From technological advances to biological understanding: The main steps toward high-precision RT in breast cancer.

Radiotherapy improves local control in breast cancer (BC) patients which increases overall survival in the long term. Improvements in treatment planning and delivery and a greater understanding of BC behaviour have laid the groundwork for high-precision radiotherapy, which is bound to further improve the therapeutic index. Precise identification of target volumes, better coverage and dose homogeneity have had a positive impact on toxicity and local control. The conformity of treatment dose due to three-dimensional radiotherapy and new techniques such as intensity modulated radiotherapy makes it possible to spare surrounding normal tissue. The widespread use of dose-volume constraints and histograms have increased awareness of toxicity. Real time image guidance has improved geometric precision and accuracy, together with the implementation of quality assurance programs. Advances in the precision of radiotherapy is also based on the choice of the appropriate fractionation and approach. Adaptive radiotherapy is not only a technical concept, but is also a biological concept based on the knowledge that different types of BC have distinctive patterns of locoregional spread. A greater understanding of cancer biology helps in choosing the treatment best suited to a particular situation. Biomarkers predictive of response play a crucial role. The combination of radiotherapy with molecular targeted therapies may enhance radiosensitivity, thus increasing the cytotoxic effects and improving treatment response. The appropriateness of an alternative fractionation, partial breast irradiation, dose escalating/de-escalating approaches, the extent of nodal irradiation have been examined for all the BC subtypes. The broadened concept of adaptive radiotherapy is vital to high-precision treatments

Is Stereotactic Body Radiotherapy (SBRT) in lymph node oligometastatic patients feasible and effective?

ObjectivesTo review the available data about stereotactic body-radiotherapy (SBRT) for oligometastatic lymph node cancer recurrence.MethodsThe inclusion criteria for this study were as follows: Medline search for the (1) English language (2) full paper (abstracts were excluded) on (3) adult oligometastatic solid cancer recurrence limited to lymph node that underwent SBRT (4) outcome data available and (5) published up to the 30th April 2014.Results38 papers fulfilling the inclusion criteria have been found: 7 review articles and 31 patient series (20 and 11 retrospective and prospective studies, respectively) including between 1 and 69 patients (636 lymph nodes). Twelve articles reported only lymph node SBRT while in 19 – all types of SBRT including lymph node SBRT were presented. Two-year local control, 4-year progression free survival and overall survival was of up to 100%, 30% and 50%, respectively. The progression was mainly out-field (10–30% of patients had a recurrence in another lymph node/nodes). The toxicity was low with mainly mild acute events and single grade 3–4 late events. When compared to SBRT for any oligometastatic cancer, SBRT for lymph node recurrence carried better prognosis and showed lower toxicity.ConclusionsSBRT is a feasible approach for oligometastatic lymph node recurrence, offering excellent in-field tumor control with low toxicity profile. The potential abscopal effect has been hypothesized as a basis of these findings. Future studies are warranted to identify the patients that benefit most from this treatment. The optimal combination with systemic treatment should also be defined

Cancer treatment-induced oral mucositis

Oral mucositis is one of the main complications in non-surgical cancer treatments. It represents the major dose-limiting toxicity for some chemotherapeutic agents, for radiotherapy of the head and neck region and for some radiochemotherapy combined treatments. Many reviews and clinical studies have been published in order to define the best clinical protocol for prophylaxis or treatment of mucositis, but a consensus has not yet been obtained. This paper represents an updated review of prophylaxis and treatment of antineoplastic-therapy-related mucositis using a MEDLINE search up to May 2006, in which more than 260 clinical studies have been found. They have been divided according to antineoplastic therapy (chemotherapy, radiotherapy, chemo-radiotherapy, high-dose chemotherapy). The prophylactic or therapeutic use of the analysed agents, the number of enrolled patients and the study design (randomized or not) were also specified for most studies. Accurate pre-treatment assessment of oral cavity hygiene, frequent review of symptoms during treatment, use of traditional mouthwashes to obtain mechanical cleaning of the oral cavity and administration of some agents like benzydamine, imidazole antibiotics, tryazolic antimycotics, povidone iodine, keratinocyte growth factor and vitamin E seem to reduce the intensity of mucositis. Physical approaches like cryotherapy, low energy Helium-Neon laser or the use of modern radiotherapy techniques with the exclusion of the oral cavity from radiation fields have been shown to be efficacious in preventing mucositis onset. Nevertheless a consensus protocol of prophylaxis and treatment of oral mucositis has not yet been obtained

173. Does the correlation between chemotherapy-induced leukopenia with response in locally advanced breast cancer exist?

PurposeThe correlation between chemotherapy-induced toxicity and treatment outcome in cancer patients has not been thoroughly studied. Our aim was to evaluate whether leukopenia following primary chemotherapy may be predictive for response in patients with locally advanced breast cancer.Patients and MethodsThe records of 164 breast cancer patients administered primary chemotherapy between 1985 and 1995 were analysed. Most of the patients presented with locally advanced disease, however included were also patients with large operable tumours. Chemotherapy included one of the three combinations: CMF; modified Cooper regimen (CMFVP); 31 patients (19%), anthracycline-based regimens (FAC and FEC); 16 patients (10%) and 118 patients (71%).ResultsThe objective response rate in the entire group was 58%; 75% in patients who developed grade 2–3 leukopenia during induction chemotherapy, and 52% in those who had no or grade 1 leukopenia (p < 0.01, multivariate analysis). No other patient- or treatment-related factor including age, performance status, T stage, N stage, supraclavicular Iymph node involvement, inflammatory carcinoma or chemotherapy regimen correlated with response to chemotherapy. There was no correlation between treatment-induced leukopenia and overall survival.ConclusionsThese findings suggest a relationship between chemotherapy induced leukopenia and tumour response in patients with locally advanced breast cancer. The prognostic impact of leukopenia is negliglble

Three-times daily radiotherapy after chemotherapy in stage III non-small cell lung cancer. Single-institution prospective study

Aim: A prospective study for stage IIIA-B non-small cell lung cancer (NSCLC), with three-times daily (3td) radiotherapy (RT), after induction chemotherapy (iCT), with or without surgery. Patients and Methods: Induction cisplatin and gemcitabine chemotherapy was delivered. Surgery and postoperative (post-op) radiotherapy were planned for responsive stage IIIA patients; definitive irradiation was performed in unresectable III A and IIIB patients. Doses of 54.4 and 64.6 Gy were delivered for the post-op and definitive treatments, respectively. Results: Out of 52 patients (pts), 37 received 3tdRT as definitive (18 pts) or post-op treatment (19 pts). Overall, the failures were similar between post-op and definitive 3tdRT (78.9% vs. 77.8%). In the post-op treatment, metastases and local failures were 52.6% and 10.5%, respectively and in the definitive radiotherapy, the incidence was similar (local 33.3% vs. systemic 44.4%). The five-year overall survival (OS) was 25% for the post-op and 21% for the definitive patients (p=0.87). Conclusion: Three-times daily postoperative radiotherapy did not improve the outcome in NSCLC, but for unresectable patients, this approach may have a role in selected cases

Salvage radical prostatectomy after external beam radiation therapy: A systematic review of current approaches

Background: Radical external beam radiotherapy (EBRT) is a standard treatment for prostate cancer patients. Despite this, the rate of intraprostatic relapses after primary EBRT is still not negligible. There is no consensus on the most appropriate management of these patients after EBRT failure. For these patients, local salvage therapy such as radical prostatectomy, cryotherapy, and brachytherapy may be indicated. Objective: The objectives of this review were to analyze the eligibility criteria for careful selection of appropriate patients and to evaluate the oncological results and complications for each method. Methods: A review of the literature was performed to identify studies of local salvage therapy for patients who had failed primary EBRT for localized prostate cancer. Results: Most studies demonstrated that local salvage therapy after EBRT may provide long-term local control in appropriately selected patients, although toxicity is often significant. Conclusions: Our results suggest that for localized prostate cancer recurrence after EBRT, the selection of a local treatment modality should be made on a patient-by-patient basis. An improvement in selection criteria and an integrated definition of biochemical failure for all salvage methods are required to determine which provides the best oncological outcome and least comorbidity

2 Ocena porównawcza dawki w odbytnicy obliczonej dwiema metodami w brachyterapii śródjamowej chorych na raka szyjki i trzonu macicy

WstępW Klinice Onkologii i Radioterapii AMG od 1985 roku stosowana jest brachyterapia cezowa przy użyciu aparatu Selektron LDR. Dawkę maksymalną w odbytnicy do roku 1995 wyznaczano stosując wprowadzony doodbytniczo drucik ołowiany w osłonce plastikowej (R1), a w ostatnich latach zgodnie z zaleceniami Raportu 38 ICRU, dodatkowo oznacza się ją lokalizując tylną ścianę pochwy przez tamponowanie gazikami zawierającymi cieniującą na radiogramach nitkę (R2).Cel pracyPorównanie dawek fizycznych (R1 i R2) i równoważnych im dawek biologicznych (r1 i r2) w odbytnicy, obliczonych powyższymi dwiema metodami.Materiał i metodyAnaliza dotyczyła 124 aplikacji cezu u 102 chorych na raka szyjki lub trzonu macicy, leczonych śródjamowo podczas skojarzonego lub pooperacyjnego napromieniania. Rozkład dawki w miednicy małej obliczano za pomocą komputerowych systemów planowania, wykorzystując 2 prostopadłe radiologiczne zdjęcia lokalizacyjne.Dawki biologiczne obliczono przy pomocy modelu liniowo-kwadratowego, przyjmując α/β=4.WynikiW 83% przypadków wartość bezwzględna dawek R1 była niższa od R2. Wartości średnie dawek R1 i R2 oraz r1 i r2 wynosiły odpowiednio: 13,2 ±4,3 Gy i 16,9 ±4,4 Gy oraz 16,8 ±8,0 Gy i 24,0 ±9,6 Gy. Średnia różnica między R1 i R2 oraz r1 i r2 wynosiła 3,7 Gy (95% CI, 3,03–4,41 Gy) i 7,2 Gy (95% CI, 5,77–8,56 Gy), odpowiednio i jest statystycznie znamienna (