Radiation Oncologists' Approach to Rectosigmoid Junction Tumors in Turkey: The Turkish Society for Radiation Oncology Gastrointestinal Group Survey Study (TROD 02-007).

BACKGROUND/AIMS: The objective was to determine the preferences and perspectives regarding preoperative evaluation and treatment strategies for rectosigmoid junction cancer among radiation oncologists using a questionnaire survey. MATERIALS AND METHODS: Since defining the correct origin of the neoplasm is essential in tailoring the most appropriate treatment scheme in the rectosigmoid junction region, we surveyed Turkish radiation oncologists about clinical decisions in rectosigmoid junction cancer patients via a 20-point questionnaire. RESULTS: Based on responses from 130 radiation oncologists surveyed across the country, 119 (91.5%) used the anterior peritoneal reflection as the landmark, while 111 (85.4%) used the distance from the anal verge to the boundary between the rectum and sigmoid. This indicates that most of the participants decided to consider both pretreatment evaluation methods. Although distance at colonoscopy can be very variable, when the discrepancy was observed between these methods, 66 (50.8%) participants made the final decision according to the distance from the anal verge in our questionnaire. The conclusion from the questionnaire is that there is difficulty in interpreting magnetic resonance imaging findings, and there is a need for anatomic landmarks relevant to the limit between the rectum and sigmoid so that clinicians can confidently facilitate the diagnosis. CONCLUSIONS: There is a wide variation in the diagnosis and decision-making of rectosigmoid junction cancer among radiation oncologists in Turkey, according to our survey, because of several definitions of the rectosigmoid junction boundaries. Considerable attention is required to clarify whether the first preoperative treatment or surgery for rectosigmoid junction cancer.

Immobilization techniques' influence on treatment plan results in postmastectomy radiotherapy.

Purpose: To compare different immobilization devices used for chest wall and nodal irradiation in breast cancer dosimetrically. Materials and Methods: All patients with left-sided breast cancer received chest wall and lymphatic irradiation. Treatment plans were created for radiotherapy in single arm (SA) lift board, double arm (DA) lift board, and wing board (WB) positions. Dose-volum e histograms (DVH) were used for evaluation based on planning target volume (PTV) coverage and organs at risk (OARs). One-way analysis of variance (ANOVA) test was performed to identify the dose-volume differences among different immobilization techniques. Results: Clinically acceptable plans were generated with all immobilization boards. Significantly lower doses in the body except target volumes were found in the SA lift board group compared to other groups (P < 0.05). No relevant differences were observed among the plans according to the other dose parameters of target volumes and OARs. Conclusion: SA board is an immobilization device that can be used safely for three-dimensional conformal radiotherapy in young left-sided breast cancer with an unfavorable anatomy as it significantly reduces low-dose exposure.

Comparison of Radiation-Induced Secondary Malignancy Risk Between Sequential and Simultaneous Integrated Boost for the Treatment of Nasopharyngeal Carcinoma: Intensity-Modulated Radiotherapy versus Volumetric-Modulated Arc Therapy.

PURPOSE: This study aimed to compare the secondary cancer risk (SCR) between the sequential boost (SEQ) technique and simultaneous integrated boost (SIB) technique in intensity-modulated radiotherapy (IMRT) and volumetric-modulated arc therapy (VMAT) in patients with nasopharyngeal carcinoma (NPC) using the concepts of organ equivalent dose (OED) and excess absolute risk (EAR). PATIENTS AND METHODS: IMRT-SEQ, VMAT-SEQ, IMRT-SIB, and VMAT-SIB plans were created with identical objective functions for five patients with early-stage NPC. Three different planning tumor volumes (PTVs; PTV1, PTV2, and PTV3) were delineated for each patient, and the prescribed doses were 50 Gy, 60 Gy, and 70 Gy (2 Gy/fraction), respectively, for the SEQ technique and 52.8 Gy, 59.4 Gy, and 69.3 Gy (33 fractions), respectively, for the SIB technique. RESULTS: All plans were clinically acceptable. There was no difference in most OED-based SCRs between IMRT and VMAT when the same fractionation scheme was used. Compared with the SEQ technique, the SIB technique in IMRT and VMAT was associated with the lowest OEDs for the oral cavity, pharynx, parotids, and submandibular glands, resulting in SCR reduction. SCR for the parotids was much lower than that for the other assessed organs when the SIB technique was used. CONCLUSION: Our findings suggest that OED-based SCRs are lower with the SIB technique than with the SEQ technique in IMRT and VMAT in most organs for which SCR was calculated; furthermore, SCR for the parotids is much lower than that for other organs when the SIB technique is used in patients with NPC.

Effect of dose constraint on the thyroid gland during locoregional intensity-modulated radiotherapy in breast cancer patients.

The aim of the present study was to compare radiation dose received by thyroid gland using different radiotherapy (RT) techniques with or without thyroid dose constraint (DC) for breast cancer patients. Computerized tomography (CT) image sets for 10 patients with breast cancer were selected. All patients were treated originally with opposite tangential field-in field (FinF) for the chest wall and anteroposterior fields for the ipsilateral supraclavicular field. The thyroid gland was not contoured on the CT images at the time of the original scheduled treatment. Four new treatment plans were created for each patient, including intensity-modulated radiotherapy (IMRT) and helical tomotherapy (HT) plans with thyroid DC exclusion and inclusion (IMRTDC(-) , IMRTDC(+) , HTDC(-) , and HTDC(+) , respectively). Thyroid DCs were used to create acceptable dose limits to avoid hypothyroidism as follows: percentage of thyroid volume exceeding 30 Gy less than 50% (V30  < 50%) and mean dose of thyroid (TDmean ) ≤ 21 Gy. Dose-volume histograms (DVHs) for TDmean and percentages of thyroid volume exceeding 10, 20, 30, 40, and 50 Gy (V10 , V20 , V30 , V40 , and V50 , respectively) were also analyzed. The Dmean of the FinF, IMRTDC(-) , HTDC(-) , IMRTDC(+) and HTDC(+) plans were 30.56 ± 5.38 Gy, 25.56 ± 6.66 Gy, 27.48 ± 4.16 Gy, 18.57 ± 2.14 Gy, and 17.34 ± 2.70 Gy, respectively. Median V30 values were 55%, 33%, 36%, 18%, and 17%, for FinF, IMRTDC(-) , HTDC(-) , IMRTDC(+) , and HTDC(+) , respectively. Differences between treatment plans with or without DC with respect to Dmean and V30 values were statistically significant (P < 0.05). When thyroid DC during breast cancer RT was applied to IMRT and HT, the TDmean and V30 values significantly decreased. Therefore, recognition of the thyroid as an organ at risk (OAR) and the use of DCs during IMRT and HT planning to minimize radiation dose and thyroid volume exposure are recommended.

Protective effects of genistein and melatonin on mouse liver injury induced by whole-body ionising radiation.

The aim of the present study was to investigate the effectiveness of melatonin and genistein in preventing radiation therapy (RT)-induced liver injury in mice. A total of 70 Swiss Albino male mice were divided into 7 equal groups (n=10/group) as follows: Melatonin (M group, G3), genistein (G group, G4), polyethylene glycol-400 (P group, G5), RT only (RT group, G2) and sham irradiation (C group, G1). RT plus genistein (RT+G group, G7) and RT plus melatonin (RT+M group, G6) were the co-treatment groups. Firstly, hepatic tissue damage was induced in mice via exposure to a single dose of 6-Gy irradiation. RT was performed with a cobalt-60 teletherapy machine (80 cm fixed source-to-surface distance, 2.5-cm depth). Melatonin was processed (100 mg/kg, intraperitoneal) 30 min before and genistein was administered (200 mg/kg, SC) one day prior to the single dose of irradiation. Six months following irradiation, all mice were sacrificed. The degree of liver injury was measured using histological liver sections. Liver injury was significantly worse in the RT group than in the control group (C; RT vs. C; P<0.05); however, liver injury decreased following co-treatment with melatonin or genistein vs. RT alone (RT+M and RT+G vs. RT; P<0.05). No difference was observed between the RT+M and RT+G groups (P>0.05). The present study revealed that melatonin and genistein administration prior to irradiation protects mice against liver injury, which may have therapeutic implications for RT-induced injuries.

Survival and prognostic factors in limited stage small cell lung cancer: A retrospective study from northeast Turkey.

AIM OF THE STUDY: The purposes of this retrospective study were to identify survival rates for limited stage small cell lung cancer (LD-SCLC) and analyze treatment outcomes and influencing factors on survival. MATERIALS AND METHODS: We conducted data from patients diagnosed with LD.SCLC between January 1998 and December 2012 at our institution. Dermographic information, treatment modalities, pretreatment clinical asessment, were recorded. Most of the patients. (88.4%) were treated with curative intent. The survival probabilties were asessed by Kaplan.Meier analysis. Cox regression was used to assess prognostic factors on overall survival and disease.free survival. RESULTS: A total of 129 patients were examined as a LD-SCLC. The median age was 60 (range; 31-86). Median follow-up time was 9.4 (SE ± 20.5) months and the median overall survival was 13.9 months [95% cumulative incidence (CI): 10.1-17.6]. On multivariate analysis, concurrent chemotherapy [HZ: 2.7 (95% CI: (1.0-7.2)] (P = 0.037) and doses of radiation therapy (<50, ≥50) [HZ: 1.4 (95% CI: (1.0-2.2)] (P = 0.046) were statistically significant on overall survival. With regard to multivariate anlaysis age (<60, ≥60) [HZ: 2.2 (95% CI: (0.6-3.7)] (P = 0.011), doses of radiation therapy (<50, ≥50) [HZ: 2.7 (95% CI: (1.0-7.2)] (P = 0.046), precense of surgery [HZ: 15.3 (95% CI: (1.5-152)] (P = 0.020), prophilactic cranial radiation therapy (PCI) [HZ: 2.3 (95% CI: (1.1-4.5)] (P = 0.014), and presence of concurrent chemoradiotherapy [HZ: 3.0 (95% CI: (1.3-6.8)] (P = 0.008) were important variable affecting disease-free survival. CONCLUSION: For LD-SCLC patients concurrent chemoradiation therapy and 50. Gy and over doses radiation therapy provided improvement on overall and disease.free survival.

Radiotherapy Induces Development of Fragmented QRS in Patients with Breast Cancer.

BACKGROUND: Myocardial fibrosis is a well-known side effect of radiotherapy. Fragmented QRS (fQRS) has been shown to be a marker of myocardial fibrosis. We postulated that radiotherapy induces development of fQRS in breast cancer patients. PATIENTS AND METHODS: Breast cancer patients receiving locoregional radiotherapy were enrolled. Patients who had fQRS on electrocardiography (ECG) before radiotherapy were excluded. All patients were revaluated for the development of fQRS at 1-year follow-up. An age-matched healthy group served as controls. RESULTS: A total of 52 breast cancer patients receiving locoregional radiotherapy were included (median age 49 years, interquartile range (IQR) 13). Of these, 19 (37%) had developed fQRS at 1-year follow-up. Compared with the control group, prevalence of fQRS was significantly higher in the irradiated group (37 vs. 12%; p < 0.002). Median total cardiac radiation dose was significantly higher in patients who had developed fQRS (5 Gy, IQR 5.2 vs. 1.7 Gy, IQR 4.4; p = 0.003). Cardiac radiation dose, entered either as a continuous variable (odds ratio (OR) 1.35, 95% confidence interval (CI) 104-1.74) or as a dichotomized variable (≥ 2.2 Gy, OR 6.48, 95% CI 1.47-28.61), was independently associated with the development of fQRS at 1-year follow-up. CONCLUSION: Radiotherapy for breast cancer induces development of fQRS on ECG. Cardiac radiation dose is independently associated with the development of fQRS.

Adjuvant radiotherapy in stage 1 seminoma: Evaluation of prognostic factors and results of survival.

PURPOSE: The purpose of this study was to evaluate the prognostic factors affecting overall survival (OS), cause-specific survival (CSS), progression-free survival (PFS), and survival among patients undergoing adjuvant radiotherapy (RT) for stage-1 seminoma. MATERIALS AND METHODS: Between August 1997 and May 2013, 68 patients diagnosed with stage-1 seminoma were retrospectively evaluated. The median age was 39 (24-74) years. All patients received adjuvant RT after inguinal orchiectomy. Fifty-eight (85.3%) patients received paraaortic RT; 10 (14.7%) received dog-leg field RT. The median RT dose was 23.4 (23.4-30.6) Gy. RESULTS: The median follow-up period was 77.5 (6.7-198.5) months. During the follow-up period, two patients developed distant metastasis, and none developed local recurrence. Two patients died from seminoma, and three died for other reasons. The 5, 10, and 15-year OS rates were 94.7%, 89.6%, and 89.6%, respectively. The 5, 10, and 15-year CSS rates were 98.5%, 96%, and 96%, respectively. The 5, 10, and 15-year PFS rate was 96.1%. The univariate analysis showed that only histological subtype was significant for OS. The 10-year survival rate was 100% among patients with seminoma histology, 90.8% among patients with a classic seminoma histology, and 50% among patients with an anaplastic seminoma histology (P < 0.001). A multivariate analysis showed that the anaplastic seminoma was a negative prognostic indicator for OS (P = 0.042). CONCLUSION: Adjuvant RT resulted in excellent long-term survival and local control in patients with stage-1 seminoma after orchiectomy. During a short follow-up, secondary malignancy (SM) and late cardiovascular morbidity were not observed. Despite those results, concern of SM and late cardiovascular morbidity remains.

Long-term results of a concomitant boost radiotherapy technique for elderly patients with muscle-invasive bladder cancer.

OBJECTIVES: To evaluate the long-term clinical efficacy and toxicity of concomitant boost radiotherapy (CBRT) in elderly patients with invasive bladder cancer. METHODS AND MATERIALS: Elderly patients (n=188; mean 75-year-old, range 70-91 years; 88.3% male/11.7% female) with T1-T4a bladder carcinoma were irradiated with CBRT. A total of 24 (12.8%) patients were diagnosed at stage T1, 117 (62.2%) were at stage T2, 28 (14.9%) at were stage T3a, 14 (7.4%) were stage T3b, and 5 (2.7%) were stage T4a. A dose of 45Gy in 1.8Gy fractions was administered to the whole pelvis 5 days/week over 5 weeks. A concomitant boost limited to the bladder tumor area plus margin or whole bladder of 22.5Gy in 1.5Gy fractions was administered from weeks 3×5. Thus, irradiation totalled 67.5Gy over 5 weeks. The interfraction interval was ≥6h/treatment day. We assessed prognostic factors for overall survival (OS), cause-specific survival (CSS) and relapse-free survival (RFS). RESULTS: Median follow-up was 46.2 months (range 4.7-155.7 months). Median overall survival was 27 months (95% CI:21-33 months). In this study, 146 (77.7%) patients had complete response, 39 (20.7%) had residual disease and 4 (1.6%) had progressive disease. The mean 3-, 5- and 10-year OS rates were respectively 41.2% (S.E.±0.036), 29% (S.E.±0.034), and 13.8% (S.E.±0.031). Significant prognostic factors for OS and CSS, by multivariate analysis, were tumor T-stage and urothelial obstruction. CONCLUSION: This CBRT protocol provided excellent results with a high complete response rate and good tolerance. This approach may therefore be particularly appropriate for elderly patients with invasive bladder cancer.

Prospective Randomized Comparison of the Effectiveness of Radiation Therapy and Local Steroid Injection for the Treatment of Plantar Fasciitis.

PURPOSE: The purpose of this study was to conduct a randomized trial of radiation therapy for plantar fasciitis and to compare radiation therapy with local steroid injections. METHODS AND MATERIALS: Between March 2013 and April 2014, 128 patients with plantar fasciitis were randomized to receive radiation therapy (total dose of 6.0 Gy applied in 6 fractions of 1.0 Gy three times a week) or local corticosteroid injections a 1 ml injection of 40 mg methylprednisolone and 0.5 ml 1% lidocaine under the guidance of palpation. The results were measured using a visual analog scale, a modified von Pannewitz scale, and a 5-level function score. The fundamental phase of the study was 3 months, with a follow-up period of up to 6 months. RESULTS: The median follow-up period for all patients was 12.5 months (range, 6.5-18.6 months). For the radiation therapy patients, the median follow-up period was 13 months (range, 6.5-18.5 months), whereas in the palpation-guided (PG) steroid injection arm, it was 12.1 months (range, 6.5-18.6 months). After 3 months, results in the radiation therapy arm were significantly superior to those in the PG steroid injection arm (visual analog scale, P<.001; modified von Pannewitz scale, P<.001; 5-level function score, P<.001). Requirements for a second treatment did not significantly differ between the 2 groups, but the time interval for the second treatment was significantly shorter in the PG steroid injection group (P=.045). CONCLUSION: This study confirms the superior analgesic effect of radiation therapy compared to mean PG steroid injection on plantar fasciitis for at least 6 months after treatment.

Evaluation of prognostic factors and survival results in gastric carcinoma: single center experience from Northeast Turkey.

OBJECTIVE: To evaluate the prognostic factors affecting overall survival (OS), disease-free survival (DFS), and survival among patients undergoing chemoradiotherapy (CRT) for locally advanced gastric carcinoma. METHODS: Between January 2001 and May 2014, 257 patients who presented to our clinic with a diagnosis of stage I-IIIC gastric cancer were evaluated. The male/female ratio of the cases was 2.02:1 and the median age was 55.16±11.8 (20-80) years. Four of the cases (1.6%) were stage IA, 13 (5.1%) were stage 1B, 41 (16%) were stage IIA, 40 (15.6%) were stage IIB, 50 (19.5%) were stage IIIA, 51 (19.8%) were stage IIIB, and 58 (22.6%) were stage IIIC. RESULTS: The mean follow-up time was 22.5 months (3.3-155.0); loco-regional recurrence was noted in 34 (13.2%) patients who underwent postoperative chemoradiotherapy, and metastases were observed in 108 (42%) patients. The median OS duration was 26.7 months (95% confidence interval, 20-33.5) and the 2-, 5-, and 10-year OS was 52.8% (standard error [S.E.] 0.032), 36.1% (S.E. 0.032), and 26.9% (S.E. 0.034) respectively. The median DFS was 53.7 months and the 2-, 5-, and 10-year DFS were 58.9% (S.E. 0.034), 47.4% (S.E. 0.037), and 40.7% (S.E. 0.042), respectively. In multivariate analysis of prognostic factors, advanced T stage (p<0.0001), advanced nodal stage (p=0.001), and surgical margin status (p<0.0001) were related to decreased OS and DFS. CONCLUSION: R1 resection, advanced T stage, and advanced nodal stage were adverse prognostic factors in gastric cancer patients who had undergone CRT after the operation.

Long-term outcomes in treatment of invasive bladder cancer with concomitant boost and accelerated hyperfractionated radiation therapy.

PURPOSE: The aim of this study was to evaluate the long-term clinical efficacy and toxicity of concomitant boost and accelerated hyperfractionated radiation therapy (CBAHRT) in patients with invasive bladder cancer. METHODS AND MATERIALS: Between October 1997 and September 2012, 334 patients with diagnoses of invasive bladder cancer were selected. These patients received CBAHRT as a bladder-conserving approach. The treatment consisted of a dose of 45 Gy/1.8 Gy to the whole pelvis with a daily concomitant boost of 1.5 Gy to the tumor. Total dose was 67.5 Gy in 5 weeks. A total of 32 patients (10.3%) had a diagnosis of stage T1, 202 (64.3%) were at stage T2, 46 (14.6%) were at stage T3a, 22 (7%) were at stage T3b, and 12 (3.8%) were at stage T4a. RESULTS: The follow-up period was 33.1 months (range, 4.3-223.3 months). Grade 3 late intestinal toxicity was observed in 9 patients (2.9%), whereas grade 3 late urinary toxicity was observed in 8 patients (2.5%). The median overall survival (OS) was 26.3 months (95% confidence interval [CI]: 21.4-31.2). The 5-, 10, and 15-year OS rates were 32.1% (standard error [SE], ± 0.027), 17.9% (SE, ± 0.025) and 12.5% (SE, ± 0.028), respectively. The median cause-specific survival (CSS) was 42.1 months (95% CI: 28.7-55.5). The 5-, 10-, and 15-year CSS rates were 43.2% (SE, ± 0.03), 30.3% (SE, ± 0.03), and 28% (SE, ± 0.04), respectively. The median relapse-free survival (RFS) was 111.8 months (95% CI: 99.6-124). The 5-, 10-, and 15-year RFS rates were 61.9% (SE, ± 0.03), 57.6% (SE, ± 0.04), and 48.2% (SE, ± 0.07), respectively. CONCLUSIONS: The CBAHRT technique demonstrated acceptable toxicity and local control rates in patients with invasive bladder cancer, and this therapy facilitated bladder conservation. In selected patients, the CBAHRT technique is a practical alternative treatment option with acceptable 5-, 10-, and 15-year results in patients undergoing cystectomy as well as concurrent chemoradiation therapy.

Evaluation of prognostic factors and survival results in pancreatic carcinomas in Turkey.

BACKGROUND: The goal of this retrospective study was to evaluate patient characteristics, treatment modalities and prognostic factors in Turkish patients with pancreatic cancer. MATERIALS AND METHODS: Between January 1997 and December 2012, 64 patients who presented to the Department of Radiation Oncology, Karadeniz Technical University, Faculty of Medicine with a diagnosis of pancreatic cancer were evaluated. The E/K ratio of the cases was 2.4/1 and the median age was 59.6 (32-80) years, respectively. Some 11 cases (18%) were stage 1, 21 (34.4%) were stage 2, 10 (16.4%) were stage 3, and 19 (31.1%) were metastatic. RESULTS: The mean follow-up time was 15.7 months (0.7-117.5) and loco-regional recurrence was noted in 11 (40.7%) who underwent surgery while metastases were observed in 41 patients (66.1%). The median overall survival (OS) was 11.2 months and the 1, 3 and 5-year OS rates were 41.7%, 9.9% and 7.9% respectively. The median disease-free survival (DFS) was 5.2 month and the1, 2 and 5 year DFS were 22.6%, 7.6% and 3.8% respectively. On univariate analysis, prognostic factors affecting OS included status of the operation (p<0.001), tumor stage (p=0.008), ECOG performance status (p=0.005) and CEA level (p=0.017).On multivariate analysis, prognostic factors affecting survival included status of the operation (p=0.033) and age (p= 0.023). CONCLUSIONS: In the current study, age and operation status were independent prognostic factors for overall survival with pancreatic patients. Thus, the patients early diagnosis and treatment ars essential. However, prospective studies with more patients are needed for confirmation.