Effect Of External Beam Radiotherapy Research Articles

Prospective randomized comparative study between EBRT alone and EBRT with ILRT boost in locally advanced unresectable esophageal cancer - Tertiary rural Indian cancer center experience

Background: Local recurrence within the gross tumor volume following a conventional radiation dose of 50 Gy is a major hurdle in achieving a better prognosis for esophageal carcinoma. Consequently, there remains a lack of consensus globally regarding the optimal dose for definitive concurrent chemoradiotherapy. Certain studies propose that radiation dose escalation could enhance clinical outcomes. Aims and Objectives: The current study aimed to compare the safety and effectiveness of external beam radiotherapy (EBRT) alone versus EBRT with intraluminal radiotherapy (ILRT) boost. Materials and Methods: A total of 60 patients with locally advanced unresectable squamous cell carcinoma of the esophagus were prospectively enrolled in this study. A comparison was conducted between 50 Gy EBRT alone and 50 Gy EBRT with 8 Gy ILRT boost, alongside weekly concurrent chemotherapy, to assess the response and toxicities. Results: On initial assessment, a complete response (CR) was achieved in 76.66% of patients in the ILRT boost arm and 70% in the EBRT alone arm (P=0.559). At the 6th-month follow-up, 60% of patients in the ILRT boost arm and 50% in the EBRT alone arm still had a CR. No statistically significant differences were observed between the two arms in terms of leukopenia (P=0.576), nephrotoxicity (P=1.0), radiation dermatitis (P=0.615), vomiting (P=0.921), and diarrhea (P=1.0). Five patients in the ILRT boost arm and three in the EBRT alone arm experienced stricture, while no cases of fistula formation were reported. Conclusion: Dose escalation with ILRT can result in an enhanced CR accompanied by manageable toxicity, ultimately leading to improved locoregional control.

Comparison of Acute Gastrointestinal Toxicity of Intensity-Modulated Radiotherapy Versus Three-Dimensional Conformal Radiotherapy in Patients of Carcinoma Cervix.

Introduction Cervical cancer is the most common gynaecological malignancy worldwide, with a higher prevalence in middle- and low-income countries. Chemoradiotherapy, followed by intracavitary brachytherapy, is the treatment of choice in locally advanced cervical cancer. The most common acute side effect of external beam radiotherapy (EBRT) is bowel toxicity in the form of diarrhoea and abdominal cramps. The treatment techniques of EBRT were revolutionised with the advent of intensity modulation. This study aims to prospectively analyse whether the dosimetric advantage of intensity-modulated radiotherapy (IMRT) over three-dimensional conformal radiotherapy (3DCRT) is translated clinically into a decrease in acute toxicity. Method Twenty-four patients were randomised into two groups: the 3DCRT and the IMRT. Acute gastrointestinal (GI) toxicity was assessed during treatment using radiation therapy oncology group grading. The factors under consideration were age, stage of the disease, treatment technique, chemotherapy, and the intention of therapy (radical or adjuvant). The mean bowel bag dose of the two techniques was analysed. Result Among the factors under consideration, it was found that the treatment technique was the only factor that had a significant association with acute bowel toxicity in both univariate (p = 0.036) and multivariate analyses (p = 0.028). The mean V25 (the volume receiving 25 Gy), V45, and V50 of the bowel bag in the IMRT arm were significantly less than the 3DCRT arm. Grades 2 and 3 acute bowel toxicities were also higher in the 3DCRT arm. Conclusion The treatment technique is essential to determining acute GI toxicity during pelvic radiotherapy. With IMRT, the dose to the bowel bag and, in turn, the acute bowel toxicity can be reduced.

PO48 Presentation Time: 10:00 AM: Clinical Implementation of an In-House Made Perineal Template for Low Dose Rate Prostate Brachytherapy Treatment

<h3>Purpose</h3> An in-house perineal needle-template device was developed to improve the interactive¹ low-dose-rate (LDR) brachytherapy treatment planning process for patients with small prostate volume size. One of the side effects of external beam radiation and androgen deprivation therapies is the significant reduction of the prostate gland volume (target) which can be challenging to plan with a standard 5mm hole spacing template. The new perineal needle template (new template) has additional rows with holes placed in a 2.5mm off-set grid pattern which provided more hole locations to place seeds inside the small prostate periphery region for a more conformal plan while meeting all dosimetric planning goals. <h3>Methods and Materials</h3> Thirty patients with different prostate gland volumes size were selected for this study. These thirty patients received either external beam radiation alone or external radiation combined with androgen deprivation therapy. Patients had LDR interactive planning performed using the new template, BARD I-125 seed model STM1251 (USA, IL), BARD QuickLink Delivery System for the seed train assembly, Oncentra - Prostate (Elekta, Sweden) for the treatment planning software (TPS) and the B-K Medical Ultrasound 3000 (USA, MA) for the internal organs imaging. On implant day (DAY 0), the radiation oncologist (physician) contoured target, urethra and rectum on TPS. The medical physicist proceeded to start the planning on the TPS using the inverse planning option to create plan and dose volume histogram (DVH) as the first iteration. Then, manually adjusted and customized the seeds locations with the MD input for a final DVH evaluation in order to proceed and deliver the implant. The AAPM TG-64² dosimetric guidelines were followed and reported. All patients had CT and MRI imaging studies performed approximately 30 days after the implant for a DAY 30 post implant evaluation. Using the Oncentra TPS, both imaging studies were fused, and the prostate, urethra and rectum were contoured. The implanted seeds were registered, and the DAY 0 prescription was used for the post-plan evaluation following the AAPM TG-64 dosimetric guidelines. <h3>Results</h3> Thirty patients were successfully treated using the new template. The new template was modeled in TPS and the ultrasound system. The new template did not affect the calculating time in the TPS and the increased amount of hole locations provided more options for an easier manual optimization "tweaking" to achieve a final plan, especially in the apex location where the target tapers down in size. Initially, physician adaptation to the new template was challenging for the first few cases but rapidly improved as the physician became more familiar with the new hole patterns. <h3>Conclusion</h3> We have successfully designed, built and implemented a new template for brachytherapy LDR treatments of small sizes targets (≤20 cc). The new template has provided a viable option to implant the seeds inside or closer to the target periphery thus improving the interactive planning process significantly.

A prospective study of radical external beam radiotherapy versus external beam radiotherapy combined with intraluminal brachytherapy for primary esophageal cancer

PURPOSEThis study compared the efficacy and side effects of external beam radiotherapy (EBRT) + intraluminal brachytherapy (IBT) with EBRT alone in patients with primary thoracic esophageal cancer. MATERIALS AND METHODSBetween 2013 and 2020, 64 patients with primary thoracic esophageal cancer without surgery received radiotherapy. Thirty-two patients received EBRT + IBT. EBRT dose was 50 Gy, 2 Gy/f, 5 times a week, and IBT dose was 10 Gy, 5 Gy/f, once a week. Thirty-two patients received EBRT alone, and the total dose was 60 Gy. The median followup was 19 months. RESULTSThe local control rates (LCR) of EBRT + IBT and EBRT alone group at 1, 2, and 3 years after treatment were 88% and 72%, 53% and 22%, 25%, and 9%, respectively. The overall survival (OS) of the EBRT + IBT and EBRT alone group at 3 years after treatment were 38% and 9%. The 3-year local recurrence-free survival (LRFS) rates of EBRT + IBT and EBRT alone group were 25% and 9%. Univariate analysis showed that EBRT + IBT could be the prognostic factor improving OS (p = 0.04), and tumor located in the mid-thoracic region exhibited a poorer prognosis on LRFS (p = 0.03). Grade 3 or higher acute side effects included two cases of dysphagia and three cases of bone marrow suppression. Severe late side effects included three cases of fistula, three cases of radiation pneumonia, and five cases of stenosis requiring treatment. CONCLUSIONSCompared with EBRT alone, EBRT + IBT is an effective treatment modality for T1∼3NanyM0 primary thoracic esophageal cancer with good local control. It can prolong the survival time of patients and has acceptable toxicity.

The role of external beam radiation therapy in the management of thyroid carcinomas: A retrospective study in Iran Cancer Institute.

Thyroid cancers are histologically classified into three types; differentiated thyroid carcinoma (DTC), medullary thyroid carcinoma (MTC), and anaplastic thyroid carcinoma (ATC). Among the several therapeutic strategies for treatment and management of thyroid cancer, surgical resection in combination with radioactive iodine therapy (RAI) is indicated for moderate to high-risk differentiated thyroid cancer (DTC) patients- according to current guidelines. However, external radiation therapy (EBRT) can be a viable alternative treatment option for these patients and scarce evidence is available regarding the efficacy and effectiveness of EBRT on thyroid cancer. This study aims at evaluating the role of EBRT in the management of thyroid carcinomas. In this retrospective cohort study, the records of 59 patients with thyroid cancer were accessed who were treated by EBRT from 2008 to 2016. The indications for EBRT included unresectable primary (definitive) or loco-regional recurrences (salvage) not suitable for RAI, palliation for local disease or metastatic foci (palliative), and the adjuvant treatment for suspected residual disease following resection. Progression-free survival (PFS) and overall survival (OS) were calculated for different types of cancer. PFS was measured from the start of EBRT to the last uneventful follow-up, recurrence, or death. Kaplan-Meier model was used for the survival analysis. Fifty-nine patients were evaluated. The histopathology of the tumors was differentiated and poorly-differentiated, medullary and anaplastic thyroid carcinomas in 22 and 6, 15 and 16 patients, respectively. Twenty-seven patients received external beam radiotherapy (EBRT) as adjuvant therapy and 18 of the cases as palliative therapy while the remaining received salvage or definitive primary EBRT. The stage of patients' cancer was as follows: stage II in 3 and III in 1, IVA in 18 and IVB in 18 and IVC in 19. Stage-based median overall survival was 26 months for IVA, 44 for IVB, and 29 for IVC. The median PFS was 18, 22 and 21 months for stages IVA, IVB and IVC, respectively. Based on our findings, EBRT may still play a role in the management of patients with thyroid carcinoma and should be considered in the armamentarium against thyroid cancers.

Improving survival prediction of oesophageal cancer patients treated with external beam radiotherapy for dysphagia

Introduction The recent POLDER trial investigated the effects of external beam radiotherapy (EBRT) on dysphagia caused by incurable oesophageal cancer. An estimated life expectancy of minimally three months was required for inclusion. However, nearly one-third of the included patients died within three months. The aim of this study was to investigate if the use of prediction models could have improved the physician’s estimation of the patient’s survival. Methods Data from the POLDER trial (N = 110) were linked to the Netherlands Cancer Registry to retrieve patient, tumour, and treatment characteristics. Two published prediction models (the SOURCE model and Steyerberg model) were used to predict three-month survival for all patients included in the POLDER trial. Predicted survival probabilities were dichotomised and the accuracy, sensitivity, specificity, and the area under the curve (AUC) were used to evaluate the predictive performance. Results The SOURCE and Steyerberg model had an accuracy of 79% and 64%, and an AUC of 0.76 and 0.60 (p = .017), respectively. The SOURCE model had higher specificity across survival cut-off probabilities, the Steyerberg model had a higher sensitivity beyond the survival probability cut-off of 0.7. Using optimal cut-off probabilities, SOURCE would have wrongfully included 16/110 patients into the POLDER and Steyerberg 34/110. Conclusion The SOURCE model was found to be a more useful decision aid than the Steyerberg model. Results showed that the SOURCE model could be used for three-month survival predictions for patients that are considered for palliative treatment of dysphagia caused by oesophageal cancer in addition to clinicians’ judgement.

Low Utilization of External Beam Radiation Therapy for Patients With Unresectable Hepatocellular Carcinoma: An Analysis of the United Network for Organ Sharing Database

External beam radiation therapy (EBRT) is a safe and emerging bridging liver-directed therapy (LDT) to liver transplant (LT) for patients with hepatocellular carcinoma (HCC). The prevalence and clinical characteristics of patients receiving EBRT as an LDT for LT have not been evaluated. Our aim was to describe the utilization of EBRT in patients with HCC evaluated for LT in the United States. We analyzed United Network for Organ Sharing data from October 2013 to June 2020 and identified patients with HCC who applied for model for end-stage liver disease (MELD) exceptions for LT wait list prioritization. The primary outcome was the period prevalence of EBRT. We examined associations between clinical variables and EBRT and fit survival models with EBRT as a time-varying predictor. We identified 18,543 patients with HCC with MELD exception applications. EBRT was used in 658 patients (3.5%) either alone (1.2%) or combined with other LDT (2.3%). Transarterial chemoembolization was the most used LDT (59.3%), followed by thermal ablation (27.9%) and radioembolization (15.2%). EBRT prevalence rose by an average of 12.2% per year (P=.001). Use of EBRT differed by geographic region, ranging from 2% to 8% (P < .001). EBRT and no EBRT groups had similar initial MELD score, portal vein thrombosis, tumor diameter, number of tumors, bilirubin, and α-fetoprotein (P > .05). Median time-to-transplant from wait list registration for EBRT versus no EBRT groups was 10 months (95% confidence interval, 9.4-10.9) versus 11.9 months (95% confidence interval, 11.7-12.2; P < .001). Evaluated as a time-varying predictor, EBRT increased the risk of LT by 30% (sub-hazard ratio, 1.30; P < .001), while the effect of EBRT on the risk of wait list removal due to clinical deterioration or death (sub-hazard ratio, 1.07; P=.489) was nonsignificant. In the United States, EBRT is rarely used compared with other LDTs and exhibits geographic variation. Low EBRT utilization highlights a gap in the treatment armamentarium for HCC.

Abstract P3-19-09: Impact of intraoperative radiation therapy and external beam radiation therapy on non-breast cancer mortality in early-stage breast cancer

Abstract Purpose: The TARGIT-A trial of kilovoltage intraoperative radiation therapy (IORT) versus external beam radiation therapy (EBRT) demonstrated a significant reduction in non-breast cancer mortality (nBCM) in women that received IORT, largely attributed to an increase in cardiac mortality in patients that received EBRT. Further, If EBRT does result in excess nBCM due to cardiac or other causes, then treatment with lumpectomy (Lump) alone or mastectomy (Mast) alone should result in lower rates of nBCM rates compared to Lump+EBRT. Our primary objective was to determine whether Lump+EBRT results in increased nBCM compared to Lump+IORT in women with early-stage breast cancer (BC) with a hypothesis that the two approaches should result in equivalent nBCM. We also tested the hypotheses that Lump+EBRT should have the same rates of nBCM as Lump alone or Mast alone. Materials/Methods: We used the Surveillance Epidemiology and End Results (SEER) database to identify women with early-stage BC treated with Lump alone, Lump+EBRT, Lump+IORT, or Mast alone from 2000-2016. SEER does not distinguish between kilovoltage IORT and electron IORT. We included patients with characteristics similar to the TARGIT-A study: age≥45 years; ductal carcinoma in situ (DCIS) or T1; lymph-node negative. We excluded patients that: received chemotherapy; received postmastectomy radiation therapy; had unknown cause of death; and had ≤1 month of follow-up. The primary endpoint was nBCM which is captured in the SEER database (patients were censored if they were alive or dead due to cancer at last follow-up). Cox-proportional hazards multivariate regression models were used to compare nBCM between Lump+EBRT and Lump+IORT adjusting for confounders that were statistically significant on univariate analysis. We secondarily compared nBCM in the Lump+EBRT vs. Lump population and Lump+EBRT vs. Mast population. Results: We identified 219,470 women that met the inclusion criteria: 121,776 Lump+EBRT; 1,735 Lump+IORT; 41,900 Lump; 54,059 Mast. Median follow-up time was 61 months for the entire cohort (IQR, 30-99 months) but was shorter for Lump+IORT patients (29 months) compared to the other groups (63 months Lump+EBRT; 62 months Mast; 57 months Lump). There were a total of 16,640 nBCM events: 6,210 Lump+EBRT; 5,708 Lump; 4,704 Mast; 18 Lump+IORT. The 5-year cumulative incidence of nBCM was 3.1% for Lump+EBRT vs. 1.6% for Lump+IORT (p=0.034). After adjustment for potential confounders (age, tumor location, marital status, race/ethnicity, DCIS vs. invasive, tumor grade, hormone receptor status, and receipt of axillary surgery), patients treated with Lump+IORT had a 38% relative reduction in the risk of nBCM compared to those treated with Lump+EBRT (HR=0.62, 95% CI 0.39-0.99, p=0.045). Other factors associated with increased nBCM included older age, divorced/single/widowed status (vs. married), Black race, high tumor grade, receipt of axillary lymph node dissection (vs. sentinel lymph node biopsy), no axillary surgery (vs. sentinel node biopsy), and ER-/PR- disease (vs. ER+ or PR+). In contrast, patients treated with Lulmp+EBRT had lower nBCM compared to those that received Lump alone (adjusted HR=0.55, 95% CI 0.53-0.57, p&amp;lt;0.0001) and compared to those that received Mast alone (adjusted HR=0.59, 95% CI 0.56-0.61, p&amp;lt;0.0001). Conclusion: In summary, contrary to our hypothesis, we found that Lump+IORT was associated with lower nBCM compared to Lump+EBRT possibly reflecting underlying selection bias. However, Lump+EBRT was not associated with an increased nBCM relative to patients treated with Lump alone or Mast alone. This suggests that the underlying mechanism for the reduced nBCM seen in patients treated with IORT in the TARGIT-A trial and this SEER analysis is not due to the potentially harmful effects of EBRT. Citation Format: Jose G Bazan, Jay Fisher, Sachin Jhawar, Erin Healy, Sasha Beyer, Julia R. White. Impact of intraoperative radiation therapy and external beam radiation therapy on non-breast cancer mortality in early-stage breast cancer [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-19-09.

Indications of external beams radiation for thyroid cancer.

The use of external beam radiation therapy (EBRT) for the treatment of the different histologic subtypes of thyroid cancer is a matter of debate. This article provides an up-to-date review on the current evidence concerning the benefits of EBRT in thyroid cancer in specific indications. Based on retrospective studies, adjuvant EBRT lessens the risk of locoregional recurrence in locally advanced differentiated thyroid cancer (DTC) and medullary thyroid cancer (MTC) with high-risk features. The effect of EBRT on overall survival remains uncertain. EBRT should also be part of the multimodality treatment in anaplastic thyroid cancer (ATC), as it improves survival rates in incompletely resected ATC. The role of EBRT in thyroid cancer remains unclear. To date, no randomized control studies are available. Retrospective data showed improved outcomes in patients with high-risk features for locoregional recurrence.

Improving survival prediction of patients treated with external beam radiotherapy for dysphagia in esophageal cancer using prediction models.

358 Background: The recently published POLDER trial investigated the effects of external beam radiotherapy (EBRT) on dysphagia caused by incurable esophageal cancer. As the effects of EBRT were presumed not to be immediate, an estimated life expectancy of minimally three months was required for inclusion. However, nearly a third of the included patients died within three months. The aim of this study was to investigate if the use of prediction models could have improved the physician’s estimation of the patient’s survival, and thus the eligibility for EBRT treatment. Methods: Data from the POLDER trial (N = 110) were linked to the Netherlands Cancer Registry to retrieve additional patient, tumor and treatment characteristics. Two published prediction models (the SOURCE model and Steyerberg model) were used to predict overall survival for all patients included in the POLDER trial. Predicted survival probabilities were dichotomized (predicted deceased/alive at three months) and the positive predictive value, negative predictive value, sensitivity, specificity and the area under the curve (AUC) were used to evaluate the predictive performance. DeLong’s test was used to test the difference between the AUCs of the SOURCE and Steyerberg models for statistical significance. Results: In the POLDER trial, 35 patients were unjustly presumed to survive three months. Predicting survival at three months, the SOURCE and Steyerberg model had an AUC of 0.76 and 0.60 respectively. The difference between the AUCs of the models was significant (p =.017). Under optimal survival cut-off scores, SOURCE would have incorrectly predicted 16 patients to survive three months. For the Steyerberg model this was 22 patients. Furthermore, using SOURCE under these cut-off scores, seven patients were incorrectly predicted to not survive three months compared to 18 patients using the Steyerberg model. Conclusions: Results showed that the SOURCE and Steyerberg models could have improved survival predictions compared to clinical judgement alone. The SOURCE model was found to be a more useful decision aid than the Steyerberg model as it was more accurate. Accepting that a small proportion of patients are incorrectly predicted not to survive three months and are not considered for EBRT treatment, we recommend using the SOURCE model for patients that are considered for palliative treatment of dysphagia caused by esophageal cancer.

Nephrotoxicity after radionuclide therapies

Radioligand therapies have opened new treatment avenues for cancer patients. They offer precise tumor targeting with a favorable efficacy-to-toxicity profile. Specifically, the kidneys, once regarded as the critical organ for radiation toxicity, also show excellent tolerance to radiation doses as high as 50–60 Gy in selected cases. However, the number of nephrons that form the structural and functional units of the kidney is determined before birth and is fixed. Thus, loss of nephrons secondary to any injury may lead to an irreversible decline in renal function over time. Our primary understanding of radiation-induced nephropathy is derived from the effects of external beam radiation on the renal tissue. With the growing adoption of radionuclide therapies, considerable evidence has been gained with regard to the occurrence of renal toxicity and its associated risk factors. In this review, we discuss the radionuclide therapies associated with the risk of nephrotoxicity, the present understanding of the factors and mechanisms that contribute to renal injury, and the current and potential methods for preventing, identifying, and managing nephrotoxicity, specifically acute onset nephropathies.

OC-0568: The effect of external beam radiotherapy on bowel motility in gynaecological cancer patients

OC-0568: The effect of external beam radiotherapy on bowel motility in gynaecological cancer patients

Prognostic Impact of Histologic Grade for Papillary Thyroid Carcinoma.

While numerous factors affect prognosis in papillary thyroid carcinoma (PTC), the comparative impact of histologic grade has not been well described. Moreover, indications for external beam radiation therapy (EBRT) remain imprecise. We evaluate clinicopathologic characteristics and outcomes for PTC stratified by grade. We profiled histologic grade for PTC (well differentiated, moderately differentiated, poorly differentiated) via hospital (National Cancer Database) and population-based (Surveillance, Epidemiology, and End Results) registries. Cox regression was used to adjust for clinicopathologic covariates. Statistical interactions between subtypes and the effect of EBRT on survival were assessed. Collectively, worsening clinicopathologic factors (age, tumor size, extrathyroidal extension, nodal spread, M1 disease) and outcomes (disease-free survival, overall survival) correlated with less differentiated state, across all histologic grades (p < 0.001). Multivariable analysis showed escalating hazard with loss of differentiation relative to well-differentiated PTC (moderately differentiated hazard ratio [HR] 1.21, 95% confidence interval [CI] 1.04-1.41, p = 0.02; poorly differentiated HR 2.62, 95% CI 2.23-3.08, p < 0.001). Correspondingly, greater survival benefit was associated with EBRT for poorly differentiated cases (HR 0.36, 95% CI 0.18-0.72, p = 0.004). This finding was upheld after landmark analysis to address potential immortal time bias (HR 0.37, 95% CI 0.17-0.80, p = 0.01). Worsening histologic grade in PTC is independently associated with parallel escalation in mortality risk, on a scale approximating or surpassing established thyroid cancer risk factors. On preliminary analysis, EBRT was associated with improved survival in the most aggressive or least differentiated subvariants. Further investigation is warranted to examine the efficacy of EBRT for select poorly differentiated thyroid carcinomas.

A qualitative study exploring men’s experience of sexual dysfunction as a result of radiotherapy and androgen deprivation therapy to treat prostate cancer

AbstractAim:Sexual dysfunction is a common side effect of external beam radiotherapy (EBRT) and androgen deprivation therapy (ADT) to treat prostate cancer. Men are likely to experience erectile dysfunction, low libido, ejaculatory problems and penile shortening. This qualitative study explored men’s perceptions of sexual dysfunction, including factors such as self-perception, relationships and information and support needs.Methods:Semi-structured interviews were carried out with n = 8 men living 18–30 months after EBRT ± ADT. The interviews were transcribed and thematic analysis was carried out.Results:All men experienced sexual dysfunction following treatment. The main themes arising were: (i) priorities—sexual issues were not a priority when making treatment decisions, (ii) information and support—men described a lack of information and support about sexual dysfunction and (iii) impact—sexual dysfunction impacted on their self-perception and relationships.Findings:Men undergoing EBRT/ADT for prostate cancer may be affected by post-treatment changes in sexual function in a range of ways. This study suggests that they would benefit from early and wide-ranging information and support on sexual dysfunction, even if they do not consider it as a priority. Candid discussions about self-perception and relationships, as well as physical changes, may equip them to cope with post-treatment changes.

An audit of radiation-induced skin reactions in the inframammary fold; does breast size impact on the severity of the reaction?

IntroductionSkin toxicity is a clinically significant side effect of external beam radiation; moist desquamation is particularly prevalent for breast patients, mainly in the axilla and inframammary fold (IMF). The aim of this audit was to assess if there is a correlation between patient breast size and the presence and extent of radiotherapy skin reaction in the IMF. MethodsBetween 22/12/2017 and 31/05/2018 forty patients undergoing standard whole breast radiotherapy using 3D planned medial and lateral tangential fields had their skin reaction recorded weekly, whilst on treatment, using the Radiotherapy Oncology Group (RTOG) scoring system. Skin reactions were also documented at three and eight weeks post radiotherapy. A measurement of the patients IMF length and bra size were also noted. Statistical analysis was carried out using IBMÒ SPSS Statistics 24. ResultsSix patients presented with grade ≥2 during week three of radiotherapy. The mean IMF length of six patients with adverse reactions 6.1 cm (±3.6 cm). As the length of the IMF increases, severity of skin reactions also increases; a positive correlation was identified between the two at both week three of radiotherapy and three weeks post radiotherapy (r = 0.401, n = 34, p = 0.05 and r = 0.671, n = 29, p = 0.00 respectively). Only one patient displayed grade 2 at eight weeks post radiotherapy (IMF length 7.5 cm). ConclusionThe findings from this study would suggest that larger breasted patients do present earlier, and with more severe radiation-induced skin reactions. Implications for practiceChanges to skin care practice could be considered for patients with larger breasts. This could be in the form of more frequent check-ups during treatment or proactive side effect management rather than reactive management.

A qualitative study exploring men’s experience of sexual dysfunction as a result of radiotherapy and androgen deprivation therapy to treat prostate cancer

Aim: Sexual dysfunction is a common side effect of external beam radiotherapy (EBRT) and androgen deprivation therapy (ADT) to treat prostate cancer. Men are likely to experience erectile dysfunction, low libido, ejaculatory problems and penile shortening. This qualitative study explored men’s perceptions of sexual dysfunction, including factors such as self-perception, relationships and information and support needs. Methods: Semi-structured interviews were carried out with n = 8 men living 18–30 months after EBRT ± ADT. The interviews were transcribed and thematic analysis was carried out. Results: All men experienced sexual dysfunction following treatment. The main themes arising were: (i) priorities—sexual issues were not a priority when making treatment decisions, (ii) information and support—men described a lack of information and support about sexual dysfunction and (iii) impact—sexual dysfunction impacted on their self-perception and relationships. Findings: Men undergoing EBRT/ADT for prostate cancer may be affected by post-treatment changes in sexual function in a range of ways. This study suggests that they would benefit from early and wide-ranging information and support on sexual dysfunction, even if they do not consider it as a priority. Candid discussions about self-perception and relationships, as well as physical changes, may equip them to cope with post-treatment changes.

Risk of Subsequent Primary Cancers After External Beam Radiotherapy Treatment of Pediatric Low Grade Gliomas: A Surveillance, Epidemiology, and End Results Analysis 1973 to 2015

Abstract INTRODUCTION Past studies have associated external beam radiotherapy (EBRT) with higher incidences of subsequent primary malignancies (SPMs). This link has been documented for leukemias, and prostate, thyroid, and bone cancers. However, the effects of EBRT on SPM development from low grade gliomas (LGGs) are not well understood. The aim of the present study was to characterize the risk of SPM development after EBRT treatment of LGGs. METHODS A total of 1439 pediatric (age 0-17) records between 1973 and 2015 were assembled from the Surveillance, Epidemiology, and End Results (SEER) database. Univariable and multivariable Cox regressions were used to evaluate the prognostic impact of demographic, tumor, and treatment-related covariates. Propensity score matching was used to balance baseline characteristics. Survival and cumulative hazard analyses measured the time to, and risk of, SPM development, stratified by receipt of EBRT. RESULTS Of the 1439 pediatric patients we analyzed, 450 received EBRT and 989 did not. A total of 65 pediatric patients were identified who developed SPMs after LGG diagnosis, and 35 of these patients received EBRT (OR: 2.70). Unadjusted Cox regressions revealed a significantly elevated SPM risk in EBRT-treated pediatric patients with LGGs (HR: 2.22, CI: 1.34-3.67). After adjusting for covariates such as race, gender, income, chemotherapy, and grade (World Health Organization I vs II), there was still a clear association between EBRT and the development of SPMs (HR: 2.52, CI: 1.50-4.23). Propensity score matching across covariates did not significantly impact the hazard ratio. Time-to-event Kaplan Meier curves demonstrated earlier SPM development in the EBRT-treated LGG pediatric population, and Nelson–Aalen cumulative hazard estimates showed higher incidences of SPM development at all time points. CONCLUSION EBRT treatment for LGGs is associated with an elevated incidence of SPMs, even after controlling for available covariates. This suggests less aggressive EBRT use in the pediatric LGG population may be warranted.

Effect of external beam radiotherapy on second primary cancer risk after radical prostatectomy.

We aimed to investigate the effect of radiotherapy (RT) in contemporary patients treated with radical prostatectomy (RP) compared to RP alone for non-metastatic prostate cancer (PCa) on the incidence of second primary cancers (SPCs). Within the Surveillance, Epidemiology, and End Results (SEER) database (2004-2015), we identified patients with PCa as the only or first primary cancer, who underwent RP and RT or RP alone. Cumulative incidence plots and multivariable Cox regression models tested for SPC rate differences according to treatment type: RP and RT vs. RP alone. Subgroup analyses focused on pelvic, primary pelvic, and non-pelvic SPCs, as well as on late SPCs (>5 years after PCa diagnosis). Of 152 161 patients, 7.1% (n=10 870) received RP and RT. Overall, 6.6 vs. 5.0% developed SPCs after RP and RT vs. RP alone, respectively (p<0.001). Cumulative incidence rates at 10 years after PCa diagnosis for RP and RT vs. RP were 12.0 vs. 8.7% (p<0.001), 2.0 vs. 1.2% (p<0.001), 2.1 vs. 1.3% (p<0.001), and 9.9 vs. 7.4% (p<0.001) for overall SPCs, primary pelvic SPCs, overall pelvic SPCs, and non-pelvic SPCs, respectively. Multivariable Cox regression models revealed an increased risk after RP and RT vs. RP alone for overall (hazard ratio [HR] 1.2; p<0.001), primary pelvic (HR 1.5; p<0.01), pelvic (HR1.4; p<0.001), non-pelvic (HR1.1; p<0.01), late overall (HR 1.2; p=0.01), and late non-pelvic SPCs (HR1.2; p=0.03). RP with RT was associated with moderately increased risk of SPCs compared to RP alone. This observation should be thoroughly discussed at informed consent and considered during followup.

The Evidence for External Beam Radiotherapy in High-Risk Neuroblastoma of Childhood: A Systematic Review

AimsExternal beam radiotherapy is widely used in various ways in the management of neuroblastoma. Despite extensive clinical experience, the precise role of radiotherapy in neuroblastoma remains unclear. The purpose of this systematic review was to survey the published literature to identify, without bias, the evidence for the clinical effectiveness of external beam radiotherapy as part of the initial multimodality treatment of high-risk neuroblastoma. We considered four areas: treatment of the tumour bed and residual primary tumour, identification of any dose–response relationship, treatment of metastatic sites, identification of any technical advances that may be beneficial. We also aimed to define uncertainties, which may be clarified in future clinical trials. Materials and methodsBibliographic databases were searched for neuroblastoma and radiotherapy. Reviewers assessed 1283 papers for inclusion by title and abstract, with consensus achieved through discussion. Data extraction on 57 included papers was carried out by one reviewer and checked by another. Studies were assessed for their level of evidence and risk of bias, and a descriptive analysis of data was carried out. ResultsFifteen papers provided some evidence that radiotherapy to the tumour bed and residual tumour may possibly be of value. However, there is a significant risk of bias and no evidence that all subgroups will benefit. There is some suggestion from six papers that dose may be important, but no hard evidence. It remains unclear whether irradiation of metastatic sites is helpful. Technical advances may be of value in radiotherapy of high-risk neuroblastoma. ConclusionsThere are data that show that radiotherapy is of some efficacy in the management of high-risk neuroblastoma, but there is no level one evidence that shows that it is being used in the best possible way. Prospective randomised trials are necessary to provide more evidence to guide development of optimal radiotherapy treatment schedules.

Benefit of Radiotherapy in Extraskeletal Myxoid Chondrosarcoma: A Propensity Score Weighted Population-based Analysis of the SEER Database.

Extraskeletal myxoid chondrosarcoma (EMC) is a rare malignancy for which the role of radiotherapy is not well-defined. We examine the effect of external beam radiotherapy (EBRT) on cancer-specific survival (CSS) for patients with localized EMC, in a propensity score weighted, population-based analysis. The Surveillance, Epidemiology, and End Results database (1973 to 2012) was queried for cases of localized EMC arising from soft connective tissues of the trunk and extremities treated with surgery and/or EBRT. Inverse probability treatment weighting was utilized, with survival analysis by weighted Cox regression and Kaplan-Meier analysis with log-rank testing. The primary endpoint was CSS. One hundred seventy-two patients were identified, diagnosed from 2004 to 2012. Ninety-four percent and 32% of 156 assessable patients underwent surgery and EBRT, respectively. By inverse probability treatment weighting, balancing covariates of age group, sex, race, grade, T stage, N stage, receipt of surgery, and anatomic site, we observed CSS of 97% versus 85% and 94% versus 85% in patients receiving EBRT versus no EBRT, at 3 and 5 years, respectively, at median follow-up of 33 months, P=0.01. A trend toward an overall survival benefit associated with EBRT was noted, P=0.06. Further adjusting for type of resection performed, CSS benefit persisted, 97% versus 85% at 3 years and 94% versus 85% at 5 years, P=0.02, with trend toward an overall survival benefit, P=0.08. The receipt of EBRT is associated with a CSS benefit in localized EMC. Aggressive local therapy, including EBRT, should be considered in these patients.