Comparison of transperineal ultrasound image guidance technique to transabdominal technique for prostate radiation therapy.

INTRODUCTION: Ultrasound (US) guidance of the prostate has long been conducted using a transabdominal (TA) approach. More recently, a transperineal (TP) approach has been made available for image guidance. Our aim was to determine if both methods produced similar alignments within the same patients. MATERIALS AND METHODS: We utilized two clinical US image guidance (IG) systems (Elekta Clarity and Best BAT). The B-mode Acquisition and Targeting USIG system is a bi-planar, so-called 2.5D USIG system, that is acquired TA. Clarity is a 3D US system that generates a volumetric 3D US data set and US-derived IG contours that are coregistered to the planning CT images. The probe is oriented in the sagittal plane against the perineum (TP). After positioning the patient for treatment using the TP USIG, we maintained the position defined by Clarity tracking and then acquired a TA-based USIG. The two US-based methods of localizing the prostate (TA vs TP) were compared via Bland-Altman (BA) statistical analysis to determine if there was alignment agreement between methods. RESULTS: The BA test for all 101 patients, 2093 fractions resulted in 95% confidence intervals (upper and lower limits of the BA test) of 0.6 mm in LR, 0.9 mm in AP and 1.0 mm in SI. The bias between the two systems was calculated as 0.03, 0.02, and 0.03 mm in LR, AP, and SI. CONCLUSIONS: Both systems resulted in statistically equivalent targeting positions for the prostate. Because of the unique intrafraction, real-time motion tracking capability of the TP system, this solution represents a unique extension to the previously reported clinical benefits of a TA approach by providing assurance of the prostate remaining in the treatment field during beam-on.

Radiation therapy and secondary malignancy in Li-Fraumeni syndrome: A hereditary cancer registry study.

BACKGROUND: Li-Fraumeni Syndrome (LFS) is a rare cancer-predisposing condition caused by germline mutations in TP53. Conventional wisdom and prior work has implied an increased risk of secondary malignancy in LFS patients treated with radiation therapy (RT); however, this risk is not well-characterized. Here we describe the risk of subsequent malignancy and cancer-related death in LFS patients after undergoing RT for a first or second primary cancer. METHODS: We reviewed a multi-institutional hereditary cancer registry of patients with germline TP53 mutations who were treated from 2004 to 2017. We assessed the rate of subsequent malignancy and death in the patients who received RT (RT group) as part of their cancer treatment compared to those who did not (non-RT group). RESULTS: Forty patients with LFS were identified and 14 received RT with curative intent as part of their cancer treatment. The median time to follow-up after RT was 4.5 years. Fifty percent (7/14) of patients in the curative-intent group developed a subsequent malignancy (median time 3.5 years) compared to 46% of patients in the non-RT group (median time 5.0 years). Four of seven subsequent malignancies occurred within a prior radiation field and all shared histology with the primary cancer suggesting recurrence rather than new malignancy. CONCLUSION: We found that four of14 patients treated with RT developed in-field malignancies. All had the same histology as the primary suggesting local recurrences rather than RT-induced malignancies. We recommend that RT should be considered as part of the treatment algorithm when clinically indicated and after multidisciplinary discussion.

Evaluation of dose distribution differences from five algorithms implemented in three commercial treatment planning systems for lung SBRT.

Early stage lung cancer is increasingly being treated using stereotactic body radiation therapy (SBRT). Several advanced treatment planning algorithms are now available in various commercial treatment planning systems. This work compares the dose distributions calculated for the same treatment plan using, five algorithms, in three different treatment planning systems. All plans were normalized to ensure the prescription dose covers 95% of the planning target volume (PTV). Dose to the planning target volume (PTV) was compared using near-minimum dose (D98%), near-maximum dose (D2%) and dose homogeneity, while dose fall-off was compared using D2cm and R50. Dose to the lung was compared using V5Gy, V20Gy and mean lung dose. Statistical analysis shows that dose distributions calculated using Eclipse's Acuros XB and RayStation's Monte Carlo were significantly different from the other dose distributions for the PTV dose parameters investigated. For lung dosimetric parameters, this difference persisted for volumetric modulated arc therapy (VMAT) plans but not for conformal arc plans. While normal tissue complication probability (NTCP) differences were significant for some of the algorithms for VMAT delivery approaches, they were not significantly different for any algorithm for conformal arc plans. All parameters investigated here were within 5% between all algorithms. The results show that, while some small dosimetric differences can be expected around the PTV, the dose distribution to the rest of the treatment area, especially the lungs, should not be clinically-relevant when switching between one of the five algorithms investigated.

Preliminary clinical experience with Calypso anchored beacons for tumor tracking in lung SBRT.

PURPOSE: To present our preliminary experience with the recently released Calypso lung beacons to track lung tumor location during stereotactic body radiation therapy (SBRT). MATERIALS/METHODS: Five recent lung SBRT patients had Calypso lung beacons implanted for tumor tracking during treatment. Beacons were placed by a pulmonologist using fluoroscopic navigation within 1 week prior to planning four-dimensional computed tomography (4DCT) acquisition. Patients were immobilized in a full-body double-vacuum bag. For the first three patients, a verification 4DCT was obtained prior to the first fraction with the patient in the treatment position to assess both beacon migration and motion of tumor and beacons relative to planning day. For each treatment fraction, Calypso was used to position the patient. A verification cone-beam CT (CBCT) confirmed the Calypso-defined target position was appropriate. Real-time Calypso tracking information was also acquired and compared to an action level that was used to determine if the tumor migrated outside of the planning target volume. RESULTS: For four patients, the implant procedure was well tolerated, with average CBCT-based shifts being within 0.2 mm of the shifts reported by Calypso at the time of imaging. The other patient had a small pneumothorax due to very peripheral tumor location and experienced beacon migration. However, the patient quickly recovered from the pneumothorax, and after deactivating that beacon, motion tracking was possible throughout his treatment. CONCLUSIONS: All patients were successfully treated with SBRT using the newly released Calypso lung beacons, with initial positioning confirmed by this clinic's current clinical standard of CBCT. The system allowed us to validate, with real-time confirmation, that the planned internal target volumes were appropriate to each day's extent of actual tumor motion. An efficient and effective workflow for utilizing the new lung beacons for SBRT treatments was developed.

Patterns of Failure Observed in the 2-Step Institution Credentialing Process for NRG Oncology/Radiation Therapy Oncology Group 1005 (NCT01349322) and Lessons Learned.

PURPOSE: To investigate patterns of failure in institutional credentialing submissions to NRG/RTOG 1005 with the aim of improving the quality and consistency for future breast cancer protocols. METHODS AND MATERIALS: NRG/RTOG 1005 allowed the submission of 3-dimensional conformal radiation therapy (3DCRT), intensity-modulated radiation therapy (IMRT), and simultaneous integrated boost (SIB) breast plans. Credentialing required institutions to pass a 2-step quality assurance (QA) process: (1) benchmark, requiring institutions to create a plan with no unacceptable deviations and ≤1 acceptable variation among the dose volume (DV) criteria, and (2) rapid review, requiring each institution's first protocol submission to have no unacceptable deviations among the DV criteria or contours. Overall rates, number of resubmissions, and reasons for resubmission were analyzed for each QA step. RESULTS: In total, 352 institutions participated in benchmark QA and 280 patients enrolled had rapid review QA. Benchmark initial failure rates were similar for 3DCRT (18%), IMRT (17%), and SIB (18%) plans. For 3DCRT and IMRT benchmark plans, ipsilateral lung most frequently failed the DV criteria, and SIB DV failures were seen most frequently for the heart. Rapid review contour initial failures (35%) were due to target rather than organs at risk. For 29% of the rapid review initial failures, the planning target volume boost eval volume was deemed an unacceptable deviation. CONCLUSIONS: The review of the benchmark and rapid review QA submissions indicates that acceptable variations or unacceptable deviations for the ipsilateral lung and heart dose constraints were the most commonly observed cause of benchmark QA failure, and unacceptable deviations in target contouring, rather than normal structure contouring, were the most common cause of rapid review QA failure. These findings suggest that a rigorous QA process is necessary for high quality and homogeneity in radiation therapy in multi-institutional trials of breast cancer to ensure that the benefits of radiation therapy far outweigh the risks.

Stereotactic body radiotherapy versus percutaneous local tumor ablation for early-stage non-small cell lung cancer.

OBJECTIVES: To compare patterns of care and overall survival (OS) between stereotactic body radiotherapy (SBRT) and percutaneous local tumor ablation (LTA) for non-surgically managed early-stage non-small-cell lung cancer (NSCLC). MATERIALS AND METHODS: The National Cancer Database (NCDB) was queried from 2004 to 2014 for adults with non-metastatic, node-negative invasive adenocarcinoma or squamous cell carcinoma of the lung with primary tumor size ≤5.0 cm who did not undergo surgery or chemotherapy and received SBRT or LTA. Patterns of care were assessed with multivariate logistic regression. After propensity-score weighting with generalized boosted regression, OS was assessed with univariate and doubly-robust multivariate Cox regression. RESULTS: Of 15,792 patients, 14,651 (93%) received SBRT and 1141 (7%) received LTA. Increasing age (OR 1.01, p = .035), treatment at an academic institution (OR 2.94, p < .001), increasing tumor size (OR 1.05, p < .001), and more recent year of diagnosis (OR 1.43, p < .001) were predictive of treatment with SBRT, whereas comorbidities (OR 0.74, p = .003) and treatment at a high-volume facility (OR 0.05, p < .001) were predictive for LTA. At a median follow-up of 26.2 months, SBRT was associated with improved OS relative to LTA within a propensity-score weighted doubly-robust multivariate analysis (HR 0.71, p < .001). On weighted subgroup analyses, improved OS was observed with SBRT for tumor sizes >2.0 cm (HR 0.72, p < .001) and for those treated at high-volume facilities (HR 0.71, p < .001). No OS difference was found with SBRT or LTA in tumor sizes ≤2.0 cm (HR 0.90, p = .227). CONCLUSION: Within the NCDB, SBRT was more commonly utilized and was associated with improved OS when compared to percutaneous LTA for patients with non-surgically managed early-stage NSCLC. Patients with small tumor volumes likely represent an appropriate population for future prospective randomized comparisons between SBRT and LTA.

Skin dose estimation using virtual structures for Contura Multi-Lumen Balloon breast brachytherapy.

PURPOSE: To propose a workflow that uses ultrasound (US)-measured skin-balloon distances and virtual structure creations in the treatment planning system to evaluate the maximum skin dose for patients treated with Contura Multi-Lumen Balloon applicators. METHODS AND MATERIALS: Twenty-three patients were analyzed in this study. CT and US were used to investigate the interfractional skin-balloon distance variations. Virtual structures were created on the planning CT to predict the maximum skin doses. Fitted curves and its equation can be obtained from the skin-balloon distance vs. maximum skin dose plot using virtual structure information. The fidelity of US-measured skin distance and the skin dose prediction using virtual structures were assessed. RESULTS: The differences between CT- and US-measured skin-balloon distances values had an average of -0.5 ± 1.1 mm (95% confidence interval [CI] = -1.0 to 0.1 mm). Using virtual structure created on CT, the average difference between the predicted and the actual dose overlay maximum skin dose was -1.7% (95% CI = -3.0 to -0.4%). Furthermore, when applying the US-measured skin distance values in the virtual structure trendline equation, the differences between predicted and actual maximum skin dose had an average of 0.7 ± 6.4% (95% CI = -2.3% to 3.7%). CONCLUSIONS: It is possible to use US to observe interfraction skin-balloon distance variation to replace CT acquisition. With the proposed workflow, based on the creation of virtual structures defined on the planning CT- and US-measured skin-balloon distances, the maximum skin doses can be reasonably estimated.

Primary Pulmonary Carcinoid Tumor: A Long-term Single Institution Experience.

OBJECTIVES: Primary carcinoid tumors of the lung are rare tumors which comprise approximately 0.5% to 5% of all lung malignancies in adults and roughly 20% to 30% of all carcinoid tumors. The purpose of this retrospective, descriptive study was to describe the incidence, characteristics, and outcomes of patients treated for primary pulmonary carcinoid tumor at a single institution. MATERIALS AND METHODS: All patients with a diagnosis of primary pulmonary carcinoid tumor treated from 1989 to 2009 were reviewed. Data collected included demographics, pathology, tobacco use, clinical presentation, tumor location, tumor spread, treatment, and survival. RESULTS: There were 59 cases of pulmonary carcinoid tumors: 47 typical (80%) and 12 atypical (20%). All but 4 patients underwent surgery, including 54 (92%) lung-sparing resections and 1 pneumonectomy. Five of 55 patients received concurrent adjuvant chemoradiation therapy; 4 patients with atypical and 1 with typical histology. Three additional patients with atypical carcinoid were treated only with adjuvant radiotherapy, palliative radiotherapy, or palliative chemotherapy, respectively. The Kaplan-Meier 5- and 10-year overall survivals were both 80% within the entire population. In the 88% of patients who achieved complete remission, disease-free survival was 98%. A review of a large series from the literature is also presented. CONCLUSIONS: Surgical resection was primary and adequate therapy for most typical carcinoid tumors with high overall survival and disease-free survival. Adjuvant chemotherapy or radiotherapy might be considered for patients with atypical carcinoid tumors who present with adverse pathologic findings.

Sequencing of Postoperative Radiotherapy and Chemotherapy for Locally Advanced or Incompletely Resected Non-Small-Cell Lung Cancer.

Purpose Although several feasibility studies have demonstrated the safety of adjuvant concurrent chemoradiotherapy (CRT) for locally advanced or incompletely resected non-small-cell lung cancer (NSCLC), it remains uncertain whether this approach is superior to sequential chemotherapy followed by postoperative radiotherapy (C→PORT). We sought to determine the most effective treatment sequence. Patients and Methods Using the National Cancer Database, we selected two cohorts of patients with nonmetastatic NSCLC who had received at least a lobectomy followed by multiagent chemotherapy and radiotherapy; cohort one included patients with R0 resection and pN2 disease, whereas cohort two included patients with R1-2 resection regardless of nodal status. Overall survival (OS) was examined using a propensity score-matched analysis with a shared frailty Cox regression. Results A total of 747 patients in cohort one and 277 patients in cohort two were included, with a median follow-up of 32.8 and 27.9 months, respectively. The median OS was 58.8 months for patients who received C→PORT versus 40.4 months for patients who received CRT in cohort one (log-rank P < .001). For cohort two, the median OS was 42.6 months for patients who received C→PORT versus 38.5 months for patients who received CRT (log-rank P = .42). After propensity score matching, C→PORT remained associated with improved OS compared with CRT in cohort one (hazard ratio, 1.35; P = .019), and there was no statistical difference in OS between the sequencing groups for cohort two (hazard ratio, 1.35; P = .19). Conclusion Patients with NSCLC who undergo R0 resection and are found to have pN2 disease have improved outcomes when adjuvant chemotherapy is administered before, rather than concurrently with, radiotherapy. For patients with positive margins after surgery, there is not a clear association between treatment sequencing and survival.

Is radiation indicated for young women with early stage, node-negative breast cancer after mastectomy? A multi-institution, retrospective review.

The role of post-mastectomy radiation for women with node negative, early stage disease is not well-defined. The purpose of this study is to more clearly define a subset of women who are ≤40 years of age with T1-T2, node negative breast cancer who may benefit from post-mastectomy radiation. Using tumor registries at two institutions, we identified 219 women ≤40 years of age with T1-T2, node negative breast cancer treated with mastectomy. Of these 219 patients, 38 received post-mastectomy radiation and 181 did not. Kaplan-Meier methods and cox proportional-hazards regression models were employed for statistical analysis. There were no locoregional failures in the women receiving post mastectomy radiation, which lead to a nonsignificant increase in freedom from locoregional recurrence (P=.08). For women not receiving post-mastectomy radiation, freedom from locoregional recurrence was 94.7% and 89.7% at 5- and 10-years. Lymphovascular space invasion (LVSI) was the only factor predictive of locoregional recurrence. For women without LVSI, freedom from locoregional recurrence was 96.0% and 93.3% at 5- and 10-years respectively. For women with LVSI who did not receive post mastectomy radiation, freedom from locoregional recurrence was 89.1% at 5-years. There were no failures in the women with LVSI who received post mastectomy radiation. For women ≤40 years of age with T1-2, node negative breast cancer treated with mastectomy and no post-mastectomy radiation, locoregional control is excellent in the absence of LVSI, regardless of other risk factors. In the presence of LVSI (regardless of other risk factors), the risk of locoregional recurrence is high and appears to be decreased with post-mastectomy radiation.

Hypofractionated Postmastectomy Radiation Therapy Is Safe and Effective: First Results From a Prospective Phase II Trial.

Purpose Conventionally fractionated postmastectomy radiation therapy (PMRT) takes approximately 5 to 6 weeks. Data supporting hypofractionated PMRT is limited. We prospectively evaluated a short course of hypofractionated PMRT, in which therapy was completed in 15 treatment days. Patients and Methods We delivered PMRT at a dose of 36.63 Gy in 11 fractions of 3.33 Gy over 11 days to the chest wall and the draining regional lymph nodes, followed by an optional mastectomy scar boost of four fractions of 3.33 Gy. Our primary end point was freedom from any grade 3 or higher toxicities. We incorporated early stopping criteria on the basis of predefined toxicity thresholds. Results We enrolled 69 women with stage II to IIIa breast cancer, of whom 67 were eligible for analysis. After a median follow-up of 32 months, there were no grade 3 toxicities. There were 29 reported grade 2 toxicities, with grade 2 skin toxicities being the most frequent (16 of 67; 24%). There were two patients with isolated ipsilateral chest wall tumor recurrences (2 of 67; crude rate, 3%). Three-year estimated local recurrence-free survival was 89.2% (95% CI, 0.748 to 0.956). The 3-year estimated distant recurrence-free survival was 90.3% (95% CI, 0.797 to 0.956). Forty-one patients had chest wall reconstructions; three had expanders removed for infection before radiation therapy. The total rate of implant loss or failure was 24% (9 of 38), and the unplanned surgical correction rate was 8% (3 of 38), for a total complication rate of 32%. Conclusion To our knowledge, our phase II prospective study offers one of the shortest courses of PMRT reported, delivered in 11 fractions to the chest wall and nodes and 15 fractions inclusive of a boost. We demonstrated low toxicity and high local control with this schedule. On the basis of our data, we have designed a cooperative group phase III prospective, randomized trial of conventional versus hypofractionated PMRT that will activate soon.

Outcomes and utilization of postmastectomy radiotherapy for T3N0 breast cancers.

BACKGROUND: The role of postmastectomy radiotherapy (PMRT) for women with pT3N0M0 breast cancer is controversial. We sought to determine the benefit of PMRT in this cohort using the National Cancer Database (NCDB). METHODS: We analyzed women with pT3N0M0 breast cancer who received mastectomy with or without PMRT between 2004 and 2012. We excluded men, women ≤18 years, neoadjuvant or unknown radiation or chemotherapy status, unknown estrogen or progesterone receptor status, unknown surgical margin status, histology other than invasive ductal or lobular carcinoma, and if death occurred <3 months after diagnosis. A total of 4291 patients was included for analysis. Chi-squared analysis was used to compare patient characteristics. Univariate (UVA) and multivariate (MVA) Cox proportional hazards modeling was used to identify factors associated with survival. Propensity score matching was performed to address confounding variables. Survival analysis was performed using Kaplan-Meier and shared frailty models. RESULTS: Of the 4291 women analyzed, 2030 (47%) received PMRT. On MVA, PMRT (HR 0.72, p < 0.001), chemotherapy (HR 0.51, p < 0.001), and hormone therapy (HR 0.63, p < 0.001) were associated with improved overall survival (OS). After propensity score matching, a matched cohort of 2800 women was analyzed. At 5 years, OS was 83.7% and 79.8% with and without PMRT, respectively (p < 0.001). This difference in OS benefit increased with time. At 10 years, OS was 67.4% and 59.2% with and without PMRT, respectively. CONCLUSIONS: PMRT was associated with improved OS in women with pT3N0M0 breast cancer, which strongly suggests PMRT may provide a survival advantage and should be considered.

Post-mastectomy Radiotherapy for pT3N0 Breast Cancers: A Retrospective, Multi-Institution Review.

The role of post-mastectomy radiotherapy for pT3N0 breast cancers remains undefined. The purpose of this study was to report institutional outcomes for women with pT3N0 breast cancers treated with and without post-mastectomy radiotherapy. We collected data from two large tumor registries on pT3N0 breast cancers diagnosed between 1985 and 2014. Kaplan-Meier estimates were used to analyze freedom from local-regional recurrence (FFLR), relapse free survival, and overall survival. This analysis identified 93 women with pT3N0 breast cancers. Of these, 53 received post-mastectomy radiotherapy and 40 did not. Median follow-up was 6.2 years and 5.3 years in the non-post-mastectomy radiotherapy and post-mastectomy radiotherapy cohorts, respectively. Women not undergoing post-mastectomy radiotherapy were more likely to be diagnosed in the 1980s and 1990s and were less likely to receive systemic therapies than women receiving post-mastectomy radiotherapy (p < 0.05). There was a trend toward increased FFLR in the women receiving post-mastectomy radiotherapy (p = 0.15). FFLR in the post-mastectomy radiotherapy cohort was 98% at both 5 and 10 years. For women not receiving post-mastectomy radiotherapy, FFLR was 88% at both 5 and 10 years. Women not receiving post-mastectomy radiotherapy in our study had an isolated local-regional failure rate of 12% at 10 years, despite receiving inferior systemic treatment by current standards. Local-regional control after post-mastectomy radiotherapy for pT3N0 breast cancers was excellent. Further research is needed to define post-mastectomy radiotherapy indications for this patient population when receiving chemotherapy and endocrine therapy in line with current guidelines.

Dosimetric evaluation of abdominal compression as a method to reduce the incidence of radiation-induced pneumonitis in lung SBRT treatment.

Abdominal compression has been shown to reduce the extent of lung tumor motion but the dosimetric impact of the approach is still in need of investigation. The current work analyzes the impact of various changes in PTV volume on key metrics of the final dose distribution to normal lung. To add clinical perspective, we also provide NTCP calculations for grade 2+ pneumonitis for each case. For a total of seventeen cases, the original ITV/PTV was reduced by systematically varied amounts and SBRT plans using dynamic conformal arc and VMAT techniques were created. DVH analysis for the normal lung comparing the original plan to the one with the ITV reduced by up to 10 mm shows that the average reduction of V5, V20 and mean lung dose is 3.8%, 2.0% and 1.1 Gy, respectively, for the conformal arc plans. Corresponding values for the VMAT plans were 3.9%, 1.9% and 1.2 Gy respectively. The mean NTCP drop for the conformal arc plans was 2.0% while it was 1.9% for the VMAT plans. These results suggest that abdominal compression has a modest impact on NTCP and on dosimetric parameters typically used to predict the risk of radiation pneumonitis in patients undergoing lung SBRT.

In the Modern Treatment Era, Is Breast Conservation Equivalent to Mastectomy in Women Younger Than 40 Years of Age? A Multi-Institution Study.

PURPOSE: Mastectomy is often recommended for women ≤40 years of age with breast cancer, as young women were under-represented in the landmark trials comparing breast conservation therapy (BCT) to mastectomy. We hypothesized that, in the modern treatment era, BCT and mastectomy result in equivalent local control rates in young women. METHODS AND MATERIALS: Breast cancer cases arising between 1975 and 2013 in women ≤40 years old were collected from the tumor registries of 2 large healthcare systems in Utah. Kaplan-Meier estimates and Cox proportional hazards models were used to analyze freedom from locoregional recurrence (FFLR), overall survival (OS), and relapse-free survival (RFS). RESULTS: This analysis identified 853 BCT candidates. A comparison of BCT to mastectomy after 2000 showed FFLR, RFS, and OS were all similar. Rate for FFLR at 10 years was 94.9% versus 92.1% for BCT and mastectomy, respectively (P=.57). For women whose cancer was diagnosed after 2000, who received BCT, FFLR and RFS rates were improved compared to those whose cancer was diagnosed prior to 2000 (P<.05), whereas OS (P=.46) rates were similar. Among those who underwent mastectomy, FFLR, OS, and RFS were significantly improved (P<.05) with diagnosis after 2000. CONCLUSIONS: FFLR rates for young women, ≤40 years of age, have significantly improved for BCT and mastectomy over time. If patients were treated after 2000, BCT appears to be safe and equivalent to mastectomy at 10 years in terms of FFLR, OS, and RFS.

The Effect of Radiation on Complication Rates and Patient Satisfaction in Breast Reconstruction using Temporary Tissue Expanders and Permanent Implants.

The optimal method of reconstruction following mastectomy for breast cancer patients receiving radiation therapy (RT) is controversial. This study evaluated patient satisfaction and complication rates among patients who received implant-based breast reconstruction. The specific treatment algorithm analyzed included patients receiving mastectomy and immediate temporary tissue expander (TE), followed by placement of a permanent breast implant (PI). If indicated, RT was delivered to the fully expanded TE. Records of 218 consecutive patients with 222 invasive (85%) or in situ (15%) breast lesions from the Salt Lake City region treated between 1998 and 2009 were retrospectively reviewed, 28% of whom received RT. Median RT dose was 50.4 Gy, and 41% received a scar boost at a median dose of 10 Gy. Kaplan-Meier analyses were performed to evaluate the cumulative incidence of surgical complications, including permanent PI removal. Risk factors associated with surgical events were analyzed. To evaluate cosmetic results and patient satisfaction, an anonymous survey was administered. Mean follow-up was 44 months (range 6-144). Actuarial 5-year PI removal rates for non-RT and RT patients were 4% and 22%, respectively. On multivariate analysis (MVA), the only factor associated with PI removal was RT (p = 0.009). Surveys were returned describing the outcomes of 149 breasts. For the non-RT and RT groups, those who rated their breast appearance as good or better were 63% versus 62%, respectively. Under 1/3 of each group was dissatisfied with their reconstruction. RT did not significantly affect patient satisfaction scores, but on MVA RT was the only factor associated with increased PI removal. This reconstruction technique may be considered an acceptable option even if RT is needed, but the increased complication risk with RT must be recognized.

Radiation therapy for clinically node-positive prostate adenocarcinoma is correlated with improved overall and prostate cancer-specific survival.

PURPOSE: To evaluate the effect of radiation therapy on prostate cancer-specific and overall survival with node-positive cancer in a retrospective Surveillance, Epidemiology and End RESULTS (SEER) population based study. METHODS AND MATERIALS: The survival of subjects with cT1-T4,cN1,M0 prostate adenocarcinoma diagnosed between 1988 and 2006 were compared with univariate and multivariate Cox regression analysis. RESULTS: A total of 1100 subjects, with a median age of 69 years and median follow-up time of 90 months, were identified. The 10-year cancer-specific survival for men who had no definitive therapy was 50.3% and for those who had radiation therapy 62.7%. This was significantly different favoring radiation therapy (hazard ratio [HR] = 0.66, 95% confidence interval [CI] = 0.54 to 0.82, P ≤ .01). On multivariate analysis evaluating age, histologic grade, T stage, year of diagnosis, marital status, SEER registry and radiation therapy, radiation therapy (HR = 0.67, 95% CI = 0.54 to 0.84, P ≤ .01), year of diagnosis (HR = 0.96, 95% CI = 0.93 to 0.99, P = .01), and low and intermediate grade disease were correlated with improved CSS. The number needed to treat to prevent 1 prostate cancer-specific death at 10 years was 8 persons. A cause of death analysis revealed non-prostate cancer deaths were not statistically different in the comparison groups. CONCLUSIONS: Radiation therapy is correlated with a clinically significant reduction in all cause and prostate cancer-specific death.

Initial experience and clinical comparison of two image guidance methods for SBRT treatment: 4DCT versus respiratory-triggered imaging.

For Stereotactic Body Radiation Therapy (SBRT) treatment of lung and liver, we quantified the differences between two image guidance methods: 4DCT and ExacTrac respiratory-triggered imaging. Five different patients with five liver lesions and one lung lesion for a total of 19 SBRT delivered fractions were studied. For the 4DCT method, a manual registration process was used between the 4DCT image sets from initial simulation and treatment day to determine the required daily image-guided corrections. We also used the ExacTrac respiratory-triggered imaging capability to verify the target positioning, and calculated the differences in image guidance shifts between these two methods. The mean (standard deviation) of the observed differences in image-guided shifts between 4DCT and ExacTrac respiratory-triggered image guidance was left/right (L/R) = 0.4 (2.0) mm, anterior/posterior (A/P) = 1.4 (1.7) mm, superior/inferior (S/I) = 2.2 (2.0) mm, with no difference larger than 5.0 mm in any given direction for any individual case. The largest error occurred in the S/I direction, with a mean of 2.2 mm for the six lesions. This seems reasonable, because respiratory motion and the resulting imaging uncertainties are most pronounced in this S/I direction. Image guidance shifts derived from ExacTrac triggered imaging at two extreme breathing phases (i.e., full exhale vs. full inhale), agreed well (less than 2.0 mm) with each other. In summary, two very promising image guidance methods of 4DCT and ExacTrac respiratory-triggered imaging were presented and the image guidance shifts were comparable for the patients evaluated in this study.