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II Study of Intensity Modulated Radiotherapy in the Treatment of Meningiomas
Abstracts / Clinical Oncology 23 (2011) S1eS58 * Hall-Edwards
Radiotherapy Research Group, Cancer Centre, Queen Elizabeth Hospital, Birmingham, UK y Department of Neuroradiology, Queen Elizabeth Hospital, Birmingham, UK z Department of Neurosurgery, Queen Elizabeth Hospital, Birmingham, UK x Gray Institute for Radiation Oncology and Biology, University of Oxford, Oxford, UK Introduction: The current standard treatment for good performance status patients with glioblastoma multiforme is maximal surgical resection followed by concomitant chemoradiotherapy using temozolomide (RT-TMZ). Although pathological specimens often confirm widespread tumour involvement, 90% of recurrences are recognised to occur locally when using radiotherapy alone. The objective of this evaluation was to determine the pattern of recurrence following RT-TMZ. Methods: A retrospective analysis of patients receiving RT-TMZ between 2006 and 2009 was performed. Analysis of all available serial crosssectional imaging was performed from diagnosis to first relapse. The site of first recurrence was defined by the relationship to the primary disease volume. Local recurrence was defined as enlargement of the primary disease or appearance of a new enhancing nodule within 2 cm. Results: Seventy-one patients were identified receiving RT-TMZ during this period. At the time of the analysis, 54 (76.1%) patients had died. Twenty-eight patients were not eligible for recurrence analysis due to either lack of progression, unsuitable imaging or suspected pseudoprogression. Patterns of first failure were as follows: 38 patients (88%) had local recurrence; three (7%) had distant recurrence in the ipsilateral cerebral hemisphere and two (4%) had recurrence in the contralateral hemisphere. Conclusion: Local recurrence remains the predominant pattern of failure following RT-TMZ. Single phase conformal radiotherapy is appropriate for the majority of these patients. An updated analysis relating site of failure to radiotherapy volume will be presented.
P91 Management of Radiation Induced Xerostomia in the UK R. Simcock, P. Shields Sussex Cancer Centre, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK Introduction: Despite the promise of IMRT, radiation induced xerostomia remains an important symptom affecting the quality of life of head and neck cancer survivors. There are no published guidelines on the optimum management of this condition. As part of the preparation for the NCRN ARIX trial of acupuncture in xerostomia we sought to understand the patterns of care for radiation induced xerostomia in the UK. Methods: An email invitation linked to a web-based survey was sent to clinical oncologists treating head and neck cancer at 58 cancer centres in the UK. Results: Twenty-eight replies were received from 26 (45%) cancer centres. All but one (96%) of the respondents believed that radiation induced xerostomia was a ‘clinically important problem’, although only one centre had a written protocol for its management. Only 36% of centres would recommend the use of pilocarpine with the reasons for not using the drug among the remainder being ‘lack of evidence of effect’ in 76% and ‘side effect profile’ in 53%. Seventy-four per cent recommended use of fluoride mouthwash and all respondents recommended artificial saliva sprays. Oralbalance (65%) and Glandosane (61%) were the most frequently used. Psychological support was offered to patients by a clinical nurse specialist (91% of centres) and speech and language therapist (79%). Twenty-five per cent of centres recommended acupuncture therapy as a treatment, with 10% of centres providing this service within their institution. Conclusion: Despite agreement that radiation induced xerostomia is an important clinical problem, there is no consistent standard of care for these patients in the UK. A wide variety of symptomatic solutions are offered. Despite level 1 evidence of benefit, pilocarpine is used in only a minority. Clinical nurse specialists are asked to provide support to the majority of patients. These results have been used to inform the control arm of the ARIX acupuncture study.
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P92 Preliminary Results from a Phase I/II Study of Intensity Modulated Radiotherapy in the Treatment of Meningiomas S. Sivabalasingham *,y, N. Fersht y, D. D'Souza y, I. Rosenberg y, C. Stacey y, P. Davies y, T. Guerro-Urbano z, S. Short *, y * UCL Cancer Institute, London, UK y Department of Oncology, University College London Hospitals NHS Trust, London, UK z Department of Oncology, Guy's and St Thomas' NHS Foundation Trust, London, UK Introduction: IMRT provides excellent dose conformality and with steep dose gradients has the ability to spare critical structures, an essential factor when treating patients with good prognosis tumours, such as meningiomas. We report the initial results of this phase I/II study, designed to prospectively assess the feasibility and efficacy of treating meningioma patients with IMRT. Methods: Patients with histologically confirmed meningioma deemed to require fractionated radiotherapy were treated with static field IMRT using a dose of 50.4 Gy in 28 daily fractions. The following assessments were performed at baseline and at 3 months, 6 months and yearly following radiotherapy: CTCAE version 3.0 toxicity scores, mini mental test examinations, pituitary function tests, visual assessments, self completed quality of life questionnaires (QLQ C30 and B20), as well as diffusion and perfusion weighted MRI. Acute toxicities were recorded during radiotherapy. Results: Twenty-three patients have been recruited to this study with a median age of 49 years: comprising 61% (14 patients) with WHO grade 1 and 39% (nine patients) with WHO grade 2. Seven-four per cent of meningiomas treated were classified as skull base tumours. All patients were treated with five to seven fields using IMRT and in all 99% of the PTV volume received >90% of the prescribed dose with a mean conformality index of 0.95 (range of 0.88e1.01). Treatment was well tolerated, with only two patients suffering grade 2 acute toxicity. Eighty-three per cent patients experienced grade 1 toxicity, of which fatigue and alopecia were the most common. Twenty-two per cent of patients noticed an improvement in their tumour related symptoms following radiotherapy. There have been no reported grade 2 late toxicities. At a median follow-up of 17 months (range 2e45 months), three patients (all with grade 2 tumours) have developed recurrent disease (two with marginal and one with in-field recurrence). Conclusion: We have demonstrated that IMRT is a highly conformal and welltolerated radiotherapy technique for meningiomas and is associated with early improvement in neurology in a significant proportion of cases.
P93 Optimising Treatment of Anal Cancer: 3D Conformal Radiotherapy with Concurrent Mitomycin C and Capecitabine D. Smith, S. Raouf Department of Radiotherapy, Queen's Hospital, Romford, UK Introduction: The ACT-II trial confirmed mitomycin C with 5-FU as the standard of care for anal cancer when combined with conventionally planned radiotherapy. Capecitabine is widely used as an oral alternative to 5-FU in gastrointestinal cancer with encouraging preliminary results for anal cancer. Modern radiotherapy techniques allow greater dose shaping than with fields selected on the basis of macroscopic disease and bony anatomy. We sought to assess the toxicity and efficacy of a new regime using mitomycin C with capecitabine and conformally planned radiotherapy. Method: All anal cancer patients at our hospital treated radically with conformal radiotherapy and concomitant mitomycin C and capecitabine between 2007 and 2010 were identified and reviewed. Results: Twelve patients were treated using this regime: three men and nine women, age range 47e80 (median 66); most had locally advanced disease with nine having stage IIIa or IIIb. All patients received 50.4 Gy in 28 fractions without delays, 92% complying completely with the planned schedule. Seven-five per cent received the full prescribed chemotherapy course (mitomycin C 6e12 mg/m2 day 1, capecitabine 500e800 mg/m2 bd days 1e14, 22e35). Only two patients developed grade 3 toxicity (skin, diarrhoea); there was grade 2 skin erythema (eight patients), bone marrow suppression (two), nausea (one) and diarrhoea (one). The clinical response at 4 weeks was complete in nine patients and partial in three. At median follow-up of 13.3 months there has been no local relapse, although one patient died of metastatic disease and one of unconnected pulmonary disease.
Radiotherapy Research Group, Cancer Centre, Queen Elizabeth Hospital, Birmingham, UK y Department of Neuroradiology, Queen Elizabeth Hospital, Birmingham, UK z Department of Neurosurgery, Queen Elizabeth Hospital, Birmingham, UK x Gray Institute for Radiation Oncology and Biology, University of Oxford, Oxford, UK Introduction: The current standard treatment for good performance status patients with glioblastoma multiforme is maximal surgical resection followed by concomitant chemoradiotherapy using temozolomide (RT-TMZ). Although pathological specimens often confirm widespread tumour involvement, 90% of recurrences are recognised to occur locally when using radiotherapy alone. The objective of this evaluation was to determine the pattern of recurrence following RT-TMZ. Methods: A retrospective analysis of patients receiving RT-TMZ between 2006 and 2009 was performed. Analysis of all available serial crosssectional imaging was performed from diagnosis to first relapse. The site of first recurrence was defined by the relationship to the primary disease volume. Local recurrence was defined as enlargement of the primary disease or appearance of a new enhancing nodule within 2 cm. Results: Seventy-one patients were identified receiving RT-TMZ during this period. At the time of the analysis, 54 (76.1%) patients had died. Twenty-eight patients were not eligible for recurrence analysis due to either lack of progression, unsuitable imaging or suspected pseudoprogression. Patterns of first failure were as follows: 38 patients (88%) had local recurrence; three (7%) had distant recurrence in the ipsilateral cerebral hemisphere and two (4%) had recurrence in the contralateral hemisphere. Conclusion: Local recurrence remains the predominant pattern of failure following RT-TMZ. Single phase conformal radiotherapy is appropriate for the majority of these patients. An updated analysis relating site of failure to radiotherapy volume will be presented.
P91 Management of Radiation Induced Xerostomia in the UK R. Simcock, P. Shields Sussex Cancer Centre, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK Introduction: Despite the promise of IMRT, radiation induced xerostomia remains an important symptom affecting the quality of life of head and neck cancer survivors. There are no published guidelines on the optimum management of this condition. As part of the preparation for the NCRN ARIX trial of acupuncture in xerostomia we sought to understand the patterns of care for radiation induced xerostomia in the UK. Methods: An email invitation linked to a web-based survey was sent to clinical oncologists treating head and neck cancer at 58 cancer centres in the UK. Results: Twenty-eight replies were received from 26 (45%) cancer centres. All but one (96%) of the respondents believed that radiation induced xerostomia was a ‘clinically important problem’, although only one centre had a written protocol for its management. Only 36% of centres would recommend the use of pilocarpine with the reasons for not using the drug among the remainder being ‘lack of evidence of effect’ in 76% and ‘side effect profile’ in 53%. Seventy-four per cent recommended use of fluoride mouthwash and all respondents recommended artificial saliva sprays. Oralbalance (65%) and Glandosane (61%) were the most frequently used. Psychological support was offered to patients by a clinical nurse specialist (91% of centres) and speech and language therapist (79%). Twenty-five per cent of centres recommended acupuncture therapy as a treatment, with 10% of centres providing this service within their institution. Conclusion: Despite agreement that radiation induced xerostomia is an important clinical problem, there is no consistent standard of care for these patients in the UK. A wide variety of symptomatic solutions are offered. Despite level 1 evidence of benefit, pilocarpine is used in only a minority. Clinical nurse specialists are asked to provide support to the majority of patients. These results have been used to inform the control arm of the ARIX acupuncture study.
S53
P92 Preliminary Results from a Phase I/II Study of Intensity Modulated Radiotherapy in the Treatment of Meningiomas S. Sivabalasingham *,y, N. Fersht y, D. D'Souza y, I. Rosenberg y, C. Stacey y, P. Davies y, T. Guerro-Urbano z, S. Short *, y * UCL Cancer Institute, London, UK y Department of Oncology, University College London Hospitals NHS Trust, London, UK z Department of Oncology, Guy's and St Thomas' NHS Foundation Trust, London, UK Introduction: IMRT provides excellent dose conformality and with steep dose gradients has the ability to spare critical structures, an essential factor when treating patients with good prognosis tumours, such as meningiomas. We report the initial results of this phase I/II study, designed to prospectively assess the feasibility and efficacy of treating meningioma patients with IMRT. Methods: Patients with histologically confirmed meningioma deemed to require fractionated radiotherapy were treated with static field IMRT using a dose of 50.4 Gy in 28 daily fractions. The following assessments were performed at baseline and at 3 months, 6 months and yearly following radiotherapy: CTCAE version 3.0 toxicity scores, mini mental test examinations, pituitary function tests, visual assessments, self completed quality of life questionnaires (QLQ C30 and B20), as well as diffusion and perfusion weighted MRI. Acute toxicities were recorded during radiotherapy. Results: Twenty-three patients have been recruited to this study with a median age of 49 years: comprising 61% (14 patients) with WHO grade 1 and 39% (nine patients) with WHO grade 2. Seven-four per cent of meningiomas treated were classified as skull base tumours. All patients were treated with five to seven fields using IMRT and in all 99% of the PTV volume received >90% of the prescribed dose with a mean conformality index of 0.95 (range of 0.88e1.01). Treatment was well tolerated, with only two patients suffering grade 2 acute toxicity. Eighty-three per cent patients experienced grade 1 toxicity, of which fatigue and alopecia were the most common. Twenty-two per cent of patients noticed an improvement in their tumour related symptoms following radiotherapy. There have been no reported grade 2 late toxicities. At a median follow-up of 17 months (range 2e45 months), three patients (all with grade 2 tumours) have developed recurrent disease (two with marginal and one with in-field recurrence). Conclusion: We have demonstrated that IMRT is a highly conformal and welltolerated radiotherapy technique for meningiomas and is associated with early improvement in neurology in a significant proportion of cases.
P93 Optimising Treatment of Anal Cancer: 3D Conformal Radiotherapy with Concurrent Mitomycin C and Capecitabine D. Smith, S. Raouf Department of Radiotherapy, Queen's Hospital, Romford, UK Introduction: The ACT-II trial confirmed mitomycin C with 5-FU as the standard of care for anal cancer when combined with conventionally planned radiotherapy. Capecitabine is widely used as an oral alternative to 5-FU in gastrointestinal cancer with encouraging preliminary results for anal cancer. Modern radiotherapy techniques allow greater dose shaping than with fields selected on the basis of macroscopic disease and bony anatomy. We sought to assess the toxicity and efficacy of a new regime using mitomycin C with capecitabine and conformally planned radiotherapy. Method: All anal cancer patients at our hospital treated radically with conformal radiotherapy and concomitant mitomycin C and capecitabine between 2007 and 2010 were identified and reviewed. Results: Twelve patients were treated using this regime: three men and nine women, age range 47e80 (median 66); most had locally advanced disease with nine having stage IIIa or IIIb. All patients received 50.4 Gy in 28 fractions without delays, 92% complying completely with the planned schedule. Seven-five per cent received the full prescribed chemotherapy course (mitomycin C 6e12 mg/m2 day 1, capecitabine 500e800 mg/m2 bd days 1e14, 22e35). Only two patients developed grade 3 toxicity (skin, diarrhoea); there was grade 2 skin erythema (eight patients), bone marrow suppression (two), nausea (one) and diarrhoea (one). The clinical response at 4 weeks was complete in nine patients and partial in three. At median follow-up of 13.3 months there has been no local relapse, although one patient died of metastatic disease and one of unconnected pulmonary disease.