Exercise therapy for trismus in head and neck cancer

The aim of this study was to analyze retrospectively effects of exercise therapy on trismus related to head and neck cancer or as a consequence of its treatment, and to compare these effects with trismus not related to head and neck cancer. Medical records of patients referred to the department of physical therapy with the diagnosis trismus were retrieved and analyzed. Data of 27 patients with trismus related to head and neck cancer and data of eight patients with trismus not related to cancer were found. The number and type of exercises were registered from the records, as was the extent of mouth opening before and after exercise therapy. The median (IQR) number of exercise treatments was 4 (3-9.3). Exercises included active range of motion exercises, hold relax techniques, manual stretching and joint distraction. The increase in mouth opening was significantly (p相似文献   

Trismus in head and neck oncology: a systematic review

The aim of this review was to identify systematically, criteria for trismus in head and neck cancer, the evidence for risk factors for trismus and the interventions to treat trismus. Three databases were searched (time period 1966 to June 2003) for the text "trismus" or "restricted mouth opening". Included in the review were clinical studies (> or = 10 patients). Two observers independently assessed the papers identified. In 12 studies nine different criteria for trismus were found without justifying these criteria. Radiotherapy (follow-up: 6-12 months) involving the structures of the temporomandibular joint and or pterygoid muscles reduces mouth opening with 18% (sd: 17%). Exercises using a therabite device or tongue blades increase mouth opening significantly (no follow-up), effect sizes (ES) 2.6 and 1.5 respectively. Microcurrent electrotherapy (follow-up 3 months) and pentoxifylline (no follow-up) increases mouth opening significantly (ES for both: 0.3).     

Prevalence of Trismus and Its Impact on Oral Health-Related Quality of Life in Patients Treated for Oral Squamous Cell Carcinoma

Oral squamous cell carcinoma, one of the most common malignancies, has a poor prognosis due to impairment in oral functions secondary to treatment. Trismus one of the major causes of impairment of oral function. The present study investigated the prevalence of trismus and its impact on oral health-related quality of life (OHRQoL) in patients treated for oral squamous cell carcinoma (OSCC). The maximum inter-incisal mouth opening of hundred OSCC patients was recorded at post-treatment and 3 months post-treatment. OHRQoL questionnaire (OHIP-14) was intervened to assess the OHRQoL of patients post-treatment and 3 months follow-up, with emphasis on correlation with grades of trismus. The prevalence of trismus was 16% pre-treatment, 72% post-treatment, and 62% at 3 months after treatment. The overall OHIP-14 scores indicated that patients with trismus reported greater impairment of OHRQoL than those without trismus at the end of treatment and 3 months follow-up. At the end of treatment, patients with severe trismus demonstrated a higher mean OHIP-14 score (23.47 ±3.34) than those with moderate (17.72 ±2.83) and mild trismus (12.66 ±3.84) with statistically significant differences (p <0.001). Equivalent results were obtained at 3 months follow-up period. Patients with trismus suffer greater impairment of OHRQoL. The findings demand the need of identifying risk factors for developing trismus and early institution of newer/modified treatment approaches for better OHRQoL in OSCC survivors.     

Failure of a 3D conformal boost to improve radiotherapy for nasopharyngeal carcinoma

Purpose: To determine whether the use of 3-dimensional (3D) boost for patients with nasopharynx cancer improves local control and reduces the risk of long-term complications.

Methods and Materials: From 1988 to 1998, 68 patients with nasopharynx cancer received conventional external beam therapy followed by a 3D boost. Disease characteristics of treated patients were as follows: WHO I histology 7%, WHO II 62%, WHO III 31%, clinical AJCC stage T1–2 45%, T3–4 55%, N0–1 63%, N2–3 37%, M0 100%. The median radiation dose was 70 Gy (68–75.6 Gy). Thirty-five patients (52%) received cisplatin-based chemotherapy. The median follow-up of surviving patients was 42 months (12–118 months).

Results: Five-year actuarial local control was 77%, regional control was 97%, progression-free survival was 56%, and overall survival was 58%. Stage was the only identifiable prognostic factor: 5-year progression-free survival was 65% for Stages I–III vs. 40% for Stage IV (p = 0.01). The incidence of Grade 3–4 complications was 25% and included hearing loss, trismus, dysphagia, chronic sinusitis, and cranial neuropathy. These results are comparable to outcomes reported with conventional radiation techniques for similarly staged patients.

Conclusion: The lack of a major benefit with the 3D boost may be related to the fact that CT planning was only used for a fraction of the total dose. We are now using intensity modulated radiation therapy to deliver the entire course of radiation. Intensity modulated radiation therapy achieves better conformal distributions than conventional 3D planning, allowing dose escalation and increased normal tissue sparing.     

Topical phenylephrine in the treatment of radiation-induced faecal incontinence

AimsAcute bowel toxicity after pelvic radiotherapy is defined as occurring within 3 months of the start of treatment; chronic gastrointestinal toxicity may continue after the acute phase or start after a latent period. One in five patients develop chronic faecal incontinence affecting quality of life; how best to treat these patients is not known.This retrospective study aimed to determine the effects of a new agent, phenylephrine gel, in the treatment of chronic radiation-induced faecal incontinence.Materials and methodsPatients prescribed phenylephrine gel for new-onset faecal incontinence after radiotherapy were identified from our database of patients treated in a specialist radiation-induced bowel damage clinic since 2000. Changes in the level of faecal incontinence were assessed using the Vaizey faecal incontinence scoring system before and after treatment.ResultsFifteen patients (nine men and six women) of mean age 70.5 years (standard deviation 8.2, age range 56–82 years) were treated with phenylephrine gel a median of 43 months after completing radiotherapy. The median Vaizey score before treatment with phenylephrine gel was 17 (interquartile range [IQR] 14–20) and after treatment was 14 (IQR 11–18) (P = 0.005). The median length of treatment with phenylephrine gel was 28 days (IQR 28–365). Scores improved in 11 out of 15 patients; four out of 15 patients showed substantial improvements of 7 or more points; and seven patients considered the gel helpful.ConclusionTopical phenylephrine gel for the treatment of radiation-induced faecal incontinence has not been previously reported. This small, retrospective study suggests that it may help most patients and, in some, the improvement may be substantial. However, larger placebo-controlled prospective studies are required.     

Role of tobacco smoking, chewing and alcohol drinking in the risk of oral cancer in Trivandrum, India: a nested case-control design using incident cancer cases

Oral cancer is one of the most common cancers in the world, with two-thirds of the cases occurring in developing countries. While cohort and nested case-control study designs offer various methodological strengths, the role of tobacco and alcohol consumption in the etiology of oral cancer has been assessed mainly in case-control studies. The role of tobacco chewing, smoking and alcohol drinking patterns on the risk of cancer of the oral cavity was evaluated using a nested case-control design on data from a randomized control trial conducted between 1996 and 2004 in Trivandrum, India. Data from 282 incident oral cancer cases and 1410 matched controls were analyzed using multivariate conditional logistic regression models. Tobacco chewing was the strongest risk factor associated with oral cancer. The adjusted odds ratios (ORs) for chewers were 3.1 (95% confidence interval (CI) = 2.1–4.6) for men and 11.0 (95%CI = 5.8–20.7) for women. Effects of chewing pan with or without tobacco on oral cancer risk were elevated for both sexes. Bidi smoking increased the risk of oral cancer in men (OR = 1.9, 95%CI = 1.1–3.2). Dose-response relations were observed for the frequency and duration of chewing and alcohol drinking, as well as in duration of bidi smoking. Given the relatively poor survival rates of oral cancer patients, cessation of tobacco and moderation of alcohol use remain the key elements in oral cancer prevention and control.     

Gamma Knife radiosurgery for numerous brain metastases: is this a safe treatment?

Gamma Knife (GK) radiosurgery has recently been employed in patients with numerous brain metastases (METs), even those with 10 or more lesions. However, cumulative irradiation doses to the whole brain (WB), with such treatment, have not been determined.

Since the GammaPlan ver. 5.10 (ver. 5.31 is presently available, Leksell GammaPlan) became available in November 1998, 92 GK procedures have been performed for 80 patients with 10 or more brain METs at our facility. The median lesion number was 17 (range: 10–43) and the median cumulative volume of all tumors was 8.02 cc (range: 0.46–81.41 cc). The median selected dose at the lesion periphery was 20 Gy (range: 12–25 Gy). Based on these treatment protocols, the cumulative irradiation dose was computed.

The median cumulative irradiation dose to the WB was 4.71 (range: 2.16–8.51) Gy. The median brain volumes receiving >2 Gy, >5 Gy, >10 Gy, >15 Gy, and >20 Gy were 1105 (range 410–1501) cc, 309 (46–1247) cc, 64 (13–282) cc, 24 (2–77) cc, and 8 (0–40) cc, respectively.

The cumulative WB irradiation doses for patients with numerous radiosurgical targets were not considered to exceed the threshold level of normal brain necrosis.     

Benefit of Using Muscle Relaxants in the Routine Treatment Protocol of Oral Submucosal Fibrosis: A Pilot Study

The aim of this present work is to describe the nature and extent of fibrosis within muscle and to correlate this with the mouth opening (MO) in OSE patients and to prove our results in improvement of mouth opening in patients with OSMF with use of “muscle relaxants” along with other modalities of treatment . The study was conducted on 40 patients who visited our outpatient department with grade 3 (<19 mm) mouth opening. 20 of these patients underwent the routine treatment protocol of weekly injection of hyaluronidase with hydrocortisone and antioxidant capsules with added lycopene for 1 month. The remaining test subjects in addition to the routine injections and antioxidants were given skeletal muscle relaxants like thiocolchicoside or chlorzoxazone. The mouth opening (interincisal distance of maxillary and mandibular incisors at maximum possible mouth opening) was measured and graded as follows: grade 1 (>40 mm), grade 2 (20–39 mm) and grade 3 (<19 mm) with the help of vernier callipers after the study period of 1 month. 17 out of the 20 test patients who received muscle relaxants in addition to the routine protocol showed marked improvement with shift from grade 3 (<19 mm) to grade 1 (>40 mm) i.e. a greater than 20 mm improvement in mouth opening. Using muscle relaxants as a adjuvant therapy in the routine protocol of treatment of oral submucosal fibrosis will not only cater and halt the problem of fibrosis but also will take care of the muscle spasm and inflammation which also inadvertently contribute to the restricted mouth opening. We found excellent improvement on adding muscle relaxants to the routine protocol which was not just an objective but also a subjective success.     

Linac radiosurgery for cerebral arteriovenous malformations: results in 169 patients

Purpose: To present the SALT group results using Linac radiosurgery (RS) for AVM in 169 evaluable patients treated from January 1990 thru December 1993.

Methods and Materials: Median age was 33 years (range 6–68 years). Irradiation was the only treatment in 55% patients. Other treatment modalities had been used prior to RS in 45%: one or more embolizations in 36%, surgery in 6%, and embolization and surgery in 3% patients. Nidus were supratentorial in 94% patients, infratentorial in 6% patients. Circular 15 MV x-ray minibeams (6–20 mm) were delivered in coronal arcs by a GE-CGR Saturne 43 Linac. Patient set-up included a Betti arm-chair, a Talairach frame. Prescribed peripheral dose was 25 Gy on the 60%–70% isodose (max dose 100%). Arteriographic results were reassessed in December 1997 at 48 to 96 months follow-up.

Results: The overall obliteration rate (OR) was 64% (108/169). AVM volumes ranged from 280 to 19,920 mm³, median 2460 mm³. OR was 70% for AVM ≤ 4200 mm³ vs. 51% for AVM > 4200 mm³ (p = 0.02). The largest nidus dimension ranged from 8 to 51 mm, median 22 mm. OR was 70% for nidus ≤ 25 mm vs. 54% for nidus > 25 mm (p = 0.04). OR was 71%, in the absence of embolization, vs. 54% for previously embolized nidus (p = 0.03). OR was 71% for monocentric RS vs. 54% for multi-isocenters (p = 0.03). Peripheral doses (Pd) ranged from 15 to 28Gy, median 25 Gy, OR was 52% in patients receiving Pd ≤ 24.1 Gy or > 25.9 Gy and 70% for 25 Gy (NS). Peripheral isodoses ranged from 50%–90%, median 70%: OR was 67% for peripheral isodoses of 65% and 70% vs. 61% for peripheral isodoses of 50%–60% (NS). The mean lesion doses (MLd) ranged from 14 to 36 Gy, median 29 Gy: OR was 72% for MLd > 28 Gy vs. 55% for values ≤ 28 Gy (p = 0.02). The mean lesion isodoses (MLi) ranged from 53 to 90 Gy, median 79%: OR was 75% for MLi > 79% vs. 57% for lower values (p = 0.03). The minimum lesion doses (mLd) ranged from 3.6 to 23, median 16 Gy: OR was 69% for mLd > 17 Gy, vs. 59% for mLd ≤ 16 Gy (p = 0.05). The minimum lesion iodoses (mLi) ranged from 9%–65%, median 45%: OR was 71% for mLi > 40%, vs. 54% for mLi ≤ 40% (p = 0.05). The coverage ratio (CR) ranged from 33%–100%, median 85%: OR was 68% for CR > 85% vs. 60% for CR ≤ 84% (NS). For patients treated according to our protocol, i.e., 24–26 Gy on the 60%–70% isodoses, OR was higher (68%) than for other patients (47%) (p = 0.02). After multivariate analysis, absence of previous embolization and mono isocentric-irradiation were independent factors predicting obliteration. Complications were: recurrent hemorrhage, 4 patients (1 patient died); brain necrosis on MRI, 2 patients; subsequent epilepsy, 4 patients; other subsequent neurologic deficits, 3 patients.

Conclusion: Overall OR was 64% (48–96 months follow-up). After monovariate analysis higher ORs were associated with smaller volumes ≤ 4200 mm³, smaller nidus size ≤ 25 mm, absence of prior embolization, monoisocentric RS, higher values for mean and minimum lesion doses and compliance to our protocol. Higher values for the peripheral dose and isodose tended to give better results. Multivariate analysis showed that the absence of prior embolization and monoisocentric irradiation were independent factors predicting successfull irradiation.     

A pilot study of pentoxifylline in the treatment of radiation-induced trismus

Radiation-induced trismus has a significant impact on the quality of life of patients receiving radiotherapy for head and neck cancers. Pentoxifylline has immunomodulatory activities that downregulate certain cytokines that have been implicated as mediators of fibrogenic reactions after radiation. A pilot study was therefore conducted to evaluate the efficacy of pentoxifylline in the treatment of radiation-induced trismus. Twenty patients with severe trismus (dental gap < or = 25 mm) after receiving radiotherapy for nasopharyngeal carcinoma were enrolled onto the study. Four patients were excluded from analysis because of poor drug compliance. The remaining 16 evaluable patients completed an 8-week course of pentoxifylline at a dose of 400 mg two to three times daily. Changes in dental gap were recorded by measuring the distance between left upper and lower incisor before and after treatment. At the end of treatment, 10 patients had a measured increase in dental gap ranging from 2 to 25 mm. Six patients had an increment of 5 mm or more. The mean dental gap before treatment was 12.5 mm compared with 16.5 mm at the end of treatment (p = 0.023). The mean difference in dental gap was 4 mm, with a 95% confidence interval of 0.6 to 7.4 mm. The drug pentoxifylline appears to exert a modest therapeutic effect in patients with radiation-induced trismus, although our findings need to be confirmed by a randomized placebo-controlled study. While awaiting more evidence from clinical studies, a therapeutic trial of pentoxifylline is worth considering in patients experiencing radiation-induced trismus.     

Use of an implanted marker and real-time tracking of the marker for the positioning of prostate and bladder cancers

Purpose: A real-time tracking radiotherapy was investigated to assess its usefulness in precise localization and verification of prostate and bladder cancers.

Methods and Materials: The real-time tracking radiation therapy (RTRT) system consists of implantation of a 2.0-mm gold marker into a clinical target volume (CTV), three-dimensional radiation treatment planning (3DRTP) system, and the use of two sets of diagnostic x-ray television systems in the linear accelerator room, image processing units, and an image display unit. The position of the patient can be corrected by adjusting the actual marker position to the planned marker position, which has been transferred from the 3DRTP and superimposed on the fluoroscopic image on the display unit of the RTRT system. The position of the markers can be visualized during irradiation and after treatment delivery to verify the accuracy of the localization. Ten patients with prostate cancer and 5 patients with bladder cancer were examined using this system for the treatment setup on 91 occasions.

Results: After manual setup using skin markers, the median of absolute value of discrepancies between the actual position of the marker and the planned position of the marker for prostate cancer was 3.4 (0.1–8.9) mm, 4.1 (0.2–18.1) mm, and 2.3 (0.0–10.6) mm for the lateral, anteroposterior, and craniocaudal directions, respectively. The 3D median distance between the actual and planned positions of the marker was 6.9 (1.1–18.2) mm for prostate cancer and 6.9 (1.7–18.6) mm for bladder cancer. After relocation using RTRT, the 3D distance between the actual and planned position of the marker was 0.9 ± 0.9 mm. Median 3D distances between actual positions after treatment delivery and planned positions were 1.6 (0.0–6.3) mm and 2.0 (0.5–8.0) mm during daily radiotherapy for the marker in patients with prostate cancer and bladder cancer, respectively.

Conclusion: We believe the new positioning system can reduce uncertainty due to setup error and internal organ motion, although further improvement is needed for the system to account for the rotational and elastic changes of the affected tissues.     

A Cross Sectional Study of Oral Submucous Fibrosis in Central India and the Effect of Local Triamcinolone Therapy

The use of processed arecanut is on the increase. In the impending danger of increased occurrence of oral submucous fibrosis and subsequent oral cancer following this habit is colossal. So an attempt is made to clinically evaluate the condition and to evaluate the effect of triamcinolone on this condition. Using the clinical data collected from the patients presenting in the ENT OPD of NSCB Medical College Hospital, Jabalpur, a cross sectional study was done and the effect of intralesional triamcinolone on this condition is noted by biweekly submucosal injections of 40 mg triamcinolone for 12 weeks and followed up for 1 year. The effect of therapy was evaluated subjectively by improvement in symptoms and objectively by increase in mouth opening. The age of occurrence and sex predilection also showed a significant change with more young males being affected by the condition. There was no significant correlation between effect of triamcinolone therapy and duration of addiction but a significant correlation (P < 0.0001) was noted with the frequency of addiction per day. A significant improvement in mouth opening is observed following local triamcinolone therapy. The results imply that the exposure and the frequency of chewing habits, and not mere the duration that is significant in producing the condition and affecting the treatment outcome. Local triamcinolone therapy has good effect in the initial stages of the disease. The fact that more youngsters are being affected needs serious consideration.     

Ultrathin Silicon Sheet in the Management of Unilateral Post-traumatic Temporo-Mandibuar Joint Ankylosis in Children: A Good Alternative to Conventional Techniques

We have described a new technique of using ultra-thin silicon sheet (0.2 mm) between two transected bony ends for temporo-mandibular joint (TMJ) ankylosis in children with advantages of short operative time, minimal foreign material insertion and faster recovery time post-operatively which makes our technique a good alternative to conventional techniques. Our study is a non-randomized prospective study conducted on 10 children aged between 4 and 15 years who presented to our tertiary care institute with severe trismus after traumatic injury and were willing to undergo this new technique. The main outcome measure taken into consideration was difference between pre-operative, intra-operative (on table) and post-operative mouth opening (minimum 2 years follow-up). The pre-operative mouth opening in our cases varied from 1 to 5 mm. The intra-operative mouth opening achieved ranged from 2.8 to 3.2 cm. The mouth opening was about more than 2.7 cm in all our cases at 2 years of follow-up. Our technique is a good alternative to conventional techniques used for TMJ ankylosis in children but few more randomized controlled trials are required to assess its effectiveness in comparison to conventional techniques and for universal adoption of this technique.     

Computed tomography (CT) evaluation of breast cancer patients with osteolytic bone metastases undergoing palliative radiotherapy—a feasibility study

Twenty-five patients with osteolytic metastases had computed tomography (CT) scans before and 3 months after palliative radiotherapy. The median % density change following single 8 Gy, 20 Gy/5#, 30 Gy/10# were: 128 (range 98–255), 141 (79–342), and 145 (65–235), respectively. It is feasible to evaluate remineralization of osteolytic lesions with palliative radiotherapy.     

Metabolic imaging of low-grade gliomas with three-dimensional magnetic resonance spectroscopy

The role of radiotherapy (RT) seems established for patients with low-grade gliomas with poor prognostic factors. Three-dimensional (3D) magnetic resonance spectroscopy imaging (MRSI) has been reported to be of value in defining the extent of glioma infiltration. We performed a study examining the impact MRSI would have on the routine addition of 2–3-cm margins around MRI T2-weighted hyperintensity to generate the treatment planning clinical target volume (CTV) for low-grade gliomas.

Twenty patients with supratentorial gliomas WHO Grade II (7 astrocytomas, 6 oligoastrocytomas, 7 oligodendrogliomas) underwent MRI and MRSI before surgery. The MRI was contoured manually; the regions of interest included T2 hyperintensity and, if present, regions of contrast enhancement on T1-weighted images. The 3D-MRSI peak parameters for choline and N-acetyl-aspartate, acquired voxel-by-voxel, were categorized using a choline/N-acetyl-aspartate index (CNI), a tool for quantitative assessment of tissue metabolite levels, with CNI 2 being the lowest value corresponding to tumor. CNI data were aligned to MRI and displayed as 3D contours. The relationship between the anatomic and metabolic information on tumor extent was assessed by comparing the CNI contours and other MRSI-derived metabolites to the MRI T2 volume.

The limitations in the size of the region “excited” meant that MRSI could be used to evaluate only a median 68% of the T2 volume (range 38–100%), leaving the volume T2c. The CNI 2 volume (median 29 cm³, range 10–73) was contained totally within the T2c in 55% of patients. In the remaining patients, the volume of CNI 2 extending beyond the T2c was quite small (median 2.3 cm³, range 1.4–5.2), but was not distributed uniformly about the T2c, extending up to 22 mm beyond it. Two patients demonstrated small regions of contrast enhancement corresponding to the regions of highest CNI. Other metabolites, such as creatine and lactate, seem useful for determining less and more radioresistant areas, respectively.

Metabolically active tumor, as detected by MRSI, is restricted mainly to the T2 hyperintensity in low-grade gliomas, but can extend outside it in a limited and nonuniform fashion up to 2 cm. Therefore, a CTV including T2 and areas of CNI extension beyond the T2 hyperintensity would result in a reduction in the size and a change in the shape of the standard clinical target volumes generated by adding uniform margins of 2–3 cm to the T2 hyperintensity.     

Varied routes of entry into secondary care and delays in the management of lung cancer in New Zealand

Aim:   To determine secondary care transit times for lung cancer patients, whether these times conformed to international guidelines and the major factors which influenced these times.
Methods:   An audit of secondary care management in Auckland-Northland of lung cancer patients diagnosed in 2004 (565 patients) provided the opportunity to assess entry routes into and transit times in secondary care.
Results:   The most common entry route was via the emergency department (ED) (35%, 198 patients), especially for those with metastatic disease ( P  < 0.0005). The median time from entry to diagnosis was 22 days (interquartile range [IQR]: 11; 42) overall, but only 11 days (IQR: 6; 18) when entry occurred via ED. The median time from entry to treatment was 64 days (38; 93); 59 days (36; 87) for palliative treatment and 76 days (50; 111) for curative treatment. Initiation of treatment within British Thoracic Society recommended times occurred for 41% patients undergoing surgical resection, 36% receiving definitive (56% palliative) radiation therapy and 40% receiving chemotherapy. The factors that influenced transit times in multivariate analysis included the entry route, the presenting symptoms, the investigations performed, the tumor type, multidisciplinary discussion and Maori ethnicity.
Conclusion:   A high proportion of lung cancer patients, especially those treated curatively, were not managed within internationally recommended timeframes. Improved access to primary care may facilitate earlier diagnosis and better resource allocation and prioritizing patients in secondary care may improve the timeliness of treatment for those most likely to benefit from it, thereby improving survival outcomes.     

Iridium-192 transperineal interstitial brachytherapy for locally advanced or recurrent gynecological malignancies

Purpose: To assess treatment outcome for patients with locally advanced or recurrent gynecological malignancies treated with continuous low-dose-rate (LDR) remote afterloading brachytherapy using the Martinez Universal Perineal Interstitial Template (MUPIT).

Materials and Methods: Between 7/85 and 6/94, 69 patients with either locally advanced or recurrent malignancies of the cervix, endometrium, vagina, or female urethra were treated by 5 different physicians using the MUPIT with (24 patients) or without (45 patients) interstitial hyperthermia. Fifty-four patients had no prior treatment with radiation and received a combination of external beam irradiation (EBRT) and an interstitial implant. The combined median dose was 71 Gy (range 56–99 Gy), median EBRT dose was 39 Gy (range 30–74 Gy), and the median implant dose was 32 Gy (range 17–40 Gy). Fifteen patients with prior radiation treatment received an implant alone. The total median dose including previous EBRT was 91 Gy (range 70–130 Gy) and the median implant dose was 35 Gy (range 25–55 Gy).

Results: With a median follow-up of 4.7 yr in survivors, the 3-yr actuarial local control (LC), disease-specific survival (DSS), and overall survival (OS) for all patients was 60%, 55%, and 41% respectively. The clinical complete response rate was 78% and in these patients the 3-year actuarial LC, DSS, and OS was 78%, 79%, and 63% respectively. On univariate analysis for local control, disease volume and hemoglobin were found to be statistically significant. On multivariate analysis, however, only disease volume remained significant (p = 0.011). There was no statistically significant difference in local control whether patients had received any prior treatment with radiation (p = 0.34), had recurrent disease (p = 0.13), or which physician performed the implant (p = 0.45). The grade 4 complication rate (small bowel obstruction requiring surgery, fistulas, soft tissue necrosis) for all patients was 14%. With a dose rate less than 70 cGy/hour, the grade 4 complication rate was 3% vs. 24% with dose rate ≥ 70 cGy/hour (p = 0.013).

Conclusion: Patients with locally advanced or recurrent gynecological malignancies treated with the remote afterloader LDR MUPIT applicator can expect reasonable rates of local control that are not operator-dependent. Complication rates with this approach are acceptable and appear to be related to the dose rate.     

Standard conditioning regimen and t-depleted donor bone marrow for transplantation in chronic myeloid leukemia

Between January 1984 to June 1985, 18 Ph¹ positive chronic myeloid leukemia (CML) patients in chronic phase (CP) underwent allogeneic bone marrow transplantation (BMT) from HLA identical and MLC negative siblings. The median age was 32.5 yr and median disease duration of CML at time of BMT was 19.3 months. The pretransplant conditioning regimen consisted of cyclophosphamide (CTX) (120 mg/kg) and 10.20 Gy total body irradiation (TBI) at 6 doses of 1.7 Gy each, administered in 3 daily fractions over 2 days at a dose rate of 15–20 cGy/min. To prevent graft-vs-host disease (GvHD) we used methotrexate (MTX) in one patient and cyclosporin-A (CYA) in the other 17 patients. In addition to CYA, given until day +365, 10 patients received donor marrow depleted of T cells with CAMPATH-1. The residual marrow lymphocytes were always <1%. The rate of engraftment was significantly correlated with the number of nucleated cells infused. Neither GvHD nor graft failure were observed among CAMPATH-1 patients. In this group one cytogenetic and one hematologic relapse occurred. The overall actuarial survival at 24 months is 78%. Of the 10 patients treated with donor marrow depleted of T cells, 9 are alive after a median follow-up of 9 months (range 5–18), with an actuarial survival of 90%.

Of the other 8 patients transplanted with untreated marrow, 5 are alive after a median followup of 19.3 months (range 3.7–24) and the actuarial survival is 63.8%. This pilot study seems to demonstrate that T-cell depletion of donor bone marrow with CAMPATH-1 is effective to prevent GvHD, while the risk of graft failure can be avoided using a “standard” conditioning regimen including a fractionated TBI with a fast dose rate and a prolonged administration of CYA at the maximum tolerable dosage. While the high frequency of relapses suggests the employ of more aggressive anti-leukemic conditioning regimens in CAMPATH-1 treated marrow recipients.     

Brachytherapy for T1-T2 floor-of-the-mouth cancers: the Gustave-Roussy Institute experience

: In a retrospective analysis, we evaluated the Gustave-Roussy Institute’s experience of locoregional control, survival, and complications of low-dose rate brachytherapy for carcinoma of the floor of the mouth.

: Between 1970 and 1985, 160 patients with previously untreated carcinoma of the floor of the mouth received interstitial brachytherapy as definitive treatment. Of the 160 patients, 79 (49%) had T1 and 81 (51%) had T2 lesions, and 127 (79%) had N0 and 33 (21%) had N1; 84% of tumors arose from the anterior floor of the mouth. Brachytherapy was performed with ¹⁹²Ir wires, according to the Paris system rules, followed by neck dissection (T2 or N1) or follow-up (T1N0).

: With a follow-up period of 9–19 years, the observed survival rates were 89% at 2 years and 76% at 5 years, and the local control rates were 93% in T1 and 88% in T2 tumors. A low rate of distant metastases was noticed (5%); 31% of patients developed a second primary cancer. Severe mucosal necrosis was observed in <10% of patients. Any grade of bone necrosis was seen in 18% of cases (only 2.5% had G3 necrosis). This complication occurred more frequently in patients with poor dental status and in those treated without dental protection during implantation (p <0.001).

: Radical brachytherapy offers excellent local control (89%) and an acceptable rate of complications (<10% severe necrosis) that may be significantly decreased with dental care and the use of protective devices. The high incidence of second malignancies remains a major concern in these patients.