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872 poster THE IMPACT OF CONCOMITANT BOOST RADIOTHERAPY IN CARCINOMA BASE OF TONGUE
H EAD N ECK CANCER
872 poster THE IMPACT OF CONCOMITANT BOOST RADIOTHERAPY IN CARCINOMA BASE OF TONGUE A. RISHI1 , S. GHOSHAL1 1 P OST G RADUATE I NSTITUTE OF M EDICAL E DUCATION AND R ESEARCH, Radiation Oncology, Chandigarh, India Purpose: To retrospectively analyze the outcome of radical radiation in patients in patients with squamous cell carcinoma of base of tongue, and evaluate the efficacy of accelerated fractionation radiotherapy with concomitant boost schedule outside a trial setting. Materials: Case records of 250 patients with carcinoma base of tongue, treated radically at PGIMER, Chandigarh, from 2004 - 2008 were analyzed. Radical radiotherapy comprised of conventional fractionation radiotherapy with or without concurrent chemotherapy and accelerated fractionation radiotherapy with concomitant boost schedule. In conventional fractionation radiotherapy, a total of 66 Gy was delivered in 33 fractions at 2 Gy per fraction (BED Gy10 = 79.2). In chemoradiation patient also received concurrent cisplatin (100mg/m2 ) 3 weekly for at least 2 cycles. In concomitant boost schedule, the large field was irradiated with 1.8 Gy/# to 45 Gy over 5 weeks and the boost was given concomitantly during the last 3 weeks of treatment as second daily fraction (1.5 Gy/#), with an interfraction interval of 6 hours. The dose to tumour was 67.5 Gy (BED Gy10 = 78.98). There were 92 patients who were treated with concomitant boost schedule, while 158 patients were treated with conventional fractionation schedule. Disease free survival was evaluated and compared among the different groups using Kaplan Meier method. Toxicity and prognostic factors were also studied among the different groups. Results: The median age of the study group was 55. Number of patients in stage I, II, III & IV were 5, 14, 64 and 167 respectively. There were 7 patients who did not complete their treatment and were excluded from analysis. The 2 year actuarial disease free survival for stage III/IV disease was 50% and 38% for concomitant boost and conventional fractionation radiotherapy, respectively (p = .03). Maximum survival difference was observed for stage III in favour of concomitant boost schedule. Distant metastasis was observed in 3 patients of concomitant boost schedule and 7 with other modality. In concomitant boost schedule grade 3 mucositis and dermatitis were observed in 67% and 11% respectively. In conventional fractionation schedule Grade 3 mucositis and dermatitis was observed in 57% and 16% respectively. Using univariate analysis, advanced stage of disease, unscheduled treatment breaks and age of patients were found to be poor prognostic factors. Conclusions: More than 90% of patients with carcinoma base of tongue presents with locally advanced disease in our institute. Radical radiation in these patients resulted in a 2 year disease free survival of 40%. The use of accelerated fractionation with concomitant boost schedule can significantly improve the outcome of treatment, particularly in stage III disease. 873 poster THE ROLE OF PET-CT IMAGING IN HEAD AND NECK CANCER PATIENTS AFTER RADICAL CHEMORADIOTHERAPY J. Sherriff1 , C. McConkey2 , T. Ogunremi3 , S. Colley3 , P. Sanghera1 , A. Hartley1 1 H ALL -E DWARDS R ADIOTHERAPY R ESEARCH G ROUP, Q UEEN E LIZABETH H OSPITAL, Cancer Centre, Birmingham, United Kingdom 2 C LINICAL T RIAL U NIT, U NIVERSITY OF WARWICK, Coventry, United Kingdom 3 Q UEEN E LIZABETH H OSPITAL B IRMINGHAM, Department of Radiology, Birmingham, United Kingdom Purpose: Positron emission tomography with computerised tomography (PET-CT) scanning is increasingly being utilised in head and neck cancer to assess response after radical concomitant chemoradiotherapy. The UK NCRN PET-NECK trial is currently evaluating this extensively in a prospective format. Whilst the results of this trial are awaited, uncertainty remains regarding the appropriate use and timing of PET-CT scanning for this patient group. The purpose of this study was to assess the use of PET-CT following chemoradiotherapy at our institution. Materials: All patients receiving radical chemoradiotherapy for head and neck cancer over a 5 year period were identified. Outcome data including local control and overall survival was collected for all patients. The positive and negative predictive values (PPV and NPV) of PET-CT for local recurrence were calculated. Results: Sixty nine patients who had a post treatment PET-CT were identified from a total of 251 patients receiving radical concomitant chemoradiotherapy. Median time from completion of chemoradiotherapy to PET-CT scan was 3.4 (Range: 2-8) months. Median follow-up in surviving patients was 19.5 and 20.1 months in the PET-CT and non-PET-CT groups respectively. Two year local control rates were 73.1 (95% CI: 60.6-85.8) % and 77.7 (95% CI: 70.484.9) % in the PET-CT and non-PET-CT groups respectively. Two year overall survival in the PET-CT group was 66.2 (52.8-79.3) % compared to 81.8 (95% CI: 74.9-88.7) %, in those not having a PET-CT scan.Of the 69 patients who had a post treatment PET-CT, 24 had local uptake: 8 within the primary tu-
S 337
mour site alone; 6 within the neck alone; 7 within both the primary site and the neck nodes and 3 locally but at a different site. Local recurrence subsequently occurred in 19 of all patients scanned. The NPV and PPV for local recurrence were 88.9% and 58.3% respectively. Conclusions: Post chemoradiation PET-CT may aid subsequent management decisions. Patients with a negative PET-CT scan post radical chemoradiotherapy have an 88.9% chance of remaining free of local recurrence 20 months post treatment. 874 poster THE ROLE OF SALVAGE SURGERY IN THE TREATMENT OF LOCOREGIONAL FAILURE AFTER RADIOTHERAPY OF BASE TONGUE TUMOR Z. Takacsi-Nagy1 , J. Fodor1 , F. Oberna2 , T. Major1 , M. Kásler2 , C. Polgár1 1
N ATIONAL I NSTITUTE OF O NCOLOGY, Department of Radiotherapy, Budapest, Hungary N ATIONAL I NSTITUTE OF O NCOLOGY, Department of Radiotherapy and Head and Neck, Laser and Reconstructive Plastic Surgery , Budapest, Hungary
2
Purpose: In this study, the results of definitive radiotherapy (RT) and salvage surgery treatment of base of tongue cancer were evaluated. Materials: A total of 94 consecutive patients (16 female and 78 male) with T1-4, N0-3 and M0 disease underwent definitive RT between 1992 and 2005. External beam RT alone (mean dose, 63 Gy) or external beam RT (mean dose 61 Gy) with brachytherapy boost (mean dose, 17 Gy) was given for 50 and 44 patients, respectively. Eight patients were subjected to neck node dissection generally at the time of brachytherapy. Results: At a median follow-up time of 95 months, 37 (39 %) patients had no residual disease or locoregional recurrence, 34 (36 %) patients had logoregional residual disease, and 23 (25 %) patients developed locoregional recurrence. The 5-year cause-specific survival for all patients was 45 % (43 of 94). In multivariate analysis, N2-3 stage and histological grade 3 proved to be independent negative predictors of cause-specific survival (relative risk: 2.2 and 3.1, respectively). The overall number of patients with locoregional failure was 57. Salvage surgery was possible in 18 (32 %) patients; more than half of the patients (31of 57) with locoregional failure was not suitable for salvage surgery due to unresectable disease, poor health status or distant metastasis. Salvage surgery was successful in 10 (56 %) patients, while 8 patients developed a second locoregional recurrence. Conclusions: For patients undergoing definitive RT more effective follow-up and care is needed to increase the rate of salvage surgery. 875 poster THREE DIMENSIONAL CONFORMAL RADIOTHERAPY (3DCRT) OF HEAD AND NECK TUMOURS WITH MULTIPLE FIELDS, AVOIDING THE USE OF ELEC-TRON BEAMS FOR SPINAL CHAIN IRRADIATION AND HALF-BEAM TECHNIQUE FOR SUPRACLAVICULAR IRRADIATION. G. Martin1 , G. Totaro2 , M. D. Falco3 2 , E. Verga2 , V. De Chiara2 , P. Morrone2 4 1 C ENTRO M ORRONE, Radiotherapy, Caserta, Italy 2 C ENTRO M ORRONE, Caserta, Italy 3 D EPARTMENT OF D IAGNOSTIC I MAGING , M OLECULAR I MAGING , I NTER VENTIONAL R ADIOLOGY AND R ADIOTHERAPY, Radiotherapy, Rome, Italy 4 C ENTRO R ICERCHE M ORRONE, Caserta, Italy Purpose: Purpose A technique to irradiate the entire neck at a dose of 5054 Gy by a 3DCRT using multiple wedged fields with a single isocenter was evaluated . This technique avoid the use of electron beams for spinal chain irradiation and half beam technique for supraclavicular irradiation. Materials: From July 2008 to october 2010 twenty patients with head and neck tumour were selected. 14 were affected by Laryngeal Ca., 1 by lymph node metastasis from sqamous cell ca., 3 by oropharynx ca., 1 rinopharinx and 1 of tongue ca. Aged from 31 to 78 years (average 62). Tree had an exclusive treatment, 17 a post operative, twelve underwent concomitant chemotherapy and two concurrent Cetuximab . All were T3-T4 from N0 to N2. TC scan was used to determine the CTV and the OAR. CTV included all the levels of neck lymph nodes. PTV was determined adding 1 cm to CTV. Isocentre was placed at the geometric centre of PTV. Eight wedged beams [OAD=330◦ , LDX=270◦ , LDXC=270◦ , OPD=210◦ 230◦ , OAS=30◦ , LSN=90◦ , LSNC=90◦ , OPS=140◦ 150◦ ] conformed on PTV with MLC were used. In eight cases (big shoulders), a ninth wedged beam [AP=0◦ ] was added . In OPD and OPS beams the gantry,the collimator angles and the MLC configuration was custom to shield at best the spinal cord. 6 MV energy Photon beams were used for all fields, except for OPD, OPS and AP, where 15 MV energy was used. The dose 50 Gy (54 Gy to the patients with lymph node metastasis from sqamous cell carcinoma) was prescribed to CTV(2 Gy/Fx) 5 day per week, with a median dose of 98% (within a range from 96,5% to 99%). The dose to PTV was not considered and estimated because part of the PTV ROI lies "in air", and so it didn’t take part in the calculation of dose
872 poster THE IMPACT OF CONCOMITANT BOOST RADIOTHERAPY IN CARCINOMA BASE OF TONGUE A. RISHI1 , S. GHOSHAL1 1 P OST G RADUATE I NSTITUTE OF M EDICAL E DUCATION AND R ESEARCH, Radiation Oncology, Chandigarh, India Purpose: To retrospectively analyze the outcome of radical radiation in patients in patients with squamous cell carcinoma of base of tongue, and evaluate the efficacy of accelerated fractionation radiotherapy with concomitant boost schedule outside a trial setting. Materials: Case records of 250 patients with carcinoma base of tongue, treated radically at PGIMER, Chandigarh, from 2004 - 2008 were analyzed. Radical radiotherapy comprised of conventional fractionation radiotherapy with or without concurrent chemotherapy and accelerated fractionation radiotherapy with concomitant boost schedule. In conventional fractionation radiotherapy, a total of 66 Gy was delivered in 33 fractions at 2 Gy per fraction (BED Gy10 = 79.2). In chemoradiation patient also received concurrent cisplatin (100mg/m2 ) 3 weekly for at least 2 cycles. In concomitant boost schedule, the large field was irradiated with 1.8 Gy/# to 45 Gy over 5 weeks and the boost was given concomitantly during the last 3 weeks of treatment as second daily fraction (1.5 Gy/#), with an interfraction interval of 6 hours. The dose to tumour was 67.5 Gy (BED Gy10 = 78.98). There were 92 patients who were treated with concomitant boost schedule, while 158 patients were treated with conventional fractionation schedule. Disease free survival was evaluated and compared among the different groups using Kaplan Meier method. Toxicity and prognostic factors were also studied among the different groups. Results: The median age of the study group was 55. Number of patients in stage I, II, III & IV were 5, 14, 64 and 167 respectively. There were 7 patients who did not complete their treatment and were excluded from analysis. The 2 year actuarial disease free survival for stage III/IV disease was 50% and 38% for concomitant boost and conventional fractionation radiotherapy, respectively (p = .03). Maximum survival difference was observed for stage III in favour of concomitant boost schedule. Distant metastasis was observed in 3 patients of concomitant boost schedule and 7 with other modality. In concomitant boost schedule grade 3 mucositis and dermatitis were observed in 67% and 11% respectively. In conventional fractionation schedule Grade 3 mucositis and dermatitis was observed in 57% and 16% respectively. Using univariate analysis, advanced stage of disease, unscheduled treatment breaks and age of patients were found to be poor prognostic factors. Conclusions: More than 90% of patients with carcinoma base of tongue presents with locally advanced disease in our institute. Radical radiation in these patients resulted in a 2 year disease free survival of 40%. The use of accelerated fractionation with concomitant boost schedule can significantly improve the outcome of treatment, particularly in stage III disease. 873 poster THE ROLE OF PET-CT IMAGING IN HEAD AND NECK CANCER PATIENTS AFTER RADICAL CHEMORADIOTHERAPY J. Sherriff1 , C. McConkey2 , T. Ogunremi3 , S. Colley3 , P. Sanghera1 , A. Hartley1 1 H ALL -E DWARDS R ADIOTHERAPY R ESEARCH G ROUP, Q UEEN E LIZABETH H OSPITAL, Cancer Centre, Birmingham, United Kingdom 2 C LINICAL T RIAL U NIT, U NIVERSITY OF WARWICK, Coventry, United Kingdom 3 Q UEEN E LIZABETH H OSPITAL B IRMINGHAM, Department of Radiology, Birmingham, United Kingdom Purpose: Positron emission tomography with computerised tomography (PET-CT) scanning is increasingly being utilised in head and neck cancer to assess response after radical concomitant chemoradiotherapy. The UK NCRN PET-NECK trial is currently evaluating this extensively in a prospective format. Whilst the results of this trial are awaited, uncertainty remains regarding the appropriate use and timing of PET-CT scanning for this patient group. The purpose of this study was to assess the use of PET-CT following chemoradiotherapy at our institution. Materials: All patients receiving radical chemoradiotherapy for head and neck cancer over a 5 year period were identified. Outcome data including local control and overall survival was collected for all patients. The positive and negative predictive values (PPV and NPV) of PET-CT for local recurrence were calculated. Results: Sixty nine patients who had a post treatment PET-CT were identified from a total of 251 patients receiving radical concomitant chemoradiotherapy. Median time from completion of chemoradiotherapy to PET-CT scan was 3.4 (Range: 2-8) months. Median follow-up in surviving patients was 19.5 and 20.1 months in the PET-CT and non-PET-CT groups respectively. Two year local control rates were 73.1 (95% CI: 60.6-85.8) % and 77.7 (95% CI: 70.484.9) % in the PET-CT and non-PET-CT groups respectively. Two year overall survival in the PET-CT group was 66.2 (52.8-79.3) % compared to 81.8 (95% CI: 74.9-88.7) %, in those not having a PET-CT scan.Of the 69 patients who had a post treatment PET-CT, 24 had local uptake: 8 within the primary tu-
S 337
mour site alone; 6 within the neck alone; 7 within both the primary site and the neck nodes and 3 locally but at a different site. Local recurrence subsequently occurred in 19 of all patients scanned. The NPV and PPV for local recurrence were 88.9% and 58.3% respectively. Conclusions: Post chemoradiation PET-CT may aid subsequent management decisions. Patients with a negative PET-CT scan post radical chemoradiotherapy have an 88.9% chance of remaining free of local recurrence 20 months post treatment. 874 poster THE ROLE OF SALVAGE SURGERY IN THE TREATMENT OF LOCOREGIONAL FAILURE AFTER RADIOTHERAPY OF BASE TONGUE TUMOR Z. Takacsi-Nagy1 , J. Fodor1 , F. Oberna2 , T. Major1 , M. Kásler2 , C. Polgár1 1
N ATIONAL I NSTITUTE OF O NCOLOGY, Department of Radiotherapy, Budapest, Hungary N ATIONAL I NSTITUTE OF O NCOLOGY, Department of Radiotherapy and Head and Neck, Laser and Reconstructive Plastic Surgery , Budapest, Hungary
2
Purpose: In this study, the results of definitive radiotherapy (RT) and salvage surgery treatment of base of tongue cancer were evaluated. Materials: A total of 94 consecutive patients (16 female and 78 male) with T1-4, N0-3 and M0 disease underwent definitive RT between 1992 and 2005. External beam RT alone (mean dose, 63 Gy) or external beam RT (mean dose 61 Gy) with brachytherapy boost (mean dose, 17 Gy) was given for 50 and 44 patients, respectively. Eight patients were subjected to neck node dissection generally at the time of brachytherapy. Results: At a median follow-up time of 95 months, 37 (39 %) patients had no residual disease or locoregional recurrence, 34 (36 %) patients had logoregional residual disease, and 23 (25 %) patients developed locoregional recurrence. The 5-year cause-specific survival for all patients was 45 % (43 of 94). In multivariate analysis, N2-3 stage and histological grade 3 proved to be independent negative predictors of cause-specific survival (relative risk: 2.2 and 3.1, respectively). The overall number of patients with locoregional failure was 57. Salvage surgery was possible in 18 (32 %) patients; more than half of the patients (31of 57) with locoregional failure was not suitable for salvage surgery due to unresectable disease, poor health status or distant metastasis. Salvage surgery was successful in 10 (56 %) patients, while 8 patients developed a second locoregional recurrence. Conclusions: For patients undergoing definitive RT more effective follow-up and care is needed to increase the rate of salvage surgery. 875 poster THREE DIMENSIONAL CONFORMAL RADIOTHERAPY (3DCRT) OF HEAD AND NECK TUMOURS WITH MULTIPLE FIELDS, AVOIDING THE USE OF ELEC-TRON BEAMS FOR SPINAL CHAIN IRRADIATION AND HALF-BEAM TECHNIQUE FOR SUPRACLAVICULAR IRRADIATION. G. Martin1 , G. Totaro2 , M. D. Falco3 2 , E. Verga2 , V. De Chiara2 , P. Morrone2 4 1 C ENTRO M ORRONE, Radiotherapy, Caserta, Italy 2 C ENTRO M ORRONE, Caserta, Italy 3 D EPARTMENT OF D IAGNOSTIC I MAGING , M OLECULAR I MAGING , I NTER VENTIONAL R ADIOLOGY AND R ADIOTHERAPY, Radiotherapy, Rome, Italy 4 C ENTRO R ICERCHE M ORRONE, Caserta, Italy Purpose: Purpose A technique to irradiate the entire neck at a dose of 5054 Gy by a 3DCRT using multiple wedged fields with a single isocenter was evaluated . This technique avoid the use of electron beams for spinal chain irradiation and half beam technique for supraclavicular irradiation. Materials: From July 2008 to october 2010 twenty patients with head and neck tumour were selected. 14 were affected by Laryngeal Ca., 1 by lymph node metastasis from sqamous cell ca., 3 by oropharynx ca., 1 rinopharinx and 1 of tongue ca. Aged from 31 to 78 years (average 62). Tree had an exclusive treatment, 17 a post operative, twelve underwent concomitant chemotherapy and two concurrent Cetuximab . All were T3-T4 from N0 to N2. TC scan was used to determine the CTV and the OAR. CTV included all the levels of neck lymph nodes. PTV was determined adding 1 cm to CTV. Isocentre was placed at the geometric centre of PTV. Eight wedged beams [OAD=330◦ , LDX=270◦ , LDXC=270◦ , OPD=210◦ 230◦ , OAS=30◦ , LSN=90◦ , LSNC=90◦ , OPS=140◦ 150◦ ] conformed on PTV with MLC were used. In eight cases (big shoulders), a ninth wedged beam [AP=0◦ ] was added . In OPD and OPS beams the gantry,the collimator angles and the MLC configuration was custom to shield at best the spinal cord. 6 MV energy Photon beams were used for all fields, except for OPD, OPS and AP, where 15 MV energy was used. The dose 50 Gy (54 Gy to the patients with lymph node metastasis from sqamous cell carcinoma) was prescribed to CTV(2 Gy/Fx) 5 day per week, with a median dose of 98% (within a range from 96,5% to 99%). The dose to PTV was not considered and estimated because part of the PTV ROI lies "in air", and so it didn’t take part in the calculation of dose