Postoperative treatment of intermediate-risk early stage cervical cancer: results of a survey from the Gynecology Study Group in the AIRO Gyn and MITO Groups

This survey investigated prognostic factors, treatment modalities, references followed and radiation oncologists' opinions to prescribe adjuvant therapy in early intermediate-risk cervical cancer. All but one recommended pelvic radiotherapy ± vaginal boost (45%) with or without chemotherapy (20%). 88% believed other prognostic factors could integrate classic risk criteria. 66% considered chemo-radiation indicated in case of lymphovascular invasion and suboptimal node dissection, high grade, size ≥ 4cm, non squamous histology and risk factors combination. This wide heterogeneity of treatments reflects the different guideline options due to the lack of defined indications. The need of integrating the classic prognostic factors with others factors was unanimously expressed by radiation oncologists. The best local and systemic therapy should be established through new studies. These results highlighted the need of a position paper to standardize adjuvant treatment in Italy and to design collaborative studies to clarify the controversial aspects

Sport collaboration as a tool in cultural diversity. The experience of a neapolitan primary school

Text our society is presented with propaganda of aesthetic standards nearing perfection, exalting models of efficiency based on the excellence of the results of their competitive capacity, on the maniacal and narcissistic exhibition of winning models, especially in the world of sports where clearly the disabled are excluded. From this collective knowledge comes the idea to create activities within the school system that foresee the reality of disabilities. The experiment was carried out in an institute in Naples and involved two fourth grade classes, twenty students per class. Controlled recreational activities were introduced, where body movement and motor skills were limited. The goal of the project was to create a spontaneous relationship between children with normal abilities and those with handicaps. Adequate athletic activities were carried out, under form of recreation, guided by a teacher, necessary to carry out the tasks: children without disabilities were put in a position where they were able to live the disability of another child. The results of the data collected through the systematic observation and that of a survey show the predisposition of the child without physical impairments with regards to the disability, eliminating through a natural process the concepts of \u201cacceptance\u201d and \u201ctolerance\u201d and the internal existence of two worlds. This experience can surely be a starting point to create and elaborate the culture of diversity already at a young age

Preliminary epi-diode characterization for HDR brachytherapy quality assurance

High Dose Rate vaginal brachytherapy for endometrial cancer has evolved from simple single-channel (i.e. cylindrical applicator) deliveries to treatments involving several channels (i.e. multichannel applicator) for the radiotherapy source to dwell, increasing the complexity of the dose distribution, and allowing more space for potential errors. For this reason real-time treatment verification has gained a greater importance than ever before, and more methods need to be developed in order to provide assurance that the dose delivery has been carried out as intended by the hospital staff. P-type silicon epi diodes have been designed at the Centre for Medical Radiation Physics (CMRP) in Australia to suit the specific needs of HDR BT, and characterized in the clinical BT facility of the Fondazione IRCCS (INT) in Italy. They have shown great potential for BT treatment verification in real time due to their radiation hardness, dose rate independence, flexibility in physical design, and ability to monitor the treatment at a 1-kHz readout frequency. Their dynamic range has been determined as ± 17 to ± 20 mm and dwell time calculation accuracy of \u3e 0.1 s has been shown. If placed on the same longitudinal plane of a treatment accessory, these detectors would enable coverage of about 40 mm for source position and dwell time tracking. Respective detector positioning at (0, +3, -3 mm) would extend this range to 45-50 mm, depending on the catheter location, proving to be sufficient for the majority of treatment cases. Further studies are encouraged to develop diodes with a wider dynamic range

An innovative gynecological HDR brachytherapy applicator system for treatment delivery and real-time verification

The multichannel vaginal cylinder (MVC) applicator employed for gynecological high dose rate (HDR) brachytherapy increases dose delivery complexity, and thus makes the treatment more prone to errors. A quality assurance (QA) procedure tracking the source throughout dose delivery can detect dwell position and time errors in the multiple channels of the applicator. A new MVC system with integrated real time in vivo treatment delivery QA has been developed based on diodes embedded on the outer surface of the MVC. It has been pre-calibrated and verified using a non-clinical treatment plan with consecutive test positions and dwell times within each catheter, followed by the delivery of ten clinical plans of adjuvant vaginal cuff brachytherapy following hysterectomy for endometrial cancer. The non-clinical verification showed overall mean dwell position and time discrepancies between the nominal and measured treatment of −0.2 ± 0.5 mm and −0.1 ± 0.1 s (k = 1), respectively. The clinical plans showed mean positional discrepancies of 0.2 ± 0.4 and 0.0 ± 0.8 mm, for the central and peripheral catheters, respectively, and mean dwell time discrepancies of −0.1 ± 0.2 and −0.0 ± 0.1 s for central and peripheral catheters, respectively. The innovative prototype of the MVC system has shown the ability to track the source with sub-mm and sub-second accuracy, and demonstrated potential for its incorporation into the clinical routine

Vaginal Toxicity Management in Patients with Locally Advanced Cervical Cancer following Exclusive Chemoradiation—A Nationwide Survey on Knowledge and Attitudes by the Italian Association of Radiotherapy and Clinical Oncology (AIRO) Gynecology Study Group

Background and Objective: Exclusive radiotherapy, including external beam radiotherapy (EBRT) and interventional radiotherapy/brachytherapy (IRT/BT), with concurrent cisplatin-based chemotherapy, represents the standard of care in patients with locally advanced cervical cancer (LACC). The emerging topic of vaginal toxicity has become a key endpoint in LACC management, although different approaches and non-standardized procedures were available. Our aim was to analyze a nationwide study of the attitudes of Italian gynecological radiation oncology teams in the management of LACC patients’ vaginal toxicities. Methods: A nationwide survey of radiation oncologists specializing in the treatment of gynecological malignancies was performed, using the free SurveyMonkey platform, consisting of 26 items. The questionnaire was proposed by the Italian Association of Radiation Oncologists (AIRO) gynecological working group to all 183 Italian radiation oncology institutions, as per AIRO’s website. Results: Fifty-eight questionnaires (31%) were completed and returned. The assessment of acute and late vaginal toxicities was systematic in 32 (55.2%) and 26 (44.8%) centers, respectively. In the case of EBRT, 70.7% of centers, according to the contouring and treatment plan data, did not contour the vagina as an organ at risk (OAR). Vaginal dose constraints were heterogeneous for both EBRT and IRT/BT. Local treatment to prevent vaginal toxicity was prescribed by 60.3% of radiation oncologists, mostly vaginal hyaluronic acid cream, and one center recommended vaginal estrogen preparations. During follow-up visits, vaginal toxicity was considered an issue to be investigated always (n = 31) or in sexually active women only (n = 11). Conclusions: This survey showed that wide variation exists with regard to recording and treating vaginal toxicity after exclusive chemoradiation for cervical cancer, underscoring the need to develop more comprehensive guidelines for contouring e-dose reporting of the vagina, so as to implement clinical approaches for vaginal toxicity

Applications of MOSkin dosimeters for quality assurance in gynecological HDR brachytherapy: An in-phantom feasibility study

In vivo dosimetry (IVD) is an excellent mode of treatment verification and detection of possible overexposures. A feasibility study was conducted to evaluate a proposed IVD procedure for gynecological HDR brachytherapy procedure quality assurance. MO. Skin dosimeters were selected due to their small size and capability of measuring steep dose gradients, such as those relevant in HDR brachytherapy procedures. Two in-phantom experiments measuring dose with MO. Skins at the position simulating the rectal wall were conducted employing a cylindrical single channel applicator and a multichannel applicator. Three MO. Skins were incorporated onto a rectal catheter, which was then attached to the applicator, separated by a small wooden plaque, simulating the vaginal to rectal wall distance and fixing catheter position. This setup was inserted into a water phantom and three treatment plans prescribing 300 cGy to 3 different targets were assigned with various dose distributions. Each treatment was administered three times, and doses measured by the MO. Skins were recorded. Doses measured by the MO. Skins were within 5% of the dose determined by the treatment planning system (TPS), ranging between 208 and 332 cGy, depending on dosimeter position on the rectal catheter. The overall average dose difference between measured and TPS values was 2.09% ± 1.15% (ranging between 0.83 and 4.27%, with measured values always higher than TPS dose), subdivided in 1.40 ± 0.37% and 2.79 ± 1.27% for single and multichannel applicator experiments, respectively. An overall dose agreement between the TPS and measured values, detector reproducibility, and practicality of the rectal catheter demonstrated the suitability of the proposed method for in vivo real time QA purposes in gynecological HDR brachytherapy

Intraluminal Brachytherapy in Unresectable Extrahepatic Biliary Duct Cancer: An Italian Pooled Analysis

Background/Aim: To evaluate the outcome of patients with unresectable extrahepatic cholangiocarcinoma (CC) treated with external-beam radiotherapy (EBRT) and concurrent chemotherapy (CT) with or without intraluminal brachytherapy (ILBT) boost or with definitive ILBT. Patients and Methods: A pooled analysis of patients with nonmetastatic unresectable CC was performed. They were treated in three different institution with EBRT plus CT with or without an ILBT boost. Some patients received only ILBT with curative dose. Results: Seventy-three patients were included in the analysis. Thirty-nine patients (53%) received EBRT treatment with ILBT boost (18 patients with CT during EBRT), while 28 patients (38%) were treated with EBRT (CT in 26 patients) and 6 patients (8.2%) with definitive ILBT (2 patients with CT). CT was administered including either the use of gemcitabine or 5-fluorouracil. With a median followup of 16 month (range=1-94 months), median overall survival (OS) was 16 months. Overall median LC was 16 months and patients who underwent ILBT had a better local control (LC) (p=0.018). Conclusion: The role of ILBT in unresectable CC is not yet supported by robust evidence in the literature. However, within this limit, preliminary results seem to suggest an improved local control in patients treated with ILBT, almost comparable to the ones of standard chemo-radiotherapy (CRT)

Study of the correlation between rectal wall in vivo dosimetry performed with MOSkins and implant modification during TRUS-guided HDR prostate brachytherapy

In transrectal-US guided HDR prostate brachytherapy, modifications of the geometry of the needle implant can arise in the time lapse between image acquisition and dose delivery. The aim of the present study was to investigate whether in vivo dosimetry measurements could be directly correlated to possible intra-fraction modifications of the implants. During 14 HDR prostate brachytherapy treatments, in vivo dosimetry measurements were performed with an array of two MOSkin detectors integrated onto the longitudinal axis of the transrectal-US probe. The implant displacement was quantified as the difference between the barycenters of the needle location on images acquired prior to treatment planning and after treatment delivery (ΔIB). A further parameter that takes into account also the needle distance from the dosimeters and the planned source dwell times was calculated (ΔwIB). Correlation analysis was performed to indicate any possible relationship between measured and calculated dose discrepancies (ΔDDPPvsTPS) and both ΔIB and ΔwIB. ΔDDPPvsTPS, ranged from a minimum of −19.5% to a maximum of 15.8%. Analysis of the implant barycentre shifts demonstrated a clear systematic trend of the needle implant in the direction of the rectum, with a consequent increase of the dose to the rectal wall. A moderate correlation of r = 0.64 was found between ΔDDPPvsTPS and ΔIB in the antero-posterior direction (ΔIBy), with r increasing to 0.74 if ΔwIBy was considered. The modification in dose to the rectal wall, as a consequence of implant migration that possibly happens in the time lapse between image acquisition and dose delivery, was correctly identified by IVD performed with MOSkins. This study is a further demonstration on how the application of IVD systems may facilitate improvements in quality for HDR prostate brachytherapy

Cervical cancer patterns of care in Italy: A radiation oncology survey of MITO and AIRO GYN groups

Large heterogeneity in therapeutic approaches to cervical cancer (CC) patients has been registered worldwide; a national survey exploring practice settings and equipments in CC treatment was distributed to radiation oncologists. Questionnaires were compiled in 90 of 194 Centers (compliance: 46.3 %). Most of respondents reported the presence of multidisciplinary tumor board, and modern equipments/techniques; 55.5 % of centers reported >1 brachytherapy (BT) equipment, thus implying the need to refer their patients outside for the remaining centers. Post-surgery radiotherapy was performed in 96.7 % of early CC (ECC) cases with pathological high risk factors. Exclusive chemoradiation with concomitant platinum schedules was referred to be used by 84.4 % of centers in locally advanced CC. Alternative options were reported with a range between 4.4 and 28.9 %. The present survey reports a broad spectrum of therapeutic options for CC in Italy. Availability and use of modern techniques is quite diffuse, but the distribution of BT resources and skills remains a challenge

In vivo rectal wall measurements during HDR prostate brachytherapy with MOSkin dosimeters integrated on a trans-rectal US probe: Comparison with planned and reconstructed doses

Background and purpose: To study if MO. Skin detectors coupled to a trans-rectal ultrasound (TRUS) probe may be used for in vivo dosimetry on the rectal wall surface during US-based HDR prostate brachytherapy and to quantify possible discrepancies between planned and delivered doses. Materials and methods: MO. Skins are a specific type of MOSFET dosimeter optimized to measure dose in steep dose gradients on interfaces. Two MO. Skins were assembled on a TRUS probe used for on-line treatment planning. Measurements of the dose to the rectal wall were performed over 18 treatment sessions and compared to the doses calculated on the pre-treatment plan (DPRE ) and reconstructed on post-treatment images (DPOST ). Results: Averages of the absolute differences between MO. Skin readings and DPRE , MO. Skin readings and DPOST and DPRE and DPOST were 6.7. ±. 5.1%, 3.6. ±. 1.9% and 6.3. ±. 4.7%, respectively. Agreement between measurements and DPOST was significantly better than between measurements and DPRE (p = 0.002) and DPRE and DPOST (p = 0.004). Discrepancy between DPOST and DPRE correlated with the time required for treatment planning. Conclusion: MO. Skin dosimeters integrated to the TRUS probe proved to be an accurate instrument for measuring the dose delivered to the rectal wall in HDR prostate brachytherapy. The delivered doses may differ significantly from those calculated in the treatment plan