This study aimed to investigate whether IMRT using VMAT is a viable and safe solution in dose escalated RT in these patients. An increasing number of prostate cancer patients are elderly and have hip prostheses. These implants pose challenges in radiotherapy treatment planning. Although intensity modulated radiotherapy (IMRT) is commonly used, there is a lack of clinical studies documenting its efficacy and toxicities in this subgroup of patients. The data from 23 patients with hip prostheses and non-metastatic prostate cancer treated with VMAT (volumetric modulated arc therapy) between 2009 and 2011, were retrospectively analyzed. Baseline characteristics, treatment details and outcome data were collected on all patients. The median follow up was 40.9 months. MRI-CT image fusion was performed and the treatment plans were created using RapidArc™ (RA) techniques utilizing 1 or 2 arcs and 10 MV photon beams. 96% of patients were treated with a dose of 72 Gy/32 fractions over 44 days. 21/23 plans met the PTV targets. The mean homogeneity index was 1.07. 20/23 plans met all OAR constraints (rectum, bladder). Two plans deviated from rectal constraints, four from bladder constraints; all were classed as minor deviations. One patient experienced late grade 3 genitourinary toxicity. Three other patients experienced late grade 2 or lower gastrointestinal toxicity. One patient had biochemical failure and one had a non-prostate cancer related death. VMAT provides an elegant solution to deliver dose escalated RT in patients with unilateral and bilateral hip replacements with minimal acute and late toxicities.

Stereotactic body radiotherapy is the technique of accurately delivering high doses of radiotherapy to small volume targets in a single or small number of sessions. The high biological effective dose of this treatment is reflected in the high rates of local control achieved across multiple tumour sites. Toxicity of the treatment can be significant and ongoing prospective trials will help define the utility of this treatment as an alternative to surgery in treating primary tumours and oligometastatic disease. Longer follow-up and survival data from prospective trials will be essential in determining the value of this resource-intensive treatment. The opportunity to combine this treatment with systemic therapies and its potential synergy with immunotherapy opens up interesting avenues for research in the future.

Background. Successful radiosurgery for arteriovenous malformations (AVMs) requires accurate nidus delineation in the 3D treatment planning system (TPS). The catheter biplane digital subtraction angiogram (DSA) has traditionally been the gold standard for evaluation of the AVM nidus, but its 2D nature limits its value for contouring and it cannot be imported into the Cyberknife TPS. We describe a technique for acquisition and integration of 3D dynamic CT angiograms (dCTA) into the Cyberknife TPS for intracranial AVMs and review the feasibility of using this technique in the first patient cohort. Patients and methods. Dynamic continuous whole brain CT images were acquired in a Toshiba 320 volume CT scanner with data reconstruction every 0.5 sec. This multi-time-point acquisition enabled us to choose the CT dataset with the clearest nidus without significant enhancement of surrounding blood vessels. This was imported to the Cyberknife TPS and co-registered with planning CT and T2 MRI (2D DSA adjacent for reference). The feasibility of using dCTA was evaluated in the first thirteen patients with outcome evaluation from patient records. Results. dCTA data was accurately co-registered in the Cyberknife TPS and appeared to assist in nidus contouring for all patients. Imaging modalities were complementary. 85% of patients had complete (6/13) or continuing partial nidus obliteration (5/13) at 37 months median follow-up. Conclusions. dCTA is a promising imaging technique that can be successfully imported into the Cyberknife TPS and appears to assist in radiosurgery nidus definition. Further study to validate its role is warranted.

Background: Recurrent head and neck squamous cell carcinomas are an understudied subgroup, lacking high-quality evidence and thus gold standard management recommendations, resulting in major variations in practice. The aim of this project was to deliver a national multidisciplinary expert consensus on patients with recurrent head and neck squamous cell carcinoma managed by curative salvage surgery. Methods: The Appraisal of Guidelines for Research and Evaluation II (AGREEII) protocol guided the Delphi process. Best practice statements were developed after literature review on the perioperative management and surgical salvage of major recurrent head and neck squamous cell carcinoma subsites. Members of the International Centre for Recurrent Head and Neck Cancer network and other UK-based professional stakeholder organizations were invited into an online Delphi study. Participants voted on statements over 3 rounds, with items modified in response to vote thresholds and comments. Results: A total of 28 experts participated, including 11 otolaryngologists, 7 oncologists, 9 oral and maxillofacial surgeons, and 1 speech and language therapist. Consensus was achieved on 73 statements, with 29 (39.7%) achieving unanimous (threshold = 100%) and 25 (34.2%) very strongly supported (threshold > 90%) agreement. Conclusions: Salvage surgeries for recurrent head and neck squamous cell carcinoma are challenging cases that require intensive multidisciplinary input to achieve cure while balancing impact on function and quality of life. In this article, we provide a large series of statements based on UK-wide expert consensus that will guide clinicians through the complex intra- and perioperative management of patients undergoing surgical salvage.

Context.— The creation of 3-dimensional prostate cancer maps could assist with surgical intervention, radiotherapy treatment planning and for correlative pathology-imaging research. Objectives.— To develop methodology for creating detailed, 3-dimensional, prostate cancer maps (3DPCM) of tumor location, extra prostatic extension sites, and positive margins and to assess the adequacy of current clinical target volumes for postoperative radiotherapy to the prostate using 3DPCM coregistered with preoperative magnetic resonance imaging. Design.— Parallel slices of prostatectomy specimens were created with ProCUT, and 2-dimensional cancer maps were generated as line diagrams after microscopic examination of each slice. The 2-dimensional cancer maps were aligned and stacked to create a 3DPCM, which was coregistered with the preoperative magnetic resonance imaging scan. The map was exported to the radiotherapy planning system and was used to determine the areas at greater risk, which were then compared against the current Radiation Therapy Oncology Group guidelines for contouring postoperative clinical target volumes to assess the adequacy of coverage. Results.— Twenty-eight patients with a mean age of 66 years (range, 52–73) underwent radical prostatectomy and postoperative radiotherapy. Seventeen patients (61%) received adjuvant radiotherapy for pT3 disease and/or positive margins, and the rest underwent salvage radiotherapy. Thirty-nine percent (11 of 28) of the patients had Gleason scores of 8 or 9. The contours based on the Radiation Therapy Oncology Group guidelines for postoperative radiotherapy resulted in inadequate coverage of extraprostatic extensions in 79% (22 of 28) and positive margins in 64% (18 of 28) of the cases. Conclusions.— We have developed a methodology for creation of 3DPCM. Modification of the radiotherapy contours, based on the 3DPCM coregistered with pretreatment magnetic resonance imaging, covers the areas at high risk of recurrence. The 3DPCM could become an important clinical and research tool for urologists, pathologists, radiologists, and oncologists.