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Hemangiopericytoma,- the role of radiation therapy
Radiation
212 ranges,
dual
registered Regarding all other
energy
plans
Oncology,
continued
to
Biology, demonstrate
a 15% advantage and TOP a 21% target volume coverage, a 12% deficeit treatment plans; the difficulty primarily
October
Physics further
advantage within the
normal
in 60
1989, Volume tissue
sparing;
normal tissue sparing Gy isodose region was
17, Supplement
1
to POP, IPSI high dose ranges. ARC as compared to
as
compared
within
the
noted for arose due to anatomical constraints with the eye. No difference was otherwise detected in target volume coverage with the outlined optimized treatment plans. Based upon imposed anatomic constraints by critical structures, inadequate coverage of tumor volume at the prescribed dose, excessive coverage of normal tissue volumes in the high dose range and relative difficulty in daily treatment setup, rotational therapy is considered inferior to dual energy photon beam irradiation for lateralized intracranial lesions. Furthermore, dual energy photon beam therapy reduces integral dose while achieving excellent target volume coverage when compared to conventional parallel opposed 6 MV photon irradiation. For lateralized intracranial malignancies, treatment plans utilizing dual energy photon irradiation provides optimal target volume coverage, minimizes integral dose, and is considered superior to more conventional treatment plans.
1008 RESULTS OP RADIOTHERAPEUTIC
NANAGEHENT OF PRIMARY CARCINOMA OP TEE VAGINA.
S.
Reddy,
Reddy,’
V.S.
Saxena,I
S.
3 N.S.
Rush-Presbyterian-St. Luke's Medical Albany Nedical College, Albany, NY3
Primary frequency.
carcinoma of Thus experience
the in
Lee,’
Center,
E.L.
Yordan,'
Chicago,
vagina is the least the management of
J.E. Graham,1
IL;l Lutheran
common among these patients
R
Phillips,*
General
Eospital,
the gynecologic has been limited.
malignancies,
and Park
P.R. Hendrickson Ridge,
ranking
1
IL;* and
fifth
in
Forty-five previously untreated patients (pts.) with primary carcinoma of the vagina were treated with radiotherapy from 1965 through 1985. All pts. were staged according to the FIG0 system. One pt. was curative Treatment consisted classified as Stage 0, 15 as Stage I, 22 as Stage II, 6 as Stage III, and 1 as Stage IV. Stage I pts. received intracavitary/interstitial radiation of intracavitary radiation alone in Stage 0 pts. with higher Stage disease than above realone or in combination with external pelvic radiation. All pts. When treated with an implant only the ceived a combination of external radiation and an implant when feasible. was between 65-70Gy. External radiation consisted of delivering a dose of 45-50 Gy total tumor dose delivered over a period of 4 l/2-5 weeks to the whole pelvis to treat the regional lymph nodes. An additional dose of 20-25Gy was delivered to the site of original involvement using an implant when feasible. If not technically the patient was treated with additional external radiation to a total dose of feasible as in advanced stages, 65-70Gy by a shrinking field technique. The absolute 2-year except one were followed either until death or for a minimum of 2 years. All pts. survival rates were 100% for Stage 0, 87% for Stage I, and 77% for Stage II pts. None of the pts. with Stage all except one did so within 16 months after diagnosis. III or IV disease survived. Of the pts. who failed, Pelvic failure as the first site of failure occurred in 86% of the pts. who failed. Distant failure as a Complications as a consequence to therapy occurred in 18% of the component occurred in 20% of all failures. pts. Vaginal necrosis that healed with conservative treatment was seen Two were of Grade I severity, 1 was of Grade rectal complications. curative radiotherapy is an effective method of treatment, severity. Thus, with early stage primary carcinoma of the vagina.
in II,
4
pts. and the other 4 pts. and the other was of Grade with acceptable morbidity, in
1009 HEMANGIOPERICYTOMAvJ. Staples, The
M.B.,
University
of
THE ROLE OF RADIATION
B.S., D.H.R.T., Iowa
College
THERAPY
R. A. Robinson,
of Medicine,
M.D.,
Division
Ph.D.*,
of Radiation
B-Chen
Wen,
Oncology,
M.D., D. H. HIJSS~~, M.D. *
Division
of Pathology
have relatively limited Hemangiopericytomas (HP) are rare tumors, and even large institutions experience in this disease. Between 1955 and 1987, 15 patients with HP were seen at the University of Iowa Hospitals and Clinics. This clinico-pathological review was undertaken to 1) evaluate the respective roles of radiotherapy and chemotherapy in management of this disease, 2) compare the initial treatment with surgery alone to treatment with surgery and postoperative radiotherapy, and 3) assess the value of mitotic activity as a nredictor of biologic behavior in HP's. The mean follow-up time was 10.2 years. Ten oatients received radiotherapy at some stage of their management. Of the total groun of 15 patients, 12 had no evidence of metastasis at presentation and were Three patients presented with metastases, and 5 developed them therefore potentially curable. Uncontrolled local disease preceded metastasis in half the patients who eventually subsequently. surgery alone - 7 patients, surgery and radiotherapy - 4 Initial treatments were: metastasized. Only 1 of the 7 patients treated initially with surgery patients, surgery and chemotherapy - 1 patient. although 2 additional patients were successfully salvaged alone has remained continually free of disease, all 4 patients treated initially with surgery and postoperative with radiation therapy. In contrast,
had III pts.
Proceedings
of the 31st Annual
ASTRO
213
Meeting
radiotherapy were alive with no evidence of disease, despite the fact that 3 of these patients had gross Irradiation also proved effective in palliation of metastases residual tumor at the time of irradiation. Local tumor control was achieved in all patients receiving >55 Gy. The single patient to bone and lung. treated initially with surgery and chemotherapy was alive with both local and metastatic disease at the time of analysis. received chemotherapy sometime during the course of their Forty percent (6/15) of the patients No complete or agents were used in 17 different regimens. management. In all, 14 chemotherapeutic partial responses were documented, although one patient exhibited transient stabilization of disease with Cyclophosphamide and Vincristine. Metastases occurred in 71% of Mitotic activity was not an accurate predictor of biologic behavior. tumors exhibiting low mitotic activity (<4 mitoses/lO HPF), and in only 28% of those with high mitotic Two tumors exhibited markedly heterogenous mitotic activity; assessment by (>4 mitoses/HPF). activity limited biopsy is therefore discouraged. The results demonstrate that radiation therapy is effective treatment for hemangiopericytomas and local recurrence after surgery alone being extremely should be an integral part of initial treatment, common. Currently available chemotherapy appears to have very limited effectiveness.
1010 PROGNOSTIC VARIABLES FOR COMPLETE RESPONSE IN CLINICAL HYPERTHERMIA L. TUPCHO?!G, M.D.,D.PHIL.,J.E. MCFARLANE RTT, F.W. WATERMAN PH.D, R.E. NERLINGER DEPARTMENT
OF RADIATION
ONCOLOGY
AND NUCLEAR
MEDICINE
THOMAS
JEFFERSON
UNIVERSITY
B.S.,D.B.LEFPE?, HOSPITAL,
PH.D.
Pt!IL*nELPHIA, PA
The identification of major prognostic factors and the establishment of thermometric criteria are vitallv Usina uni-and nulti-variate important in randomized studies evaluating the results of clinical hyperthermia. analyses, we have reviewed 79 consecutive courses of treatment for recurrent carcinoma of the breast in an attempt to identify specific thermometric parameters and other factors that correlate best with resoonse to treatment. Treatment was delivered in the period Jan, 1986 thru Dee, 1988 with external applicator 915 MHz microwave ;;;T;;Ferrnia to the supraclavicular fossa (n=lZ, 15.6%), and chest wall (n=38, 49.4%). Median age was 64 vrs. . Some patients were treated with a patchwork technique to encompass extensive chest wall disease (n=33, 41.8%). 'All had received extensive previous treatment including surgerv (88X), chemotheraoy (86") and radiation therapy (75%). Median tumor volume (TV) was 53 cc (0.5-720). Radiation therapy (RT) was to an Patients were averag2 dose of 4000 cGy (range 2000-7200) given in 10 fractions (8-40) over 34 days (14-94). treated either once (n=41, 65%) or twice a week (n=27, 34%) for l-10 treatments with Dilaudid premeditation in The median number of temperature 35% (n=28). An average of 2 fields were treated for each patient (l-6). Thermometry data included aggregated cumulative maximal catheters inserted was 4 for each field (range l-9). (MAXCM) and minimal (FIINCM) tumor dose (T43 degree equivalent) for the whole course of treatment: the median value of the maximum (MAXSTY) and the minimal (MINSTY) temperatures at steady state for each treatment in each catheter, the maximum value of the minimum (MIN) tumor temperatures recorded in each treatment, the maximum surface temperature recorded in any probe (MAXS) and the absolute maximum temperature in an,y catheter (MAX). The complete and partial response rates were 50% and 4~[ at median follow-up 4.6 months (O-24). Median Of those recurring, the disease-free survival was 10.5 months with 67% remaining free of local recurrence. The most important temperature variables were MINSTY (o=n.OnOl), MIN (o=n.r)2) and survival was 2-15.7 mo. MAXSTY (p=O.O5). Other important prognostic variables were RT (p=O.O3) and TV (p=n.O05). Resoonse was not correlated with the number of fields treated, premeditation, number of catheters inserted, number of heat In multi-variate analysis, fractions per week, total number of heat fractions or the radiation fraction size. MINSTY was the most important predictor of response ahead of TV and RT. The comolication rate was 25%(thermal blister), 25% (ulceration) and 10% (chronic fibrosis). This correlated in multivariate analvsis with TV (r=I). 82; p= 0. OOl), treatment of the supraclavicular fossa (r=r).73; p=O.OOOl), response to treatment (n=q.nl) and Neither MAXCM. MAXS or MAX correlated with the comnlication rate. The studv emohasizes the fraction size. importance of treating the whole tumor and of deliver-in? adeouate heat to all areas in at least one heat session. Cumulative minimal and maximal thermal dos e was of little utility in oredictinq resonnse.
212 ranges,
dual
registered Regarding all other
energy
plans
Oncology,
continued
to
Biology, demonstrate
a 15% advantage and TOP a 21% target volume coverage, a 12% deficeit treatment plans; the difficulty primarily
October
Physics further
advantage within the
normal
in 60
1989, Volume tissue
sparing;
normal tissue sparing Gy isodose region was
17, Supplement
1
to POP, IPSI high dose ranges. ARC as compared to
as
compared
within
the
noted for arose due to anatomical constraints with the eye. No difference was otherwise detected in target volume coverage with the outlined optimized treatment plans. Based upon imposed anatomic constraints by critical structures, inadequate coverage of tumor volume at the prescribed dose, excessive coverage of normal tissue volumes in the high dose range and relative difficulty in daily treatment setup, rotational therapy is considered inferior to dual energy photon beam irradiation for lateralized intracranial lesions. Furthermore, dual energy photon beam therapy reduces integral dose while achieving excellent target volume coverage when compared to conventional parallel opposed 6 MV photon irradiation. For lateralized intracranial malignancies, treatment plans utilizing dual energy photon irradiation provides optimal target volume coverage, minimizes integral dose, and is considered superior to more conventional treatment plans.
1008 RESULTS OP RADIOTHERAPEUTIC
NANAGEHENT OF PRIMARY CARCINOMA OP TEE VAGINA.
S.
Reddy,
Reddy,’
V.S.
Saxena,I
S.
3 N.S.
Rush-Presbyterian-St. Luke's Medical Albany Nedical College, Albany, NY3
Primary frequency.
carcinoma of Thus experience
the in
Lee,’
Center,
E.L.
Yordan,'
Chicago,
vagina is the least the management of
J.E. Graham,1
IL;l Lutheran
common among these patients
R
Phillips,*
General
Eospital,
the gynecologic has been limited.
malignancies,
and Park
P.R. Hendrickson Ridge,
ranking
1
IL;* and
fifth
in
Forty-five previously untreated patients (pts.) with primary carcinoma of the vagina were treated with radiotherapy from 1965 through 1985. All pts. were staged according to the FIG0 system. One pt. was curative Treatment consisted classified as Stage 0, 15 as Stage I, 22 as Stage II, 6 as Stage III, and 1 as Stage IV. Stage I pts. received intracavitary/interstitial radiation of intracavitary radiation alone in Stage 0 pts. with higher Stage disease than above realone or in combination with external pelvic radiation. All pts. When treated with an implant only the ceived a combination of external radiation and an implant when feasible. was between 65-70Gy. External radiation consisted of delivering a dose of 45-50 Gy total tumor dose delivered over a period of 4 l/2-5 weeks to the whole pelvis to treat the regional lymph nodes. An additional dose of 20-25Gy was delivered to the site of original involvement using an implant when feasible. If not technically the patient was treated with additional external radiation to a total dose of feasible as in advanced stages, 65-70Gy by a shrinking field technique. The absolute 2-year except one were followed either until death or for a minimum of 2 years. All pts. survival rates were 100% for Stage 0, 87% for Stage I, and 77% for Stage II pts. None of the pts. with Stage all except one did so within 16 months after diagnosis. III or IV disease survived. Of the pts. who failed, Pelvic failure as the first site of failure occurred in 86% of the pts. who failed. Distant failure as a Complications as a consequence to therapy occurred in 18% of the component occurred in 20% of all failures. pts. Vaginal necrosis that healed with conservative treatment was seen Two were of Grade I severity, 1 was of Grade rectal complications. curative radiotherapy is an effective method of treatment, severity. Thus, with early stage primary carcinoma of the vagina.
in II,
4
pts. and the other 4 pts. and the other was of Grade with acceptable morbidity, in
1009 HEMANGIOPERICYTOMAvJ. Staples, The
M.B.,
University
of
THE ROLE OF RADIATION
B.S., D.H.R.T., Iowa
College
THERAPY
R. A. Robinson,
of Medicine,
M.D.,
Division
Ph.D.*,
of Radiation
B-Chen
Wen,
Oncology,
M.D., D. H. HIJSS~~, M.D. *
Division
of Pathology
have relatively limited Hemangiopericytomas (HP) are rare tumors, and even large institutions experience in this disease. Between 1955 and 1987, 15 patients with HP were seen at the University of Iowa Hospitals and Clinics. This clinico-pathological review was undertaken to 1) evaluate the respective roles of radiotherapy and chemotherapy in management of this disease, 2) compare the initial treatment with surgery alone to treatment with surgery and postoperative radiotherapy, and 3) assess the value of mitotic activity as a nredictor of biologic behavior in HP's. The mean follow-up time was 10.2 years. Ten oatients received radiotherapy at some stage of their management. Of the total groun of 15 patients, 12 had no evidence of metastasis at presentation and were Three patients presented with metastases, and 5 developed them therefore potentially curable. Uncontrolled local disease preceded metastasis in half the patients who eventually subsequently. surgery alone - 7 patients, surgery and radiotherapy - 4 Initial treatments were: metastasized. Only 1 of the 7 patients treated initially with surgery patients, surgery and chemotherapy - 1 patient. although 2 additional patients were successfully salvaged alone has remained continually free of disease, all 4 patients treated initially with surgery and postoperative with radiation therapy. In contrast,
had III pts.
Proceedings
of the 31st Annual
ASTRO
213
Meeting
radiotherapy were alive with no evidence of disease, despite the fact that 3 of these patients had gross Irradiation also proved effective in palliation of metastases residual tumor at the time of irradiation. Local tumor control was achieved in all patients receiving >55 Gy. The single patient to bone and lung. treated initially with surgery and chemotherapy was alive with both local and metastatic disease at the time of analysis. received chemotherapy sometime during the course of their Forty percent (6/15) of the patients No complete or agents were used in 17 different regimens. management. In all, 14 chemotherapeutic partial responses were documented, although one patient exhibited transient stabilization of disease with Cyclophosphamide and Vincristine. Metastases occurred in 71% of Mitotic activity was not an accurate predictor of biologic behavior. tumors exhibiting low mitotic activity (<4 mitoses/lO HPF), and in only 28% of those with high mitotic Two tumors exhibited markedly heterogenous mitotic activity; assessment by (>4 mitoses/HPF). activity limited biopsy is therefore discouraged. The results demonstrate that radiation therapy is effective treatment for hemangiopericytomas and local recurrence after surgery alone being extremely should be an integral part of initial treatment, common. Currently available chemotherapy appears to have very limited effectiveness.
1010 PROGNOSTIC VARIABLES FOR COMPLETE RESPONSE IN CLINICAL HYPERTHERMIA L. TUPCHO?!G, M.D.,D.PHIL.,J.E. MCFARLANE RTT, F.W. WATERMAN PH.D, R.E. NERLINGER DEPARTMENT
OF RADIATION
ONCOLOGY
AND NUCLEAR
MEDICINE
THOMAS
JEFFERSON
UNIVERSITY
B.S.,D.B.LEFPE?, HOSPITAL,
PH.D.
Pt!IL*nELPHIA, PA
The identification of major prognostic factors and the establishment of thermometric criteria are vitallv Usina uni-and nulti-variate important in randomized studies evaluating the results of clinical hyperthermia. analyses, we have reviewed 79 consecutive courses of treatment for recurrent carcinoma of the breast in an attempt to identify specific thermometric parameters and other factors that correlate best with resoonse to treatment. Treatment was delivered in the period Jan, 1986 thru Dee, 1988 with external applicator 915 MHz microwave ;;;T;;Ferrnia to the supraclavicular fossa (n=lZ, 15.6%), and chest wall (n=38, 49.4%). Median age was 64 vrs. . Some patients were treated with a patchwork technique to encompass extensive chest wall disease (n=33, 41.8%). 'All had received extensive previous treatment including surgerv (88X), chemotheraoy (86") and radiation therapy (75%). Median tumor volume (TV) was 53 cc (0.5-720). Radiation therapy (RT) was to an Patients were averag2 dose of 4000 cGy (range 2000-7200) given in 10 fractions (8-40) over 34 days (14-94). treated either once (n=41, 65%) or twice a week (n=27, 34%) for l-10 treatments with Dilaudid premeditation in The median number of temperature 35% (n=28). An average of 2 fields were treated for each patient (l-6). Thermometry data included aggregated cumulative maximal catheters inserted was 4 for each field (range l-9). (MAXCM) and minimal (FIINCM) tumor dose (T43 degree equivalent) for the whole course of treatment: the median value of the maximum (MAXSTY) and the minimal (MINSTY) temperatures at steady state for each treatment in each catheter, the maximum value of the minimum (MIN) tumor temperatures recorded in each treatment, the maximum surface temperature recorded in any probe (MAXS) and the absolute maximum temperature in an,y catheter (MAX). The complete and partial response rates were 50% and 4~[ at median follow-up 4.6 months (O-24). Median Of those recurring, the disease-free survival was 10.5 months with 67% remaining free of local recurrence. The most important temperature variables were MINSTY (o=n.OnOl), MIN (o=n.r)2) and survival was 2-15.7 mo. MAXSTY (p=O.O5). Other important prognostic variables were RT (p=O.O3) and TV (p=n.O05). Resoonse was not correlated with the number of fields treated, premeditation, number of catheters inserted, number of heat In multi-variate analysis, fractions per week, total number of heat fractions or the radiation fraction size. MINSTY was the most important predictor of response ahead of TV and RT. The comolication rate was 25%(thermal blister), 25% (ulceration) and 10% (chronic fibrosis). This correlated in multivariate analvsis with TV (r=I). 82; p= 0. OOl), treatment of the supraclavicular fossa (r=r).73; p=O.OOOl), response to treatment (n=q.nl) and Neither MAXCM. MAXS or MAX correlated with the comnlication rate. The studv emohasizes the fraction size. importance of treating the whole tumor and of deliver-in? adeouate heat to all areas in at least one heat session. Cumulative minimal and maximal thermal dos e was of little utility in oredictinq resonnse.