Refining critical structure contouring in STereotactic Arrhythmia Radioablation (STAR): Benchmark results and consensus guidelines from the STOPSTORM.eu consortium.

BACKGROUND AND PURPOSE: In patients with recurrent ventricular tachycardia (VT), STereotactic Arrhythmia Radioablation (STAR) shows promising results. The STOPSTORM.eu consortium was established to investigate and harmonise STAR treatment in Europe. The primary goals of this benchmark study were to standardise contouring of organs at risk (OAR) for STAR, including detailed substructures of the heart, and accredit each participating centre. MATERIALS AND METHODS: Centres within the STOPSTORM.eu consortium were asked to delineate 31 OAR in three STAR cases. Delineation was reviewed by the consortium expert panel and after a dedicated workshop feedback and accreditation was provided to all participants. Further quantitative analysis was performed by calculating DICE similarity coefficients (DSC), median distance to agreement (MDA), and 95th percentile distance to agreement (HD95). RESULTS: Twenty centres participated in this study. Based on DSC, MDA and HD95, the delineations of well-known OAR in radiotherapy were similar, such as lungs (median DSC = 0.96, median MDA = 0.1 mm and median HD95 = 1.1 mm) and aorta (median DSC = 0.90, median MDA = 0.1 mm and median HD95 = 1.5 mm). Some centres did not include the gastro-oesophageal junction, leading to differences in stomach and oesophagus delineations. For cardiac substructures, such as chambers (median DSC = 0.83, median MDA = 0.2 mm and median HD95 = 0.5 mm), valves (median DSC = 0.16, median MDA = 4.6 mm and median HD95 = 16.0 mm), coronary arteries (median DSC = 0.4, median MDA = 0.7 mm and median HD95 = 8.3 mm) and the sinoatrial and atrioventricular nodes (median DSC = 0.29, median MDA = 4.4 mm and median HD95 = 11.4 mm), deviations between centres occurred more frequently. After the dedicated workshop all centres were accredited and contouring consensus guidelines for STAR were established. CONCLUSION: This STOPSTORM multi-centre critical structure contouring benchmark study showed high agreement for standard radiotherapy OAR. However, for cardiac substructures larger disagreement in contouring occurred, which may have significant impact on STAR treatment planning and dosimetry evaluation. To standardize OAR contouring, consensus guidelines for critical structure contouring in STAR were established.

Custom 3D-printed applicators for high dose-rate brachytherapy in skin cancer.

PURPOSE: This paper describes the protocol for the development of 3D-printed custom applicators in treating skin carcinoma, the evaluation of the materials used, and the methods for segmentation and rendering of the applicators. MATERIAL AND METHODS: The segmentation and rendering process for the applicator had six phases: (i) determination of the volume of the lesion using a computed tomography (CT) scan; (ii) delineation of the patient surface, using the same CT images; (iii) creation of the applicator in the planner and segmentation of the mold; (iv) preliminary dosimetry and establishment of the route of the catheter from the brachytherapy unit; (v) creation of the 3D applicator using specialized software; and (vi) applicator printing. Following this process, the patient returned for a second CT to undergo the definitive dosimetry with the applicator in place. Radiation therapy was then administered. RESULTS: We made a total of 16 applicators. Only three applicators had to be remade, two due to an error in the infill and the other due to incorrect catheter geometry. In all cases, correct coverage of the planning target volume was achieved with the prescribed isodose. CONCLUSIONS: The creation of custom molds in plesiotherapy for skin cancer with 3D printing is feasible. Compared to manual methods, 3D printing increases precision in applicator geometry and optimization of the dosimetry.

Determination of the optimal range for virtual monoenergetic images in dual-energy CT based on physical quality parameters.

PURPOSE: Virtual monoenergetic images (VMI) obtained from Dual-Energy Computed Tomography (DECT) with iodinated contrast are used in radiotherapy of the Head and Neck to improve the delineation of target volumes and organs at-risk (OAR). The energies used to vary from 40 to 70 keV, but noise at low keV and the use of Single Energy CT (SECT) at low kVp settings may shrink this interval. There is no guide about how to find out the optimal range where VMI has a significant improvement related to SECT images. Our study proposes a procedure to determine this optimal range, based on common image quality parameters, and establishes this range in a Siemens Somatom Confidence and a Head and Neck protocol. METHODS: We compared the quality of the VMI series at 40-60 keV versus single X-ray tube voltage computed tomography (SECT) at 80 and 120 kVp . Our reference was 120 kVp . DECT images were sequentially acquired using the Siemens Somatom Confidence RT Pro CT according to the head and neck protocol in our department. VMI series were constructed using the Syngo Via software Monoenergetic+ algorithm. Quality parameters were: image uniformity, high- and low-contrast resolution, noise, and sensitivity to the iodinated contrast. We used the Catphan 604 phantom for quality control, except when assessing iodine sensitivity. To evaluate high contrast resolution, we calculated the modulation transfer function (MTF) using the point spread function estimation of a point bead and the slanted edge methods. For the low-contrast resolution, we used a statistical method for assessing differences between contrast structures and local noise. To measure the absolute value of noise and compare its texture, we used the standard deviation and the noise power spectrum. We measured iodine sensitivity by dissolving the Optiray Ultraject iodinated contrast in water in concentrations of 0 to 4500 mg/l and then compared the contrast to noise ratio (CNR) and analyzed the linear correlation between concentration and HU. RESULTS: The entire series met the minimum quality requirements. However, the one at 40 keV presented uniformity at the limits of acceptability. The high- and low-contrast resolutions were similar between series. The noise of the VMI series decreased with increasing energy, while sensitivity to the contrast displayed the opposite behavior. All series showed linearity of HUs from very low iodine concentrations. Images at 60 keV presented lower iodine sensitivity than SECT at 80 kVp , while those at 55 keV were similar to them. CONCLUSIONS: Our method of image comparison based on standard quality parameters in phantom gave clear results about the optimal range and can be used as a guide to characterize any other DECT imaging protocols. The optimal range for using VMI images in iodinated contrasts in the Siemens system was 45-55 keV. Lower energies lacked noise and uniformity, while higher ones could be substituted by SECT images at low kilovoltage (80 kVp ).

OPTimizing Irradiation through Molecular Assessment of Lymph node (OPTIMAL): a randomized open label trial.

BACKGROUND: Conservative surgery followed by breast and nodal irradiation is the standard loco-regional early breast cancer (BC) treatment for patients with four or more involved lymph nodes. However, the treatment strategy when fewer nodes are involved remains unclear, especially when lymphadenectomy has not been performed. Sensitive nodal status assessment molecular techniques as the One-Step Nucleic Acid Amplification (OSNA) assay can contribute to the definition and standardization of the treatment strategy. Therefore, the OPTIMAL study aims to demonstrate the feasibility of incidental irradiation of axillary nodes in patients with early-stage BC and limited involvement of the SLN. METHODS: BC patients who underwent conservative surgery and whose SLN total tumour load assessed with OSNA ranged between 250-15,000 copies/µL will be eligible. Patients will be randomized to receive irradiation on the breast, tumour bed, axillary and supraclavicular lymph node areas (intentional arm) or only on the breast and tumour bed (incidental arm). All areas, including the internal mammary chain, will be contoured. The mean, median, D5% and D95% doses received in all volumes will be calculated. The primary endpoint is the non-inferiority of the incidental irradiation of axillary nodes compared to the intentional irradiation in terms of 5-year disease free survival. Secondary endpoints comprise the comparison of acute and chronic toxicity and loco-regional and distant disease recurrence rates. DISCUSSION: Standardizing the treatment and diagnosis of BC patients with few nodes affected is crucial due to the lack of consensus. Hence, the quantitative score for the metastatic burden of SLN provided by OSNA can contribute by improving the discrimination of which BC patients with limited nodal involvement can benefit from incidental radiation as an adjuvant treatment strategy. TRIAL REGISTRATION: ClinicalTrial.gov, NCT02335957; https://clinicaltrials.gov/ct2/show/NCT02335957.

Manejo de la axila en el cáncer de mama: menos es más, más es menos o todo lo contrario / Management of the axilla in breast cancer: less is more, more is less or the other way around

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Las diferentes modalidades de la radioterapia: externa, braquiterapia e intraoperatoria. Indicaciones / The different types of radiation therapy: external, brachytherapy and intraoperative. Indications

CONCLUSIONES: Se puede afirmar que la radioterapia contribuye a aumentar la supervivencia de las pacientes con cáncer de mama; las mejoras tecnológicas experimentadas en los últimos años han contribuido de forma importante a disminuir la toxicidad; estas mejoras permiten concentrar la radioterapia en menos sesiones, incluso en una única de forma intraoperatoria en un grupo muy seleccionado de pacientes; y que debemos seguir investigado para conocer en que pacientes podemos disminuir nuestros tratamientos, especialmente a nivel ganglionar

CONCLUSIONS: We can say that radiotherapy helps increase the survival of patients with breast cancer; technological improvements experienced in recent years have contributed significantly to decrease toxicity; These improvements allow to concentrate radiation therapy in fewer sessions, even in a single intraoperatively in a very selected group of patients; and we must follow investigated patients to know that we can reduce our treatments, especially ganglionic level

Consenso de seguimiento de pacientes con cáncer de mama de la Sociedad Española de Senología y Patología Mamaria / Consensus document of the Spanish Society of Senology and Breast Disease on the follow-up of patients with breast cancer

A pesar del aumento en la prevalencia del cáncer de mama, el seguimiento de estas pacientes no está totalmente estandarizado. La Sociedad Española de Senología y Patología Mamaria propuso la elaboración de un documento de consenso sobre el seguimiento que debería proponerse a las pacientes afectas de lesiones de mama in situ e infiltrantes en estadios i-iii, tratadas con intención curativa, una vez finalizados los tratamientos iniciales. En su realización han colaborado profesionales de toda España de distintas especialidades y ámbitos de actuación. Fue presentado en el Primer Congreso Español de la Mama, que se celebró en octubre de 2013 en Madrid, para su refrendo por parte de la Sociedad, y se recogieron las aportaciones de los asistentes a la sala. El objetivo principal del seguimiento es la detección precoz de recurrencias locorregionales y a distancia, de nuevos primarios, y valorar los efectos secundarios de los tratamientos aplicados. Debe también cubrir las necesidades de soporte psicológico, así como la rehabilitación y reinserción sociolaboral posterior y la educación para la salud, corrigiendo hábitos de vida no saludables. No se han descrito diferencias significativas entre el seguimiento minimalista y el intensivo, respecto al índice de recurrencia, la supervivencia global y la calidad de vida. El tipo y los años de seguimiento deberían ser distintos para cada paciente según su riesgo de recidiva y la clasificación molecular de su lesión. Este consenso ha tenido el apoyo de otras sociedades científicas relacionadas con la enfermedad mamaria, asistentes al Primer Congreso Español de la Mama (AU)

Despite the increasing prevalence of breast cancer, there is no standardized protocol for the follow-up of breast cancer survivors. The Spanish Society of Senology and Breast Disease has supported a consensus document on the follow-up of breast cancer survivors, aimed at patients diagnosed with stage i to iii disease and with invasive and intraepithelial (in situ) lesions, and treated with curative intent, after completion of the initial treatment. Practitioners from all over Spain, with different specialities and areas of activity, participated in the drafting in the document. It was presented at the First Spanish Breast Congress (Primer Congreso Español de la Mama), which took place in October 2013, for the Society's approval. Input from the audience was considered. The main aim of follow-up is the early detection of local and distant recurrences, of new primaries, and evaluation of the adverse effects of the therapies applied. Follow-up should also include psychological support, education on healthy habits, rehabilitation, and social and work reintegration. No significant differences between minimalistic and intensive follow-up have been reported regarding recurrence, overall survival, and quality of life. The length, intervals, and intensity of follow-up should be tailored according to each patient's individual risk of relapse and molecular subtype. This consensus document has the support and endorsement of other scientific societies related to breast disease and present at the congress (AU)

Tecnología y técnicas recomendadas en la irradiación externa del cáncer de mama / Recommended technology and techniques in external radiation of breast cancer

La radioterapia en el cáncer de mama se ha empleado desde hace más de 100 años para el control local de la enfermedad. Las mejoras tecnológicas incorporadas en los últimos 20-30 años han optimizado estos resultados de control local y han conseguido aumentar la supervivencia global (nivel de evidencia 1, en el metaanálisis de Oxford). Realizamos un breve recuerdo histórico de los avances que han cambiado la práctica clínica de la radioterapia en el cáncer de mama, desde las 2 dimensiones a las 3 dimensiones con la incorporación de la tomografía axial computarizada para la simulación virtual, los conceptos de volúmenes de tratamiento, órganos de riesgo, histogramas dosis-volumen y el objetivo de distribución homogénea de la dosis absorbida entre el 95 y el 107%. Las mejoras tecnológicas en las unidades de tratamiento, desde la cobaltoterapia a los aceleradores con multiláminas automáticos con colimación de los haces hasta 5 mm en un tiempo récord, acortando los tiempos de tratamiento y la protección exquisita de los órganos de riesgo, como el pulmón y el corazón. Describiremos las generalidades de las técnicas de radioterapia en el cáncer de mama, la inmovilización en supino y en prono, la posición y volúmenes de tratamiento, la calidad de la radiación, técnica y dosis recomendadas. Mencionaremos también los nuevos fraccionamientos, que están irrumpiendo en la práctica clínica asistencial de la radioterapia del cáncer de mama, con un nivel de evidencia suficiente, con resultados en control local, supervivencia, estéticos y de toxicidad similares a los del fraccionamiento de 2 Gy en 25 fracciones (AU)

Radiation therapy in breast cancer has been used for more than a century for local disease control. Improved technology in the last 20-30 years has maximized outcomes not only in achieving local control but also in increasing overall survival (level 1 evidence in an Oxford meta-analysis). We present a brief historical review of all the technical and scientific advances that have changed clinical practice in breast cancer radiotherapy. These include the switch from 2-dimensional to 3-dimensional technology with the use of computed tomography for virtual simulation, the new concepts of treatment volumes, organs at risk and dose-volume histograms, and the objective of a homogeneous distribution of the absorbed dose of between 95% and 107%. Technological advances in treatment units, from cobalt therapy to accelerators with MLC leaves with beam collimation of up to 5 mm in record time have shortened treatment times and provide exquisite protection to at-risk organs, such as the heart or lung. We describe the general features of radiation therapy techniques in breast cancer, including immobilization in supine and prone positions, the position and volumes of treatment, the quality of radiation, the technique, and recommended doses. We also mention the new dose fractions that are breaking into the clinical practice of breast cancer radiotherapy, with a considerable level of evidence showing good results in terms of local control, survival rates, and esthetic outcomes, as well as toxic effects very similar to those achieved with the standard dose of 50 Gy in 25 fractions of 2 Gy (AU)

Radioterapia y técnicas de reconstrucción mamaria / Radiotherapy and breast reconstruction techniques

Actualmente, la cirugía conservadora es el estándar quirúrgico en el tratamiento del cáncer de mama, pero en un 15-35% de los casos, debe ofrecerse la mastectomía. Hasta no hace mucho tiempo, si estas pacientes necesitaban radioterapia, la opción de la reconstrucción se retrasaba o incluso se rechazaba. Actualmente, los avances técnicos permiten poder ofrecer reconstrucción e irradiación. En el presente artículo se revisan los diferentes tipos de cirugía reconstructiva y su relación con la irradiación, de forma que se incluyen: reconstrucción inmediata con técnica heteróloga, prótesis definitivas, expansores tisulares, reconstrucción diferida con técnica heteróloga y/o autóloga, reconstrucción del complejo aréola-pezón y lipoinfiltración. Se revisan las complicaciones de la combinación de cirugía reconstructiva y radioterapia, y se establecen unas recomendaciones prácticas(AU)

Currently, conservative surgery is the standard management in breast cancer. However, in 15-35% of patients, mastectomy should be offered. Until recently, if these patients needed radiotherapy, the option of reconstruction was delayed or even rejected. Current technical advances allow both reconstruction and irradiation to be offered. This article reviews the different types of reconstructive surgery and their relationship with irradiation, including immediate heterologous reconstruction techniques, definitive prostheses, tissue expanders, delayed reconstruction with heterologous and/or autologous techniques, nipple-areola complex reconstruction, and lipofilling. We review the complications of combining radiotherapy and reconstructive surgery, and establish practical recommendations(AU)

Neuroendocrine small cell carcinoma of the uterine cervix.

Neuroendocrine small cell carcinoma of the uterine cervix (SCC) is a rare disease that mixes clinical and biological characteristics of both cervical neoplasms and neuroendocrine small cell cancer. The prognosis is poor and the optimal treatment has not yet been clarified. Multimodality treatment, with surgery and concurrent chemoradiation has recently been shown to improve local control and survival rates.

Breast metastases from a floor of the mouth carcinoma.

Metastases to the breast from extramammary tumours are uncommon and metastatis of floor of the mouth carcinoma to the breast is extremely rare. The clinical outcome of these patients remains dismal. We report the case of breast metastases from a floor of the mouth carcinoma successfully treated by conservative surgery and adjuvant radiotherapy with no demonstrable metastases 33 months after the initial diagnosis.