Background Isolated pulmonary oligometastases as the first site of dissemination after initial re... more Background Isolated pulmonary oligometastases as the first site of dissemination after initial resection of pancreatic ductal adenocarcinoma (PC) is a rare event, and the treatment in this subgroup is challenging. Recurrence in the lung after initial primary tumour resection is associated with the most long-term survivors of patients with metastatic PC. Stereotactic ablative body radiation therapy (SABR) or metastectomy for pulmonary oligometastases from PC is becoming more common. However, patients with close or positive margins after metastectomy for isolated pulmonary metastatic PC are at high risk for recurrence. This requires a treatment capable of achieving high rates of local control and improved quality of life by delaying the need for systemic chemotherapy. In other settings, SABR has been shown to achieve these goals, allowing safe dose escalation with excellent conformity and short duration of treatment. Case presentation We report the case of a 48-year old Caucasian man with a history of locally advanced PC initially treated with neoadjuvant chemotherapy followed by Whipple's resection in August 2016. After a disease-free interval of 3 years, he developed three isolated pulmonary metastases which were treated with local resection. In the setting of microscopically positive resection margins (R1), adjuvant lung SABR was delivered to all three sites. His treated lung disease remained radiologically stable for up to twenty months after SABR. Treatment was well tolerated. In January 2021, he developed a malignant pre-tracheal node which was treated with conventionally fractionated radiotherapy and remained controlled for the duration of follow-up. A year later, he developed widespread metastatic disease including pleura, bone and adrenal gland, together with presumed progression in one of the original lung lesions, receiving palliative radiotherapy for right chest wall pain. He was later found to have an intracranial metastasis and died in February 2022, 5½ years after initial treatment. Conclusion We present the case of a patient treated with SABR after R1 resection of 3 isolated pulmonary metastases from PC, with no treatment toxicities and durable local control. For well-selected patients in this setting, adjuvant lung SABR may be a safe and effective treatment option.
Background: Stereotactic radiosurgery (SRS) is the preferred treatment for vestibular schwannoma ... more Background: Stereotactic radiosurgery (SRS) is the preferred treatment for vestibular schwannoma (VS) in patients with preserved hearing and tumour diameter < 3 cm. Emerging evidence suggests restricting cochlear dose could preserve hearing. This retrospective replanning study aims to compare dynamic conformal arc therapy (DCAT), intensity modulated radiation therapy (IMRT) and volumetric modulated arc therapy (VMAT) plans for superiority of cochlear dose sparing without compromising tumour coverage. Methods: Eligibility criteria included sporadic VS, serviceable hearing and availability of CT and MRI for planning. The original gross tumour volume and brainstem OAR volume were retained; the cochlea was newly contoured on the planning CT scan (bone window). Each case was replanned using the three above techniques, prescribing 12 Gy to the 80% isodose line. No dose constraint was applied to the cochlea. Results: Eighteen patients were replanned. Mean tumour volume was 2.25 cc. Tumour coverage and tumour mean dose (DCAT: 14.2, IMRT: 14.6, VMAT: 14.5 Gy) were comparable. Paddick and RTOG conformity indices were better for DCAT (0.66 and 1.6) and VMAT (0.69 and 1.5) compared to IMRT (0.56 and 1.9). DCAT had superior gradient index (3.0) compared to VMAT (3.4) and IMRT (3.4). VMAT delivered the lowest mean brainstem maximum dose (8.3 Gy) and decreased the mean cochlear dose (3.4 Gy) by 2.3 and 2.1 Gy, and the mean cochlear maximum dose (3.6 Gy) by 2.4 and 2.5 Gy relative to DCAT and IMRT, respectively. Conclusion: LINAC-based SRS treatment using VMAT can achieve better cochlear dose sparing than DCAT or IMRT while maintaining tumour coverage.
Poster: "2015 ASM / R-0009 / Quality Performance Indicators in Radiotherapy for Early Stage ... more Poster: "2015 ASM / R-0009 / Quality Performance Indicators in Radiotherapy for Early Stage Hodgkin's Lymphoma " by: " H. Tee , D. Roos; Adelaide/AU"
Journal of medical imaging and radiation oncology, May 4, 2023
IntroductionFostering a research culture is a key goal of the Royal Australian and New Zealand Co... more IntroductionFostering a research culture is a key goal of the Royal Australian and New Zealand College of Radiologists, yet there has never been an organization‐wide enquiry into the extent to which this is being realized. The purpose of this work was to address that deficit for the Radiation Oncology (RO) Faculty to serve as a baseline for future comparison. The hypothesis was that such a culture is closer to fact than fantasy.MethodsWith College approval, three de‐identified Excel spreadsheets detailing 25 research‐related sub‐categories of the Faculty's Continuing Professional Development (CPD) database were interrogated for the 2019–21 triennium, accepting that research activity in 2020–21 would be COVID‐19 suppressed. The numbers obligated to self‐report CPD were 482, 496 and 511, respectively. Primary endpoints were the percentages of ROs claiming at least one research‐related activity overall, and in each of the sub‐categories individually, by year. Secondary endpoints were the “breadth” (number of sub‐categories claimed/individual) and “depth” (percentages solely claiming in one of four lower‐level sub‐categories), by year.ResultsROs claimed in 23/25 sub‐categories. The percentages of ROs claiming at least one research‐related activity were 71%, 44%, and 62% in 2019–21, respectively. The median number of sub‐categories claimed by these ROs was 2 (range 1–10) in each year. The commonest activity was journal article co‐author (25%, 16% and 27%, respectively). For 2019, the most representative year, other common activities were inhouse/local meeting presentation (17%), invited lecture at state level or above (15%), manuscript peer review and research project principal investigator (14% each). The percentages of ROs solely claiming in one lower‐level activity ranged between 4.4% and 5.9% per year.ConclusionA culture of research is arguably more fact than fantasy in ANZ. It is likely that Faculty curriculum requirements, research funding and other promotional initiatives have contributed substantively to this.
Correspondence and Short Communications Comments on published articles, short communicalions of a... more Correspondence and Short Communications Comments on published articles, short communicalions of a preliminary nature, case reports, technical notes and the like are accepted under this heading. The articles should he short and concise and contain a minimum of jigures, tables and references. SKIN INFILTRATION WITHIN A RADIOTHERAPY PORTAL FOR METASTATIC BLADDER CANCER-CASE REPORT AND REVIEW OF THE CLINICAL LITERATURE Since its first description in 1935, there have been occasional reports of skin infiltration by tumour in a distribution corresponding to previous radiation portals (1-7). Attempts to explain the phenomenon have invoked local capillary endothelial damage and immunological or physiological changes secondary to radiation (8-10). Whilst generally associated with biologically aggressive tumours and poor prognosis, it is unknown what predisposes a small proportion of such tumours to display this complication of radiotherapy (RT). We now describe a case of skin infiltration following left neck irradiation for nodal metastases from transitional cell carcinoma of the bladder and review the clinical literature on this effect. Case report. A 75-year-old male Jehovah's Witness with a 6-month history of haematuria had a cystoscopic resection in December 1990 of a solitary grade I1 transitional cell carcinoma showing superficial bladder muscle invasion. Complete blood picture, multiple biochemical analysis, chest x-ray and CT scan of abdomen and pelvis were negative for metastatic disease, and the tumour was staged as T2 NO MO (11). Surgery was considered inadvisable due to his age and refusal to consider blood transfusion, and he was referred for RT, receiving 52.2 Gy to pelvis with a 12.6Gy boost to bladder, 36 fractions at 1.80 Gy/fraction, completing treatment in April 1991. He remained well with negative check cystoscopies in July and November 1991, at which time he was noted to have several asymptomatic left supraclavicular nodes, the largest about 1 .S cm in diameter. Fine-needle aspiration cytology of the nodes was positive for undifferentiated carcinoma, presumed from the bladder primary. In the absence of obvious metastatic disease elsewhere on physical examination, blood tests, and chest x-ray, the decision was taken to treat the left neck with RT. From late December 1991, he had 45 Gy in 15 fractions at 3 Gy/fraction, 5 times per week, using an anterior 15 x 11 cm 4 MV photon field at D,,, with 1 cm bolus to the nodes (requiring a 10-day break after 24 Gy due to severe radiation oesophagitis), followed by two 6 MeV electron boosts, 6 Gy D,,, in 2 fractions to a 6cm diameter circle and 3 Gy D,,, in 1 fraction to a 4 cm diameter circle, over a total of 35 days. Skin reaction was limited to brisk erythema with dry desquamation, and treatment was finished in early February 1992. A few weeks later, he started developing pain in his left shoulder and left upper limb suggestive of brachial plexus involvement, and noted a patch of purplish skin in the left supraclavicular fossa. By June 1992 (5 months after completing RT), there was a diffuse, nodular violaceous tumour with well demarcated borders outlining the previous radiation field over a 14 x 10 cm area with maximum thickness above surrounding skin of about I cm (Figure). Left shoulder movements were limited due to pain, the left biceps and triceps jerks were diminished, and there was mildly decreased pin prick sensation in the left C6 distribution. His YORAM MORC
Journal of Medical Radiation Sciences, Sep 9, 2018
We describe the use of radiotherapy for parotid IgG4-related disease (IgG4-RD), initially misdiag... more We describe the use of radiotherapy for parotid IgG4-related disease (IgG4-RD), initially misdiagnosed as Kimura's disease, with sustained good partial response in a 37-year-old male. To the best of our knowledge, this is the first reported case of radiation for extra-orbital IgG4-RD, albeit inadvertently.
Journal of medical imaging and radiation oncology, Jan 6, 2020
Introduction: The Royal Australian and New Zealand College of Radiologists Faculty of Radiation O... more Introduction: The Royal Australian and New Zealand College of Radiologists Faculty of Radiation Oncology (FRO) requires trainees to complete a research project prior to the exit (phase II) examinations. We report results of a survey of current FRO trainees and Fellows graduating since 2013, regarding their experience of the overall requirement, supervision, barriers to project completion and subsequent publication. Methods: A 32-question online survey was sent via email to 285 FRO members in July 2019. Responses were anonymous. Results: The overall response rate was 32% (trainees 41%, Fellows 21%); 70% of respondents were trainees. About three-quarters of projects were retrospective reviews (64%) or surveys (13%), 94% met College requirements at first submission, 71% were published, and 81% were presented at a scientific meeting. Most assistance was provided by the project supervisor (57%), statistician (47%), another consultant (36%) or the Director of Training (28%). Finding time amongst other clinical/curriculum commitments, rotating to another training site and availability of a suitable supervisor were notable obstacles. Over half (52%) of respondents were satisfied/very satisfied with the process overall and 20% dissatisfied/very dissatisfied; 19% and 30%, respectively, thought requiring acceptance for peer review and completion prior to the phase II examination unreasonable/very unreasonable. Four per cent reported being less likely to be involved in future research as a result of this experience. Conclusion: While the majority of respondents perceive the FRO research requirements as reasonable, a significant minority are not satisfied with aspects of the programme. Amendment of the pre-phase II stipulation may be worthy of consideration.
Journal of medical imaging and radiation oncology, Nov 21, 2018
Introduction: The role of the radioprotector amifostine in ameliorating radiotherapy side effects... more Introduction: The role of the radioprotector amifostine in ameliorating radiotherapy side effects in head and neck squamous cell carcinoma (HNSCC) is controversial. This trial aimed to determine whether pretreatment with amifostine reduced the incidence of Radiation Therapy Oncology Group grade ≥2 acute and late xerostomia in patients receiving definitive or adjuvant radiotherapy for HNSCC, without reducing tumour control or survival. Methods: Between 14 September 2001 and 8 November 2004, 44 Royal Adelaide Hospital patients were randomized double-blind to receive amifostine (200 mg/m 2 IV) or placebo (normal saline IV) 5 days/week, prior to standard radiotherapy (60-70 Gy), each having ≥75% of the parotids treated to ≥40 Gy. Side effects were assessed weekly during treatment, at 3 and 5 months after radiotherapy, then every 6 months until disease progression or death. Results: The accrual target was 200 patients over 4-5 years, but the trial closed prematurely when only 44 patients had been randomized after 3 years. Of 41 evaluable patients, 80% (16/20) in the amifostine arm had grade ≥2 acute radiation salivary toxicity versus 76% (16/21) in the placebo arm (P = 1.00). The rate of grade ≥2 late radiation salivary toxicity at 12 months was 66% in the amifostine arm and 82% in the placebo arm (estimated hazard ratio 1.61, 95% confidence interval 0.74-3.49, P = 0.22). Other toxicities tended to be worse in the amifostine arm: acute grade 3-4 skin 35% vs 5% and mucous membrane 40% vs 5%; grade ≥2 vomiting 35% vs 5%, hypocalcaemia 25% vs 5% and fatigue 85% vs 33%, with only the latter retaining statistical significance after adjusting for multiple comparisons. There were no significant differences in failure-free (P = 0.70) or overall survival (P = 0.86), with estimated 4-year rates of 48% vs 54% and 49% vs 59% for the amifostine vs placebo arms respectively. Conclusion: There was no clear evidence that pretreatment with amifostine made any difference to the incidence of grade ≥2 acute or late xerostomia. Other toxicity tended to be more severe with amifostine. There was no effect on failure-free or overall survival. Acknowledging the low statistical power, these results do not support the use of IV amifostine pre-radiotherapy in HNSCC.
ABSTRACT Stereotactic radiosurgery (SRS) is a well established, minimally invasive treatment opti... more ABSTRACT Stereotactic radiosurgery (SRS) is a well established, minimally invasive treatment option for patients diagnosed with cerebral arteriovenous malformations (AVM). We present the experience in linear accelerator-based SRS for cerebral AVM treated over 14years. We prospectively followed 67 patients with 69 AVM treated with SRS from 1994 to 2008, inclusive. The mean patient age was 37years (range 7-69) with 36 women and 31 men. The median AVM size, as defined by maximal diameter, was 2.5cm (range 0.5-4.6cm) and the median marginal dose was 18Gy in one fraction. The crude angiographic obliteration rate was 55% with a 3 and 5year actuarial rate of 39% and 65%, respectively. Median time to obliteration was 4.2years. Higher treatment dose (p&lt;0.0001) and smaller maximal AVM diameter (p=0.002) were associated with an increased obliteration rate. There were no deaths from treatment. Post-treatment neurological complications occurred in 10 patients (15%) including hemorrhage in two. Twelve patients (18%) required a second SRS procedure. Larger AVM diameter was associated with increased odds of requiring re-treatment (p=0.02). Radiosurgery for intracerebral AVM is a non-invasive therapeutic option with low morbidity and a reasonable likelihood of nidus obliteration. Treatment dose and AVM diameter are the main determinants of obliteration.
International Journal of Radiation Oncology Biology Physics, Jun 1, 1999
Purpose: The dose of radioactive iodine (131 I) required to ablate thyroid remnants following sur... more Purpose: The dose of radioactive iodine (131 I) required to ablate thyroid remnants following surgery for differentiated thyroid carcinoma is controversial. Typical administered activities range from less than 30 mCi up to 100 mCi, reflecting local practice and regulations governing allowable outpatient doses. This review examines the available randomized trials designed to assess the optimal ablative dose in this setting. Methods and Materials: The authors identified three such trials published in 1987, 1991, and 1996, and critically reviewed them from a scientific and statistical point of view. Results: Two of these studies were small and lacked adequate statistical power to answer the question, and the third was very poorly conducted. Conclusion: In our opinion, the appropriate dose of 131 I for ablation of thyroid remnants remains undetermined.
We evaluated the effect of adjuvant whole brain irradiation (WBI) after surgery or radiosurgery f... more We evaluated the effect of adjuvant whole brain irradiation (WBI) after surgery or radiosurgery for solitary brain metastases in a Phase III multicentre trial with randomization to 30-36 Gy WBI or observation. The study was closed early due to slow accrual after 19 patients (WBI 10, observation 9). There was no difference in CNS failure-free survival or overall survival between the arms. There was a trend to reduced CNS relapse with WBI (30% versus 78%, P=0.12). Limited analysis of quality of life and neurocognitive function data revealed no evidence of difference between the arms. Our results are not inconsistent with two larger randomized trials and support the use of upfront WBI to decrease brain recurrence in this setting.
Background Isolated pulmonary oligometastases as the first site of dissemination after initial re... more Background Isolated pulmonary oligometastases as the first site of dissemination after initial resection of pancreatic ductal adenocarcinoma (PC) is a rare event, and the treatment in this subgroup is challenging. Recurrence in the lung after initial primary tumour resection is associated with the most long-term survivors of patients with metastatic PC. Stereotactic ablative body radiation therapy (SABR) or metastectomy for pulmonary oligometastases from PC is becoming more common. However, patients with close or positive margins after metastectomy for isolated pulmonary metastatic PC are at high risk for recurrence. This requires a treatment capable of achieving high rates of local control and improved quality of life by delaying the need for systemic chemotherapy. In other settings, SABR has been shown to achieve these goals, allowing safe dose escalation with excellent conformity and short duration of treatment. Case presentation We report the case of a 48-year old Caucasian man with a history of locally advanced PC initially treated with neoadjuvant chemotherapy followed by Whipple's resection in August 2016. After a disease-free interval of 3 years, he developed three isolated pulmonary metastases which were treated with local resection. In the setting of microscopically positive resection margins (R1), adjuvant lung SABR was delivered to all three sites. His treated lung disease remained radiologically stable for up to twenty months after SABR. Treatment was well tolerated. In January 2021, he developed a malignant pre-tracheal node which was treated with conventionally fractionated radiotherapy and remained controlled for the duration of follow-up. A year later, he developed widespread metastatic disease including pleura, bone and adrenal gland, together with presumed progression in one of the original lung lesions, receiving palliative radiotherapy for right chest wall pain. He was later found to have an intracranial metastasis and died in February 2022, 5½ years after initial treatment. Conclusion We present the case of a patient treated with SABR after R1 resection of 3 isolated pulmonary metastases from PC, with no treatment toxicities and durable local control. For well-selected patients in this setting, adjuvant lung SABR may be a safe and effective treatment option.
Background: Stereotactic radiosurgery (SRS) is the preferred treatment for vestibular schwannoma ... more Background: Stereotactic radiosurgery (SRS) is the preferred treatment for vestibular schwannoma (VS) in patients with preserved hearing and tumour diameter < 3 cm. Emerging evidence suggests restricting cochlear dose could preserve hearing. This retrospective replanning study aims to compare dynamic conformal arc therapy (DCAT), intensity modulated radiation therapy (IMRT) and volumetric modulated arc therapy (VMAT) plans for superiority of cochlear dose sparing without compromising tumour coverage. Methods: Eligibility criteria included sporadic VS, serviceable hearing and availability of CT and MRI for planning. The original gross tumour volume and brainstem OAR volume were retained; the cochlea was newly contoured on the planning CT scan (bone window). Each case was replanned using the three above techniques, prescribing 12 Gy to the 80% isodose line. No dose constraint was applied to the cochlea. Results: Eighteen patients were replanned. Mean tumour volume was 2.25 cc. Tumour coverage and tumour mean dose (DCAT: 14.2, IMRT: 14.6, VMAT: 14.5 Gy) were comparable. Paddick and RTOG conformity indices were better for DCAT (0.66 and 1.6) and VMAT (0.69 and 1.5) compared to IMRT (0.56 and 1.9). DCAT had superior gradient index (3.0) compared to VMAT (3.4) and IMRT (3.4). VMAT delivered the lowest mean brainstem maximum dose (8.3 Gy) and decreased the mean cochlear dose (3.4 Gy) by 2.3 and 2.1 Gy, and the mean cochlear maximum dose (3.6 Gy) by 2.4 and 2.5 Gy relative to DCAT and IMRT, respectively. Conclusion: LINAC-based SRS treatment using VMAT can achieve better cochlear dose sparing than DCAT or IMRT while maintaining tumour coverage.
Poster: "2015 ASM / R-0009 / Quality Performance Indicators in Radiotherapy for Early Stage ... more Poster: "2015 ASM / R-0009 / Quality Performance Indicators in Radiotherapy for Early Stage Hodgkin's Lymphoma " by: " H. Tee , D. Roos; Adelaide/AU"
Journal of medical imaging and radiation oncology, May 4, 2023
IntroductionFostering a research culture is a key goal of the Royal Australian and New Zealand Co... more IntroductionFostering a research culture is a key goal of the Royal Australian and New Zealand College of Radiologists, yet there has never been an organization‐wide enquiry into the extent to which this is being realized. The purpose of this work was to address that deficit for the Radiation Oncology (RO) Faculty to serve as a baseline for future comparison. The hypothesis was that such a culture is closer to fact than fantasy.MethodsWith College approval, three de‐identified Excel spreadsheets detailing 25 research‐related sub‐categories of the Faculty's Continuing Professional Development (CPD) database were interrogated for the 2019–21 triennium, accepting that research activity in 2020–21 would be COVID‐19 suppressed. The numbers obligated to self‐report CPD were 482, 496 and 511, respectively. Primary endpoints were the percentages of ROs claiming at least one research‐related activity overall, and in each of the sub‐categories individually, by year. Secondary endpoints were the “breadth” (number of sub‐categories claimed/individual) and “depth” (percentages solely claiming in one of four lower‐level sub‐categories), by year.ResultsROs claimed in 23/25 sub‐categories. The percentages of ROs claiming at least one research‐related activity were 71%, 44%, and 62% in 2019–21, respectively. The median number of sub‐categories claimed by these ROs was 2 (range 1–10) in each year. The commonest activity was journal article co‐author (25%, 16% and 27%, respectively). For 2019, the most representative year, other common activities were inhouse/local meeting presentation (17%), invited lecture at state level or above (15%), manuscript peer review and research project principal investigator (14% each). The percentages of ROs solely claiming in one lower‐level activity ranged between 4.4% and 5.9% per year.ConclusionA culture of research is arguably more fact than fantasy in ANZ. It is likely that Faculty curriculum requirements, research funding and other promotional initiatives have contributed substantively to this.
Correspondence and Short Communications Comments on published articles, short communicalions of a... more Correspondence and Short Communications Comments on published articles, short communicalions of a preliminary nature, case reports, technical notes and the like are accepted under this heading. The articles should he short and concise and contain a minimum of jigures, tables and references. SKIN INFILTRATION WITHIN A RADIOTHERAPY PORTAL FOR METASTATIC BLADDER CANCER-CASE REPORT AND REVIEW OF THE CLINICAL LITERATURE Since its first description in 1935, there have been occasional reports of skin infiltration by tumour in a distribution corresponding to previous radiation portals (1-7). Attempts to explain the phenomenon have invoked local capillary endothelial damage and immunological or physiological changes secondary to radiation (8-10). Whilst generally associated with biologically aggressive tumours and poor prognosis, it is unknown what predisposes a small proportion of such tumours to display this complication of radiotherapy (RT). We now describe a case of skin infiltration following left neck irradiation for nodal metastases from transitional cell carcinoma of the bladder and review the clinical literature on this effect. Case report. A 75-year-old male Jehovah's Witness with a 6-month history of haematuria had a cystoscopic resection in December 1990 of a solitary grade I1 transitional cell carcinoma showing superficial bladder muscle invasion. Complete blood picture, multiple biochemical analysis, chest x-ray and CT scan of abdomen and pelvis were negative for metastatic disease, and the tumour was staged as T2 NO MO (11). Surgery was considered inadvisable due to his age and refusal to consider blood transfusion, and he was referred for RT, receiving 52.2 Gy to pelvis with a 12.6Gy boost to bladder, 36 fractions at 1.80 Gy/fraction, completing treatment in April 1991. He remained well with negative check cystoscopies in July and November 1991, at which time he was noted to have several asymptomatic left supraclavicular nodes, the largest about 1 .S cm in diameter. Fine-needle aspiration cytology of the nodes was positive for undifferentiated carcinoma, presumed from the bladder primary. In the absence of obvious metastatic disease elsewhere on physical examination, blood tests, and chest x-ray, the decision was taken to treat the left neck with RT. From late December 1991, he had 45 Gy in 15 fractions at 3 Gy/fraction, 5 times per week, using an anterior 15 x 11 cm 4 MV photon field at D,,, with 1 cm bolus to the nodes (requiring a 10-day break after 24 Gy due to severe radiation oesophagitis), followed by two 6 MeV electron boosts, 6 Gy D,,, in 2 fractions to a 6cm diameter circle and 3 Gy D,,, in 1 fraction to a 4 cm diameter circle, over a total of 35 days. Skin reaction was limited to brisk erythema with dry desquamation, and treatment was finished in early February 1992. A few weeks later, he started developing pain in his left shoulder and left upper limb suggestive of brachial plexus involvement, and noted a patch of purplish skin in the left supraclavicular fossa. By June 1992 (5 months after completing RT), there was a diffuse, nodular violaceous tumour with well demarcated borders outlining the previous radiation field over a 14 x 10 cm area with maximum thickness above surrounding skin of about I cm (Figure). Left shoulder movements were limited due to pain, the left biceps and triceps jerks were diminished, and there was mildly decreased pin prick sensation in the left C6 distribution. His YORAM MORC
Journal of Medical Radiation Sciences, Sep 9, 2018
We describe the use of radiotherapy for parotid IgG4-related disease (IgG4-RD), initially misdiag... more We describe the use of radiotherapy for parotid IgG4-related disease (IgG4-RD), initially misdiagnosed as Kimura's disease, with sustained good partial response in a 37-year-old male. To the best of our knowledge, this is the first reported case of radiation for extra-orbital IgG4-RD, albeit inadvertently.
Journal of medical imaging and radiation oncology, Jan 6, 2020
Introduction: The Royal Australian and New Zealand College of Radiologists Faculty of Radiation O... more Introduction: The Royal Australian and New Zealand College of Radiologists Faculty of Radiation Oncology (FRO) requires trainees to complete a research project prior to the exit (phase II) examinations. We report results of a survey of current FRO trainees and Fellows graduating since 2013, regarding their experience of the overall requirement, supervision, barriers to project completion and subsequent publication. Methods: A 32-question online survey was sent via email to 285 FRO members in July 2019. Responses were anonymous. Results: The overall response rate was 32% (trainees 41%, Fellows 21%); 70% of respondents were trainees. About three-quarters of projects were retrospective reviews (64%) or surveys (13%), 94% met College requirements at first submission, 71% were published, and 81% were presented at a scientific meeting. Most assistance was provided by the project supervisor (57%), statistician (47%), another consultant (36%) or the Director of Training (28%). Finding time amongst other clinical/curriculum commitments, rotating to another training site and availability of a suitable supervisor were notable obstacles. Over half (52%) of respondents were satisfied/very satisfied with the process overall and 20% dissatisfied/very dissatisfied; 19% and 30%, respectively, thought requiring acceptance for peer review and completion prior to the phase II examination unreasonable/very unreasonable. Four per cent reported being less likely to be involved in future research as a result of this experience. Conclusion: While the majority of respondents perceive the FRO research requirements as reasonable, a significant minority are not satisfied with aspects of the programme. Amendment of the pre-phase II stipulation may be worthy of consideration.
Journal of medical imaging and radiation oncology, Nov 21, 2018
Introduction: The role of the radioprotector amifostine in ameliorating radiotherapy side effects... more Introduction: The role of the radioprotector amifostine in ameliorating radiotherapy side effects in head and neck squamous cell carcinoma (HNSCC) is controversial. This trial aimed to determine whether pretreatment with amifostine reduced the incidence of Radiation Therapy Oncology Group grade ≥2 acute and late xerostomia in patients receiving definitive or adjuvant radiotherapy for HNSCC, without reducing tumour control or survival. Methods: Between 14 September 2001 and 8 November 2004, 44 Royal Adelaide Hospital patients were randomized double-blind to receive amifostine (200 mg/m 2 IV) or placebo (normal saline IV) 5 days/week, prior to standard radiotherapy (60-70 Gy), each having ≥75% of the parotids treated to ≥40 Gy. Side effects were assessed weekly during treatment, at 3 and 5 months after radiotherapy, then every 6 months until disease progression or death. Results: The accrual target was 200 patients over 4-5 years, but the trial closed prematurely when only 44 patients had been randomized after 3 years. Of 41 evaluable patients, 80% (16/20) in the amifostine arm had grade ≥2 acute radiation salivary toxicity versus 76% (16/21) in the placebo arm (P = 1.00). The rate of grade ≥2 late radiation salivary toxicity at 12 months was 66% in the amifostine arm and 82% in the placebo arm (estimated hazard ratio 1.61, 95% confidence interval 0.74-3.49, P = 0.22). Other toxicities tended to be worse in the amifostine arm: acute grade 3-4 skin 35% vs 5% and mucous membrane 40% vs 5%; grade ≥2 vomiting 35% vs 5%, hypocalcaemia 25% vs 5% and fatigue 85% vs 33%, with only the latter retaining statistical significance after adjusting for multiple comparisons. There were no significant differences in failure-free (P = 0.70) or overall survival (P = 0.86), with estimated 4-year rates of 48% vs 54% and 49% vs 59% for the amifostine vs placebo arms respectively. Conclusion: There was no clear evidence that pretreatment with amifostine made any difference to the incidence of grade ≥2 acute or late xerostomia. Other toxicity tended to be more severe with amifostine. There was no effect on failure-free or overall survival. Acknowledging the low statistical power, these results do not support the use of IV amifostine pre-radiotherapy in HNSCC.
ABSTRACT Stereotactic radiosurgery (SRS) is a well established, minimally invasive treatment opti... more ABSTRACT Stereotactic radiosurgery (SRS) is a well established, minimally invasive treatment option for patients diagnosed with cerebral arteriovenous malformations (AVM). We present the experience in linear accelerator-based SRS for cerebral AVM treated over 14years. We prospectively followed 67 patients with 69 AVM treated with SRS from 1994 to 2008, inclusive. The mean patient age was 37years (range 7-69) with 36 women and 31 men. The median AVM size, as defined by maximal diameter, was 2.5cm (range 0.5-4.6cm) and the median marginal dose was 18Gy in one fraction. The crude angiographic obliteration rate was 55% with a 3 and 5year actuarial rate of 39% and 65%, respectively. Median time to obliteration was 4.2years. Higher treatment dose (p&lt;0.0001) and smaller maximal AVM diameter (p=0.002) were associated with an increased obliteration rate. There were no deaths from treatment. Post-treatment neurological complications occurred in 10 patients (15%) including hemorrhage in two. Twelve patients (18%) required a second SRS procedure. Larger AVM diameter was associated with increased odds of requiring re-treatment (p=0.02). Radiosurgery for intracerebral AVM is a non-invasive therapeutic option with low morbidity and a reasonable likelihood of nidus obliteration. Treatment dose and AVM diameter are the main determinants of obliteration.
International Journal of Radiation Oncology Biology Physics, Jun 1, 1999
Purpose: The dose of radioactive iodine (131 I) required to ablate thyroid remnants following sur... more Purpose: The dose of radioactive iodine (131 I) required to ablate thyroid remnants following surgery for differentiated thyroid carcinoma is controversial. Typical administered activities range from less than 30 mCi up to 100 mCi, reflecting local practice and regulations governing allowable outpatient doses. This review examines the available randomized trials designed to assess the optimal ablative dose in this setting. Methods and Materials: The authors identified three such trials published in 1987, 1991, and 1996, and critically reviewed them from a scientific and statistical point of view. Results: Two of these studies were small and lacked adequate statistical power to answer the question, and the third was very poorly conducted. Conclusion: In our opinion, the appropriate dose of 131 I for ablation of thyroid remnants remains undetermined.
We evaluated the effect of adjuvant whole brain irradiation (WBI) after surgery or radiosurgery f... more We evaluated the effect of adjuvant whole brain irradiation (WBI) after surgery or radiosurgery for solitary brain metastases in a Phase III multicentre trial with randomization to 30-36 Gy WBI or observation. The study was closed early due to slow accrual after 19 patients (WBI 10, observation 9). There was no difference in CNS failure-free survival or overall survival between the arms. There was a trend to reduced CNS relapse with WBI (30% versus 78%, P=0.12). Limited analysis of quality of life and neurocognitive function data revealed no evidence of difference between the arms. Our results are not inconsistent with two larger randomized trials and support the use of upfront WBI to decrease brain recurrence in this setting.
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Papers by Daniel Roos