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892 poster The significance of rectal bleeding after pelvic radiotherapy
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890 poster Permanent unilateral hearing loss after radiotherapy for parotid gland tumours
L. van der Putten ~, R. de Bree ~, J. T.M. Plukker2, F.R. Burlage 3, C. Smits ~, C.R. Leemans ~, J.A. Langendijk~ VU University medical center, Otolaryngology/Head and Neck Surgery, Amsterdam, The Netherlands ~University Hospital Groningen, Surgery~Surgical Oncology, Groningen, The Netherlands ~University Hospital Groningen, Radiation Oncology, Groningen, The Netherlands ~VU University medical center, Radiation Oncology, Amsterdam, The Netherlands Introduction: Purpose of this study was to determine the long-term effects of postoperative radiotherapy on hearing function in patients after parotidectomy for unilateral parotid gland tumors. The incidence and type of permanent hearing loss, the threshold radiation dose and the effects of asymmetrical hearing loss in daily life were investigated. Material and methods: This was a retrospective analysis including audiological examination in 52 patients with postoperative radiotherapy after parotidectomy for unilateral tumors of the parotid gland. Clinically relevant asymmetrical hearing loss was objectively measured by an extensive set of tests including pure tone and speech audiometry, tympanometry, otoacoustic emissions and intelligibility of speech with interfering speech noise. To determine the auditory disabilities and handicaps experienced in daily life we used a validated questionnaire developed by the VU Medical Center. The mean dose on the middle ear, cochlea and Eustachian tube was estimated by dose volume histograms (DVH's). Results: Hearing loss of at least 15 dB in 3 frequencies, relative to the contralateral ear, was found in 32% of the patients and was mainly sensorineural. Patients with an asymmetrical hearing loss had received a higher mean dose on the hearing structures compared with patients without asymmetrical hearing loss (p<0.002). A significant relation was found between asymmetrical hearing loss and a high score on the questionnaire for hearing disability and handicap (p < 0.05), Logistic regression analysis showed a threshold dose (P5) for clinically relevant hearing loss of 39 Gy, 48 Gy and 39 Gy for the inner ear, the cochlea and the Eustachian tube, respectively. The p50 was 54 Gy for the inner ear, 60 Gy for the cochlea and 57 Gy for the Eustachian tube. Conclusion: Radiation induced hearing loss is a common complication after postoperative radiotherapy for parotid gland tumours, leading to disabilities and handicaps in daily life. Radiation doses of higher than 40 to 50 Gy to the inner ear, the cochlea and Eustachian tube should be avoided. These findings could be useful for the definition of constraints for IMRT planning.
891 poster Acute morbidity related to treatment volume during 3Dconformal radiation therapy for prostate cancer A. Karlsd(~ttir~, D.C. Johannessen ~, L.P. Muren ~, T. WentzelLarsen ~, O. Dahl ~ I Haukeland University Hospital, Dept. of Oncology and Medical Physic, Bergen, Norway ~Haukeland University Hospital, Center for Clinical Research, Bergen, Norway
Posters
Purpose: To investigate the relation between acute toxicity and irradiated volume in the organs at risk (ORs) during three-dimensional conformal radiation therapy for prostate cancer. Methods and Materials: From January to December 2001, 132 prostate cancer patients were treated at Haukeland University Hospital, Bergen, Norway, and they were all prescribed a target dose of 70 Gy. Twenty-six patients (20%) received irradiation to the prostate only (Group P), 86 patients (65%) had field arrangements encompassing the prostate and seminal vesicles (Group PSV) while 20 (15%) received modified pelvic fields (Group MPF). A four-field conformal box technique was used. Acute toxicity according to the RTOG scoring system was prospectively recorded throughout the course of treatment. Results: Overall, radiation was well tolerated with 11%, 16% and 35% Grade 2 gastro-intestinal (GI) toxicity and 19%, 34% and 35% Grade 2 or higher genito-urinary (GU) toxicity in Groups P, PSV and MPF, respectively. In univariate and multivariate analyses treatment group was a significant predictor for Grade 2 or higher acute morbidity. In multivariate logistic regression, the rectum dose volume histogram (DVH) parameters were correlated to the incidence of acute Grade 2 GI toxicity, with the fractional volumes receiving more than 37-40 Gy and above 70 Gy showing the statistically strongest correlation (Fig 1). The fractional bladder volume receiving more than 14-27 Gy showed the statistically strongest correlation with acute GU toxicity. Conclusions: 3D-CRT radiation therapy to 70 Gy for prostate cancer was well tolerated. Only two of the 132 patients in the cohort experienced acute bladder toxicity Grade 3, none had Grade 3 rectal toxicity. Uni- and multivariate analyses indicated that the volume treated was a significant factor for the incidence of Grade 2 or higher acute morbidity.
!T
Figure 1: The significance levels from the multivariate analysis of each of the fractional rectum volumes when these were included one at each stage in the model, with only DVH variables ("DVH-alone") or with DVH parameters and the maximum rectum dose included in the model ("D~×"). The pvalues are based on the likelihood ratio test. 892 poster The significance radiotherapy
of
rectal
bleeding
after
pelvic
H. Williams 1, P. Vlavianos 2, P. Blake 3, D. Dearnaley~, D. Tait3, H. Andreyev 1
Posters
~lmperial College Faculty of Medicine, Medicine and Therapeutics, London, United Kingdom 2Chelsea and Westminster Hospital, Gastroenterology, London, United Kingdom 3Royal Marsden Hospital, Radiotherapy, London, United Kingdom Introduction: Radiation proctitis is a well recognised complication of radiotherapy to pelvic tumours. Rectal bleeding is the commonest problem that gastroenterologists evaluate in such patients. Clinicians often attribute rectal bleeding after radiotherapy to radiation proctitis although small studies have suggested that this may not always be correct. Aims and methods: To assess the significance of bleeding after radiotherapy and to determine whether patients require lower gastrointestinal endoscopy. If so, is flexible sigmoidoscopy adequate? We maintained a prospective register of consecutive patients referred for evaluation of rectal bleeding after radiotherapy. Results: Between November 2000 and August 2003, 171 patients were referred with rectal bleeding. 139 were men, median age 70 (range 31-82) and 32 were women median age 61 (range 30-81) a median of 2 years (range 0-21) after pelvic radiotherapy. Primary tumour sites were urological (n=139), gastrointestinal (n=7)and gynaecological (n=25). 90 patients were referred with bleeding alone, 81 patients had other symptoms, frequency (n=33), urgency (n=29), incontinence (n=37), tenesmus (n=10), diarrhoea (n=36) and change in bowel habit (n=20). 87 patients had a single diagnosis after endoscopy, 60 patients had two diagnoses, 14 had three diagnoses and 1 had four and 1 had five diagnoses. Endoscopy found that 141 patients had typical radiation proctitis. 8 patients were found to have cancer (4 relapsed, 4 new gastrointestinal primary tumour); 9 patients had high risk adenomas (>lcm or tubulovillous histology), two of whom also had cancer. 6 patients had 3 3 small (
J. Andreyev ~, P. Vlavianos4, P. Blake 2, D. Dearnaley 2, A. Norman 3, D. Tait2 ~lmperial College Faculty of Medicine, Medicine and Therapeutics, London, United Kingdom 2Royal Marsden Hospital, Radiotherapy, London, United Kingdom 3Royal Marsden Hospital, Computing, London, United Kingdom 4Chelsea and Westminster Hospital, Gastroenterology, London, United Kingdom
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Background: There is a striking lack of evidence as to the optimal management of the 50% of patients who develop permanent change in bowel habit affecting quality of life after pelvic radiotherapy. As a result, in the UK, most such patients are never referred to a gastroenterologist. Aim & Methods: To analyse the cause for gastrointestinal symptoms following pelvic radiotherapy, all diagnoses were prospectively recorded from a consecutive series of patients with symptoms starting after their radiotherapy and referred over a 32 month period to a gastroenterology clinic. Patients either underwent direct access flexible sigmoidoscopy or were investigated in a standard manner by one gastroenterologist after first being reviewed in clinic. Results: 265 patients referred from 15 institutions were investigated. They included 90 women, median age 61.5 (2284 years), 175 men, median age 70 (31-85 years). Radiotherapy was completed a median of 3 years (0.1-34) earlier in women and 2 years (0-21) in men. There were 171 patients with primary urological, 78 with gynaecological and 16 with gastrointestinal tumours. Gastrointestinal symptoms included rectal bleeding (n=171), urgency (n=82), frequency (n=80), tenesmus, discomfort or pain (n--79), faecal incontinence (n= 79), change in bowel habit (n=42), weight loss (n=19), vomiting without other obstructive symptoms (n=18), steatorrhoea (n=7), nocturnal defaecation (n=8) obstructive symptoms (n=4) or other (n=24). After investigation, significant neoplasia was found in 12%. One third of all the diagnoses were unrelated to the previous radiotherapy. More than half the patients had at least two diagnoses. Many of the abnormalities diagnosed were readily treatable. Symptoms were generally unhelpful in predicting diagnosis with the exception of pain, which was associated with the presence of neoplasia (p<0.001). Conclusion: Radiation enteritis is not a single disease entity. More than half the patients have more than one gastrointestinal diagnosis contributing to their symptoms. Following pelvic radiotherapy, specific gastrointestinal symptoms are not a reliable measure of the underlying diagnoses. Systematic evaluation of new gastrointestinal symptoms is worthwhile. 894 poster Acute diarrhea during pelvic irradiation: is small-bowel volume effect different in gynecologic patients with prior abdomen operation or not?
E. Huang, C. Wang, L. Sun, H. Hsu Kaohsiung Chang Gung Medical Center, Department of Radiation Oncology, Kaohsiung Hsien, Taiwan Purpose : To evaluate volume effect of small bowel for diarrhea during pelvic irradiation in gynecologic patients with or without prior abdomen operation. Materials and Methods: From January 1996 through December 2003, 759 patients undergoing 4-field pelvic irradiation for cervical or uterine cancer were analyzed. Whole pelvic (WP), modified whole pelvic (MWP), and lower pelvic (LP) irradiation were delivered initially. According to contrast medium within small bowel in simulation films, we categorized the small-bowel volume of full dose related to WP fields as small-volume and large-volume groups. We recorded the grade of diarrhea until 39.6 Gy/22 fractions of pelvic irradiation. The actuarial rates of overall and moderate to severe diarrhea were compared among different groups. Results : Significantly more large-volume distribution (85%) was noted in patients >60 years without prior operation (p<0.001). The rate of diarrhea was 78%, 76%, and 59% (p=0.001) in patients with WP, MWP, and LP fields,
890 poster Permanent unilateral hearing loss after radiotherapy for parotid gland tumours
L. van der Putten ~, R. de Bree ~, J. T.M. Plukker2, F.R. Burlage 3, C. Smits ~, C.R. Leemans ~, J.A. Langendijk~ VU University medical center, Otolaryngology/Head and Neck Surgery, Amsterdam, The Netherlands ~University Hospital Groningen, Surgery~Surgical Oncology, Groningen, The Netherlands ~University Hospital Groningen, Radiation Oncology, Groningen, The Netherlands ~VU University medical center, Radiation Oncology, Amsterdam, The Netherlands Introduction: Purpose of this study was to determine the long-term effects of postoperative radiotherapy on hearing function in patients after parotidectomy for unilateral parotid gland tumors. The incidence and type of permanent hearing loss, the threshold radiation dose and the effects of asymmetrical hearing loss in daily life were investigated. Material and methods: This was a retrospective analysis including audiological examination in 52 patients with postoperative radiotherapy after parotidectomy for unilateral tumors of the parotid gland. Clinically relevant asymmetrical hearing loss was objectively measured by an extensive set of tests including pure tone and speech audiometry, tympanometry, otoacoustic emissions and intelligibility of speech with interfering speech noise. To determine the auditory disabilities and handicaps experienced in daily life we used a validated questionnaire developed by the VU Medical Center. The mean dose on the middle ear, cochlea and Eustachian tube was estimated by dose volume histograms (DVH's). Results: Hearing loss of at least 15 dB in 3 frequencies, relative to the contralateral ear, was found in 32% of the patients and was mainly sensorineural. Patients with an asymmetrical hearing loss had received a higher mean dose on the hearing structures compared with patients without asymmetrical hearing loss (p<0.002). A significant relation was found between asymmetrical hearing loss and a high score on the questionnaire for hearing disability and handicap (p < 0.05), Logistic regression analysis showed a threshold dose (P5) for clinically relevant hearing loss of 39 Gy, 48 Gy and 39 Gy for the inner ear, the cochlea and the Eustachian tube, respectively. The p50 was 54 Gy for the inner ear, 60 Gy for the cochlea and 57 Gy for the Eustachian tube. Conclusion: Radiation induced hearing loss is a common complication after postoperative radiotherapy for parotid gland tumours, leading to disabilities and handicaps in daily life. Radiation doses of higher than 40 to 50 Gy to the inner ear, the cochlea and Eustachian tube should be avoided. These findings could be useful for the definition of constraints for IMRT planning.
891 poster Acute morbidity related to treatment volume during 3Dconformal radiation therapy for prostate cancer A. Karlsd(~ttir~, D.C. Johannessen ~, L.P. Muren ~, T. WentzelLarsen ~, O. Dahl ~ I Haukeland University Hospital, Dept. of Oncology and Medical Physic, Bergen, Norway ~Haukeland University Hospital, Center for Clinical Research, Bergen, Norway
Posters
Purpose: To investigate the relation between acute toxicity and irradiated volume in the organs at risk (ORs) during three-dimensional conformal radiation therapy for prostate cancer. Methods and Materials: From January to December 2001, 132 prostate cancer patients were treated at Haukeland University Hospital, Bergen, Norway, and they were all prescribed a target dose of 70 Gy. Twenty-six patients (20%) received irradiation to the prostate only (Group P), 86 patients (65%) had field arrangements encompassing the prostate and seminal vesicles (Group PSV) while 20 (15%) received modified pelvic fields (Group MPF). A four-field conformal box technique was used. Acute toxicity according to the RTOG scoring system was prospectively recorded throughout the course of treatment. Results: Overall, radiation was well tolerated with 11%, 16% and 35% Grade 2 gastro-intestinal (GI) toxicity and 19%, 34% and 35% Grade 2 or higher genito-urinary (GU) toxicity in Groups P, PSV and MPF, respectively. In univariate and multivariate analyses treatment group was a significant predictor for Grade 2 or higher acute morbidity. In multivariate logistic regression, the rectum dose volume histogram (DVH) parameters were correlated to the incidence of acute Grade 2 GI toxicity, with the fractional volumes receiving more than 37-40 Gy and above 70 Gy showing the statistically strongest correlation (Fig 1). The fractional bladder volume receiving more than 14-27 Gy showed the statistically strongest correlation with acute GU toxicity. Conclusions: 3D-CRT radiation therapy to 70 Gy for prostate cancer was well tolerated. Only two of the 132 patients in the cohort experienced acute bladder toxicity Grade 3, none had Grade 3 rectal toxicity. Uni- and multivariate analyses indicated that the volume treated was a significant factor for the incidence of Grade 2 or higher acute morbidity.
!T
Figure 1: The significance levels from the multivariate analysis of each of the fractional rectum volumes when these were included one at each stage in the model, with only DVH variables ("DVH-alone") or with DVH parameters and the maximum rectum dose included in the model ("D~×"). The pvalues are based on the likelihood ratio test. 892 poster The significance radiotherapy
of
rectal
bleeding
after
pelvic
H. Williams 1, P. Vlavianos 2, P. Blake 3, D. Dearnaley~, D. Tait3, H. Andreyev 1
Posters
~lmperial College Faculty of Medicine, Medicine and Therapeutics, London, United Kingdom 2Chelsea and Westminster Hospital, Gastroenterology, London, United Kingdom 3Royal Marsden Hospital, Radiotherapy, London, United Kingdom Introduction: Radiation proctitis is a well recognised complication of radiotherapy to pelvic tumours. Rectal bleeding is the commonest problem that gastroenterologists evaluate in such patients. Clinicians often attribute rectal bleeding after radiotherapy to radiation proctitis although small studies have suggested that this may not always be correct. Aims and methods: To assess the significance of bleeding after radiotherapy and to determine whether patients require lower gastrointestinal endoscopy. If so, is flexible sigmoidoscopy adequate? We maintained a prospective register of consecutive patients referred for evaluation of rectal bleeding after radiotherapy. Results: Between November 2000 and August 2003, 171 patients were referred with rectal bleeding. 139 were men, median age 70 (range 31-82) and 32 were women median age 61 (range 30-81) a median of 2 years (range 0-21) after pelvic radiotherapy. Primary tumour sites were urological (n=139), gastrointestinal (n=7)and gynaecological (n=25). 90 patients were referred with bleeding alone, 81 patients had other symptoms, frequency (n=33), urgency (n=29), incontinence (n=37), tenesmus (n=10), diarrhoea (n=36) and change in bowel habit (n=20). 87 patients had a single diagnosis after endoscopy, 60 patients had two diagnoses, 14 had three diagnoses and 1 had four and 1 had five diagnoses. Endoscopy found that 141 patients had typical radiation proctitis. 8 patients were found to have cancer (4 relapsed, 4 new gastrointestinal primary tumour); 9 patients had high risk adenomas (>lcm or tubulovillous histology), two of whom also had cancer. 6 patients had 3 3 small (
J. Andreyev ~, P. Vlavianos4, P. Blake 2, D. Dearnaley 2, A. Norman 3, D. Tait2 ~lmperial College Faculty of Medicine, Medicine and Therapeutics, London, United Kingdom 2Royal Marsden Hospital, Radiotherapy, London, United Kingdom 3Royal Marsden Hospital, Computing, London, United Kingdom 4Chelsea and Westminster Hospital, Gastroenterology, London, United Kingdom
$379
Background: There is a striking lack of evidence as to the optimal management of the 50% of patients who develop permanent change in bowel habit affecting quality of life after pelvic radiotherapy. As a result, in the UK, most such patients are never referred to a gastroenterologist. Aim & Methods: To analyse the cause for gastrointestinal symptoms following pelvic radiotherapy, all diagnoses were prospectively recorded from a consecutive series of patients with symptoms starting after their radiotherapy and referred over a 32 month period to a gastroenterology clinic. Patients either underwent direct access flexible sigmoidoscopy or were investigated in a standard manner by one gastroenterologist after first being reviewed in clinic. Results: 265 patients referred from 15 institutions were investigated. They included 90 women, median age 61.5 (2284 years), 175 men, median age 70 (31-85 years). Radiotherapy was completed a median of 3 years (0.1-34) earlier in women and 2 years (0-21) in men. There were 171 patients with primary urological, 78 with gynaecological and 16 with gastrointestinal tumours. Gastrointestinal symptoms included rectal bleeding (n=171), urgency (n=82), frequency (n=80), tenesmus, discomfort or pain (n--79), faecal incontinence (n= 79), change in bowel habit (n=42), weight loss (n=19), vomiting without other obstructive symptoms (n=18), steatorrhoea (n=7), nocturnal defaecation (n=8) obstructive symptoms (n=4) or other (n=24). After investigation, significant neoplasia was found in 12%. One third of all the diagnoses were unrelated to the previous radiotherapy. More than half the patients had at least two diagnoses. Many of the abnormalities diagnosed were readily treatable. Symptoms were generally unhelpful in predicting diagnosis with the exception of pain, which was associated with the presence of neoplasia (p<0.001). Conclusion: Radiation enteritis is not a single disease entity. More than half the patients have more than one gastrointestinal diagnosis contributing to their symptoms. Following pelvic radiotherapy, specific gastrointestinal symptoms are not a reliable measure of the underlying diagnoses. Systematic evaluation of new gastrointestinal symptoms is worthwhile. 894 poster Acute diarrhea during pelvic irradiation: is small-bowel volume effect different in gynecologic patients with prior abdomen operation or not?
E. Huang, C. Wang, L. Sun, H. Hsu Kaohsiung Chang Gung Medical Center, Department of Radiation Oncology, Kaohsiung Hsien, Taiwan Purpose : To evaluate volume effect of small bowel for diarrhea during pelvic irradiation in gynecologic patients with or without prior abdomen operation. Materials and Methods: From January 1996 through December 2003, 759 patients undergoing 4-field pelvic irradiation for cervical or uterine cancer were analyzed. Whole pelvic (WP), modified whole pelvic (MWP), and lower pelvic (LP) irradiation were delivered initially. According to contrast medium within small bowel in simulation films, we categorized the small-bowel volume of full dose related to WP fields as small-volume and large-volume groups. We recorded the grade of diarrhea until 39.6 Gy/22 fractions of pelvic irradiation. The actuarial rates of overall and moderate to severe diarrhea were compared among different groups. Results : Significantly more large-volume distribution (85%) was noted in patients >60 years without prior operation (p<0.001). The rate of diarrhea was 78%, 76%, and 59% (p=0.001) in patients with WP, MWP, and LP fields,