Patient selection for partial breast irradiation by intraoperative radiation therapy: Can magnetic resonance imaging be useful?- perspective from radiation oncology point of view

The guidelines of the European and American Societies of Radiation Oncology (GEC-ESTRO and ASTRO) defined the selection criteria to offer partial breast irradiation (PBI) after lumpectomy in patients with low risk breast cancer regardless pre-operative staging. A recent publication by Tallet et al. explored the impact of preoperative magnetic resonance imaging (MRI) on patient eligibility for PBI. From their study, an ipsilateral BC was detected in 4% of patients, excluding these patients from intraoperative radiotherapy (IORT). The authors suggested that preoperative MRI should be used routinely for patient's candidate to IORT, because of the rate of ipsilateral breast cancer detected. In view of Tallet's article, we analyzed some aspects of this issue in order to envisage some possible perspective on how to better identify those patients who could benefit from PBI, especially using IORT. From historical studies, the risk of breast cancer recurrence outside index quadrant without irradiation is in the range of 1.5-3.5%. MRI sensitivity for detection of invasive cancer is reported up to 100%, and it is particularly useful in dense breast. Other imaging technique did not achieve the same sensibility and specificity as conventional MRI. Of note, none of randomized trials published and ongoing on PBI included preoperative MRI as part of staging. To perform a preoperative MRI in PBI setting is an interesting issue, but the available data suggest that this issue should be preferably studied in the setting of prospective clinical trials to clarify the role of MRI and the clinical meaning of the discovered additional foci. \ua9 Journal of Thoracic Disease

FDG-PET/CT imaging for staging and radiotherapy treatment planning of head and neck carcinoma

<p>Abstract</p> <p>Background</p> <p>Positron emission tomography (PET) has a potential improvement for staging and radiation treatment planning of various tumor sites. We analyzed the use of ¹⁸F-fluorodeoxyglucose (FDG)-PET/computed tomography (CT) images for staging and target volume delineation of patients with head and neck carcinoma candidates for radiotherapy.</p> <p>Methods</p> <p>Twenty-two patients candidates for primary radiotherapy, who did not receive any curative surgery, underwent both CT and PET/CT simulation. Gross Tumor Volume (GTV) was contoured on CT (CT-GTV), PET (PET-GTV), and PET/CT images (PET/CT-GTV). The resulting volumes were analyzed and compared.</p> <p>Results</p> <p>Based on PET/CT, changes in TNM categories and clinical stage occurred in 5/22 cases (22%). The difference between CT-GTV and PET-GTV was not statistically significant (p = 0.2) whereas the difference between the composite volume (PET/CT-GTV) and CT-GTV was statistically significant (p < 0.0001).</p> <p>Conclusion</p> <p>PET/CT fusion images could have a potential impact on both tumor staging and treatment planning.</p

Radical Prostatectomy and Intraoperative Radiation Therapy in High-Risk Prostate Cancer

Intraoperative electron beam radiotherapy (IOERT) for prostate cancer (PC) is a radiotherapeutic technique, giving high doses of radiation during radical prostatectomy (RP). This paper presents the published treatment approaches for intraoperative radiotherapy analyzing functional outcome, morbidity, and oncological outcome in patients with clinical intermediate-high-risk prostate cancer. A systematic review of the literature was performed, searching PubMed and Web of Science. A “free text” protocol using the term intraoperative radiotherapy and prostate cancer was applied. Ten records were retrieved and analyzed including more than 150 prostate cancer patients treated with IOERT. IOERT represents a feasible technique with acceptable surgical time and minimal toxicity. A greater number of cases and longer follow-up time are needed in order to assess the long-term side effects and oncological outcome

Radioterapija raka prostate vođena magnetskom rezonancom: nova paradigma liječenja

Radiotherapy is one of the key treatment modalities for primary prostate cancer. During the last decade, significant advances were made in radiotherapy technology leading to increasing both physical and biological precision. Being a loco-regional treatment approach, radiotherapy requires accurate target dose deposition while sparing surrounding healthy tissue. Conventional radiotherapy is based on computerized tomography (CT) images both for radiotherapy planning and image-guidance, however, shortcomings of CT as soft tissue imaging tool are well known. Nowadays, our ability to further escalate radiotherapy dose using hypofractionation is limited by uncertainties in CT-based image guidance and verification. Magnetic resonance imaging (MRI) is a well established imaging method for pelvic organs. In prostate cancer specifically, MRI accurately depicts prostate zonal anatomy, rectum, bladder, and pelvic floor structures with previously unseen precision owing to its sharp soft tissue contrast. The advantages of including MRI in the clinical workflow of prostate cancer radiotherapy are multifold. MRI allows for true adaptive radiotherapy to unfold based on daily MRI images taken before, during and after each radiotherapy fraction. It enables accurate dose escalation to the prostate and intraprostatic tumor lesions. Technically, MRI high-strength magnetic field and linear accelerator high energy electromagnetic beams are hardly compatible, and important efforts were made to overcome these technical challenges and integrate MRI and linear accelerator into one single treatment device, called MRI-linac. Different systems are produced by two leading vendors in the field and currently, there are around 100 MRI-linacs worldwide in clinical operations. In this narrative review paper, we discuss historical perspective of image guidance in radiotherapy, basic elements of MRI, current clinical developments in MRI-guided prostate cancer radiotherapy, and challenges associated with the use of MRI-linac in clinical practice.Radioterapija je temelj liječenja raka prostate. Radioterapija je zadnjih godina značajno napredovala što je omogućilo njenu preciznost. Radioterapija zahtjeva točnu isporuku radioterapijske doze na tumor uz maksimalnu poštedu okolnog zdravog tkiva. Konvencionalna radioterapija se bazira na slikama kompjuterizirane tomografije (CT) za sve faze radioterapijskog procesa, iako su slike CT-a slabe rezolucije za prikaz mekih tkiva. Danas je naša sposobnost da još više podižemo radioterapijsku dozu limitirana nedovoljnom jasnoćom CT slika. Magnetska rezonanca (MR) za razliku od CT-a ima odličan kontrast za meka tkiva zdjelice te odlično oslikava prostatu i zdjelične strukture. Mnoge su prednosti uključenja MR u radioterapijski proces raka prostate. MR omogućava pravu adaptivnu radioterapiju na osnovi MR slika uzetih prije, tijekom i nakon radioterapije. Omogućuje eksalaciju doze na intraprostatičke tumorske strukture. Napredak tehnike je omogućio integraciju snažnog magnetskog polja MR-a i visokoenergetskih X-zraka linearnog akceleratora u jedan jedinstveni uređaj - MRI-linac. Dva su MR-linac komercijalna sustava dostupna na tržištu, a u svijetu ima instalirano preko 100 ovakvih uređaja. U ovom preglednom članku razmatramo razvoj slikovnog vođenja u radioterapiji, trenutno stanje magnetom vođene radioterapije raka prostate, kao i izazove u primjeni ove inovativne metode

Intraoperative radiotherapy in gynaecological and genito-urinary malignancies: Focus on endometrial, cervical, renal, bladder and prostate cancers

Intraoperative radiotherapy (IORT) refers to the delivery of a single radiation dose to a limited volume of tissue during a surgical procedure. A literature review was performed to analyze the role of IORT in gynaecological and genito-urinary cancer including endometrial, cervical, renal, bladder and prostate cancers. Literature search was performed by Pubmed and Scopus, using the words "intraoperative radiotherapy/IORT", "gynaecological cancer", "uterine/endometrial cancer", "cervical/cervix cancer", "renal/kidney cancer", "bladder cancer" and "prostate cancer". Forty-seven articles were selected from the search databases, analyzed and briefly described. Literature data show that IORT has been used to optimize local control rate in genito-urinary tumours mainly in retrospective studies. The results suggest that IORT could be advantageous in the setting of locally advanced and recurrent disease although further prospective trials are needed to confirm this findings

Hypofractionated radiotherapy after conservative surgery for breast cancer: analysis of acute and late toxicity

<p>Abstract</p> <p>Background</p> <p>A variety of hypofractionated radiotherapy schedules has been proposed after breast conserving surgery in the attempt to shorten the overall treatment time. The aim of the present study is to assess acute and late toxicity of using daily fractionation of 2.25 Gy to a total dose of 45 Gy to the whole breast in a mono-institutional series.</p> <p>Methods</p> <p>Eighty-five women with early breast cancer were assigned to receive 45 Gy followed by a boost to the tumour bed. Early and late toxicity were scored according to the Radiation Therapy Oncology Group criteria. For comparison, a group of 70 patients with similar characteristics and treated with conventional fractionation of 2 Gy to a total dose of 50 Gy in 25 fractions followed by a boost, was retrospectively selected.</p> <p>Results</p> <p>Overall median treatment duration was 29 days for hypofractionated radiotherapy and 37 days for conventional radiotherapy. Early reactions were observed in 72/85 (85%) patients treated with hypofractionation and in 67/70 (96%) patients treated with conventional fractionation (p = 0.01). Late toxicity was observed in 8 patients (10%) in the hypofractionation group and in 10 patients (15%) in the conventional fractionation group, respectively (p = 0.4).</p> <p>Conclusions</p> <p>The hypofractionated schedule delivering 45 Gy in 20 fractions shortened the overall treatment time by 1 week with a reduction of skin acute toxicity and no increase of late effects compared to the conventional fractionation. Our results support the implementation of hypofractionated schedules in clinical practice.</p

Ultra-Hypofractionation for Whole-Breast Irradiation in Early Breast Cancer: Interim Analysis of a Prospective Study

We report on the early clinical outcomes of a prospective series of early breast cancer (EBC) patients treated with ultra-hypofractionated post-operative whole-breast irradiation (WBI) after breast-conserving surgery (BCS) and axillary management. Primary endpoints were patient's compliance and acute toxicity. Secondary endpoints included physician-rated cosmesis and ipsilateral breast tumour recurrence (IBTR). Acute toxicity was evaluated at the end of WBI, 3 weeks and 6 months thereafter, according to the Common Terminology Criteria for Adverse Events (v. 5.0). Patients were treated between September 2021 and May 2022. The treatment schedule for WBI consisted of either 26 Gy in 5 fractions over one week (standard approach) or 28.5 Gy in 5 fractions over 5 weeks (reserved to elders). Inverse planned intensity-modulated radiation therapy (IMRT) was used employing a static technique. A total of 70 patients were treated. Fifty-nine were treated with the 26 Gy/5 fr/1 w and 11 with the 28.5 Gy/5 fr/5 ws schedule. Median age was 67 and 70 in the two groups. Most of the patients had left-sided tumours (53.2%) in the 26 Gy/5 fr/1 w or right-sided lesions (63.6%) in the 28.5 Gy/5 fr/5 ws group. Most of the patients had a clinical T1N0 disease and a pathological pT1pN0(sn) after surgery. Ductal invasive carcinoma was the most frequent histology. Luminal A intrinsic subtyping was most frequent. Most of the patients underwent BCS and sentinel lymph node biopsy and adjuvant endocrine therapy. All patients completed the treatment program as planned. Maximum detected acute skin toxicities were grade 2 erythema (6.7%), grade 2 induration (4.4%), and grade 2 skin colour changes. No early IBTR was observed. Ultra-hypofractionated WBI provides favourable compliance and early clinical outcomes in EBC after BCS in a real-world setting

Stereotactic ablative radiotherapy for oligometastatic prostate cancer

Background: The present study assessed clinical outcomes of stereotactic body radiotherapy (SBRT) in oligometastatic prostate cancer patients. Materials and methods: Between 2017 and 2020, 37 lesions (12 osseous and 25 nodal targets) detected with conventional and/or functional imaging, were treated in 29 patients (pts), in different clinical settings: de novo oligometastatic (2 pts), oligorecurrent castration-sensitive (19 pts), castration-resistant (6 pts) prostate cancers and oligoprogressive disease during systemic therapy (2 pts). SBRT was delivered with volumetric modulated arc therapy up to a total dose of 21 Gy given in 3 fractions for bone and 30 Gy in 5 fractions for nodal metastases. A total of 34% of pts received hormonal therapy. We evaluated biochemical control [prostate serum antigen (PSA) increase grade 2 was reported. Conclusions: SBRT for oligometastatic prostate cancer offers a good biochemical/local control and tangible delay of hormone/systemic therapy without major toxicities

Stereotactic radiotherapy of oligometastatic disease: a new paradigm for a curative approach

No abstract availabl

Stereotactic radiation therapy for skull base recurrences: Is a salvage approach still possible?

AimA literature review was performed to analyse the role of stereotactic radiotherapy given in a single shot or in a fractionated fashion for recurrent skull base tumours in order to ascertain if it can be a real salvage approach.BackgroundThe management of recurrent skull base tumours can have a curative or palliative intent and mainly includes surgery and RT.Materials and methodsOne-thousand-ninety-one articles were found in the search databases and the most relevant of them were analysed and briefly described.ResultsData on recurrences of meningioma, pituitary adenoma, craniopharyngioma, chordoma and chondrosarcoma, vestibular schwannoma, glomus jugulare tumours, olfactory neuroblastoma and recurrences from head and neck tumours invading the base of skull are reported highlighting the most relevant results in terms of local control, survival, side effects and complications.ConclusionsIn conclusion, it emerges that SRS and FSRT are effective and safe radiation modalities of realize real salvage treatment for recurrent skull base tumours