Kenneth W Tiver

Deep inspiration breath hold technique reduces heart dose from radiotherapy for left-sided breast cancer.

Introduction: Adjuvant left breast radiotherapy (ALBR) for breast cancer can result in significant radiation dose to the heart. Current evidence suggests a dose–response relationship between the risk of cardiac morbidity and radiation dose to cardiac volumes. This study explores the potential benefit of utilising a deep inspiration breath hold (DIBH) technique to reduce cardiac doses.

Occult breast carcinoma presenting as axillary metastases

PURPOSE Breast carcinoma presenting with axillary lymphadenopathy and no clinical or radiological evidence of a primary tumor is a rare presentation. We aimed to examine the management of the breast by observation, radiation therapy, or mastectomy. METHODS AND MATERIALS Departmental records from 1979 to 1996 of unknown primary presentations and cases of T0N1-2M0 breast carcinoma were reviewed to find cases of occult breast carcinoma presenting as axillary lymphadenopathy with no clinical or imaging evidence of a primary tumor. RESULTS There were 6047 presentations of breast carcinoma with 20 cases of occult breast carcinoma meeting the criteria. The breast was treated by observation in 6 cases, mastectomy in 2 cases, and radiotherapy to the intact breast in 12 cases. Eighty-three percent of patients (5 of 6 patients) who had observation of the breast had a local recurrence, compared to 25% who had radiotherapy to the intact breast (3 of 12 patients) and 0% who had a mastectomy (0 of 2 patients). The median recurrence-free survival was 7 months in patients who had observation of the breast, compared to 182 months in patients who had local treatment. Three of the 6 patients who underwent breast observation have died whereas 1 of the 14 who had local treatment have died, with a mean follow-up of 73 months. It was found that patients having observation of the breast had a poorer recurrence-free survival (p = 0.003) and overall survival (p = 0.05) compared to those having local treatment of the breast. CONCLUSIONS Patients with such a presentation should have a complete physical examination, mammography, ultrasound, and MRI of the breasts. If there remains no evidence of a primary tumor, an axillary dissection should be carried out and the breast treated by radiotherapy or mastectomy. Observation of the breast is not a recommended option.

Thyroid dysfunction following radiotherapy for head and neck cancer

PURPOSE To determine the frequency of hypothyroidism (both subclinical and clinical) following external beam radiotherapy to the whole of the thyroid gland in the treatment of squamous cell cancers of the head and neck. METHODS AND MATERIALS One hundred and four patients who had completed radiotherapy 30 days to 5 years earlier (84 patients) or who were scheduled for radiotherapy (20 patients) had a single measurement of serum-free thyroxine and thyroid stimulating hormone levels between August 1991 and May 1992. RESULTS None of the 20 patients assessed prior to treatment showed thyroid dysfunction. Twenty of 84 (23.8%) previously treated patients had subclinical (9.5%) or clinical (14.3%) hypothyroidism. By 5 years, up to 40% of patients may become hypothyroid. Thyroid underactivity was significantly more common in patients having both laryngectomy (including hemi-thyroidectomy) and radiotherapy compared to radiotherapy alone (p < 0.001). Hypothyroidism had not been suspected clinically in any patient tested. CONCLUSION In view of the frequency and potential morbidity of this complication, thyroid function testing should become a routine part of posttreatment follow-up for these patients.

Synchronous radiotherapy and chemotherapy in the treatment of nasopharyngeal carcinoma.

PURPOSE Because of the high rates of local tumor control obtained by combining moderate doses of external beam radiotherapy and synchronous 5-fluorouracil/mitomycin C chemotherapy in the treatment of squamous and basiloid cancers of the anal canal, we chose to investigate this regimen for nasopharyngeal cancer which shows significant local and distant failure rates after treatment with radiotherapy alone. METHODS AND MATERIALS Between 1983 and 1990, 43 patients with previously untreated squamous cell and undifferentiated nasopharyngeal cancer, without evidence of distant metastases at diagnosis were treated with radical radiotherapy and concurrent chemotherapy using mitomycin C (10 mg/m2 i.v. day 1 of radiotherapy) and 5-fluorouracil (1000 mg/m2 continuous i.v. infusion days 1-4 of radiotherapy and repeated at least 28 days later). Ninety-one percent of cases had Stage IV tumors and 93% had clinically involved regional lymph nodes. RESULTS Actuarial rates of survival, local control, regional nodal control and distant metastases at 5 years were 37%, 71%, 94%, and 53%. Grade 3 or 4 skin and mucosal reactions occurred in 30% and 34% of patients, respectively. Only one patient developed greater than Grade 2 myelosuppression and he died of overwhelming sepsis. A second patient died of malnutrition 4 months after treatment giving a 5% incidence of treatment-related mortality. Nine percent of patients developed significant late complications of treatment. CONCLUSION Despite the morbidity observed, the treatment outcome is not obviously superior to that reported for radiotherapy as a single modality of treatment.

Left‐sided breast cancer loco‐regional radiotherapy with deep inspiration breath‐hold: Does volumetric‐modulated arc radiotherapy reduce heart dose further compared with tangential intensity‐modulated radiotherapy?

Left‐sided breast cancer radiotherapy has been associated with an increase in cardiac mortality. This study investigated the potential heart‐sparing effect of volumetric‐modulated arc radiotherapy (VMAT). We compared VMAT to tangential intensity‐modulated radiotherapy (t‐IMRT) in the loco‐regional treatment of left‐sided breast cancer, including internal mammary nodal irradiation, based on deep inspiration breath‐hold (DIBH) and free‐breathing (FB).

Dosimetric comparison of volumetric modulated arc therapy and linear accelerator-based radiosurgery for the treatment of one to four brain metastases

The purpose of this study is to compare and evaluate volumetric modulated arc therapy (VMAT) and linear accelerator‐based radiosurgery (Linac RS) for the treatment of one to four brain metastases.

Basal cell carcinoma of the nose: an Australian and New Zealand radiation oncology patterns-of-practice study.

Patients with a basal cell carcinoma (BCC) of the nose may be recommended radiotherapy (RT) with a wide variation in techniques and prescribed dose fractionation schedules between clinicians. The aim of this study was to ascertain variability in the patterns of practice among Australian and New Zealand radiation oncologists (ROs) when treating BCC arising on the nose. A postal survey was sent to 222 practising ANZ ROs detailing 12 different clinical scenarios of a BCC arising on the nose. The treatment selected for each scenario was analysed according to clinician’s attitudes, training, experience and the availability of resources. The response rate was 74% (165/222) with 90 respondents treating non‐melanoma skin cancer. Training was perceived to have a marked influence on treatment practice by most (79%). In total, 72% of ROs were ‘very certain’ in their choice of a dose fractionation schedule for obtaining local control and 61% for a satisfactory cosmetic outcome, respectively. Most (76%) favoured low‐voltage photons over electrons as the optimal method of treatment, although for certain clinical scenarios most would use electrons. Dose fractionation schedules were highly variable with a lower total dose and hypofractionation favoured for older patients. Low‐voltage photons were favoured for the T1 BCC and electrons for the T2 and T4 BCC. Nearly one‐third of the ROs chose megavoltage photons for the T4 lesion. There is marked variation in treatment practices in terms of recommending RT over other treatment options, the choice of RT method, the dose fractionation schedule, the extent of field margins and the point of dose prescription.