Riccardo Santoni

Patterns of care and survival in a retrospective analysis of 1059 patients with glioblastoma multiforme treated between 2002 and 2007: a multicenter study by the Central Nervous System Study Group of Airo (italian Association of Radiation Oncology).

OBJECTIVETo investigate the pattern of care and outcomes for newly diagnosed glioblastoma in Italy and compare our results with the previous Italian Patterns of Care study to determine whether significant changes occurred in clinical practice during the past 10 years. METHODSClinical, pathological, therapeutic, and survival data regarding 1059 patients treated in 18 radiotherapy centers between 2002 and 2007 were collected and retrospectively reviewed. RESULTSMost patients underwent both computed tomography and magnetic resonance imaging either preoperatively (62.7%) or postoperatively (35.5%). Only 123 patients (11.6%) underwent a biopsy. Radiochemotherapy with temozolomide was the most frequent adjuvant treatment (70.7%). Most patients (88.2%) received 3-dimensional conformal radiotherapy. Median survival was 9.5 months. Two- and 5-year survival rates were 24.8% and 3.9%, respectively. Multivariate analysis showed the statistical significance of age, postoperative Karnofsky Performance Status scale score, surgical extent, use of 3-dimensional conformal radiotherapy, and use of chemotherapy. Use of a more aggressive approach was associated with longer survival in elderly patients. Comparing our results with those of the subgroup of patients included in our previous study who were treated between 1997 and 2001, relevant differences were found: more frequent use of magnetic resonance imaging, surgical removal more common than biopsy, and widespread use of 3-dimensional conformal radiotherapy + temozolomide. Furthermore, a significant improvement in terms of survival was noted (P < .001). CONCLUSIONChanges in the care of glioblastoma over the past few years are documented. Prognosis of glioblastoma patients has slightly but significantly improved with a small but noteworthy number of relatively long-term survivors.

Stage I seminoma of the testis: a bi-institutional retrospective analysis of patients treated with radiation therapy only

To analyse relapse patterns, toxicity and second malignancy in patients with stage I pure germ cell testicular tumours, treated in 1970–1999.

Failure of radiation therapy for brain involvement in Erdheim Chester disease.

A patient with suprasellar and brain stem involvement in Erdheim Chester disease (ECD) underwent magnetic resonance (MR) imaging and proton MR spectroscopy (1H MRS) of the ventral pons before and 1, 4 and 18 months after external whole-brain (24 Gy) radiotherapy. By revealing a decrease of the N-acetyl-aspartate/choline ratio in the pons, 1H MR spectroscopy anticipated lesions growth on MR imaging. In line with the results in four patients reported in the literature, our observation indicates that external radiation therapy is not effective for intracranial involvement in ECD.

Radiotherapy and temozolomide in anaplastic astrocytoma: a retrospective multicenter study by the Central Nervous System Study Group of AIRO (Italian Association of Radiation Oncology).

Although the evidence for the benefit of adding temozolomide (TMZ) to radiotherapy (RT) is limited to glioblastoma patients, there is currently a trend toward treating anaplastic astrocytomas (AAs) with combined RT + TMZ. The aim of the present study was to describe the patterns of care of patients affected by AA and, particularly, to compare the outcome of patients treated exclusively with RT with those treated with RT + TMZ. Data of 295 newly diagnosed AAs treated with postoperative RT ± TMZ in the period from 2002 to 2007 were reviewed. More than 75% of patients underwent a surgical removal. All the patients had postoperative RT; 86.1% of them were treated with 3D-conformal RT (3D-CRT). Sixty-seven percent of the entire group received postoperative chemotherapy with TMZ (n = 198). One-hundred sixty-six patients received both concomitant and sequential TMZ. Prescription of postoperative TMZ increased in the most recent period (2005-2007). One- and 4-year survival rates were 70.2% and 28.6%, respectively. No statistically significant improvement in survival was observed with the addition of TMZ to RT (P = .59). Multivariate analysis showed the statistical significance of age, presence of seizures, Recursive Partitioning Analysis classes I-III, extent of surgical removal, and 3D-CRT. Changes in the care of AA over the past years are documented. Currently there is not evidence to justify the addition of TMZ to postoperative RT for patients with newly diagnosed AA outside a clinical trial. Results of prospective and randomized trials are needed.

Standard or hypofractionated radiotherapy in the postoperative treatment of breast cancer: a retrospective analysis of acute skin toxicity and dose inhomogeneities

BackgroundTo identify predictive factors of radiation-induced skin toxicity in breast cancer patients by the analysis of dosimetric and clinical factors.Methods339 patients treated between January 2007 and December 2010 are included in the present analysis. Whole breast irradiation was delivered with Conventional Fractionation (CF) (50Gy, 2.0/day, 25 fractions) and moderate Hypofractionated Schedule (HS) (44Gy, 2.75Gy/day, 16 fractions) followed by tumour bed boost. The impact of patient clinical features, systemic treatments and, in particular, dose inhomogeneities on the occurrence of different levels of skin reaction has been retrospectively evaluated.ResultsG2 and G3 acute skin toxicity were 42% and 13% in CF patients and 30% and 7.5% in HS patients respectively. The retrieval and revaluation of 200 treatment plans showed a strong correlation between areas close to the skin surface, with inhomogeneities >107% of the prescribed dose, and the desquamation areas as described in the clinical records.ConclusionsIn our experience dose inhomogeneity underneath G2 – G3 skin reactions seems to be the most important predictor for acute skin damage and in these patients more complex treatment techniques should be considered to avoid skin damage. Genetic polymorphisms too have to be investigated as possible promising candidates for predicting acute skin reactions.

Radiotherapy of Seminoma of the Testis. Report on 129 Patients

From 1958 to 1974, 129 patients with pure seminoma of the testis were admitted to the Institute of Radiology, University of Florence. Sixty-two were in Stage I, 36 in Stage II A, 23 in Stage II B, 3 in Stage III, and 5 in Stage IV. Para-aortic and ipsilateral iliac nodes were treated in all cases with doses ranging from 3000 to 4200 rads. In the treatment of the supradiaphragmatic area, uniform criteria were not adopted. Out of 124 cases in Stage I, II A and B, and III, 17 suffered a relapse; all relapsed cases died except for one. Site and cause of the failures were analyzed. Prophylactic irradiation of the mediastinum and supraclavicular area appears to lower the probability of recurrence in Stage II. Doses over 3500 rads may be necessary to destroy large metastases. The presence of nonseminomatous areas in a seminoma showing inadequate regression after radiotherapy must be suspected; an exploratory laparotomy should be indicated in such a case.

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.

Quantitative magnetic resonance imaging in cervical carcinoma: a report on 30 cases

T1 and T2 relaxation times were calculated, before radiation therapy, in 30 patients with cervical carcinoma. Eight healthy young women were submitted to magnetic resonance imaging (MRI) to determine T1 and T2 times of the normal cervix. Magnetic resonance imaging was repeated, in 22 patients, during radiation therapy and at follow-up. During treatment and follow-up, patients with complete tumour response showed a significant T1 reduction compared with the pre-treatment values. With persistence of palpable or visible tumour, T1 times showed a small decrease during therapy, and a marked increase at subsequent examinations. The results suggest that the modifications of T1 times, during radiation therapy and follow-up, could be considered as a useful discriminant between patients with differing tumour response.

Efficacy of stereotactic body radiotherapy in oligorecurrent and in oligoprogressive prostate cancer: new evidence from a multicentric study

Background:The aim of the present study is to evaluate the impact of metastases-directed stereotactic body radiotherapy in two groups of oligometastatic prostate cancer (PC) patients: oligorecurrent PC and oligoprogressive castration-resistant PC (oligo-CRPC).Methods:Inclusion criteria of the present multicentre retrospective analysis were: (1) oligorecurrent PC, defined as the presence of 1–3 lesions (bone or nodes) detected with choline positron emission tomography or CT plus bone scan following biochemical recurrence; (2) oligo-CRPC, defined as metastases (bone or nodes) detected after a prostatic-specific antigen rise during androgen deprivation therapy (ADT). Primary end points were: distant progression-free survival (DPFS) and ADT-free survival in oligorecurrent PC patients; DPFS and second-line systemic treatment-free survival in oligo-CRPC patients.Results:About 100 patients with oligorecurrent PC (139 lesions) and 41 with oligo-CRPC (70 lesions), treated between March 2010 and April 2016, were analysed. After a median follow-up of 20.4 months, in the oligorecurrent group 1- and 2-year DPFS were 64.4 and 43%. The rate of LC was 92.8% at 2 years. At a median follow-up of 23.4 months, in the oligo-CRPC group 1- and 2-year DPFS were 43.2 and 21.6%. Limitations include the retrospective design.Conclusions:Stereotactic body radiotherapy seems to be a useful treatment both for oligorecurrent and oligo-CRPC.

Extreme hypofractionation for early prostate cancer: Biology meets technology

The aim of this review is to present the available radiobiological, technical and clinical data about extreme hypofractionation in primary prostate cancer radiotherapy. The interest in this technique is based on the favourable radiobiological characteristics of prostate cancer and supported by advantageous logistic aspects deriving from short overall treatment time. The clinical validity of short-term treatment schedule is proven by a body of non-randomised studies, using both isocentric (LINAC-based) or non-isocentric (CyberKnife®-based) stereotactic body irradiation techniques. Twenty clinical studies, each enrolling more than 40 patients for a total of 1874 treated patients, were revised in terms of technological setting, toxicity, outcome and quality of life assessment. The implemented strategies for the tracking of the prostate and the sparing of the rectal wall have been investigated with particular attention. The urinary toxicity after prostate stereotactic body irradiation seems slightly more pronounced as compared to rectal adverse events, and this is more evident for late occurring events, but no worse as respect to conventional fractionation schemes. As far as the rate of severe acute toxicity is concerned, in all the available studies the treatment was globally well tolerated. While awaiting long-term data on efficacy and toxicity, the analysed studies suggest that the outcome profile of this approach, alongside the patient convenience and reduced costs, is promising. Forty-eight ongoing clinical trials are also presented as a preview of the expectation from the near future.