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793 poster FDG-PET CT SCAN BASED NODAL STAGING AND OUTCOME IN ADVANCED CARCINOMA CERVIX.
G YNECOLOGICAL CANCER
Twenty patients (22.5%) presented with Grade 1- 2 urinary or bowel toxicity and 40 patients (45%) with Grade 1-2 vaginal toxicity. Conclusions: Despite the majority of locally advanced carcinoma, excellent local and regional control rates were achieved with an acceptable rate of late toxicity. Dose volume optimization resulted in a higher dose to the target volume and a better local control. 793 poster FDG-PET CT SCAN BASED NODAL STAGING AND OUTCOME IN ADVANCED CARCINOMA CERVIX. M. Upasani1 , U. Mahantshetty1 , V. Rangarajan2 , M. Thakur3 , N. Purandare2 , S. Chopra1 , R. Engineer1 , A. Maheshwari4 , R. Kerkar4 , S. K. Shrivastava1 1 TATA M EMORIAL H OSPITAL, Department of Radiation Oncology, Mumbai, India 2 TATA M EMORIAL H OSPITAL, Department Of Bio-Imaging, Mumbai, India 3 TATA M EMORIAL H OSPITAL, Department of Radiodiagnosis, Mumbai, India 4 TATA M EMORIAL H OSPITAL, Department of Gynaecologic Oncology , Mumbai, India Purpose: Nodal staging is not a part of Clinical FIGO staging in cervical cancer. However, nodal disease is an independent prognostic factor for outcome. Newer imaging modalities including MR and FDG PET-CT have been evaluated for the same. We evaluated the utility of FDG PET-CT in Advanced Carcinoma Cervix in a prospective study. One of the aims was to study the incidence of nodal involvement with FDG PET-CT and their outcome and is basis of this report. Materials: In this prospective observational study, 103 patients underwent screening and serial follow-up FDG PET-CT scans from September 2005 to December 2008. All patients underwent pre treatment USG and / or CT abdomen pelvis and MRI and FDG PET-CT followed by radical chemo-radiation. MRI & FDG PET-CT was done as per the institutional protocol. Follow-up surveillance FDG PET CT was done for these patients at 6 months interval. Results: Of the 103 patients, 62 were FIGO Stage IIB (60%) and 41 were FIGO Stage IIB (40%). Conventional imaging identified nodes in 63 patients with 44 having pelvic nodes, 16 patients with pelvic and para-aortic nodes and isolated para-aortic nodes in 3 patients. Similarly, FDG PET-CT identified nodal disease in 69 patients, with pelvic nodes in 44 patients, pelvic and paraaortic in 22 patients and isolated para-aortic nodes in 3 patients. The mean (±SD) SUV value for pelvic nodes was 6.9 (±4.2) and for the para-aortic nodes 8.8 (±10.1). FDG PET-CT identified additional pelvic nodal disease in 18 patients, additional para-aortic nodes in 12 patients who were not detected on conventional imaging. All patients underwent tailored treatment with radiation. With a median follow-up of 28 months (12 60 months), out of 103, 35 patients had recurrence or residual. 6 patients were deemed lost to followup. Follow-up PET-CT scans identified 27 patients with recurrences. By FDG PET-CT based nodal staging, 6 recurrences (3 loco-regional; 3 had local with para-aortic or distant metastasis) was seen in node negative patients while 29 recurrences were seen in node positive patients (4 loco-regional; 14 had local with para-aortic and/or distant metastasis, 4 had para-aortic nodes only, 7 had only distant metastasis). Patients with only para-aortic or solitary distant metastasis received further radical treatment successfully. Conclusions: FDG PET-CT identifies additional pelvic and para-aortic nodes in advanced carcinoma cervix. It assists in optimization of the treatment. The outcome in patients with FDG PET-CT node positive is poor as compared to node negative patients. Further follow-up and larger studies required to consolidate its impact. 794 poster HDR BRACHYTHERAPY FOR CARCINOMA OF THE UTERINE CERVIX: DIFFICULTIES IN THE INSERTION WITHOUT ANESTHESIA R. J. Miechi1 2 3 , C. Porrato1 , J. Piccinini1 , F. Maini1 , G. Tuttolomondo1 1 R ADIOTHERAPY C ENTER “D R . J OSÉ M IECHI ”, Rosario, Argentina 2 P ROVINCIAL C ENTENARY H OSPITAL, Rosario, Argentina 3 M EDICAL S CHOOL , R OSARIO N ATIONAL U NIVERSITY, Department of diagnostic imaging and radiotherapy, Rosario, Argentina Purpose: The aims of this retrospective study, for cervical cancer in patients previously treated with external beam irradiation, were to evaluate the difficulties to insert the brachytherapy applicators into the uterus without pain, or slightly unpleasantly, when no anesthesia nor sedation was used. Materials: 1096 patients treated from October 1995 to October 2010 for cervical carcinoma with HDR using a remote afterloading system, total 5480 insertions, were reviewed. Treatments were performed with a Nucletron Microselectron HDR UPS V11.22 with an Ir-192 source. Dose optimization points were initially located along a line 2 cm lateral to the tandem, beginning at the tandem tip at 0.5-cm intervals, ending at the tail, and optimized to 100% of the point A dose. There were 14.8% Stage Ib patients, 15.5% Stage IIa, 38.7% Stage IIb, 14.0% Stage IIIa, and 17.0% Stage IIIb. The median age was 50 (23-81). Radiotherapy consisted of external beam irradiation (LA-Co60) to the
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pelvis (mean dose of 45-50 Gy), combined with HDR brachytherapy (mean dose of 30 Gy to point A) given, 6 Gy per session twice weekly or 7 Gy twice weekly. The applicators were 4 and 6cm tandem lengths, and 2.0, 2.5 and 3.0cm ovoid diameters. When to insert the aplicators was impossible, only vaginal ovoid was used in spite of not having given the recommended doses. The procedure took place without anesthesia or sedation. Results: 43 patients (3.9%) were found with difficulties in the insertion, 39 of which, whose anatomy had also been severely modified by external irradiation, were advanced stages (IIb, IIIa or IIIb). The rest were in pain. Conclusions: Anesthesia or sedation can be avoided in HDR brachytherapy treatments for cervix cancer. Only a few patients, in pain or advanced stage, would need anesthesia to reach recommended doses. 795 poster IS FDG UPTAKE IN CERVICAL TUMOURS PREDICTIVE OF OUTCOMES IN CERVICAL CARCINOMAS TREATED BY RADIOCHEMOTHERAPY? J. CHAMOIS1 , K. Peignaux1 , M. Liegard-Gauthier2 , A. Berriolo-Riedinger3 , G. Truc1 , N. Blanchard1 , A. Ligey1 , F. Bonnetain2 , G. Crehange1 , P. Maingon1 1 C ENTRE G EORGES -F RANÇOIS L ECLERC, Department of Radiation Oncology, Dijon, France 2 C ENTRE G EORGES -F RANÇOIS L ECLERC, Department of Biostatistics, Dijon, France 3 C ENTRE G EORGES -F RANÇOIS L ECLERC, Department of Nuclear Medicine, Dijon, France Purpose: To determine whether cervical tumour uptake of 18-Fluoro-deoxyglucose (18FDG) measured as the maximal standardized uptake value (SUV max) is a relevant prognostic factor of tumour response to radiochemotherapy (RCT) at 45 Gy, at treatment completion and of patients’ outcomes. Materials: We retrospectively reviewed the cases of 45 patients treated by RCT and intracavitary pulse-dose-rate (PDR) brachytherapy (BT) for locally advanced cervical carcinoma.All of them had cervical MRI, 18 FDG PET at diagnosis, and clinical assessment and MRI at 45 Gy. Tumour response was evaluated at treatment completion. The largest diameters of the tumour on the first and second MRI, SUV max, and routinely used prognostic factors were recorded. Results: Stage distribution was (using FIGO): IB 11%, IIA9%, IIB 62% and IIIB 18%. The mean pretreatment SUV max was 10 (0- 21) and was higher when pelvic nodes were involved (13.4 vs. 8.9, p=0.03). The mean tumour volume measured on the first MRI was 45.2 cm3 (6.5-154). Patients received RCT delivering 45 Gy in 5 weeks on the PTV, concurrent weekly chemotherapy, and BT delivering a median dose of 30 Gy (range 15-45 Gy). At 45 Gy: the mean tumour volume regression measured on MRI was 82%. According to RECIST, 36% of patients achieved complete tumour response, 53% partial response, and 11% stable disease. FIGO stage predicted global response at 45 Gy according to RECIST (p=0.006), but SUV max did not. At treatment completion: the global response to RCT at 45 Gy was the only significant predictive factor of complete response (OR=26, 95% CI= [1.8 376], p=0.02) in univariate analysis. With a median follow-up of 27 months, the two-year actuarial overall survival and relapse free survival were respectively 84 % and 82%. In univariate regression analysis, lymph node involvement was the only significant prognostic factor for relapse (OR=8.7, CI95% [1.1-65.9], p=0.036). Using a cut-off value of 10 for SUVmax, we found that patients with SUVmax < 10 tended to have a lower risk of relapse than those with SUV max >10. Conclusions: SUV max correlated with pelvic nodal involvement. However, FIGO staging, pelvic nodal status, and tumour regression assessed by MRI following RCT at 45 Gy were more accurate than SUV max in predicting response to treatment and failure. 796 poster MOTION AND VOLUME CHANGES OF PELVIC LYMPH NODES IN CERVICAL CARCINOMA PATIENTS TREATED WITH CHEMORADIATION: WHAT MARGINS ARE REQUIRED? M. Schippers1 , G. Bol1 , B. Raaymakers1 , H. Verkooijen2 , U. van der Heide1 , A. de Leeuw1 , I. M. Jürgenliemk-Schulz1 1 U NIVERSITY M EDICAL C ENTER U TRECHT, Department of Radiation Oncology, Utrecht, Netherlands 2 U NIVERSITY M EDICAL C ENTER U TRECHT, Department of Radiology, Utrecht, Netherlands Purpose: To investigate the weekly volume changes and motion of enlarged lymph nodes in patients with cervical cancer treated with chemoradiation. Margins were derived to accommodate the changes and it was evaluated whether the clinically used treatment margins were sufficient. Materials: 17 patients with cervical cancer FIGO stages 1B-3B with enlarged pelvic lymph nodes (short axis more than 5 mm) were treated with a combination of IMRT external beam radiotherapy, PDR brachytherapy and weekly Cisplatin. All patients underwent MRI examination before and weekly during the external IMRT treatment. A total of 39 lymph nodes were delineated
Twenty patients (22.5%) presented with Grade 1- 2 urinary or bowel toxicity and 40 patients (45%) with Grade 1-2 vaginal toxicity. Conclusions: Despite the majority of locally advanced carcinoma, excellent local and regional control rates were achieved with an acceptable rate of late toxicity. Dose volume optimization resulted in a higher dose to the target volume and a better local control. 793 poster FDG-PET CT SCAN BASED NODAL STAGING AND OUTCOME IN ADVANCED CARCINOMA CERVIX. M. Upasani1 , U. Mahantshetty1 , V. Rangarajan2 , M. Thakur3 , N. Purandare2 , S. Chopra1 , R. Engineer1 , A. Maheshwari4 , R. Kerkar4 , S. K. Shrivastava1 1 TATA M EMORIAL H OSPITAL, Department of Radiation Oncology, Mumbai, India 2 TATA M EMORIAL H OSPITAL, Department Of Bio-Imaging, Mumbai, India 3 TATA M EMORIAL H OSPITAL, Department of Radiodiagnosis, Mumbai, India 4 TATA M EMORIAL H OSPITAL, Department of Gynaecologic Oncology , Mumbai, India Purpose: Nodal staging is not a part of Clinical FIGO staging in cervical cancer. However, nodal disease is an independent prognostic factor for outcome. Newer imaging modalities including MR and FDG PET-CT have been evaluated for the same. We evaluated the utility of FDG PET-CT in Advanced Carcinoma Cervix in a prospective study. One of the aims was to study the incidence of nodal involvement with FDG PET-CT and their outcome and is basis of this report. Materials: In this prospective observational study, 103 patients underwent screening and serial follow-up FDG PET-CT scans from September 2005 to December 2008. All patients underwent pre treatment USG and / or CT abdomen pelvis and MRI and FDG PET-CT followed by radical chemo-radiation. MRI & FDG PET-CT was done as per the institutional protocol. Follow-up surveillance FDG PET CT was done for these patients at 6 months interval. Results: Of the 103 patients, 62 were FIGO Stage IIB (60%) and 41 were FIGO Stage IIB (40%). Conventional imaging identified nodes in 63 patients with 44 having pelvic nodes, 16 patients with pelvic and para-aortic nodes and isolated para-aortic nodes in 3 patients. Similarly, FDG PET-CT identified nodal disease in 69 patients, with pelvic nodes in 44 patients, pelvic and paraaortic in 22 patients and isolated para-aortic nodes in 3 patients. The mean (±SD) SUV value for pelvic nodes was 6.9 (±4.2) and for the para-aortic nodes 8.8 (±10.1). FDG PET-CT identified additional pelvic nodal disease in 18 patients, additional para-aortic nodes in 12 patients who were not detected on conventional imaging. All patients underwent tailored treatment with radiation. With a median follow-up of 28 months (12 60 months), out of 103, 35 patients had recurrence or residual. 6 patients were deemed lost to followup. Follow-up PET-CT scans identified 27 patients with recurrences. By FDG PET-CT based nodal staging, 6 recurrences (3 loco-regional; 3 had local with para-aortic or distant metastasis) was seen in node negative patients while 29 recurrences were seen in node positive patients (4 loco-regional; 14 had local with para-aortic and/or distant metastasis, 4 had para-aortic nodes only, 7 had only distant metastasis). Patients with only para-aortic or solitary distant metastasis received further radical treatment successfully. Conclusions: FDG PET-CT identifies additional pelvic and para-aortic nodes in advanced carcinoma cervix. It assists in optimization of the treatment. The outcome in patients with FDG PET-CT node positive is poor as compared to node negative patients. Further follow-up and larger studies required to consolidate its impact. 794 poster HDR BRACHYTHERAPY FOR CARCINOMA OF THE UTERINE CERVIX: DIFFICULTIES IN THE INSERTION WITHOUT ANESTHESIA R. J. Miechi1 2 3 , C. Porrato1 , J. Piccinini1 , F. Maini1 , G. Tuttolomondo1 1 R ADIOTHERAPY C ENTER “D R . J OSÉ M IECHI ”, Rosario, Argentina 2 P ROVINCIAL C ENTENARY H OSPITAL, Rosario, Argentina 3 M EDICAL S CHOOL , R OSARIO N ATIONAL U NIVERSITY, Department of diagnostic imaging and radiotherapy, Rosario, Argentina Purpose: The aims of this retrospective study, for cervical cancer in patients previously treated with external beam irradiation, were to evaluate the difficulties to insert the brachytherapy applicators into the uterus without pain, or slightly unpleasantly, when no anesthesia nor sedation was used. Materials: 1096 patients treated from October 1995 to October 2010 for cervical carcinoma with HDR using a remote afterloading system, total 5480 insertions, were reviewed. Treatments were performed with a Nucletron Microselectron HDR UPS V11.22 with an Ir-192 source. Dose optimization points were initially located along a line 2 cm lateral to the tandem, beginning at the tandem tip at 0.5-cm intervals, ending at the tail, and optimized to 100% of the point A dose. There were 14.8% Stage Ib patients, 15.5% Stage IIa, 38.7% Stage IIb, 14.0% Stage IIIa, and 17.0% Stage IIIb. The median age was 50 (23-81). Radiotherapy consisted of external beam irradiation (LA-Co60) to the
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pelvis (mean dose of 45-50 Gy), combined with HDR brachytherapy (mean dose of 30 Gy to point A) given, 6 Gy per session twice weekly or 7 Gy twice weekly. The applicators were 4 and 6cm tandem lengths, and 2.0, 2.5 and 3.0cm ovoid diameters. When to insert the aplicators was impossible, only vaginal ovoid was used in spite of not having given the recommended doses. The procedure took place without anesthesia or sedation. Results: 43 patients (3.9%) were found with difficulties in the insertion, 39 of which, whose anatomy had also been severely modified by external irradiation, were advanced stages (IIb, IIIa or IIIb). The rest were in pain. Conclusions: Anesthesia or sedation can be avoided in HDR brachytherapy treatments for cervix cancer. Only a few patients, in pain or advanced stage, would need anesthesia to reach recommended doses. 795 poster IS FDG UPTAKE IN CERVICAL TUMOURS PREDICTIVE OF OUTCOMES IN CERVICAL CARCINOMAS TREATED BY RADIOCHEMOTHERAPY? J. CHAMOIS1 , K. Peignaux1 , M. Liegard-Gauthier2 , A. Berriolo-Riedinger3 , G. Truc1 , N. Blanchard1 , A. Ligey1 , F. Bonnetain2 , G. Crehange1 , P. Maingon1 1 C ENTRE G EORGES -F RANÇOIS L ECLERC, Department of Radiation Oncology, Dijon, France 2 C ENTRE G EORGES -F RANÇOIS L ECLERC, Department of Biostatistics, Dijon, France 3 C ENTRE G EORGES -F RANÇOIS L ECLERC, Department of Nuclear Medicine, Dijon, France Purpose: To determine whether cervical tumour uptake of 18-Fluoro-deoxyglucose (18FDG) measured as the maximal standardized uptake value (SUV max) is a relevant prognostic factor of tumour response to radiochemotherapy (RCT) at 45 Gy, at treatment completion and of patients’ outcomes. Materials: We retrospectively reviewed the cases of 45 patients treated by RCT and intracavitary pulse-dose-rate (PDR) brachytherapy (BT) for locally advanced cervical carcinoma.All of them had cervical MRI, 18 FDG PET at diagnosis, and clinical assessment and MRI at 45 Gy. Tumour response was evaluated at treatment completion. The largest diameters of the tumour on the first and second MRI, SUV max, and routinely used prognostic factors were recorded. Results: Stage distribution was (using FIGO): IB 11%, IIA9%, IIB 62% and IIIB 18%. The mean pretreatment SUV max was 10 (0- 21) and was higher when pelvic nodes were involved (13.4 vs. 8.9, p=0.03). The mean tumour volume measured on the first MRI was 45.2 cm3 (6.5-154). Patients received RCT delivering 45 Gy in 5 weeks on the PTV, concurrent weekly chemotherapy, and BT delivering a median dose of 30 Gy (range 15-45 Gy). At 45 Gy: the mean tumour volume regression measured on MRI was 82%. According to RECIST, 36% of patients achieved complete tumour response, 53% partial response, and 11% stable disease. FIGO stage predicted global response at 45 Gy according to RECIST (p=0.006), but SUV max did not. At treatment completion: the global response to RCT at 45 Gy was the only significant predictive factor of complete response (OR=26, 95% CI= [1.8 376], p=0.02) in univariate analysis. With a median follow-up of 27 months, the two-year actuarial overall survival and relapse free survival were respectively 84 % and 82%. In univariate regression analysis, lymph node involvement was the only significant prognostic factor for relapse (OR=8.7, CI95% [1.1-65.9], p=0.036). Using a cut-off value of 10 for SUVmax, we found that patients with SUVmax < 10 tended to have a lower risk of relapse than those with SUV max >10. Conclusions: SUV max correlated with pelvic nodal involvement. However, FIGO staging, pelvic nodal status, and tumour regression assessed by MRI following RCT at 45 Gy were more accurate than SUV max in predicting response to treatment and failure. 796 poster MOTION AND VOLUME CHANGES OF PELVIC LYMPH NODES IN CERVICAL CARCINOMA PATIENTS TREATED WITH CHEMORADIATION: WHAT MARGINS ARE REQUIRED? M. Schippers1 , G. Bol1 , B. Raaymakers1 , H. Verkooijen2 , U. van der Heide1 , A. de Leeuw1 , I. M. Jürgenliemk-Schulz1 1 U NIVERSITY M EDICAL C ENTER U TRECHT, Department of Radiation Oncology, Utrecht, Netherlands 2 U NIVERSITY M EDICAL C ENTER U TRECHT, Department of Radiology, Utrecht, Netherlands Purpose: To investigate the weekly volume changes and motion of enlarged lymph nodes in patients with cervical cancer treated with chemoradiation. Margins were derived to accommodate the changes and it was evaluated whether the clinically used treatment margins were sufficient. Materials: 17 patients with cervical cancer FIGO stages 1B-3B with enlarged pelvic lymph nodes (short axis more than 5 mm) were treated with a combination of IMRT external beam radiotherapy, PDR brachytherapy and weekly Cisplatin. All patients underwent MRI examination before and weekly during the external IMRT treatment. A total of 39 lymph nodes were delineated