The European Organisation for Research and Treatment of Cancer (EORTC; protocol 08031) phase II trial investigated the feasibility of trimodality therapy consisting of induction chemotherapy followed by extrapleural pneumonectomy and post-operative radiotherapy in patients with malignant pleural mesothelioma (with a severity of cT3N1M0 or less).Induction chemotherapy consisted of three courses of cisplatin 75 mg?m -2 and pemetrexed 500 mg?m -2 . Nonprogressing patients underwent extrapleural pneumonectomy followed by postoperative radiotherapy (54 Gy, 30 fractions). Our primary end-point was ''success of treatment'' and our secondary end-points were toxicity, and overall and progression-free survival. 59 patients were registered, one of whom was ineligible. Subjects' median age was 57 yrs. The subjects' TNM scores were as follows: cT1, T2 and T3, 36, 16 and six patients, respectively; cN0 and N1, 57 and one patient, respectively. 55 (93%) patients received three cycles of chemotherapy with only mild toxicity. 46 (79%) patients received surgery and 42 (74%) had extrapleural pneumonectomy with a 90-day mortality of 6.5%. Post-operative radiotherapy was completed in 37 (65%) patients. Grade 3-4 toxicity persisted after 90 days in three (5.3%) patients. Median overall survival time was 18.4 months (95% CI 15.6-32.9) and median progression-free survival was 13.9 months (95% CI 10.9-17.2). Only 24 (42%) patients met the definition of success (one-sided 90% CI 0.36-1.00).Although feasible, trimodality therapy in patients with mesothelioma was not completed within the strictly defined timelines of this protocol and adjustments are necessary.

The CyberKnife is a frameless image-guided radiotherapy system involving a 6-MV linear accelerator mounted on a robotic arm. The imaging system consists of two diagnostic x-ray sources mounted to the ceiling paired with amorphous silicon detectors to acquire live digital radiographic images of the tumor or tumor surrogates including bony anatomy or implanted fiducial markers. The Synchrony system enables 4D real-time tracking of tumors that move with respiration. Owing to this complex system, moving tumors can be treated with an accuracy of 2 mm or less while patients breathe normally. Clinical results of inoperable patients with peripheral early-stage lung cancer are excellent. The toxicity is low and the treatment does not result in a loss in quality of life.

No abstract

Seventy two patients presenting with symptomatic brain metastases from undiagnosed primary neoplasms were retrospectively reviewed. Primary malignancies were diagnosed before death in 54 patients and remained unknown in 18 patients. Lung cancer was the most common primary tumour (72%), followed by breast cancer, colon carcinoma, and melanoma. On physical examination, 51 patients had organ specific symptoms or signs providing guidelines to the diagnostic evaluation. In 24 of the 52 patients with a primary lung tumour, and in four of the 20 patients without, organ specific complaints or findings suggested this tumour type, resulting in a positive predictive value of 85%.Overall, radiography and CT of the chest were very useful in detection of primary lung tumours. This could partly be explained by the high prior probability of detecting such tumours. Other diagnostic procedures should be used on indication only. The prognosis of patients with confirmed primary tumour position did not differ from those with unidentified primary tumour.

PurposeTo develop a fully automated procedure for multicriterial volumetric modulated arc therapy (VMAT) treatment planning (autoVMAT) for stage III/IV non-small cell lung cancer (NSCLC) patients treated with curative intent.Materials and methodsAfter configuring the developed autoVMAT system for NSCLC, autoVMAT plans were compared with manually generated clinically delivered intensity-modulated radiotherapy (IMRT) plans for 41 patients. AutoVMAT plans were also compared to manually generated VMAT plans in the absence of time pressure. For 16 patients with reduced planning target volume (PTV) dose prescription in the clinical IMRT plan (to avoid violation of organs at risk tolerances), the potential for dose escalation with autoVMAT was explored.ResultsTwo physicians evaluated 35/41 autoVMAT plans (85%) as clinically acceptable. Compared to the manually generated IMRT plans, autoVMAT plans showed statistically significant improved PTV coverage (V95% increased by 1.1% ± 1.1%), higher dose conformity (R50 reduced by 12.2% ± 12.7%), and reduced mean lung, heart, and esophagus doses (reductions of 0.9 Gy ± 1.0 Gy, 1.5 Gy ± 1.8 Gy, 3.6 Gy ± 2.8 Gy, respectively, all p < 0.001). To render the six remaining autoVMAT plans clinically acceptable, a dosimetrist needed less than 10 min hands-on time for fine-tuning. AutoVMAT plans were also considered equivalent or better than manually optimized VMAT plans. For 6/16 patients, autoVMAT allowed tumor dose escalation of 5–10 Gy.ConclusionClinically deliverable, high-quality autoVMAT plans can be generated fully automatically for the vast majority of advanced-stage NSCLC patients. For a subset of patients, autoVMAT allowed for tumor dose escalation.