Phase 2 Clinical Trial of Separation Surgery Followed by Stereotactic Body Radiation Therapy for Metastatic Epidural Spinal Cord Compression.

PURPOSE: Stereotactic body radiation therapy (SBRT) is a postoperative treatment option for spinal metastases. Because data on surgery with SBRT are limited to retrospective studies, this single-center, single-arm, phase 2 study aimed to prospectively evaluate the outcomes of separation surgery and SBRT for metastatic epidural spinal cord compression (MESCC). METHODS AND MATERIALS: Patients with symptomatic MESCC due to a solid carcinoma were enrolled. The protocol for treatments comprised preoperative embolization, separation surgery, and spine SBRT. Surgical procedures were performed via the posterior approach, with decompression and a fixation procedure. The prescribed dose for spine SBRT was 24 Gy in 2 fractions. The primary endpoint was the 12-month local failure rate. The secondary endpoints were ambulatory functions and adverse effects. RESULTS: A total of 33 patients were registered between November 2017 and October 2019. All patients met the inclusion criteria, and all but 1 completed the protocol treatment. Of the included patients, 23 (70%) had radioresistant lesions. The Bilsky grade at registration was 1c in 3 patients, 2 in 8 patients, and 3 in 21 patients. The median follow-up duration after registration was 15 months (range, 3-35 months). Three months after the administration of treatments according to the protocol, 90% of patients (26 of 29) had disease of Bilsky grade ≤1. The 12-month local failure rate was 13%. Twenty patients could walk normally or with a cane 12 months after registration. Radiation-induced myelopathy, radiculopathy, and vertebral compression fracture were observed in 0, 1, and 6 patients, respectively. CONCLUSIONS: Separation surgery with SBRT for MESCC was effective in decompression and long-term local control. These findings suggest that larger randomized controlled trials are warranted to compare SBRT with conventional radiation therapy.

[Summary of the Report of Task Group 100 of the AAPM: Application of Risk Analysis Methods to Radiation Therapy Quality Management].

In 2016, the American Association of Physicists in Medicine (AAPM) has published a report of task group (TG) 100 with a completely new concept, entitled "application of risk analysis methods to radiation therapy quality management." TG-100 proposed implementation of risk analysis in radiotherapy to prevent harmful radiotherapy accidents. In addition, it enables us to conduct efficient and effective quality management in not only advanced radiotherapy such as intensity-modulated radiotherapy and image-guided radiotherapy but also new technology in radiotherapy. It should be noted that treatment process in modern radiotherapy is absolutely more complex and it needs skillful staff and adequate resources. TG-100 methodology could identify weakness in radiotherapy procedure through assessment of failure modes that could occur in overall treatment processes. All staff in radiotherapy have to explore quality management in radiotherapy safety.

Evaluation of multi-institutional end-to-end testing for post-operative spine stereotactic body radiation therapy.

BACKGROUND AND PURPOSE: Post-operative spine stereotactic body radiation therapy (SBRT) represents a significant challenge as there are many restrictions on beam geometry to avoid metal hardware as it surrounds the target volume. In this study, an international multi-institutional end-to-end test using an in-house spine phantom was developed and executed. The aim was to evaluate the impact of titanium spine hardware on planned and delivered dose for post-operative spine SBRT. MATERIALS AND METHODS: Five centers performed simulation, planning and irradiation of the spine phantom, with/without titanium metal hardware (MB/B), following our pre-specified protocol. The doses were calculated using the centers' treatment planning system (TPS) and measured with radiophotoluminescent glass dosimeters (RPLDs) embedded within each phantom. RESULTS: The dose differences between the RPLD measured and calculated doses in the target region were within ±â€¯5% for both phantoms studied. Differences greater than 5% were observed for the spinal cord and the out-of-the target regions due to steeper dose gradient regions that are created in these plans. Dose measurements within ±â€¯3% were observed between RPLDs that were embedded in MB and B inserts. For the spinal cord and the out-of-target regions surrounded by metal hardware, the dose measured using RPLDs was within 3% different near the titanium screws compared to the dose measured near only the metal rods. CONCLUSION: We have successfully performed the first multi-institutional end-to-end dose analysis using an in-house phantom built specifically for post-operative spine SBRT. The differences observed between the measured and planned doses in the presence of metal hardware were clinically insignificant.

A prospective multicentre feasibility study of stereotactic body radiotherapy in Japanese patients with spinal metastases.

OBJECTIVE: Stereotactic body radiotherapy has emerged as an attractive alternative to conventional radiotherapy for spinal metastases. However, it has limitations, including the need for advanced techniques and specific adverse effects. The present trial aimed to validate the feasibility and safety of stereotactic body radiotherapy in Japanese patients with spinal metastases. METHODS: Patients with one or two spinal metastases received stereotactic body radiotherapy of 24 Gy in two fractions. The primary endpoint was the proportion of severe adverse effects (≥ grade 3) in patients within 6 months after spine stereotactic body radiotherapy. Adverse effects were evaluated according to the National Cancer Institute Common Terminology Criteria for Adverse Events version 4. The treatment protocol was considered feasible and tolerable if the proportion of severe adverse effects was 10% or less. RESULTS: Overall, 20 spinal segments in 20 patients who registered between March 2014 and October 2015 were included. Minor and major deviations were observed in the planning of 2 and 0 cases, respectively. The treatment completion rate was 100%. The median follow-up after registration was 24.5 (range: 1-61) months. Although four patients experienced acute grade 2 adverse effects, no grade 3 or higher adverse effects were observed within 6 months after spine stereotactic body radiotherapy. Vertebral compression fractures were observed in two patients (14 and 16 months after stereotactic body radiotherapy). The local control and pain response rates at 6 months were 100 and 83%, respectively. CONCLUSION: This study demonstrated the feasibility and safety of spine stereotactic body radiotherapy in Japanese patients with spinal metastases.

Feasibility of spine stereotactic body radiotherapy for patients with large tumors in multiple vertebrae undergoing re-irradiation: Dosimetric challenge using 3 different beam delivery techniques.

The objective of the present study was to report whether the adequate spine stereotactic body radiotherapy (SBRT) plans were generated with feasible treatment duration for patients with large vertebral metastases undergoing re-irradiation. For 5 cases, the re-irradiation plans using static-field intensity-modulated radiation therapy (SIMRT), volumetric-modulated arc therapy (VMAT), and CyberKnife with a total prescribed dose (PD) of 24 Gy applied in 2 fractions were generated. A minimum dose to 95% of the evaluated planning target volume (PTVevl) that was >70% of PD (D95 > 70% PD) was defined as minimum criterion. For the dose tolerance of the spinal cord or thecal sac, which could affect the risk of radiation myelopathy, a volume-dose constraint of 12.2 Gy was set for the planning organ-at-risk volume of the spinal cord (PRVcord) or thecal sac and limited to 0.035 cc (D0.035 cc< 12.2 Gy) on the re-irradiation plans. For assessing the impact of the stricter dose constraint of PRVcord on the plan quality, we generated plans with a PRVcord dose constraint of D0.035 cc < 17.0 Gy, which was employed for patients with no previous history of radiation therapy (RT). Dose-volume histogram (DVH) analysis was performed for the PTVevl and spinal cord. Median PTVevl of all cases was 242.3 cc (range; 159.2 to 722.4 cc). Two out of 5 cases had a PTVevl >500 cc. The constraint of the PRVcord D0.035cc was met in all re-irradiation plans; however, a comparison between the re-irradiation plan for patients with large vertebral metastases and the plan for cases with no RT history showed that the decrease of the target dose coverage was correlated with the stricter dose constraint of the PRVcord. For SIMRT and VMAT, the re-irradiation plans met the goal of the PTVevl D95. On the other hand, CyberKnife plans could not achieve the constraints of the PTVevl D95. This discrepancy is due to the constraint of treatment duration, which is defined as the comfortable duration for patients with large spinal metastases. Regardless of the delivery method used, treatment plan quality is impacted to a greater extent by the dose tolerance of the spinal cord than by the size of the tumor.

Assessing Functionality and Benefits of Comprehensive Dose Volume Prescriptions: An International, Multi-Institutional, Treatment Planning Study in Spine Stereotactic Body Radiation Therapy.

PURPOSE: This study aimed to assess the effectiveness of multiple dose-volume specifications in minimizing interinstitutional, target-prescribed, dose variations for spine stereotactic body radiation therapy (SBRT). METHODS AND MATERIALS: Seven institutions with a total of 10 treatment apparatuses participated in this study. SBRT plans for 3 representative spinal metastases were generated using 2 different protocols (Protocols 1 and 2) for target dose. While using just 2 target dose objectives (doses delivered to 95% and maximum point dose) in Protocol 1, 3 target dose constraints (doses delivered to 95% and 50% and maximum point dose) were defined in Protocol 2 with the intent to decrease target dose variation. A dose-volume histogram analysis was performed for the evaluated planning target volume (PTVevl) and critical neural structures such as the spinal cord and cauda equina. RESULTS: Doses to the organs at risk were all maintained at the maximal tolerance in both protocols; however, the interinstitutional variation of the PTVevl dose-volume histograms was significantly decreased with Protocol 2. Furthermore, the mean PTVevl covered by the prescription dose was increased from 73.0% in Protocol 1 to 85.8% in Protocol 2. There were no differences in the mean values of the nearly maximum dose of the critical neural structures between 2 protocols. CONCLUSIONS: In spine SBRT with the emphasis on preservation of critical neural structures, the target prescribed dose should be defined by using multiple dose-volume objectives to minimize user and apparatus-dependent dose variabilities for the spinal metastases that are adjacent to the critical neural structures.

Sacral insufficiency fracture after stereotactic body radiation therapy for sacral metastasis.

Stereotactic body radiation therapy (SBRT) allows the targeting of high doses of radiation with steep dose gradients. Vertebral fracture is increasingly recognized as an adverse event after SBRT; however, no sacral fractures have been observed after SBRT. We report an extremely rare case of sacral insufficiency fracture after SBRT.

Re-irradiation for painful bone metastases using stereotactic body radiotherapy.

PURPOSE: Stereotactic body radiotherapy (SBRT) is expected to achieve safe and effective re-irradiation for painful bone metastases. This study aimed to clarify the efficacy of re-irradiation using SBRT for painful bone metastases. METHODS: Prospective database at our institution for the period between September 2013 and December 2017 were retrospectively reviewed for patients with: (1) painful bone metastases; (2) history of radiotherapy to the metastasis; and (3) SBRT performed as re-irradiation. Pain response, pain failure-free duration, analgesics medications, and adverse events were evaluated. Pain was evaluated using the Numerical Rating Pain Score, and pain response was evaluated based on International Consensus Pain Response Endpoints. Best response during follow-up was noted. Patients with complete or partial response were defined as showing pain response, and patients with pain progression were defined as showing pain failure. Adverse events were evaluated based on the RTOG/EORTC Late Radiation Morbidity Scoring Schema. RESULTS: Sixty-six patients selected from our database showed: median age, 65 years (range, 33-82 years); ECOG performance status, 0-1/2/3/4, 51/10/3/2; lesion histopathology, rectal/lung/renal/thyroid/other cancer, 13/11/9/5/28; median previous irradiated dose, 30 Gy (range, 8-70.4 Gy); median interval from latest irradiation, 21 months (range, 4-192 months); prescribed dose for SBRT, 24 Gy in 2 fractions/30 Gy in 5 fractions/35 Gy in 5 fractions, 51/13/2. Median follow-up after SBRT was 10 months (range, 1-37 months). Fifty-seven patients achieved pain response (86%). The 1-year pain failure-free rate was 55%. Median pain failure-free duration was 13 months (range, 1-24 months). Grade 4 adverse events were observed in six patients (vertebral compression fracture, n = 5; radiation myelopathy, n = 1). No other toxicities of Grade 3 or greater were encountered. CONCLUSIONS: Re-irradiation SBRT has potential to achieve good response and long-term pain control for painful bone metastases. Prospective analysis is necessary to confirm the safety and efficacy of SBRT as re-irradiation.

Stereotactic Body Radiotherapy for Spinal Metastases: Clinical Experience in 134 Cases From a Single Japanese Institution.

OBJECT: This study aimed to clarify the outcomes of stereotactic body radiotherapy for spinal metastases with a uniform dose fractionation schedule in our institution. MATERIALS AND METHODS: Patients treated with spine stereotactic body radiotherapy were retrospectively reviewed. The prescribed dose was 24 Gy in 2 fractions. End points were local control, pain control, and adverse events. Local control was defined as elimination, shrinkage, or stable disease in the tumor on imaging evaluations. Pain status was measured on a scale of 0 to 10 by patients' self-reports, and pain response was defined as the time at which pain scale score decreased by 2 or more from the baseline score without increase in analgesics. In addition, various treatment- and tumor-specific factors were evaluated to determine predictive values for local and pain control. RESULTS: This study included 134 lesions in 131 patients, with: lesion histopathology, lung/colorectal/thyroid/renal/breast/prostate/sarcoma/other cancer, 24/22/18/14/12/10/6/25; reirradiation stereotactic body radiotherapy, 82 (61.2%) cases; and postoperative stereotactic body radiotherapy for epidural spinal cord compression, 45 (33.6%) cases. Median follow-up after stereotactic body radiotherapy was 9 months. The 1-year local control rate was 72.3%. Seventy (79.5%) of the 88 cases with pain from spinal metastases achieved pain response. The 1-year pain progression-free rate was 61.7%. Regarding metastases from colorectal cancer, local and pain control rates at 1 year were significantly lower compared with other cancer types (local control rate, 34.1% vs 81.8%; P < .01; pain progression-free rate, 36.9% vs 69.9%; P = .02). On multivariate analysis, colorectal cancer metastases and radiation history were identified as independent predictors of lower local and pain control rates. Radiation-induced myelopathy, radiculopathy, and vertebral compression fractures were observed in 0, 2 (1.5%), and 16 (11.9%) cases, respectively. CONCLUSIONS: This study showed that spine stereotactic body radiotherapy achieved good local and pain control, with a clinically acceptable safety profile. However, stereotactic body radiotherapy may be less effective against spinal metastases from colorectal cancer.

Postoperative re-irradiation using stereotactic body radiotherapy for metastatic epidural spinal cord compression.

OBJECTIVE This study aimed to clarify the outcomes of postoperative re-irradiation using stereotactic body radiotherapy (SBRT) for metastatic epidural spinal cord compression (MESCC) in the authors' institution and to identify factors correlated with local control. METHODS Cases in which patients with previously irradiated MESCC underwent decompression surgery followed by spine SBRT as re-irradiation between April 2013 and May 2017 were retrospectively reviewed. The surgical procedures were mainly performed by the posterior approach and included decompression and fixation. The prescribed dose for spine SBRT was 24 Gy in 2 fractions. The primary outcome was local control, which was defined as elimination, shrinkage, or no change of the tumor on CT or MRI obtained approximately every 3 months after SBRT. In addition, various patient-, treatment-, and tumor-specific factors were evaluated to determine their predictive value for local control. RESULTS Twenty-eight cases were identified in the authors' institutional databases as meeting the inclusion criteria. The histology of the primary disease was thyroid cancer in 7 cases, lung cancer in 6, renal cancer in 3, colorectal cancer in 3, and other cancers in 9. The most common previous radiation dose was 30 Gy in 10 fractions (15 cases). The mean interval since the most recent irradiation was 16 months (range 5-132 months). The median duration of follow-up after SBRT was 13 months (range 4-38 months). The 1-year local control rate was 70%. In the analysis of factors related to local control, Bilsky grade, number of vertebral levels in the treatment target, the interval between the latest radiotherapy and SBRT, recursive partitioning analysis (RPA), the prognostic index for spinal metastases (PRISM), and the revised Tokuhashi score were not significantly correlated with local control. The favorable group classified by the Rades prognostic score achieved a significantly higher 1-year local control rate than the unfavorable group (1-year local control rate: 100% vs 33%; p < 0.01). Radiation-induced myelopathy and vertebral compression fracture were observed in 1 and 3 patients, respectively. No other grade 3 or greater toxicities were encountered. CONCLUSIONS The results indicate that spine SBRT as postoperative re-irradiation was effective, and it was especially useful for patients classified as having a good survival prognosis according to the Rades score.

Patterns of Intraosseous Recurrence After Stereotactic Body Radiation Therapy for Coxal Bone Metastasis.

PURPOSE: To analyze the detailed pattern of intraosseous failure after stereotactic body radiation therapy (SBRT) for coxal bone metastasis. METHODS AND MATERIALS: Patients treated with SBRT to coxal bone metastasis were identified by retrospective chart review. The SBRT doses were 30 Gy or 35 Gy in 5 fractions. A margin of 5 to 10 mm was added to the gross tumor volume to create the clinical target volume. We evaluated the presence or absence of intraosseous recurrence using magnetic resonance imaging. Intraosseous recurrences were assessed as "in-field" or "marginal/out-of-field." In addition, we measured the distance between the center of the recurrent tumor and the nearest edge of the initial bone metastasis in cases of marginal/out-of-field recurrence. RESULTS: Seventeen patients treated for 17 coxal bone metastases were included. Median age was 64 years (range, 48-79 years). Coxal lesions involved the ilium in 14 cases, pubis in 3, and ischium in 4 (3 lesions crossed over multiple regions). Patients most commonly had renal cell carcinoma (29.4%), followed by lung, hepatic cell, and colorectal cancers (23.5%, 11.8%, and 11.8%, respectively). Median follow-up after SBRT was 13 months (range, 2-44 months). Among all 17 cases, 7 cases developed 8 intraosseous recurrences, including in-field recurrence in 1 case and marginal/out-of-field recurrences in 7 cases. Median time to intraosseous recurrence was 10 months (range, 2-35 months). Among 7 cases with marginal/out-of-field recurrence, mean distance to the center of the recurrent tumor from the nearest edge of the initial bone metastasis was 34 mm (range, 15-55 mm). CONCLUSIONS: Most recurrences were observed out-of-field in the same coxal bone. These results suggest that defining the optimal clinical target volume in SBRT for coxal bone metastasis to obtain sufficient local tumor control is difficult.

First report of stereotactic body radiotherapy for large-volume spinal tumors.

Stereotactic body radiotherapy (SBRT) for spinal metastases is very effective for pain relief and local tumor control. However, high-level evidence is limited to lesions in a single vertebra or in 2 contiguous vertebrae. To clarify the toxicities, we report herein the results of treatment for 4 patients who received SBRT to large-volume spinal tumors. The lesions comprised bone metastasis from renal cancer, local recurrence of rectal cancer invading the spine, osteosarcoma, and giant cell tumor of bone in 1 case each. Tumor volumes ranged from 738 to 1,766 ml. Doses ranging from 24 Gy in 2 fraction to 35 Gy in 5 fractions were delivered. The median follow-up was 24 months (range 4-35 months). Pain reduction was achieved in all patients in 4 weeks after SBRT. The outcomes were partial response in 1 patient, stable disease in 2, and tumor progression in 1. One patient showed grade 3 acute radiation dermatitis 4 weeks after SBRT, and another patient showed grade 3 late radiation dermatitis.

Evaluating dosimetric differences in spine stereotactic body radiotherapy: An international multi-institutional treatment planning study.

INTRODUCTION: Stereotactic body radiotherapy (SBRT) planning for spinal metastases is a challenging task that involves complex target shapes and steep dose gradients proximal to the spinal cord. The aim of the present study is to investigate dosimetric variability among delivery systems and institutions doing spine SBRT.Materials and Methods: Three institutions (in Japan, Canada, and the USA) participated in this retrospective treatment planning study. Computed tomography (CT) datasets for three patients including fully delineated targets and organs-at-risk (OAR) were distributed to all three institutions for planning. Delivery systems included the Clinac 21EX, Vero4DRT, Synergy S, and CyberKnife. All treatment plans were generated using a prescribed dose of 24 Gy in 2 fractions and met the following objectives: the evaluated planning target volume (PTVevl, defined as the PTV minus spinal cord) should receive greater than 16.8 Gy in at least 95% of the volume (D95 > 16.8 Gy) and a maximum dose to the less than 140% of the prescribed dose (Dmax < 33.6 Gy). The maximum dose of planning risk volume (PRV) cord or thecal sac was limited to 0.035 cm3 receiving less than 17 Gy. Aside from minimum and maximum dose objectives for the PTVevl, there were no criteria regarding the shape of the PTVevl dose-volume histogram (DVH). For each completed treatment plan, the following DVH parameters were evaluated for the PTVevl: D95, D80, D50, D2 and sigma-index (S-index, standard deviation of the differential DVH). RESULTS: The PTVevl and OAR dose volume constraints were satisfied in all treatment plans. For Case 1, the mean PTVevl D50 was 25.4 ± 1.5 Gy (range: 23.7 - 27.8 Gy), for Case 2 it was 26.7 ± 2.0 Gy (23.6 - 28.6 Gy), and for Case 3 it was 26.0 ± 1.3 Gy (24.1 - 27.3 Gy). The mean PTVevl D2 was 27.3 ± 2.2 Gy (24.4 - 30.2 Gy), 28.9 ± 3.0 Gy (24.5 - 31.4 Gy) and 28.7 ± 2.7 Gy (25.2 - 31.6 Gy) for Cases 1, 2, and 3, respectively. However, there were statistically significant variations in the DVH parameters of PTVevl between apparatuses (CyberKnife versus non-CyberKnife) and among institutions (between 2 CyberKnife sites or between 2 conventional accelerator sites). CONCLUSIONS: Although all institutions met the minimum prescribed objectives, inter-institutional and inter-apparatus target dose variations were observed. Further study is necessary to determine target dose constraints that may minimize inter-institutional variations and lead to plan standardization.

Comparison of hypofractionated and conventionally fractionated whole-breast irradiation for early breast cancer patients: a single-institute study of 1,098 patients.

PURPOSE: To evaluate the efficacy and safety of hypofractionated whole-breast irradiation (HF-WBI) compared with conventionally fractionated (CF) WBI. MATERIALS AND METHODS: Patients with early breast cancer (stages 0-II and <3 positive lymph nodes) who had undergone breast-conserving surgery were eligible for the HF-WBI study. HF-WBI was administered at 43.2 Gy in 16 fractions over 3.2 weeks to the whole breast with an additional tumor-bed boost of 8.1 Gy in 3 fractions over 3 days for positive surgical margins or those <5 mm. CF-WBI was administered at 50 Gy in 25 fractions over 5 weeks to the whole breast with an additional tumor-bed boost of 16 Gy in 8 fractions over 1.4 weeks to 6 Gy in 3 fractions over 3 days, depending on margin status. RESULTS: From April 1, 2006, to December 31, 2010, 717 patients were registered and 734 breasts were treated by HF-WBI. In the same period, 381 patients and 393 breasts who matched the study criteria chose CF-WBI, so the total number of patients in this comparison was 1,098. Grade 2 acute skin reactions were observed for 24 patients (3 %) in the HF-WBI group and 53 patients (14 %) in the CF-WBI (p < 0.001) group. The median follow-up period was 27 months. Two cases of intrabreast tumor recurrence were observed in each treatment group. Regional lymph node recurrence was observed in 1 HF-WBI patient and 2 CF-WBI patients. CONCLUSION: HF-WBI is superior to CF-WBI in terms of acute skin reaction and has the same short-term efficacy.

Radiotherapy with fraction size of 2.25 Gy in T1-2 laryngeal and hypopharyngeal cancer.

This study was carried out to evaluate the influence of fraction size 2.25 Gy on local control of T1 and T2 laryngeal and hypopharyngeal cancers. Between August 2002 and December 2010, 80 patients with T1 and T2 laryngeal or hypopharyngeal cancers were treated with definitive radiotherapy with a fraction size of 2.25 Gy. Primary sites were the larynx in 69 and the hypopharynx in 11. Fifty-three patients were T1 and 27 were T2. All patients' pathology was squamous cell carcinoma except one carcinosarcoma. Radiotherapy was delivered 5 days/week with a 4-MV photon beam up to a total dose of 63.0 Gy. Median treatment time was 41 days. Statistical analysis of survival was calculated using the Kaplan-Meier method. No acute toxicity greater than grade 2 (CTCAE ver. 3.0.) including mucositis and dermatitis was observed. All but one patient had a complete response. The partial response patient received salvage surgery. The median follow-up period was 47 months (ranging from 4 to 108 months). No late toxicity greater than 1 was observed. Nine patients developed recurrence, seven local and two neck lymph nodes. Three patients died, one from laryngeal cancer and two from intercurrent diseases. The 5-year local control rates (LCRs) in the entire group, larynx T1, larynx T2 and hypopharynx T1 were 85.8%, 97.6%, 70.1% and 85.7%, respectively. The LCRs of T1 improved compared with our historical control, but not those of T2. The 2.25-Gy fraction size is safe and may have the potential to achieve good LCR in T1 lesions.

The dosimetric impact of respiratory breast movement and daily setup error on tangential whole breast irradiation using conventional wedge, field-in-field and irregular surface compensator techniques.

To evaluate the dosimetric impact of respiratory breast motion and daily setup error on whole breast irradiation (WBI) using three irradiation techniques; conventional wedge (CW), field-in-field (FIF) and irregular surface compensator (ISC). WBI was planned for 16 breast cancer patients. The dose indices for evaluated clinical target volume (CTV(evl)), lung, and body were evaluated. For the anterior-posterior (AP) respiratory motion and setup error of a single fraction, the isocenter was moved according to a sine function, and the dose indices were averaged over one period. Furthermore, the dose indices were weighted according to setup error frequencies that have a normal distribution to model systematic and random setup error for the entire treatment course. In all irradiation techniques, AP movement has a significant impact on dose distribution. CTV(evl)D(95) (the minimum relative dose that covers 95 % volume) and V(95) (the relative volume receiving 95 % of the prescribed dose) were observed to significantly decrease from the original ISC plan when simulated for the entire treatment course. In contrast, the D(95), V(95) and dose homogeneity index did not significantly differ from those of the original plans for FIF and CW. With regard to lung dose, the effect of motion was very similar among all three techniques. The dosimetric impact of AP respiratory breast motion and setup error was largest for the ISC technique, and the second greatest effect was observed with the FIF technique. However, these variations are relatively small.

Hyperfractionated radiotherapy with concurrent docetaxel for advanced head and neck cancer: a phase II study.

AIM: To evaluate the value of hyperfractionated radiotherapy with concurrent use of low-dose docetaxel in locally-advanced head and neck squamous cell cancer (HNSCC). PATIENTS AND METHODS: Patients eligible for this study had confirmed diagnosis of HNSCC stages II (>10 cm(3)) to IVB. Radiotherapy was delivered twice daily at 1.2 Gy/fraction to a total dose of 72.0 Gy. Docetaxel (10 mg/m(2)) was administered weekly during radiotherapy. RESULTS: From March 2003 to October 2008, 70 patients were treated. Primary sites included the oropharynx (n=25), hypopharynx (n=24), larynx (n=18), and other sites (n=3). Major grade 3 acute toxicities included mucositis (n=43) and treatment-related pain (n=20). The median follow-up period for surviving patients was 43 months. The 5-year local control rate and overall survival rate were 62.6% and 61.6%, respectively. CONCLUSION: This modality is a valuable treatment option for the management of locally-advanced HNSCC.

Full-dose capecitabine with local radiotherapy: one of the treatment options for inoperable T4 breast cancer.

A 48-year-old woman presented with a 15-cm diameter tumor in her left breast with fixation to the chest wall and palpable axillary lymph nodes. Pathology study showed pure-type mucinous carcinoma. Pretreatment staging investigations showed multiple lung metastases, which resulted in the diagnosis of T4N2M1 breast cancer. Four cycles of cyclophosphamide 700 mg/m(2)/epirubicin 70 mg/m(2) (CE) were performed initially, but the tumors decreased only within the treatment response criteria of stable disease (SD). The second regimen of docetaxel could not continue due to drug allergy. Two more cycles of CE did not improve the situation. Then, treatment was continued with full-dose capecitabine with local radiotherapy. She received radiotherapy to the left breast and axillary region with 60 Gy/30 fractions/6 weeks and concomitant capecitabine 2400 mg/body twice daily for 21 days; the cycles were repeated every 28 days. After radiotherapy, tumors decreased in size, and the skin ulceration disappeared. She continued to receive capecitabine on the same schedule. She now has no palpable tumor in her left breast and no tumor in the axilla or lung on CT. She is alive and well 6 years after radiotherapy.

[The role of radiotherapy in breast cancer].

Radiotherapy has been widely used in breast cancer in many situations. These are breast irradiation of breast conserving therapy,post mastectomy regional irradiation,irradiation for regional lymph nodes recurrence,breast irradiation of inoperable locally advanced cases,palliative irradiation of brain metastasis,bone metastasis and so on. The relationship among radiotherapy,surgery and systemic therapy has to be considered in those situations. In breast conserving therapy, the usefulness of breast irradiation is well established. Otherwise, a local controllability depend on a grade of residual tumor cell has not been understand. The authors conducted the survey of 941 cases of positive surgical margins and found that doses more than 60 Gy has a tendency for better local control in post menopausal cases. To reduce patient's burden,3 weeks short course irradiation (Canadian protocol) or accelerated partial breast irradiation have been introduced in breast irradiation. A subgroup which has no need to irradiate to conserving breast had not been identified. The timing between postoperative chemotherapy and irradiation is another point that has to be considered. To reduce distant metastasis,chemotherapy first has been considered better. As for post mastectomy regional irradiation, improvement of local and systemic control has been widely known these days. A timing of systemic therapy and irradiation is a point has to consider. In inoperable or far advanced T 4 tumors, breast irradiation with concurrent chemotherapy must be considered in stead of surgery. We have to know a big shortage in Japanese cancer treatment situation that we have few radiation oncologists or medical physicists in Japan. We have to educate those specialists to catch up with increasing cancer patients.

Comparison of 4 MV photon surface dose among Varian, Siemens, and Elekta linear accelerators for tangential breast treatment: a phantom study.

PURPOSE: We have compared the differences in a 4-MV photon surface dose among Varian, Siemens, and Elekta linear accelerators (linacs) with wedges for tangential breast treatment. MATERIALS AND METHODS: The wedge factor and the surface dose were measured using a solid water phantom and an ion chamber for each linear accelerator with various field sizes and wedge angles. A tangential treatment plan was applied to an elliptical hollow cylinder water phantom with a radiochromic film placed thereon. A dose was delivered to a simulated target in the phantom, and the resulting dose distribution was analyzed using a film scanner. RESULTS: Varian's wedges resulted in the highest wedge factors, ranging from 0.37 to 0.75 depending on the wedge angles. Varian's wedges led to the highest normalized skin doses, ranging between 0.40 and 0.73 depending on the wedge angles and field sizes. In the cylinder phantom test with two tangential beams, the Varian linac provided a nearly 20% higher maximum dose than the Siemens and Elekta linacs. CONCLUSION: The Varian linac resulted in the highest surface doses, and the Elekta linac led to the lowest for nearly all the measurement conditions we employed, including open beams.