Diffusion-weighted magnetic resonance imaging in painful bone metastases: Using quantitative apparent diffusion coefficient as an indicator of effectiveness of single fraction versus multiple fraction radiotherapy.

PURPOSE: Bone metastases are a common cause of cancer-related pain. The aim of this study is to determine the optimal radiotherapy schedule for the treatment of painful bone metastases and verify if could cause different biological effects on bone. This has been achieved using functional Magnetic Resonance Imaging (MRI) with diffusion-weighted imaging (DWI). PATIENTS AND METHODS: Fifteen patients received Multiple Fractions Radiation Therapy (MFRT) with a total dose of 30Gy in 10 daily fractions of 3Gy given over 2 weeks and 15 patients received a Single Fraction Radiation Therapy (SFRT) with a dose of 8Gy. Quantitative Apparent Diffusion Coefficient (ADC) values after SFRT or MFRT were compared with response to treatment (pain relief), assessed by Visual Analogue Scale (VAS) before radiotherapy and at 1 and 3 months after the completion of treatment. RESULTS: The two schedules had equal efficacy in terms of pain control, without any difference at 1 and 3 months post radiotherapy. In both treatments, pain reduction was related to an increase in the ADC. However, the median ADC value had an increase of 575 points between the baseline and 3 months (from 1010 to 1585, p=0.02) in the 30Gy group, while it was only 178 points (from 1417 to 1595) in the 8Gy group. CONCLUSIONS: The increase in the ADC values after radiotherapy corresponds to increased cell death. Despite an equal pain control, MFRT treatment seems to be more effective to achieve cancer cells kill. Our preliminary data could also explain the higher retreatment rates in SFRT vs MFRT in long survivors.

Definitive Intensity-modulated Radiation Therapy in Elderly Patients with Locally Advanced Oropharyngeal Cancer.

BACKGROUND: To evaluate the treatment tolerance and clinical outcomes in patients aged 70 years and older with locally advanced oropharyngeal cancer treated by definitive intensity-modulated radiation therapy (IMRT). PATIENTS AND METHODS: We retrospectively analyzed 15 consecutive elderly patients, with histologically-proven squamous cell carcinoma of the oropharynx, staged T3-4 with or without involved lymph nodes at diagnosis, who received definitive sequential IMRT (70 Gy; 2 Gy/fraction). Adult Comorbidity Evaluation-27 (ACE-27) score was calculated and its influence on treatment tolerance and clinical outcomes was analyzed. RESULTS: A total of 15 patients were included with a median age of 77 years (range=70-88 years). At baseline, 8 patients (53.3%) had an ACE-27 score of 1, and the remainder (n=7, 46.7%) had a comorbidity index of 0. All patients completed programmed IMRT treatment, without any reduction of total dose. Oral pain and mucositis were the most common acute side-effects, classified as grade 3 in 6 patients (40%) only. Xerostomia was reported in 13 patients (86.7%), without severe manifestation. There was no hematological toxicity. ACE-27 score was not related to higher severe acute toxicity. No patients experienced grade 3 or more late toxicity. Five-year overall survival and disease-free survival rates were 63.6% (95% confidence interval=32.7-83.3%) and 55% (95% confidence interval=24.4-77.6%), respectively. Comorbidity score did not influence survival outcomes, both overall survival (p=0.46) and disease-free survival (p=0.55). CONCLUSION: Treatment tolerance, as well as survival outcomes were good in elderly oropharyngeal cancer patients treated with definitive sequential IMRT. Due to age and comorbidity, no dose or volume reduction for IMRT should be considered in this setting of patients. A prospective randomized trial with a large sample size should be conducted to confirm our results.

Impact of Induction Chemotherapy in Locally Advanced HPV-negative Oropharyngeal Cancer. A Propensity Score-matched analysis.

AIM: To estimate the clinical outcomes of induction chemotherapy (IC) followed by standard chemoradiotherapy (CRT) and CRT alone in patients with locally advanced human papilloma virus (HPV)-negative oropharyngeal squamous cell carcinoma. PATIENTS AND METHODS: Consecutive patients with histologically-proven HPV-negative squamous cell carcinoma of the oropharynx were included and treated with IC-CRT or CRT alone. In order to compare treatment outcomes and toxicity between groups, patients were matched by primary tumor site and clinical disease stage. Overall survival (OS), disease-free survival (DFS) and metastasis-free survival (MFS) curves were calculated with the Kaplan-Meier method. RESULTS: Nine IC patients and 18 CRT patients were included. All patients completed the programmed treatment. The median follow-up was 38 months. There were no statistically significant differences in OS and DFS between groups. The 5-year MFS was 88.9% and 50.8% in the IC-CRT group, respectively. There was no meaningful difference in toxicity between patients. CONCLUSION: In HPV-negative patients with locally advanced oropharyngeal cancer, adding IC to standard CRT may increase the MFS rate. However no significant differences in OS and DFS were observed. More studies are needed to better elucidate the role of IC in this setting.