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Results of Novel Multichannel HDR Brachytherapy Applicators in the Treatment of Nonmelanoma Skin Cancer
S760
International Journal of Radiation Oncology Biology Physics
Surgery involved bone prosthesis in 9%, skin graft in 6% and musculoskeletal flap in 7%. RT was given as sole modality (2%), pre-operatively to 50Gy (12%) or post-operatively (86%). 60% received 60Gy and 15% received 66Gy. Conventional 3D conformal RT (3DCRT) was used in 81%. One patient was treated with intensity modulated RT (IMRT). Median field length was 21.7cm (range 8 - 40); RT fields crossed a joint in 46%. Co-morbidities that might affect limb function were present in 12%; at the time of assessment 4% were receiving chemotherapy. Most patients were working or retired, 9% were unemployed and 6% classified themselves as disabled. A walking aid was required in 22%, 19% used daily analgesia, and 37% reported that treatment had negatively affected their lifestyle. Of these, 17% felt this was unacceptable. Mean TESS score was 81 (range 10 - 100). RTOG/EORTC grade 2 late effects were present in 77% and grade 3/4 effects in 26%. Rate of late bone fracture was 2%. Subcutaneous fibrosis grade 2 was seen in 28%. When stratified according to RT dose (66Gy, 60Gy and 50Gy) the incidence of fibrosis was 54%, 24% and 24% respectively. Logistic regression analysis of potential prognostic factors for the full cohort will be presented with the final analysis. Conclusions: This cohort includes patients treated over a 21 year period, the majority with 3DCRT. The majority had grade 2 late effects, 26% had grade 3 toxicity, and a third reported a negative impact on their lifestyle. Practice is evolving toward the use of more IMRT for limb sarcomas, with the hope of reducing late toxicity. These results provide a benchmark for comparison in future research. Author Disclosure: F. le Grange: None. A. Cassoni: None. B. Seddon: None.
local control rate of 97%. Two patients (1%) had CTCAE v4.03 skin toxicity grade 3: one patient had small patchy necrosis without ulceration that healed spontaneously and one patient with vascular problems had widening of an ulcerated lesion of the shin that required hyperbaric oxygen and several weeks to heal. Good to excellent cosmesis was reported by physicians in 170 (94%) of 181 lesions followed. Conclusions: Multi-channel HDR skin brachytherapy applicators with preset dwell positions offer a good modality for treating non-melanoma skin carcinomas for lesions measuring up to 4 cm in size with an excellent local control and cosmesis. Author Disclosure: H.E. Gayar: None. K. Devisetty: None. V.K. Sharma: None. K. Gayar: None. T. Dillon: None. K. Gaffney: None. R. Soderstrom: None. F. Khan: None. J.L. Nettleton: None.
3395 Results of Novel Multichannel HDR Brachytherapy Applicators in the Treatment of Nonmelanoma Skin Cancer H.E. Gayar,1 K. Devisetty,1 V.K. Sharma,1 K. Gayar,2 T. Dillon,1 K. Gaffney,1 R. Soderstrom,1 F. Khan,3 and J.L. Nettleton1; 1McLaren Cancer Institute, Flint, MI, 2University of Michigan, Flint, MI, 3Michigan State University, Lansing, MI Purpose/Objective(s): Radiation therapy is under-utilized in the management of non-melanoma skin cancer primarily due to lengthy treatment course associated with electron beam radiation therapy. Single source topical skin brachytherapy applicators provide a non-uniform radiation distribution to skin which hinder appropriate dose delivery and are limited in size. We designed four multi-channel topical HDR skin brachytherapy applicators in different sizes and shapes which allow for pre-set source positions to provide a more uniform radiation dose as well as the ability to treat a larger surface area. The objective of our study is to determine the treatment outcomes using these new applicators in patients with nonmelanoma skin cancers. Materials/Methods: Following IRB approval, we retrospectively identified 163 patients with 187, biopsy proven, non-melanoma skin cancer. Patients were treated between July 2010 and June 2013. Basal cell carcinoma constituted 69% (128 lesions) and squamous cell carcinoma constituted 31% (59 lesions). Applicators diameters were 2, 3 & 4 cm round as well as an elliptical applicator of 2x3 cm. Each of the applicators had multiple parallel channels (2-4). Pre-set source dwell positions for each applicator were used. Results: Median follow-up for the study cohort was 17 months (range 7-38 months) and 6 patients were lost to follow-up. Median delivered dose was 42 Gy (range 42-50 Gy). The treatment was delivered at 6 Gy per fraction prescribed to the 80 % isodose line for a total of 7 fractions (75%), or 8 fractions (24%); 2 patients (1%) received 9 and 10 fractions of 5 Gy. Treatments were delivered 2-3 times per week. A photo of each lesion was taken before each treatment and at the time of follow-up. The majority of the patients treated had lesions of the face (77%), primarily the nose, whereas the remainder had lesions in other locations including the scalp and extremities (23%). Only 6 local failures were identified for a crude
3396 Single Institutional Series of Intraoperative Radiation Therapy (IORT) for Primary and Recurrent Retroperitoneal and Pelvic Sarcomas J.A. Johnson, V. Weinberg, C.L. Tinkle, N. Eric, and A. Gottschalk; University of California San Francisco, San Francisco, CA Purpose/Objective(s): to investigate the local control (LC), freedom from metastatic disease (MFS), disease free survival (DFS), overall survival (OS) and toxicity associated with intraoperative radiation therapy (IORT) for retroperitoneal and pelvic sarcomas (RPS). Materials/Methods: This is a retrospective analysis of patients with primary or recurrent pelvic and retroperitoneal sarcomas treated with surgery and IORT at a single institution from 1997 to 2012. Twenty eight pts with primary and 48 patients with recurrent RPS were identified. The median follow up was 35.3 mos for primary disease and 25.5 mos for recurrent disease. Low, intermediate and high grade tumors comprised 18, 21, and 43% of all primary disease, and 32, 15, and 29% of all recurrent disease. Tumor grade was unavailable for 18% of all primary and 21% of recurrent RPS. Margins were negative in 18% of all primary and 15% of all recurrent cases. The median size of all primary RPS was 12.3cm [range 5-30] and 9cm [range 1.1-42] for all recurrent. Twenty-nine % of recurrent pts received prior EBRT, 27% had post-operative EBRT and 8% had both. EBRT data was unavailable for 19% of all recurrent RPS. Fifty % of all primary RPS had post-operative and 1 other (4%) had preoperative EBRT. Range adjuvant EBRT 45-60.58Gy. The median number of prior surgeries for recurrent pts was 1 (range 1-5). The median IORT dose was 1500 cGy for both groups of pts [range 1000-2000]. 34% patients received chemotherapy at some point after diagnosis. Results: The 4-yr LC estimate is 72% (95% CI 50-86%) for primary disease and 45% (29-61%) for recurrent disease. The 4-yr MFS is 74% (50-88%) vs 69% (46-84%), respectively. To date 10/28 pts with primary disease are alive without progression and 9/48 recurrent pts are alive without progression, resulting in an overall 4-yr DFS of 44% (2462%) and 17% (8-30%), respectively. The 4-yr Kaplan-Meier estimate for OS is 68% (44-83%) for primary disease and 38% (23-52%) for recurrent disease. No relationship was seen between grade, margin status or EBRT treatment on LC for each cohort, although subsets are small. Cox’s regression model was used to determine whether tumor size is a predictor of outcome. After adjusting for disease (primary/ recurrent), tumor size was a significant predictor of LC (p Z 0.03) but not DFS (p Z 0.10). Grade 3 toxicities of any kind occurred in 22% of patients. Gr3 GI toxicity was observed in 14%. Neurologic toxicity was observed in only 10%. Conclusions: Intraoperative radiation therapy has been successfully implemented at a single institution. In our series, size predicts for local control. Local control was acceptable in spite of the low rates of negative margins, and significant toxicity was limited. Author Disclosure: J.A. Johnson: None. V. Weinberg: None. C.L. Tinkle: None. N. Eric: None. A. Gottschalk: None.
International Journal of Radiation Oncology Biology Physics
Surgery involved bone prosthesis in 9%, skin graft in 6% and musculoskeletal flap in 7%. RT was given as sole modality (2%), pre-operatively to 50Gy (12%) or post-operatively (86%). 60% received 60Gy and 15% received 66Gy. Conventional 3D conformal RT (3DCRT) was used in 81%. One patient was treated with intensity modulated RT (IMRT). Median field length was 21.7cm (range 8 - 40); RT fields crossed a joint in 46%. Co-morbidities that might affect limb function were present in 12%; at the time of assessment 4% were receiving chemotherapy. Most patients were working or retired, 9% were unemployed and 6% classified themselves as disabled. A walking aid was required in 22%, 19% used daily analgesia, and 37% reported that treatment had negatively affected their lifestyle. Of these, 17% felt this was unacceptable. Mean TESS score was 81 (range 10 - 100). RTOG/EORTC grade 2 late effects were present in 77% and grade 3/4 effects in 26%. Rate of late bone fracture was 2%. Subcutaneous fibrosis grade 2 was seen in 28%. When stratified according to RT dose (66Gy, 60Gy and 50Gy) the incidence of fibrosis was 54%, 24% and 24% respectively. Logistic regression analysis of potential prognostic factors for the full cohort will be presented with the final analysis. Conclusions: This cohort includes patients treated over a 21 year period, the majority with 3DCRT. The majority had grade 2 late effects, 26% had grade 3 toxicity, and a third reported a negative impact on their lifestyle. Practice is evolving toward the use of more IMRT for limb sarcomas, with the hope of reducing late toxicity. These results provide a benchmark for comparison in future research. Author Disclosure: F. le Grange: None. A. Cassoni: None. B. Seddon: None.
local control rate of 97%. Two patients (1%) had CTCAE v4.03 skin toxicity grade 3: one patient had small patchy necrosis without ulceration that healed spontaneously and one patient with vascular problems had widening of an ulcerated lesion of the shin that required hyperbaric oxygen and several weeks to heal. Good to excellent cosmesis was reported by physicians in 170 (94%) of 181 lesions followed. Conclusions: Multi-channel HDR skin brachytherapy applicators with preset dwell positions offer a good modality for treating non-melanoma skin carcinomas for lesions measuring up to 4 cm in size with an excellent local control and cosmesis. Author Disclosure: H.E. Gayar: None. K. Devisetty: None. V.K. Sharma: None. K. Gayar: None. T. Dillon: None. K. Gaffney: None. R. Soderstrom: None. F. Khan: None. J.L. Nettleton: None.
3395 Results of Novel Multichannel HDR Brachytherapy Applicators in the Treatment of Nonmelanoma Skin Cancer H.E. Gayar,1 K. Devisetty,1 V.K. Sharma,1 K. Gayar,2 T. Dillon,1 K. Gaffney,1 R. Soderstrom,1 F. Khan,3 and J.L. Nettleton1; 1McLaren Cancer Institute, Flint, MI, 2University of Michigan, Flint, MI, 3Michigan State University, Lansing, MI Purpose/Objective(s): Radiation therapy is under-utilized in the management of non-melanoma skin cancer primarily due to lengthy treatment course associated with electron beam radiation therapy. Single source topical skin brachytherapy applicators provide a non-uniform radiation distribution to skin which hinder appropriate dose delivery and are limited in size. We designed four multi-channel topical HDR skin brachytherapy applicators in different sizes and shapes which allow for pre-set source positions to provide a more uniform radiation dose as well as the ability to treat a larger surface area. The objective of our study is to determine the treatment outcomes using these new applicators in patients with nonmelanoma skin cancers. Materials/Methods: Following IRB approval, we retrospectively identified 163 patients with 187, biopsy proven, non-melanoma skin cancer. Patients were treated between July 2010 and June 2013. Basal cell carcinoma constituted 69% (128 lesions) and squamous cell carcinoma constituted 31% (59 lesions). Applicators diameters were 2, 3 & 4 cm round as well as an elliptical applicator of 2x3 cm. Each of the applicators had multiple parallel channels (2-4). Pre-set source dwell positions for each applicator were used. Results: Median follow-up for the study cohort was 17 months (range 7-38 months) and 6 patients were lost to follow-up. Median delivered dose was 42 Gy (range 42-50 Gy). The treatment was delivered at 6 Gy per fraction prescribed to the 80 % isodose line for a total of 7 fractions (75%), or 8 fractions (24%); 2 patients (1%) received 9 and 10 fractions of 5 Gy. Treatments were delivered 2-3 times per week. A photo of each lesion was taken before each treatment and at the time of follow-up. The majority of the patients treated had lesions of the face (77%), primarily the nose, whereas the remainder had lesions in other locations including the scalp and extremities (23%). Only 6 local failures were identified for a crude
3396 Single Institutional Series of Intraoperative Radiation Therapy (IORT) for Primary and Recurrent Retroperitoneal and Pelvic Sarcomas J.A. Johnson, V. Weinberg, C.L. Tinkle, N. Eric, and A. Gottschalk; University of California San Francisco, San Francisco, CA Purpose/Objective(s): to investigate the local control (LC), freedom from metastatic disease (MFS), disease free survival (DFS), overall survival (OS) and toxicity associated with intraoperative radiation therapy (IORT) for retroperitoneal and pelvic sarcomas (RPS). Materials/Methods: This is a retrospective analysis of patients with primary or recurrent pelvic and retroperitoneal sarcomas treated with surgery and IORT at a single institution from 1997 to 2012. Twenty eight pts with primary and 48 patients with recurrent RPS were identified. The median follow up was 35.3 mos for primary disease and 25.5 mos for recurrent disease. Low, intermediate and high grade tumors comprised 18, 21, and 43% of all primary disease, and 32, 15, and 29% of all recurrent disease. Tumor grade was unavailable for 18% of all primary and 21% of recurrent RPS. Margins were negative in 18% of all primary and 15% of all recurrent cases. The median size of all primary RPS was 12.3cm [range 5-30] and 9cm [range 1.1-42] for all recurrent. Twenty-nine % of recurrent pts received prior EBRT, 27% had post-operative EBRT and 8% had both. EBRT data was unavailable for 19% of all recurrent RPS. Fifty % of all primary RPS had post-operative and 1 other (4%) had preoperative EBRT. Range adjuvant EBRT 45-60.58Gy. The median number of prior surgeries for recurrent pts was 1 (range 1-5). The median IORT dose was 1500 cGy for both groups of pts [range 1000-2000]. 34% patients received chemotherapy at some point after diagnosis. Results: The 4-yr LC estimate is 72% (95% CI 50-86%) for primary disease and 45% (29-61%) for recurrent disease. The 4-yr MFS is 74% (50-88%) vs 69% (46-84%), respectively. To date 10/28 pts with primary disease are alive without progression and 9/48 recurrent pts are alive without progression, resulting in an overall 4-yr DFS of 44% (2462%) and 17% (8-30%), respectively. The 4-yr Kaplan-Meier estimate for OS is 68% (44-83%) for primary disease and 38% (23-52%) for recurrent disease. No relationship was seen between grade, margin status or EBRT treatment on LC for each cohort, although subsets are small. Cox’s regression model was used to determine whether tumor size is a predictor of outcome. After adjusting for disease (primary/ recurrent), tumor size was a significant predictor of LC (p Z 0.03) but not DFS (p Z 0.10). Grade 3 toxicities of any kind occurred in 22% of patients. Gr3 GI toxicity was observed in 14%. Neurologic toxicity was observed in only 10%. Conclusions: Intraoperative radiation therapy has been successfully implemented at a single institution. In our series, size predicts for local control. Local control was acceptable in spite of the low rates of negative margins, and significant toxicity was limited. Author Disclosure: J.A. Johnson: None. V. Weinberg: None. C.L. Tinkle: None. N. Eric: None. A. Gottschalk: None.