1. CARBON ION THERAPY FOR SACRAL CHORDOMAS
CTOS 14th Annual Meeting
November 13-15, 2008 London UK
CARBON ION THERAPY FOR SACRAL CHORDOMAS
Thank you chairman. Ladies and gentlemen It’s my great pleasure to give a talk to you here in london In my presentation, I would like to talk about our experience in carbon therapy for sacral chordomas
Tadashi KAMADA, MD
Research Center for Charged Particle Therapy National Institute of Radiological Sciences
Chiba, JAPAN

2. Bragg peak
This slide shows a brief summary of carbon ion beam. carbon beam has a definite range and the bragg peak. In addition to this physical selectivity. At the bragg peak, carbon beam ionization is enormous, and showing several radiobiological advantages such as cell cycle independent effect or less repairable damages.
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 : (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
Post op rec 11
This slide shows tumor characteristics in 95 sacral chordoma
More than 80 % were S2 or higher level lesions

6. Carbon ion Dose Distribution in Sacral Chordoma
代表的なものに変更
96%
90%
50%
30%
10%
Bowels were spared !
This slide shows the dose distributions in sacral chordoma.s As you can see in this slide, margins at the skin and bowel were reduced accordingly. In the right hand side, to spare the rectum, we employed the patch technique.
With 3 ports; right-left, left-right, posterior-anterior
With 3 ports; right-left, left-right
anterior-posterior(patch)
Carbon ion therapy - all 16 Fractions over 4week
Total dose: GyE : 2, 70.4GyE : 86, 73.6GyE : 7 ( GyE/fr.)
Number of port : Two ports : 2 , Three ports : 91, Patch : 2

7. Overall Survival and Local Control after Carbon Ion Therapy in Sacral Chordoma
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
Probability 12 24 36 48 60 72 84 96
108
120
Months
5 year LC: 88 %
5 year OS: 86%
Sacral Chordoma patients
Median survival time 42 mo (13-112)
Median time to local failure 35 mo(13-60)
Until Feb, 2007, the 95-chordoma patients were treated and showing 88% five-year local control rate and 86 % five-year survival rate.

8. Radiation Morbidity Acute grade No. 0 1 2 3 4 5 Skin 95 0 81 11 3 0 0
GI tract
　　　 Late grade
Skin * 2* 0
GI tract
Radiation morbidities are summarized in this slide. High grade skin complication was experienced at the very beginning of study and we reduce the dose and skin margins and increase the ports number. The incidence of skin complication was dramatically decreased.
*receiving TD of 73.6GyE
However, 15 patients required persistent medication
for peripheral neuropathy in this series.

9. DVHs of 44 Sciatic Nerve According to the Sciatic Symptoms in 22 patients with Sacral Chordoma
(ml)
(GyE) 5 10 15 20 25 30 40 50 60 70 80
Severe
Moderate
None-slight
DVH (n=44)
70GyE and 10cm
Volume
Among the observed late reactions, we analyzed the sciatic nerve symptoms persisting after treatment. We carried out the Dose Volume Histogram analysis 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. This slide shows the DVHS of each sciatic nerve and severity of found that length of more than 10cm, and a total dose of 70GYE could be critical points for sciatic nerve outcome. Now, we give 67.4GyE for sacral chordoma.
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. 9

10. Carbon Ion Radiotherapy for Sacral Chordoma (S2, 65 yo, Male)
Before treatment
These is a 65 yo male with S2 level chordoma. . Sixty six months after 70.4GyE, he has no neurological deficit and spending normal life.
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
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

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%
(1.1)
Sweden 2) 39 S+Sp surgery % 64
(1.1)
MGH. 3) 27 S surgery
　　 (2.7 ) + Proton
LBL 4) 14 S surgery
(1.2 ) + He-ion
Mayo 5) 52 S surgery
(2.5 )
NIRS 95 S C-ion
(9 )
S:sacrum
Sp:mobile spine
(disease free)
The reported 5-year local control rates of surgical treatment were 44 to 77 %, while the 5-year local control rate of our series was 88 %. Follow up period is rather short, however, carbon ion may appear to represent a promising alternative to surgery because of rather advanced lesions were treated in our series.
1) J Bone Joint Surg ) Cancer )IJROBP ) IJROBP ) 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. In Conclusion
Carbon ion therapy is suggested to be an effective and safe treatment for sacral chordomas and could be a promising alternative to surgery.

15. Carbon ion therapy--New horizon in cancer treatment
Thank you for your attention
Carbon ion therapy--New horizon in cancer treatment

16. C-ion Rx RCC：55yo Male IJROBP. 2008 80.0GyE / 16 F Before
6 years after
C-ion Rx
80.0GyE / 16 F
No pain
No bleeding
No wound
No anesthesia
RCC：55yo Male
However, today I would like to start with this slide. This is a CT image of 55 years old male with left kidney cancer. He refused surgical intervention and referred for carbon therapy. Kidney cancer is rather radio-resistant, so we gave 80 GyE in 16 fractions over 4 weeks. Slide shows a CT 6 years after treatment, complete tumor regression was observed. It looks like cut by a sharp KNIFE, but no wound, no blood loss, no pains ,and no anesthesia.
Before
IJROBP. 2008