Patient and Context Factors in the Adoption of Active Surveillance for Low-Risk Prostate Cancer.

Importance: Although active surveillance for patients with low-risk prostate cancer (LRPC) has been recommended for years, its adoption at the population level is often limited. Objective: To make active surveillance available for patients with LRPC using a research framework and to compare patient characteristics and clinical outcomes between those who receive active surveillance vs radical treatments at diagnosis. Design, Setting, and Participants: This population-based, prospective cohort study was designed by a large multidisciplinary group of specialists and patients' representatives. The study was conducted within all 18 urology centers and 7 radiation oncology centers in the Piemonte and Valle d'Aosta Regional Oncology Network in Northwest Italy (approximate population, 4.5 million). Participants included patients with a new diagnosis of LRPC from June 2015 to December 2021. Data were analyzed from January to May 2023. Exposure: At diagnosis, all patients were informed of the available treatment options by the urologist and received an information leaflet describing the benefits and risks of active surveillance compared with active treatments, either radical prostatectomy (RP) or radiation treatment (RT). Patients choosing active surveillance were actively monitored with regular prostate-specific antigen testing, clinical examinations, and a rebiopsy at 12 months. Main Outcomes and Measures: Outcomes of interest were proportion of patients choosing active surveillance or radical treatments, overall survival, and, for patients in active surveillance, treatment-free survival. Comparisons were analyzed with multivariable logistic or Cox models, considering centers as clusters. Results: A total of 852 male patients (median [IQR] age, 70 [64-74] years) were included, and 706 patients (82.9%) chose active surveillance, with an increasing trend over time; 109 patients (12.8%) chose RP, and 37 patients (4.3%) chose RT. Median (IQR) follow-up was 57 (41-76) months. Worse prostate cancer prognostic factors were negatively associated with choosing active surveillance (eg, stage T2a vs T1c: odds ratio [OR], 0.51; 95% CI, 0.28-0.93), while patients who were older (eg, age ≥75 vs <65 years: OR, 4.27; 95% CI, 1.98-9.22), had higher comorbidity (Charlson Comorbidity Index ≥2 vs 0: OR, 1.98; 95% CI, 1.02-3.85), underwent an independent revision of the first prostate biopsy (OR, 2.35; 95% CI, 1.26-4.38) or underwent a multidisciplinary assessment (OR, 2.65; 95% CI, 1.38-5.11) were more likely to choose active surveillance vs active treatment. After adjustment, center at which a patient was treated continued to be an important factor in the choice of treatment (intraclass correlation coefficient, 18.6%). No differences were detected in overall survival between active treatment and active surveillance. Treatment-free survival in the active surveillance cohort was 59.0% (95% CI, 54.8%-62.9%) at 24 months, 54.5% (95% CI, 50.2%-58.6%) at 36 months, and 47.0% (95% CI, 42.2%-51.7%) at 48 months. Conclusions and Relevance: In this population-based cohort study of patients with LRPC, a research framework at system level as well as favorable prognostic factors, a multidisciplinary approach, and an independent review of the first prostate biopsy at patient-level were positively associated with high uptake of active surveillance, a practice largely underused before this study.

IROCA-TES: Improving Quality in Radiation Oncology through Clinical Audits - Training and Education for Standardization.

Background: Clinical audits are an important tool to objectively assess clinical protocols, procedures, and processes and to detect deviations from good clinical practice. The main aim of this project is to determine adherence to a core set of consensus- based quality indicators and then to compare the institutions in order to identify best practices. Materials and methods: We conduct a multicentre, international clinical audit of six comprehensive cancer centres in Poland, Spain, Italy, Portugal, France, and Romania as a part of the project, known as IROCATES (Improving Quality in Radiation Oncology through Clinical Audits - Training and Education for Standardization). Results: Radiotherapy practice varies from country to country, in part due to historical, economic, linguistic, and cultural differences. The institutions developed their own processes to suit their existing clinical practice. Conclusions: We believe that this study will contribute to establishing the value of routinely performing multi-institutional clinical audits and will lead to improvement of radiotherapy practice at the participating centres.

Stereotactic ablative radiotherapy for oligometastatic prostate cancer.

Background: The present study assessed clinical outcomes of stereotactic body radiotherapy (SBRT) in oligometastatic prostate cancer patients. Materials and methods: Between 2017 and 2020, 37 lesions (12 osseous and 25 nodal targets) detected with conventional and/or functional imaging, were treated in 29 patients (pts), in different clinical settings: de novo oligometastatic (2 pts), oligorecurrent castration-sensitive (19 pts), castration-resistant (6 pts) prostate cancers and oligoprogressive disease during systemic therapy (2 pts). SBRT was delivered with volumetric modulated arc therapy up to a total dose of 21 Gy given in 3 fractions for bone and 30 Gy in 5 fractions for nodal metastases. A total of 34% of pts received hormonal therapy. We evaluated biochemical control [prostate serum antigen (PSA) increase < 10%)], progression free-survival (PFS) (time from SBRT to biochemical progression), local control (LC) (time from SBRT to in-field radiologic progression), hormone/systemic therapy-free survival, acute and late toxicities. Results: At 3 months, biochemical response was observed in 20/29 pts (69%). At a median follow-up of 17 months (range 6-33), 8/20 (40%) of the 3-month responders remained free from progression. Two-year PFS and LC were 37% and 70%, respectively. In-field progression occurred in 3/37 (8%) lesions. Hormone/systemic therapy was delayed by an average of 11.6 months (range 3-28). No significant difference in PFS based on the type of lesion or concomitant endocrine therapy was observed and no toxicity > grade 2 was reported. Conclusions: SBRT for oligometastatic prostate cancer offers a good biochemical/local control and tangible delay of hormone/systemic therapy without major toxicities.

Urinary toxicity in patients treated with radical EBRT for prostate cancer: Analysis of predictive factors in an historical series.

AIM AND BACKGROUND: The present study aims to identify predictive factors for urinary toxicity and self-reported symptoms after external beam radiotherapy (EBRT) for prostate cancer. METHODS: Two-hundred and eighty patients treated with EBRT for prostate cancer were included in the present study. Toxicity was scored following the grading system based on Radiation Therapy Oncology Group (RTOG) scale. International Prostatic Symptom Score (IPSS) and Consultation on Incontinence Questionnaires - Short Form (ICIQ-SF) were used to analyse self-reported symptoms. Acute and late urinary toxicities were correlated to clinical and treatment parameters, radiation dosimetry data, IPSS and ICIQ-SF. RESULTS: Median patient age was 74 years (range, 64-83). Thirty-one percent experienced acute G1 urinary toxicity, 24% G2 and 3% G3. Fourteen percent experienced G1 late urinary toxicity and 3% G2. Bladder volume<200 cc was associated with acute urinary toxicity (P=0.014); use of MRI for treatment planning allowed a lower incidence of late toxicity (P=0.062) and use of IMRT allowed for reduced incidence in late toxicity (P=0.038). Maximum bladder dose correlated with late urinary toxicity (P=0.014). The analysis of self-reported symptoms showed a significant correlation between IPSS baseline values (P=0.009), presence of nocturia (P=0.002), bladder urgency (P=0.024) and incontinence (P=0.024) and development of acute urinary toxicity at univariate analysis. At multivariate logistic regression analysis, bladder filling, IPSS value, nocturia, and urinary incontinence retained significant correlation with acute toxicity (P=0.0003). DISCUSSION: Significant independent predictors for acute urinary toxicity grade≥2 were bladder filling, IPSS value, nocturia, and urinary incontinence at baseline assessment.

Adaptive Strategy for External Beam Radiation Therapy in Prostate Cancer: Management of the Geometrical Uncertainties With Robust Optimization.

PURPOSE: We aim to develop and validate a new adaptive method for prostate cancer radiation therapy (RT), using an offline strategy to improve treatment personalization by modeling the internal target volume on individual basis and account for the residual set-up uncertainties by robust optimization. METHODS AND MATERIALS: Twenty patients with intermediate-high prostate cancer treated with radical radiation therapy were enrolled. The first step of the offline adaptive RT strategy is the identification of a patient-specific internal target volume based on the kV cone beam computed tomography (kV-CBCT) data sets acquired during the first 5 fractions. The deformable image registration algorithm ANACONDA was used to propagate the clinical target volumes (CTVs) from the reference-planning computed tomography to the CBCTs; these contours were assessed by a radiation oncologist. In the second step, the internal target volume was used to replan the treatment using a min-max robust algorithm based on the worst scenario optimization. The CTV coverage and organs-at-risk sparing achieved with the robust plan (RP) were analyzed and compared with the original standard plan, calculating the dose distributions on the residual CBCTs. RESULTS: The RP was shown to achieve optimal coverage of the CTV even in the worst scenario, with significantly lower doses to the rectum and bladder. CTV coverage of the RP was statistically better than the standard plan in terms of D99 (P = .008) and D98 (P = .02). Statistically significant mean dose reduction and D2 reduction were noted for the rectum (P < .05) and bladder (P < .009). Moreover, the RP appeared to be less sensitive to bladder and rectal filling. CONCLUSIONS: This adaptive strategy in prostate cancer radiation therapy is feasible and safe; it may be used to adapt the treatment with better target coverage and organs-at-risk sparing than standard planning target volume-based planning.

Radiotherapy in COVID-19 patient affected by multiple myeloma: a case report.

In COVID-19 pandemic, cancer patients may be vulnerable for their immunological status and need of immunosuppressive anti-neoplastic treatments. Choosing the best treatment option in COVID-19 positive cancer patients is still a challenging issue. We report the case of a 62-year-old woman diagnosed with multiple myeloma and affected by COVID-19. After the diagnosis of multiple myeloma in January 2019, the patient underwent first line therapy followed by bone marrow autologous stem cell transplantation, achieving a complete response in September 2019. In March 2020, the patient showed intrathoracic progression of the disease, resulting in a severe dysphagia and concomitant positivity to SARS-CoV-2 swab test, cough, fever, and dyspnea related to the involvement of the lung parenchyma as shown by CT-scan. After her admittance to a COVID-19 dedicated inward, she was administered oral hydroxychloroquine and darunavir-cobicistat for 7 days with stabilization of her general clinical conditions. For the worsening of dysphagia, after multidisciplinary discussion, it was decided to deliver radiotherapy to the mediastinal and paravertebral mass with 8 Gy single fraction. After 5 days, her clinical conditions improved, with reduction of dysphagia. The CT confirmed a partial response with reduction of the mass of about 50%. Viral clearance was confirmed by triple negative search for SARS-CoV-2 on nasopharyngeal swabs, one month after first documentation of positivity. Unfortunately, the patient died three months later due to a pulmonary mycotic infection causing respiratory failure. To our knowledge, this case report describes the first experience of mediastinal radiotherapy in a COVID-19 patient affected by myeloma reported in the literature. In case of clinical indication, even in presence of SARS-CoV-2 infection, radiotherapy can be safely delivered and might be considered a treatment option as shown by our experience in this challenging case of intrathoracic myeloma.

Three-dimensional surface and ultrasound imaging for daily IGRT of prostate cancer.

BACKGROUND: Image guided radiotherapy (IGRT) is an essential pre-requisite for delivering high precision radiotherapy. We compared daily variation detected by two non-ionizing imaging modalities (surface imaging and trans-abdominal ultrasound, US) to verify prostate patient setup and internal organ variations. METHODS: Forty patients with organ confined prostate cancer and candidates to curative radiotherapy were enrolled in this prospective study. At each treatment session, after laser alignment, all patients received imaging by a 3D-surface and a 3D-US system. The shifts along the three directions (anterior-posterior AP, cranial-caudal CC, and later-lateral LL) were measured in terms of systematic and random errors. Then, we performed statistical analysis on the differences and the possible correlations between the two modalities. RESULTS: For both IGRT modalities, surface imaging and US, 1318 acquisitions were collected. According with Shapiro Wilk test, the positioning error distributions were not Gaussian for both modalities. The differences between the systematic errors detected by the two modalities were statistically significant only in LL direction (p < 0.05), while the differences between the random errors were not statistically significant in any directions. The 95% confidence interval of the residual errors obtained by subtracting the random errors detected with surface images to those detected with US was included in the range from -7 mm to 7 mm corresponding to the minimum PTV margin adopted in AP direction in our clinical routine. CONCLUSIONS: From our data, it emerges that setup misalignments measured by surface imaging can be predictive of US displacements after the adjustment for systematic errors. Moreover, surface imaging can detect setup errors predictive of registration errors measured by US. This data suggest that the two IGRT modalities could be considered as complementary to each other and could represent a daily "low-cost" and non-invasive IGRT modality in prostate cancer patients.

Three-dimensional surface imaging for detection of intra-fraction setup variations during radiotherapy of pelvic tumors.

PURPOSE: Surface-based image guided radiotherapy (IGRT) allows positioning and/or monitoring patients in 3 dimensions (3D), without the use of ionizing radiation. In this study, we report on intra-fraction motion measured by acquisition of multiple images of 3D body surfaces. MATERIALS AND METHODS: Twenty-nine patients treated for pelvic tumors were enrolled. Setup variations (SV) through three consecutive body surfaces acquired by the optical IGRT system Align-RT (Vision-RT, London, UK) were analyzed before, during and at the end of treatment delivery. Displacements along the main axes (X, Y and Z) from initial (I) to mid-treatment (MT) and final (F) acquisitions were recorded. Time and direction of SV were assessed. RESULTS: A total of 6272 images from 792 fractions of 29 patients were available. The main source of misalignment was between I and MT acquisition (p < 0.001). The dominant SV direction was the vertical one (Z axis), with mean SV of -1.20 ± 0.06 mm and -1.55 ± 0.06 mm for I-MT and I-F acquisitions, respectively. The Y mean components of SV were, respectively, -0.95 ± 0.10 mm and -1.0 ± 0.10 for I-MT and I-F acquisitions, while the X deviations were 0.07 ± 0.08 mm for I-MT and 0.26 ± 0.08 mm I-F. CONCLUSION: Three-D surface imaging for patient setup monitoring highlighted remarkable mobility of patients during RT session, especially in the anterior-posterior direction (Z axis). The largest magnitude in patient movements occurred during the first part of delivery. These findings suggest that the initial setup control cannot not to be sufficient to guarantee treatment reproducibility, especially for long-lasting RT treatments.

Postoperative radiotherapy in prostate cancer: Analysis of prognostic factors in a series of 282 patients.

AIM: To assess the outcomes of patients treated with postoperative RT in relation to the possible prognostic factors. BACKGROUND: Postoperative radiotherapy (RT) has been proved to reduce the risk of biochemical recurrence in high-risk prostate cancer patients. Baseline prostate specific antigen (PSA), pathological Gleason score (GS), positive surgical margins, nodal status and seminal vesicle invasion are independent predictors of biochemical relapse. MATERIALS AND METHODS: The clinical records of 282 patients who underwent postoperative RT were retrospectively reviewed. The prognostic value of postoperative PSA, preoperative risk class, nodal status, pathological GS, margins status, and administration of hormonal therapy (HT) was analyzed. RESULTS: Postoperative RT was delivered with a median dose to the prostatic fossa of 66 Gy (range 50-72) in 1.8-2 Gy/fraction. Median follow-up was 23.1 months (range 6-119). Five-year actuarial biochemical disease-free survival (bDFS) and overall survival rates were 76% and 95%, respectively. Higher bDFS was found for patients with postoperative PSA <0.02 ng/ml (p = 0.03), low preoperative risk class (p = 0.01), pN0 (p = 0.003), GS 4-6 (p = 0.0006), no androgen deprivation therapy (p = 0.02), and irrespective of surgical margin status (p = 0.10). Multivariate analysis showed that postoperative PSA and Gleason score had a significant impact on bDFS (p = 0.039 and p = 0.05, respectively). CONCLUSIONS: Postoperative RT with a dose of 66 Gy offers an acceptable toxicity and an optimal disease control after radical prostatectomy in patients with different risk features. A postoperative PSA >0.02 ng/ml could be considered as a prognostic factor and a tool to select patients at risk for progression.

May intra-operative radiotherapy have a role in the treatment of prostate cancer?

Treatment of locally advanced prostate cancer is still a challenge. Combined treatments including hormone therapy, radiotherapy, and/or surgery can achieve less than 50% of disease free survival at 10 years. Almost 50% of patients with locally advanced disease after radical prostatectomy experience local relapse and biochemical failure occurs up to 70% of cases after radiotherapy and hormone therapy. Postoperative radiotherapy has recently demonstrated to improve biochemical and clinical outcome in pT3 and/or positive margin tumors in 3 large randomized trials. Therefore, combining surgery and intra-operative radiotherapy (IORT) might be of value in this patient population. Recently, a number of studies have shown the feasibility of IORT, delivered with dedicated linear accelerators, combined or not with external beam radiotherapy with the aim of improving clinical outcome and possibly shortening overall treatment time. Preliminary clinical results look encouraging and could be the premise for future controlled prospective phase III trials.

Multidisciplinary approach in the treatment of malignant paraganglioma of the glomus vagale: a case report.

Malignant paraganglioma of the glomus vagale is a rare tumor entity originating from paraganglia or glomus cells. It typically affects middle age. It differs from benign paraganglioma because of its rapid growth and more aggressive clinical behavior. We report the case of a 40-year-old man presenting with a 5 cm lesion in the upper right cervical region detected by computed tomography (CT) and magnetic resonance imaging (MRI), which also showed enlargement of ipsilateral spinal and jugulodigastric lymph nodes with contrast enhancement. Clinical manifestations at diagnosis included a partial neurological deficit involving the right cranial nerves X, XI and XII. Tumor vascularization was assessed by digital angiography. The tumor mass was entirely removed by a right cervical approach with en-bloc resection with the regional lymph nodes. Histopathological examination showed a paraganglioma with cellular pleomorphism, necrotic microfoci, perineural infiltration and angiogenesis. Massive metastases in two of three jugulodigastric and one spinal lymph nodes on the right side were also detected. Postoperative workup included MRI, positron emission tomography (PET)/CT, meta-iodine-benzyl-guanidine (MIBG) scan, liver ultrasound and chest radiography. Subsequently, the patient underwent conformal radiotherapy with concomitant cisplatin administration. At the last clinical and radiological follow-up examination 5 years after completion of treatment, the patient was free of tumor recurrence. The integrated treatment by surgery and chemoradiation was feasible and effective in the management of this rare case of malignant paraganglioma of the glomus vagale. Multicenter studies should be done to increase the knowledge of tumor presentation and natural history and to analyze the possible treatment options.

DTI and PWI analysis of peri-enhancing tumoral brain tissue in patients treated for glioblastoma.

To analyse the role of MR diffusion-tensor imaging (DTI) and perfusion-weighted imaging (PWI) in characterising tumour boundaries in patients with glioblastoma multiforme. Seventeen patients with surgically treated WHO IV grade gliomas who were candidates for adjuvant chemo-radiotherapy were enrolled. Before (T0) and after radiation treatment (T1), they underwent DTI and PWI, and the apparent diffusion coefficient (ADC), fractional anisotropy (FA) and relative cerebral blood volume (rCBV) in the enhancing tumour, the hyperintense tissue adjacent to the enhancing tumour, and the normal-appearing white matter (NAWM) adjacent to the hyperintense areas were analysed. The enhancing tissue at T1 was retrospectively divided on the basis of whether or not it was also enhancing at T0. The controls were the corresponding contralateral areas, on which we normalized the rCBV values, calculating the rCBV ratio. In NAWM, we did not find any significant differences in FA, ADC or rCBV. In the hyperintense perilesional regions, FA was significantly lower and ADC significantly higher than in the unaffected contralateral tissue; there were no significant differences in the rCBV maps. The values of FA, ADC and rCBV in enhancing neoplastic tissue were all significantly different from those observed in the contralateral tissue. There was no significant difference in rCBV values between the areas enhancing at T0 and those not enhancing at T0 but enhancing at T1, which may indicate the neoplastic transformation of apparently normal brain tissue. DTI metrics identify ultrastructural changes in hyperintense perilesional areas, but these are not specific for neoplastic tissue. rCBV seemed to reflect an ultrastructural alteration that was not visible at T0, but became visible (as neoplastic progression) on conventional MR images at T1. These findings could help identify tissue at risk of tumour infiltration.

Hypofractionated radiotherapy after conservative surgery for breast cancer: analysis of acute and late toxicity.

BACKGROUND: A variety of hypofractionated radiotherapy schedules has been proposed after breast conserving surgery in the attempt to shorten the overall treatment time. The aim of the present study is to assess acute and late toxicity of using daily fractionation of 2.25 Gy to a total dose of 45 Gy to the whole breast in a mono-institutional series. METHODS: Eighty-five women with early breast cancer were assigned to receive 45 Gy followed by a boost to the tumour bed. Early and late toxicity were scored according to the Radiation Therapy Oncology Group criteria. For comparison, a group of 70 patients with similar characteristics and treated with conventional fractionation of 2 Gy to a total dose of 50 Gy in 25 fractions followed by a boost, was retrospectively selected. RESULTS: Overall median treatment duration was 29 days for hypofractionated radiotherapy and 37 days for conventional radiotherapy. Early reactions were observed in 72/85 (85%) patients treated with hypofractionation and in 67/70 (96%) patients treated with conventional fractionation (p = 0.01). Late toxicity was observed in 8 patients (10%) in the hypofractionation group and in 10 patients (15%) in the conventional fractionation group, respectively (p = 0.4). CONCLUSIONS: The hypofractionated schedule delivering 45 Gy in 20 fractions shortened the overall treatment time by 1 week with a reduction of skin acute toxicity and no increase of late effects compared to the conventional fractionation. Our results support the implementation of hypofractionated schedules in clinical practice.

Intraoperative radiotherapy during radical prostatectomy for locally advanced prostate cancer: technical and dosimetric aspects.

PURPOSE: To analyze the feasibility of intraoperative radiotherapy (IORT) in patients with high-risk prostate cancer and candidates for radical prostatectomy. METHODS AND MATERIALS: A total of 38 patients with locally advanced prostate cancer were enrolled. No patients had evidence of lymph node or distant metastases, probability of organ-confined disease >25%, or risk of lymph node involvement >15% according to the Memorial Sloan-Kettering Cancer Center Nomogram. The IORT was delivered after exposure of the prostate by a dedicated linear accelerator with beveled collimators using electrons of 9 to 12 MeV to a total dose of 10-12 Gy. Rectal dose was measured in vivo by radiochromic films placed on a rectal probe. Adminstration of IORT was followed by completion of radical prostatectomy and regional lymph node dissection. All cases with extracapsular extension and/or positive margins were scheduled for postoperative radiotherapy. Patients with pT3 to pT4 disease or positive nodes received adjuvant hormonal therapy. RESULTS: Mean dose detected by radiochromic films was 3.9 Gy (range, 0.4-8.9 Gy) to the anterior rectal wall. The IORT procedure lasted 31 min on average (range, 15-45 min). No major intra- or postoperative complications occurred. Minor complications were observed in 10/33 (30%) of cases. Of the 27/31 patients who completed the postoperative external beam radiotherapy, 3/27 experienced Grade 2 rectal toxicity and 1/27 experienced Grade 2 urinary toxicity. CONCLUSIONS: Use of IORT during radical prostatectomy is feasible and allows safe delivery of postoperative external beam radiotherapy to the tumor bed without relevant acute rectal toxicity.

Conformal radiotherapy of clinically localized prostate cancer: analysis of rectal and urinary toxicity and correlation with dose-volume parameters.

AIMS AND BACKGROUND: Rectal and urinary toxicities are the principal limiting factors in delivering a high target dose to patients affected by prostate cancer. The verification of such toxicity is an important step before starting a dose-escalation program. The present observational study reports on the acute and late rectal and urinary toxicity in relation with dose-volume parameters in 104 patients with localized prostate cancer treated with 3-dimensional conformal radiation therapy. METHODS AND STUDY DESIGN: One hundred and four patients with stage T1b-T3b prostate cancer were treated with three-dimensional conformal radiation therapy to a total dose of 74 Gy, 2 Gy per fraction. Rigid dose constraints were applied for rectum and bladder. Acute and late rectal and urinary toxicities were analyzed also in relation to dose-volume histograms. Biochemical relapse-free survival was defined according to the American Society of Therapeutic Radiation Oncology (ASTRO) criteria and to the RTOG-ASTRO Phoenix Consensus Conference Recommendations using the Kaplan-Meier method. RESULTS: No grade 3 toxicity was observed. Acute and late grade 2 toxicity rates were 5.8% and 9.0% for rectum and 12.5% and 2.0% for bladder, respectively. Rectal V70 influenced the occurrence of late grade 2 toxicity. A relationship between acute and late urinary toxicity was also found. After a median follow-up of 30 months (range, 20-50), the actuarial overall and biochemical relapse-free survival rates were 84% and 77%, respectively, with a significant difference between low-intermediate and high-risk patients. CONCLUSIONS: Conformal radiotherapy to the dose of 74 Gy was administered with good compliance. The incidence of acute and late toxicity was relatively low in accord with our dose constraints. Rectal V70 proved to be a reliable prognosticator of late toxicity. Overall survival and biochemical relapse-free survival rates were more favorable for low and intermediate-risk and significantly less favorable for high-risk patients.

Reproducibility of patient setup by surface image registration system in conformal radiotherapy of prostate cancer.

BACKGROUND: The reproducibility of patient setup for radiotherapy is based on various methods including external markers, X-rays with planar or computerized image acquisition, and, more recently, surface matching imaging. We analyzed the setup reproducibility of 16 patients affected by prostate cancer who underwent conformal radiotherapy with curative intent by using a surface image registration system. METHODS: We analyzed the setup reproducibility of 16 patients affected by prostate cancer candidates for conformal radiotherapy by using a surface image registration system. At the initial setup, EPID images were compared with DRRs and a reference 3D surface image was obtained by the AlignRT system (Vision RT, London, UK). Surface images were acquired prior to every subsequent setup procedure. EPID acquisition was repeated when errors > 5 mm were reported. RESULTS: The mean random and systematic errors were 1.2 +/- 2.3 mm and 0.3 +/- 3.0 mm along the X axis, 0.0 +/- 1.4 mm and 0.5 +/- 2.0 mm along the Y axis, and 2.0 +/- 1.8 mm and -0.7 +/- 2.4 mm along the Z axis respectively. The positioning error detected by AlignRT along the 3 axes X, Y, and Z exceeded the value of 5 mm in 14.1%, 2.0%, and 5.1% measurements and the value of 3 mm in 36.9%, 13.6% and 27.8% measurements, respectively. Correlation factors calculated by linear regression between the errors measured by AlignRT and EPID ranged from 0.77 to 0.92 with a mean of 0.85 and SD of 0.13. The setup measurements by surface imaging are highly reproducible and correlate with the setup errors detected by EPID. CONCLUSION: Surface image registration system appears to be a simple, fast, non-invasive, and reproducible method to analyze the set-up alignment in 3DCRT of prostate cancer patients.

FDG-PET/CT imaging for staging and radiotherapy treatment planning of head and neck carcinoma.

BACKGROUND: Positron emission tomography (PET) has a potential improvement for staging and radiation treatment planning of various tumor sites. We analyzed the use of 18F-fluorodeoxyglucose (FDG)-PET/computed tomography (CT) images for staging and target volume delineation of patients with head and neck carcinoma candidates for radiotherapy. METHODS: Twenty-two patients candidates for primary radiotherapy, who did not receive any curative surgery, underwent both CT and PET/CT simulation. Gross Tumor Volume (GTV) was contoured on CT (CT-GTV), PET (PET-GTV), and PET/CT images (PET/CT-GTV). The resulting volumes were analyzed and compared. RESULTS: Based on PET/CT, changes in TNM categories and clinical stage occurred in 5/22 cases (22%). The difference between CT-GTV and PET-GTV was not statistically significant (p = 0.2) whereas the difference between the composite volume (PET/CT-GTV) and CT-GTV was statistically significant (p < 0.0001). CONCLUSION: PET/CT fusion images could have a potential impact on both tumor staging and treatment planning.

What is the role of radiotherapy in the treatment of mucosal melanoma of the head and neck?

Mucosal melanoma of the head and neck is a rare, poor prognosis tumour with a high tendency to recur locally and regionally after surgical resection. A number of centres have used radiotherapy to sterilize positive and close margins after non-radical surgery or to treat inoperable cases. The present article discusses the literature data to analyze the possible indications for radiotherapy in terms of patient selection and treatment strategy. In the majority of the available retrospective series, postoperative radiotherapy improves the local control of mucosal melanomas, but its effect on survival has not yet been sufficiently investigated. Radiobiological studies show a high heterogeneity in behaviour of irradiated melanoma cells and the clinical implications of this will be illustrated. In the future, a better understanding of the radiosensitivity of this rare tumour and the availability of new technical modalities might allow for a more profitable incorporation of radiotherapy into a multidisciplinary strategy.

Role of radiotherapy in the treatment of cervical lymph node metastases from an unknown primary site: retrospective analysis of 113 patients.

PURPOSE: The management of patients with cervical lymph-node metastases from unknown primary site (UPS) remains a matter of discussion. This study aimed to analyze the results and prognostic factors in a series of patients treated with radiotherapy. METHODS AND MATERIALS: Data from 113 patients who presented with cervical lymph nodes metastases from UPS treated from 1980 to 2004 were reviewed. Eighty-seven patients (77.0%) were squamous cell carcinoma (SCC). Ninety-one patients were treated with curative and 22 with palliative intent. Fifty-nine of 113 patients (52.2%) received surgery followed by radiotherapy and 54 of 113 (47.8%) received radiotherapy alone. Radiotherapy was delivered to the neck and pharyngeal mucosa in 67 patients and to the ipsilateral or bilateral neck in 45 patients. Twenty-one patients (18.5%) also received chemotherapy. RESULTS: The 5-year overall survival rates were 40.7% for the entire group and 46.6% for the SCC subgroup. The occurrence of the occult primary was observed in 23 of 113 patients (20.3%), 19 (82.6%) within the head and neck region. At multivariate analysis, treatment with curative intent and extensive irradiation of bilateral neck and pharyngeal mucosa were favorable prognostic factors for the whole series, and treatment with curative intent, extensive irradiation of bilateral neck and pharyngeal mucosa, and absence of extracapsular spread were favorable prognostic factors for the SCC subgroup. CONCLUSIONS: Patients with cervical lymph node metastases from UPS have a similar prognosis to those affected by other head and neck malignancies. Curative treatment strategies including neck dissection and extensive irradiation by three-dimensional conformal radiation therapy resulted in significantly better outcomes.