4067 Background: Defining the optimal neoadjuvant treatment for resectable locally advanced esoph... more 4067 Background: Defining the optimal neoadjuvant treatment for resectable locally advanced esophageal carcinoma remains an open question. The debate is fuelled by the fact that most of the available randomized clinical trials (RCT) accrued two histological subtypes (adenocarcinoma (AC) and squamous cell carcinoma (SCC)) and two anatomical locations (TE and GEJ). The aim of this individual patient data (IPD) meta-analysis was to investigate the effect of preoperative chemotherapy on survival with a specific focus on histological subtypes and anatomical locations. Methods: Were eligible published or unpublished RCT closed to accrual before December 2015 and comparing neoadjuvant chemotherapy (CS) to primary surgery (S), identified by electronic database, conference proceedings and clinical trial register. All analyses were conducted on IPD obtained from trial Investigators. The Primary endpoint was overall survival (OS), Secondary endpoints were disease-free survival (DFS) with a 6-m...
Context. Dysphagia is usually associated with malignancies of the head, neck, and upper gastroint... more Context. Dysphagia is usually associated with malignancies of the head, neck, and upper gastrointestinal tract but also occurs in those with tumors outside anatomic swallow regions. It can lead to aspiration pneumonia, malnutrition, reduced quality of life, and psychosocial distress. No studies have yet reliably described dysphagia prevalence in those with malignancies outside anatomic swallow regions. Objective. The objective of this study was to establish the prevalence and predictors of dysphagia in adults with solid malignancies outside the head, neck, and upper gastrointestinal tract. Methods. A cross-sectional, observational study using consecutive sampling was conducted. There were 385 participants (mean age 66 AE 12 years) with 21 different primary cancer sites from two acute hospitals and one hospice. Locoregional disease was present in 33%, metastatic in 67%. Dysphagia was screened by empirical questionnaire and confirmed through swallow evaluation. Demographic and clinical predictors were determined by univariate and multivariate binary regression. Results. Dysphagia occurred in 19% of those with malignancies outside anatomic swallow regions. Prevalence was 30% in palliative care and 32% in hospice care. Dysphagia was most strongly associated with cough, nausea, and worse performance status. It was also associated with lower quality of life and nutritional difficulties. Conclusion. Dysphagia was common and usually undiagnosed before study participation. It occurred at all disease stages but coincided with functional decline. It may therefore represent a cancer frailty marker. Oncology and palliative care services should routinely screen for this symptom. Timely dysphagia identification and management may improve patient well-being and prevent adverse effects like aspiration pneumonia and weight loss.
This paper reviews the anatomical spread and failure patterns of surgical Stage I endometrial can... more This paper reviews the anatomical spread and failure patterns of surgical Stage I endometrial cancer. The controversial aspects of the optimal adjuvant treatment are presented. An attempt is made to identify the most effective management approach based on the pertinent literature data.
Impending malignant spinal cord compression (IMSCC) may be defined as compression of the thecal s... more Impending malignant spinal cord compression (IMSCC) may be defined as compression of the thecal sac, without any visible pressure on the spinal cord itself. Although there is a perception that IMSCC patients have a better prognosis and less severe clinical symptoms than true malignant spinal cord compression (MSCC) patients, these factors have never been documented in the literature.PurposeTo record the characteristics, management and functional outcome of a group of patients with IMSCC, who were treated with radiotherapy in our institution, and compare these parameters with similar data on MSCC patients.Materials and methodsData (gender, age, primary oncological diagnosis, pain, performance status and neurological status) were prospectively collected for 28 patients. Patients were then followed up post treatment to document their response to treatment and treatment-related toxicity.ResultsThe median survival of our group of IMSCC patients is similar to that of an MSCC patient. In a...
Nous avons cherche dans ce bref tour d'horizon de la radiotherapie des tumeurs digestives en ... more Nous avons cherche dans ce bref tour d'horizon de la radiotherapie des tumeurs digestives en 1994 a repondre concretement aux questions qui reviennent le plus souvent sur ce sujet: quelle est la place de la radiotherapie a cote de la chimiotherapie dans la prise en charge therapeutique de ces malades? Quels sont les indications reconnues de la radiotherapie, et quelles sont les voies de recherche? Nous montrons que la radiotherapie est utilisee chez pres des deux tiers des malades adresses dans un service de cancerologie pour traitement d'une tumeur digestive. Les principales indications reconnues sont passees en revue: cancer du rectum, cancer du canal anal, et a un moindre degre cancer de l'œsophage et du pancreas. Enfin, les principaux axes de recherche sont decrits, en particulier associations radiotherapiechimiotherapie, radiotherapie per-operatoire et radiotherapie des tumeurs hepato-biliaires
The purpose of this study was to evaluate the interobserver variability in the contouring of the ... more The purpose of this study was to evaluate the interobserver variability in the contouring of the gross tumor volume (GTV) on magnetic resonance (MR) imaging and computed tomography (CT) for colorectal liver metastases in the setting of SABR. Methods and Materials: Three expert radiation oncologists contoured 10 GTV volumes on 3 MR imaging sequences and on the CT image data set. Three metrics were chosen to evaluate the interobserver variability: the conformity index, the DICE coefficient, and the maximum Hausdorff distance (HDmax). Statistical analysis of the results was performed using a 1-sided permutation test. Results: For all 3 metrics, the MR liver acquisition volume acquisition (MR LAVA) showed the lowest interobserver variability. Analysis showed a significant difference (P < .01) in the mean DICE, an overlap metric, for MR LAVA (0.82) and CT (0.74). The HDmax that highlights boundary errors also showed a significant difference (P = .04) with MR LAVA having a lower mean HDmax (7.2 mm) compared with CT (5.7 mm). The mean HDmax for both MR single shot fast spin echo (SSFSE) (19.3 mm) and diffusion weighted image (9.5 mm) showed large interobserver variability with MR SSFSE having a mean HDmax of 19.3 mm. A volume comparison between MR LAVA and CT showed a significantly higher volume for small GTVs (<5 cm 3) when using MR LAVA for contouring in comparison to CT. Conclusions: This study reported the lowest interobserver variability for the MR LAVA, thus indicating the benefit of using MR to complement CT when contouring GTV for colorectal liver metastases.
Background: The role of stereotactic radiosurgery (SRS) in the treatment of limited numbers of br... more Background: The role of stereotactic radiosurgery (SRS) in the treatment of limited numbers of brain metastases in selected breast cancer patients is well-established. Aims: To analyse outcome from a single institutional experience with SRS, to identify any significant prognostic factors and to assess the influence of Her-2, estrogen receptor status, and prescribed dose on outcome. Methods: The medical records of 56 patients treated at in a single institution between 2009 and 2014 were reviewed. Demographic, treatment related and outcome data were analyzed to identify prognostic factors in this patient population. The primary endpoints were overall survival and local control. Secondary endpoint was distant intra-cranial progression-free survival. Results: The median follow-up time for the entire cohort was 10.33 months (1.25-97.28). The overall median survival was 12.5months (95%CI= 5.8-19.2), with 53.3%, and 35.8% surviving at 1-and 2-years post-SRS. After adjustment for the effect of Her 2 status, uncontrolled extra-cranial disease at the time of SRS predicted for shorter survival (HR for death = 3.1, 95% CI= 1.4-6.9, p = 0.006). At the time of death, 75% of the patients had active, uncontrolled intra-cranial disease, with 56% these patients presenting intra-cranial disease only. Sustained local control was observed in 56 (59.6%) of 94 treated metastases. In univariate analysis, Her2 status, ERHer2 group status?, and prescribed SRS dose were highly significant for local progression free-survival (LPFS). After adjustment for the effect of Her 2 status, patients receiving 12-16 Gy can expect shorter LPFS than those receiving 18-20 Gy (HR = 1.7, 95% CI = 1.0-2.8, p = 0.043). After adjustment for the effect of dose group, patients with Her 2 negative cancer can expect shorter LPFS than those with Her 2 positive cancer (HR = 2.6, 95% CI = 1.5-4.4, p < 0.0005). Use of prior WBRT did not impact survival, local or distant intra-cranial progression-free survival. Armstrong et al. SRS Brain Metastases Breast Primary Conclusions: Survival outcome is similar to the published literature. Improved outcomes are observed in patients with Her 2-positive, controlled extracranial disease at the time of SRS and higher SRS dose delivered. Achieving intra-cranial control appears to be an important factor for the survival of the breast cancer patients in the era of targeted therapies.
PURPOSE Fluorouracil (5-FU) continuous infusion is superior to 5-FU bolus in patients with advanc... more PURPOSE Fluorouracil (5-FU) continuous infusion is superior to 5-FU bolus in patients with advanced colorectal cancer, but the survival difference between the two treatments is small and, therefore, the difference in toxicity profile is crucial in choosing a treatment for individual patients. MATERIALS AND METHODS We conducted a meta-analysis of all randomized trials that compared 5-FU bolus with 5-FU CI, based on individual data from 1,219 patients, to compare the toxicity of the two schedules of 5-FU administration and to identify predictive factors for toxicity. The toxicities considered were World Health Organization (WHO) grade 3 to 4 anemia, thrombopenia, leukopenia, neutropenia, nausea/vomiting, diarrhea, mucositis, and hand-foot syndrome. RESULTS Hematologic toxicity, mainly neutropenia, was more frequent with 5-FU bolus than with 5-FU CI (31% and 4%, respectively; P < .0001). Hand-foot syndrome was less frequent with 5-FU bolus than with 5-FU CI (13% and 34%, respectivel...
TPS317 Background: Malignant Spinal Cord Compression (MSCC) represents the 2nd most common cancer... more TPS317 Background: Malignant Spinal Cord Compression (MSCC) represents the 2nd most common cancer- related neurological complication, with an estimated 1 to 6% lifetime risk for all cancer patients (pts). Radiotherapy (RT) is broadly used in treatment of MSCC, and has been occasionally proposed in context of re-irradiation. Due to increased survival and use of RT, the number of pts developing MSCC in previously irradiated areas is increasing (Thirion, 2008). Preclinical and clinical data suggest that the spinal cord maximal tolerable cumulative radiation dose (MTD) depends on the received radiation schedules (total dose, dose-per-fraction [#]) and interval between treatments (Nieder, 2006). The efficacy and toxicity, especially the risk of radiation-induced myelopathy (RIM), of re-irradiation for MSCC has not been prospectively evaluated. The objective of ICORG 07-11 is to establish the efficacy and safety of a radiobiological based re-irradiation strategy in pts with MSCC occurring in a previously irradi...
Backgrounds: In addition to its curative use for early stage lung cancer, stereotactic ablative r... more Backgrounds: In addition to its curative use for early stage lung cancer, stereotactic ablative radiotherapy is also indicated for pulmonary metastatic disease. Aims of this study were to retrospectively analyze treatment outcomes and to find prognostic factors for survivals. Methods: Treatment outcomes and toxicities of 85 cases of SABR in 72 patients were retrospectively reviewed from September 2012 to April 2015. Prognostic factors were analyzed using Cox proportional hazards regression. Results: The local failure-free survival rate at 2 years was 98%. Of the case, 1-year and 2-year progression-free survival rates were 62% and 48%, and overall survival rates were 90% and 72%, respectively. Multivariate analyses demonstrated that controlled primary cancer (P = 0.01), absence of extra-pulmonary metastatic disease (P < 0.01) and disease-free interval longer than 1 year (P < 0.01) favorably affected progression-free survival. Furthermore, the absence of extra-pulmonary metastatic disease (P < 0.01) increased overall survival as well. Grade 1 or 2 radiation pneumonitis was found in 37 cases, and Grade 1 chest wall pain was found in 1 case. Conclusions: Stereotactic ablative radiotherapy demonstrated good local control with tolerable adverse effects for pulmonary metastasis. The presence or absence of extra-pulmonary metastasis was found to be prognostic factor of mortality after stereotactic ablative radiotherapy treatment.
Introduction: In 2007 ESTRO proposed a revision and harmonisation of the core curricula for radia... more Introduction: In 2007 ESTRO proposed a revision and harmonisation of the core curricula for radiation oncologists, medical physicists and RTTs to encourage harmonised education programmes for the professional disciplines, to facilitate mobility between EU member states, to reflect the rapid development of the professions and to secure the best evidence-based education across Europe. Material and methods: Working parties for each core curriculum were established and included a broad representation with geographic spread and different experience with education from the ESTRO Educational Committee, local representatives appointed by the National Societies and support from ESTRO staff. Results: The revised curricula have been presented for the ESTRO community and endorsement is ongoing. All three curricula have been changed to competency based education and training, teaching methodology and assessment and include the recent introduction of the new dose planning and delivery techniques and the integration of drugs and radiation. The curricula can be downloaded at http://www.estro-education.org/europeantraining/Pages/EuropeanCurricula.aspx. Conclusion: The main objective of the ESTRO core curricula is to update and harmonise training of the radiation oncologists, medical physicists and RTTs in Europe. It is recommended that the authorities in charge of the respective training programmes throughout Europe harmonise their own curricula according to the common framework.
Background and Purpose: To prospectively assess the feasibility and efficacy of a hypofractionate... more Background and Purpose: To prospectively assess the feasibility and efficacy of a hypofractionated accelerated radiotherapy regimen (72 Gy in 24 daily fractions, 3Gy per fraction) in patients (pts) with non-resectable non-small-cell lung cancer (NSCLC). Material and Methods: We included 25 pts with a histologically or cytologically proven NSCLC, with KPS $ 70 and # 10% weight loss over prior three months, and with tumour stage I/II medically inoperable (9 pts) or non-resectable stage III a/b without pleural effusion (16 pts). Eleven pts received induction chemotherapy. No more than 30% of the combined lung volume could receive more than 25 Gy and the maximal biological effective dose to the spinal cord was maintained below 44 Gy. Results: No grade-4 acute toxicity event was reported. Two pts had a treatment break because of grade-3 acute oesophagitis. Twenty-two pts were evaluable for long-term toxicity (median follow-up ¼ 9.7 months, range 4 to 30.2 months). There were 4 Grade-1 pulmonary and 2 Grade-1 oesophageal long-term toxicity events. Twenty-two pts were evaluable for tumour response with 7 complete and 8 partial responses, 5 stable diseases and 2 progressive diseases. The actuarial 1-year overall and thoracic-progression-free survival rates were 68% and 72% respectively. Conclusions: This study demonstrates the feasibility of the experimental radiotherapy schedule, however more data are needed to confirm its efficacy.
Context. Dysphagia is common in cancer, but underlying pathophysiology and manifestations within ... more Context. Dysphagia is common in cancer, but underlying pathophysiology and manifestations within patients are unknown. Objectives. To examine dysphagia characteristics in those with solid malignancies outside the head, neck and upper gastrointestinal tract. Methods. Seventy-three individuals with dysphagia (46 male, 27 female, aged 37-91) were recruited from a parent trial conducted in two acute hospitals and one hospice. Cranial nerve function, Oral Health Assessment Tool (OHAT), Mann Assessment of Swallowing Ability (MASA) and Functional Oral Intake Scale (FOIS) evaluated swallow profile. Results. Only 9/73 (12%) had documented dysphagia prior to study enrollment. MASA risk ratings found n=61/73 (84%) with dysphagia risk and n=22/73 (30%) with aspiration risk. Food texture modification was required for n=34/73 (47%), fluid texture modification for n=1/73 (1%). Compensatory strategies for food were needed by n=13/73 (18%) and for fluids by n=24/73 (33%). Cranial nerve deficits were present in n=43/73 (59%). Oral health problems were common, with xerostomia in two-thirds. Worse dysphagia on MASA was associated with disease progression, affecting hospice, and palliative care the most. Worse performance status was indicative of poorer MASA raw score (P<0.001, OR 2.2, 95% CI 1.5−3.4), greater risk of aspiration (P=0.005, OR 2.1, 95% CI 1.3-3.6) and lower FOIS (P=0.004, OR 2.0, 95% CI 1.2−3.2). Conclusion. Dysphagia management in those with cancer requires robust assessment to uncover clinically important needs like food texture modification and safe swallowing advice. Better assessment tools should be developed for this purpose. Oral health problems should be routinely screened in this population since they exacerbate dysphagia.
e20623 Background: Malignant spinal cord compression (MSCC) is a major oncological complication. ... more e20623 Background: Malignant spinal cord compression (MSCC) is a major oncological complication. The management of Impending Malignant Spinal Cord Compression (IMSCC) remains unclear. Radiotherapy (RT) is often the sole management of both entities. Our aim was to prospectively evaluate the functional outcome of MSCC and IMSCC. Methods: All pts with MSCC and IMSCC treated by RT in our institution were screened for 2 national trials (ICORG 05–03/07–11). Non-eligible pts were prospectively evaluated and followed with assessment of mobility (modified Tomita scale) and sphincter function (continence/ incontinence/catheter) at baseline and 5 weeks posttreatment. Results: From 08/07 to 11/08, 54 pts [23 IMSCC, 31 MSCC] were followed. 31 pts were male. The median age was 60.5 y (30–86). The primary tumours were haematological [13 pts], lung [10], prostate [8], renal cell [6] and breast [5]. 51 pts had diagnostic MRI. The compression level was cervical in 6 pts, thoracic in 27, lumbosacral i...
INTRODUCTION Which neoadjuvant treatment for locally advanced thoracic oesophagus (TE) or gastro-... more INTRODUCTION Which neoadjuvant treatment for locally advanced thoracic oesophagus (TE) or gastro-oesophageal junction carcinoma is best remains an open question. Randomised controlled trials variously accrued patients with adenocarcinoma and squamous cell carcinoma, making strong conclusions hard to obtain. The primary objective of this individual participant data meta-analysis was to investigate the effect of neoadjuvant chemotherapy on overall survival (OS). PATIENTS AND METHODS Eligible trials should have closed to accrual before 2016 and compared neoadjuvant chemotherapy and surgery (CS) to surgery alone. All relevant published and unpublished trials were identified via searches of electronic databases, conference proceedings and clinical trial registers. The main end-point was OS. Investigators were contacted to obtain the individual patient data, which was recorded, harmonised and checked. A random-effects Cox model, stratified by trial, was used for meta-analysis and subgroup analyses were preplanned. RESULTS 16 trials were identified as eligible. Individual patient data were obtained from 12 trial and 2478 patients. CS was associated with an improved OS versus surgery, hazard ratio (HR) = 0.83 [0.72-0.96], p < 0.0001, translating to an absolute benefit of 5.7% at 5-years from 16.8% to 22.5%. Treatment effects did not vary substantially between adenocarcinoma (HR = 0.73 [0.62-0.87]) and squamous cell carcinoma (HR = 0.91 [0.76-1.08], interaction p = 0.26). A somewhat more pronounced effect was observed in gastro-oesophageal junction (HR = 0.68 [0.50-0.93]) versus TE (HR = 0.87 [0.75-1.00], interaction p = 0.07). CS was also associated with a greater disease-free survival (HR = 0.74 [0.64-0.85], p < 0.001). CONCLUSIONS Neoadjuvant chemotherapy conferred a better OS than surgery alone and should be considered in all anatomical location and histological subtypes.
International Journal of Radiation Oncology*Biology*Physics
In patients receiving definitive stereotactic body radiation therapy (SBRT) for presumably node-n... more In patients receiving definitive stereotactic body radiation therapy (SBRT) for presumably node-negative, early-stage nonsmall cell lung cancer (NSCLC), many patients are staged with PET-CT alone. The role of invasive nodal staging with either bronchoscopy plus endobronchial ultrasound (EBUS) or mediastinoscopy in patients undergoing PET prior to definitive lung SBRT is uncertain. We sought to characterize the impact of nodal staging modality on clinical outcomes after SBRT for early NSCLC. Materials/Methods: Patients receiving definitive SBRT for T1-2N0 NSCLC that were determined to be node-negative by either PET plus invasive nodal staging (EBUS or mediastinoscopy) or PET alone were identified using a single-institution prospective registry. All patients received 3-5 fraction SBRT with a biologically effective dose (BED10) of 100 Gy. Patients who did not undergo pre-SBRT PET, received adjuvant systemic therapy, or who were treated with additional SBRT courses for synchronous or metachronous NSCLC were excluded from the current study. Multivariable logistic regression was performed to identify which variables were independently associated with invasive mediastinal staging. Variables evaluated included staging, age, gender, ethnicity, central versus peripheral location, stage, and histology. Results: A total of 651 patients treated from 2005 e 2016 met the above inclusion criteria. Invasive nodal staging was performed in 15.2% of patients (nZ99) with either EBUS (nZ 78) or mediastinoscopy (nZ 21). Median age at SBRT was 75.3 years (range, 49.3 e 88.8). Median follow up was 19.4 months, and median survival was 28.5 months for all patients. Factors predictive of increased likelihood to receive invasive nodal staging on multivariable analysis were young age (OR for increasing age 0.968; 95% CI 0.945 e 0.990), white race (OR for non-white 0.540; 0.304 Z 0.958), female patients (OR 1.629; 95% CI 1.031 e 2.575), central location (OR 1.978; 95% CI 1.218 e 3.211) and squamous histology (OR 2.564; 95% CI 1.243 e 5.287). On multivariable analysis, nodal and/or distant failure was not significantly different between PET alone (crude failure rate, 23.6%) versus invasive nodal staging (25.4%, pZ0.714) in this patient cohort. Conclusion: Most patients with early stage NSCLC treated with definitive SBRT did not undergo invasive nodal staging, and we identify several factors predictive of its use. There was no significant difference in nodal or distant failure based on type of nodal staging utilized.
Purpose To recommend a specific headrest, customized or standard, for head and neck radiotherapy ... more Purpose To recommend a specific headrest, customized or standard, for head and neck radiotherapy patients in our institution based primarily on an evaluation of set-up accuracy, taking into account a comparison of patient comfort, staff and patient satisfaction, and resource implications. Methods and materials Between 2008 and 2009, 40 head and neck patients were randomized to either a standard (Arm A, n = 21) or customized (Arm B, n = 19) headrest, and immobilized with a customized thermoplastic mask. Set-up accuracy was assessed using electronic portal images (EPI). Random and systematic set-up errors for each arm were determined from 668 EPIs, which were analyzed by one Radiation Therapist. Patient comfort was assessed using a visual analogue scale (VAS) and staff satisfaction was measured using an in-house questionnaire. Resource implications were also evaluated. Results The difference in set-up errors between arms was not significant in any direction. However, in this study the...
BackgroundRadiotherapy (RT) is a key treatment modality in the curative treatment of patients wit... more BackgroundRadiotherapy (RT) is a key treatment modality in the curative treatment of patients with non-small cell lung cancer (NSCLC). Incorrect definition of the gross, or clinical, target volume is a common source of error which can lead to a reduced probability of tumour control.ObjectiveThis was a pilot and a phase II study. The pilot evaluated the technical feasibility of integrating positron emission tomography–computed tomography (PET-CT) fusion. The primary outcome of the phase II study was to evaluate the safety of PET-CT scan–based RT by evaluating the rate of loco-regional recurrence outside the PET-CT planning target volume (PTV) but within conventional 3-D PTV.MethodsPatients underwent standard post-treatment follow-up, including repeated three monthly CT scans of the thorax. In case of loco-regional recurrence, three categories were considered, with only extra-PET scan PTV and intra-CT scan PTV recurrences considered as a failure. Our hypothesis was that the rate of these events would be < 10%.ResultsTwelve patients were recruited; the study closed early due to poor recruitment. The primary endpoint of the pilot was met; it was feasible to deliver a PET-CT-based plan to ≥ 60% of patients. Two patients had intra-PET scan PTV recurrences, six had extra-PET scan PTV and extra-CT, and three patients had both. Another patient had extra-PET scan PTV and extra-CT as well as extra-PET scan PTV and intra-CT scan PTV recurrence.Conclusion/advances in knowledgePET-based planning has the potential to reduce radiation treatment volumes because of the avoidance of mediastinal lymph nodes that are PET negative.
4067 Background: Defining the optimal neoadjuvant treatment for resectable locally advanced esoph... more 4067 Background: Defining the optimal neoadjuvant treatment for resectable locally advanced esophageal carcinoma remains an open question. The debate is fuelled by the fact that most of the available randomized clinical trials (RCT) accrued two histological subtypes (adenocarcinoma (AC) and squamous cell carcinoma (SCC)) and two anatomical locations (TE and GEJ). The aim of this individual patient data (IPD) meta-analysis was to investigate the effect of preoperative chemotherapy on survival with a specific focus on histological subtypes and anatomical locations. Methods: Were eligible published or unpublished RCT closed to accrual before December 2015 and comparing neoadjuvant chemotherapy (CS) to primary surgery (S), identified by electronic database, conference proceedings and clinical trial register. All analyses were conducted on IPD obtained from trial Investigators. The Primary endpoint was overall survival (OS), Secondary endpoints were disease-free survival (DFS) with a 6-m...
Context. Dysphagia is usually associated with malignancies of the head, neck, and upper gastroint... more Context. Dysphagia is usually associated with malignancies of the head, neck, and upper gastrointestinal tract but also occurs in those with tumors outside anatomic swallow regions. It can lead to aspiration pneumonia, malnutrition, reduced quality of life, and psychosocial distress. No studies have yet reliably described dysphagia prevalence in those with malignancies outside anatomic swallow regions. Objective. The objective of this study was to establish the prevalence and predictors of dysphagia in adults with solid malignancies outside the head, neck, and upper gastrointestinal tract. Methods. A cross-sectional, observational study using consecutive sampling was conducted. There were 385 participants (mean age 66 AE 12 years) with 21 different primary cancer sites from two acute hospitals and one hospice. Locoregional disease was present in 33%, metastatic in 67%. Dysphagia was screened by empirical questionnaire and confirmed through swallow evaluation. Demographic and clinical predictors were determined by univariate and multivariate binary regression. Results. Dysphagia occurred in 19% of those with malignancies outside anatomic swallow regions. Prevalence was 30% in palliative care and 32% in hospice care. Dysphagia was most strongly associated with cough, nausea, and worse performance status. It was also associated with lower quality of life and nutritional difficulties. Conclusion. Dysphagia was common and usually undiagnosed before study participation. It occurred at all disease stages but coincided with functional decline. It may therefore represent a cancer frailty marker. Oncology and palliative care services should routinely screen for this symptom. Timely dysphagia identification and management may improve patient well-being and prevent adverse effects like aspiration pneumonia and weight loss.
This paper reviews the anatomical spread and failure patterns of surgical Stage I endometrial can... more This paper reviews the anatomical spread and failure patterns of surgical Stage I endometrial cancer. The controversial aspects of the optimal adjuvant treatment are presented. An attempt is made to identify the most effective management approach based on the pertinent literature data.
Impending malignant spinal cord compression (IMSCC) may be defined as compression of the thecal s... more Impending malignant spinal cord compression (IMSCC) may be defined as compression of the thecal sac, without any visible pressure on the spinal cord itself. Although there is a perception that IMSCC patients have a better prognosis and less severe clinical symptoms than true malignant spinal cord compression (MSCC) patients, these factors have never been documented in the literature.PurposeTo record the characteristics, management and functional outcome of a group of patients with IMSCC, who were treated with radiotherapy in our institution, and compare these parameters with similar data on MSCC patients.Materials and methodsData (gender, age, primary oncological diagnosis, pain, performance status and neurological status) were prospectively collected for 28 patients. Patients were then followed up post treatment to document their response to treatment and treatment-related toxicity.ResultsThe median survival of our group of IMSCC patients is similar to that of an MSCC patient. In a...
Nous avons cherche dans ce bref tour d'horizon de la radiotherapie des tumeurs digestives en ... more Nous avons cherche dans ce bref tour d'horizon de la radiotherapie des tumeurs digestives en 1994 a repondre concretement aux questions qui reviennent le plus souvent sur ce sujet: quelle est la place de la radiotherapie a cote de la chimiotherapie dans la prise en charge therapeutique de ces malades? Quels sont les indications reconnues de la radiotherapie, et quelles sont les voies de recherche? Nous montrons que la radiotherapie est utilisee chez pres des deux tiers des malades adresses dans un service de cancerologie pour traitement d'une tumeur digestive. Les principales indications reconnues sont passees en revue: cancer du rectum, cancer du canal anal, et a un moindre degre cancer de l'œsophage et du pancreas. Enfin, les principaux axes de recherche sont decrits, en particulier associations radiotherapiechimiotherapie, radiotherapie per-operatoire et radiotherapie des tumeurs hepato-biliaires
The purpose of this study was to evaluate the interobserver variability in the contouring of the ... more The purpose of this study was to evaluate the interobserver variability in the contouring of the gross tumor volume (GTV) on magnetic resonance (MR) imaging and computed tomography (CT) for colorectal liver metastases in the setting of SABR. Methods and Materials: Three expert radiation oncologists contoured 10 GTV volumes on 3 MR imaging sequences and on the CT image data set. Three metrics were chosen to evaluate the interobserver variability: the conformity index, the DICE coefficient, and the maximum Hausdorff distance (HDmax). Statistical analysis of the results was performed using a 1-sided permutation test. Results: For all 3 metrics, the MR liver acquisition volume acquisition (MR LAVA) showed the lowest interobserver variability. Analysis showed a significant difference (P < .01) in the mean DICE, an overlap metric, for MR LAVA (0.82) and CT (0.74). The HDmax that highlights boundary errors also showed a significant difference (P = .04) with MR LAVA having a lower mean HDmax (7.2 mm) compared with CT (5.7 mm). The mean HDmax for both MR single shot fast spin echo (SSFSE) (19.3 mm) and diffusion weighted image (9.5 mm) showed large interobserver variability with MR SSFSE having a mean HDmax of 19.3 mm. A volume comparison between MR LAVA and CT showed a significantly higher volume for small GTVs (<5 cm 3) when using MR LAVA for contouring in comparison to CT. Conclusions: This study reported the lowest interobserver variability for the MR LAVA, thus indicating the benefit of using MR to complement CT when contouring GTV for colorectal liver metastases.
Background: The role of stereotactic radiosurgery (SRS) in the treatment of limited numbers of br... more Background: The role of stereotactic radiosurgery (SRS) in the treatment of limited numbers of brain metastases in selected breast cancer patients is well-established. Aims: To analyse outcome from a single institutional experience with SRS, to identify any significant prognostic factors and to assess the influence of Her-2, estrogen receptor status, and prescribed dose on outcome. Methods: The medical records of 56 patients treated at in a single institution between 2009 and 2014 were reviewed. Demographic, treatment related and outcome data were analyzed to identify prognostic factors in this patient population. The primary endpoints were overall survival and local control. Secondary endpoint was distant intra-cranial progression-free survival. Results: The median follow-up time for the entire cohort was 10.33 months (1.25-97.28). The overall median survival was 12.5months (95%CI= 5.8-19.2), with 53.3%, and 35.8% surviving at 1-and 2-years post-SRS. After adjustment for the effect of Her 2 status, uncontrolled extra-cranial disease at the time of SRS predicted for shorter survival (HR for death = 3.1, 95% CI= 1.4-6.9, p = 0.006). At the time of death, 75% of the patients had active, uncontrolled intra-cranial disease, with 56% these patients presenting intra-cranial disease only. Sustained local control was observed in 56 (59.6%) of 94 treated metastases. In univariate analysis, Her2 status, ERHer2 group status?, and prescribed SRS dose were highly significant for local progression free-survival (LPFS). After adjustment for the effect of Her 2 status, patients receiving 12-16 Gy can expect shorter LPFS than those receiving 18-20 Gy (HR = 1.7, 95% CI = 1.0-2.8, p = 0.043). After adjustment for the effect of dose group, patients with Her 2 negative cancer can expect shorter LPFS than those with Her 2 positive cancer (HR = 2.6, 95% CI = 1.5-4.4, p < 0.0005). Use of prior WBRT did not impact survival, local or distant intra-cranial progression-free survival. Armstrong et al. SRS Brain Metastases Breast Primary Conclusions: Survival outcome is similar to the published literature. Improved outcomes are observed in patients with Her 2-positive, controlled extracranial disease at the time of SRS and higher SRS dose delivered. Achieving intra-cranial control appears to be an important factor for the survival of the breast cancer patients in the era of targeted therapies.
PURPOSE Fluorouracil (5-FU) continuous infusion is superior to 5-FU bolus in patients with advanc... more PURPOSE Fluorouracil (5-FU) continuous infusion is superior to 5-FU bolus in patients with advanced colorectal cancer, but the survival difference between the two treatments is small and, therefore, the difference in toxicity profile is crucial in choosing a treatment for individual patients. MATERIALS AND METHODS We conducted a meta-analysis of all randomized trials that compared 5-FU bolus with 5-FU CI, based on individual data from 1,219 patients, to compare the toxicity of the two schedules of 5-FU administration and to identify predictive factors for toxicity. The toxicities considered were World Health Organization (WHO) grade 3 to 4 anemia, thrombopenia, leukopenia, neutropenia, nausea/vomiting, diarrhea, mucositis, and hand-foot syndrome. RESULTS Hematologic toxicity, mainly neutropenia, was more frequent with 5-FU bolus than with 5-FU CI (31% and 4%, respectively; P < .0001). Hand-foot syndrome was less frequent with 5-FU bolus than with 5-FU CI (13% and 34%, respectivel...
TPS317 Background: Malignant Spinal Cord Compression (MSCC) represents the 2nd most common cancer... more TPS317 Background: Malignant Spinal Cord Compression (MSCC) represents the 2nd most common cancer- related neurological complication, with an estimated 1 to 6% lifetime risk for all cancer patients (pts). Radiotherapy (RT) is broadly used in treatment of MSCC, and has been occasionally proposed in context of re-irradiation. Due to increased survival and use of RT, the number of pts developing MSCC in previously irradiated areas is increasing (Thirion, 2008). Preclinical and clinical data suggest that the spinal cord maximal tolerable cumulative radiation dose (MTD) depends on the received radiation schedules (total dose, dose-per-fraction [#]) and interval between treatments (Nieder, 2006). The efficacy and toxicity, especially the risk of radiation-induced myelopathy (RIM), of re-irradiation for MSCC has not been prospectively evaluated. The objective of ICORG 07-11 is to establish the efficacy and safety of a radiobiological based re-irradiation strategy in pts with MSCC occurring in a previously irradi...
Backgrounds: In addition to its curative use for early stage lung cancer, stereotactic ablative r... more Backgrounds: In addition to its curative use for early stage lung cancer, stereotactic ablative radiotherapy is also indicated for pulmonary metastatic disease. Aims of this study were to retrospectively analyze treatment outcomes and to find prognostic factors for survivals. Methods: Treatment outcomes and toxicities of 85 cases of SABR in 72 patients were retrospectively reviewed from September 2012 to April 2015. Prognostic factors were analyzed using Cox proportional hazards regression. Results: The local failure-free survival rate at 2 years was 98%. Of the case, 1-year and 2-year progression-free survival rates were 62% and 48%, and overall survival rates were 90% and 72%, respectively. Multivariate analyses demonstrated that controlled primary cancer (P = 0.01), absence of extra-pulmonary metastatic disease (P < 0.01) and disease-free interval longer than 1 year (P < 0.01) favorably affected progression-free survival. Furthermore, the absence of extra-pulmonary metastatic disease (P < 0.01) increased overall survival as well. Grade 1 or 2 radiation pneumonitis was found in 37 cases, and Grade 1 chest wall pain was found in 1 case. Conclusions: Stereotactic ablative radiotherapy demonstrated good local control with tolerable adverse effects for pulmonary metastasis. The presence or absence of extra-pulmonary metastasis was found to be prognostic factor of mortality after stereotactic ablative radiotherapy treatment.
Introduction: In 2007 ESTRO proposed a revision and harmonisation of the core curricula for radia... more Introduction: In 2007 ESTRO proposed a revision and harmonisation of the core curricula for radiation oncologists, medical physicists and RTTs to encourage harmonised education programmes for the professional disciplines, to facilitate mobility between EU member states, to reflect the rapid development of the professions and to secure the best evidence-based education across Europe. Material and methods: Working parties for each core curriculum were established and included a broad representation with geographic spread and different experience with education from the ESTRO Educational Committee, local representatives appointed by the National Societies and support from ESTRO staff. Results: The revised curricula have been presented for the ESTRO community and endorsement is ongoing. All three curricula have been changed to competency based education and training, teaching methodology and assessment and include the recent introduction of the new dose planning and delivery techniques and the integration of drugs and radiation. The curricula can be downloaded at http://www.estro-education.org/europeantraining/Pages/EuropeanCurricula.aspx. Conclusion: The main objective of the ESTRO core curricula is to update and harmonise training of the radiation oncologists, medical physicists and RTTs in Europe. It is recommended that the authorities in charge of the respective training programmes throughout Europe harmonise their own curricula according to the common framework.
Background and Purpose: To prospectively assess the feasibility and efficacy of a hypofractionate... more Background and Purpose: To prospectively assess the feasibility and efficacy of a hypofractionated accelerated radiotherapy regimen (72 Gy in 24 daily fractions, 3Gy per fraction) in patients (pts) with non-resectable non-small-cell lung cancer (NSCLC). Material and Methods: We included 25 pts with a histologically or cytologically proven NSCLC, with KPS $ 70 and # 10% weight loss over prior three months, and with tumour stage I/II medically inoperable (9 pts) or non-resectable stage III a/b without pleural effusion (16 pts). Eleven pts received induction chemotherapy. No more than 30% of the combined lung volume could receive more than 25 Gy and the maximal biological effective dose to the spinal cord was maintained below 44 Gy. Results: No grade-4 acute toxicity event was reported. Two pts had a treatment break because of grade-3 acute oesophagitis. Twenty-two pts were evaluable for long-term toxicity (median follow-up ¼ 9.7 months, range 4 to 30.2 months). There were 4 Grade-1 pulmonary and 2 Grade-1 oesophageal long-term toxicity events. Twenty-two pts were evaluable for tumour response with 7 complete and 8 partial responses, 5 stable diseases and 2 progressive diseases. The actuarial 1-year overall and thoracic-progression-free survival rates were 68% and 72% respectively. Conclusions: This study demonstrates the feasibility of the experimental radiotherapy schedule, however more data are needed to confirm its efficacy.
Context. Dysphagia is common in cancer, but underlying pathophysiology and manifestations within ... more Context. Dysphagia is common in cancer, but underlying pathophysiology and manifestations within patients are unknown. Objectives. To examine dysphagia characteristics in those with solid malignancies outside the head, neck and upper gastrointestinal tract. Methods. Seventy-three individuals with dysphagia (46 male, 27 female, aged 37-91) were recruited from a parent trial conducted in two acute hospitals and one hospice. Cranial nerve function, Oral Health Assessment Tool (OHAT), Mann Assessment of Swallowing Ability (MASA) and Functional Oral Intake Scale (FOIS) evaluated swallow profile. Results. Only 9/73 (12%) had documented dysphagia prior to study enrollment. MASA risk ratings found n=61/73 (84%) with dysphagia risk and n=22/73 (30%) with aspiration risk. Food texture modification was required for n=34/73 (47%), fluid texture modification for n=1/73 (1%). Compensatory strategies for food were needed by n=13/73 (18%) and for fluids by n=24/73 (33%). Cranial nerve deficits were present in n=43/73 (59%). Oral health problems were common, with xerostomia in two-thirds. Worse dysphagia on MASA was associated with disease progression, affecting hospice, and palliative care the most. Worse performance status was indicative of poorer MASA raw score (P<0.001, OR 2.2, 95% CI 1.5−3.4), greater risk of aspiration (P=0.005, OR 2.1, 95% CI 1.3-3.6) and lower FOIS (P=0.004, OR 2.0, 95% CI 1.2−3.2). Conclusion. Dysphagia management in those with cancer requires robust assessment to uncover clinically important needs like food texture modification and safe swallowing advice. Better assessment tools should be developed for this purpose. Oral health problems should be routinely screened in this population since they exacerbate dysphagia.
e20623 Background: Malignant spinal cord compression (MSCC) is a major oncological complication. ... more e20623 Background: Malignant spinal cord compression (MSCC) is a major oncological complication. The management of Impending Malignant Spinal Cord Compression (IMSCC) remains unclear. Radiotherapy (RT) is often the sole management of both entities. Our aim was to prospectively evaluate the functional outcome of MSCC and IMSCC. Methods: All pts with MSCC and IMSCC treated by RT in our institution were screened for 2 national trials (ICORG 05–03/07–11). Non-eligible pts were prospectively evaluated and followed with assessment of mobility (modified Tomita scale) and sphincter function (continence/ incontinence/catheter) at baseline and 5 weeks posttreatment. Results: From 08/07 to 11/08, 54 pts [23 IMSCC, 31 MSCC] were followed. 31 pts were male. The median age was 60.5 y (30–86). The primary tumours were haematological [13 pts], lung [10], prostate [8], renal cell [6] and breast [5]. 51 pts had diagnostic MRI. The compression level was cervical in 6 pts, thoracic in 27, lumbosacral i...
INTRODUCTION Which neoadjuvant treatment for locally advanced thoracic oesophagus (TE) or gastro-... more INTRODUCTION Which neoadjuvant treatment for locally advanced thoracic oesophagus (TE) or gastro-oesophageal junction carcinoma is best remains an open question. Randomised controlled trials variously accrued patients with adenocarcinoma and squamous cell carcinoma, making strong conclusions hard to obtain. The primary objective of this individual participant data meta-analysis was to investigate the effect of neoadjuvant chemotherapy on overall survival (OS). PATIENTS AND METHODS Eligible trials should have closed to accrual before 2016 and compared neoadjuvant chemotherapy and surgery (CS) to surgery alone. All relevant published and unpublished trials were identified via searches of electronic databases, conference proceedings and clinical trial registers. The main end-point was OS. Investigators were contacted to obtain the individual patient data, which was recorded, harmonised and checked. A random-effects Cox model, stratified by trial, was used for meta-analysis and subgroup analyses were preplanned. RESULTS 16 trials were identified as eligible. Individual patient data were obtained from 12 trial and 2478 patients. CS was associated with an improved OS versus surgery, hazard ratio (HR) = 0.83 [0.72-0.96], p < 0.0001, translating to an absolute benefit of 5.7% at 5-years from 16.8% to 22.5%. Treatment effects did not vary substantially between adenocarcinoma (HR = 0.73 [0.62-0.87]) and squamous cell carcinoma (HR = 0.91 [0.76-1.08], interaction p = 0.26). A somewhat more pronounced effect was observed in gastro-oesophageal junction (HR = 0.68 [0.50-0.93]) versus TE (HR = 0.87 [0.75-1.00], interaction p = 0.07). CS was also associated with a greater disease-free survival (HR = 0.74 [0.64-0.85], p < 0.001). CONCLUSIONS Neoadjuvant chemotherapy conferred a better OS than surgery alone and should be considered in all anatomical location and histological subtypes.
International Journal of Radiation Oncology*Biology*Physics
In patients receiving definitive stereotactic body radiation therapy (SBRT) for presumably node-n... more In patients receiving definitive stereotactic body radiation therapy (SBRT) for presumably node-negative, early-stage nonsmall cell lung cancer (NSCLC), many patients are staged with PET-CT alone. The role of invasive nodal staging with either bronchoscopy plus endobronchial ultrasound (EBUS) or mediastinoscopy in patients undergoing PET prior to definitive lung SBRT is uncertain. We sought to characterize the impact of nodal staging modality on clinical outcomes after SBRT for early NSCLC. Materials/Methods: Patients receiving definitive SBRT for T1-2N0 NSCLC that were determined to be node-negative by either PET plus invasive nodal staging (EBUS or mediastinoscopy) or PET alone were identified using a single-institution prospective registry. All patients received 3-5 fraction SBRT with a biologically effective dose (BED10) of 100 Gy. Patients who did not undergo pre-SBRT PET, received adjuvant systemic therapy, or who were treated with additional SBRT courses for synchronous or metachronous NSCLC were excluded from the current study. Multivariable logistic regression was performed to identify which variables were independently associated with invasive mediastinal staging. Variables evaluated included staging, age, gender, ethnicity, central versus peripheral location, stage, and histology. Results: A total of 651 patients treated from 2005 e 2016 met the above inclusion criteria. Invasive nodal staging was performed in 15.2% of patients (nZ99) with either EBUS (nZ 78) or mediastinoscopy (nZ 21). Median age at SBRT was 75.3 years (range, 49.3 e 88.8). Median follow up was 19.4 months, and median survival was 28.5 months for all patients. Factors predictive of increased likelihood to receive invasive nodal staging on multivariable analysis were young age (OR for increasing age 0.968; 95% CI 0.945 e 0.990), white race (OR for non-white 0.540; 0.304 Z 0.958), female patients (OR 1.629; 95% CI 1.031 e 2.575), central location (OR 1.978; 95% CI 1.218 e 3.211) and squamous histology (OR 2.564; 95% CI 1.243 e 5.287). On multivariable analysis, nodal and/or distant failure was not significantly different between PET alone (crude failure rate, 23.6%) versus invasive nodal staging (25.4%, pZ0.714) in this patient cohort. Conclusion: Most patients with early stage NSCLC treated with definitive SBRT did not undergo invasive nodal staging, and we identify several factors predictive of its use. There was no significant difference in nodal or distant failure based on type of nodal staging utilized.
Purpose To recommend a specific headrest, customized or standard, for head and neck radiotherapy ... more Purpose To recommend a specific headrest, customized or standard, for head and neck radiotherapy patients in our institution based primarily on an evaluation of set-up accuracy, taking into account a comparison of patient comfort, staff and patient satisfaction, and resource implications. Methods and materials Between 2008 and 2009, 40 head and neck patients were randomized to either a standard (Arm A, n = 21) or customized (Arm B, n = 19) headrest, and immobilized with a customized thermoplastic mask. Set-up accuracy was assessed using electronic portal images (EPI). Random and systematic set-up errors for each arm were determined from 668 EPIs, which were analyzed by one Radiation Therapist. Patient comfort was assessed using a visual analogue scale (VAS) and staff satisfaction was measured using an in-house questionnaire. Resource implications were also evaluated. Results The difference in set-up errors between arms was not significant in any direction. However, in this study the...
BackgroundRadiotherapy (RT) is a key treatment modality in the curative treatment of patients wit... more BackgroundRadiotherapy (RT) is a key treatment modality in the curative treatment of patients with non-small cell lung cancer (NSCLC). Incorrect definition of the gross, or clinical, target volume is a common source of error which can lead to a reduced probability of tumour control.ObjectiveThis was a pilot and a phase II study. The pilot evaluated the technical feasibility of integrating positron emission tomography–computed tomography (PET-CT) fusion. The primary outcome of the phase II study was to evaluate the safety of PET-CT scan–based RT by evaluating the rate of loco-regional recurrence outside the PET-CT planning target volume (PTV) but within conventional 3-D PTV.MethodsPatients underwent standard post-treatment follow-up, including repeated three monthly CT scans of the thorax. In case of loco-regional recurrence, three categories were considered, with only extra-PET scan PTV and intra-CT scan PTV recurrences considered as a failure. Our hypothesis was that the rate of these events would be < 10%.ResultsTwelve patients were recruited; the study closed early due to poor recruitment. The primary endpoint of the pilot was met; it was feasible to deliver a PET-CT-based plan to ≥ 60% of patients. Two patients had intra-PET scan PTV recurrences, six had extra-PET scan PTV and extra-CT, and three patients had both. Another patient had extra-PET scan PTV and extra-CT as well as extra-PET scan PTV and intra-CT scan PTV recurrence.Conclusion/advances in knowledgePET-based planning has the potential to reduce radiation treatment volumes because of the avoidance of mediastinal lymph nodes that are PET negative.
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