Dosimetric, mechanical, and geometric verification of conformal dynamic arc treatment.

A conformal dynamic arc (CD-arc) technique has been implemented at the S. Giovanni Calibita-Fatebenefratelli Hospital Radiotherapy Center. This technique is performed by rotational beams and a dynamic multileaf collimator (DMLC): during the treatment delivery the gantry rotates and the field shape, formed by the DMLC changes continuously. The aim of this study was to perform dosimetric, mechanical, and geometric verification to ensure that the dose calculated by a commercial treatment planning system and administered to the patient was correct, before and during the clinical use of this technique. Absolute dose values, at the isocenter and at other points placed in dose heterogeneity zone, have been verified with an ionization chamber in a solid homogeneous phantom. In uniform dose regions measured dose values resulted in agreements with the calculated doses within 2%. Isodose distributions have also been determined by radiographic films and compared with those predicted by the planning system. Distance to agreement between calculated and measured isodoses in dose gradient zone was within 2 mm. In conclusion, our results demonstrated the feasibility and the accuracy of the CD-arc technique for achieving highly conformal dose distributions. Up till now 20 patients have been treated with CD-arc therapy.

Intraoperative radiotherapy: current thinking.

Intraoperative radiotherapy (IORT) refers to the delivery of irradiation at surgery. A large single dose of irradiation is delivered to a surgically defined area, while uninvolved and dose-limiting tissues are displaced, the final goal of IORT being enhanced locoregional tumour control. IORT is used in most modern protocol studies as a boost radiation component of multidisciplinary treatment approaches. More recently, high activity radiation sources or mobile operating room treatment machines are used to facilitate the IORT procedure. Clinical experiences have shown that IORT may improve local control and disease-free survival, especially when used in adjuvant setting, combined with external beam irradiation in some neoplasms such as cancer of the stomach, pancreas, colorectum, and soft tissue sarcoma.

Phase I-II trial of preoperative chemoradiation in locally advanced cervical carcinoma.

BACKGROUND: 5-Fluorouracil and cisplatin are characterized by in vitro synergism as well as radiosensitization. A phase I-II study was carried out on patients with invasive cervical carcinoma (FIGO IIB-IIIA) undergoing concomitant chemoradiation with 5-fluorouracil and cisplatin followed by radical surgery. METHODS: Twenty-six patients of 53 years median age, 24 with IIB tumor and 2 with IIIA tumor, all with squamous carcinoma, entered the study. The chemoradiation protocol included external radiotherapy to the pelvis: 39.6 Gy (180 cGy/daily); 5-fluorouracil: 1 g/m(2)/daily, in continuous intravenous infusion days 1-4 and 27-30; cisplatin: 20 mg/m(2)/daily days 1-4 and 27-30. Four weeks after the end of chemoradiotherapy, patients underwent restaging and then radical surgery with pelvic and lumboaortic lymphadenectomy. RESULTS: Twenty-six patients are evaluable for acute toxicity and 24 are evaluable for objective and pathologic response. Grade 3-4 thrombocytopenia or leukopenia was observed in 6 patients and grade 3 acute gastrointestinal toxicity in 3. After chemoradiation CR and PR were observed in 64 and 36% of cases, respectively (CR + PR = 100%). Two patients were excluded from surgery for other diseases. The remaining 24 patients were operated on; 23/24 patients showed negative section margins. The histology of the surgical specimen showed the absence of disease in 13 patients (54.2%), microscopic residual tumor in 4 patients (16.6%), residual disease 1 cm in 2 patients. Median follow up was 33 months. Two-year actuarial local control was 91.7%. CONCLUSIONS: This study showed a particularly high rate of pathologic responses (complete + Tmic: 70.8%) and local control (2 years = 91.7%) in patients with advanced cervical cancer undergoing moderate doses of radiotherapy with concomitant chemotherapy followed by radical surgery.

Radiotherapy, local control and survival in cervical carcinoma.

The natural history of cervical carcinoma is characterized by a close correlation between local control and survival. Local eradication of the disease is justified for the obvious impact on the quality of life as well as on long-term survival. A series of analyses carried out in the last decades have elucidated the role of a number of prognostic factors in local control. Among treatment modalities applied to attain this aim, particular interest has been focused in recent years on concomitant radiation and chemotherapy. While some experiences have shown promising results, the precise role of this combination will be defined based on the outcomes of some randomized studies now in progress. Among the modalities of concomitant radiation and chemotherapy, some authors have proposed the following sequence: neoadjuvant chemotherapy and surgical resection. It is an aggressive approach potentially associated to major side-effects. This therapeutic modality will require an accurate assessment of clinical results both in terms of clinical response, local control and effects on organ function and quality of life.

Organ preservation in locally advanced carcinoma of the uterine cervix.

In the treatment of locally advanced carcinoma of the uterine cervix the multimodal therapeutic approach is useful to improve overall survival and disease-free survival. Two studies of concomitant radiochemotherapy were conducted. In the first, recurrences of gynecologic tumors were treated, in the second primary tumors of the uterine cervix. In the first study 29 patients, of whom 15 with endometrial cancer recurrence, 10 with cervical cancer recurrence and 4 with vulvar cancer recurrence were treated with FUMIR schedule (5-FU and mitomycin C plus concomitant radiotherapy to the pelvis in two cycles of 23.4 Gy) and subsequent brachytherapy boost. In the second study 17 patients, of whom 14 evaluable, were treated with external beam radiotherapy (ERT 40 Gy) and concomitant chemotherapy (5-FU and CDDP). Before and after treatment the patients were examined with MRI. After radiochemotherapy radical hysterectomy and histology of surgical specimen was performed. Results of first study were as follows: acute G1-G2 (RTOG) hematologic toxicity 56%, G3 4%; G1-G2 gastrointestinal 54%, G1-G2 skin 29%; G1-G2 rectum 24%; G1-G2 bladder 25%; G1-G2 vagina 30%. Local control, overall survival and disease-free survival at 24 months were 45%, 76% and 67%, respectively. Results of the second study showed 9/14 patients with complete response and 4/4 patients with partial response (93%), no change in 1, with 100% MRI accuracy as compared to histology. Based on these results a phase III clinical trial was planned in primary cancer of the uterine cervix using concomitant radiochemotherapy (CDDP + 5-FU) plus intracavitary brachytherapy for organ preservation.

[Computerization experience in a day hospital of integrated radiochemotherapy]. / Esperienza di informatizzazione in un day hospital di radiochemioterapia integrata.

INTRODUCTION: We report on a cost-effective easy-access software developed for the functional integration of the clinical records and history of oncologic patients with the management of the Day Hospital of the Radiotherapy Department of the University Hospital A. Gemelli, in Rome. MATERIAL AND METHODS: The software was designed to archive the clinical records and history of oncologic patients and the relative chemotherapy, to manage the examination scheduling, to draw up nursing files with the planned therapy and to make statistical analyses of the department activity. Five forms are available: the patient form, recording patient data; the admission form, recording the type of therapy (e.g., chemotherapy, tests, medical examinations, etc.), the relative cost and chemotherapy protocol, detailing for instance the type of drug; the nursing file, detailing chemotherapy schedule and the dilution of each drug; the menu, to select and retrieve any record. The minimum configuration requires a 386 Intel CPU, 4 Mb RAM and 4 Mb free on the hard disk. The software is the File Maker Pro 2.1 for Windows which can interact with Apple Macintosh computers. RESULTS: Since October, 1995, we have saved the clinical records of 272 oncologic outpatients (2415 entries in all), with a mean of 201/month. This computer system permitted us to save and retrieve data for both clinical and didactic purposes and to plan our activity. CONCLUSIONS: One year after it was implemented and used in clinical practice, the system is a cost-effective and user-friendly tool for the management of the Radiochemotherapy Day Hospital of our Radiotherapy Department.