Image guided adaptive brachytherapy in patients with cervical cancer
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1 Image guided adaptive brachytherapy in patients with cervical cancer 8. Årsmøde Januar Dansk Radiologisk Selskab & Selskab for klinisk Fysiologi og Nuklearmedicin Lars Fokdal Overlæge Ph.D. Department of Oncology Aarhus University hospital
2 A quick reminder about brachytherapy 200% 20% 2
3 2D brachytherapy: Limitations - NO UNFORTUNATELY NOT!! = 3
4 PDR-BT: Dose rate during one pulse 4
5 5
6 3D image guided procedure Applicator insertion 3D imaging Contouring Reconstruction of applicator 3D dose planning Dose delivery 6
7 Contouring l l 7
8 MRI-based 4D IGBT: IC optimisation HR CTV Prescription isodose Standard Optimised 8
9 MRI-based 4D IGBT: IC/IS technique 9
10 Tandem/Ring applicator for IC/IS BT Needle cap with 12 steering holes for plastic needles
11 11 MRI-based 4D IGBT: IC/IS optimisation Significant dose into sigmoid, rectum and bladder HR CTV Prescription isodose
12 Benefit of IGABT DVH parameters Small tumours (< 32cc) Point A based IGABT Large tumours ( 32cc) Point A Based IGABT Target covered 94% 94% 14% 71% OAR respected 28% 94% 66% 92% TRAK -20% +2% 12
13 Multi-institutionel data on IGABT in cervical cancer Results of the FRENCH STIC prospective study Study design: Non-randomized trial on 2D vs 3D BT 705 Patients Low stage tumors BT+Surgery All tumors EBRT+BT+Surgery Advanced tumors EBRT+BT 2D: N=76 3D: N=89 2D: N=142 3D: N=163 2D: N=118 3D: N=117 Charra-Brunaud et al. Radiother. and Oncol
14 Charra-Brunaud et al. Radiother. and Oncol Multi-institutionel data on IGABT in cervical cancer Results of the FRENCH STIC prospective study 79% 74% 23% 3% Local recurrence-free survival Cumulative toxicity CTAEv3.0
15 Mono-institutionel data on IGABT in cervical cancer l Clinical outcome in 156 patients with cervical cancer treated with EBRT and MRI-based IGABT Actuarial morbidity grade 3-5 at 3/5 years Late morbidity (LENT/SOMA) Vienna A Vienna B Bladder Bowel/rectum Vagina A EBRT alone and CT- based BT B EBRT ±chemotherapy and IGABT: Learning period C EBRT ±chemotherapy and IGABT: Protocol period Vienna C Pötter et al. Radiother. Oncol
16 Mono-institutionel data on IGABT in cervical cancer Pötter et al. Radiother. Oncol
17 Brachytherapy: OAR 141 patients treated with IGABT Median follow up 51 months 23 bladder events (G2+ LENT/SOMA) 11 GI events (G2+ LENT/SOMA) D2cc Gy D2cc 90 Gy Rektum D2cc (Gy) Blære D2cc (Gy) Georg et al. IJROBP 2012 & 2011, Koom IJROBP
18 registered patients from 12 institutions 2009 Nov Nov Apr No. of Centers No. of pts Paris 95 Mumbai 35 Leiden 11 Amsterdam 1 Århus 75 Arnhem 27 Kaposvar 11 Pamplona 6 Vienna 66 Leuven 24 Edmonton 20 Ljubljana 49 Trondheim 22 Milwaukee 5 London 51 Maastricht 18 Chandigar 6 Utrecht 39 Leeds 25 Oslo 1 18
19 ESTRO 31, Barcelona
20 IGABT in other gynaecological tumors?...is there a role for image guided adaptive brachytherapy in locally advanced or recurrent gynaecological malignancies? 20
21 Treatment concept (I) EBRT: 3D conformal or IMRT 45-50Gy / 1.8-2Gy Nodal boost if indicated Chemotherapy: Weekly cisplatin in SCC Elective target Nodal boost 21
22 Treatment concept (II) Brachytherapy: PDR schedule MR image guided treatment planning GEC-ESTRO recommendations Planning aim D90 > 80-85Gy for HR CTV Aarhus: Vienna: 70% 100% 200% GTVDG macroscopic residual tumour B Bladder HR-CTV R R IR-CTV 22
23 Outcome & DVH parameters Aarhus Vienna Number of pts Followup (month) 18 (6-61) 43 (19-87) 3 months CR (%) LC (%) 92 (2Y) 92 (3Y) OS (%) 74 (2Y) 85 (3Y) Morbidity G3+ (%) 4 - HRCTV D100 (Gy) 69 (61-80) 71 (55-88) D90 (Gy) 82 (77-88) 86 (64-110) D2cc Bladder (Gy) 65 (47-81) 80 (55-129) Rectum (Gy) 71 (50-77) 70 (46-81) Sigmoid (Gy) 52 (44-68) 60 (53-70) 23
24 Interstitial-BT in gynaecological malignancies Author (N) EBRT Brachytherapy CR (%) (Gy) Modality Applicator Dose (Gy) Martinez 1985 Jensen 1998 Eisbruch 1998 Charra 1998 Cupta 1999 Tewari 1999 Nag 2002 Weitman 2006 OS (%) DFS (%) LC (%) Morbídity G3-4 (%) Follow-up (years) LDR MUPIT PDR MUPIT < LDR Customized LDR Customized LDR MUPIT LDR Syad-Neblett LDR Syad-Neblett HDR Customized
25 Future directions in IGABT (I) Wait and see J
26 Future directions in IGABT (II) MERIT-study: MEtastatic disease in cervical cancer: The benefit of advanced Radiation treatment combined with Intensive chemotherapy Cervical cancer N+, III-IVB Randomisation IGART 85 Gy IGART 85 Gy + 4x Carboplatin/paclitaxel 26
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