Single vs. multiple fraction non-inferiority trial of stereotactic ablative radiotherapy for the comprehensive treatment of oligo-metastases/progression: SIMPLIFY-SABR-COMET

BACKGROUND

Radiotherapy delivery regimens can vary between a single fraction (SF) and multiple fractions (MF) given daily for up to several weeks depending on the location of the cancer or metastases. With limited evidence comparing fractionation regimens for oligometastases, there is support to explore toxicity levels to nearby organs at risk as a primary outcome while using SF and MF stereotactic ablative radiotherapy (SABR) as well as explore differences in patient-reported quality of life and experience.

METHODS

This study will randomize 598 patients in a 1:1 ratio between the standard arm (MF SABR) and the experimental arm (SF SABR). This trial is designed as two randomized controlled trials within one patient population for resource efficiency. The primary objective of the first randomization is to determine if SF SABR is non-inferior to MF SABR, with respect to healthcare provider (HCP)-reported grade 3-5 adverse events (AEs) that are related to SABR. Primary endpoint is toxicity while secondary endpoints include lesional control rate (LCR), and progression-free survival (PFS). The second randomization (BC Cancer sites only) will allocate participants to either complete quality of life (QoL) questionnaires only; or QoL questionnaires and a symptom-specific survey with symptom-guided HCP intervention. The primary objective of the second randomization is to determine if radiation-related symptom questionnaire-guided HCP intervention results in improved reported QoL as measured by the EuroQoL-5-dimensions-5levels (EQ-5D-5L) instrument. The primary endpoint is patient-reported QoL and secondary endpoints include: persistence/resolution of symptom reporting, QoL, intervention cost effectiveness, resource utilization, and overall survival.

DISCUSSION

This study will compare SF and MF SABR in the treatment of oligometastases and oligoprogression to determine if there is non-inferior toxicity for SF SABR in selected participants with 1-5 oligometastatic lesions. This study will also compare patient-reported QoL between participants who receive radiation-related symptom-guided HCP intervention and those who complete questionnaires alone.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT05784428. Date of Registration: 23 March 2023.

Recovery Trajectories in Adolescent Girls with Anorexia Nervosa

Background: This study aimed to document recovery trajectories among adolescents with anorexia nervosa (AN) based on three markers of remission, namely changes in body weight, food restriction, and excessive exercise, and to identify predictors of these trajectories. Methods: One hundred twenty-six adolescent girls (14.7 ± 1.3 years) were recruited during initial assessment visits at specialized eating disorder (ED) programs in five University Health Centers across the province of Quebec, Canada. z-BMI and AN symptom severity (food restriction and excessive exercise) were assessed at initial assessment visits and subsequently reassessed at each quarterly follow-up over a 12-month period to identify recovery trajectories. Results: Considering the three markers of remission, three distinct trajectories emerged: Group 1, rapid responders; Group 2, gradual responders; and Group 3, unstable responders. At initial visits, a difference between groups was found regarding the type of treatment (p = 0.01) and weight suppression (p = 0.02). Group 1 had a higher number of youths hospitalized than Group 2 and Group 3, and a greater weight suppression than Group 3. Furthermore, individuals with atypical AN were more likely to belong to Group 2 than to Group 1 and Group 3 (p < 0.0001). Conclusions: This study contributes to a better understanding of the heterogeneity of recovery trajectories in adolescent girls with AN.

Anorexia Nervosa in Adolescence: A Comprehensive Study of Multidimensional Factors Associated with Symptom Severity 1 Year Following the Diagnosis

The overarching goal of this study was to examine the unique contribution of psychological, familial, and friendship factors in explaining anorexia nervosa (AN) symptom severity 1 year following diagnosis among a sample of adolescent girls. A second objective was to determine whether friendship factors mediated the association between psychological and/or familial factors and AN symptom severity. This study included 143 adolescent girls under the age of 18 diagnosed with AN (M = 14.84, SD = 1.31). Participants were recruited from specialized eating disorder treatment programs. At admission (T1), participants completed a set of self-report questionnaires measuring psychological, familial, and friendship factors. AN symptom severity was assessed 1 year later (T2). Results of hierarchical regression analysis revealed that greater general psychological maladjustment at T1 (b = .26; se = .03; p = .00) was associated with greater AN symptom severity at T2. Greater alienation from friends at T1 (b = 1.20, se = .53, p = .03) also predicted greater AN symptom severity at T2, above and beyond the influence of adolescent girls' general psychological maladjustment. Finally, the mediating role of alienation from friends in the association between general psychological maladjustment at T1 and AN symptom severity at T2 was also identified. AN is a multidimensional disorder with a prognosis that involves both psychological and social factors. The results stemming from the present study shed light on the role of peer as a mechanism through which general psychological maladjustment is linked to AN symptom severity 1 year following diagnosis.

[An innovative process for sustaining and scaling up a school-based mental health promotion and anxiety prevention programs: The example of the HORS-PISTE program]

Context Anxiety disorders are among the most prevalent psychopathologies for children and adolescents in Quebec. The prevalence of anxiety disorders is very high and has been affecting a growing number of young people for the past 10 years. It is possible to observe an increased number of anxiety prevention programs for young people around the world. However, some authors point out that they are rarely faithfully implemented, sustained, and scaled up in several schools. Based on implementation science, this HORS-PISTE program was developed to address these important issues by preventing anxiety in Quebec high school students. Implemented in more than 100 schools, the program is now part of Action 4.3 (Promote the deployment of the HORS-PISTE program) of the new interdepartmental Action Plan on Mental Health of the Government of Quebec (2022). Purpose This article aims to describe how the Knowledge-to-Action (KTA) framework, derived of implementation science, was used to design, implement, sustain, evaluate, and scale up the HORS-PISTE program. This framework proposes a cyclical process in seven phases. Method A multi-method and multi-stakeholder approach was conducted with a grant from the Public Health Agency of Canada's Mental Health Promotion Innovation Fund, which has been supporting 20 innovative projects across Canada since 2019. It includes a pre-post evaluation protocol consisting of validated questionnaires, surveys (administered to students, parents, and teachers), semi-structured logbooks completed by program facilitators and implementation review meetings in each school. The different cycles of the program development, implementation and evaluation are discussed through the KTA framework phases. Results From 2017 to 2021, this methodology made it possible to evaluate and readjust the program each year to promote its adaptation and prepare its scaling up. This article highlights the data collected and analyzed in relation to the seven phases of the KTA framework. Conclusion This article demonstrates how implementation science can support designers of anxiety prevention programs who are concerned by scaling up and sustaining their programs. Issues in combining the scientific rigor of evaluation with the reality of the field are also raised.

Stereotactic body radiotherapy versus conventional external beam radiotherapy in patients with painful spinal metastases: an open-label, multicentre, randomised, controlled, phase 2/3 trial

BACKGROUND

Conventional external beam radiotherapy is the standard palliative treatment for spinal metastases; however, complete response rates for pain are as low as 10-20%. Stereotactic body radiotherapy delivers high-dose, ablative radiotherapy. We aimed to compare complete response rates for pain after stereotactic body radiotherapy or conventional external beam radiotherapy in patients with painful spinal metastasis.

METHODS

This open-label, multicentre, randomised, controlled, phase 2/3 trial was done at 13 hospitals in Canada and five hospitals in Australia. Patients were eligible if they were aged 18 years and older, and had painful (defined as ≥2 points with the Brief Pain Inventory) MRI-confirmed spinal metastasis, no more than three consecutive vertebral segments to be included in the treatment volume, an Eastern Cooperative Oncology Group performance status of 0-2, a Spinal Instability Neoplasia Score of less than 12, and no neurologically symptomatic spinal cord or cauda equina compression. Patients were randomly assigned (1:1) with a web-based, computer-generated allocation sequence to receive either stereotactic body radiotherapy at a dose of 24 Gy in two daily fractions or conventional external beam radiotherapy at a dose of 20 Gy in five daily fractions using standard techniques. Treatment assignment was done centrally by use of a minimisation method to achieve balance for the stratification factors of radiosensitivity, the presence or absence of mass-type tumour (extraosseous or epidural disease extension, or both) on imaging, and centre. The primary endpoint was the proportion of patients with a complete response for pain at 3 months after radiotherapy. The primary endpoint was analysed in the intention-to-treat population and all safety and quality assurance analyses were done in the as-treated population (ie, all patients who received at least one fraction of radiotherapy). The trial is registered with ClinicalTrials.gov, NCT02512965.

FINDINGS

Between Jan 4, 2016, and Sept 27, 2019, 229 patients were enrolled and randomly assigned to receive conventional external beam radiotherapy (n=115) or stereotactic body radiotherapy (n=114). All 229 patients were included in the intention-to-treat analysis. The median follow-up was 6·7 months (IQR 6·3-6·9). At 3 months, 40 (35%) of 114 patients in the stereotactic body radiotherapy group, and 16 (14%) of 115 patients in the conventional external beam radiotherapy group had a complete response for pain (risk ratio 1·33, 95% CI 1·14-1·55; p=0·0002). This significant difference was maintained in multivariable-adjusted analyses (odds ratio 3·47, 95% CI 1·77-6·80; p=0·0003). The most common grade 3-4 adverse event was grade 3 pain (five [4%] of 115 patients in the conventional external beam radiotherapy group vs five (5%) of 110 patients in the stereotactic body radiotherapy group). No treatment-related deaths were observed.

INTERPRETATION

Stereotactic body radiotherapy at a dose of 24 Gy in two daily fractions was superior to conventional external beam radiotherapy at a dose of 20 Gy in five daily fractions in improving the complete response rate for pain. These results suggest that use of conformal, image-guided, stereotactically dose-escalated radiotherapy is appropriate in the palliative setting for symptom control for selected patients with painful spinal metastases, and an increased awareness of the need for specialised and multidisciplinary involvement in the delivery of end-of-life care is needed.

FUNDING

Canadian Cancer Society and the Australian National Health and Medical Research Council.

Assessing Functionality and Benefits of Comprehensive Dose Volume Prescriptions: An International, Multi-Institutional, Treatment Planning Study in Spine Stereotactic Body Radiation Therapy

PURPOSE

This study aimed to assess the effectiveness of multiple dose-volume specifications in minimizing interinstitutional, target-prescribed, dose variations for spine stereotactic body radiation therapy (SBRT).

METHODS AND MATERIALS

Seven institutions with a total of 10 treatment apparatuses participated in this study. SBRT plans for 3 representative spinal metastases were generated using 2 different protocols (Protocols 1 and 2) for target dose. While using just 2 target dose objectives (doses delivered to 95% and maximum point dose) in Protocol 1, 3 target dose constraints (doses delivered to 95% and 50% and maximum point dose) were defined in Protocol 2 with the intent to decrease target dose variation. A dose-volume histogram analysis was performed for the evaluated planning target volume (PTV_evl) and critical neural structures such as the spinal cord and cauda equina.

RESULTS

Doses to the organs at risk were all maintained at the maximal tolerance in both protocols; however, the interinstitutional variation of the PTV_evl dose-volume histograms was significantly decreased with Protocol 2. Furthermore, the mean PTV_evl covered by the prescription dose was increased from 73.0% in Protocol 1 to 85.8% in Protocol 2. There were no differences in the mean values of the nearly maximum dose of the critical neural structures between 2 protocols.

CONCLUSIONS

In spine SBRT with the emphasis on preservation of critical neural structures, the target prescribed dose should be defined by using multiple dose-volume objectives to minimize user and apparatus-dependent dose variabilities for the spinal metastases that are adjacent to the critical neural structures.

Adolescents' perceptions of the quality of interpersonal relationships and eating disorder symptom severity: The mediating role of low self-esteem and negative mood

Few studies have examined how the perceived quality of multiple interpersonal relationships is related to eating disorder (ED) symptom severity in adolescents and how psychological variables might influence these associations. The aim of this study is to determine whether the perceived level of trust, communication, and alienation in the relationship with one's mother, father, and peers are predictive of ED severity in adolescent females and to test the mediating effects of low self-esteem and negative mood on these associations. Adolescent females aged 12 to 18 (N = 186) with a diagnosis of Anorexia Nervosa (Restrictive; AN-R or Binge/Purge; AN-B/P) completed self-report measures evaluating the perceived quality of interpersonal relationships, ED symptom severity, low self-esteem, and negative mood. Multiple regressions revealed that the level of perceived alienation in the relationship with one's mother and peers was positively associated with ED symptom severity. Low self-esteem and negative mood acted as mediators of these associations. Considering that a high level of perceived alienation in the relationship with one's mother and peers appears to be associated with more severe ED symptoms through its impact on self-esteem and mood, improvements in the quality of these interactions are likely to be an effective target of intervention among adolescents.

[What Are the Individual, Family, and Social Characteristics Differentiating Prepubertal from Pubertal Anorexia Nervosa?]

Prepubertal anorexia nervosa may entail multiple physical effects. When the onset occurs before puberty, the disorder might be associated with a poorer prognosis and a greater resistance to treatment. Until now, prepubertal anorexia nervosa studies have mostly dealt with symptomatology, but rarely with associated factors.

OBJECTIVE:

This study aims to differentiate prepubescent from pubescent anorexia nervosa regarding individual, family and social characteristics.

METHOD:

At admission in programs specialized in eating disorders, female patients (n = 19 prepubertal and 126 pubertal) and their parents filled in questionnaires (EDI-3, BDI II, IPPA, FACES IV, IDPESQ) on key individual, family and social characteristics associated with anorexia nervosa. Prepubertal and pubertal patient results were compared for each measured variable. Pubertal development and anorexia presence were assessed by a paediatrician in all patients.

RESULTS:

Prepubertal patients account for 13.8% of all cases and have a lower percentile rank than pubertal patients. The many questionnaire results showed little or no difficulty at personal, family or social level and no difference with older patients.

CONCLUSIONS:

These results contribute to challenge our current understanding of prepubertal anorexia nervosa and the prepubescent patient capacity to report their difficulties, which highlights the importance of using several respondents when defining clinical profiles.

Identification des pratiques prometteuses dans le traitement de l’anorexie mentale

L’anorexie mentale inquiète, d’une part, car elle est associée à de nombreuses complications médicales et, d’autre part, car elle est liée à un mauvais pronostic. Face à ces constats, il est impératif que les traitements les plus efficaces soient offerts aux personnes présentant une anorexie mentale. Cet article vise à présenter une revue systématique de la littérature portant sur les modalités thérapeutiques prometteuses dans le domaine de l’anorexie mentale. Parmi celles-ci, notons le traitement ambulatoire, l’importance d’une équipe multidisciplinaire ainsi que différentes approches psychothérapeutiques, dont l’approche familiale.

[Identification of promising practices in the treatment of anorexia nervosa]

Anorexia nervosa concerned, firstly, because this disorder is associated with many medical complications and secondly, because it is linked with a poor prognosis. Given these facts, it is imperative that effective treatments be available for anorexia nervosa. This article aims to present a systematic review of the literature on the best therapeutic modalities in the field of anorexia nervosa. Among these, we find outpatient treatment, importance of multidisciplinary team and various therapeutic approachs, like familial therapy.

Response assessment after stereotactic body radiotherapy for spinal metastasis: a report from the SPIne response assessment in Neuro-Oncology (SPINO) group

The SPine response assessment In Neuro-Oncology (SPINO) group is a committee of the Response Assessment in Neuro-Oncology working group and comprises a panel of international experts in spine stereotactic body radiotherapy (SBRT). Here, we present the group's first report on the challenges in standardising imaging-based assessment of local control and pain for spinal metastases. We review current imaging modalities used in SBRT treatment planning and tumour assessment and review the criteria for pain and local control in registered clinical trials specific to spine SBRT. We summarise the results of an international survey of the panel to establish the range of current practices in assessing tumour response to spine SBRT. The ultimate goal of the SPINO group is to report consensus criteria for tumour imaging, clinical assessment, and symptom-based response criteria to help standardise future clinical trials.

Patterns of epidural progression following postoperative spine stereotactic body radiotherapy: implications for clinical target volume delineation

OBJECT

The authors performed a pattern-of-failure analysis, with a focus on epidural disease progression, in patients treated with postoperative spine stereotactic body radiotherapy (SBRT).

METHODS

Of the 70 patients with 75 spinal metastases (cases) treated with postoperative spine SBRT, there were 26 cases of local disease recurrence and 25 cases with a component of epidural disease progression. Twenty-four of the 25 cases had preoperative epidural disease with subsequent epidural disease progression, and this cohort was the focus of this epidural-specific pattern-of-failure investigation. Preoperative, postoperative, and follow-up MRI scans were reviewed, and epidural disease was characterized based on location according to a system in which the vertebral anatomy is divided into 6 sectors, with the anterior compartment comprising Sectors 1, 2, and 6, and the posterior compartment comprising Sectors 3, 4, and 5.

RESULTS

Patterns of epidural progression are reported specifically for the 24 cases with preoperative epidural disease and subsequent epidural progression. Epidural disease progression within the posterior compartment was observed to be significantly lower in those with preoperative epidural disease confined to the anterior compartment than in those with preoperative epidural disease involving both anterior and posterior compartments (56% vs. 93%, respectively; p = 0.047). In a high proportion of patients with epidural disease progression, treatment failure was found in the anterior compartment, including both those with preoperative epidural disease confined to the anterior compartment and those with preoperative epidural disease involving both anterior and posterior compartments (100% vs. 73%, respectively). When epidural disease was confined to the anterior compartment on the preoperative and postoperative MRIs, no epidural disease progression was observed in Sector 4, which is the most posterior sector. Postoperative epidural disease characteristics alone were not predictive of the pattern of epidural treatment failure.

CONCLUSIONS

Reviewing the extent of epidural disease on preoperative MRI is imperative when planning postoperative SBRT. When epidural disease is confined to the anterior epidural sectors pre- and postoperatively, covering the entire epidural space circumferentially with a prophylactic "donut" distribution may not be needed.

Magnetic resonance imaging assessment of spinal cord and cauda equina motion in supine patients with spinal metastases planned for spine stereotactic body radiation therapy

PURPOSE

To assess motion of the spinal cord and cauda equina, which are critical neural tissues (CNT), which is important when evaluating the planning organ-at-risk margin required for stereotactic body radiation therapy.

METHODS AND MATERIALS

We analyzed CNT motion in 65 patients with spinal metastases (11 cervical, 39 thoracic, and 24 lumbar spinal segments) in the supine position using dynamic axial and sagittal magnetic resonance imaging (dMRI, 3T Verio, Siemens) over a 137-second interval. Motion was segregated according to physiologic cardiorespiratory oscillatory motion (characterized by the average root mean square deviation) and random bulk shifts associated with gross patient motion (characterized by the range). Displacement was evaluated in the anteroposterior (AP), lateral (LR), and superior-inferior (SI) directions by use of a correlation coefficient template matching algorithm, with quantification of random motion measure error over 3 separate trials. Statistical significance was defined according to P<.05.

RESULTS

In the AP, LR, and SI directions, significant oscillatory motion was observed in 39.2%, 35.1%, and 10.8% of spinal segments, respectively, and significant bulk motions in all cases. The median oscillatory CNT motions in the AP, LR, and SI directions were 0.16 mm, 0.17 mm, and 0.44 mm, respectively, and the maximal statistically significant oscillatory motions were 0.39 mm, 0.41 mm, and 0.77 mm, respectively. The median bulk displacements in the AP, LR, and SI directions were 0.51 mm, 0.59 mm, and 0.66 mm, and the maximal statistically significant displacements were 2.21 mm, 2.87 mm, and 3.90 mm, respectively. In the AP, LR, and SI directions, bulk displacements were greater than 1.5 mm in 5.4%, 9.0%, and 14.9% of spinal segments, respectively. No significant differences in axial motion were observed according to cord level or cauda equina.

CONCLUSIONS

Oscillatory CNT motion was observed to be relatively minor. Our results support the importance of controlling bulk patient motion and the practice of applying a planning organ-at-risk margin.

Stereotactic body radiotherapy: a new paradigm in the management of spinal metastases

Spine stereotactic body radiotherapy is based on delivering high biologically effective doses to spinal metastases, with the intent to maximize both tumor and pain control. The purpose of this review is to outline the technical details of spine stereotactic body radiotherapy, contrast clinical outcomes to low biologically effective dose conventional palliative radiotherapy, discuss the role of surgery in the era of spine stereotactic body radiotherapy, and summarize the major serious adverse events that patients would otherwise not be at risk of with conventional radiotherapy.

Prophylactic dexamethasone effectively reduces the incidence of pain flare following spine stereotactic body radiotherapy (SBRT): a prospective observational study

PURPOSE

The purpose of this study was to determine the incidence of pain flare (PF) in patients receiving spine stereotactic body radiotherapy (SBRT) treated with prophylactic oral dexamethasone (DEX) 1 h before and for 4 days following SBRT.

METHODS

Forty-seven patients were accrued on this prospective observational study. The first cohort of 24 patients was treated with 4 mg, while a second cohort of 23 patients treated with 8 mg of DEX. The Brief Pain Inventory (BPI) was used to score pain and functional interference each day during SBRT and for 10 days following. Comparisons between the 4 and 8 mg cohorts, in addition to our previously reported steroid naïve patients post SBRT (n = 41), were also performed.

RESULTS

The total incidence of PF was 19 % (9/47). The incidence in the 4 and 8 mg cohorts was 25 % (6/24) and 13 % (3/23), respectively, and the difference was not statistically significant (p = 0.46). Comparing functional interference, the 4 mg cohort had better profile in walking ability (p < 0.005) and relationships with others (p < 0.035) compared to the 8 mg cohort. Compared to our previously reported steroid naïve cohort, prophylactic DEX significantly reduced the incidence of PF (68 vs. 19 %, p < 0.0001, respectively), patients had lower worst pain scores, and improved general activity interference outcome.

CONCLUSION

We recommend prophylactic DEX for patients treated with spine SBRT. Our current practice is based on the 4 mg protocol primarily due to the improved functional interference outcomes. A randomized trial is required to finalize the optimal regimen and schedule.

Risk of vertebral compression fracture specific to osteolytic renal cell carcinoma spinal metastases after stereotactic body radiotherapy: A multi-institutional study

PURPOSE

Determine the risk of vertebral compression fracture (VCF) following stereotactic body radiotherapy (SBRT), specific to osteolytic renal cell carcinoma (RCC) spinal metastases, and associated predictive factors.

METHODS

187 RCC osteolytic spinal tumor segments in 116 patients obtained from a multi-institutional pooled database were reviewed. Each segment was evaluated according to the Spinal Instability Neoplastic Score (SINS).

RESULTS

The median follow-up was 8.0 months. 34 VCF (34/187, 18%) were observed and median time to VCF was 2.4 months. VCF was observed in 43% (10/23), 24% (4/17) and 14% (20/147) of segments treated with 24Gy/fraction (fx), 20-23Gy/fx and ≤19Gy/fx, respectively. Multivariate analysis identified dose per fx (p=0.005), baseline VCF (p<0.001) and spinal misalignment (p=0.002) as predictors of VCF. Prior conventional radiotherapy (p=0.029) was found to be protective.

CONCLUSIONS

18% of osteolytic RCC spinal metastases fractured post-SBRT. The presence of a baseline fracture, spinal mal-alignment and treatment with ≥20Gy/fx predicted for VCF.

Spine stereotactic body radiotherapy for renal cell cancer spinal metastases: analysis of outcomes and risk of vertebral compression fracture

OBJECT

The aim of this study was to evaluate local control (LC) and the risk of vertebral compression fracture (VCF) after stereotactic body radiotherapy (SBRT) in patients with renal cell cancer spinal metastases.

METHODS

Prospectively collected data on 71 spinal segments treated with SBRT in 37 patients were reviewed. The median follow-up was 12.3 months (range 1.2-55.4 months). The LC rate was assessed based on each spinal segment treated and overall survival (OS) according to each patient treated. Sixty of 71 segments (85%) were radiation naive, 11 of 71 (15%) were previously irradiated, and 10 of 71 (14%) were treated with postoperative SBRT. The median SBRT total dose and number of fractions were 24 Gy and 2, respectively. The VCF analysis also included evaluation of the Spinal Instability Neoplastic Score criteria.

RESULTS

The 1-year OS and LC rates were 64% and 83%, respectively. Multivariate analysis identified oligometastatic disease (13 of 37 patients) as a positive prognostic factor (p = 0.018) for OS. Of 61 non-postoperative spinal segments treated, 10 (16%) developed VCFs; 3 of 10 were de novo VCFs and 7 of 10 occurred as progression of an existing VCF. The 1-year VCF-free probability rate was 82%. Multivariate analysis identified single-fraction SBRT and baseline VCF as significant predictors of SBRT-induced VCF (p = 0.028 and p = 0.012, respectively).

CONCLUSIONS

Spine SBRT yields high rates of local tumor control in patients with renal cell cancer. Baseline VCF and 18-24 Gy delivered in a single fraction were predictive of further collapse. Patients with oligometastatic disease may benefit most from such aggressive local therapy, given the prolonged survival observed.

Predictive factors for local control in primary and metastatic lung tumours after four to five fraction stereotactic ablative body radiotherapy: a single institution's comprehensive experience

AIMS

We report the outcomes of a large lung stereotactic ablative body radiotherapy (SABR) programme for primary non-small cell lung cancer (NSCLC) and pulmonary metastases. The primary study aim was to identify factors predictive for local control.

MATERIALS AND METHODS

In total, 311 pulmonary tumours in 254 patients were treated between 2008 and 2011 with SABR using 48-60 Gy in four to five fractions. Local, regional and distant failure data were collected prospectively, whereas other end points were collected retrospectively. Potential clinical and dosimetric predictors of local control were evaluated using univariate and multivariate analyses.

RESULTS

Of the 311 tumours, 240 were NSCLC and 71 were other histologies. The 2 year local control rate was 96% in stage I NSCLC, 76% in colorectal cancer (CRC) metastases and 91% in non-lung/non-CRC metastases. Predictors of better local control on multivariate analysis were non-CRC tumours and a larger proportion of the planning target volume (PTV) receiving ≥100% of the prescribed dose (higher PTV V100). Among the 45 CRC metastases, a higher PTV V100 and previous chemotherapy predicted for better local control.

CONCLUSIONS

Lung SABR of 48-60 Gy/four to five fractions resulted in high local control rates for all tumours except CRC metastases. Covering more of the PTV with the prescription dose (a higher PTV V100) also resulted in superior local control.

Surgical resection of epidural disease improves local control following postoperative spine stereotactic body radiotherapy

BACKGROUND

Spine stereotactic body radiotherapy (SBRT) is increasingly being applied to the postoperative spine metastases patient. Our aim was to identify clinical and dosimetric predictors of local control (LC) and survival.

METHODS

Eighty patients treated between October 2008 and February 2012 with postoperative SBRT were identified from our prospective database and retrospectively reviewed.

RESULTS

The median follow-up was 8.3 months. Thirty-five patients (44%) were treated with 18-26 Gy in 1 or 2 fractions, and 45 patients (56%) with 18-40 Gy in 3-5 fractions. Twenty-one local failures (26%) were observed, and the 1-year LC and overall survival (OS) rates were 84% and 64%, respectively. The most common site of failure was within the epidural space (15/21, 71%). Multivariate proportional hazards analysis identified systemic therapy post-SBRT as the only significant predictor of OS (P = .02) and treatment with 18-26 Gy/1 or 2 fractions (P = .02) and a postoperative epidural disease grade of 0 or 1 (0, no epidural disease; 1, epidural disease that compresses dura only, P = .003) as significant predictors of LC. Subset analysis for only those patients (n = 48/80) with high-grade preoperative epidural disease (cord deformed) indicated significantly greater LC rates when surgically downgraded to 0/1 vs 2 (P = .0009).

CONCLUSIONS

Postoperative SBRT with high total doses ranging from 18 to 26 Gy delivered in 1-2 fractions predicted superior LC, as did postoperative epidural grade.

Vertebral compression fracture after spine stereotactic body radiotherapy: a multi-institutional analysis with a focus on radiation dose and the spinal instability neoplastic score

PURPOSE

Vertebral compression fracture (VCF) is increasingly recognized as an adverse event after spine stereotactic body radiotherapy (SBRT). We report a multi-institutional study aimed at clarifying the risk and predictive factors associated with VCF.

PATIENTS AND METHODS

A total of 252 patients with 410 spinal segments treated with SBRT were included. The primary outcome was the development of VCF (a new VCF or progression of a baseline VCF). In addition to various patient-, treatment-, and tumor-specific factors, the Spinal Instability Neoplastic Scoring (SINS) system was applied to determine predictive value.

RESULTS

The median follow-up was 11.5 months (range, 0.03 to 113 months). The median and mean overall survival rates were 16 and 26 months, respectively. We observed 57 fractures (57 of 410, 14%), with 47% (27 of 57) new fractures and 53% (30 of 57) fracture progression. The median time to VCF was 2.46 months (range, 0.03 to 43.01 months), and 65% occurred within the first 4 months. The 1- and 2-year cumulative incidences of fracture were 12.35% and 13.49%, respectively. Multivariable analysis identified dose per fraction (greatest risk for ≥ 24 Gy v 20 to 23 Gy v ≤ 19 Gy), in addition to three of the six original SINS criteria: baseline VCF, lytic tumor, and spinal deformity, as significant predictors of VCF.

CONCLUSION

Caution must be observed when treating with ≥ 20 Gy/fraction, in particular, for patients with lytic tumor, spinal misalignment, and a baseline VCF. Frequent short-term follow-up is required, as nearly two thirds of all VCF occurred within the first 4 months. We also conclude that SINS may have utility in predicting patients at high risk of SBRT-induced VCF.

Management of Bartholin's gland carcinoma using high-dose-rate interstitial brachytherapy boost

PURPOSE

To describe the patterns of use, clinical outcomes, and dose-volume histogram parameters of high-dose-rate interstitial brachytherapy (HDR-ISBT) in the management of Bartholin's gland cancer.

METHODS AND MATERIALS

Five patients with Stage II-III Bartholin's gland carcinoma treated with CT-based HDR-ISBT boost were reviewed. Plans were generated using an inverse planning simulated annealing algorithm. Dose-volume histogram parameters were assessed. The total doses of HDR-ISBT and EBRT were converted to total equivalent dose in 2Gy (EQD2).

RESULTS

All 5 patients received HDR-ISBT as a boost (median dose, 30Gy) after EBRT (median dose, 45Gy). Three patients received postoperative irradiation for gross residual tumor or positive surgical margins and 2 patients were treated by primary chemoradiotherapy. The median V100, D90, and D100 for the CTV were 98.3%, 89Gy10, and 64Gy10 (EQD2), respectively. A complete response was observed in all patients. No local recurrence occurred. All patients remain alive and free of disease (median followup, 78 months; range, 8-93). Severe vaginal toxicities were observed, including vaginal necrosis that resolved with hyperbaric oxygen therapy.

CONCLUSIONS

HDR-ISBT boost after EBRT offers excellent long-term local control in patients with Bartholin's gland carcinoma. HDR-ISBT should be considered for positive surgical margins or residual tumor after surgery and for locally advanced malignancies treated by primary chemoradiotherapy.

Macroglossia due to Systemic Amyloidosis: Is There a Role for Radiotherapy?

Background

Macroglossia due to amyloid depositions can cause cosmetic problems and functional disability, and can lead to life-threatening airway obstruction. Management of macroglossia in systemic amyloidosis is controversial, and the role of surgery is unclear.

Case Description

We present a case of a 66-year-old woman affected by macroglossia due to light chain amyloidosis who presented with eating and breathing difficulties. Because of prior successful results of radiotherapy for localized amyloid disease, our patient was treated with external beam radiation therapy (20 Gy in 10 fractions). The treatment was well tolerated by the patient. However, her systemic amyloidosis progressed, with a subclinical increase in tongue width.

Conclusions

This is the first reported use of radiotherapy for amyloidosis of the tongue. There was no evidence of benefit using a total dose of 20 Gy. This therapeutic modality is not recommended for the routine management of macroglossia.

[Nutrition education in schools]

PURPOSE

School interventions aimed at developing nutrition knowledge are among the avenues to be considered to improve young Canadians' food habits. From a new toolkit targeting elementary school children in first and second grade, the report presents attitudes and behaviours of teachers having received and used the material.

METHODS

A total of 504 primary schools located in Quebec were solicited to participate in the study. A total of 214 teachers (42.5%) answered a self-administered questionnaire; 149 received the material and 63 used it.

RESULTS

Most of the respondents believed that schools should allocate more time for nutrition education. Those who have used the material identified the most popular themes as well as new themes to be developed. Limitations to the use of the material in class were related to lack of time.

CONCLUSIONS

Results support a clear interest from teachers toward transmitting nutrition information at school and the necessity to consider schools' specific constraints and needs to benefit from these education efforts.

Canadians' level of confidence in their sources of nutrition information

North Americans have a great interest in health and nutrition. However, because sources of nutrition information are vast, the quality of the information varies. We explored the potential benefit of segmenting the Canadian population by geographical location and age in determining the principal sources of nutrition information and level of confidence in these sources. A survey was posted on the Dietitians of Canada website: subjects indicated how frequently they used different healthy eating sources and their level of confidence in the various sources. A total of 870 questionnaires were retained. Magazines, books, the Internet, food labels, and brochures were the most frequently used sources of information. Analyses indicated differences between geographic areas in the use of the media (radio, newspaper, television), dietitians, and naturopaths as sources of nutrition information (p<0.05), and between seven age groups (<18 to 65+ years) in the use of the media (p<0.05). Respondents reported being very confident about nutrition information received from dietitians, physicians, books, the government, and nurses, with some differences occurring between geographic areas (p<0.05).