Neutron therapy (dT, 14 MeV) for recurrence of rectal cancer: interim analysis from Münster.

For rectal recurrent cancer and macroscopic residual disease after surgery neutron radiotherapy has been suggested to be superior to photon radiotherapy. At the d,T generator in Münster (14 MeV) 20 patients have been treated with a combined photon-/neutron-radiotherapy: two patients with residual disease after surgery: among the 18 patients with rectal recurrence 15 for pain relief; all for tumor control. Tumor resection had been carried out in five recurrent tumors. Six patients presented with distant metastases. 30 to 40 Gy photons for tumor region and potential microscopic spread with 2 Gy per fraction and 5 to 10 Gy neutrons for macroscopic tumor volume with 0.7 to 1.6 Gy per fraction were applied using multiple fields (three to five). The mean follow-up period is nine months. Pain relief was achieved in eleven of 15 patients (73%), the onset of pain was fast, the probability for a pain-free period is 46% for nine months and for survival 56% for twelve months. Side-effects were slight to moderate beside a severe subcutaneous fibrosis in two patients. The superiority of neutrons to photons in rectal recurrent cancer remains questionable and is to be proven in a prospective trial comparing different schedules for frequency, onset and duration of pain relief, tumor control, survival and side-effects.     

Primary rectal cancer treated with high-dose-rate intraluminal brachytherapy following external radiotherapy

An 80-year-old man with rectal cancer who had diabetes and angina was treated with high-dose-rate intraluminal brachytherapy (30 Gy) following external radiotherapy (30 Gy). After this treatment, anal pain and bleeding improved greatly, and he was able to evacuate the bowels. However, the endoscopic biopsy taken five months after treatment revealed active cancer cells.     

Radiochemotherapy in Combination with Regional Hyperthermia in Preirradiated Patients with Recurrent Rectal Cancer

BACKGROUND AND PURPOSE: Encouraging results of phase II studies combining chemotherapy with radiotherapy have been published. In this study, the results of a multimodal salvage therapy including radiochemotherapy (RCT) and regional hyperthermia (RHT) in preirradiated patients with recurrent rectal cancer are reported. PATIENTS AND METHODS: All patients enrolled had received previous pelvic irradiation (median dose 50.4 Gy). The median time interval between prior radiotherapy and the onset of local recurrence was 34 months. The combined treatment consisted of reirradiation with a median dose of 39.6 Gy (30.0-45.0 Gy), delivered in fractions of 1.8 Gy/day. 5-fluorouracil was given as continuous infusion 350 mg/m(2)/day five times weekly, and RHT (BSD-2000 system) was applied twice a week within 1 h after radiotherapy. The primary endpoint was local progression-free survival (LPFS); secondary endpoints were overall survival, symptom control, and toxicity. RESULTS: 24 patients (median age 59 years) with a previously irradiated locally recurrent adenocarcinoma of the rectum were enrolled. The median LPFS was 15 months (95% confidence interval 12-18 months] with a median follow-up of 27 months (16-37 months). The overall 1-year and 3-year survival rates were 87% and 30%, respectively. Pain was the main symptom in 17 patients. Release of pain was achieved in 12/17 patients (70%). No grade 3 or 4 hematologic or skin toxicity occurred. Grade 3 gastrointestinal acute toxicity was observed in 12.5% of the patients. Paratumoral thermometry revealed a homogeneous distribution of temperatures. CONCLUSION: RCT combined with RHT is an efficient salvage therapy showing high efficacy with acceptable toxicity and can be recommended as treatment option for this unfavorable group of preirradiated patients with local recurrence of rectal cancer.     

Carcinomatous neuropathy in recurrent rectal carcinoma. The results of radiotherapy and the role of CT

More than 60% of the patients with recurrent rectal carcinoma complain of pain after radical surgery. Pelvic carcinomatous neuropathy (PCN) is a frequent cause of pain in such patients. Although the effectiveness of radiotherapy in the palliative treatment of local recurrences of rectal carcinoma is well recognized, its results in PCN are less known. The authors have evaluated the results of high-energy radiotherapy in 12 patients with recurrent rectal carcinoma and PCN, who were treated with doses between 35 and 55 Gy. Although the survival of these patients is always poor, about 50% of them achieved a significant and prolonged palliative result by radiation treatment. In patients with PCN, CT is an effective tool to detect recurrences, define their volume and relationship to critical organs, show sites of neural involvement, and optimize radiation treatment planning.     

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.     

Ergebnisse der Behandlung von Rektumkarzinomrezidiven mit schnellen Neutronen (d, T 14 MeV)

Purpose

In spite of improved surgical techniques and the use of multiple modality treatment schemes the local recurrence rate of colorectal carcinomas could not be successfully reduced up to now. Besides surgical treatment of local recurrences in some cases radiation therapy may be indicated.

Patients and Method

In the Department of Radiotherapy of the University of Münster 37 patients with recurrent rectal carcinoma were treated between the end of 1985 and September 1992 either with fast neutrons alone or with a combined photon-neutron therapy. Eighteen patients received radiotherapy with fast neutrons (14 MeV d,T) alone; the tumor dose was between 10 and 15 Gy neutrons. Nineteen patients were irradiated with a mixed-beam schedule consisting of 30 to 45 Gy photons (X 10 MV) and neutron doses ranging from 5 to 10 Gy.

Results

In 30 patients a good or complete pain relief could be observed immediately after the last irradiation. Sixteen out of 37 patients had local tumor regrowth during the follow-up period. The median survival for all 37 patients was 15.9 months. The probability for survival was 86% after 6 months and 61% after 12 months (Kaplan-Meier). The side effects were slight to moderate (EORTC/RTOG I-II).

Conclusions

This therapy showed good results concerning a fast and effective pain relief. Additionally the results seem to show a good effect concerning local control and overall survival in this negatively selected patients.     

High-dose-rate afterloading intraluminal brachytherapy for advanced inoperable rectal carcinoma

PurposeHigh-dose-rate (HDR) intraluminal brachytherapy for advanced or inoperable tumors of the rectum has been used both palliatively and to dose escalate after chemoradiation for curative treatment.MethodsBetween 1993 and 2007, 79 patients were treated with HDR afterloading brachytherapy for rectal cancer; 70 patients had adenocarcinoma of the rectum; and 9 patients had squamous cell carcinoma of the anal canal. Fifty-two patients had localized disease but were unfit for major surgery and received radiotherapy with radical intent. Twenty-seven patients with advanced or metastatic disease received palliative treatment. The median age was 82 years (range, 33–97). Radical treatment comprised either chemoradiation followed by intraluminal brachytherapy delivering 12 Gy at 1 cm in two fractions or radical monotherapy delivering up to 36 Gy at 1 cm in six fractions two to three times weekly. Palliative HDR brachytherapy schedules were predominantly 10 Gy at 1 cm single dose.ResultsObjective local tumor response was seen in 41 of 48 assessable patients (85%); of whom, 28 patients (58%) had a complete response and 13 (27%) had a partial response. The most common symptom was rectal bleeding, which was controlled with a complete response rate of 63%. The median duration of the symptom response was 3 months (range, 1–73), and the median survival of the palliative patients was 6 months (range, 1 week–37 months). The median survival for patients treated with radical intent was 18.5 months (range, 2–119). Six patients reported late toxicity with three cases of rectal ulcer, two strictures, and one fistula.ConclusionsIntraluminal HDR brachytherapy is effective as local treatment in both the radical and palliative setting, with high tumor and symptom response rates, and acceptable late toxicity.     

Quality of life after intensity-modulated radiotherapy for prostate cancer with a hydrogel spacer

BACKGROUND: Hydrogel spacer is an innovative method to protect the rectal wall during prostate cancer radiotherapy. Clinical effects are not well known. METHODS: Patients have been surveyed before, at the last day, and 2-3?months after radiotherapy using a validated questionnaire (Expanded Prostate Cancer Index Composite). Median dose to the prostate in the spacer subgroup (SP) was 78?Gy in 2?Gy fractions. The results were independently compared with two matched-pair subgroups (treated conventionally without spacer): 3D conformal 70.2?Gy in 1.8?Gy fractions (3DCRT) and intensity-modulated radiotherapy (IMRT) 76?Gy in 2?Gy fractions. There were 28?patients in each of the three groups. RESULTS: Baseline mean bowel bother scores were 96?points in all subgroups. Similar mean changes (SP 16, 3DCRT 14, IMRT 17 points) were observed at the end of radiotherapy. The smallest difference resulted in the spacer subgroup 2-3?months after radiotherapy (SP 2, 3DCRT 8, IMRT 6 points). Bowel bother scores were only significantly different in comparison to baseline levels in the spacer subgroup. The percentage of patients reporting moderate/big bother with specific symptoms did not increase for any item (urgency, frequency, diarrhoea, incontinence, bloody stools, pain). CONCLUSION: Moderate bowel quality-of-life changes can be expected during radiotherapy irrespective of spacer application or total dose. Advantages with a spacer can be expected a few weeks after treatment.     

Therapy monitoring of presacral recurrences after high-dose irradiation: value of PET, CT, CEA and pain score.

21 patients were followed by positron-emission-tomography (PET) FDG (18Flourdeoxyglucose) uptake, physical examination, CT and CEA levels after combined photon-neutron irradiation for inoperable recurrent rectal carcinoma. In order to evaluate the response to radiotherapy symptomatic relief, CEA levels, decrease of tumor volume measured by CT analysis were correlated with the FDG-uptake. The objective of this study was also to investigate if the level of FDG-uptake prior to radiotherapy or the early decrease after therapy can be used as a prognostic factor. Prior to radiotherapy sacral pain was the predominant symptom. All malignancies showed measurable tumor masses, evaluation of CEA levels and enhanced tracer accumulation of FDG in the PET cross section. The mean FDG-uptake before radiotherapy was 2.3 +/- 1.1 (range 1.1 to 5.0) in 21 patients in contrast to 1.9 +/- 0.7 (range 0.8 bis 4.0) three months after radiotherapy. In six patients FDG concentration values decreased to the range of normal soft tissue, moreover, two of them relapsed after six and 22 months. Elevated FDG-uptake of the sacral bone was noted in PET cross sections in two patients, while there was no evidence of osseous alterations in CT. Normal levels of CEA were achieved in 14 patients and complete or partial pain relief in 20 of 21 patients. A decrease of tumor volume of more than 50% was detected in the follow-up CT scans of three patients but no complete remission was found. The result suggests that enhanced glucose uptake is associated with recurrent rectal cancer. However, enhanced glycolytic activity is related not only to malignant cells but also to all proliferating cells. To distinguish between proliferation, repair, inflammation, and residual viable tumor cells is not possible and may be responsible for an unchanged or elevated FDG-uptake after radiotherapy.     

Intensity-modulated radiotherapy for previously irradiated, recurrent head-and-neck cancer.

The purpose of this work is to evaluate our initial experience in treating previously irradiated, recurrent head-and-neck cancers using intensity-modulated radiotherapy (IMRT). Between July 1997 and September 1999, 12 patients with previously irradiated, locally recurrent head-and-neck cancers were treated with IMRT. These included cancers of the nasopharynx, oropharynx, hypopharynx, larynx, paranasal sinus, skin of the head-and-neck region, and malignant melanoma. Five of these 12 patients had received radiation as the primary treatment, with doses ranging from 66.0 to 126.0 Gy, and the remaining 7 patients had undergone definitive surgeries followed by an adjuvant course of radiation treatment, with doses ranging between 36.0 and 64.8 Gy. Recurrence after the initial course of radiation occurred in periods ranging from 4 to 35 months, with 11 of 12 cases recurring fully in the fields of previous irradiation. Recurrent tumors were treated with IMRT to total doses between 30 to 70 Gy (> 50 Gy in 10 cases) prescribed at the 75% to 92% isodose lines with daily fractions of 1.8 to 2 Gy. The results revealed that acute toxicities were acceptable except in 1 patient who died of aspiration pneumonia during the course of retreatment. There were 4 complete responders, 2 partial responders, and 2 patients with stable disease in the IMRT-treated volumes. Three patients received IMRT as adjuvant treatment following salvage surgery. At 4 to 16 months of follow-up, 7 patients were still alive, with 5 revealing no evidence of disease. In conclusion, this pilot study demonstrates that IMRT offers a viable mode of re-irradiation for recurrent head-and-neck cancers in previously irradiated sites. Longer follow-up time and a larger number of patients are needed to better define the therapeutic advantage of IMRT in recurrent, previously irradiated head-and-neck cancers.     

Mitomycin C, 5-fluorouracil and radiation in advanced, locally recurrent rectal cancer.

15 patients with inoperable presacral recurrent rectal cancer following surgery were treated with combined radiation and chemotherapy. Treatment consisted of split-course radiotherapy with 50 Gy in 25 fractions over 5 weeks and, after 4 weeks, an additional 20 Gy in 10 fractions over 2 weeks. At the start of treatment and following the split course, chemotherapy was administered. Mitomycin C was given on Day 1 (dose: 15 mg/m2 i.v. bolus) and 5-fluorouracil from Day 1 to Day 5 (dose: 750 mg/m2/24 h, continuous i.v. infusion). Owing to considerable, predominantly haematological and gastrointestinal toxicity, only six out of 15 patients received treatment according to the protocol. The symptomatic relief of symptoms was good. Pain was controlled in seven of eight symptomatic patients. Seven of the patients showed response according to computed tomography, but in none of these cases was a complete remission seen. After a follow-up of at least 30 months, only three patients are alive. The 1-, 2- and 3-year survival rates are 9/15, 6/15 and 3/12, respectively. The median survival is 14 months (range 4-60+ months). In comparison with historical data from the same institution, combined radio-chemotherapy did not show any prolongation of survival or increased response rate, but increased toxicity excessively, when compared with radiation alone.     

Retrospective evaluation of radiotherapy in plantar fasciitis

Plantar fasciitis is a common painful syndrome that is usually treated by irradiation with a fraction dose (fd) of 1 Gy up to a total dose (TD) of 6 Gy according to clinical experience. By analysing our experiences with numerous former patients, we have attempted to find the relationship between dose and effect. To evaluate the effectiveness of radiotherapy and assess the impact of fd and TD in plantar fasciitis radiotherapy, we assessed 1624 irradiations (856 patients) performed using a fd of 1-3 Gy and a TD of 1-45 Gy. Analysis was carried out on the 623 irradiations (327 patients) for which complete follow-up data were available. The mean follow-up period was 74 months. The following parameters were evaluated: pain relief level; period of anaesthetic effect preservation after treatment; presence of pain and the timing of its appearance; and the intake of analgesic drugs at the last follow-up. After treatment, 48% of the patients reported a lack of pain, 21% reported pain relief greater than 50% and 17% reported pain relief less than 50%. The mean pain relief duration was 72 months. The last follow-up found that pain at rest afflicted 25% of the patients, and pain during walking afflicted 32%. A dose-effect relationship was not found. In conclusion, radiotherapy is an effective treatment for plantar fasciitis. A fd of 1.5 Gy and TD of 9 Gy should probably not be exceeded.     

Palliative radiation therapy for localized prostate symptoms in hormone refractory prostate cancer

Hormone refractory prostate cancer (HRPCa) can cause debilitating local pelvic symptoms including urinary obstruction, pelvic pain, haematuria and obstructive rectal symptoms. High-dose palliative radiation therapy (RT) is used in many centres to relieve these symptoms despite limited published evidence for its efficacy. This study aimed to assess if RT provides effective and durable palliation for local prostate symptoms in HRPCa. Thirty-five HRPCa patients received RT to the prostate for local symptoms between November 2002 and March 2006. The median dose was 60 Gy in 30 fractions (range 30-70 Gy). Response around a 6-month time point was scored as complete resolution, partial resolution, no change or local progression. Time to progression (defined as new or recurrent symptoms) or persistence of symptoms was recorded. Factors influencing outcome, such as dose, type and number of symptoms and previous transurethral resection, were examined. Twenty-one (60%) patients had a complete (n=3) or partial improvement (n=18) in symptoms. All three complete responders had haematuria as their only symptom. In the eight (23%) patients with local progression, half progressed during treatment and all had done so within 3 months. This series represents a bigger cohort than any reported in published works examining this issue. It suggests that radiation is effective in palliating the local pelvic symptoms in HRPCa.     

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.     

125I粒子植入治疗宫颈癌放疗后复发腹膜后淋巴结转移10例

目的 探讨CT引导下放射性125I粒子植入治疗宫颈癌放疗后复发腹膜后淋巴结转移初步疗效.方法 选取2011年11月至2015年10月宫颈癌放疗后复发腹膜后淋巴结转移10例患者,12个病灶,垂直径1.7 cm×1.0 cm～6.5 cm×5.0 cm,其中直径＜5.0 cm、≥5.0 cm的淋巴结分别为6个(50％)、6个(50％).应用近距离治疗计划系统(TPS)制定治疗计划,CT引导下植入125I粒子,活度0.3～0.7 mCi,术后验证D90(90％靶体积所接受的最小剂量):36～110 Gy(中位59 Gy).术后观察病灶大小变化、疼痛缓解情况及并发症.结果 10例患者随访时间4.3～16.1个月,中位随访时间9.7个月,2个月局部控制率100％、有效率58.3％,2、6、12个月生存率分别为100％、66.7％、58.3％,中位生存时间12.1个月.1例患者术后5个月死于消化道出血,6例死于肿瘤转移,3例患者生存并未见粒子植入部位复发,未见其他部位大出血、肠道感染、骨髓抑制等粒子相关严重并发症.结论 CT引导下125I粒子植入治疗宫颈癌放疗后复发腹膜后淋巴结转移取得了较满意的近期疗效,是一种安全可行的方法.     

Osteoradionekrose nach Strahlentherapie gynäkologischer Tumoren

AIM: Insufficiency fractures of the pelvis are a well known but rare and frequently misinterpreted radiation sequela. The clinical features and possible risk factors were investigated. PATIENTS AND METHODS: 71 of living 82 patients, who were treated 1986-1994 for gynecologic tumors were clinically examined. 47 patients underwent also bone scan, CT of the pelvis and 13 patients had osteodensitometry. All patients had been treated with adjuvant (n = 29) or curative intent (n = 18) by d.v. fields with 18-MV photons, with 46 Gy in 23 fractions plus brachytherapy (15-39 Gy). Median follow-up was 36 months. RESULTS: Seven patients developed pelvic insufficiency fractures 11 months (median, minimum 2 months) after treatment. All patients complained of moderate to severe pelvic pain, which resolved after 5-28 months without specific therapy in five of seven patients. At first examination all but one bone scan showed extremely increased uptake in the os sacrum and/or iliosacral joints, correlating CT scans demonstrated small fractures and bony destruction. Four of the asymptomatic 40 patients with complete radiologic examinations had medium uptake in bone scan (CT normal). Three of four examined patients with insufficiency fractures and seven of nine patients without insufficiency fractures had osteoporosis. CONCLUSION: In women who present with pelvic pain after radiotherapy for gynecologic tumors bony destruction and fractures may be indicative of a late radiation effect rather than osseous metastasis, even after early onset of symptoms.     

High-dose-rate interstitial brachytherapy for gynecologic malignancies

PURPOSE: The study aimed to assess the outcome of locally advanced cervical and vaginal cancer treated with high-dose-rate interstitial brachytherapy (HDRB). METHODS AND MATERIALS: Between 1998 and 2004, 16 previously unirradiated patients with locally advanced cervical and vaginal cancer not suitable for intracavitary brachytherapy because of distorted anatomy or extensive vaginal disease were treated with HDRB in combination with external beam radiotherapy. All patients received whole pelvis external beam radiation therapy (EBRT) followed by interstitial implantation. The median whole pelvis external beam dose was 45 Gy (range, 39.6-50.4 Gy) with 11 patients receiving parametrial boost to a median dose of 9 Gy. Twelve (75%) of these patients received chemotherapy concurrent with external beam. All patients received a single HDRB procedure using a modified Syed-Neblett template. A CT scan was performed postimplant for needle placement verification and treatment planning purpose. Dose was prescribed to the tumor volume based on the radiographic and clinical examination. All patients received 18.75 Gy in five fractions delivered twice daily. The median followup was 25 months (6-69 months). RESULTS: Median cumulative biologic effective dose (EBRT+HDRB) to tumor volume was 78.9 Gy10 with the range of 72.5-85.2Gy10. Median cumulative biologic effective dose for the rectum and bladder were 99.4 Gy3 (range, 79.6-107.8 Gy3) and 96.4 Gy3 (range, 78.3-105.3 Gy3), respectively. Complete response was achieved in 13 (81%) patients with 3 patients having persistent disease. Five of these 13 patients developed recurrence at a median time of 14 months (distant in 4 and local and distant in 1). The 5-year actuarial local control and cause-specific survival were 75% and 64%, respectively. In subset analysis, 5-year actuarial local control was 63% for cervical cancer patients and 100% for vaginal cancer patients. No patient had acute Grade 3 or 4 morbidity. Grade 3 or 4 delayed morbidity resulting from treatment occurred in 1 patient with 5-year actuarial rate of 7%. Three patients had late Grade 2 rectal morbidity and 1 patient had Grade 2 small bowel morbidity. CONCLUSIONS: Our series suggests that single interstitial implantation procedure with five fractions of 3.75 Gy each to target volume is an effective and safe fractionation schedule. The integration of imaging modality helps in decreasing dose to the critical organs. Additional patients and followup are ongoing to determine the long-term efficacy of this approach.     

Intravenous mitoxantrone use and simultaneous radiotherapy as a palliative treatment in recurrent head and neck tumors]

After preceding radiotherapy, chemotherapy and/or surgery the therapeutic options are limited in case of recurrence. In order to enhance the effect of a reduced radiation dose we have combined intravenous mitoxantrone and simultaneous irradiation. From 1988 to 1991 22 patients with recurrent head and neck carcinomas were treated with this combined regimen. 20 patients had already been irradiated with 50 to 70 Gy. The second treatment course was given with 19.8 to 56.0 Gy and simultaneous application of one to three courses of mitoxantrone. Eleven (50%) patients achieved a clinical complete remission. A partial remission was seen in nine patients.     

Soft tissue sarcomas after radiation treatment for breast cancer. Three case studies and review of literature.

AIMS: By means of 3 cases with infield soft tissue carcinomas after radiotherapy for breast cancer, symptoms and therapy are described. Consequences for treatment planning and patient's information before radiotherapy for breast cancer are discussed. PATIENTS: Three of 1,025 patients with breast cancer irradiated from 1984 to 1997 suffered from infield secondary soft tissue sarcomas. The latency periods were 61, 49 and 59 months. Two patients had been treated with breast-conserving therapy (computerized planning, 50 Gy to reference point, 5 times 2 Gy/week, 5-MV photons), 1 patient received a local boost dose of 15 Gy (10-MeV electrons), patient 3 radiotherapy of the thoracic wall and regional lymph nodes after mastectomy using 12-MeV electrons (thoracic wall) and 5-MV photons (lymph node areas) to 50 Gy, 5 times 2 Gy/week. No adjuvant chemotherapy was given. All sarcomas were very extensive, all patients died from local progression and/or distant failure after 17, 13 and 12 months. RESULTS: The incidence of spontaneous sarcomas of the breast is about 0.06%, after operation and radiotherapy 0.09 to 0.45%. No correlations to radiotherapy technique and no risk factors were found. Radiation dose could play a role, but there are very sparse data about this. CONCLUSIONS: Secondary soft tissue sarcomas are very rare, but familiar complications of radiotherapy. Only early diagnosis leads to a chance for cure. Because of unclear correlations to the treatment parameters and rareness of this event, in our opinion no regular information to the patient receiving radiotherapy for breast cancer is mandatory.     

Effectiveness of Hypofractionated Radiotherapy in Painful Bone Metastases Two Prospective Studies with 1 × 4 Gy and 4 × 4 Gy

BACKGROUND: Although effectiveness of fractionated radiotherapy for painful bone metastases is well documented, there are unanswered questions regarding the adequacy of low-dose short radiation schedules for long-term pain control which give maximum benefit in patients with a short life expectancy. PATIENTS AND METHODS: Two consecutive non-randomized prospective follow-up studies were performed at a single institution to analyze pain response and duration of response in patients with a variety of primary tumors. Included were only patients with symptomatic nonvertebral bone metastases and without impending pathologic fracture. Forty-five patients received 1 x 4 Gy to 50 different sites (group I) while 86 patients received 4 x 4 Gy to 96 sites (group II). Pain relief to irradiation was evaluated according to patient interviews using a 4-point categorical scale. Follow-up was performed 7 and 90 days after radiotherapy. RESULTS: Pain relief after 4 x 4 Gy was significantly superior to 1 x 4 Gy with pain control rates being 86.5% vs 48% at day 7 (after end of treatment) and 80% vs 55% at day 90, respectively. A subgroup analysis of patients treated with 4 x 4 Gy demonstrated a more favorable outcome for breast cancer patients in comparison to patients with other primaries concerning pain relief (96% vs 81%), pain control after 90 days (93% vs 72%), median time to pain progression (9 vs 3 months), and median overall survival (14 vs 5.5 months). CONCLUSIONS: In this study 4 x 4 Gy proved to be clearly superior to 1 x 4 Gy in relieving pain from symptomatic nonvertebral bone metastases without impending pathologic fracture. Even if radiotherapy with 1 single fraction seems to be applicable in specific cases doses higher than 4 Gy should be chosen. In breast cancer patients pain control seems to be better compared to other primaries.