I. J.

Radiation Oncology d Biology d Physics

S398

Volume 75, Number 3, Supplement, 2009

clinical findings including physical exam and endoscopy. Endoscopy and physical exam often reveal areas of visible or palpable
disease which are not clearly demonstrated on volumetric imaging. However, interpreting endoscopy images as it relates to the
volumetric imaging is subject to potential error. Localizing disease usually relies on remembering its relationship to fixed anatomic
landmarks that are visible on both CT and endoscopy which, by its nature, may be imprecise or inaccurate. We present and describe
a method of quantitative endoscopy to improve target delineation in planning for head and neck cancer.
Materials/Methods: We have developed technology that registers endoscopic images to CT images by tracking and registering the
position and orientation of the endoscope relative to the CT image set. Software developed by our group overlays this information
in both data sets in the treatment planning space. The endoscopy image and CT data sets are co-registered. After the regions of
disease are identified on the endoscopy image, the same regions are automatically identified in the CT data set.
Results: The endoscopic prototype as well as the capabilities of the registration software will be presented.
Conclusions: Although further testing and prototyping are needed, we believe quantitative endoscopy will be a valuable radiotherapy planning tool, augmenting the accuracy and precision of target delineation for head and neck cancers.
Author Disclosure: J. Cho, None; R. Weershink, None; A. Kashigar, None; D. Jaffray, None; A. Hope, None.

2483

Utilizing Biological Cost Functions and Monte Carlo Algorithms in Head and Neck IMRT Planning to
Improve Organ at Risk Sparing in Biologic Target Volume Dose Escalation

N. J. Anderson, M. Wada, C. Lawford, M. Rolfo

Austin Health Radiation Oncology, Heidelberg Heights, Australia
Purpose/Objective(s): Selective dose intensification to sub-volumes of radio-resistance, beyond the conventional IMRT prescription, is a possible strategy for improving the therapeutic ratio in locally advanced head and neck cancer patients. Dose painting,
using a hypoxic sub-volume, is one possible strategy to achieve this goal. Whilst inverse planning (IP), using physical dose constraints, may achieve an acceptable plan, the use of biological cost functions (BCF) with Monte Carlo based dose calculations may
derive better solutions. A planning study was conducted comparing physical vs. biological optimization aimed at dose escalation
based on co-registered F-MISO sub-volumes.
Materials/Methods: Five patients with locally advanced SCC of the head and neck, with a co-registered F-MISO PET scan were
included in this planning study. Optimized IMRT plans deliverable on Elekta Synergy, using step and shoot, via 7 equispaced
beams, were generated utilizing standard IP IMRT (CMS XiO), with a simultaneous integrated boost to GTV, high risk CTV
and low risk CTV to 70, 63 and 56 Gy, respectively. Dose to co-registered FMISO sub-volumes were incrementally increased
to 85 Gy. All patients were replanned utilizing BCF and Monte Carlo dose computation (CMS Monaco) and plan comparisons
undertaken.
Results: With the standard 70 Gy prescription, BCF based planning achieved significantly improved OAR sparing compared with
IP optimization. Mean spinal cord maximum decreased from 42.8 to 36.9 Gy (m =13.7%, s = 3.92, range, 9.2 to 18.7 %) and brain
stem from 36.9 to 29.5 Gy (m = 20.1%, s = 31.44, range, -16.9 to 68.8%). Right parotid mean reduced from 28.6 to 25.6 Gy (m =
10.6%, s = 12.77, range of -6.4 to 25.6%) and left parotid mean from 22.6 to 21.1 Gy (m = 6.6%, s = 8.85, range, -6.3 to 15.7%).
V30 of right parotid (m = 13.6%, s = 15.88, range, -8.6 to 31.3%) and left parotid (m = 22.6 % s = 11.26, range, 10.5 to 40.6%) also
presented considerable dose avoidance. Larynx V50 revealed substantial reduction (m = 55.8%, s = 7.03, range, 50.6 to 63.8%) in
patients where GTV excluded larynx. 85 Gy dose escalation was achieved with comparable OAR sparing using BCF planning that
was unachievable with IP optimization.
Conclusions: Biological modeling delivers significant benefits in head and neck IMRT plan optimization. Improved solutions and
associated dose distributions were achieved in this patient cohort, in the context of the standard prescription and dose escalation to
the FMISO sub-volume. Target coverage and OAR sparing was superior with BCF based optimization. Whilst there is a lack of
consensus regarding the utility of F-Miso data in establishing a consistent localization of actual radiation resistant sub-volumes, it
offers a useful model for dose escalation studies.
Author Disclosure: N.J. Anderson, None; M. Wada, None; C. Lawford, None; M. Rolfo, None.

2484

Radiation Dose Volume Effects of the Optic Nerves and Chiasm

C. Mayo1, M. K. Martel2, L. B. Marks3, J. Flickinger4, J. Kirkpatrick5

University of Massachusetts Medical Center, Worcester, MA, 2M.D. Anderson Cancer Center, Houston, TX, 3University of
North Carolina, Chapel Nill, NC, 4University of Pittsburgh, Pittsburgh, PA, 5Duke University Medical Center, Durham, NC
1

Purpose/Objective(s): Visual impairment from radiation induced optic neuropathy (RION) is an uncommon sequela to radiation
therapy. Incidence is related to dose, dose per fraction and other factors. As part of the QUANTEC effort, we analyzed published
studies for consensus on predictors of RION in the ranges of conventional, hypo-fractionation and SRS radiation therapies.
Materials/Methods: The literature was searched for publications relating radiation toxicity of the optic nerves and chiasm to quantitative dose and dose-volume measurements of those structures for fractionations ranging from conventional to SRS. Results from
these authors were inter-compared to seek consensus on predictors of RION. Agreement of models with findings was examined.
Results: Twenty two studies were identified. Average follow-up was 42 and 50 months for studies with and without incidence of
RION, respectively. The interval between RT and development of visual symptoms was generally # 3 years (mode 11.5 years,
median 2.5 years). Most conventional fractionation (1.82.0 Gy/fx) studies were carried out prior to routine use of CT based treatment planning significantly limiting detailed examination of dose-volume response. It was also not possible to asses the impact of
IMRT dose gradients on tolerance. Incidence of RION was unusual for Dmax doses \ 55 Gy, particularly for fraction sizes less
than 2 Gy. The risk rose (310%) in the region 5559 Gy and became more substantial (. 20%) for doses . 60 Gy when fractionations of 1.82.0 Gy were used. For particles, most authors found that incidence of RION was low for Dmax dose \ 54 CGE.
One exception to this range was for pituitary tumors, where authors used constrained Dmax doses \ 46 Gy for 1.8 Gy/fx. For
single-fraction SRS the studies indicated the incidence of RION was rare for Dmax\8 Gy, rose in the region 812 Gy and became

Proceedings of the 51st Annual ASTRO Meeting

.10 % in the range of 1215 Gy. There was consistent agreement on low risk of RION for Dmax # 10 Gy, and one major study
indicated low risk for Dmax # 12 Gy. BID treatment data and models indicate significantly larger tolerance at low dose per fraction. Risk increased significantly with age in studies examining the effect; more than doubling from 2050 to 5070 year groups.
Data on other clinical factors such as chemotherapy, diabetes mellitus and hypertension were inconsistent. Linear quadratic models
were inadequate for connecting RION dose thresholds for conventional fractionation to SRS fractionations. Models based on the
RET or Neuret showed better agreement.
Conclusions: Collaborative research studies are needed to quantify IMRT dose-volumes safely tolerated above 55 Gy and to guide
hypo-fractionated treatment protocols. Improving consistency within and among institutions in defining the optic nerves and chiasm is important for accurate determination of dose thresholds and dose-volume effects.
Author Disclosure: C. Mayo, None; M.K. Martel, None; L.B. Marks, None; J. Flickinger, None; J. Kirkpatrick, None.

2485

Cisplatin 30 Mg/M2/Week Decreases Toxicity without Sacrificing Efficacy in Patients Treated with
Concomitant Chemoradiotherapy for Locally Advanced Squamous Cell Carcinoma of the Head and Neck

H. E. Newlin, R. J. Amdur, C. Riggs, R. W. Hinerman, B. Chera, W. M. Mendenhall

University of Florida Shands Cancer Center, Gainesville, FL
Purpose/Objective(s): Toxicity is considerable with the standard chemotherapy regimen of cisplatin 100mg/m2 every 3 weeks
during radiotherapy (RT). We hypothesized that changing the chemotherapy regimen to a weekly dose of cisplatin 30 mg/m2 would
decrease toxicity without compromising efficacy in patients with locally advanced squamous cell carcinoma (SCC) of the head and
neck.
Materials/Methods: The study population included 121 patients with AJCC Stage II (3%), Stage III (13%), or Stage IV (84%)
SCC of the oropharynx (70%), hypopharynx (20%), or larynx (10%) treated from June 2000 to December 2006 at the University
of Florida with altered fractionation RT and concomitant cisplatin given as a once-weekly infusion of 30mg/m2. The median RT
dose was 72.4 Gy given with either twice-daily fractionation (45%) or the concomitant boost (55%) technique. IMRT was used in
each patient treated with the concomitant boost technique. Our endpoints were: analysis of acute and late toxicities, local-regional
control (LRC), disease-free survival (DFS), cause-specific survival (CSS), distant metastases (DM), and overall survival (OS).
Results: The minimum follow-up for all patients was 2 years. Seventy-nine percent of patients were able to complete at least 6
cycles of chemotherapy. Ninety-five percent of patients received RT to at least 72 Gy. The 5-year actuarial outcomes were:
LRC, 79%; CSS, 76%; DM, 12%; and OS, 59%.
Our toxicity rates (listed below) were lower than those reported for RTOG 9914 and 01291,2:
G-tube rate at the end of treatment: 52% (vs. 83% and 64%)1,2
G-tube rate at 1 year: 3% (vs. 41% and 30%)1,2
CTC Grade 4 late complications: 6% (vs. 16% and 20%)1,2
CTC Grade 5 (fatal) toxicity: 2% (the same as seen in RTOG studies) 1,2
Conclusions: Our data suggests that, compared to more intensive regimens, weekly cisplatin at 30 mg/m2 decreases toxicity without compromising tumor control in patients who receive concomitant chemo-RT for SCC of the head and neck. These results need
to be confirmed in prospective studies.
1. Garden AS, Harris J, Trotti A, Jones CU, Carrascosa L, Cheng JD, Spencer SS, Forastiere A, Weber RS, Ang KK. Long-term
results of concomitant boost radiation plus concurrent cisplatin for advanced head and neck carcinomas: a phase II trial of the radiation therapy oncology group (RTOG 99-14). Int J Radiat Oncol Biol Phys. 2008 Aug 1;71(5):13515.
2. A phase III trial to compare standard versus accelerated fractionation in combination with concurrent cisplatin for head and
neck carcinomas (RTOG 0129): Report of compliance and toxicity. K. Ang, T. Pajak, D.I. Rosenthal, F. Nguyen, C. Lu, H. Kim, R.
Axelrod, M. List, C. Silverman, R.S. Weber. ASTRO 2007 abstract. pages S12S13.
Author Disclosure: H.E. Newlin, None; R.J. Amdur, None; C. Riggs, None; R.W. Hinerman, None; B. Chera, None; W.M. Mendenhall, None.

2486

Plaque Radiotherapy for Juxtapapillary Choroidal Melanoma: Visual and Systemic Outcomes

K. Turaka1, C. L. Shields1, M. Sagoo2, J. A. Shields1

1

Wills Eye Institute, Philadelphia, PA, 2Moorefields Eye Hospital, London, United Kingdom

Purpose/Objective(s): Management of choroidal melanoma adjacent to optic disc (juxtapapillary) is challenging due to the posterior tumor location, difficulty in localization and complexity of radiation field design. Various methods used to treat these tumors
have included enucleation, proton beam radiotherapy, plaque radiotherapy, stereotactic radiotherapy and transpupillary thermotherapy (TTT). The Collaborative Ocular Melanoma Study (COMS) excluded treatment of lesions within 2 mm of the optic
disc. We report the outcomes of treatment of juxtapapillary melanoma with plaque radiotherapy.
Materials/Methods: This was a retrospective, non-comparative review of 520 consecutive cases of juxtapapillary choroidal melanoma treated with custom designed plaque radiotherapy. The variables taken for analysis included the final visual acuity, radiation
complications, recurrence of tumor, need for enucleation, systemic metastasis and mortality.
Results: The median age at presentation was 51years (range, 15 93 years). The most common presenting symptoms were reduced
visual acuity (51%), photopsia (10%) and visual field defect (13%). Optic disc overhang by tumor was absent in 389 eyes (75%),
1% to 50% overhang in 83 (16%) and 51% to 100% overhang in 48 (9%). The quadrantic location of the main tumor was superior in
146 (28%) eyes, inferior in 114 (22%), nasal in 137 (26%) and temporal in 123 (24%). The median tumor basal diameter was 9.5
mm (range, 1.520 mm) and thickness 3.5 mm (range, 1.0 14.8 mm). The radioactive isotopes used were Iodine 125 in 504 eyes
(97%), cobalt 60 in 8 (2%) and iridium 192 in 8 (2%). The plaque shape was notched in 471 eyes (91%), round in 42 eyes (8%) and
rectangular in 7 (1%). The median radiation dose to the apex of the tumor was 8000 cGy, and to the base was 28,500 cGy. KaplanMeier analysis at 2, 5 and 10 years showed poor visual acuity (# 20/200) in 21%, 55%, and 84%; visual loss of more than 5 acuity

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