Practical Radiation Oncology最新文献

Purpose: With the results of several recently published clinical trials, this guideline focused update provides evidence-based recommendations for the indications and dose-fractionation regimens for neoadjuvant radiation therapy (RT), optimal sequencing of RT and systemic therapy in the context of total neoadjuvant therapy (TNT), and considerations for selective omission of RT and surgery for rectal cancer.

Methods: The American Society for Radiation Oncology convened a multidisciplinary task force to update 3 key questions that focused on the role of RT for patients with operable rectal cancer. The key questions addressed (1) indications for neoadjuvant RT, (2) selection of neoadjuvant regimens, and (3) indications for consideration of a nonoperative management (NOM) or local excision approach after definitive/preoperative chemoradiation. Recommendations were based on a systematic literature review and created using a predefined consensus-building methodology and system for quality of evidence grading and strength of recommendation.

Results: For patients with stage II-III rectal cancer, neoadjuvant RT was strongly recommended; however, among patients deemed at lower risk of locoregional recurrence, consideration of omission of neoadjuvant RT was conditionally recommended in favor of neoadjuvant chemotherapy with a favorable treatment response or upfront surgery. For patients with T3-T4 and node positive rectal cancer undergoing neoadjuvant RT, a TNT approach was strongly recommended. Among patients with higher risk of locoregional recurrence, TNT with chemotherapy before or after long-course chemoradiation was strongly recommended, whereas TNT with short-course RT followed by chemotherapy was conditionally recommended. For patients with rectal cancer for whom NOM is a priority, concurrent chemoradiation followed by consolidation chemotherapy was strongly recommended. Selection of RT dose-fractionation regimen, sequencing of therapies, and consideration of NOM should be determined by multidisciplinary consensus, and based on disease extent, disease location, patient preferences, and quality of life considerations.

Conclusions: The task force has proposed recommendations to inform best clinical practices on the use of RT for rectal cancer with strong emphasis on multidisciplinary care. Future studies should focus on further addressing optimal treatment regimens to allow for more personalized recommendations based on individual risk stratification and patient priorities regarding quality of life.

Purpose: We report the financial toxicity and quality-of-life outcomes of our prospective phase 1 dose-escalation study of 5-fraction stereotactic partial breast irradiation (S-PBI) for early-stage breast cancer.

Materials and methods: Women with unifocal in situ or invasive epithelial histologies, clinical stages 0, I, or II with tumor size < 3 cm treated with lumpectomy were enrolled in our phase 1 5-fraction S-PBI dose-escalation trial. Our institutionally generated questionnaire on the "Patient Perspective Cost and Convenience of Care" and the EuroQol 5-Dimension 5-level questionnaire were administered to patients treated at follow-up.

Results: Between 2010 and 2015, 68 of the 75 patients who enrolled and completed treatment on trial completed at least some component of either the EuroQol 5-Dimension 5-level questionnaire or the "Patient Perspective Cost and Convenience of Care" questionnaire. Nearly all patients reported very high satisfaction with their treatment overall, particularly the shortened length of treatment. Over half of the patients reported some level of financial toxicity (FT) despite a significantly shortened treatment time. Patients who reported any FT were significantly younger than patients with no financial burden of treatment (means 59.2 and 63.7, respectively, P = .03). There was no difference in those who reported any level of FT based on patient race, ethnicity, marital, or employment status. This S-PBI regimen did not significantly affect quality of life over a 4-year follow-up.

Conclusions: These patient-reported outcomes suggest that the use of accelerated partial breast irradiation may offer low FT rates in breast cancer care, particularly for disadvantaged patient groups.

Purpose: Accurate target delineation is essential when using intensity-modulated radiotherapy (IMRT) for intact cervical cancer. In 2011, the Radiation Therapy Oncology Group (RTOG) published a consensus guideline using magnetic resonance imaging (MRI). The current project expands on the previous atlas by including computed tomography (CT)-based contours, contours with MRI and positron- emission- tomography (PET) registrations, the addition of common and complex scenarios, and to incorporate information on simulation and treatment planning techniques.

Methods and materials: Twenty-eight experts in gynecologic radiation oncology contoured three cases, first on a non-contrast CT simulation scan, then with registered diagnostic scans. The cases included (1) FIGO IIIC1 with a bulky tumor and vaginal metastasis, (2) FIGO IIB with calcified uterine fibromas, and (3) FIGO IIIC2 with large lymph nodes. The contours on all six datasets (three CT simulations without diagnostic images and three with registered images) were analyzed for consistency of delineation using an expectation-maximization algorithm for simultaneous truth and performance level estimation (STAPLE) with kappa statistics as a measure of agreement. The contours were reviewed, discussed, and edited in a group meeting prior to finalizing.

Results: Contours showed considerable agreement between experts in each of the cases with kappa statistics of 0.67-0.72. For each case, diagnostic PET±MRI was associated with an increase in volume. The largest increase was the CTV primary for Case 2 with a 20% increase in volume and 54% increase in STAPLE estimate volume, which may be due to variance in registration priorities. For the third case, 92.9% increased their CTVs based on the addition of the diagnostic PET scan. The main areas of variance were in determining the superior extent of CTV coverage, coverage of the mesorectum, and simulation and planning protocols.

Conclusions: This study shows the value as well as the challenges of using co-registered diagnostic imaging, with an average increase in volumes when incorporating MRI and PET.

Purpose/objectives: Tracking patient dose in radiation oncology is challenging due to disparate electronic systems from various vendors. Treatment planning systems (TPS), radiation oncology information systems (ROIS), and electronic health records (EHR) lack uniformity, complicating dose tracking and reporting. To address this, we examined practices in multiple radiation oncology settings and proposed guidelines for current systems.

Material/methods: A survey was conducted among members of various professional groups to understand dose reporting practices in TPS, ROIS, and EHR systems. The aim was to identify consistent components and develop guidelines.

Results: We identified six treatment scenarios where current ROIS defaults fail in accurately representing dose totals. A standardized approach involving three reference point types - Primary Treatment Plan Reference, Dose Check, and Prescription Tracking - was proposed to address these scenarios. Standardizing naming conventions for reference points was also recommended for easier integration with EHRs. The approach requires minimal modifications to existing systems and facilitates easier data transfer and display in EHRs.

Conclusion: Standardizing reference points in commercial TPS and ROIS can bridge infrastructure gaps and improve dose tracking in complex clinical scenarios. This standardization, aligned with AAPM's TG-263, paves the way for continual development of automated, standardized, interoperable tools, enhancing the ease of sharing reference point information.

Introduction: Heterotopic Ossification (HO) is a benign disorder characterized by ectopic bone formation in soft tissues that can lead to functional loss in patients. We conducted a systematic review of the evidence on the use of Radiation Therapy (RT) for the prevention or treatment of HO.

Methods and materials: Literature searches were conducted using Medline (via PubMed), Embase, and ClinicalTrials.gov to April 1_, 2023. Medical Subject Headings (MeSH) and free text terms relevant to HO and radiation therapy were used. In brief, eligible study participants were ≥18 years of age with heterotopic ossification and were treated with low-dose, external RT. Two reviewers selected relevant abstracts and abstracted full text data for analysis. The review followed the PRISMA guidelines.

Results: Ten studies evaluating the effect of RT for either the prevention or treatment of heterotopic ossification met the inclusion for evidence synthesis. Nine RCTs did not clearly report their methods and had medium risk of bias. The studies were conducted between 1988 and 2008 with follow-up ranging on average from three to 59 months post treatment. A total of 1530 participants were analyzed, and 566 were treated with RT following fracture fixation, total hip arthroplasty (THA), or total hip replacement (THR). In pooled data from eight RCTs, there was a non-significant but clinically meaningful reduction in the presence of heterotopic ossification at follow-up for patients who received RT vs. comparators (pooled OR = 0.47, 95% CI [0.19, 1.17]. There was minimal evidence of adverse events.

Conclusion: This systematic review found a clinically, but not statistically, significant benefit of prophylactic RT for HO at follow up. These findings are tempered by a moderate risk of bias. While practice patterns vary, RT for HO prophylaxis, in high-risk patients, may have benefits that outweigh the risks.

Treatment options for patients with metastatic castration-resistant prostate cancer include the use of radioligand therapy with ¹⁷⁷Lu-PSMA-617. Although ¹⁷⁷Lu-PSMA-617 can selectively target prostate cancer cells, salivary glands express PSMA on the apical lumen of the acinar epithelium. Xerostomia resulting from the use of radioligand therapy is common. Herein, we report on a case of a Common Terminology Criteria for Adverse Events version 5 grade 2 dry mouth event after administration of ¹⁷⁷Lu-PSMA-617. The patient was managed with oral hygiene and xerostomia mitigation strategies using oral rinses.

Purpose: Despite the decades of using radiotherapy for Graves' ophthalmopathy, the effects and optimal timing remain unclear. We retrospectively analyzed to evaluate the overall efficacy and response, predictive factors, and the effective timing of radiotherapy by assessing steroid requirement after radiotherapy in patients without prior surgery.

Methods and materials: Between 2008 and 2022, we analyzed 74 patients with Graves' ophthalmopathy who received radiotherapy to both orbits. Concurrent steroid therapy was administered to 51 patients. Symptoms were evaluated using a modified clinical activity score (CAS), defining responders as those with a two or more score improvement in CAS, diplopia, or a significant reduction in exophthalmos asymmetry. Common symptoms included eye swelling (81.1%), and conjunctival edema (81.1%). Diplopia observed in 48 patients (64.9%).

Results: Median follow-up was 44.5 months (range 4.8-169.6). CAS significantly improved in the early-immediate phase, one month after radiotherapy (p<0.001). However, diplopia showed significant improvement at a relatively late phase, 4 months after radiotherapy (p=0.039). Patients treated with steroids concurrently showed a faster response compared to those without steroids. Initiating radiotherapy within 12 months of symptom onset resulted in a shorter duration of steroid use after radiotherapy compared to later initiation (65 vs. 286 days, p=0.011).

Conclusions: Our study suggests an evaluation period of at least four months after radiotherapy regardless of concurrent steroid treatment, recognizing the prolonged improvement timeline for diplopia. Additionally, for reducing steroid use after radiotherapy, our study suggests optimal timing of radiotherapy within 12 months of symptom onset.

Purpose: Carbon fiber-reinforced polyetheretherketone (CFR-PEEK) instrumentation is being used more frequently in the spinal oncology landscape. Better visualization with this material allows for more precise postoperative stereotactic body radiation therapy (SBRT) planning using either computed tomography (CT)-myelography or magnetic resonance imaging (MRI) studies. We compared the dosimetric planning equivalencies and outcomes.

Methods and materials: Thirty-six consecutively treated patients were reviewed who underwent spinal fusion using CFR-PEEK instrumentation for spine metastases followed by postoperative SBRT between January 1, 2022, and April 3, 2023. Patients were divided into 2 cohorts based on the imaging modality, MRI versus CT-myelogram, used for postoperative SBRT planning. Surgical, demographic, postoperative radiation dosimetry, complication, and survival data were collected. Statistical analysis was performed in SPSS (v29.0.1.0).

Results: Eleven patients underwent CT-myelograms, and 25 patients underwent MR-spine imaging for SBRT planning. The median follow-up was 145.5 days (13-530). There were no significant differences between baseline demographic, surgical characteristics, or SBRT dosimetry between the MRI spine and CT-myelogram groups. There was no significant difference between the cohorts for survival (P = .402).

Conclusions: MR scans are an effective choice for postoperative SBRT contouring patients using CFR-PEEK instrumentation for oncologic spinal fusions. Avoidance of CT-myelography reduces the need for an invasive procedure and potential risks including cerebrospinal fluid (CSF) leak, nerve root injury, and increased procedural burden.

Low-dose chest CT imaging for lung cancer screening is revealing increasing numbers of radiographic early-stage lung cancers. This topic discussion describes when a clinical scenario merits radiotherapy without a histologic diagnosis, with an emphasis on pragmatic algorithms in settings without readily-available advanced biopsy techniques.