Managing Inconsistent Bladder Volumes in the Prostate Cancer Patient Using Daily Online Adaptive RT: A Case Report.

PURPOSE: We report the use of online adaptive radiotherapy (OART) aiming to improve dosimetric parameters in the prostate cancer patient who had lower urinary tract symptoms that caused him not to adhere to the standard bladder filling protocol. METHODS AND MATERIALS: The reference treatment plan for adaptive radiotherapy plan was generated for the pelvis and the solitary bony lesion using the Ethos treatment planning system. For each treatment session, high-quality iterative reconstructed cone beam CT (CBCT) images were acquired, and the system automatically generated an optimal adaptive plan after verification of contours. Image-guided RT (IGRT) plans were also created using the reference plan recalculated on the CBCT scan and were compared with adaptive plans. RESULTS: The reference bladder volume in the planning CT scan was 173 cc, and the mean bladder volume difference over the course was 25.4% ± 16.6%. The ART offered superior target coverage for PTV 70 Gy over online IGRT (V95: 90.5 ± 3.2 % Vs 97.3 ± 0.4%; p=0.000) and the bladder was also better spared from the high dose (V65 Gy: 17.9 ± 9.1% vs 14.8 ± 3.6%; p=0.03). However, the mean rectum V65 doses were very similar in both plans. CONCLUSION: Managing the inconsistent bladder volume was feasible in the prostate cancer patient using the CBCT-guided OART and our analysis confirmed that adaptive plans offered better target coverage while sparing the bladder from high radiation doses in comparison to online IGRT plans. KEY WORDS: radiotherapy, CBCT, online adaptive radiotherapy, image-guided RT.

Real-world clinical outcomes with daily image-guided IMRT in extremity soft tissue sarcomas.

PURPOSE: We report the clinical outcomes of patients with soft tissue sarcomas (STS) arising in extremities treated with image-guided intensity modulated radiotherapy (IG-IMRT) at our institute. Local control of the tumors treated with RT was the primary end point of this study. Analyzing overall survival and long-term toxicities were the secondary objectives. METHODS AND MATERIALS: The database of the patients with STS who received wide local excision and IG-IMRT at our institution from January 2012 to December 2020 was reviewed. Radiation was offered either preoperatively or postoperatively as part of multi-modality treatment. RESULTS: Thirty-three consecutive patients were identified and included for analysis. Twenty-eight patients (84.8%) received postoperative adjuvant radiotherapy. Dedicated MRI simulation studies were performed in 31 patients (93.9%) in the treatment position. RapidArc IMRT technique was used in 31 patients (93.9%). A total of 2954 images were acquired during 991 treatment sessions. Errors exceeding 1 mm in the x, y and z directions were corrected online before the treatment. With a median follow-up of 36 months, two patients (6.1%) developed local recurrence. The 3-year local control was 90.9% (95% CI, 0.76 - 0.98), and the 5-year overall survival was 71.7% (95% CI, 0.44 - 0.88). One patient (3.03%) sustained a pathological fracture during the follow-up period. CONCLUSION: Our results showed that IMRT with daily imaging offered excellent local control with acceptable long-term toxicity, as well as being feasible and practical to implement in our routine clinical practice.

Recurrent spinal cord compression due to extramedullary hematopoiesis in thalassemia patient: Case report.

INTRODUCTION: Spinal cord compression secondary to extramedullary hematopoiesis (EMH) is a rare condition. Variable treatment options have been reported with different efficacy and recurrence rate. Due to its rarity, no clear optimal management guidelines have been established yet. PATIENT CONCERNS AND DIAGNOSIS: We report a recurrence of spinal cord compression secondary to EMH in a 19-year-old male, with a background of transfusion-dependent beta-thalassemia on luspatercept, who presented with weakness in both lower limbs. INTERVENTIONS AND OUTCOMES: He was treated successfully both times with radiotherapy. CONCLUSION: Early diagnosis and management of EMH compressing the spinal cord are essential to prevent permanent neurological damage. Diagnosis should be suspected based on the clinical presentation and magnetic resonance imaging findings in a patient with a history of ineffective hemopoiesis. Treatment option remains controversial. Radiotherapy option seems effective, even in recurrent cases, and valid, particularly for those at high risk of surgery or who do not prefer it.

Delineating and sparing functional nephrons for radiotherapy in the case of lymphoma with polycystic kidney disease.

PURPOSE: It is imperative to spare functioning kidneys from high radiation doses when they are near enough to radiotherapy (RT) target volumes in patients with polycystic kidney disease (PKD). To achieve this intent, we designed the unique approach that we report here. METHODS AND MATERIALS: The patient who has PKD, presented with B-cell lymphoma involving paraaortic lymph nodes. After completing chemotherapy, RT was planned to the residual nodal disease. The diagnostic positron emission tomography computed tomography (PETCT) scan was fused with the RT planning CT scan. 18F-2-deoxy-2(F)-fluro-d-glucose (FDG) avid active kidneys were contoured separately, and the treatment plan was optimized to avoid these volumes. RESULTS: The functional volume was 17.52% of the right kidney whereas it was 7.44% of the left. The mean doses were 4.61 Gy and 4.2 Gy, respectively. The baseline estimated glomerular filtration rate (eGFR) was >60 mL/min; at 18 months follow-up, it was 62 mL/min. CONCLUSIONS: Delineation of functional nephrons was feasible while utilizing the staging FDG-PETCT scan for radiotherapy contouring in our patient, which aided to achieve the optimal dose-volume constraints. Further studies are warranted to analyze and quantify the benefit of this easily accessible method in the future.

Clinicopathological features and treatment outcomes of the rare, salivary duct carcinoma of parotid gland.

BACKGROUND: Salivary ductal carcinoma (SDC) of parotid gland is a rare and aggressive entity; accounting for 1-3 % of all malignant salivary gland tumors, 0.2 % of epithelial salivary gland neoplasms, 0.5 % of salivary gland carcinomas, and 1.1 % of parotid gland carcinomas. Here in we aimed to evaluate the clinico-pathological features and treatment outcomes of parotid gland SDC in Saudi population. METHODS: Among 38 patients with parotid malignancies, who were treated in two major tertiary care referral cancer centers between December 2007 and December 2014, seven cases (18.4 %) were found to have SDC, which were investigated for clinicopathological features, locoregional recurrences (LRRs), distant metastasis (DM) and survival rates. RESULTS: Mean age of cohort was 62.3 years (range: 41-83) and female predominant (71.4 %). All patients underwent total parotidectomy and ipsilateral neck dissection. Mean tumor size was 3.4 cm (range: 2.1-5.3); perineural invasion (85.8 %); lymph node involvement (42.9 %); and HER-2 neu overexpression (28.6 %). Postoperative radiation therapy (PORT) was given to six patients (dose: 50-66 Gy). Median follow-up was 20.2 months (range: 11-48). LRRs were seen in five (71.4 %) patients (base of skull, 3 patients; cervical nodes, one patient; parotid bed, one patient). LRRs were salvaged with resection (two patients) and re-irradiation (one patient with base of skull). DM in lungs was seen in three patients (42.8 %); one treated with carboplatin/paclitaxel based chemotherapy. The 4-year disease free and overall survival rates were 16.7 % and 40 % respectively. CONCLUSION: SDC of parotid gland is a rare and aggressive entity, and most of LRRs were seen in the base of skull, which warrants inclusion of base of skull in clinical target volume in PORT planning. Role of anti HER-2 targeted therapy in SDC with HER-2 neu overexpression needs further investigations.