Claudia Linsenmeier

Clinical application of flattening filter free beams for extracranial stereotactic radiotherapy.

PURPOSE To investigate the clinical application of flattening filter free (FFF) beams at maximum dose rate for stereotactic body radiotherapy (SBRT). METHODS AND MATERIALS Patients with tumors in the lung or abdomen were subjected to SBRT using 6 MV FFF or 10 MV FFF beams. For each patient, three plans were calculated using 6 MV flattened, 6 MV FFF, and 10 MV FFF beams. Treatment times were recorded and analyzed, and tumor displacements were assessed by pre- and post-treatment cone beam computed tomography (CBCT). RESULTS Altogether, 26 patients (16 lung, 10 abdominal tumors) were treated. The average dose rate per patient ranged from 442 to 1860 MU/min. Beam-on time was on average 1.6 min (1SD=0.6 min), with the total treatment times recorded at 18.5 min (1SD=3.5 min). The time advantage of using FFF beams was dose-dependent and started at 4 Gy for 6 MV FFF and at 10 Gy for 10 MV FFF beams. The average of the tumor displacements during treatment was 2.0mm (1SD = 1.0mm). CONCLUSIONS SBRT using FFF beams is time efficient and associated with excellent patient stability. According to Van Herks formula, ITV-PTV margins of 6mm are sufficient in our patient cohort. Further studies are necessary to assess clinical outcome and toxicity.

Total body irradiation (TBI) in pediatric patients. A single-center experience after 30 years of low-dose rate irradiation.

AbstractPurpose:To retrospectively analyze patient characteristics, treatment, and treatment outcome of pediatric patients with hematologic diseases treated with total body irradiation (TBI) between 1978 and 2006.Patients and Methods:32 pediatric patients were referred to the Department of Radiation-Oncology at the University of Zurich for TBI. Records of regular follow-up of 28 patients were available for review. Patient characteristics as well as treatment outcome regarding local control and overall survival were assessed. A total of 18 patients suffered from acute lymphoblastic leukemia (ALL), 5 from acute and 2 from chronic myelogenous leukemia, 1 from non-Hodgkin lymphoma, and 2 from anaplastic anemia. The cohort consisted of 15 patients referred after first remission and 13 patients with relapsed leukemia. Mean follow-up was 34 months (2–196 months) with 15 patients alive at the time of last follow-up. Eight patients died of recurrent disease, 1 of graft vs. host reaction, 2 of sepsis, and 2 patients died of a secondary malignancy.Results:The 5-year overall survival rate (OS) was 60%. Overall survival was significantly inferior in patients treated after relapse compared to those treated for newly diagnosed leukemia (24% versus 74%; p=0.004). At the time of last follow-up, 11 patients survived for more than 36 months following TBI. Late effects (RTOG ≥3) were pneumonitis in 1 patient, chronic bronchitis in 1 patient, cardiomyopathy in 2 patients, severe cataractogenesis in 1 patient (48 months after TBI with 10 Gy in a single dose) and secondary malignancies in 2 patients (36 and 190 months after TBI). Growth disturbances were observed in all patients treated prepubertally. In 2 patients with identical twins treated at ages 2 and 7, a loss of 8% in final height of the treated twin was observed.Conclusion:As severe late sequelae after TBI, we observed 2 secondary malignancies in 11 patients who survived in excess of 36 months. However, long-term morbidity is moderate following treatment with the fractionated TBI at the low-dose rate that was generally used here. Conditioning for bone marrow transplantation without radiation is an attractive option, but is not sufficiently effective to completely replace TBI for the most common pediatric indications.ZusammenfassungZiel:Retrospektive Analyse von Patientencharakteristika, Behandlung und Ergebnis bei Kindern mit hämatologischen Erkrankungen, die zwischen 1978 und 2006 mit Ganzkörperbestrahlung behandelt wurden.Patienten und Methodik:32 Kinder wurden unserer Klinik zur TBI zugewiesen, 28 Krankengeschichten waren zugänglich (n=28). 18 Patienten litten unter akuter lymphoblastischer Leukämie (ALL), 5 unter akuter (AML) und 2 unter chronisch myeloischer Leukämie (CML), einer unter Non-Hodgkin-Lymphom und zwei unter aplastischer Anämie. 15 Patienten wurden nach erster Remission zugewiesen, 13 mit Rezidiv. Bei der letzten Kontrolle lebten noch 15 Patienten (mean 34 Monate (2–196 Monate). Acht Patienten sind an einem Rezidiv verstorben, einer an einer Graft-versus-host Erkrankung, zwei an Sepsis und zwei an Sekundärtumoren.Resultate:Das 5-Jahres Gesamtüberleben lag bei 60%. Das Gesamtüberleben war signifikant (p=0.004) niedriger bei Patienten, die nach einem Rezidiv behandelt wurden (24%), als bei solchen die bei Erstdiagnose behandelt wurden (74%). Spättoxizität RTOG ≥3 waren eine Pneumonitis bei 1 Patienten, eine chronische Bronchitis bei einem Patienten, Kardiomyopathie bei 2 Patienten, eine Katarakt bei einem Patienten (48 Monate nach TBI mit 10Gy Einzeldosis) und Sekundärtumore bei 2 Patienten. Wachstumsstörungen mit einer Körpergrösse kleiner als die 25. Perzentile zeigten sich bei allen vor der Pubertät behandelten Kindern. Bei zwei eineiigen Zwillingen zeigt sich ein Verlust von 8% an Körpergrösse im Vergleich zum Zwilling.Schlussfolgerung:Wie erwartet zeigen sich schwere Spättoxizitäten nach Ganzkörperbestrahlung mit zwei Sekundärtumoren bei 11 Patienten, die länger als 36 Monate überlebt haben. Aber die Morbidität ist mässig nach fraktionierter Ganzkörperbestrahlung und der hier in fast allen Fällen verwendeten niedrigen Dosisrate. Konditionierung ohne TBI ist eine attraktive Möglichkeit, aber noch nicht effektiv genug um die TBI im Kindesalter ganz zu ersetzen.

Total Body Irradiation (TBI) in Pediatric Patients

AbstractPurpose:To retrospectively analyze patient characteristics, treatment, and treatment outcome of pediatric patients with hematologic diseases treated with total body irradiation (TBI) between 1978 and 2006.Patients and Methods:32 pediatric patients were referred to the Department of Radiation-Oncology at the University of Zurich for TBI. Records of regular follow-up of 28 patients were available for review. Patient characteristics as well as treatment outcome regarding local control and overall survival were assessed. A total of 18 patients suffered from acute lymphoblastic leukemia (ALL), 5 from acute and 2 from chronic myelogenous leukemia, 1 from non-Hodgkin lymphoma, and 2 from anaplastic anemia. The cohort consisted of 15 patients referred after first remission and 13 patients with relapsed leukemia. Mean follow-up was 34 months (2–196 months) with 15 patients alive at the time of last follow-up. Eight patients died of recurrent disease, 1 of graft vs. host reaction, 2 of sepsis, and 2 patients died of a secondary malignancy.Results:The 5-year overall survival rate (OS) was 60%. Overall survival was significantly inferior in patients treated after relapse compared to those treated for newly diagnosed leukemia (24% versus 74%; p=0.004). At the time of last follow-up, 11 patients survived for more than 36 months following TBI. Late effects (RTOG ≥3) were pneumonitis in 1 patient, chronic bronchitis in 1 patient, cardiomyopathy in 2 patients, severe cataractogenesis in 1 patient (48 months after TBI with 10 Gy in a single dose) and secondary malignancies in 2 patients (36 and 190 months after TBI). Growth disturbances were observed in all patients treated prepubertally. In 2 patients with identical twins treated at ages 2 and 7, a loss of 8% in final height of the treated twin was observed.Conclusion:As severe late sequelae after TBI, we observed 2 secondary malignancies in 11 patients who survived in excess of 36 months. However, long-term morbidity is moderate following treatment with the fractionated TBI at the low-dose rate that was generally used here. Conditioning for bone marrow transplantation without radiation is an attractive option, but is not sufficiently effective to completely replace TBI for the most common pediatric indications.ZusammenfassungZiel:Retrospektive Analyse von Patientencharakteristika, Behandlung und Ergebnis bei Kindern mit hämatologischen Erkrankungen, die zwischen 1978 und 2006 mit Ganzkörperbestrahlung behandelt wurden.Patienten und Methodik:32 Kinder wurden unserer Klinik zur TBI zugewiesen, 28 Krankengeschichten waren zugänglich (n=28). 18 Patienten litten unter akuter lymphoblastischer Leukämie (ALL), 5 unter akuter (AML) und 2 unter chronisch myeloischer Leukämie (CML), einer unter Non-Hodgkin-Lymphom und zwei unter aplastischer Anämie. 15 Patienten wurden nach erster Remission zugewiesen, 13 mit Rezidiv. Bei der letzten Kontrolle lebten noch 15 Patienten (mean 34 Monate (2–196 Monate). Acht Patienten sind an einem Rezidiv verstorben, einer an einer Graft-versus-host Erkrankung, zwei an Sepsis und zwei an Sekundärtumoren.Resultate:Das 5-Jahres Gesamtüberleben lag bei 60%. Das Gesamtüberleben war signifikant (p=0.004) niedriger bei Patienten, die nach einem Rezidiv behandelt wurden (24%), als bei solchen die bei Erstdiagnose behandelt wurden (74%). Spättoxizität RTOG ≥3 waren eine Pneumonitis bei 1 Patienten, eine chronische Bronchitis bei einem Patienten, Kardiomyopathie bei 2 Patienten, eine Katarakt bei einem Patienten (48 Monate nach TBI mit 10Gy Einzeldosis) und Sekundärtumore bei 2 Patienten. Wachstumsstörungen mit einer Körpergrösse kleiner als die 25. Perzentile zeigten sich bei allen vor der Pubertät behandelten Kindern. Bei zwei eineiigen Zwillingen zeigt sich ein Verlust von 8% an Körpergrösse im Vergleich zum Zwilling.Schlussfolgerung:Wie erwartet zeigen sich schwere Spättoxizitäten nach Ganzkörperbestrahlung mit zwei Sekundärtumoren bei 11 Patienten, die länger als 36 Monate überlebt haben. Aber die Morbidität ist mässig nach fraktionierter Ganzkörperbestrahlung und der hier in fast allen Fällen verwendeten niedrigen Dosisrate. Konditionierung ohne TBI ist eine attraktive Möglichkeit, aber noch nicht effektiv genug um die TBI im Kindesalter ganz zu ersetzen.

Follow up after IMRT in oral cavity cancer: update.

PurposeExcept for early stages (T1/2 N0), the prognosis for patients with oral cavity cancer (OCC) is known to be worse than for those with pharyngeal carcinoma. While definitive intensity modulated radiation therapy (IMRT)-chemotherapy affords loco-regional control rates (LRC) of approximately 80% in advanced pharyngeal cancer, corresponding rates are reported to be much lower for OCC. The aim of this work was to evaluate loco-regional disease control and overall survival (OAS) in a relatively large OCC patient cohort treated in the IMRT era.Methods and materialsBetween October 2002 and June 2011, 160 OCC patients were treated with curative intention IMRT at our department. 122 patients (76%) were referred with primary disease and 38 patients (24%) with a recurrent OCC at least 3 months after surgery alone. Definitive IMRT was performed in 44/160 patients (28%), whilst 116 patients underwent previous surgery. Simultaneous systemic therapy was administered in 72%.ResultsPatients with postoperative IMRT (+/−systemic therapy) with R0-1 status (n = 99) reached significantly higher LRC/OAS rates than patients following IMRT for macroscopic disease (n = 61), with 84%/80% versus 38%/33% at 3 years, respectively (p < 0.0001). This was found in patients treated for initial, as well as recurrent, disease. Less than 2% persisting grade 3/4 late effects were observed.ConclusionsIMRT for R0-1 situations translated into a highly significant superior LRC and OAS compared to the IMRT cohort treated for macroscopic disease. Treatment was well tolerated.

A psychoeducational intervention reduces the need for anesthesia during radiotherapy for young childhood cancer patients

BackgroundRadiotherapy (RT) has become an important treatment modality in pediatric oncology, but its delivery to young children with cancer is challenging and general anesthesia is often needed.MethodsTo evaluate whether a psychoeducational intervention might reduce the need for anesthesia, 223 consecutive pediatric cancer patients receiving 4141 RT fractions during 244 RT courses between February 1989 and January 2006 were studied. Whereas in 154 RT courses corresponding with 2580 RT fractions patients received no psychoeducational intervention (group A), 90 RT courses respectively 1561 RT fractions were accomplished by using psychoeducational intervention (group B). This tailored psychoeducational intervention in group B included a play program and interactive support by a trained nurse according to age to get familiar with staff, equipment and procedure of radiotherapy.ResultsGroup A did not differ significantly from group B in age at RT, gender, diagnosis, localization of RT and positioning during RT. Whereas 33 (21.4%) patients in group A got anesthesia, only 8 (8.9%) patients in group B needed anesthesia. The median age of cooperating patients without anesthesia decreased from 3.2 to 2.7 years. In both uni- and multivariate analyses the psychoeducational intervention significantly and independently reduced the need for anesthesia.ConclusionWe conclude that a specifically tailored psychoeducational intervention is able to reduce the need for anesthesia in children undergoing RT for cancer. This results in lower costs and increased cooperation during RT.

Safety of high-dose-rate stereotactic body radiotherapy

Background and purposeFlattening filter free (FFF) beams with high dose rate are increasingly used for stereotactic body radiotherapy (SBRT), because they substantially shorten beam-on time. The physical properties of these beams together with potentially unknown radiobiological effects might affect patient safety. Therefore here we analyzed the clinical outcome of our patients.Material and methodsBetween 3/2010 and 2/2014 84 patients with 100 lesions (lung 75, liver 10, adrenal 6, lymph nodes 5, others 4) were treated with SBRT using 6 MV FFF or 10 MV FFF beams at our institution. Clinical efficacy endpoints and toxicity were assessed by Kaplan-Meier analysis and CTCAE criteria version 4.0.ResultsMedian follow-up was 11 months (range: 3–41). No severe acute toxicity was observed. There has been one case of severe late toxicity (1%), a grade 3 bile duct stricture that was possibly related to SBRT. For all patients, the 1-year local control rate, progression free survival and overall survival were 94%, 38% and 80% respectively, and for patients with lung lesions 94%, 48% and 83%, respectively.ConclusionsNo unexpected toxicity occurred. Toxicity and treatment efficacy are perfectly in range with studies investigating SBRT with flattened beams. The use of FFF beams at maximum dose rate for SBRT is time efficient and appears to be safe.

Implementation and validation of a new fixation system for stereotactic radiation therapy: An analysis of patient immobilization

PURPOSE Stereotactic radiation therapy is an established treatment technique for intracranial malignancies. We evaluated a new intracranial immobilization system with an emphasis on determining the intrafraction motion and the correlation of this motion with treatment time. METHODS AND MATERIALS Patients were immobilized using the trUpoint ARCH fixation system (CIVCO Medical Solutions). We collected data from 85 lesions in 73 patients treated between November 2011 and December 2013. Sixty-nine of 73 patients (95%) used the complete mask system; for the remaining 4 patients, the system had to be adapted. Patients were treated using volumetric modulated arc therapy stereotactic radiation therapy on a TrueBeam linear accelerator (Varian Medical Systems, Palo Alto, CA). Fraction doses of 2-8 Gy were applied in 4-30 fractions. Daily cone beam computed tomography imaging was performed before the treatment and was matched to the reference computed tomography using a 6-degrees-of-freedom automatching procedure. Additionally, posttreatment cone beam computed tomography scans were performed to assess intrafraction motion for 67 patients (375 fractions). RESULTS The average 3-dimensional setup error was 2.1 ± 2.9 mm. The mean pitch and roll was -0.1 ± 0.7° and 0.2 ± 0.7°. A total of 98.0% of the pitch values and 98.9% of the roll values were <1.5°. Mean intrafractional motion was 0.51 mm (±0.27) and mean treatment time was 10.1 minutes (±1.4). The maximum intrafractional motion was 2.0 mm in the longitudinal direction; 95% of the total shifts were <1.4 mm. The linear regression showed a weak but significant influence (R(2) = 0.26, P = .01) of the treatment time on the total intrafractional shift. CONCLUSIONS The new intracranial immobilization system appears to be robust in terms of setup accuracy, intrafraction motion, and repositioning of the mask system.

EP-2113: Clinical implementation of an optical surface monitoring system(OSMS®, Varian) in breast irradiation

S993 ________________________________________________________________________________ Conclusion: When using KV-CBCT for set-up verification in stereotactic treatment a large inter-observer variability can be seen in a significant proportion of scans, particularly in extracranial treatment. Such a difference may have an impact on target coverage or organ at risk irradiation, thus requiring a proper margin. Further evaluation is needed, particularly focusing on methods to decrease such interobserver variability

Total Body Irradiation (TBI) in Pediatric Patients@@@Ganzkörperbestrahlung (TBI) in der Pädiatrie – 30 Jahre Erfahrungen mit Niedrig-Dosisraten-Bestrahlung: A Single-center Experience after 30 Years of Low-dose Rate Irradiation

AbstractPurpose:To retrospectively analyze patient characteristics, treatment, and treatment outcome of pediatric patients with hematologic diseases treated with total body irradiation (TBI) between 1978 and 2006.Patients and Methods:32 pediatric patients were referred to the Department of Radiation-Oncology at the University of Zurich for TBI. Records of regular follow-up of 28 patients were available for review. Patient characteristics as well as treatment outcome regarding local control and overall survival were assessed. A total of 18 patients suffered from acute lymphoblastic leukemia (ALL), 5 from acute and 2 from chronic myelogenous leukemia, 1 from non-Hodgkin lymphoma, and 2 from anaplastic anemia. The cohort consisted of 15 patients referred after first remission and 13 patients with relapsed leukemia. Mean follow-up was 34 months (2–196 months) with 15 patients alive at the time of last follow-up. Eight patients died of recurrent disease, 1 of graft vs. host reaction, 2 of sepsis, and 2 patients died of a secondary malignancy.Results:The 5-year overall survival rate (OS) was 60%. Overall survival was significantly inferior in patients treated after relapse compared to those treated for newly diagnosed leukemia (24% versus 74%; p=0.004). At the time of last follow-up, 11 patients survived for more than 36 months following TBI. Late effects (RTOG ≥3) were pneumonitis in 1 patient, chronic bronchitis in 1 patient, cardiomyopathy in 2 patients, severe cataractogenesis in 1 patient (48 months after TBI with 10 Gy in a single dose) and secondary malignancies in 2 patients (36 and 190 months after TBI). Growth disturbances were observed in all patients treated prepubertally. In 2 patients with identical twins treated at ages 2 and 7, a loss of 8% in final height of the treated twin was observed.Conclusion:As severe late sequelae after TBI, we observed 2 secondary malignancies in 11 patients who survived in excess of 36 months. However, long-term morbidity is moderate following treatment with the fractionated TBI at the low-dose rate that was generally used here. Conditioning for bone marrow transplantation without radiation is an attractive option, but is not sufficiently effective to completely replace TBI for the most common pediatric indications.ZusammenfassungZiel:Retrospektive Analyse von Patientencharakteristika, Behandlung und Ergebnis bei Kindern mit hämatologischen Erkrankungen, die zwischen 1978 und 2006 mit Ganzkörperbestrahlung behandelt wurden.Patienten und Methodik:32 Kinder wurden unserer Klinik zur TBI zugewiesen, 28 Krankengeschichten waren zugänglich (n=28). 18 Patienten litten unter akuter lymphoblastischer Leukämie (ALL), 5 unter akuter (AML) und 2 unter chronisch myeloischer Leukämie (CML), einer unter Non-Hodgkin-Lymphom und zwei unter aplastischer Anämie. 15 Patienten wurden nach erster Remission zugewiesen, 13 mit Rezidiv. Bei der letzten Kontrolle lebten noch 15 Patienten (mean 34 Monate (2–196 Monate). Acht Patienten sind an einem Rezidiv verstorben, einer an einer Graft-versus-host Erkrankung, zwei an Sepsis und zwei an Sekundärtumoren.Resultate:Das 5-Jahres Gesamtüberleben lag bei 60%. Das Gesamtüberleben war signifikant (p=0.004) niedriger bei Patienten, die nach einem Rezidiv behandelt wurden (24%), als bei solchen die bei Erstdiagnose behandelt wurden (74%). Spättoxizität RTOG ≥3 waren eine Pneumonitis bei 1 Patienten, eine chronische Bronchitis bei einem Patienten, Kardiomyopathie bei 2 Patienten, eine Katarakt bei einem Patienten (48 Monate nach TBI mit 10Gy Einzeldosis) und Sekundärtumore bei 2 Patienten. Wachstumsstörungen mit einer Körpergrösse kleiner als die 25. Perzentile zeigten sich bei allen vor der Pubertät behandelten Kindern. Bei zwei eineiigen Zwillingen zeigt sich ein Verlust von 8% an Körpergrösse im Vergleich zum Zwilling.Schlussfolgerung:Wie erwartet zeigen sich schwere Spättoxizitäten nach Ganzkörperbestrahlung mit zwei Sekundärtumoren bei 11 Patienten, die länger als 36 Monate überlebt haben. Aber die Morbidität ist mässig nach fraktionierter Ganzkörperbestrahlung und der hier in fast allen Fällen verwendeten niedrigen Dosisrate. Konditionierung ohne TBI ist eine attraktive Möglichkeit, aber noch nicht effektiv genug um die TBI im Kindesalter ganz zu ersetzen.