Effectiveness and Safety of Spot Scanning Proton Radiation Therapy for Skull Base Tumors: First Long Term Report of the PSI Experience
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1 Effectiveness and Safety of Spot Scanning Proton Radiation Therapy for Skull Base Tumors: First Long Term Report of the PSI Experience Carmen Ares, Antony J Lomax, Eugen B Hug, Alessandra Bolsi, Beate Timmermann, Hans Peter Rutz, Adolf Coray, Eros S Pedroni, Gudrun Goitein
2 Purpose To evaluate the effectiveness and safety of spot scanning proton radiation therapy in chordomas and chondrosarcomas of the skull base
3 Introduction Skull Base Chordomas and Chondrosarcomas: PSI Experience During the period in addition to eye treatments, chordomas and chondrosarcomas constituted the majority of our patients
4 Material and Methods N = 64 patients (Oct-98 Nov-05) Chordoma 42 (65%) Chondrosarcoma 22 (34%) Mean age 44.5 years Mean follow-up 38 months (14-92 months)
5 Prescription dose (mean) (at 2 Gy (RBE) per fraction, 4 fractions per week) Chordoma (Ch) 74 Gy (RBE) (range 68-74) Chondrosarcoma(ChSa) 68 Gy (RBE) (range 64-74) 5 patients mixed photons/protons (4 Ch, 1 ChSa) mean GTV volume Ch 27 cc ChSa 23 cc Material and Methods
6 Dose constraints for organs at risk OAR Brainstem surface Brainstem center Optic Chiasm Optic Nerves Dmax 64 Gy (RBE) 53 Gy (RBE) 60 Gy (RBE) 60 Gy (RBE)
7 Local control definition Local control defined as radiological control by MRI ± CT Local failure defined as radiological tumor progression or clinical symptomatic progression confirmed radiologically
8 Failures and deaths Skull base tumors Chordoma (n = 42) Chondrosarcoma (n = 22) Local failure male female Deaths local progression NED 5 1* Brainstem compression vs. local failures No 1* Yes 4 Abutment P= P= * patient with surgical pathway failure
9 Example of chondrosarcoma with subsequent local relapse Pre-Proton-RT GTV V95 48% Brainstem compression
10 Local control Time to local failure Chordoma Chondrosarcoma P= months Time to event Actuarial Local Control 3 years 5 years Chordomas 87 % 81 % Chondrosarcomas 94 % 94 %
11 Disease Specific Survival Chordoma, N=42 Chondrosarcoma, N=22 P= months Disease Specific Survival 3 years 5 years Chordomas 90% 81% Chondrosarcomas 100 % 100 %
12 Prognostic factor for LC in chordoma: Residual tumor volume GTV<25 GTV>25 P= Time (Months)
13 Skull Base Chordomas: Comparison of Literature n Radiation Mean dose LC 3 -yr LC 5 -yr LC 10 -yr Munzenrider, PT, RT Terahara, PT, RT Hug, PT, RT Noel, PT, RT Schulz-Ertner, Carbon, RT 60* Igaki, PT, RT Weber, (PSI) PT Ares, (PSI) 2007** 42 PT *at 3.0 CGE per fraction ** to be published
14 Skull Base Chondrosarcomas: Comparison of Literature n Radiation Mean dose LC 3 -yr LC 5 -yr LC 10 -yr Munzenrider, PT, RT Hug, PT, RT Johson, PT, RT Noel, PT, RT 91 Schulz-Ertner, Carbon, RT 60* 96 Weber, (PSI) PT Ares, (PSI) 2007** 22 PT *at 3.0 CGE per fraction ** to be published
15 Radiation induced late toxicity (CTCAE v3.0) Asymptomatic MRI white matter changes: 5 patients (= G1 neurologic toxicity) High grade late toxicity (all Ch): 4 patients optic pathway G 4 1 patient (unilateral blindness) G 3 1 patient (unilateral visual deficit, steroid dependent) neurologic G 3 2 patients (symptomatic brain necrosis) Any patient presented brainstem toxicity
16 Radiation induced toxicity (CTCAE v3.0) Actuarial 5-year freedom of high grade late toxicity 94% Due to the small number of events no risk factors predictive of high grade toxicity were identified
17 Radiation induced toxicity (CTCAE v3.0) High grade late toxicity ( grade 3) Grade 3 unilateral optic nerve neuropathy developed 20 months after treatment Grade 4 unilateral optic nerve neuropathy 12 months after treatment (preexistent unilateral visual field deficits due to tumor involvement around the optic nerve) 2 cases of Grade 3 temporal lobe brain necrosis at 12 and 19 months after treatment
18 G1 - Neurologic toxicity example Pre-PT 10/05 T1Gd 05/07 T1Gd 08/07 Carmen Ares, Center for Proton Radiation Therapy PTCOG - May 22, 2008
19 G3 - Brain necrosis example T1Gd Flair T1Gd T PT 08/05 Carmen Ares, Center for Proton Radiation Therapy PTCOG - May 22, 2008
20 Conclusions - 1 Toxicity rates similar to passive scattering based protonradiotherapy series, with comparable target definition, dose prescription and normal organ tolerance levels As the majority of late toxicities are commonly detected during the 2 first years after RT, our data demonstrate the safety and efficacy of Spot-Scanning based Proton- Radiotherapy technology delivery for skull base tumors
21 Conclusions - 2 Established outcome data for a cohort of patients treated homogeneously, that will be the basis for introducing new technologies and develop new treatment algorithms
22 Thank you for your attention
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