Can treatment of pediatric Hodgkin’s lymphoma be improved by PET imaging and proton therapy?

Background and purpose

To explore a new positron emission tomography (PET)-based target concept for pediatric Hodgkin’s lymphoma (PHL).

Patients and methods

For 10 patients, the planning target volume PTV1 was based on initial CT tumor extension and PTV2 on anatomy-related PET-positive lymph node levels after chemotherapy. The treatment techniques investigated (prescribed dose 19.8 Gy) comprised opposed-field (2F), intensity-modulated photon (IMXT), and single-field (PS) proton techniques. Treatment concepts were compared concerning dose-volume histogram (DVH) parameters and organ-equivalent doses (OED).

Results

The median PTV1 and PTV2 were 902?±?555 cm³ and 281?±?228 cm³. When using PTV2 instead of PTV1 for all techniques, the D_2% of the heart was reduced from 14 to 9 Gy and the D_mean of the thyroid from 16.6 to 2.7 Gy. Low- (20%), median- (50%), and high-dose volumes (80%) were reduced by 60% for the heart and bones using PTV2. PS reduced the high-dose volume of the lungs and the heart by up to 60%. IMXT increased the low-dose volumes and OED. PTV2 reduced OED by 54?±?10% for all organs at risk.

Conclusion

PTV2 has a high impact on the treated volume and on sparing of organs at risk. The combination of an adaptive target volume definition with protons could contribute to future PHL treatment concepts.     

Conformal breast irradiation with the arm of the affected side parallel to the body

Purpose

To propose a simple, forward-planned three-dimensional conformal radiotherapy (3D-CRT) technique for breast cancer patients with frozen shoulder.

Materials and methods

A technique is described that avoids lateral beams transmitting through the arm of the affected side. One medial, tangentially applied beam deposits most of the dose. Further beams with little weight are used to attain dose homogeneity. In order to quantify dose distribution and homogeneity in the planning target volume (PTV), as well as the scattered dose in organs at risk (OAR), the parameters D95, D5, D1, mean and median dose were determined for the individual volumes. Intensity-modulated radiotherapy (IMRT) and volumetric modulated arc therapy (VMAT) plans were created in order to compare these with the proposed technique.

Results

The described technique achieved homogenous dose deposition within the PTV. A regimen comprising 25 fractions of 2 Gy prescribed to the PTV resulted in the following dose parameters: PTV(D95): 44.3 Gy, PTV(D5): 52.7 Gy, PTV(D1): 54.8 Gy, PTV(mean): 49.3 Gy and PTV(median): 49.9 Gy. Mean lung dose was 7.0 Gy. The ipsilateral lung received a mean dose of 9.9 Gy. This plan was accepted for treatment. The IMRT and VMAT plans achieved a similar dose distribution in the PTV. These techniques also reduced dose deposition in the OAR.

Conclusion

The proposed 3D-CRT technique allows treatment of breast cancer patients who are not able to raise their arms above their head. Homogenous dose distribution in the PTV was achieved while avoiding lateral beams that transmit through the arm of the affected side. Mean lung dose was comparable to that of the conventional technique using opposed tangential beams. IMRT and VMAT also provide good target dose homogeneity with good sparing of OAR. However, these techniques are more demanding in terms of planning and quality assurance.     

Comparison of two different IMRT planning techniques in the treatment of nasopharyngeal carcinoma

Purpose

To compare the effect of two different intensity-modulated radiation therapy (IMRT) planning techniques on parotid gland doses in patients with nasopharyngeal carcinoma (NPC).

Patients and methods

Radiotherapy for 10 NPC patients referred to the University of Istanbul Cerrahpasa Medical School was planned with arc- and static seven-field IMRT. The simultaneous integrated boost (SIB) technique was used to deliver 70 Gy (2.12 Gy per fraction) to the primary tumor and involved nodes; 60 Gy (1.81 Gy per fraction) to the entire nasopharynx and 54 Gy (1.63 Gy per fraction) to elective lymph nodes in 33 fractions. Plans also aimed to keep the mean parotid dose below 26 Gy and limit the maximum doses to the spinal cord and brain stem to 45 and 54 Gy, respectively. Mean parotid gland doses for the two planning techniques were compared using a paired t-test. Target coverage and dose inhomogeneity were evaluated by calculating conformity- (CI) and homogeneity index (HI) values.

Results

Target coverage and dose homogeneity were identical and good for both planning techniques: CI?=?1.05?±?0.08 and 1.05?±?0.08; HI?=?1.08?±?0.02 and 1.07?±?0.01 for arc- and static field IMRT, respectively. Mean doses to contralateral parotid glands were 25.73?±?4.27 and 27.73?±?3.5 Gy(p?=?0.008) for arc- and static field IMRT plans, respectively, whereas mean ipsilateral parotid doses were 30.65?±?6.25 and 32.55?±?5.93 Gy (non-significant p-value), respectively. Mean monitor units (MU) per fraction for the 10 patients were considerably lower for arc- than for static field treatments—540.5?±?130.39 versus 1288.4?±?197.28 (p?<?0.001).

Conclusion

Normal tissues—particularly the parotid glands—are better spared with the arc technique in patients with NPC. MU and treatment times are considerably reduced in arc IMRT plans.     

Pelvic Ewing sarcomas

Purpose

The goal of the present work was to assess the potential advantage of intensity-modulated radiotherapy (IMRT) over three-dimensional conformal radiotherapy (3D-CRT) planning in pelvic Ewing’s sarcoma.

Patients and methods

A total of 8 patients with Ewing sarcoma of the pelvis undergoing radiotherapy were analyzed. Plans for 3D-CRT and IMRT were calculated for each patient. Dose coverage of the planning target volume (PTV), conformity and homogeneity indices, as well as further parameters were evaluated.

Results

The average dose coverage values for PTV were comparable in 3D-CRT and IMRT plans. Both techniques had a PTV coverage of V₉₅ >?98?% in all patients. Whereas the IMRT plans achieved a higher conformity index compared to the 3D-CRT plans (conformity index 0.79?±?0.12 vs. 0.54?±?0.19, p?=?0.012), the dose distribution across the target volumes was less homogeneous with IMRT planning than with 3D-CRT planning. This difference was statistically significant (homogeneity index 0.11?±?0.03 vs. 0.07?±?0.0, p?=?0.035). For the bowel, D_mean and D_1%, as well as V₂ to V₆₀ were reduced in IMRT plans. For the bladder and the rectum, there was no significant difference in D_mean. However, the percentages of volumes receiving at least doses of 30, 40, 45, and 50 Gy (V₃₀ to V₅₀) were lower for the rectum in IMRT plans. The volume of normal tissue receiving at least 2 Gy (V₂) was significantly higher in IMRT plans compared with 3D-CRT, whereas at high dose levels (V₃₀) it was significantly lower.

Conclusion

Compared to 3D-CRT, IMRT showed significantly better results regarding dose conformity (p?=?0.012) and bowel sparing at dose levels above 30 Gy (p?=?0.012). Thus, dose escalation in the radiotherapy of pelvic Ewing’s sarcoma can be more easily achieved using IMRT.     

Moderate hypofractionation and simultaneous integrated boost with volumetric modulated arc therapy (RapidArc) for prostate cancer

Purpose

In the present study, the acute toxicity profiles for prostate patients treated with simultaneous integrated boost (SIB) with volumetric modulated arcs in a hypofractionated regime are reported.

Patients and methods

A total of 70?patients treated with RapidArc between May 2010 and September 2011 were retrospectively evaluated. Patients were stratified into low (36%), intermediate (49%), and high-risk (16%) groups. Target volumes (expanded to define the planning volumes (PTV)) were clinical target volume (CTV) 1: prostate; CTV2: CTV1 + seminal vesicles; CTV3: CTV2 + pelvic nodes. Low-risk patients received 71.4?Gy to PTV1; intermediate-risk 74.2?Gy to PTV1 and 61.6 or 65.5?Gy to PTV2; high-risk 74.2?Gy to PTV1, 61.6 or 65.5?Gy to PTV2, and 51.8?Gy to PTV3. All treatments were in 28?fractions. The median follow-up was 11?months (range 3.5–23?months). The acute rectal, gastrointestinal (GI) and genitourinary (GU) toxicities were scored according to EORTC/RTOG scales.

Results

Acute toxicities were recorded for the GU [G0?=?31/70 (44%), G1?=?22/70 (31%); G2?=?16/70 (23%); G3?=?1/70 (1%)], the rectum [G0?=?46/70 (66%); G1?=?12/70 (17%); G2?=?12/70 (17%); no G3], and the GI [G0?=?54/69 (77%); G1?=?11/69 (16%); G2?=?4/69 (6%); no G3]. Median time to rectal, GU, and GI toxicities were 27, 30, and 33 days, respectively. Only the GI toxicity correlated with stage and pelvic irradiation. Univariate analysis presented significant correlations between GI toxicity and intestinal irradiation (V_50?Gy and V_60?Gy). In the multivariate analysis, the only significant dosimetric variable was V_50?Gy for the intestinal cavity.

Conclusion

Moderate hypofractionation with SIB and RapidArc was shown to be safe, with acceptable acute toxicity. Longer follow-up is needed to assess late toxicity and clinical outcome.     

Quasi-VMAT in high-grade glioma radiation therapy

Purpose

To compare a quasi-volumetric modulated arc therapy (qVMAT) with three-dimensional conformal radiation therapy (3D-CRT) and intensity-modulated radiation therapy (IMRT) for the treatment of high-grade gliomas. The qVMAT technique is a fast method of radiation therapy in which multiple equispaced beams analogous to those in rotation therapy are radiated in succession.

Patients and methods

This study included 12 patients with a planning target volume (PTV) that overlapped at least one organ at risk (OAR). 3D-CRT was planned using 2–3 non-coplanar beams, whereby the field-in-field technique (FIF) was used to divide each field into 1–3 subfields to shield the OAR. The qVMAT strategy was planned with 15 equispaced beams and IMRT was planned using 9 beams with a total of 80 segments. Inverse planning for qVMAT and IMRT was performed by direct machine parameter optimization (DMPO) to deliver a homogenous dose distribution of 60 Gy within the PTV and simultaneously limit the dose received by the OARs to the recommended values. Finally, the effect of introducing a maximum dose objective (max. dose <?54 Gy) for a virtual OAR in the form of a 0.5 cm ring around the PTV was investigated.

Results

The qVMAT method gave rise to significantly improved PTV_95% and conformity index (CI) values in comparison to 3D-CRT (PTV_95%?=?90.7?% vs. 82.0?%; CI?=?0.79 vs. 0.74, respectively). A further improvement was achieved by IMRT (PTV_95%?=?94.4?%, CI?=?0.78). In qVMAT and IMRT, the addition of a 0.5 cm ring around the PTV produced a significant increase in CI (0.87 and 0.88, respectively), but dosage homogeneity within the PTV was considerably reduced (PTV_95%?=?88.5?% and 92.3?%, respectively). The time required for qVMAT dose delivery was similar to that required using 3D-CRT.

Conclusion

These findings suggest that qVMAT should be preferred to 3D-CRT for the treatment of high-grade gliomas. The qVMAT method could be applied in hospitals, for example, which have limited departmental resources and are not equipped with systems capable of VMAT delivery.     

Individualized IMRT treatment approach for cervical lymph node metastases of unknown primary

Purpose

The goal of the present study was to evaluate the outcome of risk-adapted planning treatment volumes (PTVs) in patients with cervical lymph node metastases of unknown primary cancer (UPC) treated with intensity-modulated radiotherapy (IMRT).

Patients and material

Between January 2006 and November 2012, 28 patients with cervical lymph node metastases of UPC were treated in our institution with IMRT either postoperatively (n?=?20) or as definitive treatment (n?=?8). Nodal involvement distributed as follows: N1 (n?=?2), N2a (8), N2b (10), N2c (4), and N3 (4). Systemic therapy with cisplatin or cetuximab was added concomitantly in 20 of 28 patients (71?%). Radiotherapy using simultaneously integrated boost (SIB-IMRT) was carried out with 2.0 or 2.11 Gy single doses up to 66/70 Gy.

Results

Mean/median follow-up was 31.6/30.5 months (range 3–78 months). In all, 15 of 28 patients were treated with unilateral SIB-IMRT (54?%). An elective PTV to the contralateral oropharynx and contralateral level II–III lymph nodes was carried out in 8 patients with PET-CT suspected but not histologically proven involvement, recurrences or former tumor of the oropharynx. More extended treatment fields were reserved for patients with N2c or bilaterally N3 status (n?=?5). The 3-year overall survival, mucosal control, neck control and distant metastasis-free survival rates were 76, 100, 93, and 88?%, respectively. No patient suffered from a locoregional recurrence. Two patients treated with radiotherapy alone had persistent nodal disease. No grade II or higher late sequel has been observed.

Conclusion

Our single center approach to treat patients with cervical lymph node metastases of UPC with individualized, risk-adapted SIB-IMRT resulted in high locoregional tumor control and was well tolerated.     

Adjuvant therapy after resection of brain metastases

Background

Tumor bed stereotactic radiosurgery (SRS) after resection of brain metastases is a new strategy to delay or avoid whole-brain irradiation (WBRT) and its associated toxicities. This retrospective study analyzes results of frameless image-guided linear accelerator (LINAC)-based SRS and stereotactic hypofractionated radiotherapy (SHRT) as adjuvant treatment without WBRT.

Materials and methods

Between March 2009 and February 2012, 44 resection cavities in 42 patients were treated with SRS (23 cavities) or SHRT (21 cavities). All treatments were delivered using a stereotactic LINAC. All cavities were expanded by ≥?2 mm in all directions to create the clinical target volume (CTV).

Results

The median planning target volume (PTV) for SRS was 11.1 cm³. The median dose prescribed to the PTV margin for SRS was 17 Gy. Median PTV for SHRT was 22.3 cm³. The fractionation schemes applied were: 4 fractions of 6 Gy (5 patients), 6 fractions of 4 Gy (6 patients) and 10 fractions of 4 Gy (10 patients). Median follow-up was 9.6 months. Local control (LC) rates after 6 and 12 months were 91 and 77?%, respectively. No statistically significant differences in LC rates between SRS and SHRT treatments were observed. Distant brain control (DBC) rates at 6 and 12 months were 61 and 33?%, respectively. Overall survival (OS) at 6 and 12 months was 87 and 63.5?%, respectively, with a median OS of 15.9 months. One patient treated by SRS showed symptoms of radionecrosis, which was confirmed histologically.

Conclusion

Frameless image-guided LINAC-based adjuvant SRS and SHRT are effective and well tolerated local treatment strategies after resection of brain metastases in patients with oligometastatic disease.     

Stereotactic radiosurgery for newly diagnosed brain metastases

Background and purpose

Three doses were compared for local control of irradiated metastases, freedom from new brain metastases, and survival in patients receiving stereotactic radiosurgery (SRS) alone for one to three newly diagnosed brain metastases.

Patients and methods

In all, 134 patients were assigned to three groups according to the SRS dose given to the margins of the lesions: 13–16 Gy (n?=?33), 18 Gy (n?=?18), and 20 Gy (n?=?83). Additional potential prognostic factors were evaluated: age (≤?60 vs. >?60 years), gender, Karnofsky Performance Scale score (70–80 vs. 90–100), tumor type (non-small-cell lung cancer vs. melanoma vs. others), number of brain metastases (1 vs. 2–3), lesion size (?24 months).

Results

For 13–16 Gy, 18 Gy, and 20 Gy, the 1-year local control rates were 31, 65, and 79?%, respectively (p?p?p?p?=?0.12); 18 Gy showed a strong trend toward better local control when compared with 13–16 Gy (p?=?0.059). Freedom from new brain metastases (p?=?0.57) and survival (p?=?0.15) were not associated with SRS dose in the univariate analysis.

Conclusion

SRS doses of 18 Gy and 20 Gy resulted in better local control than 13–16 Gy. However, 20 Gy and 18 Gy must be compared again in a larger cohort of patients. Freedom from new brain metastases and survival were not associated with SRS dose.     

Changes in RBE of 14-MeV (d+T) neutrons for V79 cells irradiated in air and in a phantom: Is RBE enhanced near the surface?

Purpose

The relative biological effectiveness (RBE) for inacivation of V79 cells was determined as function of dose at the Heidelberg 14-MeV (d+T) neutron therapy facility after irradiation with single doses in air and at different depths in a therapy phantom. Furthermore, to assess the reproducibility of RBE determinations in different experiments we examined the relationship between the interexperimental variation in radiosensitivity towards neutrons with that towards low LET⁶⁰Co photons.

Methods

Clonogenic survival of V79 cells was determined using the colony formation assay. The cells were irradiated in suspension in small volumes (1.2 ml) free in air or at defined positions in the perspex phantom. Neutron doses were in the range, D₁=0.5–4 Gy.⁶⁰Co photons were used as reference radiation.

Results

The radiosensitivity towards neutrons varied considerably less between individual experiments than that towards photons and also less than RBE. However, the mean sensitivity of different series was relatively constant. RBE increased with decreasing dose per fraction from RBE=2.3 at 4 Gy to RBE=3.1 at 0.5 Gy. No significant difference in RBE could be detected between irradiation at 1.6 cm and 9.4 cm depth in the phantom. However, an approximately 20% higher RBE was found for irradiation free in air compared with inside the phantom. Combining the two effects, irradiation with 0.5 Gy free in air yielded an approximately 40% higher RBE than a dose of 2 Gy inside the phantom

Conclusion

The measured values of RBE as function of dose per fraction within the phantom is consistent with the energy of the neutron beam. The increased RBE free in air, however, is greater than expected from microdosimetric parameters of the beam and may be due to slow recoil protons produced by interaction of multiply scattered neutrons or to an increased contribution of α particles from C(n,α) reactions near the surface. An enhanced RBE in subcutaneous layers of skin combined with an increase in RBE at low doses per fraction outside the target volume could potentially have significant consequences for normal tissue reactions in radiotherapy patients treated with fast neutrons.     

Set-up uncertainty during breast radiotherapy

Purpose

The aim of this work was to establish a customized strategy for image-guided radiotherapy during whole breast irradiation. Risk factors associated with extensive errors were assessed.

Methods and materials

A series of 176 consecutive breasts in 174 patients were retrospectively assessed. Electronic portal images from 914 medial and 807 lateral directions were reviewed. On the basis of the chest wall, the deviations between the simulation and each treatment were measured. The systematic (Σ) and random error (σ) of population, and the planning target volume (PTV) margin (2?Σ?+?0.7σ) were calculated for each direction. Extensive set-up errors were defined as the fraction over the PTV margins in any direction. For extensive set-up errors, χ² tests and logistic regression analyses were conducted.

Results

The medial and lateral PTV margins for the right–left, superior–inferior, and anterior–posterior axes and the rotation of collimator were 2.6 and 2.4 mm, 4.6 and 4.6 mm, and 3.1 and 3.3 mm and 2.8 and 2.9?° and cut-off values for extensive errors were 3, 5, and 4 mm and 3?°, respectively. In χ² tests, tumor in upper outer quadrant (p?=?0.012) and chest wall thickness ≥?2.0 cm (p?=?0.003) for medial portals and age group (p?=?0.036) for lateral portals were associated with extensive errors. In multivariate tests, the extensive error on the initial fraction had a high probability of extensive set-up errors in both medial (OR?=?4.26, p?<?0.001) and lateral portals (OR?=?3.07, p?<?0.001).

Conclusion

In terms of the set-up uncertainty during breast irradiation, patients with extensive error in the initial treatment should be closely observed with serial image-guided radiotherapy.     

Volumetric evaluation of an alternative bladder point in brachytherapy for locally advanced cervical cancer

Purpose

To evaluate an alternative dose point, so-called ALG (for Alain Gerbaulet), for the bladder in comparison to the International Commission on Radiation Units and Measurements (ICRU) point and D2cm³ (minimal dose to maximally exposed 2 cm³) in a large cohort of patients with locally advanced cervical cancer treated with external beam radiotherapy followed by image-guided pulsed dose rate brachytherapy.

Methods and materials

For each patient, the ALG point was constructed 1.5 cm above the ICRU bladder, parallel to the tandem (coronal and sagittal planes). The dosimetric data from 162 patients were reviewed.

Results

Average doses to ALG and bladder points were 19.40 Gy?±?7.93 and 17.14?±?8.70, respectively (p?=?0.01). The 2 cm³ bladder dose averaged 24.40?±?6.77 Gy. Ratios between D2cm³ and dose points were 1.37?±?0.46 and 1.68?±?0.74 (p?<?0.001) for ALG and ICRU points, respectively. Both dose points appeared correlated with D2cm³ (p?<?0.001) with coefficients of determination (R²) of 0.331 and 0.399 respectively. The estimated dose to the ICRU point of the rectum was 12.77?±?4.21 and 15.76?±?5.94 for D2cm³ (p?<?0.0001). Both values were significantly correlated (p?<?0.0001, R²?=?0.485).

Conclusion

The ALG point underestimates the D2cm³, but its mean on a large cohort is closer to D2cm³ than the dose to ICRU point. However, it shows great variability between cases and the weak strength of its correlation to D2cm³ indicates that it is not a good surrogate for individual volumetric evaluation of the dose D2cm³.     

Radiotherapy for calcaneodynia

Purpose

The aim of this work was to compare the efficacy of two different dose fractionation schedules for radiotherapy of patients with calcaneodynia.

Patients and methods

Between February 2006 and April 2010, 457 consecutive evaluable patients were recruited for this prospective randomized trial. All patients received radiotherapy using the orthovoltage technique. One radiotherapy series consisted of 6 single fractions/3 weeks. In case of insufficient remission of pain after 6 weeks a second radiation series was performed. Patients were randomly assigned to receive either single doses of 0.5 or 1.0 Gy. Endpoint was pain reduction. Pain was measured before, immediately after, and 6 weeks after radiotherapy using a visual analogue scale (VAS) and a comprehensive pain score (CPS).

Results

The overall response rate for all patients was 87?% directly after and 88?% 6 weeks after radiotherapy. The mean VAS values before, immediately after, and 6 weeks after treatment for the 0.5 and 1.0 Gy groups were 65.5?±?22.1 and 64.0?±?20.5 (p?=?0.188), 34.8?±?24.7 and 39.0?±?26.3 (p?=?0.122), and 25.1?±?26.8 and 28.9?±?26.8 (p?=?0.156), respectively. The mean CPS before, immediately after, and 6 weeks after treatment was 10.1?±?2.7 and 10.0?±?3.0 (p?=?0.783), 5.6?±?3.7 and 6.0?±?3.9 (p?=?0.336), 4.0?±?4.1 and 4.3?±?3.6 (p?=?0.257), respectively. No statistically significant differences between the two single dose trial arms for early (p?=?0.216) and delayed response (p?=?0.080) were found.

Conclusion

Radiotherapy is an effective treatment option for the management of calcaneodynia. For radiation protection reasons, the dose for a radiotherapy series is recommended not to exceed 3–6 Gy.     

Does selective pleural irradiation of malignant pleural mesothelioma allow radiation dose escalation?

Background

After lung-sparing radiotherapy for malignant pleural mesothelioma (MPM), local failure at sites of previous gross disease represents the dominant form of failure. Our aim is to investigate if selective irradiation of the gross pleural disease only can allow dose escalation.

Materials and methods

In all, 12 consecutive stage I–IV MPM patients (6 left-sided and 6 right-sided) were retrospectively identified and included. A magnetic resonance imaging-based pleural gross tumor volume (GTV) was contoured. Two sets of planning target volumes (PTV) were generated for each patient: (1) a “selective” PTV (S-PTV), originating from a 5-mm isotropic expansion from the GTV and (2) an “elective” PTV (E-PTV), originating from a 5-mm isotropic expansion from the whole ipsilateral pleural space. Two sets of volumetric modulated arc therapy (VMAT) treatment plans were generated: a “selective” pleural irradiation plan (SPI plan) and an “elective” pleural irradiation plan (EPI plan, planned with a simultaneous integrated boost technique [SIB]).

Results

In the SPI plans, the average median dose to the S?PTV was 53.6?Gy (range 41–63.6?Gy). In 4 of 12 patients, it was possible to escalate the dose to the S?PTV to >58?Gy. In the EPI plans, the average median doses to the E?PTV and to the S?PTV were 48.6?Gy (range 38.5–58.7) and 49?Gy (range 38.6–59.5?Gy), respectively. No significant dose escalation was achievable.

Conclusion

The omission of the elective irradiation of the whole ipsilateral pleural space allowed dose escalation from 49?Gy to more than 58?Gy in 4 of 12 chemonaive MPM patients. This strategy may form the basis for nonsurgical radical combined modality treatment of MPM.

     

Does high-dose radiotherapy benefit palliative lung cancer patients?

Background and purpose

The present analysis compares two palliative treatment concepts for lung cancer in terms of overall survival.

Patients and methods

Survival data from 207 patients were used in a retrospective analysis. All patients received palliative treatment comprising either 25 Gy applied in 5 fractions or 50 Gy in 20 fractions. A subgroup analysis was performed to compare patients with a good–fair vs. poor overall condition.

Results

Median survival times were 21 weeks (range 6–26 weeks) for patients treated with 25 Gy in 5 fractions and 23 weeks (range 14.5–31.5 weeks) for patients treated with 50 Gy in 20 fractions (95?% confidence interval, CI; p?=?0.334). For patients with a good–fair overall condition, median survival times were 30 weeks (21.8–39.2 weeks) for 25 Gy in 5 fractions and 28 weeks (14.2–41.8 weeks) for 50 Gy in 20 fractions (CI 95?%, p?=?0.694). In patients with a poor overall condition, these values were 18 weeks (14.5–21.5 weeks) and 21 weeks (13.0–29.0 weeks), respectively (CI 95?%, p?=?0.248).

Conclusion

The palliative treatment concept of 25 Gy applied in 5 fractions is sufficient for radiation of lung cancer, given that there was no obvious survival improvement in patients treated with the higher total dose regimen.     

Concurrent hyperfractionated accelerated radiotherapy with 5-FU and once weekly cisplatin in locally advanced head and neck cancer

Purpose

In this study, the acute toxicity and long-term outcome of a hyperfractionated accelerated chemoradiation regimen with cisplatin/5-fluorouracil (5-FU) in patients with locally advanced squamous cell carcinomas of head and neck were evaluated.

Patients and methods

From 2000–2002, 38 patients with stage III (5.3?%) and stage IV (94.7?%) head and neck cancer were enrolled in a phase II study. Patients received hyperfractionated-accelerated radiotherapy with 72 Gy in 15 fractions of 2 Gy followed by 1.4 Gy twice daily with concurrent, continuous infusion 5-FU of 600 mg/m² on days 1–5 and 6 cycles of weekly cisplatin (30 mg/m²). Acute toxicities (CTCAEv2.0), locoregional control (LRC), metastases-free (MFS), and overall survival (OS) were analyzed and exploratively compared with the ARO 95-06 trial.

Results

Median follow-up was 11.4 years (95?% CI 8.6–14.2) and mean dose 71.6 Gy. Of the patients, 82?% had 6 (n?=?15) or 5 (n?=?16) cycles of cisplatin, 5 and 2 patients received 4 and 3 cycles, respectively. Grade 3 anemia, leukopenia, and thrombocytopenia were observed in 15.8, 15.8, and 2.6?%, respectively. Grade 3 mucositis in 50?%, grade 3 and 4 dysphagia in 55 and 13?%. The 2-, 5-, and 10-year LRC was 65, 53.6, and 48.2?%, the MFS was 77.5, 66.7, and 57.2?% and the OS 59.6, 29.2, and 15?%, respectively.

Conclusion

Chemoradiation with 5-FU and cisplatin seems feasible and superior in terms of LRC and OS to the ARO 95-06C-HART arm at 2 years. However, this did not persist at the 5- and 10-year follow-ups.     

Emergency CT head and neck imaging: effects of swimmer’s position on dose and image quality

Objectives

To compare the effects of different arm positions on dose exposure and image quality (IQ) in cervical spine CT after trauma in different patient groups.

Methods

Patients in standard (STD?=?126) and in swimmer’s position (SWIM?=?254) were included. Body mass index (BMI subgroup 1?=?underweight to subgroup 4?=?obese), anterior–posterior diameter (AP), left–right diameter (LR), area of an ellipse (AoE) and angle between the humeral heads (optimal STD?<?3°, optimal SWIM?>?10°) were used as grouping criteria. Computed tomography dose index (CTDI) was documented. Two radiologists rated the IQ at three levels (CV1/2, CV4/5, CV7/T1) using a semi-quantitative scale (0?=?not diagnostic, 1?=?diagnostic with limitations, 2?=?diagnostic without limitations). The Mann–Whitney U test correlations of grouping criteria with dose effects and intra-class correlation (ICC) were calculated.

Results

ICC was 0.87. BMI grouping showed the strongest correlation with dose effects: CTDI of optimal STD versus optimal SWIM positioning was 3.17 mGy versus 2.46 mGy (subgroup 1), 5.47 mGy versus 3.97 mGy (subgroup 2), 7.35 mGy versus 5.96 mGy (subgroup 3) and 8.71 mGy versus 8.18 mGy (subgroup 4). Mean IQ at CV7/T1 was 1.65 versus 1.23 (subgroup 1), 1.27 versus 1.46 (subgroup 2), 1.06 versus 1.46 (subgroup 3), 0.79 versus 1.5 (subgroup 4).

Conclusion

Patients with a BMI?>?20 kg/m² benefited from both potential dose reduction and improved image quality at the critical cervicothoracic junction when swimmer’s position was used.

Key Points

? BMI is a useful metric for personalized optimization in CT for the c-spine. ? Using swimmer’s position, patients can benefit from dose reduction. ? In some patients a superior image quality can be achieved with swimmer’s position. ? For swimmer’s positioning an angle of more than 10° is optimal.