Setup margins based on the inter- and intrafractional setup error of left-sided breast cancer radiotherapy using deep inspiration breath-hold technique (DIBH) and surface guided radiotherapy (SGRT).

PURPOSE: The use of volumetric modulated arc therapy (VMAT), simultaneous integrated boost (SIB), and hypofractionated regimen requires adequate patient setup accuracy to achieve an optimal outcome. The purpose of this study was to assess the setup accuracy of patients receiving left-sided breast cancer radiotherapy using deep inspiration breath-hold technique (DIBH) and surface guided radiotherapy (SGRT) and to calculate the corresponding setup margins. METHODS: The patient setup accuracy between and within radiotherapy fractions was measured by comparing the 6DOF shifts made by the SGRT system AlignRT with the shifts made by kV-CBCT. Three hundred and three radiotherapy fractions of 23 left-sided breast cancer patients using DIBH and SGRT were used for the analysis. All patients received pre-treatment DIBH training and visual feedback during DIBH. An analysis of variance (ANOVA) was used to test patient setup differences for statistical significance. The corresponding setup margins were calculated using the van Herk's formula. RESULTS: The intrafractional patient setup accuracy was significantly better than the interfractional setup accuracy (p < 0.001). The setup margin for the combined inter- and intrafractional setup error was 4, 6, and 4 mm in the lateral, longitudinal, and vertical directions if based on SGRT alone. The intrafractional error contributed ≤1 mm to the calculated setup margins. CONCLUSION: With SGRT, excellent intrafractional and acceptable interfractional patient setup accuracy can be achieved for the radiotherapy of left-sided breast cancer using DIBH and modern radiation techniques. This allows for reducing the frequency of kV-CBCTs, thereby saving treatment time and radiation exposure.

Setup accuracy and margins for surface-guided radiotherapy (SGRT) of head, thorax, abdomen, and pelvic target volumes.

The goal of the study was to evaluate the inter- and intrafractional patient setup accuracy of target volumes located in the head, thoracic, abdominal, and pelvic regions when using SGRT, by comparing it with that of laser alignment using patient skin marks, and to calculate the corresponding setup margins. A total of 2303 radiotherapy fractions of 183 patients were analyzed. All patients received daily kilovoltage cone-beam computed tomography scans (kV-CBCT) for online verification. From November 2019 until September 2020, patient setup was performed using laser alignment with patient skin marks, and since October 2020, using SGRT. The setup accuracy was measured by the six degrees of freedom (6DOF) corrections based on the kV-CBCT. The corresponding setup margins were calculated using the van Herk formula. Analysis of variance (ANOVA) was used to evaluate the impact of multiple factors on the setup accuracy. The inter-fractional patient setup accuracy was significantly better using SGRT compared to laser alignment with skin marks. The mean three-dimensional vector of the translational setup deviation of tumors located in the thorax, abdomen, and pelvis using SGRT was 3.6 mm (95% confidence interval (CI) 3.3 mm to 3.9 mm) and 4.5 mm using laser alignment with skin marks (95% CI 3.9 mm to 5.2 mm; p = 0.001). Calculation of setup margins for the combined inter- and intra-fractional setup error revealed similar setup margins using SGRT and kV-CBCT once a week compared to laser alignment with skin marks and kV-CBCT every other day. Furthermore, comparable setup margins were found for open-face thermoplastic masks with AlignRT compared to closed-face thermoplastic masks with laser alignment and mask marks. SGRT opens the possibility to reduce the number of CBCTs while maintaining sufficient setup accuracy. The advantage is a reduction of imaging dose and overall treatment time. Open-face thermoplastic masks may be used instead of closed-face thermoplastic masks to increase the patient's comfort.

Long-term effect and prognostic factors of a low-dose radiotherapy of painful plantar calcaneal spurs : A retrospective unicenter study.

PURPOSE: To estimate the long-term effect of low-dose radiotherapy of painful plantar calcaneal spurs, and to verify possible prognostic factors. PATIENTS AND METHODS: In this retrospective unicenter study, electronic patient files of patients with painful plantar calcaneal spurs treated with low-dose radiotherapy between July 2009 and February 2020 were reviewed. The low-dose radiotherapy consisted of a total dose of 3.0 Gy given with a fraction dose of 0.5 Gy three times a week. The pain reduction was estimated using a patient questionnaire with a visual analogue scale. Kaplan-Meier statistics and Cox regression analysis were used for the statistical analysis. RESULTS: Altogether, 864 heels of 666 patients were reviewed. The probability of an insufficient pain control 10 years after low-dose radiotherapy was 45.9% (95% confidence interval 39.4-52.4%) in the subset of patients with a minimum follow-up of 3 months (582 heels of 467 patients). Patients with an unsatisfactory pain reduction 3 months after low-dose radiotherapy were offered a re-irradiation. Forty percent of the patients who received a re-irradiation developed good pain reduction. Occurrence of an initial aggravation of pain during or within 3 months after low-dose radiotherapy (p = 0.005), and treatment of bilateral painful plantar calcaneal spurs (p = 0.008) were identified as significant unfavorable prognostic factors on univariate analysis. On multivariate analysis, the initial aggravation of pain remained as independent significant prognostic factor (p = 0.01). No clear radiation toxicity was observed. CONCLUSIONS: Low-dose radiotherapy is a safe and effective treatment option for patients with painful plantar calcaneal spurs. An initial aggravation of pain during or within 3 months after radiotherapy was identified as unfavorable prognostic factor for the treatment outcome. Re-irradiation of patients with an unsatisfactory pain reduction after low-dose radiotherapy is effective and should be offered to patients.

1x8 Gy versus 5x4 Gy for metastatic epidural spinal cord compression: a matched-pair study of three prognostic patient subgroups.

BACKGROUND: This study provides separate comparisons of 1 × 8 Gy to 5 × 4 Gy for metastatic epidural spinal cord compression (MESCC) in patients with poor, intermediate and favorable survival prognoses. METHODS: Patients receiving 1 × 8 Gy were matched to patients receiving 5 × 4 Gy for age, gender, performance status, tumor type, involved vertebrae, other bone metastases, visceral metastases, interval between tumor diagnosis and MESCC, ambulatory status and time developing motor deficits. From a study including patients with poor (N = 156) or intermediate (N = 86) survival prognoses, subgroup analyses were performed. Furthermore, 232 new patients with favorable prognoses matched the same way were included. RESULTS: In poor prognoses patients, 6-month survival rates were 10% after 1 × 8 Gy and 6% after 5 × 4 Gy (p = 0.38); in-field reRT rates in few patients alive at 6 months were 15 and 2% (p = 0.16). In intermediate prognoses patients, 6-month survival rates were 49% after 1 × 8 Gy and 58% after 5 × 4 Gy (p = 0.30). ReRT rates at 6 months were 23 and 13% (p = 0.25). In favorable prognoses patients, 6-month survival rates were 89% after 1 × 8 Gy and 91% after 5 × 4 Gy. ReRT rates at 6 months were 14 and 3% (p = 0.007). In no subgroup, RT regimen had a significant impact on motor function. CONCLUSIONS: Since in patients with poor prognoses, outcomes after 1 × 8 Gy and 5 × 4 Gy were not significantly different, 1 × 8 Gy may be an option. In patients with intermediate prognoses, a trend was found in favor of 5 × 4 Gy. In patients with favorable prognoses, need for in-field reRT was greater after 1 × 8 Gy.

Comparison of Two Radiotherapy Regimens for Metastatic Spinal Cord Compression: Subgroup Analyses from a Randomized Trial.

BACKGROUND/AIM: According to our randomized trial, 5×4Gy was comparable to 10×3Gy for metastatic spinal cord compression. Since it remained unclear whether findings applied to poor and intermediate prognoses patients, subgroup analyses were performed. PATIENTS AND METHODS: In patients with poor prognoses, 58 received 5×4Gy, 53 received 10×3Gy. In intermediate-prognoses patients, numbers were 43 and 49. RESULTS: In patients with poor prognoses, 1-month overall response (OR) was 85% after 5×4Gy and 10×3Gy (p=0.99), improvement 38% vs. 42%, ambulatory status 60% vs. 64% (p=0.83), 6-month local progression-free survival (LPFS) 75% vs. 69% (p=0.74) and 6-month overall survival (OS) 26% vs. 19% (p=0.43). In patients with intermediate prognoses, 1-month OR was 89% after 5×4Gy and 93% after 10×3Gy (p=0.85), improvement 39% vs. 45%, ambulatory status 84% vs. 82% (p=0.90), 6-month LPFS 79% vs. 92% (p=0.17) and 6-months OS 65% vs. 58% (p=0.65). CONCLUSION: 5×4Gy was not significantly inferior to 10x3Gy in both subgroups.

Results of a multicenter study investigating the potential impact of the overall treatment time on outcomes of radiation therapy alone with 5×4 Gy for metastatic epidural spinal cord compression.

PURPOSE/OBJECTIVE: A 5×4 Gy program is commonly used for metastatic epidural spinal cord compression (MESCC). It is unclear whether an overall treatment time (OTT) of 5 days (5 consecutive fractions) results in better outcomes than an OTT of 7 days (ie, no irradiation during the weekend). METHODS AND MATERIALS: A total of 111 patients who received 5×4 Gy over 5 consecutive days were retrospectively compared with 277 patients treated with 5×4 Gy over 7 days (no irradiation during the weekend) for effect on motor function, local control of MESCC, and overall survival (OS). Ten further characteristics were evaluated: age, gender, interval tumor diagnosis to MESCC, visceral metastases, other bone metastases, primary tumor type, time developing motor deficits, walking ability, vertebrae involved, and performance status. RESULTS: On multivariate analysis regarding post-radiation therapy motor function, primary tumor type (P = .011) and time developing motor weakness (P < .001) were significant, whereas the OTT did not even achieve significance on univariate analysis (P = .99). On multivariate analysis of local control, visceral metastases (P = .006) were significant. Again, the OTT was not even significant on univariate analysis (P = .81). On multivariate analysis of OS, interval tumor diagnosis to MESCC (P = .015), visceral metastases (P .001), tumor type (P = .003), walking ability (P < .001), and Eastern Cooperative Oncology Group performance score (P < .001) achieved significance. Even on univariate analysis, OTT did not have an effect on OS (P = .79). CONCLUSIONS: Longer OTT did not impair outcomes of irradiation with 5×4 Gy for MESCC; thus, no compensation (for example an additional radiation fraction) is necessary if the radiation treatment is not continued during the weekend.

Better compliance with hypofractionation vs. conventional fractionation in adjuvant breast cancer radiotherapy : Results of a single, institutional, retrospective study.

BACKGROUND: The aim of the study was to identify factors significantly associated with the occurrence of unintended treatment interruptions in adjuvant breast cancer radiotherapy. PATIENTS AND METHODS: Patients treated with postoperative radiotherapy of the breast or chest wall between March 2014 and August 2016 were evaluated. The radiotherapy regimens and techniques applied were either conventional fractionation (CF; 28 daily fractions of 1.8 Gy or 25 fractions of 2.0 Gy) or hypofractionation (HF; 15 daily fractions of 2.67 Gy) with inverse planned intensity-modulated radiotherapy (IMRT) or three-dimensional planned conformal radiotherapy (3DCRT). Logistic regression analysis was used to identify factors associated with noncompliance. Noncompliance was defined as the missing of at least one scheduled radiotherapy fraction. RESULTS: In all, 19 of 140 (13.6%) patients treated with HF and 39 of 146 (26.7%) treated with CF experienced treatment interruptions. Of 23 factors tested, the fractionation regimen emerged as the only independent significant prognostic factor for noncompliance on multivariate analysis (CF; p = 0.007; odds ratio, 2.3; 95% confidence interval, 1.3-4.2). No statistically significant differences concerning the reasons for treatment interruptions could be detected between patients treated with CF or HF. CONCLUSION: HF is significantly associated with a better patient compliance with the prescribed radiotherapy schedule compared with CF. The data suggest that this finding is basically related to the shorter overall treatment time of HF.

Role of the overall treatment time of radiotherapy with 10 × 3 Gy for outcomes in patients with metastatic spinal cord compression.

INTRODUCTION: Radiotherapy alone still is the most commonly delivered treatment modality for metastatic spinal cord compression (MSCC). MSCC is an emergency situation, which requires treatment as soon as possible. When radiotherapy is performed with the most commonly used approach 10 × 3 Gy (30 Gy in 10 fractions) over 2 weeks, the question has been asked whether an overall treatment time (OTT) of 14-15 days including two weekends without irradiation leads to worse outcomes than OTT of 12 days (beginning of radiotherapy on a Monday resulting in only one weekend break)? METHODS: A total of 412 patients with MSCC were included in this retrospective study. Ninety-two patients receiving 10 × 3 Gy over 12 days were compared to 320 patients with an OTT of 14-15 days. Ten additional factors were investigated. RESULTS: On multivariate analysis, functional outcome was associated with tumour type (P < 0.001), time developing motor deficits (P < 0.001), ambulatory status (P = 0.018) and performance score (P < 0.001); OTT had no significant impact (P = 0.40). On univariate analysis of local control of MSCC (freedom from recurrence in irradiated spinal parts), no factor was significant including OTT (P = 0.66). On multivariate analysis, visceral metastases (P < 0.001), tumour type (P < 0.001), time developing motor deficits (P < 0.001), ambulatory status (P < 0.001) and performance score (P < 0.001) were associated with survival, OTT not even on univariate analysis (P = 0.55). CONCLUSIONS: Since an OTT of 14-15 days had no negative impact on outcomes compared to 12 days, compensation in form of an additional radiation fraction or continuation of radiotherapy during weekends is not required, if radiotherapy cannot be started on a Monday.

Excellent outcomes after radiotherapy alone for malignant spinal cord compression from myeloma.

BACKGROUND: Uncertainty exists whether patients with spinal cord compression (SCC) from a highly radiosensitive tumor require decompressive spinal surgery in addition to radiotherapy (RT). This study addressed the question by evaluating patients receiving RT alone for SCC from myeloma. PATIENTS AND METHODS: Data of 238 patients were retrospectively analyzed for response to RT and local control of SCC. In addition, the effect of RT on motor function (improvement, no further progression, deterioration) was evaluated. Overall response was defined as improvement or no further progression of motor dysfunction. Prior to RT, patients were presented to a neurosurgeon for evaluation whether upfront decompressive surgery was indicated (e.g. vertebral fracture or unstable spine). RESULTS: In the entire cohort, the overall response rate was 97% (53% improvement plus 44% no further progression). Following RT, 88% of the patients were able to walk. Of the 69 non-ambulatory patients 44 patients (64%) regained the ability to walk. Local control rates at 1, 2 and 3 years were 93%, 82% and 82%, respectively. A trend towards better local control was observed for patients who were ambulatory before starting RT (p = 0.08) and those with a more favorable performance status (p = 0.07). CONCLUSIONS: RT alone provided excellent response rates, functional outcomes and local control in patients with SCC from myeloma. These results should be confirmed in a prospective randomized trial.

Impact of hypofractionation and tangential beam IMRT on the acute skin reaction in adjuvant breast cancer radiotherapy.

BACKGROUND: The purpose of the study was to evaluate the impact of multiple prognostic factors on the acute skin reaction in adjuvant breast cancer radiotherapy, in particular the impact of hypofractionation (HF) compared to conventional fractionation (CF) and tangential beam (TB) IMRT compared to three-dimensional conformal radiotherapy (3DCRT). METHODS: Two-hundred and sixty-six breast cancer patients with postoperative radiotherapy after breast conserving surgery or mastectomy were retrospectively evaluated. Patients were treated with HF (15 fractions of 2.67 Gy; n = 121) or CF (28 fractions of 1.8 Gy or 25 fractions of 2.0 Gy; n = 145) and TB-IMRT (n = 151) or 3DCRT (n = 115). The acute skin reactions were prospectively assessed using the CTCAE v4 grading scale. Ordinal regression analysis was used to assess the impact of possible prognostic factors on the maximal acute skin reaction. RESULTS: Grade 2 skin reactions were observed in 19 % of the patients treated with CF compared to 2 % treated with HF. On univariate analysis, the fractionation regimen, the PTV (breast versus chest wall), the volume of the PTV and the body mass index were significant prognostic factors for the maximum acute skin reaction. On multivariate analysis, the fractionation regimen (p < 0.00001) and the volume of the PTV (p = 0.0002) remained as independent significant factors. CONCLUSIONS: Our data suggest that HF is associated with a significantly reduced maximal acute skin reaction compared to CF.

A scoring system for predicting the survival prognosis of patients receiving stereotactic body radiation therapy (SBRT) for 1-3 lung metastases.

INTRODUCTION: The main goal of the present study was the development of a survival scoring system for patients treated with stereotactic body radiation therapy (SBRT) for very few lung metastases. Such an instrument would be of value when selecting the optimal dose for individual patients with a limited number of pulmonary lesions. METHODS: Forty-six patients receiving SBRT for 1-3 lung metastases were retrospectively analyzed. The biologically effective dose plus nine characteristics [gender, age, performance score, interval from tumor diagnosis to SBRT, primary tumor type, additional (extra-pulmonary) metastases, major location of lung metastases, number of pulmonary lesions, and volume treated with SBRT] were evaluated. Characteristics significantly associated with the survival on Cox regression analysis were incorporated in the scoring system. Scoring points were received from 1-year survival rates divided by 10. Sums of these scoring points represented the scores for the individual patients. RESULTS: Survival rates at 1 and 2 years were 66 and 56 %, respectively. On Cox regression analysis, performance score (p = 0.025), the type of primary tumor (p = 0.013) and the additional metastases (p = 0.032) had a significant impact on survival. Scores for patients ranged from 15 to 25 points. Three groups were designed: 15 points, 16-20 points, and 21-25 points. One-year survival rates were 0, 52, and 83 %, respectively (p = 0.005); 2-year survival rates were 0, 52, and 66 %, respectively. CONCLUSION: A survival scoring system for patients receiving SBRT for very few lung metastases was developed. This score allowed us to estimate the survival prognosis of these patients and can aid physicians when aiming to choose the optimal SBRT dose for individual patients.

Radiation Therapy Alone Provides Excellent Outcomes for Spinal Cord Compression from Vertebral Lymphoma.

AIM: Malignant spinal cord compression (SCC) is treated with radiotherapy (RT). Additional neurosurgery has become more widely used since a trial showed a benefit for selected patients. Although lymphomas were excluded from that trial, neurosurgery is also increasingly being performed in these patients. This study investigated whether neurosurgery is actually required for this group. PATIENTS AND METHODS: Twenty-nine patients receiving RT alone for SCC from vertebral lymphoma were analyzed for motor function, walking ability, in-field recurrence and survival. RESULTS: Overall response was 100% (72% improvement, 28% stable). At 1, 6 and 12 months after RT, 83%, 100% and 100% of patients were able to walk; 64%, 100%, and 100% of non-ambulatory patients regained their walking ability. Freedom from in-field recurrence was 100% at 6 and 12 months. Survival rates at 6 and 12 months were 79% and 75%. CONCLUSION: RT alone resulted in excellent outcomes for SCC from lymphoma. These patients may not require surgery.

Stereotactic Body Radiotherapy Provides Excellent Long-Term Local Control of Very Few Lung Metastases.

AIM: To evaluate treatment outcomes after stereotactic body radiotherapy (SBRT) for a limited number of lung metastases mainly focusing on local control. PATIENTS AND METHODS: Forty-six patients receiving SBRT for 1-3 lung metastases were retrospectively evaluated. Local control, freedom from distant progression and overall survival were evaluated in the entire series. In addition, nine factors (gender, age, performance status, interval between cancer diagnosis and SBRT, primary tumor type, other metastases, main site and number of lesions, irradiated volume, SBRT dose) were evaluated for local control. RESULTS: Local control rates at 1, 2 and 3 years were 93%, 93% and 78%, respectively. Rates of freedom from distant progression were 57%, 38% and 29%, respectively, and overall survival rates were 66%, 56% and 36%, respectively. Only one patient (2%) experienced radiation-induced pneumonitis. CONCLUSION: SBRT administered for very few lung metastases resulted in excellent long-term local control rates and was associated with very little toxicity.

Stereotactic Body Radiotherapy (SBRT) with Lower Doses for Selected Patients with Stage I Non-small-cell Lung Cancer (NSCLC).

SBRT is very effective for stage I NSCLC. Biologically effective doses (BED) >100 Gy are recommended. Elderly patients and those with a limited performance status may not tolerate these high doses. This study investigated the outcomes after lower dose SBRT (BED < 90 Gy) in 46 patients with stage I NSCLC, who were aged ≥70 years or in reduced general condition. Local control rates at 1, 2, and 3 years were 100, 95, and 95 %, respectively. Rates of freedom from distant progression were 83, 63, and 54 %, and survival rates were 77, 57, and 36 %, respectively. Seventeen patients died during the follow-up, 11 (65 %) from distant progression of NSCLC, and six (35 %) from non-malignant causes. No patient developed radiation-induced pneumonitis. Thus, SBRT with BED <90 Gy resulted in excellent local control and appears to be a reasonable option for stage I NSCLC in elderly patients and those with a poor performance status.

Stereotactic Body Radiation Therapy (SBRT) for Recurrent Non-small Cell Lung Cancer (NSCLC).

AIM: For local recurrence of non-small cell lung cancer (NSCLC), stereotactic body radiation therapy (SBRT) has become increasingly popular. Many patients with recurrent NSCLC are unable to receive high-dose SBRT [biologically effective dose (BED) >100 Gy] due to poor performance status and potential normal tissue damage. PATIENTS AND METHODS: Thirty-one patients receiving lower-dose SBRT with a BED of 57.6 to 96.0 Gy, were analyzed for local control, freedom from distant progression and survival. RESULTS: In the entire series, local control rates were 96% at 1, 2 and 3 years. Freedom from distant progression rates were 74%, 65% and 65%, respectively, and survival rates were 87%, 65% and 65%, respectively. On multivariate analysis, freedom from distant progression was significantly associated with absence of distant metastases (p=0.009), and survival with BED >75 Gy (p=0.039). CONCLUSION: SBRT with BED <100 Gy provided very promising outcomes when administered for recurrent NSCLC. A BED >75 Gy is recommended, which was superior to lower doses.

Radiotherapy With 4 Gy × 5 Versus 3 Gy × 10 for Metastatic Epidural Spinal Cord Compression: Final Results of the SCORE-2 Trial (ARO 2009/01).

PURPOSE: To compare short-course radiotherapy (RT) (4 Gy × 5) to longer-course RT (3 Gy × 10) for metastatic epidural spinal cord compression (MESCC). PATIENTS AND METHODS: Two-hundred three patients with MESCC and poor to intermediate expected survival were randomly assigned to 4 Gy × 5 in 1 week (n = 101) or 3 Gy × 10 in 2 weeks (n = 102). Patients were stratified according to ambulatory status, time developing motor deficits, and primary tumor type. Seventy-eight and 77 patients, respectively, were evaluable for the primary end point, 1-month overall response regarding motor function defined as improvement or no further progression of motor deficits. Other study end points included ambulatory status, local progression-free survival, and overall survival. End points were evaluated immediately after RT and at 1, 3, and 6 months thereafter. RESULTS: At 1 month, overall response rates regarding motor function were 87.2% after 4 Gy × 5 and 89.6% after 3 Gy × 10 (P = .73). Improvement rates were 38.5% and 44.2%, respectively, no further progression rates 48.7% and 45.5%, respectively, and deterioration rates 12.8% and 10.4%, respectively (P = .44). Ambulatory rates at 1 month were 71.8% and 74.0%, respectively (P = .86). At other times after RT, the results were also not significantly different. Six-month local progression-free survival was 75.2% after 4 Gy × 5 and 81.8% after 3 Gy × 10 (P = .51); 6-month overall survival was 42.3% and 37.8% (P = .68). CONCLUSION: Short-course RT with 4 Gy × 5 was not significantly inferior to 3 Gy × 10 in patients with MESCC and poor to intermediate expected survival.

Image-guided intensity-modulated radiotherapy of prostate cancer: Analysis of interfractional errors and acute toxicity.

PURPOSE: The aim of the study was to estimate interfractional deviations in patient and prostate position, the impact of the frequency of online verification on the treatment margins, and to assess acute radiation reactions of high-dose external beam image-guided intensity-modulated radiotherapy (IG-IMRT) of localized prostate cancer. PATIENTS AND METHODS: IG-IMRT was performed by daily online verification of implanted fiducial prostate markers using a megavoltage electronic portal imaging device (EPID). A total of 1011 image-guided treatment fractions from 23 consecutive unselected prostate cancer patients were analyzed. The median total dose was 79.2 Gy (range 77.4-81.0 Gy). Acute radiation reactions were assessed weekly during radiotherapy using the Common Terminology Criteria for Adverse Events (CTCAE) v.4.03. RESULTS: A relevant combined patient set-up and prostate motion population random error of 4-5 mm was observed. Compared to daily IGRT, image guidance every other day required an expansion of the CTV-PTV (clinical target volume-planning target volume) margin of 8.1, 6.6, and 4.1 mm in the longitudinal, vertical, and lateral directions, thereby, increasing the PTV by approximately 30-40 %. No grade 3 or 4 acute radiation reactions were observed with daily IG-IMRT. CONCLUSION: A high dose with surprisingly low acute toxicity can be applied with daily IG-IMRT using implanted fiducial prostate markers. Daily image guidance is clearly superior to image guidance every other fraction concerning adequate target coverage with minimal margins.

Predicting Survival After Irradiation for Brain Metastases from Head and Neck Cancer.

AIM: Patients with cerebral metastases from head and neck cancer are not common. This study aimed to create an instrument for estimating survival in this particular group of patients. PATIENTS AND METHODS: Survival was significantly influenced by Eastern Cooperative Oncology Group (ECOG) performance score, number of cerebral lesions and extracranial metastatic disease. These characteristics were included in our score. RESULTS: Scoring was based on 6-month survival data: ECOG 0-1=1 point, ECOG 2-3=0 points, 1-3 cerebral lesions=1 point, ≥4 cerebral lesions=0 points, lack of extracranial metastases=1 point, and presence of extracranial metastases=0 points. Addition of these points for each patient resulted in 0-3 points. Three groups were built comprising 0-1, 2 and 3 points. Six-month survival rates for these groups were 0%, 50% and 100%, respectively. CONCLUSION: This new instrument guides physicians in choosing optimal irradiation programs for patients with cerebral metastases from head-and-neck cancer.

Single-Fraction Versus 5-Fraction Radiation Therapy for Metastatic Epidural Spinal Cord Compression in Patients With Limited Survival Prognoses: Results of a Matched-Pair Analysis.

PURPOSE: This study compared single-fraction to multi-fraction short-course radiation therapy (RT) for symptomatic metastatic epidural spinal cord compression (MESCC) in patients with limited survival prognosis. METHODS AND MATERIALS: A total of 121 patients who received 8 Gy × 1 fraction were matched (1:1) to 121 patients treated with 4 Gy × 5 fractions for 10 factors including age, sex, performance status, primary tumor type, number of involved vertebrae, other bone metastases, visceral metastases, interval between tumor diagnosis and MESCC, pre-RT ambulatory status, and time developing motor deficits prior to RT. Endpoints included in-field repeated RT (reRT) for MESCC, overall survival (OS), and impact of RT on motor function. Univariate analyses were performed with the Kaplan-Meier method and log-rank test for in-field reRT for MESCC and OS and with the ordered-logit model for effect of RT on motor function. RESULTS: Doses of 8 Gy × 1 fraction and 4 Gy × 5 fractions were not significantly different with respect to the need for in-field reRT for MESCC (P=.11) at 6 months (18% vs 9%, respectively) and 12 months (30% vs 22%, respectively). The RT regimen also had no significant impact on OS (P=.65) and post-RT motor function (P=.21). OS rates at 6 and 12 months were 24% and 9%, respectively, after 8 Gy × 1 fraction versus 25% and 13%, respectively, after 4 Gy × 5 fractions. Improvement of motor function was observed in 17% of patients after 8 Gy × 1 fraction and 23% after 4 Gy × 5 fractions, respectively. CONCLUSIONS: There were no significant differences with respect to need for in-field reRT for MESCC, OS, and motor function by dose fractionation regimen. Thus, 8 Gy × 1 fraction may be a reasonable option for patients with survival prognosis of a few months.

A matched-pair analysis comparing 5x4 Gy and 10x3 Gy for metastatic spinal cord compression (MSCC) in patients with favorable survival prognoses.

BACKGROUND: It is currently not possible to get an approval of our ethics committee for a randomized trial cmparing 5x4 Gy and 10x3 Gy for MSCC that includes patients with favorable survival prognoses. Therefore, this matched-pair study following strict matching criteria was perfomed instead. METHODS: In this study, 142 receiving 5x4 Gy were retrospectively matched (1:1) to 142 patients receiving 10x3 Gy with respect to ten characteristics. These characteristics included age, gender, performance status, tumor type, involved vertebrae, other bone metastases, visceral metastases, interval between tumor diagnosis and MSCC, pre-RT ambulatory status, and time developing motor deficits. RESULTS: On multivariate analysis, post-RT motor function was associated with performance status (p<0.001), tumor type (p < 0.001), and time developing motor deficits (p<0.001). RT was successful in 76% of patients receiving 5x4 Gy and 69% receiving 10x3 Gy (p=0.14). Pre.RT ambulatory status showed a strong trend with respect to local control (LC) of MSCC in the multivariate analysis (p=0.058). 1-year LC rates were 87% after 5x4 Gy and 93% after 10x3 Gy (p=0.16). On multivariate analysis, survival (OS) was associated with performance score (p<0.001), visceral metastases (p<0.001), and pre-RT ambulatory status (p=0.004). 1-year OS rates were 68% after 5x4 Gy and 73% after 10x3 Gy (p = 0.64). CONCLUSIONS: In patients irradiated for MSCC who had favorable survival prognoses, post-RT motor function, LC and OS were not significantly different after 5x4 Gy and after 10x3 Gy.