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Rhabdomyosarcoma radiotherapy indications and outcome
 

Rhabdomyosarcoma radiotherapy indications and outcome

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Overview of Radiotherapy in the field of Rhabdomyosarcoma.

Overview of Radiotherapy in the field of Rhabdomyosarcoma.
Presented at The GEIS XI International Symposium at Seville November 29th

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    Rhabdomyosarcoma radiotherapy indications and outcome Rhabdomyosarcoma radiotherapy indications and outcome Presentation Transcript

    • Rhabdomyosarcoma Radiotherapy: Indications and Outcome Víctor Barrondo Radiation Oncology Department/Brachytherapy Section Hospital Universitario Basurto, Bilbao 1
    • Intergroup Rhabdomyosarcoma
    • GEIS XIth International Symposium / Seville - November, 29th 2013 Intergroup Rhabdomyosarcoma Study IRS I IRS II IRS III IRS IV COG D9602,D9803, D9802 (1972 – 1978) (1978 – 1984) (1984 – 1991) (1991 – 1997) (1998…) OS 55% OS 63% OS 71% OS 71% 3
    • GEIS XIth International Symposium / Seville - November, 29th 2013 4
    • GEIS XIth International Symposium / Seville - November, 29th 2013 Technology Costs Before You get excited about the low low price for 10Mb data storage, make sure you read the ultra fine print. Turns out the $3,495 price is for a refurbished unit only. The new one retails for a whopping $4,495. Oh, and there is another catch: the price is in 1980 dollars (US). Adjusted to 2010 dollars, that comes to around $13,395* *US Per Capita personal Income 1980: 9,500$ 2010: 40,500$ Source: U.S. Department of Commerce, Bureau of Economic Analysis, Survey of Current Business. http :// w w w. bea.gov/newsreleases/relsarchivespi.htm 5
    • GEIS XIth International Symposium / Seville - November, 29th 2013 Introduction • Highly malignant neoplasm arising from embryonal mesenchyme • With capacity for skeletal muscle differentiation. • 40% of all soft tissue sarcomas and 7% childhood malignancies in the US 6
    • GEIS XIth International Symposium / Seville - November, 29th 2013 Prognostic Factors • Histology • Stage • Primary site (most important prognostic factor) • Tumor size • LN involvement (especially in extremities) • Metastatic disease • Group • Extent of resection 7
    • GEIS XIth International Symposium / Seville - November, 29th 2013 Intergroup Rhabdomyosarcoma Study Group Presurgical Staging System Stage Site 1 Orbit, Non PM H&N, GU non bladder/prostate, biliary tract 3 4 Regional Lymph Nodes Distant Metastases Any N0, N1 M0 All Other Sites ≤5 N0 M0 All Other Sites ≤5 N1 M0 All Other Sites 2 Tumor Size (cm) >5 N0, N1 M0 Any Site Any Size N0, N1 M1 8
    • GEIS XIth International Symposium / Seville - November, 29th 2013 Intergroup Rhabdomyosarcoma Study Group Surgical-Patologic Grouping System Group Definition I Localized tumor, completely removed with patologically clear margins and no regional lymph node involvement. II Localized tumor, grossly removed with (a) microscopically involved margins, (b) involved grossly resected regional lymph nodes, or (c) both. III Localized tumor, with gross residual disease after grossly incomplete removal, or biopsy only. IV Distant metastases present at diagnosis 9
    • GEIS XIth International Symposium / Seville - November, 29th 2013 Current Children’s Oncology Group (COG) Risk Groups Histology Group Stage Risk Group ERMS I, II, III 1 Low (Subset A) ERMS I, II 2, 3 Low (Subset B) ERMS III 2, 3 Intermediate ARMS I, II, III 1, 2, 3 Intermediate ARMS IV 4 High ERMS IV 4 High 10
    • GEIS XIth International Symposium / Seville - November, 29th 2013 11
    • GEIS XIth International Symposium / Seville - November, 29th 2013 Radiotherapy Indications The Short Answer is… • Radiotherapy indicated in Group II-IV patients and Group I Alveolar histology. • As a result from COG D9803, RT recommended at an early time point (4 Week). . Wolden SL, Anderson JR, Crist WM, et al. Indications for radiotherapy and chemotherapy after complete resection in rhabdomyosarcoma: a report from the Intergroup Rhabdomyosarcoma Studies I to III. J Clin Oncol 1999;17(11):3468e3475. . Raney RB, Anderson JR, Brown KL, et al. Treatment results for patients with localized, completely resected (group I) alveolar rhabdomyosarcoma on Intergroup Rhabdomyosarcoma Study Group (IRSG) protocols III and IV, 1984e1997: a report from the Children’s Oncology Group. Pediatr Blood Cancer 2010;55(4):612e616. 12
    • GEIS XIth International Symposium / Seville - November, 29th 2013 Radiotherapy Doses COG D9602/D9803 IRS- IV: Hyperfractionation (59.4Gy / 1.1Gy fraction b.i.d.) did NOT improve local, regional or distant control over conventional fractionation for Group III tumors. Microscopic Residual Disease Resected Node Positive Orbital Location Gross Disease Gross Residual Disease Second Look accepted 3600 cGy 4140 cGy 4500 cGy 5040 cGy 13
    • GEIS XIth International Symposium / Seville - November, 29th 2013 Modern Radiotherapy Techniques: IMRT • Early adopters since 1999. • The next step in radiation treatment planning after 3D. • Inverse planning with computer-assisted optimization. • Dose painting. Sharp dose fall off outside target volume with selective avoidance of critical structures and tissues • Multiple Fields. Dose modulation within each field • Better immobilization, longer treatment time. 14
    • GEIS XIth International Symposium / Seville - November, 29th 2013 Modern Radiotherapy Techniques: IMRT IMRT vs 3DCRT improved target dose coverage with no improvement in LC or FFS 15
    • GEIS XIth International Symposium / Seville - November, 29th 2013 Modern Radiotherapy Techniques: IMRT Smaller Margin: 15mm using MRI&PET fusion vs 20mm. LFR 3 years: 5% Parameningeal & 0% Orbit/H&N. 16
    • GEIS XIth International Symposium / Seville - November, 29th 2013 Modern Radiotherapy Techniques: IMRT • Standard doses with PNI for adolescents and young adults (n=21) and reduced doses per fraction for children (n=20). • 16%-18% (median, 17%) decrease in the mean dose for rectum, bladder and bowel. • 90%LC (100% children, 79% young adults). 17
    • GEIS XIth International Symposium / Seville - November, 29th 2013 IMRT Functional Dose painting A) Anatomical planning target volume (PTV). B) Biological PTV. C) Fusion of anatomical and biological PTV. D) Contour based optimization. E) Voxel signal intensity based optimization.
    • GEIS XIth International Symposium / Seville - November, 29th 2013 Modern Radiotherapy Techniques: Protons • Inelastic collisions through matter • Large proportion of the energy at the Bragg peak and then falls off • Particular advantage in H&N where sparing of critical structures may be better accomplished using protons, particularly in young children. • Long-term clinical outcomes comparing proton therapy and IMRT not yet available. • Cost concern. 19
    • GEIS XIth International Symposium / Seville - November, 29th 2013 Modern Radiotherapy Techniques: Protons • LF 18% vs 17% in the IRSII-IV despite poor prognostic features compared with the IRS trial population. (59% intracranial extension vs 38%) and median time to the start of proton RT was 8 weeks (3/4LF late referral and ICE). • Reduction in late effects compared with previously published series of patients treated with photon RT (despite a higher proportion of younger patients). 20
    • GEIS XIth International Symposium / Seville - November, 29th 2013 Favourable Sites Orbit Rhabdomyosarcoma • • • • • • Most commonly embryonal histology. Small size. Rarely lymph node involvement. Standard treatment; QT+RT preserving eye. 3 year FFS 89%, OS 100%, 5 year LC 98%. Toxicity: Cataract, keratopathy, dry eye, loss of vision is rare. 21
    • GEIS XIth International Symposium / Seville - November, 29th 2013 Favourable Sites Gynaecological Rhabdomyosarcoma • Good prognosis. • Common strategy: Initial QT with local therapy to remanent disease (if present). • Surgery rate decreased from IRS I-IV. • Very good location for Brachytherapy. • 5 year OS 82%. 22
    • GEIS XIth International Symposium / Seville - November, 29th 2013 Favourable Sites Paratesticular Rhabdomyosarcoma • Initial management with Radical inguinal orchiectomy +/- RLND (CT with enlarged nodes or 10 years or older patients). • Avoid RT to scrotum to preserve contralateral testicular function if complete resection achieved. • 3 year FFS 90%. 23
    • GEIS XIth International Symposium / Seville - November, 29th 2013 Unfavourable Sites Extremity or Trunk Rhabdomyosarcoma • High rate of lymph node involvement, node sampling required. • Surgery maintaining form and function with RT preferred rather than amputation. • 10 year OS 63%, FFS 57%. 24
    • GEIS XIth International Symposium / Seville - November, 29th 2013 Unfavourable Sites Parameningeal Rhabdomyosarcoma • Intracraneal extension of disease main prognostic factor. • Surgery often limited (95% Group III). • 5 year OS 73%, FFS 69%, LC 83%. 25
    • GEIS XIth International Symposium / Seville - November, 29th 2013 Take Home Messages • Close collaboration mandatory. • Modern Radiotherapy techniques needed. • Work Hard. 26
    • GEIS International Symposium / Seville - November, 29 ThankXIYou th th 2013 bitory2k@yahoo.com @Bitorbar