Simona Allis

Radiotherapy alone or with concomitant daily low-dose carboplatin in locally advanced, unresectable head and neck cancer: definitive results of a phase III study with a follow-up period of up to ten years.

Aim and background Radiotherapy is the conventional treatment for locally advanced inoperable head and neck squamous cell carcinoma. However, the poor therapeutic results justify the development of radiochemotherapy combinations. In an attempt to improve local control and survival in patients with stage III and IV unresectable head and neck squamous cell carcinoma and based on the results of our previous dose escalation study, we undertook a prospective multicentric randomized trial. Materials and methods From November 1992 through December 1995, a total of 164 patients were randomized to receive radiotherapy alone (arm I) or combined (arm II) with daily low-dose carboplatin. Results The 3, 5 and 10-year local-regional recurrence-free survival rates were better in arm II(21.7%, 15.1% and 15.1%, respectively) than in arm I (15%, 10.7% and 10.7%), but without statistical significance (P = 0.11). The 3, 5 and 10-year disease-free survival rates showed the same positive trend for arm II (16%, 6.8% and 6.8% vs 9%, 5.5% and 5.5%, in arm I, respectively), again without statistical significance (P = 0.09). Instead, a statistical advantage was found in overall survival rates at 3, 5 and 10-years (28.9%, 9% and 5.5% in arm II and 11.1%, 6.9% and 6.9% in arm I, respectively) (P = 0.02). The 3, 5 and 10-year local-regional recurrence-free survival rates in stage IV disease were statistically better in arm II (21.5%, 15.9% and 15.9%) than in arm I (12.8%, 7.7% and 7.7%, respectively) (P = 0.04). Conclusions Long-term results in both treatment arms of the trial appear less positive than most published series. However, our findings do not exclude that carboplatin may be beneficial, but the benefit in local control must be lower than the 15% assumed to dimension the trial.

A case of primary mediastinal Ewing's sarcoma /primitive neuroectodermal tumor presenting with initial compression of superior vena cava

Ewings sarcomas and peripheral primitive neuroectodermal tumors (ES/PNETs) are high grade malignant neoplasms. These malignancies are characterized by a chromosome 22 rearrangement, arise from bone or soft tissue, predominantly affect children and young adults, and are grouped in the Ewing family of tumors. Multimodality treatment programs are the treatment of choice. Primary localization of ES/PNET in the mediastinum is extremely rare. We describe a case of ES/PNET presenting as a mediastinal mass with tracheal compression and initial signs of superior vena cava in a 66-year-old woman.

Should radiotherapy after primary systemic therapy be administered with the same recommendations made for operable breast cancer patients who receive surgery as first treatment? A critical review.

Primary systemic therapy is not only used in patients with locally advanced inoperable non-metastatic breast cancer but also for operable stage II and III cancer aimed at breast conservation. The indications for local-regional radiotherapy for patients who receive primary systemic therapy are still evolving. The purpose of this article is to provide a comprehensive discussion of how primary systemic therapy in operable breast cancer patients could affect the indications of radiotherapy to optimize local-regional treatment. An overview of available literature data regarding neoadjuvant treatment and radiotherapy is analyzed and discussed. Considering the variability of data on this issue, an appropriate approach could still be to tailor treatment decision to the individual clinical case.

Target registration errors with surface imaging system in conformal radiotherapy for prostate cancer: study on 19 patients

PurposeAccurate patient setup is a prerequisite for conformal radiotherapy (3D-CRT) and is based on various methods, including surface imaging systems. To evaluate the validity of a surface imaging system (AlignRT), we analysed setup reproducibility of a cohort of patients.Materials and methodsNineteen patients affected by prostate adenocarcinoma were enrolled in this study. We acquired 653 surface images and 99 digital portal images (DPI). Setup errors were found by matching surface images with computed tomography (CT) and DPI images.ResultsThe setup errors from the threshold of 5 mm detected by AlignRT along the Y, Z and X axes occurred in 47.4%, 42.1% and 5.3% of patients, respectively. For the threshold of 3 mm, shifts along the Y, Z and X axes were observed in 68%, 69% and 10%, respectively. Comparing AlignRT and DPI, we found a statistically significant difference in the detection of shifts along the Y and Z axes. For a threshold ≥5 mm, the two systems provided corresponding setup errors along the Y and Z axes, whereas along the X axis, the threshold was not necessary.ConclusionsAlignRT is an accurate technique for setup in 3D-CRT prostate cancer patients, especially along the lateral direction.RiassuntoObiettivoIl corretto set-up rappresenta un requisito fondamentale della radioterapia conformazionale (3D-CRT) ed i sistemi di registrazioni di immagini di superficie rappresentano una delle metodiche utilizzate per la verifica. Scopo di questo studio è verificare la validità di un sistema di registrazioni di immagini (AlignRT), analizzando una coorte di pazienti.Materiali e metodiSono stati arruolati 19 pazienti affetti da adenocarcinoma prostatico e ottenute 653 immagini di superficie e 99 immagini portali (DPI). Gli errori di set-up sono stati ottenuti confrontando le immagini di superficie con la tomografia computerizzata (TC) e con le DPI.RisultatiPer la soglia di 5 mm gli errori di set-up rilevati dal AlignRT lungo gli assi y, z e x sono stati osservati nel 47,4%, 42,1% e 5,3% dei pazienti, rispettivamente. Per la soglia di 3 mm, gli spostamenti lungo gli assi y, z e x sono stati osservati nel 68%, 69% e 10%, rispettivamente. Confrontando l’AlignRT e DPI, è stata trovata una differenza statisticamente significativa nel rilevamento degli spostamenti lungo gli assi y e z, mentre lungo l’asse x la soglia non è stata necessaria.ConclusioniAlignRT è un sistema accurato per la valutazione del set-up nei pazienti sottoposti a 3D-CRT, specialmente lungo la direzione laterale.

Is Karnofsky performance status correlate with better overall survival in palliative conformal whole brain radiotherapy? Our experience

Aim: Brain metastases (BMs) are a common event in the progression of many human cancers. The aim of this study was to evaluate the potential prognostic factors for the clinical identification of a subgroup of patients that could benefit from whole brain conformal radiotherapy (WBRT). Materials and Methods: From January 2010 to February 2014, 80 patients with a diagnosis of BMs underwent WBRT at our Radiation Oncology Department, San Luigi Hospital, Italy. Among them, 36 medical records were retrospective reviewed. Gender, age, Karnofsky performance status (KPS), number of BMs on computed tomography and/or magnetic resonance images, presence or absence of perilesional edema, presence or absence of necrosis pattern, and histology of primary tumor were analyzed. Univariate and multivariate analyses were performed. Results: In our cohort of patients, significant prognostic factors for 20 months overall survival was KPS> 70, while a statistical trend (P = 0.098) was registered regarding primary breast. Conclusion: WBRT can be still considered a standard and effective treatment in patients with BMs. High KPS and breast cancer primary tumor seem to be useful parameters for characterize a subgroup of patients with more favorable prognosis.

Role of radiotherapy in improving activity of immune-modulating drugs in advanced renal cancer: Biological rationale and clinical evidences

In the last few years, immune checkpoint inhibitors have been extensively investigated in renal cell carcinoma and led to remarkable results. Radiation therapy may increase the activity of immune modulating agents through different mechanisms, priming the immune system, recruiting immune cells to the tumor environment, and altering the immunosuppressive effects of the tumor microenvironment. Preclinical studies reported increased loco-regional control when radiation is combined with immune-checkpoint blockade. Moreover, increased systemic disease control has been demonstrated when local radiation is combined with both anti-CTLA-4 and anti-PD-1/PD-L1 inhibitors. Actually, several trials are ongoing testing the activity of radiation therapy in combination with different immune-modulating agents for the treatment of metastatic renal cell carcinoma. The aim of this paper is to focus on the biological rationale of adding radiation therapy to immune-modulating agents in renal cell carcinoma and to review the currently available clinical evidence about the combination of radiotherapy and immunotherapy.

Letter to the editor concerning Tsuchiya K et al. "Dosimetric comparison between intensity-modulated radiotherapy and standard wedged tangential technique for whole-breast radiotherapy in Asian women with relatively small breast volumes".

With great interest, we read the recent article by Tsuchiya et al. [1]. In this paper, the authors tried to identify, in the adjuvant setting after breast-conserving surgery, the optimal radiation technique for selected 25 small breast glands (median volume, 552.6 cc), comparing the dose distribution obtained with the standard wedge tangential technique (SWT), tangential-field intensity-modulated radiation therapy (T-IMRT), and 3–4 field IMRT techniques (3FIMRT or 4F-IMRT). An improved dose distribution, a shorter treatment time, and a reduction of Radiation Therapy Oncology Group (RTOG) acute high-grade skin toxicity with the T-IMRT technique [2, 3], which can be considered a simplified form of IMRT based on two tangential fields with sub-segments, have been demonstrated [4]. In their paper, Tsuchiya et al. stated that T-IMRT can be appropriate in particular for irradiation of small breasts, because of an improvement in dose homogeneity and in the dose received by 2 % of the volume (Dmax), reducing the bilateral lung mean dose and the V20 ipsilateral lung volume, compared with the other reported techniques [1]. In our unpublished data on 30 selected patients, we have pointed out that T-IMRT leads to reducing the cutaneous acute high-grade toxicity according to the RTOG scale even if the volume of our Italian breast cancer patients was higher than the Asian one (mean 910 cc, median 775 cc). In our clinical records, the tangential technique with 6 MV photons, comparing the standard wedge tangential technique (SWT) versus T-IMRT, was used, and several dosimetric parameters for planning target volume (PTV) and organs at risks (OARs) were analyzed [3]. The collapsed cone (CC) dose calculation algorithm was applied instead of the pencil beam classic (PBC) calculation model, and a statistical analysis was performed with Student t test (p \ 0.05). T-IMRT was superior to the SWT in reducing the percentage of the PTV receiving more than 110 % (V110 %) and 107 % (V107 %) prescribed dose as well as Dmax. The reduction of V110 %, V107 %, and Dmax was 50, 30, and 3 %, respectively, without compromising PTV coverage (no significant reduction of V95 % and D98) [5]. Comparing T-IMRT with SWT, our data showed no significant dosimetric differences for the heart (Dmean, V10, V20, V30 and V50) and lung (Dmax, Dmean, V10, V20, V30 and V50) but a significant reduction of hot spots, calculated as Dmax and V50. A significantly lower dose with T-IMRT (5 % reduction for Dmean) was recorded for the controlateral breast. Furthermore, a comparison between the ipsilateral lung dose distributions obtained with CC versus PBC, for T-IMRT only, showed that the use of PBC undervalues M. G. Ruo Redda (&) S. M. Anglesio S. Allis R. Verna A. Girardi E. Trevisiol A. Reali Department of Oncology, Radiation Oncology, University of Turin, S. Luigi Gonzaga Hospital, Regione Gonzole 10, Orbassano, 10043 Turin, Italy e-mail: mariagrazia.ruoredda@unito.it

Complete recovery from paraparesis in spinal cord compression due to extramedullary haemopoiesis in beta‐thalassaemia by emergency radiation therapy

Extramedullary haemopoiesis (EMH) is a complication commonly associated with beta‐thalassaemia intermedia; it is frequently asymptomatic but can sometimes lead to symptomatic tumour‐like masses. No guidelines or common consensus are available in literature regarding the different treatment strategies and only single cases have been reported. We describe a case of spinal cord compression due to intrathoracic EMH masses treated with combined radiotherapy and hydroxyurea.

A case report of narrowing primary tracheal mucosa-associated lymphoid tissue lymphoma: A multidisciplinary approach

Extranodal marginal zone lymphomas of mucosa-associated lymphoid tissue (MALT) are low-grade B-cell neoplasms, which arise in mucosal sites with prolonged lymphoid proliferation. Primary tracheal MALT lymphoma is an exceedingly rare entity for which the optimal treatment approach has not been determined. Here, we report a case of MALT lymphoma involving the trachea in a 64-year-old smoking woman who received desobstructive endoscopy and was thereafter successfully treated with (anti-CD20) immunotherapy and radiotherapy.