Purpose/Objective: Modern radiotherapy techniques such as IMRT and VMAT allow physicians to spare organs at risk of radiotherapy damage thereby improving quality of life (QoL) amongst survivors.In patients undergoing radical radiotherapy (RRT) for head and neck cancer, dose to SWOAR is increasingly being recognised as a determinant of QoL and long-term function such as dysphagia, regurgitation and tube dependency.Therefore, it has been proposed that limiting dose to SWOAR would be a desirable goal.However, there is no data on dosimetry of SWOAR during treatment or whether changes are potentially due to tumour response or inflammation thereby, supporting a strategy of enforcing strict dose constraints.This study aimed to document dosimetry of SWOAR using midway planning CT scan, whilst applying the original treatment plan as well as an adaptive plan generated de novo.Materials and Methods:  27 consecutive patients with head and neck cancer were CTsimulated (SCAN 1) and a VMAT treatment plan (PLAN1) was generated to treat to a dose of 65Gy in 30 fractions (#).Patients completed treatment based on this plan. Mid-treatment ie week 3, patients underwent a second CTsimulation to acquire mid treatment planning image (SCAN2) Retrospectively, the original treatment PLAN 1 was applied to the mid-treatment SCAN2 to create PLAN 2 In addition, a de novo plan or PLAN (ART) was generated using SCAN 2 but with the optimisation priorities and constraints unchanged from the first PLAN 1(this second plan was aimed to treat last 10 treatments to 21.67Gy in 10#)  Delineation of SWOARs was performed for Base of tongue (BOT), oesophageal inlet muscle (EIM), superior/middle/inferior pharyngeal constrictor muscle (SPCM/MPCM/IPCM), cricopharyngeal muscle (Crico), cervical oesophagus (CEso), supra-larynx and glottic larynxfor both treatment planning SCAN 1 and SCAN 2 and mean and median dose to each SWOAR was obtained.A paired t-test was used to compare the dose to SWOAR between PLAN1 (clinical plan 30#) and PLAN1(20#) PLAN2(10#) to identify if there was a significant difference when a recalculation was performed and delivered for remaining 10#.This was repeated to evaluate a significant difference when PLAN ART was to be used for remaining 10#.Results: Overall there was little difference in dosimetry to SWOAR whether treatment proceeded using the original plan recalculated (PLAN 2) or an adaptive plan generated de novo to optimise for PTV coverage (PLAN ART).The only significant difference was seen for Crico p=0.04,SPCM p=0.01 and EIM p=0.04 for PLAN 2 and for the Crico p=0.01 for PLAN ART used in conjunction with an adaptive plan.

Aim  Current management of locally advanced rectal cancer includes neoadjuvant chemoradiation in selected patients to increase the chance of a tumour‐free circumferential resection margin. There is uncertainty over the role of and selection criteria for additional systemic therapy in this group of patients. In this retrospective study we investigate the association between markers of systemic inflammatory response (SIR) and outcome from treatment.

Sir — A hypofractionated schedule of 52.5–55 Gy in 20 fractions over 4 weeks (2.625–2.75 Gy/fraction) is favoured for radical non-small cell lung cancer treatment in the UK [1Williams M.V. Summers E.T. Drinkwater K. Barrett A. Radiotherapy dose fractionation, access and waiting times in the countries of the UK in 2005.Clin Oncol (R Coll Radiol). 2007; 19: 273-286Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar]. The addition of chemotherapy improves outcome, but optimal scheduling (sequential vs concurrent) has yet to be determined. Additionally, scheduling influences the severity of toxicity, including in-field oesophagitis. Predictive studies have attempted to model oesophagitis using calculated dosimetry [2Belderbos J. Heemsbergen W. Hoogeman M. et al.Acute esophageal toxicity in non-small cell lung cancer patients after high dose conformal radiotherapy.Radiother Oncol. 2005; 75: 157-164Abstract Full Text Full Text PDF PubMed Scopus (152) Google Scholar, 3Werner-Wasik M. Pequignot E. Leeper D. et al.Predictors of severe esophagitis include use of concurrent chemotherapy, but not the length of irradiated esophagus: a multivariate analysis of patients with lung cancer treated with nonoperative therapy.Int J Radiat Oncol Biol Phys. 2000; 48: 689-696Abstract Full Text Full Text PDF PubMed Scopus (125) Google Scholar], but data relevant to concurrent chemoradiotherapy, especially hypofractionation, are minimal [4Brock J. Ashley S. Bedford J. et al.Review of hypofractionated small volume radiotherapy for early-stage non-small cell lung cancer.Clin Oncol (R Coll Radiol). 2008; 20: 666-676Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar]. In our centre, we analysed the relationship between dosimetry and oesophageal toxicity in 24 patients undergoing radical radiotherapy for non-small cell lung cancer, 55 Gy in 20 fractions over 4 weeks, from 2005 to 2006. Thirteen patients received concurrent chemotherapy with cisplatin 20 mg/m2 during fractions 1–4 and 16–19 and vinorelbine 15 mg/m2 during fractions 1, 6, 15 and 20. The remainder received between two and four cycles of sequential chemotherapy before commencing radiotherapy. All patients were computed tomography planned (5 mm axial slices) on Eclipse and three-dimensional conformal 6 MV photon therapy was delivered using three or four fields. Patients were reviewed weekly during treatment and toxicity recorded using NCI-CTC grading. On Eclipse, the oesophagus was contoured from the lower border of cricoid cartilage to the gastroesophageal junction. Dosimetric data generated included: (1) dose–volume histogram (DVH) (%) — volume of oesophagus receiving a stated dose or more relative to volume of whole organ; (2) DVH (cm3) — absolute volume receiving a stated dose or more; (3) length of oesophagus with 100% circumference receiving more than 40, 45, 50 and 55 Gy — L100/40, L100/45, L100/45 and L100/55; and (4) mean oesophageal dose. DVH data were analysed at 5 Gy dose interval steps, i.e. V5, V10, etc. Dosimetric correlation with toxicity was carried out using Spearman's testing. Oesophageal toxicity breakdown in the sequential group was n=5 (grade 1) and n=6 (grade 2). In the concurrent group, n=1 (grade 0), n=4 (grade 1), n=6 (grade 2), n=1 (grade 3), n=1 (grade 4). The sequential group showed marked correlation between incremental irradiated oesophageal volumes and worsening toxicity. Statistical significance was seen with DVH (%) for V15–V50 (P≤0.012), DVH (cm3) for V20–V50 (P≤0.008), L100/40, L100/45, L100/45 (P≤0.025) and mean oesophageal dose (P=0.001). In contrast, there was extremely poor correlation in the concurrent group. The only parameters that correlated significantly were DVH (%) V30 (P=0.041), V50 (P=0.032) and L100/50 (P=0.044). There was no difference between the mean dose to the oesophagus in the sequential group 21.7 Gy vs the concurrent group 19.6 Gy (P=0.309). In both groups, no correlation was seen between oesophagitis with gender, age, performance status and pre-treatment dysphagia. A meta-analysis by Rowell and O'Rourke [5Rowell N.P. O'Rourke N.P. Concurrent chemoradiotherapy in non-small cell lung cancer.Cochrane Database Syst Rev. 2004; (CD002140)PubMed Google Scholar] reported a higher incidence of acute oesophagitis ≥ grade 3 with concurrent compared with sequential chemoradiotherapy. This was consistent with our results. Primarily, in this study we set out to determine if conventional dosimetry would be relevant in predicting toxicity of hypofractionated chemoradiotherapy based on an initial cohort of patients treated at our centre. We found a strong correlation between dosimetry and oesophagitis in the sequential group, but not in the concurrent group. This factor should be considered in future studies.

Developments in rectal cancer imaging have revolutionised the management of this condition. It has become increasingly important for oncologists and surgeons to have a working insight into radiological assessment in order to make informed clinical decisions. In this context, we discuss the role that imaging plays in the pre-operative staging, post-operative follow-up and therapy of this disease including some novel advances in the field. Rectal cancer outcomes have improved due to modern surgical techniques, namely total mesorectal excision. Meticulous pre-operative assessment remains key. Conventional TNM staging now appears less crucial compared to assessing tumour distance from the potential plane of surgical resection (particularly the circumferential margin bounded by the mesorectal fascia), and this is reliant on high-quality imaging. Those with margin threatening disease can be offered downstaging chemoradiotherapy to facilitate successful resection. Endorectal ultrasound is useful for T staging and CT for detecting metastases. Malignant lymph node identification remains a problem and the use of size and morphological criteria may lead to misdiagnosis. In the post-operative setting, intensive follow-up is associated with improved outcomes but there are many variations in protocols. Most modalities struggle to differentiate tumour from reactive or fibrotic tissue and functional imaging is being investigated as the solution. PET scanning, particularly PET/CT, has been a major recent development. It has superior utility in detecting recurrent disease, including when conventional imaging is negative, detects occult metastases and may significantly enhance our ability to deliver accurate radiotherapy. Imaging has also opened up avenues for guided therapies aimed at ablating liver metastases. Radiofrequency ablation, in particular, is being used successfully and can improve survival of stage four patients.

Aims: Supraclavicular fossa (SCF) radiotherapy plays an important part in the adjuvant management of breast cancer but data on acute radiotherapy toxicity are lacking, particularly when differing patient treatment positions are used to allow computed tomography planning or to reduce cardiac doses.Materials and methods: We evaluated SCF and breast/chest wall acute skin toxicity in a cohort of 92 women with breast cancer, who were planned in a 'T'-grip (n = 72) or 90 degrees-grip (n = 20) position, while 'on treatment' and at 6 weeks. The modified Radiation Therapy Oncology Group (RTOG) criteria were used to score toxicity. Data on age, body mass index, smoking history, type of breast operation, prior chemotherapy, radiation dose, number of fields and field size were recorded and correlated with outcome.Results: Maximum SCF reaction score was RTOG 2a, with no moist desquamation observed. SCF reactions were less severe compared with chest wall reactions and no worse than breast reactions. There was significant resolution of toxicity at 6 weeks. SCF radiotherapy in 'T'-grip patients was well tolerated and no worse than the 90 degrees-grip group. Pain scores and sore throat occurrences were minimal. Univariate and multivariate analyses showed that smoking was associated with worsening SCF toxicity (odds ratio [OR] 2.92; P = 0.045) and delayed healing. Incremental SCF dose worsened toxicity (OR 3.65; P = 0.023). Smoking worsened breast but not chest wall toxicity.Conclusions: SCF radiotherapy was at least as well tolerated as breast radiotherapy and better tolerated than chest wall radiotherapy. The 'T'-grip position did not affect toxicity negatively. Smoking and radiation dose affected SCF toxicity.

The syndrome of inappropriate antidiuretic hormone (SIADH) secretion is a well recognised paraneoplastic phenomenon and the vast majority are associated with small cell lung carcinoma. Rarely however, the non-small cell variety can sometimes be responsible and this report describes such an occurrence. Uniquely in this case, after chemotherapy the paraneoplastic SIADH improved in parallel with a tumour response and this has not been reported previously.

Background. The association between Guillain-Barre syndrome (GBS) and malignancy is uncommon and has not been previously reported in gynecological cancers.Case. Our case documents this syndrome Occurring in a patient shortly after completion of adjuvant chemo-radiotherapy for endometrial carcinoma. We review the current literature and discuss potential pathogenic mechanisms of this likely paraneoplastic association.Conclusion. GBS in cancer patients is a potentially life-threatening condition and should be differentiated from simple chemotherapy toxicity, particularly as effective treatment is available. (C) 2005 Elsevier Inc. All rights reserved.