Hypofractionated stereotactic re-irradiation for progressive glioblastoma: twelve years' experience of a single center

PURPOSE

We aimed to evaluate the prognostic factors and the role of stereotactic radiotherapy (SRT) as a re-irradiation technique in the management of progressive glioblastoma.

METHODS

The records of 77 previously irradiated glioblastoma patients who progressed and received second course hypofractionated SRT (1-5 fractions) between 2009 and 2022 in our department were evaluated retrospectively. Statistical Package for the Social Sciences (SPSS) version 23.0 (IBM, Armonk, NY, USA) was utilized for all statistical analyses.

RESULTS

The median time to progression from the end of initial radiotherapy was 14 months (range, 6-68 months). The most common SRT schedule was 30 Gy (range, 18-50 Gy) in 5 fractions (range, 1-5 fractions). The median follow-up after SRT was 9 months (range, 3-80 months). One-year overall (OS) and progression-free survival (PFS) rates after SRT were 46% and 35%, respectively. Re-irradiation dose and the presence of pseudoprogression were both significant independent positive prognostic factors for both OS (p = 0.009 and p = 0.04, respectively) and PFS (p = 0.008 and p = 0.04, respectively). For PFS, progression-free interval > 14 months was also a prognostic factor (p = 0.04). The treatment was well tolerated without significant acute toxicity. During follow-up, radiation necrosis was observed in 17 patients (22%), and 14 (82%) of them were asymptomatic.

CONCLUSION

Hypofractionated SRT is an effective treatment approach for patients with progressive glioblastoma. Younger patients who progressed later than 14 months, received higher SRT doses, and experienced pseudoprogression following SRT had improved survival rates.

Stereotactic radiotherapy for head and neck paragangliomas: How long should we wait for treatment response?

BACKGROUND AND PURPOSE

Stereotactic radiotherapy (SRT) is an effective treatment for head & neck (H&N) paragangliomas. Nevertheless, the timeline for achieving a tumor-volume-reduction (TVR) remains unclear.

MATERIALS AND METHODS

Sixty-three cases with H&N paragangliomas received definitive SRT and were evaluated retrospectively. Statistical Package for the Social Sciences (SPSS) v23.0 (IBM, Armonk, NY, USA) was used for statistics.

RESULTS

Sixty-eight lesions were irradiated, with glomus jugulotympanicum being the most common location (44 %). Median tumor diameter and volume were 3 cm (range, 1-7.6 cm) and 15.4 cm3 (range,1-185 cm3), respectively. Median dose was 25 Gy (range, 12-37.5 Gy) in 5 fractions (range, 1-5 fractions). Median follow-up was 40 months (range, 3-184 months). Treatment response, evaluated at a median 4.6 months post-SRT (range: 3-11 months), revealed TVR in 26 cases (41 %). During follow-up, 13 additional cases showed TVR, resulting in an overall TVR rate of 62 %. The median duration for attaining TVR was 9 months (range, 3-36 months) after SRT, and TVR occurred ≥ 12 months in 42 % of cases. Patients without prior surgery (p = 0.03) and with a longer follow-up (p = 0.04) demonstrated a higher rate of TVR. The likelihood of TVR tends to increase as the SRT dose increases (p = 0.06). Overall local control (LC) rate was 100 %. No ≥ grade 3 acute or late toxicities were observed.

CONCLUSION

While SRT demonstrates an excellent LC rate for H&N paragangliomas, it's important to note that the response to treatment may require time. TVR may last beyond the initial year of treatment in a substantial proportion of patients.

Metastasis-directed radiotherapy for non-small cell lung cancer failured under TKI: A case report and literature review

Although tyrosine kinase inhibitors (TKI) have revolutionized the treatment of anaplastic lymphoma kinase rearranged non-small cell lung cancer (ALKr-NSCLC), radiotherapy (RT) still plays an essential role for treatment of both intracranial and extracranial metastases, particularly for patients experienced a TKI-failure. We reported the case of a 38-year-old woman with metastatic ALKr-NSCLC who received whole-brain radiotherapy (RT) for multiple brain metastases (BMs), initially. After RT, alectinib was initiated and the patient had a good clinico-radiological response in both intracranial and extracranial regions. However, intracranial progression was developed and, stereotactic radiosurgery (SRS) was applied to the four progressed BMs. Two months after SRS, all BMs disappeared. While patient was using alectinib, a recurrent lung lesion, a hilar lymph node and bone metastasis were detected. Stereotactic body radiotherapy (SBRT) was applied to all metastatic sites and, alectinib was continued again. Three months after SBRT, a complete response was obtained. She has been alive with the initial systemic therapy agent for more than 4years without evidence of neither disease nor toxicity. SRS/SBRT may eradicate the TKI-resistant tumoral clones and it may prevent switching the systemic therapy, even if there is a failure.

Simultaneous integrated or sequential boost to clinically involved lymph nodes in patients with locally advanced cervical cancer treated with definitive chemoradiotherapy

OBJECTIVE

The optimal treatment of metastatic lymph nodes (LNs) in locally-advanced cervical cancer (LACC) is controversial. With the widespread use of modern radiotherapy (RT) techniques, it is become possible to perform dose escalation in clinically involved LNs. This study aimed to evaluate the oncologic outcomes of dose escalation to the involved LNs with the simultaneous-integrated (SIB) or sequential boost (SEB) techniques as a part of definitive chemoradiotherapy (CRT) for patients with LACC.

METHODS

The data of 47 patients treated with definitive CRT with either a SIB or SEB technique to the metastatic LNs between 2015 and 2021 were retrospectively analyzed. All patients received 50.4 Gy/28 fractions of external-beam RT and 28 Gy/4 fractions of brachytherapy.

RESULTS

The number of boosted LNs was 146. The median size of the LNs was 2 cm (range, 1-5 cm). The median cumulative equivalent dose in 2-Gy fractions for the LNs was 64.2 Gy (range, 57.6-71.2 Gy). During the median 30 months of follow-up (range, 14-91 months), no boosted LNs recurred and the local control (LC) rate was 100%. The 2-year overall, disease-free, local recurrence-free, and distant metastasis-free survival rate was 83.1%, 70.5%, 77.5%, and 74.4%, respectively. In multivariate analysis, the non-squamous cell histology was the only negative independent prognostic factor for DFS and DMFS. Treatment was well tolerated without any serious acute toxicity. Serious late toxicity developed in three (6%) patients as ureteral stenosis, rectal bleeding and pelvic fracture in one patient each.

CONCLUSIONS

RT dose escalation provides excellent LC for the clinically involved LNs, even for bulky ones, with a low toxicity profile. Routine LN dissection may not be necessary. However, randomized trials are needed to determine the optimal treatment approach.

Evaluation of sarcopenia as a prognostic biomarker in locally advanced head and neck squamous cell carcinoma

Background: We aimed to evaluate the effect of sarcopenia on survival in head and neck squamous cell carcinoma patients treated with chemoradiotherapy. Materials & methods: Disease-free survival and overall survival were compared according to cervical computed tomography for radiotherapy in 123 sarcopenic and non-sarcopenic patients with locally advanced head and neck squamous cell carcinoma treated with chemoradiotherapy with weekly cisplatin. Results: In multivariate analyses, pretreatment sarcopenia was associated with lower disease-free survival (hazard ratio: 2.60; 95% CI: 1.38-4.87; p = 0.003) and overall survival (hazard ratio: 2.86; 95% CI: 1.40-5.85; p = 0.004). Sarcopenic patients experienced more frequent radiotherapy-related toxicities and platinum-related side effects than non-sarcopenic patients. Conclusion: Sarcopenia could be a potential biomarker to predict prognosis and treatment toxicity in head and neck squamous cell carcinoma.

Stereotactic Body Radiotherapy as an Effective Treatment for Pancreatic Cancer

Background Stereotactic body radiotherapy (SBRT) allows the delivery of an ablative radiation dose to the tumor with minimal toxicity. Although magnetic resonance imaging (MRI)-guided SBRT appears to be a promising approach in the modern era, X-ray image-guided SBRT is still used worldwide for pancreatic cancer. This study aims to evaluate the results of X-ray image-guided SBRT in patients with locally advanced pancreatic cancer (LAPC). Methodology Medical records of 24 patients with unresectable LAPC who underwent X-ray image-guided SBRT between 2009 and 2022 were retrospectively evaluated. SPSS version 23.0 (IBM Corp., Armonk, NY, USA) was utilized for all analyses. Results The median age was 64 years (range = 42-81 years), and the median tumor size was 3.5 cm (range = 2.7-4 cm). The median total dose of SBRT was 35 Gy (range = 33-50 Gy) in five fractions. After SBRT, 30% of patients showed complete and 41% showed partial response, whereas 20% had stable disease and 9% had progression. Median follow-up was 15 months (range = 6-58 months). During follow-up, four (16%) patients had local recurrence, one (4%) had a regional recurrence, and 17 (70%) had distant metastasis (DM). The two-year local control (LC), local recurrence-free survival (LRFS), overall survival (OS), and DM-free survival (DMFS) rate was 87%, 36%, 37%, and 29%, respectively. In univariate analysis, a larger tumor size (>3.5 cm) and higher cancer antigen 19-9 level (>106.5 kU/L) significantly decreased the OS, LRFS, and DMFS rates. No severe acute toxicity was observed. However, two patients had severe late toxicity as intestinal bleeding. Conclusions X-ray image-guided SBRT provides a good LC rate with minimal toxicity for unresectable LAPC. However, despite modern systemic treatments, the rate of DM remains high which plays a major role in survival.

Uterine papillary serous and clear cell carcinomas: Comparison of characteristics and clinical outcomes

INTRODUCTION

To assess the rate of disease control and survival after adjuvant treatment in patients with uterine papillary serous (PSC) and clear cell carcinoma (CCC) and compare the results between these two subtypes.

METHODS

The medical charts of 199 patients with de novo uterine PSC or CCC who underwent radiotherapy (RT) following surgery between 2001 and 2019 in three radiation oncology departments were retrospectively evaluated. Adjuvant treatment was decided by a multidisciplinary tumor board. All patients were planned to undergo adjuvant 4-6 cycles of chemotherapy with external beam RT (EBRT) and/or vaginal brachytherapy (VBT).

RESULTS

Median age was 63 years for all, 64 years for PSC, and 59 years for CCC, respectively. Complete surgical staging was applied in 98% of patients. Histopathologic subtype was PSC in 142 (71%) and pure CCC in 57 (29%) patients, respectively. FIGO stage was I in 107 (54%), II in 35 (18%), and III in 57 (28%) patients, respectively. Lympho-vascular space invasion and positive peritoneal cytology (PPC) were present in 42% and 10% of patients, respectively. All patients but 23 (12%) underwent adjuvant chemotherapy. Median follow-up was 49.5 months for all patients, 43.9 months for patients with PSC, and 90.4 months for patients with CCC, respectively. During follow-up, 20 (10%) patients developed pelvic recurrence (PR) and 37 (19%) developed distant metastasis (DM). PSC subtype increased the PR and DM rates, although the latter not statistically significant. The 5-year overall survival and disease-free survival rate was 73% and 69% for all patients, 71% and 66% for patients with PSC, and 77% and 75% for patients with CCC, respectively. The difference was more prominent in patients with stage ≥ IB disease. In multivariate analysis, advanced age and PPC significantly decreased all survival rates.

CONCLUSION

PSC has a worse prognosis than CCC with regard to pelvic and distant recurrence with a trend for decreased survival rates. Therefore, a more aggressive therapy is needed for patients with uterine PSC, particularly in patients with stage ≥ IB disease.