Transperineal implantation of hyaluronic acid in the anterior peri-rectal fat as protector to the...
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OR-38 Presentation Time: 8:30 AM Transperineal implantation of hyaluronic acid in the anterior peri- rectal fat as protector to the rectal wall from radiation delivered with either intensity modulated brachytherapy or EBRT for prostate cancer patients Pedro Prada, M.D., 1 Alvaro Martinez, M.D., F.A.C.R., 2 Jose Fernandez, M.D., 1 Angeles de la Rua, M.D., 1 Herminio Gonzalez, M.D., 3 Jose Manuel, M.D. 2 1 Radiation Oncology, Hospital Central de Asturias, Oviedo, Spain; 2 Radiation Oncology, William Beaumont Hospital, Royal Oak, MI; 3 Radiology, Hospital Central de Asturias, Oviedo, Spain. Purpose: Acute and chronic rectal toxicity remain one of the complications affecting quality of life for those patients with intermediate and high risk prostate cancer treated to high doses with radiotherapy. Most series report 1–2% for rectal ulcers, rectal proctitis grade 1–3 between 2–17%, and rectal bledding up to 20%. In an effort to decrease these complications, we began a clinical trial approved by the HIC of Asturias University injecting hyaluronic acid in the perirectal fat to increase the distance between the posterior prostate capsule and the anterior rectal wall. Methods and Materials: Patients with intermediate and high risk prostate cancer were enrolled in a clinical trial of hypofractionated accelerated irradiation interdigitating EBRT with a HDR brachytherapy boost on the 5th and 15th fraction of a 25 fraction schedule. During both fractions of HDR brachytherapy, in vivo TLD dosimeters were placed in the urethra and in the rectum prior to treatment to measure the HDR dose. Before the second HDR fraction and under TRUS-guidance 3–6 cm 3 of hyaluronic acid was injected in the anterior perirectal fat. Results: Twenty-five patients enrolled in the study received the injection of hyaluronic acid in the perirectal fat. No toxicity was produced from the hyaluronic acid or its injection. On follow up imaging, the substance itself did not migrate or change in mass or shape. Post treatment CT and MRI demonstrated stable distance from the prostate to the rectum for close to one year. The mean distance between the posterior prostate capsule and anterior rectal wall was 2.0 cm. This distance was easily demonstrated on TRUS, CT, and MR. Analyzing the measured dose, the median rectal dose when normalized to the median urethral dose demostrate a decrease in dose from 47.1% to 39.2% (p !0.001). The concordance between the measured and calculated doses was excellent. Conclusions: The 2 cm increase in distance between the rectal wall and prostate, resulting from the injection of hyaluronic acid in the perirectal fat, has significantly decreased rectal dose from intensity modulated HDR brachytherapy and conformal external beam treatments for patients with intermediate and high risk prostate cancer. Because of the stability of the compound, lasting several months, the same distance is maintained during the course of therapy. Longer followup will determine the gain in rectal toxicity. OR-39 Presentation Time: 8:40 AM Preliminary analysis of the ProQura multi-institutional prostate brachytherapy dosimetry database Peter D Grimm, D.O., 1 Gregory S Merrick, M.D., 2,3 Wayne M Butler, Ph.D., 2,3 John C Blasko, M.D., 1 John E Sylvester, M.D., 1 Zachariah A Allen, M.S., 2,3 Usman-ul-Haq Chaudhry, M.D., 2 Anthony Mazza, B.S. 1 1 Seattle Prostate Institute, WA; 2 Schiffler Cancer Center, Wheeling Hospital, Wheeling, WV; 3 Wheeling Jesuit University, Wheeling, WV. Purpose: To analyze the ProQura database in terms of individual institutional patient implant sequence number for evidence of a dosimetric learning curve. Methods and Materials: From June 1999 through September 2005, the ProQura post-implant dosimetry database accrued 4,614 patients from 56 institutions. The mean and median days between implant and post- implant CT were 30.4 and 30 days, respectively. Postoperative dosimetry consisted of overlaying the preimplant ultrasound onto the postimplant CT scan. I-125 (mean seed activity 0.32 mCi for monotherapy and 0.26 mCi for boost) and Pd-103 (mean seed activity 1.59 mCi for monotherapy and 1.27 mCi for boost) were used in 3,071 patients and 1,543 patients, respectively. Mean preimplant prostate volumes of 35.3 cm 3 and 32.9 cm 3 were noted in the Pd-103 and I-125 cohorts, respectively. Results: For the entire cohort, the mean V 100 was 88.9% and the mean D 90 was 101.9%. When analyzed in terms of patient sequence number within each institution, the mean V 100 increased from 87.3% for the first 10 patients to 88.6% for patients numbered 11–20 (p 5 0.036). Similarly, the mean D 90 for the first 10 patients was 98.9% and 102.2% for the second cohort of 10 patients (p 5 0.001). No further significant change in V 100 or V 90 was noted for the third grouping of 10 patients. When restricting the comparison to institutions with O 70 patients implanted, a significant difference in V 100 and D 90 was evident between the first and third groups of 10 patients and between the first and seventh cohorts. The mean monotherapy seed activity per prostate volume was 0.94 mCi/cm 3 for I- 125 and 4.51 mCi/cm 3 for Pd-103. Although no significant difference in dosimetric quality was noted beyond institutional patient #20, the specific monotherapy seed activity fluctuated between cohorts and reached a nadir in the seventh cohort at 0.92 mCi/cm 3 for I-125 and 4.33 mCi/cm 3 for Pd- 103. Conclusions: Dosimetric quality parameters V 100 and D 90 improve with experience and approach a plateau after 20–30 patients. OR-40 Presentation Time: 8:50 AM Cholangiocarcinoma: The impact of endobiliary high-dose-rate (HDR) brachytherapy dose response on survival Matthew Biagioli, M.D., M.S., B-Chen Wen, M.D., Brandon Patton, M.D., Caroline Hoffman, M.P.H., Mark Harvey, M.D.Radiation Oncology, University of Miami, Miami, FL. Purpose: Cholangiocarcinoma is rare with only 3,500 cases annually. Despite aggressive multimodality treatment, median survival is still dismal. Although at least one report showed a trend toward increased survival with escalation of HDR dose, the benefit of adjuvant radiation is still controversial. This retrospective study evaluates our experience with escalated doses of HDR brachytherapy for cholangiocarcinoma. Methods and Materials: From 1991–2005, 28 patients with biliary duct adenocarcinoma treated with HDR intraluminal brachytherapy were identified. Three patients were excluded: 1 had metastatic disease at diagnosis, and 2 did not receive external beam radiation therapy (EBRT). All remaining 25 patients received EBRT to a minimum dose of 45 Gy with concurrent chemotherapy followed by 1–3 HDR brachytherapy fractions of 7 Gy prescribed to 1 cm. Patients were stratified by resection or no resection and number of HDR treatments. Results: Median age was 65 years (rang: 39–83) with 6 females and 19 males. Twenty-two patients had extrahepatic disease, and 3 had intrahepatic. Twelve of the patients underwent resection. Mean external beam dose was 45.3 G 1.6 Gy with 18 receiving 45 Gy, 5 receiving 50.4 Gy and 2 receiving 54 Gy. Six, 10, and 9 patients received 1, 2, or 3 HDR treatments, respectively. Median cumulative radiation dose was 64.4 G 11.2 Gy. All patients received concurrent 5-FU or Xeloda with EBRT. Mean followup was 18.9 G 5.1 months. Kaplan-Meier estimate of mean survival was 20 G 5 months. Median survival for patients with resection versus no resection was 24 and 9 months, respectively (p 5 0.031). Median survival for 1, 2, or 3 HDR treatments was 5, 10, and 15 months, respectively (not significant). Median survival for 1, 2, or 3 HDR treatments with resection was 5, 36, and 24 months, respectively, compared with 2, 9, and 8 months without resection. Median survival in the resected group approached statistical significance (p 5 0.057) by pairwise log rank comparison but was not significant in the unresected group. When resected patients with 2 or 3 fractions were pooled and compared to only 1 fraction, median estimate of survival was 36 months versus 5 months (p 5 0.042). Conclusions: There is a survival benefit in patients who have undergone resection. Additionally, resected patients exhibit a survival benefit with 2 or 3 fractions of intraluminal HDR brachytherapy over 1 fraction. No survival benefit was observed for HDR dose escalation in unresected patients. In this study, we did not evaluate palliation of symptoms, which may benefit from dose escalation. Analysis in a prospective manner is required to further evaluate whether evaluate whether HDR dose escalation is of benefit in resected cholangiocarcinoma. 91 Abstracts / Brachytherapy 5 (2006) 78–117
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Transcript of Transperineal implantation of hyaluronic acid in the anterior peri-rectal fat as protector to the...
OR-38 Presentation Time: 8:30 AM
Transperineal implantation of hyaluronic acid in the anterior peri-
rectal fat as protector to the rectal wall from radiation delivered
with either intensity modulated brachytherapy or EBRT for prostate
cancer patients
Pedro Prada, M.D.,1 Alvaro Martinez, M.D., F.A.C.R.,2 Jose Fernandez,
M.D.,1 Angeles de la Rua, M.D.,1 Herminio Gonzalez, M.D.,3 Jose
Manuel, M.D.2 1Radiation Oncology, Hospital Central de Asturias,
Oviedo, Spain; 2Radiation Oncology, William Beaumont Hospital, Royal
Oak, MI; 3Radiology, Hospital Central de Asturias, Oviedo, Spain.
Purpose: Acute and chronic rectal toxicity remain one of the complicationsaffecting quality of life for those patients with intermediate and high riskprostate cancer treated to high doses with radiotherapy. Most series report1–2% for rectal ulcers, rectal proctitis grade 1–3 between 2–17%, andrectal bledding up to 20%. In an effort to decrease these complications,we began a clinical trial approved by the HIC of Asturias Universityinjecting hyaluronic acid in the perirectal fat to increase the distancebetween the posterior prostate capsule and the anterior rectal wall.Methods and Materials: Patients with intermediate and high risk prostatecancer were enrolled in a clinical trial of hypofractionated acceleratedirradiation interdigitating EBRT with a HDR brachytherapy boost on the5th and 15th fraction of a 25 fraction schedule. During both fractions ofHDR brachytherapy, in vivo TLD dosimeters were placed in the urethraand in the rectum prior to treatment to measure the HDR dose. Before thesecond HDR fraction and under TRUS-guidance 3–6 cm3 of hyaluronicacid was injected in the anterior perirectal fat.Results: Twenty-five patients enrolled in the study received the injection ofhyaluronic acid in the perirectal fat. No toxicity was produced from thehyaluronic acid or its injection. On follow up imaging, the substanceitself did not migrate or change in mass or shape. Post treatment CT andMRI demonstrated stable distance from the prostate to the rectum forclose to one year. The mean distance between the posterior prostatecapsule and anterior rectal wall was 2.0 cm. This distance was easilydemonstrated on TRUS, CT, and MR. Analyzing the measured dose, themedian rectal dose when normalized to the median urethral dosedemostrate a decrease in dose from 47.1% to 39.2% (p!0.001). Theconcordance between the measured and calculated doses was excellent.Conclusions: The 2 cm increase in distance between the rectal wall andprostate, resulting from the injection of hyaluronic acid in the perirectalfat, has significantly decreased rectal dose from intensity modulated HDRbrachytherapy and conformal external beam treatments for patients withintermediate and high risk prostate cancer. Because of the stability of thecompound, lasting several months, the same distance is maintained duringthe course of therapy. Longer followup will determine the gain in rectaltoxicity.
OR-39 Presentation Time: 8:40 AM
Preliminary analysis of the ProQura multi-institutional prostate
brachytherapy dosimetry database
Peter D Grimm, D.O.,1 Gregory S Merrick, M.D.,2,3 Wayne M Butler,
Ph.D.,2,3 John C Blasko, M.D.,1 John E Sylvester, M.D.,1 Zachariah A
Allen, M.S.,2,3 Usman-ul-Haq Chaudhry, M.D.,2 Anthony Mazza, B.S.1
1Seattle Prostate Institute, WA; 2Schiffler Cancer Center, Wheeling
Hospital, Wheeling, WV; 3Wheeling Jesuit University, Wheeling, WV.
Purpose: To analyze the ProQura database in terms of individualinstitutional patient implant sequence number for evidence ofa dosimetric learning curve.Methods and Materials: From June 1999 through September 2005, theProQura post-implant dosimetry database accrued 4,614 patients from 56institutions. The mean and median days between implant and post-implant CT were 30.4 and 30 days, respectively. Postoperative dosimetryconsisted of overlaying the preimplant ultrasound onto the postimplantCT scan. I-125 (mean seed activity 0.32 mCi for monotherapy and0.26 mCi for boost) and Pd-103 (mean seed activity 1.59 mCi formonotherapy and 1.27 mCi for boost) were used in 3,071 patients and1,543 patients, respectively. Mean preimplant prostate volumes of
35.3 cm3 and 32.9 cm3 were noted in the Pd-103 and I-125 cohorts,respectively.Results: For the entire cohort, the mean V100 was 88.9% and the mean D90
was 101.9%. When analyzed in terms of patient sequence number withineach institution, the mean V100 increased from 87.3% for the first 10patients to 88.6% for patients numbered 11–20 (p 5 0.036). Similarly, themean D90 for the first 10 patients was 98.9% and 102.2% for the secondcohort of 10 patients (p 5 0.001). No further significant change in V100 orV90 was noted for the third grouping of 10 patients. When restricting thecomparison to institutions with O70 patients implanted, a significantdifference in V100 and D90 was evident between the first and third groupsof 10 patients and between the first and seventh cohorts. The meanmonotherapy seed activity per prostate volume was 0.94 mCi/cm3 for I-125 and 4.51 mCi/cm3 for Pd-103. Although no significant difference indosimetric quality was noted beyond institutional patient #20, the specificmonotherapy seed activity fluctuated between cohorts and reached a nadirin the seventh cohort at 0.92 mCi/cm3 for I-125 and 4.33 mCi/cm3 for Pd-103.Conclusions: Dosimetric quality parameters V100 and D90 improve withexperience and approach a plateau after 20–30 patients.
OR-40 Presentation Time: 8:50 AM
Cholangiocarcinoma: The impact of endobiliary high-dose-rate
(HDR) brachytherapy dose response on survival
Matthew Biagioli, M.D., M.S., B-Chen Wen, M.D., Brandon Patton, M.D.,
Caroline Hoffman, M.P.H., Mark Harvey, M.D.Radiation Oncology,
University of Miami, Miami, FL.
Purpose: Cholangiocarcinoma is rare with only 3,500 cases annually.Despite aggressive multimodality treatment, median survival is stilldismal. Although at least one report showed a trend toward increasedsurvival with escalation of HDR dose, the benefit of adjuvant radiation isstill controversial. This retrospective study evaluates our experience withescalated doses of HDR brachytherapy for cholangiocarcinoma.Methods and Materials: From 1991–2005, 28 patients with biliary ductadenocarcinoma treated with HDR intraluminal brachytherapy wereidentified. Three patients were excluded: 1 had metastatic disease atdiagnosis, and 2 did not receive external beam radiation therapy (EBRT).All remaining 25 patients received EBRT to a minimum dose of 45 Gywith concurrent chemotherapy followed by 1–3 HDR brachytherapyfractions of 7 Gy prescribed to 1 cm. Patients were stratified by resectionor no resection and number of HDR treatments.Results: Median age was 65 years (rang: 39–83) with 6 females and 19males. Twenty-two patients had extrahepatic disease, and 3 hadintrahepatic. Twelve of the patients underwent resection. Mean externalbeam dose was 45.3 G 1.6 Gy with 18 receiving 45 Gy, 5 receiving50.4 Gy and 2 receiving 54 Gy. Six, 10, and 9 patients received 1, 2, or 3HDR treatments, respectively. Median cumulative radiation dose was 64.4G 11.2 Gy. All patients received concurrent 5-FU or Xeloda with EBRT.Mean followup was 18.9 G 5.1 months. Kaplan-Meier estimate of meansurvival was 20 G 5 months. Median survival for patients with resectionversus no resection was 24 and 9 months, respectively (p 5 0.031).Median survival for 1, 2, or 3 HDR treatments was 5, 10, and 15 months,respectively (not significant). Median survival for 1, 2, or 3 HDRtreatments with resection was 5, 36, and 24 months, respectively,compared with 2, 9, and 8 months without resection. Median survival inthe resected group approached statistical significance (p 5 0.057) bypairwise log rank comparison but was not significant in the unresectedgroup. When resected patients with 2 or 3 fractions were pooled andcompared to only 1 fraction, median estimate of survival was 36 monthsversus 5 months (p 5 0.042).Conclusions: There is a survival benefit in patients who have undergoneresection. Additionally, resected patients exhibit a survival benefit with 2or 3 fractions of intraluminal HDR brachytherapy over 1 fraction. Nosurvival benefit was observed for HDR dose escalation in unresectedpatients. In this study, we did not evaluate palliation of symptoms, whichmay benefit from dose escalation. Analysis in a prospective manner isrequired to further evaluate whether evaluate whether HDR doseescalation is of benefit in resected cholangiocarcinoma.
91Abstracts / Brachytherapy 5 (2006) 78–117
