Association Between Thyroid Radiation Dose and Hypothyroidism in Breast Cancer Patients Undergoing Volumetric Modulated Arc Therapy for Regional Nodal Irradiation.

BACKGROUND/AIM: To investigate the association between the thyroid dysfunction and thyroid radiation dose in regional nodal irradiation (RNI) using volumetric modulated arc therapy (VMAT) for breast cancer. PATIENTS AND METHODS: We reviewed medical data of 67 patients with breast cancer who underwent curative surgery followed by adjuvant radiotherapy, including RNI using VMAT, between 2018 and 2021. All patients had normal thyroid functional test results, including thyroid stimulating hormone (TSH), T3, and free-T4. We defined subclinical hypothyroidism as increased TSH with or without decreased levels of free-T4 and T3 after the completion of VMAT. We calculated dose-volume histogram parameters (DVHPs), including the mean dose and relative thyroid volume receiving at least 10, 20, 30, and 40 Gy. RESULTS: The median follow-up time was 23.2 months. The 3-year locoregional failure-free survival, progression-free survival, and overall survival rates were 96.3%, 94.7%, and 96.2%, respectively. The mean thyroid dose was 21.4 Gy (range=11.5-29.4 Gy). Subclinical hypothyroidism was noted in 14 patients (20.9%) and the median time to the event was 4.1 months. Among the DVHPs, the relative volume receiving ≥20 Gy (V20Gy) was associated with subclinical hypothyroidism. The 2-year rates of subclinical hypothyroidism were 24.8% and 59.1% in patients with V20Gy ≤46.3% and >46.3%, respectively. CONCLUSION: A significant proportion of patients with breast cancer developed subclinical hypothyroidism after undergoing VMAT for RNI. Our findings highlight the importance of considering the thyroid as an organ at risk for VMAT planning, and suggest that V20Gy could be a useful dose-volume constraint.

Patterns of locoregional recurrences and suggestion of the clinical target volume in resected perihilar extrahepatic cholangiocarcinoma.

Purpose: To evaluate the patterns of locoregional recurrence (LRR) in patients with perihilar extrahepatic cholangiocarcinoma (PEHC) treated with radical resection and to suggest the optimal target volume for elective nodal irradiation. Methods: Medical records of PEHC patients who underwent radical resection between January 2000 and September 2021 at five institutions were reviewed. Patients who were confirmed with LRR in the follow-up imaging study were included. The LRR sites were mapped onto the corresponding sites in template computed tomography images. The margin around the vascular structure was investigated to generate the clinical target volume (CTV) covering the common sites of regional recurrences. Results: A total of 87 LRRs in 46 patients were identified, 29 (33.3%) of which were local recurrences and 58 (66.7%) were regional recurrences. The most common site of local recurrence was the liver resection margin (n = 16), followed by the anastomosis site (n = 8). Regional recurrences were observed most commonly in the para-aortic area (n = 13), followed by in the aortocaval space (n = 11), portal vein area (n = 11), and portocaval area (n = 9). Nodal CTV was generated by adding an individualized margin around the portal vein, aorta, common hepatic artery, celiac artery, and left gastric artery. Conclusions: The LRR patterns in the resected PEHC were evaluated and specific guidelines for nodal CTV delineation were provided, which may help physicians delineating the target volume in postoperative radiotherapy for PEHC. These findings need further validation in a lager cohort.

Clinical Benefit of Bevacizumab and Irinotecan (BEV+IRI) in Patients With Relapsed/Refractory Glioblastoma (r/rGBM) and its Potential Predictors.

BACKGROUND/AIM: Bevacizumab-containing chemotherapy constitutes an important salvage treatment for recurrent/refractory glioblastoma(r/rGBM). PATIENTS AND METHODS: We retrospectively collected the data of r/rGBM patients treated with the combination of bevacizumab and irinotecan (BEV+IRI) as their salvage treatment from July 2013 and December 2021 in Konkuk Medical Center of Korea. Patients with available results from molecular diagnostic tests were eligible, and markers of interest were examined including the presence of MGMT methylation, IDH1/2 mutation, or 1p/19q co-deletion. Efficacy of BEV+IRI and its potential biomarker was explored. RESULTS: Among 21 patients, 38.1% demonstrated European Cooperative Oncology Group-Performance scale (ECOG-PS) ≥3. The majority (71.4%) received BEV+IRI as their second-line chemotherapies, and the median dose was 5 (range=1-25). Objective response rate (ORR) was 33.3% and disease-control rate (DCR) was 85.7%. Irrespective of objective response, early clinical response was achieved in 14(66.7%) patients. During the median follow-up of 16.4 months for survivors, median progression-free survival (PFS) and overall survival (OS) were 3.6 and 6.8 months, respectively. ECOG PS≥3 and TP53 loss were independent predictors of an unfavorable OS, while prompt clinical improvement could predict favorable OS. Any molecular aberration was associated with OS or PFS in the study. CONCLUSION: Salvage BEV+IRI treatment in r/rGBM conferred comparable clinical benefit. ECOG PS ≥3, TP53 loss, and lack of prompt clinical improvement after the treatment were significantly associated with an unfavorable OS.

Variation in clinical target volume delineation in postoperative radiotherapy for biliary tract cancer.

We aimed to evaluate the inter-clinician variability in the clinical target volume (CTV) for postoperative radiotherapy (PORT) for biliary tract cancer (BTC) including extrahepatic bile duct cancer (EBDC) and gallbladder cancer (GBC). Nine experienced radiation oncologists delineated PORT CTVs for distal EBDC (pT2N1), proximal EBDC (pT2bN1) and GBC (pT2bN1) patients. The expectation maximization algorithm for Simultaneous Truth and Performance Level Estimation (STAPLE) was used to quantify expert agreements. We generated volumes with a confidence level of 80% to compare the maximum distance to each CTV in six directions. The degree of agreement was moderate; overall kappa values were 0.573 for distal EBDC, 0.513 for proximal EBDC, and 0.511 for GBC. In the distal EBDC, a larger variation was noted in the right, post, and inferior direction. In the proximal EBDC, all borders except the right and left direction showed a larger variation. In the GBC, a larger variation was found in the anterior, posterior, and inferior direction. The posterior and inferior borders were the common area having discrepancies, associated with the insufficient coverage of the paraaortic node. A consensus guideline is needed to reduce inter-clinician variability in the CTVs and adequate coverage of regional lymph node area.

Prognostic impact of neutrophilia and lymphopenia on survival in anal cancer treated with definitive concurrent chemoradiotherapy: a retrospective multicenter study.

PURPOSE: This study evaluated the prognostic value of leukocyte, lymphocyte, and neutrophil counts in anal cancer patients undergoing concurrent chemoradiotherapy (CCRT). METHODS: Multi-institutional retrospective data review included 148 non-metastatic anal cancer patients treated with definitive CCRT with 5-fluorouracil plus mitomycin C between the year 2001 and 2019. The median radiation dose to the primary tumor was 54 Gy with a median pelvic dose of 45 Gy. Median follow-up duration was 56 months, and complete blood cell counts were analyzed from baseline to 1 year after the completion of radiotherapy. RESULTS: Although most patients showed a normal number of blood cells before treatment, 6.1% and 4.1% of patients showed leukocytosis (> 10,000/µl) and neutrophilia (> 7500/µl), respectively. After the initiation of treatment, seven patients (4.7%) displayed grade 4 lymphopenia (< 200/µl) at 1 month. Patients with initial leukocytosis showed inferior progression- and locoregional progression-free survival, and neutrophilia was a prognostic factor in all survival outcomes. Grade 4 lymphopenia at 1 month was also significantly associated with overall, progression-, and distant metastasis-free survival. On multivariate analyses, baseline neutrophilia was associated with 56.8-, 22.6-, 10.7-, and 23.0-fold increased risks of death, disease relapse, locoregional progression, and distant metastasis, respectively. Furthermore, lymphocytes < 200/µl at 1 month was linked to 6.8-, 5.4-, and 6.3-fold increased risks for death, disease relapse, and distant metastasis, respectively. CONCLUSION: The number of leukocytes, lymphocytes, and neutrophils readily acquired from routine blood tests before and during treatment could be an independent prognostic factor of survival in patients with anal cancer.

Interobserver variability in clinical target volume delineation in anal squamous cell carcinoma.

We evaluated the inter-physician variability in the target contouring of the radiotherapy for anal squamous cell carcinoma (ASCC). Clinical target volume (CTV) of three patients diagnosed with ASCC was delineated by seven experienced radiation oncologists from multi-institution. These patients were staged as pT1N1a, cT2N0, and cT4N1a, respectively, according to 8th edition of the American Joint Committee on Cancer staging system. Expert agreement was quantified using an expectation maximization algorithm for Simultaneous Truth and Performance Level Estimation (STAPLE). The maximum distance from the boundaries of the STAPLE generated volume with confidence level of 80% to those of the contour of each CTV in 6 directions was compared. CTV of pelvis which includes primary tumor, perirectal tissue and internal/external iliac lymph node (LN) area (CTV-pelvis) and CTV of inguinal area (CTV-inguinal) were obtained from the seven radiation oncologists. One radiation oncologist did not contain inguinal LN area in the treatment target volume of patient 2 (cT2N0 stage). CTV-inguinal displayed moderate agreement for each patient (overall kappa 0.58, 0.54 and 0.6, respectively), whereas CTV-pelvis showed substantial agreement (overall kappa 0.66, 0.68 and 0.64, respectively). Largest variation among each contour was shown in the inferior margin of the CTV-inguinal. For CTV-pelvis, anterior and superior margin showed the biggest variation. Overall, moderate to substantial agreement was shown for CTV delineation. However, large variations in the anterior and cranial boarder of the CTV-pelvis and the caudal margin of the CTV-inguinal suggest that further studies are needed to establish a clearer target volume delineation guideline.

Neutrophil-to-Lymphocyte Ratio After Definitive Concurrent Chemoradiotherapy Predicts Survival in Patients With Esophageal Squamous Cell Carcinoma.

BACKGROUND/AIM: Lymphocyte-to-monocyte ratio, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio represent systemic immune-inflammatory responses. We evaluated the association between immune-inflammatory cell ratios and prognosis in esophageal squamous cell carcinoma (ESCC) patients who underwent definitive concurrent chemoradiotherapy (dCCRT). PATIENTS AND METHODS: Medical records of 68 ESCC patients in three institutions who underwent dCCRT between 2006 and 2017 were reviewed. The immune-inflammatory cell ratios were calculated before and after dCCRT. RESULTS: The median follow-up time was 11.4 months. The 3-year overall survival (OS) rate was 21.6%. Among the immune-inflammatory cell ratios, lower post-dCCRT neutrophil-to-lymphocyte ratio (NLRpost) was associated with better OS (median 15.2 vs. 9.7 months, p=0.030). Patients with lower NLRpost had more improved OS when adjuvant chemotherapy was administered following dCCRT (median 16.6 vs. 4.8 months, p<0.001). CONCLUSION: NLRpost may be useful in predicting OS in ESCC patients after dCCRT. Furthermore, NLRpost might play a role in establishing adjuvant therapy plans following dCCRT.

The predictive value of serum myeloma protein in solitary plasmacytoma.

PURPOSE: To identify the clinical usefulness of serum M protein and to establish a rationale for regular follow-up with serum protein electrophoresis in solitary plasmacytoma. MATERIALS AND METHODS: Sixty-nine patients with solitary plasmacytoma and solitary plasmacytoma with minimal marrow involvement according to the International Myeloma Working Group criteria were retrospectively reviewed. RESULTS: At a median follow-up of 6.2 years, 5-year local control (LC), 5-year multiple myeloma-free survival (MMFS), 5-year failure-free survival (FFS), and 5-year overall survival (OS) were 82.6%, 44.1%, 41.8%, and 85.1%, respectively. Among the patients whose initial serum M protein was present or not evaluated, 37.3% of patients showed disappearance of serum M protein after various treatment. MMFS of these patients were comparable to non-secretory plasmacytoma with undetectable levels of M protein, and significantly better than patients with persistent M protein. Increase of serum M protein ≥0.1 g/dL was most predictive of treatment failure with area under the curve of 0.731. CONCLUSION: Patients who eventually showed persistence of serum M protein after treatment showed worse MMFS and FFS compared to those whose serum M protein disappeared or who had initially non-secretory disease. The increase of serum M protein level ≥0.1 g/dL from current nadir was predictive of treatment failure. Therefore, regular follow-up with serum M protein is highly recommended especially unless the patient had initially non-secretory disease.

Adjuvant Chemotherapy and Dose Escalation in Definitive Concurrent Chemoradiotherapy for Esophageal Squamous Cell Carcinoma.

BACKGROUND/AIM: To validate the effect of treatment intensification on survival in esophageal squamous cell carcinoma (ESCC) patients undergoing definitive concurrent chemoradiotherapy (dCCRT). PATIENTS AND METHODS: We reviewed the medical records of 73 ESCC patients who underwent dCCRT between 2006 and 2017 in 3 institutions. RESULTS: The median follow-up time was 13.3 months. The median overall survival (OS) and locoregional recurrence-free survival (LRFS) were 13.3 and 11.2 months, respectively. The median radiotherapy dose was 55.8 Gy, and the median biologically effective dose (BED) was 65.8 Gy. Chemotherapy was given in all patients during dCCRT, and adjuvant chemotherapy was administered in 56 patients (76.7%). Adjuvant chemotherapy improved OS (3-year, 24.2% vs. 11.8%, p=0.004). Higher BED ≥70 Gy improved LRFS (3-year, 41.7% vs. 23.6%, p=0.035). CONCLUSION: The addition of chemotherapy after dCCRT improves OS. A higher radiotherapy dose improved LRFS, but not OS. Adjuvant chemotherapy should be considered after dCCRT for better outcomes.

Post-operative radiation therapy with or without chemotherapy for anal squamous cell carcinoma incidentally discovered after local excision: a propensity score matched analysis of retrospective multicenter study.

OBJECTIVE: To evaluate the results of post-operative radiation therapy (RT) for anal squamous cell carcinoma (ASCC) incidentally detected after excision, and compare these outcomes with those of definitive RT without excision for exploring the possibility of treatment de-intensification. METHODS AND MATERIALS: A total of 25 patients with T1-2N0-1 ASCC who underwent RT following incidental tumor resection were selected from multicenter retrospective database. And, we selected one-to-one matched 25 patients receiving definitive RT from the same database using propensity score matching method, and the outcomes were compared. RESULTS: Median age was 60 years (range, 30-76), and 18 patients (72%) were female. 19 patients (76%) had T0/1 tumors and four patients (16%) had regional lymph node metastases. Hemorrhoidectomy was performed in eight patients (32%) and the others underwent local excision. 12 patients (48%) had microscopic or gross residual diseases. Median RT dose to the primary lesion was 50.4 Gy (range, 40-60). Concurrent chemotherapy was delivered to 23 patients (92%). Median follow-up period was 71 months (range, 4.5-203.1 months). None of the patients showed recurrence during follow-up. However, one patient died after 6 months due to the chemotherapy-related hematologic toxicity. When compared with those patients receiving definitive RT, clinicopathological variables were well-balanced between the two groups. While matched paired patients treated with definitive RT received a higher median RT dose of 54 Gy (range, 45-61.2) and concurrent chemotherapy was given to 22 patients (88%), overall survival was not significantly different (p = 0.262). CONCLUSION: Patients treated with RT for early stage ASCC after local excision showed favorable treatment outcomes. Further study is warranted to justify the de-intensification of the treatment for these patients. ADVANCES IN KNOWLEDGE: Post-operative RT can achieve favorable treatment outcomes in incidental ASCC with residual diseases after local excision.

Patterns of Care After Surgery for Elderly Patients With Malignant Brain Tumors: Data from the National Health Insurance Service in South Korea.

BACKGROUND/AIM: To analyze patterns of care and overall survival for elderly patients with malignant brain tumors. MATERIALS AND METHODS: The database from the National Health Insurance Service was searched January 2008-December 2016. A total of 1,607 patients aged 65-year-old or more with malignant brain tumors who underwent surgery or biopsy were extracted. Treatment performed in 180 days after surgery was divided into no treatment (N=522), radiotherapy (RT) (N=351), chemotherapy (N=69), and chemotherapy plus RT (N=665). Survival was recorded at 3, 6, 9, 12, 18, and 24 months after surgery. RESULTS: Patients were divided into groups by age: 65-69, 70-74, 75-79, and ≥80 years. Chemotherapy plus RT was most commonly used in all age groups except those aged 80 years and more. Treatment modality after surgery or biopsy was significantly prognostic (p<0.001) in univariate analysis. CONCLUSION: Adjuvant treatment can be recommended for elderly patients with malignant brain tumors based on data from the National Health Insurance Service.

Disulfiram, a Re-positioned Aldehyde Dehydrogenase Inhibitor, Enhances Radiosensitivity of Human Glioblastoma Cells In Vitro.

PURPOSE: Glioblastoma, the most common brain tumor in adults, has poor prognosis. The purpose of this study was to determine the effect of disulfiram (DSF), an aldehyde dehydrogenase inhibitor, on in vitro radiosensitivity of glioblastoma cells with different methylation status of O6-methylguanine-DNA methyltransferase (MGMT) promoter and the underlying mechanism of such effect. MATERIALS AND METHODS: Five human glioblastoma cells (U138MG, T98G, U251MG, U87MG, and U373MG) and one normal human astrocyte (NHA) cell were cultured and treated with DSF or 6MV X-rays (0, 2, 4, 6, and 8 Gy). For combined treatment, cells were treated with DSF before irradiation. Surviving fractions fit from cell survival based on colony forming ability. Apoptosis, DNA damage repair, and cell cycle distributionwere assayed bywestern blot for cleaved caspase-3, γH2AX staining, and flow cytometry, respectively. RESULTS: DSF induced radiosensitization in most of the glioblastoma cells, especially, in the cells with radioresistance as wildtype unmethylated promoter (MGMT-wt), but did not in normal NHA cell. DSF augmented or induced cleavage of caspase-3 in all cells after irradiation. DSF inhibited repair of radiation-induced DNA damage in MGMT-wt cells, but not in cells with methylated MGMT promoter. DSF abrogated radiation-induced G2/M arrest in T98G and U251MG cells. CONCLUSION: Radiosensitivity of glioblastoma cells were preferentially enhanced by pre-irradiation DSF treatment compared to normal cell, especially radioresistant cells such as MGMT-wt cells. Induction of apoptosis or inhibition of DNA damage repair may underlie DSF-induced radiosensitization. Clinical benefit of combining DSF with radiotherapy should be investigated in the future.

Radiation Therapy for Anal Squamous Cell Carcinoma: A Retrospective Multicenter Study.

AIM: To analyze the treatment outcomes, patterns of failures and prognostic factors for patients with anal cancer treated with radiotherapy (RT). MATERIALS AND METHODS: Between January 2000 and December 2015, 83 patients with anal squamous cell carcinoma were treated with definitive RT. The median RT dose applied to the primary carcinoma site was 55 (range=45-64) Gy. Seventy-six patients (91.6%) received concurrent chemotherapy, and the most common regimen was 5-fluorouracil plus mitomycin C. RESULTS: The median age of patients was 64 (range=36-86) years, and there were 21 males and 62 females. The overall complete remission rate was 89.2%. The median duration of follow-up was 51 (range=3-173) months. The actuarial 5-year overall, progression-free survival (PFS), locoregional progression-free, and distant metastasis-free survival rates were 85.0%, 70.4%, 78.2%, and 82.6%, respectively. On multivariate analysis, eventual treatment response was the only prognostic factor for overall (p=0.023) and progression-free (p<0.001) survival. Age (p=0.013) and eventual treatment response (p<0.001) were significantly associated with locoregional progression-free survival. Initial treatment response, lymph node involvement and RT technique significantly affected distant metastasis-free survival (p=0.016, 0.048 and 0.002, respectively). CONCLUSION: RT, mainly with concurrent chemotherapy, showed acceptable treatment outcomes and safe toxicity profiles.

Role of radiation therapy in primary central nervous system lymphoma : KROG 14-20 Collaborative Study of Brain and Lymphoma Committee.

We analyzed patterns of care and outcomes for patients with primary central nervous system lymphoma (PCNSL) in this multi-institutional retrospective study. Between January 2000 and December 2011, 220 patients with PCNSL received radiotherapy (RT). Among these patients, 26 patients received RT alone; 179 patients were treated with chemotherapy and radiotherapy; the rest of the patients (N = 15) initially underwent chemotherapy alone, then received RT as a salvage treatment. Most of the patients (N = 188) received methotrexate-based chemotherapy. The median follow up duration was 38 months (range 3-179 months). The median RT dose and whole brain RT (WBRT) dose were 45.0 Gy (range 20.0-59.4) and 30.6 Gy (range 18.0-45.0), respectively. Seventy-seven (35%) patients received WBRT alone, and 143 patients (65%) underwent WBRT plus boost RT. Total RT dose and WBRT dose decreased during the study period. The median survival was 64 months and actuarial 5-year overall survival was 51.4%. In multivariate analysis, age (P < 0.001), ECOG performance status (P = 0.036), deep structure involvement (P = 0.011) and treatment response (P = 0.001) were significant prognosticators. RT combined with chemotherapy is effective modality for treatment of PCNSL. The survival outcome improved in spite of total radiation dose and whole brain RT (WBRT) dose having been decreased over the study period, indicating that low-dose WBRT could be effective.

Malignant tracheal necrosis and fistula formation following palliative chemoradiotherapy: a case report.

Concurrent chemoradiotherapy is an essential treatment strategy for inoperable locally advanced non-small cell lung cancer (NSCLC). Although supportive care has improved, unexpected complications due to the disease or treatment can occur. Tracheomediastinal fistulas are very rare but can be a serious problem. Herein, we report a case of severe chondronecrosis of the distal trachea with formation of a fistula into a metastatic lymphadenopathy in a patient with stage IIIB NSCLC. The patient received external beam radiotherapy with a total dose of 35 Gy in 14 fractions, which was approximately half of the conventional therapeutic radiotherapy dose, along with concurrent cisplatin based chemotherapy. Careful evaluation, early detection, and timely intervention are essential to prevent and appropriately treat chondronecrosis, even in cases of low-dose radiotherapy application to central tumors.

Change in carbohydrate antigen 19-9 level as a prognostic marker of overall survival in locally advanced pancreatic cancer treated with concurrent chemoradiotherapy.

PURPOSE: To investigate the significance of carbohydrate antigen 19-9 (CA19-9) levels for survival in locally advanced pancreatic cancer (LAPC) treated with concurrent chemoradiotherapy (CCRT). METHODS/PATIENTS: We retrospectively reviewed data from 97 LAPC patients treated with CCRT between 2000 and 2013. CA19-9 levels (initial and post-CCRT) and their changes [{(post-CCRT CA19-9 level - initial CA19-9 level)/(initial CA19-9 level)} × 100] were analyzed for overall survival. A cut-off point of 37 U/mL was used to analyze initial and post-CCRT CA19-9 levels. In order to define an optimal cut-off point for change in CA19-9 level, the maxstat package of R was applied. RESULTS: Median overall survival was 14.7 months (95% CI 13.4-16.0), and the 2-year survival rate was 16.5%. The estimated optimal cut-off point of CA19-9 level change was 94.4%. On univariate analyses, CA19-9 level change between initial and post-CCRT was significantly correlated with overall survival (median survival time 9.7 vs 16.3 months, p < 0.001). Multivariate analyses confirmed that CA19-9 level change from initial to post-CCRT was the only prognostic factor (p < 0.001). CONCLUSIONS: Change in CA19-9 level between initial and post-CCRT was a significant prognostic marker for overall survival in LAPC treated with CCRT. A CA19-9 level increase >94.4% might serve as a surrogate marker for poor survival in patients with LAPC undergoing CCRT, and the prognostic power surpassed other CA19-9 variables including initial and post-CCRT values.

Outcome Analysis of Chemoradiation in Unresectable Pancreatic Cancer Focusing on Treatment Sequencing Strategy.

AIM: To analyze the outcomes of patients with unresectable pancreatic cancer after chemoradiotherapy (CCRT), focusing on sequencing strategy. PATIENTS AND METHODS: Data of 144 patients treated from January 1989 to December 2013 were retrospectively analyzed. Patients were divided into the scheduled group (N=27), salvage group (N=37) and upfront group (N=80) per CCRT and chemotherapy sequence. RESULTS: With a median follow-up of 10.4 months (range=1.4-164.2), median overall survival (OS) was 13.5 months. Patients in the upfront group had inferior performance status and received a lower radiation dose (p=0.007 and p<0.001, respectively). Higher radiation dose (≥45 Gy) was the sole prognosticator related with improved survival in multivariate (p=0.001) analysis, whereas treatment sequence was not a significant prognostic factor (p=0.409). CONCLUSION: No difference was found among tested sequencing strategies that were all well-tolerated, despite skewed distribution for performance and radiation dose. An upfront approach may be a viable option for patients with limited performance to undergo more active systemic chemotherapy.

Effect of Time Interval between Breast-Conserving Surgery and Radiation Therapy on Outcomes of Node-Positive Breast Cancer Patients Treated with Adjuvant Doxorubicin/Cyclophosphamide Followed by Taxane.

PURPOSE: This study evaluated the effect of surgery-radiotherapy interval (SRI) on outcomes in patients treated with adjuvant radiotherapy (RT) after breast-conserving surgery (BCS) and adjuvant four cycles of doxorubicin/cyclophosphamide (AC) followed by four cycles of taxane. MATERIALS AND METHODS: From 1999 to 2007, 397 eligible patients were diagnosed. The effect of SRI on outcomes was analyzed using a Cox proportional hazards model, and a maximal chi-square method was used to identify optimal cut-off value of SRI for each outcome. RESULTS: The median SRI was 6.7 months (range, 5.6 to 10.3 months). A SRI of 7 months was the significant cut-off value for distant metastasis-free survival (DMFS) and disease-free survival (DFS) using a maximal chi-square method. For overall survival, a significant cut-off value was not found. The patients with SRI > 7 months had worse 6-year DMFS and DFS than those with SRI ≤ 7 months on univariate analysis (DMFS, 81% vs. 91%, p=0.003; DFS, 78% vs. 89%, p=0.002). On multivariate analysis, SRI > 7 months did not affect DMFS and DFS. CONCLUSION: RT delayed for more than 7 months after BCS and adjuvant four cycles of AC followed by four cycles of taxane did not compromise clinical outcomes.

Outcome analysis of salvage radiotherapy for occult cervical cancer found after simple hysterectomy.

OBJECTIVE: The objective was to analyze the outcomes of the patients, who received salvage radiotherapy for incidentally discovered cervical cancer following simple hysterectomy, and to identify the influence of intracavitary radiotherapy on treatment outcomes. METHODS: Data from 117 patients with occult cervical cancer who underwent simple hysterectomy followed by salvage radiotherapy from September 1979 to November 2010 were collected. All the patients received external beam radiotherapy with (n = 45) or without (n = 72) intracavitary radiotherapy. Local control, disease-free survival, overall survival and treatment-related toxicity were investigated. RESULTS: The median follow-up time was 75 months. The 5- and 10-year local control/disease-free survival/overall survival rates were 93/87/87% and 90/84/83%, respectively. Among 98 patients who had no residual disease and negative resection margin on surgical specimens, 32 (33%) received intracavitary radiotherapy and 66 (67%) did not. There were no differences in patient and tumor characteristics between patients treated with and without intracavitary radiotherapy. The 5-year local control rate for the non-intracavitary radiotherapy group was 93 versus 94% for the intracavitary radiotherapy group (P = 0.564); the disease-free survival rate was 88 versus 94% (P = 0.894); the overall survival rate was 95 versus 85% (P = 0.106), respectively. Among all patients, there were 5% of Grade 3 or higher late toxicities. CONCLUSIONS: Patients with occult invasive cervical cancer discovered following simple hysterectomy could be treated safely and effectively with salvage radiotherapy. For patients with no residual disease and negative resection margin, intracavitary radiotherapy could be omitted.

Intensity-modulated fractionated stereotactic radiotherapy with reduced margin for high grade gliomas: dosimetric analysis of sparing optic nerve & chiasm.

The aim of this study was to evaluate the potential advantage of intensity modulation fractionated stereotactic radiotherapy (IM-FSRT) for sparing the optic nerve and chiasm in the management of anaplastic astrocytoma (AA) or glioblastoma (GBM). Clinical data of 16 patients with high grade gliomas were retrospectively reviewed. All patients had tumors close to the optic chiam that prohibited the full dose radiation therapy. The patients were treated with either IM-FSRT in conjunction with external beam radiation or IM-FSRT only to a total dose of 60 Gy. The final dosimetric analysis was performed. The estimated average maximum optic nerve and chiasm dose 48.6±5.0 Gy (range, 34.2-55.9). Conformity index reached as high as 0.98, and inhomogeneity coefficient was low enough to deliver the prescribed radiation dose. IM-FSRT showed excellent dose conformality to the target volume with superior normal tissue sparing effect. High precision therapy such as IM-FSRT could be a reliable treatment technique for the patients with AA or GBM for a maximal sparing of optic apparatus.