Download Consideration of Local and Systemic Therapies in Early

Treatment Guidelines for
Pre-operative Radiation Therapy
for Retroperitoneal Sarcoma:
Preliminary Consensus of an
International Expert Panel
EH Baldini, D Wang, CN Catton,
DJ Indelicato, DG Kirsch, C Deville,
C Le Pechoux, R Haas, IA Petersen,
K May, D Roberge, BA Guadagnolo,
B O'Sullivan, R Abrams, TF DeLaney
None of the authors have disclosures
Background
• The role of RT for extremity soft
tissue sarcoma is well established
• However, the role of RT for
retroperitoneal sarcoma (RPS) is
unproven
EORTC 62092-22092
(STRASS Trial)
RPS:
Randomize
Pre-Op
RT
Surgery
Surgery
Ongoing, results are eagerly anticipated
Background
• In the meantime, many centers
recommend Pre-op RT for RPS after
multidisciplinary discussion
• But, there are no RT guidelines for
this approach
Purpose
• To define radiation treatment
guidelines for Pre-operative
RT for RPS
RT Treatment Nomenclature
• GTV: Gross Tumor Volume
• CTV: Clinical Target Volume
– Expansion of GTV to include areas at risk for
harboring potential microscopic disease
• PTV: Planning Target Volume
– Expansion of CTV to account for daily patient
set-up inaccuracies and/or patient movement
• Treatment Field Borders
– Extend beyond the PTV by about 7mm to
deliver full dose to PTV
Extremity Soft Tissue Sarcoma
RT Treatment Guidelines*
CTV
• GTV + 4 cm
proximal/distal,
• 1.5 cm radial
• Edit CTV at bone
PTV
• CTV + 5-10mm per
institutional
standard
*Haas, IJROBP 84:572; 2012
4 cm
1.5 cm
GTV: red
CTV: green
PTV: orange
GTV, CTV, PTV
Note the
CTV is
edited at
the bone
interface
GTV  CTV Expansions Vary by Tumor
Tumor
Lymphoma
Prostate Cancer
Lung Cancer
GTV  CTV Expansion
0 mm
5-7 mm
7 mm
Glioblastoma Multiforme
2 cm beyond edema
Extremity STS
1.5 cm radial
4 cm proximal/distal
?
Retroperitoneal Sarcoma
Methods
• An expert panel of 15 academic
radiation oncologists who specialize
in sarcoma was convened
• Panel members reached consensus
recommendations following several
meetings, conference calls and email
correspondence
Expert Panel: US Institutions (10)
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Dana-Farber/Brigham & Women’s Hospital
Massachusetts General Hospital
Medical College of Wisconsin
University of Florida, Jacksonville
Duke University
University of Pennsylvania
Mayo Clinic
Roswell Park Cancer Institute
MD Anderson Cancer Center
Rush University
Expert Panel: European and
Canadian Institutions (4)
Canada
–Princess Margaret Cancer Centre
–McGill University Health Centre
France
–Institut Gustave Roussy
Netherlands
–Netherlands Cancer Institute
Results
Consensus Recommendations
Essential Collaboration between
Surgeon + Radiation Oncologist
Discuss resection margins of concern
Discuss potential resection of kidney, liver
– If nephrectomy is planned:
»Adequate contra-lateral renal function
should be documented
»Minimize dose to contra-lateral kidney
– If partial liver resection is planned:
»Minimize dose to remaining liver
Radiation Simulation
• Oral and IV contrast is optional
• Assessment of 4D motion (4D CT)
–Strongly recommended for tumors above
iliac crest to define GTV4D
• Contour GTV on the planning CT
–Register planning CT with diagnostic CT or
MR T1 contrast images if necessary
CTV Definition
Expand GTV symmetrically by 1.5 cm
Edit CTV:
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Bone: 0 mm
Bowel and Air Cavity: 5 mm
Renal and Hepatic interfaces: 2 mm
Skin Surface: 3-5 mm
If tumor extends through inguinal canal,
add 3 cm distally (as per extremity STS)
• If 4D CT is not performed, larger
expansions are necessary for upper
abdominal tumors
PTV Definition
• Expand CTV by 5mm
–If frequent volumetric soft tissue imaging
will be performed to confirm set-up
accuracy (i.e. cone beam CT)
• Expand CTV by 9-12 mm
–If no volumetric imaging is performed to
confirm set-up
Dose
5040 cGy
180 cGy fractions
5 ½ weeks
RPS Contours
GTV
CTV
PTV
RPS IMRT Graphic Plan
Iso-dose Levels
100%
70%
95%
50%
80%
30%
Dose-Painting Radiation Boost
to High Risk Margins
CONCEPT:
• Deliver boost dose
of RT to areas of
tumor at risk for
positive margins
after resection
• Along posterior
abdominal wall,
pre-vertebral
space, major
vessels
GTV
High Risk Boost Volume
Dose-Painting Radiation Boost
to High Risk Margins
• Efficacy is unproven
• Technique is under investigation
• May be considered, particularly on
protocol
–DeLaney Phase I/II Multi-Center DosePainting Boost, Dose-Escalation Trial
Organ at Risk (OAR) Constraints
ORGAN
CONSTRAINT
Liver
Mean Dose < 26 Gy
Stomach and Duodenum
V45<100%, V50<50%, Max 56 Gy
Kidney: if one will be resected
V18 < 15% remaining kidney
Kidney: if both will remain
Mean dose < 15 Gy, V18 < 50%
Spinal Cord
Max Dose 50 Gy
Small & Large Bowel (Bowel Bag)
V45 < 195 cc
Rectum
V50 < 50%
Testicles
V3 < 50%, Max Dose < 18 Gy
Ovary
Max Dose < 3 Gy
Femoral Head
Max Dose < 50 Gy, V40 < 64%
Treatment Technique
• Intensity modulated radiation
therapy (IMRT) preferred unless
OAR constraints can be met with
3D-conformal technique
Conclusion
• Consensus guidelines were
achieved and are
recommended for use
–To establish uniformity of
treatment
–Aid future efficacy and toxicity
assessment
Thank You
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Tom DeLaney
Dian Wang
Charles Catton
Danny Indelicato
David Kirsch
Curt Deville
Cecile Le Pechoux
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Rick Haas
Ivy Petersen
Kilian May
David Roberge
Ashleigh Guadagnolo
Brian O’Sullivan
Ross Abrams