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CARBON ION THERAPY FOR SACRAL CHORDOMAS

CTOS 14 th Annual Meeting November 13-15, 2008 London UK. CARBON ION THERAPY FOR SACRAL CHORDOMAS. Tadashi KAMADA, MD Research Center for Charged Particle Therapy National Institute of Radiological Sciences Chiba, JAPAN. Bragg peak.

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CARBON ION THERAPY FOR SACRAL CHORDOMAS

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  1. CTOS 14th Annual Meeting November 13-15, 2008 London UK CARBON ION THERAPY FOR SACRAL CHORDOMAS Tadashi KAMADA, MD Research Center for Charged Particle Therapy National Institute of Radiological Sciences Chiba, JAPAN

  2. Bragg peak Carbon beam has a definite range and the Bragg peak.In addition to this physical selectivity, ionization is enormous at the Bragg peak, and showing biological advantages such as cell cycle independent effect. Therefore, carbon beam could be a potentially curable armament for radio-resistant tumors such as chordoma.

  3. Carbon ion therapy for chodoma : Background & Material Surgery is the mainstay of treatment for chordomas. However, complete excision is frequently difficult in S2 or higher lesions without severe functional loss. On the other hand, chordoma shows minimal response to radiation or chemotherapy. • Between 1996 and 2007, 95 patients with sacral chordoma were included in the phase I/II (Kamada, JCO 2002) and phase II (Kamada, JCO 2008) study of carbon ion therapy for bone and soft tissue sarcomas.

  4. Patients Characteristics No. of Pts : 95 sacral chordma Gender : 68 males / 27 females Age : 30 - 85(median65) Presentation : 84 primary / 11 post op rec Tumor Diameter : 3～17 cm （Median：9 cm） Tumor Volume : 47～1497 cc （Median：370 cc） (From Jun 1996 to Feb 2007)

  5. Sacral Chordoma : Level of Invasion L5 10 S1 29 S2 29 S3 9 S4~ 7 Post op rec 11 More than 80 % were S2 or higher level lesions

  6. 30% 96% 50% 90% 10% Carbon ion Dose Distribution in Sacral Chordoma 代表的なものに変更 Bowels were spared ! With 3 ports; right-left, left-right anterior-posterior(patch) With 3 ports; right-left, left-right, posterior-anterior Carbon ion therapy - all 16 Fractions over 4week Total dose: 52.8-64GyE : 2, 70.4GyE : 86, 73.6GyE : 7 (3.3-4.6GyE/fr.) Number of port : Two ports : 2 , Three ports : 91, Patch : 2

  7. 1.0 0.9 0.8 0.7 Probability 0.6 0.5 0.4 0.3 0.2 0.1 0.0 0 12 24 36 48 60 72 84 96 108 120 Months Overall Survival and Local Control after Carbon Ion Therapy in Sacral Chordoma 5 year LC: 88 % 5 year OS: 86% Sacral Chordoma 95 patients Median survival time 42 mo (13-112) Median time to local failure 35 mo(13-60)

  8. Radiation Morbidity Acute grade No. 0 1 2 3 4 5 Skin 95 0 81 11 3 0 0 GI tract 95 93 2 0 0 0 0 Late grade No. 0 1 2 3 4 5 Skin 95 0 86 5 2* 2* 0 GI tract 95 94 1 0 0 0 0 *receiving TD of 73.6GyE However, 15 patients required persistent medication for peripheral neuropathy in this series.

  9. 25 (ml) Severe Moderate None-slight 20 15 10 5 0 0 10 20 30 40 50 60 70 80 (GyE) DVHs of 44 Sciatic Nerve According to the Sciatic Symptoms in 22 patients with Sacral Chordoma DVH (n=44) 70GyE and 10cm Volume This slide shows DVHs of 44 sciatic nerves in 22 patients with sacral chordoma receiving total dose of 70.4 to 73.6 GyE followed more than 2 years. We found that length of more than 10cm, and a total dose of 70GyE could be a critical point for sciatic nerve outcome. Now, we give 67.4GyE for sacral chordoma.

  10. Carbon Ion Radiotherapy for Sacral Chordoma (S2, 65 yo, Male) Before treatment 66 months after, no neurological deficit, and spending normal life 60 m after 70.4 GyE

  11. Sacral Chordoma (S1) 57yo Female C- Ion RT 70.4GyE/16Fr/4wks CTV:991cc 54 months after Dose distribution Before treatment • Alive no evidence of re-growth of tumor and ambulant. • Working as a housewife with slight urinary incontinence

  12. Local Control and Survival Rate in Chordoma No. Site treatment Local Survival of Pts. 5-year 5year 10year (new pts /y) MGH 1) 21 S surgery 77% - 50% 1972-1992 (1.1) Sweden 2) 39 S+Sp surgery 44 84% 64 1963-1998 (1.1) MGH. 3) 27 S surgery 72 82 62 1982-2002 (2.7 ) + Proton LBL 4) 14 S surgery 55 85 22 1977-1989 (1.2 ) + He-ion Mayo 5) 52 S surgery 56 74 52 1980-2001 (2.5 ) NIRS 95 S C-ion 88 86 - 1996-2007.2(9 ) S:sacrum Sp:mobile spine (disease free) 1) J Bone Joint Surg. 1998 2) Cancer.2000 3)IJROBP.2006 4) IJROBP.1993 5) J Bone Joint Surg. 2005

  13. Summary • Five years overall survival rate (86%) and Local control rate (88%) in patients with sacral chordoma treated by carbon ion therapy are similar to or even better than those in reported data on patients treated by surgical resection. • Four patients treated with a total dose of 73.6 GyE experienced Grade 3/4 skin complications. No other treatment-related surgical interventions including colostomy or urinary diversion were carried out.

  14. Carbon ion therapy is suggested to be an effective and safe treatment for sacral chordomas and could be a promising alternative to surgery. In Conclusion

  15. Carbon ion therapy--New horizon in cancer treatment

  16. C-ion Rx 80.0GyE / 16 F No pain No bleeding No wound No anesthesia 6 years after RCC：55yo Male Before IJROBP. 2008

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