SBRT-SG-01: final results of a prospective multicenter study on stereotactic body radiotherapy for liver metastases

OBJECTIVE

This study aimed to assess the efficacy and tolerability of stereotactic body radiation therapy (SBRT) for the treatment of liver metastases.

METHODS

Patients with up to 5 liver metastases were enrolled in this prospective multicenter study and underwent SBRT. Efficacy outcomes included in-field local control (LC), progression-free survival (PFS), and overall survival (OS). Acute and late toxicities were evaluated using CTCAE v.4.0.

RESULTS

A total of 52 patients with 105 liver metastases were treated between 2015 and 2018. The most common primary tumor was colorectal cancer (72% of cases). Liver metastases were synchronous with the primary tumor diagnosis in 24 patients (46.2%), and 21 patients (40.4%) presented with other extrahepatic oligometastases. All patients underwent intensity-modulated radiation therapy (IMRT)/volumetric-modulated arc therapy (VMAT) with image-guided radiation therapy (IGRT) and respiratory gating, and a minimum biologically effective dose (BED10Gy) of 100 Gy was delivered to all lesions. With a median follow-up of 23.1 months (range: 13.4-30.9 months) since liver SBRT, the median actuarial local progression-free survival (local-PFS) was not reached. The actuarial in-field LC rates were 84.9% and 78.4% at 24 and 48 months, respectively. The median actuarial liver-PFS and distant-PFS were 11 and 10.8 months, respectively. The actuarial median overall survival (OS) was 27.7 months from SBRT and 52.5 months from metastases diagnosis. Patients with lesion diameter ≤ 5 cm had significantly better median liver-PFS (p = 0.006) and OS (p = 0.018). No acute or late toxicities of grade ≥ 3 were observed.

CONCLUSIONS

This prospective multicenter study confirms that liver SBRT is an effective alternative for the treatment of liver metastases, demonstrating high rates of local control and survival while maintaining a low toxicity profile.

Challenges in radiological evaluation of brain metastases, beyond progression

MRI is the cornerstone in the evaluation of brain metastases. The clinical challenges lie in discriminating metastases from mimickers such as infections or primary tumors and in evaluating the response to treatment. The latter sometimes leads to growth, which must be framed as pseudo-progression or radionecrosis, both inflammatory phenomena attributable to treatment, or be considered as recurrence. To meet these needs, imaging techniques are the subject of constant research. However, an exponential growth after radiotherapy must be interpreted with caution, even in the presence of results suspicious of tumor progression by advanced techniques, because it may be due to inflammatory changes. The aim of this paper is to familiarize the reader with inflammatory phenomena of brain metastases treated with radiotherapy and to describe two related radiological signs: "the inflammatory cloud" and "incomplete ring enhancement", in order to adopt a conservative management with close follow-up.

Bridging the gap: Predicting brain metastasis in breast cancer

Chen et al explored clinicopathological features and prognostic factors, revealing advanced tumor stage, lung metastases, HER-2 overexpression, and triple-negative status as key contributors. Recent research connects astrocytes' role in brain metastasis with signaling pathways and the impact of Trastuzumab on HER-2 tumor survival. Factors such as positive HER2 status, lack of estrogen receptor expression, and liver metastasis are identified as additional risk factors. The routine use of magnetic resonance imaging, insights into gene mutations associated with metastasis, and the role of radiotherapy, including prophylaxis possibilities, is controversial in clinical practice. Understanding these risk factors in a multidisciplinary collaboration is precise for local treatments and targeted therapies, particularly for HER2+ tumors, impacting directly on longer survival.

Moderate hypofractionated radiation therapy and pathologic response for soft tissue sarcomas (STS) of limbs and trunk: experience from a tertiary cancer center

BACKGROUND

Preoperative radiation therapy following by limb-sparing or conservative surgery is a standard approach for limb and trunk STS. Data supporting hypofractionated radiotherapy schedules are scarce albeit biological sensitivity of STS to radiation would justify it. We sought to evaluate the impact of moderate hypofractionation on pathologic response and its influence on oncologic outcomes.

MATERIAL AND METHODS

From October 2018 to January 2023, 18 patients with limb or trunk STS underwent preoperative radiotherapy at a median dose of 52.5 Gy (range 49.5-60 Gy) in 15 fractions of 3.5 Gy (3.3-4 Gy) with or without neoadjuvant chemotherapy. A favorable pathologic response (fPR) was considered as ≥ 90% tumor necrosis on specimen examination.

RESULTS

All patients completed planned preoperative radiotherapy. Eleven patients (61.1%) achieved a fPR, and 7 patients (36.8%) a complete pathologic response with total disappearance of tumor cells. Nine patients (47%) developed grade 1-2 acute skin toxicity, and 7 patients (38.8%) had wound complications on follow-up. With a median follow-up of 14 months (range 1-40), no cases of local relapse were observed, and actuarial 3-year overall survival (OS) and distant metastases-free survival (DMFS) are 87% and 76.4%, respectively. In the univariate analysis, the presence of a favorable pathologic response (fPR) was associated with improved 3-year OS (100% vs. 56.03%, p = 0.058) and 3-year DMFS (86.91% vs. 31.46%, p = 0.002). Moreover, both complete or partial RECIST response and radiological stabilization of the tumor lesion showed a significant association with higher rates of 3-year distant metastasis-free survival (DMFS) (83% vs. 83% vs. 56%, p < 0.001) and 3-year overall survival (OS) (100% vs. 80% vs. 0, p = 0.002).

CONCLUSIONS

Preoperative moderate hypofractionated radiation treatment for STS is feasible and well tolerated and associates encouraging rates of pathologic response that could have a favorable impact on final outcomes.

Stereotactic body radiation therapy (SBRT) for spinal metastases: 12 years of a single center experience

OBJECTIVE

To assess the clinical outcomes of patients with spine metastases treated with SBRT at our institution.

MATERIALS AND METHODS

Patients with spine metastases treated with SBRT (1 fraction/18 Gy or 5 fractions/7 Gy) during the last 12 years have been analyzed. All patients were simulated supine in a vacuum cushion or with a shoulder mask. CT scans and MRI image registration were performed. Contouring was based on International Spine-Radiosurgery-Consortium-Consensus-Guidelines. Highly conformal-techniques (IMRT/VMAT) were used for treatment planning. Intra and interfraction (CBCT or X-Ray-ExacTrac) verification were mandatory.

RESULTS

From February 2010 to January 2022, 129 patients with spinal metastases were treated with SBRT [1 fraction/18 Gy (75%) or 5 fractions/7 Gy] (25%). For patients with painful metastases (74/129:57%), 100% experienced an improvement in pain after SBRT. With a median follow-up of 14.2 months (average 22.9; range 0.5-140) 6 patients (4.6%) experienced local relapse. Local progression-free survival was different, considering metastases's location (p < 0.04). The 1, 2 and 3 years overall survival (OS) were 91.2%, 85.1% and 83.2%, respectively. Overall survival was significantly better for patients with spine metastases of breast and prostate cancers compared to other tumors (p < 0.05) and significantly worse when visceral metastases were present (p < 0.05), when patients were metastatic de novo (p < 0.05), and in those patients receiving single fraction SBRT (p: 0.01).

CONCLUSIONS

According to our experience, SBRT for patients with spinal metastases was effective in terms of local control and useful to reach pain relief. Regarding the intent of the treatment, an adequate selection of patients is essential to propose this ablative approach.

Acute skin toxicity of ultra-hypofractionated whole breast radiotherapy with simultaneous integrated boost for early breast cancer

Background

Whole-breast irradiation (WBI) after breast conserving surgery (BCS) is indicated to improve loco-regional control and survival. Former studies showed that addition of tumor bed boost in all age groups significantly improved local control although no apparent impact on overall survival but with an increased risk of worse cosmetic outcome. Even though shortened regimens in 3 weeks are considered the standard, recent studies have shown the non-inferiority of a treatment regimen of 5 fractions in one-week in both locoregional control and toxicity profile, although simultaneous integrated boost (SIB) in this setting has been scarcely studied.

Materials and Methods

From March-2020 to March-2022, 383 patients with early breast cancer diagnosis and a median age of 56 years-old (range 30-99)were included in a prospective registry of ultra-hypofractionated WBI up to a total dose of 26 Gy in 5.2 Gy/fraction with a SIB of 29 Gy in 5.8 Gy/fraction in 272 patients (71%), 30-31 Gy in 6-6.2 Gy/fraction in 111 patients (29%) with close/focally affected margins. Radiation treatment was delivered by conformal 3-D technique in 366 patients (95%), VMAT in 16patients (4%) and conformal 3-D with deep inspiration breath hold (DIBH) in 4patients (1%). Ninety-three per cent of patients received endocrine therapy and 43% systemic or targeted chemotherapy. Development of acute skin complications was retrospectively reviewed.

Results

With a median follow-up of 18 months (range 7-31), all patients are alive without evidence of local, regional or distant relapse. Acute tolerance was acceptable, with null o mild toxicity: 182 (48%) and 15 (4%) patients developed skin toxicity grade 1 and 2 respectively; 9 (2%) and 2 (0.5%) patients breast edema grade 1and 2 respectively. No other acute toxicities were observed. We also evaluated development of early delayed complications and observed grade 1 breast edema in 6 patients (2%); grade 1 hyperpigmentation in 20 patients (5%); and grade 1 and 2 breast induration underneath boost region in 10(3%) and 2 patients (0.5%) respectively. We found a statistically significant correlation between the median PTV_WBI and presence of skin toxicity (p = 0.028) as well as a significant correlation between late hyperpigmentation with the median PTV_BOOST (p = 0.007) and the ratio PTV_BOOST/PTV_WBI (p = 0.042).

Conclusion

Ultra-hypofractionated WBI + SIB in 5 fractions over one-week is feasible and well tolerated, although longer follow-up is necessary to confirm these results.

Primary Chemoradiotherapy Treatment (PCRT) for HER2+ and Triple Negative Breast Cancer Patients: A Feasible Combination

Primary systemic treatment (PST) downsizes the tumor and improves pathological response. The aim of this study is to analyze the feasibility and tolerance of primary concurrent radio−chemotherapy (PCRT) in breast cancer patients. Patients with localized TN/HER2+ tumors were enrolled in this prospective study. Radiation was delivered concomitantly during the first 3 weeks of chemotherapy, and it was based on a 15 fractions scheme, 40.5 Gy/2.7 Gy per fraction to whole breast and nodal levels I-IV. Chemotherapy (CT) was based on Pertuzumab−Trastuzumab−Paclitaxel followed by anthracyclines in HER2+ and CBDCA-Paclitaxel followed by anthracyclines in TN breast cancers patients. A total of 58 patients were enrolled; 25 patients (43%) were TN and 33 patients HER2+ (57%). With a median follow-up of 24.2 months, 56 patients completed PCRT and surgery. A total of 35 patients (87.5%) achieved >90% loss of invasive carcinoma cells in the surgical specimen. The 70.8% and the 53.1% of patients with TN and HER-2+ subtype, respectively, achieved complete pathological response (pCR). This is the first study of concurrent neoadjuvant treatment in breast cancer in which three strategies were applied simultaneously: fractionation of RT (radiotherapy) in 15 sessions, adjustment of CT to tumor phenotype and local planning by PET. The pCR rates are encouraging.

Quality of life improvement in patients with bone metastases undergoing palliative radiotherapy

Background

The aim of the study was to analyze the impact of palliative radiotherapy on quality of life (QoL) in patients with symptomatic bone metastases.

Materials and methods

We present the results from a prospective multicentric study including 128 patients who provided pre- and post-radiotherapy (one month after treatment) brief pain inventory (BPI) assessments. Worst pain was recorded using the BPI (range: 0–10). Pain response was described according to the International Bone Metastases Consensus on palliative radiation. Regarding QoL, for each pre- and post-radiation BPI-questionnaire, scores from the interference domains were summed and averaged to obtain an overall interference score.

Results

There was a significant correlation between radiation treatment response and improvement in all functional interference domains except sleeping. Patients > 75 years old presented a significantly higher improvement in general activity, mood and relationships with others compared to patients ≤ 75 years old. Patients presenting a baseline pain score ≥ 8 showed a higher improvement in the general activity item (p = 0.049). There was no statistically significant association between pretreatment ECOG, chemotherapy, primary tumor location and radiation schedule with any of the functional interference items.

Conclusions

Patients who report pain relief after palliative radiotherapy also present a better quality of life including physical and psychosocial aspects.

Low-dose radiation therapy for hand osteoarthritis: shaking hands again?

BACKGROUND

Hand osteoarthritis (HOA) is one of the most common causes of pain and functional disability in western countries and there is still no definitive cure. Low-dose radiation therapy (LDRT) has anti-inflammatory properties that have shown to be effective in the symptomatic relief of various degenerative musculoskeletal disorders. We designed a clinical protocol using LDRT for symptomatic HOA and present results and tolerance in the first 100 patients included.

MATERIALS AND METHODS

Between April 2015 and March 2021, 100 patients with a median age of 60 were treated. Fifty-seven patients suffering from proximal/distal interphalangeal joint pain, 40 patients with thumb arthritis, 2 patients with radiocarpal joint affection and 1 patient with metacarpophalangeal joint pain were enrolled. LDRT comprised of 6 fractions of 0.5-1 Gy on every other day up to a total dose of 3-6 Gy. Clinical response was evaluated according to the visual analog scale (VAS) for pain level and the von Pannewitz score (VPS) for joint functionality. Any patients not achieving subjective adequate pain relief after 8 weeks of treatment were offered a second identical LDRT course.

RESULTS

With a median follow-up of 10.5 months (range 7.55-12.45), 94% reported an improvement in the pain, with a significant reduction in the VAS level after 3, 6 and 12 months (p < 0.001). Sixty-three patients needed a second course of treatment at a median time interval of 12 weeks (range 9-14). The mean VAS score before treatment was 8 (range 3-10). After treatment, it was 5 (range 1-10). After 3, 6 and 12 months, the mean VAS scores were 4 (range 0-9), 3 (range 0-9) and 3.5 (range 0-9), respectively. Seventy patients reported functionality improvements after LDRT according to the von Pannewitz score. No acute or late complications were observed.

CONCLUSION

LDRT appears to be safe and useful for HOA and is associated with good rates of pain relief and functionality improvements. However, further studies are necessary to confirm these promising results.

Macrometastasis at selective lymph node biopsy: A practical going-for-the-one clinical scoring system to personalize decision making

BACKGROUND

Axillary sentinel lymph node biopsy (SLNB) is standard treatment for patients with clinically and pathological negative lymph nodes. However, the role of completion axillary lymph node dissection (cALND) following positive sentinel lymph node biopsy (SLNB) is debated.

AIM

To identify a subgroup of women with high axillary tumor burden undergoing SLNB in whom cALND can be safely omitted in order to reduce the risk of long-term complications and create a Preoperative Clinical Risk Index (PCRI) that helps us in our clinical practice to optimize the selection of these patients.

METHODS

Patients with positive SLNB who underwent a cALND were included in this study. Univariate and multivariate analysis of prognostic and predictive factors were used to create a PCRI for safely omitting cALND.

RESULTS

From May 2007 to April 2014, we performed 1140 SLN biopsies, of which 125 were positive for tumor and justified to practice a posterior cALND. Pathologic findings at SLNB were micrometastases (mic) in 29 cases (23.4%) and macrometastasis (MAC) in 95 cases (76.6%). On univariate analysis of the 95 patients with MAC, statistically significant factors included: age, grade, phenotype, histology, lymphovascular invasion, lymph-node tumor size, and number of positive SLN. On multivariate analysis, only lymph-node tumor size (≤ 20 mm) and number of positive SLN (> 1) retained significance. A numerical tool was created giving each of the parameters a value to predict preoperatively which patients would not benefit from cALND. Patients with a PCRI ≤ 15 has low probability (< 10%) of having additional lymph node involvement, a PRCI between 15-17.6 has a probability of 43%, and the probability increases to 69% in patients with a PCRI > 17.6.

CONCLUSION

The PCRI seems to be a useful tool to prospectively estimate the risk of nodal involvement after positive SLN and to identify those patients who could omit cALND. Further prospective studies are necessary to validate PCRI clinical generalization.

5-year results of accelerated partial breast irradiation (APBI) with SBRT (stereotactic body radiation therapy) and exactrac adaptive gating (Novalis®) for very early breast cancer patients: was it all worth it?

PURPOSE

To explore the feasibility of image-guided and respiratory-gated Stereotactic Body Radiation Therapy (SBRT) for Accelerated Partial Breast Irradiation (APBI) in patients with very early breast cancer.

MATERIAL AND METHODS

Selected patients with early breast carcinoma after breast-conserving surgery were enrolled in this phase II trial. A fiducial marker was percutaneously placed close to surgical bed and five external fiducials were set on the skin. A CT scan for planning was acquired at free breathing. The treatment was planned and DVH were assessed according to international recommendations. Prescription dose was 30 Gy in five consecutive fractions of 6 Gy. A 6MV monoenergetic LINAC (linear accelerator) that combines stereoscopic X-ray imaging system and ExacTrac Adaptive Gating technique was used. PTV (planning target volume) intrafraction motion was controlled and PTV was irradiated in a selected gated area of the respiratory cycle. Shifts for a correct, gated set-up were calculated and automatically applied.

RESULTS

Between April 2013 and October 2015, a total of 23 patients were included. The median tumor size was 12 mm. The mean PTV volume was 114 cc. The mean ipsilateral lung V9 Gy was 2.2% and for left-sided breast cancers, the volume of the heart receiving 1.5 Gy was 11.5%. Maximum skin dose was 30.8 Gy. Acute toxicity was grade1 in all the patients and 100% experienced excellent/good breast cosmesis outcomes. With a median follow-up of 66 months (range 8-99 months) local-relapse-free-survival reaches 100%. One patient developed a second breast cancer outside the treated quadrant after 25.1 months.

CONCLUSION

APBI with SBRT and ExacTrac Adaptive Gating System was feasible. The acute and late toxicities were almost null and cosmesis was excellent. We also found that the margins of 5 mm applied from CTV to PTV were sufficient to compensate for geometric uncertainties.

Breast Radiotherapy-Related Cardiotoxicity. When, How, Why. Risk Prevention and Control Strategies

In recent decades, improvements in breast cancer management have increased overall patient survival; however, many cancer therapies have been linked to an important risk of cardiovascular adverse events. Cardio-oncology has been proposed as an emerging specialty to coordinate preventive strategies that improve the cardiovascular health of oncologic patients. It employs the most suitable personalized multidisciplinary management approach for each patient to optimize their cardiovascular health and improve their survival and quality of life. Radiotherapy is an essential part of the therapeutic regimen in breast cancer patients but can also increase the risk of cardiovascular disease. Therefore, minimizing the negative impact of radiation therapy is an important challenge for radiotherapy oncologists and cardiologists specializing in this field. The aim of the present review is to update our knowledge about radiation-induced cardiotoxicity in breast cancer patients by undertaking a critical review of the relevant literature to determine risk prevention and control strategies currently available.

Moderate hypofractionated post-prostatectomy radiation therapy is feasible and well tolerated: experience from a single tertiary cancer centre

PURPOSE

Conventional post-prostatectomy radiation therapy comprises 6.5-8 weeks of treatment, therefore, hypofractionated and shortened schemes arouse increasing interest. We describe our experience regarding feasibility and clinical outcome of a post-prostatectomy moderate hypofractionated image-guided radiotherapy schedule MATERIALS AND METHODS: From Oct 2015-Mar 2020, 113 patients, median age of 62 years-old (range 45-76) and prostate adenocarcinoma of low risk (30%), intermediate risk (49%) and high risk (21%) were included for adjuvant (34%) or salvage radiation therapy (66%) after radical prostatectomy (RP). All patients underwent radiotherapy with image-guided IMRT/VMAT to a total dose of 62.5 Gy in 2.5 Gy/fraction in 25 fractions. Sixteen patients (14%) received concomitant androgen deprivation therapy.

RESULTS

With a median follow-up of 29 months (range 3-60 months) all patients but three are alive. Eleven patients (10%) developed exclusive biochemical relapse while 19 patients (17%) presented macroscopically visible relapse: prostatectomy bed in two patients (2%), pelvic lymph nodes in 13 patients (11.5%) and distant metastases in four patients (4%). The 3 years actuarial rates for OS, bFRS, and DMFS were 99.1, 91.1 and 91.2%, respectively. Acute and late tolerance was satisfactory. Maximal acute genitourinary (AGU) toxicity was G2 in 8% of patients; maximal acute gastrointestinal (AGI) toxicity was G2 in 3.5% of patients; maximal late genitourinary (LGU) toxicity was G3 in 1% of patients and maximal late gastrointestinal (LGI) toxicity was G2 in 2% of patients. There were no cases of severe acute or late toxicity. No relationship was found between acute or late GI/GU adverse effects and dosimetric parameters, age, presence of comorbidities or concomitant treatments.

CONCLUSIONS

Hypofractionated radiotherapy (62.5 Gy in 25 2.5 Gy fractions) is feasible and well tolerated with low complication rates allowing for a moderate dose-escalation that offers encouraging clinical results for biochemical control and survival in patients with prostate cancer after radical prostatectomy.

Postmastectomy radiation therapy in early breast cancer: Utility or futility?

Postmastectomy radiation therapy (PMRT) has been shown to reduce the risk of locoregional recurrence (LRR), in patients with locally advanced breast cancer who are considered of high-risk because of large tumors (>5 cm) or presence of axillary lymph-node involvement, as well as to reduce breast cancer mortality. However, controversy still remains with respect to indication of PMRT in case of early-stages invasive tumors. This review aims to analyze the impact that PMRT has on final results in women with breast tumors in different scenarios that would otherwise be considered as early breast cancer, such as extensive DCIS, tumors without axillary lymph-node involvement or with minimal microscopic nodal-involvement. The existence of risk factors including young age, premenopausal status, and presence of lymphovascular invasion (LVI), high grade or tumor size >2 cm has been associated with an increased risk of LRR in these patients at early-stages and advises to consider PMRT in selected cases.

A prospective observational study of the clinical and pathological impact of stereotactic body radiotherapy (SBRT) as a neoadjuvant strategy of chemoradiation in pancreatic cancer

PURPOSE/OBJECTIVE(S)

To improve the curative resection rates and prognoses, a variety of neoadjuvant (NA) strategies have been explored in PDAC. In our institution, non-metastatic PDACs have been treated with a NA intent with induction multiagent chemotherapy and SBRT. The primary endpoint was to increase R0 resection rate. The secondary endpoints were the analysis of the clinical tolerance, the pathological response, the local control (LC) and the OS.

MATERIALS/METHODS

All consecutive patients with non-metastatic PDAC underwent SBRT as part of the NA strategy were included. A total dose of 40-62 Gy were delivered in 5-10 fractions. Surgery was performed after SBRT and restaging.

RESULTS

Since February 2014 to December 2018, 45 patients were enrolled. Thirty-two patients underwent surgery (71.1%), 10 out of 15 were initially unresectable disease patients (66.75%). R0 resection rate was 93% (30 patients) and pN0 status was achieved in 20 patients (60.6%). Tumour regression grade (TRG): 12 patients with complete response or marked response (TRG 0-1: 37.5%), 16 patients with moderate response (TRG 2: 50%) and four patients with poor response (TRG 3: 12.5%). The median follow-up was 16.2 m (range 6.6-59.6 m) since diagnosis. The LC rate achieved was very high (95.5%). Actuarial 12 and 24 m OS was 67.4% and 35.9% respectively. No grade 3 or higher toxicity related to SBRT was observed.

CONCLUSION

The results are encouraging, suggesting that SBRT has a significant role in the management of these patients and further studies will be necessary to prove these findings.

External-beam radiation therapy and high-dose rate brachytherapy combined with long-term androgen deprivation therapy in high and very high prostate cancer: preliminary data on clinical outcome

PURPOSE

To determine the feasibility of combined long-term androgen deprivation therapy (ADT) and dose escalation with high-dose-rate (HDR) brachytherapy.

METHODS AND MATERIALS

Between 2001 and 2007, 200 patients with high-risk prostate cancer (32.5%) or very high-risk prostate cancer (67.5%) were prospectively enrolled in this Phase II trial. Tumor characteristics included a median pretreatment prostate-specific antigen of 15.2 ng/mL, a clinical stage of T2c, and a Gleason score of 7. Treatment consisted of 54 Gy of external irradiation (three-dimensional conformal radiotherapy [3DCRT]) followed by 19 Gy of HDR brachytherapy in four twice-daily treatments. ADT started 0-3 months before 3DCRT and continued for 2 years.

RESULTS

One hundred and ninety patients (95%) received 2 years of ADT. After a median follow-up of 3.7 years (range, 2-9), late Grade ≥2 urinary toxicity was observed in 18% of the patients and Grade ≥3 was observed in 5%. Prior transurethral resection of the prostate (p = 0.013) and bladder D(50) ≥1.19 Gy (p = 0.014) were associated with increased Grade ≥2 urinary complications; age ≥70 (p = 0.05) was associated with Grade ≥3 urinary complications. Late Grade ≥2 gastrointestinal toxicity was observed in 9% of the patients and Grade ≥3 in 1.5%. CTV size ≥35.8 cc (p = 0.007) and D(100) ≥3.05 Gy (p = 0.01) were significant for increased Grade ≥2 complications. The 5-year and 9-year biochemical relapse-free survival (nadir + 2) rates were 85.1% and 75.7%, respectively. Patients with Gleason score of 7-10 had a decreased biochemical relapse-free survival (p = 0.007).

CONCLUSIONS

Intermediate-term results at the 5-year time point indicate a favorable outcome without an increase in the rate of late complications.

Institutional experience on the treatment of lung and liver lesions with stereotactic body radiotherapy and Novalis Exactrac Adaptive Gating technique

INTRODUCTION

Gating technique can improve the accuracy of the treatment of lung and liver lesions with SBRT, by monitoring organ tumor motion and irradiating within a selected area of the respiratory cycle.

METHODS

We have treated 75 patients (34 lung and 41 liver) with Novalis LINAC SBRT Adaptive Gating Technique. A total of 130 lesions, 49 lung lesions (11 primary NSCLC and 38 metastases) and 81 liver lesions (10 primary and 71 metastases). Prior to treatment, a fiducial marker is implanted and CT simulation is performed in breatholding with infrared external skin markers. Based on these external markers, internal tumor motion is correlated with the external respiratory signal. The outlined PTV includes (CTV=GTV) + 5 mm margin. The following doses are prescribed: liver (5Gy x 10 or 12-20Gy x 3), peripheral lung lesions (15-20 Gy x 3), and central lung lesions (5Gy x 10 or 10 Gy x5). The dose was delivered with multiple coplanar static beams. During patient setup, infrared markers track the respiratory cycle. Exactrac X-Rays localize the internal marker, quantify the tumor movement, and define the "beam on area" by correlating the external marker motion to the internal marker position. Intrafraction verification of the validity of this model is performed in real time by ExacTrac X-Rays.

RESULTS

130 lesions were evaluated with 90.5% local control at two years [93.8% in lung and 87.3% in liver lesions]. Clinical tolerance was excellent and no lung or liver toxicity grade 3 was observed.

CONCLUSION

Our clinical experience with Novalis SBRT Adaptive Gating shows that this technique is safe and efficient for the treatment of lung and liver lesions, while reducing the volume of irradiated healthy tissue. Intrafraction verification improves the treatment accuracy by a real time verification of tumor position.

Use of customized-mold brachytherapy in the management of malignancies arising in the maxillary antrum after maxillectomy: a dosimetric analysis

PURPOSE

To explore the feasibility of a intraoral mold high-dose rate (HDR) brachytherapy in the treatment of tumors arising in the maxillary antrum after maxillectomy and to describe the dosimetric profile of HDR brachytherapy in such an unusual location.

METHODS AND MATERIALS

A customized mold with four 6-French catheters was designed and produced in transparent acrylic resin. The catheters formed a soft loop that allowed the passage of the HDR source. CT-based dose evaluation in several volumes of interest, including the gross tumor volume (GTV) and several organs at risk (OARs), such as the skin of the cheek, eyeball, lens, optic nerve, optic chiasm, and spinal cord was performed.

RESULTS

Treatments were delivered uneventfully. A favorable OAR/GTV ratio was observed. The GTV D(90) was covered by the 3.8 Gy isodose (95% of the prescription isodose of 4 Gy) and the doses received by the OARs varied between 4% and 43% of the prescription isodose for the V1 cc of spinal cord and eyeball, respectively. The only structure that could not be adequately spared was the skin overlying the tumoral lesion that received between 94% and 107% of the prescription isodose (1.0 and 0.5 cm(2) of skin, respectively).

CONCLUSIONS

Intraoral mold-based HDR brachytherapy can be used to treat tumors involving the maxillary antrum provided that access is possible through a previous maxillectomy. A dose reduction of 4-43% in several OARs, such as the spinal cord, pituitary gland, optic chiasm, optic nerve, eyeball, and lens, is obtained.

Patterns of response after preoperative treatment in gastric cancer

PURPOSE

To analyze the rate of pathologic response in patients with locally advanced gastric cancer treated with preoperative chemotherapy with and without chemoradiation at our institution.

METHODS AND MATERIALS

From 2000 to 2007 patients were retrospectively identified who received preoperative treatment for gastric cancer (cT3-4/ N+) with induction chemotherapy (Ch) or with Ch followed by concurrent chemoradiotherapy (45 Gy in 5 weeks) (ChRT). Surgery was planned 4-6 weeks after the completion of neoadjuvant treatment. Pathologic assessment was used to investigate the patterns of pathologic response after neoadjuvant treatment.

RESULTS

Sixty-one patients were analyzed. Of 61 patients, 58 (95%) underwent surgery. The R0 resection rate was 87%. Pathologic complete response was achieved in 12% of the patients. A major pathologic response (<10% of residual tumor) was observed in 53% of patients, and T downstaging was observed in 75%. Median follow-up was 38.7 months. Median disease-free survival (DFS) was 36.5 months. The only patient-, tumor-, and treatment-related factor associated with pathologic response was the use of preoperative ChRT. Patients achieving major pathologic response had a 3-year actuarial DFS rate of 63%.

CONCLUSIONS

The patterns of pathologic response after preoperative ChRT suggest encouraging intervals of DFS. Such a strategy may be of interest to be explored in gastric cancer.

Relationship between Day 0 dosimetric parameters and biochemical relapse-free survival in patients treated with transperineal permanent prostate interstitial brachytherapy with (125)I seeds

OBJECTIVES

To determine the relationship between dosimetric parameters obtained on postimplantation Day 0 and biochemical relapse-free survival (bRFS) in patients treated with (125)I transperineal interstitial permanent prostate brachytherapy (TIPPB).

METHODS

Two-hundred twenty men with low-risk (n=155, 70.4%), low-volume intermediate-risk (n=63, 28.7%), or high-risk (n=2, 0.9%) prostate cancer were treated with TIPPB between December 2000 and June 2006. Seventy-four (33.6%) patients received short-term (3-6 months) androgen suppression therapy before TIPPB. The median followup for patients free of biochemical failure was of 37.9 months (range, 24.0-84.5 months).

RESULTS

The receiver operating characteristic (ROC) analysis established a best-fit cutoff value for the quantifiers D(90) and V(100) of 147Gy and 92%, respectively. The Kaplan-Meier analysis of bRFS at the cutoff value of D(90)=147Gy using the ASTRO, nadir+2, and combined (ASTRO and nadir+2) definitions showed a trend toward statistical significance for the ASTRO (p=0.076) and nadir+2 (p=0.064) definitions and a statistically significant correlation for the combined definition (p=0.033). The corresponding 7-year bRFS for the D(90) >147Gy and D(90) </=147Gy subsets using the ASTRO, nadir+2, and combined definitions were 96.5% vs. 89.7% (ASTRO, p=0.076); 93.7% vs. 70.5% (nadir+2, p=0.064); and 94.4 vs. 75.5% (combined, p=0.033). The V(100) (%) cutoff value of 92% predicted by the ROC analysis was not significant. Among other cutoff values, only D(90)=140Gy (p=0.050) and D(90)=160Gy (p=0.098) showed a trend toward statistical significance when the nadir+2 and the ASTRO definitions were used. The rest of dosimetric, tumor, and patient parameters did not show statistical correlation with bRFS in the Kaplan-Meier analysis.

CONCLUSIONS

The cutoff value of D(90)=147Gy obtained on postimplantation Day 0 showed a trend toward significant correlation with bRFS when the standard ASTRO and nadir+2 definitions were used and a weak but statistically significant correlation with bRFS as per the nonstandard combined definition in a series of patients with predominantly low-risk disease (70.4%) treated at high radiation doses (median D(90)=152.9Gy, median V(100)=92.5%).

[Stereotactic radiation therapy]

Stereotactic radiotherapy is a form of external radiotherapy that employs a system of three dimensional coordinates independent of the patient for the precise localisation of the lesion. It also has the characteristic that the radiation beams are conformed and precise, and converge on the lesion, making it possible to administer very high doses of radiotherapy without increasing the radiation to healthy adjacent organs or structures. When the procedure is carried out in one treatment session it is termed radiosurgery, and when administered over several sessions it is termed stereotactic radiotherapy. Special systems of fixing or immobilising the patient (guides or stereotactic frames) are required together with radiotherapy devices capable of generating conformed beams (lineal accelerator, gammaknife, cyberknife, tomotherapy, cyclotrons). Modern stereotactic radiotherapy employs intra-tumoural radio-opaque frames or CAT image systems included in the irradiation device, which make possible a precise localisation of mobile lesions in each treatment session. Besides, technological advances make it possible to coordinate the lesion's movements in breathing with the radiotherapy unit (gating and tracking) for maximum tightening of margins and excluding a greater volume of healthy tissue. Radiosurgery is mainly indicated in benign or malign cerebral lesions less than 3-4 centimetres (arteriovenous malformations, neurinomas, meningiomas, cerebral metastases) and stereotactic radiotherapy is basically administered in tumours of extracraneal localisation that require high conforming and precision, such as inoperable early lung cancer and hepatic metastasis.