Nodal Irradiation In Patients Research Articles

The Role of Adjuvant Radiotherapy in the Treatment of Breast Cancer.

The role of postmastectomy radiotherapy and regional nodal irradiation after radical mastectomy is defined in high-risk patients with locally advanced tumors, positive margins, and unfavorable biology. The benefit of postmastectomy radiotherapy in intermediate-risk patients (T3N0 tumors) remains a matter of controversy. It has been demonstrated that radiotherapy after breast-conserving surgery lowers the locoregional recurrence rate compared with surgery alone and improves the overall survival rate. In patients with four or more positive lymph nodes or extracapsular extension, regional lymph node irradiation is indicated regardless of the surgery type (breast-conserving surgery or mastectomy). Despite the consensus that patients with more than three positive lymph nodes should be treated with radiotherapy, there is controversy regarding the recommendations for patients with one to three involved lymph nodes. In patients with N0 disease with negative findings on axillary surgery, there is a trend to administer regional lymph node irradiation in patients with a high risk of recurrence. In patients treated with neoadjuvant systemic therapy and mastectomy, adjuvant radiotherapy should be administered in cases of clinical stage III and/or ≥ypN1. In patients treated with neoadjuvant systemic therapy and breast-conserving surgery, postoperative radiotherapy is indicated irrespective of pathological response.

Benefit of postoperative regional nodal irradiation in patients receiving preoperative systemic therapy with docetaxel/carboplatin/trastuzumab/pertuzumab for HER2-positive breast cancer

AimThe role of regional nodal irradiation (RNI) after preoperative systemic treatment (PST) with targeted therapy for HER2-positive breast cancer remains uncertain. This study aimed to investigate the impact of RNI on locoregional recurrence (LRR) and disease-free survival (DFS) outcomes after docetaxel/carboplatin/trastuzumab/pertuzumab (TCHP) for PST. MethodsWe retrospectively analyzed 255 patients who were treated with six cycles of TCHP between 2016 and 2019. The patients were divided into four groups based on clinical nodal involvement: group A, with no nodal disease; group B, with axillary lymph node (AXL) level I; group C, with AXL level I with II/III; and group D, with supraclavicular or internal mammary nodes. ResultsThe RNI group had more advanced nodal disease (C/D) than the no RNI group (56.9 % vs. 6.8 %). With a median follow-up of 51.3 months, there were two (0.8 %), three (1.2 %), and 15 (5.9 %) local, regional, and distant metastases, respectively. LRR did not differ significantly according to the RNI (2.6 % vs. 1.0 %, p = 0.651). Group D had the most frequent distant metastases (17.5 %; p = 0.005). The 4-year DFS rate was 92.7 %, and DFS did not improve significantly after RNI (p = 0.074). When stratified by clinical nodal groups and pathological axillary response, RNI had no effect on LRR/DFS outcomes. ConclusionWith a rare incidence of LRR, RNI did not significantly affect LRR or DFS in patients with HER2-positive breast cancer after with PST-TCHP. However, intensive systemic treatment is required for advanced diseases (C/D). Selective de-intensified RNI and intensified systemic treatment should be investigated in future studies.

Thyroid function post supraclavicular lymph node irradiation in patients with breast cancer

INTRODUCTION: In East Africa, the estimated incidence of breast cancer is second only to cervical cancer. Supraclavicular irradiation post-modified mastectomy is crucial to breast cancer management, as it improves local control and overall survival. However, this is associated with adverse effects, including hypothyroidism (HT), which is usually under-reported. This study aim was to evaluate radiation-induced thyroid gland functional changes following treatment of supraclavicular lymph nodes in breast cancer patients.METHODS: This was a prospective descriptive study of patients with breast cancer from May 1, 2017, to May 30, 2018. Pre and post-treatment TSH, fT4, and fT3 values were compared using a Wilcoxon signed-rank test.RESULTS: A total of 42 patients were recruited for this study, with a mean age of 55.7 years (32-71). The mean baseline TSH level was 2.90 (±6.37), with a normal range of 0.27-4.2 uIU/mL. The mean T4 and T3 level were 15.77 (±4.83), with normal ranges of 10.16-22 pmol/l for T4, and 3.46 (±6.22), with a normal range of 1.06-3.3 nmol/l for T3. A Wilcoxon signed-rank test indicated that there was a statistically significant increase in mean TSH levels over baseline when measured at three, six-, and nine-months post-treatment, with p-values of 0.0047, 0.0002, and <0.0001, respectively. In total, four patients (10%) had thyroid function tests outside the normal ranges. Zero patients developed clinical HT during the time period studied.CONCLUSION: As hypothesized, supraclavicular radiation led to subclinical HT, but the incidence of clinical HT over time remains unknown.

Incidental nodal irradiation in patients with esophageal cancer undergoing (chemo)radiation with 3D-CRT or VMAT

The extent of elective nodal irradiation (ENI) in patients undergoing definitive chemoradiotherapy (dCRT) for esophageal squamous cell carcinoma (ESCC) remains unclear. The aim of this dosimetric study was to evaluate the extent of incidental nodal irradiation using modern radiation techniques. A planning target volume (PTV) was generated for 30 patients with node-negative esophageal carcinoma (13 cervical/upper third, 7 middle third, 10 lower third/abdomen). Thereby, no elective nodal irradiation (ENI) was intended. Both three-dimensional conformal radiotherapy (3D-CRT) and volumetric-modulated arc therapy (VMAT) treatment plans (50 Gy in 25 fractions) were calculated for all patients. Fifteen nodal stations were contoured according to the definitions of the AJCC and investigated in regard to dosimetric parameters. Compared to 3D-CRT, VMAT was associated with lower dose distribution to the organs at risk (lower Dmean, V20 and V30 for the lungs and lower Dmean and V30 for the heart). For both techniques, the median Dmean surpassed 40 Gy in 12 of 15 (80%) nodal stations. However, VMAT resulted in significantly lower Dmeans and equivalent uniform doses (EUD) compared to 3D-CRT for eight nodal stations (1L, 2L, 2R, 4L, 7, 8L, 10L, 15), while differences did not reach significance for seven nodal station (1R, 4R, 8U, 8M, 10R, 16). For dCRT of ESCC, the use of VMAT was associated with significantly lower median (incidental) doses to eight of 15 regional lymph node areas compared to 3D-CRT. However, given the small absolute differences, these differences probably do not impair (regional) tumor control rates.

Necessity of Pelvic Lymph Node Irradiation in Patients with Recurrent Prostate Cancer after Radical Prostatectomy in the PSMA PET/CT Era: A Narrative Review.

The main prostate cancer (PCa) treatments include surgery or radiotherapy (with or without ADT). However, none of the suggested treatments eliminates the risk of lymph node metastases. Conventional imaging methods, including MRI and CT scanning, are not sensitive enough for the diagnosis of lymph node metastases; however, the novel imaging method, PSMA PET/CT scanning, has provided valuable information about the pelvic LN involvement in patients with recurrent PCa (RPCa) after radical prostatectomy. The high sensitivity and negative predictive value enable accurate N staging in PCa patients. In this narrative review, we summarize the evidence on the treatment and extent of radiation in prostate-only or whole-pelvis radiation in patients with positive and negative LN involvement on PSMA PET/CT scans.

Postoperative Radiotherapy Involving Tumor Bed with or without Elective Nodal Irradiation in Patients with Locally Advanced Esophageal Squamous Cell Carcinoma: A Multi-Center, Prospective Randomized Phase II Trial

<h3>Purpose/Objective(s)</h3> Postoperative radiotherapy (PORT) is necessary in patients with locally advanced esophageal squamous cell carcinoma (LA-ESCC) who have not received neoadjuvant chemoradiotherapy (NCRT). However, the optimal clinical target volume has under hot debate for decades. This clinical trial aims to estimate the optimal radiation volume of PORT for patients with LA-ESCC. <h3>Materials/Methods</h3> Patients confirmed LA-ESCC (pT3-4N0-3M0) after esophagectomy without NCRT were randomly assigned to either large-field irradiation (LFI, primary lesion and lymph node tumor bed plus elective nodal irradiation) arm or small-field irradiation (SFI, primary lesion and lymph node tumor bed alone) arm with a ratio of 1:1, stratified by T stage and number of lymph node metastasis (LN<3 vs LN≥3). The primary endpoint was disease-free survival (DFS); secondary endpoints included overall survival (OS), adverse events and first failure patterns. The log-rank test was used to estimate the survival differences. The Chi-square test was used to compare adverse events and failure patterns between groups. <h3>Results</h3> In the intention-to-treat analysis, a total of 401 patients with LA-ESCC were randomly assigned to the LFI arm (n=210) and the SFI arm (n=191). With a median follow-up of 38.9 months, the DFS and OS rates of the whole population at 1-year and 3-year were 72.9% and 51.8%, 88.4% and 61.7%, respectively, which were close to patients who received NCRT. Patients in the two irradiation arms had similar DFS (LFI vs SFI, 46.6 vs 48.1 months; HR=0.92, 95% CI, 0.68-1.25; p=0.60). The difference of OS between the two arms did not reach significant (NR vs 73.5 months, HR=0.82, 95% CI, 0.59-1.14; p=0.26). The locoregional recurrence-free survival (HR=0.57, 95% CI 0.35-0.92; p=0.022) and the failure patterns (p=0.021) between two arms were significantly different. Locoregional failure occurred in 12.9% and 20.4% of patients in the LFI arm and SFI arm, respectively; The differences of distant diseases and distant metastasis-free survival of patients between the two arms had no significance. The most frequent toxicity was grade 2 esophagitis (LFI vs SFI, 22.9% vs 16.8%). Grade 3 acute adverse events occurred in 6.7% and 2.6% of patients in the LFI and SFI arms, respectively. No toxicity of grade 4 or 5 was recorded in this study. <h3>Conclusion</h3> Both postoperative irradiation fields are alternatives for LA-ESCC patients without NCRT with the promising survival outcomes comparable to CROSS study. Patients in the LFI arm achieved better locoregional control with a safety profile consistent with the SFI arm.

Whole breast radiotherapy in cN0 early breast cancer patients with pathological sentinel lymph nodes (pN1mic, pN1a) without axillary dissection: preliminary results of the observational LISEN trial

PurposeAxillary management remains unclear when sentinel lymph node (SLN) results are positive in cN0 patients with breast cancer (BC). The trial ACOSOG Z0011 represented a revolution with axillary lymph node dissection (ALND) omission in SLN+ patients, despite critiques regarding non-uniformity of radiation fields. We conducted an observational study (LISEN) where whole breast radiotherapy (WBRT) was planned with tangential fields without nodal irradiation in patients eligible for the Z0011 trial.MethodsInclusion criteria were female patients with histologically proven BC, cT1-2cN0, planned conservative surgery, no neoadjuvant therapy. Patients were stratified into two groups: micrometastatic (pN1mic, group 1) and macrometastatic (pN1a, group 2) lymph nodes. Tangential field WBRT was mandatory. Clinical outcomes were analysed, measured from surgery until the first event.ResultsIn all, 199 patients underwent conservative surgery and SLN biopsy; 133 patients meeting criteria were analysed: 41 patients (30.8%) pN1mic and 92 (69.2%) pN1a. The 5‑year disease-free survival (DFS) was 95.0% (85.9–100%) in group 1 and 93.0% (86.3–100.0%) in group 2 (p = 0.78). Overall survival (OS) was 100% (100–100%) in group 1 and 97.4% (92.4–100%) in group 2 (p = 0.74). For the whole cohort DFS and OS were 93.6% (88.2–99.4%) and 96.9% (91.5–100.0%), respectively. For groups 1 and 2, the 5‑year outcomes were 5.0% (0.0–14.4%) and 2.3% (0.0–6.1%) for local recurrence (p = 0.51), and 6.2% (0.0–17.4%) and 7.0% (0.0–13.7%) for distant metastasis (p = 0.61), respectively. In group 1, regional recurrence (RR) and local regional recurrence (LRR) were 5.0% (0.0–14.1%; p = 0.13). In group 2, RR and LRR were 0.0% (0.0–0.0%).ConclusionOur results showed good regional control in patients who met the Z0011 trial criteria. WBRT, without nodal surgery or RT, avoiding axillary morbidity, seems to be a good choice.

Assessment of toxicity of elective pelvic lymph node irradiation in patients with high-risk prostate cancer

<h3></h3> Применение сочетанной лучевой терапии (СЛТ) позволяет повысить эффективность лечения рака предстательной железы (РПЖ) у больных высокого онкологического риска. Остается неясным, имеет ли какое-либо преимущество включение в область облучения регионарных лимфоколлекторов с профилактической целью, поскольку эскалация дозы, как и увеличение объема облучения, сопряжены с высоким риском развития лучевых осложнений, которые, как известно, негативно влияют на качество жизни пациентов. <h3>ЦЕЛЬ ИССЛЕДОВАНИЯ</h3> Изучение влияния профилактического облучения лимфатических узлов малого таза на непосредственные результаты лечения, а также на качество жизни больных РПЖ высокого онкологического риска. <h3>МАТЕРИАЛ И МЕТОДЫ</h3> В период с ноября 2019 по январь 2021 г. в МРНЦ им. А.Ф. Цыба 60 больным РПЖ в объеме гормонолучевого лечения выполнена СЛТ. Пациенты были рандомизированы в две группы: с облучением регионарных лимфоколлекторов (<i>n</i>=32) и без их облучения (<i>n</i>=28). На первом этапе лечения проведен курс конформной дистанционной лучевой терапии до суммарной очаговой дозы 46 Гр. На втором этапе однократно выполнен сеанс высокомощностной брахитерапии (¹⁹²Ir) в разовой очаговой дозе 15 Гр. <h3>РЕЗУЛЬТАТЫ</h3> Развитие острого лучевого цистита 1-й степени тяжести отмечено у 11 (34,4%) больных 1-й группы и у 12 (42,9%) пациентов 2-й (<i>p</i>=0,83). Во 2-й группе у 1 (3,6%) пациента отмечен острый лучевой цистит 2-й степени тяжести. Острый лучевой ректит 1-й степени тяжести наблюдался у 13 (40,6%) пациентов 1-й группы и у 3 (10,7%) 2-й (<i>p</i>=0,01) группы. <h3>ЗАКЛЮЧЕНИЕ</h3> Предварительный анализ исследования показал увеличение частоты развития лучевых реакций в группе пациентов с профилактическим облучением регионарных лимфоколлекторов.

Optimal Target Delineation and Treatment Techniques in the Era of Conformal Photon and Proton Breast and Regional Nodal Irradiation

PurposeRegional nodal irradiation improves disease-free and distant disease–free survival in patients with high-risk breast cancer (BC). Trials demonstrating this used 2- or 3-dimensional conformal radiation therapy (2-dimensional or 3-dimensional [3D] conformal radiotherapy [CRT]) fields based on bony anatomy. Modern volumetric-modulated arc therapy (VMAT) and pencil beam scanning proton therapy (PBSPT) may underdose regional nodes (RNs) not contoured but covered by 3D CRT. Multiple atlases guide modern treatment planning. This study addresses the risk of underdosing when relying on published atlases and treating with 3D CRT, VMAT, and PBSPT. Methods and MaterialsTargets per the Radiation Therapy Oncology Group (RTOG), European Society for Radiotherapy and Oncology (ESTRO), and Radiotherapy Comparative Effectiveness Consortium (RADCOMP) atlases were contoured on a representative patient CT scan. 3D CRT plans based on anatomic borders and VMAT and PBSPT plans for each set of target volumes were generated. Positron emission tomography/computed tomography (PET/CT) scans were reviewed. CT-positive and 18F-fluorodeoxyglucose (18F-FDG)–avid RNs (n = 389) were mapped from 102 patients with locally advanced (n = 51; median 2; range, 1-8 nodes) and metastatic (n = 51; median 4; range, 1-19 nodes) BC: axillary (AX; n = 284), supraclavicular (SCV; n = 60), and internal mammary nodal (IMN; n = 45). 18F-FDG-avid RNs falling within the 95% isodose line were considered adequately covered. Results3D CRT plans provided excellent RN coverage. Low AX nodes were covered (≥99%) in all plans. Underdosing of 18F-FDG–avid RNs falling in the high AX (78%-92%), SCV (52%-75%), and IMN (84%-89%) volumes was observed following the RTOG and ESTRO atlases for VMAT and PBSPT plans. Use of the RADCOMP atlas provided coverage of these areas (89%-100%) with slightly increased heart and lung doses. Atlas guided VMAT/PBSPT plans provided cumulative nodal coverage as follows: ESTRO (89%/88%), RTOG (93%/91%), and RADCOMP (98%/96%). ConclusionsVMAT and PBSPT for regional nodal irradiation in patients with high-risk BC risks underdosage in the high AX, SCV, and IMN nodal regions unless comprehensive target delineation is performed.

Late-term Effects of Hypofractionated Chest Wall and Regional Nodal Irradiation in Patients With Breast Cancer

Late-term Effects of Hypofractionated Chest Wall and Regional Nodal Irradiation in Patients With Breast Cancer

Variability in lymph node irradiation in patients with breast cancer-results from amulti-center survey in German-speaking countries.

Lymph node irradiation in breast cancer has gained complexity due to recently published studies and technical innovations which then led to changes in international guidelines. We sought to determine real-time variability in lymph node irradiation in clinical practice in German-speaking countries. The Department of Radiation Oncology, Technical University of Munich (TUM), developed an online-based questionnaire focusing on the indication, target definition, and treatment technique of lymph node irradiation in patients with breast cancer. The invitation to participate in the survey was sent to members of the German Society of Radiation Oncology (DEGRO) by e‑mail. The results of the survey were exported from the online platform into SPSS for adetailed analysis. In total, 100physicians completed the questionnaire between 05/2019 and 06/2019. Despite the existence of several treatment and contouring guidelines, we observed large variability of lymph node irradiation: The guideline recommendation for internal mammary irradiation is not consistently implemented in clinical practice and irradiation of the axilla after positive SLNB (sentinel lymph node biopsy) or ALND (axillary lymph node dissection) is handled very differently. Furthermore, in most clinics, the ESTRO (European Society for Therapeutic Radiology and Oncology) contouring consensus is not used, and PTV (planning target volume) definitions and margins vary considerably. Further clinical studies should be performed with aparticular focus on radiotherapy for lymphatic drainage to support and amend the existing guidelines. These studies should establish amore standardized treatment of the lymph node regions in clinical practice. Quality assurance should enforce broad implementation of consensus recommendations.

Stereotactic Body Radiation Therapy for Cholangiocarcinoma: Optimizing Locoregional Control With Elective Nodal Irradiation

PurposeTo review our institutional experience of treating cholangiocarcinoma using stereotactic body radiation therapy (SBRT). Methods and MaterialsA total of 40 patients with intrahepatic (n = 25) or perihilar (n = 15) cholangiocarcinoma treated with SBRT were retrospectively reviewed. SBRT was delivered in 1 to 5 fractions with median dose of 40 Gy. Competing risk analysis was used to estimate cumulative incidence of local in-field, local out-of-field, regional, and distant failure. Kaplan-Meier and log-rank tests were used to calculate overall survival (OS). Toxicity was scored using Common Terminology Criteria for Adverse Events, version 4.0. ResultsThe median follow-up time was 18 months. The 1-year incidence of local in-field, local out-of-field, regional, and distant failure was 8%, 23%, 13%, and 22%, respectively. Median OS was 23 months and 1- and 2-year OS rates were 69% and 39%, respectively. Patients with perihilar tumors had a 1-year incidence of regional failure of 24% and worse OS (P = .013). Patients with regional failure were more likely to develop distant metastases, 32% versus 19% at 1 year (P = .11). Acute grade 3 + hepatobiliary toxicity developed in 15 patients (36%). ConclusionsIn this series of cholangiocarcinoma patients treated with definitive SBRT, patterns of failure reveal that regional failures are not insignificant, particularly for perihilar tumors. Elective nodal irradiation of regional lymphatics should be considered when using SBRT. A prospective study of elective nodal irradiation in patients with perihilar tumors would further clarify whether this approach improves outcomes without increasing hepatobiliary toxicity.

The Potential Role of Intensity-modulated Proton Therapy in the Regional Nodal Irradiation of Breast Cancer: A Treatment Planning Study

AimsTo investigate the role of intensity-modulated proton therapy (IMPT) for regional nodal irradiation in patients with breast carcinoma in comparison with volumetric-modulated arc therapy (VMAT). Materials and methodsA cohort of 20 patients (10 in the breast-conserving surgery group and 10 post-mastectomy patients with tissue expander implants) was investigated. Proton plans were also computed using robust optimisation methods. Plan quality was assessed by means of dose–volume histograms and scored with conventional metrics. Estimates of the risk of secondary cancer induction (excess absolute risk, EAR) were carried out, taking into account fractionation, repopulation and repair. ResultsConcerning target coverage, the data proved a substantial equivalence of VMAT and IMPT: for example, coverage for the 50 Gy target, expressed in terms of V98%, was 47.8 ± 0.4, 47.6 ± 0.4, 47.3 ± 0.8, consistent with the objective of 47.5 Gy, for post-mastectomy patients for the three groups of patients. Also, the conformality of the dose distributions was similar for the two techniques, about 1.1, without statistically significant differences. Organ at risk planning aims were achieved for all structures for both techniques. The mean dose to the ipsilateral lung was 10.8 ± 1.1, 6.2 ± 0.8, 7.2 ± 1.0; for the contralateral lung was 3.2 ± 0.7, 0.3 ± 0.2, 0.4 ± 0.2; for the contralateral breast was: 3.1 ± 0.7, 0.3 ± 0.3 and 0.3 ± 0.3, whereas it was 3.9 ± 0.9, 0.4 ± 0.3 and 0.5 ± 0.5, respectively, for the heart for VMAT, IMPT and robust IMPT plans over the whole group of patients. Robust optimisation affected the near-to-maximum dose values for contralateral lung and breast, the mean dose for the heart and ipsilateral lung, with a deterioration ranging from 20 to 40% of the nominal value of IMPT plans (e.g. from 8.1 ± 6.4 to 11.4 ± 8.8 for the heart compared with 16.2 ± 5.2 for the VMAT plans). The numerical values of EAR per 10 000 patient-years were about one order of magnitude higher for VMAT than for IMPT for contralateral structures: 11.66 ± 2.01, 0.89 ± 0.80, 0.98 ± 0.77 for the contralateral breast and the three groups of plans, respectively; 14.31 ± 2.75, 1.42 ± 0.80, 1.78 ± 0.87 for the contralateral lung; and 34.86 ± 2.64, 18.85 ± 2.15, 20.98 ± 2.35 for the ipsilateral lung. ConclusionIMPT with or without robust optimisation seems to be a potentially promising approach for the radiation treatment of breast cancer when nodal volumes should be irradiated. This was measured in terms of dosimetric advantage and predicted clinical benefit. In fact, the significant reduction in estimated EAR could add further clinical value to the dosimetric sparing of the organs at risk achievable with IMPT.

124P - Late-term effects in the arm and shoulder with hypofractionated regional nodal irradiation in patients with breast cancer

124P - Late-term effects in the arm and shoulder with hypofractionated regional nodal irradiation in patients with breast cancer

P184 - Thyroid function post supraclavicular lymph node irradiation in patients with breast cancer

P184 - Thyroid function post supraclavicular lymph node irradiation in patients with breast cancer

Role of Elective Nodal Irradiation in Patients With ypN0 After Neoadjuvant Chemotherapy Followed by Breast-Conserving Surgery (KROG 16-16)

BackgroundGiven the lack of established indications for elective nodal irradiation (ENI) in ypN0 patients after neoadjuvant chemotherapy (NAC) and breast-conserving surgery (BCS), we set out to investigate the role of ENI in ypN0 patients according to subtype and pathologic complete remission (pCR) status. Patients and MethodsWe analyzed 261 patients who received NAC followed by BCS and adjuvant radiotherapy in 13 institutions of the Korean Radiation Oncology Group from 2005 to 2011. The tumors were classified into one of 3 subtypes: luminal (estrogen receptor positive or progesterone receptor positive and HER2 negative), HER2 (HER2 positive), or triple negative (estrogen receptor, progesterone receptor, and HER2 negative). We compared locoregional control (LRC), disease-free survival (DFS), and overall survival (OS) according to ENI in different subgroups generated by the subtype and pCR statuses. ResultsIn all patients, the 5-year LRC, DFS, and OS rates were 96.0%, 91.0%, and 96.8%, respectively. In all patients, axillary lymph node dissection was found to be the only favorable factor for LRC (P = .023) and DFS (P = .001). Age ≥ 50 years (P = .027), negative resection margin (P = .002), and axillary lymph node dissection (P = .002) were all favorable factors for OS. ENI did not affect LRC, DFS, or OS. Subgroup analysis by tumor subtype and pCR showed that ENI was not associated with greater LRC or DFS in any subgroups. ConclusionIn ypN0 patients after NAC and BCS, ENI did not improve LRC or survival, regardless of subtype or primary tumor response. This result should be verified through larger prospective trials.

Phase 1-2 Study of Stereotactic Ablative Radiotherapy Including Regional Lymph Node Irradiation in Patients With High-Risk Prostate Cancer (SATURN): Early Toxicity and Quality of Life

Five-fraction stereotactic ablative radiation therapy appears to be gaining popularity in treatment of prostate cancer, but it has not been extensively tested in the context of pelvic radiation. The objective of this prospective prostate and pelvic SABR study is to report the acute toxicity, late toxicity, and quality of life (QoL) after study completion. A phase 1/2 study was conducted for patients with high-risk prostate cancer. Radiation therapy was planned to deliver 25 Gy to pelvis and seminal vesicles (SV) and a simultaneous integrated boost (SIB) of up to 40 Gy to the prostate in 5 fractions, weekly, over 29 days. Androgen deprivation therapy was used for 12 to 18months. Common Terminology Criteria for Adverse Events version 3.0 was used to assess worst acute and late toxicities. QoL data was captured using the Expanded Prostate Cancer Index Composite questionnaire (EPIC). Thirty patients completed the planned treatment with a median follow-up of 25.7months (range, 18.5-30.7months). The following "worst" acute and late toxicities were observed: grade 2 genitourinary toxicity, 46.7% and 52%, respectively; grade 2 gastrointestinal toxicity, 3.3% and 32%, respectively. No grade 3 or higher toxicities were noted. Mean (95% confidence interval) EPIC urinary QoL scores were 86.6 (81.9-91.3), 87.1 (81.4-92.6), and 87.9 (80.1-95.7) at baseline, 3months and 24months; bowel scores were 94.1 (91.3-97.0), 93.2 (89.1-97.2), and 92.4 (87.7- 97.1), respectively. This gantry-based novel fractionation schedule incorporating pelvic radiation for high-risk prostate cancer in combination with androgen deprivation therapy is feasible and well tolerated.

Failure pattern of elective nodal irradiation for esophageal squamous cell cancer treated with neoadjuvant chemoradiotherapy.

To analyze the failure pattern and clinical efficacy of elective nodal irradiation in patients with esophageal squamous cell carcinoma who received neoadjuvant chemoradiotherapy. We retrospectively analyzed 173 esophageal squamous cell carcinoma patients who received neoadjuvant chemoradiotherapy including elective nodal irradiation from 2002 to 2015. Failure pattern, survival and recurrence sites were analyzed. For patients with regional recurrences, the recurrence sites were analyzed in relation to an imaginary field of involved field irradiation. After a median follow-up of 55.5 months, 58 patients (33.5%) developed recurrences. Among 22 patients with regional recurrences, infield failure occurred in 19 patients (86.4%) and outfield failure occurred in 3 patients (13.6%), of whom only 1 patient had an outfield failure without synchronous distant metastasis. Compared with the involved field irradiation field, 6 patients' failure sites (27.3%) were located in the involved field irradiation field and 13 patients' failure sites (59.1%) were out of the involved field irradiation field but within the elective nodal irradiation field. Since only a minority of patients had outfield regional recurrences, neoadjuvant chemoradiotherapy with elective nodal irradiation yields satisfactory infield control. More than half of the regional recurrences occurred within the elective nodal irradiation field but out of the involved field irradiation field. Prospective evaluation of whether elective nodal irradiation could lead to an improved survival outcome is necessary.

Long-Term Impact of Regional Nodal Irradiation in Patients With Node-Positive Breast Cancer Treated With Neoadjuvant Systemic Therapy

The impact of regional nodal irradiation (RNI) on locoregional recurrence (LRR) and any disease recurrence (DR) in women with node-positive breast cancer who receive neoadjuvant systemic therapy (NAT) is unknown. The impact of RNI on LRR and DR was estimated with the cumulative incidence method in 1289 women with stage II to III breast cancer with cytologically confirmed axillary metastases who received NAT between 1989 and 2007. Multicovariate Cox regression analysis was performed to examine the effect of RNI after accounting for other predictive and prognostic variables. The median follow-up after definitive surgery was 10.2years. Axillary pathologic complete response (pCR) was observed in 368 of 1289 patients (28.5%). On univariate analysis, axillary pCR reduced 10-year LRR risk from 9.7% to 4.8% (P=.006) and DR risk from 43.0% to 17.0% (P<.001). RNI was administered to 1080 of 1289 patients (83.8%). On univariate analysis, RNI did not affect 10-year LRR risk (no RNI, 9.4%; RNI, 8.1%; P=.62) or DR risk (no RNI, 31.3%; RNI, 36.5%; P=.16). On multicovariate analysis, RNI significantly reduced the risk of LRR (hazard ratio, 0.497; 95% confidence interval [CI], 0.279-0.884; P=.02) and DR (hazard ratio, 0.731; 95% CI, 0.541-0.988; P=.04) and showed a particularly strong reduction in risk of DR in patients with HER2+ disease who received trastuzumab (hazard ratio, 0.237; 95% CI, 0.109-0.517; P=.0003). A nomogram to predict 10-year LRR risk with and without RNI has been generated to assist clinicians in individualizing treatment decisions based on patient and disease characteristics and response to NAT. Adjuvant RNI reduces risk of LRR and DR in patients with breast cancer with axillary metastases who receive NAT across subtypes and particularly decreases the risk of DR in HER2+ breast cancer treated with trastuzumab. Enrollment on the National Surgical Adjuvant Breast and Bowel Project B-51/Radiation Therapy Oncology Group 1304 protocol is encouraged to help determine whether RNI can be omitted in patients with axillary pCR to NAT.

Retrospective Audit of Internal Mammary Nodal Irradiation in Patients of Carcinoma Breast Treated with Helical TomoTherapy

Retrospective Audit of Internal Mammary Nodal Irradiation in Patients of Carcinoma Breast Treated with Helical TomoTherapy