Proton therapy posterior beam approach with pencil beam scanning for esophageal cancer : Clinical outcome, dosimetry, and feasibility.

PURPOSE: The aim of this study is to present the dosimetry, feasibility, and preliminary clinical results of a novel pencil beam scanning (PBS) posterior beam technique of proton treatment for esophageal cancer in the setting of trimodality therapy. METHODS: From February 2014 to June 2015, 13 patients with locally advanced esophageal cancer (T3-4N0-2M0; 11 adenocarcinoma, 2 squamous cell carcinoma) were treated with trimodality therapy (neoadjuvant chemoradiation followed by esophagectomy). Eight patients were treated with uniform scanning (US) and 5 patients were treated with a single posterior-anterior (PA) beam PBS technique with volumetric rescanning for motion mitigation. Comparison planning with PBS was performed using three plans: AP/PA beam arrangement; PA plus left posterior oblique (LPO) beams, and a single PA beam. Patient outcomes, including pathologic response and toxicity, were evaluated. RESULTS: All 13 patients completed chemoradiation to 50.4 Gy (relative biological effectiveness, RBE) and 12 patients underwent surgery. All 12 surgical patients had an R0 resection and pathologic complete response was seen in 25 %. Compared with AP/PA plans, PA plans have a lower mean heart (14.10 vs. 24.49 Gy, P < 0.01), mean stomach (22.95 vs. 31.33 Gy, P = 0.038), and mean liver dose (3.79 vs. 5.75 Gy, P = 0.004). Compared to the PA/LPO plan, the PA plan reduced the lung dose: mean lung dose (4.96 vs. 7.15 Gy, P = 0.020) and percentage volume of lung receiving 20 Gy (V20; 10 vs. 17 %, P < 0.01). CONCLUSION: Proton therapy with a single PA beam PBS technique for preoperative treatment of esophageal cancer appears safe and feasible.

Low-Dose-Rate Brachytherapy Versus Cryotherapy in Low- and Intermediate-Risk Prostate Cancer.

PURPOSE: Cryotherapy and brachytherapy are definitive local treatment options for low- to intermediate-risk prostate cancer. There are both prospective and retrospective data for brachytherapy, but the use of cryotherapy has been limited primarily to single-institution retrospective studies. Currently, no published evidence has compared low-dose-rate brachytherapy versus cryotherapy. METHODS AND MATERIALS: Institutional review board approval was obtained to conduct a retrospective chart review of consecutive patients treated at our institution from 1990 to 2012. For inclusion, patients must have received a prostate cancer diagnosis and have been considered to have low- to intermediate-risk disease according to the National Comprehensive Cancer Network criteria. All patients received brachytherapy or cryotherapy treatment. Disease specifics and failure details were collected for all patients. Failure was defined as prostate-specific antigen nadir +2 ng/mL. RESULTS: A total of 359 patients were analyzed. The groups comprised 50 low-risk cryotherapy (LRC), 92 intermediate-risk cryotherapy (IRC), 133 low-risk brachytherapy (LRB), and 84 intermediate-risk brachytherapy (IRB) patients. The median prostate-specific antigen follow-up periods were 85.6 months (LRC), 59.2 months (IRC), 74.9 months (LRB), and 59.8 months (IRB). The 5-year biochemical progression-free survival (bPFS) rate was 57.9% in the cryotherapy group versus 89.6% in the brachytherapy group (P<.0001). The 5-year bPFS rate was 70.0% (LRC), 51.4% (IRC), 89.4% (LRB), and 89.7% (IRB). The bPFS rate was significantly different between brachytherapy and cryotherapy for low- and intermediate-risk groups (P<.05). The mean nadir temperature reached for cryotherapy patients was -35°C (range, -96°C to -6°C). Cryotherapy used a median of 2 freeze-thaw cycles (range, 2-4 freeze-thaw cycles). CONCLUSIONS: Results from this study suggest that cryotherapy is inferior to brachytherapy for patients with low- to intermediate-risk prostate cancer. Patient selection criteria for consideration of cryotherapy and brachytherapy are similar in terms of anesthesia candidacy. Therefore, cryotherapy would not be recommended as a first-line local therapy for this particular patient subset.

Reduced dose to urethra and rectum with the use of variable needle spacing in prostate brachytherapy: a potential role for robotic technology.

PURPOSE: Several robotic delivery systems for prostate brachytherapy are under development or in pre-clinical testing. One of the features of robotic brachytherapy is the ability to vary spacing of needles at non-fixed intervals. This feature may play an important role in prostate brachytherapy, which is traditionally template-based with fixed needle spacing of 0.5 cm. We sought to quantify potential reductions in the dose to urethra and rectum by utilizing variable needle spacing, as compared to fixed needle spacing. MATERIAL AND METHODS: Transrectal ultrasound images from 10 patients were used by 3 experienced planners to create 120 treatment plans. Each planner created 4 plan variations per patient with respect to needle positions: (125)I fixed spacing, (125)I variable spacing, (103)Pd fixed spacing, and (103)Pd variable spacing. The primary planning objective was to achieve a prostate V100 of 100% while minimizing dose to urethra and rectum. RESULTS: All plans met the objective of achieving prostate V100 of 100%. Combined results for all plans show statistically significant improvements in all assessed dosimetric variables for urethra (Umax, Umean, D30, D5) and rectum (Rmax, Rmean, RV100) when using variable spacing. The dose reductions for mean and maximum urethra dose using variable spacing had p values of 0.011 and 0.024 with (103)Pd, and 0.007 and 0.029 with (125)I plans. Similarly dose reductions for mean and maximum rectal dose using variable spacing had p values of 0.007 and 0.052 with (103)Pd, and 0.012 and 0.037 with (125)I plans. CONCLUSIONS: The variable needle spacing achievable by the use of robotics in prostate brachytherapy allows for reductions in both urethral and rectal planned doses while maintaining prostate dose coverage. Such dosimetric advantages have the potential in translating to significant clinical benefits with the use of robotic brachytherapy.

Quantitative estimation of doses to salivary glands from using brachytherapy in head and neck cancers.

PURPOSE: To quantify the percentage doses received by salivary glands (SGDs) in head and neck interstitial brachytherapy (BT). METHODS AND MATERIALS: The study included 43 patients who underwent high-dose rate iridium-192 implant for oral cavity and oropharyngeal lesions treated with BT as a boost. BT dose varied with disease stage and external radiation dose, with the total mean dose of 66±4Gy. Patients were divided into two groups, midline and lateralized, based on anatomic implant location. Different dose parameters such as D(max), D(mean), DV(30%) of individual glands were derived from dose volume histogram representing the percentage maximum dose, mean dose, and dose received by 30% volume of individual SGDs, respectively. For better perception of the impact of BT on individual SGDs, the doses received are extrapolated to radical BT dose of 60Gy. RESULTS: For lateralized implants, the highest dose received by ipsilateral parotid (PTD) was 12.3% seen in tonsillar implants. The contralateral PTD receives minimal doses. As expected, the ipsilateral submandibular gland (SMG) received high doses in the range of 80% of the total prescribed dose, whereas contralateral SMG received 10% of ipsilateral dose. For the midline implants, the mean dose range for PTD was 7-11% of the total prescribed dose and for SMG between 17% and 56%, depending on the location. CONCLUSIONS: The study quantifies the percentage doses received by the individual SGDs in interstitial head and neck BT for use in future planning of the BT procedures and for salivary functional studies, prediction of damage, and quality-of-life parameters.

Ifosfamide-based chemotherapy in locoregionally advanced nasopharyngeal cancer: evaluation of its role as neoadjuvant chemotherapy.

The use of Ifosfamide-based chemotherapy in primary nasopharyngeal carcinoma (NPC), in neoadjuvant settings [NACT] has not been sufficiently evaluated. We present here a retrospective analysis of 78 patients of untreated, locoregionally advanced NPC patients who received Ifosfamide-Cisplatin-based NACT at our institute from 1997 to 2004. Definitive treatment comprised radical radiotherapy (RT) or concurrent chemoradiotherapy (CCRT) using weekly Cisplatin. Post-NACT, 92% patients had a partial response (PR) while 3% had a complete locoregional response (CR). The rates of CR increased to 87% after completion of definitive treatment. With follow up (38 months), 29% patients developed recurrent/persistent disease. The local and locoregional control rates at 5 years were 76% and 73%, respectively. The 5-year overall survival (OAS) was 80% and disease-free survival was 65%. Grade III or more neutropenia was seen in 15%. Results of Ifosfamide-Cisplatin combination as a NACT in advanced NPC have been quite encouraging and need to be exploited further.

Chest wall metastasis from hepatocellular carcinoma in the absence of a primary: An unusual presentation.

Metastatic hepatocellular carcinoma (HCC) has an aggressive course with a very poor outcome. The common hematogenous metastatic sites are the lungs, bones, and adrenal glands. The chest wall is an extremely rare site of metastasis from HCC. We report a rare presentation in a gentleman, where the chest wall metastasis kept progressing in spite of treatment, without any evidence of a detectable primary.

Relation of maternal low birth weight to infant growth retardation and prematurity.

OBJECTIVES: This study sought to determine the relationship between maternal birth weight, infant intrauterine growth retardation, and prematurity. METHODS: Stratified and logistic regression analyses were performed on a dataset of computerized Illinois vital records of African American (N = 61,849) and White (N = 203,698) infants born between 1989 and 1991 and their mothers born between 1956 and 1975. RESULTS: Race-specific rates of small-for-gestational age (weight-for-gestational age <10th percentile) and preterm (<37 weeks) infants rose as maternal birth weight declined. The adjusted (controlling for maternal age, education, marital status, parity, prenatal care utilization, and cigarette smoking) odds ratio (95% confidence interval) of small-for-gestational age for maternal low birth weight (<2,500 g) among African Americans and Whites were 1.7 (1.1.4-1.9) and 1.8 (1.7-2.0), respectively. The adjusted odds ratio (95% confidence interval) of prematurity for maternal low birth weight (<2,500 g) among African Americans and Whites were 1.6 (1.3-1.9) and 1.3 (1.0-1.6), respectively. The racial disparity in the rates of small-for-gestational age and prematurity persisted independent of maternal birth weight: adjusted odds ratio equaled 2.2 (2.1-2.4) and 1.5 (1.4-1.7), respectively. CONCLUSIONS: Maternal low birth weight is a risk factor for infant intrauterine growth retardation and prematurity among African Americans independent of maternal risk status during pregnancy; it is a risk factor for infant intrauterine growth retardation among Whites. Maternal low birth weight fails to explain the racial disparity in the rates of small-for-gestational age and premature infants.