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741Quality assurance of patient set up in radiotherapy of pelvic tumours with electronic portal imaging
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738 PRE-, INTRA-, AND POST-OPERATIVE RADIOTHERAPY FOR RESECTABLE PANCREATIC CANCER. Valenllnl V., Trodella L, Morgantl A.G~ Doglk~o G.B.', Fro~lera O.', Turrtzlanl A. and Cellini N. tstltulo ai Radio4ogta(OMslone di Radi~erapia), (') Istltutodl Clinlca Chlrurgica, Unt~n~ta' Caltolca del S.Cu~e, Rome, Italy BACKGROUND. Surgical resection is the treatment of choice for resectable tumors of the pancreatic head. However it is related to an high incidence of local recurrence and liver metastasis. These disappointing findings led to experiences of multimodal treatment in wich surgery was associated to radiotherapy and/or chemotherapy PURPOSE, ~ m of this study was to determine feasibility and results of a combined modallty treatment for reseotable pancreabc head carcinoma based on pancreatectomy, external beam radiotherapy (EBRT) and IORT MATERIAL AND METHODS. Twenty one pabents (12 males; 9 females) with pancreatic adeno-carcinoma (UICC: stage I: 8 pts; stage II1:13 pts) underwent pancreatectomy and adjuvant radiotherapy After surgical resection, an IORT dose of 10 Gy was delivered to the tumor bed with a 6 MeV electron beam through an adequate cylindrical apphcator, varying in diameter from 6 5 to 10 cm In 3 pts 15 Gy were delivered for suspected residual microscopic disease About 4 weeks postoperatively, EBRT was started A total dose of 50 Gy (ICRU 5 0 : 1 8 Gylday) was delivered to a target volume including the tumor and the regional nodesl '11 pts underwent also preoperative "flash" EBRT of the liver and pancreas with a dose of 5 Gy, 24 hours before surgery This additional treatment was used in the second phase of our study to treat possible liver micrometastases and to reduce tumor spread during surgery RESULTS, Four pts required reoperation for postoperative complications; two of these pts subsequently dead because of sepsis and multiple organ failure, none of the observed complications seemed to be related to IORT. 15 pts received postoperative EBRT (6 excluded for surgtcal complications or poor general conditions), Dunng EBRT. 9 pts experienced Grade 1-2 gastrointestinal toxtcity and 5 pts Grade 1 hematological toxicity (EORTC-RTOG). A local recurrence was observed in 2 pts and distant metastases in 12 pts. Actuarial surv~vel at 1, 2 and 3 years was respectively 60%, 35% and 15% Median actuarial survival was 13 months ("flash" group; 25 months; "no flash" group; 105 months; log-rang; p=0 07) Actuarial local control at 1 and 2 years was respectively 100% and 83% Pathological stage resulted to be the main factor influencing outcome (medmn survival pT1-21 16 months: pT3:2 months: log-rank: p=0,02) CONCLUSION. Adjuvant radiotherapy seems to prove the expected theoretical advantages, namely a fairly good local control without severe toxicity Unfortunately these results are not matched with an tmprovement in survival due to the high incidence of intra-abdominal metastasis Thus, new therapeutic combinations should be tested, pa~iculady preoperative chemoradiation and/or adjuvant chemotherapy
V.Yu.Skoropad, B.A.Berdov, Yu.S.Mardynsky, L.N.Titova Medical Radiological Research Center of Russian Academy of Medical Sciences, Obninsk, Russia. Background, I n c i d e n c e of l o c o - r e g l o n a l and d i s t a n t r e c u r r e n c e is very high even after curative resections which determines poor prognosis in patients with gastric cancer. Purpose. A prospective randomized t r i a l has been activated to explore outcome of intensive treatment consisting of preoperative irradiation in dose dynamic fractionation regime (total dose of 27 Gy during 11 days), gastrectomy and intraoperative radiotherapy (20 Gy, 8-15 MeV to the truncus celiac area). Natherlal and Nethods. The whole treatment program takes 12-13 days. The control group received surgery as the standard treatment approach. From March 1993, 64 patients entered in the study including 31 in the experimental group. Patients in both groups did not d i f f e r concerning age, sex, tumor stage and operative procedure. There was not postoperative death. Results and Conclusion. The treatment scheme was well tolerated. We observed decreasing of postoperative pancreatitis in the experimental group. Other acute and late complications were similar to routine gastric surgery and did not d i f f e r from the control group. In p r e l i minary conclusion, the proposed treatment program seems to be feasible and is expected to result in decreasing of both loco-regional and distant recurrences.
741
740 S T E R E O T A C T I C RADIOSURGERY - ONE YEAR LATER, S.A. Costello, J. Fulton, G. Gillett, S. Bishara Dunedin Hospital, Dunedin, New Zealand A stereotactic radiosurgery service was commenced at Dunedin Public Hospital in January 1995. This is based on the CRW Ill frame and the Radionics X-Knife II planning system incorporating Angiographic, CT and MRI target acquisition. A modified linear accelerator based non-coplanar dynamic arcing technique is used. MRI target acquisition is frameless and involves the use of the Radionics Image Fusion de-warping software. 58 patients have been considered for inclusion in the programme. 31 have been accepted of which 26 have been treated. Case mix : AVM 45% Glioma 13% Meningioma 13% Acoustic Neuroma 10% AOVM 6% Metastases 3% Other 10%. The most commonly used collimator was 2 cm, 68% of patients received a single isocentre using 4 - 7 arcs. The median treatment isodose was 87% (range 75-100%), median dose 1750 cGy (range 1600-2000 cGy). Our median follow-up is short (5.1 months) however 2 AVM's have closed at one year, 1 glioma relapsed at 7 months, the remainder are not evaluable or unchanged, 3 patients have died from causes unrelated to their treated conditions. Most patients were treated as outpatients. There were no serious acute side effects (mild headache the next day being common). One patient has developed a dysconjugate gaze after Radiosurgery to his brainstem at I 1 months. Future developments include upgrading the software to enable areas in the head and neck to be targeted and to bring into operation the Gill Thomas - Cosman relocatable frame to allow multiple fractions to be employed. -
INTENSIVE TREATMENTPROGRAMIN RESECTABLE GASTRIC CANCER
QUALITY ASSURANCE OF PATIENT SET UP IN R A D I O T H E R A P Y O F P E L V I C TUMOURS W I T H E L E C T R O N I C P O R T A L IMAGING A. Moreno, J. Richart, G. Vazquez, F. Andreu, W. Sanjuanbenito, M. Porras, F. Garcia, A. Olba, J. Minguell Hospital Universitario San Juan de Alicante, Spain. I n t r o d u c t i o n : many different tumours are treated with pelvic irradiation, using simple or complex techniques. The ultimate goal of increased local control with a diminution of normal tissue toxicity will be achieved if the target volume is adequately covered by the treatment fields at each and every treatment session. Megavoltage imaging systems let us determine differences in patient positioning during routine radiotherapy, becoming an essential tool in a quality assurance program. Puroose : analyse the reproducibility of set up in the treatment of pelvis tumours. Materials and methods : an electronic portal imaging device Philips SRI-100 on line with a LINAC SL20 was used at our department. Images were analysed from 17 patients treated with a four field technique, without any immobilisation devices and with laser alignment. Images were obtained weekly. A tolerance margin of 5 mm was accepted. Set up was checked with two measurements in the Advance programme/Call for abstracts field (one in the right-left direction and other in cranio-caudal direction) and with one measurement in the lateral field. Measurements were based in anatomical reference points defined previously in the simulation fields. By comparing portal images and simulation films for each patient, we determined mean standard deviations and the number of sessions with any of the parameters out of tolerance margins. Results and conclusions : the mean standard deviations were 2.4, 1.9 and 2.1 mm in lateral, cranio-caudal and Advance programme/Call for abstracts directions. The maximum difference with simulation was 12 m2 (in the antero-posterior direction). We found out 4 patients treated exceeding tolerance of 5 mm in more than l0 sessions. It is necessary a verification and correction protocol in order to detect and keep errors of patient positioning inside tolerance margins.
738 PRE-, INTRA-, AND POST-OPERATIVE RADIOTHERAPY FOR RESECTABLE PANCREATIC CANCER. Valenllnl V., Trodella L, Morgantl A.G~ Doglk~o G.B.', Fro~lera O.', Turrtzlanl A. and Cellini N. tstltulo ai Radio4ogta(OMslone di Radi~erapia), (') Istltutodl Clinlca Chlrurgica, Unt~n~ta' Caltolca del S.Cu~e, Rome, Italy BACKGROUND. Surgical resection is the treatment of choice for resectable tumors of the pancreatic head. However it is related to an high incidence of local recurrence and liver metastasis. These disappointing findings led to experiences of multimodal treatment in wich surgery was associated to radiotherapy and/or chemotherapy PURPOSE, ~ m of this study was to determine feasibility and results of a combined modallty treatment for reseotable pancreabc head carcinoma based on pancreatectomy, external beam radiotherapy (EBRT) and IORT MATERIAL AND METHODS. Twenty one pabents (12 males; 9 females) with pancreatic adeno-carcinoma (UICC: stage I: 8 pts; stage II1:13 pts) underwent pancreatectomy and adjuvant radiotherapy After surgical resection, an IORT dose of 10 Gy was delivered to the tumor bed with a 6 MeV electron beam through an adequate cylindrical apphcator, varying in diameter from 6 5 to 10 cm In 3 pts 15 Gy were delivered for suspected residual microscopic disease About 4 weeks postoperatively, EBRT was started A total dose of 50 Gy (ICRU 5 0 : 1 8 Gylday) was delivered to a target volume including the tumor and the regional nodesl '11 pts underwent also preoperative "flash" EBRT of the liver and pancreas with a dose of 5 Gy, 24 hours before surgery This additional treatment was used in the second phase of our study to treat possible liver micrometastases and to reduce tumor spread during surgery RESULTS, Four pts required reoperation for postoperative complications; two of these pts subsequently dead because of sepsis and multiple organ failure, none of the observed complications seemed to be related to IORT. 15 pts received postoperative EBRT (6 excluded for surgtcal complications or poor general conditions), Dunng EBRT. 9 pts experienced Grade 1-2 gastrointestinal toxtcity and 5 pts Grade 1 hematological toxicity (EORTC-RTOG). A local recurrence was observed in 2 pts and distant metastases in 12 pts. Actuarial surv~vel at 1, 2 and 3 years was respectively 60%, 35% and 15% Median actuarial survival was 13 months ("flash" group; 25 months; "no flash" group; 105 months; log-rang; p=0 07) Actuarial local control at 1 and 2 years was respectively 100% and 83% Pathological stage resulted to be the main factor influencing outcome (medmn survival pT1-21 16 months: pT3:2 months: log-rank: p=0,02) CONCLUSION. Adjuvant radiotherapy seems to prove the expected theoretical advantages, namely a fairly good local control without severe toxicity Unfortunately these results are not matched with an tmprovement in survival due to the high incidence of intra-abdominal metastasis Thus, new therapeutic combinations should be tested, pa~iculady preoperative chemoradiation and/or adjuvant chemotherapy
V.Yu.Skoropad, B.A.Berdov, Yu.S.Mardynsky, L.N.Titova Medical Radiological Research Center of Russian Academy of Medical Sciences, Obninsk, Russia. Background, I n c i d e n c e of l o c o - r e g l o n a l and d i s t a n t r e c u r r e n c e is very high even after curative resections which determines poor prognosis in patients with gastric cancer. Purpose. A prospective randomized t r i a l has been activated to explore outcome of intensive treatment consisting of preoperative irradiation in dose dynamic fractionation regime (total dose of 27 Gy during 11 days), gastrectomy and intraoperative radiotherapy (20 Gy, 8-15 MeV to the truncus celiac area). Natherlal and Nethods. The whole treatment program takes 12-13 days. The control group received surgery as the standard treatment approach. From March 1993, 64 patients entered in the study including 31 in the experimental group. Patients in both groups did not d i f f e r concerning age, sex, tumor stage and operative procedure. There was not postoperative death. Results and Conclusion. The treatment scheme was well tolerated. We observed decreasing of postoperative pancreatitis in the experimental group. Other acute and late complications were similar to routine gastric surgery and did not d i f f e r from the control group. In p r e l i minary conclusion, the proposed treatment program seems to be feasible and is expected to result in decreasing of both loco-regional and distant recurrences.
741
740 S T E R E O T A C T I C RADIOSURGERY - ONE YEAR LATER, S.A. Costello, J. Fulton, G. Gillett, S. Bishara Dunedin Hospital, Dunedin, New Zealand A stereotactic radiosurgery service was commenced at Dunedin Public Hospital in January 1995. This is based on the CRW Ill frame and the Radionics X-Knife II planning system incorporating Angiographic, CT and MRI target acquisition. A modified linear accelerator based non-coplanar dynamic arcing technique is used. MRI target acquisition is frameless and involves the use of the Radionics Image Fusion de-warping software. 58 patients have been considered for inclusion in the programme. 31 have been accepted of which 26 have been treated. Case mix : AVM 45% Glioma 13% Meningioma 13% Acoustic Neuroma 10% AOVM 6% Metastases 3% Other 10%. The most commonly used collimator was 2 cm, 68% of patients received a single isocentre using 4 - 7 arcs. The median treatment isodose was 87% (range 75-100%), median dose 1750 cGy (range 1600-2000 cGy). Our median follow-up is short (5.1 months) however 2 AVM's have closed at one year, 1 glioma relapsed at 7 months, the remainder are not evaluable or unchanged, 3 patients have died from causes unrelated to their treated conditions. Most patients were treated as outpatients. There were no serious acute side effects (mild headache the next day being common). One patient has developed a dysconjugate gaze after Radiosurgery to his brainstem at I 1 months. Future developments include upgrading the software to enable areas in the head and neck to be targeted and to bring into operation the Gill Thomas - Cosman relocatable frame to allow multiple fractions to be employed. -
INTENSIVE TREATMENTPROGRAMIN RESECTABLE GASTRIC CANCER
QUALITY ASSURANCE OF PATIENT SET UP IN R A D I O T H E R A P Y O F P E L V I C TUMOURS W I T H E L E C T R O N I C P O R T A L IMAGING A. Moreno, J. Richart, G. Vazquez, F. Andreu, W. Sanjuanbenito, M. Porras, F. Garcia, A. Olba, J. Minguell Hospital Universitario San Juan de Alicante, Spain. I n t r o d u c t i o n : many different tumours are treated with pelvic irradiation, using simple or complex techniques. The ultimate goal of increased local control with a diminution of normal tissue toxicity will be achieved if the target volume is adequately covered by the treatment fields at each and every treatment session. Megavoltage imaging systems let us determine differences in patient positioning during routine radiotherapy, becoming an essential tool in a quality assurance program. Puroose : analyse the reproducibility of set up in the treatment of pelvis tumours. Materials and methods : an electronic portal imaging device Philips SRI-100 on line with a LINAC SL20 was used at our department. Images were analysed from 17 patients treated with a four field technique, without any immobilisation devices and with laser alignment. Images were obtained weekly. A tolerance margin of 5 mm was accepted. Set up was checked with two measurements in the Advance programme/Call for abstracts field (one in the right-left direction and other in cranio-caudal direction) and with one measurement in the lateral field. Measurements were based in anatomical reference points defined previously in the simulation fields. By comparing portal images and simulation films for each patient, we determined mean standard deviations and the number of sessions with any of the parameters out of tolerance margins. Results and conclusions : the mean standard deviations were 2.4, 1.9 and 2.1 mm in lateral, cranio-caudal and Advance programme/Call for abstracts directions. The maximum difference with simulation was 12 m2 (in the antero-posterior direction). We found out 4 patients treated exceeding tolerance of 5 mm in more than l0 sessions. It is necessary a verification and correction protocol in order to detect and keep errors of patient positioning inside tolerance margins.