Months Of Radiation Therapy Research Articles

Case Report: 56-year-old Woman Presenting with Progressive Hearing Loss, Chronic Otitis Media and Pulsatile Tinnitus

Introduction: Glomus tumors are rare benign lesions of the middle ear that are often associated with symptoms of progressive hearing loss and pulsatile tinnitus. Diagnosis is often delayed due to the slow growth of the tumor, and surgical resections of the mass are the mainstay treatment.
 Case Presentation: A 56-year-old Latin American female was admitted to the hospital with a year-long history of intermittent pulsatile buzzing noise, progressive hearing loss, pain and discharge of the left ear. High-resolution Computerized Tomography and Magnetic Resonance Imaging revealed evidence of an enhancing mass lesion, which extended into the external auditory canal. A tympanomastoidectomy was performed. Most of the mass was removed, but some remained because of massive bleeding. The patient received 3 months of radiation therapy after the tympanic paraganglioma was surgically removed.
 Conclusion: This case exposed the audiological findings, the location, and the extent of the tumor. Management options consist of radiation therapy and surgical management, depending on the size of the tumor. Early detection of glomus tumors is essential to prevent non-reversible complications.

Radiation induced lichen planus - an uncommon side effect

Cutaneous lichen planus is classically characterized by violaceous, pruritic, planar papules and plaques, most commonly affecting the extremities. Lichen planus following radiation therapy is extremely rare and lichen planus following radiation therapy for prostate carcinoma has not been previously reported in the literature. We report a 66-year-old man who presented to the dermatology clinic with a symmetric pruritic eruption affecting the pelvic and gluteal region within two months of radiation therapy targeting the prostate and pelvic lymph nodes for prostate adenocarcinoma. The patient did not have a prior history of lichen planus. Physical examination demonstrated well demarcated, violaceous papules and plaques in a circumferential band-like distribution on the bilateral gluteal, lumbosacral, and pelvic region. In addition, he had a few discrete lesions on the calves and dorsal feet. Punch biopsy revealed an acanthotic epidermis with "saw-tooth" rete ridges and a lichenoid inflammatory infiltrate. A diagnosis of hypertrophic lichen planus was made, reinforcing the importance for clinicians to recognize radiation therapy as a risk factor for developing lichen planus despite no prior history of lichen planus.

How Should We Proceed with ypN+ Breast Cancer Following Positive Sentinel Lymph Node Biopsy after Neoadjuvant Chemotherapy?

The appropriate treatment of the axilla in patients who receive neoadjuvant chemotherapy and subsequently have a positive sentinel lymph node (SLN) is unclear (ypN+). The Alliance A011202 trial is comparing axillary lymph node dissection (ALND) with nodal radiation therapy (RT) to comprehensive RT alone. Our study sought to provide guidance as to how to proceed in the interim in patients with SLN positive disease, ypN+, who do not undergo ALND. From 2001 to present, we retrospectively reviewed 74 women with clinical node positive or negative breast cancer who underwent neoadjuvant chemotherapy and on SLN biopsy or ALND were found to have ypN+ disease. 27 out of 74 women underwent comprehensive RT alone, instead of an ALND. Of the 47 women who underwent ALND, 4 declined RT, 3 were treated with 2-field technique and the remaining 40 women received 3-field RT, limiting dose to the dissected axilla. Doses to the axilla and supraclavicular regions ranged from 45-50.4 Gy, delivered in 23-28 fractions. Patients were followed routinely with exam and imaging. Dates and sites of local, regional, and distant failure were recorded. The effects of risk factors were examined using Cox proportional hazards models to estimate the hazard of recurrence at any given time and supplemental Fisher’s exact testing. The median follow up was 46 months (range 0-189), with a median follow up of 44.5 months for RT and 46 months for ALND. Overall local, regional and distant failure rates were found to be 6.8%, 9.5% and 14.9%, respectively. When looking at individual risk factors for recurrence, we found that the hazard of recurrence at any given time for patients with lymphovascular invasion (LVI) was 3.58 (95% CI: 1.30-9.86) times higher compared to patients who did not have LVI (p =.01). No other factors were found to be significant such as ECE, grade, hormone status or margins. When comparing patients treated with ALND and nodal RT vs comprehensive RT, we found a protective trend associated with RT, however the results did not reach significance (p=.18). Local and regional first recurrent rates were 0% and 3.7% with comprehensive RT, compared to 10.6% and 12.8% with ALND and nodal RT. 2 patients who recurred in the ALND group showed simultaneous local and regional failure, making a locoregional failure rate of 23.4%. Distant failure rates were similar at 14.8% with RT and 14.9% with ALND. Lymphedema rates of 17.4% were seen with RT compared to 26.5% with ALND (p=.39). Based on our findings, in patients who do not undergo ALND, a subset of women may benefit from comprehensive RT as it appears to be an effective means of local and regional disease control in patients with ypN+ disease. We encourage participation in Alliance A011202 to obtain randomized data in this cohort. We have an ongoing analysis to determine if the ALND group had higher risk features than the comprehensive RT group, which may have predisposed them to higher rates of failure.

Outcomes in real-world practice are different than cooperative trial for elderly patients with early breast cancer treated with adjuvant radiation therapy

BackgroundThe Cancer and Leukemia Group B 9,343 demonstrated that postoperative radiation can be safely omitted in women ≥70 years who underwent breast-conserving therapy for clinical stage I (T1N0M0) estrogen receptor positive breast cancer treated with antihormonal therapy. Whether such results are observed in real-world population is unknown. In this hospital-based data, we report the survival outcomes of patients who received adjuvant radiation therapy versus those who did not. MethodsUsing the National Cancer Data Base, we evaluated a cohort of 47,358 women with newly diagnosed breast cancer between 2004 and 2011 who underwent a lumpectomy and antihormonal therapy with the following criteria: age ≥70 years, clinical stage I, estrogen receptor positive, and negative margins. Patients were stratified into 2 groups: (1) radiation therapy and (2) no radiation therapy. Propensity score matching was used to compensate for differences in demographic and clinical characteristics of the patients. Univariate and multivariable survival analysis were employed to determine factors associated with overall survival. ResultsThe 5-year overall survival after propensity score matching was 87.2% for radiation therapy and 79.4% for no radiation therapy (P < .0001). The median survival time was 113.7 months for radiation therapy and 105.2 months for no radiation therapy. After adjusting for sociodemographic and clinical factors, the risk of overall deaths was significantly higher for those not receiving radiation therapy (hazard ratio = 1.66; 95% confidence interval, 1.54–1.79). Other significant adjusted predictors (P < .05) of poor overall survival were, advanced age, comprehensive community cancer program, facility location, poorly differentiated tumor, and high comorbidity index. ConclusionPatients who received radiation therapy had better survival outcomes than those who did not, revealing discordance between results of randomized trials and real-world setting.

Safety and Efficacy of Accelerated Hypofractionation and Stereotactic Body Radiation Therapy for Hepatocellular Carcinoma Patients With Varying Degrees of Hepatic Impairment

To report the toxicities and outcomes for stereotactic body radiation therapy (SBRT) and accelerated hypofractionated radiation therapy (AHRT) in patients with Child-Pugh (CP) class A, B, or C and albumin-bilirubin (ALBI) score 1, 2, or 3 hepatocellular carcinoma. We retrospectively reviewed the data from 146 patients with hepatocellular carcinoma who had undergone SBRT (50Gy in 5 fractions) or AHRT (45Gy in 18 fractions). The primary endpoint was liver toxicity, defined as an increase in the CP score of ≥2 within 6months of radiation therapy. The secondary endpoints of ALBI change, overall survival, and local control were also calculated. The median follow-up was 23months (range 1-59). Most received SBRT (72%), and 28% received AHRT. Of all 146 patients, 45 (31%) had a CP score elevation of ≥2 within 6months of radiation therapy (RT) (27 patients [28%] with baseline CP-A/B7 and 18 [35%] with baseline CP-B8/B9/C cirrhosis; P = .45). On multivariate analysis, neither baseline CP nor ALBI score was predictive of toxicity. No patient with a decline in liver functionality of CP ≥2 within 6months of RT returned to baseline at later time points. Eleven grade 4 toxicities were observed. The mean change in the raw ALBI score at ∼6months was similar for all baseline ALBI groups. Twenty-two patients underwent orthotopic liver transplantation after RT, 13 of whom had baseline CP-B8/B9/C liver functionality. For all patients, the 1- and 2-year treated-lesion local control was greater for SBRT than for AHRT (2-year 94% vs 65%, P<.0001). The tolerability of SBRT or AHRT as measured by a CP score decline of ≥2 within 6months of RT was similar across baseline liver functionality groups. Compared with AHRT, SBRT was associated with superior local control. Because thetrue tolerability of limited-volume RT for patients with CP-B or CP-C cirrhosis is unknown, prospective trials validating its safety and efficacy are warranted.

Effect of Radiation Treatment Volume Reduction on Lymphopenia in Patients Receiving Chemoradiation for Glioblastoma Multiforme

Acute severe lymphopenia (ASL) occurs frequently in glioblastoma (GBM) patients receiving radiation therapy and concurrent temozolomide (CRT). Previous studies have demonstrated correlation between ASL and overall survival (OS) in GBM patients as well as between ASL and the brain dose-volume histogram (DVH). Our study aims to evaluate whether reduction in radiation treatment volume in GBM patients influences total lymphocyte counts (TLCs) within the first 3 months of radiation therapy (RT). A total of 230 patients with supratentorial/nonmetastatic GBM were treated with standard-fractionated CRT from January 2007 to December 2016 and had laboratory data to evaluate TLC. Before January 2015, patients were treated with standard-field RT. After January 2015, strategies to minimize treatment volumes were implemented at our institution (limited-field RT): reduction of clinical treatment volume (CTV) margin, elimination of routine inclusion of the entire T2 abnormality, minimizing brain DVH without sacrificing coverage through optimization with intensity-modulated RT. TLCs were retrospectively compared between patients who were treated with standard-field vs. limited-field RT during the first 3 months after beginning RT. The Mann-Whitney U test was used to compare week 6, week 12, and nadir (lowest TLC within 3 months of RT) lymphocyte counts. ASL was defined as TLC of <500 cells/μL within 3 months of starting RT. ASL rate, Progression-free survival (PFS), and OS between two treatment periods were compared using Kaplan-Meier analysis. One-hundred seventy patients were treated with standard-field RT while 60 patients were treated with limited-field RT. Age, surgery type, MGMT methylation status, and IDH mutation status were not significantly different between the two groups. Median TLCs of standard-field and limited-field RT were 1400 cells/μL vs. 1500 cells/μL at baseline before RT, 800 cells/μL vs. 900 cells/μL at week 6 (p = 0.182), 900 cells/μL vs. 1100 cells/μL at week 12 (p = 0.049), and 650 cells/μL vs. 800 cells/μL at nadir (p = 0.043), respectively. Rates of ASL were 30.6% for standard-field and 18.2% for limited field (p = 0.103). After a median follow-up of 11 months, median PFS was 8 versus 6 months (p = 0.95) and median OS was 14 versus 15 months (p = 0.28) between the standard-field and limited-field RT groups. Limited-field RT appears to be associated with reduced TLC at week 12 and at nadir for GBM patients receiving CRT. Reduction of treatment volume does not appear to adversely affect PFS and OS. With increasing development of immunotherapy for GBM, limited-field RT may warrant further investigation prospectively.

Malignant melanoma metastatic to the gallbladder diagnosed by endoscopic ultrasonography-guided fine-needle aspiration.

Endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) is a safe and powerful modality for diagnosis of gallbladder lesions.[123] We report an extremely rare case in which EUS-FNA was useful for the definitive diagnosis of metastatic melanoma of the gallbladder. A 53-year-old woman was treated of a vaginal malignant melanoma. Enhanced computed tomography (CT) showed a heterogeneously enhanced mass of 3.5 cm × 3.0 cm in the vagina. No other lesions were detected in the liver, gallbladder, or other organs. Three months of radiation therapy resulted in regression of the tumor revealed by image modalities. Six months after the radiation, follow-up enhanced CT revealed a heterogeneously well-enhanced mass in the neck of the gallbladder. EUS demonstrated a 12 mm × 7 mm well-defined hypoechoic heterogeneous mass with a hyperechoic-layered structure arising from the gallbladder wall. Power Doppler EUS revealed spotty increased flow on the tumor [Figure 1]. Transduodenal EUS-FNA of the gallbladder mass using a 25-gauge FNA needle was performed without any complications. Histopathological examination demonstrated a cluster of small- to medium-sized cells without melanin pigment. The nuclei were round or oval and they were hyperchromatic with inconspicuous nucleoli [Figure 2]. Immunohistochemistry was positive for S-100 protein and HMB-45 [Figure 2], consistent with malignant melanoma. The patient received chemotherapy; however, she deceased 4 months after EUS-FNA.Figure 1: Endoscopic ultrasonography image showing a well-defined hypoechoic heterogeneous mass with a hyperechoic-layered structure arising from the gallbladder wall. Power Doppler endoscopic ultrasonography revealed spotty increased flow on the tumorFigure 2: Endoscopic ultrasonography-guided fine-needle aspiration specimen from the neck of the gallbladder showing a cluster of small- to medium-sized cells without melanin pigment. Some tumor cells have intranuclear inclusion. The nuclei are round or oval and they were hyperchromatic with inconspicuous nucleoli (inset; the tumor cells are positive for S-100 protein [above] and HMB-45 [below])Since the first case of malignant melanoma from gallbladder,[4] the interest in gallbladder melanoma has been increasing. Although more cases have been reported since then, both primary and metastatic melanomas of the gallbladder are extremely rare. Because of the rarity of gallbladder melanoma, definitive diagnosis is still difficult even if clinically suspicious. To the best of our knowledge, this is the second report of metastatic malignant melanoma of the gallbladder,[3] which was successfully diagnosed by EUS-FNA. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patients understand that her name and initial will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Radiotherapy of Prostate Cancer Using Rapid Arc: Dosimetric Study of Military Teaching Hospital Mohamed V, Morocco

Background: RapidArc®, the Varian solution of Volumetric-modulated arc therapy (VMAT) is currently used in the curative treatment of localized prostate cancer. The aim of this study was to evaluate the dosimetric parameters (effectiveness and efficiency) of the arc dynamic therapy at the Teaching Hospital Mohamed V. Materials and methods: Thirty two patients were treated with curative intent, between June 2013 and December 2014, for localized prostate cancer with RapidArc. Computed tomography (CT) based treatment planning was performed in the supine position with immobilization devices. The patients were instructed to have a comfortably full bladder and an empty rectum at CT acquisition and before each treatment. Delineation of target volume and organs at risk (OARs) was based on the consensus recommendations of the RTOG. The dose prescription was performed with simultaneous integrated boost (SIB) method. Data was collected from dose-volume histograms (DVH) either for planning target volumes (PTV2) or OARs. We calculated the homogeneity index (HI) and the conformity index (CI). We also reported acute and late toxicity related to radiation therapy. Results: The mean age was 66.63 ±7.24 years old. Of the 32 patients, 24(75%) defined as high-risk. All PTV received dose ranging from 95% to 107% of the prescribed dose. The homogeneity and conformity index was very close to 1 of all treatment plans. The dose limits were respected in all OARs as recommended in QUANTEC reviews 2010. Respectively, the analysis of the HDV in the rectum and the bladder found a V70 at 7.15 ± 5.63% and 16.88 ± 8.62% and a V60 at 16.32 ± 7.97% and 27.68 ± 10 32%. The V50 in the femoral heads was 0.39 ± 0.57% on the right and 0.71 ± 1.35% on the left. The V50, V40 and V30 in the bowel bag were 38.76 ± 39.73 cc, 155.38 ± 85,60 cc and 320.09 ± 180.41 cc, respectively. The mean MU was 555.94 ± 86.34 and delivery treatment time (min) was 1.99 ± 0.47. After three months of radiation therapy, no grade 3 or 4 toxicity was reported. The median control PSA was very low at 0,052 [0.012, 0.417] ng/ml. Conclusion: This present study demonstrated that RapidArc showed optimal PTV coverage and the best OARs sparing with less number of MUs and short treatment time. Acute GI and GU toxicities were very low. Further studies are needed to evaluate late toxicities and tumor control.

Spinal cord biological safety of image-guided radiation therapy versus conventional radiation therapy.

Tumor models were simulated in purebred Beagles at the T9-10 levels of the spinal cord and treated with spinal image-guided radiation therapy or conventional radiation therapy with 50 or 70 Gy total radiation. Three months after radiation, neuronal injury at the T9-10 levels was observed, including reversible injury induced by spinal image-guided radiation therapy and apoptosis induced by conventional radiation therapy. The number of apoptotic cells and expression of the proapoptotic protein Fas were significantly reduced, but expression of the anti-apoptotic protein heat shock protein 70 was significantly increased after image-guided radiation therapy compared with the conventional method of the same radiation dose. Moreover, the spinal cord cell apoptotic index positively correlated with the ratio of Fas/heat shock protein 70. These findings indicate that 3 months of radiation therapy can induce a late response in the spinal cord to radiation therapy; image-guided radiation therapy is safer and results in less neuronal injury compared with conventional radiation therapy.

Inequality in Palliative Radiation Therapy: A Population-based Analysis

Inequality in Palliative Radiation Therapy: A Population-based Analysis

Accuracy of F-18 Fluorodeoxyglucose PET/CT 3 Months After Completion of Radiation Therapy for Head-and-Neck Squamous Cancer

The role of PET/CT in response assessment after radiation therapy (RT) remains undefined. Our previously published data on the accuracy of FDG-PET within 12 months of RT included both FDG-PET and PET/CT data and was based on an SUV cut-off of 3.0. The purpose of this review is to evaluate accuracy in the PET/CT era using clinical context to determine accuracy.

Trajectories of quality of life among Chinese patients diagnosed with nasopharynegeal cancer.

ObjectiveThis secondary longitudinal analysis describes distinct quality of life trajectories during eight months of radiation therapy (RT) among patients with nasopharyngeal cancer (NPC) and examines factors differentiating these trajectories.Methods253 Chinese patients with NPC scheduled for RT were assessed at pre-treatment, and 4 months and 8 months later on QoL (Chinese version of the FACT-G), optimism, pain, eating function, and patient satisfaction. Latent growth mixture modelling identified different trajectories within each of four QoL domains: Physical, Emotional, Social/family, and Functional well-being. Multinomial logistic regression compared optimism, pain, eating function, and patient satisfaction by trajectories adjusted for demographic and medical characteristics.ResultsWe identified three distinct trajectories for physical and emotional QoL domains, four trajectories for social/family, and two trajectories for functional domains. Within each domain most patients (physical (77%), emotional (85%), social/family (55%) and functional (63%)) experienced relatively stable high levels of well-being over the 8-month period. Different Physical trajectory patterns were predicted by pain and optimism, whereas for Emotion-domain trajectories pain, optimism, eating enjoyment, patient satisfaction with information, and gender were predictive. Age, appetite, optimism, martial status, and household income predicted Social/family trajectories; household income, eating enjoyment, optimism, and patient satisfaction with information predicted Functional trajectories.ConclusionMost patients with NPC showed high stable QoL during radiotherapy. Optimism predicted good QoL. Symptom impacts varied by QoL domain. Information satisfaction was protective in emotional and functional well-being, reflecting the importance in helping patients to establish a realistic expectation of treatment impacts.

Carbon Dioxide Laser Treatment for Lentigo Maligna

To assess outcomes in managing primary lentigo maligna through surgical excision, radiation therapy, and carbon dioxide laser ablation. Retrospective case series review of all patients with primary lentigo maligna diagnosed and treated in London, Ontario, Canada, between July 2, 1991, and June 29, 2010. Seventy-five patients aged 39 to 93 years (mean age, 64.8 years) were included in the study; 73 patients chose treatment. Twenty-seven patients were treated with surgical excision, 31 patients with radiation therapy, and 15 patients with carbon dioxide laser ablation. The median follow-up times were 16.6 months for surgical excision, 46.3 months for radiation therapy, and 77.8 months for carbon dioxide laser ablation (P < .001). Recurrence rates by treatment modality were 4.2% (1 of 27) for surgical excision, 29.0% (9 of 31) for radiation therapy, and 6.7% (1 of 15) for carbon dioxide laser ablation. A trend toward lower recurrence rates with surgical excision and carbon dioxide laser ablation was identified, but the results were not statistically significant. Carbon dioxide laser ablation may have a role as an alternative treatment for lentigo maligna among patients in whom standard treatments, such as surgical excision and radiation therapy, are declined or carry significant morbidity.

Treatment of recurrent hepatocellular carcinoma after liver transplantation

Liver transplantation (LT) is a curative treatment for localized hepatocellular carcinoma (HCC), but the recurrence rate after LT is about 10-20%, with a dismal prognosis. Little data exist as to the natural history, treatment outcome and optimal treatment of recurrent HCC after LT. We reviewed various treatment modalities given to patients with recurrent HCC after LT. Among 132 patients who underwent LT for localized HCC, we retrospectively reviewed medical records of 39 of the 132 patients who developed recurrent HCC after LT. We analyzed the clinical outcome of various treatment modalities and treatment-related adverse events. A total of 39 (29%) of the original 132 patients had recurrent HCC, most recurrences (82%) having occurred within 1 year after LT and involved extrahepatic lesions. Only seven patients had recurrent disease limited to the liver. The median overall survival from the initial treatment of all relapsed patients was 6.9 months. There were various initial treatment modalities, namely palliative systemic chemotherapy, trans-catheter arterial chemo-embolization/infusion (TACE/I), radiation therapy (RT), surgical resection and no treatment. The median overall survival was 9.5 months for first-line chemotherapy, including those who had prior local therapy, 6.3 months TACE/I and 6.9 months for RT. Various clinical approaches have been used to treat patients with recurrent HCC after LT in a clinical setting. More effective strategies and clinical guidelines for recurrent HCC following LT must be established.

Acute Esophagitis and Late Lung Toxicity in Concurrent Chemoradiotherapy Trials in Patients with Locally Advanced Non–Small-Cell Lung Cancer: Analysis of the Radiation Therapy Oncology Group (RTOG) Database

Background We analyzed time course and factors associated with acute esophagitis (ES) and late lung toxicity (PN), as well as any association between ES and PN in patients (pts) with non–small-cell lung cancer (NSCLC) treated with concurrent chemoradiation (chemo-RT) on the Radiation Therapy Oncology Group (RTOG) trials. Materials and Methods Multivariable analysis was used to investigate factors associated with ES or PN. Results Patients (n = 528) received standard fractionated (SFX; 63 Gy) or hyperfractionated (HFX; 69.6 Gy) radiation therapy (RT) with cisplatin-based chemotherapy. Grade > 2 ES developed in 75% of pts; Grade > 3 ES, in 34%. Nineteen percent of pts developed ES by the first, 32% by the second, and 33% by the third month (and for Grade > 3 PN, 9% by 6 months, 15% by year 1, and 18% by year 2). Any PN developed in 59% of pts; Grade > 2, in 39%; Grade > 3, in 18%; and lethal PN, in 2%. Grade > 2 PN was associated with increasing RT dose and Grade > 3 PN, with HFX RT. No association was seen with ES. Grade > 3 ES was less likely to occur in non-whites and more likely, in pts treated with HFX RT. Conclusion Most (95%) pts developed ES, and 33% had severe ES, peaking within the first or second month of RT. PN developed in 57% of pts, with 18% experiencing Grade > 3 PN, with most diagnosed by 1 year from RT. No relationship was observed between 1 toxicity (ES or PN) as predictor of the other. HFX RT was associated with more severe PN or ES.

An Adolescent Female With Bulging Abdomen

CLINCAL HISTORY The patient is a 12-year-old Mexican female 3 years postoperative ovarian tumor resection with 1 month of radiation therapy in Mexico. Diagnosis of ovarian tumor was made when she presented with abdominal pain and weight loss. She did well after therapy until 6 months prior to admission, when she developed crampy lower-abdominal pain and epigastric fullness after meals. She had experienced bouts of hematuria and dysuria, and was absent of secondary sex characteristics. She lost 6.8 kg 1 month prior to admission, when she developed nausea and vomiting following intake of solid foods and began taking only liquids.

PSA bounces after brachytherapy HDR and external beam radiation therapy for prostate cancer

Summary Background The serum prostate-specific antigen (PSA) test is the most commonly used method for confirming response of prostate cancer after definitive radiation therapy (RT). PSA levels are expected to decrease after radiotherapy but usually remain detectable. Three consecutive PSA rises above the post-treatment nadir have been defined as biochemical failure by the ASTRO consensus panel [1]. Rising serum PSA concentration after RT does not always indicate treatment failure. Some patients have a temporary PSA spike, usually within 12–30 months of radiation therapy [2–4]. Most PSA bounces have a magnitude of 1.0 ng/mL or less. This observation was first described by Wallner and colleagues in 1997 [5]. Although this phenomenon is a source of anxiety for both the patient and the physician, its relevance to biochemical failure is controversial. Aim To determine the clinical and dosimetric factors that predict prostate-specific antigen (PSA) bouncing following brachytherapy HDR and three-dimensional conformal radiation therapy (3D-CRT) for prostate cancer patients. Materials/Methods The evaluated population consisted of 71 hormone-naive patients with a minimum of 2 years of follow-up and at least 6 post-treatment PSA levels. All patients were treated using 3D-CRT combined with brachytherapy HDR. A bounce was defined as a PSA rise of ≥0.2 ng/mL above the nadir followed by a subsequent 120 decline of ≥0.2 ng/mL. Clinical factors evaluated included: patient age, Gleason score, maximum initial pretreatment PSA value (iPSAmax), clinical stage, prostate volume, median time to PSA nadir, median PSA nadir value and patient follow-up in months. Dosimetric factors evaluated included the percentage of the prostate volume receiving 100% (V100), 150% (V150) and 200% (V200) of the prescribed minimal peripheral dose. Results Statistically significant predictive factors for PSA bounce were age, V100, V150, V200, iPSAmax and median time to PSA nadir. Logistic regression model for multivariate analysis revealed that only age, iPSAmax and V200 were statistically significant predictors for PSA bounce. There were no statistical differences between median nadir among patients who exhibited a PSA bounce and those who did not, but non-bouncers reached PSA nadir earlier than bouncers; median time was 12.1 vs 17.2 months respectively. Conclusion PSA bouncing occurs in approximately one third (1/3) of patients treated with 3D-CRT and brachytherapy HDR. Bouncing is associated with age, higher pretreatment PSA level and increased V200 factor.

PET/CT imaging in recurrent head and neck cancer

PET/CT offers advantages over PET alone, which is limited by poor anatomic localization and CT alone, which provides morphologic data only. Retrospective fusion of separately acquired PET and CT images allows for potential fusion misregistration in the mobile head and neck between imaging sessions. Indications for PET/CT include recurrent neoplasm, tumor surveillance, and staging. This article will focus on recurrent head and neck neoplasm including, head and neck cancer, thyroid cancer, recurrent skull base tumor. PET/CT may change management in facilitating earlier detection of recurrence than is possible with conventional CT or MR imaging, in guiding biopsy, and in detecting second primary sites and distant metastases. Limitations of PET/CT include physiologic uptake, metabolically active tissue, and muscle contraction during uptake phase. PET/CT, however, is better equipped than is PET alone to mitigate these limitations by precisely localizing FDG uptake to anatomic structures. In addition, small lesions (<1 cm) may be below scanner resolution and, therefore, a lower SUV (that is ≤ 3), may suggest neoplasm. Recent treatment may result in false negative findings, especially when PET is performed within 4 months of radiation therapy. Finally, tumors of low metabolic activity (e.g., salivary gland tumors) may be prone to false negative results. In the future, PET/CT imaging will become more useful in staging head and neck cancer with improved scanner resolution. Development of specific tumor markers may allow for tumor-specific ligands that will increase sensitivity to head and neck neoplasia. Treatment targeting for radiation therapy is an application that is likely to become widely used.

Posttreatment imaging of the nasopharynx

Nasopharyngeal carcinoma (NPC) is the most common epithelial tumor of the nasopharynx. Radiation therapy is the mainstay of treatment while surgery or chemotherapy is used in selected patients. NPC usually regresses after 3 months of radiation therapy. Nonetheless, a residual mass may be present following treatment and this does not necessarily indicate viable tumor. Imaging studies are often used in conjunction with clinical examination following treatment. While computed tomography (CT) is widely used due to its greater availability, less expensive, and less time consuming, MR imaging is now becoming the preferred modality. MR imaging is more capable than CT for identifying mature scarring, tumor recurrence and postradiation complications. However, MR imaging cannot reliably demonstrate mucosal recurrence or differentiate tumor recurrence from postradiation tissue changes. Familiarity with the imaging findings of various posttreatment changes, tumor recurrence and postradiation complications is essential for management of NPC. Comparison with previous images or imaging-guided biopsy facilitates definitive diagnosis.

MR IMAGING OF THE BREAST AFTER SURGERY FOR BREAST CANCER

Unenhanced scans, with any sequence, often give limited and unreliable information when trying to distinguish tumor recurrence from scarring. Dynamic scanning very soon after the intravenous injection of Gd-DTPA is the best available method of distinguishing between benign tissue and neoplastic recurrence after conservation treatment for breast cancer. 3-D T1-weighted gradient echo images appear to be the technique of choice, preferably with image subtraction. Rapid and pronounced tissue enhancement is strongly suggestive of tumor recurrence; however, scanning within 6 months of surgery and 9 months of radiation therapy may lead to false-positive results. Benign proliferative disease and recent fat necrosis may also mimic cancer on dynamic contrast enhanced MR images. The indications for MR imaging after tylectomy and radiotherapy are findings that are equivocal or suspicious of neoplastic recurrence on clinical examination, mammography, or ultrasound, often on a combination of these modalities. Typical clinical findings are a mass or induration at the site of surgery, a mass lesion with spiculated and irregular outline on mammography, or variable echogenicity on ultrasound. The development of these appearances on sequential examination is particularly suggestive of recurrence. When microcalcification is the only finding of a carcinoma on mammography after treatment for breast cancer, contrast enhancement is consistently present.