Neoadjuvant Radiochemotherapy in Locally Advanced Gastric Carcinoma

BACKGROUND AND PURPOSE: Gastric carcinoma is characterized by a high rate of local recurrences and distant metastases and is often not resectable due to locally advanced stage. The aim of this study was to examine feasibility and effectiveness of neoadjuvant radiochemotherapy (RCT) for locally advanced, primarily nonresectable gastric carcinoma and to achieve curative resection. PATIENTS AND METHODS: 21 patients with locally advanced gastric cancer located in cardia (n = 17) and corpus (n = 4; seven cT3; 14 cT4; 18 cN+; all cM0) with a median age of 61 years were scheduled to receive neoadjuvant RCT. Therapy consisted of a conventionally fractionated, conformal radiotherapy using the shrinking-field technique (1.8 Gy to 45 Gy + 5.4 Gy) and chemotherapy using cisplatin (20 mg/m(2), d1-5, 29-33), 5-fluorouracil (5-FU; 800 mg/m(2), d1-5, 29-33) or paclitaxel (135 mg/m(2), d1, 29). 4-6 weeks after completion of RCT, surgery was performed whenever feasible. RESULTS: Hematologic toxicity was moderate with grade 3 leukopenia in 10/21 patients and grade 3 thrombopenia in 5/21 (CTC). Nonhematologic toxicities consisted of 5/21 cases of fever as well as one fungal sepsis. Following RCT, tumors were classified resectable in 16/21 patients (76%); 12/21 patients (58%) were operated on, 11/12 achieved clear margins (R0). Response was as follows: complete remission (CR) 3/21 (14%), partial remission 13/21 (62%), no change 3/21 (14%), systemic progressive disease (PD) 2/21 (10%). The median survival and the 2-year survival rates were 18 months and 42%, respectively, for the patients following R0 resections as compared to 10 months and 0% for the remaining patients (p = 0.035). Local control (4 years) for patients following R0 resection was 89%. CONCLUSION: Neoadjuvant RCT is feasible and locally highly effective but must be further investigated involving a higher number of patients.     

Maintenance Chemotherapy after Chemoradiation Improves Survival of Patients with Locally Advanced Pancreatic Carcinoma

BACKGROUND AND PURPOSE: Currently, there is no treatment standard for patients with locally advanced pancreatic cancer (PaCa) after chemoradiation. The aim of the present study was to retrospectively assess overall survival and toxicity of chemotherapy in addition to chemoradiation in this patient group. PATIENTS AND METHODS: Three-dimensional conformal irradiation to the primary tumor (55.8 Gy) and the lymphatics (50.4 Gy) was combined with 5-fluorouracil- or gemcitabine-based chemotherapy followed by additional chemotherapy with gemcitabine until progression or no further treatment. Decision for chemotherapy was taken at the discretion of the attending physician considering the patient's desire. RESULTS: A total of 172 patients were addressed to the local tumor board. Patients with (neo)adjuvant treatment or metastatic disease were excluded (n = 90). 82 patients were treated with chemoradiation and had additional chemotherapy (n = 40) or no further treatment (n = 42). Characteristics of the two groups were equally distributed. Patients with chemotherapy had significantly longer overall survival as compared to patients without (13 months vs. 8 months; p < 0.0001; median survival = 10.7 months for all patients). Acute toxicity of maintenance chemotherapy was relatively mild. CONCLUSION: Maintenance chemotherapy after chemoradiation for patients with locally advanced PaCa may significantly increase survival rates without severe side effects and is therefore recommended as standard treatment following chemoradiation.     

Correlation Between 18F-Fluorodeoxyglucose Uptake and Epidermal Growth Factor Receptor Mutations in Advanced Lung Cancer

Purpose

Mutations in the epidermal growth factor receptor (EGFR) gene have been identified as potential targets for the treatment and prognostic factors for non-small cell lung cancer (NSCLC). We assessed the correlation between fluorodeoxyglucose (FDG) uptake and EGFR mutations, as well as their prognostic implications.

Methods

A total of 163 patients with pathologically confirmed NSCLC were enrolled (99 males and 64 females; median age, 60 years). All patients underwent FDG positron emission tomography before treatment, and genetic studies of EGFR mutations were performed. The maximum standardized uptake value (SUVmax) of the primary lung cancer was measured and normalized with regard to liver uptake. The SUVmax between the wild-type and EGFR mutant groups was compared. Survival was evaluated according to SUVmax and EGFR mutation status.

Results

EGFR mutations were found in 57 patients (60.8 %). The SUVmax tended to be higher in wild-type than mutant tumors, but was not significantly different (11.1 ± 5.7 vs. 9.8 ± 4.4, P = 0.103). The SUVmax was significantly lower in patients with an exon 19 mutation than in those with either an exon 21 mutation or wild type (P = 0.003 and 0.009, respectively). The EGFR mutation showed prolonged overall survival (OS) compared to wild-type tumors (P = 0.004). There was no significant difference in survival according to SUVmax. Both OS and progression-free survival of patients with a mutation in exon 19 were significant longer than in patients with wild-type tumors.

Conclusion

In patients with NSCLC, a mutation in exon 19 was associated with a lower SUVmax and is a reliable predictor for good survival.     

术前胃动脉灌注治疗中晚期胃癌(附3O例分析)

目的：本文通过术前胃动脉灌注抗癌药物治疗中晚期胃癌来评价其临床价值。材料与方法：30例中晚期胃癌，所有病例均经胃镜病理证实。术前动脉插管胃动脉灌注抗癌药1～3次不等，术后将切除的胃标本作病理切片以观察组织学变化。结果：组织学疗效Ⅲ级2例，Ⅱ级4例、Ⅰ级19例，总有效率为83．3％。本组切除率为93．3％，其中根治切除率与非根治切除率分别是70％和23．3％。动脉灌注后所有病例的症状均有改善。另外还分析了影响疗效的因素，其中高、中分化腺癌、印戒细胞癌、多血供肿瘤以及超选择性动脉灌注疗效较好。结论：术前胃动脉灌注抗癌药物治疗中晚期胃癌可缓解症状，提高根治率，降低局部复发和转移以提高手术治疗效果，是中晚期胃癌术前一种重要辅助治疗。     

Restaging of Locally Advanced Carcinoma of the Rectum with MR Imaging after Preoperative Radio-Chemotherapy plus Regional Hyperthermia

BACKGROUND: The restaging accuracy of MR imaging in advanced primary rectal carcinoma after preoperative radiochemotherapy and regional hyperthermia was evaluated and compared with the histopathologically verified degree of tumor remission after a course of radio-chemo-thermotherapy. PATIENTS AND METHODS: 35 patients with primary rectal carcinoma (uT3/uT4) underwent MRI using a surface coil 4-6 weeks after radiochemotherapy (n = 35), regional hyperthermia (n = 23), and before curative surgery. We defined as gold standard for the remission status the comparison of pretherapeutic endosonography with the histopathology of the resected specimen. RESULTS: T category was correctly restaged after preoperative treatment in only 19 (54%) of 35 patients. Nine of 20 responders were overstaged and seven of 15 non-responders were understaged. Concurrently, the N category was correctly restaged in 19 (54%) of 35 patients (twelve responders and seven non-responders). Overstaging occurred in four responders and two non-responders, understaging occurred in four responders and six non-responders. CONCLUSIONS: MRI proved independent of the response status as not suitable to restage locally advanced rectal carcinoma after preoperative radiochemotherapy despite optimized imaging technique and spatial resolution. Basically, imaging the morphology of a tumor cannot clearly differentiate between vital and devitalized tissue after a treatment. Functional imaging such as PET (positron emission tomography) appears more feasible for restaging after radio-chemo-thermotherapy.     

Restaging of Locally Advanced Carcinoma of the Rectum with MR Imaging after Preoperative Radio-Chemotherapy plus Regional Hyperthermia

Background: The restaging accuracy of MR imaging in advanced primary rectal carcinoma after preoperative radiochemotherapy and regional hyperthermia was evaluated and compared with the histopathologically verified degree of tumor remission after a course of radio-chemo-thermotherapy. Patients and Methods: 35 patients with primary rectal carcinoma (uT3/uT4) underwent MRI using a surface coil 4-6 weeks after radiochemotherapy (n = 35), regional hyperthermia (n = 23), and before curative surgery. We defined as gold standard for the remission status the comparison of pretherapeutic endosonography with the histopathology of the resected specimen. Results: T category was correctly restaged after preoperative treatment in only 19 (54%) of 35 patients. Nine of 20 responders were overstaged and seven of 15 non-responders were understaged. Concurrently, the N category was correctly restaged in 19 (54%) of 35 patients (twelve responders and seven non-responders). Overstaging occurred in four responders and two non-responders, understaging occurred in four responders and six non-responders. Conclusions: MRI proved independent of the response status as not suitable to restage locally advanced rectal carcinoma after preoperative radiochemotherapy despite optimized imaging technique and spatial resolution. Basically, imaging the morphology of a tumor cannot clearly differentiate between vital and devitalized tissue after a treatment. Functional imaging such as PET (positron emission tomography) appears more feasible for restaging after radio-chemo-thermotherapy. Hintergrund: Die Genauigkeit der Stadienbestimmung mittels MR-Bildgebung wurde bei primär fortgeschrittenen Rektumkarzinomen nach präoperativer Radiochemotherapie und regionaler Hyperthermie geprüft und mit der histopathologisch ermittelten Tumorremission nach präoperativer Behandlung verglichen. Patienten und Methode: 35 Patienten mit primären Rektumkarzinomen (uT3/uT4) wurden MR-tomographisch mittels Oberflächenspule 4-6 Wochen nach Radiochemotherapie (n = 35) plus Hyperthermie (n = 23) vor der kurativen Resektion untersucht. Als Goldstandard für die Remission wurde der Vergleich von prätherapeutischer Endosonographie mit dem histopathologischen Befund des Resektats definiert. Ergebnisse: Das T-Studium nach präoperativer Behandlung wurde nur bei 19 von 35 Patienten (54%) korrekt wiedergegeben, bei neun von 20 Respondern überbenimmt und bei sieben von 15 Nonrespondern unterschätzt. Daneben wurde auch cie N-Kategorie bei 19 von 35 Patienten (54%) korrekt bestimmt (bei zwölf Respondern und sieben Nonrespondern). Eine Überschätzung trat bei vier Respondern und zwei Nonrespondern auf, eine Unterschätzung bei vier Respondern und sechs Nonrespondern. Schlussfolgerungen: Die MR-Bildgebung erwies sich trotz optimierter Aufnahmetechnik mit erhöhter räumlicher Auflösung und unabhängig vom Remissionsstatus als ungeeignet, das Stadium lokal fortgeschrittener Rektumkarzinome nach präoperativer Radiochemotherapie exakt zu ermitteln. Grundsätzlich ist die Darstellung der Morphologie eines Tumors nicht geeignet, zwischen vitalem und devitalisiertem Tumorgewebe nach Vorbehandlung zu differenzieren. Funktionelle Verfahren (z. B. die Positronenemissionstomographie) könnten für die Verlaufskontrolle nach Radiochemothermotherapie geeigneter sein.     

Occurrence of Vascular Lake Phenomenon as a Predictor of Improved Tumor Response in HCC Patients That Underwent DEB-TACE

CardioVascular and Interventional Radiology - To evaluate incidence and predictive factors for the vascular lake phenomenon (VLP), as well as to compare local and overall tumor response in patients...     

Acute Toxicity of Adjuvant Radiotherapy in Locally Advanced Differentiated Thyroid Carcinoma

BACKGROUND AND PURPOSE: The indication for adjuvant postoperative radiotherapy in patients with differentiated thyroid carcinoma (DTC) extending beyond the thyroid capsule has been an issue of controversy during the past 2 decades. No randomized studies evaluating the benefit of radiotherapy have been published so far. In the Multicenter Study Differentiated Thyroid Carcinoma (MSDS), a randomization has been performed concerning external-beam radiotherapy in patients with DTC extending beyond the thyroid capsule (pT4 pN0/1/x cM0, TNM classification, 5th edition, 1997) following surgery and radioiodine therapy. Radiation-associated toxicity has been prospectively evaluated. PATIENTS AND METHODS: Radiotherapy was performed with 50.4 Gy (pN0) or 54.0 Gy (pN1/x) to the cervical, supraclavicular and upper mediastinal lymph nodes. A total dose of 59.4 Gy (R0 resection) or 66.6 Gy (R1) was used to treat the tumor bed. Conventional fractionation was used with 1.8 Gy/d. At the time of the analysis, 36 patients were randomized or allocated to treatment arm A (with external-beam radiotherapy). Of these, 22 were treated with radiotherapy, and documentation of acute toxicity was available. Toxicity was evaluated prospectively according to the RTOG/EORTC criteria. RESULTS: The maximal acute toxicity observed during radiotherapy was grade I in four patients, grade II in 16 patients, and grade III in two patients (9.1%; 95% confidence interval [95% CI] 1.1-29.2%). Toxicity was mainly observed at the pharynx, larynx, and skin. In 19 patients, residual toxicity within 100 days following radiotherapy was evaluated. No residual toxicity was observed in two patients. Maximal residual toxicity was grade I in 13 patients and grade II in four. No further grade III toxicity could be observed. CONCLUSION: The majority of patients experience mild to moderate side effects from adjuvant external-beam radiotherapy. At the first follow-up examination, most side effects have subsided. Acute toxicity is tolerable in these patients.     

肺癌穿刺标本表皮生长因子受体基因突变检测的临床价值

目的 评价肺癌穿刺针吸活检标本表皮生长因子受体(EGFR)基因突变检测的临床应用价值.方法 对46例ⅢB～Ⅳ期肺癌患者行CT引导肺部病灶针吸活检术,应用PCR直接测序法检测穿刺标本EGFR外显子19及21突变.结果 (1)46例中腺癌40例、鳞癌3例、小细胞癌1例、未分化癌2例.(2)46例中EGFR突变24例;40例腺癌中23例发生突变,3例鳞癌中1例突变;30例女性中有20例突变,16例男性中有4例突变.(3)13例EGFR突变病例接受表皮细胞生长因子受体酪氨酸激酶抑制剂(EGFR-TKI)治疗6周后首次评估均为部分缓解(PR).肿瘤进展时间(TTP)最短12周,最长102周.结论 CT导向肺癌针吸活检标本能有效检测EGFR突变,可为进展期肺癌应用EGFR-TKI靶向药物治疗筛选优势人群.     

DWI对局部进展期乳腺癌新辅助化疗疗效评价的初步研究

目的:探讨磁共振扩散加权成像(DWI)对局部进展期乳腺癌新辅助化疗疗效评价以及作为预测因子的可行性.方法:根据10例乳腺癌化疗后退缩情况将肿瘤分成缓解和进展两组,比较两组化疗前后ADC值和DWI信号强度的变化,并评价治疗前ADC值与化疗结束肿瘤退缩变化的相关性.结果:无论是治疗前还是治疗后,ADC值和DWI信号强度在缓解组和进展组间差异均无显著性意义(P＞0.05),但缓解组治疗后ADC值升高,而进展组则降低,尤其在b=1000和2000 s/mm2时明显.b=1000 s/mm2时,肿瘤高活性区和低活性区对治疗反应比较显示,肿瘤高活性区ADC值较低,治疗后ADC值升高(1.195±0.230和1.371±0.295);而肿瘤低活性区ADC值较高,治疗后ADC值反而下降(1.632±0.241和1.312±0.297);与病理对照显示,治疗后肿瘤细胞蜕变,并伴有明显的胶元和纤维化形成.治疗前ADC值与治疗后肿瘤退缩呈负相关,当b取1000和2000 s/mm2时相关更明显,前者为r= -0.802,P=0.005,后者的r = -0.745,P=0.013.结论:DWI可以对局部进展期乳腺癌新辅助化疗疗效作评价,并能对治疗疗效作出预测.     

进展期胃癌手术可根治性的CT估价

目的探讨CT评估进展期胃癌手术可根治性的价值。方法对158例进展期胃癌病例术前行CT平扫或增强扫描,用盲法根据CT表现分为宜手术治疗和不宜手术治疗2组,并与手术结果进行对照、分析。结果宜手术治疗组102例,有97例成功实行根治术,CT准确率为95.1%;不宜手术治疗组56例,仅6例成功实行根治术,50例行非根治术,CT准确率89.3%,两者差异有显著统计学意义(P<0.01)。结论术前行常规CT检查对进展期胃癌治疗方案的制订有着极其重要的指导作用。     

胃左动脉化疗灌注治疗晚期贲门癌

目的：探讨用导管经胃左动脉灌注化疗药物治疗晚期贲门癌的疗效。材料与方法：对３３例晚期贲门癌患者作了经皮胃左动脉插管灌注化疗药物。结果：多数患者的临床症状如吞咽困难、上腹不适等得到缓解，其中１年生存率为４２．４％（１４／３３），半年生存率为６９．７％（２３／３３）。本组３例灌注后出现消化道出血严重并发症。结论：经胃左永主化疗药对治疗晚期贲门癌有一定价值。     

MRI对局部进展期乳腺癌新辅助化疗早期疗效评价

目的 采用磁共振扩散加权成像(DWI)表观扩散系数(ADC)评价局部进展期乳腺癌(LABC)新辅助化疗(NCT)的早期疗效.资料与方法 32例LABC患者采用多西紫杉醇联合表柔比星(75mg/m2静脉推注,第1天给药,3周方案)进行NCT治疗.每21d为1个周期,至肿瘤缩小到可手术或保乳手术可行时停止化疗.于化疗前、化疗1个周期后和手术前行DWI扫描,分析肿瘤体积、ADC值变化及其相关性.结果 20例(62.5％,95％ CI 45.7％～79.3％)患者行2个周期化疗后出现整体有效(OR),临床完全缓解(cCR)率及病理完全缓解(pCR)率分别为156％ (5/32)和9.4％ (3/32):疾病稳定(cSD)率为34.4％ (11/32),疾病进展(cPD)率为3.1％ (1/32);第1个NCT后,cCR+部分缓解(cPR)组AD)C值显著增加[化疗前ADC值为(0.98±0.16)×103mm2/s,化疗后为( 1.22±026)×103mm2/s] (P＜ 0.001).化疗前cCR+cPR组初始ADC值显著低于cSD+cPD组[(1.13±0.06)×10-3mm2/s](P＜0.001).初始ADC值与化疗后肿瘤体积变化呈负相关(r=-0.58,P=0.02);化疗后肿瘤ADC值与肿瘤体积变化呈正相关(r=096,P＜0.001).结论 乳腺癌病灶初始ADC值及NCT后早期ADC值变化可以作为预测乳腺癌对NCT敏感性和化疗早期评价乳腺癌敏感性的指标.     

CT-Based Evaluation of Tumor Volume After Intra-Arterial Chemotherapy of Locally Advanced Carcinoma of the Oral Cavity: Comparison with Clinical Remission Rates

Purpose To assess the volume of locally advanced tumors of the oral cavity and the oropharynx before and after intra-arterial (i.a.) chemotherapy by means of computed tomography and to compare these data with clinically determined treatment response of the same patient population. Methods Eighty-eight patients with histologically proven, advanced carcinoma of the oral cavity and/or the oropharynx (local tumor stages T3/4) received neoadjuvant i.a. chemotherapy with cisplatin as part of a multimodal therapeutic regimen, comprising (1) local chemotherapy, (2) surgery, and (3) combined radio-chemotherapy. Three weeks after the intervention, residual disease was evaluated radiologically by measurement of the tumor volume and clinically by inspection and palpation of the primary tumor according to WHO criteria. Results Comparison of treatment response according to radiological and clinical criteria respectively revealed complete remission in 5% vs. 8% (p < 0.05), partial remission in 30% vs. 31%, stable disease in 61% vs. 58%, and tumor progression in 5% vs. 2%. Conclusion Radiological volumetry and clinical evaluation found comparable response rates after local chemotherapy. However, in patients with good response after local treatment, volumetric measurement with CT may help to distinguish between partial and complete remission. Thus, radiological tumor volumetry provides precise and differentiated information about tumor response and should be used as an additional tool in treatment monitoring after local chemotherapy.     

氢质子磁共振波谱监测乳腺癌新辅助化疗疗效的应用研究

目的:探讨乳腺癌氰质子磁共振波谱(~1H-MRS)的谱线特征及早期临测乳腺癌新辅助化疗疗效的价值.方法:前瞻性研究一组98例在术前进行新辅助化疗的乳腺癌患者(99个病灶,98个浸润性导管癌,1个黏液腺癌),比较按疗程随访的~1H-MRS结果(化疗前,一疗程后),观察分析胆碱共振峰的峰高、峰下面积及胆碱信噪比,以评估新辅助化疗疗效.所有病例均经手术病理证实.结果:①~1H-MRS可用于乳腺癌监测(成功率83.8%),乳腺癌可出现明显的胆碱复合峰,敏感度75.9%(63/83).②48个成功随访病灶中,8个治疗无效,40个有效;③比较治疗有效、无效组Cho峰高、峰下面积及信噪比,P<0.05,差异有统计学意义.④治疗有效组一疗程后Cho峰高、峰下面积及信噪比的变化有显著统计学意义,P<0.001,肿瘤Cho峰有下降趋势或部分消失;无效组Cho峰变化无统计学意义(P>0.05).结论:~1H-MRS可用于乳腺癌的诊断,并可在乳腺癌新辅助化疗早期通过Cho的变化,评价、预测新辅助化疗疗效,提供早期判断疗效的有价值信息.