Radiation therapy for breast cancer.

Now that the radiation literature for breast cancer is well established in terms of both local control and survival endpoints, especially for invasive breast cancer, recent reports focus on refining selection criteria of patients for treatment and on minimizing complications and maximizing cosmetic effects. The optimal treatment of patients with ductal carcinoma in situ remains a controversial issue, and the optimal sequencing of adjuvant chemotherapy and primary radiation in patients with breast-conserving surgery is emerging as a topic requiring further study.     

Radiation therapy for localized prostate cancer.

Since 1965, 401 patients with prostate cancer have received intensive local pelvic radiation therapy at the Virginia Mason Medical Center. Two hundred seventy-seven of these patients were treated from 1965 through 1975, comprising the study group. Two hundred twenty-one of this series were in the Stage C category. The 36 Stage B cancers were either medically nonoperable, or advanced extent, or had high-grade histopathology. Ten patients each were in diffuse Stage A or Stage D groups, the latter receiving local palliative intensive treatment to the prostate area. The mean age of the patients was 67.6 years. The five year survival of the Stage C group was 57.7%. There was no apparent influence on the survival of irradiated Stage C patients who received estrogen therapy. Current treatment techniques employ 10 megavolt photon beam with whole pelvic nodal fields and bilateral arc rotational boost fields. The incidence of reactions and complications is presented.     

Radiation therapy for Bowen's disease of the skin

PURPOSE: To assess the clinical outcome in the radiation therapy (RT) of squamous carcinoma in situ of the skin (Bowen's disease). We focused on the local control rate and the toxicity according to the biologically effective dose (BED). METHODS AND MATERIALS: A retrospective review was performed on 44 patients with Bowen's disease treated at Princess Margaret Hospital from April 1985 to November 2000. RT was the primary treatment for 32 patients, whereas 12 received RT for residual disease after local ablative therapy. Lesions were located as follows: scalp, 9 patients (20%); face, 12 (27%); trunk, 6 (14%), extremity, 12 (27%), perianal, 3 (7%), and penis, 2 (5%). Orthovoltage X-rays were used in the majority (39 of 44, 89%). There was no standard fractionation regimen: some physicians prescribed high doses, as for invasive skin cancer, whereas others prescribed lower doses because of the noninvasive nature of the disease, a sensitive anatomic location (e.g., extremity), or large treatment area. Because of the variations in fractionation regimens, BED was used as a common metric for biologic effect in the comparison of different regimens and analyzed for correlation with recurrence and toxicity. Local control was defined as the lack of persistent or recurrent disease at the treated site for the follow-up period. Grade 4 toxicity was defined as necrosis (cartilage/bone damage) and/or ulceration for a duration of >3 months. RESULTS: The mean patient age was 67.7 years, and the male/female ratio was 29:15. The median pretreatment lesion size was 2.65 cm(2) (range, 0.07-34.56 cm(2)). Complete remission was achieved in 42 patients, with follow-up unavailable for the remaining 2 patients. Subsequently, 3 patients experienced recurrences at 0.2, 1.1, and 1-1.5 years after complete remission. One recurrence was Bowen's disease (local); the others were squamous cell carcinoma (one local, one marginal). Four patients experienced a new squamous lesion at a distant cutaneous site. As of last follow-up, 32 patients (73%) were known to be alive. Median follow-up was 2.6 years (range, 0-11.8 years). All but 3 patients were disease-free at last follow-up, 1 of whom died with distant, but not local disease. The 5-year overall survival rate was 68%. Biologically effective dose was not associated with recurrence. The crude local control rate was 93%. There was a trend toward higher radiation doses for smaller pretreatment tumor and field sizes. The BED did not correlate with Grade 4 toxicity; however, the three cases of Grade 4 toxicity occurred in patients treated with hypofractionated regimens (dose per fraction >4 Gy) for extremity lesions. CONCLUSIONS: Radiation therapy is an effective treatment option for Bowen's disease of the skin. Local recurrences seem to be equally low in patients treated with high- and low-dose regimens. Avoiding hypofractionated regimens (dose per fraction >4 Gy) in extremity locations might reduce the risk of Grade 4 toxicity.     

Radiation therapy for prostatic cancer

From February 1979 through May 1988, a total of 26 patients with adenocarcinoma of the prostate were treated with radiation therapy for the primary site. The actuarial 5-year survival rate was 59% for 14 patients with Stage C or less disease (A; 1 case, B; 2 cases, and C; 11 cases), and 10% for 12 patients with Stage D. The logrank test showed significant difference between these two groups (p less than 0.007). Rectal radiation injuries occurred in 2 cases (8%) at 7 months (grade I) and 6 months (grade II), respectively. From the analysis of local control and complication, optimum radiation dose ranged from 64.8 Gy to 68.4 Gy (TDF 100-106). In addition, optimum boost radiation field size with rotation technique (after whole pelvic irradiation of 40-45 Gy with anteroposterior opposing fields) ranged from 30 to 48 cm2.     

Radiation therapy for gastrointestinal cancer

This article has reviewed the current role of radiation in the treatment of gastrointestinal malignancies and discussed the data supporting its use. Radiation treatment in this setting continues to evolve with the increasing implementation of more conformal delivery techniques. Further scientific investigation is needed to establish the optimal role of radiation and to better define its integration with novel systemic and biologic modalities.     

Radiation therapy for lung cancer

Radiation therapy is one of the most important modalities for the treatment of lung cancer. Current progress of radiation therapy in cooperation with the development of physics and biology is remarkable. The techniques of three-dimensional treatment planning and three-dimensional conformal radiotherapy (3D-CRT) have facilitated the use of higher radiation doses. Patients with early-stage non-small cell lung cancer (NSCLC) are candidates for curative surgical resection. However, the number of elderly patients has been increasing, and these patients often have medical contraindications that prevent curative surgery. Recently, several clinical trials on stereotactic body radiotherapy (SBRT) using the 3D-CRT technique for solitary lung tumors have been reported. The local control rate for stage I disease is more than 90%, and survival rates are promising. Now a prospective multi-institutional trial is ongoing to determine whether this modality can become a standard treatment for inoperable patients or an alternative to lobetectomy. For locally advanced NSCLC, unfortunately, recent studies have demonstrated that conventional therapies may have reached a therapeutic plateau. Now several radiation dose escalation studies utilizing conventional fractionation and 3D-CRT techniques are ongoing. The strategies of almost all of these trials are to eliminate elective nodal irradiation and deliver a higher dose of radiation to gross tumor volume while sparing normal tissues. Preliminary experience has resulted in promising survival, but should be developed to integrate into the combined treatment to completely control both local disease and other microscopically involved lesions. The combination of novel chemotherapeutic agents and molecular targeting therapies with radiation therapy is being investigated. Development of molecular imaging techniques is expected to facilitate more selective dose escalation in tumors.     

Radiation therapy for breast cancer

Over the past five decades, radiotherapy (RT) has become an integral part in the combined modality management of breast cancer. Although its significant effect on local control has been long demonstrated, only recently has adjuvant RT been shown to have a significant effect on breast cancer mortality and overall survival. This article summarizes the adjuvant role of RT after mastectomy and lumpectomy, as well as the rationale and techniques for partial-breast irradiation.     

Radiation therapy for squamous cell carcinoma of the skin

Eighty-five squamous cell skin cancers treated with radiation therapy were reviewed, including 23 untreated primary tumors, 6 recurrent tumors, 16 synchronous or metachronous nodal metastases including 3 patients from the previous two groups, and 38 sites irradiated for microscopic residual cancer after surgery. The 5-year actuarial local controls were 0.54, 0.0, 0.42, and 0.79, respectively. No relationship between local control and either tumor size or radiation dose could be shown. Salvage treatment was attempted in 7 of 32 local failures, and has been successful in 4. Cancers arising in the settings of prior irradiation, renal transplant, hematopoietic malignancies, or chronic inflammation did not fare worse, and patients with parotid node metastases generally fared better with combined irradiation and surgery. Surgery followed by adjuvant irradiation confers a 5-year disease control probability of 0.79. Irradiation alone for untreated primary lesions, for recurrent primary lesions, or for untreated nodal metastases confers a disease control probability of approximately 0.50. Local or systemic predisposing factors do not confer an appreciably different prognosis. Parotid lymph node metastases are best served by combined modality treatment.     

Radiation therapy versus chemoradiation as adjuvant treatment in high-risk endometrial cancer

Endometrial cancer is a common malignancy. Management of these tumors depends on several risk factors such as FIGO staging, myometrial invasion, histology or pelvic lymph node involvement. According to those factors, low risk, intermediate and high risk groups were defined. A high risk endometrial cancer has a poorer prognostic and more risks of recurrence. Treatment of such disease should be more aggressive. However modalities of these treatments have not yet been clearly defined.     

Radiation therapy for inflammatory breast cancer

Inflammatory Breast Cancer (IBC) is a rare and very aggressive breast cancer, still associated with poor prognosis. Therefore, management of IBC requires carefully integrated care, and ideally, patients should be evaluated in a multidisciplinary team from the beginning, to identify the best treatment strategy.IBC is usually unresectable at presentation, and neo-adjuvant systemic therapy is considered the standard of care.Response to the primary treatment, especially pathological complete response (pCR), is important to move forward to definitive local therapy with the goal to improve survival. In any case, regardless the response to neo-adjuvant therapy, surgery and radiotherapy should administered to ensure a better loco-regional tumor control. Mastectomy with axillary lymph node dissection followed by chest wall and regional nodal radiotherapy is the most frequent approach, and whether breast-conserving surgery could be preferable in some selected groups of patients with clinical complete response is still a debated question. Radiotherapy alone has recommended only in cases of persistent unresectability.To date, the approach remains as established in the current recommendations, with the best option for trimodality treatment, and further studies clearly warranted.     

Radiation therapy for early breast cancer

In women with early-stage breast cancer treated with surgery alone, microscopic residual disease may not be eliminated and can eventually cause life-threatening metastatic recurrence. Radiation therapy has been widely recommended for local control after breast-conserving surgery (BCS) and after a complete mastectomy in women at high risk of recurrence. However, even with widespread support for these recommendations within the medical community, they are not always heeded. Because local recurrence, when detected early, can often be treated with additional surgery alone, some physicians and patients still elect to avoid radiation therapy. It was felt, based upon individual trial data, that radiation therapy did not affect overall survival, but just decreased local relapse. The meta-analysis, published in the December 17/2005 Lancet, analysed individual data from 42,000 women, collected during 78 different randomised trials conducted since 1985. The availability of extensive 15-year survival data allowed the investigators to quantify the relationship between successful local control and long-term survivorship. Moreover, individual trials all show a benefit in local control and some trends toward survival advantages. The pooled meta-analysis of breast conservative surgery with or without radiation therapy Vinh Hung (2004) demonstrates a significant impact on local relapse and a small but significant impact on survival. It is considered that after BCS and in certain cases after mastectomy, radiation therapy is the standard treatment for improved local control and long-term survival.     

Radiation therapy for advanced gastric cancer

A retrospective study of 75 patients with advanced inoperable gastric cancers, referred to the National Cancer Center Hospital between 1962 and 1982, was performed. According to the Borrmann classification based on X ray findings, Type 1 was found in 3 patients, Type 2 in 5, Type 3 in 40, and Type 4 in 15. Twelve patients could not be classified. The histological type was papillary adenocarcinoma in 7 patients, tubular adenocarcinoma in 23, mucinous carcinoma in 6, poorly differentiated adenocarcinoma in 14, signet ring cell carcinoma in 12 and others in 13. The site of remote metastasis in 19 patients was Virchow's lymph node in 8 patients, Douglas pouch in 3, liver and lung in 2 each and others in 4. All patients were treated by a either telecobalt 60 unit or a linear accelerator using 6 Mv photon and the total dose to primary lesion was 4000 cGy in 5 weeks to 7000 cGy in 8-9 weeks. Complete response (CR) was achieved in 6 patients or 8.0%, partial response (PR) in 46 or 61.3%, and no change (NC) in 23 or 30.7%. The response rate based on the sum of CR and PR was about 70%. The 50% survival period in months was 26.5, 7.3, and 3.2, respectively for patients with CR, PR, and NC. For the response of advanced gastric cancer to chemotherapy in the National Cancer Center Hospital, the combined use of UFT and Mitomycin C gave the highest rate, 46%. As for as local response is concerned, the response rate to radiation was 70%, a better result than that of chemotherapy alone.     

Radiation therapy for unresectable rectal cancer

The standard approach to patients with unresectable rectal cancer is pre-op radiation therapy followed by surgery. To determine the impact of RT on local failure and survival, we present an analysis of our preliminary results of this approach in patients with unresectable rectal cancer. A total of 22 patients were analyzed (9 primary, 13 recurrent). The median follow-up was 22 months. There were two groups of patients. Group 1 included 12 patients with unresectable tumors in whom surgery was planned following pre-operative radiation therapy. Group 2 included 10 patients in whom no surgery was planned following radiation therapy due to extensive pelvic bone destruction. The whole pelvis received 4680 cGy followed by a boost of 360-1440 cGy. Six underwent brachytherapy. For the total patient group, the 3-year actuarial survival was 52% (Group 1: 91% vs Group 2: 30%). Patterns of failure as a component of failure were: local failure (or local progression): 50%, abdominal: 23%, and distant: 9%. The dose of pelvic radiation had no significant impact on the local failure rate (5040 cGy: 55% vs greater than 5700 cGy:45%). None of the seven patients with negative margins developed local failure compared with 73% of those with positive margins. The complete resection rate in Group 1 patients was 58%, and all are alive without local failure. Further follow-up will be needed to determine the ultimate local failure and survival rates.