Trends in the treatment of rectal prolapse: a population analysis.

PURPOSE: Rectal prolapse is a common condition, with conflicting opinions on optimal surgical management. Existing literature is predominantly composed of case series, with a dearth of evidence demonstrating current, real-world practice. This study investigated recent national trends in management of rectal prolapse in the Republic of Ireland (ROI). METHODS: This population analysis used a national database to identify patients admitted in the ROI primarily for the management of rectal prolapse, as defined by the International Classification of Diseases, 10th Revision (ICD-10). Demographics, procedures, comorbidities, and outcomes were obtained for patients admitted from 2005 to 2015 inclusive. RESULTS: There were 2648 admissions with a primary diagnosis of rectal prolapse; 39.3% underwent surgical correction. The majority were treated with either a perineal resection (47.2%) or an abdominal rectopexy ± resection (45.1%). The population-adjusted rate of operative intervention increased over the study period, from 25 to 42 per million (p < 0.001), with no change in the mean age of patients over time (p = 0.229). The application of a laparoscopic approach increased over time (p = 0.001). Patients undergoing an abdominal rectopexy were younger than those undergoing a perineal procedure (64.1 ± 17.3 versus 75.2 ± 15.5 years, p < 0.001) despite having a similar Charlson Comorbidity Index (p = 0.097). The mortality rate for elective repair was 0.2%. CONCLUSIONS: Despite the popularization of ventral mesh rectopexy over the study period, perineal resection Delorme's procedure remains the most common procedure employed for the correction of rectal prolapse in the ROI, with specific approach determined by age.

Temporal patterns of patient-reported trismus and associated mouth-opening distances in radiotherapy for head and neck cancer: A prospective cohort study.

OBJECTIVES: To identify temporal patterns of patient-reported trismus during the first year post-radiotherapy, and to study their associations with maximal interincisal opening distances (MIOs). DESIGN: Single institution case series. SETTING: University hospital ENT clinic. PARTICIPANTS: One hundred and ninety-six subjects who received radiotherapy (RT) for head and neck cancer (HNC) with or without chemotherapy in 2007-2012 to a total dose of 64.6/68 Gy in 38/34 fractions, respectively. All subjects were prospectively assessed for mouth-opening ability (Gothenburg Trismus Questionnaire (GTQ), European Organization for Research and Treatment of Cancer quality of life Questionnaire (EORTC QLQ-H&N35), and MIO) pre-RT and at 3, 6 and 12 months after RT. MAIN OUTCOME MEASURES: Correlations between temporally robust GTQ symptoms and MIO as given by Pearson's correlation coefficients (Pr ); temporally robust GTQ-symptom domains as given by factor analysis; rates of trismus with respect to baseline by risk ratios (RRs). RESULTS: Four temporally robust domains were identified: Eating (3-7 symptoms), Jaw (3-7), Pain (2-5) and Quality of Life (QoL, 2-5), and included 2-3 persistent symptoms across all post-RT assessments. The median RR for a moderate/severe (>2/>3) cut-off was the highest for Jaw (3.7/3.6) and QoL (3.2/2.9). The median Pr between temporally robust symptoms and MIO post-radiotherapy was 0.25-0.35/0.34-0.43/0.24-0.31/0.34-0.50 for Eating/Jaw/Pain/QoL, respectively. CONCLUSIONS: Mouth-opening distances in patients with HNC post-RT can be understood in terms of associated patient-reported outcomes on trismus-related difficulties. Our data suggest that a reduction in MIO can be expected as patients communicate their mouth-opening status to interfere with private/social life, a clinical warning signal for emerging or worsening trismus as patients are being followed after RT.

C-reactive protein as a predictor of anastomotic leak in the first week after anterior resection for rectal cancer.

AIM: Anastomotic leak (AL) after anterior resection results in increased morbidity, mortality and local recurrence. The aim of this study was to assess the ability of C-reactive protein (CRP) to predict AL in the first week after anterior resection for rectal cancer. METHOD: A retrospective review of a prospectively maintained database that included all patients undergoing anterior resection between January 2008 and December 2013 was performed. The ability of CRP to predict AL was assessed using area under the receiver-operating characteristics (AUC) curves. The severity of AL was defined using the International Study Group of Rectal Cancer (ISREC) grading system. RESULTS: Two-hundred and eleven patients were included in the study. Statistically significant differences in mean CRP values were found between those with and without an AL on postoperative days 5, 6 and 7. A CRP value of 132 mg/l on postoperative day 5 had an AUC of 0.75, corresponding to a sensitivity of 70%, a specificity of 76.6%, a positive predictive value of 16.3% and a negative predictive value of 97.5%. Multivariable analysis found that a CRP of > 132 mg/l on postoperative day 5 was the only statistically significant patient factor that was linked to an increased risk of AL (HR = 8.023, 95% CI: 1.936-33.238, P = 0.004). CONCLUSION: Early detection of AL may minimize postoperative complications. CRP is a useful negative predictive test for the development of AL following anterior resection.

Pre-placement psychological status and staff retention in a call centre.

BACKGROUND: There is a general lack of studies on staff retention and mental health status at the beginning of or prior to employment in call centres. AIMS: To evaluate the relationship between psychological status at the beginning of employment and staff retention after 6 months of employment. METHODS: The psychological well-being of new starters was evaluated using a questionnaire and Beck Depression Inventory (BDI). Early leavers were identified through a second survey performed 6 months later. RESULTS: Out of a cohort of 135 new starters, all of the 100 randomly selected employees returned their questionnaires. By the second round of the survey 6 months later, 30 employees had left. There was no significant difference between the BDI scores of leavers and those who remained in the company. Binary logistic regression showed no significant associations between leaving the company and gender, previous history of mental health diagnosis and history of mental health treatment. However, there was a significant association between age (25 or over) and leaving the company within the first 6 months of employment (odds ratio [OR] = 2.5; 95% confidence interval [CI] 1.04-6.01; P < 0.05). CONCLUSIONS: Previous mental health conditions or psychological status at the beginning of employment did not appear to contribute significantly to call centre employees leaving within 6 months. Further similar studies in other occupational sectors are recommended.

Endolaparoscopic removal of colonic polyps.

AIM: A proportion of colonic polyps is not amenable to exclusively colonoscopic removal due to their location, size or tortuosity of the colon. A combined laparoscopic/colonoscopic polypectomy or endolaparoscopic polypectomy (ELP) is an alternative to formal segmental resection. We present our experience of ELP. METHOD: This is a retrospective review of a consecutive series of patients who underwent ELP for preoperatively diagnosed benign polyps between 2010 and 2013. Data are presented as median (interquartile range, IQR). RESULTS: Thirty patients commenced ELP. Eighteen were male and the median (IQR) age was 65.4 (61.6-73.5) years. Of 30 attempted cases, 22 (73%) underwent successful ELP surgery. Patients in whom combined ELP surgery was unsuccessful were converted to laparoscopic colectomy (one) or colonic mobilization and colotomy (seven). The median operation time for successful ELP was 105 (75-125) min. The complication rate was 13.3% and the median length of stay was 2.0 (1.0-3.0) days for successful ELP compared with 5.5 (3.5-6.8) days for converted patients (P = 0.014). The median polyp size was 14 (10-22) mm; eight (26.7%) had high-grade dysplasia with two cases of invasive cancer identified. CONCLUSION: A combined endoscopic-laparoscopic approach provides an alternative to segmental resection for treating challenging colonic polyps. This approach appears to be safe and effective and should be offered to selected patients with benign colonic polyps.

The prognostic value of tumour regression grade following neoadjuvant chemoradiation therapy for rectal cancer.

AIM: To date, there is no uniform consensus on whether tumour regression grade (TRG) is predictive of outcome in rectal cancer. Furthermore, the lack of standardization of TRG grading is a major source of variability in published studies. The aim of this study was to evaluate the prognostic impact of TRG in a cohort of patients with locally advanced rectal cancer treated with neoadjuvant chemoradiation therapy (CRT). In addition to the Mandard TRG, we utilized four TRG systems modified from the Mandard TRG system and applied them to the cohort to assess which TRG system is most informative. METHOD: One-hundred and fifty-three patients with a T3/T4 and/or a node-positive rectal cancer underwent neoadjuvant 5-fluorouracil-based CRT followed by surgical resection. RESULTS: Thirty-six (23.5%) patients achieving complete pathological response (ypCR) had a 5-year disease-free survival (DFS) rate of 100% compared with a DFS rate of 74% for 117 (76.5%) patients without ypCR (P = 0.003). The Royal College of Pathologists (RCPath) TRG best condenses the Mandard five-point TRG by stratifying patients into three groups with distinct 5-year DFS rates of 100%, 86% and 67%, respectively (P = 0.001). In multivariate analysis, pathological nodal status and circumferential resection margin (CRM) status, but not TRG, remained significant predictors of DFS (P = 0.002, P = 0.035 and P = 0.310, respectively). CONCLUSION: Our findings support the notion that ypCR status, nodal status after neoadjuvant CRT and CRM status, but not TRG, are predictors of long-term survival in patients with locally advanced rectal cancer.

Radiation-induced distal ileal obstruction complicating ileostomy closure.

BACKGROUND: Radiation enteropathy is a recognized complication in patients who undergo neoadjuvant radiotherapy for locally advanced rectal cancer. Routine formation of defunctioning loop ileostomy in these patients may mask the development of stricturing, terminal ileal and radiation enteropathy which later may complicate the ileostomy closure. Our aim was to assess the preventive techniques and key warning signs. METHODS: We present two cases of ileostomy closure in patients with occult, radiation-induced, terminal ileal stricture and review the relevant literature. RESULTS: The first case was complicated by dehiscence of the ileal anastomosis due to undiagnosed, downstream stenosis of the irradiated terminal ileum. A similar terminal ileal stricture was diagnosed in the second case by contrast fluoroscopy enabling an elective ileocolic anastomosis. The literature indicates the importance of identifying such problems prior to loop ileostomy closure. CONCLUSIONS: Contrast studies before loop ileostomy closure are valuable in limiting the complications of radiation-induced distal ileal obstruction in selected patients.

Vertical rectus abdominis myocutaneous flap and quality of life following abdominoperineal excision for rectal cancer: a multi-institutional study.

BACKGROUND: To obtain a clear surgical margin, abdominoperineal excision (APE) for rectal cancer frequently leaves a large perineal defect surrounded by irradiated tissue. A vertical rectus abdominis myocutaneous (VRAM) flap may facilitate healing of this wound. The current study aims to determine the effect of VRAM flap perineal reconstruction following APE on patient quality of life (QOL). METHODS: This is a retrospective cohort study from a prospectively collected database. Data on QOL were assessed via telephone questionnaire using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ)-C30, EORTC QLQ-C29 and the Cleveland Clinic QOL questionnaires. RESULTS: Twenty-seven patients underwent primary perineal closure, and 12 patients underwent a VRAM flap perineal reconstruction. The mean duration of follow-up was 16.8 months. Overall, there was no significant difference in the Cleveland Clinic QOL score between groups (VRAM vs. no VRAM: 0.7 ± 0.2 vs. 0.7 ± 0.2, p 0.735). Patients in the VRAM group had lower levels of fatigue (5.5 ± 9.9 vs. 23.6 ± 19.2, p 0.004). Patients in the VRAM group had reduced sore skin scores around the stoma site (11.0 ± 16.2 vs. 31.8 ± 31.1, p 0.036). VRAM flap was associated with an increased incidence of abdominal wall hernia (VRAM vs. no VRAM: 25 % vs. 0 %, p 0.024). CONCLUSIONS: This study is limited by its non-randomized retrospective design and relatively small sample size. A significant difference in patient QOL was not demonstrated between VRAM flap and primary perineal closure after APE for rectal cancer. Further studies in this area are warranted.

Laparoscopic hemicolectomy for cutaneous malignant melanoma metastasis to the ileocaecal valve.

Colonic tumours are most frequently primary and lesions secondary to metastasis are uncommon. Malignant melanoma is an aggressive cancer, with a tendency to metastasize and recur. This report describes the case of a 66-year-old man who underwent wide local excision and adjuvant therapy for malignant melanoma three years prior to presentation with loose stools, abdominal cramps and iron deficiency anaemia. CT colonography showed a 6cm ileocaecal mass, and following a laparoscopic right hemicolectomy, histological examination revealed a metastatic melanoma to the ileocaecal valve. Subsequent positron emission tomography showed no residual metastatic disease. Malignant melanoma metastasis to the colon is a rare clinical entity. Metastectomy via laparoscopic right hemicolectomy is an appropriate and effective treatment.

"Primer shot" fractionation with an early treatment break is theoretically superior to consecutive weekday fractionation schemes for early-stage non-small cell lung cancer.

PURPOSE: Radiotherapy is traditionally given in equally spaced weekday fractions. We hypothesize that heterogeneous interfraction intervals can increase radiosensitivity via reoxygenation. Through modeling, we investigate whether this minimizes local failures and toxicity for early-stage non-small cell lung cancer (NSCLC). METHODS: Previously, a tumor dose-response model based on resource competition and cell-cycle-dependent radiosensitivity accurately predicted local failure rates for early-stage NSCLC cohorts. Here, the model mathematically determined non-uniform inter-fraction intervals minimizing local failures at similar normal tissue toxicity risk, i.e., iso-BED3 (iso-NTCP) for fractionation schemes 18Gyx3, 12Gyx4, 10Gyx5, 7.5Gyx8, 5Gyx12, 4Gyx15. Next, we used these optimized schedules to reduce toxicity risk (BED3) while maintaining stable local failures (TCP). RESULTS: Optimal schedules consistently favored a "primer shot" fraction followed by a 2-week break, allowing tumor reoxygenation. Increasing or decreasing the assumed baseline hypoxia extended or shortened this optimal break by up to one week. Fraction sizes of 7.5 Gy and up required a single primer shot, while smaller fractions needed one or two extra fractions for full reoxygenation. The optimized schedules, versus consecutive weekday fractionation, predicted absolute LF reductions of 4.6%-7.4%, except for the already optimal LF rate seen for 18Gyx3. Primer shot schedules could also reduce BED3 at iso-TCP with the biggest improvements for the shortest schedules (94.6Gy reduction for 18Gyx3). CONCLUSION: A validated simulation model clearly supports non-standard "primer shot" fractionation, reducing the impact of hypoxia-induced radioresistance. A limitation of this study is that primer-shot fractionation is outside prior clinical experience and therefore will require clinical studies for definitive testing.

Implementation and usefulness of single-access laparoscopic segmental and total colectomy.

AIM: Single-access laparoscopic surgery is a recent vogue in the field of minimally invasive colorectal surgery. While selected series have indicated feasibility, we prospectively examined its usefulness for resectional surgery in routine practice. METHOD: All patients undergoing laparoscopic colorectal resection over a 12-month period were considered for a single-access approach by a single surgical team in a university hospital. This utilized a 'glove' port via a 3-5 cm periumbilical or stomal site incision, with standard rigid laparoscopic instruments then being used. RESULTS: Of 76 planned laparoscopic colorectal resections, 35 (47%) were performed by this single-incision laparoscopic modality without disruption of theatre list efficiency or surgical training obligations. The mean (range) age and body mass index of these 25 consecutive right-sided resections, eight total colectomies (seven urgent operations) and two anterior resections was 58 (22-82) years and 23.9 (18.6-36.2) kg/m(2) , respectively. The modal postoperative day of discharge was 4. For right-sided resections, the mean (range) postoperative stay in those undergoing surgery for benign disease was 4.0 days, while for those undergoing operation for neoplasia (n=18, mean age 71 years) it was 5.8 days and the average lymph node harvest was 13. Use of the glove port reduced trocar cost by 58% (€60/£53) by allowing the use of trocar sleeves alone without obturators. CONCLUSION: Single-incision laparoscopic surgery is an effective option for abdominal surgery and seems especially suited for laparoscopic-assisted right-sided colonic resections. The glove port technique facilitates procedural frequency and familiarity and proves economically favourable.

Colonoscopy and computerized tomography scan are not sufficient to localize right-sided colonic lesions accurately.

AIM: Accurate preoperative localization of colonic lesions is critical especially in laparoscopic colectomy where tactile localization is absent particularly in screen-detected tumours. The study aimed to evaluate the accuracy of colonoscopy and double-contrast computerized tomography (CT) scan to localize lesions treated by right hemicolectomy. METHOD: A retrospective chart review was performed of patients treated by right hemicolectomy under the colorectal service between July 2003 and October 2006. Preoperative tumour location determined by CT scan and colonoscopy was compared with the intra-operative and histopathological findings. RESULTS: Out of 101 patients, 73 (73%) were for adenoma or cancer, with a final diagnosis of adenocarcinoma in 59 (58%). Preoperative localization was inaccurate in 29% of lesions using both CT and colonoscopy. In the transverse colon, colonoscopy alone was only 37.5% accurate, increasing to 62.5% when information from the CT scan was added. CONCLUSION: Preoperative localization of right-sided colon cancers using colonoscopy and CT scanning is unreliable in at least 29% of cases. Inaccurate localization of transverse colon tumours risks inadequate lymphadenectomy with an adverse cancer outcome. Preoperative abdominal CT scan improves accuracy but endoscopic tattoo localization should be employed routinely especially in patients undergoing laparoscopic resection.

The role of thyrotropin suppression in patients with differentiated thyroid carcinoma.

Thyroid carcinoma is the commonest endocrine malignancy. The majority of these are differentiated thyroid carcinomas, which have a good overall prognosis. Treatment includes surgical excision, radio-iodine ablation and long-term thyrotropin suppression. The degree and length of suppression required, as well as the potential side-effect remain controversial. Therefore, the aim of this study was to establish the degree of thyrotropin suppression achieved in a cohort of patients with differentiated thyroid carcinoma. A retrospective review was performed of a prospectively maintained database. All patients with a diagnosis of differentiated thyroid carcinoma between January 1998 and January 2008 were identified. Demographic data, pathological stage and the treatment that the patient received was documented. TSH and free T4 levels were identified at specific time points post-operatively. Eighty-eight patients with differentiated thyroid carcinoma were identified. Seventy patients (79.5%) were female. The mean age was 55, with a range of 18 to 79 years. The majority of patients underwent a total thyroidectomy (n=79; 89.7%) and of those 29 (32.9%) had an associated modified neck dissection. Accurate follow-up was available on forty-nine patients. TSH and free T4 were measured at 3 and 6 months, as well as at 1 and 2 years post-operatively. Adequate TSH suppression was taken at a level < 0.1 mU/L. The majority of patients (69.5%) had achieved adequate TSH suppression at 2 years. However, 65% of these same patients had a high free T4 at 2 years indicating a degree of hyperthyroidism. This study has demonstrated that TSH suppression is being adequately achieved in the majority of patients with differentiated thyroid carcinoma. However, this must be carefully weighed against the potential detrimental side-effects of long-term sub-clinical hyperthyroidism.

A 'quad-phantom' film dosimeter for use as a multi-planar verification tool for PRESAGE/optical-CT.

INTRODUCTION: To develop and characterize the accuracy and reproducibility of a quad-phantom dosimeter which will serve as an independent verification tool during commissioning of a PRESAGE/optical-CT 3D dosimetry system. METHODS: A 16cm × 12cm cylindrical quad-phantom was constructed from four pieces of solid polyurethane mimicking the PRESAGE material. Films were placed and anchored in orthogonal planes and the quad-phantom was fastened tightly together and placed in a water-filled Styrofoam container for irradiation. A simple, two-field plan consisting of 6×6cm anterior-posterior and right-lateral 6MV photon beams (400cGy) was delivered three times (fresh films inserted for each) with a Varian Clinac 600C. Image registration was performed in the Computational Environment for Radiological Research (CERR) and dose profiles and gamma analysis was performed in CERR and MATLAB. RESULTS #ENTITYSTARTX00026; DISCUSSION: Excellent reproducibility was observed during the irradiations, with ~2.3% standard deviation between all pixels. Using a 3%, 3mm gamma criteria, excellent dosimetric accuracy was observed, with 98.8% and 96.3% passing rates in the sagittal and axial planes, respectively. CONCLUSION: The preliminary results indicate that the quad-phantom can serve as a reproducible and accurate system for high resolution dosimetry in orthogonal planes and should serve as an effective verification tool for PRESAGE/optical-CT in more challenging clinical scenarios.

Dose Verification of Stereotactic Radiosurgery Treatment for Trigeminal Neuralgia with Presage 3D Dosimetry System.

Achieving adequate verification and quality-assurance (QA) for radiosurgery treatment of trigeminal-neuralgia (TGN) is particularly challenging because of the combination of very small fields, very high doses, and complex irradiation geometries (multiple gantry and couch combinations). TGN treatments have extreme requirements for dosimetry tools and QA techniques, to ensure adequate verification. In this work we evaluate the potential of Presage/Optical-CT dosimetry system as a tool for the verification of TGN distributions in high-resolution and in 3D. A TGN treatment was planned and delivered to a Presage 3D dosimeter positioned inside the Radiological-Physics-Center (RPC) head and neck IMRT credentialing phantom. A 6-arc treatment plan was created using the iPlan system, and a maximum dose of 80Gy was delivered with a Varian Trilogy machine. The delivered dose to Presage was determined by optical-CT scanning using the Duke Large field-of-view Optical-CT Scanner (DLOS) in 3D, with isotropic resolution of 0.7mm(3). DLOS scanning and reconstruction took about 20minutes. 3D dose comparisons were made with the planning system. Good agreement was observed between the planned and measured 3D dose distributions, and this work provides strong support for the viability of Presage/Optical-CT as a highly useful new approach for verification of this complex technique.

Exploring feature-based approaches in PET images for predicting cancer treatment outcomes.

Accumulating evidence suggests that characteristics of pre-treatment FDG-PET could be used as prognostic factors to predict outcomes in different cancer sites. Current risk analyses are limited to visual assessment or direct uptake value measurements. We are investigating intensity-volume histogram metrics and shape and texture features extracted from PET images to predict patient's response to treatment. These approaches were demonstrated using datasets from cervix and head and neck cancers, where AUC of 0.76 and 1.0 were achieved, respectively. The preliminary results suggest that the proposed approaches could potentially provide better tools and discriminant power for utilizing functional imaging in clinical prognosis.

Iliopsoas abscess: a re-emerging clinical entity not to be forgotten.

Iliopsoas abscesses are relatively rare clinical entities. They present with subtle and non-specific symptoms and as a result the diagnosis is often delayed, leading to significant morbidity and mortality. With an increasing number of immunocompromised patients in the population the prevalence of this condition is set to rise. Therefore, early diagnosis and appropriate management remain a challenge for clinicians. We present three patients with iliopsoas abscesses, two of which were primary and one of which was secondary to Crohn's disease. The average age of patients was 59 years and both patients with primary psoas abscesses were male. All presented with non-specific symptoms. Psoas sign was present in only one patient. CT confirmed the diagnosis in all cases. Treatment consisted of appropriate antibiotic cover and associated percutaneous drainage. The psoas abscess that was secondary to underlying Crohn's disease was subsequently treated with surgical excision of the affected segment of bowel and lavage of the abscess cavity. A high index of suspicion is required to ensure the accurate and early diagnosis of this rare clinical entity. Abdominal CT scanning remains the gold standard for diagnosis. Management is with appropriate antibiotics and adequate drainage. This can be achieved by either percutaneous or surgical drainage. Such treatment can reduce the overall morbidity and mortality of this condition.

Neo-adjuvant chemoradiotherapy in advanced rectal carcinoma: a note of caution.

Rectal cancer remains a major source of morbidity and mortality with its prognosis relating directly to the initial stage of the disease at presentation. This report highlights the potentially serious morbidity and mortality, which may be associated with neo-adjuvant chemoradiotherapy in advanced rectal cancer, emphasising the need for thorough discussion with patients on the risks and benefits of such treatment.

IMRT treatment planning for prostate cancer using prioritized prescription optimization and mean-tail-dose functions.

Treatment planning for intensity modulated radiation therapy (IMRT) is challenging due to both the size of the computational problems (thousands of variables and constraints) and the multi-objective, imprecise nature of the goals. We apply hierarchical programming to IMRT treatment planning. In this formulation, treatment planning goals/objectives are ordered in an absolute hierarchy, and the problem is solved from the top-down such that more important goals are optimized in turn. After each objective is optimized, that objective function is converted into a constraint when optimizing lower-priority objectives. We also demonstrate the usefulness of a linear/quadratic formulation, including the use of mean-tail-dose (mean dose to the hottest fraction of a given structure), to facilitate computational efficiency. In contrast to the conventional use of dose-volume constraints (no more than x% volume of a structure should receive more than y dose), the mean-tail-dose formulation ensures convex feasibility spaces and convex objective functions. To widen the search space without seriously degrading higher priority goals, we allowed higher priority constraints to relax or 'slip' a clinically negligible amount during lower priority iterations. This method was developed and tuned for external beam prostate planning and subsequently tested using a suite of 10 patient datasets. In all cases, good dose distributions were generated without individual plan parameter adjustments. It was found that allowance for a small amount of 'slip,' especially in target dose homogeneity, often resulted in improved normal tissue dose burdens. Compared to the conventional IMRT treatment planning objective function formulation using a weighted linear sum of terms representing very different dosimetric goals, this method: (1) is completely automatic, requiring no user intervention, (2) ensures high-priority planning goals are not seriously degraded by lower-priority goals, and (3) ensures that lower priority, yet still important, normal tissue goals are separately pushed as far as possible without seriously impacting higher priority goals.