radiotherapeutical options to avoid mucositis and xerostomia salivary gland tumors : rené-jean...
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Radiotherapeutical options Radiotherapeutical options to avoid Mucositis and to avoid Mucositis and
XerostomiaXerostomia
Salivary Gland Tumors :Salivary Gland Tumors :
René-Jean BensadounRené-Jean BensadounHead of Radiotherapy Department, Head of Radiotherapy Department,
Centre Antoine-Lacassagne, Centre Antoine-Lacassagne, 06189-06189-NICENICE Cedex 2 ( Cedex 2 (FranceFrance).).
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Salivary Gland tumors are considered as Radioresistant Salivary Gland tumors are considered as Radioresistant and Chemoresistant lesions.and Chemoresistant lesions.
For these tumors, the role of new radiation modalities, For these tumors, the role of new radiation modalities, (i.e. IMRT, heavy ions therapy, neutrontherapy) (i.e. IMRT, heavy ions therapy, neutrontherapy) is emphasized.is emphasized.
I will shortly present the radiotherapeutical options I will shortly present the radiotherapeutical options to avoid Mucositis and Xerostomia in Salivary Gland to avoid Mucositis and Xerostomia in Salivary Gland Tumors.Tumors.
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RT Parotids (3DCRT)RT Parotids (3DCRT)
Photons + e-
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RT Sub-mandibular GlandsRT Sub-mandibular Glands
Photons + e-
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ProblemProblem : Radioresistant (and : Radioresistant (and chemoresistant) lesionschemoresistant) lesions
->-> Limited effect of classical Limited effect of classical photontherapy photontherapy on on bulky disease bulky disease
(unresectable cases or (unresectable cases or macroscopical residual tumor macroscopical residual tumor
after surgery) after surgery)
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French National Guidelines (SOR)French National Guidelines (SOR) + French Network for Rare + French Network for Rare Head and Neck Tumors Head and Neck Tumors
(REFCOR)(REFCOR)
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Arbre 3 : Prise en charge thérapeutique du patient atteint d’une tumeur des glandes salivaires de stade II (T1b-T2b-T3a N0 M0) de bas grade
Stade II (T1b-T2b-T3a N0 M0) de bas grade
Résection macroscopiquementOU microscopiquement incomplèteOU présence de ganglions envahis
non
Standard : Chirurgie tumorale et ganglionnaire.
* La neutronthérapie n'est plus disponible en France depuis la fermeture récente de l'Unité de Neutronthérapie d'Orléans mais l’émergence de nouvelles techniques telles que la radiothérapie conformationnelle en 3 dimensions (RC3D) ou la radiothérapie conformationnelle avec modulation d'intensité (RCMI), permet d’apporter d’autres options de même que les projets français d’hadronthérapie.
Exérèse chirurgicale tumoraleStandards : Exérèse chirurgicale complète si tumeur localisée aux GSP. Exérèse chirurgicale élargie si tumeur localisée aux GSA.Option : Chirurgie élargie mutilante si tumeur étendue aux éléments nobles (nerf VII, fosse infra temporale, mandibule, base du crâne).
oui
Curage ganglionnaireStandard : Prophylactique modifié de type 3 et sélectif (groupes I, II, III) et bilatéral si lésions médianes.
Radiothérapie postopératoire tumorale et ganglionnaire *Standard : Unilatérale sauf si lésions médianes ou bilatérale.Standards de dose : Sur le site tumoral : dose totale équivalente de 65 Gy si exérèse incomplète. Sur les aires ganglionnaires : dose totale équivalente de 50 Gy.Options : Hadronthérapie (ions carbone ou neutrons) si réalisable en cas de reliquat tumoral macroscopiquement volumineux. Photonthérapie de haute énergie (RC3D).
Modalités des thérapeutiques
Standards : Pas de radiothérapie postopératoire. Pas de chimiothérapie.
Standards : Radiothérapie postopératoire tumorale et ganglionnaire. Pas de chimiothérapie.
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Arbre 4 : Prise en charge thérapeutique d’un patient atteint d’une tumeur des glandes salivaires de stade II (T1b-T2b-T3a N0 M0) de haut grade ou
de stade III (T3b-T4a N0 M0, tout T (sauf T4b) N1 M0) de bas grade
Stade II (T1b-T2b-T3a N0 M0) de haut grade ou
Stade III (T3b-T4a N0 M0, tout T (sauf T4b) N1 M0) de bas grade
Exérèse chirurgicale tumoraleStandards : Exérèse chirurgicale complète si tumeur localisée aux GSP. Exérèse chirurgicale élargie si tumeur localisée aux GSA.Option : Chirurgie élargie mutilante si tumeur étendue aux éléments nobles (nerf VII, fosse infra temporale, mandibule, base du crâne).
Résection macroscopiquementOU microscopiquement incomplète
OU présence de ganglions envahis ?
oui non
Standards : Radiothérapie postopératoire tumorale et ganglionnaire. Pas de chimiothérapie.
Curage ganglionnaireStandard : pas d’attitude standard.Options : Bilatéral si lésions médianes.Complet homolatéral conservateur.
Standard : Pas de chimiothérapie.
Option : Radiothérapie postopératoire tumorale (photons, 50 Gy)
Curage ganglionnaireStandards : Bilatéral si lésions médianes. Complet, conservateur ou non conservateur, homolatéral à l’adénopathie cliniquement envahie en cas de lésion N1.
Standard : Chirurgie tumorale et ganglionnaire.
* La neutronthérapie n'est plus disponible en France depuis la fermeture récente de l'Unité de Neutronthérapie d'Orléans mais l’émergence de nouvelles techniques telles que la radiothérapie conformationnelle en 3 dimensions (RC3D) ou la radiothérapie conformationnelle avec modulation d'intensité (RCMI), permet d’apporter d’autres options de même que les projets français d’hadronthérapie.
Modalités des thérapeutiques :
Radiothérapie postopératoire tumorale ou ganglionnaire *Standard : Unilatérale sauf si lésions médianes ou bilatérale.Standards de dose : Sur le site tumoral : dose totale équivalente de 65 Gy si exérèse incomplète. Sur les aires ganglionnaires : dose totale équivalente de 50 Gy.Options : Hadronthérapie (ions carbone ou neutrons) si réalisable en cas de reliquat tumoral macroscopiquement volumineux. Photonthérapie de haute énergie (RC3D ou RCMI).
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Heavy ions therapyHeavy ions therapyNeutrontherapyNeutrontherapy
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Parotid Gland SparingParotid Gland Sparing
with with Step-and-Shoot Step-and-Shoot IMRTIMRTin in Oropharyngeal and Nasopharyngeal Oropharyngeal and Nasopharyngeal TumorsTumors..
5 years Experience 5 years Experience
at the Centre Antoine-Lacassagne, at the Centre Antoine-Lacassagne, NICE NICE (France).(France).
René-Jean BensadounRené-Jean Bensadoun **, Serge Marcié , Serge Marcié **, Cécile Ortholan, Cécile Ortholan**, Benjamin , Benjamin Serrano Serrano **, Elisabeth Charpiot*, Jean-Pierre Gérard , Elisabeth Charpiot*, Jean-Pierre Gérard **. .
* * Radiotherapy Department, Centre Antoine-Lacassagne, Radiotherapy Department, Centre Antoine-Lacassagne,
06189-06189-NICENICE Cedex 2 ( Cedex 2 (FranceFrance).).
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pharynx IMRTpharynx IMRTMethodsMethods
Linear Accelerator
PRIMUS (Siemens) 1997 #003Simtec, Primeview
Lantis network
RX 6 MV, 300 UM/min
«step and shoot» IMRT technique
Inverse treatment planning
TMS 6.0 (Helax – MDS NORDION)TMS 6.0 (Helax – MDS NORDION)
ONCENTRA MasterPlan (Nucletron)ONCENTRA MasterPlan (Nucletron)
"pencil beam"
"collapsed cone"
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IMRT 3D CONFORMAL 2D TRADITIONAL
45 54 70 84 Gy PTV BRAINSTEM/SPINAL CORD
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IMRT Process :IMRT Process :
Courtesy of V. Gregoire
Conformal radiotherapy and IMRTConformal radiotherapy and IMRTin Head and Neck Tumorsin Head and Neck Tumors
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18F-FDGPET
18F-FDGPET
MRI (T1)MRI (T1)
CT ScanCT Scan
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Examples of fluence matrixExamples of fluence matrix
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Salivary Flow measurementSalivary Flow measurement
-> To confirm the clinical impact of -> To confirm the clinical impact of parotid gland sparing with IMRT, parotid gland sparing with IMRT, measurement of measurement of salivary flowsalivary flow, , before before and after 5 minute stimulation (with and after 5 minute stimulation (with ParafilmParafilm)) was performed at D0, at was performed at D0, at the end of treatment, at 3 months, the end of treatment, at 3 months, and will be performed every 6 and will be performed every 6 months during 2 yrs.months during 2 yrs.
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RESULTSRESULTS
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Dose PrescribedDose Prescribed
Oropharynx (30 patients) :Oropharynx (30 patients) :
Prophylactic dose (CTV1) : Prophylactic dose (CTV1) : 48-50 Gy48-50 Gy
Curative dose (CTV2) : Curative dose (CTV2) : 66-70 Gy66-70 Gy
Nasopharynx (14 patients) :Nasopharynx (14 patients) :
Prophylactic dose (nodes only) (CTV1) : Prophylactic dose (nodes only) (CTV1) : 48-50 Gy48-50 Gy
Curative dose (CTV2) : Curative dose (CTV2) : 66-70 Gy66-70 Gy
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Dosimetric ComparisonsDosimetric Comparisons
For those patients, we performed 2 types of For those patients, we performed 2 types of
Radiotherapy plans, and we made Radiotherapy plans, and we made dosimetric dosimetric
comparisonscomparisons regarding dose distribution in PTVs, regarding dose distribution in PTVs,
Spinal Canal and Parotid glands (superficial and Spinal Canal and Parotid glands (superficial and
deep lobes).deep lobes).
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Mean DoseMean Dose to the contralateralto the contralateral parotidparotid
IMRT : IMRT : Mean: Mean: 28.1 Gy28.1 Gy(range 5.5 Gy-44.1 Gy)(range 5.5 Gy-44.1 Gy) Median:Median: 29.4 29.4
GyGy
RC3D :RC3D : Mean: Mean: 47.4 Gy47.4 Gy(range 25.7 Gy-64.1 Gy)(range 25.7 Gy-64.1 Gy) Median:Median: 48.2 48.2
GyGy
RESULTS: Dosimetric ComparisonRESULTS: Dosimetric Comparison
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Mean Dose to Contralateral Parotid GlandMean Dose to Contralateral Parotid Gland
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Mean dose to the Parotids :Mean dose to the Parotids : Step and shoot IMRTStep and shoot IMRT in our in our
experience leads to :experience leads to :
21 %21 % decrease in decrease in mean dosemean dose for for the the ipsilateralipsilateral gland gland
41 %41 % decrease in decrease in mean dosemean dose for for the controlateral gland +++the controlateral gland +++
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Evolution of Measured Salivary Evolution of Measured Salivary FlowFlow
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IMRT AS
0
100
200
300
400
500
600
700
800
900
1000
0 3 6 9 12 18 24
MOIS
mg
/mn
BASSOBESSONBRIANCONBROUSSEAUDEMICHELISDESTOUMIEUXFOULONEBADIGALLAISJUHEKARAMALNATIMARCELSérie15MICELIPASEROPERINPERNINRICHEZSérie21ROPERORUIZSANTOSSEDERELTERPENTTOURLETVERGNAUDVILLEDEFRAITEURJEAN
(Evolution du flux salivaire pour chaque patient)
RCMI
Avec stimulation par Parafilm
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(Evolution du flux salivaire pour chaque patient)
RC3D
Avec stimulation par Parafilm
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3 mois p=0,0043 mois p=0,00412 mois p=0,0512 mois p=0,0518 mois p=0,0418 mois p=0,04
Evolution of Stimulated salivary Evolution of Stimulated salivary Flow after Radiation (IMRT vs Flow after Radiation (IMRT vs RC3D)RC3D)
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Radiation-Induced Radiation-Induced Mucositis(GMucositis(G33))
Radiation-Induced Radiation-Induced Mucositis(GMucositis(G33))
Chemo-Induced Mucositis(GChemo-Induced Mucositis(G33))Chemo-Induced Mucositis(GChemo-Induced Mucositis(G33))
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Thank You for your Attention !Thank You for your Attention !Hope to welcome you soon Hope to welcome you soon
on the French Riviera !!on the French Riviera !!