Radiotherapy Quality Assurance in the PORTEC-3 (TROG 08.04) Trial

AIMS

Quality assurance in radiotherapy (QART) is essential to ensure the scientific integrity of a clinical trial. This paper reports the findings of the retrospective QART assessment for all centres that participated in PORTEC-3; a randomised controlled trial that compared pelvic radiotherapy with concurrent chemoradiotherapy to the pelvis followed by adjuvant chemotherapy. The trial showed an overall survival benefit for the addition of the chemotherapy in the management of women with high-risk endometrial cancer.

MATERIALS AND METHODS

Clinicians were invited to upload a randomly selected case/s treated at each of the participating sites. Panel reviewers analysed the contours to certify that the target volumes and organ at risk structures were contoured according to guidelines. The results were categorised into acceptable, minor variation, major variation or unevaluable. The radiotherapy plans were dosimetrically evaluated using the well-established Trans-Tasman Radiation Oncology Group (TROG) protocol.

RESULTS

Between August 2010 and January 2018, data from 146 patients of 686 consecutively treated patients were retrospectively reviewed. All 16 Australia and New Zealand and 71 of 77 international centres uploaded data for evaluation. In total, 3514 dosimetric and contour variables were reviewed. Of these, 3136 variables were deemed acceptable (89.2%), with 335 minor (9.6%) and 43 major variations (1.2%). Major contour variations included the clinical target volume vaginal vault, clinical target volume parametria and differential planning target volume vault expansion.

CONCLUSION

The results of the QART assessment confirmed high uniformity and low rates of both minor and major deviations in contouring and dosimetry in all sites. This supports the safe introduction of the PORTEC-3 treatment protocol into routine clinical practice.

Ultrasound-guided Brachytherapy for Cervix Cancer

Radiotherapy and brachytherapy are the definitive treatments for locally advanced cervix cancer. The use of soft-tissue imaging, particularly magnetic resonance imaging, has enhanced their effectiveness and improved clinical outcomes. However, the use of magnetic resonance imaging is largely restricted to well-resourced centres in both the first and developing world and remains elusive to many less advantaged centres, particularly those in areas with a high burden of cervix cancer. Ultrasound is an accessible, affordable and accurate imaging modality that can be used throughout the brachytherapy procedure. Ultrasound is primarily used to ensure safe insertion of the applicator but can also be used to guide planning. The methods used to utilise ultrasound images for planning are described. Ultrasound is particularly useful as a verification aid to confirm applicator placement after patients are moved and transferred around the radiotherapy department. It can also be used to verify the dimensions of treatment volumes over the course of brachytherapy. There is a crucial unmet need for an accessible economical soft-tissue imaging modality in cervical brachytherapy. Ultrasound has the potential to meet this need.

Effects of growth factors on corneal wound healing

Healing of ocular surface wounds is a complex process involving migration, mitosis, and differentiation of epithelial and stromal cells. Endogenously produced peptide growth factors such as epidermal growth factor (EGF), transforming growth factor alpha (TGF-alpha), or transforming growth factor beta (TGF-beta) may play key roles in the natural wound healing process. Lacrimal gland cells were reported to synthesize and secrete EGF into tear fluid where it may enhance healing of corneal epithelial and stromal injuries by an exocrine pathway. EGF stimulated DNA synthesis of epithelial cells and stromal fibroblasts in culture, stimulated synthesis of fibronectin by epithelial cells and was chemotactic for human epithelial and stromal cells. Human corneal epithelial cells also synthesized TGF-alpha which may influence epithelial cells by an autocrine pathway. TGF-beta, which is a potent inducer of lysyl oxidase mRNA levels in cultures of human scleral fibroblasts, may be the factor most responsible for inducing synthesis of corneal extracellular matrix components after an injury. Treatment of epithelial injuries ocular surface wounds with exogenous peptide growth factors also accelerated healing in rabbits and primates. Treatment of severe ocular surface injuries caused by alkali with a combination of EGF, fibronectin, a synthetic collagenase inhibitor, and Aprotinin significantly blocked ulceration and enhanced epithelial regeneration. Clinical trials of topical treatment of EGF for ocular surface wounds suggest that peptide growth factors may be a valuable adjuvant for treatment of ocular surface wounds.

F-18 fluorodeoxyglucose positron emission tomography staging in radical radiotherapy candidates with nonsmall cell lung carcinoma: powerful correlation with survival and high impact on treatment

BACKGROUND

Successful treatment of nonsmall cell lung carcinoma (NSCLC) with radical radiotherapy (RT) requires accurate delineation of tumor extent. Conventional computed tomography-based noninvasive staging often estimates intrathoracic thoracic tumor extent incorrectly and fails to detect distant metastasis. High sensitivity and specificity are reported for F-18 fluorodeoxyglucose (FDG) positron emission tomography (PET) staging in potentially resectable NSCLC. The authors investigated FDG-PET staging in radical RT candidates with unresectable NSCLC.

METHODS

The authors prospectively studied 153 consecutive patients with unresectable NSCLC who were candidates for radical RT after conventional staging and had PET scans. Patients were allocated both "before PET" and "after PET" stages. Subsequent management was recorded. Survival analysis was used to compare validity of pre-PET and post-PET staging.

RESULTS

After PET, 107 patients (70%) actually received radical therapies (radical RT with or without concurrent chemotherapy, n = 102; radical surgery, n = 5); 46 patients (30%) received palliative treatment because of PET-detected distant metastasis (n = 28; 18%) or extensive locoregional disease (n = 18; 12%). Palliative therapies were RT (n = 33), chemotherapy (n = 12), or supportive care (n = 1). All five surgically treated patients underwent potentially curative resections after downstaging by PET. For radically treated patients, post-PET stage (P = 0.0041) but not pre-PET stage (P = 0.19) was strongly associated with survival. Radically treated patients survived longer than those treated palliatively (P = 0.02; 1-year survival, 69% and 44%, respectively; 2-year survival, 44% radical; no palliative patients had 2-yr follow-up).

CONCLUSIONS

Positron emission tomography-assisted staging detected unsuspected metastasis in 20%, strongly influenced choice of treatment strategy, frequently impacted RT planning, and was a powerful predictor of survival. Potential impact of FDG-PET is even greater in radical RT candidates with NSCLC than in surgical candidates.

Carcinoid tumour of the orbital muscles: A rare occurrence

Malignant carcinoid tumours are rare and usually follow an indolent course. Metastases from these tumours are uncommon, and usually involve bone, liver and lymph nodes. Orbital metastases have rarely been described, and generally involve the choroid rather than orbital structures. Our knowledge of the response of these tumours to radiotherapy is extremely limited. Two cases of orbital metastases treated with radiotherapy are presented here and the literature on the efficacy of palliative radiotherapy for this tumour is reviewed. Recommendations are made regarding an effective radiotherapy regimen for treating orbital metastases from malignant carcinoid tumours.

Molecular responses of human dermal fibroblasts to dual cues: contact guidance and mechanical load

Fibroblast contraction in wound healing involves the interaction of several cell types, cytokines, and extracellular matrix molecules. We have previously developed fibroblast alignment models using precise uniaxial mechanical loads in 3D culture and using contact guidance on fibronectin strands. Our aim here was to use contact guidance to place fibroblasts in their potentially most sensitive configuration, i.e., perpendicular to the axis of loading, to present cells with conflicting guidance cues. Gene expression at the mRNA level of cells recovered from different zones of the 3D collagen gel (with distinct orientation) was determined by quantitative RT-PCR for the matrix proteases MMP1, 2, and 3, and inhibitors TIMP1 and 2. Our results show a 2-, 4-, and 3-fold increase in MMP1, 2, and 3, respectively, in the non-aligned strain zone, relative to the aligned strain zone. These results suggest that cells unable to align to applied loads remodel their matrix far more rapidly than orientated cells. Where fibroblasts were held in an alignment perpendicular to the applied load by contact guidance, the fall in MMP mRNA expression was largely abolished, indicating that these cells remained in a mechano-activated state. The protease inhibitors TIMP1 and 2 were poorly mechano-responsive, further suggesting that changes in MMP expression result in functional matrix remodelling. These results indicate how mechanical loading in tissues may influence matrix remodelling, particularly under conflicting guidance cues.

The chemoattractant activity of the vitreous to human scleral fibroblasts following retinal detachment and proliferative vitreoretinopathy

The results are presented of a migration assay of scleral fibroblasts to 25% diluted vitreous samples from 27 patients with complex retinal detachments divided into three groups: group 1, no proliferative vitreoretinopathy (PVR); group 2, early PVR; and group 3, advanced PVR. There was a statistically significantly greater migration with vitreous samples from group 3 than with group 1 (p less than 0.0001) but no significant correlation for migration with the age of patients, duration of retinal detachment, or number of retinal procedures undertaken. Analysis of vitreous by gel electrophoresis showed that cellular migration was proportional to the number of peptide bands. Vitreous fibronectin levels were measured and there was a positive correlation between fibronectin in the vitreous samples and the migration of fibroblasts to the vitreous (r = 0.68, p less than 0.004).

Anterior tucking of the iris caused by posterior chamber lenses with polypropylene loops

One hundred ten eyes that had extracapsular cataract extraction with posterior chamber lens implantation were examined gonioscopically to ascertain the frequency of anteriorly displaced polypropylene loops "tucking" into the posterior iris surface. The association with iris transillumination defects and the development of postoperative uveitis, hyphema, and raised intraocular pressure were also recorded. Sixty-six eyes (60%) had one or two anteriorly tucked loops; 28 of them (25%) had some associated iris transillumination defect related to the implant. Twenty eyes (18%) developed persistent postoperative uveitis; 15 of them had anteriorly tucked loops. Two eyes had postoperative hyphema and in both these eyes the loops were anteriorly tucked. The means of recognizing and preventing potential complications are discussed.