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Benign skin diseases have seldom been treated with radiotherapy, unless resistant to other treatments. Eccrine syringofibroadenoma (ESFA) is a rare benign eccrine tumor. ESFA very rarely presents bilateral lesions, and seldom a nonsurgical treatment has been proposed. An exceptional case of bilateral ESFA of the foot is presented; radiotherapy was effective in treating both lesions with good cosmetic results. © 2010 Wiley Periodicals, Inc.

The objective of this study was to evaluate the safety of escalating up to 55 Gy within five weeks, the dose of external beam radiotherapy to the previous tumor site concurrently with a fixed daily dose of capecitabine, in patients with resected pancreatic cancer. MATERIAL AND METHODS: Patients with resected pancreatic carcinoma were eligible for this study. Capecitabine was administered at a daily dose of 1600 mg/m (2). Regional lymph nodes received a total radiation dose of 45 Gy with 1.8 Gy per fractions. The starting radiation dose to the tumor bed was 50.0 Gy (2.0 Gy/fraction, 25 fractions). Escalation was achieved up to a total dose of 55.0 Gy by increasing the fraction size by 0.2 Gy (2.2 Gy/fraction), while keeping the duration of radiotherapy to five weeks (25 fractions). A concomitant boost technique was used. Dose limiting toxicity (DLT) was defined as any grade>3 hematologic toxicity, grade>2 liver, renal, neurologic, gastrointestinal, or skin toxicity, by RTOG criteria, or any toxicity producing prolonged (> 10 days) radiotherapy interruption. RESULTS AND DISCUSSION: Twelve patients entered the study (median age: 64 years). In the first cohort (six patients), no patient experienced DLT. Similarly in the second cohort, no DLT occurred. All 12 patients completed the planned regimen of therapy. Nine patients experienced grade 1-2 nausea and/or vomiting. Grade 2 hematological toxicity occurred in four patients. The results of our study indicate that a total radiation dose up to 55.0 Gy/5 weeks can be safely administered to the tumor bed, concurrently with capecitabine (1600 mg/m (2)) in patients with resected pancreatic carcinoma.

Background and Purpose: Quality assurance procedures (QA) may reduce the risk of errors in radiotherapy. The aim of this study was to assess a QA program based on independent check (IC) procedures in patients undergoing 3D, intensity modulated (IMRT) and extracranial stereotactic (ESRT) radiotherapy. Materials and methods: IC for set-up (IC1) and for radiotherapy treatments (IC2) was tested on 622 patients over a year. Fifteen events/parameters and 17 parameters were verified by IC1 and IC2, respectively. A third evaluation check (IC3) was performed before treatment. Potential errors were classified based on their magnitude. Incidents involving only incorrect or incomplete documentation were segregated. Treatments were classified based on a complexity index (COMIX). Results: With IC1, 75 documentation incidents and 31 potential errors were checked, and with IC2 111 documentation incidents and 6 potential errors were checked. During the study period 10 errors undetected by standard procedures (IC1, IC2) were detected by chance or by IC3. The incidence of errors and serious errors undetected by standard procedures was 1.6% and 0.6%, respectively. There was no higher incidence of errors undetected in patients undergoing IMRT or ESRT, while there was a higher incidence of errors undetected in more complex treatments (p < 0.001). Conclusions: Systematic QA procedures can reduce the risk of errors. The risk of errors undetected by standard procedures is not correlated with the treatment technological level (3D versus IMRT/ESRT). © 2008 Elsevier Ireland Ltd. All rights reserved.

A 2D-array equipped with 729 vented plane parallel ion-chambers has been calibrated as a portal dose detector for radiotherapy in vivo measurements. The array has been positioned by a radiographic film stand at 120 cm from the source orthogonal to the radiotherapy beam delivered with the gantry angle at 180°. The collision between the 2D-array and the patient's couch have been avoided. In this work, using the measurements of the portal detector, we present a method to reconstruct the dose variations in the patient treated with step and shoot intensity-modulated beams (IMRT) for head-neck tumours. For this treatment morphological changes often occur during the fractionated therapy. In a first step an in-house software supplied the comparison between the measured portal dose and the one computed by a commercial treatment planning system within the field of view of the computed tomography (CT) scanner. For each patient, the percentage Pγ of chambers, where the comparison is in agreement within a selected acceptance criteria, was determined 8 times. At the first radiotherapy fraction the γ-index analysis supplied Pγ values of about 95%, within acceptance criteria in terms of dose-difference, ΔD, and distance-agreement, Δd, that was equal to 5% and 4 mm, respectively. These acceptance criteria were taken into account for small errors in the patient's set-up reproducibility and for the accuracy of the portal dose calculated by the treatment planning system (TPS) in particular when the beam was attenuated by inhomogeneous tissues and the shape of the head-neck body contours were irregular. During the treatment, some patients showed a reduction of the Pγ below 90% because due to radiotherapy treatment there was a change of the patient's morphology. In a second step a method, based on dosimetric measurements that used standard phantoms, supplied the percentage dose variations in a coronal plane of the patient using the percentage dose variations measured by the 2D-array portal detector. The results showed that the dose variations due to the change of the patient's morphology reached 15% and such discrepancies were displayed on the digitally reconstructed radiography of the patient. The dose discrepancies were confirmed by the hybrid plan obtained by the treatment planning system. The good results here reported show that once it is possible to have the portal dose distributions even for other gantry angles, these tests could be introduced in the clinical protocol to have major support to decide when to repeat the patient's CT scan and to re-plan the new IMRT dose calculation. © 2008 Elsevier B.V. All rights reserved.

Purpose: The squamous cell carcinoma (SCC) antigen is still considered the most accurate serologic tumor marker in cervical carcinoma. We assessed the contribution of the SCC assay to the detection of recurrences in patients treated with radiotherapy. Methods and Materials: The pattern of recurrence and follow-up data were prospectively recorded for 135 patients. Of the 135 patients, 103 (76.3%) had primary cervical carcinoma and 32 (23.7%) had already experienced disease recurrence that had been successfully treated with surgery (n = 2), surgery plus radiotherapy (n = 2), radiotherapy (n = 5), or concomitant chemoradiotherapy (n = 23). The follow-up evaluations (chest X-ray, abdominopelvic magnetic resonance imaging, gynecologic examination with colposcopy, Papanicolaou smear, and SCC assay) were performed at 6-month intervals; the evaluation was done earlier if recurrent disease was suspected. The median follow-up time was 29 months (range, 6-131). The SCC serum levels were assayed, and a cost analysis was done. Results: A total of 481 SCC determinations were performed. Of the 135 patients, 43 (31.8%) experienced disease recurrence. The SCC levels were higher in those with recurrent disease than in the disease-free patients. Elevation of SCC was documented in 34 (79.1% sensitivity) of 43 recurrences before symptoms appeared. Of the 38 patients with serum SCC elevation, 34 developed a recurrence (positive predictive value, 89.5%). Of the 97 patients with negative SCC serum levels, 88 had negative findings at the clinicoradiologic evaluation (negative predictive value, 90.7%). A simplified approach (SCC plus gynecologic examination) was evaluated. Compared with the complete follow-up program, the rate of missed recurrence was 2.2%. The total projected cost per patient for 5 years of follow-up for the simplified procedure was approximately 12.2-fold lower than the standard approach. Conclusions: Our results have shown that a simplified diagnostic approach, including the SCC assay and gynecologic examination, can detect a high rate of recurrence from cervical cancer, with a very favorable cost-effective profile. © 2007 Elsevier Inc. All rights reserved.

This work reports the results of the application of a practical method to determine the in vivo dose at the isocenter point, D(iso), of brain thorax and pelvic treatments using a transit signal S(t). The use of a stable detector for the measurement of the signal S(t) (obtained by the x-ray beam transmitted through the patient) reduces many of the disadvantages associated with the use of solid-state detectors positioned on the patient as their periodic recalibration, and their positioning is time consuming. The method makes use of a set of correlation functions, obtained by the ratio between S(t) and the mid-plane dose value, D(m), in standard water-equivalent phantoms, both determined along the beam central axis. The in vivo measurement of D(iso) required the determination of the water-equivalent thickness of the patient along the beam central axis by the treatment planning system that uses the electron densities supplied by calibrated Hounsfield numbers of the computed tomography scanner. This way it is, therefore, possible to compare D(iso) with the stated doses, D(iso,TPS), generally used by the treatment planning system for the determination of the monitor units. The method was applied in five Italian centers that used beams of 6 MV, 10 MV, 15 MV x-rays and (60)Co gamma-rays. In particular, in four centers small ion-chambers were positioned below the patient and used for the S(t) measurement. In only one center, the S(t) signals were obtained directly by the central pixels of an EPID (electronic portal imaging device) equipped with commercial software that enabled its use as a stable detector. In the four centers where an ion-chamber was positioned on the EPID, 60 pelvic treatments were followed for two fields, an anterior-posterior or a posterior-anterior irradiation and a lateral-lateral irradiation. Moreover, ten brain tumors were checked for a lateral-lateral irradiation, and five lung tumors carried out with three irradiations with different gantry angles were followed. One center used the EPID as a detector for the S(t) measurement and five pelvic treatments with six fields (many with oblique incidence) were followed. These last results are reported together with those obtained in the same center during a pilot study on ten pelvic treatments carried out by four orthogonal fields. The tolerance/action levels for every radiotherapy fraction were 4% and 5% for the brain (symmetric inhomogeneities) and thorax/pelvic (asymmetric inhomogeneities) irradiations, respectively. This way the variations between the total measured and prescribed doses at the isocenter point in five fractions were well within 2% for the brain treatment, and 4% for thorax/pelvic treatments. Only 4 out of 90 patients needed new replanning, 2 patients of which needed a new CT scan.

This work reports a practical method for the determination of the in vivo breast middle dose value, D(m) on the beam central axis, using a signal S(t), obtained by a small thimble ion chamber positioned at the center of the electronic portal imaging device, and irradiated by the x-ray beam transmitted through the patient. The use of a stable ion chamber reduces many of the disadvantages associated with the use of diodes as their periodic recalibration and positioning is time consuming. The method makes use of a set of correlation functions obtained by the ratios S(t)/D(m), determined by irradiating cylindrical water phantoms with different diameters. The method proposed here is based on the determination of the water-equivalent thickness of the patient, along the beam central axis, by the treatment planning system that makes use of the electron densities obtained by a computed tomography scanner. The method has been applied for the breast in vivo dosimetry of ten patients treated with a manual intensity modulation with four asymmetric beams. In particular, two tangential rectangular fields were first delivered, thereafter a fraction of the dose (typically less than 10%) was delivered with two multi leaf-shaped beams which included only the mammarian tissue. Only the two rectangular fields were tested and for every checked field five measurements were carried out. Applying a continuous quality assurance program based on the tests of patient setup, machine settings and dose planning, the proposed method is able to verify agreements between the computed dose D(m,TPS) and the in vivo dose value D(m), within 4%.

Objective: To investigate the feasibility and determine the recommended pre-operative intensity-modulated radiotherapy (IMRT) dose of extended-field chemoradiation along with simultaneous integrated boost (SIB) dose escalation. Methods: A radiation dose of 40Gy over 4 weeks, 2Gy/fraction, was delivered to the tumour and the lymphatic drainage (planning target volume, PTV3), which encompassed a volume larger than standard (common iliac lymphatic area up to its apex, in front of the L3 vertebra), concurrently with chemotherapy (cisplatin and 5-fluorouracil). Radiation dose was escalated to the pelvis (PTV2) and to the macroscopic disease (PTV1) with the SIB-IMRT strategy. Three dose levels were planned: Level 1 (PTV3: 40/2Gy; PTV2: 40/2Gy; PTV1: 45/2.25Gy), Level 2 (PTV3: 40/2Gy; PTV2: 45/2.25Gy; PTV1: 45/2.25Gy) and Level 3 (PTV3: 40/2Gy; PTV2: 45/2.25Gy; PTV1: 50/ 2.5Gy). All treatments were delivered in 20 fractions. Patients were treated in cohorts of between three and six per group using a Phase I study design. The recommended dose was exceeded if two of the six patients in a cohort experienced dose-limiting toxicity within 3months fromtreatment. Results: 19 patients [median age: 46 years; The International Federation of Gynecology and Obstetrics (FIGO) stage IB2: 3, IIB: 10, IIIA-IIIB: 6] were enrolled. Median follow-up was 24 months (9-60 months). The most common grade 3/4 toxicity was gastrointestinal (GI) (diarrhoea, mucous discharge, rectal/abdominal pain). At Levels 1 and 2, only one grade 3 GI toxicity per level was recorded, whereas at Level 3, two grade 3 GI toxicities (diarrhoea, emesis and nausea) were recorded. Conclusion: The SIB-IMRT technique was found to be feasible and safe at the recommended doses of 45Gy to PTV1 and PTV2 and 40Gy to PTV3 in the pre-operative treatment of patients with locally advanced cervical cancer. Unfortunately, this complex technique was unable to safely escalate dose beyond levels already achieved with three-dimensional conformal radiotherapy technique given acute GI toxicity. Advances in knowledge: A Phase I radiotherapy doseescalation trial with SIB-IMRT technique is proposed in cervical cancer. This complex technique is feasible and safe at the recommended doses.

Craniopharyngiomas (CPs) are rare benign suprasellar tumors. The standard treatment for CP is complete surgical resection or partial resection followed by adjuvant radiotherapy (RT). Adjuvant RT is typically administered at a total dose of 54 Gy with 1.8 Gy/fraction. The current study reported the case of a young patient affected by recurrent craniopharyngioma, who was treated with irradiation subsequent to several surgical resections. Image fusion and intensity-modulated radiation therapy techniques were employed to deliver a high total dose (63 Gy with 2.1 Gy/fraction) with no severe acute toxicities recorded. At the 6-year follow-up, no radiological or clinical signs of disease progression or late sequelae were observed.

We evaluated an EPID-based in-vivo dosimetry algorithm (IVD) for complex VMAT treatments in clinical routine. 19 consecutive patients with head-and-neck tumors and treated with Elekta VMAT technique using Simultaneous Integrated Boost strategy were enrolled. In-vivo tests were evaluated by means of (i) ratio R between daily in-vivo isocenter dose and planned dose and (ii) γ-analysis between EPID integral portal images in terms of percentage of points with γ-value smaller than one (γ%) and mean γ-values (γmean), using a global 3%-3 mm criteria. Alert criteria of ±5% for R ratio, γ% < 90% and γmean > 0.67 were chosen. A total of 350 transit EPID images were acquired during the treatment fractions. The overall mean R ratio was equal to 1.002 ± 0.019 (1 SD), with 95.9% of tests within ±5%. The 2D portal images of γ-analysis showed an overall γmean of 0.42 ± 0.16 with 93.3% of tests within alert criteria, and a mean γ% equal to 92.9 ± 5.1% with 85.9% of tests within alert criteria. Relevant discrepancies were observed in three patients: a set-up error was detected for one patient and two patients showed major anatomical variations (weight loss/tumor shrinkage) in the second half of treatment. The results are supplied in quasi real-time, with IVD tests displayed after only 1 minute from the end of arc delivery. This procedure was able to detect when delivery was inconsistent with the original plans, allowing physics and medical staff to promptly act in case of major deviations between measured and planned dose.

Objectives: To assess the effectiveness of a SHort-course Accelerated RadiatiON therapy (SHARON) in the treatment of patients with multiple brain metastases. Materials and Methods: A phase II clinical trial was designed. Eligibility criteria included patients with at least 3 brain metastases or metastatic disease in >3 organ systems, and Eastern Cooperative Oncology Group performance status of ≤3. Fifty patients were treated with whole brain radiotherapy at 18 Gy (4.5 Gy per fraction) in 2 days with a twice daily fractionation. The primary endpoint was the assessment of efficacy in terms of overall survival. Results: Characteristics of the 50 enrolled patients were: male/female: 24/26; median age: 65 years (range, 45 to 80 y). Eastern Cooperative Oncology Group performance status was

Complete pathological response after chemo-radiation in anaplastic thyroid cancer: A report of two cases

As all methods for in-vivo dosimetry require special efforts many physicists are often discouraged in verifying the middle dose in a patient along the beam central axis. This work reports a practical method for the determination of the middle dose value, D m , on the central beam axis, using a signal S t , obtained by a small thimble ion-chamber positioned at the center of the electronic portal imaging device, and irradiated by the X-ray beam transmitted through the patient. The use of a stable ion-chamber reduces many of the disadvantages associated to the use of diodes as their periodic recalibration and time consuming positioning. The method makes use of a set of correlation functions obtained by the S t and D m ratios, determined by irradiating a water-equivalent phantom with 6 MV, 10 MV and 5 MV X-ray beams. Several tests were carried out in phantoms with asymmetric inhomogeneities. The method here proposed is based on the determination of the water-equivalent thickness of the patient, along the beam central axis, by the treatment planning system that makes use of the electron densities obtained by a computer tomography scanner, that works with calibrated Hounsfield numbers. This way, it is therefore possible to compare the dose, D m, TPS , obtained by a treatment planning system, with the in-vivo dose D m value, both defined at density middle point (identified along the beam central axis, where the thick material, in terms of g cm −2 , above and below, is the same). The method has been applied for the in-vivo dosimetry of 30 patients, treated with conformed beams for pelvic tumor, checking: anterior-posterior or posterior-anterior irradiations and lateral-lateral irradiations. For every checked field at least five measurements were carried out. Applying a correct quality assurance program based on the tests of the patient set-up, machine settings and calculations, results showed that the method is able to verify agreements between the dose D m,TPS and the in-vivo dose value D m , within 4% for 95% of the 240 measurements carried out in-vivo .

The importance of pancreatic cancer staging is uncertain. The aim of this report was to evaluate the accuracy of combined standard imaging techniques in predicting the pathologic stage and to evaluate the prognostic effect of clinical staging to identify patient groups in which laparoscopy and laparotomy could be beneficial.Fifty-four patients were included in this analysis. The techniques used for clinical staging were endoscopic retrograde cholangiopancreatography, abdominal computed tomographic scan, and ultrasonography. All patients underwent both clinical and surgical/pathologic staging. A comparison was performed between presurgical stage and surgical/pathologic stage. The prognostic effect of different factors on survival was evaluated with both univariate (log-rank) and multivariate (Cox) analysis.Sensitivity and specificity for vascular involvement were 73.9% and 96.3%, respectively. Sensitivity and specificity for nodal involvement were 63.6% and 95.4%, respectively. A total of 33.3% of patients showed a higher than expected pathologic stage, and 3.7% showed a lower than expected pathologic stage, by comparing clinical and pathologic evaluation. A highly significant correlation was observed between clinical T stage (P = .0067) and tumor diameter (P = .0037) and patient survival. Maximal prognostic differentiation was observed by dividing patients into two groups based on imaging results: group A (favorable prognosis) and group B (unfavorable prognosis). The median survival was 25.1 and 8.0 months for group A and B, respectively. Five-year survival was 20.1% and 0%, respectively (multivariate analysis: P = .0007).Integrated standard imaging studies achieved reasonable diagnostic accuracy in our analysis. A single classification based on clinical stage and tumor diameter evaluated by imaging predicts prognosis in patients with pancreatic carcinoma.

Aims and background Clinical studies published in the last decade have shown the possible improvement in prognosis of patients with prostatic carcinoma undergoing radiation therapy with dose escalation or in combination with hormone therapy. However, in studies on hormone therapy, moderate doses of radiation therapy have been used, whereas in studies with high-dose radiotherapy, hormone therapy usually was not administered. Therefore, it is not clear whether the concomitant use of high doses and prolonged hormone therapy could determine an additional beneficial effect. The aim of the present study was therefore to evaluate the relative prognostic role of different dose levels (70 Gy) of external beam radiotherapy and of different hormone therapies (neoadjuvant only versus neoadjuvant + adjuvant). Methods A total of 426 patients (median age, 71 yrs; range, 51-87 yrs) underwent external beam radiotherapy (70 Gy median dose to prostate volume ± 45 Gy to pelvic lymph nodes) and neoadjuvant hormone therapy (bicalutamide for 30 days; goserelin, 3.6 mg every 28 days starting two months before radiotherapy and for its entire duration). Dose to the prostate was 70 Gy in 55.2%. A total of 244 patients received adjuvant hormonal therapy. The distribution according to the clinical stage was 48.1% T2 and 51.9% T3. The distribution according to the Gleason score was 14.3% grades 2-4, 66.7% grades 5-7 and 19.0% grades 8-10. The distribution according to pretreatment prostate-specific antigen levels (in ng/mL) was 7.0% for 0-4, 29.3% for 4-10, 30.3% for 10-20, and 33.3% for >20. Results With a median follow-up of 35 months (range, 1-151), 81 patients (19.0%) showed biochemical recurrence, 17 patients (4.0%) showed local disease progression, and 12 patients (2.8%) showed distant metastases. Overall, 23 patients (5.4%) showed disease progression. Four patients (0.9%) died. At the time of this writing, no patient has died from prostatic carcinoma. At univariate analysis, the radiation dose delivered to the tumor and the administration of adjuvant hormone therapy were shown to be significantly correlated with biochemical disease-free survival. At multivariate analysis, the single parameter significantly correlated with biochemical disease-free survival was the radiation dose delivered to the tumor. In the subset of patients not treated with adjuvant hormone therapy, there was a significant correlation between radiation dose and biochemical disease-free survival at univariate and multivariate analysis. A similar correlation between adjuvant hormone therapy and biochemical disease-free survival was observed in the subset of stage cT3 patients at univariate and multivariate analysis. In patients undergoing combined treatment without adjuvant hormone therapy, a significant correlation was observed between clinical stage and biochemical disease-free survival, at univariate and at multivariate analysis. Conclusions The results of the study confirmed the positive impact of radiotherapy doses >70 Gy and of adjuvant hormone therapy in patients with locally advanced prostatic carcinoma. Owing to the lack of evidence of a correlation between radiation dose and biochemical outcome in patients undergoing prolonged hormone therapy, the role of further dose escalation in patients undergoing combined hormone and radiation therapy is still unclear.

Introduction Statistical Process Control (SPC) is a tool widely used in industrial engineering for monitoring, controlling and, ideally, improving a process through statistical analysis. This technique can be applied to quality assurance (QA) practice in radiotherapy in order to characterize the treatment process variability. Purpose To apply SPC strategy to our routine VMAT pre-treatment verification QA. Materials and methods In the last years, more than 1400 patients were treated with Elekta VMAT at our institution. Plans were re-grouped according to treatment technique and disease sites: (1) 611 high-modulated complex SIB treatments (head-neck, brain, gynecological, ano-rectal; (2) 348 prostate treatments and (3) 445 liver, lung and other metastasis treated with extracranial stereotactic radiotherapy (SBRT). Groups 1 and 2–3 plans were optimized with Oncentra Masterplan (dual-arc) and Ergo++ (single arc) TPS. A total of 4030 dose measurements were performed with the PTW Seven29 array/Octavius phantom, both on coronal and sagittal planes. Doses comparison were evaluated using 3%/3 mm γ -analysis. Two metrics were evaluated: (a) points-percentage with g -value less than one (g%) and (b) mean gamma (gmean). Clinical specifications were: g % >90% and g mean Results γ pass-rate values significantly depend on plan complexity. For g %, CL and LCL were 93.9% and 89.4%, 99.1% and 96.6%, and 99.3% and 97.6%, for group 1, 2 and 3 respectively. For gmean, CL and UCL were 0.416 and 0.585, 0.361 and 0.557, and 0.304 and 0.427, for groups 1, 2 and 3 respectively. In all cases, the control limits are well within the clinical specifications. The Cpl/Cpu capability indices for g % and g mean resulted equal to 0.61 and 1.06 in group 1; 2.59 and 1.12 in group 2; 3.77 and 2.10 in group 3, respectively. g % process for group 1 was not capable at 3%/3 mm, but with 5% – 3 mm specification for g%, CL and LCL resulted 98.3% and 96.2% and Cpl was 2.84. Conclusion SPC is useful to quantifiably demonstrate the QA process conformance to clinical specifications.

Introduction Due to the increasing complexity of radiotherapy treatments, comprehensive quality assurance programs are mandatory to check the proper functioning of the whole radiotherapy chain. In vivo dosimetry (IVD), a direct method of measuring radiation doses to cancer patients during treatment, has shown unique features to trace deviations between planned and actually delivered dose distributions. Purpose To assess the usefulness of EPID-based IVD for complex VMAT treatments in clinical routine. Materials and methods 80 patients (30 with head-neck tumor, 30 with pelvic tumors and 20 patients with extracranial metastases) treated with Elekta were enrolled. IVD tests were evaluate by means of (i) R ratio between daily in-vivo isocenter dose and planned dose and (ii) γ -analysis between EPID integral portal images in terms of percentage of points with γ -value smaller than one ( γ %) and mean γ -values ( γ mean), using a global 3%-3 mm criteria. Alert criteria of ±5% for R ratio, γ % γ mean >0.67 were chosen. Results A total of 980 transit EPID images were acquired. The mean R ratio was equal to 1.001 ± 0.015 for all patients with more than 95% of tests were within 5%. For HN, pelvic and SBRT treatments, γ % and γ mean metrics reported 85.9%, 83.1% and 95.4%, and 93.3%, 92.1% and 98.1% of tests within alert criteria, respectively. The systematic use of IVD revealed relevant discrepancies in a few H–N patients due to major anatomical variations and variations due to random anatomical changes in terms of filling of rectum/bladder in pelvic tumors. No discrepancies were detected in SBRT patients. Conclusion IVD was able to detect when delivery was inconsistent with the original plans, allowing physics and medical staff to promptly act in case of major deviations.

AIM: To present a systematic review of techniques and clinical results. METHODS: A systematic review of published literature was performed. Only studies reporting patient outcome after radiosurgery (single fraction) delivered with robotic devices [i.e., robotic radiosurgery (RRS)] have been analyzed. RESULTS: A total of 96 patients from 5 studies were included. The studies are characterized by small series and different methods in terms of dose, target definition, combination with chemotherapy and/or standard fractionated radiotherapy and evaluation modalities. Preliminary results are positive in terms of tumor response (ORR = 56%) and local control of the tumor (crude rate of local progressions: 19.5%). Results for median overall survival (11.4 mo) seem comparable with the ones of prolonged chemoradiation (range: 8.6-13.0 mo). However, gastrointestinal toxicity seems to be the main limitation of RRS, especially at the duodenal level. CONCLUSION: RRS allows for local treatment in a shortened time (1 fraction) compared to traditional treatments (about 1 mo), providing the possibility for an easy integration with systemic therapies. Preliminary results did not show any outcome differences compared to standard chemoradiation. Thus, further efforts to reduce gastrointestinal toxicity are strongly needed.

In the present study, the preliminary results of the first stereotactic body radiosurgery (SRS) experience with volumetric intensity modulated arc therapy (VMAT) in oligometastatic breast and recurrent gynecological tumors (OBRGT) are reported in terms of feasibility, toxicity and efficacy. Patients were treated in a head-first supine treatment position on a customized body frame immobilization shell. SRS-VMAT treatment plans were optimized using the ERGO++ treatment planning system. Response assessment was performed 8-12 weeks after treatment by morphologic imaging modalities, or if feasible, also by functional imaging. Thirty-six lesions in 24 consecutive patients (median age, 63 years; range, 40-81) were treated: 13.9% had primary or metastatic lung lesions, 30.5% had liver metastases, 36.1% had bone lesions, 16.7% had lymph node metastases and 2.8% had a primary vulvar melanoma. The median dose was 18 Gy (BED2 Gy, α/β: 10=50.4 Gy), the minimal dose was 12 Gy (BED2 Gy, α/β: 10=26.4 Gy) and the maximal dose was 28 Gy (BED2 Gy, α/β: 10=106.4 Gy). Seven patients (29.2%) experienced acute toxicity, which however was grade 2 in only 1 case. Moreover, only 3 patients (12.5%) developed late toxicity of which only 1 was grade 2. Objective response rate was 77.7% including 16 lesions achieving complete response (44.4%) and 12 lesions achieving partial response (33.3%). The median duration of follow-up was 15.5 months (range, 6-50). Recurrence/progression within the SRS-VMAT treated field was observed in 6 patients (total lesions=7) with a 2-year inside SRS-VMAT field disease control expressed on a per lesion basis of 69%. Recurrence/progression of disease outside the SRS-VMAT field was documented in 15 patients; the 2-year outside SRS-VMAT field metastasis‑free survival, expressed on a per patient basis, was 35%. Death due to disease was documented in 6 patients and the 2-year overall survival was 58%. Although the maximum tolerated dose was not reached, SRS-VMAT resulted in positive early clinical results in terms of tumor response, local control rate and toxicity.

Aims: To present the interim results of a phase I trial on stereotactic radiosurgery (SRS) delivered using volumetric modulated arc therapy (VMAT) in patients with primary or metastatic tumours in different extracranial sites. Materials and methods: Patients were enrolled in different arms according to tumour site and clinical stage, and sequentially assigned to a given dose level. Acute toxicity, tumour response and early local control were investigated and reported. Results: One hundred lesions in 65 consecutive patients (male/female: 30/35, median age: 66 years; range: 40-89) were treated. Of these 100 lesions, 21 were primary or metastatic lung tumours, 24 were liver metastases, 30 were bone metastases, 24 were nodal metastases and one was a primary vulvar melanoma. The prescribed dose ranged from 12 (BED2Gy,α/β:10=26.4Gy) to 28Gy (BED2Gy,α/β:10=106.4Gy) to the planning target volume. Twenty-one patients (32.3%) experienced grade 1-2 acute toxicity, which was grade 2 in only two cases. The overall response rate based on computed tomography/magnetic resonance imaging was 52% (95% confidence interval 40.1-63.2%) and based on positron emission tomography scan was 90% (95% confidence interval 76.2-96.4%). As of November 2013, the median duration of follow-up was 11 months (range=1-38). Recurrence/progression within the SRS-VMAT treated field was observed in nine patients (total lesions=18): the inside SRS-VMAT field local control expressed on a per lesion basis was 87.8% at 12 months and 71.9% at 24 months. Conclusions: The maximum tolerable dose has not yet been reached in any study arm. SRS-VMAT resulted in positive early clinical results in terms of tumour response, local control rate and acute toxicity.

Background To explore the role of radiotherapy in the extrahepatic bile duct carcinoma, and to understand if and when radiotherapy could be effective for this group of patients. Methods A systematic review of recently published literature was completed. Recent studies using radiotherapy with survival data, resection rates and quality of life data have been analyzed. Results There are no randomized trials regarding the treatment of extrahepatic cholangiocarcinoma. The bulk of available studies suggest that in some cases radio-chemotherapy can be used as adjuvant therapy. Radiotherapy could also have a role in unresectable cholangiocarcinoma: external radiotherapy or intraluminal brachytherapy – alone or in combination – could improve the outcome in selected patients. Finally, radiotherapy, and in particular intraluminal brachytherapy, could be used as a palliative treatment to improve the quality of life and in controlling symptoms. Conclusion The role of radiotherapy in extrahepatic cholangiocarcinoma remains undefined due to the lack of randomized trials or otherwise properly controlled studies.