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Clinical Oncology (Royal College of... Jan 2023To retrospectively analyse the long-term results of hypofractionated stereotactic radiation therapy (HSRT) applied in five fractions for vestibular schwannomas.
AIM
To retrospectively analyse the long-term results of hypofractionated stereotactic radiation therapy (HSRT) applied in five fractions for vestibular schwannomas.
MATERIALS AND METHODS
One hundred and thirty-four patients with vestibular schwannomas underwent medical treatment of HSRT. The median follow-up time interval was 54 months (range 6-121 months). All patients had a prescribed dose of 22 Gy in five fractions to D90. Restaging was carried out by thin-slice contrast-enhanced T1 magnetic resonance imaging. Progression was defined as 2 mm post-treatment tumour enlargement. Progression or death for any reason was counted as an event in progression-free survival rates. Acute toxicity was defined as adverse events occurring within 3 months of HSRT; long-term toxicity was defined as such events occurring after 3 months.
RESULTS
In 74/128 patients who had >6 months of follow-up (54%), the HSRT resulted in a partial or a complete response. The mean time interval for response in 50% of these was 4 years, whereas in 49 patients (38%) vestibular schwannomas failed to show any response, resulting in stable disease. Five of 128 patients (4%) showed marked progressive vestibular schwannomas after treatment in the first 3 years; two of them received conventionally fractionated radiation therapy. Local control at 3, 5 and 7 years was 96%, 95% and 94%, respectively. Seven were lost to follow-up. The median planning target volume was 2.1 ml (range 0.78-8.66). The 3- and 5-year progression-free survival rates were 95% and 94%, respectively. Seven patients reported a marked deterioration in hearing ability. Post-radiation therapy magnetic resonance imaging showed variability in oedema collection, but no patient suffered from radio-necrosis. Grade 2 temporary facial nerve disorders were observed in 10 patients (8%) 3-6 months after HSRT.
CONCLUSION
Delivering HSRT in five fractions for vestibular schwannoma appears safe and efficient, combining both efficiency and short treatment time while optimising neurological function preservation.
Topics: Humans; Neuroma, Acoustic; Radiosurgery; Retrospective Studies; Dose Fractionation, Radiation; Radiation Dose Hypofractionation; Treatment Outcome; Follow-Up Studies
PubMed: 36335041
DOI: 10.1016/j.clon.2022.10.014 -
European Journal of Medical Research Feb 2023Vascular surgery of the inguinal area can be complicated by persistent lymphatic fistulas. Rapid and effective treatment is essential to prevent infection, sepsis,...
BACKGROUND
Vascular surgery of the inguinal area can be complicated by persistent lymphatic fistulas. Rapid and effective treatment is essential to prevent infection, sepsis, bleeding, and possible leg amputation. Current data on irradiation of lymphatic fistulas lack recommendation on the appropriate individual and total dose, the time of irradiation, and the target volume. Presumably, a dose of 0.3-0.5 to 1-12 Gy should be sufficient for the purpose. Currently, radiotherapy is a "can" recommendation, with a level 4 low evidence and a grade C recommendation, according to the DEGRO S2 guidelines. As part of a pilot study, we analyzed the impact and limitations of low-dose radiation therapy in the treatment of inguinal lymphatic fistulas.
PATIENTS AND METHODS
As a part of an internal quality control project, patients with lymphatic fistulas irradiated in the groin area after vascular surgery for arterial occlusive disease (AOD) III-IV, repair of pseudo aneurysm or lymph node dissection due to melanoma were selected, and an exploratory analysis on retrospectively collected data performed.
RESULTS
Twelve patients (10 males and 2 females) aged 62.83 ± 12.14 years underwent open vascular reconstruction for stage II (n = 2), III (n = 1), and IV (n = 7) arterial occlusive disease (AOD), lymph node dissection for melanoma (n = 1) or repair of a pseudoaneurysm (n = 1). Surgical vascular access was obtained through the groin and was associated with a persistent lymphatic fistula, secreting more than 50 ml/day. Patients were irradiated five times a week up to a maximum of 10 fractions for the duration of the radiation period. Fraction of 0.4 Gy was applied in the first 7 cases, while 5 patients were treated with a de-escalating dose of 0.3 Gy. There was a resolution of the lymphatic fistula in every patient without higher grade complications.
CONCLUSION
Low-dose irradiation of the groin is a treatment option for persistent lymphatic fistula after inguinal vascular surgery.
Topics: Male; Female; Humans; Groin; Retrospective Studies; Pilot Projects; Lymphatic Diseases; Vascular Surgical Procedures; Fistula; Melanoma; Dose Fractionation, Radiation; Lymph Node Excision
PubMed: 36755343
DOI: 10.1186/s40001-023-01033-6 -
Neuro-oncology Apr 2017Stereotactic radiosurgery (SRS), typically administered in a single session, is widely employed to safely, efficiently, and effectively treat small intracranial lesions....
Stereotactic radiosurgery (SRS), typically administered in a single session, is widely employed to safely, efficiently, and effectively treat small intracranial lesions. However, for large lesions or those in close proximity to critical structures, it can be difficult to obtain an acceptable balance of tumor control while avoiding damage to normal tissue when single-fraction SRS is utilized. Treating a lesion in 2 to 5 fractions of SRS (termed "hypofractionated SRS" [HF-SRS]) potentially provides the ability to treat a lesion with a total dose of radiation that provides both adequate tumor control and acceptable toxicity. Indeed, studies of HF-SRS in large brain metastases, vestibular schwannomas, meningiomas, and gliomas suggest that a superior balance of tumor control and toxicity is observed compared with single-fraction SRS. Nonetheless, a great deal of effort remains to understand radiobiologic mechanisms for HF-SRS driving the dose-volume response relationship for tumors and normal tissues and to utilize this fundamental knowledge and the results of clinic studies to optimize HF-SRS. In particular, the application of HF-SRS in the setting of immunomodulatory cancer therapies offers special challenges and opportunities.
Topics: Brain Neoplasms; Clinical Trials as Topic; Dose Fractionation, Radiation; Glioblastoma; Humans; Meningeal Neoplasms; Meningioma; Neuroma, Acoustic; Radiation Dose Hypofractionation; Radiosurgery; Treatment Outcome
PubMed: 28380634
DOI: 10.1093/neuonc/now301 -
Cancer Medicine Aug 2019We report our experience of intensity-modulated proton and carbon-ion radiotherapy (IMPT/IMCT) for head and neck sarcomas (HNS).
PURPOSE
We report our experience of intensity-modulated proton and carbon-ion radiotherapy (IMPT/IMCT) for head and neck sarcomas (HNS).
METHODS AND MATERIALS
An analysis of the ongoing prospective data registry from the Shanghai Proton and Heavy Ion Center (SPHIC) for patients with HNS was conducted. The 12- and 24-month rates of local recurrence-free, overall, distant metastasis-free, progression-free survival (LRFS, OS, DMFS, and PFS), and acute/late toxicities were calculated. The prognostic factors for the effectiveness of the treatment were also analyzed.
RESULTS
Between 7/2014 and 5/2018, 51 consecutive patients with HNS received definitive doses of IMCT (41 cases), IMPT (two cases), or their combination (eight cases). One patient had R0 resection and another treated on the Chinese Food and Drug Administration registration trial received IMPT only. Twenty-seven patients were treated according to various dose escalation trials or institutional protocols using IMCT or IMPT + IMCT boost. Twenty-two patients with locoregional recurrence (10 and four patients failed surgery or surgery followed by radiotherapy, respectively) or radiation-induced second primary sarcomas (eight patients) received salvage particle radiotherapy. With a median follow-up time of 15.7 months, four patients with second primary sarcoma died. The 1- and 2-year OS, PFS, LRFS, and DMFS rates for the entire cohort were 92.9% vs 90%, 73.6% vs 57.4%, 88.4% vs 78.9%, and 84.6% vs 76.5%, respectively. Those rates for patients without prior radiotherapy were 100% vs 100%, 82.1% vs 65.8%, 93.6% vs 85.3%, and 88.4% vs 79.5%, respectively. Multivariate analyses revealed that re-irradiation was an independent prognostic factor for both LRFS and PFS (P = 0.015 and 0.037, respectively). In addition, gross tumor volume (GTV) was an independent prognostic factor for PFS (P = 0.048). One patient experienced Grade 3 acute toxicity (oral mucositis); another experienced Grade 4 acute event (hemorrhage) which required embolization. He lately died from hemorrhage (Grade 5) at 3.4 months after the completion of treatment. No patient experienced radiation-induced acute/late toxicity of ≥ Grade 2 otherwise.
CONCLUSION
With few observed acute/late toxicities, IMPT/IMCT provided effective short-term tumor control in our patients with HNS. Further investigations, preferably in a prospective fashion, will be required to confirm the efficacy and toxicities of IMPT/IMCT in this group of patients.
Topics: Adolescent; Adult; Aged; Disease Progression; Dose Fractionation, Radiation; Female; Head and Neck Neoplasms; Heavy Ion Radiotherapy; Humans; Male; Middle Aged; Prospective Studies; Radiotherapy, Intensity-Modulated; Sarcoma; Survival Analysis; Treatment Outcome; Young Adult
PubMed: 31231939
DOI: 10.1002/cam4.2319 -
Annals of Plastic Surgery Jan 2014Perhaps the most vexing and exigent problem confronting head and neck cancer reconstruction is overcoming the impediments of collateral damage imposed by radiation...
OBJECTIVE
Perhaps the most vexing and exigent problem confronting head and neck cancer reconstruction is overcoming the impediments of collateral damage imposed by radiation therapy (XRT) on normal surrounding tissue. Radiation therapy is detrimental to bone and soft tissue repair resulting in an unacceptably high incidence of devastating wound healing complications as well as the associated morbidity of late pathologic fractures, reduced bone healing, and osteoradionecrosis. The consequences of XRT on bone vasculature, long known to be affected by radiation, have been poorly understood. The purpose of this study was to analyze the degree by which irradiation degrades existing bone vascularity using a powerful micro-computed tomography technique to attain highly precise quantitative metrics of the vascular tree.
METHODS
Fourteen 400-g male Sprague-Dawley rats underwent 35 Gy of fractionated XRT at 7 Gy/d. The animals were euthanized after 28 days, and the left ventricle was fixed and injected with Microfil (MV-122; Flow Tech, Carver, Mass) contrast. Left hemimandibles were dissected and scanned using high-resolution micro-computed tomography (18-μm voxels). The vessel number, thickness, separation, connectivity, and vessel volume fraction were analyzed for the region of interest, defined to be the volume behind the third molar spanning a total distance of 5.1 mm.
RESULTS
Stereologic analysis and subsequent analysis of variance test demonstrated a significant and quantifiable diminution in the irradiated vasculature when compared with control animals. The vessel volume fraction (0.016 vs 0.032, P ≤ 0.003) and vessel thickness (0.042 vs 0.067 mm, P ≤ 0.001) were markedly reduced. Interestingly, further analysis demonstrated no significant differences between vessel separation and vessel number.
CONCLUSIONS
The results of our study specifically quantify the corrosive affects of XRT on the vasculature of the mandible. The data from this novel technique go even further and imply retention of blood vessels but a degradation of their quality and size. Further experiments can now be directed at therapeutic interventions to reverse this process and better understand the underlying mechanism of XRT-induced bone injury.
Topics: Animals; Dose Fractionation, Radiation; Male; Mandible; Microvessels; Rats; Rats, Sprague-Dawley; X-Ray Microtomography
PubMed: 23314188
DOI: 10.1097/SAP.0b013e318255a57d -
Journal of Cancer Research and... 2021The assessment of volumetric and dosimetric changes in the head-and-neck cancer during fractionated radiotherapy by intensity-modulated radiotherapy (IMRT) technique. (Clinical Trial)
Clinical Trial
AIMS AND OBJECTIVE
The assessment of volumetric and dosimetric changes in the head-and-neck cancer during fractionated radiotherapy by intensity-modulated radiotherapy (IMRT) technique.
MATERIALS AND METHODS
A single-center prospective observational hospital-based study with a sample size of 20 cases of the head-and--neck squamous cell carcinoma over 1 year treated with chemoradiotherapy 66-70 Gy/33-35#@2 Gy/fraction with weekly cisplatin 35 mg/m. After contouring of target volumes (TVs) and organs at risk (OARs) in initial computed tomography (CT) scan, all patients were planned and treated by the IMRT technique. We re-delineated the TVs and OARs in the second (CT15#) and third (CT30#) planning CT scan, and the initial plan was implemented in the re-CT scan dataset with the same optimization and doses. The volumetric and dosimetric changes during fractionated radiotherapy of TVs and OARs were evaluated and compared. Nonparametric Wilcoxon-signed-rank test was used to compare the means between each plan.
RESULTS
For all 20 patients, plans were compared for volumetric and dosimetric parameters on repeat CT scans. The mean variation in gross tumor volume (GTV) and planning TV (PTV) was significant after 15 and 30 fractions of radiotherapy. On dosimetric evaluation, there was a significant increase in doses to GTV and OARs (parotid, spinal cord, and cochlea) with a significant P value. However, doses to the OARs were not exceeded the maximum tolerance limit.
CONCLUSION
This prospective single-center study concluded that two repeat imaging, along with re-planning improved TV coverage and decreased doses to the normal tissue. Larger studies with more sample sizes are required to set the criteria for replanning.
Topics: Aged; Antineoplastic Agents; Chemoradiotherapy; Cisplatin; Dose Fractionation, Radiation; Female; Head and Neck Neoplasms; Humans; Male; Middle Aged; Prospective Studies; Radiotherapy Dosage; Radiotherapy Planning, Computer-Assisted; Radiotherapy, Intensity-Modulated; Tomography, X-Ray Computed
PubMed: 33723161
DOI: 10.4103/jcrt.JCRT_350_20 -
Medical Physics Mar 2020To quickly and automatically propagate organ contours from pretreatment to fraction images in magnetic resonance (MR)-guided prostate external-beam radiotherapy.
PURPOSE
To quickly and automatically propagate organ contours from pretreatment to fraction images in magnetic resonance (MR)-guided prostate external-beam radiotherapy.
METHODS
Five prostate cancer patients underwent 20 fractions of image-guided external-beam radiotherapy on a 1.5 T MR-Linac system. For each patient, a pretreatment T2-weighted three-dimensional (3D) MR imaging (MRI) scan was used to delineate the clinical target volume (CTV) contours. The same scan was repeated during each fraction, with the CTV contour being manually adapted if necessary. A convolutional neural network (CNN) was trained for combined image registration and contour propagation. The network estimated the propagated contour and a deformation field between the two input images. The training set consisted of a synthetically generated ground truth of randomly deformed images and prostate segmentations. We performed a leave-one-out cross-validation on the five patients and propagated the prostate segmentations from the pretreatment to the fraction scans. Three variants of the CNN, aimed at investigating supervision based on optimizing segmentation overlap, optimizing the registration, and a combination of the two were compared to results of the open-source deformable registration software package Elastix.
RESULTS
The neural networks trained on segmentation overlap or the combined objective achieved significantly better Hausdorff distances between predicted and ground truth contours than Elastix, at the much faster registration speed of 0.5 s. The CNN variant trained to optimize both the prostate overlap and deformation field, and the variant trained to only maximize the prostate overlap, produced the best propagation results.
CONCLUSIONS
A CNN trained on maximizing prostate overlap and minimizing registration errors provides a fast and accurate method for deformable contour propagation for prostate MR-guided radiotherapy.
Topics: Dose Fractionation, Radiation; Humans; Image Processing, Computer-Assisted; Magnetic Resonance Imaging; Male; Neural Networks, Computer; Prostatic Neoplasms; Radiotherapy, Image-Guided; Time Factors
PubMed: 31876300
DOI: 10.1002/mp.13994 -
Current Oncology (Toronto, Ont.) May 2023Altered fractionation concepts and especially moderate hypo-fractionation are evaluated as alternatives to standard treatment for head and neck squamous cell carcinoma... (Review)
Review
Altered fractionation concepts and especially moderate hypo-fractionation are evaluated as alternatives to standard treatment for head and neck squamous cell carcinoma (HNSCC), associated with or not concurrent with or sequential to chemotherapy. The calculation of the iso-equivalent dose regimens has as its starting point the linear quadratic (LQ) formalism traditionally based on the "4Rs" of radiobiology. The higher rates of therapeutic failure after radiotherapy of HNSCC are associated with the heterogeneity of radio-sensibility. The identification of genetic signatures and radio-resistance scores aims to improve the therapeutic ratio of radiotherapy and to conceptualize personalized fractionation schemes. The new data regarding the involvement of the sixth "R" of radiobiology in HNSCC, especially for the HPV-driven subtype, but also for the "immune active" minority of HPV-negative HNSCCs, bring to the fore a multifactorial variation of the ratio. The involvement of the antitumor immune response and the dose/fractionation/volume factors as well as the therapeutic sequence in the case of new multimodal treatments including immune checkpoint inhibitors (ICIs) could be included as an additional term in the quadratic linear formalism especially for hypo-fractionation regimens. This term should take into account the dual immunomodulatory effect (immunosuppressant and stimulator of antitumor immunity) of radiotherapy, which varies from case to case and can bring benefit or a detrimental effect.
Topics: Humans; Squamous Cell Carcinoma of Head and Neck; Papillomavirus Infections; Dose Fractionation, Radiation; Head and Neck Neoplasms; Linear Models
PubMed: 37232820
DOI: 10.3390/curroncol30050362 -
Journal of Neurosurgery. Spine Apr 2018OBJECTIVE Spinal stereotactic body radiation therapy (SBRT) has emerged as an attractive method to deliver high doses of radiation to oligometastatic spinal tumors with...
OBJECTIVE Spinal stereotactic body radiation therapy (SBRT) has emerged as an attractive method to deliver high doses of radiation to oligometastatic spinal tumors with radioresistant histology. Because SBRT is a palliative therapy, attention to potential radiation toxicities is paramount when counseling patients. The objective of this study was to report radiation-induced myositis after SBRT, a previously undescribed complication. METHODS A total of 667 patients received 891 spine SBRT treatments (either 24 Gy in 1 fraction or 27 Gy in 3 fractions) from 2011 to 2016 and underwent retrospective review. Eleven patients were identified as having radiographic evidence of myositis following SBRT. Clinical and pathologic results were collected, including receipt of anti-vascular endothelial growth factor (VEGF) therapy, radiation dose, equivalent dose in 2-Gy fractions (EQD2), biologically effective dose (BED), and volume of muscle treated. Treatment toxicities were classified according to the Common Terminology Criteria for Adverse Events (CTCAE; version 4.03). Univariate statistical analyses were performed to evaluate the relationships between radiation fractionation schedule and myositis and between anti-VEGF therapy and myositis. RESULTS The cumulative incidence of myositis was 1.9% at 1 year. The median of the mean dose administered to muscle with myositis was 17.5 Gy. The median EQD2 was 55.1 Gy, and the median BED was 82.7 Gy. The median time to the development of clinical symptoms was 1.4 months, while the median time to imaging evidence was 4.7 months. Two patients (18.2%) had CTCAE grade 3 complications. Single-fraction spine SBRT (HR 4.5, 95% CI 1.2-16.9; p = 0.027) was associated with increased risk of developing myositis whereas receipt of anti-VEGF therapy was not (HR 2.2, 95% CI 0.6-7.1; p = 0.2). CONCLUSIONS Radiation myositis following spinal radiosurgery is a rare but important complication. Single-fraction treatment schedules may be associated with increased risk of myositis but should be validated in a larger series.
Topics: Adult; Aged; Aged, 80 and over; Dose Fractionation, Radiation; Female; Humans; Male; Middle Aged; Myositis; Radiation Injuries; Radiosurgery; Retrospective Studies; Spinal Neoplasms; Treatment Outcome
PubMed: 29372858
DOI: 10.3171/2017.8.SPINE17162 -
La Radiologia Medica Dec 2022Recent advances in non-metastatic breast cancer radiation therapy significantly reshaped our views on modern dose and fractionation schedules. Especially the advent of...
The Italian Association for Radiotherapy and Clinical Oncology (AIRO) position statements for postoperative breast cancer radiation therapy volume, dose, and fractionation.
Recent advances in non-metastatic breast cancer radiation therapy significantly reshaped our views on modern dose and fractionation schedules. Especially the advent of hypofractionation and partial breast irradiation defined a new concept of treatment optimization, that should strongly include both patient and tumour characteristics in the physician's decision-making process. Unfortunately, hypofractionation for breast cancer radiation therapy needed long time to enter the routine practice during the last decades despite the level-1 evidence published over time. Hereby we present the Italian Association for Radiotherapy and Clinical Oncology (AIRO) Breast Cancer Group position statements for postoperative breast cancer radiation therapy volume, dose, and fractionation to harmonically boost routine clinical practice implementation following evidence-based data.
Topics: Female; Humans; Breast Neoplasms; Dose Fractionation, Radiation; Medical Oncology; Radiation Oncology; Radiotherapy, Adjuvant; Italy
PubMed: 36201098
DOI: 10.1007/s11547-022-01563-9