Assessment of Lymphoma and Other Hematologic Malignancies Training Needs Among Radiation Oncology Residents: a Brief Report.

The role of radiation therapy (RT) varies across hematologic malignancies (HM). Radiation oncology (RO) resident comfort with specific aspects of HM patient management is unknown. The International Lymphoma RO Group (ILROG) assessed resident HM training opportunities and interest in an HM away elective. RO residents (PGY2-5) in the Association of Residents in RO (ARRO) database (n = 572) were emailed an anonymous, web-based survey in January 2019 including binary, Likert-type scale (1 = not at all, 5 = extremely, reported as median [interquartile range]), and multiple-choice questions. Of 134 resident respondents (23%), 86 (64%) were PGY4/5 residents and 36 (27%) were in larger programs (≥ 13 residents). Residents reported having specialized HM faculty (112, 84%) and a dedicated HM rotation (95, 71%). Residents reported "moderate" preparedness to advocate for RT in multidisciplinary conferences (3 [2-3]); make HM-related clinical decisions (3 [2-4]); and critique treatment planning (3 [2-4]). They reported feeling "moderately" to "quite" prepared to contour HM cases (3.5 [3-4]) and "quite" prepared to utilize the PET-CT five-point scale (4 [3-5]). Overall, residents reported feeling "moderately" prepared to treat HM patients (3 [2-3]); 24 residents (23%) felt "quite" or "extremely" prepared. Sixty-six residents (49%) were potentially interested in an HM away elective, commonly to increase comfort with treating HM patients (65%). Therefore, HM training is an important component of RO residency, yet a minority of surveyed trainees felt quite or extremely well prepared to treat HM patients. Programs should explore alternative and additional educational opportunities to increase resident comfort with treating HM patients.

Extensive stage small cell lung cancer (ES-SCLC) and palliative care disparities: a national cancer database study.

OBJECTIVES: Literature on disparities in palliative care receipt among extensive stage small cell lung cancer (ES-SCLC) patients is scarce. The purpose of this study was to examine disparities in palliative care receipt among ES-SCLC patients. METHODS: Patients aged 40 years or older diagnosed with ES-SCLC between 2004 and 2015 in the National Cancer DataBase (NCDB) were eligible. Two palliative care variables were created: (1) no receipt of any palliative care and (2) no receipt of pain management-palliative care. The latter variable indicated pain management receipt among those who received any palliative care. Log binomial regression models were constructed to calculate risk ratios by covariates. Unadjusted and mutually adjusted models were created for both variables. RESULTS: Among 83 175 patients, the risk of no palliative care receipt was higher among Blacks compared with Whites in unadjusted and adjusted models (both model HRs 1.02; 95% CIs 1.00 to 1.03, p<0.05). Patients older than 59 years were at a higher risk of not receiving palliative care than younger patients (HR 1.02; 95% CI 1.01 to 1.03 for 59-66, HR 1.04; 95% CI 1.03 to 1.05 for 66-74, HR 1.06; 95% CI 1.05 to 1.08 for >74). Among 19 931 patients, the risk of no pain management-palliative care was higher among black patients on unadjusted analysis (HR 1.02; 95% CI 1.00 to 1.03, p<0.05). Patients between 66 and 74 years were at a higher risk of not receiving pain management-palliative care than patients younger than 59 years (HR 1.02; 95% CI 1.00 to 1.03, p<0.05). CONCLUSIONS: Significant disparities exist in palliative care receipt among ES-SCLC patients.

Systematic review for deep inspiration breath hold in proton therapy for mediastinal lymphoma: A PTCOG Lymphoma Subcommittee report and recommendations.

PURPOSE: To systematically review all dosimetric studies investigating the impact of deep inspiration breath hold (DIBH) compared with free breathing (FB) in mediastinal lymphoma patients treated with proton therapy as compared to IMRT (intensity-modulated radiation therapy)-DIBH. MATERIALS AND METHODS: We conducted a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline using the PubMed database to identify studies of mediastinal lymphoma patients with dosimetric comparisons of proton-FB and/or proton-DIBH with IMRT-DIBH. Parameters included mean heart (MHD), lung (MLD), and breast (MBD) doses, among other parameters. Case reports were excluded. Absolute differences in mean doses > 1 Gy between comparators were considered to be clinically meaningful. RESULTS: As of April 2021, eight studies fit these criteria (n = 8), with the following comparisons: proton-FB vs IMRT-DIBH (n = 5), proton-DIBH vs proton-FB (n = 5), and proton-DIBH vs IMRT-DIBH (n = 8). When comparing proton-FB with IMRT-DIBH in 5 studies, MHD was reduced with proton-FB in 2 studies, was similar (<1 Gy difference) in 2 studies, and increased in 1 study. On the other hand, MLD and MBD were reduced with proton-FB in 3 and 4 studies, respectively. When comparing proton-DIBH with proton-FB, MHD and MLD were reduced with proton DIBH in 4 and 3 studies, respectively, while MBD remained similar. Compared with IMRT-DIBH in 8 studies, proton-DIBH reduced the MHD in 7 studies and was similar in 1 study. Furthermore, MLD and MBD were reduced with proton-DIBH in 8 and 6 studies respectively. Integral dose was similar between proton-FB and proton-DIBH, and both were substantially lower than IMRT-DIBH. CONCLUSION: Accounting for heart, lung, breast, and integral dose, proton therapy (FB or DIBH) was superior to IMRT-DIBH. Proton-DIBH can lower dose to the lungs and heart even further compared with proton-FB, depending on disease location in the mediastinum, and organ-sparing and target coverage priorities.

Patterns of Initial Relapse from a Phase 3 Study of Response-Based Therapy for High-Risk Hodgkin Lymphoma (AHOD0831): A Report from the Children's Oncology Group.

PURPOSE: The Children's Oncology Group protocol AHOD0831, for pediatric patients with high-risk classical Hodgkin lymphoma (cHL), used response-adapted radiation fields, rather than larger involved-field radiation therapy (IFRT) that were historically used. This retrospective analysis of patterns of relapse among patients enrolled in the study was conducted to study the potential effect of a reduction in RT exposure. METHODS AND MATERIALS: From December 2009 to January 2012, 164 eligible patients under 22 years old with stage IIIB (43%) and stage IVB (57%) enrolled on AHOD0831. All patients received 4 cycles of doxorubicin, bleomycin, vincristine, etoposide, prednisone, and cyclophosphamide (ABVE-PC). Those patients with a slow early response (SER) after the first 2 ABVE-PC courses were nonrandomly assigned to 2 intensification cycles with ifosfamide/vinorelbine before the final 2 ABVE-PC cycles. Response-adapted RT (21 Gy) was prescribed to initial areas of bulky disease and SER sites. Rapid early response (RER) sites without bulk were not targeted. Imaging studies at the time of progression or relapse were reviewed centrally for this retrospective analysis. Relapses were characterized with respect to site (initial, new, or both; and initial bulk or initial nonbulk), initial chemotherapy response, and radiation field (in-field, out-of-field, or both). RESULTS: Of the entire cohort, 140 patients were evaluable for the patterns of failure analyses. To investigate the pattern of failure, this analysis focuses on 23 patients who followed protocol treatment and suffered relapses at a median 1.05 years with 7.97-year median follow-up time. These 23 patients (11 RER and 12 SER) experienced a relapse in 105 total sites (median, 4; range, 1-11). Of the 105 relapsed sites, 67 sites (64%) occurred within an initial site of involvement, with 12 of these 67 sites (18%) at an initial site of bulky disease and 63 of these 67 relapses (94%) occurring in sites that were not fluorodeoxyglucose (FDG)-avid after 2 cycles of ABVE-PC (PET2-negative). Of the 105 relapsed sites, 34 sites (32%) occurred in a new site of disease (that would not have been covered by RT); and, overall, only 4 of 140 patients (2.8%) (occurring in 3 RER and 1 SER) experienced isolated out-of-field relapses that would have been covered by historical IFRT. CONCLUSIONS: For a cohort of high-risk patients with cHL patients, most failures occurred in nonbulky, initially involved sites, largely due to response-based consolidation RT delivered to patients with bulky disease. In this analysis, we discovered low rates of failures outside of these modern risk-adapted radiation treatment volumes. Also, FDG uptake on PET2 did not identify most relapse sites.

Acute lymphoblastic leukemia (ALL) in adults: disparities in treatment intervention based on access to treatment facility.

Adult acute lymphoblastic leukemia (ALL) is associated with poor outcomes. We evaluated differences by facility type in the parameters of 6766 adult ALL patients ≥ 40 years of age diagnosed from 2004 to 2015 in the National Cancer DataBase (NCDB) and survival outcomes using two-sample t-tests or chi-square tests and Cox proportional hazards models. Those treated in academic facilities were younger (mean 58.5 versus 61.7 years, p < 0.001), Black (8.1% versus 5.6%, p < 0.001), had private insurance (50.9% versus 44.0%, p < 0.001), and more likely to receive chemotherapy (93.2% versus 81.4%, p < 0.001), any radiotherapy (14.9% versus 7.3%, p < 0.001), stem cell transplant (9.4% versus 2.5%, p < 0.001), or total body irradiation (TBI) (11.3% versus 4.3%, p < 0.001). Patients treated at an academic facility had a higher hazard of death (p<.05) while those that received any chemotherapy or TBI or CNS radiation had a lower risk of death (all p < 0.05). These parameters should be evaluated in future studies.

Consensus Statement on Proton Therapy for Prostate Cancer.

Proton therapy is a promising but controversial treatment in the management of prostate cancer. Despite its dosimetric advantages when compared with photon radiation therapy, its increased cost to patients and insurers has raised questions regarding its value. Multiple prospective and retrospective studies have been published documenting the efficacy and safety of proton therapy for patients with localized prostate cancer and for patients requiring adjuvant or salvage pelvic radiation after surgery. The Particle Therapy Co-Operative Group (PTCOG) Genitourinary Subcommittee intends to address current proton therapy indications, advantages, disadvantages, and cost effectiveness. We will also discuss the current landscape of clinical trials. This consensus report can be used to guide clinical practice and research directions.

Observation with or without late radiotherapy is equivalent to early radiotherapy in high-risk prostate cancer after radical prostatectomy: A SEER-Medicare analysis on trends, survival outcomes, and complications.

BACKGROUND: We aimed to illustrate national trends of post-radical prostatectomy (RP) radiotherapy (RT) and compare outcomes and toxicities in patients receiving eRT versus observation with or without late radiotherapy (lRT). METHODS: Utilizing the Surveillance, Epidemiology, and End Results (SEER)-Medicare data from 2001 to 2011, we identified 7557 patients with high-risk pathologic features after RP (≥pT3N0 and/or positive surgical margins). Our study cohort consisted of patients receiving RT within 6 months of surgery (eRT), those receiving RT after 6 months (lRT), and those never receiving RT (observation). Another subcohort, delayed RT (dRT), encompassed both lRT and observation. Trends of post-RP RT were compared using the Cochran-Armitage trend test. Cox regression models identified factors predictive of worse survival outcomes. Kaplan-Meier analyses compared the eRT and the dRT groups. RESULTS: Among those with pathologically confirmed high-risk prostate cancer (PCa) after RP, 12.7% (n = 959), 13.2% (n = 1710), and 74.1% (n = 4888) underwent eRT, lRT, and observation without RT, respectively. Of these strategies, the proportion of men on observation without RT increased significantly over time (p = 0.004). The multivariable Cox regression model demonstrated similar outcomes between the eRT and the dRT groups. At a median follow-up of 5.9 years, five-year overall and cancer-specific survival outcomes were more favorable in the dRT group, when compared to the eRT group. CONCLUSIONS: A blanket adoption of the eRT in high-risk PCa based on clinical trials with limited follow-up may result in overtreatment of a significant number of men and expose them to unnecessary radiation toxicity.

Feeding the Controversy: When Pelvic Irradiation Improves Outcomes in High-Risk and Very High-Risk Prostate Cancer.

The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice.

Proton versus Photon Breath-Hold Radiation for Left-Sided Breast Cancer after Breast-Conserving Surgery: A Dosimetric Comparison.

PURPOSE: Radiation to breast, chest wall, and/or regional nodes is an integral component of breast cancer management in many situations. Irradiating left-sided breast and/or regional nodes may be technically challenging because of cardiac tolerance and subsequent risk of long-term cardiac complications. Deep inspiratory breath-hold (DIBH) technique physically separates cardiac structures away from radiation target volume, thus reducing cardiac dose with either photon (Ph) or proton beam therapy (PBT). The utility of combining PBT with DIBH is less well understood. METHODS AND MATERIALS: We compared photon-DIBH (Ph-DIBH) versus proton DIBH (Pr-DIBH) for different planning parameters, including target coverage and organ at risk (OAR) sparing. Necessary ethical permission was obtained from the institutional review board. Ten previous patients with irradiated, intact, left-sided breast and Ph-DIBH were replanned with PBT for dosimetric comparison. Clinically relevant normal OARs were contoured, and Ph plans were generated with parallel, opposed tangent beams and direct fields for supraclavicular and/or axillae whenever required. For proton planning, all targets were delineated individually and best possible coverage of planning target volume was achieved. Dose-volume histogram was analyzed to determine the difference in doses received by different OARs. Minimum and maximum dose (Dmin and Dmax ) as well as dose received by a specific volume of OAR were compared. Each patient's initial plan (Ph-DIBH) was used as a control for comparing newly devised PBT plan (Pr-DIBH). Matched, paired t tests were applied to determine any significant differences between the 2 plans. RESULTS: Both the plans were adequate in target coverage. Dose to cardiac structure subunits and ipsilateral lung were significantly reduced with the proton breath-hold technique. Significant dose reduction with Pr-DIBH was observed in comparison to Ph-DIBH for mean dose (D mean) to the heart (0.23 Gy versus 1.19 Gy; P < .001); D mean to the left ventricle (0.25 Gy versus 1.7 Gy; P < .001); D mean, D max, and the half-maximal dose to the left anterior descending artery (1.15 Gy versus 5.54 Gy; P < .003; 7.7 Gy versus 22.15 Gy; P < .007; 1.61 Gy versus 4.42 Gy, P < .049); D max of the left circumflex coronary artery (0.13 Gy versus 1.35 Gy; P < .001) and D mean, the volume to the ipsilateral lung receiving 20 Gy and 5 Gy (2.28 Gy versus 8.04 Gy; P < .001; 2.36 Gy versus 15.54 Gy, P < .001; 13.9 Gy versus 30.28 Gy; P = .002). However, skin dose and contralateral breast dose were not significantly improved with proton. CONCLUSION: This comparative dosimetric study showed significant benefit of Pr-DIBH technique compared with Ph-DIBH in terms of cardiopulmonary sparing and may be the area of future clinical research.

Associations between race and survival in pediatric patients with diffuse large B-cell lymphoma.

BACKGROUND: The purpose of this study was to examine the factors associated with disparities in overall survival (OS) by race in pediatric diffuse large B-cell lymphoma (DLBCL) patients. METHODS: We evaluated clinical features and survival among patients ≤21 years of age diagnosed with stage I-IV DLBCL from 2004 to 2014 from the National Cancer Database (NCDB) using a multivariable Cox proportional hazards model. RESULTS: Among 1386 pediatric patients with DLBCL, 1023 patients met eligibility criteria. In unadjusted analysis, Black patients had a significantly higher overall death rate than White patients (HRBlack vs. White 1.51; 95% CI: 1.02-2.23, p = 0.041). The survival disparity did not remain significant in adjusted analysis, though controlling for covariates had little effect on the magnitude of the disparity (HR 1.46; 95% CI 0.93-2.31, p = 0.103). In adjusted models, presence of B symptoms, receipt of chemotherapy, stage of disease, and Other insurance were significantly associated with OS. Specifically, patients with B symptoms and those with Other insurance were more likely to die than those without B symptoms or private insurance, respectively (HR 1.75; 95% CI 1.22-2.50, p = 0.002) and (HR 2.56; 95% CI, 1.39-4.73, p = 0.0027), patients who did not receive chemotherapy were three times more likely to die than those who received chemotherapy (HR 3.10; CI 1.80-5.35, p < 0.001), and patients who presented with earlier stage disease were less likely to die from their disease than those with stage IV disease (stages I-III HR 0.34, CI 0.18-0.64, p < 0.001; HR 0.50, CI 0.30-0.82, p = 0.006, HR 0.72, CI 0.43-1.13, p = 0.152, respectively). CONCLUSIONS: Our results suggest that racial disparities in survival may be mediated by clinical and treatment parameters.

The Association of Radiation Dose-Fractionation and Immunotherapy Use With Overall Survival in Metastatic Melanoma Patients.

Objective Metastatic melanoma patients often receive palliative radiotherapy (RT) and immunotherapy (IT). However, the immunological interplay between RT dose-fractionation and IT is uncertain, and the optimal treatment strategy using RT and IT in metastatic melanoma remains unclear. Our main objective was to examine the effect of RT dose-fractionation on overall survival (OS). Methods Using the National Cancer Database (NCDB), we classified metastatic melanoma patients who received palliative RT into two dose-fractionation groups - conventionally fractionated RT (CFRT; <5 Gy/fraction) and hypofractionated RT (HFRT: ≥5 Gy/fraction) - with or without IT. Survival analysis was performed using the Cox regression model, Kaplan-Meier method, and propensity-score matching (PSM). Results A total of 5,281 metastatic melanoma patients were included, with a median follow-up of 5.9 months. The three-year OS was highest in patients who received HFRT+IT [37.3% (95% CI: 31.1-43.5)] compared to those who received HFRT alone [19.0% (95% CI: 16.2-21.9)], CFRT+IT [17.6 (95%CI: 13.9-21.6)], or CFRT alone [8.6% (95%CI: 7.6-9.7); p<0.0001]. The magnitude of OS benefit with the use of IT was greater in those who received HFRT (18.3%) compared with those who received CFRT (9.0%) (p<0.0001). The addition of IT to HFRT, compared to CFRT, was associated with greater OS benefit in patients treated with RT to the brain and soft tissue/visceral (STV) sites. On PSM analysis, HFRT+IT was associated with improved three-year OS compared to other treatments. Conclusion Metastatic melanoma patients who received HFRT+IT was associated with the greatest OS benefit. Our findings warrant further prospective evaluation as to whether higher RT dose-per-fraction improves clinical outcomes in metastatic melanoma patients receiving IT.

Long-Term Outcomes in 10-Year Survivors of Early-Stage Hodgkin Lymphoma.

PURPOSE: Although radiation therapy improves progression-free survival in early-stage Hodgkin lymphoma (HL), substantial concerns remain regarding the impact of delayed normal tissue effects on quality of life and survival. We hypothesized that treatment with combined-modality therapy (CMT; chemotherapy and radiation therapy) improves overall survival among 10-year survivors compared with treatment with radiation therapy or chemotherapy alone. METHODS AND MATERIALS: We compared patients in the Surveillance, Epidemiology, and End Results database who received a diagnosis of stage I/II HL between 1983 and 2006 who received chemotherapy and/or external beam radiation and survived at least 10 years. Our primary study outcome was overall survival; we also analyzed cause-specific and other-cause-specific survival. RESULTS: Of 10,443 ten-year survivors of stage I/II classical HL, 33.6% received chemotherapy alone, 23.8% radiation therapy alone, and 42.6% CMT. Median follow-up was 16.1 years. On multivariate analysis including race, stage, sex, age, and "modern" treatment in 1995 and later, 10-year survivors who received CMT had improved overall survival relative to survivors who received RT alone (hazard ratio, 1.41; 95% confidence interval, 1.21-1.64; P < .01) or chemotherapy alone (hazard ratio, 1.35; 95% confidence interval, 1.16-1.57; P < .01). CONCLUSIONS: This survival difference was driven by an increase in death from both HL and non-HL causes in those treated with chemotherapy alone. Our analysis suggests that CMT offers optimal survivorship for patients with stage I/II HL.

Pediatric hodgkin lymphoma: disparities in survival by race.

The purpose of this study was to examine factors associated with disparities in overall survival (OS) by race in pediatric Hodgkin Lymphoma (HL) patients. We evaluated clinical features and survival among patients ≤21 years of age diagnosed with stage I-IV HL from 2004 to 2015 from the National Cancer DataBase (NCDB) using a multivariable Cox proportional hazards model. Among 11,546 patients with pediatric HL, 9285 patients met eligibility criteria. Black patients experienced a 5-year OS of 91.5% vs 95.9% in White patients (p < .0001). After adjusting for confounders, Black race was associated with a significantly decreased OS (HR = 1.50; 95% CI: 1.12-1.99; p < .01). In stratified analysis by ages ≤15 years, 16-18 years, and >18 years, Black race was associated with poorer OS among compared to Whites with rates of 95.4% vs 97.7%, 87.1% vs 96.1%, and 91.6% vs 94.6% respectively. Overall, Black pediatric HL patients had lower overall survival in this study.

Retroperitoneal Lymph Node Dissection as Primary Treatment for Men With Testicular Seminoma: Utilization and Survival Analysis Using the National Cancer Data Base, 2004-2014.

BACKGROUND: The role of retroperitoneal lymph node dissection (RPLND) as first-line treatment for testicular seminoma is less well defined than for testicular nonseminomatous germ-cell tumors. We describe utilization of primary RPLND in the United States and report on overall survival (OS) after surgery for these men. PATIENTS AND METHODS: Using 2004-2014 data from the National Cancer Data Base, we identified 62,727 men with primary testicular cancer, 31,068 of whom were diagnosed as having seminoma. After excluding men with benign, non-germ cell, and nonseminomatous germ-cell tumor histologies, those who did not undergo RPLND, those where clinical stage and survival data were unavailable, and those with testicular seminoma who underwent RPLND in the postchemotherapy setting (n = 47), 365 men comprised our final cohort. Descriptive statistics were used to summarize clinical and demographic factors. The Kaplan-Meier method was used to determine OS. RESULTS: A total of 365 men with testicular seminoma underwent primary RPLND. At a median follow-up of 4.1 years, there were 16 deaths in the entire cohort. Five-year OS was 94.2%. Subset analysis of men with stage I and IIA/B disease who underwent primary RPLND revealed 5-year OS rates of 97.3% and 92.0%, respectively (P = .035). OS did not significantly differ in patients with stage IIA versus IIB disease (91.8% vs. 92.3%, respectively, P = .907). CONCLUSION: Although RPLND is rarely used as primary therapy in testicular seminoma, OS rates appear to be comparable to rates reported in the literature for primary chemotherapy or radiotherapy. Ongoing prospective trials will clarify the role of RPLND in the management of testicular seminoma.

A novel approach to Verify air gap and SSD for proton radiotherapy using surface imaging.

PURPOSE: To develop a novel approach to accurately verify patient set up in proton radiotherapy, especially for the verification of the nozzle - body surface air gap and source-to-skin distance (SSD), the consistency and accuracy of which is extremely important in proton treatment. METHODS: Patient body surfaces can be captured and monitored with the optical surface imaging system during radiation treatment for improved intrafraction accuracy. An in-house software package was developed to reconstruct the patient body surface in the treatment position from the optical surface imaging reference capture and to calculate the corresponding nozzle - body surface air gap and SSD. To validate this method, a mannequin was scanned on a CT simulator and proton plans were generated for a Mevion S250 Proton machine with 20 gantry/couch angle combinations, as well as two different snout sizes, in the Varian Eclipse Treatment Planning Systems (TPS). The surface generated in the TPS from the CT scan was imported into the optical imaging system as an RT Structure for the purpose of validating and establishing a benchmark for ground truth comparison. The optical imaging surface reference capture was acquired at the treatment setup position after orthogonal kV imaging to confirm the positioning. The air gaps and SSDs calculated with the developed method from the surface captured at the treatment setup position (VRT surface) and the CT based surface imported from the TPS were compared to those calculated in TPS. The same approach was also applied to 14 clinical treatment fields for 10 patients to further validate the methodology. RESULTS: The air gaps and SSDs calculated from our program agreed well with the corresponding values derived from the TPS. For the phantom results, using the CT surface, the absolute differences in the air gap were 0.45 mm ± 0.33 mm for the small snout, and 0.51 mm ± 0.49 mm for the large snout, and the absolute differences in SSD were 0.68 mm ± 0.42 mm regardless of snout size. Using the VRT surface, the absolute differences in air gap were 1.17 mm ± 1.17 mm and 2.1 mm ± 3.09 mm for the small and large snouts, respectively, and the absolute differences in SSD were 0.81 mm ± 0.45 mm. Similarly, for patient data, using the CT surface, the absolute differences in air gap were 0.42 mm ± 0.49 mm, and the absolute differences in SSD were 1.92 mm ± 1.4 mm. Using the VRT surface, the absolute differences in the air gap were 2.35 mm ± 2.3 mm, and the absolute differences in SSD were 2.7 mm ± 2.17 mm. CONCLUSION: These results showed the feasibility and robustness of using an optical surface imaging approach to conveniently determine the air gap and SSD in proton treatment, providing an accurate and efficient way to confirm the target depth at treatment.

Proton Therapy For Lymphomas: Current State Of The Art.

The combination of brief chemo-radiotherapy provides high cure rates and represents the first line of treatment for many lymphoma patients. As a result, a high proportion of long-term survivors may experience treatment-related toxic events many years later. Excess and unintended radiation dose to organs at risk (particularly heart, lungs and breasts) may translate in an increased risk of cardiovascular events and second cancers after a few decades. Minimizing dose to organs at risk is thus pivotal to restrain the risk of long-term complications. Proton therapy, with its peculiar physic properties, may help to better spare organs at risk and consequently to reduce toxicities especially in patients receiving mediastinal radiotherapy. Herein, we review the physical basis of proton therapy and the rationale for its implementation in lymphoma patients, with a detailed description of the clinical data. We also discuss the potential disadvantages and uncertainties of protons that may limit their application and critically review the dosimetric studies comparing the risk of late complications between proton and photon radiotherapy.

Results of Phase 1 study on cytoreductive radical prostatectomy in men with newly diagnosed metastatic prostate cancer.

BACKGROUND: Preclinical and retrospective data suggest that cytoreductive radical prostatectomy may benefit a subset of men who present with metastatic prostate cancer (mPCa). Herein, we report the results of the first planned Phase 1 study on cytoreductive surgery. METHODS: From four institutions, 36 patients consented to the study. However, four did not complete surgery because of rapid disease progression (n = 3) and another because of an intraoperatively discovered pericolonic abscess. Men with newly diagnosed clinical mPCa to lymph nodes or bones were eligible. The primary endpoint was the rate of major perioperative complications (Clavien-Dindo Grade 3 or higher) occurring within 90 days of surgery. RESULTS: The mean age at surgery was 64.0 years. The 90-day overall complication rate was 31.2% (n = 10), of which two (6.25%) were considered major complications: one acute tubular necrosis requiring temporary dialysis and one death. In men with more than 6 months of follow-up, 67.9% had prostate specific antigen nadir ≤0.2 ng/mL, while one patient experienced a rapid rise in prostate specific antigen and another a widely disseminated disease that resulted in death 5 months after surgery. Altogether, these results demonstrate that cytoreductive radical prostatectomy is safe and surgically feasible in selected patients who present with mPCa . Yet, there may be a small subset of patients in whom surgery may cause a significant harm. CONCLUSION: Therefore, cytoreductive surgery in men with mPCa should be limited to clinical trials until robust data are available.