BACKGROUND:Proton Arc Treatment (PAT) has shown potential over Multi-Field Optimization (MFO) for out-of-target dose reduction in particular for head and neck (H&N) patients. A feasibility test, including delivery in a clinical environment is still missing in the literature and a necessary requirement before clinical application of PAT. PURPOSE:To perform a comprehensive comparison between clinically delivered MFO plans and static PAT plans for H&N treatments, followed by end-to-end commissioning of the system to prepare for clinical treatments. METHODS:Anonymized datasets of 10 patients treated for H&N cancer (median prescription dose 70 GyRBE) were selected for this study. Both MFO and PAT plans were created in RayStation and robustly optimized for setup and range uncertainties as in our clinical routine. PAT plans were created with 30 angle directions. 1. Comparisons were performed regarding: 2. nominal dose distributions in terms of target coverage, dose to primary and secondary OARs 3. robustness evaluation (D95 of the target and D1 of primary OARs) 4. Normal tissue complication probability (NTCP) values for xerostomia, swallowing dysfunction, tube feeding, and sticky saliva 5. D·LETd distributions 6. the probability of replanning at least once due to anatomical changes 7. delivery time: MFO and PAT plans, for one patient, were delivered in a clinical gantry room. For PAT, two plans with 30 and with 20 discrete beam directions were optimized and delivered. RESULTS:In PAT plans, a significant reduction was observed in the near maximum dose to the brainstem, while no statistically significant differences were found for other primary OARs or target coverage metrics (D95 and D98) in both nominal plans and robustness evaluation scenarios. For secondary OARs, PAT plans achieved an impressive reduction in mean dose. Max D·LETd distributions in brainstem, brain, and temporal lobes showed no statistical differences between MFO and PAT plans while mean D·LETd values were lower with PAT. Median NTCP was significantly reduced for xerostomia as endpoint (ΔNTCP = 8.5%), while reductions in other endpoints were not statistically significant. The number of patients that would need at least one replanning during the treatment for PAT was similar to MFO, showing that the established clinical workflow for monitoring of anatomy changes will remain the same for both delivery methods. Comparison in terms of delivery time from the start of the first beam until the end of the last (comprising all the technically motivated delays due to operation of OIS/Therapy Control System operation, gantry rotations, couch rotations, beam line preparation etc.) resulted in delivery times that were similar for both techniques. CONCLUSION:Static PAT plans demonstrate the capability to increase plan quality with respect to state-of-the-art MFO planning, since dose reduction outside of the target is significant with no reduction of the quality of the target dose distribution. NTCP evaluations, as well as linear energy transfer (LET) distributions, do not indicate risks for unexpected toxicity. Delivery time tests with different beam direction configurations have shown that PAT plans can already be delivered within similar time slots as highly conformal MFO plans. The successful end-to-end commissioning led to the world's first patient treatments using PAT, with eight patients treated to date.

Background Recent consensus statements and clinical trials have assessed the value of MRI-guided focused ultrasound surgery for pain palliation of bone metastases; however, a comparison with external beam radiation therapy (EBRT) has not been performed. Purpose To compare safety and effectiveness data of MRI-guided focused ultrasound and EBRT in the treatment of bone metastases. Materials and Methods Participants with painful bone metastases, excluding skull and vertebral bodies, were enrolled in a prospective open-label nonrandomized phase II study between January 2017 and May 2019 and underwent either MRI-guided focused ultrasound or EBRT. The primary end point was the overall response rate at 1-month following treatment, assessed via the numeric rating scale (NRS) for pain (0-10 scale, with zero meaning "no pain" and 10 meaning "the worst pain imaginable"). Secondary end points were improvements at 12-month follow-up in NRS and quality of life (QoL) measures, including the Brief Pain Inventory (BPI), QoL-Questionnaire Cancer-15 Palliative Care (QLQ-C15-PAL), and QoL-Questionnaire Bone Metastases-22 (QLQ-BM22) and analysis of adverse events. Statistical analyses, including linear regression, χ2 test, and Student t test followed the per-protocol principle. Results Among 198 participants, 100 underwent MRI-guided focused ultrasound (mean age, 63 years ± 13 [SD]; 51 women), and 98 underwent EBRT (mean age, 65 years ± 14; 52 women). The overall response rates at 1-month follow-up were 91% (91 of 100) and 67% (66 of 98), respectively, in the focused ultrasound and EBRT arms (P < .001), and complete response rates were 43% (43 of 100) and 16% (16 of 98) (P < .001). The mean baseline NRS score was 7.0 ± 2.1 for focused ultrasound and 6.6 ± 2.4 for EBRT (P = .16); at 1-month follow-up, they were reduced to 3.2 ± 0.3 and 5.1 ± 0.3 (P < .001), respectively. QLQ-C15-PAL for physical function (P = .002), appetite (P < .001), nausea and vomiting (P < .001), dyspnea (P < .001), and QoL (P < .001) scores were lower in the focused ultrasound group. The overall adverse event rates were 15% (15 of 100) after focused ultrasound and 24% (24 of 98) after EBRT. Conclusion MRI-guided focused ultrasound surgery and external beam radiation therapy showed similar improvements in pain palliation and quality of life, with low adverse event rates. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Kelekis in this issue.

Liver cancer represents one of the most common causes of death from cancer worldwide. Hepatocellular carcinoma (HCC) accounts for 90% of all primary liver cancers. Among local therapies, evidence regarding the use of radiation therapy is growing. Proton therapy currently represents the most advanced radiation therapy technique with unique physical properties which fit well with liver irradiation. Here, in this review, we aim to 1) illustrate the rationale for the use of proton therapy (PT) in the treatment of HCC, 2) discuss the technical challenges of advanced PT in this disease, 3) review the major clinical studies regarding the use of PT for HCC, and 4) analyze the potential developments and future directions of PT in this setting.

Background: Evidence for the efficacy of radiation therapy for primary liver cancer is growing. In this context, proton therapy (PT) can potentially improve the therapeutic ratio, as demonstrated by recent clinical studies. Here we report the first European clinical experience on the use of PT for primary liver cancer. Methods: All patients treated for primary liver cancer in our center entered the analysis. Patients were simulated during deep expiration breath-hold. A 15-fraction treatment schedule was adopted using active scanning PT. Clinical outcome and toxicity were retrospectively analyzed. Results: Between January 2018 and December 2019, 18 patients were treated. Fourteen patients had hepatocellular carcinoma (HCC), three patients had intrahepatic cholangiocarcinoma (ICC), and one patient had synchronous ICC-HCC. The Child-Pugh score was A5 in the majority of patients with HCC (71.4%). Median prescription dose was 58.05 Gy (range, 50.31–67.5). Median follow-up was 10 months (range, 1–19). The majority of deaths occurred from liver tumor progression. One-year overall survival (OS) was 63%. A significant correlation between worse OS and patient performance status, vascular invasion, and tumor stage was recorded. One-year local control was 90%. Toxicity was low, with a decrease in Child-Pugh score ⩾2 points detected in one patient. No cases of classic radiation-induced liver disease occurred. Conclusions: Our initial results of active scanning PT for primary liver cancer demonstrated the feasibility, safety, and effectiveness of this advanced technique in this setting. The potential of the combination of PT with other locoregional therapies is under evaluation.

Background/Aim: The aim of this study was to delineate clinical criteria to safely select elderly patients who can benefit from adding oxaliplatin to 5-fluoruracil-based neo-adjuvant chemoradiotherapy (CRT) in locally advanced rectal cancer (LARC) management. Patients and Methods: This is a single-institutional case-control study on LARC patients who received intensified neo-adjuvant CRT, between January 2007 and December 2014. Data concerning patient characteristics, treatment details and adverse events were reviewed and analyzed in two settings: young patients (<65 years) and elderly (>= 65 years). A binary logistic model was applied to analyze the potential interaction between clinical variables and severe toxicity risk. Results: In total, 100 consecutive LARC patients were included. Mean age was 63.6 years and 55% (n=55) of the patients had adult comorbidity evaluation-27 (ACE-27) score >= 1. Most cancers (81%) were lymph node positive at diagnosis. Overall, >= 5 cycles of oxaliplatin were administered to 92 patients (92%). Only 17 patients (17%) reported grade >= 3 toxicity. The elderly group did not experience significantly higher severe toxicity than the young group. ACE-27 score >= 1 was the only variable independently associated with a higher severe toxicity. The 5-year overal survival (OS) rates were 64.1% and 89.2% in the elderly and young cohort, respectively. Conclusion: Elderly LARC patients can be safely treated with intensified neo-adjuvant CRT.

BACKGROUND:Inflammatory myofibroblastic tumor (IMT) is a rare benign cancer that can express a more aggressive phenotype related to the genetic mutation of the anaplastic lymphoma kinase receptor (ALK). Involvement of trachea is extremely rare and due to the clinical and radiologic nonspecificity, the definitive diagnosis is based on the histologic evaluation of tissue specimens. Total surgical excision is curative and chemotherapy or radiotherapy has been employed in the treatment of unresectable tumors or as adjuvant therapies.CASE PRESENTATION:The case described here is being reported because of the rare tracheal location and the atypical treatment approach used for an ALK-positive IMT. A 7-week pregnant woman voluntary interrupted pregnancy and underwent total surgical excision that resulted to have close margins. Although ALK-positive expression indicated the use of ALK inhibitors, she refused any type of adjuvant therapy that could affect ovarian function. Thus, 3D conformational external beam radiotherapy was performed with a daily dose of 180 cGy, 5 times per week, up to 45 Gy at the level of trachea. A total of 62 months of follow-up showed and no signs of disease recurrence or late radiation therapy-related toxicity.CONCLUSIONS:This report describes an extremely rare case of a tracheal IMT, underlying the key role of radiotherapy as adjuvant treatment able to definitively cure IMT, limiting systemic chemotherapy-related toxicity.

Imatinib (IM) is an established first-line treatment for children with chronic myeloid leukemia (CML). However, the most effective dosage of IM and overall management of newly-diagnosed childhood CML in chronic phase (CP) are not well defined.

For many years stem cell transplant (SCT) has been considered the only curative treatment for adults and children with chronic myeloid leukemia (CML). The availability of therapies, potentially capable of eradicating the Ph+ clone, has changed the treatment approach to CML patients. In this study, we report the long-term outcome of CML patients aged <20 years treated with interferon alpha (IFN) and/or imatinib (IM), and of those submitted to SCT.