Salvage Intensity-modulated Radiotherapy Research Articles

Intensity modulated radiation therapy for definitive treatment of paraortic relapse in patients with endometrial cancer

PurposeThe paraortic nodes are a common site of recurrence of endometrial cancer, especially among patients previously treated with pelvic radiation. Intensity modulated radiation therapy (IMRT) can be used to deliver a tumoricidal dose to paraortic disease while minimizing dose to normal adjacent structures. In this study, we reviewed the outcomes of patients treated with IMRT for unresected or incompletely resected paraortic recurrences of primary uterine cancer. Methods and MaterialsBetween 2000 and 2009, 27 patients with unresected (19 patients) or incompletely resected (8 patients) paraortic relapse of endometrial cancer were treated with curative intent using IMRT. The paraortic basin was generally treated to a dose of 45-50 Gy, and gross disease was treated to a mean total dose of 61.7 Gy (range, 54-66 Gy). Seventeen patients (63%) received neoadjuvant or adjuvant chemotherapy. Fifteen (56%) received cisplatin concurrently with IMRT. Rates of overall survival and progression-free survival following salvage IMRT were determined using the Kaplan-Meier method, and differences between subgroups were assessed using the log-rank statistic. ResultsOf the 27 patients, 19 (70%) had local control of paraortic disease after a median follow-up time of 25 months (range, 4-83 months). Two-year actuarial overall survival and progression-free survival rates were 63% and 53%, respectively. Five patients (19%) experienced severe late gastrointestinal toxic effects (grade 3-5). ConclusionsIMRT can serve as salvage therapy of paraortic recurrence of endometrial cancer. However, the risk of severe gastrointestinal toxic effects is high, and care should be taken during treatment planning to minimize the dose to the small bowel.

Three Years of Salvage IMRT for Prostate Cancer: Results of the Montpellier Cancer Center

Background. To assess the feasibility of salvage intensity-modulated radiation Therapy (IMRT) and to examine clinical outcome. Patients and Methods. 57 patients were treated with salvage IMRT to the prostate bed in our center from January, 2007, to February, 2010. The mean prescription dose was 68 Gy in 34 fractions. Forty-four patients received concomitant androgen deprivation. Results. Doses to organs at risk were low without altering target volume coverage. Salvage IMRT was feasible without any grade 3 or 4 acute gastrointestinal or urinary toxicity. With a median follow-up of 21 months, one grade 2 urinary and 1 grade ≥2 rectal late toxicities were reported. Biological relapse-free survival was 96.5% (2.3% (1/44) relapsed with androgen suppression and 7.7% (1/13) without). Conclusion. Salvage IMRT is feasible and results in low acute and chronic side-effects. Longer follow-up is warranted to draw conclusions in terms of oncologic control.

Endorectal balloon reduces anorectal doses in post-prostatectomy intensity-modulated radiotherapy

Background and purposeTo investigate the effect of an endorectal balloon (ERB) on anal wall (Awall) and rectal wall (Rwall) doses in high-dose post-prostatectomy intensity-modulated radiotherapy (IMRT). Materials and methodsFor 20 patients, referred for salvage IMRT after prostatectomy for prostate cancer, two planning CT-scans were performed: one with and one without an air-filled ERB. A planning target volume (PTV) was defined, using international guidelines. Furthermore, the Awall and Rwall were delineated. In both the scans, IMRT plans were generated with a prescribed dose of 70Gy. The mean dose (Dmean), maximum dose, minimum dose, and volumes exposed to doses ranging from ⩾20 to ⩾70Gy (V20–V70) to the Awall and Rwall were calculated. Finally, inner Rwall surface areas exposed to doses ranging from ⩾20 to ⩾70Gy (A20–A70) were calculated. Dose-parameters were compared between plans with and without ERB. ResultsAll Awall parameters, except V70, were significantly reduced by the ERB with an overall Dmean reduction of 6Gy. Absolute reductions in dose–volume parameters varied from 5% to 11%. Significantly reduced Rwall V30, V40, and A40 were observed with ERB, irrespective of the target volume size. ConclusionERB application significantly reduces Awall and to a lesser degree Rwall doses in high-dose post-prostatectomy IMRT.

Endoscopic Surgery and IMRT Are Effective in Recurrent NPC

Objective: Salvage surgery and radiotherapy showed positive and similar survival outcomes in rT1/2 local recurrent nasopharyngeal carcinoma (rNPC) but no curative value in rT3/4 ones in the past. We will evaluate new techniques such as endoscopic surgery and intensity-modulated radiotherapy (IMRT) to compare with conventional radiotherapy (CRT) and chemotherapy in rNPC. Method: We did a retrospective review of 493 rNPC patients from January 2000 to December 2009. IMRT, CRT, and/or chemotherapy were suitable to all rT stage cases, but endoscopic surgery was applied to rT1 and some selected rT2/T3 cases. The 5-year overall survival rate (OS) and other oncological outcomes were summarized. Results: Among 493 cases, 120, 82, 132, and 159 were restaged in rT1N0M0, rT2N0M0, rT3N0M0, and rT4N0M0 according to AJCC/UICC 2002 TNM stage system. The 5-year OS was 73.0%, 37.0%, 17.3%, and 16.5% in rT1, rT2, rT3, and rT4 patients ( P < .05). Adjusted for rT stages, the salvage surgery and IMRT showed a better survival curve than conventional radiotherapy and chemotherapy ( P < .01). In rT1 patients, the 5-year OS of patients who received salvage endoscopic surgery was better than that of ones who received IMRT (89.3% vs 69.0%, P < .01). Cox analysis showed that age, stage, and salvage treatment were significant independent predictors for OS. Conclusion: Although patients in the earlier rT stage showed better survival than ones in the advanced rT stage, new salvage treatments based on endoscopic surgery and IMRT benefited all rT stage rNPC compared with CRT and chemotherapy. Futhermore, salvage endoscopic surgery may be a more promising option than IMRT in rT1 patients.

High-Dose Salvage Intensity-Modulated Radiotherapy With or Without Androgen Deprivation After Radical Prostatectomy for Rising or Persisting Prostate-Specific Antigen: 5-Year Results

BackgroundLong-term results with salvage radiotherapy (SRT) for a biochemical recurrence after radical prostatectomy (RP) are poor. It has been suggested that radiotherapy doses >70Gy might result in improved outcome. ObjectiveTo report on the late toxicity profile and outcome of patients treated with high-dose salvage intensity-modulated radiotherapy (HD-SIMRT) with or without androgen deprivation (AD). Design, setting, and participantsBetween 1999 and 2008, 136 patients were referred for HD-SIMRT with or without AD. The median follow-up was 5 yr. Indications for HD-SIMRT were persisting prostate-specific antigen (PSA) or a rising PSA following RP. All patients were irradiated at a single, tertiary, academic centre. AD was initiated on the basis of seminal vesicle invasion, preprostatectomy PSA >20 ng/ml, Gleason score ≥4+3 (n=43), or personal preference of the referring urologist (n=54). InterventionA median 76-Gy dose was prescribed to the RP bed using intensity-modulated radiotherapy (IMRT) in all patients. AD consisted of a luteinising hormone-releasing hormone analogue for 6 mo. MeasurementsUnivariate and multivariate analyses were used to examine the influence of patient- and treatment-related factors on late toxicity, biochemical relapse-free survival (bRFS), and clinical relapse-free survival (cRFS). Results and limitationsThe 5-yr actuarial bRFS and cRFS were 56% and 86%, respectively. On multivariate analysis, the presence of perineural invasion at RP (hazard ratio [HR]: 6.19, p=0.001) and an increasing pre-SRT PSA (PSA 0.5 ng/ml: HR: 1; PSA 1–1.5 ng/ml: HR: 1.60, p=0.30; and PSA >1 ng/ml: HR: 2.70, p=0.02) were independent factors for a decreased bRFS. The addition of AD improved bRFS (HR: 0.33, p=0.005). On multivariate analysis, none of the variables was a predictor of cRFS. The 5-yr risk of grade 2–3 toxicity was 22% and 8% for genitourinary and gastrointestinal symptoms, respectively. ConclusionsIMRT allows for safe dose escalation to 76Gy with good bRFS.

Outcome in recurrent head neck cancer treated with salvage-IMRT

BackgroundRecurrent head neck cancer (rHNC) is a known unfavourable prognostic condition.The purpose of this work was to analyse our rHNC subgroup treated with salvage-intensity modulated radiation therapy (IMRT) for curable recurrence after initial surgery alone.PatientsBetween 4/2003–9/2008, 44 patients with squamous cell rHNC were referred for IMRT, mean/median 33/21 (3–144) months after initial surgery. None had prior head neck radiation. 41% underwent definitive, 59% postoperative IMRT (66–72.6 Gy). 70% had simultaneous chemotherapy.MethodsRetrospective analysis of the outcome following salvage IMRT in rHNC patients was performed.ResultsAfter mean/median 25/21 months (3–67), 22/44 (50%) patients were alive with no disease; 4 (9%) were alive with disease. 18 patients (41%) died of disease. Kaplan Meier 2-year disease specific survival (DSS), disease free survival (DFS), local and nodal control rates of the cohort were 59/49/56 and 68%, respectively.Known risk factors (advanced initial pTN, marginal initial resection, multiple recurrences) showed no significant outcome differences. Risk factors and the presence of macroscopic recurrence gross tumor volume (rGTV) in oral cavity patients vs others resulted in statistically significantly lower DSS (30 vs 70% at 2 years, p = 0.03). With respect to the assessed unfavourable outcome following salvage treatment, numbers needed to treat to avoid one recurrence with initial postoperative IMRT have, in addition, been calculated.ConclusionA low salvage rate of only ~50% at 2 years was found. Calculated numbers of patients needed to treat with postoperative radiation after initial surgery, in order to avoid recurrence and tumor-specific death, suggest a rather generous use of adjuvant irradiation, usually with simultaneous chemotherapy.

Salvage intensity-modulated radiotherapy for rising PSA after radical prostatectomy

Introduction The aim was to prospectively evaluate both acute and late toxicity and biochemical non-evidence of disease (bNED) in patients treated with salvage intensity-modulated radiotherapy (IMRT) ± androgen deprivation (AD) for biochemical relapse after radical prostatectomy (RP). Materials and methods IMRT was prescribed to a mean prescription dose to the planning target volume (PTV) of 75 Gy to be delivered in 37 fractions of 2 Gy. In total, 135 patients were treated with IMRT. Median age was 64 years. Median PSA level was 0.8 ng/ml. AD was initiated in 94 patients. Indications were perineural invasion, seminal vesicle invasion or Gleason score ⩾8 at RP. (1) Acute toxicity ( n = 135). All patients were available for this analysis. Acute toxicity was scored using an in-house developed scoring system. (2) Late toxicity ( n = 68). Only patients with a follow-up of at least 18 months were considered for late toxicity analysis. The RILIT score was used to register gastro-intestinal (GI) toxicity. An in-house developed scale was used to register genito-urinary (GU) toxicity. (3) bNED ( n = 87). For bNED, all AD-naive patients ( n = 38) together with the AD-positive patients with a follow-up ⩾18 months ( n = 49) were considered. Factors influencing the results of salvage treatment were analyzed. Results (1) Acute toxicity ( n = 135). No patient developed grade 3 GI toxicity. We observed grade 2 toxicity in 20 patients. Four patients developed grade 3 GU toxicity. (2) Late toxicity ( n = 68). One patient developed grade 3 rectal blood loss. One patient developed grade 3 anal pain (anal fissure). We observed grade 2 GI toxicity in 9 patients. Two patients developed grade 3 GU toxicity. Twenty-one patients developed grade 2 GU toxicity. We observed an urethral stricture in 5 patients. (3) bNED ( n = 87). The 3- and 5-year bNED was 67%. Gleason score at RP, perineural invasion and capsular perforation were significant predictors for bNED. PSA before IMRT (<1.0 vs. ⩾1.0 ng/ml) showed a trend in predicting bNED ( p = 0.08). Conclusion IMRT to 75 Gy ± AD can be delivered with low levels of acute and late toxicity. In patients without perineural invasion and capsular invasion and with a Gleason score ⩽7 (3 + 4), IMRT offers very good 5-years bNED.