Baseline Karnofsky performance status is independently predictive of death within 30 days of intracranial radiation therapy completion for metastatic disease

IntroductionFor patients with brain metastases, palliative radiation therapy (RT) has long been a standard of care for improving quality of life and optimizing intracranial disease control. The duration of time between completion of palliative RT and patient death has rarely been evaluated.MethodsA compilation of two prospective institutional databases encompassing April 2015 through December 2018 was used to identify patients who received palliative intracranial radiation therapy. A multivariate logistic regression model characterized patients adjusting for age, sex, admission status (inpatient versus outpatient), Karnofsky Performance Status (KPS), and radiation therapy indication.Results136 consecutive patients received intracranial palliative radiation therapy. Patients with baseline KPS <70 (OR = 2.2; 95%CI = 1.6–3.1; p < 0.0001) were significantly more likely to die within 30 days of treatment. Intracranial palliative radiation therapy was most commonly delivered to provide local control (66% of patients) or alleviate neurologic symptoms (32% of patients), and was most commonly delivered via whole brain radiation therapy in 10 fractions to 30 Gy (38% of patients). Of the 42 patients who died within 30 days of RT, 31 (74%) received at least 10 fractions.ConclusionsOur findings indicate that baseline KPS <70 is independently predictive of death within 30 days of palliative intracranial RT, and that a large majority of patients who died within 30 days received at least 10 fractions. These results indicate that for poor performance status patients requiring palliative intracranial radiation, hypofractionated RT courses should be strongly considered.     

Liver metastases and SBRT: A new paradigm?

BackgroundThe outstanding innovations made by early diagnosis, novel surgical techniques, effective chemotherapy regimens and conformal radiotherapy, have significantly improved patients overall survival and quality of life. Multidisciplinary approach to cancer has also led to an increased prevalence of patients with few, organ-confined metastases, who can experience long-term survival even if their disease is no longer localized. Liver is one of the most common site for metastatic disease from several cancers, and when metastatic disease is confined to liver, given the ability of this organ to regenerate almost to its optimal volume, surgical resection represents the standard of care because is associated with a better prognosis. Approximately 70–90% of liver metastases, however, are unresectable and a safe, effective alternative therapeutic option is necessary for these patients.Materials and methodsA review of the current literature was performed to analyze the role of SBRT in treating liver metastases from different cancers. A literature search using the terms “SBRT” and “liver metastases” was carried out in PUBMED.ResultsStereotactic body radiation therapy has shown to provide promising results in the treatment of liver metastases, thanks to the ability of this procedure to deliver a conformal high dose of radiation to the target lesion and a minimal dose to surrounding critical tissues.ConclusionStereotactic body radiation therapy is a non-invasive, well-tolerated and effective treatment for patients with liver metastases not suitable for surgical resection.     

Brain metastases from non-small cell lung carcinoma: an overview of classical and novel treatment strategies

BackgroundThe development of brain metastases is a common problem in patients diagnosed with non-small cell lung carcinoma (NSCLC). Technological advances in surgery and radiotherapy have allowed greater local control. Moreover, the emergence of targeted therapies and immunotherapy with greater activity on the central nervous system than classical chemotherapy have given way to new strategies in the treatment of brain metastases. We review the current role of local treatments, surgery and radiotherapy, and the most effective combination strategies with the new systemic treatments.Relevance for patientsBrain metastases frequently occur during the course of NSCLC. In recent years, a range of treatments have appeared, such as targeted treatments or immunotherapy, with greater activity at the brain level than classical chemotherapy. Radiotherapy treatment is also now much more conformal and ablative doses can be delivered to the volume of the metastatic area, providing greater local control and less neurological toxicity. However, surgery is still required in cases where anatomopathological specimens are needed and when compressive effects appear. An important challenge is how to combine these treatments to achieve the best control and minimise patients’ neurological impairments, especially because of limited experience with the new target drugs, and the unknown toxicity of the different combinations. Future research should therefore focus on these areas in order to establish the best strategies for the treatment of brain metastases from non-small cell lung cancer.Core tipsIn this work, we intend to elucidate the best therapeutic options for patients diagnosed with brain metastases of NSCL, which include: surgery, WBRT, radiosurgery or systemic treatment, and the most effective combinations and timings of them, and the ones with the lowest associated toxicity.     

On the use of AAA and AcurosXB algorithms for three different stereotactic ablative body radiotherapy (SABR) techniques: Volumetric modulated arc therapy (VMAT), intensity modulated radiation therapy (IMRT) and 3D conformal radiotherapy (3D-CRT)

AimThe purpose of this study was to investigate the dosimetric characteristics of three stereotactic ablative body radiotherapy (SABR) techniques using the anisotropic analytical algorithm (AAA) and Acuros XB algorithm. The SABR techniques include coplanar volumetric modulated arc therapy (C-VMAT), non-coplanar intensity modulated radiation therapy (NC-IMRT) and non-coplanar three-dimensional conformal radiotherapy (NC-3D CRT).BackgroundSABR is a special type of radiotherapy where a high dose of radiation is delivered over a short time. The treatment outcome and accuracy of the dose delivered to cancer patients highly depend on the dose calculation algorithm and treatment technique.Materials and methodsTwelve lung cancer patients underwent 4D CT scanning, and three different treatment plans were generated: C-VMAT, NC-IMRT, NC-3D CRT. Dose calculation was performed using the AAA and Acuros XB algorithm. The dosimetric indices, such as conformity index (CI), homogeneity index, dose fall-off index, doses received by organs at risk and planning target volume, were used to compare the plans. The accuracy of AAA and Acuros XB (AXB) algorithms for the lung was validated against measured dose on a CIRS thorax phantom.ResultsThe CIs for C-VMAT, NC-IMRT and NC-3D CRT were 1.21, 1.28 and 1.38 for the AAA, respectively, and 1.17, 1.26 and 1.36 for the Acuros XB algorithm, respectively. The overall dose computed by AcurosXB algorithm was close to the measured dose when compared to the AAA algorithm. The overall dose computed by the AcurosXB algorithm was close to the measured dose when compared to the AAA algorithm.ConclusionThis study showed that the treatment planning results obtained using the Acuros XB algorithm was better than those using the AAA algorithm in SABR lung radiotherapy.     

Radiation therapy for bone-only metastases in breast cancer patients: A GOCO survey of current clinical practice

IntroductionThe role of radiation therapy (RT) for patients with bone-only metastatic (BOM) breast cancer has not been investigated sufficiently. The aim of this survey was to evaluate current clinical practice in treating breast cancer patients with BOM in Radiation Therapy Departments in Catalonia and Occitania within the scope of the GOCO group.Materials and methodsAn electronic questionnaire was completed by experienced radiation oncologists from fourteen RT centers. The items surveyed the professional experience, therapeutic approach, technique, dose stereotactic body RT (SBRT) availability.ResultsAll Radiation Oncology Departments (ROD) in Catalonia (12) and Occitania (2) responded to the survey. Eleven (78.5%) of the RODs advise RT for BOM as initial treatment in the oligometastatic setting. RT to asymptomatic bone oligometastases is more often restricted for “risky lesions”. The most inconsistent approaches were the treatment for asymptomatic lesions, when to treat bone metastases with respect to systemic treatment (ST) and the indication for RT after a complete response to ST.ConclusionWhile BOM breast cancer patients have a relatively good prognosis, there is a lack of consistency in their approach with RT. This can be explained by the absence of evidence-based guidelines and an incomplete availability of SBRT.     

肝转移癌放射治疗进展

过去的几十年,在肝转移癌的治疗方面,放疗已经越来越多的应用于临床。对于局部肝转移癌,临床上往往采取加大剂量已提高局部控制率,以期提高患者生产期。但是,对于有症状的广泛性肝转移患者则给以全肝低剂量照射。放疗已成为不适合手术或化疗等方式的肝转移癌患者的有效治疗手段。放疗靶区勾画及放疗技术进步更好的保护了高剂量靶区周围的正常肝脏组织,使得提高靶区放疗剂量的手段很好的应用于临床。关于肝转移癌的适形与立体定向放疗治疗的提高局控率及生存期的临床研究不断出现。本文就局部肝转移的根治放疗与全肝的姑息放疗临床数据做相关综述,认为放疗在肝转移癌的治疗中是安全,有效的。但是,肝转移癌的临床随机试验研究仍较匮乏。     

Radiotherapy for cervical cancer: Chilean consensus of the Society of Radiation Oncology

BackgroundCervical cancer is a public health problem in Latin America. Radiotherapy plays a fundamental role both as definitive or adjuvant treatment. There are important intra and inter-country differences regarding access and availability of radiotherapy facilities in this region. The aim of a study was to standardize the basic clinical and technical criteria for the radiation treatment of patients with CC in Chile and provide a guide for Latin American Radiation Oncologists.Materials and methodsForty-one expert radiation oncologists from the Chilean Radiation Oncology Society made a consensus using the Delphi methodology.ResultsThere was a high degree of agreement for each of the recommendations. Those with the lowest percentage were related to the definition of the conformal 3D technique as the standard for definitive external radiotherapy (81%) and the criteria for extended nodal irradiation (85%).ConclusionsThese recommendations present an updated guide for radiotherapy treatment of patients with cervical cancer for Latin America. Those should be implemented according to local resources of each institution.     

Stereotactic radiotherapy for brain metastases in patients with lung cancer; outcome and toxicity in clinical practice

BackgroundStereotactic radiotherapy (SRT) is an established modality for treating limited brain metastases (BMs). This study aimed to assess the real-life treatment outcome and associated prognostic factors for survival in a consecutive lung cancer cohort receiving SRT for BMs.Materials and methodsA retrospective review and analysis of patients with lung cancer with BMs treated with SRT in western Sweden between 2002 and 2017 were performed. Data were collected from patient charts and the radiotherapy dose planning system.ResultsOne hundred nine patients corresponding to 139 lesions were assessed; the majority were treated with single-fractionated SRT with 20 Gy. The median overall survival (OS) was 6.1 months, with a 12-month survival rate of 24%. The estimated overall disease control rate (DCR) was 84% at a median time of three months. On multivariate analysis, WHO performance status (PS) (p = 0.002) and smoking status (p = 0.005) were significant predictive factors for survival. Four percent of the patients experienced possible grade III–IV toxicity, and previously administered cranial radiation therapy was a significant independent factor (p = 0.03) associated with the risk of developing acute toxicity.ConclusionsSRT due to brain metastases from lung cancer is a well-tolerated treatment. When selecting patients suitable for treatment, PS and extracranial disease progression should be considered. Smoking cessation is probably of value even in this palliative setting. The goal of SRT for BMs is not only to improve survival but also to provide symptom relief, and future studies on SRT should assess patient-reported outcomes in addition to survival.     

Photon-beam radiotherapy in pregnant patients: Can the fetal dose be limited to 10 cGy or less?

PurposeTo estimate fetal dose and its components from three-dimensional conformal radiotherapy for several malignancies presented during pregnancy.Materials and methodsFetal dose was measured from radiotherapy for Hodgkin's lymphoma and for tumors in the region of nasopharynx, breast and lung. Anthropomorphic phantoms were used to simulate an average pregnant patient at the first, second and third trimesters of gestation. Thermoluminescent dosemeters (TLD) were employed for fetal dose measurements. Phantom exposures were also performed to estimate fetal dose due to head leakage, scatter from collimators and beam modifiers and scatter generated inside the phantom (D_in). All treatments were delivered for 6 MV photon beams.ResultsRadiotherapy of Hodgkin's lymphoma resulted in a fetal dose of 5.6–57.9 cGy depending upon the gestational age and the distance between the fetal level and the field edge. The corresponding dose ranges for treatment of nasopharyngeal, breast and lung cancer was 4.0–17.1 cGy, 3.9–24.8 cGy and 5.7–74.3 cGy, respectively. The D_in at the first trimester of gestation was always smaller than 10 cGy for all examined malignancies. Pregnancy progression resulted in D_in values above or below 10 cGy depending upon the treatment site and gestational age.ConclusionThis study provides data about the fetal exposure and the contribution of D_in to the total fetal dose from conformal radiation therapy. The D_in knowledge prior to patient's irradiation enables radiation oncologists and medical physicists to decide whether fetal dose may be limited to 10 cGy or less with or without the introduction of special shielding materials.     

COVID-RO study: the radiation oncology practice at times of COVID-19 outbreak — international survey

BackgroundRadiation therapy (RT), an essential treatment of cancer, involves multiple hospital visits. We hypothesized that radiation departments would adjust their work patterns and RT protocols in response to the SARS-CoV-2 pandemic.Materials and methodsAn electronic survey was sent during April 2020 to an international sample of radiation oncologists. The survey explored various aspects of departmental preparedness, and changes to their institutional RT protocols.ResultsA total of 68 radiation oncologists from 13 countries answered the survey. Healthcare systems were at least moderately affected in 76%. Most institutes appeared well prepared for the outbreak: regarding the availability of personal protective equipment, tests, and telemedicine/videoconference facilities. Screening for SARS-CoV-2 was applied in 59% of responders. Modification of RT protocols were minor in 66%, significant in 19% and no changes made in 15%. The extent to which protocols were modified correlated with overall healthcare disruption (p = 0.028). Normal fractionation was recommended to continue in 83% and 85% of head & neck, and cervical cancers vs. 64% of lung cancers (p = 0.001).In case the pandemic worsens, there was strong agreement to prioritize RT for aggressive cancers (80%), delay RT for slow-growing tumors (78%) and change to evidance-based hypofractionations protocols (79.4%). The option of delayed/omitted adjuvant RT (not site specific) was selected in 47%.ConclusionThis international survey concludes that, by making significant organizational adjustments and minor protocol modifications, RT may be safely continued during this pandemic. If the crisis worsens, there was strong agreement to continue the treatment of aggressive tumors and utilize evidence-based hypofractionated protocols.     

Impact of hospital volume on mortality for brain metastases treated with radiation

BackgroundThe impact of hospital volume on cancer patient survival has been demonstrated in the surgical literature, but sparsely for patients receiving radiation therapy (RT). This analysis addresses the impact of hospital volume on patients receiving RT for the most common central nervous system tumor: brain metastases.Materials and methodsAnalysis was conducted using the National Cancer Database (NCDB) from 2010–2015 for patients with metastatic brain disease from lung cancer, breast cancer, and colorectal cancer requiring RT. Hospital volume was stratified as high-volume (≥ 12 brain RT/year), moderate (5–11 RT/year), and low (< 5 RT/year). The effect of hospital volume on overall survival was assessed using a multivariable Cox regression model.ResultsA total of 18,841 patients [9479 (50.3%) men, 9362 (49.7%) women; median age 64 years] met the inclusion criteria. 16.7% were treated at high-volume hospitals, 36.5% at moderate-volume, and the remaining 46.8% at low-volume centers. Multivariable analysis revealed that mortality was significantly improved in high-volume centers (HR: 0.95, p = 0.039) compared with low-volume centers after accounting for multiple demographics including age, sex, race, insurance status, income, facility type, Charlson-Deyo score and receipt of palliative care.ConclusionHospitals performing 12 or more brain RT procedures per year have significantly improved survival in brain metastases patients receiving radiation as compared to lower volume hospitals. This finding, independent of additional demographics, indicates that the increased experience associated with increased volume may improve survival in this patient population.     

Transitioning from conformal radiotherapy to intensity-modulated radiotherapy after radical prostatectomy: Clinical benefit,oncologic outcomes and incidence of gastrointestinal and urinary toxicities

AimThe purpose of this study was to review genitourinary (GU) and gastrointestinal (GI) toxicity associated with high-dose radiotherapy (RT) delivered with 3-dimensional conformal radiotherapy (3D-CRT) and intensity-modulated radiotherapy (IMRT) or volumetric arc therapy (VMAT) following radical prostatectomy (RP).BackgroundRP is a therapeutic option for the management of prostate cancer (PrCa). When assessing postoperative RT techniques for PrCa, the published literature focuses on patients treated with 2-dimensional conventional methods without reflecting the implementation of 3D-CRT, IMRT, or VMAT.Materials and methodsA total of 83 patients were included in this analysis; 30 patients received 3D-CRT, and 53 patients received IMRT/VMAT. Acute and late symptoms of the GU and lower GI tract were retrospectively graded according to the Radiation Therapy Oncology Group and the European Organization for Research and Treatment of Cancer radiation toxicity grading systems. The relapse failure-free rate and overall survival were also evaluated.ResultsThe rate of acute GU toxicity was 9.4% vs. 13.3% for the IMRT/VMAT and 3D-CRT groups (p = 0.583). The 5-year actuarial rates of late GI toxicity for IMRT/VMAT and 3D-CRT treatments were 1.9% and 6.7%, respectively. The rate of late GU toxicity for the IMRT/VMAT and 3D-CRT treatment groups was 7.5% and 16.6%, respectively (p = 0.199). We found no association between acute or late toxicity and the RT technique in univariate and multivariate analyses.ConclusionPostprostatectomy IMRT/VMAT and 3D-CRT achieved similar morbidity and cancer control outcomes. The clinical benefit of highly conformal techniques in this setting is unclear although formal analysis is needed.     

Evidence based radiation oncology with existing technology

Aim

To assess the real contribution of modern radiation therapy (RT) technology in the more common tumoral types in Central America, Caribbean and South America.

Background

RT is an essential tool in the management of cancer. RT can be either palliative or of curative intent. In general, for palliative radiotherapy, major technologies are not needed.

Materials and methods

We analyzed the contribution of RT technology based on published evidence for breast, lung, gastric, gallbladder, colorectal, prostate and cervix cancer in terms of disease control, survival or toxicity with especial focus on Latin America.

Results

Findings indicate that three dimensional conformal radiation therapy (3D RT) is the gold standard in most common type of cancer in the studied regions. Prostate cancer is probably the pathology that has more benefits when using new RT technology such as intensity modulated radiation therapy (IMRT) versus 3DRT in terms of toxicity and biochemical progression-free survival.

Conclusions

In light of the changes in technology, the ever-increasing access of developing countries to such technology, and its current coverage in Latin America, any efforts in this area should be aimed at improving the quality of the radiotherapy departments and centers that are already in place.     

Short term clinical outcomes of accelerated hypofractionated radiotherapy in inoperable non-small cell lung cancer patients

BackgroundThis study aimed to evaluate short term clinical outcomes of accelerated hypofractionated radiotherapy (AHR T) regarding locoregional response (LRR), symptoms relief and acute toxicities in non-small cell lung cancer (NSCLC) patients. The radical treatment for inoperable NSCLC is intolerable for some patients. An alternative RT regime should be considered for them.Materials and methodsInoperable NSCLC patients who could not tolerate radical treatment were treated with AHRT (45 Gy in 15 fractions over three weeks) by using the 3-dimensional conformal (RT) technique. The LRR was assessed by chest computed tomography (CT) performed before and 6 weeks after RT. Relief of symptoms such as cough, dyspnoea and chest pain was evaluated during RT and 6 and 12 weeks after RT, compared with the status before RT. Treatment-related acute toxicities such as dysphagia and radiation dermatitis were observed during and 6 and 12 weeks after RT.ResultsTotal 65 patients (seven patients of stage II and fifty-eight patients of stage III) were included. Partial response was seen in 70.8% of patients, and stable disease was seen in 29.2% while there was neither complete response nor progressive disease after RT. Statistically significant associations were found between tumour response vs. pre-treatment tumour size and tumour response vs. performance status of the patients. Satisfactory symptom relief was found after RT, but severe acute dysphagia and radiation dermatitis (more than grade 3) were not observed.ConclusionSatisfactory LRR, symptom relief and acute toxicities were achieved by this regime. Long term studies are recommended to evaluate late toxicities and survival outcome further.Trial registration noTCTR20200110001     

Local failure after primary radiotherapy in lung cancer: Is there a role for SBRT?

AimOur purpose is to construe the role of stereotactic body radiation therapy (SBRT) in the management of lung cancer from our early experience with SBRT for salvage treatment in patients with recurrent lung cancer after initial radiation therapy.BackgroundLocoregional recurrences are a frequent challenge in patients treated with radio-chemotherapy for locally advanced NSCLC. Conventional external beam radiation therapy (EBRT) is rarely given as salvage treatment because of the risk of toxicity. There is a paucity of published studies evaluating the role of SBRT in this clinical setting.Materials and methodsBetween 2008 and present, 10 patients with biopsy proven non-small cell lung cancer (NSCLC) underwent 14 radiosurgical procedures for salvage therapy after failing initial radiation treatment. Patients’ age ranged from 54 to 88 years with a median of 74 years in 6 males and 4 females. Intervals from initial radiation treatment to salvage SBRT were 3–33 months with a median of 13 months. SBRT treatments were delivered using Intensity Modulated Volumetric Arc Therapy (VMAT). All patients received concomitant chemotherapy.ResultsOverall survival after salvage radiosurgery ranged from 6 to 41 months (mean 20 months, median 18 months). Four of the ten patients are alive with disease locally controlled. Of the remaining 6 patients, 4 had distant progression of disease with brain metastases and one had both brain and lung metastases. The other patient had a regional failure. Toxicities were found in three of the ten (30%) patients with grade I pneumonitis.ConclusionIn our early experience, salvage SBRT is an effective modality of treating patients who failed after conventional irradiation, achieving excellent results in terms of local control with acceptable toxicity. Further prospective studies are needed to determine optimal fractionation schemes.     

Normal lung tissue complication probability in MR-Linac and conventional radiotherapy

PurposeTo study normal lung tissue (NLT) complications in magnetic resonance (MR) image based linac and conventional radiotherapy (RT) techniques.Materials and MethodsThe Geant4 toolkit was used to simulate a 6 MV photon beam. A homogenous magnetic field of 1.5 Tesla (T) was applied in both perpendicular and parallel directions relative to the radiation beam.Analysis of the NLT complications was assessed according to the normal lung tissue complication probability (NTCP), the mean lung dose (MLD), and percentage of the lung volume receiving doses greater than 20 Gy (V₂₀), using a sample set of CT images generated from a commercially available 4D-XCAT digital phantom.ResultsThe results show that the MLD and V₂₀ were lower for MR-linac RT. The largest reduction of MLD and V₂₀ for MR-linac RT configurations were 5 Gy and 29.3%, respectively.ConclusionMR-linac RT may result in lower NLT complications when compared to conventional RT.     

非小细胞肺癌脑转移瘤综合治疗的预后影响因素分析

目的:研究综合治疗的非小细胞肺癌(non-small cell lung cancer,NSCLC)脑转移瘤患者生存预后影响因素,为NSCLC脑转移瘤的治疗提供更多的参考依据。方法:收集83例诊断为NSCLC脑转移瘤的患者进行回顾性研究,随访后建立临床资料数据库,采用单因素分析及Cox回归模型分析不同因素对非小细胞肺癌脑转移瘤患者生存期的影响。结果:患者中位生存期为11个月,6月、12月、18月的生存率分别为79.0%、32.7%、19.4%。经单因素和多因素分析结果显示脑转移瘤的病理类型、原发灶控制情况、治疗方式、靶向治疗是NSCLC脑转移生存的独立影响预后因素。单发转移瘤中,手术联合全脑放疗(Whole brain radiotherapy,WBRT)与手术相比风险率(hazard rate,HR)为0.645(P>0.05),说明联合方式并没有在生存中获益。多发转移瘤中,手术与WBRT相结合与单纯手术对比HR=0.297(P<0.05),有统计学意义。结论:病理类型为非腺癌,原发灶未得到控制,治疗方式不当以及未应用靶向治疗是NSCLC脑转移瘤的独立危险因素。对于单发脑转移瘤患者的局部治疗,单独手术治疗可能具有更高的优势;对于多发脑转移瘤患者的局部治疗,手术与WBRT联合可能具有更多的生存获益。     

A strategy for young members within national radiation oncology societies: the Italian experience (AIRO Giovani group)

AimTo briefly review history, structure, past events and future projects of AIRO (Associazione Italiana Radioterapia Oncologica) young group (AIRO Giovani), focusing on its specific commitment to multidisciplnary networking among junior clinical oncologists at a national and international level.BackgroundAIRO Giovani is a part of AIRO composed by members under 40 years old. Its main activities are scientific and educational meetings dedicated to young Italian radiation oncologists and collaborative research projects.Materials and MethodsAIRO Giovani structure, events organized and supported by AIRO giovani as well as scientific activities are here reported from its creation in 2007 up to current days.ResultsAIRO Giovani group was able to create a consolidated network between Italian junior radiation oncologists, while opening the possibility to collaborate with junior groups of other national scientific societies in the field of oncology and with ESTRO young members. Scientific projects carried out by the group have been successful and will be further implemented in next years.ConclusionsAIRO Giovani is still in its infancy, but its early positive experience supports the creation and development of young groups within national radiation oncology societies.