External Beam Radiation Treatment Research Articles

Pelvis Plus Prostate Radiation Therapy and the Risk of Death in Men With Newly Diagnosed Node-Positive Prostate Cancer.

Both single-institutional retrospective series and a multiinstitutional observational study1,2 find a significant association between a reduced risk of death and treatment of nodepositiveprostatecancerusing both external-beam radiation treatment (EBRT) of the prostate and pelvic lymph nodes (LNs) and androgen deprivation therapy (ADT) compared with ADT alone. However, whether this association is causal remains unanswered and requires testing in aprospective randomized trial. In this issue of JAMA Oncology, James and colleagues3 use data from the control arm in the Systemic Therapy in Advancing or Metastatic Prostate Cancer: Evaluation of Drug Efficacy (STAMPEDE) Trial to investigate this issue. Specifically, they perform a Cox regressionmultivariable analysis4 evaluating the riskof failure-free survivalwhere failure is defined as prostate-specific antigen (PSA) level; local, regional, or distant treatment failure; or death from prostate cancer, adjusting forhighest initialGleason score category (≤7, ≥8, unknown), log-transformed pre-ADT PSA level (continuous), age (<60, 60-64, 65-69, ≥70years), andWorldHealthOrganization performance status (0 vs 1 or 2) at randomization. Among 177 men with node-positive prostate cancer, 97 were planned for EBRT and 68 of these, plus 10men not originally slated for EBRT,were recordedashaving receivedEBRT to the prostate with or without pelvic LNs. After a median follow-up of 17months in the overall study cohort, 20menwith node-positiveprostate cancer experienceda failure event.The authors report that both planned and delivered prostatewith orwithoutpelvicEBRTwasassociatedwith reducedriskof failure, with adjusted hazard ratios of 0.48 (95% CI, 0.29-0.79) and 0.35 (95% CI, 0.19-0.65), respectively. There are several reasons to interpret these results with caution. First, as the authors note, EBRT use was prescribed by physician choice and therefore nonrandomized. In addition, the short median follow-up of 17 months in a study in which at least 2 years of ADTwas required and a primary end point (ie, failure-free survival) that is likely driven by PSArelated failureeventsat this shortmedian follow-up timemake it difficult topredictwhat effect a reduction inmostlyPSA failure–free survivalwill haveonoverall survival.Moreover, given the lowevent rate (20of 177 [11.3%]), theauthorswerenot able to analyze overall survival as an end point or adjust for all knownprostate cancer prognostic factors in theirmodel, such as tumor category, tertiary grade 5 inmenwith Gleason score 7prostate cancer, andpercent positive biopsies. Also,with40 deaths in the overall study cohort of which 9 could not be attributed to prostate cancer, a competing risk5 and not Cox regression analysis4 would have beenmore appropriate to analyze the end point of time to first failure or prostate cancer death. Finally, treatment use varied, in that somemen could have received irreversible and life-long testosterone suppression via bilateral orchiectomy as comparedwith 2 years of reversible ADT using a luteinizing hormone–releasing hormoneagonist.Moreover, inmen inwhomEBRTwasdelivered, the prostate was always treated whereas the pelvic LNs were only treated in a subset and thedose fractionation scheme for EBRTdeliveryvaried.Both thevariations inEBRTandADTcan affect time to first failure. Ideally, to account for these variations in treatment an adjustment in the model using a treatment propensity score would have been used, but the short median follow-up and consequently a low event rate would likelynotpermit the inclusionof thetreatmentpropensityscore and other known prostate cancer prognostic factors without running the risk of overfitting the model. Given these limitations, the conclusion that the addition of prostate and pelvic EBRT to ADT in the treatment of nodepositiveprostate cancer reduces the riskof failure,whileprobably true, cannot be rigorously concluded from the present analysisbecauseof theshortmedian follow-up, lowevent rate, nonrandomized data, and lack of adjustment for treatment variation and some known prostate cancer prognostic factors. Moreover, to affect clinical practice, at a minimum one should provide evidence in amodel powered for survival and adjusted for age, comorbidity, known prostate cancer prognostic factors, and type and duration of ADT that treatment using both pelvic and prostate RT andADT as comparedwith Related article page 348 Failure-Free Survival and Nonmetastatic Prostate Cancer Radiotherapy Original Investigation Research

A.161 - Neutron activation detectors for clinical dosimetry in external beam radiation treatments

A.161 - Neutron activation detectors for clinical dosimetry in external beam radiation treatments

Prospective evaluation of patient-reported quality of life outcomes after external beam radiation treatment for prostate cancer in Victoria: A cohort study by the Victorian Prostate Cancer Registry.

External beam radiation treatment (EBRT) for prostate cancer (CaP) can cause adverse effects on bowel, bladder and sexual function. We aimed to use CaP clinical registry data to evaluate variation in patient adverse effects after EBRT in Victoria. Study subjects were men diagnosed with primary CaP between 2009 and 2014, treated with EBRT in metropolitan Melbourne, or in one of three regional integrated cancer service (ICS) regions. Information on change in general and disease-specific health outcome 12 and 24 months after the initial diagnosis were obtained using a modified Expanded CaP index composite (EPIC)-26 survey and there was no variation of follow up between ICSs. The proportion of men with 'big bother' (the most troublesome category) was compared between the ICS regions in Victoria (n = 1,825). There was no difference in big bother in urinary and sexual function across the regions at 24 months. However, patients treated in one regional cancer service had a higher proportion with 'big bother' (11.1%) compared with the rest of the Victoria (4.8%); (χ(2) = 4.85; P = 0.02). The only significant factor for this was the location of EBRT (odds ratio = 2.6; 95% confidence interval: 1.12-6.04; P = 0.02). There was no association over time in that region with change in EBRT technique from 3-D conformal radiation therapy to intensity-modulated radiation therapy (z-test for proportion: 0.77; P: 0.44). A comprehensive clinical cancer registry system, can be used to benchmark outcomes for men diagnosed with CaP and may detect clinically relevant variations that require further detailed evaluation and response.

A phase I study of chemoradiation with weekly panitumumab following neoadjuvant chemotherapy and pelvic lymph node dissection as an organ preserving treatment of invasive bladder cancer.

392 Background: Radical Cystectomy (RC) is the standard treatment of Invasive Bladder Cancer (IBC). Although organ sparing, external beam Radiation Treatment (RT) alone is considered inferior to RC. Since the Epidermal Growth Factor receptor (EGFr) is frequently overexpressed in IBC, combined EGFr inhibition by Panitumumab (P) and RT might improve treatment outcome. In this study, the safety and efficacy of concurrent RT and P (RT/P) following Neoadjuvant Chemotherapy (NAC) and Pelvic Lymph Node Dissection (PLND) was evaluated. Methods: cT2-4N0-2M0 or cT1N1-2M0 bladder cancer patients were enrolled in the study. NAC consisted of a maximum of 4 cycles platinum-based chemotherapy. cN0 patients received NAC after PLND, while cN+ patients (confirmed by fine needle aspiration) received NAC prior to PLND. RT/P consisted of concurrent P (7 weekly doses of 2.5 mg/kg) and bladder RT (66Gy in 33 fractions). Primary end-points were treatment-related toxicity and complete clinical response (CR) assessed by Computed Tomography and cystoscopy 3 months after therapy completion. Partial response (PR) was defined as cT &lt; 2N0. Results: A total of 31 patients were included (mean age: 60±10 years), 3/31 patients were cN1-2. Three patients discontinued NAC after 3 cycles due to toxicity. After NAC (24 cisplatin-based and 7 gemcitabine/carboplatin) 13 (41.9%) patients had remaining visible disease. All patients completed RT, while 4/31 patients terminated P prematurely (2-6 doses) due to toxicity. Preliminary response results after RT/P were available for 29/31 patients. Twenty-six/29 (89.7%) patients had a CR, 3 patients PR (10.3%) of which 2 were treated with transurethral resection and intravesical treatment (TaG1-2) and 1 patient underwent immediate cystectomy after histologic confirmation of T1G3. Conclusions: These preliminary results suggest that concurrent P and RT following NAC and PLND is an organ-preserving option for IBC. Toxicity, EGFr expression, mutational status and long-term oncologic outcomes have to be awaited. Clinical trial information: NL31148.031.10.

The relative biological effectiveness of out-of-field dose

Purpose: using simulations and models derived from existing literature, this work investigates relative biological effectiveness (RBE) for out-of-field radiation and attempts to quantify the relative magnitudes of different contributing phenomena (spectral, bystander, and low dose hypersensitivity effects). Specific attention is paid to external beam radiotherapy treatments for prostate cancer.Materials and methods: using different biological models that account for spectral, bystander, and low dose hypersensitivity effects, the RBE was calculated for different points moving radially out from isocentre for a typical single arc VMAT prostate case. The RBE was found by taking the ratio of the equivalent dose with the physical dose. Equivalent doses were calculated by determining what physical dose would be necessary to produce the same overall biological effect as that predicted using the different biological models.Results: spectral effects changed the RBE out-of-field less than 2%, whereas response models incorporating low dose hypersensitivity and bystander effects resulted in a much more profound change of the RBE for out-of-field doses. The bystander effect had the largest RBE for points located just outside the edge of the primary radiation beam in the cranial caudal (z-direction) compared to low dose hypersensitivity and spectral effects. In the coplanar direction, bystander effect played the largest role in enhancing the RBE for points up to 8.75 cm from isocentre.Conclusions: spectral, bystander, and low dose hypersensitivity effects can all increase the RBE for out-of-field radiation doses. In most cases, bystander effects seem to play the largest role followed by low dose hypersensitivity. Spectral effects were unlikely to be of any clinical significance. Bystander, low dose hypersensitivity, and spectral effect increased the RBE much more in the cranial caudal direction (z-direction) compared with the coplanar directions.

Radiotherapy in well-differentiated thyroid cancer: is it underutilized?

The usual management of thyroid cancer is surgery and radioactive iodine. The role of external beam radiotherapy (EBRT) in well-differentiated thyroid carcinoma remains controversial. Indications for the use of EBRT, contained within both the American and British Thyroid Association published guidelines, include unresectable or non-iodine avid disease, extra-thyroidal extension or distant metastatic disease. A retrospective review of prospectively collected data from a single Australian institution was conducted, analysing patients referred and treated with EBRT for well-differentiated thyroid carcinoma between November 1992 and July 2013. Of 36 patients referred, 32 were treated with EBRT. Sixteen patients in total received locoregional treatment (six radical, 10 palliative), of whom 81% (13/16) had gross disease and 88% (14/16) had recurrent disease (eight with multiple recurrences). Additionally, 63% (10/16) had multiple surgical resections and 50% (8/16) had previously received multiple courses of radioactive iodine. Overall, 67% (4/6) of patients treated with radical intent had no locoregional recurrence or progression. Thirteen of the 16 patients who received locoregional EBRT remained asymptomatic from their locoregional disease at the time of last follow-up or death. The most commonly treated distant metastatic disease site was bone, with a total of 45 sites irradiated. Of these patients, 93% and 78% were symptom-free at two and four years, respectively. Our study suggests that in a select group of patients with well-differentiated thyroid carcinoma, EBRT treatment appears to provide durable tumour and symptom control.

O.32 - A dosimetric evaluation of IGART strategies for cervix cancer treatment

Introduction: Substantial organ motion and tumor shrinkage may occur during external beam radiotherapy treatment of cervix cancer. The quality of radiation delivery is influenced by these anatomical changes which warrant treatment adaptation. Imaging information obtained prior to the actual treatment can be used in off-line or on-line adaptive strategies to include the temporal aspects of radiotherapy treatment. This will ensure sufficient coverage of the target without compromising organ at risk (OAR) sparing. The aim of this study is to dosimetrically evaluate these two image guided adaptive radiotherapy (IGART) strategies.

Radiation Techniques for Increasing Local Control in the Non-Surgical Management of Rectal Cancer

A fraction of patients with rectal cancer can achieve clinical complete response following long-course chemoradiotherapy (CRT), and there is accumulating clinical evidence that these patients can be managed non-surgically with acceptable oncological outcome. Consequently, strategies for increasing the proportion of complete responders are actively being explored. Some, although limited, experience with high-dose radiotherapy indicates that there might exist a dose-response relationship for local tumour control after radiotherapy alone. Thus, tumour dose escalation could be indicated for selected patients, particularly in cases with small tumours and limited local disease. This report discusses several radiotherapy techniques for tumour boosting, focusing on technical challenges and clinical experiences with each technique. Specifically, external beam radiotherapy, brachytherapy and contact X-ray treatment for dose escalation are considered. Ultimately, no technique provides definitive advantage over others, and the choice in clinical practice will have to depend on the patient population treated as well as the technical capabilities of the treating department.

Surveillance active du cancer de la prostate

Active surveillance is part of the therapeutic possibilities of localized prostate cancer at low-risk of progression. Patients are eligible for this support modality if they meet specific criteria of indolent cancer. In this population, active surveillance will consist of a regular physical examination, monitoring of PSA and repeating prostate biopsies and/or MRI to assess the absence of evolution of the diagnosed prostate cancer. In case of modification or worsening of the monitoring criteria in favor of evolution of the cancer, the patient will be offered a deferred active treatment such as radical prostatectomy, external beam radiotherapy, brachytherapy or focal treatment. For patients still meeting the eligibility criteria, active surveillance avoids an unnecessary treatment potentially responsible of genitourinary adverse events.

Intraoperative electron-beam radiation therapy with or without external-beam radiotherapy in the management of paraaortic lymph-node oligometastases from gynecological malignancies.

To analyze long-term outcomes and prognostic factors in patients with paraaortic lymph-node oligometastases (LNO) from gynecological malignancies treated in a multimodal protocol. Patients with a histological diagnosis of LNO gynecological cancer [uterine cervix (n=14, 40%), endometrial (n=18, 51%), ovarian (n=3, 9%)] who underwent surgery with radical intent and intraoperative radiotherapy (IORT), median dose 12.5Gy) were considered eligible for participation in this study. Additionally, 51% received external-beam radiotherapy (EBRT). From 1997 to 2012, a total of 35 patients from a single institution were analyzed. With a median follow-up time of 55months (range 2-148), 5-year loco-regional control (LRC), disease-free survival (DFS) and overall survival (OS) were 79, 44 and 49%, respectively. On multivariate analysis, no EBRT treatment to the LNO (p=0.03), and time interval from primary tumor diagnosis to LNO<24months (p=0.04) remained significantly associated with locoregional recurrence (LRR). We found on multivariate analysis that only R1 margin status (p=0.01) was significantly associated with OS. From the current series of patients with gynecological LNO, it emerges the fact that EBRT promotes local control. Future prospective studies might be designed according to the predicted risk of LRR focusing on different subgroups.

Consensus and differences in primary radiotherapy for localized and locally advanced prostate cancer in Switzerland: A survey on patterns of practice.

External beam radiotherapy (EBRT), with or without androgen deprivation therapy (ADT), is an established treatment option for nonmetastatic prostate cancer. Despite high-level evidence from several randomized trials, risk group stratification and treatment recommendations vary due to contradictory or inconclusive data, particularly with regard to EBRT dose prescription and ADT duration. Our aim was to investigate current patterns of practice in primary EBRT for prostate cancer in Switzerland. Treatment recommendations on EBRT and ADT for localized and locally advanced prostate cancer were collected from 23 Swiss radiation oncology centers. Written recommendations were converted into center-specific decision trees, and analyzed for consensus and differences using a dedicated software tool. Additionally, specific radiotherapy planning and delivery techniques from the participating centers were assessed. The most commonly prescribed radiation dose was 78 Gy (range 70-80 Gy) across all risk groups. ADT was recommended for intermediate-risk patients for 6 months in over 80 % of the centers, and for high-risk patients for 2 or 3 years in over 90 % of centers. For recommendations on combined EBRT and ADT treatment, consensus levels did not exceed 39 % in any clinical scenario. Arc-based intensity-modulated radiotherapy (IMRT) is implemented for routine prostate cancer radiotherapy by 96 % of the centers. Among Swiss radiation oncology centers, considerable ranges of radiotherapy dose and ADT duration are routinely offered for localized and locally advanced prostate cancer. In the vast majority of cases, doses and durations are within the range of those described in current evidence-based guidelines.

Adverse events of local treatment in long-term head and neck rhabdomyosarcoma survivors after external beam radiotherapy or AMORE treatment

BackgroundRadiotherapy is a well-known cause of adverse events (AEs). To reduce AEs, an innovative local treatment was developed in Amsterdam: Ablative surgery, MOuld brachytherapy and surgical REconstruction (AMORE).Aims: (1) to determine the prevalence of AEs in HNRMS survivors and (2) to compare AEs between survivors treated with the international standard: external beam radiotherapy (EBRT-based: London) and survivors treated with AMORE if feasible, otherwise EBRT (AMORE-based: Amsterdam). MethodsAll HNRMS survivors, treated in London or Amsterdam between January 1990 and December 2010 (n=153), and alive ⩾2years post-treatment were eligible (n=113). A predefined list of AEs was assessed in a multidisciplinary clinic and graded according to the Common Terminology Criteria for Adverse Events. ResultsEighty HNRMS survivors attended the clinic (median follow-up 10.5years); 63% experienced ⩾1 severe or disabling event, and 76% had ⩾5 AEs (any grade). Survivors with EBRT-based treatment were, after adjustment for site, age at diagnosis, and follow-up duration, at increased risk to develop any grade 3/4 event or ⩾5 AEs (any grade) compared with survivors with AMORE-based treatments (p=0.032 and 0.01, respectively). Five year overall survival (source population) after EBRT-based treatment was 75.0%, after AMORE-based treatment 76.9%, p=0.56. ConclusionThis study may serve as a baseline inventory and can be used in future studies for prospective assessments of AEs following the introduction of novel local treatment modalities. AMORE-based local treatment resulted in similar overall survival and a reduction of AEs secondary to local treatment.

Single-Institution Multidisciplinary Management of Locoregional Oligo-Recurrent Pelvic Malignancies: Long-Term Outcome Analysis

The aim of this study was to analyze long-term outcomes and prognostic factors associated with survival in patients with locoregional oligo-recurrent (LROR) pelvic malignancies treated in a multimodal protocol. Patients with an histologic diagnosis of LROR pelvic cancer (rectal 50 %, gynecological 50 %) with absence of distant metastases, undergoing surgery with radical intent and intraoperative radiotherapy (median dose 12.5 Gy) were considered eligible for participation in this study. Additionally, 48 % received external beam radiotherapy (EBRT) (median dose 50 Gy). From 1995 to 2012, a total of 143 patients from a single institution were analyzed. With a median follow-up time of 48 months (range 2-189), 5-year locoregional control (LRC), disease-free survival (DFS), and overall survival (OS) were 53, 44, and 46 %, respectively. On multivariate analysis, no EBRT treatment to the locoregional (p ≤ 0.001), R1 margin status (p = 0.03), time interval from primary tumor diagnosis to LROR <24 months (p = 0.05), and fragmentation in the resected specimen (p = 0.004) retained significance in relation to LRC. On multivariate analysis we found that only R1 margin status (p = 0.003), primary tumor diagnosis to LROR <24 months (p = 0.02), and high histological grade (p = 0.02) were significantly associated with OS. From this analysis emerges the fact that EBRT influences local control but, given the high risk of distant metastases, DFS remains modest. Margin status, tumor fragmentation, no EBRT to the LR, and time interval from primary tumor diagnosis to LROR are the dominant factors for subsequent locoregional recurrence (LRR). Accordingly, future prospective studies might be designed which adapt treatment according to the predicted risk of subsequent LRR.

Helical 4D CT pitch management for the Brilliance CT Big Bore in clinical practice.

In external beam radiotherapy treatment planning for patients with thoracic malignancies, respiratory‐correlated CT (4D CT) is used to obtain high quality studies in the presence of respiratory motion. When helical 4D CT scans are acquired with a Brilliance CT Big Bore, the pitch must meet two conditions. It must be low enough to avoid motion artifacts, and high enough to cover the entire scan length within 120 s to prevent overheating of the X‐ray tube. We developed a nomogram that can be used to obtain a suitable pitch satisfying both requirements. We also assessed the effects on the image quality of a pitch that exceeds the maximum pitch, and of a field of view (FOV) reduction. It was shown that, for AV G and MIP reconstructions, the manufacturer's maximum pitch equation yields an underestimation due to its FOV term.PACS number: 87.57.Q‐, 87.57.cp

Radiochromic film-based quality assurance for CT-based high-dose-rate brachytherapy.

In the past, film dosimetry was developed into a powerful tool for external beam radiotherapy treatment verification and quality assurance. The objective of this work was the development and clinical testing of the EBT3 model GafChromic film based brachytherapy quality assurance (QA) system. Retrospective dosimetry study was performed to test a patient-specific QA system for preoperative endorectal brachytherapy that uses a radiochromic film dosimetry system. A dedicated phantom for brachytherapy applicator used for rectal cancer treatment was fabricated enabling us to compare calculated-to-measured dose distributions. Starting from the same criteria used for external beam intensity-modulated radiation therapy QA (3%, 3 mm), passing criteria for high- and low-dose gradient regions were subsequently determined. Finally, we investigated the QA system's sensitivity to controlled source positional errors on selected patient plans. In low-dose gradient regions, measured dose distributions with criteria of 3%, 3 mm barely passed the test, as they showed 95% passing pixels. However, in the high-dose gradient region, a more stringent condition could be established. Both criteria of 2%, 3 mm and 3%, 2 mm with gamma function calculated using normalization to the same absolute dose value in both measured and calculated dose distributions, and matrix sizes rescaled to match each other showed more than 95% of pixels passing, on average, for 15 patient plans analyzed. Although the necessity of the patient-specific brachytherapy QA needs yet to be justified, we described a radiochromic film dosimetry-based QA system that can be a part of the brachytherapy commissioning process, as well as yearly QA program.

MP88-11 EXTERNAL BEAM RADIATION THERAPY AFTER MALE TRANSOBTURATOR SLING PLACEMENT INCREASES FAILURE RATES

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Male Incontinence: Therapy1 Apr 2015MP88-11 EXTERNAL BEAM RADIATION THERAPY AFTER MALE TRANSOBTURATOR SLING PLACEMENT INCREASES FAILURE RATES Divya Ajay, John Selph, Michael Belsante, Ngoc-Bich Le, Aaron Lentz, George Webster, and Andrew Peterson Divya AjayDivya Ajay More articles by this author , John SelphJohn Selph More articles by this author , Michael BelsanteMichael Belsante More articles by this author , Ngoc-Bich LeNgoc-Bich Le More articles by this author , Aaron LentzAaron Lentz More articles by this author , George WebsterGeorge Webster More articles by this author , and Andrew PetersonAndrew Peterson More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1844AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Post-prostatectomy stress urinary incontinence (PPSUI) is a well−recognized side effect of treatment for prostate cancer that negatively impacts quality of life. There is ample evidence to suggest that patients who undergo external beam radiation therapy (EBRT) prior to transobturator sling (TOS) placement have high rates of TOS failure. However, whether EBRT delivered for biochemical recurrence after TOS placement affects continence outcomes is not known. Our objective was to evaluate TOS outcomes in patients with post-sling EBRT. METHODS We conducted an IRB approved review of all patients undergoing a male TOS placement from 2006 to 2012 at our institution. Patients who underwent placement of TOS were identified using our patient data portal (DEDUCE). Demographic and follow-up data were extracted by chart review. Success was defined post-operatively by the use of 0 or 1 security pad, a negative stress test on exam, or pad weight of less than 8 g per 24 hours. Student's T-test was performed. RESULTS During this time period 290 TOS were performed. Of these, we identified 11 patients who received EBRT after TOS placement. All of these underwent a radical prostatectomy for prostate cancer and presented with PPSUI. Average age at TOS surgery was 66.3 years (± 7.4). They underwent EBRT at a median of 18 months (IQR 11-38) from TOS placement. 8/11 (73%) were dry prior to EBRT. Of the patients who were dry, 87.5% (7/8) reported TOS failure after EBRT treatment at a median of 0 months (IQR 0-11) from the end of radiation therapy. This is in comparison to a 42.6% overall failure rate in the entire cohort (p<0.01). CONCLUSIONS EBRT delivered after male TOS placement may cause TOS failure. This information will be helpful in clinical decision making for PPSUI patients with advanced stage prostate cancer or with positive surgical margins at radical prostatectomy who may need adjuvant EBRT. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e1096 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Divya Ajay More articles by this author John Selph More articles by this author Michael Belsante More articles by this author Ngoc-Bich Le More articles by this author Aaron Lentz More articles by this author George Webster More articles by this author Andrew Peterson More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

Cost of palliative external beam radiotherapy (EBRT) use for bone metastases secondary to prostate cancer.

Evaluations of the costs of palliative external beam radiation therapy (EBRT) for treatment of bone metastases are limited. To summarize EBRT lifetime care patterns in deceased men with metastatic prostate cancer treated in a cancer hospital in the United States. A retrospective review of electronic health records identified deceased adult prostate cancer (ICD-9 185.xx) patients with bone metastases (ICD-9 198.5) and who were treated for bone pain and metastasis management with EBRT between January 1, 1995 and December 17, 2012. Common Procedural Terminology codes were used to identify all EBRT episodes (total billed EBRT services; initial and final evaluation) to calculate length of EBRT treatments and per episode costs (2011 US$). Bootstrapping approximated the 95% confidence interval for final cost estimates. 176 men were identified; 19 (10.8%) had bone metastases in >1 site. Eighty-nine men (50.6%) received >1 EBRT episode (range, 1-6; median, 2), with first episode length ranging from 1-44 calendar days (mean, 13.4; SD, 8.4) at a mean cost of $7,084 (SD, $4,028). About 70% of costs were attributable to hospital charges and 30% to physician charges. Small sample size limits broad applicability to large populations of men with prostate cancer. Care costs for EBRT constitute one of many costs that should be taken into account when planning for palliative care of prostate cancer and bone metastasis.

Comprehensive MRI simulation methodology using a dedicated MRI scanner in radiation oncology for external beam radiation treatment planning.

The use of magnetic resonance imaging (MRI) in radiation oncology is expanding rapidly, and more clinics are integrating MRI into their radiation therapy workflows. However, radiation therapy presents a new set of challenges and places additional constraints on MRI compared to diagnostic radiology that, if not properly addressed, can undermine the advantages MRI offers for radiation treatment planning (RTP). The authors introduce here strategies to manage several challenges of using MRI for virtual simulation in external beam RTP. A total of 810 clinical MRI simulation exams were performed using a dedicated MRI scanner for external beam RTP of brain, breast, cervix, head and neck, liver, pancreas, prostate, and sarcoma cancers. Patients were imaged in treatment position using MRI-optimal immobilization devices. Radiofrequency (RF) coil configurations and scan protocols were optimized based on RTP constraints. Off-resonance and gradient nonlinearity-induced geometric distortions were minimized or corrected prior to using images for RTP. A multidisciplinary MRI simulation guide, along with window width and level presets, was created to standardize use of MR images during RTP. A quality assurance program was implemented to maintain accuracy and repeatability of MRI simulation exams. The combination of a large bore scanner, high field strength, and circumferentially wrapped, flexible phased array RF receive coils permitted acquisition of thin slice images with high contrast-to-noise ratio (CNR) and image intensity uniformity, while simultaneously accommodating patient setup and immobilization devices. Postprocessing corrections and alternative acquisition methods were required to reduce or correct off-resonance and gradient nonlinearity induced geometric distortions. The methodology described herein contains practical strategies the authors have implemented through lessons learned performing clinical MRI simulation exams. In their experience, these strategies provide robust, high fidelity, high contrast MR images suitable for external beam RTP.

Recurrence patterns and survival endpoints in women with stage II uterine endometrioid carcinoma: A multi-institution study

ObjectiveThere is paucity of data in regard to prognostic factors and outcome of women with 2009 FIGO stage II disease. The objective of this study was to investigate prognostic factors, recurrence patterns and survival endpoints in this group of patients. MethodsData from four academic institutions were analyzed. 130 women were identified with 2009 FIGO stage II. All patients underwent hysterectomy, oophorectomy and lymph node evaluation with or without pelvic and paraaortic lymph node dissections and peritoneal cytology. The Kaplan–Meier approach and Cox regression analysis were used to estimate recurrence-free (RFS), disease-specific (DSS) and overall survival (OS). ResultsMedian follow-up was 44months. 120 patients (92%) underwent simple hysterectomy, 78% had lymph node dissection and 95% had peritoneal cytology examination. 99 patients (76%) received adjuvant radiation treatment (RT). 5-year RFS, DSS and OS were 77%, 90%, and 72%, respectively. On multivariate analysis of RFS, adjuvant RT, the presence of lymphovascular space invasion (LVSI) and high tumor grades were significant predictors. For DSS, LVSI and high tumor grades were significant predictors while older age and high tumor grade were the only predictors of OS. ConclusionsIn this multi-institutional study, disease-specific survival for women with FIGO stage II uterine endometrioid carcinoma is excellent. High tumor grade, lymphovascular space invasion, adjuvant radiation treatment and old age are important prognostic factors. There was no significant difference in the outcome between patients who received vaginal cuff brachytherapy compared to those who received pelvic external beam radiation treatment.

Additional androgen deprivation makes the difference

The role of additional androgen deprivation therapy (ADT) in prostate cancer (PCa) patients treated with combined HDR brachytherapy (HDR-BT) and external beam radiotherapy (EBRT) is still unknown. Consecutive PCa patients classified as D'Amico intermediate and high-risk who underwent HDR-BT and EBRT treatment ± ADT at our institution between January 1999 and February 2009 were assessed. Multivariable Cox regression models predicting biochemical recurrence (BCR) were performed. BCR-free survival was assessed with Kaplan-Meier analyses. Overall, 392 patients were assessable. Of these, 221 (56.4 %) underwent trimodality (HDR-BT and EBRT and ADT) and 171 (43.6 %) bimodality (HDR-BT and EBRT) treatment. Additional ADT administration reduced the risk of BCR (HR: 0.4, 95 % CI: 0.3-0.7, p < 0.001). D'Amico high-risk patients had superior BCR-free survival when additional ADT was administered (log-rank p < 0.001). No significant difference for BCR-free survival was recorded when additional ADT was administered to D'Amico intermediate-risk patients (log-rank p = 0.2). Additional ADT administration improves biochemical control in D'Amico high-risk patients when HDR-BT and EBRT are combined. Physicians should consider the oncological benefit of ADT administration for these patients during the decision-making process.