Description: Publication date: December 2014 Source: Radiotherapy and Oncology, Volume 113, Issue 3 Author(s): Otilia Leon , Marianne Guren , Oskar Hagberg , Bengt Glimelius , Olav Dahl , Hanne Havsteen , Gisela Naucler , Christer Svensson , Kjell Magne Tveit , Anders Jakobsen , Per Pfeiffer , Eva Wanderås , Tor Ekman , Birgitta Lindh , Lise Balteskard , Gunilla Frykholm , Anders Johnsson Objective To evaluate treatment outcome in a large population-based cohort of patients with anal cancer treated according to Nordic guidelines. Material Clinical data were collected on 1266 patients with anal squamous cell carcinoma diagnosed from 2000 to 2007 in Sweden, Norway and Denmark. 886 of the patients received radiotherapy 54–64 Gy with or without chemotherapy (5-fluorouracil plus cisplatin or mitomycin) according to different protocols, stratified by tumor stage. Results High age, male gender, large primary tumor, lymph node metastases, distant metastases, poor performance status, and non-inclusion into a protocol were all independent factors associated with worse outcome. Among patients treated according to any of the protocols, the 3-year recurrence-free survival ranged from 63% to 76%, with locoregional recurrences in 17% and distant metastases in 11% of patients. The highest rate of inguinal recurrence (11%) was seen in patients with small primary tumors, treated without inguinal irradiation. Conclusions Good treatment efficacy was obtained with Nordic, widely implemented, guidelines for treatment of anal cancer. Inguinal prophylactic irradiation should be recommended also for small primary tumors.

Description: Publication date: November 2014 Source: Radiotherapy and Oncology, Volume 113, Issue 2 Author(s): Hermine M. Dees-Ribbers , Anja Betgen , Floris J. Pos , Thelma Witteveen , Peter Remeijer , Marcel van Herk Purpose To compare inter- and intra-fraction bladder volume variations and bladder wall motion during radiotherapy (RT) for bladder cancer with full and empty bladder protocols. Materials and methods Bladder volumes, filling rates and bladder wall movement were retrospectively analyzed for 24 patients with at least 4 sets of delineable pre and post treatment cone beam CT (CBCT)-scans. Eight patients were treated with an ‘empty bladder’ (EB) protocol and sixteen patients with a ‘full bladder’ (FB) protocol. Results 24 planning CT-scans and 356 CBCT-scans (178 sets) were analyzed. The average time between pre and post irradiation CBCT was 8 min (range 6–18 min). Median filling rate was 1.94 ml/min and did not differ between EB and FB. Random variation in bladder volume and inter-fraction wall movement was slightly but not significantly larger for FB, whereas intra-fraction bladder wall movement was slightly but not significantly smaller for FB. The largest inter- and intra-fraction bladder wall movement was found in the cranial anterior direction. Conclusion Empty and full bladder protocols show similar inter- and intra-fraction wall motion, and therefore treatment choices could be purely based on organ at risk criteria.

Description: Publication date: November 2014 Source: Radiotherapy and Oncology, Volume 113, Issue 2 Author(s): Ines Joye , Christophe M. Deroose , Vincent Vandecaveye , Karin Haustermans After neoadjuvant radiochemotherapy (RCT) for locally advanced rectal cancer, 15–27% of the patients experience a pathological complete response (pCR). This observation raises the question as to whether invasive surgery could be avoided in a selected cohort of patients who obtain a clinical complete response after preoperative RCT. In this respect, there has been growing interest in functional imaging techniques to improve clinical response assessment. This systematic review focuses on the role of diffusion-weighted imaging (DWI) and 18 F-fluorodeoxyglucose positron emission tomography/computed tomography ( 18 F-FDG PET/CT) in the prediction of pCR after RCT for rectal cancer. A total of 14 publications on DWI and 25 on 18 F-FDG PET/CT were retrieved. Pooled analysis of individual patient data shows both imaging modalities have a low positive predictive value in the prediction of pCR (mean PPV of 54% and 39% for DWI- and 18 F-FDG PET/CT-based parameters respectively). Especially pre-RCT imaging is unable to predict pCR with overall accuracies of 68–72% for DWI and 44% for 18 F-FDG PET/CT. Qualitative DWI assessment 5–10 weeks after the end of RCT may outperform apparent diffusion coefficient (ADC)-based DWI-parameters (overall accuracy of 87% vs. 74–78%). Although few data are available, early changes in FDG-uptake seem promising in the prediction of pCR and the role of 18 F-FDG PET/CT during RCT should be further investigated. Quantitative and qualitative 18 F-FDG PET/CT measurements are equally effective in the assessment of pCR after RCT. The major strength of DWI and 18 F-FDG PET/CT lies in the identification of non-responders who are not candidates for organ preservation. Up to now, DWI and 18 F-FDG PET/CT are not accurate enough to safely select patients for organ-sparing strategies. Future research must focus on the integration of functional imaging with clinical data and molecular biomarkers.

Description: Publication date: Available online 26 November 2014 Source: Radiotherapy and Oncology Author(s): Dana L. Casey , Paul A. Meyers , Kaled M. Alektiar , Heather Magnan , John H. Healey , Patrick J. Boland , Suzanne L. Wolden Background and purpose To evaluate local control and survival outcomes in adults with Ewing sarcoma (ES) treated with radiotherapy (RT). Material and methods Retrospective review of all 109 patients age ⩾18 treated for ES with RT to the primary site at Memorial Sloan Kettering Cancer Center between 1990 and 2011. RT was used as the definitive local control modality in 44% of patients, preoperatively for 6%, and postoperatively for 50%. Results Median age at diagnosis was 27 years (range, 18–67). The 5-year local failure (LF) was 18%. Differences in LF were not identified when evaluated by modality of local control (RT versus combined surgery and RT), RT dose, fractionation, and RT technique. However, margin status at time of resection significantly predicted LF. The 5-year event-free survival and overall survival rates were 44% and 66% for patients with localized disease, compared with 16% and 26% for metastatic disease ( p = 0.0005 and 0.0002). Tumor size, histopathologic response to chemotherapy, and treatment on or according to a protocol were also significantly associated with survival. Conclusions This series of adults treated with modern chemotherapy and RT had prognostic factors and outcomes similar to adolescents with ES. All adults with ES should be treated with an aggressive, multidisciplinary approach.

Description: Publication date: Available online 2 December 2014 Source: Radiotherapy and Oncology Author(s): Gustavo Nader Marta , Cristiane Rufino Macedo , Heloisa de Andrade Carvalho , Samir Abdallah Hanna , João Luis Fernandes da Silva , Rachel Riera Background and purpose: Accelerated partial breast irradiation (APBI) is the strategy that allows adjuvant treatment delivery in a shorter period of time in smaller volumes. This study was undertaken to assess the effectiveness and outcomes of APBI in breast cancer compared with whole-breast irradiation (WBI). Material and methods: Systematic review and meta-analysis of randomized controlled trials of WBI versus APBI. Two authors independently selected and assessed the studies regarding eligibility criteria. Results: Eight studies were selected. A total of 8653 patients were randomly assigned for WBI versus APBI. Six studies reported local recurrence outcomes. Two studies were matched in 5 years and only one study for different time of follow-up. Meta-analysis of two trials assessing 1407 participants showed significant difference in the WBI versus APBI group regarding the 5-year local recurrence rate (HR = 4.54, 95% CI: 1.78–11.61, p = 0.002). Significant difference in favor of WBI for different follow-up times was also found. No differences in nodal recurrence, systemic recurrence, overall survival and mortality rates were observed. Conclusions: APBI is associated with higher local recurrence compared to WBI without compromising other clinical outcomes.

Description: Publication date: Available online 1 December 2014 Source: Radiotherapy and Oncology Author(s): Emelie Adolfsson , Håkan Gustafsson , Eva Lund , Gudrun Alm Carlsson , Sara Olsson , Åsa Carlsson Tedgren The aim of this work was to develop and test a remote end-to-end audit system using lithium formate EPR dosimeters. Four clinics were included in a pilot study, absorbed doses determined in the PTV agreed with TPS calculated doses within ±5% for 3D-CRT and ±7% ( k = 1) for IMRT/VMAT dose plans.

Description: Publication date: Available online 29 November 2014 Source: Radiotherapy and Oncology Author(s): Ester Orlandi , Tommaso Giandini , Eva Iannacone , Elena De Ponti , Mauro Carrara , Valeria Mongioj , Claudio Stucchi , Silvia Tana , Paolo Bossi , Lisa Licitra , Carlo Fallai , Emanuele Pignoli Background and purpose To compare volumetric modulated arc therapy (VMAT) and intensity modulated radiation therapy (IMRT) plans for treatment of unresectable paranasal sinuses cancers (PNSCs) with different clinical presentations. Material and methods Four patients treated for primary target volume only (group 1), four requiring elective nodal irradiation (group 2) and four with positive nodes in macroscopic disease (group 3) were selected. For each patient were generated 7 fields IMRT, coplanar VMAT (c-VMAT) and non-coplanar VMAT (nc-VMAT) treatment plans. Total doses were 70 Gy and 54 Gy to high dose planning target volume (HD-PTV) and low-dose-PTV, respectively. Dose–volume histogram, conformity and homogeneity index (CI and HI), and monitor units (MUs) per Gy were evaluated. Results VMAT provided significantly better target coverage, in terms of V 100% (Volume encompassed by the isodose 100%), than IMRT, in particular when nc-VMAT was used. In general, organ at risk sparing is similar with the three approaches, although nc-VMAT can allow a statistically significant reduction of dose to contralateral parotid gland and cochlea for all three groups. Conclusions VMAT can offer significant improvement of treatment for all unresectable PNSCs over existing IMRT techniques. In particular, nc-VMAT may be a further advantage for those patients with sinonasal cancers and involvement of the nodes in whom large volumes and complex/irregular shape have to be irradiated, even if clinical benefits should be established in the future.

Description: Publication date: Available online 29 November 2014 Source: Radiotherapy and Oncology Author(s): Anna Pettersson , Peter Nygren , Christina Persson , Anders Berglund , Ingela Turesson , Birgitta Johansson Background and purpose To evaluate the long-term effects of dietary intervention on gastrointestinal symptoms after highly dose-escalated radiotherapy for localized prostate cancer, using boost with protons or high-dose-rate brachytherapy. Materials and methods Patients were randomized to an intervention group ( n = 64) advised to reduce insoluble dietary fiber and lactose intake, or to a standard care group ( n = 66) advised to continue their usual diet. Gastrointestinal symptoms, other domains of health-related quality of life (HRQOL), and dietary intake were evaluated for ⩽24 months post-radiotherapy with the European Organization for Research and Treatment of Cancer quality-of-life questionnaires QLQ-C30 and QLQ-PR25, Gastrointestinal Side Effects Questionnaire, and Food Frequency Questionnaire. The effect of the intervention on gastrointestinal symptoms was evaluated using generalized estimating equations. Results Dietary intervention had no obvious effect on long-term gastrointestinal symptoms or HRQOL. The intervention group markedly reduced their dietary fiber and lactose intake during radiotherapy, but adherence tended to decline over time. The vast majority of long-term gastrointestinal symptoms were reported as ‘a little’, with a noticeable difference from pre-treatment only for unintentional stool leakage, limitations on daily activities, and mucus discharge. Conclusion Long-term gastrointestinal symptoms were predominantly mild, and dietary intervention was not superior to a usual diet in preventing these symptoms.

Description: Publication date: Available online 28 November 2014 Source: Radiotherapy and Oncology Author(s): Robbe Van den Begin , Benedikt Engels , Thierry Gevaert , Michaël Duchateau , Koen Tournel , Dirk Verellen , Guy Storme , Mark De Ridder Purpose Stereotactic body radiotherapy (SBRT) in oligometastatic colorectal cancer (CRC) resulted in a disappointing 1-year local control rate of 54% in our experience. We aimed to determine the root cause(s). Methods 47 oligometastatic CRC patients were treated with SBRT by helical tomotherapy to a dose of 40 or 50 Gy in 10 fractions, without specific respiratory motion management and PTV-margins of 10–10–12 mm in all patients. The local recurrences (LRs) were delineated on diagnostic PET–CT scans and co-registered with initial planning CTs. LRs were classified as in-field or marginal with respect to the initial dose distribution, and predictors for LR were determined. Results Out of 105 irradiated metastases, LR modeling yielded 15 in-field and 15 marginal failures. Metastases in moving organs (liver and lung) exhibited a local control of 53% at 1-year (95% confidence interval (CI): 38–67%), compared to 79% for lymph nodes (95% CI: 32–95%). The first group exhibited a sixfold increased risk compared to the latter on multivariate analysis ( p = 0.01). Conclusions The nature and locations of LR indicated that dose prescription and methodology were both inadequate for liver and lung metastases. This study demonstrates the need for individual respiratory motion management and a biological effective dose of >75 Gy.

Description: Publication date: Available online 29 November 2014 Source: Radiotherapy and Oncology Author(s): Christina T. Muijs , Jannet C. Beukema , Dankert Woutersen , Veronique E. Mul , Maaike J. Berveling , Jan Pruim , Eric J. van der Jagt , Geke A.P. Hospers , Henk Groen , John Th. Plukker , Johannes A. Langendijk Background The aim of this prospective study was to determine the proportion of locoregional recurrences (LRRs) that could have been prevented if radiotherapy treatment planning for oesophageal cancer was based on PET/CT instead of CT. Materials and methods Ninety oesophageal cancer patients, eligible for high dose (neo-adjuvant) (chemo)radiotherapy, were included. All patients underwent a planning FDG-PET/CT-scan. Radiotherapy target volumes (TVs) were delineated on CT and patients were treated according to the CT-based treatment plans. The PET images remained blinded. After treatment, TVs were adjusted based on PET/CT, when appropriate. Follow up included CT-thorax/abdomen every 6 months. If LRR was suspected, a PET/CT was conducted and the site of recurrence was compared to the original TVs. If the LRR was located outside the CT-based clinical TV (CTV) and inside the PET/CT-based CTV, we considered this LRR possibly preventable. Results Based on PET/CT, the gross tumour volume (GTV) was larger in 23% and smaller in 27% of the cases. In 32 patients (36%), >5% of the PET/CT-based GTV would be missed if the treatment planning was based on CT. The median follow up was 29 months. LRRs were seen in 10 patients (11%). There were 3 in-field recurrences, 4 regional recurrences outside both CT-based and PET/CT-based CTV and 3 recurrences at the anastomosis without changes in TV by PET/CT; none of these recurrences were considered preventable by PET/CT. Conclusion No LRR was found after CT-based radiotherapy that could have been prevented by PET/CT. The value of PET/CT for radiotherapy seems limited.