Radiation recall myositis with pazopanib in a patient with soft tissue sarcoma.

INTRODUCTION: Radiation recall reaction is an acute inflammatory reaction confined to previously irradiated areas that are most commonly triggered by the administration of anti-cancer agents after radiotherapy. Radiation recall myositis is a relatively rare form of radiation recall reaction. CASE REPORT: Here we report a 29-year-old female patient who suffered from metastatic monophasic synovial sarcoma. 8.5 months after post-operative radiotherapy of the right thigh region, the patient suffered pain, edema, redness, and increased temperature locally on the right thigh. Physical exam showed red fixed skin, rigidity and severe tenderness of region, and thigh magnetic resonance imaging revealed dense edema areas at the addiction, semimembranous-semitendinous muscle, and superior part of the biceps femoris and vastus lateralis isointense on T1AG, hyperintense T2AG images. Based on these findings, the patient was diagnosed with pazopanib-induced radiation recall myositis. MANAGEMENT & OUTCOME: Pazopanib was stopped and pentoxifylline (2 × 400 mg), Vitamin E (3 × 400 mg), and methylprednisolone (2 × 8 mg) were prescribed. After 1 month, complete relief of thigh pain and marked recovery of rigidity, as well as erythema, were achieved and no recurrence of radiation recall reaction-related symptoms was observed after the pazopanib rechallenge. DISCUSSION: Myositis is a relatively rare presentation of radiation recall reaction and physicians must be aware of the symptoms of the patients who are treated by radiotherapy and pazopanib.

Stereotactic Radiotherapy for Adrenal Metastases: A Multi-Institutional Review of Patient Characteristics and Outcomes - Turkish Society for Radiation Oncology SBRT Group Study (Trod SBRT 10-004).

INTRODUCTION: This study aimed to report the outcomes of stereotactic body radiotherapy (SBRT) for adrenal metastasis in a retrospective multi-institutional cohort. METHODS: The outcomes of 124 patients with 146 adrenal metastases who underwent SBRT within 11 years (2008-2019) were retrospectively evaluated. Survival outcomes were analyzed by the Kaplan-Meier method. Patient, tumor, and treatment characteristics and their effects on survival, local control (LC), and toxicity outcomes were analyzed by log-rank and multivariate Cox regression methods. RESULTS: The median age was 60 years. The most frequent primary tumor site was the lung, followed by the gastrointestinal system and breast. The adrenal gland was the only metastatic site in 49 (40%) patients. Median biologically effective dose (BED)10 was 61 Gy. The overall LC rate was 83%, and it was positively correlated with the BED10 and fraction dose. The 1- and 2-year local recurrence-free survival, overall survival (OS), and progression-free survival (PFS) rate was 79% and 69%, 83% and 60%, and 31% and 12%, respectively. OS significantly improved with non-lung cancer and <4-cm lesion and PFS with a fraction dose ≥8 Gy, BED10 >65 Gy, and an isolated adrenal metastasis. Fourteen patients reported an acute toxicity, and late toxicity was observed in 3 patients, including one grade 5. CONCLUSION: A satisfactory LC rate was achieved for adrenal metastasis via SBRT. A higher BED10 and fraction dose were positive prognostic factors for tumor control. However, the main problem is DM in these patients, and systemic treatment options are needed to be improved.

Is there any additional benefit of 68Ga-PSMA PET on radiotherapy target volume definition in patients with glioblastoma?

OBJECTIVE: To investigate the contribution of 68Gallium (68Ga)-PSMA (prostate-specific membrane antigen) positron emission tomography (PET) in defining radiotherapy (RT) target volume for glioblastoma and to compare the target volumes defined by Magnetic Resonance Imaging (MRI). METHODS: RT planning Computed Tomography (CT) images were fused separately with pre-operative MRI and PET/MRI images of 10 glioblastoma patients, retrospectively. The contrast-enhanced area in T1 weighted MRI was contoured as gross tumor volume (GTV) and clinical target volume (CTV1) was obtained by including the cavity and T2/FLAIR hyperintense areas after giving a margin of 2 cm to the GTV. 68Ga-PSMA uptake area was contoured as biological tumor volume (BTV) and CTV2 was obtained with a margin of 2 cm to BTV. Planning target volumes (PTVs) were created with the 3 mm added to the CTVs. Conformity index (CI), dice similarity coefficient (DSC) and overlap volume (OV) were calculated by obtaining the intersection and union volumes. Volumetric comparison, similarity and overlap analyzes were performed statistically by Wilcoxon signed rank and One sample t-test. RESULTS: The median GTV was 21,96 cc (1,04 - 82,04) and BTV was 25,58 cc (2,43 - 99,47). BTV was on average 47% larger than GTV which was statistically significant (p = 0.03). For GTV-BTV, CTV1-CTV2 and PTV1-PTV2; mean values of CI were 0,56, 0,76 and 0,76; DSC were 0,70, 0,86 and 0,86; OV were 0,88, 0,94 and 0,94, respectively. There was no significant difference on size and spatial similarity between CTV1 and CTV2, PTV1 and PTV2. CONCLUSION: Altough BTV was larger than GTV, this significance was lost while we gave the same CTV margin including the peripheral edema. It seems that it may help to improve defining non-enhancing tumor part and also recurrent tumor volume. ADVANCES IN KNOWLEDGE: Recent studies have focused on the role of 68Ga-PSMA PET in imaging of glial tumors. It has been observed that 68Ga-PSMA PET can clearly define the tumor borders and it can be beneficial in target volume delineation, especially in reirradiation of recurrent tumors.

The effect of preoperative radiotherapy on local control and prognosis in high-grade non-metastatic intramedullary osteosarcoma of the extremities.

INTRODUCTION: This study aimed to analyse the effect of preoperative radiotherapy on survival, recurrence and necrosis rates in osteosarcoma patients treated with neoadjuvant chemotherapy and limb-salvage surgery. MATERIALS AND METHODS: Osteosarcoma patients who referred to our clinic from 1998 to 2015 were investigated retrospectively. 141 patients with non-metastatic osteosarcoma of the limb who received neoadjuvant chemotherapy and underwent limb-sparing surgery with or without preoperative radiotherapy were included in the study. 73 patients had neoadjuvant chemotherapy only (CT group), while 68 patients had additional preoperative radiotherapy (CT + RT group). 5-year survival, disease-free survival, limb survival, local recurrence, metastasis, complication and necrosis rates were compared between the two groups. RESULTS: Overall 5-year survival, 5-year disease-free survival, 5-year limb survival rates were 68.5, 64.3, 65.7 for CT group and 72.1, 67.6, 64.7 for CT + RT group, respectively. Preoperative radiotherapy gave similar survival and disease-free survival rates. Limb survival, recurrence and metastasis rates were similar between the groups. The necrosis rate of the lesions was significantly higher in the CT + RT group compared to the CT group. CONCLUSION: Preoperative radiotherapy can provide a higher necrosis rate and may allow the resection of unresectable lesions in the treatment of osteosarcoma. CT + RT provided similar 5-year survival despite the larger tumour size compared to CT group. Due to the higher wound complication rate (8.2% in CT, 23.5% in CT + RT group, p = 0.01), CT + RT should be restricted to the lesions with large size or close proximity to neurovascular structures. LEVEL OF EVIDENCE: Level III; Therapeutic, Retrospective comparative study.

Comparison of kV Orthogonal Radiographs and kV-Cone-Beam Computed Tomography Image-Guided Radiotherapy Methods With and Without Implanted Fiducials in Prostate Cancer.

Introduction The aim of this study is to investigate the performance of kilovoltage (kV) cone-beam computed tomography (CBCT)-based adjustments with respect to kV-orthogonal fiducial marker-based matching in a group of patients with prostate cancer.  Methods Twenty prostate cancer patients were evaluated retrospectively: 10 with implanted fiducial markers and 10 without. Daily orthogonal kV imaging was recorded prior to radiation delivery. Images were evaluated in the left-right (LR), anterior-posterior (AP), and superior-inferior (SI) directions by matching either the implanted fiducials or going off bony anatomy, depending on the presence or absence of markers, respectively. Cone-beam computed tomography (CBCT) imaging was also subsequently acquired and images were aligned with the planning CT. The couch shifts were calculated and the patient's position was adjusted accordingly. Standard deviations and random errors were also computed. Pearson correlation and Bland-Altman analysis were performed to evaluate relationships between the datasets. Results A total of 240 images were evaluated. The Pearson correlation coefficient for shifts applied to patients with markers using kV and CBCT was 88.3%, 87.8%, and 94.5% for the LR, AP, and SI directions, respectively. For those without markers, the respective values for the LR, AP, and SI directions were: 39.3%, 22.4%, and 3.7%. A Bland-Altman analysis comparing kV and CBCT in patients with markers, revealed R2 values of 0.152, 0.282, and 0.097 in the LR, AP, and SI directions, respectively. The R2 values for patients without markers were 0.008, 0.01, and 0.057, in the LR, AP, and SI directions, respectively. Conclusions Our data suggest that CBCT can be a viable option for image-guidance in clinical settings where fiducial markers are unavailable such as situations of inaccessibility or medical contraindications.

Prognostic factors in medically inoperable early stage lung cancer patients treated with stereotactic ablative radiation therapy (SABR): Turkish Radiation Oncology Society Multicentric Study.

OBJECTIVE: We identified factors influencing outcomes in patients with medically inoperable early stage lung cancer (MIESLC) treated with stereotactic ablative radiation therapy (SABR) at 14 centers in Turkey. MATERIALS AND METHODS: We retrospectively analyzed 431 patients with stage I-II MIESLC treated with SABR from 2009 through 2017. Age; sex; performance score; imaging technique; tumor histology and size; disease stage radiation dose, fraction and biologically effective dose with an α/ß ratio of 10 (BED10 ); tumor location and treatment center were evaluated for associations with overall survival (OS), local control (LC) and toxicity. RESULTS: Median follow-up time was 27 months (range 1-115); median SABR dose was 54 Gy (range 30-70) given in a median three fractions (range 1-10); median BED10 was 151 Gy (range 48-180). Tumors were peripheral in 285 patients (66.1%), central in 69 (16%) and <1 cm from mediastinal structures in 77 (17.9%). Response was evaluated with PET/CT in most cases at a median 3 months after SABR. Response rates were: 48% complete, 36.7% partial, 7.9% stable and 7.4% progression. LC rates were 97.1% at 1 year, 92.6% at 2 years and 91.2% at 3 years; corresponding OS rates were 92.6%, 80.6% and 72.7%. On multivariate analysis, BED10 > 100 Gy (P = .011), adenocarcinoma (P = .025) and complete response on first evaluation (P = .007) predicted favorable LC. BED10 > 120 Gy (hazard ratio [HR] 1.9, 95% confidence interval [CI] 1.1-3.2, P = .019) and tumor size (<2 cm HR 1.9, 95% CI 1.3-3, P = .003) predicted favorable OS. No grade 4-5 acute side effects were observed; late effects were grade ≤3 pneumonitis (18 [4.2%]), chest wall pain (11 [2.5%]) and rib fracture (1 [0.2%]). CONCLUSION: SABR produced encouraging results, with satisfactory LC and OS and minimal toxicity. BED10 > 120 Gy was needed for better LC and OS for large, non-adenocarcinoma tumors.

Extraskeletal Ewing's sarcoma family of tumors in adults: prognostic factors and clinical outcome.

OBJECTIVE: The aim of this study was to evaluate prognostic factors, survival rate and the efficacy of the treatment modalities used in patients with extraskeletal Ewing's sarcoma. METHODS: Data of patients with extraskeletal Ewing's sarcoma followed up at our center between 1997 and 2010 were retrospectively analyzed. RESULTS: The median age of 27 patients was 24 years (range, 16-54 years). The median follow-up was 31.8 months (range, 6-144 months). Tumor size was between 1.5 and 14 cm (median: 8 cm). Eighty-five percent of patients had localized disease at presentation and 15% had metastatic disease. Local therapy was surgery alone in 16% of patients, surgery combined with radiotherapy in 42% and radiotherapy alone in 27%. All patients were treated with vincristine, doxorubicin, cyclophosphamide and actinomycin-D, alternating with ifosfamide and etoposide every 3 weeks. In patients with localized disease at presentation, the 5-year event-free survival and overall survival were 59.7 and 64.5%, respectively. At univariate analysis, patients with tumor size ≥ 8 cm, high serum lactate dehydrogenase, metastasis at presentation, poor histological response to chemotherapy and positive surgical margin had significantly worse event-free survival. The significant predictors of worse overall survival at univariate analysis were tumor size 8 ≥ cm, high lactate dehydrogenase, metastasis at presentation, poor histological response to chemotherapy, radiotherapy only as local treatment and positive surgical margin. CONCLUSIONS: Prognostic factors were similar to primary osseous Ewing's sarcomas. Adequate surgical resection, aggressive chemotherapy (vincristine, doxorubicin, cyclophosphamide and actinomycin-D alternating with ifosfamide and etoposide) and radiotherapy if indicated are the recommended therapy for patients with extraskeletal Ewing's sarcoma.

Results and complications of high dose rate and low dose rate brachytherapy in carcinoma of the cervix: Cerrahpasa experience.

PURPOSE: To evaluate the results and complications of treatment with high dose rate (HDR) compared to low dose rate (LDR) brachytherapy in cervical carcinoma. METHODS: Three hundred and seventy patients who were treated with external irradiation and intracavitary brachytherapy and followed for more than 2 years between 1978 and 1998 have been recently updated. The low dose rate group consisted of 77 cases treated between 1978 and 1982 and HDR group consisted of 293 cases treated between 1982 and 1998. All patients first received external irradiation with 60Co or 9-18 MV photons and a median dose of 54 Gy was given in 6 weeks. In the LDR group, intracavitary treatment was given with Manchester applicators loaded with radium (30 mg) in an intrauterine tube and 20 mg in vaginal ovoids. The dose delivered to point A was on average 32 Gy in one application. In the HDR group, a total dose of 24 Gy was given to point A in three insertions 1 week apart. The dose rate was 0.62 Gy at point A. RESULTS: The 5-year pelvic control rate was found to be 73% in the HDR group, compared with 86% in the radium group for stage I cases. In stage IIB and IIIB cases, the rates were 68% and 45% for HDR and 65% and 53% for LDR, respectively. In all stages, there was no statistical difference in pelvic control and survival rates between the two groups. Overall incidence of late complications was found as 31.1% and 31.9% in HDR and LDR groups, respectively. The grade 2-4 late complication rate was 14% in the HDR group compared to 19% in the LDR group (P>0.05). CONCLUSION: HDR brachytherapy in the management of the cervix appears to be a safe and efficacious approach. Pelvic control, survival and complications rates are quite similar when compared with LDR.