Whole Pelvic Radiotherapy Research Articles

Helical Tomotherapy with Simultaneous Integrated Boost for High-Risk and Lymph Node-Positive Prostate Cancer: Early Report on Acute and Late Toxicity

The use of whole pelvic radiotherapy (WPRT) for high-risk and lymph node-positive prostate cancer (PC) remains controversial. The purpose of this study was to evaluate the acute toxicity associated with helical tomotherapy in the treatment of high-risk and lymph node-positive prostate cancer. To do so, twenty-eight patients were treated to a dose of 54 Gy in daily fractions of 1.8 Gy to the pelvic lymph node area, while the prostate and the seminal vesicles received a simultaneous integrated boost (SIB) to a dose of 70.5 Gy. A SIB to a dose of 60 Gy was delivered to the involved lymph node region(s) in 8 patients with pelvic lymph node metastases. All patients received concurrent hormonal treatment. The incidence of grade 2 and 3 acute gastrointestinal (GI) toxicity was 7% and 0% respectively. Grade 2 and 3 acute genito-urinary (GU) side effects were observed in 14% and 4% of the patients respectively. No grade 4 side effects occurred. No increased toxicity was observed in the 8 lymph node-positive patients receiving a simultaneous pelvic nodal dose escalation. In conclusion, WPRT with a SIB to the prostate and seminal vesicles by helical tomotherapy resulted in a favourable toxicity profile. Pelvic nodal dose escalation in node-positive patients is feasible without increasing toxicity.

Postprostatectomy Radiotherapy for Prostate Cancer

The roles of adjuvant postoperative radiotherapy (RT) after radical prostatectomy, and salvage RT for apparent local-regional recurrence, are reviewed. Postprostatectomy patients with pT3N0 disease have improved biochemical progression-free survival, clinical progression-free survival, and local-regional control after postoperative RT. Although a benefit in overall survival has not been demonstrated, patients who have a life expectancy of ≥ 10 years likely will have improved long-term cause-specific survival if postoperative RT is administered. The optimal postoperative RT dose is probably about 70 Gy at 2 Gy per once-daily fraction. Salvage RT should be considered for patients with local regionally recurrent cancer without distant metastasis and those with a biochemical relapse. The optimal dose probably exceeds 70 Gy, but is likely not feasible because of the risk of late toxicity. Thus, the preferred dose-fractionation schedule is approximately 70 Gy in 35 once-daily fractions. The role of androgen deprivation therapy in combination with RT is ill defined, but it should be considered for high-risk patients. Similarly, the role for whole-pelvis RT is unclear, but it may be considered for those with a ≥ 20% risk of positive pelvic nodes.

IMRT significantly reduces acute toxicity of whole-pelvis irradiation in patients treated with post-operative adjuvant or salvage radiotherapy after radical prostatectomy

Purpose To investigate the role of IMRT in reducing the risk of acute genito-urinary (GU), upper gastrointestinal (uGI) and lower gastrointestinal (lGI) toxicity following whole-pelvis irradiation (WPRT) after radical prostatectomy. Patients and methods 172 consecutive patients with prostate cancer were post-operatively irradiated to the prostatic bed (PB) and pelvic lymph-nodal area with adjuvant ( n = 100) or salvage ( n = 72) intent. Eighty-one patients underwent three-dimensional conformal (3DCRT) WPRT, while the remaining 91 underwent IMRT (54/91 with helical tomotherapy (HTT); 37/91 with Linac intensity-modulated RT (LinacIMRT)). Results Patients treated with IMRT experienced a decreased risk of acute toxicity. The crude incidence of grade ⩾2 toxicity was GU 12.3% vs. 6.6% ( p = 0.19); lGI 8.6% vs. 3.2% ( p = 0.14); uGI 22.2% vs. 6.6% ( p = 0.004), for 3DCRT and IMRT, respectively. With respect to uGI and lGI, the acute toxicity profile of the HTT patients was even better when compared to that of 3DCRT patients (crude incidence:1.8% and 0.0%, respectively). Treatment interruptions due to uGI toxicity were 11/81 in the 3DCRT group vs. 2/91 in the IMRT group ( p = 0.006). Conclusions The risk of acute toxicity following post-operative WPRT delivered by means of IMRT was reduced compared to that of 3DCRT. The most significant reduction concerned uGI, mainly owing to better bowel sparing with IMRT.

Intra-Arterial Infusion Chemotherapy Using Cisplatin With Radiotherapy for Stage III Squamous Cell Carcinoma of the Cervix

To examine the effectiveness of concomitant intra-arterial infusion chemotherapy (IAIC) using cisplatin (CDDP) with radiotherapy for Stage III squamous cell carcinoma of the cervix. We analyzed 29 cases of Stage III squamous cell carcinoma of the uterine cervix treated with radiotherapy and IAIC of CDDP from 1991 to 2006. External-beam therapy was given to the whole pelvis using four opposing parallel fields with an 18-MV linear accelerator unit. A central shield was used after 30-40 Gy with external whole-pelvic irradiation, and the total dose was 50 Gy. High-dose-rate brachytherapy was given with (192)Ir microSelectron. The dose at Point A was 6 Gy per fraction, 2 fractions per week, and the total number of fractions was either 3 or 4. Two or three courses of IAIC were given concomitantly with CDDP 120 mg or carboplatin 300 mg. We confirmed excellent medicine distribution directly by using computed tomographic angiography. The 5-year overall survival rate for Stage III patients was 62%, the cause-specific survival rate was 70%, and the local relapse-free survival rate was 89%. Local recurrence, distant metastasis, and occurrences of both were 7%, 38%, and 3%, respectively. The incidence of severe acute hematologic adverse reactions (Grade > or =3) was 27% for all patients; however, all recovered without interruption of radiotherapy. Severe nonhematologic effects (Grade > or =3) were 3%, including nausea and ileus. Only 1 patient's radiotherapy was interrupted for a period of 1 week because of ileus. Severe late complication rates (Grade > or =3) for the bladder, rectum, and intestine were 3%, 3%, and 10%, respectively. A combination of IAIC and systemic chemotherapy should be considered to improve the prognosis of patients with Stage III squamous cell carcinoma of the cervix.

Integral Dose in Three-dimensional Conformal Radiotherapy, Intensity-modulated Radiotherapy and Helical Tomotherapy

Aims To evaluate the integral dose to organs at risk (OARs), normal tissue and the whole body in three-dimensional conformal radiotherapy (3DCRT), intensity-modulated radiotherapy (IMRT) and helical tomotherapy for whole pelvic radiotherapy (WPRT) in postoperative endometrial cancer patients. Materials and methods We selected 10 patients with endometrial cancer undergoing postoperative WPRT. Plans of 6MV-3DCRT, 18MV-3DCRT, 6MV-IMRT, 18MV-IMRT and helical tomotherapy were developed for each patient. The integral doses to OARs, normal tissue and the whole body were compared. Results Compared with 3DCRT, both IMRT and helical tomotherapy significantly improved dose conformity and the integral doses to OARs (8.8–29.9%, P < 0.05). Compared with 6MV-3DCRT, IMRT resulted in 13.2 and 11.0% lower integral doses to normal tissue and the whole body, respectively ( P = 0.00), whereas no significant difference was found with helical tomotherapy. Compared directly with IMRT, helical tomotherapy reduced the integral doses to the rectum and bladder. However, the integral doses to normal tissue were 13.9 and 17.1% higher than 6MV-IMRT and 18MV-IMRT plans, respectively ( P = 0.00); the integral doses to pelvic bones also slightly increased with helical tomotherapy. The use of 18MV resulted in 5.8 and 2.7% lower integral doses to normal tissue and 4.8 and 2.1% lower integral doses to the whole body in the 3DCRT and IMRT plans, respectively ( P = 0.00). Conclusions Results show that IMRT and helical tomotherapy offer better conformity and lower integral doses to OARs for postoperative WPRT of endometrial cancers compared with 3DCRT. The integral doses to normal tissue and the whole body were significantly lower with IMRT, whereas no significant difference was found with helical tomotherapy compared with 6MV-3DCRT. Compared directly with IMRT, helical tomotherapy further reduced the integral doses to the rectum and bladder, at the expense of a slightly higher integral dose to pelvic bones and normal tissue. The use of 18MV improved the integral doses to normal tissue and the whole body in both 3DCRT and IMRT.

Whole-Pelvis Radiotherapy in Combination With Interstitial Brachytherapy: Does Coverage of the Pelvic Lymph Nodes Improve Treatment Outcome in High-Risk Prostate Cancer?

To compare biochemical progression-free survival (bPFS), cause-specific survival (CSS), and overall survival (OS) rates among high-risk prostate cancer patients treated with brachytherapy and supplemental external beam radiation (EBRT) using either a mini-pelvis (MP) or a whole-pelvis (WP) field. From May 1995 to October 2005, 186 high-risk prostate cancer patients were treated with brachytherapy and EBRT with or without androgen-deprivation therapy (ADT). High-risk prostate cancer was defined as a Gleason score of > or =8 and/or a prostate-specific antigen (PSA) concentration of > or =20 ng/ml. With a median follow-up of 6.7 years, the 10-year bPFS, CSS, and OS rates for the WP vs. the MP arms were 91.7% vs. 84.4% (p = 0.126), 95.5% vs. 92.6% (p = 0.515), and 79.5% vs. 67.1% (p = 0.721), respectively. Among those patients who received ADT, the 10-year bPFS, CSS, and OS rates for the WP vs. the MP arms were 93.6% vs. 90.1% (p = 0.413), 94.2% vs. 96.0% (p = 0.927), and 73.7% vs. 70.2% (p = 0.030), respectively. Among those patients who did not receive ADT, the 10-year bPFS, CSS, and OS rates for the WP vs. the MP arms were 82.4% vs. 75.0% (p = 0.639), 100% vs. 88% (p = 0.198), and 87.5% vs. 58.8% (p = 0.030), respectively. Based on multivariate analysis, none of the evaluated parameters predicted for CSS, while bPFS was best predicted by ADT and percent positive biopsy results. OS was best predicted by age and percent positive biopsy results. For high-risk prostate cancer patients receiving brachytherapy, there is a nonsignificant trend toward improved bPFS, CSS, and OS rates when brachytherapy is given with WPRT. This trend is most apparent among ADT-naïve patients, for whom a significant improvement in OS was observed.

Predictive models of toxicity in external radiotherapy

Dose-volume modeling of late and acute toxicity in radiotherapy for prostate cancer is a rapidly evolving field of investigation. The availability of individual, 3-dimensional dose distribution and dose-volume histograms (DVHs) permits the quantitative assessment of dose-volume relations for specific endpoints by investigating the correlation between individual dose-volume data and clinical outcomes. These studies often entail a huge effort in collecting data from large populations that have been followed properly for long time. The rectum is the most investigated organ, especially concerning late bleeding, and a good consensus regarding serial-like behavior for this endpoint comes from various investigations. Concerning the bladder, the existence of a clear dose effect when the organ is wholly or partially irradiated is well known. Concerning erectile dysfunctions, the wide use of hormone therapy and drugs against impotence suggests that large, prospectively scored populations will be necessary to definitively assess dose-volume relations. Bowel irradiation during prostate cancer radiotherapy occurs during pelvic lymph node irradiation, and severe acute toxicity has yet to be modeled clearly. Evidence of a correlation between the DVH of the intestinal cavity and bowel toxicity recently was reported, providing important information about optimal dose-volume constraints to be used during whole-pelvis irradiation with intensity-modulated radiotherapy. Cancer 2009;115(13 suppl):3135-40. (c) 2009 American Cancer Society.

SU-FF-T-583: Integral Dose Variation in Three-Dimensional Conformal Radiotherapy, Intensity-Modulated Radiotherapy, and Helical Tomotherapy

Purpose: To evaluate the integral doses (IDs) to organs at risk (OARs), normal tissue (NT) and the whole body in three‐dimensional conformal radiotherapy (3DCRT), intensity‐modulated radiotherapy(IMRT) and helical tomotherapy (HT) for whole pelvic radiotherapy (WPRT) in postoperative endometrial cancer patients. Method and Materials: We selected ten patients with endometrial cancer undergoing postoperative WPRT. Plans of 3DCRT using both 6‐MV (6MV‐3DCRT) and 18‐MV (18MV‐3DCRT), static IMRT using a conventional linac with 6‐MV (6MV‐IMRT) and 18‐MV (18MV‐IMRT), and HT using 6‐MV were developed for each patient. The IDs to OARs, NT and the whole body were compared. Results: Compared with 3DCRT, both IMRT and HT significantly improved dose conformity and the IDs to OARs (8.8% − 29.9%, p < 0.05). Compared with 6MV‐3DCRT, IMRT resulted in 13.2% and 11.0% lower IDs to NT and the whole body (p=0.00), whereas no significant difference was found in HT plans. Compared directly with IMRT, HT reduced the IDs to rectum and bladder (p<0.05), whereas the IDs to NT were 13.9% higher than with 6MV‐IMRT (p=0.00), the IDs to pelvic bones also slightly increased with HT (p<0.05). The use of 18MV reduced the IDs to NT 5.8% and 2.7%, to the whole body 4.8% and 2.1% in the 3DCRT and IMRT plans (p=0.00). Conclusions: In postoperative WPRT of endometrial cancer,IMRT and HT result in better conformity and lower IDs to OARs compared with 3DCRT. The IDs to NT and the whole body were significantly lower with IMRT, whereas no significant difference was found with HT compared with 6MV‐3DCRT. Compared directly with IMRT, HT further reduced the IDs to rectum and bladder, at the expense of a slightly higher ID to pelvic bones and NT. The use of 18 MV improved the IDs to NT and the whole body in both 3DCRT and IMRT.

Dosimetric predictors of diarrhea during radiotherapy for prostate cancer

To investigate dosimetric predictors of diarrhea during radiotherapy (RT) for prostate cancer. All patients who underwent external-beam radiotherapy as part of treatment for localized prostate cancer at the University of Texas Medical Branch, Galveston, TX, USA, from May 2002 to November 2006 were extracted from the own database. From the cumulative dose-volume histogram (DVH), the absolute volumes (V-value) of intestinal cavity (IC) receiving 15, 30, and 45 Gy were extracted for each patient. Acute gastrointestinal toxicity was prospectively scored at each weekly treatment visit according to CTC (Common Toxicity Criteria) v2.0. The endpoint was the development of peak grade >or= 2 diarrhea during RT. Various patient, tumor, and treatment characteristics were evaluated using logistic regression. 149 patients were included in the analysis, 112 (75.2%) treated with whole-pelvis intensity-modulated radiotherapy (WP-IMRT) and 37 (24.8%) with prostate-only RT, including or not including, the seminal vesicles (PORT +/- SV). 45 patients (30.2%) developed peak grade >or= 2 diarrhea during treatment. At univariate analysis, IC-V(15) and IC-V(30), but not IC-V(45), were correlated to the endpoint; at multivariate analysis, only IC-V(15) (p = 0.047) along with peak acute proctitis (p = 0.041) was independently correlated with the endpoint. These data provide a novel and prostate treatment-specific "upper limit" DVH for IC.

Dose–Volume Relationships for Acute Bowel Toxicity in Patients Treated With Pelvic Nodal Irradiation for Prostate Cancer

To find correlation between dose-volume histograms (DVHs) of the intestinal cavity (IC) and moderate-severe acute bowel toxicity in men with prostate cancer treated with pelvic nodal irradiation. The study group consisted of 191 patients with localized prostate cancer who underwent whole-pelvis radiotherapy with radical or adjuvant/salvage intent during January 2004 to November 2007. Complete planning/clinical data were available in 175 of these men, 91 of whom were treated with a conventional four-field technique (50.4 Gy, 1.8 Gy/fraction) and 84 of whom were treated with IMRT using conventional Linac (n = 26, 50.4 Gy, 1.8 Gy/fraction) or Helical TomoTherapy (n = 58, 50-54 Gy, 1.8-2 Gy/fraction). The IC outside the planning target volume (PTV) was contoured and the DVH for the first 6 weeks of treatment was recovered in all patients. The correlation between a number of clinical and DVH (V10-V55) variables and toxicity was investigated in univariate and multivariate analyses. The correlation between DVHs for the IC outside the PTV and DVHs for the whole IC was also assessed. Twenty-two patients experienced toxicity (3/22 in the IMRT/tomotherapy group). Univariate analyses showed a significant correlation between V20-V50 and toxicity (p = 0.0002-0.001), with a higher predictive value observed for V40-V50. Previous prostatectomy (p = 0.066) and abdominal/pelvic surgery (p = 0.12) also correlated with toxicity. Multivariate analysis that included V45, abdominal/pelvic surgery, and prostatectomy showed that the most predictive parameters were V45 (p = 0.002) and abdominal/pelvic surgery (p = 0.05, HR = 2.4) Our avoidance IMRT approach drastically reduces the incidence of acute bowel toxicity. V40-V50 of IC and, secondarily, previous abdominal/pelvic surgery were the main predictors of acute bowel toxicity.

The sigmoid colon and bladder shielding in whole pelvic irradiation at prostate cancer (forward planned IMRT from Institute of Oncology Ljubljana)

Background. The whole pelvic irradiation (WPI) is again gaining the important role in radiotherapy of prostate cancer. With the conformal irradiation of the large fields that are covering the pelvic nodes, the extra damage is done to sigmoid colon and urinary bladder. Sparing the region between the iliac nodes is necessary since the dose delivered to the organs at risk that are partly included in the mentioned area (the sigmoid colon and bladder) can be importantly reduced. Methods. We are presenting a possible way of shielding the central region between iliac nodes that does not need to be irradiated. Dose volume histograms of standard box technique and technique with additional central shielding of sigmoid colon and urinary bladder in WPI are compared in 10 patients. Results. Applying the described shielding technique 30 to 45 % or in some cases even up to 55% of the sigmoid colon that would with standard box technique be irradiated at doses from 30 to 50 Gy is spared, and also around 10% of the bladder that would receive 45-55 Gy is spared. Conclusions. In the whole pelvic irradiation (WPI) in prostate radiotherapy the sparing of the region between the iliac nodes is crucial since it allows the dose delivered to the sigmoid colon to be reduced to the recommended restrictions. Since the sigmoid colon benefits most from described shielding, the technique is addressed as the Sigmoid Colon Shielding (SCS). The SCS technique is in use at our department at Institute of Oncology in Ljubljana.

Benefit of Whole Pelvic Radiotherapy Combined with Neoadjuvant Androgen Deprivation for the High‐Risk Prostate Cancer

Aim. To study whether use of neoadjuvant androgen deprivation therapy (N-ADT) combined with whole pelvic radiotherapy (WPRT) for high-risk prostate cancer patients was associated with survival benefit over prostate radiotherapy (PORT) only. Material and Methods. Between 1999 and 2004, 162 high-risk prostate cancer patients were treated with radiotherapy combined with long-term androgen deprivation therapy (L-ADT). Patients were prospectively assigned into two groups: A (N-ADT + WPRT + L-ADT) n = 70 pts, B (PORT + L-ADT) n = 92 pts. Results. The 5-year actuarial overall survival (OS) rates were 89% for A and 78% for B (P = .13). The 5-year actuarial cause specific survival (CSS) rates were A = 90% and B = 79% (P = .01). Biochemical progression-free survival (bPFS) rates were 52% versus 40% (P = .07), for groups A and B, respectively. Conclusions. The WPRT combined with N-ADT compared to PORT for high-risk patients resulted in improvement in CSS and bPFS; however no OS benefit was observed.

Complex abdominal wall reconstruction after radiation therapy: A full-thickness defect was repaired with a rectus femoris myofasciocutaneous flap

Usually, cervical cancer metastasizes to the pelvis or distant organs; on rare occasions, it recurs at the abdominal wall. In 1 such case, a 31-year-old woman was admitted with a bleeding tumor and enterocutaneous fistula of the abdominal wall. Two years earlier, she underwent radical abdominal hysterectomy followed by whole-pelvis radiation therapy (total dose, 60 Gy) for squamous cell carcinoma of the cervix. After treatment concluded, a painful abdominal nodule formed and grew rapidly. A period of intense pain was promptly relieved when an intestinal secretion was spontaneously discharged from the growth.

Spontaneous Intraperitoneal Rupture of the Urinary Bladder after Radiotherapy for Cervical Cancer

1)Many patients suffer severe complications from radiation therapy for cervical cancer. Severe late complications are observed in 1.24% of patients after radiation therapy for gynecological cancer; these include irradiated bladders, ureteral strictures, and urinary fistulas [1]. Spontaneous intraperitoneal rupture of the urinary bladder is a rare complication of radiation therapy. Here, we present a case of spontaneous bladder rupture after whole-pelvis radiation therapy for cervical cancer.

The potential use of intensity‐modulated radiation therapy in the management of early‐stage gynaecologic malignancies

AbstractIntroduction A literature review was conducted to establish if intensity modulated radiation therapy (IMRT) planning and treatment enhances current whole pelvic radiation therapy (WPRT) practices for early‐stage gynaecological malignancies.Our purpose was to determine if IMRT implementation at a small radiation therapy centre is feasible, and warranted, given the issues of potentially small patient numbers and limited resources.Method A literature review was undertaken to identify relevant articles that dealt with the advantages and disadvantages of IMRT for gynaecological malignancies, and accessed through online journal search engines. Early stage gynaecological malignancy patients, treated in 2006, were identified through Varian (Palo Alto, CA, USA) Varis Vision database. Patients undertaking WPRT with brachytherapy (BT) regime were the only patients considered as suitable candidates for IMRT.Results IMRT reduces toxicity to relevant organs at risk (OAR) such as small bowel (40–70%), rectum (10–66%), bladder (30–46%) and bone marrow (50–60%), but uncertainties exist in the ability to accurately delineate gross tumour volume (GTV) and OAR. Sixteen patients, 1.6% of all patients seen in 2006 at W P Holman Clinic Hobart, Tasmania received treatment to the primary gynaecological tumour alone. Out of this sixteen, seven (0.9%) patients received radical external beam radiation therapy only, four (0.5%) received further dose‐escalation treatment with BT. One patient, due to co‐morbidities was unable to undergo BT. Therefore, five (0.6%) of the patients were potential candidates for IM‐WPRT.Conclusion IMRT planning for early‐stage gynaecological malignancies enhances IM‐WPRT technique and reduces dose to OAR, therefore increasing the therapeutic ratio. At present, IMRT planning and treatment does not consider daily OAR motion and GTV shrinkage for these patients. Multiple imaging modalities provide such valuable information.IMRT implementation for early‐stage gynaecological malignancies in a small radiation therapy centre, of two linear accelerators, is hindered by limited imaging modalities. From the data collected in this study, gynaecological patient numbers are not sufficient to warrant purchase of all required imaging modalities.

An update of the Phase III trial comparing whole pelvic to prostate only radiotherapy and neoadjuvant to adjuvant total androgen suppression: Updated analysis of RTOG 94-13 with emphasis on unexpected hormone/radiation interactions: Lawton CA, DeSilvio M, Roach M III, Uhl V, Kirsch R, Seider M, Rotman M, Jones C, Asbell S, Valicenti R, Hahn S, Thomas CR Jr., Department of

This trial was designed to test the hypothesis that total androgen suppression and whole pelvic radiotherapy (WPRT) followed by a prostate boost improves progression-free survival (PFS) by ≥10% compared with total androgen suppression and prostate only RT (PORT). This trial was also designed to test the hypothesis that neoadjuvant hormonal therapy (NHT) followed by concurrent total androgen suppression and RT improves PFS compared with RT followed by adjuvant hormonal therapy (AHT) by ≥10%. Patients eligible for the study included those with clinically localized adenocarcinoma of the prostate and an elevated prostate-specific antigen level <100 ng/ml. Patients were stratified by T stage, prostate-specific antigen level, and Gleason score, and were required to have an estimated risk of lymph node involvement >15%. The difference in overall survival for the four arms was statistically significant ( P = 0.027). However, no statistically significant differences were found in PFS or overall survival between NHT vs. AHT and WPRT compared with PORT. A trend towards a difference was found in PFS ( P = 0.065) in favor of the WPRT + NHT arm compared with the PORT + NHT and WPRT + AHT arms. Unexpected interactions appear to exist between the timing of hormonal therapy and radiation field size for this patient population. Four Phase III trials have demonstrated better outcomes when NHT was combined with RT compared with RT alone. The Radiation Therapy Oncology Group's 9,413 trial results have demonstrated that when NHT is used in conjunction with RT, WPRT yields a better PFS than does PORT. It also showed that when NHT + WPRT results in better overall survival than does WPRT + short-term AHT. Additional studies are warranted to determine whether the failure to demonstrate an advantage for NHT + WPRT compared with PORT + AHT is chance or, more likely, reflects a previously unrecognized biologic phenomenon.

Adjuvant platinum-based chemotherapy (PBCTX) improves overall survival (OS) in women with uterine mixed Mullerian malignant tumors (MMMT)

16561 Background: The aim of this study was to describe clinical and pathologic characteristics of patients with MMMT of the uterus who were all treated at a single institution. In addition, we were interested in examining how these features correlated with 5 year OS. Methods: Patients diagnosed with FIGO Stage I-IV MMMT between 1993 and 2007 were identified. Clinical, pathologic and outcome data was obtained from the medical record. Median survival determinations and factors predictive of outcome were compared using the log-rank test. Results: MMMT was identified in 43 patients. The median age of diagnosis was 70 years (range 45–91). Personal history of breast cancer was present in 33% of our patients (62% with history of tamoxifen use). There were 19 stage I patients (IA - 5, IB - 10, IC - 4), 1 stage II patients, 14 stage III patients (IIIA - 4, IIIB - 3, IIIC - 7) and 9 stage IV patients. OS among all patients was 17.2% and the median OS was 36.6 months. Among the stage I patients, the OS was 36% (median - 52 months). The OS in stage III patients was 0% (median - 17 months). The OS in stage IV patients was 0% (median - 3 months). Pathologic features predictive of a worse OS included lymph vascular invasion (p=0.04), deep myometrial invasion (p=0.02), and cervical involvement (p=0.01). Within the group of patients with stage I-III disease (n=34), 47% (n=16) received adjuvant PBCTX and 59% (n=20) received whole pelvic radiation (WPRT). 29% (n=10) received combination PBCTX and WPRT. The OS for those patients who received adjuvant PBCTX was 26% (median - 51 months). The OS for stage I patients who received PBCTX was 38% (median - 52 months) and the OS for stage III patients was 0% (median - 46 months). There was a trend towards an improved survival in the stage III patients who received adjuvant chemotherapy (p=0.07). Conclusions: In our population of non-selected patients with MMMT, 33% had a personal history of breast cancer. Tamoxifen use was common among those patients with breast cancer. Stage, myometrial invasion, lymph vascular invasion, and cervical involvement were all risk factors for a worse prognosis. Adjuvant PBCTX was associated with a favorable OS in our patients. Clinical trials evaluating the role of platinum-based therapy in patients with MMMT are ongoing. No significant financial relationships to disclose.

Reduction of Prostate Motion by Removal of Gas in Rectum During Radiotherapy

To evaluate the prostate and seminal vesicle motion in patients during both simulation and radiotherapy by rectal gas removal. A total of 34 patients were treated in a whole pelvic radiotherapy (WPRT) arm and 42 patients in a non-WPRT arm. Of the 76 patients, 42 (26 in the non-WPRT arm and 16 in the WPRT arm) were instructed to insert their index finger and wash their rectums to evacuate their rectal gas. In addition to the planning computed tomography scan, three subsequent computed tomography scans were obtained during RT. The organs were outlined on each computed tomography image. Changes in the position of the prostate and seminal vesicles were analyzed using the center of mass (COM) coordinate system. The time trend, overall variations, systematic variations, and random variations were analyzed. The average cross-sectional area in the rectal gas removal group was significantly smaller than in all patients and in the WPRT arm. The vector of the prostate and seminal vesicle displacement for the rectal gas removal group was significantly smaller than in all patients. With rectal gas removal, the 95% confidence limit of the prostate displacement vector was reduced by 2.3 mm in the non-WPRT arm and 2.9 mm in the WPRT arm. The 95% confidence limit of the seminal vesicle displacement vector was reduced by 0.3 mm in the non-WPRT arm and 4.4 mm in the WPRT arm. Using rectal gas removal, the cross-sectional area could be decreased, resulting in reduced motion and margins for the prostate and seminal vesicles. This is especially important for WPRT patients who require RT to the prostate, seminal vesicles, and pelvic lymph nodes.

Improved Outcomes With Higher Doses for Salvage Radiotherapy After Prostatectomy

To evaluate relapse-free survival with higher doses for patients receiving salvage radiotherapy (RT) after radical prostatectomy (RP). A total of 122 patients with pathologically negative lymph nodes received salvage RT after RP from 1984 to 2004. Median prostate bed dose was 60 Gy for 38 patients and 70 Gy for 84 patients. Four months of total androgen suppression and whole-pelvic RT were given concurrently to 68 and 72 patients, respectively. The median follow-up was >5 years. Kaplan-Meier and Cox proportional hazards multivariable analyses were performed for all clinical, pathologic, and treatment factors predicting for biochemical relapse-free survival (bRFS). There were 60 biochemical failures after salvage RT, with a median time to failure of 1.2 years. A dose response was observed, with a 5-year bRFS rate of 25% vs. 58% for prostate bed doses of 60 Gy vs. 70 Gy (p < 0.0001). For patients receiving RT alone the 5-year bRFS rate was 17% vs. 55% (p = 0.016), and for those receiving prostate-bed-only RT it was 23% vs. 66% (p = 0.037) for doses of 60 Gy vs. 70 Gy, respectively. On multivariate analysis a prostate bed dose of 70 Gy (p = 0.012, hazard ratio [HR] 0.48 [95% Confidence Interval (CI), 0.27-0.87]), pre-RT prostate-specific antigen value < or =1 ng/mL (p < 0.0001, HR 0.28 [95% CI, 0.16-0.48]), and lack of seminal vesicle involvement (p = 0.009, HR 0.44 [95% CI, 0.26-0.77]) remained independently significant. A clinically significant dose response from 60 Gy to 70 Gy was observed in the setting of salvage RT after prostatectomy. A dose of 70 Gy to the prostate bed is recommended to achieve optimal disease-free survival.

Significance of Whole-Pelvic Radiotherapy For High-Risk Prostate Cancer Patients After Radical Prostatectomy

Evaluation of: Spiotto MT, Hancock SL, King CR: Radiotherapy after prostatectomy: improved biochemical relapse-free survival with whole pelvic compared with prostate bed only for high-risk patients.Int. J. Radiat. Oncol. Biol. Phys.69, 54–61 (2007). Although most patients with localized prostate cancer are successfully treated with radical prostatectomy, high-risk patients often manifest biochemical and/or clinical relapse. Adjuvant or salvage radiotherapy is utilized for the treatment of these patients. For definitive radiotherapy for untreated prostate cancer, a randomized clinical study (radiation therapy oncology group [RTOG] 94–13), suggested superior effects of whole-pelvic radiotherapy to prostate-only radiotherapy. On the contrary, for adjuvant or salvage radiotherapy after radical prostatectomy, the role of whole-pelvic radiotherapy has not been extensively investigated. This retrospective study demonstrated better biochemical relapse-free survival in high-risk patients receiving adjuvant or salvage whole-pelvic radiotherapy, when combined with concurrent hormonal therapy, compared with prostate bed radiotherapy. Selection for good candidates for whole-pelvic radiotherapy after radical prostatectomy will be confirmed in future and a large-scale randomized clinical trial is required before the final conclusion can be made.