Intermediate-risk endometrial cancer treated with adjuvant brachytherapy using single dosimetric planning: long-term outcome and toxicity assessment

OBJECTIVE

Brachytherapy of the vaginal dome is the recommended adjuvant treatment for intermediate-risk endometrial cancer. This study assessed the results of dosimetric planning of high-dose-rate brachytherapy exclusively in the first treatment session.

STUDY DESIGN

This retrospective study included all patients who underwent hysterectomy for endometrial cancer followed by adjuvant brachytherapy of the vaginal dome between 2012 and 2015. Local recurrence rates, overall survival (OS) rates, recurrence-free survival (RFS) rates, and related acute and late toxicity rates were evaluated.

RESULTS

This analysis included 250 patients, of whom 208 were considered to be at high-intermediate risk of disease recurrence. After a median follow-up of 56 months, the cumulative incidence of local recurrence was 4.8% at 3 years [95% confidence interval (CI) 2.8-8.3] and 7.8% at 5 years (95% CI 4.8-12.6). The 5-year OS rate was 86.2% (95% CI 80.6-90.3), and the 5-year RFS rate was 77.5% (95% CI 71.1-82.7). Acute toxicity occurred in 20 (8%) patients, of which two patients had grade ≥3 toxicity. Only one patient (0.4%) presented with late grade ≥3 toxicity.

CONCLUSION

These findings confirm the tolerability of this brachytherapy approach, indicating minimal cases of late grade ≥3 toxicity, associated with a good 5-year OS rate. With the advent of molecular prognostic factors, the current focus revolves around discerning those individuals who gain the greatest benefit from adjuvant therapy, and tailoring treatment more effectively.

Prognostic impact of post-treatment FDG PET/CT in anal canal cancer: A prospective study

BACKGROUND AND PURPOSE

The aim of our prospective study was to assess the prognostic value of 18F-FDG PET/CT performed two months post treatment for anal canal neoplasm.

POPULATION AND METHODS

Consecutive patients with histologically proved anal cancer, with 18F-FDG PET/CT pre and two months post treatment were included. Patients were not previously treated for this neoplasm and then received radiotherapy ± chemotherapy. Clinical and pathologic data were collected and for 18F-FDG PET/CT visual and quantitative analysis (standardized uptake value, metabolic volume) were performed; response was classified according to EORTC and PERCIST criteria. The results were assessed for disease free survival and local recurrence free survival using the log-Rank test RESULTS: From December 2014 to September 2019, 94 consecutive patients were screened and 78 were included in this study. Median follow-up was 51 months. Two months post treatment, 37 patients (47.4%) had a complete radiological response according to both EORTC and PERCIST criteria, 66 patients (84.6%) had a clinical complete response. For disease free survival, the prognostic value of complete response was statistically significant (p=0.02) with 18F-FDG PET/CT and with clinical examination (p<0.001). For local recurrence free survival, the prognostic value with 18F-FDG PET/CT was lower (p=0.04) than clinical examination (p < 0.007).

CONCLUSION

While clinical examination remains the gold standard for post treatment evaluation in anal cancer, 18F-FDG PET/CT has a statistically significant prognostic value. These two assessments could be combined to improve early evaluation.

Post-operative flank irradiation using conformal versus highly conformal radiotherapy techniques for paediatric renal tumours: Results from the French registry PediaRT

PURPOSE

Three-dimensional conformal RT (3D-RT) techniques are gold standard for post-operative flank radiotherapy (RT) in paediatric renal tumours. Recently, highly conformal RT (HC-RT) techniques have been implemented without comparative clinical data. The main objective of this multicentre study was to compare locoregional control (LRC) in children treated either with HC-RT or 3D-RT techniques.

METHODS

Patients treated with post-operative flank RT for renal tumour registered in the national cohort PediaRT between March 2013 and September 2019 were included. Treatment and follow-up data, including toxicities and outcomes, were retrieved from the database. LRC was calculated, and dose reconstruction was performed in case of an event.

RESULTS

Seventy-nine patients were included. Forty patients were treated with HC-RT and 39 with 3D-RT. Median follow-up was 4.5 years. Three patients had locoregional failure (LRF; 4%). HC-RT was not associated with a higher risk of LRF. Three-year LRC were 97.4% and 94.7% in the HC-RT and 3D-RT groups, respectively. The proportion of planning target volumes receiving 95% or more of the prescribed dose did not significantly differ between both groups (HC-RT 88%; 3D-RT 69%; p = .05). HC-RT was better achieving dose constraints, and a significant mean dose reduction was observed in the peritoneal cavity and pancreas associated with lower incidence of acute gastrointestinal toxicity.

CONCLUSION

LRF after post-operative flank RT for renal tumours was rare and did not increase using HC-RT versus 3D-RT techniques. Dose to the pancreas and the peritoneal cavity, as well as acute toxicity, were reduced with HC-RT compared to 3D-RT.

Failure of Initial Curative Treatment for Non-Metastatic Anal Squamous Cell Carcinoma: From Prognostic Factors Analysis to Stratified Treatment

In squamous cell anal canal neoplasms, persistent disease or recurrence after initial chemoradiotherapy are not the rule, yet their occurrence deserves to be analyzed to better identify prognostics factors. The aim of our study was to describe the patterns of failures of the initial treatment, their subsequent evolution and to identify prognostic factors in these relapsed patients. All patients with non-metastatic anal squamous cell carcinoma initially treated with curative intent at the Centre Antoine Lacassagne between 1999 and 2019, and who presented persistent disease or recurrence were analyzed. The median follow-up was 44 months. Univariate and multivariate analyses were performed to identify prognostic factors. From our database of 528 patients, 77 patients were eligible: 25 with persistent disease and 52 with recurrence after complete response. The median overall survival was 39 months (95% CI: 25.5-52.3 months) from the date of treatment failure. In univariate analysis, prognostic factors were gender, initial lymph node status, type of failure, response to treatment's failure. In multivariate analysis, only female gender remained statistically significant (HR 0.43- P=0.016). 32% of patients with persistent disease had metastatic status. 17.3% and 5.8% of recurrences respectively occurred after three and five years of follow-up. Systematic imaging could be performed after initial treatment because of distant lesions in one third of patients with persistent disease. The follow-up should not be interrupted before five years, given the significant frequency of late recurrences. In multivariate analysis, only female gender was statistically significant. Stratified treatment based on prognostic factors could be envisaged, the details of which remain to be defined.

Fractionated Stereotactic Radiation Therapy for Pituitary Adenomas: An alternative escalating protocol of hypofractionated stereotactic radiotherapy delivering 35Gy in 5 fractions

PURPOSE

Evaluate efficacy and toxicity of hypofractionated stereotactic radiotherapy (HSRT) for patients treated for pituitary adenoma (PA) with an alternative HSRT escalating protocol delivering 35Gy in 5 fractions.

MATERIAL AND METHODS

From June 2007 to March 2017, 29 patients with pituitary adenoma were treated in Antoine Lacassagne Cancer Centre with an alternative HSRT protocol. Prescribed dose was 35Gy in 5 fractions of 7Gy. Radiographic responses were assessed by annual MRI. Hormone blood samples were evaluated each year after HSRT.

RESULTS

A total of 29 patients aged between 23 and 86 years (median 54 years) were included. Twelve patients received HSRT for recurrent cases and 12 received postoperative adjuvant HSRT, 5 patients did not have surgery. After a median follow-up period of 47 months local control rate was 96%. One patient presented an out-field tumor regrowth 73 months after HSRT. The majority of PA were endocrine-active (18 patients, 62%). After HSRT, 8 patients (44%) presented complete response on initial secretion, 4 patients (23%) presented partial response on initial secretion. Four patients (14%) presented grade 2 or more acute radiation toxicities. One grade 4 visual disorder was observed for one patient.

CONCLUSIONS

HSRT delivering 35Gy in 5 fractions represents a feasible treatment and shows promising results to reduce hormonal overproduction and to improve local control in PA.

Usefulness of Stereotactic Body Radiation Therapy for Treatment of Adrenal Gland Metastases

Purpose: This study aimed to describe our institutional experience in the use of stereotactic body radiation therapy (SBRT) for the management of adrenal gland metastases from multiple primary cancers. Materials and Methods: We retrospectively reviewed 31 patients who underwent SBRT as treatment for 33 adrenal gland lesions in the academic radiotherapy department of Oscar Lambret cancer center between May 2011 and September 2018. The primary study endpoints were 1- and 2-year local control rates, defined as the absence of progression at the treatment site based on the response evaluation criteria in solid tumors (RECIST). Toxicities were graded in accordance with the Common Terminology Criteria for Adverse Events version 4.03. Results: The average tumor volume was 33.5 cm³ (standard deviation: 51.7 cm³), and the prescribed dose ranged from 30 to 55 Gy given in 3-9 fractions. The median biological effective dose was 112.5 Gy (range: 45-115.5 Gy), assuming α/β = 10. Considering progression at distant sites or death as competing events, the 1- and 2-year actuarial local control rates were 96.5% (95% confidence interval: 84.9-99.7) and 92.6% (95% confidence interval: 79.2-98.7), respectively. According to RECIST, a complete response was achieved in 10 (32.3%) lesions, a partial response in 10 (32.3%) lesions, and stability in 8 (25.8%) lesions. Three patients presented with local relapse at 8.8, 14, and 49.4 months. After a median follow-up of 18 months (range: 4.4-66.4), the median overall survival was 33.5 months (95% confidence interval: 17-not reached), while the median progression-free survival was 7.4 months (95% confidence interval: 3.8-14.1). Treatment-related toxicity was grade 1 or 2 in 42.4% of patients, including nausea (27.3%), abdominal pain (18.2%), vomiting (15.2%), and asthenia (9.1%). None of the patients developed acute grade ≥3 or late toxicity. Conclusion: SBRT seems to be a safe and effective treatment for adrenal gland metastases in patients whose primary tumor and metastatic spread are controlled by systemic treatment. With a 2-year local control rate of 92.6%, SBRT may be considered as one of the first-line treatments in oligometastatic patients with adrenal metastases.

Rehabilitation of a hemiplegic patient with cardiac assistive device

INTRODUCTION

Possible admission to a PRM unit of a hemiplegic patient equipped with a left ventricular assistance device (LVAD) may constitute a cause for concern. We are reporting our observation on the subject.

OBSERVATION

A 30-year-old hemiplegic patient presented with left hemiparesis secondary to a right middle cerebral artery (MCA) ischemic stroke having occurred during cardiopulmonary arrest. Persistence of major left ventricle dysfunction necessitated installation on 8 November 2011 of a mono-ventricular HEART-MATE II assistive device. Possible later recourse to cardiac transplantation would depend on clinical development. When admitted to a PRM unit on 18 January 2012, the patient presented with left hemiparesis and cognitive disorders. Virtually all members of the attendant medical and paramedical team were given instruction on the functioning of electrical power assistance systems. In spite of the complexity of the logistics, and notwithstanding the difficulty of managing potentially worrisome medical problems, multidisciplinary rehabilitation efforts were successful. The patient's improved condition led to the decision to undertake heart transplantation, which was carried out on 27 October 2012.

DISCUSSION AND CONCLUSION

This observation illustrates the undeniable role of PRM in decision-making and, more generally, in the opportunities that may arise in sensitive and challenging situations.

Reconstruction of 12 MV bremsstrahlung spectra from measured transmission data by direct resolution of the numeric system AF = T

An investigation of x-ray spectral reconstruction from transmission data by direct resolution of the matrix system A*F = T (using spectral algebra formalism) has been previously presented. The resolution has been done with simulated spectrum. In this paper, the method on a real case of a 12 MV photon beam was tested. A special study of the setup has been made to estimate and reduce the experimental errors that could alter the results. In order to convert F(E) (a fraction of the signal due to a photon of energy E) into photon fluence phi (E), the chamber energy response R(E) has been studied and an approximated analytical function for its representation was proposed. Spectra reconstructed from different transmission data using different attenuators, buildup caps, and ionization chambers have been compared to verify the uniqueness of the reconstructed spectra. To test the validity of the results, dosimetric values, such as Depth Dose Data have been calculated, from our spectrum, using a specific code developed by Kosunen et al. The results show a good agreement between the measured and calculated data.

Simulation of x-ray spectral reconstruction from transmission data by direct resolution of the numeric system AF = T

X-ray spectral reconstruction from transmission data was investigated by direct resolution of the matrix system A*F = T using spectral algebra. Theoretical, numerical, and physical conditions were studied to obtain the physical solution of the problem. It is shown why the least-square-fitting methods may not give good results for high energy photon spectra above several MeV. The proposed method does not need a preshaped starting spectrum. Simulation studies have been made with arbitrary but realistic spectra of different shapes and maximum energies simulating the reality and using different materials as attenuator like carbon, aluminum, and even water. Conditions on the attenuator choice to obtain the physical solution of the system are given. The reconstruction method provides good results in the radiotherapy energy range despite measurement errors. The computation is quick and implementable on a personal computer with a mathematical coprocessor.