Modern Radiotherapy Era in Breast Cancer

Radiation therapy (RT) is one of the major treatment modalities that are used in breast cancer treatment, and depending on the chest-wall anatomy, RT fields have to be customized. Techniques used in planning have been evolving since last two decades from two dimensional (2D) to three-dimensional (3D), while intensity modulated radiotherapy (IMRT), volumetric modulated arc therapy (VMAT) and even proton therapy have been an option in daily approach. In addition, technological hardware and software advances in delivery and planning systems, total treatment duration of breast RT have been shortened in last decades along with recent hypofractionated radiotherapy schemes or emerging partial-breast irradiation protocols. The other attractive approach—accelerated partial breast irradiation (APBI) could be a reasonable option for highly selected subpopulation of early-stage breast cancer patients out of a clinical trial. Long-term follow-up results have emerged heart and coronary sparing with maximum safety and efficacy. The most important advance could be named as cardiac sparing—deep breath-hold approach—in all the modern technique improvement. Although most advanced techniques in management of breast cancer have not been verified to increase survival, we suggest recommending resource stratified advanced in order to provide best technical and clinical care in this long-term survivor candidates

Increased Levels of Anxiety, Depression, and Secondary Trauma in Radiation Oncologists during COVID-19 Pandemic: A Preliminary Report from Turkey

OBJECTIVE We surveyed the anxiety, depression, and secondary trauma levels of Turkish Radiation Oncologists related with COVID pandemics. METHODS An anonymous online questionnaire survey was created to evaluate levels of depression, anxiety, and secondary trauma among Turkish Radiation Oncologists. The survey included demographics and occupational status, Secondary Traumatic Stress Scale (STSSS), The Beck Depression Inventory (BDI), The Beck Anxiety Inventory (BAI), and State-Trait Anxiety Inventory (STAI). RESULTS Seventy-two respondents provided the power of about 91.4% for the significance level of 0.05. The variance homogeneity was checked by the Levene test, the effect of COVID-19 on psychology is higher in the group of >19 (9.02 +/- 0.820), as well as the effect of social isolation (8.02 +/- 1.622), the STSS scores (34.28 +/- 9.062), the STAIS scores (60.46 +/- 5.296), the STAIT scores (82.21 +/- 9.298), the BDI scores (22.68 +/- 2.788), and the BAI scores (21.04 +/- 9.321). The multiple regressions to estimate BDI revealed statistically significant effects in STAIS, BAI, and STAIT. There is a significant correlation between STSS, STAIS, STAIT, BDI, BAI, the effect of COVID-19 on psychology, and the effect of social isolation. CONCLUSION We have established one of the first studies demonstrating the effects of COVID-19 pandemic on depression, anxiety levels, and secondary trauma on a special physician population, the Radiation Oncologists, who specifically do not directly take part in COVID19 management

Second Line Palliative Endobronchial Radiotherapy with HDR Ir 192 in Recurrent Lung Carcinoma

Purpose To observe the efficiency of reirradiation with high dose rate intraluminal brachytherapy in symptomatic palliation of recurrent endobronchial tumors. Materials and Methods Between January 1994 and June 1998, 21 patients diagnosed with recurrent endobronchial tumors following external beam radiotherapy were treated palliatively with high dose rate intraluminal irradiation at Hacettepe University Oncology Institute. A single fraction of 10 Gy was prescribed to the specified area in 9 patients and 15 Gy to 12. Results Endobronchial treatment improved the performance and reduced symptomatology in 17 (81%) patients. Ten dyspneic patients (10/14, 71%) recovered clinically with an accompanying radiological downstaging. The median symptomatic palliation was 45 days (range, 0 - 9 months), and the overall median survival was 5.5 months (range, 4 - 12 months). The palliative intrabronchial brachytherapy was well tolerated, with the exception of in one patient with a fatal hemorrhage, and another with medically salvaged bronchospasm and intrabronchial edema. Conclusion Recurrent patients with a history of previous thoracic external beam irradiation can be effectively palliated with high dose rate endobronchial reirradiation if the symptoms are directly related to the endobronchial tumor

Stereotactic body radiation therapy for management of spinal metastases in patients without spinal cord compression: a phase 1–2 trial

SummaryBackgroundSpinal stereotactic body radiation therapy (SBRT) is increasingly used to manage spinal metastases, yet the technique's effectiveness in controlling the symptom burden of spinal metastases has not been well described. We investigated the clinical benefit of SBRT for managing spinal metastases and reducing cancer-related symptoms.Methods149 patients with mechanically stable, non-cord-compressing spinal metastases (166 lesions) were given SBRT in a phase 1–2 study. Patients received a total dose of 27–30 Gy, typically in three fractions. Symptoms were measured before SBRT and at several time points up to 6 months after treatment, by the Brief Pain Inventory (BPI) and the M D Anderson Symptom Inventory (MDASI). The primary endpoint was frequency and duration of complete pain relief. The study is completed and is registered with ClinicalTrials.gov, number NCT00508443.FindingsMedian follow-up was 15·9 months (IQR 9·5–30·3). The number of patients reporting no pain from bone metastases, as measured by the BPI, increased from 39 of 149 (26%) before SBRT to 55 of 102 (54%) 6 months after SBRT (p<0·0001). BPI-reported pain reduction from baseline to 4 weeks after SBRT was clinically meaningful (mean 3·4 [SD 2·9] on the BPI pain-at-its-worst item at baseline, 2·1 [2·4] at 4 weeks; effect size 0·47, p=0·00076). These improvements were accompanied by significant reduction in opioid use during the first 6 months after SBRT (43 [28·9%] of 149 patients with strong opioid use at baseline vs 20 [20·0%] of 100 at 6 months; p=0·011). Ordinal regression modelling showed that patients reported significant pain reduction according to the MDASI during the first 6 months after SBRT (p=0·00003), and significant reductions in a composite score of the six MDASI symptom interference with daily life items (p=0·0066). Only a few instances of non-neurological grade 3 toxicities occurred: nausea (one event), vomiting (one), diarrhoea (one), fatigue (one), dysphagia (one), neck pain (one), and diaphoresis (one); pain associated with severe tongue oedema and trismus occurred twice; and non-cardiac chest pain was reported three times. No grade 4 toxicities occurred. Progression-free survival after SBRT was 80·5% (95% CI 72·9–86·1) at 1 year and 72·4% (63·1–79·7) at 2 years.InterpretationSBRT is an effective primary or salvage treatment for mechanically stable spinal metastasis. Significant reductions in patient-reported pain and other symptoms were evident 6 months after SBRT, along with satisfactory progression-free survival and no late spinal cord toxicities.FundingNational Cancer Institute of the US National Institutes of Health

Role of Radiation Therapy in Modulation of the Tumor Stroma and Microenvironment

In recent decades, there has been substantial growth in our understanding of the immune system and its role in tumor growth and overall survival. A central finding has been the cross-talk between tumor cells and the surrounding environment or stroma. This tumor stroma, comprised of various cells, and extracellular matrix (ECM), has been shown to aid in suppressing host immune responses against tumor cells. Through immunosuppressive cytokine secretion, metabolic alterations, and other mechanisms, the tumor stroma provides a complex network of safeguards for tumor proliferation. With recent advances in more effective, localized treatment, radiation therapy (XRT) has allowed for strategies that can effectively alter and ablate tumor stromal tissue. This includes promoting immunogenic cell death through tumor antigen release to increasing immune cell trafficking, XRT has a unique advantage against the tumoral immune evasion mechanisms that are orchestrated by stromal cells. Current studies are underway to elucidate pathways within the tumor stroma as potential targets for immunotherapy and chemoradiation. This review summarizes the effects of tumor stroma in tumor immune evasion, explains how XRT may help overcome these effects, with potential combinatorial approaches for future treatment modalities

Prognostic value of gross tumor volume delineated by FDG-PET-CT based radiotherapy treatment planning in patients with locally advanced pancreatic cancer treated with chemoradiotherapy

<p>Abstract</p> <p>Background</p> <p>We aimed to assess whether gross tumor volume (GTV) determined by fusion of contrast-enhanced computerized tomography (CT) and 18F-fluoro-deoxy-D-glucose positron emission tomography-CT (FDG-PET-CT) based radiotherapy planning could predict outcomes, namely overall survival (OS), local-regional progression-free survival (LRPFS), and progression-free survival (PFS) in cases with locally advanced pancreas cancer (LAPC) treated with definitive concurrent chemoradiotherapy.</p> <p>Methods</p> <p>A total of 30 patients with histological proof of LAPC underwent 50.4 Gy (1.8 Gy/28 fractions) of radiotherapy concurrent with continuously infused 5-FU followed by 4 to 6 courses of maintenance gemcitabine. Target volume delineations were performed on FDG-PET-CT-based RTP. Patients were stratified into 2 groups: GTV lesser (GTV_L) versus greater (GTV_G) than cut off value determined by receiver operating characteristic (ROC) analysis, and compared in terms of OS, LRPFS and PFS.</p> <p>Results</p> <p>Median GTV delineated according to the FDG-PET-CT data was 100.0 cm³. Cut off GTV value determined from ROC curves was 91.1 cm³. At a median follow up of 11.2 months, median OS, LRPFS and PFS for the entire population were 10.3, 7.8 and 5.7 months, respectively. Median OS, LRPFS and PFS for GTV_Land GTV_Gcohorts were 16.3 vs. 9.5 (<it>p </it>= 0.005), 11.0 vs. 6.0 (<it>p </it>= 0.013), and 9.0 vs. 4.8 months (<it>p </it>= 0.008), respectively.</p> <p>Conclusions</p> <p>The superior OS, LRPFS and PFS observed in GTV_Lpatients over GTV_Gones suggests a potential for FDG-PET-CT-defined GTV size in predicting outcomes of LAPC patients treated with definitive C-CRT, which needs to be validated by further studies with larger cohorts.</p