[en] Objective: In recent years, a large proportion of non-Hodgkin's lymphomas of the stomach are recognized as low grade tumors of the mucosa associated lymphoid tissue (MALT) type. Since the MALT morphological subtype has only gained acceptance as a malignant lymphoma after the establishment of the Working Formulation, there is limited information about its natural history, disease pattern, and longterm treatment outcome. This study is an analysis of these parameters in patients with primary MALT lymphoma of the stomach. Materials and Methods: Consecutive patients with primary gastric MALT lymphoma who received definitive treatment at the Massachusetts General Hospital between (4(78)) and (2(95)) were included in the study. The diagnosis was pathologically verified in all cases. Clinical staging studies included chest X-ray +/- chest CT, abdomino-pelvic CT or bipedal lymphangiogram, barium swallow, and bone marrow biopsy. Treatment strategies included combinations of partial or total gastrectomy, radiation (RT) and chemotherapy (chemo). RT was given via multifield technique, with 10-25MV photons, to doses of 36-50.4 Gy (1.1-1.8 Gy per fraction, 5 days a week). Survival analyses were performed by the Kaplan-Meier actuarial method. Results: There were twenty-two patients between the ages of 45 - 93 years, with a mean follow-up of 67 months. Ten were male and 12 female. The most frequent presenting symptoms were epigastric pain (77%), dyspepsia (65%), and melena (41%). The mean duration of symptoms was 27 months. Eighteen cases were clinical stage (cs)I, two csII, one csIII, and one csIV. The treatment approaches were: 1) csI:6 gastrectomy alone, 7 gastrectomy and RT, 1 gastrectomy and chemo, 2 RT alone, 1 chemo and RT, 1 no therapy; 2) csII: 2 gastrectomy and RT; 3) csIII: 1 gastrectomy and chemo; 4) csIV: 1 chemo and RT. Among 16 gastrectomy specimens, multifocal gastric involvement was evident in 50%. The most frequently involved sites were the body (63%) and antrum (44%). Of cases with body involvement, the lesser curvature was involved in (8(10)), and the greater curvature in(3(10)) . 14 csI patients underwent partial or total gastrectomy. Ten were pathological stage I and the remaining 4 (28%) were pathologically upgraded due to perigastric nodal or porta hepatis involvement. There was 1 relapse among the 17 csI patients who received definitive treatment, yielding a relapse-free survival rate of 92% at 7 years. The 7-year disease-specific and overall survival rates were 100% and 88% respectively. The two csII patients died of relapsed lymphoma at 2.5 and 4.8 years. The csIII patient relapsed after CHOP chemo, underwent salvage autologous bone marrow transplant, and is alive without disease 3.3 years from diagnosis. The csIV patient is relapse-free 5.8 years after chemo and gastric RT. For the entire study population, the 7-year relapse-free and overall survival rates were 73% and 76% respectively. Conclusions: In this study, the diagnosis of gastric MALT lymphoma was often preceded by a long period of symptoms. The frequent symptoms of epigastric pain and dyspepsia mimicked those of gastritis. Examination of gastrectomy specimens indicated that lymphomatous involvement was often multifocal, with the body and antrum being the most commonly involved sites. In this study group, about 90% of patients had localized (csI and II) disease. Among the csI patients who underwent a gastrectomy, 72% were pathological stage I and 28% were upstaged. For stage I patients, local treatment with gastrectomy with or without adjuvant therapy and definitive RT were effective treatment modalities, yielding excellent 7-year relapse-free and disease-specific survival rates of 92% and 100% respectively. These data indicate that in contrast to many other low grade lymphomas, MALT lymphoma of the stomach predominantly presents as localized disease which may be highly curable with local therapy only, and radiation may play a significant role in its treatment. A prospective clinical trial is about to begin to investigate the role of gastric irradiation (without gastrectomy) for localized gastric MALT lymphomas and also the role of antibiotic therapy in patients with associated Helicobacter pylori infection

[en] Purpose/Objective: To prospectively determine symptom response in patients receiving radiation therapy for primary lung cancer. Materials and Methods: Thirty-three consecutive lung cancer patients were evaluated between March 1996 and February 1997 at the Medical College of Virginia satellite facility which serves a local community hospital. The LCSS, a validated quality of life scale, was used prospectively during the consultation and upon subsequent follow-up. The scale allowed scoring of symptom improvement, worsening, or stability following therapy. One patient declined therapy, while another was not offered XRT. The 31 remaining patients received a median dose of 54 Gy. Eleven patients received radiotherapy with curative intent to doses between 60 and 70 Gy, 5 small cell lung carcinoma (SmCCa) patients received 54 Gy consolidative therapy, and 13 patients received 15 to 30 Gy with palliative intent. Eight patients received chemotherapy as part of their initial treatment course, including all of those diagnosed with SmCCa. Twenty-one patients completed the LCSS at least once in the three month interval after therapy, while 6 died prior to follow-up, 2 were under treatment at the time of this analysis, and 2 were lost to follow-up. Survival analysis was completed using the Kaplan-Meier method. Results: Median follow-up was 4 months (range = 1 to 14), with an estimated median survival of 5 months. Fourteen patients died of lung cancer, 12 are alive with disease, 6 are alive without disease, and 1 died without disease. Patient characteristics were median age of 69 years (range = 43 to 91), male to female ratio of 4.5 to 1, mean weight loss of 12 pounds (range = 0 to 27), and mean duration of symptoms of 3 months (range = 0 to 12). Stage was: I 9%, II = 0%, IIIA = 6%, IIIB = 43%, IV = 27%, and limited stage SmCCa = 15%. Histology was: squamous cell carcinoma = 21%, adenocarcinoma = 23%, large cell carcinoma = 23%, poorly differentiated carcinoma = 15%, mesothelioma 3%, and SmCCa = 15%. The median number of LCSS symptoms at presentation was 4, and 94% of the patients presented with at least one symptom. The incidence of observer scored symptoms was: loss of appetite = 54%, fatigue = 79%, cough 79%, dyspnea = 73%, hemoptysis = 27%, and pain = 33%. Subjective reporting of pre-treatment symptoms revealed: loss of appetite = 51%, fatigue = 82%, cough = 73%, dyspnea = 70%, hemoptysis = 24%, and pain = 36%. There was a 96% rate of agreement between subjective and objective measures. When seen at first follow-up, the 21 evaluable patients scored subjective improvement in at least one symptom at a rate of 81%, while objective assessment at those same time points showed a palliation rate of 67%. The rate of agreement between subjective and objective measures of post-therapy symptoms was 68%, with the observer more likely to underestimate the gain defined by the patients' subjective scoring. Hemoptysis was the symptom most improved by therapy, followed by cough and loss of appetite. Discussion: Here we present early results of a prospective quality of life analysis in patients treated with radiotherapy for lung cancer. These objective palliation rates agree with our previously published retrospective data, though here the patients tend to perceive an even higher subjective rate of improvement than that which is evident to the examiner. To our knowledge this report contains the first data obtained in a prospective study using a validated quality of life scale on patients receiving radiotherapy for primary lung cancer. We continue prospective accrual of patients with the goal of allowing statistical analysis of symptom response to radiation in several different subgroups of patients with this disease

[en] Purpose: Radiotherapy (RT) has an important role in breast cancer treatment after modified radical mastectomy. Many of these patients also undergo breast reconstruction. We reviewed our institutions' experience to determine the outcome of patients treated with breast reconstruction and RT. Methods and Materials: Between 1981 and 1999, 48 breast cancer patients underwent modified radical mastectomy, breast reconstruction, and ipsilateral breast RT during their treatment course. Reconstruction either preceded or followed RT. Autologous reconstruction with a transverse rectus abdominus myocutaneous (TRAM) flap was performed in 30 patients, and 18 underwent expander and implant (E/I) reconstruction. The primary endpoint was the quality of the reconstructed, irradiated breast, as measured by analyzing the actuarial incidence of complications. The cosmetic outcome was also assessed by multidisciplinary review of the follow-up visits. Results: The median follow-up from reconstruction was 32 months. The actuarial 2-year complication rate was 53% for patients receiving E/I vs. 12% for those receiving TRAM reconstruction (p<0.01). No other patient or treatment-related factors had a significant impact on complications. The cosmetic outcome was also significantly better in the TRAM subgroup than in the E/I subgroup. Conclusion: The tolerance and cosmetic outcome of breast reconstruction for breast cancer patients in irradiated sites depends significantly on the type of reconstruction used

[en] Purpose/Objective: Bladder preservation, in the interest of quality of life, is secondary to the primary treatment goal of curing the patient. To evaluate the long term efficacy of a selective bladder preserving approach we updated our prospective series which now includes 40 patients surviving and under surveillance for 5 or more years. Materials and Methods: From 1986 through 1993, 106 patients (median age 68 years) with muscle-invading tumor (stages T₂-T_4a, N_x, M₀) initiated a protocol of maximal transurethral resection followed by 2 cycles of methotrexate, cisplatin and vinblastine plus cisplatin x2 with 40Gy pelvic irradiation. Complete responders and all non-cystectomy candidates received consolidation by cisplatin and 24.8Gy. Incomplete responders underwent immediate radical cystectomy as did those who developed recurrent invasive tumor. Median follow-up is 53 months. Results: Of all 106 patients who initiated induction Combined Modality Treatment (CMT): 1) 83 patients or 78% completed CMT; 33% developed moderate or severe leukopenia, 2) 74 patients (70%) had a Complete Response (CR), 3) the 5 year actuarial overall survival is 52%; for clinical stage T₂ and T₃-T_4a this is 63% and 45%, respectively, 4) 36 patients (34%) have had cystectomy, all for tumor (6 because CMT wasn't tolerated, 13 for < CR, 17 for recurrence); no patient required cystectomy for complications; the 5 year survival with an intact functioning bladder is 43%, 5) 31 patients (20%) have had relapse of a superficial TCC with 4 requiring cystectomy after failing conservative management with a subsequent median follow-up of 58 months. Conclusion: These data demonstrate 1) that induction CMT with transurethral surgery and chemo-radiotherapy and selection for organ-conservation by response have a 52% overall survival which is comparable to immediate cystectomy-based prospective studies of patients with similar age and clinical stages and 2) that the majority of long term survivors retain fully functional bladders

[en] Purpose: Chemotherapy and accelerated superfractionated radiotherapy were prospectively applied for inflammatory breast carcinoma with the intent of breast conservation. The efficacy, failure patterns, and patient tolerance utilizing this approach were analyzed. Methods and Materials: Between 1983 and 1996, 52 patients with inflammatory breast carcinoma presented to the Medical College of Virginia Hospitals of VCU and the New England Medical Center. Thirty-eight of these patients were jointly evaluated in multidisciplinary breast clinics and managed according to a defined prospectively applied treatment policy. Patients received induction chemotherapy, accelerated superfractionated radiotherapy, selected use of mastectomy, and concluded with additional chemotherapy. The majority were treated with 1.5 Gy twice daily to field arrangements covering the entire breast and regional lymphatics. An additional 18-21 Gy was then delivered to the breast and clinically involved nodal regions. Total dose to clinically involved areas was 63-66 Gy. Following chemoradiotherapy, patients were evaluated with physical examination, mammogram, and fine needle aspiration x 3. Mastectomy was reserved for those patients with evidence of persistent or progressive disease in the involved breast. All patients received additional chemotherapy. Results: Median age was 51 years. Median follow-up was 23.9 months (6-86) months. The breast preservation rate at the time of last follow-up was 74%. The treated breast or chest wall as the first site of failure occurred in only 13%, and the ultimate local control rate with the selected use of mastectomy was 74%. Ten patients underwent mastectomy, 2 of which had pathologically negative specimens despite a clinically palpable residual mass. Response to chemotherapy was predictive of treatment outcome. Of the 15 patients achieving a complete response, 87% remain locoregionally controlled without the use of mastectomy. Five-year overall survival for complete responders was 68%. This is in contrast to the 14% 5-year overall survival observed with incomplete responders. The 5-year actuarial disease-free survival and overall survival for the entire patient cohort was 11% and 33%, respectively. All patients tolerated irradiation with limited acute effects, of which all were managed conservatively. Conclusion: Our experience demonstrates that induction chemotherapy, accelerated superfractionated radiotherapy, and the selected use of mastectomy results in excellent locoregional control rates, is well tolerated, and optimizes breast preservation. Based on our present results, we recommend that a patient's response to induction chemotherapy guide the treatment approach used for locoregional disease, such that mastectomy be reserved for incomplete responders and avoided in those achieving a complete response

[en] Purpose: To determine whether the use of routine image guided radiation therapy (IGRT) using pretreatment on-board imaging (OBI) with orthogonal kilovoltage X-rays reduces treatment delivery errors. Methods and Materials: A retrospective review of documented treatment delivery errors from 2003 to 2009 was performed. Following implementation of IGRT in 2007, patients received daily OBI with orthogonal kV X-rays prior to treatment. The frequency of errors in the pre- and post-IGRT time frames was compared. Treatment errors (TEs) were classified as IGRT-preventable or non-IGRT-preventable. Results: A total of 71,260 treatment fractions were delivered to 2764 patients. A total of 135 (0.19%) TEs occurred in 39 (1.4%) patients (3.2% in 2003, 1.1% in 2004, 2.5% in 2005, 2% in 2006, 0.86% in 2007, 0.24% in 2008, and 0.22% in 2009). In 2007, the TE rate decreased by >50% and has remained low (P = .00007, compared to before 2007). Errors were classified as being potentially preventable with IGRT (e.g., incorrect site, patient, or isocenter) vs. not. No patients had any IGRT-preventable TEs from 2007 to 2009, whereas there were 9 from 2003 to 2006 (1 in 2003, 2 in 2004, 2 in 2005, and 4 in 2006; P = .0058) before the implementation of IGRT. Conclusions: IGRT implementation has a patient safety benefit with a significant reduction in treatment delivery errors. As such, we recommend the use of IGRT in routine practice to complement existing quality assurance measures.

[en] The respiratory disease COVID-19 reached global pandemic status in 2020. Excessive inflammation is believed to result in the most severe symptoms and death from this disease. Because treatment options for patients with severe COVID-19 related pulmonary symptoms remain limited, whole-lung low-dose radiation therapy is being evaluated as an anti-inflammatory modality. However, there is concern about the long-term risks associated with low-dose pulmonary irradiation. To help quantify the benefit-risk balance of low-dose radiation therapy for COVID-19, we estimated radiation-induced lifetime risks of both lung cancer and heart disease (major coronary events) for patients of different sexes, treated at ages 50 to 85, with and without other relevant risk factors (cigarette smoking and baseline heart disease risk).

[en] Purpose: To document and explain the current radiotherapeutic management of invasive breast cancer in North America and Europe. We also identified a number of areas of agreement, as well as controversy, toward which additional clinical research should be directed. Methods and materials: An original survey questionnaire was developed to assess radiation oncologists' self-reported management of breast cancer. The questionnaire was administered to physician members of the American Society for Therapeutic Radiology and Oncology and the European Society for Therapeutic Radiology and Oncology. We present the results of the comparative analysis of 702 responses from North America and 435 responses from Europe. Results: Several areas of national and international controversy were identified, including the selection of appropriate candidates for postmastectomy radiation therapy (RT) and the appropriate management of the regional lymph nodes after mastectomy, as well as after lumpectomy. Only 40.7% and 36.1% of respondents would use postmastectomy RT in patients with 1-3 positive lymph nodes in North America and Europe, respectively. Sentinel lymph node biopsy was offered more frequently by North American than European respondents (p < 0.0001) and more frequently by academic than nonacademic respondents in North America (p < 0.05). The average radiation fraction size was larger in Europe than in North America (p < 0.01). European respondents offered RT to the internal mammary chain more often than did the North American respondents (p < 0.001). North American respondents were more likely to offer RT to the supraclavicular fossa (p < 0.001) and axilla (p < 0.01). Conclusion: Marked differences were found in physician opinions regarding the management of breast cancer, with statistically significant international differences in patterns of care. This survey highlighted areas of controversy, providing support for international randomized trials to optimize the RT management of invasive breast cancer

[en] Purpose: To present long-term outcomes of a prospective feasibility trial using either protons or 3-dimensional conformal photon-based (accelerated partial-breast irradiation [APBI]) techniques. Methods and Materials: From October 2003 to April 2006, 98 evaluable patients with stage I breast cancer were treated with APBI (32 Gy in 8 fractions given twice daily) on a prospective clinical trial: 19 with proton beam therapy (PBT) and 79 with photons or mixed photons/electrons. Median follow-up was 82.5 months (range, 2-104 months). Toxicity and patient satisfaction evaluations were performed at each visit. Results: At 7 years, the physician rating of overall cosmesis was good or excellent for 62% of PBT patients, compared with 94% for photon patients (P=.03). Skin toxicities were more common for the PBT group: telangiectasia, 69% and 16% (P=.0013); pigmentation changes, 54% and 22% (P=.02); and other late skin toxicities, 62% and 18% (P=.029) for PBT and photons, respectively. There were no significant differences between the groups in the incidences of breast pain, edema, fibrosis, fat necrosis, skin desquamation, and rib pain or fracture. Patient-reported cosmetic outcomes at 7 years were good or excellent for 92% and 96% of PBT and photon patients, respectively (P=.95). Overall patient satisfaction was 93% for the entire cohort. The 7-year local failure rate for all patients was 6%, with 3 local recurrences in the PBT group (7-year rate, 11%) and 2 in photon-treated patients (4%) (P=.22). Conclusions: Local failure rates of 3-dimensional APBI and PBT were similar in this study. However, PBT, as delivered in this study, led to higher rates of long-term telangiectasia, skin color changes, and skin toxicities. We recommend the use of multiple fields and treatment of all fields per treatment session or the use of scanning techniques to minimize skin toxicity

[en] Background: The specific aim was to determine national patterns of radiation therapy (RT) practice in patients treated for stage IB-IV (nonmetastatic) gastric cancer (GC). Methods and Materials: A national process survey of randomly selected US RT facilities was conducted which retrospectively assessed demographics, staging, geographic region, practice setting, and treatment by using on-site record review of eligible GC cases treated from 2005 to 2007. Three clinical performance measures (CPMs), (1) use of computed tomography (CT)-based treatment planning; (2) use of dose volume histograms (DVHs) to evaluate RT dose to the kidneys and liver; and (3) completion of RT within the prescribed time frame; and emerging quality indicators, (i) use of intensity modulated RT (IMRT); (ii) use of image-guided tools (IGRT) other than CT for RT target delineation; and (iii) use of preoperative RT, were assessed. Results: CPMs were computed for 250 eligible patients at 45 institutions (median age, 62 years; 66% male; 60% Caucasian). Using 2000 American Joint Committee on Cancer criteria, 13% of patients were stage I, 29% were stage II, 32% were stage IIIA, 10% were stage IIIB, and 12% were stage IV. Most patients (43%) were treated at academic centers, 32% were treated at large nonacademic centers, and 25% were treated at small to medium sized facilities. Almost all patients (99.5%) underwent CT-based planning, and 75% had DVHs to evaluate normal tissue doses to the kidneys and liver. Seventy percent of patients completed RT within the prescribed time frame. IMRT and IGRT were used in 22% and 17% of patients, respectively. IGRT techniques included positron emission tomography (n=20), magnetic resonance imaging (n=1), respiratory gating and 4-dimensional CT (n=22), and on-board imaging (n=10). Nineteen percent of patients received preoperative RT. Conclusions: This analysis of radiation practice patterns for treating nonmetastatic GC indicates widespread adoption of CT-based planning with use of DVH to evaluate normal tissue doses. Most patients completed adjuvant RT in the prescribed time frame. IMRT and IGRT were not routinely incorporated into clinical practice during the 2005-2007 period. These data will be a benchmark for future Quality Research in Radiation Oncology GC surveys.