ESTRO-ACROP-based IORT guidelines: contents + dates + authors

EXPECTED DATES

CANCER SITES/TYPES RESPONSIBLE AUTHORS

15.09.2017 proposal FC, PP 15.10.2017 all authors circulation 15.11.2017 pre-definitive all topics 15.12.2017 definitive manuscript

BREAST CANCER APBI Boost

FS CL ES

15.09.2017 proposal FC, PP 15.10.2017 all authors circulation 15.11.2017 pre-definitive all topics 15.12.2017 definitive manuscript

RECTAL CANCER

cT4 cN+ (?) Oligorecurrent

HR CS

15.09.2017 proposal FC, PP 15.10.2017 all authors circulation 15.11.2017 pre-definitive all topics 15.12.2017 definitive manuscript

PANCREATIC CANCER Resected Border-line Urresected

FC MK

15.09.2017 proposal FC, PP 15.10.2017 all authors circulation 15.11.2017 pre-definitive all topics 15.12.2017 definitive manuscript

SOFT TISSUE SARCOMAS Extremity Retroperitoneal Trunk/Central (?)

FR CF

(?) take a decision on inclusion or not of these sub-categories. FR: Falk Roeder; CF: Carlos Ferrer; MJ: Marta Jayes; PP: Philip Poortmans; FC: Felipe Calvo; FS: Felix Sedlmayer; ES: Elena Sperk; CL: Cristina Leonardi; CS: Claudio Sole; MK: Marco Krengli; HR: Harm Rutten

ESTRO-IORT Working Group/Task Force Timeline (after 2017 ESTRO meeting to December 2017)

FR: Falk Roeder; CF: Carlos Ferrer; MJ: Marta Jayes; PP: Philip Poortmans; FC: Felipe Calvo; FS: Felix Sedlmayer; ES: Elena Sperk; CL: Cristina Leonardi; CS: Claudio Sole; MK: Marco Krengli; HR: Harm Rutten

INVOLVED MEMBERS

ACTION STATUS

MJ ESTRO office provide ACROP latest guidelines and minutes from 07.05.2017 meeting Received FC May 2017

FC ACROP Guidelines + recommendations (FC) circulation among responsible authors Done 01.06.2017

FC, MK, HR,CS,FS, CL,ES,FR,CF

Elaboration proposal guidelines (ACROP based) by site/type and sent to FC + PP

Expected 15.09.2017

FC, MK, HR,CS,FS, CL,ES,FR,CF,PP

Review (FC + PP) and re-circulation all authors/all guidelines for comments Expected 15.10.2017

FC, MK, HR,CS,FS, CL,ES,FR,CF,PP

Working groups by cancer site/type submit a pre-definitive draft of guideline Agree already 15.11.207

FC, MK, HR,CS,FS, CL,ES,FR,CF,PP

Definitive manuscripts available from all groups Agree already 15.12.2017

PP FC MJ

Submission to ACROP Agree already 31.12.2017

EBRT: external beam radiotherapy; CT: chemotherapy; Gy: Gray; Kv: Kilovoltaje

Table 1. Chronologic data analysis from a 25 years literature review period on IORT for

pancreatic cancer: unresectable disease (33 articles, 1.866 patients) or post- resected status (27 articles,

1.234 patients)

DISEASE STATUS

1981-1989

1990-1999

200-2009 2010-2016

UNRESECTABLE

# Studies

# Patients

References

11

446

24-34

11

374

35-45

8

670

46-53

3

376

22, 54-55

IORT

Dose range (Gy)

Mean dose (Gy)

Electron beam

10-40

20

100%

10-40

20

100%

10-30

20

100%

10-30

20

100%

EBRT delivered

> 50% pts

27 %

54%

87%

75%

Adjuvant CT

> 50% pts

36%

36%

50%

100%

Median Survival

Range (months)

Mean (months)

8-16

10

3-18

10

7-13

11

9-16

13

RESECTED

# Studies

# Patients

References

4

37

31,34,37,56

11

253

18,35,38,42,58,63

8

606

48,52,64,69

4

338

17,23,54,70

IORT

Dose range (Gy)

Mean dose (Gy)

Electron beam

250 Kv

10-40

25

100%

--

10-30

15

100%

--

10-25

15

100%

--

6-30

15

75%

25%

EBRT delivered

> 50% pts

75%

40%

75%

75%

Adjuvant CT

> 50% pts

25%

63%

75%

100%

Median Survival

Range (months)

Mean (months)

5-18

9,5

10-19

15

9-28

15

19-24

21

25 years

>3,000 patients

>60 publications

MGH: Massachusetts General Hospital

(*) Entire group

Table 3. Institutional contemporary experiences including IOERT component in unresectable/borderlilne

disease treated with neoadjuvant chemoradiation with or without induction FORFIRINOX.

PARAMETER

MAYO CLINIC 2013 (21)

MGH 2016 (20)

Period of analysis

2002 - 2010 2010 - 2015

Initial local status:

Unresectable

Borderline

Median T size

37 (77%)

11 (23%)

--

60 (88%)

8 (12%)

3,6 cm

Neoadjuvant therapy

Chemo-radiation

Induction FORFIRINOX

31

--

68

68

Resected

# patients

R0

R1

R2

17 (35%)

11 (64%)

5 (29%)

1 (5%)

41 (68%)

19 (46%)

16 (39%)

6 (14%)

IOERT

# patients

Dose range

28 (58%)

12.5 – 20Gy

16 (26%)

10 – 17Gy

Outcomes for resection + IOERT

Local control

Median OS

3 years OS

84% (*)

+ 20 months

+ 30% (*)

73.8%

35.1 months

+ 40%

Post 2000- Post-neadjuvant

125 patients >3 years OS… +30%

Target volumen description

Tumor residue

Normal tissues exposed

Normal tissues protected/movilized

Special conditions:

Vascular manipulation Others

IORT factors

Applicator size /diameter Beveled end (degrees)

Electron energy Isodose prescription

Total dose

Number of fields Report every parameter for every field Overlaping Field –within-a-field

Protections

Fluid stability

Time of beam on

Gantry angulation

In vivo dosimetry (system/site)

Integrated pre-IORT treatment factors

Surgery: type of resection /exposure Neoadyuvant

Chemoradiation (CRT) Induction chemotherapy + CRT

Table 3. Reporting parameters for IORT electrons beam procedures in pancreatic cancer.

12 months MST 7% alive >5y Pain palliation

ESTRO-IORT Working Group/Task Force Timeline (after 2017 ESTRO meeting to December 2017)

FR: Falk Roeder; CF: Carlos Ferrer; MJ: Marta Jayes; PP: Philip Poortmans; FC: Felipe Calvo; FS: Felix Sedlmayer; ES: Elena Sperk; CL: Cristina Leonardi; CS: Claudio Sole; MK: Marco Krengli; HR: Harm Rutten

INVOLVED MEMBERS

ACTION STATUS

MJ ESTRO office provide ACROP latest guidelines and minutes from 07.05.2017 meeting Received FC May 2017

FC ACROP Guidelines + recommendations (FC) circulation among responsible authors Done 01.06.2017

FC, MK, HR,CS,FS, CL,ES,FR,CF

Elaboration proposal guidelines (ACROP based) by site/type and sent to FC + PP

Expected 15.09.2017

FC, MK, HR,CS,FS, CL,ES,FR,CF,PP

Review (FC + PP) and re-circulation all authors/all guidelines for comments Expected 15.10.2017

FC, MK, HR,CS,FS, CL,ES,FR,CF,PP

Working groups by cancer site/type submit a pre-definitive draft of guideline Agree already 15.11.207

FC, MK, HR,CS,FS, CL,ES,FR,CF,PP

Definitive manuscripts available from all groups Agree already 15.12.2017

PP FC MJ

Submission to ACROP Agree already 31.12.2017

TUMOR

VASCULATURE

3D TUMOR-BED

7 cm 15º

2D tumor-bed 10 MeV

A B

C D