Michael Ng

Australasian Gastrointestinal Trials Group (AGITG) Contouring Atlas and Planning Guidelines for Intensity-Modulated Radiotherapy in Anal Cancer

PURPOSE To develop a high-resolution target volume atlas with intensity-modulated radiotherapy (IMRT) planning guidelines for the conformal treatment of anal cancer. METHODS AND MATERIALS A draft contouring atlas and planning guidelines for anal cancer IMRT were prepared at the Australasian Gastrointestinal Trials Group (AGITG) annual meeting in September 2010. An expert panel of radiation oncologists contoured an anal cancer case to generate discussion on recommendations regarding target definition for gross disease, elective nodal volumes, and organs at risk (OARs). Clinical target volume (CTV) and planning target volume (PTV) margins, dose fractionation, and other IMRT-specific issues were also addressed. A steering committee produced the final consensus guidelines. RESULTS Detailed contouring and planning guidelines and a high-resolution atlas are provided. Gross tumor and elective target volumes are described and pictorially depicted. All elective regions should be routinely contoured for all disease stages, with the possible exception of the inguinal and high pelvic nodes for select, early-stage T1N0. A 20-mm CTV margin for the primary, 10- to 20-mm CTV margin for involved nodes and a 7-mm CTV margin for the elective pelvic nodal groups are recommended, while respecting anatomical boundaries. A 5- to 10-mm PTV margin is suggested. When using a simultaneous integrated boost technique, a dose of 54 Gy in 30 fractions to gross disease and 45 Gy to elective nodes with chemotherapy is appropriate. Guidelines are provided for OAR delineation. CONCLUSION These consensus planning guidelines and high-resolution atlas complement the existing Radiation Therapy Oncology Group (RTOG) elective nodal ano-rectal atlas and provide additional anatomic, clinical, and technical instructions to guide radiation oncologists in the planning and delivery of IMRT for anal cancer.

The impact of 18-fluorodeoxyglucose positron emission tomography on the staging, management and outcome of anal cancer.

Accurate inguinal and pelvic nodal staging in anal cancer is important for the prognosis and planning of radiation fields. There is evidence for the role of 18-fluorodeoxyglucose positron emission tomography (FDG-PET) in the staging and management of cancer, with early reports of an increasing role in outcome prognostication in a number of tumours. We aimed to determine the effect of FDG-PET on the nodal staging, radiotherapy planning and prognostication of patients with primary anal cancer. Sixty-one consecutive patients with anal cancer who were referred to a tertiary centre between August 1997 and November 2005 were staged with conventional imaging (CIm) (including computed tomography (CT), magnetic resonance imaging, endoscopic ultrasound and chest X-ray) and by FDG-PET. The stage determined by CIm and the proposed management plan were prospectively recorded and changes in stage and management as a result of FDG-PET assessed. Patients were treated with a uniform radiotherapy technique and dose. The accuracy of changes and prognostication of FDG-PET were validated by subsequent clinical follow-up. Kaplan–Meier survival analysis was used to estimate survival for the whole cohort and by FDG-PET and CIm stage. The tumour-stage group was changed in 23% (14 out of 61) as a result of FDG-PET (15% up-staged, 8% down-staged). Fourteen percent of T1 patients (3 out of 22), 42% of T2 patients (10 out of 24) and 40% of T3–4 patients (6 out of 15) assessed using CIm, had a change in their nodal or metastatic stage following FDG-PET. Sensitivity for nodal regional disease by FDG-PET and CIm was 89% and 62%, respectively. The staging FDG-PET scan altered management intent in 3% (2 out of 61) and radiotherapy fields in 13% (8 out of 61). The estimated 5-year overall survival (OS) and progression-free survival (PFS) for the cohort were 77.3% (95% confidence interval (CI): 55.3–90.4%) and 72.2% (95% CI: 51.5–86.4%), respectively. The estimated 5-year PFS for FDG-PET and CIm staged N2-3 disease was 70% (95% CI: 42.8–87.9%) and 55.3% (95% CI: 23.3–83.4%), respectively. FDG-PET shows increased sensitivity over CIm for staging nodal disease in anal cancer and changes treatment intent or radiotherapy prescription in a significant proportion of patients.

Fiducial markers and spacers in prostate radiotherapy: current applications

To review the use of fiducial markers and spacers in prostate radiotherapy (RT).

Placenta Percreta With Urinary Tract Involvement: The Case for a Multidisciplinary Approach

OBJECTIVES To reduce the complications associated with placenta percreta (PP) by adequate preoperative planning with a multidisciplinary team. PP is a rare and potentially morbid condition of pregnancy, particularly if the urinary tract is involved. Cesarean delivery and hysterectomy are typically required to reduce the pelvic hemorrhage, placing the urinary tract at risk. METHODS We reviewed our urologic consultations and experience with PP in the past year. Maternal factors, surgical timing, blood loss, surgical complications, and outcomes were recorded. The timing of the urologic assessment was divided into preoperative and perioperative. RESULTS Five cases of PP were available. Of the 5 cases, 4 had been successfully diagnosed by prenatal ultrasonography, with 2 also requiring magnetic resonance imaging. All patients underwent cesarean delivery and hysterectomy, with significant blood loss (median 12 U transfused). A preoperative urologic assessment was done in 2 of the 5 patients, with no urinary complications found in this group. Both patients had undergone cystoscopy with placement of temporary ureteral catheters, even though the cases were emergent. In contrast, 3 patients underwent urologic consultation during or immediately after surgery. All 3 had bladder injuries, with 1 ureteral injury and delayed convalescence in this group of patients. CONCLUSIONS PP remains a technically challenging and high-risk obstetric condition. In the setting of urinary tract involvement, adequate imaging, surgical planning, and preoperative urologic assessment with placement of temporary ureteral catheters were associated with a lower incidence of urologic complications in our series. Adequate preoperative planning with a multidisciplinary team is recommended to reduce the complications associated with PP.

Brachytherapy‐ State Of The Art Radiotherapy In Prostate Cancer

Radiation Oncology Victoria, Ringwood East, Vic., Australia, *Prostate Cancer Center of Seattle, Seattle, WA, USA, Wesley Hospital, Brisbane, Qld , St Vincent’s Hospital, Darlinghurst, NSW, Radiation Oncology Victoria, Epping, Department of Surgery and Olivia Newton John Cancer Research Institute, Austin Hospital, and **Department of Surgical Oncology, Peter MacCallum Cancer Centre, East Melbourne, Vic., Australia

Trans Tasman Radiation Oncology Group: development of the Assessment of New Radiation Oncology Technology and Treatments (ANROTAT) Framework

The study aim was to develop a generic framework to derive the parameters to populate health‐economic models for the rapid evaluation of new techniques and technologies in radiation oncology.

Dose planning objectives in anal canal cancer IMRT: the TROG ANROTAT experience.

Intensity modulated radiotherapy (IMRT) is ideal for anal canal cancer (ACC), delivering high doses to irregular tumour volumes whilst minimising dose to surrounding normal tissues. Establishing achievable dose objectives is a challenge. The purpose of this paper was to utilise data collected in the Assessment of New Radiation Oncology Treatments and Technologies (ANROTAT) project to evaluate the feasibility of ACC IMRT dose planning objectives employed in the Australian situation.

A single institution analysis of low-dose-rate brachytherapy: 5-year reported survival and late toxicity outcomes

Purpose To report the 5-year biochemical relapse-free survival (BRFS), overall survival (OS), and long-term toxicity outcomes of patients treated with low-dose-rate (LDR) brachytherapy as monotherapy for low- to intermediate-risk prostate cancer. Material and methods Between 2004 and 2011, 371 patients were treated with LDR brachytherapy as monotherapy. Of these, 102 patients (27%) underwent transurethral resection of the prostate (TURP) prior to implantation. Follow-up was performed every 3 months for 12 months, then every 6 months over 4 years and included prostate specific antigen evaluation. The biochemical relapse-free survival (BRFS) was defined according to the Phoenix criteria. Acute and late toxicities were documented using the Common Terminology Criteria for Adverse Events version 4.0. The BRFS and OS estimates were calculated using Kaplan-Meier plots. Univariate and multivariate analyses were performed to evaluate outcomes by pre-treatment clinical prognostic factors and radiation dosimetry. Results The median follow-up of all patients was 5.45 years. The 5-year BRFS and OS rates were 95% and 96%, respectively. The BRFS rates for patients with Gleason score (GS) > 7 and GS ≤ 6 were 96% and 91% respectively (p = 0.06). On univariate analysis, T1 and T2 staging, risk-group classification, and prostate volumes had no impact on survival at 5 years (p > 0.1). Late grade 2 and 3 genitourinary (GU) toxicities were observed in 10% and 5% of patients respectively. Additionally, patients with prior TURP had a greater incidence of late grade 2 or 3 urinary retention (p = 0.001). There were 14 deaths in total; however, none were attributed to prostate cancer. Conclusions LDR brachytherapy is an effective treatment option in low- to intermediate-risk prostate cancer patients. We observed low biochemical relapse rates and minimal GU toxicities several years after treatment in patients with or without TURP. However, a small risk of urinary retention was observed in some patients.