Simultaneous integrated boost by RapidArc therapy plus temozolomide for treatment of patients with glioblastoma multiform: A single institution experience
Purpose: The aim of this study is to report the treatment outcomes, toxicities, and dosimetric feasibility of simultaneous integrated boost by RapidArc (RA-SIB) compared with 3dimentional-conformal radiation therapy (3D-CRT) for patients with glioblastoma.
Methods: Eleven patients with unifocal glioblastoma (grade IV astrocytoma, WHO classification) were treated during the period from April 2011 until February 2013 with postoperative irradiation and concomitant temozolomide 75 mg/m2 followed by 6-12 months of adjuvant temozolomide 200 mg/m2 for 5 days/4weeks. One patient received temozolomide for 12 months, 5patients for 6 months, and 5patients did not receive adjuvant temozolomide. RA-SIB technique was used and patients received 46 Gy per fraction of 2 Gy in 23 sessions on the planning target volume (PTV1) (contrast enhancement + per-focal edema as seen in T2 MR + 2.3 cm) with concomitant daily superimposed boost (SIB) on PTV2 corresponding to the contrast enhancement + 2.3 cm. The treatment outcomes and toxicity were assessed. Dose Volume Histogram DVH analysis was performed between SIB-RA and 3D-CRT plans of each patient. For the PTV, the comparison parameters included, the mean dose, the standard deviation, maximum dose, conformity index (CI), and homogeneity index (HI).
Results: The median progression free survival (PFS) and overall survival (OS) were 13 months (95% CI, 8.2-17.8), and 16 months (95% CI, 2.1-29.9) respectively. Four of six patients (67%) showed local progression (recurrence) after initial response, all recurrences occurred at the site of PTV2. Seven patients experienced acute grade 1-2 toxicities during the treatment. Late post radiation brain edema was reported in 3 patients.
Conclusion: The SIB-RA did not prove the superiority in survival outcomes compared with the historical data using 3D-CRT. From the dosimetric standpoint, SIB-RA is a superior technique with respect to 3D-CRT when there are overlaps between organs at risk (OARs) and PTV.
Stupp R, Mason WP, van den Bent MJ, et al. Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. N Engl J Med. 2005; 352:987-96.
Wong ET, Hess KR, Gleason MJ, et al. Outcomes and prognostic factors in recurrent glioma patients enrolled onto phase II clinical trials. J Clin Oncol.1999; 17:2572-8.
Withers HR, Taylor JM, Hu Z. A comparison of mathematical models for regeneration in acutely responding tissues. Int J Radiat Oncol Biol Phys. 1988; 15:1389-400.
Mohan R, Arnfield M, Tonq S, et al. The impact of fluctuations in intensity patters on the number of monitor units and the quality and accuracy of intensity modulated radiotherapy. Med phys. 2000;27: 1226-37.
Fu KK, Pajak TF, Trotti A, et al. A Radiation Therapy Oncology Group (RTOG) phase III randomized study to compare hyperfractionation and two variants of accelerated fractionation to standard fractionation radiotherapy for head and neck squamous cell carcinomas: first report of RTOG 9003. Int J Radiat Oncol Biol Phys. 2000;48:7-16.
Bentzen SM, Saunders MI, Dische S. From CHART to CHARTWEL in non-small cell lung cancer: clinical radiobiological modeling of the expected change in outcome. Clin Oncol (R Coll Radiol). 2002;14:372-81.
Cozzi L, Fogliata A, Bolsi A, Nicolini G, Bernier J: Three-dimensional conformal vs. intensity-modulated radiotherapy in head-and-neck cancer patients: comparative analysis of dosimetric and technical parameters. Int J Radiat Oncol Biol Phys. 2004; 58:617-24.
Grills IS, Yan D, Martinez AA, et al. Potential for reduced toxicity and dose escalation in the treatment of inoperable non-small-cell lung cancer: a comparison of intensity-modulated radiation therapy (IMRT), 3D conformal radiation, and elective nodal irradiation. Int J Radiat Oncol Biol Phys. 2003; 57:875-90.
Selvaraj RN, Beriwal S, Pourarian RJ, et al. Clinical implementation of tangential field intensity modulated radiation therapy (IMRT) using sliding window technique and dosimetric comparison with 3D conformal therapy (3DCRT) in breast cancer. Med Dosim. 2007;32:299-304.
Pinkawa M, Siluschek J, Gagel B, et al. Postoperative radiotherapy for prostate cancer: evaluation of target motion and treatment techniques (intensitymodulated versus conformal radiotherapy). Strahlenther Onkol. 2007; 183:23-9.
Pinkawa M, Attieh C, Piroth MD, et al. Dose-escalation using intensity-modulated radiotherapy for prostate cancer--evaluation of the dose distribution with and without 18F-choline PET-CT detected simultaneous integrated boost. Radiother Oncol. 2009; 93:213-9.
Chan MF, Schupak K, Burman C, et al. Comparison of intensity-modulated radiotherapy with three-dimensional conformal radiation therapy planning for glioblastoma multiforme. Med Dosim. 2003; 28:261-5.
Narayana A, Yamada J, Berry S, et al. Intensity-modulated radiotherapy in high-grade gliomas: clinical and dosimetric results. Int J Radiat Oncol Biol Phys 2006; 64:892-7.
MacDonald SM, Ahmad S, Kachris S, et al. Intensity modulated radiation therapy versus threedimensional conformal radiation therapy for the treatment of high grade glioma: a dosimetric comparison. J Appl Clin Med Phys. 2007; 8:47-60.
Goswami B, Mitra S, Banerjee S, et al. RapidArc: Initial experience in high grade gliomas. International journal of radiation research 2013;11: 203-6.
NRG Oncology Group. RTOG Protocol 0825: Phase III double-blind placebo-controlled trail of conventional concurrent chemoradiation and adjuvant Temozolomide in patients with newly diagnosed Glioblastoma. Available at www.rtog.org/ClinicalTrials/ProtocolTable/StudyDetails. 6/12/2011
Shepard DM, Earl MA, Li XA, et al. Direct aperture optimization: a turnkey solution for step-and-shoot IMRT. Med Phys 2002; 29:1007–18.
Ataman F, Poortmans P, Stupp R, et al. Quality assurance of the EORTC 26981/22981; NCIC CE3 intergroup trial on radiotherapy with or without temozolomide for newly-diagnosed glioblastoma multiforme: the individual case review. Eur J Cancer. 2004;40:1724-30.
Chen YD, Fenq J, Fang T, et al. Effect of intensity-modulated radiotherapy versus three-dimensional conformal radiotherapy on clinical outcomes in patients with glioblastoma multiforme. Chin Med J. 2013; 126:2320-4.
Wagner D, Christiansen H, Wolff H, Vorwerk H. Radiotherapy of malignant gliomas: comparison of volumetric single arc technique (RapidArc), dynamic intensity-modulated technique and 3D conformal technique. Radiother Oncol. 2009;93:593-6.
Thilmann C, Zabel A, Grosser KH, et al. Intensity-modulated radiotherapy with an integrated boost to the macroscopic tumor volume in the treatment of high-grade gliomas. Int J Cancer. 2001;96:341-9.
Lorentini S, Amelio D, Giri MG, et al. IMRT or 3D-CRT in glioblastoma? A dosimetric criterion for patient selection. Technol Cancer Res Treat. 2013;12:411-20.
Cho KH, Kim JY, Lee SH, et al. Simultaneous integrated boost intensity-modulated radiotherapy in patients with high-grade gliomas. Int J Radiat Oncol Biol Phys. 2010;78:390-7.
Nakamatsu K, Suzuki M, Nishimura Y, et al. Treatment outcomes and dose-volume histogram analysis of simultaneous integrated boost method for malignant gliomas using intensity-modulated radiotherapy. Int J Clin Oncol 2008;13: 48-53.
Panet-Raymond V, Souhami L, Roberge D, et al. Accelerated hypofractionated intensity-modulated radiotherapy with concurrent and adjuvant temozolomide for patients with glioblastoma multiforme: a safety and efficacy analysis. Int J Radiat Oncol Biol Phys. 2009 Feb 1;73(2):473-8.
Sultanem K, Patrocinio H, Lambert C, et al. The use of hypofractionated intensity-modulated irradiation in the treatment of glioblastoma multiforme: Preliminary results of a prospective trial. Int J Radiat Oncol Biol Phys 2004; 58:247–52.
Rana S, Rogers K, Pokharel S, Cheng C. Evaluation of Acuros XB algorithm based on RTOG 0813 dosimetric criteria for SBRT lung treatment with RapidArc. J Appl Clin Med Phys 2014; 15:4474.
Ojala J. The accuracy of the Acuros XB algorithm in external beam radiotherapy – a comprehensive review. Int J Cancer Ther Oncol 2014; 2:020417.
Rana S, Rogers K. Dosimetric evaluation of Acuros XB dose calculation algorithm with measurements in predicting doses beyond different air gap thickness for smaller and larger field sizes. J Med Phys 2013; 38:9-14.
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