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Paediatric patients (individuals below 18 years of age) requiring cranial-spinal irradiation (CSI) at our institution are commonly planned and treated using a three isocentre (3-ISO) volumetric modulated arc therapy (VMAT) technique. A modified two isocentre (2-ISO) VMAT technique was investigated with the aim to improve workflow and reduce planning and treatment time.Five CSI paediatric patients previously treated with a 3-ISO VMAT technique were retrospectively replanned using a 2-ISO VMAT technique. The 2-ISO VMAT plans were reviewed and approved by a radiation oncologist (RO) before undergoing patient-specific quality assurance (QA) procedures, performed by a radiation oncology medical physicist (ROMP). Planning target volume (PTV) coverage, organ-at-risk (OAR) dose as well as planning and treatment durations of the first five patients utilising 2-ISO technique were compared with 3-ISO technique.The average percentage difference in PTV coverage by 95% reference dose between the 2-ISO and 3-ISO is 0.14%, and the average difference in OAR median dose is 0.68 Gy. Conformity and homogeneity indices have the same averages at 1.18 and 0.4 respectively. Patient-specific physics QA results were all comparable with the 3-ISO averages at 98.84% and the 2-ISO at 98.71%. Planning duration for the 2-ISO was reduced by up to 75%, and daily treatment duration was reduced by up to 50%. Of all the previously treated CSI patients using a 3-ISO technique, 45% were suitable for the 2-ISO technique.The 2-ISO VMAT technique provided comparable dose distribution based on PTV coverage, OAR dose and plan metric indices. Reduced planning and treatment duration with the 2-ISO technique facilitated improved workflow with decreased sedation time for paediatric patients requiring a general anaesthesia.

Pineal germinoma is rare with high cure rates following craniospinal radiotherapy. Efforts to reduce the radiotherapy dose and field via combination with chemotherapy suggest comparable disease control and reduced neurocognitive impairments, while the efficacy of immunotherapy in pineal germinoma remains undetermined. This report aimed to review clinical outcomes in patients treated for pineal germinoma in Queensland, Australia, and assess for Programmed Death-Ligand1 (PD-L1) expression. Patients who commenced radiation and/or chemotherapy for pineal germinoma from 2005 to 2017 were retrospectively identified using Queensland Oncology Online database. Demographic, diagnostic, treatment, and outcome data was obtained from electronic medical records. PD-L1 immuno-histochemistry was performed on available specimens. Eighteen patients with long-term follow-up data were identified. Median age at diagnosis was 16.8 years (range 9–46 years). Diagnosis was made histologically in fifteen patients, and radiologically in three. All patients underwent radiotherapy (median 36 Gy (range 21–54 Gy)) with lower median dose delivered with whole ventricle irradiation (12/18patients) than craniospinal irradiation (5/18patients). Sixteen patients received chemotherapy preceding radiotherapy. All patients are alive at median 7.25 years from primary treatment completion (range 2.03–13.1 years). Relapse occurred in three patients (16.67%) following treatment response, all of whom achieved remission following high-dose chemotherapy with stem-cell support and craniospinal radiotherapy. Post-treatment functional outcomes were similarly excellent. PD-L1 expression was low (1–49% cells) or negative in 87% of tumours tested but results were confounded by specimen quality and availability. Reduced-dose radiotherapy with chemotherapy does not compromise outcome and is standard of care at this institution. Immunotherapy is unlikely to become standard treatment in the near future.

A randomised phase II trial of single fraction or multi-fraction SABR (stereotactic ablative body radiotherapy) with atezolizumab in patients with advanced triple negative breast cancer (AZTEC trial) Abstract: BACKGROUND: In patients with advanced triple negative breast cancer (TNBC), immunotherapy has shown acceptable safety and efficacy in a PD-L1 (programmed death-ligand 1) positive population. Pre-clinical evidence has demonstrated that SABR can prime a more effective systemic anti-tumor response in combination with checkpoint inhibition. It is currently unknown if single or multi-fraction SABR scheduling synergises best with atezolizumab therapy. METHODS: This was a multi-centre, open label, phase 2 randomised trial of patients with advanced TNBC, unselected for (PD-L1) status, who had recurred at least 6 months post completion of (neo) adjuvant chemotherapy and received less than 2 lines of treatment in the metastatic setting. Participants were randomised to 20Gy SABR in 1 fraction or 24Gy SABR in 3 fractions to 1-4 sites of disease, with at least one metastasis left unirradiated. Within 5 days following the final fraction of radiotherapy atezolizumab was commenced at a dose of 1200 mg every 21 days and continued for up to 24 months, or until progression or intolerable toxicity. The primary endpoint is progression- free survival (PFS). Secondary endpoints include efficacy according to PD-L1 IHC status (positive: SP142 ≥1%) and TIL (tumour infiltrating lymphocyte) quantity, response assessment, overall survival and safety. Results presented are from interim analysis performed 18 weeks after the last patient commenced treatment. RESULTS: Fifty evaluable patients were recruited and randomised between 20th November 2018 and 12thApril 2021 with a median age of 57 [35 - 79] yrs. Thirty (60%) and 20 (40%) patients had received none or one previous line of chemotherapy in the metastatic setting, respectively. 14/40 (35%) patients were PD-L1 positive at baseline and 26/42 (62%) had TIL≥5%. Median follow-up was 17 months. The median PFS for the 20 Gy arm was 2.5 (90% CI: 1.7-4.5) months, 3.1 (90% CI: 1.8-3.9) months for the 24 Gy arm. For both arms combined, the PFS was 3.1 (90% CI: 1.8-3.9) months, with no difference between the arms, HR 1.2 (95% CI: 0.6-2.1), p=0.64. PFS by PD-L1 IHC status and TIL CONCLUSIONS: The efficacy between single and multi-fraction SABR in combination with Atezolizumab was similar and toxicity was acceptable. Efficacy was seen in PD-L1 positive and negative patients. Longer follow-up is required to assess the effect on OS.. (Research support and funding provided by the imCORE Network on behalf of F. Hoffmann-La Roche; AZTEC ClinicalTrials.gov Identifier: NCT03464942) Table 1.Response AssessmentResponse, n (%)All patients (n = 50)Patients with measurable disease (n = 32)Best objective response (non-SABR lesion)CR3 (6)2 (6)PR2 (4)2(6)NCR/NPD8 (16)0SD13 (26)13 (41)PD24 (48)15 (47)ORR (CR + PR)5 (10); 95% CI: 3-224 (12%); 95% CI: 4-29DCR (CR + PR + SD + non-CR/non-PD ≥24 weeks)a11 (22%); 95% CI: 12-377 (23%); 95% CI: 10-41aOne patient withdrew at 8 weeks and was not assessable for DCR. Citation Format: Steven David, Peter Savas, Shankar Siva, Michelle White, Michael W Neeson, Shane White, Gavin Marx, Robyn Cheuk, Michelle Grogan, Maria Farrell, Jessica Foudoulis, Annette Dempsey, Paul J Neeson, Mathias Bressel, Sherene Loi. A randomised phase II trial of single fraction or multi-fraction SABR (stereotactic ablative body radiotherapy) with atezolizumab in patients with advanced triple negative breast cancer (AZTEC trial) [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr PD10-02.

Objective Radiotherapy for gynaecological cancer is associated with multiple adverse effects. This randomised controlled trial evaluated the impact of a combined nurse- and peer-led psycho-educational intervention on psychological distress, preparation for treatment, quality of life, psychosexual function, unmet needs and vaginal stenosis. Methods Eligible women had a confirmed diagnosis of gynaecological cancer, scheduled to receive radiotherapy with curative intent, aged ≥18 years, and able to read and write English. Participants randomly assigned one-to-one to either four nurse-led consultations plus four peer-led telephone sessions, or to usual care. Participants completed study measures at baseline, immediately before first radiotherapy (FU1), and four weeks (FU2), three (FU3), six (FU4), and 12 months (FU5) post radiotherapy. The primary outcomes were psychological distress at FU1 and FU2 measured by the Hospital Anxiety and Depression Scale. Results Of 840 eligible participants, 625 were approached and 319 (51%) consented; 158 assigned to intervention, 160 to usual care with 1 withdrawing before randomisation. Between-groups differences for primary outcomes were trivial- and small-sized, (both p > 0.05). Notable effects on secondary outcomes favouring the intervention at FU2 included preparation for treatment (sensory/psychological concerns, d = 0.57; and procedural concerns, d = 0.52) and specific needs domains (sexuality needs, d = 0.38; and health system and information needs, d = 0.41). Conclusions There was no evidence that a nurse- and peer-led intervention had a beneficial effect on psychological distress compared to usual care. However, improved treatment readiness and lower health system and sexuality needs indicate the intervention may have addressed outcomes known to be important to this population.

Introduction Around 300 children in Australia and New Zealand (ANZ) undergo a course of radiation treatment (RT) each year. A fortnightly videoconference for radiation oncologists managing children started in 2013. We conducted an audit of the videoconference to assess its influence on the care of children who receive RT in ANZ. Methods De-identified data from minutes (August 2013-December 2019) were analysed retrospectively using three categories: meeting participation, case presentations and management decisions. Results There were 119 meetings and 334 children discussed over the six-year audit period with regular attendance from four of 11 centres treating children in ANZ. Most cases (80%) were discussed prior to RT. A change in the overall management plan was recommended for around one in eight patients (35/334, 13%). RT plan reviews were performed in 79 cases (23%). Adjustments were made to the target volume contours or treatment plan in 8% (6/79). Conclusion Increasing the frequency of the meeting to weekly and compliant with the RANZCR Peer Review Audit Tool has the capacity to review all paediatric RT patients in ANZ prior to RT and initiate changes for as many as one in eight children treated by RT each year. The meeting should be considered a core component necessary to maintain expertise in paediatric RT in all centres providing RT for children in ANZ while also acting as a proton referral panel as more children are referred abroad for proton therapy before the Australian Bragg Centre for Proton Therapy opens in Adelaide in 2024.

Introduction The traditional use of two-dimensional geometric prescription points in intracavitary brachytherapy planning for locally advanced cervical cancer is increasingly being replaced by three-dimensional (3D) planning. This study aimed to directly compare the two planning methods to validate that CT planning provides superior dosimetry for both tumour and organs at risk (OARs) in our department. Methods The CT planning data of 10 patients with locally advanced cervical cancer was audited. For each CT dataset, two new brachytherapy plans were created, comparing the dosimetry of conventional American Brachytherapy Society points and 3D-optimised volumes created for the high-risk clinical target volume (HR CTV) and OARs. Total biologically equivalent doses for these structures were calculated using the modified EQD2 formula and comparative dose-volume histogram (DVH) analysis performed. Results DVH analysis revealed that for the 3D-optimised plans, the prescription aim of D90 ≥ 100% was achieved for the HR CTV in all 10 patients. However, when prescribing to point A, only 50% of the plans achieved the minimum required dose to the HR CTV. Rectal and bladder dose constraints were met for all 3D-optimised plans but exceeded in two and one of the conventional plans, respectively. Conclusions This study confirms that the regionally relevant practice of CT-based 3D-optimised planning results in improved tumour dose coverage compared with traditional points-based planning methods and also improves dose to the rectum and bladder.

Purpose Patients with cervical and vaginal cancer sometimes have a less straightforward approach for choice of brachytherapy treatment owing to the tumor's location and clinical presentation. The staff at Royal Brisbane & Women's Hospital in Queensland, Australia, is trying to solve this problem by the use of an old technique in a new approach called vaginal molds. With a patient-specific vaginal mold, the appearance of the applicator and the dose distribution can be customized to provide an optimal treatment for each patient. Methods and Materials The technique used at the Royal Brisbane & Women's Hospital uses a flexible two-part putty, moulded to the shape of the vagina, in which standard catheters (flexible implant tubes) are incorporated, in a pattern designed to permit a dose distribution more conformal to the target volume. Results The presented technique is efficient and improves the accuracy of a homogeneous target cover and sparing of organs at risk for vaginal mold brachytherapy treatments at our institution. Conclusion This technique offers a customizable option when traditional cylindrical- or dome-type applicators cannot be used, or provide inadequate dose coverage. Molds to match the patient anatomy can be created quickly, while allowing flexibility in positioning of catheters to achieve the desired dose distribution.

Purpose: To evaluate the role of adjuvant radiotherapy in management of patients with tubular carcinoma of the breast. Methods: One hundred seventy-eight patients treated for tubular carcinoma were identified from the Queensland Radium Institute database. A retrospective review of medical records identified 115 patients meeting eligibility criteria: breast-conserving surgery for a histological diagnosis of tubular carcinoma, minimum follow up of 12 months and adequate medical records. Results: Median follow up was 64 months. There were no significant differences between patient characteristics treated with and without radiotherapy. Median age at diagnosis was 54 (36-78) years. Ninety-five percent tumours were T1 and four patients had positive axillary lymph nodes. Of 94 patients treated with adjuvant radiotherapy, one developed local relapse. Five of 21 patients who did not have adjuvant radiotherapy failed locally. Five-year relapse-free survival with and without radiotherapy was 100 and 89%, respectively (hazard ratio for radiotherapy: 0.06; 95% confidence interval 0.01-0.32, P = 0.001). Conclusion: Radiotherapy has a significant impact on relapse-free survival in patients treated with breast-conserving surgery for tubular carcinoma. © 2012 The Authors. Journal of Medical Imaging and Radiation Oncology

We undertook this study to estimate the event-free survival (EFS) of patients with newly diagnosed supratentorial primitive neuroectodermal tumor (SPNET) treated with risk-adapted craniospinal irradiation (CSI) with additional radiation to the primary tumor site and subsequent high-dose chemotherapy supported by stem cell rescue. Between 1996 and 2003, 16 patients with SPNET were enrolled. High-risk (HR) disease was differentiated from average-risk (AR) disease by the presence of residual tumor (M(0) and tumor size > 1.5 cm(2)) or disseminated disease in the neuraxis (M(1)-M(3)). Patients received risk-adapted CSI: those with AR disease received 23.4 Gy; those with HR disease, 36-39.6 Gy. The tumor bed received a total of 55.8 Gy. Subsequently, all patients received four cycles of high-dose cyclophosphamide, cisplatin, and vincristine with stem cell support. The median age at diagnosis was 7.9 years; eight patients were female. Seven patients had pineal PNET. Twelve patients are alive at a median follow-up of 5.4 years. The 5-year EFS and overall survival (OS) estimates for all patients were 68% +/- 14% and 73% +/- 13%. The 5-year EFS and OS estimates were 75% +/- 17% and 88% +/- 13%, respectively, for the eight patients with AR disease and 60% +/- 19% and 58% +/- 19%, respectively, for the eight with HR disease. No deaths were due to toxicity. High-dose cyclophosphamide-based chemotherapy with stem cell support after risk-adapted CSI results in excellent EFS estimates for patients with newly diagnosed AR SPNET. Further, this chemotherapy allows for a reduction in the dose of CSI used to treat AR SPNET without compromising EFS.

Purpose To compare the disease-free survival (DFS) of patients with surgical stage 1, intermediate-risk endometrial adenocarcinoma (EAC) treated with primary surgery with or without adjuvant vaginal vault brachytherapy (VVBT). Patients and methods A retrospective chart review identified 575 patients with stage 1B, 1C or 2A endometrial cancer who had surgery between 1990 and 2004. All patients were surgically staged and 259 patients received postoperative VVBT. The date and site of first recurrence were considered the primary statistical endpoints and were analysed by univariate and multivariate Cox models. Subgroups of patients stratified by substage and grade were created and Log-rank tests using vaginal recurrence as the endpoint were calculated within these groups. Results After a mean follow-up period of 72 months (95%-confidence interval (CI): 68 to 75 months) a total of 43 (7.5%) patients developed recurrence. Multivariate analysis demonstrated that increasing patient's age at diagnosis and stage 1C or 2A disease were independent risk factors for recurrence whereas the grade of differentiation and the type of treatment (surgery alone vs. surgery followed by postoperative VVBT) were not associated with a change in DFS. Analysis within the subgroups stratified by substage and grade did not even reveal a trend towards improved local control with VVBT. Conclusion Postoperative VVBT was not associated with a measurable reduction in the risk of recurrence in surgical stage 1, intermediate-risk endometrial cancer.

The traditional use of two-dimensional geometric prescription points in intracavitary brachytherapy planning for locally advanced cervical cancer is increasingly being replaced by three-dimensional (3D) planning. This study aimed to directly compare the two planning methods to validate that CT planning provides superior dosimetry for both tumour and organs at risk (OARs) in our department.The CT planning data of 10 patients with locally advanced cervical cancer was audited. For each CT dataset, two new brachytherapy plans were created, comparing the dosimetry of conventional American Brachytherapy Society points and 3D-optimised volumes created for the high-risk clinical target volume (HR CTV) and OARs. Total biologically equivalent doses for these structures were calculated using the modified EQD2 formula and comparative dose-volume histogram (DVH) analysis performed.DVH analysis revealed that for the 3D-optimised plans, the prescription aim of D90 ≥ 100% was achieved for the HR CTV in all 10 patients. However, when prescribing to point A, only 50% of the plans achieved the minimum required dose to the HR CTV. Rectal and bladder dose constraints were met for all 3D-optimised plans but exceeded in two and one of the conventional plans, respectively.This study confirms that the regionally relevant practice of CT-based 3D-optimised planning results in improved tumour dose coverage compared with traditional points-based planning methods and also improves dose to the rectum and bladder.

To determine the impact of anemia before and during chemoradiation in patients with cervical cancer, we collected data on hemoglobin (Hb) levels before and during treatment from 60 unselected patients with cervical carcinoma. All patients had FIGO stage IB to IVA disease and were treated with concurrent chemoradiation for the aim of cure. Patients with an Hb value below or equal to the lower 25th quartile were considered anemic. Progression-free survival (PFS) was evaluated by univariate and multivariate analyses. After a median follow-up of 26.3 months, 20 patients developed disease progression. The lowest Hb during chemoradiation (nadir Hb), the stage of disease, and parametrial involvement were correlated significantly with PFS. On multivariate analysis, the nadir Hb (relative risk [RR] 0.29) and tumor stage (RR 3.4) remained the only prognostically relevant factors predicting PFS. At 60 months the PFS was 39.1% for anemic patients and 48.0% for nonanemic patients (P < 0.0002). In patients undergoing chemoradiation for cervical carcinoma, a low nadir Hb is highly predictive of shortened PFS, whereas the Hb before treatment is prognostically not significant.

To investigate the effects of a natural oil-based emulsion containing allantoin versus aqueous cream for preventing and managing radiation-induced skin reactions.A total of 174 patients were randomized and participated in the study. Patients received either cream 1 (the natural oil-based emulsion containing allantoin) or cream 2 (aqueous cream). Skin toxicity, pain, itching, and skin-related quality of life scores were collected for up to 4 weeks after radiation treatment.Patients who received cream 1 had a significantly lower average level of Common Terminology Criteria for Adverse Events at week 3 (P.05) but had statistically higher average levels of skin toxicity at weeks 7, 8, and 9 (all P.001). Similar results were observed when skin toxicity was analyzed by grades. With regards to pain, patients in the cream 2 group had a significantly higher average level of worst pain (P.05) and itching (P=.046) compared with the cream 1 group at week 3; however, these differences were not observed at other weeks. In addition, there was a strong trend for cream 2 to reduce the incidence of grade 2 or more skin toxicity in comparison with cream 1 (P=.056). Overall, more participants in the cream 1 group were required to use another topical treatment at weeks 8 (P=.049) and 9 (P=.01).The natural oil-based emulsion containing allantoin seems to have similar effects for managing skin toxicity compared with aqueous cream up to week 5; however, it becomes significantly less effective at later weeks into the radiation treatment and beyond treatment completion (week 6 and beyond). There were no major differences in pain, itching, and skin-related quality of life. In light of these results, clinicians and patients can base their decision on costs and preferences. Overall, aqueous cream seems to be a more preferred option.

Background Radiation-induced skin reaction (RISR) is one of the most common and distressing side effects of radiotherapy in patients with cancer. It is featured with swelling, redness, itching, pain, breaks in skin, discomfort, and a burning sensation. There is a lack of convincing evidence supporting any single practice in the prevention or management of RISR. Methods/Designs This double-blinded randomised controlled trial aims to investigate the effects of a natural oil-based emulsion containing allantoin (as known as Moogoo Udder Cream®) versus aqueous cream in reducing RISR, improving pain, itching and quality of life in this patient group. One group will receive Moogoo Udder Cream®. Another group will receive aqueous cream. Outcome measures will be collected using patient self-administered questionnaire, interviewer administered questionnaire and clinician assessment at commencement of radiotherapy, weekly during radiotherapy, and four weeks after the completion of radiotherapy. Discussion Despite advances of radiologic advances and supportive care, RISR are still not well managed. There is a lack of efficacious interventions in managing RISR. While anecdotal evidence suggests that Moogoo Udder Cream® may be effective in managing RISR, research is needed to substantiate this claim. This paper presents the design of a double blind randomised controlled trial that will evaluate the effects of Moogoo Udder Cream® versus aqueous cream for managing in RISR in patients with cancer. Trial registration ACTRN 12612000568819

To evaluate the role of adjuvant radiotherapy in management of patients with tubular carcinoma of the breast.One hundred seventy-eight patients treated for tubular carcinoma were identified from the Queensland Radium Institute database. A retrospective review of medical records identified 115 patients meeting eligibility criteria: breast-conserving surgery for a histological diagnosis of tubular carcinoma, minimum follow up of 12 months and adequate medical records.Median follow up was 64 months. There were no significant differences between patient characteristics treated with and without radiotherapy. Median age at diagnosis was 54 (36-78) years. Ninety-five percent tumours were T1 and four patients had positive axillary lymph nodes. Of 94 patients treated with adjuvant radiotherapy, one developed local relapse. Five of 21 patients who did not have adjuvant radiotherapy failed locally. Five-year relapse-free survival with and without radiotherapy was 100 and 89%, respectively (hazard ratio for radiotherapy: 0.06; 95% confidence interval 0.01-0.32, P = 0.001).Radiotherapy has a significant impact on relapse-free survival in patients treated with breast-conserving surgery for tubular carcinoma.

Objective Uterine Papillary Serous Carcinoma (UPSC) is uncommon and accounts for less than 5% of all uterine cancers. Therefore the majority of evidence about the benefits of adjuvant treatment comes from retrospective case series. We conducted a prospective multi-centre non-randomized phase 2 clinical trial using four cycles of adjuvant paclitaxel plus carboplatin chemotherapy followed by pelvic radiotherapy, in order to evaluate the tolerability and safety of this approach. Methods This trial enrolled patients with newly diagnosed, previously untreated patients with stage 1b-4 (FIGO-1988) UPSC with a papillary serous component of at least 30%. Paclitaxel (175mg/m 2 ) and carboplatin (AUC 6) were administered on day 1 of each 3-week cycle for 4cycles. Chemotherapy was followed by external beam radiotherapy to the whole pelvis (50.4Gy over 5.5weeks). Completion and toxicity of treatment (Common Toxicity Criteria, CTC) and quality of life measures were the primary outcome indicators. Results Twenty-nine of 31 patients completed treatment as planned. Dose reduction was needed in 9 patients (29%), treatment delay in 7 (23%), and treatment cessation in 2 patients (6.5%). Hematologic toxicity, grade 3 or 4 occurred in 19% (6/31) of patients. Patients' self-reported quality of life remained stable throughout treatment. Thirteen of the 29 patients with stages 1–3 disease (44.8%) recurred (average follow-up 28.1months, range 8–60months). Conclusion This multimodal treatment is feasible, safe and tolerated reasonably well and would be suitable for use in multi-institutional prospective randomized clinical trials incorporating novel therapies in patients with UPSC.

The sequencing of external beam radiotherapy (EBRT) and a high-dose-rate brachytherapy (HDRB) boost is often interchangeable in clinical practice. When given before EBRT, HDRB could induce volume alterations in the prostate, which may have significant implications for EBRT dosimetry. We aimed to assess the influence of HDRB on prostate volume and, hence, prostate dosing via subsequent EBRT.Fifteen men had both pre- and post-HDRB CT performed followed by EBRT. After deidentification, the clinical target volume (CTV) was defined on each CT by a single-blinded observer. Volumes were compared for the pre- and post-HDRB scans in each patient. Radiotherapy planning was performed using the prebrachytherapy volumes aiming for the planning target volume (PTV) to be covered by 43.7Gy. After soft-tissue coregistration, this plan was also applied to the postbrachytherapy volumes.Median volume increase was 35.4% for the CTV after HDRB. No patient experienced a decrease in CTV volume (range, 0-79% volume increase; p-value0.001). Median volume increase was 26.1% for the PTVs, with no volume decrease observed (range, 8-56%; p0.001). PTV proportion achieving dose target (V43.7Gy) decreased by median of 7% (range, 0-21.5%; p=0.004). The minimum dose to the PTV (D(100)%) decreased by a median of 6Gy (range, 0.5-16Gy; p0.001).Insertion of HDRB catheters exerts substantial acute volumetric distortion on the prostate. EBRT planning performed on the basis of pre-HDRB imaging only inherently risks underdosing tumor. Planning adjustments based on repeat CT, or dedicated post-HDBT planning, is warranted for men managed with HDRB before EBRT.

BACKGROUND In patients undergoing radiation for cervical carcinoma, there is evidence that anemia is associated with an impaired outcome. For patients undergoing chemoradiation, there are no data available. The objective of this retrospective study was to examine the impact of anemia before and during chemoradiation in patients with cervical carcinoma. METHODS The authors collected data on hemoglobin (Hb) levels before and during treatment from 57 patients with cervical carcinoma. The stage of disease ranged between Stage IB and Stage IVA. All patients were treated with concurrent chemoradiation. Response to chemoradiation was evaluated by univariate and multivariate analyses. RESULTS The mean Hb level at the time of presentation was 12.9 ± 1.6 g/dL in patients with a complete clinical response (CCR) and 12.1 ± 1.4 g/dL in those with persistent disease (P = 0.126). In patients with a CCR, the mean nadir Hb level was 11.1 ± 1.3 g/dL, and in patients with treatment failure, it was 9.8 ± 1.8 g/dL (P = 0.008). A univariate logistic regression model demonstrated that the nadir Hb level was the most predictive factor for treatment failure (relative risk, 1.92; P = 0.015) followed by disease stage (relative risk, 0.51; P = 0.074). In a multivariate model, the nadir Hb level remained the only prognostically relevant factor predicting the response to chemoradiation. Only patients with nadir Hb values > 11 g/dL throughout chemoradiation had a more than 90% chance of achieving a CCR. CONCLUSIONS In patients undergoing chemoradiation for cervical carcinoma, the nadir Hb level is highly predictive of response to treatment, whereas the Hb level at the time of presentation is prognostically not significant. Cancer 2001;92:903–8. © 2001 American Cancer Society.

There is no consensus over the optimal dose fractionation schedules for high-dose-rate (HDR) brachytherapy used for gynaecological malignancy. In Australian public hospital departments of radiation oncology, HDR brachytherapy for gynaecological cancer is being more commonly used. A survey of public departments that are using this technology, or that plan to introduce this technology, was performed. Their current protocols are presented. In general, protocols are similar biologically; however, the practical aspects such as the number of fractions given do vary and may reflect resource restrictions or, alternatively, differences in interpretations of the literature and of the best protocols by clinicians.

Objectives. The aim of this study is to examine the patterns of failure after extended surgical staging and postoperative vaginal vault brachytherapy as the only adjuvant treatment in high-risk surgical Stage I patients with endometrial carcinoma. Methods. The records of all patients with endometrial carcinoma (adenocarcinoma or adenosquamous) receiving vaginal vault brachytherapy as the only adjuvant treatment from January 1989 to December 1997 were examined. A total of 489 patients were found. Of these, 133 had extended surgical staging. The study group consists of 77 surgical Stage I patients with Substages IBG3 and any grade IC. Recurrences were recorded as in the vagina, pelvis, or distant. Results. The mean follow-up interval was 45 months (range 14 to 96 months). Eleven patients had recurrence (14%). Median time to recurrence was 15 months (range 6 to 56 months). Recurrences occurred in the vagina in 7, pelvis in 1, and distantly in 3 patients. Five of 7 vaginal recurrences occurred within 2 years. All patients with distant recurrence died from disease. One patient with pelvic recurrence is alive with disease. Only 1 patient with vaginal recurrence died from disease. Six patients with isolated recurrences in the vagina were successfully treated with radiotherapy with or without local excision. All 6 have no evidence of disease at follow-up (median survival 29 months, range 20 to 71 months). Conclusions. The vagina remains the most common site of recurrence for high-risk surgical Stage I patients treated with postoperative vaginal vault brachytherapy. Close follow-up in the first 2 years is essential to detect isolated vaginal recurrences. These are amenable to salvage treatment with good disease-free survival.

Dr. Petereit and Dr. Frederickson in their letter have succinctly summarized the current state of knowledge regarding the role of adjuvant radiotherapy for stage I endometrial carcinoma patients who have been thoroughly staged. They have rightly pointed out that the emerging trend of withholding adjuvant therapy in stage I patients regardless of risk is premature given that the majority of patients in both the GOG 99 and PORTEC trials were in the low-risk category. They have also pointed out that it is equally illogical to continue to prescribe pelvic radiotherapy in high-risk stage I patients who have been thoroughly staged. Our article, together with others, has pointed to the role of vaginal brachytherapy only in high-risk stage I patients with negative lymph nodes. They have rightly pointed out that treating only the upper one-third of the vagina for higher-risk stage I disease may be insufficient to prevent vaginal recurrence, as shown in our article. The role of vaginal brachytherapy only has yet to be investigated in a randomized trial. There are some who question the value of even vaginal brachytherapy. Although the morbidity is low, it still requires hospitalization and resource utilization. Locoregional recurrences were higher in the no-radiotherapy arm for both the GOG 99 and PORTEC trials. However, there was no survival difference. This suggests that locoregional recurrences were amenable to salvage treatment with good survival. Dr. Petereit and Dr. Frederickson have proposed a randomized trial comparing vaginal brachytherapy with pelvic radiotherapy for high-risk stage I patients who are completely staged. Given the evidence from our study and that from the GOG 99 and PORTEC trials, perhaps a more appropriate trial would be to randomize patients with high-risk node-negative stage I endometrial carcinoma to receive either vaginal vault brachytherapy or no adjuvant radiotherapy. We thank Dr. Petereit and Dr. Frederickson for their interest in our article and are grateful for the opportunity to reply.

Background: To examine prognostic factors, treatment outcomes and design future studies for Osteolymphoma (OL) – also known as primary bone lymphoma.Methods: Between 1979 and 1993, 70 patients with OL were treated in nine Australian centres. The effect of patient-, tumour-, and treatment-related factors on local control, distant disease-free survival and overall survival were assessed by multivariate analysis.Results:Most patients (94%) received radiotherapy (RT) (median dose 40 Gy) and 56% received chemotherapy. Multifocal disease was present in 20% of patients. The five year rates of overall survival and local control were 59% and 82%. Although there was a trend towards better results with the addition of chemotherapy, on multivariate analysis, there were no factors identified which appeared to impact upon overall and disease-free survival. Among the distant recurrences, there was a high proportion in bone (33%). Six patients suffered pathological fractures after treatment.Conclusion:High rates of local control were achieved by RT, but the overall survival remains relatively poor, worse than nodal lymphoma. The natural history of the disease suggests that OL may be a distinct entity, different to nodal lymphomas, so the results of clinical trials in nodal lymphoma may not be relevant to OL. Prospective studies could define the outcome of combined modality therapy and set a benchmark for testing further proposals, as well as improving our knowledge of the clinical features of OL.Background: To examine prognostic factors, treatment outcomes and design future studies for Osteolymphoma (OL) – also known as primary bone lymphoma.