Effect of Daily and Every Other Day Stereotactic Body Radiation Therapy Schedules on Treatment-Related Fatigue in Patients With Hepatocellular Carcinoma.

PURPOSE: We compared the rate and severity of fatigue in patients who completed stereotactic body radiation therapy (SBRT) to the liver daily (QD) compared with every other day (QOD). METHODS AND MATERIALS: From 2010 to 2017, 91 patients with Child Pugh (CP) A (n = 57) or CP-B (n = 34) cirrhosis who completed 100 SBRT sessions to 110 hepatocellular carcinoma (HCC) lesions were analyzed in this study. Confounding variables with fatigue such as CP-C cirrhosis, Eastern Cooperative Oncology Group score >2, or a history of ascites or encephalopathy were excluded. Fatigue was assessed against several treatment- and patient-related variables with univariate and propensity score-matched multivariate analysis. The median follow-up time was 18 months. RESULTS: Patients with HCC and Barcelona-Clinic Liver Cancer stages 0 (n = 10), A (n = 32), and B (n = 58), and a median age of 62 years were analyzed. The median tumor diameter was 3 cm (1.1-11 cm). The Eastern Cooperative Oncology Group performance status score was 0 (n = 44), 1 (n = 43), or 2 (n = 13). The median dose was 45 Gy in 5 fractions, and 65 treatments were QD and 45 QOD. Grades 1 and 2 fatigue developed in 49% and 14% of treatments, respectively. Among the patients who were treated daily, 78% developed Grade 1 or 2 fatigue compared with 44% who were treated QOD (odds ratio: 4.52; P = .001). Grade 2 fatigue occurred in 22% of patients compared with 7.3% for QD and QOD treatment, respectively (odds ratio: 3.83; P = .048). There was no difference in fatigue rate for time of treatment (morning or afternoon), dose, treated volume, CP score, Barcelona-Clinic Liver Cancer stage, or performance status, which were not associated with any level of fatigue. There was no difference in local control between QD and QOD treatments. CONCLUSIONS: Compared with traditional daily treatment fractions, SBRT that is delivered QOD to cirrhotic patients with HCC may reduce the risk of fatigue.

Use of implanted gold fiducial markers with MV-CBCT image-guided IMRT for pancreatic tumours.

INTRODUCTION: Visualisation of soft tissues such as pancreatic tumours by mega-voltage cone beam CT (MV-CBCT) is frequently difficult and daily localisation is often based on more easily seen adjacent bony anatomy. Fiducial markers implanted into pancreatic tumours serve as surrogates for tumour position and may more accurately represent absolute tumour position. Differences in daily shifts based on alignment to implanted fiducial markers vs. alignment to adjacent bony anatomy were compared. METHODS: Gold fiducial markers were placed into the pancreatic tumour under endoscopic ultrasound (EUS) guidance in 12 patients. Patients subsequently received image-guided intensity-modulated radiation therapy (IG-IMRT). MV-CBCT was performed prior to each fraction and isocentre shifts were performed based on alignment to the fiducial markers. We retrospectively reviewed archived MV-CBCT datasets and calculated shift differences in the left-right (LR), superior-inferior (SI) and anterior-posterior (AP) axes relative to shifts based on alignment to adjacent bony anatomy. RESULTS: Two hundred forty-three fractions were analysed. The mean absolute difference in isocentre shifts between the fiducial markers and those aligned to bony anatomy was 3.4 mm (range 0-13 mm), 6.3 mm (range 0-21 mm) and 2.6 mm (range 0-12 mm), in LR, SI and AP directions, respectively. The mean three-dimensional vector shift difference between markers vs. bony anatomy alignment was 8.6 mm. CONCLUSIONS: These data suggest that fiducial markers used in conjunction with MV-CBCT improve the accuracy of daily target delineation compared with localisation using adjacent bony anatomy and that gold fiducial markers using MV-CBCT alignment are a viable option for target localisation during IG-IMRT.

Long-term cosmesis and toxicity following 3-dimensional conformal radiation therapy in the delivery of accelerated partial breast irradiation.

PURPOSE: To evaluate cosmesis and toxicity in early-stage breast cancer patients treated with adjuvant 3D-CRT who received accelerated partial breast irradiation (APBI). METHODS AND MATERIALS: From November 2003 to June 2006, 60 breasts on 59 patients were treated with 3-dimensional conformal radiation therapy (3D-CRT) APBI. Patients with stage 0, I, or II breast cancer were eligible if a <3-cm tumor was resected with negative surgical margins, and axillary evaluation documented 0-3 positive nodes. The mean age was 58.7 years (range, 31-88 years). Target volume and critical structure definitions, as well as dose delivery guidelines, were consistent across both institutions. Treatment was twice daily for 5 consecutive days with 3.85 Gy per fraction to 38.5 Gy. Clinical follow-up was conducted at regular intervals that included history, physical exam, and mammography. The overall cosmesis was graded using the Harvard scale and toxicity was graded according to the Common Toxicity Criteria (v4.0), including hyperpigmentation, edema, telangiectasia, mastalgia, surgical defect, fibrosis, and fat necrosis. Dose-volume histogram and treatment parameters were collected and analyzed. RESULTS: At a mean follow-up of 44.3 months (range, 2-94 months), there were 4 cases of grade 3-4 toxicity (7%): 1 patient with mastalgia; 1 patient with mastalgia and fat necrosis; 1 patient with telangiectasia; and 1 patient with fibrosis. There was no statistical correlate between dosimetric parameters and cosmetic outcome. Overall cosmetic outcome was good or excellent in 58 breasts (95%) and "fair to poor" in 3 (5%). There were no local-regional failures; 3 patients failed distantly (5%). CONCLUSIONS: Accelerated partial breast irradiation using 3D-CRT is safe and the risk of serious chronic side effect is low and acceptable.

The use of radiotherapy in the management of follicular cystitis refractory to conservative and surgical management.

Follicular cysitis is a proliferative benign lesion which can act locally malignant. Conservative management is best; however, when this fails, surgical resection is necessary up to and including cystectomy in extreme refractory cases. We present a clinical review and our results using radiation in this disease in a woman facing cystectomy.

Merkel cell tumor of the skin treated with localized radiotherapy: are widely negative margins required?

Merkel's cell carcinoma is a rare cutaneous tumor that can affect a wide variety of sites throughout the body. Commonly, it affects the skin alone and the management of limited disease can be confusing since the natural history of the disease involves distant metastasis. Traditional management has required wide local excision with negative margins of resection. We describe a case treated with local therapy alone and review the literature to suggest that complete microscopic excision may not be required if adjuvant radiotherapy is used.

Investigating the effect of genetic background on proteinuria and renal injury using two hypertensive strains.

An earlier linkage analysis conducted on a population derived from the Dahl salt-sensitive hypertensive (S) and the spontaneously hypertensive rat (SHR) identified 10 genomic regions linked to several renal and/or cardiovascular traits. In particular, loci on rat chromosomes (RNO) 8 and 13 were linked to proteinuria, albuminuria, and renal damage. At both loci, the S allele was associated with increased proteinuria and renal damage. The current study aimed to confirm the linkage analysis and to evaluate the effect of genetic background on the ability of each locus (either RNO8 or RNO13) to exert a phenotypic difference when placed on a genetic background either susceptible (S rat) or resistant (SHR) to the development of renal disease. Congenic strains developed to transfer genomic segments from either RNO8 or RNO13 from the SHR onto the S genetic background [S.SHR(8) or S.SHR(13)] demonstrated significantly reduced proteinuria and improved renal function. Both congenic strains demonstrated significantly reduced glomerular and tubular injury, with renal interstitial fibrosis as the predominant pathological difference compared with the S. In contrast, transfer of RNO8 or RNO13 genomic regions from the S onto the resistant SHR genetic background [SHR.S(8) or SHR.S(13)] yielded no significant difference in proteinuria or glomerular, tubular, or interstitial injury compared with SHR. These findings demonstrate that genetic context plays a significant and important role in the phenotypic expression of genes influencing proteinuria on RNO8 and RNO13.