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Patients with soft tissue sarcomas that arise from previously irradiated fields have traditionally been reported to have a poor prognosis. In this report, we examined the characteristics and outcomes of patients who developed a rhabdomyosarcoma in a previously irradiated field (RMS-RIF); we hypothesize that these patients should have a better outcome compared to other postradiation soft tissue sarcomas as these tumors are chemosensitive and radiosensitive. A PubMed search of the literature from 1961-2010 yielded 33 studies with data for patients with RMS-RIF. The study included 43 patients with a median age of 6.5 years at the time of radiation therapy (RT) for the initial tumor. The median RT dose was 48 Gy. The median latency period, the time from RT to development of RMS-RIF, was 8 years. The 3-year overall survival for RMS-RIF was 42%. The 3-year overall survival was 66% for patients receiving chemotherapy and local treatment (surgery and/or RT) compared to 29% for those who had systemic treatment only or local treatment only (P=.049). Other factors associated with increased 3-year overall survival included retinoblastoma initial diagnosis (P<.001), age ≤ 18 years at diagnosis of RMS-RIF (P=.003), favorable site (P=.008), and stage 1 disease (P=.002). Age at time of RMS-RIF, retinoblastoma initial tumor, favorable site, stage 1 disease, and use of both systemic and local treatment were found to be favorable prognostic factors for 3-year overall survival., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Purpose: To determine the patient, tumor, and treatment characteristics of patients with pilocytic astrocytoma (PA) and leptomeningeal dissemination (LMD)., Methods and Materials: A PubMed search of English-language studies pertaining to PA with LMD was performed using a combination of keywords that included juvenile pilocytic astrocytoma, low-grade astrocytoma, low-grade glioma, leptomeningeal dissemination, neuraxis spread, and radiotherapy. We found 26 studies with 58 patients between 1976 and 2005 that met these criteria., Results: The median survival for PA patients with LMD was 65 months. The 1-, 2-, and 5-year overall survival (OS) rate after the diagnosis of LMD was 81.1%, 75.7%, and 55.5%. The 1-, 2-, and 5-year progression-free survival (PFS) rate after the diagnosis of LMD was 69.3%, 66.5%, and 34.6%, respectively. Age, gender, primary site location, timing of LMD presentation (synchronous vs. metachronous), and LMD location did not significantly influence OS or PFS. No statistically significant difference was found in OS or PFS between the chemotherapy and radiotherapy groups. Likewise, no difference was found in OS or PFS according to the use of craniospinal irradiation vs. less extensive RT fields., Conclusions: Approximately one-half of PA patients were alive 5 years after the diagnosis of LMD. Both chemotherapy and radiotherapy have efficacy against LMD. Although the use of craniospinal irradiation did not have an effect on PFS, the patient numbers were small and a larger number treated with craniospinal irradiation is needed to determine its efficacy., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Sinonasal teratocarcinosarcoma is an extremely rare and aggressive neoplasm with <100 cases described in the literature and only 3 reported pediatric cases. We describe a 15-year-old male with a case of sinonasal teratocarcinosarcoma with extension to the cribriform plate. He presented with epistaxis, nasal obstruction, and frontal headaches and was treated with resection and postoperative chemoradiation. He is currently doing well without evidence of recurrence 45 months after therapy.

Purpose: To determine how the incorporation of PET-CT changes radiotherapy treatment in pediatric Hodgkin lymphoma., Procedure: Fifty-three Hodgkin lymphoma patients with a median age of 14 years (6-21 years) underwent multiagent chemotherapy followed by involved field radiotherapy (IFRT) to initial sites of disease. All patients had conventional staging which included CT scan of the neck, chest, abdomen and pelvis, bone marrow biopsy ± MRI, Gallium scan and bone scan. All had an initial 18-F-fluoro-deoxy-D-glucose (FDG) PET-CT. When there was discordance between conventional staging and PET-CT staging, true sites of disease were determined either by biopsy or response to multiagent chemotherapy., Results: In 19 of 53 (35.8%) patients, there was discordance between conventional staging and PET-CT findings. The most common location for the 23 sites of discordance were the spleen in 6 (26.1%), neck in 3 (13%), inguinal nodes in 3 (13%) and mediastinum in 3 (13%). A change in stage occurred in 5 (9.4%) as a result of PET-CT imaging. A change in IFRT fields occurred in 9 (17%); eight were more extensive while one was less extensive. For PET-CT, the specificity, sensitivity, positive predictive value and accuracy were 99.5%, 96.3%, 97.9%, and 98.9%., Conclusion: Incorporation of PET-CT information was found to influence IFRT design in 17% of patients, with most having more extensive radiotherapy fields., (Copyright © 2011 Wiley Periodicals, Inc.)

Purpose: To compare the characteristics and outcome of adults and children diagnosed with Wilms' tumor., Methods: The Surveillance, Epidemiology and End Results (SEER) database was analyzed for patients diagnosed with Wilms' tumor between 1973 and 2007. Patients were stratified into pediatric (<16 years) or adult (≥16 years) groups. Overall survival was the primary endpoint., Results: A total of 2342 patients (2190 pediatric and 152 adult) with Wilms' tumor were identified. Adult patients were statistically more likely to be staged as localized than pediatric patients (62.5% vs 44.7%), to not receive any lymph node sampling (57.9% vs 16.2%), and to not receive any radiation treatment (74.3% vs 53.9%). Adults had a statistically worse overall survival (OS) than pediatric patients (5-year OS, 69% vs 88%, P<.001) despite the earlier tumor stage. When stratified by treatment era, the OS of all patients treated after 1981 was statistically higher than those treated before (5-year OS, 75% vs 89%, P<.001). Significant predictors of OS on univariate analysis for adults included treatment era, SEER stage, surgery, and radiation treatment. Significant predictors of OS on multivariate analysis of all patients included adult status (hazard ratio, 4.14; P<.001), treatment era, SEER stage, and surgery., Conclusion: Adults in the SEER database had statistically worse OS than pediatric patients despite previous studies showing comparable outcome when treated on protocol. The worse outcome of SEER adults likely stems from incorrect diagnosis, inadequate staging and undertreatment. We recommend lymph node samplings for all adult Wilms' tumor patients and collaboration with pediatric oncologists., (Copyright © 2011 American Cancer Society.)

Background: To investigate the utility of stereotactic body radiotherapy (SBRT) in the treatment of painful renal cell carcinoma (RCC) bone metastases, and for a possible dose effect on time to symptom relief., Material and Methods: Eighteen patients with 24 painful osseous lesions from metastatic RCC were treated with SBRT. The most common treatment regimens were 24 Gy in 3 fractions and 40 Gy in 5 fractions. The times from treatment to first reported pain relief and time to symptom recurrence were evaluated. Median follow-up was 38 weeks (1-156 weeks)., Results: Seventy-eight percent of all patients had pain relief. Patients treated with a BED > 85 Gy achieved faster and more durable pain relief compared to those treated with a BED < 85 Gy. There was decrease in time to pain relief after a change in treatment regimen to 8 Gy × 5 fractions (BED = 86). There was only one patient with grade 1 skin toxicity. No neurological or other toxicity was observed., Conclusions: SBRT can safely and effectively treat painful RCC bony metastases. There appears to be a relationship between radiation dose and time to stable pain relief.

Purpose: Treatment for small-cell carcinoma of the bladder is largely guided by case reports, retrospective reviews, and small prospective trials. This study aimed to study outcomes using a large population-based database., Methods: The Surveillance, Epidemiology, and End Results-Medicare database (1991-2005) was used to analyze how different treatment combinations of specific bladder surgeries, chemotherapy, and radiation affected patient outcomes. Trends in the use of these combinations over time were also analyzed., Results: A total of 533 patients were retrieved from the database. A bladder-sparing approach involving transurethral resection of the bladder tumor (TURBT) combined with chemotherapy and radiation yielded no significant difference in overall survival compared with patients undergoing at least a cystectomy (of whom over 90% received radical cystectomy) with chemotherapy (p > 0.05). The analysis of treatment trends indicated that these two general strategies for cure combined to account for fewer than 20% of patients. A majority of patients (54%) received TURBT as their only surgical treatment, and a subset analysis of these patients indicated that chemotherapy played a role in all stages of disease (p < 0.05) whereas radiation improved overall survival in regional-stage disease (p < 0.05)., Conclusion: Relatively few patients with small-cell carcinoma of the bladder receive potentially curative therapies. Chemotherapy should be a major component of treatment. Cystectomy and bladder-sparing approaches represent two viable strategies and deserve further investigation to identify the patients who may benefit from organ preservation or not. In addition, the role of radiation in regional-stage disease should be investigated further, because it positively affects survival after TURBT., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Purpose: Bifocal germinoma (BFG) is a rare intracranial neoplasm for which the choice of radiation therapy (RT) field is controversial. Some believe that BFG represents disseminated disease requiring craniospinal irradiation (CSI), whereas others believe that BFG represents localized disease and advocate for more limited fields., Methods and Materials: We analyzed 20 BFG patients at our institutions with classic bifocal lesions (pineal gland and suprasellar region). In addition, we identified 60 BFG patients from the literature. The RT fields, use of chemotherapy and extent of disease were recorded and analyzed for each patient., Results: There were 55 patients with bifocal lesions only (Group I), and 25 with bifocal lesions plus ventricular and/or CSF positive disease (Group II). The 5-year progression-free survival was 95% for Group I and 80% for Group II. In Group I, there were no failures in patients receiving CSI (n = 11), two spinal failures in those treated with more limited RT fields without chemotherapy (n = 17), and one spinal failure with chemotherapy (n = 23). In Group II, there were no failures in patients receiving CSI (n = 11), but four spinal failures were observed in patients receiving more limited RT fields with chemotherapy (n = 13); 1 patient who received whole-brain RT without chemotherapy experienced failure in the spine and brain., Conclusions: CSI is associated with excellent PFS in BFG. In Group I BFG patients, omission of spinal irradiation appears to be a reasonable approach, especially when chemotherapy is used. Patients with Group II BFG are best treated with CSI., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Mucoepidermoid carcinoma (MEC) of the salivary glands has been reported to occur in patients previously treated with chemotherapy and/or radiation. The purpose of our study is to review the patient, tumor, and treatment characteristics of patients who develop a treatment-related MEC., Procedure: A PubMed search of English language articles was performed using the keywords and MeSH terms: mucoepidermoid, salivary gland, radiation-induced, second malignancy, radiotherapy, and chemotherapy., Results: The search yielded 23 articles describing 58 patients who received chemotherapy and/or radiotherapy (RT) and subsequently developed MEC. The most common initial diagnoses were acute lymphoblastic leukemia (n = 18), acne (n = 9), and Hodgkin lymphoma (n = 6). Patients were divided into three groups according to chemotherapy and RT treatment: chemotherapy alone (n = 14), RT alone (n = 14), or chemotherapy and RT (n = 30). The parotid gland was the most common site for secondary MEC. Latent time (LT) to development of MEC from initial tumor treatment was significantly shorter in the patients treated with chemotherapy ± RT versus RT alone (7.9 years vs. 27.2 years, P < 0.01). The most common treatment for MEC was surgery alone followed by surgery and postoperative RT. The 2- and 5-year overall survival rates were 98% and 93.4% while the 2- and 5-year locoregional control rates were 97.7% and 92.5%, respectively. There was no difference in survival or locoregional control between groups exposed to RT alone, chemotherapy alone, or chemotherapy with RT for the initial tumor., Conclusion: Radiation and chemotherapy-related MEC has an excellent prognosis., (Copyright © 2011 Wiley Periodicals, Inc.)

Background: Small cell carcinoma of the urinary bladder (SCCB) is difficult to characterize and study because of its rarity. For the current study, a large population-based database was used to address ill-defined clinical parameters for this disease., Methods: The authors analyzed the incidence, sociodemographics, prognostic variables, and treatment trends of this cancer in the Surveillance, Epidemiology, and End Results (SEER) limited database (1991-2005). The SEER-Medicare database (1991-2005) was used to estimate chemotherapy use., Results: There were 642 patients in the SEER limited dataset. From 1991 to 2005, the incidence of SCCB increased significantly from 0.05 to 0.14 cases per 100,000 population (P < .01; approximately 500 new cases of SCCB per year, representing 0.7% of all bladder malignancies). The median overall survival was 11 months. Elderly Caucasian men were the most commonly affected (ratio of Caucasians to non-Caucasians, 10:1; ratio of men to women, 3:1; median age, 73 years). Age, race, marital status, and TNM staging were identified as independent prognostic variables (P < .05). Patients who had stage IV disease without distant metastasis (ie, positive lymph node status) had overall and cancer-specific survival rates similar to those of patients who had stage I through III disease, but they had significantly better survival compared with patients who had distant metastasis (P < .0001). Transurethral resection of the bladder tumor became the most common surgical treatment (P < .0001), representing 55% of patients from 2001 to 2005. The receipt of radiation and chemotherapy did not change significantly during the study period., Conclusions: These comprehensive data delineated the patient population for this rare disease, described several independent prognostic variables, and demonstrated clear treatment trends for this disease. The results suggest that a simpler staging system (ie, limited stage vs extensive stage) may be appropriate for patients with SCCB., (Copyright © 2011 American Cancer Society.)

Stereotactic body radiation therapy (SBRT) is a promising treatment option for prostate cancer. Hypofractionation regimens, such as SBRT, may be more advantageous compared with conventional regimens because low α:β ratio of prostate cancer has high sensitivity to dose per fraction. In addition, a smaller and tighter margin with SBRT is expected to provide a low toxicity rate without reducing tumor control. The purpose of this article is to examine radiobiological, technical and clinical aspects of SBRT for prostate cancer.

Background: The current study was conducted to determine whether the use of cochlear-sparing intensity-modulated radiotherapy (IMRT) boost results in excess local failures in children with medulloblastoma., Methods: Fifty children with a median age of 7.8 years underwent resection, craniospinal irradiation (CSI), IMRT posterior fossa (PF) and/or tumor bed (TB) boost, and cisplatin-based chemotherapy for medulloblastoma. For standard-risk patients, the CSI dose was 18 to 23.4 grays (Gy) and was followed either by an IMRT PF boost to 36 Gy and a TB boost of 54 to 55.8 Gy (n = 29) or by an IMRT TB boost to 55.8 Gy (n = 4). For high-risk patients, the CSI dose was 36 to 39.6 Gy followed by an IMRT PF boost to 54 to 55.8 Gy (n = 8), an IMRT PF boost to 45 Gy and a TB boost to 55.8 Gy (n = 2), or an IMRT TB boost to 55.8 Gy (n = 7). For the TB boost, a 2-cm margin around the surgical bed was treated in most patients., Results: The 5-year overall and progression-free survival rates (±standard deviation) were 72% ± 6.6% and 68.3% ± 6.8%, respectively, for all patients; 77.8% ± 7.4% and 75.1% ± 7.6%, respectively, for standard-risk patients; and 60.8% ± 12.8% and 55.4% ± 12.8%, respectively, for high-risk patients. The 5-year PF control rate was 90.5% ± 4.6%. TB failures occurred in 3 patients (including 2 patients who had distant failure), whereas an isolated non-TB PF failure occurred in 1 patient., Conclusions: The use of IMRT was associated with excellent local control and did not result in excess PF failures outside of the TB., (Copyright © 2010 American Cancer Society.)

Purpose: The purpose of this study is to determine whether height measurements are affected by cranial radiation doses of 12-18 Gy., Patients and Methods: From 1997 to 2007, 23 children received cranial RT for T-cell or pre-B-cell acute lymphoblastic leukemia (ALL). Dose fractionation schemes included 18 Gy in 9 fractions (n = 8), 18 Gy in 10 fractions (n = 5), 12.6 Gy in 7 fractions (n = 6), and 12 Gy in 8 fractions (n = 4). These patients were matched and compared to a control group of 23 patients who had ALL but no cranial RT. Height z-scores at diagnosis and last follow-up were compared using the paired Student's t-test. Differences in z-scores according to host and treatment parameters were compared using the unpaired Student's t-test. Median follow-up for irradiated patients was 63.5 months while for unirradiated patients was 91 months., Results: The mean z-scores at initial diagnosis and last follow-up were 0.14 and -0.48 for patients receiving 12-12.6 Gy (P = 0.016), -0.16 and -0.89 for 18 Gy (P = 0.003), and 0.34 and 0.22 for no RT (P = 0.62). For children receiving RT, the mean difference in z-scores at initial diagnosis and last follow-up was -0.67 while for those not receiving RT, it was -0.10 (P = 0.043)., Conclusion: Children receiving 12-18 Gy cranial RT for ALL were found to have height impairment compared to those not receiving RT., (Copyright © 2010 Wiley-Liss, Inc.)

Purpose: To report the incidence of Pediatric Oncology Group (POG) Grade 3 or 4 ototoxicity in a cohort of patients treated with craniospinal irradiation (CSI) followed by posterior fossa (PF) and/or tumor bed (TB) boost using intensity-modulated radiation therapy (IMRT)., Methods and Materials: From 1998 to 2006, 44 patients with medulloblastoma were treated with CSI followed by IMRT to the PF and/or TB and cisplatin-based chemotherapy. Patients with standard-risk disease were treated with 18 to 23.4 Gy CSI followed by either a (1) PF boost to 36 Gy and TB boost to 54 to 55.8 Gy or (2) TB boost to 55.8 Gy. Patients with high-risk disease received 36 to 39.6 Gy CSI followed by a (1) PF boost to 54 to 55.8 Gy, (2) PF boost to 45 Gy and TB boost to 55.8 Gy, or (3) TB boost to 55.8 Gy. Median audiogram follow-up was 41 months (range, 11-92.4 months)., Results: POG Grade Ototoxicity 0, 1, 2, 3. and 4 was found in 29, 32, 11, 13. and 3 ears. respectively, with POG Grade 3 or 4 accounting for 18.2% of cases. There was a statistically significant difference in mean radiation dose (D(mean)) cochlea according to degree of ototoxicity, with D(mean) cochlea increasing with severity of hearing loss (p = 0.027)., Conclusions: Severe ototoxicity was seen in 18.2% of ears in children treated with IMRT boost and cisplatin-based chemotherapy. Increasing dose to the cochlea was associated with increasing severity of hearing loss., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Purpose: To perform a comprehensive literature review and analysis of cases dealing with choroid plexus carcinoma (CPC) to determine the optimal radiotherapy (RT) treatment field., Methods and Materials: A PubMed search of English language articles from 1979 to 2008 was performed, yielding 33 articles with 56 patients who had available data regarding RT treatment field. The median age at diagnosis was 2.7 years (range, 1 month-53 years). Of 54 patients with data regarding type of surgery, 21 (38.9%) had complete resection. Chemotherapy was delivered to 27 (48%) as part of initial therapy. The RT treatment volume was the craniospinal axis in 38 (68%), whole brain in 9 (16%), and tumor/tumor bed in 9 (16%). Median follow-up for surviving patients was 40 months., Results: The 5-year overall survival and progression-free survival (PFS) rates were 59.5% and 37.2%, respectively. Complete resection (p = 0.035) and use of craniospinal irradiation (CSI; p = 0.025) were found to positively affect PFS. The 5-year PFS for patients who had CSI vs. whole brain and tumor/tumor bed RT were 44.2% and 15.3%. For the 19 patients who relapsed, 9 (47%) had a recurrence in the RT field, 6 (32%) had a recurrence outside the RT field, and 4 (21%) had a recurrence inside and outside the irradiated field., Conclusion: Patients with CPC who received CSI had better PFS compared with those receiving less than CSI. This study supports the use of CSI in the multimodality management of patients with CPC., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

Stereotactic body radiation therapy (SBRT) is a novel treatment modality in radiation oncology that delivers a very high dose of radiation to the tumor target with high precision using single or a small number of fractions. SBRT is the result of technological advances in patient/tumor immobilization, image guidance, and treatment planning and delivery. This modality is safe and effective in both early stage primary cancer and oligometastases. Compared to the use of stereotactic radiosurgery for other tumor sites, SBRT is slow to be adopted in the management of genitourinary malignancies. There are now emerging data that show the safety and efficacy of this treatment modality in genitourinary (GU) malignancies especially in prostate cancer and renal cell carcinoma. Preclinical data, clinical experience, and challenges are reviewed and discussed.

Purpose: To review the existing literature regarding the characteristics, prognostic factors, treatment, and survival of patients with medulloblastoma, who develop extraneural metastasis (ENM)., Methods and Materials: A PubMed search of English language articles from 1961 to 2007 was performed, yielding 47 articles reporting on 119 patients. Factors analyzed included age, time interval to development of ENM, ENM location, central nervous system (CNS) involvement, treatment, and outcome., Results: Sites of ENM included bone in 84% of patients, bone marrow in 27% of patients, lymph nodes in 15% of patients, lung in 6% of patients, and liver in 6% of patients. Median survival was 8 months after diagnosis of ENM. The 1-, 2-, and 5-year overall survival (OS) rates after diagnosis of ENM were 41.9%, 31.0%, and 26.0%, respectively. The 1-, 2-, and 5-year progression-free survival (PFS) rates after diagnosis of ENM were 34.5%, 23.2%, and 13.4%, respectively. For patients without CNS involvement at the time of ENM diagnosis, the 1-, 2-, and 5-year OS rates for those treated with and without radiotherapy (RT) were 82.4%, 64.8%, and 64.8% vs. 51.0%, 36.6%, and 30.5%, respectively (p = 0.03, log-rank test). RT did not significantly improve OS or PFS rates for those with CNS involvement. Concurrent CNS involvement, ENM in the lung or liver, a time interval of <18 months to development of ENM, and a patient age of <16 years at ENM diagnosis were found to be negative prognostic factors for both OS and PFS., Conclusions: Several prognostic factors were identified for patients with ENM from medulloblastoma. Patients without concurrent CNS involvement, who received RT after ENM diagnosis had an OS and PFS benefit compared to those who did not receive RT., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

The kidneys are the dose-limiting organs for radiotherapy to upper abdominal cancers and during total body irradiation. The incidence of radiotherapy-associated kidney injury is likely underreported owing to its long latency and because the toxicity is often attributed to more common causes of kidney injury. The pathophysiology of radiation injury is poorly understood. Its presentation can be acute and irreversible or subtle, with a gradual progressive dysfunction over years. A variety of dose and volume parameters have been associated with renal toxicity and are reviewed to provide treatment guidelines. The available predictive models are suboptimal and require validation. Mitigation of radiation nephropathy with angiotensin-converting enzyme inhibitors and other compounds has been shown in animal models and, more recently, in patients., (Copyright 2010 Elsevier Inc. All rights reserved.)

Late effects in normal tissues following radiotherapy vary across the age spectrum. It seems that sensitivity to radiation injury is a function of the developmental dynamics and status of the organ, its regenerative potential, and ultimately the extent to which it has begun to senesce. For instance, organ maturational processes in children can be impaired or even disabled by radiation therapy, leading to a spectrum of effects that differ from those in adults, in which the capacity and means for tissues to repair damage are the predominant predictor for chronic injury. Thus, radiation-induced impairment of growth and maturation is unique to children, whereas organ damage, with tissue-specific dysfunction in repair processes, is common to both children and adults. Finally, the susceptibility to late effects in the elderly seems to involve not only a decline in their ability to repair damage, but also cell attrition, all intertwined with effects of comorbid illness that are frequent in this age group. The challenge for clinicians is to understand these differences in the sensitivity to radiation damage with respect to age to formulate a basis for modulating therapy that can rationally minimize late effects and maximize a survivor's quality of life.

Alveolar rhabdomyosarcoma (RMS) of the extremity is not infrequently associated with regional node metastasis. Knowledge of lymphatic drainage of extremity RMSs is important to determine radiotherapy fields. In this report we describe two patients with alveolar RMS of the lower extremity with inguinal metastasis at presentation. Both the distal lower extremity and inguinal region received local therapy consisting of surgery and postoperative radiotherapy. Both patients later developed in-transit lymphatic metastasis outside of the irradiated field. The in-transit lymphatics can be a site of failure in children with alveolar RMS of the extremity and nodal involvement., ((c) 2009 Wiley-Liss, Inc.)

Stereotactic radiosurgery (SRS) is one of the least invasive treatments for trigeminal neuralgia (TN). To date, most reports have been about Cobalt-based treatments (i.e., Gamma Knife) with limited data on image-guided stereotactic linear accelerator treatments. We describe our initial experience of using BrainLAB Novalis stereotactic system for the radiosurgical treatment of TN. A total of 20 patients were treated between July 2004 and February 2007. Each SRS procedure was performed using the BrainLAB Novalis System. Thin cuts MRI images of 1.5 mm thickness were acquired and fused with the simulation CT of each patient. Majority of the patients received a maximum dose of 90 Gy. The median brainstem dose to 1.0 cc and 0.1 cc was 2.3 Gy and 13.5 Gy, respectively. In addition, specially acquired three-dimensional fast imaging sequence employing steady-state acquisition (FIESTA) MRI was utilized to improve target delineation of the trigeminal proximal nerve root entry zone. Barrow Neurological Index (BNI) pain scale for TN was used for assessing treatment outcome. At a median follow-up time of 14.2 months, 19 patients (95%) reported at least some improvement in pain. Eight (40%) patients were completely pain-free and stopped all medications (BNI Grade I) while another 2 (10%) patients also stopped medications but reported occasional pain (BNI Grade II). Another 2 (10%) patients reported no pain and 7 (35%) patients only occasional pain while continuing medications, BNI Grade IIIA and IIIB, respectively. Median time to pain control was 8.5 days (range: 1-70 days). No patient reported severe pain, worsening pain or any pain not controlled on their previously taken medication. Intermittent or persistent facial numbness following treatments occurred in 35% of patients. No other complications were reported. Stereotactic radiosurgery using the BrainLAB Novalis system is a safe and effective treatment for TN. This information is important as more centers are obtaining image-guided stereotactic-based linear accelerators capable of performing radiosurgery.

Purpose: To identify pretreatment characteristics and radiotherapy parameters which may influence time interval to development of radiation-associated meningioma (RAM)., Methods and Materials: A Medline/PUBMED search of articles dealing with RAM yielded 66 studies between 1981 and 2006. Factors analyzed included patient age and gender, type of initial tumor treated, radiotherapy (RT) dose and volume, and time interval from RT to development of RAM., Results: A total of 143 patients with a median age at RT of 12 years form the basis of this report. The most common initial tumors or conditions treated with RT were medulloblastoma (n = 27), pituitary adenoma (n = 20), acute lymphoblastic leukemia (n = 20), low-grade astrocytoma (n = 19), and tinea capitis (n = 14). In the 116 patients whose RT fields were known, 55 (47.4%) had a portion of the brain treated, whereas 32 (27.6%) and 29 (25.0%) had craniospinal and whole-brain fields. The median time from RT to develop a RAM or latent time (LT) was 19 years (range, 1-63 years). Male gender (p = 0.001), initial diagnosis of leukemia (p = 0.001), and use of whole brain or craniospinal field (p

Combined modality treatment (neoadjuvant chemoradiotherapy followed by surgery) for locally advanced rectal cancer requires special attention to various organs at risk (OAR). As a result, the use of conformal dose delivery methods has become more common in this disease setting. Helical tomotherapy is an image-guided intensity modulated delivery system that delivers dose in a fan-beam manner at 7 degree intervals around the patient and can potentially limit normal tissue from high dose radiation while adequately treating targets. In this study we dosimetrically compare helical tomotherapy to 3D-CRT for stage T3 rectal cancer. The helical tomotherapy plans were optimized in the TomoPlan system to achieve an equivalent uniform dose of 45 Gy for 10 patients with T3N0M0 disease that was at least 5cm from the anal verge. The GTV included the rectal thickening and mass evident on colonoscopy and CT scan as well as with the help of a colorectal surgeon. The CTV included the internal iliac, obturator, and pre-sacral lymphatic chains. The OAR that were outlined included the small bowel, pelvic bone marrow, femoral heads, and bladder. Anatom-e system was used to assist in delineating GTV, CTV and OAR. These 10 plans were then duplicated and optimized into 3-field 3D-CRT plans within the Pinnacle planning system.The V[45], V[40], V[30], V[20], V[10], and mean dose to the OAR were compared between the helical tomotherapy and 3D-CRT plans. Statistically significant differences were achieved in the doses to all OAR, including all volumes and means except for V[10] for the small bowel and the femoral heads. Adequate dosimetric coverage of targets were achieved with both helical tomotherapy and 3D-CRT. Helical tomotherapy reduces the volume of normal tissue receiving high-dose RT when compared to 3D-CRT treatment. Both modalities adequately dose the tumor. Clinical studies addressing the dosimetric benefits are on-going.

The purpose of this study was to determine the perceived and actual chin position(s) used for radiotherapy of head-and-neck cancers in a variety of clinical settings. Dosimetrists were asked to describe the external landmarks used to set the chin position. The lateral treatment planning radiographic figures in Ang's textbook, Radiotherapy for Head and Neck Cancers: Indications and Techniques, were analyzed for chin position by drawing a horizontal line from the tip of the chin to the cervical spine. The physicians at 7 departments were asked to rate the chin positions used in their departments for head-and-neck simulations. Choices included: (1) mildly flexed, (2) neutral, (3) mildly extended, and (4) hyperextended. In addition, each center was asked to select 2 representative cases to show routine chin position. The dosimetrists fixed the chin in neutral position by placing a virtual plane defined by 3 points (the base of the nasal septum [acanthus] and the external auditory canals) perpendicular to the table top. The type of head holder was irrelevant. Eighty-two percent (31/38) of the figures in Ang's text showed positioning in the neutral position (tip of the chin intersected the cervical spine between C2-3/C3-4). Most (71.4%) of the radiotherapists thought their patients were treated in the hyperextended neck position but, in fact, 85.7% (12/14) of the simulations showed a neural neck position. Reproducible chin positioning can be obtained by using the acanthiomeatal line. Consistent use of this technique will create a uniformly positioned set of axial co-images that have consistent appearance of avoidance and lymphatic areas. This will simplify contouring on axial computed tomography (CT) images of the neck. Standardizing the chin position is an important step to developing a standardized atlas and developing an information tool for automated contouring.

Purpose: Contribution of total body irradiation (TBI) to renal toxicity in children undergoing the bone marrow transplant (BMT) remains controversial. We report our institutional retrospective study that evaluates the frequency of acute and chronic renal dysfunction in children after using total body irradiation (TBI) conditioning regimens., Materials and Methods: Between 1995 and 2003, 60 children with hematological malignancies underwent TBI as part of a conditioning regimen before allogeneic BMT. Patients received 4-14Gy at 1.75-2Gy/fraction in six-eight fractions. Lung shielding was used in all patients to limit lung dose to less than 10Gy; renal shielding was not utilized. All patients had baseline renal function assessment and renal dysfunction post-BM was mainly evaluated on the basis of persistent serum creatinine elevation at acute (0-90 days) and chronic (>90 days) intervals after completion of BMT., Results: Acute renal dysfunction (ARD) was documented in 27 patients (45%); the majority had concurrent diagnosis of veno-occlusive disease (VOD) or graft-versus-host disease (GVHD) and other potential causes (sepsis, antibiotic). The risk for delayed renal dysfunction (DRD) at 1 year approached 25% for surviving patients. The ARD was strongly linked with the risk of the DRD. There was no statistically significant relationship between ARD, DRD and underlying diagnosis, GVHD, VOD or TBI doses with both univariate and multivariate analyses. The younger age (<5 years) had significantly increased risk for the development of ARD (p=0.011)., Conclusion: Our analysis validates high incidence of renal dysfunction in the pediatric BMT population. In contrast to other reports we did not find total body irradiation dose to be a risk factor for renal dysfunction. Future prospective studies are needed to assess risk factors and interventions for this serious toxicity in children following allogeneic BM.

Purpose: To examine the patterns of failure in patients treated with intensity-modulated radiotherapy (IMRT) for head-and-neck rhabdomyosarcoma (RMS)., Methods and Materials: Between 1998 and 2005, 19 patients with a diagnosis of head-and-neck RMS received IMRT at The Methodist Hospital. There were 11 male and 8 female patients, with a median age of 6 years at time of irradiation. Tumor location was parameningeal in 7, orbital in 6, and other head-and-neck RMS in 6. Chemotherapy was given to all patients, with vincristine, actinomycin D, and cyclophosphamide being the most common regimen (n = 18). The median prescribed dose was 5040 cGy. The clinical target volume included the gross tumor volume with a 1.5-cm margin. The median duration of follow-up for surviving patients was 56 months., Results: The 4-year overall survival and local control rates were 76% and 92.9%, respectively. One patient developed a local failure in the high-dose region of the radiation field; there were no marginal failures. Distant metastasis was seen in 4 patients. Overall survival was 42.9% for parameningeal sites and 100% for other sites (p < 0.01). Late toxicities were seen in 7 patients. Two secondary malignancies occurred in 1 child with embryonal RMS of the face and a p53 mutation., Conclusions: Local control was excellent in patients receiving IMRT for head-and-neck RMS. Patterns of local failure reveal no marginal failures in this group of patients.

Purpose: Acute and late changes in magnetic resonance imaging of the pediatric brain have been described after radiotherapy (RT). We report the post-RT neuroimaging changes in the posterior fossa after intensity-modulated RT (IMRT) in children with medulloblastoma and contrast them with those of leptomeningeal disease., Methods and Materials: We performed a retrospective review of 53 consecutive children with medulloblastoma who were treated with craniospinal RT followed by IMRT to the posterior fossa and chemotherapy between 1997 and 2006., Results: After IMRT to the posterior fossa, 8 (15%) of 53 patients developed increased fluid-attenuated inversion-recovery signal changes in the brainstem or cerebellum and patchy, multifocal, nodular contrast enhancement at a median of 6 months. The enhancement superficially resembled leptomeningeal disease. However, the enhancement resolved without intervention at a median of 6 months later. The accompanying fluid-attenuated inversion-recovery signal changes occasionally preceded the enhancement, were often parenchymal in location, and resolved or persisted to a lesser degree. All 8 patients with transient magnetic resonance imaging changes in the posterior fossa were alive at last follow-up. In contrast, leptomeningeal disease occurred in 8 (15%) of our 53 patients at a median of 19.5 months after IMRT completion. Of these 8 patients, 7 demonstrated initial nodular enhancement outside the conformal field, and 7 patients died., Conclusion: Magnetic resonance imaging changes can occur in the posterior fossa of children treated with IMRT for medulloblastoma. In our experience, these transient changes occur at a characteristic time and location after RT, allowing them to be distinguished from leptomeningeal disease.

Purpose: To report the results, demographic data, and resident evaluation of the 2007 ACR radiation oncology in-training (TXIT) examination., Methods: The 2007 TXIT examination consisted of 360 multiple-choice questions covering 13 different subject areas. It included 9 demographic questions and 7 evaluation items. Five hundred seventy-two residents from 85 institutions took the 2007 TXIT examination., Results: The median raw score was 218.3 +/- 29 (range, 140-295). The mean item difficulty was 60.7%, with mean item discrimination of 0.19. The reliability coefficient was 0.92. Of the respondents to the demographic questions, 550 (96.2%), 493 (86.2%), and 402 (70.3%) residents had formal physics, biology, and clinical oncology instruction, respectively. Clinical experience was highest in breast, genitourinary, and lung cancers and lowest in soft-tissue sarcomas, pediatric tumors, and orbital neoplasms. Formal instruction in cancer biology, intensity-modulated radiation therapy, and statistics was reported by 416 (72.7%), 383 (67.0%), and 245 (42.8%) residents, respectively. On the basis of residents' responses to the evaluation questions, 31 (5.4%) did not know that the examination book was available to them after the test, 47 (8.2%) did not know that an answer key was available, and 79 (13.8%) residents did not know that rationales were available for future study., Conclusions: The reliability estimate for the ACR TXIT examination was high, typical of carefully constructed in-training examinations. The availability of the examination book, answer key, and rationales was not known by approximately 5% to 15% of residents taking the TXIT examination; therefore, a better method of informing the residents of these educational tools is needed.

Purpose: To review the literature regarding the role of radiotherapy (RT) in the treatment of patients with radiation-induced malignant gliomas (RIMGs)., Methods and Materials: A PubMed search of English-language articles dealing with RIMG was performed, yielding 52 articles with 92 patients available for review., Results: Initial tumor types treated with RT included brain tumor in 37 patients (40%), acute lymphoblastic leukemia in 33 (36%), benign disease in 11 (12%), and other in 11 (12%). Median time from RT to development of an RIMG was 8.75 years (range, 2.5-61 years). The RIMG occurred within 10 years after RT in 81% of patients with acute lymphoblastic leukemia/lymphoma, 59% of patients with brain/other, and 18% of patients with benign conditions (p = 0.002). Type of RIMG was glioblastoma in 69 (75%) and anaplastic astrocytoma in 23 (25%). One-, 2-, and 5-year overall survival rates were 29.3%, 7.3%, and 0% for patients with glioblastoma and 59.7%, 30.3%, and 20.2% for patients with anaplastic astrocytoma. For the 85 patients with data regarding treatment for RIMG, 35 underwent reirradiation to a median dose of 50 Gy (range, 30-76 Gy). For patients undergoing reirradiation, 1-, 2- and 5-year overall survival rates were 58.9%, 20.5%, and 6.8%. For those not undergoing reirradiation, they were 15.1%, 3%, and 0% (p = 0.0009)., Conclusions: The RIMG appeared earlier in patients treated for leukemia and lymphoma and latest for those treated for a benign condition. Patients who underwent reirradiation for RIMG have longer survival times compared with those not receiving RT.

Purpose: To determine the patterns of failure after intensity-modulated radiation therapy (IMRT) for localized intracranial ependymoma., Methods and Materials: From 1994 to 2005, 22 children with pathologically proven, localized, intracranial ependymoma were treated with adjuvant IMRT. Of the patients, 12 (55%) had an infratentorial tumor and 14 (64%) had anaplastic histology. Five patients had a subtotal resection (STR), as evidenced by postoperative magnetic resonance imaging. The clinical target volume encompassed the tumor bed and any residual disease plus margin (median dose 54 Gy). Median follow-up for surviving patients was 39.8 months., Results: The 3-year overall survival rate was 87% +/- 9%. The 3-year local control rate was 68% +/- 12%. There were six local recurrences, all in the high-dose region of the treatment field. Median time to recurrence was 21.7 months. Of the 5 STR patients, 4 experienced recurrence and 3 died. Patients with a gross total resection had significantly better local control (p = 0.024) and overall survival (p = 0.008) than those with an STR. At last follow-up, no patient had developed visual loss, brain necrosis, myelitis, or a second malignancy., Conclusions: Treatment with IMRT provides local control and survival rates comparable with those in historic publications using larger treatment volumes. All failures were within the high-dose region, suggesting that IMRT does not diminish local control. The degree of surgical resection was shown to be significant for local control and survival.

Purpose: To describe our preliminary experience with supine craniospinal irradiation. The advantages of the supine position for craniospinal irradiation include patient comfort, easier access to maintain an airway for anesthesia, and reduced variability of the head tilt in the face mask., Methods and Materials: The cranial fields were treated with near lateral fields and a table angle to match their divergence to the superior edge of the spinal field. The collimator was rotated to match the divergence from the superior spinal field. The spinal fields were treated using a source to surface distance (SSD) technique with the couch top at 100 cm. When a second spinal field was required, the table and collimator were rotated 90 degrees to allow for the use of the multileaf collimator and so the gantry could be rotated to match the divergence of the superior spinal field. The multileaf collimator was used for daily dynamic featherings and field-in-field dose control., Results: With a median follow-up of 20.2 months, five documented failures and no cases of radiation myelitis occurred in 23 consecutive patients. No failures occurred in the junctions of the spine-spine or brain-spine fields. Two failures occurred in the primary site alone, two in the spinal axis alone, and one primary site failure plus distant metastasis. The median time to recurrence was 17 months., Conclusion: The results of our study have shown that supine approach for delivering craniospinal irradiation is not associated with increased relapses at the field junctions. To date, no cases of radiation myelitis have developed.

The role of radiation therapy for those with leukemia cutis, particularly pediatric patients, remains unclear. This report describes the first two cases of disseminated leukemia cutis in adolescents treated with total skin electron beam therapy. Both patients had resolution of their skin disease and significant palliation of symptoms. Total skin electron irradiation is an option for adolescents suffering from significant extramedullary leukemia involving the skin. While it is uncertain if this treatment has any improvement in disease-free survival, the benefits of total skin electron therapy for symptom palliation should be considered., ((c) 2008 Wiley-Liss, Inc.)

Stereotactic radiosurgery (SRS) and fractionated stereotactic radiotherapy (FSRT) programs to treat brain tumors were implemented when we first acquired the Brainlab Novalis system in 2003. Two years later, we started an extra-cranial stereotactic radio-ablation or more appropriately a stereotactic body radiation therapy (SBRT) program using the Brainlab Novalis image-guided system at The Methodist Hospital in Houston, Texas. We hereby summarize our initial experience with this system in delivering image-guided SBRT to a total of 80 patients during our first year of clinical implementation, from February 2005 to January 2006. Over 100 lesions in more than 20 distinct anatomical sites were treated. These include all levels of spine from cervical, thoracic, lumbar, and sacral lesions. Spinal lesions encompass intramedullary, intradural, extradural, or osseous compartments. Also treated were lesions in other bony sites including orbit, clavicle, scapula, humerus, sternum, rib, femur, and pelvis (ilium, ischium, and pubis). Primary or metastatic lesions located in the head and neck, supraclavicular region, axilla, mediastinum, lung (both central and peripheral), abdominal wall, liver, kidney, para-aortic lymph nodes, prostate, and pelvis were also treated. In addition to primary radiotherapy, SBRT program using the Brainlab Novalis system allows re-irradiation for recurrence and "boost" after conventional treatment to various anatomical sites. Treating these sites safely and efficaciously requires knowledge in radiation tolerance, fraction size, total dose, biologically equivalent dose (BED), prior radiotherapy, detailed dose volume histograms (DVH) of normal tissues, and the radiosensitive/radioresistant nature of the tumor. Placement of radio-opaque markers (Visicoil, Radiomed) in anatomical sites not in close proximity to bony landmarks (e.g., kidney and liver) helps in measuring motion and providing image guidance during each treatment fraction. Tumor/organ motion data obtained using 4D-CT while the patient is immobilized in the body cast aids in planning treatment margin and determining the need for respiratory motion control, e.g., abdominal compressor, gating, or active breathing control. The inclusion of PET/CT to the Brainlab treatment planning system further refines the target delineation and possibly guides differential fraction size prescription and delivery. The majority of the patients tolerated the SBRT treatment well despite the longer daily treatment time when compared to that of conventional treatment. All patients achieved good pain relief after SBRT. Compared to conventional standard radiotherapy of lower daily fraction size, we observed that the patients achieved faster pain relief and possibly more durable symptom control. Very high local control with stable disease on imaging was observed post SBRT. Our initial experience shows that the Brainlab Novalis system is very versatile in delivering image-guided SBRT to various anatomical sites. This SBRT approach can be applied to either primary or metastatic lesions in the primary, "boost," or re-irradiation settings. The understanding of fraction size, total dose, BED, and DVH of normal tissues is very important in the treatment planning. Appropriate use of immobilization devices, radio-opaque markers for image-guidance, 4D-CT for tumor/organ motion estimates, and fusion of planning CT scans with biological/functional imaging will further improve the planning and delivery of SBRT, hopefully leading to better treatment outcome.

Background: To determine prognostic factors for local control in the radiotherapeutic management of non-metastatic Ewing sarcoma., Procedure: Forty patients with localized Ewing sarcoma (ES) were treated with primary site RT at one institution. Median RT dose was 55.8 Gy (range, 25.5-76 Gy). Chemotherapy was given to 34 patients (85%) with the most common regimen being vincristine, dactinomycin, cyclophosphamide, doxorubicin alternating with ifosfamide and etoposide (VACA + IE) in 10. Median follow-up for surviving patients was 12.3 years (range, 1.7-26.4 years)., Results: The 5- and 10-year local control rate was 78.2%. On multivariate analysis, RT dose was the only prognostic factor to impact on local control. The 5- and 10-year local control rate was 88.7% for RT dose >or=49 Gy and was 37.5% for <49 Gy (P = 0.0002, log-rank test). For tumors or=49 Gy and 50.0% for RT dose <49 Gy (P = 0.01, log-rank test). For tumors >8 cm, the 5- and 10-year local control rate was 85.7% for RT dose >or=54 Gy and 26.7% for RT dose <54 Gy (P = 0.006, log-rank test)., Conclusions: Radiotherapy dose was found to influence local control in ES. In particular, patients who received RT doses >or=49 Gy for tumor size or=54 Gy for tumor size >8 cm had improved local control.

Background: Chemotherapy and intensity-modulated radiotherapy (IMRT) have decreased treatment-related complications in adult patients with nasopharyngeal carcinoma (NPC). Our aim was to evaluate the toxicity profile of IMRT plus chemotherapy in pediatric NPC patients., Observations: Five patients were treated with chemotherapy and IMRT. All patients experienced grade 3-4 acute toxicities. With a median follow-up of 6.3 years, all patients experienced >or=3 long-term toxicities. The most common toxicities were hypothyroidism, xerostomia, hearing loss, and dental disease., Conclusions: We did not observe a significant decrease in long-term toxicities with IMRT plus chemotherapy in our small cohort of pediatric NPC patients.

Renal cell carcinoma (RCC) is often regarded as a radiation-resistant tumor. However, radiation therapy (RT) in the form of stereotactic radiosurgery (SRS) or whole-brain irradiation has been used to treat brain metastases from RCC. To date, there have been no clinical pathologic correlative findings before and after RT. Herein, we present a case of a patient with brain metastases from RCC treated with SRS. The diagnosis of clear-cell RCC was made in 2001 after right radical nephrectomy. He was also found to have lung metastases at diagnosis. He presented with neurologic symptoms in 2004, and magnetic resonance imaging showed 3 brain lesions with a significant amount of edema consistent with brain metastases. The largest lesion caused a midline shift and was surgically resected. Pathology revealed metastatic RCC. The other 2 smaller brain lesions were treated at 20 Gy respectively with shaped-beam SRS using the BrainLab Novalis system. No whole-brain irradiation was delivered. However, the patient had difficulty weaning off his steroids, and a magnetic resonance imaging performed 6 months after SRS was read as "progression of the lesions." He then underwent resection of both the irradiated brain lesions. Pathologic examination revealed necrotic tissues without any viable tumor identified. The patient has since been doing very well, now 18 months after SRS and 5 years from the initial diagnosis. This is the first reported case that demonstrates that precise high-dose radiation in the form of SRS can cause significant tumor cell death (pathologic complete response) in radiation-resistant brain metastases from RCC. This finding also provides a rationale to deliver stereotactic body RT for primary and metastatic RCC extracranially. A prospective clinical trial using stereotactic body RT for primary and metastatic RCC is under way.

The standard treatment for medulloblastoma is surgery followed by adjuvant chemotherapy and external beam radiotherapy to the craniospinal axis and posterior fossa. However, in very young children, craniospinal irradiation has a more significant detrimental effect in terms of neurocognitive function and growth. This article reviews the different strategies used for very young patients with medulloblastoma.

Purpose: To examine prognostic factors for primary site control and analyze late effects according to local treatment modality in non-metastatic Ewing sarcoma (ES)., Materials and Methods: From 1976 to 2001, 76 patients with localized ES and a median age of 14.5 years were seen and treated at one institution. Tumors were located in the extremity in 38, pelvis in 13, spine in 11, trunk in 8, and head and neck in 6. Tumor size was < or = 8 cm in 44 and >8 cm in 32. Local therapy included radiotherapy (RT) alone in 40, surgery (S) alone in 27, and surgery followed by postoperative radiotherapy (S + RT) in 9. Chemotherapy (CT) was delivered to 65 patients (86%). Median follow-up for surviving patients was 9.7 years., Results: The 5- and 10-year overall survival rates were 57.5% and 52.1% while the 5- and 10-year local control rate was 79.2%. The 5- and 10-year local control rates were 78.2% for RT, 77.6% for surgery, and 88.9% for S + RT (P = 0.68). Multivariate analysis showed that only the use of CT was found to be a prognostic factor for local control (P = 0.014). The 5- and 10-year local control rates were 83.7% for those receiving CT and 51.1% for those not receiving CT. For patients followed at least 5 years from diagnosis, late effects were seen in 10 of 19 (52.6%) receiving RT, 2 of 5 (40%) receiving S + RT, and 4 of 16 (25%) receiving surgery alone. The most common late effects with RT were muscular atrophy, limb length growth delay, and development of second malignancy. Scoliosis and decrease range of motion of an extremity were seen regardless of local treatment modality. Three patients who had surgery alone had an amputation whereas two who had RT had an amputation secondary to relapse or development of osteosarcoma., Conclusion: In this single institution study, the use of CT was the only factor found to impact on local control. Late effects were common regardless of local control strategy.

Computer visualization techniques (CVTs) are an emerging technology that can organize all cancer specialists. This article describes CVTs' ability to maximize the currently untapped advantages of intensity modulated radiotherapy (IMRT). The visual speed and dynamic strategies inherent in CVTs improves IMRT by distilling vast amounts of anatomic, multimodal imaging, textual/meaning, and surgical/outcome data into a large, rigorous, standardized evidence base of storable target delineation plans. This ability to standardize strategies will allow the collection of meaningful evidence based outcome data.

Mantle field radiotherapy for Hodgkin's disease is complicated by significant dose gradient (up to 10-20%) across the large fields required. Many different strategies of tissue compensation have been investigated, including custom physical compensators to provide better dose distributions. We present a method using dynamic multileaf collimator (dMLC) fluence modulation to simultaneously shape the treatment field and give homogeneous dose at depth throughout the classic mantle field. Five patients were treated for early-stage Hodgkin's disease with a conventional anterior-posterior-posterior-anterior (AP-PA) mantle field. The patients were planned using the Varian Eclipse treatment planning system, version 6.1.3, and treated on a Varian 2300CD. An AP-PA dynamic MLC beam-shaped and dose-compensated plan was created for each, and compared with the conventional blocked plan. Nine dose points were calculated at midplane in each plan. Chamber measurements were taken to confirm accurate dMLC delivery of the planned doses. The mean dose per fraction, relative to a central axis dose of 1.8 Gy, was increased in the conventional plans compared with the dMLC plans in the right (R) neck, left (L) neck, R supraclavicular, L supraclavicular, and L axillary points. The mediastinum tended to be underdosed relative to central axis, with the mid-mediastinal and lower mediastinal points showing improved coverage with the dMLC plans. Measurements showed excellent agreement between planned doses and delivered doses, with less than 2% in-field variation. Dynamic MLC fluence modulation was used to effectively deliver a mantle field that is both shape- and electronically-dose-compensated with sliding window MLC. Homogeneity was significantly improved throughout the treatment field, and measurements confirmed accurate dose delivery using this technique.

Purpose: The moyamoya syndrome is an uncommon late complication after radiotherapy (RT)., Methods and Materials: A PubMed search of English-language articles, with radiation, radiotherapy, and moyamoya syndrome used as search key words, yielded 33 articles from 1967 to 2002., Results: The series included 54 patients with a median age at initial RT of 3.8 years (range, 0.4 to 47). Age at RT was less than 5 years in 56.3%, 5 to 10 years in 22.9%, 11 to 20 years in 8.3%, 21 to 30 years in 6.3%, 31 to 40 years in 2.1%, and 41 to 50 years in 4.2%. Fourteen of 54 patients (25.9%) were diagnosed with neurofibromatosis type 1 (NF-1). The most common tumor treated with RT was low-grade glioma in 37 tumors (68.5%) of which 29 were optic-pathway glioma. The average RT dose was 46.5 Gy (range, 22-120 Gy). For NF-1-positive patients, the average RT dose was 46.5 Gy, and for NF-1-negative patients, it was 58.1 Gy. The median latent period for development of moyamoya syndrome was 40 months after RT (range, 4-240). Radiation-induced moyamoya syndrome occurred in 27.7% of patients by 2 years, 53.2% of patients by 4 years, 74.5% of patients by 6 years, and 95.7% of patients by 12 years after RT., Conclusions: Patients who received RT to the parasellar region at a young age (<5 years) are the most susceptible to moyamoya syndrome. The incidence for moyamoya syndrome continues to increase with time, with half of cases occurring within 4 years of RT and 95% of cases occurring within 12 years. Patients with NF-1 have a lower radiation-dose threshold for development of moyamoya syndrome.

Objective: The purpose of this study was to evaluate the patterns and distribution of tumor shape and its temporal change during radiation therapy (RT) in cervical cancer and the effect of tumor configuration changes on the correlation between region of interest (ROI)-based and diameter-based MRI tumor measurement., Materials and Methods: Serial MRI examinations (T1-weighted and T2-weighted images) were performed in 60 patients (age range, 29-75 years; mean, 53.3 years) with advanced cervical cancer (stages IB2-IVB/recurrent) who were treated with RT at four time points: start of RT, during RT (at 2-2.5 and at 4-5 weeks of RT), and post-RT. Tumor configuration was classified qualitatively into oval, lobulated, and complex based on MR film review. Two methods of tumor volume measurement were compared: ellipsoid computation of three orthogonal diameters (diameter based) and ROI volumetry by delineating the entire tumor volume on the MR workstation (ROI based). Temporal changes of tumor shape and the respective tumor volumes measured by the two methods were analyzed using linear regression analysis., Results: Most tumors (70%) had a non-oval (lobulated and complex) shape before RT and became increasingly irregular during and after RT: 84% at 2-2.5 weeks of RT (p = 0.037), 86% (p = 0.025) at 4-5 weeks, and 96% post-RT (p = 0.010), compared with 70% pre-RT. Diameter-based and ROI-based measurement correlated well before RT (r = 0.89) but not during RT (r = 0.68 at 2-2.5 weeks, r = 0.67 at 4-5 weeks of RT)., Conclusion: Most cervical cancers are not oval in shape pretherapy, and they become increasingly irregular during and after therapy because of nonconcentric tumor shrinkage. ROI-based volumetry, which can optimally measure irregular volumes, may provide better response assessment during treatment than diameter-based measurement.

Objective: To compare three different techniques of irradiating abdominal neuroblastoma., Patients and Methods: Six children with a median age of 4.1 years underwent radiotherapy (RT) to the primary site as part of treatment for high-risk neuroblastoma. Four had midline disease while two had well-lateralized lesions. Three different RT techniques were compared. Technique A used parallel-opposed AP/PA fields prescribed to the midplane of the patient. For Techniques B and C, intensity modulated radiation therapy (IMRT) plans were developed using inverse treatment planning with a sliding window or dynamic multileaf collimator approach, seven coplanar beams, and a 0.25 x 0.5 cm minimum beam resolution. The clinical target volume (CTV) included the tumor present prior to second look surgery but after induction chemotherapy with a 1.5 cm margin. The planning target volume (PTV) was the CTV with a 0.5 cm margin. The CTV was planned to receive 100% of the prescribed dose. For Technique C, the vertebral bodies adjacent to the tumor were included in the PTV to minimize heterogeneity of dose. Six MV photons were used for all techniques. Bilateral kidneys, liver, spine, spleen, stomach and bilateral iliac crests were contoured., Results: Dose to the PTV and CTV were not significantly different using the three techniques. In comparison to Technique A, Techniques B and C delivered a lower mean dose to the bilateral kidneys in the four children with midline tumors but not the two children with a lateralized tumor where the contralateral kidney received a higher mean dose. Dose to the spine was less homogeneous with Technique B compared to Techniques A and C. The spleen, liver and stomach mean doses were higher using Techniques B and C compared to Technique A., Conclusion: Although Technique C was the best method of RT delivery in midline tumors with respect to kidney doses, this was at a cost of a higher mean dose to the liver, stomach, and spleen. This, together with the theoretical increase in secondary malignancies, should be considered when treating a child with IMRT techniques. IMRT was not found to be better than the conventional AP/PA field for lateralized tumors., ((c) 2005 Wiley-Liss, Inc.)

Brain metastases from renal cell carcinoma (RCC) cause significant morbidity and mortality. More effective treatment approaches are needed. Traditionally, whole-brain radiotherapy has been used for palliation. With advances in radiation oncology, stereotactic radiosurgery and hypofractionated stereotactic radiotherapy have been utilized for RCC brain metastases, producing excellent outcomes. This review details the role of radiotherapy in various subgroups of patients with RCC brain metastases as well as the associated toxicities and outcomes. Newer radiosensitizers (eg, motexafin gadolinium [Xcytrin]) and chemotherapeutic agents (eg, temozolomide [Temodar]) used in combination with radiotherapy will also be discussed.