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INTRODUCTION The aim of this study was to evaluate the use of post-mastectomy hypofractionationed radiation therapy (HFRT) for breast cancer in Victoria, Australia. METHODS This is a population-based cohort of women with breast cancer who received post-mastectomy RT to the chest wall with or without nodal irradiation between 2012 and 2017. HFRT was defined as

Prostate-specific membrane antigen (PSMA) PET/CT is increasingly used in patients with biochemical recurrence post prostatectomy to detect local recurrence and metastatic disease at low PSA levels. The aim of this study was to assess patterns of disease detection, predictive factors and safety using [18F]DCFPyL PET/CT versus diagnostic CT in patients being considered for salvage radiotherapy with biochemical recurrence post prostatectomy. We conducted a prospective trial recruiting 100 patients with detectable PSA post prostatectomy (PSA 0.2–2.0 ng/mL) and referred for salvage radiotherapy from August 2018 to July 2020. All patients underwent a PSMA PET/CT using the [18F]DCFPyL tracer and a diagnostic CT. The detection rates of [18F]DCFPyL PET/CT vs diagnostic CT were compared and patterns of disease are reported. Clinical patient and tumour characteristics were analysed for predictive utility. Thirty-day post-scan safety is reported. Of 100 patients recruited, 98 were suitable for analysis with a median PSA of 0.32 ng/mL. [18F]DCFPyL PET/CT was positive 46.4% and equivocal 5.2%, compared to 15.5% positivity for diagnostic CT. Local recurrence was detected on [18F]DCFPyL PET/CT in 28.5%, nodal disease in 27.5% and bony metastases in 6.1% of patients. Both ISUP grade group (p 0.2 ng/mL should be considered for [18F]DCFPyL PET/CT scan. Australian New Zealand Clinical Trials Registry Number: ACTRN12618001530213 ( http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375932&isReview=true )

Introduction Neoadjuvant radiotherapy (NART) as part of a multi-modality approach for locally advanced breast cancer (LABC) requires further investigation. Importantly, this approach may allow for a single-staged surgical procedure, with mastectomy and immediate autologous reconstruction. Multiple other potential benefits of NART include improved pathological downstaging of breast disease, reduced overall treatment time, elimination of time period with breast tissue deficit and improved patient satisfaction. Methods This is a retrospective multi-institutional review of patients with LABC and high-risk breast disease undergoing NART. Eligible patients sequentially underwent neoadjuvant chemotherapy (NACT) with or without HER2-targeted therapy, NART, followed by mastectomy with immediate autologous breast reconstruction (BR) 4- to 6 weeks post-completion of radiotherapy. Patient and tumour characteristics were analysed using descriptive statistics. Surgical complications were assessed using the Clavien-Dindo Classification (Ann Surg 2004; 240: 205). Results From 3/2013 to 9/2019, 153 patients were treated with NART. The median age was 47 years (IQR 42-52), with median body mass index of 27. Eighteen patients experienced Grade 3 acute surgical complications. This included 13 Grade 3B breast-site events and 9 Grade 3B donor-site events, where further surgical intervention was required for management of wound infection, wound dehiscence, flap or mastectomy skin necrosis, haematoma and internal mammary venous anastomotic thrombosis. No autologous flap loss was observed. Conclusion Neoadjuvant radiotherapy facilitates a single-stage surgical procedure with mastectomy and immediate autologous BR, eliminating the delay to reconstructive surgery and thus shortening a woman's breast cancer journey. The findings of this review support the use of NART, with comparable rates of surgical complications to standard sequencing.

Introduction: Adjuvant radiotherapy (RT), including regional lymph node (RLN) irradiation is an important treatment in early stage breast cancer patients after breast-conserving surgery both the Radiation Therapy Oncology Group (RTOG) and European Society for Radiotherapy and Oncology (ESTRO). Our primary aim was to quantitatively compare target volumes delineated by ROs, to assess if either guideline has superior contouring reproducibility. Methods: Three ROs contoured breast clinical target volumes (CTVs), axillary lymph node levels 1-3, supraclavicular and internal mammary nodal (CTVn_IMN) volumes for 8 post-operative patients using the ESTRO and RTOG guidelines for each patient. The inter-observer variability in contouring was measured by the generalized Dice Similarity Coefficient (DSC). Mean DSC values were calculated to compare the common volume accuracy between observers.ss Results: The breast CTV contours showed the highest level of agreement between the ROs within each guideline (ESTRO DSC mean 0.92±0.04 and RTOG DSC mean 0.90±0.03). Due to the small standard deviation in DSC values, this difference of 0.02 was found to be statistically significant (p=0.031). The mean DSC for CTVn_IMN was 0.63 (±0.10) for ESTRO and 0.62 (±0.20) for RTOG guidelines, showing the least level of agreement for both guidelines. Within the axillary nodal volumes, level 1 showed the greatest agreement among the ROs for both ESTRO and RTOG guidelines with a mean DSC of 0.81 (±0.08) & 0.82 (±0.06) respectively. The range of mean DSC values for ESTRO and RTOG guidelines was 0.66-0.92 and 0.62-0.90 respectively. Conclusion: Overall, neither guideline showed a notable improvement in reproducibility between ROs.

Summary Background BIG 3-07/TROG 07.01 is an international, multicentre, randomised, controlled, phase 3 trial evaluating tumour bed boost and hypofractionation in patients with non-low-risk ductal carcinoma in situ following breast-conserving surgery and whole breast radiotherapy. Here, we report the effects of diagnosis and treatment on health-related quality of life (HRQOL) at 2 years. Methods The BIG 3-07/TROG 07.01 trial is ongoing at 118 hospitals in 11 countries. Women aged 18 years or older with completely excised non-low-risk ductal carcinoma in situ were randomly assigned, by use of a minimisation algorithm, to tumour bed boost or no tumour bed boost, following conventional whole breast radiotherapy or hypofractionated whole breast radiotherapy using one of three randomisation categories. Category A was a 4-arm randomisation of tumour bed boost versus no boost following conventional whole breast radiotherapy (50 Gy in 25 fractions over 5 weeks) versus hypofractionated whole breast radiotherapy (42·5 Gy in 16 fractions over 3·5 weeks). Category B was a 2-arm randomisation between tumour bed boost versus no boost following conventional whole breast radiotherapy, and category C was a 2-arm randomisation between tumour bed boost versus no boost following hypofractionated whole breast radiotherapy. Stratification factors were age at diagnosis, planned endocrine therapy, and treating centre. The primary endpoint, time to local recurrence, will be reported when participants have completed 5 years of follow-up. The HRQOL statistical analysis plan prespecified eight aspects of HRQOL, assessed by four questionnaires at baseline, end of treatment, and at 6, 12, and 24 months after radiotherapy: fatigue and physical functioning (EORTC QLQ-C30); cosmetic status, breast-specific symptoms, arm and shoulder functional status (Breast Cancer Treatment Outcome Scale); body image and sexuality (Body Image Scale); and perceived risk of invasive breast cancer (Cancer Worry Scale and a study-specific question). For each of these measures, tumour bed boost was compared with no boost, and conventional whole breast radiotherapy compared with hypofractionated whole breast radiotherapy, by use of generalised estimating equation models. Analyses were by intention to treat, with Hochberg adjustment for multiple testing. This trial is registered with ClinicalTrials.gov , NCT00470236 . Findings Between June 1, 2007, and Aug 14, 2013, 1208 women were enrolled and randomly assigned to receive no tumour bed boost (n=605) or tumour bed boost (n=603). 396 of 1208 women were assigned to category A: conventional whole breast radiotherapy with tumour bed boost (n=100) or no boost (n=98), or to hypofractionated whole breast radiotherapy with tumour bed boost (n=98) or no boost (n=100). 447 were assigned to category B: conventional whole breast radiotherapy with tumour bed boost (n=223) or no boost (n=224). 365 were assigned to category C: hypofractionated whole breast radiotherapy with tumour bed boost (n=182) or no boost (n=183). All patients were followed up at 2 years for the HRQOL analysis. 1098 (91%) of 1208 patients received their allocated treatment, and most completed their scheduled HRQOL assessments (1147 [95%] of 1208 at baseline; 988 [87%] of 1141 at 2 years). Cosmetic status was worse with tumour bed boost than with no boost across all timepoints (difference 0·10 [95% CI 0·05–0·15], global p=0·00014, Hochberg-adjusted p=0·0016); at the end of treatment, the estimated difference between tumour bed boost and no boost was 0·13 (95% CI 0·06–0·20; p=0·00021), persisting at 24 months (0·13 [0·06–0·20]; p=0·00021). Arm and shoulder function was also adversely affected by tumour bed boost across all timepoints (0·08 [95% CI 0·03–0·13], global p=0·0033, Hochberg adjusted p=0·045); the difference between tumour bed boost and no boost at the end of treatment was 0·08 (0·01 to 0·15, p=0·021), and did not persist at 24 months (0·04 [–0·03 to 0·11], p=0·29). None of the other six prespecified aspects of HRQOL differed significantly after adjustment for multiple testing. Conventional whole breast radiotherapy was associated with worse body image than hypofractionated whole breast radiotherapy at the end of treatment (difference –1·10 [95% CI –1·79 to –0·42], p=0·0016). No significant differences were reported in the other PROs between conventional whole breast radiotherapy compared with hypofractionated whole breast radiotherapy. Interpretation Tumour bed boost was associated with persistent adverse effects on cosmetic status and arm and shoulder functional status, which might inform shared decision making while local recurrence analysis is pending. Funding National Health and Medical Research Council, Susan G Komen for the Cure, Breast Cancer Now, OncoSuisse, Dutch Cancer Society.

Stereotactic body radiotherapy has emerged as one of the preferred treatments for patients with spine metastases, with the potential for long-term control from lesion irradiation. Post-treatment vertebral compression fractures are a known complication of this therapy, contributing to worsening pain and reduced quality of life, sometimes requiring surgical intervention. This review explores the current knowledge of post-radiotherapy fractures, in terms of the rates and associated predictive factors. A search of databases including Medline, Embase and the Cochrane Library was conducted using keywords such as 'vertebral compression fracture', 'stereotactic body radiotherapy' and 'spine metastases'. The search was limited to published studies up to March 2019, reporting clinical outcomes including both the post-treatment fracture rate and statistical identification of associated risk factors. Rates of post-treatment fractures ranged from 4 to 39%. A variety of factors were found to increase the risk, including the appearance of lytic vertebral disease, degree of pre-existing compression, spinal malalignment, increased dose per fraction and a Spinal Instability Neoplastic Score >6. This knowledge can enable clinicians to counsel patients when considering management options for spine metastases, maintaining the balance between local tumour control and the risk of subsequent fracture.

Radiation therapy (RT) is an established treatment for breast cancer and is associated with a reduction in disease recurrence and death. Thoracic RT is associated with incidental cardiac exposure, which can lead to a spectrum of radiation-induced heart disease (RIHD) ([1][1]). The mechanisms

In recent years, we have seen the integration of magnetic resonance imaging (MRI) simulators into radiotherapy centres and the emergence MR linear accelerators (MR-linac). Currently, there are limited studies to demonstrate the clinical effectiveness of MRI guided radiotherapy (MRIgRT) treatment for breast cancer patients. The objective of this scoping review was to identify and map the existing evidence surrounding the clinical implementation of MRIgRT for breast cancer patients. We also identified the challenges and knowledge gaps in the literature. The scoping review was reported in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) extension for Scoping Reviews reporting guidelines. Titles and abstracts were screened by two independent reviewers. Quantitative and qualitative data were extracted and summarised using thematically organised tables. Results identify that accelerated partial breast irradiation (APBI) is the most common form of treatment for MRIgRT. The presence of the magnet does not affect target coverage or violate organ at risk (OAR) constraints compared to standard radiotherapy methods. Consideration is advised for skin and chest wall (CW) due to the electron return effect (ERE) and areas such as armpit and chin due to the electron stream effect (ESE). Clinically, bolus has been used to protect and prevent unwanted dose in these areas. Overall treatment for APBI on the MR-linac is feasible.

BACKGROUND Image-guided radiotherapy (IGRT) has significantly improved the precision in which radiotherapy is delivered in cancer treatment. Typically, IGRT uses bony landmarks and key anatomical structures to locate the tumor. Recent studies have demonstrated the feasibility of peri-tumor fiducials in enabling even more accurate delineation of target and normal tissue. The use of gold coils as fiducials in gastrointestinal tumors has been extensively studied. However, placement requires expertise and specialized endoscopic ultrasound equipment. This article reports the long-term outcomes of using a standard gastroscopy to inject liquid fiducials for the treatment of oesophageal and gastric tumors with IGRT. AIM To assess the long-term outcomes of liquid fiducial-guided IGRT in a cohort of oesophageal and gastric cancer patients. METHODS A retrospective cohort study of consecutive adults with Oesophagogastric cancers referred for liquid fiducial placement before definitive/neo-adjuvant or palliative IGRT between 2013 and 2021 at a tertiary hospital in Melbourne, Australia was conducted. Up to four liquid fiducials were inserted per patient, each injection consisting of 0.2-0.5mL of a 1:1 mixture of iodized oil (Lipiodol; Aspen Pharmacare) and n-butyl 2-cyanoacrylate (Histoacryl®; B. Braun). A 23-gauge injector (Cook Medical) was used for the injection. All procedures were performed by or under the supervision of a gastroenterologist. Liquid fiducial-based IGRT (LF-IGRT) consisted of computer-assisted direct matching of the fiducial region on cone-beam computerised tomography at the time of radiotherapy. Patients received standard-IGRT (S-IGRT) if fiducial visibility was insufficient, consisting of bone match as a surrogate for tumor position. Radiotherapy was delivered to 54Gy in 30 fractions for curative patients and up to 45Gy in 15 fractions for palliative treatments. RESULTS 52 patients were referred for liquid fiducial placement within the study period. A total of 51 patients underwent liquid fiducial implantation. Of these a total of 31 patients received radiotherapy. Among these, the median age was 77.4 years with a range between 57.5 and 88.8, and 64.5% were male. Twenty-seven out of the 31 patients were able to have LF-IGRT while four had S-IGRT. There were no complications after endoscopic implantation of liquid fiducials in our cohort. The cohort overall survival (OS) post-radiotherapy was 19 mo (range 0 to 87 mo). Whilst the progression-free survival (PFS) post-radiotherapy was 13 mo (range 0 to 74 mo). For those treated with curative intent, the median OS was 22.0 mo (range 0 to 87 mo) with a PFS median of 14.0 mo (range 0 to 74 mo). Grade 3 complication rate post-radiotherapy was 29%. CONCLUSION LF-IGRT is feasible in 87.1% of patients undergoing liquid fiducial placement through standard gastroscopy injection technique. Our cohort has an overall survival of 19 mo and PFS of 13 mo. Further studies are warranted to determine the long-term outcomes of liquid-fiducial based IGRT.

Introduction To examine the long-term outcomes of high dose rate brachytherapy boost (HDR-BT) combined with external beam radiotherapy (EBRT) for intermediate and high-risk prostate cancer patients. Methods Data from 95 patients who underwent combined EBRT (50.4 Gy) and HDR-BT to the prostate between 2010 and 2017 were retrospectively analysed. Biochemical progression free survival (bPFS), local recurrence free survival (LRFS), metastatic free survival (MFS) and overall survival (OS) were estimated using Kaplan-Meier method. Regression analysis was conducted to identify important predictors of outcomes. Results A total of 24 patients received an initial HDR-BT dose of 18 Gy in three fractions, with the remaining 71 patients receiving 16 Gy in two fractions as per departmental protocol changes. Most patients (88%) received androgen deprivation therapy. A transurethral resection of the prostate (TURP) was performed in 14 patients and hydrogel spacers (HS) were used in 30 patients. Median follow-up was 58 months. The 5-year bPFS, LRFS, MFS and OS were 92%, 100%, 92% and 88%. Univariate regression revealed no statistical association between patient characteristics and time to relapse (all P > 0.1). Late > grade 2 genitourinary (GU) toxicity was 6.3%. The use of HS or prior TURP had no impact on late GU toxicity. Late Grade 1 gastrointestinal (GI) toxicity was 5.3%. Conclusion The combined HDR-BT with EBRT resulted in excellent bPFS. The cumulative risk of late GU and GI toxicity was low and can be further improved with preventative strategies such as a pre-emptive TURP and/or HS insertion.

Purpose To report on rectal dosimetric and toxicity outcomes of intermediate and high-risk prostate cancer patients undergoing combined high-dose-rate (HDR) brachytherapy and external beam radiotherapy (EBRT) with or without hydrogel spacer (HS) insertion. Material and methods A total of 97 patients were analyzed in this study, with 32 patients (33%) who had HS insertion compared with a preceding group of 65 patients (67%) without HS. HS safety, the dosimetric effects on organs at risk (rectal, urethral, penile bulb, and bladder) as well as gastrointestinal (GI) and genitourinary toxicity were evaluated and compared between the two groups. Results The median prostate-rectal separation achieved with HS was 10 mm (range, 5-14 mm). There were no post-operative complications following HS insertion. Patients with HS had significantly lower radiation dose to the rectum across all rectal dose volumes from rV30 to rV80, whether in absolute volume (cc) or as percentage of contoured OAR (p < 0.001). There was also significantly less acute > grade 1 GI toxicity (12.5% vs. 30.8%, p = 0.05) and a trend towards less late grade 1 GI toxicity (0% vs. 7.7%; p = 0.11) in the HS group compared to the non-HS group. Conclusions Insertion of HS in prostate cancer patients receiving combined HDR and EBRT is safe and has resulted in a significant radiation dose reduction to the rectum, resulting in significantly less acute GI toxicity and a trend towards less late GI toxicity.

Purpose Prostate specific membrane antigen (PSMA) PET/CT is increasingly used in men with biochemical recurrence post-prostatectomy to detect local recurrence and metastatic disease at low PSA levels. The aim of this study was to assess patterns of disease detection, predictive factors and safety using 18F-DCFPyL PET/CT versus diagnostic CT in men being considered for salvage radiotherapy with biochemical recurrence post-prostatectomy.Methods We conducted a prospective trial recruiting 100 patients with biochemical failure post-prostatectomy (PSA 0.2-2.0ng/mL) in men referred for salvage radiotherapy from August 2018 to July 2020. All patients underwent a PSMA PET/CT using the 18F-DCFPyL tracer and a diagnostic CT. The detection rates of 18F-DCFPyL PET/CT vs diagnostic CT were compared and patterns of disease are reported. Clinical patient and tumour characteristics were analysed for predictive utility. Thirty-day post-scan safety is reported.Results Of 100 patients recruited, 98 were suitable for analysis with a median PSA of 0.32ng/mL. 18F-DCFPyL PET/CT was positive or equivocal in 52% compared to 19.6% for diagnostic CT. Local recurrence was detected on 18F-DCFPyL PET/CT in 29.2%, nodal disease was seen in 29.6% and bony metastases in 7.1%. Both ISUP grade group (p = 0.003) and pre-scan PSA (p = 0.061) were significant predictors of 18F-DCFPyL PET/CT positivity, and logistic regression generated probabilities combining the two showed improved prediction rates. No significant safety events were reported post 18F-DCFPyL administration.Conclusions 18F-DCFPyL PET/CT increases detection of disease in men with biochemical recurrence post-prostatectomy compared to diagnostic CT. Men being considered for salvage radiotherapy with a PSA > 0.2ng/mL should be considered for 18F-DCFPyL PET/CT scan.Clinical Trial Registration Australian New Zealand Clinical Trials Registry Number: ACTRN12618001530213. Registration date 13.9.2018 http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375932&isReview=true

Background In recent years, we have seen the incorporation of magnetic resonance imaging (MRI) simulators into radiotherapy centres and the emergence of the new technology of MR linacs. However, the significant health care resources associated with this advanced technology impact immediate widespread use and availability. There are currently limited studies to demonstrate the clinical effectiveness and inform decision-making on the use of MRI in radiotherapy. The objective of this scoping review is to identify and map the existing evidence surrounding the clinical implementation of MRI-guided radiotherapy in patients with breast cancer. It also aims to identify challenges and knowledge gaps in the literature. Methods We will perform a comprehensive search in MEDLINE and EMBASE databases from January 2010 onwards. Grey literature sources will include the WHO International Clinical Trials Registry Platform. We will include systematic reviews, randomised and non-randomised controlled studies published in English. Literature should examine the use of magnetic resonance imaging-guided radiotherapy in adults with breast cancer, regardless of cancer stage or severity. Two reviewers will independently screen all titles, abstracts and full-text reports. Data will be extracted and summarised using qualitative (e.g. content and thematic analysis) methods and presented in tables. Discussion The results from this review will consolidate the evidence surrounding MRI-guided radiotherapy for breast cancer, contributing to the development and optimisation of patient selection, simulation, planning, treatment delivery, quality assurance and research, to help improve patient outcomes, cancer care and treatment for women with breast cancer. Systematic review registration The protocol is available on Open Science Framework at DOI 10.17605/OSF.IO/8TEV6

Background Radiation therapy to upper abdominal sites is technically challenging due to motion of tumors and surrounding organs resulting from normal respiration. Breath-hold, using an Active Breathing Coordinator is one strategy used to reduce motion in these tumor sites. Though widely used, no studies have prospectively compared the different breath-hold techniques (inspiration, deep-inspiration and expiration) using ABC in the same patient cohort. Methods Patients planned for radiation therapy to upper abdominal tumors are invited to participate in this prospective study. Participants attempt three breath hold techniques: inspiration, deep-inspiration and expiration breath-hold, in random order. kV fluoroscopy images of the dome of diaphragm are taken of five consecutive breath-holds in each technique. Reproducibility and stability of tumour position are measured, and used to select the technique with which to proceed to planning and treatment. Reproducibility at planning and each treatment fraction is measured, along with breath hold time, treatment efficiency and patient experience. Discussion The screening method was validated after the first three participants. This screening process may be able to select the best breath-hold technique for an individual, which may lead to improved reproducibility. The screening process is being piloted as a prospective clinical trial. Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR): 12618001691235. Registered 12th October 2018. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=376109&isReview=true.

Aims Intensity-modulated radiotherapy (IMRT) is increasingly used in the treatment delivery of chemoradiotherapy in anal cancer with the ability to reduce toxicity. We report on 4 year outcomes since the introduction of IMRT and identify the most predictive bowel organ at risk that correlates with acute diarrhoea. Materials and methods Fifty-eight patients receiving definitive chemoradiotherapy for squamous or basaloid cell anal carcinoma (T1-4NanyM0) were reviewed. Fifty-four per cent of patients had stage III disease and most (79%) were treated with a dose of 54 Gy in 30 fractions. Patient acute gastrointestinal toxicity was recorded using Common Terminology Criteria of Adverse Events (CTCAE) diarrhoea grading. Four different methods of bowel were re-contoured for each patient and correlated with acute diarrhoea. Locoregional control and overall survival were analysed. Results CTCAE grade 3 or more diarrhoea occurred in 11/58 patients (19%). Seven patients did not complete treatment; 10 patients (17%) required a treatment break of 3 or more days. ‘Bowel cavity’ was the best predictor of acute grade 3 toxicity using volume (P = 0.002) or volume to bowel cavity in 5 Gy bins (V5–V50Gy); P 300 cm3 predicts a 42% risk. Four year progression-free survival was 84% (95% confidence interval 73–92%) and overall survival was 88% (95% confidence interval 75–95%). Conclusion Chemoradiation using IMRT provides excellent local control and acceptable acute gastrointestinal toxicity. Bowel cavity is the most sensitive predictor for grade 3 versus grade 0–2 diarrhoea, with any volume receiving 5–50 Gy discriminatory.

The purpose of this study was to determine whether the degree of prostate to rectal separation using a hydrogel spacer (HS) and its effect on decreasing rectal dose can be reproduced in the community setting. Thirty one patients with cT1-3aN0M0 prostate adenocarcinoma receiving radical radiotherapy to 78 Gy were recruited to the study. The primary endpoint was the proportion of patients achieving at least 25% reduction in volume of rectum receiving 70 Gy (rV70). Other endpoints included degree of prostate to rectum separation, HS insertion-related adverse events and the proportion of patients with grade 1 or worse acute or late gastrointestinal (GI) and genitourinary (GU) toxicity. All patients had successful insertion of their HS with no peri-operative toxicity. The mean prostate–rectal separation achieved was 10.5 mm. Twenty nine (93.5%) patients achieved a reduction in rV70 of at least 25%. Acute grade 1 GI toxicity was reported in 3 patients. All symptoms had resolved by 3 months post RT. Late grade 1 GI toxicity was reported in one patient (3.2%) with bowel frequency occurring at 6 months and resolving by 12 months post RT. There was no grade 2 or 3 acute or late GI toxicity seen. In conclusion, this study illustrates that the application and benefits of HS on reducing GI rectal dose endpoints and toxicities during prostate cancer RT can be reliably replicated in a community setting similar to centres participating in the randomised trial under high quality assurance trial monitoring.

Objective To report on the dosimetric benefits and late toxicity outcomes after injection of hydrogel spacer (HS) between the prostate and rectum for patients treated with prostate radiotherapy (RT). Patients and methods In all, 76 patients with a clinical stage of T1-T3a prostate cancer underwent general anaesthesia for fiducial marker insertion plus injection of the HS into the perirectal space before intensity-modulated RT (IMRT) or volumetric-modulated arc RT (VMAT). HS safety, dosimetric benefits, and the immediate- to long-term effects of gastrointestinal (GI) toxicity were assessed. Results There were no postoperative complications reported. The mean (range) prostate size was 66.0 (25.0-187.0) mm. Rectal dose volume parameters were observed and the volume of rectum receiving 70 Gy (rV70 ), 75 Gy (rV75 ) and 78 Gy (rV78 ) was 7.8%, 3.6% and 0.4%, respectively. In all, 21% of patients (16/76) developed acute Grade 1 GI toxicities, but all were resolved completely by 3 months after treatment; whilst, 3% of patients (2/76) developed late Grade 1 GI toxicities. No patients had acute or late Grade ≥2 GI toxicities. Conclusion Injection of HS resulted in a reduction of irradiated rectal dose volumes along with minimal GI toxicities, irrespective of prostate size.

Purpose To report the 5-year biochemical relapse-free survival (BRFS), overall survival (OS), and long-term toxicity outcomes of patients treated with low-dose-rate (LDR) brachytherapy as monotherapy for low- to intermediate-risk prostate cancer. Material and methods Between 2004 and 2011, 371 patients were treated with LDR brachytherapy as monotherapy. Of these, 102 patients (27%) underwent transurethral resection of the prostate (TURP) prior to implantation. Follow-up was performed every 3 months for 12 months, then every 6 months over 4 years and included prostate specific antigen evaluation. The biochemical relapse-free survival (BRFS) was defined according to the Phoenix criteria. Acute and late toxicities were documented using the Common Terminology Criteria for Adverse Events version 4.0. The BRFS and OS estimates were calculated using Kaplan-Meier plots. Univariate and multivariate analyses were performed to evaluate outcomes by pre-treatment clinical prognostic factors and radiation dosimetry. Results The median follow-up of all patients was 5.45 years. The 5-year BRFS and OS rates were 95% and 96%, respectively. The BRFS rates for patients with Gleason score (GS) > 7 and GS ≤ 6 were 96% and 91% respectively (p = 0.06). On univariate analysis, T1 and T2 staging, risk-group classification, and prostate volumes had no impact on survival at 5 years (p > 0.1). Late grade 2 and 3 genitourinary (GU) toxicities were observed in 10% and 5% of patients respectively. Additionally, patients with prior TURP had a greater incidence of late grade 2 or 3 urinary retention (p = 0.001). There were 14 deaths in total; however, none were attributed to prostate cancer. Conclusions LDR brachytherapy is an effective treatment option in low- to intermediate-risk prostate cancer patients. We observed low biochemical relapse rates and minimal GU toxicities several years after treatment in patients with or without TURP. However, a small risk of urinary retention was observed in some patients.

Introduction Delayed breast reconstructions are preferred if post mastectomy radiotherapy is indicated due to lower complication rates compared to immediate permanent implant or autologous reconstructions (AR) but cosmetic outcomes are inferior. Radiotherapy has a deleterious effect on implants and autologous tissue and often an interim tissue expander is place which has inherent pain and complications. However, neoadjuvant radiotherapy (NART) prior to surgery allows for definitive oncological surgery to be performed with an immediate AR in a single operation and the avoidance of a temporary expander. The aim of this study is to assess the safety and downstaging impact of NART. Methods This is a prospective review of patients who underwent NART at GenesisCare Victoria, the Austin and the Alfred hospital. 59 LABC patients (median age 49.2 years) were divided into two groups; clinically staged and pathologically staged for reporting. There were 15 pathologically staged patients (pStage 2A-3C) and 43 clinically staged patients (cStage 2A-3B). All patients initially underwent NACT, followed by NART (median dose 50.4Gy in 28 fractions) to the breast, supraclavicular fossa and level 3 axilla with or without coverage of their Level 1 and 2 axilla, and/or internal mammary nodes. Approximately 6 weeks after completing NART, patients underwent definitive surgery and AR. Results All patients completed their NART with minimal toxicity and no break in treatment. 55 patients had a skin-sparing mastectomy (SSM) and 3 patients had a modified radical mastectomy. All clinically staged patients underwent an AD. ARs with a DIEP flap were performed in the majority of patients (51). The average length of hospitalisation was 6.2 days. The Miller Payne (MP) scoring index was used to record pathological responses in clinically staged patients. Overall 36 patients achieved significant downstaging of their disease, with MP scores of 5/5 for 20 and 4/5 for 16. Only 1 patient failed to achieve any downstaging with a MP score of 1/5. All 12 Her2 positive patients, 3/5 Triple negative patients and 5/26 Luminal A/B patients achieved a MP score of 5/5. All patients achieved R0 resection margins. This included 6 patients who had initial cT4 disease (cT4a X2, cT4b X1 and cT4d X3). 15 patients had initial cN2/3 disease and all successfully underwent their axillary dissections with R0 resections achieved. 10/15 had no involved axillary nodes with significant scarring seen in 6. 5/15 had residual involved nodes with significant scarring seen in 3 patients. Post surgical toxicities were graded using Clavien-Dindo classification. 8 significant grade 3 toxicities were seen in 6 patients, with no grade 4 or 5 toxicities. No patients developed DVT or PE. No flap losses were seen. Median follow up is 23 months. Cosmesis was rated as good to excellent in all cases. 1 patient developed simultaneous loco-regional and distant recurrence with another 3 patients developing distant metastases only. Conclusion This review demonstrated that NART is a safe technique, which has not lead to an increase in surgical complication rates or resulted in a detriment in cosmetic outcome. NART can achieve a shorter, simpler reconstructive journey for patients. Citation Format: Baker C, Chao MW, Jassal S, Neoh D, Bevington E, Hyett A, Grinsell D, Loh SW, Zantuck N, Stoney D, Foley C, Law M, Chew G, Yu V, Cheng M, Guerrieri M, Taylor K, Chipman M, Cokelek M, Lim Joon D, Foroudi F. The safety and pathological impact of neoadjuvant radiotherapy for local advanced breast cancer undergoing mastectomy and autologous reconstruction [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-11-16.

PURPOSE/OBJECTIVE(S) To report on rectal dosimetry and toxicity outcomes in men with prostate cancer (PCa) treated with I125 low-dose rate brachytherapy (LDR-BT) with or without hydrogel (HS) or hyaluronic acid (HA) rectal spacer (RS) insertion. The working hypothesis is the increased retroprostatic distance achieved from RS insertion results in reduced rectal dosimetry and subsequent reduction in rectal toxicity outcomes. MATERIALS/METHODS Seventy consecutive men treated with LDR-BT between December 2017 and July 2019 were included in this study, twenty-eight (40%) men had RS insertion according to the preference of the referring urologist, compared to a group of forty-two men (60%) without RS. Descriptive statistics were used to compare the RS safety, dosimetric effects on organs at risk (rectum and urethra), as well as gastrointestinal (GI) and genitourinary (GU) toxicities (assessed using the CTCAEv4) between the two groups. RESULTS The mean prostate-rectal separation with RS at mid prostate was 9.9mm (SD 2.8mm). There were no post-operative complications for RS insertion. There was significantly reduced rectal dosimetry in RS group vs non-RS group, the median RV100 was 0cc (IQR = 0-0.0cc) vs 0.4cc (IQR = 0.1-1.1cc) (P < 0.001) respectively. Mean rectal D1cc and D2cc were 52.4% vs 84.2% (P < 0.001) and 45.7% vs. 70.0% (P < 0.001) for RS and non-RS group respectively. There were no discernible differences in the mean urethral D20, D5, and D1. There were significantly less ≥ grade 1 acute and late GI toxicities in the RS group when compared to the non-RS group (0% vs 24% P = 0.004 for acute GI toxicity: 4% vs 33%, P = 0.003 for late GI toxicity). Strong association remained for RS with late GI toxicity (odds ratios < 0.2) even after accounting for the confounding effects of post-implant RV100, D1cc and D2cc. CONCLUSION Insertion of RS in men treated with LDR-BT is safe and results in significantly lower values in rectal dosimetry. The reduction in rectal dosimetry with RS insertion translates into significantly reduced rates of acute and late GI toxicities.

Background: Vesico-urethral anastomosis (VUA) is critical to the clinical target volume (CTV) in post-prostatectomy radiotherapy (PPRT), as it is the commonest site of recurrence. Typically, this is performed on a CT alone but guidelines recommend MRI. Objective: To evaluate the VUA spatial differences between CT (ctVUA) and MRI (mrVUA) and analyse its impact on the CT defined CTV (ctCTV) as recommended by published guidelines. Materials and methods: We identified 34 patients with a co-registered simulation CT and T2 weighted MRI. The VUA was located on CT and MRI whilst blinded to the opposing scan. The differences were analysed using Wilcoxon's Signed Rank Test. The mrVUA coverage was investigated using three ctCTV margins of 5 mm, 8 mm and 12 mm. Results: Median age was 63 years with 59% having pT3a disease and median Gleason score of 7. The mrVUA was coincident with the ctVUA in 12% and inferior in 88%. Median difference was 5 mm (010 mm) (P < 0.0001). Only a ctCTV margin of 12 mm would have encompassed all mrVUAs. A ctCTV margin of 8 mm and 5 mm resulted in 12% and 38% cases where the VUA was excluded from the ctCTV. Conclusions: MRI is important for the accurate delineation of VUA for PPRT. (C) 2017 Elsevier B.V. All rights reserved.

OBJECTIVES: To report the outcomes of stereotactic ablative body radiotherapy (SABR) in men with oligometastatic prostate cancer (PCa) diagnosed on prostate-specific membrane antigen (PSMA)-positron emission tomography/computed tomography (PET/CT), based on a single-institution experience and the published literature. PATIENTS AND METHODS: This was a retrospective cohort study of the first 20 consecutive men with oligometastatic PCa, treated with SABR in a single institution, who had biochemical recurrence after previous curative treatment (surgery/radiotherapy), had no evidence of local recurrence, were not on palliative androgen deprivation therapy (ADT), and had PSMA-PET/CT-confirmed oligometastatic disease (≤3 lesions). These men were treated with SABR to a dose of 30 Gy in three fractions for bone metastases, and 35-40 Gy in five fractions for nodal metastases. The outcomes of interest were: PSA response; local progression-free survival (LPFS); distant progression-free survival (DPFS); and ADT-free survival (ADTFS). A literature review was performed to identify published studies reporting on outcomes of PSMA-PET/CT-guided SABR. RESULTS: In our institutional cohort, 12 men (60%) had a decline in PSA post-SABR. One man had local progression 9.6 months post-SABR, with 12-month LPFS of 93%. Ten men had distant progression outside of their SABR treatment field, confirmed on PSMA-PET/CT, with 12-month DPFS of 62%, of whom four were treated with palliative ADT, two received prostate bed radiotherapy for prostate bed progression (confirmed on magnetic resonance imaging), and four received a further course of SABR (of whom one had further progression and was treated with palliative ADT). At last follow-up, six men (one with local progression and five with distant progression) had received palliative ADT. The 12-month ADTFS was 70%. Men with longer intervals between local curative treatment and SABR had better DPFS (P = 0.03) and ADTFS (P = 0.005). Four additional studies reporting on PSMA-PET/CT-guided SABR for oligometastatic PCa were identified and included in the review, giving a total of 346 patients. PSA decline was reported in 60-70% of men post-SABR. The 2-year LPFS, DPFS and ADTFS rates were 76-100%, 27-52%, and 58-62%, respectively. CONCLUSION: Our results showed that PSMA-PET/CT could have an important role in identifying men with true oligometastatic PCa who would benefit the most from metastases-directed therapy with SABR.

Aims Stereotactic body radiotherapy (SBRT) is a locally ablative therapy used for the treatment of patients with spine metastases. However, it is associated with higher rates of vertebral compression fractures (VCF) than conventionally fractionated palliative radiotherapy. The purpose of this study was to determine the rate of VCF following spine SBRT and to identify the risk factors associated with this outcome. Materials and methods We retrospectively reviewed patients treated at two Australian institutions from January 2015 to March 2019. Descriptive statistics were used to assess patient, tumour and treatment factors. The Log-rank test and Cox proportional hazards model were applied in univariate and multivariable analyses to identify factors associated with VCF, local control and overall survival. Results We evaluated 113 spinal segments from 84 patients, with a median follow-up time of 11.9 months. The median dose and fractionation utilised was 30 Gy in three fractions (67.3%), with a single-fraction rate of 0.9%. The median Spinal Instability Neoplastic Score (SINS) of the lesions was 4/18, with most (84.1%) being SINS stable, scoring between 0 and 6. Five VCFs were observed (three progression of pre-existing fractures and two de novo), a cumulative VCF risk of 4.4%. Four of five fractures occurred within the first year after treatment, with a median time to VCF of 9.2 months. A pre-existing VCF (P = 0.011) was associated with subsequent fracture on multivariable analysis, whereas all VCF segments displayed lytic disease appearance. All fractures were managed conservatively with analgesia, without requirement for subsequent surgical intervention. Conclusion SBRT to spine metastases is safe with respect to VCF, with rates around the lower limit observed in similar studies. Knowledge of factors that predispose to post-treatment fracture, such as pre-existing compression, lytic vertebral disease and SINS >6 will aid in the counselling and selection of patients for this therapy.

Introduction When irradiating the left breast, a small portion of the heart and left anterior descending coronary artery (LAD) are often included in the treatment field. Deep inspiration breath-hold (DIBH) techniques reduce dose to coronary structures, but are resource intensive and may not be tolerated by all patients. The aim of this study was to evaluate a simple multi-leaf collimator (MLC) modification technique with respect to target coverage and organ-at-risk sparing. Methods Forty nine patients with left-sided breast cancer, planned with a simultaneous integrated boost technique were retrospectively replanned with additional shielding of the LAD. Dose to the target volumes (whole breast and boost) and organs at risk (heart, ipsilateral lung and LAD) were assessed on both plans. Results Significant dose reductions were observed for all organs at risk when LAD shielding was introduced, with a reduction in mean LAD dose of 7.0 Gy, mean LAD planning risk volume (PRV) dose of 5.9 Gy, maximum LAD dose of 12 Gy and mean heart dose of 0.73 Gy. Target volume coverage was clinically acceptable for 96% of patients, using the left anterior descending coronary artery shielded plan (LADSP). No difference was observed between the standard plan (SP) and LADSP in nine patients (18%). Conclusions For selected patients, the implementation of a simple MLC shielding technique can reduce the dose to cardiac structures, whilst maintaining breast and boost volume dosimetry. This technique is simple to implement and may be used as an alternative to DIBH for those patients who are unable to fulfill the selection criteria, or departments who are not resourced to perform DIBH.

PurposeTo compare currently available non-three-dimensional methods (Response Evaluation Criteria in Solid Tumors [RECIST], European Association for Study of the Liver [EASL], modified RECIST [mRECIST[) with three-dimensional (3D) quantitative methods of the index tumor as early response markers in predicting patient survival after initial transcatheter arterial chemoembolization (TACE).Materials and methodsThis was a retrospective single-institution HIPAA-compliant and institutional review board-approved study. From November 2001 to November 2008, 491 consecutive patients underwent intraarterial therapy for liver cancer with either conventional TACE or TACE with drug-eluting beads. A diagnosis of hepatocellular carcinoma (HCC) was made in 290 of these patients. The response of the index tumor on pre- and post-TACE magnetic resonance images was assessed retrospectively in 78 treatment-naïve patients with HCC (63 male; mean age, 63 years ± 11 [standard deviation]). Each response assessment method (RECIST, mRECIST, EASL, and 3D methods of volumetric RECIST [vRECIST] and quantitative EASL [qEASL]) was used to classify patients as responders or nonresponders by following standard guidelines for the uni- and bidimensional measurements and by using the formula for a sphere for the 3D measurements. The Kaplan-Meier method with the log-rank test was performed for each method to evaluate its ability to help predict survival of responders and nonresponders. Uni- and multivariate Cox proportional hazard ratio models were used to identify covariates that had significant association with survival.ResultsThe uni- and bidimensional measurements of RECIST (hazard ratio, 0.6; 95% confidence interval [CI]: 0.3, 1.0; P = .09), mRECIST (hazard ratio, 0.6; 95% CI: 0.6, 1.0; P = .05), and EASL (hazard ratio, 1.1; 95% CI: 0.6, 2.2; P = .75) did not show a significant difference in survival between responders and nonresponders, whereas vRECIST (hazard ratio, 0.6; 95% CI: 0.3, 1.0; P = .04), qEASL (Vol) (hazard ratio, 0.5; 95% CI: 0.3, 0.9; P = .02), and qEASL (%) (hazard ratio, 0.3; 95% CI: 0.15, 0.60; P < .001) did show a significant difference between these groups.ConclusionThe 3D-based imaging biomarkers qEASL and vRECIST were tumor response criteria that could be used to predict patient survival early after initial TACE and enabled clear identification of nonresponders.

Introduction This is a retrospective study conducted to report the tumor control and late toxicity outcomes of patients with intermediate-risk prostate cancer undergoing combination external beam radiation therapy and low dose rate brachytherapy (LDR-PB). Methods and Materials Thirty-one patients received 45 Gray (Gy) of external beam radiation therapy to the prostate and seminal vesicles, together with a brachytherapy boost via a transperineal prostate implant of I125 (108 Gy). In addition, some patients received 6 months of androgen deprivation therapy depending on physician preference. Biochemical failure was defined using the Phoenix consensus definition of the nadir PSA +2 ng/mL. Toxicity was graded using the Common Terminology Criteria for Adverse Events version 4.0. Results The biochemical progression-free survival, metastases-free survival, and overall survival at 5 years were 87.1%, 96.3%, and 92%, respectively. The incidence of late grade ≥1 and ≥2 genitourinary (GU) toxicities were 54.8% and 6.5%, respectively. The incidence of late grade 3 GU toxicity was 6.5% with urinary retention occurring in two patients requiring either a bladder neck incision or transurethral resection of the prostate. The incidence of late grade ≥1 and 2 gastrointestinal toxicities were 19.4% and 6.5%, respectively. No patients developed grade 3 gastrointestinal toxicity. Conclusion Our small series has shown a high biochemical progression-free survival consistent with the ASCENDE-RT and NRG Oncology/RTOG0232 LDR-PB boost arms. In addition, the risk of late grade 3 GU toxicity is far lower than that reported by the ASCENDE-RT study but comparable to other LDR-PB boost and LDR alone reports in the literature. Therefore, we are comfortable to continue offering LDR-PB boost to our patients with intermediate-risk prostate cancer.

Objectives To review the use of fiducial markers and spacers in prostate radiotherapy (RT). Materials and Methods We reviewed the literature on the use of fiducial markers to improve accuracy in delivery of RT for prostate cancer. We discuss the rationale for fiducials, the types available, the procedures and complications. We also reviewed the current literature on the novel use of spacers to reduce rectal toxicity during prostate irradiation. Results Prostate motion is a significant problem both during and between RT treatments. Intraprostatic fiducials allow accurate prostate localisation ensuring RT treatment accuracy. Insertion of gold fiducials are a cost-effective marker that can be easily and quickly implanted and at least three fiducials are recommended. Severe complications from fiducial implantation are uncommon and marker migration is very rarely clinically significant. Spacers are a novel method to distance the rectum from the prostate during RT, reducing acute rectal toxicity, and have no detrimental impact on health-related quality of life. Conclusions Intraprostatic fiducials are now standard of care when delivering prostate RT and early data shows benefit of spacers in reducing RT rectal toxicity.

Radiation therapy (RT) is an established adjuvant treatment for breast cancer and is associated with a significant reduction in disease recurrence and death. Treatment of left sided breast cancer is associated with some incidental exposure of the heart to radiation which can lead to a spectrum of

Introduction Conventional clinical staging for prostate cancer has many limitations. This study evaluates the impact of adding MRI scans to conventional clinical staging for guiding decisions about radiotherapy target coverage. Methods This was a retrospective review of 115 patients who were treated between February 2002 and September 2005 with radical radiotherapy for prostate cancer. All patients had MRI scans approximately 2 weeks before the initiation of radiotherapy. The T stage was assessed by both conventional clinical methods (cT-staging) as well as by MRI (mT-staging). The radiotherapy target volumes were determined first based on cT-staging and then taking the additional mT staging into account. The number of times extracapsular extension or seminal vesicle invasion was incorporated into target volumes was quantified based on both cT-staging and the additional mT-staging. Results Extracapsular extension was incorporated into target volumes significantly more often with the addition of mT-staging (46 patients (40%) ) compared with cT-staging alone (37 patients (32%) ) (P = 0.002). Seminal vesicle invasion was incorporated into target volumes significantly more often with the addition of mT-staging (21 patients (18%) ) compared with cT-staging alone (three patients (3%) ) (P < 0.001). A total of 23 patients (20%) had changes to their target coverage based on the mT-staging. Conclusions MRI scans can significantly change decisions about target coverage in radical radiotherapy for prostate cancer.

Aims: This study compares the volumetric and spatial relationships of gross tumour volume (GTV) derived from CT (CT-GTV) and GTV derived from MRI (MR-GTV) to determine the utility of multi-modality imaging for radiotherapy treatment planning in rectal cancer. Methods and Materials: Fifteen patients with T3 rectal cancer were accrued over 18 months. The male : female ratio was 2:1. The average age was 60.3 years (range 38-79). All patients underwent a diagnostic MRI and CT and MRI simulation. Data sets were co-registered. A site specialised diagnostic radiologist contoured all volumes in consultation with a radiation oncologist. CT-GTV was contoured while blinded to MR data sets. MR-GTV was contoured independently 2-4 weeks later whilst blinded to its respective CT-GTV data. Tumour volumes were analysed for three anatomical subregions (sigmoid, rectal and anal). Reference points on tumour volumes were used for spatial comparison and analysis. Results: The mean CT-GTV/MR-GTV ratio was 1.2 (range 0.5-2.9). The tumour volume ratios for the rectal subregion were well correlated. CT-GTV provided adequate spatial coverage of tumour in reference to MR-GTV with the average mean discrepancy of 0.12 (range -0.08-0.38) or a maximum discrepancy of < 0.4 cm (1.54 standard deviation). CT-GTV coverage was inadequate for tumours with MRI evidence of anal and sigmoid invasion. Conclusions: Conventional simulation CT imaging provided a reasonable estimate of the GTV. Multi-modality imaging with staging MRI can assist target volume definition where there is involvement of the sigmoid and anorectal region and avoid geographic misses. The role of a simulation MRI may aid in this process but remains investigational.

Purpose To assess the correlation of 18F-FDG-PET (PET) response to pathological response after neoadjuvant chemoradiation (CRT) for locally advanced rectal cancer. Methods and materials Twenty patients with locally advanced rectal cancer were identified between 2001 and 2005. The median age was 57 years (range 37–72) with 14 males and 6 females. All patients were staged with endorectal ultrasound and/or MRI, CT, and PET. The clinical staging was T3N0M0 (16), T3N1M0 (2), and T3N0M1 (2). Restaging PET was performed after CRT, and prior to definitive surgery. The response on PET and pathology was assessed and correlated. Patient outcome according to PET response was also assessed. Results Following CRT, a complete PET response occurred in 7 patients, incomplete response in 10, and no response in 3 patients. At surgery, complete pathological response was recorded in 7 patients, incomplete response in 10 and no response in 3. There was a good correlation of PET and pathological responses in complete responders (5/7 cases) and non-responders (3/3 cases). After a median follow-up of 62 months (range 7–73), twelve patients were alive with no evidence of disease. All patients achieving complete metabolic response were alive with no evidence of disease, while as those who had no metabolic response, all died as a result of metastatic disease. Conclusions PET is a promising complementary assessment tool for assessing tumor response after CRT if there is a complete or no response. PET response may also predict for outcome.

Purpose Changes in F-18 fluorodeoxyglucose (FDG) uptake in normal tissues after chemoradiation therapy (CRT) potentially limit the ability of positron emission tomography (PET) to provide early assessment of therapeutic response. This study evaluated whether such changes negatively impact interpretation of posttherapy PET performed within 6 weeks of CRT completion and before definitive surgery in patients with locally advanced rectal cancer. The positive predictive value (PPV) and specificity of post-CRT PET, read clinically, was determined in 63 consecutive rectal cancer patients who had undergone preoperative CRT. Methods and Materials A schema for identifying and scoring postradiation effects on PET was prospectively defined and applied in a blinded manner. This was compared with initial clinical reporting of response. Histologic assessment of the operative specimens was used as the reference standard. Correlation between clinical proctitis during CRT and radiation changes on subsequent PET was also assessed. Results Clinical reporting of post-CRT PET yielded a high PPV (94%; 95% confidence interval, 89--100%) but may have been exaggerated by the low prevalence of complete tumor clearance (16%). The specificity was 80% with only two false-positive results. On blinded reading, significant post-CRT effects on PET were recorded in 4 of 63 patients (6% 95% confidence interval, 0–13%), but pattern recognition converted both false-positive PET results to a complete metabolic response. Clinical CRT proctitis was not correlated with PET findings. Conclusion Postradiation effects do not appear to significantly compromise the interpretation of PET for therapeutic response assessment. The proposed PET pattern of response may further improve the specificity of PET.

Die Standardbehandlung eines Rektumkarzinoms wird immer noch von den Ergebnissen randomisierter, klinischer Studien definiert, die den optimalen Zeitpunkt und den Einsatz von adjuvanter Chemotherapie und Bestrahlung im Vergleich mit einer Operation untersuchen. Die klinischen Problemstellungen, fur die nur begrenztes aktuelles Datenmaterial als Hilfestellung bei der Entscheidungsfindung zur Verfugung steht, finden sich bei Patienten mit Rektumkarzinom im hoheren Alter und/oder signifikanten Begleiterkrankungen sowie bei Patienten, die eine Operation ablehnen. An sechs australischen Kliniken wurde eine retrospektive Analyse von Rektumkarzinompatienten, die aufgrund eines sehr hohen operativen Risikos oder Verweigerung einer Operation ausschlieslich mit Bestrahlung oder einer Radiochemotherapie behandelt worden waren, durchgefuhrt. Identifiziert wurden 48 Patienten mit einem medianen Alter von 76 Jahren (49–94 Jahre), die zwischen August 1998 und Juni 2005 behandelt worden waren. 24 Patienten (50%) wurden als medizinisch inoperabel eingestuft, und 24 Patienten lehnten eine Operation ab. Die Behandlung bestand bei 36 Patienten aus einer Radiochemotherapie (mit 5-Fluorouracil) und bei zwolf Patienten aus ausschlieslicher Bestrahlung; 93% fuhrten die geplante Behandlung bis zum Ende durch. Bei 56% wurde ein komplettes klinisches Ansprechen und bei 30% ein partielles Ansprechen festgestellt. Bei einem medianen Follow-up von 49 Monaten zeigte sich bei 18 Patienten ein Fortschreiten der Erkrankung; dies betraf zehn von 24 Patienten in der medizinisch inoperablen Gruppe sowie acht von 24 Patienten in der Gruppe, die eine Operation verweigerte. Von den 25 verstorbenen Patienten waren 16 an der fortschreitenden Erkrankung und neun an nicht karzinombezogenen Ursachen gestorben. Radiochemotherapie oder ausschliesliche Bestrahlung stellt eine sichere Alternative dar, die bei medizinisch als inoperabel eingestuften oder eine Operation verweigernden Patienten in einem signifikant langeren progressionsfreien Uberleben und Gesamtuberleben resultiert. Letztendlich wird die Erkrankung allerdings bei vielen Patienten fortschreiten.

Purpose To assess the utility of FDG-PET in anal cancer for staging and impact on radiotherapy planning (RTP), response and detection of recurrent disease. Methods and materials Fifty histopathological anal cancer patients were reviewed between 1996 and 2006. The median age was 58 years (range 36-85) with 19 males:31females. Clinical assessment with CT was compared to PET. Impact on management, disease response, recurrence and metastases was evaluated. Results The non-PET staging was Stage I(8), Stage II(18), Stage III(22), and Stage IV(2)s. The primary was strongly FDG avid in 98% with non-excised tumors compared to CT (58%). PET upstaged 17% with unsuspected pelvic/inguinal nodal disease. Pre-treatment PET identified 11 additional by involved nodal groups in 48 patients causing RTP amendments in 19%. Post-treatment PETs at median 17 weeks (range 9–28) showed complete responses in 20 (80%) and 5 (20%) partial responses (PR). PRs were biopsy positive in 2 and negative in 3. Fifteen had follow-up scans of which all nine PETs detected recurrences were pathologically confirmed. Conclusions Anal cancer is FDG-PET avid. PET upstages 17% and changes the RTP in 19%. PET can aid in anal cancer staging and identification of residual disease, recurrent/metastatic disease but warrants further prospective studies.

The standard management of rectal cancer continues to be defined by the results of randomized, clinical trials exploring the optimal timing and use of adjuvant chemotherapy and radiation therapy in relation to surgery. The patient with rectal cancer who is elderly and/or has significant comorbidities and the patient who refuses surgery are clinical contexts for which there is limited current data to guide decision making. A retrospective analysis was performed at six Australian centers of patients with rectal cancer treated with radiation therapy or chemoradiation alone because of excessive operative risk or patient refusal of surgery. We identified 48 patients treated between August 1998 and June 2005 with a median age of 76 (range, 49–94) years. Twenty-four patients (50 percent) were considered medically inoperable and 24 patients refused surgery. Treatment was with chemoradiation (with 5-fluorouracil) in 36 patients and radiotherapy alone in 12 patients; 93 percent completed the planned therapy. A clinical complete response was seen in 56 percent and a partial response in 30 percent of patients. At a median follow-up of 49 months, 18 patients have disease progression, including 10 of 24 in the medically inoperable group and 8 of 24 in the refused surgery group. Of the 25 deceased patients, 16 died from progressive disease and 9 from noncancer causes. Chemoradiation or radiotherapy alone is a safe alternative that results in significant progression-free and overall survival times in patients who are considered medically inoperable or refuse to undergo surgery. Ultimately, however, many patients will progress.