Combination Of EBRT Research Articles

The Role of Adjuvant Therapy for the Treatment of Micrometastases in Endometrial Cancer: A Systematic Review and Meta-Analysis.

Endometrial cancer is the most incident gynecological cancer. Lymph node dissemination is one of the most important factors for the patient's prognosis. Pelvic lymph nodes are the primary site of extra-uterine dissemination in endometrial cancer (EC), setting the 5-year survival to 44-52%. It is standard practice for radiation therapy (RT) and/or chemotherapy (CTX) to be given as adjuvant treatments to prevent the progression of micrometastases. Also, administration of EC patients with RT and/or CTX regimens before surgery may decrease micrometastases, hence the need for lymphadenectomy. The primary aim of the systematic review and meta-analysis is to assess whether adjuvant RT and/or CTX improve oncological outcomes through the management of micrometastases and nodal recurrence. We performed systematic research using the string "Endometrial Neoplasms" [Mesh] AND "Lymphatic Metastasis/therapy" [Mesh]. The methods for this study were specified a priori based on the recommendations in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Outcomes were 5-year overall survival, progression-free survival, recurrence rate, and complications rate. We assessed the quality of studies using the Newcastle-Ottawa Scale (NOS). A total of 1682 patients with stage I-to-IV EC were included. Adjuvant treatment protocols involved external-beam RT, brachytherapy, and CTX either alone or in combination. The no-treatment group showed a non-statistically significant higher recurrence risk than any adjuvant treatment group (OR 1.39 [95% CI 0.68-2.85] p = 0.36). The no-treatment group documented a non-statistically significant higher risk of death than those who underwent any adjuvant treatment (RR 1.47 [95% CI 0.44-4.89] p = 0.53; I2 = 55% p = 0.000001). Despite the fact that early-stage EC may show micrometastases, adjuvant treatment is not significantly associated with better survival outcomes, and the combination of EBRT and CTX is the most valid option in the early stages.

Radiotherapy for Postoperative Vaginal Recurrences of Cervical Cancer Patients: Analysis of Recurrent Causes and Prognosis

Vagina is the most common site of cervical cancer recurrence, and salvage radiotherapy (RT) is recommended owing to its effectiveness and tolerable adverse events. Several studies have focused on prognostic factors of RT treatment for postoperative recurrent cervical cancer patients. However, few researches identified different recurrent causes as a prognostic factor and studied the relationship between recurrent causes and survival. The aim of this study was to identify the recurrent causes affecting prognosis of vaginal recurrent patients treated with salvage RT. One hundred and twenty-six female patients with vaginal recurrent cervical cancer, treated with salvage RT between July 2011 and January 2020, were reviewed in this study. Among these patients, a combination of EBRT and BRT was delivered to 94 patients, EBRT alone was delivered to 20 patients. Causes of recurrence were distributed into five groups: (1) selection of surgical indication (n = 15): included ①surgery beyond indication (n = 8) and ②neoadjuvant therapy (n = 7);(2) Positive surgical margin (n = 18); (3) nonstandard RT (n = 20): include ④no RT, despite indications of postoperative RT (n = 15), and ⑤insufficient postoperative RT dose (n = 5); (4) with risk factors but no indication for RT according to the Sedlis criteria (n = 29): include ⑥non-squamous carcinoma (n = 7) and ⑦only one intermediate risk factor in Sedlis criteria (n = 22); (5) HPV infection (n = 44). Log-rank tests and Cox proportional hazards regression methods were used to identify prognostic factors. The median follow-up time of the 126 cervical cancer patients was 39.1 months with estimated 5-year OS, PFS and LC rates of 79%, 75% and 86%, respectively. In multivariate analysis, recurrence pattern (including endovaginal recurrence, paravaginal recurrence, invasion of surrounding organs and distant metastasis, p < 0.05) and causes of recurrence were independent prognostic factors for OS. Recurrence because of "(1) the selection of surgical indication" (p < 0.05) was associated with poor OS, while recurrence because of "(2) positive surgical margin" was associated with prolonged OS. Multivariate analysis also revealed that recurrence pattern, causes of recurrence (p < 0.05) and re-irradiation were independently factors for PFS. Majority of patients with recurrence causes of HPV infection (79.5%) and positive surgical margin (77.8%) experienced endovaginal recurrence. Patients with recurrence cause of selection of surgical indication had the highest proportion (26.7%) of recurrence with invasion of surrounding organs, and 53.3% experienced re-irradiation. The results this research suggest that salvage RT is an effective treatment for vaginal recurrences in postoperative patients with cervical cancer. Causes of recurrence was an independently factor for OS and PFS, and recurrence caused by selection of surgical indication was associated poor survival.

Impact of Lymphopenia on Definitive Treatment of Locally Advanced Cervical Cancer

Pre-treatment lymphopenia prior to initiating treatment has been correlated with reduced survival in a number of different cancers. The purpose of this study is to evaluate the association between lymphopenia and survival in women with locally advanced cervical cancer (LACC) treated with primary chemoradiation (CRT). We retrospectively reviewed patients with LACC treated at a single institution from 2005 - 2021 with available lymphocyte information. Patient and treatment characteristics were recorded including age, tumor size and stage, EBRT dose/fractionation, and brachytherapy dosimetry data. Absolute lymphocyte counts (ALC) were collected prior to initiating CRT and at 3-month intervals following CRT and graded based on severity of lymphopenia using CTCAE v 5.0. Overall survival (OS), progression free survival (PFS), and local control (LC) were calculated from the start of treatment to date of last follow-up. Kaplan-Meier survival analysis was performed to evaluate whether lymphocyte changes were associated with OS, PFS, or LC. A total of 124 patients met study inclusion criteria with stage IB - IV disease (41 stage I, 41 stage II, 36 stage III, 6 stage IV) and a median follow up of 3.6 years (range 0.2-16.5 years). The median age was 49 years (range 26-77). The median EBRT dose was 45 Gy (range: 26-57.5 Gy) and 44.2% of patients received para-aortic (PA) nodal EBRT (28.8% elective and 15.4% with positive PA nodes). 5-year OS, PFS, and LC were 60.3% (95% CI 51.5-70.7), 47.5% (95% CI 39-58), and 75.5% (95% CI 67.3-82.9), respectively. Pre-treatment lymphopenia (ALC <1000 cells/mm3) was present in 11 (9%) patients. When the total cohort was divided into patients with and without pre-treatment lymphopenia, OS was statistically improved in the patients without baseline lymphopenia, with a 5-year OS of 63.2% (95% CI 53.9-73.9) versus 35.3% (95% CI 14.5-86.3) in the lymphopenia group (p = 0.034). LC also trended to being improved in the patients without lymphopenia, though this did not reach statistical significance in our small sample size of lymphopenic patients, with 5-year LC of 76.8% (95% CI 68.4-84.3) versus 67.5% (05% CI 36.6-93.8), p = 0.45. In this single institution experience of LACC treated with definitive CRT, we found that baseline lymphopenia is associated with inferior OS. Patients with higher pre-CRT ALC may represent a population with more robust immune systems, producing more favorable tumor responses to treatment. Additional studies are warranted to investigate the evolving role of combined EBRT and systemic therapy in LACC.

Volumetric image guidance for intravaginal brachytherapy: A dosimetric and clinical study.

The present retrospective dosimetric and clinical study aims to explore the subset of patients who will benefit from volumetric image guidance in intravaginal brachytherapy (IVBT). Sixty-three consecutive patients who underwent IVBT using single-channel intravaginal cylinder were analyzed. The most common IVBT dose protocol was 1100 cGy in two fractions (with external beam radiotherapy [EBRT]) and 2200 cGy in four fractions (when used alone). The factors affecting the dose to organs at risk (OARs) (such as treated length, orientation of applicator, EBRT) and target volume were analyzed. Local control rate and late toxicities were reported. There was a statistically significant increase in equivalent dose at 2 Gy per fraction (EQD2) doses of all OARs with the addition of EBRT. In 39.4%, EQD2 D2cc dose of rectum was more than 65 Gy. There was a statistically significant positive correlation with increasing treated length in D5cc (Gy) of rectum and D5cc (Gy) of urethra (Pearson's correlation coefficient of 0.375, P = 0.002 and Pearson's correlation coefficient of 0.394, P = 0.001, respectively). There was a statistically significant increase in D2cc and D5cc of rectum with posterior orientation. Air gaps were noted in 81% of applications. Median duration of follow-up was 30 months. One patient had vaginal recurrence in lower third of vagina. One patient was recorded with grade 2 hemorrhagic radiation proctitis. Computed tomography (CT)-based volumetric planning is an effective method to evaluate doses to OARs and confirm the adequacy of dose coverage, and we recommend routine use of the same. Image guidance is most beneficial in patients being treated with a combination of IVBT and EBRT, posterior orientation, and those who are treated for the entire length of vagina.

Is hospitalization within 6 months of completion of radiation therapy for endometrial cancer associated with decreased survival? (584)

<b>Objectives:</b> Radiation therapy (RT) is a core component in the management of women with locally advanced endometrial cancer (EC). For patients with early-stage (I and II), intermediate-risk disease, adjuvant RT is considered the standard of care. We hypothesized that hospitalization within six months of the completion of RT was associated with decreased overall survival (OS) and progression-free survival (PFS). We tried to identify factors predictive of a patients' likelihood of hospitalization within a short term of RT completion. <b>Methods:</b> An IRB-approved, retrospective cohort study included all patients who were diagnosed with EC and treated with radiation at our institution from January 2019 through December 2020. Data collected included functional status, disease stage, treatment course, hospitalizations, and demographics. Performance status was monitored via the Kamofsky Performance Scale. Common terminology criteria for adverse event (CTCAE) constipation and fatigue grades were gathered to provide insight into a patient's tolerance of RT. Statistical analysis was performed via Fisher's exact test. The Kaplan-Meier product estimator was utilized to derive survival curves, which were then compared via log-rank test. A critical value of p <0.05 was set for statistical significance. <b>Results:</b> Of 287 eligible patients, 27 (9.4%) were hospitalized within six months of RT. Of those patients, 13 of 27 (48%) were hospitalized within 30 days of completion of RT, and an additional five patients were hospitalized within 45 days of completion of radiation. The median length of hospitalization was six days, with hospital stays ranging from one to 20 days. Of patients who were hospitalized, 15 received EBRT alone, ten received vaginal brachytherapy alone, and two received a combination of EBRT + brachytherapy. The most common indications for hospitalization included disease progression, vaginal bleeding, altered mental status, failure to thrive, infection, and cardiovascular events. Most patients (21/27) did not undergo procedural intervention during their hospitalization, although two patients were admitted to the intensive care unit, and ultimately five of 27 patients expired during the hospitalization. Of the patients who expired, 40% of deaths were disease-related, while 60% were from other causes. Of the six patients who underwent procedural intervention during their admission, interventions included palliative RT, uterine artery embolization, biopsy, pleural catheter placement, and scheduled procedures unrelated to their disease process, inclusive of cholecystectomy and colonoscopy. Hospitalization within six months was associated with both decreased OS (p < 0.0001) and decreased PFS (p <0.0001). There was no significant variation in performance status, as indicated by Kamofsky's performance score, between patients who were and were not hospitalized within six months of completion of RT. BMI, age, constipation, and fatigue were not statistically significant predictors of a patients' likelihood of short interval hospitalization. <b>Conclusions:</b> Women with EC who received RT as part of their treatment and were hospitalized within six months had a statistically significant decreased OS and PFS. Age, BMI, race, and performance status were not found to be predictive of a patient's risk of short interval hospitalization.

Effectiveness and Secondary Incontinence Rates after Urethroplasty for Severe Radiation-Induced Urethral Stenosis: A Systematic Review and Meta-Analysis

Radiation-induced urethral stenosis (RIUS) is an important complication after cancer treatment, which sometimes requires surgical urethroplasty. To date, there is no precise estimate of effectiveness of urethroplasty and rates of secondary urinary incontinence (SUI) in this scenario. A systematic search of databases (PubMed and EMBASE) was performed with the terms “urethroplasty”, “radiotherapy”, “stenosis” and their variants. The pooled summary of overall stenosis resolution rate and the proportion of cases that developed SUI were calculated using the random-effects model weighted by the inverse variance. All statistical analyses were performed using R software version 3.5.1. This study is registered in the Open Science Framework online public database (10.17605/OSF.IO/WDQZJ). Using our search strategy, 96 studies were initially found. After applying inclusion and exclusion criteria, 8 retrospective studies met requirements for the meta-analysis, totaling 256 patients (98.4% prostate cancer and 1.6% colorectal cancer). Mean age of the patients from the series varied between 67.7-69 years. The proportion of cases treated with EBRT, BT, combination EBRT, or not specified were 45.7%, 28.9%, 13.3%, and 12.1%, respectively. Most of the strictures involved the bulbomembranous region (n = 212, 82.8%), followed by membranous only (9.8%), bladder neck (1.6%), pan-urethral (0.8%), or not specified (5.1%). Sixty-one percent of the cases (n = 157) were submitted to primary anastomosis, while the remaining (n = 86) required reconstruction with graft or flap. The mean follow-up time after urethroplasty varied in the range of 10 months and 50.5 months. The pooled stenosis resolution rate was 80% (95%CI: 74-86%). There was no correlation between percentage of reconstructive techniques (Spearman’s rank correlation coefficient [rho] = 0.20, p = 0.74) or percentage of combined EBRT + BT (rho = -0.31, p = 0.53) and stenosis resolution rate. Fifty-three cases developed SUI after urethroplasty, with a pooled rate of 19% (95%CI: 10-31%). Urethroplasty after RIUS is effective in 80% of cases, independently of previous RT modality or urethroplasty technique, but one in every 5 patients develop SUI after procedure.

Outcome of Definitive Treatments in Primary Vaginal Cancer Patients: An Institutional Review

To review the treatment outcome in primary vaginal cancer patients who underwent definitive treatment at our institution. A total of 43 patients with histologically proven primary vaginal cancer, who were treated between January 2005 to December 2015, were identified. All were treated with definitive radiotherapy with or without concurrent chemotherapy. Radiotherapy was delivered as a combination of external beam radiotherapy and brachytherapy to a minimum dose of 60 Gy. Four patients were FIGO stage I, 13 were stage II, 23 stage III patients and three patients were stage IVA. The median age was 60 years (range 42–76). The median follow-up was 29 months with a range of 3 to 70 months. The different variables looked into like the histology, lower third of vagina involvement and prior hysterectomy did not show any difference in survival. Addition of concurrent chemotherapy was the only factor which showed a trend towards better survival with a p value of 0.09. Even in the subset of patients with prior hysterectomy, those who received definitive treatment with concurrent chemo-radiotherapy had a better two-year progression-free survival than those who received radiotherapy alone (57.4% Vs 10.5%). A combination of EBRT and brachytherapy with concurrent chemotherapy is a reasonable option in the management of primary vaginal cancer. Further optimization of the dose and techniques of radiotherapy are warranted.

Treatment patterns among newly diagnosed women with cervical cancer in the United States.

e18019 Background: To address the gap in US-based real-world data, this analysis described the real-world treatment patterns among newly diagnosed cervical cancer patients. Methods: Women newly diagnosed with cervical cancer between Jan 2015 – June 2018, with a confirmatory diagnosis or treatment within 2 months, and continuous enrollment for 12 months prior and 6 months post diagnosis were identified in the Optum Clinformatics DataMart database. Surgeries (hysterectomy, conization, lymphadenectomy and trachelectomy), radiation (external beam radiotherapy [EBRT]/brachytherapy) and systemic therapies (chemotherapy/immunotherapy) received after diagnosis were described by line of therapy (LOT). The start of the first LOT was the date of the first treatment. All treatments initiated within 90 days of a surgery or the end of radiotherapy, and all systemic treatment started within 28 days of any previous treatment were a part of the same LOT. Most frequently received treatments in LOT1 and 2 and time to treatment initiation were described. Results: Out of 1,004 newly diagnosed women, 655 (65.2%) received at least LOT1 and 162 (16.14%) received LOT2. Median time to first LOT was 1.5 (1.4 – 1.7) months from diagnosis. Surgery was the most common treatment in LOT1 (58.0%). Among patients receiving radiation, the majority received a combination of EBRT and brachytherapy (LOT1: 66.9%, LOT2: 58.0%). The use of chemotherapy increased with subsequent LOTs (LOT1: 53.3%, LOT2: 61.1%). Treatments received in LOT1 and LOT2 are described in the table. Conclusions: This analysis shows that newly diagnosed cervical cancer patients are primarily receiving guideline recommended treatment with surgery or chemoradiation as primary treatment. Radiation therapy includes EBRT and brachytherapy. Counts ≤ 10 are not reported (NR). [Table: see text]

Impact and Outcomes of Pretreatment Total Serum Testosterone on Localized Prostate Cancer Patients.

Purpose To investigate how pretreatment testosterone levels correlate with progression-free survival, metastasis-free survival, and overall survival in a propensity-adjusted localized prostate cancer population. Methods Men diagnosed with clinical NCCN-risk stratified very-low, low, intermediate, high, and/or very-high risk prostate cancer who had a baseline total serum testosterone level≥100 ng/dl measured within the 100 days preceding the first definitive therapy were identified from our prospectively gathered institutional database. Cohorts below (100–239 ng/dl), within (240–593 ng/dl), or above (594 + ng/dl) one standard deviation from the mean testosterone level (416 ng/dl) were used for comparison. Progression-free, metastasis-free, and overall survival were evaluated. A separate cohort of men not receiving ADT was used to evaluate testosterone recovery after various treatment modalities (surgery, external beam radiation, brachytherapy, or combined EBRT + Brachy). Results There was no statistically significant difference between the low, average, and high testosterone cohorts for PFS, MFS, or OS. In men not using ADT, there were no statistically significant changes in testosterone levels 1 year after therapy, regardless of therapy type. Conclusion In men with serum testosterone levels >=100 ng/dl at diagnosis, baseline testosterone does not impact PFS, MFS, or OS. Recovery of testosterone back to baseline is expected for men undergoing either surgery, external beam or brachytherapy, or combined modality radiation when not using ADT.

Trends and Predictors of Adjuvant Therapy for Adverse Features Following Radical Prostatectomy: An Analysis From Cancer of the Prostate Strategic Urologic Research Endeavor

OBJECTIVETo determine trends and predictors of adjuvant therapy in patients with adverse features at radical prostatectomy (RP), and to investigate the associations of adjuvant therapy and adverse feature type with survival. METHODSFrom the Cancer of the Prostate Strategic Urologic Research Endeavor registry (1990-2017), 2209 men with adverse features (pT3N0M0 disease and/or positive surgical margins), and 108 men with positive lymph nodes (pN1) at RP were identified. Temporal trends were evaluated, and predictors of adjuvant therapy were assessed with multivariate logistic regression. Kaplan-Meier analysis and competing risks regression were used to test cumulative incidence and risk of all-cause and prostate cancer-specific mortality. RESULTSOf 2209 men with adverse features and pN0 disease, 89 (4.0%), 82 (3.7%), and 30 (1.4%) received adjuvant external beam radiation therapy (ERBT) alone, androgen deprivation therapy (ADT) alone, or combined EBRT and ADT, respectively. Of 108 men with pN1 disease, 54 (50%) received ADT with or without EBRT. Adjuvant treatment for patients with adverse features decreased from 13.3% (1990-1994) to 6% or less (2005-2017, Ptrend <.001). Patients with margin positive pT3a (odds ratio 4.13; 95% confidence interval 2.21-7.73; P<.01) and margin positive pT3b disease (odds ratio 7.09; 95% confidence interval 3.66-1.73; P<.01) had greater odds of receiving adjuvant therapy compared to patients with margin negative pT3a disease. Adverse feature type was associated with prostate cancer-specific mortality in univariate analysis (log-rank P <.01), but not in competing risks regression (P= .06). CONCLUSIONAdjuvant therapy declined for men with adverse features at RP. Providers do not treat all adverse feature types the same way, despite broad treatment recommendations in guidelines.

PO-0736 Radiation necrosis after a combination of EBRT and iodine-125 brachytherapy in gliomas

PO-0736 Radiation necrosis after a combination of EBRT and iodine-125 brachytherapy in gliomas

Late toxicity after single dose HDR prostate brachytherapy and EBRT for localized prostate cancer: Clinical and dosimetric predictors in a prospective cohort study

PurposeTo describe the genitourinary (GU) and gastrointestinal (GI) late toxicity profile and to analyse the clinical and dosimetry outcomes predictors of the combination of EBRT and high-dose-rate (HDR) prostate brachytherapy (BT) for localized prostate cancer. Materials and methodsBetween January 2012 and May 2017, 210 patients were included in a prospective protocol. Treatment consisted in HDR-BT (15 Gy single fraction) plus 3DCRT (37.5 Gy/15 fractions). Univariate and multivariate logistic regressions were used to analyse the impact of variables on late toxicity. ResultsMedian age was 71 (56–82), 12.4% of patients had low, 44.3% intermediate and 41% high-risk prostate cancer. Median prostate volume was 28.4 cc. Median V100, V150, V200 were 98.2%, 27% and 7.4% respectively. Median urethra Dmax, rectum D1cc and D2cc, were 113.5%, 62.2%% and 54.2% respectively.After a median follow-up of 41 months (5–75) late G2 GU and GI late toxicity was observed in 14.8% and 5.2% of patients respectively. Late G3 GU and GI toxicity occurred in 0% and 1% of patients respectively.There were no outcome correlations with late G ≥ 2 GU toxicity on univariate analysis. Previous cardiovascular comorbidity (p = 0.042), and dose to the rectum D2cc (p = 0.016) and D1cc (p = 0.017) were associated with G ≥ 2 GI toxicity.Multivariate analysis showed that rectum D1cc (HR11.56; 95%CI 1.4–92.1; p = 0.021) and prior history of cardiovascular disease (HR3.6; 95%CI 1–12.9; p = 0.045) remained independent predictors of G ≥ 2 GI toxicity. ConclusionsThere is a low incidence of late GU and GI morbidity using single fraction HDR-BT and hypofractionated EBRT. Previous cardiovascular disease and dose to the rectum were observed to correlate with GI toxicity.

External beam radiation plus intraluminal brachytherapy in locally advanced, inoperable carcinoma esophagus: A retrospective study from tertiary cancer care center

Background: Worldwide, an estimated 572,034 esophageal cancer cases and 508,585 deaths occurred in 2018 and it accounts for approximately 3.2% of all malignancy. Because esophagus has no serosal covering with extensive, longitudinal connecting system of lymphatic plexus, direct invasion to contiguous structures and lymph node metastasis occurs early. Unresectable or metastatic disease at the time of diagnosis is seen in approximately 80% of patients, with cure rate 87% of patients. Conclusion: In patients with locally advanced carcinoma of esophagus and poor performance status who are unable to tolerate radical concurrent chemoradiation, combination of EBRT plus ILBT produces good local control, DFS, and durable relief of dysphagia with acceptable toxicity.

325. Feasibility of a combination of 90Y/177Lu-Radiopeptide Therapy (Peptide Receptor Radionuclide Therapy – PRRT) and External Beam Radiation Therapy (EBRT) in neuroendocrine tumors (NETs)

Purpose PRRT with 90Y-DOTATOC and 177Lu-DOTATATE showed up to 35% objective responses in NETs and acceptable toxicity. Given NET indolent behavior, multiple treatments are sequentially applied; EBRT is proposed frequently as oligometastatic/palliative setting. Our aim was to assess whether the combination of PRRT and EBRT (PRRT + EBRT) arise concerns about tolerability. Methods Over our 807 patients receiving PRRT (1997–2014), 17% underwent also EBRT (14% after PRRT, 3% before PRRT). Among these, 25 patients had dosimetry and clinical data of PRRT + EBRT. The primary NETs were pancreas (12), lung (7), others (6), with multiple metastases in liver (13), bone (10), others (11). EBRT was adjuvant in 18 sites, palliative in 22. Bone metastases were treated with 3D conformal EBRT. Oligometastaseswere treated with image-guided IMRT or stereotactic EBRT, accounting for absorbed doses (AD) from PRRT. AD to Organs At Risk (OARs) and tumours were assessed and toxicity investigated (CTCAE v4). For PRRT, OARs were kidneys and red-marrow; AD to the liver was also evaluated. OARs for EBRT depended on the tumour site. Results The table reports the median value (range) of administered activities and absorbed doses to OARs for the PRRT as well as doses delivered with EBRT. Individual metabolism leaded to large AD variability in PRRT (tumour: 1–42 Gy/GBq, 90Y-DOTATOC; 1–56 Gy/GBq, 177Lu-DOTATATE).No severe red-marrow toxicity was observed (14 patients grade I-II; 3 none); no kidney toxicity was shown but in 1 patient (grade I). Median (range) follow-up was 3.5 (0.2–12.3) years. 7 patients died. Conclusions PRRT and EBRT have different OARs, with the great potential to increase AD to tumours without increasing toxicity, especially in red-marrow and liver. This opens the way to future prospective studies. However, EBRT irradiating liver metastases may (rarely) deliver non-negligible AD to kidneys once summed to AD from PRRT. PRRT + EBRT imposes multidisciplinary dosimetry discussion.

Contemporary prostate cancer radiation therapy in the United States: Patterns of care and compliance with quality measures

PurposeQuality measures represent the standards of appropriate treatment agreed upon by experts in the field and often supported by data. The extent to which providers in the community adhere to quality measures in radiation therapy (RT) is unknown. Methods and materialsThe Comparative Effectiveness Analysis of Surgery and Radiation study enrolled men with clinically localized prostate cancer in 2011 and 2012. Patients completed surveys and medical records were reviewed. Patients were risk-stratified according to D’Amico classification criteria. Patterns of care and compliance with 8 quality measures as endorsed by national consortia as of 2011 were assessed. ResultsOverall, 926 men underwent definitive RT (69% external beam radiation therapy [EBRT]), 17% brachytherapy (BT), and 14% combined EBRT and BT with considerable variation in radiation techniques across risk groups. Most men who received EBRT had dose-escalated EBRT (>75 Gy; 93%) delivered with conventional fractionation (<2 Gy; 95%), intensity modulated RT (76%), and image guided RT (85%). Most men treated with BT received I125 (77%). Overall, 73% of the men received EBRT that was compliant with the quality measures (dose-escalation, image-guidance, appropriate use of androgen deprivation therapy, and appropriate treatment target) but only 60% of men received BT that was compliant with quality measures (postimplant dosimetry and appropriate dose). African-American men (64%) and other minorities (62%) were less likely than white men (77%) to receive EBRT that was compliant with quality measures. ConclusionsMost men who received RT for localized prostate cancer were treated with an appropriately high dose and received image guidance and intensity modulated RT. However, compliance with some nationally recognized quality measures was relatively low and varied by race. There are significant opportunities to improve the delivery of RT and especially for men of a minority race.

The impact of adjuvant vaginal brachytherapy in women with Stage II uterine endometrioid carcinoma: Results of a National Cancer Database analysis

PurposeTo report survival outcomes in women with Stage II uterine endometrioid carcinoma who received adjuvant radiation therapy (RT) without chemotherapy using the National Cancer Database. Methods and MaterialsThe National Cancer Database was queried for women with International Federation of Gynecology and Obstetrics Stage II uterine endometrioid carcinoma who underwent hysterectomy followed by adjuvant RT without chemotherapy. The χ2 tests were performed to compare differences in outcome by type of adjuvant RT (external beam radiation therapy [EBRT] alone, vaginal brachytherapy [VBT] alone, or combination of EBRT and VBT). Overall survival (OS) was assessed by Kaplan–Meier and log-rank tests. Univariate and multivariate analyses were performed to identify predictors of OS. ResultsWe identified 2681 women. Simple hysterectomy was performed on 2261 women (84%). Adjuvant EBRT, VBT, and combination RT were administered to 27%, 36%, and 37%, respectively. There was a statistically significant difference in OS by modality of adjuvant RT (p = 0.01) favoring women who received VBT alone or in combination with EBRT. The 5-year OS was 80%, 87%, and 83% for women who received EBRT, VBT, and combination RT, respectively (p = 0.001). On multivariate analysis, old age, African-American race, no or fewer number of examined lymph nodes, and higher tumor grade were independent predictors of worse OS. RT modality did not sustain its independent prognostic significance as a predictor of OS. ConclusionsIn this nationwide hospital-based study of women with International Federation of Gynecology and Obstetrics Stage II uterine endometrioid carcinoma, adjuvant VBT alone provided excellent survival outcomes and may be a reasonable adjuvant RT modality for properly selected women with adequate lymph node dissection and low-grade tumors.

Effect on prostate volume following neoadjuvant treatment with an androgen receptor inhibitor monotherapy versus castration plus an androgen receptor inhibitor in prostate cancer patients intended for curative radiation therapy: A randomised study.

To avoid pubic arch interference, prostate cancer patients are treated with neoadjuvant androgen deprivation therapy (ADT) to achieve prostate volume (PV) reduction prior to radiation treatment. The aim of the present randomised study was to compare the effects on PV of two regimens of ADT, an androgen receptor inhibitor monotherapy vs. castration plus an androgen receptor inhibitor. Consecutive patients with non-metastatic prostate cancer were included in a randomised neoadjuvant study, comparing an androgen receptor inhibitor monotherapy vs. castration plus an androgen receptor inhibitor. PV was assessed prior to the start of endocrine neoadjuvant treatment and prior to the start of radiation therapy (RT). PV assessment was performed by transrectal ultrasound. A total of 110 patients were included. Final sample constituted 88 (80%) patients due to lack of PV information. Castration plus an androgen receptor inhibitor was more effective in PV reduction compared with an androgen receptor inhibitor alone (P<0.001). Planning target volume decreased in the combination arm. There was no significant difference in clinical or demographic or length of neoadjuvant hormonal treatment between the groups. Overall, a significantly larger PV reduction was achieved by castration plus androgen receptor inhibitor, as compared with androgen receptor inhibitor monotherapy. The PV reduction, however, appeared not to translate into better health associated quality of life during the subsequently given curative intended combined EBRT and HDR-brachytherapy. Potential differences between these two treatments regarding anti-tumor effects on micro metastatic disease and radiation potentiating effect remains to be addressed in future prospective trials.

Multicentre evaluation of a novel vaginal dose reporting method in 153 cervical cancer patients

Background and purposeRecently, a vaginal dose reporting method for combined EBRT and BT in cervical cancer patients was proposed. The current study was to evaluate vaginal doses with this method in a multicentre setting, wherein different applicators, dose rates and protocols were used. Material and methodsIn a subset of patients from the EMBRACE study, vaginal doses were evaluated. Doses at the applicator surface left/right and anterior/posterior and at 5mm depth were measured. In addition, the dose at the Posterior–Inferior Border of Symphysis (PIBS) vaginal dose point and PIBS±2cm, corresponding to the mid and lower vagina, was measured. Results153 patients from seven institutions were included. Large dose variations expressed in EQD2 with α/β=3Gy were seen between patients, in particular at the top left and right vaginal wall (median 195 (range 61–947)Gy/178 (61–980)Gy, respectively). At 5mm depth, doses were 98 (55–212)Gy/91 (54–227)Gy left/right, and 71 (51–145)Gy/67 (49–189)Gy anterior/posterior, respectively. The dose at PIBS and PIBS±2cm was 41 (3–81)Gy, 54 (32–109)Gy and 5 (1–51)Gy, respectively. At PIBS+2cm (mid vagina) dose variation was coming from BT. The variation at PIBS−2cm (lower vagina) was mainly dependent on EBRT field border location. ConclusionsThis novel method for reporting vaginal doses coming from EBRT and BT through well-defined dose points gives a robust representation of the dose along the vaginal axis. In addition, it allows comparison of vaginal dose between patients from different centres. The doses at the PIBS points represent the doses at the mid and lower parts of the vagina. Large variations in dose throughout the vagina were observed between patients and centres.

Dosimetric predictors of sexual function decline following LDR brachytherapy for prostate cancer (PCa).

113 Background: Conventional dosimetric standards for implant quality do not adequately predict patient reported QoL measures following prostate brachytherapy. We used a dynamic learning knowledgebase (Oncospace) to explore relationships between dose and patient-reported outcomes. Methods: Patient reported quality of life outcomes were prospectively collected for 366 patients with stage cT1-T2 PCa over a 10 year interval. Patients received Pd-103 seed implantation under real-time ultrasound guidance, and completed a QoL instrument (IIEF-5) prior to treatment and at follow-up. Multivariate risk models were used to evaluate dose/toxicity relationships and the Oncospace learning environment generated prediction models using granular dose volume relationships. Results: Median follow-up was 36 months (SD 28.5). In the cohort, 23.7% (n = 87) received combined brachytherapy and EBRT; 14.7% (n = 54) had received prior androgen suppression therapy. Sexual QoL data at minimum of 2 years was available in 141 men. The mean decrement in sexual function per the IIEF-5 instrument was 3.76 points (SD 10.3), with 17.0% of men reporting a decrement of 10 points or greater. There was no significant association with prior androgen suppression (p = 0.20) or combined EBRT use (p = 0.69). DVH curves were queried and dichotomized according to stable sexual function vs significant decline ( &gt; 10) at 2 years post-implant. A logistic regression model was used to generate probability surface maps of volumetric dose effects on outcomes. Logistic regression revealed a correlation between dose to the cavernosal nerves and total SHIM score throughout the high dose region of the DVH curve (p &lt; 0.05). No similar dose/volume correlation with sexual function emerged for structures. Conclusions: Granular dose/volume and toxicity correlation using the Oncospace learning environment exposed a statistically significant relationship between volumetric dose to the cavernosal nerves and sexual function decline in patients undergoing LDR brachytheramarpy. Minimization of dose to the cavernosal nerves may preserve sexual function after permanent prostate seed brachytherapy.

The role of high-dose-rate brachytherapy (HDR-BT) in the radiotherapy of esophageal carcinoma

Objective:To study the role of high-dose-rate brachytherapy (HDR-BT) in the radiotherapy of esophageal cancer.Methods:We reviewed 89 patients with esophageal carcinoma treated with radiation therapy between March 1999 and December 2005 in our hospital.There were 62 patients in the external beam radiotherapy group (EBRT group) and 27 patients in the combination of HDR-BT and EBRT group (combined group).Forty-two patients received sequential or concurrent chemotherapy.Patients in EBRT group were firstly treated with parallel-opposed antero-posterior field at a total dose of 40Gy,and then off-cord oblique fields were used at a final median total dose of 65Gy (ranged from 40 to 70Gy). HDR-BT was commonly performed weekly for 2-3 times at a dose fraction of 4-7Gy.Some patients received sequential or concurrent chemotherapy with cisplatin and fluorouracil.The endpoints were complete release (CR),improvement of obstruction, local-recurrence free survival (LRFS) and overall survival (OS).Chi-square test was used for comparison of the difference in CR rate and the improvement in patients' food intaking.Kaplan-Meier method was exployed to analyze patient survival and Log-rank test was used to compare the difference in OS and LRFS.Results:The median follow-up period was 34 months.Sixty-three patients died during the follow up.The CR rates of EBRT group and combined group were 10% and 29%,respectively (P=0.049).The improvement rate in food intaking in the two groups were 67.7% and 74.1%,respectively (P=0.795).The 5-year LRFS was 24% in EBRT group and 36% in combined group (P=0.332).The 5-year OS was 18% in EBRT group and 21% in combined group (P=0.401).The 5-year OS was 42% in patients with tumor smaller than 5cm and 36% in patients with tumor larger than 5cm (P=0.045).The 5-year OS was 16% in patients treated with brachytherapy and 14% in patients who didn't receive brachytherapy (P=0.685).Conclusion:The combination of HDR-BT and EBRT can improve the response rate and the long term survival of patients with small esohpageal carcinoma.