External Beam Research Articles

LI-RADS radiation-based treatment response algorithm for HCC: what to know and how to use it.

Locoregional treatments (LRT) continue to advance for hepatocellular carcinoma (HCC). Selective internal radiation therapy (SIRT) or transarterial radioembolization (TARE) with radioactive 90 Yttrium (Y90) microspheres is currently widely accepted, and external beam and stereotactic body radiation (EBRT/SBRT) are increasingly used as LRT1-5. Assessment of treatment response after these radiation-based therapies can be challenging, given that the adjacent liver also undergoes treatment related changes, inflammatory changes occur, and there is a variable time for response to develop. In 2017, the liver imaging reporting and data system (LI-RADS) workgroup initially developed a single algorithm for the imaging assessment of treatment response encompassing all types of locoregional therapies, the LI-RADS treatment response (LR-TR) algorithm. Recognizing that response and imaging patterns differ between radiation and non-radiation based therapies, the LR-TR working group recently updated the algorithm to reflect the unique characteristics of tumor response for therapies involving radiation. This article aims to elucidate the changes in the new version of the LI-RADS TR, with a guide for algorithm utilization and illustration of expected and unexpected findings post liver directed therapies for HCC.

Adjuvant Chemotherapy With or Without Radiotherapy for Resected Pancreatic Cancer After Multiagent Neoadjuvant Chemotherapy.

Adjuvant therapy is associated with improved pancreatic cancer survival after neoadjuvant chemotherapy and surgery. However, whether adjuvant treatment should include radiotherapy is unclear in this setting. This study queried the National Cancer Database for pancreatic adenocarcinoma patients who underwent curative resection after multiagent neoadjuvant chemotherapy between 2010 and 2019 and received adjuvant treatment. Adjuvant chemotherapy plus radiotherapy (external beam, 45-50.4 gray) was compared with adjuvant chemotherapy alone. Uni- and multivariable Cox regression was used to assess survival associations. Analyses were repeated in a propensity score-matched subgroup. Of 1983 patients who received adjuvant treatment after multiagent neoadjuvant chemotherapy and resection, 1502 (75.7%) received adjuvant chemotherapy alone and 481 (24.3%) received concomitant adjuvant radiotherapy (chemoradiotherapy). The patients treated with adjuvant chemoradiotherapy were younger, were treated at non-academic facilities more often, and had higher rates of lymph node metastasis (ypN1-2), positive resection margins (R1), and lymphovascular invasion (LVI+). The median survival was shorter for the chemoradiotherapy-treated patients according to the unadjusted analysis (26.8 vs 33.2 months; p = 0.0017). After adjustment for confounders, chemoradiotherapy was associated with better outcomes in the multivariable model (hazard ratio [HR], 0.75; 95% confidence interval [CI], 0.61-0.93; p = 0.008). The association between chemoradiotherapy and improved outcomes was stronger for the patients with grade III tumors (HR, 0.53; 95% CI, 0.37-0.74) or LVI+ tumors (HR, 0.58; 95% CI, 0.44-0.75). In a subgroup of 396 propensity-matched patients, chemoradiotherapy was associated with a survival benefit only for the patients with LVI+ or grade III tumors. After multiagent neoadjuvant chemotherapy and resection for pancreatic cancer, additional adjuvant chemoradiotherapy versus adjuvant chemotherapy alone is associated with improved survival for patients with LVI+ or grade III tumors.

Comparative Analysis of External and Internal Radiotherapy- Dependent Plans in Patients with Gynecological Cancer.

Radiotherapy plays a key role in the treatment of gynecological cancer. Modern radiotherapy techniques with external beams (e-RT) are applied in a broad spectrum of gynecological cancer cases. However, high radiation doses, affecting normal tissue adjacent to cancer, represent the main disadvantage of e-RT regimens. For this reason, brachytherapy (BT), an internal beam-based technique (i-RT), is suggested following e-RT. Our purpose was to compare e-RT plans using volumetric-modulated arc therapy (VMAT) with those using 3D conformal techniques (3D-CRT) and compare BT plans guided by 3D or 2D imaging based on the potential corresponding toxicity levels. In this preliminary, non-randomized comparative retrospective study, 15 females suffering gynecological cancer were enrolled. Modern e-RT and i-RT (BT) techniques were applied. Concerning e-RT, D95/D99/rectum 2cc/bladder 2cc and small intestine 2cc were measured and compared; in i-RT, rectum 2cc/bladder 2cc were measured and compared. The median dose to the planning target volume in VMAT was 97.4 Gy compared with 92.9 Gy in 3D-CRT. Τhe rectum received almost 5 Gy less in VMAT compared to 3D-CRT (median of 43.5 Gy vs. 48.6 Gy; p=0.001). In the bladder, dose differences were minimal, while the small intestine received 47.6 Gy in VMAT (p=0.001). Regarding 3D-BT, the rectum received 63.1 Gy compared with 49.9 Gy (p=0.009) in 2D-BT. Concerning the bladder, mean 2D-BT and 3D-BT doses were 71.9 and 65 Gy, respectively, differing non-significantly. VMAT was found to be superior to 3D-CRT, especially in dose distribution, volume coverage and protection of critical organs. Similarly, 3D-BT should be preferred over 2D-BT due to critical advantages.

Radiation Therapy With or Without Cisplatin for Local Recurrences of Endometrial Cancer: Results From an NRG Oncology/GOG Prospective Randomized Multicenter Clinical Trial.

Pelvic recurrence is a frequent pattern of relapse for women with endometrial cancer. A randomized trial compared progression-free survival (PFS) after treatment with radiation therapy alone as compared with concurrent chemotherapy. Between February 2008 and August 2020, 165 patients were randomly assigned 1:1 to receive either radiation treatment alone or a combination of chemotherapy and radiation treatment. The primary objective of this study was to determine whether chemoradiation therapy was more effective than radiation therapy alone at improving PFS. The majority of patients had low-grade (1 or 2) endometrioid histology (82%) and recurrences confined to the vagina (86%). External beam with either the three-dimensional or intensity modulated radiation treatment technique was followed by a boost delivered with brachytherapy or external beam. Patients randomly assigned to receive chemotherapy were treated with once weekly cisplatin (40 mg/m2). Rates of acute toxicity were higher in patients treated with chemoradiation as compared with radiation treatment alone. Median PFS was longer for patients treated with radiation therapy alone as compared with chemotherapy and radiation (median PFS was not reached for RT v 73 months for chemoradiation, hazard ratio of 1.25 (95% CI, 0.75 to 2.07). At 3 years, 73% of patients treated definitively with radiation and 62% of patients treated with chemoradiation were alive and free of disease progression. Excellent outcomes can be achieved for women with localized recurrences of endometrial cancer when treated with radiation therapy. The addition of chemotherapy does not improve PFS for patients treated with definitive radiation therapy for recurrent endometrial cancer and increases acute toxicity. Patients with low-grade and vaginal recurrences who constituted the majority of those enrolled are best treated with radiation therapy alone.

Endometrial cancer with positive sentinel lymph nodes: pathologic characteristics of metastases as predictors of extent of lymphatic dissemination and prognosis

ObjectivesTo assess predictors of extensive lymph node dissemination and non-vaginal recurrence in patients with endometrial cancer with positive sentinel lymph nodes (SLNs).MethodsPatients with endometrial cancer who underwent primary surgery with...

Practical Implications of the American Society for Radiation Oncology Radiation Oncology Case Rate Program Proposal for Radiation Oncologists

The American Society for Radiation Oncology has proposed the Radiation Oncology Case Rate Program (ROCR) to advocate for fair reimbursement for radiation oncologists. ROCR would replace Medicare fee-for-service with a case rate payment for each of the 15 most common cancer types treated with external beam or stereotactic radiation therapy. This topic discussion attempts to provide a concise overview of the practical implications for radiation oncologists should the ROCR payment program be legislated by Congress and subsequently implemented by the Center for Medicare and Medicaid Services. This topic discussion covers the practical changes to billing and reimbursement, the Health Equity Achievement in Radiation Therapy payment, the Quality of Care requirement, and the available tool to calculate the effect of the ROCR based on an individual practice's case mix.

Practice patterns, time trends and quality of care of uterine cancer in Belgium: An analysis of the EFFECT database

ObjectivesTo investigate the practice patterns and quality of care for uterine cancer on a national level in Belgium, including trends in practice over the period 2012–2016. MethodsQuality indicators were measured using the EFFectiveness of Endometrial Cancer Treatment (EFFECT) database. Multivariable logistic mixed regression was used to test for associations between the quality indicators and year of diagnosis, adjusted for potential confounders and intra-cluster correlations. ResultsThe EFFECT database includes 4178 patients diagnosed with uterine cancer in the period 2012–2016. Minimally invasive surgery (laparoscopic or robotic-assisted) was applied in 61.6% of patients who had surgery for clinical stage I endometrial carcinoma (EC), increasing from 52.9% in 2012 to 66.4% in 2016. At least pelvic lymph node staging was performed in 69.0% of patients with clinical stage I, high-grade EC; and in 63.9% of patients with clinical stage I-II serous carcinoma, clear cell carcinoma or carcinosarcoma. The latter increased from 48.8% in 2012 to 77.2% in 2016. Adjuvant radiotherapy (external beam and/or brachytherapy) was offered to 33.5% of patients who had surgery without lymph node staging for pathological stage I EC at high-intermediate or high risk of recurrence. Adjuvant chemotherapy was administered to 64.4% of patients with pathological stage III-IVA EC. ConclusionsStudy results indicate an overall good quality of care for patients with uterine cancer in Belgium. Treatment areas with potential room for improvement include the use of minimally invasive surgery, comprehensive surgical staging and adjuvant therapy, which confirms the remaining controversies in uterine cancer treatment and the need for further research.

Outcomes in Locally Advanced Non-Metastatic Prostate Cancer Presenting with Low PSA at Diagnosis.

Men with low serum prostate-specific antigen (PSA) and high Gleason grade group (GGG) are thought to have poor outcomes compared to high PSA secretors. However, there is limited outcome data to support this. We report clinical outcomes from a single-institutional cohort of men presenting with locally advanced prostate cancer but low serum PSA. Data from electronic database of a UK tertiary cancer center was acquired for men with histological diagnosis of prostate adenocarcinoma, GGG 4 or 5, stage ≥cT3a, and PSA <10ug/L at diagnosis. Men with metastatic disease, or prior androgen deprivation therapy (ADT) were excluded. Biochemical progression was defined as per Phoenix criteria (PSA > nadir+2) for primary radiotherapy, or PSA >0.2 ug/L after primary prostatectomy (and post-operative radiotherapy, if received). Overall survival (OS, from date of diagnosis to death), metastasis-free survival (MFS, from diagnosis to first recorded metastasis or death), and biochemical progression free survival (bPFS, from diagnosis to biochemical progression or death) were estimated by Kaplan Meier method, and multivariable analysis performed using Cox proportional hazards method. Medical records of 7,200 men presenting with non-metastatic prostate cancer from 2013 to 2021 were screened, of which 270 men satisfying the eligibility criteria were included for this study. Initial analysis of 123 men shows median PSA at presentation 7.1 ug/L (IQR 5.6-8.5), and median age 70 years (IQR 65-75). Histology was GGG 4 in 47.6% and 5 in 52.4%. Tumor stage was cT3a in 56.6%, cT3b in 36.9%, and T4 in 6.6%. Pelvic nodes were involved in 5% patients. Majority (83.7%) were treated with radical radiotherapy (external beam alone 64.2%, brachytherapy boost 19.5%), with 24 months ADT; 11.4% underwent radical prostatectomy, and 4.9% received ADT alone. Three men (2.4%) received docetaxel, and one received abiraterone. At a median follow up of 66 months (IQR 27-77), 36 (29.3%) patients had biochemical failure. Total 23 (18.6%) patients had metastases at recurrence, which were visceral in 4%, bone-only in 10%, and nodal-only in 4%. Total 38 (30.6%) patients had died, 23% with prostate cancer and 11% due to other causes. Five-year bPFS was 65.9%, MFS 69.0%, and OS was 77.4%. GGG 5 (versus 4) was associated with significantly worse 5-year bPFS (59.4% vs 73.9%, HR 1.8, 95% CI 1.0-3.2, p = 0.05) and MFS (59.2% vs 81.6%, HR 2.2, 1.2-4.2, p = 0.02). On multivariable analysis including age and PSA at diagnosis, only GGG 5 was associated with worse bPFS (HR 1.8, 1.0-3.3, p = 0.05) and MFS (HR 2.42, 1.25-4.67, p = 0.009). Men with low secreting but high Gleason grade group prostate cancer are a relatively rare group with poor clinical outcomes despite being non-metastatic. Ongoing work (expected completion June 2023) will analyze remaining cases, and compare outcomes within an expanded multicentric cohort with matched controls having elevated PSA at presentation.

Outcomes and after Hyperfractionated, Accelerated Reirradiation for Recurrent Anal Squamous Cell Carcinoma

Abdominoperineal resection (APR) is the standard salvage treatment for recurrent or persistent squamous cell carcinoma of the anus (SCCA). However, reirradiation (reRT) can be used preoperatively or for those who are not candidates for surgery. Using a single institutional database, patients were identified who underwent reRT for SCCA from 2003 to 2022. Response to reRT and outcomes after reRT were recorded. Variables analyzed included age at reRT, sex, reason for reRT (recurrent SCCA vs new SCCA after pelvic radiation for a different malignancy), interval between initial radiation and reRT, reRT dose, concurrent chemotherapy, receipt of APR and the presence of distant metastases at the time of reRT. Cox Proportional Hazard Model was used; multivariable analysis for all factors with a univariate P-value <0.1 on univariable analysis. A total of 42 patients received reRT, which consisted of 1.5 Gray (Gy) twice daily fractions with ≥6-hour interval to a total dose ranging 30Gy to 54Gy (median [IQR] 39Gy [39-42Gy]. Thirty-eight patients (90.5%) received concurrent chemotherapy; most often with weekly cisplatin and 5-fluorouracil (N = 23, 54.8%). Median [IQR] follow-up after reRT was 11.4 months [4.9-40.8 months]. Median [IQR] initial radiation dose was 54Gy [54-58Gy], and median [IQR] interval between initial radiation and reRT was 3.6 years [2.1-6.0 years]. For 8 patients (19.1%), the initial radiation was given for a different pelvic malignancy prior to being diagnosed with SCCA. Four of these patients received brachytherapy alone or in conjunction with external beam. For the remaining 34 patients, the initial radiation was for SCCA and the reRT was for recurrent SCCA either in the anal canal (N = 23, 67.6%) or regional nodes (N = 11, 32.3%). Four patients (9.5%) had distant disease at the time of reRT. Eleven patients (26.2%) had planned APR after preoperative reRT; 1 patient had a pathologic complete response (pCR), 2 patients had a near pCR (<5% viable cancer). Twenty-nine patients (69.0%) were treated with reRT alone; 15 (51.7%) attained a clinical CR. Two patients (4.8%) were treated with palliative intent and response was not assessed. Median local recurrence free survival (LRFS) was 9.9 months; 2- and 3-year LRFS were both 41%. Median distant metastasis free survival (DMFS) was 11.8 months; 2- and 3-year DMFS were 38% and 34%, respectively. Median overall survival (OS) was 40.5 months; 2- and 3-year OS were 54% and 51%, respectively. On multivariable analysis, only the presence of distant disease at the time of reRT was significantly associated with worse LRFS (HR (95% CI) 4.14 (1.34-12.81); P = .014), worse DMFS (4.06 (1.37-12.06); P = .012) and worse OS (5.73 (1.57-20.9); P = .008). ReRT is an option for patients presenting with either recurrent SCCA or new SCCA after prior pelvic radiation for a different malignancy. ReRT can be given prior to planned salvage APR or alone for patients who are not surgical candidates with an approximate 50% cCR rate.

Efferocytosis Nanoinhibitors to Promote Secondary Necrosis and Potentiate the Immunogenicity of Conventional Cancer Therapies for Improved Therapeutic Benefits.

Efferocytosis of apoptotic cancer cells by tumor-associated macrophages or other phagocytes is reported to promote tumor immunosuppression by preventing them from secondary necrosis, which would lead to the release of intracellular components and thus enhanced immunogenicity. Therefore, current apoptosis-inducing cancer treatments (e.g., chemotherapy and radiotherapy) are less satisfactory in eliciting antitumor immunity. Herein, a nanoparticulate inhibitor of efferocytosis is prepared by encapsulating BMS777607, a hydrophobic inhibitor of receptors in macrophages responsible for phosphatidylserine-dependent efferocytosis, with biocompatible poly(lactic-co-glycolic acid) and its amphiphilic derivatives. The yielded nano-BMS can inhibit the efferocytosis of apoptotic cancer cells, thus redirecting them to immunogenic secondary necrosis. As a result, intratumorally injected nano-BMS is capable of activating both innate and adaptive antitumor immunity to achieve greatly improved therapeutic responses, when synergized with nonimmunogenic chemotherapy by cisplatin, immunogenic chemotherapy by oxaliplatin, or radiotherapy by external beams. Moreover, we further demonstrate that the inhalation of nano-BMS could significantly promote the efficacy of cisplatin chemotherapy to suppress tumor lung metastases. Therefore, this study highlights a general strategy to potentiate the immunogenicity of different cancer treatments by suppressing efferocytosis-propelled tumor immunosuppression, showing tremendous clinical potential in rescuing existing cancer therapies for more effective treatment.

PSOR06 Presentation Time: 12:25 PM: Early Outcomes and Hormone-Free Survival Following Salvage MARS for MRI-Visible Post-Surgical Bed Recurrences and Focal Intraprostatic Recurrences Following External Beam and Following Brachytherapy

PSOR06 Presentation Time: 12:25 PM: Early Outcomes and Hormone-Free Survival Following Salvage MARS for MRI-Visible Post-Surgical Bed Recurrences and Focal Intraprostatic Recurrences Following External Beam and Following Brachytherapy

The Role of Radiation Therapy in Adult and Pediatric Keloid Management: A National Survey of Radiation Oncologists.

Radiation therapy is a promising modality for treating keloids after surgical excision. However, it is currently not standard practice among physicians because of concern surrounding the risk of radiation-induced secondary cancers, especially among pediatric patients. There is minimal research assessing the complications for radiation therapy in keloid management. The goal of this study was to determine radiation oncologists' perspectives about the utility and appropriateness of radiation therapy for keloid management in both adult and pediatric patients. This study also aimed to characterize radiation modality, dose, fractionation, and secondary complications observed by providers. An electronic survey was delivered to 3102 members of the American Society for Radiation Oncology. The survey subjects were radiation oncologists who are currently practicing in the United States. Rates of responses were analyzed. A total of 114 responses from practicing radiation oncologists were received. Of these, 113 providers (99.1%) supported radiation therapy for keloid management in adults, whereas only 54.9% supported radiation therapy for pediatric patients. Of 101 providers that treated adults in the past year, the majority used external beam: electrons (84.2%), applied 3 fraction regimens (54.4%), and delivered radiation within 24 hours postexcision (45.5%). In pediatric patients, only 42 providers reported treating at least 1 patient. The majority used electron beam radiation (76.2%), applied 3 faction regimens (65%), and delivered radiation on the same day of keloid excision (50.0%) The main concern when treating pediatric patients were risk of secondary malignancy (92.1%). Although radiation therapy appears to be a widely accepted adjuvant treatment option for adults with keloids, the use of radiation therapy for pediatric patients is less widely accepted because of concerns regarding secondary malignancy. The findings suggest additional studies need to be carried out to assess the risk of those complications.

KORTUC, a novel hydrogen peroxide‑based radiosensitizer for the enhancement of brachytherapy in patients with unresectable recurrent uterine cervical cancer.

Kochi Oxydol Radiation Therapy for Unresectable Carcinoma (KORTUC) is a novel radiosensitizer invented by Professor Ogawa at Kochi University (Japan) in 2006. The current study aimed to report the experience of the present authors with the use of KORTUC treatment in combination with interstitial brachytherapy (ISBT), with or without external beam (EB) radiotherapy (RT), in patients with locally recurrent cervical cancer (LRCC), who were likely to have a high risk of poor prognosis. Between April 2012 and January 2020, 14 female patients (15 tumoral lesions) with LRCC underwent KORTUC with ISBT. Their previous treatments included surgery (n=4), radiation therapy (n=8) and surgery plus RT (n=3). The primary lesions were located in the vaginal stump (n=5), pelvic wall (n=3), cervix (n=3), vaginal wall (n=2) and lymph nodes (n=2). At 2 h before RT, KORTUC was injected intratumorally via direct colposcopy. The dose of KORTUC ranged from 4-12 ml, adjusted for the tumor size. For patients who underwent ISBT, KORTUC was administered before and after insertion of the applicator before irradiation. Intratumoral injection of KORTUC was completed without any technical or safety issues in all 15 patients; it was well tolerated with no adverse events observed. KORTUC also showed preferable efficacy; a clinical complete response was observed in 87% of patients and the initial response rate was 100%. The 2-year local control rate in patients who underwent ISBT + KORTUC was 79%, whereas it was 63% in the re-irradiation group which was significantly lower (P=0.02) than that in the non-irradiation group (100%). Based on this finding, KORTUC with external irradiation is considered to be an optimal treatment strategy for patients with newly diagnosed LRCC this disease. Additionally, KORTUC may be an effective radiation response enhancer in multiple cancer types in which locoregional control after RT alone remains poor.

A Single Site Pilot Project Examining Radiation Oncology Nursing Education Needs And Nursing Confidence

Background Moskalenko et al. published the first radiation oncology (RO) nursing needs assessment in the USA in 2021. No RO nursing credential or scope of practice exists in the USA. RO and related disciplines are rarely covered in nursing education. Opportunities for continuing education (CE) are limited at the local, state, and national levels. However, nurses are required to sustain clinical knowledge by obtaining CE credits for multiple organizations. RO nurses serve a growing role with increasing patient acuity, complex multidisciplinary team care, concurrent systemic therapies, and survivorship. Methods Permission was obtained to use and adapt the needs assessment from Moskalenko et al. for a pilot study at a single academic medical center RO department. Nurses were asked for demographics regarding experience and education. A five-point Likert scale (1, "Extremely Confident"; 2, "Quite Confident"; 3, "Somewhat Confident"; 4, "Not Very Confident"; 5, "Not At All Confident") was used to capture confidence levels regarding educating patients, and providing acute versus late care. A knowledge pre-test was developed with physician input. A series of self-study recorded PowerPoint presentations was created. A knowledge post-test and feedback are planned. Results Item response rates ranged from 92-100% (n=12-13). 91% (n=11) of respondents reported being RNs for ≥5 years, 75% (n=9) reported having ≥5 years of oncology experience, and 50% (n=6) reported ≥5 years of RO experience. 66.6% (n=8) of respondents reported being oncology certified nurses, and 17% (n=2) nurses reported having the Oncology Nursing Society/Oncology Nursing Credentialing Corporation radiation therapy certificate. On-the-job experience (100%; n =12), physicians (83%; n=10), and nursing colleagues (67%; n =8) were the most reported sources of RO knowledge. All nurses reported responsibility for patient education, with 58% (n=7) "Somewhat Confident" to "Not At All Confident" that they could explain simulation and concurrent chemoradiation therapy to patients. 67% (n=8) reported being "Somewhat Confident" to "Not At All Confident" that they could explain brachytherapy, external beam, CT, MRI, or PET scans to patients. The greatest number of nurses reported they were "Extremely Confident" to "Quite Confident" managing lung and prostate/GU patients acutely (both 67%; n=8) and prostate chronically (67%; n=8). The greatest number of nurses expressed they were "Somewhat Confident" to "Not At All Confident" managing pediatric patients acutely (75%; n=9) and chronically (92%; n=11). Discussion We report findings from a RO nursing needs assessment from a single academic healthcare facility. These data may inform ongoing efforts to optimize RO nursing education. Moskalenko et al. published the first radiation oncology (RO) nursing needs assessment in the USA in 2021. No RO nursing credential or scope of practice exists in the USA. RO and related disciplines are rarely covered in nursing education. Opportunities for continuing education (CE) are limited at the local, state, and national levels. However, nurses are required to sustain clinical knowledge by obtaining CE credits for multiple organizations. RO nurses serve a growing role with increasing patient acuity, complex multidisciplinary team care, concurrent systemic therapies, and survivorship. Permission was obtained to use and adapt the needs assessment from Moskalenko et al. for a pilot study at a single academic medical center RO department. Nurses were asked for demographics regarding experience and education. A five-point Likert scale (1, "Extremely Confident"; 2, "Quite Confident"; 3, "Somewhat Confident"; 4, "Not Very Confident"; 5, "Not At All Confident") was used to capture confidence levels regarding educating patients, and providing acute versus late care. A knowledge pre-test was developed with physician input. A series of self-study recorded PowerPoint presentations was created. A knowledge post-test and feedback are planned. Item response rates ranged from 92-100% (n=12-13). 91% (n=11) of respondents reported being RNs for ≥5 years, 75% (n=9) reported having ≥5 years of oncology experience, and 50% (n=6) reported ≥5 years of RO experience. 66.6% (n=8) of respondents reported being oncology certified nurses, and 17% (n=2) nurses reported having the Oncology Nursing Society/Oncology Nursing Credentialing Corporation radiation therapy certificate. On-the-job experience (100%; n =12), physicians (83%; n=10), and nursing colleagues (67%; n =8) were the most reported sources of RO knowledge. All nurses reported responsibility for patient education, with 58% (n=7) "Somewhat Confident" to "Not At All Confident" that they could explain simulation and concurrent chemoradiation therapy to patients. 67% (n=8) reported being "Somewhat Confident" to "Not At All Confident" that they could explain brachytherapy, external beam, CT, MRI, or PET scans to patients. The greatest number of nurses reported they were "Extremely Confident" to "Quite Confident" managing lung and prostate/GU patients acutely (both 67%; n=8) and prostate chronically (67%; n=8). The greatest number of nurses expressed they were "Somewhat Confident" to "Not At All Confident" managing pediatric patients acutely (75%; n=9) and chronically (92%; n=11). We report findings from a RO nursing needs assessment from a single academic healthcare facility. These data may inform ongoing efforts to optimize RO nursing education.

An in-vivo study of the combined therapeutic effects of pulsed non-thermal focused ultrasound and radiation for prostate cancer

Purpose The purpose of this study was to investigate the in vivo combined effects of pulsed focused ultrasound (pFUS) and radiation (RT) for prostate cancer treatment. Materials and Methods An animal prostate tumor model was developed by implanting human LNCaP tumor cells in the prostates of nude mice. Tumor-bearing mice were treated with pFUS, RT or both (pFUS + RT) and compared with a control group. Non-thermal pFUS treatment was delivered by keeping the body temperature below 42 °C as measured real-time by MR thermometry and using a pFUS protocol (1 MHz, 25 W focused ultrasound; 1 Hz pulse rate with a 10% duty cycle for 60 sec for each sonication). Each tumor was covered entirely using 4–8 sonication spots. RT treatment with a dose of 2 Gy was delivered using an external beam (6 MV photon energy with dose rate 300MU/min). Following the treatment, mice were scanned weekly with MRI for tumor volume measurement. Results The results showed that the tumor volume in the control group increased exponentially to 142 ± 6%, 205 ± 12%, 286 ± 22% and 410 ± 33% at 1, 2, 3 and 4 weeks after treatment, respectively. In contrast, the pFUS group was 29% (p < 0.05), 24% (p < 0.05), 8% and 9% smaller, the RT group was 7%, 10%, 12% and 18% smaller, and the pFUS + RT group was 32%, 39%, 41% and 44% (all with p < 0.05) smaller than the control group at 1, 2, 3, and 4 weeks post treatment, respectively. Tumors treated by pFUS showed an early response (i.e. the first 2 weeks), while the RT group showed a late response. The combined pFUS + RT treatment showed consistent response throughout the post-treatment weeks. Conclusions These results suggest that RT combined with non-thermal pFUS can significantly delay the tumor growth. The mechanism of tumor cell killing between pFUS and RT may be different. Pulsed FUS shows early tumor growth delay, while RT contributes to the late effect on tumor growth delay. The addition of pFUS to RT significantly enhanced the therapeutic effect for prostate cancer treatment.

Change in vaginal length and sexual function in women who undergo surgery ± radiation therapy for endometrial cancer

PURPOSEEndometrial Cancer (EC) is the most common gynecologic malignancy in the United States. Standard treatment is TAH/BSO with radiation therapy (RT) and chemotherapy given based on risk. Treatment can cause significant vaginal changes, including shortening, narrowing, loss of elasticity, atrophy, and dryness. These are not life threatening, but affect a woman's physical, psychological, and social functioning. Adjuvant vaginal dilator use is often advised, but there are inconsistent recommendations on use. This prospective study compared vaginal length changes and sexual function in women compliant with dilation versus not after surgery and RT. METHODS AND MATERIALSEnrolled patients underwent surgery for Stage I-IIIC EC ±RT. Vaginal dilator use was recommended for women receiving RT (external beam or brachytherapy). Vaginal length was measured with a vaginal sound and the Female Sexual Function Index (FSFI) was used to assess sexual function. RESULTSForty-one enrolled patients had sufficient data for analysis. Dilation significantly increased FSFI scores (p = 0.02) while RT without dilation showed a significant decrease (p = 0.04). Dilation helped maintain vaginal length for all patients (0 cm vs. 1.8 cm loss (p = 0.03)). Individual arms did not show statistically significant changes in length with dilation, though the trend showed RT without dilation had an average loss of 2.3 cm as compared to only 0.2 cm for regular dilation. Notably, there was no difference in length change with dilation for surgery alone versus surgery and RT (p = 0.14). CONCLUSIONThis data provides novel, prospective evidence of the benefit of vaginal dilation for maintaining vaginal length and improving sexual health after any pelvic treatment for EC. This evidence also supports that the addition of RT after surgery does not appear to significantly worsen vaginal shortening. This study has important implications for providing a strong foundation for future studies and helping to establish solid clinical management criteria for the prevention of vaginal stenosis and promotion of female sexual health.

Are active dwell positions always necessary in the ring/ovoids channel of the cervical applicator in the intracavitary-interstitial brachytherapy of cervical cancer?

To compare dosimetric parameters of brachytherapy (BT) treatment plans made with or without active source positions of the ring/ovoid (R/O) applicator in locally advanced cervical cancer patients. Sixty patients with cervical cancer without vaginal involvement were selected for the study, who received intra-cavitary/interstitial BT. For each patient, two plans with and without active source dwell positions in R/O were created, using the same dose-volume constraints. EQD2 total doses from external beam and BT of target volumes and organs at risk (OARs) between the competing plans were compared. There was no significant difference in the dose of high-risk clinical target volume (HR-CTV) and gross tumor volume (GTV) between the plans with inactive vs. active R/O. The mean D98 of intermediate-risk clinical target volume (IR-CTV) was significantly lower with inactive R/O; however, the GEC-ESTRO (EMBRACE II study) and ABS criteria were fulfilled in 96% in both plans. There was no difference in dose homogeneity, but conformity of the plans with inactive R/O was higher. Doses to all OARs were significantly lower in plans without R/O activation. While all the plans without R/O activation fulfilled the recommended dose criteria for OARs, it was less achievable with R/O activation. Inactivation of R/O applicator results in similar dose coverage of the target volumes with lower doses to all OARs, as activation of R/O in cervix cancer patients when HR-CTV does not extend to R/O applicator. The use of active source positions in R/O shows worse performance regarding the fulfilment of the recommended criteria for OARs.

Conventional Therapies of Oral Cancers: Highlights on Chemotherapeutic Agents and Radiotherapy, Their Adverse Effects, and the Cost Burden of Conventional Therapies.

Oral cancer (OC) is increasing worldwide, and it is mostly present to clinic in the late-stage of disease. Cancer of the lips, tongue, hard palate, upper and lower gingiva, buccal mucosa, and retromolar trigone are all included in the category of oral cavity cancer. Disease symptomatology and pathological grading decides the course of treatment. Several treatment modalities either alone in combinations may be utilized for oral squamous cell carcinoma (OSCC), including surgery, radiotherapy (external beam radiotherapy/brachytherapy), and adjuvant systemic therapy (chemotherapy or immunotherapy). Cancer patients also face a greater risk of oral side effects from chemotherapy, such as slowed tissue healing, bone, and salivary gland damage and disintegration, and disruption of the normal bacterial balance in the mouth. Consequently, the economic burden of the salivary gland, oral cavity, and oropharyngeal cancers must be also known for budget allocation, designing different programs and management strategies targeting oral cancers by any healthcare institutes. This article provides a summary of the most recent research that supports the use of chemotherapy for patients with advanced illness both alone and in conjunction with radiation including its adverse events and cost burden for oral cancers.

Dose Escalation by Intraluminal Brachytherapy in Cancer Esophagus – A Retrospective Audit

Introduction- Chemoradiation (CRT) in esophageal cancer as a definitive modality of treatment has shown an increasing trend of utilization over surgical modalities. Local failures after chemoradiotherapy have led to the concept of radiation dose escalation, but simultaneously it leads to the concerns of radiation related toxicities of strictures and fistulas. Considering this fact dose escalation with intraluminal brachytherapy seems and optimal option. The present study retrospectively analyzed the safety and efficacy of using ILBT as a boost after external beam radiotherapy.Materials and Methods- Records of patients with Esophageal Carcinoma (EC) registered in the radiotherapy department between December 2008 to June 2016 were retrospectivelyanalyzed. Data was collected on patient, tumor and treatment characteristics and patient outcomes. The toxicitieshematological or radiation-induced were documented. Theresponse assessment after treatment and survival parameters were analyzed. Univariate and multivariate analyses were done for survival parameters. Statistical significance was considered if p-value was less than 0.05.Results- A total of 69 patients were eligible for the present analysis. Male to female ratio 1.09:1, with median age of 60 years. The common primary side was the middle 1/3rd esophagus. The mean tumor length was 6.4cm and all patients had squamous cell carcinoma. EBRT dose of 59.4 Gy was received 94.2% of patients, 13 (18.8%) received ILRT radiotherapy with 6Gy in a single setting. The median concurrent chemotherapy administered were 5. Grade 3 and 4 acute hematological toxicities were seen in terms of anemia (7.2%), leucopenia (18.8%) and thrombocytopenia (1.4%). Stenosis was seen in 40.6% of patients among which only 13 patients required dilatation. Nine of the patients receiving intraluminal brachytherapy (ILBT) developed fistula. The compete response was better in ILBT group (84.61 vs 57.49%, p=0.07). The median overall survival for all patients was 15 months. Overall survival was increased in patients of ILBT group (41 months versus 12 months, p=0.005).Conclusion- ILBT has the advantage of high precision and avoidance of dose to critical structures which could be optimally used for dose escalation in patients of cancer esophagus.

A study of non small cell lung cancer (NSCLC) patients with brain metastasis: A single centre experience

BackgroundLung cancer is the leading cause of cancer death with the majority of cases being non-small cell lung cancer (NSCLC) [1]. A common complication of NSCLC is brain metastasis (BM) [2, 3], where the prognosis remains poor despite new treatments. Real world data complements data gained from clinical trials, providing information on patients excluded from prospective research [4]. However, information from patient notes may prove incomplete and difficult to extract. We developed an algorithm to identify patients in our clinical database with brain metastasis from the electronic health record (EHR). MethodsWe retrospectively extracted data from the EHR of patients managed at a large teaching hospital between 2007 and 2018. Using the ICD-10 code C34, for lung cancer, our algorithm used phrases associated with BMs to search the unstructured text of radiology reports. Summary statistics and univariant analysis was performed for overall survival. Results818 patients were identified as potentially having BM and 453 patients were confirmed on clinical review of their records. The median age of patients was 69 years, 50% were female and 66% had a performance status of >2. 12.2% had an identifiable mutation and 11.5% were identified as PD-L1 positive. In the first line setting, 65% of patients received symptomatic treatment, 23% received systemic anticancer therapy (SACT), 6.1% surgery and 10% radiotherapy, of which 6.5% had external beam and 3.5% stereotactic radiosurgery. Regarding those treated with SACT, 35% had an intracranial response to treatment (3% had complete response, 32% had a partial response). Median survival was 2 months (1.9 – 2.4 months 95% CI). ConclusionThe real-world prognosis for NSCLC patients with BMs is poor. By using an algorithm, we have reported outcomes on a comprehensive cohort of patients which helps identify those for whom an active treatment approach is appropriate.