Initial Radiotherapy Research Articles

Dedicated Diagnostic Radiology/Radiation Oncology Rounds: Added Value Beyond Traditional Tumor Boards

ObjectivesWe aimed to evaluate the impact of collaborative discussion between diagnostic radiologists and radiation oncologists on radiation oncology management for thoracic oncology patients. MethodsWe reviewed cases presented at multidisciplinary thoracic tumor boards (TTB) (n = 122) and diagnostic radiology/radiation oncology rounds (DR/ROR) (n = 45). Changes in planned radiation management following imaging discussion were categorized—no change, timing change, and treatment volume change. Phase of care was also classified. In DR/ROR, radiation oncologists were surveyed regarding (1) change in radiation oncology management and (2) change in confidence (both 5-point Likert scales). ResultsDiscussion of imaging with a radiologist changed radiation oncology management in 31.1% of TTB cases and 68.9% of DR/ROR cases (P < 0.001). Changes to the timing of initiating radiation therapy occurred with similar frequency in the 2 settings (31.1% vs 46.7%, P = 0.063). Changes to target volume occurred more frequently in DR/ROR (35.6% vs <1%), P < 0.001. Over half of imaging discussions in DR/ROR resulted in at least “moderate” change in radiation oncology management, and the level of confidence held by the radiation oncologists increased following discussion with radiologists in 95.6% of cases. ConclusionCollaborative discussions between radiation oncologists and diagnostic radiologists in a multispecialty tumor board and in targeted 2-specialty rounds are not redundant, but result in different management changes and at different phases of care. Our study emphasizes the importance of consultation with physicians as an area where radiologists can add value, specifically the added benefit of smaller collaborative discussions.

Impact of time to initiation of radiotherapy on survival after resection of newly diagnosed glioblastoma

Background and purposeTo evaluate the effect of timing of radiotherapy (RT) on survival in patients with newly diagnosed primary glioblastoma (GBM) treated with the same therapeutical protocol.Materials and methodsPatients with newly diagnosed primary GBM treated with the same therapeutical scheme between 2010 and 2015 in our institution were retrospectively reviewed. The population was trichotomized based on the time interval from surgery till initiation of RT (< 28 days, 28–33 days, > 33 days). Kaplan-Meier and Cox regression analyses were used to compare progression free survival (PFS) and overall survival (OS) between the groups. The influence of various extensively studied prognostic factors on survival was assessed by multivariate analysis.ResultsOne-hundred-fifty-one patients met the inclusion criteria. Between the three groups no significant difference in PFS (p = 0.516) or OS (p = 0.902) could be demonstrated. Residual tumor volume (RTV) and midline structures involvement were identified as independent prognostic factors of PFS while age, O-6-Methylguanine Methyltransferase (MGMT) status, Ki67 index, RTV and midline structures involvement represented independent predictors of OS. Patients starting RT after a prolonged delay (> 48 days) exhibited a significantly shorter OS (p = 0.034).ConclusionInitiation of RT within a timeframe of 48 days is not associated with worsened survival. A prolonged delay (> 48 days) may be associated with worse OS. RT should neither be delayed, nor forced, but should rather start timely, as soon as the patient has recovered from surgery.

Role of early and aggressive post-operative radiation therapy in improving outcome for pediatric central nervous system atypical teratoid/rhabdoid tumor.

The purpose of the study is to evaluate possible prognostic factors and optimal management for pediatric atypical teratoid/rhabdoid tumor (AT/RT) of the central nervous system (CNS). Twenty-eight pediatric patients with CNS AT/RT who were treated with radiation therapy (RT) as part of multimodality treatment regimens at a single institution (1996-2015) were reviewed. Survival outcomes were analyzed in relation to possible prognostic factors. The 28 patients analyzed were followed up for a median 48-month period. Median progression-free survival (PFS) was 11months, and overall survival (OS) was 57months. Patients < 3years old had RT delayed for a longer period after surgery (p = 0.04), and the mean RT dose to tumor bed was lower (p < 0.01) than in patients ≥ 3years old. In multivariate analysis, a higher primary tumor bed RT dose was identified as a favorable prognostic factor for both PFS (hazard ratio [HR] = 0.85 per gray, p < 0.01) and OS (HR = 0.92 per gray, p = 0.02). In addition, an interval between surgery and RT initiation > 2months, with disease progression observed before RT, as compared with an interval ≤ 2months without disease progression prior to RT, was associated with worse PFS (HR = 8.50, p < 0.01) and OS (HR = 5.27, p < 0.01). Early and aggressive RT after surgery is critical for successful disease control in AT/RT patients. Conversely, a delay in RT until disease progression is observed that leads to unfavorable outcomes.

Survival Impact of Time to Initiation of Adjuvant Radiation for Merkel Cell Carcinoma: An Analysis of the National Cancer Database

PurposeThis study aimed to determine the impact of time to initiation (TTI) of adjuvant radiation therapy (RT) on overall survival (OS) for patients with stage I or II Merkel cell carcinoma (MCC). Methods and materialsThe National Cancer Database was queried for patients with MCC of the head and neck, trunk, or extremities diagnosed between 2006 and 2014. Patients who did not undergo resection or receive adjuvant RT within 180 days of surgery were excluded. TTI was defined as the time from resection to first RT fraction. Linear regression was used to define factors associated with TTI. Recursive partitioning analysis modeling was performed to determine an optimal threshold for TTI. Cox proportional hazards modeling was performed to define covariates associated with OS. ResultsA total of 2293 patients were included in this study. The median TTI for the cohort was 62 days (interquartile range, 43-86 days). TTI was not associated with OS for the overall cohort by multivariable Cox modeling (P = .19). Age, treatment facility type, lymph node examination, anatomic subsite, and surgical margin were associated with TTI (P < .05). Age, sex, insurance status, Charlson-Deyo comorbidity score, lymph node examination status, tumor size, and surgical margin were associated with OS (all P < .05). ConclusionsIncreased TTI of adjuvant RT was not associated with OS for patients with early stage MCC in this analysis of the National Cancer Database. The median TTI of 62 days from resection to adjuvant RT initiation for our study cohort contextualizes TTI on a national level and may offer reassurance for patients with prolonged postoperative wound healing or intercurrent illness delaying immediate RT initiation. Despite the lack of a clear detriment to survival with increased TTI up to 180 days from surgery, unnecessary delays in initiating adjuvant therapy should continue to be minimized while ensuring optimal recovery from resection.

Reirradiation for diffuse intrinsic pontine glioma: a systematic review and meta-analysis.

Diffuse intrinsic pontine glioma (DIPG) is a pediatric brain tumor with dismal prognosis despite initial radiation therapy (RT). The clinical consequences of attempting reirradiation (reRT) in these patients to alleviate both symptomatology and improve prognosis are currently unclear. Thus, the aim of this systematic review and meta-analysis was to clarify the efficacy and safety of reRT in DIPG. Searches of seven electronic databases from inception to January 2019 were conducted following the appropriate guidelines. Articles were screened against prespecified criteria. The incidence and duration of clinical outcomes were then extracted and pooled by means of meta-analysis from the included studies. A total of 7 studies satisfied all criteria, describing 90 cases of DIPG in which reRT was attempted 11.8-14 months after initial RT. Based on a random-effects model, the incidences of clinical improvement and radiologic response following reRT were 87% (95% CI, 78-95%) and 69% (95% CI, 52-84%), respectively. The incidence of acute serious toxicity was 0% (95% CI, 0-4%). Pooled overall survivals from initial diagnosis and time of reRT were 18.0 months (95% CI, 14.2-21.7) and 6.2 months (95% CI, 5.5-7.0), respectively. Based on these results, the clinical consequences of reRT for DIPG when administered appropriately and safely at first progression appear acceptable, and potentially favorable, based on the limited evidence in the current literature. Concerns regarding acute serious toxicity were not realized. It is likely that a subcohort of all DIPG diagnoses will be most amenable to improve prognosis with reRT, and greater investigation is required to identify their characteristics.

Ependymoma of the Spinal Cord in Children: A Retrospective French Study

Ependymoma is the most frequent spinal tumor in adults but it is rather uncommon in children. The aim of the present study was to retrospectively summarize the clinical and therapeutic experience in the treatment of pediatric spinal ependymomas in France. In the present retrospective multicenter study, data from patients aged <18 years who had been treated from 2000 to 2010 for spinal ependymomas were collected. Epidemiologic and tumor- and treatment-related data were analyzed. The prognostic factors for progression-free survival (PFS) were assessed. We identified 28 patients (22 males, 6 females). Their median age at surgery was 13.67 years (range, 0.7-17.6). Initial gross total resection (GTR) was achieved in 22 children and subtotal resection (STR) in 6. Histologically, 15 tumors were myxopapillary ependymomas and 11 were grade II and 2 grade III ependymomas. Adjuvant initial radiotherapy (RT) was performed in 6 patients. The median follow-up period was of 40 months (range, 2.3-127.5). The 5-year PFS rate was 51% (95% confidence interval, 26.3%-71.2%), and the overall survival rate was 100%. On univariate analysis, only GTR had a significant influence on PFS (P= 0.0013). A subgroup analysis showed a benefit of RT delivered to patients with GTR; however, RT failed to prevent relapse in the group with initial STR. Our data suggest that initial adjuvant RT might improve PFS after GTR but will not prevent relapse in patients with STR. Further studies are needed to define more specific treatments for the latter group.

Predictors of weight loss during and after radiotherapy in patients with head and neck cancer: A longitudinal study.

Weight loss is a multifactorial condition that commonly affects patients receiving radiotherapy for head and neck cancers. The aims of this study were to 1) describe body weight changes over time in patients receiving radiotherapy for head and neck cancers and 2) explore the influence of pretreatment weight loss, body mass index (BMI) category, symptom burden, mucositis, and nutritional support on body weight changes over time. Using a longitudinal design, this study investigated a consecutive cohort of head and neck cancer patients who were treated with radiotherapy between January 2015 to January 2016 in a Taiwan medical center (n = 128). Data regarding symptom burden, mucositis severity, and body weight were collected before radiotherapy (T1), one month after the initial radiotherapy (T2), at the completion of radiotherapy (T3), and one month after the completion of radiotherapy (T4). On average, the participants' body weight decreased by 3.09 kg (SD = 2.79) from T1 to T2, 1.72 kg (SD = 2.06) from T2 to T3, and continued to decrease by 1.04 kg (SD = 2.87) from T3 to T4. The results of a generalized estimating equation showed that BMI category, symptom burden, mucositis, and nutritional support were directly and independently related to body weight changes over time in patients with head and neck cancers. Head and neck cancer patients experience significant weight loss during and after radiotherapy. The study findings are relevant for assessing nutritional status and providing necessary support measures at critical moments for patients treated with radiotherapy.

Abstract P5-13-18: Barriers to adjuvant radiotherapy treatment for breast cancer in a teaching hospital in Brazil

Abstract BACKGROUND: Adjuvant treatment of non-metastatic breast cancer (BC) represents an important paradigm of multimodality approach in oncology practice, with an established role for radiotherapy (RT). A delay of adjuvant radiotherapy can lead to poorer results. When chemotherapy (CT) is not indicated, RT should be initiated within 8 weeks after surgery. If CT is administered first, RT should be started within 7 months from surgery, since there is a continuous relation between time to radiotherapy and local recurrence. Brazil's public healthcare system, SUS, faces many challenges caring for cancer patients: inadequate funding, inequitable distribution of resources and services, among others. According to research done by Lins et al, around 458 linear accelerators would be necessary to supply the Brazilian public health demand and end the waiting line for radiation therapy. Currently, our healthcare system has 283 machines, which are responsible for more than 70% of our population. Furthermore, patients lack understanding of treatment windows, which is an additional hurdle. METHODS: We randomly selected 122 charts of female BC patients submitted to treatment with curative intent from 2003-2017 in Hospital das Clínicas da UFMG, the biggest teaching hospital of the 3rd largest city in Brazil. Primary endpoint was to determine median time from surgery to adjuvant radiotherapy, and second point was to determine median radiotherapy time. RESULTS: Twenty eight patients were not included in the analysis, 26 due to lack of information in the charts and two for not having received the proposed radiotherapy. Ninety four patients were included: median age was 49 years old (21-90), 21.5% were stage I, 41.9% stage II and 34.4% stage III at diagnosis. Patients received chemotherapy (neo or adjuvant), hormonotherapy, or both, according to oncologists discretion. All patients were submitted to surgery and radiotherapy. Long median times from referral to RT initiation and to radiotherapy completion were identified: 54 days and 97 days, respectively, as well as 7 months from surgery to beginning of RT (1-16) and 9 months from diagnosis to its completion (2-29).Biopsies were performed in 27 different sites and RT in 12. IntervalMedian Time (days)Biopsy to results13 (1-77)Referral to RT initiation54 (1-238)Referral to RT completion97 (43-238)RT initiation to RT completion42 (20-80) IntervalMedian Time (months)Surgery to RT initiation7 (1-16)Diagnosis to RT completion9 (2-29) CONCLUSIONS: This study shows that intervals for completion of adjuvant radiotherapy are well above recommended, mostly due to long delays in initiating radiotherapy. Although in our study all patients were conducted by the same oncology team, the system is fragmented, making it even more difficult for patients to receive multidisciplinary care and improve prognosis. There is undeniable need for more radiotherapy machines, but since their acquisition depends on costly governmental actions, we need to think about strategies that may allow us to better use the resources already available. We believe that Patient Navigation plays an important role here and were are establishing this program in our institution with Global Cancer Institute support. Citation Format: Vieira CM, Nogueira-Rodrigues A, Sousa CF, Krush L, Goss PE. Barriers to adjuvant radiotherapy treatment for breast cancer in a teaching hospital in Brazil [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-13-18.

Abstract P3-12-14: Incidence of radiation induced sarcoma attributable to radiotherapy in adults: A population-based study of the SEER cancer registry across 17 primary tumor sites

Abstract Background: More than half of cancer patients will receive radiotherapy during the treatment of their cancer; however, a rare and fatal treatment complication is radiation induced sarcoma (RIS). Notably, a large percentage of RIS patients are breast cancer survivors. Previous studies have investigated the incidence of all secondary cancers due to radiotherapy but have not noted the incidence of RIS in a contemporary population-based cohort in the US. To evaluate the relative risk of RIS, we examined data from the Surveillance, Epidemiology, and End Results (SEER) database. We hypothesized that breast cancer would have a higher incidence of RIS compared to 17 other primary cancer sites. Methods: This was a retrospective cohort study that examined SEER registries from 1973 and 2013. We included patients aged 18 years or older who were diagnosed with a primary cancer. We excluded patients with missing information on initial radiotherapy treatment or stage and those who died less than two years from the date of their primary cancer diagnosis. RIS was defined as those who developed a secondary sarcoma near the site of their original malignancy and after a 24-month latency period. Results: Our study included 1,745,867 patients with an average age of 60 years and mean follow up time of 9.2 years. Breast cancer comprised the largest number with 693,701 patients of which 161 (0.02%) had a secondary sarcoma. Prostate cancer comprised the second largest group with 594,271 patients of which 75 (0.01%) had a secondary sarcoma. Of the 359 patients with secondary sarcomas, 242 (67.4%) had RIS. Breast cancer had the highest number of RIS patients at 126 (52.1%) compared to all combined non-breast cancer sites at 116. Interestingly, 172 (71.1%) RIS patients were females, which correlated with the attributable RIS cases from breast and uterine cancer. The relative risk of RIS in breast cancer versus 17 other primary cancer sites was 1.21 (CI: 1.01-1.45, p &amp;lt;0.03, adjusted for age at primary diagnosis, gender, and latency). Conclusions: This study confirms the low incidence of RIS in breast cancer, which has been demonstrated to be around 0.03% - 0.2% in the literature. Our results suggest that breast cancer portends a somewhat higher risk for RIS compared to 17 primary solid malignancies. Although some of the risk is attributable to the high incidence rate of breast cancer, breast cancer patients had a higher relative risk of RIS than other solid tumors after adjusting for covariates. Female gender may be associated with an increased risk for RIS compared to males. Further investigations should be performed to confirm these epidemiological findings given that radiation fields, doses, intention to cure, margin status and systemic therapy are not recorded in SEER. Nonetheless, this study is hypothesis generating in that the majority of RIS cases in solid tumors are attributable to breast cancer in this large population-based series. Citation Format: Snow AE, Struycken LC, Koc M, Greco JP, Zhu Y, In GK, Dorff TB, Lang JE. Incidence of radiation induced sarcoma attributable to radiotherapy in adults: A population-based study of the SEER cancer registry across 17 primary tumor sites [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-12-14.

Abstract PD8-12: Safety and efficacy of palbociclib and radiotherapy in metastatic breast cancer patients: Initial results of a novel combination

Abstract Purpose: Palbociclib is a selective CDK4/6 inhibitor approved for the treatment of metastatic ER+/HER2- breast cancer. Inhibition of CDK4/6 prevents cell cycle progression from G1 to the more radioresistant S phase, raising the possibility of an enhanced therapeutic effect if combined with radiotherapy (RT). Despite this potential benefit, clinicians seldom use this combination due to fear that RT may exacerbate palbociclib toxicity, particularly leukopenia. Our aim is to report the preliminary results of patients with metastatic breast cancer who received RT while receiving palbociclib. Methods: We retrospectively reviewed records of all patients who were treated with palbociclib at our institution from 2015-2018. Patients who received RT for symptomatic metastases concurrently or within 14 days of last drug administration were included in our analysis. Local treatment effect was assessed by clinical exam and subsequent CT or MRI imaging, if applicable. Toxicity was graded based on CTCAE v5.0. Results: A total of 16 females received palliative RT in association with palbociclib. The median age of the treated patients was 59.6 (range 33.3-91.0) years. The median time of closest palbociclib use to RT administration was 5 (range 0-14) days. The following sites were treated in order of frequency: bone (10-axial skeleton [8-vertebra]; 1-ilium), brain (4: 3-WBRT &amp; 1-SRS), and mediastinum (1). RT dose/fractionation for bone was 30 Gy/10 fxn (7), 35 Gy/14 fxn (2), 37.5 Gy/15 fxn (1), and 18 Gy/1 fxn (1). WBRT dose/fractionation was 30 Gy/10 fxn for all patients. SRS brain dose was 25 Gy/5 fxn. The patient treated to the mediastinum received 36 Gy/18 fxn. At most recent follow-up, 12 patients are still living. The median time from RT to last known follow-up or death is 10.3 (range 1.7-29.6) months. Pain relief was achieved in 15 of 16 (93.8%) patients. No radiographic local failure was noted in the 13 patients with evaluable follow-up imaging. The combination of RT and palbociclib was well-tolerated. Grade 1 fatigue, dermatitis, and nausea was noted in 5, 3, and 1 patient, respectively. One patient with WBRT developed Grade 1 headache. Six of 16 patients were leukopenic prior to RT initiation. Following RT, 7 patients were observed to have a drop in WBC count, of which 2 dropped into the leukopenic range. Only a total of 5 patients were leukopenic following RT, of which 3 were leukopenic before receiving RT. No acute or late Grade 2 or higher cutaneous, neurological, gastrointestinal, or hematologic toxicities were noted. Conclusions: The use of RT in patients receiving palbociclib resulted in minimal Grade 1 and no Grade 2+ toxicities, including leukopenia. This treatment can be used safely in symptomatic patients without discontinuation of systemic therapy. Further larger prospective studies with longer follow-up are needed to confirm these results. Citation Format: Chowdhary M, Sen N, Chowdhary A, Usha L, Cobleigh M, Patel KR, Wang D, Barry PN, Rao RD. Safety and efficacy of palbociclib and radiotherapy in metastatic breast cancer patients: Initial results of a novel combination [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD8-12.

Reduced-Dose Radiation Therapy to the Primary Site is Effective for High-Risk Neuroblastoma: Results From a Prospective Trial

For patients with high-risk neuroblastoma (HR-NB), a dose of 21Gy to the primary tumor site after gross total resection (GTR) provides excellent local control. However, no clinical trial has specifically evaluated the optimal dose of radiation therapy (RT), and RT-related long-term toxicities are of increasing concern. We sought to assess local control, survival outcomes, and toxicity after a reduction in dose to the primary site from 21Gy to 18Gy. After induction chemotherapy and GTR, patients with HR-NB were enrolled and treated on an RT dose-reduction prospective trial with 18Gy hyperfractionated RT given in twice-daily fractions of 1.5Gy each. The 25 study subjects were 1.6 to 9.5 (median, 4.3) years old at enrollment and included 23 (92%) with stage IV and II (8%) with MYCN-amplified stage III disease. Eleven (44%) were in complete remission (CR), and 14 (56%) had persistence of osteomedullary disease postinduction. Three patients (12%) received proton therapy, and the rest received intensity modulated photon therapy. After a follow-up of 1.8 to 4.2 (median, 3.5) years from initiation of RT, no failures occurred within the RT field; 3 patients had marginal recurrences. The respective 3-year progression-free and overall survival rates were 54.5% and 90.9% for patients in first CR and 42.9% and 76.2% for patients not in metastatic CR. Acute toxicity was negligible. Reduced-dose RT with 18Gy did not compromise local control or survival outcomes in our cohort of patients with HR-NB after GTR. These findings support assessing further RT dose reduction and validation on a larger, multi-institutional trial.

PTV margin analysis for prostate patients treated with initial pelvic nodal IMRT and prostate proton boost

To evaluate the planning target volume (PTV) margins for prostate cancer patients treated with initial intensity-modulated radiation therapy (IMRT) to pelvic lymph nodes and a proton boost to the prostate using cone-beam computed tomography (CBCT) and radiographs as image guidance. We analyzed data from prostate patients (n = 15) treated with initial pelvic IMRT and a proton boost to the prostate. CBCT and 2-dimensional (2D) radiographs were used for IMRT and proton pre-treatment alignments, respectively. Translations from bony-matching, implanted marker seed matching, and seed-bony differences were obtained from CBCTs. Pretreatment and post-treatment 2D radiographs were analyzed for residual setup errors and intrafractional organ motion. PTV margins of prostate and pelvic lymph nodes for seed-matching, bony-matching and the skin mark-matching approach were obtained using 2.5 * Σ + 0.7 * σ formula, where Σ is the systematic error and σ is the random error summed in quadrature of various error components. For the seed-matching approach, the prostate margins were 1.5 mm, 3.5 mm, and 2.7 mm for the left-right (LR), superior-inferior (SI), and anterior-posterior (AP) directions, respectively; pelvic lymph node margins were 2.3 mm, 7.1 mm, and 7.0 mm. For the bony-matching approach, the prostate margins were 2.7 mm, 7.8 mm, and 7.5 mm for the LR, SI, and AP directions, respectively; pelvic lymph node margins were 0.7 mm, 1.5 mm, and 1.4 mm. For the skin mark-matching approach, the prostate margins were 7.6 mm, 13.4 mm, and 11.4 mm for the LR, SI, and AP directions, respectively; pelvic lymph node margins were 8.2 mm, 12.6 mm, and 12.3 mm. The seed-matching approach, as compared to the bony-matching approach, reduced prostate margins, which may in turn reduce dose to the bladder and rectum at the expense of increased but acceptable margins for the pelvic lymph nodes.

Radiation Therapy for Extrapelvic Lymph Node Recurrence After Curative Treatment for Cervical Cancer.

To investigate outcomes of patients with cervical cancer who received radiation therapy for extrapelvic lymph node recurrence after initial pelvic radiotherapy. The treatment charts of 20 patients were retrospectively reviewed, and factors influencing patient's prognosis were statistically analyzed. The three-year in-field tumor control rate was 55% and overall survival (OS) at 2, 3, and 5 years was 55%, 45%, and 37.5%, respectively. The rate of the three-year OS in patients with recurrence within and after 9 months was 20% and 70%, respectively (p=0.016). None of the 4 patients who were diagnosed with supraclavicular lymph node recurrence alone at more than 9 months after initial treatment experienced further recurrence. Five-year survival of the remaining 16 patients was only 21% (p=0.021). Time to recurrence significantly influenced survival in patients with cervical cancer who received radiotherapy for extra-pelvic lymph node recurrence. Supraclavicular lymph node recurrence alone had a favorable impact on patient's prognosis.

Emerging Treatment Strategies for Primary Breast Extranodal Marginal Zone Lymphoma of Mucosa-associated Lymphoid Tissue

IntroductionWe report our experience in treating patients with primary breast extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT) to better elucidate the natural history and optimal treatment approach for these patients. Patients and MethodsPatients with localized primary breast MALT lymphoma treated between 1995 and 2016 were included. Disease-related endpoints including progression-free survival (PFS) were analyzed. ResultsEleven patients met inclusion criteria; all patients were women with a median age of 62 years (range, 42-75 years). Most (73%) patients presented with stage I disease, and most (73%) patients were treated initially treated with radiation therapy (RT). Local control following RT was 100%; all patients with progression following RT experienced distant relapse. Additionally, none of the 3 patients treated with ultra-low-dose RT (4 Gy) experienced subsequent progression (local or distant). Six (55%) patients progressed after initial therapy, of whom 5 received initial RT; the 5-year PFS after initial therapy was 60%. Salvage systemic therapy was utilized in all patients with progression, with 5 of 6 patients receiving single-agent rituximab. Of the patients treated with salvage therapy, only 1 experienced second relapse, with a 5-year PFS of 100% after salvage systemic therapy. With a median follow-up of 8 years, there were no deaths in the cohort. ConclusionsPatients with primary breast MALT lymphoma achieve excellent outcomes. Initial RT affords local control, and although subsequent distant progression is common, salvage rituximab yields high rates of PFS.

Patterns of failure for early-stage glottic carcinoma: 10 years' experience in conformal radiotherapy era.

Larynx cancer is the most common head-and-neck cancer in Turkey. Vocal cords are involved nearly 70%-80% of laryngeal carcinomas. We aim to present our 10 years' experience and failure patterns of the patients with T1 and T2 glottic laryngeal carcinoma by same manner, technique, doses, and physician in conformal radiotherapy (RT) era. Between January 2005 and December 2015, a total of 143 patients treated with definitive RT for early-stage glottis laryngeal cancer were selected. The total dose was 65.25 Gy in 29 fractions. The median follow-up time was 64 (range: 12-150) months. All of the patients had a complete clinical response to the treatment. A 5-year local control (LC) rates were 84.5%, 91.8%, 74%, and 56% for overall, T1a, T1b, and T2, respectively. Ultimate LC rates (after salvage treatment) for 5 years were 90%, 95%, 92%, and 75% for overall, T1a, T1b, and T2, respectively. Regional neck control for the whole group was 92% for 5 years. After the initial RT, a total of 22 (15.4%) patients had disease recurrence at any site of the neck or larynx. Median time to disease recurrence was 59.5 months (range: 5-150). This study represents a large and long-term analysis of early-stage glottic carcinoma treated by same manner, technique, doses, and physician in conformal RT era. Definitive RT provides a high LC rate, tolerable toxicity, and favorable voice quality. Extension beyond the vocal cords and T2 stage are the most important unfavorable prognostic factors regarding LC.

Stereotactic Radiosurgery for Intracranial Ependymomas: An International Multicenter Study.

Stereotactic radiosurgery (SRS) is a potentially important option for intracranial ependymoma patients. To analyze the outcomes of intracranial ependymoma patients who underwent SRS as a part of multimodality management. Seven centers participating in the International Gamma Knife Research Foundation identified 89 intracranial ependymoma patients who underwent SRS (113 tumors). The median patient age was 16.3 yr (2.9-80). All patients underwent previous surgical resection and radiation therapy (RT) of their ependymomas and 40 underwent previous chemotherapy. Grade 2 ependymomas were present in 42 patients (52 tumors) and grade 3 ependymomas in 48 patients (61 tumors). The median tumor volume was 2.2 cc (0.03-36.8) and the median margin dose was 15 Gy (9-24). Forty-seven (53%) patients were alive and 42 (47%) patients died at the last follow-up. The overall survival after SRS was 86% at 1 yr, 50% at 3 yr, and 44% at 5 yr. Smaller total tumor volume was associated with longer overall survival (P= .006). Twenty-two patients (grade 2: n= 9, grade 3: n= 13) developed additional recurrent ependymomas in the craniospinal axis. The progression-free survival after SRS was 71% at 1 yr, 56% at 3 yr, and 48% at 5 yr. Adult age, female sex, and smaller tumor volume indicated significantly better progression-free survival. Symptomatic adverse radiation effects were seen in 7 patients (8%). SRS provides another management option for residual or recurrent progressive intracranial ependymoma patients who have failed initial surgery and RT.

Whole-gland salvage treatment for recurrent prostate cancer after initial definitive radiotherapy: A case series of 125I brachytherapy and robot-assisted radical prostatectomy.

PurposeTo analyze outcomes following whole-gland salvage treatments applied to patients with pathology-proven, locally recurrent prostate cancer following primary definitive radiotherapy.Material and methodsEighteen consecutive patients who received whole-gland salvage treatments at our institution were retrospectively reviewed. All patients underwent transperineal template-guided mapping biopsy (TTMB) using the standard iodine-125 (125I) brachytherapy (BT) setup. Twelve patients received 125I BT, and six patients underwent robot-assisted laparoscopic prostatectomy (RARP). Prostate-specific antigen (PSA) failure was determined using the Phoenix definition (nadir + 2 ng/ml) following BT and a PSA level of > 0.2 ng/ml following RARP. Toxicities were graded according to CTCAE version 4.0.ResultsThe median follow-up times were 71 and 11 months for the BT and RARP groups, respectively. In the BT group, the median dose to 90% of the prostate was 131 Gy. The median time to biochemical failure was 47 months, and the biochemical relapse-free survival (BRFS) rates were 56% (95% confidence interval [CI]: 33-94%) and 46% (95% CI: 25-88%) at 3 years and 5 years, respectively. Four patients (33%) developed grade 2 genitourinary (GU) toxicity, and two (17%) developed grade 3 GU toxicity. No patients developed grade ≥ 2 gastrointestinal (GI) toxicity. In the RARP group, three out of six patients (50%) had PSA failure, and four patients (67%) developed grade 2 GU toxicity. No patients developed grade 3 GU toxicity or grade ≥ 2 GI toxicity. On pre-salvage magnetic resonance imaging (MRI), no patients were suspected of having T3 or higher stage lesions. However, three patients (50%) had pT3a and two patients (33%) had pT3b (i.e., seminal vesicle invasion) stage lesions.ConclusionsWhole-gland salvage BT is an effective treatment with an acceptable toxicity profile. The pathology findings from RARP imply that there is a room for improvement in diagnoses made by MRI in the pre-salvage setting.

Importance of Extracting Intergroup Differences by Treatment Purpose and Content of Free-Response Answers That Should Be Considered when Screening for Pain by Administering the “Ease of Living Questionnaire” to Patients Undergoing Initial Radiotherapy

Importance of Extracting Intergroup Differences by Treatment Purpose and Content of Free-Response Answers That Should Be Considered when Screening for Pain by Administering the “Ease of Living Questionnaire” to Patients Undergoing Initial Radiotherapy

Coût de la radiothérapie des métastases osseuses en France : étude rétrospective monocentrique

PurposeThe cost of radiotherapy is a concern for health systems. The conventional non fractionated or multifractionated schemes have shown the same efficacy in terms of pain relief but a non fractionated treatment seems less expensive. However, in general practice, multifractionated treatments are still the majority, which represents an additional cost for society. Moreover, the use of stereotactic body radiotherapy becomes more democratic and offers new curative perspectives, but at what price? Material and methodsA monocentric retrospective study was conducted in a French radiotherapy department to evaluate and compare the cost of irradiation of uncomplicated bone metastases according to the selected radiotherapy regimen : 30Gy in 10 fractions, 20Gy in five fractions, 8Gy in one fraction or stereotactic body radiotherapy. ResultsBetween January 2014 and December 2015, 91 patients receiving 116 treatments were included in the study, including 44 men (48%) and 47 women (52%) were 63 years old (25–88 years). Thirty-four treatments (29%) were performed by 30Gy in 10 fractions (30Gy group), 24 treatments (21%) by 20Gy in 5 fractions (20Gy group), 25 treatments (22%) by 8Gy in one fraction (8Gy group) and 33 treatments (28%) by stereotactic body radiotherapy (SBRT group). The cost of stereotactic body radiotherapy was significantly higher than that of three-dimensional treatments (P<0.001). If the cost of transport was added to this cost, stereotactic body radiotherapy remained the most expensive (P<0.001). The cost of the irradiation delivering 30Gy treatment was significantly higher than the cost of treatment with 20Gy (P=0.006) or 8Gy (P<0.001), even after adding the transport cost (P<0.001), with no significant difference between 20Gy and 8Gy (P=0.11). For the overall cost of treatment including the total cost of treatments, associated transport and reirradiation, stereotactic body radiotherapy was the most expensive treatment (P<0.001) and this cost was significantly higher in the 30Gy group than in the 20Gy group (P=0.012) or 8Gy group (P=0.001), with no significant difference between 20Gy and 8Gy (P=0.38). There was no significant difference in the cost of follow-up between 30Gy, 20Gy, 8Gy and stereotactic body radiotherapy at one month (P=0.09) but at three months (P=0.01) and six months (P=0.0001), this cost was significantly higher after a three-dimensional treatment. There was no significant difference in overall cost including initial radiotherapy, transport and overall follow-up over 6 months between groups (P=0.04). ConclusionStereotactic body radiotherapy is an efficient and curative irradiation technique but more expensive. It is preferred for some patients with a longer life expectancy in a non-palliative treatment setting. The treatment delivering 8Gy treatment appears to be the most cost-effective while leading to an equivalent efficiency to multifractionated treatments and preserving the quality of life of patients.

The importance of the optimal volume in the treatment of locally recurrent nasopharyngeal carcinoma; brachytherapy or stereotactic radiotherapy?

Introduction: Nasopharyngeal carcinoma (NPC) is commonly known as a radiosensitive tumor with the initial good response to radiation. Despite the improved outcome in loco regional control by the introduction of combining treatment, modern radiotherapy techniques and enhanced imaging studies, local recurrent after primary treatment with rate ranges from 15-58% in 5 years, still remains one of the major causes of failure for patients with NPC. Re irradiation with various treatment modalities have been reported as a salvage option of NPC recurrent. Considering Limitation of critical organ tolerance doses because of the initial radiotherapy, brachytherapy (BT) and Stereotactic radiotherapy (SRT) irradiation have been encouraging especially if the recurrent lesion is small. The techniques can deliver a highly precise dose to the tumor while minimizing radiation to the surrounding normal tissue. Incidence of severe acute and late complications in these, depending to dose per fraction, total dose, time interval from previous radiotherapy and CTV is different. We compared optimal volume and toxicity in patients with locally recurrent nasopharyngeal carcinoma treated with BT and SRT. Materials and Methods: We retrospectively reviewed treatment plan of 12 patients with locally recurrent NPC were treated with BT between 1394 and 1397. However, the technique is applicable only to a small volume tumor, may produce some severe complications, such as soft palate perforation, sphenoid base fistula. But BT were well tolerated with no severe acute complications in this study. Median Tumor volume was 63 cc. The results of studies conducted with SRT despite the high probability of acute complications, Local control was better. Results: Improved local control and reduction of complications in both methods was reported to be significant respect to other ways. But the results of Similar study SRT showed that with more fractionated dese, late complications can be reduced. Tumor volume Range of 10.3–56.2 ml in early stage recurrent had Acceptable response rate to treatment. Common Late toxicities in SRT included cranial nerve injury, massive nasopharyngeal hemorrhage, and temporal lobe necrosis. The results of this study showed that with delivery proper dose of each session and the total time in SRT, can decrease Possible late complications. Conclusion: It was concluded that the best outcomes with re irradiation related on limited volume recurrence. According to the results of similar experience, SRT is superior to brachytherapy both in terms of providing sufficient dose for para nasopharyngeal spread and local control. SRT currently not routinely available in Most clinics as yet, but it has great potential in future cases of head and neck cancer.