Description: Publication year: 2012 Source: Radiotherapy and Oncology, Volume 104, Issue 2

Description: Publication year: 2012 Source: Radiotherapy and Oncology, Volume 104, Issue 3 Jeffrey Kit Loong Tuan, Tam Cam Ha, Whee Sze Ong, Tian Rui Siow, Ivan Weng Keong Tham, Swee Peng Yap, Terence Wee Kiat Tan, Eu Tiong Chua, Kam Weng Fong, Joseph Tien Seng Wee Background and purpose We sought to evaluate the nature and frequency of late toxicities in a cohort of nasopharyngeal cancer (NPC) patients treated with conventional radiotherapy alone. Methods and materials Seven-hundred and ninety-six consecutive NPC patients treated using conventional radiotherapy at a single center from 1992 to 1995 were retrospectively analyzed. Patients with histology proven, completely staged, Stage I–IVB World Health Organization Type I–III NPC and completed radical radiotherapy were included. Patients with incomplete staging investigations, distant metastases at diagnosis, previous treatment, and incomplete radiotherapy were excluded. Radiotherapy-related complications were categorized using the RTOG Late Radiation Morbidity Scoring Criteria. Results Median follow-up was 7.2 years. The 5-year overall survival and disease free survival were 69% and 56%, respectively, and the corresponding 10-year rates were 52% and 44%. Among 771 patients with at least 3 months of follow-up post treatment, 565 (73%) developed RT-related complications. Diagnosed neurological complications were cranial nerve palsies ( n = 70; 9%), temporal lobe necrosis ( n = 37; 5%), Lhermitte’s syndrome ( n = 7; 1%), and brachial plexopathy ( n = 2; 0.3%). Non-neurological complications included xerostomia ( n = 353; 46%), neck fibrosis ( n = 169; 22%), hypo-pituitarism ( n = 48; 6%), hearing loss ( n = 120; 16%), dysphagia ( n = 116; 15%), otorrhea ( n = 101; 13%), tinnitus ( n = 94; 12%), permanent tube feeding ( n = 61; 8%), trismus ( n = 45; 6%), second malignancies within treatment field ( n = 17; 2%), and osteo-radionecrosis ( n = 13; 2%). Conclusions While radiotherapy is curative in NPC, many patients suffer significant late treatment morbidities with conventional radiotherapy techniques.

Description: Publication year: 2012 Source: Radiotherapy and Oncology, Volume 104, Issue 3 Lei Chen, Yan-Ping Mao, Fang-Yun Xie, Li-Zhi Liu, Ying Sun, Li Tian, Ling-Long Tang, Ai-Hua Lin, Li Li, Jun Ma Purpose To evaluate the 7th edition of the International Union against Cancer/American Joint Committee on Cancer (UICC/AJCC) staging system for nasopharyngeal carcinoma (NPC) in patients treated with intensity-modulated radiotherapy. Methods and materials We performed a retrospective data review from 512 patients with biopsy-proven, nonmetastatic NPC in our cancer center (South China) between January 2003 and December 2006. Results The local relapse-free survival rates (LRFS) and disease failure-free survival rates (DFS) in the 6th edition system T1 and T2a stages were not significantly different ( P = 0.629 and P = 0.820), while the LRFS and DFS of T1 and T2 using the 7th edition system were significantly different ( P = 0.019 and P = 0.009). The LRFS and DFS between T2 and T3 in the 7th edition systems were lack of significance ( P = 0.874 and P = 0.589). The total difference in distant metastasis-free survival rate and DFS between N0 and N3 was slightly larger using the 7th edition system than the 6th edition. The nodal dimension of a cervical lymph node was not a significant prognostic factor. Conclusions We observed a better segregation of survival curves by using the 7th edition system. It seems reasonable to downstage T3 as T2 and reject nodal greatest dimension from the N-staging system in the future revised edition.

Description: Publication year: 2012 Source: Radiotherapy and Oncology Tanja Alderliesten, Jan-Jakob Sonke, Anja Betgen, Corine van Vliet-Vroegindeweij, Peter Remeijer Purpose To investigate the accuracy of surface imaging for monitoring intrafraction motion purposes in frameless stereotactic body radiotherapy (SBRT) of lung cancer by comparison with cone-beam computed tomography (CBCT). Materials and methods Thirty-six patients (18 males, 18 females) were included. During each fraction, three CBCT scans were acquired; CBCT1: before treatment, CBCT2: after correction for tumor misalignment, and CBCT3: after treatment. Intrafraction motion was derived by registering CBCT2 and CBCT3 to the mid-ventilation planning CT scan. Surfaces were captured concurrently with CBCT acquisitions. Retrospectively, for each set of surfaces, an average surface was created: Surface1, Surface2, and Surface3. Subsequently, Surface3 was registered to Surface2 to assess intrafraction motion. For the differences between CBCT- and surface-imaging-derived 3D intrafraction motions, group mean, systematic error, random error and limits of agreement (LOA) were calculated. Results Group mean, systematic and random errors were smaller for females than for males: 0.4 vs. 1.3, 1.3 vs. 3.1, and 1.7 vs. 3.3 mm respectively. For female patients deviations between CBCT-tumor- and 3D-surface-imaging-derived intrafraction motions were between −3.3 and 4.3 mm (95% LOA). For male patients these were substantially larger: −5.9–9.5 mm. Conclusion Surface imaging is a promising technology for monitoring intrafraction motion purposes in SBRT for female patients.

Description: Publication year: 2012 Source: Radiotherapy and Oncology Louise Vagner Laursen, Ulrik Vindelev Elstrøm, Anne Vestergaard, Ludvig P. Muren, Jørgen Baltzer Petersen, Jacob Christian Lindegaard, Cai Grau, Kari Tanderup Purpose Due to the often quite extended treatment fields in cervical cancer radiotherapy, uncorrected rotational set-up errors result in a potential risk of target miss. This study reports on the residual rotational set-up error after using daily cone beam computed tomography (CBCT) to position cervical cancer patients for radiotherapy treatment. Methods and materials Twenty-five patients with locally advanced cervical cancer had daily CBCT scans (650 CBCTs in total) prior to treatment delivery. We retrospectively analyzed the translational shifts made in the clinic prior to each treatment fraction as well as the residual rotational errors remaining after translational correction. Results The CBCT-guided couch movement resulted in a mean translational 3D vector correction of 7.4 mm. Residual rotational error resulted in a target shift exceeding 5 mm in 57 of the 650 treatment fractions. Three patients alone accounted for 30 of these fractions. Nine patients had no shifts exceeding 5 mm and 13 patients had 5 or less treatment fractions with such shifts. Conclusion Twenty-two of the 25 patients have none or few treatment fractions with target shifts larger than 5 mm due to residual rotational error. However, three patients display a significant number of shifts suggesting a more systematic set-up error.

Description: Publication year: 2012 Source: Radiotherapy and Oncology, Volume 104, Issue 3 Szu-Huai Lu, Jason Chia-Hsien Cheng, Sung-Hsin Kuo, Jason Jeun-Shenn Lee, Liang-Hsin Chen, Jian-Kuen Wu, Yu-Hsuan Chen, Wan-Yu Chen, Shu-Yu Wen, Fok-Ching Chong, Chien-Jang Wu, Chun-Wei Wang Purpose Volumetric modulated arc therapy (VMAT), a novel technique, employs a linear accelerator to conduct dynamic modulation rotation radiotherapy. The goal of this study was to compare VMAT with helical tomotherapy (HT) and step-and-shoot intensity-modulated radiation therapy (IMRT) for nasopharyngeal carcinoma (NPC) patients with regard to the sparing effect on organs at risk (OARs), dosimetric quality, and efficiency of delivery. Materials and methods Twenty patients with NPC treated by HT were re-planned by VMAT (two arcs) and IMRT (7–9 fields) for dosimetric comparison. The target area received three dose levels (70, 60, and 54 Gy) in 33 fractions using simultaneous integrated boosts technique. The Philips Pinnacle Planning System 9.0 was adopted to design VMAT, using SmartArc as the planning algorithm. For a fair comparison, the planning target volume (PTV) coverage of the 3 plans was normalized to the same level. Dosimetric comparisons between VMAT, HT, and IMRT plans were analyzed to evaluate (1) coverage, homogeneity, and conformity of PTV, (2) sparing of OARs, (3) delivery time, and (4) monitor units (MUs). Results The VMAT, HT, and IMRT plans had similar PTV coverage with an average of 96%. There was no significant difference between VMAT and HT in homogeneity, while the homogeneity indices of VMAT (1.06) and HT (1.06) were better than IMRT plans (1.07, p 〈 0.05). HT plans provided a better conformity index (1.17) than VMAT (1.28, p = 0.01) and IMRT (1.36, p = 0.02). When compared with IMRT, VMAT and HT had a better sparing effect on brain stem and spinal cord ( p 〈 0.05). The effect of parotid sparing was similar between VMAT (mean = 26.3 Gy) and HT (mean = 27.5 Gy), but better than IMRT (mean = 31.3 Gy, p 〈 0.01). The delivery time per fraction for VMAT (5.7 min) were much lower than for HT (9.5 min, p 〈 0.01) and IMRT (9.2 min, p 〈 0.01). Conclusions Our results indicate that VMAT provides better sparing of normal tissue, homogeneity, and conformity than IMRT, and shorter delivery time than HT.

Description: Publication year: 2012 Source: Radiotherapy and Oncology, Volume 104, Issue 3 Atsuya Takeda, Yohei Oku, Naoko Sanuki, Etsuo Kunieda, Naoyoshi Koike, Yousuke Aoki, Toshio Ohashi, Shogo Iwabuchi, Kentaro Takatsuka, Toshiaki Takeda, Akitomo Sugawara Purpose To investigate threshold dose (TD) of focal liver reaction (FLR) following stereotactic body radiotherapy (SBRT) for patients with hepatocellular carcinoma (HCC) and liver cirrhosis. Materials and methods In consecutive 50 patients receiving SBRT for small HCC, 38 patients receiving SBRT and follow up 〉6 months, FLR on follow-up CT had been previously studied. Patients with good concordance between FLR and highly irradiated area were eligible. Dose volume histogram (DVH) was used to identify TDs for FLR. Clinical factors were analyzed for correlation with TDs. Results Of 24 eligible patients, 23 had Child–Pugh score A and 1 scored B. Presence of FLR peaked at a median of 6 (range; 3–12) months. The median and 95% confidential intervals of TDs of pre-contrast and portal-venous phase CT were 32.4 Gy (30.3–35.4) and 34.4 Gy (31.9–36.0), respectively. Each median coefficient representing the concordance was 74.9% (range; 55.8–98.0%) and 80.5% (range; 70.8–92.4%), respectively. No clinical factors significantly correlated with the TDs. Conclusion We proposed 30 Gy/5 fractions as TD of FLRs following SBRT for patients with HCC and liver cirrhosis. This TD will enable us to predict injured liver volume and to avoid complication beforehand from toxicity. Further pathological and clinical studies, in addition to more practical and precise data of DVH, are needed to clarify the significance of FLRs.

Description: Publication year: 2012 Source: Radiotherapy and Oncology, Volume 104, Issue 3 Sara Madaschi, Claudio Fiorino, Marco Losa, Roberto Lanzi, Elena Mazza, Micaela Motta, Lucia Perna, Elena Brioschi, Marina Scavini, Michele Reni

Description: Publication year: 2012 Source: Radiotherapy and Oncology, Volume 104, Issue 3 Chenghe Lin, Yan Yu, Hong-guan Zhao, Aimin Yang, Hong Yan, Yali Cui Purpose Quercetin (3, 3,′ 4′, 5, 7 – five-flavonoids) is one of the main components of flavonoids, with multifunctions on immune function, anti-oxidation, anti-viral, anti-inflammatory, and cardiovascular protection. We hypothesize that a combination of quercetin with radiation would increase tumor radiosensitivity. To test this hypothesis, we conducted in vitro and in vivo studies. Methods and materials The in vitro radio-sensitization activity of quercetin was tested in DLD1, HeLa and MCF-7 tumor cell lines by colony formation assays. The in vivo activity was assessed in the DLD-1 human colorectal cancer xenograft model in nude mice. Mechanistic studies were conducted in several cell lines using Western blot analysis and immunofluorescence microscopy. Results We found that quercetin can significantly increase tumor radiosensitivity both in vitro and in vivo . The in vitro Sensitizing Enhancement Ratios in DLD1, HeLa and MCF-7 cells were 1.87, 1.65, and 1.74, respectively. The mean doubling time of tumor xenografts was significantly increased in irradiated mice treated with quercetin. At the cellular level, exposure to quercetin resulted in prolonged DNA repair. The mechanistic studies demonstrated that quercetin induced radio-sensitization is through inhibiting the ATM kinase, one of the critical DNA damage response proteins. Conclusion We demonstrate both in vitro and in vivo evidence that combination of quercetin with radiotherapy can enhance tumor radiosensitivity by targeting the ATM-mediated pathway in response to radiation.

Description: Publication year: 2012 Source: Radiotherapy and Oncology, Volume 103, Issue 2 Ashwini Budrukkar, Vikas Jagtap, Seema Kembhavi, Anusheel Munshi, Rakesh Jalali, Tanuja Seth, Vani Parmar, Ritu Raj Upreti, Rajendra Badwe, Rajiv Sarin Purpose To report the incidence of clinical, pathological and radiological fat necrosis (FN) in women treated with accelerated partial breast irradiation (APBI) using interstitial brachytherapy (BRT) for early-stage breast cancer and to study certain variables associated with it. Methods and materials Between May 2000 and August 2008, 171 women were treated with APBI using high dose rate (HDR) BRT. Patients were treated to a dose of 34 Gy/10 fractions/1 week with two fractions/day after intraoperative/postoperative placement of catheters. Results At a median follow up of 48 months (SD: 28) 20 women developed FN with median time to detection being 24 months (range: 4–62 months, SD: 20). Actuarial 5 and 7 year FN rate was 18% and 23%, respectively. Grade 1 FN was seen in 4, grade 2 in 8 and grade 4 in 8 women. Additional investigations such as aspiration/biopsy were done in 9 patients. Volume of excision was the only significant factor affecting FN ( p = 0.04). Conclusions Actuarial FN rate of 18% at 5 years in our study was comparable to other reported series of FN. Median time of detection of FN was 24 months. Higher volume of excision resulted in an increased incidence of fat necrosis.