Radiation recall reaction with docetaxel administration after accelerated partial breast irradiation with electronic brachytherapy.

PURPOSE: Accelerated partial breast irradiation (APBI) offers several advantages over whole breast irradiation. Electronic brachytherapy may further reduce barriers to breast conserving therapy by making APBI more available. However, its toxicity profile is not well characterized. METHODS AND MATERIALS: A 60-year-old woman was treated with APBI using Axxent (Xoft, Sunnyvale, CA) electronic brachytherapy. One month after APBI, a cycle of docetaxel and cyclophosphamide was given. Within 3 weeks, the patient developed an ulcerative radiation recall reaction in the skin overlying the lumpectomy cavity. To investigate this toxicity, the skin dose from electronic brachytherapy was compared with the dose that would have been delivered by an iridium-192 ((192)Ir) source. Additionally, a dose equivalent was estimated by adjusting for the increased relative biologic effectiveness (RBE) of low energy photons generated by the electronic source. RESULTS: Using electronic brachytherapy, the skin dose was 537cGy per fraction compared with 470cGy for an (192)Ir source. Given an RBE for a 40kV source of 1.28 compared with (192)Ir, the equivalent dose at the skin for an electronic source was 687cGy-equivalents, a 46% increase. CONCLUSIONS: We present a case of an ulcerative radiation recall reaction in a patient receiving APBI with electronic brachytherapy followed by chemotherapy. Our analysis shows that the use of electronic brachytherapy resulted in the deposition of significantly higher equivalent dose at the skin compared with (192)Ir. These findings suggest that standard guidelines (e.g., surface-to-skin distance) that apply to (192)Ir-based balloon brachytherapy may not be applicable to electronic brachytherapy.

Cost of radiotherapy versus NSAID administration for prevention of heterotopic ossification after total hip arthroplasty.

PURPOSE: Heterotopic ossification (HO), or abnormal bone formation, is a common sequela of total hip arthroplasty. This abnormal bone can impair joint function and must be surgically removed to restore mobility. HO can be prevented by postoperative nonsteroidal anti-inflammatory drug (NSAID) use or radiotherapy (RT). NSAIDs are associated with multiple toxicities, including gastrointestinal bleeding. Although RT has been shown to be more efficacious than NSAIDs at preventing HO, its cost-effectiveness has been questioned. METHODS AND MATERIALS: We performed an analysis of the cost of postoperative RT to the hip compared with NSAID administration, taking into account the costs of surgery for HO formation, treatment-induced morbidity, and productivity loss from missed work. The costs of RT, surgical revision, and treatment of gastrointestinal bleeding were estimated using the 2007 Medicare Fee Schedule and inpatient diagnosis-related group codes. The cost of lost wages was estimated using the 2006 median salary data from the U.S. Census Bureau. RESULTS: The cost of administering RT was estimated at $899 vs. $20 for NSAID use. After accounting for the additional costs associated with revision total hip arthroplasty and gastrointestinal bleeding, the corresponding estimated costs were $1,208 vs. $930. CONCLUSION: If the costs associated with treatment failure and treatment-induced morbidity are considered, the cost of NSAIDs approaches that of RT. Other NSAID morbidities and quality-of-life differences that are difficult to quantify add to the cost of NSAIDs. These considerations have led us to recommend RT as the preferred modality for use in prophylaxis against HO after total hip arthroplasty, even when the cost is considered.

Management of a patient with borderline resectable pancreatic cancer. Case report and review.

The definition and management of borderline resectability for periampullary pancreatic adenocarcinoma are evolving. In this case report, we discuss the presentation, workup, and therapeutic management of a 40-year-old man who presented with borderline resectable, periampullary pancreatic cancer and underwent a margin-negative resection following neoadjuvant chemoradiotherapy.

Psoas muscle metastases in non-small cell lung cancer.

Lung cancer is the leading cause of cancer-related death in the U.S. and often spreads via lymphatics or through hematogenous metastasis to the brain, bone and adrenal glands. Isolated metastases to skeletal muscle, including the psoas muscles, are very uncommon. The present report is a case series of three patients with psoas metastases from non-small cell lung cancer (NSCLC) and a review of the relevant literature. Three patients presented with psoas muscle metastases from NSCLC detected on diagnostic imaging. All patients were treated with radiotherapy to the psoas muscle, and two patients were treated with curative intent on an oligometastatic paradigm. Radiotherapy to the psoas muscle was effective and well tolerated.

Radiation therapy for heterotopic ossification prophylaxis afer high-risk elbow surgery.

Heterotopic ossification (HO) is a common complication of elbow trauma or surgery. HO can impair joint function; when it does, surgical removal is required. Radiotherapy (RT) prevents HO formation in the hip. However, few data exist on the efficacy of RT in preventing HO formation in the elbow. We retrospectively analyzed the outcomes of elbow surgery followed by prophylactic single-fraction RT and use of nonsteroidal anti-inflammatory drugs (NSAIDs). All patients had ectopic bone resected at surgery or significant risk factors for development of ectopic bone. Of the 52 patients who underwent RT after high-risk elbow surgery, 44 had postoperative radiographs of the treated elbow available for evaluation. At a median follow-up of 136 days, 21 patients (48%) had radiographic evidence of HO. In all cases, however, the HO was small and not functionally significant. No complications were attributed to RT use. This retrospective review represents the largest published series of patients who have undergone postoperative RT to prevent HO formation in the elbow. Our findings support the idea that RT, in combination with NSAID use, is safe and efficacious in preventing development of clinically significant HO in the elbow.

Helical tomotherapy delivery of an IMRT boost in lieu of interstitial brachytherapy in the setting of gynecologic malignancy: feasibility and dosimetric comparison.

Interstitial brachytherapy is an important means by which to improve local control in gynecologic malignancy when intracavitary brachytherapy is untenable. Patients unable to receive brachytherapy have traditionally received conventional external beam radiation alone with modest results. We investigated the ability of Tomotherapy (Tomotherapy Inc., Madison, WI) to replace interstitial brachytherapy. Six patients were selected. The planning CT of each patient was contoured with the planning target volume (PTV), bladder, rectum, femoral heads, and bowel. Identical contour sets were exported to Tomotherapy and Nucletron PLATO (Nucletron B.V., Veenendaal, The Netherlands). With Tomotherapy, the PTV was prescribed 31 Gy in 5 fractions to 90% of the volume. With PLATO, 600 cGy × 5 fractions was prescribed to the surface of the PTV. Dose delivered was normalized to 2 Gy fractions (EQD2) and added to a hypothetical homogenous 45-Gy pelvic dose. Tomotherapy achieved a D90 of 87 Gy EQD2 versus 86 Gy with brachytherapy. PTV dose was more homogeneous with tomotherapy. The dose to the most at-risk 2 mL of bladder and rectum with Tomotherapy was of 78 and 71 Gy EQD2 versus 81 and 75 Gy with brachytherapy. Tomotherapy delivered more dose to the femoral heads (mean 1.23 Gy per fraction) and bowel. Tomotherapy was capable of replicating the peripheral dose achieved with brachytherapy, without the PTV hotspots inherent to interstitial brachytherapy. Similar maximum doses to bowel and bladder were achieved with both methods. Excessive small bowel and femoral head toxicity may result if previous pelvic irradiation is not planned accordingly. Significant challenges related to interfraction and intrafraction motion must be overcome if treatment of this nature is to be contemplated.

Review and commentary on the role of radiation therapy in the adjuvant management of pancreatic cancer.

Currently, pancreatic cancer is fatal in over 90% of cases. Complete resection (if possible) is required for cure but the optimal adjuvant therapy is controversial. Given that pancreatic cancer frequently recurs both locoregionally and distantly, oncologic principles support the role of both adjuvant chemotherapy and radiotherapy. The historic trials evaluating chemoradiotherapy are too limited to provide clear guidance, but when viewed together with single institution data they suggest that chemoradiotherapy is beneficial. New data strongly support the use of adjuvant gemcitabine chemotherapy, but the benefit of the addition of radiation is still under investigation and no consensus exists on a standard of care. Clearly, no combination of currently available agents is sufficient to provide acceptable cure rates in pancreatic cancer and novel therapies must be found.

Toxicity associated with bowel or bladder puncture during gynecologic interstitial brachytherapy.

PURPOSE: Interstitial brachytherapy for gynecologic malignancies is associated with significant toxicity. Some reports have correlated this toxicity with needle puncture of the visceral organs. This study examined our experience with interstitial brachytherapy and investigated the relationship between the visceral puncture and toxicity. METHODS AND MATERIALS: The outcomes of 36 patients treated with interstitial brachytherapy for gynecologic malignancies at a single institution between 2002 and 2007 were reviewed. Computed tomography was used to guide needle placement based solely on tumor coverage. No attempts were made to avoid visceral puncture; however, the source dwell times were minimized in these areas. RESULTS: At a median follow-up of 21 months, the crude locoregional control rate was 78%. Bowel puncture was noted in 26 patients and bladder puncture in 19. The mean operating time was 50 min, and 86% of patients were discharged in

Variation in post-surgical lumpectomy cavity volume with delay in initiation of breast irradiation because of chemotherapy.

PURPOSE: The addition of a radiotherapy boost has been shown to improve local control in breast conservation therapy. Three dimensional planning provides more accurate targeting of the operative bed than clinical setup using the lumpectomy scar. However, contraction of the lumpectomy cavity over time may have implications for the volume of tissue included in the boost field. METHODS AND MATERIALS: The clinical variables and treatment planning volumes for patients receiving whole-breast radiotherapy at a single institution between July 1, 2006, and December 31, 2007 were analyzed retrospectively. RESULTS: Of the 93 patients identified, 29 received chemotherapy (CTX) and 64 did not; CTX was sequenced before radiotherapy in all patients. Patients receiving CTX were more likely to have higher T and N stage and a longer interval between definitive breast surgery and radiation. The lumpectomy specimens of women receiving CTX trended toward being larger than those of women not receiving CTX (113.4 cm(3) vs. 74.6 cm(3), p = 0.08). Despite this, the volume of the lumpectomy cavity measured on computed tomography was smaller in patients receiving CTX (9.1cm(3) vs. 16.8 cm(3), p = 0.02), as was the volume of the planning target volume (56.6 cm(3) vs. 79.9 cm(3), p = 0.02). CONCLUSIONS: Patients receiving CTX were at higher risk for local recurrence. However, as a result of lumpectomy bed contraction, these patients received a boost to a smaller volume than patients not receiving CTX. This finding is counterintuitive and supports re-evaluation of the optimal size of the boost field. In addition, these results may have implications for patients treated with partial breast irradiation.

Tomotherapy and multifield intensity-modulated radiotherapy planning reduce cardiac doses in left-sided breast cancer patients with unfavorable cardiac anatomy.

PURPOSE: For patients with left-sided breast cancers, radiation treatment to the intact breast results in high doses to significant volumes of the heart, increasing the risk of cardiac morbidity, particularly in women with unfavorable cardiac anatomy. We compare helical tomotherapy (TOMO) and inverse planned intensity modulated radiation therapy (IMRT) with three-dimensional conformal radiotherapy using opposed tangents (3D-CRT) for reductions in cardiac volumes receiving high doses. METHODS AND MATERIALS: Fifteen patients with left-sided breast cancers and unfavorable cardiac anatomy, determined by a maximum heart depth (MHD) of >or=1.0 cm within the tangent fields, were planned for TOMO and IMRT with five to seven beam angles, in addition to 3D-CRT. The volumes of heart and left ventricle receiving >or=35 Gy (V35) were compared for the plans, as were the mean doses to the contralateral breast and the volume receiving >or=20 Gy (V20) for the ipsilateral lung. RESULTS: The mean MHD was 1.7 cm, and a significant correlation was observed between MHD and both heart and left ventricle V35. The V35s for IMRT (0.7%) and TOMO (0.5%) were significantly lower than for 3D-CRT (3.6%). The V20 for IMRT (22%) was significantly higher than for 3D-CRT (15%) or TOMO (18%), but the contralateral breast mean dose for TOMO (2.48 Gy) was significantly higher than for 3D-CRT (0.93 Gy) or IMRT (1.38 Gy). CONCLUSIONS: Both TOMO and IMRT can significantly reduce cardiac doses, with modest increases in dose to other tissues in left-sided breast cancer patients with unfavorable cardiac anatomy.

Upright 3D treatment planning using a vertical CT.

In this report, we describe a novel technique used to plan and administer external beam radiation therapy to a patient in the upright position. A patient required reirradiation for thymic carcinoma but was unable to tolerate the supine position due to bilateral phrenic nerve injury and paralysis of the diaphragm. Computed tomography (CT) images in the upright position were acquired at the Northern Illinois University Institute for Neutron Therapy at Fermilab. The CT data were imported into a standard 3-dimensional (3D) treatment planning system. Treatment was designed to deliver 24 Gy to the target volume while respecting normal tissue tolerances. A custom chair that locked into the treatment table indexing system was constructed for immobilization, and port films verified the reproducibility of setup. Radiation was administered using mixed photon and electron AP fields.

A virtual matching technique for three-field breast irradiation using 3-D planning.

Patients with breast cancer are often treated with radiation to the breast (or chest wall) and draining regional lymph nodes. This is typically performed with a three-field technique in which an anterior supraclavicular field is matched to opposed tangent fields. A single isocenter technique is not always possible. Several techniques have been described to create a perfect match using a conventional simulator. We describe and test a simple, fast and accurate technique to estimate the couch and collimator angles required for a perfect geometric match using 3-D treatment planning software. This method requires no mathematical formulae and is verifiable relative to patient anatomy. An external skin contour is created on the axial slice at the match line and displayed with a 3-D representation. Using a beam's eye view (BEV) of a tangent field, small couch and collimator rotation adjustments are made sequentially until the contour edges are superimposed. The virtual external contour technique was easy to use, gave verification of the match in the BEV and yielded estimates of couch and collimator rotations very close to those calculated using published formulae.

A dosimetric analysis comparing treatment of low-risk prostate cancer with TomoTherapy versus static field intensity modulated radiation therapy.

OBJECTIVES: Static field intensity modulated radiation therapy (IMRT) has demonstrated dosimetric and clinical benefits over 3-dimensional conformal radiation therapy. TomoTherapy is a unique form of IMRT that may offer further improvements. METHODS: The study population consisted of 15 patients with low-risk prostate cancer treated at Rush University with TomoTherapy (n = 7) or IMRT (n = 8). For each patient, both a TomoTherapy plan and an IMRT plan were generated using identical planning objectives. The planning target volume (PTV) was defined as the prostate and proximal seminal vesicles plus a margin. The prescription dose was 7740 cGy in 43 fractions. Radiation Therapy Oncology Group (RTOG) normal tissue guidelines were used as constraints, and the PTV coverage was made equivalent for the paired plans by equalizing the PTV V100. RTOG benchmark DVH values for the rectum and bladder and mean dose to the penile bulb were recorded. The volume of PTV receiving ≥ 105% of the prescription dose was measured. RESULTS: The mean DVH values for each of the RTOG constraints for rectum and bladder were significantly improved using TomoTherapy. The volume of the PTV that received at least 105% of the dose was higher with IMRT (11.7% vs. 0.2%, <0.001). The mean dose to the penile bulb was higher with TomoTherapy (40.4 Gy vs. 27.4 Gy, P = 0.005). CONCLUSIONS: TomoTherapy offers a more favorable dose distribution to the bladder and rectum, as well as improved target homogeneity in comparison with IMRT.

Case report and dosimetric analysis of an axillary recurrence after partial breast irradiation with mammosite catheter.

Partial breast irradiation (PBI) was designed in part to decrease overall treatment times associated with whole breast radiation therapy (WBRT). WBRT treats the entire breast and usually portions of the axilla. The goal of PBI is to treat a smaller volume of breast tissue in less time, focusing the dose around the lumpectomy cavity. The following is a case of a 64-year-old woman with early-stage breast cancer treated with PBI who failed regionally in the ipsilateral axilla. With our dosimetric analysis, we found that the entire area of this axillary failure would have likely received at least 45 Gy if WBRT had been used, enough to sterilize microscopic disease. With PBI, this area received a mean dose of only 2.8 Gy, which raises the possibility that this regional failure may have been prevented had WBRT been used instead of PBI.