01 planning for hn india feb 2013 (cancer ci 2013) avraham eisbruch
TRANSCRIPT
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IMRT planning for HN cancr: Some clinical issues
Avraham Eisbruch
University of Michigan
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Defining the targets
The GTV:
1. Clinical information: palpation, mirror/fiberoptic exam, direct endoscopy report
2. Imaging: Planning CT (contrast-enhanced)• Register with MRI / PET
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Nasopharynx caCT
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Nasopharynx caMRI
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Using FDG-PET to define the GTV
• How exactly should PET be used?
• If the PET-based and CT-based GTVs differ, what is the “truth”?
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Using PET-CT for GTV delineation
CT-GTVs
The GTVs on CT and FDG-PET usually correlate well
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FDG-PET may define the GTV better than CT
Lt BOT cancer. The GTV is blurred by CT artifact
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FDG-PET may define the GTV better than CT
Lt tonsil cancer. CT: Retropharyngeal node was part of the CTV. PET: it should be a GTV.
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FDG-PET may be false negative: failure to detect obvious gross disease
#1
#2
#1
LN #2: extensive necrosis; not detected by PET
Primary ca Primary ca
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PET may be false positive: Benign lymphatic tissue in the BOT accumulates FDG
Consult Nuc Med to verify that the signal intensity/SUV are right
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Suspicious nodes on CT, PET (-): CTVs or GTVs?
?
? + +
Use clinical judgement
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PET vs. other imaging modalities vs. LN pathology
Adams et al, Eur J Nuc Med 1998
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Larynx cancer: Matching the surgical specimen, CT, and PET
Daisne, …Gregoire, Radiology 2004
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Matching the surgical specimen, CT, MRI, and PET
• The GTVs according to PET were usually slightly smaller than the CT/MRI volumes
• No modality showed the extent of the primary with complete accuracy– evaluation of submucosal tumor extension was
deficient by all modalities.
Daisne, …Gregoire, Radiology 2004
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Summary: Outlining the primary tumor GTV
• Use the PET and CT/MRI information for composite GTV delineation
• Add clinical examination results, especially for the mucosal extent of the gross disease
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Summary: Outlining the nodal GTVs
• Wherever a node is PET (+), include in the GTV
• If CT is highly suspicious and PET is (-), include in the GTV.
• In borderline cases of (+) CT and (-) PET, use clinical judgement to define as GTV or CTV.
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Can FDG-PET be used to define the CTVs?
• Sentinel node biopsy and neck dissection in the clinically (-) neck: nodes were examined by the pathologists at 2 mm slices
• Occult metastases (size 1.2-1.5 mm): in 5/12 patients;
• FDG PET correctly identified only one (sensitivity of 25%).
• We cannot rely on PET for outlying the CTV.
Stoeckli et al, Head Neck 2002
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Outlining Lymph Node CTVs
• Which LN groups at at risk for each tumor site and stage?
• How should the LN be delineated on the planning CT?
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Som et al.,Arch. Otolaryngol.Head Neck Surg.1999
Neck Node Levels
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www.rtog.org/hnatlas/main.htm
Gregoire,Levendag, et al.
WWW.RTOG.ORG
Researchers
HN Atlas
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Cranial-most extent of neck CTV
• In the clinically (-) non-nasopharyngeal ca:– The bottom of the transverse process of C1
• Gregoire et al
This will ensure coverage of the JD (sub-digastric) nodes
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Rouviere, 1938
Oral cavity lymphatics
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Rouviere, 1938
Pharyngeal lymphatics
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What about nasopharyngeal cancer?
Lateral retroph. n
Junctional n.
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Level II
Level V
Nasopharynx ca
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Should we biopsy all non-specific parotid nodules?
IJROBP 2007
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Parotidean LN metastases in NPC
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Eustachian Tube: Lymphatic Drainage
In addition to sub-digastric and RPN: Lymphatics to parotidean nodes
H. Rouviere, 1932
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Parotidean LN metastases in NPC
Due to retrograde flow when level II is heavily involved?
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Tonsil ca, T3N2c
Parotidean LN metas
Primary Tu
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No nasopharyngeal involvement…
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…but significant ipsilateral level II nodal involvement
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Parotidean metastases
• Risk of retrograde lymphatic drainage when level II is heavily involved
• Suggest: omit ipsilateral parotid sparing if ipsilateral level II is heavily involved.
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Can we improve outcome by GTV dose escalation?
• Escalate doses to the whole GTV
• Escalate the doses to the parts of the GTV judged to be at highest risk
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Escalate/accelerate doses to the whole GTV
• Baylor: “SMART”: 60 Gy/2.4 Gy/fraction
– BED2Gy 70 Gy, over 5 weeks
– Concurrent with chemotherapy: not tolerable due to acute mucositis• Amosson, ASTRO 2003
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Escalate/accelerate doses to the whole GTV
• Nasopharynx ca: 64.8/2.4/fr. Over 5.5 weeks conc. with cisplatin– “modest increase in toxicities”
• WS Koom, Head Neck 2008
• Larynx/hypopharynx ca: 67.2 Gy/2.4 conc. with cisplatin– “acceptable acute toxicity”.
• Guerrero-Urbano , Radiother Oncol 2007
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High fraction doses: Oropharyngeal ca
• RTOG 00-22: 66 Gy/30 fractions, no chemo– Few long-term complications
• 6% ORN• Eisbruch et al, IJROBP 2009
• Stanford: 66 Gy/30 fractions, conc. chemo– Few long-term complications
• Orocutaneous fistula, tracheal stenosis, ORN
• Daly ME et al, IJROBP 2009
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Moderately high fraction doses: laryngeal/hypopharyngeal ca
• MSKCC: 70 Gy/32-33 fractions (2.12 Gy/fraction) conc with chemo– Late complications:
• 20% PEG dependency at 2 years• Laryngeal necrosis, necrotizing skin fascitis
• Lee NY, IJROBP 2007
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Escalate the dose to part of the GTV
• The FDG-PET avid part of the GTV tumor
• Hypoxic regions within the GTV
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CTV
• Outlining the CTV– Anatomically: taking into account the
compartments at risk– Uniformly, arbitrary margins: 1-2.5 cm
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CTV Doses and their BED(2 Gy)(assuming alpha/beta 10 Gy and loss of 0.7 Gy/day of
extending treatment)
Total dose (Gy) Dose /fraction (Gy) BED2 (Gy)
63 1.8 60
59 1.7 54
56 1.6 49
52 1.5 42
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Considerations
• Conc chemo: – Adds 12 Gy/ 2 Gy fractions (Kasibhatla et al,
IJROBP 2007)– Adds 7 Gy/2 (Fowler JF, IJROBP
• Very good prognosis patients, such as HPV-related oropharyngeal ca, may require quite low doses
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How should we treat the low neck?
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NTCP: Glottic edema grade 2+
Rancati T, IJROBP 2009
Extensive neck RT for non-laryngeal cancer, mostly no conc. chemo
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No effort to spare the larynx/esophagus: High rates of dysphagia after whole-neck IMRT compared with split-field.
Fua et al, 2007
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split field vs whole neck IMRT
Head Neck 2004
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Amdur et al, Head Neck 2004
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Laryngeal shield: do not extend caudally because jugular vein and nodes become more medial
Mendenhall, Amdur, Million, 1992
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Extend the midline block to shield also inferior constrictor and esophagus
Caudell JJ IJROBP 2009
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Whole neck IMRT or
upper neck IMRT + abutted AP low neck field
• Abutting AP low neck field: 30% of the recurrences were in the low neck – Chao et al IJROBP 2003
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Whole-neck IMRT in cases of low neck involvement or high risk
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Higher weight to targets or organs
• PTV doses: 99%-107% presc. doses• Larynx/constr./esophagus: reduce mean
dose as much as possible (<20 Gy)
– Targets weigh higer than organs
– Organs weigh higher than targets
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PTVs (yellow/purple) weigh lower than larynx/inf. constrictor
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PTVs (yellow) weigh higher than esophagus
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The low neck
• Split-field technique is simpler, faster, less monitor units, likely less skin toxicity
• Whole-field IMRT allows better certainty in target coverage– may be preferable in cases of gross low neck
involvement or when the low neck is at high risk
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Rosenthal et al, IJROBP 2008
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Rosenthal et al, IJROBP 2008
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Oral cavity
Not included in the cost function
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Oral cavity
Included
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Lt tonsillar cancer
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After 23 fractions (GTV dose 46 Gy) concurrent with carboplatin+taxol
Estimated lip mucositis site dose 30 Gy/1.3 Gy/fraction
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Mucosal point doses vs. length of time of mucositis
Narayan et al, IJROBP 2008;72:756
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Lt tonsillar ca, chemo-RT: oral cavity outside the PTVs spared
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Induction chemotherapy for HN cancer
Response to induction chemo:
CR 9%, PR 59%CR 17%, PR 55%
Patients proceed to chemo-RT after most tumors shrink by induction.
GTVs: the pre-chemo or the post-chemo volumes?
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Neoadjuvant chemo: Its tumor effect may be trivial even if clinical CR is achieved.
Ian Tannock
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After induction chemotherapy
• Use the pre-chemo targets• It is essential to examine the patient, have
adequate imaging studies, and preferably simulate the patient before chemo starts.
• Re-simulate after induction chemo and register the pre-chemo GTVs to the new planning CT.
• Same principle: do not reduce the GTV as tumor shrinks during RT.
Salama et al, IJROBP 2009
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Acknowledgements• UM Rad-Onc residents, students & fellows
– Felix Feng– Mary Feng– Alex Lin– Siavash Jabbari– Laura Dawson– Aron Popovtzer– Iris Gluck
• Otolaryngol-HN Surgery– Doug Chepeha– Ted Teknos– Carol Bradford– Gregory Wolf
• Speech pathology– Teresa Lyden– Marc Haxer
• Dentistry– Carol-Anne Murdoch-Kinch– Jonathan Ship
• Rad-Onc Physics– Randall Ten Haken– Karen Vineberg– Dick Fraas
• NKI, Amsterdam– Marco Schwartz– Coen Rasch
Supported by NCI grants PO1 59827 and HN SPORE P50 CA/DE97248