Postoperative External Beam Radiotherapy Research Articles

Unraveling the efficacy network: A network meta-analysis of adjuvant external beam radiation therapy methods after hepatectomy.

Primary liver cancer is a malignant tumor with a high recurrence rate that significantly affects patient prognosis. Postoperative adjuvant external radiation therapy (RT) has been shown to effectively prevent recurrence after liver cancer resection. However, there are multiple RT techniques available, and the differential effects of these techniques in preventing postoperative liver cancer recurrence require further investigation. To assess the advantages and disadvantages of various adjuvant external RT methods after liver resection based on overall survival (OS) and disease-free survival (DFS) and to determine the optimal strategy. This study involved network meta-analyses and followed the PRISMA guidelines. The data of qualified studies published before July 10, 2023, were collected from PubMed, Embase, the Web of Science, and the Cochrane Library. We included relevant studies on postoperative external beam RT after liver resection that had OS and DFS as the primary endpoints. The magnitudes of the effects were determined using risk ratios with 95% confidential intervals. The results were analyzed using R software and STATA software. A total of 12 studies, including 1265 patients with hepatocellular carcinoma (HCC) after liver resection, were included in this study. There was no significant heterogeneity in the direct paired comparisons, and there were no significant differences in the inclusion or exclusion criteria, intervention measures, or outcome indicators, meeting the assumptions of heterogeneity and transitivity. OS analysis revealed that patients who underwent stereotactic body radiotherapy (SBRT) after resection had longer OS than those who underwent intensity modulated radiotherapy (IMRT) or 3-dimensional conformal RT (3D-CRT). DFS analysis revealed that patients who underwent 3D-CRT after resection had the longest DFS. Patients who underwent IMRT after resection had longer OS than those who underwent 3D-CRT and longer DFS than those who underwent SBRT. HCC patients who undergo liver cancer resection must consider distinct advantages and disadvantages when choosing between SBRT and 3D-CRT. IMRT, a RT technique that is associated with longer OS than 3D-CRT and longer DFS than SBRT, may be a preferred option.

Disease Control and Toxicity Outcomes after Intraoperative HDR Brachytherapy for Neck Recurrences in Patients Previously Irradiated Head and Neck Cancer

Despite recent advances in local and systemic therapies for head and neck squamous cell carcinomas (HNSCC), the most common types of treatment failure remain local and regional. Patients with HNSCC also have a higher risk of developing secondary head and neck tumors due to a field cancerization phenomenon. Treatment of these recurrences poses a challenge, particularly in patients having previously received full dose external beam radiotherapy (EBRT) to the head and neck region. This study evaluates the clinical outcomes of intraoperative Harrison-Anderson-Mick applicator (HAM) HDR brachytherapy (BT) after salvage neck dissection for neck recurrences in patients previously irradiated for HNSCC. All patients having received HAM BT for HNSCC neck recurrences at a single institution were identified. Demographic, treatment, disease control and toxicity data were collected retrospectively. Toxicity was graded as per Common Terminology Criteria for Adverse events version 5. The Kaplan Meier method was used to assess overall survival (OS) and ipsilateral regional control (IRC) from the time of HAM BT. Nineteen patients with regional recurrence of HNSCC were treated with HAM BT Ir-192 between July 2006 and June 2022, with a median follow-up for survival of 51.4 months (range: 2.5-186.7). The median BT dose was 12.5 Gy delivered intraoperatively at 5 mm tissue depth/1 cm from source. Fifteen patients (78.9%) also received postoperative EBRT to a median dose of 46 Gy in 23 fractions and 13 (68.4%) received systemic therapy. Six patients (31.6%) developed ipsilateral neck recurrences (4 who had adjuvant EBRT and 2 who did not), 2 patients had primary site recurrences and 5 patients developed distant metastases. In terms of acute toxicity, 4 patients had grade 3 dysphagia requiring feeding tube (FT) placement and one patient required surgical intervention for wound necrosis. In terms of late toxicity, 2 additional patients required FT placement and 1 was able to have it removed. No grade 4+ late toxicities were noted. The IRC at the site of HAM BT at 1 year was 71.5% and 63.6% at 5 years. The 1-year OS was 81.3% and 5-year OS was 40.9%. Intraoperative HAM BT resulted in favorable rates of IRC with acceptable toxicity in the reirradiation setting for HNSCC.

ESTRO-ACROP recommendations for evidence-based use of androgen deprivation therapy in combination with external-beam radiotherapy in prostate cancer

Background and purposeThere is no consensus concerning the appropriate use of androgen deprivation therapy (ADT) during primary and postoperative external-beam radiotherapy (EBRT) in the management of prostate cancer (PCa). Thus, the European Society for Radiotherapy and Oncology (ESTRO) Advisory Committee for Radiation Oncology Practice (ACROP) guidelines seeks to present current recommendations for the clinical use of ADT in the various indications of EBRT. Material and methodsA literature search was conducted in MEDLINE PubMed that evaluated EBRT and ADT in prostate cancer. The search focused on randomized, Phase II and III trials published in English from January 2000 to May 2022. In case topics were addressed in the absence of Phase II or III trials, recommendations were labelled accordingly based on the limited body of evidence. Localized PCa was classified according to D’Amico et al. classification in low-, intermediate and high risk PCa. The ACROP clinical committee identified 13 European experts who discussed and analyzed the body of evidence concerning the use of ADT with EBRT for prostate cancer. ResultsKey issues were identified and are discussed: It was concluded that no additional ADT is recommended for low-risk prostate cancer patients, whereas for intermediate- and high-risk patients four to six months and two to three years of ADT are recommended. Likewise, patients with locally advanced prostate cancer are recommended to receive ADT for two to three years and when ≥ 2 high-risk factors (cT3-4, ISUP grade ≥ 4 or PSA ≥ 40 ng/ml) or cN1 is present ADT for three years plus additional Abiraterone for two years is recommended. For postoperative patients no ADT is recommended for adjuvant EBRT in pN0 patients whereas for pN1 patients adjuvant EBRT with long-term ADT is performed for at least 24 to 36 months. In the setting of salvage EBRT ADT is performed in biochemically persistent PCa patients with no evidence of metastatic disease. Long-term ADT (24 months) is recommended in pN0 patients with high risk of further progression (PSA ≥ 0.7 ng/ml and ISUP grade group ≥ 4) and a life expectancy of over ten years, whereas short-term ADT (6 months) is recommended in pN0 patients with lower risk profile (PSA < 0.7 ng/ml and ISUP grade group 4). Patients considered for ultra-hypofractionated EBRT as well as patients with image based local recurrence within the prostatic fossa or lymph node recurrence should participate in appropriate clinical trials evaluating the role of additional ADT. ConclusionThese ESTRO-ACROP recommendations are evidence-based and relevant to the use of ADT in combination with EBRT in PCa for the most common clinical settings.

Long-term Outcomes of Diffuse or Recurrent Tenosynovial Giant Cell Tumor Treated with Postoperative External Beam Radiation Therapy

Tenosynovial giant cell tumor (TGCT) is a rare proliferative disorder of synovial membrane that previously was known as pigmented villonodular synovitis. Primary treatment involves surgical resection; however, complete removal of all disease involvement is difficult to achieve. Radiation may be useful to reduce the risk of recurrence. We report and update our institutional experience treating diffuse and recurrent TGCT with postsurgical external beam radiation therapy. We performed a retrospective chart review of 30 patients with TGCT from 2003 to 2019 treated with radiation therapy. Each patient was evaluated for demographics, radiation treatment parameters, surgical management, complications, and outcome. With mean follow-up of 82 months (range, 3-211), 24 patients (80%) who underwent surgery followed by radiation therapy did not experience any further relapse, and all 30 patients achieved local control (100%) with additional salvage therapy after radiation therapy. The most common site of disease was the knee (n=22, 73%), followed by the ankle (n=5, 16%) and the hand (n=3, 10%). Seven patients (24%) presented at time of initial diagnosis and 23 (76%) presented with recurrent disease after surgical resection, with an average of 2.6 surgical procedures before radiation therapy. After resection, 18 of 30 patients (67%) demonstrated residual TGCT by imaging. The median radiation therapy dose delivered was 36 Gy (range, 34-36 Gy) in 1.8 to 2.5 Gy/fractions for 4 weeks. In the assessment of posttreatment joint function, 26 sites (86%) exhibited excellent or good function, 2 (7%) fair, and 2 poor (7%) as determined by our scoring system. There were no cases of radiation-associated malignancy. Among patients with diffuse or recurrent TGCT, postsurgical external beam radiation therapy provided excellent local control and good functional status, with minimal treatment-related complications. Postsurgical radiation therapy is a well-tolerated noninvasive treatment that should be considered after maximal cytoreductive resection to prevent disease progression and recurrence.

Non-pigmented villonodular synovitis of knee joint in a 11-year-old boy on long term steroids: a case report

&lt;p&gt;Pigmented villonodular synovitis (PVNS) is a rare condition, commonly affecting the knee joint and hip joint. It is seldomly seen in pediatric age group. Aetiology is unknown. Magnetic resonance imaging (MRI) is the imaging modality of choice. Managed by surgical resection of the synovium performed with an open, arthroscopic or combined approach. Post-operative adjuvant external beam radiotherapy have reduced recurrence rate. In this case report we are going to present a rare case of eleven-year-old boy on long term steroid intake, who presented with a history of pain and swelling of right knee joint with restriction of range of movements. MRI suggested extensive villonodular synovitis of knee joint. Diagnostic arthroscopy showed extensive villonodular synovitis of suprapatellar pouch, medial gutter, lateral gutter, intercruciate space, posterior-medial and posterior-lateral compartments and villi had atypical yellow fatty appearance. Extensive arthroscopic synovectomy was done and histopathology showed chronic synovitis. Post-operatively pain and swelling reduced and range of movements improved. Arthroscopic synovectomy is the most effective line of management for villonodular synovitis.&lt;/p&gt;

Intraoperative radiation therapy for locally advanced and recurrent head and neck cancer.

The purpose of the present study was to present a single institution experience with intraoperative radiation therapy (IORT) for patients with head and neck cancer (HNC). The present study included all patients with HNC treated consecutively with IORT at Loyola University Medical Center between January 2014 and December 2018. Charts were reviewed for patient and tumor characteristics, IORT technical details, IORT-induced adverse events and treatment outcomes. The study included 23 eligible patients. Median patient age was 66 years (range, 34-91 years). Tumor sites included the parotid gland (43%), lymph nodes (43%), oral tongue (9%) and ear (4%). A total of 48% of patients received IORT upfront with or without postoperative adjuvant external beam radiation therapy (EBRT), whereas 52% received salvage IORT after local tumor recurrence. The median prescribed IORT dose was 7.5 Gy (range, 5-14 Gy) in a single fraction prescribed to 5 mm depth with flat applicators (median diameter, 5 cm). A total of 92% of patients did not experience wound healing complications. One patient (4%) developed postoperative acute thromboembolic stroke and a second patient (4%) experienced protracted wound healing. At a median follow up of 36 months (range, 2-81 months), overall survival was 52%. In addition, 48% of patients were reported to have no evidence of disease, and although two had died of unrelated causes, 13% of patients were alive with disease and 39% died with the disease. The local-regional recurrence rate was 39% (median time to local recurrence, 11 months; range, 1-34 months), the rate of distant metastasis was 35% (median time to distant metastasis, 16 months; range, 4-40 months), and 21% of patients had both local-regional recurrence and distant metastases. The percentages of local-regional recurrence and distant metastases among patients receiving salvage IORT were 58 and 50% respectively, compared with 18 and 18% respectively in those receiving upfront IORT with or without adjuvant EBRT. In the present single institution retrospective study, it was concluded that IORT for patients with locally advanced and recurrent HNC was a safe treatment modality, with tumor control comparable to historical IORT data. Larger prospective studies are needed to further assess the utility of IORT in the management of locally advanced and recurrent HNC.

Intraoperative radiation therapy for locally advanced and recurrent head and neck cancer.

6058 Background: Intraoperative Radiation Therapy (IORT) allows precise delivery of radiation therapy (RT) to a limited target area at high risk of cancer recurrence while minimizing RT to nearby organs at risk. IORT may be particularly beneficial for patients with locally recurrent head and neck cancer (HNC) in a previously irradiated field and for locally advanced HNC cases, in which obtaining negative surgical margins may be difficult. This study aims to present a single institution experience with IORT for HNC patients. Methods: This study included HNC patients treated consecutively with IORT at our institution between 2014 and 2018. Charts were reviewed for patients’ and tumors’ characteristics, IORT technical details, IORT-induced adverse events, and treatment outcomes. Results: The study included 23 eligible patients. Median patient age was 66 (range 33-91). Tumor sites included parotid gland (43%), lymph nodes (43%), oral tongue (9%), and ear (4%). 52% of patients received IORT upfront with or without postoperative adjuvant external beam radiation therapy (EBRT), while 48% received salvage IORT after local tumor recurrence. The median prescribed IORT dose was 7.5 Gy (range 5-14 Gy) in a single fraction prescribed to 5 mm depth with Flat applicators (median diameter of 5 cm). 92% of patients did not experience wound healing complications. One patient (4%) developed postoperative acute thromboembolic stroke, a second patient (4%) experienced protracted wound healing. At a median follow-up of 36 months (range 2-81), 42% of patients presented with no evidence of disease (NED), overall survival was 54%, 13% of patients were alive with disease, and 46% died with disease. Local-regional recurrence rate was 39% (median time to local recurrence was 18 months, range 2-60), rate of distant metastasis was 43% (median time to distant metastasis was 23 months, range 5-60), and 30% of patients had both local-regional recurrence and distant metastases. The percent of local-regional recurrence and distant metastases among patients receiving salvage IORT was 64% and 73% respectively, compared to 23%, and 15% respectively in those receiving upfront IORT with or without adjuvant EBRT. Conclusions: In this single institution chart review study, IORT to locally advanced and recurrent HN cancer patients was a safe treatment modality, with tumor control comparable to historical EBRT data. Larger prospective studies are needed to further assess the utility of IORT in the management of locally advanced and recurrent HN cancer.

A Study of Multivariate Modalities of Therapy in Gall Bladder Malignancies with Different Clinical, Radiological and Histo-Pathological Profiles at a Low Resource Indian Cancer Centre

Introduction: The effectiveness of adjuvant radiation therapy (RT) in the treatment of GBC has not yet been established. The effectiveness of adjuvant radiation therapy (RT) in the treatment of GBC has not yet been established. Following surgical resection, postoperative external beam RT can diminish local relapse; though effect on global survival has not been confirmed due to lack of good quality clinical trials. Thus the aim of the study was to assess the efficacy of the multivariate modality of therapy in Gallbladder malignancies. Materials and method: The present prospective comparative study of multivariate modality of therapy in Gallbladder malignancies was carried out in a low resource North Indian cancer center from. Only those patients were selected who were histologically confirmed of adenocarconima of gall bladder, squamous cell carcinoma and oat cell carcinoma. Staging was done according to TNM classification no concurrent medical illness, Karnofsky performances status of patient &gt;70. Statistical analyses were performed using SPSS version 23.0 (SPSS Inc., Chicago, IL, USA). A value of p&lt;0.05 was considered statistically significant. Result: Majority (29.3%) of the cases were aged 61-70 years just followed by the age group 41-50 years, females were in majority (73.2%). Higher stage had significantly higher risk of partial or no response (p&lt;0.001). An increasing trend of toxicities was observed with increasing dose. Significant association was found between toxicities and treatment response at dose 2000 cGy (p&lt;0.001) and 4500 cGy (p&lt;0.001). The Cox regression analysis showed higher hazard ratio for stage IV (HR=2.33 95% CI : 0.31-17.66) followed by stage II/III (HR=1.67 95% CI : 0.17-16.02). Conclusion: Healthcare professionals should discuss the indeterminate benefit and possible risks of adjuvant therapy when counseling their patients and reassure enrollment in clinical trials of novel regimens. The curative potential of current adjuvant therapy in gallbladder cancer is questionable, justifying placebo-controlled investigation of novel chemotherapy combinations or alternative approaches. To confirm the efficacy of adjuvant therapy, a major randomized controlled trial is required with large sample size. The improvement in radiation delivery with intensity modulated radiotherapy (IMRT), image guided radiotherapy has further paved the way for exploration of adjuvant radiation for GBC.

Safety and efficacy of salvage high-dose rate brachytherapy for prostate-bed recurrences following radical prostatectomy and external beam radiotherapy.

This retrospective study aims to evaluate the efficacy and safety of salvage HDR brachytherapy in second local recurrences of prostate cancer after applying radical prostatectomy (RP) and post-operative external beam radiotherapy (EBRT). Fifteen patients with locally recurrent prostate cancer after RP and EBRT were salvaged with HDR brachytherapy. Patients had no nodal or distant metastasis evidence on imaging findings, including whole body bone scan, CT scan, and MRI or PSMA PET scan. HDR brachytherapy was applied with 36Gy in four fractions, in two implantations with 1week apart. We followed the patients for a control visit every 3months for 2years, and every 6months thereafter. Fifteen patients with the mean age of 64years (ranged 51-79) underwent salvage HDR brachytherapy. The mean baseline level of PSA was calculated 2.26ng/ml (ranged from 0.21 to 9, SD = 2.33), which has been significantly decreased in all patients. Hence, two of our patients experienced a biochemical failure during the follow-up period. Our results showed that 86.6% (n = 13) of patients had never experienced a significant increment in PSA level after a median follow-up of 48months (ranging from 12 to 132months). Besides, salvage HDR brachytherapy did not induce any significant side effects such as acute or late rectal complications, despite causing urinary complication. HDR brachytherapy could be considered as a treatment in well-selected patients with the second recurrence in their prostatic bed after the former EBRT allowing for dose escalating to the second nodular recurrence.

Cancer of the oral mucosa (cancer of the tongue, floor of mouth, lower jaw, cheek)/lip: modern therapeutic technologies

Purpose. Evaluation of the effectiveness of three treatment options for cancer oral mucosa (cancer of the tongue and floor of mouth, cheek, lower jaw)/lip (OC/lip). Materials and methods. Treated 100 patients with OC/lip: combined treatment with surgery at the first stage and postoperative conformal external beam radiation therapy (EBRT) of 50 Gy — 40 patients; combined conformal EBRT and brachytherapy (BT HDR) — 40 patients; EBRT and photodynamic therapy (PDT) with intensive laser hyperthermia — 20 patients. The age of the patients ranged from 26 to 90 years; among them were 55 men and 45 women. Results. Five-year overall survival (OS) and relapse-free survival (RFS) in patients with tumors of various localization was 88% and 73.3% respectively with a good quality of life. Five-year OS was for combined method of treatment — 82,8%; combined EBRT and brachytherapy — 94,4% and EBRT in combination with PDT and laser hyperthermia — 83,3% (р=0,561). With tumors of stage I–II, the five-year OS was 94.4% and III–IV stage — decreased to 73.1% with a high level of statistical significance of the χ²=6.042, p=0.014. Conclusions. OC and lip cancer is most effectively cured in the I–II stage of the disease with the initial implementation of the surgical stage preceding EBRT. EBRT with photodynamic therapy and laser hyperthermia is effective for contraindications for patients to brachytherapy. The determination of PM (predictive markers) is a promising direction in optimizing the antitumor treatment of malignant neoplasms of OC/lip.

Postoperative external beam radiotherapy for locoregional control in iodine refractory differentiated thyroid cancer.

BackgroundThe role of postoperative external beam radiotherapy (EBRT) in patients with residual iodine refractory-differentiated thyroid cancer (IR-DTC) is still inconclusive. The aim of this retrospective study was to evaluate locoregional control (LRC) and overall survival (OS), and potential side effects after postoperative EBRT for both microscopic and macroscopic non-radically resected, locally advanced IR-DTC.MethodsBetween 1990 and 2016, 49 patients with locally advanced IR-DTC received EBRT for microscopic (R1; n = 28) or macroscopic (R2; n = 21) locoregional residual disease. For more insight into the added effect of EBRT, we performed an intrapatient sub-analysis in 32 patients who had undergone more than 1 surgical intervention, comparing LRC after primary, curative-intended surgery with LRC after repeated surgery plus EBRT. To estimate LRC and OS, we used Kaplan–Meier curves. From 2007 onward, we prospectively recorded toxicity data in our head and neck cancer database (n = 10).ResultsLRC rates 5 years after EBRT were higher for R1 (84.3%) than for R2 (44.9%) residual disease (P = 0.016). The 5-year OS rate after EBRT was 72.1% for R1 and 33.1% for R2 disease (P = 0.003). In the intrapatient analysis (n = 32), LRC rates were 6.3% 5 years after only initial surgery and 77.9% after repeated surgery with EBRT (P < 0.001). Acute toxicity was limited to grade I and II xerostomia, mucositis, and hoarseness; only one patient developed late grade III dysphagia.ConclusionsPostoperative EBRT is associated with long-lasting LRC and OS with acceptable toxicity in patients with locally advanced IR-DTC, especially in microscopic residual disease.

Dosimetric Comparison of Upfront Boosting With Stereotactic Radiosurgery Versus Intraoperative Radiotherapy for Glioblastoma.

PurposeTo simulate and analyze the dosimetric differences of intraoperative radiotherapy (IORT) or pre-operative single-fraction stereotactic radiosurgery (SRS) in addition to post-operative external beam radiotherapy (EBRT) in Glioblastoma (GB).MethodsImaging series of previously treated patients with adjuvant radiochemotherapy were analyzed. For SRS target definition, pre-operative MRIs were co-registered to planning CT scans and a pre-operative T1-weighted gross target volume (GTV) plus a 2-mm planning target volume (PTV) were created. For IORT, a modified (m)GTV was expanded from the pre-operative volume, in order to mimic a round cavity as during IORT. Dose prescription was 20 Gy, homogeneously planned for SRS and calculated at the surface for IORT, to cover 99% and 90% of the volumes, respectively. For tumors > 2cm in maximum diameter, a 15 Gy dose was prescribed. Plan assessment was performed after calculating the 2-Gy equivalent doses (EQD2) for both boost modalities and including them into the EBRT plan. Main points of interest encompass differences in target coverage, brain volume receiving 12 Gy or more (V12), and doses to various organs-at-risk (OARs).ResultsSeventeen pre-delivered treatment plans were included in the study. The mean GTV was 21.72 cm3 (SD ± 19.36) and mGTV 29.64 cm3 (SD ± 25.64). The mean EBRT and SRS PTV were 254.09 (SD ± 80.0) and 36.20 cm3 (SD ± 31.48), respectively. Eight SRS plans were calculated to 15 Gy according to larger tumor sizes, while all IORT plans to 20 Gy. The mean EBRT D95 was 97.13% (SD ± 3.48) the SRS D99 99.91% (SD ± 0.35) and IORT D90 83.59% (SD ± 3.55). Accounting for only-boost approaches, the brain V12 was 49.68 cm3 (SD ± 26.70) and 16.94 cm3 (SD ± 13.33) (p<0.001) for SRS and IORT, respectively. After adding EBRT results respectively to SRS and IORT doses, significant lower doses were found in the latter for mean Dmax of chiasma (p=0.01), left optic nerve (p=0.023), right (p=0.008) and left retina (p<0.001). No significant differences were obtained for brainstem and cochleae.ConclusionDose escalation for Glioblastoma using IORT results in lower OAR exposure as conventional SRS.

Intraoperative radiotherapy for glioblastoma: A systematic review of techniques and outcomes

BackgroundDespite multimodality treatment, the prognosis of glioblastoma (GBM) has remained poor. Intraoperative radiation therapy (IORT) offers additional local control by directly applying a radiation source to the resection margin, where most recurrences occur. MethodsWe performed a systematic review on the oncologic outcomes and toxicities of IORT for GBM in the era of modern external beam radiation therapy (EBRT) and chemotherapy with temozolamide. ResultsFour studies representing 123 patients were included. Majority (81%) were newly diagnosed, and gross total resection was reported in 13–80% of cases. IORT modalities included electrons from a linear accelerator (LINAC) and photons from a 50-kV x-ray device. Median doses were from 12.5 to 20 Gy for electron-based studies and 10–25 Gy for photon-based studies. Adjuvant treatment consisted of 46–60 Gy post-operative EBRT in electron-based studies and the Stupp protocol in photon-based studies. Complications included radiation necrosis (2.8–33%), infection, hematoma, perilesional edema, and wound dehiscence. Median time to local recurrence was 9.9–16 months and the reported overall progression-free survival was 11.2–12.2 months. Median overall survival was 13–14.2 months for the electron-based studies and 13.8–18 months for the photon-based studies. ConclusionIORT resulted in improved local control and comparable overall survival rates with the Stupp protocol. Although photon-based IORT had better results than electron IORT, this may be due to improvements in other forms of adjuvant treatment rather than the IORT modality itself. The overall effect of IORT on GBM treatment is still inconclusive due to the small number of patients and heterogeneous reporting of data.

Role of Adjuvant Radiotherapy in Early Stage Tongue Cancer: Need for Establishing Stringent Guidelines.

The primary objective of this study was to determine, using population-based data, whether the addition of postoperative radiotherapy (RT) provides an overall survival benefit in patients with early primary squamous cell carcinoma (SCC) of tongue. The study included the data of tongue cancer patients treated between January 2016 and July 2019 retrieved from our hospital database. Tumours limited to pathologic T1 and T2 category managed with primary surgery with or without postoperative external beam RT were included. Overall survival (OS) and disease-free survival (DFS) were the main outcomes of interest. A total of 211 cases of oral cancer were evaluated and all the patients had clear surgical and pathological margins. Postoperative adjuvant therapy (PORT) was received by 16 patients. Comparison of DFS and OS at 2-year follow-up depicted a similar outcome (p = 0.582 and p = 0.312 respectively). Findings from our study suggest that in the absence of any absolute advantage on quantifiable survival and disease control, it is necessary to define stringent criteria when advocating PORT in early tongue cancer.

The Case Selection for Vaginal Cuff Brachytherapy in Cervical Cancer Patients After Radical Hysterectomy and External Beam Radiation Therapy.

ObjectiveTo explore the suitable cases for vaginal cuff brachytherapy (VCB) combined with external beam radiation therapy (EBRT) in the postoperative treatment of cervical cancer.MethodsWe retrospectively analyzed the clinical data of 214 postoperative cervical cancer patients who received radiotherapy from January 2008 to December 2015. Among them, 146 patients received postoperative EBRT, 68 received EBRT plus VCB. There was no statistical difference in clinical and pathological characteristics between these two groups. Those who with negative vaginal cuff underwent supplemented 12–18 Gy/2–3 Fx VCB. Survival analyses were performed using Kaplan–Meier method, and Cox model was used to analyze prognostic factors.ResultsThe median follow-up was 52 months (9–136 months), and 4-year RFS (recurrence-free survival) was 77%. Among them, 58 patients (27.10%) had local or distant recurrences, 29 (13.55%) in pelvis, six (2.80%) with metastases to para-aortic, 19 (8.88%) with distant metastases (including inguinal lymph nodes) and four (1.87%) with both local and distant recurrences. The postoperative brachytherapy boost did not improve RFS or OS (overall survival) among the investigated subjects, P = 0.77, P = 0.99, respectively. Neither it decreased the local relapse in the pelvis or vaginal cuff, P = 0.56, P = 0.59. Subgroup analyses showed that brachytherapy boost improved RFS in patients who had bulky mass (>4 cm) as well as 1) with deep stromal invasion (>50% stromal invasion), P = 0.012 or 2) received low EBRT dose (≤45 Gy), P = 0.033, and in patients with deep stromal invasion as well as received low EBRT dose (P = 0.018).ConclusionsWe first proposed the case selection model for postoperative EBRT plus VCB. Brachytherapy boost were considered in the setting of postoperative radiotherapy if the patients had at least two out of these following factors: bulky mass, deep stromal invasion and low EBRT dose.

Impact of Immunohistochemical profiling of Glioblastoma multiforme on clinical outcomes: Real-world scenario in resource limited setting

ObjectiveIntuition into the molecular pathways of glioblastoma multiforme (GBM) has changed the diagnostic, prognostic, and therapeutic approaches. We investigated the influence of various clinical and molecular prognostic factors on survival outcomes in radically treated GBM patients. MethodsMedical records of 160 GBM patients treated between January-2012 and December-2018 with surgery followed by post-operative external beam radiotherapy (EBRT) with/without temozolomide (TMZ) were reviewed. Immunohistochemical (IHC) assays were performed for IDH1mutation, ATRX loss, TP53 overexpression and Ki-67% index. Apart from disease and treatment-related factors’ influence on clinical outcomes, the impact of IHC markers in prognostication was analyzed using appropriate statistical tests. ResultsThe median overall survival (OS) was 14 months. EBRT with concurrent TMZ was given to 60% of patients and 42.5% completed the standard Stupp-protocol. Significant improvements in OS was observed in patients aged ≤ 50years (2-year OS: 22.1% vs. 12.5%, p = 0.001), those who underwent gross total resection (2-year OS: 21.8% vs. 12.8%, p = 0.002), received concurrent TMZ (21.9% vs. 12.5%, p = 0.005), completed the entire Stupp-protocol (2-year OS: 23.4% vs. 6.5%, p = 0.000), and with Ki-67 index <20% (2-year OS: 23.3% vs. 11.6%, p = 0.015). On multivariate analysis, IDH1 mutation, ATRX loss, TP53 expression, and Ki-67 ≤ 20% were significant prognosticators of outcomes. ConclusionGBM patients treated with concurrent chemoradiation and those who completed the full Stupp-protocol experienced better survival outcomes. Molecular biology significantly impacts clinical outcomes and plays a key deterministic role in newer management strategies.

Pilot Study of External Beam Radiotherapy for Recurrent Unremitting Tracheal Stenosis.

Tracheal stenosis can have a variety of presentations, severities, causes, and be a difficult condition to treat. Some patients demonstrate recurrent stenosis after multiple endoscopic treatments and are either poor candidates for open procedures or do not desire open surgery. We sought to evaluate low-dose postoperative external beam radiotherapy (EBRT) as a novel therapy for patients with recurrent tracheal stenosis refractory to endoscopic therapies. We performed a retrospective review of patients with recurrent tracheal stenosis who underwent EBRT in addition to endoscopic dilation. We compared the number of endoscopic procedures required in the 6 months before EBRT to the number required in the 6 months after EBRT. Six patients met criteria for inclusion in our study. The cause of stenosis was variable among the study population. In the 6 months leading up to EBRT, patients underwent an average 6.2 endoscopic procedures. This dropped to an average 1.9 procedures in the 6 months following EBRT (P < .001). Herein, we show that low-dose postoperative external beam radiotherapy (EBRT), a novel therapy for patients with recurrent tracheal stenosis refractory to endoscopic therapies, is effective in decreasing the frequency of endoscopic dilations. 4.

Electron beam intraoperative radiotherapy for metastatic epidural spinal cord compression: a prospective observational study.

To assess the additional effects of intraoperative radiotherapy (IORT) with decompression surgery and adjuvant external beam radiotherapy (EBRT) for metastatic epidural spinal cord compression (MESCC).This single-arm institutional prospective observational study recruited patients between June 2017 and March 2020 and included those with symptoms of spinal cord compression owing to metastases, who were diagnosed using MRI. Patients with radiation-sensitive primary tumors and those who could not tolerate surgery were excluded. The treatment protocol comprised decompression surgery and electron beam IORT of 20 Gy in a single fraction followed by EBRT of 30 Gy in 10 fractions. The primary endpoints included the 1-year local failure rate and ambulatory functions.The study was closed in May 2019 owing to changes in treatment policies at our institution. Twenty patients were registered between June 2017 and May 2019. Although all patients completed surgery and IORT, 2 did not receive postoperative EBRT. Patients most commonly had colorectal cancer (4 patients), followed by thyroid cancer, renal cell carcinoma, lung cancer, breast cancer, sarcomas, and other cancers (3, 3, 2, 2, 2, and 4 patients, respectively). The median follow-up duration was 16 months (range 2-30 months); the 1-year local failure rate was 16%. On comparing ambulatory functions pre-treatment and at 1 year after treatment, improvement, no change, and worsening were observed in 3, 9, and 0 patients, respectively.This study's findings suggest that decompression surgery and IORT followed by EBRT are effective in achieving local control and maintaining ambulation in patients with MESCC.

Utilization of multimodality therapy with primary radical prostatectomy versus radiation therapy for Gleason 8–10 prostate cancer

PurposeThe role of multimodality therapy (MMT) in the treatment of Gleason 8–10 prostate cancer remains controversial. We sought to evaluate factors associated with MMT utilization for primary radical prostatectomy (RP) and primary radiation therapy (RT). Methods and MaterialsFrom the National Cancer Database, we conducted a retrospective review of 81,528 men with National Cancer Center Network Gleason 8–10 prostate cancer diagnosed between 2004 and 2015, who underwent (1) primary RP with or without early postoperative external beam RT (EBRT) or (2) primary RT (androgen deprivation therapy + EBRT) with or without brachytherapy (BT) boost. Using multivariable logistic regression models, we evaluated factors associated with the utilization of MMT, defined as early postoperative EBRT for primary RP or BT boost for primary RT. ResultsFor primary RP, the percentages of men who underwent MMT for Gleason 8 and 9–10 disease were 12.2% and 24.1%, respectively. On multivariable logistic regression, men with Gleason 9–10 were more likely to undergo MMT (odds ratio 1.03 [1.02, 1.04]), although adverse pathologic features such as T3b-4 (1.24 [1.23, 1.25]) disease demonstrated the strongest associations. For primary RT, the percentages of men who underwent BT boost for Gleason 8 and 9–10 disease were 11.8% and 9.8%, respectively. On multivariable logistic regression, men with Gleason 9–10 disease were less likely to receive BT boost (0.99 [0.98, 0.99]). ConclusionsMen with more aggressive Gleason 9 disease were more likely to undergo MMT if they underwent primary RP but not primary RT. Further blood-based or imaging biomarkers may aid in identifying optimal candidates for MMT, especially for primary RT.

Long-Term Follow-up Results of Advanced or Multiply Recurrent Pigmented Villonodular Synovitis/Tenosynovial Giant Cell Tumor Following External Beam Radiation Therapy

Pigmented Villonodular Synovitis (PVNS) and Tenosynovial Giant Cell Tumor (TGCT) are rare proliferative disorders of the synovial membrane that represent two manifestations of the same disease spectrum. While TGCT presents with focal lesions, PVNS exhibits greater clinical aggression partly due to its diffuse form affecting the entire synovium. Primary treatment involves extensive surgical resection of the involved hypertrophic synovium to achieve local control. Unfortunately, complete removal of all lesions is often difficult to achieve, leading to refractory and multiply recurrent disease for a disorder considered essentially benign. Such high-risk cases may lead to local destruction and severe symptoms including joint pain, swelling, hemorrhagic effusion, and erythema. In this report, we reviewed our experience treating advanced and recurrent PVNS with postoperative external beam radiation therapy. We identified twenty-nine patients diagnosed with PVNS and subsequently treated with radiation therapy between 2003-2017. Each case was retrospectively reviewed for patient demographics, radiation treatment parameters, surgical treatments, complications, and outcomes. All patients had diagnostic imaging and pathological review at presentation. With a median follow-up of 26.91 months (range, 2.17-191.69 months), 24 patients (83%) achieved initial local control following radiation therapy. Ultimate local control was achieved in 27 patients (93%). The most common location of disease was the knee joint with 20 cases (69%), followed by the ankle with 5 (17%), the hand with 3 (10%), and the hips with 1 (4%). Six sites (21%) were primary presentations and 23 sites (79%) were recurrent, with an average of 2.78 surgical interventions before radiation therapy. Following cytoreductive surgery, 18/27 sites (67%) had suspected or proven residual PVNS. The mean dose of radiation delivered was 34.7 Gy (range, 7-36 Gy). Twenty-five sites (86%) had post-radiation therapy imaging. In the assessment of PVNS-related function, 26 joints (90%) were scored as excellent or good function, 2 joints (7%) as fair, and 1 joint as poor (3%). The patient with poor function underwent two further surgical interventions that was complicated by wound dehiscence and infection, which ultimately led to above the knee amputation. Radiation therapy was well tolerated with no Grade 3/4 complications. For patients presenting with extensive or refractory PVNS, postoperative external beam radiation therapy provided excellent local control and maintained good functional status. Adjuvant radiation in moderate doses eschewed treatment-related complications and thus should be offered following maximal cytoreduction to prevent disease recurrence.