PURPOSE: The purpose of this study was to investigate the feasibility of dual-isocenter (DI) radiation therapy under magnetic resonance linear accelerator (MR-Linac) guidance for patients with advanced cervical cancer. M...PURPOSE: The purpose of this study was to investigate the feasibility of dual-isocenter (DI) radiation therapy under magnetic resonance linear accelerator (MR-Linac) guidance for patients with advanced cervical cancer. METHODS AND MATERIALS: A total of 24 patients with cervical cancer treated with Elekta 1.5 T MR-Linac from September 2022 to December 2024 were enrolled. Patients were stratified into single-isocenter (SI) or DI radiation therapy groups based on craniocaudal tumor target size. Postradiation therapy toxicities (assessed up to February 2025), dosimetric data, and radiation treatment time were analyzed. RESULTS: Among the 24 patients (median age, 59 years; range, 35-78 years), 10 received SI radiation therapy and 14 received DI radiation therapy. Key findings includes the following: (1) using Common Terminology Criteria for Adverse Events, version 5.0, systematic evaluation of skin, gastrointestinal, urinary, performance status, and gynecologic-related toxicities revealed no statistically significant differences in postradiation therapy toxicities between the 2 groups (P > .05); (2) dosimetric data for both groups were presented; (3) the mean treatment time for SI radiation therapy was 1337 seconds (approximately 22 minutes), compared with 2495 seconds (approximately 42 minutes) for DI radiation therapy. CONCLUSIONS: This study established a workflow for DI radiation therapy and demonstrated its feasibility through comparable toxicity profiles between DI and SI approaches. In addition, the dosimetric data and mean treatment time for both techniques in patients with cervical cancer provide a clinical foundation for magnetic resonance-guided radiation therapy using the Unity MR-Linac system.
PURPOSE: This analysis offers an in-depth view of the financial potential and hurdles of radioligand therapies (RLTs) for health care institutions covered under the 340B Drug Pricing Program. Using Pluvicto (lutetium Lu...PURPOSE: This analysis offers an in-depth view of the financial potential and hurdles of radioligand therapies (RLTs) for health care institutions covered under the 340B Drug Pricing Program. Using Pluvicto (lutetium Lu 177 vipivotide tetraxetan) as a case study, we aim to highlight the economic misalignment between health care institutions and radiation oncologists. METHODS AND MATERIALS: We provide an overview of the 340B program and perform a financial analysis of Pluvicto. This was achieved by identifying acquisition and reimbursement costs and comparing the wholesale acquisition cost with the calculated 340B ceiling price using Health Resources and Services Administration formulas. In addition, we compared physician work incentives by analyzing Medicare work relative value unit (wRVU) generation for a standard 6-dose course of Pluvicto versus a 20-fraction external beam radiation therapy plan. RESULTS: This analysis discovered that under the 340B program, covered entities can acquire Pluvicto at a discount of approximately 31.7% below the wholesale acquisition cost ($34,970.71 vs $51,168.13 per dose). This was shown to generate a potential gross margin of over $101,000 for a full 6-dose course. Even with the large gross margin generated, we discovered that physician compensation remains disproportionately low. A full course of Pluvicto generates approximately 20.6 wRVUs compared with 47 wRVUs for a standard external beam radiation therapy course. This creates a "wRVU trap" where radiation oncologists are financially penalized for the time-intensive training and management required for RLT. CONCLUSIONS: The 340B program offers significant revenue opportunities for hospitals administering RLTs like Pluvicto. However, current physician compensation models do not align with the clinical effort required. To ensure sustainable RLT adoption, health systems must leverage 340B margins to develop alternative incentive models that adequately compensate radiation oncologists for their role in this precision therapy.
PURPOSE: The International Soft Tissue Sarcoma Database Consortium is a collaboration of the North American and European pediatric oncology cooperative groups that aims to provide treatment recommendations for pediatric...PURPOSE: The International Soft Tissue Sarcoma Database Consortium is a collaboration of the North American and European pediatric oncology cooperative groups that aims to provide treatment recommendations for pediatric patients' sarcoma diagnoses. METHODS AND MATERIALS: The International Soft Tissue Sarcoma Database Consortium radiation oncology committee has developed international consensus guidelines for the use of radiation for local therapy in pediatric patients with metastatic rhabdomyosarcoma (RMS) based on grade and quality of evidence. Specifically, the guidelines address management based on disease burden, disease location, and local therapy options that focus on radiation techniques. RESULTS: Patients who present with metastatic RMS at initial diagnosis should be strongly considered for definitive therapy to the primary site and radiation to involved regional lymph nodes after neoadjuvant chemotherapy. When feasible, local treatment of all sites of disease is recommended. Evaluation of the location, size, and extent of disease and patient prognosis should be used when deciding which radiation dose and modality therapy is most appropriate for metastatic disease. CONCLUSIONS: Although the evidence is limited, these consensus guidelines highlight consensus positions regarding the best practice treatment to assist providers as they navigate treatment decisions for their pediatric patients with metastatic RMS.
PURPOSE: Modern technology has facilitated dose-escalated stereotactic body radiation therapy (SBRT) through real-time soft-tissue delineation and adaptive radiation therapy for locally advanced/unresectable pancreatic c...PURPOSE: Modern technology has facilitated dose-escalated stereotactic body radiation therapy (SBRT) through real-time soft-tissue delineation and adaptive radiation therapy for locally advanced/unresectable pancreatic cancer (LAPC). The current study examined published prospective trials in SBRT for LAPC to inform clinical decision-making with support from the International Stereotactic Radiosurgery Society. METHODS AND MATERIALS: A systematic review and meta-analysis was conducted of all prospective trials in definitive SBRT (up to 6 fractions) for LAPC. Random-effects meta-analysis was performed, and metaregression was used to assess the effect of covariates on outcomes of interest, including local control (LC), progression-free survival (PFS), overall survival (OS), and toxicities. RESULTS: A total of 23 prospective studies were identified, including 901 patients. Most studies (n = 21, 91.3%) used systemic therapy before SBRT and delivered a median dose of 40 Gy in 5 fractions (range, 24-50 Gy in 3-6 fractions). The pooled 12- and 24-month LC estimate was 82% and 70%, respectively; 12-month PFS and OS rates were 35% and 63%, respectively; and 24-month PFS and OS rates were 15% and 28%, respectively. On univariable metaregression, SBRT with ≥5 fractions was associated with improved 12-month LC and OS. Inclusion of an elective clinical target volume was associated with improved 24-month PFS and OS. A higher biologically effective dose (BED) was associated with improved 24-month LC and OS. Surgery was associated with improved 12- and 24-month OS and 12-month PFS. The pooled estimate for risk of any grade 3-4 toxicities was 2%, and that of grade 5 toxicities was 0.2% (7 events), mostly gastrointestinal bleeding. There were no predictors of grade 3-4 or 5 toxicities. CONCLUSIONS: Modern radiation therapy techniques allow safe delivery of high radiation doses for LAPC. SBRT provides excellent and durable LC with low rates of treatment-related grades ≥3 toxicities.
PURPOSE: Carotid blowout syndrome (CBS) is a rare but devastating complication following radiation therapy for nasopharyngeal carcinoma (NPC). This study aimed to identify clinically actionable risk factors for CBS and t...PURPOSE: Carotid blowout syndrome (CBS) is a rare but devastating complication following radiation therapy for nasopharyngeal carcinoma (NPC). This study aimed to identify clinically actionable risk factors for CBS and to explore heterogeneity among anatomically high-risk patients. METHODS AND MATERIALS: Patients with NPC treated with a single course of definitive radiation therapy were retrospectively analyzed. Propensity score matching was applied to balance baseline characteristics between patients with and without CBS. Clinical, anatomic, and dosimetric variables were evaluated using logistic regression, with variable selection by least absolute shrinkage and selection operator. Model discrimination was assessed using the area under the receiver operating characteristic curve (AUC). Heterogeneity analyses were performed among patients with macroscopic internal carotid artery (ICA) encasement. RESULTS: After matching, 31 patients with CBS and 62 matched controls were analyzed. Macroscopic ICA encasement and hypertension were strongly associated with CBS occurrence. In multivariable analysis, ICA encasement, hypertension, and ICA D0.5cc remained independent predictors of CBS, yielding good discrimination (AUC = 0.83). Among patients with macroscopic ICA encasement, those who developed CBS more frequently had hypertension and tended to receive higher irradiation to the pericarotid soft tissues, although dose differences were not statistically significant. Notably, progression to nasopharyngeal soft tissue necrosis with ICA exposure was observed exclusively in patients who developed CBS, whereas no patient who remained CBS-free demonstrated overt soft tissue necrosis during follow-up. CONCLUSIONS: CBS risk after definitive radiation therapy for NPC is primarily driven by anatomic vulnerability and systemic vascular factors. Pericarotid soft tissue injury and impaired post-radiation therapy healing appear to modulate progression from anatomic risk to clinical events. These findings support a risk-adapted surveillance and management strategy for patients with ICA encasement.
PURPOSE: Survivorship care plans (SCPs) and treatment summaries (TS) are intended to bridge oncology and primary care, yet it is unclear how well publicly available templates capture radiation therapy (RT) details necess...PURPOSE: Survivorship care plans (SCPs) and treatment summaries (TS) are intended to bridge oncology and primary care, yet it is unclear how well publicly available templates capture radiation therapy (RT) details necessary for safe, coordinated follow-up. We evaluated RT content in US society-sponsored, non-paywalled SCP/TS templates against elements recommended by the American Society for Radiation Oncology (ASTRO). METHODS AND MATERIALS: We identified SCP/TS templates from national medical organizations via targeted web searches. Guided by the ASTRO survivorship template, we abstracted the presence of RT variables including site, technique/modality, total dose, dose per fraction, fractionation, special procedures (eg, brachytherapy), treatment dates, toxicity, sequencing within multimodality care, concurrent chemotherapy, and radiation oncology contact information. Variables were recorded as present/absent and summarized descriptively. RESULTS: Eighteen templates met inclusion; 11/18 (61.1%) were by the American Society of Clinical Oncology, and 14/18 (77.8%) targeted adult populations. RT was mentioned in 17/18 (94.4%), and a radiation oncology contact was listed in 15/18 (83.3%). Key technical details were uncommon: total dose and/or modality 6/18 (33.3%); dose per fraction 4/18 (22.2%); fractionation 5/18 (27.8%); special procedures 3/18 (16.7%); toxicity 2/18 (11.1%). No template captured RT sequencing within multimodality therapy or concurrent chemotherapy. Treatment end dates were more commonly captured than start dates. The Children's Oncology Group template was the most comprehensive across RT variables. CONCLUSIONS: Many public templates omit core radiation therapy data. Adopting a simple standard set of fields for site, technique, total dose, dose per fraction, fractionation, sequencing, toxicity, and a radiation oncology contact would improve clarity, safety, and care transitions.
Lakomy DS, Padgett M, Kang K
… +12 more, Tsai R, Sager O, Kalaghchi B, Panni R, Sanford D, Grierson P, Lim KH, DeNardo D, DeSelm C, Mo A, Waters MR, Kim H
PURPOSE: Isolated locoregional recurrence of pancreatic adenocarcinoma occurs in 25% to 50% of cases after surgical resection and has limited treatment options. Data on ablative stereotactic body radiation therapy (SBRT)...PURPOSE: Isolated locoregional recurrence of pancreatic adenocarcinoma occurs in 25% to 50% of cases after surgical resection and has limited treatment options. Data on ablative stereotactic body radiation therapy (SBRT) with daily online adaptation for this condition are limited. Our objective was to illustrate the efficacy and safety of adaptive radiation for isolated locoregional recurrences of pancreatic adenocarcinoma. METHODS AND MATERIALS: This was a retrospective cohort study of 46 patients treated with adaptive 5-fraction SBRT for isolated locoregional recurrence of pancreatic adenocarcinoma after surgical resection between 2015 and 2024. Kaplan-Meier curves with log-rank analysis and Cox regression were conducted to assess oncologic outcomes, including locoregional recurrence-free survival, distant metastasis-free survival, and overall survival. Variables of clinical significance, including biologically effective dose, planning target volume, and receipt of salvage chemotherapy in conjunction with salvage radiation, were assessed. Local failure was defined by response evaluation criteria in solid tumors. Toxicities were assessed using the National Cancer Institute Common Terminology Criteria for Adverse Events v5.0 criteria. RESULTS: Radiation dose median was 50 Gy in 5 fractions. Seven patients had received prior radiation, and 27 patients received chemotherapy as part of their salvage treatment. The median duration of chemotherapy was 3.9 months. Forty-six patients were treated with a median age of 65 years; the majority were White and male. Median time to local recurrence from initial diagnosis was 20 months. Online adaptation was performed for 91% of fractions. Median follow-up from recurrent diagnosis and end of salvage radiation was 14 and 10.4 months, respectively. One-year local control was 73%, and 1- and 2-year overall survival were 69% and 42%, respectively. Chemotherapy had a statistically significant effect on progression-free survival (HR, 0.45; 95% confidence interval, 0.23-0.89; P = .02). No acute grade 3+ toxicities occurred, but 3 late grade 3+ toxicities were documented. CONCLUSIONS: Adaptive SBRT permits a high biologically effective dose in 5 fractions and results in local control concordant with conventionally fractionated salvage radiation for locoregionally recurrent pancreatic ductal adenocarcinoma after definitive surgery, even after prior radiation with a reasonable toxicity profile. Future work may combine adaptive radiation with coverage of extrapancreatic neural tract anatomy and additional chemotherapy to improve outcomes.
PURPOSE: A phase 3 trial has shown that high-dose, accelerated, hyperfractionated, twice-daily thoracic radiation therapy (54 Gy in 30 fractions) is clinically effective for patients aged <70 years with limited-stage sma...PURPOSE: A phase 3 trial has shown that high-dose, accelerated, hyperfractionated, twice-daily thoracic radiation therapy (54 Gy in 30 fractions) is clinically effective for patients aged <70 years with limited-stage small cell lung cancer (LS-SCLC). This retrospective study compares the real-world effectiveness of high-dose hyperfractionated simultaneous integrated boost radiation therapy with standard-dose radiation therapy. METHODS AND MATERIALS: This retrospective study was conducted at Peking University Cancer Hospital, including patients with histologically or cytologically confirmed LS-SCLC. All eligible patients received 4 courses of thoracic radiation therapy combined with concurrent chemotherapy (cisplatin or carboplatin and etoposide). Patients were categorized into 3 groups based on the radiation therapy dose: (1) the 54 Gy group (54 Gy in 30 fractions, twice daily); (2) the 45 Gy group (45 Gy in 30 fractions, twice daily); and (3) the 60 Gy group (60-70 Gy in 30-35 fractions, once daily). The primary endpoints were real-world progression-free survival and overall survival. RESULTS: Between March 2010 and November 2024, a total of 353 patients were included in the study. The median follow-up was 54.9 months (range, 2.9-151.6 months). After applying inverse probability of treatment weighting (IPTW), the clinical features were well balanced between the groups. The median real-world progression-free survival was significantly better in the 54 Gy group (29.7 months [95% CI, 15.9-not reached]) compared with the 45 Gy group (15.0 months [95% CI, 11.8-30.4]; hazard ratio [HR], 1.23 [95% CI, 1.01-1.50]) and the 60 Gy group (13.5 months [95% CI, 11.4-15.9]; HR, 1.29 [95% CI, 1.09-1.54]) both before (P = .011) and after (P = .033) IPTW. The median overall survival was also significantly longer in the 54 Gy group (63.9 months [95% CI, 57.1-not reached]) compared with the 45 Gy group (42.9 months [95% CI, 32.3-70.8]; HR, 1.76 [95% CI, 1.19-2.61]) and the 60 Gy group (38.0 months [95% CI, 30.8-51.9]; HR, 1.60 [95% CI, 1.05-2.44]) both before (P = .015) and after (P = .006) IPTW. Treatment-related toxicities were similar across the 3 groups. CONCLUSIONS: High-dose, accelerated, hyperfractionated, twice-daily thoracic radiation therapy (54 Gy) was well tolerated and effective in this large, real-world cohort study of patients with LS-SCLC compared with standard-dose (45 Gy twice daily and 60-70 Gy every day) radiation therapy.
PURPOSE: Brain arteriovenous malformations (AVMs) are high-risk vascular anomalies associated with hemorrhage, neurological morbidity, and mortality. Stereotactic radiosurgery (SRS) is a well-established, noninvasive tre...PURPOSE: Brain arteriovenous malformations (AVMs) are high-risk vascular anomalies associated with hemorrhage, neurological morbidity, and mortality. Stereotactic radiosurgery (SRS) is a well-established, noninvasive treatment that achieves durable obliteration while preserving neurological function. This case-based guideline summarizes contemporary SRS-based AVM management and outcomes. METHODS AND MATERIALS: Three illustrative cases were selected: a small, unruptured Spetzler-Martin grade (SMG) I AVM treated with single-fraction SRS, a large SMG V AVM managed with volume-staged SRS, and a ruptured SMG II AVM treated with embolization followed by definitive SRS. RESULTS: Single-fraction SRS achieves durable obliteration for small AVMs, whereas staged approaches allow safe treatment of large or complex lesions and complement microsurgery and embolization. Treatment planning emphasizes integration of advanced imaging, precise nidus delineation, and dose-volume optimization. Long-term surveillance remains essential to confirm obliteration and detect delayed complications. CONCLUSIONS: This case-based guideline highlights practical principles of SRS for brain AVM management, emphasizing individualized selection, multidisciplinary collaboration, and meticulous planning to optimize safety and efficacy.
PURPOSE: The conventional computed tomography (CT)-based consultation to simulation process for hippocampal-sparing whole-brain radiation therapy (HS-WBRT) typically requires several days, delaying treatment initiation f...PURPOSE: The conventional computed tomography (CT)-based consultation to simulation process for hippocampal-sparing whole-brain radiation therapy (HS-WBRT) typically requires several days, delaying treatment initiation for patients who would benefit from expedited care. We developed a simulation-free, magnetic resonance imaging (MRI)-only workflow for HS-WBRT to accelerate treatment start and maintain dosimetric quality through online adaptive radiation therapy. METHODS AND MATERIALS: An in-house deep learning algorithm was developed to generate synthetic CT (sCT) images from diagnostic MRI scans. To address the limited field-of-view of diagnostic MRI, a hybrid sCT-reference CT stitching method was developed to create a full planning sCT suitable for HS-WBRT, through preserving patient-specific brain anatomy while supplementing inferior regions with matched reference anatomy. Using the resulting sCT, a patient-specific reference plan was created and then adapted to the setup position and patient anatomy during the first fraction. Subsequent fractions were delivered using the first-fraction adapted plan or readapted as needed. Commissioning included 5 retrospective emulator cases and a phantom end-to-end test to validate workflow feasibility, plan quality, and interoperability. Clinical feasibility was prospectively assessed in 5 patients. RESULTS: All retrospective and phantom tests met predefined endpoints, including protocol compliance, secondary quality assurance ≥95% (3%/2 mm), and error-free data transfer. In the prospective cohort, hippocampal contours were finalized in all cases during the online session without resimulation. The first-fraction adaptive plan met all HS-WBRT protocol constraints. For patients prescribed 30 Gy in 10 fractions (n = 4), median hippocampus D and D100% were 14.6 Gy (range, 13.0-15.7 Gy) and 7.2 Gy (range, 7.0-7.5 Gy), respectively. For the patient prescribed 20 Gy in 10 fractions, hippocampus D and D100% were 14.6 Gy and 5.2 Gy. All other organs-at-risk met institutional limits. The workflow eliminated CT simulation, enabling a clinical approved plan within 2 days of diagnostic imaging. Median on-couch adaptation time was 39 minutes. CONCLUSIONS: This MRI-only, simulation-free workflow is clinically feasible, shortens time to treatment, and enhances patient experience without compromising dosimetric quality.