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PO-390 INTRAOPERATIVE AND PERCUTANEOUS IR-192 BRACHYTHERAPY FOR MULTIPLY IRRADIATED LESIONS OF THE SPINE
World Congress of Brachytherapy 2012 delivering a 50-kV maximal energy X-ray beam. Out of a total of 28 patients, one had two synchronous tumours. Age ranged from 48 to 94 years (median: 77.3), with a male female ratio of 1. Site: lateral canthus = 3 %, medial canthus = 31%, lower eyelid = 45 %, upper eyelid = 21 %. There were 80 % (23) basal cell carcinomas, 17% (5) squamous cell carcinoma, 3% (1) melanoma. No tumour exceeded T1b. Five patients were referred for radical radiotherapy treatment (first event) and twenty-four patients for post-operative treatment: among them, R0 excision = 2 (1 first event, 1 recurrence), R1 excision = 22 (15 first events, 7 recurrences). They were treated according to 2 schemes: 42 Gy in six fractions of 7 Gy (23 %) for radical treatment, 35 Gy in 5 fractions of 7 Gy (77 %) in case of post-operative treatment. Results: Follow-up ranged from 2 to 24 months. Five patients were lost to follow-up. One local relapse occurred 2 months after treatment, outside the treated area. Side effects: All patients had Grade I (55%) or II (45 %) erythema and loss of the eyelashes in the treated area during treatment. 17% had GI eye watering, 10% suffered from a GII conjunctivitis, and 3% had a G II pilo sebaceous gland infection. Sequelae: persistent watering of the eye for 21%, xerosis for 14%, one ectropion, one definitive loss of eyelashes and one with slightly depigmented skin. No cataract was observed. Majority of patients assessed were more than satisfied with both the cosmetic and function that followed radiotherapy.
S 155 PO-389 INTERSTITIAL PERMANENT IMPLANTATION OF 125 I SEEDS FOR REFRACTORY CHEST WALL MATASTASIS OR RECURRENCE P. Jiang1, J. Wang1, Y. Jiang1, W. Jiang1, N.A. Meng1, R. Yang1 1 Peking University Third Hospital, Radiotherapeutic Department, Beijing, China Purpose/Objective: To evaluate the efficacy and safety of 125I seeds implantation for refractory chest wall matastasis or recurrence under CT guidance. In addition we assessed initial data obtained on the therapeutic response for refractory chest wall matastasis or recurrence. Materials and Methods: A retrospective review of 20 patients ( from Jul,2004 to Jan, 2011) who underwent interstitial permanent implantation of 125 I seeds under CT guidance. All patients had ever received at least one modality treatment before 125I seeds implantation and had been reviewed by the surgeons and radiation oncologists, that they were considered not suitable for salvage surgery and external beam radiation therapy again or the patients refused to receive. The tumor volumes were measured using CT scans at 5-mm intervals 3-5days before seed implantation.Postoperative dosimetry was routinely performed for all patients. The D90 (the doses delivered to 90% of the target volume de?ned by CT using dose-volume histogram) of the implanted 125 I seeds ranged from 100Gy to 160Gy (median:130Gy). The activity of 125 I seeds ranged from 0.5mCi to 0.78mCi (median: 0.71mCi). The total number of seeds implanted ranged from 8 to 269 (median: 53). The follow-up period ranged from 3 to 54 months(median: 11.5months). The survival and local control probabilities were calculated by the Kaplan-Meier method. Results: The 1- ,2-,3-and 4-year tumor control rates were all 88.7% respectively. The 1- and 2-,3-,4-year cancer specific survival rates were 56.5% and 47.1%, 47.1%, 47.1% respectively. The 1- and 2-,3-,4year overall survival rates were 53.3% and 35.6%, 35.6%, 35.6% respectively, with a median survival of 15 months (95% CI,7.0–22.9). Mild brachial plexus injury was seen in one patient, grade 1 or 2 skin reactions were seen in 6 patients (30%) who had received external beam radiation therapy before. No grade 3 and 4 skin side effects were found. Rib fracture, ulceration, pneumothorax or hemopneumothorax were not seen. Conclusions: Interstitial permanent implantation of 125 I seeds under CT guidance is feasible, efficacy and safe for refractory chest wall matastasis or recurrence. PO-390 INTRAOPERATIVE AND PERCUTANEOUS IR-192 BRACHYTHERAPY FOR MULTIPLY IRRADIATED LESIONS OF THE SPINE Y. Yamada1, M.R. Folkert1, G.N. Cohen2, M. Zaider2, J. Chiu2, E. Lis3, G. Krol3, M.H. Bilsky4 1 Memorial Sloan-Kettering Cancer Center, Radiation Oncology, New York NY, USA 2 Memorial Sloan-Kettering Cancer Center, Medical Physics, New York NY, USA 3 Memorial Sloan-Kettering Cancer Center, Neuroradiology, New York NY, USA 4 Memorial Sloan-Kettering Cancer Center, Neurosurgery, New York NY, USA
Conclusions: CXR therapy of the eyelid for skin carcinoma is an effective treatment, with no local relapse except one outside the treated area, with few significant side effects or sequelae in this elderly population.
Purpose/Objective: While advances in stereotactic external beam radiation therapy have improved local control of spine metastases, progression of disease is still a significant problem and repeat irradiation is complicated by normal tissue tolerance, particularly that of the spinal cord. Intraoperative and percutaneous high-dose rate brachytherapy techniques have been developed to address this issue and improve local control, pain control, and prevent progressive neurological deficits. Materials and Methods: A series of patients were identified with progressive disease at multiply irradiated sites in the spine; 2 patients subsequently received intraoperative HDR brachytherapy using catheters placed in the vertebral bodies during surgery and 1 patient was treated with percutaneously implanted catheters with the assistance of interventional radiology. In all cases catheter placement was performed under general anesthesia; using either direct visualization or fluoroscopic guidance, trocars were placed into the vertebral body and pedicles, after which flexible afterloader
S156 catheters were placed through these trocars and the position of the catheters was confirmed by fluoroscopic imaging. A planning CT scan was taken in the treatment position; using this intraoperative CT scan and preoperative imaging, the patient's spinal cord/cauda, gross tumor volume and a clinical volume were contoured. A treatment plan was generated and following plan review and approval, the patients were treated with radiation delivered in a single fraction using highdose-rate Ir-192 brachytherapy. All treatments were performed using a GammaMed Plus HDR Unit, after which the catheters were removed. Patients were reassessed clinically at 2-4 weeks and then with serial imaging and clinical assessment. Results: In all cases treatment was successfully delivered with no brachytherapy-related complications. At a median followup of 5.7 months, there has been no local progression of disease. Median dose delivered was 1400 cGy (range 1200-1800 cGy) with a median GTV V90 of 57% (range 40-89%). In all cases the spinal cord/cauda maximum dose constraints were met. 2 patients (66.7%) had significant pain relief 1-4 weeks following treatment. Conclusions: Intraoperative and percutaneous Ir-192 HDR spine brachytherapy is not associated with complications or acute toxicity; while these therapeutic methodologies are in the early investigational stages, they may provide a safe and effective means of treating multiply irradiated sites of disease progression in the spine. In addition, use of the percutaneous technique provides a novel salvage treatment modality for patients who are not appropriate surgical candidates. PO-391 INTRAOPERATIVE BRACHYTHERAPY FOR THORACIC MALIGNANCIES RESECTED WITH CLOSE OR POSITIVE MARGINS A.J. Wu1, G.N. Cohen2, K.E. Rosenzweig3, M.J. Zelefsky1, M.S. Bains4, A. Rimner1 1 Memorial Sloan-Kettering Cancer Center, Radiation Oncology, New York NY, USA 2 Memorial Sloan-Kettering Cancer Center, Medical Physics, New York NY, USA 3 Mount Sinai Medical Center, Radiation Oncology, New York NY, USA 4 Memorial Sloan-Kettering Cancer Center, Thoracic Surgery, New York NY, USA Purpose/Objective: Local recurrence is a significant problem after surgical resection of thoracic malignancies, particularly when close or positive margins are anticipated. As intraoperative radiotherapy can deliver radiation directly to the threatened margin, we used this technique in an attempt to reduce local recurrence, particularly for patients who had already received external beam radiation. We reviewed our experience with thoracic intraoperative brachytherapy to assess disease control and toxicity outcomes. Materials and Methods: We performed a retrospective review of patients undergoing permanent I-125 mesh placement or temporary Ir192 afterloading therapy during surgical resection of primary or metastatic thoracic tumors between 2001 and 2011. In general, for I125 brachytherapy, iodine seeds were sutured into a mesh at 1cm intervals to form a planar implant delivering 100-150Gy to the MPD, which was then sutured onto the at-risk site. For Ir-192 brachytherapy, a HAM applicator was apposed to the at-risk site, then connected to the afterloader to deliver 12-15Gy to a depth of 0.5cm from the applicator surface. Results: Forty-one procedures (33 permanent, 8 temporary) were performed on 40 patients (28-74 years old, median 57). Histology of tumors was NSCLC (n=19), sarcoma (n=12), mesothelioma (n=2), thymic carcinoma (n=7) and metastatic renal cell carcinoma (n=1). Treated sites were lung (n=16), chest wall/paraspinal (n=16), and mediastinum (n=9). Twenty-six patients had previously received EBRT to the area (median 50.4 Gy). Final margins were microscopically negative in 20 cases (49%) and positive or not assessable in the remainder. The median size of the treated area was 25cm2 (range: 470cm2). The median followup was 30 months. Actuarial local control at 1 and 2 years was 74% and 67% respectively. Overall survival at 1 and 2 years was 86% and 75% respectively. No perioperative deaths occurred. There was no significant difference in local control according to margin status or brachytherapy technique. Seven patients (17%) experienced toxicity possibly related to brachytherapy: 4 patients required reoperation for empyema, 1 patient developed
World Congress of Brachytherapy 2012 apparent bronchopleural fistula, and 1 patient developed possible radiation pneumonitis. One patient, who also had a distant history of mantle-field irradiation for lymphoma, died from complications of SVC syndrome possibly related to radiation fibrosis, four years after brachytherapy. Conclusions: Intraoperative brachytherapy is associated with good local control after resection of thoracic tumors felt to be at very high risk for recurrence due to close or positive margins. There does not appear to be an excessive rate of severe toxicity attributable to brachytherapy. Intraoperative brachytherapy should be considered in situations where the oncologic completeness of thoracic tumor resection is in doubt. PO-392 POSTOPERATIVE INTERSTITIAL PULSED-DOSE-RATE (PDR) BRACHYTHERAPY IN THE TREATMENT OF THERAPY-RESISTANT KELOIDS R. Davila Fajardo1, R. Van Os1, O. Lapid2, R. Noordanus3, B. Pieters1 1 Academic Medical Center, Radiation Oncology, Amsterdam, The Netherlands 2 Academic Medical Center, Plastic Surgery, Amsterdam, The Netherlands 3 Flevoziekenhuis Hospital, Plastic Surgery, Almere, The Netherlands Purpose/Objective: To evaluate the results of pulsed-dose-rate (PDR) brachytherapy after excision of the therapy-resistant keloids treated between 2007 and 2011 in our institution. Materials and Methods: Between July 2007 and December 2011, 24 consecutive patients (11 male, 13 female), with 28 keloids were treated in our department with immediate adjuvant brachytherapy after surgical excision. Most of them appeared to be caused by previous trauma, surgery or infection. Histological keloid confirmation was obtained in 14% of the cases. In 91% of the patients the Fitzpatrick scale grade was recorded. Sixty four percent of the keloids had been previously treated either by surgical excision or intralesional steroid injections (Kenacort-A®), the rest conservatively. The median follow-up time was 7.2 months [range 0-34.4]. All keloids underwent surgical excision under local anaesthetic, placing of a plastic catheter (Best®) and the wound was primarily closed with subcutaneous suture. The irradiation was performed with a PDR afterloader device using an Ir-192 source. One single fraction of 13Gy was administered with a 100% reference isodose line at the surface of the skin (4-7mm) in the central plane. Biologically effective dose (BED) 29.9Gy (α/β=10). Recurrence was defined as a growing nodular pruritic scar infield or beyond the surgical and irradiated area. Results: Recurrence free survival at 12 months was 80% (figure 1. Kaplan-Meier curve). The median time to recurrence was 5.3 months [range 0-34.4]. Four patients developed pruritus in a flat scar and they were treated with steroid injections with no growing nodular scar in the follow-up. These patients are not included in the recurrence group. Multivariate analysis showed the gender as significant factor for recurrence free survival to the detriment of male condition (p=0.04). While Fitzpatrick scale grade and location of the keloid were no significant factors for recurrence free survival (p=0.27 and p=0.54, respectively).Three patients developed hyperpigmentation of the scar, grade1 as toxicity of the irradiation, probably also related to the use of steroids, and one hypopigmentation of the scar grade 1, (CTC 4.0). No second malignancy has been described.
S 155 PO-389 INTERSTITIAL PERMANENT IMPLANTATION OF 125 I SEEDS FOR REFRACTORY CHEST WALL MATASTASIS OR RECURRENCE P. Jiang1, J. Wang1, Y. Jiang1, W. Jiang1, N.A. Meng1, R. Yang1 1 Peking University Third Hospital, Radiotherapeutic Department, Beijing, China Purpose/Objective: To evaluate the efficacy and safety of 125I seeds implantation for refractory chest wall matastasis or recurrence under CT guidance. In addition we assessed initial data obtained on the therapeutic response for refractory chest wall matastasis or recurrence. Materials and Methods: A retrospective review of 20 patients ( from Jul,2004 to Jan, 2011) who underwent interstitial permanent implantation of 125 I seeds under CT guidance. All patients had ever received at least one modality treatment before 125I seeds implantation and had been reviewed by the surgeons and radiation oncologists, that they were considered not suitable for salvage surgery and external beam radiation therapy again or the patients refused to receive. The tumor volumes were measured using CT scans at 5-mm intervals 3-5days before seed implantation.Postoperative dosimetry was routinely performed for all patients. The D90 (the doses delivered to 90% of the target volume de?ned by CT using dose-volume histogram) of the implanted 125 I seeds ranged from 100Gy to 160Gy (median:130Gy). The activity of 125 I seeds ranged from 0.5mCi to 0.78mCi (median: 0.71mCi). The total number of seeds implanted ranged from 8 to 269 (median: 53). The follow-up period ranged from 3 to 54 months(median: 11.5months). The survival and local control probabilities were calculated by the Kaplan-Meier method. Results: The 1- ,2-,3-and 4-year tumor control rates were all 88.7% respectively. The 1- and 2-,3-,4-year cancer specific survival rates were 56.5% and 47.1%, 47.1%, 47.1% respectively. The 1- and 2-,3-,4year overall survival rates were 53.3% and 35.6%, 35.6%, 35.6% respectively, with a median survival of 15 months (95% CI,7.0–22.9). Mild brachial plexus injury was seen in one patient, grade 1 or 2 skin reactions were seen in 6 patients (30%) who had received external beam radiation therapy before. No grade 3 and 4 skin side effects were found. Rib fracture, ulceration, pneumothorax or hemopneumothorax were not seen. Conclusions: Interstitial permanent implantation of 125 I seeds under CT guidance is feasible, efficacy and safe for refractory chest wall matastasis or recurrence. PO-390 INTRAOPERATIVE AND PERCUTANEOUS IR-192 BRACHYTHERAPY FOR MULTIPLY IRRADIATED LESIONS OF THE SPINE Y. Yamada1, M.R. Folkert1, G.N. Cohen2, M. Zaider2, J. Chiu2, E. Lis3, G. Krol3, M.H. Bilsky4 1 Memorial Sloan-Kettering Cancer Center, Radiation Oncology, New York NY, USA 2 Memorial Sloan-Kettering Cancer Center, Medical Physics, New York NY, USA 3 Memorial Sloan-Kettering Cancer Center, Neuroradiology, New York NY, USA 4 Memorial Sloan-Kettering Cancer Center, Neurosurgery, New York NY, USA
Conclusions: CXR therapy of the eyelid for skin carcinoma is an effective treatment, with no local relapse except one outside the treated area, with few significant side effects or sequelae in this elderly population.
Purpose/Objective: While advances in stereotactic external beam radiation therapy have improved local control of spine metastases, progression of disease is still a significant problem and repeat irradiation is complicated by normal tissue tolerance, particularly that of the spinal cord. Intraoperative and percutaneous high-dose rate brachytherapy techniques have been developed to address this issue and improve local control, pain control, and prevent progressive neurological deficits. Materials and Methods: A series of patients were identified with progressive disease at multiply irradiated sites in the spine; 2 patients subsequently received intraoperative HDR brachytherapy using catheters placed in the vertebral bodies during surgery and 1 patient was treated with percutaneously implanted catheters with the assistance of interventional radiology. In all cases catheter placement was performed under general anesthesia; using either direct visualization or fluoroscopic guidance, trocars were placed into the vertebral body and pedicles, after which flexible afterloader
S156 catheters were placed through these trocars and the position of the catheters was confirmed by fluoroscopic imaging. A planning CT scan was taken in the treatment position; using this intraoperative CT scan and preoperative imaging, the patient's spinal cord/cauda, gross tumor volume and a clinical volume were contoured. A treatment plan was generated and following plan review and approval, the patients were treated with radiation delivered in a single fraction using highdose-rate Ir-192 brachytherapy. All treatments were performed using a GammaMed Plus HDR Unit, after which the catheters were removed. Patients were reassessed clinically at 2-4 weeks and then with serial imaging and clinical assessment. Results: In all cases treatment was successfully delivered with no brachytherapy-related complications. At a median followup of 5.7 months, there has been no local progression of disease. Median dose delivered was 1400 cGy (range 1200-1800 cGy) with a median GTV V90 of 57% (range 40-89%). In all cases the spinal cord/cauda maximum dose constraints were met. 2 patients (66.7%) had significant pain relief 1-4 weeks following treatment. Conclusions: Intraoperative and percutaneous Ir-192 HDR spine brachytherapy is not associated with complications or acute toxicity; while these therapeutic methodologies are in the early investigational stages, they may provide a safe and effective means of treating multiply irradiated sites of disease progression in the spine. In addition, use of the percutaneous technique provides a novel salvage treatment modality for patients who are not appropriate surgical candidates. PO-391 INTRAOPERATIVE BRACHYTHERAPY FOR THORACIC MALIGNANCIES RESECTED WITH CLOSE OR POSITIVE MARGINS A.J. Wu1, G.N. Cohen2, K.E. Rosenzweig3, M.J. Zelefsky1, M.S. Bains4, A. Rimner1 1 Memorial Sloan-Kettering Cancer Center, Radiation Oncology, New York NY, USA 2 Memorial Sloan-Kettering Cancer Center, Medical Physics, New York NY, USA 3 Mount Sinai Medical Center, Radiation Oncology, New York NY, USA 4 Memorial Sloan-Kettering Cancer Center, Thoracic Surgery, New York NY, USA Purpose/Objective: Local recurrence is a significant problem after surgical resection of thoracic malignancies, particularly when close or positive margins are anticipated. As intraoperative radiotherapy can deliver radiation directly to the threatened margin, we used this technique in an attempt to reduce local recurrence, particularly for patients who had already received external beam radiation. We reviewed our experience with thoracic intraoperative brachytherapy to assess disease control and toxicity outcomes. Materials and Methods: We performed a retrospective review of patients undergoing permanent I-125 mesh placement or temporary Ir192 afterloading therapy during surgical resection of primary or metastatic thoracic tumors between 2001 and 2011. In general, for I125 brachytherapy, iodine seeds were sutured into a mesh at 1cm intervals to form a planar implant delivering 100-150Gy to the MPD, which was then sutured onto the at-risk site. For Ir-192 brachytherapy, a HAM applicator was apposed to the at-risk site, then connected to the afterloader to deliver 12-15Gy to a depth of 0.5cm from the applicator surface. Results: Forty-one procedures (33 permanent, 8 temporary) were performed on 40 patients (28-74 years old, median 57). Histology of tumors was NSCLC (n=19), sarcoma (n=12), mesothelioma (n=2), thymic carcinoma (n=7) and metastatic renal cell carcinoma (n=1). Treated sites were lung (n=16), chest wall/paraspinal (n=16), and mediastinum (n=9). Twenty-six patients had previously received EBRT to the area (median 50.4 Gy). Final margins were microscopically negative in 20 cases (49%) and positive or not assessable in the remainder. The median size of the treated area was 25cm2 (range: 470cm2). The median followup was 30 months. Actuarial local control at 1 and 2 years was 74% and 67% respectively. Overall survival at 1 and 2 years was 86% and 75% respectively. No perioperative deaths occurred. There was no significant difference in local control according to margin status or brachytherapy technique. Seven patients (17%) experienced toxicity possibly related to brachytherapy: 4 patients required reoperation for empyema, 1 patient developed
World Congress of Brachytherapy 2012 apparent bronchopleural fistula, and 1 patient developed possible radiation pneumonitis. One patient, who also had a distant history of mantle-field irradiation for lymphoma, died from complications of SVC syndrome possibly related to radiation fibrosis, four years after brachytherapy. Conclusions: Intraoperative brachytherapy is associated with good local control after resection of thoracic tumors felt to be at very high risk for recurrence due to close or positive margins. There does not appear to be an excessive rate of severe toxicity attributable to brachytherapy. Intraoperative brachytherapy should be considered in situations where the oncologic completeness of thoracic tumor resection is in doubt. PO-392 POSTOPERATIVE INTERSTITIAL PULSED-DOSE-RATE (PDR) BRACHYTHERAPY IN THE TREATMENT OF THERAPY-RESISTANT KELOIDS R. Davila Fajardo1, R. Van Os1, O. Lapid2, R. Noordanus3, B. Pieters1 1 Academic Medical Center, Radiation Oncology, Amsterdam, The Netherlands 2 Academic Medical Center, Plastic Surgery, Amsterdam, The Netherlands 3 Flevoziekenhuis Hospital, Plastic Surgery, Almere, The Netherlands Purpose/Objective: To evaluate the results of pulsed-dose-rate (PDR) brachytherapy after excision of the therapy-resistant keloids treated between 2007 and 2011 in our institution. Materials and Methods: Between July 2007 and December 2011, 24 consecutive patients (11 male, 13 female), with 28 keloids were treated in our department with immediate adjuvant brachytherapy after surgical excision. Most of them appeared to be caused by previous trauma, surgery or infection. Histological keloid confirmation was obtained in 14% of the cases. In 91% of the patients the Fitzpatrick scale grade was recorded. Sixty four percent of the keloids had been previously treated either by surgical excision or intralesional steroid injections (Kenacort-A®), the rest conservatively. The median follow-up time was 7.2 months [range 0-34.4]. All keloids underwent surgical excision under local anaesthetic, placing of a plastic catheter (Best®) and the wound was primarily closed with subcutaneous suture. The irradiation was performed with a PDR afterloader device using an Ir-192 source. One single fraction of 13Gy was administered with a 100% reference isodose line at the surface of the skin (4-7mm) in the central plane. Biologically effective dose (BED) 29.9Gy (α/β=10). Recurrence was defined as a growing nodular pruritic scar infield or beyond the surgical and irradiated area. Results: Recurrence free survival at 12 months was 80% (figure 1. Kaplan-Meier curve). The median time to recurrence was 5.3 months [range 0-34.4]. Four patients developed pruritus in a flat scar and they were treated with steroid injections with no growing nodular scar in the follow-up. These patients are not included in the recurrence group. Multivariate analysis showed the gender as significant factor for recurrence free survival to the detriment of male condition (p=0.04). While Fitzpatrick scale grade and location of the keloid were no significant factors for recurrence free survival (p=0.27 and p=0.54, respectively).Three patients developed hyperpigmentation of the scar, grade1 as toxicity of the irradiation, probably also related to the use of steroids, and one hypopigmentation of the scar grade 1, (CTC 4.0). No second malignancy has been described.