The Radiotherapy of Locally Advanced Esophageal Cancer of Inoperable Forms with Escalated Dose of 66-70 Gy.

Squoamous cell carcinoma and adenocarcinoma account for more than 90% of all esophageal cancer cases. The total dose recommended in the actual NCCN guidelines is 50.4 Gy in 1,8 Gy fractions for the treatment of an esophageal cancer, a dose who never cure a macroscopic tumor. We present here 3 clinical cases where we delivered 66-70 Gy in 2 Gy fraction and a local cure was obtained. We examine and describe critically the role of curative radiotherapy for the management of esophageal cancer or combined with other modalities. Each patient had a PET/CT examination before starting the curative treatment. We also describe and present the role of radiation technologies and the concept of target volume delineation for the different parts of the esophagus as extrathoracic, intrathoracic and the eso-gastric junction. We present clinical cases of extrathoracal, intrathoracal and an esophageal junction cancer who were treated with curative intent by applying a combined radiochemotherapy with a total dose of 66-70 Gy in 33-35 fractions. Despite of the data from the literature the local cure of an esophageal cancer in the extrathoracic, intrathoracic or at the eso-gastric junction by using IMRT technics and by applying a total dose of 66-70 Gy in standard fractionation is possible.

The Remodeling in Advanced Breast Cancer Radiotherapy.

New concepts had to be developed since the progress in diagnostic methods, tumor characterization and progress in treatment delivery (more aggressive surgery and radiotherapy) made possible new approaches for locally advanced breast cancer. The process of remodeling is now a reality and the local cure of locally advanced tumor by only high dose radiotherapy is now possible. Based on modern irradiation techniques as IMRT, VMAT or Tomotherapy, target volume conformal dose distributions delivered to complex targets made possible the "remodeling" process at the soft and/or bone tissue. We present from our own experience clinical cases of "remodeling" at the level of chest wall and bone metastases at the spine and pelvic bone.

New Language and Old Problems in Breast Cancer Radiotherapy.

New developments in breast cancer radiotherapy make possible new standards in treatment recommandations based on international guidelines. Developments in radiotherapy irradiation techniques from 2D to 3D-Conformal RT and to IMRT (Intensity Modulated Arc Therapy) make possible to reduce the usual side effects on the organs at risk as: skin, lung, miocard, bone, esophagus and brahial plexus. Dispite of all these progresses acute and late side effects are present. Side effects are as old as the radiotherapy was used. New solutions are available now by improving irradiation techniques. New techniques as sentinel node procedure (SNP) or partial breast irradiation (PBRT) and immediate breast reconstruction with silicon implants (IBRIS) make necessary new considerations regarding the target volume delineations. A new language for definition of gross tumor volume (GTV), clinical target volume (CTV) based on the new diagnostic methods as PET/CT,nonaparticle MRI will have real impact on target delineation and irradiation techniques. "The new common language in breast cancer therapy" would be the first step to improve the endresults and finally the quality of life of the patients.

[Presentation of a 3D conformal radiotherapy technique for head-and-neck tumors resulting in substantial protection of the parotid glands]. / Etablierung einer 3D-Konformationstechnik zur Radio therapie von Kopf-Hals-Tumoren unter Berücksichtigung der Parotisschonung.

PURPOSE: The aim of this study was to improve the irradiation technique for the treatment of head-and-neck tumors and, in particular, to make use of the advantages found in modern 3D planning to protect the parotid glands. PATIENTS AND METHODS: For this investigation the 3D dataset of a standard patient with oropharyngeal carcinoma of UICC stage IVA was used. In the CT scans (slice thickness 5 mm) the planning target volume (PTV), the boost volume and both parotids were delineated. Three different techniques were calculated for two different dose levels (50 Gy for PTV and 64 Gy for boost volume, using single doses of 2 Gy). For technique 1 (T1) a parallel opposed field photon/electron irradiation was designed, for technique 2 (T2) an opposed/arc field irradiation was employed, and for technique 3 (T3) a combination of a static coplanar and arc field irradiation was designed. The sum doses D(min), D(max) and D(mean) for PTV, boost volume, and ipsilateral and contralateral parotid gland were evaluated, and the time needed for calculation of the plans was also determined. RESULTS: For all techniques used, the calculated doses in the PTV (D(min) 5.6 +/- 0.1 Gy, D(max) 73.7 +/- 0.1 Gy, and D(mean) 57.9 +/- 0.5 Gy) and in the boost volume (D(min) 46.9 +/- 1.5 Gy, D(max) 73.8 +/- 0.12 Gy, and D(mean) 65.8 +/- 0.9 Gy) were equal. Significant differences were found regarding the three different techniques, e.g., for the ipsilateral parotid gland D(min) (T1 = 47.4, T2 = 50.6, and T3 = 38.4 Gy) as well as for the contralateral parotid gland D(min) (T1 = 42.1, T2 = 44.2, and T3 = 17.8 Gy) and D(mean) (T1 = 51.3, T2 = 52.8, and T3 = 32.6 Gy). Regarding the three different techniques, significant differences were found in favor of T3. The determined planning times were as follows: T1 = 90, T2 = 60, and T3 = 90 min. CONCLUSION: The combination of static coplanar and arc field technique (T3) resulted in a substantially better protection as compared to both other techniques. This was especially the case with regard to the contralateral parotid gland, when the dose distributions were calculated equally for PTV and boost volume. In this study, the D(mean) dose of the contralateral parotid gland was lower than the TD(50) of 37 Gy (95% confidence interval 32-43 Gy) previously assumed by the authors. Therefore, it can be concluded that in the present study a more intensive protection of this gland and a reduction in xerostomia were possibly obtained.