Deep Inspiration Breath-Hold (DIBH) produces a clinically meaningful reduction in ipsilateral lung dose during loco-regional radiation therapy for some women with right-sided breast cancer

Publication date: Available online 19 October 2016
Source:Practical Radiation Oncology
Author(s): Jessica L. Conway, Leigh Conroy, Lindsay Harper, Marie Scheifele, Haocheng Li, Wendy L. Smith, Tannis Graham, Tien Phan, Ivo A. Olivotto
Background & PurposeTo determine whether Deep Inspiration Breath Hold (DIBH) produced a clinically meaningful reduction in pulmonary dose compared to free breathing (FB) during loco-regional radiation for right-sided breast cancer.Materials & MethodsFour-field, modified-wide tangent plans with full nodal coverage were developed for 30 consecutive patients on paired DIBH and FB CT scans. Nodes were contoured according to ESTRO guidelines. Plan metrics were compared using Wilcoxon signed-rank testing.ResultsTwenty-one patients (70%) had ≥5% reduction in ipsilateral lung V20 with DIBH compared to FB. The mean ipsilateral lung V20 decrease was 7.8% (0 to 20%; p<0.001). The mean lung dose (MLD) decreased on average by 3.4Gy with DIBH (−0.2 to 9.1; p<0.001). The mean reduction in liver volume receiving 50% of the prescribed dose was 42.3cc (0 to 178.9; p<0.001).ConclusionsDIBH reduced the ipsilateral lung V20 by ≥5% for the majority of patients. For some patients, the volume of liver receiving a potentially toxic dose was reduced with DIBH. DIBH should be available as a treatment strategy to reduce ipsilateral lung V20 prior to compromising IMC nodal coverage for patients with right-sided breast cancer during loco-regional RT if the V20 on FB exceeds 30%.



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Long-term results of adjuvant versus early salvage post-prostatectomy radiation: a large single institutional experience

Publication date: Available online 19 October 2016
Source:Practical Radiation Oncology
Author(s): Daniela L. Buscariollo, Michael Drumm, Andrzej Niemierko, Rebecca H. Clayman, Sigolene Galland-Girodet, Danielle Rodin, Adam S. Feldman, Douglas Dahl, Francis J. McGovern, Aria Olumi, Alec Eidelman, William U. Shipley, Anthony L. Zietman, Jason A. Efstathiou
PurposeTo evaluate freedom from biochemical failure (FFBF), freedom from androgen deprivation therapy (FFADT), freedom from distant metastases (FFDM), and overall survival (OS) after adjuvant radiation therapy (ART) versus early salvage radiation therapy (ESRT) in men with prostate cancer and adverse pathologic features (pT3 and/or positive surgical margins).Methods and MaterialsOf 718 patients consecutively treated with postoperative radiation therapy (RT) for prostate cancer between 1992 and 2013, we retrospectively identified 171 men receiving ART and 230 receiving ESRT (RT delivered at PSA ≤0.5ng/ml) who had adverse pathologic features. Post-irradiation FFBF (BF was defined as PSA rise to ≥0.2ng/ml), FFADT, FFDM, and OS were compared using Kaplan–Meier and Cox regression methods. Propensity score (PS)-matching was performed to estimate treatment effects while accounting for covariates predicting treatment allocation.ResultsMedian follow-up was 7.4 and 8.0years for patients treated with ART and ESRT, respectively. Ten-year FFBF (69% versus 56%, p=0.003) and 10-year FFADT (88% versus 81%, p=0.046) rates were higher after ART; however, FFDM and OS did not significantly differ. After PS-matching, ART was associated with improved FFBF (p<0.0001), FFADT (p=0.0001), and FFDM (p=0.02). Findings were confirmed in multivariable analyses in unmatched and PS-matched cohorts.ConclusionPostoperative RT confers excellent long-term cancer control. These results suggest ART may be associated with improved FFBF, FFADT, and FFDM, but comparable OS. Given the retrospective study design, these findings should be interpreted with caution. Optimal timing of postoperative RT further awaits results of ongoing trials.



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The Likelihood of Unacceptable Normal Tissue Doses in Breast Cancer Patients Undergoing Regional Nodal Irradiation in Routine Clinical Practice

Publication date: Available online 19 October 2016
Source:Practical Radiation Oncology
Author(s): Jose Bazan, Dominic DiCostanzo, Karla Kuhn, Lonika Majithia, Allison Quick, Nilendu Gupta, Julia White
PurposeAs indications for regional nodal irradiation (RNI) for breast cancer have expanded, so too has scrutiny over potential late toxicity from radiotherapy. This emphasizes the need for careful radiation treatment planning to maximize the therapeutic ratio. We sought to evaluate how often unacceptable dosing (UD) to organs-at-risk (OAR) occurs and what factors were associated with this for patients receiving RNI in daily practice.Materials and MethodsTreatment records of patients who received RNI from 2/2012–5/2015 were studied. The NSABP B51/RTOG 1304 clinical dose-volume constraints for targets/OAR receiving RNI were used as the benchmark. Dose volume histograms (DVH) were analyzed for the rate of ≥1 UD to the following: Heart mean>5Gy; ipsilateral lung (IL): V20>35%, V10>60%, V5>70%; contralateral lung (CL) V5>15%; contralateral breast (CB) V4.1>5%. Logistic regression was used to test the association between UD to OAR and key variables.Results203 consecutive cases received RNI (105 left, 98 right). RT was to CW in 171 (84%). Internal mammary nodes (IMN) were included in 170 (84%). 77.4% of cases met all OAR constraints. The most common OAR UD were to the CB (n=32, 15.7%) and IL V5 (n=22, 10.8%). On multivariate analysis, use of IMRT (OR=64.7, 95% CI 20.8–201.5, p<0.001) and use of nodal boost (OR=5.5, 95% CI 1.1–27.1, p=0.04) but not IMN irradiation (OR=2.7, p=0.35) or reconstruction (OR=0.62, p=0.33) were independently associated with higher OAR UD rate. For 3DCRT plans, 7.9% had OAR UD.ConclusionThe OAR UD rate with 3DCRT+/−DIBH in routine clinical practice is low and not independently associated with IMN irradiation or reconstruction presence. Women treated with IMRT had a significantly higher overall OAR UD rate, and clinicians should be aware of this as they initiate RNI treatment planning.



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Hydrogel spacer distribution within the perirectal space in patients undergoing radiotherapy for prostate cancer: Impact of spacer symmetry on rectal dose reduction and the clinical consequences of hydrogel infiltration into the rectal wall

Publication date: Available online 17 October 2016
Source:Practical Radiation Oncology
Author(s): Benjamin W. Fischer-Valuck, Anupama Chundury, Hiram Gay, Walter Bosch, Jeff Michalski
PurposeHydrogel prostate-rectum spacers, biomaterials placed between the prostate and rectum, continue to gain interest as a method to reduce or limit rectal dose during dose escalated prostate cancer radiation therapy. Since the spacer is initially injected into the perirectal space as a liquid, the final distribution can vary. The purpose of this study was to evaluate hydrogel spacer (SpaceOAR® system) implantation and distribution from a recent prospective randomized control trial and correlate spacer symmetry with rectal dose reduction as well as rectal wall infiltration (RWI) to acute and late toxicity.Methods and MaterialsT2-weighted magnetic resonance imaging images for 149 patients enrolled on a prospective clinical trial who received transperineal spacer injection were assessed for hydrogel spacer midline symmetry and RWI using a semi-qualitative scoring system. Symmetry was then correlated to rectal dose reduction using a student t-test (one tailed, paired) while a Fisher's Exact test was used to correlate RWI with acute and late rectal toxicity. All patients had control treatment plans created prior to spacer injection.ResultsHydrogel spacer was symmetrically placed at midline for 71 (47.7%) patients at the prostate mid-gland as well as one centimeter superior and inferior to mid-gland. The remaining 78 (50.9%) patients had some level of asymmetry with only 2 (1.3%) having far lateral-distribution (i.e>2cm) of hydrogel spacer. As the hydrogel spacer became more asymmetric, the level of rectal dose reduction relative to their control plans decreased. However, all but the most asymmetrical 1.3% had significant rectal dose reduction (p<0.05). Rectal wall hydrogel spacer infiltration was seen in 9 (6.0%) patients. There was no correlation between RWI and procedure-related adverse events or acute/late rectal toxicity.ConclusionsSignificant reduction of rectal dose can still be achieved even in the setting of asymmetric hydrogel spacer placement. RWI does not correlate with patient complications.



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Recommendations for MRI-based contouring of gross tumor volume and organs at risk for radiotherapy of pancreatic cancer

Publication date: Available online 17 October 2016
Source:Practical Radiation Oncology
Author(s): H.D. Heerkens, W.A. Hall, X.A. Li, P. Knechtges, E. Dalah, E.S. Paulson, C.A.T. van den Berg, G.J. Meijer, E.J. Koay, C.H. Crane, K. Aitken, M. van Vulpen, B.A. Erickson
PurposeLocal recurrence is a common and morbid event in patients with unresectable pancreatic adenocarcinoma. A more conformal and targeted radiation dose to the macroscopic tumor in non-metastatic pancreatic cancer is likely to reduce acute toxicity and improve local control. Optimal soft tissue contrast is required to facilitate delineation of a target and creation of a planning target volume with margin reduction and motion management. MRI offers considerable advantages in optimizing soft tissue delineation and is an ideal modality for imaging and delineating a gross tumor volume within the pancreas, particularly as it relates to conformal radiation planning. Currently, no guidelines have been defined for the delineation of pancreatic tumors for radiotherapy treatment planning. Moreover, abdominal MRI sequences are complex and the anatomy relevant to the radiation oncologist can be challenging. The purpose of this study is to provide recommendations for delineation of gross tumor volume (GTV) and organs at risk (OARs) using MRI and incorporating multiple MRI sequences.MethodsFive pancreatic cancer patients and one healthy subject were imaged with MRI either on 1.5T or on 3T magnets in two separate institutes. The GTV and OARs were contoured for all patients in a consensus meeting.ResultsAn overview of MRI-based anatomy of the GTV and OARs is provided. Practical contouring instructions for the GTV and the OARs with the aid of MRI were developed and included in these recommendations. In addition, practical suggestions for implementation of MRI in pancreatic radiation treatment planning are provided.ConclusionsWith this report we attempt to provide recommendations for MRI-based contouring of pancreatic tumors and organs at risk. This could lead to better uniformity in defining the GTV and OARs for clinical trials and in radiotherapy treatment planning with the ultimate goal of improving local control while minimizing morbidity.SummaryThese recommendations describe the contouring of pancreatic tumors and organs at risk (OAR) using MRI. Practical contouring instructions for the gross tumor volume and OAR are provided based on five pancreatic cancer patients and one healthy subject. This report provides recommendations on how to integrate MRI into radiation treatment planning for pancreatic tumors and addresses the potential challenges of MRI.



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Lost in the Woods

Publication date: Available online 17 October 2016
Source:Practical Radiation Oncology
Author(s): Jyoti Mayadev




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Erratum to: Roos DE, Keys NK, Kirkwood ID. The bone scan as a “biological dosimeter”. Front cover images with case history. Pract Radiat Oncol. July/August 2016;6

Publication date: Available online 17 October 2016
Source:Practical Radiation Oncology
Author(s): Daniel E Roos, Robert N Keys, Ian D Kirkwood




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