Course Of External Beam Radiotherapy Research Articles

Utilization of spatially fractionated radiotherapy in the management of a patient with inoperable uterine leiomyosarcoma

Utilization of spatially fractionated radiotherapy in the management of a patient with inoperable uterine leiomyosarcoma

Adenocarcinoma of the Gartner’s duct. A case from practice

Background. A malignant tumour of the Gartner’s duct is one of the rarely encountered tumours in gynaecological oncology. Only in rare cases does the epithelium of the Gartner’s duct become a source of vaginal and cervical adenocarcinoma, as the Gartner’s duct is present in 25% of women, and mesonephric cysts occur in 1% of cases.
 Purpose. To familiarise the medical community with the peculiarities of the clinical course of malignant tumours of the Gartner’s duct and methods of their treatment.
 Materials and methods. Patient L., born in 1974, who underwent special treatment at the State Organization «Grigoriev Institute for Medical Radiology and Oncology of the National Academy of Medical Sciences of Ukraine» with a diagnosis of grade II adenocarcinoma of the Gartner’s duct (T2NxM0), clinical group 3.
 Results and discussion. After examination, the patient underwent two cycles of neoadjuvant polychemotherapy and a preoperative course of external beam radiation therapy (EBRT) on the vulvar area with a total radiation dose of 30 Gy. Two weeks later, surgery was performed to remove the tumour of the Gartner’s duct from the surrounding tissues. Three weeks after the surgery, the patient’s course of EBRT was extended to the total dose of 50 Gy, and 3 cycles of adjuvant polychemotherapy were performed. The follow-up period was 3 years, with no evidence of disease recurrence.
 Conclusions. The dissemination of information about this rare but serious disease will allow doctors to be informed, as well as to predict and diagnose it in a timely manner. As a result, they can plan adequate special treatment and determine the prognosis of this disease.

Environmental Toxicity of Driving Distance to External Beam Radiotherapy (EBRT) for Head and Neck Cancer Patients

For many patients undergoing external beam radiotherapy (EBRT), distance from home to treatment center is significant and require housing in closer proximity to minimize this travel burden. Patient transport also contributes significantly to the carbon footprint of EBRT. We sought to define the difference of carbon dioxide (CO2) emissions from commuting for patients who stay at a charity housing (CH) facility during treatment for head and neck cancer (HNC) versus a commute from home. Patients with HNC were enrolled in an IRB-approved prospective protocol from 2019-2021. A distance of 3 miles (mi) was calculated from CH to our facility using Google Maps. Driving distance from home was indicated by patient self-report. Distance traveled per day Mon-Fri was doubled to account for driving to and from treatment. It was assumed that patients staying at CH returned home on weekends and that all used a standard, gasoline powered automobile for transportation to and from home. Transportation from CH to treatment was via a gasoline powered, 6-person shuttle. Both forms of transport were considered light-duty vehicles (LDV) with mileage and tailpipe emissions corresponding to the US on-road average (23.7 mi per gallon and 0.84 lb CO2/mi). For estimation of CH emissions, conversions were made from the reported electricity bill multiplied by the North Carolina grid emissions rate of 0.698 lb CO2/kWh. Natural gas used by CH for heating (prorated per patient) was estimated using the Piedmont Natural Gas rate (located in NC) and the monthly gas bill. Emissions from patient homes were assumed to be similar for patients commuting and making use of CH and therefore ignored. Forty-nine patients enrolled in the study: 38 drove themselves to treatment daily, and 2 stayed at CH. The remaining 9 patients indicated that they stayed with friends/family or in a hotel where travel distance to DCI was unknown. CH electricity emissions were estimated to be 8,823 lb CO2/month. CH gas emissions were estimated to be 2,210.6 lb CO2/month. Emissions at CH were calculated as 137.9 lb CO2 per patient per month. The median emissions of those who drove daily per course of EBRT was 1205.4 lb CO2 (IQR 366.0 - 2221.2). For the 2 patients who stayed at the CH, total mi per course were 650 and 774. Including emissions of CH, emissions per patient were 1305.6 and 1523.2 lb CO2. If these patients were to have driven daily from their home, emissions would have been doubled (2368.8 and 2646 lb CO2, respectively). CH was estimated to result in fewer emissions for those that live ≥ 12 miles from the treatment facility. Affordable and safe housing, such as charity housing is not only convenient for patients, but also reduces the environmental impact of travel for care for HNC. Patients who stayed at the charity housing in this study reduced their emissions from travel by nearly a half compared to driving daily in a personal vehicle. Further studies are imperative to continue to measure and mitigate the environmental toxicity of cancer care.

Surgically targeted radiation therapy (STaRT) for recurrent brain metastases: Initial clinical experience

PURPOSEThis study evaluates the outcomes of recurrent brain metastasis treated with resection and brachytherapy using a novel Cesium-131 carrier, termed surgically targeted radiation therapy (STaRT), and compares them to the first course of external beam radiotherapy (EBRT). METHODSConsecutive patients who underwent STaRT between August 2020 and June 2022 were included. All patients underwent maximal safe resection with pathologic confirmation of viable disease prior to STaRT to 60 Gy to a 5-mm depth from the surface of the resection cavity. Complications were assessed using CTCAE version 5.0. RESULTSTen patients with 12 recurrent brain metastases after EBRT (median 15.5 months, range: 4.9–44.7) met the inclusion criteria. The median BED10Gy90% and 95% were 132.2 Gy (113.9–265.1 Gy) and 116.0 Gy (96.8–250.6 Gy), respectively. The median maximum point dose BED10Gy for the target was 1076.0 Gy (range: 120.7–1478.3 Gy). The 6-month and 1-year local control rates were 66.7% and 33.3% for the prior EBRT course; these rates were 100% and 100% for STaRT, respectively (p < 0.001). At a median follow-up of 14.5 months, there was one instance of grade two radiation necrosis. Surgery-attributed complications were observed in two patients including pseudomeningocele and minor headache. CONCLUSIONSSTaRT with Cs-131 presents an alternative approach for operable recurrent brain metastases and was associated with superior local control than the first course of EBRT in this series. Our initial clinical experience shows that STaRT is associated with a high local control rate, modest surgical complication rate, and low radiation necrosis risk in the reirradiation setting.

Stereotactic Body Radiation Therapy: A Radiosurgery Society Guide to the Treatment of Localized Prostate Cancer Illustrated by Challenging Cases

Traditionally, external beam radiotherapy (EBRT) for localized prostate cancer (PCa) involved lengthy courses with low daily doses. However, advancements in radiation delivery and a better understanding of prostate radiobiology have enabled the development of shorter courses of EBRT. Ultrahypofractionated radiotherapy, administering doses greater than 5 Gy per fraction, is now considered a standard of care regimen for localized PCa, particularly for intermediate-risk disease. Stereotactic body radiotherapy (SBRT), a specific type of ultrahypofractionated radiotherapy employing advanced planning, imaging, and treatment technology to deliver in five or fewer fractions, is gaining prominence as a cost-effective, convenient, and safe alternative to longer radiotherapy courses. It is crucial to address practical considerations related to patient selection, fractionation scheme, target delineation, and planning objectives. This is especially important in challenging clinical situations where clear evidence for guidance may be lacking. The Radiosurgery Society endorses this case-based guide with the aim of providing a practical framework for delivering SBRT to the intact prostate, exemplified by two case studies. The article will explore common SBRT dose/fractionation schemes and dose constraints for organs-at-risk. Additionally, it will review existing evidence and expert opinions on topics such as SBRT dose escalation, the use of rectal spacers, the role of androgen deprivation therapy in the context of SBRT, SBRT in special patient populations (e.g., high-risk disease, large prostate, high baseline urinary symptom burdens, and inflammatory bowel disease), as well as new imaging-guidance techniques like Magnetic Resonance Imaging for SBRT delivery.

Experience with intraoperative radiation therapy in an urban cancer center

Background/objectiveIntra-operative radiation therapy (IORT) is a newer partial breast irradiation technique that has been well studied in 2 large randomized trials, the TARGIT-A and ELIOT trials. We initiated our IORT program in 2018 in the context of a registry trial, and aim to report our early results thus far.MethodsWe instituted an IORT practice using Intrabeam® low energy 50kVp x-rays for selected breast cancer cases in 2018. Patients were enrolled on our institutional registry protocol which allowed for IORT in ER + patients with grade 1–2 DCIS ≤ 2.5 cm or invasive disease ≤ 3.5 cm in patients of at least 45 years of age.ResultsBetween January 2018 and December 2021, 181 patients with clinical stage 0-IIA ER + breast cancer were evaluated. One hundred sixty-seven patients ultimately received IORT to 172 sites. The majority of patients received IORT at the time of initial diagnosis and surgery (160/167; 95.8%). Re-excision post IORT occurred in 16/167 patients (9.6%) due to positive margins. Adjuvant RT to the whole breast +/- LN was ultimately given to 23/167 (13.8%) patients mainly due to positive sentinel LN found on final pathology (12/23; 52%); other reasons were close margins for DCIS (3/23; 13%), tumor size (3/23; 4.3%), and multifactorial (5/23; 17.4%). Five patients (3%) had post-operative complications of wound dehiscence. There were 3 local recurrences (1.6%) at a median follow-up of 27.9 months (range: 0.7– 54.8 months).ConclusionsIORT has been proven to be a safe and patient-centered form of local adjuvant RT for our population, in whom compliance with a longer course of external beam radiation can be an issue. Long term efficacy remains to be evaluated through continued follow up. In the era of COVID-19 and beyond, IORT has been an increasingly attractive option, as it greatly minimizes toxicities and patient visits to the clinic.Trial registrationAll patients were prospectively enrolled on an institutional review board-approved registry trial (IRB number: 2018–9409).

Remote Activity Monitoring and Electronic Patient-Reported Outcomes Collection During Radiotherapy for Head and Neck Cancer: A Pilot Study.

Modern wearable devices provide objective and continuous activity data that could be leveraged to enhance cancer care. We prospectively studied the feasibility of monitoring physical activity using a commercial wearable device and collecting electronic patient-reported outcomes (ePROs) during radiotherapy (RT) for head and neck cancer (HNC). Patients planned for a course of external beam RT with curative intent for HNC were instructed to use a commercial fitness tracker throughout the RT course. During weekly clinic visits, physician-scored adverse events were recorded during using Common Terminology Criteria for Adverse Events version 4.0, and patients completed ePRO surveys using a clinic tablet or computer. Feasibility of activity monitoring was defined as collection of step data for at least 80% of the RT course for at least 80% of patients. Exploratory analyses described associations between step counts, ePROs, and clinical events. Twenty-nine patients with HNC were enrolled and had analyzable data. Overall, step data were recorded on 70% of the days during patients' RT courses, and there were only 11 patients (38%) for whom step data were collected on at least 80% of days during RT. Mixed effects linear regression models demonstrated declines in daily step counts and worsening of most PROs during RT. Cox proportional hazards models revealed a potential association between high daily step counts and both reduced risk of feeding tube placement (hazard ratio [HR], 0.87 per 1,000 steps, P < .001) and reduced risk of hospitalization (HR, 0.60 per 1,000 steps, P < .001). We did not achieve our feasibility end point, suggesting that rigorous workflows are required to achieve continuous activity monitoring during RT. Although limited by a modest sample size, our findings are consistent with previous reports indicating that wearable device data can help identify patients who are at risk for unplanned hospitalization.

Planned organ preservation for elderly patients with rectal cancer using short course radiotherapy and a contact brachytherapy boost-an International multi-institution analysis.

The use of external beam radiotherapy (EBRT) and contact X-Ray brachytherapy (CXB) is emerging as an effective alternative in patients with early stage rectal cancer with the intent of organ preservation (OP). Short course radiotherapy (SCRT) is an alternative EBRT schedule for patients not fit for chemotherapy or for longer courses of EBRT. There are no multicentre studies that have reported on the outcomes of SCRT with a CXB boost, therefore we present these from patients from centres from the UK and Sweden. From the Guildford Colorectal Database or local databases, 258 patients who underwent SCRT and CXB with the intent of OP from five centres treated between 2007 and 2019 were identified. Response and survival data was analysed and presented. With a median age of 81, 226 patients were treated with radiotherapy alone (RTA) and 32 immediately after local excision (ILE). Median follow-up was 24 months. 70% and 97% of patients in the RTA and ILE groups respectively had a complete clinical response (cCR) after SCRT with CXB. Of those, local relapse was seen in 16% of the RTA and 3% of the ILE group. Median survival was 40 months after CXB in the RTA and 52 months in the ILE group. 94% of patients remained stoma-free to the point of latest follow-up. This data suggests that CXB when combined with SCRT, in a mainly elderly and comorbid population, provides good palliation with stoma-avoidance. Oncological outcomes compare with previously published work. A greater focus is required on quality of life outcomes after OP.

Experience in the use of low-temperature plasma in the therapy of radiation reactions.

The use of low-temperature plasma is a modern and developing direction in medicine, including rehabilitation. Low-temperature plasma (LTP) has a high antiseptic, wound-healing activity, and is also a safe method of physical exposure. In the in-patient facility of clinical unit of Federal State Budgetary Educational Institution of Further Professional Education Russian Medical Academy of Continuous Professional Education of the Ministry of Healthcare of the Russian Federation named after Prof. Yu.N. Kasatkinа, a patient was treated with low-temperature argon plasma after selective right cervical lymph node dissection, resection of the mandible, and tissues of the oral floor with defect plasty with a fibular autograft for cancer of the gingival mucosa of the mandible on the right pT4aN0M0, stage IVa. In the process of EBRT (external beam radiation therapy), the patient developed a complication in the form of a local radiation reaction with the formation of a fistulous opening in the area of the postoperative scar. The fistulous opening and the affected area were treated with a cooled air-plasma flow. During the continued use of LTP, the termination of pyorrhea, a decrease in hyperemia and edema in the area of tissues damaged by ionizing radiation were noted. The patient was promptly continued radiation therapy.&#x0D; Thus, the use of this therapeutic factor in the program of medical rehabilitation is an effective way of local impact on the pathological focus, allows you to achieve a quick reparative effect, eliminates and prevents the development of bacterial complications. In addition, the use of an air-plasma flow contributes to the rapid relief of manifestations of radiation reactions, having a beneficial effect on damaged tissues, as well as shortening the rehabilitation period for severe cancer patients in the postoperative period and during the course of EBRT. The results of LTP action have a positive effect on the general condition of patients and improve their quality of life.

Early onset of severe lymphopenia during definitive radiotherapy correlates with mean body dose and predicts poor survival in cervical cancer.

BACKGROUND: Lymphopenia during definitive radiotherapy (RT) has been shown to reduce survival in patients with cervical cancer. However, there are few studies on the significance of onset time of lymphopenia during RT in patients with cervical cancer.OBJECTIVE: This study aimed to exam the prognostic significance of early onset of severe lymphopenia (EOSL) during definitive RT in patients with cervical cancer.METHODS: Newly diagnosed cervical cancer patients treated with definitive RT from January 2015 to December 2019 were eligible for this retrospective study. EOSL was defined as first onset of grade 3–4 lymphopenia 3 weeks from the start of RT. Mean body dose (MBD) was the mean radiation dose absorbed by the body during the whole course of external beam RT (EBRT) and was directly obtained from the dose volume histogram (DVH) of the EBRT planning. Logistic regression analysis and restricted cubic spline (RCS) models were applied to assess relationships between clinicopathological factors and EOSL. Survival analysis was performed using Kaplan-Meier curves and log-rank test. A COX regression model was developed to predict overall survival (OS).RESULTS: A total of 104 patients were included and 59.6% had EOSL. MBD ( 0.04), concurrent cisplatin ( 0.011), and pre-RT absolute lymphocyte count (ALC) ( 0.001) were associated with EOSL. A linear relationship ( for non-linearity 0.803) between MBD and risk of EOSL was found. Patients with EOSL had decreased OS (2-yr 75.1% vs 91.1%, 0.021) and progression-free survival (PFS) (2-yr 71.2% vs 83.7%, 0.071). An OS prediction COX model was developed with C-index of 0.835 and AUC of 0.872.CONCLUSIONS: EOSL during definitive RT correlates with MBD and predicts poor survival in patients with cervical cancer.

Characteristics of endoprosthesis replacement of bones and joints in patients with metastatic lesions

The article presents the results of endoprosthesis replacement of joints and bones in 19 patients with bone metastasis. The complications resulted from endoprosthesis replacement of joints and bones in cases of bone metastasis were observed in 4 (21.1%) patients, and tumor recurrences were observed in 2 (10.5%) patients. In the preoperative period, 19 patients underwent courses of external beam radiotherapy with a total radiation dose (TRD) of 40 Gray, with a single mediated dose (SMD) of 2–2.5 Gray. Also, all patients received preoperative multiagent chemotherapy treatment cycles depending on the primary source of the tumor, and in cases of hormone-dependent tumors, the patients received hormone therapy. Depending on the specific anatomical and functional changes, special implant designs, tools, and techniques were used, which complemented the standard technique of operations. The basic principles of oncosurgery have been adhered to during endoprosthesis replacement of joints and bones, i.e. standard principles of resection and ablastics, removing en bloc of a biopsy area. In endoprosthesis replacement, a cement type of endoprosthesis fixation was used. For an adequate formation of the muscle envelope of the endoprosthesis, a plastic stage of the ope-ration was performed, which allowed to adequately cover the installed endoprosthesis, and thus, reduce the risk of infectious complications. Both displaced and free vascularized musculocutaneous flaps on microvascular anastomoses were used as plastic material. To limit the contact of the metal part of the endoprosthesis with the surrounding tissues and to reconstruct the tendon ligamentous apparatus, a tube of polyethylene tetraphthalate was used, resected tendon and muscles were sutured to it, which allowed to more fully restore joint action. The functioning of extremity according to the MSTS scale after endoprosthesis replacement of joints ranged from 70 to 92 %, and also the quality of life of patients improved up to 70–75 points.

ПРИМЕНЕНИЕ ДЕЗОКСИРИБОНУКЛЕАТА НАТРИЯ ДЛЯ ПРОФИЛАКТИКИ ЛУЧЕВОГО ЦИСТИТА У ПАЦИЕНТОВ С РАКОМ ТЕЛА ИЛИ ШЕЙКИ МАТКИ

Results: To develop a method for reducing the frequency and severity of early radiation reactions in patients with cancer of the uterus or cervix.&#x0D; Material and methods: We analyzed the results of treatment of 60 patients with cancer of the uterus and cervix, patients received a postoperative course of external beam radiotherapy combined with the intramuscular administration of the Derinat® radioprotector (sodium deoxyribonucleate); in the second arm, they received a postoperative course of external beam radiotherapy and standard therapy in case of radiation cystitis. The assessment of radiation reactions severity was performed with the EORTC QLQ-C30 criteria, WBC count, IPSS scale, urine analysis and cystoscopic examination evaluated with the developed by us scale.&#x0D; Results: Evaluation of the quality of life in patients with cervical or uterine cancer at the final stage of treatment using the IPSS scale showed that in the arm of patients with sodium deoxyribonucleate, there was a 30.4 % (p&gt; 0.05) decrease in the symptoms of urinary disorders. The use of the radioprotector sodium deoxyribonucleate also statistically significantly reduced the incidence of radiation cystitis by 73 %. According to cystoscopy, the total bladder injury score at the end of treatment was 147 % lower. The number of leukocytes in the urine analysis at the end of treatment was 116.3 % lower (p≤0.01) in those who received sodium deoxyribonucleate&#x0D; Conclusion: The data obtained indicate the radioprotective efficacy of sodium deoxyribonucleate and make it possible to recommend its intramuscular administration to patients with cancer of the uterus and cervix against the background of external beam radiation therapy to reduce the frequency and severity of acute radiation cystitis in patients with cancer of the uterus or cervical cancer receiving external beam radiation therapy.

An Unusual Case of Coexistence:De-Differentiation of a Papillary Thyroid Carcinoma into SquamousCell Carcinoma

Background: Squamous cell carcinoma (SCC) of the thyroid is a rare condition comprising less than 1% of thyroid cancer. SCC of the thyroid may arise from de-differentiation of aggressive thyroid carcinomas secondary to chronic thyroid gland inflammation1. Thyroid SCC is a variant of undifferentiated thyroid carcinoma and is also associated with tall-cell variant of Papillary thyroid carcinoma (PTC). Given its aggressive clinical course, early recognition of the disease is essential to management. Clinical Case: A 67-year-old, Filipino male, presented with anterior neck mass over a period of 11-months. He was clinically euthyroid. Neck ultrasound showed enlarged thyroid gland with hypoechoic left thyroid nodule (1.9cm x 1.2cm) where fine needle aspiration biopsy showed a colloid nodule. Patient then manifested with compressive symptoms, undocumented weight loss and easy fatigability. He had total thyroidectomy with histopathology consistent with Diffuse Sclerosing Variant of PTC with Squamous Differentiation, arising from chronic lymphocytic thyroiditis with extra-thyroidal extension. Immunohistochemical markers showed (+) TTF-1, (+) HBME-1 and (+) PAX – 8. Two months after thyroidectomy, he noticed palpable cervical nodes and hoarseness of voice. PET-CT scan showed hypermetabolism in the thyroid bed and tumor recurrence with 2 FDG-avid lymph nodes, on Level III with SUVS up to 8.5. RAI imaging showed functioning thyroid tissues. Patient had completion thyroidectomy with selective neck dissection within 3 months after initial surgery. Histopathology revealed Keratinizing Squamous Cell Carcinoma metastatic to lymph nodes. Molecular studies were not pursued by patient. Repeat PET/CT Scan showed rapid tumor recurrence in the left thyroid bed with strap muscle and thyroid cartilage infiltration, as well as cervical lymph node invasion. PEG insertion and prophylactic tracheostomy addressed nutritional status and airway protection, respectively. He was treated with course of external beam radiation (60 Gy in 33 fractions). He had concurrent chemotherapy with Carboplatin-Paclitaxel regimen for only 2 cycles. After 13 months of initial presentation, patient eventually succumbed to cardiac arrest. Conclusion: This transformation of the thyroid is a malignancy with high mortality, with average survival length of only less than a year. Combined modality with surgery, radiotherapy and chemotherapy to prevent disease progression and local recurrence is needed. Multidisciplinary approach is significant in the management due to its poor survival rate.

Radiation therapy in treatment of patients with meningeal hemangiopericytoma (solitary fibrous) tumor of dura mater

Tactics of treating patients with meningeal hemangiopericytoma, or a solitary fibrous tumor of the dura mater remains controversial due to their rarity and heterogeneity of global experience, however, analysis of clinical data indicates that the best results are achieved when performing a total removal of the primary tumor and then following a course of external-beam radiation therapy on surgical bed in adequate total doses.

Retrospective Review of Factors Associated with Survival in Patients Treated with Gamma Knife for Recurrent Glioblastoma.

Stereotactic radiosurgery (SRS) has been utilized to offer patients a non-surgical option for glioblastoma recurrence. Prior studies indicate that dose >15 Gy has a positive impact on patient survival. We hypothesized that both treatment dose and the volume of recurrence would correlate with patient outcome in a retrospective review of a single institutional experience. This was a single institution retrospective review of all patients treated with radiosurgery for glioblastoma recurrence from 2009-2018. All patients were treated with 59.4-60 Gy in 1.8-2.0 Gy fractions with concurrent temozolamide at the time of their initial diagnosis. Overall survival (OS) was estimated using Kaplan-Meier survival curves and examined using multivariate cox proportional hazard regression models (MVA). Data management and decision management software was used for analyses. Fifty-five patients were eligible for analysis with a median follow-up of 18.2 months. Median age was 55 years (range: 16-82 years), and 35 patients (64%) were male. Fifty-two (95%) underwent either gross total or subtotal resection at the time of initial treatment. Fourteen patients (25%) underwent a second surgical resection prior to GK. Six patients (11%) had already received a repeat course of external beam radiation for a previous recurrence. Median dose was 15 Gy (range: 7-25Gy). Dose >15 Gy was associated with a trend towards improved survival (p=0.058). There was no association between dose and volume of recurrence (R2=0.01). On MVA, dose >15 Gy (p=0.02) and time >20.2 months from primary therapy to GK (p=0.03) were associated with improved OS. Age, RPA group, and volume of recurrence were not significant predictors of outcome. Findings are consistent with previous literature supporting dose >15 Gy and longer freedom from recurrence as features predictive of OS for patients with recurrent glioblastoma. Because volume of recurrence was not associated with delivered dose or patient survival, these results suggest dose >15 Gy should be considered regardless of volume. Further studies are needed to characterize toxicity.

Clinical Outcomes of Spatially Fractionated GRID Radiotherapy in the Treatment of Bulky Tumors of the Head and Neck.

ObjectivesThe clinical outcomes of patients treated with spatially fractionated GRID radiotherapy (SFGRT) for bulky tumors of the head and neck at a single institution were evaluated retrospectively. Endpoints of interest included tumor response, symptom improvement, treatment tolerance, and adverse events.MethodsInstitutional review board approval was obtained prior to study initiation. The institutional database was queried for patients with tumors of the head and neck treated with SFGRT between August 2007 and April 2015. Medical records of identified patients were reviewed for treatment details and clinical endpoints of interest. SFGRT was delivered in one fraction of 15 gray (Gy) or 20 Gy; 6 megavolt (MV) or 18 MV photon beams were passed through a multileaf collimator (MLC)-based or brass GRID template. All patients had a planned course of conventionally-fractionated external beam radiotherapy (EBRT) to begin on the day following SFGRT delivery.ResultsTwenty-one consecutive patients meeting study criteria were identified. The most common tumor histology was squamous cell carcinoma. Median patient age was 59 years (range 13 - 83 years); median maximum tumor dimension was 9.5 centimeters (cm) (range 5.0 - 25.0 cm). Fifteen patients (71.4%) completed their full course of EBRT. Twelve patients were treated with palliative intent for local tumor symptoms, of which 54.5% experienced some degree of symptom improvement. Of nine patients treated with curative intent, 44.4% achieved a clinical complete response (CR). Concurrent chemotherapy was administered in 12 patients, with all patients being treated having definitively received chemotherapy. Radiation Therapy Oncology Group (RTOG) grade three or higher skin toxicity occurred in five patients; no grade five events were reported.ConclusionsOur institutional experience suggests that SFGRT is a feasible treatment option for the palliative or definitive management of large tumors of the head and neck. In combination with EBRT, SFGRT can provide timely symptom management and improve patient quality of life in the palliative setting. In the definitive setting, the addition of chemotherapy to SFGRT and EBRT can result in an excellent clinical response. Treatment toxicity was found to be within an acceptable range. When considering SFGRT for patients with these challenging presentations, careful patient selection is needed to identify those who will likely tolerate a full course of EBRT following SFGRT, as these patients are most likely to receive maximal benefit from SFGRT treatment. More data on the feasibility and efficacy of this radiation modality will be helpful for continued optimization of SFGRT delivery and patient selection.

Novel intraoperative radiotherapy utilizing prefabricated custom three-dimensionally printed high-dose-rate applicators

BackgroundIntraoperative radiotherapy (IORT) is an effective strategy for the delivery of high doses of radiotherapy to a residual tumor or resection cavity with relative sparing of nearby healthy tissues. This strategy is an important component of the multimodality management of pediatric soft tissue sarcomas, particularly in cases where patients have received prior courses of external beam radiotherapy. PurposeTumor beds with significant topographic irregularity remain a therapeutic challenge because existing IORT technologies are typically most reliable with flat surfaces. To address this limitation, we have developed a novel strategy to create custom, prefabricated high-dose-rate (HDR)-IORT applicators designed to match the shape of an anticipated surgical cavity. Methods and MaterialsSilastic applicators are constructed using three-dimensional (3D) printing and are derived from volumetric segmentation of preoperative imaging. ResultsHDR preplanning with the applicators improves dosimetric accuracy and minimizes incremental operative time. In this report, we describe the fabrication process for the 3D-printed applicators and detail our experience utilizing this strategy in two pediatric patients who underwent HDR-IORT as part of complex base of skull sarcoma resections. ConclusionsEarly experience suggests that usage of the custom applicators is feasible, versatile for a variety of clinical situations, and enables the uniform delivery of high superficial doses of radiotherapy to irregularly shaped surgical cavities.

Is brachytherapy a viable treatment option for muscle-invasive bladder cancer?

Event Abstract Back to Event Is brachytherapy a viable treatment option for muscle-invasive bladder cancer? Liam Mannion1, 2*, Mieke Van Hemelrijck1 and Simon Hughes3 1 Department of Translational Oncology and Urology Research, Faculty of Life Sciences & Medicine, King's College London, United Kingdom 2 City University of London, United Kingdom 3 Guy's and St Thomas' NHS Foundation Trust, United Kingdom Purpose: Muscle-invasive bladder cancer (MIBC) is an aggressive disease with a high mortality rate. Treatment typically involves a cystectomy which is an undesirable option for most patients. Objectives: To evaluate the clinical effectiveness of brachytherapy for solitary urinary bladder tumours in terms of survival. Methods: A systematic review was conducted using the preferred reporting items of systematic reviews and meta-analysis (PRISMA) guidelines with defined search terms: an online search was performed using the PubMed database with the terms brachytherapy AND urinary bladder cancer AND survival. Three individual searches were performed using MeSH and title/abstract searches. The builder option was used to combine the three initial searches which resulted in 80 articles. Results: 21 studies were included in the final analysis. Ten separate endpoints were reported within the articles, 17 of the 21 articles reported overall survival at 5 years, with a combined number of 2889 patients at risk and 1775 alive after 5 years (61.4%) Conclusion: Brachytherapy for MIBC is an alternative (and organ preserving option) for solidarity (<5cm) tumours when combined with a short course of external beam radiotherapy. Figure 1 Keywords: Brachytherapy, muscle invasive bladder cancer, Survival, Internal radiation, Urinary bladdder Conference: Bladder Cancer Translational Research Meeting, London, United Kingdom, 29 Mar - 29 Mar, 2019. Presentation Type: Poster Topic: Development of personalised treatment Citation: Mannion L, Van Hemelrijck M and Hughes S (2019). Is brachytherapy a viable treatment option for muscle-invasive bladder cancer?. Front. Oncol. Conference Abstract: Bladder Cancer Translational Research Meeting. doi: 10.3389/conf.fonc.2019.01.00011 Copyright: The abstracts in this collection have not been subject to any Frontiers peer review or checks, and are not endorsed by Frontiers. They are made available through the Frontiers publishing platform as a service to conference organizers and presenters. The copyright in the individual abstracts is owned by the author of each abstract or his/her employer unless otherwise stated. Each abstract, as well as the collection of abstracts, are published under a Creative Commons CC-BY 4.0 (attribution) licence (https://creativecommons.org/licenses/by/4.0/) and may thus be reproduced, translated, adapted and be the subject of derivative works provided the authors and Frontiers are attributed. For Frontiers’ terms and conditions please see https://www.frontiersin.org/legal/terms-and-conditions. Received: 01 Mar 2019; Published Online: 27 Sep 2019. * Correspondence: Mr. Liam Mannion, Department of Translational Oncology and Urology Research, Faculty of Life Sciences & Medicine, King's College London, London, SE1 1UL, United Kingdom, Liam.mannion@city.ac.uk Login Required This action requires you to be registered with Frontiers and logged in. To register or login click here. Abstract Info Abstract The Authors in Frontiers Liam Mannion Mieke Van Hemelrijck Simon Hughes Google Liam Mannion Mieke Van Hemelrijck Simon Hughes Google Scholar Liam Mannion Mieke Van Hemelrijck Simon Hughes PubMed Liam Mannion Mieke Van Hemelrijck Simon Hughes Related Article in Frontiers Google Scholar PubMed Abstract Close Back to top Javascript is disabled. Please enable Javascript in your browser settings in order to see all the content on this page.

Medication adherence in patients with chronic heart failure at King Chulalongkorn Memorial Hospital, The Thai Red Cross Society

To examine associations between radiation therapy (RT) noncompliance and clinical outcomes.We reviewed all patients who completed courses of external beam RT with curative intent in our department from the years 2007 to 2012 for cancers of the head and neck, breast, lung, cervix, uterus, or rectum. Patients who missed 2 or more scheduled RT appointments (excluding planned treatment breaks) were deemed noncompliant. Univariate, multivariable, and propensity-matched analyses were performed to examine associations between RT noncompliance and clinical outcomes.Of 1227 patients, 266 (21.7%) were noncompliant. With median follow-up of 50.9 months, 108 recurrences (8.8%) and 228 deaths (18.6%) occurred. In univariate analyses, RT noncompliance was associated with increased recurrence risk (5-year cumulative incidence 16% vs 7%, P<.001), inferior recurrence-free survival (5-year actuarial rate 63% vs 79%, P<.001), and inferior overall survival (5-year actuarial rate 72% vs 83%, P<.001). In multivariable analyses that were adjusted for disease site and stage, comorbidity score, gender, ethnicity, race, and socioeconomic status (SES), RT noncompliance was associated with inferior recurrence, recurrence-free survival, and overall survival rates. Propensity score–matched models yielded results nearly identical to those seen in univariate analyses. Low SES was associated with RT noncompliance and was associated with inferior clinical outcomes in univariate analyses, but SES was not associated with inferior outcomes in multivariable models.For cancer patients being treated with curative intent, RT noncompliance is associated with inferior clinical outcomes. The magnitudes of these effects demonstrate that RT noncompliance can serve as a behavioral biomarker to identify high-risk patients who require additional interventions. Treatment compliance may mediate the associations that have been observed linking SES and clinical outcomes.

(OA22) Inter-Fractional Motion in Patients With Intact Cervical Cancer Treated on a MRI Guided External Beam Radiation Therapy System

Treatment verification has improved significantly over the past decades, now with the ability to have on-board MRI guidance. MRI provides superior soft tissue contrast compared to CT-based imaging modalities and provides better delineation of pelvic organs and gross tumor volumes (GTV) for those with cervical cancer. Consensus contouring guidelines for intensity modulated radiation therapy (IMRT) for cervical cancer advise including the whole uterus in the target volume and adding large planning target volume (PTV) margins to account for inter- and intra-fractional uncertainties. The primary objectives of our analysis was to assess the inter-fractional GTV motion for those with an intact cervix using on-board, daily MRI and to assess the relationship between bladder and rectal volumes and GTV motion. We analyzed 125 daily set-up MRI’s from five patients with intact cervical cancer who received MRI-guided pelvic IMRT at our institution between September 2016 and October 2017. The GTV, bladder, uterus, and rectum were contoured on all 125 MRI’s, which included 25 daily set-up MRI’s for each patient. The daily set-up MRI was registered with the planning MRI to assess organ motion. Tumor motion was assessed using GTV centroid displacements baselined to the planning MRI. Tumor volume and organ volumes were determined for each fraction. Then, a linear regression analysis was utilized to evaluate the relationship between rectal and bladder volumes and GTV motion. Patients were advised to have comfortable bladder filling for treatment. The initial GTV’s ranged in size from 31.9 cc to 119.5 cc. All GTV’s decreased in size during the course of external beam radiation, ranging from 34.0% to 85.2% of the initial tumor volumes on the final day of treatment. The ranges of daily centroid GTV displacement for all patients were from 0.08 cm to 2.23 cm, and the median GTV displacement for each patient was 0.69 cm to 1.04 cm. On linear regression analysis, 4 out of 5 patients demonstrated a strong relationship between rectal volume and GTV displacement with 26.4% of these displacements larger than 1 cm. Rectal volumes had the strongest impact on anterior-posterior GTV motion. Rectal volume appeared to better correlate with GTV displacement than bladder volume. However, for large tumors (>75 cc), tumor shrinkage during the course of radiation therapy seemed to have the most significant impact on GTV displacement. GTV shrinkage for large tumors strongly correlated with inferior GTV shifts, which were up to 1.4 cm in magnitude. Inter-fractional target motion is considerable and is affected by a variety of factors, including target volume changes, rectal volume, and, to a lesser degree, bladder volume. Our data suggests GTV shrinkage for large tumors has the greatest impact on GTV displacement. Inclusion of the whole uterus within the target volume and large CTV to PTV expansions remain standard practice. However, since the GTV is easily visible on daily MR imaging, one could think that eventually the target volume may exclude the uterine fundus and may also allow for decreased PTV margins with the ultimate goal of decreasing treatment toxicity.