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This research proposes augmenting cropped computed tomography (CT) slices with data attributes to enhance the performance of a deep-learning-based automatic left-femur segmentation scheme. The data attribute is the lying position for the left-femur model. In the study, the deep-learning-based automatic left-femur segmentation scheme was trained, validated, and tested using eight categories of CT input datasets for the left femur (F-I–F-VIII). The segmentation performance was assessed by Dice similarity coefficient (DSC) and intersection over union (IoU); and the similarity between the predicted 3D reconstruction images and ground-truth images was determined by spectral angle mapper (SAM) and structural similarity index measure (SSIM). The left-femur segmentation model achieved the highest DSC (88.25%) and IoU (80.85%) under category F-IV (using cropped and augmented CT input datasets with large feature coefficients), with an SAM and SSIM of 0.117–0.215 and 0.701–0.732. The novelty of this research lies in the use of attribute augmentation in medical image preprocessing to enhance the performance of the deep-learning-based automatic left-femur segmentation scheme.

Objective: The primary aim was to compare the psychometric properties among the Patient Health Questionnaire (PHQ-9) (both including and excluding somatic symptom items), the depression subscale of the Hospital Anxiety and Depression Scale (HADS-D), and the Center for Epidemiologic Studies Depression Scale (CES-D) in detecting depression in cancer patients receiving radiotherapy. The secondary aim was to investigate the prevalence of depression in this group of patients.Materials and Methods: Overall, 198 participants with cancer diagnosis from a radiology clinic took part in the study. They completed PHQ-9, HADS-D, and CES-D questionnaires and were interviewed in line with the Mini-International Neuropsychiatric Interview (M.I.N.I.) to confirm the diagnosis. The PHQ-9 was analyzed for three scoring methods: sum-score, inclusive (including all items), and exclusive (excluding 4 somatic symptom items) methods. The psychometric properties of each questionnaire were analyzed. The prevalence of depression measured by the M.I.N.I. was evaluated.Results: The sum-score method of the PHQ-9 had an equal sensitivity (100%) to the HADS-D and CES-D, and had a slightly higher specificity (91.1%) than the HADS-D (87.4%) and CES-D (90.6%). When compared results within the PHQ-9, the sum-score method had greater sensitivity than the inclusive (71.4%) and exclusive (42.9%) methods, and had a slightly lower specificity than the inclusive (96.9%) and exclusive (97.4%) methods. The prevalence of depression assessed by the M.I.N.I was 3.5%.Conclusion: The sum-score method of the PHQ-9 seemed to be the best tool to use for depression screening in cancer patients receiving radiotherapy due to its excellent sensitivity and specificity.

The most common site of recurrence of prostate cancer after definite radiation therapy is the dominant intraprostatic lesion (DIL). This study aimed to investigate the feasibility and safety of definite volumetric modulated arc therapy (VMAT) with simultaneous integrated boost (SIB) to the DIL in patients with unfavorable intermediate to high-risk prostate cancer.In this prospective uncontrolled clinical trial, patients were delivered VMAT at a dose of 87.75 Gy in 39 fractions or 70 Gy in 20 fractions to the DIL in combination with androgen deprivation therapy. Genitourinary (GU) and rectal toxicity, International Prostate Symptom Score (IPSS) and IPSS quality of life (IPSS-QOL) score were collected.Forty-five patients with a median follow-up of 20 months were analyzed. The cumulative incidence of acute grade ≥ 2 GU and rectal toxicity was 33.1% and 9.5%, respectively. Regarding late toxicity, the cumulative incidence of grade ≥ 2 GU and rectal toxicity was 12.6% and 2.8%, respectively. During treatment, the mean increase of IPSS was +7.4 ± 4.2 and the mean increase of IPSS-QOL was +1.7 ± 1.3. However, both IPSS and IPSS-QOL scores returned to their baseline levels by 3-months post-treatment. No significant correlation between baseline characteristics and grade ≥ 2 GU or rectal toxicity was found.Focal SIB to the DIL of ≥ 90 Gy EQD2 in unfavorable intermediate to high-risk prostate cancer patients resulted in tolerable toxicity profiles. The mean IPSS and IPSS-QOL scores both worsened during treatment; however, both scores returned to baseline level by 3 months after treatment.

Objective: Communication Skills via Health Literacy (CSvHL) was a pilot elective communication skills training (CST) course, which allowed preclinical medical students to gain communication competence through the experience of being a health educator for high school students (HSSs). The efficacy of CSvHL was explored. Materials and Methods: All 10 medical students were prepared for their HSS-health-educator roles by participating in several observation sessions at an outpatient department and via communication workshops. In-field health education courses were subsequently delivered to HSSs by the medical students. Developments of the medical students’ communication skills were fostered through loops of learning activities and regular feedbacks. Assessments of the pre- and post-CSvHL communication skill levels by means of an OSCE, with adapted ComON Check were evaluated by each medical student, a standardized patient, and three medical instructors. Results: In general, the overall and category-specific average ComON Check scores of the whole class were significantly improved after the CSvHL course. The 3 communication defects with the lowest scores in the pre-CSvHL assessments were subsection division, summarization, and comprehension-check while counseling. Conclusion: CSvHL was successfully established as a preclinical-year CST course. The improvements in the ComON Check scores reflected the transformative learning gained from the hands-on experience, individualized CST, and 360° feedback OSCE for communication skill assessment.

Purpose In this paper, excess dose is originally proposed to represent the dose outside the target volume that encompass only organs at risk (OARs), not the whole dose volume of isodose surface volume (ISV). By means of spatial consideration, excess dose-related parameters would also compensate inconsistent applicator positions and OARs motion, which may deviate the identical dose small-volume assumption of D2cc. Late toxicity correlations of these parameters were investigated. Material and methods A retrospective review was performed on cervical cancer high-dose-rate image-guided adaptive brachytherapy (HDR-IGABT). From ISVs of 60 to 100 Gy EQD2 (a/β = 3), excess dose-related parameters were derived as following: toxicity negligible volume (Vneg = V60 of toxicity negligible organs; high-risk clinical target volume - HR-CTV, uterus, and vagina), excess dose volume (Vex = ISV - Vneg), Vneg normalized parameters of excess dose volume ratio (Rex = Vex/Vneg), and indirect excess dose volume ratio (iRex = ISV/Vneg). Relationships between toxicity and these parameters were analyzed using a mean difference and a probit analysis method. Net reclassification indices (NRIs) were used to compare iRex60 and D2cc gastrointestinal (GI) toxicity prediction. Results From 143 cases with an incidence of 34.9% and 10.5% of 3-year grade 2-4 GI and genitourinary (GU) toxicity, respectively, comparisons of means showed significant difference between grade 0-1 and 2-4 toxicities for late GI toxicity for all parameters, except ISV. There was a dose-response relationship with toxicity for each parameter across the range of 60-100 Gy EQD2. ED10 of iRex60 and iRex70 were 2.1 and 1.2, respectively. By comparing iRex60 and D2cc, additive and absolute NRIs were +6.45 and +7.69%, respectively. The reclassification significantly occurred in range of 65-75 Gy of rectum D2cc. Conclusions Excess dose-related parameters, including Vex, Rex, and iRex, showed significant mean differences and parameter-toxicity relationships for late GI but not for GU toxicities. Positive NRIs suggest iRex60 utilization for spatial control of dose expansion, in addition to high-dose control with OAR small volumes. Further investigations are needed to define the optimum use of these predictors.

To investigate the vaginal 11-point and volumetric dose-toxicity relationships in definitive cervical cancer radiotherapy.A retrospective cohort study of patients with cervical cancer with a complete response of at least 12 months was performed. Additional per vaginal examinations and patient-scoring questionnaires on the date of patient enrolment were assessed for vaginal strictures. Retrospective dosimetric analysis of vaginal 11-point and volumetric doses was performed with descriptive and probit analyses to investigate dose-toxicity relationships.Ninety-seven patients were included in the study, with a 20-month median follow-up. The incidence rate of grade 3 vaginal strictures was 22.7%. A comparison between patients with grade 1-3 vaginal strictures revealed significant differences in age, stage, initial tumour size, and vaginal involvement. PIBS + 2, PIBS, PIBS-2, D + 5, and D2cc were all significantly different among grade 1-3 vaginal strictures and showed significant probit coefficients. The lateral dose points were significantly higher in grade 2 strictures, but negative probit coefficients failed to establish causal inferences. Post-estimation analyses yielded effective doses (ED) for 15% and 20% probability of grade 3 vaginal strictures (ED15 and ED20) for PIBS + 2 at 57.4 and 111 GyThis study showed a significant relationship between age, tumour size, and lower-third vaginal involvement with the incidence of vaginal toxicity. The goal of a cumulative radiotherapy dose of ≤ 55 Gy

Background and Purpose: To report the workflow and dose accumulation for bladder preservation for a bladder cancer patient, using magnetic-resonance-guided radiation therapy (MRgRT) and the simultaneous integrated boost (SIB) technique at mid-bladder volume.Materials and Methods: A muscle-invasive bladder cancer patient was treated with MRgRT. The patient was treated with the SIB technique at mid-bladder volume, with 45 Gy to the whole bladder (CTV WB) and 55 Gy to the tumor bed (CTV boost) in 20 fractions. Daily re-optimization with an adapt-to-position (ATP) strategy was utilized for dose adjustment to encompass the bladder within anisotropic planning target volume (PTV WB and PTV boost). Results: The mean daily treatment time was 55 minutes (range, 35–73). The actual whole-bladder and tumor-bed-boost doses were 45.74 ± 5.91 and 54.1 ± 4.62 Gy, respectively. PTV WB encompassing CTV WB was 95.69% ± 5.36%. PTV boost encompassing CTV boost was 97.52% ± 6.05%. The actual rectal and bowel doses were below the reference plan doses.Conclusions: The use of MRgRT with the SIB and ATP strategy proved feasible for bladder cancer treatment. Mid-bladder volume allowed treatment with the SIB technique under MR monitoring.

Objective: Malnutrition is the most common problem in head and neck cancer (HNC) patients receiving concurrent chemoradiotherapy. The radiation toxicities cause decreased food intake, with resultant severe weight loss and malnutrition. This study sought to determine whether an active nutrition improvement counseling program before and during concurrent chemoradiotherapy for HNC patients could increase the treatment completion rate without the interruptions caused by the side effects of chemoradiotherapy. Methods: The findings of a prospective study of the effects of an active nutrition improvement program before and during concurrent chemoradiotherapy (study, n = 32) was compared with those of a retrospective chart review of HNC patients who had received definite or postoperative concurrent chemoradiotherapy (control, n = 80). The correlations between nutritional status and the number of treatment completions, number of tube feeding insertions during treatment, RTOG toxicity, nutritional status, and quality of life were obtained. Results: There was no statistically significant difference between the concurrent chemoradiotherapy completion rates of both groups (p = 0.121; 95% CI, 0.226-1.188). The major cause of delayed or discontinued chemotherapy was oral mucositis. No significant differences were found in the tube feeding insertion rates and RTOG toxicities of both groups. However, the data showed a clinically significant difference in the concurrent chemoradiotherapy completion rate for the study group (56%), more than 15 percentage points higher than the control group’s rate (40%). Conclusion: An active nutrition improvement program before and during concurrent chemoradiotherapy is clinically beneficial for HNC patients, providing a higher treatment completion rate than otherwise.

OBJECTIVES: To demonstrate the usefulness of perfusion computed tomography (PCT) in the detection of local recurrent/residual (LR) tumor in patients with nasopharyngeal carcinoma (NPC) after radiotherapy. MATERIALS AND METHOD: Over three years (from June 2010 to May 2013), 138 post-radiotherapy NPC patients were recruited for this prospective study. Patients were informed and consent was obtained for PCT of the nasopharynx additional to the routine contrast-enhanced CT scan of the nasopharynx. Two years follow-up after perfusion CT was performed, patients were divided into LR and non-LR groups. The perfusion CT parameters of the nasopharynx included, blood flow (BF), blood volume (BV), mean transit time (MTT) and permeability surface area product (PS). These parameters were analyzed and compared between the two groups. RESULTS: There are significantly higher PCT parameters including: BF, BV, PS and significantly lower MTT (p 0.75) between two reviewers. CONCLUSIONS: PCT is a useful method to identify local recurrent/residual tumor after radiotherapy in patients with NPC. Keywords: perfNusion CT, nasopharyngeal carcinoma, local recurrence, prospective study DOI: 10.31524/bkkmedj.2019.02.004

Background: The concept of the use of MRI for image-guided adaptive brachytherapy (IGABT) in locally advanced cervical cancer was introduced 20 years ago. Here, we report on EMBRACE-I, which aimed to evaluate local tumour control and morbidity after chemoradiotherapy and MRI-based IGABT. Methods: EMBRACE-I was a prospective, observational, multicentre cohort study. Data from patients from 24 centres in Europe, Asia, and North America were prospectively collected. The inclusion criteria were patients older than 18 years, with biopsy-proven squamous cell carcinoma, adenocarcinoma, or adenosquamous carcinoma of the uterine cervix, The International Federation of Gynecology and Obstetrics (FIGO) stage IB–IVA disease or FIGO stage IVB disease restricted to paraaortic lymph metastasis below the L1–L2 interspace, suitable for curative treatment. Treatment consisted of chemoradiotherapy (weekly intravenous cisplatin 40 mg/m2, 5–6 cycles, 1 day per cycle, plus 45–50 Gy external-beam radiotherapy delivered in 1·8–2 Gy fractions) followed by MRI-based IGABT. The MRI-based IGABT target volume definition and dose reporting was according to Groupe Européen de Curiethérapie European Society for Radiation Oncology recommendations. IGABT dose prescription was open according to institutional practice. Local control and late morbidity were selected as primary endpoints in all patients available for analysis. The study was registered with ClinicalTrials.gov, NCT00920920. Findings: Patient accrual began on July 30, 2008, and closed on Dec 29, 2015. A total of 1416 patients were registered in the database. After exclusion for not meeting patient selection criteria before treatment, being registered but not entered in the database, meeting the exclusion criteria, and being falsely excluded, data from 1341 patients were available for analysis of disease and data from 1251 patients were available for assessment of morbidity outcome. MRI-based IGABT including dose optimisation was done in 1317 (98·2%) of 1341 patients. Median high-risk clinical target volume was 28 cm3 (IQR 20–40) and median minimal dose to 90% of the clinical target volume (D90%) was 90 Gy (IQR 85–94) equi-effective dose in 2 Gy per fraction. At a median follow-up of 51 months (IQR 20–64), actuarial overall 5-year local control was 92% (95% CI 90–93). Actuarial cumulative 5-year incidence of grade 3–5 morbidity was 6·8% (95% CI 5·4–8·6) for genitourinary events, 8·5% (6·9–10·6) for gastrointestinal events, 5·7% (4·3–7·6) for vaginal events, and 3·2% (2·2–4·5) for fistulae. Interpretation: Chemoradiotherapy and MRI-based IGABT result in effective and stable long-term local control across all stages of locally advanced cervical cancer, with a limited severe morbidity per organ. These results represent a positive breakthrough in the treatment of locally advanced cervical cancer, which might be used as a benchmark for clinical practice and all future studies. Funding: Medical University of Vienna, Aarhus University Hospital, Elekta AB, and Varian Medical Systems.

Background and purpose To investigate the relationship between deformable image registration (DIR) recalculated dose on cone beam computed tomography (CBCT) and gastrointestinal and genitourinary toxicity in postoperative prostate cancer patients treated with volumetric modulated arc therapy and its actual delivered dose. Material and methods A total of 114 patients were retrospectively studied. Delineation of rectum and bladder was performed on each CBCT image. Actual delivered dose on CBCT available fraction was recalculated using DIR. Dosimetric parameters of rectum and bladder were then evaluated by Quantitative Analyses of Normal Tissue Effects in the Clinic study. Differences in mean volume between patients with grade 0-1 and grade 2-5 CTCAEv5.0 toxicities were compared. Relationship between toxicity and radiation volume was analyzed using logit analysis. Results Significant differences between the actual and planned dose-volume were observed in nearly all doses of rectum. High-grade acute rectal toxicity was significantly associated with planned dose-volume in V50 and V75, and actual dose in all doses. High-grade chronic rectal toxicity was significantly associated with all planned and actual rectal dose-volume parameters. There was no significant association between all dose-volume parameters and acute or chronic bladder toxicity. Conclusion Significant differences between actual and planned dose-volume, and significant association between actual dose-volume and acute rectal toxicity, but not planned dose-volume suggests that actual dose-volume may more precisely reflect toxicity due to daily variation in the rectum during the treatment course. Adaptive planning should be considered as a novel approach for reducing toxicity.

Purpose This study was performed using end-to-end testing and real-time in vivo skin dose measurements, using metal oxide semiconductor field effect transistor (MOSFET) dosimeters on our first chronic psoriasis patient treated with iridium-192 (192Ir) high-dose-rate (HDR) brachytherapy (BT). Material and methods Treatment delivery was planned with the prescription dose of 1.8 Gy to a 3 mm depth for 12 fractions, using our custom-fabricated surface mold and Varian soft catheters. The optimal technique to provide an adequate and acceptable skin dose as well as its feasibility were evaluated by an end-to-end exercise using a perspex finger phantom. The accuracy and reliability of MOSFET dose measurement was explored with a thermoluminescence dosimetry (TLD) before being used in vivo to monitor skin doses during treatment delivery for each BT fraction. Results Using custom-made surface mold (2.4 mm Med-Tec thermoplastic mask for hand fixation and 5 applicators attached to each finger for dose delivery), the optimal skin dose on the phantom was obtained without the need for additional bolus to increase thickness of applicator. We acquired mean skin doses at different skin depths from various dose-volume parameters of no-bolus and 3 mm-added bolus plans. They were 125% and 110% (1 mm), 120% and 108% (2 mm), and 114% and 106% (3 mm), respectively. There was excellent agreement between MOSFET and TLD for 192Ir HDR-BT within ±3% (mean 2.65%, SD = 2.05%). With no energy correction, MOSFET overestimated the Acuros BV surface doses by up to 7% in the phantom study and in the clinical case. Conclusions We demonstrated achievable HDR-BT for our first case of nail bed psoriasis. The end-to-end exercise was an efficient methodology to evaluate new feasibility for this technique. Real-time dose monitoring using MOSFET was an effective and reliable tool to ensure treatment quality and patient safety.

Purpose Titanium ring cap applicator (VariSource) was applied in treating cervical cancer patients by using image-guided brachytherapy (IGBT). However, its sizes appeared to be relatively large for most of our patients. Thus, we have developed a specific applicator “Siriraj Ring Cap,” which is slightly smaller and more suitable for our patients. This study was to evaluate effectiveness of this equipment. Methods and Materials Locally advanced cervical cancer patients were treated with external beam radiation therapy with or without concomitant chemotherapy. Siriraj Ring Cap was applied in all of the patients for at least one fraction. Dosimetric analysis was performed in each fraction of IGBT. Clinical outcomes of these patients were evaluated. Results Twenty-nine patients with 117 dosimetric planning were evaluated between January and December of 2014. Siriraj Ring Cap was fit to all patients in this study. By using this applicator, radiation doses to the targets ( D 90 high-risk clinical target volume and D 90 intermediate-risk clinical target volume) were higher in each fraction. There were no statistically differences of radiation doses to the bladder, rectum, sigmoid colon, and small bowel. Within 2-year followup, 3 patients (10.3%) developed locoregional recurrence. Two-year disease-free survival and overall survival were 75.9% and 89.7%, respectively. According to RTOG/EORTC complication criteria, Grade 1, 2, and 3 gastrointestinal complications were developed in 2 (6.9%), 4 (13.8%), and 1 (3.4%) patients, respectively. For genitourinary complications, 3 patients (10.3%) and 1 patient (3.4%) had Grades 1 and 2, respectively. Conclusions Siriraj Ring Cap is feasible for IGBT in cervical cancer patients with narrow vagina. Dosimetry and clinical outcomes were satisfactory by using our specific applicator.

Purpose The dose distributions obtained from three imaging approaches for target delineation in cervical cancer using high-dose-rate (HDR) brachytherapy were investigated. Material and methods Ten cervical cancer patients receiving four fractions of HDR brachytherapy were enrolled. Based on different imaging approaches, three brachytherapy plans were developed for each patient: with the high-risk clinical target volume (HRCTV) delineated on magnetic resonance (MRI) images for every fraction (approach A; MRI-only); on MRI for the first fraction and computed tomography (CT) images for the subsequent fractions (approach B; MRI1st/CT); and on CT images for all fractions (approach C; CT-only). The volume, height, width at point A, width at maximum level, and dosimetric parameters (D100, D98, D95, and D90 of the HRCTV; and D0.1cc, D1cc, and D2cc of all organs at risk, or organ at risk - OAR: bladder, rectum, sigmoid colon, and bowel) provided by each approach were compared. Results The mean HRCTV volume, width, and height obtained from approach C (CT-only) were overestimated compared to those from approaches A (MRI-only) and B (MRI1st/CT). The doses to the HRCTV for approaches A and B were similar. However, the HRCTV doses for approach C were significantly lower than those for approaches A and B for all parameters (D95-D100). As to the OAR, the three approaches showed no differences. Conclusions A combination of MRI and CT is a safe alternative approach for cervical cancer HDR brachytherapy. The technique provides comparable dosimetric outcomes to MRI-based planning, while being more cost-effective.

Background and purpose Traditionally, vaginal dose points have been defined at the vaginal source level, thus not providing dose information for the entire vagina. Since reliable vaginal dose volume/surface histograms are unavailable, a strategy for comprehensive vaginal dose reporting for combined EBRT and BT was established and investigated. Material and methods An anatomical vaginal reference point was defined at the level of the Posterior–Inferior Border of Symphysis (PIBS), plus two points ±2cm (mid/introitus vagina). For BT extra points were selected for the upper vagina at 12/3/6/9o'clock, at the vaginal surface and 5mm depth. A vaginal reference length (VRL) was defined from ring centre to PIBS. Fifty-nine patients treated for cervical cancer were included in this retrospective feasibility study. Results The method was applicable to all patients. Total EQD2 doses at PIBS and ±2cm were 36.7Gy (3.1–68.2), 49.6Gy (32.1–89.6) and 4.3Gy (1.0–46.6). At the vaginal surface at ring level doses were respectively 266.1Gy (67.6–814.5)/225.9Gy (61.5–610.5) at 3/9o'clock, and 85.1Gy (55.4–140.3)/72.0Gy (49.1–108.9) at 12/6o'clock. Mean VRL on MRI was 5.6cm (2.0–9.4). Conclusions With this novel system, a comprehensive reporting of vaginal doses is feasible. The present study has demonstrated large dose variations between patients observed in all parts of the vagina, resulting from different contributions from EBRT and BT.

Grace Kusumawidjaja,1 Patricia Zhun Hong Gan,1 Whee Sze Ong,2 Achiraya Teyateeti,3 Pittaya Dankulchai,3 Daniel Yat Harn Tan,1 Eu Tiong Chua,1 Kevin Lee Min Chua,1 Chee Kian Tham,4 Fuh Yong Wong,1 Melvin Lee Kiang Chua1,5 1Division of Radiation Oncology, National Cancer Centre, Singapore; 2Division of Clinical Trials and Epidemiological Sciences, National Cancer Centre, Singapore; 3Department of Radiology, Division of Radiation Oncology, Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand; 4Division of Medical Oncology, National Cancer Centre, Singapore; 5Duke-NUS Graduate Medical School, Singapore Background: Glioblastoma multiforme (GBM) is the most aggressive primary brain tumor with high relapse rate. In this study, we aimed to determine if dose-escalated (DE) radiotherapy improved tumor control and survival in GBM patients. Methods: We conducted a retrospective analysis of 49 and 23 newly-diagnosed histology-proven GBM patients, treated with DE radiotherapy delivered in 70 Gy (2.33 Gy per fraction) and conventional doses (60 Gy), respectively, between 2007 and 2013. Clinical target volumes for 70 and 60 Gy were defined by 0.5 and 2.0 cm expansion of magnetic resonance imaging T1-gadolinium-enhanced tumor/surgical cavity, respectively. Bilateral subventricular zones (SVZ) were contoured on a co-registered pre-treatment magnetic resonance imaging and planning computed tomography dataset as a 5 mm wide structure along the lateral margins of the lateral ventricles. Survival outcomes of both cohorts were compared using log-rank test. Radiation dose to SVZ in the DE cohort was evaluated. Results: Median follow-up was 13.6 and 15.1 months for the DE- and conventionally-treated cohorts, respectively. Median overall survival (OS) of patients who received DE radiotherapy was 15.2 months (95% confidence interval [CI] =11.0–18.6), while median OS of the latter cohort was 18.4 months (95% CI =12.5–31.4, P=0.253). Univariate analyses of clinical and dosimetric parameters among the DE cohort demonstrated a trend of longer progression-free survival, but not OS, with incremental radiation doses to the ipsilateral SVZ (hazard ratio [HR]=0.95, 95% CI =0.90–1.00, P=0.052) and proportion of ipsilateral SVZ receiving 50 Gy (HR =0.98, 95% CI =0.97–1.00, P=0.017). Conclusion: DE radiotherapy did not improve survival in patients with GBM. Incorporation of ipsilateral SVZ as a radiotherapy target volume for patients with GBM requires prospective validation. Keywords: glioblastoma multiforme, intensity-modulated radiotherapy, dose escalation, subventricular zones

Background and purposeRecently, a vaginal dose reporting method for combined EBRT and BT in cervical cancer patients was proposed. The current study was to evaluate vaginal doses with this method in a multicentre setting, wherein different applicators, dose rates and protocols were used.Material and methodsIn a subset of patients from the EMBRACE study, vaginal doses were evaluated. Doses at the applicator surface left/right and anterior/posterior and at 5 mm depth were measured. In addition, the dose at the Posterior–Inferior Border of Symphysis (PIBS) vaginal dose point and PIBS±2 cm, corresponding to the mid and lower vagina, was measured.Results153 patients from seven institutions were included. Large dose variations expressed in EQD2 with α/β = 3 Gy were seen between patients, in particular at the top left and right vaginal wall (median 195 (range 61–947) Gy/178 (61–980) Gy, respectively). At 5 mm depth, doses were 98 (55–212) Gy/91 (54–227) Gy left/right, and 71 (51–145) Gy/67 (49–189) Gy anterior/posterior, respectively. The dose at PIBS and PIBS±2 cm was 41 (3–81) Gy, 54 (32–109) Gy and 5 (1–51) Gy, respectively. At PIBS+2 cm (mid vagina) dose variation was coming from BT. The variation at PIBS−2 cm (lower vagina) was mainly dependent on EBRT field border location.ConclusionsThis novel method for reporting vaginal doses coming from EBRT and BT through well-defined dose points gives a robust representation of the dose along the vaginal axis. In addition, it allows comparison of vaginal dose between patients from different centres. The doses at the PIBS points represent the doses at the mid and lower parts of the vagina. Large variations in dose throughout the vagina were observed between patients and centres.

Cervical cancer is the most common female cancer in the developing countries. Treatments of bulky stage IB cervical cancer have been challenged as the local control is relatively poor compared to smaller stage I disease, whether treated by radical surgery or irradiation. The treatment options are definitive concurrent chemoradiation therapy or radical surgery with or without neoadjuvant or adjuvant therapy. The treatment decision is based on the patients' status and preferences, tumor characteristics, and experiences of clinician. This study will review and compare the treatment modalities and rationales of a combination of treatment including surgery, radiation therapy, and chemotherapy for bulky stage IB cervical carcinoma.

Inoperable endometrial cancer may be treated with curative aim using radical radiotherapy alone. The radiation techniques are external beam radiotherapy (EBRT) alone, EBRT plus brachytherapy and brachytherapy alone. Recently, high-dose-rate brachytherapy has been used instead of low-dose-rate brachytherapy. Image-guided brachytherapy enables sufficient coverage of tumour and reduction of dose to the organs at risk, thus increasing the therapeutic ratio of treatment. Local control rates with three-dimensional brachytherapy appear better than with conventional techniques (about 90–100% and 70–90%, respectively).