Practical Radiation Oncology - Articles in Press

Audit tool for external beam radiation therapy departments - Corrected Proof

Timothy Ritter, James M. Balter, Choonik Lee, Don Roberts, Peter L. Roberson — 2012-05-16

Abstract: Purpose: Development of a self-contained audit tool for external beam radiation therapy to assess compliance with the major recommendations from professional organizations and generally accepted standards of practice. Intensity modulated radiation therapy, stereotactic body radiation therapy, stereotactic radiosurgery, and volumetric modulated arc therapy were included in this review.Methods and Materials: A physics quality working group developed a department vision, distinguished and summarized key references, and condensed important elements of good documentation practices. The results were then compiled in a checklist format and used to perform audits at 3 sites.Results: The final audit tool contains 65 items spanning a wide range of external beam radiation therapy practices. Several of the audit items address issues not commonly identified by other authoritative sources. A total of 48 process improvements were identified at the 3 sites audited.Conclusions: The enclosed self-inspection list may be useful to a site as an annual review tool, as an aid in preparation for the American College of Radiology-American Society for Therapeutic Radiology and Oncology practice accreditation, or as a catalyst for general quality improvement. Sites can quickly identify opportunities for improvement by concentrating on high importance items and commonly identified areas of noncompliance.

Pilot study of a computed tomography-compatible shielded intracavitary brachytherapy applicator for treatment of cervical cancer - Corrected Proof

2012-05-14

Abstract: Purpose: The traditional Fletcher-Williamson tandem and ovoid brachytherapy applicators for treatment of cervical cancer have ovoid shields that reduce the dose to the bladder and rectum. However, these shields produce artifact on computed tomography (CT) that prevents acquisition of high-quality images. To address this limitation, we designed and tested a novel CT-compatible applicator with movable shields, called MDA3.Methods and Materials: Fifteen patients with stage IB1-IIB cervical cancer requiring definitive radiation therapy were enrolled in a prospective pilot study to evaluate image quality with the MDA3. Image quality was assessed by comparing an initial scan obtained with the shields shifted to minimize shield artifact to a second scan obtained with the shields in treatment position. The 2 scans were then compared by a radiation oncologist blinded to the image source. In addition, image quality was assessed by analysis of Hounsfield values in the normal tissues.Results: The MDA3 was successfully employed for intracavitary brachytherapy in 15 patients. CT images obtained with the shields shifted were superior to CT images obtained with the shields in treatment position in every case as evaluated by the radiation oncologist (P < .0001). The presence of the shields in the treatment position significantly increased the mean Hounsfield values within the bladder (P = .002) and rectum (P = .001) due to high-density image artifact.Conclusions: This novel applicator provides a clinically feasible solution to overcome the limitation of lack of ovoid shields on currently available CT-compatible applicators.

Impact of magnetic resonance imaging on computed tomography-based treatment planning and acute toxicity for prostate cancer patients treated with intensity modulated radiation therapy - Corrected Proof

2012-05-14

Abstract: Purpose: To evaluate rectal and bladder dosimetric and clinical acute toxicity endpoints for prostate patients treated with intensity modulated radiation therapy (IMRT) using magnetic resonance images (MRI) registered to computed tomographic (CT) simulation images versus CT alone.Materials and Methods: The charts of 155 consecutive prostate cancer patients at our institution from 2004 to 2008 were reviewed. A cohort of 15 IMRT treatment plans was created to compare dosimetric endpoints for CT-MRI vs CT alone. A subsequent clinical comparison involved 81 patients (CT-MRI [n = 28] vs CT alone [n = 53]). Acute genitourinary and rectal toxicity rates for the CT-MRI and CT cohorts were compared; also, univariate and multivariate regression analyses were performed using all major demographic, disease, and treatment factors as covariates.Results: Contoured prostate volumes were 43.0 vs 55.7 cm3 (P < .001, n = 15) for CT-MRI vs CT definition, with significant reductions in all bladder dose endpoints and rectal V20, V30, and V70. Grades 0, 1, and 2 toxicity rates for CT-MRI (n = 28) vs CT (n = 53) were, respectively, 25%, 25%, and 50% vs 8%, 21%, and 72% (acute genitourinary [GU], P = .024) and 39%, 29%, and 32% vs 32%, 28%, and 40% (acute rectal, P = .495). On univariate regression, only MRI use and International Prostate Symptom Scores reached significance for acute GU toxicity. On multivariate regression, age, prostate volume, and MRI use reached statistical significance for acute GU toxicity. No factor reached significance for rectal toxicity.Conclusions: This study demonstrates a statistically significant reduction in clinical acute GU toxicity with the clinical implementation of MRI in the treatment planning process.

Intensity modulated radiation therapy for definitive treatment of paraortic relapse in patients with endometrial cancer - Corrected Proof

2012-05-07

Abstract: Purpose: The paraortic nodes are a common site of recurrence of endometrial cancer, especially among patients previously treated with pelvic radiation. Intensity modulated radiation therapy (IMRT) can be used to deliver a tumoricidal dose to paraortic disease while minimizing dose to normal adjacent structures. In this study, we reviewed the outcomes of patients treated with IMRT for unresected or incompletely resected paraortic recurrences of primary uterine cancer.Methods and Materials: Between 2000 and 2009, 27 patients with unresected (19 patients) or incompletely resected (8 patients) paraortic relapse of endometrial cancer were treated with curative intent using IMRT. The paraortic basin was generally treated to a dose of 45-50 Gy, and gross disease was treated to a mean total dose of 61.7 Gy (range, 54-66 Gy). Seventeen patients (63%) received neoadjuvant or adjuvant chemotherapy. Fifteen (56%) received cisplatin concurrently with IMRT. Rates of overall survival and progression-free survival following salvage IMRT were determined using the Kaplan-Meier method, and differences between subgroups were assessed using the log-rank statistic.Results: Of the 27 patients, 19 (70%) had local control of paraortic disease after a median follow-up time of 25 months (range, 4-83 months). Two-year actuarial overall survival and progression-free survival rates were 63% and 53%, respectively. Five patients (19%) experienced severe late gastrointestinal toxic effects (grade 3-5).Conclusions: IMRT can serve as salvage therapy of paraortic recurrence of endometrial cancer. However, the risk of severe gastrointestinal toxic effects is high, and care should be taken during treatment planning to minimize the dose to the small bowel.

Methods for image guided and intensity modulated radiation therapy in high-risk abdominal neuroblastoma - Corrected Proof

Atmaram S. Pai Panandiker, Chris Beltran, Jonathan Gray, Chiaho Hua — 2012-05-07

Abstract: Purpose: Our purpose was to determine methods for image guided intensity modulated radiation therapy (IMRT) in pediatric abdominal high-risk neuroblastoma and to quantify the degree of normal tissue dose reduction by using volumes compliant with International Commission on Radiation Units and Measurements (ICRU) Report 62.Methods and Materials: Eight consecutive children with high-risk abdominal neuroblastoma (median age, 2.5 years; range, 20 months-5 years) were treated with IMRT using volumes accounting for physiologic motion (IMRT_phys) and daily pretreatment cone beam computed tomographic localization. Comparative IMRT planning using conventional volumes (IMRT_std) provided quantification for dose reduction to normal tissues.Results: The IMRT_phys plan reduced the mean planning target volume from 668.8 ± 200.6 cc to 393.0 ± 132.5 cc (P < .001) and reduced mean body V50 from 1774.4 ± 383.9 cc to 1385.7 ± 365.7 cc (P < .001). The IMRT_phys plan reduced the percent mean dose to the ipsilateral kidney from 70.1% ± 4.3% to 66.0% ± 5.2% (P =.002); that to the contralateral kidney was reduced from 56.3% ± 7.0% to 40.7% ± 9.5% (P < .001), and that to the liver was reduced from 57.8% ± 16.0% to 22.1% ± 6.8% (P = .001).Conclusions: For IMRT planning, ICRU 62-compliant volume definition with image guidance in the pediatric abdomen enables volumetric reduction of the planning target volume and reduces normal tissue dose. These methods provide a framework for more conformal treatment planning in the pediatric abdomen.

Importance of initial aggressive treatment for pineal parenchymal tumor of intermediate differentiation: A case report and review of literature - Corrected Proof

Madeera Kathpal, Tina Mayer, Roy Rhodes, Shabbar Danish, Atif Khan — 2012-05-07

A 41-year-old African-American male presented at an outside institution with complaint of progressively worsening double vision for 1 to 2 months, with dimming of vision in his left eye. Pertinent past medical, surgical, family, or social history consisted of previous tobacco, alcohol, and cocaine abuse. Magnetic resonance imaging (MRI) of the brain, with and without gadolinium, revealed a heterogeneously enhancing mass with numerous flow voids. The mass was centered in the region of the pineal gland and it was inseparable from the medullary velum. The mass was hyperintense on T1-weighted imaging suggesting hemorrhage or calcifications. There was associated hydrocephalus with no other abnormalities seen.

Gastric lymph node contouring atlas: A tool to aid in clinical target volume definition in 3-dimensional treatment planning for gastric cancer - Corrected Proof

2012-05-03

Abstract: Purpose: To develop a contouring atlas of the gastric lymph node stations to be used in defining and planning clinical target volumes in 3-dimensional treatment planning for gastric cancers.Methods and Materials: Four physicians, including 2 radiation oncologists, a diagnostic radiologist, and a surgical oncologist specialized in gastric cancer, convened over the course of multiple meetings. Four patients were identified as representative cases, including 3 gastric cancer patients treated with differing surgical approaches (total gastrectomy, Ivor-Lewis esophagogastrectomy, and distal gastrectomy) and 1 patient with intact gastric anatomy. Radiographic delineation of lymph node stations was established for each case to highlight differences between intact anatomy and different postoperative anatomy.Results: Consensus was achieved among physicians in order to create a computed tomographic-based contouring atlas of gastric lymph node stations. Detailed radiographic lymph node station delineation for both intact gastric anatomy and post-surgical anatomy are discussed.Conclusions: This report serves as a template for the delineation of gastric lymph node stations to aid in the definition of elective clinical target volumes to be used in conformal treatment planning.

Target volume changes through high-dose-rate brachytherapy for cervical cancer when evaluated on high resolution (3.0 Tesla) magnetic resonance imaging - Corrected Proof

2012-05-03

Abstract: Purpose: To evaluate tumor volume changes that occurred during courses of high-dose-rate brachytherapy (HDR) using high resolution (3.0 Tesla) magnetic resonance imaging (MRI), along with the regression after external beam radiation therapy (EBRT).Methods and Materials: Fourteen patients with International Federation of Gynecology and Obstetrics stage IB1-IV cervical cancer were studied retrospectively. All patients underwent EBRT with concurrent chemotherapy followed by HDR brachytherapy. Gross tumor volume (GTV) and high-risk clinical target volume (HR-CTV) were contoured on a 3.0 Tesla MRI on the day of the HDR and on diagnostic MRI (1.5 Tesla) prior to EBRT. Two physicians independently contoured the GTV and HR-CTV on a total of 46 MRI data sets for the HDR plans. The percent volume changes of GTV and HR-CTV were quantified after EBRT and again after each HDR. The conformity indices (CIs) of the 2 contours were assessed.Results: GTV and HR-CTV considerably regressed after the first ( --31.7% ± 19.3% and --26.4% ± 6.9%, respectively) and the second (--26.8% ± 14.3% and --23.8% ± 11.0%) fraction of HDR while relatively small regressions were observed after the third (--16.3% ± 14.2% and --10.6% ± 13.4%) and the fourth (--8.0% ± 3.4% and --9.0% ± 8.0%) fractions. The lymph node-positive on positron emission tomography (PET) and stage III or IV group showed, on average, more than 200% larger GTV and HR-CTV before EBRT than those of the other patients. The GTV and HR-CTV for the group were larger on average more than 150% after EBRT and before the first HDR fraction than the other group. Interobserver CI did not vary significantly (0.75 ± 0.11) for HR-CTV, although a smaller CI (0.56 ± 0.21) was found for GTV.Conclusions: Larger tumor regressions were observed after the first and second fractions of HDR than after all subsequent fractions. The PET-identified lymph node-positive patient group and stage III or higher tumors showed larger tumor volumes before and after EBRT than other cases.

Systematic review of brain metastases prognostic indices - Corrected Proof

2012-04-30

Abstract: Purpose: A variety of prognostic indices for patients with brain metastases have been published in the literature, to guide clinical decision-making and clinical trial stratification. The purpose of this investigation is to perform a systematic review of all primary and validation reports of such prognostic systems. An assessment of index operating characteristics and misclassification rates was performed to assist in highlighting the advantages and disadvantages of competing systems.Methods and Materials: A systematic review of the English language literature regarding primary and validation brain metastases prognostic indices was performed according to PRISMA guidelines. Clinical, treatment, statistical, and prognostic index classification details were abstracted and organized into tables. Receiver operator characteristic curves were created from available Kaplan-Meier curves using a novel digitization procedure. From these curves, various operating characteristics such as positive predictive value (PPV), negative predictive value (NPV), accuracy (ACC), likelihood ratio (LR), and area under the curve (AUC) were calculated. Additionally, the major misclassification rate (MMR), defined as good or poor risk patients misclassified into the opposite group, was calculated for all available receiver operator characteristic curves.Results: A total of 9 prognostic systems have been published in the medical literature. In terms of the poor prognostic group, observed ranges are as follow: for PPV (0.25-0.72), NPV (0.72-0.97), ACC (0.57-0.95), LR (1.54-16.4), AUC (0.64-0.90), and MMR (0.02-0.39). Similarly, ranges of PPV (0.52-0.96), NPV (0.31-0.77), ACC (0.41-0.74), LR (1.69-20), AUC (0.64-0.89), and MMR (0.00-0.19) were observed for the good prognostic group.Conclusions: Operating characteristic and major misclassification analyses of all available prognostic index information demonstrated a range of results. As the ideal prognostic index has not yet been defined, further research into alternative approaches is warranted. Information contained within this report can serve as a benchmark for future investigations of existing and proposed prognostic indices.

Intensity modulated radiation therapy class solutions in Philips Pinnacle treatment planning for central nervous system malignancies: Standardized, efficient, and effective - Corrected Proof

Anna Likhacheva, Matthew Palmer, Weiliang Du, Paul D. Brown, Anita Mahajan — 2012-04-27

Abstract: Background: The use of intensity modulated radiation therapy (IMRT) is becoming more commonplace in the treatment of central nervous system (CNS) malignancies. However, the determination of beam arrangements is still an empirical process, and optimization of any given plan may take hours on the part of the dosimetrist and the physician to achieve optimal conformity and normal tissue doses. Regional CNS class solutions (CS) for IMRT planning with the Philips Pinnacle treatment planning system (version 8.0; ADAC Laboratories, Milpitas, CA) have been in partial implementation at our institution since 2009. The purpose of this present work was to investigate their validity in clinical practice.Materials and Methods: The plans of 55 patients treated for high-grade gliomas since 2009 were analyzed retrospectively. Thirty plans were categorized as having been planned with class solutions and 25 plans with user-defined optimization. Each plan was evaluated based on the following: (1) mean dose to the brain; (2) brain V30; and (3) Radiation Therapy Oncology Group (RTOG) conformity index (CIRTOG). These data were then compared with 140 historical benchmark plans that were generated using user-defined optimization prior to 2009.Results: The CS plans for gliomas in frontal, parietal-occipital, and temporal regions typically resulted in superior mean brain dose, brain V30, and conformity index when compared with user-defined plans. The CS plans for brainstem gliomas exhibited improved CIRTOG, but not brain V30 and brain mean dose. In trials of planning efficiency, the CS technique reduced treatment planning time by more than 2 times, independent of prior planning experience.Conclusions: We have developed a CS protocol for IMRT planning of gliomas that has dramatically simplified this complex planning process, allowing dosimetrists of all levels of experience to produce highly conformal plans in a time efficient manner.

Physician assistant and nurse practitioner utilization in radiation oncology within an academic medical center - Corrected Proof

2012-04-26

Abstract: Purpose: To assess the utilization of physician extenders working in radiation oncology in an academic medical center and to identify opportunities to improve their utilization.Methods and Materials: A workload analysis and patient flow analysis were conducted on physician extenders employed by the University of Michigan Health System Radiation Oncology Department in order to better understand their utilization and impact on patient flow.Results: Nearly half (46%) of physician extender time was spent performing indirect patient care. Physician extenders performed most (84.3%) of the first encounters for follow-up appointments; however, these patients were seen independently by physician assistants (PAs) and nurse practitioners (NPs) only 51% of the time. Physician extenders perceived their utilization within the department would be improved with well-defined position goals (80%), less clerical work (40%), more involvement in treatment planning (40%), more training (40%), and more involvement with new patient consults (20%). Physicians felt the utilization of physician extenders could be improved by providing more training (33%), increased physician extender involvement in treatment planning (22%), increased physician extender involvement in new patient consults (11%), and increased autonomy (11%).Conclusions: This study highlights the importance of collecting data to allow for evaluation of PA and NP performance and utilization. We have highlighted a unique methodology for analyzing physician extender duties and workflow that could be employed by other organizations and medical practices, regardless of specialty, to examine PA and NP deployment and to identify opportunities to optimize their utilization.

Gastric perforation following stereotactic body radiation therapy of hepatic metastasis from colon cancer - Corrected Proof

Matthew J. Furman, Giles F. Whalen, Shimul A. Shah, Sidney P. Kadish — 2012-04-19

Surgical resection of liver metastases from colon cancer is a safe and effective therapy, yielding a 5-year survival rate of 35%-40%. For patients who are medically inoperable or who decline surgery, nonsurgical methods such as radiofrequency ablation (RFA) and stereotactic body radiation therapy (SBRT) have been employed. SBRT treatment of liver metastases from colon cancer has been in general clinical use only over the last 5-6 years. While there have been published reports on efficacy and technique from some large centers, clinical experience with SBRT has been limited. In this paper, we report a significant and life-threatening complication related to the SBRT of a hepatic metastasis.

Feasibility and advantages of using flattening filter-free mode for radiosurgery of multiple brain lesions - Corrected Proof

Jia-Zhu Wang, Roger Rice, Arno J. Mundt, Ajay Sandhu, Kevin T. Murphy — 2012-04-16

Abstract: Purpose: The 6-MV flattening filter-free mode (6F) of the Varian TrueBeam (Varian Medical Systems, Palo Alto, CA) enables faster dose delivery and shortens treatment time, which are especially beneficial for stereotactic radiosurgery. This study is to evaluate the feasibility and advantages of using 6F in stereotactic radiosurgery treatment of multiple brain lesions in comparison with regular 6-MV mode (6X).Materials and Methods: Ten patients having 2-12 brain metastases treated by intensity modulated stereotactic radiosurgery were selected for this study. For each patient, 2 RapidArc (RA; Varian Medical Systems) plans were generated: one using the 6F mode with a dose rate of 1400 monitor units (MU)/minute and another using the regular 6X mode of 600 MU/minute for a Varian TrueBeam linac. For each patient, both plans employed the same beam arrangement and optimization process.Results: The dosimetric parameters of homogeneity, conformity, and gradient indices were calculated and found to be comparable in the 6F and 6X plans for each patient. The mean dose to the normal brain and maximal doses to brainstem, chiasm, eyes, and optical nerves were also comparable in both RA plans using either 6F or 6X. The total number of MUs in the RA plans using 6F was 10%-20% more than that in the RA plan using 6X, but the beam-on-time was much less if 6F was used for planning and dose delivery (50% less).Conclusions: The fast delivery of the 6F beam is not only beneficial in stereotactic radiosurgery of a single brain lesion, but also for treating multiple brain lesions (2-12 lesions in this study group). Due to the beam falloff away from the central axis for large field sizes, more MUs are needed for 6F beams as compared with 6X. However, for the 6F mode with 1400 MU/minute, the delivery times are still much shorter compared with the 6X mode, thus greatly shortening the treatment time.

Definitive radiation therapy for squamous cell carcinoma of the pharyngeal wall - Corrected Proof

2012-04-16

Abstract: Purpose: To analyze the results of definitive radiation therapy (RT) for squamous cell carcinoma of the pharyngeal wall.Methods and Materials: Between 1964 and 2009, 170 patients were treated with definitive RT; all living patients had a 1.7-year minimum follow-up.Results: The 5-year rates of local control and ultimate local control were the following: T1, 93% and 93%; T2, 84% and 91%; T3, 60% and 62%; and T4, 44% and 44%. Multivariate analysis revealed stage I-II tumors, female gender, and altered fractionation were associated with improved local-regional control. The 5-year cause-specific and overall survival rates were the following: I, 88% and 50%; II, 89% and 57%; III, 49% and 31%; IV, 35% and 21%; and overall, 50% and 31%, respectively. Fatal complications occurred in 9 patients (5%).Conclusions: Local-regional control and survival are related to extent of disease and treatment technique. Although outcomes have improved in recent years, the morbidity of treatment is significant and a substantial proportion of patients die due to cancer.

Required target margins for image-guided lung SBRT: Assessment of target position intrafraction and correction residuals - Corrected Proof

2012-04-09

Abstract: Purpose: With increased use of stereotactic body radiotherapy (SBRT) for early-stage lung cancer, quantification of intrafraction variation (IFV) is required to develop adequate target margins.Methods and Materials: A total of 409 patients with 427 tumors underwent 1593 fractions of lung SBRT between 2005 and 2010. Translational target position correction of the mean target position (MTP) was performed via onboard cone-beam computed tomography (CBCT). IFV was measured as the difference in MTP between the post-correction CBCT and the post-treatment CBCT and was calculated on 1337 fractions.Results: Mean IFV-MTP was 0.0 ± 1.7 mm, 0.6 ± 2.2 mm, and −1.0 ± 2.0 mm in the mediolateral (ML), anteroposterior (AP), and craniocaudal (CC) dimensions, and the vector was 3.1 ± 2.0 mm; 67.8% of fractions had an IFV vector greater than 2 mm, and 14.3% greater than 5 mm. Weight, excursion, forced expiratory volume in the first second of expiration, diffusing capacity of the lung for carbon monoxide, and treatment time were found to be significant predictors of IFV-MTP greater than 2 mm and 5 mm. Significant differences in IFV-MTP were seen between immobilization devices with a mean IFV of 2.3 ± 1.4 mm, 2.7 ± 1.6 mm, 3.0 ± 1.7 mm, 3.0 ± 2.5 mm, 3.3 ± 1.7 mm, and 3.3 ± 2.2 mm for the body frame, hybrid device, alpha cradle, body fix, wing board, and no immobilization, respectively (P < .001). Estimated required target margins for the entire cohort were 4.3, 6.1, and 6.0 mm in the ML, AP, and CC dimensions, with differences in margins based on immobilization.Conclusions: IFV is dependent on several factors: immobilization device, treatment time, pulmonary function, and bodyweight. These factors are responsible for a significant portion of target margins with a mean IFV vector of 3 mm. Target margins of 6 mm or greater are required to encompass IFV in all dimensions when using four-dimensional CT with CBCT without respiratory gating or compression.

Anatomic distribution of [18F] fluorodeoxyglucose-avid lymph nodes in patients with cervical cancer - Corrected Proof

2012-04-05

Abstract: Purpose: Current information about the anatomic distribution of lymph node (LN) metastases from cervical cancer is not precise enough for optimal treatment planning for highly conformal radiation therapy. To accurately define the anatomic distribution of these LN metastases, we mapped [18F] fluorodeoxyglucose positron emission tomography (FDG PET)-positive LNs from 50 women with cervical cancer.Methods and Materials: Records of patients with cervical cancer treated from 2006 to 2010 who had pretreatment PET/computed tomography (CT) scans available were retrospectively reviewed. Forty-one consecutive patients (group 1) with FDG-avid LNs were identified; because there were few positive paraortic LNs in group 1, 9 additional patients (group 2) with positive paraortic LNs were added. Involved LNs were contoured on individual PET/CT images, mapped to a template CT scan by deformable image registration, and edited as necessary by a diagnostic radiologist and radiation oncologists to most accurately represent the location on the original PET/CT scan.Results: We identified 190 FDG-avid LNs, 122 in group 1 and 68 in group 2. The highest concentrations of FDG-avid nodes were in the external iliac, common iliac, and paraortic regions. The anatomic distribution of the 122 positive LNs in group 1 was as follows: external iliac, 78 (63.9%); common iliac, 21 (17.2%); paraortic, 9 (7.4%); internal iliac, 8 (6.6%); presacral, 2 (1.6%); perirectal, 2 (1.6%); and medial inguinal, 2 (1.6%). Twelve pelvic LNs were not fully covered when the clinical target volume was defined according to Radiation Therapy Oncology Group guidelines for intensity modulated radiation therapy for cervical cancer.Conclusions: Our findings clarify nodal volumes at risk and can be used to improve target definition in conformal radiation therapy for cervical cancer. Our findings suggest several areas that may not be adequately covered by contours described in available atlases.

Prevalence and significance of subcentimeter hepatic lesions in patients with localized pancreatic adenocarcinoma - Corrected Proof

2012-04-05

Abstract: Purpose: To determine the prevalence and significance of incidental, subcentimeter hepatic lesions in patients with a new diagnosis of pancreatic cancer.Materials and Methods: This Institutional Review Board-approved retrospective study included 101 patients [45% men, median age 63 years (34-85)] treated for localized pancreatic adenocarcinoma at Brigham and Women's Hospital and Dana Farber Cancer Institute from January 1999 to December 2007. Initial staging and follow-up computed tomographic scans were reviewed to determine the frequency of liver lesions that were initially too small to characterize and later proved to be metastases. Clinical variables known to be prognostic for patients with pancreatic cancer were also recorded. Using Cox regression, we calculated adjusted hazard ratios to determine the association between presence of liver lesions and overall survival.Results: A total of 31 patients (30.7%) had subcentimeter hepatic lesions on staging scans. Of these patients, 21 (20.7% of total, 67.7% of patients with lesions) had eventual metastases to the liver. Finally, of this group, 5 patients (5.0% of total, 16.1% of patients with lesions) eventually had a metastatic focus at the specific site of the original lesion. Liver lesions predicted the occurrence of metastatic disease to the liver compared with patients without lesions (67.7% with lesions vs 44.4% without, P = .034). The presence of subcentimeter liver lesions at diagnosis was significantly associated with reduced overall survival (hazard ratio 1.65; 95% confidence interval 1.03-2.64, P = .036).Conclusions: Subcentimeter lesions in the liver are common in patients with a new diagnosis of pancreatic cancer. Approximately 16% of these lesions represent metastases. The presence of indeterminate liver lesions may be associated with reduced overall survival.

Concurrent chemotherapy and intensity modulated radiation therapy in the treatment of anal cancer: A retrospective review from a large academic center - Corrected Proof

2012-04-05

Abstract: Purpose: To assess the toxicity and efficacy of intensity modulated radiation therapy (IMRT) combined with chemotherapy in treatment of anal cancer.Methods and Materials: We examined the records of 34 consecutive patients who received chemoradiation therapy with IMRT as initial treatment for squamous cell carcinoma of the anus between June 2005 and January 2009. The median radiation dose was 50.4 Gy (range, 48.6-57.6 Gy). Chemotherapy was given concurrently: 5-fluorouracil alone in 1 patient and combination 5-fluorouracil and mitomycin C in all others. Endpoints included local control and survival, as well as toxicity. Acute and late toxicity was scored with the Common Terminology Criteria for Adverse Events version 3.0.Results: Twenty-eight patients presented with T1 and T2 disease and 6 with T3 and T4 disease. Fourteen patients had regional nodal metastases. The median age was 59 years (range, 46-85 years). Median follow-up in surviving patients was 22 months. The estimated 2-year survival was 93% (95% confidence interval, 76%-98%). Three patients (9%) had local relapse (estimated 2-year local control, 90%; 95% confidence interval, 74%-97%). One patient had relapse in a regional node. Acute grade 3-4 hematologic toxicity was observed in 20 patients (59%). Other acute grade 3 or grade 4 toxicity included the gastrointestinal tract in 3 patients (9%) and skin in 5 patients (15%). Two patients (6%) had late grade 3 or grade 4 gastrointestinal tract toxicity.Conclusions: Treatment of anal squamous cell carcinoma with IMRT and chemotherapy is effective and has an acceptable toxicity profile.

Stability of endoscopic ultrasound-guided fiducial marker placement for esophageal cancer target delineation and image-guided radiation therapy - Corrected Proof

2012-04-05

Abstract: Purpose: Fiducial markers have been integrated into the management of multiple malignancies to guide more precise delivery of radiation therapy (RT). Fiducials placed at the margins of esophageal tumors are potentially useful to facilitate both RT target delineation and image-guided RT (IGRT). In this study, we report on the stability of endoscopic ultrasound (EUS)-guided fiducial placement for esophageal cancers and utilization for radiation treatment planning and IGRT.Methods: An institutional review board-approved database was queried for patients treated for esophageal cancer with chemoradiotherapy (CRT). Patients included in the analysis had a diagnosis of esophageal cancer, were referred for treatment with CRT, and had fiducials placed under EUS guidance. Images acquired at time of radiation treatment planning, daily IGRT imaging, post-treatment restaging, and surveillance scans were analyzed to determine the stability of implanted markers.Results: We identified 60 patients who underwent EUS-guided fiducial marker placement near the margins of their esophageal tumors in preparation for RT treatment planning. A total of 105 fiducial markers were placed. At time of CT simulation, 99 markers were visualized. Fifty-seven patients had post-treatment imaging available for review. Of the 100 implanted fiducials in these 57 patients, 94 (94%) were visible at time of RT simulation. Eighty-eight (88%) fiducials were still present post-treatment imaging at a median of 107 days (range, 33-471 days) after implantation.Conclusions: EUS-guided fiducial marker placement for esophageal cancer aids in target delineation for radiation planning and daily IGRT. Fiducial stability is reproducible and facilitates conformal treatment with image-guided RT techniques.

Radiation recall reaction with anastrozole treatment in breast cancer - Corrected Proof

Ayfer Haydaroglu, Fatma Sert, Ali Can Kazandi, Idil Unal — 2012-04-05

Radiation recall reactions (RRR) are acute inflammatory tissue reactions that may develop in the preirradiated areas following the administration of certain triggering agents.

Clinical evaluation of interfractional variations for whole breast radiotherapy using 3-dimensional surface imaging - Corrected Proof

2012-04-05

Abstract: Purpose: To evaluate the impact of 3-dimensional (3D) surface imaging on daily patient setup for breast radiotherapy.Materials and Methods: Fifty patients undergoing treatment for whole breast radiotherapy were setup daily using an AlignRT system (VisionRT, London, UK) for 3D surface-based alignment. Daily alignments were performed against a reference surface topogram and shifts from skin marks were recorded daily. This investigation evaluated the following: (1) the performance of the surface-based imaging system for daily breast alignment; (2) the absolute displacements between setup with skin marks and setup with the surface-based imaging system; and (3) the dosimetric effect of daily alignments with skin marks versus surface-based alignments.Results: Displacements from 1258 treatment fractions were analyzed. Sixty percent of those fractions (749) were reviewed against MV portal imaging in order to assess the performance of the AlignRT system. Daily setup errors were given as absolute displacements, comparing setup marks against shifts determined using the surface-based imaging system. Averaged over all patients, the mean displacements were 4.1 ± 2.6 mm, 2.7 ± 1.4 mm, and 2.6 ± 1.2 mm in the anteroposterior (AP), superoinferior (S/I), and left-right (L/R) directions, respectively. Furthermore, the standard deviation of the random error (σ) was 3.2 mm, 2.2 mm, and 2.2 mm in the A/P, S/I, and L/R directions, respectively.Conclusions: Daily alignment with 3D surface imaging was found to be valuable for reducing setup errors when comparing with patient alignment from skin marks. The result of the surface-based alignments specifically showed that alignment with skin marks was noticeably poor in the anteroposterior directions. The overall dosimetric effect of the interfractional variations was small, but these variations showed a potential for increased dose deposition to both the heart and lung tissues. Although these interfractional variations would not negatively affect the quality of patient care for whole breast radiotherapy, it may require an increase in PTV margin, especially in cases of partial breast irradiation.

Radiation oncology information systems and clinical practice compatibility: Workflow evaluation and comprehensive assessment - Corrected Proof

Luis E. Fong de los Santos, Michael G. Herman — 2012-03-15

Abstract: Purpose: To map the level of clinical practice compatibility with a radiation oncology information system (ROIS) through a workflow- and clinical process-based method aimed at optimizing the safety, efficacy, and efficiency of patient care; to improve the understanding of the critical relationship between the clinical practice and ROIS.Methods and materials: Clinic-specific workflow and infrastructure were classified into clinical processes, information management, and technological innovation integration. Clinical information systems-information technology infrastructure and process maps were generated by a team of experts, representing clinical constituents. These maps served as the basis for evaluating connectivity and process flow and to guide the development of a quantitative survey where all clinical tasks and subprocesses were ranked according to importance in patient care and scored by the team of experts for performance. Process maps and survey output were used to measure ROIS compatibility with the practice and to guide practice improvement.Results: Practice-specific process and infrastructure maps were generated. The developed survey was applied and results indicate a range of ROIS compatibility with clinical workflow and infrastructure. Survey results combined with experiential feedback provided specific prioritized guidance to improve both ROIS performance and clinic-specific processes and infrastructure.Conclusions: This work provides a systematic and customizable tool to understand and evaluate clinical information and workflow and its compatibility with a given ROIS. The analysis provides insight into workflow improvements and information systems and information technology infrastructure limitations. Participating in such a process provides the entire team with a deeper understanding of the critical relationship between the clinical practice and the ROIS.

Evaluation of adherence to quality measures for prostate cancer radiotherapy in the United States: Results from the Quality Research in Radiation Oncology (QRRO) Survey - Corrected Proof

2012-03-14

Abstract: Purpose: The purpose of this survey was to test the feasibility of using proposed quality indicators to assess radiotherapy quality in prostate cancer management based on a 2007 stratified random survey of treating academic and nonacademic US institutions.Methods and Materials: A total of 414 patients with clinically localized prostate cancer treated with external beam radiotherapy (EBRT) or brachytherapy were selected from 45 institutions. Indicators used as specific measurable clinical performance measures to represent surrogates for quality of radiotherapy delivery included established measures such as the use of prescription doses ≥75 Gy for intermediate- and high-risk EBRT patients and androgen-deprivation therapy (ADT) in conjunction with EBRT for patients with high-risk disease, and emerging measures, including daily target localization (image-guidance) to correct for organ motion for EBRT patients.Results: Among the 354 patients treated with EBRT, the beam energy was recorded in 353 patients. One hundred sixty-seven patients (47%) were treated with 6 MV photons, 31 (9%) were treated with 10 MV, 65 (18%) received 15 MV, and the remaining 90 (26%) 16-23 MV. For intermediate- plus high-risk patients (n = 181), 78% were treated to ≥75 Gy. Among favorable-risk patients, 72% were treated to ≥75 Gy. Among high-risk EBRT patients, 60 (87%) were treated with ADT in conjunction with EBRT and 13% (n = 9) with radiotherapy alone. Among low- and intermediate-risk patients, 10% and 42%, respectively, were treated with ADT plus EBRT. For 24% of EBRT patients (85 of 354), weekly electronic portal imaging was obtained as verification films without daily target localization, and the remaining 76% were treated with daily localization of the target using various methods.Conclusions: Adherence to defined quality indicators was observed in a majority of patients. Approximately 90% of high-risk patients were treated with ADT plus EBRT and ≈80% of intermediate- and high-risk patients received prescription doses ≥75 Gy, consistent with the published results of randomized trials.

Computed tomographic atlas for the new international lymph node map for lung cancer: A radiation oncologist perspective - Corrected Proof

Rod Lynch, Graham Pitson, David Ball, Line Claude, David Sarrut — 2012-03-14

Abstract: Purpose: To develop a reproducible definition for each mediastinal lymph node station based on the new TNM classification for lung cancer.Methods and Materials: This paper proposes an atlas using the new international lymph node map used in the seventh edition of the TNM classification for lung cancer. Four radiation oncologists and 1 diagnostic radiologist were involved in the project to put forward a reproducible radiologic description for the lung lymph node stations.Results: The International Association for the Study of Lung Cancer lymph node definitions for stations 1 to 11 have been described and illustrated on axial computed tomographic scan images using a certified radiotherapy planning system.Conclusions: This atlas will assist both diagnostic radiologists and radiation oncologists in accurately defining the lymph node stations on computed tomographic scan in patients diagnosed with lung cancer.

Definitive treatment of supernumerary lower chest wall primary breast cancer - Corrected Proof

Brandi R. Page, Faisal Ahmed, John W. Thomson — 2012-03-07

Ectopic breast tissue is estimated to occur in 1% of the population. These include accessory mammary glands (polymastia), supernumerary nipples (hyperthelia) along “milk lines” from the axilla to the groin. Embryologic mammary ridges regress during development, excluding the 2 pectoral areas, later forming the breasts. Failure of regression may yield supernumerary breast tissue. Some cases have been associated with congenital urologic anomalies and familial inheritance. Though difficult to accurately characterize, between 0.28% and 0.6% of breast cancers have been reported to occur in ectopic breast tissue away from the milk line, or “mammae erraticae.” Reported sites include the axillae, vulva, sub-inframammary fold, thigh in a male, perineum, buttock, and face. Few publications discuss treatment implications. We report our approach to staging, diagnosis, and treatment and review of the literature for accessory breast cancer.

Reliability of oral examinations: Radiation oncology certifying examination - Corrected Proof

2012-03-05

Abstract: Purpose: Oral examinations are used in certifying examinations by many medical specialty boards. They represent daily clinical practice situations more realistically than do written tests or computer-based tests. However, there are repeated concerns in the literature regarding objectivity, fairness, and extraneous factors from interpersonal interactions, item bias, reliability, and validity. In this study, the reliability of oral examination on the radiation oncology certifying examination, which was administered in May of 2010, was analyzed.Methods and Materials: One hundred fifty-two candidates rotated though 8 examination stations. Stations consisted of a hotel room equipped with a computer and software that exhibited images appropriate to the content areas. Each candidate had a 25-30 minute face-to-face encounter with an oral examiner who was a content expert in one of the following areas: gastrointestinal, gynecology, genitourinary, lymphoma/leukemia/transplant/myeloma, head/neck/skin, breast, central nervous system/pediatrics, or lung/sarcoma. This type of design is typically referred to as a repeated measures design or a subject by treatment design, although the oral examination was a routine event without any experimental manipulation.Results: The reliability coefficient was obtained by applying Feldt and Charter's simple computational alternative to analysis of variance formulas that yielded KR-20, or Cronbach's coefficient alpha of 0.81.Conclusions: An experimental design to develop a blueprint in order to improve the consistency of evaluation is suggested.

Determination of planning target volume for whole stomach irradiation using daily megavoltage computed tomographic images - Corrected Proof

2012-03-05

Abstract: Purpose: Whole stomach radiation therapy is often used in the management of gastric lymphoma. However, very limited data exist with regard to planning target volume requirements for the whole stomach. This study retrospectively analyzed daily megavoltage computed tomographic (CT) scans of gastric lymphoma patients in order to help determine the interfraction variation of the stomach position.Methods and Materials: Forty-one daily megavoltage CT images from 3 gastric lymphoma patients were used for stomach contouring. Each patient's megavoltage CT images were rigidly registered to their CT simulation data sets, and the margin in each direction that covered at least 95% of the daily stomach volumes was computed using a simple grid search. Patient setup variation was also calculated from the daily patient shifts. The organ motion margin was then added to the setup margin to render the total margin.Results: A uniform margin of 2.2 cm is required to cover 95% of the stomach over the treatment course. However, direction-specific margins were observed from 1.72, 1.88, 0.92, 2.23, 1.90, and 0.86 cm for the right, left, posterior, anterior, superior, and inferior directions, respectively.Conclusions: The results of this study provide helpful 3-dimensional volumetric information to the limited existing data on margin requirements for whole stomach radiation therapy.

Use of intensity modulated radiation therapy to reduce acute and chronic toxicities of breast cancer patients treated with traditional and accelerated whole breast irradiation - Corrected Proof

2012-02-27

Abstract: Purpose: The purpose of this analysis was to examine the impact of applying intensity modulated radiation therapy (IMRT) on toxicity with traditional and accelerated whole breast irradiation (AWBI).Methods and Materials: A total of 335 patients with stage 0-IIB breast cancer were treated with either a conventional wedge technique (S-WBI, n = 87), IMRT (I-WBI, n = 93), or AWBI with IMRT (I-AWBI, n = 155). S-WBI and I-WBI patients received a median dose of 45 Gy to the breast with a median 16-Gy tumor bed boost for a cumulative median dose of 61 Gy. I-AWBI patients received a median dose of 42.56 Gy via an accelerated IMRT plan, without a boost. Acute and chronic toxicities were assessed using Common Toxicity Criteria v.3.0.Results: Median follow-up was 11.0, 9.1, and 1.1 years for S-WBI, I-WBI, and I-AWBI patients, respectively. When comparing patients of all breast sizes, I-WBI showed decreased incidences of grade 2+ acute radiation dermatitis and induration compared with I-AWBI (1% vs 23%, P < .001/0% vs 5%; P = .05 ) and S-WBI (1% vs 12%, P = .007/0% vs 6%; P = .02). I-WBI also had lower rates of chronic edema compared with S-WBI patients (3% vs 13%, P = .03). In larger breasted patients, I-WBI was associated with reduced acute toxicities compared with S-WBI with regard to grade 2 + dermatitis and edema (0% vs 19%, P = .02/7% vs 24%, P = .06). No differences were seen between I-WBI and I-AWBI with IMRT techniques with the exception of increased acute radiation dermatitis in I-AWBI patients (0% vs 38%, P < .001).Conclusions: This analysis confirms previous data which have demonstrated that RT with IMRT is associated with reduced toxicities compared with conventional techniques. In larger breasted women, with the exception of acute skin reactions, I-AWBI showed comparable rates of toxicities compared with I-WBI. These data support the use of IMRT to expand the role of AWBI and the currently accruing Radiation Therapy Oncology Group 1005 trial.

Radiotherapy following gross total resection of adult soft tissue sarcoma of the head and neck - Corrected Proof

2012-02-20

Abstract: Purpose: This study reports the outcomes of adults with soft tissue sarcoma (STS) of the head and neck following resection and postoperative radiotherapy (RT), and provides a framework for explaining the issues that radiation oncologists must understand to manage patients with this diverse group of tumors.Methods and Materials: Twenty-four patients met the following inclusion criteria of this study: age ≥19 years, head or neck primary site, STS, with the exception of rhabdomyosarcoma, Ewing, or angiosarcoma variants, and curative-attempt treatment with gross total tumor resection followed by RT.Results: All patients underwent gross total tumor resection followed by adjuvant RT at our institution during the 28-year period between June 1, 1981, and December 31, 2009. This is a mature study with a median follow-up of 11 years (range, 0.6-27 years). No patient was lost to follow-up. All recurrences were at the primary site. No patient developed an isolated regional or distant recurrence. No patient developed synchronous nodal or distant recurrences at the time of local recurrence. Half of the recurrences presented within 1 year of completing RT, but there were 2 cases where we did not detect recurrence until years 6 and 8 after RT. No recurrence was successfully salvaged. The actuarial rate of local control and relapse-free survival was 83% (95% CI [confidence interval], 63%-94%) at 5 years and 73% (95% CI, 51%-87%) at 10 years. The incidence of moderate to severe treatment complications was 4%.Conclusions: Our series documents that gross total resection followed by RT cures most patients (75%) with the most common types of STS of the head and neck. All recurrences were local, meaning near the primary site in tissue that received the full RT prescription dose. For this reason, modifying the approach to treatment of the primary tumor site is the only strategy that will meaningfully improve outcomes for this group of patients.

Salvage craniospinal irradiation with an intensity modulated radiotherapy technique for patients with disseminated neuraxis disease - Corrected Proof

Randy L. Wei, Son T. Nguyen, James N. Yang, Johannes Wolff, Anita Mahajan — 2012-02-20

Abstract: Purpose: To report the use and results of a novel intensity modulated radiotherapy (IMRT)-based technique used for salvage craniospinal irradiation (CSI) in 6 patients who developed neuraxis disease after initial high-dose conformal radiotherapy (RT) to the brain.Methods and Materials: After Institutional Review Board approval, all patients treated for disseminated leptomeningeal disease with salvage CSI using IMRT with conventional external beam radiotherapy were identified. The medical records and radiotherapy dosimetry were reviewed. Tolerance, morbidity, tumor control, and overall survival were evaluated.Results: Six patients who received IMRT-based salvage CSI were identified. The median age was 6.5 years (range 2- 34 years) at initial RT and 7.7 years (range, 3-35 years) at salvage CSI. Disease progression necessitating salvage CSI was noted at a median of 10 months (range, 1-26 months) from the initial RT. The original disease site remained well controlled in all 6 patients. The median dose of the initial RT treatment was 52 Gy (range, 30.6-60 Gy). Salvage CSI dose was 36 Gy in 20 fractions in all 6 patients. IMRT was used to treat the cranial contents excluding the previously treated area. Five pediatric patients received electron beams to spine and 1 adult patient received photon beams to spine. IMRT allowed a conformal and uniform dose distribution to the target tissue while excluding previously treated areas. Salvage CSI dose of 36 Gy, delivered using IMRT and 36 Gy using electrons or photons to the spine, proved effective in providing good control of the disease.Conclusions: This technique of salvage CSI was effective in this patient cohort for leptomeningeal dissemination occurring outside of an area of focal irradiation. The technique was well tolerated and thus far has not been associated with any significant toxicity. Salvage therapy has been effective in 4 of the 6 patients thus far.

The efficacy of external beam radiotherapy and stereotactic body radiotherapy for painful spinal metastases from renal cell carcinoma - Corrected Proof

2012-02-17

Abstract: Purpose: Palliative radiotherapy is routinely used to treat painful spinal metastases from renal cell carcinoma (RCC). Conventionally planned external beam radiotherapy (CRT) has been standard, with high-dose stereotactic body radiotherapy (SBRT) becoming increasingly common given the radioresistant nature of RCC. We compared the efficacy and durability of pain relief produced by these 2 modalities.Methods and Materials: Patients with painful spinal metastases from RCC treated from 2002-2010 were included. Response was defined similar to the Radiation Therapy Oncology Group 0631 protocol: complete response (CR) being resolution of pain without increased narcotics; partial response (PR) included patients with an incomplete reduction in pain without increased narcotics. Patients who experienced a CR or PR were coded as having pain relief, while those with persistent pain or additional narcotics requirements were coded as failures. Achievement of pain relief was analyzed using competing risk analysis with death as the competing event. Time to pain relief was plotted using cumulative incidence analysis.Results: A total of 110 patients (34 CRT; 76 SBRT) were included. Median follow-up was 4.3 months (range, 0.2-38). Median Karnofsky performance score was higher for patients treated with SBRT compared with CRT (80 vs 70; P = .0004). Overall pain response rates were 68% for CRT and 62% for SBRT, with respective CR and PR rates of 12% and 56% for CRT, and 33% and 29% for SBRT (P = .01). Median time to pain relief was 0.6 weeks for CRT versus 1.2 weeks for SBRT (P = .29). For patients who achieved pain relief (n = 79), median duration was 1.7 months for CRT versus 4.8 months for SBRT (P = .095). On univariate analysis no factors were significantly related to pain relief.Conclusions: CRT was not statistically different than SBRT for pain relief in symptomatic spine metastases from RCC and should be used as first line treatment. The appropriate use of SBRT in this population merits prospective study.

Evaluation of dose variation to normal and critical structures for lung hypofractionated stereotactic body radiation therapy - Corrected Proof

Heeteak Chung, Laurence Court, Steven H. Lin, Dhananjay Kulkarni, Peter Balter — 2012-02-16

Abstract: Purpose: To quantify the dose received by normal and critical structures during lung stereotactic body radiation therapy (SBRT) when registered to tumor or bone.Methods and Materials: Sixteen patients with lung cancer receiving a total dose of 50 Gy in 4fractions for lung SBRT were retrospectively studied. Cone-beam computed tomography (CT) was performed for all fractions, and the images obtained were registered with planning CT with respect tosoft tissue for target localization. Isocenter shifts were determined for each fraction from differences between the bony and tumor alignments; doses were then recalculated based on the new isocenters and summed over all 4 fractions to compare against the planned normal and critical tissue dose. The normal and critical structures evaluated were total and ipsilateral lung, spinal cord, and esophagus. The first data collected were isocenter coordinate shifts in all 3 Cartesian coordinates for both tumor andbony alignments. The second were the dose differences to the normal and critical structures fromthe planned and recalculated doses for alignment based on the tumor.Results: The study showed that while the maximum isocenter coordinate shifts in any direction couldbe as much as 1.60 cm, the normal and critical structure dose variations between the original plans and the simulated plans showed almost no change. The mean volume of total lung that receivedat least 20Gy difference for total lung and ipsilateral lung were 0.01% and −0.04%, respectively. For the esophagus, spinal cord, and heart the maximum and mean dose differences were 0.25 Gy and −0.04 Gy, −0.08 Gy and −0.02 Gy, and 0.02 Gy and 0.05 Gy, respectively.Conclusions: Target localization using daily cone-beam CT with soft tissue registration was appropriate for minimizing the dose to the normal and critical structures without the need to re-plan due to the changes in the tumor position. For tumors located close to a critical structure, daily cone-beam CT is recommended to determine the appropriate isocenter shifts.

Palliative radiotherapy in patients with esophageal carcinoma: A retrospective review - Corrected Proof

2012-02-13

Abstract: Purpose: Palliative radiotherapy has traditionally been used as a noninvasive means of palliating dysphagia in patients with incurable esophageal cancer. Insertion of an esophageal stent is a traditional alternative and newer treatment modalities such as brachytherapy and laser therapy are being increasingly investigated and employed. There are few large series in the literature which examine the role of short palliative radiotherapy regimens in this patient group. This retrospective review aims to demonstrate the useful role that external beam radiotherapy can have in the palliation of patients with incurable esophageal carcinoma.Methods and Materials: One hundred forty-eight patients with histologically proven esophageal cancer, who were unsuitable for radical treatment, were identified. Notes were reviewed to determine baseline characteristics, indications for radiotherapy, response to treatment, need for further intervention, time to further intervention, and survival.Results: The median age of patients who received palliative radiotherapy was 74 years (range, 31-91). Forty-nine percent of patients (n = 73) were performance status 2 or 3, 70% (n = 103) had adenocarcinoma, 58% (n = 86) had locally advanced disease, and 28% (n = 41) had metastatic disease. Ninety-three percent of patients (n = 138) complained of dysphagia prior to radiotherapy. Eighty-nine percent of patients (n = 132) received a dose of 20 Gy in 5 fractions. Only 2 patients (1%) failed to complete the prescribed course of treatment. Following radiotherapy, 75% of patients experienced an improvement in dysphagia and 25% of patients gained weight. Twenty-six percent of patients (n = 38) required subsequent insertion of an esophageal stent and a further 3% (n = 5) received retreatment with radiotherapy. The median stent (and retreatment)-free survival was 4.9 months. Median overall survival was 6.1 months.Conclusions: Despite a lack of randomized comparison to other modalities, external beam radiotherapy remains an effective, noninvasive, and generally well-tolerated means to palliate dysphagia in selected patients with incurable esophageal carcinoma.

Spot scanning proton therapy for craniopharyngioma - Corrected Proof

2012-02-13

Craniopharyngiomas are histologically benign tumors that represent the third most common pediatric brain tumor. Despite their benign appearance, craniopharyngiomas are locally invasive with a propensity for recurrence. Historically craniopharyngiomas were treated with surgery alone. However, aggressive surgical resection is frequently associated with significant sequealae including endocrinopathies. As early as 1961, groups began to report the benefits of employing more limited surgical resection followed with adjuvant radiation therapy. Radiation therapy now holds a more prominent role in the treatment of craniopharyngiomas when coupled with limited surgical resection., Understandably, fears persist over the long-term complications of irradiation in the developing brain, including cognitive dysfunction, vascular disease, and secondary malignancies. However, in counseling patients and parents the practitioner must also consider the implications of tumor recurrence and additional surgical interventions.

Contouring inguinal and femoral nodes; how much margin is needed around the vessels? - Corrected Proof

Carolyn H. Kim, Adam C. Olson, Hayeon Kim, Sushil Beriwal — 2012-02-10

Abstract: Purpose: To determine the optimal margin needed around the femoral vessels for appropriate inguinofemoral lymph node coverage and to propose guidelines defined by anatomic boundaries for clinical target volume delineation.Methods and Materials: Twenty-two patients with pelvic malignancies and involved inguinal lymph nodes treated with conformal radiation therapy were selected. Lymph nodes were considered positive if they were pathologically malignant by biopsy, had 18F-fluorodeoxyglucose avidity on positron emission tomography or measured ≥1.5 cm on computed tomographic scan. We measured distance from the center of node(s) to the edge of the nearest femoral vessel.Results: There were 52 total positive inguinal nodes among 22 patients. Relative to the femoral vessels, the location of the nodes were 51.9% anteromedial, 21.2% anterior, 11.5% anterolateral, 9.6% medial, 1.9% posterior, and 3.9% lateral. To cover ≥90% disease, the margins needed around the nearest femoral vessel were anteromedial ≥35 mm, anterior ≥23 mm, anterolateral ≥25 mm, medial ≥22 mm, posterior ≥9 mm, and ≥32 mm lateral. The corresponding anatomic boundaries were the following: laterally, medial border of the iliopsoas; medially, lateral border of adductor longus or medial end of pectineus; posteriorly, iliopsoas muscle laterally and anterior aspect of the pectineus muscle; medially and anteriorly, the anterior edge of the sartorius muscle. Most of the macroscopic nodes were medial or anteromedial to the femoral vessels. No patient had involved posterior or lateral nodes alone without positive nodes in the anterior or anteromedial positions.Conclusions: Circumferential margins around femoral vessels required to adequately cover this nodal region were >2 cm in most directions. Contouring the inguinal lymph nodes as a compartment defined by the anatomic landmarks suggested above may be more reproducible. Physicians should exercise caution in extrapolating pelvic nodal contouring guidelines to inguinal lymph nodal contouring.

Plan quality and treatment planning technique for single isocenter cranial radiosurgery with volumetric modulated arc therapy - Corrected Proof

2012-02-01

Abstract: Purpose: To demonstrate plan quality and provide a practical, systematic approach to the treatment planning technique for single isocenter cranial radiosurgery with volumetric modulated arc therapy (VMAT; RapidArc, Varian Medical systems, Palo Alto, CA).Methods and materials: Fifteen patients with 1 or more brain metastases underwent single isocenter VMAT radiosurgery. All plans were normalized to deliver 100% of the prescription dose to 99%-100% of the target volume. All targets per plan were treated to the same dose. Plans were created with dose control tuning structures surrounding targets to maximize conformity and dose gradient. Plan quality was evaluated by calculation of conformity index (CI = 100% isodose volume/target volume) and homogeneity index (HI = maximum dose/prescription dose) scores for each target and a Paddick gradient index (GI = 50% isodose volume/100% isodose volume) score for each plan.Results: The median number of targets per patient was 2 (range, 1-5). The median number of non-coplanar arcs utilized per plan was 2 (range, 1- 4). Single target plans were created with 1 or 2 non-coplanar arcs while multitarget plans utilized 2 to 4 non-coplanar arcs. Prescription doses ranged from 5-16 Gy in 1-5 fractions. The mean conformity index was 1.12 (± SD, 0.13) and the mean HI was 1.44 (± SD, 0.11) for all targets. The mean GI per plan was 3.34 (± SD, 0.42).Conclusions: We have outlined a practical approach to cranial radiosurgery treatment planning using the single isocenter VMAT platform. One or 2 arc single isocenter plans are often adequate for treatment of single targets, while 2-4 arcs may be more advantageous for multiple targets. Given the high plan quality and extreme clinical efficiency, this single isocenter VMAT approach will continue to become more prevalent for linac-based radiosurgical treatment of 1 or more intracranial targets and will likely replace multiple isocenter techniques.

Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es): An American Society for Radiation Oncology evidence-based guideline - Corrected Proof

2012-02-01

Abstract: Purpose: To systematically review the evidence for the radiotherapeutic and surgical management of patients newly diagnosed with intraparenchymal brain metastases.Methods and Materials: Key clinical questions to be addressed in this evidence-based Guideline were identified. Fully published randomized controlled trials dealing with the management of newly diagnosed intraparenchymal brain metastases were searched systematically and reviewed. The U.S. Preventative Services Task Force levels of evidence were used to classify various options of management.Results: The choice of management in patients with newly diagnosed single or multiple brain metastases depends on estimated prognosis and the aims of treatment (survival, local treated lesion control, distant brain control, neurocognitive preservation).Single brain metastasis and good prognosis (expected survival 3 months or more): For a single brain metastasis larger than 3 to 4 cm and amenable to safe complete resection, whole brain radiotherapy (WBRT) and surgery (level 1) should be considered. Another alternative is surgery and radiosurgery/radiation boost to the resection cavity (level 3). For single metastasis less than 3 to 4 cm, radiosurgery alone or WBRT and radiosurgery or WBRT and surgery (all based on level 1 evidence) should be considered. Another alternative is surgery and radiosurgery or radiation boost to the resection cavity (level 3). For single brain metastasis (less than 3 to 4 cm) that is not resectable or incompletely resected, WBRT and radiosurgery, or radiosurgery alone should be considered (level 1). For nonresectable single brain metastasis (larger than 3 to 4 cm), WBRT should be considered (level 3).Multiple brain metastases and good prognosis (expected survival 3 months or more): For selected patients with multiple brain metastases (all less than 3 to 4 cm), radiosurgery alone, WBRT and radiosurgery, or WBRT alone should be considered, based on level 1 evidence. Safe resection of a brain metastasis or metastases causing significant mass effect and postoperative WBRT may also be considered (level 3).Patients with poor prognosis (expected survival less than 3 months): Patients with either single or multiple brain metastases with poor prognosis should be considered for palliative care with or without WBRT (level 3).It should be recognized, however, that there are limitations in the ability of physicians to accurately predict patient survival. Prognostic systems such as recursive partitioning analysis, and diagnosis-specific graded prognostic assessment may be helpful.Conclusions: Radiotherapeutic intervention (WBRT or radiosurgery) is associated with improved brain control. In selected patients with single brain metastasis, radiosurgery or surgery has been found to improve survival and locally treated metastasis control (compared with WBRT alone).

The role of radiation oncologists and discussion of fertility preservation in young cancer patients - Corrected Proof

Clement K. Gwede, Susan T. Vadaparampil, Sarah Hoffe, Gwendolyn P. Quinn — 2012-01-27

Abstract: Purpose: The risk of infertility increases after cancer treatment with chemotherapy, with radiotherapy, and in some cases with surgery. The goal of these secondary analyses was to examine potential differences in practice behaviors, specifically referral and discussion of fertility preservation, among oncologists (ie, surgical oncologists, medical oncologists, and radiation oncologists).Methods and Materials: Two items examining discussion and referral for fertility preservation were administered as part of a larger 53-item survey measuring oncologists’ fertility preservation knowledge, practice behaviors, and attitudes was developed and mailed to a nationally representative, stratified, random sample of US oncology care physicians.Results: There was a significant difference by oncology subspecialty in discussion of the impact of treatment on future fertility for cancer patients of childbearing age. Follow-up χ2 tests of discussion and specialty showed 82% of radiation oncologists “always/often” discussed the impact of treatment on fertility, compared with 51% for surgical oncologists. There was not a significant difference between oncology specialty and reported referrals to reproductive endocrinologist with 24% to 31% of all oncologist types reporting “rarely/never” referring patients of child-bearing age to an infertility specialist or reproductive endocrinologist.Conclusions: These findings are important particularly for radiation oncologists, who may have a unique role in communicating fertility preservation options to their patients given their opportunity for multiple patient encounters. As such, there is a notable opportunity for further research into the reasons why and how to implement provider education about fertility preservation to improve quality of life and quality care for patients of reproductive potential.

Variation in external beam treatment plan quality: An inter-institutional study of planners and planning systems - Corrected Proof

2012-01-11

Abstract: Purpose: This study quantifies variation in radiation treatment plan quality for plans generated by a population of treatment planners given very specific plan objectives.Methods and Materials: A “Plan Quality Metric” (PQM) with 14 submetrics, each with a unique value function, was defined for a prostate treatment plan, serving as specific goals of a hypothetical “virtual physician.” The exact PQM logic was distributed to a population of treatment planners (to remove ambiguity of plan goals or plan assessment methodology) as was a predefined computed tomographic image set and anatomic structure set (to remove anatomy delineation as a variable). Treatment planners used their clinical treatment planning system (TPS) to generate their best plan based on the specified goals and submitted their results for analysis.Results: One hundred forty datasets were received and 125 plans accepted and analyzed. There was wide variability in treatment plan quality (defined as the ability of the planners and plans to meet the specified goals) quantified by the PQM. Despite the variability, the resulting PQM distributions showed no statistically significant difference between TPS employed, modality (intensity modulated radiation therapy versus arc), or education and certification status of the planner. The PQM results showed negligible correlation to number of beam angles, total monitor units, years of experience of the planner, or planner confidence.Conclusions: The ability of the treatment planners to meet the specified plan objectives (as quantified by the PQM) exhibited no statistical dependence on technologic parameters (TPS, modality, plan complexity), nor was the plan quality statistically different based on planner demographics (years of experience, confidence, certification, and education). Therefore, the wide variation in plan quality could be attributed to a general “planner skill” category that would lend itself to processes of continual improvement where best practices could be derived and disseminated to improve the mean quality and minimize the variation in any population of treatment planners.

Novel setup techniques for radiation treatment of severely obese patients with cervical cancer - Corrected Proof

Alexander C Whitley, Brendan M. Prendergast, Robert Y. Kim — 2012-01-09

The prevalence of overweight (body mass index [BMI] > 25 kg/m2) and obesity (BMI >30 kg/m2) in the United States currently exceeds two-thirds of the adult population. Obesity and severe obesity (BMI > 40 kg/m2) may impact the management of early-stage cervical cancer, where surgical resection is often the preferred treatment. Due to medical comorbidities and surgical risks, these patients are often not considered surgical candidates, and definitive radiation or chemoradiation may be the only curative option.

Screening colonoscopy before prostate cancer treatment can detect colorectal cancers in asymptomatic patients and reduce the rate of complications after brachytherapy - Corrected Proof

2012-01-06

Abstract: Purpose: To investigate the incidence of undiagnosed, asymptomatic synchronous colorectal cancer (CRC) by using screening colonoscopy before brachytherapy, and to compare the subsequent rates of CRC and rectal toxicity in this screened population with those rates in unscreened patients after brachytherapy.Methods and Materials: Patient, disease, and treatment characteristics, including history of colonoscopy and CR malignancy, were extracted from the medical records of all men who had undergone brachytherapy as monotherapy for low- or intermediate-risk prostate cancer at a single tertiary cancer care center between January 2000 and December 2009. The frequency of biopsy or polypectomy at screening colonoscopy, incidence of CR malignancy before and after prostate cancer diagnosis, and rate of brachytherapy toxicity including rectal bleeding were compared between men who had had screening colonoscopy before brachytherapy and men who had not.Results: Of the 451 men identified, 268 had undergone screening colonoscopy during the 36 months before brachytherapy and 183 had not. Of the 268 men who had had screening colonoscopy, 117 (44%) underwent biopsy or polypectomy, and 6 (3.2%) were found to have asymptomatic CRC. After brachytherapy, CRC was diagnosed in 3 (1.6%) of the 183 men who had not had screening colonoscopy before treatment versus 0 of the 268 men who had had screening colonoscopy (P = 0.035). Rectal toxicity was more common and more severe among men who had not undergone screening colonoscopy compared with those who had had screening colonoscopy before brachytherapy (14% vs 6%, P = 0.003). More unscreened patients (18% vs 5%) underwent postbrachytherapy colonoscopy (P < 0.001), with the potential of subjecting the irradiated rectum to biopsy.Conclusions: More than 3% of men with newly diagnosed prostate cancer in this study presented with undiagnosed, asymptomatic CRC, and the rate of postbrachytherapy rectal complications was higher among unscreened than among screened patients. We recommend screening colonoscopy for men who have not had CRC screening within the 3 years preceding prostate cancer diagnosis before radiation therapy to avoid unnecessary rectal biopsies and the associated risk of major complications.

Radiotherapy for hilar or mediastinal lymph node metastases after definitive treatment with stereotactic body radiotherapy or surgery for stage I non-small cell lung cancer - Corrected Proof

2012-01-03

Abstract: Purpose: Management of regional lymph node (LN) recurrence is an important issue in definitive treatment of non-small cell lung cancer (NSCLC). We evaluated clinical outcomes of conventional radiotherapy for hilar or mediastinal LN metastases developing after stereotactic body radiotherapy (SBRT) or surgery for stage I NSCLC.Methods and Materials: Between 2004 and 2008, 26 patients with hilar or mediastinal LN metastases without local recurrence and distant metastasis after SBRT (n = 14) or surgery (n = 12) were treated with conventional radiotherapy. Twelve of the 14 post-SBRT patients (86%) were judged medically inoperable at the time of SBRT. All patients were treated to the hilum and mediastinum with conventional daily fractions of 2.0 Gy (n = 25) or 2.4 Gy (n = 1). The median total dose for treating metastatic LN was 60 Gy (range, 54-66 Gy) for the post-SBRT patients and 65 Gy (range, 60-66 Gy) for the post-surgery patients. Only 1 of the 14 post-SBRT patients and 8 of the 12 post-surgery patients received chemotherapy.Results: For all 26 patients, the overall and cause-specific survival rates at 3 years from radiation for LN metastases were 36% and 51%, respectively (14% and 39%, respectively, for the 14 post-SBRT patients and both 64% for the 12 post-surgery patients). Three of the SBRT patients were alive at 35 to 43 months with (n = 2) or without (n = 1) further recurrence, and 4 of the post-surgery patients were alive at 36 to 62 months with (n = 2) or without (n = 2) further recurrence. The incidence of ≥grade 2 pulmonary toxicity was 49% at 1 year (53% for post-SBRT patients and 44% for post-surgery patients). A grade 5 pulmonary toxicity was observed in 1 of the post-SBRT patients.Conclusions: Conventional radiotherapy could successfully salvage LN relapses after SBRT as well as after surgery in 7 of 26 patients. Radiotherapy in this setting appears reasonably well tolerated.

Can trained volunteers provide psychosocial support to patients undergoing radiotherapy? The perspective of patients and volunteers - Corrected Proof

2011-12-26

Abstract: Purpose: Clinic-based psychosocial interventions, including volunteer-based ones, may be a cost-efficient and acceptable means of integrating psychosocial support into cancer care during radiotherapy. The present study evaluated a new psychosocial volunteer support program in a large radiotherapy clinic.Methods and Materials: Patients were asked to complete a demographic and satisfaction with care questionnaire. Clinic volunteers were asked to report their interactions with patients on shift logs.Results: Of the 182 participating patients, 93 (51%) recalled meeting a volunteer in the clinic, with the 2 most common support types provided being the following: “listening and caring,” and “information on services.” Analysis of 224 volunteers' shift logs indicated that almost all interactions (94%) were initiated by the volunteers, and almost half (47%) involved the patients' companions in the clinic. The most common support type documented was “information and navigation” (71%), followed by “emotional” (47%), “diversional” (21%), and “physical/practical” (17%) support.Conclusions: Trained volunteers can effectively provide clinic-based psychosocial support and information to a high proportion of radiotherapy patients. These findings demonstrate that volunteer support is a feasible means of meeting the psychosocial needs of patients with cancer attending outpatient radiotherapy clinics, who may not require or want professional psychosocial support.

The impact of class III (morbid) obesity on heterotopic ossification outcomes - Corrected Proof

2011-12-21

Abstract: Purpose: Obesity is associated with a chronic low inflammatory process that may act as common soil for the pathogenesis of obesity-related comorbidities including heterotopic ossification (HO). The purpose of this study is to compare the incidence of HO between patients with body mass index (BMI) <40 versus ≥40 after operative treatment of displaced acetabular fractures followed by radiation therapy (RT) ± indomethacin.Methods and Materials: This is a single institution retrospective chart review of 419 patients. All patients with well-documented BMI underwent operative treatment followed by RT ± indomethacin. All patients received 700 cGy to the soft tissues around the proximal femur and acetabulum without bone shielding. All RT were given postoperatively within 72 hours. The patients were divided into 2 groups: Group (A) BMI < 40 and Group (B) BMI ≥40. HO was assessed with X-ray. BMI was used as a surrogate measure to test the risk of HO despite prophylaxis.Results: The incidence of HO among all patients is 21% (89 of 419), while among those in group A (BMI <40), 68 of 374 patients developed HO (18%); in the morbidly obese group (BMI ≥40) 21of 45 patients developed HO (47%). The difference between the rates of HO in the 2 groups was 29%; the χ2 test showed a significant difference between the 2 BMI groups (P < .001 at α = 0.05).Conclusions: There is a higher incidence of HO among the morbidly obese patients despite RT ± indomethacin. RT doses for HO prophylaxis in morbidly obese patients need to be reassessed; also, understanding the signaling pathways in target tissues in obese patients at which adipokines control metabolism may reveal novel therapies. Higher radiation doses ± indomethacin may need to be considered and optimally evaluated in the context of a prospective, randomized clinical trial.

Planning comparison of intensity modulated radiation therapy delivered with 2 tangential fields versus 3-dimensional conformal radiotherapy for cardiac sparing in women with left-sided breast cancer - Corrected Proof

Neil K. Taunk, Robert G. Prosnitz — 2011-12-15

Abstract: Purpose: In women with unfavorable thoracic anatomy undergoing left breast radiation therapy (RT) after breast-conserving surgery, a significant volume of the heart may receive high-dose radiation, which has been shown previously to be associated with increased late cardiac morbidity and mortality. Use of intensity modulated radiation therapy (IMRT) has been proposed to reduce cardiac dose in these patients. We compared cardiac exposure from IMRT delivered from 2 opposed fields and 3-dimensional conformal radiation therapy (3DCRT) plans employing simple heart blocks.Methods and Materials: Fourteen patients with left-sided breast cancer treated with breast-conserving surgery and RT were identified to have unfavorable cardiac anatomy, defined as maximum heart depth (MHD) ≥1.0 cm within the unblocked opposed tangential fields. 3DCRT plans utilized dynamic wedges, segments, and custom heart blocks designed by the treating physician. Tangent IMRT plans were optimized to reduce cardiac dose while maintaining planning target volume (PTV) coverage equal to that achieved with the 3DCRT plan. We generated tangential field plans with complete heart block (CHB) or no heart block (NHB) for comparison. Plans were normalized to deliver 46 Gy to the PTV. Dose to the heart, PTV, and lumpectomy cavity were compared.Results: Mean MHD was 1.44 cm (1.0-1.86 cm). There was no significant difference in PTV receiving >95% of the prescription dose between 3DCRT and IMRT, as intended. Mean V30 to the heart was 0% for CHB plans, 1.7% for 3DCRT plans, 1.8% for IMRT plans, and 3.3% for NHB plans, respectively. There was no significant difference in heart V30 for 3DCRT and IMRT plans (P = .8). IMRT plans delivered 256 total monitor units compared with 201 in 3DCRT plans (P < .01).Conclusions: Inverse-planned tangent IMRT does not reduce high-dose radiation to the heart compared with 3DCRT, incorporating a simple heart block in women with left-sided cancer and unfavorable cardiac anatomy when PTV coverage was equalized for both plans. In select patients with early-stage breast cancer and unfavorable thoracic anatomy, 3DCRT with heart block may be sufficient to adequately protect the heart from high-dose radiation.

Preservation of adrenal function after successful stereotactic body radiation therapy of metastatic renal cell carcinoma involving the remaining contralateral adrenal gland - Corrected Proof

2011-12-12

Renal cell carcinoma (RCC) metastases have been reported in almost every organ. The most common involved organs are the lungs, liver, kidneys, bones, and brain. Autopsy series have reported RCC adrenal metastases rates ranging from 7% to 19%. Contralateral adrenal involvement is rare. In one study the incidence was 2.5%. In addition contralateral adrenal metastases from RCC can present late, even after 23 years from primary tumor resection. Such unusual delay in presentation, infrequent occurrence, and confusing clinical presentation can lead to misdiagnosis, delayed diagnosis, or failure to treat promptly.

Stereotactic body radiation therapy and 3-dimensional conformal radiotherapy for stage I non-small cell lung cancer: A pooled analysis of biological equivalent dose and local control - Corrected Proof

2011-12-05

Abstract: Purpose: To determine the relationship between tumor control probability (TCP) and biological effective dose (BED) for radiation therapy in medically inoperable stage I non-small cell lung cancer (NSCLC).Methods and Materials: Forty-two studies on 3-dimensional conformal radiation therapy (3D-CRT) and SBRT for stage I NSCLC were reviewed for tumor control (TC), defined as crude local control ≥ 2 years, as a function of BED. For each dose-fractionation schedule, BED was calculated at isocenter using the linear quadratic (LQ) and universal survival curve (USC) models. A scatter plot of TC versus BED was generated and fitted to the standard TCP equation for both models.Results: A total of 2696 patients were included in this study (SBRT: 1640; 3D-CRT: 1056). Daily fraction size was 1.2-4 Gy (total dose: 48-102.9) with 3D-CRT and 6-26 (total dose: 20-66) with SBRT. Median BED was 118.6 Gy (range, 68.5-320.3) and 95.6 Gy (range, 46.1-178.1) for the LQ and USC models, respectively. According to the LQ model, BED to achieve 50% TC (TCD50) was 61 Gy (95% confidence interval, 50.2-71.1). TCP as a function of BED was sigmoidal, with TCP ≥ 90% achieved with BED ≥ 159 Gy and 124 Gy for the LQ and USC models, respectively.Conclusions: Dose-escalation beyond a BED 159 by LQ model likely translates into clinically insignificant gain in TCP but may result in clinically significant toxicity. When delivered with SBRT, BED of 159 Gy corresponds to a total dose of 53 Gy in 3 fractions at the isocenter.

Neoadjuvant chemoradiation followed by interstitial prostate brachytherapy for synchronous prostate and rectal cancer - Corrected Proof

Haoming Qiu, Joseph M. Herman, Nita Ahuja, Theodore L. DeWeese, Danny Y. Song — 2011-12-02

Abstract: Purpose: To describe outcomes with the use of neoadjuvant pelvic chemoradiation followed by prostate interstitial brachytherapy for the treatment of synchronous prostate and rectal cancers.Methods and Materials: An Internal Review Board approved retrospective review was undertaken of 4 patients with synchronous prostate and rectal cancer treated between 2006 and 2008. Patients underwent pelvic chemoradiation followed by prostate brachytherapy, then low anterior resection of the rectum with diverting loop ileostomy and adjuvant chemotherapy. Follow-up evaluation included imaging and laboratory analysis of cancer markers in addition to routine interval history and physical examination.Results: At 38-62 months postdiagnosis (24-53 months post-treatment), 6 of 8 cancers remained without evidence of relapse. One patient had rising carcinoembryonic antigen levels but no clinically evident rectal cancer relapse; another developed bony metastasis of his high-risk prostate cancer. Three patients experienced grade 1-2 treatment-related toxicity; one patient had grade 3 gastrointestinal toxicity from radiation and surgery, which precluded his receiving adjuvant chemotherapy and ileostomy reversal.Conclusions: Chemoradiation followed by prostate brachytherapy, surgery, and adjuvant chemotherapy may be utilized to manage patients with synchronous prostate and rectal cancers.

De-intensification of treatment for human papilloma virus associated oropharyngeal squamous cell carcinoma: A discussion of current approaches - Corrected Proof

Sagar C. Patel, Trevor Hackman, David Neil Hayes, Bhishamjit S. Chera — 2011-11-18

The chemoradiotherapy (CRT) regimen for most oropharyngeal squamous cell carcinoma (OPSCC) is 70 Gy with concurrent cisplatin 100 mg/m2 × 3 cycles. Possibly less intensive chemotherapy, radiation therapy (RT), or surgery may be just as effective in HPV-associated OPSCC. Herein we report on a human papilloma virus (HPV)-associated OPSCC patient who obtained a pathologic complete response after receiving an incomplete course of CRT and discuss the current approaches for de-intensified treatment.

Angiosarcoma of the breast following breast conservation therapy: A case report and review of the literature - Corrected Proof

Sudha B. Mahalingam, Sarah McDonough — 2011-11-17

Breast conservation for early-stage breast cancer has become the standard of care in the last 2 decades. As part of breast conservation therapy (BCT), whole breast irradiation following lumpectomy is increasingly used, with many women surviving long term after treatment. Radiation-induced tumors typically occur after a latent period of several years. Sarcomas comprise 12% of these radiation-induced tumors. Among these, fibrosarcomas and chondrosarcomas have been described. Angiosarcomas, however, are rare, comprising only 1% of all soft tissue sarcomas; because they are malignant tumors arising from the vascular endothelium, more commonly they involve skin and subcutaneous tissues. Only 8% of angiosarcomas occur in the breast; of these, primary sarcomas are extremely rare. The first case of secondary angiosarcoma of the breast following breast conservation therapy was described in 1987; since then, 221 cases have been reported world wide. Few of these cases of secondary angiosarcomas have been reported following postmastectomy chest wall radiation therapy. We describe in this report the clinical course of a patient who developed angiosarcoma of the irradiated breast 8 years following BCT.