Search

Background: Accelerated partial breast irradiation (APBI) is an option for adjuvant radiotherapy according to ASTRO and ESTRO recommendations. Among the available techniques, volumetric-modulated arc therapy (VMAT) is attractive but has not been extensively studied for APBI. This study assessed its feasibility, tolerance and early oncological outcomes., Methods: We analysed the data of nine patients (median age 74 years) with ten lesions (one bilateral cancer) treated from May 2011 to July 2012 with APBI using VMAT. The radiation oncologist delineated the surgical tumour bed, and added an 18 mm isotropic margin to obtain the planning target volume (PTV). The dose was 40 Gy prescribed in 4 Gy fractions given twice a day over five days. Patients were regularly followed for toxicities and oncological outcomes., Results: Mean PTV was 100.0 cm(3) and 95 % of the PTV received a mean dose of 99.7 % of the prescribed dose. Hot spots represented 0.3 % of the PTV. 6.2 %, 1.6 % and 0.3 % of the ipsilateral lung volume received 5 Gy (V5Gy), 10 Gy (V10Gy) and 20 Gy (V20Gy), respectively. Regarding the contralateral lung, V5Gy was 0.3 %, and V10Gy and V20Gy were nil. V5Gy accounted for 3.1 % of the heart. An average 580 monitor units were delivered. No acute or late grade ≥ 2 toxicities were observed. With a median follow-up of 26 months, no relapses occurred., Conclusion: In our study, VMAT allowed optimal dosimetry with consequential high therapeutic ratio in elderly and frail patients.

Background: The Montpellier cancer institute phase II trial started in 2004 and evaluated the feasibility of intraoperative radiotherapy (IORT) technique given as a sole radiation treatment for patients with an excellent prognostic and very low recurrence risk., Methods: Forty-two patients were included between 2004 and 2007. Inclusion criteria were patients ≥ 65 years old, T0-T1, N0, ductal invasive unifocal carcinoma, free-margin > 2 mm. IORT was delivered using dedicated linear accelerator. One fraction of 21 Gy was prescribed and specified at the 90% isodose using electrons. In vivo dosimetry was performed for all patients. Primary end-point was the quality index. Secondary endpoints were quality of life, local recurrences, cosmetic results, specific and overall survival., Results: At inclusion, median age was 72 years (range, 66-80). Median tumor diameter was 10 mm. All patients received the total prescribed dose. No acute grade 3 toxicities were observed. Late cosmetic results were good at 5 years despite the poor agreement of accuracy assessment between patients and physicians. Four patients (9.5%) experienced a local failure and underwent salvage mastectomy. The 5 year-disease free survival is 92.7% (range 79.1-97.6). All patients are still alive with a median follow-up of 72 months (range 66-74)., Conclusion: Our results confirm with a long-term follow-up that exclusive partial breast IORT is feasible for early-breast cancer in selected patients. IORT provides good late cosmetics results and should be considered as a safe and very comfortable "one-step" treatment procedure. Nevertheless, patient assessments are essential for long-term quality results.

Purpose: To assess outcomes of patients with carcinoma of the anal canal (CAC) treated with intensity-modulated radiation therapy (IMRT)., Method and Materials: From August 2007 to January 2011, seventy-two patients suffering from CAC were treated with IMRT. Concurrent chemotherapy was added in case of locally advanced tumors. Radiation course consisted in delivering an initial plan to the PTV1 defined as the primary tumor and the risk area including pelvic and inguinal nodes. Forty-five Gy in daily 1.8 Gy-daily fractions were delivered five days a week. A second plan of 14.4-20 Gy to the primary tumor (PTV2) was administered in 1.8-2 Gy-daily fractions, 5 days a week. We present here the results of dosimetry, toxicities, and clinical outcome of the first 39 patients with a median follow-up of 24 months., Results: Thirty-one women and eight men were included in the present analysis. Tumors were classified as stages I, II, III and IV in 2, 7, 27 and 2 patients, respectively. Median age was 59 years (range, 38-85). Radiotherapy alone (RT) or combined with chemotherapy (RCT) were delivered in 6 (15%) and 33 (85%) patients, respectively.Six patients (15%) required a treatment break ≥ 3 days, and median time for treatment break was 8 days (range, 3-14 days). Acute grade 3 gastrointestinal (GI) and genitourinary (GU) toxicities were seen in 10 and 5% of patients, respectively. Grade 4 toxicity was only hematologic and occurred in 12% patients receiving RCT. With a median follow-up of 24 months, no patient experienced any late grade 4 toxicity. The 2-year overall survival rate was 89%, the 2-year local relapse free survival was 77% and the 2-year colostomy-free survival rate was 85%., Conclusion: IMRT is well tolerated with acceptable treatment interruption allowing dose escalation.

Background: To compare volumetric-modulated arc therapy (RapidArc) plans with conventional intensity-modulated radiation therapy (IMRT) plans in anal canal cancers., Methods: Ten patients with anal canal carcinoma previously treated with IMRT in our institution were selected for this study. For each patient, three plans were generated with the planning CT scan: one using a fixed beam IMRT, and two plans using the RapidArc technique: a single (RA1) and a double (RA2) modulated arc therapy. The treatment plan was designed to deliver in one process with simultaneous integrated boost (SIB) a dose of 59.4 Gy to the planning target volume (PTV2) based on the gross disease in a 1.8 Gy-daily fraction, 5 days a week. At the same time, the subclinical disease (PTV1) was planned to receive 49.5 Gy in a 1.5 Gy-daily fraction. Plans were normalized to 99% of the PTV2 that received 95% of the prescribed dose. Planning objectives were 95% of the PTV1 will receive 95% of the prescribed dose and no more than 2% of the PTV will receive more than 107%. Dose-volume histograms (DVH) for the target volume and the organs at risk (bowel tract, bladder, iliac crests, femoral heads, genitalia/perineum, and healthy tissue) were compared for these different techniques. Monitor units (MU) and delivery treatment time were also reported., Results: All plans achieved fulfilled objectives. Both IMRT and RA2 resulted in superior coverage of PTV than RA1 that was slightly inferior for conformity and homogeneity (p < 0.05).Conformity index (CI95%) for the PTV2 was 1.15 ± 0.15 (RA2), 1.28 ± 0.22 (IMRT), and 1.79 ± 0.5 (RA1). Homogeneity (D5% - D95%) for PTV2 was 3.21 ± 1.16 Gy (RA2), 2.98 ± 0.7 Gy (IMRT), and 4.3 ± 1.3 Gy (RA1). RapidArc showed to be superior to IMRT in terms of organ at risk sparing. For bowel tract, the mean dose was reduced of 4 Gy by RA2 compared to IMRT. Similar trends were observed for bladder, femoral heads, and genitalia. The DVH of iliac crests and healthy tissue resulted in comparable sparing for the low doses (V10 and V20). Compared to IMRT, mean MUs for each fraction was significantly reduced with RapidArc (p = 0.0002) and the treatment time was reduced by a 6-fold extent., Conclusion: For patients suffering from anal canal cancer, RapidArc with 2 arcs was able to deliver equivalent treatment plan to IMRT in terms of PTV coverage. It provided a better organ at risk sparing and significant reductions of MU and treatment time per fraction.

Objective: We assessed the rate of aspiration following radiation for non-nasopharyngeal head and neck cancer., Design: Retrospective study., Setting: Veterans Administration Hospital., Patients: Thirty-three patients who underwent radiation for head and neck cancer. Modified barium swallow was performed prior to and following treatment to assess the persistence of dysphagia and aspiration risk. All patients were cancer free at the time of the swallowing study. Dysphagia severity was graded from 1 to 7., Results: Preradiation baseline dysphagia was observed as follows: 10 grade 1, 14 grade 2, 9 grade 3, and 1 grade 4. Following radiation, at a median follow-up of 3 months, nine patients had grade 1, eight patients had grade 2, six patients had grade 3, two patients had grade 4, three patients had grade 5, two patients had grade 6, and three patients had grade 7. Overall, 24% (8 of 33) of the patients developed aspiration (grades 5-7). Fifteen percent (5 of 33) of the patients had severe aspiration (grades 6-7) requiring tube feedings. All patients who developed severe aspiration continued to require tube feedings more than 1 year following treatment completion., Conclusion: Aspiration is a significant source of morbidity following radiation for non-nasopharyngeal head and neck cancer. Aspiration may develop for all tumour stages or sites. Diagnostic studies such as modified barium swallow should be included in future prospective head and neck cancer studies to assess the prevalence of aspiration because of its often silent nature.

Background: To compare the dosimetric advantage of three different intensity-modulated radiation therapy (IMRT) plans to a three dimensional (3D) conventional radiation treatment for anal cancer with regards to organs-at-risk (OAR) avoidance, including iliac bone marrow., Methods: Five patients with T1-3 N0-1 anal cancer and five with T4 and/or N2-3 tumors were selected. Clinical tumor volume (CTV) included tumor, anal canal and inguinal, peri-rectal, and internal/external iliac nodes (plus pre-sacral nodes for T4/N2-3 tumors). Four plans were generated: (A) AP/PA with 3D conformal boost, (B) pelvic IMRT with conformal boost (C) pelvic IMRT with IMRT boost and (D) IMRT with simultaneous integrated boost (SIB). The dose for plans (A) to (C) was 45 Gy/25 followed by a 14.4 Gy/8 boost, and the total dose for plan (D) (SIB) was 59.4 Gy/33. Coverage of both PTV and the volume of OAR (small bowel, genitalia, iliac crest and femoral heads) receiving more than 10, 20, 30, and 40 Gy (V10, V20, V30, V40) were compared using non parametric statistics., Results: Compared to plan (A), IMRT plans (B) to (D) significantly reduced the V30 and V40 of small bowel, bladder and genitalia for all patients. The V10 and V20 of iliac crests were similar for the N0-1 group but were significantly reduced with IMRT for the N2-3/T4 group (V20 for A = 50.2% compared to B = 33%, C = 32.8%, D = 34.3%). There was no statistical difference between 2-phase (arm C) and single-phase (SIB, arm D) IMRT plans., Conclusion: IMRT is superior to 3D conformal radiation treatment for anal carcinoma with respect to OAR sparing, including bone marrow sparing.

Background: To compare non coplanar field (NCF) with coplanar field (CF) -intensity-modulated radiotherapy (IMRT) planning for ethmoid cancer., Methods: Seven patients treated with NCF IMRT for ethmoid cancer were studied. A CF IMRT optimization was prepared with the same constraints as for the NCF treatment. The maximum point doses (D max) obtained for the different optic pathway structures (OPS) should differ no more than 3% from those achieved with the NCF IMRT plan. The distribution of the dose in the target volume and in the critical structures was compared between the two techniques, as well as the Conformity (CI) and the Homogeneity Indexes (HI) in the target volume., Results: We noted no difference between the two techniques in the OPS for the D1, D2, and D5%, in the inner ear and controlateral lens for the average Dmax, in the temporo-mandibular joints for the average mean dose, in the cord and brainstem for the average D1%. The dose-volume histograms were slightly better with the NCF treatment plan for the planning target volume (PTV) with a marginally better HI but no impact on CI. We found a great improvement in the PTV coverage with the CF treatment plan for two patients with T4 tumors., Conclusion: IMRT is one of the treatment options for ethmoid cancer. The PTV coverage is optimal without compromising the protection of the OPS. The impact of non coplanar versus coplanar set up is very slight.

Background: Epidermal growth factor receptor (EGFR) represents a major target for current radiosensitizing strategies. We wished to ascertain whether a correlation exists between the expression of EGFR and treatment outcome in a group of patients with rectal adenocarcinoma who had undergone preoperative radiotherapy (RT)., Methods: Within a six-year period, 138 patients underwent preoperative radiotherapy and curative surgery for rectal cancer (UICC stages II-III) at our institute. Among them, 77 pretherapeutic tumor biopsies were available for semi-quantitative immunohistochemical investigation evaluating the intensity and the number (extent) of tumor stained cells. Statistical analyses included Cox regression for calculating risk ratios of survival endpoints and logistic regression for determining odds ratios for the development of loco-regional recurrences., Results: Median age was 64 years (range: 30-88). Initial staging showed 75% and 25% stage II and III tumors, respectively. RT consisted of 44-Gy pelvic irradiation in 2-Gy fractions using 18-MV photons. In 25 very low-rectal-cancer patients the primary tumor received a boost dose of up to 16 Gy for a sphincter-preservation approach. Concomitant chemotherapy was used in 17% of the cases. All patients underwent complete total mesorectal resection. Positive staining (EGFR+) was observed in 43 patients (56%). Median follow-up was 36 months (range: 6-86). Locoregional recurrence rates were 7 and 20% for EGFR extent inferior and superior to 25%, respectively. The corresponding locoregional recurrence-free survival rate at two years was 94% (95% confidence interval, CI, 92-98%) and 84% (CI 95%, 58-95%), respectively (P = 0.06). Multivariate analyses showed a significant correlation between the rate of loco-regional recurrence and three parameters: EGFR extent superior to 25% (hazard ratio = 7.18, CI 95%, 1.17-46, P = 0.037), rectal resection with microscopic residue (hazard ratio = 6.92, CI 95%, 1.18-40.41, P = 0.032), and a total dose of 44 Gy (hazard ratio = 5.78, CI 95%, 1.04-32.05, P = 0.045)., Conclusion: EGFR expression impacts on loco-regional recurrence. Knowledge of expression of EGFR in rectal cancer could contribute to the identification of patients with an increased risk of recurrences, and to the prediction of prognosis.