- Email: [email protected]
Long Term Outcomes from LDR Brachytherapy in Treatment of Oral Tongue Cancer
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Abstracts / Brachytherapy 15 (2016) S21eS204
implanted in lesions was 33.4224.61, the local control rate of target lesions of CR,PR,SD,PD was 27,5,2,1 respectively. ORR591.4%. The median survival time was 44 months after surgery (95% CI:24.364-63.636). The survival rates of one year,two years,three years was 92.23%, 77.73%, 61.69%. The median survival time was 22 months after seeds implantation (95% CI:6.901-37.099), the survival rates of one year, two years, three years was 56.98%, 39.07%, 25.05% respectively. Mild pancreatitis occurred in 3 cases and stomach bleeding occurred in 1 case due to puncture; duodenal ulcers occurred in 1 case because of the complications of 125I Brachytherapy. Conclusions: The CT-guided 125I seeds brachytherapy for extrahepatic lymph node metastasis from hepatocellular carcinoma has a good localcontrol rate, which may benefit the OS of patients.
pre-defined intervals (3, 6, and 12 months for the first year) after the procedure. Results: In 2015, six patients with recurrent or residual cancer (3 anal, 3 rectal) were enrolled on this protocol, and treated at the initial dose level of 15 Gy in 3 fractions. For MRI-based dosimetry, the median target volume was 15.2 cc (range, 5.9-36.3). Median values for the V100 and D90 were 98.7% (93.8-99.9) and 599 cGy (537-655) respectively. The median anorectal D0.2cc (excluding the target volume) was 683.6 cGy (492.6-715.7). Treatment was delivered as planned for 5 patients. One patient was treated with a single-channel Bougie applicator for the third fraction, due to the development of severe circumferential narrowing that prevented insertion of the endorectal applicator. At a median follow up of 6.8 months (6.2-8.7), one patient developed a local recurrence at 4.7 months and underwent an abdominoperineal resection. Three patients developed grade 2 proctitis, and the patient with severe circumferential narrowing experienced grade 2 rectal bleeding. One patient died from a synchronous hepatocellular carcinoma at 7.4 months after HDR brachytherapy. Conclusion: The initial clinical results for endoluminal HDR brachytherapy with concurrent chemotherapy are encouraging. The clinical efficacy and toxicity associated with this treatment will be more clearly defined as the protocol matures.
Figure. Male, 49, HCC, stageC, Multiple retroperitoneal lymph node metastasis, The target lymph nodes CR three years after the implanted with 125I seeds.
PO94 Prospective Evaluation of Endoluminal High Dose Rate Brachytherapy with Concurrent Chemotherapy for Rectal or Anal Cancer Patients: Initial Clinical Results Martin T. King, MD, PhD1, Gil’ad N. Cohen, MS1, Abraham Wu, MD1, Karyn A. Goodman, MD, MS2. 1Memorial Sloan Kettering Cancer Center, New York, NY, USA; 2University of Colorado Cancer Center, Aurora, CO, USA. Purpose: To present initial clinical results of a prospective dose escalation protocol of endoluminal high dose rate (HDR) brachytherapy with concurrent chemotherapy for rectal or anal cancer patients undergoing non-operative management. Materials and Methods: All patients were enrolled on a prospective, institutional review board (IRB)-approved dose escalation protocol evaluating endoluminal HDR brachytherapy with concurrent chemotherapy. Inclusion criteria included histologically confirmed locally residual or recurrent cancer of the rectum or anus as well as prior pelvic external beam radiation therapy. Brachytherapy was delivered with the anorectal (AR-1) applicator (Ancer Medical, Hialeah, FL). This applicator consisted of an inner balloon, which supported 8 channels for the radioactive source, and a compliant outer balloon for optimal deformation against exophytic lesions. The applicator insertion and treatment delivery were performed under general anesthesia in 3 weekly sessions. Magnetic resonance imaging (MRI)-based treatment planning was performed while under general anesthesia during the first session only. Capecitabine (825 mg/m2 BID) was administered from Monday through Friday on the weeks of brachytherapy. Efficacy and toxicity were evaluated by clinical assessment and MRI examinations at
PO95 Long Term Outcomes from LDR Brachytherapy in Treatment of Oral Tongue Cancer Juskaran Chadha, DO1, Kenneth Hu, MD2, Adam Jacobson, MD3, Mark Persky, MD3, Stimson Schantz, MD4, Theresa Tran, MD3, Mark Urken, MD5, Zujun Li, MD6, Bruce Culliney, MD7, Louis Harrison, MD8. 1 Internal Medicine, Mount Sinai West, New York, NY, USA; 2Radiation
Abstracts / Brachytherapy 15 (2016) S21eS204
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3
Oncology, NYU, New York, NY, USA; Otolaryngology, NYU, New York, NY, USA; 4Otolaryngology, New York Ear and Eye Infirmary of Mount Sinai, New York, NY, USA; 5Otolaryngology, Mount Sinai Beth Israel, New York, NY, USA; 6Hematology & Medical Oncology, NYU, New York, NY, USA; 7 Hematology & Medical Oncology, Mount Sinai Beth Israel, New York, NY, USA; 8Radiation Oncology, Moffitt Cancer Cancer, Tampa, FL, USA. Purpose: Brachytherapy (BT) is a useful modality to decrease dose to normal tissue when used in the primary setting and offers the chance for salvage treatment in patients previously irradiated. For oral tongue cancer it can be used as stand-alone treatment or in combination with external beam radiation therapy (EBRT), surgery and/or chemotherapy. We review our 10-year experience with respect to outcomes and late toxicity. Materials and Methods: Between 1/04 and 12/14, 39 patients with oral tongue cancer received Ir-192 LDR BT as part of their treatment course. Patient characteristics were as follows: Median age 53 years (range 20 88); T-stage: 20T1:15T2:1T3:2T4:1multifocal, and N-stage: 26N0; 4N1; 4N2; 5Nx. Thirty one patients had primary (18T1: 10T2: 1 T3 and 2 T4) and 8 had recurrent disease (3T1, 4T2, 1 multifocal). The combination of EBRTþBT was prescribed for 20 patients, and 19 patients received BT alone. Eight patients were treated definitively with either EBRTþBT (n56; T2N0, multifocal primary, T2N2b, T3N0, T4N1, T4N2c) or with BT alone (n52; both T2N0). Thirty-one patients received adjuvant therapy either with EBRTþBT (n514) or with BT alone (n517). Indications for adjuvant EBRTþBT were elective nodal RT (n53), LNþ (n53), PNI (n57) and recurrence (n51). Indications for adjuvant BT alone included close/positive margin (n511), PNI (n52) or both close/positive þ PNI (n54). Among the 17 patients treated with adjuvant BT alone, 13 underwent elective neck node dissection (LND), while 4 did not. The median EBRT dose was 54Gy (30.6- 70Gy), and 1 patient received protons. The median BT dose in the EBRTþBT group was 20 Gy (10 - 27Gy). The median BT dose in the BT alone group was 45 Gy (30-60 Gy). The median number of catheters used was 4 (2 - 12). The catheters were positioned 5mm from the mandible, and oral lead shields were used during brachytherapy. Tracheostomy was performed in the majority of patients and 8 patients also had LND at the time of BT catheter placement. Nine patients in the EBRT þ BT group received systemic therapy. Results: The median follow up is 40.5 mo (7-118 mo). Overall, the 3-yr local control (LC), regional control (RC) and overall survival (OS) is 88%, 75.4%, and 83%, respectively. Among the definitively treated patients, the 3-yr LC, RC and OS is 100%, 85.7%, and 60%, respectively. Among the 14 patients treated with adjuvant EBRTþBT, the 3-yr LC, RC and OS is 91.7%, 78.8% and 100%, respectively. The 17 patients receiving adjuvant BT alone had a 3-yr LC, RC and OS is 82%, 67.3% and 84.6%, respectively. In this subset, patients undergoing LND had better RC compared to no LND (3-yr RC 84% vs 25%, p50.017). Two patients experienced early (!6 mo) grade 3-4 toxicity; 1 osteoradionecrosis and 1 ulcer. The patient with early osteoradionecrosis had prior history of soft palate ca treated with cisplatin þ 70Gy EBRT, and the second primary oral tongue ca in the prior RT field was treated with 36Gy protons þ 27 Gy BT. Three patients experienced late (O6 mo) grade 3-4 toxicity. The patient with delayed osteoradionecrosis received a dose of 50Gy BT alone using 8 catheters. Two patients presented with delayed ulcer in the FOM/tongue. One patient received EBRTþBT using 12 catheters, and the 2nd patient received 60Gy BT alone. Therefore,
suggesting that large volume implants and/or high BT dose may increase the risk of late toxicity. Conclusion: Oral tongue BT can be used to deliver highly individualized and conformal therapy, as definitive or adjuvant treatment delivered either as a boost or stand-alone therapy. High local control rates can be achieved in patients with positive margins with BT alone. LND is important to maintain high levels of regional control particularly in those receiving BT alone.
PO96 Single Institute Experience of High Dose Rate Interstitial Brachytherapy for Head and Neck Malignancies with Curative Intent and Use of Angiocatheters as Carriers of Iridium - 192 Implants Vibhay Pareek, DNB, Junior Resident, Rajendra L. Bhalavat, MD, DMRE Radiation Oncology, Manish Chandra, DNB, Radiation Oncology, Lalitha Nellore, DNB, Radiation Oncology, Pratibha Bauskar, DipRP. Radiation Oncology, Jupiter Hospital, Thane, India. Purpose: To evaluate the treatment outcomes with HDR Interstitial Brachytherapy in Head and Neck Cancers at our Institute with use of Angiocatheters as carrier source of Iridium - 192 wire implants. Study Design and Setting: Retrospective study conducted at Jupiter Hospital, Thane. Material and Methods: 58 Patients with Head and Neck malignancies of varying TNM staging as per AJCC staging criteria were analyzed retrospectively between 2008 and 2015. 42 patients (72.41%) received EBRT with HDR - BRT and 26 patients (27.59%) received BRT alone. 23 patients (39.65%) received concurrent Chemotherapy. The age group ranged from 27 to 81 years (Median age 56 years) with 41 patients (70.69%) males and 17 patients (29.31%) females. HDR BRT was delivered with Iridium - 192 wire implants using plastic bead techniques with varying dose rates. The Biological equivalent doses (BED) were calculated for both BRT and EBRT keeping a/b 5 10 for tumor and a/b 5 3 for normal tissue and subsequently median BED doses were calculated and similarly 2 Gy equivalent dose (EQD2) were calculated and loco-regional control and disease free survival was assessed. Results: After completion of HDR - BRT, Patients were followed up one month later and subsequently every 3 months for first 2 years and thereafter every 6 months with median follow up period of 25 months (Range 2-84 months). The DFS probability at year 1 was 82.76% and 68.05% at year 7. The overall survival probability was 91.37% at year 1 and 85.89% at year 5. The local control rate was 67.27% and the control rates according to the stage of disease and T size classification are mentioned in Table 1. The rate of local recurrence was 8.62%, Regional Recurrence was 1.72%, Loco-Regional Failure was 3.44% and Distant metastases following local or regional failure was 17.23%. The Median BED for a/b 5 10 was 86.775Gy and DFS was 74.07% in patients receiving more than 86.775Gy and DFS was 64.82% in patients receiving less than 86.775Gy and Median BED for a/b 5 3 was 128.76Gy and DFS was 74.07 in patients receiving more than 128.76Gy as compared to 64.82% in patients receiving less than 128.76Gy. The median EQD2 for a/b 5 10 was 71.6Gy and for a/b 5 3 was 75.85Gy. The DFS was 75.86% in patients receiving more than median dose of
Table 1
Local Control Local Recurrence Regional recurrence Loco-regional recurrence Distant metastases with LR/RR
T1
T2
T3
T4
Stage 1
Stage 2
Stage 3
Stage 4
Recurrence
Residual
87.5% 12.5%
76.19% 4.76% 4.76% 4.76% 9.52%
63.63% 9.09% 27.27%
85.71% 14.28% -
85.71% 14.28%
76.47% 5.88% 5.88% 11.76%
88.89% 11.11% -
64.28% 7.14% 7.14% 21.42%
25% 25% 12.5% 37.5%
50% 50%
Abstracts / Brachytherapy 15 (2016) S21eS204
implanted in lesions was 33.4224.61, the local control rate of target lesions of CR,PR,SD,PD was 27,5,2,1 respectively. ORR591.4%. The median survival time was 44 months after surgery (95% CI:24.364-63.636). The survival rates of one year,two years,three years was 92.23%, 77.73%, 61.69%. The median survival time was 22 months after seeds implantation (95% CI:6.901-37.099), the survival rates of one year, two years, three years was 56.98%, 39.07%, 25.05% respectively. Mild pancreatitis occurred in 3 cases and stomach bleeding occurred in 1 case due to puncture; duodenal ulcers occurred in 1 case because of the complications of 125I Brachytherapy. Conclusions: The CT-guided 125I seeds brachytherapy for extrahepatic lymph node metastasis from hepatocellular carcinoma has a good localcontrol rate, which may benefit the OS of patients.
pre-defined intervals (3, 6, and 12 months for the first year) after the procedure. Results: In 2015, six patients with recurrent or residual cancer (3 anal, 3 rectal) were enrolled on this protocol, and treated at the initial dose level of 15 Gy in 3 fractions. For MRI-based dosimetry, the median target volume was 15.2 cc (range, 5.9-36.3). Median values for the V100 and D90 were 98.7% (93.8-99.9) and 599 cGy (537-655) respectively. The median anorectal D0.2cc (excluding the target volume) was 683.6 cGy (492.6-715.7). Treatment was delivered as planned for 5 patients. One patient was treated with a single-channel Bougie applicator for the third fraction, due to the development of severe circumferential narrowing that prevented insertion of the endorectal applicator. At a median follow up of 6.8 months (6.2-8.7), one patient developed a local recurrence at 4.7 months and underwent an abdominoperineal resection. Three patients developed grade 2 proctitis, and the patient with severe circumferential narrowing experienced grade 2 rectal bleeding. One patient died from a synchronous hepatocellular carcinoma at 7.4 months after HDR brachytherapy. Conclusion: The initial clinical results for endoluminal HDR brachytherapy with concurrent chemotherapy are encouraging. The clinical efficacy and toxicity associated with this treatment will be more clearly defined as the protocol matures.
Figure. Male, 49, HCC, stageC, Multiple retroperitoneal lymph node metastasis, The target lymph nodes CR three years after the implanted with 125I seeds.
PO94 Prospective Evaluation of Endoluminal High Dose Rate Brachytherapy with Concurrent Chemotherapy for Rectal or Anal Cancer Patients: Initial Clinical Results Martin T. King, MD, PhD1, Gil’ad N. Cohen, MS1, Abraham Wu, MD1, Karyn A. Goodman, MD, MS2. 1Memorial Sloan Kettering Cancer Center, New York, NY, USA; 2University of Colorado Cancer Center, Aurora, CO, USA. Purpose: To present initial clinical results of a prospective dose escalation protocol of endoluminal high dose rate (HDR) brachytherapy with concurrent chemotherapy for rectal or anal cancer patients undergoing non-operative management. Materials and Methods: All patients were enrolled on a prospective, institutional review board (IRB)-approved dose escalation protocol evaluating endoluminal HDR brachytherapy with concurrent chemotherapy. Inclusion criteria included histologically confirmed locally residual or recurrent cancer of the rectum or anus as well as prior pelvic external beam radiation therapy. Brachytherapy was delivered with the anorectal (AR-1) applicator (Ancer Medical, Hialeah, FL). This applicator consisted of an inner balloon, which supported 8 channels for the radioactive source, and a compliant outer balloon for optimal deformation against exophytic lesions. The applicator insertion and treatment delivery were performed under general anesthesia in 3 weekly sessions. Magnetic resonance imaging (MRI)-based treatment planning was performed while under general anesthesia during the first session only. Capecitabine (825 mg/m2 BID) was administered from Monday through Friday on the weeks of brachytherapy. Efficacy and toxicity were evaluated by clinical assessment and MRI examinations at
PO95 Long Term Outcomes from LDR Brachytherapy in Treatment of Oral Tongue Cancer Juskaran Chadha, DO1, Kenneth Hu, MD2, Adam Jacobson, MD3, Mark Persky, MD3, Stimson Schantz, MD4, Theresa Tran, MD3, Mark Urken, MD5, Zujun Li, MD6, Bruce Culliney, MD7, Louis Harrison, MD8. 1 Internal Medicine, Mount Sinai West, New York, NY, USA; 2Radiation
Abstracts / Brachytherapy 15 (2016) S21eS204
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3
Oncology, NYU, New York, NY, USA; Otolaryngology, NYU, New York, NY, USA; 4Otolaryngology, New York Ear and Eye Infirmary of Mount Sinai, New York, NY, USA; 5Otolaryngology, Mount Sinai Beth Israel, New York, NY, USA; 6Hematology & Medical Oncology, NYU, New York, NY, USA; 7 Hematology & Medical Oncology, Mount Sinai Beth Israel, New York, NY, USA; 8Radiation Oncology, Moffitt Cancer Cancer, Tampa, FL, USA. Purpose: Brachytherapy (BT) is a useful modality to decrease dose to normal tissue when used in the primary setting and offers the chance for salvage treatment in patients previously irradiated. For oral tongue cancer it can be used as stand-alone treatment or in combination with external beam radiation therapy (EBRT), surgery and/or chemotherapy. We review our 10-year experience with respect to outcomes and late toxicity. Materials and Methods: Between 1/04 and 12/14, 39 patients with oral tongue cancer received Ir-192 LDR BT as part of their treatment course. Patient characteristics were as follows: Median age 53 years (range 20 88); T-stage: 20T1:15T2:1T3:2T4:1multifocal, and N-stage: 26N0; 4N1; 4N2; 5Nx. Thirty one patients had primary (18T1: 10T2: 1 T3 and 2 T4) and 8 had recurrent disease (3T1, 4T2, 1 multifocal). The combination of EBRTþBT was prescribed for 20 patients, and 19 patients received BT alone. Eight patients were treated definitively with either EBRTþBT (n56; T2N0, multifocal primary, T2N2b, T3N0, T4N1, T4N2c) or with BT alone (n52; both T2N0). Thirty-one patients received adjuvant therapy either with EBRTþBT (n514) or with BT alone (n517). Indications for adjuvant EBRTþBT were elective nodal RT (n53), LNþ (n53), PNI (n57) and recurrence (n51). Indications for adjuvant BT alone included close/positive margin (n511), PNI (n52) or both close/positive þ PNI (n54). Among the 17 patients treated with adjuvant BT alone, 13 underwent elective neck node dissection (LND), while 4 did not. The median EBRT dose was 54Gy (30.6- 70Gy), and 1 patient received protons. The median BT dose in the EBRTþBT group was 20 Gy (10 - 27Gy). The median BT dose in the BT alone group was 45 Gy (30-60 Gy). The median number of catheters used was 4 (2 - 12). The catheters were positioned 5mm from the mandible, and oral lead shields were used during brachytherapy. Tracheostomy was performed in the majority of patients and 8 patients also had LND at the time of BT catheter placement. Nine patients in the EBRT þ BT group received systemic therapy. Results: The median follow up is 40.5 mo (7-118 mo). Overall, the 3-yr local control (LC), regional control (RC) and overall survival (OS) is 88%, 75.4%, and 83%, respectively. Among the definitively treated patients, the 3-yr LC, RC and OS is 100%, 85.7%, and 60%, respectively. Among the 14 patients treated with adjuvant EBRTþBT, the 3-yr LC, RC and OS is 91.7%, 78.8% and 100%, respectively. The 17 patients receiving adjuvant BT alone had a 3-yr LC, RC and OS is 82%, 67.3% and 84.6%, respectively. In this subset, patients undergoing LND had better RC compared to no LND (3-yr RC 84% vs 25%, p50.017). Two patients experienced early (!6 mo) grade 3-4 toxicity; 1 osteoradionecrosis and 1 ulcer. The patient with early osteoradionecrosis had prior history of soft palate ca treated with cisplatin þ 70Gy EBRT, and the second primary oral tongue ca in the prior RT field was treated with 36Gy protons þ 27 Gy BT. Three patients experienced late (O6 mo) grade 3-4 toxicity. The patient with delayed osteoradionecrosis received a dose of 50Gy BT alone using 8 catheters. Two patients presented with delayed ulcer in the FOM/tongue. One patient received EBRTþBT using 12 catheters, and the 2nd patient received 60Gy BT alone. Therefore,
suggesting that large volume implants and/or high BT dose may increase the risk of late toxicity. Conclusion: Oral tongue BT can be used to deliver highly individualized and conformal therapy, as definitive or adjuvant treatment delivered either as a boost or stand-alone therapy. High local control rates can be achieved in patients with positive margins with BT alone. LND is important to maintain high levels of regional control particularly in those receiving BT alone.
PO96 Single Institute Experience of High Dose Rate Interstitial Brachytherapy for Head and Neck Malignancies with Curative Intent and Use of Angiocatheters as Carriers of Iridium - 192 Implants Vibhay Pareek, DNB, Junior Resident, Rajendra L. Bhalavat, MD, DMRE Radiation Oncology, Manish Chandra, DNB, Radiation Oncology, Lalitha Nellore, DNB, Radiation Oncology, Pratibha Bauskar, DipRP. Radiation Oncology, Jupiter Hospital, Thane, India. Purpose: To evaluate the treatment outcomes with HDR Interstitial Brachytherapy in Head and Neck Cancers at our Institute with use of Angiocatheters as carrier source of Iridium - 192 wire implants. Study Design and Setting: Retrospective study conducted at Jupiter Hospital, Thane. Material and Methods: 58 Patients with Head and Neck malignancies of varying TNM staging as per AJCC staging criteria were analyzed retrospectively between 2008 and 2015. 42 patients (72.41%) received EBRT with HDR - BRT and 26 patients (27.59%) received BRT alone. 23 patients (39.65%) received concurrent Chemotherapy. The age group ranged from 27 to 81 years (Median age 56 years) with 41 patients (70.69%) males and 17 patients (29.31%) females. HDR BRT was delivered with Iridium - 192 wire implants using plastic bead techniques with varying dose rates. The Biological equivalent doses (BED) were calculated for both BRT and EBRT keeping a/b 5 10 for tumor and a/b 5 3 for normal tissue and subsequently median BED doses were calculated and similarly 2 Gy equivalent dose (EQD2) were calculated and loco-regional control and disease free survival was assessed. Results: After completion of HDR - BRT, Patients were followed up one month later and subsequently every 3 months for first 2 years and thereafter every 6 months with median follow up period of 25 months (Range 2-84 months). The DFS probability at year 1 was 82.76% and 68.05% at year 7. The overall survival probability was 91.37% at year 1 and 85.89% at year 5. The local control rate was 67.27% and the control rates according to the stage of disease and T size classification are mentioned in Table 1. The rate of local recurrence was 8.62%, Regional Recurrence was 1.72%, Loco-Regional Failure was 3.44% and Distant metastases following local or regional failure was 17.23%. The Median BED for a/b 5 10 was 86.775Gy and DFS was 74.07% in patients receiving more than 86.775Gy and DFS was 64.82% in patients receiving less than 86.775Gy and Median BED for a/b 5 3 was 128.76Gy and DFS was 74.07 in patients receiving more than 128.76Gy as compared to 64.82% in patients receiving less than 128.76Gy. The median EQD2 for a/b 5 10 was 71.6Gy and for a/b 5 3 was 75.85Gy. The DFS was 75.86% in patients receiving more than median dose of
Table 1
Local Control Local Recurrence Regional recurrence Loco-regional recurrence Distant metastases with LR/RR
T1
T2
T3
T4
Stage 1
Stage 2
Stage 3
Stage 4
Recurrence
Residual
87.5% 12.5%
76.19% 4.76% 4.76% 4.76% 9.52%
63.63% 9.09% 27.27%
85.71% 14.28% -
85.71% 14.28%
76.47% 5.88% 5.88% 11.76%
88.89% 11.11% -
64.28% 7.14% 7.14% 21.42%
25% 25% 12.5% 37.5%
50% 50%