Radiotherapy and Brachytherapy for Unresectable Cholangiocarcinoma

ABSTRACT Cholangiocarcinoma is a rare cancer arising from the bile ducts and carrying a poor prognosis. Radical surgery is the gold standard treatment and the only potential cure for this cancer but less than half of the tumours are resectable at the time of diagnosis. The role of radiotherapy or chemoradiotherapy remains undefined due to the lack of randomized phase three trials. The only randomized study on chemoradiation versus chemotherapy was a phase II trial comparing chemotherapy (gemcitabine plus oxaliplatin) with chemoradiation (50 Gy plus concurrent 5-fluorouracil plus cisplatin) in locally advanced biliary tract cancer. Unfortunately, the trial was closed before completion due to slow recruitment. Radiation therapy, chemotherapy and/or chemoradiation can be used in patients with non-resectable disease in an attempt to downstage the tumour, palliate symptoms and extend survival. Further studies are needed to better define the role of radiotherapy in the setting of advanced biliary cancers. \uf02

T staging and target volume definition by imaging in gu tumors

The diagnosis of prostate cancer is usually per formed with random transrectal ultrasonography guided biopsies in patients that are found with elevated serum PSA or positive digital rectal examination. PSMA positron emission tomogra phy/computed tomography (PET/CT) imaging showed good accuracy to stage prostate cancer, but the sensitivity of this method remains subop timal, particularly in the detection of small lymph nodal metastasis. Magnetic resonance imaging (MRI) currently plays a main role in the different phases of pros tate cancer management such as the detection, local staging, active surveillance, and follow-up. Instead CT is limited to the assessment of distant metastases as it shows low sensitivity in the iden tification of both localized lesions and lymph node metastases. The use of multiparametric MRI has been demonstrated to improve the accuracy of tumor localization, making MRI the modality of choice for local staging of prostate tumor. Radiotherapy (RT) for prostate cancer can be modulated in terms of dose, target volumes, and integration with androgen deprivation therapy. This modulation is performed by defining differ ent risk groups based on PSA value, Gleason score, and tumor/nodal stage. According to the different risk groups, the clinical target volume includes only the prostatic gland in low-risk pros tate cancer, and prostate, seminal vesicles, and pelvic lymph nodes (LNs) in high-risk prostate cancer. Using external beam radiotherapy (EBRT), MRI allows reduction of delineated tar get volumes while improving extracapsular extension and seminal vesicle invasion detection with potential impact on clinical outcome. Also, in brachytherapy treatments, MRI can accurately identify prostate gland

Radiotherapy of pancreatic cancer in older patients: A systematic review

Pancreatic cancer (PaC) will soon be one of the main causes of cancer mortality. Furthermore, its incidence is higher in the older population and radiotherapy (RT) represents a treatment option. The aim of this review was to evaluate feasibility and outcome of RT in older patients with PaC. A systematic literature review of patients aged 6565\u202fyears with PaC treated with RT was performed using the PRISMA methodology. Eleven papers (1830 patients) fulfilled our inclusion criteria and were analyzed. RT was prescribed either alone or as an adjuvant treatment. Prescribed RT dose ranged from 22.0 to 70.0\u202fGy with conventional fractionation or hypo-fractionated schedule and delivered by three-dimensional conformal RT, intensity modulated RT or stereotactic body RT. Grade\u202f 65\u202f3 acute and grade\u202f 65\u202f2 late toxicity rates ranged between 0.0% and 52.6% (median: 0.5%) and between 0.0% and 15.0% (median: 0%), respectively. Median overall survival and two-year survival rate were 11.3\u202fmonths (range: 6.4-69.0\u202fmonths) and 49.0% (range 6.6-75.5%), respectively. RT in older patients seems to be tolerable and safe particularly in terms of late toxicity irrespective of the treatment settings. Therefore, RT can represent a treatment option in PaC even in an older population. Further analyses and prospective trials enrolling older patients are needed to better define the risk/benefit ratio in different treatment settings

Intensity modulated radiation therapy and oral mucosa sparing in Head and neck cancer patients: A systematic review on behalf of Italian Association of Radiation Oncology – Head and neck working group

Oral mucositis is a common dose-limiting toxicity during radiotherapy with or without chemotherapy in head and neck cancer patients. This potentially severe complication globally worsens quality of life and negatively impacts local control and survival's outcomes. Several studies have been published on feasibility and/or clinical benefit of intensity modulated radiotherapy (IMRT) mucosa-sparing technique. In 2017, the Italian Association of Radiation Oncology Head and Neck Cancer Working Group organized a study group to perform a systematic review. The aim was to verify if practical indications, including dose-constraints and demonstrated clinical benefit, could be proposed for oral mucosa (OM)-sparing IMRT in order to reduce the incidence of severe acute mucositis. Although dose to OM should be reduced as much as possible without compromising target volumes coverage, it is still tricky to firmly state that OM-sparing procedure should be considered the standard of care, especially due to high subjective variability in OM contour

Brachytherapy boost after chemoradiation in anal cancer: A systematic review

Radio-chemotherapy (RCT) is the primary treatment of anal cancer (AC). However, the role and the optimal total dose of a radiation boost is still unclear. No randomized controlled trials nor systematic reviews have been performed to analyze the efficacy of brachytherapy (BRT) as boost in AC. Therefore, we performed this systematic review based on PRISMA methodology to establish the role of BRT boost in AC. A systematic search of the bibliographic databases: PubMed, Scopus, and Cochrane library from the earliest possible date through January 31, 2018 was performed. At least one of the following outcomes: local control (LC), loco-regional control (LRC), overall survival (OS), disease-free survival (DFS), or colostomy-free survival (CFS) had to be present for inclusion in this systematic review in patients receiving a BRT boost. Data about toxicity and sphincter function were also included. Ten articles fulfilled the inclusion criteria. All the studies had retrospective study design. All studies were classified to provide a level of evidence graded as 3 according to SIGN classification. Median 5-year LC/LRC, CFS, DFS, and OS were: 78.6% (range, 70.7-92.0%), 76.1% (range, 61.4-86.4%), 75.8% (range, 65.9-85.7%), and 69.4% (63.4-82.0%), respectively. The reported toxicities were acceptable. RCT is the treatment cornerstone in AC. High-level evidences from studies on BRT boost in AC are lacking. Further studies should investigate: efficacy of BRT boost in comparison to no boost and to external beam boost, patients who can benefit from this treatment intensification, and optimal radiation dose

Whole lung irradiation in patients with osteosarcoma and ewing sarcoma

Whole lung irradiation (WLI) represents standard therapy for patients with pulmonary metastases from Ewing sarcoma although the impact on clinical outcomes and toxicity is still unclear. The aim of this study was to evaluate toxicity after WLI in patients with Ewing sarcoma and osteosarcoma as well as overall survival (OS) and event-free survival (EFS)

Definitive Radiotherapy in Invasive Vaginal Carcinoma: A Systematic Review

This study systematically reviews the recent literature on the role of definitive radiotherapy (RT) in the management of vaginal cancer (VC) and presents comprehensive data on clinical outcomes and toxicity

Stereotactic radiotherapy of pancreatic cancer: A systematic review on pain relief

Locally advanced pancreatic carcinoma (LAPC) has a poor prognosis and the purpose of treatment is survival prolongation and symptom palliation. Radiotherapy has been reported to reduce pain in LAPC. Stereotactic RT (SBRT) is considered as an emerging radiotherapy technique able to achieve high local control rates with acceptable toxicity. However, its role in pain palliation is not clear. To review the impact on pain relief with SBRT in LAPC patients, a literature search was performed on PubMed, Scopus, and Embase (January 2000–December 2017) for prospective and retrospective articles published in English. Fourteen studies (479 patients) reporting the effect of SBRT on pain relief were finally included in this analysis. SBRT was delivered with both standard and/or robotic linear accelerators. The median prescribed SBRT doses ranged from 16.5 to 45 Gy (median: 27.8 Gy), and the number of fractions ranged from 1 to 6 (median: 3.5). Twelve of the 14 studies reported the percentage of pain relief (in patients with pain at presentation) with a global overall response rate (complete and partial response) of 84.9% (95% CI, 75.8%–91.5%), with high heterogeneity (Q 2 test: P<0.001; I 2 =83.63%). All studies reported toxicity data. Acute and late toxicity (grade ≥3) rates were 3.3%–18.0% and 6.0%–8.2%, respectively. Reported gastrointestinal side effects were duodenal obstruction/ ulcer, small bowel obstruction, duodenal bleeding, hemorrhage, and gastric perforation. SBRT achieves pain relief in most patients with pancreatic cancer with an acceptable gastrointestinal toxicity rate. Further prospective studies are needed to define optimal dose/fractionation and the best systemic therapies modality integration to reduce toxicity and improve the palliative outcome. Finally, the quality of life and, particularly, pain control should be considered as an endpoint in all future trials on this emerging treatment technique