New cases of invasive cancer in the United States occur among nearly 1.5 million people annually. In 2007, more than 1,500 people died per day with this diagnosis. Cancer is responsible for nearly one in every four deaths reported in the country. Enormous amounts of money and research have been, and are being spent, in an attempt to improve these numbers. While prevention and early detection remain the key to long-term success, treatment in the neo-adjuvant, adjuvant and metastatic settings still centre around two main treatment modalities - radiation therapy and chemotherapy. This article will review the advances that have been made in both areas that are making these treatments more precise and convenient, as well as less toxic, for the patient. In the field of radiation therapy this involves the development of new therapy planning and delivery systems, such as intensity-modulated radiation therapy (IMRT), and positron emission and computed tomography, PET-CT. Chemotherapy has also evolved with the development of targeted chemotherapy for the treatment of specific malignancies as well as improved supportive care agents which allow for the administration of dose-dense chemotherapy when appropriate.

Purpose/Objective: To evaluate the incidence of acute skin toxicity in patients with breast cancer treated with intensity modulated radiation therapy (IMRT) following breast conserving surgery.Materials/Methods: Between February 2003 and January 2005, 506 patients with early stage breast cancer underwent breast conservation surgery and definitive breast irradiation using 2-angle tangential field IMRT. The median dose delivered to the entire breast was 50 Gy in 25 fractions. Electron beam boost to the lumpectomy cavity was delivered via enface electrons with a median dose of 10 Gy for a median total dose of 60 Gy in 30 fractions. Throughout the course of radiation treatment, all patients were evaluated on a weekly basis by the treating radiation oncologist for acute skin toxicity including erythema and desquamation which were graded using the RTOG toxicity scale.Results: The median breast volume (TV) in this cohort of patients was 894 cc (range 104–3387 cc). For all patients, the incidence of acute erythema grades 0,1,2, and 3 were 23%, 45%, 31%, and 1%, respectively. The rates of acute skin desquamation grades 0,1,2, and 3 were 81.5%, 14%, 4%, and 0.5%, respectively. The median maximum dose delivered to the TV was 55 Gy using IMRT. The median % of TV receiving more than the prescribed dose was 83%. The median % of TV receiving more than 110% and less than 95% of prescribed dose was 0% and 8%, respectively. The incidence of desquamation significantly correlated with TV (p<0.001), max dose to TV (p=0.017) and % TV receiving more than prescribed dose (p=0.016). There was no significant correlation of these dosimetric quantities or TV to skin erythematic grade.Tabled 1Correlation Analysis of Breast Volume and Dosimetric Values with Acute Skin Desquamation Toxicity for Breast IMRT Purpose/Objective: To evaluate the incidence of acute skin toxicity in patients with breast cancer treated with intensity modulated radiation therapy (IMRT) following breast conserving surgery. Materials/Methods: Between February 2003 and January 2005, 506 patients with early stage breast cancer underwent breast conservation surgery and definitive breast irradiation using 2-angle tangential field IMRT. The median dose delivered to the entire breast was 50 Gy in 25 fractions. Electron beam boost to the lumpectomy cavity was delivered via enface electrons with a median dose of 10 Gy for a median total dose of 60 Gy in 30 fractions. Throughout the course of radiation treatment, all patients were evaluated on a weekly basis by the treating radiation oncologist for acute skin toxicity including erythema and desquamation which were graded using the RTOG toxicity scale. Results: The median breast volume (TV) in this cohort of patients was 894 cc (range 104–3387 cc). For all patients, the incidence of acute erythema grades 0,1,2, and 3 were 23%, 45%, 31%, and 1%, respectively. The rates of acute skin desquamation grades 0,1,2, and 3 were 81.5%, 14%, 4%, and 0.5%, respectively. The median maximum dose delivered to the TV was 55 Gy using IMRT. The median % of TV receiving more than the prescribed dose was 83%. The median % of TV receiving more than 110% and less than 95% of prescribed dose was 0% and 8%, respectively. The incidence of desquamation significantly correlated with TV (p<0.001), max dose to TV (p=0.017) and % TV receiving more than prescribed dose (p=0.016). There was no significant correlation of these dosimetric quantities or TV to skin erythematic grade.

Purpose/Objective: Limited data exists for dose-volume relationship of parotid gland when patients receive chemoradiation. The purpose of this study is to evaluate the relationship between parotid dose and severity of acute and "early" late xerostomia for patients receiving chemoradiation for head and neck cancers. Materials/Methods: 333 patients with head and neck cancer (HNC) were treated with intensity modulated radiation therapy (IMRT). Of these, 209 patients (63%) were treated with concurrent chemotherapy & radiation and 124 (37%) were treated with radiation alone. All patients underwent a simulation procedure simulated for IMRT treatment planning in a Uni-frame® head immobilization system (MED-TEC Corp, Orange City, IA) and centrally planned on Varian Eclipse (version 6.5) in a distributed cancer network. The superficial lobe of the parotid gland was contoured and the dose volume histogram for parotid tissue was evaluated using the Eclipse planning system. The mean dose to the parotid gland were obtained. Patients were evaluated during treatment for acute xerostomia using the RTOG toxicity scoring system as well as in follow up after completion of treatment for evaluation of late xerostomia. The maximum scores for the early and late toxicities were used for this study. Patients were divided into two groups: group 1 with patients with mean parotid dose less than 26 Gy and group 2 with patients with mean parotid dose greater than 26 Gy. A non-parametric correlation and Chi square analysis was performed to determine the relationship between these two groups with the grade of acute and late xerostomia for patients treated using IMRT with and without chemotherapy. The median follow up after completion of radiation treatment is 8 months. Results: The median mean parotid dose for HNC patients treated with IMRT with and without chemotherapy is 26.5 and 25 Gy, respectively (p=NS). For all patients with mean parotid dose less than 26 Gy, rate of Grade 2 and 3 acute salivary toxicity were 20% and 3% compared to 33% and 9%, respectively, for patients with mean parotid dose greater than 26 Gy (p=0.005). The rates of Grade 2 and 3 late salivary toxicity for all patients with mean parotid dose < 26 Gy was 8 and 0%, respectively, compared to 23% and 5% for patients with mean parotid dose > 26 Gy (p <0.0001). The grade 2 and 3 acute salivary for toxicities for patients receiving IMRT alone was 16 and 3%, respectively, while 27 and 6%, respectively for patients receiving IMRT and chemotherapy (p<0.0001). For patients with mean parotid dose < 26 Gy, the grade 3 acute and late salivary toxicity was 0 and 0% for patients who were treated with IMRT alone in contrast to 9% and 0%,respectively for patients receiving IMRT and chemotherapy(p=0.001). For patients with mean parotid dose greater than 26 Gy, the Grade 3 acute and late salivary toxicity was 3 and 6%,respectively, for patients treated with IMRT alone compared to 32% and 4%, respectively, for patients receiving chemotherapy and IMRT (p=0.02). Conclusions: This study suggests that distinct dose volume relationships exists for patients treated with chemoradiation versus radiation alone using IMRT for HNC. Patients who received IMRT and chemotherapy had significantly increased acute and late salivary toxicity regardless of the mean parotid dose. A more detailed characterization of this relationship and evaluation of the NTCP is underway with an expanded cohort of patients in order to establish appropriate parotid dose-volume constraints for patients treated with chemoradiation using IMRT.

Purpose/Objective: Acute mucositis is a common acute toxicity for patients treated with radiation therapy for head and neck cancer (HNC) and is significantly increased when combined with chemotherapy. The purpose of this study is to evaluate the correlation between the dose to the oral cavity and the severity of acute mucositis in HNC patients treated with chemotherapy and IMRT. Materials/Methods: Between April 2002 through September 2004, 70 patients with HNC were treated with IMRT with 5–7 fields using dynamic multileaf collimators. All patients also received combination chemotherapy. Patients underwent a simulation procedure for IMRT treatment planning in a Uni-frame® head immobilization system (MED-TEC Corp, Orange City, IA) and centrally planned on Varian Eclipse (version 6.5) in a distributed cancer network. For each patient, the oral cavity was contoured and the dose volume histogram was evaluated using the Eclipse planning system. The median dose delivered to the primary site was 70 Gy. Throughout radiation treatment, all patients were evaluated on a weekly basis by the radiation oncologist to evaluate acute mucositis using the RTOG toxicity scale. The maximum toxicity score was used for this study. Using SPSS 12.0, a non-parametric correlation analysis was performed between the acute mucositis grade and the percent volume of oral cavity receiving doses higher than 15, 30, 40, 45, 50 Gy (V15,V30,V40,V45,V50). Results: The rates of acute mucositis grades 0, 1, 2, and 3 were 6%, 27%, 51% and 16%, respectively. There was no grade 4 or 5 acute mucositis. The median V15, V30, V40, V45, and V50 were 69%, 61%, 30%, 19% and 10%, respectively. There was a statistically significant correlation between acute mucositis grade (p<0.05) and the V15, 30,40,45 (Table 1) while V50 marginal significance (p=0.06). Conclusions: Dose and volume to the oral cavity significantly correlates to the grade of acute mucositis in patients treated with HNC and chemotherapy. The rates of grade 3–4 of mucositis in this study compares favorably to recent clinical trial data (RTOG 91-11) in patients treated with conventional radiation techniques (43% vs. 16%). Further investigation is warranted to explore the dose volume relationship parameters and normal tissue complication probability (NTCP) for oral cavity. Once found, dose volume constraints could be used for IMRT inverse planning to further reduce the incidence of acute mucositis when chemotherapy is used in conjunction with IMRT. Tabled 1Correlation Analysis of Percent Volume of Oral Cavity Receiving More Than 15,30,40,45,50 Gy with Grade of Acute Oral Mucositis