Local High-Dose Radiotherapy and Sparing of Normal Tissue Using Intensity-Modulated Radiotherapy (IMRT) for Mucosal Melanoma of the Nasal Cavity and Paranasal Sinuses

PURPOSE: To evaluate the clinical outcome of intensity-modulated radiotherapy (IMRT) in patients with mucosal melanoma (MM) of the nasal cavity and paranasal sinuses. PATIENTS AND METHODS: Between January 1999 and September 2004, eight patients with histologically proven MM of the nasal cavity and paranasal sinuses were treated with IMRT. A median dose of 66 Gy was applied to the macroscopic tumor (gross tumor volume [GTV]; range, 60-68 Gy) as an integrated boost and a median dose of 59 Gy (range, 54-64 Gy) to the clinical target volume (CTV) with IMRT. RESULTS: Treatment-related toxicity was very mild in most patients. Overall survival was 80% at 5 years. Calculated from treatment with IMRT as primary radiotherapy, survival was 100% at 1 year and 75% at 3 years. After IMRT, local progression-free survival was 71.4% at 1 year and 57.1% at 3 years, respectively. Distant progression-free survival after IMRT was 57.1% at 1 year and 28.6% at 3 years. CONCLUSION: Local dose escalation with IMRT yields good treatment results with respect to local and distant tumor control as well as survival, while treatment-related toxicity can be minimized.     

Centroblastic-Centrocytic Non-Hodgkin's Lymphoma Stage I–III: Patterns of Failure Following Radiotherapy

AIM: To investigate the patterns of failure and survival after involved-field or more extensive radiotherapy for centroblastic-centrocytic non-Hodgkin's lymphoma (NHL) as well as the impact of radiotherapy dose on local control. PATIENTS AND METHODS: 47 patients with Stage I-III centroblastic-centrocytic NHL were treated with involved-field (IF) extended-field radiotherapy (EF-RT) or total lymphatic irradiation (TLI). The involved regions received 25.5-50 Gy, non-involved regions were treated with a dose of 26 Gy in most cases. RESULTS: In Stage I/II, the majority of relapses (64%) were nodal and were located adjacent or distant to the former radiation portals. 79% of relapses occurred after IF-RT, 21% after EF-RT or TLI. 5-year overall survival (OAS) after EF-RT/TLI and IF-RT for Stages I/II was 85% and 83%, respectively (n.s.); relapse free survival (RFS) was 73% and 61%, respectively (n.s.). A tendency for better overall survival was found for patients who relapsed at one or two sites (5-year overall survival 100%) compared to patients with three or more relapse sites (5-year overall survival 0%). For Stage III overall survival was 72%, freedom from progression (FFP) was 27% at 5 years. We found a dose-effect correlation for local control with a relapse rate of 31% after 26-34 Gy and 4% after application of 36 Gy; no relapses occurred after doses of 40 Gy or more. CONCLUSION: In involved lymph node regions a relatively small number of relapses was observed after application of a minimal dose of 36 Gy. In Stages I/II most relapses were located outside the radiation portals, yet EF-RT was not superior to IF-RT in terms of overall survival and relapse free survival. Prospective randomized trials are necessary to prove a potentially favorable effect of more extended radiotherapy portals (TLI or TNI [total nodal irradiation]) and to evaluate the optimal radiotherapy dose.     

Radiotherapy of carcinoma of the biliary system

One hundred and twenty-two patients with carcinoma of the biliary system were treated with radiotherapy at Jichi Medical School Hospital from 1977 to 1988. Of these, 100 patients were retrospectively analyzed to obtain the outcome of radiation treatment, while 22 patients were excluded from the analysis for recurrence or previous operation when referred. Most of the patients received a total dose of 40 to 60 Gy, with a fraction dose of 1.8 to 3.0 Gy at 3 to 5 settings per week, and 1.3 to 1.5 Gy with interval of 4 to 6 hrs. in the case of accelerated hyperfractionation. It was observed that the over-all median survival time was 5.0 months and that crude survival rates were 24.1% at 1 year and 16.7% at 2 years. From the investigation of prognostic factors by log-rank test, local response after radiation treatment was found to be a factor which influenced the survival rate with a fair statistical significance. As compared to the survival rate of the patients with no response group (NC plus PD), that of good response group (CR plus PR) was significantly higher (p less than 0.005). Of 6 surviving more than 2 years, 5 patients had good responses including 3 complete responses. The survival rate seems to be higher in a group of the short interval between the first symptom and the start of radiotherapy, of no body weight loss, of a short stenosis and of incomplete obstruction, but is not statistically significant. The results suggest that combined modality or altered fractionation regimes should be tried for carcinoma of the biliary system.     

Clinical Results of a Concomitant Boost Radiotherapy Technique for Muscle-Invasive Bladder Cancer

PURPOSE: To update the results of external radiotherapy with a focal concomitant boost technique on local control and bladder function in patients with muscle-invasive bladder cancer. PATIENTS AND METHODS: The authors retrospectively evaluated 92 elderly or disabled patients with localized T2-4 N0-1 M0 transitional cell carcinoma of the bladder and a median age of 79 years, not suitable for radical surgery and treated between 1994 and 2005. Treatment consisted of a dose of 40 Gy/2 Gy to the small pelvis with a daily concomitant boost of 0.75 Gy to the tumor. Total dose was 55 Gy in 4 weeks. RESULTS: Complete remission rate after evaluation by means of cystoscopy at 3 months was 78%. 3-year local control rate amounted to 56%, and 3-year overall survival to 36%. The posttreatment bladder capacity was comparable with the pretreatment capacity and was > or = 200 ml in 81% of the cases. Mean bladder capacity did not deteriorate at longer follow-up. CONCLUSION: The local control rate after external beam radiotherapy in elderly patients with a focal concomitant boost for localized muscle-invasive bladder cancer was 56% at 3 years. Functional bladder outcome was good.     

Transperineal Low-Dose Rate Iridium-192 Interstitial Brachytherapy in Cervical Carcinoma Stage IIB

PURPOSE: To assess local control, survival and complications in patients with cervical carcinoma Stage IIB treated radically with transperineal Iridium-192 low-dose rate interstitial brachytherapy following external beam radiotherapy. PATIENTS AND METHODS: 65 women (age 25-70 years, mean 47 years) with cervical carcinoma Stage IIB were initially treated with external beam radiotherapy on a telecobalt or 6 MV linear accelerator to a dose of 50 Gy delivered in 5-6 weeks. After 2-3 weeks of completing external radiation, patients received interstitial brachytherapy with Iridium-192 (activity 0.5-1 mCi/cm) using a Syed-Neblett perineal template. The median dose delivered to the implant volume was 24 Gy (range 20-32 Gy) delivered at an average dose rate of 0.70 Gy/h (range 0.40-1.20 Gy/h). A point defined at 1.5 cm lateral to the central uterine tandem at the level of os was taken as a representative for assessing the dose to the cervix. Mean doses delivered by interstitial brachytherapy to point A, cervix, point B and rectum were 38 Gy, 34 Gy, 16 Gy and 16 Gy, respectively. RESULTS: At a median follow-up of 53 months, the actuarial disease free survival and overall survival for 65 patients at both 5 and 10 years was 64% and 44%, respectively. Response to radiotherapy was a strong predictor of local control with 82% of patients continuing to have pelvic control after initial complete response. Overall, nine (14%) patients had persistent disease, ten (15%) developed a central recurrence after initial control and three patients developed distant metastasis on follow-up. No patient had any immediate treatment-related complication. Late toxicity included grade I-II rectal reactions in five patients and grade IV bladder complication (vesico-vaginal fistula) in two patients. 5 years after treatment, one patient developed intestinal obstruction, which was relieved after conservative management. Two patients developed vaginal stenosis. The 5- and 10-year disease free survival was 48% in patients aged less than 45 years as compared to 80% in patients of more than 45 years (p = 0.009). Dose to the cervical point was a prognostic indicator with 5- and 10-year disease free survival of 47% in patients who received < 35 Gy in comparison to 80% in patients who had > 35 Gy (p = 0.03). There was no difference in local control and survival in patients with minimal and moderate parametrial involvement. Bulky disease (> 4 cm) at presentation and a longer gap between external radiation and brachytherapy showed a trend towards inferior local control. CONCLUSIONS: Interstitial brachytherapy after external beam irradiation in patients with cervical carcinoma Stage IIB results in acceptable local control, survival and complication rates. Increased dose to the cervical disease results in improved local control and survival and should therefore be considered while optimizing brachytherapy treatment plans. Comparison of the results with those of standard intracavitary therapy remains to be proven in a randomized trial.     

Strahlenbehandlung von follikulären Keimzentrumslymphomen

Purpose

Follicle centre lymphoma grade I, II (REAL) or centroblastic-centrocytic lymphoma (Kiel classification) present a well defined clinical entity from a clinical point of view. These lymphomas are not curable by chemotherapy in early or advanced stages. They are treated by radiation therapy in early stages, but up to now the curative potency of radiotherapy has not been confirmed by prospective clinical trials.

Patients and Method

Between January 1986 and August 1993 117 adults with follicle centre lymphoma were recruited from 24 institutions to enter the multicentric prospective, not randomised clinical trial. Patients with histologically proven nodal follicle centre lymphoma of stages I, II and limited III were included. They were treated by a standardised radiotherapy regimen, in stage I by extended field and in stages II and III by total nodal irradiation. Dose per fraction was 1.8 to 2.0 Gy, in the abdominal bath 1.5 Gy up to a total dose of 26 Gy in adjuvant situation and 36 Gy to enlarged lymphoma.

Results

All patients developed a complete remission at the end of radiotherapy. Median follow-up is 68 months. Overall survival of all patients is 86±3% at 5 and 8 years. Stage adjusted survival at 5 and 8 years was 89% for stage I, 86% for stage II and 81% for III. Patients in stages I and II <60 years had survival rates of 94% at 5 and 8 years, patients >60 years 63% (p < 0.0001). Recurrence free survival of all patients is 70% at 5 and 60±5% at 8 years. The number of recurrences is high with 29% at 5 and 41% at 8 years. All recurrences were seen within 7 years. The probability of localised nodal in-field recurrences is 11% and 22% at 5 and 8 years, respectively. Adverse prognostic factors were identified by multivariate analysis: age >60 years, treatment breaks ≥7 days and dose deviations >20% from prescribed doses Acute side effects of extended field irradiation were moderate.

Conclusions

On the basis of these results radiotherapy is a potentially curative therapeutic approach in stages I, II and limited III of follicle centre lymphoma. The optimal technique is total lymphoid irradiation with doses of 30 Gy in the adjuvant situation and 40 to 44 Gy in enlarged lymphomas. The number of local recurrences leads to the assumption that the extension of radiotherapy to the total lymphoid system might reduce their frequency.     

Langzeittumorkontrolle und Fertilität nach paraaortal limitierter Radiotherapie des Seminoms im Stadium I

PURPOSE: To review patterns of relapse in a long-term analysis of patients with Stage I seminoma treated by orchidectomy and radiotherapy to the paraaortic lymph nodes only and to follow follicle stimulating hormone (FSH) levels dependent on testicular scatter dose. PATIENTS AND METHODS: From 1980 to 1995, 58 patients with Stage I seminoma received elective radiotherapy to the paraaortic lymph nodes only (Th12 to L4), with a mean total dose of 28.07 Gy (+/- 2.2 SD), using fractional doses between 1.5 and 2 Gy (mean 1.62 Gy +/- 0.083 SD). Since 1989, testicular scatter doses were measured routinely by in-vivo thermoluminescent dosimetry (TLD) in 45 patients. In 26 patients with normal pre-treatment values of FSH, FSH-levels were repeatedly controlled after radiotherapy in order to evaluate any radiation-induced sequelae. RESULTS: During a mean observation period of 69.4 months (range 30 to 210), 2 out of 57 patients (3.5%) developed regional recurrences in the ipsilateral pelvic lymph nodes 14 months and 5 years after radiotherapy, respectively. One patient was lost to follow-up. The relapse-free survival rate at 5 years was 96.5% after radiotherapy alone. After salvage chemotherapy, both relapse-free survival and overall survival rates come to 100%. The mean testicular scatter dose in 45 patients was 0.22 Gy (+/- 0.087 SD). Seven out of 26 patients (26.9%) developed a transient increase of FSH-levels, reaching peak values at 4.2 months and returning to normal ranges within 18 months after radiotherapy. Below 0.2 Gy, no effect on FSH was observed. Testicular scatter doses showed no clear correlation to FSH risings (Figure 1). CONCLUSION: After exclusive paraaortic radiation of Stage I seminoma, even at follow-up periods in excess of 5 years the incidence of pelvic lymph node relapses remains below 4%. However, there seems to be a small potential for the development of late recurrences. With limited radiotherapy, permanent radiation-induced effects on the remaining testicle are very unlikely.     

不可手术结直肠癌肝转移瘤二程放疗疗效和安全性分析

目的 分析不可手术结直肠癌肝转移瘤接受二程放疗的疗效和安全性。方法 回顾性收集2017—2023年于北京大学肿瘤医院接受二程放疗的28例不可手术结直肠癌肝转移患者的资料,分析二程放疗的可行性。结果 28例患者二程放疗后中位随访时间为20.2个月。二程放疗距首程放疗的中位时间为11.1个月。首程放疗和二程放疗的中位生物有效剂量(BED)分别为100和96 Gy,分别有25例(89.3%)和24例(85.7%)患者接受了体部立体定向放射治疗。首程放疗和二程放疗的正常肝脏平均受量的2 Gy分次的等效剂量(EQD2)分别为10.1和 7.9 Gy。二程放疗后的完全缓解率和部分缓解率分别为54.5%和18.2%,客观反应率为72.7%。二程放疗后基于患者的2年的累积局部失败率为17.0%,基于病灶的2年的累积局部失败率为15.1%,1年无进展生存(PFS)为27.4%,3年总生存(OS)为46.7%。二程放疗后患者的耐受性良好,大部分患者(75.0%)出现1~2级急性不良反应,只有1例(3.6%)患者出现3级急性不良反应。结论 对于不可手术结直肠癌肝转移患者,二程放疗安全有效。     

Conformation radiotherapy of carcinoma of the prostate]

During the period from 1975 to 1989, 84 patients with carcinoma of the prostate were treated with conformation radiotherapy at Tokyo Metropolitan Komagome Hospital. The radiation field encompassed only the area of the prostate gland; it did not include the pelvic lymph nodes. The clinical stage of the 84 tumors was 22 in Stage A, 31 in Stage B, 15 in Stage C and 16 in Stage D. The average age of patients was 73.4 years, with range of 54 to 88 years. The average dose to the tumor was 65.7 Gy, with range of 60 Gy to 70 Gy. Hormone therapy was applied to 42 cases. The 5- and 10-year cumulative survival rates were 90.7% and 70.5% for Stage A, 41.7% and 26.7% for Stage B, 48.9% and 48.9% for Stage C, and 32.6% and 0% for Stage D, respectively. The 5-year cause-specific cumulative survival rates were 100% for Stage A, 92.3% for Stage B, 65.0% for Stage C and 40.3% for Stage D, respectively. Patients with poorly differentiated adenocarcinomas or undifferentiated carcinomas showed poorer survival than those with well-differentiated carcinoma. Only 7 cases suffered in-field recurrence, and 2 cases suffered recurrence at pelvic lymph nodes. Acute reactions were noted in 13 cases. Late complications following treatment were acceptable. Mild to moderate complications were recognized in 2 cases, but neither patient required surgery. In conclusion, our data suggest the advantage of the conformation technique applied to radiation therapy for carcinoma of the prostate.     

Cervical lymph node metastases from an unknown primary tumor

From 1978 through August 1986, 32 patients with lymph node metastases of the neck and unknown primary tumor were treated at the Radiotherapeutic Hospital of the University Erlangen-Nürnberg. Most of the cases were large metastases from squamous cell carcinomas or anaplastic carcinomas. The patients were treated by surgery and postsurgical radiotherapy or radiotherapy alone. In nearly all patients the target volume comprised both sides of the neck including the median structures as well as the base of the tongue and the nasopharynx. A dose of at least 50 Gy was aimed at, which was given within five weeks by individual doses of 2 Gy each. The survival at three years is 70% and at five years 52%. Out of twenty patients irradiated with more than 50 Gy following lymph node extirpation or radical excision of the lymph nodes of the neck, sixteen are tumor-free. The five year survival of this group is 80%. The results of radiotherapy alone are unsatisfactory, because only two out of nine patients are alive with follow-up periods of less than one year. Two primary tumors were found after the end of treatment. Both were situated within the ORL areas beyond the ancient irradiation fields, and both were developed by patients who at first had only been treated by local irradiation. Half of the patients with lymph node metastases of the neck and unknown primary tumors can be cured by complete tumor excision and postsurgical irradiation. The target volume of radiotherapy comprises both sides of the lymph drainage area of the neck as well as the mucous membranes of the ORL region including nasopharynx and base of the tongue. The dose is at least 50 Gy which is given after surgery with conventional fractionation.     

伽玛刀立体定向放疗结合全脑照射治疗脑转移瘤临床效果分析

目的 分析立体定向放疗结合全脑照射治疗脑转移瘤的疗效和预后,同时观察服用替莫唑胺(TMZ)与放疗结合对患者生存率的影响。方法 脑转移瘤患者52例,按照治疗方法不同分为2组,一组为全脑照射(WBRT)+立体定向放疗(SRT,伽玛刀),共35例,一组为单纯SRT,共17例。全脑放疗分次剂量为1.8~3.0 Gy/次,1 次/d,5 次/周,总剂量D_T30~40 Gy,WBRT+SRT组全脑后伽玛刀补量采用45%~75%等剂量曲线包绕PTV,边缘剂量12~15 Gy,中心剂量20~30 Gy。单纯SRT组分次立体定向放疗采用45%~75%等剂量曲线包绕PTV,边缘剂量36~40 Gy,中心剂量70~80 Gy。随访1~2年。所选52例患者中有20例患者放疗期间及放疗后服用替莫唑胺胶囊,同步化疗组化疗方案为:口服替莫唑胺75 mg/m²,1次/d,直至放疗结束,放疗结束后再服用3~6个月,剂量改为150 mg/m²。结果 放射治疗后1~3个月,复查CT/MRI显示总有效率(CR+PR)为84.62%,WBRT+SRT组有效率为88.57%,SRT组有效率为76.47%;肿瘤的6个月及1年的局部控制率分别为92.10%和85.20%。WBRT+SRT组的平均生存期13.2个月,中位生存期11个月;6个月生存率为71.40%,12个月生存率为54.30%,18个月生存率为14.30%。SRT组的平均生存期10.2个月,中位生存期9个月;6个月生存率为41.20%,12个月生存率为23.50%,18个月生存率为5.88%。替莫唑胺+放疗与单纯放疗的6个月、12个月及18个月生存率分别为80.00%和56.30%、60.00%和37.50%、10.00%和12.50%。结论 WBRT+SRT治疗脑转移瘤总体上优于单纯SRT治疗。放疗+TMZ联合治疗与单纯放疗相比,替莫唑胺在放疗过程中服用可提高患者生存率,不良反应无显著增加。     

Endometrial carcinoma in patients aged 75 years or older: outcome and complications after postoperative radiotherapy or radiotherapy alone.

A retrospective analysis is reported of 89 patients at least 75 years old (median age 79 years) treated with irradiation for endometrial carcinoma between 1972 and 1989, the median follow-up being 39 months. In 66 patients radiotherapy was given postoperatively and in one case preoperatively, 22 patients were treated with radiotherapy alone: intravaginal insertions exclusively in 22 patients (median dose 60 Gy to the mucosa) and combined with external radiotherapy in 53 patients (median external target dose 45 Gy; three or four fields, all treated daily, 1.8 to 2.0 Gy per fraction, five fractions per week; 30 Gy to the vaginal mucosa with low-dose rate). A few patients were treated with external radiotherapy or intrauterine insertions only. 65% of the patients treated with radiotherapy alone and 34% of the patients receiving postoperative radiotherapy had FIGO stage II or III disease. Five-year actuarial overall survival and disease-free survival for all patients with adenocarcinomas treated with curative intent was 47.5% and 57.2%, respectively. In 48 patients with surgical stages I and II, treated with postoperative adjuvant radiotherapy, overall actuarial survival is 58.2% and disease-free survived 65.5% at five years. After postoperative vaginal insertions only, no vaginal recurrence occurred. With combined external and intravaginal radiotherapy in surgical stage I and II, 4/36 patients (11%) showed a recurrence in the vagina only, the abdominal and pelvic recurrence rate being 8.3%. Grade 3 to 4 late toxicity was observed in 6/53 patients (11.3%) treated with external and intravaginal radiotherapy. However, in patients receiving external radiotherapy less than 45 Gy and intravaginal radiotherapy 30 to 40 Gy, as is standard postoperative adjuvant treatment today, only one grade 3 late toxicity was observed in 17 patients (5.9%). We conclude, that treatment of elderly patients with adenocarcinoma of the uterus should follow the same pattern as in younger patients, the acute side-effects and late toxicity of radiotherapy being similar.     

Radiotherapy of solitary and multiple eosinophilic granulomas of bone (stage I)

Between 1957 and 1990 15 patients with solitary (stage Ia by Greenberger) and 2 patients with multiple (stage Ib) eosinophilic granuloma of the bone were treated by radiotherapy in 18 locations after previous surgery. The doses applied varied from 6 Gy to 42 Gy (median for patients under 18 years: 8 Gy, for patients over 18 years: 30 Gy). Median follow-up was 9 years (range, 0.3-33 years). Local control rate and survival were 100%. Three patients with granuloma developed a second granuloma within 13 years after primary diagnosis (two bone manifestations, one cutaneous manifestation). Long-term follow-up of patients with solitary eosinophilic granuloma is necessary.     

Management of non-Hodgkin's lymphoma of the thyroid: the Royal Marsden Hospital experience

A retrospective review was conducted of patients treated for thyroid non-Hodgkin's lymphoma (TNHL) at the Royal Marsden Hospital between 1936 and 1996 to determine the effect of radiotherapy (RT) on outcome. 91 patients were identified from the Thyroid Unit Database. There were 77 females and 14 males with a median age of 65 years (range 22-87 years). RT was delivered according to two separate policies: (1) involved field radiotherapy (IFRT) to the thyroid bed and cervical lymph nodes; (2) extended field radiotherapy (EFRT) covering the thyroid bed, cervical and mediastinal lymph nodes. 89 patients received RT as part of definitive treatment following surgery, to a dose of approximately 40 Gy. 25 patients received IFRT and 64 patients EFRT. 27 patients received cytotoxic chemotherapy. 18 patients (72%) treated with IFRT died of TNHL with a median relapse free survival (RFS) of 10 months and a median overall survival (OS) of 21 months. In contrast, only 29 patients (46%) treated with EFRT died of TNHL with a median RFS of 76 months (p = 0.01 for RFS with respect to IFRT and p = 0.04 for OS). Significantly more patients treated with IFRT relapsed locally (52% vs 27%). There was no difference in the rates of systemic relapse (20% vs 22%). EFRT alone for Stage I, but not for Stage II disease, yielded acceptable rates of local control and disease free survival with doses of at least 40 Gy. These historical data strongly support the addition of combination chemotherapy to the treatment regimen in all patients with Stage II disease. Indeed, in recent years this has become the standard of care for all cases of thyroid lymphoma unless the histology is of marginal zone type (mucosa associated lymphoma tissue (MALT) lymphoma).     

Brachytherapy boost: a novel approach for epiglottic carcinoma

PURPOSE: Epiglottic (epilaryngeal) carcinoma has been treated conventionally by radical external beam radiotherapy or partial laryngectomy. The aim of this study is to evaluate the role of brachytherapy boost as a novel approach for lingual epiglottic lesions. METHODS AND MATERIALS: Twenty-three patients with T(2-3)N(0-1) lingual epiglottic carcinoma (SCC) were treated with curative intent between January 1990 and December 2001 using low dose rate interstitial (192)Ir implant boost, moderate dose of 25Gy at 0.5cm (mean dose rate, 50.5 cGy/h) 3 weeks after moderate dose of external beam radiotherapy (mEBRT) of 46Gy/23#/28-31d. RESULTS: Complete response after mEBRT was observed in 18 of the 23 patients (78%) and partial response was seen in 5 of the 23 patients (22%). After implant, all patients had complete response. Locoregional control was seen in 19 of the 23 patients (82.6%). Two patients developed distant metastases. Disease-free survival and overall survival at 5 years were 68.3% and 66.7%, respectively. Disease-free survival at 5 years showed a trend toward better outcome for biologically equivalent doses >85Gy compared with biologically equivalent doses <85Gy (80% vs. 68%) (p=0.18). All patients had minimal to acceptable xerostomia. CONCLUSIONS: Interstitial boost with mEBRT is feasible, effective, and a novel approach for lingual epiglottic lesions.     

Radical radiotherapy with high-dose-rate brachytherapy for uterine cervix cancer long-term results

The aim of this is to report the results of radical radiotherapy in carcinoma of the cervix treated by high-dose rate (HDR) intracavitary brachytherapy and external beam radiotherapy (XRT) at a single centre in Singapore. This is a retrospective analysis of 106 consecutive cases with histologically proven cervical cancer, treated by HDR brachytherapy and XRT at the Mount Elizabeth Hospital from 1990 to 1993. External beam radiotherapy to the pelvis was delivered with 6 MV photons, to 45-50.4 Gy in 1.8 Gy fractions. High-dose-rate brachytherapy comprised two to three applications of an intrauterine tandem with paired ovoids, to a median dose of 18 Gy to point 'A', carried out during XRT. All 106 patients completed treatment. Their ages ranged from 32 to 80 years (median 57 years). Most patients presented with stage II or III disease (44 and 37%, respectively) and with squamous cell carcinoma (91%). Median follow-up time was 59 months (range 2-169 months). The 5-year relapse-free survival rate across all stages was 71%. The corresponding overall survival rate was 69%. Local control was achieved in 86 patients (81%); six patients had residual disease (6%), and 14 patients had local recurrence (13%). Fourteen patients developed metastatic disease (13%). On univariate analysis, tumour stage, haemoglobin level, number of brachytherapy treatments and overall treatment time were found to be prognostic factors for overall survival. Late complications were mild (Radiation Therapy Oncology Group score 1-2), except for one patient with grade 4 rectal toxicity. The complication rates were 8, 14 and 45%, respectively, for the rectum, bladder and vagina (stenosis). The use of two to three fractions of HDR intracavitary brachytherapy in addition to pelvic XRT achieves good outcomes.     

Herpes Zoster in Breast Cancer Patients after Radiotherapy

PURPOSE: We have studied the incidence of herpes zoster in patients with adjuvant radiotherapy for breast cancer with special emphasis on possible correlations with other prognostic factors or survival. PATIENTS AND METHODS: From 1/1985 through 12/1993, 1,155 breast cancer patients received postoperative radiotherapy with curative intent in our department. After mastectomy 961 patients were irradiated and after breast-preserving treatment 194 patients. The age ranged from 34 to 79 years, the median follow-up was 3.1 years (range: 0.3 to 12.4 years). There were 443 women (38%) pre- and 712 (62%) postmenopausal. 21% had T3- to T4-tumors, 55% had axillary lymph node involvement, and 65% received additional systemic hormonal and/or cytotoxic therapy. In case of postmastectomy radiotherapy, the lateral chest wall and lymphatics (axilla, parasternal and supraclavicular nodes) were irradiated with an anterior photon field to 50 Gy (axilla 44 Gy) and most of the chest wall with an electron field to 44 Gy in 2-Gy fractions. After breast-preservation, the breast was irradiated via tangential fields with 6- to 8-MV photons up to 50 Gy plus 8 Gy electron boost to the tumor bed. Most of the patients were followed routinely in the department for 2 to 5 years. The frequency of zoster was determined retrospectively by reviewing the patients' records. RESULTS: A zoster after radiotherapy occurred in 41/1,155 patients (3.7%), mostly within the first 2 years after completion of radiotherapy. All infections remained localized and there was no evidence for systemic infections. Type of treatment (mastectomy vs breast-preservation) had no impact on the frequency of herpes zoster (36/961 patients after mastectomy and 5/194 patients after breast-preservation). There was also no correlation with other prognostic factors such as age, menopausal status, stage of disease or the use of adjuvant chemotherapy, nor was the occurrence of zoster linked to the degree of acute skin reaction in the radiation field. Moreover, patients with zoster had the same prognosis as compared to patients without zoster with regard to local control and survival. CONCLUSIONS: The observed frequency of zoster (about 4% of patients after postoperative radiotherapy) in this retrospective study suggests that the risk of developing zoster in this patient group may be 3- to 5-fold higher as compared to the incidence in the general population. However, the occurrence of zoster was not linked to prognosis and treatment response.     

Merkel Cell Carcinoma: The Role of Radiation Therapy in General Management

BACKGROUND: Merkel cell carcinoma (MCC) is a rare malignant, locally aggressive tumor of the skin. Because few data exist about the clinical course of irradiated patients, we reviewed the 17 patients treated at our institution since 1982. PATIENTS AND METHODS: The median age at diagnosis was 71 years (range 47 to 88 years). Twelve patients presented with lymph node involvement (Stage II), 5 patients with negative lymph nodes (Stage I). Five patients were irradiated immediately after initial surgical excision of the primary tumor. Eleven patients underwent a surgical treatment of recurrence prior to the first irradiation. Only 1 patient received primary radiotherapy. A median dose of 52.8 Gy (range 40 to 60 Gy) in the region of the primary tumor and a median dose of 49.5 Gy (range 30 to 54 Gy) in the regional lymph nodes were delivered. RESULTS: The median overall survival after first diagnosis was 45 months. Three-year overall survival was 57%, 5-year cause-specific survival was 73% (Kaplan Meier). Local control could be achieved in the 5 patients irradiated immediately after surgical treatment of the primary tumor. In contrast, an in-field recurrence occurred in 5 of 12 patients irradiated after surgical excision of relapsed disease. Five patients developed distant metastases. None of these patients was irradiated immediately after surgical excision of the primary tumor. CONCLUSIONS: With respect to our experience, a local control can be achieved with an immediate postoperative radiotherapy of the primary tumor site and the adjacent lymph nodes.     

Radiotherapy of carcinoma of the auditory canal

From 1973 through 1986, twelve patients suffering from carcinomas of the outer auditory canal were irradiated at the Radiologic Hospital of Essen. The five-year survival was 64% after postoperative irradiation and 0% after irradiation alone. Considering the data communicated by other authors, the following therapy recommendations can be deduced: early stages where bones or cartilages are not involved represent an indication for sole operation. These tumors can be successfully treated by sole radiotherapy, too. In case of greater tumors, combined surgery and postoperative radiotherapy is the most favorable method. Besides a high total dose (50 to 60 Gy for microscopic tumor residues, about 70 Gy for macroscopic tumor residues), a sufficiently great target volume has to be chosen which includes the ear, the temporal bone, the preauricular lymph nodes and the angle of mandible. To prevent bone and cartilage necroses, it is recommended to restrict the individual doses to 1.8 to 2 Gy each.     

High-dose-rate brachytherapy for previously irradiated patients with recurrent esophageal cancer

Purpose Our objective was to assess the feasibility, efficacy, and complications of high-dose-rate (HDR) brachytherapy for patients with recurrent esophageal cancer after external radiotherapy. Materials and methods Six patients with recurrent esophageal cancer after external radiotherapy were treated with HDR brachytherapy (Ir-192 source) from January 2003 to February 2004. The median age of the patients was 69 years. All patients had received external radiotherapy (median dose 60 Gy) before HDR brachytherapy. All patients underwent HDR brachytherapy once a week with a dose of 4 or 5 Gy per fraction in the esophageal mucosa (median total dose 20 Gy). The Kaplan-Meier method was used to calculate local control rates. Results The median overall survival period was 30.0 months. Local control was observed in five patients and residual tumor in one patient. Persistent local control was observed in two patients. No patient died of esophageal cancer, and all patients survived. We observed no severe late complications related to HDR brachytherapy. Conclusion These data suggest that HDR brachytherapy is an effective and safe treatment for patients with recurrent esophageal cancer after external radiotherapy.