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Pediatric radiosurgery: Therapy needing evaluation
304
I. J. Radiation
Oncology
l Biology
l Physics
Volume 48, Number 3, Supplement.
2000
Conclusion: Fractionated conformal proton beam therapy provides excellent local control for acoustic neuromas. The 42% rate of useful hearing preservation appears similar to published data from stereotactic radiosurgery as well as microsurgical series. No fifth or seventh cranial nerve injuries were observed. Other treatment related morbidities were minimal.
2078
pd.t’ e ~aTICradiosurgery:
J. M. Buatti,’ W. A. Friedman,’
Therapy
needing evaluation
F. J. Bova,’ L. B. Mandell,’
A. C. Pauline.’
N. A. Mayr.’ S. L. Meeks’
‘Universif?; of I~~YI, Iowa Cif?, IA, ‘Uifiversiry of Florida. Gnirzrsvillr, FL Purpose: Radiosurgery is seldom applied to children and protocol accrual with radiosurgery in pediatric cooperative low. Hence, critical review of a large experience is undertaken to assess utility and toxicity.
groups is
Materials and Methods: Seventy-two radiosurgery treatments in patients less than or equal to 21 years of age were delivered between 1988 and 1999. The median age of patients was 15 years (range 2-21). Patients required general anaesthesia if under age 13 (31%). There were 33 males and 39 females. Patients had benign conditions in 55 (7Wc) cases and malignant tumors in 17 (24%) cases. Benign disease included: Arteriovenous malformation (AVM) 40 (73%), low grade astrocytoma 3 (5%), acoustic schwannoma 3 (5%), functioning pituitary adenoma 3 (5%), meningiomn 2 (4%). vein of galen aneurysntiavm 3 (5%), facial nerve schwannoma 1 (15%). Malignant tumors included aupratentorial primitive neurectodermal tumor (PNET) 3 (I 8%). malignant glioma 3 (18%), sarcoma 3 (18%),metastases 3 ( 18%), ependymoma 2 (12%), rhabdoid 1 (6%),neuroblastoma I (6%),yolk sac 1 (6%). Fifty percent of patients were treated with single isocenter plans and 25% were treated with more than three isocenters. Prescriptions were most often to the 80% isovolume for single isocenter plans and to the 70 % isovolume in multi-isocenter plans. The median prescription dose was 15.0 Gy for benign tumors and AVMs and 12.5 Gy for malignant tumors where radiosurgery was part of an integrated radiation therapy treatment course or as palliation for recurrence. Results: Nineteen of twenty-five eligible patients with AVM were evaluable with angiography for definitive follow-up 36 or more months after initial treatment. Forty-two percent had angiographic cure (8/l 9). Two had intracranial hemorrhage and cure by subsequent surgery. Two were cured by retreatment with either surgery or additional radiosurgery. An additional five had MRI suggestive of cure without angiographic confirmation. Radiosurgery induced neurologic deficit occurred in 2 (5%) patients and 1 had a permanent deficit. Control of benign tumors ocurred in 92% of cases (I l/l 2). Hormonal control of functioning pituitary tumors was 100%. The one recurrence was a pilocytic astroctoma that recurred 42 months after 75 Gy. There were no complications in this group. Malignant tumors were a diverse group. All three PNET’s were treated for recurrence on/after chemotherapy and 2/3 are disease free at 36 and 48 months. One had progression and death at 3 1 months. The yolk sac tumor was disseminated and is disease free at 48 months. Two of three patients with sarcoma had progression after radiosurgery and one is disease free at I8 months. All patients with astrocytomas had progressive disease although one did not progress until more than 4 years after treatment. Two of three metastases were controlled although all died of progressive disease within one year. Both the patient with the rhabdoid tumor and neuroblastoma had rapidly progressive disease. One patient had symtomatic radiation necrosis (6%) and a permanent neurologic deficit. Conclusion: Radiosurgery ia an effective and underutilized with larger cohorts in controlled trials is needed.
2079
c omparison
modality
for children
with central nervous disease. Further study
of patterns of failure between T3 and T4 rectal cancer after preoperative
chemoradiation
C. Crane, N. Sanfilippo, N. Taylor, J. Skibber, B. Feig, N. Vauthey, K. Hunt, L. Ellis, S. Curley, R. Dubrow, Hamilton. P. Allen, R. Wolff, F. Sinicrope, T. Brown, P. Hoff, N. Janjan The Univ.
K. Cleary, S.
of TexasM.D. Anderson Can. Ctr., Houston, TX
Purpose: To compare the patterns of local and distant metastatic chemoradiation (CT/RT)
failure between T3 and T4 rectal cancer after preoperative
Methods and Materials: Preoperative CT/RT was given to 109 T3 and 45 T4 rectal cancers. Staging contirmation of T4 disease was accomplished by CT (N - 31), endorectal ultrasound (N = 5), or pelvic exam with vaginal mucosal involvement (N = 9). RT, delivered with 18 Mv photons and 3-field belly board technique total 45 Gy/25 fractions in 90% of T3 and 89% of T4 tumors. The remaining cases received additional RT (median 52.5 Gy range 52.5 Gy to 65 Gy) with intraoperative RT (N = 3) or interstitial implant (N = 2). CT consisted of 5FU (300 mg/m2) given as a continuous infusion during RT (5 days/wk). Kaplain-Meier methodology was used to calculate the 4-yr actuarial distant metastases (DM), and overall survival (OS). A Mantel-Haenszel comparison was used to determine statistical signiticance. Results: The median follow-up for all patients and living patients, were 34.5 and 39.0 months, respectively. Resection was not performed in 8 T4 patients (18%) because of the development of DM found with pre-surgical imaging or at exploration. Multivisceral resection was required in 30 T4 patients (66%) to obtain clear surgical margins. Rates of LF were not signiticantly different between T3 and T4 cases (14% vs 17%. respectively: p = 0.113). When cases of isolated LF were evaluated, no difference continued to be observed between T3 (8%) and T4 (12%) disease presentations (p = 0.113). The LF rate was 14% for both T3 and T4 cases when only resected cases were considered. However, the DM rdte (26% vs 47%: p = 0.001) and the OS rate (70% vs 47%; p=O.O04) were both worse in the T4 group. Conclusions: Aggressive multimodality therapy that includes multivisceral resection results in similar rates of local failure for T3 and T4 disease. However, among T4 patient’s survival is limited by high rates of distant metastases. Future strategies with novel chemoradiation approaches, such as altered fractionation and new chemotherapeutic agents are needed to improve both locoregional control and overall survival in locally advanced rectal cancer.
I. J. Radiation
Oncology
l Biology
l Physics
Volume 48, Number 3, Supplement.
2000
Conclusion: Fractionated conformal proton beam therapy provides excellent local control for acoustic neuromas. The 42% rate of useful hearing preservation appears similar to published data from stereotactic radiosurgery as well as microsurgical series. No fifth or seventh cranial nerve injuries were observed. Other treatment related morbidities were minimal.
2078
pd.t’ e ~aTICradiosurgery:
J. M. Buatti,’ W. A. Friedman,’
Therapy
needing evaluation
F. J. Bova,’ L. B. Mandell,’
A. C. Pauline.’
N. A. Mayr.’ S. L. Meeks’
‘Universif?; of I~~YI, Iowa Cif?, IA, ‘Uifiversiry of Florida. Gnirzrsvillr, FL Purpose: Radiosurgery is seldom applied to children and protocol accrual with radiosurgery in pediatric cooperative low. Hence, critical review of a large experience is undertaken to assess utility and toxicity.
groups is
Materials and Methods: Seventy-two radiosurgery treatments in patients less than or equal to 21 years of age were delivered between 1988 and 1999. The median age of patients was 15 years (range 2-21). Patients required general anaesthesia if under age 13 (31%). There were 33 males and 39 females. Patients had benign conditions in 55 (7Wc) cases and malignant tumors in 17 (24%) cases. Benign disease included: Arteriovenous malformation (AVM) 40 (73%), low grade astrocytoma 3 (5%), acoustic schwannoma 3 (5%), functioning pituitary adenoma 3 (5%), meningiomn 2 (4%). vein of galen aneurysntiavm 3 (5%), facial nerve schwannoma 1 (15%). Malignant tumors included aupratentorial primitive neurectodermal tumor (PNET) 3 (I 8%). malignant glioma 3 (18%), sarcoma 3 (18%),metastases 3 ( 18%), ependymoma 2 (12%), rhabdoid 1 (6%),neuroblastoma I (6%),yolk sac 1 (6%). Fifty percent of patients were treated with single isocenter plans and 25% were treated with more than three isocenters. Prescriptions were most often to the 80% isovolume for single isocenter plans and to the 70 % isovolume in multi-isocenter plans. The median prescription dose was 15.0 Gy for benign tumors and AVMs and 12.5 Gy for malignant tumors where radiosurgery was part of an integrated radiation therapy treatment course or as palliation for recurrence. Results: Nineteen of twenty-five eligible patients with AVM were evaluable with angiography for definitive follow-up 36 or more months after initial treatment. Forty-two percent had angiographic cure (8/l 9). Two had intracranial hemorrhage and cure by subsequent surgery. Two were cured by retreatment with either surgery or additional radiosurgery. An additional five had MRI suggestive of cure without angiographic confirmation. Radiosurgery induced neurologic deficit occurred in 2 (5%) patients and 1 had a permanent deficit. Control of benign tumors ocurred in 92% of cases (I l/l 2). Hormonal control of functioning pituitary tumors was 100%. The one recurrence was a pilocytic astroctoma that recurred 42 months after 75 Gy. There were no complications in this group. Malignant tumors were a diverse group. All three PNET’s were treated for recurrence on/after chemotherapy and 2/3 are disease free at 36 and 48 months. One had progression and death at 3 1 months. The yolk sac tumor was disseminated and is disease free at 48 months. Two of three patients with sarcoma had progression after radiosurgery and one is disease free at I8 months. All patients with astrocytomas had progressive disease although one did not progress until more than 4 years after treatment. Two of three metastases were controlled although all died of progressive disease within one year. Both the patient with the rhabdoid tumor and neuroblastoma had rapidly progressive disease. One patient had symtomatic radiation necrosis (6%) and a permanent neurologic deficit. Conclusion: Radiosurgery ia an effective and underutilized with larger cohorts in controlled trials is needed.
2079
c omparison
modality
for children
with central nervous disease. Further study
of patterns of failure between T3 and T4 rectal cancer after preoperative
chemoradiation
C. Crane, N. Sanfilippo, N. Taylor, J. Skibber, B. Feig, N. Vauthey, K. Hunt, L. Ellis, S. Curley, R. Dubrow, Hamilton. P. Allen, R. Wolff, F. Sinicrope, T. Brown, P. Hoff, N. Janjan The Univ.
K. Cleary, S.
of TexasM.D. Anderson Can. Ctr., Houston, TX
Purpose: To compare the patterns of local and distant metastatic chemoradiation (CT/RT)
failure between T3 and T4 rectal cancer after preoperative
Methods and Materials: Preoperative CT/RT was given to 109 T3 and 45 T4 rectal cancers. Staging contirmation of T4 disease was accomplished by CT (N - 31), endorectal ultrasound (N = 5), or pelvic exam with vaginal mucosal involvement (N = 9). RT, delivered with 18 Mv photons and 3-field belly board technique total 45 Gy/25 fractions in 90% of T3 and 89% of T4 tumors. The remaining cases received additional RT (median 52.5 Gy range 52.5 Gy to 65 Gy) with intraoperative RT (N = 3) or interstitial implant (N = 2). CT consisted of 5FU (300 mg/m2) given as a continuous infusion during RT (5 days/wk). Kaplain-Meier methodology was used to calculate the 4-yr actuarial distant metastases (DM), and overall survival (OS). A Mantel-Haenszel comparison was used to determine statistical signiticance. Results: The median follow-up for all patients and living patients, were 34.5 and 39.0 months, respectively. Resection was not performed in 8 T4 patients (18%) because of the development of DM found with pre-surgical imaging or at exploration. Multivisceral resection was required in 30 T4 patients (66%) to obtain clear surgical margins. Rates of LF were not signiticantly different between T3 and T4 cases (14% vs 17%. respectively: p = 0.113). When cases of isolated LF were evaluated, no difference continued to be observed between T3 (8%) and T4 (12%) disease presentations (p = 0.113). The LF rate was 14% for both T3 and T4 cases when only resected cases were considered. However, the DM rdte (26% vs 47%: p = 0.001) and the OS rate (70% vs 47%; p=O.O04) were both worse in the T4 group. Conclusions: Aggressive multimodality therapy that includes multivisceral resection results in similar rates of local failure for T3 and T4 disease. However, among T4 patient’s survival is limited by high rates of distant metastases. Future strategies with novel chemoradiation approaches, such as altered fractionation and new chemotherapeutic agents are needed to improve both locoregional control and overall survival in locally advanced rectal cancer.