Adequate 3D Treatment Volume Adequate 3D Treatment Volume in Preoperative Radiotherapy in Preoperative Radiotherapy in Extremity Soft Tissue Sarcoma in Extremity Soft Tissue Sarcoma Kim BK, Chen YL, Kirsch DG, Kobayashi W, Goldberg S, Wolfgang J, Kim BK, Chen YL, Kirsch DG, Kobayashi W, Goldberg S, Wolfgang J, Kung JH, Doppke K, Raskin KA, Springfield DS, Schwab JH, Kung JH, Doppke K, Raskin KA, Springfield DS, Schwab JH, Yoon SS, Hornicek FJ, Nielson GP, DeLaney TF Yoon SS, Hornicek FJ, Nielson GP, DeLaney TF Department of Radiation Oncology, Orthopedic Oncology, Department of Radiation Oncology, Orthopedic Oncology, Surgical Oncology, Pathology, Massachusetts General Hospital, Surgical Oncology, Pathology, Massachusetts General Hospital, Boston, MA, USA Boston, MA, USA
21
Embed
Preoperative Radiotherapy In Extremity Soft Tissue Sarcoma
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Adequate 3D Treatment Adequate 3D Treatment Volume Volume
in Preoperative Radiotherapy in Preoperative Radiotherapy in Extremity Soft Tissue in Extremity Soft Tissue
SarcomaSarcoma
Kim BK, Chen YL, Kirsch DG, Kobayashi W, Goldberg S, Wolfgang J, Kim BK, Chen YL, Kirsch DG, Kobayashi W, Goldberg S, Wolfgang J,
Kung JH, Doppke K, Raskin KA, Springfield DS, Schwab JH, Kung JH, Doppke K, Raskin KA, Springfield DS, Schwab JH,
Potential Advantages of Preoperative RT Potential Advantages of Preoperative RT More precise definition of tumor – accurate/small More precise definition of tumor – accurate/small
fieldfield Increase R0 resection/ possible limb preservationIncrease R0 resection/ possible limb preservation Decrease the risk of tumor seedingDecrease the risk of tumor seeding
Complications Complications Increased wound complications vs.Increased wound complications vs. Decreased late morbiditiesDecreased late morbidities
Adequate 3D Treatment Volume for Preoperative Adequate 3D Treatment Volume for Preoperative RT?RT?
Target Volume of Preoperative RTTarget Volume of Preoperative RT
InstitutionInstitution LongitudinLongitudinalal
MarginMargin
Radial Radial MarginMargin
RT RT Schedule Schedule
PreoperativPreoperativee
ChemotheraChemotherapypy
RTOG 9514 RTOG 9514 (2006)(2006)
9 cm9 cm >> 2 cm 2 cm 44 Gy/ 22 44 Gy/ 22 fx,fx,
SplitSplit
MAIDMAID
MGHMGH(2003)(2003)
6-9 cm6-9 cm >> 2 cm 2 cm 44 Gy/ 22 44 Gy/ 22 fx,fx,
SplitSplit
MAIDMAID
SR2 NCI SR2 NCI CanadaCanada(2002)(2002)
5 cm5 cm ? ? >> 2 cm 2 cm 50 Gy/ 25 50 Gy/ 25 fxfx
MDACCMDACC(2004)(2004)
5-7 cm5-7 cm << 1/3 of 1/3 ofcircumferecircumfere
ncence
50 Gy/ 25 50 Gy/ 25 fxfx
CCRT with CCRT with DoxorubicinDoxorubicin
MSKCCMSKCC(2007)(2007)
5 cm5 cm 2 cm2 cm 50 Gy/ 25 50 Gy/ 25 fx,fx,
IMRTIMRT
Peter Peter MacCallumMacCallum(2006)(2006)
6 cm (PTV)6 cm (PTV) -- 50.4 Gy/ 28 50.4 Gy/ 28 fxfx
--
Univ. of Univ. of FloridaFlorida(2002)(2002)
5-10 cm 5-10 cm (av. 10)(av. 10)
Involved Involved compartmecompartme
ntnt
50.4 Gy/ 42 50.4 Gy/ 42 fx,fx,
1.2 bid1.2 bid
Groningen Groningen Univ.Univ.(1999)(1999)
Entire Entire tumor tumor regionregion
Entire Entire tumor tumor regionregion
35 Gy/ 10 35 Gy/ 10 fxfx
IA IA DoxorubicinDoxorubicin
ObjectivesObjectives
Retrospective StudyRetrospective Study
Analyze the pattern of local failure (LF). Analyze the pattern of local failure (LF).
Patients with extremity STSPatients with extremity STS
Treated with 3D XRT using CT simulationTreated with 3D XRT using CT simulation
Elucidate optimal 3D radiation field design.Elucidate optimal 3D radiation field design.
Evaluate other results and prognostic Evaluate other results and prognostic factors. factors.
Materials and MethodsMaterials and Methods
AccrualAccrual July 2000 – Dec 2006 (56 patients)July 2000 – Dec 2006 (56 patients)Period of FU Period of FU 15 - 76 months (median 41: alive 46, 15 - 76 months (median 41: alive 46,
dead 20.5)dead 20.5)
Sex (M: FM)Sex (M: FM) 37 (66.1%) : 19 (33.9%)37 (66.1%) : 19 (33.9%)AgeAge 18 - 89 years (median: 50.6)18 - 89 years (median: 50.6)
Exclusion CriteriaExclusion Criteria
Age < 18 years, Recurrent disease, Initially diagnosed M1, Age < 18 years, Recurrent disease, Initially diagnosed M1, Desmoid tumor, Dermatofibrosarcoma protuberance, Ewing’s Desmoid tumor, Dermatofibrosarcoma protuberance, Ewing’s sarcoma, Rhadomyosarcoma sarcoma, Rhadomyosarcoma
§ § Postoperative boost RT was given to the patients with (+) or multiple Postoperative boost RT was given to the patients with (+) or multiple close RMclose RM
††No residual disease in 4 patients out of 6 (Unplanned excision (3), No residual disease in 4 patients out of 6 (Unplanned excision (3), Incision biopsy (1))Incision biopsy (1))
No residual disease : Residual diseaseNo residual disease : Residual disease§ § 3 : 6 (2-4 cm) 3 : 6 (2-4 cm) There was no treatment failure.There was no treatment failure.§§RM (+) 0RM (+) 0‡‡, < 1 mm (1), 1 mm (1), 1< , < 1 mm (1), 1 mm (1), 1< << 5 mm (3), 5< 5 mm (3), 5< <<10 mm (1)10 mm (1)
* * Freedom From Distant Metastasis : Actuarial, Freedom From Distant Metastasis : Actuarial, ††Number of remained Number of remained patients at 3/ 5 Yearpatients at 3/ 5 Year
93.2 93.2 %%
(31)(31)
93.2%93.2%(12)(12) 91.591.5
%%(31)(31)
88.5%88.5%(12)(12)
Local Recurrence as First Local Recurrence as First Failure (3) Failure (3)
Local Recurrence as Cumulative Local Recurrence as Cumulative Failure (5)Failure (5)
Local Failure (LF) Initial (3) Local Failure (LF) Initial (3) Cumulative (5) Cumulative (5)Onset (months)Onset (months) 12 - 3512 - 35 12 - 3812 - 38InfieldInfield 11 33Infield & Extend to Infield & Extend to outfieldoutfield
22*,†*,† 22*,†*,†
**Small CTV due to anatomic site (1) : Foot, synovial sarcomaSmall CTV due to anatomic site (1) : Foot, synovial sarcoma††Unplanned incision with positive resection margin (1) : Leg, MFHUnplanned incision with positive resection margin (1) : Leg, MFH
Postop. RTPostop. RT 0.42360.4236 0.63250.6325 0.29940.2994 0.00030.0003†† 0.06820.0682**pSize (pSize (<< 10 vs. >10 cm), 10 vs. >10 cm), † †Negative correlation (Poor results treated with Negative correlation (Poor results treated with chemotherapy or RT)chemotherapy or RT)Age (Age (<<50 vs. > 50), pGrade (1+2 vs. 3), Site (Proximal vs. Distal), cStage & pStage 50 vs. > 50), pGrade (1+2 vs. 3), Site (Proximal vs. Distal), cStage & pStage (1+2 vs. 3), (1+2 vs. 3), cSize (cSize (<< 5 cm vs. 5 < 5 cm vs. 5 < << 10 cm vs. 10 < 10 cm vs. 10 < << 15 cm vs. > 15 cm), pSize ( 15 cm vs. > 15 cm), pSize (<< 8 cm vs. > 8 8 cm vs. > 8 cm)cm)
Margin Status & Local FailuresMargin Status & Local Failures
SurgicSurgical al
No of No of ptspts
ResectionResection No of No of ptspts
No of pts with LRNo of pts with LR
ExtentExtent Margin Margin (RM)(RM)
InitialInitial CumulatiCumulativeve
R1R1 66 PositivePositive 66 33 33
R0R0 5050 < 1 mm< 1 mm 1414 00 22
1 mm1 mm 1010 00 00
> 1 mm> 1 mm 2626 00 00
p = < 0.0001p = < 0.0001
RM Positive vs. NegativeRM Positive vs. Negative
p = 0.0016p = 0.0016
RM < 1 mm vs. RM < 1 mm vs. >> 1 mm 1 mm RM RM << 1 mm vs. > 1 mm 1 mm vs. > 1 mm
OS Age (p= 0.0360, HR 1.039), cSize (p=0.0056, HR 1.195)
DFS pStage (p=0.0040, HR 15.420)
LC RM (negative vs. positive, p=0.0029, HR 16.512)
FFDM pStage (p=0.013, HR 12.374)
ComplicationsComplications
Wound Complications (SR2 criteria) Wound Complications (SR2 criteria) No (%) No (%)
1717 (30.4(30.4))
Secondary operations for wound careSecondary operations for wound care** 1212 (70.6(70.6))
Readmission for wound care Readmission for wound care 00 (0)(0) Invasive procedures for wound management Invasive procedures for wound management 22 (11.8(11.8
)) Deep wound packing to the wound Deep wound packing to the wound >> 2 cm at 2 cm at any time any time
Factors Related to Wound ComplicationsFactors Related to Wound ComplicationsVolume of resected specimen (p=0.0216), CTV (p= 0.0433), Volume of resected specimen (p=0.0216), CTV (p= 0.0433), DM (p= 0.0490), DM (p= 0.0490), ? Unplanned excision (p= 0.0926)? Unplanned excision (p= 0.0926)
Chronic Complications Chronic Complications No (%) No (%)
Fracture Fracture 33†† (5.4)(5.4)
††Femur(2), ulnar (1): Prior periosteal peeling (2) or bone resection (1)Femur(2), ulnar (1): Prior periosteal peeling (2) or bone resection (1)
There was no chronic complication requiring amputation There was no chronic complication requiring amputation for management or causing significant functional loss.for management or causing significant functional loss.
ConclusionsConclusions
1. These margin definitions1. These margin definitions (CTV: radial 1-1.5 cm & longitudinal 3.5 cm, PTV: CTV + (CTV: radial 1-1.5 cm & longitudinal 3.5 cm, PTV: CTV + 0.5-0.8 cm)0.5-0.8 cm)
appear appropriate for the majority of appear appropriate for the majority of patients.patients.
2. Patients with positive margin are at highest 2. Patients with positive margin are at highest risk for LF &risk for LF & maymay be treated more aggressively.be treated more aggressively.
3. Wound complication rate was comparable to 3. Wound complication rate was comparable to other studies.other studies.
4. Wound complications were significantly 4. Wound complications were significantly related to the related to the Vol. of resected specimen, CTV, and presence Vol. of resected specimen, CTV, and presence of diabetes.of diabetes.
ThankThank
you for you for
your your
attentionattention
!!
Acute Skin ToxicityAcute Skin Toxicity
Grade Grade RTOG Definition RTOG Definition No (%) No (%)
00 No change over baselineNo change over baseline 44 (7.1)(7.1)
11 Follicular, faint or dull erythema, Follicular, faint or dull erythema, epilation, dry desquamation, epilation, dry desquamation, decreased sweatingdecreased sweating
3939 (69.(69.6)6)
22 Tender or bright erythema, Tender or bright erythema, patchy moist desquamation, patchy moist desquamation, moderate erythemamoderate erythema
1212 (21.(21.4)4)
33 Confluent moist desquamation other Confluent moist desquamation other than skin folds, pitting edemathan skin folds, pitting edema
00 (0)(0)
44 Ulceration, hemorrhage, necrosisUlceration, hemorrhage, necrosis** 11 (1.8)(1.8)**P/E prior to XRT, skin involvement (+), MFH, Gr 3/3, 75% necrosis after P/E prior to XRT, skin involvement (+), MFH, Gr 3/3, 75% necrosis after preoperative RT preoperative RT RTRT
Infield FailureInfield Failure
All infield failures were located in GTV or CTV. All infield failures were located in GTV or CTV.