Lisa Hazard

Radiation therapy is associated with improved survival in patients with pancreatic adenocarcinoma: Results of a study from the surveillance, epidemiology, and end results (SEER) registry data

The role of adjuvant radiation therapy in pancreatic cancer is controversial. For the current study, the authors evaluated the effect of preoperative and postoperative radiation therapy on survival in patients with pancreatic adenocarcinoma.

Combined adjuvant radiation and interferon-alpha 2B therapy in high-risk melanoma patients: the potential for increased radiation toxicity

PURPOSE Surgically resected melanoma patients with high-risk features commonly receive adjuvant therapy with interferon-alpha 2b combined with radiation therapy; the purpose of our study was to evaluate the potential enhancement of radiation toxicity by interferon. METHODS AND MATERIALS Patients at LDS Hospital and the University of Utah Medical Center in Salt Lake City treated with interferon during radiotherapy or within 1 month of its completion were retrospectively identified, and their charts were reviewed. If possible, the patients were asked to return to the LDS Hospital radiation therapy department for follow-up. RESULTS Five of 10 patients receiving interferon-alpha 2b therapy during radiation therapy or within 1 month of its completion experienced severe subacute/late complications of therapy. Severe subacute/late complications included two patients with peripheral neuropathy, one patient with radiation necrosis in the brain, and two patients with radiation necrosis in the s.c. tissue. One patient with peripheral neuropathy and one patient with radiation necrosis also developed lymphedema. CONCLUSIONS In vitro studies have identified a radiosensitizing effect by interferon-alpha on certain cell lines, which suggests the possibility that patients treated with interferon and radiation therapy may experience more severe radiation toxicities. We have observed severe subacute/late complications in five of 10 patients treated with interferon-alpha 2b during radiation therapy or within 1 month of its completion. Although an observational study of 10 patients lacks the statistic power to reach conclusions regarding the safety and complication rates of combined interferon and radiation therapy, it is sufficient to raise concerns and suggest the need for prospective studies.

Local-regional radiation therapy after breast reconstruction: what is the appropriate target volume? A case-control study of patients treated with electron arc radiotherapy and review of the literature.

The oncologic safety and cosmetic outcome of immediate breast reconstruction in breast cancer patients requiring radiation therapy remains ill-defined. Between 1980 and 1998, 18 patients were treated at the University of Utah Medical Center with mastectomy, immediate breast reconstruction, and adjuvant radiation therapy delivered via an electron arc technique. A case–control study was performed matching reconstructed patients in a 1:2 ratio with patients undergoing mastectomy without reconstruction, using number of lymph nodes and tumor size. Median follow-up was 61 months for the reconstructed group. Five-year local–regional control, disease-free survival, and overall survival rates were 87%, 58%, and 74% respectively in the reconstructed group, versus 88%, 57%, and 67% respectively in the matched control group. Cosmesis was good/excellent in 11 of 13 living patients (85%). Significant capsular contraction occurred in 18% of prosthetic reconstruction patients, and revisional surgery was required in 24% of prosthetic reconstruction patients. Utilizing the electron arc technique, the median radiation dose to the chest wall at the midlevel of the ribs was 20% of the prescribed dose, and no patient failed deep to the implant. These results suggest that in appropriately selected patients, structures deep to the reconstruction are not at high risk for local–regional recurrence, and immediate breast reconstruction yields comparable local–regional control, disease-free survival, and overall survival rates to nonreconstructed patients, with acceptable cosmetic results.

Curative radiation therapy for pancreatic malignancies.

Surgery is generally considered as the only curative therapy for pancreatic cancer; however, even with optimal surgery, long-term cure is achieved in very few patients, thus highlighting the need for adjuvant therapies. Radiation therapy, usually in combination with chemotherapy, plays a role in the setting of unresectable, nonmetastatic pancreatic cancer. Its role in the adjuvant setting remains controversial and as yet undefined. This article reviews the role of radiation therapy in the adjuvant and definitive settings, and describes recent improvements in the delivery of radiotherapy that allow for improved dose delivery with decreased toxicity.

Preoperative Radiation Therapy for Upper Rectal CancerT3,T4/Nx: Selectivity Essential

This review explores the current available literature regarding the role of neoadjuvant therapy for upper locally advanced rectal cancers (≥10 cm-15 cm). Although there is a paucity of data evaluating the outcomes of preoperative chemoradiation for upper rectal cancers the authors suggest that T3N0 tumors will not likely benefit from radiation and that treatment of T4N0 should be individualized.

The role of radiation therapy in the control of locoregional and metastatic cancer.

High energy X‐rays have been used for cancer therapy since their discovery in 1895. Major radiobiological discoveries and technological advances in radiation physics have greatly increased the accuracy of radiation. The recent integration of radiation therapy and imaging systems provides radiation oncologists with sophisticated dose delivery capability allowing continued improvements in the control of loco‐regional and metastatic disease while decreasing toxicity. Key technical aspects of current radiation therapy are described with examples extending to several clinical areas. J. Surg. Oncol. 2011;103:627–638.

Impact of prone versus supine positioning on small bowel dose with pelvic intensity modulated radiation therapy

Purpose To report the results of a prospective study that compares small bowel doses during prone and supine pelvic intensity modulated radiation therapy. Methods and materials Ten patients receiving pelvic radiation therapy each had 2 intensity modulated radiation therapy plans generated: supine and prone on a belly board (PBB). Computed tomography on rails was performed weekly throughout treatment in both positions (10 scans per patient). After image fusion, doses to small bowel (SB) loops and clinical target volume were calculated for each scan. Changes between the planned and received doses were analyzed and compared between positions. The impact of bladder filling on SB dose was also assessed. Results Prone treatment was associated with significantly lower volumes of SB receiving ≥20 Gy. On average, prone on a belly board positioning reduced the volume of SB receiving a given dose of radiation by 28% compared with supine positioning. Target coverage throughout the treatment course was similar in both positions with an average minimum clinical target volume dose of 88% of the prescribed prone dose and 89% of the supine (P = .54). For supine treatment, SB dose was inversely correlated with bladder filling (P = .001-.013; P > .15 for prone). For 96% of treatments, the volume of SB that received a given dose deviated >10% from the plan. The deviation between the planned and delivered doses to SB did not differ significantly between the positions. Conclusions Prone positioning on a belly board during pelvic IMRT consistently reduces the volume of SB that receives a broad range of radiation doses. Prone IMRT is associated with interfraction dose variation to SB that is similar to that of supine positioning. These findings suggest that prone positioning with daily image guided radiation therapy is an effective method for maximizing SB sparing during pelvic IMRT.

Complete Resolution of a Malignant Biliary Stricture Using Combined Neoadjuvant Chemoradiation and Brachytherapy Boost Prior to Orthotopic Liver Transplantation

Complete Resolution of a Malignant Biliary Stricture Using Combined Neoadjuvant Chemoradiation and Brachytherapy Boost Prior to Orthotopic Liver Transplantation To limit recurrence and intra-operative tumor dissemination at the time of transplant, there is increasing evidence that neoadjuvant chemoradiation and brachytherapy boost helps facilitate successful liver transplantation in patients with earlystage unresectable hilar cholangiocarcinoma. In published reports, a complete response to neoadjuvant therapy frequently limits the ability to detect residual disease in the hepatectomy specimen, thereby inviting criticism over whether published results are due to the neoadjuvant protocol per se, or selection of patients with earlystage or pre-malignant disease. In this report, a 41 year old male with a malignant biliary stricture received 45 Gy external beam radiation in conjunction with 5-fluoruracil as a prelude to transplant. This was followed by a transluminal boost of radiation (2000 cGy) using an Iridium-192 brachytherapy wire inserted through percutaneously-placed biliary catheters. Using this approach, we document the complete resolution of the patient’s malignant stricture, thereby objectively quantifying tumor response prior to orthotopic liver transplantation.

Adjuvant EBRT improves survival in patients with lymph-node-negative pancreatic cancer.

Therole of adjuvant external-beam radiotherapy (EBRT) for the treatment of pancreatic adenocarcinoma remains controversial.A randomised trial by the Gastrointestinal Study Group demonstrated a survival benefit with the addition of chemoradiotherapy to surgery, and a randomised trial by the European Organisation for Research andTreatment ofCancer also showed a trend towards improved survivalwith adjuvant chemoradiotherapy. On the other hand, a randomised trial by the European Study Group for PancreaticCancer (ESPAC),which comprised four adjuvant treatment arms (observation, chemotherapy alone, radiotherapy with concurrent chemotherapy, and radiotherapy with concurrent chemotherapy followedbymaintenance chemotherapy), revealed that the survival of patientswho received radiotherapy (with or without maintenance chemotherapy) was inferior to that of patients who did not receive radiotherapy. The authors of this report concluded that radiotherapy haddeleterious effects on survival. The reasons for the decrease in survival in patients receiving radiotherapy on the ESPAC trial remain unclear. Radiation was not reported to increase treatment-relatedmortality, but late radiation toxicity is difficult to report accurately because it can be difficult to differentiate from symptoms of a progressive tumour, andpatientsmaybe lost to follow-up. The ESPAC trial did not describe radiation field size and technique, and central review of radiation plans was not required. The Radiation Therapy Oncology Group (RTOG) has reported that amajor deviation from the protocol-defined radiation therapy plan was associated with inferior survival for patientswith pancreatic cancer enrolled on the RTOG 97-04 trial, suggesting that radiation technique is important. The current study based on the SEER registry by Artinyan et al. (see opposite) demonstrates that the addition of radiotherapy to surgery in patients with T1–3N0M0 pancreatic adenocarcinoma is associated with improved survival. Limitations of the SEER registry include its retrospective nature and lack of information regarding surgical-margin status and the use of chemotherapy. In addition, it is not possible to determine any bias in the