Radiobiological rationale for stereotactic hypofractionated radiosurgery Part I. LQED2 or BED formalism

In conventional radiotherapy, 5R’s mechanisms influence tumour cell kill, but in SHRS they do not sufficiently explain the biology of large doses. Indirect cell death is also induced by endothelial damage, stem cell death and antitumour immunity are also activated by a single dose ≥ 12–15 Gy. These three processes defined as extra 3R’s are characterizers in details. Despite some controversies, LQED formalism seems not quite adequate for SHRS. Experimental and a few clinical studies suggest BED formalism as much more useful. Both formalisms are compared and discussed. Clinical reports show a monotonical increase in Tumour Cure Probability (TCP) with higher BED doses. The advantage of SHRS results in significant shortening overall treatment time and in delivery of the BED doses higher than 100 Gy, producing an increase in the TCP, likely unachievable by conventional dose fractionation

Radiobiological rationale for stereotactic hypofractionated radiosurgery Part II. Normal tissue tolerance — dose constraints

The response of normal tissues/organs to SHRS is more complex than to conventional radiotherapy. Tolerance doses TD5/5 and TD50/5, proposed by Rubin and Casarett, cannot be simply used for SHRS. Instead of LQED2, the BED is advised. The term risk dose (RD) corresponds better than TD to the risk of late morphological and functional disorders (OAR). BED doses show a rapid gradient with increasing distance of the OAR from the tumour GTV. Other risk factors include the dose-volume relationship, OAR organization (serial or parallel) and the ratio of the FSU to the target call. Vasculoendothelial cell damage initiates series of processes resulting in clinical and functional late effect. Using available data and studies, RDmin and RDmax for doses are listed as physical and BED doses for various OAR and dose-volume constraints. The RD values and constraints are rough estimates, since the available SHRS data are sparse and fragmentary, which should be interpreted cautiously and need further clinical validation

Radiobiological rationale for stereotactic hypofractionated radiosurgery Part II. Normal tissue tolerance — dose constraints

The response of normal tissues/organs to SHRS is more complex than to conventional radiotherapy. Tolerance doses TD5/5 and TD50/5, proposed by Rubin and Casarett, cannot be simply used for SHRS. Instead of LQED2, the BED is advised. The term risk dose (RD) corresponds better than TD to the risk of late morphological and functional disorders (OAR). BED doses show a rapid gradient with increasing distance of the OAR from the tumour GTV. Other risk factors include the dose-volume relationship, OAR organization (serial or parallel) and the ratio of the FSU to the target call. Vasculoendothelial cell damage initiates series of processes resulting in clinical and functional late effect. Using available data and studies, RDmin and RDmax for doses are listed as physical and BED doses for various OAR and dose-volume constraints. The RD values and constraints are rough estimates, since the available SHRS data are sparse and fragmentary, which should be interpreted cautiously and need further clinical validation

An effectiveness evaluation of the palmar fascia irradiation of patients suffering from Dupuytren’s disease

Introduction. Dupuytren’s disease (DD) is a fibroproliferative disorder of an unknown etiology manifested by a progressive contracture of fingers. The basic method of the treatment is surgery. Among non-surgical treatments, radiotherapy (RT) represents a relevant method. The aim of the study was to evaluate the efficacy of palmar fascia irradiation in patients with Dupuytren’s Disease. Material and methods. The research included a group of 117 patients with Dupuytren’s disease irradiated in the Department of Radiotherapy in the Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology in Gliwice. Patients’ medical records from the Institute of Oncology in Gliwice and the Provincial Hospital of Orthopedics and Trauma Surgery in Piekary Śląskie have been analysed retrospectively. The following were assessed: smoking history and the subjective evaluation of the effect of the therapy and its side effects before irradiation and check-up visits. All patients were irradiated to a total dose of 21 Gy given in 7 fractions. Results. After the RT, 35% of patients showed an improvement, in 58% of patients the disease progress stopped, whereas 7% of patients reported a deterioration. During the observation period, 7.5% of patients noted a deterioration of the contracture or the topical condition, in 35% stagnancy was observed, and 57.5% of patients showed a reduction of the contracture and an improvement in the topical condition. After the RT, 87.5% of patients had no side effects, in 7.5% there was a slight skin erythema, 2.5% had superficial epidermis exfoliation, and 2.5% reported dry skin. Conclusions. The obtained results allow one to conclude that palmar fascia irradiation is an effective method of treatment for patients with Dupuytren’s disease and it is characterised by a low proportion of complications

Radiobiological rationale for Stereotactic Hypofractionated Radiosurgery (SHRS) Part I. LQED2 or BED formalism

In conventional radiotherapy, 5R’s mechanisms influence tumour cell kill, but in SHRS they do not sufficiently explain the biology of large doses. Indirect cell death is also induced by endothelial damage, stem cell death and antitumour immunity are also activated by a single dose ≥ 12–15 Gy. These three processes defined as extra 3R’s are characterizers in details. Despite some controversies, LQED formalism seems not quite adequate for SHRS. Experimental and a few clinical studies suggest BED formalism as much more useful. Both formalisms are compared and discussed. Clinical reports show a monotonical increase in Tumour Cure Probability (TCP) with higher BED doses. The advantage of SHRS results in significant shortening overall treatment time and in delivery of the BED doses higher than 100 Gy, producing an increase in the TCP, likely unachievable by conventional dose fractionation

The “one-isocenter-quarter-beam” technique as a radiotherapy of breast cancer patients

AimTo describe the “one-isocentre-quarter-beam” technique, used in the Department of Radiotherapy, Maria Skłodowska-Curie Memorial Cancer Center, and in the Institute of Oncology, Gliwice Branch.Materials/MethodsSixty eight patients were treated using the “one-isocentre-quarter-beam” technique in our department. On the basis of this experience, we show the methods for treatment planning and irradiation and the methodology for marking the isocentre and fields. The workloads and times necessary for treatment planning and everyday irradiation were described along with the methodology for the collimation of the side of the lung and for the best alignment of tangential breast and supraclavicular fields. Other methods for irradiation were also compared and described.ResultsThis technique, with some modifications, is useful in several clinical situations, such as postoperative irradiation of patients after radical mastectomy or breast conserving therapy.The application of the described technique, together with the use of the IMRT technique, promises new possibilities.ConclusionsThe “one-isocentre-quarter-beam” technique permits the avoidance of hot spots. Planning is more time-consuming though an overall time benefit is seen during everyday irradiation. Reproducibility of positioning is simple and precise

Ocena skuteczności napromieniania rozcięgna dłoniowego u pacjentów cierpiących na chorobę Dupuytrena

Wstęp. Choroba Dupuytrena jest zaburzeniem fibroproliferacyjnym o nieznanej etiologii. Objawia się postępującym przykurczem palców dłoni. Podstawową metodą leczenia jest postępowanie chirurgiczne. Wśród niechirurgicznych metod leczenia swoje miejsce znajduje m.in. radioterapia (RT). Celem pracy jest ocena skuteczności napromieniania rozcięgna dłoniowego u pacjentów cierpiących na chorobę Dupuytrena. Materiał i metody. Analiząobjęto grupę 117 pacjentów cierpiących na chorobę Dupuytrena leczonych w Zakładzie Radioterapii w Centrum Onkologii — Instytutu im. Marii Skłodowskiej-Curie w Gliwicach. Retrospektywnie przeanalizowano dokumentacjęmedycznąInstytutu oraz Wojewódzkiego Szpitala Chirurgii Urazowej w Piekarach Śląskich. Zebrano dane sprzed napromieniania oraz z wizyt kontrolnych, dotyczące palenia tytoniu oraz subiektywnej oceny efektu zastosowanego leczenia i powikłań po nim. Wszyscy chorzy byli napromieniani do dawki całkowitej 21 Gy podanej w 7 dawkach frakcyjnych. Wyniki. Bezpośrednio po RT 35% chorych zgłaszało poprawę, u 58% odnotowano zatrzymanie procesu chorobowego, 7% chorych zgłosiło pogorszenie. W trakcie dalszej obserwacji u 7,5% chorych odnotowano pogorszenie stanu miejscowego, u 35% stagnację, u 57,5% poprawę stanu miejscowego. U 87,5% chorych nie odnotowano objawów ubocznych po RT, u 7,5% wystąpił niewielki rumień skóry, u 2,5% chorych powierzchowne łuszczenie naskórka, a 2,5% zgłaszało suchość dłoni. Wnioski. Uzyskane wyniki pozwalają sformułować wniosek, że radioterapia rozcięgna dłoniowego jest skutecznąmetodąleczenia pacjentów cierpiących na chorobę Dupuytrena oraz cechuje się niewielkim odsetkiem powikłań

Is there a place for radiotherapy in the management of giant condyloma: literature review

Olbrzymie kłykciny kończyste zwane również guzem Buschke-Loewensteina powstają w wyniku zezłośliwienia kłykcin kończystych okolicy odbytu i narządów płciowych. Z uwagi na duże rozmiary i okolice zajęte, leczenie chirurgiczne, będące podstawową terapią, w wielu przypadkach jest niemożliwe do przeprowadzenia lub okaleczające. Rola radioterapii nie jest jednoznaczna. Autorzy przedstawiają dane z piśmiennictwa potwierdzające skuteczność leczenia kłykcin olbrzymich promieniami.Giant condyloma also known as Buschke-Loewenstein tumour, is a malignant tumour of the genital and anal area, arising from genital warts. Due to the large size and the infiltrated region, in many cases surgical treatment, which is essential, is impossible to perform without maiming the patient. The role of radiation therapy is not clear. The authors present a literature review of the efficacy of giant condyloma radiotherapy

Overall and GTV subvolumes tumour control probability (TCP) for head and neck cancer treated by 3D-IMRT with inhomogeneous dose distribution

Introduction.  In this study, an original model has been developed to estimate the real TCP that is a product of the TCPs calculated for GTV subvolumes of head and neck cancer based on 3D-IMRT dose planning. Material and methods.  Retrospective pilot group consist of 16 cases of oropharyngeal cancer in stage T1–2N0 previously treated with 3D-IMRT with at least 3-year follow-up. The total dose (TD) was 60–70 Gy in 2.0 Gy fractions delivered over 42–49 days. Within GTV two subvolumes were marked out: SVA with the planned 100% TD, and underdosed (90–95%) SVB. The TCP for both was calculated using the original formula developed by Withers and Maciejewski. Results.  During 3-year follow-up, 8 local recurrences (LR) occurred. In about 70% of SVB “dose cold spots” encompassed more than 50% GTV volume. This resulted in the TCPSVB decrease to 60%. Thus, the real overall TCP was much lower than a priori predicted, and in these cases local recurrences occurred. Discussion.Both cold spot SVB volumes and their dose deficit strongly correlated with a high risk of LR. Conclusions.In conclusion the magnitude of dose deficit and the size of cold subvolume within GTV have an indepen­dent negative impact on real TCP and demand dose re-planning

The comparison of intensity modulated radiotherapy (IMRT) and conformal radiotherapy (CFRT) in planning of adiuvant radiotherapy for patients with pancreatic cancer

Wstęp. Rak trzustki jest szóstą przyczyną zgonów z powodu nowotworów złośliwych w Polsce. Wyniki leczenia są złe,a rokowanie niepomyślne. Podstawową metodą leczenia jest operacja i adiuwantowa chemio- lub radiochemioterapia.Znaczny postęp technologiczny, jaki dokonał się w ciągu ostatnich kilkunastu lat, umożliwia przeprowadzenie radioterapiiw sposób bardziej bezpieczny i precyzyjny dzięki zastosowaniu nowych technik w planowaniu radioterapii,obrazowaniu i prowadzeniu napromieniania.Cel. Celem badania jest porównanie radioterapii wiązką z modulacją intensywności dawki (IMRT) i radioterapii konformalnej3D (CFRT) u chorych na raka trzustki.Materiał i metoda. U każdego z piętnastu chorych wykonano cztery plany leczenia: techniką dwóch pól naprzeciwległych(2P), dwóch pól naprzeciwległych i jednego pola skośnego (3P), dwóch pól naprzeciwległych i dwóch pólskośnych (4P) oraz z zastosowaniem techniki z modulacją intensywności dawki (IMRT).Planowanie wykonano zgodnie z zaleceniami protokołu ICRU 50 i 62 w celu uzyskania dawki minimalnej w obszarzePTV nie niższej aniżeli 95% dawki całkowitej. Plany leczenia zostały porównane przy użyciu histogramów rozkładudawki w jej objętości (DVH — Dose Volume Histogram). Wyznaczono parametry V20 dla każdej z nerek, V30 dla wątroby,dawkę maksymalną dla rdzenia kręgowego i jelit, dawkę minimalną w obszarze PTV, dawkę średnią dla całej wątrobyoraz obu nerek. Obliczono wartości procentowego współczynnika pokrycia objętości tarczowej (PTC), indeksukonformalności (CI) oraz indeksu homogenności (HI). Celem porównania poszczególnych technik przeprowadzonoanalizę statystyczną przy pomocy nieparametrycznego testu Wilcoxona.Wyniki. Dawka minimalna w obszarze PTV (PTVmin) dla techniki dwupolowej wynosiła 42,8 Gy, dla techniki 3P— 42,9 Gy, 4P — 43,2 Gy oraz 43,2 Gy dla IMRT (p = 0,006). Dawka maksymalna w rdzeniu kręgowym była akceptowalnadla wszystkich technik planowania (3P — 44 Gy, 4P — 42 Gy, IMRT — 45 Gy) z wyjątkiem techniki dwupolowej2P — 47,7 Gy (2P vs IMRT p = 0,00065, 3P vs IMRT p = 0,95, 4P vs IMRT p = 0,005). Wartości parametru V20 dla nerekbyły porównywalne we wszystkich planach konformalnych. Dla lewej nerki wynosiły odpowiednio: 44,7%, 41%,40% w oparciu o techniki 2P, 3P i 4P oraz 11,3%, 10,7%, 9,2% dla nerki prawej. Wartości parametru V20 dla lewej nerkiwynosiły 18% i 6% dla nerki prawej po zastosowaniu planowania techniką IMRT (p < 0,002). Parametr V30 dla wątrobybył porównywalny we wszystkich wykonanych planach leczenia: 2P — 8,3%, 3P — 8%, 4P — 7% oraz IMRT — 7%.(2P vs IMRT p = 0,015, 3P vs IMRT p = 0,04, 4P vs IMRT p = 0,36). Dawka maksymalna w objętości jelit była porównywalnai akceptowalna po zastosowaniu każdej z technik napromieniania: 2P — 48,5 Gy, 3P — 47,0 Gy, 4P — 46,7 Gy,IMRT — 48,0 Gy (p = 0,001).Wnioski. Zastosowanie IMRT w planowaniu uzupełniającej radioterapii u chorych na raka trzustki pozwala na uzyskanielepszego rozkładu dawki i lepszą ochronę nerek w porównaniu z innymi technikami konformalnymi. Wszystkiezastosowane techniki pozwalają na uzyskanie porównywalnych rozkładów dawek w obszarze wątroby i jelit.Introduction. Pancreatic cancer is the sixth highest cause of mortality in patients with malignant neoplasms in Poland.The results of treatment are poor and prognosis unfavourable. The basic method of treatment is surgery withadjuvant chemo or radiochemotherapy.Aim. The aim of the study was to compare CFRT (2F, 3F, 4F) and IMRT in planning of adiuvant radiotherapy for fi fteenpatients with pancreatic cancer.Material and method. For each patient from this group four treatment plans were performed: three for CFRT andone for IMRT. The CFRT plans consisted of two opposite fi elds (2F), two opposite fi elds and one oblique fi elds (3F),two lateral and two oblique fi elds (4F) and the IMRT plan. The treatment plans were performed to achieve a minimumdose to the PTV which was no lower than 95% of the total prescribed dose. Treatment plans were compared usingdose-volume histograms (DVH) and using V20 parameter for left (LK) and right kidney (RK), V30 for liver (L), maximaldose for spinal cord (SC), maximal dose for intestines (IN), mean dose for whole liver and each kidney. The PTC (PercentTarget Coverage), CI (Conformity Index) and HI (Homogenity Index) parameters were evaluated for each plan. For theevaluation of statistical signifi cance the nonparametric Wilcoxon’s test was performed.Results. The minimum dose in the PTV (PTVmin) for 2F plan was: 42.8 Gy, 3F — 42.9 Gy, 4F — 43.2 Gy and in IMRT— 43.2 Gy (p = 0.006). The maximal dose for spinal cord was acceptable in all plans (3F — 44 Gy, 4F — 42 Gy, IMRT— 45 Gy) except in 2F — 47.7 Gy (2F vs IMRT p = 0.00065, 3F vs IMRT p = 0.95, 4F vs IMRT p = 0.005). The median volumefor each kidney V20 was comparable for all conformal plans. For the left kidney 44.7%, 41%, 40% for 2F, 3F and4F respectively and 11.3%, 10.7%, 9.2% for the right kidney. The V20 for the left kidney was 18% and 6% for the rightkidney using the IMRT plans (p < 0.002). The V30 for the liver was comparable for each of the plans: 2F — 8,3%, 3F— 8%, 4F — 7% and IMRT — 7%. (2F vs IMRT p = 0.015, 3F vs IMRT p = 0.04, 4F vs IMRT p = 0.36). The maximal doseto the intestines was acceptable in all plans 2F — 48.5 Gy, 3F — 47.0 Gy, 4F — 46.7 Gy, IMRT — 48.0 Gy (p = 0.001).Conclusions. Using IMRT in the planning of adjuvant radiotherapy for patients after surgery for pancreatic cancerachieves a better dose distribution and protection of kidneys compared to standard conformal planning. All techniquesachieved a similar dose distribution in the liver and intestines