Image guided adaptive brachytherapy in patients with cervical cancer 8. Årsmøde Januar 2013. Dansk Radiologisk Selskab & Selskab for klinisk Fysiologi og Nuklearmedicin Lars Fokdal Overlæge Ph.D. Department of Oncology Aarhus University hospital
A quick reminder about brachytherapy 200% 20% 2
2D brachytherapy: Limitations - NO UNFORTUNATELY NOT!! = 3
PDR-BT: Dose rate during one pulse 4
5
3D image guided procedure Applicator insertion 3D imaging Contouring Reconstruction of applicator 3D dose planning Dose delivery 6
Contouring l l 7
MRI-based 4D IGBT: IC optimisation HR CTV Prescription isodose Standard Optimised 8
MRI-based 4D IGBT: IC/IS technique 9
Tandem/Ring applicator for IC/IS BT Needle cap with 12 steering holes for plastic needles 11 10 9 12 1 2 3 8 7 6 5 4 10
11 MRI-based 4D IGBT: IC/IS optimisation Significant dose into sigmoid, rectum and bladder HR CTV Prescription isodose
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
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. 2012 13
Charra-Brunaud et al. Radiother. and Oncol. 201214 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
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 1993-1997 A Vienna 1889-2000 B Bladder 3 3 3 Bowel/rectum 10 5 4 Vagina 31 7 3 A EBRT alone and CT- based BT B EBRT ±chemotherapy and IGABT: Learning period C EBRT ±chemotherapy and IGABT: Protocol period Vienna 2001-2008 C Pötter et al. Radiother. Oncol. 2011 15
Mono-institutionel data on IGABT in cervical cancer Pötter et al. Radiother. Oncol. 2011 16
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 70-75 Gy D2cc 90 Gy Rektum D2cc (Gy) Blære D2cc (Gy) Georg et al. IJROBP 2012 & 2011, Koom IJROBP 2009 17
2005 796 registered patients from 12 institutions 2009 Nov. 2009 Nov. 2010 Apr. 2012 2013 No. of Centers 9 17 20 No. of pts. 111 306 610 1000 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
ESTRO 31, Barcelona 201219
IGABT in other gynaecological tumors?...is there a role for image guided adaptive brachytherapy in locally advanced or recurrent gynaecological malignancies? 20
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
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
Outcome & DVH parameters Aarhus Vienna Number of pts. 28 13 Followup (month) 18 (6-61) 43 (19-87) 3 months CR (%) 92 100 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
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) 63 50 LDR MUPIT 35-37 83 5 1-7 34 46 PDR MUPIT 30 74 63 41 29 <1-3 20 40-45 LDR Customized 14-42 65 65 18 1-7 78 34 44 0-60 21-60 0 LDR Customized 28-72 28 35-72 82 56 62 70 10 5 69 30-74 LDR MUPIT 17-40 78 41 55 60 14 3 48 12 15 11 0-48 0 0-50 45-50 LDR Syad-Neblett 26-51 51 LDR Syad-Neblett 18-50 18-35 93 65 77 17 5 100 77 100 15 5 23 43-50 HDR Customized 14-21 78 42 47 9 5 24
Future directions in IGABT (I) Wait and see J www.embracestudy.dk www.retroembrace.com 25
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 www.embracestudy.dk 26