Linac-based stereotactic radiation therapy for canine non-lymphomatous nasal tumours: 29 cases (2013-2016)

Stereotactic Radiation Therapy Planning, Dose Prescription and Delivery in Veterinary Medicine: A Systematic Review on Completeness of Reporting and Proposed Reporting Items

Increasing numbers of dogs and cats with cancer are treated with stereotactic radiosurgery, stereotactic radiation therapy or stereotactic body radiotherapy (SRS, SRT or SBRT). We provide a systematic review of the current data landscape with a focus on technical and dosimetric data of stereotactic radiotherapy in veterinary oncology. Original peer-reviewed articles on dogs and cats with cancer treated with SRT were included. The systematic search included Medline via PubMed and EMBASE. The study was performed according to the Preferred Reporting Items for Systematic Reviews (PRISMA) statement. We assessed the manuscripts regarding outcome reporting, treatment planning, dose prescription, -delivery and -reporting as well as quality assurance. As of February 2024, there are 80 peer-reviewed publications on various disease entities on SRS, SRT and SBRT in veterinary medicine. Overall, we found often insufficient or highly variable technical data, with incomplete information to reproduce these treatments. While in some instances, technical factors may not impact clinical outcome, the variability found in protocols, outcome and toxicity assessments precludes accurate and reliable conclusions for a benefit of stereotactic radiotherapy for many of the treated diseases. In line with the extensive recommendations from human stereotactic radiotherapy practise, we propose a draft of reporting items for future stereotactic radiation treatments in veterinary medicine. SRS, SRT and SBRT have specific clinical and technological requirements that differ from those of standard radiation therapy. Therefore, a deep understanding of the methodologies, as well as the quality and precision of dose delivery, is essential for effective clinical knowledge transfer.

Histological and Molecular Biological Changes in Canine Skin Following Acute Radiation Therapy-Induced Skin Injury

Radiation therapy is a crucial cancer treatment, but it can damage healthy tissues, leading to side effects like skin injuries and molecular alterations. This study aimed to elucidate histological and molecular changes in canine skin post-radiation therapy (post-RT) over nine weeks, focusing on inflammation, stem cell activity, angiogenesis, keratinocyte regeneration, and apoptosis. Four male beagles received a cumulative radiation dose of 48 Gy, followed by clinical observations, histological examinations, and an RT-qPCR analysis of skin biopsies. Histological changes correlated with clinical recovery from inflammation. A post-RT analysis revealed a notable decrease in the mRNA levels of Oct4, Sox2, and Nanog from weeks 1 to 9. VEGF 188 levels initially saw a slight increase at week 1, but they had significantly declined by week 9. Both mRNA and protein levels of COX-2 and Keratin 10 significantly decreased over the 9 weeks following RT, although COX-2 expression surged in the first 2 weeks, and Keratin 10 levels increased at weeks 4 to 5 compared to normal skin. Apoptosis peaked at 2 weeks and diminished, nearing normal by 9 weeks. These findings offer insights into the mechanisms of radiation-induced skin injury and provide guidance for managing side effects in canine radiation therapy.

Update in Veterinary Radiation Oncology: Focus on Stereotactic Radiation Therapy

Stereotactic radiotherapy (SRT) involves the precise delivery of highly conformal, dose-intense radiation to well-demarcated tumors. Special equipment and expertise are needed, and a unique biological mechanism distinguishes SRT from other forms of external beam radiotherapy. Families find the convenient schedules and minimal acute toxicity of SRT appealing. Common indications in veterinary oncology include nasal, brain, and bone tumors. Many other solid tumors can also be treated, including spinal, oral, lung, heart-base, liver, adrenal, and prostatic malignancies. Accessibility of SRT is improving, and new data are constantly emerging to define parameters for appropriate case selection, radiation dose prescription, and long-term follow-up.

Canine primary liver tumors treated with stereotactic body radiation therapy: A case series

Stereotactic body radiation therapy (SBRT) is an increasingly used alternative treatment option for nonresectable hepatocellular carcinoma (HCC) in people. Comparatively, the publication of SBRT of dogs with HCC is limited. The objective of this retrospective, descriptive case series was to evaluate the clinical outcomes and toxicity data of SBRT in dogs with HCC and imaging-documented primary liver tumors using volumetric-modulated arc therapy delivery at two private institutions. Medical records of 14 dogs treated between 2018 and 2023 were reviewed. All dogs had macroscopic tumors, and 9 of 14 dogs had HCC diagnoses confirmed on cytology or histopathology. The median longest tumor diameter was 5.5 cm. The median percentage of planning target volume relative to liver volume was 27.1%. Most dogs were treated with three daily fractions of 7-7.5 Gy. All dogs completed their radiotherapy protocols. Three of nine HCC dogs experienced partial responses and clinical improvement. Five of nine HCC dogs had stable disease. Overall median survival time was 164 days for nine HCC dogs (range: 93-706 days). One late grade 5 liver and two late grade 3 kidney side effects were reported. One dog received repeated SBRT to the same HCC treatment field, and one dog had two courses of SBRT to bifocal HCC treatment fields, both with no more than grade 2 acute and chronic toxicities.

Outcomes of 35 dogs with craniomaxillofacial osteosarcoma treated with stereotactic body radiation therapy

Canine craniomaxillofacial osteosarcoma (OSA) is most commonly treated surgically; however, in cases where surgery is not feasible or non-invasive treatment is desired, stereotactic body radiation therapy (SBRT) may be elected for local tumour control. In this study, we evaluated 35 dogs treated with SBRT. Nine dogs (26%) had calvarial, seven (20%) had mandibular and 19 (54%) had maxillary OSA. Median time to first event (TFE) was 171 days, and overall median survival time (MST) was 232 days. Site-specific MSTs were 144 days for mandible, 236 days for calvarium and 232 days for maxilla (p = .49). Pulmonary metastatic disease was observed in 12/35 (34%) patients and was detected pre-SBRT in six dogs (17%) and post-SBRT in the remaining six dogs (17%). Eighteen adverse events post-SBRT were documented. Per veterinary radiation therapy oncology group criteria, five were acute (14%) and three were late (9%) grade 3 events. Neurological signs in two dogs were suspected to be early-delayed effects. Cause of death was local progression for 22/35 (63%) patients, metastasis for 9/35 (26%) patients and unknown for four. On univariate analysis, administration of chemotherapy was associated with a longer TFE (p = .0163), whereas volume of gross tumour volume was associated with a shorter TFE (p = .023). Administration of chemotherapy and five fractions versus single fraction of SBRT was associated with increased survival time (p = .0021 and .049). Based on these findings, a treatment protocol incorporating chemotherapy and five fractions of SBRT could be considered for dogs with craniomaxillofacial OSA electing SBRT with careful consideration of normal tissues in the field.

A retrospective study of sinonasal tumors in 182 dogs treated with stereotactic radiotherapy (3 × 10 Gy) (2010-2015)

BACKGROUND

Stereotactic radiotherapy (SRT) is an emerging treatment for sinonasal tumors in dogs. Reported results regarding tumor control and incidence of acute and late radiation morbidities are inconsistent.

OBJECTIVES

To determine treatment efficacy and prognostic indicators of SRT in dogs with sinonasal tumors and to quantify acute and late radiation morbidities.

ANIMALS

One hundred and eighty-two client-owned dogs with sinonasal tumors diagnosed cytologically, histologically, or radiographically that underwent SRT.

METHODS

Single-arm retrospective study by reviewing medical records of dogs treated with SRT (10 Gy × 3) between 2010 and 2015. Kaplan-Meier analysis was used to determine overall survival (OST; from the first day of SRT to death by any cause) and disease-specific survival times (DSST; OST but censoring tumor/treatment-unrelated death). Tumors were staged using modified Adams criteria.

RESULTS

Median OST and DSST of dogs treated with 1 course of SRT was 441 (95% CI: 389-493 days) and 482 (428-536 days) days, respectively with skin/oral cavity acute morbidities observed in 3% of dogs. DSST in dogs with stage 4 disease showed no statistical difference compared to other stages (P = .64). Oro-nasal (n = 2) or naso-cutaneous (n = 11) fistula development occurred in 7.1% of dogs with median time of 425 days (range: 83-1733 days). Possible chronic rhinitis after SRT was recorded in 54 of 88 dogs (61%) where information was available.

CONCLUSIONS AND CLINICAL IMPORTANCE

Results are comparable to other reports of treatment of SRT. Acute morbidities were minimal. Modified Adams stage scheme appeared to be inappropriate for prognostication for dogs with sinonasal tumors treated with SRT.

Contouring in the optic plane improves the accuracy of computed tomography-based segmentation of the optic pathway

Canine optic pathway structures are often contoured on CT images, despite the difficulty of visualizing the optic pathway with CT using standard planes. The purpose of this prospective, analytical, diagnostic accuracy study was to examine the accuracy of optic pathway contouring by veterinary radiation oncologists (ROs) before and after training on optic plane contouring. Optic pathway contours used as the gold standard for comparison were created based on expert consensus from registered CT and MRI for eight dogs. Twenty-one ROs contoured the optic pathway on CT using their preferred method, and again following atlas and video training demonstrating contouring on the optic plane. The Dice similarity coefficient (DSC) was used to assess contour accuracy. A multilevel mixed model with random effects to account for repeated measures was used to examine DSC differences. The median DSC (5th and 95th percentile) before and after training was 0.31 (0.06, 0.48) and 0.41 (0.18, 0.53), respectively. The mean DSC was significantly higher after training compared with before training (mean difference = 0.10; 95% CI, 0.08-0.12; P < 0.001) across all observers and patients. DSC values were comparable to those reported (0.4-0.5) for segmentation of the optic chiasm and nerves in human patients. Contour accuracy improved after training but remained low, potentially due to the small optic pathway volumes. When registered CT-MRI images are not available, our study supports routine addition of an optic plane with specific window settings to improve segmentation accuracy in mesaticephalic dogs ≥11 kg.

Canine oral squamous cell carcinoma as a spontaneous, translational model for radiation and immunology research

Introduction

Improving outcomes for oral squamous cell carcinoma (OSCC) patients has been hindered by a lack of effective predictive animal models. Spontaneously occurring canine OSCC could help fill this gap. The objective of this study was to characterize the immune landscape of canine OSCC to advance understanding of how dogs could serve as a surrogate for human OSCC.

Methods/Results

Canine OSCC contains a heterogenous tumor immune microenvironment. CD3+ T cells were the predominant tumor infiltrating immune cell population; however, there was a wide range CD3+ T cell density across samples. The most common CD3+ T cell micro-anatomical distribution was defined as "pre-existing immunity", but the remaining 20% of tumors were characterized as "immunologically ignorant" or "excluded infiltrates" patterns. When compared to normal oral mucosa, the tumor gene expression pattern suggests that canine OSCC microenvironment is highly inflamed and characterized by the presence of an anti-tumor immune response dominated by cytotoxic\effector T cells and NK cells (CD8a, GZMA, OX40, and HLA-A); however, overexpression of genes associated with effector T cell exhaustion and microenvironmental immunosuppression was also identified (PD-1, LAG3, CXCL2). Correlations between CD3+ T cell density and immune gene expression revealed key genes associated with cytotoxic anti-tumor T cell responses (GZMA, GZMB, PRF1), co-stimulation of T cells (CD27, CD28, ICOS), and other immune processes, including Type I IFN response (TNF, TNFSF10), and T cell exhaustion (CTLA4, PD-1). CD3+ T cell density in canine OSCC was significantly correlated with a cytolytic activity score (mean PRF1 and GZMA expression), suggestive of active effector CD8 T cell function. CD204+ macrophages were the second most abundant tumor infiltrating immune cell, and when comparing to normal oral mucosa, two differently expressed genes linked to tumor associated macrophages and myeloid derived suppressor cells (MDSC) were identified: CXCL2, CD70. Overexpression of CXCL2 was also identified in canine OSCC "T cell-high" tumors compared to "T cell-low" tumors.

Discussion

This study identified actionable immunotherapy targets which could inform future comparative oncology trials in canine OSCC: CTLA-4, PD-1, CXCL2. These data provide a good first step towards utilizing spontaneous canine OSCC as a comparative model for human OSCC radiation and immuno-oncology research.

HPRT1 Most Suitable Reference Gene for Accurate Normalization of mRNA Expression in Canine Dermal Tissues with Radiation Therapy

Reference genes are crucial in molecular biological studies as an internal control for gene re-search as they exhibit consistent expression patterns across many tissue types. In canines, radiation therapy is the most important therapeutic tool to cure various diseases like cancer. However, when using radiation for therapeutic strategy, radiation exposure to healthy tissues leads to some possible side effects such as acute radiation-induced skin injury and alters gene expression. Therefore, the analysis of a change in reference gene expression during the skin recovery process after radiation therapy is essential in healthy canine tissue. In the present study, we analyzed eight reference genes (ACTB, GAPDH, YWHAZ, GUSB, HPRT1, RPL4, RPS5, and TBP) in canine dermal tissues at 0, 1, 2, 3, 4, 5, 7, and 9 weeks of radiation exposure that affected the skin condition of canines. The stability of reference genes is determined by evaluating radiation therapy’s effect on healthy canine dermal tissue. Epidermal marker, Keratin 10 expression varies each week after irradiation, and HPRT1 is found to be the most suitable for normalization of mRNA expression in radiation-exposed canine dermal tissues. Changes in the gene expression level were evaluated by using a reliable tool such as quantitative real-time polymerase chain reaction (qRT-PCR). In order to achieve a valid qRT-PCR result, the most stable reference genes used for normalization after the radiation exposure process are important. Therefore, the current study was designed to evaluate the most stable reference gene for the post-irradiation canine tissues. After radiation exposure, the alternation of reference gene expression was estimated by three algorithms (geNorm, Normfinder, and Bestkeeper). The RG validation programs (GeNorm and NormFinder) suggested that HPRT1, RPL4, and TBP were suitable for normalization in qRT-PCR. Furthermore, three algorithms suggested that HPRT1 was the most stable reference gene for normalization with qRT-PCR results, regardless of before and after radiation exposure. Whereas GAPDH was found to be the most unstable reference gene. In addition, the use of stable or unstable reference genes for the normalization of Keratin 10 expression showed statistical differences. Therefore, we observed that, to obtain accurate and suitable PCR results of the canine tissues with and without radiation exposure, the HPRT1 reference gene is recommended for normalization with its high stability. Additionally, the use of RGs such as HPRT1, RPL4, and TBP for normalization in qRT-PCR experiments is recommended for post-radiation canine tissues to generate more accurate and reliable data. These results will provide fundamental information regarding internal controls for gene expression studies and can be used for the analysis of gene patterns in regenerative medicine.

Comparison of epidermal growth factor receptor (EGFR) and cyclooxygenase-2 (COX-2) immunohistochemical expression and outcomes in canine nasal carcinomas treated with radiation therapy

The expression of epidermal growth factor receptor (EGFR) and cyclooxygenase-2 (COX-2) has been reported in human nasopharyngeal and canine nasal carcinomas. The present study measured EGFR and COX-2 expression and calculated correlations between these proteins and clinical variables and outcomes in dogs with nasal carcinoma treated with radiation therapy. Before treatment, the immunohistochemistry of EGFR and COX-2 was performed in 67 biopsied tissues from canine nasal carcinomas. The correlations between these protein levels, clinical variables, and outcomes were evaluated. EGFR and COX-2 were detected in 88.1% and 82.1% of our samples, respectively. Neither EGFR nor COX-2 was associated with T stage and cribriform plate destruction. Dogs with low EGFR levels had a significantly longer survival time than dogs with high EGFR expression (P=0.043). The COX-2 expression level was not significantly associated with survival times after radiation therapy (P=0.653). Overexpression of EGFR is negatively correlated with survival in dogs with nasal carcinoma. Future studies should identify tumor biomarkers to develop therapeutic targets for effective treatments for canine nasal carcinomas.

Stereotactic radiotherapy (10 Gy X 3) for canine nonlymphomatous intranasal tumors is associated with prolonged survival and minimal risk of severe radiotoxicity

OBJECTIVE

To describe oncologic outcomes following administration of a uniform stereotactic radiotherapy protocol (SRT; 10 Gy X 3) for canine intranasal tumors and to identify whether any clinical or dosimetric factors were predictive of event-free or overall survival time (EFST or OST).

ANIMALS

129 dogs.

PROCEDURES

In this single-institution retrospective study, the medical records database was searched for canine nonlymphomatous intranasal tumors treated with 10 Gy X 3 SRT between August 2013 and November 2020. Findings regarding adverse effects and outcomes were analyzed overall, for dogs grouped on the basis of life stage (mature adult, senior, or end of life), and for treatment-related or tumor-related variables to identify potential predictors of outcome.

RESULTS

After SRT, most dogs clinically improved with minimal acute radiotoxicity. The median EFST was 237 days; median OST was 542 days. Receipt of other tumor-directed therapies before or after SRT was associated with improved EFST in senior dogs (hazard ratio [HR], 0.416) and improved OST in mature adult (HR, 0.241) and senior dogs (HR, 0.348). In senior dogs, administration of higher near-minimum radiation doses was associated with improved EFST (HR, 0.686) and OST (HR, 0.743). In senior dogs, chondrosarcoma was associated with shorter OST (HR, 7.232), and in dogs at end of life, having a squamous cell or transitional carcinoma was associated with worse EFST (HR, 6.462).

CLINICAL RELEVANCE

This SRT protocol results in improved quality of life and prolonged OST for dogs of all life stages. Radiation protocol optimization or use of multimodal therapy may further improve outcomes.

Outcome of stereotactic body radiation for treatment of nasal and nasopharyngeal lymphoma in 32 cats

Background

The safety and efficacy of stereotactic body radiation therapy (SBRT) in the treatment of localized nasal lymphoma in cats has not been described.

Hypothesis

Stereotactic body radiation therapy with or without adjuvant chemotherapy is an effective and well‐tolerated treatment for localized nasal lymphoma in cats.

Animals

Thirty‐two client owned cats referred to Colorado State University for the treatment of nasal lymphoma.

Methods

Retrospective study of cats treated with SBRT between 2010 and 2020 at Colorado State University. Diagnosis of nasal lymphoma was obtained via cytology or histopathology. Signalment, radiation protocol, concurrent treatments, adverse effects, and survival were recorded.

Results

Progression free survival was 225 days (95% CI 98–514) and median survival time (MST) was 365 days (95% CI 123–531). No significant difference in survival was identified between cats that received 1 versus greater than 1 fraction (MST 427 vs. 123 days, P = 0.88). Negative prognostic factors included cribriform lysis (MST 121 vs. 876 days, P = 0.0009) and intracalvarial involvement (MST 100 vs. 438 days, P = 0.0007). Disease progression was noted in 38% (12/32), locally in 22% (7/32), and systemically in 16% (5/32). No cats developed acute adverse effects. Ten cats developed late adverse effects: keratitis/keratitis sicca (n = 2), alopecia (n = 4), and leukotrichia (n = 4). Twenty‐four cats (75%) had signs consistent with chronic rhinitis.

Conclusions

SBRT is effective and well tolerated for treating localized nasal lymphoma in cats. Outcomes for cats with lower stage disease (canine modified Adam's stage 3 and lower) are comparable to historic data of cats treated with fractionated radiation therapy.

Re-irradiation of canine non-lymphomatous nasal tumors using stereotactic radiation therapy (10 Gy x 3) for both courses: assessment of outcome and toxicity in 11 dogs

No uniformly beneficial treatments exist for dogs with non‐lymphomatous nasal tumours (NLNT) that relapse after radiotherapy (RT). Reirradiation may prolong survival and improve quality of life. In this retrospective study, we describe outcomes for 11 dogs that had CT‐confirmed locoregional progression of NLNT after an initial course of stereotactic RT (SRT#1; 10 Gy × 3) and were then re‐treated with the same type of protocol (SRT#2, also 10 Gy × 3). The median time between SRT #1 and SRT #2 was 243 days (95% CI: 78–385 days). Ten dogs (91%) had a clinical benefit after SRT#1; five dogs (45%) had clinical benefit after SRT#2. Adverse events after SRT#2 included nasocutaneous or oronasal fistula formation (N = 3 at 180, 270, and 468 days), seizures (N = 2 at 78 and 330 days), bacterial or fungal rhinitis (N = 2 at 240 and 385 days), and facial swelling (N = 1 at 90 days). All 11 dogs have died, due to disease progression, presumed radiotoxicity, or declining quality of life; in most cases, it was difficult to discern between these conditions. The median overall survival time (OST) from SRT#1 was 745 days (95% CI: 360–1132). The median overall survival time (OST) from SRT #2 was 448 days (95% CI: 112–626). For these dogs, survival was prolonged, but adverse events after SRT#2 were common (8/11; 73%). Therefore, before consenting to re‐irradiation with this protocol, pet owners should be counselled about survivorship challenges, including risk for severe toxicities, and persistence of clinical signs.

Dose-escalated simultaneously integrated boost radiation protocol fails to result in a survival advantage for sinonasal tumors in dogs

The prognosis for canine sinonasal tumors remains rather poor despite definitive-intent radiotherapy (RT). Theoretical calculations predicted improved outcomes with simultaneously integrated boost (SIB) protocols. With the hypothesis of clinically detectable differences in outcome between groups, our retrospective study evaluated prognostic variables and outcome in dogs treated with regular versus SIB RT. Dogs with sinonasal tumors treated with either a regular (10 × 4.2 Gy) or new SIB protocol (10 × 4.83 Gy to macroscopic tumor) were included. Information regarding signalment, tumor stage, type, clinical signs, radiation toxicity, response, and outcome was collected. Forty-nine dogs were included: 27 treated regularly and 22 treated with SIB RT. A total of 69.4% showed epistaxis, 6.1% showed epileptic seizures, 46.9% showed stage IV tumors, and 6.1% showed lymph node metastases. Early toxicity was mostly mild. Late grade 1 skin toxicity (alopecia/leucotrichia) was seen in 72.1% of dogs, and a possible grade 3 ocular toxicity (blindness) was seen in one dog. Complete/partial resolution of clinical signs was seen in 95.9% of patients as best clinical response and partial remission was seen as best imaging response in 34.7%. The median progression-free survival (PFS) was 274 days (95% CI: 117-383) for regular and 300 days (95% CI: 143-451) for SIB RT, which was not significantly different (P = 0.42). Similarly, the median overall survival (OS) was 348 days (95% CI: 121-500) for regular and 381 days (95% CI: 295-634) for the SIB RT (P = 0.18). Stratified by protocol, the hazard ratio of stage IV versus stage I-III tumors was 2.29 (95% CI: 1.156-4.551, P = 0.02) for OS but not PFS. All dogs showed acceptable toxicity. In contrast to theoretical predictions, however, we could not show a statistically significant better outcome with the new protocol.

Pilot study evaluating stereotactic body radiation therapy for feline facial squamous cell carcinomas

OBJECTIVES

The use of stereotactic body radiation therapy (SBRT) has not been assessed in advanced-stage feline solar-induced facial squamous cell carcinomas (SCCs). The objective of this study was to provide preliminary data on the use and safety profile of coarse fractions administered with an SBRT regime to manage advanced-stage feline solar-induced facial SCCs.

METHODS

This retrospective study assessed five cats diagnosed with advanced-stage solar-induced facial SCCs that received SBRT as their primary treatment or, in one cat, following failed surgical intervention. Tumour sites received three fractions totalling 26.25-27 Gy over a 3-5-day period.

RESULTS

All patients developed acute effects following SBRT including alopecia, epilation and erythema. Late effects were mild and included alopecia, variable pigmentation and leukotrichia within radiation fields. All patients were alive at the time of article submission, with overall survival times ranging from 118 to 991 days.

CONCLUSIONS AND RELEVANCE

The results suggest that coarse fractions administered with an SBRT technique is a safe and effective treatment tool for the management of advanced-stage feline solar-induced facial SCCs. These data provide preliminary evidence to support larger, prospective studies evaluating the management of feline facial SCCs with SBRT.

Comparative study of the collapsed cone convolution and Monte Carlo algorithms for radiation therapy planning of canine sinonasal tumors reveals significant dosimetric differences

Computer-based radiation therapy requires high targeting and dosimetric precision. Analytical dosimetric algorithms typically are fast and clinically viable but can have increasing errors near air-bone interfaces. These are commonly found within dogs undergoing radiation planning for sinonasal cancer. This retrospective methods comparison study is designed to compare the dosimetry of both tumor volumes and organs at risk and quantify the differences between collapsed cone convolution (CCC) and Monte Carlo (MC) algorithms. Canine sinonasal tumor plans were optimized with CCC and then recalculated by MC with identical control points and monitor units. Planning target volume (PTV)_air , PTV_{soft tissue} , and PTV_bone were created to analyze the dose discrepancy within the PTV. Thirty imaging sets of dogs were included. Monte Carlo served as the gold standard calculation for the dosimetric comparison. Collapsed cone convolution overestimated the mean dose (D_mean ) to PTV and PTV_{soft tissue} by 0.9% and 0.5%, respectively (both P < 0.001). Collapsed cone convolution overestimated D_mean to PTV_bone by 3% (P < 0.001). Collapsed cone convolution underestimated the near-maximum dose (D₂ ) to PTV_air by 1.1% (P < 0.001), and underestimated conformity index and homogeneity index in PTV (both P < 0.001). Mean doses of contralateral and ipsilateral eyes were overestimated by CCC by 1.6% and 1.7%, respectively (both P < 0.001). Near-maximum doses of skin and brain were overestimated by CCC by 2.2% and 0.7%, respectively (both P < 0.001). As clinical accessibility of Monte Carlo becomes more widespread, dose constraints may need to be re-evaluated with appropriate plan evaluation and follow-up.

Canine comparative oncology for translational radiation research

PURPOSE

Laboratory and clinical research are essential for advancing radiation research; however, there is a growing awareness that conventional laboratory animal models and early-phase clinical studies in patients have not improved the low success rates and late-stage failures in new cancer therapy efforts. There are considerable costs and inefficiencies in moving preclinical research into effective cancer therapies for patients. Canine translational models of radiation research can fill an important niche between rodent and human studies, ultimately providing valuable, predictive, translational biological and clinical results for human cancer patients. Companion dogs naturally and spontaneously develop cancers over the course of their lifetime. Many canine tumor types share important similarities to human disease, molecularly and biologically, with a comparable clinical course. Dogs receive state-of-the-art medical care, which can include radiotherapy, experimental therapeutics, and novel technologies, offering an important opportunity for radiobiology and radiation oncology research. Notably, the National Cancer Institute has developed the Comparative Oncology Program to promote this area of increased research interest.

CONCLUSION

In this review, the benefits and limitations of performing translational radiation research in companion dogs will be presented, and current research utilizing the canine model will be highlighted, including studies across research areas focusing on common canine tumor types treated with radiotherapy, comparative normal tissue effects, radiation and immunology research, and alternative radiation therapy approaches involving canine cancer patients.

Patterns of local residual disease and local failure after intensity modulated/image guided radiation therapy for sinonasal tumors in dogs

BACKGROUND

Most dogs with sinonasal tumors (SNT) treated with radiation therapy (RT) died because of local disease progression.

HYPOTHESIS/OBJECTIVES

Our hypothesis is that the majority of local failure and residual disease would occur within the radiation field.

ANIMALS

Twenty-two dogs with SNT treated with RT.

METHODS

Retrospective cohort study.

INCLUSION CRITERIA

dogs with SNT receiving 10 daily fractions of 4.2 Gy with intensity modulated radiation therapy (IMRT)/image guided radiation therapy (IGRT) and follow-up cone beam computed tomography (CBCT). Each CBCT was registered with the original radiation planning CT and the gross tumor volume (GTV) contoured. The GTV was classified as residual (GTVr) or a failure (GTVf). The dose statistic for each GTV was calculated with the original IMRT plan. For GTVf, failures were classified as "in-field," "marginal," or "out-field" if at least 95, 20-95, or less than 20% of the volume of failure was within 95% (D95) of the total prescription dose, respectively.

RESULTS

There were 52 follow-up CBCT/CTs. Overall there was a GTVr for 20 dogs and GTVf for 16 dogs. The majority of GTVr volume was within the original GTV. GTVf analysis showed that 75% (12/16) were "in-field," 19% (3/16) were "marginal" and 6% (1/16) were "out-field."

CONCLUSION AND CLINICAL IMPORTANCE

In-field failures are the main pattern for local recurrence, and there is evidence of radioresistant subvolumes within the GTV.

Retrospective evaluation of intranasal carcinomas in cats treated with external-beam radiotherapy: 42 cases

Background

Little is known regarding the comparative efficacy of various irradiation strategies used to treat intranasal carcinomas (INC) in cats.

Objectives

Investigate outcomes and prognostic factors associated with survival for cats with INC.

Animals

Forty‐two cats with INC that underwent radiotherapy (RT).

Methods

Single‐arm retrospective study. Medical record review for cats with INC that underwent RT at 1 of 7 veterinary RT facilities. Irradiation protocols categorized as: definitive‐intent fractionated RT (FRT), definitive‐intent stereotactic RT (SRT), and palliative‐intent RT (PRT). Median overall survival time (OST) and disease progression‐free survival (PFS; documented by advanced transverse imaging, or recurrence of symptoms) were calculated. Associations between tumor stage, RT protocol/intent, and adjunctive treatment usage and outcome were calculated.

Results

Cats underwent SRT (N = 18), FRT (N = 8), and PRT (N = 16). In multivariate modeling, cats received definitive‐intent treatment (DRT; FRT/SRT) had significantly longer median PFS (504 days, [95% confidence interval (CI): 428–580 days] vs PRT 198 days [95% CI: 62–334 days]; p = 0.006) and median OST [721 days (95% CI: 527–915 days) vs 284 days (95% CI: 0–570 days); p = 0.001]). Cats that underwent second DRT course at time of recurrence lived significantly longer than cats that received 1 RT course (either DRT or PRT [median OST 824 days (95% CI: 237–1410 days) vs 434 days (95% CI: 277–591 days); p = .028]).

Conclusion

In cats with INC, DRT is associated with prolonged OST and PFS as compared to PRT. If tumor progression occurs, a second course of DRT should be considered.

Neoadjuvant chemotherapy and radiation therapy in veterinary cancer treatment: a review

Multi-modality treatment strategies are more becoming commonplace in veterinary oncology practice yet the evidence base is far inferior to what has been generated in people. Surgery is unquestionably the cornerstone of most solid tumour treatment plans but certain scenarios dictate combining surgery with systemic chemotherapy and radiation therapy as an adjunct. By using these in the neoadjuvant setting, one can leverage certain effects of the treatment to improve local disease control, improve overall survival, gain insight into drug efficacy, reduce surgical morbidity and reduce long-term complications. An unintended consequence of combining therapies is an increased flow of information between members of the care team upfront that in almost all cases leads to improved patient outcomes albeit a difficult metric to quantify. This review sets out to explore some of the principles of neoadjuvant therapies and discuss potential opportunities to expand the evidence base in veterinary medicine.

Outcome of external beam radiotherapy for treatment of noncutaneous tumors of the head in horses: 32 cases (1999-2015)

Background

The long‐term outcomes of external beam radiotherapy for treatment of noncutaneous tumors of the head in horses is unknown.

Objective

To report the long‐term outcomes for treatment of noncutaneous tumors of the head of horses, and report short and long‐term clinical adverse effects.

Animals

Thirty‐two horses treated in 2 referral hospitals.

Methods

In this retrospective study, medical records of horses receiving radiation therapy for noncutaneous tumors between 1999 and 2015 were reviewed. Signalment, tumor type, treatment protocol, tumor control duration, and survival were recorded. Kaplan‐Meier survival curves were generated for overall survival (OS), by tumor type and location, and compared using Log‐rank tests, and treatment protocol adherence.

Results

Follow‐up ranged from 2 to 145 months (median 14 months). Of 32 horses, 16 (50%) were alive at the time of reporting, with complete tumor response occurring in 12 (38%). Horses with tumors of the maxilla/nasal cavity had significantly shorter median OS compared to horses with tumors in other locations (21 months vs 145 months) (P = .06). Adverse effects resulting from the tumor or the therapy occurred in 20/32 (63%). The occurrence of major adverse effects and delays in treatment protocol were not significantly associated with median survival estimates.

Conclusions and Clinical Importance

External beam radiotherapy can be used to treat a variety of noncutaneous tumors of the head of horses. Adverse effects related to radiotherapy or the tumor are common.

Treatment of nasal tumours in dogs: a review

Nasal tumours are common neoplasms in dogs and often represent a diagnostic and therapeutic challenge due to their confined location within the nasal cavities. The main goal of this review is to extract the most relevant information from a wide and often confusing evidence-based medicine on the treatment of canine nasal tumours and conclude with current recommendations. This report highlights the different therapeutic modalities available and describes their technical aspects, interests and limitations. Megavoltage radiotherapy, as the most recent treatment and standard of care, is particularly examined, especially the different types of radiotherapy units, the main protocols used and their advantages and limits. Newer and non-conventional treatments are also discussed.

Definitive-intent intensity modulated radiotherapy for modified-Adams' stage 4 canine sinonasal cancer: A retrospective study of 29 cases (2011-2017)

Dogs with sinonasal tumors with cribriform plate lysis (modified Adams' stage 4) treated with non-conformal definitive radiotherapy (RT) have short median survivals of 6-7 months. Intensity-modulated radiotherapy with its greater conformality and tumor dose homogeneity may result in more favorable outcomes. Dogs with epithelial or mesenchymal sinonasal tumors and CT evidence of cribriform lysis that received 10 daily fractions of 4.2 Gray using IMRT by helical tomotherapy were included in this single-institution retrospective case series study. Dogs with distant metastasis, previous treatment, or concurrent chemotherapy were excluded. Based on CT, tumors were divided into two groups: cribriform plate lysis only (stage 4a) or intracranial extension (stage 4b). Twenty-nine dogs were included, 23 with carcinoma and six with sarcoma. Eight dogs had stage 4b tumors; two presented with neurologic signs. Two dogs had lymph node metastasis at diagnosis, one confirmed and one suspected. Radiation dose distributions were standardized and patient positioning for RT was verified daily using on-board megavoltage CT. All evaluable dogs had improvement of clinical signs. Median progression free survival was 177 days (95% CI, 128-294 days). Median overall survival was 319 days (95% CI, 188-499 days). Radiotherapy was well tolerated. The most common side effect was grade 1 or 2 oral mucositis. Two dogs that received additional treatment at progression (stereotactic RT [1]; surgery [1]) developed significant late effects. Image-guided definitive-intent IMRT may improve survival in dogs with modified Adams' stage 4 sinonasal tumors and is associated with low morbidity. Intracranial tumor extension was not prognostic in this cohort of uniformly treated dogs.

Volumetric tumor response assessment is inefficient without overt clinical benefit compared to conventional, manual veterinary response assessment in canine nasal tumors

Accurate assessment of tumor response to therapy is critical in guiding management of veterinary oncology patients and is most commonly performed using response evaluation criteria in solid tumors criteria. This process can be time consuming and have high intra- and interobserver variability. The primary aim of this serial measurements, secondary analysis study was to compare manual linear tumor response assessment to semi-automated, contoured response assessment in canine nasal tumors. The secondary objective was to determine if tumor measurements or clinical characteristics, such as stage, would correlate to progression-free interval. Three investigators evaluated paired CT scans of skulls of 22 dogs with nasal tumors obtained prior to and following radiation therapy. The automatically generated tumor volumes were not useful for canine nasal tumors in this study, characterized by poor intraobserver agreement between automatically generated contours and hand-adjusted contours. The radiologist's manual linear method of determining response evaluation criteria in solid tumors categorization and tumor volume is significantly faster (P < .0001) but significantly underestimates nasal tumor volume (P < .05) when compared to a contour-based method. Interobserver agreement was greater for volume determination using the contour-based method when compared to response evaluation criteria in solid tumors categorization utilizing the same method. However, response evaluation criteria in solid tumors categorization and percentage volume change were strongly correlated, providing validity to response evaluation criteria in solid tumors as a rapid method of tumor response assessment for canine nasal tumors. No clinical characteristics or tumor measurements were significantly associated with progression-free interval.

Ocular and periocular radiation toxicity in dogs treated for sinonasal tumors: A critical review

Visual impairment from radiation‐induced damage can be painful, disabling, and reduces the patient's quality of life. Ocular tissue damage can result from the proximity of ocular organs at risk to irradiated sinonasal target volumes. As toxicity depends on the radiation dose delivered to a certain volume, dose‐volume constraints for organs at risk should ideally be known during treatment planning in order to reduce toxicity. Herein, we summarize published ocular toxicity data of dogs irradiated for sinonasal tumors from 36 publications (1976‐2018). In particular, we tried to extract a dose guideline for a clinically acceptable rate of ocular toxicity. The side effects to ocular and periocular tissues were reported in 26/36 studies (72%) and graded according to scoring systems (10/26; 39%). With most scoring systems, however, toxicities of different ocular and periocular tissues are summed into one score. Further, the scores were mostly applied in retrospect and lack volume‐ and dose‐data. This incomplete information reflects the crux of the matter for radiation dose tolerance in canine ocular tissues: The published information of the last three decades does not allow formulating dose‐volume guidelines. As a start, we can only state that a mean dose of 39 Gy (given in 10 x 4.2 Gy fractions) will lead to loss of vision by one or both eyes, while mean doses of <30 Gy seem to preserve functionality. With a future goal to define tolerated doses and volumes of ocular and periocular tissues at risk, we propose the use of combined ocular toxicity scoring systems.

Outcome of intensity-modulated radiation therapy-based stereotactic radiation therapy for treatment of canine nasal carcinomas

Stereotactic radiation therapy (SRT) has emerged as a convenient definitive treatment modality in veterinary medicine, but few studies exist evaluating outcome with treatment for canine nasal tumors, and no studies report the treatment of one single tumor histotype. This retrospective, observational study evaluates toxicity, response, and survival in 17 dogs with nasal carcinomas treated with SRT. Dogs received a median of 3000 centigray in three fractions via 6-MV linear accelerator. Eighty-eight percent of patients (n = 15) demonstrated clinical benefit. Of dogs with repeated CT imaging (n = 10), 60% (n = 6) achieved a partial response and 10% (n = 1) achieved a complete response. Median progression-free survival (PFS) was 359 days. Median survival time (MST) was 563 days. Among dogs evaluable for acute toxicity, 50% (n = 10) developed low grade toxicity (grade 1, n = 4; grade 2, n = 1). No patients developed grade 3 toxicity. 16 dogs (87%) evaluable over the long term developed signs consistent with possible late toxicity. The majority of late toxicities were mild (alopecia, hyperpigmentation, and leukotrichia n = 10; ocular discharge and keratoconjunctivitis sicca n = 5). Thirty-seven percent of patients (n = 6) developed seven possible grade 3 late toxicities (blindness, n = 3; fistula, n = 1; seizures, n = 3), which were difficult to distinguish from progressive disease in most patients. Of the prognostic factors evaluated (demographics, tumor stage, dosimetric data, epistaxis, facial deformity, clinical response, image-based response, nonsteroidal anti-inflammatory drugs, and chemotherapy), only clinical response was a positive prognostic factor on MST (P < .00). No factors were found to be significantly associated with PFS.

Outcome and Metastatic Behavior of Canine Sinonasal Osteosarcoma (2005-2015)

Sinonasal neoplasms in dogs behave locally aggressively, and metastatic disease has not been a common cause of death. The metastatic rate of sinonasal osteosarcoma (OSA) is not well characterized, and reported outcomes of these patients are variable. The purpose of this study is to evaluate the outcome and metastatic behavior of canine sinonasal OSA. Medical records of canine patients diagnosed with sinonasal OSA via histopathology between January 2005 and December 2015 were reviewed. Patients with any form of treatment or no treatment were included. Time to local progression, time to metastasis, and overall survival data were evaluated. Variables that may impact outcome, such as tumor stage and treatment type, were evaluated. Twenty-seven dogs were identified that fit the inclusion criteria. Overall, 30.0% of dogs developed metastasis over the disease course, with a median time to metastasis of 458 days (95% confidence interval [CI] 318-758 days). The median time to local progression was 335 days (95% CI 264-544 days). The overall median survival time was 410 days (95% CI 341-627 days). Regarding metastasis, sinonasal OSA behaves similarly to sinonasal neoplasms of other histologies and dissimilarly to appendicular OSA. The outcome of treated patients appears similar to that of sinonasal tumor patients with other histologies.

Radiotherapy isocenters verified by matching to bony landmarks of the canine and feline head differ when localized using volumetric versus planar imaging

The "gold standard" for verification of patient positioning before linear accelerator-based stereotactic radiation therapy is kilovoltage cone-beam computed tomography (kV-CBCT), which is not uniformly available or utilized; planar imaging is sometimes used instead. The primary aim of this study was to determine if the position of the bony skull, when used as a surrogate for isocenter verification, is different when orthogonal megavoltage (MV) portal or kilovoltage (kV/kV) radiographs are used for image guidance, rather than kV-CBCT. A secondary aim was to determine the influence of intra-observer variability, body size and skull conformation on positioning, as determined using these three imaging modalities. Dogs and cats receiving radiotherapy of the head were recruited for this prospective analytical study. Planar (MV portal and kV/kV images) and volumetric (kV-CBCT) images were acquired before treatment, and manually coregistered with reference images. Differences in skull position when matched based on MV portal, kV/kV images and kV-CBCT were compared. A total of 65 subjects and 148 unique datasets were evaluated. The Wilcoxon rank-sum test was used to evaluate effects of transitioning between imaging modalities. When comparing magnitude of shifts in MV to kV-CBCT, MV to kV/kV and kV/kV to kV-CBCT, there were statistically significant differences. Results were not measurably impacted by body size, skull conformation or interobserver differences. Based on shift magnitude and direction, an isotropic setup margin of at least 1 mm should be incorporated within the planning target volume when MV or kV planar imaging is used for position verification.

Changes in target volume during irradiation of canine intranasal tumors can significantly impact radiation dosimetry

Nasal tumor size can change during radiation therapy (RT). The amount of peritumoral fluid (eg, mucohemorrhagic effusions) can also fluctuate. How often this occurs and the magnitude of change are unknown. Likewise, there are no data which describe dosimetric effects of these changing volumes during a course of RT in veterinary medicine. This study addresses that gap in knowledge. Using pet dogs with nasal tumors, three CT image sets were created. Different Hounsfield units were applied to the gross tumor volume (GTV) of each image set: unchanged, -1000 (AIR), -1000 (to the portion of the GTV that actually underwent volume reduction during clinical RT; REAL). Two plans were created: 18-fraction three-dimensional conformal RT (3DCRT) and three-fraction intensity-modulated stereotactic RT (IM-SRT). For nearby normal tissues and GTV, near-maximum doses (D_2% and D_5% ) and volumes receiving clinically significant doses were recorded. To verify "AIR" results, thermoluminescent dosimeters recorded dose in cadavers that were irradiated using both 3DCRT and IM-SRT plans. "AIR" scenario had ≤1.5 Gray (Gy) increases in D_2% and ≤3.2 cc increases of volume. "REAL" scenario had ≤0.97 Gy increases in D_5% and ≤0.55 cc increases of volume at clinically relevant doses. Both were statistical significant. Results suggest that near-complete resolution of GTV warrants plan revision.

Update in Veterinary Radiation Oncology: Focus on Stereotactic Radiation Therapy

Stereotactic radiotherapy (SRT) involves the precise delivery of highly conformal, dose-intense radiation to well-demarcated tumors. Special equipment and expertise are needed, and a unique biological mechanism distinguishes SRT from other forms of external beam radiotherapy. Families find the convenient schedules and minimal acute toxicity of SRT appealing. Common indications in veterinary oncology include nasal, brain, and bone tumors. Many other solid tumors can also be treated, including spinal, oral, lung, heart-base, liver, adrenal, and prostatic malignancies. Accessibility of SRT is improving, and new data are constantly emerging to define parameters for appropriate case selection, radiation dose prescription, and long-term follow-up."

Imaging in Non-neurologic Oncologic Treatment Planning of the Head and Neck

Imaging is critical for the diagnosis and staging of veterinary oncology patients. Although cytology or biopsy is generally required for diagnosis, imaging characteristics inform the likelihood of a cancer diagnosis, can result in a prioritized list of differentials that guide further staging tests, and assist in the planning of surgery, radiation, and chemotherapy options. Advanced imaging, such as CT and MRI, can better define the extent of disease for surgical and radiation planning for head and neck cancer cases in particular. Additionally, new imaging technologies are continually being translated into veterinary fields, and they may provide more options for cancer patients as they become more widely available.

Prognostic significance of midline shift of the olfactory or frontal lobes of the brain in canine nasal carcinomas treated by palliative radiotherapy: a pilot study

Canine nasal carcinomas are often treated with radiotherapy. Presence of lysis of the cribriform plate by tumor invasion (stage 4 by modified Adams’s staging system) is a well-known prognostic factor. In this study, dogs with stage 4 disease were divided into two subgroups based on the presence or absence of midline shift of the olfactory or frontal lobes of the brain (Stage 4a: without presence of midline shift. Stage 4b: with midline shift). The median survival time of dogs with midline shift was significantly shorter than that of dogs without midline shift (64 vs. 208 days). Our results indicate that the finding of a midline shift might have a prognostic significance in dogs with nasal carcinoma treated with radiotherapy.

A survey of stereotactic radiation therapy in veterinary medicine

Radiotherapy plays an important role in curative and palliative cancer treatment. As a novel radiation delivery technique, stereotactic radiotherapy utilizes three-dimensional-conformal treatment planning, high-precision beam delivery technology, and patient specific position verification to target tumors, often in one to five high-dose fractions. Currently, there is no consensus about best stereotactic radiotherapy practices in veterinary radiotherapy. The objective of this study was to document the breadth of perspectives, techniques, and applications of stereotactic radiotherapy in veterinary medicine. We conducted an online survey of American College of Veterinary Radiology members specializing in radiation oncology to assess how, when, and why stereotactic radiotherapy is being used. Both stereotactic radiotherapy users and nonusers completed the survey. The overall response and survey completion rates were 54% (67/123) and 87% (58/67), respectively. Overall, 55% of respondents reported providing stereotactic radiotherapy at their facility, with a median of 4.5 canine cases and one feline case per month. Delivery methods included C-arm linear accelerator with multi-leaf collimator, helical tomotherapy, and CyberKnife. Nonpituitary intracranial tumors, pituitary tumors, and sinonasal tumors were the most common cancers treated using stereotactic radiotherapy in both species. The most common fractionation scheme was three fractions of 10 Gy/fraction. The results of this survey suggest common availability of stereotactic radiotherapy in veterinary radiation facilities. These results provide valuable information regarding current stereotactic radiotherapy practices in veterinary medicine, and may provide an initial step toward standardizing methods and establishing consensus guidelines.

Stereotactic radiation therapy for the treatment of functional pituitary adenomas associated with feline acromegaly

Background

Conventional fractionated radiotherapy has been shown to be partially effective for management of pituitary tumors in cats that cause acromegaly and diabetes mellitus (DM), but, the efficacy and safety of stereotactic radiation therapy (SRT) as a treatment for acromegalic cats has not been described.

Hypothesis

Stereotactic radiation therapy is an effective and safe treatment for controlling acromegaly associated with pituitary adenomas in cats. Additionally, SRT‐treated acromegalic cats with DM will experience a decrease in insulin requirements after radiation therapy.

Animals

Fifty‐three client‐owned cats referred to Colorado State University for SRT to treat pituitary tumors causing poorly controlled DM secondary to acromegaly.

Methods

Retrospective study of cats treated for acromegaly with SRT between 2008 and 2016 at Colorado State University. Diagnosis of acromegaly was based on history, physical examination, laboratory results, and cross‐sectional imaging of the pituitary. Signalment, radiation protocol, insulin requirements over time, adverse effects, and survival were recorded.

Results

Median survival time was 1072 days. Of the 41 cats for which insulin dosage information was available, 95% (39/41) experienced a decrease in required insulin dose, with 32% (13/41) achieving diabetic remission. Remission was permanent in 62% (8/13) and temporary in 38% (5/13) cats. Median duration to lowest insulin dose was 9.5 months. Of the treated cats, 14% developed hypothyroidism and required supplementation after SRT.

Conclusions

Stereotactic radiation therapy is safe and effective for treating cats with acromegaly. Cats treated with SRT have improved survival time and control of their DM when compared to previously reported patients treated with non‐SRT.