Purpose or ObjectiveBrain metastases (BM) affect up to 40% of patients with metastatic disease.Recent advances in systemic therapy means patients are living longer whilst the widespread availability of stereotactic radiosurgery (SRS) for brain metastases provides a realistic expectation of local control in suitable patients.The is a lack of data on the prevalence of treatment modalities used and the patterns of care these patients experience.We aim to quantify the proportion of patients receiving SRS, Whole brain radiotherapy (WBRT), neurosurgery and best supportive care (BSC) in a tertiary oncology centre. Material and MethodsOver a two year period (1 st Jan 2016 -31 st Dec 2017), adult patients with a new radiologically confirmed diagnosis of BM were identified by retrieving all MRI and CT head scans that contained the words 'metastases', 'metastasis' or 'met' in the report.Only patients with a confirmed primary cancer were included.Patients who underwent SRS, WBRT or surgery were considered to have received 'treatment' for their BM.Receiving systemic anticancer treatment or steroids were not considered to be 'treatment'.Patients who did not receive 'treatment' for their BM were identified as BSC. ResultsOf 2,422 scans, reviewed, there were 236 cases of newly diagnosed BM.The median age at diagnosis was 65 years (range 30-87).The median survival across all groups was 115 days (range 1-829).There were more females (58%) than males (42%).Lung cancer was the most common primary site (49%), followed by breast (20%) and melanoma (13%).At the time of diagnosis, 47% had controlled extracranial disease.Lung primaries carried the worst prognosis ( median survival 95 days) with breast (202 days) the best.Half of the cases received some form of treatment for their BM with the other half receiving BSC.There were 127 treatments delivered to 118 patients.WBRT (39.5%) and SRS (39.5%) were the most common with surgery used in 21%.Treatment modality varied according to primary tumour site.In breast WBRT (54%) was the most common treatment followed by SRS (15%).In lung and melanoma, this was reversed with SRS (21% & 53% respectively) more commonly used than WBRT (14% & 6% respectively).Patients who received SRS lived the longest; their median survival was not reached at assessment, compared to surgery (210 days) and WBRT (202 days).We identified 7 cases who received WBRT where an opportunity to give SRS may have been missed.Of the 50% of patients who did not receive any treatment; median survival was 55 days.Of these, 62% had contact with palliative care services.Amongst treated patients, 54% were seen by palliative care. ConclusionHalf of all patients receive no brain directed therapy.Radiotherapy is the most common treatment though SRS may have been to 7 others who WBRT.We suggest a well resourced and dedicated dedicated BM MDT would provide more consistent decision making as which was established this year in our centre.We will reassess the patterns of care after a year.

The optimal clinical target volume (CTV) definition for the malignant gliomas is still debated. To compare the role of margin or edema in CTV’s delineation, we analyzed the pattern of recurrence and the impact on outcomes of the two different CTV in patients (pts) with GBM, treated with RT plus TMZ. Pts with a histological diagnosis of GBM, observed from 2002 to 2008, were evaluated. All pts received 3D-CRT with a total dose of 5940 cGy on CTV1 including tumor bed +/− residual mass + 1,5 cm and 4500 cGy on CTV2 including tumor bed +/− residual mass plus edema (Group A) or plus 3 cm subsequently (Group B). TMZ was administered according to Stupp’s schedula. An independent review an expert radiation oncologist was carried out for CTV validation. Relapse was defined as in-field, marginal or distant if greater than 80%, 20-80%, or less than 20% of the recurrent volume fell within the 95% isodose line. The acute toxicity was assessed according to RTOG score. The primary endpoint was the impact of the two different CTV2 delineations on recurrence pattern; the secondary endpoints were overall survival (OS) and disease free survival (DFS). Among 261 pts observed, 141 were evaluable: 66 in group A and 75 in group B. Median age was 61 years (range 21-81), 88 males (75%) and 53 females (25%). The two groups were comparable for the age (p: 0.78), the sex (p: 0.34) and the surgery (p: 0.45). In Group A recurrences were observed in 61 (92%) pts: 43 in field (70%), 23 marginal (23%), and 7 distant (7%). The median PTV1 volume was were 361 cc (Range 98-623). In Group B recurrences were observed in 66 (85%) pts: 38 in filed (61%), 19 marginal (30%), and 7 distant (19%). The median PTV1 volume was 223 cc (Range 2-540). The median follow-up was of 57 months (range 6-116). No significant difference was observed for patterns of failure (p: 0.9). No difference in the two groups in terms of acute toxicity was recorded. Median PFS and OS were respectively 13 and 17.8 months. Incomplete surgery significantly impact on DFS (p: 0.009) and OS (p: 0.008); old age (<65yrs pts) impact only on OS (p:0.01 and p:0.003). At the multivariate analysis five unfavorable predictive factors on survival outcome were indentified: male sex (p: 0.003), age > 65 yrs (p: 0.03), presence of residual disease after the first surgery (p: 0.002), CTV size (p: 0.01) and edema included in CTV (p: 0.02). Our study shows that there is no correlation between the way to delineate CTV and the patterns of failure. The pattern of failure seems not to be correlated with the way of delineating the CTV2, while adding the edema negatively impacts both the DFS and OS, increases the PTV volume, without influencing the acute toxicity.

There is no standard treatment available for recurrent high-grade gliomas. Despite some evidence of improvement in progression-free survival, no significant increase in overall survivor (OS) has been demonstrated with any particular approach. The porpose of this retrospective analysis was to evaluate the impact on OS with different salvage therapies, including no treatment, systemic therapy, or retreatment plus systemic therapy in patients affected by recurrence of Glioblastoma (GBM) to generate new hypotheses for future trial. Patients (pts) affected by GBM’s recurrence and treated with Stupp’s schedula, were included in this retrospective analyses. Those who died less a month after progression or with a poor performance status were excluded. Patients were divided into 3 groups: reirradiation plus chemotherapy (group A) chemotherapy alone (group B) no treatment (group C). Overall Survival was calculated using the Kaplan-Meier method and compared between three groups. We retrospectively evaluated files relative to 217 patients with recurrence treated according to Stupp’s schedula for GBM from January 2009 to May 2016. Among them, 153 patients were evaluable for this analysis; 64 patients were excluded because they died less than one month after progression or for a poor performance status. Sixty-nine out of 153 patients (45%) belonged to Group C, 63 (41%) to group B, and 21 (14%) to group A. Median follow-up was 48 months in all patients. Median survival time from diagnosis was 18 months for the entire cohort: 14 months for patients of Group C, 28 months for group B, and 30 months for those of group A. Type of treatment at recurrence time proved to significantly impact on OS (p=0.0001). Patients who received no salvage treatment had poorer survival than those who received chemotherapy alone or in combination with radiotherapy. Reirradiation plus chemotherapy seems to favor highest survival. Further investigations are needed to define the optimal choice of therapy, and in particular the role of reirradiation patients with recurrent GBM.

Results: SBRT treatment: maximum small bowel and duodenum dose-volume constraints were exceeded in 5/30 (16.7%) and 2/30 (6.7%), respectively.Dose to OARs was: small bowel: Dmax 31.5-40.5Gy, V30 0.2-13.4cc; duodenum: Dmax 35.7-36.6Gy, V30 2.1-3.7 cc.SBRS treatment: maximum small bowel and duodenum dosevolume constraints were exceeded in 2/21 patients (9.5%) and 1/21 patient (4.7%), respectively.Dose to OARs was: small bowel: Dmax 15.6-16.3Gy, V12 1.7-8.5 cc; duodenum Dmax 16.0 Gy, V12 0.1 cc.With a median follow up of 24 months after SBRT and 18 months after SBRS, no early or late severe toxicity was observed in patients in whom constraints were not respected. Conclusion:Patients irradiated on small bowel and duodenum did not develop severe toxicity although the administered doses were above constrains proposed in literature.A prolonged follow-up and a larger population are needed to confirm the safety of dose-volume constraints other than those reported in literature about SBRT and SBRS on abdominal area.

Results: Sim and weekly CBCT volumes were tested for nonnormality and leverage.4 men had Sim volumes that were well in excess of 500mL, and by mid-course, had greatly reduced.The extreme cases exerted strong leverage.In 38 men, bladder volumes were log-normally distributed.Compliant men had bladder volumes (162 mL) statistically significantly larger (p<0.01)than men refusing (83 mL).The random inter-fraction variation was the same in both groups (33%).Compliant men had a mean systematic increase in bladder volume of 12% (95%CI = 4.8-21%, p < 0.01) relative to Sim, compared to 32% (95%CI = 12%-55%, p < 0.01) in the refusing group. Conclusion:Systematic and random changes in bladder volume during PCa IGRT are relatively insensitive to bladder filling in PCa IGRT, provided the Sim volume is not excessive (> 500mL).Volumes at Sim are statistically significantly different between groups, so there may be implications for dose planning.We have proposed a follow-on project to measure the effect of changing the drinking instructions, so men are advised to drink and practice holding as much water as they can comfortably tolerate without voiding for 1 hour.

Conclusion:We registered an higher PTV dose coverage between MRIdian's and the RapidArc and IMRT plans for cervical cancer, with a HI advantage for the PTV1.Differences were described for OaRs, especially for low dose areas (V5 Body).The MRIdian's planning platform showed to be user friendly and allowed to reach dosimetrical goals comparable to RapidArc and IMRT gold standards.The evaluation of a possible reduction in PTV margins and a proper target coverage by MRI based gating will be analyzed when the system will become operative.

In this paper, we propose a new Adaptive Modulation and Coding (AMC) method for Communication-Based Train Control (CBTC) systems using Wireless Local Area Network (WLAN). The goal of the proposed method is to enhance the control performance by choosing a transmission mode which decreases the average delay with respect to both Medium Access Control (MAC) contention and channel fading according to both average Signal-to-Noise Ratio (SNR) and the number of competing vehicles. The effectiveness of the proposed method is shown via computer simulations.