Course Of External Beam Radiotherapy Research Articles

Prospective Phase II Study Evaluating the Relationship of Fatigue and Plasma Inflammatory Cytokine Levels in Prostate Cancer (PC) Patients Undergoing External Beam Radiation Therapy (EBRT)

Cancer patients undergoing EBRT experience significant fatigue during treatment that negatively impacts physical functioning and quality of life (QOL). Our hypothesis was that EBRT-induced increases in inflammatory cytokines resulting from tissue toxicity play an important mechanistic role in treatment-related fatigue. We undertook a prospective, longitudinal, single arm, Phase II study with specific aims to evaluate the relationship between cytokines, patient activity levels, and self-reported fatigue-related symptoms during a standard course of EBRT for PC. 28 men undergoing EBRT for low to intermediate risk PC without androgen therapy (ADT) were accrued onto an institutional review board-approved prospective clinical trial. Participants used an Actiwatch Score (MiniMitter/Respironics Inc.) to record their daily fatigue level, on a 1 - 10 scale (1 = no fatigue, 10 = worst fatigue), prior to and during EBRT to 78 Gy at 2 Gy/fraction. Peripheral blood was collected immediately prior to the 1st treatment and then after the 5th, 15th, 25th, and 39th treatment. Cytokine analysis was performed using a bead based immunofluorescence assay (Luminex Inc.) for serum IL-1α, IL-1β, TNF-α, IL-6, IL-8, IL-10 and VEGF. Area under the curve analysis with respect to total (AUCt) across the repeated measures was computed for fatigue and serum cytokine response measures. Multiple regressions were used to test the relationship between the serum cytokine response and fatigue measures. Participants were 96% Caucasian with an average age of 66.8 yrs (range 58 - 81). Gleason Score = 6 - 7, clinical stage = T1c - T2b, and initial average PSA = 7.7 ng/mL. Average pre-treatment levels of fatigue were 2 ± 1. We observed a significant correlation between pre-treatment levels of fatigue and serum levels of IL-6 (r = 0.42, p = 0.026), IL-1α (r = 0.408, p = 0.031), and VEGF (r = 0.42, p = 0.023). The average change in fatigue level by the end of treatment was 1.4 ± 1.8. The only significant correlation identified was between total IL-6 and total fatigue response to treatment (r = 0.396, p = 0.041). The observed relationship between serum IL-6 levels and fatigue is consistent with existing studies in cancer patients. None of the other inflammatory cytokines analyzed were associated with fatigue response during treatment. This lack of an association may be related to small sample size or the relatively small average increase in fatigue level during treatment Our study establishes a feasible model for prospectively evaluating activity, symptoms, and cytokines related to fatigue that serves as a standard for future protocols.

2035 POSTER Early Mortality After 40,670 Courses of External Beam Radiotherapy in Unselected Patients

2035 POSTER Early Mortality After 40,670 Courses of External Beam Radiotherapy in Unselected Patients

Moderate dose escalation with single-fraction high-dose-rate brachytherapy boost for clinically localized intermediate- and high-risk prostate cancer: 5-year outcome of the first 100 consecutively treated patients

Purpose To analyze the clinical outcome and toxicity data of the first 100 consecutive patients treated with a single-fraction high-dose-rate brachytherapy (HDR-BT) and external beam radiotherapy (EBRT). Methods and Materials Two-hundred eighty patients have been treated with HDR-BT boost for localized intermediate- to high-risk prostate cancer. Among these, the outcome and toxicity of the first 100 patients treated with a single HDR-BT fraction were assessed. A median dose of 60 Gy EBRT was given to the prostate and vesicles. Interstitial HDR-BT of 10 Gy was performed during the course of EBRT. Results Median followup time was 61.5 months. The 5-year actuarial rates of overall survival, cause-specific survival, disease-free survival, and biochemical no evidence of disease (bNED) for the entire cohort were 93.3%, 99.0%, 89.3%, and 85.5%, respectively. The 7-year actuarial rate of bNED was 84.2% for the intermediate-risk group and 81.6% for the high-risk group ( p = 0.8464). The 7-year actuarial rates of bNED for Grade 1, 2, and 3 tumors were 97.5%, 80.0%, and 67.1%, respectively. The 5-year probability for developing late Grade 3 gastrointestinal and genitourinary (GU) toxicity was 2.1% and 14.4%, respectively. Grade 3 GU complications occurred significantly more frequently in patients with a history of preirradiation transurethral resection (29.1% vs. 8.8%; p = 0.0047). Conclusions Five-year outcome after 60 Gy EBRT plus a single fraction of 10 Gy HDR-BT boost is encouraging. Preradiation transurethral resection significantly increases the risk of late severe GU complications.

Image-Guided Radiotherapy for Breast Cancer Patients: Surgical Clips as Surrogate for Breast Excision Cavity

To determine the use of surgical clips as a surrogate for localization of the excision cavity and to quantify the stability of the clips' positions during the course of external beam radiotherapy for breast cancer patients, using cone beam computed tomography (CBCT) scans. Twenty-one breast cancer patients with surgical clips placed in the breast excision cavity were treated in a supine position with 28 daily fractions. CBCT scans were regularly acquired for a setup correction protocol. Retrospectively, the CBCT scans were registered to the planning CT scans, using gray-value registration of the excision cavity region and chamfer matching of the clips. Subsequently, residual setup errors (systematic [Σ] and random [σ]) of the excision cavity were estimated relative to the clips' registration. Finally, the stability of the clips' positions were quantified as the movement of each separate clip according to the center of gravity of the excision cavity. When clips were used for online setup corrections, the residual errors of the excision cavity were Σ(left-right) = 1.2, σ(left-right)= 1.0; Σ(cranial-caudal) = 1.3, σ(cranial-caudal)= 1.2; and Σ(anterior-posterior) = 0.7, σ(anterior-posterior)= 0.9 mm. Furthermore, the average distance (over all patients) between the clips and centers of gravity of the excision cavities was 18.8 mm (on the planning CT) and was reduced to 17.4 mm (measured on the last CBCT scan). Clips move in the direction of the center of gravity of the excision cavity, on average, 1.4 mm. The clips are good surrogates for locating the excision cavity and providing small residual errors.

The Role of Chemo-Radiotherapy in the Management of Locally Advanced Carcinoma of the Vulva

To retrospectively investigate the outcome and toxicity of concurrent chemo-radiotherapy in the treatment of locally advanced vulvar cancer (LAVC). Between 1996 and 2007, 28 consecutive patients with LAVC were treated with chemoradiation (20 primary tumors and 8 loco-regional recurrences). Treatment consists of 2 separate courses of external-beam radiotherapy (40 Gy-2 weeks split-20 Gy). During each course of radiotherapy, 5-fluorouracil (1000 mg/m/d), was given as a continuous intravenous infusion over the first 4 days, and mitomycin-C (10 mg/m on day 1), as a bolus intravenous injection. Outcome measures were rates of complete and partial response, loco-regional control, progression-free survival, overall survival, and toxicity. The median follow-up was 42 months and the median age of patients was 68 years. Twenty patients (72%) achieved complete remission, 4 patients (14%) partial remission, for an overall response rate of 86%. Four patients (14%) had progressive disease directly after chemo-radiotherapy. The actuarial rates of loco-regional control, progression-free survival and overall survival at 4 years were 75%, 71%, and 65%, respectively. There was no treatment break for acute toxicity. Vulvar desquamation was the main acute treatment-related side effect (93%). Three patients developed transient grade 2 neutropenia or thrombocytopenia. Mild skin fibrosis and atrophy (n = 6, 21%), radiation ulcer (n = 4, 14%, in one patient treatment was needed), telangectasia (n = 3, 11%), and lymphoedema (n = 2, 7%) were the most common late toxicity of chemoradiation. These data support the use of concurrent chemoradiotherapy as an effective alternative to primary ultra-radical surgery to treat LAVC with an acceptable toxicity profile.

A Bile Duct Cancer Patient Whose Stent Shifted Significantly Over the Course of External Beam Radiotherapy

A Bile Duct Cancer Patient Whose Stent Shifted Significantly Over the Course of External Beam Radiotherapy

Prostate Cancer, HIV, and Radiation Therapy: Should Treatment Decisions and Radiation Parameters be Altered Based on this Evolving Diagnosis?

Prostate Cancer, HIV, and Radiation Therapy: Should Treatment Decisions and Radiation Parameters be Altered Based on this Evolving Diagnosis?

Feasibility and Toxicity of a Single Fraction High-dose-rate Brachytherapy followed by a Course of EBRT for Localized Prostate Cancer: The French Experience about 100 Patients; A Retrospective Study

Evaluate the feasibility and toxicity of radiation dose escalation delivered with a single fraction high-dose-rate (HDR) brachytherapy boost followed by external beam radiotherapy (EBRT) for intermediate and high risk localized prostate cancer - a retrospective study.

Holiday Treatment Breaks May Adversely Predict for Loss of Tumor Control

An emerging body of literature has stressed the importance of radiation prescription compliance and overall duration of treatment in patients undergoing definitive radiotherapy. Holiday breaks represent a barrier to prescription compliance. Unstudied are those patients whose course of external beam radiotherapy (EBRT) spans the entire winter holiday season, including Thanksgiving, Christmas, and New Years Day. The purpose of this study was to examine overall prescription compliance and use radiobiologic principles to calculate the potential impact on local tumor control (LCT).

When tumor repopulation starts? The onset time of prostate cancer during radiation therapy

Purpose. To analyze published clinical data and provide a preliminary estimate of tumor repopulation rate and its onset time during radiation therapy for prostate cancer. Methods. Data on prostate cancer treated with external beam radiotherapy (EBRT) by Perez et al. (2004), Amdur et al. (1990) and Lai et al. (1991) were analyzed in this study. The stage-combined pelvic control rate from Perez et al. was calculated to be 0.95±0.01, 0.87±0.02, and 0.72±0.04 for patients treated ≤7 weeks, 7.1–9 weeks, and >9 weeks respectively. Based on the Linear-Quadratic model, extended to account for tumor repopulation, the least χ2 method was used to fit the clinical data and derive the onset time (Tk) and effective doubling time (Td) for prostate cancer. Similar analysis was performed for the other two datasets. Results. Best fit was achieved with onset time Tk=34±7 days and doubling time Td=12±2 days. These parameters were independent of the choice of the α/β values currently published in the literature. Analyses of the other two datasets showed Tk=42±7 days with Td=9 ± 3 days, and Tk=34±6 days with Td=34±5 days, respectively. Tk was found to be dependent on tumor stage. Conclusions. Consistent values for onset time Tk were obtained from different datasets, while the range of doubling time Td was large. Tumor repopulation starts no later than 58 days (at 90% confidence level) in the course of EBRT for prostate cancer.

High-Dose Split-Course Radiation Therapy for Anal Cancer: Outcome Analysis Regarding the Boost Strategy (CORS-03 Study)

To retrospectively assess the clinical outcome in anal cancer patients treated with split-course radiation therapy and boosted through external-beam radiation therapy (EBRT) or brachytherapy (BCT). From January 2000 to December 2004, a selected group (162 patients) with invasive nonmetastatic anal squamous cell carcinoma was studied. Tumor staging reported was T1 = 31 patients (19%), T2 = 77 patients (48%), T3 = 42 patients (26%), and T4= 12 patients (7%). Lymph node status was N0-1 (86%) and N2-3 (14%). Patients underwent a first course of EBRT: mean dose 45.1 Gy (range, 39.5-50) followed by a boost: mean dose 17.9 Gy (range, 8-25) using EBRT (76 patients, 47%) or BCT (86 patients, 53%). All characteristics of patients and tumors were well balanced between the BCT and EBRT groups. The mean overall treatment time (OTT) was 82 days (range, 45-143) and 67 days (range, 37-128) for the EBRT and BCT groups, respectively (p < 0.001). The median follow-up was 62 months (range, 2-108). The 5-year cumulative rate of local recurrence (CRLR) was 21%. In the univariate analysis, the prognostic factors for CRLR were as follows: T stage (T1-2 = 15% vs. T3-4 = 36%, p = 0.03), boost technique (BCT = 12% vs. EBRT = 33%, p = 0.002) and OTT (OTT <80 days = 14%, OTT ≥80 days = 34%, p = 0.005). In the multivariate analysis, BCT boost was the unique prognostic factor (hazard ratio = 0.62 (0.41-0.92). In the subgroup of patients with OTT <80 days, the 5-year CRLR was significantly increased with the BCT boost (BC = 9% vs. EBRT = 28%, p = 0.03). In the case of OTT ≥80 days, the 5-year CRLR was not affected by the boost technique (BCT = 29% vs. EBRT = 38%, p = 0.21). In anal cancer, when OTT is <80 days, BCT boost is superior to EBRT boost for CRLR. These results suggest investigating the benefit of BCT boost in prospective trials.

Pulsed-Dose-Rate Intracavitary Brachytherapy for Cervical Carcinoma

The aim of present study was to analyze the results of pulsed-dose-rate (PDR) brachytherapy in patients with cervical carcinoma treated at our center. From September 2003 to September 2005, 48 patients with histopathologically proved cervical carcinoma, stages IB to IVA, were treated with PDR intracavitary radiotherapy (ICRT) and pelvic irradiation at our center. Radiotherapy consisted of whole pelvis external beam radiation therapy (EBRT) with a dose of 40 Gy in 22 fractions over 4.5 weeks followed by 10 Gy in 5 fractions over 1 week with midline shielding. Weekly chemotherapy (Cisplatin, 40 mg/m) was administered during the course of EBRT to suitable patients. After an interval of 1 to 2 weeks, a single session of standard ICRT application was done to deliver a dose of 27 Gy to point A by PDR (hourly pulse, 70 cGy). Median age was 50 years (range: 30-65). FIGO stage distribution of the patients was as follows: stage IB, 6; stage IIA, 1; stage IIB, 15; stage IIIB, 25; and stage IVA, 1. Follow-up period ranged from 3 to 50 months (median: 15 months). Ten patients had disease recurrence (5 each in stage IIB and stage IIIB). Eight patients had pelvic failure, 1 had bone metastases, and 1 had supraclavicular node metastases. Overall grades III to IV late toxicity rate at 50 months was 6%. For the median follow-up period of 15 months, the actuarial recurrence-free survival in stages I to II was 82% and stages III to IV was 78%. Our results reveal that PDR ICRT in combination with pelvic EBRT provides excellent pelvic disease control, survival, and low radiation related morbidity rate in the patients with cervical carcinoma.

External Beam Radiotherapy Followed by 90Y Ibritumomab Tiuxetan in Relapsed or Refractory Bulky Follicular Lymphoma

We combined external beam radiotherapy (EBRT) with yttrium-90 ibritumomab tiuxetan ((90)Y-IT) in an attempt to improve therapeutic response in patients with relapsed or refractory bulky follicular lymphoma (RRBFL). Between February 2006 and September 2007, 11 patients with RRBFL were treated with EBRT followed by (90)Y-IT. Bulky disease (BD) was defined as >5 cm. EBRT was delivered to BD as 2,400 cGy in eight fractions using computed tomography (CT)-based planning. BD was contoured as the gross tumor volume. A planning margin of 1 to 2 cm was added depending on anatomical location. After recovery of complete blood counts (CBC), (90)Y-IT was administered at a dose of 0.3 or 0.4 mCi/kg depending on platelet counts. Hematologic toxicity was monitored through weekly CBC. Response was measured by positron emission tomography/CT or CT 3-4 months after (90)Y-IT. Only 2 patients required prolonged breaks between EBRT and (90)Y-IT. The median time after (90)Y-IT for platelets to recover to >100,000/ml was 55 days (range, 41-128 days). Platelet counts for 1 patient, who had received 4 previous chemotherapy regimens, never reached 100,000/ml. The complete and overall responses to combined therapy as measured 3-4 months after (90)Y-IT were 64%. No patients relapsed within the EBRT field. With a median follow-up of 36.1 months, 6 patients have relapsed, 2 of whom have died. Median progression-free survival was 17.5 months. In contrast to prior failure analysis data for RRBFL patients treated with (90)Y-IT alone, a brief course of EBRT prevented relapse in sites of BD. EBRT used to pretreat bulky sites may improve clinical outcomes and potentially extend survival when combined with (90)Y-IT.

A Simple and Effective Daily Pain Management Method for Patients Receiving Radiation Therapy for Painful Bone Metastases

The incidence of painful bone metastases increases with longer survival times. Although external beam radiation therapy (EBRT) is an effective palliative treatment, it often requires several days from the start of treatment to produce a measurable reduction in pain scores and a qualitative amelioration of patient pain levels. Meanwhile, the use of analgesics remains the best approach early on in the treatment course. We investigated the role of radiation therapists as key personnel for collecting daily pain scores to supplement assessments by physician and oncology nursing staff and manage pain more effectively during radiation treatment. Daily pain scores were obtained by the radiation therapists for 89 patients undertaking a total of 124 courses of EBRT for bone metastases and compared with pretreatment pain scores. The majority of patients (71%) were treated to 30 Gy (range, 20-37.5) in 10 fractions (range, 8-15 fractions). One hundred nineteen treatment courses (96%) were completed. Pain scores declined rapidly to 37.5%, 50%, and 75% of the pretreatment levels by Days 2, 4, and 10, respectively. Pain was improved in 91% of patients with only 4% of worse pain at the end of treatment. Improved pain scores were maintained in 83% of patients at 1-month follow-up, but in 35% of them, the pain was worse than at the end of treatment. Collection of daily pain scores by radiation therapists was associated with an effective reduction in pain scores early on during EBRT of painful osseous metastases.

PSA Decrease During Combined-Modality Radiotherapy Predicts for Treatment Outcome

Prostate-specific antigen (PSA) is the well-used marker in the diagnosis, prognosis, and follow-up for prostate cancer patients. Although reports have focused on the importance of pretreatment PSA levels, doubling time, and posttreatment nadirs, there is little information on the value of PSA during the course of radiotherapy. Retrospective review of PSA values obtained midway through a course of radiotherapy treatment for prostate cancer. Patients had a PSA (midPSA) measured after a course of external beam radiation (EBRT) before planned transperineal low-dose-rate brachytherapy implant (LDR). A total of 717 patients were analyzed with a median follow-up of 5.8 years, all censored patients had a minimum follow-up of 2 years. A total of 277 patients had low-risk disease, 267 patients had intermediate risk, and 173 patients had high-risk disease. Androgen blockade was used in 512 patients. A total of 653 patients had a midPSA decrease after EBRT, the median decrease was 6.2 ng/mL. Patients who had a midPSA decrease ≥25% compared with pretreatment PSA had improved overall survival of 10.0 vs. 7.4 years (p < 0.0004) and improved disease-free survival of 9.8 vs. 7.3 years (p < 0.01). When stratified by use of androgen blockade, midPSA remained significant for both androgen and non-androgen patients. PSA response after EBRT before brachytherapy predicts for long-term outcome; this may allow for risk stratification and intervention with higher LDR doses to improve outcomes.

Subungual Squamous Cell Carcinoma

We report the outcomes of three patients who were treated with external beam radiotherapy as an alternative to distal phalanx amputation for subungual squamous cell carcinomas between December 2004 and September 2006. The patients' ages ranged from 46 to 83 years and the median follow-up time was 48 months (range: 36-52 months). As of the current date, the three patients show no signs of recurrence following a course of external beam radiotherapy. Complete function of the treated digit was obtained in all three patients. Irradiation should be considered as an alternative modality choice in the treatment of subungual squamous cell carcinoma in lieu of distal phalanx amputation.

Brachytherapy versus cystectomy in solitary bladder cancer: A case control, multicentre, East-Netherlands study

Purpose Comparing the outcome of surgery and brachytherapy-based radiotherapy in patients with solitary T1G3/T2 bladder tumour in, a retrospective case-control study, because efforts for a randomised clinical trial comparing these modalities have failed. Materials and methods Cystectomy group. Patients were selected using the pathological registration system (PALGA). 289 cases of TURT followed by cystectomy, indicated by a muscle – invading bladder tumour were performed in three East-Netherlands medical centres between 1991 and 2001. Out of this group 179 patients with clinical T2N0M0 bladder tumour were selected. All the consecutive files were analysed by a urologist and a radiation oncologist and 65 of those patients (mean age 63.7 years) would have been eligible for brachytherapy, based on an initial analysis: cystoscopy estimated tumour size, post-TURT pathological report, completed by CT-scan and/or, MRI-scan. A final pathological report after radical cystectomy was not considered for patients’ selection. Brachytherapy group. Patients were selected using a prospective registration study aiming at determination of our treatment results. 89 Patients (mean age 68.4 years) underwent TURT followed by a course of external beam irradiation and interstitial brachytherapy from 1983 till 2005 in the Arnhem Radiotherapy Institute. Results The median follow-up for the brachytherapy group was 5.7 years (range 0.2–21.4 years), for the cystectomy group was 5.05 years (range: 0.04–16.8 years). No difference in disease-specific survival (DSS) could be detected with a 5- and 10-year DSS of 71% and 66% in the brachytherapy group and 60% and 57% in the cystectomy group, respectively. Five-year overall survival (OS) was 57% in the brachytherapy group and 52% in the cystectomy group, however, the 10-year OS was better in the cystectomy than in the brachytherapy group (42% and 33%, respectively). This is caused by the significant age difference in favour of the cystectomy group. Cystectomy-free survival in the brachytherapy group was 70%. Conclusion Radical cystectomy is the treatment of choice for patients with muscle-invasive bladder carcinoma. However, in a selected patient population a bladder sparing treatment, i.e. a combination of transurethral tumour resection (TURT), external beam irradiation and interstitial brachytherapy, can be applied successfully. This concerns a solitary, T1G3 or T2 bladder tumour, with a diameter < 5 cm.

EXPRESSION OF CELL CYCLE-ASSOCIATED PROTEINS IN SUPERFICIAL BLADDER CANCER: CORRELATION WITH INTRAVESICAL RECURRENCE FOLLOING TRANSURETHRAL RESECTION

Comparing the outcome of surgery and brachytherapy-based radiotherapy in patients with solitary T1G3/T2 bladder tumour in, a retrospective case-control study, because efforts for a randomised clinical trial comparing these modalities have failed.Cystectomy group. Patients were selected using the pathological registration system (PALGA). 289 cases of TURT followed by cystectomy, indicated by a muscle – invading bladder tumour were performed in three East-Netherlands medical centres between 1991 and 2001. Out of this group 179 patients with clinical T2N0M0 bladder tumour were selected. All the consecutive files were analysed by a urologist and a radiation oncologist and 65 of those patients (mean age 63.7 years) would have been eligible for brachytherapy, based on an initial analysis: cystoscopy estimated tumour size, post-TURT pathological report, completed by CT-scan and/or, MRI-scan. A final pathological report after radical cystectomy was not considered for patients’ selection.Brachytherapy group. Patients were selected using a prospective registration study aiming at determination of our treatment results. 89 Patients (mean age 68.4 years) underwent TURT followed by a course of external beam irradiation and interstitial brachytherapy from 1983 till 2005 in the Arnhem Radiotherapy Institute.The median follow-up for the brachytherapy group was 5.7 years (range 0.2–21.4 years), for the cystectomy group was 5.05 years (range: 0.04–16.8 years). No difference in disease-specific survival (DSS) could be detected with a 5- and 10-year DSS of 71% and 66% in the brachytherapy group and 60% and 57% in the cystectomy group, respectively. Five-year overall survival (OS) was 57% in the brachytherapy group and 52% in the cystectomy group, however, the 10-year OS was better in the cystectomy than in the brachytherapy group (42% and 33%, respectively). This is caused by the significant age difference in favour of the cystectomy group. Cystectomy-free survival in the brachytherapy group was 70%.Radical cystectomy is the treatment of choice for patients with muscle-invasive bladder carcinoma. However, in a selected patient population a bladder sparing treatment, i.e. a combination of transurethral tumour resection (TURT), external beam irradiation and interstitial brachytherapy, can be applied successfully. This concerns a solitary, T1G3 or T2 bladder tumour, with a diameter < 5 cm.

Angiosarcoma of the liver after multimodality therapy for gallbladder carcinoma

Background. Treatment-induced angiosarcoma is a rare complication of cancer therapy and is best known for arising on the chest wall after a mastectomy. We report an unusual case of a treatment-induced angiosarcoma developing in the liver after adjuvant radiotherapy for gallbladder carcinoma. Case report. Radiation-induced angiosarcoma of the liver developed in a 46-year-old woman after radiotherapy for stage IIB (T3N1M0) adenocarcinoma of the gallbladder in 1991. The patient subsequently underwent resection, postoperative external beam radiotherapy, and multiagent chemotherapy. Several severe late adverse effects developed, including duodenal obstruction with fistula formation and chronic mesenteric ischemia secondary to occlusion of the superior mesenteric artery. Six years after her gallbladder resection and adjuvant treatment, a fatal grade 4 of 4 angiosarcoma of the liver developed within the radiation field. Conclusions. To our knowledge, this is the first case of radiation-induced angiosarcoma of the liver after radiotherapy for gallbladder carcinoma. Normal organ dose-volume limits should be considered carefully when delivering a course of external beam radiotherapy in the upper abdomen.

Quantification of Anatomic Positional Variation and Movement over the Course of External Beam Radiation

Quantification of Anatomic Positional Variation and Movement over the Course of External Beam Radiation