Radiotherapy quality assurance review in a multi-center randomized trial of limited-disease small cell lung cancer: the Japan Clinical Oncology Group (JCOG) trial 0202.

BACKGROUND: The purpose of this study was to analyze the radiotherapy (RT) quality assurance (QA) assessment in Japan Clinical Oncology Group (JCOG) 0202, which was the first trial that required on-going RT QA review in the JCOG. METHODS: JCOG 0202 was a multi-center phase III trial comparing two types of consolidation chemotherapy after concurrent chemoradiotherapy for limited-disease small cell lung cancer. RT requirements included a total dose of 45 Gy/30 fx (bis in die, BID/twice a day) without heterogeneity correction; elective nodal irradiation (ENI) of 30 Gy; at least 1 cm margin around the clinical target volume (CTV); and interfraction interval of 6 hours or longer. Dose constraints were defined in regards to the spinal cord and the lung. The QA assessment was classed as per protocol (PP), deviation acceptable (DA), violation unacceptable (VU), and incomplete/not evaluable (I/NE). RESULTS: A total of 283 cases were accrued, of which 204 were fully evaluable, excluding 79 I/NE cases. There were 18 VU in gross tumor volume (GTV) coverage (8% of 238 evaluated); 4 VU and 23 DA in elective nodal irradiation (ENI) (2% and 9% of 243 evaluated, respectively). Some VU were observed in organs at risk (1 VU in the lung and 5 VU in the spinal cord). Overall RT compliance (PP + DA) was 92% (187 of 204 fully evaluable). Comparison between the former and latter halves of the accrued cases revealed that the number of VU and DA had decreased. CONCLUSION: The results of the RT QA assessment in JCOG 0202 seemed to be acceptable, providing reliable results.

Relation between elective nodal failure and irradiated volume in non-small-cell lung cancer (NSCLC) treated with radiotherapy using conventional fields and doses.

INTRODUCTION: The role of elective nodal irradiation of non-small-cell lung cancer (NSCLC) patients treated with radiotherapy remains unclear. We investigated the significance of treating clinically uninvolved lymph nodes by retrospectively analyzing the relationship between loco-regional failure and the irradiated volume. METHODS: Between 1998 and 2003, patients with IA-IIIB NSCLC were treated with radiotherapy. The eligibility criteria for this study were an irradiation dose of 60Gy or more and a clinical response better than stable disease. Typical radiotherapy consisted of 40 Gy/20 fr to the tumor volumes (clinical target volume of the primary tumor [CTVp], of the metastatic lymph nodes [CTVn], and of the subclinical nodal region [CTVs]), followed by off-cord boost to CTVp+n to a total dose 60-68 Gy/30-34 fr. The relationship between the sites of recurrence and irradiated volumes was analyzed. RESULTS: A total of 127 patients fulfilled the eligibility criteria. Their median overall and progression-free survival times were 23.5 (range, 4.2-109.7) and 9.0 months (2.2-109.7), respectively. At a median follow-up time of 50.5 months (range, 14.2-83.0) for the surviving patients, the first treatment failure was observed in 95 patients (loco-regional; 41, distant; 42, both; 12). Among the patients with loco-regional failure, in-field recurrence occurred in 38 patients, and four CTVs recurrences associated with CTVp+n failure were observed. No isolated recurrence in CTVs was observed. CONCLUSIONS: In-field loco-regional failure, as well as distant metastasis, was a major type of failure, and there was no isolated elective nodal failure. Radiation volume adequacy did not seem to affect elective nodal failure.

Pattern of tumor recurrence in initially nonmetastatic breast cancer patients: distribution and frequency of metastases at unusual sites.

BACKGROUND: Breast cancer is likely to have systemic involvement. However, to the authors' knowledge there are few reports to date regarding clinically detected patterns of metastasis, meticulously studied in regard to the natural history of breast cancer, including unusual sites of metastasis. METHODS: Patients treated for invasive breast cancer from April 1983 to May 2007 were retrospectively analyzed. Patterns of clinically apparent tumor recurrence, focusing especially on unusual metastases, were studied as well as possible risk factors for unusual metastases and their influence on survival. RESULTS: Overall, 3783 patients were eligible for the current analysis. The median duration of follow-up was 5.0 years (range, 0.6 years-20.4 years). Cumulative 5-year and 10-year survival rates were 89.7% and 81.5%, respectively. "Unusual metastasis" was defined as systemic failure with a frequency of < or =1%; in the current series; it was observed in 85 (2.2%) patients %. Of those, 70 (82%) had preceding metastasis in the usual sites. The median duration until the development of usual and unusual metastasis was 2.3 years and 3.6 years, respectively (P < .0001). Among 764 patients with distant metastasis, the 5-year cumulative overall survival rate in those with or without unusual metastasis was 53.5% and 53.4 years, respectively (P = .33). No risk factors for unusual metastasis were identified. CONCLUSIONS: This retrospective study examined the frequency of unusual metastases in a large number of Japanese patients with initially nonmetastatic breast cancer. The prognosis of patients with unusual metastases was found to be similar to that of patients with metastasis only at more usual sites.