Emine Elif ÖZKAN, Zümrüt ARDA KAYMAK, İbrahim ÇOBANBAŞ, Şehnaz EVRIMLER, Mustafa KAYAN

EFFECT OF TARGET DELINEATION AND DOSE PARAMETERS ON LOCAL FAILURE PATTERN AFTER ADJUVANT RADIOTHERAPY IN GLIOBLASTOMA: EVALUATION OF EORTC AND RTOG GUIDELINES

Objective We aimed to investigate the correlation between dose distribution and relapse pattern in glioblastoma pa tients who underwent adjuvant radiotherapy (RT) and to discuss European Organisation for Research and Treatment of Cancer (EORTC) and Radiation The rapy Oncology Group (RTOG) guidelines commonly used for target volume delineation. Materials and Method Thirty-one consecutive glioblastoma patients who underwent adjuvant concomitant chemoradioterapy (temozolamide) after biopsy or surgical resection in our clinic between October 2011 and June 2018 were enrolled. Total dose of 60 Gy with 14 Gy boost af ter 46 Gy RT was given with 3 dimensional confor mal (3DCRT) in 22 patients and intensity modulated technique (IMRT) in 9 patients. All patients were ad ministered concomitant temozolamide 75 mg/m2/day. The MR images taken within 2 weeks before RT is considered as basal investigation. Recurrent lesions in control MR spectroscopy images within 2-3 months after RT were retrospectively contoured by a radio logist and fused with planning CT images. Increase in contrast enhancement and enhanced volume in T1 MR sequences or increase in edema in T2/FLAIR sequences is reported as progression. Recurrence is defined as new emerged lesions apart from resection cavity or known postoperative residual lesion. The fu sed images are evaluated dosimetrically to calculate D95 (Dose of %95 volume), D50 (Dose of %50 volu me), V%95 (volume receiving % 95 of planned dose) of recurrent area. Results Median age of patients was 59 (28 -78) years with a median survival of 17 (5 - 66) months in 17 (5 -64) months of median follow up. Median overall survival was found to be 17 (5 - 66) months. GTR, subtotal resection (STR) and biopsy were performed in 19, 10 and 2 patients respectively. All but one patient had re sidual mass in the postroperative images. During fol low up 1 patient progressed whereas 16 patient was stable. Recurrence was detected in 14 patients. Who le volume of recurred lesions was in PTV60 in 12 pa tients. In the remaining 2 patients, volume of recurrent lesion in PTV60 were 98.7 and 61.8 % respectively. Mean recurrent volume was found 11.14 (0.7 – 48) cc. The mean of maximum, minimum and mean do ses were 6246 cGy (6043 – 6439), 5805 cGy (3574 – 6098) and 6106 cGy (5906 – 6223) respectively. Conclusion In our study 95% of the recurrent lesions were in PTV 60. In our opinion, the contribution of 46 Gy to edema, especially for patients with a large operation cavity and residual lesion which could cause high normal tis sue toxicity is controversial. Therefore, single phase treatment is reasonable in these patients.

GLİOBLASTOMA OLGULARINDA HEDEF BELİRLENMESİ VE DOZ PARAMETRELERİNİN ADJUVAN RADYOTERAPİ SONRASI LOKAL NÜKS PATERNİ ÜZERİNE ETKİSİ: EORTC VE RTOG KILAVUZLARININ DEĞERLENDİRİLMESİ

Amaç Çalışmamızın amacı glioblastoma (GBM) tanısı ile adjuvan radyoterapi (RT) eş zamanlı temozolamid uygulanmış olan hastalarda nüks paterninin doz dağı lımı ile ilişkisinin değerlendirilmesidir. Buna ek olarak çalışma sonuçlarının ışığında GBM olgularında RT hedef belirlenmesinde kullanılan European Organisa tion for Research and Treatment of Cancer (EORTC) ve Radiation Therapy Oncology Group (RTOG) kıla vuzları tartışılması amaçlandı. Gereç ve Yöntem Kliniğimizde, biyopsi veya cerrahi eksizyon sonrası GBM tanısı almış ve Ekim 2011 – Haziran 2018 ta rihleri arasında adjuvan RT eş zamanlı temozolamid uygulanmış 31 hasta çalışmaya alındı. Radyoterapi 22 hastaya 3 boyutlu konformal, 9 hastaya ise yo ğunluk ayarlı RT tekniği ile 46 Gy (Faz I) sonrası 14 Gy boost (Faz II) olmak üzere toplam 60 Gy şeklinde uygulandı. Tüm hastalar RT eş zamanlı 75 mg /m2/ gün temozolamid aldı. Hastaların radyoterapi öncesi iki hafta içerisinde çekilmiş olan MR görüntüleri baz olarak alındı. Radyoterapi sonrası 2-3. ay veya son rasındaki kontrol T1 MR görüntülerinde operasyon kavitesi veya postoperatif rezidüel lezyonun kontrast tutulumunda artış, kontrast tutan volümde artış, T2/ FLAIR görüntülerde ödemde artış olan hastalar prog resyon olarak değerlendirilirken operasyon kavitesi veya postoperatif rezidüel lezyondan ayrı, yeni geli şen lezyonlar nüks olarak kabul edildi. Nüks lezyonlar uzman radyolog tarafından MR spektroskopi görüntü leri üzerine konturlandı. Bu görüntüler planlama CT görüntüleri ile füzyon yapılarak nüks lezyon alanının retrospektif dozimetrik değerlendirilmesi yapıldı. Do zimetrik incelemede nüks lezyon alanının maksimum, minimum ve ortalama dozları, D95(%95 inin aldığı doz), D50 (%50 sinin aldığı doz), V%95 (planlanan dozun %95 ini alan volüm) değerlendirildi. Bulgular Çalışmaya alınan 31 hastanın ortalama yaşı 59 yıl (28 -78) olup median takip süresi 17 (5 -64) aydır. Median genel sağkalım 17 (5 - 66) ay olarak bulundu. Ope rasyon 19 hastada GTR, 10 hastada STR şeklinde olup 2 hasta biyopsi ile tanı almış idi. Bir hasta hariç tüm hastalarda postoperatif MR görüntülerinde rezidü mevcut idi. Takip süresinde 1 hastada progresyon, 14 hastada nüks saptanırken 16 hastanın stabil olduğu gözlendi. Nüks olan 12 hastada lezyon %100 oranın da PTV60 içinde yer almakta iken kalan iki hastada bu oran sırasıyla %98.7 ve 61.8 idi. Ortalama nüks volü mü 11.14 (0.7 – 48) cc olarak bulundu. Nüks lezyon ların ortalama maksimum, minimum ve mean dozları, D95, D50, V%95 sırasıyla 6246 cGy (6043 – 6439), 5805 cGy (3574 – 6098) ,6106 cGy (5906 – 6223), 5941 cGy (4588 – 6162), 6123 cGy (6009 – 6217), 11,04 cc (0.7 – 48.37) idi. Sonuç Çalışmamızda rekürren lezyonların % 95 oranında PTV 60 içerisinde olduğu görüldü. Bu sonuç baz alın dığında, ödem alanını içeren hedef volüme faz I ola rak 46 Gy uygulanmasının katkısı tartışmalıdır. Özel likle operasyon kavitesi ve rezidü boyutu büyük olan ve normal doku toksistesinin yüksek olacağı öngörü len hastalarda tek fazlı tedavi tercih edilebilir.

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