Radiotherapy Data Research Articles

PyCuRT: An Automated Data Curation Workflow for Radiotherapy Big Data Analysis using Pythons’ NyPipe

Personalized medicine in Radiotherapy (RT) aims to increase tumor control probability and decrease normal tissue toxicity. Recently, Radiomics is widely used to infer tumor/tissue characteristics and link outcome to applied dose and underlying biology. The building of robust models requires high amounts of data, which are often only available from multiple centers/sites. Missing standardization of data (inconsistent naming schemes, differences in acquisition parameters) makes manual curation necessary, which can be extremely time-consuming. Here, we propose a fully automated general framework that can sort all relevant RT data with minimal human intervention - pyCuRT. Our method builds upon NyPipe, a Python package used to create complex analysis workflows. Any DICOM directory containing different radiological data e.g., batch exported from PACS systems without specific structure requirements, can be used as input for pyCuRT. It checks the integrity of files and sorts them based on DICOM attributes. For RT data, using information from the RT Plan, pyCuRT links together the DICOM-RT objects, i.e., the RT planning CT, Structure Set (SS), and Dose Distribution (DD). Furthermore, the structure within the SS showing the highest overlap with the DD can be automatically identified, allowing the extraction of inconsistently named structures. The final output has a subject/session/scan structure. Parallelization is implemented to speed up computation on multi-core machines. Successful curation has been achieved in retrospectively collected data cohorts of 3 different cancer entities (brain n = 621, rectal n = 127, and pancreatic n = 13 for a total of ∼50000 scans), from several various institutions across Germany. In the rectal cohort, e.g., from more than 2000 present images, 774 CT scans with 224 unique series descriptions were identified. From them, pyCuRT extracted the RT planning CTs, and linked them to the corresponding RT-DD and RT-SS automatically. Furthermore, all structures with any combination of GTV or PTV in the name were correctly extracted from the SSs and saved as NIFTI (the 35 RT-SS not containing those structures were identified correctly). The total processing time was around 2 hours and a half, which corresponds to less than 3 seconds per scan. We propose a new, fully automated method to curate radiotherapy data coming from different institutions and vendors. Its robustness and usability were demonstrated in three cohorts of tumor entities treated with RT. Future work will expand the workflow to automatically classify MR sequences.

Erectile Dysfunction and Absorbed Dose to Penile Base Structures in a Randomized Trial Comparing Ultrahypofractionated and Conventionally Fractionated Radiation Therapy for Prostate Cancer

To study the relationships between absorbed dose to penile base structures and erectile dysfunction (ED) in patients treated with ultrahypofractionated (UHF) radiation therapy (RT) or conventionally fractionated (CF) RT for prostate cancer. This dose-response study comprises 673 patients (57%) of the 1180 per-protocol patients included in the HYPO-RT-PC trial (median follow-up 5, years), where patients were randomized to CF (39 × 2.0 Gy, 8 weeks) or UHF (7 × 6.1 Gy, 2.5 weeks). No androgen deprivation therapy was allowed. Only patients with erectile function sufficient for intercourse at baseline and complete RT data were included in this study. Erectile function was assessed by physician at regular follow-ups. The main endpoint was severe ED (EDs). The penile bulb (PB) and crus were retrospectively delineated on the treatment planning computed tomography scans. Dose-volume descriptors were derived from EQD2 converted dose matrices (α/β = 3 Gy). Univariable and multivariable Cox proportional hazard regression and logistic regression were used to find predictors for EDS. No significant difference in EDs was found between CF and UHF. During the follow-up period, EDs occurred in 27% of the patients in both treatment groups. Average (median) PB mean dose, Dmean, was 24.5 (20.2) in CF and 18.7 (13.1) Gy3 in UHF. Age was the only significant predictor for EDs in Cox analyses. All dose-volume variables contributed significantly in univariable logistic regression at 2-year follow-up. Age and near maximum dose (D2%) were significant predictors for EDs in multivariable logistic regression analyses at both 1 and 2 years. The frequency of EDS was similar in the CF and UHF treatment groups. Age at radiation therapy was the strongest predictor for EDs, followed by dose to PB, and was most evident for younger patients. We propose D2 % <50 Gy3 and Dmean <20 Gy3 to the PB as the primary objectives to be applied in the treatment planning process.

Radiation Records in the National Cancer Database: Variations in Coding and/or Practice Can Significantly Alter Survival Results.

The aim of the current work was to quantify internally inconsistent and anomalous radiation therapy (RT) data in the National Cancer Database (NCDB) and determine their association with overall survival (OS) using node-positive uterine cancer as a test clinical scenario. We identified all NCDB participants with International Federation of Gynecology and Obstetrics stage IIIC1 to IIIC2 uterine cancer treated with hysterectomy and adjuvant RT between 1998 and 2012. Variables that were reviewed to identify anomalous data included RT site, modality, dose, fractions, timing, duration, and stage. We used χ2 testing to associate anomalous data with reporting facility and demographic variables. OS was estimated using the Kaplan-Meier method and comparison between cohorts was performed using the log-rank test. Univariable and multivariable Cox proportional hazards regression analyses were performed. Of the 14,298 analyzed participants, 2,288 (16.0%) had one or more anomalous data entry, 538 (3.8%) likely because of an incomplete RT course. χ2 testing suggested differences in anomalous data prevalence by reporting facility type (P = .0007), geographic region (P < .001), distance from participants' homes (P < .001), diagnosis year (P < .001), and location of RT relative to reporting facility (P = .0038). Five-year OS in those with one or more anomalous data entry was 51.3% versus 58.0% for those without anomalous data (P < .001), and anomalous data remained significantly associated with OS on multivariable analysis. After excluding insufficient, excessive, or unknown total RT dose, anomalous data were no longer significant on multivariable analysis. The overwhelming majority of RT data within the NCDB seem to be appropriate for the clinical scenario. Nevertheless, approximately one eighth of participants in this test clinical scenario had adjuvant RT data that were internally inconsistent or outside generously defined norms. The presence of anomalous RT data was significantly associated with compromised OS, an effect not observed after correcting for total RT dose.

Incidence of Otitis Media with Effusion in Cases of Head and Neck Malignancies Undergoing Radiotherapy: A Prospective Observational Study.

This study was done to evaluate the incidence of otitis media with effusion (OME) in cases of head and neck malignancies who undergo irradiation, excluding nasopharyngeal malignancies. This prospective observational study was done at a tertiary care hospital. Adult patients of head and neck malignancies treated with radiotherapy (RT) with or without concurrent chemotherapy as definitive or adjuvant therapy from September 2017 to August 2018 were included. Cases of nasopharyngeal malignancies and cases of malignancies of other sites extending to nasopharynx causing mechanical obstruction to ET were excluded. The otoscopy, tympanometry and pure tone audiometry findings of these patients were recorded pre RT, immediately after completion of RT and at 6months post RT. The pre and post RT data were analysed to determine the incidence of OME. 39.3% of ears had retracted tympanic membrane (TM) and 7.1% had air-fluid levels in middle ear at first follow up (FFU). At second follow up (SFU), 13% of ears continued to have retracted TM while none had air-fluid levels. At FFU, 23.2% of ears had 'B' curve on tympanometry, indicative of OME while 19.6% of ears had 'C' curve, indicative of Eustachian tube (ET) dysfunction. At SFU, 1.8% had B curve while 14.3% had C curve, indicating improvement in ET function as compared to that at FFU. There is a considerable percentage of non-nasopharyngeal head and neck malignancy cases who develop OME post RT, however, in most of them it resolves spontaneously.

Patterns of failure following proton beam therapy for head and neck rhabdomyosarcoma

PurposePediatric patients with rhabdomyosarcoma (RMS) of the head and neck (H&N) are treated with multimodal therapy, often with radiotherapy (RT) as definitive local therapy. We report on the patterns of failure following proton beam therapy (PBT) for H&N RMS. MethodsForty-six H&N RMS patients were enrolled on a prospective registry protocol between 2006 and 2015. All were treated with a combination of chemotherapy (ChT) and PBT. Most patients (25 patients, 54%) had parameningeal tumors, of which 11 (24%) had intracranial extension (ICE). Thirteen patients (28%) had primary tumors greater than 5 cm. Median total cyclophosphamide (CPM) equivalent dose was 13.2 g/m2 (range 0–16.8 g/m2). Median RT dose was 50.4 Gy(RBE) (range 36 Gy[RBE]–50.8 Gy[RBE]). ResultsWith median follow-up of 3.9 years, five-year overall survival was 76%, and five-year progression-free survival was 57%. Seventeen patients (37%) experienced relapse, including 7 with local failure (LF). Five-year local control (LC) was 84%. Tumor size greater than 5 cm predicted increased risk of LF (hazard ratio [HR] 6.49, p = 0.03), as did the presence of ICE at diagnosis (HR 5.21, p = 0.03). Six relapses occurred in patients with ICE; all included a component of central nervous system relapse, with leptomeningeal disease and/or LF with an intracranial component. Delayed RT delivery after week 4 of ChT predicted increased risk of relapse for ICE patients (HR 10.49, p = 0.006). ConclusionsPBT confers excellent LC, and a favorable late toxicity profile as compared with prior photon RT data. Our observations support ongoing trial efforts to dose-escalate RT for patients with larger tumors. However, these data raise concerns regarding excess failures among patients with ICE.

Modeling the Risk of Neurocognitive Effects from Radiation Therapy in Childhood Cancer Survivors: Initial Results From the Pediatric Normal Tissue Effects in the Clinic (PENTEC) CNS Task Force

Brain injury from radiation therapy (RT) includes necrosis and neurocognitive (NC) impairment that can affect childhood cancer survivors’ quality-of-life. PENTEC seeks to quantitate RT dose-dependence of adverse effects and the risk modification by age and other factors. The PENTEC CNS task force reports preliminary results of RT related NC outcomes. A literature search for studies reporting incidence of RT associated NC sequelae (impaired IQ, NC function, or need for special education) was performed. Prescribed doses were converted to equivalent 2 Gy/fraction (EQD2). The Lyman-Kutcher-Burman formalism with generalized equivalent uniform dose (gEUD) was used for modeling normal tissue complication probability (NTCP) of NC effects. For whole brain (WB)/craniospinal or partial brain (PB) RT it was assumed that the prescribed dose uniformly irradiated the entire brain or 1/8 of the brain, respectively. In this analysis, a simple composite variable reflecting various NC endpoints was used. The model was fitted using a weighted least squares method and corrected for the patient number in each study. Best-fit parameter confidence intervals were determined using a bootstrap resampling technique. The search identified 1173 abstracts; each was evaluated by 2 reviewers. Two hundred nineteen studies with useful information were short-listed. The 62 highest scored articles were abstracted and the 19 studies (21 data sets, 1498 patients) with objective NC testing and RT data were analyzed (Table). Preliminary results show a sigmoidal dose-response for NC impairments: D50 corresponding to 50% risk of complication of 26.6 Gy (68% CI 25.5-27.9 Gy); slope of dose response 0.35 (0.31-0.40) and volume parameter 0.46 (0.40-0.59). The model indicates a 5% NC risk associated with 11.3 Gy WB and 29.8 Gy PB RT.Abstract 1032; TableStudyYearPtsWB/CS Dose (Gy)Focal Dose (Gy)Neurocognitive Function DeclineIncidence of Endpoint %Fouladi200331-52.2IQ0Fouladi Focal200538-54IQ < 7023.6Fouladi CSI20051418-3051.9IQ71.4Waber19952718-IQ0Krull201310224-IQ52Vern-Gross201434-59.4IQ0Agbahiwe2017483656IQ54.1Merchant2000823.4-3250.4IQ12.5Merchant200488-23.4-32IQ0Merchant200978-54IQ100Merchant201477-52.13IQ0Merchant20145823.4-39.655.8NC100Edelstein20112418-General50Waber200412518-General0Christopherson20143928.854General49Krull 18 Gy201316718-General12.3Krull 24 Gy201318624-General27Jakacki200461854Status50Cheng20162223.440Process Speed33.3Van Dijk201228521-24.849.3-51.3Disorder14.4Yeom20134118-39.654Special Ed70 Open table in a new tab The initial results of this meta-analysis confirm a RT dose and volume relationship to NC injury risk. Further model refinement will include the effect of age, chemotherapy and include a formal evaluation of heterogeneity across studies.

The Importance of Imaging in Radiation Oncology for National Clinical Trials Network Protocols

Imaging is essential in successfully executing radiation therapy (RT) in oncology clinical trials. As technically sophisticated diagnostic imaging and RT were incorporated into trials, quality assurance in the National Clinical Trials Network groups entered a new era promoting image acquisition and review. Most trials involving RT require pre- and post-therapy imaging for target validation and outcome assessment. The increasing real-time (before and during therapy) imaging and RT object reviews are to ensure compliance with trial objectives. Objects easily transmit digitally for review from anywhere in the world. Physician interpretation of imaging and image application to RT treatment plans is essential for optimal trial execution. Imaging and RT data sets are used to credential RT sites to confirm investigator and institutional ability to meet trial target volume delineation and delivery requirements. Real-time imaging and RT object reviews can be performed multiple times during a trial to assess response to therapy and application of RT objects. This process has matured into an effective data management mechanism. When necessary, site and study investigators review objects together through web media technologies to ensure the patient is enrolled on the appropriate trial and the intended RT is planned and executed in a trial-compliant manner. Real-time imaging review makes sure: (1) the patient is entered and eligible for the trial, (2) the patient meets trial-specific adaptive therapy requirements, if applicable, and (3) the intended RT is according to trial guidelines. This review ensures the study population is uniform and the results are believable and can be applied to clinical practice.

A review on methods to estimate a CT from MRI data in the context of MRI-alone RT

Background: In recent years, Radiation Therapy (RT) has undergone many developments and provided progress in the field of cancer treatment. However, dose optimisation each treatment session puts the patient at risk of successive X-Ray exposure from Computed Tomography CT scans since this imaging modality is the reference for dose planning. Add to this difficulties related to contour propagation. Thus, approaches are focusing on the use of MRI as the only modality in RT. In this paper, we review methods for creating pseudo-CT images from MRI data for MRI-alone RT. Each class of methods is explained and underlying works are presented in detail with performance results. We discuss the advantages and limitations of each class.&#x0D; Methods: We classified recent works in deriving a pseudo-CT from MR images into four classes: segmentation-based, intensity-based, atlas-based and hybrid methods and the classification was based on considering the general technique applied.&#x0D; Results: Most research focused on the brain and the pelvic regions. The mean absolute error ranged from 80 to 137 HU and from 36.4 to 74 HU for the brain and pelvis, respectively. In addition, an interest in the Dixon MR sequence is increasing since it has the advantage of producing multiple contrast images with a single acquisition.&#x0D; Conclusion: Radiation therapy is emerging towards the generalisation of MRI-only RT thanks to the advances in techniques for generation of pseudo-CT images and the development of specialised MR sequences favouring bone visualisation. However, a benchmark needs to be established to set in common performance metrics to assess the quality of the generated pseudo-CT and judge on the efficiency of a certain method.

Use of Radiation Therapy Within the Last Year of Life Among Cancer Patients

We examined radiation therapy (RT) use within the last year of life (LYOL). As palliative RT (PRT) has been well studied in patients with ≥6-week life expectancies, we hypothesized that PRT use would be constant over the LYOL, except for the last 30days, when use would decline given lack of prospective data supporting it. At a single institution, 870 cancer patients died between October 2, 2014, and September 30, 2015, and had ≥3 evaluation and management visits within the LYOL. Claims and RT data were extracted and linked. Over the LYOL, we evaluated RT use by intent (curative vs palliative) and indications. Within the LYOL, one-third of patients underwent RT in the last 365 days of life to 444 sites, which decreased to 24.3% and 8.5% in the last 180 and 30days of life, respectively.Patients who received any RT in the last 365days of life were younger at death and had a higher proportion of lung, sarcoma, and transplant disease groups. One-quarter of sites were irradiated with curative intent, which remained constant over the LYOL. In contrast, PRT was used at a supralinear rate, in which treatment of bone metastases and use of single-fraction PRT increased closer to death. PRT appears to be disproportionately used closer to death, with an increasing proportion of irradiated sites being bone metastases. This may be secondary to increased symptoms from advanced cancer toward the end of life. As patients with very poor prognoses (eg, within 30days of death) are generally not included in RT clinical trials, further studies are warranted to assess whether PRT for bone metastases at the end of life is efficacious.

Reirradiation in patients with diffuse intrinsic pontine gliomas: The Canadian experience.

Clinical trials have failed to demonstrate a survival benefit of adjuvant chemotherapy in diffuse intrinsic pontine gliomas (DIPG). Radiation therapy (RT) is the only effective treatment thus far and reirradiation (rRT) has become an option at the time of progression. The aim of this study was to review the Canadian experience of DIPG rRT with a focus on the safety and possible efficacy of this approach. We retrospectively reviewed the demographic, clinical, and RT data of patients with DIPG treated in Canada with rRT. Since January 2011, we identified 16 patients with progressive DIPG who received rRT. Median time from diagnosis to progression was 10.5 months (range, 4-37 months). rRT was given focally in 14 patients at a dose ranging from 21.6 to 36Gy. rRT was well tolerated by all children but one. All but three patients showed neurological improvement. With a median follow-up from original diagnosis of 19.2 months, all patients died, with a median time from rRT to death of 6.48 months (range, 3.83-13.26 months). When compared to a historic cohort of 46 consecutive patients, the median time from progression to death was 92 days in the non-reirradiated patients versus 218 days in the reirradiated ones (P=0.0001). In this limited experience, rRT was safe and feasible in patients with progressive DIPG, providing neurological improvement and a prolonged life span in most patients. Prospective Canadian rRT protocols are ongoing to further assess the benefit of this approach, including quality of life assessment.

Quality of Reported Radiation Data as Recorded in the NCDB for Node Positive Uterine Cancer

The National Cancer Database (NCDB) is often used for comparative effectiveness research, and an ostensible strength is the inclusion of radiation therapy (RT) data. This project seeks to quantify internally inconsistent RT data using lymph node positive (N+) uterine cancer as a test clinical scenario. All subjects in the NCDB between 1998-2012 with clinical (c) or pathologic (p) N+ invasive uterine cancer treated with hysterectomy within 6 months of diagnosis (dx) followed by adjuvant RT were identified. T4 disease was excluded to limit analysis to stage IIIC1-IIIC2. Variables reviewed to identify coding inconsistent with accepted norms of adjuvant RT include site, modality, dose, fractions, timing, and duration. Chi squared test was used to correlate inconsistent coding with facility-specific variables available within the NCDB. 14,480 women met inclusion criteria, but 182 were excluded from further analysis because of inconsistent coding suggesting N0 and M1 stage. Overall 2,288 (16.0%) of the 14,298 remaining subjects had ≥1 of the following inconsistencies: site (n=142); modality (n=91); dose (n=1,625), fractions (n=1,031), timing/duration (n=699). 553 (24.2%) of these 2,288 subjects, however, had inconsistencies limited to variables which may result from an incomplete course of RT. Therefore, 1,735 (12.1%) subjects had fundamental inconsistencies in RT coding. Many of these 'fundamental' inconsistencies were likely errors of magnitude (extra or missing 0), wrong site, dose recorded was too high to be reasonable in an adjuvant setting, time duration that was inconsistent with the recorded therapy, or record of a fraction size that is never used clinically. The following variables were associated with higher rates of inconsistent coding: non-comprehensive community cancer programs (p=0.0007); South Central, South Atlantic, and Pacific locations (p<0.0001); reporting hospital ≥50 miles from patient’s residence (15.5% for <50 miles vs 52.9% for ≥100 miles, p<0.0001); and when all or a portion of RT was not administered at the reporting facility (15.8% for all RT at same facility vs 21.9% for regional or boost elsewhere, p=0.0038). 7,781 (54.4%) subjects had unknown or blank data in ≥1 variable(s) analyzed. While the majority of RT data within the NCDB appears to be appropriate for the clinical scenario, a significant portion of RT data within the NCDB for N+ uterine cancer is internally inconsistent. Additionally, much of the RT data is missing or not adequately specified. Data auditing is indicated for work using the NCDB to examine the effects of RT, particularly on the specific effects of dose, fractionation, and timing. These findings may also be used to direct improvements within the NCDB coding methodology to allow for more accurate reflection of the treatment received.

An Efficient Tool for Structure Label Harmonization

The aim of the study is to develop an efficient solution to addressing the inconsistency of structure labels in treatment plans. Significant efforts have been made in recent years to develop standards for structure labels and other clinical data captured in radiation therapy (RT). While adoption of these standards will enable standardized structure labels in future clinical practices, we need an efficient way of transforming existing clinical cases so that the structure labels all conform to proposed standards. This capability is important for integrating large datasets of RT data to support efforts of rapid learning and precision medicine. It is particularly important when multiple sites in an organ are treated at various time intervals, for example, in repeat radiosurgeries involving multiple brain lesions. We propose a rule-based method for structure label harmonization. Each rule specifies the standard name for an existing structure label that satisfies certain character patterns. These character patterns are described in a special language called regular expressions. The system starts by preprocessing the structure labels, which replaces special characters, separates words by capital letters, and removes any duplicated structure labels. After preprocessing, each structure will have one or multiple well-formed structure labels. By using an algorithm similar to human perception, the system finds similar patterns among the labels from the same structure. This process includes identifying planning keywords, ordering priority by physicians' signature, extracting common strings, and finding acronyms. It then generates a regular expression that forms all the rules. The system will also perform a crosscheck in the generated regular expressions to prevent mismatch between structure labels having similar patterns. Then, it creates a dictionary specifying for each structure, the standard structure name proposed by AAPM TG263 and its corresponding regular expressions. In this study, we used a training set of 104 prostate cases and 102 brain-SRS cases to generate a dictionary. The regular expressions in the dictionary covered all OARs (Organ-at-risk) and non-planning structures in the training set. As an initial validation we applied the regular expressions to a validation set of 100 prostate test cases. The results were encouraging. Ninety-one (91) cases had all structures correctly identified and relabeled. The remaining 9 cases had one or two missing/misclassified structures. These structure labels were due to rare patterns that did not appear in the training cases. Further work is under way to incorporate a learning capability to improve generalization incrementally. This study presents a rule-based approach to harmonize structure labels in existing clinical treatment plans. Preliminary tests demonstrate the feasibility of this system to efficiently and automatically harmonize structure labels across large datasets.

Neoadjuvant Radiotherapy is Associated with R0 Resection and Improved Survival for Patients with Extremity Soft Tissue Sarcoma Undergoing Surgery: A National Cancer Database Analysis.

Neoadjuvant radiotherapy (RT) is increasingly advocated for the management of soft tissue sarcoma (STS). Therefore, this study sought to characterize the impact of neoadjuvant RT on rates of R0 resection and overall survival (OS) in extremity STS patients undergoing surgery. From January 2003 to December 2012, the study identified patients with a diagnosis of extremity STS from the National Cancer Database. After exclusion of patients younger than 18years, not treated by surgery, who had metastases at diagnosis, intraoperative RT, and missing or unknown data, 27,969 patients were identified. Logistic regression and Cox-proportional hazard analysis were used to compare rates of R0 resection among preoperative, postoperative, and no-RT cohorts and to determine predictors of R0 resection and OS. The mean age of the patients was 59.5±17.1years, and 45.9% were female. The median tumor size was 10.5cm. The data showed that 51% of the patients did not receive RT, 11.8% received preoperative RT, and 37.2% received postoperative RT. The rates of R0 resection were 90.1% for the preoperative RT cohort, 74.9% for the postoperative RT cohort, and 79.9% for the no-RT cohort (P<0.001). The independent predictors for achievement of R0 resection included academic facility type (odds ratio [OR] 1.36; 95% confidence interval [CI] 1.20-1.55), histologic subtype, tumor size (OR 0.99; 95% CI 0.99-0.99), Charlson score (OR 0.92; 95% CI 0.84-0.99), and preoperative RT (OR 1.83; 95% CI 1.61-2.07). Both R0 resection and RT (pre- or post-operative) were associated with increased OS. Preoperative RT independently predicts higher rates of R0 resection for patients with extremity STS undergoing surgical resection. Negative surgical margins and pre- or postoperative RT are associated with improved OS.

Tolerance of Orthotopic Ileal Neobladders to Radiotherapy: A Multi-institutional Retrospective Study.

The present retrospective study analyzed the tolerance of orthotopic ileal neobladders to radiotherapy by reviewing the acute and late toxicity in patients who underwent postoperative radiotherapy after radical cystectomy/cystoprostatectomy. A multi-institutional database was created for patients who had undergone radical cystectomy/cystoprostatectomy and neobladder reconstruction, followed by adjuvant radiotherapy (RT). The patient and tumor characteristics were recorded. The RT data were reviewed to determine the treatment technique used, the radiation dose received by the neobladder, and acute and late toxicity evaluated using the Common Terminology Criteria for Adverse Events, version 4.0, scale. A total of 25 patients were included, with a median age of 64 years. Of the 25 patients, 18 received a dose of 45 to 50.4 Gy. The most common reasons for postoperative radiotherapy were close or positive surgical margins and pT3-pT4 or N+ disease. Ten patients underwent intensity modulated RT. All but 1 patient completed the RT course. Of the patients who completed their RT schedule, none had grade≥ 3 acute gastrointestinal toxicity. One patient who received concurrent chemotherapy developed grade 3 acute genitourinary toxicity. Three patients reported late grade 1 genitourinary toxicity (frequency of urination, mild leakage at night), with no reports of chronic gastrointestinal toxicity. None of the patients experienced neobladder perforation, leak, or fistula. The use of moderate doses of pelvic RT (range, 45-50.4 Gy) was well tolerated among the 25 patients who underwent RT after cystoprostatectomy with orthotopic neobladder creation. This finding supports the use of postoperative RT to moderate doses in this patient population when clinically indicated.

A national approach for automated collection of standardized and population-based radiation therapy data in Sweden

PurposeTo develop an infrastructure for structured and automated collection of interoperable radiation therapy (RT) data into a national clinical quality registry. Materials and methodsThe present study was initiated in 2012 with the participation of seven of the 15 hospital departments delivering RT in Sweden. A national RT nomenclature and a database for structured unified storage of RT data at each site (Medical Information Quality Archive, MIQA) have been developed. Aggregated data from the MIQA databases are sent to a national RT registry located on the same IT platform (INCA) as the national clinical cancer registries. ResultsThe suggested naming convention has to date been integrated into the clinical workflow at 12 of 15 sites, and MIQA is installed at six of these. Involvement of the remaining 3/15 RT departments is ongoing, and they are expected to be part of the infrastructure by 2016. RT data collection from ARIA®, Mosaiq®, Eclipse™, and Oncentra® is supported. Manual curation of RT-structure information is needed for approximately 10% of target volumes, but rarely for normal tissue structures, demonstrating a good compliance to the RT nomenclature. Aggregated dose/volume descriptors are calculated based on the information in MIQA and sent to INCA using a dedicated service (MIQA2INCA). Correct linkage of data for each patient to the clinical cancer registries on the INCA platform is assured by the unique Swedish personal identity number. ConclusionsAn infrastructure for structured and automated prospective collection of syntactically interoperable RT data into a national clinical quality registry for RT data is under implementation. Future developments include adapting MIQA to other treatment modalities (e.g. proton therapy and brachytherapy) and finding strategies to harmonize structure delineations. How the RT registry should comply with domain-specific ontologies such as the Radiation Oncology Ontology (ROO) is under discussion.

Therapeutic radiotherapy for giant cell tumor of the spine: a systemic review.

Giant cell tumor of the bone (GCTB) is a benign but locally aggressive tumor. Giant cell tumor of the spine (GCTS) accounts for 3-6 % of GCTB. Surgery remains the treatment of choice. For those not suitable for surgery, therapeutic radiotherapy (RT) is one classic modality. Although there are several articles on therapeutic RT for GCTS therapy, few systemic reviews have been performed on effects of therapeutic RT on GCTS. We searched EMBASE and Medline databases for papers reporting therapeutic radiotherapy for GCTS patients not suitable for surgical resection. The inclusion criteria and prognosis indicators have been defined prior to data extraction. Information of the included patients has been discreetly recorded. We analyzed the prognosis of therapeutic RT and multiple data concerning the GCTS patients. The indicators for prognosis were computed by SPSS software. The local control (LC) and overall survival (OS) rate was estimated by the Kaplan-Meier method. p values ≤0.5 were considered statistically significant. We included 13 studies comprising 42 patients who received therapeutic radiotherapy with doses ranging from 21 to 80 Gy. The results suggested a response rate of 100 %, OS of 97.6 %, 1-year local control rate (LC) of 85.4 %, 2-year LC rate of 80.2 %, and overall LC of 79 %. No patient reported malignant transformation albeit four had post-RT neurological complications. Four had distant metastasis of the tumor. Patients with previously repeated recurrence had worse prognosis after RT (p = 0.028). No association between dosage and prognosis was found. Therapeutic RT could provide a satisfactory prognosis for GCTS patients according to this study, and can be an alternative treatment modality for GCTS patients not suitable for surgery.

Radiation therapy at end of life in children.

Few data exist on evaluating utilization patterns of radiotherapy (RT) at the end of life (EOL) in children. Metastatic disease in pediatric patients is not pathognomonic for palliative treatment intent; further complicating the issue are complexities surrounding the very select population of children receiving proton therapy (PrT). We compared data for RT and PrT in terms of death rate within 30 days. We performed chart reviews for patients receiving radiation therapy at age ≤21 years treated at Indiana University Health Proton Therapy Center (IUHPTC) between June 2008 and June 2013 and University of Miami Radiation Oncology Department (UM) between June 2000 and June 2013. Included were patients not completing prescribed courses of RT, and those dying within 30 days of therapy. Comparison was made of differences between practice data for PrT and conventional RT. At IUHPTC, 2 children of 272 did not complete their courses and died within 30 days (0.7%). At UM, data are available for 425 children; 9 did not complete their courses and 7 died within 30 days (1.6%). Neither the number of patients who did not complete treatment nor the 30-day death rates (P=.21) for PrT and RT were significantly different. Delivery of RT for children at EOL is complex. Frequency of RT at EOL in children occurs in is <2% of cases, and is not significantly less frequent in the proton milieu. This appears to be about an order of magnitude less than in adults.

Fiducial markers and spacers in prostate radiotherapy: current applications

To review the use of fiducial markers and spacers in prostate radiotherapy (RT). We reviewed the literature on the use of fiducial markers to improve accuracy in delivery of RT for prostate cancer. We discuss the rationale for fiducials, the types available, the procedures and complications. We also reviewed the current literature on the novel use of spacers to reduce rectal toxicity during prostate irradiation. Prostate motion is a significant problem both during and between RT treatments. Intraprostatic fiducials allow accurate prostate localisation ensuring RT treatment accuracy. Insertion of gold fiducials are a cost-effective marker that can be easily and quickly implanted and at least three fiducials are recommended. Severe complications from fiducial implantation are uncommon and marker migration is very rarely clinically significant. Spacers are a novel method to distance the rectum from the prostate during RT, reducing acute rectal toxicity, and have no detrimental impact on health-related quality of life. Intraprostatic fiducials are now standard of care when delivering prostate RT and early data shows benefit of spacers in reducing RT rectal toxicity.

Abstract P5-14-19: Radiation field design on the ACOSOG Z0011 trial

Abstract Purpose/Objective: The landmark ACOSOG Z0011 trial established that axillary lymph node dissection (ALND) is unnecessary in breast cancer patients with one or two positive sentinel lymph nodes (SLN) who undergo lumpectomy, radiation therapy (RT) and systemic therapy. At a median follow-up of 6.3 years there were no differences in overall survival or local-regional recurrences between patients receiving ALND or SLN biopsy alone. The protocol required whole breast RT using standard tangential fields, but the extent of RT coverage of the regional nodes in these patients has not previously been described. We sought to ascertain this information. Methods: The RT data on the ACOSOG Z0011 trial was collected from case report forms completed by enrolling providers 18 months after enrollment. The response options on the forms included breast, supraclavicular, &amp; other. We reviewed these data and, in 2011-2013, we attempted to identify and contact all treating radiation oncology practices to request detailed radiation treatment records for central review. RT data was sent to the Quality Assurance Review Center (QARC) and reviewed by two independent radiation oncologists, blinded regarding the arm to which the patients were randomized. Results: Of the 891 patients enrolled on Z0011, 35 withdrew consent prior to surgery, leaving 856 who were analyzed in the primary report on trial outcomes.1 Among the 605 of these patients with a completed adjuvant radiation therapy form, 89% were noted to receive whole breast RT. Of these, 89 patients (15%) were recorded as also receiving treatment to the supraclavicular region. Detailed RT records were received on 228 patients: 104/389 (26.7%) and 124/404 (30.7%) on the ALND and SLND arms, respectively. Of the 228 patients, 185 patients (81.1%) received tangent-only treatment. Among these 185 patients, there was sufficient data to evaluate tangent field height in 142 (76.8%). High tangent RT fields (with cranial tangent border within 2 cm of the humeral head) were used in 52.6% (40/76) patients randomized to the ALND arm and 50% (33/66) patients randomized to the SLND arm. Of the 228 patients with records reviewed, 43 (18.9%) received directed regional nodal RT using ≥3 fields: 22 in the ALND and 21 in the SLND arm. Those receiving directed nodal RT tended to have greater nodal involvement (p&amp;lt;0.001). Conclusions: Most patients treated on the Z0011 trial received tangential field RT alone, and some received no radiotherapy at all. Some patients received directed nodal irradiation via a third field. In a subgroup for whom detailed RT records were available, the highest rates of directed nodal irradiation were among those with multiple nodes involved. As survival rates and local-regional recurrences were similar in the study arms, no conclusions can be drawn from this analysis on whether this additional radiation treatment was necessary or beneficial. 1JAMA 2011; 305 (6): 569-575. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-14-19.

Primary Bone Lymphoma (PBL): Impact Of Novel Treatment On Need For Radiation Therapy (RT), a Population Based Study

BackgroundPBL is a known, but uncommon Non Hodgkin's Lymphoma (NHL). The data regarding its presentation and treatment, are few, and come from single institution studies. There are no large prospective trials available. The treatment has been similar to other NHL and the role of RT not clear in the contemporary period. MethodsWe reviewed data from Surveillance, Epidemiology, and End Results (SEER) 17 Regs Research Data registry for PBL patients. Patients with extra-nodal NHL arising from the bony structures, as their primary site, were chosen for the analysis. Analysis was done using SPSS Statistics software. ResultsData regarding 2700 patients were available and 54% of the patients were men, rest female. The median age at presentation was 58 (range 1-85 years. These patients were diagnosed with PBL from 1973 thru 2010. Diffuse Large B Cell Lymphoma (DLBCL) was the most common subtype – 62.7% and B cell Lymphoma (NOS) was the second most common 8.9%. Staging data for the PBL was available in 54.9% of all patients and among those with data available, only 14% had stage 4 disease. RT data was available in 2638 patients (of the total 2700) and only these were included in the survival analysis. Chemotherapy data are not available from the SEER database, but given the unanimity in the treatment of aggressive lymphomas, can be presumed to be standard CHOP chemotherapy and similar across all patients.In all, 1571 (60%) received RT. Of these, 864 patients were diagnosed before 2000 of which 612 received RT. Mean survival was higher in those who received RT 230.6 +_ S.E 6.03 vs. 200.9+- S.E 6.2 months, P=0.002. Rest of the 1774 patients were diagnosed after 2000 of which 959 received RT. Mean survival was 62.5 +- SE 1.37 months in those who received RT as compared to 56.4 +_ SE 1.5 months in those who did not receive RT, p= 0.026.DLBCL was the pathological subtype in1654 patients, with a mean age of 58 years and 54.4 % of these patients were men. Data about staging was not available for 53% of these patients, and of those with staging data known, 14.6 % were stage 4. One thousand and eighteen patients received RT. Among patients with DLBCL, mean survival was higher in those who received RT 115.6 +_ S.E 4.09 months vs 86.8 +- S.E 3.6 months in those who did not receive RT, P=0.0001. (Figure 1, Kaplan-Meier survival curve for the two groups). We also calculated survival in the two groups after excluding stage 4 , mean survival in those who received RT 124+- S.E 4.4 was higher than those who did not receive RT 100.2 +- SE 4.3 , p=0.0001. [Display omitted] Survival among the patients with DLBCL were analyzed based on date of diagnosis and compared among patients' who were diagnosed before 2000 or during/after 2000, as the use of rituximab in addition to chemotherapy started after 2000. One thousand and thirty seven patients were diagnosed after 2000 , in these patients , mean survival was not statistically different in those who received RT (60.93+_ S.E 1.6 months )when compared to those who did not receive RT ( 57.14+- 1.9months ) , p= 0.304. (Figure 2). Rest of the 517 patients were diagnosed before 2000 of which 367 received RT. Mean survival was higher (230.7+-S.E.7.9 ) in those who received RT in this group as compared to those who did not receive RT ( 197+-8.6 ) , p=0.01 (Figure 3). [Display omitted] [Display omitted] ConclusionDLBCL is the most common subtype of PBL, with a good prognosis. The benefit of RT is supported in PBL as a whole group. However, in patients with DLBCL treated after 2000, there was no statistically significant improvement after addition to RT. Prospective trials using chemo-immunotherapy with rituximab are needed to assess the need for RT, as the synergistic beneficial effects of Rituximab, may have reduced the need of RT. Disclosures:No relevant conflicts of interest to declare.