Comparison of rectal and bladder ICRU point doses to the GEC ESTRO volumetric doses in Cervix cancer

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1 Comparison of rectal and bladder ICRU point doses to the GEC ESTRO volumetric doses in Cervix cancer Poster No.: RO-0049 Congress: RANZCR FRO 202 Type: Authors: Scientific Exhibit G. Govindarajulu, A. Capp, C. Dempsey, S. Oultram, P. O'Brien; Newcastle/AU Keywords: Radiation therapy / Oncology, Dosimetry, CT, Genital / Reproductive system female, Neoplasia DOI: 0.594/ranzcrfro202/RO-0049 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply RANZCR's endorsement, sponsorship or recommendation of the third party, information, product or service. RANZCR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold RANZCR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies,.ppt slideshows,.doc documents and any other multimedia files are not available in the pdf version of presentations. Page of 9

2 Purpose To compare the ICRU point doses to the GEC-ESTRO recommended volume doses for rectum and bladder in HDR brachytherapy for cervix cancer. Methods and Materials The treatment records of patients treated with curative intent for cervical cancer and receiving HDR brachytherapy between January 2006 and December 200 were reviewed retrospectively. The rectum and bladder were contoured retrospectively on the CT datasets obtained at the time of brachytherapy simulations using the Oncentra planning system and D2cc derived for each treatment. The EQD2Gy (equivalent dose in 2 Gy) was calculated using the LQ equation with #/# = 3. The EBRT and brachytherapy doses were added using the work sheet for dose reporting by the GEC-ESTRO group. The volumetric doses were then compared with the ICRU point doses for bladder and rectum. An attempt was made to correlate these doses to late toxicities. Statistical Analysis Statistical analysis was done using the SPSS statistical computer package version 20. Descriptive statistical analysis was undertaken. Pearson's correlation coefficients were computed to compare the doses to the ICRU points and D2cc. Results A total of 39 patients were treated with radical intent with External Beam and HDR brachytherapy between January 2006 to December 200. Only 37 patients were included in the analysis as two were excluded as they had one brachytherapy insertion. Patient characteristics and treatment details are shown in table. Table Patient characteristics Page 2 of 9

3 Total no of patients 37 Age median (range) years 63 ( 2-83 ) Histology 30 Squamous cell carcinoma 6 Adenocarcinoma Neuroendocrine carcinoma Stage( FIGO 2009) IB/IIA IIB IIIB IVA External Beam Radiation )Site Pelvis Pelvis+Para-aortic 2) Dose 45Gy in 25# 50Gy in 25# 50.4 Gy in 28# (2-6) Concurrent chemotherapy Cisplatinum 40mg/sq m weekly No of cycles Median (range) Brachytherapy Total no of applications 36 Page 3 of 9

4 Three Four Dose 24Gy in 3 # 8 Gy in 3# Applicator Tandem+ovoids Tandem +ring Tandem +vaginal cylinder Treatment time - days Median (range) 54 (37-82) Clinical outcome Local control and survival The median follow up was 24 months (range -54 months).at the last follow up 5 patients had local failure,3 of whom also had distant relapse.a total of 0 patients had distant relapse which included nodal,pulmonary and leptomeningeal deposits.(table 2) Mean survival was 42 months.as of December 20 9 patients had died. Table 2 Relapse patterns Site of relapse Stage IB/IIA Stage IIB Stage III B Local only - Page 4 of 9

5 Local &Distant Distant only 2 5 ICRU point vs.volumetric dose comparison for rectum & bladder There was less variation in the rectal doses as compared to the bladder which may be due to different bladder filling volumes. The ICRU and volumetric doses correlated well with the Pearson's correlation coefficient (r) value being >0.6. The doses are depicted in table 3 and the error plot in chart. Table 3 ICRU and D2cc dose information ICRU EQD2Gy D2cc EQD2Gy D2cc/ICRU r value (Mean+/- SD) (Mean+/- SD) (ratio) (Pearson's correlation ) Rectum 76.3+/ / ± Bladder 99.4+/ /-6.7.4± Toxicity Grade 3 or 4 recto-sigmoid toxicity was noted in 5 patients; 4 patients required intervention for radiation proctitis and one developed a sigmoid stricture. All four patients with radiation proctitis had rectal doses greater than 75 Gy EQD2Gy at both the ICRU point and the D2cc rectal volume. Urinary Grade 3 toxicity was noted in 3 patients. Radiation cystitis in one, increased urinary frequency requiring ditropan in another& third patient had ureteral stenosis for which the cause is not clear. Page 5 of 9

6 Images for this section: Fig. : Chart. Error plot for bladder and rectal doses Page 6 of 9

7 Conclusion Discussion Brachytherapy is an integral part of treatment for advanced cervical cancer. Traditionally, the brachytherapy prescription has been based on dose points defined using conventional two dimensional imaging. Point A dosing is based on the Manchester System and the rectal and bladder reference points are based on ICRU report No 38. However these reference points give limited information on the actual dose received by the rectum and bladder. The integration of 3-D treatment planning has led to the development of GEC -ESTRO volumetric concepts in cervical brachytherapy. Good correlation has previously been described for D2cc and ICRU dose points, more so for rectum than bladder, 2. In our series, the Pearson's correlation coefficient is >0.6 for ICRU and volumetric rectal and bladder doses. There is significant variation in the bladder dose but this appears to be similar to published literature. Our rectal and bladder EQD2Gy doses are higher than reported in some other studies 3-7, but have occurred predominantly in patients with advanced stage disease in whom high rates of local control have been obtained. Apart from the study of Vinod et al 3, these other studies have generally used different applicators or MRI planning which could account for some of the differences. It is known that MRI gives better tissue contrast and therefore one would achieve a more accurate delineation of organs. Table 4 gives the comparative values from other reports adopting a similar approach. Anecdotally, we have noticed a decrease in rectal and bladder doses since changing to MRI planning and the use of the Vienna ring. For the patients with rectal toxicity, both the ICRU point doses and the Rectum D2cc doses were above 73Gy, indicating that shift to a volume based treatment prescription could predict for treatment related toxicity. Table 4 Comparison of ICRU 38 Parameters and 3D Image guided DVH parameters in mean ±SD Page 7 of 9

8 Author No. of Datasets Vinod 3 62 Tandem & Ovoids Mahanshetty 77 4 Tandem & Ovoids Kirisits 7 76 Tandem & Ring Current study Tandem & Ovoids Type of Imaging Applicators Modality EQD2Gy Rectum EQD2Gy Bladder ICRU D2cc ICRU D2cc CT 64±0 67± 93±27 0±24 CT+MRI 63.5± ± ± ±24.6 MRI 69±3 64±6 75±6 83± 9 CT 76.3± ± ± ±6.7 Conclusion We have found that there is good correlation of the D2cc volume parameter with the traditionally used ICRU based dose prescription. Our median ICRU and volumetric doses are higher than some others reported and all patients suffering significant toxicity had doses higher than the median. We have addressed this by moving to MRI based planning using the Vienna ring and reducing the number of patients receiving EBRT to 50.4Gy. Personal Information References. Pelloski CE, Palmer M, Chronowski GM, et al. Comparison between CT based volumetric calculations of ICRU reference point estimate of radiation doses delivered to bladder and rectum during intracavitary radiotherapy for cervical cancer. Int J Radiat Oncol Biol Phys 2005, 62: Kim RY, Shen S, Duan J, et al. Image-based 3D treatment planning of Intracavitary brachytherapy for cancer of cervix: DVH of bladder, rectum, sigmoid colon and small bowel. Brachytherapy 2007; 6: Page 8 of 9

9 3. Vinod SK, Caldwell K, Lau A, et al. A comparison of ICRU point doses and volumetric doses of organs at risk (OAR) in brachytherapy for cervical cancer. Journal of Medical Imaging and radiation oncology 20; 55: Mahanshetty U, Swamidas J, Khanna N, et al. Reporting & Validation of Gynaecological Groupe Europeen de Curietherapie European Society for Therapeutic Radiology and oncology (ESTRO) Brachytherapy recommendations for MR image-based dose volume parameters of clinical outcome with High Dose-Rate brachytherapy in cervical cancer. Int J Gynecol cancer.20; 2(6): Kirisits C, Potter R, Stefan L, et al. Dose and Volume parameters for MRI-based treatment planning in intracavitary brachytherapy for cervical cancer. Int J Radiat Oncol Biol Phys 2005; 62: Yaparpalvi R, Mutyala S, Gorla GR, et al. Point Vs Volumetric bladder and rectal doses in combined intracavitary-interstitial high-dose-rate brachytherapy: correlation and comparison with published vienna applicator data. Brachytherapy 2008; 7: Kirisits C, Lang S, Dimopoulous J, et al. The vienna applicator for combined intracavitary and interstitial brachytherapy of cervical cancer: design, application, treatment planning and dosimetric results. Int J Radiat Oncol Biol Phys 2006; 65: Page 9 of 9

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