intraoperative radiation therapy is it a standard now

Summary The question whether and for whom the gold standard of whole breast radiotherapy (WBRT) may be replaced by accelerated partial breast irradiation (APBI) is one of the most controversial issue in the adjuvant breast cancer setting. Among different APBI techniques, intraoperative radiation therapy (IORT) is particularly appealing to patients and physicians, because the procedure is fast, convenient, normal structures sparing and able to solve some clinical problems, like the integration with chemotherapy. Early findings from phase II and randomized phase III trials show the approach of APBI in selected patients at low risk for local recurrence is safe and well tolerated, but short follow-up creates some reservations. Since recurrences of breast cancer can occur after a considerably time delay, final assessment of APBI will only be valid after sufficient follow-up from prospective randomized trials with large patients number. Until then APBI should be considered experimental. Furthermore, many questions regarding the appropriate patient selection criteria, treatment volume and dose fractionation still exist. In the context of risk-adapted RT, the key to success is the proper selection of the patients. Both the American and European Society of Radiology and Oncology provided a consensus statement regarding patient selection criteria based on tumour and patient-related features. The 5-year results of the non-randomized ELIOT study from Milan, using 21 Gy-full dose, identified a group of patients who may be good candidates for the treatment. The stratification of patients according to clinical phenotype or by molecular class and a widespread use of preoperative breast magnetic resonance imaging might be better identify patients eligible for APBI

Partial breast irradiation: Targeting volume or breast molecular subtypes?

The eligibility criteria for partial breast irradiation (APBI) are mainly based on histopathological factors, which not always explain the clinical behaviour of breast cancers. International guidelines represent useful platform to collect data for continued refinement of patient selection, but the clinical applicability to APBI series showed some limitations, particularly among the intermediate and high-risk groups. The heterogeneity of APBI techniques, along with the heterogeneity of breast cancer, generates clinical results, where the predictive value of the histopathological factors can assume different weight. There is a need of further refinement and implementation of risk factors. Currently, the impact of breast cancer subtype on local control is matter of investigation, and treatment decision about radiotherapy is generally made without regard to the breast cancer subtype. However, receptor status information is easily available and some histopathological factors have not a definite role, there is no uniform interpretation. As molecular classification becomes more feasible in the clinical practice, it will provide added value to conventional clinical tumour characteristics in predicting local recurrence in breast cancer and may play an important role as predictor of eventual patient outcomes

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

A Case of RhabdomyoSarcoma Following a Metal Surgical Implant

Patient. We report a 51-year-old male presenting with Grade III rhabdomyosarcoma

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

integration of enhanced optical tracking techniques and imaging in igrt

Patient setup/Optical tracking/IGRT/Treatment surveillance. In external beam radiotherapy, modern technologies for dynamic dose delivery and beam conformation provide high selectivity in radiation dose administration to the pathological volume. A comparable accuracy level is needed in the 3-D localization of tumor and organs at risk (OARs), in order to accomplish the planned dose distribution in the reality of each irradiation session. In-room imaging techniques for patient setup verification and tumor targeting may benefit of the combined daily use of optical tracking technologies, supported by techniques for the detection and compensation of organ motion events. Multiple solutions to enhance the use of optical tracking for the on-line correction of target localization uncertainties are described, with specific emphasis on the compensation of setup errors, breathing movements and non-rigid deformations. The final goal is the implementation of customized protocols where appropriate external landmarks, to be tracked in real-time by means of noninvasive optical devices, are selected as a function of inner target localization. The presented methodology features high accuracy in patient setup optimization, also providing a valuable tool for on-line patient surveillance, taking into account both breathing and deformation effects. The methodic application of optical tracking is put forward to represent a reliable and low cost procedure for the reduction of safety margins, once the patient-specific correlation between external landmarks and inner structures has been established. Therefore, the integration of optical tracking with in-room imaging devices is proposed as a way to gain higher confidence in the framework of Image Guided Radiation Therapy (IGRT) treatments

Can circumcision be avoided in adult male with phimosis? Results of the PhimoStopTM prospective trial

Background: Circumcision as surgical treatment of adult phimosis is not devoid of complications. Efficacy of alternative non-surgical options is unclear. PhimoStop (TM) is a therapeutic protocol which involves the use of appropriately shaped silicone tuboids of increasing size to obtain a non-forced dilation of the prepuce. The aim of the study was to evaluate the efficacy and durability of results of PhimoStop (TM) device for the treatment of adult male phimosis.Methods: A prospective trial was conducted between 2018 and 2020 on 85 consecutive adult male patients affected by phimosis and with an indication for circumcision. Patients were treated with PhimoStop (TM) protocol and they were evaluated at baseline and after treatment through a subjective (patient self-reported information on various domains of his sexual function) and an objective assessment (evaluation of phimosis severity grade according to the Kikiros scale pre- and post-treatment, re-assessment of indication for circumcision post-treatment and validated questionnaires scores). Primary endpoint was to avoid the scheduled circumcision in 33% of the patients enrolled.Results: Seventy-one patients (84%) completed the device usage phase as per study protocol. Median duration of tuboid application was 60 days. Thirty-seven patients (52.1%) had no indication for circumcision after treatment. Even considering patients lost to follow-up as failures, primary endpoint was reached in 43.5% of cases. There was a significant reduction of the grade of phimosis after treatment (P<0.001). Moreover IIEF-5 showed a statistically significant improvement after treatment (P< 0.001). Thirty/37 patients who met the primary endpoint (81%) still have a successful resolution of their phimosis avoiding circumcision at a median follow-up of 24 months.Conclusions: PhimoStop (TM) device is effective for the treatment of adult male phimosis of Kikiros grade < 2. The results seem to be durable in most patients at a median follow-up of 24 months. Randomized clinical trials are necessary in order to confirm our results and assess cost-efficacy

Review of photon and proton radiotherapy for skull base tumours

An extremely large variety of benign and malignant tumours occur at skull base; these tumour lesions are in the proximity to structures deputed to relevant physiologic functions, limiting extensive surgical approaches to this body district. Most recent progresses of surgery and radiotherapy have allowed to improve local control with acceptable rates of side effects. Various photon radiotherapy techniques are employed, including 3-dimensional conformal radiotherapy, intensity modulated radiotherapy (IMRT), stereotactic radiotherapy (SRT) and brachytherapy that is manly limited to the treatment of primary or recurrent nasopharyngeal carcinoma. Proton beam radiotherapy is also extensively used thanks to its physical characteristics. Our review, focusing in particular on meningioma, chordoma, and chondrosarcoma, suggests that proton therapy plays a major role in the treatment of malignant tumours whereas photon therapy still plays a relevant role in the treatment of benign tumour lesions

Intraoperative Radiation Therapy for Breast Cancer: Technical Notes

Abstract: Interest in intraoperative radiation therapy (IORT) for breast cancer is increasing as the possible benefits of this technique for the patient become apparent. The rationale for the use of this segmental radiation therapy in place of whole-breast irradiation is based on the finding that approximately 85% of breast relapses are confined to the same quadrant of the breast as the primary tumor. Phase I and II trials have demonstrated no increase in postsurgical complication rates following the use of single-dose IORT in localized breast cancers. Longer follow-up is needed to assess the cosmetic outcome. Clinical trials to evaluate the effectiveness of IORT in the treatment of breast cancer are currently under way at the European Institute of Oncology (EIO) at the University of Milan, Italy, and at Memorial Sloan-Kettering Cancer Center (MSKCC) in New York. Here we report the two different techniques in use in these trials

Heating cancer stem cells to reduce tumor relapse

Tumour relapse is believed to be caused by rare cancer-cells with stem-cell properties (cancer stem cells) that are intrinsically resistant to available treatments. The identification of novel strategies to increase their sensitivity has major clinical implications. Latest clinical trials have shown a positive antitumoral effect of hyperthermia in combination with chemotherapy or radiotherapy. In a recent paper, the combination of increased temperature at the tumour site, generated by laser treatment of intravenously-injected gold nanoshells, and ionizing radiations enhances radiosensitivity of cancer stem cells and tumor response. At the root of the success of hyperthermia in enhancing radio-sensitization of cancer stem cells is the inhibition of their capacity to repair DNA damage, affecting the survival rate of these cells