- Email: [email protected]
PO-0702: Prognostic value of early PET-CT to predict response after neoadjuvant RCT in locally advanced rectal cancer
S22
Conclusions: The absence of clear relationship between RBA and absorbed dose suggests possible modulation of skin response related to other factors such as breast volume, drug assumption, concomitant morbidities, phenotype and genotype. Moreover, RS is a good, objective and sensitive tool for the evaluation of relative skin changes. Initial skin reactions, which are hardly detectable by the physician, seem to be a good indicator of the development of possible acute skin toxicity within the entire RT. This study was partially funded by the LILT Lega Italiana per la lotta contro i tumori (Milano). PO-0701 From supine to prone breast radiotherapy: an unaffordable cost? L. Van den Berghe1, B. Vanderstraeten1, L. Veldeman1, N. Flamée1, Y. Lievens1 1 Ghent University Hospital, Radiotherapy, Ghent, Belgium Purpose/Objective: Whereas the supine position remains standard in most radiotherapy centres, prone breast irradiation is gaining attention due to the potential of improved organ sparing. We compared the cost of prone versus supine whole breast irradiation (WBI) and put it in context of other types of breast irradiation. Materials and Methods: In 2012, a multicentre time-driven activitybased costing (TD-ABC) study was conducted computing the costs of all delivered radiotherapy treatments in the framework of a national project on innovative radiotherapy techniques (1). The current study focuses on the different types of breast irradiation delivered at our institution, all employing intensity-modulated radiotherapy (IMRT). Three data sets were used. First, the baseline TD-ABC study used average treatment time slots for WBI-IMRT in daily practice (DP), regardless of prone or supine position. To analyse a possible difference between the two treatment set-ups, we introduced the actual differences in measured times between prone and supine irradiation. Finally, before introduction of prone breast treatments in daily practice, a comparative clinical trial was conducted including daily measurements of the time necessary for positioning, imaging and irradiation in prone versus supine. These data from the trial phase (TP) were used as a third data set. In addition to the thus calculated costs, direct material costs were added for the individual bra used for prone breast treatments. Results: The treatment time slots are longer in prone than in supine position, as well in DP (prone: 16,6 minutes, supine: 14,9 minutes) as in the TP (21,2 minutes for prone irradiation and 19,4 minutes for supine treatment). The average cost of WBI in our daily practice amounts to 4,444€ in case 15 fractions are delivered. When accounting for differences in prone and supine positioning, we found an only slightly higher cost of 4,597€ in prone irradiation versus 4,379€ in supine. Our calculations however show that the cost was significantly higher in the TP, in line with the higher time requirements: 5,679€ for prone compared to 5,306€ for supine position, with an incremental cost of 374€ € between both set-ups. Figure 1 demonstrates the costs of prone and supine WBI in the context of other breast irradiations in DP. Not unexpectedly, the cost increases with number of fractions and with complexity of the target volume (addition of lymph nodes).
ESTRO 33, 2014
Conclusions: Prone WBI delivered with IMRT is only slightly more expensive than WBI-IMRT delivered in supine position. This extra cost will have to be weighed against the decrease in toxicity. The total treatment cost decreased after completion of the learning curve by achievement of shorter treatment times, demonstrating that the nursing staff clearly got accustomed to the new method of positioning. (1) https://kce.fgov.be/publication/report%20198/
POSTER: CLINICAL TRACK: GASTROINTESTINAL TUMOURS (UPPER AND LOWER GI) PO-0702 Prognostic value of early PET-CT to predict response after neoadjuvant RCT in locally advanced rectal cancer M.A. Gambacorta1, L. Leccisotti2, C. Valentini1, C. De Waure3, M. Boccardi1, A.R. Alitto1, A. Stefanelli2, M.C. Barba4, A. Giordano2, V. Valentini1 1 Sacred Heart Catholic University of Rome, Radiation Oncology Department, Rome, Italy 2 Sacred Heart Catholic University of Rome, Nuclear Medicine Institution, Rome, Italy 3 Sacred Heart Catholic Unversity of Rome, Hygiene and biostatistics, Rome, Italy 4 San Peter Hospital Fatebene Fratelli, Radiation Oncology Department, Rome, Italy Purpose/Objective: To evaluate if changes in 18F-FDG uptake during and after preoperative RCT could predict pathological response in Locally Advanced Rectal Cancer (LARC) patients (pts), to discriminate the subgroup of non responders pts which may benefit from alternative treatment strategy. Materials and Methods: From December 2006 to September 2011, 126 consecutive pts with histological confirmed LARC were prospectively enrolled at our Institution. All pts underwent 18F-FDG PET-CT at three different time: before preoperative RCT (baseline PET-CT), at the end of the second week of preoperative RCT (early PET-CT) and before surgery (late PET-CT). Maximum Standardized Uptake Value (SUVmax) was measured. Tumor SUVmax values were employed to assess the response to preoperative RCT by calculating a response index (RI), as RI=[(SUV2SUV1)/SUV1]×100. Changes in 18F-FDG uptake between baseline and early PET-CT (early RI) and between baseline and late RCTPET-CT (late RI) were correlated to the pathological tumor response. Preoperative 5-FU based RCT (total dose of 5040-5500cGy according to T stage, extramesorectal lymph nodes and MRF involvement) treatment was delivered to pts with LARC or with stage I low-lying tumor. Standard surgical procedure was the total mesorectal excision at least 8 weeks after the end of RCT. Surgical specimens were classified according to (yp)TNM definition. Tumor response to pre-operative RCT was performed according to the tumor regression grade (TRG) score: the tumors were grouped into responders (TRG1) and non responders (TRG25); complete responders were also defined with respect to pathological analysis if ypT0ypN0. Results: According to TRG classification, 31/126 pts (24.6%) were classified asTRG1 and 95/126 pts (75.4%) were classified as TRG2-5. With respect to pathological examination, available on 124 patients, 28 (22.6%) were classified as responders and 96 (77.4%) as non responders.
S23
ESTRO 33, 2014 SUVmax was significantly higher on baseline PET-CT compared to early and late PET-CT both in responders (TRG1) and non responders (TRG2-5). The AUC of early RI in identifying non responders according to TRG and (yp)TNM was 0.75 (95%CI 0.62-0.88) and 0.74 (95%CI 0.61-0.87); the optimal cut-off was identified as a reduction of 61.2% (sensitivity of 85.4% and specificity of 65.2% in identifying non responders according to TRG and 83.1% and 65% in identifying non responders according to y(p)TNM).
resection or a radical course of chemoradiation in a hypofractionated scheme in combination with intraluminal brachytherapy in our institute. Materials and Methods: Fifty three patients treated with EBRT (50 Gy in 20 fractions) and HDR brachytherapy (12 Gy in 2 fractions) were retrospectively analysed. Toxicity and dysphagia were scored.
Conclusions: The reduction of tumor SUVmax of 61.2% could be an optimal cut-off to distinguish TRG1 from TRG2-5 on early PET-CT. The positive predictive value of identifying non responders at early PET-CT (91.3%), seems to be useful to identify the absence of response to preoperative treatment early, allowing the clinicians to tailor treatment. Although it is known that integration with other data could improve the predictive values of PET-CT1.
Results: Of all patients 64.2% completed the whole scheduled treatment. Nineteen percent of patients was over 80 years old. The 1 and 2 year estimated local recurrence free survival rates were 77% and 66% respectively. The median follow up was 9 months (range 1-53 months). A grade III stenosis was reported in 8 patients (15%). Four patients (7,5%) died of complications from their treatment; 2 died of perforation of the esophagus, 1 had an acute lethal bleeding and 1 patient died of an esophago-pericardial fistula after reirradiation. Post treatment 49.1% of patients could consume a normal diet.
1 van Stiphout RG, Lammering G, Buijsen J, et al Development and external validation of a predictive model for pathological complete response of rectal cancer patients including sequential PET-CT imaging. Radiother Oncol. 2011 Jan; 98(1) : 126-33. doi:. 1016/ j.radonc. 2010.12.002. Epub 2010 Dec 20.
Conclusions: A curatively intended hypofractionated radiotherapy scheme combined with brachytherapy is feasible for, mostly elderly, patients not eligible for neoadjuvant chemoradiotherapy and surgery or definitive chemoradiation. The 1 year local recurrence free survival is 77%.
PO-0703 Does neoadjuvant chemotherapy improve the pathologic complete remission rate for rectal cancer patients? T. Vuong1, A. Garant1, T. Niazi1, P. Kavan2, C.A. Vasilevsky3, F. Letellier4, M. Boutros3, G. Batist2 1 Jewish General Hospital, Department of Radiation Oncology, Montreal, Canada 2 Jewish General Hospital, Department of Oncology, Montreal, Canada 3 Jewish General Hospital, Department of Surgery, Montreal, Canada 4 Centre Hospitalier Pierre Boucher, Department of Surgery, Longueuil, Canada
PO-0705 Phase I/II study of image-guided and radiobiologically guided radiotherapy for hepatic lesions M. Lock1, S. Gaede1, M. Plotnick1, E. Wong1 1 The London Regional Cancer Centre, Department of Radiation Oncology, London Ontario, Canada
Purpose/Objective: Pathologic complete response (pCR) is presently commonly used as a surrogate of neoadjuvant treatment in patients (pts) with rectal cancer. The present study is looking at the potential role of neoadjuvant FOLFOX chemotherapy (CT) in a randomized phase II study using a two-to-one weighing in favor of CT in patients at high risk of recurrence based on Magnetic resonance imaging (MRI) criteria for nodes (N), circumferential radial margin (CRM) and extramural venous invasion (EMVI). Materials and Methods: Eighty-five patients qualified for the selection criteria and signed an informed consent form from 2010 to September 2013. Fifthly-seven patients were treated in arm A with 6 cycles of neoadjuvant FOLFOX chemotherapy, followed by high dose rate endorectal brachytherapy (HDREBT) using 26 Gy in 4 fractions, then surgery with an additional 6 cycles of CT. Twenty-eight patients were treated in arm B, with upfront HDREBT, then surgery followed by 12 cycles of same CT. At the time of this analysis, 46 outof 57 pts and 26 out of 28 pts in their respective arms completed their surgery and were consequently evaluable for pathologic pT,N status. All patient tumors were recorded prospectively for tumor bulk defined as circumferential, semi-circumferential or less than circumferential at the time of tumor marking by endoscopy; MRI defined T, N status, EMVI and CRM. In arm A, a pelvic MRI was obtained at completion of neoadjuvant CT for HDRBT planning and defined as no response/ progression; minimal response, partial response or complete response. Results: The distribution of T stage, nodes, CRM and EMVI were well balanced between the 2 arms. In arm A, the pT0 rate was 30.4 % compared to 34% for arm B; pCR rates were 26.08% and 26.9% respectively (p=0.775). There was no significant difference observed in the incidence of pathologically negative nodes in arm A and B with respectively 65% and 61.53%. Conclusions: In the first seventy-two patients who completed surgery in a randomized phase II study testing the value of neoadjuvant CT for rectal cancer, there is no significant trend to suggest that CT will improve the pCR rate when given before radiation therapy. PO-0704 Hypofractionated external beam radiotherapy combined with highdose-rate brachytherapy in esophageal cancer J. Dortmans1, P.M. Braam1, H. Rütten1 1 Radboud University Medical Center, Radiotherapy, Nijmegen, The Netherlands Purpose/Objective: To evaluate the results of curatively intended radiation treatment in patients with esophageal cancer not suitable for a
Purpose/Objective: To report clinical outcomes of an image-guided and radiobiologically-guided radiotherapy treatment for hepatic lesions. Materials and Methods: Patients with hepatic lesions treated using an individualized radiobiologically-guided and image-guided radiation protocol were selected. The dose was individualized based on the radiobiological estimate of the liver normal tissue complication probability (NTCP). A NTCP of 5% or less was accepted. Volume of liver irradiated and DVH constraints (bowel, stomach, spinal cord, kidneys) were also factors in dose selection. Varian Real time Position Management (RPM) was employed for respiratory gating during CT simulation and treatment. Localization with IV contrast was used for simulation. RECIST criteria were used for progression assessment and NCIC CTCAE V4.0 was used for toxicity assessment. Survival was estimated by Kaplan Meier method. Results: Patient data: 152 patients received individualized radiotherapy between June 2004 and December 2012. 40 were excluded as they were treated for microscopic residual disease, pre-op. Colorectal (25%), cholangiocarcinoma (11%), and hepatocellular carcinoma (38%) accounted for over 70% of cases. 78% were Child-Pugh A. 23% of cases had imaging or pathologic evidence of cirrhosis. 36% had more than 3 lesions (range1-8). However, 92% of cases had only 2 or less lesions treated. 50% had known intra- or extra-hepatic lesions that were not treated by radiation. Patients were heavily pre-treated with 40% receiving chemotherapy before radiation. Median followup was 36 months. HCC Mets Tumour Volume (cm3)
180 (1.3-995)
Total Dose (cGy)
4700 (2940-8300) 5180 (2750-8775)
30 (0.4-1804)
Dose/Fraction (cGy)
475 (230-1000)
470 (180-1333)
Equivalent Dose in 2Gy/Fraction 55 (36.5-107)
61 (33-156)
NTCP (%)
2.9 (0-10)
2.2 (0-5.5%)
Treatment data: Liver NTCP was not the dose limiting variable in 85% of patients. 33% received more than 70Gy in 2Gy/fraction equivalent dose. Outcome data: 64% had recurrence or progression with 33% having only out-of-radiation-field recurrence, 20% having only in-radiation-field recurrence, and 12% having both in and out-of-field recurrence/progression. Median survival was 11.3 months (95% CI 8.3 to 17.8 months). Overall, Child-Pugh B score increased the risk of death by 2.4 times compared to Child-Pugh A by multivariate analysis. Any NCIC CTCAE 4.0 Grade 0, 1, 2, and 3 were found before treatment in 22%, 45%, 31% and 2% of patients, respectively. The primary toxicities reported were abdominal pain/bloating (27%) and fatigue (28%). This is likely tumor-related as opposed to treatment-related toxicity, as change scores indicate unchanged or improved rating compared to pre-radiation scores except for fatigue and pain/bloating. There was no radiation-induced liver disease (RILD) or treatment-related grade 4/5 toxicity. RILD did not appear to be a significant symptomatic issue even with a more conservative NTCP calculation.
Conclusions: The absence of clear relationship between RBA and absorbed dose suggests possible modulation of skin response related to other factors such as breast volume, drug assumption, concomitant morbidities, phenotype and genotype. Moreover, RS is a good, objective and sensitive tool for the evaluation of relative skin changes. Initial skin reactions, which are hardly detectable by the physician, seem to be a good indicator of the development of possible acute skin toxicity within the entire RT. This study was partially funded by the LILT Lega Italiana per la lotta contro i tumori (Milano). PO-0701 From supine to prone breast radiotherapy: an unaffordable cost? L. Van den Berghe1, B. Vanderstraeten1, L. Veldeman1, N. Flamée1, Y. Lievens1 1 Ghent University Hospital, Radiotherapy, Ghent, Belgium Purpose/Objective: Whereas the supine position remains standard in most radiotherapy centres, prone breast irradiation is gaining attention due to the potential of improved organ sparing. We compared the cost of prone versus supine whole breast irradiation (WBI) and put it in context of other types of breast irradiation. Materials and Methods: In 2012, a multicentre time-driven activitybased costing (TD-ABC) study was conducted computing the costs of all delivered radiotherapy treatments in the framework of a national project on innovative radiotherapy techniques (1). The current study focuses on the different types of breast irradiation delivered at our institution, all employing intensity-modulated radiotherapy (IMRT). Three data sets were used. First, the baseline TD-ABC study used average treatment time slots for WBI-IMRT in daily practice (DP), regardless of prone or supine position. To analyse a possible difference between the two treatment set-ups, we introduced the actual differences in measured times between prone and supine irradiation. Finally, before introduction of prone breast treatments in daily practice, a comparative clinical trial was conducted including daily measurements of the time necessary for positioning, imaging and irradiation in prone versus supine. These data from the trial phase (TP) were used as a third data set. In addition to the thus calculated costs, direct material costs were added for the individual bra used for prone breast treatments. Results: The treatment time slots are longer in prone than in supine position, as well in DP (prone: 16,6 minutes, supine: 14,9 minutes) as in the TP (21,2 minutes for prone irradiation and 19,4 minutes for supine treatment). The average cost of WBI in our daily practice amounts to 4,444€ in case 15 fractions are delivered. When accounting for differences in prone and supine positioning, we found an only slightly higher cost of 4,597€ in prone irradiation versus 4,379€ in supine. Our calculations however show that the cost was significantly higher in the TP, in line with the higher time requirements: 5,679€ for prone compared to 5,306€ for supine position, with an incremental cost of 374€ € between both set-ups. Figure 1 demonstrates the costs of prone and supine WBI in the context of other breast irradiations in DP. Not unexpectedly, the cost increases with number of fractions and with complexity of the target volume (addition of lymph nodes).
ESTRO 33, 2014
Conclusions: Prone WBI delivered with IMRT is only slightly more expensive than WBI-IMRT delivered in supine position. This extra cost will have to be weighed against the decrease in toxicity. The total treatment cost decreased after completion of the learning curve by achievement of shorter treatment times, demonstrating that the nursing staff clearly got accustomed to the new method of positioning. (1) https://kce.fgov.be/publication/report%20198/
POSTER: CLINICAL TRACK: GASTROINTESTINAL TUMOURS (UPPER AND LOWER GI) PO-0702 Prognostic value of early PET-CT to predict response after neoadjuvant RCT in locally advanced rectal cancer M.A. Gambacorta1, L. Leccisotti2, C. Valentini1, C. De Waure3, M. Boccardi1, A.R. Alitto1, A. Stefanelli2, M.C. Barba4, A. Giordano2, V. Valentini1 1 Sacred Heart Catholic University of Rome, Radiation Oncology Department, Rome, Italy 2 Sacred Heart Catholic University of Rome, Nuclear Medicine Institution, Rome, Italy 3 Sacred Heart Catholic Unversity of Rome, Hygiene and biostatistics, Rome, Italy 4 San Peter Hospital Fatebene Fratelli, Radiation Oncology Department, Rome, Italy Purpose/Objective: To evaluate if changes in 18F-FDG uptake during and after preoperative RCT could predict pathological response in Locally Advanced Rectal Cancer (LARC) patients (pts), to discriminate the subgroup of non responders pts which may benefit from alternative treatment strategy. Materials and Methods: From December 2006 to September 2011, 126 consecutive pts with histological confirmed LARC were prospectively enrolled at our Institution. All pts underwent 18F-FDG PET-CT at three different time: before preoperative RCT (baseline PET-CT), at the end of the second week of preoperative RCT (early PET-CT) and before surgery (late PET-CT). Maximum Standardized Uptake Value (SUVmax) was measured. Tumor SUVmax values were employed to assess the response to preoperative RCT by calculating a response index (RI), as RI=[(SUV2SUV1)/SUV1]×100. Changes in 18F-FDG uptake between baseline and early PET-CT (early RI) and between baseline and late RCTPET-CT (late RI) were correlated to the pathological tumor response. Preoperative 5-FU based RCT (total dose of 5040-5500cGy according to T stage, extramesorectal lymph nodes and MRF involvement) treatment was delivered to pts with LARC or with stage I low-lying tumor. Standard surgical procedure was the total mesorectal excision at least 8 weeks after the end of RCT. Surgical specimens were classified according to (yp)TNM definition. Tumor response to pre-operative RCT was performed according to the tumor regression grade (TRG) score: the tumors were grouped into responders (TRG1) and non responders (TRG25); complete responders were also defined with respect to pathological analysis if ypT0ypN0. Results: According to TRG classification, 31/126 pts (24.6%) were classified asTRG1 and 95/126 pts (75.4%) were classified as TRG2-5. With respect to pathological examination, available on 124 patients, 28 (22.6%) were classified as responders and 96 (77.4%) as non responders.
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ESTRO 33, 2014 SUVmax was significantly higher on baseline PET-CT compared to early and late PET-CT both in responders (TRG1) and non responders (TRG2-5). The AUC of early RI in identifying non responders according to TRG and (yp)TNM was 0.75 (95%CI 0.62-0.88) and 0.74 (95%CI 0.61-0.87); the optimal cut-off was identified as a reduction of 61.2% (sensitivity of 85.4% and specificity of 65.2% in identifying non responders according to TRG and 83.1% and 65% in identifying non responders according to y(p)TNM).
resection or a radical course of chemoradiation in a hypofractionated scheme in combination with intraluminal brachytherapy in our institute. Materials and Methods: Fifty three patients treated with EBRT (50 Gy in 20 fractions) and HDR brachytherapy (12 Gy in 2 fractions) were retrospectively analysed. Toxicity and dysphagia were scored.
Conclusions: The reduction of tumor SUVmax of 61.2% could be an optimal cut-off to distinguish TRG1 from TRG2-5 on early PET-CT. The positive predictive value of identifying non responders at early PET-CT (91.3%), seems to be useful to identify the absence of response to preoperative treatment early, allowing the clinicians to tailor treatment. Although it is known that integration with other data could improve the predictive values of PET-CT1.
Results: Of all patients 64.2% completed the whole scheduled treatment. Nineteen percent of patients was over 80 years old. The 1 and 2 year estimated local recurrence free survival rates were 77% and 66% respectively. The median follow up was 9 months (range 1-53 months). A grade III stenosis was reported in 8 patients (15%). Four patients (7,5%) died of complications from their treatment; 2 died of perforation of the esophagus, 1 had an acute lethal bleeding and 1 patient died of an esophago-pericardial fistula after reirradiation. Post treatment 49.1% of patients could consume a normal diet.
1 van Stiphout RG, Lammering G, Buijsen J, et al Development and external validation of a predictive model for pathological complete response of rectal cancer patients including sequential PET-CT imaging. Radiother Oncol. 2011 Jan; 98(1) : 126-33. doi:. 1016/ j.radonc. 2010.12.002. Epub 2010 Dec 20.
Conclusions: A curatively intended hypofractionated radiotherapy scheme combined with brachytherapy is feasible for, mostly elderly, patients not eligible for neoadjuvant chemoradiotherapy and surgery or definitive chemoradiation. The 1 year local recurrence free survival is 77%.
PO-0703 Does neoadjuvant chemotherapy improve the pathologic complete remission rate for rectal cancer patients? T. Vuong1, A. Garant1, T. Niazi1, P. Kavan2, C.A. Vasilevsky3, F. Letellier4, M. Boutros3, G. Batist2 1 Jewish General Hospital, Department of Radiation Oncology, Montreal, Canada 2 Jewish General Hospital, Department of Oncology, Montreal, Canada 3 Jewish General Hospital, Department of Surgery, Montreal, Canada 4 Centre Hospitalier Pierre Boucher, Department of Surgery, Longueuil, Canada
PO-0705 Phase I/II study of image-guided and radiobiologically guided radiotherapy for hepatic lesions M. Lock1, S. Gaede1, M. Plotnick1, E. Wong1 1 The London Regional Cancer Centre, Department of Radiation Oncology, London Ontario, Canada
Purpose/Objective: Pathologic complete response (pCR) is presently commonly used as a surrogate of neoadjuvant treatment in patients (pts) with rectal cancer. The present study is looking at the potential role of neoadjuvant FOLFOX chemotherapy (CT) in a randomized phase II study using a two-to-one weighing in favor of CT in patients at high risk of recurrence based on Magnetic resonance imaging (MRI) criteria for nodes (N), circumferential radial margin (CRM) and extramural venous invasion (EMVI). Materials and Methods: Eighty-five patients qualified for the selection criteria and signed an informed consent form from 2010 to September 2013. Fifthly-seven patients were treated in arm A with 6 cycles of neoadjuvant FOLFOX chemotherapy, followed by high dose rate endorectal brachytherapy (HDREBT) using 26 Gy in 4 fractions, then surgery with an additional 6 cycles of CT. Twenty-eight patients were treated in arm B, with upfront HDREBT, then surgery followed by 12 cycles of same CT. At the time of this analysis, 46 outof 57 pts and 26 out of 28 pts in their respective arms completed their surgery and were consequently evaluable for pathologic pT,N status. All patient tumors were recorded prospectively for tumor bulk defined as circumferential, semi-circumferential or less than circumferential at the time of tumor marking by endoscopy; MRI defined T, N status, EMVI and CRM. In arm A, a pelvic MRI was obtained at completion of neoadjuvant CT for HDRBT planning and defined as no response/ progression; minimal response, partial response or complete response. Results: The distribution of T stage, nodes, CRM and EMVI were well balanced between the 2 arms. In arm A, the pT0 rate was 30.4 % compared to 34% for arm B; pCR rates were 26.08% and 26.9% respectively (p=0.775). There was no significant difference observed in the incidence of pathologically negative nodes in arm A and B with respectively 65% and 61.53%. Conclusions: In the first seventy-two patients who completed surgery in a randomized phase II study testing the value of neoadjuvant CT for rectal cancer, there is no significant trend to suggest that CT will improve the pCR rate when given before radiation therapy. PO-0704 Hypofractionated external beam radiotherapy combined with highdose-rate brachytherapy in esophageal cancer J. Dortmans1, P.M. Braam1, H. Rütten1 1 Radboud University Medical Center, Radiotherapy, Nijmegen, The Netherlands Purpose/Objective: To evaluate the results of curatively intended radiation treatment in patients with esophageal cancer not suitable for a
Purpose/Objective: To report clinical outcomes of an image-guided and radiobiologically-guided radiotherapy treatment for hepatic lesions. Materials and Methods: Patients with hepatic lesions treated using an individualized radiobiologically-guided and image-guided radiation protocol were selected. The dose was individualized based on the radiobiological estimate of the liver normal tissue complication probability (NTCP). A NTCP of 5% or less was accepted. Volume of liver irradiated and DVH constraints (bowel, stomach, spinal cord, kidneys) were also factors in dose selection. Varian Real time Position Management (RPM) was employed for respiratory gating during CT simulation and treatment. Localization with IV contrast was used for simulation. RECIST criteria were used for progression assessment and NCIC CTCAE V4.0 was used for toxicity assessment. Survival was estimated by Kaplan Meier method. Results: Patient data: 152 patients received individualized radiotherapy between June 2004 and December 2012. 40 were excluded as they were treated for microscopic residual disease, pre-op. Colorectal (25%), cholangiocarcinoma (11%), and hepatocellular carcinoma (38%) accounted for over 70% of cases. 78% were Child-Pugh A. 23% of cases had imaging or pathologic evidence of cirrhosis. 36% had more than 3 lesions (range1-8). However, 92% of cases had only 2 or less lesions treated. 50% had known intra- or extra-hepatic lesions that were not treated by radiation. Patients were heavily pre-treated with 40% receiving chemotherapy before radiation. Median followup was 36 months. HCC Mets Tumour Volume (cm3)
180 (1.3-995)
Total Dose (cGy)
4700 (2940-8300) 5180 (2750-8775)
30 (0.4-1804)
Dose/Fraction (cGy)
475 (230-1000)
470 (180-1333)
Equivalent Dose in 2Gy/Fraction 55 (36.5-107)
61 (33-156)
NTCP (%)
2.9 (0-10)
2.2 (0-5.5%)
Treatment data: Liver NTCP was not the dose limiting variable in 85% of patients. 33% received more than 70Gy in 2Gy/fraction equivalent dose. Outcome data: 64% had recurrence or progression with 33% having only out-of-radiation-field recurrence, 20% having only in-radiation-field recurrence, and 12% having both in and out-of-field recurrence/progression. Median survival was 11.3 months (95% CI 8.3 to 17.8 months). Overall, Child-Pugh B score increased the risk of death by 2.4 times compared to Child-Pugh A by multivariate analysis. Any NCIC CTCAE 4.0 Grade 0, 1, 2, and 3 were found before treatment in 22%, 45%, 31% and 2% of patients, respectively. The primary toxicities reported were abdominal pain/bloating (27%) and fatigue (28%). This is likely tumor-related as opposed to treatment-related toxicity, as change scores indicate unchanged or improved rating compared to pre-radiation scores except for fatigue and pain/bloating. There was no radiation-induced liver disease (RILD) or treatment-related grade 4/5 toxicity. RILD did not appear to be a significant symptomatic issue even with a more conservative NTCP calculation.