Disease sites : Gynaecological tumours

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patients had locally advanced tumors, 1 patient had a tumor arising from a reconstructed gastric tube after the resection of esophageal cancer, and 1 had early-stage cancer of the gastric remnant (primary gastric cancer was resected several years ago). Two of 8 had peritoneal carcinomatosis. The indication for radiotherapy included the inoperable state (n=6) or the patients' refusal of operation (n=2). The median prescribed dose was 60Gy/30fr. Seven patients underwent various chemotherapy (S-1/CDDP for 2, PACfor 2, S-1 for 1, 5-FU/LV for 1, FP for 1), and six patients underwent hyperthermia. Median follow-up time was 19.5 months (range, 6-39 months). Tumor response was evaluated at 2.5-3 months according to the WHO criteria. Results: Complete response (CR) was achieved in 4 patients. The treatment resulted in partial response (PR) in 3 patients, no change (NC) in 1 patient, and there was no progression disease. The response rate was 88%. We experienced 1 local recurrence among CR cases which was salvaged by EMR. Two patients who showed CR are still alive without evidence of the disease for more than 2 years, while 2 patients died from other malignancies after they kept CR for more than 2 years. Among 4 cases who showed PR or NC, one patient is alive with stable disease being treated with chemotherapy and hyperthermia, while three patients died from the disease. Grade 3 acute gastritis occurred in 2 patients and grade 4 leucopoenia in 1 patient. We observed no late toxicities greater than grade 2. Conclusions: Although the number of our patients is small, our clinical results of semi-radical radiotherapy with chemotherapy and hyperthermia for primary gastric cancer seem to be encouraging. The semi-radical radiotherapy might be an alternative treatment in the patients with locally advanced, inoperable gastric cancer. 738 poster TUMOR DELINEATION BASED ON TIME ACTIVITY CURVE DIFFERENCES ASSESSED WITH DYNAMIC FOG PET-CT IN RECTAL CANCER PATIENTS M. Janssen 1, M. Oellers 1, G. Bosmans 1, J. Lee 2, J. Buijsen 1, D. De Ruysscher 1, P. Lambln 1, A. Dekker 1, G. Lammerlng 1 1 DEPARTMENT OF RADIATION ONCOLOGY (MAASTRO), RESEARCH INSTITUTE GROW, UNIVERSITY, Radiation Oncology, Maastricht, Netherlands 2 DEPARTMENT OF RADIATION ONCOLOGY, CENTER FOR MOLECULAR IMAGING AND EXPERIMENTAL, Radiation Oncology, Brussels, Belgium

Purpose: Accurate tumor deiineation is of crucial importance for successful treatment in radiotherapy. The main goal of this research was the development of an unsupervised tumor delineation method based on time activity curve (TAG)shape differences between tumor tissue and healthy tissue. The tumor contour resulting from dynamic PET analysis was compared to two tumor contours resulting from manual tumor delineation by a radiation oncologist and SUV-thresholding of static PET data. Materials: Dynamic PET-CT acquisition was performed for 60 minutes starting directly after FOG injection. After acquisition and reconstruction, the data were filtered to attenuate noise. Correction for tissue motion during acquisition was applied. For tumor delineation, the TAC slope-values were k-means clustered into 2 clusters. The resulting tumor contour (contour-one) was compared to a contour manually drawn by the radiation oncologist (contour-two) and one contour generated using a threshold of the maximum SUV (contourthree). Results: The tumor volumes of contour-two and -three were significantly larger than the tumor volumes of contour-one, with both contour-two and three containing many voxels showing flat TACs at low activities. However, in some cases, contour-two did not cover all voxels showing upward TACs. Conclusions: Both automated SUV-contourlng and manual tumor delineation possibly incorrectly assign healthy tissue, showing flat TACs, as being malignant. On the other hand, In some cases, the manually drawn tumor contours do not cover all voxels showing steep upward TACs, suspected to be malignant. These findings suggest a role for tumor contouring based on dynamic PET analysis.

Clinical/Disease sites logical tumours

Gynaeco-

739 poster RELATIONSHIP BETWEEN AN INVESTIGATION INTO THE MRI-BASED DVH PARAMETERS AND VAGINAL MORBIDITY IN CERVICAL CANCER BRACHYTHERAPY E. Fidarova 1, S. SchOssler 2, J. Dimopoulos 1, B. Bachtiary 1, P. Georg 1, D. Berger 1, C. Kirisits 1, R. Potter 1 1 MEDICAL UNIVERSITY OF VIENNA, Radiotherapy, Vienna, Austria 2 CHRISTIAN ALBRECHTS UNIVERSITY OF KIEL, Radiotherapy, Kiel, Germany

Purpose: To evaluate vaginal morbidity and investigate whether there is a correlation between late vaginal changes and DVH-parameters for vaginal mucosa in patients with locally advanced cervical cancer treated by definitive radiochemotherapy, including 3D MRI-based brachytherapy. Materials: 26 cervical cancer patients (median age 55 yrs, range: 38-80) with the FIGO stages IB-IVB (IB=2, IIAB=11, IIB=9, IIIAB=1, IIIB=1, IVA=1, IVB=1) were included. The vaginal length, elasticity, macroscopic/microscopic mucosal appearance (atrophy, teleangiectasiae (TA), contact bleeding, fibrosis, ulceration, and necrosis), the maturation index, and the maturation value (MV) were assessed. Vaginal morbidity was recorded using LENT/SOMA scale. The vaginal wall was contoured on axial T2-weighted MR images. In case of poor visualisation a 4 mm thickness was assumed. Total doses were normalised to 2Gy per fraction using LQ equation (EQD2, a/I3=3Gy). The doses to the most exposed 0.1 (dose), 1,2,5 and 10 crrr' volumes were calculated and correlated to an overall LENT/SOMA grade and single adverse events. Results: Median follow-up was 28 months (range: 4-114). All patients experienced late vaginal morbidity. LENT/SOMA grade distribution was as follows: G1=9/26 pts (35%), G2=17/26 pts (65%), G3 and G4=0/26 pts. Shortening of vagina occurred in 17/26 pts (65%) and decreased vaginal elasticity was found in 12/26 pts (46%). TA were detected In the majority of patients: 23/26 (88%); 11/26 pts (42%) had contact bleeding. TA were mainly located in the proximal third of vagina (20/23 pts-87%), but also were present in the middle (14/23 pts-61%) and the distal thirds (4/23 pts-17%). Ulceration in the proximal third of the vagina was observed only in one patient. In 13 out of 16 patients with atrophic mucosal changes the MV was below 50. There was no significant correlation between either the overall LENT/SOMA score or single adverse events and the DVH-parameters. Conclusions: The proximal third of vagina was mainly affected by the adverse changes. Obtained results demonstrated that vaginal morbidity was not significantly correlated to any DVH-parameters which are commonly used in 3D MRI-based cervical cancer brachytherapy. New dosimetric concepts are required to establish dose volume relationships and dose constraints. In addition, the influence of quality of post-treatment care and other co-factors have to be assessed in future prospective studies. 740 poster BLOOD PERFUSION IN CERVICAL TUMORS PRIOR TO CHEMORADIATION IS INDICATIVE FOR TUMOR REGRESSION AFTER FOUR WEEKS OF TREATMENT U. van der Heide 1, C. Arteaga de Castro 1, G. Groenendaal 1, C. van den Berg 1, J. Roesink 1, I. JOrgenliemk-Schulz 1 1 UNIVERSITY MEDICAL CENTER - UTRECHT, Department of Radiation Oncology, Utrecht, Netherlands

Purpose: During external-beam radiotherapy of patients with cervical cancer a substantial regression of the tumor volume can be achieved, which benefits the effectiveness of intracavitary boosting in the later phase of the treatment. The rate of tumor regression varies between patients but can be as large as 50% of the volume per week. We investigated if the measurement of tumor perfusion prior to the treatment can be used to predict this regression. Materials: 13 patients with cervical cancer were monitored with MRI scans prior to and weekly in the first four weeks of cherno-radlatlon. T2-weighted sagittal and axial scans were made on a 1.5T MRI scanner. Also, a dynamic contrast-enhanced series was made in each exam: 15 ml of 0.5M gadoliniumDTPA was injected in 10 seconds, followed by a saline flush; Scans were repeated 120 times at a 2.4 second interval with a 3D spoiled gradient echo sequence (TRITE 4.9/1.6 ms, flip angle 30, 10 slices, 256x256). The precontrast T1 was derived using three pre-scans with different flip angles (4.5, 8 and 16). Concentration-time curves were analyzed using the Tofts model, yielding quantitative 3D maps of the blood flow parameter K'caos. Results: The average pre-treatment tumor volume was 60 ml [6 154 ml]. After 4 weeks of treatment the volume was on average reduced to 35% of the pre-treatment volume [9 65%]. However, no correlation was found between tumor reduction and pre-treatment tumor volume (p=O.77). The average K'can, in the tumor showed an increasing trend during the course of the treatment, but no significance was reached. However, the 10th percentile of the tumor voxels (representing the voxels with poorest perfusion) did show a significant increase in K'ran, after two weeks of treatment, from 0.17 rnin' prior to treatment to 0.29 min' (p=0.003). A significant correlation was found between the 10th percentile K'raos prior to treatment and tumor reduction after 4 weeks (p=0.04), with a smaller value of the 10th percentile of Klran, corresponding to a smaller tumor reduction after 4 weeks. Conclusions: On average, substantial tumor regression is observed during the first 4 weeks of chemoradlation. Also, an increase in blood perfusion is found in the poorest perfused part of the tumor. In contrast to initial tumor size, the K'ran, in the poorest perfused part of the tumor prior to treatment is indicative of tumor regression during the first 4 weeks of chemoradiation. 741 poster CLINICAL PROFILE OF PATIENTS WITH ENDOMETRIAL CARCI-

CLINICAL/DISEASE SITES

NOMA HAVING CO-MORBID ILLNESSES M. Kumar " D. Sharma " G. Rath " S. Kumar " A. Bahl " P. Julka 1 AIIMS, Radiation Oncology, New Delhi, India

1

Purpose: Association of co-morbid medical conditions with endometrial carcinoma is well known. There are few reports regarding the clinical outcome of endometrial carcinoma patients having co-morbid conditions. The aim of this study was to analyze the clinical profile and outcome of endometrial carcinoma patients having co-morbid conditions. Materials: A retrospective anaiysis was carried out of the patients with endometrial carcinoma having co-morbid conditions. The clinical case records were studied for distribution according to age, co-morbid medical illnesses, stage at presentation, pathological characterisitics viz. garde, myometrial invasion etc., and treatment. Results: Of 133 patients who had endometrial carcinoma, 76 (57%) had associated co-morbid conditions. Age of the patients ranged from 39-72 years (median age 58 years). Patient population over 60 years was significantly higher as compared to patients without any co-morbidity (53% vs 28%). A total of 92 medical disorders were found in these 76 patients. Hypertension was the commonest disorder followed by diabetes mellitus (DM 28, hypertension 46, asthma 3, angina/coronary artery disease 5, and hypothyroidism 10). Seventy two patients underwent surgery (total abdominal hysterectomy with bilateral oopherectomy) while remaining 4 could not be operated due to medical illnesses. The distribution according to stage, adjuvant therapy, and acute treatment related toxicity and disease controi was comparable to the historical control patients in our institute. Conclusions: About 57% patients of endometrial carcinoma at our institute present with associated co-morbid conditions. Age at presentation was found to be statistically higher in these patients. Rest of the clinical and therapeutic factors were comparable. 742 poster COMPARISON AT PLANNING LEVEL BETWEEN VARIAN RAPIDARC AND DYNAMIC SLiGING WINDOW IMRT IN CERVIX CANCER. L. Cozzi " K. Dinshaw 2, S. K. Shrivastava 2, R. Engineer 2, M. Umesh 2, S. Jamema 2, A. Fogliata " D. Deshpande 2 1 10SI, Medical Physics, Bellinzona, Switzerland 2 TATA MEMORIAL HOSPITAL, Radiotherapy, Mumbai, India

Purpose: The potential benefits and limitations of the new volumetric aperture based intensity modulated arc therapy (RapidArc, RA) from Varian and of the "conventional" dynamic sliding window IMRT were investigated on a cohort of cervix cancer patients. RapidArc consists of a planning and delivery method based on a single arc where multileaf collimator, dose rate and gantry speed are optimised simultaneously to achieve the needed degree of modulation. RapidArc is based on direct aperture field optimisation. The entire process aims to reduce delivery time and to minimise monitor units per Gy needed. Materials: Plans for 8 patients affected by cervix carcinoma were optimised for both IMRT and Rapidarc on the Varian Eclipse system using a non-clinical engineering release of the RapidArc optimiser. Plans were computed for 6 MV beams on a Varian linac equipped with a Millennium multileaf with 120 leaves. Dose prescription was set to 50 Gy in 2 Gy fractions asking for +-5% target homogeneity. Maximum dose to Rectum, bladder and small bowel was fixed at 47.5 Gy while additional constraints were asked to rectum (mean<45 Gy, D35%<40Gy, D50%<30Gy), bladder (mean<42 Gy, D40%<40Gy, D50%<35Gy) and bowel (D30%<30Gy, 050%<25 Gy). Results: In all instances RA proved to be superior to IMRT. Both techniques satisfied constraints on target volumes (D99-D1 -10% for both cases). RA offered a better sparing of healthy tissue (body outline minus target) with RA showing a mean dose of -3 Gy inferior to IMRT. Evaluation of Rectum and Bladder was performed on both the whole organs or on the fraction of organ not included in the PTV. In the first case, none of the techniques fulfilled all constraints even if RA was superior to IMRT (e.g about 5 Gy reduction in mean dose to Rectum and 2 Gy for bladder). For partial organs the difference between the two techniques increased remarkably. Similarly RA was superior to RapidArc for other objectives with differences ranging from 6 to 20 Gy. MU per Gy on RA were in average -250 while for IMRT -650-800 with a delivery time lower than 2 minutes for RA and around 6-8 minutes for IMRT (inclusive of multiple beam repositioning). Conclusions: RA presented significantly increased conformal avoidance compared to IMRT in cervix cancer patients associated to a significant reduction of treatment time (with potentially important bioloqical consequences), 743 poster COMPUTED TOMOGRAPHY-BASED DOSE-VOLUME PARAMETERS OF THE RECTUM AND LATE RECTAL COMPLICATIONS IN PATIENTS WITH CERVICAL CANCER TREATED WITH HIGH-DOSE

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RATE INTRACAVITARY BRACHYTHERAPY S. KatD " H. Kiyohara " T. Ohno " T. Nakano 2, H. Tsujii 1 1 NIRS, Research Center Hospital for Charged Particle Therapy, Chiba, Japan 2 GUNMA UNIVERSITY GRADUATE SCHOOL OF MEDICINE, RadiatiDn Oncology, Maebashi, Japan

Purpose: TD evaluate the efficacy of CT-based dose-volume parameters ot the rectum as the predictive factors for late rectal complications (LRC) in patients with cervical cancer treated with radiotherapy alone, Materials: Eighty-fDur patients treated with radiotherapy alone between January 2000 and December 2004 were retrospectively analyzed. All patients received the combination of external beam radiotherapy (EBRT) and highdose-rate intracavitary brachytherapy (HDR-ICBT). The median total dose ot EBRT was 50 Gy, consisting ot whole pelvic lrradlation and central shielding pelvic irradiation. The median total dose to point A in HDR-ICBT was 24 Gy in 4 fractions. HDR-ICBT was prescribed using X-ray based two-dimensional dosimetry and planning. Patients underwent CT scans of the pelvis with the applicators in place to generate three-dimensional dose dtstnbutions. The external contours ot the rectum were delineated on the CT images, and the minimum doses delivered to 0.1cc, 1cc, zcc, and 5cc ot the most irradiated rectal volumes were determined from the dose-volume histgrams. The ICRU rectal reference point dose was derived from the conventional method. The doses in EBRT and ICBT were transformed to the biologically equivalent doses in 2 Gy fractions (EQD2) using cd (3 ratio ot 3 Gy, and the total rectal doses tor dose-volume parameters (DO.1cc, D1cc, D2cc, D5cc, and DICRU) were calculated. The correlation between the dose-volume parameters and the actuarial rate of LRC was analyzed. Results: The median follow-up duration for all patients was 46 months (range, 12-79 months). Twenty patients developed LRC (Grade 1: 12, Grade 2: 8). The 5-year actuarial rate of LRC was 27.4%. There was a statistically significant difference in DO.1 cc, 01 cc, D2cc, and D5cc between patients with and without LRC (p<0.001), whereas the difference in DICRU was not statistically significant (p=0.07). The 5-year LRC rates in patients with D2cc of 0-40 Gy, 40-50 Gy, 50-60 Gy, 60-70 Gy, 70-80 Gy, and 80Gy < were 0%, 19.6%, 11.4%, 41.9%, 50%, and 62.5%, respectively (p=0.005). When patients were qrouped with DICRU, there was no significant difference in the 5-year LRC rates among them. Conclusions: The present study suggests that CT-based dose-volume parameters may be qood predictors of LRC in radiotherapy tor cervical cancer. 744 poster CONCOMITANT CHEMO-RADIATION IN ADVANCED STAGE CARCINOMA CERVIX A PHASE III RANDOMIZED TRIAL (CRACX TRIAL NCT 00193791) S. K. Shrivastava " U. Mahantshetty " R. Engineer " S. Gupta 2, A. Maheshwari 3, R. Kerkar 3, H. Tongaonkar 3, K. Dinshaw 1 1 TATA MEMORIAL HOSPITAL, Hadiatlon Oncology, Mumbai, India 2 TATA MEMORIAL HOSPITAL, Medical Oncoloqy, Mumbai, India 3 TATA MEMORIAL HOSPITAL, Surgical Oncoloqy, Mumbai, India

Purpose: The main stay of treatment has traditionally been radical radiation therapy. Over 19 randomized trials have been published addressing the issue ot chemo-radlotherapy. However, heteroqeneous data, poor randomization, inadequate number of patients, sub-optimal radiotherapy, non-uniform use of chemotherapeutic drugs, its sequencing and poor documentation have not yet provided the evidence to SUbstantially alter the practice. The Cochrane and Canadian meta-analyses have to a large extent tried to address, but Carctnorna Cervix Stage III accounted for only 30-35% and moreover evaluation with optimal radiation schedules and comparison of late toxicities still remains unanswered. However, the role of chemo-radiatton in Carcinoma Cervix Stage IIIB in developing countries still remains unexplored, With an aim to evaluate the role and benefit of chemo-radiation in patients with cervical cancer we initiated this randomized study. Materials: Patients with cervical cancer FIGO IIiB after obtaining written inform consent are randomize to either the Standard arm of Radical Hadiation Therapy alone or the study arm of Concurrent Chemo-radiation with Cisplatin (40 mg/m2 weekly x 5#). With an expected improvement in absolute survival by 10% for stages IIIB, error ot 0.05, power ot detection of 80% and 10% patients more to compensate for lost-to-fellow-up and major violations, a total of 850 patients will be randomized with stratification. Results: This is an audit of onqoinq randomized study, till December 2007, 528 patients have been randomizeo. Out ot 528, 14 patients are on treatment and 514 have completed treatment. The treatment related grade III toxicities in the form of Gastrotntestinel (3% Vs 4%), qenltourinary (2% Vs 3.5%), anemia (1% Vs 6.8%), neutropenia (1% Vs 5.2%) and thrombocytopenia (1% Vs 3.5%) were higher in chemoradiation arm and required active support more often than radical radiation arm. Till December 2007, the median follow-up was 24 months, 48 patients in radiation alone while 37 patients in Chernoradiation arm had recurrences. Conclusions: Concomitant Chernoradiation although feasible appears to be associated with higher incidence ot Grade III hematological and gastrointestinal toxicities, These toxicities need active support tor completion ot planned

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treatment. In this ongo ing randomized study, completion ot accrual, comparison of toxicities and outcome is essential to evaluate the exact role of concurrent chemoradiation in advance cervical cancers. An interim analysis is scheduled in December 2008 to assess the toxicities and early outcome. 745 poster CONSOLIDATIVE WHOLE ABDOMINAL INTENSITY MODULATED RADIOTHERAPY ( IM RT) FOR HIGH RISK STAGE FIGO III PATIENTS WITH OVARIAN CANCER : FIRST RESULTS OF THE OVAR-IMRT-01 STUDY N. Rochet 1 , F. Sterzing 1 , A. Jensen 1 , J. Dinkel 2 , K. Herfarth 1 , K. Schubert 1 , M. Eichbaum 3, A. Schneeweiss 3 , C. Sohn 3, W. Harms 4 , J. Debus 1 1 UNIVERSITY OF HEIDELBERG, Department of Radiation Oncology, Heidelberg, Germany 2 GERMAN CANCER RESEARCH CENTER , Department of Radiology, Heidelberg, Germany 3 UNIVERSITY OF HEIDELBERG, Department of Gynaecology and Obstetrics, Heidelberg, Germany 4 ST. CLARASPITAL, Department of Radiation Oncology, Basel, Switzerland

Purpose: The prognosis for patients with advanced epithelial ovarian cancer remains poor despite aggressive surgical resection and platinum-based chemotherapy. Despite whole abdominal irradiation's (WAI) clinically proven efficacy the use of radiotherapy in ovarian cancer has profoundly decreased mainly due to high toxicity. Modern intensity-modulated radiation therapy (IMRT) could allow to spare kidneys, liver and bone marrow while still adequately covering the peritoneal cavity with a homogenous dose. The OVARIMRT-01 study is a single center pilot trial of a phase 1/11 study to assess the feasibility of intensity-modulated WAI. Materials: Eight patients with advanced ovarian cancer stage FIGO III, R1 or R2< 1cm after surgical resection and platinum-based chemotherapy were treated with WAI as consolidat ion therapy using intensity modulated radiation therapy (IMRT) to a total dose of 30 Gy in 1.5 Gy fractions. IMRT was applied using step-and-shoot-IMRT (n:3) or helical tomotherapy (n=5). Organs at risk (OARs) were bone marrow, kidneys, liver, spinal cord, thoracic and lumbosacral vertebral bodies and pelvic bones. The plann ing target volume (PTV) included the entire peritoneal cavity plus pelvic and para-aortic node regions. Results : Intensity-modulated WAI enabled a very homogeneous dose distribution with excellent sparing of OARs. Very satisfying target coverage was achieved, with a mean V90 of 88%, a mean V95 of 78%, a mean V105 of 14% and a mean V110 of 5%. Mean liver dose was 23 Gy and mean kidney doses were 10 Gy and 9 Gy respectively. Treatment could be performed without interruptions in mean daily time of 25,3 minutes and was well tolerated. Common Toxicity Criteria Grade 3 was experienced by 3 patients for neutropenia, by 2 patients for gastrointestinal toxicity and by 1 patient for transient liver enzyme elevation. Median follow-up is 11 months (1-16), 6 patients are in complete remission, 2 are in progress (local progress n=1, hepatic metastasis n=1). Small bowel obstruction occurred in 2 patients. Conclusions: Intensity-modulated WAI is clinically feasible and can be performed on a daily basis. It enabled excellent coverage of the PTV and effective sparing of liver, kidneys and bone marrow. Intensity-modulated WAI provides a new promising option in the adjuvant treatment of advanced ovarian cancer stage FIGO III, toxicity and outcome will be evaluated in a further phase II study. 746 poster EVALUATION OF ACUTE NORMAL TISSUE REACTIONS DURING RADIOTHERAPY IN WOMAN WITH GYNAECOLOGICAL CANCERS DIAGNOSIS. Z. Warenczak 1 , A. Roszak 1 , H. Wlodarczyk 1 1 GREATPOLAND CANCER CENTER, Gynecological Oncology, Poznan, Poland

Purpose: Acute radiotherapy reactions are commonly underestimated and underreported in literature. Our aim was to evaluate the incidence and score of acute reactions during definitive and adjuvant radiotherapy. Materials: Performed was detailed prospective analysis of 263 patients with gynaecological malignancies . All patients received both intracavitary (BRT) and external beam irradiation (EBRT). We divided all patients in too two groups and made analysis between them and in the groups. First group of 90 patients, with cervical cancer was treated with definitive radiotherapy exclusively (RT) or radiochemiotherapy (RCHT). Second group of 173 patients with cervical cancer (CC) and endometrial cancer (EC) was treated with adjuvant radiotherapy after surgery. Analysis included acute bowel and urinary tract reaction. The score of adverse effects was assessed using EORTC and CTCAEv3,0 scales. Chi-quadrate , U Manna-Whitneya and Fishera statistical models were used for calculations . Results: Post radiation reaction during therapy was found in 55,1% of patients. Significantly more side effects were observed in definitive than in

postoperat ive radiotherapy group (p
Purpose: To evaluate outcome, failure patterns , prognostic factors and radiothe rapy (RT) toxicity after postoperative RT for EC in Tarragona Province (Spain). Materials: A retrospective population-based review was conducted on 232 patients (pts) with EC treated between 1997 and 2000 from different gynae· cological Dpt. and in a single oncoroqist institution with RT Units. Multivariate analysis 01 variables were performed for the end points 01 disease-free survival (DFS), overall survival (OS), adjuvant RT, RT toxicity (RTOG), prognostic factors for survival and the distance in Km to the RT Units. Results: Mean age: 64 years (35·88 ). Distance to RT Units < 70 Km in 85% pts, >70 Km in 15% pts. Median follow-up: 70 months (2-132). FIGO Stage (S): 8.2% lA, 36.2% IB, 19% IC, 7.8% IIA, 6.5% liB, 7.3% lilA, 1.3% IIIB, 3.4% IIIC, 2.6% IVA, 2.2 IVB. Pathology: endometrioid 74.5%, papillary 3.9%, serous 3.4%, clear-cell 2.2%, squamous cell 3%, adenosquamous 1.3%, mixed 3.9%. Grade (G): 35.7% G1, 45.3% G2, 19% G3; Miometrial invasion: 44.1% >50%, 46% <50%,9 .9% not invasion. Treatment: 1) Surgery in 93.5%: 84.4% abdominal, 5.2% vaginal, 49.6% lymph nodes dissection . 2) RT in 73.5%: 47% external beam radiotherapy (EBI) and brachytherapy (BT), 9.4% BT alone, 17.1% EBI alone. Mean dose EBI 50Gy, mean dose BT: 17.23Gy. 3) Chemotherapy in 11.1% & Hormonal treatment in 6.9%. 3). Grade 3 & 4 toxicity: 12 (9%) pts, 6 early & 6 late. Relapses: 26/232 (11.6%) loco-regional recurrence S·I : 11/26 (42%), S-II: 1/26 (3.8%), S-III : 5/26 (19.2%), S-IV: 3/26 (11.5%). Metastasis : 28/232 (12.5%). Survivals at 5 years: 1) OS in all stages was 78.8% and 83%, 89.6% and 76% for SI, SII and Sill , respectively. 2) DFS was 76.5% for all pts and 82.3%, 86.22% and 68.24% for SI, SII and Sill , respectively 3) LRFS was 75.8% for all pts and 83%, 89.6% and 66.6% for SI, SII and Sill , respectively. Multivariate analysis : significant prognostic factors for poor outcome were age (p<0.01), lymph nodes dissection (p<0.001), pathologic subtype (p<0.001), grade of differentiat ion (grade III vs grade 1·11, p<0.001), and deep myometrial invasion (p<0.005). The pts who lived over than 70 Km received more treatment with radiotherapy (p=0.09). Conclusions: Survivals, RT toxicity and relapse sites were similar to the other reported series. Predictors of poor outcome were age, lymph nodes dissection, pathology subtype, grade of differentiation and deep myometrial invasion. Patients of Tarragona province are in need of a better accessibility to the Radiation Units. 748 poster EXTERNAL BEAM RADIOTHERAPY WITH CONCURRENT CISPLATIN IN ADVANCED CERVICAL CANCER - HEMATOLOGICAL TOXICITY, TREATMENTS RESULTS V. Parvanova 1, I. Mihaylova 1 , E. Petkova 1, S. Georgieva 1, A. Chakarova 1

NATIONAL ONCOLOGICAL CENTER HOSPITAL, Bulgaria 1

Radiotherapy, Sofia,

CLINICAL/DISEASE SITES

Purpose: Examination of acute hematological toxicity and overall survival in External Beam Radiation Therapy (EBRT) + cisplatin versus EBRT alone In patients with advanced cervical cancer. Materials: Between 2003 and 2006, 187 patients with cervical cancer, median age 44 years (26-67) have been treated In Dept of Radiotherapy, National Hospital of Oncology Sofia and followed for mean period of 24 months (3 60). 3 patients were lost of follow up. Clinical stage distribution of all patients is the following: IB2- 40%, IIA,B 34%, IIIA,B 23%, IVA 2%. The patients from the two groups are comparable in age and clinical stage. Group I -102 patients (55 %), treated with EBRT + cisplatin once weekly - 50 mg i.v., total dose of 200 mg. Group II - 85 patients (45 %) were treated with EBRlone. A post operative radiotherapy for the volume of the pelvis using "Box" technique with daily dose of 2 Gy, 5 times per week in total dose of 50 Gy has been applied in 148 patients 79%. Definitive radiation therapy using "Box" technique with daily dose of 2 Gy, 5 times per week in total dose of 60 Gy has been appiied in 39 patients 21%. Criteria for inclusion: metastatic pelvic lymph nodes N+, positive vaginai, or parametriai margins, Iymphovascular space involvement, size of lesion> 4cm, advance clinical stage 2: by FIGO. The acute hematological toxicity has been assessed using the Common xicity Criteria version 3,0. The vaiues of: HGB, WBC, LV, PLT were checked before the start and in the last week of the treatment course. Results: Hematological toxicity has been examined in 1-5 grades. tabl.lln patients with EBRT + cisplatin (group .), the treatment has been interrupted in 6 patient (6,2%) for period of 1 week due to hematological toxicity, recovered without medication treatment. The overall survivai in patients treated with EBRT + cisplatin is 81% versus 75% in patients treated with EBRT alone. Conclusions: The observed hematological toxicity in patients with advanced cervical cancer, treated with EBRT + cisplatin don't violate the treatment course, in comparison with the patients treated with EBRT alone. The unsatisfactory overall survival difference - only 6 % observed in group versus group II, could be explained with the advanced stage of cervical cancer B-VA in 69%, from which - 70% are N+.

749 poster FACTORS INFLUENCING THE TOLERANCE OF PREOPERATIVE RADIOCHEMOTHERAPY FOR RECTAL CANCER R. Bibik " M. Spych 2, A. Rychter " J. Fijuth 2 1 COPERNICUS MEMORIAL HOSPITAL OF LODZ, REGIONAL CANCER CENTER, Department of Radiation Oncology, Lodz, Poland 2 MEDICAL UNIVERSITY OF LODZ, Department of Radiation Oncology, Lodz, Poland

Purpose: Diarrhea is the most common and intense early reaction(ER) during preoperative radiochemotherapy of rectal cancer, which may interfere with treatment continuation. So the aim of this paper was to identify the clinical factors and physical parameters correlating with ER based on treatment technique evaluation and patient's characteristic. Materials: 50 consecutive patients with locally advanced rectal cancer treated with radiochemotherapy in Copernicus Memoriai Hospital were under evaluation. Early radiotherapy reactions had being assessed every week during radiotherapy treatment according to modified EOTRC/RTOG scale. The endpoint for this analysis was the occurrence of radiation enteritis of Grade 3 or higher. The statistical analyses were performed to determinate risk factors of early radiation enteritis. Age, pre-treatment haemoglobin level, bladder volume, diet compliance and alcohol use during radiotherapy treatment were included to statistical analysis of clinical factors. Following parameters related to radiotherapy technique were included to statistical analysis: volumes of intestine receiving doses between V5 Gy and V50 Gy, median and maximal PTV dose and maximal intestine doses. Results: 24 (48%) patients developed Grade 3 enteritis according to modified RTOG/EORTC score and 10 (20%) according to standard RTOG/EORTC scale. This was the most common and intense side effect during preoperative radiochemotherapy of patients with locally advanced rectal cancer. The clinical factors influencing development of early gastrointestinal radiotherapy complication were: age, haemoglobin levei and bladder volume (respectively: p=O, 0003, p=O.OOl, 0,008). Statistical analysis of dose volume histograms revealed that there were significant differences between groups with clinical manifestation of early radiation enteritis and without this manifestation in volumes of bowel included in isodoses 20 Gy(V20) to 45 Gy (V50) (p values were between 0,02 and 0,00009). Multivariate analysis of clinical and dosimetric parameters showed that the only factors influencing occurrences of gastrointestinal complication were volumes of bowel included within the 40 Gy and 45 Gy isodoses. This indicates that volume of irradiated bowel within

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the clinically significant dose is the most Important factor for development of radiation enteritis. Conclusions: Early intestinal, postradlological reaction which is the most common and intensive complication during radiochemotherapy of patients with locally advanced rectal cancer, influencing the treatment tolerance and compliance to protocol. The most important clinical factors influencing development of ER were patients younger age and low pre-treatment haemoglobin concentration. The factors connected with irradiation technique having impact on complications presence were the V 20 Gy to V 45Gy of bowel. 750 poster IMAGE-GUIDED RADIATION DOSIMETRY FOR CERVICAL CANCER VERSUS CLASSICAL POINT A DOSIMETRY K. Hatano " M. Sakai " H. Araki " T. Imagunbai " N. Tohyama " T. Kodama 1 1 CHIBA CANCER CENTER, Radiation Oncology, Chiba, Japan

Purpose: Current clinical practice when using intracavitary brachytherapy for cervical cancer is to prescribe the dose to Point A. However, this is an empirical method using a virtual point unrelated to actual anatomy and does not reflect the dose to the tumour. The tumour volume irradiated by the first brachytherapy fraction can be very variable when using only Point A for dose specification. For different patients, Point A may be situated within the tumour volume, or alternatively, outside the volume. Therefore if treatment is prescribed on the basis of Point A dose, even when using an optimisation procedure, the results can be underdosage or overdosage to the tumour and overdosage to organs at risk (OARs). However, when the tumour volume can be measured using MR imaging the dose distrribution to the gross tumour volume (GTV) can be optimised. Improved conformality of the 3D dose distribution for cervical cancer with a reduction in late morbidity. The objective of this study is to compare the relationship of toxicity and maximum dose of OAR when using classical Manchester Point A dosimetry with the use of image-guilded radiation therapy (IGRT) using MR/CT to obtain beter 3D conformality. Materials: 1995-2003. The study population consisted of 82 patients treated between January 1995 and December 2003, with FIGO stage distribution as follows: Ib: 12, lIa:2, IIb:32, Ilia: 2, IlIb: 21, IVa:l, IVb:12.. All cases had histologically confirmed squamous cell carcinoma of the uterine cervix. All patrients were treated with external beam radiotherapy and MR imageguided intracavitary HDR brachytherapy. The mean age of the patients was 61.3 years (range 33-85 years). The median follow-up period was 60 months (range 5-135 months). All patients were treated with 30 Gy whole pelvic Irradiation followed by a 20 Gy boost to the parametrium. Both CT and MR imaging were performed at the times of the first and third brachytherapy fractions. CT/MR compatible applicators were used. The GTV was defined by a high signal intensity region obtained using MR imaging. The planning target volume (PTV) included a 1cm margin cranio-caudally. We delivered 6 Gy per fraction to the PTV: one fraction per week, to a total dose of 24 Gy. Before 1995 a total of 248 patients were treated with the same external irradiation technique followed by intracavitary brachytherapy using a Manchester system optimisation technique of 6 Gy per fraction to a total dose of 24 Gy to Point A). For the two time periods 1995-2003 for IGRTand Before 1995 for non-IGRT, the five-year survival rates were compared according to stage, in terms of Point A mean dose. We also evaluated the minimum tumor control dose. Toxicity was assessed using maximum rectal dose, bladder dose and late genitourinary morbidity rates. Results: The benefit of OS & RFS at 5 years for stage lib (92.4% vs. 64.2% & 96.7% vs. 83.7%)) & 111(68.7% vs. 52.8% & 85.2% vs. 62.5%) patients in IGRT group. Total mean Point A dose by HDR-brachytherapy of IGRT group was 19.84 Gy(range:4.08-28.40Gy). The total maximum rectal dose by HDR-brachytherapy for each group was 21.96Gy (mean: 8.56Gy) and 40Gy (mean:25.6Gy), respectively. The maximun bladder dose by HDR-brachytherapy for each group was 23.76Gy(mean: 7.2Gy) and 48.2Gy (mean: 12.1Gy), respectively. Minimum tumor dose for local control was 45Gy/fraction to a total dose of 16-20Gy by brachytherapy. From an analysis of late rectal complication rate & maximum rectal dose in Non-IGRT group, about 44% of the treated patients experienced Grade 1&2 rectal bleeding. The maximum rectal dose of these patients was higher than or equal to 8Gy/frac. On the other hand, patients whose maximum rectal dose/fraction was less than 8Gy experienced no rectal bleeding. From the data of Non-IGRT group, we should reduce the maximum rectal dose to less than 8Gy/fraction. In IGRT group, maximum rectal dose has been reduced to less than 8Gy/frac. IGRT enabled us to reduce the rate of grade 1-2 rectal bleeding from 44% to 14% (one third). IGRT Non-IGRT Morbidity at 5 years Grade 1 bladder 2/82 18.5% (46/248) Grade 1 rectal 10/8230.2% (75/248) Grade 2 rectal 2/82 13.3% (33/248) Grade 1 bladder/rectal 20.1% (50/248) Grade 2 bladder/rectal 13.3% (33/248) Grade 3 bladder/rectal None 5.6% (14/248) Conclusions: Although the patient numbers are small in the IGRT group, the results indicate that with IGRT using MR/CT imaging has less morbidity than that of the non-IGRT dosimetry. Minimum tumor dose of brachytherapy should be 16-20 Gy /4fraction. We have to reduce the miximum rectal dose to less than 8Gy/farc. to a total dose of 32Gy by HDR brachytherapy.

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751 poster IMAGE-GUIDED STEREOTACTIC RADIATION THERAPY IN PATIE NTS WITH ISOLATED PARAAORTIC LYMPH NODE METASTASIS FROM CARCINOMA OF UTERUS C. Choi 1 , C. Cho 1 , S. Yoo 1 , M. Kim 1, H. Yoo 1 , K. Yang 1, Y. Seo 1 , J. Kang 1 , D. Lee 2 1 KOREA INSTITUE OF RADIOLOGICAL AND MEDICAL SCIENCES, Radiation Oncology, Seoul, Korea Republic of 2 KOREA INSTITUE OF RADIOLOGICAL AND MEDICAL SCIENCES, CyberKn ife Cente r, Seoul, Korea Republic of

Purpose: Isolated paraaortic lymph node (PALN) metastasis is defined to be a disease confined to PALN only as metastatic site. The survival outcome of patients with isolated PALN metastas is is dismal. This result is due to the limited effectiveness of salvage therap ies. Salvage surgery or radiation therapy has a limited role in patients with isolated PALN recurrence because of their potential morb idity and mortality are excessive. We hypothesized that stereotactic radiation therapy (SRT) using the CyberKnife (CK) system would lead to better local control via delivery of higher dose to tumor and this result wouid be translated to survival gain, ultimately. The aims of this study are to evaluate the role of SRT as local treatment for isolated PALN metastasis from carcinoma of uterus. Materials: From September 2002 to October 2007,30 patients with isolated PALN metastasis from carcinoma of uterus , who had received SRT using CK at Korea Institute of Radiolog ical and Medical Sciences (KIRAMS), were enrolled for this retrospective analysis. All patients were proven to have isolated PALN metastasis by computed tomography (CT) and/or positron emission tomography (PET) -CT. Twenty-eight patients were uterine cervi x cancers and remaining 2 were endometr ial cancers. Age ranged from 31 to 68 years old (median 52 years). The latent time between initial treatment and first relapse ranged from 3 to 81 months (median 14 months). After detection of isolated PALN metastasis , 25 of 30 patients received chemotherapy with concomitant SRT as salvage treatment. Tumor volume ranged from 13.2 cc to 57.3 cc (median 16.3 ee). The follow-up duration ranged from 3 to 67 months (median 21 months). Twenty-six patients were treated with SRT, whi le the remaining 4 patients with external beam radiation therapy (27 Gy to 45 Gy) followed by SRT boost (13 to 33 Gy ). Doses of SRT ranged from 33 Gy to 45 Gy (median 39 Gy) in 3 fractions. Overall survival (OS), local control (LC) rate and disease progress ion-free survival (DPFS) rate were calculated according to KaplanMeier method. Comparison between prognos is groups was performed by log-rank analysis . Toxicities were evaluated using the Radiation Therapy Oncology GroUp/European Organization for Research and Treatment of Cancer (RTOG/EORTC) radiation morbidity criteria. Results: The 4-year overall survival rate was 50.1 % and median survival time was not reached yet. Overall survival rate of symptomatic patients was significantly lower than asymptomatic patients (p = 0.002). The 4-year actuarial local control rate was 67.4%. Patients with 17 cc or less planning target volume (PTV) had significantly higher local control rate (p = 0.09). The 4-year disease progression-free survival rate and median time to disease progreso sion was 45.0% and 32 months, respectively. Small PTV was a favorabie prognostic factor (p = 0.043). Grade 3 or more complication requiring hospitalization was reported in 1 patient at 18 months after SRT. The patient was suffered from ureter stricture and underwent procedure to insert catheter. Conclusions: The overall survival rate and local control rate were promising with low toxicities. SRT using CK could be regarded as an effective treatme nt modality to treat isolated PALN metastasis from carcinoma of uterus. 752 poster IMRT AS A SINGLE MODALITY IN T HE TREATMENT OF LOCALLY ADVANCED CARCINOMA OF THE CERVI X H. Coomber 1, H. AI-Booz 2 BRISTOL HAEMATOLOGY AND O NCOLOGY CENTER, Medical Physics, Bristol, United Kingdom 2 BRISTOL HAEM ATOLOGY AND ONCOLOGY CENTER, Clinical Oncology, Bristol, United Kingdom 1

Purpose: Curren tly, patients with locally advanced carcinoma of the cervix who have an anaestheti c! operative risk or other contraind ication to proceed with brachylherapy are having lower doses of radiotherapy than planned . We are aiming to study the possib ility of using IMRT as the sole modality of treatment to be able to del iver a radical dose to the PTV and minimal dose to the organs at risk, to avoid under-treating this group of patients. Materials: The study included ten patients with locally advanced cervical cancer, and a performance status of 0/1, who were successful in completing their radical dose of External beam radiotherapy (50.4 Gy/ 25 fractions/ 5 weeks) with weekly Cisplatin chemo therapy (40mg/m2 IV infusion) between October 2007 and February 2008. This was followed by three fractions of intra uterine brachytherapy and parametrial boost as indicated. The same planning CT scans were re-outlined as per IMRT protocol , which is not currently the standard modality of treatment in our centre . The GTV, CTV and surrounding organs were delineated. Isodoses were checked with the new plan, and calculation of the doses achieved to the PTV and the doses received to the

organs at risk are documented . Results: Provisional check to the IMRT DVH's reveal nearly 90% of the plans examined receive the intended dose to the PTV, and only 2% of the plan s have a rectal dose in excess of 63Gy. More detailed data will be presented at the meeting. Conclusions: Omitting intrauterine brac hyl herapy for patie nts with locally advanced cervical carcinoma is possible by delivering the intended radical dose by IMRT. We are suggest ing that this moda lity of treatment can be used for those who are not fit for brachylherapy, however, this cannot be replacing the standard radiotherapy currently used with both external and internal treatment until a multi-centre randomised trial takes place and confirm the above. 753 poster INTRAPERITONEAL ALPHA·RADIOIMMUNOTHERAPY OF OVARIAN CANCER - PHARMACOKINETICS AND DOSIMETRY OF 211-ATMX35 F(AB ')2 IN A PHASE I STUDY E. Haglund 1, H. Andersson 2, T. Back " C. Divgi 3 , J. Elgqvist 4, S. Frost 1 , J. Himmelman 5, G. Horvath 4 , R. Hultborn .. H. Jensen 6, S. Lindegren 1 , S. Palm 1 , L. Jacobsson 1 1 INSTITUTE OF CLINICAL SCIENCES, THE SAHLGRENSKA ACADEM Y, Radiophysics, Gothenburg, Sweden 2 SAHLGRENSKA UNIVERSITY HOSPITAL, Oncology, G6teborg, Sweden 3 UNIVERSITY HOSPITAL OF PENNSYLVANIA, Nuclear Medicine and Clinic ak Molecular Imaging Section, New York, USA 4 INSTITUTE OF CLINICAL SCIENCES, THE SAHLGREN SKA ACADEMY, Oncology, Gothenburg , Sweden 5 SAHLGRENS KA UNIVERSITY HOSPITAL, Nuclear Medicine, G6tebo rg, Sweden 6 COPENHAGEN UNIVERSITY HOSPITAL, PET and Cyclotron Unit, Copenhagen , Denmark

Purpose: The alpha particle-emitter 2 11 At labeled to a monoclonal antibod y has in several animal studies proved effective in treatment of microscop ic ovar ian cancer in the peritoneal cavity. In this study pharmacokinetics and radiotoxicity are evaluated in patients after intraperitoneal injection of 211 At· MX35 F(ab·)2. Materials: Nine patients in good remission following second-line chemotherapy for recurrent ovarian carcinoma par ticipated in the study with informed consent. The patients underwen t laparoscopy and peritonea l scintigraphy before the therapy. During the laparoscopy a peritoneal catheter was inserted and the peritoneal cavity was inspected to exclude presence of macro scopic tumor growlh or major adhes ions. The scintigraphy was made to study the fluid distr ibution in the ~eriton eal cavity. For the therapy, patients were infused with 33-172 MBq 11 At-MX35 F(ab')2 in 1-2 L Extraneal solution via the peritone al catheter. The remaining solution was drained from the peritoneal cavity after 24h. Gamma camera whole body scans were made at 1, 6, 12 and 24h. All urine and samples of blood and peritoneal fluid were collected at 1 48h and measured for radioact ivity content. Results: The 24h and 48h urinary excretion of 2 11 At was 2% and 8% respectively. The thyroid uptake was 1% at 24h in the first five patients. The following patients were effectively blocked by potassium perchlorate. No other organ uptake could be detected . Estimated absorbed radiation doses were : to bone marrow 0.08 mGy/MBq, to unblocked thyroid 15 mGy/MBq and to the peritoneal surface 8 mGy/MBq . No adverse effects were observed in labora tory parameters or subjectively. Conclusions: At least 150 MBq of 211 At·M X35 F(ab')2 in 1-2L solution could safely be administered intraperitoneally. Extrapolation from animal data indicates that this activity level should result in sufficiently high absorb ed doses to erradicate micrometa stases on the per itoneum. 754 poster LATE RADIATION EFFECTS TO THE RECTUM AND BLADDER IN GYNAECOLOGIC CANCER PATIENTS: RE-SCORI NG AFTER 8 YEARS WITH LENT/SO MA AND RTOG /EORTC LATE-EFFECTS SCORING SCALES Y. Anaca k 1 , Y. Bolukbasi 1, Z. Ozsaran 1 , D. Yalman 1 , A. Aras 1 1 EGE UNIVERSITY HOSPITAL, Radiation Oncology, Izmir, Turkey

Purpose: In 1999 we evaluated the late effects of radiotherapy to the rectum and bladder in 116 gynaecological cancer patients using two different scoring scales (LENT/SOMA and RTOG/EORTC ). The results were published in the red journal (Anacak et aI., 2001). In this study we recalled the same patients after 8 years and scored the late effects using the same questionnaires . The purpose of this study is to evaluate radiation effects at a later period and to see whether there is a change by time and to check whether the correlation between the two scoring systems still exist after 8 years. Materials: All patients were treated by a combination of external irradiation and intracavitary HDR brachytherapy between 1988 and 1998. First evaluation was done in 1999 where 116 pat ients were participated; minimum followup time was 6 months. Patients were re-evaluated in 2007. There were 63 patients in the 2nd evaluation since 20 pat ients died of their disease or other

CLINICA L/DISEASE SITES

reasons and 33 patients were either lost to follow-up or refused to participate. Median lollow-up time was 120 months (range 102-163). The median age of those 63 patients was 63 (38 to 79); diagnosis was cancer of the uterine cerv ix in 47 patients and cancer of the endometrium in 26. The total doses to ICRU points were as follows: bladder 55.5±4.71 Gy and rectum 55.8±3.24 Gy. Resul1s : The correlation between the two scoring scales were analysed using the Spearman's rho rank correlation test. There was a moderate correlation between LENT/SOMA and RTOG/EORTC scales both for rectum (r=0.69, p<0.01) and bladder (r=0.52, p<0.01). This correlation was lower than the previous analysis in 1999 - it was r=0.81 for rectum and r=0.69 for bladder.

Grade 3/4 toxicity was as follows

I

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I

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[1999[2007 F

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I2007

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Conclusions : The late effects of radiation may be healed or worsened after a certai n period. In this study the late effects scores of rectum and bladder did not change in 55-70% of the patients many years after. Late effects to bladder was better in 25-30% but worsened in the remaining 15-20% of the patients; late effects to rectum was better in 20-25% and worse in 25-35% of the patients. The correlation between LENT/SOMA and RTOO/EORTC still exists but it is not as strong as in 1999. 755 poster MONITORING OF RADIATION CYSTITIS DEVELOPMENT USING DIRECT AND POLARIZATION -SENS ITIVE OPTICAL COHERENCE TOMOGRAPHY • A. Maslennikova " E. Tararova 2, O. Streltsova 2, N. Gladkova 3, E. Kiseleva 3, M. Karabut 4 , E. Zagaynova 5 1 NIZHNY NOVGOROD STATE MEDICAL ACADEM Y, Radiation Oncology, Nizhny Novgorod, Russian Federation 2 NIZHNY NOVGOROD STATE MEDICAL ACADEMY, Urology, Nizhny Nov~orod, Russian Federation NIZHNY NOVGOROD STATE MEDICAL ACADEMY, Problems of optical coherence tomography, Nizhny Novgorod , Russian Federation 4 N.I.LoBACHEVSKY NIZHN Y NOVGOROD STATE UNIVERSITY, Biophysics, Nizhny Novgorod, Russian Federation 5 NIZHNY NOVGORO D STATE MEDICAL ACADEMY, Institute of applied and fundamental medicine, Nizhny Novgorod, Russian Federation

Purpose: Radiation therapy is an important management tool for the treatment 01 malignancies of pelvic organs, creating significant potential for the development of radiation injury to the bladder. The sequelae of radiation injury can range from minor temporary irritative voiding symptoms and asymptomatic hematuria to more severe complications such as gross hematuria , contracted nonfunctional bladder, persistent incontinence, fistula format ion, necrosis, and death. Collagen deposition plays an important role in this process, because it causes severe scarring and further blood vessel obliteration, resulting in tissue hypoxia and necrosis. This study objective was to estimate changes of the bladder's mucosa in the course and after radiation therapy using direct and polarization-sensitive optical coherence tomography (OCT) imaging. These methods permit to evaluate not only epithelial and connective tissue correlation, but to obtain detail information about collagen's structure too. Materials: From April 2007 to December 2007, 18 patients with stage I-III of cerv ical cancer completed the prospect ive study. Treatment (6 MeV external beam irradiation and brachytherapy) was planned taking into account localization and extent of the tumor. OCT-monitoring was performed once a week , start ing from the first day of irradiation , in four points on the anterior, posterio r and lateral walls of the bladder and one point on bladder's neck. To evaluate the dynamics of bladder's mucosa in the course of irradiation, the presence of the horizontal stratified structure, well delineating epithelium, lamina propria and submucosa of OCT images, was taken into account in the direct polarizatio n. The occurrence of distinct signal in the orthogonal polarization was important to estimate changes of collagen fibers in lamina propria and submucosa l layer.

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S243

Resul ts: The most pronounced changes of urothelium and collagen fibers were registered in the bladder's neck area. In this zone, the epithelial layer is very thin, but connective tissue layer is of a considerable depth and gives a sharp signal in the orthogo nal polarization (Fig.1 a). It early terms after irradiation beginning, there were no evident changes in OCT images. After total dose 2628 Gy, images began to lose a stra1ified structure in the direct polarization. After total dose 3238 Gy, a complete loss of layer's structure was observed. In the orthogonal polarization, a sharp attenuat ion up to total disappearance of the signal became apparent in this very time (Fig.1 b). These features reflect serious structural disorders of collagen fibers and thei r deposition as a sequent of radiation damage . In one month after irradiation, mucosal structure remains abnormal. Conclusi ons : Polarization-sensitive optical coherence tomography reflects the process of radiation injury development of the bladder either in urolhelium and underlying connective tissue.

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GYNAECOLOGICAL TUMOURS

Table 1. meellan

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10mm

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4 mm

13mm

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757 poster ORGANS AT RISK DISPLACEMENTS AND THE CONSECUTIVE DOSIMETRIC IMPACT DURING BRACHYTHERAPY FOR CERVICAL CANCER T. Romdhani Messai 1, I. Dumas 2, N. Magne 1 , C. Chargari 1, N. Gillion I, C. Haie-Meder 1 1 GUSTAVE Roussy, Radiation Oncology, Villejuif, France 2 GUSTAVE Roussy, Physics, Villejuif, France

756 poster MRI-BASED ASSESSMENT OF SH IFTS IN VAGINAL POSITION IN PATIENTS WITH GYNECOLOGICAL TUMORS AFTER HYSTERECTOMY M. Teet-Bosma 1 , U. van der Heide 1 , L. van de Bunt 1, G. de Kart 2 , H. Schreuder 3 , I. Jurgenliemk-Schulz 1 I UMC-UTRECHT, Radiotherapy, Utrecht, Netherlands 2 UMC-UTRECHT,Radiology, Utrecht, Netherlands 3 UMC-UTRECHT, gynecology, Utrecht, Netherlands

Purpose: An important concern in pelvic radiotherapy in patients with gynecologic malignancies is the considerable volume of the organs at risk (bladder, rectum and bowel) included in the conventional radiation fields. An approach to reduce the irradiated volumes of these organs and thus the risk of treatment-related sequelae is 3-D conformal or intensity- modulated radiotherapy (IMRT). However, the margins to be added to the CTV (clinical target volume) to generate the PTV (planning target volume) in patients who have undergone hysterectomy are not well defined so far. The purpose of this study is to define the changes in the position of the vaginal CTV's during the course of radiation therapy in order to create adequate margins to generate the PTV·s. Materials: Fifteen endometrial en cervical cancer patients after hysterectomy were included. Each patient underwent five MRI exams on a 1.5 Tesla MRI scanner (weekly during the radiotherapy). Seventy-five datasets were gen erated. Vaginal CTV's were contoured on MRI (T2 weighted slices in three dimensions); the inferior boundary of the CTV was defined as the caudal border of the symphysis. The changes in the vaginal positions relative to the position of the vagina on the first MRI of each patient were measured Results: The margins, which accommodate the changes in the position of the vaginal CTV on five consecutive MRI exams, are indicated in table 1. Conclusions: In gynecological patients after a hysterectomy we found a substantial shift of the position of the vagina on five consecutive MRl's. To accommodate the changes in the position of the vaginal CTV an inhomogeneous PTV margin is needed with a maximum in the posterior dimension. When smaller PTV margins are chosen to profit from the use of IMRT or 3-D conformal treatment more specific position verification , based on the position of the target volume during the course of radiotherapy, is mandatory. Future work includes the following: (1) Defining the correlation of the shift of the vaginal CTV with changes in the volume of the surrounding organs at risk. (2) Defining position shifts of the lymphatic regions and the parametrial tissue on consecutive MR images and their correlation with changes in the volume of the organs at risk.

Purpose: To investigate organs at risk (OAR) displacements and the consecutive dosimetric impact during PDR brachylherapy for cervical cancer. Materials: Nine patients having PDR brachytherapy for cervical carcinoma were enrolled in this study. All patients were treated with external beam radiation therapy with concomitant chemotherapy prior to brachylherapy. The brachylherapy plan was applied using MRI exam. Three CT scan images were acquired at regular interval during brachytherapy. OAR (rectum, bladder and sigmoid) were delineated in each CT scan. The first part of the study was to investigate OAR displacement and variability. The different CT scans were matched together aligning bony structures . The geometrical shifts of the isocenter of each OAR and the volume variation were studied. The second part of the study was to compare the dose parameters of the OAR (D2cc bladder, D2cc rectum, D2cc sigmoid) when applying the same dwell positions and times on each CT scans. D2cc reported in this study represent only the brachytherapy contribution.For statistic analysis, we performed repeated measures ANOVA using nonparametric methods. Results: Organ at risk displacement: The main direction for the rectal and bladder isocenter displacement was into the crania-caudal direction. The mean shift was 2.5 mm (SD = 4.4 mm) for the rectal isocenter and 1.6 mm (SD = 4.1 mm) for the bladder isocenter. The sigmoid isocenter displacement was mainly found into the antero-posterior direction with a mean shift of 4.3 mm (SD = 9.6 mm). The rectal isocenter displacement between the 3 CT exams was statistically significant in the cranio -caudat direction (p=0.02) and the antero-poster ior direction (p
Purpose: From 1990 to 2005 436 patients were treated with combined radiotherapy and hyperthermia (RHT) for locally advanced cervical cancer (LACC). We evaluated treatment outcome and investigated the relationship between various prognostic factors, thermal dose'parameters and treatment outcome. for all patients treated in a randomized trial comparing standard radiotherapy to RHT and for all patients treated since that trial closed. Materials: Follow-up data of 436 patients was gathered by the first author

CLINICAL/DISEASE SITES

(MF) and reviewed by the last author (JZ). Primary endpo int was local control , disease specific surv ival and late toxic ity were secondary endpoint s. Relationsh ips between outcome parameters and prognostic and treatmentrelated factors were ana lysed using logistic regression analysis (response rate) or Cox Regression Analys is (iocal control, disease specific survival , late toxicity). Univariate and multivariate analyses were performed using the most important patie nt- tumour- and treatm ent-rel ated factors. Results: The addition of hyperthermia to stand ard radiotherapy resu lts in long-term major improvement of local control (37 to 56 %, P = 0.01) and survival (20 to 37 %, P = 0.03), without increasing late toxicity at 12 years follow-up . Local control and survival of patients treated since the trial closed are simila r to the results of RHT-arm of the trial. In addition to common ly identified prog nostic factors, thermal pa ram eters incorporating both time and temperature have a significant influence on tumour control endpoints in multivariate analysis. A temperature increase of 1 DC is expected to result in at least 6 % increase of chance of cure. Conclusions: Our results confirm previously found beneficial effects from add ing hyperthermia to radiotherapy for patients with LACC ; local control and survival are significantly improved compared to.radiotherapy alone , the treatment results are consistent over time and can be reproduced in a large group of patients. Therefore , it is justified to offer RT+HT as an alternative to chemoradiation for patients with LACC for patients who are unfit to receiv e concomitant chemotherapy. The finding of a thermal dose response relationship can be an important stepping stone for further improvement of therapy. 759 poster POINT VS VOLUMETRIC BLADDER AND RECTAL DOSIMETRY IN COMBINED INTRACAVITARY-INTERSTITIAL HIGH DOSE-RATE (H DR) BRACHYTHERAPY: CORRELATION AND COMPARISON WITH PUBLISHED VIENNA APPLIC ATOR DATA R. Yaparpalvi 1 , S. Mutyala 1 , N. Thawan i 1 , D. Mah 1 , S. Kalnicki 1 1 MONTEFIORE MEDICAL CENTER/AECOM , Radiation Onco logy, New York, USA

Purpose: We correlated rectal and bladder point and volumetric dose data in patients treated for advanced cerv ix cancers with combi ned intracavitaryinterstitial (IC+IS) high dose -rate brachy1herapy (HDR BT). The results are compared with published Vienna applicator data Materials: We retrospec tively analyzed 30 individual IC+IS implants from 10 patients treated with external beam radiat ion therapy (EBRT) followed by HDR BT for locally adva nced cervix carcinom a. EBRT consisted of 45 Gy to the pelvi s followed by 9-14.4 Gy boost to the parametria . BT consisted of a total dose of 21 Gy delivered in 7 Gy fraction . For each implant , CT-image based si mulation and image-guided BT treatment planning was perform ed. Bladder and rectal doses were evaluated and analyzed using both ICRU reteren ce poin ts and dose-volume histograms (DVHs). From these DVHs, minimal doses to highest irradiated 0.1cc, 1 cc, 2 cc, and 5 cc volumes of rectum and bladder were individually recorded in each case (designated as DO.1cc, D1cc , D2cc and D5cc respectively ). The cumulative doses to the rectum and bladder were calculated by combin ing contributions from external beam therapy and BT. In these calculations, the dose contributions to bladder and rectum from parametrial boost with midline shielding were not considered. To facilitate comparison with published literature, the total doses were normal ized to 2-Gy fractions (EQD2) using the equation EQD2totai = EQD2EBRT+ EQD2BT . Results: The results are summarized and compa red with the Vienna applicator study in Table 1. The dose values in Table 1 co rrespond to mean EQD2 dose values averaged over the study popul ation. The mean contour ed blad der volume was 68 ± 22cc . The mean contoured rectal volume was 52 ± 16cc. ICRU rectal referen ce dose correlated best with volumetr ic recta l D2cc dose (rS= 0.91, p=0.0003); however, the IC RU bladder dose did not correlat e with bladder D2cc dose (rS= 0.23 , p=0 .50). Conclusions : Our study findings reveal a strong correlation between ICRU rectal reference dos e and volumetric rectal D2cc dose in combi ned intracavi tary -interstitial high dose -rate (HDR) brachy1herapy. This surrogate rectal-dose relationship is valuable in establis hing recta l tolerance dose levels in transitioning from traditional 2-D to image based 3-D dose plann ing.

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0-92

760 poster POST CHEMORADIOTHERAPY STRESS FRACTURES TO THE PELVIS: IS IMRT THE ANSWER? H. AI-Booz 1 , J. Hughes 2 , A. Stapleton 3 1 BRISTOL HAEMATO LOGY AND ONCOLOGY CENTER, Clin ical Oncology , Bristol, United Kingdom 2 BRISTOL ROYAL INFIRMARY, Radiology, Bristol, United Kingdom 3 BRISTOL HAEMATOLOGY AND ONCOLOGY CENTER, Medical Physics, Bristol, United Kingdom

Purpose : We have noted an increase in the prevalence of patients presenting with radiologically confirmed stress fractures within 6 months of complet ing radiotherapy. We set out to study the dose delivered to radiological stress fractures when IMRT is subsliluted for conformal 3D CT plann ing for locally advanced carcinoma of the cerv ix. Materials: 30 patients treated over the past year with a radical dose of CT planned external beam radiotherapy (50.4 Gy/ 28 fractions! 5.5 weeks ) combined with weekly Cisplatin chemotherapy (40mg/m2 IV infusion). This was followed by three fractions of intrauterine HDR brachy1herapy (13.5 Gy/3 tractions) and parametrial boost as indicated (5.4 Gy/3fractions! 1.8 Gyl fraction). Five patients had pers istent lower back pain between three and six months post completion of treatment. Sacral ala stress fractures were identified on T1w spin echo MRI of the pelv is. We identified the area of fracture on MRI and correlated this with the plann ing CT. Isodoses were highlighted and the dose delivered to the area of the fracture was determined . We then re-calculated the isodoses using the previous plann ing CT as per IMRT protocol ; the GTV, CTV and surrounding organs were delineated. Doses to the area of the fracture were re-examined and compared to the correlating area on the original plan. Results: Using our standard techniqu e, the area of stress fracture received 95% of the total dose delivered to the whole pelvis (95% of the 50.4Gy /28#) in two of five patients. In the th ree other patients the area of stress fracture received between 101- 103% of the total dose delivered to the whole pelvis. On the IMRT plans, initial analysis of the DVH's demonstrate that the dose to area of stress fracture would not exceed the 88% of the total dose delivered to the whole pelvis. More deta iled data will be presen ted at the meeting. Conclusions: IMRT will reduce the dose to the sacrum dur ing radical radiotherapy to the pelv is for pati ents with locally advanced cerv ical carc inoma . While the sacrum is not recogn ized as an organ at risk in standard planning , the recogn ition of the high prevalence of these early stress fractures suggests that does reduction to the pelvis should be considered . 761 poster QUALITY ASSURANCE FOR A PROSPECTIVE MULTI · INSTITUTIONAL TRIAL OF DEFINITIVE RADIOTHERAPY USING HIGH-DOSE-RATE INTRACAVITARY BRACH YTHERAPY FOR UTERINE CERVICAL CANCER : THE INDIVIDUAL CASE REVIEW T. Toita 1 , M. Oguchi 2 , T. Ohno 3 , S. Kato 4, Y. Niibe 5 , T. Kodai ra 6 , T. Kazumoto 7 , M. Katao ka 8, N. Shikama 9, M. Kenjo 10, T. Teshima 11 , K.

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Hayakawa 5, Y. Kagami 12 UNIVERSITY OF THE RYUKYUS, GRADUATE SCHOOL OF MEDICAL SCIENCE, Radiology, Okinawa, Japan 2 CANCER INSTITUTE HOSPITAL, Radiation Oncology, Tokyo, Japan 3 GUNMA UNIVERSITY, GRADUATE SCHOOL OF MEDICINE, Department of Radiology and Radiation Oncology, Maebashi, Japan 4 NATIONAL INSTITUTE OF RADIOLOGICAL SCIENCES, Research Center for Charged Particle Therapy, Chiba-shi, Japan 5 KITASATO UNIVERSITY, SCHOOL OF MEDICINE, Radiology, Sagamihara, Japan 6 AICHI CANCER CENTER, Radiation Oncology, Nagoya, Japan 7 SAITAMA CANCER CENTER, Radiology, Saitama, Japan 8 NATIONAL SHIKOKU CANCER CENTER, Radiology, Ehime, Japan 9 SHINSHU UNIVERSITY, SCHOOL OF MEDICINE, Radiology, Matsumoto, Japan 10 HIROSHIMA UNIVERSITY, GRADUATE SCHOOL OF MEDICAL SCIENCE, Radiology, Hiroshima, Japan 11 OSAKA UNIVERSITY, GRADUATE SCHOOL OF MEDICINE, Department of Medical Physics and Engineering, Suita, Japan 12 NATIONAL CANCER CENTER HOSPITAL, Radiation Oncology Division, Tokyo, Japan

762 poster

1

Purpose: To assess compliance with a radiotherapy protocol of the multiinstitutional prospective study (JAROG0401), which investigated the efficacy and toxicity of definitive radiotherapy using high-dose rate intracavitary brachytherapy (HDR-ICBT) for patients with early stage uterine cervical cancer. Materials: Individual case review (ICR) of all 60 patients entered into the study was performed. Patient data including pretreatment MRI (T2WI), data of external beam radiotherapy (EBRT) (treatment chart, simulation films/ digitally reconstructed radiographs (DRR), portal films/ electronic portal imaging device (EPID) data, and dose distributions), and data of HDR-ICBT (treatment chart, AP/ lateral orthogonal films, and isodose distributions for all insertions) were collected by mail. All radiological images and dose distributions were digitally processed, mounted on Microsoft PowerPoint, and converted into CD-ROM format. Other data such as treatment charts were submitted as hard copies. The radiotherapy parameters reviewed were clearly stated in the study protocol. Protocol compliance with 16 items of radiotherapy was evaluated according to prearranged criteria. The data were reviewed and evaluated by participating radiation oncologists on the quality assurance (QA) committee of the JAROG. The QA committee met and performed ICR three times during the patient accrual period and immediately after a final patient entered. The ICR results of each QA committee were fed back immediately to the participating institutions. Results: Of the 60 patients (63%) evaluated, 38 were "acceptable" for all 16 items according to the criteria. The items described by quantitative values, such as prescribed doses, some time intervals and overall treatment were well followed. The number of cases evaluated as "deviation" decreased with each successive QA committee meeting; 6/15 in the 1st meeting, 7/20 in the 2nd, and 6/25 in the 3rd. Ten patients (17%) were evaluated as "deviation" using the method of point A determination. Conclusions: The present ICR demonstrated generally good radiotherapy protocol compliance. The decreasing number of "deviations" with each successive QA committee meeting suggested that the QA program couid improve protocol compliance of radiotherapy. A dummy run or benchmark case evaluation might work effectively for some QA, such as point A determination, in future multi-institutional studies involving HDR-ICBT.

Summary of the individualcase review Items

1) Time interval between patient entryand treatment start

2) Beamenergyof EBRT 3) Doily fraction dose of EBRT (prescribed) 4) Total dose of EBRT (prescribed) 5) Did !'TV of EBRTfollow _ I ? 6) Dosehomogeneity in !'TV of EBRT# 7)Set-upti.mingofMB 8) Set-upposition and shape of MB 9) Were all ports tteated dally? 10) Divergencebetween&imulation ftlmandverification film It) Time interval between thedateof2OGy andHDR-ICBTstart 12)Single point A dose of IIDR-ICBT (prescribed) 13)Total point A dose of IIDR-ICBT (prescribed) 14) Did determination of pointA follow protocol? IS) lllik organ (rectum, bladder, vagina) dose calculation (ICRU 38) 16) Overall trearment time

Evalualion

Deviation 1

0 0 0 1 1 0 J 0 6

1 J

1 10 3 0

Acceptable 59 60 60 60 59 59 60 59 60 54 59 59 59

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RADIOTHERAPY INDUCES LONG-TERM SYMPTOMS FROM SIX SEPARATE REGIONS IN GYNECOLOGICAL CANCER SURVIVORS E. Avall-Lundqvist " G. Dunberger 2, H. Lind 2, A. C. Waldenstrom 3, M. AI-Abany 2, U. Nyberg 4, E. Onelov 2, G. Steineck 5 1 KAROLINSKA UNIVERSITY HOSPITAL, Department of Gynecologic Oncology, Stockholm, Sweden 2 KAROLINSKA INSTITUTET, Department of Clinical Cancer Epidemiology, Stockholm, Sweden 3 SAHLGRENSKA UNIVERSITY HOSPITAL, Department of Gynaecological Oncology, Goteborq, Sweden 4 ST GORAN HOSPITAL, Section of Psychiatry, Stockholm, Sweden 5 KAROLINSKA INSTITUTET/SAHLGRENSKA ACADEMY, Department of Clinical Cancer Epidemiology, Stockholm/Gothenburg, Sweden

Purpose: A patient-reported inventory of radiotherapy-induced symptoms among long term gynecological cancer survivors is lacking. Materials: Eight hundred and sixty-nine women, who had been treated with radiotherapy for a gynecological cancer during 1991 to 2003 at two Departments of Gynaecological Oncology in Sweden, participated in a populationbased study. A control group of 480 women from the Swedish Population Registry, matched for age and regional residence, was also included. In preparation, we made in-depth Interviews with 26 women with a history of gynecological cancer. Based on their experience, we constructed a questionnaire, including 351 questions and validated face-to-face with 20 individuals. The women answered the questions covering experienced physical symptoms from the bowei, anal sphincter, urinary and genital tract, the skeleton as well as lower abdomen and legs. The questionnaire also covered demographical, psychological and quality of life questions Results: Response rate was 79% for cancer survivors and 72% for control women. Mean follow-up was 7.8 years. The highest relative risk (RR) was found for unexpected defecation in clothing (RR 20.9; 95% CI 6.0-72.2), protracted genital pain (RR 11.3; 95% CI3.7-33.9), loose stools while asleep (RR 9.9; 95% CI 4.4-22.4) and pain from sacrum when walking indoors (RR 9.0; 95% CI 5.0-16.0). Vomiting with abdominal pain (RR 4.0; 95% CI 1.8-8.7), difficulty feeling when bladder is full (RR 4.0; 95% CI 2.1-7.5) and protracted leg pain (RR 2.0; 95% CI 1.4-2.9) were symptoms also strongly associated with radiotherapy. Conclusions: Pelvic radiotherapy is related to long-term symptoms from all studied regions namely the bowel, anal sphincter, urinary and genital tract, skeleton as well as lower abdomen and legs 763 poster RECURRENT ENDOMETRIAL CARCINOMA: RESULTS AFTER SALVAGE RADIOTHERAPY WITH HDR BRT ALONE OR IN COMBINATION WITH EBRT S. Gribaudo " E. Madon " U. Monetti " A. Mussano " V. Richetto " A. Sardo " A. Urgesi 1 1 A.O. OIRM-S.ANNA, Radiotherapy, Turin, Italy

Purpose: To evaluate the efficacy, long-term disease control, survival and complication rates of high dose rate brachytherapy (HDR BRT) alone or in combination with external beam radiotherapy (EBRT) in the treatment of patients with local recurrences of adenocarcinoma of the endometrium. Materials: From 1997 to 2006 107 pts with vaginal or pelvic recurrence of endometrial carcinoma were treated; 89 endometrioid (83.2%). Mean age at the recurrence 73 (41-87). Mean time to relapse was 33 months (range 3-122). Symptoms were: vaginal bleeding 35 (32.7%), vaginal bleeding and abdominal pain 29 (27.1%), abdominal or back pain 33 (30.8%); 10 patients (9.3%) were asymptomatic. Staging with the Perez modified FIGO for primary vaginal carcinoma: 35 pts Stage I (32.7%), 62 Stage II (57.9%), 5 Stage III (4.7%), 5 Stage IV (4.7%). Primary treatment: 81 (75.7%) surgery alone, 14 (13.1%) surgery plus EBRT, 9 (8.4%) surgery plus CTH, 3 (2.8%) RT alone.HDR BRT was used in 96 pts (93 intracavitary and 3 interstitial) in 35 cases BRT HDR alone, in 61 was combined with EBRT. EBRT doses from 30.6 to 66.6 Gy. Intracavitary HDR BRT doses from 15 to 25 Gy in combination with EBRT and from 30 to 55 Gy when used alone; fraction size 5-6 Gy. Prescriptions for intracavitary therapy were at depths ranging between 5 and 10 mm, according with the lesion size and 3-4 fractions/week were used. Intracavitary vaginal applicators was used: vaginal cylinders, vaginai shielded cylinders, vaginal Miami applicator and vaginal ovoids. EBRT: 6 MV photons AP-PA and 4 fields box technique; a central lead shield was used in the last part of EBRT in the 25% pts and in some cases (bulky disease, previously irradiated pts) was used with a DMLC collimator. Results: Median follow-up was 75 months (range 18-132). CR was achieved in 99 pts (92.5%). The 5-year overall survival were: 82.4% in Stage I, 55.2% in Stage II, 60.6% in Stage III and 40% in Stage IV. The 5-year DFS were 80% in Stage I, 51.7% in Stage II, 54.1% in Stage III and 40% in Stage IV. Median time to relapse in the 14 local recurrences was 15 months (range 647); 6 of these pts have been retreated with further HDR intracavitary BRT and 4 achieved a new complete response. The late complications were scoring according to the Franco-Italian Glossary, in 55% pts there were no late

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complication. Affected organs included vagina 43.9% (26.1% G1 11.2% G2 6.5% G3), bladder 17.7% (9.3% G1 8.4% G2 no G3) and rectum 19.6% (7.5% G1 11.2% G2 1% G3); two pts developed a severe necrosis of the mucosa of the inferior third of the vagina which resolved after medical therapy. Conclusions: Treatment of local recurrences of endometrial adenocarcinoma with HDR BRT alone or in combination with EBRT is effective. Factors determining treatment outcome were relapse Stage (I-IIA), association of EBRT and HDR BRT, total dose. HDR BRT alone if the staging of relapses is correct is efficacy and safe. Second salvage HDR BRT is possible. Severe complications are rare even in pre-irradiated pts.

size (p=0.044), and positive peritoneal cytology (p=0.006) and the use of chemotherapy (p=0.005) had a significant effect on overall survival. Prognostic factors influencing disease-free survival were stage (p=0.009), positive peritoneal cytology (p=O.OOO) and the use of chemotherapy (p=0.002). The only prognostic factor affecting local control was stage (p=O.OOO). Conclusions: Postoperative radiotherapy seems to be an effective adjuvant treatment providing high local control rates in uterine sarcomas. However its efficacy should be clarified by randomized trials. The important prognostic factors influencing the treatment results were stage, histologic subtype, tumor size and positive peritoneal cytology.

764 poster

766 poster

RESULTS OF PILOT STUDY WITH USE PET (18FDG) IN RADIOTHERAPY TREATMENT PLANNING IN PATIENTS WITH CERVIX CARCINOMA H. Dolezelova " P. Siampa 2, B. Ondrova 2, J. Gombosova 2, T. Novotny 2, J. Ruzickova 2, J. Garcic 2, L. Hynkova 2, H. Soukalova 2 1 MASARYK MEMORIAL CANCER INSTITUTE· AND MEDICAL FACULTY MASARYK UNIVERSITY, Radiation Oncology, Brno, Czech Republic 2 MEMORIAL CANCER INSTITUTE AND MEDICAL FACULTY MASARYK UNIVERSITY, Radiation Oncology, Brno, Czech Republic

RESULTS OF TREATMENT IN PATIENTS WITH STAGE I ENDOMETRIAL CARCINOMA G. K. Rath " D. Sharma " K. Milind " P. Julka " A. Bahl " K. Haresh " S. Kumar 1 1 ALL INDIA INSTITUTE OF MEDICAL SCIENCES, Radiation Oncology, NewDelhi, India

Purpose: Positron emission tomography (PET) is a complementary method to determine target volumes in radiotherapy. Daily using of PET In the oncology praxis can change treatment strategy and Improve its outcome. Results of this pilot study show the role of PET with 18F-fluorodeoxyglicose (18FDG) in staging of cervical carcinoma and in the radiotherapeutic planning. Materials: Between March 2005 and May 2007, 51 patients with cervical carcinoma were treated with combination of external beam radiotherapy and HDR brachytherapy (uterovaginal application; 4-5 fractions), with or without concomitant cisplatin. The lymphatic nodes treatment field size was determined by PET/CT fusion. We used standard regime of radiotherapy: 5x1.8 Gy/fractions/week. The upper board of radiation field depends on lymph involvement: in case no lymph involvement the upper board was in L4/5; with involved iIIiac nodes or paraaortic nodes the upper board was moved to Th12/L 1. Treatment results were evaluated by PET 3 and 9 months after treatment. Results: The difference in the results of PET and CT was evaluated in this study. In 32 cases (62.7%) the results of PET and CT were identical, in 14 cases (27.5%) the nodal involvement was more extensive according to PET, in 5 cases (9.8%) the nodal involvement was more extensive according to CT. PET results 3 months after treatment were as follows: in 3 cases (5.9%) stable disease, in 35 cases (68.6%) negative, in 4 cases (7.8%), progression of disease, in 3 cases (5.9%) partial regression. There should not occur any false positive results caused by inflammatory reaction persisting 3 months after radiotherapy, as was confirmed by repeating PET 9 months after treatment. Conclusions: The results of this study confirmed the important role of PET in diagnosis and treatment of cervical carcinoma and in determination of target volumes in radiotherapy. PET was found to be a standard staging examination of cervical carcinoma in Masaryk Mem. Cancer Inst. The predictive value of PET has not yet been validated. THIS STUDY WAS SUPPORTED BY THE RESEARCH GRANT IGA MZ CR NR/8322-3 765 poster RESULTS OF POSTOPERATIVE RADIOTHERAPY IN THE TREATMENT OF UTERINE SARCOMAS: A RETROSPECTIVE ANALYSIS OF 46 PATIENTS D. Yalman " Z. Ozsaran " B. Baltalarli 2, O. Demir 3, A. Aras 1 1 EGE UNIVERSITY FACULTY OF MEDICINE, Radiation Oncology, Izmir, Turkey 2 PAMUKKALE UNIVERSITY FACULTY OF MEDICINE, Radiation Oncology, Denizli, Turkey 3 ATATURK STATE HOSPITAL, Radiation Oncology, Izmir, Turkey

Purpose: The aim of this study is to evaluate the treatment outcome, survival data and prognostic factors in patients with uterine sarcoma treated by postoperative radiotherapy. Materials: Records of 46 patients treated between 1993-2003 were reviewed. Median age was 55 (range 31-75). There were 21 mixed mullerian tumors, 12 leiomyosarcomas, 11 endometrial stromal sarcomas and 2 adenosarcomas. According to FIGO classification 65.2% were Stage I, 17.4% Stage II, 13% Stage III and 4.3% Stage IV. All patients received external radiotherapy with 1.8 Gy daily fractions up to 50.4-64 Gy (median 50.4 Gy). Intracavitary brachytherapy was applied to 39 patients. Twelve patients received adjuvant chemotherapy. Results: Median follow-up time was 48 months (6-144 months). Seventeen patients (37%) developed distant metastases and one patient had local failure. Five-year overall, disease-free and local recurrence-free survival rates were 57.8%, 60.5% and 97.8% respectively. Univariate analysis demonstrated that stage (p=0.011), histologic subtype (p=0.010), tumor

Purpose: The aim of this study was to analyze the results of treatment in patients with stage I endometrial carcinoma. Materials: The study population consisted of 70 patients who underwent surgery and found to have FIGO stage I endometrial carcinoma. The surgical procedure followed was total abdominal hysterectomy (TAH) plus bilateral salpingo oopherectomy (BSO) with or without lymph node sampling. The policy of adjuvant treatment was as follows: stage lA, Grade 1-2, no adjuvant treatment; Stage IA grade 3, IB grade 1-2; intravaginal brachytherapy (IVBT) alone; stage IB grade 3, IC grade 1-3; pelvic external beam radiotherapy (EBRT) combined with IVBT. The dose of IVBT was 7 Gy x 3 fractions (high dose rate, once a week fraction) prescribed at 0.5 cm from the surface of intravaginal applicator. The length of vagina treated was 3-5 cm. The dose of IVBT, when combined with EBRT, was 6 Gy x 2 fractions. Pelvic EBRT dose was 5040 cGy in 28 fractions over 5.5 weeks with conventional fractionation schedule. Pelvic control rate, overall survival and late toxicity (RTOG criteria) were determined in different substages. Results: The age of the patients ranged from 23-76 years (median 54 years). The distribution of the stage and grade was as follows: IA GI, 5; IA G2, 0; IA G3, 2; IB G1, 29; IB G2, 5; IB G3, 8; IC G1, 8; IC G2, 6; and IC G3, 7 patients. Of 70 patients, 62 (89%) had pelvic disease control. The 5 year projected survival was 76%. The severe late radiation related morbidity (RTOG grade 3-4) was 6%. Conclusions: Our policy of adjuvant treatment in stage provides excellent disease control and survival with minimal long term toxicity. 767 poster ROLE OF VARIOUS METHODS OF BRACHYTHERAPY IN CARCINOMA OF VAGINA S. Kucucuk " B. Sarper 2, I. Aslay " G. Kemikler 3, I. Ozbay 3, M. Dincer " S. Berkman 4, Y. Eralp 5, R. Disci 6, G. Tore 1 1 ISTANBUL UNIVERSITY ONCOLOGY INSTITUTE, Radiation Oncology, Istanbul, Turkey 2 KOCAELI UNIVERSITY MEDICAL SCHOOL, Radiation Oncology, Kocaeli, Turkey 3 ISTANBUL UNIVERSITY ONCOLOGY INSTITUTE, Medical Physics, Istanbul, Turkey 4 ISTANBUL UNIVERSITY ISTANBUL MEDICAL SCHOOL, Department of Gynecology and Obstetrics, Istanbul, Turkey 5 ISTANBUL UNIVERSITY ONCOLOGY INSTITUTE, Medical Oncology, Istanbul, Turkey 6 ISTANBUL UNIVERSITY ISTANBUL MEDICAL SCHOOL, Department of Biostatistics, Istanbul, Turkey

Purpose: To analyze the impact of the total doses of irradiation, biological equivalent dose (BED) and brachytherapy techniques on treatment results in patients treated with definitive radiotherapy for carcinoma of the vagina. Materials: Fifty patients with carcinoma of the vagina who received radiation therapy were reviewed, retrospectively. Forty two patients (84%) were treated with a combination of external beam irradiation (EBRT) and brachytherapy, and 8 (16%) were treated with EBRT only. Fifteen patients (36%) received high dose rate (HDR), 27 (64%) received low dose rate (LDR) brachytherapy. Results: With a median follow-up of 42 months, 24 patients (48%) were recurred locally. The local recurrence rates (LRR) in patients treated with EBRT alone, EBRT and HDR brachytherapy, EBRT and LDR brachytherapy were 88%, 60% and 29%, respectively. Although overall survival was similar in LDR and HDR group (47.6%, 41.8%, respectively), local disease free survival (LDFS) was higher in LDR group than in HDR group (60.2%, 33.3%, respectively). LRR were decreased from 63% to 30.4% when total dose exceeds 70 Gy , 55.8% to 25% when BED value exceeds 80 Gy. Response to EBRT, brachytherapy, total dose and BED values were significant factors in LDFS on univariate analysis, brachytherapy and tumor dimension (>4 ern) were the prognostic factors on multivariate analysis.

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Conclusions: Definitive radiotherapy is the treatment choice for the patients with vaginal carcinoma . Optimal outcomes can be achieved with adequate dose delivery. Brachytherapy, which can be individualized to cover the target volume, plays an effective role in this treatment. 768 poster STANDARD BONY LANDMARK-BASED SUPERIOR BORDER IS NOT RELIABLE FOR RADIATION TREATMENT IN PATIENTS WITH CERVICAL CANCER B. Santamaria Torruco 1 , D. Vilar Compte 2 , M. Rodrigue z Ponce 1 , F. Herrera Martinez 1, A. Calvo Fernandez 1 , A. Poitevin Chacon 1 1 INSTITUTO NACIONAL DE CANCEROLOGIA, Department of Radiation Oncology , D.F., Mexico 2 INSTITUTO NAcrONAL DE CANCEROLOGIA, Department of Infectious Diseases, D.F., Mexico Purpose: The purpose of this study was to evaluate whether the pelvic-field superior border for cervical cancer based on bony landmarks set up in the intervertebral space between L4 and L5 adequately covers the common iliac nodal group within the treatment volume of 3D-stimulated patients. Additionally, we registered bony landmark-based aorta location and measured from intervertebral space between L4-L5 to aortic bifurcation and the distance from vertebral space between L4-L5 to optimal coverage limit in which common iliac nodes were included. We also estimated whether there was a correlation between patient height in Mexican population and bifurcation location. Materials: We included patients with uterine cervical cancer stages IBIVA and patients who had undergone surgery for their primary disease who presented high risk factors (positive margins, vascular and lymphat ic permeation, pelvic node invasion) and who had not been treated previously with radiotherapy. Computed tomography simulation was used with patients in prone position using 0.5-em slices. Planning was with Eclipse system. Images were reconstructed to identify aortic bifurcation location, as well as optimal location of treatment volume coverage to correlate this with anatomic bony landmarks. Adequate planning volume was defined as 1.5 em above the bifurcation of the aorta covered with isodose curve of +5 to 7% and was considered inadequate when the distance was >1.5 em. Distance from L4L5 vertebral space to the bifurcation was measured in em, and was also measured 1.5 em above this landmark to determine optimal treatment volume-coverage distance. Patient height measured in em was correlated with the aortic bifurcat ion location. Results: 101 patients with uterine cervix cancer were included . Mean age was 48 ± 4 years. Patient clinical stage: IBI, 6 (5.9%); IB2, 4 (4.0%); IIA, 1 (1.0%); liB, 47 (46.5%); lilA, 2 (2%); IIIB, 24 (23.8%) ;stage IVA 2 (2.5%), and 14 (13.9%) were operated on with high risk factors. Optimal limit setup coverage was suitable in 21 (20.8%) of patients. Optimal distance to coverage: median was 3.0 em (0.06.9 em). In 85, 90, and 95 percentile : 4.5, 5.0, and 5.6 em. Anatomic bony landmark-based optimal location (Figure 1) was: If the treatment border was placed at L4/L5 interspace, only 5% of cases was covered, while this was 35.6% if placed in mid-L4, 77.2% at L4-L3 interspace, 94.1% in mid-L3, while if placed at L2-L3 interspace, 100% was covered. Relationship between patient size and bifurcation location. Mean patient height was 150 em (140173 em) and was correlated with the aortic location. Spearman rank correlation was performed with 0.193 as coefficient of association with p <0.5. We found no association between aortic-bifurcation height and location. Conclusions: Our findings support great common iliac-node intervariability in Mexican women with cervical cancer and the uncertainty of the standard bony landmark-based super ior border.

769 poster THE COMPARATIVE ANALYSIS OF EPIDEM IOLOGICAL SITUATION OF CERVICAL CANCER IN POLAND AND WIELKOPOLSKA RE GION , SINCE THE MOMENT OF COMMENCEMENT OF NATIONAL SCREENING PROGRAM OF EARLY DETECTION OF THIS CANCER A. Roszak 1 , A. Dyzmann-Sroka 2, R. Stachlewsk i 2 1 GREAT POLAND CANCER CENTRE, Radiation and Gynecological Oncology Ward, Poznan, Poland 2 GREAT POLAND CANCER CENTRE, Regional Cancer Registry and Dept. of Organization and Contracting of Services, Poznan, Poland

Purpose: The comparative analysis of cerv ical cancer incidence and mortality trends in Wielkopolska region in compar ison with Poland and Europe during last 20 year. In comparison with the World , Poland is one of the countries with medium incidence of cervical cancer. However among European countries Poland occupies 7th place (for 38 countries) by incidence rate as well as by mortality rate. The analysis of 5 year survival rate in Poland shows a iow number of recoveries after cervical cancer (48.2%), that places Poland on the last place among the registered European countries (Globocan 2002). Materials: Scientific material was based on data from: GLOBOCAN 2002 (www-dep.iarc.fr/GLOBOCAN), EUROCARE-3 Study and from Cancer Case Report Card sent to Wielkopolska Cancer Registry as well as to Polish Nationai Cancer Registry. The incidence and mortality data were acquired from cancer registry records from years 1985 - 2005 . Crude rates were calcuiated based on the population data obtained from the Central Statistical Office. For the purpose of calculation of standardized rates "Standard world population" was used . Results: During last 20 years the epidemiological situation have been improved. The number of cervical cancer incidents decreased from 3843 to 3263 (by 15,1%), while the number of female population increased by 3%. Standard ized rate also decreased from 16,8 to 11,5 (by 5,3%). In 2005 cervical cancer according to its frequency occurrence occupied 6th place among the most frequent female cancers. The cervical cancer incidence in Poland is diverse (from 9,5 to 13,4 in particular regions ), Wielkopolska occupies high 4th place among 16 regions. In years 1985-2005 the number of deaths decreased from 2028 to 1796 (by 12%). Standard ized rate also decreased from 8,3 to 5,7 (by 2,6). In 2005 cervical cancer according to its death frequency occupied 7th place among the most frequent female cancers. Standardized rate of deaths is between 3,9 and 8,1; Wielkopolska occupies 6th place among 16 regions. Analize of incidence and mortality trends during last 20 years in Wielkopolska reflects representa tive trends for average values in Poland, standardized incidence rate decreased by 4,8, standardized mortality rate decreased by 3,2. Low results of 5 year survival rates among patients with cervical cancer in Poland com es out of no active and popula tion screen ing program and of women attitude to preventive programs, which follows to cancer detection in III or IV stadium. At the moment of commencement of active screening program Poland has the same situation as the most of developed countries 20-30 years ago. Conclusions: Polish main problem is that in spite of the slow decrease of the incidence for cervical cancer, percentage of cases detected in 0, lA, IB stadium and the survival rate is the lowest in Europe (last place among 23 countries). This situation can be changed only through society education and the active population screening programs (named invitations system, increased access to examinations and health service also by implementation of cytobuses ) including HPV vaccination. 770 poster T HE IMPACT OF RADIATION -INDUCED MORBIDITY ON HEALTHRELATED QUALITY OF LIFE AMONG PATIENTS WITH CERVICAL CANCER E. Pras 1, M. Berveling 1 , J. Langendijk 1 ~VERS ITY MEDICAL CENTER GRONINGEN, Radiation Oncology, Groningen, Netherlands

Purpose: Radiotherapy is an important treatment modality for patients with cervical cancer. Growing evidence indicates that more aggressive treatment regimens, such as the delivery of radiotherapy (RT) with concomitant chemotherapy (CHn improve tumor control and survival in these patients. The purposes of this study were: (1) to assess the cumulative incidence of late radiation-induced morbidity among patients treated for cervical cancer ; (2) to assess whether the addition of concomitant chemotherapy to radiation resulted in higher rates of late radiation-induced morbidity and, (3) to investigate the possible association between late radiation-induced morbidity and health-related quality of life (HRQoLl . Materials: For the purpose of this study, we composed a sample of 114 patients with cervical cancer treated with curative intent. Thirty-nine patients (34%) were treated with radiotherapy alone and 75 patients (66%) with concomitant chemoradiation. Toxicity according to the CTCAE was scored retrospectively by reviewing medical charts 'using a standardised checklist, focussing on bladder- and intestinal toxicity. HRQoL was assessed using the EORTC QLQ-C30 questionnaire. A multivariate analysis of variance was used to analyze the impact of morbidity on HRQOL.

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Results: For treatment-related bladder morbidity, the highest incidence was observed for cystitis (39%), and the lowest incidence for urine incontinence (22%). No significant differences were found between the two treatment groups. The analysis showed that CTCAE-cystitis, CTCAE-bladder, CTCAE-incontinence and CTCAE-enteritis were all significantiy associated with HRQoL in general. More specifically, all grade 2-4 radiation-induced urinary tract toxicity had a large impact on the general dimensions of HRQoL, such as on physical, role, emotional and social functioning as well as on global QoL. Similar results were found for CTCAE-enteritis. Conclusions: The addition of concomitant CHT to RT did not result in an increased risk of late radiation-induced sides effects. However, urinary tract and intestinal side effects are found in a relatively large proportion of patients, and have a major negative impact on HRQoL. The results of this study stresses the importance of prevention of these side effect, e.g. by using advanced and imaging guided radiation delivery techniques. 771 poster VESICAL INSTILLATIONS OF HYALURONIC ACID REDUCE THE ACUTE VESICAL TOXICITY INDUCED BY HIGH DOSE BRACHYTHERAPY A. Rodriguez Perez " P. M. Samper Ots " M. C. Lopez Carrizosa 2, J. M. Delgado Perez 2, A. Sotoca Ruiz 2 1 HOSPITAL CENTRAL DE LA DEFENSA GOMEZ ULLA, Radiation Oncology, Madrid, Spain 2 HOSPITAL CENTRAL DE LA DEFENSA, Radiation Oncology, MADRID, Spain

Purpose: To determine whether the intravesical use of hyaluronic acid (HA) reduces acute and late vesical toxicity induced by radiotherapy. Materials: Single-centre retrospective study of patients diagnosed with cervical and endometrial cancer treated between September 2002 and November 2007 with brachytherapy (BT) with or without intravesical instillation of HA. Patients were assigned consecutively to the two treatment groups (HA or non-HAl. Forty mg of HA was instilled intravesically for approximately 30 minutes prior to each BT session. Rates of acute and late vesical toxicity were recorded in the two groups using the RTOG criteria. Results: Ninety-five clinical histories of patients treated with BT were reviewed (48 with HA instillation and 47 without). The diagnoses were cervical cancer (28.4%), endometrial cancer (70.5%) and vaginal cancer (1.1%). Surgery had been administered in 85.3% of cases, external radiotherapy in 76.8%, and chemotherapy in 25.3%. There were no significant differences between the HA group and the non-HA group with regard to the total number of BT sessions (mean: 5.0 vs 4.9, n.s.), dose per session (mean: 478.13 vs 505.32 cGy; n.s.), total dose (mean: 24.02 vs 24.86 Gy; n.s.) or biological equivalent dose (mean: 35.59 vs 37.82; n.s.). In all the sessions the percentage of patients presenting acute vesical toxicity was lower in the HA group (p<0.05), the differences being statistically significant after the 2nd (20.8% vs 40.4%) and 4th sessions (10.9% vs 31.9%). Though late toxicity did not show significant differences between groups, no patients in the HA group presented vesical toxicity after six months of follow-up, compared with three patients in the non-HA group. Over the whole study period, from the start of BT until the end of follow-up at 60 months, the percentage of patients presenting vesical toxicity of degree 2 or more was significantly lower in the HA group than in the non-HA group (2.08% vs 12.8%; p<0.05). Conclusions: Vesical instillations of HA decrease the incidence and the degree of acute vesical toxicity induced by high dose brachytherapy, and reduce the percentage of patients that develop toxicity of degree 2 or more.

Clinical/Disease sites . Head and neck 772 poster A COMPARISON OF TREATMENT PLANS USING L1NAC-BASED INTENSITY-MODULATED RADIATION THERAPY AND HELICAL TOMOTHERAPY FOR MAXILLARY SINUS CARCINOMA S. Y Kim " K. C. Keum " Y B. Kim " C. G. Lee " J. W. Kim " D. H. Lee " H. I. Yoon " B. C. Jeon " J. Seong " G. E. Kim 1 1 YONSEI CANCER CENTER, Radiation Oncology, Seoul, Korea Republic of

Purpose: To explore a helical tomotherapy (TOMO) technique capable of conforming a more homogenous isodose distribution to an irregular-shaped tumor of the maxillary sinus, with concomitantly sparing the adjacent critical normal organs including the orbit, comparing with a linac-based step-andshoot IMRT (S-IMRT) technique. Materials: The S-IMRT plans and the TOMO plans were establishsd for 10 patients with maxillary sinus cancer. 66 Gy over 33 Fractions was prescribed for planning simulation to cover the high-risk planning target volume (HPTV) with 95% isodose line. Each plan was independently optimized using

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both the CORVUS planning system, and Tomotherapy Hi-Art system, version 2.0. The resulting treatment plans were compared using isodose distribution, dose statistics, dose volume histogram(DVH), dose homogeneity index (DHI) of the PTV and also using equivalent uniform dose (EUD) of organs at risk (OARs), dose statistics, and dose-volume histogram (DVH) of the adjacent critical structures. Results: The TOMO plan for each patient demonstrated improved dose homogeneity of the PTV compared to S-IMRT plan. The average V95% (HPTV receiving more than 95% of the prescribed dose) of TOMO plan was similar to that of S-IMRT (92.92% vs. 95.07), but average V107% (HPTV receiving more than 107% of the prescribed dose) was 0% in TOMO compared with 18.74% in S-IMRT.The average maximum dose reduction was 8 Gy, and DHI increase was 8% for HPTV in TOMO compared with S-IMRT (79 Gy vs. 71 Gy and, 89% vs 97%). The average EUD reduction for ipsilateral optic nerve was 7%, and contralateral optic nerve was 8%. Conclusions: With concomitantly sparing the surrounding visual pathway structures, our TOMO technique was quantitatively similar to S-IMRT plan technique with respect to the dose homogeneity within the HPTV. Therefore, we believe that our TOMO technique can be used routinely in treatment of maxillary sinus cancer. 773 poster ACCELERATED FRACTIONATION IN THE TREATMENT OF HEAD AND NECK SQUAMOUS CELL CARCINOMA AT THE BC CANCER AGENCY J. Wu " A. Chew 2, J. Hay " B. Sheehan " B. Baerg " E. Berthelet 3, H. Kader 3, F.Wong 4, C. Leong 4, A. Karvat 4 1 VANCOUVER CANCER CENTRE, BCCA, Radiation Oncology, Vancouver, Canada 2 UBC, Department of Medicine, Vancouver, Canada 3 VANCOUVER ISLAND CANCER CENTRE, BCCA, Radiation Oncology, Victoria, Canada 4 FRASER VALLEY CANCER CENTRE, BCCA, Radiation Oncology, Vancouver, Canada

Purpose: Standard radiotherapy fractionation schedules for locally advanced squamous cell carcinoma (SCC) of the head and neck (H&N) have been shown to be inferior to altered fractionation schedules. A modified DAHANCA accelerated fractionation (AF) regimen has been used at the British Columbia Cancer Agency (BCCA) since 2000. We will review the BCCA experience with AF and compare results with those of the DAHANCA group. Materials: A retrospective review of 109 patients treated between March 2000 and June 2007 with curative intent and AF schedules was conducted. Initially, patients were treated with 33 fractions (2Gy) over 5.5 weeks or 38 days, similar to the DAHANCA regimen with median treatment of 39 days, (n=74); over time, the schedule was shortened to 5 weeks or 33 days (n=35). Large fields encompassing microscopic disease delivered 50Gy in 25 daily fractions; smaller boost fields to gross disease (16Gy in 8 fractions) were given every 3-4 days as BID fractions, >6 hours after the large field. In accordance with standard practice at BCCA patients with less than T2N2a disease were treated with 60Gy in 25 fractions over 5 weeks, and those with bulky N3 tumours or poorly differentiated histology had combination chemotherapy and radiation; these were not part of the review. Patterns of failure, secondary control measures, outcome and sequelae were recorded. Disease-free and overall survival curves were calculated using the Kaplan-Meier method. Results: Follow-up from the end of radiotherapy ranged from 9-95 months. 69% of patients had no evidence of disease; 16% failed locally; 4% had neck failure and 13% distant failure. 7% required salvage surgery; 5% had planned neck dissection; and 6% developed a second primary. 6% were admitted to hospital, <1% interrupted treatment and 6% required G-tubes. At last visit 70% of patients were alive. Preliminary analysis is comparable with DAHANCA study results (18% T failure, 5% N failure, 4% distant failure and 56% survival 60 months after randomisation). A detailed analysis comparing BCCA and DAHANCA patient population, outcomes and survival curves will be presented. Subset analysis of the two BCCA schedules will also be discussed. Conclusions: As previously shown by DAHANCA, AF is superior to conventional radiotherapy schedules. The BCCA modified AF schedules are effective in treating locally advanced H&N SCC, are well tolerated with acceptable adverse effect rates and produce survival rates comparable to DAHANCA.