Radiotherapy for non-malignant disorders: state of the art and update of the evidence-based practice guidelines

Every year in Germany about 50,000 patients are referred and treated by radiotherapy (RT) for "non-malignant disorders". This highly successful treatment is applied only for specific indications such as preservation or recovery of the quality of life by means of pain reduction or resolution and/or an improvement of formerly impaired physical body function owing to specific disease-related symptoms. Since 1995, German radiation oncologists have treated non-malignant disorders according to national consensus guidelines; these guidelines were updated and further developed over 3 years by implementation of a systematic consensus process to achieve national upgraded and accepted S2e clinical practice guidelines. Throughout this process, international standards of evaluation were implemented. This review summarizes most of the generally accepted indications for the application of RT for non-malignant diseases and presents the special treatment concepts. The following disease groups are addressed: painful degenerative skeletal disorders, hyperproliferative disorders and symptomatic functional disorders. These state of the art guidelines may serve as a platform for daily clinical work; they provide a new starting point for quality assessment, future clinical research, including the design of prospective clinical trials, and outcome research in the underrepresented and less appreciated field of RT for non-malignant disorders.

Advances in radiotherapy and targeted therapies for rectal cancer

The last decade witnessed a significant progress in understanding the biology and immunology of colorectal cancer alongside with the technical innovations in radiotherapy. The stepwise implementation of intensity-modulated and image-guided radiation therapy by means of megavolt computed tomography and helical tomotherapy enabled us to anatomically sculpt dose delivery, reducing treatment related toxicity. In addition, the administration of a simultaneous integrated boost offers excellent local control rates. The novel challenge is the development of treatment strategies for medically inoperable patient and organ preserving approaches. However, distant control remains unsatisfactory and indicates an urgent need for biomarkers that predict the risk of tumor spread. The expected benefit of targeted therapies that exploit the tumor genome alone is so far hindered by high cost techniques and pharmaceuticals, hence hardly justifying rather modest improvements in patient outcomes. On the other hand, the immune landscape of colorectal cancer is now better clarified with regard to the immunosuppressive network that promotes immune escape. Both N2 neutrophils and myeloid-derived suppressor cells (MDSC) emerge as useful clinical biomarkers of poor prognosis, while the growing list of anti-MDSC agents shows promising ability to boost antitumor T-cell immunity in preclinical settings. Therefore, integration of genetic and immune biomarkers is the next logical step towards effective targeted therapies in the context of personalized cancer treatment.

[Economic and logistical problems of radiation oncology]

An analysis of economic and logistical problems of radiation oncology is presented based on domestic and foreign literature. Despite the high efficacy of radiotherapy this branch of oncology is not financed enough in most countries. As a consequence, it is ubiquitously marked radiotherapy capacity deficit that does not allow to fully realize its therapeutic potential. Medical electron accelerators and related equipment have become increasingly complex and expensive and radiotherapy techniques more consuming. Even in developed countries growing waiting times for radiotherapy, not using the most modern and efficient radiotherapy technologies (image guiding, etc.) has become a daily reality. Based on these data, we assessed the prospects and possibilities of upgrading the technical base of radiation oncology in Russia including the development of hadron therapy.

[Radiation physics for beginners]

The clinical development of ionizing irradiation, both in the fields of medical imaging and radiotherapy treatment, is the result of a comprehensive understanding of the basics of radiation physics. This has lead to major innovations in the field of radiotherapy. Those innovations aim at a better dose distribution i.e. hitting the target while leaving healthy tissues as much as possible outside of the high-dose region. New techniques such as treatment with heavy ions are the reflections of the continuous evolution of science and knowledge in the field. At the boundaries of radiation physics, we are reaching the field of radiation biology. The combination of knowledge issued from both scientific fields does offer a unique opportunity for treatment optimization.

[Topics of radiation biology for cancer treatment]

Recent advances in the field of radiation therapy (RT) have considerably improved treatment outcomes of various cancers. It is related to not only the technological progress in medical physics but also the analytical progress in radiation biological effectiveness. However, the treatment results of RT, especially in advanced cancer, are still insufficient, therefore it is necessary to establish a safety and more effective method for treating cancer. Understanding the radiation biology is essential to appreciate the effect of RT. Hence, we review the controversial point of RT for radiation biology and introduce the results of basic research.

A roadmap for change: charting the course of the development of a new, advanced role for radiation therapists

A new model of care has been piloted in Ontario that expands the role of radiation therapists to improve access and treatment quality for patients requiring radiation therapy. The advanced practice Clinical Specialist Radiation Therapist (CSRT) role was created to redistribute activities amongst healthcare team members, allowing each to work to the full scope of practice, thereby better streamlining services, addressing systematic pressures in the existing model of care, and increasing patients' access to treatment. This paper provides an overview of the approaches used to develop and implement an advanced practice (AP) role, and it offers guidance on the use of an evidence-based approach to the evaluation of such positions. This article also utilizes the experience and knowledge developed during the CSRT projects to provide a framework for organizations embarking on similar AP implementation initiatives.

[On the state and prospects of development of remote neutron therapy]

The state and prospects of remote neutron therapy were analyzed in this review. Years of experience with fast neutrons, both positive and negative, allow evaluating the most promising ways of further development of this area of radiation therapy. These include conducting targeted research for those tumors which received some encouraging results, a use of the combination of fast neutron therapy and conformal photon therapy as well as the creation of specialized medical facilities for neutron therapy based on optimization of both parameters of spatial distribution of the dose and radiobiological characteristics.

[Current treatment strategies for papillary thyroid microcarcinoma]

The increase in the incidence of thyroid cancer is accompanied by a mortality rate that is stable or perhaps even slightly decreasing. This phenomenon is due to the increased frequency of papillary microcarcinomas (thyroid tumors with a diameter of less than 1 cm), which is presumably attributable to the improved diagnosis enabled by high resolution ultrasound and fine needle aspiration cytology. The American and European Thyroid Associations have recently published new guidelines for the diagnosis and therapy of differentiated thyroid tumors. These guidelines are aimed at minimizing the diagnostic and therapeutic procedures without reducing their effectiveness. This goal is particularly important for papillary thyroid microcarcinoma patients, who have an excellent prognosis and almost normal life expectancy. This article summarizes the history of thyroid surgery and introduces papillary thyroid microcarcinoma--an important topic in modern thyroid oncology. Current methods for diagnosis, treatment and follow-up care of this disease are discussed.

Patterns of care for locally advanced vulvar cancer

OBJECTIVE

Patients with locally advanced vulvar carcinoma can be treated with primary surgery or neoadjuvant chemoradiation. Neoadjuvant treatment appears to be associated with decreased morbidity and acceptable long-term outcomes. We examined the patterns of care for women with locally advanced vulvar cancer.

STUDY DESIGN

Data from the Surveillance, Epidemiology, and End Results (SEER) database was used to examine women with stage III-IVA vulvar cancer treated from 1988 to 2008. Primary therapy was classified as surgery or radiation. Multivariable logistic regression models were developed to examine the use of primary radiotherapy.

RESULTS

We identified a total of 2292 women including 1757 who underwent primary surgery (76.7%) and 535 treated with primary radiation (23.3%). The use of primary radiation increased with time from 18.0% in 1988 to 30.1% in 2008. In a multivariable model, older women (odds ratio [OR], 1.33; 95% confidence interval [CI], 1.03-1.72), black women (OR, 1.59; 95% CI, 1.14-2.23), and patients with stage IVA tumors (OR, 2.23; 95% CI, 1.78-2.81) were more likely to receive primary radiation. Among women treated with primary radiotherapy, only 17.8% ultimately underwent surgical resection.

CONCLUSION

The use of primary radiation for locally advanced vulvar cancer is limited but has increased over time. Multiple patient and tumor factors influence use. The majority of patients with stage III-IVA vulvar cancer treated with primary radiation therapy did not undergo surgical resection.

The dentist's role within the multi-disciplinary team maintaining quality of life for oral cancer patients in light of recent advances in radiotherapy

Every year in Ireland over 400 people are diagnosed with head and neck cancer. Oral cancer, a specific type of head and neck cancer, is usually treated with surgery and often requires radiotherapy (RT). However, side effects of RT treatment, which include mucositis, xerostomia, radiation caries, trismus and osteoradionecrosis, can seriously compromise a patient's quality of life. Treatment for oral cancer patients is managed in a multidisciplinary team. General dental practitioners (GDPs), consultant/specialist dentists and oral-maxillofacial surgeons play an important role in these patients' care. Recent advances in the delivery of RT have not only improved locoregional control and survival rates, but have also reduced the incidence and severity of RT-associated side effects; however, no mode of RT delivery has successfully eliminated side effects. The role of dentists is essential in maintaining oral health and all patients should be dentally screened prior to commencing RT. Recent reports have attempted to standardise the quality of care for the oral cancer patient and have highlighted the significance of the role of the GDP. Despite the advancements in RT delivery, the dental team is still faced with a number of challenges, including the high number of patients lost to follow-up dental care, lack of an effective treatment for xerostomia, poor patient compliance, and a lack of standardised guidelines and funding. Addressing these challenges will involve increased communication between all members of the multidisciplinary team and increased involvement of the GDP, thereby ensuring that dental care continues to evolve concurrently with new methods of RT delivery.

Current perspectives in bladder cancer management

More than 350,000 new cases of bladder cancer are diagnosed worldwide each year; the vast majority (> 90%) of these are transitional cell carcinomas (TCC). The most important risk factors for the development of bladder cancer are smoking and occupational exposure to toxic chemicals. Painless visible haematuria is the most common presenting symptom of bladder cancer; significant haematuria requires referral to a specialist urology service. Cystoscopy and urine cytology are currently the recommended tools for diagnosis of bladder cancer. Excluding muscle invasion is an important diagnostic step, as outcomes for patients with muscle invasive TCC are less favourable. For non-muscle invasive bladder cancer, transurethral resection followed by intravesical chemotherapy (typically Mitomycin C or epirubicin) or immunotherapy [bacillus Calmette-Guérin (BCG)] is the current standard of care. For patients failing BCG therapy, cystectomy is recommended; for patients unsuitable for surgery, the choice of treatment options is currently limited. However, novel interventions, such as chemohyperthermia and electromotive drug administration, enhance the effects of conventional chemotherapeutic agents and are being evaluated in Phase III trials. Radical cystectomy (with pelvic lymphadenectomy and urinary diversion) or radical radiotherapy are the current established treatments for muscle invasive TCC. Neoadjuvant chemotherapy is recommended before definitive treatment of muscle invasive TCC; cisplatin-containing combination chemotherapy is the recommended regimen. Palliative chemotherapy is the first-choice treatment in metastatic TCC.

Old but new methods in radiation oncology: hyperbaric oxygen therapy

The presence of hypoxic tumor cells is widely regarded as one of the main reasons behind the failure to control malignant tumors with radiotherapy treatments. Since hyperbaric oxygenation (HBO) improves the oxygen supply to the hypoxic tumor cells, HBO therapy has previously been used in combination with simultaneous radiotherapy to treat malignant tumors. In some clinical trials, significant improvements in local control and survival have been seen in cancers of the head and neck and the uterine cervix. However, the delivery of simultaneous HBO therapy and radiotherapy is both complex and time-consuming, with some trials reporting increased side effects. As a result, the regimen of HBO therapy in combination with simultaneous radiotherapy has yet to be used as a standard treatment for malignant tumors. In recent years, however, radiotherapy immediately after HBO therapy has been emerging as an attractive approach for overcoming hypoxia in cancer treatment. Several studies have reported that radiotherapy immediately after HBO therapy was safe and seemed to be effective in patients with high-grade gliomas. Also, this approach may protect normal tissues from radiation injury. To accurately estimate whether the delivery of radiotherapy immediately after HBO therapy can be beneficial in patients with high-grade gliomas and other cancers, further prospective studies are warranted.

Multiple malignancies in a single patient : a glimpse into 30 years of interdisciplinary oncology

We report on an 83-year-old woman who suffered from seven manifestations of at least five different nonmetastasizing malignancies during a period spanning more than three decades. Although suspected, an inherited genetic tumor syndrome could not be detected. This patient history exemplifies the development of interdisciplinary oncology and specifies the success but also the risks of intensified locoregional treatments. In particular, radiation oncologists routinely have to perform a risk-benefit analysis, rendering their work both challenging and fascinating.

Meningioma challenge: analysis of 80-year experience of Burdenko Neurosurgical institute and future perspectives

The paper describes the history of meningioma surgery at Burdenko Neurosurgical Institute, analyses of accumulated series of patients and assesses effectiveness of different techniques for meningioma diagnosis and treatment of. We analyzed 15413 patients with meningiomas operated in Burdenko Neurosurgical Institute from 1932 to 2011. Mathematical analysis was performed using Statistica 6.0 program. Mortality rate during World War II reached a disastrous level of 45,8%, in 21st century it is below 1%. Temporary and permanent morbidity has also decreased. While in 1961 Karnofsky performance score was 71, in 2011 it became 83. The probability of postoperative tumour recurrence also diminished, from 40% in 1960-s to 29% in 1996 and presumably to 25% nowadays. Independent factors that influence the risk of recurrence are primary gross total resection, grade of anaplasia and radiation therapy. However, unreasonably aggressive surgery leads to significant increase of morbidity. Further improvement of surgical results in patients with meningiomas depends on implementation of new technologies for neurovisualization, abandoning extensive surgical approaches whenever possible, finding the "balance" between radical removal and expected functional outcome, wider application of radiosurgery and three-dimensional conformal radiation therapy.

Radiotherapy for NSCLC: review of conventional and new treatment techniques

Radiotherapy is an essential modality in the management of lung cancer. It is used as a single modality or in combination with other modalities and aimed at cure or palliation. Recent advances in the simulation techniques or more precise targeting of the tumor made radiotherapy more effective tool in the fight against lung cancer. Using PET scan and better gating for tumor motion are examples of these advances. This brief review will present summary of the role of radiotherapy in management of lung cancer.

Trends over three decades of the risk of second primary cancer among patients with head and neck cancer

OBJECTIVES

Patients with a head and neck squamous cell carcinoma (HNSCC) carry a high risk of second primary cancer (SPC). In recent years, a rise in incidence of human papillomavirus (HPV)-associated HNSCC has been recorded. Moreover, tobacco and alcohol consumption levels have changed and major advances have been made in radiation treatment approaches. This raises the question of a modification to the risk of SPC, taking into account variations of patient characteristics related to the HPV-cancer epidemic.

MATERIALS AND METHODS

All patients with a first HNSCC diagnosed between 1975 and 2006 in the French Bas-Rhin region were followed up for 10 years. Multivariate Poisson regression models were used to model standardized incidence rates and excess absolute risks (EARs) over years of diagnosis, taking into account confounders such as sex, age, subsite of first HNSCC and follow-up.

RESULTS

Among these 6258 patients, 1326 presented with a SPC. High EAR values were observed for SPC of lung, head and neck, and esophagus sites (EAR of 172.8, 159.3 and 72.5 excess cancers per 10,000 person-years, respectively). Multivariate analysis showed that the excess risk of SPC of head and neck (P<.001) and esophagus (P=.029) sites decreased, with 53% lower EARs values in 2000-2006 compared to 1975-1979. In contrast, the excess risk of SPC of the lung did not change significantly (P=.174).

CONCLUSIONS

Efforts made by public health policy-makers and oncology care providers should be sustained to develop effective smoking cessation interventions, as the excess risk of lung SPC remains high and unchanged.

Thyroid eye disease: towards an evidence base for treatment in the 21st century

Thyroid eye disease (TED) is the most common extrathyroidal manifestation of Graves' disease. Incomplete understanding of its pathogenesis has hindered development of targeted therapies that might alter the natural course of disease. Smoking cessation and maintenance of euthyroidism appear to reduce the rate of onset and severity of TED. Recent evidence suggests that selenium may lessen the inflammatory symptoms in mild disease. Corticosteroids remain the primary treatment for patients with moderate to severe active TED. Surgical decompression is commonly undertaken in the chronic stable phase, and only rarely in the active phase when vision is threatened by compressive optic neuropathy. Orbital radiotherapy remains an adjunctive strategy during active disease. Targeted immunotherapies have the potential to alter disease progression, but further evidence is needed to establish safety and efficacy. In this article, we review evidence from prospective therapeutic trials of several treatment modalities. We focus on moderate to severe active TED.

A clinical approach to technology assessment: how do we and how should we choose the right treatment?

The evidence required to support the use of new technology in medicine differs from that required for new drugs. On one extreme, very little may be required for small devices, but on the other strong evidence is required to support the use of truly novel, potentially dangerous, and high-cost machines. The randomized controlled trial is built into the evaluation of drugs and suits them well. It is not so well suited to the evaluation of major devices in which installation costs and return on investment are important. We discuss where the randomized controlled trial may still play a role and what alternatives may exist when this is not possible. We also discuss the role that independent bodies may have in determining whether or not a new device is not only safe but also adds to the medical landscape in a way that justifies its cost.

Is there a role of radiotherapy in the management of pancreatic neuroendocrine tumors (PNET)?

Pancreatic neuroendocrine tumors (PNET) represent a heterogeneous group of tumors with varying tumor biology and prognosis. Advanced PNETs remain a difficult therapeutic challenge because of their high malignant potential and their resistance to conventional chemotherapy although there have been recent developments with promising results with the use of novel agents for the treatment of this disease. Combined modality chemoradiation is not widely used in the management of locally advanced pancreatic endocrine tumors. We discuss Abstract #335 from 2012 ASCO GI Cancers Symposium and share our experience to discuss efficacy and toxicity of concurrent capecitabine or infusional 5-fluorouracil and radiotherapy in patients with resected, locally advanced and metastatic PNET. Prospective studies to investigate the role of radiation and chemoradiation are warranted.

[Radionuclide therapy for cancer--what's new?]

Radionuclide therapy is radiation therapy, the effect of which is based on radiation damage in cancer cells. The most common radionuclide therapy for cancer is radioiodine therapy for thyroid cancer. Two new forms of treatment have recently been initiated in Finland: 177lutetium octreotate therapy for neuroendocrine tumors, pheochromocytoma and paraganglioma as well as radioembolization (selective internal radiation therapy, SIRT) with 90yttrium-coated resin beads against liver metastases. Still in experimental use, 223radium chloride is a drug prolonging survival in prostate cancer that has metastasized to bone. The treatments require special knowledge and collaboration between several units.

[Trends in the use of primary radiotherapy for cancer in the Netherlands in patients with breast, prostate, rectal and lung tumours]

OBJECTIVE

To provide insight in the application of radiotherapy as part of primary treatment of patients with cancer in the Netherlands.

DESIGN

Retrospective, descriptive population-based study.

METHOD

Data concerning patients with breast, prostate, rectal and non-small cell lung cancer were selected from the Netherlands Cancer Registry in 4 regions, covering 50% of the Dutch population. The selection concerned data from 1997-2008 and, except for prostate cancer, only patients without distant metastases were included.

RESULTS

Between 1997 and 2008, the use of primary external radiotherapy increased approximately 7% in breast cancer patients and approximately 30% in rectal cancer patients. In the latter group preoperative radiotherapy strongly increased, while postoperative radiotherapy decreased. For prostate cancer there was an increase in brachytherapy (9%). The use of external beam radiotherapy in patients with prostate cancer and non-small cell lung cancer remained the same. Regional differences in the extent of use of radiotherapy for breast and rectal cancer clearly decreased. These differences remained limited for external beam radiotherapy in prostate and non-small cell lung cancer. Older patients less often received radiotherapy.

CONCLUSION

The increase in use of radiotherapy for breast cancer is explained by the increase in breast conserving surgery. The trends in use in patients with rectal cancer and breast cancer are presumably related to the implementation of multidisciplinary practice guidelines. The implementation of these guidelines probably also contributed to the decrease in regional differences in the use of radiotherapy.

The International Core Literature Consensus (ICLC): an alternative curriculum for Oncologists

Oncologists must familiarize themselves with a complex evidence base. Several curricula have been devised, but it is not clear how these are used. We chose breast cancer, since this has a large literature base. Of the 285 radiation and medical oncology trainees in the USA and UK responding to our survey, over 90% reported knowledge of the literature was essential. Just over half of respondents had actually read the ASCO or ESMO curricula, with only 23% reporting that the curricula were important in their learning. Our survey revealed dissatisfaction with current curricula and a demand for more pragmatic literature guidance. We designed an alternative curriculum by using a 21-member peer review group to validate a list of key papers in breast oncology. Oncologists in training need guidance to direct their study. A curriculum based on an International Core Literature Consensus might match the needs of trainees more closely.

Update on external beam radiation therapy in thyroid cancer

Surgery is the mainstay of treatment for thyroid cancer. The role for external beam radiotherapy (EBRT) as an adjuvant to surgery or as the primary therapy is established in anaplastic thyroid cancer but is controversial in differentiated thyroid cancer and uncertain in medullary thyroid cancer. This update reviews the recent reported success of combining EBRT with taxanes in anaplastic thyroid cancer. Also discussed are the recent reports from large single institutions that support the recommendations of the American and British Thyroid Associations on the use of EBRT in high-risk differentiated thyroid cancer. Further evidence on the role of EBRT in MTC is discussed. The important advances in the delivery of EBRT using intensity-modulated radiation and image-guided radiation that result in more accurate and potentially more effective radiation therapy with less toxicity are also discussed.

The risks to healthy tissues from the use of existing and emerging techniques for radiation therapy

As radical radiotherapy treatments become more effective, more and more cancer patients are becoming cured of their disease and surviving for decades. Damage to exposed healthy tissues that becomes manifest in the medium-to-long-term is becoming a more significant factor in the choice of individual treatment plans and treatment modality. However, currently there are no reliable objective methods for predicting in an individual patient the occurrence of normal tissue complications, or second cancers caused by radiation. This is especially needed as new competing techniques and modalities become available, such as IMRT, protons, carbon ions, etc., all advancing the ability to focus the radiation dose on the target while sparing normal tissue. ALLEGRO is a Euratom-funded project that is currently investigating the current state of knowledge, and attempting to define the priority research areas. Preliminary considerations of the problems to be solved and research priorities are presented.

The treatment of spinal metastases

BACKGROUND

The rising life expectancy of cancer patients has led to a greater need for treatment of spinal metastases. Interdisciplinary collaboration is important so that each patient's treatment can be properly tailored to the overall prognosis. The main factors to be considered are the histology of the primary tumor, potential spinal instability, and compression of neural structures.

METHODS

We discuss the treatment options for spinal metastases on the basis of a selective literature review and our own extensive experience in an interdisciplinary tumor center.

RESULTS

For spinal canal compression or impending spinal instability, the treatment of choice is decompression and stabilization, by either a dorsal approach (lumbar and thoracic spine) or a ventral approach (cervical spine). Radical ventral tumor resection is indicated only for solitary metastases in patients with a favorable long-range prognosis. If the tumor is radiosensitive, radiotherapy is given either as adjuvant treatment after surgery or as the primary treatment for multiple spinal metastases in the absence of an acute neurological deficit. Various fractionation schemes with different total radiation doses are used. Bisphosphonate treatment is an integral component of the overall treatment strategy.

CONCLUSION

The treatment of spinal metastases requires interdisciplinary collaboration and must be tailored to each patient's overall prognosis.

[Advances in radiotherapy of malignant tumours]

The authors discuss changes in the equipment and technologies of radiotherapy during the past 10-15 years. These changes ensured the improvement of diagnostics and treatment of neoplasms by two other main methods, surgical and medicamental. Modifications in the combined application of radiotherapy and surgery and of radio- and pharmacotherapy are discussed.

[Radiation therapy in France in 2010]

Radiation therapy contributes, with others therapeutic means, to cure many cancers without mutilation and sparing conservative functions. In France, in 2010, about 180,000 patients underwent external radiation therapy in 177 centers assumed by 660 radiation oncologists. Many progress and changes have been made during the past years with the implementation of new techniques as conformal and intensity modulated techniques. Renewal of innovative treatment machines is rapidly ongoing. Since 2007, after medical accidents, quality and security policies have been improved and coordinated to a national level with the active cooperation of the main institutional and professional partners. The new national "Plan Cancer 2009-2013" leads to improvement for patients to access to innovative and safe treatments and to clinical research.

[Radiotherapy and combined therapy in breast cancer: standards and innovations in the adjuvant setting]

Due to the significant advances in the diagnosis and treatment of breast cancer seen in the last decades, increased survival rates and better outcomes of patients are being observed. The role of radiotherapy remains pivotal in the treatment of early breast cancer. In the adjuvant setting, whole breast irradiation remains the standard of care using a relatively well standardized radiation technique. The recent technology advances and 3D conformal radiotherapy allow for better volumes definition resulting to increased organ at risk--sparing and therefore treatment optimization. Sophisticated techniques and emerging options (such as accelerated partial breast irradiation) are not routinely used yet outside of a clinical trial. Moreover, new drugs and targeted therapies have recently been introduced to the clinical practice for treatment individualization according to the specific tumours' prognosis and/or prediction of the drugs' efficacy based on new biological tools. Regarding the synergistic effect of these molecules with ionizing radiation, rigorous prospective evaluation of combined therapy is important to ensure improved long-term benefit/risk ratio. In this review, the significant advances of radiotherapy and combined therapy in the new era of breast cancer management will be discussed.

[Result of the onsite dosimetry and questioning about quality assurance/ quality control of radiotherapy in the Hokuriku area - a comparison with past results -]

PURPOSE

To analyze temporal changes in human resources in the radiotherapy section, quality assurance/quality control (QA/QC) and dose difference for radiotherapy in the Hokuriku area based on the results of past investigations and our investigation.

METHOD

We visited radiotherapy sections of 17 hospitals in the Hokuriku area (5 in Toyama, 9 in Ishikawa and 3 in Fukui) to measure the dose at the reference point of a linear accelerator (LINAC), as we asked questions to a radiotherapist about human resources, QA/QC of LINAC, etc. We compared our results with past reports (1992 to 2007) on the dose difference, human resources and frequency of dose monitor system calibration.

RESULTS

The number of physicians has not changed since 1999, but the number of radiotherapists was significantly increased. Weekly dose monitor system calibration has been achieved in 80% of the institutions in our survey. This percentage was significantly higher than in the past surveys. The dose difference distribution from our onsite dosimetry did not significantly differ from that from the onsite dosimetry in 2007. 91% of the institutions have accomplished within 2% of the dose difference.

CONCLUSION

We found that the number of physicians has not increased since 1999, but the number of radiotherapists has increased. We conclude that the increment of radiotherapists led to 80% achievement of the weekly dose monitor system calibration. Almost all institutions in Hokuriku area have properly performed QA of the dose monitor system.

Radiation therapy and stereotactic radiosurgery for the treatment of Cushing's disease: an evidence-based review

PURPOSE OF REVIEW

The indications, efficacy, and safety of radiation therapy and stereotactic radiosurgery for Cushing's disease are evaluated.We queried PubMed using the terms, 'Cushing's disease', 'radiotherapy', and 'radiosurgery', then evaluated each study for the number of patients, method of radiation delivery, type of radiation therapy or radiosurgical device used, treatment parameters (e.g. maximal dose, tumor margin dose), length of follow-up, tumor-control rate, complications, rate of hormone normalization, newly onset loss of pituitary function, and method used to assess endocrine remission.

RECENT FINDINGS

A total of 39 peer-reviewed studies with 731 patients were included. The reported rates of tumor-volume control following radiotherapy and radiosurgery vary considerably from 66-100%. Additionally, the reported rates of endocrine remission vary substantially from 17-100%. The incidence of serious complications following radiosurgery is quite low. Although post-treatment hypopituitarism and disease recurrence were uncommon, they did occur, and this underscores the necessity for long-term follow-up in these patients.

SUMMARY

Radiosurgery and, in the modern era, less commonly, radiation therapy, offer both well tolerated and reasonably effective treatment for recurrent or residual Cushing's adenomas.

[Current status and future of particle radiotherapy at the Hyogo Ion Beam Medical Center]

The Hyogo Ion Beam Medical Center was established in May 2001, a leading project of the Hyogo Cancer Strategy . Its major feature is that both proton and carbon ion beams can be generated. Particle beam radiation therapy had been performed in 2,639 patients as of the end of March 2009. The diseases were prostate cancer, head and neck tumors, liver cancer, lung cancer, and bone soft tissue tumors, in decreasing order of frequency, and these 5 major diseases accounted for 87% of the cases. By beam-type therapy, 2,122 and 517 patients (80 and 20%) were treated with proton and carbon ion beams, respectively. The outcomes surpassed those of surgical therapy realizing cancer therapy without resection. Current problems of particle beam radiation therapy include the unclear effect of differential use of proton and carbon ion beams and the necessity of laying in large-scale equipment, which prevents its dissemination. We are now aiming at the development and clinical application of a laser-driven proton radiotherapy device in cooperation with the Japan Atomic Energy Agency.

[Current status and limitation of particle radiation therapy]

Almost 9,000 patients have been treated by particle radiation therapy as a highly advanced medical technology in Japan, and definitive evaluation of this technology might now be possible. The process of approval of medical equipment, the law of medical technologists, and the law of medicine for particle radiation therapy have also been prepared. Number of facilities is expected to increase, and time has come that the fee of this medicine would cover by social insurance. Much debate, however, has been published in English journals upon proton therapy. The National Cancer Institute has started to support clinical trials in the United States. In Japan, however, research funding is still quite small.

[Proton therapy on locally advanced cancer]

Conventionally, radiation considerably affects normal cells on the body's surface before it reaches the focal lesion; it is reduced and weakened at the focal lesion, and unable to fully demonstrate the potential effectiveness of radiotherapy. The radiation level in proton beam (particle beam) therapy characteristically reaches a peak (a Bragg peak) at a particular depth. Radiation can be concentrated on only the focal lesion while keeping damage to normal cells low, because cancer is irradiated by matching the peak position to the focal cancer. When a proton beam is blasted inside the body, the radiation reaches the cancer cells, yet normal cells are hardly affected. The blast reaches the DNA inside the nucleus of cancer cells. When the proton beam hits the DNA, the DNAs of cancer cells are damaged directly or indirectly. When this occurs, the probability is high that both double helixes of the DNA will be damaged, and significant effectiveness can be expected from the proton beam, with respect to cancer cells that may return with traditional radiation. Proton therapy effectiveness is confirmed for prostate cancer, liver cancer, lung cancer, head and neck cancer (including sinus cancer), and eye tumor (including uveal melanoma). All of these conditions have been difficult to treat with traditional radiation and surgery.

[Present status of carbon ion radiotherapy for malignant tumors]

Between June 1994 and February 2009, a total of 4, 504 patients with malignant tumors were registered in phase I/II dose-escalation studies and clinical phase II trials using carbon ion beams generated at the Heavy Ion Medical Accelerator in Chiba (HIMAC). Carbon ion radiotherapy (CIRT) has a unique advantage due to the biological properties and excellent dose distribution for malignant tumors compared with other radiotherapy. The cell mortality rate from a carbon ion beam is higher than that from a photon beam when the same physical dose is irradiated. This cell killing effect ratio is expressed by the relative biological effectiveness (RBE), and the RBE of a carbon ion beam has been reported to be 2-3, meaning that the cell killing effect of a carbon beam is two to three times stronger than that of a photon beam. In terms of the physical characteristics, CIRT exhibits a spread-out Bragg peak (SOBP) and makes for a better dose distribution of the target volume by specified beam modulations. In the initial dose-escalation studies, grade 3 or more late rectal complications had developed in some patients. However, the adverse effects were resolved because of the use of appropriate dose levels and modification of the radiation technique. CIRT can carry out hypofractionated radiotherapy with a large fraction dose and reduce the overall treatment times compared with conventional radiotherapy. It can also achieve better local tumor control even for radio resistant tumors such as malignant melanoma, hepatocellular carcinoma and bone and soft tissue sarcomas with minimal morbidity to the normal surrounding tissues. It was concluded that CIRT is an effective local treatment for patients with malignant tumors for whom surgical resection is not a viable option, and it presents a promising alternative to surgery.

[Heavy ion tumor therapy]

Heavy ion tumor therapy can reach a millimeter precision everywhere in the body and a greater biological effectiveness in radioresistant tumors compared to the normal tissue. Therefore it is possible to treat mainly resistant or otherwise inoperable tumors with ion beams with great success. In line with the excellent results achieved in a pilot project at GSI several new centers are under construction. In this article, basics of heavy ion tumor therapy are given and the clinical results of the pilot project are described.