Durvalumab impacts progression-free survival while high-dose radiation >66 Gy improves local control without excess toxicity in unresectable NSCLC stage III: Real-world data from the Austrian radio-oncological lung cancer study association registry (ALLSTAR).

BACKGROUND: Chemo-radioimmunotherapy with total radiation doses of 60-66 Gy in 2 Gy fractions is the standard of care for non-small cell lung cancer (NSCLC) UICC stage III. The Austrian radio-oncological lung cancer study association registry (ALLSTAR) is a prospective multicentre registry intended to document clinical practice at the beginning of the Durvalumab era. PATIENTS AND METHODS: Patients were eligible if they had pathologically verified unresectable NSCLC stage III with a curative treatment option. Chemo-radiation combined with immunotherapy was performed according to local treatment practices. The endpoints were local control (LC), progression-free survival (PFS) and toxicity. RESULTS: Between 2020/03 and 2023/04, 12/14 (86 %) Austrian radiation-oncology centres recruited 188 patients (median 17, range: 1-89). PD-L1 testing was performed in 173/188 (93 %) patients. The median interval between the end of chemoradiotherapy and start of Durvalumab was 14 days (range: 1-65). About 40 % (75/188) of the patients received a total radiation dose of > 66 Gy (range: 67.1-100), which improved 2-year LC (86 % versus 60 %, HR = 0.41; 95 %-CI: 0.17-0.98; log-rank p-value < 0.05). Median PFS for patients with Durvalumab was 25.8 months (95 %-CI: 21.9-not reached) compared to 15.7 months (95 %-CI: 13.2-27.8) for those without (HR = 1.88; 95 %-CI: 1.16-3.05; log-rank p-value < 0.01). The rates of esophageal and pulmonary toxicities were 34.6 % and 23.9 %, respectively, including one case of grade 4 pneumonitis. In the subcohort of 75 patients who received > 66 Gy, 19 (25 %) cases of pulmonary toxicity grades 1-3 were observed. CONCLUSION: While Durvalumab impacts PFS, LC can be improved by total radiation doses > 66 Gy without excess toxicity.

The positive non-sentinel status is not the main decisional factor for chemotherapy assignment in breast cancer with micrometastatic disease in the sentinel lymph node.

BACKGROUND: Surgical and systemic treatment modalities for breast cancer (BC) patients with micrometastatic disease in the sentinel lymph node biopsy (SNB) are controversial. The aim of this study was to evaluate decisional factors associated with assignment of adjuvant chemotherapy (CT). PATIENTS AND METHODS: In a retrospective multicentric European study we evaluated cases of primary BC patients who underwent SNB. Logistic regression (LR) and recursive partitioning analyses (RPA) were performed to determine factors associated with CT. RESULTS: Of the 172 patients with micrometastatic disease, 39.5% received adjuvant CT. In the group treated with CT, patients tended to be younger (P = 0.001), with higher grade (P = 0.001) and HER2 positive tumors (P = 0.006) compared to patients without CT. In multivariate LR, age (P = 0.0027), high grading (P = 0.01) HER2 positivity (P = 0.03), and positive non-SN status (P = 0.03) were significantly associated with CT. RPA demonstrated that tumor grade, and not the non-SN status, was the first split in the partition tree followed by HER2 status, and non-SN status influencing the probability for CT administration. CONCLUSION: High tumor grade is the main decisional factor followed by HER2 positivity and then by the positive non-SN status for CT in micrometastatic disease in the SN.

Quantitative assessment of irradiated lung volume and lung mass in breast cancer patients treated with tangential fields in combination with deep inspiration breath hold (DIBH).

PURPOSE: Comparison of the amount of irradiated lung tissue volume and mass in patients with breast cancer treated with an optimized tangential-field technique with and without a deep inspiration breath-hold (DIBH) technique and its impact on the normal-tissue complication probability (NTCP). MATERIAL AND METHODS: Computed tomography datasets of 60 patients in normal breathing (NB) and subsequently in DIBH were compared. With a Real-Time Position Management Respiratory Gating System (RPM), anteroposterior movement of the chest wall was monitored and a lower and upper threshold were defined. Ipsilateral lung and a restricted tangential region of the lung were delineated and the mean and maximum doses calculated. Irradiated lung tissue mass was computed based on density values. NTCP for lung was calculated using a modified Lyman-Kutcher-Burman (LKB) model. RESULTS: Mean dose to the ipsilateral lung in DIBH versus NB was significantly reduced by 15%. Mean lung mass calculation in the restricted area receiving ≤ 20 Gy (M(20)) was reduced by 17% in DIBH but associated with an increase in volume. NTCP showed an improvement in DIBH of 20%. The correlation of individual breathing amplitude with NTCP proved to be independent. CONCLUSION: The delineation of a restricted area provides the lung mass calculation in patients treated with tangential fields. DIBH reduces ipsilateral lung dose by inflation so that less tissue remains in the irradiated region and its efficiency is supported by a decrease of NTCP.

Wide tangential fields including the internal mammary lymph nodes in patients with left-sided breast cancer. Influence of respiratory-controlled radiotherapy (4D-CT) on cardiac exposure.

PURPOSE: To evaluate the impact of wide-tangent fields including the internal mammary chain during deep inspiration breath-hold (DIBH) radiotherapy in patients with left-sided breast cancer on cardiac exposure. PATIENTS AND METHODS: Eleven patients with left-sided breast cancer were irradiated postoperatively and underwent CT scans during free breathing and DIBH. For scientific interest only, treatment plans were calculated consisting of wide tangents including the ipsilateral mammary lymph nodes using both, the free breathing and respiratory-controlled CT scan. The resulting dose-volume histograms were compared for irradiated volumes and doses to organs at risk. RESULTS: The mean patient age was 51 years (range: 37-65 years). Radiotherapy using wide tangents with DIBH as compared to free breathing led to a significantly lower cardiac exposure. Mean irradiated heart volumes (> or = 20 Gy) were 14 cm(3) (range: 0-51.3 cm(3)) versus 35 cm(3) (range: 2.1-78.7 cm(3); p = 0.01). For eight patients, DIBH reduced irradiated relative lung volume, while in three patients, the lung volume slightly increased. CONCLUSION: Radiation exposure of organs at risk can significantly be reduced for breast cancer patients using the DIBH technique. If radiotherapy of the internal mammary lymph nodes is considered necessary, DIBH may be the preferable technique.

Quantification of contralateral breast dose and risk estimate of radiation-induced contralateral breast cancer among young women using tangential fields and different modes of breathing.

PURPOSE: Whole breast irradiation with deep-inspiration breath-hold (DIBH) technique among left-sided breast cancer patients significantly reduces cardiac irradiation; however, a potential disadvantage is increased incidental irradiation of the contralateral breast. METHODS AND MATERIALS: Contralateral breast dose (CBD) was calculated by comparing 400 treatment plans of 200 left-sided breast cancer patients whose tangential fields had been planned on gated and nongated CT data sets. Various anatomic and field parameters were analyzed for their impact on CBD. For a subgroup of patients (aged ≤45 years) second cancer risk in the contralateral breast (CB) was modeled by applying the linear quadratic model, compound models, and compound models considering dose-volume information (DVH). RESULTS: The mean CBD was significantly higher in DIBH with 0.69 Gy compared with 0.65 Gy in normal breathing (P=.01). The greatest impact on CBD was due to a shift of the inner field margin toward the CB in DIBH (mean 0.4 cm; range, 0-2), followed by field size in magnitude. Calculation with different risk models for CBC revealed values of excess relative risk/Gy ranging from 0.48-0.65 vs 0.46-0.61 for DIBH vs normal breathing, respectively. CONCLUSION: Contralateral breast dose, although within a low dose range, was mildly but significantly increased in 200 treatment plans generated under gated conditions, predominately due to a shift in the medial field margin. Risk modeling for CBC among women aged ≤45 years also pointed to a higher risk when comparing DIBH with normal breathing. This risk, however, was substantially lower in the model considering DVH information. We think that clinical decisions should not be affected by this small increase in CBD with DIBH because DIBH is effective in reducing the dose to the heart in all patients.

High risk of recurrence for patients with breast cancer who have human epidermal growth factor receptor 2-positive, node-negative tumors 1 cm or smaller.

PURPOSE: To evaluate the risk of recurrence in women diagnosed with T1a and T1b, node-negative, human epidermal growth factor receptor 2 (HER2) -positive breast cancer. METHODS: We reviewed 965 T1a,bN0M0 breast cancers diagnosed at our institution between 1990 and 2002. Dedicated breast pathologists confirmed HER2 positivity if 3+ by immunohistochemistry or if it had a ratio of 2.0 or greater by fluorescence in situ hybridization (FISH). Patients who received adjuvant chemotherapy or trastuzumab were excluded. Kaplan-Meier product was used to calculate recurrence-free survival (RFS) and distant recurrence-free survival (DRFS). Cox proportional hazard models were fit to determine associations between HER2 status and survival after adjustment for patient and disease characteristics. Additionally, 350 breast cancers from two other institutions were used for validation. RESULTS: Ten percent of patients had HER2-positive tumors. At a median follow-up of 74 months, there were 72 recurrences. The 5-year RFS rates were 77.1% and 93.7% in patients with HER2-positive and HER2-negative tumors, respectively (P < .001). The 5-year DRFS rates were 86.4% and 97.2% in patients with HER2-positive and HER2-negative tumors, respectively (P < .001). In multivariate analysis, patients with HER2-positive tumors had higher risks of recurrence (hazard ratio [HR], 2.68; 95% CI, 1.44 to 5.0; P = .002) and distant recurrence (HR, 5.3; 95% CI, 2.23 to 12.62; P < .001) than those with HER2-negative tumors. Patients with HER2-positive tumors had 5.09 times (95% CI, 2.56 to 10.14; P < .0001) the rate of recurrences and 7.81 times (95% CI, 3.17 to 19.22; P < .0001) the rate of distant recurrences at 5 years compared with patients who had hormone receptor-positive tumors. CONCLUSION: Patients with HER2-positive T1abN0M0 tumors have a significant risk of relapse and should be considered for systemic, anti-HER2, adjuvant therapy.

Postoperative irradiation of left-sided breast cancer patients and cardiac toxicity. Does deep inspiration breath-hold (DIBH) technique protect the heart?

PURPOSE: To evaluate the impact of deep inspiration breath-hold (DIBH) technique during postoperative left-sided tangential breast irradiation on minimizing irradiated heart amount compared to normal breathing. PATIENTS AND METHODS: In 22 patients with left-sided breast cancer, postoperative CT scanning was performed in different respiratory phases using the Varian Real-time Position Management System for monitoring of respiratory chest wall motion. Each patient underwent two CT scans: during normal breathing and DIBH. For each scan, an optimized plan was designed with tangential photon fields encompassing the clinical target volume after breast-conserving surgery or modified radical mastectomy. The resulting dose-volume histograms were compared between both breathing techniques for irradiated volume and dose to the heart. RESULTS: The mean patient age was 51 years (range: 34-77 years). The DIBH-gated technique was well accepted by all patients. The significant reduction in dose to the irradiated heart volume for the DIBH technique compared to the normal breathing was 56% (mean heart dose: 2.3 Gy vs. 1.3 Gy; p = 0.01). CONCLUSION: This study demonstrates that irradiated cardiac volumes can significantly be reduced in left-sided breast cancer patients using DIBH technique for postoperative tangential radiotherapy. Moreover, the technique is safe and feasible in daily routine.

Postoperative irradiation in breast cancer patients with one to three positive axillary lymph nodes. Is there an impact of axillary extranodal tumor extension on locoregional and distant control?

BACKGROUND AND PURPOSE: To evaluate the impact of extracapsular extension (ECE) on locoregional and distant control in breast cancer patients with one to three positive axillary lymph nodes treated with postoperative irradiation. As shown in literature, ECE is diagnosed in up to 30% of node-positive breast cancer patients. Consequences of ECE and prognosis of these patients are unclear. PATIENTS AND METHODS: The medical records of 1,142 node-positive females with a carcinoma of the breast, postoperatively irradiated between 1994 and 2003, were retrospectively reviewed. Of the 274 patients presenting with one to three positive axillary lymph nodes, 91 (33.2%) showed ECE. While all patients were irradiated using tangential fields, only eight out of 274 patients received additional nodal irradiation. RESULTS: Patients' mean age was 58.2 years (range, 28-96 years), and the mean observation period 42.9 months (range, 6.6-101 months). In 93.4% of patients, locoregional control was achieved. On multivariate analysis of metastases-free survival, the hazard ratios for ECE and histological grade 3 were 2.71 (95% confidence interval [CI], 1.316-5.581; p = 0.007) and 2.435 (95% CI, 1.008-5.885; p = 0.048), respectively. The 3-year and 5-year metastases-free survival rates for patients with ECE were 78% and 66%, compared to 90% and 87% in patients without ECE (p = 0.0048). CONCLUSION: Locoregional recurrence remains low in breast cancer patients (one to three positive axillary lymph nodes +/- ECE) treated with surgery, adequate axillary dissection, and tangential field irradiation only. However, ECE is significantly linked to a considerable risk for subsequent distant failure.

Lymphatic fistulas: obliteration by low-dose radiotherapy.

BACKGROUND: Lymphatic drainage from the surgical wound is an uncommon but challenging complication of surgical intervention. Protracted lymphorrhea contributes to morbidity, favors infections and results in a prolonged hospital stay. Treatment options include surgical ligation and, more conservatively, leg elevation, continuous local pressure, subatmospheric pressure dressings, and low-dose radiotherapy. This study examines the efficacy of low-dose radiotherapy. PATIENTS AND METHODS: 17 patients (19 fistulas) with lymphorrhea following vena saphena harvesting (n = 7), femoropopliteal bypass (n = 3), varicose vein surgery (n = 2), hip arthroplasty (n = 3; five fistulas), shunt surgery (n = 1), and piercing (n = 1) were referred for external radiotherapy. Depending on the depth of the fistula, orthovoltage (n = 12), electrons (4-11 MeV; n = 2) or photons (8 MV; n = 3) were used. Fractions between 0.3 Gy and 2 Gy were applied; the individual total dose depended on the success of the radiotherapy, i. e., the obliteration of the lymph fistula, and varied from 1 to 12 Gy. RESULTS: In 13 out of 17 patients complete obliteration of the fistula was achieved. Interestingly, this was achieved in nine of the ten patients irradiated with total doses of

[Progress in radiotherapy and current status]. / Fortschritte in der Strahlentherapie und derzeitiger Stand.

Within the first decade of the 20th century, years after the discovery of X-rays, radiotherapy was established as an independent medical discipline. Since then, the knowledge of and the applications in radiotherapy have grown enormously. In the year of 1994 the clinical disciplines radiology and radiooncology finally became separate clinical specialities in Austria. Radiotherapy plays an important role in the curative and palliative setting of oncologic therapy. Tridimensional volumetric definition of the tumor and the proximity to organs at risk are based on high precision technique like ultrasound sonography, computerised tomography, magnetic resonance imaging and positron emission tomography. The main goal of radiation therapy is the successful sterilization of tumor cells in a carefully defined target volume considering adequate safety margins. The volume of the irradiation is often irregular and therefore shaped fields were used, which minimise the amount of radiosensitive normal tissue within the radiation fields. In this way, it is possible to decrease acute and late radiation induced complications. Dose-volume histograms ascertain irradiated volumes and dose distributions of the target and critical organs. The key breakthrough development of computer-controlled multi-leaf-collimators enables time-saving and precise irradiation of a target (macroscopic tumor and an adequate safety margin), permitting a dose distribution that confirms exactly to the intended target volume. The procedures of 3D conformal radiotherapy are more complex and expensive than conventional radiotherapy, but are essential for assuring high quality of modern cancer treatment.

Phyllodes tumor: an unexpected tumor of the breast. A report on six patients.

BACKGROUND AND PURPOSE: To evaluate the role of adjuvant radiotherapy for an unexpected malignancy of the breast, known as phyllodes tumor, a retrospective study was undertaken. PATIENTS AND METHODS: Between 1994 and 2002, six female patients with a phyllodes tumor (borderline, n = 2; malignant, n = 4) were irradiated after modified radical mastectomy at our institution. No patient received adjuvant systemic therapy. RESULTS: Two patients experienced local failure, after 17 months (malignant) and 23 (borderline) months of observation. One of the patients with local relapse died intercurrently, the other because of multiple pulmonary metastases. Four patients are alive and show no evidence of disease. Median follow-up was 33.8 months (range 29-42 months). CONCLUSION: Based on the data from the literature and the authors' findings, it is concluded that surgery with wide negative margins is the preferred initial treatment option. There is no indication for axillary dissection, since these tumors rarely metastasize to regional lymph nodes. In patients with phyllodes tumors showing adverse prognostic factors, postoperative irradiation is recommended.

Palliative treatment of unresectable bile duct tumours.

PURPOSE: Report on outcome of intraluminal high-dose-rate iridium-192 (HDR-Ir192) brachytherapy with or without external radiotherapy in patients with unresectable bile duct tumours suffering from symptoms of malignant obstructive jaundice. MATERIAL AND METHODS: Fourteen patients (mean age: 63 years) who were unsuitable for surgical resection on preoperative evaluation/laparotomy or inoperable due to poor general condition were referred for palliative radiotherapy. After percutaneous transhepatic drainage, HDR-Ir192 brachytherapy was performed with a single dose of 2.5 Gy. Brachytherapy was given twice a day with at least a 6-h interval for 2 days, 2 or 3 days apart, up to a total dose of 10 Gy. Five patients received small-volume external radiotherapy (RT) (45 - 50.4 Gy/1.8 Gy) additionally. RESULTS: Palliation with relief of the aggravating symptoms of obstructive jaundice was achieved in all patients. The actuarial 2-year survival rate of all patients was 11.9 % with a median survival of 6.5 months. Patients treated with brachytherapy alone had a median survival of 4.5 months as compared with 6.5 months after combined internal and external irradiation (log rank, P = 0.95). CONCLUSION: Patients with advanced unresectable bile duct cancer face a dismal prognosis; however, biliary drainage, and intraluminal brachytherapy with or without external RT, seem to be able to improve quality of life in the remaining time span.

Extracapsular extension in positive axillary lymph nodes in female breast cancer patients. Patterns of failure and indications for postoperative locoregional irradiation.

BACKGROUND AND PURPOSE: There has been little information regarding lymph node-positive breast cancer patients with extracapsular extension (ECE). The aim of this study was to evaluate the role of ECE in predicting survival and relapse rates. PATIENTS AND METHODS: From 1994-2002, 1,078 lymph node-positive women with breast carcinoma were treated at our institution, whereas 301 patients (27.9%) presented with ECE. 91 patients (30.2%) were identified as having three or less lymph nodes involved, 27.9% patients four to six, 15.6% patients seven to nine, and 26.2% patients ten or more nodes, respectively. The median age was 58.4 years (range: 28-84 years) and the median follow-up 34 months (range: 2-99 months). Nodal irradiation was given to patients with four or more positive lymph nodes. Chemotherapy was administered to 69.8%, hormonal therapy to 53.2%, and combined systemic treatment to 26% of patients. RESULTS: The 1-, 3-, and 5-year overall survival (OS) was 98%, 84%, and 73%, the 1-, 3-, and 5-year disease-free survival (DFS) 95%, 69%, and 58%, and the 1-, 3-, and 5-year metastasis-free survival (MFS) 96%, 73%, and 60%. The relapse rates were 6.6% (local), 0.3% (supraclavicular), 0.7% (isolated axillary), 1% (local + axillary), and 0.7% (local + supraclavicular), respectively. 81 patients (27%) developed distant metastases. In December 2002, 245 patients (81.4%) were alive, 202/245 without progression, 32/245 with distant metastases, 5/245 with local/locoregional recurrence, and 6/245 patients with local and distant failure. CONCLUSION: Isolated axillary nodal failure remains low in lymph node-positive patients with ECE. Balancing the risks and benefits of irradiation, we continue to recommend that complete axillary irradiation is not routinely indicated after adequate axillary dissection.

Long-term results after external radiotherapy in age-related macular degeneration. A prospective study.

PURPOSE: To prospectively evaluate the short- and long-term efficacy of external radiotherapy (RT) in patients with age-related macular degeneration (AMD) by comparing two different dose schedules. PATIENTS AND METHODS: In this prospective, nonrandomized, comparative study including 80 patients, the efficacy of external RT with a total dose of 14.4 Gy (group A, n = 40) and 25.2 Gy (group B, n = 40) was compared. Patients of group A were irradiated between September 1995 and July 1996, patients of group B between August 1996 and November 1997. 67 patients presented with occult choroidal neovascularization (CNV), 13 with classic subfoveal lesions. Complete ophthalmologic investigation was performed before RT, at intervals of 3 months during the 1st year after RT, and of 6 months thereafter. RESULTS: 12 months after RT, vision deteriorated in 85% (14.4 Gy) and 65% (25.2 Gy) of patients. Central visual field decreased with both dose schedules. There was no morphological benefit in neovascular changes. After 48 months, complete follow-up was possible in 46 patients who showed a significant loss of vision similar to the natural course of AMD. CONCLUSION: External RT of AMD with 14.4 Gy as well as with the escalated dose of 25.2 Gy showed a poor beneficial outcome after 6 and 12 months, respectively. After a follow-up of 4 years, visual outcome in irradiated patients was similar to the natural course of the disease. A conspicuous efficacy of RT in prevention of blindness could not be demonstrated.

Regional nodal recurrence in the management of breast cancer patients with one to three positive axillary lymph nodes. Outcome of patients following tangential irradiation without a separate nodal field.

PURPOSE: To examine the prognosis of breast cancer patients (T1-3, one to three positive axillary lymph nodes) and locoregional failure rate after breast-conserving therapy/modified radical mastectomy and adequate axillary dissection following tangential radiotherapy without irradiation of the regional lymph nodes. PATIENTS AND METHODS: From 1994 to 2002, the medical records of 183 breast cancer patients (T1-3, one to three involved axillary lymph nodes) were examined in order to identify those experiencing regional nodal recurrence, with or without local recurrence. The median age of the patient population was 58 years (range, 28-86 years). All patients underwent surgical treatment, either breast-conserving therapy (n = 146) or modified radical mastectomy (n = 37). The median number of lymph nodes removed was twelve (range, seven to 26 nodes). Irradiation was given to the breast through tangential fields. Chemotherapy was administered to 101 patients (55%), hormonal therapy to 124 (60%), and combined systemic treatment to 47 (26%). RESULTS: The median observation time was 44.4 months (range, 11-102 months). Of the 14 patients (7.7%) with a relapse, six (3.3%) had a local recurrence, five (2.8%) a regional relapse, and three (1.6%) a simultaneous recurrence. Nine out of 14 patients with locoregional relapse developed distant failure subsequently and seven of them (78%) died of the disease. CONCLUSION: Regional recurrence is uncommon among patients with one to three positive axillary lymph nodes treated with surgery, adequate axillary dissection, and tangential field irradiation only. The authors conclude that regional nodal irradiation should not routinely be given following adequate axillary dissection when only one to three lymph nodes are positive.

Fractionated intraluminal HDR 192Ir brachytherapy as palliative treatment in patients with endobronchial metastases from non-bronchogenic primaries.

AIM: To evaluate the efficacy of iridium-192 high-dose rate (HDR) endobronchial brachytherapy for the palliation of symptoms caused by endobronchial metastases of non-bronchogenic primaries. PATIENTS AND METHOD: Between 1991 and 1998, eleven patients (female n = 3, male n = 8; age: median 66 years, range 44-81 years) underwent intraluminal HDR brachytherapy for histologically confirmed endobronchial metastases from non-pulmonary primary tumors of various sites like urogenital tract (n = 5), gastrointestinal tract (n = 3), ear/nose/throat (n = 2) and breast (n = 1). The median time between diagnosis of the primary non-bronchogenic tumor and histopathological diagnosis of the endobronchial metastases was 39 months, range 1-99 months. A total dose of 15-20 Gy was delivered in three to four fractions of 5-6 Gy once a week. No palliative chemotherapy was added. RESULTS: Median follow-up after palliative brachytherapy was 15 months (range 1.4-59 months). Objectively, complete endoscopic response was observed in three (27%) patients, and in five (46%) others partial opening of the initially obstructed airway was achieved. Treatment was judged unsuccessful in three (27%) patients. No patient showed up with local progression. At date of analysis five patients were alive with documented residual tumor (80%) or complete response (20%). Relief of symptoms occurred in the vast majority of patients (n = 8, 73%). CONCLUSION: HDR intraluminal brachytherapy palliates symptoms in patients suffering from endobronchial metastases of non-pulmonary primary tumors. The applied treatment is a safe, effective and well tolerated palliative procedure leading to an improved patient quality of life.

Radiation-induced osteosarcoma of the chest wall.

A case of radiation-induced sarcoma of the chest wall is reported. Twenty-seven years 11 months after orthovoltage radiotherapy of the right breast a 69-year-old woman developed a radiation-induced osteosarcoma of the right thoracic wall. Initial diagnosis has been T-cell lymphoma of the skin. The right breast was irradiated with tangential fields and a total dose of 40 Gy, 2 Gy/day, 5 days a week. Orthovoltage treatment was performed in two courses of 20 Gy, 3 months apart. The clinical appearance of the secondary sarcoma was a diffuse infiltrated area in the irradiated breast which seemed to be fixed to the chest wall. Magnetic resonance imaging (MRI) demonstrated a mass in the right anterior thoracic wall which destroyed the fourth to the sixth rib. The tumor infiltrated the thoracic wall, including subcutaneous tissue and pericardium, as well as extending into the subphrenic space. Biopsy of the lesion revealed a poorly differentiated osteosarcoma. The patient's general condition precluded surgical or chemotherapeutic intervention; she died due to a cerebral stroke 6 months later. This case fulfilled all criteria for radiation-induced sarcoma, as there was a prior history of radiotherapy, latency period of several years, development of sarcoma within the irradiated field, and histologic confirmation of sarcoma.

Covered stents in transjugular portosystemic shunt: healing response to non-porous ePTFE covered stent grafts with and without intraluminal irradiation.

The aim of this study was to evaluate the healing response to a new commercially available ePTFE-covered stent graft used to create transjugular intrahepatic portosystemic shunts (TIPS) in an animal model with and without intraluminal irradiation. The study was designed for ten domestic normotensive pigs. The TIPS was created using a ePTFE-covered stent graft (Viatorr, Gore, Flagstaff, Ariz.). Five animals were scheduled for intraluminal irradiation with iridium 192 immediately after TIPS creation with a dosage of 18 Gy. Shunt venograms were performed every 2 weeks. Animals from the irradiated and non-irradiated group were killed at 2-week intervals. Maximum follow-up was planned for 8 weeks in each group, with two animals in reserve. Gross specimen evaluation and histological examination, including scanning electron microscopy, was performed. Two animals died from interventional complications. In the irradiation group, one shunt occlusion and one stenosis occurred after 2 weeks. The stenosis regressed until the end of the 8-week follow-up period and probably was caused by a resolving thrombus. In the non-irradiated group, no shunt dysfunction was observed. One animal died early due to encephalopathy. Histology revealed an increased inflammatory reaction in the irradiation group, a lesser degree of incorporation of the stent graft, and a lesser degree of endothelialization of the inner surface compared with the non-irradiated group. No significant foreign body reaction was found at any time in any of the animals. The Viatorr stent graft was well tolerated in the pig model. Intraluminal irradiation seemed to have an adverse effect on the healing response. The TIPS patency was prolonged in both the irradiated and non-irradiated group compared with data from the literature; however, seemingly better results were observed in the non-irradiated group.