Uptake of ultra-hypofractionated radiation therapy following breast-conserving surgery among patients with early-stage breast cancer: a multi-institutional questionnaire survey.

BACKGROUND: In patients with early-stage breast cancer following breast surgery, ultra-hypofractionated (UHF) breast/chest wall radiation therapy (RT) has been shown to be non-inferior to a moderate-hypofractionated (MHF) regimen, with a minimal risk of breast induration, in the FAST-Forward trial, and UHF is now becoming the standard regimen in Europe. Herein, we aimed to investigate Japanese patients' attitudes toward the UHF regimen. METHODS: A questionnaire-based survey was conducted at 13 RT centers in nine prefectures across Japan. All patients underwent breast-conserving surgery, followed by either conventional fractionation (2 Gy/fr) or MHF (2.66 Gy/fr) whole-breast irradiation (WBI) with or without a tumor bed boost. The questionnaire consisted of 13 questions mainly addressing quality-of-life during RT. Key questions included an 11-point scale (0-10) for rating the patients' enthusiasm for the UHF regimen and prioritization of the following treatment-related effects: treatment efficacy, acute/late adverse effects, physical/emotional/financial burden, and breast cosmesis. The patient and treatment characteristics were assessed by a physician. RESULTS: In total, 247 questionnaires were administered between November 2022 and June 2023. The age distribution was as follows: < 50:50 s:60 s: ≥ 70 = 59 (24%):76 (30%):63 (26%):49 (20%). Sixty-nine percent of patients rated their enthusiasm for the UHF regimen at ≥ 6 out of 10 points (45% rated 10/10). Treatment efficacy was the highest priority for most patients (89%), whereas breast cosmesis the lowest priority (53%). CONCLUSIONS: Patients' enthusiasm for UHF-WBI was observed across the cohort. These results could motivate researchers and clinicians to introduce UHF regimens in clinical practice.

Radiotherapy for ductal carcinoma of the prostate: an analysis based on the Japanese radiation oncology study group survey.

BACKGROUND: The clinical characteristics of prostate ductal carcinoma is still unclear, and treatment strategy has not yet been established due to its rarity. Therefore, we conducted a multicenter survey of radiation therapy for prostate ductal carcinoma in Japan. METHOD: Data of patients with ductal carcinoma of the prostate treated with radiation therapy between 1996 and 2018 were extracted from the database of each facility. RESULTS: Fifty-two treatment records of 41 patients were collected from nine institutions. The treatment purpose and situations were varied curative intent to palliation. Twenty-eight patients received curative treatments. The median follow-up period of these patients was 68 months. Androgen deprivation therapy was combined with radiation therapy in 26 cases (93%). X-ray and particle irradiation was used. Radiation dose range was 63-78 Gy; 5-year overall survival, progression-free survival and biochemical relapse-free survival were 87.0, 79.3 and 79.3%, respectively. One patient experienced Grade 3 radiation proctitis and one experienced Grade 3 radiation cystitis. There were no Grade 4 or worse adverse events. CONCLUSION: Most patient received similar treatment with adenocarcinoma of prostate, and the clinical results were compatible. For more reliable evidence, further studies are required.

Durable Response After Combination Therapy With Enfortumab Vedotin and Radiotherapy in Metastatic Urothelial Carcinoma: A Report of Two Cases.

Enfortumab vedotin for urothelial carcinoma is a potentially effective anti-tumor drug that can be used in 3rd-line therapy or later, even in relatively advanced stages of the disease. Here, we present two cases of treatment using enfortumab vedotin with subsequent radiotherapy for primary lesions, and long-term disease control was achieved. The first case involved a 78-year-old man previously treated with pembrolizumab following gemcitabine plus carboplatin for lower ureteral carcinoma with multiple lung and lymph node metastases. Six months after the initiation of enfortumab vedotin, the primary tumor and metastases notably shrank. However, the primary tumor regrew, and radiotherapy was initiated along with enfortumab vedotin. The second case involved a 60-year-old man who was initially treated with avelumab following gemcitabine plus cisplatin for bladder cancer with multiple lymph node metastases. After two months of enfortumab vedotin, the primary and metastatic lesions shrunk. However, the primary tumor regrew, and radiotherapy was initiated. In both cases, the primary tumor and metastases recorded long-term shrinkage. The combination of radiotherapy and enfortumab vedotin may be an effective treatment option.

Stereotactic body radiotherapy with a single isocentre for multiple pulmonary metastases.

A 45-year-old male developed a second set of pulmonary metastases 5 years after surgery for extraskeletal mucinous chondrosarcoma of the left shoulder. He already underwent a lobectomy and two segmentectomies for a first set of pulmonary metastases 2 years ago. The closely grouped three nodules within the left lower lung formed a planning target volume (PTV) for stereotactic body radiotherapy (SBRT) with a single isocentre, which was focused on the centre of the largest nodule (the simultaneous plan). Dose-volume histogram analysis confirmed that the plan was superior to an alternative plan, in which SBRT plans would have been produced for each individual tumour (the individual plan). The mean, maximum and minimum PTV doses were 54.0, 57.5 and 47.3 Gy, respectively, in the simultaneous plan, and 65.6, 87.2 and 52.3 Gy, respectively, in the individual plan. The homogeneity index, conformity index, and the maximum dose delivered to the surrounding healthy lung were 1.21, 0.71, and 37.7 Gy, respectively, in the simultaneous plan and 1.66, 4.44, and 46.2 Gy, respectively, in the individual plan. The patient developed Grade two pneumonitis, but remained healthy until 4 years after the SBRT. When multiple closely grouped metastases are treated using SBRT, the use of a single isocentre should be considered.

Modified Glasgow prognostic score can predict survival of muscle invasive bladder cancer patients after radiotherapy.

In patients with various cancers, modified Glasgow prognostic score (mGPS) before treatment has predicted prognoses after antitumor therapy. This study aimed to assess whether pretreatment mGPS also has predictive value in patients with muscle-invasive bladder cancer (MIBC) after radiotherapy. A retrospective review accumulated 98 consecutive MIBC patients treated with definitive 3D-conformal radiotherapy from January 2011 to December 2016 in a single center. It included cT2-4bN0-3M0 patients with a median age of 79 years (range: 49 to 95 years). Radiotherapy was delivered at 60-66 Gy for bladder cancer. Patients were categorized in terms of their pretreatment serum albumin and C-reactive protein (CRP) values as mGPS_0, mGPS_1, and mGPS_2. Among them, cumulative overall survival (OS) rates were compared by Kaplan-Meier plots with log-rank tests. The number of patients with mGPS_0, mGPS_1, and mGPS_2 were 40, 40, and 18, respectively. The median follow-up time for all patients was 19 months (range: 2-73 months). The 2-year OS rate for all patients was 75.7%. The 2-year OS rates for mGPS_0, mGPS_1, and mGPS_2 were 85.1%, 71.3%, and 60.9%, respectively. Kaplan-Meier curves revealed a significantly higher cumulative OS rate for mGPS_0 compared with mGPS_1 and mGPS_2 (P = 0.003). Using multivariate Cox regression analysis, mGPS_0 and good performance status were associated with favorable OS rates, of which mGPS_0 was more significant (Hazard ratio 2.74, 95% CI 1.30-5.57, P = 0.008). Modified Glasgow prognostic score may be a novel biomarker that can predict survival in patients with MIBC after radiotherapy.

Partial Bladder Boost Using Lipiodol Marking During Image-guided Radiotherapy for Bladder Cancer.

BACKGROUND/AIM: Secure dose escalation is required to compensate avoidance of concurrent chemotherapy in radiotherapy for increasing elderly bladder cancer. We aimed to evaluate the efficacy of lipiodol submucosally injected as a fiducial marker during image-guided radiotherapy (Lip-IGRT) for muscle invasive bladder cancer (BC). PATIENTS AND METHODS: Twenty-three patients with T2a-4aN0-1M0 BC underwent whole-bladder irradiation of 46 Gy and Lip-IGRT of 20 Gy, conventionally. The bladder volume exposed to 19 Gy (bV19:%) on Lip-IGRT was referred as an index predicting cystitis. RESULTS: Lipiodol consistently highlighted the boundaries of 20 tumors (88%) on planning and portal verification images. Three of 4 patients under oral anticoagulant agents usage were complicated with grade ≥2 hematuria for 3 days (a patient with a bV19 of >50%) or more than a year (2 patients with bV19 of <50%) after the injection. The 3-year overall survival and disease-free survival rates were 70.4% and 71.1%, respectively. CONCLUSION: Lipiodol marking is an effective way of demarcating BC. However, it is necessary to address the comorbidities of elderly patients.

Variability of treatment planning of seed implantation: A Japanese multicenter simulation study.

PURPOSE: This multicenter study was conducted to evaluate the current variability of treatment planning of seed implantation in Japanese centers and the feasibility of two virtual trials. METHODS AND MATERIALS: Two types of contour data were sent to 12 radiation oncologists with a request letter that asked them to make treatment plans on the data in the same manner as in their own practice. Five of the 12 radiation oncologists were asked to participate in the two virtual trials in which the D90 (dose to the hottest 90% of prostate volume) was 1) required to be set at just 180 Gy and 2) increased as much as possible without violating other limitations. RESULTS: A relatively high dose with a small deviation was irradiated to the prostate in Japanese centers (mean D90 = 188 Gy; SD = 10 Gy). In the virtual trials, all five physicians could achieve 180 Gy for the D90 with a very small deviation, although the urethral dose showed relatively large deviations. Dose escalation without increase of urethral dose or V150 was difficult, although the rectum could be spared by most of the physicians. CONCLUSION: Our study showed a relatively high dose with a small deviation was prescribed to the prostate in Japanese centers. Consolidated protocols such as D90 = 180 Gy could be available for future trials. Meanwhile, our study suggested that some cautions might be needed for urethral dose and the V150, even when a relatively low D90 was requested.

Three-dimensional summation of rectal doses in brachytherapy combined with external beam radiotherapy for prostate cancer.

BACKGROUND AND PURPOSE: To determine the dose constraints for rectal bleeding in brachytherapy (BRT) combined with external beam radiotherapy (EBRT). MATERIALS AND METHODS: Post-BRT, pelvic computed tomography images were used for subsequent EBRT planning and BRT postplans in 37 patients. The physical doses for each plan were converted to biologically effective doses, and corresponding voxel doses were integrated to plot the summed dose-volume histogram (sum-DVH). Between 5 patients with (bled-pts) and 32 without (spared-pts) grade 2 or 3 rectal bleeding, the differences in the mean minimal dose (rDn) covering the rectal volume of 0.5-10.0 cc and the rectal volume (rVn) receiving the calculated dose of 20-150Gy were compared. RESULTS: The differences in the summed-rDn were determined by BRT exposure, while those of the summed-rVn were determined in the low-dose range and superimposed in the high-dose range by EBRT exposure. Of the 13 patients with rV150 of >1.2 cc, 4 were bled-pts (30.8%). Of the 24 patients with rV150 of ≤ 1.2cc, 1 was a bled-pts (4.2%) (p=0.024; odds ratio, 10.2; CI (95%), 1.0-104.3). CONCLUSIONS: The mono-scale DVH analysis is a promising method for exploring the threshold for rectal bleeding in combined radiotherapy.

Spontaneous temporomandibular joint herniation into the external auditory canal through a persistent foramen tympanicum (Huschke): radiographic features.

Persistent foramen tympanicum (Huschke) is an anatomical variation located in the anteroinferior portion of the external auditory canal. We present a case of symptomatic temporomandibular joint (TMJ) herniation into the external auditory canal though an enlarged osseous defect. The herniated retrodiscal TMJ tissue moved backward when the patient's mouth was closed, and forward, when opened. Magnetic resonance imaging findings were useful for differentiating TMJ herniation from salivary fistula caused by an ectopic salivary gland.

Combined intra-arterial infusion and systemic chemoradiotherapy for stage IV squamous cell carcinoma of the mandibular gingiva.

PURPOSE: The purpose of this study was to show the effectiveness of combining intra-arterial infusion and systemic chemotherapy with concurrent radiotherapy for treatment of stage IV mandibular gingival cancer. MATERIALS AND METHODS: A total of 23 patients with mandibular gingival cancer were treated with either docetaxel by intra-arterial infusion followed by systemic chemoradiotherapy with cisplatinum and 5-fluorouracil as a monthly regimen, or with docetaxel and cisplatinum by intra-arterial infusion followed by systemic chemoradiotherapy with 5-fluorouracil as a weekly or biweekly regimen. Tumor responses, locoregional control, overall survival, disease-specific survival, and adverse events were evaluated. RESULTS: Of the 23 patients enrolled in the study, 22 completed the treatment. With regard to clinical stages, 82 % were diagnosed as IVA and 18 % IVB. Complete and partial response was observed in 82 and 18 %, respectively. Five-year overall survival, disease-specific survival, and locoregional control were 51, 70, and 72 %, respectively. No statistically significant difference was seen between the monthly regimen and the weekly plus biweekly regimen, although the latter resulted in longer survival and 88 % control. CONCLUSION: Combined intra-arterial infusion and systemic chemoradiotherapy may be an effective treatment for patients with stage IV mandibular gingival cancer.

Narrow safety range of intraoperative rectal irradiation exposure volume for avoiding bleeding after seed implant brachytherapy.

BACKGROUND & PURPOSE: Rectal toxicity is less common after 125I seed implant brachytherapy for prostate cancer, and intraoperative rectal dose-volume constraints (the constraint) is still undetermined in pioneering studies. As our constraint failed to prevent grade 2 or 3 rectal bleeding (bled-pts) in 5.1% of patients, we retrospectively explored another constraint for the prevention of rectal bleeding. MATERIALS AND METHODS: The study population consisted of 197 patients treated with the brachytherapy as monotherapy using real-time intraoperative transrectal ultrasound (US)-guided treatment at a prescribed dose of 145 Gy. Post-implant dosimetry was performed on Day 1 and Day 30 after implantation using computed tomography (CT) imaging. Rectal bleeding toxicity was classified by CTC-AE ver. 3.0 during a mean 29-month (range, 12-48 months) period after implantation. The differences in rV100s were compared among intraoperative, Day 1 and Day 30 dosimetry, and between that of patients with grade 2 or 3 rectal bleeding (the bled-pts) and of the others (the spared-pts). All patients were divided into groups based on provisional rV100s that were increased stepwise in 0.1-cc increments from 0 to 1.0 cc. The difference in the ratios of the bled-pts to the spared-pts was tested by chi-square tests, and their odds ratios were calculated (bled-OR). All statistical analyses were performed by t-tests. RESULTS: The mean values of rV100us, rV100CT_1, and rV100CT_30 were 0.31 ± 0.43, 0.22 ± 0.36, and 0.59 ± 0.68 cc, respectively. These values temporarily decreased (p = 0.020) on Day 1 and increased (p = 0.000) on Day 30. There was no significant difference in rV100s between the bled-pts and spared-pts at any time of dosimetry. The maximum bled-OR was identified among patients with an rV100us value above 0.1 cc (p = 0.025; OR = 7.8; 95% CI, 1.4-145.8); an rV100CT_1 value above 0.3 cc (p = 0.014; OR = 16.2; 95% CI, 3.9-110.7), and an rV100CT_30 value above 0.5 cc (p = 0.019; OR = 6.3; 95% CI, 1.5-42.3). CONCLUSION: By retrospective analysis exploring rV100 as intraoperative rectal dose-volume thresholds in 125I seed implant brachytherapy for prostate cancer, it is proved that rV100 should be less than 0.1 cc for preventing rectal bleeding.