Survey on brachytherapy training among radiation oncology residents in the German-speaking regions of Europe.

PURPOSE This survey aimed to determine the perception of brachytherapy training among residents in the DACH region, consisting of Austria, Germany and Switzerland. MATERIAL & METHODS An online questionnaire containing 22 questions related to trainee demographics (n = 5) and to brachytherapy training (n = 17) was sent in two iterations in 11/2019 and 02/2020. The following topics were evaluated: institutional support, barriers to training, extent of training, site-specific training (prostate, gynaecology, breast, gastrointestinal and skin), preferences for further training and outlook on overall development of brachytherapy. The responses were mostly based on a Likert scale of 1 to 5, thereby reflecting strength of opinion. Descriptive statistics were used to describe frequencies. RESULTS Among the 108 respondents, approximately 69% of residents considered the ability to perform brachytherapy independently to be important or somewhat important. However, only 31% of respondents reported to have a dedicated brachytherapy training during residency. The major limitation to achieve independence in performing brachytherapy was seen in a low case load in Austria, in the lack of training in Switzerland and in both of them in Germany. CONCLUSION The interest in brachytherapy training among residents in German-speaking countries was generally high, but there is a perceived lack of sufficient case volumes and partially also in formal training opportunities. Fellowships at departments with a high case load as part of a formalised curriculum and dedicated hands-on workshops at national or international conferences might help to overcome these issues

Early morbidity and dose–volume effects in definitive radiochemotherapy for locally advanced cervical cancer: a prospective cohort study covering modern treatment techniques

PURPOSE: Predicting morbidity for patients with locally advanced cervix cancer after external beam radiotherapy (EBRT) based on dose–volume parameters remains an unresolved issue in definitive radiochemotherapy. The aim of this prospective study was to correlate patient characteristics and dose–volume parameters to various early morbidity endpoints for different EBRT techniques, including volumetric modulated arc therapy (VMAT) and adaptive radiotherapy (ART). METHODS AND MATERIALS: The study population consisted of 48 patients diagnosed with locally advanced cervix cancer, treated with definitive radiochemotherapy including image-guided adaptive brachytherapy (IGABT). Multiple questionnaires (CTCAE 4.03, QLQ-C30 and EORTC QLQ-CX24) were assessed prospectively for patients treated with different EBRT techniques, including online adaptive VMAT. Contouring and treatment planning was based on the EMBRACE protocols. Acute toxicity, classified as general, gastrointestinal (GI) or genitourinary (GU) and their corresponding dose–volume histograms (DVHs) were first correlated by applying least absolute shrinkage and selection operator (LASSO) and subsequently evaluated by multiple logistic binomial regression. RESULTS: The treated EBRT volumes varied for the different techniques with ~2500 cm(3) for 3D conformal radiotherapy (3D-CRT), ~2000 cm(3) for EMBRACE‑I VMAT, and ~1800 cm(3) for EMBRACE-II VMAT and ART. In general, a worsening of symptoms during the first 5 treatment weeks and recovery afterwards was observed. Dose–volume parameters significantly correlating with stool urgency, rectal and urinary incontinence were as follows: bowel V(40Gy) < 250 cm(3), rectum V(40Gy) < 80% and bladder V(40Gy) < 80–90%. CONCLUSION: This prospective study demonstrated the impact of EBRT treatment techniques in combination with chemotherapy on early morbidity. Dose–volume effects for dysuria, urinary incontinence, stool urgency, diarrhea, rectal bleeding, rectal incontinence and weight loss were found

Factors associated with post-relapse survival in patients with recurrent cervical cancer : the value of the inflammation-based Glasgow Prognostic Score

Purpose The aim of the present study was to assess the value of the Glasgow Prognostic Score (GPS) as a prognostic tool for predicting post-relapse survival (PRS) in patients with recurrent cervical cancer. Methods We retrospectively evaluated the data of 116 patients with recurrent cervical cancer in whom serologic biomarkers had been assessed at the time of relapse. The GPS was calculated as follows: patients with elevated serum C-reactive protein levels and hypoalbuminemia were allocated a score of 2, and those with 1 or no abnormal value were allocated a score of 1 and 0, respectively. To assess the association between factors including the GPS and PRS, we performed uni- and multivariate survival analyzes. Results After a median follow-up of 20.9 months from recurrence, a 5-year PRS rate of 25% (SE 4.7%) was observed. Only in 29.8% of the patients, recurrence was limited to the pelvis. In uni- and multivariate survival analyzes, the GPS [HR 1.6 (95% CI 0.92.4), p=0.01], a history of radiation therapy as part of initial treatment [HR 2.7 (95% CI 1.16.9), p=0.03], and the presence of peritoneal carcinomatosis or multiple sites of relapse [HR 4.2 (95% CI 1.99.3), p<0.001] were associated with shorter PRS. The GPS correlated with higher squamous cell carcinoma antigen levels (p=0.001), shorter median PRS (p=0.009), and less intensive treatment for relapse (p=0.02). Conclusions A higher GPS at the time of relapse, a history of radiation therapy, and the presence of peritoneal carcinomatosis or multiple sites of relapse are independently associated with shorter PRS in patients with recurrent cervical cancer.(VLID)365858

Image guided adaptive external beam radiation therapy for cervix cancer: Evaluation of a clinically implemented plan-of-the-day technique

Background: Radiotherapy for cervix cancer is challenging in patients exhibiting large daily changes in the pelvic anatomy, therefore adaptive treatments (ART) have been proposed. The aim of this study was the clinical implementation and subsequent evaluation of plan-of-the-day (POTD)-ART for cervix cancer in supine positioning. The described workflow was based on standard commercial equipment and current quality assurance (QA) methods. Materials and methods: A POTD strategy, which employs a VMAT plan library consisting of an empty bladder plan, a full bladder plan and a motion robust backup plan, was developed. Daily adaption was guided by cone beam computed tomography (CBCT) imaging after which the best plan from the library was selected. Sixteen patients were recruited in a clinical study on ART, for nine POTD was applied due to their large organ motion derived from two computed tomography (CT) scans with variable bladder filling. All patients were treated to 45 Gy in 25 fractions. Plan selection frequencies over the treatment course were analyzed. Daily doses in the rectum, bladder and cervix-uterus target (CTV-T) were derived and compared to a simulated non-adapted treatment (non-ART), which employed the robust plan for each fraction. Additionally, the adaption consistency was determined by repeating the plan selection procedure one month after treatment by a group of experts. ART-specific QA methods are presented. Results: 225 ART fractions with CBCTs were analyzed. The empty bladder plan was delivered in 49% of the fractions in the first treatment week and this number increased to 78% in the fifth week. The daily coverage of the CTV-T was equivalent between ART and the non-ART simulation, while the daily total irradiated volume V42.75 Gy (95% of prescription dose) was reduced by a median of 87 cm3. The median delivered V42.75 Gy was 1782 cm3. Daily delivered doses (V42.75 Gy, V40 Gy, V30G) to the organs at risk were statistically significantly reduced by ART, with a median difference in daily V42.75 Gy in rectum and bladder of 3.2% and 1.1%, respectively. The daily bladder V42.75 Gy and V40 Gy were decreased by more than 10 percent points in 30% and 24% of all fractions, respectively, through ART. The agreement between delivered plans and retrospective expert-group plan selections was 84%. Conclusion: A POTD-ART technique for cervix cancer was successfully and safely implemented in the clinic and evaluated. Improved normal tissue sparing compared to a simulated non-ART treatment could be demonstrated. Future developments should focus on commercial automated software solutions to allow for a more widespread adoption and to keep the increased workload manageable

Strahlentherapie und Onkologie / Increased genitourinary fistula rate after bevacizumab in recurrent cervical cancer patients initially treated with definitive radiochemotherapy and image-guided adaptive brachytherapy

Hintergrund und Ziel Patientinnen mit Rezidiv eines Zervixkarzinoms (RecCC), die primär eine bildgesteuerte adaptive Brachytherapie (IGABT) und kombinierte Radiochemotherapie (RCHT) erhalten hatten, werden derzeit in unserem Institut mit einer Kombination aus Chemotherapie (CHT) und Bevacizumab (BEV) behandelt. Ziel dieser Studie war es, das Risiko für das Auftreten gastrointestinaler (GI) sowie urogenitaler (GU) Fisteln unter CHT sowie CHT + BEV zu analysieren. Patienten und Methode In diese retrospektive Datenanalyse wurden insgesamt 35 konsekutive Patientinnen mit RecCC, die primär mit RCHT und IGABT behandelt worden waren, inkludiert. Klinisch-pathologische Risikofaktoren für das Auftreten einer GI- sowie GU-Fistel wurden erhoben. Die Raten an Fistelbildungen in der CHT-Gruppe und in der Gruppe mit CHT + BEV wurden verglichen. Ergebnisse Von 35 Patientinnen erhielten 25 eine CHT und 10 CHT + BEV. Insgesamt wurde bei 6 Patientinnen eine Fistel diagnostiziert, davon 2 in der Gruppe mit CHT (8 %) und 4 in der mit CHT + BEV (40 %). GU-Fisteln entwickelten sich ausschließlich in der Gruppe mit CHT + BEV (3/4; 75 %). Von den 6 Patientinnen (83 %) mit Fistelbildung hatten 5 eine vorangehende invasive diagnostische Abklärung und 1 Patientin wurde einer neuerlichen Radiotherapie unterzogen. Ein Lokalrezidiv hatten 3/6 Patientinnen entwickelt. Weitere Risikofaktoren für die Entwicklung einer Fistel konnten nicht identifiziert werden. Schlussfolgerung Die zusätzliche Gabe von BEV zur CHT bei RecCC-Patienten, die primär mit IGABT und RCHT behandelt wurden, könnte möglicherweise zu einer erhöhten Rate an GU-Fisteln führen. Zukünftige Studien sollten Risikofaktoren für Fistelbildung untersuchen, um eine gründliche Patientenselektion für die Gabe von BEV bei RecCC zu ermöglichen.Background and purpose Patients with recurrent cervical cancer (RecCC) who received definitive radiochemotherapy including image-guided adaptive brachytherapy (IGABT) as primary treatment are currently treated in our institution with palliative intent by chemotherapy (CHT) combined with bevacizumab (BEV). We aim to evaluate the risk of gastrointestinal (GI)/genitourinary (GU) fistula formation in these patients. Materials and methods Data of 35 consecutive patients with RecCC treated initially with radiochemotherapy and IGABT were collected. Known and presumed risk factors associated with fistula formation were evaluated. Fistula rate was compared between patients receiving CHT or CHT+BEV. Results Of the 35 patients, 25 received CHT and 10 patients received CHT+BEV. Clinical characteristics were comparable. Fistulae were reported in 6 patients: two fistulae (8%) in the CHT group, four (40%) in the CHT+BEV group. GU fistula occurred in the CHT+BEV group only (3/4). Of these 6 patients with fistulae, 5 (83%) had undergone previous invasive procedures after the diagnosis of RecCC and 1 patient had undergone pelvic re-irradiation; 3/6 patients had developed a local recurrence. No other risk factors for fistula formation were identified. Conclusion In patients with RecCC after definitive radiochemotherapy including IGABT, the addition of BEV to CHT may increase the risk for GU fistula formation, particularly after invasive pelvic procedures. Future clinical studies are required to identify predictors for fistula formation to subsequently improve patient selection for the addition of BEV in the RecCC setting.(VLID)363265

Risk Reclassification of Patients with Endometrial Cancer Based on Tumor Molecular Profiling: First Real World Data

Recently, guidelines for endometrial cancer (EC) were released that guide treatment decisions according to the tumors’ molecular profiles. To date, no real-world data regarding the clinical feasibility of molecular profiling have been released. This retrospective, monocentric study investigated the clinical feasibility of molecular profiling and its potential impact on treatment decisions. Tumor specimens underwent molecular profiling (testing for genetic alterations, (immune-)histological examination of lymphovascular space invasion (LVSI), and L1CAM) as part of the clinical routine and were classified according to the European Society for Medical Oncology (ESMO) classification system and to an integrated molecular risk stratification. Shifts between risk groups and potential treatment alterations are described. A total of 60 cases were included, of which twelve were excluded (20%), and eight of the remaining 48 were not characterized (drop-out rate of 16.7%). Molecular profiling revealed 4, 6, 25, and 5 patients with DNA polymerase-epsilon mutation, microsatellite instability, no specific molecular profile, and TP53 mutation, respectively. Three patients had substantial LVSI, and four patients showed high L1CAM expression. Molecular profiling took a median of 18.5 days. Substantial shifts occurred between the classification systems: four patients were upstaged, and 19 patients were downstaged. Molecular profiling of EC specimens is feasible in a daily routine, and new risk classification systems will change treatment decisions substantially