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In the UK, the standard of care for esophageal cancer has generally combined surgery with neoadjuvant chemotherapy, with definitive chemoradiotherapy (d CRT) being reserved for certain subgroups. Chemoradiotherapy followed by surgery (trimodality therapy) has not been widely adopted. The outcomes of patients undergoing d CRT or trimodality therapy at our cancer center between 2004 and 2012 were restrospectively analyzed. Trimodality therapy was offered to selected patients of good performance status ( World Health Organisation performance status 0/1), with squamous cell carcinoma or bulky adenocarcinoma. d CRT was offered to patients of good PS but with comorbidities, upper third tumors or at patient's request. Patients received four cycles of chemotherapy with a platinum agent (mostly cisplatin) and a fluoropyrimidine (mostly 5-fluorouracil) over a total of 11 weeks. Cycles 3 and 4 were given concurrently with radiotherapy: 50 Gy in 25 fractions for d CRT and 45 Gy in 25 fractions in the trimodality group. Surgery occurred 8-10 weeks following the completion of chemoradiotherapy. The cut-off length for maximum gross tumor volume length was 10 cm. One hundred two patients were included (47 received d CRT, and 55 received trimodality treatment). The majority of tumors were stage III (80.4%), and two-thirds were located in the distal esophagus (64.7%). Median follow-up was 44 months. The 2-year overall survival ( OS) was 57.3% (median OS 39.7 months) for the d CRT group and 77.8% (median not reached) for the trimodality group. The 5-year OS rates were 38% and 58%, respectively. Postoperative mortality rate was low at 1.8%, and the pathological complete response rate was 23.6%. In conclusion, trimodality treatment for patients with esophageal and junctional gastroesophageal tumors offers high rates of 2-year survival, and the potential for long-term cure. d CRT is an established alternative for patients that are not fit or suitable for surgery. [ABSTRACT FROM AUTHOR]

Abstract: Radiation therapy for the treatment of malignant pleural mesothelioma has historically been limited by its efficacy. However, the increasing incidence of this tumour and the emergence of new technologies present a number of opportunities and challenges for this treatment modality. Radiotherapy is used to palliate mesothelioma patients with chest wall pain. Responses of over 60% have been seen, although the duration of response is often disappointing. The optimum dose has not been shown and many of the previous studies were small retrospective studies. An improved response has been seen in several studies where hyperthermia was added to radiotherapy. However, further investigation of this technique, which is not widely available, is required. There has not been any comparison of radiotherapy with chemotherapy in the palliation of patients with malignant pleural mesothelioma. Prophylactic chest wall radiotherapy to intervention sites successfully reduces the incidence of malignant seeding along the intervention tracts. However, the optimum dose and timing of treatment are not clear. There is no role for radical radiotherapy alone, but the role of radiotherapy as part of multimodality therapy is discussed. There have been studies of intensity-modulated radiotherapy as part of multimodality therapy and this technique needs to be evaluated further. [Copyright &y& Elsevier]

Purpose and Method. Hyper-fractionated radiotherapy for treatment of soft tissue sarcomas is designed to deliver a higher total dose of radiation without an increase in late normal tissue damage. In a previous study at the Royal Marsden Hospital, a total dose of 75 Gy using twice daily 1.25 Gy fractions resulted in a higher incidence of late damage than conventional radiotherapy using 2 Gy daily fractions treating to a total of 60 Gy. The current trial therefore used a lower dose per fraction of 1.2 Gy and lower total dose of 72 Gy, with 60 fractions given over a period of 6 weeks. Subjects. A total of 37 patients (22 males and 15 females) with a median age of 56 years (range 19-88 years) were treated. Results. Of eight patients treated pre-operatively, six showed a partial response and in two the tumour was static. The maximum acute toxicities were grade 1 in eight, grade 2 in 14 and grade 3 in 15 patients. Late toxicities of the skin were graded 1 in 10 and grade 2 in nine patients. Five patients complained of pain in the irradiated bone and soft tissues, which was of moderate severity (grade 2). Stiffness was graded 2 in three patients and severe (grade 3) in one. Three patients had moderate and one patient had severe lymphoedema following treatment. The 5-year recurrence-free survival probability of patients treated radically was 76%. Following excision of local recurrences the study group had a disease-free survival probability of 86% at 5 years. Discussion. The regime is well tolerated with comparable local control and late complication rates to standard daily fractionated therapy. The potential benefit of this regime needs to be defined in a prospective randomized trial. [ABSTRACT FROM AUTHOR]

Over the past decade the field of lung cancer management has seen many developments. Coupled with an ageing population and increasing rates of comorbid illness, the work-up for treatments with curative intent has become more complex and detailed. As well as improvements in imaging and staging techniques, developments in both surgery and radiotherapy may now allow patients who would previously have been considered unfit or not appropriate for treatment with curative intent to undergo radical therapies. This overview will highlight published studies relating to investigation and staging techniques, together with assessments of fitness, with the aim of helping clinicians to determine the most appropriate treatments for each patient. We also highlight areas where further research may be required. [ABSTRACT FROM AUTHOR]

There is a paucity of evidence on which to produce recommendations on neither the clinical nor the imaging follow-up of lung cancer patients after curative-intent radiotherapy. In the 2019 National Institute for Health and Care Excellence lung cancer guidelines, further research into risk-stratification models to inform follow-up protocols was recommended. A retrospective study of consecutive patients undergoing curative-intent radiotherapy for non-small cell lung cancer from 1 October 2014 to 1 October 2016 across nine UK trusts was carried out. Twenty-two demographic, clinical and treatment-related variables were collected and multivariable logistic regression was used to develop and validate two risk-stratification models to determine the risk of disease recurrence and death. In total, 898 patients were included in the study. The mean age was 72 years, 63% (562/898) had a good performance status (0–1) and 43% (388/898), 15% (134/898) and 42% (376/898) were clinical stage I, II and III, respectively. Thirty-six per cent (322/898) suffered disease recurrence and 41% (369/898) died in the first 2 years after radiotherapy. The ASSENT score (age, performance status, smoking status, staging endobronchial ultrasound, N-stage, T-stage) was developed, which stratifies the risk for disease recurrence within 2 years, with an area under the receiver operating characteristic curve (AUROC) for the total score of 0.712 (0.671–0.753) and 0.72 (0.65–0.789) in the derivation and validation sets, respectively. The STEPS score (sex, performance status, staging endobronchial ultrasound, T-stage, N-stage) was developed, which stratifies the risk of death within 2 years, with an AUROC for the total score of 0.625 (0.581–0.669) and 0.607 (0.53–0.684) in the derivation and validation sets, respectively. These validated risk-stratification models could be used to inform follow-up protocols after curative-intent radiotherapy for lung cancer. The modest performance highlights the need for more advanced risk prediction tools. • Two validated risk prediction models for disease recurrence and death are presented. • The performance of the scores are modest. • Rates of further curative intent treatment for disease recurrence were low (4%). • The majority with disease recurrence were managed with best supportive care (57%). • More advanced risk prediction tools and research into optimal follow-up is needed. [ABSTRACT FROM AUTHOR]

Abstract: Aims: This report reviews current radiotherapy practice across the UK in the management of lung cancer, and the way new treatments and technologies are being introduced, where improvements have occurred, and where work is still required. We wanted to determine adherence to both National Radiotherapy Advisory Group and National Institute for Health and Clinical Excellence (NICE) guidance. This survey was conducted on behalf of the Department of Health Lung Cancer & Mesothelioma Advisory Group. Materials and methods: We sent a questionnaire to all UK radiotherapy departments. It covered radical radiotherapy dose fractionation, the use of concurrent or sequential chemotherapy for both non-small cell and small cell lung cancers, the use of continuous hyperfractionated accelerated radiotherapy, new radiotherapy techniques, the use of positron emission tomography/computed tomography for planning purposes and patient accrual into current National Cancer Research Network UK trials. Results: This UK-wide survey of radiotherapy practice for lung cancer showed broad compliance with NICE clinical guidance, but highlighted significant variation in fractionation schedules and the use of concomitant chemoradiotherapy. Clinical trial entry into lung cancer radiotherapy trials was variable and many centres are not fully participating in recruitment into these trials. Conclusions: This report has shown the variability of radiotherapy provision nationally. Current practice is largely consistent with current and updated NICE recommendations and best practice and should be recognised as such. It has also highlighted areas where improvements are still needed, particularly fractionation and new technologies. One particular aspect of concern is the poor recruitment to current UK-based clinical trials in lung cancer. [Copyright &y& Elsevier]