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Advantages of 3D CT based treatment planning in female patients with Hodgkin lymphoma compared to conventional non CT planned mantle technique
Proceedings of the 40th A n n u a l A S T R O Meeting
2235 A PHASE I-II STUDY OF BIWEEKLY CHOP AND RADIOTHERAPY FOR STAGE I-II HEAD-AND-NECK NONHODGKIN'S LYMPHOMA Takeshi Nishioka, Hiroki Shirato, Toshihiro Kitahara, Kenji Kagei, Seiko Hashirnoto, Shinichi Shimizu, Akira Yamazaki, Yukio Inuyama* and Kazuo Miyasaka Department of Radiology, Department of Otolaryngology*, Hokkaido University School of Medicine, Sapporo, Japan Purpose: The purpose of this prospective study was to evaluate the efficacy and toxicity of an accelerated regimen of CHOP using G-CSF combined with radiotherapy for early-stage head-and-neck NHL. Materials and Methods: From November 1993 to October 1997, a total of 31 patients with aggressive NHL (mean age 53, male:female 18:13, Stage I:11 21:10, T-cell:B-cell 8:23) were enrolled in the study. The primary site was Waldeyer's ring in 11, extranodal in 11 and neck in 9. The most common histology (Working Formulation) was diffuse large cell (19 patients). Two courses of CHOP were given at an interval of 2 weeks. Standard doses of chemotherapeutic agents were used except for vincristine, for which the maximum dose was set at 1.5mgYoody. To maintain the duration of treatment, G-CSF (2-3 microgram/kg s.c.) was given if WBC count was less than 3000/mm 3. Radiotherapy (40Gy/16-20fr/4-5wks to the involved sites) was initiated within 2 weeks after the start of the second course of the CHOP for B-cell lymphoma. It was given prior to chemotherapy for T-cell lymphoma. The mean follow up was 22 months. Survival rates were calculated by the Kaplan-Meier method. Toxicity was evaluated according to WHO grading. Results: 28/31 (90.3%) patients completed chemotherapy as planned. One patient developed a herpes infection during the first course of CHOP and didn't receive the second treatment. Two patients required dose reduction of the second course of CHOP due to liver complications. Grade 3 WBC toxicity (1000-2000/mm 3) was seen in 16 patients (51.6%), and grade 4 (<1000/ram 3) in 3 (12.9%). Grade 3 platelet toxicity (2.5-4.9"103/mm 3) was seen in 3 patients (9.7%) but there was no grade 4 toxicity. Grade 2-3 liver toxicity was seen in 3 patients (9.7%). No cardiac toxicity was observed. Radiotherapy was completed as planned in all but 3 patients, who required an interruption of 1 to 6 days due to enhanced mucositis. There was no treatment-related death. The 3-year disease free survival and disease specific survival rate was 75.3% and 84.9%, respectively. The 3-year disease free survival rate for B-cell and T-cell immunophenotype was 80.1% and 64.3%, respectively. No patients developed recurrence within the radiation fields. Conclusion: Biweekly CHOP combined with radiotherapy is feasible for early-stage head-and-neck NHL without major side effects. Our preliminary results were comparable to those obtained with standard treatments.
2236 ADVANTAGES OF 3D CT BASED TREATMENT PLANNING IN FEMALE PATIENTS WITH HODGKIN LYMPHOMA COMPARED TO CONVENTIONAL NON CT PLANNED MANTLE TECHNIQUE T.Vuong, W.Parker, P.Fava, D.Parmar, H.J.Patrocinio, E.B.Podgorsak. Department of Radiation Oncology, McGIII University, Montreal, Canada. Objectives: While Hodgkin patients are cured from their tumors, the long term follow up reveals treatment related death. The relatively high risk of second cancer is well known in patients cured from Hodgkin lymphoma. In the adult population treated with radiation therapy, breast cancer dominates mainly in female patients. With the introduction of 3D planning technology, we attempt to optimize protection of breast tissues using virtual simulation. Methods: To minimize the irradiated breast volume, a virtual simulation technique making use of a Styrofoam breast immobilization device has been developed. The device, designed for female patients lying in the prone position, maximizes the breast volume directly underneath the lung shielding. The patient lies prone with the breasts pendant in grooves in the immobilization device. Breast placement is verified using an AP pilot view to ensure positioning under the lungs ACT scan of the neck and thoracic regions is taken and the lymph nodes, breasts, and other critical structures are outlined. Virtual simulation of the mantle fields (typically AP/PA isocentric beams) is performed and beam blocks are drawn on the digitally reconstructed radiographs (DRR) generated by the virtual simulation package. The shielding is designed to allow adequate margins around lymph nodes while maximizing the shielding of the lungs and breasts. Three scans were obtained; First in prone position with positioning of the breasts in grooves in the Styrofoam device, then supine and prone positions as in our previous standard non CT planned treatment technique. Dose-volume histograms of the breast volume were obtained comparing our previous standard mantle technique to the current virtual positioning assisted by CT simulation. Results: This study done over 10 consecutive female patients with Hodgkin lymphoma shows that there is less volume of breast tissue exposure when patients are treated in the prone position with virtual positioning of their breasts, using CT sim planning, as compared to the traditional technique. We were also able to refine our target volume based on CT imaging instead of the classic bony land marks; hence a custom-made lung shielding was obtained The following results were derived from Dose - volume histograms : Volume of breast treated as Clinac 23 Clinac 23 (AP) . (PA) 5 Gy 12% 18% 10 Gy 10% 12% 15 Gy 8% 0%
ue used: T4 (AP) 48% 42% 30%
T4 (PA) _ 61%j 54% 3%
Conclusion: This study shows the usefulness of modern technology based on 3D simulation in the planning of a highly curable disease such as Hodgkin lymphoma. This technology allows for virtual positioning verification and refining the clinical tumor volume, therefore providing better protection of critical structures Based on our study, 3D CT based treatment planning is highly recommended in the optimal treatment of patients with Hodgkin lympboma, and hopefully this technique will help to alleviate the incidence of second malignancies
345
2235 A PHASE I-II STUDY OF BIWEEKLY CHOP AND RADIOTHERAPY FOR STAGE I-II HEAD-AND-NECK NONHODGKIN'S LYMPHOMA Takeshi Nishioka, Hiroki Shirato, Toshihiro Kitahara, Kenji Kagei, Seiko Hashirnoto, Shinichi Shimizu, Akira Yamazaki, Yukio Inuyama* and Kazuo Miyasaka Department of Radiology, Department of Otolaryngology*, Hokkaido University School of Medicine, Sapporo, Japan Purpose: The purpose of this prospective study was to evaluate the efficacy and toxicity of an accelerated regimen of CHOP using G-CSF combined with radiotherapy for early-stage head-and-neck NHL. Materials and Methods: From November 1993 to October 1997, a total of 31 patients with aggressive NHL (mean age 53, male:female 18:13, Stage I:11 21:10, T-cell:B-cell 8:23) were enrolled in the study. The primary site was Waldeyer's ring in 11, extranodal in 11 and neck in 9. The most common histology (Working Formulation) was diffuse large cell (19 patients). Two courses of CHOP were given at an interval of 2 weeks. Standard doses of chemotherapeutic agents were used except for vincristine, for which the maximum dose was set at 1.5mgYoody. To maintain the duration of treatment, G-CSF (2-3 microgram/kg s.c.) was given if WBC count was less than 3000/mm 3. Radiotherapy (40Gy/16-20fr/4-5wks to the involved sites) was initiated within 2 weeks after the start of the second course of the CHOP for B-cell lymphoma. It was given prior to chemotherapy for T-cell lymphoma. The mean follow up was 22 months. Survival rates were calculated by the Kaplan-Meier method. Toxicity was evaluated according to WHO grading. Results: 28/31 (90.3%) patients completed chemotherapy as planned. One patient developed a herpes infection during the first course of CHOP and didn't receive the second treatment. Two patients required dose reduction of the second course of CHOP due to liver complications. Grade 3 WBC toxicity (1000-2000/mm 3) was seen in 16 patients (51.6%), and grade 4 (<1000/ram 3) in 3 (12.9%). Grade 3 platelet toxicity (2.5-4.9"103/mm 3) was seen in 3 patients (9.7%) but there was no grade 4 toxicity. Grade 2-3 liver toxicity was seen in 3 patients (9.7%). No cardiac toxicity was observed. Radiotherapy was completed as planned in all but 3 patients, who required an interruption of 1 to 6 days due to enhanced mucositis. There was no treatment-related death. The 3-year disease free survival and disease specific survival rate was 75.3% and 84.9%, respectively. The 3-year disease free survival rate for B-cell and T-cell immunophenotype was 80.1% and 64.3%, respectively. No patients developed recurrence within the radiation fields. Conclusion: Biweekly CHOP combined with radiotherapy is feasible for early-stage head-and-neck NHL without major side effects. Our preliminary results were comparable to those obtained with standard treatments.
2236 ADVANTAGES OF 3D CT BASED TREATMENT PLANNING IN FEMALE PATIENTS WITH HODGKIN LYMPHOMA COMPARED TO CONVENTIONAL NON CT PLANNED MANTLE TECHNIQUE T.Vuong, W.Parker, P.Fava, D.Parmar, H.J.Patrocinio, E.B.Podgorsak. Department of Radiation Oncology, McGIII University, Montreal, Canada. Objectives: While Hodgkin patients are cured from their tumors, the long term follow up reveals treatment related death. The relatively high risk of second cancer is well known in patients cured from Hodgkin lymphoma. In the adult population treated with radiation therapy, breast cancer dominates mainly in female patients. With the introduction of 3D planning technology, we attempt to optimize protection of breast tissues using virtual simulation. Methods: To minimize the irradiated breast volume, a virtual simulation technique making use of a Styrofoam breast immobilization device has been developed. The device, designed for female patients lying in the prone position, maximizes the breast volume directly underneath the lung shielding. The patient lies prone with the breasts pendant in grooves in the immobilization device. Breast placement is verified using an AP pilot view to ensure positioning under the lungs ACT scan of the neck and thoracic regions is taken and the lymph nodes, breasts, and other critical structures are outlined. Virtual simulation of the mantle fields (typically AP/PA isocentric beams) is performed and beam blocks are drawn on the digitally reconstructed radiographs (DRR) generated by the virtual simulation package. The shielding is designed to allow adequate margins around lymph nodes while maximizing the shielding of the lungs and breasts. Three scans were obtained; First in prone position with positioning of the breasts in grooves in the Styrofoam device, then supine and prone positions as in our previous standard non CT planned treatment technique. Dose-volume histograms of the breast volume were obtained comparing our previous standard mantle technique to the current virtual positioning assisted by CT simulation. Results: This study done over 10 consecutive female patients with Hodgkin lymphoma shows that there is less volume of breast tissue exposure when patients are treated in the prone position with virtual positioning of their breasts, using CT sim planning, as compared to the traditional technique. We were also able to refine our target volume based on CT imaging instead of the classic bony land marks; hence a custom-made lung shielding was obtained The following results were derived from Dose - volume histograms : Volume of breast treated as Clinac 23 Clinac 23 (AP) . (PA) 5 Gy 12% 18% 10 Gy 10% 12% 15 Gy 8% 0%
ue used: T4 (AP) 48% 42% 30%
T4 (PA) _ 61%j 54% 3%
Conclusion: This study shows the usefulness of modern technology based on 3D simulation in the planning of a highly curable disease such as Hodgkin lymphoma. This technology allows for virtual positioning verification and refining the clinical tumor volume, therefore providing better protection of critical structures Based on our study, 3D CT based treatment planning is highly recommended in the optimal treatment of patients with Hodgkin lympboma, and hopefully this technique will help to alleviate the incidence of second malignancies
345