Intensity-modulated Radiotherapy Group Research Articles

Twice-Daily Thoracic Radiotherapy by Intensity-Modulated Radiation Therapy (IMRT) or Simultaneous Integrated Boost (SIB) IMRT With Concurrent Chemotherapy for Limited-Stage Small Cell Lung Cancer Patients? A Propensity-Score Matched Analysis

<h3>Purpose/Objective(s)</h3> Concurrent chemoradiotherapy is the standard treatment for limited-stage small-cell lung cancer patients (SCLC), but the optimal dose and schedule of radiotherapy have not been established. <h3>Materials/Methods</h3> We retrospectively reviewed the clinical records of limited-stage SCLC patients treated with twice-daily thoracic radiotherapy by intensity modulated radiotherapy (IMRT) or Simultaneous integrated boost IMRT (SIB-IMRT) with concurrent chemotherapy between December 2009 to December 2017. The patients were divided into two groups according to the radiotherapy dose. The patients of SIB-IMRT group received 57Gy at 1.9Gy twice-daily to the gross tumor volume (GTV), 51Gy at 1.7Gy twice-daily to the clinical target volume (CTV) and 45Gy at 1.5Gy twice-daily to the planning target volume (PTV), and the patients of IMRT group received 45Gy at 1.5Gy twice-daily to PTV. A 1:1 propensity score matching (PSM) was applied to balance observable potential confounding factors between two groups. Primary endpoint was progression-free survival (PFS). Overall survival (OS), objective tumor response (ORR) and treatment-related toxicities were also evaluated. Statistical analyses were conducted using SPSS version 22.0 and statistical significance was defined as <b>P</b> < 0.05. <h3>Results</h3> A total of 112 patients were enrolled in our study, including 71 patients in IMRT group and 41 patients in SIB-IMRT group. After PSM, the clinical features were well balanced between two groups included 37 patients each. ORR in IMRT group and SIB-IMRT group were 94.6% (35/37) and 97.3% (36/37), respectively. Median PFS was 17.54 months in IMRT group <b>vs</b> 34.92 months in SIB-IMRT group (<b>P</b> = 0.047). Median OS was 38.52 months in IMRT group <b>vs</b> 63.41 months in SIB-IMRT group (<b>P</b> = 0.261). The incidence of grade 3-4 treatment-related toxicities was 43.24% (32/74), and there was no significant difference between two groups (<b>P</b> = 0.639). <h3>Conclusion</h3> Compared with IMRT, the high dose of twice-daily thoracic radiotherapy by SIB-IMRT approach with concurrent chemotherapy for the patients with limited-stage SCLC were well-tolerated and may improve PFS, but PFS improvement didn't result in significant advantage in OS.

Patient Reported Outcomes (PRO) in Those Receiving a High Dose Rate (HDR) Brachytherapy Prostate Boost Compared to Intensity Modulated Radiotherapy (IMRT) Alone

Prospective data show improved biochemical control-at a cost of worse urinary and overall physical function scores-in patients receiving a low dose rate (LDR) prostate brachytherapy boost when compared to IMRT alone. An HDR prostate boost may cause less toxicity than LDR brachytherapy. We, therefore, compared patient status post an HDR prostate boost or IMRT alone to see if there were any differences in PRO data between groups.American Urologic Association (AUA) symptom score and Sexual Health Inventory for Men (SHIM) score were prospectively collected for men with intermediate/high risk prostate cancer at a single institution. Genitourinary (GU) and gastrointestinal (GI) toxicity were also obtained and graded using the Common Terminology Criteria for Adverse Events v3.0 (CTCAE). Patients had undergone either IMRT plus an HDR prostate boost (n = 53) or IMRT alone (n = 346). Patients were excluded if they had prior TURP, a history of irritable bowel disease (IBD), or a prostate size greater than 75 cc. PRO were compared at baseline and at 1-2 years. AUA and SHIM scores were compared using a two-sample Wilcoxon rank-sum test.We identified 346 patients treated between 2001 and 2018 with IMRT alone (80 Gy median EBRT dose) and 53 patients treated with HDR boost (46 Gy median EBRT dose). Patient characteristics and unadjusted PRO scores are reported below in the table. There was no grade 4 or 5 acute or late GU or GI events.Zero grade 3 late GI events occurred in the IMRT plus HDR group, while 1.7% of patients (n = 6) in the IMRT alone group experienced late grade 3 GI toxicity; this difference was not statistically significant. Patients receiving an HDR boost have greater change in AUA score at 1-2 years compared to the IMRT alone patients; this change does not appear clinically significant. SHIM scores are higher in the HDR group before and after treatment, suggesting patients selected for a prostate boost may have better erectile function at baseline. Lastly, clinicians seem more comfortable withholding ADT in patients receiving an HDR prostate boost, possibly due to the higher ablative dose provided by HDR brachytherapy.

Evaluation of endocrine therapy combined with intensity modulated radiation therapy in patients with advanced prostate cancer

Abstract Objective The aim of this study was to study the effect of endocrine therapy combined with intensity-modulated radiation therapy in patients with advanced prostate cancer. Methods The clinical data of 231 patients with advanced prostate cancer treated with radiotherapy in our hospital from May 2010 to March 2018 were collected. A total of 135 patients were treated with endocrine therapy combined with intensity-modulated radiotherapy, and 96 patients were treated with intensity-modulated radiotherapy only because of drug allergy, serious adverse reactions, and economic reasons. Two months after the end of the treatment, the short-term curative effect was evaluated using imaging reexamination. The total prostate-specific antigen (TPSA) and free prostate-specific antigen (FPSA) were detected before and 2 months after the end of the treatment. All patients were followed up for at least 3 years, and the metastasis-free survival rate and cumulative survival rate of the two groups were calculated. Results The remission rates (RRs) of the observation and control groups were 64.45% and 46.87%, respectively; the difference was not statistically significant (P &gt; 0.05); however, the efficacy distribution of the endocrine therapy combined with intensity-modulated radiotherapy group was significantly better than that of the intensity-modulated radiotherapy group (P &lt; 0.05). There was no significant difference in clinical efficacy between the two groups in different TNM stages and Gleason grades. After treatment, the levels of TPSA and FPSA were significantly decreased compared with those before treatment; however, the decrease in the endocrine therapy combined with the intensity-modulated radiation therapy (IMRT) group was significantly higher than that in the IMRT group (P &lt; 0.05). Although there were no significant differences in the 1-year and 3-year cumulative survival rates between the two groups, the 1-year and 3-year metastasis-free survival rates of the endocrine therapy combined with the IMRT group were 60% and 38.17%, respectively, which were significantly higher than those of the IMRT group (37.5% and 20.83%, P &lt; 0.05). Conclusion Endocrine therapy combined with IMRT significantly improved the clinical efficacy of advanced prostate cancer, reduced PSA (prostate specific antigen) levels, and improved the metastasis-free survival rates.

Analysis of Health-Related Quality of Life of Patients with Clinically Localized Prostate Cancer After Treatment with Intensity Modulated Radiation Therapy (IMRT) Versus 3D Radiation Therapy

Abstract Background Prostate cancer is the most common malignancy in men. Patients with localized prostate cancer have multiple treatment options including active surveillance, prostatectomy, brachytherapy, and external beam radiation therapy (EBRT). Aim of the Work: to report on the quality of life outcomes in a number of male patients who underwent intensity modulated radiation therapy (IMRT) for clinically localized cancer prostate, compared to patients underwent 3D CRT, using licensed Arabic version of FACT-P questionnaire. Patients and Methods The present study included 103 patients diagnosed by localized prostate cancer. Patients files were collected from International medical center and oncology department at Ain Shams University hospital from June 2018 to December 2018. They were divided into two groups: Group I consisted of 51 patients treated using 3D CRT, all of them are under hormonal treatment. They completed a questionnaire at (Month 0) baseline, then on the followup visit, after 3, 6 months (Month 3, 6). Group II consisted of 52 patients treated by IMRT and hormonal treatment, the same dose range and field as 3D CRT. They participated and completed the questionnaire at the same phases (Month 0, 3, 6) with the same methods as the 1st group. Results stability in HRQoL (social and emotional subscales) in 3DCRT and the IMRT groups, and no significant difference among the two groups was observed throughout the follow-up period, although the radiation doses prescribed differed from one another. And showed a significant improvement in scores of (physical, functional and prostate concerns) subscales. Conclusion The two approaches used in this study showed similar patterns of alterations regarding general and disease specific HRQL with mild superiority for IMRT for the first 6 months after radiation therapy. Comparison of results between the 3DCRT and the IMRT groups revealed no substantial degrees of impairment in rectal toxicity and sexual function despite the dose escalation in the IMRT protocol. Thus, IMRT seems to offer a good treatment delivery approach with favorable HRQL outcomes.

Does post-operative radiotherapy improve the treatment outcomes of intracranial hemangiopericytoma? A retrospective study

BackgroundIntracranial hemangiopericytoma is a rare disease and surgery is the mainstay treatment. Although postoperative adjuvant radiotherapy is often used, there are no reports comparing different radiotherapy techniques. The purpose of this study is to analyze the impact of post-operative radiotherapy and different radiotherapy technique on the results in patients with intracranial hemangiopericytoma (HPC).MethodsWe retrospectively reviewed 66 intracranial HPC patients treated between 1999 and 2019 including 29 with surgery followed by radiotherapy (11 with intensity-modulated radiotherapy (IMRT) and 18 with stereotactic radiosurgery (SRS)) and 37 with surgery alone. Chi-square test was used to compare the clinical characteristic between the groups. The Kaplan-Meier method was used to analyze overall survival (OS) and recurrence-free survival (RFS). Multivariate Cox proportional hazards models were used to examine prognostic factors of survival. We also underwent a matched-pair analysis by using the propensity score method.ResultsThe crude local control rates were 58.6% in the surgery plus post-operative radiotherapy group (PORT) and 67.6% in the surgery alone group (p = 0.453). In the subgroup analysis of the PORT patients, local controls were 72.7% in the IMRT group and 50% in the SRS group (p = 0.228). The median OS in the PORT and surgery groups were 122 months and 98 months, respectively (p = 0.169). The median RFS was 96 months in the PORT group and 72 months in the surgery alone group (p = 0.714). Regarding radiotherapy technique, the median OS and RFS of the SRS group were not significantly different from those in the IMRT group (p = 0.256, 0.960). The median RFS were 112 and 72 months for pathology grade II and III patients, respectively (p = 0.001). Propensity score matching did not change the observed results.ConclusionIn this retrospective analysis, PORT did not improve the local control rates nor the survivals. The local control rates after IMRT and SRS were similar even though the IMRT technique had a much higher biological dose compared with the SRS technique.

Comparison of Radiation Pneumonitis in Lung Cancer Patients Treated with HT versus IMRT and Circulating Lymphocyte Subsets as Predicting Risk Factors.

PurposeWe sought to compare the symptomatic radiation pneumonitis (RP) in lung cancer patients treated with helical tomotherapy (HT) versus intensity-modulated radiotherapy (IMRT), and examine the predictive value of circulating lymphocyte subsets affecting the occurrence of RP.Patients and MethodsCirculating lymphocyte subsets, clinical characteristics, dosimetric parameters and pulmonary function were collected from 130 lung cancer patients treated with HT (n = 53) or IMRT (n = 77) from 2016 through 2020. Symptomatic RP was compared between groups. Binary logistic regression was used to identify predictors of RP.ResultsThe IMRT group had larger planning target volume (319.9 vs 240.8 cc, P = 0.041); more ECOG performance status 0–1 (96.1% vs 79.2%, P = 0.002); more stage III–IV disease (94.8% vs 37.6%, P = 0.028); and more combined systemic therapy (85.7% vs 69.8%, P = 0.022). Grade ≥2 RP were comparable between IMRT and HT groups (16.9% vs 15.1%, P = 0.785). For stage III–IV disease, IMRT was associated with lower lung V10 (31.9% vs 35.8%, P = 0.047) and lower incidence of grade 5 RP (0% vs 9.1%, P = 0.018). All lymphocyte subsets reduced after radiotherapy. The decrease degree of total T cell count and CD4+ T cell count were larger after IMRT than HT (P = 0.043, P = 0.021). In univariate analysis, the smoking status, lower baseline FEV1, and higher total T cell count, higher CD8+ T cell count, lower total B cell count, lower CD4+/CD8+ ratio after radiotherapy were associated with the development of grade ≥2 RP. The higher CD8+T cell count after radiotherapy was the only risk factor associated with grade ≥2 RP in multivariable analysis (OR 1.003; 95% CI: 1.000–1.005; P = 0.044).ConclusionIMRT was associated with lower lung V10 and less grade 5 RP than HT for stage III–IV lung cancer. Higher CD8+ T cell count after radiotherapy was associated with an increased risk of RP. HT may better preserve total T cell and CD4+ T cell than IMRT.

Comparison Between Dose-Escalated Intensity Modulated Radiation Therapy and 3-Dimensional Conformal Radiation Therapy for Salvage Radiation Therapy After Prostatectomy

PurposeTo compare long-term outcomes and late toxicity between patients treated with 3-dimensional conformal radiation therapy (3D-CRT) and with dose-escalated intensity modulated radiation therapy (IMRT) as salvage radiation therapy (SRT) after prostatectomy. Methods and MaterialsA total of 110 patients who had been treated at our institution between 2010 and 2018 with SRT for biochemical recurrence after radical prostatectomy were included. The patients were treated either by 3D-CRT with 64 Gy (59 patients) or by IMRT with 70 Gy (51 patients). The irradiation target was the prostate bed only (106 patients) or the prostate bed and pelvic region (4 patients). Twelve patients (11%) received concurrent androgen deprivation therapy. The differences in clinical outcomes and late gastrointestinal (GI) and genitourinary (GU) toxicity between the 3D-CRT and IMRT groups were retrospectively assessed. Toxicities were recorded using the Common Terminology Criteria for Adverse Events, version 5.0. Prostate-specific antigen (PSA) progression after SRT was defined as an increase in the serum PSA level of 0.2 ng/mL from the PSA nadir after SRT and confirmed by a second PSA measurement that was higher than the first. ResultsThe median follow-up time was 7.8 years for 3D-CRT (range:,0.3-9.2 years) and 3.1 years for IMRT (range, 0.4-7.2 years). There was no significant difference in the 4-year biochemical no-evidence-of-disease (bNED) rate between the 3D-CRT and IMRT groups (43.5% vs 52.1%; P = .20). Toxicity analysis showed no significant difference in late GI or GU toxicities of grade 2 or greater between the 3D-CRT and IMRT groups. The respective 4-year cumulative rates of toxicity in the 3D-CRT and IMRT groups were as follows: grade ≥2 GI toxicity, 8.8% and 4.4% (P = .42); grade ≥2 GU toxicity, 19.1% and 20.3% (P = .93); and grade ≥2 hematuria, 5.3% and 8.0% (P = .67). In the 3D-CRT group, the 8-year cumulative rates of GI toxicity, GU toxicity, and hematuria of grade 2 or greater were 8.8%, 28.4%, and 12.6%, respectively. ConclusionsDose-escalated IMRT showed no improvements in bNED or late toxicity compared with 3D-CRT. In addition, the results suggest that GU toxicity can occur after a long period (even after 6 years), whereas GI toxicity is seldom newly observed after 4 years.

Clinical Outcomes of Pencil Beam Scanning Proton Therapy in Locally Advanced Non-Small Cell Lung Cancer: Propensity Score Analysis.

Simple SummaryWe analyzed the oncologic outcomes and toxicities after intensity-modulated radiation therapy (IMRT) or pencil beam scanning proton therapy (PBSPT) in patients with locally advanced non-small cell lung cancer treated with concurrent chemoradiation therapy. Due to an imbalance in baseline characteristics between IMRT and PBSPT, we used propensity score-based statistical analysis. Regarding radiation therapy planning, PBSPT exhibited superior sparing of the lung, heart, and spinal cord compared to intensity-modulated (photon) radiotherapy in patients with advanced NSCLC. However, PBSPT resulted in higher incidence of grade 3 or more dermatitis and esophagitis compared to IMRT. Despite declined baseline lung function, PBSPT demonstrated a comparable rate of symptomatic radiation pneumonitis compared to IMRT. PBSPT could be an effective and safe treatment technique with comparable locoregional control.This study compared the efficacy and safety of pencil beam scanning proton therapy (PBSPT) versus intensity-modulated (photon) radiotherapy (IMRT) in patients with stage III non-small cell lung cancer (NSCLC). We retrospectively reviewed 219 patients with stage III NSCLC who received definitive concurrent chemoradiotherapy between November 2016 and December 2018. Twenty-five patients (11.4%) underwent PBSPT (23 with single-field optimization) and 194 patients (88.6%) underwent IMRT. Rates of locoregional control (LRC), overall survival, and acute/late toxicities were compared between the groups using propensity score-adjusted analyses. Patients treated with PBSPT were older (median: 67 vs. 62 years) and had worse pulmonary function at baseline (both FEV1 and DLCO) compared to those treated with IMRT. With comparable target coverage, PBSPT exhibited superior sparing of the lung, heart, and spinal cord to radiation exposure compared to IMRT. At a median follow-up of 21.7 (interquartile range: 16.8–26.8) months, the 2-year LRC rates were 72.1% and 84.1% in the IMRT and PBSPT groups, respectively (p = 0.287). The rates of grade ≥ 3 esophagitis were 8.2% and 20.0% after IMRT and PBSPT (p = 0.073), respectively, while corresponding rates of grade ≥ 2 radiation pneumonitis were 28.9% and 16.0%, respectively (p = 0.263). PBSPT appears to be an effective and safe treatment technique even for patients with poor lung function, and it does not jeopardize LRC.

Toxicity Profiles and Survival Outcomes Among Patients With Nonmetastatic Nasopharyngeal Carcinoma Treated With Intensity-Modulated Proton Therapy vs Intensity-Modulated Radiation Therapy

Patients with nonmetastatic nasopharyngeal carcinoma (NPC) are primarily treated by radiotherapy with curative intent with or without chemotherapy and often experience substantial treatment-related toxic effects even with modern radiation techniques, such as intensity-modulated radiation therapy (IMRT). Intensity-modulated proton therapy (IMPT) may improve the toxicity profile; however, there is a paucity of data given the limited availability of IMPT in regions with endemic NPC. To compare toxic effects and oncologic outcomes among patients with newly diagnosed nonmetastatic NPC when treated with IMPT vs IMRT with or without chemotherapy. This retrospective cohort study included 77 patients with newly diagnosed nonmetastatic NPC who received curative-intent radiotherapy with IMPT or IMRT at a tertiary academic cancer center from January 1, 2016, to December 31, 2019. Forty-eight patients with Epstein-Barr virus (EBV)-positive tumors were included in a 1:1 propensity score-matched analysis for survival outcomes. The end of the follow-up period was March 31, 2021. IMPT vs IMRT with or without chemotherapy. The main outcomes were the incidence of acute and chronic treatment-related adverse events (AEs) and oncologic outcomes, including locoregional failure-free survival (LRFS), progression-free survival (PFS), and overall survival (OS). We identified 77 patients (25 [32.5%] women; 52 [67.5%] men; median [interquartile range] age, 48.7 [42.2-60.3] years), among whom 28 (36.4%) were treated with IMPT and 49 (63.6%) were treated with IMRT. Median (interquartile range) follow-up was 30.3 (17.9-41.5) months. On multivariable logistic regression analyses, IMPT was associated with lower likelihood of developing grade 2 or higher acute AEs compared with IMRT (odds ratio [OR], 0.15; 95% CI, 0.03-0.60; P = .01). Only 1 case (3.8%) of a chronic grade 3 or higher AE occurred in the IMPT group compared with 8 cases (16.3%) in the IMRT group (OR, 0.21; 95% CI, 0.01-1.21; P = .15). Propensity score matching generated a balanced cohort of 48 patients (24 IMPT vs 24 IMRT) and found similar PFS in the IMPT and IMRT groups (2-year PFS, 95.7% [95% CI, 87.7%-100%] vs 76.7% [95% CI, 60.7%-97.0%]; hazard ratio [HR], 0.31; 95% CI, 0.07-1.47; P = .14). No locoregional recurrence or death was observed in the IMPT group from the matched cohort. Two-year LRFS was 100% (95% CI, 100%-100%) in the IMPT group and 86.2% (95% CI, 72.8%-100%) in the IMRT group (P = .08). Three-year OS was 100% (95% CI, 100%-100%) in the IMPT group and 94.1% (95% CI, 83.6%-100%) in the IMRT group (P = .42). Smoking history was the only clinical factor significantly associated with both poor LRFS (HR, 63.37; 95% CI, 3.25-1236.13; P = .006) and poor PFS (HR, 6.33; 95% CI, 1.16-34.57; P = .03) on multivariable analyses. In this study, curative-intent radiotherapy with IMPT for nonmetastatic NPC was associated with significantly reduced acute toxicity burden in comparison with IMRT, with rare late complications and excellent oncologic outcomes, including 100% locoregional control at 2 years. Prospective trials are warranted to direct the optimal patient selection for IMPT as the primary radiotherapy modality for nonmetastatic NPC.

Outcome and safety analysis of endometrial cancer patients treated with postoperative 3D-conformal radiotherapy or intensity modulated radiotherapy

Background We sought to analyze the toxicity rates and the treatment outcomes in endometrial cancer (EC) patients treated with postoperative three-dimensional conformal radiotherapy (3DCRT) and intensity-modulated radiotherapy (IMRT). Material and methods The clinical data of 646 EC patients treated with postoperative adjuvant 3DCRT (265 patients, 41%) or with IMRT (381 patients, 59%) between April 2007 and August 2019 were retrospectively analyzed. The primary endpoints were treatment-related acute and late gastrointestinal (GI) and genitourinary (GU) toxicities. The secondary endpoints were LC and overall survival (OS) and disease-free survival (DFS). Results Median follow-up time was 37 months. The rates for acute GI and GU toxicities of any grade for the entire group were 55.6% and 46.8%, respectively. Acute grade ≥2 GI toxicity was significantly less in patients treated with IMRT compared to those treated with 3DCRT (11.0% vs. 19.2%, p=.004). However, no significant difference grade ≥2 GU toxicities was observed between the 3DCRT and IMRT groups (15.1% vs. 11.0%; p=.15). Acute grade ≥2 GI and GU toxicities were higher in patients receiving systemic chemotherapy, while paraaortic field irradiation increases only the risk of acute grade ≥2 GI toxicity. Estimated 3-year late grade ≥3 GI toxicity rates in the 3DCRT- and IMRT-treated patients were 4.6% and 1.9% (p= .03), respectively. The patients treated with adjuvant ChT had higher rates of late serious GI complications than those without adjuvant ChT. No significant difference in terms of survival and disease control was observed between the 3DCRT and IMRT treatment groups. No significant factor for LC was found in the multivariate analysis. Conclusion In this multicentric study involving one of largest patient population, we found that IMRT-treated EC patients showed comparable clinical outcomes but with a lower incidence of GI toxicities compared with those treated with 3DCRT.

The effect of surgery plus intensity-modulated radiotherapy on treatment in laryngeal cancer: A clinical retrospective study.

As a common head and neck tumor, laryngeal cancer has attracted heightened attention for its treatment and prognosis. Surgery and radiotherapy were mainly therapeutic approaches in laryngeal cancer, and intensity-modulated radiotherapy (IMRT) was a precision treatment way in radiotherapy. However, the therapeutic effect of surgery plus IMRT in laryngeal cancer was rarely reported. This study aims to determine the effect of IMRT on the treatment of patients with laryngeal cancer. A total of 125 patients with laryngeal cancer were collected and retrospectively analyzed based on their clinical data and follow-up results. These patients had a clear treatment plan for surgery and intensity-modulated radiotherapy. Smoking, lymph node metastasis, TNM staging and therapeutic approaches could affect the survival of patients with laryngeal cancer. It was shown that the laryngeal function retention rate in the simple IMRT group was significantly higher than the simple surgery group and surgery plus IMRT group. The 5-year survival rate of surgery plus IMRT, simple surgery and simple IMRT were 82.86%, 53.85% and 43.33%, respectively. The locoregional recurrences rate of surgery plus IMRT, simple surgery and simple IMRT were 14.29%, 34.62% and 43.33%. Surgery plus IMRT was a feasible and efficacious treatment technique for patients with laryngeal cancer, which effectively prolong the survival time of patients.

Intensity-modulated proton therapy for oropharyngeal cancer reduces rates of late xerostomia

Background and purposeTo determine rates of xerostomia after intensity-modulated radiotherapy (IMRT) or intensity-modulated proton therapy (IMPT) for oropharyngeal cancer (OPC) and identify dosimetric factors associated with xerostomia risk. Materials and methodsPatients with OPC who received IMRT (n = 429) or IMPT (n = 103) from January 2011 through June 2015 at a single institution were studied retrospectively. Every 3 months after treatment, each patient completed an eight-item self-reported xerostomia-specific questionnaire (XQ; summary XQ score, 0–100). An XQ score of 50 was selected as the demarcation value for moderate-severe (XQs ≥ 50) and no-mild (XQs < 50) xerostomia. The mean doses and percent volumes of organs at risk receiving various doses (V5-V70) were extracted from the initial treatment plans. The dosimetric variables and xerostomia risk were compared using an independent-sample t-test or chi-square test. ResultsThe median follow-up time was 36.2 months. The proportions of patients with moderate-severe xerostomia were similar in the two treatment groups up to 18 months after treatment. However, moderate-severe xerostomia was less common in the IMPT group than in the IMRT group at 18–24 months (6% vs. 20%; p = 0.025) and 24–36 months (6% vs. 20%; p = 0.01). During the late xerostomia period (24–36 months), high dose/volume exposures (V25-V70) in the oral cavity were associated with high proportions of patients with moderate-severe xerostomia (all p < 0.05), but dosimetric variables regarding the salivary glands were not associated with late xerostomia. ConclusionIMPT was associated with less late xerostomia than was IMRT in OPC patients. Oral cavity dosimetric variables were related to the occurrence of late xerostomia.

Radiation-induced acute injury of intensity-modulated radiotherapy versus three-dimensional conformal radiotherapy in induction chemotherapy followed by concurrent chemoradiotherapy for locoregionally advanced nasopharyngeal carcinoma: a prospective cohort study

To address whether the addition of intensity-modulated radiotherapy (IMRT) compared to three-dimensional conformal radiotherapy (3D-CRT) aggravate radiation-induced acute injury of locoregionally advanced nasopharyngeal carcinoma (LANPC) patients with induction chemotherapy (IC) followed by concurrent chemoradiotherapy (CCRT). We conducted a prospective study of 182 patients in the stage III to IVb with biopsy-proven nonmetastatic LANPC who newly underwent radiotherapy and sequentially received IC, followed by CCRT at our institution. Occurring time of radiation-induced toxicities were estimated and compared using the Kaplan–Meier method and Log-rank test. The most severe acute toxicities included oral mucositis in 97.25% and dermatitis in 90.11%. Subset analysis revealed that Grade 3–4 acute dermatitis were significantly higher in the IMRT than 3D-CRT. Oral mucositis and dermatitis were the earliest occurrence of acute injuries (2 years: 60.44% and 17.58%). Patients in IMRT group achieved significantly lower risk of bone marrow toxicity, but higher risk of leukopenia and gastrointestinal injury. Multivariate analyses also demonstrated that IMRT, female gender and hepatitis were the independent prognostic factors for bone marrow toxicity. In a combined regimen of IC followed by CCRT for the treatment of LANPC, IMRT seems to be an aggressive technique with a trend towards increased gastrointestinal and hematological toxicities, but decreased bone marrow toxicity than those treated with 3D-CRT. This study provides a comprehensive summary of prospective evidence reporting the side effects in the management of LANPC patients. We quantify the occurrence risks of chemoradiotherapy-induced acute injuries through analysis of time-to-event.

Stereotactic body radiotherapy versus intensity-modulated radiotherapy for hepatocellular carcinoma with portal vein tumor thrombosis.

It is unclear whether robotic stereotactic body radiotherapy (SBRT) is superior to intensity-modulated radiotherapy (IMRT) in advanced hepatocellular carcinoma (HCC). This study aimed to compare the long-term outcomes of SBRT with those of IMRT in HCCs with portal vein tumor thrombosis (PVTT). We retrospectively evaluated 287 HCC patients with PVTT who underwent radiotherapy between January 2000 and January 2017. Of them, 154 and 133 patients were treated with IMRT and SBRT, respectively. Overall survival (OS), progression-free survival (PFS), intrahepatic control (IC), and local control (LC) were evaluated in univariable and propensity-score matched analyses. After matching, 102 well-paired patients were selected. There was no significant difference in the 6-, 12-, 24-, and 60-month cumulative OS (73.5, 42.9, 23.6, 7.6% vs. 72.4, 45.1, 29.8, 13.2%, p = 0.151), PFS (53.9, 29.3, 21.8, 7.5% vs. 54.5, 19.3, 12.0, 9.6%, p = 0.744), IC (61.4, 45.7, 39.0, 26.8% vs. 75.1, 45.8, 35.9, 28.7%, p = 0.144), and LC (85.2, 56.5, 52.1, 47.4% vs. 87.4, 65.2, 62.1, 62.1%, p = 0.191) between the IMRT and SBRT groups. A biologically effective dose assumed at an a/b ratio of 10 (BED10) of ≥ 100Gy was the optimal cutoff for predicting the OS, PFS, IC, and LC in the patients who received SBRT. When high-precision tracking technology is available, SBRT appears to be a safe and more time-efficient treatment, achieving comparable OS, PFS, IC and LC to IMRT for local advanced HCC with PVTT. A BED10 ≥ 100Gy is recommended if tolerated by normal tissue.

Normal Tissue Injury Induced by Photon and Proton Therapies: Gaps and Opportunities.

Despite technological advances in radiation therapy (RT) and cancer treatment, patients still experience adverse effects. Proton therapy (PT) has emerged as a valuable RT modality that can improve treatment outcomes. Normal tissue injury is an important determinant of the outcome; therefore, for this review, we analyzed 2 databases: (1) clinical trials registered with ClinicalTrials.gov and (2) the literature on PT in PubMed, which shows a steady increase in the number of publications. Most studies in PT registered with ClinicalTrials.gov with results available are nonrandomized early phase studies with a relatively small number of patients enrolled. From the larger database of nonrandomized trials, we listed adverse events in specific organs/sites among patients with cancer who are treated with photons and protons to identify critical issues. The present data demonstrate dosimetric advantages of PT with favorable toxicity profiles and form the basis for comparative randomized prospective trials. A comparative analysis of 3 recently completed randomized trials for normal tissue toxicities suggests that for early stage non-small cell lung cancer, no meaningful comparison could be made between stereotactic body RT and stereotactic body PT due to low accrual (NCT01511081). In addition, for locally advanced non-small cell lung cancer, a comparison of intensity modulated RTwith passive scattering PT (now largely replaced by spot-scanned intensity modulated PT), PT did not provide any benefit in normal tissue toxicity or locoregional failure over photon therapy. Finally, for locally advanced esophageal cancer, proton beam therapy provided a lower total toxicity burden but did not improve progression-free survival and quality of life (NCT01512589). The purpose of this review is to inform the limitations of current trials looking at protons and photons, considering that advances in technology, physics, and biology are a continuum, and to advocate for future trials geared toward accurate precision RT that need to be viewed as an iterative process in a defined path toward delivering optimal radiation treatment. A foundational understanding of the radiobiologic differences between protons and photons in tumor and normal tissue responses is fundamental to, and necessary for, determining the suitability of a given type of biologically optimized RT to a patient or cohort.

Xerostomia Severity and Quality of Life After Nasopharyngeal Cancer Radiotherapy: Intensity Modulated vs Two-dimensional Radiation Therapy in Indonesia

Introduction : Two-dimensional technique (2DRT) is most commonly used in Indonesia. This technique causes severe late toxicity particularly in nasopharyngeal cancer (NPC). Radiation techniques such as Intensity-Modulated Radiation Therapy (IMRT) and Three-Dimensional Conformal Radiation Therapy (3DCRT) provide larger doses at the site of NPC while preserving normal tissue. This study aims to compare late side effects and quality of life (QoL) between IMRT and 2DRT groups. Method : This was a cross-sectional study with consecutive sampling. Salivae samples were collected at least 6 months after last radiation date. Xerostomia severity were determined by measuring whole saliva flow rate which then categorized based on Common Terminology Criteria for Adverse Events (CTCAE). European Organization for Research and Treatment of Cancer (EORTC) core questionnaire and EORTC head and neck module (QLQ-H&N35) wereused to assess QoL. Result: The IMRT group had higher saliva flow rate than 2DRT group (1,085 ±0,409 vs 0,188 ± 0,219 stimulated, 0,500±0,254 vs 0,196 ±0,156 unstimulated, p<0.001). According to CTCAE, IMRT group experienced less grades 2 and 3 of xerostomia compared to 2DRT group (p<0.05). Moderate correlation between recovery time and saliva flow rate (p<0.05) was found in IMRT group at least 6 months after last radiation date. QLO-C30 scores were higher in IMRT group than those in 2DRT group, particularly in global health status, physical functioning, emotional functioning, pain and insomnia (p<0.05). IMRT group scored better in several QLQ-H&N35 subscales namely head and neck pain, swallowing, speech problems, trouble with social eating, trouble with social contact, dry mouth (p<0.05) and sticky saliva (p<0.001). Conclusion : IMRT was significantly superior to 2DRT in preserving and sparing the salivary gland especially parotid and improving quality of life .Thus, we recommend to treat NPC cases in Indonesia with IMRT to reduce toxicity of the treatment and improve quality of life, as it commonly affects people at productive age.

Concurrent high-dose intensity-modulated radiotherapy and chemotherapy for unresectable locally advanced and metastatic pancreatic cancer: a pilot study

AbstractAim:To evaluate the efficacy of concurrent chemotherapy and high-dose (≥55 Gy) intensity-modulated radiotherapy (CCIMRT) in comparison with chemotherapy alone and intensity-modulated radiotherapy (IMRT) alone for unresectable locally advanced or metastatic pancreatic cancer.Methods:Forty-six patients with pancreatic cancer undergoing CCIMRT (n = 17), chemotherapy alone (n = 16) or IMRT alone (n = 13) were analysed. Overall survival (OS), locoregional progression-free survival (LRPFS) and gastrointestinal toxicities were evaluated. The median radiation dose was 60 Gy (range, 55–60) delivered in a median of 25 fractions (range, 24–30). Gemcitabine (GEM) alone, GEM + S-1, S-1 alone, FOLFIRINOX and GEM + nab-paclitaxel were used in CCIMRT and chemo-monotherapy.Results:The 1-year OS rate was 69% in the CCIMRT group, 27% in the chemotherapy group and 38% in the IMRT group (p = 0·12). The 1-year LRPFS rate was 73, 0 and 40% in the 3 groups, respectively (p = 0·012). Acute Grade ≥ 2 gastrointestinal toxicity (nausea, diarrhea) was observed in 12% (2/17) in the CCIMRT group, 25% (4/16) in the chemotherapy group and 7·7% (1/13) in the IMRT group (p = 0·38). Late Grade 3 gastrointestinal bleeding was observed in 6·3% (1/16) in the chemotherapy group.Conclusion:High-dose CCIMRT yielded acceptable toxicity and favorable OS and LRPFS.

Phase II Trial of Proton Therapy vs. Photon IMRT for GBM: Secondary Analysis Comparison of Progression Free Survival between RANO vs. Clinical Assessment

BackgroundThis secondary image analysis of a randomized trial of proton radiotherapy (PT) versus photon intensity-modulated radiotherapy (IMRT) compares tumor progression based on clinical radiological assessment versus Response Assessment in Neuro-Oncology (RANO).MethodsEligible patients were enrolled in the randomized trial and had MR imaging at baseline and follow-up beyond 12 weeks from completion of radiotherapy. “Clinical progression” was based on a clinical radiology report of progression and/or change in treatment for progression.ResultsOf 90 enrolled patients, 66 were evaluable. Median clinical progression-free survival (PFS) was 10.8 (range: 9.4–14.7) months; 10.8 months IMRT versus 11.2 months PT (P = .14). Median RANO-PFS was 8.2 (range: 6.9, 12): 8.9 months IMRT versus 6.6 months PT (P = .24). RANO-PFS was significantly shorter than clinical PFS overall (P = .001) and for both the IMRT (P = .01) and PT (P = .04) groups. There were 31 (46.3%) discrepant cases of which 17 had RANO progression more than a month prior to clinical progression, and 14 had progression by RANO but not clinical criteria.ConclusionsBased on this secondary analysis of a trial of PT versus IMRT for glioblastoma, while no difference in PFS was noted relative to treatment technique, RANO criteria identified progression more often and earlier than clinical assessment. This highlights the disconnect between measures of tumor response in clinical trials versus clinical practice. With growing efforts to utilize real-world data and personalized treatment with timely adaptation, there is a growing need to improve the consistency of determining tumor progression within clinical trials and clinical practice.

Effects of leuprolide acetate on the quality of life of patients with prostate cancer: A prospective longitudinal cohort study.

PurposeThe aim of this study was to investigate the effect of androgen deprivation therapy (ADT) on the health-related quality of life (HRQOL) of patients with prostate cancer (PC) and compare the changes in the HRQOL between ADT alone and ADT plus intensity-modulated radiation therapy (IMRT).Materials and methodsPatients with PC were prospectively recruited between October 2018 and April 2020. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire and the PC-specific module (PR25) were administered before ADT (baseline) and at 3, 6, and 12 months after ADT. All patients received subcutaneous injections of 45 mg leuprolide acetate at 6-month intervals for 12 months.ResultsFifty-five of the 71 patients (77.5%) completed the 12-month study. Twenty-two of the 55 patients received IMRT. There were no differences in the baseline characteristics with respect to IMRT. Compared with baseline, physical function and role function deteriorated after 3 months (p = 0.003, p = 0.019). However, the global quality of life (QOL) did not change over time. The symptom scales of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire indicated that there was a statistically significant deterioration in dyspnea and fatigue symptoms at 12 months (p = 0.004, p = 0.004). Responses to the QLQ-PR25 revealed that patients experienced an increase in hormonal treatment-related symptoms after 3, 6, and 12 months (p = 0.002, 0.001, and 0.004). Comparisons between the ADT group and ADT plus IMRT group showed that body function and role function did not differ between the two groups (p = 0.815, p = 0.759), and there was also no difference in global QOL (p = 0.624).ConclusionOur results indicate that treatment with leuprolide acetate at 6-month intervals was not accompanied by changes in global QOL, despite deterioration of body and role functions and hormonal treatment-related symptoms. The combination of ADT and IMRT did not lead to additional deterioration in the HRQOL.

Intensity-modulated Radiation Therapy (IMRT) May Reduce Diarrhea With Similar Treatment Efficacy Even In Japanese Treatment Strategy For Cervical Cancers

The RTOG 1203 trial showed that IMRT after hysterectomy could reduce acute radiation enteritis (ARE) compared to 3-dimensional conformal radiotherapy (3DCRT). However, it should be investigated whether IMRT could reduce ARE in radical radiotherapy for cervical cancers, considering the inter- and intra-fractional motions of the uterus (5-15 mm) and larger target volume. In Japan, treatment strategy for cervical cancers differs from that of other countries. The intestine is shielded during whole-pelvic irradiation (WPI) and brachytherapy starts earlier. Thus, even in 3DCRT, the ARE incidence can be lower than in other countries. We applied radical IMRT for cervical cancers using tomotherapy and investigated whether the IMRT protocol could reduce ARE and other toxicities. We reviewed patients with cervical cancers treated at 3 institutions that employed the same protocol. In the protocol, patients with UICC 8th stage IB-IVA cervical cancers received radical WPI ± paraaortic irradiation with 45-50.4 Gy delivered at a daily fraction of 1.8 Gy five times a week. Platinum-containing chemotherapy was delivered to ≥ stage III or tumors with ≥ 4 cm in the maximum diameter. After 20-30 Gy of WPI depending on the stage, the rectum, bladder and intestine were shielded and intracavitary brachytherapy (2-4 times at a point A dose of 5-6 Gy) was carried out. In IMRT, a block structure was contoured instead of the center shielding in 3DCRT. The block structure median dose was reduced to ≤ 0.9 Gy/fr. From 2007 to 2011, 3DCRT was used. From 2012, the IMRT protocol was introduced. We compared the IMRT and 3DCRT groups. All patients treated with the protocols were analyzed except patients with: 1) previous history of hysterectomy or radiotherapy and 2) small cell cancer. ARE was defined as the increase in stool of 4–6 times per day over the baseline. In total, 169 patients were treated according to the protocols. Of them, IMRT was delivered to 93 (median age, 63 years) and 3DCRT to 76 (61 years). Chemotherapy was administered to 73 in the IMRT group and 50 in the 3DCRT group (p = 0.08). Lymph node metastases were seen in 44 in the IMRT group and 26 in the 3DCRT group (p = 0.12). The 3-year overall survival and locoregional recurrence rates after IMRT were 84% and 17%, respectively. In the 3DCRT group, these rates were 70% and 20%, respectively. No difference was seen between the 2 groups (p > 0.2). ARE occurred less frequently in the IMRT group than in the 3DCRT group (17/93 vs 24/76, p < 0.05). Grade 3 toxicities were observed in 5 in the IMRT group (rectal bleeding 2, sigmoid colon stenosis 1, bladder tamponade 2) and in 3 in the 3DCRT group (rectal bleeding 1, small intestinal perforation 2) (p = 0.73). There was no ≥ grade 4 toxicity in both groups. Even in the Japanese treatment strategy for cervical cancers, use of IMRT may reduce ARE with similar treatment efficacy.