The Evolution of Radiation for H&N Rhabdomyosarcoma Parag Sanghvi Department of Radiation Medicine September 20 2006
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Transcript The Evolution of Radiation for H&N Rhabdomyosarcoma Parag Sanghvi Department of Radiation Medicine September 20 2006
The Evolution of Radiation for
H&N Rhabdomyosarcoma
Parag Sanghvi
Department of Radiation Medicine
September 20 2006
Objectives
Background
Role of Radiation in Orbital and Parameningeal
RMS
IRS IV – Radiation
IRS V – Impact of radiation dose reduction
Rhabdomyosarcoma
Highly malignant neoplasm arising from
embryonal mesenchyme
With capacity for skeletal muscle differentiation
Intergroup Rhabdomyosarcoma
Study Group
COG, CCG, POG
IRS I (1972 – 1978)
IRS II (1978 – 1984)
IRS III (1984 – 1991)
IRS IV (1991 – 1997)
IRS V (1998 – present)
OS 55%
OS 63%
OS 71%
OS 71%
Epidemiology
Most common pediatric STS (approximately 50%)
3.5% of all malignancies under age of 15; 2% of all
malignancies in 15-19 age group
90 % of all RMS in individuals < 25 years; 60-70% in
<10 years
Peak age 2- 5 years
Incidence in US – 250 cases / year
Male preponderance (1.4:1)
Racial predisposition (White children 4 times as likely as
black children)
Epidemiology
1/3 of RMS patients have other congenital
abnormalities
GI, GU, CV, CNS
Majority of cases are sporadic; but some are
associated with genetic conditions
Li Fraumeni (p53 mutation)
NF 1
Beckwith - Wiedemann
Prognostic Factors
Histology
Stage
Primary site (most important prognostic factor)
Tumor Size
LN involvement (especially in extremities)
Metastatic disease
Group
Extent of resection
Age
< 1 and alveolar histology
>10
Skull base erosion, CN palsy, Intracranial extension
Histology
Gross disease
Soft, fleshy tumors with variation in the extent of
invasion and necrosis
IHC stains to ascertain muscle of origin
Antidesmin, antivimentin, anti-muscle specific actin
Anti-Myo D Ab
Histology
Embryonal
Most common
60-70% of all childhood RMS
H&N, GU sites
Intermediate prognosis
Boytroid
Subtype of embryonal
10% of all childhood RMS
Bladder, vagina, nasopharynx,
nares, middle ear, biliary tree
Superior prognosis
Spindle cell
Subtype of embryonal
Most common site is
paratesticular
Superior Prognosis
Alveolar
20% of RMS
More common in adolescents
Tumors involving extremities,
trunk, perianal and perineal
Undifferentiated
Diagnosis of exclusion
Previously called pleiomorphic
Rare in children, more common
in adults
Histology and Survival
Histology and Survival
Staging (based on IRS – V)
Stage I
Sites
Orbit
H&N (excluding parameningeal)
GU (non-bladder, non-prostate)
Biliary tract
Tumor invasiveness: T1 or T2
Tumor Size: a or b
Lymph node status: any N
Metastasis: M0
(T1: confined to anatomic site of origin; T2: extension; a: <5 cm in diameter; b:
>5 cm in diameter; N0: no clinically involved LN; N1: clinically involved LN;
M1: metastasis present)
Stage II
Stage II
Stage II
Sites
Parameningeal
Nasopharynx/Nasal Cavity
Middle Ear and Mastoid
region
Paranasal Sinuses
Infratemporal fossa
Pterygopalatine fossa
Parapharyngeal space
Bladder or Prostate
Extremity
Tumor Invasiveness: T1
or T2
Tumor size: a
Lymph node status: N0 or
Nx
Metastasis: M0
Stages III & IV
Stage III
Sites: Same as Stage II
Tumor Invasiveness: T1
or T2
Tumor size and Lymph
Node status
a N1
b any N
Metastasis: M0
Stage IV
Sites: All
Metastasis: M1
Site of primary tumor
Site
Incidence
H& N (non-PM)
10%
Parameningeal
16%
GU
22%
Orbit
9%
Extremities
18%
Other
25%
Lymph Node Metastasis
IRS I & II
Site
% LN Metastasis
Extremity
Upper
Lower
12%
16%
9%
GU
Paratesticular
Bladder
Prostate
26%
6%
5%
GYN
1%
H&N
Orbit
Other
6%
0%
8%
Group
Group I: Localized dz; completely resected
A. Confined to muscle or organ of origin
B. Outside infiltration
Group II: Gross Total Resection
A: With microscopic residual disease
B: Regional lymphatic spread, resected
C: Both
Group
Group III: Incomplete resection with gross
residual disease
A: After biopsy only
B: After major resection (more than 50%)
Group IV: Distant metastases @ diagnosis
Group
Group
Incidence
I
16%
II
20%
III
48%
IV
16%
Histology, Stage and Group vs. Survival
Cytogenetics
Alveolar Rhabdomyosarcoma
T(2,13)(p35;q14)
70% of all alveolar RMS
Fuses PAX3:FKHR
T(1,13)(p36:q14)
20% all alveolar RMS
Fuses PAX7:FKHR
Occurs in younger children, better prognosis
Genomic amplification
MDM2, CDK4
Near-tetraploidy
Cytogenetics
Embryonal
Rhabdomyosarcoma
Loss of heterozygosity at
11p15.5
Loss of amplification
Hyperploidy
Cell cycle control
Myogenesis = Mesenchymal
fibroblast Skeletal muscle
Controlled by MyoD protein
family (Myogenin, MYF5,
MYF6)
Can stain RMS cells with antiMyoD Ab
Tumor Suppressor
Genes
P53 mutation
Protooncogenes
N-myc amplification
Especially seen in
alveolar histology
The Role of Radiation Therapy in
Orbital and Parameningeal
Rhabdomyosarcoma
Orbital RMS
Orbital RMS
9% of all RMS
Most common single
H&N site
Usually diagnosed early;
presents with eye
swelling, globe
displacement
2/3 of cases are Group
III
Can invade meninges via
SOF
84% Embryonal; 10%
Alveolar
5 y OS for Embryonal
94%; for Alveolar 74%
Histology and Survival
Historical management
Orbital Exenteration was standard treatment until
mid 1960s
High rate of local failure
Poor survival
Late 1960s, Cassady et al. showed that RT after
biopsy offered local control in 4/5 patients
Orbital RMS
IRS I
Group I patients randomized to VAC +/- RT
Group II VA + RT +/- C
Group III/IV VAC + RT +/- Adriamycin
Pts with Group II or III disease 85-94% OS @ 6 years
5 y OS 89%; 3/6 deaths 2/2 other causes
Complete or Partial surgical excision no longer recommended
standard of care
Orbital RMS
IRS II
Group I VA or VAC (no RT)
Group II VA + RT +/- C
Group III VAC +RT +/- Adriamycin
No improvement in any of the more intensive
chemotherapy arms
OS/FFS better in all arms compared to IRS I
Orbital RMS
IRS III
Group I VA only
Groups II and III, VA +RT
No difference in OS or FFS compared to IRS II
3 y/o FFS 92% and OS 100%
IRS IV
Group I VA only
Group II VA + CD RT
Group III VAC vs. VAI vs. VIE AND CD RT vs. HF XRT
RT doses 50.4 Gy vs. 59.4 Gy
Groups I & II pts. 3 y FFS 91%, OS 100% (no change
compared to IRS III
Orbital RMS
IRS IV
Group III, 3 y FFS 94%, OS 98%
No difference in the 3 chemotherapy arms or the 2 RT arms
However, when compared to IRS III, pts. with 3 drug
chemotherapy regimens did better than VA regimen
IRS V
Due to concern for treatment related toxicities
Chemotherapy C/I/E dropped; back to VA
RT dose decreased to 45 Gy
SIOP MMT 84 trial
Evaluated eliminating radiation in Group II/III patients
34 patients treated initially with VA alone
RT reserved for those who did not achieve a complete
response
22 patients initially did not get radiation 11 failed
locally
10/11 salvaged with RT + chemotherapy
3/11 developed distant mets 2 died
4 y/o EFS 62%; 4y/o OS 84%
Orbital RMS
Conclusions
Total surgical extenteration no longer standard of care
Chemotherapy alone in Group I patients is effective
Chemo + RT for Group II and III patients
Future trend for RT
Dose reduction
Electrons, Protons
IMRT treatment planning
Parameningeal RMS
R infratemporal
mass invading
through the
petrous bone
Parameningeal RMS
L Ear
Parameningeal RMS
16 % of all RMS
41 % of all H&N RMS
Most cases in children < 8 -10 years of age
Can extend intra-cranially and produce
neoplastic meningitis (35% of all PM RMS)
<20% have LN involvement (IRS III)
Most have favorable histology (Embryonal:
Alveolar 4:1)
Parameningeal RMS
Meningeal penetration and leptomeningeal
tumor cell seeding must be assessed
Complete surgical extirpation almost never
possible
76% are Group III (IRS III)
Hence, surgery is generally either a biopsy or
subtotal resection
Parameningeal RMS - Sites
Nasal Cavity/Nasopharynx/Paranasal Sinuses
can invade through basal foramina, sinus
roofs
Middle Ear can extend through tegmen
tympani into the middle cranial fossa or through
posterior mastoid into the posterior cranial fossa
Parapharyngeal space
Pterygopalatine / Infratemporal fossa
PM RMS
IRS I
3 y PFS 46%
Orbit 91 %
Non-PM H&N 75%
Meningeal extension occurred in 35% of cases at a
median time of 5 months after diagnosis
Meningeal extension was likely fatal 90%
Associated with inadequate margins and doses < 50 Gy
PM RMS – IRS II -III
IRS II
Increase field size to sequential CSI for patients with any
meningeal extension
Local + WBRT – Wk 0
Spinal RT – Wk 6
Dose age and tumor size dependent
40 –55 Gy
IRS II (1980 – 1984) and IRS III (1984 – 1987)
Omit spinal irradiation; WBRT for any meningeal extension
Start @ Wk 0
Dose age and tumor size dependent
41.4 – 50.4 Gy
PM RMS – IRS IV
IRS IV Pilot (1987 –1991)
Local XRT for CNP or CBBE – Wk 0
WBRT for ICE – Wk 0
IRS IV (1991 – 1997)
Local XRT for any meningeal extension
Dose
For Group III disease, RT question was about
hyperfractionation
59.4 Gy (1.1 Gy bid) vs. 50.4 Gy
PM RMS – IRS II - IV
CSI
WBRT
IF/WBRT IF
PM RMS – IRS II - IV
Primary Site
Primary Site and Meningeal
Involvement
Prognostic Factors – 5 y FFS
Age
<1
1-9
10+
Meningeal Involvement
46%
73%
54%
Primary Site
NP/NC
Ear/Mas
PPS
PNS
PPF/ITF
74%
73%
72%
57%
53%
None
CNP/CBBE
Any ICE
77%
65%
60%
Histology
Emb/Boy
Alv/Und
Other
70%
59%
65%
Tumor Size
<5 cm
>5 cm
71%
67%
5 y/o FFS & OS by Meningeal
involvement
5 y FFS and OS by Histology and
Meningenal Involvement
Timing of RT in patients with
meningeal involvement
35%
18%
5 y LFR – overall 20%; RT < 2 weeks – 18%; >2 weeks 35%
Timing of RT in patients with ICE
16%
37%
LF vs. FFS and Meningeal
Involvement
Local Failure by Radiation Dose
Did people really get WBRT?
Local Failure and Radiation Fields
23%
17%
CNS Failure and Radiation Fields
9%
9%
Multivariate analysis
Statistically significant worse prognostic factors
controlling for tumor size
Age > 10 (p = 0.002)
RT dose <47.5 Gy (p = 0.01)
Meningeal Impingement (p =0.001)
Timing of RT was NOT a significant factor
Conclusions
Availability of cross-sectional imaging improved
ability to diagnose ICE and hence led to better
treatment planning and earlier delivery of RT
Patients with tumors > 5 cm benefited from dose
> 47.5 Gy
WBRT not necessary to achieve high control
rates; but good planning is!
Timing of RT – impacted LF rates but not FFS;
not significant on multivariate analysis
Background
IRS II and IRS III showed local relapse rate of 16% and
LR relapse rate of 32 % respectively in Group III
patients
RCT comparing hyperfractionation vs. conventional
fractionation in Group III patients
Hyperfractionation = More than 1 fraction a day
Goal to improve LCR by 10% without increasing late
side effects
Rationale based on 10-15% improvement seen in LRC
in other H&N cancers in adults with HF
Criteria / Treatment Logistics
Stage 1, 2, and 3 and Group III patients
CF = 50.4 Gy in 1.8 Gy/fraction given daily
HF = 59.4 GY in 1.1 Gy/fraction given bid
atleast 6 hours apart
Pre-op/Pre-chemo volume + 2 cm margin
RT started week 9 or week 0 if cord compression
or any meningeal involvement
Results – OS and FFS
FFS – CF vs. HF
5 y Failure Rates
Conclusion
Hyperfractionation did NOT improve local,
regional or distant control over conventional
fractionation for Group III tumors
IMRT
IMRT
The next step in radiation treatment planning after 3D
Inverse planning with computer-assisted optimization
Dose painting
Sharp dose fall off outside target volume with selective
avoidance of critical structures and tissues
Multiple Fields
Dose modulation within each field
Better immobilization, longer treatment time
IMRT
IMRT
Patient Characteristics
28 patients
21 parameningeal, 3 orbit, 4 other H&N
7% Group II, 89% Group III, 4% Group IV
21% Stage I, 21% Stage 2, 54% Stage 3, 4% Stage
4
57% Embryonal, 32% Alveolar, 11% Undifferentiated
Median RT dose 50.4 Gy (41.4 – 55.8 Gy)
Median F/U 2 years
Results
3 y/o LCR
Orbit 100%
Non PM H&N 100%
PM 95%
1 patient with Stage IV
failed
Alveolar/paranasal sinus
Local/Regional/Distant
mets irradiated
Failed Locally
3 y/o RCR
Overall 93%
Orbit 100%
Non PM H&N 100%
PM 93%
3 y/o DFS
Overall 65%
PM 60%
Other sites 80%
Histology and Survival
ICE and Survival
IRS V
Low Risk
Sub-group A
Histology: Embryonal / Boytroid
Stage 1, Groups I, II(N0)
Stage 1, Group III(N0) Orbit only
Stage 2, Group I(N0)
Low Risk
Subgroup B
Histology: Embryonal /Boytroid
Stage 1, Grp II (N1) – microscopic residual dz.
Stage 1, Grp III (N1) orbit only – gross residual dz.
Stage 1, Grp III (N0 or N1) – gross residual dz.
Stage 2, Grp II (N0) – microscopic residual dz, 5cm primary
Stage 3, Grp I or II (N0 or N1) - 5cm with + LN or > 5cm
primary regardless of LN status, - margins or microscopic
residual dz.
Rationale
5 y OS (IRS – IV) 90-95%
5 y FFS 78-89%
Primary site, Tumor size and T stage were not
prognostic
Rationale
Rationale
IRS V
Low Risk - D9602
Low Risk – Orbit (Embryonal /Boytroid)
VA chemotherapy
RT starts @ week 3
Low Risk – PM (Embryonal/Boytroid)
Chemotherapy: Group I VA, if Stage 3 or Group II
VAC
RT starts @ week 3
Patient Characteristics
Stage 1, Group IIA
XRT dose reduction from IRS IV
41.4 Gy 36 Gy
60 pts accrued
VA Chemotherapy
Decrease in FFS/OS currently attributed to less
chemotherapy when compared to IRS IV
Outcomes - Subgroup A
Stage 1 Group IIA
Subgroup A – Stage 1 Group III Orbit
77 patients assigned to VA therapy and reduced RT dose
XRT dose reduced from 50.4 /59.4 from IRS IV to 45 Gy
10 relapses (all had a local failure component); 3 deaths
FFS and OS @ 3 years – 88% and 97%
The decrease in FFS/OS in IRS V compared to IRS IV
partly attributed to less chemotherapy
It is similar to results from IRS III with VA chemotherapy
Outcomes – Subgroup A
Orbit
Subgroup B – Stage 2/3 Group IIA (N0)
16 patients accrued; treated with VAC
chemotherapy and reduced dose RT
RT dose reduced from 41.4 Gy 36 Gy
No impact on FFS with reduced dose RT
Subgroup B – Stage 2/3 Group IIA (N0)
Intermediate Risk – D9803
Chemotherapy
Randomizes patients to VAC vs. VTC
T – Topotecan
Topoisomerase I inhibitor
S – phase specific
Orbit – Alveolar/Undiff
H&N (non-PM, non Orbit)
H&N PM – Grp III (all histologies)
High Risk – D9802
PM RMS – Stage IV/Group IV
PM RMS – Stage IV/Group IV
Thanks
Acknowledgements:
Dr. Carol Marquez
Dr. John Holland
Dr. Charles Thomas