44 Phase II study: Interstitial pdr-brachytherapy for patients with recurrent head and neck cancer

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44 Phase II study: Interstitial pdr-brachytherapy for patients with recurrent head and neck cancer
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  SI4 Saturday, 9 June 2001 Proffered pape, s same position, corregistration (fusion) of the two image sets with a dedicat- ed software, transfer of the new image set to the TPS via DICOM, definition of target and organs at risk (OAR) in the corregistrated (fused) images set and calculation of the definitiv dosimetry. The accuracy of image fusion was quantified by recording the distance between the center of the prostatic ure- thra on axial MR vs CT images after fusion in each patient. The differences in dosimeric parameters were evaluated using t-Student test. Results: The accuracy of the fusion protocol was high. The average dis- tance between the center of the prostatic urethra on axial MR vs CT scan was lmm (range, 0mm-4mm). The median prostate TRUS volume was 32cc. The median prostate CT volume was 43cc (34% greater). The medi- an prostate CT-MRI was 34cc (2.5% greater). The dosimetric results are shown in the following table: CT based PP CT-MRI based PP p value D90 (1125) 150Gy 156Gy 0,003 V100 82% 88% 0,003 V150 45% 42% 0.110 V200 14% 13% 0,560 Conclusion: image corregistration is a feasible technique for postimplant dosimetric analysis. CT-MRI corregistrated images predict prostate size and morphology with a high degree of accuracy significantly improving accuracy of dosimetry and DVH related parameters providing a more real- istic and consistent way of assessing the quality of a prostate seed implant. 40 oral Urinary retention following ultrasound guided brachytherapy for prostate cancer: incidence and risk factors J.C. B/asko M. Fisher P.D. Grimm J.E. Sy/vester. R. Meier W.A. Cavanagh Seattle Prostate/nstitute Seattle. USA Purpose: to determine the incidence and possible risk factors associated with urinary retention requiring an indwelling catheter following 125- Iodine/103-Palladium brachytherapy for prostate carcinoma. Methods and materials: between November 1999 and March 2000. 242 consecutive men underwent permanent source brachytherapy at our insti- tution as definitive treatment for early stage carcinoma of the prostate. External beam radiation (32%) or neoadjuvant hormonal treatment (34%) were used in addition to brachytherapy at the discretion of the treating physician. All 242 men were sent a one-page questionnaire relating to the need for bladder catheterization because of urinary obstruction post- implant. All men had been followed at least one year following implantation. Results: as of this writing, 175/242 (72%) questionnaires have been returned. Of the 175 respondents, 21 (12%) required bladder catheteriza- tion for the treatment of urinary obstruction. Median time of catheter dura- tion was 29 days. Five of the 175 respondents (2.9%) required a catheter longer than three months. Duration of catheterization was as follows: less than 24 hours- 1/175 (1%), 1 day to 1 week- 7/175 (4%), 1 week to 1 month- 4/175 (2%); 1 month to 3 months- 3/175 (2%); 3 months to 6 months- 1/175 (0.5%); greater than 6 months- 4/175 (2%). In univariate analyses, age, isotope type, adjuvant external beam radiation, neoadjuvant hormonal therapy, serum PSA at presentation, stage, prostate volume, number of seeds, number of needles, post-implant dosimetric para- meters of Vl00, V150 and D90 were not significantly associated with the need for catheterization. Patients presenting with an I-PSS score of 10 or greater, however, had a 21% rate of catheterization, compared with an 8.6% risk for those with a score of less than 10 (p=0.028). I-PSS score greater than 10 also attained significance on logistic regression (p=0.026), with no other variables achieving significance in the model. Conclusion: this series depicts a 12% rate of urinary retention requiring catheterization following permanent 125-1odine/103-Palladium prostate brachytherapy. An I-PSS symptom score of 10 or greater at presentatioin was associated with a significantly higher risk of retention. 41 oral Iodine 125 brachytherapy for prostate cancer. Experience of the group Curie-Cochin L. Chauveinc 1 T. Flam 2 J.C. Rosenwald 1 P. Araya 1 N. Thiounn 2 F. Firmin 1 B. Debre 2 J.M. Cosset 1 l lnstitut Curie Paris France 2H6pital Cochin Paris France From May 1998 to January 2001, 170 patients were implanted with Iodine 125 seeds for a prostate cancer at the Paris Institute Curie, in collaboration with the urotogy Unit of the Cochin Hospital. Selection criteria were as fol- lows: T1/-F2, PSA _<15, Gleason _<7, and no extra prostatic extension at the endorectal coil RMI exploration. The dosimetric quality control followed the recommendations of the ABS and the ESTRO, based on the CT-scan eval- uation at two months (prescribed dose 145 Gy, D90> 145 Gy). Median age of the patients was 66.5 years (48-80). Median PSA level was 9 ng/ml (1.8-15). 19% of the patients has a Gleason 7 tumors. RapidStrand seeds with the preplanning method were used for the 17 first implantations. Loose seeds with the real time 3 D dosimetry method was used for all the following patients. In the first t7 patients series, only 2 implantations met the AS requirements (D90>145 Gy). For all the other patients, implantations showed a D90>145 Gy with a median value of 183 Gy (145-240). Using RTOG bladder toxicity, 15% of the patients were grade 0, 37% grade 1, 35% grade 2, and 17% grade 3. Only 5 patients (3%) had to keep a tem- porary bladder catheter. As for the rectal toxicity, 24% of the patients had grade 1 rectal complications, with no patients with grade 2 or 3 toxicities. At 1 year, 71% of the available patients had a PSA level below 1 ng/ml, and 48% below 0.5 ng/ml. Conclusion: after a slightly disappointment for the first series treated with the preplanning technique, probably at least partly due to the learning curve , all dosimetric results of the 153 bellow patients treated with the loose seeds were satisfactory. Toxicity looks acceptable. Preliminary results are satisfactory, but have to be reconsidered with a longer follow-up. 42 oral 5-year results following conformal HDR brachytherapy HDR- CBT) and elective pelvic irradiation for high-risk prostate can- cer initial PSA > 20 ng/ml): is hormonal therapy beneficial ? R. Galalae T. Loch A. Oldorp N. Ndrnberg H. Bertermann. P. Niehoff. P. Kohr. B. Kimmig G. Kovacs Interdisciplinary Brachytherapy Center Christian-Albrechts-University. KieL Germany Purpose: to report 5-year results of a close escalating protocol using HDR- CBT combined with elective irradiation of pelvic lymphatics in men with Iocallly advanced prostate cancer and initial PSA>20 ng/ml and the influ- ence of hormonal ablation. Material and methods: sixty consecutive treated patients were evaluated. The median initial PSA was 34.5 ng/ml (minimum 20 ng/ml). The Iocore- gional pelvic lymphatics were treated to 50 Gy by external-beam radiother- apy (EBRT); the close in the prostate was limited to 40 Gy using individual compensators. The prostate was boosted to the nominal total dose of 70 Gy by 2 fractions of transrectal ultrasound (TRUS) guided and preplanned HDR-CBT, which were integrated in the percutaneus series. We segregat- ed the patients in two prognostic groups: group I, n=31 (PSA > 20 ng/ml and grading G1-2 and Gleason < 7) and group II, n=29 (PSA > 20 ng/ml and grading G3 or Gleason > 7). The influence of hormonal therapy was also analyzed. Results and discussion: the median follow-up was 63 months (minimum 24 months). The 5-year bNED survival according to Kaplan-Meier was 59% for the entire cohort with initial PSA > 20 ng/ml. For group I the bNED survival rate was 67.7%, for group II 38%. A significant difference for bNED survival segregating patients by hormonal ablation could not be demonstrated (p=0.17). Hanks et al. (IJROBP 41: 501-10, 1998) reported bNED survival rates of 30% following conformal EBRT at 5 years and dose level > 72 Gy in the same patient cohort (PSA > 20 ng/ml). In comparison with these data the bNED survival in our material seems to be superior with 59%. Stratify- ing patients in the defined prognostic groups no significant difference was seen in the group I1: Kie139%, Fox Chase 36%. However, in the group I the bNED rate in our material was 68%, while it was 32% in the Fox Chase material. Conclusion: the results confirm, that local dose esclation by HDR-CBT is an effective treatment method especially in men with high-risk advanced prostate cancer. A benefit of adjuvant hormonal ablation could not be demonstrated. 43 oral Patterns and predictors of acute toxicity after HDR brachytherapy and 3D-CRT for localized prostate cancer: pre- liminary results of phase I-II dose escalation study A. Raben 1 A. Grebler 1 R. Ivker 2 J. Geltzeiler 1. J. Yang 1. S. Shoengold 2 A. Helfman 2 D. Raben 3 A. Baron 3 C. Zeng 3 1Monmouth Medical Center Radiation Oncology Long Branch USA 2Newark Beth Israel Medical Center Radiation Oncology Newark USA 3University of Colorado Health Science Center Radiation Oncology Den- ver USA Purpose: To evaluate the patterns of acute gastrointestinal (GI) and geni- tourinary (GU) toxicity and symptom resolution during the initial 12 months  Proffered papers Saturday 9 June 2001 SI5 after high dose-rate brachytherapy (HDR-BRT) and three-dimensional con- formal radiotherapy (3D-CRT) in the treatment of localized prostate cancer. In addition to identify pre-treatment patient characteristics and dosimetric variables which predicted for > grade 2 acute morbidity in these patients. Materials and Methods: Between 3/98 and 1/00 100 patients with interme- diate-high risk prostate cancer were prospectively treated on a Phase I-II dose escalation trial combining HDR-BRT and 3D-CRT. All patients were treated with 6-8 weeks ol neoadjuvant androgen deprivation therapy (NAAD). HDR-BRT consisted of 16.5 Gy Iridium-192 in 3 fractions in 62 (62%) patients, and the dose was subsequently escalated to 18 Gy in 3 fractions in 38 (38%) patients. 3D-CRT consisted of 50.4 Gy using a 4-6 field conformal technique. 60 patients received HDR-BRT prior to 3D-CRT and 40 patients were treated with 3D-CRT followed by the HDR-BRT. Patients enrolled met at least one of the following criteria PSA>IO, Gleason score > 7, Stage T2b-T3, or bilobar involvement with 4-6 positive cores on needle biopsy. Seventy-two patients were followed for a minimum of 6 months and 54 patients were followed for a minimum of 12 months (follow- up range: 6-30 months). Acute toxicity was assessed at 1, 3, 6 and 12 months after treatment using the RTOG morbidity scoring classification. Evaluations also included base-line and sequential IPSS scores. Dosimet- tic parameters from the HDR-computer-optimized plan including maximal rectal and urethral doses were correlated with acute toxicity. Results: Overall, 6% of patients (N=100) developed acute urinary retention after HDR-BRT necessitating catheter placement with a median time to res- olution in 3 days (range:2-7 days). The incidence of grade 2 GU toxicity (symptoms requiring medications) at 1,3, 6, and 12 months for 54 patients with f/u > 12 months were 26%, 15%, 3%and 9%, respectively. One patient (2%) developed a urethral stricture (grade 3 GU) at a median of 12 months after therapy. The maximal urethral dose and baseline IPSS scores corre- lated with acute GU toxicity. The mean urethral dose among patients expe- riencing Grade 2 GU toxicity was 2.1 Gy versus 1.9 Gy for Grade 1 toxicity 1.7 Gy for Grade 0. The mean pre-treatment IPSS score in patients experi- encing grade 2 toxicity was 11 versus a mean IPSS score of 6 for Grade 0 / 1. The IPSS post-treatment score at 12 months, normalized or improved compared to pre-treatment scores in 70% and worsened in 30% with a mean change of 5 points. The incidence of grade 2 GI toxicity (rectal bleed- ing) at 1, 3, 6, and 12 months for 54 patients were 7%, 7%, 2%, and 4% respectively. No Grade 3 GI toxicities were observed. The following vari- ables were tested for predictive value in univariate analysis: prostate gland size, age, sequencing of HDR and 3D-CRT, dose per fraction, MaxUrethral and MaxRectal dose, IPSS score, 4 versus 6 field 3D-CRT, diabetes and prior TURP. Only Pre-treatment IPSS score (p=0.08) was strongly predic- tive as a continuous variable for Grade 2/3 GU toxicity. Age (p = 0.049). Max-Urethral Dose (p = 0.037) and 4-field technique (p = 0.01)were predic- tive as continuous variables of Grade 2 GI toxicity. The median f/u time for the 18 Gy dose group was 6 months (1-12). Three of 13 patients (23%) with 6 months f/u experienced Grade 2 GU toxicity. Conclusion: Excellent acute tolerance was observed in these patients after HDR-BRT and 3D-CRT. The incidence of acute grade 2 morbidity corre- lated with the maximum urethral dose from HDR-BRT and baseline IPSS scores. Preliminary acute tolerance outcome of 18 Gy dose level of this dose escalation was comparable to patients treated with first dose level of 16.5 Gy. HEAD AND NECK-SKIN- EYE TUMOURS 44 oral Phase II study: interstitial pdr-brachytherapy for patients with recurrent head and neck cancer M.H. Geiqer V. Strnad M. Letter R. Sauer University Erlangen-Nuremberg Department of Radiation Therapy Erlan- gen Germany Purpose: The purpose of this prospective Phase II study was to examine the effectiveness of the interstitial pulse-dose-rate (PDR) brachytherapy, especially on the local control and the incidence of side effects in patients with recurrent head and neck tumors. Patients and Methods: From October 1997 to December 2000 38 patients with recurrent head and neck tumors were treated with interstitial PDR brachytherapy according to the study protocol. There were 9/38 patients with T1 disease, 15/38 with T2, 6/38 with T3 and 8/38 with T4 tumors. 31/38 patients were pretreated with radiotherapy. The patients recieved interstitial PDR brachytherapy (DREF = 19.2 - 56.7 Gy) as part of their treat- ment regimen alone (11/38) or in combination with external radiation (15/38). The pulses (dp = 0.4 - 0.7 Gy)were delivered 24 hours a day with a time interval of one hour between two pulses resulting in an effective dose rate from 0.4 Gy/h to 0.7 Gy/h. 10 of the patients were treated with con- comitant application of 5-flourouracil (5-FU) and cisplatin (CDDP) during the external radiotherapy. Simultaneous chemotherapy (5-FU, CDDP) with interstitial PDR-Brachytherapy was delivered in 10 patients. 13 patients also recieved interstitial hyperthermia. The analysis was performed after median follow-up of 6 month (1 - 30 months). Results: Local tumor control was achieved in 29 of 38 patients (76.3%). The Kaplan-Meier estimates shows a disease- free survival of 57 % after two years, the overall survival was 38 %. The treatment was well tolerated. There were no osteoradionecrosis, 1 patient developed soft tissue necrosis. No complication required hospitalization or surgical intervention. Conclusions: Interstitial PDR-Brachytherapy in patients with recurrent head and neck cancer is a feasible and effective treatment even in combination with external radiotherapy, simultaneous chemotherapy or interstitial hyper- thermia. 45 oral Organ-preservation treatment in locally advanced (stage III and IV) base of tongue and oral tongue carcinoma M. Duclos 1. M Black 2. M. Hier 2 A. Zeitouni 3 K. Kost 3 N. Sedaghi 3 T. Vuong 1 G. Shenouda 1. K. Sultanem 1. T. Dionisopoulos 4 1Montreal general hospital radiation oncololgy Montreal Canada 2jewish general hospital head and neck surgery Montreal Canada 3Royal Victoria hospital head and neck surgery Montreal Canada 4jewish general hospital plastic surgery Montreal Canada Purpose: Combined modality treatment plays a central role in the manage- ment of locally advanced (Stage III and IV) oropharynx and oral cavity car- cinomas. Radical surgery remains a key element in order to obtain satisfy- ing local control. However. major speach and swallowing impairment may occur. The aim of this study was to prospectively evaluate the impact on local control of a less aggressive surgical approach combined with intersti- tial high dose rate brachytherapy (HDRB) boost perform during the same procedure. In all cases these two treatment were combined with postoper- ative external beam radiotherapy (EBRT) in oral tongue primary and pre- ceeded by combined EBRT and chemotherapy in base of tongue carcino- mas. Methods: Between May 1995 and January 2001, 41 patients underwent interstitial HDRB and a less aggressive but still curatitve surgery. The chemotherapy used consisted in Cisplatinum 100mg/m on days 1, 22 and 43. The EBRT dose used was 60 Gy, using 2Gy per fraction. The dose of HDRB varies from 15-21Gy, using 3Gy/fraction, given BID or TID. 39% of the patients presented with base of tongue carcinoma and 61% with oral tongue primary. Stage III represented 88°'0 of our population. Local control and toxicity were analysed using Kaplan-Meier life-table method with statis- tical evaluation using the Cox test. Results: With a median follow-up of 21 months, the overall two-year local control was 80.5%. In patients presenting with oral tongue cancer, 87% of stage III and 50% of stage IV patients achieved a two-year local control, compare to 85% and 33% with base ot tongue primary. Salvage therapy was possible in 62.5% of the patients who failed. No patient developed dis- tant metastasis. 7.3% of the patients developed soft tissue necrosis or oste- oradionecrosis. Conclusion: Interstitial HDRB is feasible as a boost for patients with local- ly advanced carcinomas of the oral tongue and base of tongue for which a less aggressive but still curative surgery is performed. Local control appear comparable to the low dose rate brachytherapy data and to the current sur- gical lillerature. The toxicity profile appears acceptable. 46 oral Salvage PDR/HDR brachytherapy for local recurrence of head and neck cancer after primary external beam radiotherapy EBRT) P. Niehoff G. Kovacs. S. Maune R. Galalae A. OId6rp S. H6ft H. Donner Interdisciplinary Brachytherapy Center University Hospital of Kiel Kiel Germany Introduction: Patients suffering from local recurrence of head and neck can- cer were treated with salvage, fractionated HDR/PDR brachytherapy (BT). Material and methods: Seven female and 11 male patients in the mean age of 56.5 years (range (34-78 years) were treated between 1993 and 1996. All patients had previous EBRT with a mean dose of 62.4 Gy (range 36 - 86 Gy). The mean EBRT - BT time interval was 17 months (range 2-67 months). Seven patients received HDR schedule with daily 2 x 2.5 Gy with an interval of 6 hours. Eleven patients received PDR schedule with daily 5xl Gy in two hour pulses, 5x weekly. A mean dose of 25.7 Gy (range 10- 40 Gy ) was delivered to the PTV shaped reference isodose. The plastic tube technique was used followed by CT based 3D inverse planning. Four patients were treated with additional EBRT, the applied mean EBRT dose
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