Simultaneous integrated boost for adjuvant treatment of breast cancer--intensity modulated vs. conventional radiotherapy: the IMRT-MC2 trial.

BACKGROUND: Radiation therapy is an essential modality in the treatment of breast cancer. Addition of radiotherapy to surgery has significantly increased local control and survival rates of the disease. However, radiotherapy is also associated with side effects, such as tissue fibrosis or enhanced vascular morbidity. Modern radiotherapy strategies, such as intensity modulated radiotherapy (IMRT), can shorten the overall treatment time by integration of the additional tumor bed boost significantly. To what extent this might be possible without impairing treatment outcome and cosmetic results remains to be clarified. METHODS/DESIGN: The IMRT-MC2 study is a prospective, two armed, multicenter, randomized phase-III-trial comparing intensity modulated radiotherapy with integrated boost to conventional radiotherapy with consecutive boost in patients with breast cancer after breast conserving surgery. 502 patients will be recruited and randomized into two arms: patients in arm A will receive IMRT in 28 fractions delivering 50.4 Gy to the breast and 64.4 Gy to the tumor bed by integrated boost, while patients in arm B will receive conventional radiotherapy of the breast in 28 fractions to a dose of 50.4 Gy and consecutive boost in 8 fractions to a total dose of 66.4 Gy. DISCUSSION: Primary objectives of the study are the evaluation of the cosmetic results 6 weeks and 2 years post treatment and the 2- and 5-year local recurrence rates for the two different radiotherapy strategies. Secondary objectives are long term overall survival, disease free survival and quality of life. TRIAL REGISTRATION: ClinicalTrials.gov Protocol ID: NCT01322854.

Stereotactic body radiotherapy (SBRT) for adrenal metastases of oligometastatic or oligoprogressive tumor patients.

INTRODUCTION: Local ablative treatment strategies are frequently offered to patients diagnosed with oligometastatic disease. Stereotactic body radiotherapy (SBRT), as ablative treatment option, is well established for lung and liver metastases, whereas for isolated adrenal gland metastases the level of evidence is scarce. MATERIAL AND METHODS: This single-institution analysis of oligometastatic or oligoprogressive disease was limited to patients who received SBRT to adrenal metastasis between 2012 and 2019. Patient, tumor, treatment characteristics, and dosimetric parameters were analyzed for evaluation of their effect on survival outcomes. RESULTS: During the period of review 28 patients received ablative SBRT to their adrenal gland metastases. Most common primary tumors were non-small cell lung cancers (46%) with most patients diagnosed with a single adrenal gland metastasis (61%), which occurred after a median time of 14 months. SBRT was delivered to a median biological effective dose at α/ß of 10 (BED10) of 75 Gy (range: 58-151 Gy). Median gross tumor volume (GTV) and median planning target volume (PTV) were 42 and 111 mL, respectively. The homogeneity and conformity indices were 1.17 (range: 1.04-1.64) and 0.5 (range: 0.4.0.99), respectively, with the conformity index being affected by dose restrictions to organs at risk (OARs) in 50% of the patients. Overall response rate based on RECIST criteria was 86% (CR = 29%, PR = 57%) with 2-year local control (LC) of 84.8%, 2-year progression-free survival (PFS) of 26.3%, and 1-and 2-year overall survival (OS) of 46.6 and 32.0%, respectively. During follow up, only two local recurrences occurred. A trend for superior LC was seen if BED10 was ≥75Gy (p = 0.101) or if the PTV was < 100 ml (p = 0.072). SBRT was tolerated well with only mild toxicity. CONCLUSION: SBRT for adrenal metastases resulted in promising LC with low toxicity. Treatment response appeared to be superior, if SBRT was applied with higher BED. As the close proximity of OARs often limits the application of sufficiently high doses, further dose escalations strategies and techniques should be investigated in future.

Acute toxicity of normofractionated intensity modulated radiotherapy with simultaneous integrated boost compared to three-dimensional conformal radiotherapy with sequential boost in the adjuvant treatment of breast cancer.

BACKGROUND: Intensity-modulated radiotherapy (IMRT) improves dose homogeneity and late toxicity compared to simple tangential techniques in adjuvant whole-breast radiotherapy for patients with breast cancer. Simultaneous-integrated boost (SIB) radiotherapy shortens the overall treatment time and improves dose homogeneity. However, prospective randomized trials regarding IMRT with SIB for adjuvant radiotherapy in breast cancer are lacking. METHODS: The IMRT-MC2 (MINT) trial is a phase III prospective randomized controlled trial comparing IMRT with SIB (Arm A: whole breast 28 × 1.8 Gy, Boost 28 × 2.3 Gy) to 3D-conformal radiotherapy with a sequential boost (Arm B: whole breast 28 × 1.8 Gy, boost 8 × 2 Gy) in patients with breast cancer after BCS. Indication for boost radiotherapy was defined as age < 70 years or age > 70 years with presence of additional risk factors. This is a retrospective analysis of acute toxicity at one of two trial sites. RESULTS: Five hundred two patients were randomized, of which 446 patients were eligible for this analysis. There was no statistically significant difference in terms of any grade radiation dermatitis between the two treatment arms at the end of treatment (p = 0.26). However, radiation dermatitis grade 2/3 (29.1% vs. 20.1 and 3.5% vs. 2.3%) occurred significantly more often in Arm A (p = 0.02). Breast/chest wall pain at the first follow-up visit was significantly more common in patients treated on Arm B (p = 0.02). CONCLUSIONS: Treatment on both arms was well tolerated, however there were some differences regarding radiodermatitis and breast pain. Further analyses are ongoing. TRIAL REGISTRATION: clinicaltrials.gov , NCT01322854 , registered 24th March 2011.

Halfpipe coaxial cannula for self-contained vacuum-assisted biopsy systems: feasibility in a pig breast model.

OBJECTIVE: The purpose of this article is to discuss the development of a dedicated halfpipe coaxial cannula for stereotactic vacuum-assisted biopsy. We evaluated the system by retrieving 18 copper targets from a pig breast model in the upright position via vertical and lateral approaches. CONCLUSION: Sampling was successful in 15 of 18 cases. Errors occurred only in superficial lesions biopsied via the vertical approach. The halfpipe coaxial cannula shows promise for improving positioning accuracy, avoiding target dislocation, and obviating repeated needle repositioning.

Acute Toxicity and Early Oncological Outcomes After Intraoperative Electron Radiotherapy (IOERT) as Boost Followed by Whole Breast Irradiation in 157 Early Stage Breast Cancer Patients-First Clinical Results From a Single Center.

Introduction: Breast conserving surgery (BCS) followed by postoperative whole breast irradiation (WBI) is the current standard of care for early stage breast cancer patients. Boost to the tumor bed is recommended for patients with a higher risk of local recurrence and may be applied with different techniques. Intraoperative electron radiotherapy (IOERT) offers several advantages compared to other techniques, like direct visualization of the tumor bed, better skin sparing, less inter- and intrafractional motion, but also radiobiological effects may be beneficial. Objective of this retrospective analysis of IOERT as boost in breast cancer patients was to assess acute toxicity and early oncological outcomes. Material and Methods: All patients, who have been irradiated between 11/2014 and 01/2018 with IOERT during BCS were analyzed. IOERT was applied using the mobile linear accelerator Mobetron with a total dose of 10 Gy, prescribed to the 90% isodose. After ensured woundhealing, WBI followed with normofractionated or hypofractionated regimens. Patient reports, including diagnostic examinations and toxicity were analyzed after surgery and 6-8 weeks after WBI. Overall survival, distant progression-free survival, in-breast and contralateral breast local progression-free survival were calculated using the Kaplan-Meier method. Furthermore, recurrence patterns were assessed. Results: In total, 157 patients with a median age of 57 years were evaluated. Postoperative adverse events were mild with seroma and hematoma grade 1-2 in 26% and grade 3 in 0.6% of the patients. Wound infections grade 2-3 occurred in 2.2% and wound dehiscence grade 1-2 in 1.9% of the patients. Six to eight weeks after WBI radiotherapy-dependent acute dermatitis grade 1-2 was most common in 90.9% of the patients. Only 4.6% of the patients suffered from dermatitis grade 3. No grade 4 toxicities were documented after surgery or WBI. 2- and 3-year overall survival and distant progression-free survival, were 97.5 and 93.6, and 0.7 and 2.8%, respectively. In-breast recurrence and contralateral breast cancer rates after 3 years were 1.9 and 2.8%, respectively. Conclusion: IOERT boost during BCS is a safe treatment option with low acute toxicity. Short-term recurrence rates are comparable to previously published data and emphasize, that IOERT as boost is an effective treatment.

Radiotherapy for Colorectal Cancer: Current Standards and Future Perspectives.

BACKGROUND: Multimodal treatment approaches are indispensable for patients with advanced-stage colorectal cancer. Radiotherapy has been established as essential part of perioperative concepts and was introduced as an option to face challenges such as local relapse or oligometastases. METHODS: A literature review was performed to summarize evidence and current standards of radiotherapeutic concepts in the treatment of colorectal cancer. RESULTS: For stage II/III rectal cancer, neoadjuvant radiotherapy is superior to adjuvant treatment. Two preoperative regimens have been established and are commonly used with different objectives: short-course radiotherapy (SC-RT) and long-course chemoradiotherapy (LC-CRT). Both reduce the risk of local relapse. Additionally, LC-CRT aims at downsizing the tumor to potentially reduce radicalness of surgery. There is increasing evidence that not all stage II/III rectal cancer patients need neoadjuvant irradiation but also that in some cases surgery might be omitted. Stereotactic body radiotherapy (SBRT) of the liver shows high rates of local control in oligometastatic patients. Intraoperative and particle radiotherapy extend the spectrum of treatment options for locally recurrent patients. CONCLUSION: Radiotherapeutic concepts are crucial for the primary management of locally advanced colorectal cancer and can essentially contribute to treatment approaches in locally recurrent, oligometastatic or palliative patients.

Quality of life and fatigue of patients with spinal bone metastases under combined treatment with resistance training and radiation therapy- a randomized pilot trial.

BACKGROUND: The aim of this trial was to compare the effects of resistance training versus passive physical therapy on quality of life (QoL), fatigue, and emotional distress outcomes during radiation therapy in patients with spinal bone metastases under radiotherapy (RT). METHODS: In this randomized trial, 60 patients were treated from September 2011 until March 2013 into one of the two groups: isometric resistance training or physical therapy with thirty patients in each group during RT. EORTC QLQ-BM22, EORTC QLQ-FA13, and FBK-R10 were assessed at baseline, three months, and six months after RT. RESULTS: Psychosocial aspects in resistance training group (Arm A) were significantly improved after three (p = 0.001) and six months (p = 0.010). Other rated items of the QLQ-BM22 painful site, and pain characteristics were without significant differences. Functional interference showed a positive trend after six months (p = 0.081). After six months, physical fatigue (p = 0.013), and interference with daily life (p = 0.006) according to the QLQ-FA13 assessment improved in Arm A significantly. Emotional distress was in Arm A lower after six months (p = 0.016). The Cohen's effect size confirmed the clinically significant improvement of these findings. CONCLUSIONS: In this group of patients we were able to show that guided isometric resistance training of the paravertebral muscles can improve functional capacity, reduce fatigue and thereby enhance QoL over a 6-months period in patients with stable spinal metastases. The results offer a rationale for future large controlled investigations to confirm these findings. TRIAL REGISTRATION: Clinical trial identifier NCT01409720.

Integration of interactive three-dimensional image post-processing software into undergraduate radiology education effectively improves diagnostic skills and visual-spatial ability.

PURPOSE: Integrating interactive three-dimensional post-processing software into undergraduate radiology teaching might be a promising approach to synergistically improve both visual-spatial ability and radiological skills, thereby reducing students' deficiencies in image interpretation. The purpose of this study was to test our hypothesis that a hands-on radiology course for medical students using interactive three-dimensional image post-processing software improves radiological knowledge, diagnostic skills and visual-spatial ability. MATERIALS AND METHODS: A hands-on radiology course was developed using interactive three-dimensional image post-processing software. The course consisted of seven seminars held on a weekly basis. The 25 participating fourth- and fifth-year medical students learnt to systematically analyse cross-sectional imaging data and correlated the two-dimensional images with three-dimensional reconstructions. They were instructed by experienced radiologists and collegiate tutors. The improvement in radiological knowledge, diagnostic skills and visual-spatial ability was assessed immediately before and after the course by multiple-choice tests comprising 64 questions each. Wilcoxon signed rank test for paired samples was applied. RESULTS: The total number of correctly answered questions improved from 36.9±4.8 to 49.5±5.4 (p<0.001) which corresponded to a mean improvement of 12.6 (95% confidence interval 9.9-15.3) or 19.8%. Radiological knowledge improved by 36.0% (p<0.001), diagnostic skills for cross-sectional imaging by 38.7% (p<0.001), diagnostic skills for other imaging modalities - which were not included in the course - by 14.0% (p=0.001), and visual-spatial ability by 11.3% (p<0.001). CONCLUSION: The integration of interactive three-dimensional image post-processing software into undergraduate radiology education effectively improves radiological reasoning, diagnostic skills and visual-spatial ability, and thereby even diagnostic skills for imaging modalities not included in the course.