radiation iberapy in patients treated with external bCalll radiation and imracavitary HDR-braehytherapy lot Ib-ll FIGO stages of the uterine cervix. The medical records of 45 patients Irealed It.i our Inslilunon from January 1992 to December 1994 were retrospeclivcly reviewed. Before radiotherapy all patients were submitted to radical hysterectomy and pelvic m',de sampling or lymphedenectomy and were surgically staged according Io FIGO staging system. Stage Pts Grading PTS Hislology IrFS lh 19 GI 6 adenosquamous 12 lla 14 G2 18 squamous 33 lib 12 G3 14 Unknown 7 External pelvic radiotherapy was performed utilizing 23 MV photons with a 4-fields box technique. All patients were treated five times a week with a daily dose of 1.8 G) and with a total of 45 Gy to the whole pelvis. External beam radiotherapy preceded Ihe intracavilary irradiation, lntmcavitary therapy was executed through remotely controlled BUCHLER aflerloading system with 192-1r. Two 5 Gy doses were given weekly to the reference point up to 15-20 Gy. The reference point was defined at 5 mm from the surface of the applicator. According to ICRU 50 dose normalization to PTV was defined by isodose curve of 95%. Dose distribution and planning treatment was realized by computerized planning system and the estimale dose at reference point was 60-65Gy. Until now thirty-five palients are disease free. Ten out of forty-five palieats have a recurrence of diseam. The late complications were found in five oul of thirty-five patienls. Complication PTS Sites of relapse PTS Ureteral fibrosis I central pelvic metast. 3 Bladder conlraClion I bone metast. I Rectosigmoid morbid. 3 para-aonic node involv. 4 supradiafragm, recurr. 2 Our preliminary results showed that postoperative irradiation induce excellent tumor control rates with acceptable complication rotes.
CURATIVE CANCER
RADIOTHERAPY
IN
ENDOMETRIAL
V. Fusco. M. T m i a n o , A. Raguso, P. Corsa, M. Liocc, F. Ricci, P. Lauriola*, M. M a n g i a n t i n i * , S. Parisi Radiotherapy D e p a r t m e n t . * Medical Physics D e p a r t m e n t "'Casa S o l l i e v o della Sofferenza" Hospital, S, G i o v a n n i IL (FG) - Italy
In the patients with medically or surgically inoperable endometdal cancer, who are unable to tolerate surgery because poor medical condictions, radiation therapy (ERT+BRT or BRT alone), is only effective alternative treatment. This retrospective study reports our data on survival, complications and local control in 60 patients treated with a combination of external beam radiation therapy (ERT) and intracavitary high dose rate (HDR) brachitherapy (BRT) or intracavitary HDRBRT alone, at Radiotherapy Department of "Casa Sollievo della Sofferenza" Hospital in S. Giovanni Rotondo (FoggiaItaly), from January 1985 to December 1995. The average age of patients was 69 years. Figo stage distribution was: Stage I: 41, Stage II: 11, Stage Ill: 8. Median follow-up was 25,5 months. The ERT was performed with 6-8 MV Linac, with conventional technique and daily fractions with a total dose of 45-50 Cry. Intracavitary HDR-BRT was delivered by means of an HDR remote al~erloading unit, containing a linear source of 192 Iridium (370 Gbq). The dose was specified to point A in 32 patients and in 26 to uterine contour. 2-3 intracavitary insertions (mean dose 6-7 Gy for a single fraction) were performed with weekly interval. Five-years actuarial survival (Kaplan-Meier method) was 77.7% in Stage I, 90% in Stage II, and 75% in Stage III. Complications (Grade 2-3) scored with French-ltalian Glossary, were: genital 6.6%, gastrointestinal 10%.
65 P E R I N E A L B R A C H Y T H E R A P Y IN A N A L C A N A L A N D R E C T A L MALIGNANT DISEASES
G. T u r c ato , M.D. , G.B. Pizzi, M.D., Department of Radiation O n c o l o g y , Mestre Hospital. Venice-Mestre, Italy
66 BRACHYTHERAPY FOR TREATMENT OF V U L V A R CANCER_ A. Vitturini, Torcia.
N.
Raffetto,
M.
Valeriani
e
P.
Introduction : Sphincter preservation was the goal in distal rectum and anal malignancies by combining conservative surgery or external beam irradiation with interstitial Brachythcrapy. Patients & methods : Between October 1992 and December 1997, 54 patients received a Brachytberapy (BRT) perineal implant : 37 with anal canal carcinoma ( stage I: 7, stage 2 : 22. stage 3 A : 5 . stage 3 B : 3 ) , 16 with distal rectal adenocarcinoma (stage I : 14, stage 2 : l, stage 3 ; / ) and I rectal melanoma stage 1. The median follow-up was of 28 months (range I - 61 ). Seven patients where treated after exeisional surgery (Ri - R2) by BRT : 2 anal canal (I with local failure) and 5 rectal (2 with local failure and I melanoma) with a median dose of 52,14 Gy (range 40-60 Gy) . Exclusive BRT was performed in 6 anal canal and 4 rectal carcinoma with doses ranging from 50 to 60 Gy (median dose of 53.3 Gy) . After external beam pelvic and perineal field irradiation 38 (70.3 %) patients where boosted by BRT, generally two months after its completion: 29 anal canal cancers with a median dose of 19.78 Gy (range 15-25 Gy) and 8 low rectal with a median dose of 20,62 Gy (range 15-30 Gy) in accordance with the tumour regression after the external beam irradiation. For implantation 4 - I I needles were used. The anal applicator consist of a Teflon open ring with two concentric rows of holes, 8 holes t cm apart in the inner row and 9 holes 1,35 cm apart in the outer row. 26 patients underwent LDR implant and 28 underwent PDR implant (from June 1995) by a PDR micro-Selectron (Nucletron International) with a dose-rate of about 90 cGyth. The pulse width in PDR implant was around 10 minutes with a pulse period of about I hour, theoretically equivalent to the continuous LDR irradiation. Results : Them were no local failure in the rectal cancer while four (10,8 %) were observed in the anal canal carcinoma, all in the post external beam irradiation group ( 13.8 %). Eight patients were died, 6/37 patients with anal canal (3 with local failure, 2 with distant metastasis and I for other causes) and 2/t6 patients wilh rectal cancer ( I due to pancreatic cancer, I for other causes) No differences in immediate complications were observed in LDR and PDR implanted patients. The sphincter preservation obtained in the series treated with exclusive radiation therapy - external beams and BRT implant - in anal canal cancer was 86.2 % with a median follow-up of 28.8 months (range 1-62 months) Conclusions : The satisfactory sphincter preservation obtained, in respect to results reported in literature, may be due to the limited follow up time It is possible that more patients may experience recurrent disease.
External beam radiotherapy and brachytherapy can be the radical treatment for carcinoma of the vulva. Brachytherapy alone is reported, in few studies, to be effeciveve in managing the disease. Seventy patients with carcinoma of the vulva were treated at Istitute of Radiology of the University "La Sapienza" of Rome, between 19751995. Brachytherapy alone was performed in 8 stage II-III inoperable patients and in 11 postoperative local recurrences. All cases were clinically negative for limphnode involvement. Patients were treated by 1921r wires (LDR) using afterloading technique and single or double plane implant. Total brachytherapy dose was 45-65 Gy at a median dose rate of 45 cGy/h. Two of the 8 patients treated at first presentation recurred locally after 2 years and 3 years respectively. Of the 11 cases treated for recurrence, 2 had local and inguinal recurrence, 1 inguinal and 4 local recurrence. Overall 5-year survival was 50% for patients at first presentation and 30% for recurrents. In our study 1921r brachytherapy has allowed a high local control for patients treated at first presentation, without inguinal recurrence. Patients treated for postoperative recurrence ltave a satisfying local control but a poorer outcome.
67
68
P O S T O P E R A T I V E RADIOTHERAPY WITH EXTERNAl. BF.AM I"IIERAPY AND HDR BRACHYTHERAPY IN T I l E T R E A T M E N T O F U T E R I N E C E R V I X CANCER. Frezza P.. Silvestro G., Ehno M. Deparlment of Radiotherapy - Nalional Cancer [nSliltae "Fond. G Pascale" NapoLi. The role of postoperative irradiation in palienl, with cervical czlrclnollla has hal yet been clearly established. Mosl invesligalors have been reported thai postoperative irradiation decrease Ih¢ risk of pelvic recurrence. The aim of this sludy is to determine Ihe incidence ol late complications and treatment tailures of radiation iberapy in patients treated with external bCalll radiation and imracavitary HDR-braehytherapy lot Ib-ll FIGO stages of the uterine cervix. The medical records of 45 patients Irealed It.i our Inslilunon from January 1992 to December 1994 were retrospeclivcly reviewed. Before radiotherapy all patients were submitted to radical hysterectomy and pelvic m',de sampling or lymphedenectomy and were surgically staged according Io FIGO staging system. Stage Pts Grading PTS Hislology IrFS lh 19 GI 6 adenosquamous 12 lla 14 G2 18 squamous 33 lib 12 G3 14 Unknown 7 External pelvic radiotherapy was performed utilizing 23 MV photons with a 4-fields box technique. All patients were treated five times a week with a daily dose of 1.8 G) and with a total of 45 Gy to the whole pelvis. External beam radiotherapy preceded Ihe intracavilary irradiation, lntmcavitary therapy was executed through remotely controlled BUCHLER aflerloading system with 192-1r. Two 5 Gy doses were given weekly to the reference point up to 15-20 Gy. The reference point was defined at 5 mm from the surface of the applicator. According to ICRU 50 dose normalization to PTV was defined by isodose curve of 95%. Dose distribution and planning treatment was realized by computerized planning system and the estimale dose at reference point was 60-65Gy. Until now thirty-five palients are disease free. Ten out of forty-five palieats have a recurrence of diseam. The late complications were found in five oul of thirty-five patienls. Complication PTS Sites of relapse PTS Ureteral fibrosis I central pelvic metast. 3 Bladder conlraClion I bone metast. I Rectosigmoid morbid. 3 para-aonic node involv. 4 supradiafragm, recurr. 2 Our preliminary results showed that postoperative irradiation induce excellent tumor control rates with acceptable complication rotes.
CURATIVE CANCER
RADIOTHERAPY
IN
ENDOMETRIAL
V. Fusco. M. T m i a n o , A. Raguso, P. Corsa, M. Liocc, F. Ricci, P. Lauriola*, M. M a n g i a n t i n i * , S. Parisi Radiotherapy D e p a r t m e n t . * Medical Physics D e p a r t m e n t "'Casa S o l l i e v o della Sofferenza" Hospital, S, G i o v a n n i IL (FG) - Italy
In the patients with medically or surgically inoperable endometdal cancer, who are unable to tolerate surgery because poor medical condictions, radiation therapy (ERT+BRT or BRT alone), is only effective alternative treatment. This retrospective study reports our data on survival, complications and local control in 60 patients treated with a combination of external beam radiation therapy (ERT) and intracavitary high dose rate (HDR) brachitherapy (BRT) or intracavitary HDRBRT alone, at Radiotherapy Department of "Casa Sollievo della Sofferenza" Hospital in S. Giovanni Rotondo (FoggiaItaly), from January 1985 to December 1995. The average age of patients was 69 years. Figo stage distribution was: Stage I: 41, Stage II: 11, Stage Ill: 8. Median follow-up was 25,5 months. The ERT was performed with 6-8 MV Linac, with conventional technique and daily fractions with a total dose of 45-50 Cry. Intracavitary HDR-BRT was delivered by means of an HDR remote al~erloading unit, containing a linear source of 192 Iridium (370 Gbq). The dose was specified to point A in 32 patients and in 26 to uterine contour. 2-3 intracavitary insertions (mean dose 6-7 Gy for a single fraction) were performed with weekly interval. Five-years actuarial survival (Kaplan-Meier method) was 77.7% in Stage I, 90% in Stage II, and 75% in Stage III. Complications (Grade 2-3) scored with French-ltalian Glossary, were: genital 6.6%, gastrointestinal 10%.