Background: Hypofractionated "dose escalation" intensity-modulated radiotherapy (IMRT) might be able to improve locoregional control in prostate cancer without an increase in OAR toxicity. Image ...guidance is a widely accepted approach to increase the therapeutic ratio in external radiotherapy (IGRT). If IGRT and IMRT are combined it is even possible to use SIB approach in order to reduce the number of fractions and therefore the treatment time length. Materials and Methods: Between December 2009 and January 2012 in our institution we treated 61 patients with high risk prostate carcinoma ( greater than or equal to T3 or Gleason score greater than or equal to 8or PSA greater than or equal to 20 ng/ml). The median age was 73 years (range 61-88). All patients underwent a neoadjuvant, concomitant and adjuvant hormonal therapy with antiandrogen (bicalutamide 150 mg) in 19 patients (31.1%) and LHRH analogous in the other 42 patients (68.9%) for a total of 2 years overall starting 3 months before radiotherapy. Stage was cT1c in 3 patients (4.9%), cT2a in 5 patients (8.2%), cT2b in 10 patients (16.4%), and cT2c in 6 patients (9.8%), cT3a in 17 patients (27.9%), cT3b in 18 patients (29.5%) and cT4 in 2 patients (3.3%). Gleason score was 5 in 3 patients (4.9%), Gleason 6 in 15 patients (24.6%), Gleason 7 in 19 patients (31.1%), Gleason 8 in 17 patients (27.9%) and Gleason score 9 in 7 cases (11.5%). All patients performed a simulation CT scan with 2.5 mm slice thickness to execute 3D conformal planning IMRT (intensity-modulated radiation therapy) developed with Eclipse System. Patients were immobilized with a footlocker in supine position. All patients underwent proper rectal and bladder preparation. MR imaging was fused with planning CT to help clinical target volume (CTV) delineation. The CTV1 included the pelvis, CTV2 included the seminal vesicles and CTV 3 only the prostate. The margins for the planning target volume (PTV) were 5 mm in all directions. The total dose to PTV1 was 45 Gy in 25 fractions (1.8 Gy each fraction), the total dose to PTV2 was 55 Gy (2.2 Gy each fraction) and the total dose to PTV3 was 68.75 Gy in 25 fractions (2.75 Gy each fraction). 5 days per week. Patients were controlled during treatment with Cone-Beam (ChiloVoltage) CT. Follow-up evaluations were performed at 1, 3, 6, 9 and 12 months after treatment, and every 6 months thereafter. Acute side effects were evaluated according to the RTOG/EORTC late morbidity Scoring Scale. Results: Median follow-up was 14 months (range 2-29 months). The acute toxicities during the treatment were: grade 1-2 gastrointestinal (GI) toxicity in 7 patients (11.5%), grade 1-2 genitourinary (GU) toxicity in 15 patients (24.6%); grade 3 GU toxicity in 1 patient (1.1%). The toxicities, 1 month after the end of the treatment, were grade 1-2 GI in 1 patient (1.7%), grade 1-2 GU in 10 patients (16.4%). The toxicities, 3 months after the end of the treatment, were grade 1-2 GI in 1 patient (1.7%), grade 1-2 GU in 4 patients (6.6%). The median PSA at diagnosis was 10.1 (range 2.92-45.4) and that at the last follow-up was 0.06 ng/ml (range 0-1.1 ng/ml). Conclusion: Technological progress enables the implementation of new technologies such as intensity-modulated radiation therapy (IMRT) and image guided radiotherapy (IGRT). IMRT allows to minimize the volume of irradiated normal tissue and reduce acute toxicity in all patients.
Aim: To evaluate the tolerance and the clinical efficacy of hypofractionated radiotherapy in patients affected by intermediate risk prostate cancer. Patients and Methods: Between March 2007 and ...November 2011, 106 patients with intermediate risk prostate cancer were treated with 3-dimension conformal hypofractionated radiotherapy. Intermediate risk was defined as clinical stage T1-T2 and pre-radiotherapy PSA between 10 and 20 ng/mL, and Gleason Score equal to <7 or clinical stage T1-T2 and pre-radiotherapy PSA between less than or equal to 20 ng/mL, and Gleason Score equal to 7. Prostate biopsy was performed to all patients to confirm the diagnosis. A total dose of 43.8 Gy was delivered to seminal vesicles and 54.75 Gy to the prostate, 3.65 Gy per fraction, three times a week for a total of 5 weeks. All patients underwent neoadjuvant, concomitant and adjuvant hormonal therapy (OT) for a total duration of 9 months. Acute and late toxicities were evaluated according to RTOG scale. The nadir PSA after radiotherapy plus 2 ng/mL was used for defining biochemical relapse (Phoenix criteria). Results: Median follow-up was 25 months (range 4-55 months). Five patients (4.7%) developed biochemical failure: of these patients were found to have metastasis to regional lymphnode, while two patients developed bone metastasis. Six patients (5.9%) died from causes different from prostate cancer without biochemical failure, while patients died due to disease progression. Acute toxicities (within 3 months from the end of RT) were as follow: Grade 1 Genitourinary (GU) toxicities were 43.2%, while 10% presented Grade 2 toxicities; Grade 1 Gastrointestinal (GI) toxicities were 9.6%, Grade 2 GI toxicities were 10.8%. Late GU and GI toxicities greater than or equal to Grade 2 recorded at the last follow-up were 3.3% and 4.6% respectively. No patient developed grade 4 toxicity. 2-year BFS and 4-year BFS were 94.4% and 92%, respectively. Conclusion: The hypofractionated schedule used was well tolerated with a low rate of acute and late grade greater than or equal to 2 gastrointestinal and genitourinary toxicities. Hypofractionation is useful to obtain high rate of tumor control also if longer follow-up is needed.
Background: In the past decades, three-dimensional conformal radiotherapy (3D-CRT) has become the standard treatment technique for prostate irradiation. There is now growing evidence supporting the ...benefit of hypofractionated and intensity-modulated radiation therapy (IMRT) with simultaneously integrated boost (SIB). Patients and Methods: At our institution between November 2009 and January 2011, we treated 27 patients with high-risk prostate carcinoma (T3 or Gleason score >8 or PSA >20 ng/ml). The median age was 73 (range, 67-82) years. Median PSA at diagnosis was 10.5 (range 3.89-45.4) ng/ml. Stage was cT1c in 1/27 (3.7%) patients, cT2a in 1/27 (3.7%), cT2b in 5/27 (18.5%), cT2c in 1/27 (3.7%), cT3a 8/27 (29.6%) and cT3b in 11/27 (40.7%) patients. Gleason score was 6 in 7/27 (25.9%) patients, 7 (3+4) in 8/27 (29.6%) and 8 in 12/27 (44.4%) patients. All patients underwent a simulation computed tomography (CT) scan with 2.5 mm slice thickness to execute 3D conformal planning. They were immobilized with a footlocker in supine position. Half an hour before the CT scan, all patients urinated and drank 0.5 1 of water. Magnetic resonance imaging scans were fused with the planning CT scan for all patients to help delineation of the clinical target volume (CTV). Subsequently, the patients were submitted to image-guided radiation therapy (IGRT) for implementation of linear accelerator with on-board imaging system. CTV1 included the pelvis, CTV2 included the seminal vesicles and CTV3 included only the prostate. The margins for the planning target volume (PTV) were 5 mm in all directions. All patients were submitted to IMRT developed with the Eclipse System. All patients underwent additional neoadjuvant hormonal therapy, concomitant with adjuvant radiotherapy for a total of nine months, starting three months before radiotherapy with anti-androgen (bicalutamide 150 mg) in 13/27 (48.14%) patients and LHRG analog in the remaining 14/27 (51.85%) patients. Radiation was delivered in 25 fractions in total, with 4 fractions per week. The total radiation dose was 45 Gy to the pelvis (1.8 Gy per fraction), 55 Gy to PTV2 (2.2 Gy per fraction) and 68.75 Gy to PTV3 (2.75 Gy per fraction). All patients were monitored during treatment daily with a portable imaging system equipped with a cone-beam kilovoltage CT. All patients were visited once a week during treatment, one month after the completion of radiotherapy and every three months during follow-up. Results: Median follow-up for all patients was 6 (range 2-12) months. We considered acute toxicity, in particular, because of the shortness of follow-up, although we did not observe any late effects in patients with a follow-up longer than three months. We observed only acute grade 1 genitourinary toxicity in 3/27 (11.1%) patients during treatment and after one month from radiation therapy. Regarding gastrointestinal toxicity, two patients (7.4%) presented grade 1 and 2 diarrhea, cured with medical therapy. During the follow-up period, no patients experienced worsening of their symptoms. Discussion and Conclusion: Technological progress enables the implementation of new technologies such as IMRT and IGRT. IMRT is capable of minimizing the volume of normal tissue irradiated, notably reducing acute radiation-induced toxicity in patients.
Introduction: Hypofractionation presents crescent interest in the treatment of prostate cancer. We have evaluated the acute toxicity in patients with low-risk prostate cancer treated with ...hypofractioneted IGRT in our institution. Materials and Patients. Between March 2007 and April 2012 we have treated 45 patients with low- risk prostate cancer (T1-T2 and Gleason score less than or equal to 6 and PSA less than or equal to 10 ng/ml)). The median age was 71 (range 58-82). All patients underwent prostate biopsy. Stage was cT1c in 18 patients (40%); cT2a in 14 patients (31, 1%); cT2b in 10 patients (22.2%); cT2c in 3 patients (6.7%). Gleason score was 6(3+3) in all patients. All patients performed a simulation CT scan with 2.5 mm slice thickness to execute 3D conformal planning. They were immobilized in supine position with a footlocker. 28 patients (66.7%) were treated with a total dose of 45Gy on the first 1.5 cm of seminal vescicles and 60 Gy on prostate; 3 Gy for fraction 5 times a week and a total time of 4 weeks. 14 patients (33.3%) were treated with a total dose of 46.5 Gy on the first 1.5 cm of seminal vesicles and 62 Gy on prostate; 3.1 Gy for fraction 5 times a week and a total time of 4 weeks. Margin from CTV to PTV was 5 mm in all directions. The external beam radiation therapy was performed with image guided technique (IGRT), with daily cone-beam TC. Follow-up evaluations were performed at 3, 6, 9 and 12 months after treatment, and every 6 months thereafter. Acute side effects were evaluated according to the RTOG/EORTC late morbidity Scoring Scale. Results: Median follow-up was 20 months (range 3-62 months). The acute toxicities during the treatment were: grade 1-2 gastrointestinal (GI) toxicity in 7 patients (15.6%), grade 1-2 genitourinary (GU) toxicity in 19 patients (42.2%)%; grade 3 GU toxicity in 1 patient (2.2%). The toxicities 3 month after the end of the treatment were grade 1-2 GI in 4 patients (8.9%), grade 1-2 GU in 12 patients (26.7%). The toxicities 6 months after the end of the treatment were grade 1-2 GI in 2 patient (4.4%), grade 1-2 GU in 6 patients (13.3%). The median PSA before the start of radiotherapy was 5 (range 1.74-8.43) and at the last follow-up was 0.83 ng/ml (range 0-5.05 ng/ml). Conclusion: This study showed that the hypofractionated radiation therapy was well tolerated with a low grade of toxicity, but it needed a longer follow-up to determine possible late toxicity and local control.
Purpose The authors report acute toxicity in 14 patients with locally advanced head and neck squamous cell carcinoma treated with radiotherapy and cetuximab.
The aim of the present paper is to compare the integral dose received by non-tumor tissue (NTID) in stereotactic body radiation therapy (SBRT) with modified LINAC with that received by ...three-dimensional conformal radiotherapy (3D-CRT), estimating possible correlations between NTID and radiation-induced secondary malignancy risk. Eight patients with intrathoracic lesions were treated with SBRT, 23 Gy × 1 fraction. All patients were then replanned for 3D-CRT, maintaining the same target coverage and applying a dose scheme of 2 Gy × 32 fractions. The dose equivalence between the different treatment modalities was achieved assuming α/β = 10Gy for tumor tissue and imposing the same biological effective dose (BED) on the target (BED = 76Gy10). Total NTIDs for both techniques was calculated considering α/β = 3Gy for healthy tissue. Excess absolute cancer risk (EAR) was calculated for various organs using a mechanistic model that includes fractionation effects. A paired two-tailed Student t-test was performed to determine statistically significant differences between the data (p ≤ 0.05). Our study indicates that despite the fact that for all patients integral dose is higher for SBRT treatments than 3D-CRT (p = 0.002), secondary cancer risk associated to SBRT patients is significantly smaller than that calculated for 3D-CRT (p = 0.001). This suggests that integral dose is not a good estimator for quantifying cancer induction. Indeed, for the model and parameters used, hypofractionated radiotherapy has the potential for secondary cancer reduction. The development of reliable secondary cancer risk models seems to be a key issue in fractionated radiotherapy. Further assessments of integral doses received with 3D-CRT and other special techniques are also strongly encouraged.
The best treatment of Nasopharyngeal Carcinoma (NPC) is still an open question. The purpose of this retrospective study was to determine risk factors that affect locoregional control and treatment ...outcome of NPC patients after radiotherapy, with or without chemotherapy.
Between January 1976 and December 1996, 66 consecutive patients (stage I = 0; stage II = 13; stage III = 32; stage IV = 21) were given definitive radiotherapy at a single Institution. Concurrent or adjuvant chemotherapy was also given to 14 of them (21%). Multivariate analysis was performed to evaluate age, T stage, N stage, radiotherapy dose, histology, chemotherapy bone of skull erosions or cranial nerve palsies and base of skull involvement as prognostic factors of locoregional control and overall survival.
By the end of January 2000, after a median follow-up of 66 months and a minimal follow-up of 36 months, the event-free overall survival rate of 5 years was 48% and the overall survival 54%. Risk factor analysis revealed that radiotherapy dose, age and stage were the most important factors for overall survival of these patients. The 5 year overall survival was 89% for stage II and 49% for stage III-IV (p = 0.004), 62% for dose higher than 60 Gy and 20% for dose below 60 Gy (p = 0.007), 62% for age below 65 years and 36% for age higher than 65 years (p = 0.027). The concurrent or adjuvant chemotherapy did not have prognostic significance.
We confirm the need to determine the risk factors in patients with NPC. The choice of treatment, whether radiotherapy alone, at dose > 60 Gy, or radiotherapy plus chemotherapy, should be made after identification of patients with high risk disease, suitable for the combined modality.
Surgical repair of ventral hernias may often be quite difficult; however, the use of prosthesis, now generally accepted by many surgeons, has improved the results of such type of surgery. The Authors ...experience confirm the safety of the expanded PTFE and its versatility of employment, obtaining good functional and aesthetic results.
Computed Tomography (CT) with rectal air inflation was compared with transrectal ultrasound (TRUS) in the preoperative staging of lower rectal cancer in 126 patients. Precontrast and postcontrast CT ...scans were performed with 5 mm thick slices; the rectum was previously inflated with air and antiperistaltic agents were administered. Preoperative results were compared with histologic findings. The accuracy, sensitivity and specificity of CT in predicting perirectal spread were 76%, 62% and 83%, whereas the corresponding figures for TRUS were 84%, 69% and 92%. The accuracy, sensitivity and specificity of CT and TRUS for nodal involvement were 58%, 60%, 57% and 72%, 68% and 66%, respectively. These results show that TRUS predicts perirectal spread and detects nodal metastases better than CT. However CT, when performed appropriately, shows tumor spread into perirectal fat and locoregional lymph nodes with high accuracy. Lymphatic involvement is strictly correlated with tumor size: TRUS and CT correctly staged only 57% and 43%, respectively, of the cases with nodal metastases and max. diameter of 5 mm. TRUS sometimes overstaged perirectal tumor growth (13 patients in our series) due to perirectal inflammation (9 cases) or artifacts caused by the presence of air bubbles between the probe and the tumor surface (4 patients). TRUS is a very useful tool for detecting tumor distance from the anal opening; in our series, the distance was incorrectly calculated only in one case (3 cm with TRUS versus 4 cm at surgery).
