Lung tumor motion change during stereotactic body radiotherapy (SBRT): an evaluation using MRI.

The purpose of this study is to investigate changes in lung tumor internal target volume during stereotactic body radiotherapy treatment (SBRT) using magnetic resonance imaging (MRI). Ten lung cancer patients (13 tumors) undergoing SBRT (48 Gy over four consecutive days) were evaluated. Each patient underwent three lung MRI evaluations: before SBRT (MRI-1), after fraction 3 of SBRT (MRI-3), and three months after completion of SBRT (MRI-3m). Each MRI consisted of T1-weighted images in axial plane through the entire lung. A cone-beam CT (CBCT) was taken before each fraction. On MRI and CBCT taken before fractions 1 and 3, gross tumor volume (GTV) was contoured and differences between the two volumes were compared. Median tumor size on CBCT before fractions1 (CBCT-1) and 3 (CBCT-3) was 8.68 and 11.10 cm3, respectively. In 12 tumors, the GTV was larger on CBCT-3 compared to CBCT-1 (median enlargement, 1.56 cm3). Median tumor size on MRI-1, MRI-3, and MRI-3m was 7.91, 11.60, and 3.33 cm3, respectively. In all patients, the GTV was larger on MRI-3 compared to MRI-1 (median enlargement, 1.54 cm3). In all patients, GTV was smaller on MRI-3m compared to MRI-1 (median shrinkage, 5.44 cm3). On CBCT and MRI, all patients showed enlargement of the GTV during the treatment week of SBRT, except for one patient who showed minimal shrinkage (0.86 cm3). Changes in tumor volume are unpredictable; therefore, motion and breathing must be taken into account during treatment planning, and image-guided methods should be used, when treating with large fraction sizes.

Squamous cell carcinoma of the anal margin: the university of Florida experience.

OBJECTIVE: To update our experience in treating squamous cell carcinoma of the anal margin with definitive radiotherapy (RT). METHODS: A total of 26 patients treated curatively with RT between 1979 and 2008, with or without concurrent chemotherapy, were retrospectively reviewed. American Joint Committee on Cancer stage distribution was: T1, N = 1; T2, N = 16; T3, N = 9; N0, N = 25; and N1, N = 1. Concurrent chemotherapy was administered in 12 of 26 patients (T2, 19%; T3, 100%). Median age was 48.5 years (range, 31-84 years) with a median follow-up of 8.4 years (range, 0.9-16.1 years). Median total dose was 59.4 Gy in 33 fractions. Elective inguinal lymph-node irradiation was administered to 23 of 25 N0 patients. RESULTS: The 10-year cause-specific survival, disease-free survival, and overall survival were 92%, 88%, and 56%, respectively. Of the 26 patients, 24 experienced complete tumor regression; their local-control rate was 96%. Four patients developed recurrences (1 local, 2 regional, and 1 local/regional/distant). The 2 patients who did not receive elective inguinal lymph-node irradiation recurred in this region. Ten patients died of intercurrent disease between 2.0 and 15.9 years after RT. Two patients died with disease at 10.7 and 18.2 months after RT, whereas 1 patient is alive with local disease at 11.2 years after RT. The remaining 13 patients are alive and disease-free between 1.0 and 16.1 years after RT. The anal-sphincter-preservation rate was 88% with no severe long-term complications after RT. CONCLUSIONS: Patients with squamous cell carcinoma of the anal margin have a high probability of cure with sphincter preservation after RT with or without concurrent chemotherapy.

Concomitant weekly cisplatin and altered fractionation radiotherapy in locally advanced head and neck cancer.

BACKGROUND: Both concomitant chemotherapy and altered fractionation radiotherapy (RT) have been shown to improve outcomes for patients with locoregionally advanced head and neck squamous cell carcinomas. However, both strategies also increase acute toxicity, and it is questionable whether the 2 can be safely combined. Traditional concomitant chemotherapy regimens include high-dose cisplatin given at 100 mg/m2 every 3 weeks. The authors' purpose was to report efficacy and toxicity after weekly cisplatin (30 mg/m2/wk) concurrent with altered fractionation RT. METHODS: One hundred twenty-one patients with American Joint Committee on Cancer stages II (3%), III (13%), or IV (84%) squamous cell carcinomas of the oropharynx (70%), hypopharynx (20%), or larynx (10%) were treated between 2000 and 2006 at the University of Florida with hyperfractionated RT (55 patients) or concomitant boost RT (66 patients) and concomitant cisplatin (30 mg/m2/wk). RESULTS: Median follow-up was 2.9 years; median follow-up on survivors was 3.6 years. Seventy-nine percent of patients completed ≥6 cycles of chemotherapy; 94% received ≥7200 centigrays. Seven (6%) patients changed from cisplatin to carboplatin because of bone marrow toxicity. Gastrostomy tube feeding was required in 54% of patients either before (16%) or during RT (38%). Two (1.6%) patients died from therapy-related complications. The 5-year outcomes were: local control, 83%; locoregional control, 79%; distant metastasis-free survival, 88%; cause-specific survival, 76%; and overall survival, 59%. Seven (6%) patients had severe late complications. Three (3%) patients required a permanent gastrostomy tube. CONCLUSIONS: Concomitant weekly cisplatin with altered fractionation RT is a safe and effective treatment regimen.

The effect of intravenous contrast on photon radiation therapy dose calculations for lung cancer.

OBJECTIVE: The aim of this study was to evaluate the effect of intravenous contrast-enhanced computed tomography (CT) scans on the photon radiation dose calculations for lung cancer treatment planning. MATERIALS AND METHODS: Nonionic iodinated intravenous contrast (Iohexol) was administered during the treatment planning CT scan of 9 patients with node-positive non-small-cell lung cancer (NSCLC). The potential effect of intravenous contrast was studied by changing the density of the contrast-enhanced vessels. A total of 9 patients were treated in this study: 5 patients with intensity-modulated radiation therapy (IMRT), and 4 patients with three-dimensional (3D) conformal radiation therapy. A treatment plan was generated from an unmanipulated "normal contrast" planning scan. The same planning parameters were then applied to a "no contrast" planning scan. The effect of intravenous contrast was quantified by calculating the percent change of dose in a variety of target and normal structures. To evaluate a worst-case scenario, the comparison between "normal contrast" and "no contrast" planning scans was repeated, assigning each vessel the artificial high density of 1.3 g/cm. RESULTS: Dose differences between the planning image set using intravenous contrast and the image set without contrast were less than 2.5% for planning target volumes. A worst-case scenario in which normal contrast was overridden with an artificially high density of 1.3 g/cm led to small dose differences of less than 3%. CONCLUSIONS: Planning lung radiation therapy treatment using CT scans that contain intravenous contrast does not result in clinically significant errors in dose delivery.

Does surgical closure technique affect early mammographic detection of tumor recurrence after breast-conserving therapy?

PURPOSE: Scarring in the tumor bed may mask or mimic local recurrence of tumor on surveillance mammography. Type of surgical closure technique used during lumpectomy may impact the pattern or density of scar tissue apparent in the tumor bed on mammography. This study sought to determine whether surgical closure type affects tumor-bed scar formation and impacts interpretation of surveillance mammography in women treated with breast-conserving therapy for early-stage breast cancer. MATERIALS AND METHODS: One hundred women who received breast-conserving therapy were selected; 99 of them had 2-year post-treatment mammograms for the treated breast. Craniocaudal and mediolateral oblique views were reviewed by 3 subspecialty radiologists who routinely read mammograms. The mammograms were scored on 5-point scales for overall breast density and scarring within the tumor bed. RESULTS: The analyses did not demonstrate greater scarring or density in breast status post superficial closure compared with breast status post full-thickness closure, or vice versa (P > 0.05 for scarring and density). There were no detectable differences between the 2 closure techniques either within the data from individual reviewers, within the composite data for the entire group of reviewers, or in instances where 2 of 3 reviewers agreed (P > 0.05). There was significant interobserver variability in scoring among the mammographers for both scarring (P = 0.001) and density (P < 0.0001). CONCLUSION: Based on our study of the 2-year post-treatment mammograms, there was no evidence that closure technique impacts degree of scarring in the tumor bed. However, striking interobserver variability in scoring density and scarring was noted.

Tumor localization using cone-beam CT reduces setup margins in conventionally fractionated radiotherapy for lung tumors.

PURPOSE: To determine whether setup margins can be reduced using cone-beam computed tomography (CBCT) to localize tumor in conventionally fractionated radiotherapy for lung tumors. METHODS AND MATERIALS: A total of 22 lung cancer patients were treated with curative intent with conventionally fractionated radiotherapy using daily image guidance with CBCT. Of these, 13 lung cancer patients had sufficient CBCT scans for analysis (389 CBCT scans). The patients underwent treatment simulation in the BodyFix immobilization system using four-dimensional CT to account for respiratory motion. Daily alignment was first done according to skin tattoos, followed by CBCT. All 389 CBCT scans were retrospectively registered to the planning CT scans using automated soft-tissue and bony registration; the resulting couch shifts in three dimensions were recorded. RESULTS: The daily alignment to skin tattoos with no image guidance resulted in systematic (Sigma) and random (sigma) errors of 3.2-5.6 mm and 2.0-3.5 mm, respectively. The margin required to account for the setup error introduced by aligning to skin tattoos with no image guidance was approximately 1-1.6 cm. The difference in the couch shifts obtained from the bone and soft-tissue registration resulted in systematic (Sigma) and random (sigma) errors of 1.5-4.1 mm and 1.8-5.3 mm, respectively. The margin required to account for the setup error introduced using bony anatomy as a surrogate for the target, instead of localizing the target itself, was 0.5-1.4 cm. CONCLUSION: Using daily CBCT soft-tissue registration to localize the tumor in conventionally fractionated radiotherapy reduced the required setup margin by up to approximately 1.5 cm compared with both no image guidance and image guidance using bony anatomy as a surrogate for the target.

Unresectable squamous cell carcinoma of the lung: an outcomes study.

PURPOSE: To report survival and control rates in patients with inoperable squamous cell carcinoma (SCC). METHODS AND MATERIALS: Two hundred seventy-five patients with inoperable squamous cell carcinoma of the lung (Stages I-IIIB) who received radiotherapy alone or combined with chemotherapy given with curative intent at the University of Florida between 1963 and 2006 were retrospectively analyzed. RESULTS: Overall survival (OS) at 5 years for Stages I, II, and III was 10%, 14%, and 7% (p = 0.0034); local-regional control at 5 years was 51%, 38%, and 29% (p = 0.0003); and freedom from metastases at 5 years was 81%, 60%, and 65% (p = 0.0689), respectively. Patients who received doses > or = 65 Gy had improved cause-specific survival (CSS), OS, and metastasis-free survival at 5 years compared with those who received doses < 65 Gy. Five-year regional control was significantly improved with twice-daily vs. once-daily treatment (37% vs. 14%, p = 0.02). Chemotherapy significantly improved 5-year regional control (36% for patients who received chemotherapy vs. 13% for those who did not; p = 0.01). CONCLUSIONS: Dose escalation, accelerated fractionation, and combined modality therapies improve outcomes in SCC of the lung. Our review of the literature highlights the different natural history for SCC vs. other non-small cell lung cancers and emphasizes the importance of tailoring treatment strategies to individual patients. At the University of Florida, we have begun treating unresectable Stage III patients with SCC of the lung using 69.6 Gy twice daily with concurrent chemotherapy.

Neurotropic melanoma of the head and neck with clinical perineural invasion.

OBJECTIVE: The purpose of this article is to report our experience with neurotropic melanoma, a rare malignancy that sometimes produces neurologic symptoms because of a direct extension of the primary tumor. METHODS: We report 3 consecutive patients with neurotropic melanoma of the head and neck who presented with clinical perineural invasion. RESULTS: Two patients had incompletely resectable tumors and were treated with definitive radiotherapy (RT), and 1 patient received surgery and postoperative RT. One patient experienced recurrence in a regional lymph node 30 months after RT and underwent salvage surgery; he is disease-free at 45 months after initial treatment. The remaining 2 patients are disease-free 34 months and 14 months after treatment. CONCLUSIONS: Radiotherapy alone or combined with surgery may provide relatively long-term local control in patients who have neurotropic melanoma with clinical perineural invasion.

Plasma cell granuloma of the maxillary sinus: a case report and literature review.

BACKGROUND: Plasma cell granulomas are rare and heterogeneous tumor-like lesions of mixed inflammatory cell infiltrates of unknown etiology. Although they have the potential to occur in sites throughout the body, their occurrence in the paranasal sinuses and nasal cavity is uncommon and often associated with unique clinical characteristics and natural history. METHODS: We present a case of an aggressive plasma cell granuloma of the maxillary sinus and a review of the literature (28 cases). RESULTS: The patient was treated with definitive radiotherapy (45 Gy in 25 fractions) and experienced a local recurrence 2 years later. The lesion initially responded to corticosteroids and then progressed. Resection was performed and was followed by another recurrence. The patient was treated with radiosurgery and is disease free 8 years after initial treatment. CONCLUSIONS: Review of the literature indicates that the optimal first line of treatment is high-dose corticosteroids. Surgery is indicated if the lesion fails to respond. Radiotherapy is indicated if complete resection is not feasible.

Squamous cell carcinoma of the anal margin.

PURPOSE: To define the optimal treatment of patients with squamous cell carcinoma (SCCA) of the anal margin. METHODS: Nineteen patients treated with curative intent by radiotherapy (RT) alone or combined with adjuvant chemotherapy (CTX) between 1979 and June 2000 were analyzed. The pertinent literature was reviewed and discussed as it related to our experience. RESULTS: Local control after RT or RT and CTX was observed in all 19 patients (100%). One T1 patient developed inguinal lymph node metastases and subsequently died secondary to regional and distant disease. This patient did not receive elective inguinal node RT; the lymph nodes of the other 18 patients in this analysis were irradiated. Four patients died of intercurrent disease at 25, 29, 37, and 113 months after RT, respectively. The remaining 14 patients were alive and disease-free from 52 to 143 months after treatment. No patient suffered a severe complication or required a diverting colostomy or an abdominoperineal resection (APR) after treatment. Review of the literature reveals that the probability of cure is similar after RT alone or combined with CTX compared with surgery. Therefore, the choice of treatment depends on the anticipated functional result. CONCLUSIONS: Patients with SCCA of the anal margin have a high likelihood of cure with sphincter preservation after RT or RT and CTX. Patients with well to moderately differentiated T1 tumors may undergo excision if it can be accomplished without compromising the sphincter. The remainder are treated with RT. Adjuvant CTX is indicated for those with T3-T4 tumors and/or involved regional nodes.