Benefit Of External Beam Radiotherapy Research Articles

Treatment and Outcomes in pT4 Well-Differentiated Thyroid Carcinoma

Locally advanced, pT4 well differentiated thyroid carcinoma is a relatively rare entity and the benefit of external beam radiotherapy (EBRT) is unclear. The purpose of this study is to evaluate locoregional control (LRC) and cancer specific survival (CSS) of patients with pT4 well differentiated thyroid carcinoma in the largest retrospective cohort to date. Electronic records of patients with pT4 well-differentiated thyroid carcinoma treated at our institution from 2001 to 2013 were reviewed. Log-rank test and multivariable Cox regression were used to establish factors impacting locoregional control and cancer specific survival. A total of 232 patients were treated during this time period. The most common histologies were papillary carcinoma (n=192) and follicular carcinoma (n=11). The median age was 58 and 61% were female. Median follow up time was 11 years. The median tumor size was 3.1cm (interquartile range: 2.0-5.0cm), 60% had multifocal disease, 33% lymphovascular invasion, 9% perineural invasion and 64% had node positive disease. Local invasion into the strap muscles was seen in 51%, trachea 33%, larynx 4%, pharynx 3%, and recurrent laryngeal nerve 1%. 22% patients had an R0 resection, 55% R1 and 23% R2. 92% patients received adjuvant radioactive iodine therapy. A total of 88 patients received external beam radiotherapy with a median dose of 60Gy. There were 7 acute grade 3 toxicities (3 dysphagia, 2 nausea, and 2 pain) and 7 late grade 3 toxicities in the cohort (2 dysphagia, 3 esophageal stricture, 1 pain, 1 laryngeal stenosis). There were no grade 4 toxicities observed. Ten year LRC was 65%, CSS was 85%, and OS was 75%. On multivariate analysis, older age (p=0.02, HR 1.02, 95% CI 1.0-1.04), larynx invasion (p=0.05, HR 3.32, 95% CI 1.0-11.0) and larger tumor size (p=0.01, HR 1.17, 95% CI 1.04-1.32) were associated with worse LRC. Older age (p<0.001, HR 1.10, 95% 1.06-1.15), lymphovascular invasion (p=0.002, HR 3.3, 95% 1.5-7.2), perineural invasion (p=0.02, HR 2.9, 95% 1.19-7.48), and tracheal invasion (p=0.009, HR 2.7, 95% CI 1.3-5.5) were associated with worse CSS. Adjuvant RT was not associated with improved LRC and CSS when the entire cohort was assessed. However, for patients with microscopic or macroscopic residual disease (R1 and R2 resection), adjuvant radiotherapy was associated with improved LRC on multivariable analysis (p=0.02, HR 0.45, 95% CI 0.23-0.90). Despite locally advanced disease; 10 year CSS was 85% in this cohort of patients with pT4 DTC. Adjuvant radiotherapy improved LRC for patients with R1 and R2 resections. There was a low rate of toxicity from EBRT for the cohort.

Defining the survival benefit of adjuvant pelvic radiotherapy and chemotherapy versus chemotherapy alone in stages III-IVA endometrial carcinoma

ObjectivesTo determine which patients with locoregionally advanced endometrial cancer may benefit from pelvic external beam radiotherapy (EBRT) in addition to chemotherapy compared to chemotherapy alone. MethodsPatients with FIGO stages III–IVA endometrial carcinoma between 2004 and 2016 who underwent at least total hysterectomy and adjuvant multiagent chemotherapy were identified in the National Cancer Database. The primary outcome was overall survival according to receipt of pelvic EBRT, analyzed using the Kaplan-Meier method and Cox multivariable regression. ResultsIn total, 13,270 patients were identified (62% pure endometrioid, 38% serous/clear cell or mixed histology; 22.6% stage IIIA, 4.7% stage IIIB, 71.2% stage IIIC, 1.5% stage IVA), of whom 40% received pelvic EBRT. In univariable analysis, EBRT was associated with absolute 5-year survival increases of 5% and 9% in the endometrioid and non-endometrioid cohorts, respectively (P < 0.0001). In multivariable analyses stratified by stage and histology, patients with a significant benefit from EBRT were stage IIIC (specifically IIIC2) endometrioid (adjusted hazard ratio [HR] 0.73, P = 0.01) and stages IIIB and IIIC non-endometrioid (adjusted HR 0.52, P = 0.01 and adjusted HR 0.79, P < 0.0001). The benefit of EBRT in node-positive patients persisted in those who underwent more extensive lymphadenectomy. ConclusionsStages III–IVA endometrial cancer comprised a heterogeneous population with respect to the added benefit of radiotherapy compared to chemotherapy alone. Patients with stage IIIC2 endometrioid and stages IIIB–C non-endometrioid cancer may be most likely to benefit from pelvic EBRT.

May non-metastatic clinically localized castration-resistant prostate cancer after primary androgen ablation benefit from salvage prostate radiotherapy?

A proportion of patients with localized prostate cancer is still treated with primary androgen deprivation therapy (PADT) alone. Some of these patients may develop a PSA rising despite castration. The purpose of this study was to retrospectively evaluate the potential benefit of external beam radiotherapy (EBRT) in this cohort. Forty-two patients presenting a non-metastatic castration-resistant prostate cancer after PADT were referred to our institution and underwent RT between June 2003 and July 2011. Biochemical failure (BF) after EBRT was defined according to Phoenix criteria (nadir + 2 ng/mL "at call"). Median RT dose was 78 Gy. Median duration of PADT was 54 months (range 10.2-181 months). Median follow-up after EBRT was 53 months. Twenty-one patients had BF after EBRT (median time 27.4 months): 13 presented with loco-regional and/or distant metastases, while in 8 patients, a PSA rise only was observed. Ten patients died of prostate cancer (and no patient died of causes other than prostate cancer). Five-year biochemical disease-free survival (bDFS), distant metastases-free survival (DMFS) and cancer-specific survival (CSS) were, respectively, 39.4, 60 and 65 %. On multivariate analysis, GS, nadir PSA (nPSA) and a pre-EBRT PSA ≤5 ng/mL significantly affected bDFS, while Gleason score (GS) and T stage significantly affected distant metastases onset. No factors affected CSS at multivariate analysis. EBRT may be a suitable therapeutic option, able to provide an excellent loco-regional control and to obtain a systemic disease control in up to 60 % of patients at 5 years, especially in patients presenting with lower Gleason score and T stage at diagnosis and lower pre-RT PSA and nPSA post-RT.

Clinical outcomes of adjuvant external-beam radiotherapy for differentiated thyroid cancer

Evaluate the clinical benefit of external beam radiotherapy (RTx) for locally invasive thyroid carcinoma with follicular cell differentiation (DTC). The Multicentre Study on Differentiated Thyroid Cancer (MSDS) was planned as a prospective multicenter trial on the benefit of adjuvant RTx in locally invasive DTC (pT4; UICC 1997) with or without lymph node metastases and no known distant metastases. All patients were treated with thyroidectomy, 131I-therapy, and TSH-suppression and were randomized to receive additional RTx or not. In 4/2003 the trial became a prospective cohort study after only 45 of then 311 patients had consented to randomization. 351 of 422 patients met the trial's inclusion criteria. Age was 48 +/- 12 years (mean +/- SD). 25% were men. Tumours were papillary in 90% and follicular in 10%. Of 47 patients randomized or allocated to RTx, 26 actually received RTx. Mean follow-up was 930 days. In an actual treatment analysis, 96% (25/26) of the RTx-patients reached complete remission (CR) vs. 86% in the non-RTx patients. Recurrences occurred in 0 vs. 3 % of patients: 6 reoperated for regional lymph node metastases, 1 tracheal invasion treated with tracheoplasty, 1 local invasion necessitating laryngectomy, 2 distant metastases (1 lung, 1 lung + bone). Serious chronic RTx toxicity occurred in 1/26 patients. The MSDS trial showed low mortality and recurrence rates and a weak benefit of RTx in terms of local control that did however not reach statistical significance. Routine RTx in locally invasive DTC can no longer be recommended.

Adjuvant external beam radiotherapy in the treatment of endometrial cancer (MRC ASTEC and NCIC CTG EN.5 randomised trials): pooled trial results, systematic review, and meta-analysis

SummaryBackgroundEarly endometrial cancer with low-risk pathological features can be successfully treated by surgery alone. External beam radiotherapy added to surgery has been investigated in several small trials, which have mainly included women at intermediate risk of recurrence. In these trials, postoperative radiotherapy has been shown to reduce the risk of isolated local recurrence but there is no evidence that it improves recurrence-free or overall survival. We report the findings from the ASTEC and EN.5 trials, which investigated adjuvant external beam radiotherapy in women with early-stage disease and pathological features suggestive of intermediate or high risk of recurrence and death from endometrial cancer.MethodsBetween July, 1996, and March, 2005, 905 (789 ASTEC, 116 EN.5) women with intermediate-risk or high-risk early-stage disease from 112 centres in seven countries (UK, Canada, Poland, Norway, New Zealand, Australia, USA) were randomly assigned after surgery to observation (453) or to external beam radiotherapy (452). A target dose of 40–46 Gy in 20–25 daily fractions to the pelvis, treating five times a week, was specified. Primary outcome measure was overall survival, and all analyses were by intention to treat. These trials were registered ISRCTN 16571884 (ASTEC) and NCT 00002807 (EN.5).FindingsAfter a median follow-up of 58 months, 135 women (68 observation, 67 external beam radiotherapy) had died. There was no evidence that overall survival with external beam radiotherapy was better than observation, hazard ratio 1·05 (95% CI 0·75–1·48; p=0·77). 5-year overall survival was 84% in both groups. Combining data from ASTEC and EN.5 in a meta-analysis of trials confirmed that there was no benefit in terms of overall survival (hazard ratio 1·04; 95% CI 0·84–1·29) and can reliably exclude an absolute benefit of external beam radiotherapy at 5 years of more than 3%. With brachytherapy used in 53% of women in ASTEC/EN.5, the local recurrence rate in the observation group at 5 years was 6·1%.InterpretationAdjuvant external beam radiotherapy cannot be recommended as part of routine treatment for women with intermediate-risk or high-risk early-stage endometrial cancer with the aim of improving survival. The absolute benefit of external beam radiotherapy in preventing isolated local recurrence is small and is not without toxicity.FundingMedical Research Council, National Cancer Research Network, National Cancer Institute of Canada, with funds from the Canadian Cancer Society.

United States radiation oncologists’ and urologists’ opinions about screening and treatment of prostate cancer vary by region

Objectives To examine whether physicians’ views on prostate cancer screening and treatment vary by geographic region in the United States. Methods A mail survey was sent in 1998 to a random sample of physicians in the United States who were listed as radiation oncologists (response rate 76%, n = 559) and urologists (response rate 64%, n = 504) in the American Medical Association Registry of Physicians and practicing at least 20 hr/wk. Results Radiation oncologists and urologists in Florida were more likely to report recommending routine prostate-specific antigen testing for men aged 75 years and older than were their colleagues in other regions of the United States. The Florida physicians were more likely to report treating at least 20% of their patients with brachytherapy and to report believing that brachytherapy has survival value for men with a less than 10-year life expectancy. No regional differences were found in the radiation oncologists’ and urologists’ beliefs about the survival value of radical prostatectomy; however, for men with a less than 10-year life expectancy, Florida urologists had more confidence in the survival benefit of external beam radiotherapy than urologists in other regions ( P = 0.04). Radiation oncologists in Florida reported higher rates of recommending early androgen deprivation for a rising PSA after both radiotherapy and surgery ( P = 0.008 and P = 0.001, respectively) than did their colleagues in other regions. Conclusions Florida radiation oncologists and urologists reported beliefs and practices that differed from their colleagues in other regions of the United States. Whether the distinctive style of prostate cancer diagnosis and treatment in Florida results in improved outcomes has yet to be proved.

Cholangiocarcinoma of the Hepatic Hilum (Klatskin Tumor).

Since the description by Klatskin in 1965, the management of patients with adenocarcinoma of the hepatic bile duct bifurcation is viewed as a challenging clinical problem with a relatively poor prognosis. Surgery continues to be the mainstay of therapy. Complete resection of the tumor with negative histologic margins offers the best possibility of long-term survival, and hepatic resection is a critical component of the operative approach. Adjuvant chemoradiotherapy has failed to provide a significant survival benefit. Orthotopic liver transplantation for otherwise unresectable lesions remains controversial, as tumor recurrence has been reported in more than 90% of patients. With the shortage of organs, such patients to be selected carefully for transplanation. For patients who present with widespread disease and those with high operative risks, advances in interventional radiology and endoscopy have facilitated nonsurgical management options. Biliary decompression using expandable metallic stents provides superior patency and decreased frequency of hospitalization when compared with plastic stents. Moreover, patients treated with expandable metal stents have survival rates comparable with those who undergo surgical decompression, with fewer early complications. The benefit of external beam radiotherapy for palliation of proximal cholangiocarcinoma is uncertain. Radiotherapy in conjunction with biliary stenting has a survival benefit over stenting alone, but is not without potential toxicity. It should be considered as an adjunct to biliary decompression in all patients with good performance status, because modern conformal CT-based dosimetry can minimize toxicity to normal adjacent tissue. Photodynamic therapy is emerging as a new palliative treatment modality for patients with unresectable tumors in whom stenting has failed. It offers the advantage of an endoscopic delivery system, and unlike radiotherapy, photodynamic therapy may be delivered repeatedly.

External beam radiotherapy for subretinal neovascularization in age-related macular degeneration: is this treatment efficient?

Purpose: Control of the natural course of subretinal neovascularization (SRNV) in age-related macular degeneration (AMD) is difficult. Only a subset of patients is suitable for laser coagulation. This prospective study aimed to determine the efficacy and individual benefit of external beam radiotherapy (EBRT).Methods and Materials: The prospective trial included 287 patients with subfoveal neovascularization due to AMD which was verified by fluorescein angiography. Patients have been treated between January 1996 and October 1997. All patients received a total dose of 16 Gy in 2-Gy daily fractions with 5–6 MeV photons based on computerized treatment planning in individual head mask fixation. This first analysis is based on 73 patients (50 women, 23 men, median age 74.3 years), with a median follow-up of 13.3 months and a minimum follow-up of 11 months.Results: All patients completed therapy and tolerability was good. First clinical control with second angiography was performed 6 weeks after irradiation, then in 3-month intervals. Eighteen patients with SRNV refusing radiotherapy served as a control group and were matched with 18 irradiated patients. After 7 months median visual acuity (VA) was 20/160 for the irradiated and 20/400 for the untreated patients. One year after radiotherapy final median VA was 20/400 in both groups.Conclusion: These results suggest that 16 Gy of conventionally fractionated external beam irradiation slows down the visual loss in exudative AMD for only a few months. Patients’ reading vision could not be saved for a long-term run.