Moist Skin Care Can Diminish Acute Radiation-Induced Skin Toxicity

BACKGROUND: Radiation treatment may induce acute skin reactions. There are several methods of managing them. Validity of these methods, however, is not sufficiently studied. We therefore investigated, whether moist skin care with 3% urea lotion will reduce acute radiation skin toxicity. PATIENTS AND METHODS: 88 patients with carcinomas of the head and neck undergoing radiotherapy with curative intent (mean total dose 60 Gy, range: 50-74 Gy) were evaluated weekly for acute skin reactions according to the RTOG-CTC score. In 63 patients, moist skin care with 3% urea lotion was performed. The control group consisted of 25 patients receiving conventional dry skin care. The incidence of grade I, II, and III reactions and the radiation dose at occurrence of a particular reaction were determined and statistically analyzed using the log-rank test. The dose-time relations of individual skin reactions are described. RESULTS: At some point of time during radiotherapy, all patients suffered from acute skin reactions grade I, > 90% from grade II reactions. 50% of patients receiving moist skin care experienced grade I reactions at 26 Gy as compared to 22 Gy in control patients (p = 0.03). Grade II reactions occurred at 51 Gy versus 34 Gy (p = 0.006). Further, 22% of the patients treated with moist skin care suffered from acute skin toxicity grade III as compared to 56% of the controls (p = 0.0007). CONCLUSION: Moist skin care with 3% urea lotion delays the occurrence and reduces the grade of acute skin reactions in percutaneously irradiated patients with head and neck tumors.     

Hyperfractionated Radiotherapy in Locally Advanced Nasopharyngeal Cancer

BACKGROUND: Despite numerous randomized trials suggesting a benefit of unconventional fractionation in locally advanced head and neck cancer, the role of this approach in nasopharyngeal carcinoma is debatable. Based on the current clinical experience, the authors introduced hyperfractionated irradiation in the treatment of locally advanced head and neck cancer, including nasopharyngeal tumors. The preliminary results of this treatment approach in nasopharyngeal cancer patients are presented, with special focus on the pattern of failure and toxicity. PATIENTS AND METHODS: 43 patients with nasopharyngeal cancer (stage II-IV, TNM 1997) underwent hyperfractionated irradiation. In 34 cases, radiotherapy was preceded by a median of three cycles of cisplatin-based induction chemotherapy. Irradiation was delivered using a shrinking-field technique up to a total dose of 74.4 Gy in 62 fractions of 1.2 Gy twice daily (minimum 6-h interval)/5 days/week. RESULTS: Acute toxicity of hyperfractionated radiotherapy was significant but tolerable. Mucositis proved the most common side effect (grade 3: 24 patients, grade 4: three patients). Severe late toxicity was not observed. 30 of 34 patients (88%) responded to induction chemotherapy. At 6 weeks after completion of radiotherapy, complete response was seen in 35 patients (81%), partial response in five (12%), stable disease in one, and progressive disease in two. After a median follow-up of 32 months, 18 patients (41%) developed progressive disease. Primary tumor progression was observed in three patients, and seven patients each showed regional lymph node progression and distant metastases. In one case both regional lymph node progression and distant metastases were diagnosed. The 2-year progression-free survival and overall survival rates were 58% and 84%, respectively. CONCLUSION: Hyperfractionated radiotherapy seems a feasible and active regimen in locally advanced nasopharyngeal carcinoma. Accompanying acute and late toxicity is acceptable and does not compromise delivery of the planned irradiation dose. This regimen is associated with a high local control rate; relatively high nodal and distant failure, however, call for further treatment modifications, e. g., optimization of irradiation technique and/or dose escalation as well as improved systemic therapies.     

鼻咽癌放疗后继发性皮肤晚期放射损伤

目的 通过分析皮肤早期放射反应对皮肤晚期放射反应的影响,探讨皮肤的继发性晚期放射损伤。方法 对门诊随访的放疗后生存5年以上的335例鼻咽癌患者进行调查研究,其中放疗时中位年龄41岁(12～67岁),240例伴颈部淋巴结转移。鼻咽原发灶首程放疗中位剂量为70Gy(55～86Gy),以面颈野为主野放疗71例,以耳前野为主野放疗264例。颈部根治性放疗中位剂量为64Gy(46～72Gy),预防照射中位剂量为55Gy(21～67Gy)。48例合并化疗。根据1995年SOMA标准评价皮肤晚期放射反应。结果 随访间隔中位时间为14年(5～38年)。63例无皮肤晚期反应,1、2、3、4级皮肤晚期反应发生率分别为43.9%(147例)、20.9%(70例)、13.7%(46例)、2.7%(9例)。44例放疗中出现湿性脱皮反应,其中1、2、3、4级皮肤晚期反应发生率分别为41%(18例)、23%(10例)、30%(13例)和5%(2例);无湿性脱皮患者的相应发生率分别为44.3%(129例)、20.6%(60例)、11.3%(33例)和2.4%(7例),两者差异有统计学意义(χ²=17.42,P=0.002)。分层分析结果显示初诊时是否伴颈部淋巴结转移、放疗野及颈部淋巴结放疗剂量均对皮肤晚期反应发生有关,而性别、年龄及是否联合使用化疗与皮肤晚期反应的发生无关。 结论 严重的皮肤早期放射反应可能增加皮肤晚期放射反应,可能存在继发性皮肤晚期放射损伤。     

Recurrent head and neck cancer: retreatment of previously irradiated areas with combined chemotherapy and radiation therapy-results of a prospective study

PURPOSE: To prospectively test the effectiveness of combined chemotherapy and radiation therapy for recurrent head and neck cancer. MATERIALS AND METHODS: In 32 patients, external-beam radiation therapy (2 Gy/d) was administered as a 5-day course with simultaneous hydroxyurea (1.5 g/d orally) and 5-fluorouracil (300 mg/m(2)/d bolus), followed by 9 days of rest. This cycle was repeated until a cumulative soft-tissue radiation dose of 110 Gy (including prior radiation therapy) was reached. RESULTS: At a median follow-up of 18 months, three patients were alive, and 29 had died. The overall 1-year survival rate was 39%. The overall response rate was 41% (13 patients). Acute toxicity was low. According to World Health Organization and Radiation Therapy Oncology Group criteria, there were three cases of grade 3 mucositis or dermatitis and three cases of grade 3 or 4 neutropenia. Three patients had grade 3 late effects: one oral trismus, one jugular venous thrombosis, and one cerebral stroke. CONCLUSION: The combination of simultaneous 5-fluorouracil and hydroxyurea infusion and local reirradiation is feasible for retreatment of recurrent head and neck tumors. This regimen provides short-term tumor control in most patients and long-term control in a few patients.     

Surgery with Complete Resection Improves Survival in Radiooncologically Treated Patients with Cervical Lymph Node Metastases from Cancer of Unknown Primary

PURPOSE: To assess long-term toxicity, outcome and prognostic factors after multimodal treatment of cervical lymph node metastases from cancer of unknown primary (CUP). PATIENTS AND METHODS: In a retrospective study, the treatment results of 84 patients with CUP (median age 63 years, N1 n = 0, N2 n = 44, N3 n = 39, Nx n = 1), treated between 1971 and 2002 with radiotherapy (n = 84, median dose 60 Gy), platinum-based chemotherapy (n = 23) and surgery (n = 69, tonsillectomy [n = 40], neck dissection [n = 52], suprahyoid dissection [n = 18], lymph node excision [n = 14]), were analyzed. RESULTS: After a mean follow-up time of 25 months (ranging from 0.1 to 260 months), the 3- and 5-year overall (disease-free) survival rates were 30% (39%) and 27% (34%), respectively. 75% of individuals achieved remission, whereas 23% showed no change or progression after treatment. The 3-, 5- and 10-year local control rates were 58%, 58% and 46%, respectively. 40% of patients suffered grade 3/4 late toxicity: severe skin contracture/induration (n = 2) and severe xerostomia (n = 32). Tonsillectomy (p = 0.003) and neck dissection (p = 0.037) performed before radiotherapy significantly improved outcome. Other prognostic factors were age (p = 0.0235), extracapsular spread (n = 63; p = 0.0045), incomplete resection (n = 24; p = 0.0026), nodal disease (p = 0.0034), and distant metastases (n = 17; p = 0.0002). After multivariate analysis only extracapsular spread (p = 0.004) and tonsillectomy (p = 0.01) showed impact on survival. CONCLUSION: Irradiation of cervical lymph node metastases from CUP is an effective treatment option with acceptable late toxicity. Complete tonsillectomy and neck dissection significantly improved survival in N2/N3 disease. Extracapsular spread was the best predictor for survival and local control. Prospective studies defining a standard treatment are needed.     

Radiotherapy for Orbital Lymphoma

PURPOSE: To analyze the effectiveness of radiotherapy in the management of orbital non-Hodgkin's lymphoma (NHL). PATIENTS AND METHODS: 42 patients (median age 64.5 years) were reviewed retrospectively. The median follow-up period was 58 months. 26 patients had stage IE orbital lymphoma (22 indolent, four aggressive NHLs). 16 patients had advanced NHLs in stages II-IV with orbital involvement (eleven indolent, five aggressive NHLs). The median radiation dose was 40 Gy (20-46 Gy) for indolent lymphoma and 44 Gy (20-48 Gy) for aggressive lymphoma. Patients with stage IE were treated with at least 30 Gy. RESULTS: The 5-year local control rate for patients with stage I was 100%, the 5-year overall survival 91%. Two distant relapses were found, but no lymphoma-related death was detected. The 5-year local control rate for patients in stages II, III, and IV was 80%. Two local failures were detected. The 5-year overall survival for the advanced stages was 47%, nine patients with stages III and IV died due to systemic progression of lymphoma. Acute, radiotherapy-related complications grade 3/4 were not observed. Late effects grade 1/2 were documented in 45%. Six patients, treated with doses of > 36 Gy, developed grade 3 complications (four cataract, two dryness). CONCLUSION: Radiotherapy alone yields excellent local control and overall survival rates in orbital lymphoma stage IE. Local irradiation is also well tolerated and effective in advanced NHL stages with orbital infiltration. Doses of > 36 Gy resulted in an increase of late complications.     

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.     

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.     

Simultane radiochemotherapie mit carboplatin bei patienten mit inoperablen fortgeschrittenen Kopf-Hals-Tumoren der stadien UICCIII und IV

BACKGROUND: The results of treating advanced tumors in the head and neck region with radiotherapy alone are disappointing. Concurrent radiotherapy and chemotherapy may improve this situation. The treatment results of concurrent radiochemotherapy at the University of Rostock were analyzed retrospectively. PATIENTS AND METHODS: From 1991 to 1996 92 patients with head and neck tumors were treated with concurrent radiochemotherapy (1.8 to 63 Gy; 70 mg/m2 carboplatin day 1 to 5 and 29 to 33) with palliative tumor resection (n = 37) or without surgical treatment (n = 55). Remission rate, overall survival and disease-free survival, local control and acute toxicity were analyzed. RESULTS: Six weeks after radiochemotherapy 56.5% of patients had a complete remission, 36% a partial remission and 7.5% "no change". With a median follow-up of 42 months (6 to 74 months) overall survival, disease-free survival and local control were 24.3%, 28.9%, 18.0% 5 years after treatment. All these criteria were significantly better in patients with palliative tumor resection compared to no surgical treatment (uni- and multivariate) and in patients with Stage III than in patients with Stage IV carcinomas (univariate), overall survival was significantly better in patients with Stage III (multivariate). A pretherapeutic Hb level below 7.0 mmol/l (11.27 g/dl) reduced the local control significantly (uni- and multivariate). Grade III and IV mucositis was detected in 10%, Grade III leucopenia in 12% of treated patients. Grade IV leucopenia and Grade III thrombopenia were observed in 1 patient each. CONCLUSION: The toxicity of this treatment is tolerable. However, additional trials must be conducted before considering the palliative tumor resection as standard therapy.     

Outcome of post-prostatectomy radiotherapy in one institution

We present a retrospective study to evaluate the outcome of postoperative radiotherapy for biochemical or clinical recurrent prostate cancer. Twenty-six patients (median age 60 years) underwent radiotherapy after radical prostatectomy between January 1997 and January 2004. Seven patients received adjuvant radiotherapy and 19 received salvage radiotherapy. The median prostate-specific antigen at diagnosis was 8.6 (0.9-89) and most (23 patients) presented with T(3)N(0) disease. The median follow up was 19.5 months (5-84 months). All patients received a dose of 61.2 Gy at 1.8 Gy per fraction, 20 initially receiving 45 Gy to the lesser pelvis. The median dose to the bladder, rectum and left femoral head were 55.6, 57.5 and 33.8 Gy, respectively. All patients were managed radiotherapeutically by the first author. Twenty-four patients are alive. Two patients have died, one from oesophageal cancer and the second from metastatic prostate cancer. Two other patients also developed metastatic disease. Four asymptomatic patients with a rising prostate-specific antigen are under observation. None of the 26 patients has developed a local recurrence. Seven patients have developed grade 1 late bowel effects and three a grade 2 late effect. Eight patients suffer from grade 1 late genitourinary effects and two from grade 2 effects. One patient developed impotence, whereas 23 patients were rendered impotent postoperatively. There were no grade 3/4 late effects. Postoperative radiotherapy is well tolerated and provides effective local control.     

Hyperfractionated accelerated radiotherapy with concomitant integrated boost of 70–75?Gy in 5?weeks for advanced head and neck cancer

Background and purpose

The present study was performed to evaluate the feasibility of a new, 5-week regimen of 70–75?Gy hyperfractionated accelerated radiotherapy with concomitant integrated boost (HARTCIB) for locally advanced, inoperable head and neck cancer.

Methods and materials

A total of 39?patients with very advanced, stage?IV nonmetastatic head and neck squamous cell carcinoma (median gross tumor volume 72?ml) were included in this phase?I dose escalation study. A total of 50?fractions intensity-modulated radiotherapy (IMRT) were administered twice daily over 5?weeks. Prescribed total dose/dose per fraction for planning target volume (PTV_tumor) were 70?Gy in 1.4?Gy fractions, 72.5?Gy in 1.45?Gy fractions, and 75?Gy in 1.5?Gy fractions for 10, 13, and 16?patients, respectively. Uninvolved lymphatic nodes (PTV_uninvolved) were irradiated with 55?Gy in 1.1?Gy fractions using the concomitant integrated boost.

Results

Acute toxicity was evaluated according to the RTOG/EORTC scale; the incidence of grade?3 mucositis was 51% in the oral cavity/pharynx and 0% in skin and the recovery time was ≤?9?weeks for all patients. Late toxicity was evaluated in patients in complete remission according to the RTOG/EORTC scale. No grade?3/4 late toxicity was observed. The 1-year locoregional progression-free survival was 50% and overall survival was 55%.

Conclusion

HARTCIB (75?Gy in 5?weeks) is feasible for patients deemed unsuitable for chemoradiation. Acute toxicity was lower than predicted from radiobiological models; duration of dysphagia and confluent mucositis were particularly short. Better conformity of radiotherapy allows the use of more intensive altered fractionation schedules compared with older studies. These results suggest that further dose escalation might be possible when highly conformal techniques (e.g., stereotactic radiotherapy) are used.     

Selective Lymph Node Dissection Following Hyperfractionated Accelerated Radio-(Chemo-)Therapy for Advanced Head and Neck Cancer

BACKGROUND: 2-year results of a German multicenter randomized trial showed that accelerated chemoradiation with MMC/5-FU to 70.6 Gy is more effective than accelerated radiation to 77.6 Gy alone at equivalent levels of acute and late radiation morbidity. Frequency, histopathology and impact on local tumor control of selective lymph node dissection were analyzed. PATIENTS AND METHODS: Between February 1996 and October 2000 at Tübingen University 42 randomized patients plus 45 non-randomized patients with stage III/IV MO head and neck cancer were treated according to this protocol. After completion of hyperfractionated accelerated (chemo-)radiation a selective lymph node dissection was performed, if the primary tumor was in complete remission and clinical plus computed tomography proved residual lymph node disease. 17 of 38 patients with residual node metastasis underwent uni- or bilateral selective node dissection, the remaining patients had residual primary tumors, clinical deterioration or refused neck dissection. RESULTS: After a median follow-up of 26 months, the Kaplan-Meier analysis showed a 2-year overall survival of 49%, disease-specific survival of 64% and loco-regional tumor control of 60%, respectively. 3-year loco-regional tumor control in randomized patients was 52% compared to 58% in non-randomized patients (log rank p = 0.23). 2-year loco-regional tumor control in stage cT4cN0 was 76% compared to 57% in cT2-4 cN1-3 tumors. Subgroup analysis of patients with involved nodes revealed a 2-year loco-regional tumor control of 74% after complete remission of primary tumor and neck disease, 53% after complete remission of primary tumor and partial remission of neck disease. In patients with selective lymph node dissection loco-regional tumor control was 62%. Histopathological examination showed viable tumor in eight of 17 patients. CONCLUSIONS: Selective lymph node dissection of residual neck masses after completion of hyperfractionated accelerated radio-(chemo-)therapy is likely to contribute to loco-regional tumor control in advanced head and neck cancer.     

Neck Lymph Node Metastases from an Unknown Primary Tumor

Background and Purpose: Up to 10% of all neck lymph node metastases present without a known primary site. The optimal treatment strategy for these patients is still undefined. The purpose of this retrospective analysis is to assess the outcome in patients with neck metastases from an unknown primary tumor (CUP). Furthermore, prognostic factors and treatment modalities are discussed. Patients and Methods: From 1984 to 2003, 28 patients with squamous cell neck metastases from a CUP were treated at the authors institution. In 17 patients, neck dissection (twelve radical, five modified radical) was performed. In that case, adjuvant radiotherapy was carried out with a mean of 56.7 Gy. In eleven patients, only biopsies were done. These patients received definitive radiotherapy with a mean of 66.8 Gy. In summary, 25 patients received extended radiotherapy including both sides of the neck and potential mucosal primary sites. Additional chemotherapy was administered to five patients. Results: The duration of follow-up was 4.1–189.5 months (median 45.1 months). After this period of time, ten patients (36%) remained alive. 5-year overall survival was 40.1%, neck control rate 72.7%. No subsequent primary could be detected. Extracapsular extension and surgery had significant influence on prognosis. Grade 3 toxicity (mucositis or skin reactions) was seen in three patients; no hematologic toxicity > grade 2 was observed. 19 patients suffered from grade 2 xerostomia. Conclusion: With radical surgery followed by radiotherapy good survival rates in patients with neck metastases from a CUP can be obtained. Whether limited radiotherapy might be equal to extended irradiation and can reduce side effects, must be shown in ongoing clinical trials.     

三维适形放疗结合化疗治疗直肠癌术后复发的临床研究

目的探讨三维适形放射治疗结合化疗治疗直肠癌术后复发的疗效.方法回顾性分析61例直肠癌术后复发患者采取首先给予常规放射治疗44 Gy/22次,再给予三维适形放射治疗加量3 Gy/次,共5～7次,肿瘤总量（DT）59～65 Gy/27～29次结合化疗（5-氟尿嘧啶0.75 g/m^2 ＋CF200 mg,d1～5和d29～33;顺铂40 mg/m^2,d1～3和d29～31）的疗效,生存分析采用Kaplan-Meier法.结果患者1、2、3年肿瘤局部控制率分别为86.9%、67.2%、37.7%;1、2、3年生存率分别为80.3%、62.3%、39.2%,中位生存期24.6个月;1、2、3年无瘤生存率分别为79.7%,52.5%、31.1%.急性放射反应主要是急性放射性肠炎和放射性膀胱炎,多为1～2级.结论三维适形放射治疗结合化疗可提高术后局部复发或转移直肠癌的控制率和生存率,改善其生存质量.     

Re-irradiation of soft-tissue sarcoma.

Re-irradiation for local recurrence of malignancy after radical radiotherapy is of proven benefit at head and neck sites but has seldom been used elsewhere. This paper reports a series of 10 patients re-irradiated with external-beam techniques for local recurrence of soft-tissue sarcoma of the limb and limb girdle following initial limb conserving management with surgery and radiotherapy (dose range 33-60 Gy). Median survival was 14 months following re-treatment. Two cases received treatment with high-energy electrons and the rest with megavoltage photons. Five patients re-treated with radical intent (dose range 40-60 Gy) had a median survival of 36 months and median recurrence-free survival of 16 months. All five patients treated palliatively (dose range 12-50 Gy) have died, although two demonstrated local control until death. Acute reactions were not severe. Radionecrosis was seen in one patient who was re-irradiated twice (total dose 145 Gy) and subsequently required amputation. One other case required amputation for persistent local disease, but in the remaining eight, limb conservation was achieved. Re-irradiation of soft-tissue offers good local control and may avoid amputation.     

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.     

Toxicity and outcome of pelvic IMRT for node-positive prostate cancer

Background and purpose

This study reports on the treatment techniques, toxicity, and outcome of pelvic intensity-modulated radiotherapy (IMRT) for lymph node-positive prostate cancer (LNPPC, T1-4, c/pN1 cM0).

Patients and methods

Pelvic IMRT to 45–50.4?Gy was applied in 39?cases either after previous surgery of involved lymph nodes (n?=?18) or with a radiation boost to suspicious nodes (n?=?21) with doses of 60–70?Gy, usually combined with androgen deprivation (n?=?37). The prostate and seminal vesicles received 70–74?Gy. In cases of previous prostatectomy, prostatic fossa and remnants of seminal vesicles were given 66–70?Gy. Treatment-related acute and late toxicity was graded according to the RTOG criteria.

Results

Acute radiation-related toxicity higher than ?grade?2 occurred in 2?patients (with the need for urinary catheter/subileus related to adhesions after surgery). Late toxicity was mild (grade 1–2) after a median follow-up of 70?months. Over 50% of the patients reported no late morbidity (grade 0). PSA control and cancer-specific survival reached 67% and 97% at over ?5?years.

Conclusion

Pelvic IMRT after the removal of affected nodes or with a radiation boost to clinically positive nodes led to an acceptable late toxicity (no grade 3/4 events), thus justifying further evaluation of this approach in a larger cohort.     

鼻咽癌时间调节化疗诱导加同期调强放疗的疗效分析

目的 探讨顺铂+氟尿嘧啶(PF)方案时间调节化疗诱导加同期调强放疗(IMRT)治疗鼻咽癌的临床疗效。方法 回顾性分析48例初治鼻咽癌患者行PF方案时间调节化疗诱导联合同期放化疗的疗效。将鼻咽和颈部的靶体积划分为鼻咽大体肿瘤体积(GTV_nx)、颈部大体肿瘤体积(GTV_nd)、临床靶体积1(CTV₁)和临床靶体积2(CTV₂)。GTV_nx、GTV_nd、CTV₁、CTV₂处方剂量分别73.92~77.88、69.96、60.06~66.00、50.96~56.00 Gy,采用传统照射分割方式。采用Kaplan-Meier法进行生存分析。RTOG／EORTC标准评价急性反应和晚期损伤。结果 完全缓解(CR)20例,占41.6%,部分缓解(PR)23例,占47.9%,稳定(SD)2例,占4.2%。肿瘤局部控制率为89.6%,1、2、4年的生存率分别是93.8%、79.2%、64.5%。多数患者仅表现为1~2级急性反应和0~1级晚期损伤,未观察到4级急性反应和晚期损伤。剂量体积分布直方图(DVH)分析显示IMRT提高了靶体积照射总剂量和分次剂量,减少了危及器官受照总剂量和分次剂量。结论 PF方案时间调节化疗诱导加同期配合IMRT是鼻咽癌安全的治疗方案。     

化疗并后程加速超分割放疗中晚期食管癌

目的观察同期化疗并后程加速超分割放疗(后超组)和同期化疗并常规分割放疗治疗食管癌(常规组)的疗效和毒性,寻找更有效的局部控制率和降低远处转移率并提高生存率的治疗方法.方法选择病变长度≤12 cm、无远处转移证据的中晚期食管癌分后超组和常规组各40例.两组化疗方案相同.后超组放疗第1～28天,为常规分割放疗,缩野后行加速超分割放疗,总剂量为67 Gy/38次,共42 d.常规组放疗为全程常规分割放疗,总剂量为70 Gy/35次,共49 d.结果近期疗效后超组Ⅰ+Ⅱ级31例占77.5%,Ⅲ+Ⅳ级9例占22.5%,常规组Ⅰ+Ⅱ级22例占55.0%,Ⅲ+Ⅳ级18例占45.0%(P＜0.05).后超组和常规组1,2年局部控制率分别为77.14%、51.86%和55.21%、31.28%(P=0.049);后超组和常规组1,2年生存率分别为72.22%、48.64%和54.09%、27.33%(P=0.041).急性放射性食管炎后超组明显重于常规组,且持续时间长.白细胞下降、胃肠道不良反应及放射性肺炎两组比较,其差异无显著性(P＞0.05).结论(1)同期化疗并后程加速超分割放疗的放射性食管炎虽有所增加,但多数患者能耐受;(2)同期化疗并后程加速超分割放疗较同期化疗并常规分割放射治疗提高了近期疗效、局控率及生存率.     

Irradiation with and without Razoxane in the Treatment of Incompletely Resected or Inoperable Recurrent Rectal Cancer

BACKGROUND AND PURPOSE: In an earlier phase II study, irradiation together with razoxane was shown to improve local control in recurrent rectal cancer. Therefore, the Austrian Society of Radiooncology (OGRO) initiated a randomized controlled trial in 1992 to compare this combined treatment versus radiation therapy alone. PATIENTS AND METHODS: Between 1992 and 1999, 36 patients with localized recurrences of rectal cancer were randomized to receive radiotherapy without (group A) or with razoxane (group B). The prognostic variables of the two groups were similar except for a longer median latency period from initial surgery to local recurrence in group A. High-energy photons with daily fractions between 170 and 200 cGy were used. The median total radiation dose was 60 Gy in each group. The patients in group B received a median razoxane dose of 9.6 g (range, 5-12 g). Main outcome measures were local control, overall survival, and toxicity. RESULTS: The combined treatment with razoxane increased the local control rate compared to radiotherapy alone (39% vs. 8%; p = 0.05). The median survival time was not different between the groups (20 months each). No patient in arm A but four of 18 patients in arm B survived 5 years. Acute toxic effects were of moderate degree in both groups. There were no substantial differences as to late side effects. CONCLUSION: Radiotherapy together with razoxane is superior to radiation treatment alone in recurrent rectal cancer as far as local control is concerned. In some patients, long-term survival was achieved with razoxane and radiotherapy.