Plan quality analysis of stereotactic ablative body radiotherapy treatment planning in liver tumor.

PURPOSE: Stereotactic ablative body radiotherapy (SABR) in the liver, RTOG-1112 guides the treatment modalities including the dose constraints for this technique but not the plan parameters. This study is not only analyzing the plan quality by utilizing the plan parameters and indexes but also compares treatment modalities from the protocol implementation. METHOD AND MATERIAL: Twenty-five patients treated in the period from February 2020 to September 2022 were recruited in this analysis. Two planners randomly selected the patients and modalities. The modalities employed were Volumetric-Modulated Arc Therapy (VMAT) and Helical Tomotherapy (HT). Various parameters and indexes were used to access not only the plan quality but also to compare each modality. The parameters and indexes studied were the homogeneity index (HI), conformity index (CI), gradient distance (GD), and the dose received by the organs at risk. RESULT: The data reveals that the mean volume of PTV is 60.8 ± 53.9 cc where these targets exhibit no significant difference between each modality. The HI shows a consistent value for both modalities. Between each modality, the CI value shows less deviation, but the HT shows slightly higher performance than VMAT. The value of GD is 1.5 ± 0.3 cm where the HT provides a shorter distance compared to VMAT as well. CONCLUSION: The parameters and indexes should be utilized for the plan evaluation although in the guidelines this was not required. Various modalities were employed for treatment. Both can achieve the treatment criteria with slightly low performance of VMAT.

Breast Cancer Subtypes in Northern Thailand and Barriers to satisfactory survival outcomes.

BACKGROUND: The incidence of breast cancer (BC) in Thailand has been rising at an alarming rate. The annual incidence of BC in Thailand has doubled over a span of 15 years. A retrospective study was conducted with the primary objective of assessing and comparing survival rates of patients with BC, stratified by subtype of BC. METHODS: A retrospective study was implemented for a cohort of women receiving a diagnosis of invasive BC with the objective of assessing and comparing their overall survival, stratified by BC subtype. Thai women receiving a diagnosis of their first primary invasive BC between January 2006 and December 2015 at Chiang Mai University Hospital were studied with 3,150 cases meeting the eligible criteria. RESULTS: The median follow-up time was 4.9 years (Inter Quartile Range: 2.8-7.7). The most common diagnosed subtype was luminal B-like (n = 1,147, 36.4%). It was still the most prevalent subtype (35.8%) in women younger than 40 years and the 40-60 age-group, The proportion of patients with TNBC is the highest in women aged less than 40 years with 19.3% compared to the other age categories. Finally, among women older than 60 years, the proportion of each subtype was relatively uniform. Most women received a diagnosis of stage II disease. Triple negative subtype increased overall mortality in advanced staging (stages III and IV) (aHR:1.42, 95% CI: 0.96-2.11). The 5-year overall survival rate was found in luminal A-like at 82.8%, luminal B-like at 77.6%, HER-2 enriched at 66.4% and triple negative subtype at 64.2%. CONCLUSION: The histologic subtype, correlated with age and staging influenced the OS. Our results confirmed the association of triple negative BC with poor prognosis especially in advanced stage. The adjuvant medical treatment in our country could not be accessible in some group of patients, so the results of treatment and survival especially HER-2 enriched are lower than other countries without treatment barrier.

The prognostic value of excision repair cross-complementing Group 1 expression in nasopharyngeal cancer patients.

BACKGROUND: Overexpression of excision repair cross-complementing Group 1 (ERCC-1) is related to cisplatin resistance and defective repair of radiation damage. The purpose of this study was to evaluate the clinical significance of excision (ERCC-1) expression in nasopharyngeal cancer (NPC). MATERIALS AND METHODS: We conducted a retrospective review of patients diagnosed with NPC between 2000 and 2013. The archived tissues were analyzed using immunohistochemistry to determine ERCC-1 expression. The ERCC-1 expression level along with other clinical factors and overall survival (OS) were analyzed. Hazard ratio (HR) with a 95% confidence interval was calculated to assess the risk. RESULTS: The analysis of ERCC-1 expression was available in 262 NPC patients who had medical records at our hospital. Among those patients, 221 (84%) were treated with curative radiotherapy (RT)/concurrent chemoradiotherapy, 22 (7%) were treated with palliative RT alone, and 19 (9%) were given best supportive care. There was no correlation between ERCC-1 expression and stage of cancer or OS. No difference in 5-year OS was found between patients with low ERCC-1 expression and high ERCC-1 expression (38% vs. 36%; P = 0.981). The adjusted HR (aHR) of cancer death increased with cancer stage (aHR = 2.93 for advanced Stages III-IV; P = 0.001) and age (aHR = 2.11 for age >55; P ≤ 0.001). ERCC-1 expression exhibited no prognostic significance in our study (aHR = 1). CONCLUSION: In this study, ERCC-1 expression has no statistical significance to be considered a prognostic factor for OS among NPC patients. On the other hand, cancer stage, age, and types of treatment can be prognostic factors in NPC patients.

Intermediate-term results of trans-abdominal ultrasound (TAUS)-guided brachytherapy in cervical cancer.

OBJECTIVES: To report the intermediate-term results of trans-abdominal ultrasound (TAUS)-guided brachytherapy in cervical cancer. MATERIALS AND METHODS: Ninety-two patients with cervical cancer (stage IB-IVA, according to FIGO staging), were treated by curative radiotherapy from February 2012 to June 2015. All patients were treated with whole pelvic radiotherapy to 50 Gy in 25 fractions and central shielding after 44 Gy, in combination with TAUS-guided brachytherapy, in order to escalate the total dose (EQD2) to the minimal dose at cervical points (in EQD2 concepts) defined by TAUS, while maintaining low doses to ICRU bladder and rectal points. The treatment results and toxicity profiles were reported. RESULTS: At median follow-up time of 41.2 months (range 8 to 61 months) the pelvic control, disease-free survival, and overall survival rates were 84.8%, 75%, and 88%, respectively. The mean applied doses to cervix, bladder, and rectal points were 83.5, 72.3, and 76.5 Gy, respectively. Eight patients developed grade 2 Gastrointestinal toxicity. CONCLUSION: The 3-year results demonstrated that TAUS-guided brachytherapy is feasible and associated with excellent tumor control/toxicity rates in cervical cancer.

The Outcome of the First 100 Nasopharyngeal Cancer Patients in Thailand Treated by Helical Tomotherapy.

BACKGROUND: The aim of the study was to analyse of two-year loco-regional failure free survival (LRFFS), distant metastasis free survival (DMFS), overall survival (OS), and toxicity outcomes of the first 100 nasopharyngeal carcinoma patients in Thailand treated by helical tomotherapy. PATIENTS AND METHODS: Between March 2012 and December 2015, 100 patients with non-metastatic nasopharyngeal carcinoma were treated by helical tomotherapy. All patients were treated by platinum-based concurrent chemoradiotherapy and adjuvant or neo-adjuvant chemotherapy. RESULTS: The median age was 51 years (interquartile ranges [IQR]: 42.5-57.0). The mean ± SD of D95% of planning target volume (PTV) 70, 59.4 and 54 were 70.2 ± 0.5, 59.8 ± 0.6, and 54.3 ± 0.8 Gy, respectively. The mean ± SD of conformity index, and homogeneity index were 0.89 ± 0.13 and 0.06 ± 0.07. Mean ± SD of D2 % of spinal cord and brainstem were 34.1 ± 4.4 and 53.3 ±6.3 Gy. Mean ± SD of D50 of contralateral and ipsilateral parotid gland were 28.4 ± 6.7 and 38.5 ± 11.2 Gy. At a median follow-up of 33 months (IQR: 25-41), the 2-year LRFFS, DMFS, OS were 94% (95%CI: 87-98%), 96% (95% CI: 89-98%), and 99% (95% CI: 93-100%), respectively. Acute grade 3 dermatitis, pharyngoesophagitis, and mucositis occurred in 5%, 51%, and 37%, respectively. Late pharyngoesophagitis grade 0 and 1 were found in 98% and 2% of patients. Late xerostomia grade 0, 1 and 2 were found in 17%, 78% and 5%, respectively. CONCLUSIONS: Helical tomotherapy offers good dosimetric performance and achieves excellent treatment outcome in nasopharyngeal carcinoma patients.

Combined chemoradiation of cisplatin versus carboplatin in cervical carcinoma: a single institution experience from Thailand.

BACKGROUND: To report the results of combined chemoradiation (CCRT) with cisplatin versus carboplatin in locally advanced cervical carcinoma. METHODS: From 2009 to 2013, 255 patients with stage IIB-IVA cervical carcinoma, according to FIGO staging were prospectively assigned to be treated with pelvic radiotherapy followed by brachytherapy given concurrently with cisplatin or carboplatin in the treatment of locally advanced cervical cancer. Treatment outcomes and toxicitiy were evaluated. RESULTS: Two-hundred and thirteen patients could be evaluated. At a median follow-up time of 43 months (6-69 months), the 3-year local control, disease-free survival, metastasis-free survival and overall survival rates were 93, 80.8, 85.0 and 87.3 %, respectively. No statistical difference in terms of local control, disease-free survival, metastasis-free survival and overall survival rates between cisplatin and carboplatin treatments was observed in this study. Eighty-six percents of the patients in the carboplatin group could receive more than 4 cycles, while there were only 72 % in the cisplatin group who completed more than 4 cycles (p = 0. 02). In terms of acute toxicity, cisplatin caused significantly more anemia (p = 0.026), neutropenia (p = 0. 044) and nephrotoxicity (p = 0. 031) than carboplatin. No difference in late toxicity was observed in this study. CONCLUSION: Carboplatin yielded comparable results to cisplatin in concurrent chemo-radiation for locally advanced cervical cancer. In addition, carboplatin was associated with a better compliance rate and was associated with less of anemia, neutropenia and nephrotoxicity.

The treatment outcome of radical radiotherapy in laryngeal cancer.

OBJECTIVE: This study reports the treatment outcome of radiotherapy alone for laryngeal cancer MATERIAL AND METHOD: A retrospective analysis was performed on 138 patients with stage I to IV squamous cell carcinoma of larynx who received radiotherapy alone in Division of Therapeutic Radiology and Oncology, Faculty of Medicine, Chiang Mai University, Thailand between 2003 and 2009. RESULTS: The 4-year local control (LC) rate in all patients was 44.1%. The 4-year overall survival (OS) was 82.1%. The 4-year LC rates for stage I, II, III, and IV were 75.3%, 69.4%, 57.1%, and 36.9%,respectively (p = 0.0055). Finally, the 4-year OS rates for stage I, II, III, and IV were 85%, 78.6%, 91.1%, and 71.5%, respectively. The laryngeal preservation rate of all stages was 73%. CONCLUSION: In conclusion, the treatment outcome of radiotherapy alone in all stages of laryngeal cancer in our center was unsatisfactory when compared to other series.

Preliminary results of adjuvant image-guided vaginal brachytherapy alone for early stage endometrial carcinoma.

Objective: This retrospective study evaluated the preliminary outcomes of image-guided vaginal brachytherapy (IG-VBT) in the adjuvant treatment of high intermediate risk endometrial cancer. Materials and Methods: Data were collected from 48 patients who underwent adjuvant IG-VBT between 2019 and 2022 at the Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Chiang Mai University. The vaginal cuff clinical target volume (CTV-VC) is composed of a 4-mm-thick band around vaginal cylinder at the upper 3 cm of the vaginal cuff. A total dose of 21 Gy in three fractions was delivered to the CTV-VC, and the dose to the bladder and rectum were evaluated. Treatment details, patient characteristics, and outcomes were analyzed. Descriptive statistics were used for analysis, and Kaplan-Meier method was employed for survival analysis. Results: The mean age was 62 years, with mainly endometrioid carcinoma pathology (96 %). All patients were at stage I, with 87.5 % receiving complete surgical staging. Mean total treatment time was 10 days with mean D90 of CTV-VC was 29.7 Gy, and D2cc of bladder, rectum, and sigmoid were 24.6 Gy, 21.0 Gy, and 7.7 Gy, respectively. At a median follow-up of 37 months, 3-year local control, disease-free survival, and overall survival rates were 100 %, 100 %, and 97.9 %. respectively. Two patients (4.2 %) experienced grade 1-2 gastrointestinal toxicity, while no genitourinary toxicity or serious adverse events were observed. Conclusions: The preliminary results of IG-VBT in endometrial cancer demonstrated favorable outcomes in terms of vaginal control and toxicity. Further studies with larger cohorts and longer follow-up durations are warranted.

Retrospective Analysis of All Types of Adjuvant Radiotherapy in Endometrial Cancer: Single-Center Experiences in a Middle-Income Country.

OBJECTIVE: We retrospectively analyzed the efficacy, focusing on overall survival (OS) and the patterns of failure, along with the toxicities of adjuvant radiotherapy (RT) in endometrial cancer patients. METHODS: Two-hundred and nineteen patients with endometrial cancer patients who received adjuvant radiotherapy ± adjuvant chemotherapy (ACT) from January 2014 to December 2018 were investigated for overall survival (OS), local recurrence-free survival rate (LRFS), regional recurrence-free survival rate (RRFS), and distant metastasis-free survival rate (DMFS). RESULT: Two-hundred and fourteen patients were evaluated. The numbers of VBT alone, EBRT plus VBT, and adjuvant chemotherapy (ACT) plus EBRT plus VBT were 65 (30.4%), 80 (37.4%), and 69 (32.2%) patients, respectively. Stage I (107 patients) was the most common followed by stage III (87 patients). With a median follow-up time of 67 months (IQR 56-78), the 5-year overall survival rates for VBT alone, EBRT plus VBT, and EBRT plus VBT plus ACT were 84.4%, 65%, and 57.4%, respectively. The most common severe (grade 3-4) acute toxicity was neutropenia (4.6%), followed by diarrhea (3.7%). Grade 3-4 late proctitis was found in only 1.9%. On multivariate analysis, advanced age (HR 6.15, p: 0.015), lymph node involvement (HR 6.66, p: 0.039), cervical involvement (HR 10.60, p: 0.029), and substantial LVSI (HR 21.46, p: 0.005) were associated with a higher risk of death. CONCLUSION: Advanced age (>65), substantial LVSI, lymph node involvement, and cervical stromal involvement were associated with poor overall survival. These findings here will help identifying high-risk patients and would make it possible to avoid unnecessary adjuvant treatment among patients with a good prognosis.

Intermediate-term results of image-guided brachytherapy and high-technology external beam radiotherapy in cervical cancer: Chiang Mai University experience.

OBJECTIVE: To evaluate the outcomes of image-guided brachytherapy combined with 3D conformal or intensity modulated external beam radiotherapy (3D CRT/IMRT) in cervical cancer at Chiang Mai University. METHODS: From 2008 to 2011, forty-seven patients with locally advanced cervical cancer were enrolled in this study. All patients received high-technology (3D CRT/IMRT) whole pelvic radiotherapy with a total dose of 45-46 Gy plus image-guided High-Dose-Rate intracavitary brachytherapy 6.5-7 Gy × 4 fractions to a High-Risk Clinical Target Volume (HR-CTV) according to GEC-ESTRO recommendations. The dose parameters of the HR-CTV for bladder, rectum and sigmoid colon were recorded, as well as toxicity profiles. In addition, the endpoints for local control, disease-free, metastasis-free survival and overall survival were calculated. RESULTS: At the median follow-up time of 26 months, the local control, disease-free survival, and overall survival rates were 97.9%, 85.1%, and 93.6%, respectively. The mean dose of HR-CTV, bladder, rectum and sigmoid were 93.1, 88.2, 69.6, and 72 Gy, respectively. In terms of late toxicity, the incidence of grade 3-4 bladder and rectum morbidity was 2.1% and 2.1%, respectively. CONCLUSIONS: A combination of image-guided brachytherapy and IMRT/3D CRT showed very promising results of local control, disease-free survival, metastasis-free survival and overall survival rates. It also caused a low incidence of grade 3-4 toxicity in treated study patients.

Development of a quality assurance system in radiation oncology: A 12-year experience in a University Hospital.

PURPOSE: This study aimed to report 12 years of experience in the development of a quality assurance system in radiation oncology in a university hospital. MATERIAL AND METHODS: We developed the Quality Assurance Program in Radiation Oncology (QUAPRO) in 2008 to detect treatment deviation in the radiotherapy (RT) process with three steps of near-miss detection: simulation and prescription (primary check, PC), treatment planning (secondary check, SC), and treatment delivery process (tertiary check, TC). We transferred our paper-based medical records to electronic-based radiotherapy information systems (RTISs) in 2013. QUAPRO was completely integrated into RTIS in 2017. Since then, electronic-based incident reporting has been conducted. The program is called the Radiation Incident Learning System (RILS). The near-miss rates were compared during the three time periods: 2008-2012, 2013-2017, and 2017-2020. RESULTS: Five years of paper-based QUAPRO for 2008-2012 demonstrated a fluctuation in the checking ratio, with a gradually increasing rate of near misses of 3.5-19.7%. After electronic-based medical records were developed in 2013, the results revealed a dramatic increase from a rate of 2.7 to 4.2 in the number of checks per patient and achieved an increased rate of near misses of 24.7% for PC, SC, and TC. The rate of near misses gradually decreased to 5.3% after 2017 because of RT workflow improvement. CONCLUSION: The analysis of 12 years in near-miss data reflected the effectiveness of our quality assurance program. The QUAPRO system can detect near-miss incidents in the whole RT workflow and illustrate the detection improvement when integrated into electronic-based medical records. Regular feedback and exploration of near-miss reporting are recommended for proper RT workflow improvement.

Reduction in severity of radiation-induced dermatitis in head and neck cancer patients treated with topical aloe vera gel: A randomized multicenter double-blind placebo-controlled trial.

PURPOSE: To assess the efficacy of topical aloe vera gel on radiation induced dermatitis (RID) in head and neck cancer (HNC) patients. METHOD: In this multicenter randomized double-blind controlled study, HNC patients treated with concurrent chemoradiation (CCRT) received either aloe vera gel or placebo gel. Adverse skin toxicity levels were evaluated with the radiation-induced skin reaction assessment scale (RISRAS). RESULTS: One hundred-twenty patients were enrolled in this study. Analysis of the baseline characteristics did not reveal any differences between the groups. The median RISRAS values from the 1st to the 8th week of the CCRT course were not statistically different between the two groups. In the 5th and 6th weeks of treatment, moderate to severe grades of skin erythematous were observed at values of 13.6% and 24.1% versus 27.8 and 42.6% for members of the aloe vera gel group and the placebo group, respectively (p = 0.05 for the 5th week and p = 0.038 for the 6th week). In the 7th week, moderate to severe instances of moist desquamation were observed in eight patients (19.0%) in the placebo group (p = 0.001). Subjects experienced a burning sensation with RISRAS scores of 3-4 in the 7th week representing only 11.9% of patients in the placebo group (p = 0.016). CONCLUSION: Topical applications of aloe vera gel significantly reduced moderate to severe grades of skin erythematous and instances of moist desquamation in HNC patients receiving CCRT. In this study, there was no prophylactic efficacy for RID in the aloe vera gel group when compared to the placebo group.

Spatial Distribution of Head and Neck Cancer in Chiang Mai, Thailand.

BACKGROUND: The incidence of Head and neck (HN) cancers in Thailand is rising and survival rates not improving. Variations of its incidence among geographical areas may due to various contributing factors. METHODS: We focused on data from 25 districts within Chiang Mai province, Thailand. The temporal change was described separately into two periods, 2007-2012 and 2013-2018. The OpenBUGS and the Quantum Geographic Information System were utilized to determine the geographical patterns in the incidence of HN cancer and focus on oropharynx. RESULTS: The number of new cases of HN cancer was 1,186, of which 835 cases (70%) were male. Among those patients 548 diagnosed in 2007-2012 and 638 diagnose in 2013-2018. High risk patterns of both overall HN and oropharyngeal cancer incidences were found in the central and southern areas of the province in 2007-2013. However, the geographical patterns of the incidence of oropharyngeal cancer showed the changed pattern, with high RR in central and northern areas in more recent period. Over two periods, the RR of the cancers incidence decrease. The RR of oropharyngeal increased in Fang district and it remained high in Mueang district. CONCLUSION: This study have highlighted specific areas with a high risk of head and neck cancer and oropharyngeal cancer incidences in Chiang Mai province, along with the spatial inequalities in their distributions, with cluster formation. These results may be helpful in guiding any strategy put in place to respond to the high risk incidence of the cancers in specific areas.

Brachytherapy dose changes: comparing in-room and out-room image-guided brachytherapy. A randomized study.

Purpose: Image-based brachytherapy, involving an image machine and a brachytherapy unit in the same room (in-room brachytherapy [IRBT]), limits patient movements; however, this technique may not be feasible in high workload centers. In this study, we compared changes in the dose and volume of organs at risk (OARs) with out-room brachytherapy (ORBT) technique, in which patients musted be transferred to a waiting room and then transferred back for brachytherapy delivery. Material and methods: This was a randomized prospective study comparing changes in D2cc doses and volume of OARs during IRBT and ORBT. Patients underwent CT for treatment planning (CT1) installed in brachytherapy loading room, and another CT immediately before brachytherapy (CT2) during each fraction. While patients remained on CT table after CT1 during treatment planning and delivery in IRBT arm, they were transferred out to waiting room and back to CT table in ORBT arm. CT2 was analyzed with CT1 to evaluate any changes in volumes and doses. Results: A total of 294 fractions of brachytherapy were considered. The findings indicated no significant differences in the mean D2cc changes (Gy) (CT2 minus CT1) to the bladder, rectum, and sigmoid between IRBT and ORBT (mean ±SD: -0.07 ±0.36 vs. -0.01 ±0.39, p = 0.1426; -0.15 ±0.32 vs. -0.14 ±0.29, p = 0.8898; -0.17 ±0.38 vs. -0.19 ±0.31, p = 0.5221, respectively). Moreover, significant correlations were observed between D2cc changes and volume changes to each of OARs, p < 0.001. Conclusions: IRBT does not result in differences in dose changes between planning and pre-treatment imaging when compared with ORBT. Consequently, ORBT can be considered for routine practice in high workload centers. Correlations in volume change and dose change to OARs were also observed.

Stereotactic radiosurgery for limited brain metastasis using three different techniques: helical tomotherapy, volumetric modulated arc therapy, and cone-based LINAC radiosurgery.

PURPOSE: Specific radiation delivered to tumors by stereotactic radiosurgery (SRS) has become widely used in the treatment of brain metastasis. This study aimed to compare radiation therapy planning and its parameters from SRS using three different modalities: helical tomotherapy (HT), volumetric modulated arc therapy (VMAT), and cone-based linac radiosurgery (Cone-based). MATERIALS AND METHODS: Each contouring dataset of patents who experienced one to four brain metastasis received SRS in our center was re-planned to create radiation therapy planning in all three treatment systems (HT, VMAT, and Cone-based). The parameters of conformity index (CI), homogeneity index (HI), CI50, and gradient index (CGI) were analyzed to compare the effects of the three techniques. Decision score analysis was used to evaluate the performance on dosimetric and organs-at-risk parameters among the different techniques by applying the Cone-based technique as a benchmark. RESULTS: A total of 21 patients with 39 lesions were included in this study. The results from the decision score analysis demonstrated statistically identical CI, CI50, and CGI values between Cone-based and VMAT for single lesions. For multiple lesions, VMAT also provided better CI when compared to Cone-based technique while HT exhibited the poorest dosimetric parameters. Moreover, VMAT exhibited the lowest BrainV5Gy value and displayed the shortest beam-on time calculation. CONCLUSION: We have conducted a comprehensive comparison of SRS planning approaches. The Cone-based technique revealed the highest HI value, while VMAT provided the best estimated beam-on time value. HT displayed a feasible SRS modality for single lesions, but not for multiple lesions.

Survival outcome of cervical cancer patients treated by image-guided brachytherapy: a 'real world' single center experience in Thailand from 2008 to 2018.

The objective of our study was to evaluate the survival outcome of cervical cancer patients treated using image-guided brachytherapy (IGBT). From 2008 to 2018, 341 patients with cervical cancer were treated by radical radiotherapy. IGBT (by computed tomography [CT] or transabdominal ultrasound [TAUS]) was used to treat all of these patients. The characteristic data and patient status after treatment were recorded. All data were evaluated for survival outcome analysis. From a total of 341 patients, 295 patients were analyzed and 46 patients were excluded due to data missing in the survival outcomes. At the median follow-up time of 48 months (IQR 30-80 months), The 4-year local control, progression-free survival and overall survival rates were 89.5%, 74.9% and 69.1%, respectively. For overall survival, the size (> 5 cm), pathology (non-SCCA), stage (stage III-IV by FIGO 2009), lymph node (LN) (presented) and overall treatment time (OTT) (> 56 days) showed statistical significance in univariate analysis while non-SCCA pathology, advanced stage, presented LN and longer OTT showed statistical significance in multivariate analysis. In conclusion, our analysis reports a 4-year overall survival rate of 69.1%. Non-SCCA pathology, advanced stage disease, LN presence and longer OTT showed worse prognostic factors in multivariate analysis.

Comparison of clinical outcomes achieved with image-guided adaptive brachytherapy for cervix cancer using CT or transabdominal ultrasound.

PURPOSE: This study aimed to evaluate retrospectively the treatment results when using various image-guided adaptive brachytherapy treatments for cervical cancer treated by radical radiotherapy. METHODS AND MATERIALS: From 2014 to 2017, 188 patients with cervical carcinoma were treated by whole pelvic radiotherapy plus four fractions of image-guided brachytherapy. Eight patients were excluded because of missing data. Consequently, 180 patients were analyzed. Of 180 patients, 92 were treated by CT-based brachytherapy (CT-BT), and transabdominal ultrasound-based brachytherapy (TAUS-BT) was used to treat another group. The treatment results and toxicity outcomes were evaluated by comparing the image-guidance techniques. RESULTS: The mean follow-up time was 32 months (interquartile range 29.5-42 months). The mean age was 57 years (interquartile range from 50 to 65 years). In the CT-BT group, the mean cumulative doses to high-risk clinical target volume, bladder, rectum, and sigmoid were 87.2 Gy, 84.0 Gy, 68.8 Gy, and 69.8 Gy, respectively. In the TAUS-BT group, the mean cumulative doses to the cervix reference, bladder, and rectum points were 84.0 Gy, 65.5 Gy, and 74.0 Gy, respectively. There were no differences in the 2-year local control rate (p = 0.88) and disease-free survival rate (p = 0.34) in both groups. No difference in gastrointestinal and genitourinary toxicity was observed in both groups, but there was higher vaginal toxicity in the TAUS-BT group compared with the CT-BT group (p = 0.03). CONCLUSIONS: No difference in treatment results was observed between CT-based and TAUS-based approaches. However, TAUS-BT had higher vaginal toxicity in our retrospective analysis.

Two-year outcome of concurrent chemoradiation with carboplatin with or without adjuvant carboplatin/fluorouracil in nasopharyngeal cancer: A multicenter randomized trial.

BACKGROUND: According to the noninferiority result of chemoradiation with carboplatin in our previous nasopharyngeal carcinoma (NPC) study along with the inconclusive data on the efficacy of adjuvant chemotherapy (AC) following concurrent chemoradiotherapy (CCRT), we designed to assess the role of adjuvant carboplatin/fluorouracil following CCRT with carboplatin in locoregionally advanced NPC. MATERIALS AND METHODS: A multicenter randomized trial was conducted at 5 cancer centers in Thailand. We enrolled in stage T2N0M0-T4N2M0 (American Joint Cancer Committee 7th edition) WHO Type 2 NPC patients. N3 or metastatic disease patients were excluded. Participants were randomized into 2 groups: CCRT plus AC group vs the CCRT alone group. Patients in both groups received weekly carboplatin 100 mg/m2 for 6 cycles concurrently with radiotherapy 69.96-70 Gy. Patients in the AC group subsequently received 3 cycles of carboplatin area under curve-5 plus 1000 mg/m2/day of fluorouracil infusion within 96 hours every 3 weeks. We report the 2-year overall survival (OS), disease-free survival (DFS), loco-regional recurrence-free survival (LRFS), and distant metastasis-free survival (DMFS). Treatment-related toxicities and compliance were also explored. RESULTS: Of 175 patients, 82 (46.9%) were assigned to the AC group, and 93 (53.1%) to the CCRT group. The compliance rate during CCRT was 90% and 86% in the AC and CCRT group, whereas 81.7% during adjuvant treatment in the AC group. With a median follow-up time of 24.4 months (interquartile range 17.9-24.4), the 2-year OS rate was 89.6% in the AC group and 81.8% in the CCRT group (P= 0.167). The 2-year DFS rate was 86.8% in the AC group and 74.6% in the CCRT group (P = 0.042). The 2-year LRFS rate was 91.5% in the AC group and 88.2% in the CCRT group (P = 0.443). The 2-year DMFS rate was 85.4% in the AC group and 79.6% in the CCRT group (P = 0.294). The most frequent serious (grade 3/4) nonhematologic toxicity was acute mucositis, which occurred 5% in the AC group vs 4% in the CCRT group (P = 0.498). For hematologic toxicity, grade 3-4 leukopenia were found 10% and 5% in the adjuvant and CCRT groups, respectively (P = 0.003). Multivariate analyses determined stage N2 disease was an adverse prognostic factor associated with shorter OS, DFS, and DMFS. And the adjuvant treatment was a significant protective factor for only DFS. CONCLUSIONS: The addition of adjuvant carboplatin/fluorouracil following CCRT with carboplatin significantly improved 2-year DFS in stage T2N0M0-T4N2M0 NPC albeit there was a nonsignificant trend in favor of a higher 2-year OS, LRFS, and DMFS. Long-term efficacy and late toxicities of AC still require exploration.

Phase II, Randomized Study of Spartalizumab (PDR001), an Anti-PD-1 Antibody, versus Chemotherapy in Patients with Recurrent/Metastatic Nasopharyngeal Cancer.

PURPOSE: No standard treatment exists for platinum-refractory, recurrent/metastatic nasopharyngeal cancer (NPC). This phase II study (NCT02605967) evaluated progression-free survival (PFS) of spartalizumab, an antiprogrammed cell death protein-1 (PD-1) monoclonal antibody, versus chemotherapy, in NPC. PATIENTS AND METHODS: Patients with nonkeratinizing recurrent/metastatic NPC who progressed on/after platinum-based chemotherapy were enrolled. Spartalizumab was dosed 400 mg once every 4 weeks, and chemotherapy was received per investigator's choice. RESULTS: Patients were randomized to receive either spartalizumab (82 patients) or chemotherapy (40 patients). The most common spartalizumab treatment-related adverse events were fatigue (10.3%) and pruritus (9.3%). Median PFS in the spartalizumab arm was 1.9 months versus 6.6 months in the chemotherapy arm (P = 0.915). The overall response rate in the spartalizumab arm was 17.1% versus 35.0% in the chemotherapy arm. Median duration of response was 10.2 versus 5.7 months in the spartalizumab versus chemotherapy arms, respectively. Median overall survival was 25.2 and 15.5 months in the spartalizumab and chemotherapy arms, respectively. Tumor RNA sequencing showed a correlation between response to spartalizumab and IFNγ, LAG-3, and TIM-3 gene expression. CONCLUSIONS: Spartalizumab demonstrated a safety profile consistent with other anti-PD-1 antibodies. The primary endpoint of median PFS was not met; however, median overall survival and median duration of response were longer with spartalizumab compared with chemotherapy.

Arginine, glutamine, and fish oil supplementation in cancer patients treated with concurrent chemoradiotherapy: A randomized control study.

We evaluated the effectiveness of arginine, glutamine, and fish oil supplementation in patients' ability to adhere to the planned regimen and associated toxicities in patients who received concurrent chemoradiotherapy (CCRT). Eighty-eight cancer patients were randomized into 2 groups, A; regular diet and B; regular diet plus nutritional supplementation during their CCRT course. Logistic regression was used to assess the association between toxicity and the study groups. Survival analysis was performed using the Kaplan-Meier method, and log-rank tests were used to compare between the 2 groups. Among 88 patients, 45%, 32%, and 23% were head and neck cancer, esophageal cancer, and cervical cancer patients, respectively. Significantly higher grade 3-4 hematologic toxicities were found in group A than in group B (23% vs 5%, P= 0.03). The CCRT completion rate was lower in group A than in group B (75% vs 91%), but the difference was not statistically significant (P= 0.09). Adjusted for type of cancer and age, group B patients were associated with lower hematologic toxicities of CCRT, P= 0.03. Two-year overall survival was 47% for group A, and 61% for group B, P= 0.22. In conclusion, incidence of severe hematologic toxicities were significantly lower in patients with arginine, glutamine, and fish oil supplementation during CCRT. These findings, therefore, need further studies on the isocaloric design.