PurposeTo analyze dosimetric parameters of patients receiving adjuvant breast radiotherapy (RT) in the prone versus supine position.Methods and materialsForty-one out of 55 patients with pendulous breasts and candidates for adjuvant RT were enrolled in the study after informed consent. They underwent computed tomography (CT)-simulation in both prone and supine position. Target and non target volumes were outlined on CT images. Prescribed dose was 50 Gy delivered by two tangential photon fields followed by 10 Gy electron boost. Target coverage and dose homogeneity to clinical target volume (CTV) and planning target volume (PTV) were assessed by V95, V105 and V107 and dose to lung, heart and left anterior descending coronary artery (LAD) by V5, V10, V20, and mean and maximum dose. Data were analyzed by Student’s t-test.ResultsCTV and PTV coverage was significantly better in supine than in prone position. Lung V5, V10, and V20 were significantly lower in prone than in supine position. Heart V5, V10, V20, and LAD mean and maximum dose, in the 17 patients with left breast tumor, were lower in prone than in supine position, but without statistical significance. Based on treatment planning data and on treatment feasibility, 29/41 patients (70.7%) were treated in prone position. Acute and late toxicities of patients treated in prone and in supine position were not statistically different.ConclusionProne position is a favorable alternative for irradiation of mammary gland in patients with pendulous breasts and in our series was adopted in 71% of the cases.

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This is the first report on a large cohort of patients treated with IORT in Europe. It gives a picture of patient selection methods and treatment modalities, with emphasis on the main tumour types that are typically treated by this technique and may benefit from it.

Radio-induced apoptosis is mediated by the activation of tumor protein p53, Bax and caspases. The purpose of this study was to investigate the early activation of this pathway in men receiving in vivo irradiation immediately before radical prostatectomy for locally advanced prostate cancer. We also investigated cell proliferation index (Ki-67), proto-oncogene (p53) and anti-apoptotic protein (Bcl-2) levels as potential predictive factors. We selected a homogeneous sample of 20 patients with locally advanced prostate cancer and candidate to radical prostatectomy. To assess the apoptotic pathways, Bax, is studied through immunofluorescence assay, before and after 12 Gy single dose intraoperative radiotherapy (IORT) to the prostate, on bioptic samples and on surgical specimens. Moreover, before and after IORT, Bcl-2, p53, and Ki-67 were also detected through immunohistochemistry. A count of positive Bax spots for immunofluorescence was performed on tumor cells, prostatic intraepithelial neoplasia (PIN), and healthy tissue areas before and after IORT. We also analyzed Caspases 3 and 9 expressions after IORT. Before IORT, Bcl-2 mean value in neoplastic cells was 2.23% ± 1.95, mean Ki-67 in neoplastic area was 4.5% ± 3.8, and p53 was 22.5% ± 6.8. After IORT, Bcl-2 mean value in neoplastic cells was 8.85 ± 8.92%, Ki-67 in neoplastic area was 7.8 ± 6.09%, and p53 was 24.9 ± 26.4%. After the irradiation, healthy areas expressed significantly lower levels of Bax (2.81 ± 1.69%) with respect to neoplastic cells (p < 0.0001), while in PIN areas, Bax positive cells were significantly more present than in neoplastic areas (p = 0.0001). At statistical analysis, it was observed that cancer cells with Ki-67 ≥ 8% had a trend toward greater expression of Bax (p = 0.0641). We observed an increase of Bcl-2 expression after IORT in neoplastic areas (p = 0.0041). Biopsy specimens with p53 ≥ 18% and Ki-67 ≥ 8% had worse post-operative staging with extracapsular invasion (p = 0.04 for both parameters) and nodal positivity (p = 0.04 for p53 and p = 0.0001 at pathology for ki-67). No correlation between IORT and Caspases activation was noted. In conclusion, after 12 Gy IORT, Bax was overexpressed in tumor and PIN cells. Pre-operative Ki-67 and p53 definition could be used in future studies to predict patients with worse pathological stage, while Bcl-2 activation after IORT might be a predictive factor for loco-regional failure. Intraoperative radiotherapy (IORT) is the ultimate expression of a dose-intensification treatment modality, with a high irradiation dose delivered during a surgical procedure. The rationale of hypofractionation and dose-intensification schemes of radiotherapy of prostate cancer is based on the particularly high level of sensitivity of prostate cancer cells to fraction size radiotherapy 1. The IORT technique was described in a previous study from our institution 2 .

This technique allows the surgeon to morcellate a bulky uterus in cases of endometrial cancer and reduces the chance of neoplastic cell spillage during debulking at TLH. Vaginal morcellation following oncologic rules permits a rapid uterine extraction and may avoid a number of unnecessary laparotomies.