A comparative planning study of step-and-shoot IMRT versus helical tomotherapy for whole-pelvis irradiation in cervical cancer.

The aim of this study was to compare the dosimetric parameters of whole-pelvis radiotherapy (WPRT) for cervical cancer between step-and-shoot IMRT (SaS-IMRT) and Helical Tomotherapy™ (HT). Retrospective analysis was performed on 20 cervical cancer patients who received WPRT in our center between January 2011 and January 2014. SaS-IMRT and HT treatment plans were generated for each patient. The dosimetric values for target coverage and organ-at-risk (OAR) sparing were compared according to the criteria of the International Commission on Radiation Units and Measurements 83 (ICRU 83) guidelines. Differences in beam-on time (BOT) were also compared. All the PTV dosimetric parameters (D5%, D50% and D95%) for the HT plan were (statistically significantly) of better quality than those for the SaS-IMRT plan (P-value < 0.001 in all respects). HT was also significantly more accurate than SaS-IMRT with respect to the D98% and Dmean of the CTV (P-values of 0.008 and <0.001, respectively). The median Conformity Index (CI) did not differ between the two plans (P-value = 0.057). However, the Uniformity Index for HT was significantly better than that for SaS-IMRT (P-value < 0.001). The median of D50% for the bladder, rectum and small bowel were significantly lower in HT planning than SaS-IMRT (P-value < 0.001). For D2%, we found that HT provided better sparing to the rectum and bladder (P-value < 0.001). However, the median of D2% for the small bowel was comparable for both plans. The median of Dmax of the head of the left femur was significantly lower in the HT plan, but this did not apply for the head of the right femur. BOT for HT was significantly shorter than for SaS-IMRT (P-value < 0.001). HT provided highly accurate plans, with more homogeneous PTV coverage and superior sparing of OARs than SaS-IMRT. In addition, HT enabled a shorter delivery time than SaS-IMRT.

The treatment outcome of radical radiotherapy in laryngeal cancer.

OBJECTIVE: This study reports the treatment outcome of radiotherapy alone for laryngeal cancer MATERIAL AND METHOD: A retrospective analysis was performed on 138 patients with stage I to IV squamous cell carcinoma of larynx who received radiotherapy alone in Division of Therapeutic Radiology and Oncology, Faculty of Medicine, Chiang Mai University, Thailand between 2003 and 2009. RESULTS: The 4-year local control (LC) rate in all patients was 44.1%. The 4-year overall survival (OS) was 82.1%. The 4-year LC rates for stage I, II, III, and IV were 75.3%, 69.4%, 57.1%, and 36.9%,respectively (p = 0.0055). Finally, the 4-year OS rates for stage I, II, III, and IV were 85%, 78.6%, 91.1%, and 71.5%, respectively. The laryngeal preservation rate of all stages was 73%. CONCLUSION: In conclusion, the treatment outcome of radiotherapy alone in all stages of laryngeal cancer in our center was unsatisfactory when compared to other series.

Real-world outcomes of postmastectomy radiotherapy in breast cancer patients with 1-3 positive lymph nodes: a retrospective study.

OBJECTIVE: To assess the treatment outcomes and to explore the determinants of clinical outcome in breast cancer patients with 1-3 positive nodes who did or did not receive postmastectomy radiotherapy (PMRT) in a tertiary care referral cancer center in Northern Thailand. METHODS: We investigated a retrospective cohort of registered breast cancer patients at the Faculty of Medicine, Chiang Mai University, Thailand from 2001-2007. Analysis was performed using Cox regression models to identify factors affecting the overall survival (OS) and relapse-free survival (RFS) rates. Comparisons were made between two cohorts: women who received adjuvant PMRT (74 patients) and women who did not receive adjuvant PMRT (81 patients). RESULTS: A total of 155 patients were included with a median follow-up period of 4.45 years. There was a statistically significant 4-year OS difference between the two groups of patients: 100% for the PMRT group and 93.1% for the non-PMRT group (P = 0.044). The 4-year RFS was 85.9% for patients receiving PMRT and 78.3% for patients who did not receive PMRT (P = 0.291). On multivariate analysis of OS, using hormonal treatment was the only significant independent factor associated with improved OS. On multivariate analysis of RFS, none of the variables were significantly associated with improved RFS. PMRT was notfound to be a prognostic variable related to the outcome of patients using a logistic regression model. CONCLUSION: Our retrospective, hospital-based analysis demonstrated that PMRT improved the treatment outcome in terms of OS for women with 1-3 node positive early-stage breast cancer.

Randomized phase III trial of concurrent chemoradiotherapy vs accelerated hyperfractionation radiotherapy in locally advanced head and neck cancer.

The aim of this study was to compare the efficacy and safety of concurrent chemoradiotherapy (CCRT) vs accelerated hyperfractionation with concomitant boost (CCB) as a primary treatment for patients with Stage III-IV squamous cell carcinoma of head and neck (SCCHN). A total of 85 non-metastatic advanced SCCHN patients were accrued from January 2003 to December 2007. Of these, 48 and 37 patients received CCRT and CCB, respectively. The patients were randomized to receive either three cycles of carboplatin and 5-fluorouracil plus conventional radiotherapy (CCRT, 66 Gy in 6.5 weeks) or hybrid accelerated radiotherapy (CCB, 70 Gy in 6 weeks). The primary endpoint was determined by locoregional control rate. The secondary endpoints were overall survival and toxicity. With a median follow-up of 43 months (range, 3-102), the 5-year locoregional control rate was 69.6% in the CCRT arm vs 55.0% in the CCB arm (P = 0.184). The 5-year overall survival rate was marginally significantly different (P = 0.05): 76.1% in the CCRT arm vs 63.5% in the CCB arm. Radiotherapy treatment interruptions of more than three days were 60.4% and 40.5% in the CCRT arm and CCB arm, respectively. The median total treatment time was 55.5 days in the CCRT arm and 49 days in the CCB arm. The rate of Grade 3-4 acute mucositis was significantly higher in the CCB arm (67.6% vs 41.7%, P = 0.01), but no high grade hematologic toxicities were found in the CCB arm (27.2% vs 0%). CCRT has shown a trend of improving outcome over CCB irradiation in locoregionally advanced head and neck cancer.

Effect of pelvic lymph node irradiation in salvage therapy for patients with prostate cancer with a biochemical relapse following radical prostatectomy.

Radiation therapy (RT) as salvage treatment for a biochemical relapse following prostatectomy has been shown to be of benefit measured by serum prostate-specific antigen (PSA) control. However, identifying a target volume for RT has not been well established in this setting. In this study, the results of postoperative RT delivered to extended fields (EFs), prostatic fossa, and pelvic lymph nodes encompassing at least the obturator lymph nodes are compared with treatment of limited fields (LFs), prostatic fossa only, as salvage treatment for patients with a biochemical relapse. Between 1987 and 1999, 68 patients were referred for postprostatectomy RT. Of these patients, 46 were treated for salvage intent by RT alone without adjuvant hormones, 21 patients were treated to EFs and 25 treated to LFs. All patients were treated using 4-field plans. The mean field sizes measured 15 x 14 cm (AP/PA fields) and 12 x 14 cm LFs for the EFs and 10 x 10 cm (AP/PA fields) and 10 x 10 cm (lateral fields) for the LFs. The mean total doses for the EFs and LFs were 6300 and 6200 cGy, respectively, using 180-cGy daily increments. All patients treated to the EFs received boost doses to the prostatic fossa after 4500 cGy total dose to the pelvis. The 10-year actuarial biochemical disease-free survival (DFS) rates for the EF and LF groups were 52% and 47%, respectively (P = 0.523). The distant metastasis-free survival (DMFS) rates were 77% and 78% (P = 0.925), and overall survival (OS) rates were 88% and 68% (P = 0.615) for the EF and LF group, respectively. A subset analysis of patients with adverse pathologic features (including tumor-involved surgical margins, lymph node involvement, seminal vesicle involvement, extracapsular extension, and/or perineural invasion) showed biochemical DFS rates of 57% and 44% (P = 0.217) for the EF and LF groups, respectively. The DMFS rates were 84% and 72% (P = 0.423), and OS rates 92% and 61% (P = 0.366) for the EF and LF groups, respectively. For patients with increasing PSA levels after a radical prostatectomy, salvage irradiation is a viable option for biochemical control. Our results suggest that EF radiation with coverage of pelvic lymph nodes shows a trend toward better PSA control in those with adverse pathologic features, although statistical significance was not achieved because of the limited number of patients who satisfied the restricted criteria excluding use of adjuvant hormones.

Sinonasal undifferentiated carcinoma: case series and literature review.

PURPOSE: The purpose of this study was to understand the natural history and progression of sinonasal undifferentiated carcinoma (SNUC) to establish optimal management guidelines. Methods and materials We analyzed 8 consecutively treated patients diagnosed with SNUC between 1995 and 2002 at UCLA Medical Center. Staging was classified by the Kadish System with 7 patients presenting at stage C and 1 patient with stage B disease. Five patients received surgery. Four of these 5 patients received adjuvant radiotherapy, with 2 patients receiving it concurrently with chemotherapy (cisplatinum/5-fluorouracil). One patient received surgery alone as definitive management. Of the remaining 3 patients who did not receive surgical treatment, concurrent chemotherapy and radiation was used. RESULTS: At last follow-up, 6 of the 8 patients were still alive (overall survival 75%) with mean survival time of 20.6 months. However, only 2 of the 6 were alive and free of disease (disease-free survival 25%) with a mean disease-free survival time of 12.3 months. Locoregional recurrence occurred in 5 of the 8 patients (63%). Time to recurrence ranged from 3 to 30 months. Distant metastasis presented in 4 of the 8 patients (50%), all with disease spread to bone. Two of the 4 patients with distant metastasis were found to have locoregional disease recurrence at the same time. Time to metastasis ranged from 2 to 30 months. Results also show that the 5 patients who received surgery are still alive with a mean survival time of 23 months at last follow-up. Meanwhile, 1 of the 3 patients who received no surgical therapy is alive, with a mean survival time of 16.7 months in this group. CONCLUSIONS: SNUC has proven to have a poor prognosis. Although limited by small numbers, this study along with reported series in the past appear to suggest longer survival results with aggressive multimodality therapy, especially with the incorporation of complete surgical resection.

Early nodal response as a predictor for necessity of functional neck dissection after chemoradiation.

PURPOSE: Chemoradiation is increasingly becoming the standard of care for node-positive squamous cell cancer of the head and neck. Response to chemoradiation for clinically node-positive disease in the neck is often difficult to ascertain because clinical response may or may not be predictive of pathological response. This often leads to uncertainty about the necessity of a functional neck dissection after chemoradiation. In this study, we retrospectively analyzed a cohort of node-positive patients to examine pathological response as well as clinical outcome after chemoradiation with or without functional neck dissection. METHODS: Using the radiation oncology records from 1993 until 2003, a population of 420 patients with squamous cell cancer of the head and neck were identified. Of these, 34 patients were clinically node positive at the time of diagnosis and under went chemoradiation as their primary therapy. All patients received a concurrent platinum-based regimen. Median radiation dose to gross neck disease was 68.4 Gy (range: 50.4-73.8 Gy). RESULTS: Median follow-up time was 25 months (range: 4-88 months). Patients with a complete response (17/34, 50%) after receiving 50 Gy finished the full course of therapy but did not undergo functional neck dissection. Only one patient (1/17) in this observation group experienced relapse in the neck. Patients with a partial response who received 50 Gy (17/34) completed therapy and under went functional neck dissection, regardless of response at the end of therapy. Fifty percent (3/6) with positive pathology had a regional relapse in the neck, whereas only 1/11 patients with negative pathology relapsed in the neck. This result compared favorably with those who were observed after chemoradiation. CONCLUSIONS: Clinical response at 50 Gy can be an effective means of selecting patients for functional neck dissection. Patients with complete response at 50 Gy may be observed with a low regional recurrence rate. Those patients with a partial response should undergo adjuvant neck dissection.

Efficacy of radiation therapy in the local control of desmoplastic malignant melanoma.

BACKGROUND: Desmoplastic malignant melanoma (DMM) is a rare variant of malignant melanoma with high local recurrence rate after surgical excision. We performed a retrospective review to address the role of radiation therapy in local control of this tumor. METHODS: Between 1976 and 1997, 44 patients with the pathologic diagnosis of DMM were registered at our tumor registry. Fourteen patients received postoperative RT, and one patient received preoperative RT. Three of the irradiated lesions had gross residual or positive surgical margins. Doses ranged from 44 to 66 Gy. RESULTS: Sixty-eight percent of DMM lesions occurred in the head and neck region. Forty-eight percent (21 of 44) of patients experienced a local recurrence after initial excision (mean time to recurrence, 12 months). Local failure in head and neck was 46% (14 of 30). Clark level, primary site, and neurotropism did not predict local recurrence; the Clark level predicted distant metastasis. No viable tumor was found in the surgical specimen of the patient who received preoperative RT. None of 15 patients who received adjuvant irradiation had any additional recurrences (mean follow-up, 64.7 months). By contrast, four of seven patients with history of recurrence who did not receive RT had local relapse (p =.005). The incidence of distant metastasis did not reach statistical significance between the irradiated and nonirradiated groups. CONCLUSIONS: The high rate of local recurrence of DMM after surgical resection is dramatically reduced by adjuvant radiation therapy. We recommend adjuvant postoperative radiation therapy as a part of treatment of DMM.

Prospective study of stereotactic radiosurgery without whole brain radiotherapy in patients with four or less brain metastases: incidence of intracranial progression and salvage radiotherapy.

This prospective study was conducted to evaluate the treatment outcome after stereotactic radiosurgery (SRS) alone with special attention to its influence on intracranial freedom from progression (FFP), local control, time to whole brain radiotherapy (WBRT), and survival. Forty-one patients with brain metastases who met the inclusion criteria were enrolled in this prospective cohort and treated by SRS alone between January 1998 and September 2001. The overall local control rate was 76%. The one year actuarial intracranial FFP was 33%. Ten patients (24%) had relapse at treated site. Twenty-three patients (56%) had intracranial progression with a median time of 4.25 months (1-24.6). Salvage radiotherapy was given in 21 patients (51%). Only 12 (29%) patients required WBRT with the median time to WBRT after SRS of 4.85 months. Nine patients (22%) underwent additional SRS at the median time of 5 months after the first procedure. The median survival was 10 months. At the time of follow up, 16 patients (39%) were still alive with a range of 6-31 months. This prospective study suggests that the omission of WBRT in the initial treatment of patients with SRS for four or less brain metastases may allow up to 70% of patients to avoid WBRT.