The Role of BPA-PET in Prediction of H&N Cancer

Treatment failure after BNCT

Yu-Ming Liu, Yi-Wei Chen, Pin-Lun Li, Ko-Han Lin, Yu-Wen Hu, Ling-Wei Wang

Div. of Radiation Oncology, Dept.of Oncology

Taipei Veterans General Hospital

Taiwan

Cancer of the Lip and Oral Cavity (C00-C08), World Age-Standardised Incidence Rates, World Regions, 2008 Estimates, Cancer Research

UK

Mortality of Cancer in Taiwan (2010)

Liver

Lung

Colorectal

Oral, pharynx

Esophagus

Stomach

Prostate

Pancreas

non hodgkin lymphoma

Leukemia

Total

Treatment of head & neck cancer

Surgery and radiation therapy with or without chemotherapy, but despite therapy, many cancers recur.

Further treatment for recurrent H & N cancer after multi-disciplined treatment is not uncommon

Photon beams re-irradiation is not recommended because of high complication and low successful rate.

LONG-TERM OUTCOME OF CONCURRENT CHEMOTHERAPYAND REIRRADIATION FOR RECURRENT AND SECOND PRIMARYHEAD-AND-NECK SQUAMOUS CELL CARCINOMA

115 previously irradiated patients without overt metastases Surgical resection, concurrent chemotherapy and re-irradiation The median lifetime radiation dose was 131 Gy. The median F/U for survival patients was 67.4 months (18.5–158.7). The median OS and PFS was 11 and 7 months (range, 0.2–158.7) The 3-year OS = 22 % PFS = 33 % Locoregional control = 51 % Freedom from distant metastasis = 61 % For recurrent and second primary head-and-neck cancer, trimodality the

rapy with OP, C/T and re-RT for a full second dose offers potential for long-term survival.

Owing to the substantial toxicity and lack of an optimal regimen, re-irradiation of recurrent head-and-neck cancer should be limited to clinical trials.

Salama et al., Int. J. Radiation Oncology Biol. Phys., Vol. 64, No. 2, pp. 382–391, 2006

In theory, BNCT provides a means to selectively eradicate malignant cells and spare normal cells.

To ensure success, a sufficient amount of 10B should be selectively delivered to the tumor and an adequate number of thermal neutrons should be absorbed in order to sustain a lethal 10B(n,α) 7Li capture reaction

[Ono et al., IJROBP 34: 1081-1086, 1996]. For BPA-based BNCT, it is necessary to analyze the act

ual distribution of BPA in vivo before determining factors for its indication, as well as before planning treatment and predicting outcome. For these purposes, numerous authors have used 18F-BPA-PET prior to employing BPA-based BNCT.

Trial in Taiwan A phase I/II trial of boron neutron capture therapy (BNC

T) for recurrent head and neck cancer at Tsing Hua Open-Pool Reactor (THOR) ” was drafted at Taipei Veterans General Hospital (TVGH) in 2008 and was approved by Institution Review Board of TVGH and our Department of Health in 2009.

The primary end points: treatment toxicities and tumor response rate.

The secondary end points: time to tumor progression, progression-free survival, overall survival, and change of quality of life.

Web site: www. clinicaltr ials .gov; ID: N CT01173172. August 2010 – Jan. 2014

Schema Pt

registration

(D-14±3)

1st 18F-BPA PET

T/N (D-12)

1st CT Sim

(D-7)

1st

THOR (D-3)

2nd 18F-BPA PET

T/N (D21)

2nd

CT Sim (D22±3)

2nd

THOR (D26±3)

1st BNCT(D-1)

2nd BNCT

(D29±3)

FDG-PET/CT or MRI

Evaluation(D84±3)

•The BPA-uptake in ‘ ‘normal’’ tissue was measured in the subcutaneous connective tissue several cm away from the tumors.• 20– 25 Gy(Eq) to 80% of GTV/Fx for 2 Fx at interval of 30 days.•BPA injection - 1 st phase: 180 mg/kg/h for 2 h before neutron irradiation - 2nd phase: 1.5 mg/kg/min concurrent with irradiation and stopped when beam was off.•Response Evaluation Criteria in Solid Tumors (version 1.1).•MRIs before and after BNCT were performed for tumor size evaluation

•High response rate with acceptable toxicity was obtained for this clinical trial with BNCT at THOR.•The decreased T/N ratios after first fraction of BNCT may indicate that the second fraction is less efficient than the previous one.

Hypothesis & Aim The success of BNCT ultimately depends upon the

selective delivery of 10B-atoms to tumor cells. Boron concentrations in surrounding normal structures as

well as in the tumor itself, for which 18F-BPA PET was utilized.

To the best of our knowledge, treatment failure of local recurrence and features of 10B uptake in tumors according to 1

8F-BPA-PET images have yet to be adequately assessed. The present study therefore aimed to qualitatively and qua

ntitatively elucidate the features of 18F-BPA-PET imaging in the outcome of BNCT therapy of recurrent head and neck cancer patients.

T/N ratio by pre-treatment BPA-PET

After IV. 60 min, Tumor mean value =7.0; Normal tissue mean value =1.6T/N=4.37

Methods and Materials

12 advanced recurrent head & neck tumor patients who had received BNCT from 2010/8 to 2013/12 in Taiwan without distant failure

In-field failure vs. complete response. The relationship between patient characters,

disease status, pre-BNCT RT, 1st T/N ratio, treatment dosage, BPA-PET data, and clinical response were analyzed.

BPA-PET scan for 10B uptake

BNCT Treatment GTV according to pretreatment MR and 18F-PET/CT scan

Response Evaluation by 18F-PET/CT

Maxillary sinus carcinoma rT3, CR

Patient and tumor characters

Pt No.

Age/Sex Primary Site Pathology Prior OPPrior RT Dose (Gy/cours

e)

Recurrent Stage

Tumor diameter (cm)

1 68/M Hypopharynx Squamous Y 134.6/2 T1N2a 4.00

2 71/M Gingiva Squamous Y 66 T4 7.50

3 49/F Nasal Cavity Sinonasal Ca Y 120/2 T4 5.00

4 57/M Tongue Squamous Y 70 T3 4.50

5 52/MTongue base

Squamous Y 70 T4a 5.30

6 46/M NPC Undiff Ca Y 136/2 T4 3.90

7 54/MMaxillary sinus

Squamous N 70 T3 8.90

8 48/MMaxillary sinus

Spindle cell sarcoma

Y 107/2 T4b 6.00

9 58/F NPCNon-keratinizing Ca

Y 122/2 T3 2.50

10 59/M NPCNon-keratinizing Ca

N 136/2 T1 3.90

11 56/M Oral Squamous Y 129.5/2 T1 0.88

12 62/M Buccal Squamous Y 128/2 T4a 6.60

Prescription Dose, T/N ratio, tumor response and survival status

Pt No.

Interval

(month)

1st T/N

1st Fx D80 (Gy-eq)

2nd T/N

2nd Fx D80 (Gy-eq)

Total Dose (Gy-e

q)

Tumor Respo

nse

Survival Status

Surv (mont

hs)

1 9.97 3.00 19.1 2.60 12.50 31.60 PD DOC 12.2

2 26.77 3.80 25.1 1.75 12.70 37.80 PD DOC 6.3

3 13.93 4.46 31.1 2.78 17.30 48.40 CR DOC 32.5

4 6.37 3.73 19.6 2.00 13.50 33.10 Respon

seDOC 13.3

5 6.50 3.33 13.7 2.09 9.30 23.00 Respon

seDOI 8.5

6 7.73 6.16 36.9 2.57 21.10 58.00 CR alive 38.6

7 17.07 5.69 35.0 2.50 18.10 53.10 CR alive 35.2

8 28.17 2.50 20.0 2.50 19.40 39.40 CR alive 26.0

9 33.70 1.05 19.1 1.79 9.90 29.00 Respon

sealive 37.3

10 42.37 3.00 19.2 2.71 18.30 37.50 CR alive 6.8

11 5.13 3.30 20.01 20.01 CR alive 8.8

12 9.57 3.92 26.5 2.27 16.80 43.30 PD alive 6.4DOC: death of cancer; DOI: death of incurrent cause PD: progression disease; CR: complete response; Response: partial response & stable disease

Measurement of BPA-PET

Parameter definition Only 1st BPA-PET data were analysis BPA-M: BPA uptake value inside GTV volume Min BPA_M: min BPA uptake value inside GTV Max BPA_M: max BPA uptake value inside GTV BPA_H: BPA uptake value 30% of BPA_M≧ (min. BPA-M + 30% of max BPA-M) BPA_L: BPA uptake < 30% of BPA_M Vol_L/H (cm3): Volume ratio between BPA_L and

BPA_H according to BPA-PET BPA_L/H: BPA uptake value ratio between BPA_

L and BPA_H according to BPA-PET

BPA_min

BPA_max

BPA_H

BPA_L

BPA_H

BPA_L

CR(-) CR(+) p

Age 61±7 52±5 0.093

M/F 5/1 5/1

Pathology SqCC 5/6 2/6 0.099

Pre RT Dose (Gy) 92.5±33 108.3±28 0.284

Interval s/p EBRT (months)

15.5±12 19.1±14 0.605

Recurrent T stage 0.639

T1 1 2

T3 2 1

T4 3 3

Tumor (cm) 5.1±1.8 4.8±2.7 0.801

1st T/N 3.1±1.1 4.2±1.5 0.211

Total Dose-eq (Gy) 33±7 42.7±13.6 0.16

Volume L/H 1.5±0.8 0.7±0.2 0.134

BPA L/H 0.6±0.1 0.6±0.1 0.396

Results

Tumors were easily identified as high uptake areas in all cases. Areas of the dorsum tongue to middle pharynx were expressed as high uptake areas in all of the cases.

18F-BPA-PET is useful in demonstrating the presence of a tumor. Thus, it is crucial high uptake area corresponding to the dorsum area of the tongue when diagnosing a tumor using this technique.

18F-BPA-PET

Right maxilla Mucoepidermoid carcinoma

Brain parenchyma (a) Parotid gland (b). The high uptake area: - Tumor (arrows); - Dorsum surface of the

tongue (arrowheads). Differentiation betwee

n the two structures was difficult on the 18F-BPA-PET

18F-BPA-PET Aanterior maxilla a

denocarcinoma High uptake area:

- Tumor (arrow).

- Surface of the oral tongue and tongue base (arrowhead)

Left maxilla squamous cell carcinomaHigh uptake area - Jaw bone (arrows). - Tumor (arrowheads).

Tumor to brain (T/B) ratio = radioactivity of tumor/brain.Normal tissue to brain (N/B) ratio = radioactivity of normal tissue/brain.

1st head and neck cancer patient treated with up-front BNCT and conventional radiotherapy.

BNCT followed by chemoradiation as first-line therapy of a patient diagnosed with large, inoperable head and neck carcinoma

Case Report 53 y/o woman CC:: obstructed nose and headache. Dx: Intranasal poorly differentiated car

cinoma, A 7.4 × 6 .7 × 4 .4 cm tumour causing

exophthalmos and diplopia

BNCT, 400 mg/kg of L- BPA -fructose ivf.

GTV dose = 31 Gy (W), PTV dose = 28 Gy (W), Optic chiasm = 4 Gy (W )

IMRT was given 6 weeks later with 44 Gy/17 Fx, followed by SBRT booster dose of 6 Gy.

Iv with cetuximab (250 mg/m 2) + cisplatin (40 mg/m 2), weekly during IMRT.

A radiological complete response was achieved one month after RT.

Summary

Histology of squamous cell carcnoma, Total Dose-eq (Gy), Volume BPA uptake heterogeneity data might be a prognostic factor for clinic response though no statistic significance.

The volume BPA uptake heterogeneity data were 0.7±0.2 (0.44-1.0) in CR group and 1.5±0.8 (0.71-2.69) in non-CR group, respectively

There is only 12 patients in this study. F/U of 20 months (6.4 – 38.6 months). The CR is depended on the FDG-PET 3 months after BNCT. However, its predictive and prognostic value remains to be cla

rified.

Conclusion BNCT is an effective treatment for advanced

local recurrent head and neck tumor with high percentage image CR rate in 20 months follow-up (6.4 – 38.6 months).

Though no statistic significance noted, volume of BPA uptake heterogeneity might be a prognostic factor for clinic response.

The low BPA uptake volume might need further RT boost for local control.

Thank you for your attention