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OC-0085: In search for the optimal HDR brachytherapy radiation scheme after excision in keloid treatment
S43 ESTRO 36 _______________________________________________________________________________________________ into this study. We excluded patients with relapse after previous radiotherapy/brachytherapy or follow-up < 12 months. 5-year relapse free survival was estimated. Cox regression model was used to find any factors associated with local control. Results Ninety eight patients (56 females/42 males) were analyzed in this retrospective study. Median age was 72 years (45-91). 112 primary and 43 post surgery lesions to total of 167 were treated with surface brachytherapy. Median of lesions’ greatest dimension was 2 cm (0.2-8). Median total dose was 45 Gy (30-50 Gy) with dose per fraction of 5 Gy. Dose was specified 0.3-0.5 cm from the surface of the applicator. Median follow-up was 54 months (12-95). 5-year local relapse-free survival was 94%. Single factor linked to local failure was lesion localization in the concha and/or external acoustic meatus (HR-2.6; 1.4-3.8; p-0.0000). Conclusion Surface HDR brachytherapy is very effective for the treatment of basal cell caner. Lesions localized in the concha/external acoustic meatus should be managed carefully. OC-0084 Results of excision and 13 Gy single dose HDR brachytherapy for keloids C. Hafkamp1, O. Lapid2, R. Dávila Fajardo1, A. Van de Kar2, C. Koedooder1, L. Stalpers1, B. Pieters1 1 Academic Medical Center P.O. Box, Radiation Oncology, Amsterdam, The Netherlands 2 Academic Medical Center P.O. Box, Plastic and Reconstructive Surgery, Amsterdam, The Netherlands Purpose or Objective To investigate the outcome of a single dose of 13 Gy HDR given postoperatively for the treatment of keloids. Surgical treatment of keloids results in high recurrence rates of 50-80%. Therefore surgical resection is often combined with radiotherapy. We report the result in terms of both local control and cosmesis. Material and Methods Between 2007 and 2015, 61 patients were treated for 72 keloids. All patients were contacted to participate. All patients had a surgical excision followed by 13 Gy HDr brachytherapy within 4 hours. Usually a single catheter was placed in the wound bed with dose prescribed at 4-7 mm from the source axis. In some cases a volume implant was applied according to the Paris-system geometry and dosimetry or the dose was prescribed at dose points on the skin. A recurrence was defined as an elevation of the scar outside the initial wound. Cosmetic assessment was according to the Patient and Observer Scar Assessment Scale (POSAS). The POSAS score can range from 6-60, higher scores correspond with worse scarring. Results Twenty-four patients (39%) with 29 keloids consented to participate in the study. The median age at treatment was 31 years (15 – 64 years). The median follow-up period was 53 months, (19 – 95 months). The most frequent localization was the ear (n=14). Recurrence was reported for 7 (24.1%) out of 29 keloids. Two recurrences were localized presternally, two on one ear, one in the neck, one abdominal and one on the shoulder. Patients scored on average 24.3 for their total POSAS score (range 6 – 52) and the observer scored on average 14.6 (range 6 – 42) (Figure 1). Patients scored stiffness as the most bothersome side effect followed by thickness. The observer gave the highest score to overall impression followed by surface area.
Conclusion Compared to favorable reports in the literature, typically reporting about 10% recurrence rates, we found a high recurrence rate of 24% following excision and brachytherapy for keloids. This may be explained by our much longer follow-up of at least 1.5 years, and a more stringent and objective definition of response by the POSAS patient and observer reported outcome. Our results may have been further negatively biased by selection; despite repeated invitations, the willingness to participate was very low, partly explained by the poorer socio-economic background of the patients. Publication bias may also have deterred publication of less favorable results, and stresses the need of prospective multicenter trials with a uniform scoring system. OC-0085 In search for the optimal HDR brachytherapy radiation scheme after excision in keloid treatment. E. Bijlard1, G.M. Verduijn2, J.X. Harmeling1, H. Dehnad3, M.A.M. Mureau1 1 Erasmus Medical Center Rotterdam Daniel den Hoed Cancer Center, Plastic Surgery, Rotterdam, The Netherlands 2 Erasmus Medical Center Rotterdam Daniel den Hoed Cancer Center, Radiation Oncology, Rotterdam, The Netherlands 3 University Medical Center Utrecht, Radiation oncology, Utrecht, The Netherlands Purpose or Objective Keloids are benign lesions that can cause physical symptoms and disturbing appearance. Excision with radiation is considered the most effective treatment option for recurrent keloids. Previously a BED of 30Gy was reported as the minimal effective dose to prevent keloid recurrence, this was based mainly on external radiation (EBRT) studies. In a recent review high dose rate (HDR) brachytherapy achieves favorable outcome over EBRT. The included studies used different radiation schemes. The optimal scheme for HDR brachytherapy in keloid treatment preventing recurrences and treatment side effects needs to be determined. Material and Methods We retrospectively collected patient and keloid characteristics, information on complications, and (partial or full) keloid recurrence of all patients who received excision with HDR brachytherapy in center 1 from 2010 to May 2014 and in center 2 from 2009 to 2014. In case follow-up was insufficient or information was missing, telephone interviews were performed. Center 1 used 9 Gy 2 hours postoperatively and 9 Gy 6 hours later. Center 2 used 6 Gy six hours postoperatively, followed by additional 2x6 Gy a day later. Center 3 has recently published a prospective cohort, in detail, using 6 Gy 4 hours postoperatively and 6 Gy the next day. We compared results of all 3 centers. All centers used an Ir192 HDR source. Results Comparing the 3 centers no significant differences were found in recurrence rates (full recurrence 9.3%, 3.1%, 8.6% p=0.31, no recurrence 79%, 77%, 91% p=0.169 for center 1,
S44 ESTRO 36 _______________________________________________________________________________________________ 2 and 3 respectively). Before treatment symptoms of itch (80% and 69%) and pain (67% and 58%) were present in a majority of cases in center 1 and 2, after treatment complaints were relieved completely or less severe in most patients (no or less itch 95%, no or less pain 95%). The scheme of 2x9Gy resulted in more and more severe complications, with 3x6Gy less complications were found, and using 2x6Gy even fewer and less severe complications were reported (major complication 24%, 16%, 6% p=0.046, minor complication 56%, 39%, 17% p<0.001 for center 1, 2 and 3 respectively). Conclusion We conclude that the scheme using the lowest dose of radiation seems to have a similar good outcome on recurrences as well as a lower risk on mild as well as more severe side effects, like infections, chronic wounds and apparent pigmentation differences. Our results show that when using brachytherapy a BED of 30Gy is not needed and 19Gy can be sufficient. We recommend using a lower radiation scheme, i.e. 2x6Gy, to reduce adverse events and minimize stochastic effect of this treatment.
hypertrophied scars were observed. Pigmentary abnormalities were detected in 3 patients and additional 7 patients had a mild delay in the wound healing process. Conclusion Interstitial brachytherapy is able to deliver conformal radiation exactly in the scar with extremely low exposure of other normal tissues. It is suitable to most shapes and irregular surfaces. Brachytherapy is cost-effective und can be offered in the majority of radiotherapy centers. Our three-fraction treatment schedule reduces the treatment period to two days and is therefore convenient for the patients. A radiobiological analysis of more than 2500 patients from multiple centers found a low α/β-value for local control of keloids (Flickinger et. al. 2011 IJROBP). The analysis recommended a treatment concept with few fractions and high doses per fraction delivered in a short period of time as early as possible after resection. Our results confirm it and suggest that brachytherapy may be advantageous in the management of high-risk keloids, even after failure of external beam radiotherapy.
OC-0086 Perioperative interstitial high-dose-rate (HDR) brachytherapy for the treatment of recurrent keloids P. Jiang1, M. Geenen2, F.A. Siebert1, R. Baumann1, P. Niehoff3, D. Druecke4, J. Dunst1 1 UKSH- Campus Kiel, Department of Radiation Oncology, Kiel, Germany 2 Lubinus Clinic, Department of Reconstructive Surgery, Kiel, Germany 3 University Witten-Herdecke, Department of Radiation Oncology, kiel, Germany 4 UKSH- Campus Kiel, Department of Reconstructive Surgery, Kiel, Germany
Poster Viewing : Session 2: Palliative and health services research
Purpose or Objective Perioperative radiotherapy of keloids can reduce the risk of recurrence. Due to the wide variety of concepts the optimal treatment regime remains unclear. We established in our clinic a protocol of perioperative interstitial HDR-Brachytherapy with 3 fractions of 6 Gy and achieved an excellent local control rate of 94%. (Jiang. et. al. 2015 IJROBP). We report now an update of our longterm results of this prospective study of perioperative interstitial brachytherapy. Here we include 29 patients with a median follow-up of 5 years. Material and Methods From 2009 to 2015, 29 patients with 37 recurrent keloids were treated with perioperative interstitial HDRbrachytherapy; 3 patients had been previously treated with adjuvant external beam radiotherapy and presented with recurrences in the pretreated area. After (re-) excision the keloids, a single plastic flexible brachytherapy tube for irradiation was placed subcutaneously before closing the wound. The target volume covered the scar in total length. CT-based treatment planning was used in selected cases, e.g. if two lesions in close proximity were to be treated or for lesions in difficult anatomic locations (e.g. helix of the ear). Brachytherapy was given in three fractions with a single dose of 6 Gy in 5mm tissue depth, with the exception of one patient with a keloid on the helix who received a single dose of 6 Gy to the whole tissue. The first fraction was given within 6 hours after surgery, the other two fractions on the first postoperative day. Follow-up visits were scheduled at 6 weeks, 3 months, 6 months, 1 year, and every year thereafter. Results No procedure-related complications (e.g. secondary infections) occurred. 23 patients had keloid-related symptoms prior to treatment like pain and pruritus; disappearance of symptoms was noticed in all patients after treatment. After a median follow-up of 49,7 months (range: 7,9 to 92,7 months), 3 keloid recurrences and 2
PV-0087 Improvement of models for survival prediction through inclusion of patient-reported symptoms C. Nieder1, T. Kämpe1, B. Mannsåker1, A. Dalhaug1, E. Haukland1 1 Nordlandssykehuset HF, Dept. of Oncology and Palliative Medicine, Bodoe, Norway Purpose or Objective Widely used prognostic scores, e.g., for brain metastases and incurable lung cancer are based on disease- and patient-related factors such as extent of metastases, age and performance status (PS), which were available in the databases used to develop the scores. Few groups were able to include prospectively recorded patient-reported symptoms. In our department, all patients were assessed with the Edmonton Symptom Assessment System (ESAS, a questionnaire addressing 11 major symptoms and wellbeing on a numeric scale of 0-10) at the time of treatment planning since 2012. Therefore, we analyzed whether or not baseline symptom severity provides relevant prognostic information, which should be included during development of prognostic scores. Material and Methods A retrospective review of 112 patients treated with palliative radiotherapy (PRT) between 2012 and 2015 was performed. The patients scored their symptoms before PRT. ESAS items were dichotomized (below/above median). Uni- and multivariate analyses were performed to identify prognostic factors for survival, and from these a predictive model was developed. Results The most common tumor types were pro state (30%), breast (12%) and non-small cell lung c ancer (26%), predominantly with distant metastases. M edian survival was 8 months. Univariate analyses identified 12 factors that were associated with survival, including several ESAS items. Multivariate analysis confirmed the significance of 6 factors, from which a predictive model was developed. These were ESAS pain while not moving (median 3), ESAS appetite (median 5), ECOG PS, pleural effusion/pleural metastases, iv antibiotics during or within 2 weeks before PRT and no systemic cancer treatment. The table shows the prognostic score resulting from the multivariate model. One or two points were assigned, depending on the hazard ratio of each factor. Patients with a point sum of 0-1 had an estimated median survival of 23 months, a point sum of 2-3 8.4 months, a point sum of 4-5 4.2 months and a point sum of 6 or more 1.8 months (p=0.001).
Conclusion Compared to favorable reports in the literature, typically reporting about 10% recurrence rates, we found a high recurrence rate of 24% following excision and brachytherapy for keloids. This may be explained by our much longer follow-up of at least 1.5 years, and a more stringent and objective definition of response by the POSAS patient and observer reported outcome. Our results may have been further negatively biased by selection; despite repeated invitations, the willingness to participate was very low, partly explained by the poorer socio-economic background of the patients. Publication bias may also have deterred publication of less favorable results, and stresses the need of prospective multicenter trials with a uniform scoring system. OC-0085 In search for the optimal HDR brachytherapy radiation scheme after excision in keloid treatment. E. Bijlard1, G.M. Verduijn2, J.X. Harmeling1, H. Dehnad3, M.A.M. Mureau1 1 Erasmus Medical Center Rotterdam Daniel den Hoed Cancer Center, Plastic Surgery, Rotterdam, The Netherlands 2 Erasmus Medical Center Rotterdam Daniel den Hoed Cancer Center, Radiation Oncology, Rotterdam, The Netherlands 3 University Medical Center Utrecht, Radiation oncology, Utrecht, The Netherlands Purpose or Objective Keloids are benign lesions that can cause physical symptoms and disturbing appearance. Excision with radiation is considered the most effective treatment option for recurrent keloids. Previously a BED of 30Gy was reported as the minimal effective dose to prevent keloid recurrence, this was based mainly on external radiation (EBRT) studies. In a recent review high dose rate (HDR) brachytherapy achieves favorable outcome over EBRT. The included studies used different radiation schemes. The optimal scheme for HDR brachytherapy in keloid treatment preventing recurrences and treatment side effects needs to be determined. Material and Methods We retrospectively collected patient and keloid characteristics, information on complications, and (partial or full) keloid recurrence of all patients who received excision with HDR brachytherapy in center 1 from 2010 to May 2014 and in center 2 from 2009 to 2014. In case follow-up was insufficient or information was missing, telephone interviews were performed. Center 1 used 9 Gy 2 hours postoperatively and 9 Gy 6 hours later. Center 2 used 6 Gy six hours postoperatively, followed by additional 2x6 Gy a day later. Center 3 has recently published a prospective cohort, in detail, using 6 Gy 4 hours postoperatively and 6 Gy the next day. We compared results of all 3 centers. All centers used an Ir192 HDR source. Results Comparing the 3 centers no significant differences were found in recurrence rates (full recurrence 9.3%, 3.1%, 8.6% p=0.31, no recurrence 79%, 77%, 91% p=0.169 for center 1,
S44 ESTRO 36 _______________________________________________________________________________________________ 2 and 3 respectively). Before treatment symptoms of itch (80% and 69%) and pain (67% and 58%) were present in a majority of cases in center 1 and 2, after treatment complaints were relieved completely or less severe in most patients (no or less itch 95%, no or less pain 95%). The scheme of 2x9Gy resulted in more and more severe complications, with 3x6Gy less complications were found, and using 2x6Gy even fewer and less severe complications were reported (major complication 24%, 16%, 6% p=0.046, minor complication 56%, 39%, 17% p<0.001 for center 1, 2 and 3 respectively). Conclusion We conclude that the scheme using the lowest dose of radiation seems to have a similar good outcome on recurrences as well as a lower risk on mild as well as more severe side effects, like infections, chronic wounds and apparent pigmentation differences. Our results show that when using brachytherapy a BED of 30Gy is not needed and 19Gy can be sufficient. We recommend using a lower radiation scheme, i.e. 2x6Gy, to reduce adverse events and minimize stochastic effect of this treatment.
hypertrophied scars were observed. Pigmentary abnormalities were detected in 3 patients and additional 7 patients had a mild delay in the wound healing process. Conclusion Interstitial brachytherapy is able to deliver conformal radiation exactly in the scar with extremely low exposure of other normal tissues. It is suitable to most shapes and irregular surfaces. Brachytherapy is cost-effective und can be offered in the majority of radiotherapy centers. Our three-fraction treatment schedule reduces the treatment period to two days and is therefore convenient for the patients. A radiobiological analysis of more than 2500 patients from multiple centers found a low α/β-value for local control of keloids (Flickinger et. al. 2011 IJROBP). The analysis recommended a treatment concept with few fractions and high doses per fraction delivered in a short period of time as early as possible after resection. Our results confirm it and suggest that brachytherapy may be advantageous in the management of high-risk keloids, even after failure of external beam radiotherapy.
OC-0086 Perioperative interstitial high-dose-rate (HDR) brachytherapy for the treatment of recurrent keloids P. Jiang1, M. Geenen2, F.A. Siebert1, R. Baumann1, P. Niehoff3, D. Druecke4, J. Dunst1 1 UKSH- Campus Kiel, Department of Radiation Oncology, Kiel, Germany 2 Lubinus Clinic, Department of Reconstructive Surgery, Kiel, Germany 3 University Witten-Herdecke, Department of Radiation Oncology, kiel, Germany 4 UKSH- Campus Kiel, Department of Reconstructive Surgery, Kiel, Germany
Poster Viewing : Session 2: Palliative and health services research
Purpose or Objective Perioperative radiotherapy of keloids can reduce the risk of recurrence. Due to the wide variety of concepts the optimal treatment regime remains unclear. We established in our clinic a protocol of perioperative interstitial HDR-Brachytherapy with 3 fractions of 6 Gy and achieved an excellent local control rate of 94%. (Jiang. et. al. 2015 IJROBP). We report now an update of our longterm results of this prospective study of perioperative interstitial brachytherapy. Here we include 29 patients with a median follow-up of 5 years. Material and Methods From 2009 to 2015, 29 patients with 37 recurrent keloids were treated with perioperative interstitial HDRbrachytherapy; 3 patients had been previously treated with adjuvant external beam radiotherapy and presented with recurrences in the pretreated area. After (re-) excision the keloids, a single plastic flexible brachytherapy tube for irradiation was placed subcutaneously before closing the wound. The target volume covered the scar in total length. CT-based treatment planning was used in selected cases, e.g. if two lesions in close proximity were to be treated or for lesions in difficult anatomic locations (e.g. helix of the ear). Brachytherapy was given in three fractions with a single dose of 6 Gy in 5mm tissue depth, with the exception of one patient with a keloid on the helix who received a single dose of 6 Gy to the whole tissue. The first fraction was given within 6 hours after surgery, the other two fractions on the first postoperative day. Follow-up visits were scheduled at 6 weeks, 3 months, 6 months, 1 year, and every year thereafter. Results No procedure-related complications (e.g. secondary infections) occurred. 23 patients had keloid-related symptoms prior to treatment like pain and pruritus; disappearance of symptoms was noticed in all patients after treatment. After a median follow-up of 49,7 months (range: 7,9 to 92,7 months), 3 keloid recurrences and 2
PV-0087 Improvement of models for survival prediction through inclusion of patient-reported symptoms C. Nieder1, T. Kämpe1, B. Mannsåker1, A. Dalhaug1, E. Haukland1 1 Nordlandssykehuset HF, Dept. of Oncology and Palliative Medicine, Bodoe, Norway Purpose or Objective Widely used prognostic scores, e.g., for brain metastases and incurable lung cancer are based on disease- and patient-related factors such as extent of metastases, age and performance status (PS), which were available in the databases used to develop the scores. Few groups were able to include prospectively recorded patient-reported symptoms. In our department, all patients were assessed with the Edmonton Symptom Assessment System (ESAS, a questionnaire addressing 11 major symptoms and wellbeing on a numeric scale of 0-10) at the time of treatment planning since 2012. Therefore, we analyzed whether or not baseline symptom severity provides relevant prognostic information, which should be included during development of prognostic scores. Material and Methods A retrospective review of 112 patients treated with palliative radiotherapy (PRT) between 2012 and 2015 was performed. The patients scored their symptoms before PRT. ESAS items were dichotomized (below/above median). Uni- and multivariate analyses were performed to identify prognostic factors for survival, and from these a predictive model was developed. Results The most common tumor types were pro state (30%), breast (12%) and non-small cell lung c ancer (26%), predominantly with distant metastases. M edian survival was 8 months. Univariate analyses identified 12 factors that were associated with survival, including several ESAS items. Multivariate analysis confirmed the significance of 6 factors, from which a predictive model was developed. These were ESAS pain while not moving (median 3), ESAS appetite (median 5), ECOG PS, pleural effusion/pleural metastases, iv antibiotics during or within 2 weeks before PRT and no systemic cancer treatment. The table shows the prognostic score resulting from the multivariate model. One or two points were assigned, depending on the hazard ratio of each factor. Patients with a point sum of 0-1 had an estimated median survival of 23 months, a point sum of 2-3 8.4 months, a point sum of 4-5 4.2 months and a point sum of 6 or more 1.8 months (p=0.001).