Non-invasive physical plasma for preventing radiation dermatitis in breast cancer: Results from an intrapatient-randomised double-blind placebo-controlled trial

Background and Purpose

To investigate the effect of topical non-invasive physical plasma (NIPP), a volatile mix generated out of ambient air, on prevention of acute radiation dermatitis (RD) during and after whole-breast irradiation (WBI).

Materials and Methods

Lateral and medial breast halves were randomised within each patient to receive either 120 s of NIPP or sham treatment daily during WBI. Standard skin care with urea lotion was applied to the whole breast. Blinded acute skin toxicity was assessed weekly for each breast half separately and included clinician- (CTCAE) and patient-reported (modified RISRAS), and objective (spectrophotometry) assessments. As an additional external control, a comparable standard of care (SoC) patient collective from a previous prospective trial was used.

Results

Sixty-four patients were included. There were no significant differences between breast halves. Post-hoc comparison with a similar SoC control collective revealed OR = 0.28 (95% CI 0.11-0.76; p = 0.014) for grade ≥ 2 RD upon WBI completion, along with less hyperpigmentation (p < 0.001), oedema (p = 0.020), dry (p < 0.001) and moist desquamation (p = 0.017), pain, itching, and burning (p < 0.001 for each). Tolerability of NIPP was excellent and side effects were not observed.

Conclusion

Even though there were no differences between intrapatient-randomised breast halves, the overall incidence and severity of acute radiation-induced skin toxicity were considerably lower when compared to a prospectively collected SoC cohort. Our data suggest the potential benefit of NIPP in RD prevention. A randomised trial with a physical control group is warranted to confirm these promising results (DRKS00026225).

Safety and efficacy of helical tomotherapy following lung-sparing surgery in locally advanced malignant pleural mesothelioma

PURPOSE

To assess the value of radiation therapy (RT) with helical tomotherapy (HT) in the management of locally advanced malignant pleural mesothelioma (MPM) receiving no or lung-sparing surgery.

METHODS

Consecutive MPM cases not undergoing extrapleural pneumonectomy and receiving intensity-modulated (IM) HT were retrospectively evaluated for local control, distant control, progression-free survival (PFS), and overall survival (OS). Impact of age, systemic treatment, RT dose, and recurrence patterns was analyzed by univariate and multivariate analysis. As a secondary endpoint, reported toxicity was assessed.

RESULTS

A total of 34 localized MPM cases undergoing IMHT were identified, of which follow-up data were available for 31 patients. Grade 3 side effects were experienced by 26.7% of patients and there were no grade 4 or 5 events observed. Median PFS was 19 months. Median OS was 20 months and the rates for 1‑ and 2‑year OS were 86.2 and 41.4%, respectively. OS was significantly superior for patients receiving adjuvant chemotherapy (p = 0.008).

CONCLUSION

IMHT of locally advanced MPM after lung-sparing surgery is safe and feasible, resulting in satisfactory local control and survival. Adjuvant chemotherapy significantly improves OS. Randomized clinical trials incorporating modern RT techniques as a component of trimodal treatment are warranted to establish an evidence-based standard of care pattern for locally advanced MPM.

Optimized Conformal Total Body Irradiation with VMAT Using a Linear-Accelerator-Based Radiosurgery Treatment System in Comparison to the Golden Standard Helical TomoTherapy

Modern irradiation techniques for optimized conformal TBI can be realized by Helical Tomotherapy (HT) or Volumetric Modulated Arc Therapy (VMAT), depending on the availability of suitable specialized equipment. In this dosimetric planning study, we compared both modalities and addressed the question of whether VMAT with small field sizes is also suitable as a backup in case of HT equipment malfunctions. For this purpose, we retrospectively used planning computed tomography (CT) data from 10 patients treated with HT with a total dose of 8 Gy (n = 5) or 12 Gy (n = 5) for treatment planning for VMAT with a small field size (36 × 22 cm). The target volume coverage, dose homogeneity at target volume, and dose reduction in organs at risk (OAR) (lungs, kidneys, lenses) were analyzed and compared. One patient was irradiated with both modalities due to a device failure of the HT equipment during the study, which facilitated a comparison in a real clinical setting. The findings indicate that in addition to a higher mean dose to the lenses in the 12 Gy group for VMAT and a better dose homogeneity in the target volume for HT, comparably good and adequate target dose coverage and dose reduction in the other OAR could be achieved for both modalities, with significantly longer treatment times for VMAT. In conclusion, after appropriate optimization of the treatment times, VMAT using linear accelerator radiosurgery technology can be used both as a backup in addition to HT and in clinical routines to perform optimized conformal TBI.

Whole body irradiation with intensity-modulated helical tomotherapy prior to haematopoietic stem cell transplantation: analysis of organs at risk by dose and its effect on blood kinetics

BACKGROUND

Intensity-modulated helical tomotherapy (HT) is a promising technique in preparation for bone marrow transplantation. Nevertheless, radiation-sensitive organs can be substantially compromised due to suboptimal delivery techniques of total body irradiation (TBI). To reduce the potential burden of radiation toxicity to organs at risk (OAR), high-quality coverage and homogeneity are essential. We investigated dosimetric data from kidney, lung and thorax, liver, and spleen in relation to peripheral blood kinetics. To further advance intensity-modulated total body irradiation (TBI), the potential for dose reduction to lung and kidney was considered in the analysis.

PATIENTS AND METHODS

46 patients undergoing TBI were included in this analysis, partially divided into dose groups (2, 4, 8, and 12 Gy). HT was performed using a rotating gantry to ensuring optimal reduction of radiation to the lungs and kidneys and to provide optimal coverage of other OAR. Common dosimetric parameters, such as D05, D95, and D50, were calculated and analysed. Leukocytes, neutrophils, platelets, creatinine, GFR, haemoglobin, overall survival, and graft-versus-host disease were related to the dosimetric evaluation using statistical tests.

RESULTS

The mean D95 of the lung is 48.23%, less than half the prescribed and unreduced dose. The D95 of the chest is almost twice as high at 84.95%. Overall liver coverage values ranged from 96.79% for D95 to 107% for D05. The average dose sparing of all patients analysed resulted in an average D95 of 68.64% in the right kidney and 69.31% in the left kidney. Average D95 in the spleen was 94.28% and D05 was 107.05%. Homogeneity indexes ranged from 1.12 for liver to 2.28 for lung. The additional significance analyses conducted on these blood kinetics showed a significant difference between the 2 Gray group and the other three groups for leukocyte counts. Further statistical comparisons of the dose groups showed no significant differences. However, there were significant changes in the dose of OAR prescribed with dose sparing (e.g., lung vs. rib and kidney).

CONCLUSION

Using intensity-modulated helical tomotherapy to deliver TBI is a feasible method in preparation for haematopoietic stem cell transplantation. Significant dose sparing in radiosensitive organs such as the lungs and kidneys is achievable with good overall quality of coverage. Peripheral blood kinetics support the positive impact of HT and its advantages strongly encourage its implementation within clinical routine.

Helical versus static approaches to delivering tomotherapy to the junctional target for patients taller than 135 cm undergoing total body irradiation

BACKGROUND

Helical TomoTherapy^® is widely used for total body irradiation as a component of conditioning regimens before allogeneic bone-marrow transplantation. However, this technique limits the maximum length of a planning target volume to 135 cm. Therefore, patients taller than 135 cm require two planning computed tomography scans and treatment plans. The junctional target between these two treatment plans is thus a critical region for treatment planning and delivery. Here, we compare radiation coverage of the junctional target between helical and static approaches to treatment planning and delivery to determine which approach allows high quality irradiation planning and provides more robustness against patient movement.

METHODS

We retrospectively analyzed 10 patients who underwent total body irradiation using a static four-field box planning approach and nine patients who underwent total body irradiation using a helical planning approach. All patients were taller than 135 cm. The junctional target volume was divided into 10 slices of 1 cm thickness (JT₁-JT₁₀) for analysis. Dosimetric parameters and dose-volume histograms were compared to assess the quality of coverage of the junctional target between the helical and static planning approaches.

RESULTS

The D₅₀ for the total junctional target was slightly higher than the prescribed dose for both helical and static approaches, with a mean of 108.12% for the helical group and 107.81% for the static group. The mean D₉₅ was 98.44% ± 4.19% for the helical group and 96.20% ± 4.59% for the static group. The mean homogeneity index covering the entire junctional target volume was 1.20 ± 0.04 for the helical group and 1.21 ± 0.05 for the static group. The mean homogeneity index ranged from 1.08 ± 0.01 in JT₁ to 1.22 ± 0.06 in JT₆ for the helical group and from 1.06 ± 0.02 in JT₁ to 1.19 ± 0.05 in JT₆ for the static group. There were no significant differences in parameters between helical and static groups. However, the static approach provided robustness against up to 30 mm of lateral movement of the patient.

CONCLUSIONS

As long as TBI using helical TomoTherapy^® is limited to a maximum length of 135 cm, the junctional target must be addressed during treatment planning. Our analysis shows that the static four-field box approach is viable and offers higher robustness against lateral movement of the patient than the helical approach.

Dosimetric Comparison Between Helical Tomotherapy and Volumetric Modulated Arc Therapy in Patients With Malignant Pleural Mesothelioma

AIMS

To carry out a dosimetric comparison and constraints feasibility proof of adjuvant radiotherapy through helical tomotherapy or volumetric modulated arc therapy (VMAT) for malignant pleural mesothelioma patients after pleurectomy/decortication.

MATERIALS AND METHODS

Retrospective calculations were carried out on previously acquired simulations. A whole-pleura volume with 50.4 Gy in 28 fractions was prescribed, simulating a no residual tumour situation. Calculations were carried out using an anisotropic analytical algorithm with a 2.0 mm grid. Beam-on time, planning target volume (PTV) coverage, homogeneity index and organ at risk exposure were compared.

RESULTS

Sixteen patient plans were calculated per device. Constraints were met overall by both modalities. For helical tomotherapy and VMAT plans, median beam-on times were 13.8 (11.6-16.1) min and 6.4 (6.1-7.0) min; P = 0.006. The median left-sided radiotherapy PTV D₉₈ were 48.1 (48.0-48.8) Gy and 47.6 (46.5-48.3) Gy; P = 0.023. No significant difference for right-sided radiotherapy was found. PTV D₂ for left-sided radiotherapy was higher with VMAT (P = 0.014). For right-sided radiotherapy, helical tomotherapy showed higher doses (P = 0.039). No homogeneity index differences for left-sided radiotherapy (P = 1.00) and right-sided radiotherapy (P = 0.598) were seen. Significant organ at risk exposure differences were found on left-sided radiotherapy whole-lung V_20, as well as D₅₀ (both P = 0.008). Higher contralateral lung and ipsilateral kidney exposures were found with VMAT plans for both treatment sides.

CONCLUSION

Adjuvant radiotherapy after pleurectomy/decortication in malignant pleural mesothelioma patients, with a VMAT- or helical tomotherapy-based platform, is dosimetrically feasible. Lung sparing was mostly improved with helical tomotherapy. Technique selection must be carried out according to availability and clinical criteria.

Acute radiation-induced skin toxicity in hypofractionated vs. conventional whole-breast irradiation: An objective, randomized multicenter assessment using spectrophotometry

PURPOSE

Radiation dermatitis represents one of the most frequent side effects in breast cancer patients undergoing adjuvant whole-breast irradiation (WBI). Whether hypofractionated WBI induces comparable or less acute radiation-induced skin reactions than conventional WBI is still not fully clarified, as randomized evidence and objective assessments are limited. The aim of this study was to objectively determine frequency and severity of acute radiation-induced skin reactions during hypofractionated vs. conventionally fractionated adjuvant WBI.

METHODS

In this randomized multicenter study, a total of 140 breast cancer patients underwent either hypofractionated or conventional WBI following breast-preserving surgery. Maximum radiation dermatitis severity was assessed at completion and during follow-up by physician-assessed CTCAE v4.03 and the patient-reported RISRAS scale. Additionally, photospectrometric skin readings were performed to objectify skin color differences between both treatment arms.

RESULTS

Radiation dermatitis severity was significantly lower in patients receiving hypofractionation compared with conventional fractionation (mean 1.05 vs. 1.43, p = .024). Grade 0 radiation dermatitis occurred in 21.43% vs. 4.28%, grade ≥2 in 27.14% vs. 42.91% and grade ≥3 in 0% vs. 4.34% of patients following hypofractionated and conventional WBI, respectively. Objective photospectrometric measurements (n = 4200) showed both decreased erythema severity (p = .008) and hyperpigmentation (p = .002) in the hypofractionation arm. Patients allocated to hypofractionated WBI also reported less pain (p = .006), less hyperpigmentation (p = <0.001) and less limitations of day-to-day activities (p = <0.001).

CONCLUSION

Physician and patient-assessed toxicity scorings as well as objective photospectrometric skin measurements revealed that hypofractionated WBI yielded lower rates and severity of acute radiation-induced skin toxicity.

Hydrofilm Polyurethane Films Reduce Radiation Dermatitis Severity in Hypofractionated Whole-Breast Irradiation: An Objective, Intra-Patient Randomized Dual-Center Assessment

Radiation-induced skin injury represents the most frequent side effect in breast cancer patients undergoing whole-breast irradiation (WBI). Numerous clinical studies on systemic and topical treatments for radiation dermatitis have failed to provide sustainable treatment strategies. While protective skin products such as dressings are undoubtedly the standard of care in wound care management, their utilization as preventive treatment in radiotherapy has been somewhat neglected in recent years. In this prospective, intra-patient randomized observational study, Hydrofilm polyurethane films were prophylactically applied to either the medial or lateral breast-half of 74 patients with breast cancer undergoing hypofractionated whole-breast irradiation following breast-preserving surgery. Maximum radiation dermatitis severity was assessed using Common Terminology Criteria for Adverse Events (CTCAE) v4.03 toxicity scores, photospectrometric erythema and pigmentation measurements and patient-assessed modified Radiation-Induced Skin Reaction Assessment Scale (RISRAS) scale. Phantom studies revealed a clinically negligible dose build-up of less than 0.1% with Hydrofilm. Compared to the control compartments physician-assessed radiation dermatitis severity was reduced in the hydrofilm compartments (mean 0.54 vs. 1.34; p = < 0.001). Objective photospectrometric skin measurements showed decreased erythema (p = 0.0001) and hyperpigmentation (p = 0.002) underneath Hydrofilm. Hydrofilm also completely prevented moist desquamation, and significantly reduced patients' treatment-related symptoms of itching, burning, pain, and limitations of day-to-day-activities. Significant beneficial effects were observed in terms of radiation dermatitis severity, erythema, hyperpigmentation as well as subjective treatment-related symptom experiences, while adverse reactions were rare and minor. Therefore, a prophylactic application of Hydrofilm polyurethane films can be suggested in hypofractionated WBI.

Tomotherapy in malignant mesothelioma: a planning study to establish dose constraints

PURPOSE

A planning study was performed for helical tomotherapy treatment. We evaluated the maximum achievable protection of organs at risk (OARs) in patients with malignant pleural mesothelioma after pleurectomy with simultaneous optimal target coverage.

MATERIALS AND METHODS

The datasets of 13 patients were included. The applied dose to the planning target volume (PTV) was 50.4 Gy with single doses of 1.8 Gy per fraction. Presuming optimal target coverage, we evaluated the applied dose to the OARs with special regard to the contralateral lung.

RESULTS

For left-(lsRT)/right(rsRT)-sided radiotherapy, target coverage for the PTV showed a D98 (mean) of 49.37/49.71 Gy (98.0%/98.6%) and a D2 (mean) of 54.19/54.61 Gy (107.5%/108.3%). The beam-on time was kept below 15 min. The achieved mean dose (D50) to the contralateral lung was kept below 4 Gy for lsRT and rsRT. With regard to the other organs at risk the applied doses were as follows: mean dose (lsRT): ipsilateral kidney (Dmean) 13.03 (5.32-22.18) Gy, contralateral kidney (Dmean) <2.0 Gy, heart (Dmean) 22.23 (13.57-27.72) Gy, spinal cord D1 <Gy; mean dose (rsRT): ipsilateral kidney (Dmean) 10.22 (6.30-18.04) Gy, contralateral kidney (Dmean) <2.1 Gy, heart (Dmean) 8.02 (6.0-10.38) Gy, spinal cord D1 <35.5 Gy.

CONCLUSION

With helical tomotherapy, postoperative treatment for malignant pleural mesothelioma after pleurectomy achieves good target coverage combined with simultaneous dose sparing to the (especially contralateral) OARs.

Prophylactically applied Hydrofilm polyurethane film dressings reduce radiation dermatitis in adjuvant radiation therapy of breast cancer patients

PURPOSE

Radiation-induced skin injury represents one of the most common side effects in breast cancer patients receiving adjuvant whole-breast radiotherapy. Numerous systemic and topical treatments have been studied in the prevention and management of radiation-induced skin injury without providing sustainable treatment strategies. While superficial barrier-forming skin products such as dressings are the standard of care in wound care management, their utilization as preventive treatment approach in radiotherapy has barely attracted attention.

METHODS

In this prospective, intra-patient randomized study, Hydrofilm polyurethane film dressings were applied prophylactically to either the medial or lateral breast half of 62 patients with breast cancer undergoing adjuvant radiation therapy following breast conserving surgery. The breast half contralateral to the film dressing was concurrently treated with 5% urea lotion as control skin care. Maximum severity of radiation dermatitis was assessed using RTOG/EORTC toxicity scores, photospectrometric erythema measurements and patient-assessed modified RISRAS scale.

RESULTS

In the Hydrofilm compartments, mean maximum RTOG/EORTC radiation dermatitis severity grades were significantly reduced from 1.33 to 0.35 and photospectrometric measurements showed significantly reduced erythema severity, as compared to the control compartments, with an overall response rate of 89.3%. Hydrofilm completely prevented moist desquamation and significantly reduced patients' subjective experience of itching and pain.

CONCLUSION

The obtained results along with a favorable cost-benefit ratio and an easy and quick application suggest a prophylactic application of Hydrofilm in adjuvant radiotherapy of breast cancer patients to reduce or even prevent radiation dermatitis.

Patient positioning in head and neck cancer : Setup variations and safety margins in helical tomotherapy

OBJECTIVE

To evaluate the interfractional variations of patient positioning during intensity-modulated radiotherapy (IMRT) with helical tomotherapy in head and neck cancer and to calculate the required safety margins (sm) for bony landmarks resulting from the necessary table adjustments.

MATERIALS AND METHODS

In all, 15 patients with head and neck cancer were irradiated using the Hi-Art II tomotherapy system between April and September 2016. Before therapy sessions, patient position was frequently checked by megavolt computed tomography (MV-CT). Necessary table adjustments (ta) in the right-left (rl), superior-inferior (si) and anterior-posterior (ap) directions were recorded for four anatomical points: second, fourth and sixth cervical vertebral body (CVB), anterior nasal spine (ANS). Based upon these data sm were calculated for non-image-guided radiotherapy, image-guided radiotherapy (IGRT) and image guidance limited to a shortened area (CVB 2).

RESULTS

Based upon planning CT the actual treatment required ta from -0.05 ± 1.31 mm for CVB 2 (ap) up to 2.63 ± 2.39 mm for ANS (rl). Considering the performed ta resulting from image control (MV-CT) we detected remaining ta from -0.10 ± 1.09 mm for CVB 4 (rl) up to 1.97 ± 1.64 mm for ANS (si). After theoretical adjustment of patients position to CVB 2 the resulting ta ranged from -0.11 ± 2.44 mm for CVB6 (ap) to 2.37 ± 2.17 mm for ANS (si). These data imply safety margins: uncorrected patient position: 3.63-9.95 mm, corrected positioning based upon the whole target volume (IGRT): 1.85-6.63 mm, corrected positioning based upon CVB 2 (IGRT): 3.13-6.66 mm.

CONCLUSIONS

The calculated safety margins differ between anatomic regions. Repetitive and frequent image control of patient positioning is necessary that, however, possibly may be focussed on a limited region.

MRI during radiotherapy of glioblastoma : Does MRI allow for prognostic stratification?

AIM

To evaluate the role of magnetic resonance imaging (MRI) as a predictor for the clinical course in patients with glioblastoma.

PATIENTS AND METHODS

In 64 patients with glioblastoma undergoing (chemo)radiotherapy MRI studies were obtained before radiation, after 30 gray (Gy), after 60 Gy and during follow-up. MRI findings were assigned to categories: definite progression, questionable progression, no change. Patients were followed clinically.

RESULTS

At 30 Gy, 23 of 64 patients (36 %) demonstrated definite (dp; n = 15) or questionable (qp; n = 8) progression; in 41/64 (64 %) no change was found compared with preradiation MRI. After radiotherapy at 60 Gy, 26 of 64 (41 %) patients showed dp (n = 18) or qp (n = 8). In 2 cases with qp at the 30 Gy MRI, progress was unquestionable in the 60 Gy MRI study. In the 64 patients, 5 of the 60 Gy MRIs showed dp/qp after being classified as no change at the 30 Gy MRI, 2 of the 30 Gy MRIs showed qp, while the 60 Gy MRI showed tumour regression and 3 fulfilled the criteria for pseudoprogression during ongoing radiotherapy. The 30 Gy study allowed for prognostic stratification: dp/qp compared to stable patients showed median survival of 10.5 versus 20 months.

CONCLUSION

MR follow-up after 30 Gy in patients undergoing (chemo)radiotherapy for glioblastoma allows prognostic appraisal. Pseudoprogression has to be taken into account, though rare in our setting. Based on these findings, early discussion of treatment modification is possible.

Extraretinal induced visual sensations during IMRT of the brain

Background

We observed visual sensations (VSs) in patients undergoing intensity modulated radiotherapy (IMRT) of the brain without the beam passing through ocular structures. We analyzed this phenomenon especially with regards to reproducibility, and origin.

Methods and Findings

Analyzed were ten consecutive patients (aged 41-71 years) with glioblastoma multiforme who received pulsed IMRT (total dose 60Gy) with helical tomotherapy (TT). A megavolt—CT (MVCT) was performed daily before treatment. VSs were reported and recorded using a triggered event recorder. The frequency of VSs was calculated and VSs were correlated with beam direction and couch position. Subjective patient perception was plotted on an 8x8 visual field (VF) matrix. Distance to the orbital roof (OR) from the first beam causing a VS was calculated from the Dicom radiation therapy data and MVCT data. During 175 treatment sessions (average 17.5 per patient) 5959 VSs were recorded and analyzed. VSs occurred only during the treatment session not during the MVCTs. Plotting events over time revealed patient-specific patterns. The average cranio-caudad extension of VS-inducing area was 63.4mm (range 43.24-92.1mm). The maximum distance between the first VS and the OR was 56.1mm so that direct interaction with the retina is unlikely. Data on subjective visual perception showed that VSs occurred mainly in the upper right and left quadrants of the VF. Within the visual pathways the highest probability for origin of VSs was seen in the optic chiasm and the optic tract (22%).

Conclusions

There is clear evidence that interaction of photon irradiation with neuronal structures distant from the eye can lead to VSs.

[Change of Taste during and after IM- /IG-Radiotherapy for Head and Neck Cancer Patients]

OBJECTIVE

Taste dysfunction is a common side effect during irradiation of head and neck. Our aim was to determine the time-dependent course and a possible dependency of this side effect to the radiation-dose during irradiation with helical tomotherapy.

PATIENTS AND METHODS

31 patients with malignant tumours in the region of head and neck received an IG-/IM-radiotherapy (helical tomotherapy).The median total dose was 63 Gy (range 30-66 Gy). For all patients the subjective taste dysfunction was documented and correlated to the median (D50) tongue dose.

RESULTS

A subjective taste dysfunction was registered by the patients themselves after 9 BT (days of radiotherapy) (median). This correlates to a mean dose (D50) of 15.3 Gy (back third of tongue (back ZD)), 11.3 Gy (middle ZD), 8.2 Gy (front ZD). A subjective ageusia occurred after 15 BT (median) (28.9 Gy (back ZD), 22.2 Gy (middle ZD), 17.7 Gy (front ZD)). A starting recovery was registered by 77% of the patients in the first 6-8 weeks after the end of radiotherapy.

CONCLUSION

The time-dependent course of taste dysfunction during radiotherapy and the following recovery is predictable. A dependency of taste dysfunction to radiation-dose exists. Based on the collected data a targeted dose reduction to the tongue with a view to minimize the taste dysfunction is thinkable and aim of further studies.