Re-irradiation after stereotactic body radiotherapy for spine metastases from hepatocellular carcinoma: a case report

Modern radiotherapy machines with refinements in planning software and image-guidance apparatuses have made stereotactic body radiotherapy (SBRT) more widely available as an effective tool in the management of spine metastases. In conventional palliative radiotherapy, the aim has traditionally been pain relief and short-term local control. In contrast, SBRT aims to deliver an ablative dose to enhance local control, with a smaller number of fractions while sparing the organs at risk (OAR), especially the spinal cord. Recently, trials have asserted the role of spine SBRT as an effective modality for durable local control, in addition to achieving pain relief. The quality of evidence for spine SBRT data is maturing, while prospective published trials on re-irradiation SBRT in spine remain sparse. The purpose of the present case report is to share the challenges faced while salvaging a dorsal spine metastasis and ablating a new right adrenal metastatic lesion in proximity of the transplanted liver.     

The impact of respiratory gating on lung dosimetry in stereotactic body radiotherapy for lung cancer

The purpose of this study was to evaluate the impacts of respiratory gating and different gating windows (GWs) on lung dosimetry in stereotactic body radiotherapy (SBRT) for lung cancer.Gated SBRT plans were developed using the four-dimensional computed tomography data from 17 lung cancer patients treated with SBRT. Using amplitude-based end-exhalation gating, we established 2 fixed GWs with approximate duty cycles of 50% (50% GW) and 25% (25% GW), respectively, for this study.For highly mobile tumors (3D mobility > 10 mm), additional benefits in lung-dose reductions were achieved with the 25% GW, as a result of inadequate mobility and planning target volume reductions obtained with the 50% GW. In these tumors, the absolute differences compared to the non-gated and 50% gated plans, were 0.5 Gy and 0.33 Gy for the mean lung dose and 1.11% and 0.71% for the V20, respectively. Dosimetric benefits were achieved with the 50% GW, compared with the non-gated plan, for tumors with both low mobility and small volume (gross tumor volume ≤ 10 cc). Among the identified predictive factors of dosimetric benefits, the lateral distance from midspinal canal and the motion range in anterior–posterior direction might be stronger factors because of their correlations with many of the lung-dose parameters and greater predictive capacity.The results of the present study might facilitate the selection of appropriate patients and the optimal GW according to the tumor characteristics for gated lung SBRT.     

Definitive single fraction stereotactic ablative radiotherapy for inoperable early-stage breast cancer: A case report

We review a case of inoperable early stage breast cancer treated definitively with the use of stereotactic ablative radiotherapy (SABR). A 57-year-old female with a history of decompensated cirrhosis with early stage breast cancer was treated with 25 Gy in one fraction. At her 7-month follow up visit, there was a complete resolution of disease on imaging. This case represents a novel approach for the treatment of breast cancer with SABR when surgery is contraindicated.     

Cell-free DNA as a prognostic marker in stage I non-small-cell lung cancer patients undergoing stereotactic body radiotherapy

Abstract

Objective: To evaluate whether plasma cell-free DNA (cfDNA) was related to clinical outcome in inoperable stage I non-small cell lung cancer (NSCLC) patients undergoing stereotactic body radiotherapy (SBRT).

Materials and methods: Plasma cfDNA was assessed at baseline, before the last day and 45 days after the end of SBRT, in 22 NSCLC patients. Twenty-two healthy controls were also evaluated.

Results: Plasma cfDNA was higher in patients than in controls. An association with unfavourable disease-free survival was found for continuous baseline cfDNA increments (HR?=?5.9, 95%CI: 1.7–19.8, p?=?0.04).

Conclusion: Plasma cfDNA may be a promising prognostic biomarker in high-risk NSCLC patients.     

Setup accuracy and dose attenuation of a wooden immobilization system for lung stereotactic body radiotherapy

BackgroundWe evaluated the setup error and dose absorption of an immobilization system with a shell and wooden baseplate (SW) for lung stereotactic body radiotherapy (SBRT).Materials and methodsSetup errors in 109 patients immobilized with an SW or BodyFix system (BF) were compared. Dose attenuation rates of materials for baseplates were measured with an ion-chamber. Ionization measurements were performed from 90° to 180° gantry angle in 10° increments, with the ball water equivalent phantom placed at the center of the wood and carbon baseplates whose effects on dose distribution were compared using an electron portal imaging device.ResultsThe ratio for the anterior-posterior, cranial-caudal, and right-left of the cases within 3-mm registered shifts in interfractional setup error were 90.9%, 89.2%, and 97.4% for the SW, and 93.2%, 91.6%, and 98.0% for the BF, respectively. For intrafractional setup error, 98.3%, 97.4%, and 99.1% for the SW and 96.6%, 95.8%, and 98.7% for the BF were within 3-mm registered shifts, respectively. In the center position, the average (minimum/maximum) dose attenuation rates from 90° to 180° for the wooden and carbon baseplates were 0.5 (0.1/2.8)% and 1.0 (–0.1/10.1)% with 6 MV, respectively. The gamma passing rates of 2%/2 mm for the wooden and carbon baseplates were 99.7% and 98.3% (p < 0.01).ConclusionsThe immobilization system with an SW is effective for lung SBRT since it is comparable to the BF in setup accuracy. Moreover, the wooden baseplate had lower radiation attenuation rates and affected the dose distribution less than the carbon baseplate.     

Interfractional diaphragm changes during breath-holding in stereotactic body radiotherapy for liver cancer

Aim and background

IGRT based on bone matching may produce a large target positioning error in terms of the reproducibility of expiration breath-holding on SBRT for liver cancer. We evaluated the intrafractional and interfractional errors using the diaphragm position at the end of expiration by utilising Abches and analysed the factor of the interfractional error.

Prognostic factors and clinical outcomes after stereotactic radiotherapy for primary lung tumors

AimTo characterize the population treated with SBRT for early-stage primary lung tumors in our institution, determine their outcomes, and identify potential prognosis factors.BackgroundStereotactic radiotherapy (SBRT) is an alternative treatment for inoperable patients with early-stage lung cancer. It confers a local control rate around 90% at 3 years, and 2−3 year overall survival rates of 43–60% in this population.Materials and methodsWe retrospectively analyzed all patients treated in our department between 2012 and 2017 and evaluated local progression-free survival (L-PFS), nodal or distant progression-free survival (ND-PFS), global progression-free survival (G-PFS), overall survival (OS), and disease specific survival (DSS). Univariate (UVA) and multivariate (MVA) models were built to assess the influence of each variable.ResultsWe identified 218 patients with 233 tumors. Most were male (78.9%) with a median age of 73 years. Median follow-up was 22 months. At 18 months, L-PFS was 93.7%, ND-PFS was 82.2%, G-PFS was 76.0%, DSS was 90.5%, and OS was 78.0% in ≤ T2 tumors. On UVA, T2 tumors were associated with lower L-PFS, G-PFS and DSS than T1, with no significant impact on ND-PFS or OS, an effect that persisted on MVA. On UVA, L-PFS and G-PFS were negatively influenced by female gender and a 5-fraction schedule was associated with worse G-PFS, which was not confirmed on MVA.ConclusionOur local and distant control rates and survival were similar to those previously reported. On MVA, T2 tumors displayed lower L-PFS, G-PFS and DSS, with no difference in OS.     

Effects of reconstruction methods on dose distribution for lung stereotactic body radiotherapy treatment plans

Radiation and Environmental Biophysics - The aim of the present study was to investigate the effect of tumour motion on various imaging strategies as well as on treatment plan accuracy for lung...     

Evaluation of the target dose coverage of stereotactic body radiotherapy for lung cancer using helical tomotherapy: A dynamic phantom study

AimTo evaluate the target dose coverage for lung stereotactic body radiotherapy (SBRT) using helical tomotherapy (HT) with the internal tumor volume (ITV) margin settings adjusted according to the degree of tumor motion.BackgroundLung SBRT with HT may cause a dosimetric error when the target motion is large.Materials and methodsTwo lung SBRT plans were created using a tomotherapy planning station. Using these original plans, five plans with different ITV margins (4.0–20.0 mm for superior-inferior [SI] dimension) were generated. To evaluate the effects of respiratory motion on HT, an original dynamic motion phantom was developed. The respiratory wave of a healthy volunteer was used for dynamic motion as the typical tumor respiratory motion. Five patterns of motion amplitude that corresponded to five ITV margin sizes and three breathing cycles of 7, 14, and 28 breaths per minute were used. We evaluated the target dose change between a static delivery and a dynamic delivery with each motion pattern.ResultsThe target dose difference increased as the tumor size decreased and as the tumor motion increased. Although a target dose difference of <5 % was observed at ≤10 mm of tumor motion for each condition, a maximum difference of -9.94 % ± 7.10 % was observed in cases of small tumors with 20 mm of tumor motion under slow respiration.ConclusionsMinimizing respiratory movement is recommended as much as possible for lung SBRT with HT, especially for cases involving small tumors.     

Survival outcome after stereotactic body radiotherapy for locally advanced and borderline resectable pancreatic cancer: A systematic review and meta-analysis

BackgroundSome studies reported stereotactic body radiotherapy (SBRT) has demonstrated superior therapeutic results than conventional radiotherapy. Nevertheless, this statement is controversial and the trial attempting to prove this is underway. We conducted this systemic review and meta-analysis aiming to combine the latest and most complete information about the survival outcomes and toxicities following SBRT for locally advanced pancreatic cancer (LAPC) and borderline resectable pancreatic cancer (BRPC).MethodsItems involving SBRT and pancreatic cancer were searched in PubMed, EMBASE, Cochrane Library, SCOPUS and Web of Science. Median overall survival (OS), 1/2/3-year OS, median progression-free survival (PFS), 1/2/3-year PFS and incidence of grade 3–5 toxicities were the endpoints of interest in this meta-analysis. These endpoint proportions were pooled and analyzed using R.ResultsFor the LAPC series, the median OS was 14.1 months; pooled 1/2/3-year OS rates were 57%, 19% and 10%, respectively; the median PFS was 10 months; pooled 1/2/3-year PFS rates were 36%, 12% and 4%; pooled incidence rates of acute gastrointestinal (GI), acute hematologic and late GI toxicity (grade≥3) were 2%, 4% and 8%. For the BRPC series, the median OS was 17.5 months; pooled 1/2-year OS rates were 75% and 29%; the median PFS was 12.2 months; pooled 1/2-year PFS rates were 48% and 18%; the incidence rates of toxicity (grade ≥ 3) were all 0%.ConclusionsOur meta-analysis based on published results of OS, PFS and incidence rates of toxicity demonstrated that SBRT does not show desirable therapeutic result than the standard therapies for LAPC and BRPC.     

Patient-specific tumor and respiratory monitoring phantom design for quality controls of stereotactic ablative body radiotherapy in lung cancer cases

The design, production and adaptability to clinical routine of a patient-specific tumor and respiratory monitoring phantom (TRMP) was investigated using 3D printer technology. TRMP and GTV modelling were done using 4D-CT images of the inhalation phase. The model was converted to STL (Stereolithography) format and printed with STH (Strong Herbal) biopolymer with HU (Hounsfield Unit) suitable for imaging purposes. The assembly of TRMP motorized parts and mechanical equipment has been completed and made suitable for clinical use. In the first part of the study, the deviations of radio-opaque markers attached to the TRMP sternum to perform mechanical quality control tests and T1-7 costal vertebrae in CC, AP, and LAT directions were evaluated. In the second part of the study, in order to evaluate the usability of the TRMP in quality assurance (QA), point dose measurements with BeO OSL dosimetry and EBT3 gafchromic film measurements were taken in Trilogy® radiotherapy accelerator and CyberKnife® robotic radiosurgery accelerator. In this study, we present a highly flexible TMRP capable of performing independent internal and external motions. TRMP was successfully tested in different treatment accelerators, both mechanically and dosimetrically.     

Pregnancy,delivery, and breastfeeding after total gastrectomy for gastric cancer: a case report

Background

The reports of pregnancy after total gastrectomy for gastric cancer are rare.

Case presentation

We report a case of a 35-year-old woman, gravida 0, para 0, who became pregnant and delivered a baby 2?years and 6?months after laparoscopic-assisted total gastrectomy for early gastric cancer. Postoperatively, she showed a good progress during the follow-up and was continuously taking oral iron supplement and administered with methylcobalamin intramuscular injection. Two years after gastrectomy, she became pregnant. During the pregnancy, she kept taking iron and vitamin B₁₂ supplementation and had a good course of pregnancy and a normal delivery. However, 2?months after the delivery, liver dysfunction was detected via blood examination. The patient switched from exclusive breastfeeding to combined feeding with formula, and her laboratory results returned to normal. During 10?years of follow-up after the delivery, the patient was in good condition without any recurrence and nutritional deficiencies, and her child had thrived.

Conclusions

Careful monitoring and management of iron and vitamin deficiencies are essential during pregnancy and the lactation periods for patients who previously underwent total gastrectomy. During the lactation period, a combination of formula and breastfeeding provides maternal and fetal nutritional support.

     

EPID-based in vivo dosimetry for stereotactic body radiotherapy of non-small cell lung tumors: Initial clinical experience

PurposeEPID-based in vivo dosimetry (IVD) has been implemented for stereotactic body radiotherapy treatments of non-small cell lung cancer to check both isocenter dose and the treatment reproducibility comparing EPID portal images.Methods15 patients with lung tumors of small dimensions and treated with volumetric modulated arc therapy were enrolled for this initial experience. IVD tests supplied ratios R between in vivo reconstructed and planned isocenter doses. Moreover a γ-like analysis between daily EPID portal images and a reference one, in terms of percentage of points with γ-value smaller than 1, P_γ<1, and mean γ-values, γ_mean, using a local 3%–3 mm criteria, was adopted to check the treatment reproducibility. Tolerance levels of 5% for R ratio, P_γ<1 higher than 90% and γ_mean lower than 0.67 were adopted.ResultsA total of 160 EPID images, two images for each therapy session, were acquired during the treatment of the 15 patients. The overall mean of the R ratios was equal to 1.005 ± 0.014 (1 SD), with 96.9% of tests within ± 5%. The 2 D image γ-like analysis showed an overall γ_mean of 0.39 ± 0.12 with 96.1% of tests within the tolerance level, and an average P_γ<1 value equal to 96.4 ± 3.6% with 95.4% of tests with P_γ<1 > 90%. Paradigmatic discrepancies were observed in three patients: a set-up error and a patient morphological change were identified thanks to CBCT image analysis whereas the third discrepancy was not fully justified.ConclusionsThis procedure can provide improved patient safety as well as a first step to integrate IVD and CBCT dose recalculation.     

Dosimetric selection for helical tomotherapy based stereotactic ablative radiotherapy for early-stage non-small cell lung cancer or lung metastases

Background

No selection criteria for helical tomotherapy (HT) based stereotactic ablative radiotherapy (SABR) to treat early stage non-small cell lung cancer (NSCLC) or solitary lung metastases has been established. In this study, we investigate the dosimetric selection criteria for HT based SABR delivering 70 Gy in 10 fractions to avoid severe toxicity in the treatment of centrally located lesions when adequate target dose coverage is desired.

Materials and Methods

78 HT-SABR plans for solitary lung lesions were created to prescribe 70 Gy in 10 fractions to the planning target volume (PTV). The PTV was set to have ≥95% PTV receiving 70 Gy in each case. The cases for which dose constraints for ≥1 OAR could not be met without compromising the target dose coverage were compared with cases for which all target and OAR dose constraints were met.

Results

There were 23 central lesions for which OAR dose constraints could not be met without compromising PTV dose coverage. Comparing to cases for which optimal HT-based SABR plans were generated, they were associated with larger tumor size (5.72±1.96 cm vs. 3.74±1.49 cm, p<0.0001), higher lung dose, increased number of immediately adjacent OARs ( 3.45±1.34 vs. 1.66±0.81, p<0.0001), and shorter distance to the closest OARs (GTV: 0.26±0.22 cm vs. 0.88±0.54 cm, p<0.0001; PTV 0.19±0.18 cm vs. 0.48±0.36 cm, p = 0.0001).

Conclusion

Delivery of 70 Gy in 10 fractions with HT to meet all the given OAR and PTV dose constraints are most likely when the following parameters are met: lung lesions ≤3.78 cm (11.98 cc), ≤2 immediately adjacent OARs which are ≥0.45 cm from the gross lesion and ≥0.21 cm from the PTV.     

Appropriate endpoints for stereotactic body radiotherapy for bone metastasis: Classification into five treatment groups

Treatment of bone metastasis using stereotactic body radiotherapy (SBRT) is being widely used in clinical practice. The reported clinical advantages of SBRT include high pain and local control rates, high response rates against bone metastasis from radio-resistant tumors, and safe re-irradiations. Although most reports in the literature use local control as the primary treatment endpoint, this endpoint is not appropriate because local control does not relate directly to patient benefit. Herein, we proposed five pathophysiology-based patient groups, as well as appropriate endpoints for each group.     

Prune perineum syndrome: report of a second case

A child is reported with a constellation of anomalies which include acetabular dysplasia with bilateral dislocated hips, persistent cloaca, hypoplastic kidney, two umbilical vessels, anal atresia and no obvious external genitalia. These anomalies are strikingly similar to a case reported by Peeden et al ('79) which was referred to as prune perineum. A discussion on possible underlying cause(s) of caudal dysplasia is included.     

Urethral foreign body management: a case report

The management of urethral foreign bodies may require the use of various surgical techniques in a urologist's armamentarium. We report a unique case of a urethral foreign body requiring percutaneous and endoscopic techniques for removal.     

Normal tissue complication probability models for severe acute radiological lung injury after radiotherapy for lung cancer

PurposeTo derive Normal Tissue Complication Probability (NTCP) models for severe patterns of early radiological radiation-induced lung injury (RRLI) in patients treated with radiotherapy (RT) for lung tumors. Second, derive threshold doses and optimal doses for prediction of RRLI to be used in differential diagnosis of tumor recurrence from RRLI during follow-up.Methods and materialsLyman-EUD (LEUD), Logit-EUD (LogEUD), relative seriality (RS) and critical volume (CV) NTCP models, with DVH corrected for fraction size, were used to model the presence of severe early RRLI in follow-up CTs. The models parameters, including α/β, were determined by fitting data from forty-five patients treated with IMRT for lung cancer. Models were assessed using Akaike information criterion (AIC) and area under receiver operating characteristic curve (AUC). Threshold doses for risk of RRLI and doses corresponding to the optimal point of the receiver operating characteristic (ROC) curve were determined.ResultsThe α/βs obtained with different models were 2.7–3.2 Gy. The thresholds and optimal doses curves were EUDs of 3.2–7.8 Gy and 15.2–18.1 Gy with LEUD, LogEUD and RS models, and μ_d of 0.013 and 0.071 with the CV model. NTCP models had AUCs significantly higher than 0.5. Occurrence and severity of RRLI were correlated with patients’ values of EUD and μ_d.ConclusionsThe models and dose levels derived can be used in differential diagnosis of tumor recurrence from RRLI in patients treated with RT. Cross validation is needed to prove prediction performance of the model outside the dataset from which it was derived.