Dose Fractionation Schedules Research Articles

Palliative radiotherapy for bone metastases from lung cancer: Evidence-based medicine?

To review current recommendations for palliative radiotherapy for bone metastases secondary to lung cancer, and to analyze surveys to examine whether global practice is evidence-based, English language publications related to best practice palliative external beam radiotherapy (EBRT) for bone metastases (BM) from lung cancer were sought via literature search (2003-2013). Additional clinical practice guidelines and consensus documents were obtained from the online Standards and Guidelines Evidence Directory. Eligible survey studies contained hypothetical case scenarios which required participants to declare whether or not they would administer palliative EBRT and if so, to specify what dose fractionation schedule they would use. There is no convincing evidence of differential outcomes based on histology or for spine vs non-spine uncomplicated BM. For uncomplicated BM, 8Gy/1 is widely recommended as current best practice; this schedule would be used by up to 39.6% of respondents to treat a painful spinal lesion. Either 8Gy/1 or 20Gy/5 could be considered standard palliative RT for BM-related neuropathic pain; 0%-13.2% would use the former and 5.8%-52.8% of respondents the latter (range 3Gy/1-45Gy/18). A multifraction schedule is the approach of choice for irradiation of impending pathologic fracture or spinal cord compression and 54% would use either 20Gy/5 or 30Gy/10. Survey results regarding management of complicated and uncomplicated BM secondary to lung cancer continue to show a large discrepancy between published literature and patterns of practice.

Non-melanoma skin cancer treated with HDR Valencia applicator: clinical outcomes.

PurposeRadiotherapy (RT) has played a significant role in treating non melanoma skin cancer (NMSC). High-dose-rate brachytherapy (HDR-BT) approaches have a paramount relevance due to their adaptability, patient protection, and variable dose fractionation schedules. Several innovative applicators have been introduced to the brachytherapy community. The Valencia applicator is a new superficial device that improves the dose distribution compared with the Leipzig applicator. The purpose of this work is to assess the tumor control, cosmesis, and toxicity in patients with NMSC treated with the Valencia applicator and a new regimen of hypofractionation.Material and methodsFrom January 2008 to March 2010, 32 patients with 45 NMSC lesions were treated with the Valencia applicator in the Hospital La Fe. The gross tumor volume was visually assessed, but the tumor depth was evaluated using ultrasound imaging. All lesions for the selected cases were limited to 4 mm depth. The prescription dose was 42 Gy in 6 or 7 fractions (biologically effective dose [BED] ≈ 70 Gy), delivered twice a week.ResultsNinety-eight percent of the lesions were locally controlled at 47 months from treatment. Ninety-three percent of patients were out at least 36 months from treatment. The treatment was well tolerated in all cases. The highest skin toxicity was grade 1 RTOG/EORTC, having resolved with topical treatment at 4 weeks in all but one case which required 2 months. There were no grade 2 or higher late adverse events.ConclusionsIn patients with superficial basal cell carcinoma lesions less than 25 mm in maximum diameter, HDRBT treatment with the Valencia applicator using a hypofractionated regimen provides excellent results, for both cosmetic and local control at a minimum of 3 years follow-up. Moreover, the shorter hypofractionated regimen facilitates compliance, which is very relevant for the elderly patients in our series. Valencia applicators offer a simple, safe, quick, and attractive nonsurgical treatment option.

Single versus multiple fractions of repeat radiation for painful bone metastases: a randomised, controlled, non-inferiority trial

Although repeat radiation treatment has been shown to palliate pain in patients with bone metastases from multiple primary origin sites, data for the best possible dose fractionation schedules are lacking. We aimed to assess two dose fractionation schedules in patients with painful bone metastases needing repeat radiation therapy. We did a multicentre, non-blinded, randomised, controlled trial in nine countries worldwide. We enrolled patients 18 years or older who had radiologically confirmed, painful (ie, pain measured as ≥2 points using the Brief Pain Inventory) bone metastases, had received previous radiation therapy, and were taking a stable dose and schedule of pain-relieving drugs (if prescribed). Patients were randomly assigned (1:1) to receive either 8 Gy in a single fraction or 20 Gy in multiple fractions by a central computer-generated allocation sequence using dynamic minimisation to conceal assignment, stratified by previous radiation fraction schedule, response to initial radiation, and treatment centre. Patients, caregivers, and investigators were not masked to treatment allocation. The primary endpoint was overall pain response at 2 months, which was defined as the sum of complete and partial pain responses to treatment, assessed using both Brief Pain Inventory scores and changes in analgesic consumption. Analysis was done by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00080912. Between Jan 7, 2004, and May 24, 2012, we randomly assigned 425 patients to each treatment group. 19 (4%) patients in the 8 Gy group and 12 (3%) in the 20 Gy group were found to be ineligible after randomisation, and 140 (33%) and 132 (31%) patients, respectively, were not assessable at 2 months and were counted as missing data in the intention-to-treat analysis. In the intention-to-treat population, 118 (28%) patients allocated to 8 Gy treatment and 135 (32%) allocated to 20 Gy treatment had an overall pain response to treatment (p=0·21; response difference of 4·00% [upper limit of the 95% CI 9·2, less than the prespecified non-inferiority margin of 10%]). In the per-protocol population, 116 (45%) of 258 patients and 134 (51%) of 263 patients, respectively, had an overall pain response to treatment (p=0·17; response difference 6·00% [upper limit of the 95% CI 13·2, greater than the prespecified non-inferiority margin of 10%]). The most frequently reported acute radiation-related toxicities at 14 days were lack of appetite (201 [56%] of 358 assessable patients who received 8 Gy vs 229 [66%] of 349 assessable patients who received 20 Gy; p=0·011) and diarrhoea (81 [23%] of 357 vs 108 [31%] of 349; p=0·018). Pathological fractures occurred in 30 (7%) of 425 patients assigned to 8 Gy and 20 (5%) of 425 assigned to 20 Gy (odds ratio [OR] 1·54, 95% CI 0·85-2·75; p=0·15), and spinal cord or cauda equina compressions were reported in seven (2%) of 425 versus two (<1%) of 425, respectively (OR 3·54, 95% CI 0·73-17·15; p=0·094). In patients with painful bone metastases requiring repeat radiation therapy, treatment with 8 Gy in a single fraction seems to be non-inferior and less toxic than 20 Gy in multiple fractions; however, as findings were not robust in a per-protocol analysis, trade-offs between efficacy and toxicity might exist. Canadian Cancer Society Research Institute, US National Cancer Institute, Cancer Council Australia, Royal Adelaide Hospital, Dutch Cancer Society, and Assistance Publique-Hôpitaux de Paris.

Patterns of Practice in the Prescription of Palliative Radiotherapy for the Treatment of Thoracic Symptoms of Lung Cancer at the Rapid Response Radiotherapy Program between 2006 and 2012

Objective: Radiation therapy can often be used for palliation of thoracic symptoms in patients presenting with locally advanced lung cancer or lung metastases. The aim of this study was to examine whether patterns of practice in prescription of palliative thoracic radiation therapy have changed over time in the Rapid Response Radiotherapy Program. Secondary outcomes were factors that may have influenced the treatment regimen prescribed, including patient, disease, and organisational factors. Methods: This study was a retrospective review of a prospective database of patients with locally advanced lung cancer or lung metastases referred to the Rapid Response Radiotherapy Program for thoracic symptoms between 1 July 2006 and 30 April 2012. Patient demographics, and organisational and disease factors were descriptively analysed. Differences in proportions between unordered categorical variables were examined using chi-squared test. Univariate logistic regression analysis and backward stepwise selection procedure were used to determine the most significant factors in prescription practice. Results: A total of 175 courses of palliative thoracic radiation therapy were prescribed. The median age of the patients was 71 years, and the median Karnofsky Performance Status was 60. The most commonly prescribed treatment regimen was 20 Gy in 5 fractions (20 Gy/5), which made up 64% of all the courses prescribed. There was a significant increase in frequency of the prescription of 20 Gy/5 over time (p = 0.02). The site of radiation (disease factor) and years of certification for independent practice of the treating radiation oncologist (organisational factor) were also significant factors in the prescription of 20 Gy/5 over time (both p = 0.02). Conclusion: A significant increase in the prescription of 20 Gy/5 was observed over time. However, the prescription of a higher dose fractionation schedule for patients with a higher performance status, as seen in other clinical trials and guidelines, was not observed. Future studies should further explore other possible factors such as patient survival, preference, comorbidities, and disease burden that may influence the dose fractionation prescribed.

Compliance with evidence-based guidelines for radiation of vertebral metastases.

36 Background: Evidence based guidelines pertaining to the management of bony metastases have been published. However, up to 30% of oncology treatments deviate from evidence based standards and widespread variations in clinical practice continue to exist. To explore patterns of care in the treatment of vertebral metastases in a group of working age, insured patients, we assessed treatment plans submitted for preauthorization through eviti Connect. Methods: Eviti Connect is a web-based application that enables oncology providers to obtain automated precertification for patients. The platform evaluates treatment plans for consistency with EBM and compliance with payer policies and plan language. All requests for radiation treatment submitted during a two year period from 6/1/11-5/31/13 were reviewed. Peer to peer discussions were conducted in cases that deviated from EBM. Results: A total of 229 cases for the treatment of vertebral metastases were submitted. 46/229 plans (19.8%) did not meet EBM standards. Some cases displayed more than one deviation. Reasons for non-compliance included atypical treatment schedules (8.69%), SRS/SBRT (36.9%), IMRT (32.6%), and IGRT (58.7%). In 26/46 cases (56.5%) the treating physician provided a medical rationale for the deviation. In 9 cases the physician altered the plan to be compliant; in 5 cases the physician did not agree to a change. The most common dose fractionation schedules were 30 Gy/10 fractions (48.9%) and 37.5 Gy/15 fractions (20.5%). 17 cases were treated using 20 Gy/5 fractions and only 2 cases were treated using 8 Gy X 1. Conclusions: Radiation of vertebral metastases was prescribed in accordance with EBM in the majority of cases. The main reasons for deviation were patient-specific issues that justified the medical necessity of the variance. Case review and peer to peer discussion contributed to understanding the rationale for treatment deviation from guidelines and allowed providers to bring plans into compliance with EBM. Overall only 5% of plans were non-evidence based or lacked a medical justification for deviation. Consistent with patterns of care across the US, within this group of patients, single fraction and hypofractionated radiation regimens were underutilized.

Patterns of Practice in the Prescription of Palliative Radiotherapy for the Treatment of Bone Metastases at the Rapid Response Radiotherapy Program between 2005 and 2012

We examined whether patterns of practice in the prescription of palliative radiation therapy for bone metastases had changed over time in the Rapid Response Radiotherapy Program (rrrp). After reviewing data from August 1, 2005, to April 30, 2012, we analyzed patient demographics, diseases, organizational factors, and possible reasons for the prescription of various radiotherapy fractionation schedules. The chi-square test was used to detect differences in proportions between unordered categorical variables. Univariate logistic regression analysis and the simple Fisher exact test were also used to determine the factors most significant to choice of dose-fractionation schedule. During the study period, 2549 courses of radiation therapy were prescribed. In 65% of cases, a single fraction of radiation therapy was prescribed, and in 35% of cases, multiple fractions were prescribed. A single fraction of radiation therapy was more frequently prescribed when patients were older, had a prior history of radiation, or had a prostate primary, and when the radiation oncologist had qualified before 1990. For patients with bone metastasis, a single fraction of radiation therapy was prescribed with significantly greater frequency.

Consolidating duodenal and small bowel toxicity data via isoeffective dose calculations based on compiled clinical data

PurposeTo consolidate duodenum and small bowel toxicity data from clinical studies with different dose fractionation schedules using the modified linear quadratic (MLQ) model. A methodology of adjusting the dose–volume (D,v) parameters to different levels of normal tissue complication probability (NTCP) was presented. Methods and MaterialsA set of NTCP model parameters for duodenum toxicity were estimated by the χ2 fitting method using literature-based tolerance dose and generalized equivalent uniform dose (gEUD) data. These model parameters were then used to convert (D,v) data into the isoeffective dose in 2 Gy per fraction, (DMLQED2,v) and convert these parameters to an isoeffective dose at another NTCP (DMLQED2’,v). ResultsThe literature search yielded 5 reports useful in making estimates of duodenum and small bowel toxicity. The NTCP model parameters were found to be TD50(1)model = 60.9 ± 7.9 Gy, m = 0.21 ± 0.05, and δ = 0.09 ± 0.03 Gy-1. Isoeffective dose calculations and toxicity rates associated with hypofractionated radiation therapy reports were found to be consistent with clinical data having different fractionation schedules. Values of (DMLQED2’,v) between different NTCP levels remain consistent over a range of 5%-20%. ConclusionsMLQ-based isoeffective calculations of dose–response data corresponding to grade ≥2 duodenum toxicity were found to be consistent with one another within the calculation uncertainty. The (DMLQED2,v) data could be used to determine duodenum and small bowel dose–volume constraints for new dose escalation strategies.

Prevention and management of radiation-induced dermatitis, mucositis, and xerostomia

Current strategies for preventing and managing radiation-induced dermatitis, mucositis, and xerostomia are reviewed, with an emphasis on pharmacologic interventions. Nearly two thirds of all patients with cancer receive radiation therapy during the course of treatment, frequently resulting in acute skin and mucosal toxicities. The severity of radiotherapy-associated toxicities varies according to multiple treatment- and patient-related factors (e.g., total radiation dose and dose fractionation schedule, volume of organ or tissue irradiated, use of concurrent versus sequential chemotherapy, comorbid conditions, functional performance status). Three major radiation toxicities encountered in clinical practice are (1) radiation dermatitis, typically managed with a variety of topical agents such as water-based moisturizing creams or lotions, topical steroids, antiinflammatory emulsions, and wound dressings, (2) radiation-induced oral mucositis, which can be managed through proper basic oral care practices, appropriate pain management, and the use of medicated mouthwashes and oral rinses and gels, and (3) radiation-induced xerostomia, which can be alleviated with saliva substitutes, moistening agents, and sialagogues. Pharmacists involved in the care of patients receiving radiotherapy can play an important role in optimizing symptom control, educating patients on self-care strategies, and adverse effect monitoring and reporting. Radiation-induced dermatitis, mucositis, and xerostomia can cause significant morbidity and diminished quality of life. Pharmacologic interventions for the prevention and treatment of these toxicities include topical agents for dermatitis; oral products, analgesics, and palifermin for mucositis; and amifostine, saliva substitutes, and pilocarpine for xerostomia.

Hypofractionated radiosurgery for intact or resected brain metastases: defining the optimal dose and fractionation

BackgroundHypofractionated Radiosurgery (HR) is a therapeutic option for delivering partial brain radiotherapy (RT) to large brain metastases or resection cavities otherwise not amenable to single fraction radiosurgery (SRS). The use, safety and efficacy of HR for brain metastases is not well characterized and the optimal RT dose-fractionation schedule is undefined.MethodsForty-two patients treated with HR in 3-5 fractions for 20 (48%) intact and 22 (52%) resected brain metastases with a median maximum dimension of 3.9 cm (0.8-6.4 cm) between May 2008 and August 2011 were reviewed. Twenty-two patients (52%) had received prior radiation therapy. Local (LC), intracranial progression free survival (PFS) and overall survival (OS) are reported and analyzed for relationship to multiple RT variables through Cox-regression analysis.ResultsThe most common dose-fractionation schedules were 21 Gy in 3 fractions (67%), 24 Gy in 4 fractions (14%) and 30 Gy in 5 fractions (12%). After a median follow-up time of 15 months (range 2-41), local failure occurred in 13 patients (29%) and was a first site of failure in 6 patients (14%). Kaplan-Meier estimates of 1 year LC, intracranial PFS, and OS are: 61% (95% CI 0.53 – 0.70), 55% (95% CI 0.47 – 0.63), and 73% (95% CI 0.65 – 0.79), respectively. Local tumor control was negatively associated with PTV volume (p = 0.007) and was a significant predictor of OS (HR 0.57, 95% CI 0.33 - 0.98, p = 0.04). Symptomatic radiation necrosis occurred in 3 patients (7%).ConclusionsHR is well tolerated in both new and recurrent, previously irradiated intact or resected brain metastases. Local control is negatively associated with PTV volume and a significant predictor of overall survival, suggesting a need for dose escalation when using HR for large intracranial lesions.

Randomized controlled phase II trial of simvastatin as prophylaxis against radiation-induced skin toxicity in breast cancer patients.

TPS1143 Background: Most women receiving adjuvant radiation (RT) for breast cancer (BC) have significant acute skin toxicities ranging from erythema to moist desquamation. Late skin toxicities include fibrosis and telangiectasia. The inflammatory response to RT is mediated by RT-induced endothelial cell expression of the cell adhesion molecule E-selectin, to which neutrophils and monocytes adhere and then infiltrate into tissues. Blockade of this mechanism could interrupt the inflammatory cascade at an early stage. Preclinical studies have shown that statins can inhibit RT-induced E-selectin expression and skin and intestinal inflammation in vivo without impairing DNA damage or tumour response to RT. Retrospective clinical studies have shown reduced relapse rates with statins in breast cancer patients. Thus statins have the potential to reduce the acute RT-induced inflammatory component without compromising the DNA-damaging effects essential to cancer cell death. This is the only registered trial evaluating the effects of statins on acute RT toxicity. Methods: Randomised open controlled phase II trial of simvastatin 40mg daily during and for 3 weeks after RT. Eligibility: women with invasive or in-situ BC receiving whole-breast +/- lymphatic RT; dose fractionation schedules include 50Gy/25 #, 45Gy/20#, 42.5Gy/16 # or 40Gy/15#, with or without a boost; may have had prior chemotherapy, and be on hormonal or Trastuzumab therapy during RT; no prior statins within 6 weeks of starting RT. Stratification by breast conserving surgery vs mastectomy, use of boost and fraction size (&lt;2 Gy vs &gt;2 Gy). Primary endpoint: incidence of &gt; grade 2 acute RT-related skin toxicity. Secondary endpoints: time to onset of skin toxicity, proportion requiring additional topical treatment, compliance with trial medication, statin-related toxicities and subjective RT-related toxicities (breast discomfort and fatigue). Statistical design: 130 randomised patients gives 90% power (one-sided a 0.20) to detect a reduction in &gt; grade 2 acute skin toxicity from 55% to 35%. Enrolment opened January 2013, planned to complete by April 2014. Clinical trial information: ACTRN12612000662864.

Palliative radiotherapy for bone metastases: assessment of factors influencing dose-fractionation schedules at a UK cancer centre

AbstractContextMeta-analyses demonstrate single-fraction radiotherapy to be as effective as multi-fraction treatment in palliating painful bone metastases, although surveys suggest reluctance in prescribing single fractions.AimsAssess the factors influencing the choice of dose-fractionation regimen in an unselected population; examine retreatment rates and subsequent skeletal events.MethodsData were extracted from case notes for 120 patients treated in 2000 and 2006 in a single centre serving a defined population; analysis used χ2 and Fisher's exact statistical tests.ResultsAn 8 Gy fraction was the commonest regimen prescribed (single-fraction delivery rate 53·6%). Tumour site was a significant factor in choice of dose-fractionation schedule. Patients with metastatic breast carcinoma were significantly less likely to receive single-fraction treatment compared with those with metastatic lung carcinoma (year 2000: p = 0·038, 2006: p = 0·001). There was a significantly higher retreatment rate following single-fraction compared with multi-fraction treatment (11% versus 3%). There were two subsequent neural axis compressions and four pathological fractures.ConclusionsSingle-fraction treatment is the commonest regimen but multiple fractions are still frequently delivered. Better prognosis groups appear more likely to receive multi-fraction treatment, possibly to avoid the need for retreatment. Subsequent skeletal events are rare but carry high morbidity when they occur.

Radiotherapy for calcaneodynia

The aim of this work was to compare the efficacy of two different dose fractionation schedules for radiotherapy of patients with calcaneodynia. Between February 2006 and April 2010, 457consecutive evaluable patients were recruited for this prospective randomized trial. All patients received radiotherapy using the orthovoltage technique. One radiotherapy series consisted of 6single fractions/3weeks. In case of insufficient remission of pain after 6weeks a second radiation series was performed. Patients were randomly assigned to receive either single doses of 0.5 or 1.0Gy. Endpoint was pain reduction. Pain was measured before, immediately after, and 6weeks after radiotherapy using a visual analogue scale (VAS) and a comprehensive pain score (CPS). The overall response rate for all patients was 87 % directly after and 88 % 6weeks after radiotherapy. The mean VAS values before, immediately after, and 6weeks after treatment for the 0.5 and 1.0Gy groups were 65.5 ± 22.1 and 64.0 ± 20.5 (p = 0.188), 34.8 ± 24.7 and 39.0 ± 26.3 (p = 0.122), and 25.1 ± 26.8 and 28.9 ± 26.8 (p = 0.156), respectively. The mean CPS before, immediately after, and 6weeks after treatment was 10.1 ± 2.7 and 10.0 ± 3.0 (p = 0.783), 5.6 ± 3.7 and 6.0 ± 3.9 (p = 0.336), 4.0 ± 4.1 and 4.3 ± 3.6 (p = 0.257), respectively. No statistically significant differences between the two single dose trial arms for early (p = 0.216) and delayed response (p = 0.080) were found. Radiotherapy is an effective treatment option for the management of calcaneodynia. For radiation protection reasons, the dose for a radiotherapy series is recommended not to exceed 3-6Gy.

Novel 3D conformal technique for treatment of choroidal melanoma with external beam photon radiotherapy

To report a 3D conformal radiotherapy (3D-CRT) technique that utilises a specific eye immobilisation and treatment set-up method as an alternative to stereotactic radiotherapy (SRT), for treatment of juxtapapillary choroidal melanoma (CM) and report early treatment outcomes of this technique. A contact lens and rod system was designed to provide eye immobilisation and a treatment reference point for 3D-CRT. The technique is described in detail in the body of the paper. A retrospective chart review was conducted to report freedom from local progression (FFLP) and radiation toxicity in a cohort of patients treated with a dose of 50 Gy in five fractions. Eleven eligible patients with juxtapapillary CM were treated between 2003 and 2009. The median follow-up was 3.2 years (range 1.2-5.3). The FFLP was 100% (95% confidence interval 71.5-100). The reproducibility of the set-up and eye immobilisation for fractionation was excellent. The mean dose to the planning target volume was 51.4 Gy (interquartilic range 51.0-51.9). Normal tissue dose constraints were achieved; however, the quality of the 3D-CRT plan was variable. The highest acute radiation toxicity score was Common Toxicity Criteria version 3 grade 1. Vision outcomes were poor. In this small series, a novel non-stereotactic technique was found to be an accurate method for the treatment of CM with a high rate of freedom from tumour progression, in keeping with the SRT series. The quality of the conformal plan was variable. Investigation of the optimal dose-fractionation schedule to minimise late radiation toxicity without compromise of tumour control is the focus of ongoing clinical research at our centre.

Study of two different dose fractionation schedules of post mastectomy chest wall irradiation in carcinoma breast patients

Background: Breast cancer is the most frequently diagnosed cancer and the leading cause of cancer death in women. Aim: To compare two different dose fractionation schedules in terms of overall treatment, locoregional control, acute and late toxicities and patient compliance. Materials and methods: Patients of postmastectomy non metastatic breast cancer were randomized in two arms: Arm A (45) Arm B (46) according to dose fractionation schedule of external radiation given to chest wall and draining lymphatics. Arm A was given 50 Gy in 25 fractions and Arm B was given 40Gy in 17 fractions. After completion of radiation patients were kept on follow up. Results: Median follow up was 20 months. In arm A & B the median overall treatment time was 40 and 27 days with respective ranges of 36-47 days and 22-33 days .The patients in both the arms tolerated radiation well, skin reactions were most common followed by nausea and vomiting .Grade II and III acute reactions were comparable in both arms. There was non-significant increase in both late skin and subcutaneous skin toxicities in arm B. Result of treatment of both arms are, chest wall failure 5% v/s 9% (p>.05), nodal failure 8% v/s 7%(p>.05) and distant metastasis 25% v/s 28% (p>.05). Conclusion: Both the studied dose fractionation schedules are equally efficacious in terms of locoregional control, acute and late toxicities. The shorter schedules in Arm B gives an added advantage of decreased overall treatment time giving better compliance and reduces work load of overburdened department.

Radiation Therapy for Chronic Hidradenitis Suppurativa

Background: Hidradenitis suppurativa is a chronic follicular occlusive disease in apocrine gland-bearing regions. Frequently refractory to conventional oral and topical treatments, it may require surgical intervention. Objective: To investigate the effectiveness of radiation therapy for refractory hidradenitis suppurativa. Methods and materials: Five patients with refractory Hurley stage II/III hidradenitis suppurativa were treated with radiation therapy to 13 affected sites. Electron beam radiation to a total dose of 7.5 gray was applied over 3 consecutive days. Results: The mean age of patients was 45 years; 80% had hidradenitis suppurativa for ≥ 6 years. Three patients had Hurley stage III; 2 had Hurley stage II. All had been treated previously with topical and oral antibiotics and other therapies, including surgery, radiation therapy, Nd:YAG laser therapy, and infliximab. No complete responses were observed, but 53% of the lesions had a partial response. Lesions in the axilla, gluteal, and inguinal areas had response rates of 100%, 67%, and 50%, respectively, compared to 0% for perineal lesions. Conclusions: Radiation therapy may be a promising treatment for refractory hidradenitis suppurativa. A prospective study is warranted to further evaluate response rates, define optimal dose fractionation schedules, and better understand the risk of long-term toxicity.

Radiotherapy for achillodynia

Background and purpose The aim of this study was to compare the efficacy of two different dose-fractionation schedules for radiotherapy of patients with achillodynia.

Benign painful shoulder syndrome

To compare the efficacy of two different dose-fractionation schedules for radiotherapy of patients with benign painful shoulder syndrome. Between February 2006 and February 2010, 312 consecutive evaluable patients were recruited for this prospective randomized trial. All patients received radiotherapy with an orthovoltage technique. One radiotherapy course consisted of 6 single fractions in 3 weeks. In case of insufficient remission of pain after 6 weeks, a second radiation series was performed. Patients were randomly assigned to receive either single doses of 0.5 or 1.0 Gy. The endpoint was pain reduction. Pain was measured before, right after, and 6 weeks after radiotherapy using a visual analogue scale (VAS) and a comprehensive pain score (CPS). The overall response rate for all patients was 83% directly after and 85% 6 weeks after radiotherapy. The mean VAS values before, directly after, and 6 weeks after treatment for the 0.5 and 1.0 Gy groups were 56.8 ± 23.7 and 53.2 ± 21.8 (p = 0.158), 38.2 ± 26.1 and 34.0 ± 24.5 (p = 0.189), and 33.0 ± 27.2 and 23.7 ± 22.7 (p = 0.044), respectively. The mean CPS before, directly after, and 6 weeks after treatment was 9.7 ± 3.0 and 9.5 ± 2.7 (p = 0.309), 6.1 ± 3.6 and 5.4 ± 3.6 (p = 0.096), 5.3 ± 3.7 and 4.1 ± 3.7 (p = 0.052), respectively. Despite a slight advantage in the VAS analysis for the 1.0 Gy group for delayed response, the CPS analysis revealed no statistically significant differences between the two single-dose trial arms for early (p = 0.652) and delayed response quality (p = 0.380). Radiotherapy is an effective treatment option for the management of benign painful shoulder syndrome. Concerning radiation protection, the dose for a radiotherapy series is recommended not to exceed 3-6 Gy.

PO43 Study of two different dose fractionation schedules of post mastectomy chest wall irradiation in carcinoma breast patients

PO43 Study of two different dose fractionation schedules of post mastectomy chest wall irradiation in carcinoma breast patients

A systematic review of stereotactic radiotherapy ablation for primary renal cell carcinoma

What's known on the subject? and What does the study add? At present, little is known about the role of stereotactic ablative body radiotherapy in the treatment of primary renal cell carcinoma. The published evidence to date totals 126 patients worldwide. The majority of evidence is retrospective in nature. The present study adds context to the current literature by providing an overall summary of the evidence. • To critically assess the use of stereotactic ablative body radiotherapy (SABR) for the treatment of primary renal cell carcinoma with particular focus on local control and toxicity outcomes. • A systematic search on PubMed was performed in January 2012 independently by two radiation oncologists using structured search terms. • Secondary manual searches were performed on citations in relevant publications and abstracts in major radiotherapy journals. • Outcomes, techniques, biological doses and scientific rigour of the studies were analysed. • In total 10 publications (seven retrospective and three prospective) were identified. A wide range of techniques, doses and dose fractionation schedules were found. • A total of 126 patients were treated with between one and six fractions of SABR. Median or mean follow-up ranged from 9 to 57.5 months. A weighted local control was reported of 93.91% (range 84%-100%). • The weighted rate of severe grade 3 or higher adverse events was 3.8% (range 0%-19%). The weighted rate of grade 1-2 minor adverse events was 21.4% (range 0%-93%). The most commonly employed fractionation schedule was 40 Gy delivered over five fractions. • Current literature suggests that SABR for primary renal cell carcinoma can be delivered with promising rates of local control and acceptable toxicity. • However, there was insufficient evidence to recommend a consensus view for dose fractionation or technique. • This indicates the need for further prospective studies assessing the role of this technique in medically inoperable patients.

Clinical Outcomes of Biological Effective Dose-Based Fractionated Stereotactic Radiation Therapy for Metastatic Brain Tumors From Non-Small Cell Lung Cancer

To evaluate the efficacy and toxicity of fractionated stereotactic radiation therapy (FSRT) based on biological effective dose (BED), a novel approach to deliver a fixed BED irrespective of dose fractionation, for brain metastases from non-small cell lung cancer (NSCLC). Between March 2005 and March 2009 we treated 299 patients with 1 to 5 lesions from NSCLC (573 total brain metastases) with FSRT using Novalis. The dose fractionation schedules were individually determined to deliver a peripheral BED10 (α/β ratio = 10) of approximately 80 Gy10. The median number of fractions was 3 (range, 2-10), the median peripheral BED10 was 83.2 Gy (range, 19.1-89.6 Gy). Patients were followed up with magnetic resonance imaging (MRI) studies performed at 1- to 2-month intervals. The local tumor control rate and overall local progression-free and intracranial relapse-free survival were calculated by the Kaplan-Meier method. Local control rates for all 573 lesions at 6 and 12 months were 96.3% and 94.5%, respectively. By multivariate analysis the tumor diameter was the only factor predictive of the local control rate (P=.001). The median overall survival, local progression-free survival, and intracranial relapse-free survival were 17.1, 14.9, and 4.4 months, respectively. The overall survival, local progression-free survival, and intracranial relapse-free survival rates at 6 and 12 months were 78.5% and 63.3%, 74.3% and 57.8%, and 41.0% and 21.8%, respectively. Six patients (2%) manifested progressive radiation injury to the brain even during therapy with corticosteroids; they underwent hyperbaric oxygen therapy, and follow-up MRI showed improvement. This study showed that BED-based FSRT for brain metastases from NSCLC is a promising strategy that may yield excellent outcomes with acceptable toxicity. Criteria must be established to determine the optimal dose fractionation for individual patients.