Local Control Rates Research Articles

Outcomes of Management of Progressive Radiosurgery-Treated Brain Metastasis With Resection Followed by Pathology-Informed Management: A Retrospective Study

BACKGROUND AND OBJECTIVES: In patients treated with stereotactic radiosurgery (SRS) for brain metastases, follow-up imaging demonstrating progression may result from treatment effect/radionecrosis (RN) or tumor progression. We report long-term outcomes for a cohort of patients who demonstrated radiological progression on serial imaging after initial radiation and who underwent resection, at which point histology informed further management. METHODS: A retrospective chart review identified 76 patients with an associated 82 brain lesions between 2009 and 2022, that were initially treated with SRS, and then demonstrated suspicious imaging developing through at least 2 scan time points with either pathologic confirmation of tumor or RN. RESULTS: Of the 82 lesions, 55 lesions (67.1%) were found to be tumor and were treated with repeat radiation and 27 (32.9%) were found to have pathologically confirmed RN and conservatively managed. 14/27 lesions ultimately found to be radionecrotic required steroids preoperatively due to neurological symptoms. None of these lesions required further intervention with median postsurgery follow-up of 24.4 months (range 1-104 months). There were 55 instances (in 51 patients) of confirmed recurrent/progressive tumor who we treated with repeat aggressive radiation with either Cs-131 brachytherapy (12 [21.8%]) or SRS (43 [78.2%]). Among patients treated with reirradiation, the median follow-up to local failure was 15.2 months (95% CI 7.3-26.6 months). The 2-year local control rate was 79.5% (95% CI 68.3%-92.5%). CONCLUSION: These results support resection of radiosurgery-treated lesions with progression continuing through serial imaging, and this pathology-informed management results in excellent control of both RN and tumor progression after radiosurgery.

Proton beam therapy for craniopharyngioma: a systematic review and meta-analysis.

Craniopharyngioma is a rare and slow-growing benign sellar or parasellar epithelial tumor. The number of patients receiving proton beam therapy (PBT) has increased. This study aimed to systematically evaluate and analyze the comprehensive evidence regarding the safety and efficacy of PBT for craniopharyngioma. We searched four databases: the Cochrane Library, PubMed, Embase, and Web of Science. The period was from their inception to February 16, 2024. Two researchers independently screened the literature and extracted data. Among 486 candidate articles, eight studies were included in our study. Exactly 393 patients with craniopharyngioma underwent PBT in these studies. These studies reported data on survival and toxicity. The median sample size was 42.5 patients. The median age was9.1-37years; the female proportion was 48.9%, and the median follow-up time was 29-91.4months. All patients were treated once daily, five times a week, with a fraction of 1.8Gy (RBE) per session. The median total dose was 54.0Gy (RBE). The local control rates at 3 and 5years in these studies were 99% and 93%, respectively. The overall survival rates at 3 and 5years in these studies were both 100%. The incidence of acute and late toxicities was mainly grade 1-2. The main late toxicities included vascular and visual toxicities, hypothalamic obesity, endocrinopathy, and panhypopituitarism. PBT for craniopharyngioma, especially in children and adolescents, has shown impressive local control and acceptable acute and late toxicities.

Respiratory-gated proton beam therapy for intrahepatic cholangiocarcinoma without fiducial markers.

Intrahepatic cholangiocarcinoma (ICC) is a challenging primary liver cancer with a poor prognosis, especially in unresectable cases. Traditional palliative irradiation is limited in reducing liver doses. This study aimed to evaluate the efficacy and toxicity of respiratory-gated proton beam therapy without fiducial markers for intrahepatic cholangiocarcinoma. Between October 2011 and February 2022, 24 patients (median [range] age, 71 [41-88] years) were evaluated at our institution. Twelve patients were pathologically diagnosed with ICC. All patients underwent respiratory-gated proton beam therapy at a dose of 48-83.6 (relative biological effectiveness) in 20-38 fractions with four-dimensional computed tomography planning. The median follow-up period was 18.5 (range, 2.0-74.0) months. The median tumor size was 41 (range, 10-134) mm. Twenty-one patients were classified as having Child-Pugh class A, and three patients were classified as having Child-Pugh class B. Local progression was defined as any growth of the irradiated tumor. The median survival time was 28months for all patients. The Kaplan-Meier estimates of the 2-year overall survival, progression-free survival, and local tumor control rates were 51%, 26%, and 73%, respectively. Local tumor control rates were non-inferior to those reported in previous studies using fiducial markers. One patient had grade 4 pleural effusion; however, whether this was an adverse event due to the proton beam therapy was unclear. Respiratory-gated proton beam therapy without fiducial markers is an effective and less invasive treatment option for ICC, showing potential for improved local control and tolerable adverse effects.

Efficacy of palliative hemostatic radiotherapy for tumor bleeding and pain relief in locally advanced pelvic gynecological malignancies.

The appearance of symptomatic tumor-related vaginal bleeding and pain in advanced incurable cancer patients with pelvic gynecological malignancies remains atherapeutic challenge in oncological treatment. The aim of our analysis was to evaluate the efficacy and safety of palliative hemostatic radiotherapy. We retrospectively identified patients who had received palliative hemostatic radiotherapy (RT) at our institution between 2011 and 2023 and evaluated acute toxicity, local control, cessation of bleeding, and pain relief. In total, 40patients with amedian planning target volume of 804 cm3 were treated with amedian total dose of 39 Gy in 13fractions, resulting in 6‑month and 1‑year local control rates of 66.9 and 60.8%, respectively. No higher-grade (>gradeIII) acute RT-induced toxicity appeared. Complete cessation of bleeding was achieved in 80.0% of all patients after amedian of 16days and pain relief was documented in 60.9% at first follow-up. 37.5% of the women required ablood transfusion and 25% an additional tamponade with local hemostatic agents. Successful stopping of bleeding was significantly less frequent in patients receiving anticoagulation concurrently with radiation and in the case of infield re-irradiation. Patients with ahigher total RT dose had cessation of bleeding significantly more often, with acut-off value of at least EQD2 (α/β = 10) = 36 Gy. The applied RT technique and planning target volume had no significant influence on the occurrence of bleeding cessation. Palliative hemostatic radiotherapy for locally advanced pelvic gynecological malignancies is safe and effective in achieving high control rates of hemostasis in tumor bleeding and pain relief.

SURG-41. OPTIMIZING PATIENT OUTCOMES IN PETROCLIVAL MENINGIOMA TREATMENT: EVALUATING SURGICAL, RADIOSURGICAL, RADIOTHERAPY AND COMBINED TREATMENT APPROACHES

Abstract Petroclival meningiomas pose a formidable challenge due to their proximity to critical neurovascular structures, necessitating complex surgical interventions with a high risk of complications. Stereotactic radiosurgery (SRS) offers an alternative or complementary treatment option, yet the optimal treatment strategy remains undefined. We aimed to evaluate the local control rates following surgical resection, radiotherapy, and SRS for petroclival meningiomas and to assess the incidence of cranial nerve palsies associated with each treatment modality. This retrospective study reviewed medical records of patients treated for petroclival meningiomas at Stanford University between 1980-April 2024. Pre- and post-treatment radiological data were analyzed to assess local control. Cranial nerve function was evaluated pre- and post-treatment, and at last follow-up. A total of 171 patients (129 females; median age 54.65 years) diagnosed with petroclival meningioma were identified. Treatment modalities included: 31 patients underwent surgical resection alone, 27 received SRS alone, 11 received radiotherapy alone, 36 underwent combined surgical resection and SRS, 28 received combined surgical resection and radiotherapy, 9 were treated with a triad of surgical resection, SRS, and radiotherapy, and 29 were managed with serial imaging alone. The percentage change of tumor volume from diagnosis to follow-up for these groups was -55.6%, 28.9%, 73.0%, -64.9%, -12.0%, 35.3%, and -8.8%, respectively. The incidence of new cranial nerve palsies was highest (68%) in patients who underwent surgical resection. The percentage of worsening pre-existing palsies was greater in patients receiving single-modality non-surgical treatment. Surgery, radiotherapy, and SRS demonstrated promising local control rates for specific patient cohorts with petroclival meningiomas. Patients receiving combination therapies generally fared better than those receiving single-modality treatments, with surgery followed by SRS yielding the best outcome. The incidence of cranial nerve palsies was lower following SRS and radiotherapy compared to surgery. Future research should focus on refining multi-modal treatment strategies to minimize complications and improve patient quality of life.

RADT-22. EFFICACY AND SAFETY OF CYBERKNIFE STEREOTACTIC RADIOSURGERY FOR OCCIPITAL CONDYLE METASTASIS

Abstract BACKGROUND Occipital condyle metastasis (OCM) is a rare condition characterized by severe occipital pain and neurological symptoms due to lower cranial nerve deficits, stemming from its anatomical location. Despite the widespread use of stereotactic radiosurgery (SRS) for cranial metastases, its specific impact on OCM remains underexplored. OBJECTIVE This study evaluates the efficacy and safety of CyberKnife SRS in treating OCM, focusing on symptom control and local tumor control. METHOD We retrospectively analyzed cases of OCM treated with SRS at our institute from 2012 to 2023, evaluating patient demographics, presenting symptoms, treatment parameters, and outcomes. Key measures included occipital pain, dysfunctions of cranial nerves IX, X, and XII, and local tumor control. RESULTS Eighteen patients (10 females) with a median age of 64 years (range: 40-79) were treated. Common presentations included occipital pain (44%) and lower cranial nerve deficits (28%). The median target volume was 6.95 cc (range: 0.95-72.7), and the median margin dose was 20 Gy (range: 16-40). The median follow-up period was 7 months (range: 1-44). Notably, only one patient experienced tumor recurrence and subsequently died from primary cancer progression five months after treatment. SRS achieved a 93.8% local tumor control rate over three years, with a median overall survival of 13 months. Among those presenting with symptoms, 87.5% reported pain relief, and 80% observed improvements in cranial nerve function. The only patient without clinical symptom improvement also had tumor recurrence. CONCLUSION CyberKnife SRS is a promising treatment for OCM, offering significant pain relief and improvement in neurological symptoms with excellent local control rates. This non-invasive therapy provides a valuable alternative to surgery, potentially enhancing the quality of life for patients with limited treatment options due to this challenging condition.

RADT-50. CLINICAL OUTCOME OF DAILY 5-FRACTIONATED GAMMA KNIFE RADIOSURGERY FOR LARGE BRAIN METASTASES

Abstract INTRODUCTION With the introduction of the Gamma Knife Icon, hypo-fractionated Gamma Knife radiosurgery (GKRS) for large brain metastases (LBMs) is beginning to be performed. This study aimed to assess the clinical outcome and risk of the daily 5-fractionated GKRS for LBMs. METHODS A total of 100 patients who underwent 5-fractionated GKRS for LBMs (> 14cm3) were enrolled. Forty-six were male patients, and the median age was 60 years. Most common primary cancer sites were lung (41 non-small cell cancers), breast (24), and kidney (14). The median tumor volume was 22cm3 (14 – 69cm3) and marginal dose was 35Gy (50% isodose line) in 5 fractions. Median follow-up duration was 18 months (3 – 72 months). RESULTS The last follow-up showed local tumor control in 74 cases. The cumulative 1, 2, and 3-year local tumor control rates were 73, 65, and 60%, respectively. Eighty-six tumors showed best MRI response in a year, and median tumor volume decrease rate was 80% (22 – 100%). Thirty patients experienced dramatically tumor volume decrease (> 95%). Median progression free and overall survival were 7 and 16 months, respectively. Radiation necrosis occurred in 24 patients, of which only 9 had neurological symptoms and treated with steroid and bevacizumab. CONCLUSIONS The daily 5-fractionated GKRS for very LBMs showed favorable local tumor control and acceptable radiation necrosis, but questionable survival benefit. In the future, prospective multi-center study is needed.

RADT-21. EFFICACY AND SAFETY OF DONUT-SHAPED CIRCUMFERENTIAL SPINE CYBERKNIFE STEREOTACTIC BODY RADIOTHERAPY FOR METASTATIC SPINE DISEASE

Abstract BACKGROUND Spinal metastases (SM) with epidural spinal cord compression (ESCC) are challenging to manage due to the risk of radiation-induced injury. Traditional approaches often avoid circumferential stereotactic body radiotherapy (SBRT) because of these risks. The efficacy and safety of donut-shaped circumferential SBRT, which envelops the spinal column while sparing the cord, remains underexplored. OBJECTIVE This study evaluates the safety and efficacy of donut-shaped circumferential spine CyberKnife SBRT in treating spinal metastases, focusing on preventing radiation-induced myelopathy and achieving local tumor control. METHOD We retrospectively analyzed patients treated with donut-shaped circumferential spine SBRT from 2014 to 2023. We evaluated demographics, grade of ESCC (Bilsky), prior treatments, symptoms, treatment parameters, and outcomes. Key measures included SBRT dosimetric data, radiation exposure to the spinal cord or cauda equina, adherence to dose-volume constraints, occurrence of post-SBRT myelopathy, other radiation-induced complications, and local tumor control. RESULTS Forty-eight lesions from 43 patients (median age: 65 years; range: 20-78) were analyzed. Only one patient underwent separation surgery for severe ESCC (Bilsky grade 3). The median clinical target volume (CTV) was 63.77 cc (range: 20.31-270.05), and the median margin dose was 24 Gy (range: 18-30). Over a median follow-up of 8 months (range: 1-91), local tumor control rates were 91.1% at 6 months, 87.1% at 1 year, 82.8% at 3 years, and 62.1% at 5 years. Median overall survival was 17 months. Of 20 lesions exceeding dose constraints, only one patient displayed clinical myelopathy symptoms, correlating with local tumor recurrence. There was no radiographic myelopathy or other radiation-induced complications during follow-up. CONCLUSION Donut-shaped circumferential spine CyberKnife SBRT provides effective and safe treatment for spinal metastases with or without epidural involvement. It achieves substantial local tumor control and has a minimal incidence of radiation-induced myelopathy, offering a viable non-surgical option for managing this complex condition.

SURG-53. LONG TERM FOLLOW-UP OF RESECTION PLUS CESIUM-131 BRACHYTHERAPY FOR PREVIOUSLY IRRADIATED RECURRENT BRAIN METASTASES

Abstract BACKGROUND Recurrent brain metastases (rBM) after previous radiosurgery present a clinical dilemma, as the advantages of reirradiation need to be weighed against the potential of significant radiation toxicity. Salvage resection with Cs-131 brachytherapy offers improved dosimetry due to reduced integral dose to healthy brain compared to repeat radiosurgery. We previously reported initial results of rBM treated with resection and salvage Cs131 brachytherapy; we present an updated analysis of tumor control with extended follow-up. METHODS We analyzed consecutive patients with rBM previously treated with radiosurgery, who underwent salvage resection plus implantation of Cs131 seeds (GammaTile, GT Medical Technologies). The prescribed brachytherapy dose was 60 Gy at 5mm from the cavity. Median follow-up was calculated using reverse Kaplan-Meier. Local recurrence was defined by new nodular contrast enhancement with hyperperfusion within 5mm of the resection cavity. Marginal recurrence was defined as >5mm but not beyond 1cm from the cavity. Local control and overall survival (OS) from brachytherapy were analyzed using Kaplan-Meier. RESULTS Twenty-five patients underwent Cs131 implantation in 30 tumor cavities. The median presurgical rBM maximal diameter was 2.95 cm (range 1.1-6.3). The most common histology was lung adenocarcinoma (n=8, 27%) followed by breast (n=7, 23%) and renal cell (n=3, 10%). Radiographic gross- or near-total resection was achieved in 80% of lesions. The median number of Cs131 seeds implanted was 17, (range 6-30), (median strength 3.5 U/seed). With median follow-up of 37 months (95%CI:29-45), twelve and 24-month OS was 55% and 41%, respectively. Four tumors recurred (3 in-field, one marginal) for a 1- and 2-year local control rate of 87% and 81%, respectively. Data for adverse radiation effects is under analysis and will be presented. CONCLUSIONS With over 3 years of follow-up, intraoperative brachytherapy with collagen-embedded Cs131 implants was associated with durable local control for this challenging clinical scenario. A randomized Phase II trial of Cs131 vs. standard of care for rBM (NCT04690348) is actively accruing.

RTID-05. STUDY PROTOCOL: A MULTICENTER, INTERNATIONAL RANDOMIZED CONFIRMATORY TRIAL: LOW-ENERGY X-RAY INTRAOPERATIVE RADIATION THERAPY (LEX-IORT) VS. ADJUVANT FRACTIONATED STEREOTACTIC RADIOTHERAPY (FSRT) IN THE MANAGEMENT OF BRAIN METASTASES (LEXIMATE)

Abstract BACKGROUND Fractionated stereotactic radiotherapy to the resection cavity boosts local control of resected brain metastases significantly. However, start of systemic tumor-directed treatment may be protracted and in-hospital times prolonged. Lately, lex-ioRT of BM has been described as a safe and effective one stop-shop treatment modality with a 1-year local control rate of up to 98% while potentially improving patient convenience. Study Design: The LEXIMATE-trial is a multicenter, international, randomized open-label confirmatory trial comparing lex-IORT with FSRT of resected BM. In the experimental arm, INTRABEAM (Carl Zeiss Meditec AG) is used to deliver IORT by application of 50-kV photons at a standard dose of 30 Gy prescribed to the applicator surface. Standard linear accelerator or Gamma Knife based FSRT (3-7 fractions) to the surgical bed is used in the control arm. The primary endpoint is the cumulative incidence of local recurrences (as per RANO-BM) considering death without prior local recurrence as competing event. Inclusion criteria include histologically confirmed BM with indication for resection according to EANO-ESMO/ASCO-SNO-ASTRO guidelines, ≤5 other brain lesions compatible with BM and amenable to radiosurgery and history of solid cancer or CT scan suggestive for localized or metastasized solid cancer (except germ cell tumors, lymphoma, small-cell lung cancer). The resection cavity must be <5cm in size, IORT doses to brainstem or optical tract may not exceed 8 Gy. Study design: Randomized, open-label, non-inferiority. Sample size: 70 patients per group to show a non-inferiority of the experimental therapy compared to the control therapy with a power of approximately 80%. DISCUSSION The best radio-oncologic procedure for resected BM remains under debate. The LEXIMATE-trial offers an opportunity to provide more solid prospective data on effectiveness, safety and patient comfort both for established and new RT techniques.

RADT-15. THE ROLE OF STEREOTACTIC RADIOSURGERY IN WHO GRADE II MENINGIOMAS: RESULTS FROM A LARGE EUROPEAN MULTICENTER STUDY

Abstract BACKGROUND This study evaluates the outcomes of WHO grade II meningiomas treated with stereotactic radiosurgery (SRS) using a large, multi-institutional European database. We aim to investigate the long-term tumor control rate and morbidity associated with SRS. METHODS Data from 355 consecutive patients treated between 1992 and 2022 at 16 European radiosurgery centers were retrospectively analyzed. After excluding 40 patients due to loss to follow-up, results from 315 patients were included. Clinical and imaging data were independently collected by each center and uniformly entered into a multicenter database. RESULTS The median age of patients was 56 years, with 54% being female. The median follow-up duration was 46.3 ± 36.9 months. Tumors had prior surgical treatment and biopsy in 99% and 1% of cases, respectively. Tumors received previous radiotherapy or SRS in 27.4% of cases. SRS was performed due to local progression in 89.6% of cases, residual tumor in 6.4%, and distant progression in 4.0%. SRS characteristics included a median target volume of 5.1 cm³ and a median margin dose of 16 Gy (53.5% isodose). The 3-year local control rate was 72.0%, with a progression-free survival rate of 66.6% and an overall survival rate of 89.7%. Transient and permanent morbidity rates were 6.4% and 3.5%, respectively. Multivariate analysis identified previous radiotherapy and age as significant factors influencing these outcomes. CONCLUSIONS This study is the largest to date on SRS in WHO grade II meningiomas. Our data shows that SRS is a viable and safe treatment option for residual and recurrent WHO grade II meningiomas

Verification of linear energy transfer optimized carbon-ion radiotherapy.

Linear energy transfer (LET) verification was conducted using a silicon-on-insulator (SOI) microdosimeter during the commissioning of LET-optimized carbon-ion radiotherapy. This advanced treatment technique is expected to improve local control rates, especially in hypoxic tumors. 
Approach: An SOI microdosimeter with a cylindrical sensitive volume of 30 μm diameter and 5 μm thickness was used. Simple cubic plans and patient plans using the carbon-ion beams were created by treatment planning system, and the calculated LETd values were compared with the measured LETd values obtained by the SOI microdosimeter. 
Main results: Reasonable agreement between the measured and calculated LETd was seen in the plateau region of depth LETd profile, whereas the measured LETd were below the calculated LETd in the peak region, specifically where LETd exceeds 75 keV/μm. The discrepancy in the peak region may arise from the uncertainties in the calibration process of the SOI microdosimeter. Excluding the peak region, the average ratio and standard deviation between measured and calculated LETd values were 0.996 and 7%, respectively. 
Significance: This verification results in the initiation of clinical trials for LET-optimized carbon-ion radiotherapy at QST Hospital, National Institutes for Quantum Science and Technology.

Once-a-Week Ablative Radiotherapy as Replacement of Prolonged Fractionation in Frail Patients: Feasibility and Toxicity Results

Introduction The aim of this work was to explore the use of an original once-weekly radiotherapy fractionation in elderly or frail patients with recurrence or metastasis from different solid malignancies. Material and Methods A retrospective analysis was conducted on 29 patients treated from 2011 to 2019 with a once-weekly radiotherapy schedule. Patients received a median dose of 27.5 Gy, with weekly fractions of 4-5 Gy over 7-10 weeks. The treatment aimed at both palliative and cytoreductive objectives. Primary endpoints were feasibility and compliance, secondary outcome was acute toxicity. Results All patients completed the planned radiotherapy without interruptions. Acute toxicity was mild, with only one patient developing grade 3 toxicity (bowel perforation). Three months post-treatment, 74% of patients experienced symptom relief and tumor response. One-year local control rates were 26.7%, and treatment was generally well-tolerated. Conclusion This once-weekly hypofractionated radiotherapy regimen demonstrated feasibility, good tolerance, and promising tumor response in frail and elderly patients. Although limited by a small sample size, the approach offers a practical alternative for patients unable to undergo conventional daily radiotherapy. Further studies on larger cohorts are required to validate these findings.

Ten-Year Outcome After Supracricoid Partial Laryngectomy in cT3M0 Laryngeal Squamous Cell Carcinoma-A STROBE Analysis.

The aim of this study was to document 10-year outcomes after supracricoid partial laryngectomy (SCPL) in selected cT3M0 laryngeal squamous cell carcinoma (SCC) patients. This real-life retrospective observational study analyzed an inception cohort of 168 patients with isolated, untreated, selected cT3M0 laryngeal SCC, that were consecutively managed by SCPL during the period 1973-2013, and followed up until death or for a minimum of 10 years in 92% of cases at a single French academic and tertiary referral care center. Prior induction chemotherapy, arytenoid cartilage removal, level II-IV neck dissection, and postoperative radiation therapy were performed on 148, 77, 136, and 27 patients, respectively. The main objective was to determine 10-year actuarial local control and laryngeal preservation estimates. Secondary objectives included 10-year actuarial survival and cause-of-death analysis, and assessment of correlations between endpoints and clinical variables. The significance threshold was set at p < 0.005. Ten-year actuarial local control, laryngeal preservation, and survival estimates were 90%, 85%, and 52%, respectively. Salvage treatment resulted in an overall 99% local control rate. Metachronous second primary cancer, intercurrent disease without evidence of SCC, SCPL-related death, and uncontrolled local recurrence accounted for 31%, 26%, 7%, and 2% of causes of death. On univariate analysis, overall local recurrence and laryngeal preservation rates varied significantly, from 5% to 54% and 90% to 46% when resection margins were R0 and R1, respectively. The present study highlighted successful 10-year outcomes after SCPL, providing further evidence in favor of its integration into the conservative armamentarium for endolaryngeal cT3 SCC. 4 Laryngoscope, 134:4557-4563, 2024.

The Role of CT and MR Imaging in Stereotactic Body Radiotherapy of the Spine: From Patient Selection and Treatment Planning to Post-Treatment Monitoring.

Spine metastases (SMs) are common, arising in 70% of the cases of the most prevalent malignancies in males (prostate cancer) and females (breast cancer). Stereotactic body radiotherapy, or SBRT, has been incorporated into clinical treatment algorithms over the past decade. SBRT has shown promising rates of local control for oligometastatic spinal lesions with low radiation dose to adjacent critical tissues, particularly the spinal cord. Imaging is critically important in SBRT planning, guidance, and response monitoring. This paper reviews the roles of imaging in spine SBRT, including conventional and advanced imaging approaches for SM detection, treatment planning, and post-SBRT follow-up.

Stereotactic Radiosurgery Dose Reduction for Melanoma Brain Metastases Patients on Immunotherapy or Target Therapy: A Single-Center Experience.

Better local control but higher rates of adverse radiation events (ARE) have been reported when combining American Society for Radiation Oncology (ASTRO)-guideline-suggested dose (SD) stereotactic radiosurgery (SRS) with immunotherapy or targeted therapy for melanoma brain metastases. The objective of this study is to explore the efficacy and safety of lower prescription doses compared with ASTRO guidelines for single-fraction SRS for patients with melanoma metastases who are concurrently receiving immunotherapy or targeted therapy. We conducted a retrospective, single-center study on 194 patients who underwent SRS between 2009 and 2022. After propensity score matching, 71 patients with 292 metastases were included in the ASTRO-SD (20-24 Gy for <2 cm, 18 Gy for ≥2 to <3 cm) group and 33 patients with 292 metastases in the reduced dose (RD, <20 Gy for <2 cm, <18 Gy for ≥2 to <3 cm) group. The median diameter (5.4 vs 5.2 mm, P = .6), prescription volume (0.2 vs 0.2 cm3, P = .2), and radiographic follow-up (11 vs 12 months, P = .2) were similar in the 2 groups. The cumulative incidence of progressing metastases was significantly higher in the SD compared with the RD group (P = .018). Higher prescription volumes and ASTRO-suggested radiation doses were associated with local progression in multivariable analysis. Radiographic AREs were significantly more common in the SD compared with the RD group (8.6% vs 3.1%, P = .005). BRAF and other tyrosine kinase inhibitors' concurrent use, higher prescription volumes, and ASTRO-suggested radiation doses were associated with an increased risk of radiographic ARE. This study provides evidence that RD SRS could offer reduced toxicity rates, while maintaining high local control as compared with the current guideline-SDs for the treatment of melanoma brain metastases.

External beam radiotherapy followed by image-guided adaptive brachytherapy in locally advanced cervical cancer: a multicenter retrospective analysis.

To evaluate oncological outcomes and toxicities in patients with locally advanced cervical cancer (LACC) treated with concurrent chemoradiotherapy followed by image-guided adaptive brachytherapy at two Italian centres. A retrospective analysis was conducted on 122 patients with LACC treated between 2010 and 2022. Primary endpoints were local control (LC), pelvic control (PC), and nodal control (NC). Secondary endpoints included disease-free survival (DFS), metastasis-free survival (MFS), overall survival (OS), and late toxicity. Correlations between patient characteristics and oncological outcomes were conducted. Brachytherapy planning was CT and MRI-based in 88 (72.1%) and 34 patients (27.9%), respectively. The mean total dose (EQD2) delivered to high-risk clinical target volume was 82Gy. Overall treatment time was ≤ 50days and > 50days in 48 (39.3%) and 74 patients (60.7%), respectively. At a mean follow up of 101months, 3 and 5-year LC rates were 87% and 85%, respectively. Five-year PC and NC rates were 77% and 85.1%. Five-year DFS and OS were 61% and 65.4%, respectively, with significant correlations between these outcomes and FIGO stage and nodal status at diagnosis. Gastrointestinal, genitourinary and vaginal adverse effects were the most reported late toxicities and 8 (6.5%) grade 3-5 events were observed. 32 patients (26.2%) had vaginal stenosis and it was significantly related to 3D imaging used for brachytherapy planning. The study confirmed the efficacy and safety of chemoradiotherapy and IGABT for LACC. Full implementation of MRI treatment planning and interstitial techniques could further enhance personalized treatment and outcomes.

Comparative analysis of clinical treatment outcomes: Breath-hold vs. free-breathing techniques in liver stereotactic body radiotherapy.

The aim of this study was to clarify the safety and efficacy of breath-hold irradiation in liver stereotactic body radiotherapy (SBRT). A retrospective analysis was conducted on 57 consecutive patients who received SBRT for hepatocellular carcinoma or liver metastases between 2013 and 2021. Breath-hold irradiation was implemented for patients treated after April 2020. The median follow-up period for all patients was 16.4 months (IQR: 7.36-20.9). The 2-year overall survival rate was 64.4% (95% CI: 47.4-77.2), and the local control rate was 84.3% (95% CI: 69.7-92.3) for all patients. The 1-year overall survival was 80.0% (95% CI: 60.8-90.5) versus 82.0% (95% CI: 53.5-93.9) in the free-respiratory (FR) group versus the breath-hold (BH) group, respectively (P = 0.60). The 1-year local control rates were 78.1% (95% CI: 57.5-89.5) in the FR group and 95.7% (95% CI: 72.9-99.4) in the BH group, respectively (P = 0.16). Radiation-induced liver injury, defined by an escalation of ≥2 in Child-Pugh score, was observed in four patients within each group (FR 13% vs. BH 15%). There were no gastrointestinal adverse events of Grade 3 or higher. Breath-hold irradiation can be safely administered and has demonstrated clinical potential in improving local control. Further research into dose escalation using breath-hold techniques is warranted.

Stereotactic body radiotherapy alone versus stereotactic body radiotherapy after incomplete transarterial therapy for hepatocellular carcinoma.

We investigated the clinical outcomes of stereotactic body radiation therapy (SBRT) alone versus SBRT after incomplete transarterial chemoembolization (TACE) for a single recurrent hepatocellular carcinoma (HCC) smaller than 5 cm. We retrospectively reviewed the medical records of patients who underwent SBRT for a single recurrent HCC ≤5 cm, without vascular invasion or extrahepatic metastasis. Patients were divided into the SBRT-alone group and the TACE-SBRT group. The primary outcome was the local control (LC) rate, and secondary outcomes were survivals and treatment-related toxicities. We additionally conducted a propensity score matching (PSM) analysis. A total of 477 patients were available for analysis. Among them, 54 patients received SBRT without prior treatment to the target lesion (SBRT-alone group), whereas 423 patients received SBRT for viable HCC after TACE (TACE-SBRT group). The 3-year LC rates did not differ between the two groups (SBRT-alone group, 88.6% vs. TACE-SBRT group, 89.6%, P = 0.918). The 3-year rates of overall survival, out-of-field intrahepatic recurrence-free survival and recurrence-free survival were also not significantly different (P = 0.479, 0.290 and 0.273, respectively). Even after PSM, LC and survival rates at 3 years were not significantly different. SBRT alone demonstrated comparable local control and survival outcomes to SBRT following incomplete TACE. SBRT alone may be considered an alternative treatment option for a single recurrent HCC smaller than 5 cm when curative treatments or TACE are not feasible.

Therapeutic strategies for mobile spine chordoma: en bloc Versus intralesional surgery with adjuvant charged-particle therapy.

The aim of this retrospective study is to analyze the impact of en bloc resection with negative margins versus intralesional resection plus adjuvant hadron-therapy (HT) on local control (LC) and overall survival (OS) in patients with mobile spine chordomas. Mechanical complications incidence as well as risk factors, and outcome differences are investigated as secondary endpoints. 33 patients in a period from January 2013 to December 2021 were enrolled for the final analysis. The inclusion criteria were: lesions located in the mobile spine (C1-L5), age ≥ 15 years, minimum follow-up of 2 years, en bloc or intralesional surgical resection, virgin or recurrent chordomas, with only one previous surgical treatment. No difference was found in terms of LC between the two groups. The presence of pathologic fracture at pre-operative imaging and the presence of macroscopic residual tumor after surgery, independently from its entity, seemed to be associated with an increased risk of LR. No difference was found between planned en bloc and planned intralesional surgery in terms of mechanical complications occurrence. Eight patients (24.24%) had mechanical complications during the follow up period: male sex, presence of pathologic fracture at baseline, a combined surgical approach, the use of carbon fiber-only hardware appeared to be associated with an increased risk of mechanical complications after the primary surgery. En bloc resection, whenever possible, is always to be preferred for its widely recognized potential in LC and OS improvement. However, technology advances in high-dose conformal charged-particle therapy have allowed improvement of local control rates as an adjuvant therapy of intralesional surgery for mobile spine chordoma, with acceptable acute and chronic toxicity.