Oligometastasis in breast cancer-current status and treatment options from a radiation oncology perspective

Evidence from a few small randomized trials and retrospective cohorts mostly including various tumor entities indicates a prolongation of disease free survival (DFS) and overall survival (OS) from local ablative therapies in oligometastatic disease (OMD). However, it is still unclear which patients benefit most from this approach. We give an overview of the several aspects of stereotactic body radiotherapy (SBRT) in extracranial OMD in breast cancer from a radiation oncology perspective. A PubMed search referring to this was conducted. An attempt was made to relate the therapeutic efficacy of SBRT to various prognostic factors. Data from approximately 500 breast cancer patients treated with SBRT for OMD in mostly in small cohort studies have been published, consistently indicating high local tumor control rates and favorable progression-free (PFS) and overall survival (OS). Predictors for a good prognosis after SBRT are favorable biological subtype (hormone receptor positive, HER2 negative), solitary metastasis, bone-only metastasis, and long metastasis-free interval. However, definitive proof that SBRT in OMD breast cancer prolongs DFS or OS is lacking, since, with the exception of one small randomized trial (n = 22 in the SBRT arm), none of the cohort studies had an adequate control group. Further studies are needed to prove the benefit of SBRT in OMD breast cancer and to define adequate selection criteria. Currently, the use of local ablative SBRT should always be discussed in a multidisciplinary tumor board

Die Herzmortalität nach Strahlentherapie, Chemotherapie und endokriner Therapie des Mammakarzinoms

Background!#!To design a simulator for novices without prior experience in embolization with liquid agents such as n-Butyl cyanoacrylate (n-BCA) and to evaluate the simulator using surveys and post hoc video analysis.!##!Materials and methods!#!The simulator was created using computer-aided design software and three-dimensionally printed. Before an embolization, trainees completed questionnaires regarding their level of expertise and self-reported confidence level. The participants were shown an instruction video and each participant performed four embolizations on the simulator. Subsequently, the participants completed surveys on self-reported confidence level and assessed the simulator's face and content validity.!##!Results!#!Five experts and twelve novices trained on the simulator. The experts were radiology residents and fellows with at least 5 years of work experience in interventional radiology. The novices were medical students and radiology residents without any previous experience with embolization. Based on the surveys, the experts assessed the simulator as very useful for embolization training. Performance, e.g. mean duration embolization between experts (mean ± standard deviation = 189 ± 42 s) and novices (mean ± standard deviation = 235 ± 66 s) were significantly different (p = .001). The overall simulation of the embolization process, simulated complications, and educational capabilities of the simulator were evaluated positively. In the novice group the self-reported confidence level significantly increased (p = .001).!##!Conclusion!#!The liquid embolization simulator proposed here is a suitable educational tool for training embolization procedures. It reduces the duration of embolization procedures and improves the confidence level of beginners in embolization

Das Lymphödemrisiko von Mammakarzinompatientinnen nach Operation oder Strahlentherapie der Axilla

Background!#!Patients with atraumatic abdominal pain are common in the emergency department and have a relatively high hospital mortality, with a very wide spectrum of different causes. Rapid, goal-directed diagnosis is essential in this context.!##!Methods!#!In a Delphi process with representatives of different disciplines, a diagnostic treatment pathway was designed, which is called the Abdominal Pain Unit (APU).!##!Results!#!The treatment pathway was designed as an extended event process chain. Crucial decision points were specified using standard operating procedures.!##!Discussion!#!The APU treatment pathway establishes a consistent treatment structure for patients with atraumatic abdominal pain. It has the potential to improve the quality of care and reduce intrahospital mortality over the long term

Kardioonkologie: Herzdosis während einer Radiotherapie im Thoraxbereich

Background!#!Patients with atraumatic abdominal pain are common in the emergency department and have a relatively high hospital mortality, with a very wide spectrum of different causes. Rapid, goal-directed diagnosis is essential in this context.!##!Methods!#!In a Delphi process with representatives of different disciplines, a diagnostic treatment pathway was designed, which is called the Abdominal Pain Unit (APU).!##!Results!#!The treatment pathway was designed as an extended event process chain. Crucial decision points were specified using standard operating procedures.!##!Discussion!#!The APU treatment pathway establishes a consistent treatment structure for patients with atraumatic abdominal pain. It has the potential to improve the quality of care and reduce intrahospital mortality over the long term

Adjuvante Radiotherapie beim Niedrigrisikomammakarzinom: Langzeitergebnisse der ABCSG-8A-Studie

Background!#!There are different contouring guidelines for definition of the clinical target volume (CTV) for intensity-modulated radiation therapy (IMRT) of anal cancer (AC). We conducted a planning comparison study to evaluate and compare the dose to relevant organs at risk (OARs) while using different CTV definitions.!##!Methods!#!Twelve patients with a primary diagnosis of anal cancer, who were treated with primary chemoradiation (CRT), were selected. We generated four guideline-specific CTVs and subsequently planned target volumes (PTVs) on the planning CT scan of each patient. An IMRT plan for volumetric arc therapy (VMAT) was set up for each PTV. Dose parameters of the planned target volume (PTV) and OARs were evaluated and compared, too.!##!Results!#!The mean volume of the four PTVs ranged from 2138 cc to 2433 cc. The target volumes contoured by the authors based on the recommendations of each group were similar in the pelvis, while they differed significantly in the inguinal region. There were no significant differences between the four target volumes with regard to the dose parameters of the cranially located OARs. Conversely, some dose parameters concerning the genitals and the skin varied significantly among the different guidelines.!##!Conclusion!#!The four contouring guidelines differ significantly concerning the inguinal region. In order to avoid inguinal recurrence and to protect relevant OARs, further investigations are needed to generate uniform standards for definition of the elective clinical target volume in the inguinal region

Ösophaguskarzinom: Prognoseverbesserung durch neoadjuvante Radiochemotherapie

Purpose!#!Digitalization of medical education is an important trend in terms of reforming and modernizing the global education environment. It has been long requested by students and politicians. The goal of this study was to assess the student perception of a newly developed digital educational program in radiation oncology (RO) using an interactive e‑book combined with short learnings clips on a YouTube channel combined with periodic videoconferences and a forum for queries.!##!Methods!#!We performed five evaluations during and at the end of two terms with multiple-choice and free-text answers. We evaluated student perception of our new digital learning scenario in three semesters: one pre-clinical and two clinical semesters. In addition, we analyzed all comments from the kMED forum, the YouTube channel, or the e‑mail contacts. We analyzed the learning behavior of the students based on access to the videos and the number and quality of the reflective questions answered as well as the results of the final examinations.!##!Results!#!The students accepted the offer for asynchronous teaching and mainly learned on weekdays (74% of the videos), but also on weekends (23%) and less on public holidays (4%). The answer quality of the reflective questions was good with over 50% correct answers on the first attempt. Learning to be on one's own authority was very difficult for the students, even in the last clinical semesters of the medical study. Without direct intervention by the teacher, access to the learning material by the students was limited and delayed. Therefore, voluntary interim tests were performed during the first analysis term, which led to an increased number of student accesses to the videos and higher number of answers. Nevertheless, in the first analysis term, the average results in the final exam of the students who did not perform the interim test were below average at 59.1%, and the students who performed the test had better results at 69.5% but this was also not satisfactory. In the second analysis term, we taught with the same digital teaching model but with an additional scheme for learning over the term, 2‑week compulsory intermediate tests, and frequent videoconferences to answer any questions. In this term, we measured a success rate of 93% in the final exam. All annotations were very positive regarding the new educational project. The evaluations showed high acceptance of the new education program. The students stated they would prefer the new education course to be continued in future.!##!Conclusion!#!Digital teaching methods make not only the type and quality of teaching transparent, but also the learning behavior of the students. Our analysis has shown that, in addition to the quality of the teaching, the clear structure and specification of the learning content per learning week as well as regular monitoring of what has been learned are of decisive importance for the learning success of the students

Breast clinical target volume: HU-based glandular CTVs and ESTRO CTVs in modern and historical radiotherapy treatment planning

Purpose!#!The current study aimed to compare contouring of glandular tissue only (gCTV) with the clinical target volume (CTV) as defined according to European Society for Radiotherapy and Oncology (ESTRO) guidelines (eCTV) and historically treated volumes (marked by wire and determined by palpation and anatomic landmarks) in breast cancer radiotherapy.!##!Methods!#!A total of 56 consecutive breast cancer patients underwent treatment planning based solely on anatomic landmarks/wire markings ('wire based'). From these treatment plans, the 50% and 95% isodoses were transferred as structures and compared to the following CT-based volumes: eCTV; a Hounsfield unit (HU)-based automatic contouring of the gCTV; and standardized planning target volumes (PTVs) generated with 1‑cm safety margins (resulting in the ePTVs and gPTVs, respectively).!##!Results!#!The 95% isodose volume of the wire-based plan was larger than the eCTV by 352.39 ± 176.06 cm!##!Conclusion!#!Historical wire and anatomic landmarks-based treatment planning sufficiently covers the glandular tissue and the theoretical gPTV generated for the glandular tissue. Modern CT-based CTV and PTV definition according to ESTRO results in a larger treated volume than the historical wire-based techniques. HU-standardized glandular tissue contouring results in a significantly smaller CTV and might be an option for reducing the treatment volume and improving reproducibility of contouring between institutions

Long-term survival in metastasized leiomyosarcoma: a case report and review of the literature

BACKGROUND: Leiomyosarcoma of the mesosigma is a very rare entity, with low 5-year survival rates. Treatment consists of resection of the primary tumor and, if applicable, of synchronous or metachronous metastases. Local treatment options for metastatic disease should be exploited as long as possible, as response to chemotherapy is reportedly disappointing. Stereotactic radiotherapy is a fairly new locally effective treatment option which has been well established in stereotactic radiotherapy of lung tumors. Whether repeated stereotactic radiotherapy sessions for treatment of lung metastases can be safely and successfully performed over a long time period is not yet well documented. CASE REPORT: We present the case of a 71-year-old female patient who had a primary diagnosis of lung metastases 12 years ago. Atypical resections of 4 lung metastases were performed in 2001 and 2002. Between 2004 and 2011, 7 sessions of stereotactic body irradiation of lung metastases were performed. All stereotactic treatment were tolerated well (no radiation pneumonitis, FEV1 was 1.3 L [67.8%] in 2004 and 0.99 L [56.3%] in 2011). CONCLUSIONS: The present case could demonstrate that a repetitive treatment of lung metastases with multiple stereotactic radiotherapy sessions can lead to long-term survival with a good quality of life