CARBON ION THERAPY FOR SACRAL CHORDOMAS

CARBON ION THERAPY FOR SACRAL CHORDOMAS

Tadashi KAMADA, MD

Research Center for Charged Particle Therapy National Institute of Radiological Sciences

Chiba, JAPAN

CTOS 14th Annual Meeting November 13-15, 2008 London UK

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.

Bragg peak

Carbon ion therapy for chodoma : Background & Material 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.

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 c

c ） (From Jun 1996 to Feb 2007)

Patients CharacteristicsPatients Characteristics

L5 10

S1 29

S2 29

S3 9

S4~ 7

Post op rec 11

Sacral Chordoma : Level of Invasion

More than 80 % were S2 or higher level lesions

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

代表的なものに変更

96% 90% 50% 30% 10%

With 3 ports; right-left, left-right

anterior-posterior(patch) With 3 ports; right-left, left-right, posterior-anterior

Carbon ion Dose Distribution in Sacral Chordoma

Bowels were spared !

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

Pro

bab

ility

0 12 24 36 48 60 72 84 96 108 120Months

5 year OS: 86%

5 year LC: 88 %

Overall Survival and Local Control after Carbon Ion Therapy in Sacral Chordoma

Sacral Chordoma 95 patients

Median survival time 42 mo (13-112)

Median time to local failure 35 mo(13-60)

Radiation MorbidityRadiation 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

However, 15 patients required persistent medication

for peripheral neuropathy in this series.

*receiving TD of 73.6GyE

DVH (n=44)Severe

Moderate

None-slight

(ml)

(GyE)0

5

10

15

20

25

0 10 20 30 40 50 60 70 80

DVHs of 44 Sciatic Nerve According to the Sciatic Symptoms in 22 patients with Sacral Chordoma

Vo

lum

e

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.

70GyE and 10cm

Before treatment

60 m after 70.4 GyE66 months after, no neurological deficit, and spending normal life

Carbon Ion Radiotherapy for Sacral Chordoma (S2, 65 yo, Male)

Sacral Chordoma (S1) 57yo Female C- Ion RT 70.4GyE/16Fr/4wks

Dose distribution Before treatment 54 months after

•Alive no evidence of re-growth of tumor and ambulant.

•Working as a housewife with slight urinary incontinence

CTV:991cc

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% 641963-1998 (1.1)

MGH. 3) 27 S surgery 72 82 62 1982-2002 　　 (2.7 ) + Proton

LBL 4) 14 S surgery 55 85 221977-1989 (1.2 ) + He-ion

Mayo 5) 52 S surgery 56 74 521980-2001 (2.5 )

NIRS 95 S C-ion 88 86 -1996-2007.2 (9 )

1) J Bone Joint Surg. 1998 2) Cancer.2000 3)IJROBP.2006 4) IJROBP.1993 5) J Bone Joint Surg. 2005

S:sacrumSp:mobile spine

(disease free)

◆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.

SummarySummary

Carbon ion therapy is suggested to be

an effective and safe treatment for

sacral chordomas and could be a

promising alternative to surgery.

In ConclusionIn Conclusion

Carbon ion therapy--New horizon in cancer treatment

Before

RCC ： 55yo Male

IJROBP. 20086 years after

C-ion Rx 80.0GyE / 16 F

No pain

No bleeding

No wound

No anesthesia