Factors Associated with Duration of Overall Treatment Time for Cervical Cancer Treated with Definitive Chemoradiotherapy.

Introduction For women with intact cervical cancer treated by definitive chemoradiotherapy, the adverse impact of treatment prolongation is well-established. We aimed to identify potentially modifiable factors associated with the unwanted increase in the time required to complete the prescribed course of therapy. Methods We retrospectively examined treatment records of 104 consecutive cervical cancer patients receiving chemoradiation for cervical cancer, which included cervical high-dose-rate intracavitary brachytherapy performed at a single referral center. Association of factors, including distance to care, driving time, and income level with overall treatment time, was explored. Results Guideline-concordant treatment duration was achieved in 34% of cases. There was no significant correlation between treatment duration and any of the patient-related characteristics assessed in this study. Transitioning of the radiation oncology physician staffing at the brachytherapy center from a private practice non-integrated group to a large integrated group was associated with a decrease in mean overall treatment time, 61 vs. 68 days, p = 0.007. Conclusions We did not identify a modifiable patient-related factor amenable to a financial intervention. Administration of brachytherapy within an integrated system resulted in a shortened duration of the entire course of therapy for intact cervical cancer.

Outcomes of Stereotactic Body Radiotherapy for Hepatocellular Carcinoma with Severe Cirrhosis and Ineligibility for Transplant.

BACKGROUND/AIM: Our study reviewed the results of patients with hepatocellular carcinoma and Child-Pugh score 8-11 cirrhosis treated with stereotactic body radiotherapy when liver transplant was not an option. PATIENTS AND METHODS: A retrospective review was performed on 15 patients with Child-Pugh class B and C cirrhosis treated with stereotactic body radiotherapy. The median total dose was 35 Gy in 4-5 fractions. None were listed for a liver transplant due to either being outside of the Milan criteria or to medical contraindications. RESULTS: The overall survival was 26.7% at 6 months, with a mean survival of 152 days. The mean survival with and without ascites was 3.3 months and 8.3 months, respectively. CONCLUSION: For hepatocellular carcinoma with cirrhosis of Child-Pugh score 8 or more, prognosis after liver stereotactic body radiotherapy was suboptimal. While irradiation achieved local tumor control, progressive cirrhosis was a common cause of death. Patients without ascites at the time of radiotherapy had the best prognosis.

A comparison of outcomes for early oropharyngeal cancers treated with single-modality surgery versus radiotherapy.

AIMS: We retrospectively compared results of surgery alone (SX) or radiotherapy alone (RT) for early stage tonsil and base of tongue cancers. MATERIALS & METHODS: Outcomes for 386 SX and 362 RT patients from Surveillance, Epidemiology and End RESULTS database were analyzed using propensity covariate adjusted and inverse probability weighting models. RESULTS: With median follow-up of 71 months, unadjusted overall survival at 5 years was 66.1% for SX versus 50.2% for RT (p < 0.001). Unadjusted cancer-specific survival was 80.9% for SX versus 67.3% for RT (p < 0.001). In multivariate analysis, treatment modality maintained association with overall survival and cancer-specific survival. Inverse probability weighting-adjusted 5-year overall survival was 75.2% for SX versus 67.4% for RT (p = 0.002). Inverse probability weighting-adjusted cancer-specific survival was 86.0% for SX versus 77.4% for RT (p < 0.001). CONCLUSION: Explanations for higher survival for SX include comorbidities, superiority of surgery and underascertainment of postoperative radiation in Surveillance, Epidemiology and End Results.

Early-stage central lung cancer and volumetric modulated arc therapy: a dosimetric case study with literature review.

BACKGROUND/AIM: In the present article we review on the use of Volumetric Modulated Arc Therapy (VMAT) for a small lung nodule that was centrally located in close proximity to the mediastinal structures. CASE REPORT: An inoperable patient with central, clinical stage IA adenocarcinoma of the right lung was treated with external-beam radiation therapy of 52.5 Gy in 15 factions. A single 360° coplanar arc VMAT plan (360-VMAT) was used for treatment and compared to step-and-shoot Intensity Modulation Radiotherapy (IMRT) and a single 180° ipsilateral partial arc VMAT plan (180-VMAT). RESULTS: Planning Target Volume (PTV) coverage was not different, and 360-VMAT had the highest dose homogeneity. Both 360-VMAT and 180-VMAT reduced esophageal dose compared to IMRT. While IMRT had the lowest lung dose, all 3 plans achieved acceptable sparing of the lung. 180-VMAT had the highest dose conformity. Both 360-VMAT and 180-VMAT improved esophageal sparing compared to IMRT. CONCLUSION: Use of VMAT in early-stage, centrally located NSCLC is a promising treatment approach and merits additional investigation.

Use of image-guided stereotactic body radiation therapy in lieu of intracavitary brachytherapy for the treatment of inoperable endometrial neoplasia.

PURPOSE: Retrospective analysis of patients with invasive endometrial neoplasia who were treated with external beam radiation therapy followed by stereotactic body radiation therapy (SBRT) boost because of the inability to undergo surgery or brachytherapy. METHODS AND MATERIALS: We identified 11 women with stage I-III endometrial cancer with a median age of 78 years that were not candidates for hysterectomy or intracavitary brachytherapy secondary to comorbidities (91%) or refusal (9%). Eight patients were American Joint Committee on Cancer (AJCC) stage I (3 stage IA, 5 stage IB), and 3 patients were AJCC stage III. Patients were treated to a median of 4500 cGy at 180 cGy per fraction followed by SBRT boost (600 cGy per fraction×5). RESULTS: The most common side effect was acute grade 1 gastrointestinal toxicity in 73% of patients, with no late toxicities observed. With a median follow-up of 10 months since SBRT, 5 patients (45%) experienced locoregional disease progression, with 3 patients (27%) succumbing to their malignancy. At 12 and 18 months from SBRT, the overall freedom from progression was 68% and 41%, respectively. Overall freedom from progression (FFP) was 100% for all patients with AJCC stage IA endometrial carcinoma, whereas it was 33% for stage IB at 18 months. The overall FFP was 100% for International Federation of Obstetrics and Gynecology grade 1 disease. The estimated overall survival was 57% at 18 months from diagnosis. CONCLUSION: In this study, SBRT boost to the intact uterus was feasible, with encouragingly low rates of acute and late toxicity, and favorable disease control in patients with early-stage disease. Additional studies are needed to provide better insight into the best management of these clinically challenging cases.

Repeat stereotactic body radiation therapy for patients with pulmonary malignancies who had previously received SBRT to the same or an adjacent tumor site.

OBJECTIVES: Retrospective analysis of patients with recurrences at or closely adjacent to the site of prior lung stereotactic body radiation therapy (SBRT) who received repeat SBRT. MATERIALS AND METHODS: Nine patients with non-small cell lung cancer (n = 8) or oligometastatic colonic adenocarcinoma (n = 1) were treated with image-guided lung SBRT to a median of 60 Gy (range, 30-60) in a median of 3 fractions (3-5). Patients developed in-field relapse (n = 3) or recurrence adjacent (≤ 3.5 cm away) to the previous tumor location (n = 6) and received 2 nd lung SBRT to a median of 60 Gy. RESULTS: Median follow-up after 2 nd SBRT was 22 months (4-40). All completed prescribed course of repeat SBRT and acute toxicity was limited. There was no grade >3 late toxicity. 3 (33.3%) patients developed Grade 3 late reactions: 2 pulmonary and 1 chest wall pain. Late pulmonary toxicity included 2 (22.2%) patients with Grade 3 and 3 (33.3%) with Grade 2. One patient (11.1%) had late Grade 3 and 1 (11.1%) Grade 2 chest wall pain. 1 (11.1%) developed Grade 2 late brachial plexopathy. No myelopathy was observed. Two patients developed progression of tumors treated by 2 nd SBRT. Local recurrence free survival and overall survival was 75% and 68.6%, respectively at 2 years. Relative volume of ipsilateral lung receiving 5 Gy (V5) and V10 were lower for 2 nd SBRT. CONCLUSION: Repeat image-guided SBRT for patients with small peripheral recurrences was feasible and severe toxicity was not observed. Additional studies are needed to evaluate the safety and efficacy of lung reirradiation using 2 nd SBRT.

A comprehensive analysis of cardiac dose in balloon-based high-dose-rate brachytherapy for left-sided breast cancer.

PURPOSE: To investigate radiation dose to the heart in 60 patients with left-sided breast cancer who were treated with balloon-based high-dose-rate brachytherapy using MammoSite or Contura applicators. METHODS AND MATERIALS: We studied 60 consecutive women with breast cancer who were treated with 34 Gy in 10 twice-daily fractions using MammoSite (n = 37) or Contura (n = 23) applicators. The whole heart and the left and right ventricles were retrospectively delineated, and dose-volume histograms were analyzed. Multiple dosimetrics were reported, such as mean dose (D(mean)); relative volume receiving 1.7, 5, 10, and 20 Gy (V1.7, V5, V10, and V20, respectively); dose to 1 cc (D(1cc)); and maximum point dose (D(max)). Biologic metrics, biologically effective dose and generalized equivalent uniform dose were computed. The impact of lumpectomy cavity location on cardiac dose was investigated. RESULTS: The average ± standard deviation of D(mean) was 2.45 ± 0.94 Gy (range, 0.56-4.68) and 3.29 ± 1.28 Gy (range, 0.77-6.35) for the heart and the ventricles, respectively. The average whole heart V5 and V10 values were 10.2% and 1.3%, respectively, and the heart D(max) was >20 Gy in 7 of 60 (11.7%) patients and >25 Gy in 3 of 60 (5%) patients. No cardiac tissue received ≥30 Gy. The V1.7, V5, V10, V20, and D(mean) values were all higher for the ventricles than for the whole heart. For balloons located in the upper inner quadrant of the breast, the average whole heart D(mean) was highest. The D(mean), biologically effective dose, and generalized equivalent uniform dose values for heart and ventricles decreased with increasing minimal distance from the surface of the balloon. CONCLUSIONS: On the basis of these comprehensive cardiac dosimetric data, we recommend that cardiac dose be routinely reported and kept as low as possible in balloon-based high-dose-rate brachytherapy treatment planning for patients with left-sided breast cancer so the correlation with future cardiac toxicity data can be investigated.

Combination of IG-IMRT and permanent source prostate brachytherapy in patients with organ-confined prostate cancer: GU and GI toxicity and effect on erectile function.

PURPOSE: To assess toxicity outcomes of image-guided intensity-modulated radiation therapy (IG-IMRT) combined with permanent prostate seed implant in a cohort of patients with localized prostate cancer. METHODS AND MATERIALS: A retrospective analysis was performed on 67 patients with the median pretreatment prostate-specific antigen level of 5.4. The Gleason score was less than 7 in 7 patients, 7 in 52 patients, and greater than 7 in 8 patients. The median followup was 28.2 months (range, 12-89.5 months). Treatment consisted of 45 (n=65) or 50.4 Gy (n=2) at 1.8 Gy/fraction of IG-IMRT to the prostate and seminal vesicles. Eight patients had simultaneous irradiation of pelvic lymph nodes to 45 (n=65) or 50.4 Gy (n=2). After IG-IMRT, patients received transperineal prostate implant boost with either (103)Pd (n=65, the prescribed D(90) of 100 Gy) or (125)I (n=2, D(90) of 110 Gy). Eleven patients received androgen deprivation therapy with radiotherapy. RESULTS: Toxicity higher than Grade 3 was not observed. The combined incidence of acute and late Grade 3 genitourinary toxicity was 6%. The combined incidence of acute and late Grade 3 gastrointestinal toxicity was 3%. At least one episode of gastrointestinal bleeding on followup, which could be attributed to radiation, was recorded in 14.9% of patients. For patients achieving erections before radiation, the 3-year Kaplan-Meier potency preservation rate was 66.5%. CONCLUSIONS: The early toxicity of the combination of IG-IMRT and low-dose rate brachytherapy boost in this study was favorable.

Influence of concurrent anastrozole on acute and late side effects of whole breast radiotherapy.

OBJECTIVES: To retrospectively compare radiation toxicity in patients treated with concurrent anastrozole and whole breast irradiation versus women treated sequentially with whole breast irradiation followed by hormonal suppression. METHODS: The records of 249 consecutive estrogen or progesterone receptor positive breast cancer patients treated with breast-conserving surgery and postoperative whole breast irradiation were reviewed. Of total, 57 patients (the concurrent anastrozole group) received concurrent anastrozole prior to and during radiotherapy. In 126 patients (the sequential group), adjuvant hormone suppression therapy (anastrozole, other aromatase inhibitors, or tamoxifen) was administered after the completion of breast irradiation. In 66, women either concurrent tamoxifen was given with radiation or the sequence of hormonal therapy was not known. These women were excluded from the analysis. RESULTS: The frequency of acute grade 2 radiation dermatitis (24.6% in the concurrent anastrozole group vs. 20.6% in the sequential group; P = 0.55), grade 3 radiation dermatitis (8.8% vs. 7.1%; P = 0.77) and treatment interruptions due to skin reactions (14.0% vs. 11.2%; P = 0.69) did not differ between groups. The rates of clinically detectable breast fibrosis were not different (24.2% vs. 24.7%; P = 0.97). With a median follow-up of 28 months and 30.8 months, respectively, 1 local failure occurred in the concurrent anastrozole group and 5 in the sequential group. CONCLUSIONS: Anastrozole, administered concurrently with whole breast irradiation, did not increase acute or late morbidity when compared with sequential administration of radiation and hormonal suppression therapy.

Mammary fat necrosis following radiotherapy in the conservative management of localized breast cancer: does it matter?

PURPOSE: Fat necrosis is a well-described and relatively common complication arising from post-lumpectomy irradiation of the breast, most commonly breast brachytherapy. We wish to assess the clinical significance of fat necrosis resulting from post-lumpectomy breast irradiation. METHODS: We reviewed the literature to determine the overall incidence and significance of fat necrosis to determine whether or not fat necrosis poses a significant clinical problem. RESULTS: Fat necrosis occurs in up to one-quarter of patients following post-lumpectomy breast irradiation. Only rarely is invasive intervention required however, it does significantly degrade the quality of all modalities of breast imaging. CONCLUSIONS: Fat necrosis is a common complication of radiotherapy which rarely requires therapeutic intervention. However, post-therapeutic clinical imaging such as mammography, ultrasound and magnetic resonance imaging are affected which may result in additional diagnostic procedures up to and including biopsy.

Reduction in radiation-induced morbidity by use of an intercurrent boost in the management of early-stage breast cancer.

PURPOSE: Electron or photon boost immediately following whole-breast irradiation performed after conservation surgery for early-stage breast cancer is the accepted standard of care. This regimen frequently results in Grade III dermatitis, causing discomfort or treatment interruption. Herein, we compare patients treated with whole-breast irradiation followed by boost compared with a cohort with a planned intercurrent radiation boost. METHODS AND MATERIALS: The records of 650 consecutive breast cancer patients treated at Allegheny General Hospital (AGH) between 2000 and 2008 were reviewed. Selected for this study were 327 patients with T1 or T2 tumors treated with external beam radiotherapy postlumpectomy. One hundred and sixty-nine patients were treated by whole-breast radiotherapy (WBRT) followed by boost at completion. One hundred fifty-eight were treated with a planned intercurrent boost (delivered following 3,600 cGy WBRT). The mean whole breast radiation dose in the conventionally treated group was 5,032 cGy (range, 4500-5400 cGy), and the mean whole breast dose was 5,097 cGy (range, 4860-5040 cGy) in the group treated with a planned intercurrent boost. RESULTS: The occurrence of Grade III dermatitis was significantly reduced in the WBRT/intercurrent boost group compared with the WBRT/boost group (0.6% vs. 8.9%), as was the incidence of treatment interruption (1.9% vs. 14.2%). With a median follow-up of 32 months and 27 months, respectively, no significant difference in local control was identified. CONCLUSIONS: Patients treated with intercurrent boost developed less Grade III dermatitis and unplanned treatment interruptions with similar local control.