Early clinical outcomes for 3 radiation techniques for brain metastases: focal versus whole-brain.

PURPOSE: To present our novel technique for brain metastases (low-dose whole brain radiation therapy [WBRT] with simultaneous integrated boost (SIB) and focal, frameless stereotactic intensity modulated radiotherapy [IMRT]) in the context of patterns of failure, dosimetry, acute toxicity, and overall survival for 3 different radiation techniques. METHODS AND MATERIALS: We retrospectively reviewed 92 patients undergoing radiation for brain metastases via the following: (1) "prophylactic" WBRT to a low dose (median 30 Gy) with an SIB to the gross tumor volume plus 2-3 mm margin (median dose 45 Gy) in 10-15 fractions; (2) focal, frameless image-guided stereotactic IMRT (S-IMRT) in 5 fractions to tumor only (median 30 Gy); or (3) conventional (c)WBRT using 2 lateral opposed beams in 10-15 fractions (30-37.5 Gy). The primary endpoints were local (LBC), distant (DBC), and total brain control (TBC) for each of the 3 types of brain radiation. Survival, toxicity, and dosimetry were reported as secondary endpoints. RESULTS: LBC was achieved in 72%, 78%, and 56% for SIB, S-IMRT, and cWBRT, respectively. DBC (ie, no new brain metastases) was observed in 92%, 67%, and 81% for SIB, S-IMRT, and cWBRT, respectively. TBC (LBC + DBC) was 72%, 67%, and 56% for SIB, S-IMRT, and cWBRT, respectively. No statistical difference in overall survival was observed (P = .067), and only 1 patient experienced biopsy proven radionecrosis. CONCLUSIONS: TBC after low-dose WBRT with SIB was acceptable and at least comparable to S-IMRT and cWBRT. SIB seems to be a safe and effective treatment strategy for patients with brain metastases and may efficiently combine the benefits of cWBRT and stereotactic radiosurgery.

Superiority of equivalent uniform dose (EUD)-based optimization for breast and chest wall.

We investigate whether IMRT optimization based on generalized equivalent uniform dose (gEUD) objectives for organs at risk (OAR) results in superior dosimetric outcomes when compared with multiple dose-volume (DV)-based objectives plans for patients with intact breast and postmastectomy chest wall (CW) cancer. Four separate IMRT plans were prepared for each of the breast and CW cases (10 patients). The first three plans used our standard in-house, physician-selected, DV objectives (phys-plan); gEUD-based objectives for the OARs (gEUD-plan); and multiple, "very stringent," DV objectives for each OAR and PTV (DV-plan), respectively. The fourth plan was only beam-fluence optimized (FO-plan), without segmentation, which used the same objectives as in the DV-plan. The latter plan was to be used as an "optimum" benchmark without the effects of the segmentation for deliverability. Dosimetric quantities, such as V(20Gy) for the ipsilateral lung and mean dose (D(mean)) for heart, contralateral breast, and contralateral lung were used to evaluate the results. For all patients in this study, we have seen that the gEUD-based plans allow greater sparing of the OARs while maintaining equivalent target coverage. The average ipsilateral lung V(20Gy) reduced from 22 +/- 4.4% for the FO-plan to 18 +/- 3% for the gEUD-plan. All other dosimetric quantities shifted towards lower doses for the gEUD-plan. gEUD-based optimization can be used to search for plans of different DVHs with the same gEUDs. The use of gEUD allows selective optimization and reduction of the dose for each OAR and results in a truly individualized treatment plan.

Multidisciplinary treatment of synchronous primary rectal and prostate cancers.

BACKGROUND: A 58-year-old Caucasian man with a history of irritable bowel syndrome and occasional rectal bleeding presented with a 4-week history of progressive, bright red blood per rectum. A digital rectal examination revealed a 3 cm distal, midrectal mass. Laboratory tests showed an elevated serum prostate-specific antigen of 32 ng/ml but other physical and medical examinations were unremarkable. INVESTIGATIONS: Digital rectal examination, colonoscopy, rectal mass biopsy, endorectal ultrasound, transrectal ultrasound-guided prostate biopsy, CT scan and MRI. DIAGNOSIS: Clinical stage III (T3N1M0), moderately differentiated adenocarcinoma of the rectum and clinical stage II (T1cN0M0) adenocarcinoma of the prostate. MANAGEMENT: Intensity-modulated radiation therapy, chemoradiation, chemotherapy, hormone therapy and surgery.