Andrea Lancia

Salvage Stereotactic Body Radiotherapy for Patients With Prostate Cancer With Isolated Lymph Node Metastasis: A Single-Center Experience

OBJECTIVE The study objective was to evaluate the efficacy of salvage stereotactic body radiation therapy (SBRT) as a treatment modality in patients with oligometastatic prostate cancer. METHODS A total of 16 patients with 18 isolated lymph nodes with recurrent prostate cancer were treated between 2008 and 2013. All patients underwent [(11)C] choline-positron emission tomography/computed tomography before SBRT. Two patients were treated in different sessions for metachronous metastases. Ten patients received androgen deprivation therapy concomitant to SBRT (total dose range, 12-35 Gy, delivered in 1-5 daily fractions). RESULTS The mean and median follow-up periods were 29.35 and 29.38 months, respectively (range, 6.3-68.8 months). Local disease control and a decrease in serum prostate-specific antigen were obtained in 15 of 16 patients (94%); only 1 patient had an in-field progression. In the 6 patients without androgen deprivation therapy at the time of SBRT, the mean time of deferment of palliative androgen deprivation therapy was 23.7 months (range, 2.5-51 months). At last follow-up, 8 patients had active prostate cancer disease; biochemical progression was observed after a mean time of 7.9 months from the completion of SBRT. One patient died of disease. Overall survival was 94%. The 2-year biochemical relapse-free survival was 44%. Late toxicity (gastrointestinal) was observed in 1 patient who had a G3 toxicity. CONCLUSIONS SBRT seems to be safe, effective, and minimally invasive in the eradication of limited nodal recurrence from oligometastatic prostate cancer. SBRT is well tolerated by patients with low toxicity and yielded a local control of the disease.

Exploring All Avenues for Radiotherapy in Oligorecurrent Prostate Cancer Disease Limited to Lymph Nodes: A Systematic Review of the Role of Stereotactic Body Radiotherapy

CONTEXT Stereotactic body radiotherapy (SBRT) is emerging as a treatment option in patients affected by oligorecurrent prostate cancer disease limited to lymph nodes, a subgroup of patients who would otherwise be treated only with androgen deprivation therapy (ADT). OBJECTIVE To perform a systematic review of SBRT for oligorecurrent prostate cancer limited to lymph nodes. EVIDENCE ACQUISITION We performed a systematic review of PubMed/Medline in October 2016 according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA). We searched for studies reporting on biochemical or clinical progression and/or toxicity or complications of SBRT. Reports were excluded if these end points could not be ascertained or separately analyzed, or if insufficient details were provided. EVIDENCE OF SYNTHESIS A total of 363 patients from nine studies were collected. Of these patients, 211 were treated with SBRT for a total of 270 lymph nodes. With an alpha-beta ratio of 3 Gy, the biologically effective dose in fractionated SBRT was >100 Gy in all studies (range, 88-216 Gy). With a median follow-up of 19.23 mo, local control was achieved in 98.1% of patients. Median progression-free survival (defined as biochemical and/or radiological progression) was 22.5 mo (range, 11-30 mo). Information about ADT during SBRT was available in 281 patients, of whom 114 (40.5%) were on ADT during SBRT, and the duration of hormone therapy ranged from 1 to 17.5 mo. Median ADT-free survival was 32.8 mo (range, 25-44 mo). About toxicity, Common Terminology Criteria for Adverse Events toxicity scale was most used. Acute and/or late grade ≥2 toxicity was reported in only 5.6% of patients, and no patient developed grade 4 toxicity. CONCLUSIONS SBRT seems to be promising in lymph node oligorecurrent prostate cancer, although there is a weak level of evidence to support such investigational treatment, which is currently based on retrospective studies of single-institution or pooled experiences. ADT-free survival is an interesting end point, which needs to be investigated. PATIENT SUMMARY We performed a systematic review to assess outcomes and toxicity of stereotactic body radiotherapy (SBRT) for patients affected by oligorecurrent prostate cancer limited to lymph nodes. We concluded that SBRT is a promising therapy in this setting, but it needs to be validated in randomized controlled trials.

Oligometastatic cancer: stereotactic ablative radiotherapy for patients affected by isolated body metastasis

Abstract Background: To evaluate the outcome of patients affected by a single isolated body metastasis treated with stereotactic body radiotherapy (SBRT). Material and methods: Seven-eight patients were treated with SBRT for isolated body metastasis. The most frequent primary tumor was prostate cancer (28.2%), followed by colorectal cancer (23.1%) and lung cancer (20.5%). Median age at diagnosis of oligometastatic disease was 70 years (range 47–88). Median Karnofsky Performance Status (KPS) was 90 (range 70–100). The most common SBRT fractionation scheme was 5 × 7 Gy (total dose 35 Gy). Response to radiotherapy was determined according to RECIST criteria v1.1. Toxicity was registered according to Common Terminology Criteria for Adverse Events (CTCAE) v4.0. The survival analysis was performed with the Kaplan–Meier method. The correlation between time actuarial incidence and clinical parameters was studied, and the Kaplan–Meier method of log-rank test was applied. Results: With a median follow-up of 22.68 months, local control was achieved in 89.7% of the cases. The two-year overall survival (OS) and progression-free survival (PFS) were 68% and 42%, respectively. On univariate analysis, KPS ≥80 is predictive for improved OS (p = .001) and PFS (p = .001). Acute toxicity of grade ≥2 occurred in eight (10.2%) patients and late grade ≥2 toxicity in five (6.4%) patients. Conclusions: Ablative radiotherapy in ‘early oligometastatic state’ is a safe, effective and minimally invasive treatment modality. A good performance status (KPS ≥80) seems to influence the clinical outcome.

Intensity-modulated and 3D-conformal radiotherapy in hypofractionated prostate cancer treatment using Elekta Beam ModulatorTM micro-MLC: A dosimetric analysis

External beam radiotherapy is a therapeutic option for the radical treatment of localized prostate cancer [1]. High-dose conformal radiotherapy with conventional 2 Gy daily fractions to a total dose of 74–80 Gy is the standard of care, with an overall treatment time of 7–8 weeks [2]. However, hypofractionated radiation therapy (HFRT) for localized prostate cancer is becoming very attractive and several phase 3 randomized controlled trials have demonstrated the safety of moderate hypofractionation [3–8]. Many of these trials employed intensity-modulated radiation therapy (IMRT) with image-guidance in order to deliver the hypofractionated treatment [4,6,8]. However, three-dimensional conformal radiotherapy (3DCRT) has been used too [3,5,7]. Respect to 3DCRT, IMRT increases the dose gradient near the structures maximizing the dose to the tumor while sparing normal tissue. However, it requires more time for planning and for daily treatment delivery. Micro-multi-leaf collimators (micro-MlCs) offer the potential to improve target dose distribution and normal tissues sparing both in 3DCRT and in IMRT [9,10]. The Elekta beam ModulatorTM is a high definition multileaf collimator (4 mm leaf width at the isocenter) integrated on the Elekta synergy s linear accelerator (Elekta Oncology systems, Crawley, UK) [11]. The purpose of this dosimetric study is to evaluate the impact of the Elekta beam ModulatorTM micro-MlC in the development of IMRT and 3DCRT plans, using two different hypofractionation schedules for prostate cancer radiotherapy.

The role of adjuvant radiotherapy in the treatment of papillary tumors of the pineal region: some general considerations and a case-report

BACKGROUND Papillary tumor of the pineal region (PTPR) is a recently defined tumor entity. Its clinical course is characterized by frequent local recurrence, and patients may experience the burden of symptoms due to the anatomical location of the growing mass. Guidelines for treatment protocols, and the role of radiotherapy are still being investigated. CASE We report the case of a 27-year old woman who was referred to our department after she was diagnosed with PTPR and had undergone multiple surgical interventions. We delivered adjuvant conformal radiotherapy on the gross residual tumor to a total dose of 59.4 Gy (33 × 1.8 Gy). DISCUSSION After a follow-up period of 41 months, we obtained a complete response to the treatment, according to the Response evaluation criteria in solid tumors criteria (RECIST). Radiation treatment was well tolerated, and the patient did not develop acute and late side effects. The neurological symptoms, which were documented at the diagnosis and after the surgical procedure, have not been recorded at last follow-up. CONCLUSIONS Formal consensus for managing patients with a diagnosis of PTPR are nonexistent. Despite surgery, this tumor has a tendency to recur. Radiotherapy could have a role in the adjuvant setting and needs to be investigated in a multicenter setting with a long follow-up.Key words: radiotherapy - neurosurgery - magnetic resonance - pineal region - brain tumor.

Volumetric image-guided conformal radiotherapy for localized prostate cancer: Analysis of dosimetric and clinical factors affecting acute and late toxicity

Aim To identify factors influencing toxicity in patients affected by localized prostate cancer treated with conformal image-guided radiotherapy. Background Image guidance in combination with conformal techniques is the standard of care in localized prostate cancer, but factors affecting toxicity are still under investigation. Materials and methods 294 patients were analyzed. Median age at diagnosis was 71 year. 76 Gy (38 × 2 Gy) were delivered to the target volume. We used the χ2 test to analyse associations between toxicity and dosimetric and clinical parameters. Multivariate analysis was performed using binary logistic regression. Kaplan-Meier method was used for survival analysis. Results Median follow-up was 62.9 months. Acute grade ≥2 gastro-intestinal toxicity (GI) was 12.1%. Acute genito-urinary (GU) toxicity of grade ≥2 was 33.9%. Actuarial 4 and 5 years late grade ≥2 GI was 3% and 4%, respectively. Four and 5-year late grade ≥2 GU toxicity was 6% and 10%. At multivariate analysis for acute toxicity rectal V70 was correlated with GI toxicity (p = 0.01, HR 2.73 CI 1.19-6.26), and smoking habit with GU toxicity (p < 0.01, HR 2.50 CI 1.51-4.14). For late toxicity, rectal V70 was correlated with gastro-intestinal toxicity (p = 0.04, HR 4.76 CI 1.07-21.13), and pre-radiotherapy urinary symptoms with genito-urinary toxicity (p = 0.01, HR 2.84 CI 1.29-6.22). Discussion Conformal image-guided radiotherapy shows low rates of toxicity. Smoking should be avoided during radiotherapy. Besides the evaluation of high doses received by the organs at risk, individual factors, such as co-morbidities and lifestyle choices, have an impact on normal-tissue complication risk.

Technical solutions to reduce mediastinal irradiation in young patients undergoing treatment for lymphomas: Preliminary experience

This study aims at optimizing treatment planning in young patients affected by lymphoma (Stage II to III) by using an inclined board (IB) that allows reducing doses to the organs at risk. We evaluated 19 young patients affected by stage I to III lymphomas, referred to our Department for consolidation radiotherapy (RT) treatment on the mediastinum. Patients underwent 2 planning computed tomography (CT) scans performed in different positions: flat standard position and inclined position. A direct comparison between the different treatment plans was carried out analyzing dosimetric parameters obtained from dose-volume histograms generated for each plan. Comparison was performed to evaluate the sparing obtained on breast and heart. Dosimetric evaluation was performed for the following organs at risk (OARs): mammary glands, lungs, and heart. A statistically significant advantage was reported for V5, V20, and V30 for the breast when using the inclined board. A similar result was obtained for V5 and V10 on the heart. No advantage was observed in lung doses. The use of a simple device, such as an inclined board, allows the optimization of treatment plan, especially in young female patients, by ensuring a significant reduction of the dose delivered to breast and heart.

Evaluation of serrated intraprostatic gold coils positional stability using on-board cone beam computed tomography scans acquired throughout the radiation treatment course

PURPOSE To investigate intraprostatic gold coils positional stability analyzing intermarker distance in on-board cone beam computed tomography (CBCT) scans acquired throughout the entire treatment course. METHODS AND MATERIALS A total of 29 fiducial markers (FMs) were implanted in 10 patients through the transperineal approach, under ultrasound guidance. After 2 weeks from the FM implantation, all the patients underwent CT and magnetic resonance imaging under radiation therapy-planning conditions. The planning CT was the reference CT (CTref) used to calculate the initial intermarker distances. For every patient, 8 CBCTi (i varying from 1 to 8) acquired once a week during the treatment course were selected to calculate intermarker distances and compared with CTref. Reconstructed images of CBCTi were exported to the treatment planning system, and every FM was contoured. A point of interest at the center of mass of each contoured FM was created. The mean coordinates obtained for point of interest at the center of mass of FMs were used to calculate relative marker distances on CTref and CBCTi. RESULTS No patient developed postimplantation complications. A total of 224 marker distance variations (MDVs) were calculated for all 29 markers. The average directional variation of all MDVs (± standard deviation [SD]) was -0.14 ± 0.86 mm. The average absolute variations of all MDVs (± SD) were 0.71 ± 0.51 mm. The largest observed variation was 1.9 mm. All patients had not significant temporal trends in their marker distances. The SD of the MDVs was computed for each set of markers in all 10 patients. The SDs ranged between 0.4 and 1.1 mm in individual patients. The average of the mean SDs was 0.6 mm. CONCLUSIONS The three-dimensional definition of each fiducial marker volume, using on-board CBCT, demonstrated the stability of FMs position throughout the entire radiation therapy treatment course.