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In the original article published, the last sentence in the sixth paragraph of the introduction section is incorrect. The correct sentence is “This data, were confirmed also in an Italian phase II study, in which it has been demonstrated that gemcitabine-based chemoradiotherapy was correlated with improved overall survival, especially in pts who are clinically more fit to complete the foreseen treatment schedule (CRT) (Mattiucci et al. 2010)”. The original article has been corrected.

Purpose: Hepatocellular carcinoma (HCC) in early stages benefits from local ablative treatments such as radiofrequency ablation (RFA) or transarterial chemoembolization (TACE). In this context, radiotherapy (RT) has shown promising results but has not been thoroughly evaluated. Magnetic resonance-guided RT (MRgRT) may represent a paradigm shifting improvement in stereotactic body radiotherapy (SBRT) for liver tumors. Methods: We retrospectively evaluated HCC patients treated on a hybrid low-tesla MRgRT unit. A total biologically effective dose (BED) > 100 Gy was delivered in 5 consecutive fractions, respecting the appropriate organs-at-risk constraints. Hybrid MR scans were used for treatment planning and cine MR was used for delivery gating. Patients were followed up for toxicity and treatment–response assessment. Results: Ten patients were enrolled, with a total of 12 lesions. All the lesions were irradiated with no interruptions. Six patients had already performed previous local therapies. Median follow-up after SBRT was 6.5 months (1–25). Two cases of acute toxicity were reported (G ≤ 2 according to CTCAE v4.0). At the time of the analysis, 90% of the population presented local control. Child–Pugh before and after treatment remained unchanged in all but one patient. Conclusion: MRgRT is a feasible and safe option showing favorable toxicity profile for HCC treatment.

The modern management of esophageal cancer is crucially based on a multidisciplinary and multimodal approach. Radiotherapy is involved in neoadjuvant and adjuvant settings; moreover, it includes radical and palliative treatment intention (with a focus on the use of a stent and its potential integration with radiotherapy). In this review, the above-mentioned settings and approaches will be described. Referring to available international guidelines, the background evidence bases will be reviewed, and the ongoing, more relevant trials will be outlined. Target definitions and radiotherapy doses to administer will be mentioned. Peculiar applications such as brachytherapy (interventional radiation oncology), and data regarding innovative approaches including MRI-guided-RT and radiomic analysis will be reported. A focus on the avoidance of surgery for major clinical responses (particularly for SCC) is detailed.

Introduction: Pancreatic cancer (PC) is one of the most aggressive tumours, and better risk stratification among patients is required to provide tailored treatment. The meaning of radiomics and texture analysis as predictive techniques are not already systematically assessed. The aim of this study is to assess the role of radiomics in PC. Methods: A PubMed/MEDLINE and Embase systematic review was conducted to assess the role of radiomics in PC. The search strategy was ‘radiomics [All Fields] AND (“pancreas” [MeSH Terms] OR “pancreas” [All Fields] OR “pancreatic” [All Fields])’ and only original articles referred to PC in humans in the English language were considered. Results: A total of 123 studies and 183 studies were obtained using the mentioned search strategy on PubMed and Embase, respectively. After the complete selection process, a total of 56 papers were considered eligible for the analysis of the results. Radiomics methods were applied in PC for assessment technical feasibility and reproducibility aspects analysis, risk stratification, biologic or genomic status prediction and treatment response prediction. Discussion: Radiomics seems to be a promising approach to evaluate PC from diagnosis to treatment response prediction. Further and larger studies are required to confirm the role and allowed to include radiomics parameter in a comprehensive decision support system.

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Purpose: To investigate the potential benefits of a hypofractionated radiotherapy boost (HRB) after chemotherapy (CT) and concomitant chemoradiotherapy (CRT) in locally advanced pancreatic cancer (LAPC) patients. Primary endpoints were early and late toxicity, local control (LC) and pain-free progression (PFP) assessment. Two-years overall survival (OS), metastasis-free survival (MFS) and disease-free survival (DFS) were secondary endpoints. Materials and methods: Patients (pts) affected by unresectable non-metastatic LAPC, previously treated with CT and CRT in upfront or sandwich setting, were selected for sequential HRB. Total prescribed dose was 30 Gy in 5 fractions (fr) to pancreatic primary lesion. Dose de-escalation was allowed in case of failure in respecting organs at risk constraints. Early and late toxicity were assessed according to CTCAE v.4.0 classification. The Kersh-Hazra scale was used for pain assessment. Local Control, PFP, MFS and DFS were calculated from the date of HRB to the date of relapse or the date of the last follow-up. Results: Thirty-one pts affected by unresectable, non-metastatic LAPC were consecutively enrolled from November 2004 to October 2019. All pts completed the planned HRB. Total delivered dose varied according to duodenal dose constraint: 20 Gy in 5 fr (N: 6; 19.4%), 20 Gy in 4 fr (N: 5; 16.2%), 25 Gy in 5 fr (N: 18; 58.0%) and 30 Gy in 6 fr (N: 2; 6.4%). Early and late toxicity were assessed in all pts: no Grade 3 or 4 acute gastrointestinal toxicity and no late gastrointestinal complications occurred. Median LC was 19 months (range 1–156) and 1- and 2-year PFP were 85% and 62.7%, respectively (median 28 months; range 2–139). According to the Kersh-Hazra scale, four pts had a Grade 3 and four pts had a Grade 1 abdominal pain before HRB. At the last follow-up only 3/31 pts had residual Grade 1 abdominal pain.Median MFS was 18 months (range 1–139). The 2-year OS after HRB was 57.4%, while

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Background: Patient’s satisfaction is recognized as an indicator to monitor quality in healthcare services. Patient-reported experience measures (PREMs) may contribute to create a benchmark of hospital performance by assessing quality and safety in cancer care. Methods: The areas of interest assessed were: patient-centric welcome perception (PCWP), punctuality, professionalism and comfort using the Lean Six Sigma (LSS) methodology. The RAMSI (Radioterapia Amica Mia SmileINTM (SI) My Friend RadiotherapySI), project provided for the placement of SI totems with four push buttons using HappyOrNot technology in a high-volume radiation oncology (RO) department. The SI technology was implemented in the RO department of the Fondazione Policlinico Universitario A. Gemelli IRCCS. SI totems were installed in different areas of the department. The SI Experience Index was collected, analyzed and compared. Weekly and monthly reports were created showing hourly, daily and overall trends. Results: From October 2017 to November 2019, a total of 42,755 votes were recorded: 8687, 10,431, 18,628 and 5009 feedback items were obtained for PCWP, professionalism, punctuality, and comfort, respectively. All areas obtained a SI-approved rate ≥ 8.0 Conclusions: The implementation of the RAMSI system proved to be doable according to the large amount of feedback items collected in a high-volume clinical department. The application of the LSS methodology led to specific corrective actions such as modification of the call-in-clinic system during operations planning. In order to provide healthcare optimization, a multicentric and multispecialty network should be defined in order to set up a benchmark.

Background: The implementation of multidisciplinary tumor board (MDTB) meetings significantly ameliorated the management of oncological diseases. However, few evidences are currently present on their impact on pancreatic cancer (PC) management. The aim of this study was to evaluate the impact of the MDTB on PC diagnosis, resectability and tumor response to oncological treatment compared with indications before discussion. Patients and methods: All patients with a suspected or proven diagnosis of PC presented at the MDTB from 2017 to 2019 were included in the study. Changes of diagnosis, resectability and tumor response to oncological/radiation treatment between pre- and post-MDTB discussion were analyzed. Results: A total of 438 cases were included in the study: 249 (56.8%) were presented as new diagnoses, 148 (33.8%) for resectability assessment and 41 (9.4%) for tumor response evaluation to oncological treatment. MDTB discussion led to a change in diagnosis in 54/249 cases (21.7%), with a consequent treatment strategy variation in 36 cases (14.5%). Change in resectability was documented in 44/148 cases (29.7%), with the highest discrepancy for borderline lesions. The treatment strategy was thus modified in 27 patients (18.2%). The MDTB brought a modification in the tumor response assessment in 6/41 cases (14.6%), with a consequent protocol modification in four (9.8%) cases. Conclusions: MDTB discussion significantly impacts on PC management, especially in high-volume centers, with consistent variations in terms of diagnosis, resectability and tumor response assessment compared with indications before discussion.

Purpose: Surgery, external beam radiotherapy (EBRT), and interventional radiotherapy (IRT, BrachyTherapy BT) are the current therapeutic options for nose vestibule (NV) squamous cell carcinoma (SCC). In this article, we evaluate the nose functional parameters of patients affected by SCCs of the NV, primarily treated by interstitial IRT comparing them with healthy controls and with patients treated with intensity-modulated EBRT. Methods: Ten patients treated by using IRT (group 1), 10 healthy controls and eight patients treated by EBRT (group 2) on the region of the nose were submitted to clinical evaluation (with the NOSE scale score), rhinomanometry, olfactory testing, nasal citology, and evaluation of mucociliary clearance through saccharine test. Results: No long-term skin or cartilaginous toxicity are recorded. The olfactometry threshold discrimination identification TDI is lower in EB group. The mean NOSE scale score was significantly higher in group 2 than in group 1 and healthy controls (p < 0.05). The distribution of cytologic patterns resulted significantly different as well. Patients treated by EB have a significantly impaired mucociliary clearance, with a mean time for the transport of the stained marker, which is more than double in the patients treated by EB than in those treated with IRT (p < 0.001). Conclusions: Nasal function and cytological findings are significantly better, substantially preserved, in patients treated by IRT than in those treated by EBRT, bringing new relevant evidence for the establishment of interstitial IRT as the new standard for the treatment of the primary lesion in cT1 and cT2 -Wang staging NV SCCs.

We evaluate the role of stereotactic body radiotherapy using volumetric modulated arc therapy (VMAT) technique as an alternative to high-dose rate brachytherapy (HDR-BT) in the treatment of vaginal cuff in postoperative endometrial cancer. CT scans of 8 patients were used in this study. The clinical target volume (CTV) was defined as the 0.5 cm tissue around the applicator (then subtracting the applicator). Total dose was 30Gy delivered in 5 fractions. In HDR-BT, dose was prescribed at a distance of 0.5 cm from the surface applicator. For VMAT irradiation, a planning target volume (PTV) was obtained from CTV by an expansion of 3 mm. Two VMAT plans were generated using a full arc rotation. The first plan was optimized with an anatomy-based optimization module (PO-VMAT) using a 1mm multileaf collimator beam margin to enhance dose heterogeneity and dose fallout outside the target. The second plan was generated with a full-inverse planning module (FI-VMAT). Conformity (CI100, CI50, CI25), gradient (GI) indexes, and integral doses were calculated. To account for various dose heterogeneity distributions we calculated the equivalent uniform dose (EUD) using the Niemerko model. A Kruskal-Wallis analysis of variance followed by Dunn's-type multiple comparisons was performed. Dose distributions were more heterogeneous with HDR-BT: Dmean was 144.2% of prescription dose for CTV in HDR-BT and 118.5 and 108.6% for PTV in PO-VMAT and FI-VMAT, respectively. The mean values of EUD for CTV were 136.9%, 130.0 %, and 111.0% of prescription dose in HDR-BT, PO-VMAT, and FI-VMAT plans, respectively. GI indexes were 2.81, 3.41, and 4.14 for HDR-BT, PO-VMAT, and FI-VMAT, respectively. Near-maximal doses (D0.1cc) for rectum and bladder were significantly higher in HDR-BT plans compared to PO-VMAT and FI-VMAT plans (rectum: 131.2% vs112.8% vs 112.0%, respectively; bladder: 129.2% vs 108.7%, and 109.8%, respectively). PO-VMAT plans were able to mimic the HDR-BT dose distribution, showing a suc

Introduction: The possibility of intentionally triggering non targeted effects (NTEs) using spatially fractionated radiotherapy (SFRT) alone or combined with immunotherapy is an intriguing and fascinating area of research. Among different techniques for SFRT, stereotactic body radiotherapy targeting exclusively the central hypoxic segment of bulky tumors, (SBRT-PATHY) might trigger immunogenic cell death more efficiently. This in silico study aims to identify the best possible dosimetric trade-off for prescribing SFRT with volumetric modulated arc (VMAT) based stereotactic radiotherapy (SRT). Material and methods: Eight spherical volumes defined “Gross Tumor Volumes” (GTVs) were generated with diameters of 3–10 cm (with incremental steps of 1 cm), simulating tumor lesions. The inner third part of each GTV (GTVcentral) was selected to simulate the central hypoxic area and a ring structure was derived around it to simulate the tumor periphery (GTVperipheral). Volumetric modulated arc radiation treatment (VMAT) plans were calculated to deliver a single fraction of 10 Gy to each GTVcentral with different dose prescription methods: target mean and isodose driven (40, 50, 60, 70, 80 and 90%). The volume of GTVperipheral receiving less than 2 Gy was recorded as dosimetric performance indicator. Results: 56 possible dosimetric scenarios were analyzed. The largest percentage of GTVperipheral spared from the dose of 2 Gy was achieved with dose prescription methods to the 70% isodose line for lesions smaller than 6 cm (range 42.9–48.4%) and to the target mean for larger ones (range 52.9–64.5%). Conclusions: Optimizing the dose prescription method may reduce the dose to tumor periphery in VMAT-based SFRT, thus potentially sparing tumor infiltrating immune cells. The optimal method may vary according to the size of the lesion. This should be taken into account when designing prospective trials using SFRT.

Introduction: Magnetic Resonance-guided Radiation Therapy (MRgRT) allows online adaptations (OA) of the treatment plan to optimize daily dose distribution based on patient's anatomy, just before fraction delivery. The aim of this study is to evaluate feasibility and the dosimetric improvement of the OA workflow implemented in our institution for locally advanced pancreatic cancer (LAPC) patients, in terms of target coverage and organs at risk (OARs) sparing. Methods: We retrospectively analysed 8 LAPC patients treated with MRgRT in combination with the OA approach, using video-assisted inspiratory breath-hold for a total of 38 fractions with a dose ranging from 30 Gy to 40 Gy in 5 fractions. Dose distribution of the baseline plan was first calculated based on daily anatomy, obtaining a “predicted” plan to assess the dosimetric improvement. If the dose distribution did not meet the constraints set in the planning phase, PTV, GTV and OARs were re-contoured within a distance of 3 cm from the PTV external edge and a new online “adaptive” plan was generated. Other clinical and planning parameters were also evaluated to assess the feasibility and the dosimetic benefit of the online adaptive workflow. Results: Out of 38 total fractions, 26 (68.4%) were adapted online and 12 (31.6%) were delivered using the baseline plan. The use of the adaptive workflow resulted to be feasible in our clinical practice and advantageous in all the patients: mean PTV V95% increased by 10.8% (5.7–20.8) while mean CTV V98% of 12.6% (7.3–17.7). Also OARs V33 and V25 showed a positive trend avoiding unnecessary irradiation. Conclusion: OA workflow improves the dosimetric benefit of MRgRT, preventing the occurrence of high-doses to OARs and increasing the safety of stereotactic treatment for LAPC, without any drawback for our daily clinical practice routine.

Pancreatic cancer represents a modern oncological urgency. Its management is aimed to both distal and local disease control. Resectability is the cornerstone of treatment aim. It influences the clinical presentation’s definitions as up-front resectable, borderline resectable and locally advanced (unresectable). The main treatment categories are neoadjuvant (preoperative), definitive and adjuvant (postoperative). This review will focus on i) the current indications by the available national and international guidelines; ii) the current standard indications for target volume delineation in radiotherapy (RT); iii) the emerging modern technologies (including particle therapy and Magnetic Resonance [MR]-guided-RT); iv) stereotactic body radiotherapy (SBRT), as the most promising technical delivery application of RT in this framework; v) a particularly promising dose delivery technique called simultaneous integrated boost (SIB); and vi) a multimodal integration opportunity: the combination of RT with immunotherapy.

Conventionally fractionated chemoradiation (CRT) or chemotherapy (CHT) are considered as standard options in locally advanced pancreatic cancer (LAPC) while stereotactic body radiotherapy (SBRT) is an emerging treatment in this setting. The aim of this study was to compare two cohorts of LAPC patients treated with SBRT ± CHT vs CRT ± CHT in terms of local control (LC), distant metastases-free survival (DMFS), progression-free survival (PFS), overall survival (OS), and toxicity. Eighty patients were included. Patients in the two cohorts were matched according to: age ≤/>65 years, tumor diameter (two cut-offs

Introduction: Although catheter ablation is the current gold standard treatment for refractory ventricular arrhythmias, sometimes its efficacy is not optimal and it's associated with high risks of procedural complication and death. Stereotactic arrhythmia radioablation (STAR) is increasingly being adopted for such clinical presentation, considering its efficacy and safety. Case Presentation: We do report our experience managing a case of high volume of left ventricle for refractory ventricular tachycardia in advanced heart failure patient, by delivering a single fraction of STAR through an highly personalization of dose delivery applying repeated inter- and continuous intra-fraction image guidance. Conclusion: According to the literature reports, we recommend considering increasing as much as possible the personalization features and safety technical procedure as long as that is not significantly affecting the STAR duration. Moreover, the duration in itself shouldn't be the main parameter, but balanced into the frame of possibly obtainable outcome improvement. At best of our knowledge, this is the first report applying such specific technology onto this clinical setting. Future studies will clarify these issues.

Peritoneal carcinosis (PC) is characterized by poor prognosis. PC is currently treated as a locoregional disease and the possibility to perform very precise treatments such as stereotactic body radiation therapy (SBRT) has opened up new therapeutic perspectives. More recently, the introduction of Magnetic Resonance-guided Radiation Therapy (MRgRT) allowed online adaptation (OA) of treatment plan to optimize daily dose distribution based on patient’s anatomy. The aim of this study is the evaluation of the effectiveness of SBRT OA workflow in an oligometastatic patient affected by PC. We report the clinical case of a patient affected by PC originating from colon cancer, previously treated with chemotherapy and surgery, addressed to OA SBRT treatment on a single chemoresistant PC nodule, delivered with a 0.35 T MR Linac. Treatment was delivered using gating approach in deep inspiration breath hold condition in order to reduce intrafraction variability. Prescription dose was 35 Gy in 5 fractions. The PTV V95% of the original plan was 96.6%, while the predicted values for the following fractions were 11.9, 56.4, 0, 0, and 61%. Similarly, the small bowel V19.5 Gy of the original plan was 4.63 cc, while the predicted values for the following fractions were 3.7, 8.6, 10.7, 1.96, 3.7 cc. Thanks to the OA approach, the re-optimized PTV V95% coverage improved to 96.1, 89.0, 85.5, 94.5, and 94%; while the small bowel V19.5 Gy to 3.36; 3.28; 1.84; 2.62; 2.6 cc respectively. After the end of RT, the patient was addressed to follow-up, and the re-evaluation 18F-FDG PET-CT was performed after 10 months from irradiation showed complete response. No acute or late toxicities were recorded. MRgRT with OA approach in PC patients is technically and clinically feasible with clean toxicity result. Online adaptive SBRT for oligometastases opens up new therapeutic scenarios in the management of this category of patients.

Purpose: The aim of this paper was to evaluate treatment outcomes following interventional radiotherapy (brachytherapy – BT) for nasal vestibule cancer. Material and methods: Considering histological diagnosis and staging, a multidisciplinary tumor board indicated an exclusive interventional radiotherapy for all patients. Plastic tubes were placed mainly with interstitial approach. The total dose was 44 Gy in 14 fractions, 3 Gy/fraction (except for the first and last fractions, 4 Gy), 2 fractions per day (b.i.d.), 5 days a week. Inclusion criteria for this analysis were: patients affected by squamous cell carcinoma with follow-up more than 6 months. Results: 20 patients with primary nasal vestibule cancer were treated with IRT from May 2012 to June 2019. We excluded 4 patients due to follow-up less than 6 months and 2 patients affected by basal cell carcinoma. In total, 14 consecutive previously untreated patients were considered for definitive analysis, median age was 67.5 (range, 51-83) years, median follow-up was 53 (range, 6-84) months. All patients followed the protocol except one, who received a total dose of 42 Gy in 12 fractions, 3 Gy per 6 fractions, and 4 Gy per 6 fractions. Local control at 12, 24, and 36 months was 85.7%. Overall survival at 12 months was 92.3%, at 24 months was 76.9%, and at 36 months was 69.2%. Staging system proposed by Wang was statistically significant on local control (LC), disease-free survival (DFS), disease-specific survival (DSS), and overall survival (OS). Excellent cosmetic results were observed. Conclusions: This study confirms that interventional radiotherapy could be considered as a definitive treatment in nasal vestibule cancer with excellent oncological and cosmetic outcomes.

Background: Interventional radiotherapy (brachytherapy; IRT) reemerged in the last decades as a potentially useful tool in head and neck oncology after a set of clear technical improvements were developed. Methods: Sixty-one high dose ratio (HDR) IRT treatments were recommended and performed on 58 patients. We classified the cases into four relatively homogeneous groups based on the clinical needs that led to the recommended IRT. Also, we separately evaluated primary and recurrent cases. Results: Disease-specific survival was significantly different among the four treatment groups. The group with the best prognosis was the cohort treated locally by exclusive interstitial IRT for resectable midface malignancies (2-year relapse-free survival = 82%, disease-specific survival = 89%). Conclusion: HDR IRT is a valuable tool in well-defined clinical situations and, in particular, in recurrences. In midface malignancies, it could become the preferred primary treatment.

Purpose: Concurrent chemoradiation (CCRT) is the standard curative treatment of anal canal cancer (ACC). The role of a brachytherapy (BRT) boost in this setting is still debated. Therefore, the aim of this analysis was to retrospectively evaluate the clinical outcomes in a large cohort of ACC patients treated with CCRT plus BRT boost or external beam radiotherapy (EBRT) boost. Material and methods: Patients with non-metastatic ACC, treated in our department between January 2003 and December 2014 were included in this analysis. The initial treatment was based on EBRT to the pelvis (prescribed dose, 45 Gy/1.8 Gy) plus concurrent chemotherapy (5-fluorouracil and mitomycin-C). Patients received a pulsed-dose-rate BRT boost on the primary tumor (median dose, 20 Gy; range, 13-25 Gy) 2-3 weeks after the end of CCRT. In patients with contraindications to BRT, an EBRT boost (prescribed dose, 16 Gy, 2 Gy/fraction) was delivered immediately after CCRT. Results: One-hundred-twenty-three patients were included in this analysis (median age, 61 years; range, 36-93 years; squamous-cell carcinoma, 78%; HIV+, 6%; median follow-up, 71 months; range, 2-158 months). The actuarial 5-year local control (LC), distant metastasis-free survival, colostomy-free survival, and overall survival (OS) rates were 81.7%, 92.3%, 62.3%, and 74.0%, respectively. At univariate analysis, patients aged ≤ 65 years (p < 0.010), cT1-2 stage (p = 0.004), and receiving a BRT boost (p = 0.015) showed significantly improved OS. At multivariate analysis, advanced tumor stage cT3-cT4 (HR, 2.12; 95% CI: 1.09-4.14; p = 0.027), and age > 65 years (HR, 3.03; 95% CI: 1.54-5.95; p = 0.001) significantly predicted increased risk of mortality. The crude rate of toxicity-related colostomies was 4.9%. Conclusions: The role of BRT boost in ACC remains unclear since the outcomes were not clearly different compared to CCRT alone. However, further improvement of clinical results in ACC treatment is needed, and therefore pr

Objective Stereotactic body radiation therapy (SBRT) has been used in the treatment of cholangiocarcinoma (CC) but toxicity and clinical results of SBRT in CC are still limited and sparse. Therefore, the aim of this systematic review was to analyze the results of SBRT in the setting of advanced CC. Methods A systematic literature search was conducted on PubMed, Scopus, and Cochrane library using the PRISMA methodology. Studies including at least 10 patients with diagnosis of advanced CC regardless of tumor site and other treatments were included. The primary outcome was overall survival (OS) and secondary endpoints were local control (LC) and toxicity rates. The ROBINS-I risk of bias tool was used. Results 10 studies (231 patients) fulfilled the selection criteria and were included in this review. All but one study showed moderate to serious risk of bias. Median follow up was 15 months (range: 7.8-64.0 months). Pooled 1 year OS was 58.3% (95% CI: 50.2-66.1%) and pooled 2 year OS was 35.5% (95% CI: 22.1-50.1%). Pooled 1 year LC was 83.4%, (95% CI: 76.5-89.4%). The reported toxicities were acceptable and manageable with only one treatment-related death. Conclusion The role of SBRT in CC is not yet supported by robust evidence in literature. However, within this limit, preliminary results seem almost comparable to the ones of standard chemotherapy or chemoradiation. Advances in knowledge SBRT seems effective in terms of LC with acceptable treatment-related toxicities. Therefore, SBRT can be considered a therapeutic option at least in selected patients with CC, possibly combined with adjuvant chemotherapy (CHT).

Radiotherapy (RT) is a treatment option for advanced biliary tract cancer (BTC), often combined with sequential and/or concurrent chemotherapy. The use of modern RT techniques requires accurate clinical target volume (CTV) definition and delineation. However, guidelines for CTV delineation in BTC are lacking. Therefore, the aim of this study was to propose a computer tomography (CT) atlas for CTV definition of BTC. We previously proposed guidelines to define the nodal CTV (CTV-N) in BTC. In this study, based on a literature analysis, we defined the margins to be added to the gross tumor volume (GTV; subclinical and microscopic disease) to define the primary tumor CTV (CTV-T). An abdominal contrast enhanced planning CT scan was performed on three different patients with unresectable intrahepatic cholangiocarcinoma (CC), extrahepatic CC and gallbladder cancer. The GTV and anatomical reference structures were outlined on CT images. Then, based on our guidelines, the CTV-T and CTV-N were delineated and merged to define the final CTV in the three patients. An atlas, showing the defined CTV, was generated from the reference CT images to illustrate the CTV for intra-hepatic CC, extra-hepatic CC and gallbladder cancer. This atlas can be used as an aid for CTV definition in patients with BTC treated with modern RT techniques.

Purpose: To compare the survival and toxicity outcomes in patients with endometrial cancer treated with either high-dose-rate (HDR) or low-dose-rate (LDR) vaginal brachytherapy (VBT) following external beam radiotherapy (EBRT). Material and methods: From January 2000 to December 2014, patients with endometrial cancer after radical hysterectomy with/without pelvic and/or para-aortic lymphadenectomy were treated with adjuvant EBRT (45 Gy, 1.8 Gy/ day to the whole pelvis) and subsequent VBT boost (HDR dose of 7 Gy in one fraction or LDR VBT dose of 25 Gy). The dose was prescribed at 0.5 cm from the surface of the applicator and the proximal half to two-thirds of the vagina was irradiated. The outcomes of patients were evaluated in terms of local control (LC), overall survival (OS), and rates of adverse events. Results: We analyzed data of 200 patients treated with EBRT followed by HDR VBT boost in 78 patients and LDR VBT boost in 122 patients. With a median follow-up of 25 months (range, 6-163), 5-year OS was 98% and 97% in the LDR and HDR groups, respectively (p = 0.37). The 5-year LC was similar (93% in both groups) (p = 0.81). In multivariate analyses, none of the factors assessed (age, stage, grade) impacted OS (p = 0.37) or LC (p = 0.81). Patients treated with LDR VBT after EBRT had higher rates of acute gastrointestinal toxicity. No differences were found in acute genitourinary or hematological toxicities. Late toxicity such as vaginal stenosis was registered during regular follow-up visits and was similar in the two groups (p = 0.67). Conclusions: In our analysis, there were no differences in terms of OS and late toxicity outcomes for patients receiving LDR or HDR VBT. HDR VBT is a safe technique in comparison to LDR VBT.

Objectives: Treatment of oligometastatic patients is a current challenge in radiation oncology. Aim of this study is to define a dose–response relationship for hypofractionated radiotherapy of oligometastases. Methods: Retrospective analysis of metastases treated by hypofractionated stereotactic radiotherapy was performed. Delivered dose was calculated both as biological effective dose (BED10), and as ratio between BED10 and the logarithm of metastasis volume (BED10 logVolume Ratio, BVR). Two dose–response models were defined by logistic regression. The fitted outcome was the Metastases Complete Response (MCR). Performances of the models were assessed by area under the receiver operating curve (AUC) and by bootstrap calibration of original data. BED10 and BVR impact on survival outcomes has been evaluated. Results: Fifty-three patients with 79 metastases were analyzed. AUC and calibration of BVR-based logistic model showed better accuracy in predicting MCR with respect to BED10-based model. No significant difference between the two ROCs was observed (De Long test p value > 0.05), but significant discordance in calibration resulted in the BED10 model (p value < 0.05 in Hosmer–Lemeshow Goodness of fit test). BVR returned also better results in multivariate analyses for survival outcomes. Conclusions: The ratio between BED10 and the logarithm of metastasis volume (BVR), as a corrective factor for fitting the probability of metastases response to stereotactic radiotherapy, could be a tool for evaluating and prescribing treatments for oligometastatic disease. BVR can be useful for producing more reliable survival statistics too.

Aim: Identifying the best care for a patient can be extremely challenging. To support the creation of multifactorial Decision Support Systems (DSSs), we propose an Umbrella Protocol, focusing on prostate cancer. Materials & methods: The PRODIGE project consisted of a workflow for standardizing data, and procedures, to create a consistent dataset useful to elaborate DSSs. Techniques from classical statistics and machine learning will be adopted. The general protocol accepted by our Ethical Committee can be downloaded from cancerdata.org. Results: A standardized knowledge sharing process has been implemented by using a semi-formal ontology for the representation of relevant clinical variables. Conclusion: The development of DSSs, based on standardized knowledge, could be a tool to achieve a personalized decision-making.

Aim: Identifying the best care for a patient can be extremely challenging. To support the creation of multifactorial Decision Support Systems (DSSs), we propose an Umbrella Protocol, focusing on prostate cancer. Materials & methods: The PRODIGE project consisted of a workflow for standardizing data, and procedures, to create a consistent dataset useful to elaborate DSSs. Techniques from classical statistics and machine learning will be adopted. The general protocol accepted by our Ethical Committee can be downloaded from cancerdata.org. Results: A standardized knowledge sharing process has been implemented by using a semi-formal ontology for the representation of relevant clinical variables. Conclusion: The development of DSSs, based on standardized knowledge, could be a tool to achieve a personalized decision-making.

The case of a patient undergoing quadrantectomy of lower quandrants of the right breast and ipsilateral axillary lymph node dissection for breast cancer followed by adjuvant radiotherapy is discussed. The stage of the disease and prognostic factors are analyzed for prognosis. Comorbidities ruled out chemotherapy. Radiation therapy was planned followed by clinicoinstrumental controls. After the second control ipsilateral costal bone metastases were observed; radiation therapy for palliation was prescribed