Advances in personalized radiotherapy

Radiotherapy is a mainstay of cancer treatment. The clinical response to radiotherapy is heterogeneous, from a complete response to early progression. Recent studies have explored the importance of patient characteristics in response to radiotherapy. In this editorial, we invite contributions for a BMC Cancer collection of articles titled 'Advances in personalized radiotherapy' towards the improvement of treatment response.

Radiation Therapy Planning Using Fibroblast Activation Protein Inhibitor

Computed tomography (CT), MR imaging, and PET with fluorodeoxyglucose F18/CT are commonly used for radiation therapy planning; however, issues including precise nodal staging on CT or false positive results on PET/CT limit their usability. Clinical trials using fibroblast activation protein ligands for additional imaging have provided promising results regarding staging and target volume delineation-particularly suitable for sarcoma, some gastrointestinal tumors, head and neck tumors, and lung and pancreatic cancer. Although further prospective trials are necessary to identify clinical settings for its application in radiation oncology, fibroblast activation protein inhibitor PET/CT indisputably represents an excellent opportunity for assisting radiotherapy planning.

A Century of Fractionated Radiotherapy: How Mathematical Oncology Can Break the Rules

Radiotherapy is involved in 50% of all cancer treatments and 40% of cancer cures. Most of these treatments are delivered in fractions of equal doses of radiation (Fractional Equivalent Dosing (FED)) in days to weeks. This treatment paradigm has remained unchanged in the past century and does not account for the development of radioresistance during treatment. Even if under-optimized, deviating from a century of successful therapy delivered in FED can be difficult. One way of exploring the infinite space of fraction size and scheduling to identify optimal fractionation schedules is through mathematical oncology simulations that allow for in silico evaluation. This review article explores the evidence that current fractionation promotes the development of radioresistance, summarizes mathematical solutions to account for radioresistance, both in the curative and non-curative setting, and reviews current clinical data investigating non-FED fractionated radiotherapy.

Contemporary radiotherapy: present and future

Oncology care is increasingly a multidisciplinary endeavour, and radiation therapy continues to have a key role across the disease spectrum in nearly every cancer. However, the field of radiation oncology is still one of the most poorly understood of the cancer disciplines. In this Review, we attempt to summarise and contextualise developments within the field of radiation oncology for the non-radiation oncologist. We discuss advancements in treatment technologies and imaging, followed by an overview of the interplay with advancements in systemic therapy and surgical techniques. Finally, we review new frontiers in radiation oncology, including advances within the metastatic disease continuum, reirradiation, and emerging types of radiation therapy.

Moving Forward in the Next Decade: Radiation Oncology Sciences for Patient-Centered Cancer Care

In a time of rapid advances in science and technology, the opportunities for radiation oncology are undergoing transformational change. The linkage between and understanding of the physical dose and induced biological perturbations are opening entirely new areas of application. The ability to define anatomic extent of disease and the elucidation of the biology of metastases has brought a key role for radiation oncology for treating metastatic disease. That radiation can stimulate and suppress subpopulations of the immune response makes radiation a key participant in cancer immunotherapy. Targeted radiopharmaceutical therapy delivers radiation systemically with radionuclides and carrier molecules selected for their physical, chemical, and biochemical properties. Radiation oncology usage of “big data” and machine learning and artificial intelligence adds the opportunity to markedly change the workflow for clinical practice while physically targeting and adapting radiation fields in real time. Future precision targeting requires multidimensional understanding of the imaging, underlying biology, and anatomical relationship among tissues for radiation as spatial and temporal “focused biology.” Other means of energy delivery are available as are agents that can be activated by radiation with increasing ability to target treatments. With broad applicability of radiation in cancer treatment, radiation therapy is a necessity for effective cancer care, opening a career path for global health serving the medically underserved in geographically isolated populations as a substantial societal contribution addressing health disparities. Understanding risk and mitigation of radiation injury make it an important discipline for and beyond cancer care including energy policy, space exploration, national security, and global partnerships.

Implications of Radiotherapy Utilization in Korea from 2010 to 2019

BACKGROUND

This study was to assess the rate of radiotherapy (RT) utilization according to the modality in South Korea to identify the implications of contemporary RT patterns.

METHODS

We collected information from claims and reimbursement records of the National Health Insurance Service from 2010 to 2019. We classified the location of each institution as capital (Seoul, Incheon, and Gyeonggi-do) and non-capital areas.

RESULTS

The rate of RT utilization in total cancer patients nationwide was 24.5% in 2010, which consistently has increased to 36.1% in 2019 (annual increase estimate [AIE], 4.5%). There was an abrupt increase in patients receiving intensity-modulated RT (IMRT), with an AIE of 33.5%, and a steady decline in patients receiving three-dimensional conformal RT (3DCRT), with an AIE of -7.1%. The commonest RT modality was IMRT (44.5%), followed by 3DCRT and stereotactic RT (SRT) (37.2% and 13.5%) in 2019. An increasing trend of advanced RT (such as IMRT and SRT) utilization was observed regardless of the region, although the AIE in the capital areas was slightly higher than that in non-capital areas.

CONCLUSION

The utilization of overall RT application and especially of advanced modalities remarkably increased from 2010 to 2019. We also found gaps in their AIEs between capital and non-capital areas. We should ensure that advanced RT is accessible to all cancer patients across South Korea.

Radiation therapy in head and neck cancer

This review summarizes the beginning of radiotherapy, techniques of modern radiation therapy with different types, toxicities induced by radiotherapy and their management. Head and neck radiation therapy is still improving for the better management and control of the cancer and induced radiotherapy toxicities.

[Application and Development Trend of Medical Image Automatic Segmentation Technology in Radiation Therapy]

The development of medical image segmentation technology has been briefly reviewed. The applications of auto-segmentation of organs at risk and target volumes based on Atlas and deep learning in the field of radiotherapy have been introduced in detail, respectively. Then the development direction and product model for general automatic sketching tools or systems based on solid clinical data are discussed.

Trends in Use and Comparison of Stereotactic Body Radiation Therapy, Brachytherapy, and Dose-Escalated External Beam Radiation Therapy for the Management of Localized, Intermediate-Risk Prostate Cancer

This cohort study examines trends in the use of brachytherapy, external beam radiotherapy, and stereotactic body radiation therapy for disease management in patients with localized prostate cancer and compares outcomes between these therapies.

Evaluation of Use of Shorter Radiation Regimens for Breast and Prostate Cancer in the US, 2015-2017

This cross-sectional study examines the usage rates and trends of shorter vs longer radiation regimens for breast cancer and prostate cancer treatments in the US.

Association of Innovations in Radiotherapy and Systemic Treatments With Clinical Outcomes in Patients With Melanoma Brain Metastasis From 2007 to 2016

IMPORTANCE

Treatments for melanoma brain metastasis changed between 2007 and 2016 with the advent of new radiotherapy techniques, targeted therapeutic agents, and immunotherapy. Changes in clinical outcomes over time have not been systematically investigated in large population-based studies.

OBJECTIVE

To investigate the association of innovations in radiotherapy techniques and systemic therapies with clinical outcomes among patients with melanoma brain metastasis.

DESIGN, SETTING AND PARTICIPANTS

This population-based cohort study included all patients who received radiotherapy and/or surgery for the treatment of melanoma brain metastasis in Ontario, Canada, between January 1, 2007, and June 30, 2016. Brain treatment patterns and clinical outcomes were described by period (2007-2009, 2010-2012, and 2013-2016). Provincial administrative records were used to obtain data on surgery, radiotherapy, and drugs. Follow-up data were censored on August 31, 2016. A Kaplan-Meier analysis and multivariable Cox regression analyses were performed. Data were analyzed between November 8, 2017 and May 13, 2020.

MAIN OUTCOMES AND MEASURES

Overall survival, whole-brain radiotherapy-free survival, and time to subsequent brain treatment.

RESULTS

A total of 1096 patients (mean [SD] age, 61.7 [14.0] years; 751 men [68.5%]) with melanoma brain metastasis received treatment in Ontario between January 1, 2007, and June 30, 2016. Of those, 326 patients received treatment from 2007 to 2009 (period 1), 310 patients received treatment from 2010 to 2012 (period 2), and 460 patients received treatment from 2013 to 2016 (period 3). Patient age, other sociodemographic characteristics, and disease factors were similar between periods. Whole-brain radiotherapy was the first local brain-directed treatment used in 246 patients (75.5%; 95% CI, 70.8%-80.1%) in period 1, decreasing to 239 patients (52.0%; 95% CI, 47.4%-56.5%) in period 3. The use of partial-brain radiotherapy techniques as the first treatment increased from 11 patients (3.4%; 95% CI, 1.4%-5.3%) in period 1 to 98 patients (21.3%; 95% CI, 17.6%-25.0%) in period 3. After the first treatment for melanoma brain metastasis, the use of BRAF and MEK inhibitors and immunotherapy increased from less than 6 patients (<1.8%; 95% CI, <0.4% to <3.3%) in period 1 to 188 patients (40.9%; 95% CI, 36.4%-45.4%) in period 3. Overall survival was greater in period 3 (1-year survival, 21.8% [95% CI, 17.9%-25.9%] and 2-year survival, 13.8% [95% CI, 10.4%-17.8%]; Wilcoxon P = .001) compared with period 1 (1-year survival, 12.3% [95% CI, 9.0%-16.1%] and 2-year survival, 6.4% [95% CI, 4.1%-9.5%]), with an adjusted hazard ratio (aHR) of 0.65 (95% CI, 0.56-0.77). The findings were unchanged after accounting for the variation in imaging practice between periods. Between period 1 and period 3, the use of whole-brain radiotherapy decreased (aHR, 0.32; 95% CI, 0.22-0.46), and the use of multiple brain-directed treatments increased (aHR, 2.16; 95% CI, 1.48-3.14).

CONCLUSIONS AND RELEVANCE

These findings suggest that innovations in systemic therapy and radiotherapy are associated with improvements in clinical outcomes among patients with melanoma brain metastasis, even in population-wide routine practice. Overall survival improved over time, and the use of whole-brain radiotherapy decreased. However, many patients continued to receive whole-brain radiotherapy in the last period (2013-2016) examined.

Next-generation therapies for adrenocortical carcinoma

Almost one decade ago, etoposide, doxorubicin, cisplatin and mitotane (EDP-M) has been established as first-line systemic therapy of metastatic adrenocortical carcinoma (ACC). Although heterogeneous, the prognosis of advanced stage ACC is still poor and novel treatments are urgently needed. This article provides a short summary of current systemic ACC treatment and provides a comprehensive overview of new therapeutic approaches that have been investigated in the past years, including drugs targeting the IGF pathway, tyrosine kinase inhibitors, radionuclide treatment, and immunotherapy. The results of most of these trials were disappointing and we will discuss possible reasons why these drugs failed (e.g. drug interactions with mitotane, disease heterogeneity with exceptional responses in very few patients, and resistance mechanisms to immunotherapy). We then will present potential new drug targets that have emerged from many molecular studies (e.g. wnt/β-catenin, cyclin-dependent kinases, PARP1) that may be the foundation of next-generation therapies of ACC.

Meeting report on ICRR2019, the 16th International Congress on Radiation Research

The 16th International Congress of Radiation Research (ICRR2019) was held in Manchester, UK, in August 2019. The Congress, which is held every four years, covered a wide spectrum of topics relevant for all aspects of radiation research including basic mechanisms, translational research, radiotherapy and health effects, and ecology. Here, we provide a report of the plenary and keynote talks presented at the meeting.

The evolving role of radiotherapy in non-small cell lung cancer

Lung cancer is the most commonly diagnosed cancer and biggest cause of cancer mortality worldwide with non-small cell lung cancer (NSCLC) accounting for most cases. Radiotherapy (RT) plays a key role in its management and is used at least once in over half of patients in both curative and palliative treatments. This narrative review will demonstrate how the evolution of RT for NSCLC has been underpinned by improvements in RT technology. These improvements have facilitated geometric individualization, increasingly accurate treatment and now offer the ability to deliver truly individualized RT. In this review, we summarize and discuss recent developments in the field of advanced RT in early stage, locally advanced and metastatic NSCLC. We highlight limitations in current approaches and discuss future potential treatment strategies for patients with NSCLC.

Anal Squamous Cell Carcinoma: Radiation Therapy Alone Must Be Avoided

BACKGROUND

Anal squamous cell carcinoma (ASCC) is the most common histological subtype of anal cancer. Rates have been observed to increase in recent years. Combined chemoradiotherapy (CCRT) is currently the gold standard of treatment. The aim of this study is to assess ASCC prevalence, treatment trends, and overall survival (OS) in the United States.

METHODS

Patients diagnosed with stage I-IV ASCC were identified from the National Cancer Database from 2004 to 2015. The primary outcome was 5-year OS, which was analyzed using Kaplan-Meier survival curves, log-rank test, and Cox proportional hazards models.

RESULTS

34,613 cases were included (stage I: 21.45%; II: 41.00%; III: 31.62%; IV: 5.94%), with an increasing trend in prevalence. CCRT was the most used treatment. Multimodal treatment, combining surgery with CCRT, offered the best OS rates for stage I, II, and IV cancers (I: 84.87%; II: 75.12%; IV: 33.08%), comparable with survival of stage III patients treated with CCRT (III: 61.14%). Radiation alone had the worse OS rates, and on adjusted analysis, radiation treatment alone had the greatest risk of mortality (I: hazard ratio, 2.01; 95% confidence interval, 1.14-3.54; P = 0.016; II: 2.05, 1.44-2.93, P < 0.001; IV: 1.99, 0.99-4.02, P = 0.054).

CONCLUSIONS

ASCC has increased in prevalence, notably in stage III and IV disease. Although CCRT is the most commonly used treatment type for all stages of ASCC, multimodal treatment offers better OS in stages I, II, and IV. Treatment with radiation alone offers the worst OS no matter the stage and should no longer be used as a solitary treatment modality.

Factual survey of the clinical use of deformable image registration software for radiotherapy in Japan

Deformable image registration (DIR) has recently become commercially available in the field of radiotherapy. However, there was no detailed information regarding the use of DIR software at each medical institution. Thus, in this study, we surveyed the status of the clinical use of DIR software for radiotherapy in Japan. The Japan Society of Medical Physics and the Japanese Society for Radiation Oncology mailing lists were used to announce this survey. The questionnaire was created by investigators working under the research grant of the Japanese Society for Radiation Oncology (2017-2018) and intended for the collection of information regarding the use of DIR in radiotherapy. The survey was completed by 161 institutions in Japan. The survey results showed that dose accumulation was the most frequent purpose for which DIR was used in clinical practice (73%). Various commissioning methods were performed, although they were not standardized. Qualitative evaluation with actual patient images was the most commonly used method (28%), although 30% of the total number of responses (42% of institutions) reported that they do not perform commissioning. We surveyed the current status of clinical use of DIR software for radiotherapy in Japan for the first time. Our results indicated that a certain number of institutions used DIR software for clinical practice, and various commissioning methods were performed, although they were not standardized. Taken together, these findings highlight the need for a technically unified approach for commissioning and quality assurance for the use of DIR software in Japan.

Funding for radiation research: past, present and future

For more than a century, ionizing radiation has been indispensable mainly in medicine and industry. Radiation research is a multidisciplinary field that investigates radiation effects. Radiation research was very active in the mid- to late 20th century, but has then faced challenges, during which time funding has fluctuated widely. Here we review historical changes in funding situations in the field of radiation research, particularly in Canada, European Union countries, Japan, South Korea, and the US. We also provide a brief overview of the current situations in education and training in this field. A better understanding of the biological consequences of radiation exposure is becoming more important with increasing public concerns on radiation risks and other radiation literacy. Continued funding for radiation research is needed, and education and training in this field are also important.

Use of Active Surveillance or Watchful Waiting for Low-Risk Prostate Cancer and Management Trends Across Risk Groups in the United States, 2010-2015

This cancer epidemiology study uses SEER data to examine US trends in use of active surveillance, watchful waiting, radiotherapy, and surgical management of localized prostate cancer among men with low-, intermediate-, and high-risk disease treated between 2010 and 2015.

Radiotherapy and immune response: the systemic effects of a local treatment

Technological developments have allowed improvements in radiotherapy delivery, with higher precision and better sparing of normal tissue. For many years, it has been well known that ionizing radiation has not only local action but also systemic effects by triggering many molecular signaling pathways. There is still a lack of knowledge of this issue. This review focuses on the current literature about the effects of ionizing radiation on the immune system, either suppressing or stimulating the host reactions against the tumor, and the factors that interact with these responses, such as the radiation dose and dose / fraction effects in the tumor microenvironment and vasculature. In addition, some implications of these effects in cancer treatment, mainly in combined strategies, are addressed from the perspective of their interactions with the more advanced technology currently available, such as heavy ion therapy and nanotechnology.

Recent advances in managing brain metastasis

Brain metastases are the most common malignancy encountered in the central nervous system (CNS), with up to 30-40% of cancer patients developing brain metastases at some point during the course of their disease. The management of brain metastasis is rapidly evolving and the roles of local therapies such as whole-brain radiation therapy, stereotactic radiosurgery, and resection along with systemic therapies are in flux. An emphasis on the neurocognitive side effects associated with treatment has gained prominence. Novel molecular studies have demonstrated important evolutionary patterns underpinning the development of brain metastasis and leptomeningeal disease, which may be key to unlocking new therapeutic strategies. This article provides a framework for incorporating the results of recent randomized radiotherapy clinical trials into practice, expounds upon the emphasis on cognition being an important driver in therapeutic selection, describes the importance of CNS-penetrating systemic therapies, and provides an overview of the novel molecular insights that will likely set the stage for future developments in this field.

Peptide Receptor Radiotherapy Comes of Age

Peptide receptor radionuclide therapy is a form of systemic radiotherapy shown to be effective in treating neuroendocrine tumors expressing somatostatin receptors. The NETTER-1 trial was the first randomized phase III clinical trial evaluating a radiolabeled somatostatin analog, and demonstrated significant improvement in progression-free survival among patients with midgut neuroendocrine tumors treated with ¹⁷⁷Lu-DOTATATE versus high-dose octreotide. This article discusses the evolution of peptide receptor radionuclide therapy, side effects, and potential future treatment approaches.

[Implementation of innovations in healthcare: radiotherapy as an example]

The implementation of innovations is considered necessary in healthcare, both for improving patient outcomes and services and to reduce costs. Two problems can occur during the implementation process: innovations that have not been properly evaluated in terms of patient outcomes or cost-effectiveness can sometimes spread quickly, whereas innovations that have shown to lead to significant improvements in a research study setting may struggle to find their way into clinical practice. Problems may also arise when organizational innovations are implemented that are not evidence-based: an example would be the implementation of a new ICT system that affects the patient's environment negatively upon introduction. In this article, the problems surrounding innovation implementation in medical care are described in general and in more concrete terms, we describe how Dutch radiotherapy centres perform in this area. Based on the findings, a systematic plan is described that can help to innovate more effectively and efficiently to the benefit of clinical practice in all disciplines.

Hadrontherapy in the World and the Programmes of the Tera Foundation

Hadrontherapy was born in 1938, when neutron beams were used in cancer therapy, but it has become an accepted therapeutical modality only in the last five years. Fast neutrons are still in use, even if their limitations are now apparent. Charged hadron beams are more favorable, since the largest specific energy deposition occurs at the end of their range in matter. The most used hadrons are at present protons and carbon ions. Both allow a dose deposition which conforms to the tumour target. Radiobiological experiments and the results of the first clinical trials indicate that carbon ions have, on top of this macroscopic property, a different way of interacting with cells at the microscopic level. There are thus solid hopes to use carbon beams of about 4500 MeV to control tumours which are radioresistant both to X-rays and protons. After discussing these macroscopic and microscopic properties of hadrontherapy, the hospital-based facilities, running or under construction, are reviewed. The conclusion is that, while in USA and Japan twelve of these centres will be running around the year 2001, in Europe very little is foreseen to use hadrontherapy to treat deep-seated tumours. The most advanced programme is the Italian one, which is described in the last Sections of the report. The main activities concern the construction, near Milano, of a centre for protons and carbon ions called CNAO (National Centre for Oncological Hadrontherapy) and the development of new type of proton accelerators. The Istituto Superiore di Sanità in Rome obtained the initial financing for constructing, in collaboration with ENEA, a 3 GHz linac, which eventually will accelerate protons to 200 MeV, so as to allow deep protontherapy. These, and other hadrontherapy centres in Italy and Europe, will be connected with oncology centres, hospitals and clinics by a multimedial network called RITA, so that before referral each patient's case can be discussed directly by doctors, even located far away, with the experts sitting in the hadrontherapy centres.

Radiotherapy with Heavy Ions: Radiobiology, Clinical Indications and Experience at GSI, Darmstadt

In the history of external beam radiotherapy, the trend for a better conformation as well as for a higher biological efficiency has been the driving force for the improvement of clinical results. However, these two goals had to be followed with separate types of radiation, i.e. photons and neutrons, and could not be combined. For the first time being, beams of heavy ions like carbon offer the possibility to combine both advantageous properties: better targeting and higher biological efficiency. Particle beams have an inverse depth dose profile, with a maximum dose in the deep seated tumor, a finite range, small lateral scattering, and a drastically increased biological efficiency in the tumor. These properties maximize the deletion effects on tumor cells. In addition, particle beams can be directed precisely in the limit of one or two millimeters, and can be monitored using positron emission tomography (PET) with the same precision. In the following paper the conditions are given that are necessary to translate these properties into clinical routine.

ÖGRO survey on radiotherapy capacity in Austria : Status quo and estimation of future demands

BACKGROUND

A comprehensive evaluation of the current national and regional radiotherapy capacity in Austria with an estimation of demands for 2020 and 2030 was performed by the Austrian Society for Radiation Oncology, Radiobiology and Medical Radiophysics (ÖGRO).

MATERIALS AND METHODS

All Austrian centers provided data on the number of megavoltage (MV) units, treatment series, fractions, percentage of retreatments and complex treatment techniques as well as the daily operating hours for the year 2014. In addition, waiting times until the beginning of radiotherapy were prospectively recorded over the first quarter of 2015. National and international epidemiological prediction data were used to estimate future demands.

RESULTS

For a population of 8.51 million, 43 MV units were at disposal. In 14 radiooncological centers, a total of 19,940 series with a mean number of 464 patients per MV unit/year and a mean fraction number of 20 (range 16-24) per case were recorded. The average re-irradiation ratio was 14%. The survey on waiting times until start of treatment showed provision shortages in 40% of centers with a mean waiting time of 13.6 days (range 0.5-29.3 days) and a mean maximum waiting time of 98.2 days. Of all centers, 21% had no or only a limited ability to deliver complex treatment techniques. Predictions for 2020 and 2030 indicate an increased need in the overall number of MV units to a total of 63 and 71, respectively.

CONCLUSION

This ÖGRO survey revealed major regional differences in radiooncological capacity. Considering epidemiological developments, an aggravation of the situation can be expected shortly. This analysis serves as a basis for improved public regional health care planning.

Topics of nuclear medicine research in Europe

Last year in the European Journal of Nuclear Medicine and Molecular Imaging, we introduced some recent nuclear medicine research conducted in Japan. This was favorably received by European readers in the main. This year we wish to focus on the Annals of Nuclear Medicine on some of the fine nuclear medicine research work executed in Europe recently. In the current review article, we take up five topics: prostate-specific membrane antigen imaging, recent advances in radionuclide therapy, [¹⁸F]fluorodeoxyglucose positron-emission tomography (PET) for dementia, quantitative PET assessment of myocardial perfusion, and iodine-124 (¹²⁴I). Just at the most recent annual meeting of the European Association of Nuclear Medicine 2016, Kyoto was selected as the host city for the 2022 Congress of the World Federation of Nuclear Medicine and Biology. We hope that our continuous efforts to strengthen scientific cooperation between Europe and Japan will bring many European friends and a great success to the Kyoto meeting.

Major clinical research advances in gynecologic cancer in 2016: 10-year special edition

In 2016, 13 topics were selected as major research advances in gynecologic oncology. For ovarian cancer, study results supporting previous ones regarding surgical preventive strategies were reported. There were several targeted agents that showed comparable responses in phase III trials, including niraparib, cediranib, and nintedanib. On the contrary to our expectations, dose-dense weekly chemotherapy regimen failed to prove superior survival outcomes compared with conventional triweekly regimen. Single-agent non-platinum treatment to prolong platinum-free-interval in patients with recurrent, partially platinum-sensitive ovarian cancer did not improve and even worsened overall survival (OS). For cervical cancer, we reviewed robust evidences of larger-scaled population-based study and cost-effectiveness of nonavalent vaccine for expanding human papillomavirus (HPV) vaccine coverage. Standard of care treatment of locally advanced cervical cancer (LACC) was briefly reviewed. For uterine corpus cancer, new findings about appropriate surgical wait time from diagnosis to surgery were reported. Advantages of minimally invasive surgery over conventional laparotomy were reconfirmed. There were 5 new gene regions that increase the risk of developing endometrial cancer. Regarding radiation therapy, Post-Operative Radiation Therapy in Endometrial Cancer (PORTEC)-3 quality of life (QOL) data were released and higher local control rate of image-guided adaptive brachytherapy was reported in LACC. In addition, 4 general oncology topics followed: chemotherapy at the end-of-life, immunotherapy with reengineering T-cells, actualization of precision medicine, and artificial intelligence (AI) to make personalized cancer therapy real. For breast cancer, adaptively randomized trials, extending aromatase inhibitor therapy, and ribociclib and palbociclib were introduced.

Present state and issues in IORT Physics

Literature was reviewed to assess the physical aspects governing the present and emerging technologies used in intraoperative radiation therapy (IORT). Three major technologies were identified: treatment with electrons, treatment with external generators of kV X-rays and electronic brachytherapy. Although also used in IORT, literature on brachytherapy with radioactive sources is not systematically reviewed since an extensive own body of specialized literature and reviews exists in this field. A comparison with radioactive sources is made in the use of balloon catheters for partial breast irradiation where these are applied in almost an identical applicator technique as used with kV X-ray sources. The physical constraints of adaption of the dose distribution to the extended target in breast IORT are compared. Concerning further physical issues, the literature on radiation protection, commissioning, calibration, quality assurance (QA) and in-vivo dosimetry of the three technologies was reviewed. Several issues were found in the calibration and the use of dosimetry detectors and phantoms for low energy X-rays which require further investigation. The uncertainties in the different steps of dose determination were estimated, leading to an estimated total uncertainty of around 10-15% for IORT procedures. The dose inhomogeneity caused by the prescription of electrons at 90% and by the steep dose gradient of kV X-rays causes additional deviations from prescription dose which must be considered in the assessment of dose response in IORT.

Highlights lecture EANM 2015: the search for nuclear medicine's superheroes

The EANM 2015 Annual Congress, held from October 10th to 14th in Hamburg, Germany, was outstanding in many respects. With 5550 participants, this was by far the largest European congress concerning nuclear medicine. More than 1750 scientific presentations were submitted, with more than 250 abstracts from young scientists, indicating that the future success of our discipline is fuelled by a high number of young individuals becoming involved in a multitude of scientific activities. Significant improvements have been made in molecular imaging of cancer, particularly in prostate cancer. PSMA-directed PET/CT appears to become a new gold standard for staging and restaging purposes. Novel tumour specific compounds have shown their potential for target identification also in other solid neoplasms and further our understanding of tumour biology and heterogeneity. In addition, a variety of nuclear imaging techniques guiding surgical interventions have been introduced. A particular focus of the congress was put on targeted, radionuclide based therapies. Novel theranostic concepts addressing also tumour entities with high incidence rates such as prostate cancer, melanoma, and lymphoma, have shown effective anti-tumour activity. Strategies have been presented to improve further already established therapeutic regimens such as somatostatin receptor based radio receptor therapy for treating advanced neuroendocrine tumours. Significant contributions were presented also in the neurosciences track. An increasing number of target structures of high interest in neurology and psychiatry are now available for PET and SPECT imaging, facilitating specific imaging of different subtypes of dementia and movement disorders as well as neuroinflammation. Major contributions in the cardiovascular track focused on further optimization of cardiac perfusion imaging by reducing radiation exposure, reducing scanning time, and improving motion correction. Besides coronary artery disease, many contributions focused on cardiac inflammation, cardiac sarcoidosis, and specific imaging of large vessel vasculitis. The physics and instrumentation track included many highlights such as novel, high resolution scanners. The most noteworthy news and developments of this meeting were summarized in the highlights lecture. Only 55 scientific contributions were mentioned, and hence they represent only a brief summary, which is outlined in this article. For a more detailed view, all presentations can be accessed by the online version of the European Journal of Nuclear Medicine and Molecular Imaging (Volume 42, Supplement 1).

Obstetric and offspring risks of women's morbid conditions linked to prior anticancer treatments

BACKGROUND

Literature shows the effects of type of cancer and/or anticancer treatment on live birth percentages and/or pregnancy and neonatal complications in female cancer survivors. However, studies analyzing the obstetric and offspring risks of the morbid conditions associated with previous anti-cancer treatments are missing. The present review aims to uncover these risks.

METHODS

A literature search based on publications up to March 2016 identified by PubMed and references cited in relevant articles.

RESULTS

The morbid conditions associated with prior anticancer treatments including chemotherapy, radiotherapy, surgery, and/or hematopoietic stem-cell transplant may induce not only obstetric and neonatal complications but also long-term effects on offspring. Whereas some risks are predominantly evidenced in untreated women others are observed in both treated and untreated women. These risks may be superimposed on those induced by the current women's trend in Western societies to postpone maternity.

CONCLUSIONS

Medical professionals should be aware and inform female cancer survivors wishing to have a child not only of the short- and long-term risks to themselves and their prospective offspring of previous anticancer treatments, fertility-preservation technologies, and pregnancy itself, but also of those risks linked to the morbid conditions induced by prior anticancer treatments. Once female cancer survivors wishing to have a child have been properly informed about the risks of reproduction, they will be best placed to make decisions of whether or not to have a biological or donor-conceived child. In addition, when medical professionals be aware of these risks, they will be also best placed to provide appropriate treatments before/during pregnancy in order to prevent or alleviate the impact of these morbid conditions on maternal and offspring health.

What is the best way to radiate the prostate in 2016?

Prostate cancer treatment with definitive radiation therapy (RT) has evolved dramatically in the past 2 decades. From the initial 2-dimensional planning using X-rays, advances in technology led to 3-dimensional conformal RT, which used computerized tomography-based planning. This has allowed delivery of higher doses of radiation to the prostate while reducing dose to the surrounding organs, resulting in improved cancer control. Today, intensity-modulated RT (IMRT) is considered standard, where radiation beams of different shapes and intensities can be delivered from a wide range of angles, thus further decreasing doses to normal organs and likely reducing treatment-related toxicity. In addition, image guidance ascertains the location of the prostate before daily treatment delivery. Brachytherapy is the placement of radioactive seeds directly in the prostate, and has a long track record as a monotherapy for low-risk prostate cancer patients with excellent long-term cancer control and quality of life outcomes. Recent studies including several randomized trials support the use of brachytherapy in combination with external beam RT for higher-risk patients. RT for prostate cancer continues to evolve. Proton therapy has a theoretical advantage over photons as it deposits most of the dose at a prescribed depth with a rapid dose fall-off thereafter; therefore it reduces some doses delivered to the bladder and rectum. Prospective studies have shown the safety and efficacy of proton therapy for prostate cancer, but whether it leads to improved patient outcomes compared to IMRT is unknown. Hypofractionated RT delivers a larger dose of daily radiation compared to conventional IMRT, and thus reduces the overall treatment time and possibly cost. An extreme form of hypofractionation is stereotactic body radiation therapy where highly precise radiation is used and treatment is completed in a total of 4 to 5 sessions. These techniques take advantage of the biological characteristic of prostate cancer, which is more sensitive to larger radiation doses per fraction, and therefore could be more effective than conventional IMRT. Multiple randomized trials have demonstrated noninferiority of moderately hypofractionated RT compared to conventional fractionation. There is also a growing body of data demonstrating the safety and efficacy of stereotactic body radiation therapy for low- and intermediate-risk prostate cancer.

Clinical Proton Radiation Therapy Research at the Francis H. Burr Proton Therapy Center

The Francis H. Burr Proton Therapy Center has a 230 MeV cyclotron from which proton beams are directed to two isocentric gantries, a stereotactic intracranial beam line, and an eye line. Because of improved physical dose distribution, proton radiotherapy allows dose escalation to improve local tumor control in anatomic sites and histologies where local control is suboptimal with photons. The improved dose localization also reduces normal-tissue doses with an anticipated reduction in acute and late toxicity. Clinical treatment protocols, developed to exploit the dosimetric advantages of protons over photons, have been grouped into two broad categories. In the first, dose is escalated for anatomic sites where local control with conventional radiation doses has been suboptimal. In the second, normal-tissue sparing with protons is designed to minimize acute and late toxicity. Treatment of patients on clinical research protocols has been encouraged. Patient treatments began on the first gantry in November 2001; on the eye line in April 2002; on the second gantry in May 2002; and on the stereotactic intracranial line in August 2006. The facility currently treats 60 patients per day, including up to six children daily under anesthesia. Dose-escalation studies have been completed for early stage prostate cancer (in conjunction with Loma Linda University) and sarcomas of the cervical spine/base of skull and thoracolumbosacral spine. Protocols are in progress or development for carcinoma of the nasopharynx, paranasal sinus carcinoma, non-small-cell lung carcinoma, locally advanced carcinoma of the prostate, hepatocellular carcinoma, and pancreatic cancer. Studies evaluating the use of protons for morbidity reduction include protocols for craniospinal irradiation in conjunction with systemic chemotherapy for medulloblastoma, retinoblastoma, pediatric rhabdomyosarcoma, other pediatric sarcomas, and accelerated, hypofractionated partial breast irradiation for T1N0 breast carcinomas. For pediatric patients, protons have also been accepted as an alternative to photons for children enrolled in Children's Oncology Group (COG) protocols. Treatment of patients on these studies has often required the development of new treatment techniques ( i.e., matching abutting fields for craniospinal irradiation), respiratory gating, and development of appropriate clinical infrastructure support ( i.e., increase in availability of pediatric anesthesia) to allow appropriate treatment. In addition, a clinical research infrastructure for protocol development and data management is required. Results to date indicate that proton radiation therapy offers several potential treatment advantages to patients that can be studied in the setting of clinical trials. Patients' willingness to enter these clinical trials seems to be quite high; accrual to selected studies has been favorable.

Trends in the Application of Postmastectomy Radiotherapy for Breast Cancer With 1 to 3 Positive Axillary Nodes and Tumors ≤5 cm in the Modern Treatment Era: A Retrospective Korean Breast Cancer Society Report

Despite high-level evidence, the benefit of postmastectomy RT in these patients in recent years has not been fully elucidated. We investigated postmastectomy radiotherapy (RT) use and evaluated clinicopathologic and treatment factors influencing RT use in Korean women with pT1-2N1 breast cancer.We identified women diagnosed with pT1-2N1 breast cancer between 1994 and 2009 using the Korean Breast Cancer Registry. Factors associated with RT use were evaluated using logistic regression analysis. The median follow-up was 95 months.Of the 6196 women, 11.9% underwent postmastectomy RT. RT was applied more frequently in women with 3 positive lymph nodes (adjusted odds ratio [OR], 2.69) and larger tumors (OR per centimeter, 1.10). RT use was not significantly associated with well-established risk factors (e.g., tumor grade, hormone receptor status, and lymphovascular space invasion). Although RT utilization increased gradually during the study period (OR per year, 1.07), factors associated with RT were similar over time. The estimated 5-year overall survival increased significantly from 84.1% in 1994 to 2000 to 94.6% in 2005 to 2009.This population-based analysis revealed that the indications for postmastectomy RT in pT1-2N1 breast cancer in Korea are based solely on conventional anatomical factors, although their survival has increased significantly in the modern treatment era. There is a significant unmet need for better risk stratification in these patients and for tailored RT with the incorporation of tumor biology-associated factors.

Supply and Demand for Radiation Oncology in the United States: Updated Projections for 2015 to 2025

PURPOSE

Prior studies have forecasted demand for radiation therapy to grow 10 times faster than the supply between 2010 and 2020. We updated these projections for 2015 to 2025 to determine whether this imbalance persists and to assess the accuracy of prior projections.

METHODS AND MATERIALS

The demand for radiation therapy between 2015 and 2025 was estimated by combining current radiation utilization rates determined by the Surveillance, Epidemiology, and End Results data with population projections provided by the US Census Bureau. The supply of radiation oncologists was forecast by using workforce demographics and full-time equivalent (FTE) status provided by the American Society for Radiation Oncology (ASTRO), current resident class sizes, and expected survival per life tables from the US Centers for Disease Control.

RESULTS

Between 2015 and 2025, the annual total number of patients receiving radiation therapy during their initial treatment course is expected to increase by 19%, from 490,000 to 580,000. Assuming a graduating resident class size of 200, the number of FTE physicians is expected to increase by 27%, from 3903 to 4965. In comparison with prior projections, the new projected demand for radiation therapy in 2020 dropped by 24,000 cases (a 4% relative decline). This decrease is attributable to an overall reduction in the use of radiation to treat cancer, from 28% of all newly diagnosed cancers in the prior projections down to 26% for the new projections. By contrast, the new projected supply of radiation oncologists in 2020 increased by 275 FTEs in comparison with the prior projection for 2020 (a 7% relative increase), attributable to rising residency class sizes.

CONCLUSION

The supply of radiation oncologists is expected to grow more quickly than the demand for radiation therapy from 2015 to 2025. Further research is needed to determine whether this is an appropriate correction or will result in excess capacity.

Lung cancer: Biology and treatment options

Lung cancer remains the leading cause of cancer mortality in men and women in the U.S. and worldwide. About 90% of lung cancer cases are caused by smoking and the use of tobacco products. However, other factors such as radon gas, asbestos, air pollution exposures, and chronic infections can contribute to lung carcinogenesis. In addition, multiple inherited and acquired mechanisms of susceptibility to lung cancer have been proposed. Lung cancer is divided into two broad histologic classes, which grow and spread differently: small-cell lung carcinomas (SCLCs) and non-small cell lung carcinomas (NSCLCs). Treatment options for lung cancer include surgery, radiation therapy, chemotherapy, and targeted therapy. Therapeutic-modalities recommendations depend on several factors, including the type and stage of cancer. Despite the improvements in diagnosis and therapy made during the past 25 years, the prognosis for patients with lung cancer is still unsatisfactory. The responses to current standard therapies are poor except for the most localized cancers. However, a better understanding of the biology pertinent to these challenging malignancies, might lead to the development of more efficacious and perhaps more specific drugs. The purpose of this review is to summarize the recent developments in lung cancer biology and its therapeutic strategies, and discuss the latest treatment advances including therapies currently under clinical investigation.

Contemporary Trends in the Utilization of Radiotherapy in Patients With Renal Cell Carcinoma

OBJECTIVE

To examine the utilization of radiation therapy (RT) in patients with renal cell carcinoma (RCC) using a large national tumor registry.

MATERIALS AND METHODS

Patients diagnosed with RCC were identified using the National Cancer Data Base. Our primary objective was to assess temporal trends in the utilization of RT. Our secondary objective was to identify patient and treatment factors associated with receipt of RT. The Cochran-Armitage test was used for trend analysis. Multivariable logistic regression was performed to identify factors associated with RT use.

RESULTS

A total of 279,427 patients were diagnosed with RCC from 1998 to 2010. A total of 233,572 (83.6%) had localized or locally advanced disease, whereas the remaining 45,855 (16.4%) had metastatic disease. There was a decrease in radiotherapy across all patients during this period (1.5%-0.6%, P <.001); as salvage or adjuvant therapy with surgery (1.3%-0.3%, P <.001), and in patients with metastatic disease (33.3%-28.5%, P <.001). Factors associated with increased RT use in patients with nonmetastatic RCC included male gender, receipt of systemic therapy, higher stage, higher grade, nonacademic treatment facility, facility location, and sarcomatoid or other histology.

CONCLUSION

In the National Cancer Data Base, we observed a decrease in the use of RT for patients with RCC from 1998 to 2010. Patients with more aggressive disease characteristics were more likely to receive RT. Well-designed clinical trials are needed to clarify the role of RT in the management of these patients.

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.