Irene Giacomelli

Organs at risk in the brain and their dose-constraints in adults and in children: A radiation oncologist’s guide for delineation in everyday practice

PURPOSE Accurate organs at risk definition is essential for radiation treatment of brain tumors. The aim of this study is to provide a stepwise and simplified contouring guide to delineate the OARs in the brain as it would be done in the everyday practice of planning radiotherapy for brain cancer treatment. METHODS Anatomical descriptions and neuroimaging atlases of the brain were studied. The dosimetric constraints used in literature were reviewed. RESULTS A Computed Tomography and Magnetic Resonance Imaging based detailed atlas was developed jointly by radiation oncologists, a neuroradiologist and a neurosurgeon. For each organ brief anatomical notion, main radiological reference points and useful considerations are provided. Recommended dose-constraints both for adult and pediatric patients were also provided. CONCLUSIONS This report provides guidelines for OARs delineation and their dose-constraints for the treatment planning of patients with brain tumors.

Does lymphocyte-to-monocyte ratio before, during, or after definitive chemoradiation for locally advanced pancreatic cancer predict for clinical outcomes?

BACKGROUND Elevated pre-treatment lymphocyte (L) to monocyte (M) ratio (LMR) in peripheral blood has been suggested to correlate with improved survival in some malignancies, but data in the context of pancreatic cancer (PC) is limited. The aim of this study was to evaluate the prognostic significance of LMR before, during and after definitive chemoradiotherapy (CRT) for locally advanced pancreatic cancer (LAPC). METHODS We retrospectively reviewed 57 patients with LAPC treated with definitive CRT at a single institution from 2005 to 2013. Complete blood counts were obtained before (TP1), during the third week (TP2) and at the end of CRT (TP3). Univariate analysis (UVA) included gender, age, body mass index, pre-treatment CA19-9, T stage, N stage, induction chemotherapy (ICT), absolute L count (TP1, TP2, TP3), absolute M count (TP1, TP2, TP3), LMR (TP1, TP2, TP3), and relative LMR changes (TP2 ÷ TP1, TP3 ÷ TP1, TP3 ÷ TP2). RESULTS Median follow-up was 14 months. Twelve patients received ICT. Median LMR was 2.7 (range, 0.8-5.25), 1.4 (range, 0.3-5) and 0.98 (range, 0.3-3.4) at TP1, TP2 and TP3, respectively. Superior PFS was significantly associated with an absolute M count during CRT <0.1 (P=0.04) while pre-CRT L count ≥1.1 trended towards significance (P=0.09). Superior OS was significantly associated with change in LMR (TP3 ÷ TP2) > 0.32 (P<0.0001) while pre-CRT LMR ≥2.6 trended towards significance (P=0.06). CONCLUSIONS Factors significantly associated with overall survival (OS) and progression-free survival (PFS) were change in LMR at the end of CRT and absolute M count during CRT. This analysis suggests treatment-time-specific immune system parameters may affect clinical outcomes and warrant continued investigation.

Complete response in metastatic renal cell carcinoma after radiotherapy and everolimus: a clinical case and review of the literature

We report the case of a man affected by renal cell carcinoma with vertebral metastases, who presented a radiological complete response after systemic treatment with everolimus.

Oral Lapacho-Based Medication: An Easy, Safe, and Feasible Support to Prevent and/or Reduce Oral Mucositis During Radiotherapy for Head and Neck Cancer.

The aim of our Phase II study is to demonstrate the benefits, safety, and tolerance of Orasol Plus, an easy and feasible Lapacho-based medication. Orasol Plus is a nutritional, swallowable solution, useful to support the defenses of the oropharyngeal mucosa. Between January and June 2014, 40 consecutive adult patients affected by head and neck cancer were enrolled. Orasol Plus was administered 3 times a day from the first day till the end of radiotherapy. Primary endpoint was to evaluate tolerance and safety of Orasol Plus; secondary endpoint was to evaluate the effect of Orasol Plus on the incidence of treatment discontinuation. Nearly all patients used Orasol Plus easily till the end of radiotherapy without interruptions. Only 11 (27.5%) patients developed oral mucositis (OM) Grade 2 and only 4 (10%) patients OM Grade 3, no patient developed OM Grade 4. No patient discontinued radiotherapy because of OM. Orasol Plus was well tolerated and the compliance of patients was optimal, mainly due to the fact that it can be swallowed. Data from our study are encouraging and they need to be confirmed by a Phase III study.

Cyberknife stereotactic radiotherapy for isolated nodal recurrence of prostate cancer.

257 Background: We report a preliminary clinical experience in stereotactic body radiation therapy (SBRT) delivered using Cyberknife for isolated nodal metastases from prostate cancer. Methods: Between November 2011 and December 2013, 30 patients (39 lesions) were treated with SRT for recurrent prostate cancer with isolated nodal metastases. Prescribed doses and schedules of fractionation varied according to site of disease, ranging from 24 Gy in 1 fraction to 36 Gy in 3 fractions. Most commonly used schedules were 30 Gy in 3 fractions and 36 in Gy in 3 fractions on alternating days. Biochemical response, acute and late toxicity were analyzed. Results: At a median follow-up of 12 months (range: 2-24.9), reduction of PSA ≥ 50% was observed in 18 cases, reduction < 50% was observed in 7, while PSA was stable in 1 case and raised in 8 cases. At the time of analysis, among the 30 patients treated, 2 were dead for systemic disease; 12 patients experienced a relapse of disease in other sites and were treated wi...

P13.21ORGANS AT RISK IN THE BRAIN AND THEIR DOSE-CONSTRAINTS IN THE ADULTS AND IN THE CHILDREN: A RADIATION ONCOLOGIST'S GUIDE FOR DELINEATION

The aim of this study is to provide a stepwise contouring guide to delineate the organs at risk in the brain as it would be done in the everyday practice of planning radiotherapy for brain cancer treatment. Acute and late toxicity with risk of visual and hearing deficits, hormonal impairment and neurocognitive alterations, is a critical point in radiation treatment of patients affected by brain tumors. Moreover, accurate delineation of organ at risks is essential for the inverse-planning process of intensity modulated radiation treatment (IMRT). However, anatomic cerebral normal structures are not always easily recognizable either on simulation CT scan and on coregistered MRI scan used for radiotherapy planning. We have developed a detailed anatomy atlas on Computed tomography (CT) imaging and magnetic resonance (MR) imaging of brain. The following regions of interest were defined: optic chiasm, cochlea, pituitary gland, temporal lobe and hippocampus. Some main notions of anatomy of the organs at risk are provided together with some landmarks easily to be found on the imaging scans. Detailed contouring recommendations are provided in order to significantly improve the contour accuracy and concordance. This report also provides for all the above-mentioned organs at risk a systematic review for the recommended dose constraints both for adult and pediatric patients. This guide is a useful tool for improving daily practice and decreasing the differences in organs at risk delineation between radiation oncologists.

Multiple Cutaneous Angiosarcomas after Breast Conserving Surgery and Bilateral Adjuvant Radiotherapy: An Unusual Case and Review of the Literature

Breast angiosarcomas (BAs) are rare but serious events that may arise after radiation exposure. Disease outcome is poor, with high risk of local and distant failure. Recurrences are frequent also after resection with negative margins. The spectrum of vascular proliferations associated with radiotherapy in the setting of breast cancer has expanded, including radiation-associated atypical vascular lesions (AVLs) of the breast skin as a rare, but well-recognized, entity. Although pursuing a benign behavior, AVLs have been regarded as possible precursors of postradiation BAs. We report an unusual case of a 71-year-old woman affected by well-differentiated bilateral cutaneous BA, diagnosed 1.9 years after adjuvant RT for synchronous bilateral breast cancer. Whole-life clinical followup is of crucial importance in breast cancer patients.