Conventional External Beam Radiation Research Articles

Clinical impact of extended field radiation therapy in Stage III carcinoma cervix versus conventional field techniques: A comparative study.

The aim of the study was to examine tumor control and clinical outcomes of extended field irradiation and compare it with those treated with conventional field in same disease profile and also to determine toxicities associated with radiation treatment. This study included 50 biopsy-proven and registered International Federation of Gynecology and Obstetrics Stage III cases of carcinoma cervix treated with concurrent computed tomography (injection cisplatin 40 mg/m2 weekly) + external beam radiotherapy (EBRT) upto 50 Gy + high-dose-rate intracavitary brachytherapy (ICBT) (22.5 Gy). Twenty-five patients were randomized to each arm. Arm A: Conventional field EBRT 50 Gy with concurrent weekly chemotherapy followed by ICBT. Arm B: Extended field EBRT 50 Gy with concurrent weekly chemotherapy followed by ICBT. At 12-month follow-up, 43 patients (86%) had attained CR. Overall, seven patients (14%) were in noncomplete response (CR) group (non-CR = patients with partial response, stable disease, or progressive disease). The non-CR rate was 16% for Arm A and 20% for Arm B. Among seven patients of non-CR group, six had local disease and one had failure at distant site. Five (10%) patients died in this study, 2 (8%) in Arm A and 3 (12%) patients in Arm B. Residual disease was seen in 2 (4%) patients. Grade III diarrhea was seen in eight patients (16%), 3 in Arm A (12%) and 5 in Arm B (20%). Fifteen patients (30%) developed Grade III skin toxicity. Seven patients in Arm A (28%) and 8 patients (32%) in Arm B developed Grade III toxicity. Twenty-five (50%) cases presented with varying stages of vaginal adhesions and stenosis. Majority of patients achieved CR with minimal acute and late toxicities with similar results in both arms. No patient had pelvic or para-aortic metastasis until recent follow-up.

Radiation myelopathy following stereotactic body radiation therapy for spine metastases.

Stereotactic body radiation therapy (SBRT) is now considered a standard of care treatment option in the management of spine metastases. One of the most feared complications of spine SBRT is radiation myelopathy (RM). We provided a narrative review of RM following spine SBRT based on review of the published literature, including data on spinal cord dose constraints associated with the risk of RM, strategies to mitigate the risk, and management options for RM. There are limited published data of cases of RM following spine SBRT with detailed spinal cord dosimetry. The HyTEC report provided recommendations for the point maximal dose (Dmax) for the spinal cord that is associated with a < 5% risk of RM for 1-5 fractions spine SBRT. In the setting of spine SBRT reirradiation after previous conventional external beam radiation therapy (cEBRT), factors associated with RM are: SBRT spinal cord Dmax, cumulative spinal cord Dmax, and the time interval between previous RT and SBRT reirradiation. There are various strategies to mitigate the risk of RM, including accurate delineation of the spinal cord (or thecal sac), strict adherence to the recommended spinal cord dose constraints, and robust treatment immobilisation set-up and delivery. Limited effective treatment options are available for patients who develop RM, and these include corticosteroids, hyperbaric oxygen, and bevacizumab; however, none have been supported by high quality evidence. RM is a rare but devastating complication following SBRT for spine metastases. There are strategies to minimise the risk of RM to ensure safe delivery of spine SBRT.

Treatment of Metastatic Spinal Disease; what the Radiologist needs to know.

Advancements in technology and multidisciplinary management have revolutionized the treatment of spinal metastases. Imaging plays a pivotal role in determining the treatment course for spinal metastases. This article aims to review the relevant imaging findings in spinal metastases from the perspective of the treating clinician, describe the various treatment options, and discuss factors influencing choice for each available treatment option. Cases that once required radical surgical resection or low-dose conventional external beam radiation therapy, or both, are now being managed with separation surgery, spine stereotactic radiosurgery/stereotactic body radiation therapy, or both, with decreased morbidity, improved local control, and more durable pain control. The primary focus in determining treatment choice is now on tumor control outcomes, treatment-related morbidity, and quality of life.

Mature Local Control and Reirradiation Rates Comparing Spine Stereotactic Body Radiation Therapy With Conventional Palliative External Beam Radiation Therapy

Stereotactic body radiation therapy (SBRT) improves complete pain response for painful spinal metastases compared with conventional external beam radiation therapy (cEBRT). We report mature local control and reirradiation rates in a large cohort of patients treated with SBRT versus cEBRT enrolled previously in the Canadian Clinical Trials Group Symptom Control 24 phase 2/3 trial. One hundred thirty-seven of 229 (60%) patients randomized to 24 Gy in 2 SBRT fractions or 20 Gy in 5 cEBRT fractions were retrospectively reviewed. By including all treated spinal segments, we report on 66 patients (119 spine segments) treated with SBRT and 71 patients (169 segments) treated with cEBRT. The primary outcomes were magnetic resonance-based local control and reirradiation rates for each treated spine segment. The median follow-up was 11.3 months (interquartile range, 5.3-27.7 months), and median overall survival in the SBRT and cEBRT cohorts were 21.6 (95% confidence interval [CI], 11.3, upper bound not reached) and 18.9 (95% CI, 12.2-29.1) months (P = .428), respectively. The cohorts were balanced with respect to radioresistant histology and presence of mass (paraspinal and/or epidural disease extension). Risk of local failure after SBRT versus cEBRT at 6, 12, and 24 months were 2.8% (95% CI, 0.8%-7.4%) versus 11.2% (95% CI, 6.9%-16.6%), 6.1% (95% CI, 2.5%-12.1%) versus 28.4% (95% CI, 21.3%-35.9%), and 14.8% (95% CI, 8.2-23.1%) versus 35.6% (95% CI, 27.8%-43.6%), respectively (P < .001). cEBRT (hazard ratio [HR], 3.48; 95% CI, 1.94-6.25; P < .001) and presence of mass (HR, 2.07; 95% CI, 1.29-3.31; P = .002) independently predicted local failure on multivariable analysis. The 1-year reirradiation rates and median times to reirradiation after SBRT versus cEBRT were 2.2% (95% CI, 0.4-7.0%) versus 15.8% (95% CI, 10.4%-22.3%) (P = .002) and 22.9 months versus 9.5 months, respectively. cEBRT (HR, 2.60; 95% CI, 1.27-5.30; P = .009) and radioresistant histology (HR, 2.00; 95% CI, 1.12-3.60; P = .020) independently predicted for reirradiation. Eight of 12 iatrogenic vertebral compression fractures were after SBRT and 4 of 12 after cEBRT; grade 3 adverse fracture effects were isolated to the SBRT cohort (5 of 12). Risk of local failure and reirradiation is lower with SBRT compared with cEBRT for spinal metastases. Although the iatrogenic vertebral compression fracture rates were within expectations, grade 3 vertebral compression fractures were isolated to the SBRT cohort.

Clinical and histopathologic effects of neoadjuvant intra-arterial chemoradiotherapy with cisplatin in combination with oral S-1 on stage III and IV oral cancer

The aim of this study was to examine the clinical and histopathologic effects of neoadjuvant intra-arterial chemoradiotherapy (IACRT) using cisplatin in combination with oral S-1 (tegafur/gimeracil/oteracil potassium) on stage III and IV oral squamous cell carcinoma. Thirty patients received infusions of superselective intra-arterial cisplatin 60 mg/m2 by the Seldinger method and conventional external beam radiotherapy (total 40 Gy) combined with oral S-1 on the day of irradiation. Curative surgery and neck dissection were performed 4 to 6 weeks after IACRT. The clinical response of the primary lesion was evaluated approximately 4 weeks after IACRT. The surgically resected specimens were examined for histologic features according to the grading system for histologic evaluation and for residual tumor grade (RGrades). Histopathologic evaluation of the therapeutic effect was grade 2 in 10 patients and grade 3 in 16 patients. According to the distribution of RGrades, the remaining tumor cells were mostly in the central area of the primary lesion, as seen in 24 patients. These findings indicate that neoadjuvant IACRT with cisplatin and oral S-1 was an effective treatment, suggesting the possibility of reducing the extent of curative surgery based on RGrades.

Trends in the use of radiation for meningioma across the United States.

PurposeMeningiomas are tumors originating from arachnoid cap cells on the surface of the brain or spinal cord. Treatment differs by grade but can consist of observation, surgery, radiation therapy or both. We utilized the National Cancer Database (NCDB) to compare trends in the use stereotactic radiosurgery (SRS) and external beam radiation therapy (EBRT) in the management of meningioma.Materials and MethodsWe queried the NCDB from 2004–2015 for meningioma patients (grade 1–3) treated with radiation therapy, either SRS or EBRT. Multivariable logistic regression was used to identify predictors of each treatment and to generate a propensity score. Propensity adjusted Kaplan-Meier survival curve analysis and multivariable Cox hazards ratios were used to identify predictors of survival.ResultsWe identified 5,406 patients with meningioma meeting above criteria with 45%, 44%, and 11% having World Health Organization (WHO) grade 1, 2, and 3 disease, respectively. Median follow up was 43 months. Predictors for SRS were grade 1 disease, distance from treatment facility, and histology. The only predictor of EBRT was grade 3 disease. Treatment year, histology, race and female sex were associated with improved survival. Five- and 10-year survival rates were 89.2% versus 72.6% (p < 0.0001) and 80.3% versus 61.4% (p = 0.29) for SRS and EBRT respectively. After propensity matching 226 pairs were generated. For SRS, 5-year survival was not significantly improved at 88.2% compared with EBRT (p = 0.056).ConclusionIn the present analysis, predictors of SRS utilization in management of meningioma include WHO grade 1 disease, distance from treatment facility and histology whereas conventional EBRT utilization was associated with grade 2 and 3 disease. Future studies need to be performed in order to optimize management of atypical and malignant meningioma.

The Changing Landscape for the Treatment of Painful Spinal Metastases: is Stereotactic Body Radiation Therapy the New Standard of Care?

Due to advancements in systemic targeted and immunotherapies resulting in improved disease control and overall survival, and the increasing use of computed tomography and spine magnetic resonance imaging surveillance, the number of patients presenting with both asymptomatic and symptomatic spinal metastases is increasing. The need for versatile tumour ablative local management strategies, beyond the limits afforded by conventional palliative external beam radiation therapy (cEBRT), is increasingly more important. Stereotactic body radiation therapy (SBRT) was developed to meet such a need. This highly conformal technique allows the delivery of high biologically effective doses of radiation to the vertebral target, while controlling the differential dose exposure to the adjacent critical neural tissue. Identifying patients with painful spine metastases who would gain the most benefit from this important therapeutic option can be challenging. Here we summarise the randomised evidence specific to spine SBRT, comparing cEBRT with SBRT for pain control in patients with spine metastases in the palliative setting to better understand the role of spine SBRT in modern oncological spinal care.

Radiotherapy for spinal metastasis: A narrative review

Despite the rapid evolution of systemic therapies and significant advances in surgical techniques, radiation therapy by itself or as an adjuvant to surgery remains the modality of choice for local control of spinal metastasis. Radiation can be used with an ablative intent for lasting local control of spinal metastasis or with a palliative intent to ameliorate pain, prevent pathological fractures, and relieve epidural spinal cord compression. This article aims to review the various modalities of radiotherapy. The lack of precision with conventional external beam radiotherapy (cEBRT) poses a significant radiation hazard to vital structures adjacent to the spine. This necessitates lowering of the radiation dosage, which may not be adequate to treat certain resistant tumors. Currently, the use of cEBRT is recommended for radiosensitive histologies only. Stereotactic body radiotherapy (SBRT) allows tumoricidal doses of radiation to be safely delivered to the tumor tissue. SBRT has been shown to provide durable local control, even for spine metastasis from tumors with radioresistant histologies. SBRT can also be offered as a reirradiation technique for tumor progression following a course of cEBRT. Currently, SBRT alone is recommended for radioresistant spinal metastasis limited to 1–2 spinal segments, with limited paraspinal spread and mild-to-moderate spinal cord compression in a stable spine. Charged particle therapy is useful for resistant histologies and further reduces the dose to normal structures within the vicinity of the tumor.

Linear Accelerator Based External Beam Radiotherapy in Glomus Jugulare Tumour: A Retrospective Review from a Tertiary Cancer Hospital in Kenya

Objective: Tumours originating from jugular bulb, carotid bifurcation, Vagus nerve are collectively called Paragangliomas. They are slow growing, essentially benign tumours, but can be detrimental if untreated. There is limited evidence on the effectiveness of fractionated radiotherapy in the management ofs Glomus jugulare tumours. The aim of this study is to determine the efficacy of Linear accelerator based fractionated external beam radiotherapy on unilateral inoperable Glomus jugulare paragangliomas. Method: This is a retrospective analysis of all the 12 cases of inoperable, unilateral Glomus jugulare tumours treated during the period 2011-2016 at a tertiary cancer centre in Kenya. Minimum follow up duration was 3 years. Patient characteristics, disease staging, immediate complications and therapeutic efficacy were analysed from the case files. Results: The 12 patients diagnosed with inoperable Glomus jugulare tumours reported in this period were treated with external beam radiotherapy to a tumour dose of 54 Gy in 30 fractions over a period of 6 weeks using IMRT technique in 6 MV Linear accelerator. 2/3rd of the patients were females in 5th and 6th decade of life. Onset of first symptom to initiation of treatment was found to be 1.7 years. Headache, earache, and tinnitus were the main complaints. No major side effects were recorded during therapy. Mean length of the tumour in its maximum dimension at the time of diagnosis was 4.5 cm. At the end of one-year post therapy, a mean reduction of 6.5 mm in the tumour length was observed, (Range: 0 - 15 mm). Tumour size remained static for a year and thereafter a slow growth pattern of 1mm per year was observed. Conclusion: Fractionated external beam radiotherapy is an effective and non-invasive treatment for advanced, inoperable Glomus jugulare paragangliomas. Clinical stability through tumour control was observed. Though newer radiation techniques like Cyberknife, Proton therapy offer better tumour control, conventional external beam radiotherapy is an effective tool in disease containment in resource limited countries.

Clinical Correlates of Portal Venous or Superior Mesenteric Vein Thrombosis Following Neoadjuvant Therapy with Dose Escalated Radiation for Borderline Resectable or Locally Advanced Pancreatic Adenocarcinoma

Neoadjuvant regimens for borderline resectable and locally advanced pancreatic adenocarcinoma (PDAC) are incorporating radiation dose escalation through conventional external beam radiation (EBRT), intraoperative radiation therapy (IORT), and stereotactic body radiation (SBRT). We conducted a retrospective review of patients treated with and without IORT dose escalation to identify risk factors for portal vein and superior mesenteric vein thrombosis (PVT/SMVT).We identified 96 patients with locally advanced or borderline-resectable PDAC treated at our institution with neoadjuvant therapy followed by exploratory laparotomy between 2009 and 2014. Patients considered at risk for close or positive surgical margins based on preoperative imaging were treated with dose escalated RT consisting of EBRT with or without IORT boost to a biological equivalent dose (BED) greater than 100. Prognostic factors for PVT/SMVT were evaluated using the Wilcoxon rank-sum test, Fisher exact test, and Cox proportional hazards model.Median follow-up was 23 months. Fifty-six patients received IORT (58%). Twenty-nine patients (30%) developed PVT/SMVT, fifteen of which (52%) occurred in the setting of local recurrence (LR). Median time to PVT/SMVT was 10 months for patients with and without LR. On multivariate analysis, local recurrence and venous resection and repair with vascular interposition grafts were significantly associated with PVT/SMVT. IORT dose escalation and history of diabetes were not associated with PVT/SMVT. Six patients underwent both IORT and vascular repair, one with vascular interposition graft, of whom 50% developed PVT/SMVT. While the fourteen patients who developed PVT/ SMVT in the absence of LR did not experience a decrease in overall survival, there was significant morbidity associated with PVT/SMVT in this setting, with ten patients developing ascites requiring frequent paracenteses and additional interventions.Approximately 30% of patients who underwent neoadjuvant chemoradiation for PDAC developed PVT/SMVT a median of 10 months following surgery. This was significantly associated with local recurrence and vascular resection with reconstruction with vascular grafts, but not with escalating RT dose. PVT/SMVT in the absence of LR was associated with significant morbidity.

Treatment of Chordomas and Chondrosarcomas With CyberKnife Robotic Hypofractionated Radiosurgery: A Single Institution Experience.

IntroductionThe aim of this study is to determine the efficacy and safety of CyberKnife® (Accuray, Inc., Sunnyvale, CA) hypofractionated radiosurgery (HfRS) in the treatment of chordomas and chondrosarcomas.MethodsA total of 24 patients retrospectively identified with chordomas (19 patients) or chondrosarcomas (five patients) were treated between 2012 and 2019 with HfRS as monotherapy or an adjuvant, rescue, or combination therapy. Tumors were located in the skull base (75%) and vertebral spine (25%). Of these, 19 patients underwent previous partial resection and four patients received previous conventional external beam radiation therapy (EBRT) (60-74 Gy). Exclusive or rescue HfRS (20 patients) was administered in five fractions with a median dose of 37.5 Gy (30-40 Gy). Combined tomotherapy-EBRT treatment (median dose: 54 Gy) and HfRS (16.5-30 Gy in 3-12 fractions) were performed in four patients with bulky chordomas.ResultsThe median follow-up from HfRS was 28 months. During clinical follow-up, no deaths were registered with overall survival (OS) of 100% and the actuarial local recurrence-free survival (LRFS) was 93% at one year, 85% at three years, and 68% at five years. Acute toxicity related to HfRS was present in a single patient.ConclusionsIt is seen that HfRS is effective and safe for chordomas and chondrosarcomas, with rates of LRFS comparable to other radiation modalities.

Concurrent Sorafenib and Radiotherapy versus Radiotherapy Alone for Locally Advanced Hepatocellular Carcinoma: A Propensity-Matched Analysis

PurposeEvidence is lacking concerning the benefit of the combination of sorafenib and radiotherapy to treat advanced hepatocellular carcinoma (HCC). To date, no publication has reported the outcomes of radiotherapy alone versus concurrent therapy. We aimed to compare the effectiveness of radiotherapy alone versus concurrent radiotherapy and sorafenib for locally advanced hepatocellular carcinoma.Materials and MethodsWe conducted a propensity score matching (PSM) cohort study comparing the effectiveness of the concurrent use of sorafenib and external beam radiotherapy versus radiotherapy alone in Barcelona Clinic Liver Cancer (BCLC) stage B or C, nonsurgically managed, nonmetastatic patients with HCC. Two subpopulations were matched based on baseline characteristics. Stratified analysis was also performed to assess the heterogeneous effects of the two arms. Overall survival (OS) was compared. Radiation-induced liver disease (RILD) and overt gastrointestinal (GI) bleeding events were also recorded.ResultsSeven hundred thirty-one BCLC stage B or C nonmetastatic HCC patients were identified from 2007 to 2017. Of these, 347 patients met the inclusion criteria (Radiotherapy alone: 269 patients; concurrent therapy: 78 patients). Propensity score matching yielded 73 patients each in the radiotherapy and concurrent groups. The median OS was 9.6 months in the radiotherapy-alone group and 9.9 months in the concurrent group (hazard ratio (HR): 1.12; 95% CI=0.78–1.62; p=0.544). Posttreatment toxicities, including radiation-induced liver disease and overt gastrointestinal bleeding, showed no significant differences between the groups.ConclusionIn our study, the concurrent use of sorafenib and conventional external beam radiotherapy shows no survival benefit over radiotherapy alone for locally advanced hepatocellular carcinoma.

Ocular, Orbital, and Adnexal Toxicity With High-dose Volumetric Modulated Arc Radiation Therapy for Orbital Malignancies.

Conventional modalities of external-beam radiation therapy (EBRT) are associated with high incidences of severe vision-threatening ocular and orbital toxicities when used to treat orbital malignancies. We investigate toxicities associated with high-dose volumetric modulated arc therapy (VMAT), a commonly used contemporary treatment modality for these tumors. Retrospective analysis of malignant orbital tumors managed with adjuvant high-dose VMAT preceded by globe-salvaging surgical therapy (GST) or exenteration. Dosimetric quantitation of target volumes and critical structures was performed. Incidence and severity of ocular, orbital, and adnexal toxicities were evaluated and assessed with regard to conventional EBRT toxicities for orbital malignancies described in the literature. Eighty-four subjects (mean age = 65.9 ± 9.7 years) were included (N = 48 and N = 36 in GST and exenteration subgroups, respectively). Mean dose was 64.8 ± 2.1 Gy to the planning target volume. Dosing to critical structures typically did not surpass known tissue tolerance limits. Median follow up was 18.3 months. Visual acuity in the GST subgroup was not significantly different after VMAT (0.25 ± 0.06) compared with baseline (0.23 ± 0.02; P = 0.302). Whereas severe toxicities reported by major systematic analyses in the literature with older EBRT modalities were relatively common-for example, retinopathy (16-40%), optic neuropathy (16%), and corneal perforation (13%)-toxicities with VMAT were typically mild and less common. The most common toxicities with VMAT were mild dry eye (81.3%; 39/48), cataract (21.1%; 8/38 phakic eyes), and periocular dermatitis (15.5%; 13/84). Vision-threatening toxicities, including severe corneal pathologies, retinopathy, or optic neuropathy, were rare. There were no contralateral ocular or adnexal toxicities. High-dose VMAT for orbital malignancies demonstrated low incidence and severity of eye-related toxicity, in contradistinction to adverse events reported from conventional forms of radiotherapy.

Spinal stereotactic radiotherapy for painful spinal metastasis.

Conventional external beam radiotherapy is the standard of care for patients with cancer who have localised metastatic bone pain. Pain response is reported as a combination of complete (defined as a pain score of 0 on an 11-point scale of 0–10) and partial (defined as a reduction of ≥2 points, without an increase in analgesic consumption) responses, in accordance with the International Consensus Pain Response Endpoints to promote consistent reporting in clinical trials.1 Pooled data from almost 30 randomised trials show that 65% of patients treated with conventional external beam radiotherapy had an overall response for pain (ie, a partial or complete response) and 25% had a complete response for pain.

Strategies to Minimize Late Effects From Pelvic Radiotherapy.

During the past 30 years, radiation treatment techniques have significantly improved, from conventional external-beam radiation therapy, to three-dimensional conformal radiation therapy, to current intensity-modulated radiation therapy, benefiting patients who undergo treatment of pelvic malignancies. Modern treatment options also include proton beam irradiation as well as low and high dose rate brachytherapy. Although the acute adverse effects of these modalities are well documented in clinical trials, less well known are the true incidence and optimal management of those late adverse effects that can occur months to years later. In a population of survivors of cancer that is steadily increasing, with many such patients receiving radiotherapy at some time during their disease course, these late effects can become a considerable management and quality-of-life issue. This review will examine the range of late toxicities that can occur from pelvic radiotherapy and explore strategies to prevent and mitigate them.

Feasibility of Proton Beam Therapy as a Rescue Therapy in Heavily Pre-Treated Retinoblastoma Eyes.

Simple SummaryA variety of therapies are available for the treatment of retinoblastomas. Nevertheless, despite exhaustion of all therapeutic methods, refractory or recurrent courses of the disease occur. In eyes with a function worthy of preservation radiation therapy may become unavoidable. Proton beam therapy, compared to conventional photon-based radiotherapy, is a highly conformal form of radiation therapy with a high biological effectiveness with a simultaneously reduced probability of radiation-related side-effects and induction of secondary primary malignancies. The aim of our retrospective study was to evaluate the efficacy of proton beam therapy as rescue therapy in 15 heavily pretreated retinoblastoma eyes. In our retrospective series of a highly negatively selected patient population, we were able to preserve 60% of the eyes with a manageable side effect profile. A cataract, as the most common long-term complication, was evident in 44.4% of the preserved eyes. There was no in-field second tumor manifestation during follow-up, therefore the preliminary data of this study and series published by others suggest that the risk is significantly lower after proton beam therapy compared to conventional external beam radiation therapy using photons.Despite the increased risk of subsequent primary tumors (SPTs) external beam radiation (EBRT) may be the only therapeutic option to preserve a retinoblastoma eye. Due to their physical properties, proton beam therapy (PBT) offers the possibility to use the effectiveness of EBRT in tumor treatment and to decisively reduce the treatment-related morbidity. We report our experiences of PBT as rescue therapy in a retrospectively studied cohort of 15 advanced retinoblastoma eyes as final option for eye-preserving therapy. The average age at the initiation of PBT was 35 (14–97) months, mean follow-up was 22 (2–46) months. Prior to PBT, all eyes were treated with systemic chemotherapy and a mean number of 7.1 additional treatments. Indication for PBT was non-feasibility of intra-arterial chemotherapy (IAC) in 10 eyes, tumor recurrence after IAC in another 3 eyes and diffuse infiltrating retinoblastoma in 2 eyes. Six eyes (40%) were enucleated after a mean time interval of 4.8 (1–8) months. Cataract formation was the most common complication affecting 44.4% of the preserved eyes, yet 77.8% achieved a visual acuity of >20/200. Two of the 15 children treated developed metastatic disease during follow-up, resulting in a 13.3% metastasis rate. PBT is a useful treatment modality as a rescue therapy in retinoblastoma eyes with an eye-preserving rate of 60%. As patients are at lifetime risk of SPTs consistent monitoring is mandatory.

Radiotherapy for Clinically Localized T3b or T4 Very-High-Risk Prostate Cancer-Role of Dose Escalation Using High-Dose-Rate Brachytherapy Boost or High Dose Intensity Modulated Radiotherapy

Simple SummaryRecently, high-risk prostate cancer was subdivided to a very-high-risk group considered to have the worst prognosis, including clinical stage T3b–T4, primary Gleason pattern 5, or more than four biopsy cores with Gleason score 8–10. Among these, T3b–T4 stage is a special interest in radiotherapy because of their wider target volume outside the prostate. We examined this subgroup and found that dose escalation in radiotherapy both with brachytherapy or intensity modulated radiotherapy (IMRT) improved biochemical free survival rate but not in prostate cancer specific survival rate and overall survival rate.To examine the efficacy of dose escalating radiotherapy into patients with cT3b or T4 localized prostate cancer, we compared Group A (86 conventional dose external beam radiotherapy: EBRT group, treated with 70–72 Gy) and group B (39 high dose EBRT group (HDEBRT group, 74–80 Gy) and 124 high-dose-rate brachytherapy (HDR) + EBRT (HDR boost)) using multi-institutional retrospective data. The actuarial 5-year biochemical disease-free survival (bDFS) rate, prostate cancer specific survival rate (PSS), and overall survival rate (OS) were 75.8%, 96.8%, and 93.5%. Group B showed superior 5-year bDFS rate (81.2%) as compared to the group A (66.5%) (p < 0.0001) with a hazard ratio of 0.397. Equivocal 5-year PSS (98.3% and 94.8% in group B and group A) and OS (both 93.7%) were found between those groups. Accumulated late grade ≥ 2 toxicities in gastrointestinal and genitourinary tracts were similar among those three groups. Therefore, both HDEBRT and HDR boost could be good options for improving the bDFS rate in cT3–T4 localized prostate cancer without affecting PSS and OS.

A comparative study to evaluate the feasibilityand efficacy of use of mehendi vs temporary pen markings for skin marking in patients undergoing conventional external beam radiotherapy with Cobalt 60 machine

Introduction and Aim: The most common practice for marking the radiation field borders in conventional radiotherapy is with marker pens. In the hot and humid environment in India these markings rapidly fade and require remarking. In some cases, they require re-simulation and re-planning. Mehndi has been used in India for ceremonial marking on skin for long. Here we seek to evaluate the same for radiotherapy.&#x0D; Materials and Methods: Eighty-two patients with no history of hyper-sensitivity to mehendi were scheduled to be analyzed on per protocol treatment basis, with 41 in each arm. Subjects were randomized by lottery method till the target number in one of the arms is reached. Since one subject in each arm had not received the per protocol management due to default, two more subjects were included and randomized. The minimum duration of treatment was 5 weeks. Markings were done either with mehndi cones (Arm A) or conventionally used Skin marking pens. They were repeated as per requirements. The number of application and gap between them were recorded. The data was later analyzed with SPSS v23 for frequencies, independent sample T test, including Mann-Whitney test. The analysis was per protocol.&#x0D; Results: No incidence of hypersensitivity to mehendi occurred.The mean and median number of applications was significantly less in the Mehndi arm compared to control arm (median being 2 in mehndi arm compared to 4 in Pen arm). The median gap between applications and each application was also significantly lower in the Mehndi arm (11.5 days vs 7.25 days). There was no significant difference with visualization. The comfort level of the technologists, consultants and patients were better with Mehndi than with pen arm on Likert scale.&#x0D; Conclusion: Mehndi is more durable than the pen marking it is equally visible for health care professionals and more comfortable to patients. The skin tone of our patients did not pose any challenge in visualization during set up either in ambient lighting or with lasers.

Spinal laser interstitial thermal therapy: single-center experience and outcomes in the first 120 cases.

The objective of this study was to present the results of a consecutive series of 120 cases treated with spinal laser interstitial thermal therapy (sLITT) to manage epidural spinal cord compression (ESCC) from metastatic tumors. The electronic records of patients treated from 2013 to 2019 were analyzed retrospectively. Data collected included demographic, pathology, clinical, operative, and imaging findings; degree of epidural compression before and after sLITT; length of hospital stay; complications; and duration before subsequent oncological treatment. Independent-sample t-tests were used to compare means between pre- and post-sLITT treatments. Survival was estimated by the Kaplan-Meier method. Multivariate logistic regression was used to analyze predictive factors for local recurrence and neurological complications. There were 110 patients who underwent 120 sLITT procedures. Spinal levels treated included 5 cervical, 8 lumbar, and 107 thoracic. The pre-sLITT Frankel grades were E (91.7%), D (6.7%), and C (1.7%). The preoperative ESCC grade was 1c or higher in 92% of cases. Metastases were most common from renal cell carcinoma (39%), followed by non-small cell lung carcinoma (10.8%) and other tumors (35%). The most common location of ESCC was in the vertebral body (88.3%), followed by paraspinal/foraminal (7.5%) and posterior elements (4.2%). Adjuvant radiotherapy (spinal stereotactic radiosurgery or conventional external beam radiation therapy) was performed in 87 cases (72.5%), whereas 33 procedures (27.5%) were performed as salvage after radiotherapy options were exhausted. sLITT was performed without need for spinal stabilization in 87 cases (72.5%). Post-sLITT Frankel grades were E (85%), D (10%), C (4.2%), and B (0.8%); treatment was associated with a median decrease of 2 ESCC grades. The local control rate at 1 year was 81.7%. Local control failure occurred in 25 cases (20.8%). The median progression-free survival was not reached, and overall survival was 14 months. Tumor location in the paraspinal region and salvage treatment were independent predictors of local recurrence, with hazard ratios of 6.3 and 3.3, respectively (p = 0.01). Complications were observed in 22 cases (18.3%). sLITT procedures performed in the lumbar and cervical spine had hazard ratios for neurological complications of 15.4 and 17.1 (p < 0.01), respectively, relative to the thoracic spine. sLITT is safe and provides effective local control for high-grade ESCC from vertebral metastases in the thoracic spine, particularly when combined with adjuvant radiotherapy. The authors propose considering sLITT as an alternative to open surgery in selected patients with spinal metastases.

Stereotactic Body Radiotherapy (SBRT) Versus Conventional Palliative Radiotherapy (CRT) for Patients With Painful Spinal Metastases: A Phase 3, Randomized Controlled Trial

Background: Conventional external beam radiation (CRT) is standard palliative treatment for spinal metastases; however, complete response rates for pain are low. Stereotactic body radiotherapy (SBRT) delivers high dose ablative radiotherapy. We aimed to compare complete response rates (CR) for pain between SBRT and CRT to painful spinal metastases. Methods: We did this multicenter, phase 2/3, randomised controlled trial in 13 hospitals in Canada and 5 in Australia and New Zealand. Patients were eligible if they were aged 18 years and older, a spine MRI confirmed painful (pain measured as ≥2 points using the Brief Pain Inventory) site of spinal metastasis, no more than three consecutive vertebral segments to be included in the treatment volume, an Eastern Cooperative Oncology Group performance status of 0 to 2, and no frank instability or neurologically symptomatic spinal cord or cauda equina compression. Patients were randomized (1:1) to receive either 24Gy in 2 SBRT fractions or 20Gy in 5 CRT fractions using standard techniques. Treatment assignment was performed centrally using a minimization method to achieve balance for the stratification factors of radioresistant (gastrointestinal, sarcoma, melanoma and renal cell cancer metastases) vs. radiosensitive (all other histologies) histologic type, presence or absence of “Mass” on imaging (extra-osseous paraspinal and/or epidural disease extension), and center. Patients, caregivers and investigators were not masked to the treatment allocation. The primary endpoint was the CR rate for pain at 3 months post-radiation. Final analysis populations included the intent-to-treat (ITT) population for all efficacy endpoints, and the as-treated population for safety and quality assurance analyses. The trial is registered with ClinicalTrials.gov (NCT02512965). Findings: Patients were enrolled from January 2016 to September 2019. All 229 patients were included in the ITT analyses including 4 of the 114 patients randomized to SBRT who did not initiate the study intervention, 2 of the 115 in the CRT arm that initiated at least one fraction of radiation treatment but withdrew prior to completion, 22 (19%) patients in the CRT arm and 16 (14%) patients in the SBRT arm who were in-evaluable at the primary endpoint assessment at 3 months, and 39 (34%) patients in the CRT arm and 36 (32%) patients in the SBRT arm who were inevaluable at the 6 month endpoint. The median baseline worst pain score was 5 (range, 2-10) in both arms, and the median follow-up was 6.7 months (range, 0.2-8.9). At 3 months, 16/115 (14%) in the CRT arm vs. 40/114 (36%) in the SBRT arm (p=0.0002) achieved a CR for pain. Significance was retained on multivariable analyses (MVA, p=0.0003) and the risk ratio (RR) was 1.33 (95% C.I., 1.14 – 1.55) favoring SBRT. At 6 months, 18/115 (16%) in the CRT arm vs. 37/114 patients (33%) in the SBRT arm achieved a CR (p=0.004), significance was retained on MVA (p=0.007), and the RR was 1.24 (95% C.I., 1.07 – 1.44) favoring SBRT. The 3 month radiation site specific progression-free-survival rates for CRT vs. SBRT were 86% vs. 92% and, at 6 months, 69% vs. 75%, respectively. Quality-of-life outcomes were comparable with only financial perception at 1 month (p=0.03) favoring SBRT. Grade 2+ adverse events were observed in 12% and 11% in the CRT and SBRT arms, respectively. Interpretation: SBRT is superior to CRT in improving the CR rate for pain in selected patients with spinal metastases. Trial Registration: (NCT02512965). Funding: Canadian Cancer Society (CCS) and the National Health and Medical Research Council (NHMRC). Declaration of Interests: AS declares prior consulting services and/or honorarium for past educational seminars for Varian Medical Systems, Elekta AB, Astra Zeneca, Medtronic Kyphon, and BrainLAB, and research grants from Elekta AB and Varian Medical Systems. SS declares research grants from Varian Medical Systems, Merck-Sharp-Dohme and Bayer Pharmaceuticals and honorarium for past educational seminars and advisory board participation from Astra Zeneca and Reflexion. SDM declares grant support from Novartis/AAA and honorarium from Ipsen. MF declares grants from Elekta AB and honorarium for past educational seminars from Elekta AB and Varian Medical Systems. JG, IT, MK, MGF, ML, PJM, YL, MB, JB, KD, GLM, RKW, SKL, WRP, and ZG have no conflicts of interests to declare. Ethics Approval Statement: Each participating center obtained approval from their local research ethics board, and each patient provided written informed consent. All data were collected, maintained and analyzed by the Canadian Cancer Trials Group (CCTG) in Kingston, Ontario, Canada. The trial was sponsored in Canada by the CCTG and in Australia and New Zealand by the Trans Tasman Radiation Oncology Group (TROG), and independently monitored by the independent CCTG Data Safety Monitoring Board.