Patel KR, Schott E, Huang EP
… +5 more, Cooley-Zgela T, Ning H, Cheng J, Turkbey B, Citrin DE
Pract Radiat Oncol
· 2026 · PMID 41173140
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PURPOSE: Salvage stereotactic body radiation therapy (SBRT) for intraprostatic recurrence of prostate cancer is under study in early-phase clinical trials. Presently, the impact of this treatment on toxicity and health-r...PURPOSE: Salvage stereotactic body radiation therapy (SBRT) for intraprostatic recurrence of prostate cancer is under study in early-phase clinical trials. Presently, the impact of this treatment on toxicity and health-related quality of life (HRQOL) is poorly defined. To our knowledge, we present the first report in the literature of HRQOL and psychometric outcomes from a mature, prospective clinical trial. METHODS AND MATERIALS: NCT03253744 was a phase 1 trial of focal salvage SBRT to doses of 40.0 to 42.5 Gy with target volume delineation guided by F-DCFPyL positron emission tomography/computed tomography and magnetic resonance imaging. Secondary endpoints included longitudinal assessment of National Cancer Institute Common Terminology Criteria for Adverse Events version 5.0 adverse events (AEs) and corresponding patient-reported outcome measures (PROMs). PROMs included the Expanded Prostate Cancer Inventory Composite (EPIC)-26, American Urologic Association Internal Prostate Symptom Score, Sexual Health Inventory for Men, Patient-Reported Outcomes Measurement Information System (PROMIS) Anxiety, PROMIS Depression, and PROMIS Psychosocial Illness Impact-Positive. Study assessments were conducted at baseline, 1 month, and at every 3-month interval post-SBRT until study completion or biochemical failure. RESULTS: Seventeen participants underwent salvage SBRT and were observed for a median of 24 months (min-max: 18-24 months). Toxicity assessment was completed in all participants, and the HRQOL response rate was 91%. Genitourinary (GU) toxicity was more common than gastrointestinal toxicity with a 24-month cumulative incidence of G2+ AEs of 76.5% (95% CI, 44.6%-90.0%) versus 29.4% (95% CI, 4.1%-48.1%) and G3+ AEs of 11.8% (95% CI, 0.0%-25.8%) versus 5.9% (0.0%-16.4%). GU toxicity peaked at 12 to 15 months and was associated most strongly with urethral reirradiation dose. PROMs were concordant with AEs, with significant differences from baseline noted in the American Urologic Association symptom index, EPIC GU irritation, and EPIC GU incontinence scores at 3 to 6 months, 6 to 9 months, and 9 to 18 months, respectively. No significant differences were noted in gastrointestinal PROMs or PROMIS measures. CONCLUSIONS: Salvage SBRT has a favorable treatment-related toxicity and HRQOL profile. Primarily, GU toxicities were observed corresponding to decrements in PROMs.
Low-dose-rate (LDR) brachytherapy is a well-established treatment modality for localized prostate cancer, requiring meticulous planning and evaluation to ensure optimal clinical outcomes. This technical report, developed...Low-dose-rate (LDR) brachytherapy is a well-established treatment modality for localized prostate cancer, requiring meticulous planning and evaluation to ensure optimal clinical outcomes. This technical report, developed by the American Brachytherapy Society, serves as a guide for radiation oncology residents, physicists, and trainees, providing essential principles, methodologies, and quality metrics for planning and assessing prostate LDR brachytherapy. This report outlines key components of prostate LDR brachytherapy, including patient selection, implant techniques, treatment planning principles, and postimplant dosimetry evaluation. Best practices for preimplant imaging, intraoperative seed placement, and postprocedure quality assessment are discussed, emphasizing evidence-based recommendations and consensus guidelines.
PURPOSE: This study aimed to evaluate the association between primary bladder urothelial carcinoma T-stage, G-grade, and pelvic lymph node metastasis (PLNM), and to delineate the location of metastatic pelvic lymph nodes...PURPOSE: This study aimed to evaluate the association between primary bladder urothelial carcinoma T-stage, G-grade, and pelvic lymph node metastasis (PLNM), and to delineate the location of metastatic pelvic lymph nodes across different T-stage and G-grade combinations. METHODS AND MATERIALS: Surgical and pathologic data from 1555 patients who underwent radical cystectomy with pelvic lymph node dissection for bladder urothelial carcinoma at our hospital between October 2014 and September 2024 were collected and analyzed. Pelvic lymph nodes were anatomically classified into 6 regions: peri-vesical, internal iliac/obturator, external iliac, presacral, common iliac, and paraortic. Descriptive statistics were used to quantify PLNM rates and distribution patterns by T-stage and G-grade. Multivariate logistic regression identified independent predictors of PLNM. RESULTS: Of the 1555 patients analyzed, 297 (19.1%) exhibited pathologically confirmed PLNM. Stratified by T-stage, PLNM rates progressively increased from 2.6% in Ta/Tis/T1 patients to 11.0% in T2, 29.8% in T3, and 50.0% in T4. Similarly, G-grade stratification revealed no lymph node involvement in G1 patients (0%), whereas PLNM rates rose to 2.9% in G2 and 23.9% in G3. Notably, among T2G3, T3G3, and T4G3 patients with lymph node metastasis, 96.9%, 93.6%, and 84.9% of patients had metastases exclusively below the iliac bifurcation, whereas 100%, 95.7%, and 95.9% had metastases exclusively below the aortic bifurcation, respectively. Multivariate logistic regression confirmed T-stage (odds ratio, 2.766; 95% CI, 2.347-3.259; P < .001) and G-grade (odds ratio, 3.794; 95% CI, 1.874-7.681; P < .001) as independent predictors of PLNM, with no significant associations observed for age, sex, or tumor size. CONCLUSIONS: We present a detailed map of PLNM in patients with bladder urothelial carcinoma with different T-stages and G-grades. The internal iliac/obturator packages appear to be most commonly involved. These findings demonstrate the significant impact of T-stage and G-grade on both the incidence and extent of PLNM. Collectively, these results may support future personalized treatment tailored to tumor stage and grade.
PURPOSE: Immunoradiation therapy, the combination of radiation therapy (RT) and immunotherapy, represents a promising advancement in cancer treatment by enhancing local and systemic tumor control and improving patient re...PURPOSE: Immunoradiation therapy, the combination of radiation therapy (RT) and immunotherapy, represents a promising advancement in cancer treatment by enhancing local and systemic tumor control and improving patient response rates. Although RT has long been a cornerstone of oncologic care, its efficacy is often limited by various tumor resistance mechanisms. Immunotherapy, which leverages the immune system to combat cancer, offers a complementary means to enhance RT's effectiveness. This review aims to provide a real-world guide for optimizing immunoradiation therapy in clinical practice and to bridge the gap between research and clinical application. METHODS AND MATERIALS: This review synthesizes current literature and clinical experience related to the integration of immunotherapy and RT, focusing on four critical areas: pretreatment factors, immunotherapy sequencing, RT planning, and posttreatment follow-up. Key considerations include prior patient treatments, the timing and type of immunotherapy, radiation dosing and fractionation strategies, tumor size, organs at risk, and effective post-RT monitoring, which collectively will help tailor a precise approach. In addition, the review highlights emerging approaches that incorporate artificial intelligence into RT planning and the development of personalized immunoradiation therapy. RESULTS: Evidence from recent studies demonstrates that the combination of RT and immunotherapy can enhance both local tumor control and systemic immune activation. To dissect further, the results of our review emphasize the importance of variables impacting treatment outcomes such as: prior chemotherapy, use of steroids, absolute lymphocyte counts, radiation dose and sequencing of immunotherapy in regard to RT, avoiding organs at risk, devising novel lymphocyte sparing techniques, and pulsed RT approach in cases of progression. CONCLUSIONS: By addressing the key factors influencing treatment design and implementation, immunoradiation therapy can be effectively tailored to improve therapeutic outcomes. Furthermore, the integration of artificial intelligence and multidisciplinary coordination may help in automated planning, treatment precision, and advancing personalized care in clinical oncology.
PURPOSE: The 5-year results of the FAST-Forward trial demonstrated noninferiority of local tumor control using a 26 Gy in 5 fraction regimen compared with 40 Gy in 15 fractions for breast cancer patients receiving adjuva...PURPOSE: The 5-year results of the FAST-Forward trial demonstrated noninferiority of local tumor control using a 26 Gy in 5 fraction regimen compared with 40 Gy in 15 fractions for breast cancer patients receiving adjuvant whole breast radiation therapy (WBRT) with or without a sequential conventionally fractionated tumor bed boost (2 Gy per fraction). Here, we reported our institutional experience using the FAST-Forward regimen with a novel sequential boost regimen of 5.2 Gy in 1 fraction or 10.4 Gy in 2 fractions. METHODS AND MATERIALS: Patients with nonmetastatic invasive breast cancer or ductal carcinoma in situ treated with adjuvant WBRT of 26 Gy in 5 fractions from January 7, 2019, to January 6, 2022, were identified from an institutional database. Clinical outcomes, including adverse events, disease control, and patient-reported outcomes, were collected. Survival outcomes were estimated using the Kaplan-Meier method. Associations between toxicities and clinicopathologic and treatment characteristics were assessed using logistic regression. RESULTS: A total of 311 consecutive patients were included; the use of a 1- or 2-fraction boost was left to the discretion of the treating physicians (54% 1-fraction, 8.7% 2-fraction, and 38% no boost). Median follow-up was 32 months. Overall survival and local recurrence-free survival probabilities at 36 months were 96% (95% CI, 94-99) and 93% (95% CI, 90-97), respectively. Acute and late toxicities occurred at a higher rate in the 2-fraction versus 1-fraction and no boost groups (37.4%, 10.8%, and 12.2% [acute] and 22.7%, 8.6%, and 7.9% [late], respectively). Boost receipt, greater boost volume, 15× energy, increasing breast V95%, and bolus use were associated with the risk of acute grade ≥ 2 toxicities. CONCLUSION: A 5-fraction ultrahypofractionated WBRT regimen for early-stage breast cancer with either no boost or a single-fraction boost of 5.2 Gy resulted in excellent disease control and acceptable toxicity. Increased toxicity was observed with a boost of 10.4 Gy in 2 fractions and is no longer used at our institution.
PURPOSE: Large, prevalent hepatocellular carcinomas (HCCs) are associated with poor prognosis and treatment resistance. While stereotactic body radiation therapy is effective against small HCCs, its application in large...PURPOSE: Large, prevalent hepatocellular carcinomas (HCCs) are associated with poor prognosis and treatment resistance. While stereotactic body radiation therapy is effective against small HCCs, its application in large tumors is limited by technical challenges and dose-limiting toxicities. This study evaluated long-term outcomes of large, locally advanced HCCs treated with stereotactically designed hypofractionated image guided radiation therapy (HIGRT) in the preimmunotherapy era. METHODS AND MATERIALS: This observational study was conducted using a strictly adhered, single-institutional protocol. Patients had HCCs >5 cm, were ineligible for curative intervention at multidisciplinary team meetings with Child-Pugh (CP) scores A5-B7. Participants received stereotactically designed HIGRT 4 weeks after transarterial chemoembolization, if given. Fractional dose was limited to 4 Gy/fraction (fr) in an individualized course of 6-10 frs, 5 fr/wk, aiming for the highest achievable dose delivery while respecting normal tissue constraints. Primary endpoint was local control (LC). Secondary endpoints included overall survival (OS), objective response, surgical conversion and toxicities. RESULTS: Consecutive patients (n = 156) were treated with a median 2 Gy-equivalent dose of 32.7 Gy (range, 28-46.7Gy) during 2006 to 2017. Median tumor size was 12.9 cm (range, 5.1-25.7 cm). One-year and 2-year LC, best-achievable objective response rates reached 85.5% (95% CI, 79.4%-91.6%), 74.1% (95% CI, 64.5%-83.7%), and 65.7% respectively. As median follow-up among survivors reached 76.1 months (range, 59.2-95.8 months), 1-year and 2-year OS rates were 45.4% (95% CI, 37.6%-53.2%) and 26.8% (95% CI, 19.8%-33.8%), respectively. Successful surgical conversion among responders (n = 14, 9.0%) achieved the longest median OS (47.7 months; 95% CI, 25.3-70.1 months). Grade ≥3 gastrointestinal toxicities (5.1%), CP score progression ≥2 at 3 months (18.9%) were manageable, with no significant differences across CP stages. CONCLUSIONS: The safety, LC of modest-dose, individualized, stereotactically designed HIGRT regimen in large, unresectable HCCs with adverse disease factors is comparable to the established 5fr-based stereotactic body radiation therapy, with achievable surgical conversion, OS and preserved tolerability in moderately impaired liver function, rendering an attractive option when systemic therapy is otherwise ineligible or inaccessible.
Jimenez RB, Abdou Y, Anderson P
… +17 more, Barry P, Bradfield L, Bradley JA, Heras LD, Khan A, Matsen C, Rabinovitch R, Reyna C, Salerno KE, Schellhorn SE, Schofield D, Taparra K, Washington I, Wright JL, Zeidan YH, Zellars RC, Horst KC
PURPOSE: This guideline provides evidence-based recommendations on the use of postmastectomy radiation therapy (PMRT) in the treatment of breast cancer. PMRT refers to the treatment of the chest wall and ipsilateral regi...PURPOSE: This guideline provides evidence-based recommendations on the use of postmastectomy radiation therapy (PMRT) in the treatment of breast cancer. PMRT refers to the treatment of the chest wall and ipsilateral regional nodes, including at-risk axillary, supra/infraclavicular, and internal mammary nodes. Updated recommendations detail indications for PMRT in the upfront surgical setting and after neoadjuvant systemic therapy, and provide guidance on appropriate target volumes, dosing, and treatment techniques. METHODS: The American Society for Radiation Oncology, American Society of Clinical Oncology, and the Society of Surgical Oncology convened a multidisciplinary task force to address 4 key questions focused on radiation therapy (RT) in patients with breast cancer who undergo mastectomy including (1) indications for PMRT after upfront surgery, (2) indications for PMRT after neoadjuvant systemic therapy followed by surgery, (3) appropriate PMRT treatment volumes and dose-fractionation regimens, and (4) treatment techniques. Recommendations were based on a systematic literature review and created using a predefined consensus-building methodology and system for quality of evidence grading and strength of recommendation. RESULTS: After upfront mastectomy, PMRT is indicated for most patients with node-positive breast cancer and select patients with node-negative disease. PMRT is also recommended after neoadjuvant systemic therapy, both for patients presenting with locally advanced disease and for those with residual nodal disease at the time of surgery. PMRT is conditionally recommended for patients with cT1-3N1 or cT3N0 breast cancer with pathologically negative nodes after neoadjuvant systemic therapy (ypN0). When PMRT is delivered, treatment to the ipsilateral chest wall/reconstructed breast and regional lymphatics is recommended, with moderate hypofractionation preferred, but with conventional fractionation approaches acceptable in rare cases. Computed tomography-based volumetric treatment planning with 3-dimensional conformal RT is recommended, with intensity modulated RT advised when 3-dimensional conformal RT is unable to achieve treatment goals. Deep inspiration breath hold techniques are also recommended for normal tissue sparing. For patients with skin involvement, positive superficial margins, and/or lymphovascular invasion, the use of a bolus is recommended, but the routine use of tissue-equivalent bolus is not recommended. CONCLUSIONS: These evidence-based recommendations guide clinical practice on the use of PMRT in patients with breast cancer.
PURPOSE: Urinary toxicity following radical prostatectomy (RP) and postoperative radiation therapy (RT) includes urinary incontinence and vesicourethral anastomosis strictures. With the increasing use of stereotactic bod...PURPOSE: Urinary toxicity following radical prostatectomy (RP) and postoperative radiation therapy (RT) includes urinary incontinence and vesicourethral anastomosis strictures. With the increasing use of stereotactic body RT (SBRT), dose escalation, and reirradiation of the prostate bed (PB), standardization of the definition of urinary organs-at-risk (OARs) in the post-RP setting is needed. This work aimed to provide a comprehensive review of the anatomic and physiopathological changes occurring after RP, as well as a consensus on urinary OAR delineation for prostate cancer external beam RT in the post-RP setting. METHODS AND MATERIALS: A multidisciplinary task force, comprising 3 radiation oncologists, 1 uroradiologist, and 2 urologists, was created in 2024. First, OARs potentially involved in urinary toxicity were identified and discussed. A literature review was performed, addressing several questions relative to surgical procedures and reconstructive strategies. A focus was also given to potential complications following RP and its impact on urinary OARs. Second, results were presented and discussed with a panel of radiation oncologists, members of the "Francophone Group of Urological Radiation Therapy." Thereafter, the Francophone Group of Urological Radiation Therapy experts were asked to answer a dedicated questionnaire, including 26 questions on the controversial issues related to the delineation of urinary OARs. RESULTS: The following structures were identified as critical for RT in the post-RP setting: bladder, bladder neck, bladder trigone, vesicourethral anastomosis, membranous urethra, and striated sphincter. A consensus was reached for 25 out of 26 items. CONCLUSIONS: New clinical scenarios at risk of toxicity in the post-RP setting are emerging, including especially PB reirradiation with SBRT, PB SBRT, and dose-escalated RT to the PB. This consensus highlights contemporary urinary structures in the post-RP setting. It also proposes a standardized definition of urinary OARs for the development of future clinical trials.
Reirradiation of spinal metastases using stereotactic body radiation therapy (SBRT) presents clinical challenges, with limited patient outcomes data to guide decision-making. We report a retrospective, single-institution...Reirradiation of spinal metastases using stereotactic body radiation therapy (SBRT) presents clinical challenges, with limited patient outcomes data to guide decision-making. We report a retrospective, single-institutional experience of 107 lesions treated in 91 patients. Of these, 88 (72%) lesions were initially irradiated with conventional radiation therapy (median equivalent dose of 33 Gy to the target, IQR, 23-35 Gy) with a median time to reirradiation of 12 months (IQR, 4-21 months). For reirradiation, most lesions received either 1 fraction (18-24 Gy) or 3 fractions (30-36 Gy) of SBRT. The median equivalent dose in 2 Gy fractions was 38 Gy (IQR, 30-41 Gy), 27 Gy (22-36 Gy), and 65 (54-73 Gy) for previous courses, reirradiation, and cumulatively, respectively. At 1 year, overall survival was 61% with a cumulative incidence of local failure at 12% and vertebral compression fracture at 9% considering death as a competing risk. None of the 79 treated lesions at L1 or above developed radiation myelitis, but 5 patients developed chronic peripheral neuropathy. In our analysis, most adverse events or local failures occur within the 2 years after retreatment. These findings demonstrate the safety and effectiveness of spine reirradiation with SBRT.
PURPOSE: Decision regret is a well-established negative outcome in prostate cancer. We hypothesized that baseline comorbidities, which impact treatment tolerability, are associated with regret. METHODS AND MATERIALS: In...PURPOSE: Decision regret is a well-established negative outcome in prostate cancer. We hypothesized that baseline comorbidities, which impact treatment tolerability, are associated with regret. METHODS AND MATERIALS: In a prospective, population-based cohort of patients with prostate cancer, patient-reported regret was assessed at 12 months after treatment using a validated measure. Comorbidities were assessed using medical record abstraction and scored using the validated National Cancer Institute Comorbidity Index. Multivariable logistic regression was used to assess the association between the comorbidity score and regret, accounting for treatment-related symptoms, treatment received, and sociodemographic measures. RESULTS: This was a diverse cohort, comprising 25.3% Black patients and 24.2% living in rural areas. A total of 108 out of 981 patients (11%) reported regret. In multivariable analysis, comorbidity score (odds ratio [OR], 1.58; p < .05), not being married (OR, 1.72; p = .04), worsening of bowel symptoms (OR, 2.12; p < .01), and worsening of urinary obstruction/irritation (OR, 1.60; p = .05) were associated with decision regret. In addition, radiation therapy was associated with less regret compared with radical prostatectomy (OR, 0.48; p = .015). CONCLUSIONS: Among men with localized prostate cancer, baseline comorbidity burden was associated with increased decision regret. These results illustrate the importance of assessing baseline comorbidities and incorporating their consideration into the treatment decision-making process, ensuring that patients have realistic expectations and make informed decisions.
Radiation recall dermatitis is a known but rare adverse effect that is characterized by the development of dermatitis in the region of prior irradiated tissue triggered by exposure to a systemic agent. Capivasertib is a...Radiation recall dermatitis is a known but rare adverse effect that is characterized by the development of dermatitis in the region of prior irradiated tissue triggered by exposure to a systemic agent. Capivasertib is a small-molecule inhibitor targeting the phosphatidylinositol 3-kinase/protein kinase B pathway recently approved in locally advanced and metastatic breast cancer; however, the safety of its use in the setting of palliative radiation is currently unclear. Here, we report a case of radiation recall dermatitis in a patient with metastatic breast cancer on capivasertib with history of radiation to the right lower extremity managed with corticosteroids, antibiotics, and switching to alpelisib.
PURPOSE: Addressing religion and spirituality (R/S) in the patient care setting has shown associations with health care outcomes and quality of life. Patients with gynecologic malignancies demonstrate increased distress...PURPOSE: Addressing religion and spirituality (R/S) in the patient care setting has shown associations with health care outcomes and quality of life. Patients with gynecologic malignancies demonstrate increased distress and fear following treatment. The Faith or belief, Importance and Influence of spirituality, spiritual Community; and interventions to Address spiritual needs (FICA) Spiritual History Tool outlines 4 domains of assessment. Using the FICA Spiritual History Tool, we sought to evaluate the importance of R/S for patients with gynecologic cancer who had undergone external beam radiation therapy or brachytherapy and assess the most meaningful questions from the FICA Spiritual History Tool that best facilitate conversation. METHODS AND MATERIALS: Eleven patients with gynecologic malignancy treated with external beam radiation therapy and/or brachytherapy were interviewed with the FICA Spiritual History Tool to assess each question as helpful or unhelpful, and to select 1 or 2 questions they perceived to best open the conversation with providers. RESULTS: Average age was 59 years old (range, 37-74). Religious identities included Christian denominations, Buddhist, Jewish, Muslim, and Hindu. Nine of 11 patients (82%) rated the importance of their faith as 5/5. On average, 9.5 of 11 questions (range, 7-11) were thought to be helpful if asked. All patients reported the same 6 questions as helpful, ranging across all domains. The two most common questions identified to best facilitate conversation were related to alleviating stress: "Do you have spiritual beliefs that help you cope with stress?" and "Have your beliefs influenced you in how you handle stress?" CONCLUSIONS: Among gynecological cancer patients who underwent radiation therapy, conversations regarding R/S are highly coveted across a spectrum of demographics and ethnic identities. How R/S helps patients cope with stress was identified as the most meaningful question to open this conversation with providers. Furthermore, engaging patients on their R/S invites further conversation and understanding regarding stress, coping, and anxiety surrounding treatment, findings that should be explored in larger cohorts.