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Objectives To report overall survival and local control for patients identified in the RSSearch® Patient Registry with metastatic cancer to the lung treated with SBRT. Methods Seven hundred two patients were identified with lung metastases in the RSSearch® Registry. Of these patients, 577 patients had SBRT dose and fractionation information available. Patients were excluded if they received prior surgery, radiation, or radiofrequency ablation to the SBRT treated area. Between April 2004-July 2015, 447 patients treated with SBRT at 30 academic and community-based centers were evaluable for overall survival (OS). Three hundred four patients with 327 lesions were evaluable for local control (LC). All doses were converted to Monte Carlo equivalents and subsequent BED Gy10 for dose response analysis. Results Median age was 69 years (range, 18–93 years). Median Karnofsky performance status (KPS) was 90 (range 25/75% 80–100). 49.2% of patients had prior systemic therapy. Median metastasis volume was 10.58 cc (range 25/75% 3.7–25.54 cc). Site of primary tumor included colorectal (25.7%), lung (16.6%), head and neck (11.4%), breast (9.2%), kidney (8.1%), skin (6.5%) and other (22.1%). Median dose was 50 Gy (range 25/75% 48–54) delivered in 3 fractions (range 25/75% 3–5) with a median BED of 100Gy10 (range 25/75% 81–136). Median OS for the entire group was 26 months, with actuarial 1-, 3-, and 5-year OS of 74.1%, 33.3, and 21.8%, respectively. Patients with head and neck and breast cancers had longer median OS of 37 and 32 months respectively, compared to colorectal (30 months) and lung (26 months) which corresponded to 3-year actuarial OS of 51.8 and 47.9% for head and neck and breast respectively, compared to 35.8% for colorectal and 31.2% for lung. The median LC for all patients was 53 months, with actuarial 1-, 3-, and 5-year LC rates of 80.4, 58.9, and 46.3%, respectively. There was no difference in LC by primary histologic type (p = 0.49). Improved LC was observed for lung metastases that received SBRT doses of BED ≥100Gy10 with 3-year LC rate of 77.1% compared to 45% for lung metastases treated with BED 11 cc. (p = 0.005) Two-year LC rates for tumor volumes 27 cc were 72.9, 64.2 and 45.6%, respectively. This correlated with improved OS with 2-year OS rates of 62.4, 60.9 and 46.2% for tumor volumes 27 cc, respectively (p = 0.0023). In a subset of patients who received BED ≥100Gy10, 2-year LC rates for tumor volumes 27 cc were 82.8, 58.9 and 68.6%, respectively (p = 0.0244), and 2-year OS rates were 66.0, 58.8 and 28.5%, respectively (p = 0.0081). Conclusion Excellent OS and LC is achievable with SBRT utilizing BED ≥100Gy10 for lung metastases according to the RSSearch® Registry data. Patients with small lung metastases (volumes

Purpose The aim of this study was to define current patterns of care among radiation oncologists who use skin surface brachytherapy for the treatment of cutaneous squamous cell carcinoma (cSCC) and basal cell carcinoma (BCC) in academic and community settings. Methods and Materials A 30-question electronic survey was administered to clinician members of the American Brachytherapy Society. The respondents were asked to provide details regarding their clinical practice and their approach to skin surface brachytherapy. Results A total of 16 surveys were returned. Among the respondents, aggregate experience varied from 8 to 1800 cases. Most preferred brachytherapy over external beam radiation because of shorter treatment course, conformality of treatment for irregular or curved targets, and shallow dose deposition. Of the total, 60% of respondents routinely estimated lesion depth via ultrasound before initiating treatment. Treatment margin on gross disease varied widely (range, 3–15 mm; median, 5 mm). Hypofractionation was the preferred dose schedule. Prescribed doses ranged from 30 Gy in five fractions to 64 Gy in 32 fractions (EQD2, 40 Gy–65 Gy). There was a tendency to increase the number of fractions for larger targets, although some used the same fractionation regardless of anatomic location or lesion size. There was no consensus on dosimetric constraints, and some respondents reported cases of severe toxicity, particularly when treating the pretibial skin. Conclusions This pattern of care study suggests that skin brachytherapy can be a convenient and safe tool for treatment of BCC and cSCC. Prospective trials and the development of expert consensus guidelines would be beneficial for optimizing skin surface brachytherapy and reducing practice variation.

Brachytherapy is an excellent definitive treatment modality for select patients with localized prostate cancer. Sixty-four patients with Stage T2a prostate adenocarcinoma were identified from the series of prostate patients receiving conformal outpatient brachytherapy between 1990 and 1997. Pretreatment Gleason scores and prostate specific antigen (PSA) values ranged from 2 to 10 and 1.5 to 100, respectively. Median follow-up was 48.5 months. The 5-year overall survival rate was 82.5%, whereas the cause-specific survival rate was 93.7%. The biochemical freedom-from-relapse (bFFR), defined as a PSA level of ≤ 1.0 for patients presenting with Gleason scores of ≤ 5, was 68%; 80% with Gleason scores of ≤ 5 and presenting PSA levels of ≤ 10. In patients with Gleason scores of 6 at presentation, the overall bFFrR was 67%; 87% with a Gleason scores of 6 and PSA levels of ≤ 10. The bFFR was maintained in more than half of patients with Gleason scores of 7 only if they presented with PSA levels of ≤ 10. All patients who presented with PSA levels of ≤ 10 had bFFRs of 75%, compared to 36% for those patients presenting with PSA levels of > 10. These data show that patients with Gleason scores of ≤ 5 can achieve very good PSA control with brachytherapy, especially if the presenting PSA level is ≤ 10. Consideration of PSA is of greater import when a Gleason score ≥ 6 is encountered at presentation. Our data show that durable bFFR can be achieved in patients presenting with Stage T2a disease, Gleason scores of 5–7, and PSA levels of ≤ 10. These results need to be confirmed with further follow-up and other prospective data.

Experimental radiobiology has by happenstance focused on the implications of intraoperative and high-dose-per-fraction radiotherapy in more detail than it has standard fractionated radiotherapy. This is because the majority of radiobiological literature of tumor and normal tissue features in vivo and in vitro studies in which the radiation was administered in a single fraction. Similarly, when fractionation is used experimentally, fraction sizes near the clinical 1.8–2 Gy size used for most external beam irradiation therapy (EBRT) are rarely utilized. As a result, much of our radiobiological understanding of tumor and normal tissue response should and does relate well to that observed clinically for intraoperative irradiation therapy (IORT).

The goals of this ongoing Phase III study of adjuvant local hyperthermia with radiotherapy were to evaluate how tumor control and normal tissue complications were related to patient and treatment variables. Canine veterinary patients with localized malignancies were stratified by histology and anatomic site and randomized into three groups. All patients received radiotherapy (60CO) in 3.5 Gy fractions given Mon-Wed-Fri to 14 treatments (49 Gy). One group received radiotherapy alone while the others also received microwave-induced hyperthermia (44 degrees C) for 30 minutes once each week. Hyperthermia followed radiotherapy and was given to one group immediately and delayed 4-5 hours in the other. Adjuvant hyperthermia resulted in a significant (p less than .05) increase in complete response rate, reduction in the frequency of non-responders, and increased persistent local control relative to radiotherapy alone. Hyperthermia increased the complete response rate regardless of histology, site, or volume and with the current sample size control was significantly (p less than .05) greater for sarcomas, tumors of the trunk and extremities, and those with volumes less than 10 cc. Quantitative clinical assessment of the acute response of skin and oral mucosa indicated that hyperthermia significantly enhanced these acute reactions, which required roughly twice the healing time observed with radiotherapy alone. Quantitative histologic scoring of changes seen between pre- and post-therapy skin biopsies indicated that a treatment induced decline in the frequency of dermal blood vessels, sebaceous glands, and hair follicles was enhanced by adjuvant hyperthermia, particularly in the late response evaluation interval. The probability of tumor control and adverse normal tissue responses correlated with several measures of thermal dose. Thermal doses in excess of 120 equivalent minutes at 43 degrees C correlated positively with increased skin reactions and negatively with the complete response rate, and these trends were usually evident during the animals' first treatment.

Patterns of specific absorption rates generated by interstitial, microwave antenna arrays must be experimentally ascertained and quantified to facilitate their clinical incorporation. Phantom studies involved the use of four single-gap, coaxial antennas oriented in a 2 cm square array. These dipoles were driven in phase by a microwave generator at a frequency of 915 MHz. The inherent limitations in modifying the specific absorption rate patterns were addressed with the addition of bolus to the phantom. These additions of Guy's muscle tissue-equivalent material were made either proximal or distal to the phantom proper. Experiments conducted in the presence and absence of tissue-equivalent material bolus showed the ability to achieve broader bands of 50% power deposition in certain bolus conditions. These heating patterns were sufficiently reproducible and predictable to warrant clinical application of the bolus addition. A through-and-through method of catheter implantation allowed for bolus addition when deemed necessary. Treatments with veterinary and human patients using the bolus method to modify heating patterns yielded augmented patterns of power deposition. The effective length of the antennas that would radiate efficiently was essentially broadened via introduction of a microwave-interacting medium. As a result of the tissue equivalent material's ability to absorb microwave power, it was necessary to interpose minimally-interactive styrofoam spacers to limit heat transfer effects at the tissue-bolus interfaces.

Experimental radiobiology has inadvertently studied the implications of intraoperative and high-dose-per-fraction radiotherapy in more detail than it has standard fractionated radiotherapy. This is because the majority of radiobiological literature of tumor and normal tissue features in vivo and in vitro studies in which the radiation was given in a single fraction. Similarly, when fractionation is used experimentally, the experiment rarely features fraction sizes near the clinical 1.8- to 2-Gy size used for most external beam irradiation (EBRT). As a result much of our understanding of tumor and normal tissue response should and does relate well to that observed clinically for intraoperative irradiation (IORT).

Purpose This paper demonstrates how the communication patterns and protocol rigors of a methodology called crew resource management (CRM) can be adapted to a radiation oncology environment to create a culture of patient safety. CRM training was introduced to our comprehensive radiation oncology department in the autumn of 2009. With 34 full-time equivalent staff, we see 100-125 patients daily on 2 hospital campuses. We were assisted by a consulting group with considerable experience in helping hospitals incorporate CRM principles and practices. Implementation steps included developing change initiative skills for key leaders, providing training in teamwork and communications, creating site-specific tools for safety and efficiency, and collecting data to document results. Methods and materials Our goals were to improve patient safety, teamwork, communication, and efficiency through the use of tools we developed that emphasized teamwork and communication, cross-checking, and routinizing specific protocols. Our CRM plan relies on the following 4 pillars: patient identification methods; "pause for the cause"; enabling all staff to halt treatment and question decisions; and daily morning meetings. We discuss some of the hurdles to change we encountered. Results Our safety record has improved. Our near-miss rate before CRM implementation averaged 11 per month; our near-miss rate currently averages 1.2 per month. In the 5 years prior to CRM implementation, we experienced 1 treatment deviation per year, although none rose to the level of "mis-administration." Since implementing CRM, our current patient treatment setup and delivery process has eliminated all treatment deviations. Our practices have identified situations where ambiguity or conflicting documentation could have resulted in inappropriate treatment or treatment inefficiencies. Our staff members have developed an extraordinary sense of teamwork combined with a high degree of personal responsibility to assure patient safety and have spoken up when they considered something potentially unsafe. We have increased our efficiency (and profitability); in 2012, our units of service were up 11.3% over 2009 levels with the same staffing level. Conclusions The rigor and standardization introduced into our practice, combined with the increase in communication and teamwork have improved both safety and efficiency while improving both staff and patient satisfaction. CRM principles are highly adaptable and applicable to the radiation oncology setting.