Comparing log file to measurement-based patient-specific quality assurance.

Recent technological advances have allowed the possibility of performing patient-specific quality assurance (QA) without time-intensive measurements. The objectives of this study are to: (1) compare how well the log file-based Mobius QA system agrees with measurement-based QA methods (ArcCHECK and portal dosimetry, PD) in passing and failing plans, and; (2) evaluate their error sensitivities. To these ends, ten phantom plans and 100 patient plans were measured with ArcCHECK and PD on VitalBeam, while log files were sent to Mobius for dose recalculation. Gamma evaluation was performed using criteria 3%/2 mm, per TG218 recommendations, and non-inferiority of the Mobius recalculation was determined with statistical testing. Ten random plans were edited to include systematic errors, then subjected to QA. Receiver operating characteristic curves were constructed to compare error sensitivities across the QA systems, and clinical significance of the errors was determined by recalculating dose to patients. We found no significant difference between Mobius, ArcCHECK, and PD in passing plans at the TG218 action limit. Mobius showed good sensitivity to collimator and gantry errors but not MLC bank shift errors, but could flag discrepancies in treatment delivery. Systematic errors were clinically significant only at large magnitudes; such unacceptable plans did not pass QA checks at the TG218 tolerance limit. Our results show that Mobius is not inferior to existing measurement-based QA systems, and can supplement existing QA practice by detecting real-time delivery discrepancies. However, it is still important to maintain rigorous routine machine QA to ensure reliability of machine log files.

Palliative radiotherapy for bladder cancer: a systematic review and meta-analysis.

BACKGROUND/PURPOSE: The optimal dose fractionation for palliative radiotherapy (RT) in patients with symptomatic advanced bladder cancer is unclear. This study aimed to determine if a higher dose of RT was associated with improved symptoms response rates. METHODS: We searched PubMed, Central and Embase for eligible studies published from 1990 to 2019. The primary outcomes were symptoms response rates for hematuria, dysuria and frequency. Secondary outcomes included treatment-related adverse events and quality of life. RESULTS: We found one randomized, four prospective and eight retrospective non-comparative observational studies including 1320 patients who received palliative bladder radiotherapy for symptom relief. The dose fractionation schedules varied across studies ranging from 8 Gy single fraction to 60 Gy in 2 to 8 Gy per fraction. The pooled response rates for hematuria, dyuria and frequency symptoms were 74%, 58% and 71% respectively. A higher dose of RT was not associated with improved response rates of hematuria and frequency. However, a higher dose of RT was associated with a longer duration of hematuria response and reduced response of dysuria. Grade 3 gastrointestinal and genitourinary toxicity occurred in up to 26% of patients. Health-related quality of life (HRQOL) outcomes were reported in one study. CONCLUSION: This systematic review demonstrates that a higher dose of bladder RT was not associated with improved response rates of hematuria and frequency symptoms but was associated with reduced response of dysuria. Higher doses of bladder RT was associated with more durable hematuria response. Prospective studies to determine the effects of palliative bladder radiotherapy on HRQOL outcomes are warranted.

Clinical Outcomes of Dose-escalated Radiotherapy for Localised Prostate Cancer: A Single-institution Experience.

BACKGROUND/AIM: To report the outcomes of patients with prostate cancer treated with dose-escalated radiotherapy over a 15-year period at our Institution. PATIENTS AND METHODS: Patients with biopsy-proven cT1-4N0M0 disease who received radical external beam radiotherapy (EBRT) were reviewed. The endpoints were 5-year overall survival (OS), freedom from biochemical failure (FFBF) and late treatment toxicities. RESULTS: A total of 236 patients were eligible. Median follow-up was 70 months. Low-, intermediate- and high-risk disease was found in 9%; 29% and 62% of patients, respectively. The median radiation dose was 73.8 Gy. Overall 42% of patients had dose escalation to >74 Gy. Five-year OS and FFBF were 95.2%/81.6%/75.4% and 95.0%/98.0%/82.0% for low-/intermediate-/high-risk patients, respectively. Dose escalation to >74 Gy did not improve FFBF (hazard ratio=0.97, 95% confidence intervaI=0.43-2.19, p=0.93) and was associated with a 4.3-fold increase in the odds of grade 3 or more rectal bleeding (p<0.01). CONCLUSION: Dose escalation to >74 Gy did not improve OS or FFBF but was associated with a higher rate of grade 3 or more rectal haemorrhage.

Acute testicular ischaemia following aortoiliac stenting for aortoiliac occlusive disease.

Endovascular treatment is increasingly employed as the treatment for symptomatic aortoiliac occlusive disease. One of the possible complications of aortoiliac stenting is the development of emboli. We present a case of a 60-year-old patient presenting with right scrotal pain immediately following aortoiliac stenting for right common iliac, proximal external iliac and proximal internal iliac arteries thrombosis. He was found to have testicular ischaemia with absent blood flow on duplex ultrasonography. The patient was managed expectantly and reduced blood flow spontaneously returned to the testis over the next few weeks.

Efficacy of Palliative Bladder Radiotherapy for Hematuria in Advanced Bladder Cancer Using Contemporary Radiotherapy Techniques.

BACKGROUND/AIM: The aim of this study was to review the outcomes of palliative radiotherapy (RT) for hematuria treated with modern RT techniques. PATIENTS AND METHODS: This was a retrospective cohort study. The primary endpoint was symptom response rate. Secondary endpoints included symptom recurrence rate, overall survival and treatment-related toxicity. RESULTS: Median age was 82 years (range=36-98 years). Median biologically effective dose (BED) was 36 Gy. Sixty-seven percent of patients (39/58) responded to RT. The median survival duration was 5.6 months (range=0.02-47.6 months). One third (13/39) of responders had recurrence of hematuria. Competing Risk regression with death as the competing risk showed that patients treated with low BED regimen (<36 Gy) had 5.76 times the hazard of recurrence compared to high BED regimen (>36 Gy) (p=0.01). One patient (2%) developed grade 3 nausea and vomiting which required admission for intravenous hydration. CONCLUSION: BED regimens should be recommended as they are associated with a significantly lower rate of recurrent hematuria.

Radical radiotherapy in older patients with muscle invasive bladder cancer.

BACKGROUND: Muscle invasive bladder cancer (MIBC) is prevalent in the older patients, who are a vulnerable population with multiple co-morbidities and at increased risk of complications. Radical cystectomy is often not suitable, hence radical radiotherapy (RT) is an alternative option. We reviewed the outcomes of older patients treated with RT with or without concurrent chemotherapy (CRT) at our institution. METHODS: We retrospectively reviewed patients aged 65 years and above treated with radical RT for MIBC at our institution between March 2002 to January 2017. Data was collected from institutional medical records and RT databases. The primary outcome was 2- and 5-year overall survival (OS), recurrence free survival (RFS), and toxicities. Univariate cox proportional hazard regression models were performed to identify independent factors with significant impact on survival. RESULTS: We identified 45 patients (34 males, 11 females) with a median age of 77 years (range 65-95). All patients received maximal transurethral resection of the bladder tumour prior to RT. Median dose of total RT was 64 Gy (range 50-69.8 Gy). Twenty one patients (47%) received CRT. Planned treatment was completed in 42 (93.3%) patients. Median follow-up was 31 months (range 1-147 months). The 2- and 5-year OS was 64% and 44%, respectively. The 2- and 5-year RFS was 68% and 49%, respectively. Median RFS was 34 months (range 8-121 months). Median OS was 56 months (range 18-100 months). Univariate analysis showed that performance status (0-1 vs. 2-3; HR 2.7, 95% CI 1.07-6.8, p = 0.035) and International Society of Geriatric Oncology (SIOG) group (≤2 vs. >2; HR 3.23, 95% CI 1.12-8.64, p = 0.019) were significantly associated with increased hazard for death. One patient (2%) had grade 3 cystitis. CONCLUSION: Radical RT is well tolerated in older patients with MIBC. We report outcomes similar to published data. Older patients should be considered for curative treatment despite their age. However, careful selection is warranted as frail patients (PS ≥2; SIOG >2) may benefit less.

Spontaneous regression of locally advanced nonsmall cell lung cancer: A case report.

RATIONALE: Spontaneous regression of non-small cell lung cancer is exceptionally rare. PATIENT CONCERNS: Treatment-related toxicity. DIAGNOSES: We report a case of a patient diagnosed with locally advanced non-small cell lung cancer. INTERVENTIONS: The patient declined potentially curative treatment, and did not receive any anti-cancer treatment. OUTCOMES: He has survived more than two years since his initial diagnosis, maintaining his good performance status. Serial imaging with computed tomography scans showed tumour regression and near-complete resolution of his disease. LESSONS: Spontaneous regression of non-small cell lung cancer, by virtue of its scarcity, has not been well-studied and is poorly understood. Further studies are required, in order to clarify the mechanisms by which spontaneous regression occurs, and possibly identify new targets for cancer treatment.

Fractionated External-beam Radiation Therapy For Incompletely Resected Intracranial Extra-axial Cavernous Haemangioma: A Case Report.

We report a case of a cavernous haemangioma arising from the left trigeminal nerve causing mass effect, midline shift and hydrocephalus. Surgical resection was attempted after immediate insertion of bilateral extra-ventricular drains, but complete resection was not achieved, with residual disease at the superior orbital fissure and cavernous sinus. Stereotactic radiosurgery was deemed unsuitable in view of proximity to the left optic nerve and optic chiasm, and the patient was hence treated with fractionated external-beam radiation therapy (RT) to a total dose of 40 Gy in 20 daily fractions over four weeks. The patient tolerated RT well, with no significant toxicity. MRI done eighteen months after completion of RT showed the continued decrease in the size of the lesion with reduced mass effect on the optic chiasm.

Long-term remission after low dose radiotherapy in patient with extensive squamous cell carcinoma of the hand: A case report.

RATIONALE FOR CASE REPORT: Cutaneous Squamous Cell Carcinoma (cSCC) of the hand is uncommon and tends to have poorer outcomes. Surgical resection with wide margins around the tumor is recommended as the treatment of choice, and radiotherapy is considered second-line treatment. Nodal evaluation involves dissection necessitating some morbidity. The role of less invasive modalities of nodal evaluation is not well established. CASE PRESENTATION: We report a case of locally advanced case of hand cSCC. Positron emission tomography-computed tomography (PET-CT) showed disease involving full thickness of the hand as well as the ipsilateral axillary node. To achieve adequate surgical margins would have necessitated amputation at the wrist, which the patient did not consent to. Instead, he was given a two-and-a-half week course radiotherapy to the hand without axillary radiation. With the radiotherapy treatment, he managed to achieve complete remission of disease while retaining full function of the hand, which was maintained at 22 months post-treatment. MAIN LESSONS: CSCC of the hand is uncommon and challenging to treat. Radiotherapy is a highly effective treatment modality which is able to achieve functional preservation. Care should be taken when evaluating nodal status using PET-CT.