术前,术后放疗的直肠癌治疗中作用的评估和比较

目的：评估和比较辅助性术前、术后放疗在直肠癌治疗中的作用。方法：１９８８年２月～１９９５年２月收治经病理证实的直肠癌１７６例,配合手术分别采用术前单次放疗、术前常规放疗和术后放疗。术前单次放疗组３８例,剂量为５Ｇｙ,并于放疗后４８ｈ内手术;术前４０Ｇｙ常规放疗组４３例,多为临床晚期（Ｔ３～４占６０．５％）,中位剂量４０Ｇｙ,放疗后休４周再行手术;术后放疗组９５例,以病变晚期和淋巴结阳性为主（Ｔ３～４占６２．１％,Ｔ２～４Ｎ＋占８１．１％）,采用中位剂量５４Ｇｙ常规分割,疗程约６周,手术后３～４周开始接受放疗。结果：全部病例平均随访８４个月,Ｋａｐｌａｎ－Ｍｅｉｅｒ法计算生存率。术前单次放疗组３年、５年局部复发率分别为７８．９％和５０．０％,常规术前４０Ｇｙ放疗组为６７．４％和５１．１％;术后放疗组为５８．９％和     

Intraoperative radiotherapy for resectable and unresectable pancreatic carcinoma

Eighty patients with pancreatic carcinoma were treated by intraoperative radiotherapy (IORT) with or without surgical resection of the tumor, and the results were compared with those of 111 patients treated by surgery alone. For resectable patients, the radiation dose was 30 Gy and the average field sizes were 8 or 10 cm; for unresectable patients, these values were 20–30 Gy and 6 or 8 cm, respectively. No side effects of IORT were observed. In 49 resectable stage III patients, the IORT group (n=16) had a higher survival rate than the non-IORT group (n=33); i.e., 1-year survival rates of 44.6% vs 23% and 2-year survival rates of 37.2% vs 7.7% after surgery (P<0.05). However, there was no significant difference in survival rate between the IORT group (n=28) and the non-IORT group (n=29) in 57 resectable patients in stage IV. In unresectable patients, the IORT group (n=31) (P<0.05) had a higher survival rate than the non-IORT group (n=38) (P<0.05). The palliative effect of IORT on abdominal or back pain was evaluated in 15 patients who had such symptoms and did not undergo tumor resection. Overall, pain decreased or disappeared in 13 of these patients (87%). Offprint requests to: A. Nakao     

Percutaneous radiotherapy for low-risk prostate cancer: options for 2007

Technical developments of radiotherapy (RT) over the recent years yielded in better conformation to the target volume thus increasing the therapeutic ratio and decreasing side effects. This paper discusses these options for low-risk prostate cancer. There has been evidence from randomized trials, that for low-risk PCA doses >70 Gy are significant better in case of biochemical disease-free survival (bNED). Image-guided radiotherapy (IGRT) has been proven in several studies for reduced safety margins around the prostate target volume. Intensity-modulated radiotherapy (IMRT) allow treatment with higher doses and 5-year results are reported from several studies. Data from several randomized trials about adjuvant RT after radical prostatectomy (RP) have been reported. In two phase-III trials a significant advantage of 20% bNED was demonstrated for doses between 76 and 79 Gy compared with 70 Gy. Using IGRT, the safety margin around the prostate can be reduced for about 30–50%. Doses of >80 Gy can be given safely to the prostate with IMRT and <5% grade-III/IV late side effects. Adjuvant RT for positive margins after RP has been of proven advantage. Three phase-III trials achieved a significant better bNED of 20% for 5 years. The effect of doses >70 Gy have been proven for low-risk PCA. IGRT resulted in reduced safety margins and a decrease of acute and late side effects. The addition of IMRT allowed higher doses to the prostate. Adjuvant RT after RP for positive margins achieved a significant better bNED.     

Percutaneous transperineal placement of gold 198 seeds for treatment of carcinoma of the prostate

Thirty-one patients have been treated for carcinoma of the prostate with 198Au seeds placed transperineally using transrectal ultrasonic guidance. Twenty patients have been followed postoperatively for periods ranging from 3 to 31 months, with an average follow-up time of 12 months. Cumulative dose of radiation to the prostate calculated by dosimetry was either 9,000 rads or 15,000 rads. Serial transrectal ultrasound examinations performed on these patients showed a decrease in prostate size in all patients within 6 months of treatment, with a statistically significant decrease observed between the third and sixth months. No significant difference in amount or rate of tumor regression was noted when tumor stage and grade were correlated to volume decrease after treatment. Patients who received the larger doses of radiation (15,000 rads) showed a significantly greater rate of decline in prostatic volume than those who received 9,000 rads. Seven patients underwent prostate biopsy between 12 and 18 months after treatment; six biopsies showed residual tumor. Complications after treatment included urinary retention because of prostatic edema (three), radiation urethritis (three), and rectal ulceration (one). Transperineal placement of 198Au is well tolerated and offers an alternative to external beam radiation for treatment of carcinoma of the prostate.     

Conformal high dose rate brachytherapy improves biochemical control and cause specific survival in patients with prostate cancer and poor prognostic factors

PURPOSE: To improve outcome for patients with prostate cancer with poor prognostic factors higher than conventional radiation doses are required. To achieve this outcome a brachytherapy boost was given. We report the results of the first high dose rate dose-escalation brachytherapy trial. MATERIALS AND METHODS: Between 1991 and 2000, 207 patients were prospectively enrolled in a dose escalation trial including pelvic radiotherapy and conformal high dose rate prostate brachytherapy boost. The dose was increased from 5.5 to 11.5 Gy. per implant. Patient eligibility for the study included pretreatment prostate specific antigen 10 or greater, Gleason 7 or greater or clinical stage T2b or higher. No patient received hormonal therapy. The American Society for Therapeutic Radiology and Oncology consensus panel definition of biochemical failure was applied. RESULTS: Median patient age was 69 years. Mean followup was 4.7 years (range 0.6 to 10.4). The 5-year actuarial biochemical control rate was 74%. The 5-year biochemical control was 85% for 1 poor prognostic factor, 75% for 2 and 50% for all 3 (p = 0.001). On Cox regression multivariate analysis lower brachytherapy dose, and higher Gleason and nadir value were associated with biochemical failure. The 5-year actuarial overall survival was 92%, cause specific survival 98% and disease-free survival 68%. The 5-year actuarial rates of complications were 8% and 0% for grades 3 and 4 genitourinary, and 0.5% and 0.5% for grades 3 and 4 gastrointestinal, respectively. The 5-year actuarial impotence rate was 51%. CONCLUSIONS: For patients with poor prognostic factors external beam radiation therapy with conformal high dose rate brachytherapy boost improved biochemical control, resulting in a high cause specific survival rate with low toxicity. Another important advantage is that the patient is not radioactive after the high dose rate implant.     

A prospective case series assessing the Imperial College London intraoperative radiotherapy protocol for advanced rectal cancer: an IDEAL phase 2a study

Aim

Intraoperative radiotherapy (IORT) decreases local recurrence rates for advanced rectal cancer. Nevertheless, utilization of IORT is limited due to the associated logistical and financial challenges. The aim of this study is to describe the development and delivery of a novel IORT protocol for advanced rectal cancer that overcomes these difficulties in the context of the early phase of an IDEAL 2a study. The primary outcome measure was the ability to deliver IORT using this novel protocol with IORT-related toxicity as the secondary outcome measure.

Method

Consecutive patients with advanced rectal cancer expected to have involved (R1) resection margins were enrolled. After resection, 12 Gy low-energy photon IORT was delivered using the Axxent device with a custom-designed elliptical spherical balloon applicator.

Results

Six patients with a median age of 47 years (range 33–88 years; five women) were enrolled between 2018 and 2019. The indication was advanced cancer in four patients and atypical invasive pelvic side wall lymph nodes in two. IORT was successfully delivered in all cases. No toxicity was encountered. Three advanced cancer patients had R1 resection and one had complete resection (R0); resection margin status could not be established for the two lymph node cases. Five patients were alive at 3.4 (2.9–4.1) year follow-up. None of the R1 cases recurred.

Conclusion

This is the first study to describe a novel IORT protocol using low-energy photon IORT for advanced rectal cancer. IORT could be delivered in all cases and no IORT-related toxicity was encountered. Available oncological outcome data are encouraging, but further studies will be necessary to determine the oncological effectiveness of this protocol.     

益气养阴活血方治疗鼻咽癌放疗后黏膜反应30例

目的:探讨益气养阴活血中药防治放射性黏膜反应的临床疗效。方法:治疗组30例病人在放疗期间应用益气养阴活血中药,对照组常规处理。结果:两组患者均完成放射治疗,但对照组中5例病人因黏膜反应严重,放疗过程中被迫中断1~2周;放射性黏膜损伤反应程度、黏膜损伤的出现时间以及患者生活质量(卡氏评分)比较,两组均有统计学差异。结论:中药能减低鼻咽癌放射性黏膜反应临床症状,推迟其出现的时间,提高鼻咽癌放疗完成率,提高患者的生活质量。     

Radiotherapy and Surgery in 50 Cases of Osteosarcoma Treated without Adjuvant Chemotherapy

A consecutive series of osteosarcoma patients from one hospital is described. In 1962 radiotherapy with delayed surgery according to Cade was replacing surgery alone as the adopted treatment programme. Statistically the results were the same before and after this time with 5 out of 29 and 6 out of 21 patients, respectively, surviving 5 years. With radiation alone none out of eight survived. Surgery alone produced 3 out of 14 and radiation with delayed surgery 6 survivors out of 15. As surgery with or without radiotherapy is equally ineffective in controlling osteosarcoma a prospective randomized trial of the relative merits of chemotherapy and interferon as adjuvant therapy seems highly desirable.     

Retrospective analysis of 74 cases of seminoma treated with radiotherapy

BACKGROUND: Standard post-orchiectomy radiotherapy (RT) is accepted as a standard management option for stage I seminoma. METHODS: Retrospective evaluation of 74 patients with stage I seminoma was performed according to the Royal Marsden staging system. All of the patients underwent RT in the Radiation Oncology Department of Gülhane Military Medical Academy between 1974 and 1995. The median age of patients was 27 years (range, 20-56). Radiotherapy was applied to all of the patients after orchiectomy for adjuvant purposes. Sixty-nine patients underwent RT while five patients who had recurrence received chemotherapy following radiotherapy. RESULTS: After a mean follow-up period of 54 months, the 5-year overall survival rate was 98.61%, which complied with the literature. The disease-free survival rate was 90.54%. According to the World Health Organization toxicity scale, acute enteritis was 9.4% for grade I and 5.4% for grade II, while nausea/vomiting was 36.4% for grade I and 5.4% for grade II. CONCLUSION: To avoid acute toxicity related to RT, prognostic risk factors should be well-known and patients with low risk factors should be monitored carefully after orchiectomy. RT should be directed to the para-aortic +/- ipsilateral pelvic lymph nodes in high risk patients. Although post-orchiectomy RT is a traditional management option for clinical stage I seminoma, the results of RT should be well-known to compare it with other treatment options (e.g. RPLND, adjuvant chemotherapy and surveillance).     

Salvage cystectomy after failure of interstitial radiotherapy and external beam radiotherapy for bladder cancer

OBJECTIVE: To evaluate the long-term results of salvage cystectomy after interstitial radiotherapy (IRT) and external beam radiotherapy (EBRT) for transitional cell carcinoma, and to assess the morbidity and functional results of the different urinary diversions used. PATIENTS AND METHODS: The records of 27 patients treated with salvage cystectomy in one institution between 1988 and 2003 were retrospectively analysed. RESULTS: Salvage cystectomy was used after failure of IRT in 14 or EBRT in 13 patients, with a 3- and 5-year survival probability of 46% (95% confidence interval 26-65) and 33 (11-54)%. The 5-year overall survival after cystectomy was 54% after IRT and 14% after EBRT (P = 0.12). Tumour category, response to radiation, American Society of Anesthesiology score, and complete tumour resection had a significant influence on survival. Five of seven patients with incomplete resection died because of local disease, with a median survival of 5 months. There was clinical understaging after radiotherapy in 41% of patients. Nine patients had an orthotopic neobladder, with complete day- and night-time continence in eight and four, respectively. All patients but one had good voiding function. There were early complications in two and late complications in six patients (for Bricker, seven of 14 and none; for Indiana, none of four and two of four). The duration of hospitalization was not influenced by the type of diversion. Erectile function was maintained in four of six patients after a sexuality-preserving cystectomy and neobladder. CONCLUSIONS: Salvage cystectomy can be performed with acceptable morbidity using any type of urinary diversion. Understaging after radiotherapy is common, but preoperative selection needs improving. A very significant factor for an adverse outcome and death from local tumour recurrence was incomplete resection, suggesting that salvage cystectomy should only be attempted if complete resection is probable.     

超级伽玛刀治疗胰腺癌的疗效及安全性探讨

目的 评价超级伽玛刀治疗胰腺癌的安全性和有效性.方法 47例胰腺癌病人接受超级伽玛刀治疗,在临床靶区(CTV)边缘外放5～10 mm形成计划靶区(PTV),治疗采用深圳海博公司的SGS-I型立体定向伽玛射线治疗系统,治疗边缘剂量2.5～4 Gy/次,9～23次,5次/周,边缘累计剂量33～57.5 Gy,观察病人的有效率、生存时间和临床受益反应(CBR).结果 总有效率(CR+PR)84.1%,1年局控率58%,2年局控率38%,疼痛完全缓解率57.1%,总缓解率89.3%,临床受益反应(CBR)有效率64.4%;中位生存期12个月,平均生存期13.6个月,1、2年生存率55.3%、17.5%.RTOGⅠ～Ⅱ级胃肠道反应发生率43.2%,无RTOGⅢ胃肠道反应者.结论 S GS-I型立体定向伽玛射线治疗系统采用中等剂量 分割的方法治疗胰腺癌是有效的,并且副作用很低,明显提高了病人的生存质量.     

放疗后脊柱肉瘤的临床特点及治疗方法

目的 探讨放疗后脊柱肉瘤的起因、临床特点、治疗及预后。方法 自1997年以来共收治5例放疗后肉瘤患者，其中4例为脊柱原发性巨细胞瘤术后，1例为何杰金病。均予以肿瘤切除内固定术及术后化疗。结果 术后所有患者的症状均有不同程度的缓解，经2～5年随访，3例死亡，2例复发。结论 脊柱原发性肿瘤的首次手术一定要彻底，同时避免脊柱承受大剂量、长期的X线照射，以尽可能预防放疗后脊柱肉瘤的发生。     

Accuracy of a multidisciplinary team-led discussion in predicting postmastectomy radiotherapy

Introduction

Immediate breast reconstruction (IBR) is performed increasingly following mastectomy for breast cancer. The literature suggests higher reconstructive failure and poorer cosmesis in the subgroup of patients receiving postmastectomy radiotherapy (PMRT) following IBR. We set out to determine the accuracy of a multidisciplinary team (MDT) discussion in predicting PMRT.

Methods

Preoperative MDT discussions were recorded prospectively over a 12-month period (from February 2011) in a symptomatic breast unit. The estimated need for PMRT was stratified into ‘PMRT not required’, ‘PMRT possibly required’, ‘PMRT probably required’ and ‘PMRT required’ groups.

Results

Of 156 referrals included in the study, 76 patients (49%) underwent mastectomy: 61 simple mastectomy, 10 skin sparing mastectomy (SSM) and delayed-immediate breast reconstruction, 3 SSM and implant-based IBR, and 2 mastectomy IBR with an autologous flap. The IBR rate was therefore 19.7%. The proportion of patients who received PMRT was 14% (3/21) in the ‘PMRT not required’, 30% (7/23) in the ‘PMRT possibly required’, 65% (9/14) in the ‘PMRT probably required’ and 94% (17/18) in the ‘PMRT required’ groups. Assigning a linear numerical score (1–4) to these groups (higher score representing greater likelihood of receiving PMRT), the predicted need for PMRT correlated with the proportion of patients who ultimately received PMRT (linear regression r²=0.98, p=0.01).

Conclusions

This study has examined the factors influencing MDT discussions regarding IBR, demonstrating that the MDT is reasonably accurate at predicting need for PMRT. Whether such accuracy is clinically adequate and/or reproducible across units is debatable.     

Evolving Concepts in the Management of Jugular Paraganglioma: A Comparison of Radiotherapy and Surgery in 88 Cases

Surgery for jugular paraganglioma (PGL) tumors often results in the acquisition of neurological deficits where none had been present previously. This has a significant impact on the quality of life. Radiotherapy is a recognized alternative therapy. The aim of this study was to compare the results of radiotherapy and surgery for the management of jugular PGL in terms of function and tumor control to define a treatment algorithm. We conducted a retrospective and comparative analysis of the treatment of 41 patients by conventional radiotherapy and 47 patients by surgery via tertiary referral at an academic medical center. Forty-seven patients with type C and/or D jugular PGLs (mean age, 46 years) underwent surgery after endovascular embolization between 1984 and 1998 using an infratemporal fossa type A approach. The facial nerve was transposed in 18 patients. An adjunctive neurosurgical procedure was required in 14 patients. Mean follow-up was 66 months (range, 17 months to 14 years). Forty-one patients with type C jugular PGLs (mean age, 59.5 years) were treated by external beam or conformational radiotherapy between 1988 and 2003 with a total mean dose of 45 Gy (range, 44 to 50 Gy). Mean follow-up was 50 months (range, 18 months to 13 years). The primary outcome measures were tumor control and cranial nerve status. Surgical resection, total or subtotal, yielded an overall 86% rate of either cure or tumor stabilization. Radiotherapy achieved local control in 96% of patients. For surgery, the main postoperative complications were dysphagia, aspiration, and facial paralysis. Patients treated by radiotherapy developed minor disabilities. We concluded that radiotherapy and surgery achieve similar oncologic outcomes, but the former achieves tumor control with less morbidity. Our data favor radiotherapy as treatment for jugular PGLs, but we acknowledge that the aims of these two treatment modalities are different, namely, eradication of tumor by surgery versus stabilization of tumor with radiotherapy. The search for the better quality of life has to be weighed against the uncertainty of the long-term behavior of the tumor.