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− intraluminal radiotherapy (ILT) in symptomatic NSCLC patients: quality of life and palliation of symptoms
Posters, 6th Annual BTOG Meeting, 2008 distances. 27 Gy/6 # has been used as an alternative in our centre for patients requiring HDPR with travel difficulties. 27 Gy in 6 fractions is known to provide useful symptom palliation. We wished to see whether 27 Gy/6 # provided equivalent outcomes to 39 Gy/13 #. Methods: We retrospectively assessed all patients in Northern Ireland who received HDPR for NSCLC between 2001 and 2005. Actuarial survival curves were constructed. The first analysis utilised Cox regression modelling to compensate for prognostic factors which may have affected outcome. In the second analysis survival curves for patients treated by consultants with a known preference for a particular HDPR regimen were compared. Symptom control issues were not assessed in this audit. Results: 106 patients received 36 Gy-39 Gy/12 13 # and 66 patients 27 Gy/6 #. There were no significant differences in the groups with respect to stage, PS, or weight loss; however more patients received chemotherapy in the 39 Gy/13 # group. For the 39 Gy/13 # group the median survival time (MST) and 1 year overall survival was 6.4 months and 27% respectively and, for the 27Gy/6# group, 4.4 months and 12% respectively (p = 0.05). On multivariate analysis the effect of fractionation remained. When analysed by consultant preference there was no difference between the various regimens for overall survival, but the numbers were small (16 patients had 6 # and 84 patients had 13 #). Conclusions: There was a suggestion of decreased survival in the Cox regression analysis; this may however have been due to an uncompensated prognostic factor or patient selection. Analysis of consultant practices with a known preference for a regimen showed no survival difference. Prospective randomised trials would be required to determine equivalence and should look at quality of life issues, until then there should be some caution in assuming de facto equivalence. 84 Complying with the national cancer waiting time targets in the context of continuous hyperfractionated radiotherapy (CHART) R. Klapper, P. Mulvenna, G. Mazdai, R. McMenemin, P.J. Atherton, F. Mcdonald. Northern Centre for Cancer Treatment (NCCT), UK Introduction: A CHART service was implemented in August 2005 at the Northern Centre for Cancer treatment with the support of the Northern Cancer Network and NUTHT. A Superintendent radiographer with specialist responsibility for CHART was appointed to develop and co-ordinate the service in collaboration with the multi-disciplinary lung team. The national waiting time targets have a major impact on how the service is now delivered in order for the trust to avoid breeches to cancer waiting times. Methods: The usual and most logical method of implementing a CHART service is to deliver 1 Cohort of CHART per month, to ensure a fluid patient pathway. However, in order to comply with the national cancer waiting time targets, the service at NCCT is provided in a flexible manner depending on when patients are referred into the system, this has had a major impact on scheduling and workflow within a department as a whole. Results: The poster will include the logistics of how the CHART service at NCCT has been established and the strategies set in place to ensure a sustainable compliance with national cancer waiting times. Conclusion: The service has been successful; however the poster clarifies the additional pressure and co-ordination needs with the influence of the national cancer waiting time targets.
S27 85 Results of a prospective database and a patient satisfaction survey, in the delivery of continuous hyperfractionated accelerated radiotherapy (CHART) R. Klapper, P. Mulvenna, G. Mazdai, R. McMenemin, P. Atherton, F. Mcdonald. Northern Centre for Cancer Treatment (NCCT), UK Introduction: Treatment outcome after conventional radiotherapy is far from satisfactory. Two Year survival rates are 15 20% with the majority of these patients subsequently dying from intra-thoracic disease (Saunders et al., 1999) CHART involves delivering 54 GY in 36 Fractions over 12 consecutive days (1.5Gy per Fraction). With a minimal interval of 6 hours between each treatment. A CHART service was successfully implemented in August 2005 at NCCT with the support of the Northern Cancer Network and NUTHT. The positive results from the initial CHART trial (Saunders et al., 1997) have been significant enough to justify a change in clinical practice. The evidence on which many clinical centres in the UK have implemented a CHART service is the foundation for which the current service at NCCT is based. Methods: A prospective database was created between August 2005 to November 2007. In addition, a patient satisfaction survey was carried out prospectively to assess their experience of this relatively new modality of radiotherapy. Results: To date, the CHART Service at NCCT has treated 80 patients. Data for the first 40 CHART patients will be included. The median survival time is 23 months which matches well to the published data. Conclusion: The prospective data confirms the feasibility of delivering an effective treatment in a centre where the patients attending come from wide geographical catchments. In addition it is an independent data set which has yielded similar survival outcome to that of published data. 86 A randomised trial of external beam radiotherapy (EBRT) +/ intraluminal radiotherapy (ILT) in symptomatic NSCLC patients: quality of life and palliation of symptoms P. Jain1 , L. Lee1 , W. Appel2 , R. Swindell3 , P. Barber4 , R. Stout1 , P.A. Burt1 . 1 Clinical Oncology, Christie Hospital, Manchester; 2 Royal Preston Hospital, Preston; 3 Medical Statistics, Christie Hospital, Manchester; 4 Thoracic Medicine, Wythenshawe Hospital, Manchester, UK Introduction: Local symptoms due to NSCLC are often difficult to palliate even with EBRT. ILT is an effective treatment modality in relieving symptoms arising from local disease. The addition of ILT to EBRT can increase the cumulative dose of irradiation and hence lead to better palliation and improved quality of life. Methods: 98 stage III/IV lung cancer patients with symptoms due to local disease were randomized to receive EBRT +/ ILT. 11 key symptoms or clinical signs were assessed by clinicians and patient ratings using the Rotterdam symptom check list and HAD scores. The primary endpoints were a comparison of the two groups for symptom relief and acute and late side-effects (palliation) and their effect on patients’ functional status and patient-rated QL outcomes. A secondary objective was response and survival in the two groups. Results: The groups were well balanced regards number of patients and demographics. Follow up is complete. Palliation from treatment was similar in the two groups with regards to haemoptysis, dyspnoea, and chest pain. Cough was better palliated with EBRT than EBRT + ILT at two months post treatment. There were no additional acute toxicities when ILT was added to EBRT. There was no difference in CXR response between the two groups. 1 year overall survival for the entire population was 45.7%, dropping to 9.6% at 3 years. There was a better 2 and 3 year survival in the group treated with EBRT + ILT: 22.9% vs 15.2% and 16.7% vs 2.2%.
S28 Conclusion: Immediate ILT did not lead to improved palliation. However it was associated with little toxicity. 87 Determining internal target volume (ITV) for mobile lung tumours: 2-D kilovoltage (kV) fluoroscopy, 3D or 4D cone-beam CT (CBCT)? P. Jain1,4 , T. Marchant2 , J. Davies3 , M. Duffy3 , G.R. Watkins4 , P.A. Burt1 , C. Faivre-Finn1 , M. Harris1 , R. Stout1 , C. Moore2 , P. Price4 . 1 Clinical Oncology; 2 North Western Medical Physics; 3 Wade Centre for Radiotherapy Research, Christie Hospital; 4 Academic Radiation Oncology, University of Manchester, UK Introduction: ICRU 62 recommends the generation of an ITV for mobile tumours. Several modalities can identify tumour motion. The study aims were (i) to assess how best to measure tumour motion & how representative the tumour motion seen at simulation is to that during treatment and (ii) compare slow 3D CBCT with 4D CBCT with respect to ITV generation. Methods: 8 patients undergoing radical radiotherapy with mobile lung tumours were studied. 2-D kV-fluoroscopy was carried out at simulation, and kV-fluoroscopy and 3D CBCT were obtained during treatment. Dynamic, 4-D CBCT images were subsequently reconstructed by sorting the images from the CBCT into 6 respiratory phases. Longitudinal tumor motion was measured during treatment using 2-D KV-fluoroscopy and 4-D CBCT images and compared to that documented at simulation. Gross tumour volume (GTV), using similar window settings, were contoured and compared on the 3D CBCT & 4-D CBCT acquired during treatment. Results: There was a weak correlation between tumour motion measured at d0 and the mean tumour motion measured during treatment using 4-D CBCT. There was good correlation between tumour motion measured during treatment with 4-D CBCT and 2-D kV-fluoroscopy (Spearman’s correlation, ø = 0.833, p = 0.01). GTVs contoured on images acquired during treatment were consistently smaller in all patients on 3D CBCT compared with 4D CBCT by a factor of 1.4 1.9. Conclusion: The underestimation of tumour volume by 3D CBCT reflects the extremes of breathing motion not represented by a slow scan. An ITV generated using a 3D CBCT is likely to be inferior to a 4-D scan as it lacks accuracy and clarity in delineation of GTV. All mobile tumours should ideally be planned using a 4-D CT scan to account for the correct magnitude of tumour motion, and allow individualisation of planning margins. Tumour motion at simulator may not always be representative of that seen during treatment. Attempts should be made to verify tumour motion during treatment to validate the ITV obtained at planning either using 2-D fluoroscopy or 4-D CBCT. 88 Can hyperpolarized 3 He MRI detect radiation induced lung damage? R.H. Ireland1,2 , J.M. Wild1 , N. Woodhouse1 , N. Hoggard1 , G. Brown2 , J.A. Swinscoe2 , O. Din2 , M.Q. Hatton2 . Academic Units of 1 Radiology and 2 Clinical Oncology, University of Sheffield, Sheffield, UK Introduction: Initial studies indicate that hyperpolarized helium-3 (3 He) MRI may be a useful adjuvant for the evaluation of radiotherapy treatment and its side effects [1,2]. The aim of this study was to develop techniques for the comparison of 3 He MR images acquired from lung cancer patients before and after radiotherapy treatment. Methods: Five NSCLC radiotherapy patients gave informed consent to undergo 3 He MRI for an ethics approved study. 3 He gas was polarized on site and ventilation images were acquired during a single breath-hold. With patients in the treatment position, 3 He MRI was acquired using an elliptical birdcage coil with a 3D acquisition sequence [3]. Images were acquired prior to radiotherapy and 3 months post-treatment. Radiotherapy planning CT was also obtained. The 3 He MR images
Posters, 6th Annual BTOG Meeting, 2008 were transferred to a radiotherapy planning system. Pre and post treatment MRI were registered to each other and to the treatment planning CT using anatomical landmark based rigid registration. 3 He MRI were then fused with the dose distribution calculated from the radiotherapy plan. Results: Registration of pre and post treatment images was possible for all five patients and enabled comparison with the planning CT and dose distribution.
Left) Pre-treatment 3He MRI. Middle) Post-treatment 3He MRI. Right) Planning CT and radiotherapy dose distribution.
Conclusions: This study demonstrates the feasibility of assessing pre and post therapy regional ventilation changes in lung cancer patients. Fusion of the 3 He MRI and radiation dose may enable effects on lung ventilation to be investigated. Acknowledgments: Supported by a Postdoctoral Award from the UK National Institute of Health Research, EPSRC, Sheffield Teaching Hospitals Research Trust and Yorkshire Cancer Research. We are also grateful for the loan of the 3 He gas polarizer from GE Healthcare and support from Spectra Gases and Philips Medical Systems. References: Reference(s) [1] Ireland RH et al. Int J Radiat Oncol Biol Phys 68(1):273 281, 2007. [2] Ward ER et al. Int J Radiat Oncol Biol Phys 58(5):1562 1569, 2004. [3] Wild JM et al. Magn Reson Med 52(3):673 678, 2004.
89 Fatal exacerbation of stable interstitial pulmonary fibrosis following CHART J. Duckers1 , D. Vardill1 , R. Mehta1 , D. Parry1 , S. Williams2 , J.F. Lester2 . 1 Princess of Wales Hospital, Bridgend; 2 Velindre Hospital, Cardiff, UK Introduction: Acute radiation pneumonitis within a treatment field is well described in thoracic radiotherapy (RT). We present a case of fatal bilateral acute pneumonitis in a patient with stable Interstitial Pulmonary Fibrosis (IPF) treated with CHART. Case History: A 67 year old man with stable IPF (azathioprine 150 mg, prednisolone 5 mg daily maintenance) received CHART in April 2007 for a 2 cm peripheral stage IIB non small cell lung carcinoma. Two months later he developed progressive dyspnoea and a dry cough. CXR showed new bilateral interstitial pulmonary infiltrates. His blood gas showed an oxygen of 8.0 kPa (FiO2 0.98). His CRP was 66 mg/L and his white blood cell count was 9.5×109 /L. Blood and sputum cultures were negative. Bronchoscopy was not attempted because of the severe hypoxaemia. He was treated with broad spectrum intravenous antibiotics including co-trimoxazole, pulsed intravenous methylprednisolone and diuretics. Despite intensive management, he died of respiratory failure 18 days after admission and six weeks after completing CHART. Discussion: Unilateral chest wall RT is known to cause bilateral lymphocytic alveolitis in patients with breast cancer. This phenomenon is thought to be responsible for the occurrence of cryptogenic organising pneumonia (COP) seen after thoracic RT, irrespective of tumour type. Our patient had steroid unresponsive disease which makes COP less likely. IPF is a significant comorbidity which may restrict patients’ access to surgery or radical RT. Patients with IPF may be more vulnerable to the pneumonitic effects of some chemotherapy agents such as gefitinib. In addition anticancer therapy for lung cancer (chemotherapy, RT and surgery) has been associated
S27 85 Results of a prospective database and a patient satisfaction survey, in the delivery of continuous hyperfractionated accelerated radiotherapy (CHART) R. Klapper, P. Mulvenna, G. Mazdai, R. McMenemin, P. Atherton, F. Mcdonald. Northern Centre for Cancer Treatment (NCCT), UK Introduction: Treatment outcome after conventional radiotherapy is far from satisfactory. Two Year survival rates are 15 20% with the majority of these patients subsequently dying from intra-thoracic disease (Saunders et al., 1999) CHART involves delivering 54 GY in 36 Fractions over 12 consecutive days (1.5Gy per Fraction). With a minimal interval of 6 hours between each treatment. A CHART service was successfully implemented in August 2005 at NCCT with the support of the Northern Cancer Network and NUTHT. The positive results from the initial CHART trial (Saunders et al., 1997) have been significant enough to justify a change in clinical practice. The evidence on which many clinical centres in the UK have implemented a CHART service is the foundation for which the current service at NCCT is based. Methods: A prospective database was created between August 2005 to November 2007. In addition, a patient satisfaction survey was carried out prospectively to assess their experience of this relatively new modality of radiotherapy. Results: To date, the CHART Service at NCCT has treated 80 patients. Data for the first 40 CHART patients will be included. The median survival time is 23 months which matches well to the published data. Conclusion: The prospective data confirms the feasibility of delivering an effective treatment in a centre where the patients attending come from wide geographical catchments. In addition it is an independent data set which has yielded similar survival outcome to that of published data. 86 A randomised trial of external beam radiotherapy (EBRT) +/ intraluminal radiotherapy (ILT) in symptomatic NSCLC patients: quality of life and palliation of symptoms P. Jain1 , L. Lee1 , W. Appel2 , R. Swindell3 , P. Barber4 , R. Stout1 , P.A. Burt1 . 1 Clinical Oncology, Christie Hospital, Manchester; 2 Royal Preston Hospital, Preston; 3 Medical Statistics, Christie Hospital, Manchester; 4 Thoracic Medicine, Wythenshawe Hospital, Manchester, UK Introduction: Local symptoms due to NSCLC are often difficult to palliate even with EBRT. ILT is an effective treatment modality in relieving symptoms arising from local disease. The addition of ILT to EBRT can increase the cumulative dose of irradiation and hence lead to better palliation and improved quality of life. Methods: 98 stage III/IV lung cancer patients with symptoms due to local disease were randomized to receive EBRT +/ ILT. 11 key symptoms or clinical signs were assessed by clinicians and patient ratings using the Rotterdam symptom check list and HAD scores. The primary endpoints were a comparison of the two groups for symptom relief and acute and late side-effects (palliation) and their effect on patients’ functional status and patient-rated QL outcomes. A secondary objective was response and survival in the two groups. Results: The groups were well balanced regards number of patients and demographics. Follow up is complete. Palliation from treatment was similar in the two groups with regards to haemoptysis, dyspnoea, and chest pain. Cough was better palliated with EBRT than EBRT + ILT at two months post treatment. There were no additional acute toxicities when ILT was added to EBRT. There was no difference in CXR response between the two groups. 1 year overall survival for the entire population was 45.7%, dropping to 9.6% at 3 years. There was a better 2 and 3 year survival in the group treated with EBRT + ILT: 22.9% vs 15.2% and 16.7% vs 2.2%.
S28 Conclusion: Immediate ILT did not lead to improved palliation. However it was associated with little toxicity. 87 Determining internal target volume (ITV) for mobile lung tumours: 2-D kilovoltage (kV) fluoroscopy, 3D or 4D cone-beam CT (CBCT)? P. Jain1,4 , T. Marchant2 , J. Davies3 , M. Duffy3 , G.R. Watkins4 , P.A. Burt1 , C. Faivre-Finn1 , M. Harris1 , R. Stout1 , C. Moore2 , P. Price4 . 1 Clinical Oncology; 2 North Western Medical Physics; 3 Wade Centre for Radiotherapy Research, Christie Hospital; 4 Academic Radiation Oncology, University of Manchester, UK Introduction: ICRU 62 recommends the generation of an ITV for mobile tumours. Several modalities can identify tumour motion. The study aims were (i) to assess how best to measure tumour motion & how representative the tumour motion seen at simulation is to that during treatment and (ii) compare slow 3D CBCT with 4D CBCT with respect to ITV generation. Methods: 8 patients undergoing radical radiotherapy with mobile lung tumours were studied. 2-D kV-fluoroscopy was carried out at simulation, and kV-fluoroscopy and 3D CBCT were obtained during treatment. Dynamic, 4-D CBCT images were subsequently reconstructed by sorting the images from the CBCT into 6 respiratory phases. Longitudinal tumor motion was measured during treatment using 2-D KV-fluoroscopy and 4-D CBCT images and compared to that documented at simulation. Gross tumour volume (GTV), using similar window settings, were contoured and compared on the 3D CBCT & 4-D CBCT acquired during treatment. Results: There was a weak correlation between tumour motion measured at d0 and the mean tumour motion measured during treatment using 4-D CBCT. There was good correlation between tumour motion measured during treatment with 4-D CBCT and 2-D kV-fluoroscopy (Spearman’s correlation, ø = 0.833, p = 0.01). GTVs contoured on images acquired during treatment were consistently smaller in all patients on 3D CBCT compared with 4D CBCT by a factor of 1.4 1.9. Conclusion: The underestimation of tumour volume by 3D CBCT reflects the extremes of breathing motion not represented by a slow scan. An ITV generated using a 3D CBCT is likely to be inferior to a 4-D scan as it lacks accuracy and clarity in delineation of GTV. All mobile tumours should ideally be planned using a 4-D CT scan to account for the correct magnitude of tumour motion, and allow individualisation of planning margins. Tumour motion at simulator may not always be representative of that seen during treatment. Attempts should be made to verify tumour motion during treatment to validate the ITV obtained at planning either using 2-D fluoroscopy or 4-D CBCT. 88 Can hyperpolarized 3 He MRI detect radiation induced lung damage? R.H. Ireland1,2 , J.M. Wild1 , N. Woodhouse1 , N. Hoggard1 , G. Brown2 , J.A. Swinscoe2 , O. Din2 , M.Q. Hatton2 . Academic Units of 1 Radiology and 2 Clinical Oncology, University of Sheffield, Sheffield, UK Introduction: Initial studies indicate that hyperpolarized helium-3 (3 He) MRI may be a useful adjuvant for the evaluation of radiotherapy treatment and its side effects [1,2]. The aim of this study was to develop techniques for the comparison of 3 He MR images acquired from lung cancer patients before and after radiotherapy treatment. Methods: Five NSCLC radiotherapy patients gave informed consent to undergo 3 He MRI for an ethics approved study. 3 He gas was polarized on site and ventilation images were acquired during a single breath-hold. With patients in the treatment position, 3 He MRI was acquired using an elliptical birdcage coil with a 3D acquisition sequence [3]. Images were acquired prior to radiotherapy and 3 months post-treatment. Radiotherapy planning CT was also obtained. The 3 He MR images
Posters, 6th Annual BTOG Meeting, 2008 were transferred to a radiotherapy planning system. Pre and post treatment MRI were registered to each other and to the treatment planning CT using anatomical landmark based rigid registration. 3 He MRI were then fused with the dose distribution calculated from the radiotherapy plan. Results: Registration of pre and post treatment images was possible for all five patients and enabled comparison with the planning CT and dose distribution.
Left) Pre-treatment 3He MRI. Middle) Post-treatment 3He MRI. Right) Planning CT and radiotherapy dose distribution.
Conclusions: This study demonstrates the feasibility of assessing pre and post therapy regional ventilation changes in lung cancer patients. Fusion of the 3 He MRI and radiation dose may enable effects on lung ventilation to be investigated. Acknowledgments: Supported by a Postdoctoral Award from the UK National Institute of Health Research, EPSRC, Sheffield Teaching Hospitals Research Trust and Yorkshire Cancer Research. We are also grateful for the loan of the 3 He gas polarizer from GE Healthcare and support from Spectra Gases and Philips Medical Systems. References: Reference(s) [1] Ireland RH et al. Int J Radiat Oncol Biol Phys 68(1):273 281, 2007. [2] Ward ER et al. Int J Radiat Oncol Biol Phys 58(5):1562 1569, 2004. [3] Wild JM et al. Magn Reson Med 52(3):673 678, 2004.
89 Fatal exacerbation of stable interstitial pulmonary fibrosis following CHART J. Duckers1 , D. Vardill1 , R. Mehta1 , D. Parry1 , S. Williams2 , J.F. Lester2 . 1 Princess of Wales Hospital, Bridgend; 2 Velindre Hospital, Cardiff, UK Introduction: Acute radiation pneumonitis within a treatment field is well described in thoracic radiotherapy (RT). We present a case of fatal bilateral acute pneumonitis in a patient with stable Interstitial Pulmonary Fibrosis (IPF) treated with CHART. Case History: A 67 year old man with stable IPF (azathioprine 150 mg, prednisolone 5 mg daily maintenance) received CHART in April 2007 for a 2 cm peripheral stage IIB non small cell lung carcinoma. Two months later he developed progressive dyspnoea and a dry cough. CXR showed new bilateral interstitial pulmonary infiltrates. His blood gas showed an oxygen of 8.0 kPa (FiO2 0.98). His CRP was 66 mg/L and his white blood cell count was 9.5×109 /L. Blood and sputum cultures were negative. Bronchoscopy was not attempted because of the severe hypoxaemia. He was treated with broad spectrum intravenous antibiotics including co-trimoxazole, pulsed intravenous methylprednisolone and diuretics. Despite intensive management, he died of respiratory failure 18 days after admission and six weeks after completing CHART. Discussion: Unilateral chest wall RT is known to cause bilateral lymphocytic alveolitis in patients with breast cancer. This phenomenon is thought to be responsible for the occurrence of cryptogenic organising pneumonia (COP) seen after thoracic RT, irrespective of tumour type. Our patient had steroid unresponsive disease which makes COP less likely. IPF is a significant comorbidity which may restrict patients’ access to surgery or radical RT. Patients with IPF may be more vulnerable to the pneumonitic effects of some chemotherapy agents such as gefitinib. In addition anticancer therapy for lung cancer (chemotherapy, RT and surgery) has been associated