Cumulative incidence of ICP was significantly lower with TKI plus RT than with TKI alone; however, there was no significant difference in OS or neurological death. Deferring brain RT may not compromise neurologic and survival outcome in selected patients, but close magnetic resonance imaging follow-up is recommended for patients who defer brain RT.

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BackgroundThe purpose of this study was to identify parameters capable of predicting the deterioration of hepatic function after helical tomotherapy in patients with unresectable locally advanced hepatocellular carcinoma.MethodsBetween March 2006 and February 2012, 72 patients were eligible for this study. All patients received hypofractionated radiotherapy using the TomoTherapy Hi-Art (TomoTherapy, Madison, WI, USA) at Seoul St. Mary's Hospital and Incheon St. Mary's Hospital, the Catholic University of Korea. The radiation dose was a median 50 Gy (range: 40–50 Gy) in 10 fractions to 95% of the planning target volume. Radiation-induced hepatic toxicity was defined as an increase of at least 2 points in the Child-Pugh (CP) score within 3 months after completion of helical tomotherapy.ResultsAn increase of at least 2 points in the CP score occurred in 32 of the 72 patients (44.4%). Multivariate logistic regression analysis revealed that pretreatment CP class and V15Gy were significant parameters associated with an increase in CP score (p = 0.009 and p < 0.001, respectively). The area under receiver operating characteristic curve was 0.863 for V15Gy (p < 0.001). For V15Gy, with a cutoff value of 43.2%, the accuracy was 0.806 (58/72) with a sensitivity of 0.938 and a specificity of 0.725.ConclusionsAn increase of at least 2 points in the CP score is a radiation dose-limiting factor, and the non-target normal liver receiving a dose more than 15 Gy (V15Gy) should be <43.2% to reduce the risk of the deterioration of hepatic function.

The aim of this study was to analyze tumor control and clinical outcomes of patients with uterine cervical cancer treated by chemoradiotherapy according to pelvic lymph node (PLN) positivity and boost irradiation to PLN and to determine toxicities associated with boost irradiation.We retrospectively reviewed patients with uterine cervical cancer treated with chemoradiotherapy between March 2000 and April 2015. Clinical characteristics, failure pattern, and survival outcomes of patients with or without PLN metastasis and those with or without boost irradiation were analyzed.A total of 80 cases were PLN-negative and 46 were PLN-positive. A total of 11 patients underwent PLN boost irradiation. The 2-year and 5-year overall survival (OS) rates showed significant difference between the PLN-positive and PLN-negative groups (P = .010). The 2-year and 5-year progression-free survival (PFS) rates showed significant difference between the 2 groups (P = .032). The 2-year and 5-year OS rates of the no-boost irradiation group were 82.9% and 58.3%, respectively, whereas all patients in the boost irradiation group were alive at the time of analysis (P = .065). There was no recurrence in the boost irradiation group. The difference in PFS was significant between the boost and the no-boost irradiation groups (P = .023). The 2-year and 5-year pelvic-recurrence free survival (PRFS) did not show significant difference but the tendency of increased risk of pelvic recurrence in no-boost group (boost vs no-boost; 81.9% and 70.2% vs 100% and 100% in 2-year and 5-year PRFS, respectively, P = .156). Boost irradiation to PLN could improve locoregional control especially in large pelvic LN (≥1.5 cm). Our results showed that only 1 acute and late toxicity of higher than grade 3 occurred.PLN metastasis was significant prognostic factor in cervix cancer treated by chemoradiotherapy. In the boost irradiation group, there was no recurrence or death with significantly better PFS. Boost irradiation to PLN is expected to improve locoregional control, but further follow-up and assessment are needed.

PurposeThis study investigated setup error and effectiveness of weekly image-guided radiotherapy (IGRT) of TomoDirect for early breast cancer.Materials and MethodsOne hundred and fifty-one breasts of 147 consecutive patients who underwent breast conserving surgery followed by whole breast irradiation using TomoDirect in 2012 and 2013 were evaluated. All patients received weekly IGRT. The weekly setup errors from simulation to each treatment in reference to chest wall and surgical clips were measured. Random, systemic, and 3-dimensional setup errors were assessed. Extensive setup error was defined as 5 mm above the margin in any directions.ResultsAll mean errors were within 3 mm of all directions. The mean angle of gantry shifts was 0.6°. The mean value of absolute 3-dimensional setup error was 4.67 mm. In multivariate analysis, breast size (odds ratio, 2.82; 95% confidence interval, 1.00 to 7.90) was a significant factor for extensive error. The largest significant deviation of setup error was observed in the first week of radiotherapy (p < 0.001) and the deviations gradually decreased with time. The deviation of setup error was 5.68 mm in the first week and within 5 mm after the second week.ConclusionIn this study, there was a significant association between breast size and significant setup error in breast cancer patients who received TomoDirect. The largest deviation occurred in the first week of treatment. Therefore, patients with large breasts should be closely observed on every fraction and fastidious attention is required in the first fraction of IGRT.

We evaluated 5-year follow-up of stereotactic body radiation therapy (SBRT) with Cyberknife for prostate cancer patients.Forty-five men with prostate adenocarcinoma who received SBRT using Cyberknife from May 2006 to November 2012 were enrolled in this study. They were prostate cancer patients with old age and medical comorbidities who received a total of 36 Gy to the prostate in 5 fractions with either everyday or every other day schedule. Prostate-specific antigen (PSA) levels at initial diagnosis and after radiation were traced. Primary endpoints were biochemical relapse-free survival (bRFS), progression-free survival (PFS), and overall survival (OS). The definition of biochemical relapse was a PSA level of nadir + 2 ng/mL. Progression was defined as biochemically or clinically detected disease and the start of salvage therapy.After median follow-up of 63 months, the 5-year bRFS for all patients was estimated at 89.7%. The 5-year PFS was estimated at 71%. Four cases of biochemical relapse were observed, including two patients who experienced locoregional failure and one patient who had distant metastasis with biochemical relapse. The 5-year OS was estimated at 94.3%. There were five deaths, all of which were unrelated to prostate cancer. There was no grade 3 or higher acute complication. Grade 3 or higher late urinary toxicity was reported in 2 (4.4%) of 45 patients.The 5-year survival and toxicity outcome of SBRT using Cyberknife on prostate cancer patients with old age or comorbidities were favorable and safe in an investigational study.

Objectives: Despite complete surgical resection, 30–40% of patients with stage I–IIA non-small-cell lung cancer (NSCLC) have recurrences. We aimed to elucidate the effect of lymphovascular invasion (LVI) on the prognosis and patterns of recurrence in patients with pathologically confirmed T1–2N0 NSCLC. Methods: We evaluated 381 patients who underwent complete resection and were diagnosed with pathologic T1–2N0 NSCLC between March 2000 and January 2012. Local recurrence, nodal recurrence, and distant metastasis were defined and analyzed. Results: LVI was present in 72 patients (18.9%). The 5-year disease-free survival (DFS) for all patients was 69.9%. Patients with LVI showed a significant decrease in 5-year DFS (47.3 vs. 74.4%, p < 0.001). LVI was a significant prognostic predictor in multivariate analysis (p = 0.003). The patients with LVI showed a significantly increased 5-year cumulative incidence of nodal recurrence (22.5 vs. 8.7%, p < 0.001) and distant metastasis (30.4 vs. 14.9%, p = 0.004). However, no difference was shown between the two groups in the 5-year cumulative incidence of local recurrence (p = 0.416). Conclusions: LVI is a negative prognostic factor in patients with stage I–IIA NSCLC. The presence of LVI significantly increases the risk of nodal and distant recurrence.

PurposeSurgical clips are used as a target for postoperative breast radiotherapy, and displacement of surgical clips would result in inaccurate delivery of radiation. We investigated the displacement range of surgical clips in the breast during postoperative radiotherapy following breast-conserving surgery.MethodsA total of 178 patients who received breast-conserving surgery and postoperative radiation of 59.4 Gy in 33 fractions to the involved breast for 6.5 weeks were included. Surgical clips were used to mark the lumpectomy cavity during breast-conserving surgery. Patients undertook planning computed tomography (CT) scan for whole breast irradiation. Five weeks after beginning radiation, when the irradiation dose was 45 Gy, planning CT scan was performed again for a boost radiotherapy plan in all patients. The surgical clips were defined in both CT images and compared in lateromedial (X), anteroposterior (Y), superoinferior (Z), and three-dimensional directions.ResultsThe 90th percentile of displacement of surgical clips was 5.31 mm (range, 0.0–22.2 mm) in the lateromedial direction, 7.1 mm (range, 0.0–14.2 mm) in the anteroposterior direction, and 6.0 mm (range, 0.0–10.0 mm) in the superoinferior direction. The 90th percentile of three-dimensional displacement distance was 9.8 mm (range, 0.0–28.2 mm). On the multivariate analysis, seroma ≥15 mL was the only independent factor associated with the displacement of surgical clips. In patients with seroma ≥15 mL, the 90th percentile of displacement of surgical clips was 15.1 mm in the lateromedial direction, 12.7 mm in the anteroposterior direction, 10.0 mm in the superoinferior direction, and 21.8 mm in the three-dimensional distance.ConclusionA target volume expansion of 10 mm from surgical clips may be sufficient to compensate for the displacement of clips during postoperative radiotherapy after breast-conserving surgery. For patients who had a seroma, a replanning CT scan for a boost radiation should be considered to ensure exact postoperative radiotherapy in breast cancer.