肝细胞肝癌肾上腺转移的放射治疗

目的探讨肝癌肾上腺转移的放射治疗效果.方法回顾性总结本院22例肝癌肾上腺转移病人,用6MX或15MV光子,进行肾上腺病灶外照射,剂量36～54Gy,中位剂量50Gy.结果14例肾上腺转移病人出现疼痛症状,外放疗后11例(78.6%)疼痛得到完全缓解;2例(14.3%)得到明显缓解,但仍需要止痛药治疗;73%(15/22)病例的肿瘤明显缩小;全部病例中位生存期为10个月;未出现因肾上腺转移灶致死病例;副作用轻微.结论肝细胞肝癌肾上腺转移对放射治疗敏感,50Gy的放疗剂量是比较安全的姑息性治疗.     

Focal 3D conformal high-dose hypofractionated radiotherapy for brain metastases

The optimal management of patients with few brain metastases is complex. On one hand, stereotactic radiation therapy is a keystone of treatment but is only applicable to highly selected patients fulfilling specific criteria who have access to an adequate radiation unit. On the other, whole-brain radiation therapy may improve survival, but deleterious effects on neurocognitive functions are well known. It has, however, been reported that selected subgroups of patients may benefit from focal dose escalation to brain metastases to prolong survival and the time to intracranial disease progression. Here, we discuss a clinical case to consider the interest of a focal high-dose hypofractionated radiation delivered through a conventional linear accelerator on a large brain metastasis for a patient with metastatic melanoma excluded for stereotactic radiotherapy.     

Role of stereotactic radiosurgery in the treatment of brain metastases

Stereotactic radiosurgery (SRS) is a highly conformal form of radiation therapy designed to deliver a high dose in a single treatment to the target volume while sparing adjacent normal tissues. Its role in the treatment of brain metastases continues to be defined, but the recently reported RTOG 95-08 trial demonstrated a survival benefit with the addition of SRS to whole-brain radiation therapy in select patients with a single brain metastasis, as well as a local control and palliative benefit in select patients with 1 to 3 brain metastases. The authors review the role of SRS in the treatment of brain metastases and discuss the use of SRS with or without whole-brain radiation therapy, optimal dose of SRS, SRS delivery methods, and selection of appropriate patients for SRS.     

Radiation therapy for adrenal gland metastases from hepatocellular carcinoma

BACKGROUND: The adrenal gland is a common site of extrahepatic metastases from hepatocellular carcinoma. However, it has been the subject of few studies, and the optimal treatment remains unclear. Methods previously tried for the management of adrenal gland metastasis of hepatocellular carcinoma included surgical resection, transarterial chemoembolization or percutaneous ethanol injection, on the basis of case reports. External beam radiation therapy has seldom been applied for patients with adrenal gland metastases. METHODS: We retrospectively studied 22 patients with adrenal metastases from hepatocellular carcinoma who were treated with limited-field external beam radiation therapy. The radiation dose to the adrenal lesion ranged from 36 to 54 (median 50) Gy, while the intrahepatic lesions were treated with either surgical resection or transarterial chemoembolization. RESULTS: Among the 14 patients who had pain related to adrenal metastases, 11 (78.6%) had complete pain relief without medication that lasted until death. Two (14.3%) patients had marked pain relief, but still required analgesics. Partial responses were observed in 73% of the patients. The median survival period for all patients was 10 months. No patient died from complications related to adrenal metastasis. Adverse effects were mild. CONCLUSION: Adrenal metastases from hepatocellular carcinoma are sensitive to radiation treatment. Radiation therapy with 50 Gy for adrenal gland metastases is a good palliative therapy with reasonable safety.     

The palliative efficacy of a single high dose of radiation in treatment of symptomatic osseous metastases

Radiation therapy is effective for palliation of painful metastatic osseous lesions. Various fractionation doses have been previously described. The present study was initiated to evaluate the efficacy of a high single dose of radiation on pain relief, with the goal of reducing the number of radiation sessions to a minimum. Treatment consisted of a high single dose of radiation ranging between 6 to 10 Gy administered to painful osseous metastases. Prior to radiation therapy response to conservative analgesic therapy was minimal in most cases. Response to radiation therapy thereafter was 71.3% lasting up to 6 and 12 months in 37.3% and 20.9% of cases respectively.     

Management and results of localized Ewing's sarcoma.

Seventy-six patients with localized Ewing's sarcoma who received primary treatment at M.D. Anderson Hospital from 1948 through December 1975 were reviewed. Patients have been divided into four groups according to the different treatment regimens they received: Group I, moderate dose radiotherapy alone; Group II, high dose radiotherapy alone; Group III, radiotherapy plus vincristine and cytoxan; and Group IV, radiotherapy plus vincristine, Adriamycin, cytoxan and actinomycin. The problem of local recurrence appears to be solved with combined chemotherapy and radiation therapy with only one of 36 patients having a recurrence at the primary site in Groups III and IV. Multimodal therapy is the preferred treatment to obtain control of the primary lesion by radiation therapy while preserving good function. However, the major cause of failure remains distant metastases, 19 of 36 (53%) in Groups III and IV. In addition, 4 of 10 patients who have survived over 5 years have developed osteogenic sarcoma.     

Hepatic irradiation in the management of metastatic hormone-secreting tumors

Three patients with extensive liver metastases from hormone-secreting tumors were treated with external beam radiation therapy to palliate signs and symptoms of tumor mass and/or hormone secretion. These patients experienced an objective response of 3, 14, and 24 months duration, respectively, as measured by plasma hormone levels and/or computed tomography (CT) scanning. Using conventional fractionation, a dose of 2400 to 3000 rad was delivered without significant acute or late toxicity. Although these tumors have a long natural history (many years), even after the development of liver metastases, radiation therapy can provide effective palliation and should be considered as a therapeutic option.     

Radiation therapy in bone metastases from lung cancer

The record of 73 patients with 153 sites of bone metastases from a lung cancer treated by radiation have been reviewed to evaluate the effectiveness of pain relief. Radiation therapy for bone metastases was found to be very effective. Sufficient symptomatic improvement was achieved in 94% of all patients, while 63% obtained almost complete pain relief that was sustained until death. Onset of a symptomatic response to radiotherapy was within less than 20 Gy in total dose in more than 80% of all patients. There were no significant differences in the frequency of pain relief among the various histological types of primary lung tumors.     

脑转移瘤伽玛刀配合全脑放疗的临床研究

目的探讨脑转移瘤伽玛刀治疗配合全脑放疗的疗效。方法自2002年3月至2006年3月收治脑转移瘤患者79例。原发灶控制稳定,脑转移患者中,44例采用伽玛刀配合全脑放疗,35例单纯给予伽玛刀治疗。伽玛刀治疗处方等剂量线采用45%～75%等剂量包绕计划靶区,边缘剂量15～20 Gy,中心30～45 Gy;全脑放疗每次分割剂量为2～3 Gy,1次/d,每周照射5次,总剂量25～30 Gy。结果伽玛刀治疗开始后3个月,复查MRI,影像学结果显示总的有效率为83.5%（66/79）。伽玛刀配合全脑放疗组的1年生存率为29.5%,2年生存率9.1%;单纯伽玛刀组患者的1年生存率为17.1%,2年生存率2.9%。随访期内未见严重放射性并发症。结论对脑转移瘤采用伽玛刀配合全脑放疗是较有效的局部治疗方式,副反应轻,均能耐受治疗。     

Palliative radiation therapy for brain metastases from endometrial carcinoma: report of two cases

Although endometrial carcinoma is a common invasive neoplasm of the female genital tract, brain metastases are extremely rare and few reports exist of their treatment with radiation therapy. We report two patients with manifest clinical signs of brain metastases from endometrial carcinoma on computed tomography (CT) or magnetic resonance imaging (MRI). These two patients had multiple brain metastases, with widespread dissemination late in the course of the disease and received palliative whole-brain radiation therapy to a total dose of 50 Gy in 25 fractions (case 1) and 30 Gy in 10 fractions (case 2). After radiation therapy, improvement of neurological function (NF) was observed in both patients. The duration of improvement of NF was 9 weeks in case 1 and 12 weeks in case 2. The patients died 5 months and 3 months after the diagnosis of brain metastases, respectively. In these two cases, palliative radiation therapy was effective in improving the quality of the remaining lifetime and appears to be the best treatment for brain metastases from endometrial carcinoma as well as those frequently seen from other primaries.     

LINAC Radiosurgery as Single Treatment in Cerebral Metastases

Summary Objective: Stereotactic radiosurgery is a radiation technique of high radiation dose focused on a stereotactic intracranial target in a single fraction with high precision. LINAC Radiosurgery has gained increasing relevance in the treatment of brain metastases since it was introduced by Sturm (1987). Method and patient selection: From January 1996 to August 2003 110 patients were treated with LINAC Radiosurgery. A combination of the University of Florida system and the X Knife System developed by Radionics was used in all patients. Seventy patients had a single and 40 patients multiple metastatic lesions at the time of diagnosis and treatment. Overall 161 intracerebral metastases were treated. Median tumor volume was 3.1 ccm (0.3–15 ccm). Median radiation dose to the tumor margin was 1830 cGy (range 1100–2200 cGy) prescribed to the 80% isodose line. Whole brain radiation therapy with a total dose of 30 Gy in 10 fractions was performed in 35 patients because of multiple metastases and LINAC Radiosurgery was used as boost for recurrences. In 75 patients LINAC Radiosurgery was used as single treatment. Results: The follow-up period was between 6 and 72 months. Local tumor control rate was 89.4%. Seventeen out of 161 metastases treated showed local recurrence. Eleven out of 75 patients treated with radiosurgery as single treatment developed distant recurrence and 3 out of 35 patients who were treated with whole brain radiation therapy (WBRT) and radiosurgery as boost. The 1-year survival rate is 54.9% with a median survival of 54 weeks. Conclusion: LINAC Radiosurgery is an effective and safe treatment modality in patients with cerebral metastases located in any area of the brain. WBRT should be preserved for patients with multiple metastases or be delayed until multiple recurrence occurs. Surgery is still the treatment of choice in metastases with mass effect and surgical accessible location.     

Targeted and systemic radiotherapy in the treatment of bone metastasis

Cancer metastasis to the bone develops commonly in patients with a variety of malignancies, and is a major cause of morbidity and diminished quality of life in a significant proportion of cancer patients. The effective treatment of bone metastasis requires cooperation between medical, surgical and radiation oncologists. Radiotherapy, either in the form of targeted external beam radiation therapy, or systemic administration of radionuclides, plays a central role in treatment of symptomatic bone metastases. The appropriate external beam treatment techniques, dose and fractionation regimens for the treatment of symptomatic, localized bone metastasis have been established in prospective clinical trials. Large-field, hemi-body irradiation has been utilized for treatment of symptoms related to more widely disseminated bone metastases, but has been associated with substantial toxicity. Strontium-89 and Samarium-153 are widely available systemically administered radionuclides that are useful for the treatment of widely disseminated disease, and have largely supplanted the use of hemi-body irradiation. Combined with appropriate medical and surgical interventions, as well as the appropriate use of analgesics, radiotherapy is a well-tolerated and highly effective treatment for the palliation of symptomatic bone metastases.     

Recurrences of rectal cancers: results of a multimodal approach with intraoperative radiation therapy. French Group of IORT. Intraoperative Radiation Therapy

PURPOSE: Prognosis of recurrent rectal cancer remains poor, mainly because of the difficulties of achieving a satisfactory local control. Intraoperative radiation therapy (IORT) allows for the delivery of a complementary single dose to the tumor residues or to the tumor bed and could be useful jn a multimodal treatment. In an attempt to evaluate this interest, a retrospective analysis of patients treated with IORT in six French hospitals has been performed. METHODS AND MATERIALS: Data have been collected in 73 patients (41 men), with a mean age of 62 years, treated with IORT. Initial rectal tumors were large (mean diameter: 45 mm), partially or totally fixed to the contiguous structures in 39%, and with nodal involvement in 50% of the cases. Initial surgery had been a sphincter-sparing surgery in 67%; external radiation therapy had been delivered in 52%, and a chemotherapy had been given in 10% of the patients. Recurrences were isolated (without metastases) in 86%, and were posterior or posterolateral in 55% of the cases. Surgery allowed for a complete macroscopical resection in 57%, a partial resection with gross residual disease in 29%, and no resection in 14% of the recurrences. Intraoperative radiation therapy was delivered in a dose of 10 to 25 Gy (mean 18.5) through localizators of a mean diameter of 75 mm (60 to 110). External radiation therapy, either preoperative or postoperatively was given to 30 patients without prior radiation therapy. Ten patients received additional chemotherapy with 5-fluorouracil. RESULTS: Four postoperative deaths occurred. Postoperative morbidity occurred in 16 patients and some complications were probably related to the IORT procedure. Four long-term complications were observed. Overall actuarial survival occurred in 72.4% of the patients at 1 year, in 44.6% at 2 years, and in 30.6% at 3 years. Twenty-one local failures have been observed. Actuarial local control occurred in 71.3% of the patients at 1 year, 47.7% at 2 years, and 31.3% at 3 years. CONCLUSION: Intraoperative radiation therapy is a complementary treatment for recurrences of rectal cancer. It provides encouraging results, particularly in some selected situations, when patients have not previously been treated with external radiation therapy. Further studies of multimodal treatments are necessary.     

Focal radiation therapy of brain metastases after complete surgical resection

Brain metastases are a frequent occurrence in cancer patients and result in significant morbidity and mortality. The three main treatments for brain metastases include surgery, radiation, and/or chemotherapy, alone or in combination. After resection alone, local recurrence rates are high. Whole brain radiation therapy can decrease the probability of recurrence; however, this has some disadvantages. Focal radiation therapy (FRT) may provide many of the same benefits without some of these disadvantages. In this study, we retrospectively analyzed patients with single brain metastases treated with FRT after surgery. Doses ranged from 14 Gy as single dose stereotactic radiosurgery (SRS) to 54 Gy in 27 2-Gy fractions as conformal fractionated radiotherapy. Four of the seven patients had a same-site recurrence, with an average time to recurrence of 115.5 d. Median dose in the patients that had same-site recurrence was 42 Gy. One of these patients is currently living. Two patients did not have recurrence, and one patient had a recurrence at a different site within the brain. The low rate of out-of-field recurrences during the patients life indicates focal radiation may be a reasonable therapeutic alternative. Given the number of patients with same-site recurrences, wide field margins around the tumor volume or higher radiation doses than those typically used in palliative regimens may be useful in post-excisional FRT. Additionally, we found that a longer delay in the initiation of FRT after initial diagnosis may result in a decreased time to same-site recurrence. However, further studies are warranted given the small number of patients in this study.     

Limited‐Stage Small Cell Lung Cancer: Current Chemoradiotherapy Treatment Paradigms

In the U.S., the prevalence of small cell lung cancer (SCLC) is declining, probably reflecting the decreasing prevalence of tobacco use. However, a significant number of patients will receive a diagnosis of SCLC, and approximately 40% of patients with SCLC will have limited‐stage (LS) disease, which is potentially curable with the combination of chemotherapy and radiation therapy. The standard therapy for LS‐SCLC is concurrent chemoradiotherapy, and the 5‐year survival rate observed in clinical trials is approximately 25%. The standard chemotherapy remains cisplatin and etoposide, but carboplatin is frequently used in patients who cannot tolerate or have a contraindication to cisplatin. Substantial improvements in survival have been made through improvements in radiation therapy. Concurrent chemoradiotherapy is the preferred therapy for patients who are appropriate candidates. The optimal timing of concurrent chemoradiotherapy is during the first or second cycle, based on data from meta‐analyses. The optimal radiation schedule and dose remain topics of debate, but 1.5 Gy twice daily to a total of 45 Gy and 1.8–2.0 Gy daily to a total dose of 60–70 Gy are commonly used treatments. For patients who obtain a near complete or complete response, prophylactic cranial radiation reduces the incidence of brain metastases and improves overall survival. The ongoing Radiation Therapy Oncology Group and Cancer and Leukemia Group B and the European and Canadian phase III trials will investigate different radiation treatment paradigms for patients with LS‐SCLC, and completion of these trials is critical.     

Radiation therapy in brain metastases

From 1980 to 1985, 126 patients with a brain metastases from various malignant tumors were treated by hypervoltage irradiation with conventional fractionation at the Department of Radiotherapy at the Cancer Institute Hospital. The patients without an extracranial metastases or without neurological symptoms had a longer survival than did the other patients. Radiotherapy of more than 30 Gy improved the neurological functions and reduced the risk of death from the brain metastases. For long-term local control of brain metastases, whole brain irradiation with boost therapy for localized lesions may be a better treatment than other radiation methods and the total radiation dose required may be more than 50 Gy.     

Hirnmetastasen

Surgical resection is one of the main keystones in the available treatment options for brain metastases. Today, surgery for brain tumors has acquired a high level of safety because of continuing updates in surgical technology and imaging. With respect to survival of patients with singular metastases, it has been demonstrated in prospective randomized treatment trials that surgical removal followed by whole-brain radiation therapy has a significant advantage over radiation therapy alone. Multiple metastases (a maximum of four) can also be surgically resected. Postoperative whole-brain radiation should follow. Factors such as age, clinical condition, extracranial metastases, and others play a role in treatment outcome. In cases of relapse, repeat surgery can be of value and should be considered. In cases of metastases of the brainstem and basal ganglia, histological evidence should be sought by means of stereotactic biopsy. Supportive treatment comprises the reduction of elevated brain pressure by the use of corticosteroids and anti-epileptic therapy. Alternative and complementary treatment modalities (surgery, radiosurgery, radiation, and chemotherapy) have improved overall survival rates of patients with cerebral metastases.     

The role of radiotherapy in the treatment of liver metastases

Radiotherapy has historically played a minor role in the treatment of patients with unresectable liver metastases from colorectal cancer and other malignancies. This can be attributed chiefly to the low tolerance of the whole liver to radiation. High-precision radiotherapy planning techniques have allowed much higher doses of radiation to be delivered safely to focal liver metastases, while sparing most of the normal liver. When combined with hepatic arterial fluorodeoxyuridine, high-dose focal liver radiotherapy is associated with excellent response rates, local control, and survival in patients with unresectable liver metastases from colorectal cancer. Radiotherapy, with and without concurrent systemic chemotherapy, has also been used with encouraging outcomes for patients with liver metastases from colorectal cancer and other cancers. There appears to be a radiation dose response for liver metastases; tumors treated with doses of 70 Gy or greater are likelier to have durable local control. Advancements in tumor imaging, in radiotherapy techniques that will allow the safe delivery of higher doses of radiation, and in novel tumor radiation sensitizers and normal tissue radioprotectors should substantially improve the outcome of patients with unresectable liver metastases treated with radiotherapy.     

Hyperthermia and radiation therapy in the treatment of recurrent Merkel cell tumors

A high incidence of local recurrence, spread to regional lymph nodes, and distant metastases has been reported after surgical excision of Merkel cell tumors (MCT). The use of postoperative radiation therapy and/or chemotherapy is reviewed from the literature. Despite adjuvant treatment, local tumor recurrences frequently develop. Two patients are presented with metastatic MCT recurrent in previously irradiated sites who had excellent clinical responses and local control following retreatment with local hyperthermia in conjunction with low to moderate dose radiation therapy. These patients represent the first reported use of hyperthermia in the management of MCT. The encouraging local responses described suggest a potential role for the use of hyperthermia and concomitant radiation therapy in the treatment of recurrent MCT.     

Vemurafenib and radiation therapy in melanoma brain metastases

Brain metastases in malignant melanoma carries a poor prognosis with minimal response to any therapy. The purpose of this pilot analysis was to find the effectiveness of vemurafenib, an oral BRAF inhibitor, and radiation therapy in V600 mutated melanoma with brain metastases. BRAF mutation status of the melanoma patients was determined by real-time PCR assay. Retrospective analysis was performed on twelve patients who had the mutation and were treated with either stereotactic radiosurgery or whole brain radiation therapy prior to or along with vemurafenib at a dose of 960 mg orally twice a day. Clinical and radiological responses, development of new brain metastases, overall survival and toxicity were assessed. Improvement in neurological symptoms was seen in 7/11 (64 %) following therapy. Radiographic responses were noted in 36/48 (75 %) of index lesions with 23 (48 %) complete responses and 13 (27 %) partial responses. Six month local control, freedom from new brain metastases and overall survival were 75, 57 and 92 %. Four patients had intra-tumoral bleed prior to therapy and two patients developed steroid dependence. One patient experienced radiation necrosis. This retrospective study suggests that melanoma patients with brain metastases harboring BRAF mutation appear to be a distinct sub-group with a favorable response to vemurafenib and radiation therapy and acceptable morbidity.