- Email: [email protected]
9 Preliminary results in first 100 patients treated with I-125 implantation for localized prostatic cancer
s3
10
9 PRELIMINARY RESULTS IN FIRST 100 PATIENTS TREATED WITH I-125 IMPLANTATION FOR LOCALIZED PROSTATIC CANCER. J.J. Battermann, Department of Radiation Oncology, University Utrecht, The Netherlands
Hospital
STEREOTACTIC
TRANSGLUTEAL of
Panes G. Koutrouvelis, Uro-Prostate Institute,
APPROACH for
PROSTATE
BRACYTHERAPY
CARCER
M.D.
Vienna,
Virginia,
U.S.A.
:
Introduction implantation of I-125 seeds is one of the treatment modalities for localized prostatic cancer. It is cost-effective (about half the costs of external beam irradiation and about one fifth of the costs of radical prostatectomyj, takes only one to three days of hospitalization and has little
A new 3.dimensional slereotacuc rranspluteal CT-guided approach 1~ presented for bracflherap) oflocahred prostate adenocarclnom.! blxry patients aged hl) to VO years tsrape 1 ,. I :I ha\e txetl treated hy 1111. method wh Pd.103 seeds dune the past two years. The prescribed dose was 12.000 cGy. Volume and treatment plannmg were performed twh CT Placemenl of the afterloading needles was accomplished ulth a palmred.
side effects.
:
Material and methods in the period October 1989 through October 1995, 100 patients underwent I-125 treatment at the Utrecht University Hospital. Age varied from 45 till 91, 67.3 years. Breakdown accordmg to stage is TO: 9, Tl: 23, T2: 61 and T3 with GI 48, G2: 39, G3. 4 and Gx: 5. Initial PSA values are available since the end of 1991 and are used for follow)up. PSA value alone is not used as criterium for patient selection. Lymph node dissection was performed in I8 patients, with one patient having a positive node. The implantation is performed under spinal or general anaesthesia. Needles are placed under ultrasound guidance (B & K ultrasound system), using a fixation device and template. With the Mlck applrcator 3 5 seeds are placed through each needie.
mean age : 3,
:
FDA-approved stereotactic system mounted on a CT table. The mean PSA level was I? 0 n&ml. The prostatic volume was hO-1511cm’ in 33 patwntc Fdieen patents had moderate obsrrucrne uroparhy prmr fil the prweduw TURP defects were present in 13 panems. one of whom had unsucccssfull! undergone external radmtion therapy and hormonal manlpularlon III@, grade rumors (Cileason‘s score. 7.10) r\err prewnt 11, IX pa,,mtc. k’s_\ levels decreased to less than 4 n&ml ,n 96% of the pa,,en,s measured three to SIX months atier the prwedure and to less than ? ns ml in h?“. 01’ the patwnrs. Prostar~ VO~UIIIC dccrrased by 4ll”,,.Xl’~ I, 111paw”,\ mz.l\urrd three to s,x months after the procedure. There was s~gnificam cl~ntcal ~mpro!emenl tn patient< wfh obstructne uropath? m thrrc to $11 ahmth\ With the e‘iceptmn of and burnmp of urma,,on ,,hczr\ed ,,I XI”,, of patxnts for a transent period of one to three months. there hwe bren no slpilicant complications. No patwnts experxnced mcontmcnw or mfectlon. Patients who wrrr sruually xtnr prw to the prorrdure remained so after the procedure The trdns~lu~eal approach with 3-d stereouxils oilers se\cral ad\nnl.lgei o\er the transpermeal ultrasound gutded method’ I” terms of precision ut
:
Results survival varied from more than 6 months (92 patients) till more than 60 months (5 patients), I2 patxnts died, of which 3 showed progressive disease. Results of treatment were scored as NED (no signs of progression, PSA decrease and PSA value below 4 at last follow-up), stable (idem. but PSA 5 - IO at last follow-up), or progression (signs of progression, PSA increase, PSA value above IO at last follow-up). Excluding patients with a follow-up of less than six months, 57 patients were NED, 13 patients were stable and I8 patients showed progression.
frequency
needle placement. treatment of ddiicult pattents wth laree prostate glands and TURP defects. and avoidance of bone mterferencc and urethral penetratmn I’hc wnpluty of th,s techmque makes rhl\ oriltmrnr d iuhlc alternat~w to watchful wattlag m selected patients and can he appltcdhle fo candIdate, who refuse surgery and patients wrh f&led external what,,,,,
:
Conclusions Implantation of I-125 seeds in the treatment of localized prostate cancer offers a cost-effective, simple modality with little side effects and control rates comparable to other modalities. Longer follow-up LSrequtred to estabhsh persisting control.
therapy. It can also be wewed as an excellent choxe for patients who are poor surgxal risks, patxnts wth large prostate rolumes oxer hll cm’ and panents wtb lURP defrcts.
12
11 INSTITUT GUSTAVE-ROUSSY EXPERIENCE WlTH IM-RAOPERATrVE INTERSTITIAL LOW DOSE RATE (LDR) BRACEYTEERAPY N SOFT TISSUE SARCOMAS
A. Gerbaulet. M. Perez Payo. C. Haie-Meder. J. G&n. J-L. Habrand. E. Lanigau. H. Marsiglia. M. Albano. Institut GwtaveRoussy (IGR), 94805 Viiejuifcedex (France)
LOW DOSE-RATE INTRA-OPERATIVE SOFT TISSUE SARCOMAS 85 CASES
presenting
with
soft
FOR
M Delannes I’). L Thomas (“). P Mallel (‘), E Stockle (“), Ch Chevreau(^). B N EUI Y). N Daly-Schveltzer (^). J P~gneux (“). G Kantor (“) (*) Centre Claudu Regaud. Toulouse- (“) Instltut BergomB. Bordeaux France MATERIAL
tissue sarcomas (STS) were treated with LDR interstitial brachytherapy @IT) at IGR Among them, 50 ad&s, !?om 1972 to 1995. above 15 years of age. are reported. Patient characteristics : * age disttibution : 15-30 yr 30 % ; 30-50 yr 38 % ; 5 50 ye 32 %, * male 38 %, * tumor site : H&N 2 % ; trunk 24.5 % ; upper limb 44.9 % ; lower limb 28 % * hunor size : 2-5 cm 52 % ; 5-8 cm 38 % ; > 8 cm I6 %. * Pathology : 10 histologic types with Grade I : 18 % : II : 40 % ; Ill : 42 %. Treatment : IBT was a part of initial treatment in I5 cases (Group A) and for sakage in 35 cases (Group B). The BT technique using Paris system rules. was uniform : plastic tubes were implanted iatra-operatively then aBerloaded with iridium 192 ties. BT was combined with external beam radiotherapy in 2 cases and with chemotherapy in 10 cases. IBT technical aspects : delay Tom surgery to loading Y 2 days : 48 % ; doses : 55 - 75 Gy : 86 % ; number of sources : 2-5 : 28 %, 6 - 10 : 66 %. 5 10 : 6 %, single or dual plane implants were used in 98 % of cases.; dose rate : 2.5 - 50 cGyh‘l : 62 % ; reference volume < 35 cc : 20 %, 35-65 cc : 40 %. > 65 cc m 40 %. Results : I) Overall survival (OS) : 68 %. local failures (LF) I8 %, (50 % within or at lateral border of reference volume) : distant metastasis (DM) : 32 %, necrosis (NEC) : 38 %. 2) Group A :LF : 4 %, DM : 20 %, NEC : 33 %. 3) Group B : LF : 36 %, DM : 48 %, NEC : 44 %. Conclusion : If the role of consewative surgery is essentieI, pathological lindings (residual disease, grading) provide the indications for IBT : 1)prophylactic treatment : +/- IBT (Gr I), IBT (GT II, III). 2) positive margin : microscopic : IBT ; macroscopic : IBT boost + external beam radiotherapy. 102 patients
BRACHYTHERAPY REPORT
AND METHODS
Between May 1986 and January 1994, 85 patients wth soft tissue sarcomas underwent mtra-operative mterstltlal wnplants in conlunction wth conservatwe tumor resecbons Brachytherapy was part of the m&al treatment in 62 cases, and was reaked m 23 cases for recurrent tumor 70/85 (62 %) tumors were located in the Iambs. 56185 (66 %) were T2 or T3 38185 (45 %) were wolvmg or close to neuro-vascular structures The Implant dose was 40 - 65 Gy when brachytherapy was the only treatment (31185 p), mostly for recurrent sarcomas, and 12 25 Gy (mean 20 Gy) when combmed with external lrradlatlon (54185 p) RESULTS Medmn follow-up 1s40 months 4 years actuarial suwlval rate is 70 8 % for the whole series, 74 5 % for prewously untreated patients, 61 8 % for pabents treated for recurrent tumors 4 years actuarial local control rate is respectively 86 4 % 95.7 % and 68 1 % Of the 8 patients with local relapse, 1 IS alive wlthout evolutlve disease,
-
-
7 have developped pulmonary metastasis Acute side-effects occured in 18185 patients (21 %) requlnng surgical repafr I” 8 cases Late side-effects were mostly fibrosis (30 p), lymphoedemas (8 p) neuropathles (5 p) As a result, functional lmpalrement was observed I” 13185 (15 %) patients No amputation was required for side-effects CONCLUSION This senes emphasues brachytherapy combined with external irradlatlon IS a safe and efficient treatment technique in the treatment of sof tissue sarcomas The local control rate appears sattsfactory and the side-effects tolerable, with tlmked functronal lmpa&rement
:
10
9 PRELIMINARY RESULTS IN FIRST 100 PATIENTS TREATED WITH I-125 IMPLANTATION FOR LOCALIZED PROSTATIC CANCER. J.J. Battermann, Department of Radiation Oncology, University Utrecht, The Netherlands
Hospital
STEREOTACTIC
TRANSGLUTEAL of
Panes G. Koutrouvelis, Uro-Prostate Institute,
APPROACH for
PROSTATE
BRACYTHERAPY
CARCER
M.D.
Vienna,
Virginia,
U.S.A.
:
Introduction implantation of I-125 seeds is one of the treatment modalities for localized prostatic cancer. It is cost-effective (about half the costs of external beam irradiation and about one fifth of the costs of radical prostatectomyj, takes only one to three days of hospitalization and has little
A new 3.dimensional slereotacuc rranspluteal CT-guided approach 1~ presented for bracflherap) oflocahred prostate adenocarclnom.! blxry patients aged hl) to VO years tsrape 1 ,. I :I ha\e txetl treated hy 1111. method wh Pd.103 seeds dune the past two years. The prescribed dose was 12.000 cGy. Volume and treatment plannmg were performed twh CT Placemenl of the afterloading needles was accomplished ulth a palmred.
side effects.
:
Material and methods in the period October 1989 through October 1995, 100 patients underwent I-125 treatment at the Utrecht University Hospital. Age varied from 45 till 91, 67.3 years. Breakdown accordmg to stage is TO: 9, Tl: 23, T2: 61 and T3 with GI 48, G2: 39, G3. 4 and Gx: 5. Initial PSA values are available since the end of 1991 and are used for follow)up. PSA value alone is not used as criterium for patient selection. Lymph node dissection was performed in I8 patients, with one patient having a positive node. The implantation is performed under spinal or general anaesthesia. Needles are placed under ultrasound guidance (B & K ultrasound system), using a fixation device and template. With the Mlck applrcator 3 5 seeds are placed through each needie.
mean age : 3,
:
FDA-approved stereotactic system mounted on a CT table. The mean PSA level was I? 0 n&ml. The prostatic volume was hO-1511cm’ in 33 patwntc Fdieen patents had moderate obsrrucrne uroparhy prmr fil the prweduw TURP defects were present in 13 panems. one of whom had unsucccssfull! undergone external radmtion therapy and hormonal manlpularlon III@, grade rumors (Cileason‘s score. 7.10) r\err prewnt 11, IX pa,,mtc. k’s_\ levels decreased to less than 4 n&ml ,n 96% of the pa,,en,s measured three to SIX months atier the prwedure and to less than ? ns ml in h?“. 01’ the patwnrs. Prostar~ VO~UIIIC dccrrased by 4ll”,,.Xl’~ I, 111paw”,\ mz.l\urrd three to s,x months after the procedure. There was s~gnificam cl~ntcal ~mpro!emenl tn patient< wfh obstructne uropath? m thrrc to $11 ahmth\ With the e‘iceptmn of and burnmp of urma,,on ,,hczr\ed ,,I XI”,, of patxnts for a transent period of one to three months. there hwe bren no slpilicant complications. No patwnts experxnced mcontmcnw or mfectlon. Patients who wrrr sruually xtnr prw to the prorrdure remained so after the procedure The trdns~lu~eal approach with 3-d stereouxils oilers se\cral ad\nnl.lgei o\er the transpermeal ultrasound gutded method’ I” terms of precision ut
:
Results survival varied from more than 6 months (92 patients) till more than 60 months (5 patients), I2 patxnts died, of which 3 showed progressive disease. Results of treatment were scored as NED (no signs of progression, PSA decrease and PSA value below 4 at last follow-up), stable (idem. but PSA 5 - IO at last follow-up), or progression (signs of progression, PSA increase, PSA value above IO at last follow-up). Excluding patients with a follow-up of less than six months, 57 patients were NED, 13 patients were stable and I8 patients showed progression.
frequency
needle placement. treatment of ddiicult pattents wth laree prostate glands and TURP defects. and avoidance of bone mterferencc and urethral penetratmn I’hc wnpluty of th,s techmque makes rhl\ oriltmrnr d iuhlc alternat~w to watchful wattlag m selected patients and can he appltcdhle fo candIdate, who refuse surgery and patients wrh f&led external what,,,,,
:
Conclusions Implantation of I-125 seeds in the treatment of localized prostate cancer offers a cost-effective, simple modality with little side effects and control rates comparable to other modalities. Longer follow-up LSrequtred to estabhsh persisting control.
therapy. It can also be wewed as an excellent choxe for patients who are poor surgxal risks, patxnts wth large prostate rolumes oxer hll cm’ and panents wtb lURP defrcts.
12
11 INSTITUT GUSTAVE-ROUSSY EXPERIENCE WlTH IM-RAOPERATrVE INTERSTITIAL LOW DOSE RATE (LDR) BRACEYTEERAPY N SOFT TISSUE SARCOMAS
A. Gerbaulet. M. Perez Payo. C. Haie-Meder. J. G&n. J-L. Habrand. E. Lanigau. H. Marsiglia. M. Albano. Institut GwtaveRoussy (IGR), 94805 Viiejuifcedex (France)
LOW DOSE-RATE INTRA-OPERATIVE SOFT TISSUE SARCOMAS 85 CASES
presenting
with
soft
FOR
M Delannes I’). L Thomas (“). P Mallel (‘), E Stockle (“), Ch Chevreau(^). B N EUI Y). N Daly-Schveltzer (^). J P~gneux (“). G Kantor (“) (*) Centre Claudu Regaud. Toulouse- (“) Instltut BergomB. Bordeaux France MATERIAL
tissue sarcomas (STS) were treated with LDR interstitial brachytherapy @IT) at IGR Among them, 50 ad&s, !?om 1972 to 1995. above 15 years of age. are reported. Patient characteristics : * age disttibution : 15-30 yr 30 % ; 30-50 yr 38 % ; 5 50 ye 32 %, * male 38 %, * tumor site : H&N 2 % ; trunk 24.5 % ; upper limb 44.9 % ; lower limb 28 % * hunor size : 2-5 cm 52 % ; 5-8 cm 38 % ; > 8 cm I6 %. * Pathology : 10 histologic types with Grade I : 18 % : II : 40 % ; Ill : 42 %. Treatment : IBT was a part of initial treatment in I5 cases (Group A) and for sakage in 35 cases (Group B). The BT technique using Paris system rules. was uniform : plastic tubes were implanted iatra-operatively then aBerloaded with iridium 192 ties. BT was combined with external beam radiotherapy in 2 cases and with chemotherapy in 10 cases. IBT technical aspects : delay Tom surgery to loading Y 2 days : 48 % ; doses : 55 - 75 Gy : 86 % ; number of sources : 2-5 : 28 %, 6 - 10 : 66 %. 5 10 : 6 %, single or dual plane implants were used in 98 % of cases.; dose rate : 2.5 - 50 cGyh‘l : 62 % ; reference volume < 35 cc : 20 %, 35-65 cc : 40 %. > 65 cc m 40 %. Results : I) Overall survival (OS) : 68 %. local failures (LF) I8 %, (50 % within or at lateral border of reference volume) : distant metastasis (DM) : 32 %, necrosis (NEC) : 38 %. 2) Group A :LF : 4 %, DM : 20 %, NEC : 33 %. 3) Group B : LF : 36 %, DM : 48 %, NEC : 44 %. Conclusion : If the role of consewative surgery is essentieI, pathological lindings (residual disease, grading) provide the indications for IBT : 1)prophylactic treatment : +/- IBT (Gr I), IBT (GT II, III). 2) positive margin : microscopic : IBT ; macroscopic : IBT boost + external beam radiotherapy. 102 patients
BRACHYTHERAPY REPORT
AND METHODS
Between May 1986 and January 1994, 85 patients wth soft tissue sarcomas underwent mtra-operative mterstltlal wnplants in conlunction wth conservatwe tumor resecbons Brachytherapy was part of the m&al treatment in 62 cases, and was reaked m 23 cases for recurrent tumor 70/85 (62 %) tumors were located in the Iambs. 56185 (66 %) were T2 or T3 38185 (45 %) were wolvmg or close to neuro-vascular structures The Implant dose was 40 - 65 Gy when brachytherapy was the only treatment (31185 p), mostly for recurrent sarcomas, and 12 25 Gy (mean 20 Gy) when combmed with external lrradlatlon (54185 p) RESULTS Medmn follow-up 1s40 months 4 years actuarial suwlval rate is 70 8 % for the whole series, 74 5 % for prewously untreated patients, 61 8 % for pabents treated for recurrent tumors 4 years actuarial local control rate is respectively 86 4 % 95.7 % and 68 1 % Of the 8 patients with local relapse, 1 IS alive wlthout evolutlve disease,
-
-
7 have developped pulmonary metastasis Acute side-effects occured in 18185 patients (21 %) requlnng surgical repafr I” 8 cases Late side-effects were mostly fibrosis (30 p), lymphoedemas (8 p) neuropathles (5 p) As a result, functional lmpalrement was observed I” 13185 (15 %) patients No amputation was required for side-effects CONCLUSION This senes emphasues brachytherapy combined with external irradlatlon IS a safe and efficient treatment technique in the treatment of sof tissue sarcomas The local control rate appears sattsfactory and the side-effects tolerable, with tlmked functronal lmpa&rement
: