Adjuvant Intensity-modulated Radiation Therapy Research Articles

Geometric and dosimetric evaluation of the differences between rigid and deformable registration to assess interfraction motion during pelvic radiotherapy.

Appropriate internal margins are essential to avoid a geographical miss in intensity-modulated radiation therapy (IMRT) for endometrial cancer (EC). This study evaluated interfraction target motion using rigid and non-rigid approximation strategies and calculated internal margins based on random and systematic errors using traditional rigid margin recipes. Dosimetric impact of target motion was also investigated. Cone beam CTs (CBCTs) were acquired days 1-4 and then weekly in 17 patients receiving adjuvant IMRT for EC; a total of 169 CBCTs were analysed. Interfraction motion for the clinical target volume vaginal vault and upper vagina (CTVv) was measured using bony landmarks and deformation vector field displacement (DVFD) within a 1 mm internal wall of CTVv. Patient and population systematic and random errors were estimated and margins calculated. Delivered dose to the CTVv and organs at risk was estimated. There was a significant difference in target motion assessment using the different registration strategies (p < 0.05). DVFD up to 30 mm occurred in the anterior/posterior direction, which was not accounted for in PTV margins using rigid margin recipes. Underdosing of CTVv D95% occurred in three patients who had substantial reductions in rectal volume (RV) during treatment. RV relative to the planning CT was moderately correlated with anterior/posterior displacement (r = 0.6) and mean relative RV during treatment was strongly correlated with mean relative RV at CBCT acquired days 1-3 (r = 0.8). Complex and extensive geometric changes occur to the CTVv, which are not accounted for in margin recipes using rigid approximation. Contemporary margin recipes and adaptive treatment planning based on non-rigid approximation are recommended.

Scar Bolus Omission During Adjuvant Intensity Modulated Radiation Therapy (IMRT) Does Not Increase Risk of Incisional Recurrence for Oral Cavity Cancers

Locoregionally advanced oral cavity cancers have an increased risk of locoregional recurrence despite multimodality therapy. In an effort to decrease scar recurrences in the post-operative setting, bolus has historically been used to increase the dose to the neck scar in intermediate and high-risk contexts. Since transitioning to IMRT for most post-operative oral cavity cases, we have routinely omitted bolus placement on the neck scar. Here we examine rates of scar recurrences using this approach. This is an institutional review board approved retrospective study. Patients with intermediate or high risk squamous cell carcinoma of the oral cavity treated with post-operative IMRT were identified from an institutional database. Patients were treated using tomotherapy based IMRT. Demographics, clinical/pathologic parameters, dosimetric data, and cancer-related outcomes were recorded and analyzed. Statistical software was used to determine Kaplan Meier estimates for disease control and survival. Twenty-eight pts met inclusion criteria for this analysis and were treated from 2009 to 2017. Median age was 56 years old (range 35-75); 59% were male. All patients underwent complete resection of the primary tumor with selective neck dissection. Subsites included 11 floor of mouth (40%), 6 oral tongue (21%), 5 buccal mucosa (18%), 3 lower lip (11%), 2 hard palate (7%), and 1 retromolar trigone (4%). Seventy-one percent were pathologically node positive; 36% had extracapsular extension (ECE). Concurrent chemotherapy was used in 53% of patients. Twenty-four patients (86%) were treated using SIB technique. The post-operative neck was irradiated in all cases. Median dose to the highest risk volume was 6000 cGy (range 5800-6600 cGy). Median treatment package time was 95 days (range 76-137 days). Median follow up for surviving patients after treatment was 21 months (range 3-93 months). One patient experienced a local recurrence at 2 months. Four patients developed distant metastatic progression at a median of 3 months (range 1-16 months). No patients have experienced a regional nodal relapse and there have been no scar recurrences. 3-year actuarial estimates for DFS and OS are 74.7% and 87.4%. Scar recurrences after post-operative IMRT are rare. Bolus omission has not compromised disease control along the scar.

Adoption of AJCC 8th Edition for p16+ Oropharynx Cancers May Result in Decreased Utilization of Adjuvant Therapies Due to Shifts in Pathologic Nodal Staging

The 8th edition of the AJCC (American Joint Committee on Cancer) system no longer includes nodal laterality or size in the pN staging system for p16+ oropharynx cancers. This is because number of involved lymph nodes provides better discriminatory ability for recurrence than laterality, size, or presence of high risk nodal features (i.e. extracapsular extension [ECE]). At our institution, we have routinely offered adjuvant radiotherapy (+/- chemotherapy) for patients with traditional intermediate or high risk features independent of p16 status as per NCCN guidelines. Here, we examine a cohort of p16+ patients staged and treated according to AJCC 7th edition and reclassify them according to the 8th edition to determine rate of nodal downstaging based on the new system. Patients with pathologically node positive p16+ oropharyngeal cancer treated with primary surgery (most commonly TORS with selective neck dissection) followed by adjuvant intensity modulated radiation therapy (+/- chemotherapy) were included for analysis. Demographics, pathology, and treatment details were collected from the electronic medical record. Indications for adjuvant therapy were recorded and patients were re-staged according to the AJCC 8th edition. Rates of nodal downstaging were recorded. A total of 28 patients met inclusion criteria and were treated from 2012 to 2017. 93% were male. 24 (85%) primaries were tonsillar and 4 (15%) base of tongue. An ipsilateral selective neck dissection was performed in 17 (61%) cases. A total of 27 patients had pre-operative imaging (CT or PET) consistent with nodal involvement. The median number of involved lymph nodes was 2 (range 1-8). 13 (46%) had pathologic evidence of ECE, one (4%) microscopic perineural invasion (PNI), and five (18%) had lymphovascular space invasion (LVSI). Five patients (18%) had a microscopically positive margin. AJCC 7th edition N staging was as follows: N1: 10 (36%), N2a: 1 (4%), and N2b: 17 (60%). 15 of 18 (83%) AJCC 7th N2 patients were downstaged to AJCC 8th N1. Seven of these 15 (47%) patients did not have other adverse pathologic features (i.e. pT3, ECE, positive margin, PNI, LVSI). Radiation therapy was delivered using a simultaneous integrated boost technique in all cases. The median dose to the highest risk volume was 60 Gy (range 60-66 Gy). 13 patients (46%) received concurrent chemotherapy. At a median follow up of 25 months (range 3 months to 10 years), there have been no recurrences in this cohort. Nodal downstaging from pN2 to pN1 with the adoption of AJCC 8th edition is common for surgically-treated node positive p16+ oropharynx cancer. Although number of positive nodes has high discriminatory ability for recurrence, it is unknown whether the omission of adjuvant therapy in patients with < 5 positive nodes is safe. Until this is known, the decision to recommend adjuvant therapy should be highly dependent on a thorough understanding of pathologic findings rather than relying purely on the new pathologic N stage.

Toxicity and Clinical Outcomes in Patients with Uterine Cancer Treated with Adjuvant Intensity Modulated Radiation Therapy and Vaginal Brachytherapy (IMRT+VB) “Sandwiched” between Combination Paclitaxel and Carboplatin

The IMRT technique for uterine cancer helps to lower dose to organs at risk, especially the bone marrow. PORTEC-2 also showed comparable outcomes of VB alone compared to external pelvic RT for high-intermediate risk patients. Few reports examine the combination of IMRT+VB, especially in the setting of chemotherapy for advanced patients. Here, we look at the long-term effects of adjuvant IMRT+VB “sandwiched” between carboplatin and paclitaxel chemotherapy (C-T Cx). We reviewed 206 patients treated with adjuvant IMRT+VB and sandwich chemotherapy for Stage I-III uterine cancer from 2009 - 2016. Patients were surgically staged with no visible residual disease. Chemotherapy regimen involved C-T Cx every 21 days for 3 cycles, followed by IMRT+VB, followed by 3 additional cycles of C-T Cx. Patients were to have received at least one cycle post-RT to be included. Toxicities were graded with CTCAE, version 4.03. Rates for local control (LC), distant metastasis (DM), disease-free survival (DFS), and overall survival (OS) were examined using Kaplan-Meier survival curves. Median age and follow-up was 70 years (range: 36-94) and 39 months (range: 6.23-110.1 months), respectively. Ethnicity distribution was 48% African-American, 31% Hispanic, 17% White, 4% Asian, and 1% other. Histological type revealed 42% EAC, 40% UPSC, and 18% CS. FIGO stage distribution: IA-30%, IB-15%, II-16%, IIIA-7%, IIIB-15%, IIIC1-18%, and IIIC2-12%. Grade distribution: 1 – 9.7%, 2 – 8.7 %, 3 – 80.6%. LVSI was present in 51.5% of patients. Twenty-four (12%) patients underwent extended-field IMRT. Acute grade 2 and 3 GI toxicity was present in 17 (8.3%) and 4 (1.9%) patients, respectively. Two (1.0%) patients had acute grade 2, but none had grade ≥3 GU toxicity. Acute grade ≥3 neutropenia, anemia, and thrombocytopenia were present in 33.5%, 10.7%, and 11.7%, respectively. Late grade 2 and 3 GI toxicity was in 8 (3.9%) and 7 (3.4%) patients, respectively, including one with a colovesicular fistula. Five (2.4%) had late grade 2 but none had grade ≥3 GU toxicity. A large portion (21.4%) had grade 1 vaginal stenosis (VS), followed by grades 2 (9.2%) and 3 (1.0%). Stages I-II and III had similar five-year rate of LC (95.2% vs. 91.4%; logrank p=0.94) but significantly different DM rate (22.0% vs 49.6%; logrank p=0.002). Stages I-II and III had significantly different DFS (76.7% vs. 48.9%; logrank p=0.0012) but similar OS (86.0% vs. 85.7%; logrank p=0.79). Compared to EAC, CS was significantly more likely to have worse OS (HR: 7.65, 95% CI 1.53-38.4; p=0.013), DFS (HR: 3.83, 95% CI 1.80-8.15; p=0.0005), and DM rate (HR: 4.27, 95% CI 1.96-9.30; p=0.0003). Although not statistically significant, UPSC trended towards inferior OS (p=0.09) compared to EAC. This study represents the largest cohort of uterine cancer patients receiving adjuvant IMRT+VB “sandwiched” between chemotherapy. Patients have good long-term clinical outcomes and a low toxicity profile.

A Prospective Study of IMRT Versus 3D-CRT for Post-Operative Cervical Cancer Patients.

The use of intensity-modulated radiation therapy (IMRT) in postoperative cervical cancer is on the rise, yet there is still some controversy to adopt adjuvant IMRT as standard practice. The purpose of this study is to compare the difference between IMRT and three dimensional conformal radiation therapy (3D-CRT) especially in quality of life for pelvic radiation of postoperative treatment with cervical cancer. A total of 398 patients were enrolled from Oct 2015 to Oct 2017. They were selected randomly into two groups: IMRT group (n=190) and 3D-CRT group (n=208). Each patient received a prescribed dose of 45Gy/25F. Radiation dosimetry, the grade 2-4 in GI and GU; the score from functional assessment of cancer therapy scale-cervix (FACT-CX) scale and expanded prostate cancer index composite for clinical practice (EPIC-CP) scale were compared. (1) There was no significant difference on age, culture level, family economic condition and ratio of radiochemotherapy in two groups (P>0.05). (2) Dosimetric comparison: IMRT plans had a significant better conformity index (CI) of PTV compared with 3D-CRT (P<0.05). Compared with 3D-CRT plans , V40 of the small bowel, rectum, bladder, V20 and V10 of bone marrow were all significantly reduced (P<0.05). (3) The incidence of acute grade 2-3 gastriontestinal reaction was significantly high for 3D-CRT group versus the IMRT group(24.0%,15.8%; P=0.04). The incidence of acute grade 2-3 urinary toxicity was high for 3D-CRT group versus the IMRT group(25.5%,17.9%),but has no statistically difference P=0.07). (4) Quality of life scale: FACT-Cx score were 84.8±16.3 and 71.2±17.9 before and after radiation therapy in 3D-CRT group, 81.8±15.5 and 76.4±14.4 in IMRT group. FACT-Cx score was decreased significantly from beginning of radiation in 3D-CRT group ,it was reached 12.3±4.5,but it was only 5.1±2.3 in IMRT group(t=15.530, P=0.000). EPIC-CP scale score: EPIC-CP score were 15.4 ± 6.2 and 21.7±7.1 before and after radiation therapy in 3D-CRT group, 15.6 ± 6.9 and 18.4±7.2 in IMRT group. EPIC-CP score was increased significantly from beginning of radiation in 3D-CRT group ,it was reached 6.6±4.1,but it was only 3.1±4.2 in IMRT group(t=5.500, P=0.000). IMRT has shown a dosimetric advantage and also provided good quality of life for the postoperative patients with cervical cancer compared to 3D-CRT. Long term follow up will be needed to determine late toxicity and DFS/OS.

Unilateral cochlea sparing in locoregionally advanced head and neck cancer: aplanning study.

Cochlea sparing can reduce late ototoxicity in head and neck cancer patients treated with cisplatin-based radiochemotherapy. In this situation, amean cochlear dose (MCD) constraint of 10 Gy has been suggested by others based on the dose-effect relationship of clinical data. We aimed to investigate whether this is feasible for primary and postoperative radiochemotherapy in locoregionally advanced tumors without compromising target coverage. Ten patients treated with definitive and ten patients treated with adjuvant intensity-modulated radiotherapy (IMRT) and concurrent chemotherapy were investigated. The cochleae and aplanning risk volume (PRV) with a3 mm margin were newly delineated, whereas target volumes and other organs at risk were not changed. The initial plan was recalculated with aconstraint of 10 Gy (MCD) on the low-risk side. The quality of the resulting plan was evaluated using the difference in the equivalent uniform dose (EUD). Aunilateral MCD of below 10 Gy could be achieved in every patient. The mean MCD was 6.8 Gy in the adjuvant cohort and 7.6 Gy in the definitive cohort, while the non-spared side showed amean MCD of 18.7 and 30.3 Gy, respectively. The mean PRV doses were 7.8 and 8.4 Gy for the spared side and 18.5 and 29.8 Gy for the non-spared side, respectively. The mean EUD values of the initial and recalculated plans were identical. Target volume was not compromised. Unilateral cochlea sparing with anMCD of less than 10 Gy is feasible without compromising the target volume or dose coverage in locoregionally advanced head and neck cancer patients treated with IMRT. Aprospective evaluation of the clinical benefit of this approach as well as further investigation of the dose-response relationship for future treatment modification appears promising.

Magnitude of benefit for adjuvant radiotherapy following minimally invasive surgery in intermediate to high risk HPV-positive oropharyngeal squamous cell carcinoma

ObjectiveTo determine the outcomes and toxicities of minimally-invasive surgery with adjuvant intensity-modulated radiotherapy +/− chemotherapy (AT) compared to definitive surgical therapy (ST) in a contemporary cohort of HPV-positive oropharyngeal squamous cell carcinoma (OPSCC). MethodsFrom 2005 to 2013, a consecutive cohort of 190 HPV-positive OPSCC patients was retrospectively reviewed from multi-institutional databases maintained by the Departments of Otorhinolaryngology and Radiation Oncology. A total of 116 AT patients and 42 ST patients with intermediate or high risk pathologic features were included in the final analysis. All patients received minimally invasive surgery. Time to recurrence and time to death from the onset of surgery were evaluated. Toxicity data collected included dysphagia or xerostomia requiring feeding tube placement >6 months, or mandibular osteonecrosis requiring surgery or hyperbaric oxygen. ResultsAll AT patients received IMRT to a median dose of 60 Gy. Chemotherapy delivered to 67.2% of AT patients. AT group included more high-risk patients given higher nodal classification (p = 0.005) and extracapsular extension (p = 0.0005). AT improved disease-free survival (HR 2.77, CI 1.22–6.28; p = 0.02) and local-regional control (HR 14.83, CI 3.240–67.839; p = 0.001). Disease-free survival with AT and tumor extracapsular extension was improved when compared to ST (HR of 4.34, CI 1.540–12.213; p = 0.006). Dysphagia or mandibular osteonecrosis toxicity after AT vs. ST of 19.0% vs. 2.4%. ConclusionsAT improved local-regional control and disease-free survival but was associated with greater toxicity. The recurrence benefit was most pronounced in tumors with extracapsular extension.

Does ITV vaginal procedure ensure dosimetric coverage during IMRT of post-operative gynaecological tumours without instructions concerning rectal filling?

To find out whether the internal target volume (ITV) vaginal procedure ensures dosimetric coverage during intensity-modulated radiation therapy (IMRT) of post-operative gynaecological tumours without instructions on rectal filling. The ITV vaginal procedure does not necessarily include all movements of the bladder, and does not include changes in the rectal volume. We should know if the vaginal ITV is a useful tool in maintaining CTV coverage during treatment. A retrospective analysis of 24 patients treated between July 2012 and July 2014 with adjuvant IMRT for gynaecological cancer. All patients underwent empty and full bladder CT on simulation (CT-planning) and three weeks later (CT-control). ITV displacement was measured and the 3D vector was calculated. ITV coverage was then evaluated by comparing the volume covered by the prescription isodose on both CT's. Patients were asked to have full bladder but they did not follow recommendations for the rectum. The mean 3D vector was 0.64±0.32cm (0.09-1.30). The mean ITV coverage loss was 5.8±5.7% (0-20.2). We found a significant positive correlation between the 3D vector and the loss of coverage (Pearson correlation, r=0.493, 95% CI: 0.111-0.748, p=0.0144). We did not find any significant correlation between the bladder and rectal parameters with the 3D vector and loss of dosimetric coverage. We found a trend between the maximum rectal diameter in CT-planning and 3D vector (r=0.400, 95% CI: -0.004 to 0.692, p=0.0529). ITV vaginal procedure contributed to ensuring a good dose coverage without instructions on rectal filling.

Adenoid cystic carcinoma of the nasopharynx: a case report and a discussion about prognostic factors and the role of local treatments.

Adenoid cystic carcinoma (ACC) is a rare epithelioid malignancy. It occurs most frequently in the salivary glands, while its localization in the nasopharynx is rare and few cases have been reported in the literature. We report the case of a 32-year-old woman presenting with ACC of the nasopharynx who was treated with surgery and adjuvant intensity-modulated radiation therapy (IMRT, total dose: 68 Gy) and concomitant chemotherapy (cisplatin 100 mg/m² on the first and 21st days of IMRT). During irradiation, the patient developed G1 dermatitis and G2 mucositis (RTOG). Clinical and instrumental reevaluation 17 months after the end of radiotherapy did not show any signs of relapse, and she did not show any sign of local mild-severe toxicity. Adjuvant radiotherapy after standard complete surgical resection seems to be effective and well tolerated and should be strongly considered in the multidisciplinary approach to this infrequent carcinoma.

Clinical outcomes of limb salvage surgery with postoperative intensity-modulated radiation therapy for soft-tissue sarcoma and metastasis.

The primary aim of intensity-modulated radiation therapy (IMRT) for treating soft tissue sarcoma of an extremity is the reduction of morbidity and maintenance of local control. We evaluated the outcomes and toxicity of adjuvant IMRT following function-preserving surgery to treat patients with soft tissue sarcoma and metastasis of the extremities. We retrospectively reviewed prospective databases at Kure Medical Center and Aichi Medical University between 2013 and 2016 and identified 10 patients with lower extremity soft tissue sarcoma who underwent both limb-sparing surgery and postoperative IMRT at one of our institutions. There were 7 men and 3 women (mean age, 67.2 years; range, 48-87 years) included in the study. Of these, four patients were continuously disease-free, two showed no evidence of disease, and four died due to disease. The average functional score was 82% (range, 53-100%). Among the 10 patients, 2 (22%) had grade 1-2 edema and 1 (11%) had grade 2 joint stiffness. Another patient developed grade 2 acute dermatitis. There were no severe complications such as infection, tissue necrosis, fracture, or nerve palsy. Although the number of patients in this study was small, our results show that adjuvant IMRT following function-preserving surgery for soft tissue sarcoma of the extremity can be valuable for treating unmanageable tumors.

MS 06.05 The Use of Adjuvant IMRT after Pleurectomy/Decortication

MS 06.05 The Use of Adjuvant IMRT after Pleurectomy/Decortication

Prospective Validation of Bone Marrow Constraints for Hematological Toxicity in Patients Undergoing Chemoradiation for Cervical Cancer

Dose volume constraints (DVCs) have been proposed for reducing hematological toxicity (HT) in patients undergoing chemo radiation (CRT). The present study was undertaken to investigate validity of the DVCs during three-dimensional conformal radiation (3DCRT) or intensity modulated radiotherapy (IMRT) for cervical cancer. Clinical database of patients receiving bowel sparing adjuvant IMRT or 3DCRT with weekly concurrent cisplatin (40 mg/m2) within context of an ongoing trial was reviewed. No prospective BM sparing was performed. RT planning scans were de-archived and BM was contoured using Whole Bone (WB) and free hand inner cavity (FH) technique. Segmentation into sub-regions namely whole pelvic lumbar, lumbosacral spine, sacrum, ilium, ischium, femoral head and neck, whole pelvis and lower pelvis was performed. WB and FH BM subvolumes receiving 10, 20, 30, 40 Gy were determined. Receiver operator characteristics analysis was performed to identify DVCs that predict for grade ≥ II HT. All data was dichotomized across these DVCs for univariate and multivariate analysis. Finally an independent sample t test was performed to identify treatment technique that best spares the BM sub-regions that predict for HT. Overall 128 patients (IMRT=73; 3DCRT=55) that received CRT were included. Grade ≥ II HT and ≥ III HT was observed in 33.3% and 4.3% respectively. Grade ≥ II anemia, leucopenia, neutropenia and thrombocytopenia was observed in 14.3%, 21.9%, 5% and 0.7% patients respectively. On univariate analysis none of the known predictive factors (V10 or V40) predicted for overall Grade ≥ II HT. However Grade ≥ II neutropenia was predicted by Whole pelvic lumbar V20 >75% (WB and FH, p< 0.04,0.02) and V40 FH>35% (p<0.02), Whole pelvic V10 WB>90% (p<0.03), Whole Pelvic FH V20>75% (p<0.03) and lower pelvis FH >55% (p<0.04) and femoral head and neck FH V10> 80% and V20>35% (p< 0.03 and 0.02 respectively). On multivariate analysis, whole pelvic lumbar FH V40 >35%, whole pelvic WB V10>90%, femoral head and neck V 20 >35% predicted for Grade ≥ II neutropenia. Of the identified DVCs, V40 and V20 are better spared with IMRT (p<0.0001) whereas V10 is better spared by 3DCRT (p<0.0001) BM sub-volume doses predict for Grade ≥ II neutropenia in patients receiving CRT. As both high dose and low dose regions are important, the planning aim for BM sparing IMRT should be defined accordingly in prospective studies.

Survival improvements with adjuvant therapy in patients with glioblastoma.

Evaluate survival of patients diagnosed with glioblastoma multiforme (GBM) managed with adjuvant intensity modulated radiation therapy and temozolomide since the introduction of the European Organisation for Research and Treatment of Cancer and National Cancer Institute of Canada Clinical Trials Group (EORTC-NCIC) protocol. All patients with GBM managed between May 2007 and December 2014 with EORTC-NCIC protocol were entered into a prospective database. The primary endpoint was the median survival. Univariate predictors of survival were evaluated with respect to tumour resection, age and Eastern Cooperative Oncology Group (ECOG) performance status using log-rank comparisons. Two hundred and thirty-three patients were managed under the protocol and analysed for outcome. The median age was 57 years; the rate of gross total resection, subtotal resection and biopsy were 47.2%, 35.2% and 17.6%, respectively. At progression, 49 patients had re-resection, and in addition to second-line chemotherapy, 86 patients had Bevacizumab including 26 with re-irradiation. Median survival was 17.0 months (95% CI: 15.4-18.6). On univariate evaluation, extent of resection (P = 0.001), age, ECOG performance status and recursive partitioning analysis class III were shown to significantly improve survival (P < 0.0001). The median survival for gross total resection, age <50 years, ECOG 0-1 and recursive partitioning analysis class III were 21, 27, 20 and 47 months, respectively. This study confirms the significant improvement in median survival in GBM that has occurred in recent years since introduction of the EORTC-NCIC protocol. Further improvements have occurred presumably related to subspecialized care, improved resection rates, sophisticated radiotherapy targeting and early systemic salvage therapies. However, the burden of the disease within the community remains high and the median survival improvements over time have plateaued.

Quality of Life after post-prostatectomy intensity modulated radiation therapy to the prostate bed with or without the use of gold fiducial markers for image guidance or higher total radiotherapy doses.

ABSTRACTPurpose To evaluate quality of life (QoL) after post-prostatectomy intensity modulated radiation therapy (IMRT) in the “adjuvant” setting starting within 4 months of radical prostatectomy for adverse features; and “salvage” setting for a PSA≥0.2ng/mL.Materials and Methods Retrospective review of 130 patients who underwent IMRT to the prostate bed±gold fiducial marker placement for image guidance to 64.8-72.0Gy (median, 70.2Gy) between 2004 and 2013. Higher doses were defined as 70.2-72.0Gy and lower doses were defined as 64.8-68.4Gy. Androgen deprivation therapy (ADT) was given to 4/48 (8%) adjuvant patients and 9/82 (11%) salvage patients. International Prostate Symptom Score (IPSS), Sexual Health Inventory for Men (SHIM), and Expanded Prostate Cancer Index Composite-26-bowel (EPIC-26-bowel) questionnaires were used to assess urinary, sexual, and bowel QoL, respectively.Results Median follow-up was 46 months. There were better urinary (p=0.03) and sexual (p=0.002) QoL scores with adjuvant IMRT relative to salvage IMRT. The use of prostate bed fiducial markers did not significantly affect urinary, sexual, or bowel QoL (p=0.39, p=0.49, and p=0.40, respectively). Higher total radiotherapy doses did not significantly affect urinary, sexual, or bowel QoL (p=0.21, p=0.61, and p=0.36, respectively).Conclusions There was no significant change in urinary, sexual, and bowel sexual QoL with post-prostatectomy IMRT regardless of whether prostate bed fiducial markers or higher total radiotherapy doses were used. QoL with IMRT in the present study compares favorably with prior reports for three-dimensional conformal radiation therapy.

Improved Survival in Patients with Resected Pancreatic Carcinoma Using Postoperative Intensity-Modulated Radiotherapy and Regional Intra-Arterial Infusion Chemotherapy.

BackgroundWe assessed the role of adjuvant intensity-modulated radiotherapy (IMRT) in combination with chemotherapy for pancreatic carcinomas after curative resection and identified prognostic factors related to pancreatic carcinoma after multidisciplinary treatment strategies.Material/MethodsPancreatic carcinoma patients (n=61) who received adjuvant radiotherapy after resection (median dose, 50.4 Gy) between 2010 and 2016 were retrospectively identified. Sixty patients received chemotherapy, including concurrent chemoradiotherapy (CCRT), systemic chemotherapy, and regional intra-arterial infusion chemotherapy (RIAC). The Kaplan-Meier method was used to measure the 3-year overall survival (OS) and disease-free survival (DFS) rates. Log-rank univariate analysis and multivariate Cox regression model analysis were used to identify prognostic factors.ResultsMedian follow-up time was 25.5 (range, 4.9–59.7) months. The 3-year OS and DFS rates were 31.0% and 16.1%, respectively. The median OS and DFS were 27.4 and 16.7 months, respectively. Multivariate analysis indicated that independent favorable predictors for OS were CCRT (p=0.039) and postoperative RIAC (p=0.044). Moreover, postoperative RIAC (p=0.027), and pre-radiotherapy CA19-9 ≤37 U/mL (p=0.0080) were independent favorable predictors for DFS. The combination of radiotherapy and chemotherapy was tolerated well by the patients, and no treatment-related death occurred.ConclusionsCombined IMRT and adjuvant chemotherapy appeared safe and effective for pancreatic carcinoma. CCRT was associated with improved survival with acceptable toxicity. We propose that radiotherapy could be a part of postoperative treatment, but it should be administered concurrently with chemotherapy. Adding RIAC was associated with improved OS and DFS and it could be integrated into the postoperative treatment regimen.

MP53-14 MULTIMODAL TREATMENT FOR HIGH-RISK PROSTATE CANCER WITH HIGH-DOSE INTENSITY-MODULATED RADIATION THERAPY, CONCURRENT INTENSIFIED-DOSE DOCETAXEL AND LONG-TERM ANDROGEN DEPRIVATION THERAPY AFTER RADICAL PROSTATECTOMY AND LYMPHADENECTOMY: RESULTS OF A PROSPECTIVE PHASE II TRIAL.

You have accessJournal of UrologyProstate Cancer: Advanced (including Drug Therapy) III1 Apr 2017MP53-14 MULTIMODAL TREATMENT FOR HIGH-RISK PROSTATE CANCER WITH HIGH-DOSE INTENSITY-MODULATED RADIATION THERAPY, CONCURRENT INTENSIFIED-DOSE DOCETAXEL AND LONG-TERM ANDROGEN DEPRIVATION THERAPY AFTER RADICAL PROSTATECTOMY AND LYMPHADENECTOMY: RESULTS OF A PROSPECTIVE PHASE II TRIAL. Fabio Zattoni, Roberto Bortolus, Alessandro Morlacco, Mauro Arcicasa, Fabio Matrone, and Filiberto Zattoni Fabio ZattoniFabio Zattoni More articles by this author , Roberto BortolusRoberto Bortolus More articles by this author , Alessandro MorlaccoAlessandro Morlacco More articles by this author , Mauro ArcicasaMauro Arcicasa More articles by this author , Fabio MatroneFabio Matrone More articles by this author , and Filiberto ZattoniFiliberto Zattoni More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1665AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To evaluate the safety and oncologic outcomes of adjuvant chemo (CHT), high-dose intensity-modulated radiation therapy (IMRT) and long-term androgen deprivation (ADT) therapy following radical prostatectomy (RP) and extended lymphadenectomy (PLND) in high risk prostate cancer patients. METHODS Data of patients were collected in prospectively maintained database after IRB approval. Inclusion criteria of the study were: 1) high-risk localized (PSA level ≥20 ng/ml or clinical stage T2c or Gleason score ≥8) or locally advanced (clinical stage T3 or N+, any PSA level, any Gleason score) prostate cancer after RP and PLND 2) patients suitable to receive CHT and RT after surgery. Exclusion criteria were: 1) uncontrolled chronic disease; severe infection; peripheral neuropathy or prior malignancy within the last 5 years before study entry; 2) prior CHT, pelvic RT or local treatments for prostate cancer. Adjuvant IMRT with concurrent Docetaxel and long-term ADT were stared after 3-6 months form surgery. IMRT was performed in 4 to 6 field technique with 15-to 18-MV. Docetaxel was administered in a standard 1-hour intravenous weekly dose (30 mg if body surface area <1.8 m2 and 40 mg if body surface area ≥1.8 m2) for 6-7 weeks. ADT was maintained for 2 years. Acute and late toxicity were evaluated with the Common Terminology Criteria for Adverse Events version 3.0. Biochemical and clinical recurrence-free survival were explored with the Kaplan-Meier method. RESULTS Overall 42 patients were included in the study. Acute Genito-Urinary (GU) toxicity was observed with grade I, II and III in 4 (9.5%), 2 (4.8%), and 1 (2.3%) patients, respectively. Acute Gastro-Intestinal (GI) toxicity was found found with grade I and II in 12 (29.3%) and 3 (7.2%), respectively. In those patients with acute toxicity, concomitant GU and GI toxicity occurred in 3 (7.2%) cases. No acute grade ≥IV toxicity was detected. A residual GU grade I toxicity was present only in 1 patient. Allergy due to CHT has been evaluated in 3/42 (7.1%) patients. Continence (defined as absence of any urinary leak) after RP and post IMRT was achieved in 29 (69%) and 27 (64.3%), respectively. After a median follow up of 3.4 years, a PSA recurrence and clinical recurrence were observed in 7 (16.7%) and 4 (9.5%) patients. A 5-year biochemical and clinical recurrence-free survival rate were 70.7% and 84.0%, respectively. 5-year overall free survival was 93.6%. None of patients died for prostate cancer during follow up. CONCLUSIONS This phase II trial test a novel multimodal treatment paradigm for high-risk prostate cancer. Toxicity was acceptably low and long term oncological outcomes were good. Further studies are needed to compare this novel treatment paradigm to the standard of care. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e718-e719 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Fabio Zattoni More articles by this author Roberto Bortolus More articles by this author Alessandro Morlacco More articles by this author Mauro Arcicasa More articles by this author Fabio Matrone More articles by this author Filiberto Zattoni More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Safety and efficacy of intensity-modulated radiotherapy in the management of spermatic cord sarcoma

PurposeSpermatic cord sarcoma is a rare disease, which management remains controversial due to the lack of guidelines. The standard therapeutic approach is surgical: wide soft-tissue resection with radical inguinal orchidectomy, The diagnosis is made during the analysis of the specimen. The high rate of local recurrence indicates adjuvant radiotherapy of the tumor bed. The aim of this series is to determine the efficacy and safety of postoperative intensity-modulated radiotherapy for spermatic cord sarcomas. Patients and methodsOur series included five consecutive cases of spermatic cord sarcoma treated between 2011 and 2014. The indications for radiotherapy were: R1 status after initial surgery, R1 status after wide en bloc resection and orchiectomy, high French federation of cancer centers (FNCLCC) grade, tumor size over 5cm, tumor resection during surgery. ResultsMedian age at diagnosis was 66years (range 46–84years). Median follow-up was 18months (range 6–28months). Four patients had repeat surgery after incomplete removal. All surgeries were orchidectomy with primary ligation of testicular vessels. One patient did not have an in sano margin after the second surgical procedure. The median tumor size was 60mm (range 30–150mm). No recurrence was observed during the follow-up. ConclusionNo grade 4 toxicities were reported and the most frequent acute toxicity was dermatitis. No recurrence was reported after adjuvant intensity-modulated radiotherapy. The treatment is feasible and well tolerated and seems to provide encouraging results regarding locoregional control of the disease. Dynamic or rotational intensity-modulated radiotherapy is now recommended to decrease acute toxicities while improving the efficacy of this approach.

Clinical outcome of intensity modulated radiotherapy for carcinoma showing thymus-like differentiation.

PurposeTo evaluate the efficacy and toxicity of adjuvant intensity-modulated radiotherapy (IMRT) after surgery for carcinoma showing thymus-like differentiation (CASTLE).MethodsBetween September 2008 and June 2015, 14 CASTLE patients were retrospectively enrolled. The clinical features, treatment procedure and clinical outcomes were reviewed. All patients received postoperative IMRT. The radiation doses ranged from 56Gy/28 fractions to 66Gy/33 fractions. Treatment-related toxicities were graded by National Cancer Institute Common Toxicity Criteria (NCI-CTC) version 3.0.ResultsAfter a median follow-up period of 42 months, only one patient suffered local recurrence and distant metastasis. The most frequently seen acute toxicities were mucositis and dermatitis (grade 1-2). No grade 3-4 toxicities were observed.ConclusionsAlthough based upon a small series of consecutively treated patients, our study showed that adjuvant IMRT provides satisfactory local-regional control for CASTLE, with acceptable toxicities. Further studies are still warranted to clarify our findings.

Maximum surgical resection and adjuvant intensity-modulated radiotherapy with simultaneous integrated boost for skull base chordoma.

Local recurrence is common after surgical resection of clivus chordoma. We report the results of maximum surgical resection followed by intensity-modulated radiotherapy with simultaneous integrated boost (IMRT-SIB). We reviewed 14 consecutive clivus chordoma cases undergoing postoperative IMRT-SIB using the institutional protocol between 2005 and 2013. Total and near-total resections were achieved in 11 patients (78.6%), partial in 2 patients (14.3%), and 1 patient (7.1%) received RT for recurrent tumor after total resection. Gross residual or the high-risk area defined the planning target volume (PTV)1; PTV2 was the postoperative tumor bed plus a 3-5-mm margin, and PTV3 was PTV2 plus a 5-10mm margin. A moderate hypofractionation schedule was used: doses to PTV1, PTV2 and PTV3 were 3.9Gy, 3.15Gy and 2.8Gy through 15 fractions for the first two patients, and the rest received 2.5Gy, 2.2Gy and 1.8Gy through 25 fractions. The biologically equivalent dose in 2-Gy fractions (EQD2) was 65-68Gy for PTV1, 52-56Gy for PTV2, and 44.3-44.8Gy for PTV3. Median follow-up was 41months. Eight patients were free of disease for median 42.5months (range 23-91 months), four patients had stable disease for median 60.5months (range 39-113 months), and 1 patient showed partial response for 38months after RT. Local progression was seen in one patient who received EQD2 67.8Gy after partial resection. Estimated 5-year progression-free and overall survival rates were 92.9%. Surgery improved the neurologic deficit in six patients, and IMRT-SIB was well tolerated without lasting toxicity. Our experience suggests that maximum resection and high-dose IMRT-SIB can achieve local control without significant morbidities.

Long-term outcomes using adjuvant pelvic intensity modulated radiation therapy (IMRT) for endometrial carcinoma

PurposeWe evaluated the long-term outcome and toxicity of adjuvant intensity modulated radiation therapy (IMRT) for high-risk endometrial carcinoma via a retrospective institutional review of patients treated in this setting with extended follow-up. Methods and materialsPatients with endometrial cancer who underwent comprehensive surgical staging followed by adjuvant IMRT with or without sequential chemotherapy between 1999 and 2010 were reviewed. Median doses delivered with IMRT and brachytherapy were 45 Gy in 25 fractions and 10 Gy in 2 fractions; 10.2% received extended field and 94.5% received vaginal brachytherapy. Kaplan-Meier estimates are provided for rates of locoregional (in-field) relapse, distant metastasis, and disease-free survival, and overall survival. Gastrointestinal (GI) and genitourinary (GU) toxicity reported were graded with the Common Terminology Criteria for Adverse Events, version 4.03. ResultsA total of 128 patients were identified. Median age at diagnosis was 64 years. Most patients (82.8%) had endometrioid adenocarcinoma followed by papillary serous (10.2%), clear cell (4.7%), and carcinosarcoma (2.3%). International Federation of Gynecology and Obstetrics staging distribution was as follows: IA, 13.3%; IB, 32.8%; II, 30.4%; IIIA, 5.5%; IIIC1, 9.4%; and IIIC2, 8.6%. Most (85.9%) underwent nodal dissections (28.1% pelvic only and 57.8% pelvic and para-aortic). Two patients (1.6%) experienced acute grade 3 GI toxicity; no other acute grade ≥3 GI/GU toxicities were noted. With a median follow-up of 57.0 months, 5-year locoregional relapse was 2.5%: vagina (n = 3), parametrium (n = 1), pelvic node (n = 1). Five-year estimates of distant metastasis, disease-free survival, and overall survival were 16.5%, 73.4%, and 77.4%, respectively. Five-year actuarial rates of late grade 3 GI and GU toxicities were 3.2% and 0.0%. The 5-year rate of symptomatic pelvic insufficiency fracture was 4.4%. ConclusionsThis study represents the largest cohort of endometrial cancer patients with extended follow-up receiving adjuvant IMRT. High rates of pelvic disease control and limited late toxicities demonstrate safety and efficacy of this approach in the setting of extended follow-up.