Fiducial markers implantation for prostate image-guided radiotherapy: a report on the transperineal approach.

INTRODUCTION: In the external beam prostate cancer radiation therapy, daily gland displacement could lead to a target missing. The use of intra-prostatic gold fiducial markers for daily prostate position verification and correction before and during treatment delivery (image-guided radiotherapy, IGRT) is widely used in the radiation therapy centers to accurately target the prostate. Usually, the fiducial markers are implanted through the rectum, with complications such as infections and rectal bleeding. We report our experience in prostate fiducial markers implantation through a transperineal approach. PATIENTS AND METHODS: Between September 2011 and January 2018 at our center, 101 patients underwent gold seed fiducial marker transperineal ultrasound-guided implantation for prostate IGRT. We retrospectively reviewed their features and outcome. Twenty-two (21.8%) patients had previously been subjected to a transurethral prostate resection (TURP) for obstructive urinary symptoms because of benign prostatic hypertrophy. No antibiotic prophylaxis was used. RESULTS: The procedure was well tolerated. In one patient, a single episode of self-limiting urinary bleeding occurred just after it. No other complication was recorded. All the patients, at the evaluation before discharge, reported no pain or dysuria. No rectal bleeding, hematospermia, urinary obstruction or infection were reported in the next days. No markers lost or migration occurred. DISCUSSION AND CONCLUSION: According to our experience, prostate fiducial markers implantation through a transperineal approach is safe and should be recommended to limit the use of antibiotic therapy and patients morbidity. A previous TURP was not related to a higher risk of loss of seeds.

Radiotherapy for oligometastatic cancer: a survey among radiation oncologists of Lombardy (AIRO-Lombardy), Italy.

AIMS: To evaluate the use of radiotherapy (RT) for oligometastatic cancer (OMC) among radiation oncologists in Lombardy, Italy. METHODS AND STUDY DESIGN: A survey with 12 items regarding data of 2016 was sent to all 34 Lombardy RT centers. The survey included six general items and six specific items regarding patient/disease/treatment characteristics. RESULTS: Thirteen centers answered the survey (38%). All centers responded to general items and 12 centers submitted patient/disease/treatment data. General items The majority of centers (8/13) consider OMC if metastases number is less than 5. The most commonly prescribed dose/fraction is 5-10 Gy (8/13) using schedules of 3-5 fractions (11/13). Patient data items A total of 15.681 patients were treated in 2016 with external beam RT in 12 responding centers, and 1.087 patients were treated for OMC (7%). Primary tumor included lung, prostate, breast, colorectal and other malignancies in 33%, 21%, 12%, 9% and 25% of all OMC patients, respectively. Brain, lymph node, lung, bone, liver and others were the most common treated sites (24%, 24%, 22%, 17%, 8% and 5%, respectively). One and more than one metastasis were treated in 75 and 25% of patients, respectively. The vast majority of patients (95%) were treated with image-guided intensity-modulated RT or stereotactic RT. CONCLUSIONS: Seven percent of all RT patients in Lombardy are treated for OMC. Extreme hypofractionation and high-precision RT are commonly employed. The initiative of multicenter and multidisciplinary collaboration has been undertaken in order to prepare the platform for prospective and/or observational studies in OMC.

CBCT-based Prostate IGRT With and Without Implanted Markers: Assessment of Geometric Corrections and Time for Completion.

BACKGROUND/AIM: Cone-beam computed tomography (CBCT) is the most commonly used system in modern radiotherapy of prostate cancer for daily positioning verification. The use of intraprostatic radiopaque fiducials (FMs) may be added to CBCT. We wanted to investigate the possible advantage of using FMs in daily CBCT repositioning. MATERIALS AND METHODS: We selected three CBCTs for each treatment course for 13 patients (seven with and six without use of FMs) treated at our centre. Seven experienced Radiation Oncologists retrospectively reviewed the CBCTs, recording couch movements for correct patient positioning, and time spent to do it. Analysis of variance and t-test were carried out for comparison of different groups and for differences in mean values of the movements recorded (with p<0.05 as significance level). RESULTS: No statistically significant difference was found between operators in the analysis of images with FMs nor of images without them. A difference was only found in the mean corrections in couch rotation and pitch angle, which were higher in the FM group, and in the mean time for image analysis, which was shorter in this group. Using the van Herk formula, we found a possible reduction of clinical target volume and planning target volume margins for the FM group. CONCLUSION: According to our study, the use of intraprostatic FMs in daily CBCT seems useful for better detection of and correction for non-negligible rotational errors. Furthermore, FMs reduced the time to treatment start, which is very important in reducing the risk of intrafraction organ motion. These results need to be confirmed by further studies.

Image-guided robotic radiosurgery as salvage therapy for locally recurrent prostate cancer after external beam irradiation: retrospective feasibility study on six cases.

AIMS AND BACKGROUND: Technological advances in treatment planning and execution are providing new potential opportunities in the treatment of recurrent prostate cancer. This study was conducted to evaluate the feasibility and safety of reirradiation with image-guided radiosurgery using CyberKnife, a robotic arm-driven compact linear accelerator, for intraprostatic recurrence after external beam radiotherapy (EBRT). METHODS: Between September 2007 and May 2008, 6 patients diagnosed with locally recurrent prostate cancer after EBRT were treated using the CyberKnife system. The total reirradiation dose was 30 Gy in five fractions. Prior to radiosurgery four patients were treated with androgen-deprivation therapy. Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer criteria and the Houston-Phoenix definition (PSA nadir + 2 ng/mL) were used for toxicity and biochemical failure evaluation, respectively. RESULTS: After a median follow-up of 11.2 months (range, 9.6-18.6 months), all patients are alive with no evidence of severe urinary or rectal acute morbidity. Local control cannot be exactly determined due to the short follow-up and the bias of the use of androgen ablation. Four patients had biochemical failure, three of them with clinical failure evidence (lymph node, bone and lung metastasis, respectively): none of these patients had clinical evidence of tumor persistence in the prostate. CONCLUSIONS: Salvage radiosurgery with CyberKnife after irradiation is feasible with low urinary and rectal morbidity. A longer follow-up and a larger number of patients are necessary to evaluate its effectiveness and optimal patient selection criteria.

Noise induced epigenetic effects: A systematic review.

BACKGROUND: Noise-induced hearing loss (NIHL) is one of the leading causes of acquired sensorineural hearing loss. However, molecular mechanisms responsible for its pathogenesis remain to be elucidated. Epigenetic changes, i.e. DNA methylation, histone and microRNA expression modifications may function as a link between noise exposure and hearing loss. Therefore, the aim of the present review was to assess whether epigenetic alterations may serve as biomarkers of noise exposure or early effect. MATERIALS AND METHODS: A systematic review of studies available in Pubmed, Scopus, and ISI Web of Science databases was performed. RESULTS: Noise exposure was able to induce alterations in DNA methylation levels in workers and animal models, resulting in expression changes of genes related to hearing loss and also to extra-auditory effects. Differently expressed microRNAs were determined in NIHL workers compared to noise-exposed subjects with normal hearing, supporting their possible role as biomarkers of effect. Acoustic trauma affected histon acethylation and methylation levels in animals, suggesting their influence in the pathogenesis of acute noise-induced damage and their role as targets for potential therapeutic treatments. CONCLUSIONS: Although preliminary data suggest a relationship between noise and epigenetic effects, the limited number of studies, their different methodologies and the lack of adequate characterization of acoustic insults prevent definite conclusions. In this context, further research aimed to define the epigenetic impact of workplace noise exposure and the role of such alterations in predicting hearing loss may be important for the adoption of correct risk assessment and management strategies in occupational settings.

The Impact of Thyroid Diseases on the Working Life of Patients: A Systematic Review.

Thyroid diseases are characterized by a wide range of physical and mental symptoms that can affect biological function, emotional and social life of patients. However, their impact on work functioning is not yet fully understood. Therefore, this review aims to address the way in which thyroid diseases can affect occupational outcomes, i.e., the employment rate, sick leave, working capacity and work income of patients. A systematic review of Pubmed, Scopus and ISI Web of Knowledge databases has been performed. Although it is not possible to extrapolate precise data for benign pathologies, about a third of the survivors of thyroid cancer could be unemployed. Hyperthyroid and hypothyroid patients presented a greater risk of long-term sick leave than controls, depending on the severity of the disease. Hyperthyroidism impaired working ability in about a third of affected patients, particularly in cases complicated by orbitopathy with diplopia. A possible influence of thyroid diseases on various occupational outcomes emerged from our review, however further research seems necessary to understand the relationship between work problems, specific pathological characteristics over time and risk factors in the workplace. This may support a comprehensive, interdisciplinary management of thyroid disorders, with benefits for patients' personal, social and professional life.

Salvage high dose rate brachytherapy after primary external beam irradiation in localized prostate cancer: a case report.

No standard treatment exists for locally relapsed prostate cancer after primary external beam radiotherapy with no evidence of distant metastases. Radical prostatectomy, brachytherapy, cryotherapy and high-intensity focused ultrasound are currently used as local salvage treatments. Data on the safety and effectiveness of high dose rate (HDR) brachytherapy in this scenario are limited. We report on a patient who has no evidence of disease and no late urinary or gastrointestinal toxicity 33 months after receiving HDR treatment for recurrent prostate cancer.

Lymph node metastases of Merkel cell carcinoma from unknown primary site: report of three cases.

Merkel cell carcinoma (MCC) is an uncommon aggressive neuroendocrine skin carcinoma. It usually affects sun-exposed skin of white elderly people. MCC is characterized by a high incidence of early locoregional relapse and distant metastases. Because of its rarity and the resulting lack of prospective randomized trials, data regarding the optimal treatment of MCC are limited. Despite aggressive multimodality treatment, the prognosis of patients bearing MCC is often poor. We report three cases of lymph node metastases of MCC with unknown primary sites. Two patients died 17 and 28 months after diagnosis due to brain and pancreatic metastases, respectively, without evidence of cutaneous disease. The third patient is alive and free of tumor at 16 months from the diagnosis. After an accurate diagnosis of lymph node metastases from MCC, the absence of a primary tumor at complete initial evaluation and during adequate follow-up can confirm this particular clinical scenario. The prognosis seems to be analogous to that of cases with similar disease stage (lymph node involvement) but a known primary site.

Radiotherapy for head and neck cancer in Lombardy: a survey by the Lombardy Group of the Italian Association for Radiation Oncology.

AIMS: In 2013, a survey was conducted to analyze the available resources and their use in the radiation treatment of patients with malignancies of the head and neck region in Lombardy, on behalf of the Lombardy group of the Italian Association of Radiation Oncology. METHODS: A questionnaire was sent to 26 of 34 radiotherapy centers active in the region. Two centers were excluded because they did not treat head and neck cancers (Besta Neurological Institute and Cyberknife center), 4 had started their activity in 2013 or late 2012, and 2 satellite centers had their results included in the main center's response. Items investigated included number of patients with head and neck cancer treated in 2012, general technical issues, and integration with surgery and chemotherapy. RESULTS: Twenty-four questionnaires were returned (92% response rate). There was a good consistency on the use of radiotherapy in different settings, whereas integration with chemotherapy showed more heterogeneous data. Treatment techniques were 3D conformal radiotherapy or intensity-modulated radiotherapy with image-guided radiotherapy in most cases and a low rate of treatment-related death was observed. CONCLUSIONS: This survey provides important data on the use of radiotherapy resources for patients with head and neck cancer in Lombardy. The data offer the opportunity to further investigate issues that could better standardize head and neck cancer treatment and allocate resources across the region.

Postoperative management of keloids: low-dose-rate and high-dose-rate brachytherapy.

PURPOSE: We report the experience of the Radiation Oncology Department of the European Institute of Oncology in Milan, Italy, on the adjuvant low-dose-rate (LDR) and high-dose-rate (HDR) interstitial brachytherapy. Brachytherapy might be useful to improve keloids recurrence rate or reduce keloids treatment side effects instead of external beam radiotherapy. METHODS AND MATERIALS: Data on 70 consecutive patients treated after complete keloid surgical excision were retrospectively analyzed. First 38 patients and 46 keloids were treated with adjuvant LDR brachytherapy and the following 39 patients and 50 keloids underwent HDR treatment. Median delivered dose of LDR therapy was 16 Gy; HDR median dose was 12 Gy. Sixty-four keloids (66.7%) were symptomatic at diagnosis with pain, itching, or stress. RESULTS: Fourteen relapses over 46 treated keloids (30.4%) were observed in the LDR group and 19 of 50 keloids (38%) in the HDR group (p = 0.521). Recurrence rate was significantly higher in males (p = 0.009), in patients younger than 44 years (p < 0.0001), for arms, neck, and chest wall anatomic sites (p = 0.0001) and for symptomatic keloids (p = 0.017). Aesthetic outcome was better in case of larger keloids (>8 cm) (p = 0.064). Symptomatic relief was achieved in 92% of HDR patients and only 68% of LDR patients (p = 0.032). CONCLUSIONS: Postoperative brachytherapy is an effective treatment for keloids. In our study, LDR and HDR treatments resulted in similar recurrence rate. Better symptomatic relief was reported in case of HDR treatment compared with the LDR regimen.

Radiation therapy in primary orbital lymphoma: a single institution retrospective analysis.

BACKGROUND: Primary orbital lymphoma is a rare disease that accounts for 10% of all orbital tumors. Radiotherapy on the orbital cavity is the treatment of choice for this unusual presentation of localized non-Hodgkin's lymphoma (NHL). The aim of this study is to retrospectively evaluate the effectiveness and the toxicity of radiation treatment in patients with primary orbital lymphoma. METHODS: Forty-seven consecutive patients having primary orbital lymphoma treated in our department between May 1983 and September 2006 were investigated in a retrospective study. Either 60Co gamma rays or 6 MV X rays were used to deliver daily fractions of 1.8 or 2.0 Gy, 5 times/week, with total doses ranging from 34.2 to 50 Gy. Forty-three patients had stage IE, three had stage II and one stage IV disease. Thirty-eight patients had marginal zone B-cell lymphoma, 5 diffuse large B cell lymphoma, 3 mantle cell lymphoma and 1 Burkitt lymphoma. Local control (LC), disease free survival (DFS), overall survival (OS) and late side effects were evaluated in all patients. RESULTS: With a median follow up of 45 months, LC was obtained in 100% of patients. The estimated 5- and 7-year DFS rates were 75.8% and 55.3%, and the 5- and 7-year OS rates were 88.7% and 79.9% respectively. Acute toxicity was minimal. Late toxicity such as cataract, keratitis, retinopathy and xerophthalmia occurred respectively in 12 (25.5%), 5 (10.6%), 1 (2.1%), and 9 (19.1%) patients. CONCLUSION: Radiotherapy is an effective and at the same time well tolerated treatment for primary orbital lymphoma.