ABSTRACTS OF THE 21st ANNUAL MEETING OF THE ITALIAN ...

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emifentanil combination and cisatracurium as muscle relaxant and was maintained at 40-60 SE. We maintained ET CO 2 at 30-40 mm Hg by ventilation. Observations were continued until the end of surgery and early postoperative period. Results: The respiratory plateau pressure gradually increased from 15 (±4) to 28 (±5) cm H 2O and CVP was up to 24 (±4) mmHg. Target effect-site concentrations for propofol (1.9-2.3 μg/ml) and remifentanil (4.3-6.2 ng/ml) were less than those predicted to maintain adequate SE during surgery. No conscious awareness was detected. The parameters evaluated by Aldrete’s score in the early postoperative recovery period returned to the normal clinical range for all patients. Two cases of periorbital and facial edema required intravenous central line infusion of 18% mannitol (100 ml bolus) without significant changes of clinical signs. There was only one case of cognitive and behavioral disorder seven days after surgery. Discussion and Conclusion: Pneumoperitoneum and head-down position increase filling pressures, without any clinical effect on cardiac performance but have significant effects on the pharmacokinetics of propofol and remifentanil, thus reducing target concentrations in comparison with other surgical procedures. TCI is effective in inducing a good anesthetic effect, maintaining hemodynamic and respiratory stability and ensuring rapid recovery. 1 Kalmar AF et al: Influence of steep Trendelenburg position and CO 2 pneumoperitoneum on cardiovascular, cerebrovascular and respiratory homeostasis during robotic prostatectomy. Br J Anaesth 104(4): 433-439, 2010. 2 Wang LP et al: Low and moderate remifentanil infusion rates do not alter target-controlled infusion propofol concentrations necessary to maintain anesthesia as assessed by bispectral index monitoring. Anesth Analg 104(2): 325- 331, 2007. 115 SIMULTANEOUS INTEGRATED BOOST RADIOTHERAPY IN HIGH-GRADE PROSTATE CANCER: RESULTS OF TOXICITY WITH IGRT Flavia Monaco1 , Maurizio Valeriani1 , Mattia Falchetto Osti1 , Vitaliana De Sanctis1 , Cosimo De Nunzio2 and Riccardo Maurizi Enrici1 1Radioterapia Oncologica, 2Urologia, Ospedale Sant’Andrea, Roma, Italy Background: In the past decades, three-dimensional conformal radiotherapy (3D-CRT) has become the standard treatment technique for prostate irradiation. There is now growing evidence supporting the benefit of hypofractionated and intensity-modulated radiation therapy (IMRT) with 1868 ANTICANCER RESEARCH 31: 1807-1956 (2011) simultaneously integrated boost (SIB). Patients and Methods: At our institution between November 2009 and January 2011, we treated 27 patients with high-risk prostate carcinoma (T3 or Gleason score >8 or PSA >20 ng/ml). The median age was 73 (range, 67–82) years. Median PSA at diagnosis was 10.5 (range 3.89-45.4) ng/ml. Stage was cT1c in 1/27 (3.7%) patients, cT2a in 1/27 (3.7%), cT2b in 5/27 (18.5%), cT2c in 1/27 (3.7%), cT3a 8/27 (29.6%) and cT3b in 11/27 (40.7%) patients. Gleason score was 6 in 7/27 (25.9%) patients, 7 (3+4) in 8/27 (29.6%) and 8 in 12/27 (44.4%) patients. All patients underwent a simulation computed tomography (CT) scan with 2.5 mm slice thickness to execute 3D conformal planning. They were immobilized with a footlocker in supine position. Half an hour before the CT scan, all patients urinated and drank 0.5 l of water. Magnetic resonance imaging scans were fused with the planning CT scan for all patients to help delineation of the clinical target volume (CTV). Subsequently, the patients were submitted to imageguided radiation therapy (IGRT) for implementation of linear accelerator with on-board imaging system. CTV1 included the pelvis, CTV2 included the seminal vesicles and CTV3 included only the prostate. The margins for the planning target volume (PTV) were 5 mm in all directions. All patients were submitted to IMRT developed with the Eclipse System. All patients underwent additional neoadjuvant hormonal therapy, concomitant with adjuvant radiotherapy for a total of nine months, starting three months before radiotherapy with anti-androgen (bicalutamide 150 mg) in 13/27 (48.14%) patients and LHRG analog in the remaining 14/27 (51.85%) patients. Radiation was delivered in 25 fractions in total, with 4 fractions per week. The total radiation dose was 45 Gy to the pelvis (1.8 Gy per fraction), 55 Gy to PTV2 (2.2 Gy per fraction) and 68.75 Gy to PTV3 (2.75 Gy per fraction). All patients were monitored during treatment daily with a portable imaging system equipped with a cone-beam kilovoltage CT. All patients were visited once a week during treatment, one month after the completion of radiotherapy and every three months during follow-up. Results: Median followup for all patients was 6 (range 2-12) months. We considered acute toxicity, in particular, because of the shortness of follow-up, although we did not observe any late effects in patients with a follow-up longer than three months. We observed only acute grade 1 genitourinary toxicity in 3/27 (11.1%) patients during treatment and after one month from radiation therapy. Regarding gastrointestinal toxicity, two patients (7.4%) presented grade 1 and 2 diarrhea, cured with medical therapy. During the follow-up period, no patients experienced worsening of their symptoms. Discussion and Conclusion: Technological progress enables the implementation of new technologies such as IMRT and IGRT. IMRT is capable of minimizing the volume of normal tissue irradiated, notably reducing acute radiation-induced toxicity in patients.
Abstracts of the 21st Annual Meeting of the Italian Society of Uro-Oncology (SIUrO), 22-24 June, 2011, Naples, Italy 116 IS BIOPTIC DIAGNOSIS OF LOW-RISK PROSTATE CANCER REAL? SINGLE-CENTER EXPERIENCE Giandavide Cova, Claudio Lamon, Francesco Beniamin and Luigi Maccatrozzo Struttura Complessa di Urologia, Ospedale Ca’ Foncello, Treviso, TV, Italy Background: Clinically insignificant prostate cancer defined as cT1c stage, Gleason score ≤6, PSA ≤10 ng/ml, and tumor volume ≤0.5 mm is characterized by limited biologic malignancy and is, possibly, suitable for non-radical treatment. The purpose of this study was to perform a retrospective analysis of the outcome of patients with clinically insignificant prostate cancer, who underwent radical prostatectomy, in order to assess the predictors of cancer-related outcome. Patients and Methods: From January 2004 to December 2010, we performed 958 retropubic radical prostatectomies. Among these patients, 111 (12%) had clinically insignificant prostate cancer according to the biopsy criteria. Biopsy and specimen Gleason score, prostate biopsy sampling (standard vs. saturation), pathological stage, extraprostatic involvement and surgical margin status were evaluated. During followup, the patients had semiannual PSA test and clinical evaluation. Results: A total of 89 patients (80%) had clinically significant prostate cancer in the prostatectomy specimen, with 81% of the patients having organ-confined disease. Gleason score was 6 in 66% of the cases. Surgical margins were positive in 21 cases (19%) and extraprostatic involvement occurred in 21 cases (19%). Concordance between biopsy and specimen Gleason score was limited, with clinical undergrading occurring in 49 cases (44%), regardless of the biopsy scheme. The median follow-up duration was 38 months. At follow-up, extraprostatic extension and surgical margin status were independent predictors of biochemical recurrence-free survival (p=0.008). Discussion and Conclusion: The risk of overtreatment in patients with prostate cancer ranges from 0 to 48% according to literature data. As yet, major variables predictive of clinically insignificant prostate cancer are not available. In our experience, only 20% of patients undergoing radical prostatectomy for clinically insignificant prostate cancer had clinically insignificant cancer in the prostatectomy specimen, whereas in 19% of the cases, a high-risk disease was found. Although low-risk prostate cancer does exist, predictive variables allowing such patients to be identified are still lacking. The risk of overtreatment is present but currently counterbalanced by the risk of undertreatment. 117 HYPOFRACTIONATED RAPIDARC INTENSITY-MODULATED RADIOTHERAPY FOR POSTOPERATIVE OR SALVAGE TREATMENT OF PROSTATE CARCINOMA Dario Zerini1 , Barbara Alicja Jereczek-Fossa1,2 , Roberta Mauro1,2 , Cristiana Fodor1 , Maria Bonora1,2 , Paola Fanti1,2 , Isa Bossi-Zanetti1,2 , Federica Gherardi1,2 , Andrea Vavassori1 , Sabrina Vigorito3 , Rosa Luraschi3 , Stefania Comi3 , Federica Cattani3 , Raffaella Cambria3 , Ottavio De Cobelli4,5 , Federica Mazzoleni5 , Fabrizio Verweij4,5 , Deliu-Victor Matei4,5 , Gennaro Musi5 , Epifanio Scardino5 and Roberto Orecchia1,2 1Divisione di Radioterapia Oncologica, 3Divisione di Fisica Medica, e 5Divisione di Urologia, Istituto Europeo di Oncologia, Milano, Italy; 2Divisione di Radioterapia Oncologica, e 4Divisione di Urologia, Università degli Studi di Milano, Milano, Italy Aim: To assess the feasibility and acute toxicity of a mildly hypofractionated intensity-modulated radiotherapy (IMRT) treatment for prostate cancer in a postoperative or salvage setting, delivered to the prostatic bed and, in selected cases, pelvic lymph nodes, using a Linac with recently implemented RapidArc technology, Trilogy – Varian (RA-IMRT). Patients and Methods: Between January 2010 and December 2010, 70 prostate cancer patients (median age: 68 years, range: 54-79 years; median GS score: 7; median iPSA: 8.5 ng/ml) were treated in a postoperative (45 patients) or salvage setting (25 patients) after an open (42 patients), laparoscopic (3 patients), or robotic prostatectomy (24 patients). Pelvic radiotherapy (RT) was added in cases of pN1 or cN0/pNx, if the estimated risk of lymph node involvement was >30%, calculated on pre- and/or postoperative data using the available online Memorial Sloan–Kettering Cancer Center nomogram, RA-IMRT was delivered using a mildly hypofractionated schedule. The prescription dose to the prostate bed was 2.2 Gy per fraction ×30 fractions totaling 66 Gy (equivalent to 69 Gy, according to the linear quadratic model with alpha/beta ratio of 1.5 Gy) in cases of undetectable postoperative PSA, or 2.2 Gy per fraction ×31 fractions totaling 68.2 Gy (equivalent to 72 Gy), or 2.3 Gy per fraction ×30 fraction totaling 69 Gy (equivalent to 75 Gy) in cases of detectable postoperative PSA or salvage therapy. In cases of pelvic lymph-node therapy, the simultaneous integrated boost (SIB) approach was employed and a dose of 1.7 or 1.8 Gy per fraction ×30 fractions totaling 51-54 Gy was delivered to the N0 or N+ sites, respectively. Patients were invited to have a full bladder (drinking 0.5 l of water 1 h before each RA-IMRT session) and empty rectum and were treated in the supine position, with legs immobilized with a Combi-Fix device. The clinical target volume (CTV) for the tumor (CTV-T) included the prostatic bed only. The 1869
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255 ACCURACY OF ENDORECTAL MRI AND
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