- Email: [email protected]
EP-1303: Clinical outcomes of patients with advanced cervical cancer and percutaneous nephrostomy : An audit
S698 ESTRO 36 _______________________________________________________________________________________________
Conclusion Interference of the three different treatment modalities makes it very difficult to unravel dose-effect relations for this patient group. Internal motion of the organs could have induced mismatches between planned and irradiated EBRT dose. Despite interplay effects of Cisplatin and IGABT, we found some trends i.e. correlation of early weight loss with body V43Gy, severity of vomiting and diarrhea. Consequently, rescanning for the ART patient group is now rescheduled to week 4, to adapt EBRT to reduced body volume if necessary. For GU toxicity, we recommend the combination of daily bladder volume during EBRT and IGABT to be assessed with non-rigid analyses in a larger patient group. EP-1302 Acute toxicity of prophylactic para-aortic chemoradiation for cervical cancer treated in IMAT era N. Ballari1, B. Rai1, R. Miriyala1, A. Bahl1, B.R. Mittal2, S. Ghoshal1 1 Post Graduate Institute of Medical Education and Research, Radiotherapy and Oncology, Chandigarh, India 2 Post Graduate Institute of Medical Education and Research, Nuclear Medicine, Chandigarh, India
Purpose or Objective Prophylactic paraaortic irradiation is being increasingly advocated for patients of locally advanced cervical cancer. Up to 25% of patients with FDG avid pelvic lymph nodes harbor micro-metastases in paraaortic lymph nodes, corroborating the postulated benefit of prophylactic paraaortic irradiation. However, acute toxicity was a major limiting factor when 2-dimensional extended field radiotherapy planning was used with concurrent cisplatin. With the use of intensity modulated radiotherapy (IMRT) in the form of intensity modulated arc therapy (IMAT), doses to organs at risk could be successfully reduced, limiting the treatment related toxicities. The purpose of our study was to prospectively evaluate the tolerance and acute toxicity in patients of locally advanced cervical cancer undergoing prophylactic extended field paraaortic irradiation by IMAT, with concurrent cisplatin. Material and Methods Patients of FIGO stage IIB-IIIB cervical cancer with FDG avid pelvic lymph nodes,were prospectively accrued between 2014 and 2016. All patients received 45 Gy in 5 weeks to pelvic and paraaortic target volumes, with simultaneous integrated boost (SIB) of 55 Gy in 5 weeks to gross nodal disease by IMAT (RapidarcTM), with weekly concurrent cisplatin of 40 mg/m2, followed by intracavitary brachytherapy. Acute toxicity was monitored twice a week, using CTCAE v 4.03 for gastrointestinal (GI) and genitourinary (GU) toxicity, and RTOG criteria for hematological toxicity. Treatment interruptions were taken as a surrogate for tolerance. Descriptive statistics were used to evaluate acute toxicities; multivariate analysis was used to correlate the toxicities with doses to organs at risk. Results Out of the 15 patients recruited, treatment interruptions due to acute toxicity were observed in none. No grade 3 or 4 acute toxicity was reported in GI, GU or hematological domains. Among GI toxicities, vomiting and diarrhea of ≥ grade 2 were observed in 13.3%, while nausea, anorexia and dyspepsia of ≥ grade 2 were observed in 6%. Grade 1 proctitis was reported in 26%, while none had ≥ grade 2 proctitis. Only 6% of patients experienced grade 1 GU toxicity in the form of increased frequency and cystitis, while none had ≥ grade 2 toxicity. Hematological toxicity in the form of ≥ grade 2 anemia was observed in 46%, while 13.3% of patients had ≥ grade 2 leucopenia and 6% had ≥ grade 2 thrombocytopenia. On multivariate analysis, significant correlation was observed between volume of bowel bag receiving 45 Gy (median, 142 cc) and ≥ grade 2 vomiting (p=0.003). Other dosimetric correlates of toxicity were statistically insignificant. Conclusion Extended field prophylactic para-aortic irradiation with concurrent cisplatin is well tolerated in patients of locally advanced cervical cancer with FDG avid pelvic lymphnodes, treated with IMAT. While none of our patients experienced grade 3 or grade 4 toxicities in GI, GU or hematological domains, proportion of ≥ grade 2 toxicities was within acceptable levels. EP-1303 Clinical outcomes of patients with advanced cervical cancer and percutaneous nephrostomy : An audit R. Salunkhe1, S. Chopra1, S. Kulkarni2, R. Engineer1, U. Mahantshetty1, N. Shetty2, J. Ghosh3, S. Gupta3, S.K. Shrivastava1 1 Tata Memorial Hospital, Radiation Oncology, Mumbai, India 2 Tata Memorial Hospital, Interventional Radiology, Mumbai, India
S699 ESTRO 36 _______________________________________________________________________________________________
3
Tata Memorial Hospital, Medical Oncology, Mumbai, India Purpose or Objective To determine outcomes of patients with locally advanced cervical cancer who presented with deranged renal functions necessitating urinary diversion with Percutaneous Nephrostomy (PCN) before and during course of pelvic radiation Material and Methods The retrospective audit was approved by institutional review board. The hospital database from January 2010June 2015 was reviewed to identify patients with locally advanced cervical cancer and deranged serum creatinine at baseline. Patients wherein PCN was advised at baseline or during treatment were selected for this audit. Pretreatment patient, tumour and treatment related factors that impacted choice of treatment and overall survival in patients undergoing PCN were analysed using univariate and multivariate analysis Results Over a 5 year study period, 128 patients with primary or recurrent cervical cancer underwent PCN. Of these 56 (44%) underwent PCN before and during treatment and 60 patients (44%) received PCN after completion of primary treatment within the setting of local or distant recurrence that necessitated systemic chemotherapy. Overall 12 (9%) patients did not receive any treatment after PCN due to anticipated poor tolerance. Median serum creatinine before and after a week of PCN was 3.8mg/dl (0.4-7.4 ) and 1.6 mg/dl ( 0.6-1.7 ). Median hospital stay was 13 days(4-67). Overall 62.5% patients developed procedure related urinary infection following PCN and 8% patients died secondary to infective complications. Of the 56 patients that received PCN before treatment, 54 received either radical (n=31) or palliative radiation (n=23). Of those planned for radical radiation, 34 were stage III, 15 were Stage IV with median tumour size of 4.5 cms. Only 16/54 patients could complete planned concurrent chemoradiation (29%). Median survival for the cohort undergoing PCN prior to treatment was 205 days (7-369) For 16 patients that completed radical chemoradiation the median survival was 254 days (107380) and 18/54 for those receiving palliative radiation was 146 days (41 - 146). On univariate analysis restricted to cohort of patients receiving radiation Karnofsky performance score <70 at time of PCN (p=0.005), Serum creatinine >3mg/dl (p=0.004), post procedure infection (p=0.002) were factors for poor outcomes of procedure. Conclusion Conclusion - There is significant fall in serum creatinine and improvement in renal function occurs after percutaneous nephrostomy. Yet the median survival was dismal and patients had considerable procedure related morbidity further adding to the duration of hospital stay. Careful selection of patients to undergo percutaneous nephrostomy is important for the success of the procedure EP-1304 A moderate ipofractionation schedule with IMRT in preoperative locally advanced cervical cancer R. Autorino1, M. Campitelli1, A. Martino1, A. Nardangeli1, G. Mattiucci1, V. Frascino1, D. Smaniotto1, A. Valentini2, G. Ferrandina3, M. Gambacorta1 1 Polyclinic University A. Gemelli- Catholic University, Institute of Radiotherapy, Rome, Italy 2 Polyclinic University A. Gemelli- Catholic University, Institute of Radiology, Rome, Italy 3 Polyclinic University A. Gemelli- Catholic University, Institute of Oncological Gynecology, Rome, Italy Purpose or Objective To analyze the efficacy and tolerability of intensity modulated radiation therapy (IMRT) simultaneous
integrated boost (SIB) associated to cisplatin based chemotherapy. in preoperative setting of patients with locally advanced cervical cancer Material and Methods From September 2014 to December 2015, we analyzed patients with locally advanced cervical cancer undergone to neoadjuvant intensity-modulated extended-field chemoradiation plus simultaneous integrated boost. A radiation dose of 39.6 Gy, 1.8 Gy/fraction, was delivered to the pelvis plus a radiation dose to the primary tumor delivered with SIB-IMRT strategy for a total of 50.6 Gy, 2.3 Gy/fraction in 25 fractions. Cisplatin based chemotherapy was delivered associated to radiotherapy. Radical hysterectomy plus pelvic with or without aortic lymphadenectomy was performed within 6 to 8 weeks from CRT. Statistical analysis was performed using Systat program. Results 29 patients (median age: 52 years; The International Federation of Gynecology and Obstetrics (FIGO) stage IB2: 1, IIB: 19, IIIA: 1; IIIB: 5; IVA: 3) were analyzed. The treatment was well tolerated with a good compliance: no patients had grade 3/4 gastrointestinal or genitourinary toxicity; grade 3 leukopenia and neutropenia were reported in only 1 case (stage FIGO IVA) without interruption of the treatment. pCR was documented in 15 cases (51%) and 4 patients (13%) had a microscopic residual disease (persistent tumor foci of 3 mm maximum dimension). At median follow-up of 12.5 months (range: 7-19 months), the 1-year local control was 95%, whereas the 1-year disease-free and overall survival rates were 95% and 100%, respectively. Conclusion The treatment was globally well tolerated with a good compliance. Results in terms of efficacy were comparable with literature data. Local control and overall survival will be further evaluated with a longer follow-up. EP-1305 Hemoglobin monitoring in Endometrial Carcinoma: how preoperative anemia impacts overall survival. K. Holub1, A. Biete1 1 Hospital Clínic i Universitari de Barcelona, Radiation Oncology Dpt., Barcelona, Spain Purpose or Objective To investigate the hematological parameters for anemia in relation to survival in endometrial carcinoma (EC) and to audit hemoglobin (Hb) monitoring before, during and after radiotherapy. Material and Methods We retrospectively evaluated 233 patients (p) out of a total cohort of 248p diagnosed with EC and treated with radiotherapy (RDT) in our center between January 2011 and December 2015. We analyzed the presence of anemia defined as Hb<12g/dL in four specific intervals: pretreatment (Hb), before RDT(Hb2), during (Hb3) y after RDT (Hb4). We estimated how many patients with basal Hb<12g/dL were monitored for anemia afterwards and if pretreatment Hb level has prognostic value for Overall Survival (OS). Statistics: Ch2, Kaplan-Meier test, T-test. Results Age at diagnosis (years): mean 64.9 (range 36-90). All patients underwent surgery before RDT, with pelvic lymphadenectomy in 187p (80.3%). Histology: endometrioid 172p(73.8%), non-endometrioid 61p(26.2%). FIGO stage (2009): IA-60p (27.8%), IB-92p(39.5%), II32p(13.7%), IIIA-9p(3.9%), IIIB-0, IIIC1-20(8.6%), IIIC28(3.4%), IVA-9(3.9%), IVB-3(1.3%). Grade: I-50p(21.5%), II91p(39%), III-88p(37.8%). Majority of patients was treated with combination of EBRT+BT (mean dose 41.2 Gy, range 5-75). Mean follow-up (months): mean 32. Progression was observed in 40p (17.2%): only 1p developed pelvic node
Conclusion Interference of the three different treatment modalities makes it very difficult to unravel dose-effect relations for this patient group. Internal motion of the organs could have induced mismatches between planned and irradiated EBRT dose. Despite interplay effects of Cisplatin and IGABT, we found some trends i.e. correlation of early weight loss with body V43Gy, severity of vomiting and diarrhea. Consequently, rescanning for the ART patient group is now rescheduled to week 4, to adapt EBRT to reduced body volume if necessary. For GU toxicity, we recommend the combination of daily bladder volume during EBRT and IGABT to be assessed with non-rigid analyses in a larger patient group. EP-1302 Acute toxicity of prophylactic para-aortic chemoradiation for cervical cancer treated in IMAT era N. Ballari1, B. Rai1, R. Miriyala1, A. Bahl1, B.R. Mittal2, S. Ghoshal1 1 Post Graduate Institute of Medical Education and Research, Radiotherapy and Oncology, Chandigarh, India 2 Post Graduate Institute of Medical Education and Research, Nuclear Medicine, Chandigarh, India
Purpose or Objective Prophylactic paraaortic irradiation is being increasingly advocated for patients of locally advanced cervical cancer. Up to 25% of patients with FDG avid pelvic lymph nodes harbor micro-metastases in paraaortic lymph nodes, corroborating the postulated benefit of prophylactic paraaortic irradiation. However, acute toxicity was a major limiting factor when 2-dimensional extended field radiotherapy planning was used with concurrent cisplatin. With the use of intensity modulated radiotherapy (IMRT) in the form of intensity modulated arc therapy (IMAT), doses to organs at risk could be successfully reduced, limiting the treatment related toxicities. The purpose of our study was to prospectively evaluate the tolerance and acute toxicity in patients of locally advanced cervical cancer undergoing prophylactic extended field paraaortic irradiation by IMAT, with concurrent cisplatin. Material and Methods Patients of FIGO stage IIB-IIIB cervical cancer with FDG avid pelvic lymph nodes,were prospectively accrued between 2014 and 2016. All patients received 45 Gy in 5 weeks to pelvic and paraaortic target volumes, with simultaneous integrated boost (SIB) of 55 Gy in 5 weeks to gross nodal disease by IMAT (RapidarcTM), with weekly concurrent cisplatin of 40 mg/m2, followed by intracavitary brachytherapy. Acute toxicity was monitored twice a week, using CTCAE v 4.03 for gastrointestinal (GI) and genitourinary (GU) toxicity, and RTOG criteria for hematological toxicity. Treatment interruptions were taken as a surrogate for tolerance. Descriptive statistics were used to evaluate acute toxicities; multivariate analysis was used to correlate the toxicities with doses to organs at risk. Results Out of the 15 patients recruited, treatment interruptions due to acute toxicity were observed in none. No grade 3 or 4 acute toxicity was reported in GI, GU or hematological domains. Among GI toxicities, vomiting and diarrhea of ≥ grade 2 were observed in 13.3%, while nausea, anorexia and dyspepsia of ≥ grade 2 were observed in 6%. Grade 1 proctitis was reported in 26%, while none had ≥ grade 2 proctitis. Only 6% of patients experienced grade 1 GU toxicity in the form of increased frequency and cystitis, while none had ≥ grade 2 toxicity. Hematological toxicity in the form of ≥ grade 2 anemia was observed in 46%, while 13.3% of patients had ≥ grade 2 leucopenia and 6% had ≥ grade 2 thrombocytopenia. On multivariate analysis, significant correlation was observed between volume of bowel bag receiving 45 Gy (median, 142 cc) and ≥ grade 2 vomiting (p=0.003). Other dosimetric correlates of toxicity were statistically insignificant. Conclusion Extended field prophylactic para-aortic irradiation with concurrent cisplatin is well tolerated in patients of locally advanced cervical cancer with FDG avid pelvic lymphnodes, treated with IMAT. While none of our patients experienced grade 3 or grade 4 toxicities in GI, GU or hematological domains, proportion of ≥ grade 2 toxicities was within acceptable levels. EP-1303 Clinical outcomes of patients with advanced cervical cancer and percutaneous nephrostomy : An audit R. Salunkhe1, S. Chopra1, S. Kulkarni2, R. Engineer1, U. Mahantshetty1, N. Shetty2, J. Ghosh3, S. Gupta3, S.K. Shrivastava1 1 Tata Memorial Hospital, Radiation Oncology, Mumbai, India 2 Tata Memorial Hospital, Interventional Radiology, Mumbai, India
S699 ESTRO 36 _______________________________________________________________________________________________
3
Tata Memorial Hospital, Medical Oncology, Mumbai, India Purpose or Objective To determine outcomes of patients with locally advanced cervical cancer who presented with deranged renal functions necessitating urinary diversion with Percutaneous Nephrostomy (PCN) before and during course of pelvic radiation Material and Methods The retrospective audit was approved by institutional review board. The hospital database from January 2010June 2015 was reviewed to identify patients with locally advanced cervical cancer and deranged serum creatinine at baseline. Patients wherein PCN was advised at baseline or during treatment were selected for this audit. Pretreatment patient, tumour and treatment related factors that impacted choice of treatment and overall survival in patients undergoing PCN were analysed using univariate and multivariate analysis Results Over a 5 year study period, 128 patients with primary or recurrent cervical cancer underwent PCN. Of these 56 (44%) underwent PCN before and during treatment and 60 patients (44%) received PCN after completion of primary treatment within the setting of local or distant recurrence that necessitated systemic chemotherapy. Overall 12 (9%) patients did not receive any treatment after PCN due to anticipated poor tolerance. Median serum creatinine before and after a week of PCN was 3.8mg/dl (0.4-7.4 ) and 1.6 mg/dl ( 0.6-1.7 ). Median hospital stay was 13 days(4-67). Overall 62.5% patients developed procedure related urinary infection following PCN and 8% patients died secondary to infective complications. Of the 56 patients that received PCN before treatment, 54 received either radical (n=31) or palliative radiation (n=23). Of those planned for radical radiation, 34 were stage III, 15 were Stage IV with median tumour size of 4.5 cms. Only 16/54 patients could complete planned concurrent chemoradiation (29%). Median survival for the cohort undergoing PCN prior to treatment was 205 days (7-369) For 16 patients that completed radical chemoradiation the median survival was 254 days (107380) and 18/54 for those receiving palliative radiation was 146 days (41 - 146). On univariate analysis restricted to cohort of patients receiving radiation Karnofsky performance score <70 at time of PCN (p=0.005), Serum creatinine >3mg/dl (p=0.004), post procedure infection (p=0.002) were factors for poor outcomes of procedure. Conclusion Conclusion - There is significant fall in serum creatinine and improvement in renal function occurs after percutaneous nephrostomy. Yet the median survival was dismal and patients had considerable procedure related morbidity further adding to the duration of hospital stay. Careful selection of patients to undergo percutaneous nephrostomy is important for the success of the procedure EP-1304 A moderate ipofractionation schedule with IMRT in preoperative locally advanced cervical cancer R. Autorino1, M. Campitelli1, A. Martino1, A. Nardangeli1, G. Mattiucci1, V. Frascino1, D. Smaniotto1, A. Valentini2, G. Ferrandina3, M. Gambacorta1 1 Polyclinic University A. Gemelli- Catholic University, Institute of Radiotherapy, Rome, Italy 2 Polyclinic University A. Gemelli- Catholic University, Institute of Radiology, Rome, Italy 3 Polyclinic University A. Gemelli- Catholic University, Institute of Oncological Gynecology, Rome, Italy Purpose or Objective To analyze the efficacy and tolerability of intensity modulated radiation therapy (IMRT) simultaneous
integrated boost (SIB) associated to cisplatin based chemotherapy. in preoperative setting of patients with locally advanced cervical cancer Material and Methods From September 2014 to December 2015, we analyzed patients with locally advanced cervical cancer undergone to neoadjuvant intensity-modulated extended-field chemoradiation plus simultaneous integrated boost. A radiation dose of 39.6 Gy, 1.8 Gy/fraction, was delivered to the pelvis plus a radiation dose to the primary tumor delivered with SIB-IMRT strategy for a total of 50.6 Gy, 2.3 Gy/fraction in 25 fractions. Cisplatin based chemotherapy was delivered associated to radiotherapy. Radical hysterectomy plus pelvic with or without aortic lymphadenectomy was performed within 6 to 8 weeks from CRT. Statistical analysis was performed using Systat program. Results 29 patients (median age: 52 years; The International Federation of Gynecology and Obstetrics (FIGO) stage IB2: 1, IIB: 19, IIIA: 1; IIIB: 5; IVA: 3) were analyzed. The treatment was well tolerated with a good compliance: no patients had grade 3/4 gastrointestinal or genitourinary toxicity; grade 3 leukopenia and neutropenia were reported in only 1 case (stage FIGO IVA) without interruption of the treatment. pCR was documented in 15 cases (51%) and 4 patients (13%) had a microscopic residual disease (persistent tumor foci of 3 mm maximum dimension). At median follow-up of 12.5 months (range: 7-19 months), the 1-year local control was 95%, whereas the 1-year disease-free and overall survival rates were 95% and 100%, respectively. Conclusion The treatment was globally well tolerated with a good compliance. Results in terms of efficacy were comparable with literature data. Local control and overall survival will be further evaluated with a longer follow-up. EP-1305 Hemoglobin monitoring in Endometrial Carcinoma: how preoperative anemia impacts overall survival. K. Holub1, A. Biete1 1 Hospital Clínic i Universitari de Barcelona, Radiation Oncology Dpt., Barcelona, Spain Purpose or Objective To investigate the hematological parameters for anemia in relation to survival in endometrial carcinoma (EC) and to audit hemoglobin (Hb) monitoring before, during and after radiotherapy. Material and Methods We retrospectively evaluated 233 patients (p) out of a total cohort of 248p diagnosed with EC and treated with radiotherapy (RDT) in our center between January 2011 and December 2015. We analyzed the presence of anemia defined as Hb<12g/dL in four specific intervals: pretreatment (Hb), before RDT(Hb2), during (Hb3) y after RDT (Hb4). We estimated how many patients with basal Hb<12g/dL were monitored for anemia afterwards and if pretreatment Hb level has prognostic value for Overall Survival (OS). Statistics: Ch2, Kaplan-Meier test, T-test. Results Age at diagnosis (years): mean 64.9 (range 36-90). All patients underwent surgery before RDT, with pelvic lymphadenectomy in 187p (80.3%). Histology: endometrioid 172p(73.8%), non-endometrioid 61p(26.2%). FIGO stage (2009): IA-60p (27.8%), IB-92p(39.5%), II32p(13.7%), IIIA-9p(3.9%), IIIB-0, IIIC1-20(8.6%), IIIC28(3.4%), IVA-9(3.9%), IVB-3(1.3%). Grade: I-50p(21.5%), II91p(39%), III-88p(37.8%). Majority of patients was treated with combination of EBRT+BT (mean dose 41.2 Gy, range 5-75). Mean follow-up (months): mean 32. Progression was observed in 40p (17.2%): only 1p developed pelvic node