Does radiotherapy planning without breath control compensate intra-fraction heart and its compartments' movement?

This prospective study investigated radiation dose and volume changes during breathing cycle. Ten patients with left breast carcinoma receiving radiotherapy were included. Treatment planning images were obtained as three different sets of series taken: without breath control (F), deep inspiration (I), and end of expiration (E), with 3-mm intervals. As such, whole breath cycle was simulated. CT images taken during I and E were registered to F, according to DICOM coordinates. Each patient's target and organ at risk volumes were contoured by the primary radiation oncologist except heart components which were contoured by radiologist on F, I and E series. Radiotherapy planning was done on F series, then planning and beam data were transferred from F to I and E image series. Target and organs at risk (OAR) dose distributions for E and I image series were obtained. Dose changes between F, E, and I phases for whole heart and components, namely, left ventricle (LV), right ventricle (RV), left auricle (LA), right auricle (RA), and left anterior descendent artery (LAD) were examined. Furthermore, the issue of any compartment representing the maximum heart dose was investigated. Volume and dose variations for heart, LV, RV, LA, RA, and LAD were observed during breath cycle. Exposured dose was more than defined tolerance level for LV, RV, and LAD in some patients. However, dose differences between F-I and F-E were not statistically significant. Radiotherapy planning without breath control is not capable of compensating for whole intra-fraction heart and its components' volumes and dose changes.

Lycopene in the prevention of gastrointestinal toxicity of radiotherapy.

We conducted a study to investigate if lycopene could reduce gastrointestinal toxicity of abdominal and pelvic radiation in Wistar albino rats. Animals received either a control diet (Group 1), lycopene-supplemented diet (Group 2), control diet and radiation (Group 3), and lycopene-supplemented diet plus radiation (Group 4). In Groups 2 and 4, the rats received 5 mg/kg/day lycopene for 10 days. In Groups 3 and 4, the rats received single fraction 8 Gy abdominal and pelvic radiation (RT) on Day 10. Study endpoints included weight loss, diarrhea, duration of diarrhea, survival, and an oxidative stress marker, plasma level of thiobarbituric acid reactive substance (TBARS). The rats receiving RT only had significantly higher weight loss rate compared to the lycopene plus RT group (P = 0.001). Plasma TBARS levels after RT were also significantly higher in the RT only group compared to lycopene plus RT group (P = 0.001). In conclusion, lycopene supplementation significantly reduced the weight loss and prevented oxidative stress in rats treated with abdominopelvic radiation.

Assessment of setup accuracy in patients receiving postmastectomy radiotherapy using electronic portal imaging.

PURPOSE: The aim of this study was to investigate the setup accuracy for patients undergoing postmastectomy radiotherapy using electronic portal imaging. MATERIALS AND METHODS: Ten patients undergoing radiotherapy via tangent (TG), supraclavicular-axillary (SA), and internal mammary (IM) fields were included. To explore the setup accuracy, distances between chosen landmarks were taken as reference parameters (RPs). The difference between measured RPs on simulation films and electronic portal images (EPIs) was calculated as the setup error. RESULTS: A total of 30 simulation films and 120 EPIs were evaluated. In the SA field, calculated RPs were lung length (LL), clavicle-field center perpendicular distance, and clavicle-field center transverse distance. The mean of the standard deviations (SDs) of the random errors (sigma) for these parameters were 4.7, 7.3, and 7.6; and the SDs of the systematic errors (Sigma) were 6.8, 4.4, and 13.5, respectively. In the TG fields, the calculated RPs were the central lung distance (CLD), maximum lung distance (MLD), and central soft-tissue distance (CSTD). In the medial TG field, the sigma values for these parameters were 3.4, 3.6, and 4.1, respectively; and the sigma values were 6.6, 2.6, and 3.4, respectively. In the lateral TG field, Sigma values for the calculated RPs were 2.4, 3.2, and 3.3l, respectively; and the Sigma values were 5.6, 3.6, and 4.8, respectively. CONCLUSION: CLD, MLD, and CSTD in TG fields and LL in SA fields are easily identifiable and are helpful for detecting setup errors using EPIs in patients undergoing postmastectomy radiotherapy.

Intraluminal brachytherapy with metallic stenting in the palliative treatment of malignant obstruction of the bile duct.

PURPOSE: To describe the outcome of intraluminal high-dose-rate (HDR) brachytherapy with metallic stenting in patients with obstructing extrahepatic cholangiocarcinoma. MATERIALS AND METHODS: Eight patients with inoperable and/or unresectable extrahepatic bile duct carcinomas were treated with intraluminal brachytherapy (ILBT) followed by self-expandable metallic stent placement. Following percutaneous transhepatic drainage, ILBT was delivered by an HDR-Ir-192 source using the Micro-Selectron afterloading device. Two treatments were planned one week apart, with each treatment consisting of a single 10 Gy fraction. Biliary patency and palliative effect were assessed by serial labs (including bilirubin/alkaline phosphatase), symptomatic improvement, and/or cholangiography. RESULTS: All eight patients tolerated the first application of ILBT well, and five of them completed two-intraluminal treatments. Six of eight had satisfactory control of jaundice until death. Pain relief was observed in four of five (80%) and pruritus in six of seven (86%) patients experiencing such symptoms. The mean and median times of stent patency were 6.9 and 5 months (range, 4-14), respectively. Gastrointestinal bleeding and/or cholangitis occurred in three patients. CONCLUSION: HDR ILBT with metallic stenting for patients with obstructive jaundice from extrahepatic bile duct carcinoma appears to be feasible and associated with acceptable toxicity. These treatments may lead to an improved quality of life in these patients.

Geometric and dosimetric variations of ICRU bladder and rectum reference points in vaginal cuff brachytherapy using ovoids.

PURPOSE: To investigate the interfractional geometric and dose variations of rectal reference point (R) and bladder reference point (BL) doses in patients receiving vaginal cuff irradiation using high-dose-rate brachytherapy with 2 ovoids and the change in calculated radiobiologic-equivalent dose of R and BL. METHODS: ICRU-38 R and BL reference doses were calculated. The variation in positions of ovoids, R, and BL were determined. Whether the magnitude of displacement shows a time trend and has an effect on calculated R and BL doses was evaluated. The relation between the ovoid diameter and both the magnitude of displacement and changes in R and BL doses was studied. Changes in radiobiologic-equivalent dose of rectum and bladder were determined. RESULTS: The average magnitude of displacements was 3.2 and 12.1 mm, showed no time trend, and no tendency to displacement in a certain direction. Mean changes in BL and R doses were 64-75 cGy and 47-58 cGy, respectively. There was a relation between neither ovoid size and displacement nor R and BL dose change. Dose and geometric variation showed no correlation (p > 0.05). The differences in radiobiologic-equivalent dose of R and B were not significant. CONCLUSION: Although there were significant differences in R and B position and doses among the fractions, the magnitudes of dose changes were relatively small, and total calculated radiobiologic-equivalent doses of R and B did not change significantly. According to the results of this study, the benefit of treatment planning is limited to supporting treatment planning in each fraction.

Results of postoperative radiotherapy in the treatment of 29 uterine sarcoma patients.

AIMS AND BACKGROUND: The objective of this study was to evaluate the results of surgery combined with postoperative radiotherapy (RT) in patients with uterine sarcoma in order to describe the patterns of relapse and to define prognostic factors. METHODS: We report on 29 patients with uterine sarcoma (US) treated from 1980 to 1995; 18 patients with primary tumors were treated with surgery and adjuvant irradiation, while 11 patients with local recurrences (LR) after previous surgical resection received only radiotherapy. We evaluated the influence of stage, histology, grade, menopausal status, total radiation dose and brachytherapy on survival. Histological diagnosis was leiomyosarcoma in 13 patients (44.8%), endometrial stromal sarcoma in 10 patients (34.5%), and mixed mesodermal tumors in six patients (20.7%). Fifteen patients presented with stage I-II disease, three with stage III, and 11 with local recurrences. External pelvic RT was administered to all patients, in five patients combined with brachytherapy. The mean total dose was 54 Gy (SE 1.78). Univariate and multivariate analyses were carried out. RESULTS: Overall survival (OS) for the stage I-III group was 61.1% at two years and 33.3% at five years (median 29 months, SE 13.79). Disease-free survival (DFS) was 55.6% at two years and 33.3% at five years. Median DFS was 26 months (SE 14.85). In LR cases, median OS was only 10 months (SE 4.5). Multivariate analysis demonstrated that stage was the only prognostic factor after RT for US. CONCLUSIONS: These data suggest that postoperative and/or salvage RT has a questionable impact on disease-free and over-all survival because of the lack of homogeneity of stages in the series reported in the literature; it has, however, acceptable late side effects. Prospective multicenter trials including a statistically evaluable number of patients are necessary to further clarify the role of RT treatment programs for US.

The great mimicker: zona zoster at the mastectomy site causing contralateral intramammary lymph node enlargement.

Zona zoster is rarely observed in patients with malignancy; when present, it follows a dermatomal fashion. Involvement of widely separated regions is very rare. Hereby, zona zoster causing enlarged intramammary lymph nodes (IMLN) in the opposite breast is reported for the first time in literature. The masses were hypoechoic on US with no hilum and hypervascular on color Doppler US. MRI showed hypointense masses with type 3 time-intensity curve and adjacent vessel sign. The complete regression of the nodes after the antiviral therapy confirmed the diagnosis. In breast cancer patients, IMLN enlargements may mimic breast cancer metastasis, and zona zoster infection of the mastectomy site may present with contralateral IMLN enlargement due to altered lymphatic drainage. When breast US is not sufficient for the differential diagnosis, breast MRI may warrant proper diagnosis, and prevent unnecessary biopsies. Antiviral treatment with followup would be sufficient for management.