Hypofractionated Radiotherapy for T1N0M0 Glottic Cancer: Retrospective Analysis of Two Different Cohorts of Dose-fractionation Schedules from a Single Institution

AimsTo determine the influence of dose and fractionation on tumour characteristics, toxicity, disease control and survival outcomes in T1 glottic carcinoma.Materials and methodsBetween 1975 and 2000, treatment charts of 652 patients with T1 glottic carcinoma who received curative radiation with four hypofractionated schedules (50 Gy/15 fractions [3.3 Gy/fraction] or 55 Gy/16 fractions [3.43 Gy/fraction] or 60 Gy/24 fractions or 62.5 Gy/25 fractions [2.5 Gy/fraction]) were analysed. The patients were divided into two groups based on fraction size <3 Gy and >3 Gy. Local control and overall survival were calculated. Patient- and tumour-related factors affecting local control were analysed using univariate and multivariate analysis. Factors affecting late toxicity were also analysed.ResultsThe local control and overall survival at 10 years were 84 and 86.1%, respectively, for T1 glottic carcinoma. The response to radiation had a significant effect on local control with univariate analysis (P = 0.001). Other factors, such as beam energy, anterior commissure involvement and fractionation, did not affect local control. Persistent radiation oedema was seen in 123 patients (23.4%) and was significantly worse in patients who received radiation with a larger field size (>36 cm²) on a telecobalt machine (P < 0.001).ConclusionsRadical radiotherapy schedules incorporating a higher dose per fraction yield acceptable local control rates and late toxicity. Telecobalt therapy for early glottic cancer is a safe alternative to treatment with 6 MV photons on a linear accelerator in terms of local control and late toxicity as long as field sizes smaller than 36 cm² are used.     

Utilization Patterns of Single Fraction Radiation Therapy for Multiple Myeloma

BackgroundPatients with multiple myeloma (MM) are living longer than ever before thanks to new therapies. As a consequence, radiation therapy (RT) is increasingly important in the management of bone lesions from MM. Current American Society for Radiation Oncology guidelines recommend greater usage of 8 Gy in 1 fraction for treatment of these lesions. The objective of this study is to analyze utilization of 8 Gy in 1 fraction for treatment of MM bone lesions in the United States utilizing the National Cancer Data Base (NCDB).Materials and MethodsThe NCDB was used to identify patients with MM treated with palliative RT for painful bony lesions in the period between 2004 and 2014. Utilization rate of RT in this patient population as well as single-fraction (SFRT) versus multiple-fraction RT (MFRT) was compared according to demographic, socioeconomic, and logistic details.ResultsA total of 95,190 patients met our inclusion criteria. Of these, 10,261 (10.8%) patients received RT, and a total of 243 (2.4%) of these patients received SFRT over the 10-year period. There was an 11.73% annual increase (P = .0001) in SFRT utilization from 2004 to 2014. Older age, black race, longer distance from the treatment facility, lower degree of education, treatment at an academic or integrated healthcare network, worse comorbidities, and more recent diagnoses were all associated with increased usage of SFRT.ConclusionSFRT for the management of MM painful bony metastases remains underutilized. Trends show that radiation oncologists do not appear to be changing their approach to treating this disease.     

The Safety and Efficacy of Radiation Therapy with Concurrent Dexamethasone,Cyclophosphamide, Etoposide,and Cisplatin-Based Systemic Therapy for Multiple Myeloma

IntroductionThe concurrent delivery of radiation therapy (RT) with salvage chemotherapies in the management of relapsed and refractory multiple myeloma (MM) is an area of ongoing investigation. This study examined the safety and efficacy of palliative RT given in the setting of concurrent dexamethasone, cyclophosphamide, etoposide, and cisplatin (DCEP).Patients and MethodsFifty-five patients with MM received RT to 64 different sites within three weeks of receiving DCEP from 2010 to 2020. A median dose of 20 Gray (range 8-32.5 Gy) was delivered in a median of 5 fractions (range 1-15). Patients received a median of 1 cycle (range 1-5) of DCEP. Rates of hematologic and RT toxicity were recorded along with pain, radiographic, and laboratory responses to treatment.ResultsRT was completed in 98% of patients. 21% of patients experienced RTOG grade 3+ hematologic toxicity before RT, which increased to 35% one-month post-RT (P = .13) before decreasing to 12% at 3 to 6 months (P = .02). The most common toxicity experienced was thrombocytopenia. Grade 1 to 2 non-hematologic RT-related toxicity was reported in 15% of patients while on treatment and fell to 6% one-month after completing RT. Pain resolved in 94% of patients with symptomatic lesions at baseline. Stable disease or better was observed in 34/39 (87%) of the targeted lesions on surveillance imaging.ConclusionRT administered concurrently with DCEP was well-tolerated by most of the patients in this series, with low rates of hematologic and RT-related toxicity. RT was also very effective, with the vast majority of patients demonstrating resolution of their pain and a significant response on follow-up imaging.     

Comparison of passive-beam proton therapy,helical tomotherapy and 3D conformal radiation therapy in Hodgkin's lymphoma female patients receiving involved-field or involved site radiation therapy

PurposeSecond cancers and cardiovascular toxicities are long term radiation toxicity in locally advanced Hodgkin's lymphomas. In this study, we evaluate the potential reduction of dose to normal tissue with helical tomotherapy and proton therapy for Hodgkin's lymphoma involved-field or involved-site irradiation compared to standard 3D conformal radiation therapy.Patients and methodsFourteen female patients with supradiaphragmatic Hodgkin's lymphoma were treated at our institution with 3D conformal radiation therapy or helical tomotherapy to a dose of 30 Gy in 15 fractions. A planning comparison was achieved including proton therapy with anterior/posterior passive scattered beams weighted 20 Gy/10 Gy.ResultsMean doses to breasts, lung tissue and heart with proton therapy were significantly lower compared to helical tomotherapy and to 3D conformal radiation therapy. Helical tomotherapy assured the best protection of lungs from doses above 15 Gy with the V_20 Gy equal to 16.4%, compared to 19.7% for proton therapy (P = 0.01) or 22.4% with 3D conformal radiation therapy (P < 0.01). Volumes of lung receiving doses below 15 Gy were significantly larger for helical tomotherapy than for proton therapy or 3D conformal radiation therapy, with respective lung doses V_10 Gy = 37.2%, 24.6% and 27.4%. Also, in the domain of low doses, the volumes of breast that received more than 10 Gy or more than 4 Gy with helical tomotherapy were double the corresponding volumes for proton therapy, with V_4 Gy representing more than a third of one breast volume with helical tomotherapy.ConclusionsHelical tomotherapy achieved a better protection to the lungs for doses above 15 Gy than passive proton therapy or 3D conformal radiation therapy. However, dose distributions could generally be improved by using protons even with our current passive-beam technology, especially allowing less low dose spreading and better breast tissue sparing, which is an important factor to consider when treating Hodgkin's lymphomas in female patients. Prospective clinical study is needed to evaluate the tolerance and confirm these findings.     

Feasibility and Efficacy of Local Radiotherapy With Concurrent Novel Agents in Patients With Multiple Myeloma

IntroductionThis study evaluated the safety and efficacy of radiotherapy (RT) with concurrent novel agents (NAs), cytotoxic therapy (CTx), or both in the management of osteolytic bone lesions in multiple myeloma (MM).Patients and MethodsA total of 39 patients with MM received RT to 64 different bone sites during the 2007-2012 period, with a dose of 8 to 37.5 Gy (mean, 26.8 Gy) delivered in 1 to 15 fractions (median, 10 fractions). Of these patients, 21 also received concurrent NAs or CTx. Pain response, M protein and κ light chain response, and adverse events were evaluated.ResultsRT was completed in 35 of 39 patients (89.7%) in this study. Pain relief was observed in 30 of 31 patients (96.7%). Hematologic toxicity (grade 3 or 4 by the Radiation Therapy Oncology Group system) was seen in 43.2% of treated patients, and NA therapy was stopped in 2 patients owing to grade 4 toxicity. RT adverse effects resolved at 4 to 6 weeks posttreatment. Changes in pre- and posttreatment levels of M protein trended toward significance in patients treated with RT + systemic therapy (ST) versus. RT alone (ΔM Protein_RT+ST = 5.6 g/L; ΔM Protein_RT = 0 g/L; P = .089).ConclusionTreating MM with RT concurrently with CTx including NAs was safe and well tolerated in the majority of patients (14 of 16 [87.5%] for those taking NAs and 19 of 21 [90.5%] for all patients). Excellent clinical pain response (> 95%) was also seen in patients regardless if they were treated with RT + ST or RT alone.     

Trends in Radiation Fractionation for Bone Metastases: A Contemporary Nationwide Analysis

PurposeRadiation therapy remains an important palliative tool for patients with bone metastases. The guidelines from the American Society for Therapeutic Radiation Oncology recommend the use of fewer fractions based on randomized data. We used the National Cancer Database to examine trends in radiation fractionation for patients with bone metastases.Methods and MaterialsWe queried breast, prostate, and non-small cell lung cancer in the National Cancer Database from 2010 to 2015 for patients with bone metastases at the time of diagnosis who received bone-directed radiation therapy of 8 Gy in 1 fraction, 20 Gy to 24 Gy in 5 to 6 fractions, 30 Gy in 10 fractions, or >30 Gy in 10 fractions. We tabulated the baseline characteristics, and a multivariable logistic regression analysis was used to identify predictors of single-fraction treatment.ResultsWe identified 17,859 patients who met the study criteria. The median patient age was 67 years, and the majority of patients (67%) had primary prostate cancer. Most patients (62%) received spine treatment. Single-fraction treatment increased over time from 3% in 2010 to 7% by 2015. Use of more protracted courses (>30 Gy in 10 fractions) decreased from 34% to 15% over the same interval. The most commonly used regimen (50%-60% of cases) remained 30 Gy in 10 fractions. Predictors of single-fraction treatment included increased age, no systemic therapy, increasing distance from facility, treatment at an academic center, nonspine/nonskull metastasis, and more recent treatment year.ConclusionsUse of single-fraction radiation for bone metastases has increased steadily but still accounts for <10% of palliative courses. The use of more protracted regimens has decreased significantly, although 30 Gy in 10 fractions remains the most widely used regiment.     

Lung Metastases Treated with Image-guided Stereotactic Body Radiation Therapy

AimsTo evaluate outcomes after treatment with image-guided stereotactic body radiation therapy (SBRT) using daily online cone beam computed tomography for malignancies metastatic to the lung.Materials and methodsForty-seven lung metastases in 32 patients were treated with volumetrically guided SBRT. The median age was 62 years (21–87). Primaries included colorectal (n = 10), sarcoma (n = 4), head and neck (n = 4), melanoma (n = 3), bladder (n = 2), non-small cell lung cancer (n = 2), renal cell (n = 2), thymoma (n = 2), thyroid (n = 1), endometrial (n = 1) and oesophageal (n = 1). The number of lung metastases per patient ranged from one to three (68% single lesions). SBRT was prescribed to the edge of the target volume to a median dose of 60 Gy (48–65 Gy) in a median of four fractions (four to 10). Most lesions were treated using 12 Gy fractions (92%) to 48 or 60 Gy.ResultsThe median follow-up was 27.6 months (7.6–57.1 months). The 1, 2 and 3 year actuarial local control rates for all treated lesions were 97, 92 and 85%, respectively. Two patients with colorectal primaries (four lesions in total) had local failure. The median overall survival was 40 months. The 1, 2 and 3 year overall survival from the time of SBRT completion was 83, 76 and 63%, respectively. There were no grade 4 or 5 toxicities. Grade 3 toxicities (one instance of each) included pneumonitis, dyspnoea, cough, rib fracture and pain.ConclusionSBRT with daily online cone beam computed tomography for lung metastases achieved excellent local tumour control with low toxicity and encouraging 2 and 3 year survival.     

Optimisation of Radiation Therapy in Bladder Preservation Therapy for Patients With Clinical Stage T2N0M0 Bladder Cancer

AimsA novel bladder preservation therapy, the OMC (Osaka Medical College) regimen, which combines radiation therapy with balloon-occluded arterial infusion of anticancer agents, is a treatment option for patients with muscle-invasive bladder cancer (MIBC). We retrospectively analysed the effects of changes in radiation dose and irradiation field on treatment efficacy and adverse events.The purpose of this study is to use the results of this study to help determine a course of radiation therapy for bladder preservation therapy of cT2N0M0 MIBC.Materials and methodsWe examined 352 patients with clinical stage T2N0M0 (cT2N0M0) MIBC classified into the following groups based on the irradiation method: group A, the whole pelvis (50 Gy/25 fractions) + local bladder (10 Gy/5 fractions); group B, the small pelvis (50 Gy/25 fractions) + local bladder (10 Gy/5 fractions); group C, the whole pelvis (40 Gy/20 fractions) + local bladder (10 Gy/5 fractions).ResultsThe complete response rate, 3-year overall survival and progression-free survival rates in group A were 92.9%, 94.9% and 82.1%, respectively; in group B were 87.2%, 86.7% and 76.7%, respectively; and in group C were 95.2%, 92.6% and 71.1%, respectively. No significant differences between the groups were noted. The incidence of ≥grade 3 urinary tract and gastrointestinal toxicities were not significantly different among the groups (group A: 7.8%, 1.7%; B, 11.1%, 0%; C, 7.1%, 1.8%, respectively). The 3-year progression-free rates of the common iliac lymph node (CILN) region in patients who received whole-pelvis and small-pelvis irradiation were 99.0 and 89.0% (P < 0.01), respectively, with the latter group having significantly high lymph node recurrence in the CILN region.ConclusionsOur findings showed that the optimal radiation therapy for patients with cT2N0M0 MIBC undergoing the OMC regimen is whole-pelvis irradiation including the CILN region, with a total dose of 50 Gy/25 fractions.     

Intensity modulated stereotactic body radiation therapy for single or multiple vertebral metastases with spinal cord compression

PurposeThe purpose of this study was to evaluate the efficacy and toxicity of intensity modulated radiation therapy with simultaneous integrated boost (SIB-IMRT) for single or multiple vertebral metastases (VM) with spinal cord compression using tomotherapy.Methods and materialsThirty patients with 40 VM were treated with SIB-IMRT as initial radiation therapy. Either 40 Gy in 8 fractions or 48 Gy in 16 fractions was prescribed depending on the Katagiri prognostic index. The radiation doses to the spinal cord and other risk organs were reduced to tolerance levels using intensity modulation. One to 4 lesions in consecutive vertebrae were treated in 1 course of SIB-IMRT. Radiologic and physical examinations were performed at 1-3 month intervals after SIB-IMRT. The Barthel index (BI) and numerical rating scale (NRS) were used to evaluate activities of daily living (ADL) and pain status, respectively.ResultsThe median follow-up period was 8 months. The NRS significantly dropped at 1 month after SIB-IMRT (P < .0001) and the effect continued for over 2 months. No significant BI decrease was observed at 2 months after SIB-IMRT (P = .7). The 1-year local control rate was 84% (95% confidence interval, 70%-100%). No grade ≥ 2 neurologic toxicity resulting from SIB-IMRT was observed.ConclusionsSIB-IMRT could be successfully applied to VM with spinal cord compression in up to 4 consecutive vertebrae. Good ADL preservation and pain control were achieved with acceptable toxicity.     

Robotic stereotactic body radiation therapy for tumours of the liver: Radiation-induced liver disease,incidence and predictive factors

PurposeRobotic stereotactic body radiation therapy is a new option to treated unresecable liver tumours. The objectives were to assess the tolerance of this technique, to identify predictive factors for toxicity and evaluate the efficiency of this treatment.Patients and methodsFrom June 2010 to November 2012, robotic stereotactic body radiation therapy was proposed for 56 patients with unresecable hepatocellular carcinomas (23 patients) or hepatic metastases (41 patients). Two or less hepatic lesions, lesion size under 75 mm and WHO score under 3 were selection criteria. The prescribed dose was 45 Gy/3 fractions or 60 Gy/3 fractions. The primary end-point was toxicity, using the radiation-induced liver disease definition and to identify predictive factors. Secondary end-points were in-field local control and overall survival.ResultsThe median follow-up was 12.5 months. The one-year local control rate and the one-year overall survival rate were 64% [CI95%: 48.2 to 76.5%] and 89% [CI95%: 76 to 95%], respectively. For patient treated with a total dose of 60 Gy, no one experienced recurrence. According to the definition we took, radiation-induced liver disease rate was 0 or 9%. A lesion size at least 35 mm was a predictive factor to liver toxicity (P = 0.01).ConclusionUsing robotic stereotactic body radiation therapy, the incidence of radiation-induced liver disease is weak and spontaneously reversible. Prospective studies are required to put in evidence other predictive factors of radiation-induced liver disease and confirm the optimal dose treatment.     

A Phase I/II Study of Stereotactic Hypofractionated Once-weekly Radiation Therapy (SHORT) for Prostate Cancer

AimsStereotactic radiation therapy has been investigated predominantly in patients with low–intermediate-risk disease. We conducted a clinical trial of stereotactic hypofractionated radiation therapy delivered in once-weekly fractions on patients with all-risk non-metastatic disease to test feasibility, acute toxicities and patient-reported outcomes.Materials and methodsIn this phase I/II study, 30 patients with prostatic adenocarcinoma, any Gleason score, T1-4N0 and prostate-specific antigen ≤60 ng/ml were treated with volumetric intensity modulated arc radiation therapy to a dose of 35 Gy in five fractions delivered once weekly. Patients with high-risk disease also received elective nodal irradiation to a dose of 25 Gy in five fractions simultaneously. Androgen deprivation was offered to intermediate- and high-risk patients. The primary outcome was acute toxicity. Secondary outcome measures included biochemical control and late toxicity. Patient-reported outcomes were measured using the International Prostate Symptom Score and European Organization for Research and Treatment of Cancer (EORTC) Quality-of-Life Questionnaire (QLQ).ResultsAll 30 patients completed treatment per-protocol. Most patients had T3 (60%) and Gleason 7 (50%) tumours. The median prostate-specific antigen was 17 ng/ml. High-risk disease was present in 20 patients (66.7%). There was a low incidence of acute toxicities (grade 2 + urinary 3.3%, grade 2 rectal 0%). Within the EORTC QLQ framework, only the urinary symptom score showed a clinically meaningful worsening from a mean of 20/100 at baseline to 34/100 at the end of treatment (P < 0.001), but reduced to 24/100 at 6 months (P = 0.08). With a median follow-up of 41.5 months, two patients each reported grade 2 late urinary and rectal toxicity. The 3- and 4-year biochemical control rates were 96.7 and 87.9%, respectively.ConclusionIn a cohort of mainly high-risk cancers, stereotactic once-weekly radiation therapy was easy to implement and well tolerated, with a low incidence of acute and late toxicity and excellent biochemical control.     

Stereotactic radiotherapy for large solitary brain metastases

PurposeTo assess effectiveness and toxicity levels of stereotactic radiation therapy without whole brain radiation therapy in patients with solitary brain metastases larger than 3 cm.Patients and methodsBetween June 2007 and March 2009, 12 patients received fractionated stereotactic radiation therapy and 24 patients underwent stereotactic radiosurgery. For the fractionated stereotactic radiation therapy group, 3 × 7.7 Gy were delivered to the planning target volume (PTV); median volume and diameter were 29.4 cm³ and 4.4 cm, respectively. For the stereotactic radiosurgery group, 14 Gy were delivered to the PTV; median volume and diameter were 15.6 cm³ and 3.7 cm, respectively.ResultsMedian follow-up was 218 days. For the fractionated stereotactic radiation therapy group, local control rates were 100% at 360 days and 64% at 720 days; for the stereotactic radiosurgery group, rates were 58% at 360 days and 48% at 720 days (P = 0.06). Median survival time was 504 days for the fractionated stereotactic radiation therapy group and 164 days for the stereotactic radiosurgery group (P = 0.049). Two cases of grade 2 toxicity were observed in the fractionated stereotactic radiation therapy group, and 6 cases of grade 1–2 toxicity, in the stereotactic radiosurgery group.ConclusionsThis study provides data to support that fractionated stereotactic radiation therapy without whole brain radiation therapy with a margin dose of 3 fractions of 7.7 Gy for treatment of solitary large brain metastases is efficient and well-tolerated. Because of the significant improvement in overall survival, this schedule should be assessed in a randomized trial.     

Impact of different radiation techniques and doses on cardiac implantable electronic devices

Background and objectivePurpose of this investigation was to get deeper insight into the impact of different radiation techniques and doses on cardiac implantable electric devices (CIEDs). We aimed to mimic a worst-case scenario with very high doses and external radiation being applied directly on the devices.MethodsRadiation was applied on 21 CIEDs as photon or electron therapy with maximum dose of 150 Gy in fractions of 2 -20 Gy. CIEDS were put directly into the beam. Brachytherapy was applied with doses of 6 Gy to a maximum of 42 Gy. Check-ups took place after every fraction and one week after radiation. We calculated the estimated potential risk for the health and survival of patients as well as the risk for CIEDs’ loss of function.Results28 life- or health-threatening errors occurred during photon therapy, 3/7 devices showed complete loss of function. During electron therapy, 31 potentially patient-threatening errors and 2 losses of function were detected. During brachytherapy, none of the devices showed loss of function but 8 patient-threatening errors occurred. Inadequate shock releases were mostly seen after photon and brachytherapy, random noises occurred more often during electron therapy. The earliest potentially serious error occurred during after 2 Gy photon radiation and 6 Gy brachytherapy. Losses of function occurred earliest at 80 Gy.ConclusionThe results underline the warning for precaution concerning CIED patients derived from recommendations in the literature. Our study offers new information especially about the impact of electron radiation and brachytherapy on CIEDs. Risk for the devices to for loss of telemetry or battery capacity might be negligible with normafractionated therapy.     

Feasibility and toxicity of hypofractionated image guided radiation therapy for large volume limited metastatic disease

PurposeHypofractionated image guided radiation therapy (HIGRT) is increasingly used for limited metastases. Reported studies have mostly treated small volume tumors. Here, we report the toxicity and oncologic outcomes following treatment of large volume metastases.Methods and MaterialsHIGRT patients treated from October 2005 to March 2010 were reviewed. Gross tumor volumes (GTV) and planning target volumes (PTV) were obtained from planning software. A metastasis was considered large volume if the treated PTV exceeded 50 cc. Patients were treated with either 10-fraction (4-5 Gy per fraction) or 3-5 fraction (8-14 Gy per fraction) regimens. Toxicity was obtained from both prospectively collected databases and retrospectively from patient charts.ResultsSixty-four patients with 93 treated lesions > 50 cc were identified. The median GTV and PTV volumes were 41 and 119 cc, respectively. The median number of treated large volume lesions was 1, and a maximum of 3 large volume lesions were treated in a single patient. Primary malignancies included non–small cell lung cancer, renal cell, colorectal, breast, bladder, pituitary, small cell lung cancer, sarcoma, head-and-neck cancer, and hepatocellular cancer. Treated sites included lung (n = 33), regional lymph nodes (n = 20), bone (n = 17), adrenal (n = 9), and liver (n = 6). The most frequently used treatment regimen was 50 Gy in 5 Gy fractions. The median follow-up was 27 months for surviving patients. Treated lesion control was 78%. Low rates of acute and late grade 3 or higher toxicity were reported, with 3 and 5 patients experiencing each, respectively.ConclusionsHIGRT to large volume oligometastatic disease is tolerable and feasible with promising tumor control. Local radiation therapy should be considered in patients with large volume, limited metastatic disease.     

Postoperative Radiotherapy for Multiple Myeloma of Long Bones: Should the Entire Rod Be Treated?

PurposeTo characterize local relapse after surgical fixation and postoperative radiotherapy (RT) for multiple myeloma (MM) with cortical involvement of long bones.Patients and MethodsWe retrospectively identified patients with MM involving cortical long bones treated with surgical fixation followed by postoperative RT at our institution. Local failures, defined as radiographic recurrence along the surgical hardware, were documented, and potential associations of independent variables (RT dose, fractionation, and extent of hardware coverage) with local failure were assessed by univariate Cox regression.ResultsWe identified 33 patients with 40 treated sites with a median follow-up of 25.7 months; 68% of treatments were for pathologic fracture, and 32% were for impending fracture. The most common dose and fractionation were 20 to 25 Gy in 8 to 12 fractions. On average, 76% of the surgical hardware was covered by the postoperative RT field (median, 80%; range, 28%-100%). Local failure was observed in 5 cases (12.5%), 2 within the RT field and 3 out of field. None of the relapses resulted in hardware failure, and 2 were retreated with RT. The extent of hardware coverage predicted disease relapse along the hardware (hazard ratio = 6.44; 95% confidence interval, 1.09-37.97; P = .04); however, total RT dose, biologically effective dose, and number of fractions did not.ConclusionAfter internal fixation of long bones with MM, full hardware coverage with the RT field could reduce the risk, though small, of disease developing in the future in the proximate hardware. Postoperative RT doses of 20 to 25 Gy in 8 to 10 fractions can achieve excellent local control.     

Propensity-Weighted Survival Analysis of SBRT vs. Conventional Radiotherapy in Unfavorable Intermediate-Risk Prostate Cancer

BackgroundProstate stereotactic body radiotherapy (SBRT), which delivers high-dose precision treatment in ≤5 fractions, is a shorter, more convenient, and less expensive alternative to conventionally fractionated radiotherapy (CRFT; ∼44 fractions) or moderately hypofractionated radiotherapy (MFRT; 20-28 fractions). SBRT has not been widely adopted but may have radiobiologic advantages over CFRT/MFRT. We hypothesized that SBRT would be associated with improved overall survival (OS) versus CFRT or MFRT ± androgen deprivation therapy (ADT) for unfavorable-intermediate-risk prostate cancer (UIR-PCa).MethodsMen with UIR-PCa treated with SBRT (35-40Gy in ≤5 fractions) or biologically equivalent doses of CFRT (72-86.4Gy in 1.8-2.0Gy/fraction) or MRFT (≥60Gy in 2.4-3.2Gy/fraction; biologically effective doses ≥120) were identified in the National Cancer Database (NCDB). Unweighted and propensity-weighted multivariable Cox analysis (MVA) was used to compare OS hazard ratios.ResultsOf 28,028 men with UIR-PCa who received CFRT with (n = 12,872) or without ADT (n = 12,984); MFRT with (n = 251) or without ADT (n = 281); and SBRT with (n = 212) or without ADT (n = 1,428) were identified. Relative to CFRT without ADT, CFRT+ ADT (HR 0.92, 95% CI 0.87-0.97, P = .002) and SBRT without ADT (HR 0.74, 95% CI 0.61-0.89, P = .002) were both associated with improved OS on MVA. Relative to CFRT+ADT, SBRT without ADT correlated with improved OS on MVA (HR:0.81, 95% CI 0.67-0.99, P = .04). Propensity-weighted MVA demonstrated that SBRT (HR:0.80, 95% CI 0.65-0.98, P = .036) and ADT (HR:0.91, 95% CI 0.86-0.97, P = .002) correlated with improved OS. SBRT was not associated with improved OS versus MFRT.ConclusionSBRT, which offers a cheaper and shorter treatment course that mitigates COVID-19 exposure, was associated with improved OS versus CFRT for UIR-PCa. These results confirm guideline-based recommendations that SBRT is a viable option for UIR prostate cancer. The results from this large retrospective study require further validation in clinical trials.     

Patterns of locoregional failure in women with early-stage breast cancer treated by whole breast irradiation in the lateral isocentric decubitus position: Large-scale single-centre experience

PurposeThe purpose of this study was to evaluate locoregional control and describe the patterns of failure in patients with breast cancer receiving whole breast radiotherapy in the isocentric lateral decubitus position technique.Patients and methodsIn a series of 832 consecutive female patients with early-stage breast cancer including invasive and in situ tumours treated by breast-conserving surgery followed by three-dimensional conformal whole breast irradiation in the isocentric lateral decubitus position between 2005 and 2010, all patients who experienced locoregional recurrence were studied. Five-year recurrence-free and overall survival rates were calculated. Regional recurrence mapping patterns were also determined.ResultsThe median age of this series of 832 women was 61.5 years (range: 29–90 years). Various types of fractionation were used: 50 Gy in 25 fractions (17.9%), 66 Gy in 33 fractions (50 Gy in 25 fractions to breast followed by sequential boost to tumour bed to a total dose 66 Gy in 33 fractions.) (46.5%), 40 Gy in 15 fractions or 41.6 Gy in 13 fractions (26.1%) and 30 Gy in 5 fractions (9.5%). With a median follow-up of 6.4 years, only 36 patients experienced locoregional recurrence and no association with the fractionation regimen was identified (P = 0.2). In this population of 36 patients, 28 (3.3%) had “in-breast” local recurrences (77.8%), two had local recurrences and regional lymph node recurrence (5.6%), and six had regional lymph node recurrence only (in non-irradiated areas; 16.6%). The median time to recurrence was 50 months. Complete mapping of patterns of recurrences was performed and, in most cases, local recurrences were situated adjacent to the primary tumour bed. Cases of local recurrences presented a significantly lower distant metastasis rate (P < 0.001) and had a significantly longer overall survival compared to patients with regional lymph node recurrence (P < 0.001). However, multivariate Cox regression analysis showed that the site of recurrence had no significant impact on overall survival (P = 0.14).ConclusionThe results of this study indicate a low local recurrence rate. Further careful follow-up and recording of recurrences is needed to improve the understanding of patterns of recurrence.     

Chimioradiothérapie de rattrapage à visée curative de rechutes pelviennes isolées de cancers du col utérin

PurposeEvaluation of the results of salvage radiation therapy with curative intent in the treatment of recurrent cervical carcinoma.Patients and methodsFourteen patients with a recurrence of a cervical cancer were treated in our department between 1982 and 2009. Five patients had a pelvic relapse, four a vaginal relapse and five a pelvic lymph node relapse. Four patients had first a surgical resection of the relapse, which was incomplete in two patients. All patients had pelvic radiotherapy with a median dose of 55 Gy in conventional fractionation. Concurrent chemotherapy was administered to 12 patients. A vaginal brachytherapy with a median dose of 20 Gy was performed in addition in 3 patients. The median follow-up was 39 months.ResultsSafety of radiation therapy was correct with 29% of grade 3 acute or intestinal toxicity. Tumor control was observed in 10 patients (71%). Four patients presented a locoregional tumor progression. At the time of analysis, three patients had died from their cancer. From the date of relapse, the rate of overall survival at 2 and 5 year was respectively 84% and 74%. Three patients (21%) had severe late effects.ConclusionIn our experience, chemoradiotherapy can achieve a high rate of remission in patients with isolated pelvic recurrence of cervical cancer. This treatment is feasible only if the patient had not received radiation therapy before or if the relapse is out of the previously irradiated volume.