There is concern that African-American men (AA) with low-risk prostate cancer (PC) may harbor more aggressive disease and thus may not be candidates for active surveillance. However, poorer outcomes seen in prior studies may be due to disparities in access to medical care rather than true biological difference. Our study tested the hypothesis that AA receiving care in an equal access medical system are more likely to experience adverse pathologic outcomes and increased mortality after radical prostatectomy (RP) compared to white men. This is an observational cohort study of men diagnosed with low-risk PC at the Veterans Health Administration between 1/1/2001 and 10/31/2015 who received RP. We excluded patients with a Gleason score > 6, Clinical T stage > 2A, and PSA >10 or missing income, education, and PSA values. The impact of AA race on adverse pathologic outcomes was assessed in a log-binomial regression; prostate cancer-specific mortality (PCSM) was assessed by Fine-Gray competing risks regression; and all-cause mortality was assessed in a Cox proportional hazards regression. Adverse pathologic outcomes included Gleason score > 4+3, tumor stage ≥ 3, lymph node involvement, and positive surgical margins. Mortality outcomes included PCSM and all-cause mortality. Covariates included race, age, baseline PSA level, clinical tumor stage, Charlson Comorbidity Index (CCI) score, statin use, antiplatelet use, antihypertensive use, alcohol abuse, substance abuse, smoking status, region, income, education, and year of diagnosis. PCSM was modeled as a function of AA race to avoid over-fitting due to the low number of PCSM deaths. The cohort included 3,524 (white: 2,479, AA: 1,045) men followed for a median of 7.2 years. During follow-up, 209 (5.93%) men were upgraded to Gleason score ≥4+3, 378 (10.72%) to pathologic tumor stage ≥ 3, 24 (0.68%) had positive lymph nodes, and 51 (14.61%) had positive surgical margins. There was no significant difference between AA and white patients for Gleason score (RR=1.03, 95% CI=0.75-1.42, p=0.81), tumor stage (RR=0.93, 95% CI=0.73-1.18, p=0.57), lymph node involvement (RR = 0.83, 95% CI=0.68-1.02, p=0.07), and positive surgical margins (RR=1.20, 95% CI=0.99-1.46, p=0.06). A total of 14 patients experienced PCSM (14-year cumulative incidence: AA 0.41%, white 0.41%, p=0.54). There was no significant difference in PCSM (SHR=0.96, 95% CI=0.30-3.08, p=0.95). Finally, a total of 210 patients (5.9%) experienced death from any cause (14-year overall survival: AA 90.9%, white 91.3%, p=0.56). There was no significant difference in all-cause mortality between AA and white patients (HR=1.23, 95% CI=0.90-1.69, p=0.19). We did not observe any significant differences in adverse pathologic outcomes, PCSM, or all-cause mortality between AA and white men who received their care within an equal access health system. These data do not support the exclusion of AA men from active surveillance protocols.

Checkpoint blockade immunotherapy (CBI) targeting the PD-1 and CTLA-4 pathways is revolutionizing oncology. However, objective response rates for single agent CBI in solid malignancies remain low and combinatorial strategies are required to improve outcomes. Our group has pioneered the use of radiation (RT) and stereotactic body radiation therapy (SBRT) in combination with anti-PD-1 CBI. We previously demonstrated in tumor models that RT+ CBI can enhance antigen specific immune responses and improve local and systemic tumor control. Nevertheless, the clinical benefit of SBRT+CBI remains unclear. Our primary objective was to conduct a clinical trial to test the hypothesis that SBRT + CBI increases objective response rates (ORR) compared to CBI alone. Here we present an interim analysis. We designed and opened an investigator initiated Phase II study (ClinicalTrials.gov NCT02843165) which randomizes patients (1:1) with advanced metastatic disease to receive investigators choice of anti-PD-1/PD-L1 CBI versus anti-PD-1/PD-L1 CBI combined with concurrent SBRT. SBRT was started 1-21 days after C1D1 of CBI and was prescribed at 9.5Gy x 3 fractions delivered to 1-3 non-CNS tumor foci consecutively or every other day. The study is powered to detect a 33% relative improvement in ORR with a total anticipated enrollment of 146. Safety and Toxicity was analyzed prospectively for all patients using CTCAE 4.0. ORR are measured from unirradiated tumors using RECIST 1.1 criteria. Three research blood draws are obtained to analyze immune correlates. We performed an interim analysis of safety and toxicity among all patients and between treatment groups. We have enrolled a total of 35 patients at this time. There were a total of 126 CTCAE toxicity events observed with 67 (53.2%) Low grade (CTCAE 1-2), and 59 (46.8%) High grade (CTCAE 3-5) events with a mean followup of 5.1 months. The most common toxicities were fatigue, nausea, pain, and rash. The most common SBRT treatment sites were lung, liver, adrenal gland, and soft tissue. Experimental treatment attributions are as follows: 18 events (14.3%) Unrelated, 44 events (34.9%) Unlikely, 48 events (38.1%) Possible, and 13 events (10.3%) Probable or Definite. There were 7 (5.5%) high grade events attributed as probably or definitely related to study: one grade 4 fatigue, one grade 3 weight loss, one grade 3 rash, and two grade 3 electrolyte abnormalities, and two grade 3 acute kidney injury. When comparing between CBI and CBI+SBRT treatment groups there was no significant difference in any grade of toxicity at this time. Our interim analysis suggests that SBRT to lung, liver, adrenal and soft tissues prescribed at 9.5Gy x 3 fractions combined with concurrent anti-PD-1/PD-L1 CBI appears to be safe and well tolerated in patients with advanced metastatic disease. Continued analysis of safety and toxicity, ORR, and immune correlates between randomized treatment groups is ongoing.

There is limited evidence on the association between the use of androgen deprivation therapy (ADT) and depression. Thus, the objective of this study is to determine whether ADT is associated with an increased risk in depression in prostate cancer (PC) patients treated with definitive radiation therapy (RT). This is an observational cohort study of men diagnosed with non-metastatic PC at the United States Department of Veterans Affairs between January 1, 2001 and October 31, 2015 who received definitive RT with or without ADT. Patients with missing covariates, including prostate specific antigen (PSA), Gleason score, clinical T, M, and N stages, and income were excluded. We also excluded patients with a prior diagnosis of attention deficit hyperactive disorder, traumatic brain injury, posttraumatic stress disorder, schizophrenia, anxiety, bipolar disorder, depression or psychiatric use within one year prior to PC diagnosis. Finally, patients who initiated ADT more than one year after their PC diagnosis were excluded. Fine-Gray competing risks regression with inverse probability weighting of the propensity score was used to evaluate the association between ADT and depression. ADT was measured as a time-varying exposure. The primary outcome was new development of depression. Secondary outcomes included outpatient and inpatient psychiatry use. Exposure was ascertained from filled prescription records and outcomes from ICD-9 codes. Variables included in the propensity score and FG model were age, CCI score, statin use, antiplatelet use, antihypertensive use, antidepressant use, alcohol abuse, substance abuse, race, marital status, smoking status, region, Gleason score, income, education, clinical T stage, PSA, and year of diagnosis. The study cohort included 25,017 male veterans who were followed for a median time of 6.8 years. A total of 15,250 patients received RT alone while 9,767 received RT and ADT. During follow-up, 602 patients had a new diagnosis of depression, 243 had inpatient psychiatric use, and 5,056 had outpatient psychiatric use. In the multivariable competing risks regression model, there was an association between ADT and depression (SHR = 1.51, 95% CI = 1.33-1.73, p-value < 0.0001), and a significant dose response effect at ADT length <1 year (SHR = 1.33, 95% CI = 1.16-1.54, p-value < 0.0001) and length >1 year (SHR = 1.94, 95% CI = 1.66-2.27, p-value < 0.0001). There was an association between ADT and outpatient psychiatric use (SHR = 1.16. 95% CI = 1.11-1.22, p-value < 0.0001) but no association between ADT and inpatient psychiatric use (SHR = 0.86, 95% CI = 0.69-1.06, p-value = 0.16). We observed an increase in the risk of depression and outpatient psychiatric use among a large cohort of men with PC who received ADT with definitive RT. These results may highlight potential long-term risks of ADT on mental health in the treatment of PC.

Prior studies of accelerated partial breast irradiation (APBI) with passive scatter proton therapy have demonstrated promising dosimetric and clinical results. Disadvantages of passive scatter therapy include the use of multiple proton beams and higher skin doses, leading to an increase in clinically apparent skin toxicity. Scanning beam Intensity Modulated Proton Therapy (IMPT) has potential advantages over passive scatter proton therapy in regards to field selection, treatment duration, dose homogeneity, and normal tissue sparing. This retrospective review represents our clinical experience using IMPT technique for treatment of breast cancer with APBI. Between March 2014 and February 2015, 5 patients with IDC or DCIS underwent IMPT treatment. All patients underwent CT based simulation and treatment planning and were setup supine on a breast board or in the prone position. Daily setup and localization was accomplished with 4-6 skin surface fiducial markers tracked with orthogonal x-ray pairs. Treatment was administered while free breathing in 10 M-F daily fractions over a 2 week period, with 3800-4000 cGy prescribed to the gross operative cavity and 3400-3850 cGy prescribed to the clinical target volume which was defined as 10-15 mm expansion of the operative cavity respecting anatomical boundaries. Treatment was delivered with a single enface scanning proton beam. Normal organs were contoured and skin was defined as the volume within 3 mm of the exterior body contour. Clinical outcomes were monitored during and after treatment and later abstracted from the EMR. Mean total patient time in treatment room was 17 minutes. Enface proton beam setups included LAO, AP, LL and RAO. Maximum and mean doses are as follows: cardiac 531.4 cGy/4.3 cGy, ipsilateral lung 2610 cGy/55.3 cGy, chest wall 3682 cGy/692.2 cGy and skin 3 mm of 3966 cGy/889 cGy. All patients experienced grade 1 dermatitis of skin overlying the treatment area, grade 1 fatigue and no other acute toxicity. With a mean follow-up time of 7 months, 2 patients had minor dry skin in the treatment area and no other late toxicities. All patients self-reported ‘good to excellent’ cosmetic outcomes at time of most recent follow-up. No patients had evidence of local failure at the time of most recent follow up. Single field scanning beam IMPT is a feasible and effective approach for treating APBI. Improved treatment time and use of a single scanning beam helps to reduce delivery uncertainties and reduce intra-fractional motion and respiratory variance. IMPT delivers superior skin sparing when compared with passive scatter proton therapy. IMPT provides excellent normal tissue sparing dosimetry and good acute toxicity profile.

Radiosurgery is well accepted in the treatment of patients with intracranial metastases, but the role of frameless radiosurgery is unknown. Here, we describe our clinical experience with a novel single isocenter technique for frameless intensity modulated stereotactic radiosurgery (IMRS) to treat multiple intracranial metastases. After obtaining institutional review board approval, a review of radiation oncology records was performed. Between 2006 and 2012, 100 consecutive patients received optically guided frameless IMRS using a single centrally located isocenter for multiple intracranial metastases at a single center. Patients had a median of 4 intracranial metastases (range, 2-18). A total of 465 intracranial metastases were treated in a median of 1 fraction (range, 1-5) to a median dose of 20 Gy (range, 15-50 Gy). Clinical examination occurred every 2-4 months and included magnetic resonance imaging (MRI) to assess intracranial progression. Regional failure was defined as intracranial failure outside of the treatment volume. Local control, regional control, and overall survival were estimated by the Kaplan-Meier method. Toxicity was graded according to the Radiation Therapy Oncology Group scale. Median follow-up for all patients was 4.3 months (range, 0.2-58.3 months), with 83 patients (83.0%) followed until their death. For the remaining 17 patients alive at the time of analysis, median follow-up was 9.2 months (range, 2.2-58.3 months). Actuarial 6- and 12-month overall survival was 49.5% (95% Confidence Interval [CI], 40.5-60.6%) and 34.1% (95% CI, 25.7-45.2%), respectively. Actuarial 6- and 12-month local control was 89% (95% CI, 83-95%) and 84% (95% CI, 77-91%), respectively. Regional failure was observed in 39 patients (39.0%). 25 patients (25.0%) received salvage therapy. Grade 3 or greater treatment-related toxicity was observed in 5 patients (5.0%) and included intracranial hemorrhage, seizure, and radionecrosis. Median total treatment time was 17.2 minutes (range, 2.8-55.3 minutes). Frameless, single isocenter IMRS for the simultaneous treatment of multiple intracranial metastases can produce clinical outcomes comparable to those of conventional frame-based radiosurgery techniques with the advantages of a noninvasive approach and shortened treatment time.

BACKGROUND Black patients with metastatic colorectal cancer have inferior survival compared to white patients. The purpose of this study was to examine disparity in specialist consultation and multimodality treatment and the impact that treatment inequality has on survival. METHODS We identified 9935 non-Hispanic white and 1281 black patients with stage IV colorectal cancer aged 66 years and older from the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database. Logistic regression models identified race-based differences in consultation rates and subsequent treatment with surgery, chemotherapy, or radiation. Multivariable Cox regression models identified potential factors that explain race-based survival differences. All statistical tests were two-sided. RESULTS Black patients had lower rates of consultation with surgery, medical oncology, and radiation oncology. Among patients seen in consultation, black patients received less surgery directed at the primary tumor, liver- or lung-directed surgery, chemotherapy, and radiotherapy. Unadjusted survival analysis found a 15% higher chance of dying for black patients compared with white patients (hazard ratio [HR] = 1.15; 95% confidence interval (CI) = 1.08 to 1.22; P < .001). Adjustment for patient, tumor, and demographic variables marginally reduced the risk of death (HR = 1.08; 95% CI = 1.01 to 1.15; P = .03). After adjustment for differences in treatment, the increased risk of death for black patients disappeared. CONCLUSIONS Our study shows racial disparity in specialist consultation as well as subsequent treatment with multimodality therapy for metastatic colorectal cancer, and it suggests that inferior survival for black patients may stem from this treatment disparity. Further research into the underlying causes of this inequality will improve access to treatment and survival in metastatic colorectal cancer.

A multi-institutional report of clinical outcomes of women undergoing 3D planning for image guided brachytherapy (IGBT) for cervical cancer with at least 1 MRI. Women with FIGO IB-IVA cervical carcinoma diagnosed between 2007 and 2011 were treated with IGBT at 2 collaborating academic centers. Patients were treated with definitive external beam radiation therapy (EBRT) with concurrent chemotherapy followed by high-dose-rate (HDR) IGBT. All patients underwent planning computed tomography (CT) simulation at the time of each implant. All patients had at least 1 pelvic MRI at the beginning of IGBT for target delineation or planning. The dose was prescribed to the high-risk CTV (HRCTV) according to the GEC-ESTRO guidelines. Toxicity was graded according to the RTOG criteria. Follow-up time was measured from the date of last treatment. Time to local regional failure (LRF) was defined as time to first radiographic or pathologic evidence of disease recurrence anywhere in the pelvis and was estimated using the cumulative incidence function. Disease-free survival (DFS) time was defined as time to first evidence of LRF, distant metastasis, or death from any cause. Patients not experiencing any of these events were censored at last known medical encounter. The DFS and overall survival (OS) were estimated using the Kaplan-Meier method. One hundred ten patients were evaluated. Mean and median follow-up times were 10.6 and 8 months, respectively, with a range of 0-42.8 months. Twenty-nine percent of patients were stage I-IIA and 71% were stage IIB-IVA. IMRT and 3D conformal RT were used in 69% and 31% of patients, respectively. Median EBRT dose was 45 Gy with 65% of patients receiving a boost to involved nodes or parametria. The median dose to the HRCTV was 2750 cGy (range, 2550 to 3000) in 5 (range, 3-5) fractions. The median combined IMRT/IGBT EQD2 sum D90 (dose to 90% volume) to the HRCTV was 84.2 Gy (range, 64.4-115.1). The median treatment course duration was 50 days. Two patients having persistent local disease and 1 found to have distant metastases during treatment were excluded from DFS analysis. One year LRF was 2.2%. One patient had an isolated pelvic recurrence at 9.6 months. One-year OS and DFS were 95.7% (95% CI: 91.0-100%) and 89% (95% CI, 77%, 100%), respectively. Forty-three patients (39%) experienced grade ≥2 acute toxicity, with 2 cases of acute grade 3 toxicity and no grade ≥4 toxicities. There was 1 late grade ≥3 toxicity observed. This study is the first multi-institutional and largest report to date of CT/MRI based IGBT for treatment of cervical cancer in the United States. The results are promising with high local control and acceptable toxicity. Further investigation is needed to assess the long-term safety and efficacy of this treatment.

Intensity-modulated radiotherapy (IMRT) in post-prostatectomy patients (pts) has increased the demand for more accurate treatment delivery using image-guidance. Previous studies have reported on kilovoltage (kV) planar techniques using radio-opaque clips as fiducial markers for prostate bed (PB) localization, however many pts who have undergone robotic radical prostatectomy (RP) do not have not radio-opaque clips. With the increasing use of robotic RP, we began using kV cone-beam CT (CBCT). The purpose of this study is to review our clinical experience using this approach and to compare our results with non-robotic RP pts in which daily kV planar imaging was performed using the Trilogy on-board imaging (OBI) system. Fifty IMRT pts treated following RP were analyzed: 27 conventional RP pts with daily kV planar imaging and 23 robotic RP pts (without radio-opaque clips) with daily CBCT. The PB was localized with CBCT by aligning soft tissue on CBCT and simulation CT, whereas with OBI it was aligned by matching clip positions to those on the DRR. Shifts were recorded in anterior-posterior (AP), superior-inferior (SI), and left-right (LR) axes. Total error (TE) was defined as the change in PB position on the OBI or CBCT compared to the DRR or simulation CT. PB motion (PBM) was the PB position change relative to bone. Set-up error (SE) was the set-up inaccuracy using tattoos compared to bony alignment. SE was calculated as TE minus PBM. Differences in TE, SE, and PBM were analyzed using mixed models analysis. Acute toxicity was graded using RTOG criteria. Toxicity frequency differences were analyzed using Fisher's exact test. Total error was measured in 752 CBCTs and 725 OBI image pairs. PBM and SE were measured in 585 CBCTs and 384 OBI image pairs. The mean (±SD) TE was greater with OBI compared to CBCT in the AP (4.8 ± 4.4 vs. 3.2 ± 4.4 mm, p<0.01), SI (3.8 ± 3.7 vs. 1.9 ± 3.7, p < 0.01), and LR (3.9 ± 3.5 vs. 2.8 ± 3.5, p < 0.01). PBM was greater with OBI in the AP (2.6 ± 1.6 vs. 0.9 ± 1.6mm, p < 0.01), SI (2.4 ± 1.5 vs. 0.4 ± 1.5, p < 0.01), and LR (1.0 ± 0.9 vs. 0.4 ± 0.9, p < 0.01). SE was also greater in the AP (5.2 ± 3.8 vs. 3.7 ± 3.8, p < 0.01), SI (4.9 ± 4.1 vs. 1.9 ± 4.1, p < 0.01), and LR (3.8 ± 3.4 vs. 2.8 ± 3.4, p < 0.01). Frequencies of acute ≥ grade 2 GI (7 vs. 13%, p = 0.7) and GU (11 vs. 9%, p = 1.0) were similar for OBI and CBCT pts. No > grade 2 toxicities were seen. These results suggest that although the magnitudes of TE, PBM, SE were larger with OBI compared to CBCT, the levels of acute toxicity were acceptable and comparable between the two. The reasons for the differences are unclear, but we postulate that discernment of the PB on the CBCT is difficult. Further studies are needed to evaluate the benefits and risks of CBCT in this setting.

Previous studies have found associations between acute hematologic toxicity (HT) and the volume of pelvic bone marrow (BM) receiving > = 10 and 20 Gy (V10 and V20) in patients undergoing pelvic intensity modulated radiation therapy (IMRT). However, BM dosimetric guidelines for extended-field IMRT (EF-IMRT) are lacking. The purpose of this study was to determine if dosimetric parameters of the extended BM volume, including all lumbar vertebrae, are correlated with HT. Thirty-nine cervical cancer patients (pts) treated with concurrent cisplatin (40mg/m2/week) and IMRT were analyzed. External beam RT doses were 41.4-50.4 Gy delivered in 23-28 fractions. Fields extended superiorly to the intervertebral spaces at L4/L5 (31 pts), L3/L4 (1 pts), L2/L3 (3 pts), and T12/L1 (4 pts). All patients have planning CT scans that spanned from the mid-femur to T12/L1. Extended BM (EBM) included all the lumbar and sacral vertebrae (LSBM), as well the os coxae, acetabulae, and proximal femora. HT was measured using the acute white blood cell count (WBC) nadir, defined as the lowest value occurring between the start of chemoradiotherapy and two weeks following external beam RT. Generalized linear modeling (GLM) was used to test associations between log-transformed WBC nadir and dosimetric parameters, adjusting for age and body mass index (BMI). The mean (SD) WBC nadir for all patients was 2.3 (0.81), with 13 patients (33%) developing grade ≥ 3 leukopenia. The mean (SD) EBM-V10 and V20 were 75% (7.0) and 60% (7.2), respectively. The mean LSBM-V10 and V20 were 64% (15.1) and 60% (14.7), respectively. Statistically significant correlations were observed between decreasing log(WBC nadir) and both log(EBM-V10) and log(EBM-V20); coefficient estimates (β) for from the GLM model were -1.5 (95% confidence interval (CI): -2.7,-0.03; p = 0.016) and -1.1 (95% CI: -2.0, -0.13; p = 0.023). Significant correlations were also observed between log(WBC nadir) and both log(LSBM- V10) (β = -0.62; p = 0.025) and log(LSBM-V20) (β = -0.60; p = 0.027). R2 values for the GLM models were low (< 0.14) indicating a high degree of unexplained variation in the models. Model estimates imply that maintaining EBM-V10 < 80%, EBM-V20 < 66%, LSBM-V10 < 80%, and LSBM-V20 < 73%, could reduce the risk of grade ≥ 3 leukopenia. These data suggest that increased BM radiation dose, especially along the lumbosacral spine, is associated with increased HT for women receiving concurrent IMRT and cisplatin. Efforts to reduce BM irradiation may limit HT, but further study is needed to identify optimal dosimetric planning constraints for EF-IMRT.

The Strut Adjusted Volume Implant, SAVI, is a multi-catheter, single entry brachytherapy device for APBI designed for adaptability to anatomic constraints. There are four sizes with 6, 8, or 10 peripheral struts available for source dwell positions providing excellent dosing flexibility. Since the sizes were designed to fit multiple cavity sizes, a study was undertaken to evaluate the amount of target breast tissue treated with each device, and compare that to published data for other available devices. A retrospective review of 67 patients treated at the University of California San Diego was undertaken to evaluate the size of the treated target breast tissue. Mean sizes and ranges of the PTV-eval (1 cm expansion of the cavity excluding the cavity volume, 5mm below the skin, and chest wall) were evaluated for each SAVI size. The data was further subdivided into patients with no normal tissue restrictions on the PTV-eval, and those with chestwall and/or skin restrictions, limiting the size and shape of the PTV-eval. A symmetrical expansion of 1 cm from the 6, 8 and 10 SAVI would give ideal PTV-evals of approximately 59, 74, and 110cc. In this patient population, the 6 mini, 6, 8, and 10 strut device treated a mean and SD (with range in parentheses) of 45.2 ± 6 cc (37.9-53.9 cc), 47.6 ± 11 cc (23.2-65.9 cc), 71.9 ± 17 cc (40.5-105.1 cc), and 89.3 ± 22 cc (62-133.1 cc). Review of the data confirms that proximity to the skin, chestwall, or both reduced the PTV-eval. Published data on the Contura catheter demonstrates a mean PTV-eval of 89.7 cc (71.9-108.9 cc) and 94.9 ± 12 cc (74.4-119.8) for the Mammosite. Of the patients treated with the 6 mini or 6 SAVI, 86% had the PTV-eval reduced secondary to either proximity of skin or chestwall. Of all patients treated, 48% had skin bridges less than 7 mm, 30% less than 5 mm, and 15% less than 3 mm. Dosimetry for the entire cohort demonstrated a V90% (volume receiving 90% of the dose) of 96%, V150 and V200 (volume of tissue receiving 150 and 200% of the dose, respectively) of 27 and 13 cc. As expected, the size of the PTV-eval increases with size of SAVI catheter device. In this study, the 8 strut and especially the 10 strut device can treat an equivalent PTV-eval size well within the ranges published for MammoSite and Contura. The 6 mini device and 6 device, while treating less normal tissue, was usually chosen secondary to normal tissue proximity restrictions, limiting the amount of target tissue desirable to treat. In fact, many of these patients would not be eligible for balloon brachytherapy only based on skin proximity of < 5mm and < 3 mm, and disregarding chestwall proximity.

Recent months have seen many negative news stories on radiation therapy (RT) which may leave readers with concerns about the quality and delivery of RT. These articles beg the question of how RT is portrayed in the press and how its portrayal differs from that of other oncologic specialties. The purpose of this study was to perform a review of RT-related newspaper articles assessing their tone and content, and to compare these results with those of chemotherapy (CT) articles. Articles referring to RT and/or CT in 8 top-ranked (by circulation) newspapers published between 1/09 and 3/10 were identified using on-line archives. The following domains were assessed: title and references to efficacy, toxicity, cost and novelty, each scored as negative, positive or neutral. References to unethical behavior or negligence were scored as negative. Total positive and negative scores were calculated based on the number of positive and negative references. Differences in the frequency and mean scores between the RT and CT articles were compared using mixed models analysis to account for effects of clustering. A total of 943 articles were identified (217 RT, 481 CT, 242 both). Mean number of articles/paper was 118 (range, 30-260). Most (70%) referred to a specific disease, predominantly breast and prostate cancers. While the percentage of RT articles with RT in the title was significantly lower than the percentage of CT articles with CT in the title (2.9 vs. 8.4%, p < 0.001), the tone of RT titles was significantly more negative (69 vs. 27%, p = 0.008). RT articles were more likely to refer to severe toxicities (17 vs. 12%, p = 0.01), negligent behaviors (7 vs. 0%, p = 0.02) and less likely to refer positively to novelty (6 vs. 10%, p = 0.01). References to costs were more common in CT articles (8 vs. 5%, p = 0.06). In both groups, 23% of articles referred positively to efficacy (p = 0.78). RT articles had a lower mean number of total positive references (0.41) compared to CT articles (0.50) (p = 0.04), with most referring to efficacy and novelty in both groups. The mean number of total negative references was comparable in the RT (0.64) and the CT (0.61) groups (p = 0.57). While most negative CT references were about mild toxicities, most negative RT references were about severe toxicities. On multivariate analysis, the following characteristics were correlated with a lower cumulative score (positive minus negative references): RT-focused (p < 0.001), breast cancer (p = 0.05) and non-disease specific content (p = 0.001). Our results suggest that RT is portrayed negatively in the press and, on many measures, more so than CT. Since our patients are likely readers of these articles, it is important for Radiation Oncologists to be aware of this portrayal and seek opportunities to publicize the benefits of our modality.

Purpose/Objective(s)Following stereotactic radiosurgery (SRS) of intracranial malignancies, it can be difficult to distinguish between radiation effect and tumor progression on magnetic resonance imaging (MRI). To address this problem, we have studied the post-SRS imaging characteristics of pediatric intracranial tumors in an effort to determine the frequency of MRI changes that mimic disease progression.Materials/MethodsSerial MRI evaluations were performed on 22 lesions in 13 patients (median age: 12 years) who underwent optically-guided frameless SRS for either juvenile pilocytic astrocytoma (JPA) (n = 4), medulloblastoma (n = 4), ependymoma (n = 2), osteosarcoma metastasis (n = 1), atypical rhabdoid teratoid tumor (ATRT) (n = 1), or pineocytoma (n = 1). Prescription doses ranged from 14-30 Gy in 1-5 fractions. Tumor response was qualified as complete (CR), partial (PR), stable disease (SD), or progressive disease (PD) according to the revised Response Evaluation Criteria for Solid Tumors, version 1.1.ResultsMedian radiographic follow-up after SRS was 17 months (range, 2-39). A total of 89 follow-up MRI scans were reviewed with a median of 8 per patient (range, 1-13). During serial MRI evaluation, 9 lesions met criteria for PD at a median of 4.4 months (range, 3-19). However, of these, 3 represented transient tumor edema with 2 (JPA, ATRT) later developing a CR at a median of 15 months, and 1 persisting as SD at 12 months. The remaining 6 lesions were true local failures. Of the 13 lesions that did not show evidence of PD, a CR was obtained in 11 lesions at a median of 3 months (range, 2-6), and SD was seen in the remaining 2 tumors at last follow-up.ConclusionsLesion enlargement following SRS for pediatric intracranial tumors is common, and a proportion of patients with PD at early radiographic follow-up may later develop complete resolution of their lesions. Physicians caring for these children should be aware of these radiographic changes to avoid unwarranted medical and surgical interventions. Purpose/Objective(s)Following stereotactic radiosurgery (SRS) of intracranial malignancies, it can be difficult to distinguish between radiation effect and tumor progression on magnetic resonance imaging (MRI). To address this problem, we have studied the post-SRS imaging characteristics of pediatric intracranial tumors in an effort to determine the frequency of MRI changes that mimic disease progression. Following stereotactic radiosurgery (SRS) of intracranial malignancies, it can be difficult to distinguish between radiation effect and tumor progression on magnetic resonance imaging (MRI). To address this problem, we have studied the post-SRS imaging characteristics of pediatric intracranial tumors in an effort to determine the frequency of MRI changes that mimic disease progression. Materials/MethodsSerial MRI evaluations were performed on 22 lesions in 13 patients (median age: 12 years) who underwent optically-guided frameless SRS for either juvenile pilocytic astrocytoma (JPA) (n = 4), medulloblastoma (n = 4), ependymoma (n = 2), osteosarcoma metastasis (n = 1), atypical rhabdoid teratoid tumor (ATRT) (n = 1), or pineocytoma (n = 1). Prescription doses ranged from 14-30 Gy in 1-5 fractions. Tumor response was qualified as complete (CR), partial (PR), stable disease (SD), or progressive disease (PD) according to the revised Response Evaluation Criteria for Solid Tumors, version 1.1. Serial MRI evaluations were performed on 22 lesions in 13 patients (median age: 12 years) who underwent optically-guided frameless SRS for either juvenile pilocytic astrocytoma (JPA) (n = 4), medulloblastoma (n = 4), ependymoma (n = 2), osteosarcoma metastasis (n = 1), atypical rhabdoid teratoid tumor (ATRT) (n = 1), or pineocytoma (n = 1). Prescription doses ranged from 14-30 Gy in 1-5 fractions. Tumor response was qualified as complete (CR), partial (PR), stable disease (SD), or progressive disease (PD) according to the revised Response Evaluation Criteria for Solid Tumors, version 1.1. ResultsMedian radiographic follow-up after SRS was 17 months (range, 2-39). A total of 89 follow-up MRI scans were reviewed with a median of 8 per patient (range, 1-13). During serial MRI evaluation, 9 lesions met criteria for PD at a median of 4.4 months (range, 3-19). However, of these, 3 represented transient tumor edema with 2 (JPA, ATRT) later developing a CR at a median of 15 months, and 1 persisting as SD at 12 months. The remaining 6 lesions were true local failures. Of the 13 lesions that did not show evidence of PD, a CR was obtained in 11 lesions at a median of 3 months (range, 2-6), and SD was seen in the remaining 2 tumors at last follow-up. Median radiographic follow-up after SRS was 17 months (range, 2-39). A total of 89 follow-up MRI scans were reviewed with a median of 8 per patient (range, 1-13). During serial MRI evaluation, 9 lesions met criteria for PD at a median of 4.4 months (range, 3-19). However, of these, 3 represented transient tumor edema with 2 (JPA, ATRT) later developing a CR at a median of 15 months, and 1 persisting as SD at 12 months. The remaining 6 lesions were true local failures. Of the 13 lesions that did not show evidence of PD, a CR was obtained in 11 lesions at a median of 3 months (range, 2-6), and SD was seen in the remaining 2 tumors at last follow-up. ConclusionsLesion enlargement following SRS for pediatric intracranial tumors is common, and a proportion of patients with PD at early radiographic follow-up may later develop complete resolution of their lesions. Physicians caring for these children should be aware of these radiographic changes to avoid unwarranted medical and surgical interventions. Lesion enlargement following SRS for pediatric intracranial tumors is common, and a proportion of patients with PD at early radiographic follow-up may later develop complete resolution of their lesions. Physicians caring for these children should be aware of these radiographic changes to avoid unwarranted medical and surgical interventions.

Purpose/Objective(s)Intensity-modulated radiation therapy (IMRT) has an emerging role in the management of post-prostatectomy patients with prostate cancer. To account for organ motion, we have devised a unique system of prostate-bed localization using daily image-guidance to existing surgical clips. We report here on the acute and late gastrointestinal (GI) and genitourinary (GU) toxicity associated with this technique.Materials/MethodsFifty patients (pts) were treated between 2005 and 2008 with IMRT following radical prostatectomy. Median pt age was 63 (range, 52-77). Pathologic stages were T1c (2%), T2a (4%), T2b (6%), T2c (30%), T3a (26%), T3b (28%), T4 (2%) and unavailable (2%). Median Gleason score was 7 (range 6-9). Adjuvant therapy was given to 13 pts (26%), and salvage therapy to 37 pts (74%). The median radiation dose was 68 Gy (range, 62-68) given in 34 fractions (range, 31-37). The planning target volume was generated with an 8-10 mm margin around the prostate bed, except posteriorly where it was reduced to 5 mm. Prostate bed localization was performed daily by taking orthogonal kilovoltage (kV) images (90%) or cone-beam CT (CBCT) (10%). Patients were repositioned according to the alignment of surgical clips between the kV or CBCT images and the planning digitally reconstructed radiographs (DRRs). Follow-up occurred every 3-6 months. Toxicity was graded according the Common Toxicity Criteria version 3.0. Acute toxicities were defined as events occurring during treatment or ≤90 days from the completion of treatment. Late toxicities were new or persisting events occurring >90 days from treatment completion.ResultsMedian follow-up for all 50 pts was 24 months (range, 13-38). Grade 1 and grade 2 acute GI toxicities occurred in 29 (58%) and 7 (14%) pts. Grade 1 and 2 acute GU toxicity occurred in 26 (52%) and 9 (18%) pts. No grade 3 or higher acute GI or GU toxicity was observed. In addition, no pts required treatment interruptions. Grade 1 and 2 late GI toxicity occurred in 4 (8%) and 1 (2%) pts, respectively. No grade 3 or higher late GI toxicity was observed. Grade 1, 2, and 3 late GU toxicity occurred in 4 (10%), 8 (16%) and 1 (2%) pts. The single grade 3 GU toxicity was bleeding requiring coagulation in a pt on coumadin. The 2-year cumulative incidence of grade 2 or higher late GI toxicity was 2% (95% confidence interval [C.I.], 0.3-14). The 2-year cumulative incidence of grade 2 or higher and grade 3 or higher late GU toxicity was 16% (95% C.I., 9-30) and 2% (95% C.I., 0.3-14), respectively. No grade 4 events were observed.ConclusionsImage-guided IMRT in the post-prostatectomy setting can reduce the incidence of acute and late GI/GU toxicity. More importantly, no severe high-grade acute or late GI/GU toxicities were observed. Purpose/Objective(s)Intensity-modulated radiation therapy (IMRT) has an emerging role in the management of post-prostatectomy patients with prostate cancer. To account for organ motion, we have devised a unique system of prostate-bed localization using daily image-guidance to existing surgical clips. We report here on the acute and late gastrointestinal (GI) and genitourinary (GU) toxicity associated with this technique. Intensity-modulated radiation therapy (IMRT) has an emerging role in the management of post-prostatectomy patients with prostate cancer. To account for organ motion, we have devised a unique system of prostate-bed localization using daily image-guidance to existing surgical clips. We report here on the acute and late gastrointestinal (GI) and genitourinary (GU) toxicity associated with this technique. Materials/MethodsFifty patients (pts) were treated between 2005 and 2008 with IMRT following radical prostatectomy. Median pt age was 63 (range, 52-77). Pathologic stages were T1c (2%), T2a (4%), T2b (6%), T2c (30%), T3a (26%), T3b (28%), T4 (2%) and unavailable (2%). Median Gleason score was 7 (range 6-9). Adjuvant therapy was given to 13 pts (26%), and salvage therapy to 37 pts (74%). The median radiation dose was 68 Gy (range, 62-68) given in 34 fractions (range, 31-37). The planning target volume was generated with an 8-10 mm margin around the prostate bed, except posteriorly where it was reduced to 5 mm. Prostate bed localization was performed daily by taking orthogonal kilovoltage (kV) images (90%) or cone-beam CT (CBCT) (10%). Patients were repositioned according to the alignment of surgical clips between the kV or CBCT images and the planning digitally reconstructed radiographs (DRRs). Follow-up occurred every 3-6 months. Toxicity was graded according the Common Toxicity Criteria version 3.0. Acute toxicities were defined as events occurring during treatment or ≤90 days from the completion of treatment. Late toxicities were new or persisting events occurring >90 days from treatment completion. Fifty patients (pts) were treated between 2005 and 2008 with IMRT following radical prostatectomy. Median pt age was 63 (range, 52-77). Pathologic stages were T1c (2%), T2a (4%), T2b (6%), T2c (30%), T3a (26%), T3b (28%), T4 (2%) and unavailable (2%). Median Gleason score was 7 (range 6-9). Adjuvant therapy was given to 13 pts (26%), and salvage therapy to 37 pts (74%). The median radiation dose was 68 Gy (range, 62-68) given in 34 fractions (range, 31-37). The planning target volume was generated with an 8-10 mm margin around the prostate bed, except posteriorly where it was reduced to 5 mm. Prostate bed localization was performed daily by taking orthogonal kilovoltage (kV) images (90%) or cone-beam CT (CBCT) (10%). Patients were repositioned according to the alignment of surgical clips between the kV or CBCT images and the planning digitally reconstructed radiographs (DRRs). Follow-up occurred every 3-6 months. Toxicity was graded according the Common Toxicity Criteria version 3.0. Acute toxicities were defined as events occurring during treatment or ≤90 days from the completion of treatment. Late toxicities were new or persisting events occurring >90 days from treatment completion. ResultsMedian follow-up for all 50 pts was 24 months (range, 13-38). Grade 1 and grade 2 acute GI toxicities occurred in 29 (58%) and 7 (14%) pts. Grade 1 and 2 acute GU toxicity occurred in 26 (52%) and 9 (18%) pts. No grade 3 or higher acute GI or GU toxicity was observed. In addition, no pts required treatment interruptions. Grade 1 and 2 late GI toxicity occurred in 4 (8%) and 1 (2%) pts, respectively. No grade 3 or higher late GI toxicity was observed. Grade 1, 2, and 3 late GU toxicity occurred in 4 (10%), 8 (16%) and 1 (2%) pts. The single grade 3 GU toxicity was bleeding requiring coagulation in a pt on coumadin. The 2-year cumulative incidence of grade 2 or higher late GI toxicity was 2% (95% confidence interval [C.I.], 0.3-14). The 2-year cumulative incidence of grade 2 or higher and grade 3 or higher late GU toxicity was 16% (95% C.I., 9-30) and 2% (95% C.I., 0.3-14), respectively. No grade 4 events were observed. Median follow-up for all 50 pts was 24 months (range, 13-38). Grade 1 and grade 2 acute GI toxicities occurred in 29 (58%) and 7 (14%) pts. Grade 1 and 2 acute GU toxicity occurred in 26 (52%) and 9 (18%) pts. No grade 3 or higher acute GI or GU toxicity was observed. In addition, no pts required treatment interruptions. Grade 1 and 2 late GI toxicity occurred in 4 (8%) and 1 (2%) pts, respectively. No grade 3 or higher late GI toxicity was observed. Grade 1, 2, and 3 late GU toxicity occurred in 4 (10%), 8 (16%) and 1 (2%) pts. The single grade 3 GU toxicity was bleeding requiring coagulation in a pt on coumadin. The 2-year cumulative incidence of grade 2 or higher late GI toxicity was 2% (95% confidence interval [C.I.], 0.3-14). The 2-year cumulative incidence of grade 2 or higher and grade 3 or higher late GU toxicity was 16% (95% C.I., 9-30) and 2% (95% C.I., 0.3-14), respectively. No grade 4 events were observed. ConclusionsImage-guided IMRT in the post-prostatectomy setting can reduce the incidence of acute and late GI/GU toxicity. More importantly, no severe high-grade acute or late GI/GU toxicities were observed. Image-guided IMRT in the post-prostatectomy setting can reduce the incidence of acute and late GI/GU toxicity. More importantly, no severe high-grade acute or late GI/GU toxicities were observed.

Purpose/Objective(s)Stereotactic radiosurgery (SRS) has a well-established role in the management of patients (pts) with brain metastases (BM). We describe here our clinical experience using a unique single-isocenter frameless intensity-modulated SRS (IMSRS) approach for multiple BM.Materials/Methods26 pts (138 lesions) were treated with our single-isocenter IMSRS technique between March 2005 and May 2008. Treatment plans were created using a planning contrast-enhanced MRI fused to the simulation CT; target lesions were contoured by the treating radiation oncologist and neurosurgeon and expanded by 1-3 mm. A single, centrally-located isocenter was used. All pts were treated with frameless IMSRS utilizing an optically-guided bite-block fiducial array. Primary tumors were breast (42%), lung (31%) and melanoma (27%). Pts had a median (range) of 5 (2-13) lesions with a median size of 10 mm (1-45 mm). Median prescription dose was 18 Gy (4-25 Gy) and was given in a single fraction (fx), except for one patient who was given 25 Gy in 5 Gy fx. Whole-brain radiotherapy (WBRT) was given to 6 pts (23%). Follow-up MRI and clinical exam occurred every 2-4 months. Total treatment time and beam-on time were measured. Treatment response was analyzed by survival and local control (LC). LC was defined as absence of progression of the treated lesion. Toxicity was graded by the RTOG scale.ResultsFor all 26 patients, the median follow-up was 3.3 months (range, 0.2-21.3 months). The 6 and 12 month actuarial survivals were 50% (95% confidence interval [C.I.], 31-70%) and 38% (95% C.I., 19-56%), respectively. Six pts were alive at the time of analysis and had a median follow-up of 14.6 months (range, 9.3-18.0). Of 21 pts (116 lesions) evaluable for LC, 17 pts (81%) and 108 lesions (93%) did not show evidence of progression. Actuarial 6 and 12 month LC rates were 97% (95% C.I., 93-100%) and 83% (95% C.I., 71-96%), respectively. Tumors ≤ 1.5 cm had a better 6 month LC (98% and 90%, p = 0.008) than those > 1.5 cm. Salvage therapy included repeat SRS (4 pts), WBRT (5 pts), and surgery (1 pt). Acute and late grade 3 toxicities occurred in 1 (4%) and 2 (8%) pts, respectively. No grade 4 toxicities were observed. Total treatment time and beam-on time ranged from 9.0-38.9 (median, 21.0) and 2.0-17.9 (median, 5.4) minutes, respectively.ConclusionsPatients with multiple BM that are treated with frameless IMSRS using a single isocenter approach have an excellent LC rate with survival and toxicities outcomes that compare favorably to conventional SRS. As the planning and treatment time is substantially shorter than multiple isocenter methods, our technique is both appealing to patients and ideal for busy clinics. Purpose/Objective(s)Stereotactic radiosurgery (SRS) has a well-established role in the management of patients (pts) with brain metastases (BM). We describe here our clinical experience using a unique single-isocenter frameless intensity-modulated SRS (IMSRS) approach for multiple BM. Stereotactic radiosurgery (SRS) has a well-established role in the management of patients (pts) with brain metastases (BM). We describe here our clinical experience using a unique single-isocenter frameless intensity-modulated SRS (IMSRS) approach for multiple BM. Materials/Methods26 pts (138 lesions) were treated with our single-isocenter IMSRS technique between March 2005 and May 2008. Treatment plans were created using a planning contrast-enhanced MRI fused to the simulation CT; target lesions were contoured by the treating radiation oncologist and neurosurgeon and expanded by 1-3 mm. A single, centrally-located isocenter was used. All pts were treated with frameless IMSRS utilizing an optically-guided bite-block fiducial array. Primary tumors were breast (42%), lung (31%) and melanoma (27%). Pts had a median (range) of 5 (2-13) lesions with a median size of 10 mm (1-45 mm). Median prescription dose was 18 Gy (4-25 Gy) and was given in a single fraction (fx), except for one patient who was given 25 Gy in 5 Gy fx. Whole-brain radiotherapy (WBRT) was given to 6 pts (23%). Follow-up MRI and clinical exam occurred every 2-4 months. Total treatment time and beam-on time were measured. Treatment response was analyzed by survival and local control (LC). LC was defined as absence of progression of the treated lesion. Toxicity was graded by the RTOG scale. 26 pts (138 lesions) were treated with our single-isocenter IMSRS technique between March 2005 and May 2008. Treatment plans were created using a planning contrast-enhanced MRI fused to the simulation CT; target lesions were contoured by the treating radiation oncologist and neurosurgeon and expanded by 1-3 mm. A single, centrally-located isocenter was used. All pts were treated with frameless IMSRS utilizing an optically-guided bite-block fiducial array. Primary tumors were breast (42%), lung (31%) and melanoma (27%). Pts had a median (range) of 5 (2-13) lesions with a median size of 10 mm (1-45 mm). Median prescription dose was 18 Gy (4-25 Gy) and was given in a single fraction (fx), except for one patient who was given 25 Gy in 5 Gy fx. Whole-brain radiotherapy (WBRT) was given to 6 pts (23%). Follow-up MRI and clinical exam occurred every 2-4 months. Total treatment time and beam-on time were measured. Treatment response was analyzed by survival and local control (LC). LC was defined as absence of progression of the treated lesion. Toxicity was graded by the RTOG scale. ResultsFor all 26 patients, the median follow-up was 3.3 months (range, 0.2-21.3 months). The 6 and 12 month actuarial survivals were 50% (95% confidence interval [C.I.], 31-70%) and 38% (95% C.I., 19-56%), respectively. Six pts were alive at the time of analysis and had a median follow-up of 14.6 months (range, 9.3-18.0). Of 21 pts (116 lesions) evaluable for LC, 17 pts (81%) and 108 lesions (93%) did not show evidence of progression. Actuarial 6 and 12 month LC rates were 97% (95% C.I., 93-100%) and 83% (95% C.I., 71-96%), respectively. Tumors ≤ 1.5 cm had a better 6 month LC (98% and 90%, p = 0.008) than those > 1.5 cm. Salvage therapy included repeat SRS (4 pts), WBRT (5 pts), and surgery (1 pt). Acute and late grade 3 toxicities occurred in 1 (4%) and 2 (8%) pts, respectively. No grade 4 toxicities were observed. Total treatment time and beam-on time ranged from 9.0-38.9 (median, 21.0) and 2.0-17.9 (median, 5.4) minutes, respectively. For all 26 patients, the median follow-up was 3.3 months (range, 0.2-21.3 months). The 6 and 12 month actuarial survivals were 50% (95% confidence interval [C.I.], 31-70%) and 38% (95% C.I., 19-56%), respectively. Six pts were alive at the time of analysis and had a median follow-up of 14.6 months (range, 9.3-18.0). Of 21 pts (116 lesions) evaluable for LC, 17 pts (81%) and 108 lesions (93%) did not show evidence of progression. Actuarial 6 and 12 month LC rates were 97% (95% C.I., 93-100%) and 83% (95% C.I., 71-96%), respectively. Tumors ≤ 1.5 cm had a better 6 month LC (98% and 90%, p = 0.008) than those > 1.5 cm. Salvage therapy included repeat SRS (4 pts), WBRT (5 pts), and surgery (1 pt). Acute and late grade 3 toxicities occurred in 1 (4%) and 2 (8%) pts, respectively. No grade 4 toxicities were observed. Total treatment time and beam-on time ranged from 9.0-38.9 (median, 21.0) and 2.0-17.9 (median, 5.4) minutes, respectively. ConclusionsPatients with multiple BM that are treated with frameless IMSRS using a single isocenter approach have an excellent LC rate with survival and toxicities outcomes that compare favorably to conventional SRS. As the planning and treatment time is substantially shorter than multiple isocenter methods, our technique is both appealing to patients and ideal for busy clinics. Patients with multiple BM that are treated with frameless IMSRS using a single isocenter approach have an excellent LC rate with survival and toxicities outcomes that compare favorably to conventional SRS. As the planning and treatment time is substantially shorter than multiple isocenter methods, our technique is both appealing to patients and ideal for busy clinics.

Studies evaluating cervical cancer tumor regression using CT or MRI have documented significant reductions in tumor volume midway through treatment, suggesting that midtreatment replanning may be beneficial. This study will investigate the dosimetric implications of midtreatment replanning, using daily cone beam computed tomography (CBCT). Ten FIGO Stage IB2–IIIB intact cervical cancer patients undergoing intensity modulated radiation therapy received between 17 and 24 (median, 22) CBCT scans using a gantry-mounted CBCT imager. The CBCTs were fused to the initial simulation CT using rigid registration, then clinical target volumes (CTV) and normal tissues were delineated on each CBCT and subsequently cast onto the planning CT. Using a 1 cm planning target volume (PTV) margin, two plans were generated: one based on the simulation CT and one based on the volumes derived from a midtreatment CBCT. These plans were used to simulate a nonadaptive and adaptive approach. The nonadaptive approach used only the CT simulation-based plan, whereas the adaptive approach implemented the CBCT-based plan midway through treatment for the remainder of the treatment course. The contours created from the daily CBCTs were used to generate dose–volume histograms of the CTV and normal tissues. Volume receiving 100% of the prescription dose (V100) for CTV, bladder, small bowel, and rectum was calculated for each day and compared between the nonadaptive and adaptive approaches. Conformity indices (CI) (dice coefficient) of the CTVs and the volume receiving 1.8 Gy were compared. Mean CTV V100 was improved with the adaptive approach (97.9% vs. 98.9%; p = 0.002). Reductions in mean V100 for both bladder (57.8 vs. 48.7, p < 0.001) and small bowel (34.4 vs. 27.4; p < 0.001) were seen using the adaptive approach. In contrast, no difference was seen for the mean rectal V100 (50.1 vs. 54.7; p = 0.07). Mean CI was significantly improved with replanning (0.49 vs. 0.56; p < 0.001). Overall, mean CI improved in 9/10 women. Similarly, mean V100 for bowel and bladder improved in 6 and 7 patients, respectively. Of these women, the median reductions in V100 were 16% and 27%. Mixed results were seen for the rectum with 3 patients seeing no change, 4 patients with a median improvement of 12% (range, 9–20%), and 3 with a median decrement of 19% (9–41%). Overall, adaptive radiotherapy performed midtreatment in patients with cervical cancer is associated with a net dosimetric benefit in terms of target coverage, normal tissue sparing, and improved conformity. However, results are variable with the potential for substantial worsening of rectal sparing in some patients. Studies are ongoing to further evaluate the benefits and risks of this approach, as well as optimal timing and frequency of replanning.