Purpose: evaluation and comparison of volumetric modulated RapidarcTM radiotherapy (RA-IMRT) vs linac based Stereotactic body radiotherapy (SBRT) in the salvage treatment of isolated lymph node recurrences in patients affected by gynaecological cancer. Materials and Methods From January 2010 to September 2011, 15 patients affected by isolated lymph nodes recurrence of gynaecological cancer underwent salvage radiotherapy after conventional imaging staging with CT and 18-FDG-PET/CT. Two different radiotherapy techniques were used in this study: RA-IMRT (RapidarcTM implemented radiotherapy Varian Medical System, Palo Alto, CA, USA) or SBRT (BrainLAB, Feldkirchen, Germany). Five patients underwent CT scan and all patients underwent 18FDG-PET/CT for pre-treatment evaluation and staging. The mean total dose delivered was 54.3 Gy (range 50-60 Gy with conventional fractionation and 27.4 Gy (range 12-40 Gy hypofractionation) for RA-IMRT and SBRT respectively. The mean number of fractions was 27.6 fractions (range 25-31) and 3-4 fractions , the mean overall treatment duration was 40.5 days (range 36-45) and 6.5 days (range 5-8 days) for RA-IMRT and SBRT respectively. Results: At the time of the analysis, October 2011, the overall survival was 92.3 % (80% for RA-IMRT and 100% for SBRT). Six patients are alive with no evidence of disease and also six patients are alive with clinically evident disease in other sites (40% and 50% patients RA-IMRT vs SBRT respectively, one patient died for systemic progression of disease and two patient were not evaluable at this time. Conclusions: Our preliminary results showed that, the use of RA-IMRT and SBRT are an excellent local therapy for isolated lymph nodes recurrences of gynaecological cancer with a good toxicity profile and local control rate, even if any long term survivors would be expected. New treatment modalities like Cyberknife are also being implemented.

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Several methods to reduce respiratory-induced motion have been described in literature, with the goal of increasing accuracy of treatment to minimize normal tissue toxicity or increase dose to the target volume. We analyzed two different techniques of respiratory gating: the deep inspiration breath hold technique and the respiratory gating using the Real-time Position Management (RPM) system. The first method is a self-gating technique in which radiation treatment take place during a phase of breath-holding. The second technique use a reflective marker placed on the patient’s anterior surface. The motion of the marker is tracked using a camera interfaced to a computer. The gating thresholds are set when the tumor is in the desired portion of the respiratory cycle. These thresholds determine when the gating system turns the treatment beam on and off. We compared both techniques with a standard external radiation treatment. The dosimetric analysis has led to considerable advantage of these methods compared to the external radiation treatment, particularly in reducing the dose to the lung.

La chirurgia con ultrasuoni focalizzati guidati da MRI (MR-g-FUS) è un trattamento di minima invasività, guidato dal più sofisticato strumento di imaging a disposizione, che utilizza a scopo diagnostico e terapeutico forme di energia non ionizzante. Le sue caratteristiche portano a pensare un suo possibile e promettente utilizzo in numerose aree della patologia umana, in particolare scheletrica. L'osteoma osteoide affligge frequentemente pazienti di giovane età, è una patologia benigna, con origine ed evoluzione non chiare, e trova nella termoablazione con radiofrequenza continua sotto guida CT (CT-g-RFA) il suo trattamento di elezione. Questo lavoro ha valutato l’efficacia, gli effetti e la sicurezza del trattamento dell’osteoma osteoide con MR-g-FUS. Sono stati presi in considerazione pazienti arruolati per MR-g-FUS e, come gruppo di controllo, pazienti sottoposti a CT-g-RFA, che hanno raggiunto un follow-up minimo di 18 mesi (rispettivamente 6 e 24 pazienti). Due pazienti erano stati esclusi dal trattamento MR-g-FUS per claustrofobia (2/8). Tutti i trattamenti sono stati portati a termine con successo tecnico e clinico. Non sono state registrate complicanze o eventi avversi correlati all’anestesia o alle procedure di trattamento, e tutti i pazienti sono stati dimessi regolarmente dopo 12-24 ore. La durata media dei trattamenti di MR-g-FUS è stata di 40±21 min. Da valori di score VAS pre-trattamento oscillanti tra 6 e 10 (su scala 0-10), i trattamenti hanno condotto tutti i pazienti a VAS 0 (senza integrazioni farmacologiche). Nessun paziente ha manifestato segni di persistenza di malattia o di recidiva al follow-up. Nonostante la neurolisi e la risoluzione dei sintomi, la perfusione del nidus è stata ritrovata ancora presente in oltre il 70% dei casi sottoposti a MR-g-FUS (4/6 pazienti). I risultati derivati da un'analisi estesa a pazienti più recentemente arruolati confermano questi dati. Il trattamento con MR-g-FUS sembra essere efficace e sicuro nel risolvere la sintomatologia dell'osteoma osteoide. / Magnetic Resonance guided Focused Ultrasound Surgery (MR-g-FUS) is a minimally invasive treatment guided by the most sophisticated imaging tool available in today clinical practice. Both imaging and therapeutic sides of the equipment are based on non-ionizing energy. This technique is a very promising option as potential treatment of several pathologies, including skeletal disorders. Osteoid osteoma is considered a benign lesion of the bone, and it usually affects young patients. Although the origin and evolution of the disease have not been completely understood, the treatment of choice was found in thermal ablation by continuous radiofrequency under CT guidance (CT-g-RFA). This work aimed at the evaluation of the efficacy, the effects and the safety of MR-g-FUS in the treatment of osteoid osteoma. Patients enrolled for MR-g-FUS treatment of osteoid osteoma were included, as well as a control group made up of patients routinely submitted to CT-g-RFA. Only patients with a minimum follow-up period of 18 months were considered (6 and 24 patients, for MR-g-FUS and CT-g-RFA respectively). Two patients had been previously excluded from MR-g-FUS, because of claustrophobia (2/8 patients). All treatments were concluded with technical and clinical success. No complications or adverse events were registered. The mean duration of an entire MR-g-FUS procedure was 40(±21) min, and all patients were discharged after 12-24 h. The interventional procedures took the patients from pre-treatment VAS ranging 6-10 to post-treatment score 0 (removing drugs). No patient showed persistence or recurrence of the disease during the follow-up. Despite the neurolysis carried out by MR-g-FUS, the nidus presented with still active vascularization at imaging follow-up in over 70% of lesions undergoing MR-g-FUS (4/6 patients). Results achieved by extending the analysis to more recently recruited patients confirm data as preliminarily reported. MR-g-FUS seems to be effective and safe in the treatment of symptoms related to osteoid osteoma.

Obiettivo: Il nostro obiettivo è stato quello di confrontare la tomoterapia (HT) e la protonterapia ad intensità modulata (IMPT) nel trattamento del tumore prostatico, seguendo un protocollo di boost simultaneo (SIB) e moderatamente ipofrazionato. Materiali e metodi: Abbiamo selezionato 8 pazienti, trattati con HT e abbiamo rielaborato i piani con 2 campi IMPT. La dose prescritta è stata di 74 Gy sul PTV1 (prostata e vescicole seminali prossimali), 65.8 Gy sul PTV2 (vescicole seminali distali) e 54 Gy sul PTV3 (linfonodi pelvici). Risultati: Sia con IMPT che con HT abbiamo ottenuto una copertura e una omogeneità di dose del target sovrapponibile. Oltre i 65 Gy, HT e IMPT erano equivalenti per il retto, mentre con l’IMPT c’era maggior risparmio della vescica e del bulbo penieno da 0 a 70 Gy. Da 0 fino a 60 Gy, i valori dosimetrici dell’IMPT erano molto più bassi per tutti gli organi a rischio (OARs), eccetto che per le teste femorali, dove la HT aveva un vantaggio dosimetrico rispetto all’IMPT nel range di dose 25-35 Gy. La dose media agli OARs era ridotta del 30-50% con l’IMPT. Conclusioni: Con le due tecniche di trattamento (HT e IMPT) si ottiene una simile distribuzione di dose nel target. Un chiaro vantaggio dosimetrico dell’IMPT sul HT è ottenuto dalle medie e basse dosi. Le attuali conoscenze sulle relazioni dose-effetto e sul risparmio delle madie e basse dosi con l’IMPT non sono ancora state quantificate dal punto di vista clinico. / Purpose: To compare helical tomotherapy (HT) and intensity modulated proton therapy (IMPT) on prostate cancer treatments delivered with simultaneous integrated boost (SIB) in moderate hypofractionation. Material and methods: Eight patients treated with HT were replanned with two-field IMPT (2fIMPT). The prescribed dose was 74 Gy in 28 fractions on PTV1 (prostate + proximal seminal vesicles) and 65.8 Gy on PTV2 (distal seminal vesicles) and 54 Gy on PTV3 (pelvic lymph-node). Results: IMPT and HT achieved similar target coverage and dose homogeneity. Above 65 Gy, HT and IMPT were equivalent in the rectum, while IMPT spared the bladder and the penile bulb from 0 to 70 Gy. From 0 up to 60 Gy, IMPT dosimetric values were (much) lower for all OARs except the femur heads, where HT was better than 2fIMPT in the 25–35 Gy dose range. OARs mean doses were typically reduced by 30–50% by IMPT. Conclusions: HT and IMPT produce similar dose distributions in the target volume. A clear dosimetric advantage of IMPT on HT is obtained with medium and low doses. The current knowledge on dose–effect relations does not allow to quantify the clinical impact of the large sparing of IMPT at medium-to-low doses.

Obiettivo: valutare la tossicità ed il controllo di malattia di un trattamento radioterapico ipofrazionato ad alte dosi con tecnica ad intensità modulata (IMRT) guidata dalle immagini (IGRT) in pazienti affetti da carcinoma prostatico a rischio intermedio, alto ed altissimo di recidiva. Materiali e metodi: tutti i pazienti candidati al trattamento sono stati stadiati e sottoposti al posizionamento di tre “markers” fiduciali intraprostatici necessari per l’IGRT. Mediante tecnica SIB – IMRT sono stati erogati alla prostata 67,50 Gy in 25 frazioni (EQD2 = 81 Gy), alle vescichette 56,25 Gy in 25 frazioni (EQD2 = 60,35 Gy) e ai linfonodi pelvici, qualora irradiati, 50 Gy in 25 frazioni. La tossicità gastrointestinale (GI) e genitourinaria (GU) è stata valutata mediante i CTCAE v. 4.03. Per individuare una possibile correlazione tra i potenziali fattori di rischio e la tossicità registrata è stato utilizzato il test esatto di Fisher e la sopravvivenza libera da malattia è stata calcolata mediante il metodo di Kaplan-Meier. Risultati: sono stati arruolati 71 pazienti. Il follow up medio è di 19 mesi (3-35 mesi). Nessun paziente ha dovuto interrompere il trattamento per la tossicità acuta. Il 14% dei pazienti (10 casi) ha presentato una tossicità acuta GI G ≥ 2 e il 15% (11 pazienti) ha riportato una tossicità acuta GU G2. Per quanto riguarda la tossicità tardiva GI e GU G ≥ 2, essa è stata documentata, rispettivamente, nel 14% dei casi (9 pazienti) e nell’11% (7 pazienti). Non è stata riscontrata nessuna tossicità, acuta o cronica, G4. Nessun fattore di rischio correlava con la tossicità. La sopravvivenza libera da malattia a 2 anni è del 94%. Conclusioni: il trattamento radioterapico ipofrazionato ad alte dosi con IMRT-IGRT appare essere sicuro ed efficace. Sono comunque necessari ulteriori studi per confermare questi dati ed i presupposti radiobiologici dell’ipofrazionamento del carcinoma prostatico. / Purpose: to evaluate toxicity and control of disease with hypofractionated high-dose intensity-modulated (IMRT) and image guided (IGRT) radiotherapy in patients with intermediate, high and very high risk of prostate cancer. Materials and Methods: patients eligible for treatment were staged and three fiducial "markers" needed for IGRT were implanted in the prostate. It was delivering with SIB- IMRT 67,50 Gy in 25 fractions (EQD2 = 81 Gy) to the prostate, 56,25 Gy in 25 fractions (EQD2 = 60,35 Gy) to the seminal vesicles and 50 Gy in 25 fractions to the pelvic lymph nodes, when irradiated. Gastrointestinal (GI) and genitourinary (GU) toxicity were assessed using CTCAE v. 4.03. Correlation between potential risk factors and toxicity was performed using the Fisher's test and disease-free survival was calculated using the Kaplan-Meier method. Results: seventy-one patients were evaluated. The mean follow-up was 19 months (3-35 months). No patient had to discontinue treatment for acute toxicity. 14% of patients (10 cases) presented acute GI G ≥ 2 and 15% (11 patients) reported acute toxicity GU G2. Regarding the late toxicity GI and GU G ≥ 2, it has been detected, respectively, in 14% (9 patients) and 11% of cases (7 patients). There was no incidence of any acute or late toxicity G4. No risk factor correlated with toxicity. The disease-free survival at 2 years was 94%. Conclusions: hypofractionated high-dose IMRT-IGRT radiotherapy appears to be safe and effective. However, further studies are needed to confirm these data and the radiobiological bases of hypofractionated radiotherapy of prostate cancer.