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Belgioia L, Fozza A, Trapani L, Carmisciano L, Cavagnetto F, Agostinelli S, Guenzi M, Friedman D, Fregatti P, Corvò R. Ten Daily Fractions for Whole Breast Cancer Irradiation: Long Term Results. In Vivo 2021; 35:2875-2880. [PMID: 34410981 DOI: 10.21873/invivo.12576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 06/09/2021] [Accepted: 06/16/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM To report the feasibility and oncological outcomes in breast cancer patients treated with a short hypofractionated radiotherapy schedule. PATIENTS AND METHODS We evaluated 380 breast cancer patients treated with ten daily fractions of radiotherapy up to 39 Gy on tumor bed. Primary endpoint was local relapse rate (LRR). Secondary endpoints were overall survival (OS) and metastasis-free survival (MFS). RESULTS The median follow up was 5.0 years. Two- and 5-year LRR rates were 0.2 and 2%, respectively. Two- and 5-year MFS rates were 96.1% and 90.5%, respectively. Two and 5-year OS rates were 97.4% and 95%, respectively. CONCLUSION This short schedule may represent an alternative option to standard mild hypofractionated radiotherapy in breast cancer patients due to its excellent feasibility and very low recurrence rate.
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Affiliation(s)
- Liliana Belgioia
- Department of Health Science (DISSAL), University of Genoa, Genoa, Italy; .,Radiation Oncology Department, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Alessandra Fozza
- Radiation Oncology Department, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Luca Trapani
- Department of Health Science (DISSAL), University of Genoa, Genoa, Italy
| | - Luca Carmisciano
- Department of Health Science (DISSAL), Biostatistics Unit, University of Genoa, Genoa, Italy
| | - Francesca Cavagnetto
- Medical Physics Department, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Stefano Agostinelli
- Medical Physics Department, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Marina Guenzi
- Radiation Oncology Department, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Daniele Friedman
- Department of Surgical Science and Integrated Diagnostic (DISC), University of Genoa, Genoa, Italy.,Department of Surgery, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Piero Fregatti
- Department of Surgical Science and Integrated Diagnostic (DISC), University of Genoa, Genoa, Italy.,Department of Surgery, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Renzo Corvò
- Department of Health Science (DISSAL), University of Genoa, Genoa, Italy.,Radiation Oncology Department, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
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Barra S, Guarnieri A, di Monale E Bastia MB, Marcenaro M, Tornari E, Belgioia L, Magrini SM, Ricardi U, Corvò R. Short fractionation radiotherapy for early prostate cancer in the time of COVID-19: long-term excellent outcomes from a multicenter Italian trial suggest a larger adoption in clinical practice. LA RADIOLOGIA MEDICA 2021; 126:142-146. [PMID: 32415472 PMCID: PMC7227177 DOI: 10.1007/s11547-020-01216-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 04/27/2020] [Indexed: 12/12/2022]
Abstract
INTRODUCTION To evaluate stereotactic body radiotherapy (SBRT) in low-risk Prostate Cancer patients as preferred treatment option in emergency health conditions. MATERIALS AND METHODS From April 2013 to September 2015, 28 patients with low-risk prostate cancer were prospectively enrolled. The SBRT prescribed dose was 36.25 Gy in 5 fractions, twice a week. Primary endpoints were acute and late toxicity. Secondary endpoints were biochemical recurrence free survival (bRFS) and overall survival. RESULTS Median follow-up was 65.5 months (range 52-81). No acute G3 or G4 toxicity was recorded. Acute G1 or G2 genitourinary (GU) toxicity occurred in 43% and acute G1-G2 gastrointestinal (GI) toxicity in 14%. Late G1 and G3 GU toxicity in 18% and 3.5%, respectively. The G3 toxicity was not directly attributable to radiotherapy. Late G1 GI toxicity occurred in 18%. 5yy bRFS was 96.5% (95% CI 82.3-99.4%). CONCLUSIONS Stereotactic body radiotherapy for early prostate cancer reported safe toxicity profile and a good clinical outcome at the median follow-up of 5 years. It may be an useful option if radiotherapy is required in emergency medical conditions.
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Affiliation(s)
- Salvina Barra
- Radiation Oncology Department, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Alessia Guarnieri
- Radiation Oncology Department AO Città della Salute e della Scienza - Molinette, University of Turin, Turin, Italy
| | | | - Michela Marcenaro
- Radiation Oncology Department, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Elena Tornari
- Health Science Department (DISSAL), University of Genoa, Genoa, Italy
| | - Liliana Belgioia
- Radiation Oncology Department, IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
- Health Science Department (DISSAL), University of Genoa, Genoa, Italy.
| | - Stefano Maria Magrini
- Radiation Oncology Department, University and Spedali Civili of Brescia, Brescia, Italy
| | - Umberto Ricardi
- Radiation Oncology Department AO Città della Salute e della Scienza - Molinette, University of Turin, Turin, Italy
| | - Renzo Corvò
- Radiation Oncology Department, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Health Science Department (DISSAL), University of Genoa, Genoa, Italy
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Phase II trial of high dose stereotactic body radiation therapy for lymph node oligometastases. Clin Exp Metastasis 2020; 37:565-573. [PMID: 32556682 DOI: 10.1007/s10585-020-10047-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 06/12/2020] [Indexed: 10/24/2022]
Abstract
Lymph nodes are common sites of oligometastases for several primaries. Stereotactic body radiation therapy (SBRT) represents an effective treatment but no consensus exists regarding dose and fractionation. Aim of this trial was to evaluate safety and efficacy of high-dose SBRT. We included patients with 1 to 3 lymph node metastases. Primary end-point was safety, while secondary end-points were in-field local control (LC), out-field lymph nodal progression free survival (LPFS), distant metastasis free survival (DMFS), progression free survival (PFS) and overall survival (OS). 64 lesions in 52 patients were treated from 2015 to 2019. Most common primary tumor was genitourinary cancer (75%), in particular prostate cancer (65.4%). With a median follow-up of 24.4 months (range 3-49), treatment was very well tolerated, with only 4 (7.7%) patients reporting acute side effects, all classified as grade 1, in the form of pain, fatigue, nocturia and dysuria. No toxicity ≥ grade 2 were reported. Rates of LC at 1, 2 and 3 years were 97.9%, 82.1% and 82.1%. Male sex (HR 0.12, p value 0.014) was associated with improved LC. LPFS at 1, 2 and 3 years were 69.6%, 49.6% and 46.1%, respectively, and DMFS was 81.74%, 67.5% and 58.5%, respectively. Presence of lesions in other organs was correlated with inferior DMFS (HR 3.82, p = 0.042). PFS at 1, 2 and 3 years were 67.4%, 42.4% and 31.86%, respectively. OS at 1, 2 and 3 years were 97.3%, 94.2%, 84%, respectively and significantly correlated with in-field recurrence (HR 8.72, p = 0.000). Our prospective trial confirms safety and efficacy of SBRT in the management of lymph node metastases. Registered Clinical trial NCT02570399.
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Yamashita H, Ogita M, Aoki S, Abe O, Nakagawa K. Linear accelerator-based stereotactic body radiation therapy in the treatment of oligometastatic disease. Mol Clin Oncol 2020; 13:109-114. [PMID: 32714532 PMCID: PMC7366231 DOI: 10.3892/mco.2020.2065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 10/11/2019] [Indexed: 01/15/2023] Open
Abstract
The present study reports the clinical outcomes of hypofractionated stereotactic body radiation therapy (SBRT) for oligometastasis (OM) originating from various tumors. Between February 2012 and April 2017, 40 patients with unresectable OM were treated with SBRT. Of these patients, 92% showed a solitary nodal metastasis and the rest had up to three metastases. The dose prescription was 50 Gy in 10 fractions with three-dimensional conformal techniques or volumetric intensity-modulated arc therapy. Median follow-up was 14 months. Of the 40 patients, none showed local progression at the site of SBRT, but 20 patients showed tumor growth at distant sites during follow-up. The 2- and 3-year overall survival rates were 45.1 and 36.1%, respectively. The 2- and 3-year progression-free survival rates were 35.4 and 26.5%, respectively. The interval between diagnosis and detection of OM (<2 vs. >2 years) and primary tumor site (esophagus vs. others) emerged as significant variables affecting survival. Grade 3 subacute and grade 4 chronic toxicities were observed in 1 and 2 patients, respectively. SBRT of 50 Gy in 10 fractions for OM from various primary tumors was shown to lead to good clinical outcomes from the viewpoints of local control and toxicity frequency. However, additional studies are required to identify the patient groups likely to receive maximal benefits from such treatment.
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Affiliation(s)
- Hideomi Yamashita
- Department of Radiology, University of Tokyo Hospital, Tokyo 113-8656, Japan
| | - Mami Ogita
- Department of Radiology, University of Tokyo Hospital, Tokyo 113-8656, Japan
| | - Shuri Aoki
- Department of Radiology, University of Tokyo Hospital, Tokyo 113-8656, Japan
| | - Osamu Abe
- Department of Radiology, University of Tokyo Hospital, Tokyo 113-8656, Japan
| | - Keiichi Nakagawa
- Department of Radiology, University of Tokyo Hospital, Tokyo 113-8656, Japan
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Ito M, Kodaira T, Koide Y, Okuda T, Mizumatsu S, Oshima Y, Takeuchi A, Mori T, Abe S, Asai A, Suzuki K. Role of high-dose salvage radiotherapy for oligometastases of the localised abdominal/pelvic lymph nodes: a retrospective study. BMC Cancer 2020; 20:540. [PMID: 32517673 PMCID: PMC7285737 DOI: 10.1186/s12885-020-07033-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 06/03/2020] [Indexed: 02/03/2023] Open
Abstract
Background Abdominal/pelvic lymph node (LN) oligometastasis, a pattern of treatment failure, is observed occasionally, and radiotherapy may work as salvage therapy. The optimal prescription dose, however, is yet to be determined. This study assessed the efficacy of high-dose radiotherapy. Methods The medical records of 113 patients at 4 institutes were retrospectively analysed who had 1 to 5 abdominal/pelvic LN oligometastases and were treated with definitive radiotherapy between 2008 and 2018. The exclusion criteria included non-epithelial tumours, uncontrolled primary lesions, palliative intent, and re-irradiation. The prescription dose was evaluated by using the equivalent dose in 2 Gy fractions (EQD2). Patients receiving EQD2 ≥ 60 Gy were placed into the high-dose group, and the remaining others the low-dose group. Kaplan-Meier analyses were performed to evaluate overall survival (OS), local control (LC), and progression-free survival (PFS). Univariate log-rank and multivariate Cox proportional hazards model analyses were performed to explore predictive factors. Adverse events were compared between the high-dose and low-dose groups. Results The primary tumour sites included the colorectum (n = 28), uterine cervix (n = 27), endometrium (n = 15), and ovaries (n = 10). The rate of 2-year OS was 63.1%, that of LC 59.7%, and that of PFS 19.4%. On multivariate analyses, OS were significantly associated with solitary oligometastasis (hazard ratio [HR]: 0.48, p = 0.02), LC with high-dose radiotherapy (HR: 0.93, p < 0.001), and PFS with long disease-free interval (HR: 0.59, p = 0.01). Whereas high-dose radiotherapy did not significantly improve 2-year OS in the entire cohort (74.8% in the high-dose vs. 52.7% in the low-dose; p = 0.08), it did in the subgroup of solitary oligometastasis (88.8% in the high-dose vs. 56.3% in the low-dose; p = 0.009). As for Late grade ≥ 3 adverse event, ileus was observed in 7 patients (6%) and gastrointestinal bleeding in 4 (4%). No significant association between the irradiation dose and adverse event incidence was found. Conclusions As salvage therapy, high-dose radiotherapy was recommendable for oligometastasis in the abdominal/pelvic LNs. For solitary oligometastasis, LC and OS were significantly better in the high-dose group.
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Affiliation(s)
- Makoto Ito
- Department of Radiology, Aichi Medical University Hospital, 1-1 Yazako-Karimata, Nagakute, Aichi, 480-1195, Japan.
| | - Takeshi Kodaira
- Department of Radiation Oncology, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, Aichi, 484-8681, Japan
| | - Yutaro Koide
- Department of Radiation Oncology, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, Aichi, 484-8681, Japan
| | - Takahito Okuda
- Department of Radiation Oncology, Toyota Memorial Hospital, 1-1-1 Heiwa-cho, Toyota, Aichi, 471-8513, Japan
| | - Shinichiro Mizumatsu
- Department of CyberKnife Center, Aoyama Hospital, 100-1 Kozakai-tyo-doji, Toyokawa, Aichi, 441-0195, Japan
| | - Yukihiko Oshima
- Department of Radiology, Aichi Medical University Hospital, 1-1 Yazako-Karimata, Nagakute, Aichi, 480-1195, Japan
| | - Arisa Takeuchi
- Department of Radiology, Aichi Medical University Hospital, 1-1 Yazako-Karimata, Nagakute, Aichi, 480-1195, Japan
| | - Toshie Mori
- Department of Radiology, Aichi Medical University Hospital, 1-1 Yazako-Karimata, Nagakute, Aichi, 480-1195, Japan
| | - Souichirou Abe
- Department of Radiology, Aichi Medical University Hospital, 1-1 Yazako-Karimata, Nagakute, Aichi, 480-1195, Japan.,Department of Radiation Oncology, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, Aichi, 484-8681, Japan
| | - Ayumi Asai
- Department of Radiology, Aichi Medical University Hospital, 1-1 Yazako-Karimata, Nagakute, Aichi, 480-1195, Japan
| | - Kojiro Suzuki
- Department of Radiology, Aichi Medical University Hospital, 1-1 Yazako-Karimata, Nagakute, Aichi, 480-1195, Japan
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Chiola I, Belgioia L, Vaccara EML, Gusinu M, Corvò R. Reirradiation of pulmonary artery intimal sarcoma: A case report. Clin Case Rep 2019; 7:1342-1346. [PMID: 31360482 PMCID: PMC6637327 DOI: 10.1002/ccr3.2216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 04/02/2019] [Accepted: 05/05/2019] [Indexed: 11/23/2022] Open
Abstract
We report here the case of a patient with 4 years long-term survival after treatment with surgery, chemotherapy, and radiotherapy with good local control. This case highlights the possible role of radiation therapy in this tumor.
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Affiliation(s)
- Ilaria Chiola
- Health Science Department (DISSAL)University of GenoaGenoaItaly
| | - Liliana Belgioia
- Health Science Department (DISSAL)University of GenoaGenoaItaly
- Radiation Oncology DepartmentIRCCS San Martino HospitalGenoaItaly
| | | | - Marco Gusinu
- Medical Physics DepartmentIRCCS San Martino HospitalGenoaItaly
| | - Renzo Corvò
- Health Science Department (DISSAL)University of GenoaGenoaItaly
- Radiation Oncology DepartmentIRCCS San Martino HospitalGenoaItaly
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Belgioia L, Bacigalupo A, Missale F, Vecchio S, Chiola I, Callegari S, Verzanini E, Peretti G, Corvò R. Individualized treatment of head neck squamous cell carcinoma patients aged 70 or older with radiotherapy alone or associated to cisplatin or cetuximab: impact of weekly radiation dose on loco-regional control. Med Oncol 2019; 36:42. [PMID: 30927146 DOI: 10.1007/s12032-019-1264-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 03/18/2019] [Indexed: 12/12/2022]
Abstract
The purpose of this study is to evaluate if, in elderly HNC patients, loco-regional control (LRC) is influenced by average weekly radiation dose (AWD). From 2009 to 2017, 150 consecutive HNC elderly patients were analyzed. AWD was calculated by dividing total dose in Gray by overall treatment time in weeks. Patients were divided in 2 groups: Group 1 (70-75 years) and Group 2 (> 75 years). Primary endpoint was LRC; secondary endpoints were overall survival (OS) and compliance to treatment. The median age was 76 years (range 70-92), the distribution of patients by age was 72 and 78 patients in Group 1 and in Group 2, respectively; overall median follow-up was 23 months. Optimal cut-off of AWD for LRC was 9.236 (p = 0.018). Median OS was 73 months. In univariate survival analysis low PS (p = 0.005), T3-T4 (p = 0.021), Stage III-IV (p = 0.046) and AWDLow (< 9.236) (p = 0.018) were significantly associated with lower LRC; low PS (p < 0.001) and Group 2 (p = 0.006) were also associated with lower OS. Considering patients treated with radiotherapy alone AWDLow was significantly associated with lower LRC (p = 0.04) whereas among patient treated with chemoradiotherapy AWD did not affected LRC (p = 0.18). The multivariate analysis confirmed the significant value of PS for the prediction of LRC and OS (p = 0.035 and p < 0.001, respectively). In elderly patients an AWD of > 9.236 Gy was found to be beneficial for RT alone regimen. When radiotherapy alone is indicated in elderly patients an effort should be made to maintain an increased AWD in order to improve LRC.
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Affiliation(s)
- Liliana Belgioia
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy. .,Radiation Oncology Department, IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
| | - Almalina Bacigalupo
- Radiation Oncology Department, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Francesco Missale
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Genoa, Genoa, Italy.,IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Stefania Vecchio
- Medical Oncology Department, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Ilaria Chiola
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Serena Callegari
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Elisa Verzanini
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Giorgio Peretti
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Genoa, Genoa, Italy.,IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Renzo Corvò
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.,Radiation Oncology Department, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
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Spanish Society of Radiation Oncology clinical guidelines for stereotactic body radiation therapy in lymph node oligometastases. Clin Transl Oncol 2015; 18:342-51. [PMID: 26329294 DOI: 10.1007/s12094-015-1383-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 08/08/2015] [Indexed: 02/06/2023]
Abstract
Data in the literature support the existence of a state of limited metastases or oligometastases. Favorable outcomes have been observed in selected patients with such oligometastases that are treated with local ablative therapies, which include surgical extirpation, stereotactic body radiation therapy (SBRT), and radiofrequency ablation. The role of SBRT in the setting of lymph node oligometastases is still emerging but the early results for local control are promising. However, the biggest challenge is to identify patients who will benefit from treatment of their oligometastatic disease with local aggressive therapy. Patients are initially categorized based upon examination of the initial biopsy, location, stage, and previous treatments received. Appropriate patient management with SBRT requires an understanding of several clinicopathological features that help to identify several subsets of patients with more responsive tumors and a good tolerance to SBRT. In an effort to incorporate the most recent evidence, here the Spanish Society of Radiation Oncology presents guidelines for using SBRT in lymph node oligometastases.
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Jereczek-Fossa BA, Ronchi S, Orecchia R. Is Stereotactic Body Radiotherapy (SBRT) in lymph node oligometastatic patients feasible and effective? Rep Pract Oncol Radiother 2014; 20:472-83. [PMID: 26696788 DOI: 10.1016/j.rpor.2014.10.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Revised: 08/27/2014] [Accepted: 10/10/2014] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES To review the available data about stereotactic body-radiotherapy (SBRT) for oligometastatic lymph node cancer recurrence. METHODS The inclusion criteria for this study were as follows: Medline search for the (1) English language (2) full paper (abstracts were excluded) on (3) adult oligometastatic solid cancer recurrence limited to lymph node that underwent SBRT (4) outcome data available and (5) published up to the 30th April 2014. RESULTS 38 papers fulfilling the inclusion criteria have been found: 7 review articles and 31 patient series (20 and 11 retrospective and prospective studies, respectively) including between 1 and 69 patients (636 lymph nodes). Twelve articles reported only lymph node SBRT while in 19 - all types of SBRT including lymph node SBRT were presented. Two-year local control, 4-year progression free survival and overall survival was of up to 100%, 30% and 50%, respectively. The progression was mainly out-field (10-30% of patients had a recurrence in another lymph node/nodes). The toxicity was low with mainly mild acute events and single grade 3-4 late events. When compared to SBRT for any oligometastatic cancer, SBRT for lymph node recurrence carried better prognosis and showed lower toxicity. CONCLUSIONS SBRT is a feasible approach for oligometastatic lymph node recurrence, offering excellent in-field tumor control with low toxicity profile. The potential abscopal effect has been hypothesized as a basis of these findings. Future studies are warranted to identify the patients that benefit most from this treatment. The optimal combination with systemic treatment should also be defined.
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Affiliation(s)
| | - Sara Ronchi
- Department of Radiotherapy of the European Institute of Oncology, Milan, Italy ; Centro Nazionale di Adroterapia Oncologica (CNAO), Pavia, Italy ; University of Milan, Milan, Italy
| | - Roberto Orecchia
- Department of Radiotherapy of the European Institute of Oncology, Milan, Italy ; Centro Nazionale di Adroterapia Oncologica (CNAO), Pavia, Italy ; University of Milan, Milan, Italy
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