Conventional External Beam Radiation Research Articles

Down-staging of hepatocellular carcinoma via external-beam radiotherapy with subsequent liver transplantation: A case report

Despite the widespread use of locoregional therapies [radiofrequency ablation and transarterial chemoembolization (TACE)], there is currently a lack of high-quality evidence supporting their use for hepatocellular carcinoma (HCC) in patients on the liver transplantation (LT) waiting list or requiring down-staging. Radiotherapy has rarely been used in this setting and has usually been in the form of more complex and less accessible techniques such as proton-beam and stereotactic body radiation therapy. Only 1 report describes the use of conventional 3-dimensional conformal external-beam radiotherapy (cEBRT) techniques as neoadjuvant or down-staging therapy for patients who are LT candidates. This report describes the use of cEBRT in a 52-year-old hepatitis C-positive man with cirrhosis. A 40-mm right lobe HCC was treated initially with TACE while he was on the waiting list. The lesion progressed beyond transplant criteria (76 mm). Conventional external-beam radiotherapy (EBRT) was used (54 Gy in 27 fractions) to down-stage the lesion. EBRT was well tolerated and resulted in a complete radiological response with no arterial enhancement of the lesion for a total of 16 months. Subsequent LT and a review of the explant demonstrated complete histological necrosis of the lesion. This report provides the first description of complete histological necrosis of HCC through the use of cEBRT techniques as down-staging/neoadjuvant therapy before LT. Because of its potential efficacy, accessibility, tolerability, noninvasive and outpatient nature, and ability to treat lesions adjacent to vessels and biliary structures, further trials examining the efficacy of cEBRT versus other neoadjuvant techniques are urgently required.

Initial Findings With the Use of a Novel Performance Metric to Identify Institutional Rates of Radiation Discontinuation

Initial Findings With the Use of a Novel Performance Metric to Identify Institutional Rates of Radiation Discontinuation

Cosmetic outcome after intraoperative radiotherapy or external beam radiotherapy for early breast cancer: An objective assessment of patients from a randomized controlled trial.

59 Background: The international randomised contolled TARGeted Intraoperative radioTherapy (TARGIT) trial has demonstrated non-inferiority between the novel technique of TARGIT (intra-operative radiotherapy with Intrabeam) and conventional whole-breast external beam radiotherapy (EBRT) in women with early breast cancer, in terms of the primary outcome measure of risk of local relapse within the treated breast. With very low recurrence rates, cosmesis becomes an increasingly important outcome of breast conserving treatment with both surgery and radiotherapy. This study was performed to determine if the single high dose of TARGIT leads to impaired cosmesis. Methods: A validated, objective assessment tool for evaluation of cosmetic outcome was used. Frontal digital photographs were taken at baseline (before TARGIT or EBRT) and yearly thereafter for up to five years. The photographs were analysed by BCCT.core software which produces a composite score based on symmetry, colour and scar. Results: 342 patients were assessed, all over 50 years old with a median age at baseline of 64 years (IQR 59 to 68). The scores were dichotomised into Excellent and Good (EG), and Fair and Poor (FP). There were statistically significant increases in the odds of having an outcome of EG for patients in the TARGIT group relative to the EBRT group at year 1 (OR = 2.07, 95% CI 1.12 to 3.85, p = 0.021) and year 2 (OR = 2.11, 95% CI 1.0 to 4.45, p = 0.05). Conclusions: Following an objective assessment of aesthetic outcome in patients from a randomised setting, this study demonstrates that those treated with targeted intraoperative radiotherapy have a superior cosmetic result compared with those patients who received conventional whole-breast external beam radiotherapy.

Study of the radiotherapy modality for patients with stage IIb-IIIb cervical stump cancer

To investigate the radiotherapy modality progress of stageIIb-IIIb cervical stump cancer. The clinical data of 13 patients with stageIIb-IIIb cervical stump cancer undergoing radiotherapy from January 2000 to April 2012 was reviewed. Before 2006, 8 patients received conventional external beam radiotherapy and brachytherapy.Since 2006, 5 patients received intensity-modulated radiotherapy (IMRT) and brachytherapy. The median survival was 12-139 months. The median overall survivals and disease free survivals in the conventional radiotherapy (CRT) group were 57 months and 50 months, 3 cases of them recurred during 8-19 months and died of tumor progression.While, the median overall survivals and disease free survival in the IMRT group both were 21 months and nobody recurred. In the CRT group, 7 patients suffered toxicities, including 5 patients grade I-II acute rectum reaction, 2 patients grade I bladder reaction; and 3 had grade I-III, late rectum reaction, 2 patients for grade II bladder late reaction.In the IMRT group, toxicities including 1 case grade I acute or late rectum reaction, and no bladder reaction. In our experience, the recommended IMRT and interstitial brachytherapy for the selected patients with advanced cervical stump carcinoma may be obtain better tumor dose distribution and more sparing of the organ at risk.

Glomus jugulare tumours: A 15 year radiotherapy experience in South Australia

Glomus jugulare tumours (GJT) are one of a family of benign hypervascular neoplasms that arise from chief cells of the paraganglionic tissue from the dome of the jugular bulb. Historically, these tumours have primarily been managed surgically but radiation is an alternative treatment modality. The purpose of this retrospective review was to determine the patient survival, tumour control, clinical control rates and long term toxicity of GJT treated with radiation in South Australia. Between 1996 and 30 June 2012, 15 patients with GJT (16 tumours) were managed with radiotherapy. Twelve patients were female and the median age was 62years. Thirteen patients (87%) were treated with conventional external beam radiotherapy and two patients (13%) with stereotactic radiosurgery. The mean duration of follow-up was 4years (range 1month–15years 4months). The close-out date for survival analyses was 31 October 2012. Crude overall survival, tumour control, clinical control and long term grade >2 toxicity rates were 100%, 94% (15/16), 94% and 7% (1/16), respectively. The Kaplan-Meier 5 and 10year clinical and tumour control rates were both 93% (95% confidence interval: 61–99%). Radiation is an effective treatment modality for GJT. With comparable patient survival, arguably improved tumour and clinical control rates relative to surgery, minimal toxicity and ongoing advances in radiotherapy technologies, radiation should be strongly considered for the primary management of GJT.

Objective assessment of cosmetic outcome after targeted intraoperative radiotherapy in breast cancer: results from a randomised controlled trial

The international randomised targeted intraoperative radiotherapy (TARGIT) trial has demonstrated evidence of non-inferiority between the novel technique of TARGIT (intra-operative radiotherapy with Intrabeam(®)) and conventional external beam radiotherapy (EBRT) in women with early breast cancer in terms of the primary outcome measure of risk of local relapse within the treated breast. Cosmesis is an increasingly important outcome of breast conserving treatment with both surgery and radiotherapy contributing to this. It was unknown if the single high dose of TARGIT may lead to damaging fibrosis and thus impair cosmesis further, so we objectively evaluated the aesthetic outcome of patients within the TARGIT randomised controlled trial. We have used an objective assessment tool for evaluation of cosmetic outcome. Frontal digital photographs were taken at baseline (before TARGIT or EBRT) and yearly thereafter for up to 5years. The photographs were analysed by BCCT.core, a validated software which produces a composite score based on symmetry, colour and scar. 342 patients were assessed, median age at baseline 64years (IQR 59-68). The scores were dichotomised into Excellent and Good (EG), and Fair and Poor (FP). There were statistically significant increases in the odds of having an outcome of EG for patients in the TARGIT group relative to the EBRT group at year 1 (OR 2.07, 95% CI 1.12-3.85, p=0.021) and year 2 (OR 2.11, 95% CI 1.0-4.45, p=0.05). Following a totally objective assessment in a randomised setting, the aesthetic outcome of patients demonstrates that those treated with TARGIT have a superior cosmetic result to those patients who received conventional external beam radiotherapy.

Radioterapia nos tumores da hipófise – atualizações e controvérsias

IntroductionRadiotherapy is an effective treatment for residual or recurrent pituitary tumors with tumor volume control and decrease or normalization of excess hormone secretion in the clinically functioning adenomas. The risks of long-term toxicity, being the hypopituitarism the most frequent, make radiation therapy a rarely used second-line treatment. ObjectivesTo describe efficacy, safety and role of conventional external beam radiotherapy, as well as radiosurgery in the treatment of pituitary tumors. Material and MethodsSearch of original or review papers published until January 2012 with the following keywords“pituitary radiotherapy”, “radiotherapy for pituitary adenomas”, “stereotactic radiotherapy”, “pituitary radiosurgery”, “radiation therapy”, “radiotherapy for Cushing's Disease”, “radiotherapy for acromegaly”, “radiotherapy for non-functioning pituitary adenomas”, “radiotherapy for prolactin-secreting pituitary tumors”. ConclusionsRadiotherapy still has a complementary role to surgical resection, although it could be appropriate as a first-line treatment in selected cases. The new modalities of radiation treatment show promising results in the reduction of toxicity as well as in the latency of hormonal response; however more studies are necessary to prove long-term efficacy and safety.

TU‐G‐108‐02: Left Atrium Dose‐Volume Parameters Predict for Clinically Significant Radiation Pneumonitis

Purpose: To detect and quantify the association between cardiac substructure irradiation and the risk of developing radiation pneumonitis (RP) within a multivariate framework for patients treated with conventional external beam radiotherapy for non‐small‐cell lung cancer (NSCLC). Methods: All evaluable 3‐D conformal radiation therapy (3D‐CRT) treatment plans for patients with registered outcomes treated for NSCLC between 1991 and 2001 were eligible for this study (N=209). RP events occurred in 49 (23.4%) patients, with events defined as requiring steroid management or more intensive intervention (CTCAE v.4.0 Grade 2 or greater). Cardiac substructures including the left ventricle, right ventricle, left atrium, right atrium, ascending aorta, and descending aorta were contoured and individually reviewed by a single physician. Cross‐validation methods were used to build a multivariate model included clinical factors (age, gender, race, performance status, weight loss, smoking history, and histology); dosimetric parameters for cardiac substructures and normal lung [D5–D100, V10–V80, mean dose, maximum dose, and minimum dose ]; other treatment factors (chemotherapy, treatment time, fraction size); and the center of mass of the GTV within the lung, in the superior‐inferior dimension (GTV_COMSI). An optimal multivariate model was obtained by step‐wise variable selection and logistic regression. Results: Statistically significant variables (p less than 0.05) with the highest univariate Spearman rank correlations (Rs) included: Left atrium D5 (Rs,0.235), left atrium D10 (Rs,0.228), right ventricle Dmax (Rs,0.2), right atrium Dmax (Rs,0.197), and GTV_COMSI (Rs,0.22). The optimal logistic model used four variables, incorporating the left atrium D20 and V30, the lung D35, and the GTV_COMSI; (Rs=0.31) with an area under the receiver‐operator curve of 0.75. The best model using only whole‐heart variables had an Rs=0.26. Conclusion: Left atrium dose‐volume parameters had greater predictive power than other heart substructures and previously derived lung parameters to predict RP, and were incorporated into a robust prognostic multiparametric model.

The NOMS Framework: Approach to the Treatment of Spinal Metastatic Tumors

Spinal metastases frequently arise in patients with cancer. Modern oncology provides numerous treatment options that include effective systemic, radiation, and surgical options. We delineate and provide the evidence for the neurologic, oncologic, mechanical, and systemic (NOMS) decision framework, which is used at Memorial Sloan-Kettering Cancer Center to determine the optimal therapy for patients with spine metastases. We provide a literature review of the integral publications that serve as the basis for the NOMS framework and report the results of systematic implementation of the NOMS-guided treatment. The NOMS decision framework consists of the neurologic, oncologic, mechanical, and systemic considerations and incorporates the use of conventional external beam radiation, spinal stereotactic radiosurgery, and minimally invasive and open surgical interventions. Review of radiation oncology and surgical literature that examine the outcomes of treatment of spinal metastatic tumors provides support for the NOMS decision framework. Application of the NOMS paradigm integrates multimodality therapy to optimize local tumor control, pain relief, and restoration or preservation of neurologic function and minimizes morbidity in this often systemically ill patient population. NOMS paradigm provides a decision framework that incorporates sentinel decision points in the treatment of spinal metastases. Consideration of the tumor sensitivity to radiation in conjunction with the extent of epidural extension allows determination of the optimal radiation treatment and the need for surgical decompression. Mechanical stability of the spine and the systemic disease considerations further help determine the need and the feasibility of surgical intervention.

Comparing intensity modulated radiotherapy and conventional external beam radiotherapy in cervical cancer.

5610 Background: To compare Intensity-modulated radiation therapy (IMRT) with conventional external beam radiation therapy (CXRT) regarding morbidity, tumor response, and quality of life (QOL) in cervical cancer patients. Methods: Between 8/2009-2/2010, 50 patients (pts) with age range 20-85, with FIGO Stage IIA- IIIB were prospectively randomized 2:1 to CXRT and IMRT at Indo-American Cancer Institute. Both groups received concurrent chemotherapy (weekly cisplatin 30-40mg/m2) with external beam radiation (EBRT), 50Gy/25fractions followed by intracavitary brachytherapy at 21Gy/3fractions. Complications and QOL were evaluated during treatment and in follow-up with CTC 4.0 and EORTC QLQ-C30, and disease recurrence was based on pelvic exam. Analysis used Chi square(X2) at a significance level of 0.05. Results: Average time to completion was 49 and 48 days in CXRT and IMRT arms (p>.05). Four pts did not complete the treatment in the CXRT. Two months after completion 31/35 (89%) of CXRT and 15/15 (100%) of IMRT had complete response (p>.05). At 5 months, 30/35 (86%) of CXRT, and 14/15 (100%) of IMRT had no loco-regional disease (LRD); 1 IMRT pt died from distant metastasis (DM). At 18 months, 25/35 (72%) in CXRT and 14/15 (93.5%) in IMRT had no LRD or DM. Most common acute side effects in the CXRT were Grade 1 vomiting/cystitis/diarrhea and Grade 2 nausea/skin reactions/proctitis. One pt developed vesicovaginal fistula (VVF) after 50Gy by EBRT. Most common acute side effects in the IMRT were Grade1 nausea/vomiting/cystitis/proctitis/diarrhea. Two pts had grade 3 neutropenia in the 5th week of RT. QOL was better in IMRT (p <.01) based on functional, symptom, single items, and global scales except for pain, insomnia, loss of appetite. Diarrhea, financial problems were worse in the CXRT (p<.05). Chronic complications such as radiation induced proctitis in 5 patients, and sub-acute intestinal obstruction in 2 patients during follow-up period in CXRT vs. IMRT (p < 0.001). Conclusions: IMRT is superior to CXRT with fewer chronic side effects and similar acute side effects and treatment responses. This is the first randomized clinical trial of these treatments in cervical cancer.

Cosmetic outcome after intraoperative radiotherapy or external beam radiotherapy for early breast cancer: An objective assessment of patients from a randomized controlled trial.

1110 Background: The international randomised contolled TARGeted Intraoperative radioTherapy (TARGIT) trial has demonstrated non-inferiority between the novel technique of TARGIT (intra-operative radiotherapy with Intrabeam) and conventional whole-breast external beam radiotherapy (EBRT) in women with early breast cancer, in terms of the primary outcome measure of risk of local relapse within the treated breast. With very low recurrence rates, cosmesis becomes an increasingly important outcome of breast conserving treatment with both surgery and radiotherapy. This study was performed to determine if the single high dose of TARGIT leads to impaired cosmesis. Methods: A validated, objective assessment tool for evaluation of cosmetic outcome was used. Frontal digital photographs were taken at baseline (before TARGIT or EBRT) and yearly thereafter for up to five years. The photographs were analysed by BCCT.core software which produces a composite score based on symmetry, colour and scar. Results: 342 patients were assessed, all over 50 years old with a median age at baseline of 64 years (IQR 59 to 68). The scores were dichotomised into Excellent and Good (EG), and Fair and Poor (FP). There were statistically significant increases in the odds of having an outcome of EG for patients in the TARGIT group relative to the EBRT group at year 1 (OR = 2.07, 95%CI 1.12 to 3.85, p = 0.021) and year 2 (OR = 2.11, 95%CI 1.0 to 4.45, p = 0.05). Conclusions: Following an objective assessment of aesthetic outcome in patients from a randomised setting, this study demonstrates that those treated with targeted intraoperative radiotherapy have a superior cosmetic result compared with those patients who received conventional whole-breast external beam radiotherapy.

A comparative study of the response and toxicities in locally advanced head and neck cancer patients treated with paclitaxel, cisplatinum, 5-FU versus docetaxel, cisplatinum, 5-FU as neoadjuvant chemotherapy followed by concurrent chemoradiation.

6089 Background: To evaluate the response and toxicity of docetaxel, cisplatinum, 5-FU vs paclitaxel, cisplatinum, 5-FU as neoadjuvant chemotherapy (NACT) followed by concurrent chemoradiation (CTRT) with weekly cisplatinum in locally advanced head and neck cancer. Methods: 40 locally advanced head and neck cancer patients who satisfied the eligibility criteria were randomized.21 patients received three cycles of NACT i.e paclitaxel (175 mg/m2) on d1, cisplatinum (30 mg/m2) and 5-FU (600 mg/m2) d2-d4 (TCF) and 19 patients received three cycles of NACT docetaxel (75 mg/m2) on d1, cisplatinum (30 mg/m2) and 5-FU (600 mg/m2) d2-d4 at three week intervals, followed by concurrent weekly cisplatinum 30 mg/m2 along with conventional external beam radiation of total tumor dose dose 66 Gy. Response was assessed after NACT and again after six weeks, three months and six months of completion of chemoradiation. Toxicities were assessed after each cycles of NACT and also weekly during CTRT and thereafter. Results: Two weeks after completion of NACT complete response (CR) in TCF was 4.76%, partial response (PR) 80.9% and no response 9.5%. However in DCF, CR was 15.78 % PR was 73.68%. 10.52% patientd died due to toxicity. With a median follow up of seven months, in TCF CR was 57.14%, PR 33.33% and no response was 4.76%, whereas in DCF CR was 78.94%, PR 10.52% and death 10.5%. On evaluation of toxicities during NACT, patients in DCF had more significant neutropenia and in TCF more incidence of neuropathy. During CTRT, in TCF grade II and III mucositis was 54%, grade II neutropenia 5.6%, and grade II anemia 5.3%. In DCF mucositis grade II and III was 49.0%, neutropenia grade II 18.7% and anemia grade II was 7.4%. Late toxicities included were comparable in both arms. Conclusions: With a median follow up of 7 months, the CR in DCF was 78.94%, superior than TCF i.e 57.14%. Neutropenia was significant in DCF and neuropathy was high in TCF. In CTRT mucositis was the commonest toxicity observed in both TCF and DCF which was not statistically significant.

Spontaneous cerebrospinal fluid rhinorrhea secondary to anterior fossa osteoradionecrosis

Osteoradionecrosis (ORN) after radiation therapy of head and neck or brain tumor most often presents in the mandible, followed by the maxillary bone. This case report describes a patient who presented with spontaneous cerebrospinal fluid (CSF) rhinorrhea 12 months after conventional external beam radiotherapy for frontotemporal anaplastic astrocytoma, and was diagnosed with anterior fossa ORN. Osteolysis in the anterior fossa on CT scan confirmed the diagnosis. A prompt temporal muscle graft with pericranial flap seal treated both the ORN and the CSF rhinorrhea, but observation would have been a suitable conservative option if ORN presented without CSF rhinorrhea.

Editorial: Separation surgery

The management of patients with spine metastases from a functional and health-related quality of life (HRQOL) perspective is one of the most challenging issues faced by both oncologists and spine surgeons. Higher levels of evidence have been achieved over the past decade in defining the positive impact of surgery and/or conventional external beam radiation therapy (cEBRT) in these patients.1,3 More recently, stereotactic radiosurgery (SRS) has provided a successful treatment option for traditionally radioresistant tumors, but has been limited in a setting where extensive epidural disease restricts radiation dose due to the threat of cord toxicity.2 In this patient group, maximally invasive surgery to achieve gross-total resection of the tumor was often necessary to prevent local recurrence and optimize HRQOL. This surgery is resource intensive, with a not-insignificant adverse event rate, so it is not ideal in those patients who are systemically compromised and have limited life expectancy. To address this problem, Laufer et al.4 report on a treatment method of surgically removing the epidural disease (separation surgery) and then administering high-dose SRS to the remaining tumor, thus providing a means of potentially achieving local control while minimizing surgical insult and cord toxicity. The study has a strong rationale and clear purpose: to determine local recurrence rate after separation surgery and SRS. The study design is a retrospective case series involving a relatively large consecutive patient cohort treated at a specialized cancer center between 2002 and 2011. The study design is reasonable for the research question, given the complexity of the patient population and the evolution of the treatment method, but not optimal with the number of potential confounders, treatment variability, and difficulty in accurately determining the primary or dependent outcome. Unfortunately, the validity or accuracy of local recurrence determination is difficult due to changes in technology over time, reviewer variability (imaging reports were used as well as neuroradiology and neurosurgeon review), lack of technique standardization (CT myelogram and MRI), effect of spinal implant imaging artifact, lack of standardized time periods, and quantitative evaluation. With these limitations, the magnitude of the group without local recurrence (82% of the patients) is questionable; however, such an impressive effect change cannot be ignored, and the positive effect is probably a true finding. The authors use a very appropriate and robust statistical analysis to try and overcome the treatment variability and aforementioned limitations. The variability leaves the study underpowered on a number of secondary outcomes, but trends can be observed. The study does not include a patient-focused HRQOL instrument to ensure that impressive imaging outcomes are correlated with those of the patient. This omission is not critical, given the research question being asked, and using local recurrence rate as the primary outcome is a reasonable surrogate for HROQL outcome in prospective tumor research. Finally, the generalizability of the study’s findings must be considered. The breadth and variability of the cohort supports external validity, but the specialization and technology of the center and subspecialization of the surgeons and oncologists may limit it. The management of patients with symptomatic spinal metastases is difficult. Carrying out high-quality clinical research involving patients whose quality of life you are trying to optimize for their remaining time is even more demanding. The authors should be congratulated for giving us evidence for a treatment method that potentially fills a therapeutic void in this truly deserving patient population. Can we implement the findings from this study into our clinical practice despite its being at the lower level of study design hierarchy? Though the study is statistically sound and optimal within the restraints of a retrospective design, its limitations diminish its impact. The effect size, external validity within the context of large cancer centers, and the unique patient population probably support cautious implementation of this treatment method. As the technique evolves and is used by more centers, prospective evaluation will be essential. (http://thejns.org/doi/abs/10.3171/2012.10.SPINE12743)

Local disease control for spinal metastases following “separation surgery” and adjuvant hypofractionated or high-dose single-fraction stereotactic radiosurgery: outcome analysis in 186 patients

Decompression surgery followed by adjuvant radiotherapy is an effective therapy for preservation or recovery of neurological function and achieving durable local disease control in patients suffering from metastatic epidural spinal cord compression (ESCC). The authors examine the outcomes of postoperative image-guided intensity-modulated radiation therapy delivered as single-fraction or hypofractionated stereotactic radiosurgery (SRS) for achieving long-term local tumor control. A retrospective chart review identified 186 patients with ESCC from spinal metastases who were treated with surgical decompression, instrumentation, and postoperative radiation delivered as either single-fraction SRS (24 Gy) in 40 patients (21.5%), high-dose hypofractionated SRS (24-30 Gy in 3 fractions) in 37 patients (19.9%), or low-dose hypofractionated SRS (18-36 Gy in 5 or 6 fractions) in 109 patients (58.6%). The relationships between postoperative adjuvant SRS dosing and fractionation, patient characteristics, tumor histology-specific radiosensitivity, grade of ESCC, extent of surgical decompression, response to preoperative radiotherapy, and local tumor control were evaluated by competing risks analysis. The total cumulative incidence of local progression was 16.4% 1 year after SRS. Multivariate Gray competing risks analysis revealed a significant improvement in local control with high-dose hypofractionated SRS (4.1% cumulative incidence of local progression at 1 year, HR 0.12, p = 0.04) as compared with low-dose hypofractionated SRS (22.6% local progression at 1 year, HR 1). Although univariate analysis demonstrated a trend toward greater risk of local progression for patients in whom preoperative conventional external beam radiation therapy failed (22.2% local progression at 1 year, HR 1.96, p = 0.07) compared with patients who did not receive any preoperative radiotherapy (11.2% local progression at 1 year, HR 1), this association was not confirmed with multivariate analysis. No other variable significantly correlated with progression-free survival, including radiation sensitivity of tumor histology, grade of ESCC, extent of surgical decompression, or patient sex. Postoperative adjuvant SRS following epidural spinal cord decompression and instrumentation is a safe and effective strategy for establishing durable local tumor control regardless of tumor histology-specific radiosensitivity. Patients who received high-dose hypofractionated SRS demonstrated 1-year local progression rates of less than 5% (95% CI 0%-12.2%), which were superior to the results of low-dose hypofractionated SRS. The local progression rate after single-fraction SRS was less than 10% (95% CI 0%-19.0%).

Five year retrospective survival analysis of triple negative breast cancer in North-West India

In our institute, about 10% of total cancer is female breast cancer. This analysis was performed to check triple negativity among these patients with their survival strength up to 5 years in relation to different age groups, stage and chemotherapy protocols. 208 immunohistochemistry proved triple negative breast cancer patients registered and treated until 2008 were retrospectively selected for the study. Overall survival up to 5 years was observed on the basis of stage, different age groups and chemotherapy regimens. All patients had undergone surgery, conventional external beam radiation therapy and adjuvant chemotherapy. The survival analyses were performed using the Kaplan-Meier method. The majority of patients (41%) were in the age group 21-30 years. Stage IV was seen in 18% of the patients at diagnosis and mainly in 21-40 years age group. Only 3% of females were >70 years age and were of Stage I and II. Overall 5 year survival in Stage I in Cyclophosphamide, Adriamycin/Epirubicin, 5-Flurouracil group was 37.5% as compared with Docetaxel/Paclitaxel, Epirubicin group 93% (P < 0.0001). Triple negativity in North-West India is about 11.8%. We observed it in younger patients mainly with highly aggressive behaviors. Taxane based chemotherapy gives better result as compared with anthracycline based regimens in all stages.

Single fraction conventional external beam radiation therapy for bone metastases: A systematic review of randomised controlled trials

PurposeTo determine the optimal dose of single fraction conventional palliative radiation therapy for the relief of pain caused by bone metastases. Material and methodsOvid version of EMBASE and EMBASE Classic, MEDLINE, the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials were searched for relevant randomised controlled trials. Pain response data were standardised according to the clinical trial endpoints recommended by the International Bone Metastases Consensus Working Party. ResultsFrom 2696 references we selected 26 articles for review. These described 24 trials that cumulatively randomised 3233 patients to 28 single fraction arms: two arms received 4Gy, one 5Gy, one 6Gy, twenty-two 8Gy, one 10Gy and one 8–15Gy. Eighty-four percent of all patients received 8Gy and this imbalance precluded formal modelling analyses for different doses. Efficacy endpoints and pain assessment times varied. In general, higher doses produced better pain response rates. The overall (OR) and complete (CR) pain response rates for different doses according to available intention-to-treat (ITT) and assessable patient (A) figures were: 4Gy [OR(ITT)=23–47%, OR(A)=44–47%, CR(ITT)=15–18%, CR(A)=15–26%], 5Gy [OR(A)=72%, CR(A)=55%], 6Gy [OR(ITT&A)=65%, CR(ITT&A)=21%], 8Gy [OR(ITT)=21–81%, OR(A)=31–93%, CR(ITT)=9–52%, CR(A)=14–57%], 10Gy [OR(A)=84%, CR(A)=39%]. In trials that directly compared different single fraction doses, 8Gy was statistically superior to 4Gy. Conclusions8Gy was by far the most commonly administered single fraction dose within 24 randomised trials of conventional radiation therapy for the palliation of bone metastases. 8Gy should be the standard dose against which future treatments are compared due to its reproducible pain response rate and its established safe profile. The optimal dose for the relief of pain remains an open question, however, 8Gy produced statistically superior pain response rates compared to 4Gy in trials directly comparing those doses, and in general across all trials doses of 8Gy or more produced numerically superior pain response rates compared to doses less than 8Gy.

Radiation Treatment for WHO Grade II and III Meningiomas

The treatment of meningiomas is tailored to their histological grade. While World Health Organization (WHO) grade I lesions can be treated with either surgery or external beam radiation, WHO Grade II and III lesions often require a combination of the two modalities. For these high-grade lesions, conventional external beam radiation is delivered to either the residual tumor or the surgical resection margin. The optimal timing of radiation, either immediately following surgical resection or at the time of recurrence, is yet to be determined. Additionally, another method of radiation delivery, brachytherapy, can be administered locally at the time of surgery for recurrent lesions. Altogether, the complex nature of WHO grade II and III meningiomas requires careful treatment planning and delivery by a multidisciplinary team.

Hypofractionated external-beam radiation therapy (HEBRT) versus conventional external-beam radiation (CEBRT) in patients with localized prostate cancer: a systematic review and meta-analysis

BackgroundThe purpose of this work was to conduct a systematic review and meta-analysis of all randomized controlled trials comparing the efficacy and side effect profile of hypofractionated versus conventional external-beam radiation therapy for prostate cancer.MethodsSeveral databases were searched, including Medline, EmBase, LiLACS, and Central. The endpoints were freedom from biochemical failure and side effects. We performed a meta-analysis of the published data. The results are expressed as the hazard ratio (HR) or risk ratio (RR), with the corresponding 95% confidence interval (CI).ResultsThe final analysis included nine trials comprising 2702 patients. Freedom from biochemical failure was reported in only three studies and was similar in patients who received hypofractionated or conventional radiotherapy (fixed effect, HR 1.03, 95% CI 0.88–1.20; P = 0.75), with heterogeneity [χ2 = 15.32, df = 2 (P = 0.0005); I2 = 87%]. The incidence of acute adverse gastrointestinal events was higher in the hypofractionated group (fixed effect, RR 2.02, 95% CI 1.45–2.81; P < 0.0001). We also found moderate heterogeneity on this analysis [χ2 = 7.47, df = 5 (P = 0.19); I2 = 33%]. Acute genitourinary toxicity was similar among the groups (fixed effect, RR 1.19, 95% CI 0.95–1.49; P = 0.13), with moderate heterogeneity [χ2 = 5.83, df = 4 (P = 0.21); I2 = 31%]. The incidence of all late adverse events was the same in both groups (fixed effect, gastrointestinal toxicity, RR 1.17, 95% CI 0.79–1.72, P = 0.44; and acute genitourinary toxicity, RR 1.16, 95% CI 0.80–1.68, P = 0.44).ConclusionHypofractionated radiotherapy in localized prostate cancer was not superior to conventional radiotherapy and showed higher acute gastrointestinal toxicity in this meta-analysis. Because the number of published studies is still small, future assessments should be conducted to clarify better the true role of hypofractionated radiotherapy in patients with prostate cancer.

Intra‐arterial cisplatin with concomitant radiation for advanced hypopharyngeal cancer

The current study evaluated the efficacy of radiation and concomitant high-dose superselective intra-arterial cisplatin infusion (RADPLAT) for patients with advanced hypopharyngeal cancer. Retrospective, single-institutional study. Between February 2004 and October 2010, 43 patients with T2N0 or worse cancer were given superselective intra-arterial infusions of cisplatin (100-mg/m(2) or 75-mg flat dose per week) with simultaneous intravenous infusions of thiosulfate to neutralize cisplatin toxicity and conventional external beam radiotherapy (60-66 Gy). In total, three, seven, 21, and 12 patients were diagnosed with stage II, III, IVA, and IVB cancer, respectively. During the median follow-up period of 34 months, the 3-year overall survival, disease-specific survival, and progression-free survival rates for all patients were 52.2%, 68.2%, and 56.1%, respectively. The 3-year local control and laryngoesophageal dysfunction-free survival rates were 81.6% and 49.4%, respectively. No patient died because of treatment toxicity. Among grade IV toxicity, cerebral infarction (n = 1) and laryngeal necrosis (n = 1) resulting in laryngectomy were observed. Despite being a single-institution experience, the results of the current study suggest that RADPLAT can achieve favorable survival rates and high rates of laryngeal preservation for patients with advanced hypopharyngeal cancers. Laryngoscope, 2012.