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.

Contouring of the Pharyngeal Superior Constrictor Muscle (PSCM). A cooperative study of the Italian Association of Radiation Oncology (AIRO) Head and Neck Group.

BACKGROUND AND PURPOSE: Irradiation of the Pharyngeal Superior Constrictor Muscle (PSCM) seems to play a crucial role in radiation-related swallowing dysfunctions. Purpose of our study was to quantify operator-related variability in the contouring of PSCM on Computed Tomography (CT) scans and adherence with contours derived from MR images. MATERIALS AND METHODS: Three sets of treatment planning CT and their corresponding MR images were selected. Contouring of the PSCM was performed using both a literature-based method, derived from literature review, and an optimized method, derived from Magnetic Resonance (MR) images thus obtaining "literature-based" and "optimized" contours. Each operator contoured the PSCM on CT scans according to both methods for three times in three different days. Inter- and intra-operator variability and adherence to a contour obtained from MR images (named "MR-derived" contour) were analyzed. RESULTS: Thirty-four operators participated and 612 contours were obtained. Both intra- and inter-operator variability and adherence to the "MR-derived" contour were significantly different between the two methods (p⩽0.05). The "optimized" method showed a lower intra- and inter-operator variability and a higher adherence to the "MR-derived" contour. CONCLUSIONS: The "optimized" method ameliorates both operator-related variability and adherence with MR images.

Patterns of postoperative radiotherapy for head and neck cancer in Italy: a prospective, observational study by the head and neck group of the Italian Association for Radiation Oncology (AIRO).

AIMS AND BACKGROUND: Our previous survey showed that the patterns of postoperative radiotherapy (PORT) for head and neck cancer (HNC) in Italy might be suboptimal. A prospective observational study was therefore designed to evaluate this issue in greater detail. METHODS: All radiotherapy centers involved in the HNC Working Group of the Italian Radiation Oncology Association were asked to enter into the study all patients treated with PORT during a 6-month period. RESULTS: A total of 200 patients were accrued by 24 centers from December 2008 to May 2009. Larynx (38%) and oral cavity (34%) were the most common primary sites. The median time between surgery and the start of radiotherapy was 69 days (range, 25-215 days). Seventy-nine percent of cases with no evidence of risk factors for local recurrence were treated with high-dose radiotherapy to the primary site. In about 75% of cases the pN0 neck was included in the target volume. Concomitant chemotherapy was delivered to about 60% of patients with major risk factors and 21% of patients with no risk factors. CONCLUSIONS: Three issues emerged from our study as potential targets for future investigations: the impact on clinical outcome of the interval between surgery and the start of PORT; factors driving radiation oncologists to overtreat volumes at low risk of recurrence; and problems associated with the delivery of concomitant chemotherapy.

Postoperative adjuvant radio(chemo)therapy for rectal cancer: an appraisal.

AIMS AND BACKGROUND: Rectal cancer can be considered a broad-spectrum disease, where the surgeon, radiation oncologist and medical oncologist have a peculiar and specific place in order to work harmoniously as a good orchestra. The reality in common general hospitals is far from that of comprehensive cancer centers, particularly for postoperative approaches. The adjuvant therapy of rectal cancer is not codified worldwide, and it is strongly dependent on preoperative staging procedures, surgeon's acts and pathologist's decisions. Starting from our 10-year experience, we analyzed the various steps of postoperative approaches, defining possible decision errors, the incongruity of some attitudes, and the lack of knowledge of recent achievements of science in this disease. METHODS: A total of 194 patients with advanced surgically removed rectal cancer (pT3-4 pN0-any pT pN+) treated with postoperative radio(chemo)therapy was reviewed retrospectively. Anterior resection was performed in 126, abdominoperineal resection in 48, and other surgical procedures in 20 patients. Irradiation was conducted with a single daily fraction of 1.8 Gy until 45 Gy, and chemotherapy consisted of the combination of 5-fluorouracil and folinic acid (Machover schedule): 47% of patients with positive nodes did not receive chemotherapy. RESULTS: Five-year overall survival was 60.6% and relapse-free survival was 55.5%. The main prognostic factors were pathological T and N stages. The principal route of progression was distant metastases. Acute toxicity was severe in 1 case (drug toxic hepatitis) and very severe in 16 patients, and late severe sequelae appeared in 13 patients. CONCLUSIONS: The outcome of rectal cancer patients has not changed during the last decade, and this was confirmed in our study. The improvement of radiotherapy techniques has reduced the adverse acute and late toxicity. The best postsurgical approach for pT3pN0 cancer remains unsolved, as the good chemotherapy combination and the real solution could be the application of a new Consensus Conference.

Anxiety, depression and informed consent in patients referred to a radiotherapy department.

AIMS AND BACKGROUND: Informing cancer patients is an ethical, legal and deontological aspect of patient management. Patients need clear instructions in order to be able to accept or refuse medical procedures. Many reports in the literature have shown differences among physicians in informing cancer patients. The aim of this study was to assess patients' understanding of diagnosis, planned radiotherapy and risk of early and late effects, their satisfaction with the discussion with the doctor and correlation with anxiety and depression after the disclosure of a cancer diagnosis. METHODS: From April to July 2000 a physician with psychiatric training conducted interviews with patients after their consultation with the radiotherapist and asked them to fill in a questionnaire. Anxiety and depression were measured by means of a scoring system [HAD(A) and HAD(D)] such as the patient's satisfaction and the physician's belief in it. Eighty-two outpatients referred to our radiotherapy department were studied. RESULTS: We did not find any correlation between HAD(A) and HAD(D) scores and comprehension scores of disease, treatment schedule, side effects and patient satisfaction, or between any scores and presumed predictive variables such as diagnosis, gender, age, treatment aims, time from diagnosis, education, marital status, profession, life habits, and the role of the doctor obtaining the informed consent. CONCLUSIONS: We may conclude that informed consent does not seem to increase reactive anxiety or depression. Its quality is high in our department but must be improved.

Guidelines for the delineation of nodal regions of the head and neck on axial computed tomography images.

Delineation of target volumes is increasingly recognized as the most crucial step within the process of modern conformal radiotherapy. In the field of head and neck radiation oncology, the need for a standardized methodology in the delineation of nodal regions of the neck on computed tomography (CT) images has recently emerged. To address this issue, a consensus document has been prepared by the Head and Neck Working Party of the AIRO-Lombardia Cooperative Group, based on the proceedings of multidisciplinary meetings and on literature findings. The document contains detailed guidelines for the delineation on CT images of the nodal regions of the neck, including for each nodal region (1 to 7) the description of anatomical limits as seen on CT images.