Importance:Standard-of-care management of radiorecurrent prostate cancer (PCa) involves systemic therapy; however, some patients seek to avoid the adverse events (AEs) that are associated with androgen-deprivation therapy (ADT). Objective:To determine outcomes of local therapy without systemic therapy for radiorecurrent PCa. Data Sources:MEDLINE, Embase, Web of Science Core Collection, and Google Scholar were searched from inception up to May 2025. No date or language filters were used. Data were analyzed from June to November 2025. Study Selection:Prospective and retrospective studies were selected that investigated local salvage therapies without concomitant systemic treatment for locally recurrent PCa after definitive radiotherapy. Eligible studies provided ADT-free survival (ADT-FS) and/or metastasis-free survival (MFS). Authors were contacted for additional data. Data Extraction and Synthesis:This study was prospectively registered and adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Risk of bias was assessed using Risk of Bias Assessment Tool for Nonrandomized Studies, version 2. Individual patient data were reconstructed from Kaplan-Meier curves or retrieved from authors. ADT-FS, MFS, and rates of AEs were pooled in a random-effects models. Main Outcomes and Measures:Main outcomes were ADT-FS and MFS, which were modeled as pooled summary Kaplan-Meier curves, and rates of severe or worse AEs, which were modeled as proportions. Outcomes were stratified by treatment method. Results:Thirty-one studies (4525 patients) were identified that assessed salvage high-dose-rate brachytherapy (HDR-BT; 336 patients), low-dose-rate brachytherapy (LDR-BT; 92 patients), stereotactic body radiotherapy (SBRT; 213 patients), radical prostatectomy (sRP; 1476 patients), cryotherapy (1621 patients), high-intensity focused ultrasonography (HIFU; 677 patients), or mixed methods (110 patients). Prospective studies comprised approximately one-fourth of the evidence (1055 patients); however, none were identified for sRP. Pooled 2-year and 5-year ADT-FS (2887 patients) were 76.8% and 55.2%, respectively. Pooled 2-year and 5-year MFS (3425 patients) were 90.4% and 75.2%, respectively. Rates of severe or worse AEs (2308 patients) ranged from 14% for LDR-BT, 13% for sRP, 5% for HDR-BT, 5% for HIFU, 4% for SBRT, and 2% for cryotherapy. Risk of bias concerns primarily regarded patient selection. Limitations included a lack of randomized clinical trials. Conclusions and Relevance:The findings of this systematic review and meta-analysis suggest that local therapies alone have reasonable efficacy in well-selected patients with locally radiorecurrent PCa. ADT-free survival was maintained for more than three-quarters of patients at 2 years and more than half at 5 years. Approximately one in ten experience an early metastatic event. Rates of severe toxic effects were manageable, in particular for salvage HDR-BT, HIFU, SBRT, and cryotherapy.

QuestionWhat are the outcomes of local salvage therapies alone for local recurrence of prostate cancer after definitive radiotherapy?FindingsIn this meta-analysis of 31 studies involving 4525 patients, pooled 2-year and 5-year androgen deprivation therapy-free survival rates were 76.8% and 55.2% and metastasis-free survival rates were 90.4% and 75.2%; rates of severe or worse adverse events ranged from 2% to 14% depending on the treatment method.MeaningThe study results suggest that local salvage therapies alone have reasonable efficacy in well-selected patients with local recurrence of prostate cancer after radiotherapy who wish to avoid androgen deprivation therapy. ImportanceStandard-of-care management of radiorecurrent prostate cancer (PCa) involves systemic therapy; however, some patients seek to avoid the adverse events (AEs) that are associated with androgen-deprivation therapy (ADT).ObjectiveTo determine outcomes of local therapy without systemic therapy for radiorecurrent PCa.Data SourcesMEDLINE, Embase, Web of Science Core Collection, and Google Scholar were searched from inception up to May 2025. No date or language filters were used. Data were analyzed from June to November 2025.Study SelectionProspective and retrospective studies were selected that investigated local salvage therapies without concomitant systemic treatment for locally recurrent PCa after definitive radiotherapy. Eligible studies provided ADT-free survival (ADT-FS) and/or metastasis-free survival (MFS). Authors were contacted for additional data.Data Extraction and SynthesisThis study was prospectively registered and adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Risk of bias was assessed using Risk of Bias Assessment Tool for Nonrandomized Studies, version 2. Individual patient data were reconstructed from Kaplan-Meier curves or retrieved from authors. ADT-FS, MFS, and rates of AEs were pooled in a random-effects models.Main Outcomes and MeasuresMain outcomes were ADT-FS and MFS, which were modeled as pooled summary Kaplan-Meier curves, and rates of severe or worse AEs, which were modeled as proportions. Outcomes were stratified by treatment method.ResultsThirty-one studies (4525 patients) were identified that assessed salvage high-dose-rate brachytherapy (HDR-BT; 336 patients), low-dose-rate brachytherapy (LDR-BT; 92 patients), stereotactic body radiotherapy (SBRT; 213 patients), radical prostatectomy (sRP; 1476 patients), cryotherapy (1621 patients), high-intensity focused ultrasonography (HIFU; 677 patients), or mixed methods (110 patients). Prospective studies comprised approximately one-fourth of the evidence (1055 patients); however, none were identified for sRP. Pooled 2-year and 5-year ADT-FS (2887 patients) were 76.8% and 55.2%, respectively. Pooled 2-year and 5-year MFS (3425 patients) were 90.4% and 75.2%, respectively. Rates of severe or worse AEs (2308 patients) ranged from 14% for LDR-BT, 13% for sRP, 5% for HDR-BT, 5% for HIFU, 4% for SBRT, and 2% for cryotherapy. Risk of bias concerns primarily regarded patient selection. Limitations included a lack of randomized clinical trials.Conclusions and RelevanceThe findings of this systematic review and meta-analysis suggest that local therapies alone have reasonable efficacy in well-selected patients with locally radiorecurrent PCa. ADT-free survival was maintained for more than three-quarters of patients at 2 years and more than half at 5 years. Approximately one in ten experience an early metastatic event. Rates of severe toxic effects were manageable, in particular for salvage HDR-BT, HIFU, SBRT, and cryotherapy. This systematic review and meta-analysis examines outcomes of local therapy without systemic therapy for radiorecurrent prostate cancer.

Objective. A robotic needle implant device for MR-guided high-dose-rate (HDR) prostate brachytherapy was developed. This study aimed to assess the feasibility and spatial accuracy of HDR brachytherapy using the robotic device, for a single intraprostatic target point. Approach. Five patients were treated from November 2019-June 2022 with the robot. The robot fits a 1.5 T MR scanner and the needle can be shifted and angulated. An intraprocedural MR scan was fused with the diagnostic MR and one preplanned needle position was selected for robotic insertion. The needle entry point and angles were set for a needle tip target point within the intraprostatic target volume. The needle was tapped stepwise towards the target point pneumatically. Final needle position was verified with MR, followed by plan optimization and dose delivery. Any remaining planned needles were inserted manually. Needle tip to geometrical target error (NTG-error) was defined as the deviation of the actual tip position relative to the predefined geometric target point, using MR-coordinates. Needle tip to treatment target error (NTT-error) was defined as the deviation of the actual tip position relative to the treatment target point, using fused MR-images pre- and post-needle implantation taking into account prostate deformation. Difference between NTT-error and NTG-error and fiducial marker shifts indicated prostate movement. For determining prostate deformation, the Jaccard index and prostate volumes were assessed. Main results. The robotic device was able to tap the needle to the planned depth for all patients. Mean robotic procedure duration was 142 min. NTG-error was 3.2 (range 1.1-6.7) mm and NTT-error 4.5 (range 2.6-9.6) mm. Marker displacements were smaller than 3 mm. No treatment-related acute toxicity was reported. Feasibility of needle placement within the prostate was considered adequate. Significance. MR-guided robotic needle insertion is feasible with a mean geometric accuracy of 3.2 mm and <3 mm prostate movement.

Background:MRI-guidance may aid better discrimination between Organs at Risk (OARs) and target volumes in proximity of the mediastinum. We report the first clinical experiences with Stereotactic Body Radiotherapy (SBRT) of (ultra)central lung tumours on a 1.5 T MR-linac.Materials and Methods:Patients with an (ultra)central lung tumour were selected for MR-linac based SBRT treatment. A T2-weighted 3D sequence MRI acquired during free breathing was used for daily plan adaption. Prior to each fraction, contours of Internal Target Volume (ITV) and OARs were deformably propagated and amended by a radiation oncologist. Inter-fractional changes in volumes and coverage of target volumes as well as doses in OARs were evaluated in offline and online treatment plans.Results:Ten patients were treated and completed 60 Gy in 8 or 12 fractions. In total 104 fractions were delivered. The median time in the treatment room was 41 min with a median beam-on time of 8.9 min. No grade ≥3 acute toxicity was observed. In two patients, the ITV significantly decreased during treatment (58 % and 37 %, respectively) due to tumour shrinkage. In the other patients, 81 % of online ITVs were within ±15 % of the volume of fraction 1. Comparison with the pre-treatment plan showed that ITV coverage of the online plan was similar in 52 % and improved in 34 % of cases. Adaptation to meet OAR constraints, led to decreased ITV coverage in 14 %.Conclusions:We describe the workflow for MR-guided Radiotherapy and the feasibility of using 1.5 T MR-linac for SBRT of (ultra) central lung tumours.

We appreciate the comments made by Grivas et al regarding our article on automated contouring of neurovascular structures on prostate MRI [[1]van den Berg I. Savenije M.H.F. Teunissen F.R. van de Pol S.M.G. Rasing M.J.A. van Melick H.H.E. et al.Deep learning for automated contouring of neurovascular structures on magnetic resonance imaging for prostate cancer patients.Phys Imaging Radiat Oncol. 2023; 26100453https://doi.org/10.1016/j.phro.2023.100453Abstract Full Text Full Text PDF Scopus (1) Google Scholar]. We are thankful for recognizing the potential of our artificial intelligence model beyond MR-guided radiotherapy (MRgRT). In line with our article, we contend that automated contouring of the neurovascular bundles (NVBs) holds potential for patients undergoing robot-assisted radical prostatectomy (RARP), facilitating nerve-sparing indications and their integration into three-dimensional prostate models. For men undergoing neurovascular-sparing MRgRT, the NVBs and internal pudendal arteries are considered clinically relevant structures to spare as they are important for erectile function. A major challenge is that these structures lie in close proximity to the prostate and are therefore subjected to relatively high doses of radiation [[2]Teunissen F.R. Wortel R.C. Hes J. Willigenburg T. de Groot-van Breugel E.N. de Boer J.C.J. et al.Adaptive magnetic resonance-guided neurovascular-sparing radiotherapy for preservation of erectile function in prostate cancer patients.Phys Imaging Radiat Oncol. 2021; 20: 5-10https://doi.org/10.1016/j.phro.2021.09.002Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar]. It is yet unknown whether complete contouring of the fascia would decrease the chance of erectile dysfunction in MRgRT. Given a median fascia thickness of 3.8 mm on MRI, as reported in your previous work [[3]Grivas N. van der Roest R.C. de Korne C.M. KleinJan G.H. Sikorska K. Schoots I.G. et al.The value of periprostatic fascia thickness and fascia preservation as prognostic factors of erectile function after nerve-sparing robot-assisted radical prostatectomy.World J Urol. 2019; 37: 309-315https://doi.org/10.1007/s00345-018-2387-3Crossref PubMed Scopus (4) Google Scholar], sparing the entire fascia proves challenging with a 2 mm margin from clinical target volume to planning target volume around the prostate in MRgRT with the MR-Linac system. Perhaps dose de-escalation to the fascia may be an option for men with non-high-risk prostate cancer in the future. The prostate would receive a relatively lower dose but a dose escalation (boost) could be administered to the dominant index lesion as tumor recurrence often occurs infield after primary radiotherapy. This approach may improve tumor control and allow better sparing of erectile function. If the complete fascia, including the NVBs, proves to be of greater interest than the NVBs alone for patients undergoing RARP, we suggest applying transfer learning. This is a technique that involves reusing parts of our pre-trained model for a new, related task [[4]Bin R.R. Albert M.V. Transfer Learning: Leveraging Trained Models on Novel Tasks.in: Albert M.V. Lin L. Spector M.J. Dunn L.S. Bridging Human Intelligence and Artificial Intelligence. Educational Communications and Technology: Issues and Innovations. Springer, Cham2022: 65-74https://doi.org/10.1007/978-3-030-84729-6_4Google Scholar]. The fascia could be added to our nnU-Net model. Our model was trained using high resolution MRI data with a 2 mm slice thickness, in contrast to the 3 mm slice thickness on T2-weighted imaging described in the PI-RADSv2 MRI acquisition guideline [[5]Cuocolo R. Stanzione A. Ponsiglione A. Verde F. Ventimiglia A. Romeo V. et al.Prostate MRI technical parameters standardization: A systematic review on adherence to PI-RADSv2 acquisition protocol.Eur J Radiol. 2019; 120108662https://doi.org/10.1016/j.ejrad.2019.108662Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar]. A finer slice thickness enables more precise contouring and more accurate assessment of the NVBs and fascia. To create a robust artificial intelligence model, we would suggest to include MRI data from patients undergoing RARP compliant to PI-RADSv2 guidelines and high-resolution MRI data from patients undergoing MRgRT. Finally, we believe the nnU-Net model can be employed for segmenting the complete fascia, followed by post-processing steps to calculate fascia thickness and surface area. Predicting erectile dysfunction after radiotherapy and RARP could be accomplished by integrating clinical and MRI-based variables from both patient groups. The assessment of erectile function can be performed using the IIEF-5 questionnaire. A combined radiotherapy and RARP data-driven prediction model can aid clinicians and patients in determining the suitability of neurovascular-sparing therapy and selecting the most appropriate treatment approach. Before routine clinical use, a segmentation and prediction model should be externally validated. The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Background and purpose: Radiorecurrent prostate cancer is often confined to the prostate, predominantly near the index lesion. The purpose of this study was to look at recurrence characteristics in patients treated with focal salvage high dose-rate (HDR) brachytherapy.Materials and methods: Patients treated with MRI-guided HDR brachytherapy, with a single fraction of 19 Gy from July 2013 to October 2021 as focal salvage treatment, were prospectively included in the current study. Imaging data were collected regarding the occurrence of local, regional and distant recurrences, including location of local recurrences (LR) in relation to the HDR radiotherapy field.Results: One hundred seventy-five patients were included after focal salvage HDR brachytherapy (median follow-up 36 months (IQR 23-50)). Three-years biochemical recurrence-free survival, LR-free survival, in-field LR-free survival, out-of-field LR-free survival, any-recurrence-free survival and ADT-free survival were 43% (95%CI 34%-52%), 51% (41%-61%), 70% (61%-80%), 92% (88%-97%), 42% (32%-52%) and 86% (80%-92%), respectively. Larger GTV-size and shorter PSA doubling time were associated with in-field LR in multivariable analysis.Conclusion: After focal salvage HDR brachytherapy with a dose of 1x19 Gy for local prostate cancer recurrence, subsequent recurrences are mostly local and in-field. (c) 2023 The Author(s). Published by Elsevier B.V. Radiotherapy and Oncology 180 (2023) 1-7 This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Background and purpose: Manual contouring of neurovascular structures on prostate magnetic resonance imaging (MRI) is labor-intensive and prone to considerable interrater disagreement. Our aim is to contour neurovascular structures automatically on prostate MRI by deep learning (DL) to improve workflow and interrater agreement.Materials and methods: Segmentation of neurovascular structures was performed on pre-treatment 3.0 T MRI data of 131 prostate cancer patients (training [n = 105] and testing [n = 26]). The neurovascular structures include the penile bulb (PB), corpora cavernosa (CCs), internal pudendal arteries (IPAs), and neurovascular bundles (NVBs). Two DL networks, nnU-Net and DeepMedic, were trained for auto-contouring on prostate MRI and evaluated using volumetric Dice similarity coefficient (DSC), mean surface distances (MSD), Hausdorff distances, and surface DSC. Three radiation oncologists evaluated the DL-generated contours and performed corrections when necessary. Interrater agreement was assessed and the time required for manual correction was recorded.Results: nnU-Net achieved a median DSC of 0.92 (IQR: 0.90-0.93) for the PB, 0.90 (IQR: 0.86-0.92) for the CCs, 0.79 (IQR: 0.77-0.83) for the IPAs, and 0.77 (IQR: 0.72-0.81) for the NVBs, which outperformed DeepMedic for each structure (p < 0.03). nnU-Net showed a median MSD of 0.24 mm for the IPAs and 0.71 mm for the NVBs. The median interrater DSC ranged from 0.93 to 1.00, with the majority of cases (68.9%) requiring manual correction times under two minutes. Conclusions: DL enables reliable auto-contouring of neurovascular structures on pre-treatment MRI data, easing the clinical workflow in neurovascular-sparing MR-guided radiotherapy.

Background and purpose: Radiation damage to neural and vascular tissue, such as the neurovascular bundles (NVBs) and internal pudendal arteries (IPAs), during radiotherapy for prostate cancer (PCa) may cause erectile dysfunction. Neurovascular-sparing magnetic resonance-guided adaptive radiotherapy (MRgRT) aims to preserve erectile function after treatment. However, the NVBs and IPAs are not routinely contoured in current radiotherapy practice. Before neurovascular-sparing MRgRT for PCa can be implemented, the interrater agreement of the contouring of the NVBs and IPAs on pre-treatment MRI needs to be assessed. Materials and methods: Four radiation oncologists independently contoured the prostate, NVB, and IPA in an unselected consecutive series of 15 PCa patients, on pre-treatment MRI. Dice similarity coefficients (DSCs) for pairwise interrater agreement of contours were calculated. Additionally, the DCS of a subset of the inferior half of the NVB contours (i.e. approximately prostate midgland to apex level) was calculated. Results: Median overall interrater DSC for the left and right NVB was 0.60 (IQR: 0.54 - 0.68) and 0.61 (IQR: 0.53 - 0.69) respectively and for the left and right IPA 0.59 (IQR: 0.53 - 0.64) and 0.59 (IQR: 0.52 - 0.64) respectively. Median overall interrater DSC for the inferior half of the left NVB was 0.67 (IQR: 0.58 - 0.74) and 0.67 (IQR: 0.61 - 0.71) for the right NVB. Conclusion: We found that the interrater agreement for the contouring of the NVB and IPA improved with enhancement of the MRI sequence as well as further training of the raters. The agreement was best in the subset of the inferior half of the NVB, where a good agreement is clinically most relevant for neurovascular-sparing MRgRT for PCa.

MR-guided brachytherapy offers a focal salvage treatment for the local recurrence in case of isolated locally recurrent prostate cancer in the prostate and/or seminal vesicles after primary radiotherapy. By focusing on only the local recurrence instead of the whole prostate, chances of additional toxicity of the bladder, urethra and rectum can be minimized. In almost all patients, the treatment leads to a good initial treatment response that persists in about half of patients, while others will develop progressive disease later on. For selecting suitable patients, factors such as preexistent urinary- and bowel complaints, localization and size of the recurrence, PSA doubling time and time between primary radiotherapy and development of the recurrence are relevant. MR-guided brachytherapy can provide a suitable salvage strategy, with the aims of deferring androgen deprivation therapy and a chance of cure.

Radiorecurrent prostate cancer is conventionally confirmed using systematic and/or targeted biopsies. The availability of multiparametric (mp) MRI and prostate specific membrane antigen (PSMA) PET/CT has increased diagnostic accuracy. The objective was to determine the positive predictive value (PPV) of combined mp-MRI and PSMA PET/CT and whether pathology verification with MR-targeted biopsies remains necessary for patients with radiorecurrent prostate cancer. Patients with locally recurrent prostate cancer who were referred for 19 Gy single-dose MRI-guided focal salvage high dose rate (HDR) brachytherapy between 2015 and 2018 were included in the current analysis. Patients were selected if they underwent pre-biopsy mp-MRI and PSMA PET/CT. Based on these images, lesions suspect for isolated tumor recurrence were transperineally biopsied using transrectal ultrasound fused with MRI. A total of 41 patients were identified from the database who underwent cognitive targeted (n = 7) or MRI/PSMA-transrectal ultrasound (TRUS) fused targeted (n = 34) biopsies. A total of 40 (97.6%) patients had positive biopsies for recurrent cancer. Five patients initially had negative biopsies (all MRI/PSMA-TRUS fusion targeted), four of whom recurrence was confirmed after a re-biopsy. One (2.4%) patient refused re-biopsy, leading to a positive predictive value (PPV) for combined imaging of 97.6%. Biopsies can therefore safely be withheld when the results of the combined mp-MRI and PSMA PET/CT are conclusive, avoiding an unnecessary invasive and burdensome procedure.

Background and purpose: Online adaptive MR-guided treatment planning workflows facilitate daily contour adaptation to the actual anatomy. Allocating contour adaptation to radiation therapists (RTTs) instead of radiation oncologists (ROs) might allow for increasing workflow efficiency. This study investigates conformity of adapted target contours provided by dedicated RTTs and ROs. Materials and methods: In a simulated online procedure, 6 RTTs and 6 ROs recontoured targets and organs at risk (OAR) in prostate cancer (n = 2), rectal cancer (n = 2) and lymph node-oligometastases (n = 2) cases. RTTs gained contouring competence beforehand by following a specific in-house training program. For all target contours and the reference delineations volumetric differences were determined and Dice similarity coefficient (DSC), conformity index (CI) and generalized CI were calculated. Delineation time and -confidence were registered for targets and OAR. Impact of contour adaptation on treatment plan quality was investigated. Results: Delineation conformity was generally high with DSC, CI and generalized CI values in the range of 0.81-0.94, 0.87-0.95 and 0.63-0.85 for prostate cancer, rectal cancer and LN-oligometastasis, respectively. Target volumes were comparable for both, RTTs and ROs. Time needed and confidence in contour adaptation was comparable as well. Treatment plans derived with adapted contours did not violate dose volume constrains as used in clinical routine. Conclusion: After tumor site specific training, daily contour adaptations as needed in adaptive online radiotherapy workflows can be accurately performed by RTTs. Conformity of the derived contours is high and comparable to contours as provided by ROs.

Irradical (R1-2) resection for non-small cell lung cancer (NSCLC) is associated with a dismal prognosis. Adjuvant treatment attempts to improve survival outcomes, but evidence on the optimal strategy is limited. The purpose of this study was to compare overall survival (OS) between different adjuvant treatment strategies in these patients. Out of 8,528 patients with newly diagnosed NSCLC from 2015-2018, those with an R1-2 resection were identified from the Netherlands Cancer Registry. First, OS was compared between adjuvant treatment groups 'no therapy', 'radiotherapy (RT) only', 'chemotherapy only', and 'chemo- and radiotherapy (CRT)' using multinomial propensity score-weighted Cox regression analysis. Second, three 1:1 propensity score-matched sets were created for chemotherapy vs no chemotherapy, RT only vs no therapy, and CRT vs chemotherapy only. Kaplan-Meier and Cox regression analyses for OS were performed in each set. With a median follow-up of 23 months, 427 patients were selected. In the weighted regression analysis, compared to no adjuvant therapy, chemotherapy and CRT were associated with improved OS (HR 0.41, 95%CI: 0.22-0.76; and HR 0.55, 95%CI: 0.37-0.81, respectively), whereas RT was not (HR 1.04, 95%CI: 0.73-1.50). In the matched sets, OS was improved after chemotherapy (+/- RT) compared to no chemotherapy (HR 0.47, 95%CI: 0.32-0.69). No OS difference was observed between matched groups of RT only vs no adjuvant therapy (HR 1.13, 95%CI: 0.74-1.72), nor for CRT vs chemotherapy only (HR 1.37, 95%CI: 0.70-2.71). Adjuvant chemotherapy, but not radiotherapy, improves survival after an R1-2 resection in stage I-III NSCLC.

Purpose: This R-Ideal stage 1b/2a study describes the workflow and feasibility of long-course fractionated online adaptive MR-guided chemoradiotherapy with reduced CTV-to-PTV margins on the 1.5T MR-Linac for patients with esophageal cancer. Methods: Patients with esophageal cancer scheduled to undergo chemoradiation were treated on a 1.5T MR-Linac. Daily MR-images were acquired for online contour adaptation and replanning. Contours were manually adapted to match the daily anatomy and an isotropic CTV-to-PTV margin of 6 mm was applied. Time was recorded for all individual steps in the workflow. Feasibility and patient tolerability were defined as on-table time of <= 60 min and completion of >95% of the fractions on the MR-Linac, respectively. Positioning verification and post-treatment MRIs were retrospectively analyzed and dosimetric parameters were compared to standard non-adaptive conventional treatment plans. Results: Nine patients with esophageal cancer were treated with chemoradiation; eight patients received 41.4 Gy in 23 fractions and one received 50.4 Gy in 28 fractions. Four patients received all planned fractions on the MR-Linac, whereas for two patients >5% of fractions were rescheduled to a conventional linac for reasons of discomfort. A total of 183 (86%) of 212 scheduled fractions were successfully delivered on the MR-Linac. Three fractions ended prematurely due to technical issues and 26 fractions were rescheduled on a conventional linac due to MR-Linac downtime (n = 10), logistical reasons (n = 3) or discomfort (n = 13). The median time per fraction was 53 min (IQR = 3 min). Daily adapted MR-Linac plans had similar target coverage, whereas dose to the organs-at-risk was significantly reduced compared to conventional treatment (26% and 12% reduction in mean lung and heart dose, respectively). Conclusion: Daily online adaptive fractionated chemoradiotherapy with reduced PTV margins is moderately feasible for esophageal cancer and results in better sparing of heart and lungs. Future studies should focus on further optimization and acceleration of the current workflow.

Objective. To evaluate feasibility of chemoradiation as alternative for extensive surgery in patients with locally advanced vulvar cancer and to report on locoregional control, toxicity and survival. Methods. In a multicenter, prospective phase II trial patients with locally advanced vulvar cancer were treated with locoregional radiotherapy combined with sensitizing chemotherapy (capecitabine). Treatment feasibility, percentage locoregional control, survival and toxicity were evaluated. Results. 52 patients with mainly T2/T3 disease were treated according to the study protocol in 10 centers in the Netherlands from 2007 to 2019. Full dose radiotherapy (tumor dose of 64.8Gy) was delivered in 92% and full dose capecitabine in 69% of patients. Most prevalent acute >_ grade 3 toxicities were regarding skin/ mucosa and pain (54% and 37%). Late >_grade 3 toxicity was reported for skin/mucosa (10%), fibrosis (4%), GI incontinence (4%) and stress fracture or osteoradionecrosis (4%). Twelve weeks after treatment, local clinical complete response (cCR) and regional control (RC) rates were 62% and 75%, respectively. After 2 years, local cCR persisted in 22 patients (42%) and RC was 58%. Thirty patients (58%) had no evidence of disease at end of follow-up (median 35 months). In 9 patients (17%) extensive surgery with stoma formation was needed. Progression free survival was 58%, 51% and 45% and overall survival was 76%, 66%, 52% at 1,2, and 5 years. Conclusions. Definitive capecitabine-based chemoradiation as alternative for extensive surgery is feasible in locally advanced vulvar cancer and results in considerable locoregional control with acceptable survival rates with manageable acute and late toxicity. (c) 2021 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Background. Patients who are surgically treated for stage I to III non-small cell lung cancer (NSCLC) have dismal prognosis after incomplete (R1-R2) resection. Our study aimed to develop a prediction model to estimate the chance of incomplete resection based on preoperative patient-, tumor-, and treatment-related factors. Methods. From a Dutch national cancer database, NSCLC patients who had surgical treatment without neoadjuvant therapy were selected. Thirteen possible predictors were analyzed. Multivariable logistic regression was used to create a prediction model. External validation was applied in the American National Cancer Database, whereupon the model was adjusted. Discriminatory ability and calibration of the model was determined after internal and external validation. The prediction model was presented as nomogram. Results. Of 7156 patients, 511 had an incomplete resection (7.1%). Independent predictors were histology, cT stage, cN stage, extent of surgery, and open vs thoracoscopic approach. After internal validation, the corrected C statistic of the resulting nomogram was 0.72. Application of the nomogram to an external data set of 85,235 patients with incomplete resection in 2485 patients (2.9%) resulted in a C statistic of 0.71. Calibration revealed good overall fit of the nomogram in both cohorts. Conclusions. An internationally validated nomogram is presented providing the ability to predict the individual chance of incomplete resection in patients with stage I to III NSCLC planned for resection. In case of a high predicted risk of incomplete resection, alternative treatment strategies could be considered, whereas a low risk further supports the use of surgical procedures. (C) 2021 by The Society of Thoracic Surgeons. Published by Elsevier Inc.

Irradical resection of non-small-cell lung cancer (NSCLC) is a detrimental prognostic factor. Recently, Rasing et al. presented an internationally validated risk score for pre-treatment prediction of irradical resection. We hypothesized that chemoradiation therapy (CRT) could serve as an alternative approach in patients with a high risk score and compared overall survival (OS) outcomes between surgery and CRT. Patients from a population-based cohort with stage IIB–III NSCLC between 2015 and 2018 in The Netherlands were selected. Patients with a ‘Rasing score’ > 4 who underwent surgery were matched with patients who underwent CRT using 1:1 nearest-neighbor propensity score matching. The primary endpoint of OS was compared using a Kaplan–Meier analysis. In total, 2582 CRT and 638 surgery patients were eligible. After matching, 523 well-balanced pairs remained. Median OS in the CRT group was 27.5 months, compared with 45.6 months in the surgery group (HR 1.44, 95% CI 1.23–1.70, p < 0.001). The 114 surgical patients who underwent an R1–2 resection (21.8%) had a worse median OS than the CRT group (20.2 versus 27.5 months, HR 0.77, 95% CI 0.61–0.99, p = 0.039). In NSCLC patients at high predicted risk of irradical resection, CRT appears to yield inferior survival compared with surgery. Therefore, choosing CRT instead of surgery cannot solely be based on the Rasing score. Since patients receiving an R1–2 resection do have detrimental outcomes compared with primary CRT, the treatment decision should be based on additional information, such as imaging features, comorbidities, patient preference, and the surgeon’s confidence in achieving an R0 resection.