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Obtaining parotid constraints in intensity modulated radiation therapy for head and neck cancers
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Posters total number of 344 lymph nodes were identified in the pathological specimens of these 56 levels for a mean number of 6.1 nodes (SD: 5.1) per level. None of them was found to contain cancer. Conclusions: The dissection of a radiologically negative neck level is not necessary. 183 poster NEOADJUVANT CHEMOTHERAPY AND CONCOMITANT CHEMORADIOTHERAPY WITH ACCELERATED FRACTIONATED SCHEDULE IN ADVANCED CARCINOMA OFTHE HEAD AND NECK. L. Perez Romasanta ~, L. L6pez Louzara2,V. Mu~oz Garz6n 2,J. Casal Rubio 3 IHosPITAL GENERALDE ClUDAD REAL,Radiation Oncology± Ciudad Real,
Spain 2HosPITALDOMEIXOEIRO-INST.GALEGODEMEDIClNATI~CNICA~Radiation Onco/-
ogy, Vigo, Spain, 3HosPm~LDOMEiXOEJRO,Medical Oncology, Vigo, Spain Purpose/Objective: Locoregionally advanced head and neck cancer is a challanging condition to confront with for oncologists. Treatment results with conventional approach (surgery and radiotherapy) are suboptimal. Combined chemo-radiotherapy or accelerated hyperfractionated radiotherapy have been proposed as treatment alternatives. We analyze toxicity, Iocoregional control rates and survival for advanced head and neck cancer, treated with neoadjuvant chemotherapy (CT) and concomitant chemo-radiotherapy with accelerated fractionation schedule. Materials/Methods: In a prospective study, from 1999 to 2004, combined chemo-radiotherapy treatment was used in 68 pts (males 62, mean age 55.4 yrs old). Sites of origin were oropharynx 18 (26.5%), larynx 16 (23.5%), hypopharynx 15 (22.1%), oral cavity 14 (20.6%), unknown 3 (4.4%), paranasal sinus 1, and nasopharynx 1. Tumors were classified as UICCTNM stage IV 54 (79.4%), stage III 12 (17.6%), stage I-II 2 (3%). Neoadjunvant CT consisted of two cycles of cisplatin and 5-fluoruracil (CDDP lO0mg/sqm, day 1; 5-FU 1,000mg/sqm iv, days 1-5 every 28 days). Concomitant CT consisted of weekly cisplatin (25mg/sqm iv). 72 Gy in 42 fractions, 5 days a week, BID in the last 12 days of irradiation, were intended to be administered in 6 weeks. The mean RT treatment time was 45 days. Surgery as part of the primary treatment was attempted for biopsy-proven residual tumor at the primary site or clinical/radiological residual lymph nodes in the neck. Surgical rescue after tumor recurrence was attempted in 11 pts. Results: Grade >3 mucositis was recorded in 53 pts (84.2%). Enteral nutrition through nasogastric-feeding tube or percutaneous gastrostomy tube was required in 21 pts (30.9%). Mortality rate attributable to treatment was 7.7% (3.8% acute and 3.8% chronic). The 5-year Iocoregional control rate was 77.1% (CI 65.0%-89.2%). The 5-year disease-free survival was 49.4% (CI 62.8%-36.0%). The 5-year overall survival was 43.5% (C129.3%-57.7%). In multivariate analysis, complete response after primary treatment was the only independent factor for survival. Conclusions: In our study, the tumor response after combined treatment was the only independent factor for survival. The benefit in tumor control and survival rates has been obtain at the expense of severe acute and late toxicity. This approach could be offered under intensive supportive care to a selected population of patients. 184 poster OBTAINING PAROTID CONSTRAINTS IN INTENSITY MODULATED RADIATION THERAPY FOR HEAD AND NECK CANCERS M. Garg ~, A. Ahn 2,R. Smith 3,D. Mah 2,C. Guha 2,S. Kalnicki 2 7MONTEFIOREMEDICALCENTER/AECOM,Radiation Oncology, New York,
USA, 2MONTEFIOREMEDICALCENTER,Radiation Ontology, Bronx, USA, 3MONTEFIOREMEDICALCENTER,Otorhinolaryngology, Bronx, USA
Purpose/Objective: Numerous studies have indicated the usefulness of parotid dosing in IMRT for head and neck cancers.We report our experience on patients treated with IMRT for head and neck cancers on the parotid constraints and the feasibility of achieving them using the Eclipse planning system. Materials/Methods: 106 patients with advanced head and neck cancer were treated with normal tissue sparing IMRT (median dose 70.2 Gy) and concomitant chemotherapy (Cisplatin based). The PTV expansion was 1 cm around the gross disease and 0.5 cm around microscopic disease. During IMRT planning, the ipsilateral and contralateral parotids were designated as avoidance structures. Mean dose of 26 Gy was set as parotid constraint. Hot spots were kept below 10% outside the PTV. Results: For the entire group, mean ipsilateral parotid dose was 32 Gy and mean contralateral dose was 23 Gy. It was possible to obtain a mean contralateral parotid dose below 26 Gy in 53 (62.3%) patients. Only 29 (34%) patients had a mean dose of less than 26 Gy to the ipsilateral parotid. The constraints were met for both parotids in 27 (31%) patients. 72% of patients who received >26 Gy to their contralateral parotid had N2B or greater neck disease and all of them were treated with definitive intent to a total dose of 70 Gy. Conclusions: Bilateral parotid constraints were achieved in only 31% of the patients. Contralateral parotid constraint was however achieved in 63% of the patients. It is difficult to obtain parotid constraints in patients with advanced neck disease and oropharyngeal cancer. Constraints are easier to achieve in patients with negative neck nodes and those receiving post-operative radiation therapy. We are also evaluating the relationship of parotid dose to acute and long-term toxicity. 185 poster OPTIMIZING THE TREATMENT OFNASOPHARYNGEAL CANCER: ANUPDATE OF THE MILAN EXPERIENCE INCLUDING IMRT AND CHEMOTHERAPY INTENSIFICATION M. Palazzi~, S. Tomatis 2,E. Orlandi 3,P. Bossi4,M. Guzzo 5,P. Potepan 6,E. Pignoli2,C. Bergamini 4,L. Licitra4,G. ScaramelliniS,G. Cant65, R Olmi 3 ~ISTITUTONAZIONALETUMORI,Radiotherapy, Milan, Italy, 21NT,Medical Physics, Milan, Italy, 31NT,Radiotherapy, Milan, Italy, 41NT,H&N Medical Oncology± Milan, Italy, SlNT,H&N Surgery, Milan, Italy, 61NT,Radiology, Milan, Italy Purpose/Objective: Non-metastatic carcinoma of the nasopharynx is a unique disease, with relatively high cure rates after radiotherapy (RT) with or without chemotherapy (CT). In a previous report (IJROBP 2004) we showed a relevant improvement of clinical outcome over time in our series of 171 consecutive cases treated between 1990 and 1999: disease-free survival rate at 3 years was 66% for the whole series, but improved in the decade from 53% (199091 ) to 69% (1998-99). In the present report we analyze the outcome of the following cohort of patients (pts). Materials/Methods: Between 2000 and 2005 we treated 69 nonmetastatic, consecutive pts with a pathological diagnosis of squamous or undifferentiated carcinoma of the nasopharynx. T-stage was T1 in 17, T2 in 28, T3 in 10 and T4 in 14 cases. N-stage was NO in 16, N1 in 16, N2 in 25 and N3 in 12 pts. Clinical stage was I in 5%, II in 33%, Ill in 26% and IV in 35% of cases. No significant difference was observed in the proportion of early vs advanced stages compared to the previous cohort of pts (1990-1999). Radiotherapy was still conventional in 40 patients, but from 2003 we started to use fully 3D planning (18 pts) and in 2005 we introduced IMRT (11 pts). Fractionation was always conventional (2 Gy/d) and total dose ranged from 66 to 70 Gy. IMRT was delivered with the step-and-shoot technique and a sequential approach was used (2 or 3 PTVswere irradiated sequentially). Concomitant CT was given to 18 pts, both induction and
Posters total number of 344 lymph nodes were identified in the pathological specimens of these 56 levels for a mean number of 6.1 nodes (SD: 5.1) per level. None of them was found to contain cancer. Conclusions: The dissection of a radiologically negative neck level is not necessary. 183 poster NEOADJUVANT CHEMOTHERAPY AND CONCOMITANT CHEMORADIOTHERAPY WITH ACCELERATED FRACTIONATED SCHEDULE IN ADVANCED CARCINOMA OFTHE HEAD AND NECK. L. Perez Romasanta ~, L. L6pez Louzara2,V. Mu~oz Garz6n 2,J. Casal Rubio 3 IHosPITAL GENERALDE ClUDAD REAL,Radiation Oncology± Ciudad Real,
Spain 2HosPITALDOMEIXOEIRO-INST.GALEGODEMEDIClNATI~CNICA~Radiation Onco/-
ogy, Vigo, Spain, 3HosPm~LDOMEiXOEJRO,Medical Oncology, Vigo, Spain Purpose/Objective: Locoregionally advanced head and neck cancer is a challanging condition to confront with for oncologists. Treatment results with conventional approach (surgery and radiotherapy) are suboptimal. Combined chemo-radiotherapy or accelerated hyperfractionated radiotherapy have been proposed as treatment alternatives. We analyze toxicity, Iocoregional control rates and survival for advanced head and neck cancer, treated with neoadjuvant chemotherapy (CT) and concomitant chemo-radiotherapy with accelerated fractionation schedule. Materials/Methods: In a prospective study, from 1999 to 2004, combined chemo-radiotherapy treatment was used in 68 pts (males 62, mean age 55.4 yrs old). Sites of origin were oropharynx 18 (26.5%), larynx 16 (23.5%), hypopharynx 15 (22.1%), oral cavity 14 (20.6%), unknown 3 (4.4%), paranasal sinus 1, and nasopharynx 1. Tumors were classified as UICCTNM stage IV 54 (79.4%), stage III 12 (17.6%), stage I-II 2 (3%). Neoadjunvant CT consisted of two cycles of cisplatin and 5-fluoruracil (CDDP lO0mg/sqm, day 1; 5-FU 1,000mg/sqm iv, days 1-5 every 28 days). Concomitant CT consisted of weekly cisplatin (25mg/sqm iv). 72 Gy in 42 fractions, 5 days a week, BID in the last 12 days of irradiation, were intended to be administered in 6 weeks. The mean RT treatment time was 45 days. Surgery as part of the primary treatment was attempted for biopsy-proven residual tumor at the primary site or clinical/radiological residual lymph nodes in the neck. Surgical rescue after tumor recurrence was attempted in 11 pts. Results: Grade >3 mucositis was recorded in 53 pts (84.2%). Enteral nutrition through nasogastric-feeding tube or percutaneous gastrostomy tube was required in 21 pts (30.9%). Mortality rate attributable to treatment was 7.7% (3.8% acute and 3.8% chronic). The 5-year Iocoregional control rate was 77.1% (CI 65.0%-89.2%). The 5-year disease-free survival was 49.4% (CI 62.8%-36.0%). The 5-year overall survival was 43.5% (C129.3%-57.7%). In multivariate analysis, complete response after primary treatment was the only independent factor for survival. Conclusions: In our study, the tumor response after combined treatment was the only independent factor for survival. The benefit in tumor control and survival rates has been obtain at the expense of severe acute and late toxicity. This approach could be offered under intensive supportive care to a selected population of patients. 184 poster OBTAINING PAROTID CONSTRAINTS IN INTENSITY MODULATED RADIATION THERAPY FOR HEAD AND NECK CANCERS M. Garg ~, A. Ahn 2,R. Smith 3,D. Mah 2,C. Guha 2,S. Kalnicki 2 7MONTEFIOREMEDICALCENTER/AECOM,Radiation Oncology, New York,
USA, 2MONTEFIOREMEDICALCENTER,Radiation Ontology, Bronx, USA, 3MONTEFIOREMEDICALCENTER,Otorhinolaryngology, Bronx, USA
Purpose/Objective: Numerous studies have indicated the usefulness of parotid dosing in IMRT for head and neck cancers.We report our experience on patients treated with IMRT for head and neck cancers on the parotid constraints and the feasibility of achieving them using the Eclipse planning system. Materials/Methods: 106 patients with advanced head and neck cancer were treated with normal tissue sparing IMRT (median dose 70.2 Gy) and concomitant chemotherapy (Cisplatin based). The PTV expansion was 1 cm around the gross disease and 0.5 cm around microscopic disease. During IMRT planning, the ipsilateral and contralateral parotids were designated as avoidance structures. Mean dose of 26 Gy was set as parotid constraint. Hot spots were kept below 10% outside the PTV. Results: For the entire group, mean ipsilateral parotid dose was 32 Gy and mean contralateral dose was 23 Gy. It was possible to obtain a mean contralateral parotid dose below 26 Gy in 53 (62.3%) patients. Only 29 (34%) patients had a mean dose of less than 26 Gy to the ipsilateral parotid. The constraints were met for both parotids in 27 (31%) patients. 72% of patients who received >26 Gy to their contralateral parotid had N2B or greater neck disease and all of them were treated with definitive intent to a total dose of 70 Gy. Conclusions: Bilateral parotid constraints were achieved in only 31% of the patients. Contralateral parotid constraint was however achieved in 63% of the patients. It is difficult to obtain parotid constraints in patients with advanced neck disease and oropharyngeal cancer. Constraints are easier to achieve in patients with negative neck nodes and those receiving post-operative radiation therapy. We are also evaluating the relationship of parotid dose to acute and long-term toxicity. 185 poster OPTIMIZING THE TREATMENT OFNASOPHARYNGEAL CANCER: ANUPDATE OF THE MILAN EXPERIENCE INCLUDING IMRT AND CHEMOTHERAPY INTENSIFICATION M. Palazzi~, S. Tomatis 2,E. Orlandi 3,P. Bossi4,M. Guzzo 5,P. Potepan 6,E. Pignoli2,C. Bergamini 4,L. Licitra4,G. ScaramelliniS,G. Cant65, R Olmi 3 ~ISTITUTONAZIONALETUMORI,Radiotherapy, Milan, Italy, 21NT,Medical Physics, Milan, Italy, 31NT,Radiotherapy, Milan, Italy, 41NT,H&N Medical Oncology± Milan, Italy, SlNT,H&N Surgery, Milan, Italy, 61NT,Radiology, Milan, Italy Purpose/Objective: Non-metastatic carcinoma of the nasopharynx is a unique disease, with relatively high cure rates after radiotherapy (RT) with or without chemotherapy (CT). In a previous report (IJROBP 2004) we showed a relevant improvement of clinical outcome over time in our series of 171 consecutive cases treated between 1990 and 1999: disease-free survival rate at 3 years was 66% for the whole series, but improved in the decade from 53% (199091 ) to 69% (1998-99). In the present report we analyze the outcome of the following cohort of patients (pts). Materials/Methods: Between 2000 and 2005 we treated 69 nonmetastatic, consecutive pts with a pathological diagnosis of squamous or undifferentiated carcinoma of the nasopharynx. T-stage was T1 in 17, T2 in 28, T3 in 10 and T4 in 14 cases. N-stage was NO in 16, N1 in 16, N2 in 25 and N3 in 12 pts. Clinical stage was I in 5%, II in 33%, Ill in 26% and IV in 35% of cases. No significant difference was observed in the proportion of early vs advanced stages compared to the previous cohort of pts (1990-1999). Radiotherapy was still conventional in 40 patients, but from 2003 we started to use fully 3D planning (18 pts) and in 2005 we introduced IMRT (11 pts). Fractionation was always conventional (2 Gy/d) and total dose ranged from 66 to 70 Gy. IMRT was delivered with the step-and-shoot technique and a sequential approach was used (2 or 3 PTVswere irradiated sequentially). Concomitant CT was given to 18 pts, both induction and