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The role of radiotherapy (RT) in the approach of renal cellular carcinoma, renal pelvis and ureter is quite restricted. The aim of this study is to present a systematic review in order to situate the current status of RT in the management of these entities.

Purpose. To assess feasibility, efficacy, toxicity, and cosmetic results of intraoperative radiotherapy (IORT) with electrons delivered by standard linear accelerators (Linacs) during breast conserving surgeries for early infiltrating breast cancer (BC) treatment.Materials and Methods. A total of 152 patients with invasive ductal carcinoma (T≤3.0 cm) at low risk for local relapses were treated. All had unicentric lesions by imaging methods and negative sentinel node. After a wide local excision, 21 Gy were delivered on the parenchyma target volume with electron beams. Local recurrences (LR), survival, toxicity, and cosmetic outcomes were analyzed.Results. The median age was 58.3 years (range 40–85); median follow-up was 50.7 months (range 12–101.5). There were 5 cases with LR, 2 cases with distant metastases, and 2 cases with deaths related to BC. The cumulative incidence rates of LR, distant metastases, and BC death were 3.2%, 1.5%, and 1.5%, respectively. Complications were rare, and the cosmetic results were excellent or good in most of the patients.Conclusions. IORT with electrons delivered by standard Linacs is feasible, efficient, and well tolerated and seems to be beneficial for selected patients with early infiltrating BC.

To present local control, complications, and cosmetic outcomes of intraoperative radiation therapy (IORT) for early breast cancer, as well as technical aspects related to the use of a nondedicated linear accelerator.This prospective trial began in May of 2004. Eligibility criteria were biopsy-proven breast-infiltrating ductal carcinoma, age40 years, tumor3 cm, and cN0. Exclusion criteria were in situ or lobular types, multicentricity, skin invasion, any contraindication for surgery and/or radiation therapy, sentinel lymph node involvement, metastasis, or another malignancy. Patients underwent classic quadrantectomy with intraoperative sentinel lymph node and margins evaluation. If both free, the patient was transferred from operative suite to linear accelerator room, and IORT was delivered (21 Gy). Primary endpoint: local recurrence (LR); secondary endpoints: toxicities and aesthetics. Quality assurance involved using a customized shield for chest wall protection, applying procedures to minimize infection caused by patient transportation, and using portal films to check collimator-shield alignment.A total of 152 patients were included, with at least 1 year follow-up. Median age (range) was 58.3 (40-85.4) years, and median follow-up time was 50.7 (12-110.5) months. The likelihood of 5-year local recurrence was 3.7%. There were 3 deaths, 2 of which were cancer related. The Kaplan-Meier 5-year actuarial estimates of overall, disease-free, and local recurrence-free survivals were 97.8%, 92.5%, and 96.3%, respectively. The overall incidences of acute and late toxicities were 12.5% and 29.6%, respectively. Excellent, good, fair, and bad cosmetic results were observed in 76.9%, 15.8%, 4.3%, and 2.8% of patients, respectively. Most treatments were performed with a 5-cm collimator, and in 39.8% of the patients the electron-beam energy used was ≥12 MeV. All patients underwent portal film evaluation, and the shielding was repositioned in 39.9% of cases. No infection or anesthesia complications were observed.Local control with IORT was adequate, with low complication rates and good cosmetic outcomes. More than one-third of patients benefited from the "image-guidance" approach, and almost 40% benefited from the option of higher electron beam energies.

Background Clinically localized prostate cancer may be treated by different approaches of radiation therapy. The aim of this study was to report the results of disease control and toxicity in patients with clinically localized prostate cancer treated with high dose IMRT alone with 1 cm PTV posterior margin. Methods From September 2001 to April 2008, 140 patients with localized prostate cancer were treated with definitive IMRT (dose ≥ 74 Gy) without hormone therapy. Outcomes were measured from the conclusion of radiotherapy. Biochemical failure was defined as PSA nadir + 2.0 ng/dL. Toxicities were assessed using the NCI-CTCAE-version 3.0. Median follow-up was 58 months. Results Biochemical failure occurred in 13.6% of patients. Actuarial 5-year biochemical control rates were 91.7%, 82.5% and 85.9% for low-, intermediate-, and high-risk patients, respectively. Stage T2 patients presented a risk of biochemical failure almost three times higher than stage T1 (RR = 2.91; 95% CI: 1.04; 8.17). Distant metastases occurred in 3 (2%) patients. Five-year metastasis-free and overall survivals were 96% and 97.5%, respectively. Late grade 3 genitourinary and gastrointestinal toxicity rates were, respectively, 1.6% and 3%. Conclusion High-dose IMRT alone with 1 cm posterior PTV margin was effective and safe for patients with localized prostate cancer.

Intensity-modulated radiation therapy (IMRT) provides the possibility of dose-escalation with better normal tissue sparing. This study was performed to assess whether IMRT can improve clinical outcomes when compared with two-dimensional (2D-RT) or three-dimensional conformal radiation therapy (3D-CRT) in patients with head and neck cancer.Only prospective phase III randomized trials comparing IMRT with 2D-RT or 3D-CRT were eligible. Combined surgery and/or chemotherapy were allowed. Two authors independently selected and assessed the studies regarding eligibility criteria and risk of bias.Five studies were selected. A total of 871 patients were randomly assigned for 2D-RT or 3D-CRT (437), versus IMRT (434). Most patients presented with nasopharyngeal cancers (82%), and stages III/IV (62.1%). Three studies were classified as having unclear risk and two as high risk of bias. A significant overall benefit in favor of IMRT was found (hazard ratio - HR=0.76; 95% CI: 0.66, 0.87; p0.0001) regarding xerostomia scores grade 2-4, with similar loco-regional control and overall survival.IMRT reduces the incidence of grade 2-4 xerostomia in patients with head and neck cancers without compromising loco-regional control and overall survival.

1059Background: Several phase III trials of breast IORT have recently been published with findings that have generated significant controversy and discussion. As different techniques were used in these trials in a broad range of patients, it is unclear if the results obtained were due to differences in technique, type of radiation or patient selection. The goal of the current study was to review findings from studies using only electron IORT in appropriately selected patients considered suitable for APBI. Methods: We performed a literature search addressing the use of electron IORT as the sole radiation treatment for early stage breast cancer. Publications that delivered IORT prior to tumor excision, and those that did not deliver the prescription dose as deeply as the chest wall, were excluded. The ASTRO and ESTRO Consensus guidelines were used to select patients from these studies based upon society derived criteria for the application of APBI. ESTRO Good category differs from ASTRO Suitable in that it ...

Brachytherapy is an adequate option as monotherapy for localised prostate cancer. The objective of this study was to evaluate and compare biochemical failure free survival (BFFS) after low-dose-rate brachytherapy (LDRB) alone for patients with prostate cancer using ASTRO and Phoenix criteria, and detect prognostic factors.Data on 220 patients treated between 1998 and 2002 with LDRB were retrospectively analysed. Neoadjuvant hormone therapy was used in 74 (33.6%) patients.Median follow-up was 53.5 months (24-116). Five year BFFS was 83.0% and 83.7% using, respectively, the ASTRO and Phoenix criteria. Low -and intermediate- risk patients presented, respectively, 86.7% and 77.8% 5-year BFFS using the ASTRO definition (p=0.069), and 88.5% and 78.6% considering the Phoenix criteria (p=0.016). Bounce was observed in 66 (30%) patients. Multivariate analysis detected PSA at diagnosis10 ng/ml and less than 50% positive biopsy fragments as favourable prognostic factors, regarding BF using both criteria. For the Phoenix criteria, also Gleason score7 and low-risk group were identified as independent favourable prognostic factors.LDRB alone should be considered mostly for low-risk patients. PSA level was a strong independent prognostic factor. We support the use of the Phoenix criteria for detection of BF in patients submitted to LDRB alone.

The role of radiotherapy (RT) in the treatment of urinary bladder cancer has undergone several modifications along the last decades. In the beginning, definitive RT was used as treatment in an attempt to preserve the urinary bladder; however, the results were poor compared to those of radical surgery. Recently, many protocols have been developed supporting the use of multi-modality therapy, and the concept of organ preservation began to be reconsidered. Although phase III randomized clinical studies comparing radical cystectomy with bladder preservation therapies do not exist, the conservative treatment may present low toxicity and high indexes of complete response for selected patients. The aim of this study was to review the literature on the subject in order to situate RT in the current treatment of urinary bladder cancer.

Background: Mycosis fungoides (T-cell non-Hodgkin’s lymphoma) is a quite rare neoplasia, which follows an indolent course, characterized by presenting epidermotropism in spite that there is a possibility of compromise of structures like lymph nodes and visceral organs. Its incidence increases starting from the fourth decade of life with posterior drop after more or less the age of 80, having preference for men. Objective: To analyze the role of radiotherapy in the therapeutic approach of patients with diagnosis of mycosis fungoides. Conclusions: Radiotherapy is indicated for patients suffering from mycosis fungoides in all stages especially when the disease has affected more than 50% of the body surface. Starting from stage IB, total skin irradiation is employed with a dose of 30 to 36 Gy with boost at medical criterion.

ResumoA questão do término da vida é fonte de reflexões desde os primórdios da civilização e demanda diligências para a tentativa de seu enquadramento social ao longo da história do pensamento humano. Com o desenvolvimento e aprimoramento da medicina, podese modificar, na maioria das vezes, a história natural das doenças. É possível prolongar a vida e adiar o processo do morrer. Isso engendrou um novo protótipo médico em que há necessidade de se conviver e cuidar de pacientes gravemente enfermos, situação muitas vezes acompanhada de árduo sofrimento. A sociedade atribui ao médico a função de ser o responsável por debelar e vencer a morte. No contexto oncológico, essas questões surgem de forma salutar, uma vez que, em diversas situações, não há possibilidade de se oferecer uma terapêutica curativa aos enfermos. O objetivo do presente artigo é debater as relações que norteiam a temática proposta, baseando-se em uma revisão de literatura. Busca-se, assim, uma perspectiva que figura como um caminho argumentativo que conduz evidências a esse debate.SummaryThe issue of life-ending has been a source of considerations since the dawn of civilization, and calls for great circumspection when one attempts to fit it socially throughout the history of human thinking. The development and improvement of Medicine might modify, in most cases, the natural history of disease. We have managed to prolong life and the process of dying. This has created a new medical prototype that needs to care for terminally-ill patients, a situation often accompanied by severe suffering. Society attributes to the physician the role of being responsible for conquering and overcoming death. In the oncology context, these questions are well addressed, as in many situations there is no possibility to offer a curative treatment to the patients. The objective of the present study was to discuss the relations that guide the proposed theme, based on a medical literature review. Therefore, a perspective is sought as an argumentative alternative that brings evidence to the proposed debate.

Background This study aimed to compare the clinical target volumes (CTV) delineated by computed tomography (CT) and positron emission tomography (PET)/CT using fluoro-deoxy-glucose to assess the impact of using PET information for radiotherapy (RT) planning. Methods We retrospectively reviewed data on patients with tumors from different sites who had indications for RT and had undergone RT treatment planning with PET/CT at our institution between July 2003 and July 2009. Statistical analysis included the comparison of CTV planned for treatment only by CT (CTV(CT)) with that by PET/CT (CTV(PET)) using the Wilcoxon test for paired samples. Results Of 105 patients eligible for analysis, 56.2% were men. The most common diagnoses were head and neck cancer (28.6%), lung cancer (21.9%), lymphoma (11.4%), upper gastrointestinal (10.5%), and others (14.3%). Comparison of CTV(CT) and CTV(PET) revealed that RT planning has changed in 77% of cases because of PET/CT additional information, with impact on treatment volume varying according to diagnosis. Despite the absolute difference observed between median CTVs, there was no significant difference between CTV(CT) and CTV(PET) (114 vs. 90.4 ml, respectively; P=0.1266), considering all patients. Nonetheless, a significant difference between CTVs delineated by CT and PET/CT was found when only head and neck, lung and lymphoma cases--representing more than 60% of the sample--were examined (112.5 and 80.7 ml, respectively; P=0.0053). Conclusion We have shown that PET/CT use promotes significant changes in the CTV delineated for treatment of different tumors, modifying RT planning. Our data suggest that PET/CT has a good potential for optimizing RT treatment planning, especially in head and neck, lung, and lymphoma tumors.

ResumoO câncer de mama é a neoplasia maligna mais frequente entre as mulheres. A escolha terapêutica depende do estádio clínico da doença, das características anatomopatológicas, idade, entre outros. O objetivo do presente estudo é apresentar uma atualização dos conceitos e definições da radioterapia (RT) no tratamento conservador do câncer de mama estádio inicial, enfatizando as indicações, contraindicações, dose e fracionamento da RT (esquema clássico, hipofracionado e irradiação parcial da mama), RT adjuvante no carcinoma ductal in situ (CDIS), irradiação das cadeias linfonodais e relação da RT com preditores moleculares de recorrência. Foram utilizadas as bases de dados MEDLINE, SciELO e Cochrane para a seleção dos principais artigos disponíveis sobre a temática proposta. A RT adjuvante tem um papel definido na abordagem das pacientes com câncer da mama submetidas à terapia cirúrgica conservadora. Em pacientes selecionadas, podem-se empregar esquemas de RT hipofracionada ou irradiação parcial das mamas. Todas as pacientes com CDIS devem receber RT adjuvante. Não se sabe a correlação do papel da RT com preditores moleculares de recorrência local e sistêmica.SummaryBreast cancer (BC) is the most common malignancy among women. Therapeutic options are based on disease staging, histopathological characteristics, age, and others. The objective of the present study is to carry out an update of the concepts and definitions of radiotherapy (RT) in conservative treatment of early-stage breast cancer, with emphasis on indications, contraindications, RT dose fractionation schedules (classic, hypofractionated and partial breast irradiation), adjuvant RT in ductal carcinoma in situ (DCIS) and molecular predictors of recurrence. MEDLINE, SciELO and Cochrane databases were used for article selection. Adjuvant RT is indicated for patients with BC who underwent conservative breast surgery. In selected patients, hypofractionated or partial breast irradiation can be used. Adjuvant RT should be provided for all patients with DCIS. The correlation of RT and molecular predictors of local and systemic recurrence are not yet well-known.

Micose fungoide é um tipo de linfoma não Hodgkin de células T raro que acomete primariamente a pele. Caracteriza-se pela presença de placas eritematosas que evoluem para lesões ulceradas, tumores em toda a pele ou ainda infiltração de medula óssea em estágios avançados. Como opção de tratamento para os casos iniciais, tem-se quimioterapia e corticoterapia tópica, fototerapia e radioterapia. Este estudo relata o caso de um doente com múltiplas lesões tumorais na pele já biopsiadas com diagnóstico de micose fungoide. O paciente foi refratário ao tratamento com quimioterapia tópica e fototerapia, sendo então indicada irradiação total da pele com elétrons Mycosis fungoides is a rare type of non-Hodgkin's lymphoma of T cells that primarily affects the skin. It is characterized by the presence of erythematous plaques that evolve into ulcerated lesions, tumors throughout the skin or even bone marrow infiltration in advanced stages. Chemotherapy and topical steroids, phototherapy and radiotherapy are treatment options for early cases. This study reports the case of patient with multiple tumor lesions in the skin already biopsied with diagnosis of mycosis fungoides. The patient was refractory to both treatments with topical chemotherapy and phototherapy. It was then indicated total skin irradiation with electrons

Considering the psychosocial beneits obtained with immediate breast reconstruction (IBR), this procedure has been increasingly applied in Brazil, mainly in the immediate surgical context. he two main modalities of IBR used are the ones that employ autogenous tissue or artiicial breast implants or expanders. here is no consensus regarding the ideal time to carry out the IBR within the multimodal context of oncological treatment, especially when there is indication of radiotherapy (RT) ater the mastectomy – which depends on the surgical specimen – and also considering the lack of randomized studies comparing RT preand post-plasty. here is a rationale followed by many large American centers, to choose RT before IBR for two main reasons: Ater the procedure, tissue that does not belong to the breast bed (muscle laps, skin and prosthesis) would be irradiated without need. he IBR carried out before the RT can lead to inadequate planning, either with excessive irradiation of adjacent organs, or insuicient irradiation of the surgical bed and/or lymph node draining. Other obstacles to be faced are related to the size of breast reconstruction that is carried out, which very oten modiies the patient’s anatomy due to the large-volume plasty and the use of expanders with metallic components within the irradiation ield, which can result in regions of under and overdose, clinically translating as a higher chance of developing complications ater the RT. Moreover, breast medialization, symmastia and lat chest naturally impair radiotherapy planning. On the other hand, in addition to the aforementioned psychological gain with the immediate breast reconstruction, another justiication by those supporting this technique is that RT can compromise the skin and subjacent tissue quality, thus impairing the plasty, consequently afecting the cosmetic results. In this context, complications can arise ater IBR folGUSTAVO NADER MARTA, SAMIR ABDALLAH HANNA, EDUARDO MARTELLA, JOAO LUIS FERNANDES DA SILVA

Mycosis fungoides is a rare type of non-Hodgkin's lymphoma of T cells that primarily affects the skin. It is characterized by the presence of erythematous plaques that evolve into ulcerated lesions, tumors throughout the skin or even bone marrow infiltration in advanced stages. Chemotherapy and topical steroids, phototherapy and radiotherapy are treatment options for early cases. This study reports the case of patient with multiple tumor lesions in the skin already biopsied with diagnosis of mycosis fungoides. The patient was refractory to both treatments with topical chemotherapy and phototherapy. It was then indicated total skin irradiation with electrons.

Purpose: To present and evaluate the results of the use of Image Guided Radiotherapy(IGRT) using Megavoltage Cone Beam CT (MVCBCT) in prostate patients with fiducial markers. Method and Materials: 14 patients with 3 gold seed markers each were treated. The treatment unit was a Siemens Primus. The MVCBCT images were acquired using 3 MU, after skin mark alignment, prior to the treatment and registered manually with the planning CT using the seeds as surrogates. The resulting table coordinates shift in each direction (Lateral, Longitudinal and Vertical) to align the prostate in respect to the isocenter was stored. Different action levels (AL) were simulated and population margins (2.5∑+0.7σ) calculated for each scenario considering a residual error of 2 mm for intra‐fraction and observer errors; as well as the fraction of the days that would need table corrections. Results: 335 MVCBCT images were generated. The average prostate localization errors detected prior to the treatment were: 2±2 mm (Lateral), 3±2 mm (Longitudinal), 3±3 mm (Vertical). The population margins calculation for a non‐AL and for ALs from 8 to 2 mm, indicates that the margins for the non‐AL scenario of 5, 7 and 6 mm, in the Lateral, Longitudinal and Vertical directions respectively, can be reduced to 3 mm in all directions, applying IGRT daily with an AL of 3 mm, and thus acting in 84% of the days. Conclusion: The technique enables a fast and precise prostate localization with low dose. The AL is an important choice and will have a direct impact in the CTV to PTV margin that can be used for the procedure. The simulations indicate that with a 3 mm action level, a 3 mm margin could be used and thus reducing toxicity without compromising the local control.

e11560 Background: To report single-institution series of breast intra-operative radiotherapy (IORT) using nondedicated linear accelerator. Methods: Prospective phaseII trial opened in May 2004. El...

Summary The issue of life-ending has been a source of considerations since the dawn of civilization, and calls for great circumspection when one attempts to fit it socially throughout the history of human thinking. The development and improvement of Medicine might modify, in most cases, the natural history of disease. We have managed to prolong life and the process of dying. This has created a new medical prototype that needs to care for terminally-ill patients, a situation often accompanied by severe suffering. Society attributes to the physician the role of being responsible for conquering and overcoming death. In the oncology context, these questions are well addressed, as in many situations there is no possibility to offer a curative treatment to the patients. The objective of the present study was to discuss the relations that guide the proposed theme, based on a medical literature review. Therefore, a perspective is sought as an argumentative alternative that brings evidence to the proposed debate.

Introdução: Os sarcomas de partes moles (SPM) compõem um grupo diverso de malignidades mesenquimais, que requer tratamento multidisciplinar. Embora a cirurgia seja a principal modalidade de tratamento da doença localizada, a radioterapia (RT) é incorporada no manejo conservador, seja de forma neoadjuvante ou adjuvante. Com o desenvolvimento de técnicas modernas de RT bem como esquemas alternativos de entrega de dose, a radioterapia estereotáxica ablativa (SABR) surge como uma modalidade promissora. Entretanto, o papel da SABR no tratamento dos SPM permanece incerto. Materiais e métodos: Trata-se de um estudo unicêntrico prospectivo, fase II de braço único. Pacientes com sarcomas de partes moles de extremidades (SPME), candidatos à cirurgia conservadora do membro foram incluídos. O tratamento experimental consistiu em SABR com 40 Gy em 5 frações realizadas em dias alternados, seguido de cirurgia após um intervalo mínimo de 4 semanas. O objetivo primário foi avaliar a taxa de complicação de ferida operatória. Os objetivos secundários do estudo foram avaliar as taxas de controle local (CL), sobrevida livre de metástase (SLM), sobrevida câncer específica (SCE), sobrevida global (SG) e demais toxicidades. Resultados: Vinte e cinco pacientes foram recrutados entre outubro de 2015 e novembro de 2019 e completaram o protocolo. A taxa mediana de regressão histopatológica foi de 65% (0-100) e 20,8% dos tumores apresentaram resposta patológica completa (RPC). Complicação de ferida operatória ocorreu em 7 pacientes (28%). Três pacientes foram submetidos à desarticulação decorrente de oclusão vascular após a reconstrução e 1 paciente foi amputado devido à disfunção motora grau 3. Após um seguimento mediano de 20,7 meses, o risco em 2 anos para recorrência local, metástase à distância e sobrevida câncer-específica foi de 0, 44,7% e 10,6% respectivamente. Conclusões: SABR neoadjuvante à cirurgia aparenta aumentar a taxa de RPC em pacientes com SPME, com taxa de complicação de ferida operatória aceitável. Entretanto, devido ao número de amputações maior do que o esperado, é necessária uma amostra maior de pacientes com um seguimento mais longo para uma melhor conclusão sobre a segurança global dessa estratégia Background: Soft tissue sarcomas (STS) comprise a diverse group of mesenchymal malignancies that require multidisciplinary care. Although surgery remains the primary form of treatment for those with localized disease, radiation therapy (RT) is often incorporated either in the neo- or adjuvant setting. Given the development of modern RT techniques and alternative dosing schedules, stereotactic ablative radiotherapy (SABR) has emerged as a promising technique. However, the current role of SABR in the treatment of STS of the extremities remains uncertain. Methods and Materials: This was a singlecenter, prospective, single-arm phase II trial. Patients with localized extremity STS (eSTS) who were candidates for limb-preservation surgery were included. Experimental treatment consisted of SABR with 40 Gy in 5 fractions, administered on alternate days, followed by surgery after a minimum interval of 4 weeks. The primary outcome was the rate of wound complication. Secondary outcomes included 2-year local control (LC), metastasis-free survival (MFS), cancer-specific survival (CSS), and overall survival (OS) rates (and other toxicities). Results: Twenty-five patients were enrolled between October 2015 and November 2019 and completed the treatment protocol. The median rate of histopathologic regression was 65% (range 0-100) and 20.8% of tumors presented pathologic complete response (pCR). Wound complications were observed in 7/25 patients (28%). Three patients underwent disarticulation by vascular occlusion after plastic reconstruction and one patient was amputated by grade 3 limb dysfunction. After a median follow up of 20.7 months, the 2-year estimated risk of local recurrence, distant metastasis and cause-specific death were 0%, 44.7% and 10.6% respectively. Conclusions: Neoadjuvant SABR appears to improve the pCR for patients with eSTS, with acceptable rate of wound complications. Nevertheless, this benefit should be weighed against the risk of late of vascular toxicity with SABR regimen since, even in a short median follow-up, a higher rate of amputation than expected was observed. A larger sample size with longer follow-up is necessary to conclude the overall safety of this strategy