Ninety-degree angled collimator: a dosimetric study related to dynamic intensity-modulated radiotherapy in patients with endometrial carcinoma.

BACKGROUND: Our purpose was to ensure that the dose constraints of the organs at risk (OARs) were not exceeded while increasing the prescription dose to the planning target volume (PTV) from 45 to 50.4 Gray (Gy) with the dynamic intensity-modulated radiotherapy (IMRT) technique. While trying for this purpose, a new dynamic IMRT technique named 90° angled collimated dynamic IMRT (A-IMRT) planning was developed by us. METHODS: This study was based on the computed tomography data sets of 20 patients with postoperatively diagnosed International Federation of Gynecology and Obstetrics stage 2 endometrial carcinoma. For each patient, conventional dynamic IMRT (C-IMRT, collimator angle of 0° at all gantry angles), A-IMRT (collimator angle of 90° at gantry angles of 110°, 180°, 215°, and 285°), and volumetric modulated arc therapy (VMAT) were planned. Planning techniques were compared with parameters used to evaluate PTV and OARs via dose-volume-histogram analysis using the paired two-tailed Wilcoxon's signed-rank test; p < 0.05 was considered indicative of statistical significance. RESULTS: All plans achieved adequate dose coverage for PTV. Although the technique with the lowest mean conformality index was A-IMRT (0.76 ± 0.05) compared to both C-IMRT (0.79 ± 0.04, p = 0.000) and VMAT (0.83 ± 0.03, p = 0.000), it protected the OARs especially the bladder (V45 = 32.84 ± 2.03 vs. 44.21 ± 6.67, p = 0.000), rectum (V30 = 56.18 ± 2.05 vs. 73.80 ± 4.75, p = 0.000) and both femoral heads (V30 for right = 12.19 ± 1.34 vs. 21.42 ± 4.03, p = 0.000 and V30 for left = 12.58 ± 1.48 vs. 21.35 ± 4.16, p = 0.000) better than C-IMRT. While the dose constraints of the bladder, rectum and bilateral femoral heads were not exceeded in any patient with A-IMRT or VMAT, they were exceeded in 19 (95%), 20 (100%) and 20 (100%) patients with C-IMRT, respectively. CONCLUSIONS: OARs are better protected when external beam radiotherapy is applied to the pelvis at a dose of 50.4 Gy by turning the collimator angle to 90° at some gantry angles with the dynamic IMRT technique in the absence of VMAT.

Does a Close Surgical Margin for Ductal Carcinoma In Situ Associated with Invasive Breast Carcinoma Affect Breast Cancer Recurrence?

Purpose: Our aim was to determine if a close surgical margin (<2 mm, but no ink on tumor) for ductal carcinoma in situ (DCIS) associated with invasive breast cancer (IBC) leads to an increased rate of ipsilateral breast tumor recurrence (IBTR).Patients and Methods: Six hundred and twenty-eight patients with T1-2 IBC who underwent breast conserving therapy (BCT) and had no ink on tumor between 2009 and 2017 in our institution were included in the study. Age, tumor size, axillary lymph node status, resection margin status of DCIS as closer than 2 mm or ≥2 mm, DCIS as present or absent, extensive intraductal component as yes or no were investigated. All patients were followed-up for IBTR.Results: The median age was 50 years (range, 29-82), and median tumor size was 25 mm (range, 5-50). Median follow-up time was 56 months (range, 12-114). Of the 628 IBC patients, 440 (70%) were found to be associated with DCIS. Of the 440 patients with DCIS, 119 (27%) had a close margin (<2 mm) and 321 (73%) had a margin ≥2 mm for DCIS. Among 440 IBC patients associated with DCIS, there were three local recurrences. One developed in a patient who had a close surgical margin for DCIS, and in the other two patients, surgical margins were ≥2 mm.Conclusions: No ink on tumor is an adequate margin for IBC associated with DCIS in patients who undergo BCT and it is not associated with increased IBTR.

Radical radiotherapy in patients with cervix uteri carcinoma: experience of Ondokuz Mayis University.

BACKGROUND: Radical radiotherapy is the standard treatment for patients with locally advanced cervix uteri carcinoma (FIGO stage IB2-IVA). Worldwide, incidence and mortality rates vary among regions because of differences in lifestyles and treatment standards. Herein, we evaluated the outcomes of radical radiotherapy in patients with locally advanced cervix uteri carcinoma from the middle Black Sea region of Turkey. METHODS: We retrospectively reviewed the records of 64 consecutive patients with locally advanced cervix uteri carcinoma who were treated from January 2013 to 2016 in our radiation oncology department. All patients staging and radiotherapy planning were performed with modern imaging techniques including magnetic resonance imaging and positron-emission-tomography/computed tomography before radical radiotherapy. Thereafter, all of them were treated with external beam radiotherapy and concurrent cis-platinum-based chemotherapy followed by three-dimensional intra-cavitary high-dose-rate brachytherapy. RESULTS: The median age at diagnosis was 54.5 years. The median follow-up period was 21 months. Acute grade 3 toxicity was detected in 3.1% of patients. Late toxicity was not detected in any patient. The 1- and 3-year progression-free survival rates were 83.6 and 67.5%, respectively. The 1- and 3-year overall survival rates were 95.7 and 76.9%, respectively. The most important prognostic factor was the FIGO stage. Distant metastasis was the most common cause of death in patients with locally advanced cervix uteri carcinoma despite radical radiotherapy. CONCLUSIONS: In patients with locally-advanced cervix uteri carcinoma from the middle Black Sea region of our developing country, acceptable toxicity and survival rates are achieved similar to the recent literature from developed countries with using of modern staging, planning and radical radiotherapy techniques. However, recurrence was mostly in the form of distant metastases and further investigations on systemic therapies are required.

Management of the Axilla in T1-2 Breast Cancer Patients with Macrometastatic Sentinel Node Involvement Who Underwent Breast-Conserving Therapy.

PURPOSE: The aims of our study were to determine the incidence of axillary recurrence and arm morbidity in T1-2 invasive breast cancer patients with macrometastases on the sentinel lymph node (SLN) who underwent breast-conserving therapy (BCT), with or without axillary lymph node dissection (ALND). METHODS: One hundred and nine T1-2 invasive breast cancer patients with macrometastases on the SLN who underwent BCT in our institution were included in the study. Patients with 1-2 positive SLN and without extra nodal extension (ENE) on the SLN did not undergo ALND (SLN-only group) and patients with ENE or patients who had >2 metastatic nodes underwent level I, II ALND (ALND group). The SLN-only group received radiotherapy to three axillary levels, the supraclavicular fossa, and ± mammaria interna. ALND group received radiotherapy to axillary level III, the supraclavicular fossa, and ± mammaria interna. The incidence of axillary recurrence and arm morbidity were investigated. RESULTS: Of the 109 patients, 18 patients with >2 metastatic SLNs and 10 with ENE on the SLN underwent ALND and 81 patients underwent SLN only. Median follow-up time was 37 months (3-77). There was no axillary recurrence in SLN-only group. However, in the ALND group 1 patient had developed axillary metastasis. There were 2 objective lymphoedema and 3 arm-shoulder restriction cases in the SLN-only group, and 2 and 3 in the ALND group, respectively. CONCLUSIONS: Axillary dissection could safely be omitted in patients with 1-2 macrometastatic SLN and without ENE who undergo BCT and axillary radiotherapy.

Dosimetric Comparison of Three Different Radiotherapy Techniques in Antrum-Located Stomach Cancer

Background: The current optimal radiotherapy (RT) planning technique for stomach cancer is controversial. The design of RT for stomach cancer is difficult and differs according to tumor localization. Dosimetric and clinical studies have been performed in patients with different tumor localizations. This may be the main source of inconsistencies in study results. For this reason, we attempted to find the optimal RT technique for patients with stomach cancer in similar locations. Methods: This study was based on the computed tomography datasets of 20 patients with antrum-located stomach cancer. For each patient, treatments were designed using physical wedge-based conformal RT (WB-CRT), field-in-field intensity-modulated RT (FIF-IMRT), and dynamic intensity-modulated RT (IMRT). The techniques were compared in terms of expected target volume coverage and the dose to organs at risk (OAR) using a dose-volume histogram analysis. Results: FIF-IMRT was the most homogenous technique, with a better homogeneity index than WBCRT (p<0.001) or IMRT (p<0.001). However, IMRT had a better conformity index than WBCRT (p<0.001) or FIF-IMRT (p<0.001). Additionally, all OAR, including the kidneys, liver, and spinal cord, were better protected with IMRT than with WBCRT (p=0.023 to <0.001) or FIF-IMRT (p=0.028 to <0.001). Conclusions: In comparison to FIF-IMRT and WBCRT, IMRT appears to be the most appropriate technique for antrum-located stomach cancer. To establish whether IMRT is superior overall will require clinical studies, taking into account differences in both tumor localization (cardia, body, and antrum) and organ movement in patients with stomach cancer.

Male Breast Cancer: 20 Years Experience of a Tertiary Hospital from the Middle Black Sea Region of Turkey.

BACKGROUND: Male breast cancer is a rare neoplasm, and its treatments are based on those of female breast cancer. This study aimed to analyze 20 years of male breast cancer clinical characteristics and treatment results from the Middle Black Sea Region of Turkey. MATERIALS AND METHODS: A retrospective analysis of 16 male breast cancer patients treated in our tertiary hospital between 1994 and 2014 was performed. Epidemiologic data, tumor characteristics, and treatments were recorded and compared with 466 female breast cancer ((premenopausal; n=230)+(postmenopausal n=236)) patients. The 5-year disease-free and overall survival rates were calculated. RESULTS: Male breast cancer constituted 0.1% of all malignant neoplasms in both sexes, 0.2% of all malignant neoplasms in males, and 0.7% of all breast cancers. The mean patient age in this study was 59.8±9.5 (39-74) years. The mean time between first symptom and diagnosis was 32.4±5.3 (3-60) months. Histology revealed infiltrative ductal carcinoma in 81.3% of patients. The most common detected molecular subtype was luminal A, in 12 (75%) patients. Estrogen receptor rate (93.8%) in male breast cancer patients was significantly higher than that in female breast cancer (70.8% in all females, p=0.003; 68.2% in postmenopausal females, p=0.002) patients. Most of the tumors (56.3%) were grade 2. Tumor stage was T4 in 50% of males. The majority (56.3%) of the patients were stage III at diagnosis. Surgery, chemotherapy, radiotherapy and endocrine-therapy were applied to 62.5%, 62.5%, 81.2% and 73.3%, respectively. Loco-regional failure did not occur in any of the cases. All recurrences were metastastic. The 5-year disease-free and overall survival rates in male breast cancer patients were 58% and 68%, respectively. CONCLUSIONS: Tumors found in male breast cancer patients were similar in size to tumors found in females, but they advanced to T4 stage more rapidly because of the lack of breast parenchymal tissues. The rate of estrogen receptor expression tended to be higher in male breast cancer patients than in female breast cancer patients. Metastasis is the most important problem in initially non-metastatic male breast cancer patients.

Prognostic significance of concomitant radiotherapy in newly diagnosed glioblastoma multiforme: a multivariate analysis of 116 patients.

BACKGROUND AND OBJECTIVES: Currently, radiotherapy with concomitant and adjuvant temozolomide has become the standard treatment for glioblastoma. The purpose of this study was to report our experience with radiation plus concomitant temozolomide in 116 patients with glioblastoma multiforme (GBM) and examine the value of different prognostic factors. DESIGN AND SETTING: Retrospective analysis of 116 patients with newly diagnosed GBM, who were treated at our department between January 1994 and March 2009. PATIENTS AND METHODS: Age, gender, Karnofsky performance scale (KPS) score, a preoperative history of seizures, extent of surgery, total radiotherapy dose, and use of concomitant and adjuvant temozolomide were evaluated in uni- and multivariate analyses. Survival was determined using the Kaplan-Meier method, and differences were compared using the log rank test. Cox regression analysis was conducted to identify the independent prognostic factors. RESULTS: The median overall survival time was 9 months, and the 1- and 2-year survival rates were 41.9% and 9.6%, respectively. The univariate analysis revealed that age, KPS score, presence of seizures, radiation doses, and use of concomitant and adjuvant temozolomide were significant prognostic factors. The multivariate analysis confirmed that the age, KPS score, presence of seizures, radiation doses, and use of concomitant and adjuvant temozolomide were independent, significant prognostic factors. CONCLUSIONS: The results of our analyses demonstrate that radiation with concomitant and adjuvant temozolomide yields encouraging outcomes in patients with GBM, validating the results published in research papers. In addition, age, KPS score, presence of seizures, and radiation doses were identified as prognostic factors.

Religious and spiritual practices among patients with cancer.

The aim of this study was to investigate the frequency with which cancer patients engage in religious and spiritual practices, the methods used, the reasons for such a search, and the levels of depression and hopelessness in patients who seek spiritual assistance. One hundred and ten radiation oncology patients, who gave voluntary informed consent were included in this study. Questionnaires about religious and spiritual practices were administered, along with the Beck Depression and Beck Hopelessness scales. Twenty percent of the patients preferred spiritual practices. Female gender, lower education levels, and higher depression and hopelessness scores were associated with this preference. The frequency of depression was 18.2%, and the frequency of hopelessness was 20.9%. A significant number of cancer patients engaged in religious and spiritual practices. We recommend that practitioners offer their patients brief but sufficient information about religious and spiritual support and determine their patients' depression and hopelessness levels.

Dosimetric comparison of three different external beam whole breast irradiation techniques.

INTRODUCTION: The purpose of this study was to compare the dosimetries of three different external beam whole breast radiotherapy techniques: two-dimensional RT (2D-RT), three-dimensional conformal RT (3D-CRT), and field-in-field intensity-modulated RT (FiF-IMRT). In addition, we aimed to evaluate the patients who needed more or less complex treatment modalities. METHODS: Thirty patients were included in the study. All the patients had early-stage breast cancer and conserving surgery had been performed. Plans that employed the three techniques were generated for each patient. Dosimetric comparisons were conducted, and correlations with patient characteristics and dosimetric outcomes were analyzed. RESULTS: The 2D-RT technique was found to be suboptimal for treating the intact breast. Its dose homogeneity index (DHI) was 20.68. The authors were unable to define a patient characteristic in which 2D-RT dosimetry would perform better. FiF-IMRT was found to be the superior technique with a better homogeneity in the breast (DHI=9.35 and P=0.000002 when compared to 3D-CRT). When compared according to patient characteristics, again the FiF-IMRT planning is the best for all subgroups, but the DHI gets worse by increased breast volume and separation. While FiF-IMRT achieves better DHI in the breast, it has little effect on heart and lung doses. But the normal tissues' volume (cc) that gets the 100% of the prescribed dose (V100) was lowered because of the treatment without wedges and scatter and with less monitor unit. CONCLUSIONS: 2D-RT could not be performed safely on the intact breast in any of the subgroups. FiF-IMRT is a superior technique for breast dosimetry, and normal tissue. For patients with large breast size or separation, further intensive techniques must be investigated.

Malignant lymphoma associated with Behçet's disease: A report of 2 cases.

Herein we report 2 cases of malignant lymphoma associated with Behçet's disease. Case 1, a 53-yearold man, was diagnosed as Behçet's disease at the age of 26 years, and was treated with cyclophosphamide and prednisolone. At 45 years of age, bilateral enlarged lymph nodes were observed in the patient's neck. Evaluation of a lymph node biopsy specimen showed Hodgkin's disease and chemotherapy was administered. Due to disease recurrence 7 years later, chemotherapy and radiotherapy were administered. Case 2, a 67-year-old male, was diagnosed as Behçet's disease at age 44 years and began colchicine treatment. At 60 years of age a mass in his left tonsillar fossa was noted. Evaluation of a left tonsil biopsy specimen showed malignant lymphoma. Radiotherapy and chemotherapy were subsequently administered. At the time this report was written both patients were disease-free. Malignant lymphoma associated with Behçet's disease is rare-only 17 cases have been published. In addition to the presented cases, the literature regarding malignant lymphoma associated with Behçet's disease is reviewed.

Effects of preoperative conventional and hyperfractionated radiotherapy on the healing of rat colonic anastomoses.

BACKGROUND: One problem associated with end to end anastomoses after preoperative radiotherapy is leakage. The strength of the anastomoses is very important. Fractionation schedules are widely under investigation to achieve higher doses with less toxicity and high curative potential. The aim of this study was to compare preoperative conventional and hyperfractionated radiotherapy effects on anastomoses. MATERIALS AND METHODS: Sixty Wistar albino rats were divided into 3 groups: control, conventional radiotherapy (2 Gy/fraction, total 44 Gy), and hyperfractionated radiotherapy (1.2 Gy/fraction, total 52.8 Gy). 5 weeks after completion of the treatment, the rats underwent end to end anastomoses to the rectum. Following the surgery, the bursting pressure of the anastomoses and the hydroxyproline levels were measured on days 3 and 7. RESULTS: The bursting pressure was lower in both radiotherapy groups on the 3rd day. On day 7, the results of the conventional radiotherapy arm matched those of the control group, but the results of the hyperfractionated group did not (p = 0.001). On day 3, hydroxyproline levels were significantly lower in both radiotherapy groups than in the control group (p = 0.001). On the 7th day, the statistical difference disappeared within the radiotherapy groups. However, the hydroxyproline levels of the 2 radiotherapy arms were still lower than those of the control group (p = 0.001). CONCLUSION: Hyperfractionation strongly inhibits collagen synthesis and is associated with protracted healing.

Intrathoracic malignant peripheral nerve sheath tumor with angiosarcoma in a child with NF1.

Malignant peripheral nerve sheath tumors (MPNSTs) are uncommon in children and adolescents but occur more frequently in NF1 patients. Angiosarcomatous differentiation in MPNSTs is a rare entity with poor prognosis. We report on a 13-year-old boy with intrathoracic angiosarcoma arising in MPNST associated with NF1.

The sequencing of radiation therapy and chemotherapy after mastectomy in premenopausal women with breast cancer.

OBJECTIVE: The purpose of this study was to evaluate the prognostic importance of the sequencing of radiation therapy and chemotherapy after mastectomy in high-risk premenopausal women with breast cancer in addition to other known prognostic factors in the literature. METHODS: In this retrospective study, 176 premenopausal women with breast cancer were evaluated. The median age at referral was 39 years (range, 28-59 years); 106 patients had stage II and 70 had stage III disease. All were subjected to mastectomy. The median number of lymph nodes removed was 19. The influence of age, histological grade, number of nodes removed, number of positive nodes, tumor size, estrogen receptor status, lymphovascular invasion and sequencing of radiotherapy and chemotherapy on 5-year locoregional disease-free survival, 5-year systemic disease-free survival, 5-year disease-free survival and 5-year cancer-specific survival were studied. RESULTS: The 5-year locoregional disease-free survival was 94% for the entire patient population. Because of the small number of locoregional recurrences, none of the evaluated factors was prognostically significant for locoregional recurrence. The 5-year systemic disease-free, disease-free and cancer-specific survival rates were 72, 70 and 77%, respectively. On multivariate analysis of host, tumor and treatment-related factors, the number of positive nodes [RR 1.9 (95% CI: 1.36-2.63), RR 2 (1.46-2.84 ) and RR 1.8 (1.3-2.71), respectively], histopathological grade [RR 1.8 (95% CI: 1.24-2.65), RR 1.9 (1.34-2.88), RR 2.5 (1.65-4.07), respectively], estrogen receptor status [RR 3.5 (95% CI: 1.5-8.6), RR 3.9 (1.64-9.41), RR 2.5 (1.05-6.24), respectively] and the sequencing of radiotherapy and chemotherapy [RR 1.6 (95% CI: 1.17-2.39), RR 1.7 (1.25-2.54), RR 1.6 (1.14-2.43), respectively] were all significant independent predictors of outcome. CONCLUSIONS: Our results show that in addition to traditional prognostic factors, the sequencing of radiation therapy and chemotherapy also predict for increased risk of any type of recurrence or further tumor death.