clinical experiences withtomotherapy protocols at hsr site stage indication schedule n fractions gy...
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How IMRT is changing since itsfi t i It lHow IMRT is changing since itsfi t i It lfirst use in Italyfirst use in Italy
October 21-22, 2011University of Modena and Reggio EmiliaUniversity of Modena and Reggio Emilia
CLINICAL EXPERIENCES WITHCLINICAL EXPERIENCES WITH TOMOTHERAPY AT HSRTOMOTHERAPY AT HSR
NADIA DI MUZIONADIA DI MUZIO
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TOMOTHERAPY PROTOCOLS AT HSR
SITE STAGE INDICATIONSCHEDULE
n fractions Gy / f
H&N IVa/bradical 30 1.8-
2.15(2.25)
dj 30 1 8 2 3adjuvant 30 1.8-2.3
LUNG IIIa/b radical 25 2.5
PANCREAS III radical 15 > 3.2
pT2-T4pN0 adjuvant 20 2.9PROSTATE
T1-T3 radical 28 1.85-2.65
LUNG MTS max 3 < 3cm radical 6 > 6LUNG MTS max 3 , < 3cm radical 6 > 6
LIVER MTS max 4 , < 3cm radical 5 > 8
RETREATMENTS var radical var var
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TomoTherapy :
work-flow at HSR
CT +
PET HN, lung, pelvis
NMR b i l iNMR brain, pelvis
4D-PET/CT lung, pancreas, liver
SPECT lungg
Contouring BTV/GTV and OARs
Planning strategy:
Constraints related to dose/fraction value
Patient dosimetry: Part of QC. Critical cases
Daily MVCT-KVCT match
treatment
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Up to 20% of patients are excluded from radical
RT treatment because of unsuspected metastasesPET
Lardinois et al. 2003
Schrevens et al 2004
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Impact of the motion on PET images : Lung Study
PET SUVBASAL: 2.0BIN1: 2 6
BASAL BIN‐ 1 BIN‐ 2
BIN1: 2.6BIN2: 2.3BIN3: 2.5BIN4: 3 2BIN4: 3.2BIN5: 2.9BIN6: 2.5
BIN‐ 3 BIN‐ 4 BIN‐ 5SUV =: SUVbw(g/ml)
BIN‐ 6 HSR‐Milano
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Impact of the motion on PET images: Liver Study
“St ti ”“Static”PET 4D‐PET
SUVPhase 6=3.1SUV=1.8
“Static”
4D‐PETPET
SUVPhase 1=2.9SUV=1.6
SUV =: SUVbw(g/ml)HSR‐Milano
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RPM Respiratory Gating™ System
TM : Varian Medical System Gating School Copenhagen
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4D Data Sorting
Patient Breathing Curve
X‐ray ONPET acquisition
CT or PET Images Phases
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Goal:Define the target volume and the volume of space that encompasses tumor motion.
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4D-PET/CT CONTOURING
st
BTV
exp
insp sum
HSR , Milan
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4D-PET/CT CONTOURING
ITV ITV
HSR , Milan
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SIMULTANEOUSSIMULTANEOUS
INTEGRATED
BOOSTBOOST
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TARGET DOSETARGET DOSE
Intermediate risk Intermediate risk
VolumesVolumes Low risk NCCNLow risk NCCN
Intermediate risk Intermediate risk NCCN NCCN
Roach formula Roach formula <15%<15%
HighHigh risk NCCNrisk NCCNRoach formula Roach formula ≥≥ 15%15%
D/frD/fr DtotDtot D/frD/fr DtotDtot D/frD/fr DtotDtot
PTVPTV11PTVPTV11(LN+P+VSI)*(LN+P+VSI)* 1.851.85 51.851.8 1.851.85 51.851.8
PTVPTV22(P+VSI)(P+VSI) 22 5656 2 22 2 61 661 6 2 342 34 65 565 5PTVPTV22(P+VSI)(P+VSI) 22 5656 2.22.2 61.661.6 2.342.34 65.565.5
PTVPTV33(P+(P+ VSVS11//33)) 2.22.2 61.661.6 2.342.34 65.565.5 2.652.65 74.274.2
PP TVTV44 (P)(P) 2.552.55 71.471.4 2.652.65 74.274.2 2.652.65 74.274.2
PP OVERLAPOVERLAP 2.342.34 65.565.5 2.342.34 65.565.5 2.342.34 65.565.5
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TOMOSIB ( + LN )
PTVPBowelsout of N
Femoral headOverlap
Rectum PTV SVFemoral head
PTV LN
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60 pts median follow up : 47.2 months ( 34.2- 60.1 m)
ACUTE TOXICITYACUTE TOXICITYRESULTSRESULTS
4550
484225G0
UGI 29/60
LGIGURTOG
303540
GU12(5)1821G1
484225G0
202530 GU
LGI(rectum)UGI
002G3
0012G2
51015
05
G0 G1 G2 G3
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100 pts median follow up : 40.7 months (18.4-60.1 m)
ACUTE TOXICITYRESULTS
70
80
RTOG GU LGI UGI
G0 35 71 7250
60
GUG0 35 71 72
G1 38 28 25
30
40GULGI(rectum)UGI
G2 25 1 3
G3 2 0 0 10
20
0G0 G1 G2 G3
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60 pts median follow up : 47.2 months ( 34.2‐ 60.1 m)
LATELATE TOXICITYTOXICITYRESULTSRESULTS
50
60
605148G0
UGI 29/60
LGIGURTOG
40
50
GU076G1
605148G0
20
30GULGI(rectum)UGI
002G3
024G2
10
20
0G0 G1 G2 G3
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100 pts median follow up : 40.7 months ( 18.4- 60.1 m)
LATELATE TOXICITYTOXICITYRESULTSRESULTS
60
70
6957G0
LGIGURTOG
40
50
2223G1
6957G0
30
40GULGI(rectum)
05G3
915G2
10
20
0G0 G1 G2 G3
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DFS median follow up 40 m (17 57 months)DFS median follow up 40 m (17‐57 months)
97%
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PANCREATIC CANCERHypofractionated Tomotherapy with concomitant
h th i d d ti d ichemotherapy in advanced pancreatic adenocarcinoma. Preliminary results of a phase I study.
ENDPOINT
To determine the radiotherapy MTD to tumor sub volume infiltrating vesselsTo determine the radiotherapy MTD to tumor sub‐volume infiltrating vessels
METHODS
44 patients in stage III or IV previously CT‐treated
Simulation performed with contrast enhanced 4D CT/PETSimulation performed with contrast‐enhanced 4D‐CT/PET
GTV1: the tumor, and
GTV2: a tumor sub‐volume 1 cm around infiltrated vessels
were contoured on 4D‐CT.
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MATERIALS AND METHODSMATERIALS AND METHODSMATERIALS AND METHODSMATERIALS AND METHODS
• ● From June 2005 to November 2008
• ● 44 pts (♀. 23; ♂. 11)
SIB GROUPSIB GROUP: : 2525 ptsptsPTV2PTV2 44.25 44.25 GyGy/15 f. +/15 f. +
SIBSIB withwith dose escalationdose escalation toto PTV1PTV1• ●Median age: 60 ys (40‐74)
• ●Median KPS : 90 (60‐100)
SIB SIB withwith dose escalation dose escalation toto PTV1 PTV1 (48 (48 GyGy: 4 : 4 ptspts, 50 , 50 GyGy: 6 : 6 ptspts, ,
52 52 GyGy: 3 : 3 ptspts, 55 , 55 GyGy: 6 : 6 ptspts, 58 , 58 GyGy 7 7 ptspts))ed a S : 90 (60 00)
• ● Adenocarcinoma: 44
II d ti CHT 29 di N° f l 6
c.i.c.i. 5FU / CAPECITABINE 5FU / CAPECITABINE 5-FU 250mg/m2/day c i in the first 6 pts• ● IInduction CHT 29 pz, mmedian N° of cycles : 6
(2‐11)• (PEXG: 11, PDXG: 8, PEFG: 6, GEM: 3,
CDDP+GEM: 1)
5 FU 250mg/m2/day c.i. in the first 6 pts. 23 remaining pts received capecitabine, 1250 mg/m2/day
• ● Stage: III 23 pts, IV 3 pts (2 pts with CR ofhepatic metastases, 1 pt with stable disease 6 months after the end of CHT), local relapse 3 pts No SIB GROUP: 19 No SIB GROUP: 19 ptspts
44 2544 25 GG /15 f PTV (/15 f PTV (PTV2PTV2))44.25 44.25 GyGy /15 f. PTV (/15 f. PTV (PTV2PTV2))
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MATERIALS AND METHODSMATERIALS AND METHODS
volumes Definition:
SIB GROUPSIB GROUP Non SIB GROUPNon SIB GROUP
GTV in 4 series of 4D CT
GTV in 4 series of 4D-CT4D-CT 4D CT
GTV2GTV2 GTV1GTV1GTV2GTV2(tumor)(tumor)
GTV1 GTV1 (infiltrated vessels (infiltrated vessels + 5+ 5--10 mm)10 mm)
ITV=ITV1ITV=ITV1boolean Union
ITV2ITV2 ITV1ITV1
ITV=ITV1ITV=ITV1boolean Union
4D4D--PTV2PTV2 4D4D--PTV1PTV14D4D--PTV=4DPTV=4D--PTV2PTV2
0.5-0.5-0.7 cm
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Volume definition:Volume definition:
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Pancreatic Tumour: two 4D‐PTV
4D‐PTV24D PTV1 4D PTV2
(44.25 Gy, 15 fr)
4D‐PTV1
“Vascular region ”
(48 58 Gy 15 fr)(48‐58 Gy, 15 fr)
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STST‐‐PTVs 3DCRT vs 4DPTVs 3DCRT vs 4D‐‐PTVs 3DCRTPTVs 3DCRT
ST‐PTV vs 4D‐PTC: GEOMETRIC RESULTS
4D‐PTVs were smaller than ST‐PTVs in all pts
4D‐PTVs were 36% smaller than ST‐PTV (mean value 187 cm3 vs 295 cm3 p=0 0006)cm3, p=0.0006)
Overlapping volumes between 4D‐PTVs and stomach was 59% smallerpp gthan overlapping volumes between ST‐PTVs and stomach (mean value 7 vs 18 cm3, P=0.0014)
Overlapping volumes between 4D‐PTVs and duodenum was 43% smallerthan overlapping volumes between ST PTVs and duodenum (mean valuethan overlapping volumes between ST‐PTVs and duodenum (mean value 9 vs 16 cm3, P=0.006)
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STST‐‐PTVs 3DCRT vs 4DPTVs 3DCRT vs 4D‐‐PTVs 3DCRTPTVs 3DCRT
3DCRT TargetsOrgan DVH
ParametersST-PTV(MeanV l )
4D-PTV(MeanV l )
OrganSpared
(%)
P
Values) Values) (%)
Stomach D mean 22 6 17 6 22% 0 007Stomach D_meanV20V50
22.648.513,9
17.639.78.3
22%18%40%
0.0070.010.004
Duode-num
D_meanV20
35.069.9
30.163.4
24%9%
0.010.01
V50 36.1 25.3 29% 0.01Kidney D_mean
V209.0
18 56.9
13 223%28%
0.030 05V20
V3018.511.2
13.27.7
28%31%
0.050.06
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3DCRT vs TOMOTHERAPY
Target = 4DPTVs
Organ DVHP t
3DCRT( )
TOMO( )
OrganS d PParameters (Mean values) (Mean values) Spared
(%)P
Stomach D mean 17 6 16 5 8% 0 36Stomach D_meanV20V50
17.639.78.3
16.529.24.3
8%29%48%
0.360.0040.001
Duode-num
D_meanV20
30.163.4
24.650.5
17%20%
0.0030.001
V50 25.3 12.7 49% 0.001Kidney D_mean
V206.913 2
13.318 0
-48%26%
0.00060 16V20
V3013.27.7
18.01.2
-26%84%
0.160.01
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Pancreatic Tumour: HT plan
Dose distribution two 4D‐PTV
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PANCREATIC CANCERRESULTS
DOSE LEVELS:
I level, 48 Gy: 3 ptsI level, 48 Gy: 3 ptsII level, 50 Gy: 6 ptsIII level, 52Gy: 3 ptsIV level 55 Gy: 6 ptsIV level, 55 Gy: 6 ptsV level, 58 Gy: 7 pts
G3 TOXICITYG3 TOXICITY:
Gastric ulcer: 1 pt at the II level
Gastro‐duodenitis: 1 at the IV level
COMMENTS:COMMENTS:The planned final dose to PTV1 was 58 Gy
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RESULTS:TOXICITYRESULTS:TOXICITYEarly toxicity
SIB Group N°Pts (%) Non SIB Group N° Pts(%)
Diarroea G1 3 ( 20%) 5 (12% )
Diarroea G2 2 ( 13%) 2 (15%)
Nausea e vomiting G1 5 ( 33%) 5 ( 28%)
N i i G2 3 (1 %) 9 (20%)Nausea e vomiting G2 3 (15 %) 9 (20%)
Nausea e vomiting G3 0 ( 0%) 1 (4% )
Anorexia G1 3 (13%) 1 (7% )
Anorexia G2: 1 ( 6%) 1 (7% )Anorexia G2: 1 ( 6%) 1 (7% )
Abdominal pain G1 2 (13%) 0 ( 0%)
Abdominal pain G2 3 (20 %) 5 ( 38%)
Weigth loss G1 1 ( 6%) 0 ( 0%)Weigth loss G1 1 ( 6%) 0 ( 0%)
trombocitopenia G1 1 ( 6%) 1 (7% )
Neutropenia G2 0 (0%) 2 (15%)
Hepatotoxicity G1 2 (13%) 2 ( 15%)
E l T i it G3 t i l i SIB G 1/25 ti t (4%)
Hepatotoxicity G1 2 (13%) 2 ( 15%)
Hepatotoxicity G2 1 (6%) 0 (0%)
●● Early Toxicity G3: gastric ulcer in SIB Group : 1/25 patients (4%) ●● LateLateToxicity: hemorragic gastro-duodenitis G3 in Non SIB Group : 1/19 pz (5%)
“Common Terminology Criteria for Adverse Events (CTCAE)” v 3.0‐NCI‐ 2003.
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RESULTS: RESPONSES CT/RESPONSES PETRESULTS: RESPONSES CT/RESPONSES PET
RESPONSES SIB Group No SIB Group 29 / 44 pts
CT PET
RESPONSES SIB Group (24/25 pts)
No SIB Group (19/19 pts)
29 / 44 pts
PR 4 pts (17%) 3 pts (16%) 20 pts (68%)
CR 0 pts (0%) 1 pts (6%) 3 pts (10%)
SD 17 pts (70%) 11 pts (58%) 4 pts (15%)
PD 3 pts (13%) 4 pts (20%) 2 pts (7%)p ( ) p ( ) p ( )
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RESULTS: SITES OF FIRST PROGRESSIONRESULTS: SITES OF FIRST PROGRESSION
Local + systemic: 23/44 (53%)l l / ( )Local only: 4/44 (10%)
Median TTP : 12 2 mMedian TTP : 12 2 mMedian TTP : 12.2 m. Median TTP : 12.2 m. Median TTLP: 16.2 m. Median TTLP: 16.2 m. Median OS : 18 6 mMedian OS : 18 6 mMedian OS : 18.6 m.Median OS : 18.6 m.
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Time to progression
44
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Time to local progression
44
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Overall Survival
44
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PANCREATIC CANCERPANCREATIC CANCERPANCREATIC CANCERPANCREATIC CANCER
A dose of 44.25 Gy in 15 fractions on PTV2 concomitant to 5-FU c.i. or oral capecitabine is feasible and effective ( mild rate of toxicity)capecitabine is feasible and effective ( mild rate of toxicity) .
Th i b i fil d l d i hThe concomitant boost to infiltrated vessels does not seem to improve the response rate; however, once the maximum tolerated dose to the tumor sub-volume is reached, its efficacy will be tested on potentially operable disease.
The sequence of induction chemotherapy followed by chemoradiationseems to allow the best long term survival resultseems to allow the best long term survival result
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DOSEDOSE
ESCALATION
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DOMINANT INTRAPROSTATIC LESION (DIL)
Mounting evidence that radioresistant cells and/or high‐clonogen density volumes may bevolumes may be concentrated in one or more local foci [Cellini 2002] , named “dominant intra‐prostatic lesions” (DIL)
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Intraprostatic IMRT boosting under DCE‐MRI and MRST guidance
Van Lin et al2006
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Intraprostatic IMRT boosting under DCE‐MRI and MRST guidance
Van Lin et al.,2006
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DIL dose escalation by Tomotherapy: Planning study design at HSRPlanning study design at HSR
• DIL defined by T2WI + diffusion weighted (DWI) MRIdiffusion weighted (DWI) MRI
• PTV DIL = DIL + 5mmPTV DIL DIL 5mm
• Increasing the dose to PTV‐DIL i 28 f i IGRTDIL in our 28 fractions IGRT scenario (71.4 Gy to prostate) with Tomotherapy
PTVDIL
• N=7 patients
PTVDIL71,4 Gy; 2,55 Gy/fr (EQD2=75 Gy)80 Gy; 2,86 Gy/fr (EQD2=86 Gy)
PTV(p+sv)71 4 G 2 55 G /f
y; , y/ ( Q 2 y)90 Gy; 3,21 Gy/fr (EQD2=99 Gy)100 Gy; 3,57 Gy/fr (EQD2=113 Gy)120 Gy; 4 29 Gy/fr (EQD2=143 Gy)*71,4 Gy; 2,55 Gy/fr 120 Gy; 4.29 Gy/fr (EQD2=143 Gy)*
EQD2 calculated with α/β=10
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PTV‐DILD il li IGRT (MVCT)• Daily on‐line IGRT (MVCT)
• Minimization of prostate shape deformation through dailyMinimization of prostate shape deformation through daily rectal enema; rectum emptying procedures if full rectum at daily MVCT [Fiorino IJROBP 2008]
• Residual “safe” margin (IGRT system uncertainty, intra‐fraction, contouring) = 5 mmfraction, contouring) 5 mm
Example of post‐MVCT emptying procedure1° SCAN 2° SCAN
(1 h ft )(1 h after)
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Constraints‐ Rectum constraints:
‐ Bladder constraints:
V75 < 0.1 cc
Constraints
V80 < 0.1 cc (EQD2=94Gy)
V75 (EQD2=85Gy) < 1 cc
“As low as possible” out PTV
‐Femoral heads
BRA
V70 (EQD2=77Gy) < 2 cc
V68.5 (EQD2=75Gy) < 5%
Dmax < 40 Gy
‐Urethra
CHY
V65.5 (EQD2=70Gy) < 20%
V40 < 60%
V90 < 0.1 cc
‐ Bulbus of the penis
Y
V52<50%
EQD2 calculated with α/β 3α/β=3
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Results (Patient with large overlap b PTV DIL d )between PTV‐DIL and rectum)
P+SV = DIL = 71 4 G
Step 0
71.4 Gy
P+SV = 71.4 Gy DIL= 80 Gy
Step 1
y
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P+SV = 71.4 Gy yDIL= 100 Gy
Step 3
DIL
RectumPTV‐DIL
PTV
BladderF. Heads
urethra
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Preliminary conclusions
Ultra‐high dose escalation (EQD2 > 110 Gy) on DIL definedUltra high dose escalation (EQD2 > 110 Gy) on DIL defined by T2WI‐DWI MRI should be feasible
Tomotherapy guarantees target coverage, maintaining a 5 mm margin while respecting the constraints on OARs (in particular no significant increase of rectal NTCP is expectedparticular, no significant increase of rectal NTCP is expected compared to conventional dose delivery)
DIL theorem + availability of powerful IMRT/IGRT tools + predictive NTCP = rationale for future clinical pstudies….ΔTCP evaluations in progress….
A Clinical Phase I‐II study should start within the year
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RECTAL CANCERRECTAL CANCER
PURPOSETo test the clinical feasibility of adaptive RT concomitant to oxaliplatin (oxa) and 5FU c.i. in rectal cancer.
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BACKGROUND: ANALYSIS OF RECTUM VOLUME VARIATION DURING TOMOTHERAPY
• The rectum was retrospectively contoured on the daily Megavoltage images (MVCT) of six patients previously treated with Tomotherapy. The variations of rectum volume during Tomotherapy were examinedTomotherapy were examined.
• Rectal volume shows a linear decrease of 58.2 % between the start and end of the treatment (range: 28.6%‐75.4%); most of the rectum volume variation was observed in the first half of th t t t ith d ti f 50%the treatment with an average reduction of 50%.
• A first estimate of optimized margins for adaptive RT with concomitant boost to the tumour was achieved by expanding the rectal contouring during the initial MVCT s and subsequently d i h d h lf f h i h diff i (0 5 0 7 1 1 5 2 )during the second half of the treatment with different margins (0.5, 0.7, 1, 1.5, 2 cm).
• In the second half of the treatment, more than 90% (range: 82.4%‐100%) of the rectal volume union was contained within a margin of 0.5 cm, while a margin of at least 1 cm is necessary to obtain the same coverage in the first part of the treatment.
• Based on the results of this investigation, a pilot adaptive approach was started in which aBased on the results of this investigation, a pilot adaptive approach was started in which a concomitant boost is delivered on the last 6 treatment fractions.
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PATIENT CHARACTERISTICSPATIENT CHARACTERISTICS
• N° of patients treated: 12 (F:4, M: 8)• Median age: 54 years (37‐77)• Median KPS: 100• Eligibility criteria : histologically proven adenocarcinoma,
li i l t T3 T4 T ith N iticlinical stage T3‐T4 or anyT with N positive• Clinical stage:
T3N+: 7 ptsT3N+: 7 pts T4N0: 3 pts (anal canal infilration) T4N+: 2 pts (cervical and vaginal infiltration : 1 pt; anal canalT4N+: 2 pts (cervical and vaginal infiltration : 1 pt; anal canal infiltration: 1 pt)
• Distance of tumor from anus ≤6 cm/> 6 cm: 6/6 pts
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MATERIALS AND METHODS♦ Simulation and contouring: ‐ after positioning on Comby‐fix®, patients underwent a contrast‐enhanced CT and MRI simulation; both examinations were repeated after 10 Tomotherapy fractions. ; p py
♦ PTV1: CTV (mesorectum and regional lymph‐nodes) with a margin of 0.5 cm.
♦ ‐ PTV2: residual tumour visible on the intermediate MRI/CT with a margin of 0.5 cm, taking rectal deformation into account.
♦ Prescription dose: ‐ 41.4 Gy in 18 fractions, 2.3 Gy/fr, to PTV1.dose escalation consisted of a concomitant boost on PTV2: 2 7 Gy/fr (3 pts) 2 9 Gy/fr (9‐ dose escalation consisted of a concomitant boost on PTV2: 2.7 Gy/fr (3 pts), 2.9 Gy/fr (9 pts) on the last 6 fractions.
♦ Concomitant ChT: Oxaliplatin (100mg/m2) on day ‐14, 0 (the start of RT), +14, 5‐FU ♦ Co co ta t C O a p at ( 00 g/ ) o day , 0 (t e sta t o ), , 5 U(250mg/m2/day c.i.) from day ‐14 to the end of RT.
♦ All patients completed RT with a median treatment time of 24 days, and all received 100% of ChT dose.
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DOSE DISTRIBUTION WITH TOMOTHERAPY
PTV1 PTV2
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RESULTS
i iAcute toxicity (NCI‐CTC‐v3)
Acute ToxicityAcute Toxicity G1G1--G2G2diarrhoeadiarrhoea 45%45%diarrhoeadiarrhoea 45%45%
tenesmustenesmus 45%45%
rectal bleeding rectal bleeding 27%27%
dermatitisdermatitis 27%27%
No G3 acute toxicity occurred
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RESULTS
♦ N° of patients undergoing surgery 11/12 pts♦ N° of patients undergoing surgery: 11/12 pts
♦Median time from RT to surgery: 13 weeks (10‐19)
♦ Type of surgery: ‐ LAR: 8 pts‐Miles: 2 pts‐ The youngest pt (37 y) with initial minimal infiltration of anal canal (T4N0) achieved complete remission, refused the operation, and is still free from
i h f h d f hprogression 16 months after the end of the treatment.
♦ Response:‐ CR: 3/12 pts (25%)‐ Downstaging: 8/12 pts (67%)‐ SD: 1 pt (8%)p ( )
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OUTCOME OF SURGERY Clinical Clinical
stagestageType of surgeryType of surgery ResponseResponse TRGTRG Residual cell
vitality
1 T3N1 LAR T2N0 3 1%
2 T4N0 Miles pCR 4 -
3 T4N0 No surgery cCR3 T4N0 No surgery cCR - -
4 T4N0 LAR pCR 4 -
LAR+hysterectomyand bilateral 5 T4N2 salpingo-oophorectomy T4N0 3 20% 6 T4N2 Laparoscopic Miles T3N0 3 5%
7 T3N2 LAR T1N0 3 <5%7 T3N2 LAR T1N0 3 5%
8 T3N1 LAR T2N0 3 5%9 T3N2 LAR T3N1 3 1 % 10 T3N1 LAR T3N1 2 50%
11T3N1 LAR T3N0 3 1 mm from radial
margin
12 T3N2 LAR T3N0 3 focal residual
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RECTAL CANCERRECTAL CANCER
• The estimation of rectal volume variation gives the possibility to better guide d f l h lirradiation for preoperative treatment. In particular the tumour volume
reduction and the possibility to decrease the PTV margin in the second half of the treatment could allow an escalation of tumour dose using SIB adaptive t t i ith d d i f th T t f th b tstrategies with reduced margins for the T component of the boost.
• This “adaptive” approach seems to be feasible and well tolerated: no G3 acute toxicity occurred in the 12 pts treated.
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CONCLUSIONSCONCLUSIONS
Tomotherapy offers:
• Great versatility in dose modulation
• Efficacy in SIB delivery
• Good possibility to irradiate targets in motion
• Possibility to perform adaptive radiation therapy and focalPossibility to perform adaptive radiation therapy and focaldose escalation (thanks to IGRT)