Treatment results of radiotherapy with or without surgery for posterior pharyngeal wall cancer of oropharynx and hypopharynx: prognostic value of tumor extension

PURPOSE: We have been treating posterior pharyngeal wall cancer of the oropharynx and hypopharynx with external radiotherapy according to our policy reported in the 1970s. MATERIALS AND METHODS: Between 1968 and 1995, 51 patients were treated. Treatment policy was decided on the basis of the treatment response after 40 Gy of radiotherapy. Thirty-six good responders were treated with radical radiotherapy, eight poor responders received radical surgery, and the other seven patients could not receive radical treatment because of tumor or patient factors. RESULTS: The 5-year local control and cause-specific survival rates were 56% and 48% for all 51 patients. The 5-year local control rate was 52% for radical radiotherapy. Tumors limited to the posterior wall showed better treatment results (76% for both local control and cause-specific survival) than tumors involving the postcricoid area (0% and 10%). CONCLUSION: Radiotherapy for carefully selected patients dependent on response after 40 Gy of radiotherapy is a useful policy. Tumor extension is an important prognostic factor.     

Prospective study of HDR (192Ir) versus MDR (137Cs) intracavitary brachytherapy for carcinoma of the uterine cervix

PURPOSE: The aim of this study was to compare the results of high-dose rate (HDR) and medium-dose rate (MDR) intracavitary brachytherapy for carcinoma of the uterine cervix on the basis of a prospective study and to determine the dose rate conversion factor (DRCF) from low-dose rate (LDR) to MDR via HDR, because a DRCF of 0.54 from LDR to HDR has been widely accepted. MATERIALS AND METHODS: Between August 1991 and July 1999, 104 patients were entered into this trial to compare results between HDR (n=54) and MDR (n=50). Three patients were excluded from this study, leaving 54 HDR patients and 47 MDR patients eligible. Method and dose of external beam radiotherapy were the same for both groups. For HDR intracavitary brachytherapy, point A dose was adjusted to 32 Gy/4 fractions for stages I and II, to 30 Gy/4 fractions for stage III, and to 22.5 Gy/3 fractions for stage IV. The corresponding values for MDR were 35.6 Gy/4 fractions, 34 Gy/4 fractions, and 25.5 Gy/3 fractions. The average dose rate at point A was 30 Gy/hour (9.0-65.2) for HDR and 1.7 Gy/hour (1.3-2.2) for MDR. We assumed a DRCF of 0.9 from MDR to HDR. RESULTS: The 3-year cause-specific survival rates for HDR were 85%, 83%, 75%, and 0% for stages I, II, III, and IV, respectively. The corresponding figures for MDR were 100%, 82%, 58%, and 40%. Six of the HDR patients (11%) and 2 of the MDR patients (4%) developed Kottmeier's grade 2 or 3 late complications. A DRCF of 0.6 from LDR to MDR could be derived from a DRCF of 0.9 from MDR to HDR and one of 0.54 from LDR to HDR. CONCLUSIONS: There were no statistically significant differences in cause-specific survival and incidence of late complications between HDR and MDR. A DRCF of 0.6 from LDR to MDR could be determined. However, because the results of this trial were preliminary, a further study is needed.     

Prognosis and organ preservation in oropharyngeal cancer treated with radiotherapy

The records of 102 patients with squamous cell carcinoma of the oropharynx treated at National Sapporo Hospital with external and/or interstitial radiotherapy between 1978 and 1996 were reviewed to evaluate the treatment results, focusing on primary control and functional preservation. Ninety-five patients had been primarily treated with curative intent initially. Of these 95 patients, 4% were in stage I, 19% in stage II, 42% in stage III and 34% in stage IV. Twenty-one patients (22%) had been treated with multidisciplinary chemotherapy, and 19 patients (20%) had been boosted with brachytherapy mainly using Au-198 grains. The cause-specific survival rates at 5 and 10 years were 63% and 52%, respectively. The local control rates at 5 and 10 years were 70% and 51%, respectively. The most important factors affecting local control were the subsite of the primary tumor and N stage. Based on these findings, it is considered that radiotherapy combined with/without chemotherapy except for N3 and the posterior wall type is an effective method of achieving tumor control and preserving organ function, compared with other methods including surgical procedures.     

Low-dose-rate vs. high-dose-rate intracavitary brachytherapy for carcinoma of the cervix: The University of Alabama at Birmingham (UAB) experience

PURPOSE: To review the clinical outcome retrospectively of cervical cancer patients treated definitively with either high-dose-rate (HDR) or low-dose-rate (LDR) brachytherapy. METHODS AND MATERIALS: One hundred sixty patients (44 Stage I, 83 Stage II, and 33 Stage III) were treated from 1990 to 2000 with curative intent for carcinoma of the cervix. One hundred three LDR patients were compared to 57 HDR patients. Two groups were treated during the same period. An external beam dose of 45 Gy to the entire pelvis was delivered at 1.8 Gy per fraction to most patients before the first intracavitary insertion in both groups. Brachytherapy was delivered in one to two LDR implants or four to five HDR implants at 6 Gy per fraction. The prescribed dose to Point A for LDR was at least 80-85 Gy. Patient characteristics were similar for each cohort. Point A doses were similar for each stage. The primary endpoints assessed were survivals and failure sites. Endpoints were estimated using the Kaplan-Meier method and comparisons between treatment groups were performed using the log-rank test. RESULTS: The median followup was 48 months for the LDR group and 59 months for the HDR group. For all stages combined and stage for stage in both groups, there was no statistically significant difference in locoregional control, cause-specific survival, and overall survival for LDR compared with HDR. Locoregional control and overall survival were 78% and 60% for LDR compared to 76% and 55% for HDR at 3 years, respectively (p = 0.96 and p = 0.48). Median cause-specific survival values for LDR vs. HDR were 71 and 81 months, respectively (p = 0.62). The cause-specific survival for LDR patients was 62% compared with 59% for HDR patients at 3 years. For Stage IB2, II, and III LDR patients, cause-specific survival rates were 62%, 67%, and 45%, compared to 67%, 57%, and 33% for HDR at 3 years, respectively (p = 0.75, p = 0.95, and p = 0.48). For patients with a recorded site of first failure, the most common site was locoregional (56%) and then distant metastases (26%). Eight patients who were cancer free developed late complications requiring surgical intervention. Two patients were in the HDR group (3.5%) and 5 in the LDR group (4.8%). CONCLUSIONS: Similar outcome was observed for LDR compared with HDR intracavitary brachytherapy for the entire cohort. In this review, HDR group was not inferior to LDR group in advanced stages. This is likely because our patients were treated with brachytherapy after a high dose of external pelvic radiotherapy in both LDR and HDR patients.     

Die postoperative Strahlentherapie beim Endometriumkarzinom Eine retrospektive Analyse von 541 Patienten

PURPOSE: This retrospective study was designed to evaluate the role of adjuvant radiotherapy for surgically treated endometrial carcinoma. PATIENTS AND METHODS: From 1980 through 1988, 541 patients were treated with either intravaginal cuff irradiation with a high-dose-rate (HDR) Iridium-192 remote afterloading technique (n = 294) or with combined HDR-brachytherapy and additional external pelvic irradiation to 54 Gy (n = 247) after surgery for endometrial cancer. Afterloading irradiation was administered in 4 fractions 4 to 6 weeks after surgery. A dose of 30 Gy was delivered at a depth of 0.5 cm from the vaginal mucosa. RESULTS: Patients with HDR-brachytherapy alone showed a 5-year survival of 94.3% for Stage I and 73.6% for Stage II (p = 0.0007). Patients who received both brachytherapy and additional external pelvic irradiation had a 5-year survival of 94.1% for Stage I, 81.1% for Stage II, 70.4% for Stage III and 46.9% for Stage IV (p = 0.0001). The main predictors for survival in a multivariate analysis were stage and grading. Patients with combined radiotherapy had a local recurrence rate of 3.2%, whereas patients with brachytherapy alone who were better selected and had more favorable prognostic factors showed a recurrence rate of 2%. Low-risk patients (Stage I, Grade 1, low infiltration) in the HDR-brachytherapy group had 6 relapses, mainly caused by insufficient treatment on the basis of papillary histology. High-risk patients with poorly differentiated tumors, which infiltrate more than half the myometrial wall might benefit from additional external radiotherapy in terms of reduction of local recurrence and better survival. Five-year actuarial survival rate was 93.6% after combined radiotherapy vs 86.7% after brachytherapy alone. Complications were graded according to the RTOG scoring system. Severe late complications were fistulas of bladder and/or bowel, which occurred in 2.8% in the combined radiotherapy group, and 0.7% in the HDR brachytherapy group. CONCLUSIONS: Low-risk patients should be generally treated postoperative with HDR-brachytherapy alone. Combined radiotherapy decreased pelvic relapses for high-risk patients with overall low complication rates. We conclude that an individually adjusted postoperative radiotherapy allows a well tolerated treatment with excellent results.     

早期鼻腔NK／T细胞淋巴瘤三组放射治疗剂量的效果比较

目的探讨放疗剂量对早期鼻腔NK／T细胞淋巴瘤预后的影响。方法将64例早期鼻腔NK／T细胞淋巴瘤患者,根据放疗剂量大小分为〈50Gy组（n=20）,51～60Gy组（n=24）和〉60Gy组（n=20）,观察比较各组局部控制率和5年生存率。结果经随访〈50Gy组局部控制率68．5％,5年生存率42．1％。51～60Gy组局部控制率达到82．5％,生存率达60．9％。两组对比在局部控制率和5年生存率有统计学意义（P〈0．05）,但51—60Gy组和〉60Gy组对比无统计学意义。结论以51—60Gy剂量的放疗能保证良好的局部控制率,提高患者总生存率,建议临床在选择放疗剂量时以51—60Gy为宜。     

The age-specific results of the adjuvant radiotherapy of breast carcinoma]

BACKGROUND: Aim of our work was to evaluate the standards of treatment in elder women with breast cancer and their results of radiation therapy. PATIENTS AND METHODS: In our hospital 218 breast cancer patients were treated in the years 1990 and 1991. Forty-three women were younger than 50 years of age (group I), 92 between 50 and 64 years (group II), 83 elder than 64 years (group III). One hundred and forty-nine patients underwent mastectomy, 65 patients had conservative treatment (Table 5). Four patients were not operable. All of the patients were irradiated uniformly loco-regionally with 50 Gy Co-60-photons, followed by a boost to the tumor bed with 10 Gy with 6- to 12-MeV electrons. Forty-four patients had an additional chemotherapy. RESULTS: The 5-year survival rate was 79.8% (n = 174), the disease free survival was 59.1% (n = 129) (Table 6). The mean rate of local recurrence was 3.6% (n = 8), 4% after mastectomy (n = 6) and 3% (n = 2) with breast conservation. Age group specific 5-year survival rates were 72% (I), 85.6% (II) and 77.1% (III), respectively, disease free survival rates were 48.8% (I), 65.2% (II) and 57.8% (III), respectively. The rates of local recurrence were 9.3% (I), 3.2% (II) and 1.2% (III), respectively. Significant age group specific differences in surgical and radiotherapeutical treatment could not be found. CONCLUSION: The curative chance of treatment has to be used in every age. A treatment of elder patients below the actual valid standards of treatment is not justified.     

Interstitial Brachytherapy with Ir-192 Low-Dose-Rate in the Treatment of Primary and Recurrent Cancer the Oral Cavity and Oropharynx

AIM: To evaluate the impact of postoperative interstitial brachytherapy with and without external radiotherapy in the treatment of primary and recurrent squamous cell carcinoma of the oral cavity and oropharynx. PATIENTS AND METHODS: Between 1985 and 1997, a total of 318 patients were treated by interstitial Ir-192 low-dose-rate brachytherapy as part of their primary (n = 236) or recurrent treatment (n = 82). There were 263 male (83%) and 55 (17%) female patients. The distribution of UICC (1997) stages was as follows: I (61 patients, 19%), II (71 patients, 22%), III (58 patients, 18%), IV (128 patients, 40%). The primary tumor site was located in the oral cavity in 201 patients (63%), in the oropharynx in 86 patients (27%), lower lip in 19 patients (6%) and other regions in twelve cases (4%). Treatment concepts did not vary over the time and were dictated by the initial tumor extension: a total of 175 patients (55%) received a combination of surgery, interstitial brachytherapy (23-25 Gy) and external radiotherapy (50-60 Gy), 60 patients (19%) surgery and interstitial brachytherapy (45-55 Gy) alone. Advanced disease not amenable to primary surgery was either treated by radiochemotherapy and interstitial brachytherapy in 39 patients (12%) or a combination of interstitial brachytherapy, external radiotherapy and interstitial hyperthermia in 44 patients (14%). RESULTS: Overall survival rates following primary and recurrent treatment were 50 +/- 4% and 29 +/- 5%, respectively, at 5 years (p < 0.0001). A significant impact on overall survival rate was noted for UICC stage: patients in stage I/II had survival rates of 64 +/- 5% and 57 +/- 10%, respectively, while patients in stage III/IV had survival rates of 39 +/- 5% and 15 +/- 5%, respectively, at 5 years (p < 0.0001). In addition, grading (p = 0.01) and hemoglobin levels (p = 0.05) had a significant influence on overall survival. Local tumor control rates for all patients were 74 +/- 3% and 57 +/- 7% at 5 years following primary and recurrent treatment (p = 0.01), respectively. The 145 patients treated for primary disease by a uniform concept of surgery, interstitial brachytherapy and external radiotherapy achieved excellent local control rates with 92 +/- 4% (stage I/II) and 65 +/- 6% (stage III/IV) at 5 years. Late treatment-related toxicity with soft tissue necrosis and/or osteonecrosis requiring mandibular resection was 7.5%. CONCLUSION: Local tumor excision followed by postoperative interstitial brachytherapy with and without external radiotherapy is associated with excellent locoregional control, a low risk of chronic sequelae and may therefore considered as a new approach avoiding mutilating radical surgery.     

Re-irradiation with interstitial pulsed-dose-rate brachytherapy for unresectable recurrent head and neck carcinoma

PurposeTo assess the long-term results of protocol-based interstitial pulsed-dose-rate (PDR) brachytherapy combined with simultaneous chemotherapy in selected patients with recurrent head and neck tumors not amenable to salvage surgery.Methods and MaterialsA total of 51 patients with recurrent head and neck cancer were treated with interstitial PDR brachytherapy. Forty patients (78%) had salvage brachytherapy alone using a median total dose of 60 Gy. Salvage brachytherapy in combination with external beam therapy was performed in 11 patients (22%) using a median total dose of D_REF = 27 Gy. Simultaneously with the PDR brachytherapy, a concomitant chemotherapy was administered in 35/51 (69%) of patients. The analysis was performed after a median followup of 58 months.ResultsLocal control rates calculated according to Kaplan–Meier after 2 and 5 years were 71% and 57%, respectively. Comparing results of salvage PDR brachytherapy with or without simultaneous chemotherapy, the 5-year local recurrence-free survival rates were 78.9% vs. 38.5% (p = 0.01), respectively. No other patient or treatment-related parameters had a significant influence on treatment results. A total of 9/51 (17.7%) and 6/51 (11.8%) patients developed soft-tissue necrosis or bone necrosis, respectively, but only 2% of patients required surgical treatment.ConclusionsPDR interstitial brachytherapy with pulse doses between 0.4 and 0.7 Gy/h/24 h with simultaneous chemotherapy is an effective and safe option for curative therapy in selected patients with head and neck cancer in previously irradiated areas, which are not suitable for salvage surgery.     

Biochemical Response after 3-D Conformal Radiotherapy of Localized Prostate Cancer to a Total Dose of 66 Gy

BACKGROUND: Since the introduction of 3-D conformal radiotherapy (CRT) doses of /= 70 Gy should be considered. As a consequence of our earlier analysis a prospective multicenter treatment optimization protocol has been initiated in 1999. The protocol includes a risk-adapted dose increase from 70 Gy in low-risk patients to 74 Gy in high-risk patients including short-term androgen ablation.     

Behandlungsergebnisse beim follikulären Keimzentrumslymphom Stadium I und II

PURPOSE: Radiotherapy is a curative treatment modality in the early stages of follicle centre lymphoma. Survival rates, patterns of failure and prognostic factors were evaluated in a retrospective analysis. PATIENTS AND METHODS: 116 patients with follicle centre lymphoma stage I and II were treated between 1970 and 1999 in Dresden. Therapy modalities were radiotherapy alone (103 patients) or combined radiotherapy/chemotherapy (13 patients). Radiotherapy was applied as involved-field-(IFI)- (104 patients), extended-field- (nine patients) or total-nodal- (three patients) irradiation. Patients received doses between 25 Gy and 50 Gy (median 35 Gy). RESULTS: The 5- and 10-year actuarial overall survival rates were 76% and 51%. Relapse free survival was 62% and 48% respectively. The median follow-up was 4,0 years. Relapses after complete remission were registered in 44 cases. Six patients have had in-field-recurrences. The majority of out-field-recurrences were nodal relapses (50%). 11% of relapses occurred outside of lymph nodes or were disseminated failures (18%). Significant favorable prognostic factors identified by multivariate and univariate analysis were low age (age < 50 years vs. age > 50 years), low stage and performance of bipedal lymphangiography as primary staging procedure. CONCLUSIONS: Radiotherapy is an effective and tolerable treatment modality for follicle centre lymphoma in the early stages I and II. We registered a high proportion of nodal recurrences, which may be minimized by prophylactic extended radiotherapy.     

Concurrent Radiochemotherapy of Locally Recurrent or Advanced Sarcomas of the Uterus

BACKGROUND: Uterine sarcomas are rare tumors. Until now, no data on the treatment of recurrent or advanced uterine sarcomas using concurrent radiochemotherapy (RCT) has been available. PATIENTS AND METHODS: From 01/1997 to 03/2004, seven patients with locally recurrent (n = 6) or locally advanced uterine sarcomas (n = 1) received concurrent RCT after tumor surgery (R1/2 resection in 3/7 patients). A total radiation dose of 45 Gy was applied in single doses of 1.8 Gy using an external-beam technique; in addition, three to four intracavitary doses of 5 Gy were applied. Concurrent chemotherapy was generally administered as follows: 1.2 g/m(2) ifosfamide on days 1-5 and 29-33 in combination with 50 or 40 mg/m(2) adriamycin on days 2 and 30. 3/7 patients received further cycles of chemotherapy. The median follow- up was 35 months. RESULTS: All recurrences (before RCT) were localized either in the vagina or in or directly proximal to the vaginal stump. The main side effects of RCT were hemotoxicity (grade 3: n = 3/7; grade 4: n = 4/7; neutropenic fever n = 1/7) and diarrhea (grade 3: n = 5/7). At the median follow-up (35 months), 4/7 patients had recurrences (one local recurrence; one lymph node recurrence outside the irradiated field, two distant metastases). Local control in the irradiated field was 80% +/- 18% after 3 years. Disease-free survival calculated according to Kaplan-Meier was 57% +/- 19% after 3 years. Presently, 5/7 patients are still alive, corresponding to a 3-year survival rate of 83% +/- 15%. CONCLUSION: Concurrent RCT shows good local effectiveness with a good long-term survival. Further evaluation in phase II studies is recommended.     

Radiotherapy for Stage I–III Nodal Low-Grade Non-Hodgkin’s Lymphoma

BACKGROUND: To evaluate retrospectively long-term results and patterns of recurrence in patients with low-grade non-Hodgkin's lymphoma (NHL) Ann Arbor stage I-II and limited stage III. PATIENTS AND METHODS: 58 patients, who had been treated between 1980 and 1996, were analyzed. Median follow-up period was 8.75 years. 48 patients (83%) presented with follicular lymphoma (stage I: 23 patients, stage II and III: 15 and ten patients, respectively). Median age was 51 years. Irradiation was applied with a median total dose of 40 Gy. 13 patients (22%) additionally received chemotherapy. End points of the investigation were remission rate, overall- and disease-free survival, and patterns of recurrence, as well as the prognostic impact of age, B-symptoms, chemotherapy, irradiation dose, treatment volume, and Ann Arbor stage. RESULTS: 6 weeks after treatment 91% of the patients had complete, 7% partial response. One patient (2%) was classified as progressive disease. Overall survival rate was 86% and 69% at 5 and 10 years, respectively. Corresponding disease-free survival rates were 73% and 63%. Regarding overall survival, multivariate analysis identified age (p = 0.001) as independent prognostic factor. In the subgroup of patients with follicular lymphoma 92% were found in complete, 6% in partial remission, one patient (2%) with progressive disease. Overall survival rates at 5 und 10 years were 87% and 70%, disease-free survival rates 75% and 64%, respectively. Out-of-field recurrence rate for all 58 patients was 34% and the proportion of relapses at nodal or lymphatic sites outside the treated areas in relation to all registered recurrences was 77%. CONCLUSIONS: Our results maintain external radiotherapy as a curative concept in the treatment of limited stage low-grade lymphoma, especially in younger patients. Patterns of recurrence would favor total nodal irradiation (TNI) as an appropriate approach for these patients.     

Radiation therapy for the esophageal carcinoma: external irradiation versus high-dose rate intraluminal irradiation.

From September 1977 through December 1989, 149 patients with esophageal carcinoma were treated with external irradiation (EI) with or without high-dose rate intraluminal irradiation (HDRII) using remote afterloading system. Two-year relapse-free survival rates were 52% in sage I (n = 23), 24% in stage II (n = 61) and 19% in stage III (n = 65). Two-year survival rates were 66% in complete response (CR) group (n = 65) and 7 to 9% in non-CR group (n = 84). Concerning CR group external irradiation alone (mean +/- S. D.: 66.5 +/- 5.2 Gy) showed higher local control rate than EI (60.0 +/- 0.4 Gy) + HDRII (10 Gy) (30/38 versus 15/27, p = 0.044), especially in ulcerative type (17/19 versus 5/11, p = 0.009). This preliminary result suggests that HDRII is not effective for the local control of the ulcerative lesion as a boost therapy.     

A retrospective analysis of the use of brachytherapy in relation to early stage squamous cell carcinoma of the oropharynx and its relationship to second primary respiratory and upper digestive tract cancers

The purpose of this study was to retrospectively evaluate brachytherapy for early stage squamous cell carcinoma of the oropharynx (SCO) in relation to second primary respiratory and upper digestive tract cancers (RUDT). Between 1976 and 2001, 111 previously untreated patients with stage I or II SCO were treated with Au-198 seed brachytherapy alone (36 cases) or Au-198 seed brachytherapy plus external irradiation (75 cases). Of the 111 patients, 28 patients had stage I disease and 83 patients had stage II disease. Each patient was evaluated for therapeutic efficacy, post-treatment quality of life (QOL) and a second cancer. The 5-year and 10-year cause-specific actuarial survival rates for stage I and II SCO were 87% and 86%, respectively. We found that the 5-year and 10-year survival rates for all SCOs combined with second primary RUDT cancers were 71% and 45%, respectively. 51 second primary RUDT cancers occurred successively in 41 patients following treatment for early stage oropharyngeal cancer and this was the sole prognostic factor by the multivariate analysis. Au-198 seed brachytherapy with or without ipsilateral external irradiation of up to 30 Gy was associated with fewer late complications in the oral cavity and salivary gland. We concluded that our treatment policy of brachytherapy with or without external irradiation for patients with early stage SCO was effective and acceptable from the standpoint of tumour control and post-treatment QOL.     

Concurrent Radiochemotherapy with Vinorelbine plus Cisplatin or Carboplatin in Patients with Locally Advanced Non-Small-Cell Lung Cancer (NSCLC) and an Increased Risk of Treatment Complications

BACKGROUND: In elderly patients, patients with multiple morbidities, and patients with a reduced general condition, the standard treatment of inoperable non-small-cell lung cancer (NSCLC) consists of either chemotherapy or radiation therapy alone and is associated with an extremely poor prognosis. We therefore investigated the feasibility, toxicity, and efficacy of radiotherapy with concurrent chemotherapy using vinorelbine plus cisplatin or carboplatin in NSCLC patients at risk for treatment complications. PATIENTS AND METHODS: A total of 33 patients (six women, 27 men, median age 65 years) with locally advanced, functionally inoperable pulmonary carcinomas, recurrent lung cancer or postoperative macroscopic residual tumors (R2) with an increased risk of treatment complications (WHO performance status 2/3; cardiac, renal or pulmonary failure; marked pretherapeutic weight loss; age between 71-75 years) received 12.5 mg of vinorelbine per m(2) body surface area (BSA) on days 1, 8, 15, 29, 36 and 43 plus either cisplatin 20 mg/m(2) BSA (ten patients) or carboplatin 70 mg/m(2) BSA (23 patients) on days 1-5 and 29-33 together with conventionally fractionated radiotherapy. The tumor regions were irradiated with doses of up to 63 Gy (90% isodose), and potentially affected lymph nodes received doses of up to 45.0 or 50.4 Gy (90% isodose). RESULTS: Briefly, 31 of 33 patients successfully completed radiation therapy and 26 received four cycles of vinorelbine plus at least two cycles of cisplatin or carboplatin. Hematotoxic side effects included grade III leukocytopenia (n = 8), grade III thrombocytopenia (n = 5), and grade IV thrombocytopenia (n = 2). Other side effects consisted of peripheral neuropathy grade III (n = 1) and esophagitis grade IV (n = 1). Severe pneumonitis did not occur. Six patients had pneumonia before radiochemotherapy. 21 patients (63%) exhibited a complete (n = 7) or partial response (n = 14) to chemoradiation. The twelve nonresponders had either stable (n = 9) or progressive disease (n = 3). The survival rates plus standard deviations were as follows: 1-year survival: 60 +/- 8%, 2-year survival: 36 +/- 9%, 3-year survival: 24 +/- 9%, median survival time: 17 months (5;29 months; 95% confidence interval [CI]), median progression-free survival: 11 months (9;13 months; 95% CI). The median follow-up time was 14 months. CONCLUSION: Conventionally fractionated radiochemotherapy with vinorelbine plus a platinum derivative is feasible in patients with NSCLC and increased risk of treatment complications. Compared to patient populations described in the literature, the survival rates achieved by concurrent radiochemotherapy appear to be better than those achieved with radiotherapy alone.     

Postoperative radiotherapy of salivary gland tumors. Prognostic factors and treatment results]

A retrospective analysis of 63 patients with malignant major salivary gland tumours treated between 1972 and 1988 is presented. In 54 patients the tumour was located in the parotid gland, in the remaining nine patients the tumour was located in the submandibular gland, 31 patients were treated for stage I to II disease, 32 patients for stage III to IV disease. All patients were irradiated postoperatively using 60 Co. 137 Cs photons or electrons of adequate energies. As basic techniques ipsilateral portals, a wedge pair of portals or parallel opposed fields were used. The target doses ranged between 45 and 70 Gy with fractions of three to five times 2 to 3 Gy weekly, dependent on postoperative status and stage. In 25% of the patients a local recurrence was evident after radiotherapy with 13% developing distant metastases. The five-year survival was 95% for stage I, 83% for stage II, 30% for stage III and 7% for stage IV. Additionally, the prognosis varied according to lymph node involvement, grading and microscopic or macroscopic residual disease.     

Managing nasopharyngeal carcinoma with intracavitary brachytherapy: one institution's 45-year experience

PURPOSE: At our institution, we have been using intracavitary brachytherapy as a boost in selected cases of both primary and recurrent nasopharyngeal carcinoma. The local control, distant metastasis-free rate, overall survival, and morbidity are presented. METHODS AND MATERIALS: Between January 1, 1955, and August 2000, 576 patients with a diagnosis of nasopharyngeal carcinoma were seen at the department of radiation oncology, University of California-San Francisco, and 55 patients received intracavitary brachytherapy as one part of their treatment. All patients were treated with megavoltage external beam radiation, including 43 patients treated for initial disease and 12 for recurrence. Brachytherapy was routinely used for early cases of T1 and T2 lesions and selected cases of more advanced lesions, as well as recurrent lesions. The median age was 48 years (range 22-85 years); there were 17 women and 38 men, and 39 patients were ethnic Chinese, 13 were white, and 3 were other races. Stage at treatment (primary and recurrent) was I (n=13), II (n=18), III (n=19), and IV (n=5); 18 patients had concurrent chemotherapy. The brachytherapy applicators used were Rotterdam (n=24), balloon (n=16), ovoid (n=14), and ribbon (n=1). The dose rate was high (n=24), low (n=29), or pulsed (n=2). External beam doses ranged from 54 to 72 Gy for primary disease and 30 to 42 Gy for recurrent disease. Brachytherapy doses ranged from 5 to 7 Gy for high dose rate and 10 to 54 Gy for low dose rate. RESULTS: With a median follow-up of 36 months in those who were treated for primary carcinoma, the 5-year estimate of local control was 89%, the distant metastasis-free rate was 75%, and the overall survival estimate was 86%. Recurrent patients had a median follow-up of 50 months; the 5-year estimate of local control was 64%, the distant metastasis-free rate was 100%, and the overall survival estimate was 91%. Patients with Stage I or II disease had a longer overall survival compared with those with Stage III or IV (p=0.05). There was a significant difference in the rate of distant metastases due to nodal status (N0 vs. N1-N3, p=0.02) or to overall stage (I/II vs. III/IV, p=0.005). CONCLUSIONS: Intracavitary boost brachytherapy was found to be effective and well tolerated in selected cases of both primary and recurrent nasopharyngeal carcinoma.     

The role of pulsed-dose-rate brachytherapy in previously irradiated head-and-neck cancer

PURPOSE: The purpose of this prospective study was to analyze the value of interstitial pulsed-dose-rate (PDR) brachytherapy (iBT) with regard to local control and the incidence of side effects in patients with head-and-neck cancer in a previously irradiated area. METHODS AND MATERIALS: From October 1997 to September 2001, 43 patients with head-and-neck cancer in a previously irradiated area (31 patients with recurrent cancer) were treated with iBT alone or in combination with external beam radiation. Thirty-four of 43 patients received interstitial PDR brachytherapy (DREF=20-60 Gy) as part of their curative treatment regimen alone or in combination with external radiation. Nine patients were implanted for palliative purposes. The pulses were delivered 24 h/day with a time interval of 1 h between two pulses. The dose per pulse (dp) ranged from 0.4-0.7 Gy. Sixteen of 43 (37%) patients also received cisplatin or carboplatin with 5-fluorouracil during the time of the iBT. Additionally 20/43 (47%) patients were treated with interstitial hyperthermia. Thirteen of 43 (30%) patients received external beam radiation in a dose range from 20-67 Gy. A follow-up of all patients was done to analyze local control and survival, and acute and delayed toxicity. This analysis was performed after a median follow-up of 24 months (6-48 months). RESULTS: Local tumor control was achieved in 34 of a total of 43 patients (79%) and in 30/34 patients (88%) treated for curative intention. Distant metastases were observed in 5/43 (12%) patients. The 2-year local recurrence-free survival rates, disease-free survival rates, and overall survival rates according to the Kaplan-Meier method for all patients were 68%, 62%, and 49%, respectively, and for patients treated with curative intention they were 80%, 77% and 66%, respectively. There was no statistical difference in the probability of local recurrence in patients subgrouped by recurrent tumor vs. secondary primary, tumor size, grading and lymphangiosis. The application of chemotherapy or hyperthermia did not have significant influence on the therapy results. Soft tissue necrosis was the only serious side effect seen in 2/43 patients (4.7%). No other serious side effects were observed. CONCLUSIONS: Interstitial pulsed-dose-rate brachytherapy for patients with previously irradiated head-and-neck cancer is an effective therapy with minimal toxicity. The role of chemotherapy and hyperthermia in these patients remains unclear. Further randomized studies with larger patient numbers are necessary to draw a definite conclusion.     

Radiotherapy combined with simultaneous chemotherapy with mitomycin-C and 5-fluorouracil for inoperable head and neck cancer

The feasibility and effectiveness of a combined chemoradiotherapy treatment modality for locally advanced head and neck cancer was tested in a phase II trial. From March 1995 to June 1998, 35 patients with advanced squamous cell carcinoma of the head and neck were treated with a continuous intravenous infusion of 5-fluorouracil (600 mg m-2 24 h-1 for Days 1 to 5 (120 h)) and mitomycin-C (10 mg m-2 intravenously) on Day 5 during the first week of radiotherapy and on Day 36. 31 patients had stage IV disease; 4 patients had stage III; and 1 patient had stage II. Patient ages ranged from 42-69 years (median 56.7 years). The tumours involved were as follows: oral cavity (n = 11); oropharynx (n = 14); hypopharynx/larynx (n = 10). Radiotherapy was delivered to a total dose of 70 Gy with conventional fractionation (2 Gy per fraction, five times a week). Chemotherapy was well tolerated and all patients received the intended dose. Mild nausea occurred in five patients. After a mean follow-up of 21 months (range 10-44 months), 8 (23%) patients remain alive. A complete response was seen in 28 (80%) patients. When a recurrence appeared, it was within the first year after treatment. 1- and 2-year overall survival rates were 46% and 23%, respectively. Grade 3 mucositis occurred in 17% of patients. Grade 1-2 thrombopaenia occurred in 3 (9%) patients, grade > 2 leukopaenia in 4 (11%) patients, and grade > or = 2 anaemia in 3 (9%) patients. We observed a treatment interruption of maximum 1 week for six patients owing to mucositis. Febrile neutropaenia or aplasia were not observed. The concomitant use of 5-fluorouracil, mitomycin-C and radiotherapy in locally advanced head and neck carcinoma is well tolerated in this group of patients. This protocol showed good locoregional response with a very low toxicity profile.