Shin JY, Assel M, Wu AJ
… +18 more, Gelblum DY, Guttmann DM, Shepherd AF, Reyngold M, Gewanter R, Rimner A, Mueller BA, Iyengar P, Chaunzwa T, Ma J, Billing D, McMillan MT, Mankuzhy NP, Austria MD, Simone CB, Shaverdian N, Vickers AJ, Gomez DR
INTRODUCTION: We hypothesized that, in patients at high risk for RE, giving sucralfate prophylactically would reduce the need for opioid pain medication. METHODS AND MATERIALS: Patients were enrolled from January 2023 to...INTRODUCTION: We hypothesized that, in patients at high risk for RE, giving sucralfate prophylactically would reduce the need for opioid pain medication. METHODS AND MATERIALS: Patients were enrolled from January 2023 to April 2025 at a single tertiary care center. Patients were randomized to receive 1 gram twice a day within the first five fractions of radiotherapy (RT), with frequency increased during RT at clinician discretion, or standard supportive care. The proportion of patients who took any opioids over the previous 24 hours at the end of the treatment course was compared between groups using logistic regression with the stratification variables and concurrent chemotherapy status as covariates. RESULTS: The trial was closed early due to lack of differences between arms with 117 patients randomized (n=56 in the experimental arm). Rates of opioid use were 30% in both groups (absolute adjusted decrease in the prophylactic sucralfate arm -0.4%; 95% CI -14%, 13%, p>0.9). Rates of grade 2 - 3 RE were non-significantly lower in the prophylactic sucralfate arm (59% vs 69%, absolute adjusted risk decrease 11%; 95% CI -7.2%, 28%; p=0.2). In patients receiving very high esophageal dose (V60 Gy ≥15%), all controls (n=4) experienced grade 2-3 RE compared to only half of those in the experimental arm (6 of 12) (Fisher's exact test p=0.2). CONCLUSIONS: We did not find evidence to support early use of sucralfate in patients at high risk of radiation esophagitis. Limited medical options for the management of RE warrant the continued need to explore further avenues to combat this painful condition.
PURPOSE: This retrospective study determines if uniform fasting protocols successfully limit stomach volume variation and proximity to the planning target volume throughout radiation treatment. METHODS AND MATERIALS: A t...PURPOSE: This retrospective study determines if uniform fasting protocols successfully limit stomach volume variation and proximity to the planning target volume throughout radiation treatment. METHODS AND MATERIALS: A total of 74 patients with cancer were instructed to fast for 2 hours before receiving stereotactic body radiation therapy to their pancreas. The entire stomach and the stomach near the planning target volume (stomach_3cm) were contoured at simulation and on each treatment image. Patients were grouped into 3 clusters based on their SD in stomach volume across treatments. The simulation stomach volume was used as a predictor of successful fasting using the Mann-Whitney U test. The relationship between the stomach volume and the stomach_3cm volume was calculated. RESULTS: Among 74 patients, 58% were classified as unsuccessful at fasting with a significantly larger SD than the successful cluster (P < .00001). The volume at simulation of the successful fasting cluster (183 cm) was significantly different from the variable and unsuccessful clusters (255 cm and 238 cm) (P < .001). The correlation coefficient of the stomach and stomach_3cm was 0.28 (R = 0.08). CONCLUSIONS: Uniform fasting instructions did not result in reproducible stomach volumes during treatment for the majority of patients. Patients with a simulated stomach volume ≥200 cm are likely to demonstrate greater interfraction variability. The entire stomach volume during treatment did not correlate well with the stomach volume near the tumor. These findings suggest that under standardized fasting protocols, baseline stomach volume may help identify patients at a higher risk of gastric variability, and that additional strategies may be needed to improve reproducibility in selected patients.
Kennedy WR, Raju-Salicki S, Thomas MA
… +10 more, Zoberi JE, Garcia J, Sievert D, Mahmood M, Margenthaler J, Cyr A, Samson P, Bagegni NA, Brunt L, Zoberi I
PURPOSE: To report safety, feasibility, toxicity, cosmetic and quality-of-life (QoL) outcomes of a single institutional prospective phase I/II clinical trial evaluating a novel three-fraction accelerated partial breast i...PURPOSE: To report safety, feasibility, toxicity, cosmetic and quality-of-life (QoL) outcomes of a single institutional prospective phase I/II clinical trial evaluating a novel three-fraction accelerated partial breast irradiation (Tri-APBI) regimen. METHODS AND MATERIALS: From August 2018 to March 2021, 75 patients with low-risk hormone sensitive, HER2 negative breast cancer were enrolled on Tri-APBI, delivered with high dose rate (HDR) brachytherapy (22.5 Gy in 3 fractions) or external beam radiation therapy (EBRT) (25.5 Gy in 3 fractions) over 2-3 days. Modality was chosen by the treating physician. Planning target volume (PTV) for all patients was created using a 1-cm expansion of breast tissue around the surgical bed limited by 0.5 cm from the skin surface. RESULTS: Stage I disease was present in 79%, while the remainder had DCIS. Tri-APBI was delivered with EBRT in 45 patients (60%) and HDR in 30 (40%). At a median follow-up of 49 months (IQR 42 - 55 months), there were two ipsilateral breast tumor recurrences (IBTR), cumulatively 2.6%, both successfully salvaged. There were no axillary or distant recurrences. There was no CTCAEv4.0 grade 2+ toxicity observed. Good-to-excellent pretreatment cosmesis was present in 94% and 99% by patient and physician rating, respectively, and in 91% and 98% at latest follow-up. Quantitative cosmesis assessed by percentage of breast retraction assessment (pBRA) showed that breast asymmetry did not worsen compared to pre-treatment, with a baseline mean pBRA of 8.1% (CI 4.1 - 12) and a 24-month mean pBRA of 6.1% (CI 4.0 - 8.1). Tri-APBI did not negatively impact most domains of patient-reported quality of life, except breast symptom burden at 48 and 60 months and sexual functioning at 36 months only. CONCLUSIONS: Tri-APBI as delivered with EBRT or HDR in this trial was feasible and well-tolerated, with low IBTR rates at 4 years and minimal impact on patient-reported quality of life, qualitative, and quantitative cosmesis. Further follow-up is needed to evaluate long-term oncologic efficacy.
PURPOSE: Peer review is an integral process in the field of radiation oncology to ensure that radiation plans meet appropriate clinical and dosimetric standards. We report a pilot quality assessment of our peer review pr...PURPOSE: Peer review is an integral process in the field of radiation oncology to ensure that radiation plans meet appropriate clinical and dosimetric standards. We report a pilot quality assessment of our peer review process and a model for utilizing the results of this pilot project for resident education. METHODS: This study prospectively tracked peer review in our department over the course of 9 months and tracked all plans that were not approved. Reasons for lack of approval were recorded. Plans that did not pass peer review were anonymized and imported to a shared folder for future educational use. Eight cases were used in a mock peer review didactics session with the residents. The session was led by two residents, a dosimetrist, and attending physician while the remaining residents were tasked with finding the error or reason for lack of approval. Pre-and post-session surveys were conducted to evaluate the value of the session. RESULTS: Out of 2,209 total cases presented during peer review, 37 treatment plans (2%) were not approved. The most common reasons for disapproval included contours (24%), dose (22%), and workflow (22%). Breast and skin cases had the highest numbers of not approved plans, 19% and 16% respectively. Relative to the total number of cases presented for each disease site, skin had the highest rate of disapproval at 5.4% followed by gynecologic treatments at 4.3%. All residents found the mock peer review didactics session to be "helpful" or "very helpful" on the post-session survey and would want additional sessions in the future. CONCLUSION: Overall, our study showed a low rate of disapproval during peer review, and our resident survey results indicated that a mock peer review didactics session would be a valuable addition to training.
Hong L, Poortmans P, Aznar M
… +17 more, Brooks ED, Casey D, Choi JI, Corradini S, Jagsi R, Keilty D, Koch A, Kronborg C, Kubeczko M, McClatchy D, Popovic M, Salerno KE, Shaitelman SF, Sharma M, Tsang Y, Mayo C, Gabryś D
Pract Radiat Oncol
· 2026 May · PMID 42207068
·
Full text
PURPOSE: Reirradiation (reRT) for locally or regionally recurrent breast cancer is increasingly considered, but practice patterns remain heterogeneous. This study reports results from an international Reirradiation Colla...PURPOSE: Reirradiation (reRT) for locally or regionally recurrent breast cancer is increasingly considered, but practice patterns remain heterogeneous. This study reports results from an international Reirradiation Collaborative Group (ReCOG) survey evaluating contemporary clinical reRT practices and key knowledge gaps in optimal breast reRT approaches. METHODS AND MATERIALS: Radiation oncologists, medical physicists, and dosimetrists with expertise in breast radiation therapy completed a structured ReCOG survey between February 2024 and June 2025. Respondents were asked about patient selection, factors influencing the choice between second breast-conserving therapy and mastectomy, reRT dose-fractionation schedules, planning methods, and knowledge gaps affecting clinical decision making. RESULTS: Thirty-seven respondents participated, from Europe (n = 19), North America (n = 14), and other regions (n = 4), representing 32 identifiable institutions. The most common reasons for not offering reRT included high risk of major side effects from prior radiation therapy such as fibrosis or lymphedema (40%), short relapse interval (33%), or limited life expectancy (17%). Among patients receiving reRT, fibrosis (31%), pain (17%), and arm lymphedema (14%) were reported as the most impactful toxicities on quality of life. Conventional fractionation (45-60 Gy in 1.8 to 2 Gy fractions over 23-30 fractions) was the most frequently selected regimen, followed by moderate hypofractionated schedules (40 Gy in 15 fractions). One respondent reported using twice daily dose of 40 to 50Gy in 1.25 to 1.5Gy fractions. External-beam photon techniques were the predominant modality, with intensity modulated radiation therapy/volumetric modulated arc therapy preferred, while proton therapy and brachytherapy were used selectively. Hyperthermia use was limited (n = 7). Most respondents (80%) performed plan summation when prior DICOM radiation therapy data were available, but specific methods varied. Organs of interest (OOI) dose guidance was most consistently applied for the brachial plexus, heart, lungs, and skin, although thresholds differed widely. The top 3 knowledge gaps identified were as follows: (1) long-term toxicity and oncologic outcome data, (2) standardized and validated OOI dose guidance, and (3) consensus on optimal reRT dose-fractionation schedules, and the scarcity of prospective trials. CONCLUSIONS: This ReCOG survey reveals substantial heterogeneity in breast cancer reRT practices. The identified knowledge gaps highlight the need for standardized clinical guidelines and practical clinical toolsets to support decision making in patient selection, technical planning, and OOI dose guidance to improve outcomes for patients undergoing reRT.
PURPOSE/OBJECTIVE(S): To create a magnetic resonance image (MRI)-based atlas of prostate bed recurrence for prostate cancer patients undergoing salvage radiotherapy (sRT) after radical prostatectomy and to evaluate the c...PURPOSE/OBJECTIVE(S): To create a magnetic resonance image (MRI)-based atlas of prostate bed recurrence for prostate cancer patients undergoing salvage radiotherapy (sRT) after radical prostatectomy and to evaluate the consistency of contouring guidelines for the prostatic fossa clinical target volume (PF-CTV). MATERIALS/METHODS: Patients with biochemical recurrence and MRI-detected prostate bed lesions before sRT were included. Each lesion was contoured on T2-weighted MRI, using dynamic-contrast-enhanced sequences for guidance. Lesions were transferred to a reference T2-weighted dataset through deformable co-registration to generate a 3D recurrence incidence map. The volume and the location of the lesions were extracted. 7 PF-CTV contouring strategies were implemented on the reference T2w to assess coverage: European Organization for Research and Treatment of Cancer, Faculty of Radiation Oncology Genito-urinary Group, Francophone Group of Urological Radiotherapy, Radiation Therapy Oncology Group (RTOG), Princess Margaret Hospital (PMH), European Society for Radiotherapy and Oncology-Advisory Committee for Radiation Oncology Practice (ESTRO) and PERYTON. Centroid- and volume-based coverage rates were calculated, and statistical comparisons performed using Cochran's Q or Friedman tests. Correlations were analyzed with phi or Spearman's coefficients. RESULTS: 131 patients with 140 recurrences were identified. The lesions were located at the vesicourethral anastomosis (VUA) (53%), bladder neck (BN) (29%) and retrovesical (RV) (18%). Median volume of the lesion was 0.48 cm (range 0.03-40.5 cm) (VUA), 0.29 cm (0.09-3.72) (RV) and 0.49 cm (0.02-3.51) (BN). Centroid-based coverage ranged from 65%-93%, with ESTRO, PMH and PERYTON achieving the highest rates (92.1-92.9%). Volume-based coverage ranged from 63,7%-91,2%, again favoring ESTRO (91.2%) and PERYTON (90.3%). EORTC showed significantly lower coverage than all other contouring strategies in most comparisons, while strong positive correlations were found among the remaining definitions, with the highest between PMH and RTOG (rho = 0.94). CONCLUSION: According to the criterium of coverage, our data support the use of ESTRO and PERYTON definition. Here we provide an MRI-based atlas of prostatic bed recurrence that can help optimize sRT contours.
PURPOSE: This study aimed to compare the effects of biodegradable balloon and hydrogel perirectal spacers versus no spacer on prostate motion during stereotactic body radiation therapy (SBRT). METHODS AND MATERIALS: We a...PURPOSE: This study aimed to compare the effects of biodegradable balloon and hydrogel perirectal spacers versus no spacer on prostate motion during stereotactic body radiation therapy (SBRT). METHODS AND MATERIALS: We analyzed 341 SBRT fractions with continuous ultrasound tracking in 70 patients treated for localized prostate cancer. Patients received a balloon spacer (118 fractions), a hydrogel spacer (88 fractions), or no spacer (135 fractions) based on institutional availability and U.S. Food and Drug Administration approval timeline. Motion was quantified using Poisson regression analysis of clinically meaningful deviation events (≥2-3 mm for ≥3 seconds), fast Fourier transform analysis of dominant oscillatory amplitudes, and 3-dimensional motion envelope volumes calculated from covariance-derived ellipsoids. RESULTS: At the 3 mm threshold, balloon spacers reduced deviation events by 53% (incidence rate ratio, 0.47; 95% CI, 0.31-0.69; P < .001) and hydrogel spacers by 28% (incidence rate ratio, 0.72; 95% CI, 0.55-0.93; P = .013) compared with no spacer. Balloon spacers demonstrated significantly smaller dominant oscillatory amplitudes across all spatial dimensions: antero-posterior (0.50 vs 0.73 mm, P = .005), superior-inferior (0.30 vs 0.46 mm, P = .005), and left-right (0.20 vs 0.27 mm, P = .064) versus no spacer. The 3-dimensional motion envelope volume was substantially reduced with balloon spacers (0.58 mm) compared with no spacer (2.04 mm, P = .002) or hydrogel (2.79 mm, P < .001). CONCLUSIONS: In this retrospective SBRT cohort, rectal spacing, particularly with a biodegradable balloon, was associated with less intrafraction prostate motion. These findings suggest a potential motion-stabilizing effect of spacer design.
PURPOSE: Stereotactic arrhythmia radiation therapy (STAR) is an emerging noninvasive treatment for patients with therapy-refractory ventricular tachycardia. However, STAR's targeting accuracy is challenged by cardiorespi...PURPOSE: Stereotactic arrhythmia radiation therapy (STAR) is an emerging noninvasive treatment for patients with therapy-refractory ventricular tachycardia. However, STAR's targeting accuracy is challenged by cardiorespiratory motion, which may necessitate compromises in dose delivery to protect nearby organs-at-risk, particularly the stomach. Noninvasive mechanical ventilation (NIMV) at 60 breaths/min with 15 cmH₂O positive end-expiratory pressure (NIMV) has been shown to reduce respiratory motion and to potentially increase anatomic separation between thoracic structures. This study aimed to quantify the effect of NIMV on cardiorespiratory motion of the left diaphragm and the minimal heart-stomach distance. METHODS AND MATERIALS: We retrospectively analyzed magnetic resonance imaging (MRI) data from 22 healthy volunteers who underwent 2 sessions while free-breathing, breath-holding, and undergoing NIMV. Diaphragm motion was quantified using coronal cine MRIs. The minimal heart-stomach distance was measured using 3-dimensional MRIs during breath-hold inhalation (BH-inhalation), exhalation (BH-exhalation), and NIMV. Encompassing volumes of the heart and stomach were generated from BH-inhalation and BH-exhalation scans to evaluate overlap or separation during free-breathing. Lastly, cine frames were deformably registered to assess temporal heart-stomach distance variation. RESULTS: NIMV significantly reduced median cranial-caudal diaphragm motion by half from 30 mm (IQR, 16 mm) during free-breathing to 15 mm (IQR, 7 mm; P < .001). The median of the minimal heart-stomach distances increased to 16.8 mm with NIMV, significantly larger than during BH-inhalation (10.3 mm; P = .04) and BH-exhalation (4.6 mm; P < .01), whereas analysis emulating free-breathing showed frequent heart and stomach internal-volume overlap (27 of 41 sessions) or minimal median distance of 3.4 mm (IQR, 7 mm) between the heart and stomach, which can result in significant stomach dose during STAR. Median temporal heart-stomach distance was 19.2 mm during NIMV versus 7.1 mm during free-breathing. CONCLUSIONS: NIMV significantly reduces diaphragm motion and increases the distance between heart and stomach in healthy volunteers, supporting its integration with STAR to potentially improve targeting and reduce stomach toxicity, especially for inferior wall ventricular tachycardia targets.
PURPOSE: Despite growing evidence supporting the use of accelerated partial breast irradiation (APBI) and partial breast irradiation (PBI) for early-stage, low-risk breast cancer, utilization remains limited. This study...PURPOSE: Despite growing evidence supporting the use of accelerated partial breast irradiation (APBI) and partial breast irradiation (PBI) for early-stage, low-risk breast cancer, utilization remains limited. This study evaluates trends and geographic variations in APBI/PBI adoption within the National Cancer Database from 2010 to 2022. METHODS AND MATERIALS: We used the National Cancer Database to identify patients who underwent margin-negative lumpectomy and radiation from 2010 to 2022 with favorable breast cancer: age ≥50 years, hormone receptor-positive/human epidermal growth factor receptor 2-negative, pathologic T1N0, grade 1-2, and nonlobular histology. Patients were stratified by the type of radiation therapy (APBI or whole breast irradiation [WBI]). The primary outcome was the annual utilization rate of accelerated partial breast irradiation (APBI/PBI) compared with WBI. RESULTS: Overall, 256,549 patients met all eligibility criteria. In this cohort, 31,154 (12.1%) received APBI/PBI. The use of APBI/PBI increased from 7.5% (2010-2017) to 16.2% (2018-2022) (P < .001). In the final year, among the 26,124 patients analyzed, 6100 (23.3%) received any form of APBI/PBI, and 4778 (18.2%) were treated with either 30 Gy/5Fx external beam APBI or brachytherapy. CONCLUSIONS: We found a significant rise in APBI/PBI use in patients with low-risk hormone receptor-positive/human epidermal growth factor receptor 2-negative breast cancer. Despite the increasing trend, even in the most recent year, fewer than 1 in 4 potentially eligible patients received APBI/PBI. Among patients treated in 2022, fewer than 1 in 5 patients received 30 Gy/5Fx external beam APBI or brachytherapy, the 2 forms of APBI that possess the combination of similar cancer control outcomes, greater convenience, and less toxicity compared with WBI.
Mitra A, Moore LC, Kallis K
… +14 more, Rash DL, Einck JP, Nwachukwu C, Yashar CM, Mayadev JS, Ayala-Peacock DN, Balogun OD, Chino JP, Contreras JA, Zoberi I, Kisling K, Zou J, Vasconcelos N, Meyers SM
PURPOSE: The study aims to evaluate the quality and clinical acceptability of artificial intelligence automated plans compared with manual clinical plans through blinded physician review, for cervical brachytherapy appli...PURPOSE: The study aims to evaluate the quality and clinical acceptability of artificial intelligence automated plans compared with manual clinical plans through blinded physician review, for cervical brachytherapy applicators. METHODS AND MATERIALS: Automated plans were generated using dose predictions from a U-Net with anatomic masks, dwell position location masks, and applicator-specific 3-dimensional dose inputs (where dose was computed using uniform dwell times). Model data included 2005 brachytherapy plans from 7 implant types (train/validation/test split = 62%/19%/19%). Test set dose predictions were fed into an optimizer to produce automated plans. Randomized automated and clinical plan pairs were presented to 10 expert gynecologic brachytherapy physicians, who indicated plan preference, scored plans from 1 to 5 (where 5 indicates the highest quality), and guessed which plan was automated. Five physicians from our center reviewed 130 plans in total across all 7 implants. Five external physicians from 3 other centers each reviewed 2 plan sets per implant type (70 plans). Autoplan scores were compared between physician groups and with clinical plans using Wilcoxon signed-rank tests (P < .05 considered significant). RESULTS: Autoplans were deemed better or equivalent in approximately 50% of cases for both physician groups, with the highest preference rates for hybrid implants (>58% on average). Selection rates varied between physicians, often due to different prioritization of tumor coverage versus organ sparing and/or loading preferences. Automated and clinical plans scored 4 (acceptable plan with clinically unimportant stylistic differences) on average (P > .05 for all comparisons). Slightly reduced preference rates and scores for external physicians were attributed to stylistic planning differences not captured in model training data from our center. Physicians correctly identified about 50% of autoplans, consistent with random chance, indicating indistinguishability from clinical plans. CONCLUSIONS: Our brachytherapy artificial intelligence automated planning technology produced automated plans comparable in quality and indistinguishable from manual, clinical plans in a median of 1.4 minutes.