Advantages of 3D registration technology (3DRT) in clinical application of unruptured intracranial aneurysm follow-up: A novel method to judge aneurysm growth.

BACKGROUND AND PURPOSE: Currently available methods for determining aneurysm growth are not accurate enough. Therefore, we introduced a more intuitive and accurate 3D registration technology (3DRT) to judge the growth of aneurysms. MATERIALS AND METHODS: We developed an in-house technique for 3DRT and calculated its derivative parameters, voxel change rate (VCR), maximum growth vector (MGV), and parent artery coincidence (PAC). To verify the accuracy, growing aneurysms and stable aneurysms matching 1:3 were selected, and a 3DRT measurement was performed. We calculated the sensitivity, specificity, and accuracy of cases with VCR > 20%, MGV > 1 mm, and combined indicator of VCR > 20% + MGV >1 mm. In addition, we analyzed the cause of the poor registration effect, where the registration effect of PAC > 0.7 was considered acceptable. We also collected 24 consecutive aneurysms for agreement analysis of 2D manual measurement and 3DRT. RESULTS: Twenty-seven growing aneurysms and 81 stable aneurysms were included in the normal model group, and 88 aneurysms with good registration effect in the adjusted model group. For aneurysms with VCR > 20%, the sensitivity and the specificity were the highest at 81.48% and 91.35%, respectively, while in the adjusted model group, the sensitivity and the specificity increased to 94.44% and 94.29%, respectively. When using VCR > 20% as the growth metric, the AUC value in the normal and the adjusted model group was 0.856 and 0.947, respectively. The ICC between 2D manual measurements and the 3DRT was 0.95 (95%CI: 0.88-0.98), and the time spent between the two groups had a significant difference (10.96 min vs. 3.44 min, p<0.01, 95% CI, 6.49-8.53). CONCLUSIONS: A 3DRT can be used to determine the growth of the aneurysm more efficiently, intuitively, and accurately.

High-dose-rate brachytherapy boost for elderly patients with intermediate to high-risk prostate cancer: 5-year clinical outcome of the PROSTAGE cohort.

Purpose: To analyze the oncological outcome in elderly (>70 years) prostate cancer after high-dose rate brachytherapy (HDB) boost. Materials/methods: In this retrospective study, patients with intermediate (IR) and high-risk (HR) prostate cancer underwent external beam radiation therapy (EBRT) followed by HDB boost with/without androgen deprivation therapy (ADT). The impact of age (≤70y vs. > 70y) was investigated. Oncological outcome focused on biochemical relapse-free survival (bRFS), cause-specific (CSS) and overall survival (OS). Late genito-urinary (GU) and gastro-intestinal (GI) toxicities were investigated. Results: From 07/08 to 01/22, 518 pts received a HDB boost, and 380 were analyzed (≤70y:177pts [46.6%] vs. > 70y:203pts [53.4%]). Regarding NCCN classification, 98 pts (≤70y: 53pts; >70y: 45pts; p = 0.107) and 282 pts (≤70y: 124pts; >70y: 158pts; p = NS) were IR and HR pts respectively. Median EBRT dose was 46 Gy [37.5-46] in 23 fractions [14-25]. HDB boost delivered a single fraction of 14/15 Gy (79%). ADT was used in 302 pts (≤70y: 130pts; >70y: 172pts; p = 0.01). With MFU of 72.6 months [67-83] for the whole cohort, 5-y bRFS, 5-y CSS and 5-y OS were 88% [85-92], 99% [97-100] and 94% [92-97] respectively; there was no statistical difference between the two age groups except for 5-y CSS (p = 0.05). Late GU and GI toxicity rates were 32.4% (G ≥ 3 7.3%) and 10.1% (no G3) respectively. Conclusions: For IR and HR prostate cancers, HDB boost leads to high rates of disease control with few late G ≥ 3 GU/GI toxicities. For elderly pts, HDB boost remains warranted mainly in HR pts, while competing comorbidity factors influence OS.

Dose-volume predictors of post-radiation primary hypothyroidism in head and neck cancer: A systematic review.

BACKGROUND AND PURPOSE: This systematic review aims to identify radiation dose-volume predictors of primary hypothyroidism after radiotherapy in patients with head and neck cancer (HNC). MATERIALS AND METHODS: We performed a systematic literature search of Medline, EMBASE and Web of Science from database inception to July 1, 2021 for articles that discuss radiation dose-volume predictors of post-radiation primary hypothyroidism in patients with HNC. Data on the incidence, clinical risk factors and radiation dose-volume parameters were extracted. A meta-analysis was performed using the random-effects model to estimate the pooled odds ratio (OR) of thyroid volume as a predictor of the risk of post-radiation hypothyroidism, adjusted for thyroid radiation dosimetry. RESULTS: Our search identified 29 observational studies involving 4,530 patients. With median follow-up durations ranging from 1.0 to 5.3 years, the average crude incidence of post-radiation primary hypothyroidism was 41.4 % (range, 10 %-57 %). Multiple radiation dose-volume parameters were associated with post-radiation primary hypothyroidism, including the thyroid mean dose (Dmean), minimum dose, V25, V30, V35, V45, V50, V30-60, VS45 and VS60. Thyroid Dmean and V50 were the most frequently proposed dosimetric predictors. The pooled adjusted OR of thyroid volume on the risk of post-radiation primary hypothyroidism was 0.89 (95 % confidence interval, 0.85-0.93; p < 0.001) per 1 cc increment. CONCLUSION: Post-radiation primary hypothyroidism is a common late complication after radiotherapy for HNC. Minimizing inadvertent exposure of the thyroid gland to radiation is crucial to prevent this late complication. Radiation dose-volume constraints individualized for thyroid volume should be considered in HNC radiotherapy planning.

Organs at risk radiation dose constraints.

Dose constraints are essential for performing dosimetry, especially for intensity modulation and for radiotherapy under stereotaxic conditions. We present the update of the recommendations of the French society of oncological radiotherapy for the use of these doses in classical current practice but also for reirradiation.

Pelvic radiation therapy with volumetric modulated arc therapy and intensity-modulated radiotherapy after renal transplant: A report of 3 cases.

AIM: Describe characteristics and outcomes of three patients treated with pelvic radiation therapy after kidney transplant. BACKGROUND: The incidence of pelvic cancers in kidney transplant (KT) recipients is rising. Currently it is the leading cause of death. Moreover, treatment is challenging because anatomical variants, comorbidities, and associated treatments, which raises the concern of using radiotherapy (RT). RT has been discouraged due to the increased risk of urethral/ureteral stricture and KT dysfunction. MATERIALS AND METHODS: We reviewed the electronic health records and digital planning system of patients treated with pelvic RT between December 2013 and December 2018 to identify patients with previous KT. CASES DESCRIPTION: We describe three successful cases of KT patients in which modern techniques allowed full standard RT for pelvic malignances (2 prostate and 1 vaginal cancer) with or without elective pelvic nodal RT, without allograft toxicity at short and long follow-up (up to 60 months). CONCLUSION: When needed, RT modern techniques remain a valid option with excellent oncologic results and acceptable toxicity. Physicians should give special considerations to accomplish all OAR dose constraints in the patient's specific setting. Recent publications recommend KT mean dose <4 Gy, but graft proximity to CTV makes this unfeasible. We present 2 cases where dose constraint was not achieved, and to a short follow-up of 20 months renal toxicity has not been documented. We recommend the lowest possible mean dose to the KT, but never compromising the CTV coverage, since morbimortality from recurrent or progressive cancer disease outweighs the risk of graft injury.

Locally advanced inoperable primary or recurrent non-small cell lung cancer treated with 4-week hypofractionated radiation therapy (3 Gy/fraction).

BACKGROUND: The prognosis of locally advanced non-small cell lung cancer (NSCLC) treated with conventional radiotherapy remains poor. Hypofractionation reduces overall treatment time increasing biological effect in patients not suitable for concurrent chemo-radiotherapy. METHOD: From January 2009 to October 2016, 76 inoperable locally advanced primary or recurrent NSCLC patients were treated with 60 Gy in 20 fractions of 3 Gy/each for 4 weeks as exclusive or post-chemotherapy treatment. Fifty-eight patients (76.3%) had stage III and 18 (23.7%) stage IV (≤ 2 metastases) disease: 63 primary (82.9%) and 13 recurrent (17.1%). RESULTS: Median and 2-year overall survival were 17 months and 38.9%, respectively. Median and 2-year loco-regional progression free survival were 27 months and 55.3%, respectively. Univariate and multivariate analyses demonstrated that patients with complete response presented better outcomes, whereas no statistically relevant difference was evidenced in terms of previous chemotherapy, recurrent vs primary disease, volume and stage. Thirty patients (39.5%) presented acute esophagitis (1-grade 3) and 19 (25.0%) acute pneumonitis (2-grade 3). Six patients (7.9%) developed grade 2-3 late pneumonitis and 3 patients (3.9%) grade 1 late esophagitis. CONCLUSION: In patients not suitable of concurrent radio-chemotherapy, exclusive or sequential hypofractionated schedule using 60 Gy in 20 fractions was well tolerated and presented promising results. Complete local response was a predictor of better outcomes, and any efforts will be made to perform prospective clinical trials to further evaluate hypofractionated regimens with increased lesional BED.

Inoperable early-stage primary and early recurrent non-small cell lung cancer: outcomes of a mono-institutional experience using a moderate hypofractionated schedule.

BACKGROUND: Patients with medically inoperable early-stage non-small cell lung cancer (NSCLC) may beneficiate of a hypofractionated radiation therapy in order to intensificate the treatment and to reduce the number of hospital access. METHODS: From 2007 to 2015, 27 patients with early-stage primary or limited loco-regional recurrent (T2a > 4 cm, T2b N0 or T1-2 N1M0) NSCLC were treated. All patients were medically inoperable or refused surgery and were treated with 60 Gy in 20 fractions, 5 times per week. Thirteen (48.1%) presented limited recurrence after surgery and 14 (51.9%) primary disease. RESULTS: Median follow-up was 34 months. Twelve patients achieved a CR (44.4%) and 8 a PR (29.6%) with a tumour response rate of 74%. Median overall survival (OS) and 2-year OS were 34 months and 63.0%, respectively. Median and 2-year loco-regional progression-free survival (LR-PFS) were 31 months and 51.4%, respectively. Survival outcomes were statistically favourable in patients with partial or complete response with respect to patients with stable or progressive disease, whereas stage (N0 vs N1) and primary or relapse/recurrent disease not. No cases of acute toxicity > grade 2 were observed. Seven patients (25.9%) presented grade 2 late toxicities. CONCLUSION: Sixty Gy in 20 fractions is well tolerated and achieves good clinical outcomes in early primary or recurrent NSCLC patients. A greater number of patients and a longer follow-up are necessary to confirm the results obtained with our treatment.

Network meta-analysis of treatment regimens for inoperable advanced hepatocellular carcinoma with portal vein invasion.

PURPOSE: We assessed the efficacy and safety of different modalities using the network meta-analysis for inoperable hepatocellular carcinoma (HCC) with portal vein invasion. The interested modalities included stereotactic body radiotherapy (SBRT) combined with transarterial chemoembolization (TACE), three-dimensional radiotherapy (3D-RT) combined with hepatic arterial infusion chemotherapy (HAIC) or TACE, TACE plus sorafenib, and use of SBRT, HAIC, sorafenib, and TACE alone. METHODS: PubMed and Cochrane Library electronic databases were systematically searched for eligible studies published up to June 2017. We used network meta-analysis to compare the disease control rate (DCR) and severe adverse events for the eight interested regimens included in this analysis. Study quality was assessed following the Grading of Recommendations, Assessment, Development and Evaluations method. RESULTS: Fifteen studies published between 2010 and 2016 involving a total of 2,359 patients were enrolled in this network meta-analysis. With indirect comparison of DCR and overall safety, the pooled results showed that RT plus HAIC was the most effective regimen in treating advanced HCC with portal vein tumor thrombosis, followed by RT plus TACE. HAIC alone and sorafenib combined with HAIC appeared least effective intervention regimens. The incidence of treatment-related adverse events of grade 3 or 4 occurred less in the patients who received SBRT alone compared with other interested regimens. CONCLUSION: 3D-RT combined with HAIC or TACE showed more favorable treatment responses compared with other regimens in advanced HCC patients with portal vein tumor thrombosis.

Comparación Clínica de radioterapia de intensidad modulada vs. radioterapia 3D en tratamiento neoadyuvante del cáncer de recto localmente avanzado / Clinical comparison of intensity modulated radiotherapy vs. 3D radiotherapy in neoadjuvant treatment of locally advanced rectal cancer

El objetivo de este trabajo fue comparar ventajas potenciales de la radioterapia de intensidad modulada (IMRT) vs. la radioterapia 3D (3DRT) en el control loco-regional y la toxicidad aguda en pacientes con cáncer de recto localmente avanzado (CRLA). Se analizaron retrospectivamente 235 pacientes con adenocarcinoma de recto T2/T4 y N0/N1 sometidos a radioquimioterapia neoadyuvante entre febrero de 2010 y agosto de 2015. La modalidad radiante se correlacionó con los resultados clínicos (control local y a distancia) y las tasas de toxicidades agudas urinarias, hematológicas, gastrointestinales (GI) y dérmicas. Ciento cuarenta (59.6%) recibieron IMRT y 95 (40.4%) 3DRT. La mediana de seguimiento fue de 36 meses. Las tasas de recidiva local y metástasis a distancia fueron similares entre IMRT y 3DRT. No se encontraron diferencias estadísticamente significativas en control local (CL) ni en supervivencia global (SG) entre IMRT y 3DRT (p=0.56 y p=0.24, respectivamente), ni en colostomía libre para tumores rectales bajos (p=0.44). IMRT implicó menor toxicidad cutánea (p<0.001), hematológica (p<0.0001), urinaria (p=0.0017), y gastrointestinal (p=0.0006). La incidencia de diarrea grado ≥ 3 fue del 16% entre los pacientes del grupo 3DRT frente al 5% de del grupo IMRT. En el análisis univariado, el estadio clínico T, edad, KPS, y quimioterapia adyuvante se asociaron con mejor SG (todos p<0.05) y la dosis total de radiación se asoció con mejor período libre de enfermedad (p=0.0065) Postulamos que IMRT permitiría un aumento de dosis en forma segura con el potencial de aumentar la tasa de respuestas patológicas completas (RPC), en particular en tumores rectales bajos (AU)

The aim was to compare the advantages of IMRT vs. 3D in loco regional control and acute toxicity in patients with locally advanced rectum cancer. We analyzed retrospectively 235 patients with rectal adenocarcinoma T2/T4 and N0/N1 undergoing chemo radiation between February 2010 and August 2015. The radiant modality was correlated with clinical outcomes (local and systemic control) and rates of acute urinary, hematological, gastrointestinal and dermal toxicities. One hundred and forty patients (59.6%) received IMRT and 95 (40.4%) received 3D. The median follow-up time was 36 months. The rates of local recurrence and distant metastases were similar between IMRT vs. 3D. No statistically significant differences were found in local control or survival between IMRT and 3D (p=0.56 and p =0.24, respectively), nor in free colostomy for low rectal tumors (p= 0.44). IMRT resulted in lower dermal (p<0.001), hematological (p<0.0001), urinary (p=0.0017), and gastrointestinal toxicity (p=0.0006). The incidence of diarrhea grade ≥ 3 was 16% among 3D patients vs. 5% in IMRT. In the univariate analysis, clinical stage T, age, KPS, and adjuvant chemotherapy were associated with better overall survival (all p<0.05) and the total dose of radiation was associated with better disease-free period (p=0.0065). We postulate that IMRT would allow us to increase dose in a safe manner with the potential to increase rate of complete pathological responses, particularly in low rectal tumors (AU)