Recommendations for Post-Operative Radiotherapy after complete resection of Thymoma - a French DELPHI consensus initiative

BACKGROUND

Thymomas are rare intrathoracic malignancies that can relapse after surgery. Whether or not Post-Operative Radiotherapy (PORT) should be delivered after surgery remains a major issue. RADIORYTHMIC is an ongoing, multicenter, randomized phase 3 trial addressing this question in patients with completely R0 resected Masaoka-Koga stage IIb/III thymoma. Experts in the field met to develop recommendations for PORT.

METHODS

A scientific committee from the RYTHMIC network identified key issues regarding the modalities of PORT in completely resected thymoma. A DELPHI-method was used to question 24 national experts, with 115 questions regarding: 1/ Imaging techniques, 2/ Clinical Target Volume (CTV) and margins, 3/ Dose constraints to Organs At Risk, 4/ Dose and fractionation, 5/ Follow-up and records. Consensus was defined when opinions reached ≥ 80% agreement.

RESULTS

We established the following recommendations: pre-operative contrast-enhanced CT-scan is recommended (94% agreement); optimization of radiation delivery includes either a 4D-CT based planning (82% agreement), a breath-holding inspiration breath-hold-based planning, or daily control CT-imaging (81% agreement); imaging fusion based on cardiovascular structures of pre-operative and planning CT-scan is recommended (82% agreement); right coronary and left anterior descending coronary arteries should be delineated as cardiac substructures (88% agreement); rotational RCMI/VMAT is recommended (88% agreement); total dose is 50Gy (81% agreement) with 1.8-2Gy per fraction (94% agreement); cardiac evaluation, and follow-up for patients with history of cardiovascular disease is recommended (88% agreement) with EKG and evaluation of LVEF at 5 years and 10 years.

CONCLUSION

This is the first consensus for PORT in thymoma. Implementation will help to harmonize practices.

Surface-guided radiotherapy overview: Technical aspects and clinical applications

In radiotherapy, patient positioning has long been ensured by ionizing imaging (kV or MV). Over the past ten years, surface-guided radiotherapy has appeared in radiotherapy departments. It is a continuous three-dimensional acquisition of the surface of the patient, based on the use of several optical cameras. The acquired surface is compared to an expected surface (usually taken from the planning scanner). Operators can constantly appreciate poor position, anatomical deformity or patient shift. Thus, the system allows an aid to the positioning of the patient, possibly without tattooing, but also a follow-up of the patient during the duration of the session. The most obvious contribution of the system concerns the treatment of the breast. In fact, for this location, the bone registration is not ideal and the target is visible in surface-guided radiotherapy. These systems also make it possible to treat in deep inspiration breath hold. But several other locations can benefit from it (pelvis, thorax, etc.).

Stereotactic body radiotherapy for extra-cranial oligoprogressive or oligorecurrent small-cell lung cancer

Introduction

The role of local ablative treatments, including stereotactic body radiotherapy (SBRT), is an area of active research in oligometastatic patients. Small cell lung cancer (SCLC) has a poor prognosis, with common diffuse metastatic evolution. We evaluated the outcomes after SBRT in uncommon oligoprogressive/oligorecurrent SCLC presentation.

Methods

Data of SCLC patients who received SBRT for oligoprogressive/oligorecurrent metastatic disease at four centers were retrospectively analyzed. Patients with synchronous oligometastatic disease, SBRT for primary lung tumor and brain radiosurgery were not included. Relapse and survival rates were defined as the time between the date of SBRT and the first event.

Results

Twenty patients (60% with initially limited-disease [LD]) presenting 24 lesions were identified. Oligoprogression and oligorecurrence were observed in 6/20 (30%) and 14/20 (70%) patients, respectively. SBRT was delivered to one (n = 16) to two (n = 4) lesions (median size, 26 mm), mainly to lung [n = 17/24] metastases. At a median follow-up of 2.9 years, no local relapse was observed and 15/20 patients experienced a distant relapse (DR). The median DR and OS were 4.5 months (95 %CI: 2.9-13.7 months) and 17.2 months (95 %CI: 7.5-65.2 months), respectively. The 3-year distant control and OS rates were 25% (95 %CI: 6-44%) and 37% (95 %CI: 15-59%), respectively. Initial LD (vs extensive-disease) was the only prognosis factor associated with a lower risk of post-SBRT DR (HR: 0.3; 95% CI: 0-0.88; p = 0.03). There was no severe observed SBRT-related toxicities.

Conclusion

Prognosis was poor, with DR occurring in most patients. However, local control was excellent and long term response after SBRT may rarely occur in patients with oligoprogressive/oligorecurrent SCLC. Local ablative treatments should be discussed in a multidisciplinary setting on well-selected cases.

Impact of radiation on host immune system in patients treated with chemoradiotherapy and durvalumab consolidation for unresectable locally advanced non-small cell lung cancer

Background

The optimal modalities of radiotherapy when combining concurrent chemoradiation (CCRT) and immunotherapy (IO) for locally advanced non-small cell lung cancer (LA-NSCLC) remain to be determined. The aim of this study was to investigate the impact of radiation on different immune structures and immune cells in patients treated with CCRT followed by durvalumab.

Material and methods

Clinicopathologic data, pre- and post-treatment blood counts, and dosimetric data were collected in patients treated with CCRT and durvalumab consolidation for LA-NSCLC. Patients were divided into two groups according to the inclusion (NILN-R+) or not (NILN-R-) of at least one non-involved tumor-draining lymph node (NITDLN) in the clinical target volume (CTV). Progression-free survival (PFS) and overall survival (OS) were estimated by the Kaplan-Meier method.

Results

Fifty patients were included with a median follow-up of 23.2 months (95% CI 18.3-35.2). Two-year PFS and 2-year OS were 52.2% (95% CI 35.8-66.3) and 66.2% (95% CI 46.5-80.1), respectively. In univariable analysis, NILN-R+ (hazard ratio (HR) 2.60, p = 0.028), estimated dose of radiation to immune cells (EDRIC) >6.3 Gy (HR 3.19, p = 0.049), and lymphopenia ≤ 500/mm³ at IO initiation (HR 2.69, p = 0.021) were correlated with poorer PFS; lymphopenia ≤ 500/mm³ was also associated with poorer OS (HR 3.46, p = 0.024). In multivariable analysis, NILN-R+ was the strongest factor associated with PFS (HR 3.15, p = 0.017).

Conclusion

The inclusion of at least one NITDLN station within the CTV was an independent factor for poorer PFS in the context of CCRT and durvalumab for LA-NSCLC. The optimal sparing of immune structures might help in achieving better synergy between radiotherapy and immunotherapy in this indication.

Clinical and pathological characterization of 158 consecutive and unselected oligometastatic breast cancers in a single institution

PURPOSE

Data about incidence, biological, and clinical characteristics of oligometastatic breast cancer (OMBC) are scarce. However, these data are essential in determining optimal treatment strategy. Gaining knowledge of these elements means observing and describing large, recent, and consecutive series of OMBC in their natural history.

METHODS

We collected data retrospectively at our institution from 998 consecutive patients diagnosed and treated with synchronous or metachronous metastatic breast cancer (MBC) between January 2014 and December 2018. The only criterion used to define OMBC was the presence of one to five metastases at diagnosis.

RESULTS

Of 998 MBC, 15.8% were classified OMBC. Among these, 88% had one to three metastases, and 86.7% had only one organ involved. Bone metastases were present in 52.5% of cases, 20.9% had progression to lymph nodes, 14.6% to the liver, 13.3% to the brain, 8.2% to the lungs, and 3.8% had other metastases. 55.7% had HR+/HER2- OMBC, 25.3% had HER2+OMBC, and 19% had HR-/HER2- OMBC. The HR+/HER2- subtype statistically correlated with bone metastases (p = 0.001), the HER2+subtype with brain lesions (p = 0.001), and the HR-/HER2- subtype with lymph node metastases (p = 0.008). Visceral metastases were not statistically associated with any OMBC subtypes (p = 0.186). OMBC-SBR grade III was proportionally higher than in the ESME series of 22,109 MBC (49.4% vs. 35.1%, p < 0.001).

CONCLUSION

OMBC is a heterogeneous entity whose incidence is higher than has commonly been published. Not an indolent disease, each subgroup, with its biological and anatomical characteristics, merits specific management.

Diagnosis, biology and epidemiology of oligometastatic breast cancer

Does oligometastatic breast cancer (OMBC) deserve a dedicated treatment? Although some authors recommend multidisciplinary management of OMBC with a curative intent, there is no evidence proving this strategy beneficial in the absence of a randomized trial. The existing literature sheds little light on OMBC. Incidence is unknown; data available are either obsolete or biased; there is no consensus on the definition of OMBC and metastatic sites, nor on necessary imaging techniques. However, certain proposals merit consideration. Knowledge of eventual specific OMBC biological characteristics is limited to circulating tumor cell (CTC) counts. Given the data available for other cancers, studies on microRNAs (miRNAs), circulating tumor DNA (ctDNA) and genomic alterations should be developed Finally, safe and effective therapies do exist, but results of randomized trials will not be available for many years. Prospective observational cohort studies need to be implemented.

Quality assurance program and early toxicities in the phase III BONBIS randomized trial evaluating the role of a localized radiation boost in ductal carcinoma in situ

PURPOSE

To describe the quality assurance (QA) program and early toxicities in the phase III randomized trial BONBIS (NCT00907868) on the role of a localized radiation boost in ductal carcinoma in situ (DCIS).

MATERIALS AND METHODS

From November 2008 to July 2014, 2004 patients were randomized in arm A (only whole breast radiotherapy, WBRT) and arm B (WBRT + boost). The QA program involved 44 participant centers that performed the dummy run (DR). Compliance and uniformity of clinical target volume (CTV) delineations, and dose prescription and delivery according to the BONBIS trial radiotherapy guidelines were analyzed. Acute toxicities (during and up to 3 months after radiotherapy completion, NCI-CTCAE v3.0 classification) were evaluated in 1929 patients.

RESULTS

The differences in whole breast CTV (CTV1) and planning target volume (PTV1) were ≤10%, and the differences in boost CTV (CTV2) and PTV (PTV2) were ≥20% compared with the reference DR values; 95% of the prescribed dose encompassed 98.7% and 100% of the median CTV1 and CTV2. Grade ≥2 breast erythema (38.3% vs. 22.4% of grade 2 and 5.4% vs. 2.1% of grade 3, p < 0.001), grade ≥2 dermatitis (2.8% vs. 0.7%, p < 0.001), and grade 2 hyperpigmentation (6.9% vs. 3.6%, p = 0.005) were more frequent in arm B than arm A. No acute lung or cardiac toxicity was observed. Smoking history, large breast size, and large breast CTV were strong predictive factors of grade ≥2 acute skin toxicities.

CONCLUSIONS

The QA program showed deviations in breast and tumor bed delineation. The boost significantly increased acute skin toxicities.

[Rib fracture following intra-operative radiotherapy for breast cancer. Case Report and local experience]

Intra-operative radiotherapy for breast cancer has been developed throughout the last two decades. It is already well-established regarding local control and toxicity for intra-operative radiotherapy using electrons as we now have the necessary background knowledge. However, very few data on later toxicity are available for intra-operative radiotherapy using low-energy photons. We report here the case of a 36-year-old woman who experienced rib fracture following intra-operative and external radiotherapy. This patient has been included in the Targit-boost trial. The intra-operative irradiation has been operated with an INTRABEAM device delivering low-energy photons of 50-kV.

[Image-guided radiotherapy in lung cancer]

Image-guided radiotherapy takes place at every step of the treatment in lung cancer, from treatment planning, with fusion imaging, to daily in-room repositioning. Managing tumoral and surrounding thoracic structures motion has been allowed since the routine use of 4D computed tomography (4DCT). The integration of respiratory motion has been made with "passive" techniques based on reconstruction images from 4DCT planning, or "active" techniques adapted to the patient's breathing. Daily repositioning is based on regular images, weekly or daily, low (kV) or high (MV) energy. MRI and functional imaging also play an important part in lung cancer radiation and open the way for adaptative radiotherapy.

Abstract P3-12-10: First 6-month report of the longitudinal PHACS study (Pharmacology and Hormonotherapy (HT) for Adjuvant breast Cancer (BC) Study, NCT01127295)

Background: BC is a hormone-dependent disease for 75% of pts. HT is used in both adjuvant and metastatic settings for hormone–receptor (HR) positive tumors. In adjuvant situation, a 5-year HT period at least is recommended. Side-effects (SE) frequently alter quality of life and compliance, reducing the well-known benefits in risks of relapses and specific deaths. Underlying mechanisms are well understood for estrogen deprivation-induced events such as hot flashes, but little is known on arthralgia under aromatase inhibitors (AI). So, pharmacogenomics (PG), pharmacokinetics (PK), potential medications interactions are of value to explain individual drugs exposures, possible related side-effects and compliance to treatment.

Methods: We performed a prospective, multicenter, longitudinal study registering early clinical outcomes and SE during the first 3 years of adjuvant HT with tamoxifen (T) or AI. All tumors expressed at least one HR (&gt;10%). The choice of HT molecule and one-drug or sequential treatment were left to the investigator. Pts were followed every 6 months with clinical examination by the referent oncologist and PK sampling each time. Biologic research consisted in PG investigations of different genes involved in the PK and pharmacodynamics of T and AI (95 SNPs) at baseline. SE, concurrent medications and compliance were registered by both the pts on a diary card and the physician. Evaluation was done only on new occurrence or increased grade of symptoms.

Results: This first report focuses on characteristics of the population and the results after the 6 first months of treatment. Between June 2010 and October 2014, 23 centers recruited 2000 pts. 23 were excluded leaving 1977 fully evaluable women; 879 (44%) started with T, 1098 (55%) with AI (554 letrozole (L), 390 anastrozole (A), 154 exemestane (E)). 56% of them had previously received chemotherapy, 96% radiotherapy and 8% trastuzumab.

Main characteristics were well balanced between the 2 classes of drugs; T was given mainly for pre- or perimenopausal pts. Most frequent co-morbidities were hypertension (8% T, 31% AI) and dyslipidemia or diabetes (T 11%, AI 26%). To note, almost 30% of pts described arthralgias at entrance and 37% had hot flashes.

At 6 months, 122 pts (6%; 43 T, 79 AI) had stopped treatment mainly for toxicity (11 T; 12 AI), progression or death (7 T; 4 IA), personal reasons (15 T; 37AI); 4 asked for changing T and 52 AI (equally for the 3 drugs). All these events were significantly more frequent for AI pts (p=0.042) and with E within the AI class (p&lt;0.001).

Main changes in onset or increased intensity of symptoms concerned hot flushes with all drugs (30%), asthenia (20%), insomnia (20%), weight gain (17%), arthralgias (15% for T, 30% for AI), thrombotic events (24 of which 11 with T). 3 grade3 SAE HT-related were reported.

Biological data are reported in 2 other abst. (M. White-Koning. abst.#850248, F. Thomas, abst.#851525).

Conclusions: These preliminary data on the first 6-months exposure to HT on adjuvant setting in the real-life confirm early rates of withdraws and toxicities. Longer follow-up and subsequent PK analysis should help to understand persistent side-effects and reasons for non-compliance to adjuvant HT.

Citation Format: Roché H, Venat-Bouvet L, Debled M, Jacot W, Suc E, Dalenc F, Molnar-Stanciu D, Dohollou N, Franck D, Ferrer C, Laharie-Mineur H, Lavau-Denes S, Massabeau C, Mauries V, Robert J, Pinguet F, Marquet P, Evrard A, Chatelut E, Filleron T. First 6-month report of the longitudinal PHACS study (Pharmacology and Hormonotherapy (HT) for Adjuvant breast Cancer (BC) Study, NCT01127295) [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-12-10.

Continuous Infusion of Cilengitide Plus Chemoradiotherapy for Patients With Stage III Non-Small-cell Lung Cancer: A Phase I Study

INTRODUCTION

Because of our previous preclinical results, we conducted a phase I study associating the specific αvβ3/αvβ5 integrin inhibitor cilengitide, given as a continuous infusion, with exclusive chemoradiotherapy for patients with stage III non-small-cell lung cancer.

PATIENTS AND METHODS

A standard 3+3 dose escalation design was used. Cilengitide was given as a continuous infusion (dose levels of 12, 18, 27, and 40 mg/h), starting 2 weeks before and continuing for the whole course of chemoradiotherapy (66 Gy combined with platinum/vinorelbine), and then at a dose of 2000 mg twice weekly in association with chemotherapy. 2-Deoxy-2-[fluorine-18]fluoro-d-glucose positron emission tomography (PET) and computed tomography scans were performed before and after the first 2 weeks of cilengitide administration and then every 3 months.

RESULTS

Of the 14 patients included, 11 were evaluable for evaluation of the dose-limiting toxicities (DLTs). One DLT, a tracheobronchial fistula, was reported with the 40 mg/h dose. No relevant adverse events related to cilengitide were observed overall. At the PET evaluation 2 months after chemoradiotherapy, 4 of 9 patients had a complete response and 4 had a partial response. The median progression-free and overall survival was 14.4 months (95% confidence interval [CI], 8.4 to not reached) and 29.4 months (95% CI, 11.73 to not reached), respectively.

CONCLUSION

Cilengitide, given continuously with chemoradiotherapy, showed acceptable toxicity and gave encouraging clinical results.

Multidisciplinary Tumor Board Decision Making for Postoperative Radiotherapy in Thymic Epithelial Tumors: Insights from the RYTHMIC Prospective Cohort

INTRODUCTION

Thymic epithelial tumors (TETs) are rare intrathoracic malignancies for which surgery represents the mainstay of the treatment. Current practice for postoperative radiotherapy (PORT) is highly variable, and there is a lack of prospective, high level evidence. Réseau Tumeurs Thymiques et Cancer (RYTHMIC) is the nationwide network for TETs in France. Established in 2012, it prospectively collects data on all TET patients, for whom management is discussed at a national multidisciplinary tumor board (MTB). We assessed whether PORT decisions at the MTB were in accordance with RYTHMIC guidelines and ultimately implemented in patients.

METHODS

All consecutive patients for whom PORT was discussed at the MTB from 2012 to 2015 were identified from the RYTHMIC prospective database, and a complete review of their medical records was performed.

RESULTS

A total of 274 patients, including 243 with thymoma (89%) and 31 with thymic carcinoma (11%), were analyzed. The decision of the MTB was in accordance with guidelines in 221 patients (92%) of the 241 with stage I or III TET. An MTB decision to deliver PORT was made for 117 patients (43%). PORT was ultimately initiated in 101 patients. The most frequent reason for not delivering PORT was excessive (>3 months) delay after surgery. Dose-volume constraints defined by the International Thymic Malignancy Interest Group were followed in all but four patients.

CONCLUSION

Our data provide a unique insight into the decision-making process for PORT in TETs, highlighting the need for systematic discussion at an expert MTB, while stressing the value of current available guidelines.

Phase II Study of a Radiotherapy Total Dose Increase in Hypoxic Lesions Identified by 18F-Misonidazole PET/CT in Patients with Non-Small Cell Lung Carcinoma (RTEP5 Study)

See an invited perspective on this article on page 1043.This multicenter phase II study investigated a selective radiotherapy dose increase to tumor areas with significant ¹⁸F-misonidazole (¹⁸F-FMISO) uptake in patients with non-small cell lung carcinoma (NSCLC). Methods: Eligible patients had locally advanced NSCLC and no contraindication to concomitant chemoradiotherapy. The ¹⁸F-FMISO uptake on PET/CT was assessed by trained experts. If there was no uptake, 66 Gy were delivered. In ¹⁸F-FMISO-positive patients, the contours of the hypoxic area were transferred to the radiation oncologist. It was necessary for the radiotherapy dose to be as high as possible while fulfilling dose-limiting constraints for the spinal cord and lungs. The primary endpoint was tumor response (complete response plus partial response) at 3 mo. The secondary endpoints were toxicity, disease-free survival (DFS), and overall survival at 1 y. The target sample size was set to demonstrate a response rate of 40% or more (bilateral α = 0.05, power 1-β = 0.95). Results: Seventy-nine patients were preincluded, 54 were included, and 34 were ¹⁸F-FMISO-positive, 24 of whom received escalated doses of up to 86 Gy. The response rate at 3 mo was 31 of 54 (57%; 95% confidence interval [CI], 43%-71%) using RECIST 1.1 (17/34 responders in the ¹⁸F-FMISO-positive group). DFS and overall survival at 1 y were 0.86 (95% CI, 0.77-0.96) and 0.63 (95% CI, 0.49-0.74), respectively. DFS was longer in the ¹⁸F-FMISO-negative patients (P = 0.004). The radiotherapy dose was not associated with DFS when adjusting for the ¹⁸F-FMISO status. One toxic death (66 Gy) and 1 case of grade 4 pneumonitis (>66 Gy) were reported. Conclusion: Our approach results in a response rate of 40% or more, with acceptable toxicity. ¹⁸F-FMISO uptake in NSCLC patients is strongly associated with poor prognosis features that could not be reversed by radiotherapy doses up to 86 Gy.

Outcome of pN0 Triple-Negative Breast Cancer with or without Lymph Node Irradiation: A Single Institution Experience

The optimal management of patients with pathologically node-negative triple-negative breast cancer (pN0 TNBC) remains unclear. We hypothesized that lymph node irradiation (LNI; internal mammary chain/periclavicular irradiation) had an impact on outcomes of pN0 TNBC. A cohort of 126 consecutive patients with pN0 TNBC treated between 2007 and 2010 at a single institute were included. All radiotherapy (breast/chest wall, ±LNI) was delivered adjuvantly, following completion of surgery ± chemotherapy. Tumors were reviewed and histologic features were described. Tissue microarrays were constructed and tumors were assessed by immunohistochemistry using antibodies against ER, PR, HER2, Ki-67, cytokeratins 5/6, 14, epidermal growth factor receptor and androgen receptor. Patients were divided into two groups for statistical analysis: LNI (LNI+) or no LNI (LNI-). We focused on disease-free survival (DFS), metastasis-free survival (MFS), and overall survival (OS). Fifty-seven and 69 patients received or not LNI, respectively. Median age was 52 (range [25-76]) and 55 (range [29-79]) in LNI+ and LNI- group (p = 0.23). LNI was associated with larger tumors (p = 0.033), central/internal tumors (33 versus 4, p < 0.01) and more chemotherapy (86% versus 59.4% p < 0.01). The median follow-up was 53.5 months. The rate of first regional relapse (associated or not with distant relapse) was low in both groups. There was no difference in 4-year DFS (82.2% versus 89.9%; p = 0.266), MFS (87.0% versus 91.1%; p = 0.286) and OS (85.8% versus 89.9%; p = 0.322) between LNI+ and LNI- group, respectively. In univariate analysis, only clinical size (T >10 mm versus ≤10 mm), histologic size (pT >10 mm versus ≤10 mm) and grade 3 (versus grade 2) were found to be significantly associated with shorter DFS. Omission of LNI in patients with pN0 TNBC does not seem to result in poorer outcome. Further studies are needed to specifically evaluate LNI in pN0 TNBC with histologic grade 3 and/or (p)T >10 mm.

[Breast ductal carcinoma in situ with microinvasion: pathological review and clinical implications]

PURPOSE

Recent improvements in the detection of breast cancer at an early stage have resulted in a rising incidence of breast ductal carcinoma in situ with microinvasion. So far, there is no consensus regarding its optimal management. We hereby report on our 10-year single institutional experience in breast ductal carcinoma in situ with microinvasion including pathological reviewing.

PATIENTS AND METHODS

All consecutive patients treated for a ductal carcinoma in situ with microinvasion at the Institut Claudius-Regaud (Toulouse, France) over a 10-year period were included in this study. We reviewed all available histological materials.

RESULTS

Sixty-three patients were eligible for this study. Two patients presented with a lymph node invasion at diagnosis. Each patient benefited from initial surgical management, which consisted either in mastectomy (n=25) or conservative resection (n=37). Axillary exploration was performed in 52 patients (82%). After a median follow-up of 61.3 months [46.9;69], the 5-year overall survival and disease free survival were 98.2 (95% CI=[88.2;99.7]) and 89.5% (95% CI=[76.3;95.6]) respectively. Two delayed invasive relapses occurred leading to one specific death. The pathological review highlighted a trend towards a loss of HR and HER2 expression (9%) in the microinvasive component in comparison with its surrounded in situ carcinoma.

CONCLUSION

The risk of initial lymph node involvement and delayed invasive local relapse deserve an optimal locoregional management including lymph node evaluation. The non-negligible discrepancy's rate between in situ and microinvasive components justifies HR status and HER2 expression assessment on the microinvasive component.

Early experience of helical tomotherapy for hepatobiliary radiotherapy

Helical tomotherapy (HT), an image-guided, intensity-modulated, radiation therapy technique, allows for precise targeting while sparing normal tissues. We retrospectively assessed the feasibility and tolerance of the hepatobiliary HT in 9 patients. A total dose of 54 to 60 Gy was prescribed (1.8 or 2 Gy per fraction) with concurrent capecitabine for 7 patients. There were 1 hepatocarcinoma, 3 cholangiocarcinoma, 4 liver metastatic patients, and 1 pancreatic adenocarcinoma. All but one patient received previous therapies (chemotherapy, liver radiofrequency, and/or surgery). The median doses delivered to the normal liver and to the right kidney were 15.7 Gy and 4.4 Gy, respectively, below the recommended limits for all patients. Most of the treatment-related adverse events were transient and mild in severity. With a median followup of 12 months, no significant late toxicity was noted. Our results suggested that HT could be safely incorporated into the multidisciplinary treatment of hepatobiliary or pancreatic malignant disease.