111Oral Presentations / Brachytherapy 8 (2009) 105e180

GYN PROFERRED PAPERS I

Sunday May 31, 2009

3:20 PMe4:30 AM

OR12 Presentation Time: 3:20 PM

A Comparison Between LDR and MRI Conformal HDR

Brachytherapy of Cervical Cancer: Results, Patterns of Failure and

Late Complications

David L Bernshaw, MBBS, BMedSci, Sylvia van Dyk, DipSci, Chrishanthi

I Rajasooriyar, MBBS, M.D., Kailash Narayan, MBBS, Ph.D., Srinivas

Kondalsamy-Chennakesavan, MBBS, M.P.H. Radiation Oncology, Peter

MacCallum Cancer Centre, Melbourne, Victoria, Australia.

Purpose: This retrospective study of patients with locally advanced cervixcancer, compares patterns of failure, late toxicity and survival in patientstreated for cure with chemoradiation then LDR or conformal imageguided HDR (IGHDRc) brachytherapy (BT). IGHDRc planning uses realtime trans-abdominal ultrasound (TAUS) and subsequent MRI imaging to:i) ensure and verify adequate and consistent uterine tandem placement, ii)localize target volume and define of normal tissue volumes and iii)provide adaptive conformal brachytherapy planning.Methods and Materials: Between Jan 1996-May 2006, 217 FIGO stagedpatients had initial MRI and PET and followup (including PET at6 months). Post chemoRT, 90 patients received LDR BT (T & O, standardPt A dose using Manchester loadings, TAUS for placement only andorthogonal planning films) and 127 received IGHDRc BT (MRI compatibleT & O, TAUS for insertion, positioning and interfraction comparison andMRI.) A library plan is modified per TAUS parameters obtained using thetandem as fiducial marker. Post RT, MRI is obtained (applicator in situ),and the plan modified for subsequent fractions if needed. HDRc patientsare prescribed 80 Gy (10) (EBRT plus BT) to the outer margin of the tumortarget. Local control, survival and toxicity have been compared.Results: 5-year OS was 60% (SE 5 4%), 5-year FFS was 55% (SE 5 3%)(no sig. diff.). Local (central)/other pelvic failure was 9%/14% for bothgroups. Median time to recurrence was 6 months IGHDRc vs 7monthsLDR. IGHDRc mean Pt A dose was 11 Gy less than for the LDR plan.Local failure in patients receiving O72.6 Gy(10) to Pt A was 17.5% cf3.1% if !72.6 Gy (10). Paraaortic/systemic failure is 21%/23% for theLDR group, 19%/23% for the IGHDRc group. Pt A, bladder and rectalpoint doses are lower cf traditional LDR plans. Gd 3/4 toxicity is 4% forthe IGHDRc group reduced from 8% in the LDR group. 68% of theIGHDRc group are asymptomatic cf 42% of the LDR group.Conclusions: Compared with LDR, IGHDRc planning significantlyreduces severe and symptomatic late radiation effects with similarpatterns of failure and survival. Applicable in any setting, TAUS basedIGHDRc has the potential to improve the therapeutic ratio but is likely tobe of greatest utility for those treating cervix cancer with radiation inunder-resourced settings where MRI is not available.

Late Toxicity Rates/100 Person-years Followup by Types of

Brachytherapy

Rate/100 Rate/100 Rate/100

RTOG

Toxicity

Gr

person-yrs

FU

HR

(95%

CI)

person-yrs

FU

HR

(95%

CI)

person-yrs

FU

HR

(95%

CI)

LDR

HDRc

LDR

HDRc

LDR

HDRc

1

3.2 2.8 1.02

(0.41-

2.54)

9.4 7.9

0.67

(0.39-

1.15)

13.4 10.8

0.68

(0.41-

1.13)

2

2.7 1.4 0.43

(0.14-

1.27)

4.5 1.6 *

0.33

(0.11-

0.94) *

12.9 3.4 *

0.22

(0.11-

0.46) *

3&4

0.7 0.6 0.62

(0.09-

4.09)

1.6 0.6

0.38

(0.07-

2.08)

4.6 1.7 *

0.33

(0.11-

0.98) *

HR: Hazard Ratio HDRc relative to LDR. * 5 statistically significant

OR13 Presentation Time: 3:30 PM

High-dose-rate intracavitary brachytherapy in locally advanced

uterine cervix cancer using three different fractionation schedules:

An Indian experience

Sayan Kundu, MBBS, Swapnendu Basu, M.D., Koushik Ghosh,

Aloke Ghosh Dastidar, M.D. Radiotherapy, Medical College & Hospital,

Kolkata, West Bengal, India.

Purpose: Carcinoma of the cervix is the most common malignancy amongIndian women and most women present at an advanced stage. Acombination of megavoltage external beam radiotherapy (EBRT) andintracavitary brachytherapy is the accepted definitive mode of treatment.The American Brachytherapy Society (ABS) has recommended thatindividual fraction size should be !7.5 Gy and range of fractions shouldbe 4-8. The primary disadvantage of HDR brachytherapy is the potentiallate toxicity of large doses per fraction. Many HDR brachytherapyfractionation schedules, varying from institution to institution are in useand the optimal schedule is yet to be decided. To reduce the duration ofhospital stay, to improve patient compliance and to decrease the patientload in our institution thereby treating more patients of cervical carcinomaby HDR-brachytherapy, we have undertaken this study to assess thefeasibility of a large fraction size (9 Gy/# for 2 fractions) by HDR-brachytherapy in locally advanced carcinoma cervix. Study end points arelocal control, disease-free survival (DFS), acute and late radiation reactions.Methods and Materials: This is a single institution 3-arm prospective trialinitiated in October 2004. A total of 149 patients with histologically provensquamous cell carcinoma of the cervix (Stage IIB-IIIB) with KPSO70 wereenrolled in the study after informed consent. All the patients receivedexternal beam radiotherapy by four-field box technique to 50 Gy in 25fractions over 5 weeks with concurrent chemotherapy (CDDP 40 mg/m2

weekly during EBRT). Arm 1 (n 5 49) patients received 4 fractions ofHDR- intracavitary brachytherapy of 6 Gy/# each week. Arm 2 (n 5 51)patients were treated with 3 fractions of HDR intracavitary brachytherapyof 7 Gy/# each week and Arm 3 (n 5 51) patients were treated with 9 Gy/# of HDR-brachytherapy for 2 fractions.After completion, patients are on 2 monthly followup to detect tumorresponse, recurrence (local or distant), acute and late reactions (recordedas per RTOG criteria).Results: Result of followup with a median duration of 36 months ispresented here. The 3-year actuarial local control in Arm 1 was 71.42%(35/49 patients), in Arm 2 was 76.47% (39/51 patients) and in Arm 3 was77.55% (38/49 patients) [p 5 0.42 compared to Arm 1 and 0.9 comparedto Arm 2]. The local control according to stage was 89%, 67% and63.5%, respectively, for stage IIB, IIIA and IIIB in Arm 1 in contrast to87.5%, 73.5% and 69.25% in Arm 2 and 90.5%, 74.5% and 68% in Arm 3.Disease-free survival (DFS) rate at 3 years were 64.5%, 66.67% and 67.5%in Arm 1, Arm 2 and Arm 3, respectively. Two patients each in Arm 1 andArm 2 developed grade 3 and 4 rectal toxicity. One patient in Arm 3developed grade 3 rectal toxicity. Two patients in Arm 1 had Grade 3bladder toxicity. One patient each in Arm 2 and 3 had >3 Grade bladdertoxicity.Conclusions: High-dose-rate intracavitary brachytherapy (HDR-ICBT)using 9 Gy/fraction for 2 fractions one week apart is comparable to 7 Gy/# for 3 fractions and 6 Gy/# for 4 fractions, in terms of local control andtoxicity in locally advanced carcinoma cervix and can be standardized,provided a geometrically favored application is possible and dose to thecritical structures minimized.

OR14 Presentation Time: 3:40 PM

Comparison of CT and MRI cervical cancer brachytherapy target

and normal tissue volumes

Ramez N. Eskander, M.D.,1 Daniel J. Scanderbeg, Ph.D.,2 Cheryl Saenz, M.D.,1

Catheryn Yashar, M.D.2 1Reproductive Medicine, UCSD Medical Center,

San Diego, CA; 2Radiation Oncology, UCSD, San Diego, CA.

Purpose: To evaluate the differences between target and normal tissuedelineation between MRI and CT in cervical cancer patients and to