As treatment for prostate cancer matures with many options for local, regional and systemic care, patients are living longer. Coupled with aggressive therapy for oligometastatic disease and improvements in multiple treatment pathways including radiopharmacy, both disease-free and overall survival are improving for many patients. Success can also bring new challenges that require new thought processes for care. In this paper we present two patients who had undergone previous radiation therapy for adenocarcinoma of the prostate with curative intent who required consideration for re-irradiation each more than 15 years away from primary management.

Radiation therapy delivered with definitive intent is challenging in the treatment of malignancies involving the extremities. Often, the target volume of interest is circumferential in the extremity compartment and sparing normal tissue and providing conformal avoidance to bone/soft tissue is difficult to achieve. In this manuscript we review the use of volumetric modulated arc therapy (VMAT) to provide concurrent and simultaneous radiation treatment to tumors in both anterior and posterior compartments including the popliteal fossa with appropriate sparing of normal tissue for lymphatic drainage. The use of advanced therapy technology can make a significant difference in the comprehensive management of patients with both epithelial and non-epithelial non-Hodgkin lymphoma lesions in the extremities.

Cancer remains a significant medical challenge for modern health care. Therapies have improved. Chemotherapy can now be applied and targeted to specific expression products and biomarkers. Radiation therapy is directed to specific targets with applied image guidance including less normal tissue in the treatment fields. Surgery has improved with robotics and improvements in rehabilitation and recovery. More patients are surviving their primary challenge from malignancy. As such, more patients now have the imprint of therapy upon their normal tissues. It is important for all practitioners, including primary care physicians and medical subspecialists, to participate in the aftercare of these patients with a comprehensive strategic manner to both prevent normal tissue injury and ameliorate injury if/when it occurs.

Introduction: Hematuria can be a distressing and debilitating complication of urothelial carcinoma (UC) of the kidney for patients who are not candidates for surgery or ureteroscopic ablation. We retrospectively assessed the efficacy, tolerability, and safety of stereotactic body radiotherapy (SBRT) for controlling gross hematuria in this patient population. Materials and Methods: Institutional Review Board (IRB)-approved review of the records, laboratory values, pathology, and imaging of 8 consecutive patients treated with SBRT over a 5-year period for uncontrolled gross hematuria caused by UC of the renal pelvis or calyces. Results: Therapy was delivered in 3 to 5 treatments over 1 to weeks. Individual treatments lasted an average of 17.2 minutes. No patient experienced treatment-related pain, vomiting, or diarrhea. All enjoyed cessation of bleeding within a week of completing therapy. Hematuria recurred in 2 patients in 4 and 22 months. Of the patients who have not re-bled, 3 expired of metastatic disease or co-morbidities, and 3 remain alive up to 6 years posttreatment. Of patients who have survived longer than a year, creatinine has changed by -0.05 to +0.35, and estimated glomerular filtration rate has fallen by an average of 22%. No patient has required dialysis. Conclusions: SBRT appears to be an effective and well-tolerated means of palliating gross hematuria secondary to UC of the renal pelvis or calyces in patients who are unfavorable candidates for nephrectomy or ureteroscopic ablation. Treatment was associated with a moderate decline in renal function.

Mucin is a hyaluronic acid complex found in modest quantity in dermal connectives tissues. It serves as a protective barrier and supports tissue elasticity. Mucin has an important role as a response vehicle to injury and trauma in multiple body regions. Although thought to be produced by connective tissue, fibroblasts, and mast cells, the origin and regulatory mechanisms associated with production and absorption of mucin are largely unknown. Accumulation of unregulated large volumes of mucin in subcutaneous tissues can result in pain and limited wound healing when tissues over saturated with mucin are injured. Repair systems are less effective in edematous tissue as cell systems required for healing cannot accumulate at the site of injury in an organized enterprise manner. Clinically relevant forms of mucinosis have been described in hypothyroidism, thyrotoxicosis, and scleromyxedema associated with monoclonal gammopathies. Mucinosis has also been associated with systemic lupus, systemic sclerosis, and dermatomyositis including patients treated with chemoradiotherapy. In this paper we present a case report of an individual who had exhausted traditional therapies for mucinosis associated with an underlying thyroid disorder and had significant difficulty walking due to pain and discomfort in both her feet and distal lower extremities. We report on successful application of radiation therapy to effectively treat her symptoms.

Dystrophic calcification in breast tissue and the chest wall is a common finding in patients undergoing definitive therapy including radiation treatment for breast cancer. In this report, we correlate significant and symptomatic dystrophic dense calcification as a late treatment effect associated with radiation therapy and correlate dosimetry and radiation dose and daily dose fractionation asymmetry to the development of calcifications.

This chapter details the history of radiation therapy, identifies essential components to a modern department of radiation therapy, and focuses on salient areas of improvement in patient outcome for the next generation of cancer patients. Tumor is more sensitive to radiation in an oxygenated environment; therefore a larger oxygen component to the tumor microenvironment should have a direct positive effect on tumor cell kill. The science of radiation biology continues to expand as radiation therapy continues to increase in demand as a patient care option. Brachytherapy can be used as a sole modality of care for patients with low risk factors for recurrence and as part of an integrated care plan combined with external radiation therapy for patients with intermediate and high risk features for tumor recurrence. Radiosurgery and stereotactic radiation therapy are important areas of research as cell kill from high dose therapy may be exceptionally proficient.

To the Editor: Likhacheva et al ( 1 Likhacheva A. Mitin T. Khmelevsky E. The red beam: Past, present, and future of radiation oncology in Russia. Int J Radiat Oncol Biol Phys. 2017; 97: 220-224 Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar ) take justifiable pride in the contributions made by Russian pioneers in the advancement of radiation therapy, but publishing “the world's first clinical textbook of radiation oncology,” however, was not one of their distinctions. Reshetillo's 1906 text (Lechenie luchami Rentgena) was preceded by several others ( 2 Pusey W.A. Caldwell E.W. The Practical Application of the Röntgen Rays in Therapeutics and Diagnosis. WB Saunders, Philadelphia1903 Google Scholar , 3 Freund L. Grundriß der gesamten Radiotherapie für praktische Ärzte. Urban & Schwarzenberg, Vienna1903 Google Scholar , 4 Allen C.W. Radiotherapy and Phototherapy. Lea Brothers, New York1904 Google Scholar , 5 Belot J. Traité de radiothérapie. G Steinheil, Paris1904 Google Scholar ). Like Reshetillo, the authors of most early radiation therapy texts were dermatologists (reflecting the superficial penetration of the x rays produced by early equipment). Russians can claim the earliest published report of successful treatment of cancer by brachytherapy: St. Petersburg pathologists Semen W. Goldberg and Efim S. London described the favorable response of rodent ulcers to radium in 1903 ( 6 Goldberg S.Z. London E.S. Zur frage der beziehungen zwischen bequerelstrahlen und hautaffectionen. Dermatol Z. 1903; 10: 457-462 Crossref Google Scholar ). The Red Beam: Past, Present, and Future of Radiation Oncology in RussiaInternational Journal of Radiation Oncology, Biology, PhysicsVol. 97Issue 2PreviewThe history of medicine and science in Russia is full of global “firsts,” and Russians are rightly proud of this scientific heritage. Even non-Russians with a working knowledge of scientific history can cite, for instance, that the periodic table of elements was conceived by Dmitri Mendeleev, the first virus was isolated by Dmitry Ivanovski, and the first extraterrestrial satellite placed in orbit and first manned space flight, respectively, were accomplished by teams of Soviet scientists and engineers. Full-Text PDF In Reply to AronowitzInternational Journal of Radiation Oncology, Biology, PhysicsVol. 98Issue 2PreviewTo the Editor: In our article, we purposely used the phrase “might be” to describe whether Reshetillo's publication represented the first radiation therapy textbook (1, 2). This was meant to reflect the ambiguity of using a modern term (“textbook”) that denotes a mature and standardized curriculum to describe a foundational primer published at the turn of the past century. Our statement was not meant in any way to detract from the contributions of other international figures who published early works in radiation therapy. Full-Text PDF

To the Editor: We were fascinated by Nicolas Foray's account of the life and work of Victor Despeignes ( 1 Foray N. Victor Despeignes, the forgotten pioneer of radiation oncology. Int J Radiat Oncol Biol Phys. 2016; 96: 717-721 Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar ) and the circumstances surrounding his brief investigation of the therapeutic properties of x-rays. We were puzzled, however, by Professor Foray's estimation of delivered dose (0.36 Gy at 3-cm depth, per 30-minute session), because there was a paucity of data necessary to make such a calculation. Victor Despeignes, the Forgotten Pioneer of Radiation OncologyInternational Journal of Radiation Oncology, Biology, PhysicsVol. 96Issue 4PreviewThe story of the discovery of X rays by Wilhelm Roentgen in December 1895 is very well known and documented (1) (Fig. 1). The story of radiation therapy's pioneers is, however, far more obscure, likely for 2 reasons. First, the ideas that emerged at the end of the 19th century, and which were the basis of the first attempts with radiation therapy, seem somewhat irrelevant today. This is notably the case of the parasitic theory of cancer (2). Second, and probably more importantly, the available documentation from this period made by clinical investigators, unlike scientific investigators, is scant and often incomplete. Full-Text PDF In Reply to Aronowitz and GrimardInternational Journal of Radiation Oncology, Biology, PhysicsVol. 97Issue 5PreviewTo the Editor: I warmly thank Drs Aronowitz and Grimard for their interest in the story of Despeignes (1). I fully agree with them that the technical characteristics of the radiation therapy conducted by Despeignes must be analyzed with caution. The determination of “the most probable scenario of irradiation” invoked in the article (2) was made through simulation studies performed with oncologists and physicists and published in French in my first biography of Despeignes (Table 1) (3). Its major conclusions follow. Full-Text PDF

On an evening in December 1913, radiologists assembled at New York's Hotel St. Denis for the demonstration of an x-ray apparatus that would revolutionize their specialty ( 1 Anonymous Editorial. Am J Roentgenol. 1913; 1: 93 Google Scholar ). William Coolidge's “hot cathode” tube would provide reliable, adjustable x-ray production that introduced precision and reproducibility to radiology.

We report the case of a man presenting with a solitary brain lesion that proved to be the sole metastasis of a previously undiagnosed high-grade prostate cancer. He was treated aggressively and remains without evident disease beyond three years. We have found a handful of similar reported cases, but survival beyond a year is highly unusual. Brain metastases occur in 1% of patients afflicted with prostate cancer; far less commonly the brain is the sole focus of metastasis. These cases generally carry a dismal prognosis. We present a case in which the primary and metastatic sites were treated aggressively, with a surprisingly favourable outcome.

The optimal sequencing of brachytherapy and external beam radiotherapy (EBRT) for patients receiving combined modality for localized prostate cancer has not been established, and in this series we report our updated experience of patients treated with brachytherapy followed by EBRT. Retrospective review of patients with localized adenocarcinoma of the prostate treated with combined 103Pd brachytherapy and supplemental EBRT. Variables assessed included T stage, Gleason score, pre-treatment PSA, use of androgen deprivation therapy (ADT), EBRT dose, brachytherapy dose, and PSA nadir. Biochemical failure was defined as a PSA rise of ≥ 2 ng/mL above nadir. Kaplan-Meier curves were used to estimate biochemical failure-free survival (BFFS). 126 patients received 103Pd brachyhterapy (median 80 Gy) followed by EBRT (median 45 Gy). Median time between therapies was 7 weeks. Median age was 65 years (range 48 to 80). By risk groupings (D'Amico) 17% were low-risk, 56% were intermediate-risk, and 27% were high-risk. The majority of low-risk patients had either perineural invasion or ≥ 50% involved biopsy cores. Of the intermediate-risk patients, 41% were favorable and 59% were unfavorable (NCCN definition). Neoadjuvant and concurrent androgen deprivation therapy (ADT) was used in 21% of patients. With a median follow-up of 65 months (range 19 to 156 months), 12 patients had a biochemical failure. There was no statistically significant difference in BFFS based on T-stage, Gleason Score, or initial PSA. The median PSA nadir was 0.1 and occurred at a median of 32 months from the end of EBRT. A nadir of ≤ 0.5 (91% of patients) and a nadir of ≤ 0.2 (83% of patients) were each associated with significantly improved BFFS (p<0.0001 each). Patients with favorable intermediate-risk prostate cancer had significantly improved BFFS compared to those with unfavorable intermediate-risk disease (p<0.048). Overall, treatment was well-tolerated with no cases of Grade > 2 urinary or rectal toxicity reported. Long-term disease control and low morbidity is observed for patients with localized prostate adenocarcinoma treated with interstitial brachytherapy followed by EBRT. Prospective research assessing the relative therapeutic ratio of alternate sequencing approaches would appear warranted. PSA nadir appears to predict for biochemical failure, and may guide earlier intervention. Separating favorable and unfavorable intermediate-risk prostate cancer appears to have prognostic and perhaps predictive implications and merits further assessment.

Danish physician Niels Ryberg Finsen (1860-1904) explored the use of light in the treatment of dermatological disorders in the 1890s. Sunlight, especially the short wavelength portion of the spectrum, had previously been found to be “inimical to the development of bacteria” ( 1 Downes A. Blunt T.P. Researches on the effect of light upon bacteria and other organisms. Proc R Soc Lond. 1877; 26: 488-500 Crossref Google Scholar ), and Finsen demonstrated that focused violet and ultraviolet (UV) rays could eradicate lesions of lupus vulgaris (cutaneous tuberculosis) ( 2 Finsen N.R. The treatment of lupus vulgaris by concentrated chemical rays. in: Phototherapy. Edward Arnold, London1901: 63-79 Google Scholar ). This chronic, progressive infection of the young was also called “wolf cancer,” because it disfigured the face of its victim. Finsen's light was also applied in the management of other skin diseases, including cancer, with limited success. He was awarded the 1903 Nobel Prize in Physiology or Medicine “in recognition of his work on the treatment of diseases, and in particular the treatment of lupus vulgaris by means of concentrated light rays” ( 3 Physiology or Medicine 1903—Presentation speech. Nobel Prize Organization. http://www.nobelprize.org/nobel_prizes/medicine/laureates/1903/press.htmlDate: 2014 Google Scholar ). Finsen had introduced a new therapeutic modality, phototherapy.

Although brachytherapy had been established as a highly effective modality for the treatment of cancer, its application was threatened by mid-20th century due to appreciation of the radiation hazard to health care workers. This review examines how the introduction of afterloading eliminated exposure and ushered in a brachytherapy renaissance. (C) 2015 Elsevier Inc. All rights reserved.

Breast cancer was among the first malignancies to be treated by x-irradiation ( 1 Gocht H. Therapeutische verwendung der Röntgenstrahlen [Therapeutic use of x-rays]. Fortschr Geb Röntgenstr. 1897; 1: 14-28 Google Scholar ). Initially, radiation therapy was limited to palliation of unresectable or recurrent disease or for patients unwilling to undergo mastectomy ( 2 Leonard CL. The Röntgen treatment of malignant disease of the beast. Paper presented at the 5th Annual Meeting of the American Roentgen Ray Society, 1905. St. Louis, MO. Google Scholar ). Postsurgical recurrences were so common, however, that by 1905, prophylactic “raying” was often applied both before and after surgery ( 3 Johnston G.C. Ante- and post-operative treatment of cancer of the breast. Arch Phys Ther. 1905; 2: 245-249 Google Scholar ) (intraoperative irradiation was also used [ 4 Pfahler G.E. Non-operative treatment of cancer of the breast. in: Deaver J.B. McFarland J. The Breast: Its Anomalies, Its Diseases, and Their Treatment. P. Blakiston's and Sons, Philadelphia1917: 637-670 Google Scholar ]). Preoperative treatment was believed to be especially efficacious, as it was thought to obliterate lymphatic vessels that might transmit tumor emboli generated by surgical manipulation ( 5 Boggs R.H. Postroentgen treatment of carcinoma of the breast. Am J Roentgenol. 1918; 5: 301-304 Google Scholar , 6 Quick D. Pre-operative and postoperative x-ray in carcinoma of the breast. Am J Roentgenol. 1920; 7: 597-601 Google Scholar ). Although the value of perioperative radiation therapy was debated, by the 1920s, its use had become “so popularized that the public is demanding it; and the surgeon is always willing to let the radiologist share the responsibility of the recurrence” ( 7 Boggs R.H. Ante-operative radiation of carcinoma of the breast. Am J Roentgenol. 1922; 9: 508-513 Google Scholar ). The targets of adjuvant treatment were shaped by the “centrifugal lymphatic permeation” theory of Sampson Handley that motivated the heroic operations of the era ( 8 Handley W.S. The routes of lymphatic dissemination in the parietes. in: Handley W.S. Cancer of the Breast and Its Operative Treatment. John Murray, London1906: 47-58 Google Scholar ). Axillary, supraclavicular, internal mammary, suprascapular, paravertebral, supraxiphoid, lateral intercostal, and even inguinal nodes were believed to be at risk and were irradiated along with the chest wall; some roentgenologists also prophylactically irradiated the liver ( 5 Boggs R.H. Postroentgen treatment of carcinoma of the breast. Am J Roentgenol. 1918; 5: 301-304 Google Scholar ). Beams were directed through up to a dozen anterior, posterior, and axillary portals (Fig. 1) ( 4 Pfahler G.E. Non-operative treatment of cancer of the breast. in: Deaver J.B. McFarland J. The Breast: Its Anomalies, Its Diseases, and Their Treatment. P. Blakiston's and Sons, Philadelphia1917: 637-670 Google Scholar ).

The ABC of the X Rays (1) by William Henry Meadowcroft (1853-1937). Meadowcroft was Thomas Edison’s secretary and biographer (Edison was an early x-ray investigator). The text is an elementary exposition of x-rays, x-ray tubes, and suitable power sources. Practical Radiography (2) by Henry Snowden Ward (18651911) and William A. Anthony. Ward was editor of a British photography journal, The Photogram, which featured a section on radiography. Not surprisingly, his book deals with equipment and techniques for taking radiographic exposures. Roentgen Rays and Phenomena of the Anode and Cathode (3) by Edward Pruden Thompson. Thompson was an electrical engineer and patent attorney in New York. His text is a compendium of approximately 200 synopses of seminal papers exploring electrical and radiant phenomena (including publications of Faraday, J.J. Thomson, Crookes, Tesla, Hertz, Lenard, Edison, and Roentgen). The X Ray or Photography of the Invisible and Its Value in Surgery (4) by William James Morton (1845-1920) and Edwin W. Hammer. The only text authored by a physician, it contained sections on medical, surgical, and dental radiography (with a brief speculative chapter on the “curative action of the X ray”). Even the use of radiographs as legal evidence was addressed. It is the only one of the volumes that mentioned radiation toxicity, but it made no recommendations regarding radiation safety.

Purpose: To outline the evolution of computerized brachytherapy treatment planning in the United States through a review of technological developments and clinical practice refinements.Material and methods: A literature review was performed and interviews were conducted with six participants in the development of computerized treatment planning for brachytherapy.Results: Computerized brachytherapy treatment planning software was initially developed in the Physics Departments of New York's Memorial Hospital (by Nelson, Meurk and Balter), and Houston's M. D. Anderson Hospital (by Stovall and Shalek). These public-domain programs could be used by institutions with adequate computational resources; other clinics had access to them via Memorial's and Anderson's teletype-based computational services. Commercial brachytherapy treatment planning programs designed to run on smaller computers (Prowess, ROCS, MMS), were developed in the late 1980s and early 1990s. These systems brought interactive dosimetry into the clinic and surgical theatre.Conclusions: Brachytherapy treatment planning has evolved from systems of rigid implant rules to individualized pre- and intra-operative treatment plans, and post-operative dosimetric assessments. Brachytherapy dose distributions were initially calculated on public domain programs on large regionally located computers. With the progression of computer miniaturization and increase in processor speeds, proprietary software was commercially developed for microcomputers that offered increased functionality and integration with clinical practice.

The modern prostate brachytherapy procedure is characterized by ultrasound guidance, template assistance, and a return to a "closed" transperineal approach. This review traces the introduction and evolution of these elements and charts the development of the procedure from the ashes of previous, failed efforts. (C) 2014 Elsevier Inc.

This chapter in Cancer Concepts: a Guidebook for the Non-Oncologist describes the principles of Radiation Oncology. Radiation Oncology utilizes ionizing radiation to treat cancer (and occasionally a few benign conditions). Radiotherapy or radiation therapy (RT) was initially developed in conjunction with diagnostic radiology, but has evolved into a separate specialty. Currently, more than fifty percent of cancer patients undergo RT at some point during the course of their cancer. Most receive treatment with curative intent (radical therapy); however, patients with incurable disease receive shorter, gentler courses of therapy to relieve cancer-induced symptoms.