Agostinelli, S.

Carella, A.M.

Corvò, R.

Ibatici, A.

Lamanna, G.

Vagge, S.

Vidano, G.

Elsevier - Publisher Connector 

3rd ESTRO Forum 2015                                                                                                                                         S403 
 
3000 Leuven, Belgium 
5University Hospitals Leuven, 
Department of Thoracic Surgery, Leuven, Belgium 
6KU Leuven -
 University of Leuven University Hospitals Leuven, 
Radiation Oncology Department, Leuven, Belgium 
 
Purpose/Objective: Our purpose is to optimize RT target 
definition and treatment planning in lung-sparing VMAT for 
malignant pleural mesothelioma. In this multistep process, 
we identified 2 main objectives: 1) to investigate which 
imaging modality is optimal for GTV definition (CT, PET/CT 
or MRI); 2) to develop a model able to identify the maximum 
safe dose escalation level for each patient. 
Materials and Methods: Sixteen consecutive stage I-IV MPM 
patients were retrospectively identified from an institutional 
database and included. For the contouring phase, a CT with 
IV contrast, 18FDG-PET/CT and MRI were obtained. CT was 
rigidly co-registered with PET/CT and with MRI. Three sets of 
pleural GTVs were defined: GTVCT, GTVCT+PET/CT and GTVCT+MRI. 
'Quantitative' and 'qualitative' evaluations of the contoured 
GTVs were performed. For the planning phase, the GTV with 
the lower 'geographical miss' rate was chosen to generate the 
PTV. The first 6 consecutive left-sided and right-sided 
patients were selected, for a total of 12 patients. For all 
patients, VMAT plans were created. Prescription dose was 50 
Gy in 2-Gy fractions delivered to the PTV, and progressive 
dose-escalation steps (with 4 Gy increment) were attempted. 
The correlation between the contralateral/ipsilateral lung 
volume ratio and the PTV/total lung volume ratio with the 
achieved PTV dose was investigated. 
Results: Compared to CT, PET/CT identified geographical 
miss in 10/16 patients, and MRI avoided frank GTV 
underestimation in 15/16 patients. In 15/16 patients, MRI 
modified also PET/CT contours. Differences in mean volumes 
ranged from 1.7 to 5% and were not significantly different. 
Mean Jaccard index (indicating lower concordance) was lower 
in MRI-based contours versus all the others. For 10/12 
patients was possible to generate a 50 Gy VMAT plan. The 
maximum achievable dose was 54 Gy, 58 Gy and 62 Gy in 7, 4 
and 1 patients, respectively. A significant correlation 
between the contralateral/ipsilateral lung volume ratio and 
the PTV/total lung volume ratio with the achieved PTV dose 
was found (p=0.05).  
 
 
Conclusions: To the best of our knowledge, this is the first 
study showing that the integration of MRI into the target 
volume definition in MPM may allow improving the accuracy 
of GTV delineation and reducing the probability of 
geographical misses. Patients with a higher ratio of 
contralateral/ipsilateral lung volume and lower ratio of 
PTV/total lung volume are less likely to achieve a therapeutic 
RT dose. 
 
PO-0804 
Volumetric Total Lymphoid Irradiation: step-up an 
effective treatment for stem cell transplantation in 
lymphoma 
S. Vagge1, G. Lamanna1, G. Vidano1, A. Ibatici2, 
S. Agostinelli3, A.M. Carella2, R. Corvò1 
1IRCCS San Martino IST, Radiation Oncology, Genova, Italy 
2IRCCS San Martino IST, Hematology, Genova, Italy 
3IRCCS San Martino IST, Medical Physics, Genova, Italy 
 
Purpose/Objective: For patients with relapsed/refractory 
Hodgkin’s disease (HD) and non-Hodgkin lymphoma (NHL), 
autologous hematopoietic stem cell transplantation (aHSCT) 
is the standard of care. HD treatment by accelerated 
hyperfractionated total lymphoid irradiation (TLI) with three-
dimensional conformal radiotherapy (3D-CRT) has been 
investigated in dated clinical trials with good clinical 
outcomes. Today IGRT and IMRT allow the reduction of 
unbearable radiation dose to healthy tissues. Herein we 
report our preliminary clinical experience in planning and 
delivery of newly designed short-course hypofractionated TLI 
by Helical Tomotherapy (HT) followed by HDT and aHSCT. 
Materials and Methods: From February 2011 to March 2012, 
S404                                                                                                                                         3rd ESTRO Forum 2015 
 
10 patients with relapsed/refractory HD (n=7), diffuse Large 
B Cell (n=2) and follicular B-cell NHL (n=1) were treated. 
Median age was 41 years (range 20-61) and median number of 
previous lines of therapy was 3 (range 2-4). Conditioning 
chemotherapy consisted of high-dose melphalan 140 mg/sqm 
for all patients except one heavily pre-treated. 
Hypofractionated TLI was delivered as a12 Gy radiotherapy 
course in 3 consecutive daily fractions followed after 2 days 
rest by HDT and hHSCT. A conventional 3D-CRT-TLI plan was 
compared with all HT-TLI plan for all patients. Daily IGRT was 
performed to validate the patients setup margins reliability 
due to the large extension of the target (from the nodal 
chains of the neck to the inguinal ones included the spleen). 
Outcomes measures were treatment related mortality (TRM), 
progression free survival (PFS) and overall survival (OS). 
Results: All patients had chemosensitive disease at salvage 
chemotherapy, with complete remission (CR) obtained in 6 
patients (HD=5, NHL= 1), and partial remission (PR) in 4. 
Conditioning regimen was very well tolerated. All patients 
showed complete engraftment and median time to neutrophil 
and platelet recovery was of 15 (range 9-21) and 17 days 
(range 9-21), respectively. Three patients developed grade 
3/4 mucositis, grade 2 vomiting and 5 reported fever of 
undetermined origin. There was no TRM within the first 100 
days. After a median follow-up of 36 months (range 31 – 44) 
the 3-year PFS and OS were 50% and 90% respectively. In HL 
patients the 3-year PFS was 71% and OS was 100%. HT-TLI in 
comparison with conformal 3D-CRT-TLI reduced the mean 
and the higher (V80%) doses to the organs at risk from 5% to 
76% and from 47% to 100% respectively. The target volume 
was irradiated with higher conformity and homogeneity with 
HT. Measured setup corrections and replanned dose on daily 
MVCT scans showed robustness of the patient immobilization 
technique. 
Conclusions: Although from a limited number of patients, 
this original analysis showed the clinical feasibility of 
hypofractionate HT-TLI with HDT and ASCT. Preliminary 
outcomes in high risk HL shown remarkable efficacy to be 
considered as safe and effective eligible treatment. 
 
PO-0805 
Intensity Modulated Radiotherapy for the treatment of 
retroperitoneal sarcoma 
M.A.C.G. Maria Almudena Cascales1, A.L. Antonin Levy1, 
F.M. Florent Martinetti2, D.B. Deborah Belemsagha1, 
J.B. Jane Brahim2, A.L.C. Axel Le Cesne3, 
S.B. Silvie Bonvalot4, C.L.P. Le Pechoux1 
1Gustave Roussy, Radiation Oncology Department, Villejuif, 
France 
2Gustave Roussy, Radiophysics Department, Villejuif, France 
3Gustave Roussy, Medical Oncology Department, Villejuif, 
France 
4Gustave Roussy, General Surgery Department, Villejuif, 
France 
 
Purpose/Objective: To analyze toxicities, dosimetry 
parameters, and oncology outcomes in a series of patients 
with retroperitoneal sarcoma treated with Intensity 
Modulated Radiotherapy (IMRT).  
Materials and Methods: Retrospective analysis of 35 
consecutive patients with histologically proven 
retroperitoneal sarcoma treated with IMRT from 2006 to 2013 
in our institution. IMRT was delivered in a step-and-shoot 
technique with daily IGRT. Toxicity was described following 
the CTCAE v4 classification. As several patients had some 
symptoms before IMRT, we made a matched-pair comparison 
(paired-sample sign test) between treatment related 
acute/chronic toxicities and baseline symptoms. Relapse-free 
and survival intervals were estimated by using Kaplan-Meier 
method. 
Results: Median follow up was 28 months. Of the 35 patients 
there were 18 women and 17 men. Median age 57 was years 
(22-74). 19 and 16 patients were treated after extended 
resection, and preoperatively, respectively. 24 patients 
presented a primary tumor, and 11 were treated for a first 
local recurrence. 26 patients presented a liposarcoma (11 G1, 
4 G2 and 11 G3). Median tumor size was 17.5 cm (5-30). 
Median radiotherapy dose was 50.40 Gy with 1.8 Gy fractions. 
Median dosimetry values were: PTV volume 1033cc, 
contralateral kidney 3.68 Gy, and peritoneal Cavity 22.34 Gy. 
The most frequent acute toxicity was gastrointestinal (GI) 
(26/35, mainly G1; 18 patients), followed by lymphopenia 
(22/35, all without clinical significance). Most frequent (no 
clinically relevant) ≥ G2 toxicities were: lymphopenia (n=19), 
GI (n=8) and albumine decrease (n=3). Late ≥ G2 toxicities 
were: GI (n=6), fatigue (n=3), lymphopenia (n=3), kidney 
injury (n=2) and anemia (n=2). In comparison with baseline, 
there were found significant differences in the following 
acute (fatigue [p=0.04], GI [p<0.001], and lymphopenia 
[p<0.001]) and late (≤G2 kidney injury [p=0.008]) toxicities. 
Recurrences were observed in 11 patients: local (n=10), 
sarcomatosis (n=3) and distant (n=5; 2 Lung, 1 Liver, 1 bone, 
1 Node). A salvage treatment was delivered in all patients. 
Median time to local failure was 8 months (0-35). At 2-year, 
disease free survival, locoregional free–survival, and overall-
survival rates were 77%, 82%, and 83%, respectively. 
Conclusions: IMRT for retroperitoneal sarcomas is well 
tolerated with no acute clinically relevant severe toxicity. 
Mild late Kidney injury was observed in 23% pts. Outcomes 
are consistent with those observed in recent studies. The 
ongoing trial EORTC 62092-22092 is awaited to establish the 
true role of high precision preoperative radiotherapy in 
retroperitoneal sarcoma. 
 
PO-0806 
Dosimetric evaluation of TomoTherapy and 3D 
conventional radiotherapy with respect to bone marrow 
sparing 
M. Devecka1, S. Kampfer1, C. Hugo1, G. Habl1, K.A. Kessel1, 
S.E. Combs1 
1Klinikumm rechts der Isar Technische Universität München  
(TUM), Department of Radiation Oncology, München, 
Germany 
 
Purpose/Objective: Craniospinal irradiation (CSI) is indicated 
for various diseases of the central nervous system, such as 
germinoma, medulloblastoma and ependymoma, in curative 
settings, or as palliative treatment in patients with good 
performance status suffering from meningeosis 
carcinomatosa. Due to the irradiation of a very large volume 
and its close proximity to the vertebrae, a major side effect 
of CSI is bone marrow suppression. We performed a 
treatment plan comparison of 3D and IMRT as TomoTherapy 
to evaluate the different techniques regarding bone marrow 


PO-0804: Volumetric Total Lymphoid Irradiation: step-up an effective treatment for stem cell transplantation in lymphoma 

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PO-0804: Volumetric Total Lymphoid Irradiation: step-up an effective treatment for stem cell transplantation in lymphoma

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