Outcomes in patients with high- and very high-risk localized prostate cancer treated with definitive IMRT and long-term hormone therapy.

BACKGROUND: The aim of this study was to evaluate the effectiveness of intensity-modulated radiation therapy in combination with long-term androgen deprivation therapy for high-risk and very high-risk localized prostate cancer while also investigating factors associated with the therapeutic effect. METHODS: Men who fulfilled criteria for the National Comprehensive Cancer Network high-risk or very high-risk localized prostate cancer and were treated with definitive intensity-modulated radiation therapy (74-78 Gy) of the prostate and the seminal vesicle combined with androgen deprivation therapy in our institution from 2007 to 2016 were identified (n = 197). In principle, patients received androgen deprivation therapy for 3-6 months before radiation, concurrently, and for 2 years after completion of intensity-modulated radiation therapy. RESULTS: The median follow-up period was 96 months. The 5-year and 10-year overall survival rates in the overall population were 96.9% and 89.3%, respectively. The 5-year and 10-year cumulative incidence rates of biochemical failure were 2.5% and 16.3% in the high-risk group, and 8.6% and 32.0% in the very high-risk group, respectively, indicating a significant difference between the two groups (P = 0.023). Grade Group 5 and younger age (cutoff: 70 years old) were independent predictors of recurrence (P = 0.016 and 0.017, respectively). Patients exhibiting biochemical failure within <18 months after completion of androgen deprivation therapy displayed an increased risk of cancer-specific mortality (P = 0.039) when contrasted with those who had a longer interval to biochemical failure. CONCLUSIONS: Patients with the National Comprehensive Cancer Network very high-risk prostate cancer, particularly those with Grade Group 5 and younger age, showed worse outcomes following intensity-modulated radiation therapy and long-term androgen deprivation therapy.

What is the optimal isodose line for stereotactic radiotherapy for single brain metastases using HyperArc?

PURPOSE: The study aimed to investigate the optimal isodose line (IDL) in linear accelerator-based stereotactic radiotherapy for single brain metastasis, using HyperArc. We compared the dosimetric parameters for target and normal brain tissue among six plans with different IDLs. METHODS: This study included 30 patients with single brain metastasis. We retrospectively generated six plans for each tumor with different IDLs (80%, 70%, 60%, 50%, 40%, and 33%) using HyperArc. All treatment plans were normalized to the prescription dose of 35 Gy in five fractions which was covered by 95% of the planning target volume (PTV), defined by adding a 1.0 mm margin to the gross tumor volume (GTV). The dosimetric parameters were compared among the six plans. RESULTS: For GTV > 0.1 cm3, the ratio of brain-GTV volumes receiving 25 Gy to PTV (V25Gy/PTV) was significantly lower at IDL 40%-70% than at IDL 80% and 33% (p < 0.01, retrospectively). For GTV < 0.1 cm3, V25Gy/PTV decreased continuously as IDL decreased. The values of D99% and D80% for GTV increased with decreasing IDL. An IDL of 50% or less was required to achieve D99% of greater than 43 Gy and D80% of greater than 50 Gy. The mean values of D99% and D80% for IDL 50% were 44.3 and 51.9 Gy. CONCLUSION: The optimal IDL is 40%-50% for GTV > 0.1 cm3. These lower IDLs could increase D99% and D80% of GTV while lowering V25Gy of normal brain tissue, which may help reduce the risk of radiation necrosis and improve local control.

Influence of radiation dose and predicted tumor invasion depth on local recurrence after definitive chemoradiotherapy for stage 0-I esophageal squamous cell carcinoma: a propensity score-weighted, retrospective, observational study.

BACKGROUND: The optimal radiation dose for treating non-metastatic superficial esophageal squamous cell carcinoma is unknown. In this retrospective observational study, we investigated the influence of radiation dose and pretreatment endoscopic prediction of tumor invasion depth on local recurrence after definitive chemoradiotherapy in patients with superficial esophageal squamous cell carcinoma. METHODS: We analyzed 134 patients with clinical Tis-T1N0M0 esophageal squamous cell carcinoma who underwent chemoradiotherapy at our institution between 2006 and 2019. Patients were grouped into standard-dose (50.0-50.4 Gy) and high-dose (60.0 Gy) radiotherapy groups. The outcomes of interest were local recurrence and major local recurrence (endoscopically unresectable local recurrent tumors). Kaplan-Meier analysis and the log-rank test were used with propensity score and inverse probability of treatment weighting. Cox proportional hazards analysis was performed to identify predictors of local recurrence and major local recurrence. RESULTS: The median follow-up times were 52 and 84 months for the standard-dose and high-dose groups, respectively. The adjusted 3-year local recurrence and major local recurrence rates in the standard-dose and high-dose groups were 33.8 and 9.6% (adjusted hazard ratio, 4.00 [95% confidence interval: 1.64-9.73]; adjusted log-rank p = 0.001) and 12.5 and 4.7% (adjusted hazard ratio, 3.13 [95% confidence interval: 0.91-10.81]; adjusted log-rank p = 0.098), respectively. Cox proportional hazards analysis showed that standard-dose radiotherapy and endoscopic findings of deep submucosal invasion are independently associated with local recurrence and major local recurrence. CONCLUSIONS: High-dose radiotherapy is more beneficial for local tumor control than standard-dose radiotherapy in patients with non-metastatic superficial esophageal squamous cell carcinoma. The use of high-dose radiotherapy may merit consideration for tumors with deep submucosal invasion.

Risk of thoracic soft tissue sarcoma after breast cancer radiotherapy: a population-based cohort study in Osaka, Japan.

Postoperative radiotherapy for breast cancer reportedly increases the risk of thoracic soft tissue sarcomas, particularly angiosarcomas; however, the risk in the Japanese population remains unknown. Therefore, this study aimed to investigate the incidence of thoracic soft tissue sarcoma among patients with breast cancer in Japan and determine its association with radiotherapy. This retrospective cohort study used data from the population-based cancer registry of the Osaka Prefecture. The inclusion criteria were female sex, age 20-84 years, diagnosis of breast cancer between 1990 and 2010, no supraclavicular lymph node or distant metastasis, underwent surgery and survived for at least 1 year. The primary outcome was the occurrence of thoracic soft tissue sarcomas 1 year or later after breast cancer diagnosis. Among the 13 762 patients who received radiotherapy, 15 developed thoracic soft tissue sarcomas (nine angiosarcomas and six other sarcomas), with a median time of 7.7 years (interquartile range, 4.0-8.6 years) after breast cancer diagnosis. Among the 27 658 patients who did not receive radiotherapy, four developed thoracic soft tissue sarcomas (three angiosarcomas and one other sarcoma), with a median time of 11.6 years after diagnosis. The 10-year cumulative incidence was higher in the radiotherapy cohort than in the non-radiotherapy cohort (0.087 vs. 0.0036%, P < 0.001). Poisson regression analysis revealed that radiotherapy increased the risk of thoracic soft tissue sarcoma (relative risk, 6.8; 95% confidence interval, 2.4-24.4). Thus, although rare, breast cancer radiotherapy is associated with an increased risk of thoracic soft tissue sarcoma in the Japanese population.

Safety and Feasibility of Combining On-Demand Selective Locoregional Treatment with First-Line Atezolizumab Plus Bevacizumab for Patients with Unresectable Hepatocellular Carcinoma.

Various locoregional treatments for localized hepatocellular carcinoma (HCC) have been developed. This retrospective study investigated the safety and feasibility of combining on-demand selective locoregional treatment for residual lesions after tumor shrinkage (complete response [CR] oriented) or for solitary or few drug-resistant lesions (progressive disease (PD) salvage) with first-line atezolizumab plus bevacizumab (atezo/bev) for unresectable HCC. Twenty-nine patients with unresectable HCC were included. Fourteen locoregional treatments were performed (CR oriented, 7; PD salvage, 7) in ten patients in the combination-therapy group. All patients in the combination-therapy group successfully achieved a CR or PD salvage status after the planned locoregional treatment. The objective response rate of the combination-therapy group (80.0%) was higher than that of the atezo/bev alone group (21.1%; p = 0.005). Progression-free survival (PFS) and overall survival (OS) were longer in the combination group (medians for PFS and OS not reached) than in the atezo/bev alone group (median PFS, 7.4 months; median OS, 19.8 months) (PFS, p = 0.004; OS, p < 0.001). The albumin-bilirubin score did not change, and no severe complications occurred after locoregional treatment. When performed in a minimally invasive manner, on-demand selective locoregional treatment combined with first-line atezo/bev could be safe and feasible for unresectable HCC.

The effects of distance between the imaging isocenter and brain center on the image quality of cone-beam computed tomography for brain stereotactic irradiation.

In linear accelerator-based stereotactic irradiation (STI) for brain metastasis, cone-beam computed tomography (CBCT) image quality is essential for ensuring precise patient setup and tumor localization. However, CBCT images may be degraded by the deviation of the CBCT isocenter from the brain center. This study aims to investigate the effects of the distance from the brain center to the CBCT isocenter (DBI) on the image quality in STI. An anthropomorphic phantom was scanned with varying DBI in right, anterior, superior, and inferior directions. Thirty patients undergoing STI were prospectively recruited. Objective metrics, utilizing regions of interest included contrast-to-noise ratio (CNR) at the centrum semiovale, lateral ventricle, and basal ganglia levels, gray and white matter noise at the basal ganglia level, artifact index (AI), and nonuniformity (NU). Two radiation oncologists assessed subjective metrics. In this phantom study, objective measures indicated a degradation in image quality for non-zero DBI. In this patient study, there were significant correlations between the CNR at the centrum semiovale and lateral ventricle levels (rs = - 0.79 and - 0.77, respectively), gray matter noise (rs = 0.52), AI (rs = 0.72), and NU (rs = 0.91) and DBI. However, no significant correlations were observed between the CNR at the basal ganglia level, white matter noise, and subjective metrics and DBI (rs < ± 0.3). Our results demonstrate the effects of DBI on contrast, noise, artifacts in the posterior fossa, and uniformity of CBCT images in STI. Aligning the CBCT isocenter with the brain center can aid in improving image quality.

Association of increasing gross tumor volume dose with tumor volume reduction and local control in fractionated stereotactic radiosurgery for unresected brain metastases.

BACKGROUND: Fractionated stereotactic radiosurgery (fSRS) is an important treatment strategy for unresected brain metastases. We previously reported that a good volumetric response 6 months after fSRS can be the first step for local control. Few studies have reported the association between gross tumor volume (GTV) dose, volumetric response, and local control in patients treated with the same number of fractions. Therefore, in this study, we aimed to investigate the GTV dose and volumetric response 6 months after fSRS in five daily fractions and identify the predictive GTV dose for local failure (LF) for unresected brain metastasis. METHODS: This retrospective study included 115 patients with 241 unresected brain metastases treated using fSRS in five daily fractions at our hospital between January 2013 and April 2022. The median prescription dose was 35 Gy (range, 30-35 Gy) in five fractions. The median follow-up time after fSRS was 16 months (range, 7-66 months). RESULTS: GTV D80 > 42 Gy and GTV D98 > 39 Gy were prognostic factors for over 65% volume reduction (odds ratio, 3.68, p < 0.01; odds ratio, 4.68, p < 0.01, respectively). GTV D80 > 42 Gy was also a prognostic factor for LF (hazard ratio, 0.37; p = 0.01). CONCLUSIONS: GTV D80 > 42 Gy in five fractions led to better volume reduction and local control. The goal of planning an inhomogeneous dose distribution for fSRS in brain metastases may be to increase the GTV D80 and GTV D98. Further studies on inhomogeneous dose distributions are required.

Enhancing the Contouring Efficiency for Head and Neck Cancer Radiotherapy Using Atlas-based Auto-segmentation and Scripting.

BACKGROUND/AIM: Intensity-modulated radiation therapy can deliver a highly conformal dose to a target while minimizing the dose to the organs at risk (OARs). Delineating the contours of OARs is time-consuming, and various automatic contouring software programs have been employed to reduce the delineation time. However, some software operations are manual, and further reduction in time is possible. This study aimed to automate running atlas-based auto-segmentation (ABAS) and software operations using a scripting function, thereby reducing work time. MATERIALS AND METHODS: Dice coefficient and Hausdorff distance were used to determine geometric accuracy. The manual delineation, automatic delineation, and modification times were measured. While modifying the contours, the degree of subjective correction was rated on a four-point scale. RESULTS: The model exhibited generally good geometric accuracy. However, some OARs, such as the chiasm, optic nerve, retina, lens, and brain require improvement. The average contour delineation time was reduced from 57 to 29 min (p<0.05). The subjective revision degree results indicated that all OARs required minor modifications; only the submandibular gland, thyroid, and esophagus were rated as modified from scratch. CONCLUSION: The ABAS model and scripted automation in head and neck cancer reduced the work time and software operations. The time can be further reduced by improving contour accuracy.

Abscopal effect in a patient with advanced hepatocellular carcinoma upon resuming bevacizumab in combination with atezolizumab after radiotherapy.

Combining bevacizumab with atezolizumab enhances the antitumor effects of the treatment by activating an immune response. This combination is approved for the treatment of unresectable hepatocellular carcinoma (HCC). An abscopal effect is associated with an immune response triggered by radiation-induced immunogenic cell death, based on experimental models. Thus, combining radiotherapy and immunotherapy is expected to induce an abscopal effect. However, the clinical significance of immunotherapy in the abscopal effect remains unknown due to the rarity of clinical cases. Herein, we report a case of advanced HCC with lung and adrenal metastases. The antitumor efficacy of atezolizumab and bevacizumab (atezo/bev) was enhanced following stereotactic body radiotherapy (SBRT), although atezo/bev did not yield a sufficient therapeutic response pre-SBRT. Furthermore, an abscopal effect following SBRT was not observed during atezolizumab alone but was evoked after resuming bevacizumab in combination with atezolizumab, culminating in the patient achieving a complete response status. These findings suggest that immune activation following radiotherapy may be related to the induction of an abscopal effect in clinical practice as well as in experimental settings, and combining immunotherapy with bevacizumab post-radiotherapy could evoke an abscopal effect in a case of HCC, even though immune checkpoint inhibitor use alone may be insufficient.

Multifraction stereotactic radiotherapy utilizing inhomogeneous dose distribution for brainstem metastases: a single-center retrospective analysis.

Brainstem metastases are challenging to manage owing to the critical neurological structures involved. Although stereotactic radiotherapy (SRT) offers targeted high doses while minimizing damage to adjacent normal tissues, the optimal dose fractionation remains undefined. This study evaluated the efficacy and safety of multifraction SRT with an inhomogeneous dose distribution. This retrospective study included 31 patients who underwent 33 treatments for 35 brainstem lesions using linear accelerator-based multifraction SRT (30 Gy in five fractions, 35 Gy in five fractions or 42 Gy in 10 fractions) with an inhomogeneous dose distribution (median isodose, 51.9%). The outcomes of interest were local failure, toxicity and symptomatic failure. The median follow-up time after brainstem SRT for a lesion was 18.6 months (interquartile range, 10.0-24.3 months; range, 1.8-39.0 months). Grade 2 toxicities were observed in two lesions, and local failure occurred in three lesions. No grade 3 or higher toxicities were observed. The 1-year local and symptomatic failure rates were 8.8 and 16.7%, respectively. Toxicity was observed in two of seven treatments with a gross tumor volume (GTV) greater than 1 cc, whereas no toxicity was observed in treatments with a GTV less than 1 cc. No clear association was observed between the biologically effective dose of the maximum brainstem dose and the occurrence of toxicity. Our findings indicate that multifraction SRT with an inhomogeneous dose distribution offers a favorable balance between local control and toxicity in brainstem metastases. Larger multicenter studies are needed to validate these results and determine the optimal dose fractionation.

Effect of topical agents on skin surface dose in volumetric modulated arc therapy for head and neck cancer.

In volumetric modulated arc therapy (VMAT), the effect of an increase in skin surface dose due to topical agents might be negligible. We investigated the bolus effects of three types of topical agents in VMAT for head and neck cancer (HNC). Topical agents of different thicknesses (0.1, 0.5 and 2 mm) were prepared. When each topical agent was set, the surface doses were measured for the anterior static field and VMAT, with and without a thermoplastic mask. No significant differences were observed among the three topical agents. For topical agent thicknesses of 0.1, 0.5 and 2 mm, the increases in surface dose for the anterior static field without the thermoplastic mask were 7-9, 30-31 and 81-84%, respectively. With the thermoplastic mask, the corresponding increases were 5, 12-15 and 41-43%, respectively. The increases in surface dose for VMAT without the thermoplastic mask were 5-8, 16-19 and 36-39%, respectively, and those with the thermoplastic mask were 4, 7-10 and 15-19%, respectively. The rate of increase in surface dose with the thermoplastic mask was smaller than that without the thermoplastic mask. The increase in surface dose with topical agents of clinical standard thickness (0.02 mm) was estimated to be 2% with the thermoplastic mask. The increase in surface dose with topical agents in dosimetric simulation, compared with control situation, is not significant in clinical conditions for HNC patients.

Dose reduction of hippocampus using HyperArc planning in postoperative radiotherapy for primary brain tumors.

To compare dosimetric parameters for the hippocampus, organs at risk (OARs), and targets of volumetric modulated arc therapy (VMAT), noncoplanar VMAT (NC-VMAT), and HyperArc (HA) plans in patients undergoing postoperative radiotherapy for primary brain tumors. For 20 patients, HA plans were generated to deliver 40.05 to 60 Gy for the planning target volume (PTV). In addition, doses for the hippocampus and OARs were minimized. The VMAT and NC-VMAT plans were retrospectively generated using the same optimization parameters as those in the HA plans. For the hippocampus, the equivalent dose to be administered in 2 Gy fractions (EQD2) was calculated assuming α/ß = 2. Dosimetric parameters for the PTV, hippocampus, and OARs in the VMAT, NC-VMAT, and HA plans were compared. For PTV, the HA plans provided significantly lower Dmax and D1% than the VMAT and NC-VMAT plans (p < 0.05), whereas the D99% and Dmin were significantly higher (p < 0.05). For the contralateral hippocampus, the dosimetric parameters in the HA plans (8.1 ± 9.6, 6.5 ± 7.2, 5.6 ± 5.8, and 4.8 ± 4.7 Gy for D20%, D40%, D60% and D80%, respectively) were significantly smaller (p < 0.05) than those in the VMAT and NC-VMAT plans. Except for the optic chiasm, the Dmax in the HA plans (brainstem, lens, optic nerves, and retinas) was the smallest (p < 0.05). In addition, the doses in the HA plans for the brain and skin were the smallest (p < 0.05) among the 3 plans. HA planning, instead of coplanar and noncoplanar VMAT, significantly reduces the dosage to which the contralateral hippocampus as well as other OARs are exposed without compromising on target coverage.

[Improved Patients' Satisfaction Level of Radiation Therapy: The Effect of "Explainer Videos about Radiation Therapy", "Treatment of Breast Cancer Patients by Female Radiation Therapists" and "Treating Male Patients While Wearing Underwear in Pelvic Radiation Therapy"].

PURPOSE: The questionnaire survey investigated whether "Explainer videos about radiation therapy (RT-Video)", "Treatment of breast cancer patients by female radiation therapists (F-RTT)" and "Treating male patients while wearing underwear in pelvic radiation therapy (M-RTT)" can improve patient's satisfaction. METHODS: The RT-Video survey included questions regarding the impression of radiation therapy, improving its understanding, and anxiety reduction (102 patients received radiation therapy). Fifty-one breast cancer patients were asked whether they preferred an F-RTT treatment. Subsequently, the patients treated with F-RTT (41 patients) and M-RTT (50 patients) were surveyed about their treatment satisfaction on a five-point scale. RESULTS: RT-Video improved the understanding of radiation therapy for 86 out of 102 patients (84%). In all, 68 out of 102 patients (68%) had a negative impression of radiotherapy; among them, watching the RT-Video reduced anxiety in 63% of patients. A total of 14 out of 51 breast cancer patients (28%) preferred the F-RTT treatment. The percentage of patients who received treatment satisfaction by F-RTT and M-RTT was 95% and 84%, respectively. CONCLUSION: RT-Video, F-RTT and M-RTT treatments improved patients' satisfaction.

Improvement of target coverage using automated non-coplanar volumetric modulated arc therapy planning in stereotactic radiotherapy for cervical metastatic spinal tumors.

This study aimed to compare dosimetric parameters for targets and organs at risk (OARs) between volumetric modulated arc therapy (VMAT) and automated VMAT (HyperArc, HA) plans in stereotactic radiotherapy for patients with cervical metastatic spine tumors. VMAT plans were generated for 11 metastases using the simultaneous integrated boost technique to deliver 35 to 40 and 20 to 25 Gy for high dose and elective dose planning target volume (PTVHD and PTVED), respectively. The HA plans were retrospectively generated using 1 coplanar and 2 noncoplanar arcs. Subsequently, the doses to the targets and OARs were compared. The HA plans provided significantly higher (p < 0.05) Dmin (77.4 ± 13.1%), D99% (89.3 ± 8.9%), and D98% (92.5 ± 7.7%) for gross tumor volume (GTV) than those of the VMAT plans (73.4 ± 12.2%, 84.2 ± 9.6 and 87.3 ± 8.8% for Dmin, D99% and D98%, respectively). In addition, D99% and D98% for PTVHD were significantly higher in the HA plans, whereas dosimetric parameters were comparable between the HA and VMAT plans for PTVED. The Dmax values for the brachial plexus, esophagus, and spinal cord were comparable, and no significant difference was observed in the Dmean for the larynx, pharyngeal constrictor, thyroid, parotid grand (left and right), and Submandibular gland (left and right). The HA plans provided significantly higher target coverage of GTV and PTVHD, with a comparable dose for OARs with VMAT plans. The results of this study may contribute to the improvement of local control in clinical practice.

Linear accelerator-based stereotactic radiotherapy for brain metastases, including multiple and large lesions, carries a low incidence of acute toxicities: a retrospective analysis.

BACKGROUND: Data on acute toxicities after stereotactic radiotherapy (SRT) for brain metastases, including multiple and large lesions, are lacking. We aimed to evaluate the incidence and nature of toxicities immediately after SRT using a linear accelerator. METHODS: This retrospective study reviewed the medical records of 315 patients with brain metastases treated with SRT at our institution between May 2019 and February 2022. In total, 439 SRT sessions were performed for 2161 brain metastases. The outcome of interest was immediate side effects (ISEs), defined as new or worsening symptoms occurring during SRT or within 14 days after the end of SRT. RESULTS: Grade ≥ 2 and ≥ 3 ISEs occurred in 16 (3.6%) and 7 (1.6%) cases, respectively. Among 63 treatments for 10 or more lesions (range: 10-40), 1 (1.6%) ISE occurred. Among 22 treatments for lesions with a maximum tumor volume of > 10 cc, 2 (9.1%) ISEs occurred. Grade ≥ 3 ISEs included 1, 4, 1, and 1 cases of grade 3 nausea, grade 3 new-onset partial and generalized seizures, grade 3 obstructive hydrocephalus, and grade 5 intracranial hemorrhage, respectively. ISEs were more common in patients with a larger maximum tumor volume, primary sites other than lung and breast cancer, and pre-treatment neurological symptoms. CONCLUSION: SRT using a linear accelerator for brain metastases, including multiple and large lesions, is safe, with a low incidence of ISEs. Serious complications immediately after SRT are rare but possible; therefore, careful follow-up is necessary after treatment initiation.

Dual-energy computed tomography-based iodine concentration as a predictor of histopathological response to preoperative chemoradiotherapy for pancreatic cancer.

To explore predictors of the histopathological response to preoperative chemoradiotherapy (CRT) in patients with pancreatic cancer (PC) using dual-energy computed tomography-reconstructed images. This retrospective study divided 40 patients who had undergone preoperative CRT (50-60 Gy in 25 fractions) followed by surgical resection into two groups: the response group (Grades II, III and IV, evaluated from surgical specimens) and the nonresponse group (Grades Ia and Ib). The computed tomography number [in Hounsfield units (HUs)] and iodine concentration (IC) were measured at the locations of the aorta, PC and pancreatic parenchyma (PP) in the contrast-enhanced 4D dual-energy computed tomography images. Logistic regression analysis was performed to identify predictors of histopathological response. Univariate analysis did not reveal a significant relation between any parameter and patient characteristics or dosimetric parameters of the treatment plan. The HU and IC values in PP and the differences in HU and IC between the PP and PC (ΔHU and ΔIC, respectively) were significant predictors for distinguishing the response (n = 24) and nonresponse (n = 16) groups (P < 0.05). The IC in PP and ΔIC had a higher area under curve values [0.797 (95% confidence interval, 0.659-0.935) and 0.789 (0.650-0.928), respectively] than HU in PP and ΔHU [0.734 (0.580-0.889) and 0.721 (0.562-0.881), respectively]. The IC value could potentially be used for predicting the histopathological response in patients who have undergone preoperative CRT.

Volumetric reduction of brain metastases after stereotactic radiotherapy: Prognostic factors and effect on local control.

BACKGROUND AND PURPOSE: Few reports include volumetric measurements as endpoints after stereotactic radiotherapy (SRT) despite the importance of such measurements. This study aimed to (1) investigate the impact of the volumetric response (specifically, an over 65% and over 90% volume reduction in brain metastases) at 6 months post-SRT on local control and (2) identify the predictive factors for a volumetric response of over 65% and over 90%. MATERIALS AND METHODS: This study included 250 unresected brain metastases (>0.3 cc) treated with SRT. Doses were stratified according to the biological effective dose (BED). The BED was calculated using four models: linear-quadratic (LQ): α/ß = 10; LQ: α/ß = 20; LQ cubic: α/ß = 12; and LQ linear: α/ß = 10. The median prescription dose was 30 Gy/3 fractions (BED20, 45). The median follow-up time after SRT was 18.6 months (range, 6.4-81.8 months). RESULTS: In the multivariate analysis, over 65% volume reduction and over 90% volume reduction were prognostic factors for local control (hazard ratio: 2.370, p = 0.011 and hazard ratio: 3.161, p = 0.014, respectively). A dose of 80% of the gross tumor volume (GTV) D80 > BED20 58 was a predictive factor for over 65% and over 90% volume reductions (odds ratio: 1.975, p = 0.023; odds ratio: 3.204, p < 0.001, respectively). CONCLUSION: Robust volume reduction of brain metastases at 6 months post-SRT can predict local control. GTV D80 in the LQ model: α/ß = 20 may be warranted for good volume reduction.

Prolonged overall treatment time negatively affects the outcomes of stereotactic body radiotherapy for early-stage non-small-cell lung cancer: A propensity score-weighted, single-center analysis.

Previous studies have reported conflicting results for the effect of overall treatment time with stereotactic body radiotherapy on tumor control in early-stage non-small-cell lung cancer. To examine this effect, we conducted a propensity score-weighted, retrospective, observational study at a single institution. We analyzed the data of 200 patients with early-stage non-small-cell lung cancer who underwent stereotactic body radiotherapy (48 Gy in 4 fractions) at our institution between January 2007 and October 2013. Patients were grouped into consecutive (overall treatment time = 4-5 days, n = 116) or non-consecutive treatment groups (overall treatment time = 6-10 days, n = 84). The outcomes of interest were local control and overall survival. The Cox regression model was used with propensity score and inverse probability of treatment weighting. The median overall treatment times in the consecutive and non-consecutive groups were 4 and 6 days, respectively. The 5-year local control and overall survival rates in the consecutive vs. the non-consecutive group were 86.3 vs. 77.2% and 55.5 vs. 51.8%, respectively. After propensity score weighting, consecutive stereotactic body radiotherapy was associated with positive local control (adjusted hazard ratio 0.30, 95% confidence interval 0.14-0.65; p = 0.002) and overall survival (adjusted hazard ratio 0.56, 95% confidence interval 0.34-0.91; p = 0.019) benefits. The prolonged overall treatment time of stereotactic body radiotherapy treatment negatively affected the outcomes of patients with early-stage non-small-cell lung cancer. To our knowledge, this is the first study to show that in patients with early-stage non-small-cell lung cancer treated with the same dose-fractionation regimen, consecutive stereotactic body radiotherapy has a more beneficial effect on tumor control than non-consecutive stereotactic body radiotherapy.

Intra-fractional patient setup error during fractionated intracranial stereotactic irradiation treatment of patients wearing medical masks: comparison with and without bite block during COVID-19 pandemic.

The immobilization of patients with a bite block (BB) carries the risk of interpersonal infection, particularly in the context of pandemics such as COVID-19. Here, we compared the intra-fractional patient setup error (intra-SE) with and without a BB during fractionated intracranial stereotactic irradiation (STI). Fifteen patients with brain metastases were immobilized using a BB without a medical mask, while 15 patients were immobilized without using a BB and with a medical mask. The intra-SEs in six directions (anterior-posterior (AP), superior-inferior (SI), left-right (LR), pitch, roll, and yaw) were calculated by using cone-beam computed tomography images acquired before and after the treatments. We analyzed a total of 53 and 67 treatment sessions for the with- and without-BB groups, respectively. A comparable absolute mean translational and rotational intra-SE was observed (P > 0.05) in the AP (0.19 vs 0.23 mm with- and without-BB, respectively), SI (0.30 vs 0.29 mm), LR (0.20 vs 0.29 mm), pitch (0.18 vs 0.27°), roll (0.23 vs 0.23°) and yaw (0.27 vs 22°) directions. The resultant planning target volume (PTV) margin to compensate for intra-SE was <1 mm. No statistically significant correlation was observed between the intra-SE and treatment times. A PTV margin of <1 mm was achieved even when patients were immobilized without a BB during STI dose delivery.

Improvement of image quality and assessment of respiratory motion for hepatocellular carcinoma with portal vein tumor thrombosis using contrast-enhanced four-dimensional dual-energy computed tomography.

To assess the objective and subjective image quality, and respiratory motion of hepatocellular carcinoma with portal vein tumor thrombosis (PVTT) using the contrast-enhanced four-dimensional dual-energy computed tomography (CE-4D-DECT). For twelve patients, the virtual monochromatic image (VMI) derived from the CE-4D-DECT with the highest contrast to noise ratio (CNR) was determined as the optimal VMI (O-VMI). To assess the objective and subjective image quality, the CNR and five-point score of the O-VMI were compared to those of the standard VMI at 77 keV (S-VMI). The respiratory motion of the PVTT and diaphragm was measured based on the exhale and inhale phase images. The VMI at 60 keV yielded the highest CNR (4.8 ± 1.4) which was significantly higher (p = 0.02) than that in the S-VMI (3.8 ± 1.2). The overall image quality (4.0 ± 0.6 vs 3.1 ± 0.5) and tumor conspicuity (3.8 ± 0.8 vs 2.8 ± 0.6) of the O-VMI determined by three radiation oncologists was significantly higher (p < 0.01) than that of the S-VMI. The diaphragm motion in the L-R (3.3 ± 2.5 vs 1.2 ± 1.1 mm), A-P (6.7 ± 4.0 vs 1.6 ± 1.3mm) and 3D (8.8 ± 3.5 vs 13.1 ± 4.9 mm) directions were significantly larger (p < 0.05) compared to the tumor motion. The improvement of objective and subjective image quality was achieved in the O-VMI. Because the respiratory motion of the diaphragm was larger than that of the PVTT, we need to be pay attention for localizing target in radiotherapy.