imrt vs. brachytherapy for soft tissue sarcoma. external rt in sts nci trial (yang jc et al, jco...
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IMRT vs. BRACHYTHERAPY
FOR
SOFT TISSUE SARCOMA
EXTERNAL RT IN STS
NCI Trial (Yang JC et al, JCO 1998)
Extremity / Superficial Trunk STS (n=141)LSS Alone (n=71)LSS + External Radiotherapy (n=70)
Ext. Radiotherapy: 45Gy (WF) + 18Gy (Boost)
Median FU: 115mths
Local ControlLSS Alone: 76% LSS + External Radiotherapy: 98%
p=0.0001
+ve impact in high grade as well as low grade sts
Level I Evidence
MSKCC Trial (Pisters PWT et al, JCO 1996)
Extremity / Superficial Trunk STS (n=164)LSS Alone (n=86)LSS + Interstitial Brachytherapy (n=78)
Brachytherapy: 42-45Gy in 4-6 days
Median FU: 76mths
Local ControlLSS Alone: 69% LSS + Interstitial Brachytherapy: 82%
p=0.04
+ve impact in 119 pts. with high grade sts onlyno improvement in 45 pts. with low grade sts
Level I Evidence
BRACHYTHERAPY FOR STS
• Three prospective trials investigating the impact of limited radiation volumes on toxicity rates and local control
• RTOG 0630• United Kingdom VORTEX trial• COG ARST 0332 trial
• Radiation volume reduction aims at sparing healthy surrounding tissues to potentially decrease treatment toxicities
• Lymphedema• Subcutaneous Fibrosis• Joint Stiffness
TRIALS ADRESSING TARGET VOLUME
• Local Control
• Complications
• Functional Outcomes
• QOL
• Duration of Treatment
• Cost of Treatment
Dept of Radiation Onology, MSKCC, USA
Cancer July 2011
PATIENTS & METHODS
January 1995 – December 2006
134 Adult Patients
Inclusion Criteria:
Primary PresentationExtremityHigh GradeLimb Sparing Surgery at MSKCCAdj. Brachyherapy / IMRT at MSKCC
Brachytherapy (Jan 1995 – Nov. 2003), n = 71 (53%)
IMRT (Feb 2002 – Dec 2006), n = 63 (47%)
BRACHYTHERAPY
LDR Brachytherapy: Dose Rate – 0.41Gy / Hour
Total Dose – 45Gy
Started – Post op Day ≥ 5
Intensity Modulated Radiation Therapy
Pre – Operative
N = 10
Dose : 50Gy/ 25 # @ 2Gy/#
WLE : 4-6 wks after RT
CTV : Gross Tumor + 3cm long 0.5cm bone
1.5cm Radial
PTV : CTV + 2cm
Post – Operative
N = 53
Dose : 63Gy (Median)
Started 4–6 wks after Sx
CTV : Sx bed + 3cm expansion
0.5cm bone 1.5cm Radial
PTV : CTV + 2cm
PROGNOSTIC FACTORS
5 YEAR LOCAL CONTROL (Actuarial)
Median FU: 46 mths
Whole Group: 86%
IMRT: 92%
BRT: 81%
Significant Wound Complications
IMRT: 19%
BRT: 11% p=0.6
AUTHORS INFERENCE
Post-op adjuvant RT using IMRT technique results in
Superior outcomes compared to Brachytherapy for Local Disease Control
Should be considered the treatment of choice for extremity sts
PRE-OP VS. POST-OP RADIOTHERAPYRandomized Trial
O’Sullivan et al, Lancet 2002
Extremity STS (n=190)Pre-op RT + LSS (n=94)LSS + Post-op Ext. RT(n=96)
Pre-op Ext. RT Dose: 50Gy/ 25#Post-op Ext. RT Dose: 66Gy/ 33#
Primary endpoint: Complication rate within 120 days Median FU: 3.3 years
Pre-op Post-opWound Complications 35% 17% p=0.011Local Control 91%(3yr) 90%(3yr) p=0.711Overall Survival 84%(3yr) 74%(3yr) p=0.048
Level I Evidence
O’Sullivan Cancer 2013
Local Control: 65 – 89%
Complications: 1 – 50%
RESULTS WITH LDR BRACHY ALONE
RESULTS WITH HDR BRACHY ALONE
Local Control: 50 – 100%
Adverse Effects: 0 – 50%
Laskar et al, Ann Surg Oncology 2007
RESULTS
TOXICITIES
S Laskar Annals of Surgical Oncolog 2007
CENTER PTS BRACHY LC(%)
MSKCC (Pister et al.) 164 LDR/HDR 89
Tata Memorial Hosp. (1983-92) 151 LDR 71
Fox Chase 130 LDR/HDR 82
MSKCC (Harrison et al.) 126 LDR 82
Inst. Claudius Regaud 112 LDR/HDR 89
MSKCC (Alekhteyar et al.) 105 LDR 86
Institute Gustave Roussy 50 LDR 62
Tata Memorial Hospital (1990-2003) 155 LDR/HDR 71
LITERATURE REVIEW
10 year local control - 91.7%
LONG TERM DATA TMH (TMH – UNPUBLISHED 2012)
Laskar et al, Pediatric Blood & Cancer 2007
RESULTS
INTERSTITIAL BRACHYTHERAPY IN THE ERA of
IMRT / IGRT / DOSE PAINTING WITH NUMBERS
Hong et al., IJROBP 2004Lancet Oncology 2006
IMAGE GUIDED BRACHYTHERAPY
2500 INR = 40 USD
300INR – 6 USD
Brachy: 450 USD (At TMH)IMRT: 1400 USD (At TMH)Protons: 100-200,000 USD
IMRT BRT Verdict
Local Control *** **
Complications ** ***
Functional Outcome
** **
QOL No Data No Data
Treatment Duration
* ****
Treatment Cost ** ***
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Randomised Clinical Trial: IMRT vs. BRT
SUMMARY