Verity Ahern

Review of deep inspiration breath-hold techniques for the treatment of breast cancer.

Radiation treatment to the left breast is associated with increased cardiac morbidity and mortality. The deep inspiration breath‐hold technique (DIBH) can decrease radiation dose delivered to the heart and this may facilitate the treatment of the internal mammary chain nodes. The aim of this review is to critically analyse the literature available in relation to breath‐hold methods, implementation, utilisation, patient compliance, planning methods and treatment verification of the DIBH technique. Despite variation in the literature regarding the DIBH delivery method, patient coaching, visual feedback mechanisms and treatment verification, all methods of DIBH delivery reduce radiation dose to the heart. Further research is required to determine optimum protocols for patient training and treatment verification to ensure the technique is delivered successfully.

Extracorporeal irradiation for malignant bone tumors

PURPOSE Extracorporeal irradiation (ECI) has been used selectively in the management of primary malignant bone tumors since 1996. We report our techniques for ECI and the short-term oncologic and orthopedic outcomes. METHODS AND MATERIALS Sixteen patients with primary malignant bone tumors were treated with ECI from 1996 to 2000. The median age was 14 years. The histologic diagnoses were Ewings sarcoma (11), osteosarcoma (4) and chondrosarcoma (1). The treated sites were femur (7), tibia (4), humerus (2), ilium (2), and sacrum (1). Following induction chemotherapy in Ewings sarcomas and osteosarcoma, en bloc resection of the tumor and tumor-bearing bone was performed. A single dose of 50 Gy was delivered to the bone extracorporeally using either a linear accelerator (9 cases) or a blood product irradiator (7 cases). The orthopedic outcome was recorded using a standard functional scale. RESULTS At a median follow-up of 19.5 months, there were no cases of local recurrence or graft failure. One patient required amputation due to chronic osteomyelitis. For the 10 patients with follow-up greater than 18 months, the functional outcomes were graded good to excellent. CONCLUSION The short-term oncologic and orthopedic results are encouraging and suggest that ECI provides a good alternative for reconstruction in limb conservative surgery in selected patients. This technique should only be used in a multidisciplinary setting, where careful follow-up is available to assess the long-term outcomes.

Paraneoplastic myelopathy at diagnosis in a patient with pathologic stage 1A Hodgkin disease

The case of a patient with pathologic Stage 1A Hodgkin disease is reported in whom subacute paraneoplastic myelopathy developed before treatment. Myelography, computed tomography, magnetic resonance imaging, and lumbar puncture examination showed no evidence of central nervous system involvement. The patient was treated with combination chemotherapy (to avoid spinal cord exposure to radiation) without neurologic improvement. The patients neurologic condition responded well to intrathecal dexamethasone.

Locally advanced breast cancer: Defining an optimum treatment regimen

PURPOSE This retrospective review examines response, local control and freedom from distant failure for patients with locally advanced breast cancer treated by chemotherapy and radiotherapy without routine surgery. METHODS AND MATERIALS 67 patients were treated between January 1980 and December 1988 at Westmead Hospital, NSW, Australia. Median follow-up for surviving patients was 56 months. Four successive protocols evolved, each with three phases induction chemotherapy (adriamycin or novantrone, cyclophosphamide) (three cycles), radiotherapy then chemotherapy (cyclophosphamide, methotrexate, 5-fluorouracil) of progressively shorter duration. Radiotherapy and chemotherapy were concurrent in the fourth regimen. RESULTS Clinical complete response (disappearance of all known disease) after chemotherapy, radiotherapy and additional chemotherapy was 18%, 55% and 79% respectively. Seven additional patients subsequently underwent mastectomy (N = 2), local excision (N = 1) or a radiation boost (N = 4) for a total complete response rate of 90%. Twenty one patients (31%) failed to achieve a complete response (N = 7) or recurred locally (N = 14). The crude 2-year rate of local recurrence was 50% for tumors > 10 cm (N = 10) and 14% for smaller tumors (n = 57) and was not influenced by protocol. Two-year actuarial freedom from distant failure was 67% at 2 years. CONCLUSION Local control can be achieved for patients with locally advanced breast cancer with a primary tumor < 10 cm using chemotherapy and radiotherapy without routine mastectomy.

Association of cyclophosphamide use with dental developmental defects and salivary gland dysfunction in recipients of childhood antineoplastic therapy

The aim of this study was to examine the effect of antineoplastic therapy on dental development and saliva function in recipients of childhood antineoplastic therapy.

Three-dimensional dose distribution of tangential breast irradiation: results of a multicentre phantom dosimetry study

BACKGROUND AND PURPOSE One aspect of good radiotherapeutic practice is to achieve dose homogeneity. Dose inhomogeneities occur with breast tangent irradiation, particularly in women with large breasts. MATERIALS AND METHODS Ten Australian radiation oncology centres agreed to participate in this multicentre phantom dosimetry study. An Alderson radiation therapy anthropomorphic phantom with attachable breasts of two different cup sizes (B and DD) was used. The entire phantom was capable of having thermoluminescent dosimeters (TLD) material inserted at various locations. Nine TLD positions were distributed throughout the left breast phantom including the superior and inferior planes. The ten centres were asked to simulate, plan and treat (with a prescription of 100 cGy) the breast phantoms according to their standard practice. Point doses from resultant computer plans were calculated for each TLD position. Measured and calculated (planning computer) doses were compared. RESULTS The dose planning predictability between departments did not appear to be significantly different for both the small and large breast phantoms. The median dose deviation (calculated dose minus measured dose) for all centres ranged from 2. 3 to 5.3 cGy on the central axis and from 2.1 to 7.5 cGy for the off-axis planes. The highest absolute dose was measured in the inferior plane of the large breast (128.7 cGy). The greatest dose inhomogeneity occurred in the small breast phantom volume (median range 93.2-105 cGy) compared with the large breast phantom volume (median range, 100.1-107.7 cGy). There was considerable variation in the use (or not) of wedges to obtain optimized dosimetry. No department used 3D compensators. CONCLUSION The results highlight areas of potential improvement in the delivery of breast tangent radiotherapy. Despite reasonable dose predictability, the greatest dose deviation and highest measured doses occurred in the inferior aspects of both the small and large breast phantoms.

Limb preservation surgery with extracorporeal irradiation in the management of malignant bone tumor: the oncological outcomes of 101 patients

BACKGROUND En bloc resection, extracorporeal irradiation (ECI) and reimplantation have been used selectively at our centers as part of limb preservation surgery of malignant bone tumors since 1996. We report the long-term oncological outcomes. PATIENTS AND METHODS One hundred one patients were treated with ECI at two Australian centers between 1996 and 2011. A single dose of 50 Gy was delivered to the resected bone segments. The irradiated bones were reimplanted immediately as a biological graft. Patients were treated with chemotherapy as per standard protocol. The three main histological diagnoses were Ewings sarcoma (35), osteosarcoma (37) and chondrosarcoma (20). There were nine patients with a range of different histologies. RESULTS There was one local recurrence (2.86%) in Ewings sarcoma and the 5-year cumulative overall survival was 81.9%. There was no local recurrence in osteosarcoma and five distant recurrences. The 5-year cumulative overall survival was 85.7%. The local recurrence rate was 20% (4 of 20) in chondrosarcoma, and the 5-year cumulative overall survival was 80.8%. Limb preservation was achieved in 97 patients. For the 64 patients with disease in the pelvis or lower limb, 53 (82.3%) could walk without aids at the time of last follow-up. CONCLUSIONS This large series of ECI shows an excellent long-term local control. It is a good alternative reconstruction method in selected patients. The overall survival is comparable to other published series.

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).

Paediatric radiation oncology in the care of childhood cancer: A position paper by the International Paediatric Radiation Oncology Society (PROS)

Paediatric malignancies are a challenge for the radiation oncologist due to their rarity, the great variety of histological types, and the complexity of treatment concepts that evolve over time. The Paediatric Radiation Oncology Society (PROS) is the only internationally operating society for paediatric radiation oncology. The objectives of PROS are to set a world-wide standard of excellence with respect to radiation oncology aspects in curing children and adolescents with cancer, to provide a forum for communication between radiation oncologists, and to exchange information with all professionals involved in the management of paediatric and adolescent cancer. Challenges include the need to promote education and support practice in low and middle income countries (LMIC) as well as the cost and availability of modern treatment technologies for all but most especially these countries. Collaborations with other societies that include for example the education programmes provided jointly with ESTRO, and the upgraded technical platform of the PROS web site offer new possibilities to enhance the efficacy of PROS in education and support of paediatric radiation oncology practice world-wide. PROS has made an important contribution to the management of childhood malignancies over the past decade and new and developing collaborations between PROS and other societies or organizations will ultimately lead to a reduction in world-wide health care inequalities.

Clinical equipoise: Protons and the child with craniopharyngioma

Childhood craniopharyngioma is a complex condition to manage. Survival figures are high but the potential for long‐term morbidity is great. There is much debate regarding the best management for these tumours with increasing interest in the use of proton beam therapy. We have therefore reviewed our radiotherapy (RT) practice at Westmead Hospital and the literature regarding the use of protons for these children.