Search

Purpose Brachytherapy is an essential technique to deliver radiation therapy and is involved in the treatment of multiple disease sites as monotherapy or as an adjunct to external beam radiation therapy. With a growing focus on the cost and value of cancer treatments as well new payment models, it is essential that standardized quality measures and metrics exist to allow for straightforward assessment of brachytherapy quality and for the development of clinically significant and relevant clinical data elements. We present the American Brachytherapy Society consensus statement on quality measures and metrics for brachytherapy as well as suggested clinical data elements. Methods and Materials Members of the American Brachytherapy Society with expertise in disease site specific brachytherapy created a consensus statement based on a literature review and clinical experience. Results Key quality measures (ex. workup, clinical indications), dosimetric metrics, and clinical data elements for brachytherapy were evaluated for each modality including breast cancer, cervical cancer, endometrial cancer, prostate cancer, keratinocyte carcinoma, soft tissue sarcoma, and uveal melanoma. Conclusions This consensus statement provides standardized quality measures and dosimetric quality metrics as well as clinical data elements for each disease site to allow for standardized assessments of brachytherapy quality. Moving forward, a similar paradigm can be considered for external beam radiation therapy as well, providing comprehensive radiation therapy quality measures, metrics, and clinical data elements that can be incorporated into new payment models.

PURPOSE/OBJECTIVE(S) Patients with recurrent head and neck squamous cell carcinoma (HNSCC) who present with carotid encasement (CE) > 180˚, skin involvement and/or require bolus are not eligible for SBRT per RTOG 3507. The objective of this study was to characterize our institutional experience of SBRT for patients ineligible for RTOG 3507. MATERIALS/METHODS Patients with recurrent HNSCC treated with SBRT from 2010-2020 with a history of prior radiation were extracted from an IRB approved database. Patients were evaluated based on CE > 180˚ or ≤180˚ and if there was skin involvement and/or use of bolus. The primary outcome was incidence of treatment related carotid bleeding event (CBE) and skin toxicity after SBRT in the absence of disease. RESULTS Thirty-one patients were treated with SBRT to 37 sites with a median follow up of 8 months (mo) (range 2-47). The median time from prior radiation to SBRT was 13 mo (range 2-257). SBRT fractionation included 35 Gy (13%), 40 Gy (57%), and 45 Gy (30%) in 5 fractions. SBRT was delivered every other day (76%) or 2 fractions (24%) per week. Concurrent immunotherapy was given in 11% and cetuximab in 8%. A total of 30% (N = 11) of sites treated exhibited CE > 180˚ and 70% (N = 26) ≤180˚. There were no CBE related to SBRT, however 18% (N = 2) of patients with CE > 180˚ experienced fatal CBE related to progressive disease at 2.3 mo and 7.6 mo from SBRT. The risk of CBE was potentially related to CE > 180˚ (P = 0.08). Skin involvement and/or use of bolus was present in 43% (N = 16) of sites treated and absent in 57% (N = 21). The rate of treatment related skin toxicity was 19% (N = 3) and only occurred in those with pre-SBRT skin involvement and/or use of bolus. The cumulative incidence of treatment related skin toxicity at 3 mo and 6 mo was 13% (95% CI 1.9-33.6) and 27% (95% CI 4.0-58.8), respectively. Of the 3 treatment related skin toxicities there was one each of grade 2, 3, and 5. Grade 5 toxicity was related to untreated SBRT wound infection as the patient transitioned to hospice. The risk of treatment related skin toxicity was possibly related to pre-SBRT skin involvement and/or use of bolus (P = 0.007). Of the 13 sites with pre-SBRT skin involvement, 31% (N = 4) completely resolved, 54% (N = 7) had residual ulceration attributed to disease, and 15% (N = 2) had ulceration related to SBRT toxicity. The cumulative incidence of local failure at site of SBRT at 3 mo and 6 mo was 13% (95% CI 4-27.3) and 38% (95% CI 20.5-55.9), respectively. The median time of local and regional recurrence free survival were 7 and 5.5 mo, respectively. Median OS was 8 mo and the estimated 1-year OS was 25% (95% CI 9.9-40.9). CONCLUSION The risk of toxicity following SBRT for patients with > 180˚ CE, skin involvement and/or use of bolus appears to be largely related to persistent or recurrent disease. There were no CBE related to SBRT in the absence of disease and 31% of patients with pre-SBRT skin involvement exhibited complete healing after SBRT. Consideration of SBRT may still be beneficial for such patients with appropriate counselling.

Purpose/objective(s) Hypofractionated intensity modulated radiation therapy (H-IMRT) is uncommonly used in head and neck cancers due to concern for toxicity. This study reviews our experience using H-IMRT for head and neck cancers and explores its tolerability and efficacy. Materials/methods This single institution IRB approved retrospective study includes patients with head and neck cancers treated with definitive or post-operative H-IMRT from 2011-2020. Patients treated with ≥50Gy in 20 fractions to the primary tumor site and/or neck with at least 3 months of follow up were included. Patients treated to a superficial target only without proximity to mucosal surfaces or coverage of the elective neck (e.g., scalp; skin only targets) were excluded. Patients undergoing re-irradiation were excluded. Toxicity was scored using CTCAE v4.0. Acute toxicity included events occurring within 90 days of H-IMRT completion. Late toxicities occurred any time thereafter. Multiple toxicities in the same patient were scored separately. Results Fifty-nine patients with a median follow up of 10.9 months (range 3.0-111.5) were included. The majority of patients were white (93%) and male (78%) with a median age of 79.1. The most common primary tumor sites were skin (42%), major salivary glands (22%), and oral cavity (9%). The most frequent histologies included squamous cell carcinoma (66%) followed by thyroid cancer (7%), melanoma (5%), and Merkel cell carcinoma (5%). Treatment was delivered post-operatively in 80% and definitively in 20% of patients. All patients were treated with ≥50 Gy in 20 fractions, with the most common dose being 50 Gy (53%) followed by 55 Gy (44%). In 64% of patients a secondary elective dose of 45-50 Gy was used. Site treated included primary tumor site/bed with unilateral neck (54%), primary tumor site/bed with bilateral neck (19%), primary tumor site/bed alone (14%), unilateral neck (8%), and bilateral neck (5%). Five patients (8%) experienced a locoregional failure at a median time of 5.4 months (range 2.8-13.9). There were no grade 4 or 5 toxicities. Ten patients (17%) experienced acute grade 3 toxicity including mucositis (12%) and dermatitis (5%). Forty-six patients (78%) had an acute grade 2 toxicity, most commonly dermatitis (41%), pain (32%), fatigue (32%), dysgeusia (31%) and xerostomia (22%). Five patients (8%) experienced grade 2 late complications including neck fibrosis in three patients and trismus, aspiration pneumonia, and osteoradionecrosis in one patient each. No patient experienced grade 3 or higher late toxicity. No patients required the placement of a feeding tube or tracheostomy. Conclusion Hypofractionated IMRT in the definitive or post-operative treatment of head and neck cancers using ≥50Gy in 20 fractions appears safe and well tolerated with modest toxicity. Prospective studies comparing the safety and efficacy of H-IMRT to conventionally fractionated IMRT are warranted.

One of the priorities of governments in Canada is to reduce long waiting times for health services. This has raised the prospect of introducing waiting time care guarantees. Such guarantees affirm the healthcare system's social contract with the public and provide an entitlement to Canadians to receive timely care. There are clinical, legal and political implications, which must be considered and well managed before introduction. Other countries have ventured down this path. They teach us that waiting time care guarantees are good policy and make good sense. Correspondingly, they remind us not to make a promise we are not ready to keep.

Differential sticking is one of the major downhole complications encountered in drilling operations. Generally oil base spotting fluids are used to release the stuck ups. However, the results are not always good. Based on sticking severity in the laboratory experiments, differential sticking has been classified into two major categories viz.; normal and extreme differential sticking. Sticking of first category can be released by using conventional oil base spotting technique, however, it fails to release the extreme stuck ups which invariably results in operations like jarring, washover, side tracking etc. and leads to loss of considerable precious rig days, costly drill string and/ or loss of the well. In order to meet the challenges of such extreme stuck ups, a new acid based formulation (Formulation- A) has been developed. It reacts chemically with the cake instantaneously and destroys it. The chemical destruction of the cake leads to the release of both types i.e. extreme as well as normal differential sticking. It has no adverse effect on the properties of drilling fluid and is also non damaging to the drill string. The two case histories i.e. in the deep well no. GGG, TD- 2900 m. with horizontal drift of 660 m. in the Geleki field and high drift well no. AAA, TD-1835 m. with horizontal drift 904 m. in Ahmedabad field prove the usefulness and effectiveness of this formulation in releasing more than 7 days old severe stuck ups. Said formulation designed in tune with the expected contact area exhibited excellent results with quick release of stuck ups. This technique has since been widely accepted for the use in extreme cases of stuck ups.