The position and current status of radiation therapy after primary systemic therapy in breast cancer: a national survey-based expert consensus statement

Background: Primary systemic therapy (PST) is changing the role of radiation therapy (RT) in breast cancer. Without randomized studies, the optimal indications for RT after PST and surgery are not clear. The present study provides consensus-based recommendations to clarify the role of RT. Methods: Radiation oncologists (n = 82; 77 % response rate) in Spain were surveyed to determine their recommendations for locoregional RT following PST and surgery. Results: Most (98 %) specialists support whole breast irradiation after breast-conserving surgery (BCS), regardless of pathologic response to PST. In T1-T2 and T3-T4 tumours with sentinel node biopsy (SNB) prior to PST, 91 and 56 % of respondents, respectively, recommend irradiating the supraclavicular (level IV) and axillary level III nodes when nodal involvement is detected (9 and 44 % of respondents recommend irradiating these areas by independent of nodal status). If SNB is not available, 57 and 30 % of specialists agreed that the aforementioned nodal regions should be irradiated (33 and 65 % of respondents recommend irradiating these areas by independent of nodal status). Between 58 and 76 % of specialists agreed that nodal levels I and II should be irradiated in cases of insufficient lymphadenectomy or when [75 % of the resected nodes are involved. Conclusion: Agreement is strong regarding the indications for local RT after PST and surgery, but less so for nodal irradiation. All patients who undergo BCS should receive RT, even with complete pathologic response. After mastectomy, RT is recommended in all node-positive stage III cases. Prospective studies will clarify indications for RT in this patient population (AU)

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Radiotherapy dose escalation with concurrent chemotherapy in locally advanced cervix cancer is feasible

Background. To test the feasibility of radiotherapy dose escalation using volumetric arc therapy (VMAT) and image-guided radiotherapy (IGRT) with concurrent chemotherapy in locally advanced cervix cancer (LACC) and compare this with whole-pelvis three-dimensional conformal radiation therapy (CRT) in terms of clinical toxicity. Methods. Database was reviewed for all LACC patients treated during 2011 and 2012. Twenty patients who were treated with escalated dose of radiotherapy using VMAT were selected for analysis. A matched cohort of 40 patients who had 3DCRT between 2005 and 2008 was selected as control. Mean basal hemoglobin, average weekly hemoglobin, and maximal drop in hemoglobin were measured for both 3DCRT and VMAT groups and treatment toxicity scored according to RTOG criteria. Charts were also reviewed for other acute and late toxicities including the rate of compliance with prescribed treatment. Results. Mean age was 46 (30-63) and 47 years (33-67), mean tumor size was 5.5 and 5 cm and blood transfusion rate was 55 and 45 % in CRT and VMAT groups, respectively. Hemoglobin toxicity (Grade I-II) was encountered in 97.5 and 90 % (p 0.0.3) while Grade I-III Leukopenia was 90 and 70 % (p 0.02), respectively. There was no Grade 3 or 4 GI or GU toxicity. Conclusion. VMAT/IGRT with dose escalation is feasible in LACC without excessive toxicity as compared to CRT "Box". We propose a randomized control trial of this novel approach of higher radiation dose and volume against the standard prescription based on CRT (AU)

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Hypofractionated helical tomotherapy using 2.5-2.6 Gy daily fractions for localized prostate cancer

BACKGROUND: The purpose of this study is to evaluate the tolerability of hypofractionated helical tomotherapy (HT) in the treatment of localized prostate cancer. MATERIALS AND METHODS: We evaluated 48 patients with primary adenocarcinoma of the prostate (cT1-T3N0M0) who were treated with hypofractionated HT from August 2008 through July 2011. Hypofractionated regimens included: 68.04 Gy at 2.52 Gy/fraction, 70 Gy at 2.5 Gy/fraction, and 70.2 Gy at 2.6 Gy/fraction. Genitourinary (GU) and gastrointestinal (GI) toxicity was scored using the Radiation Therapy Oncology Group scoring system. RESULTS: Thirty-two patients were treated with 68.04 Gy, 5 patients with 70 Gy, and 11 with 70.2 Gy. The median age at diagnosis was 69 years (range 49-87) and the median follow-up 11 months (range 7-40). Grade 2 acute GI toxicity occurred in 9 patients (19 %). No grade 3 or higher acute GI toxicity was observed. Grade 2 and 3 acute GU toxicities occurred in 19 and 6 % of patients, respectively. The incidence of late grade 2 GI and GU toxicity was 4 and 2 %, respectively. No grade 3 or higher late toxicities were observed. Multivariate analysis showed that patients treated at 2.6 Gy/fraction or those who received a total radiation dose ≥70 Gy had higher rates of grade ≥2 acute GU toxicity (P = 0.004 and P = 0.048, respectively). CONCLUSION: Hypofractionated HT in the treatment of localized prostate cancer is well tolerated with no grade 3 or higher early or late GI and GU toxicities. Further research is needed to assess definitive late toxicity and tumor control (AU)