Hypofractionated radiotherapy boost for dose escalation as a treatment option for high-grade spinal cord astrocytic tumor

Summary Purpose To retrospectively analyze the outcome of post-operative radiotherapy for spinal cord glioma with the emphasis on the hypofractionated radiotherapy boost for dose escalation as a treatment option for high-grade spinal cord astrocytic tumors. Materials and methods Forty-one patients with spinal cord glioma received post-operative radiotherapy between 1979 and 2003. The median age was 34 years (range, 10–66 years). Median follow-up was 49 months (range, 5–291 months). There were 12 low-grade astrocytic tumors, 11 high-grade astrocytic tumors, 16 low-grade ependymal tumors and 2 high-grade ependymal tumors. Among 11 patients with high-grade astrocytic tumors, 5 with anaplastic astrocytoma and 1 with glioblastoma received hypofractionated radiotherapy boost for dose escalation. The median total dose of the conventional radiotherapy was 45.5 Gy in 19 fractions (range, 30.0–60.0 Gy). The median normalized total dose (using daily dose of 2.0 Gy and an α/‰β ratio of 2.0) of the hypofractionated radiotherapy boost was 131 Gy₂ (range, 85–249). Results The Kaplan–Meier survival rates at 10 years from the date of the first surgery were 64% for the entire group, 47% for the astrocytic tumors and 84% for the ependymal tumors, respectively (P=0.009). Among 11 patients with high-grade astrocytic tumors, the actuarial survival rate at 10 years was 35%. The actuarial survival rates at 10 years were 67% for those who received hypofractionated radiotherapy boost for dose escalation, and 20% for those who did not (P=0.47). Discussion The results for ependymal tumors and low-grade astrocytic tumors were comparable to those reported in the literature. Hypofractionated radiotherapy boost for dose escalation may help to prolong the survival of patients with high-grade astrocytic tumors.     

Dose–response relationship for fractionated irradiation in the treatment of spinal meningeal melanocytomas: a review of the literature

Summary Complete resection (CTR) of meningeal melanocytomas results in better outcome than incomplete resection (ITR). After ITR, outcome is improved by radiotherapy. CTR is less frequent with spinal melanocytomas than with cerebral melanocytomas. This study of 49 spinal melanocytoma patients was performed to define an appropriate radiation dose after ITR. All reported spinal melanocytoma cases were reviewed for extent of surgery, radiotherapy (total dose, dose per fraction), and outcome. CTR was compared to ITR for local control (LC) and overall survival (OS). ITR alone was compared to ITR plus radiotherapy (ITR + RT). In the ITR + RT group, doses of 50–52.2 Gy (1.8–2.0 Gy per fraction) were compared to doses < 50 Gy (30–45 Gy). The 5-year LC was 78% after CTR alone vs. 22% after ITR alone (P < 0.001). Five year OS was 83 and 40% (P = 0.011) respectively. ITR + RT was superior to ITR for LC (59% vs. 22%, P = 0.029) and OS (85% vs. 40%, P = 0.10). In the ITR + RT group, 50–52.2 Gy resulted in better LC than 30–45 Gy (100% vs. 33%; P = 0.042), but not in significantly better OS (100% vs. 77%, P = 0.33). CTR was associated with better significantly outcome than ITR. After ITR, the outcome was significantly improved by radiotherapy, 50–52.2 Gy was significantly superior to 30–45 Gy. To reduce the risk of radiation myelopathy, 50.4 Gy (1.8 Gy per fraction) appears appropriate for most patients. The recurrence rates after CTR would mandate the use of post-operative radiotherapy in all spinal meningeal melanocytoma cases. Our results should be confirmed in a larger series of patients when available.     

The combination of cisplatin and vinorelbine with concurrent thoracic radiation therapy for locally advanced stage IIIA or IIIB non-small-cell lung cancer

Aims: The aims of this study were to assess the efficacy and toxicity of concurrent chemoradiotherapy with divided schedule of cisplatin and vinorelbine in patients with locally advanced non-small-cell lung cancer (NSCLC). Methods: Patients with previously untreated, unresectable, and stage IIIA or IIIB NSCLC were eligible if they had a performance status of 0 or 1, were 75 years or younger, and had adequate organ function. Twenty-six patients (24 men and 2 women; median age, 66 years; age range, 42–75 years) were enrolled. Both cisplatin (40 mg/m²) and vinorelbine (20 mg/m²) were given on days 1 and 8 every 3 weeks. Beginning on day 2 of chemotherapy, thoracic radiotherapy was given for approximately 6 weeks (2 Gy per fraction; total dose, 60 Gy). Results: Five of the 26 patients achieved a complete response, and 16 achieved a partial response for an overall response rate of 80.8% (95% confidence interval, 60.6–93.4%). The median survival time was 23 months (range, 4–43 months). Overall survival rates at 1 and 2 years were 80 and 56%, respectively. Hematologic toxicities included grade 3–4 neutropenia in 84.6% of patients, grade 3–4 thrombocytopenia in 3.8%, and grade 3–4 anemia in 61.5%. Two patients (7.7%) had grade 3 radiation esophagitis that resolved completely without dilation. Grade 3–4 radiation pneumonitis occurred in two patients (7.7%) and was treated with corticosteroids. Both patients had a good partial resolution of symptoms and radiographic abnormalities. There were no treatment-related deaths. The actual delivered dose intensities for both cisplatin and vinorelbine were 79.5%. Radiotherapy was completed in 96% of patients. Conclusion: Concurrent chemoradiotherapy with cisplatin and vinorelbine administered on a divided schedule is effective and well tolerated in patients with locally advanced NSCLC.     

The results of hypofractionated radiotherapy in 31 patients with high-grade gliomas

In this prospective study, we investigated the effects of hypofractionated radiotherapy for patients with high-grade gliomas. About 31 patients with glioblastoma multiforme or anaplastic astrocytoma were studied between October 2003 and December 2004. Hypofractionated radiotherapy (3 Gy/fraction/day) was delivered to a total dose of 45 Gy in 15 fractions in 10 patients (32%) who had total excision before radiotherapy and to a total dose of 54 Gy in 18 fractions in 21 patients (68%) who had subtotal excision or biopsy alone. Sex, age, type of surgery, tumor grade, Karnofsky performance status, time between surgery and initiation of radiotherapy, and total radiotherapy dose were analyzed as potential prognostic factors for survival using the univariate log-rank method. The median follow-up was 15 months (4–16 months). A total of 15 patients (48%) died of their illness; 16 patients (52%) were still alive at the last follow-up. The median survival time was 8 months. Actuarial 1–year overall survival was 40%. Type of surgery, timing of radiotherapy after surgery, and initial Karnofsky performance status were significant prognostic factors for survival. No grade 3–4 acute or late neurotoxicity was observed. The tolerance of patients to hypofractionated RT was not different from that for conventional radiotherapy. This treatment schedule can be used for patients with high-grade gliomas. Future investigations are needed to determine the optimal fractionation for high-grade gliomas.     

Boron neutron capture therapy of brain tumors: clinical trials at the finnish facility using boronophenylalanine

Summary Two clinical trials are currently running at the Finnish dedicated boron neutron capture therapy (BNCT) facility. Between May 1999 and December 2001, 18 patients with supratentorial glioblastoma were treated with boronophenylalanine (BPA)-based BNCT within a context of a prospective clinical trial (protocol P-01). All patients underwent prior surgery, but none had received conventional radiotherapy or cancer chemotherapy before BNCT. BPA-fructose was given as 2-h infusion at BPA-dosages ranging from 290 to 400 mg/kg prior to neutron beam irradiation, which was given as a single fraction from two fields. The average planning target volume dose ranged from 30 to 61 Gy (W), and the average normal brain dose from 3 to 6 Gy (W). The treatment was generally well tolerated, and none of the patients have died during the first months following BNCT. The estimated 1-year overall survival is 61%. In another trial (protocol P-03), three patients with recurring or progressing glioblastoma following surgery and conventional cranial radiotherapy to 50–60 Gy, were treated with BPA-based BNCT using the BPA dosage of 290 mg/kg. The average planning target dose in these patients was 25–29 Gy (W), and the average whole brain dose 2–3 Gy (W). All three patients tolerated brain reirradiation with BNCT, and none died during the first three months following BNCT. We conclude that BPA-based BNCT has been relatively well tolerated both in previously irradiated and unirradiated glioblastoma patients. Efficacy comparisons with conventional photo radiation are difficult due to patient selection and confounding factors such as other treatments given, but the results support continuation of clinical research on BPA-based BNCT.     

X线立体定向放射治疗44例腹膜后转移癌近期疗效观察

Objective： To investigate the therapeutic effects of stereotactic radiotherapy for retroperitoneal metastatic tumor. Methods： From August 1997 to October 2004, 44 patients with retroperitoneal metastatic tumors were treated with stereotactic radiotherapy. The planning target volume was encompassed by 90%-95% isodose line. Fractional dose was from 6 Gy to 8 Gy, and they were treated 2-3 times per-week and 4-8 times in all. The total radiation doses of PTV were from 32 Gy to 48 Gy. Results： After the radiotherapy, the pain was obviously relieved in 81.8% patients. Three months after completion of radiotherapy passed and then, abdominal CT was performed to evaluate the results. The whole effective rate was 81.8% [CR 27.7% （12/44） and PR 54.5% （24/44）], and six months after radiotherapy, CR was 27.7% （12/44） and PR was 59.1% （26/44）. The middle survival time was 12 months. Conclusion： It is suggested that stereotactic radiotherapy for retroperitoneal metastatic tumor is a safe and effective method.     

A Phase I Trial of 5-Fluorouracil with Cisplatin and Concurrent Standard-dose Radiotherapy in Japanese Patients with Stage II/III Esophageal Cancer

Objective: In Japan, 5-fluorouracil (5-FU) 400 mg/m² on Days 1–5,8–12, 36–40 and 43–46 with cisplatin (CDDP)40 mg/m² on Days 1, 8, 36 and 43 plus concurrent radiotherapywith 2 weeks planned interruption (60 Gy) was standard for thepatients with esophageal cancer. This Phase I trial was designedto determine the maximal tolerated dose (MTD) and dose-limitingtoxicity (DLT) of 5-FU on Days 1–4 and 29–32 withCDDP on Days 1 and 29 plus concurrent radiotherapy (50.4 Gy)among the Japanese. Methods: Escalating doses of 5-FU and CDDP were administered with concurrentradiotherapy (50.4 Gy). Treatment was continued until DLT appeared. Results: Twelve patients with previously untreated clinical Stage II/IIIsquamous cell esophageal carcinoma were studied. One of sixpatients given Level 1 (5-FU 800 mg/m² on Days 1–4 and29–32 with CDDP 75 mg/m² on Days 1 and 29) developed aDLT of incomplete protocol treatment due to Grade 3 esophagitis.The MTD was not reached at Level 2 (5-FU 1000 mg/m² with CDDP75 mg/m²). The complete response rate was 67% at Level 1 and100% at Level 2. Conclusions: Dose Level 2 with 50.4 Gy radiotherapy was recommended for Japanesepatients.     

High-dose radiotherapy to 78 Gy with or without temozolomide for high grade gliomas

Objectives To describe outcomes associated with high-dose radiotherapy with and without temozolomide for high grade central nervous system (CNS) neoplasms. Methods Retrospective chart review of 60 patients diagnosed with malignant glioma treated with ≥70 Gy radiotherapy. Results Median age at diagnosis was 52 years, and 52 patients had astrocytomas (38 glioblastomas). Median prescribed radiotherapy dose was 78 Gy (range 70–80), and 29 patients received concurrent temozolomide. Eighty-six percent completed the planned course treatment. Three patients experienced RTOG grade 3 acute CNS toxicity; late brain necrosis was suspected in four patients. Overall median survival was 13 months (range 2–83). Within glioblastoma patients, temozolomide provided a statistically significant survival improvement over no chemotherapy (median survival 12.7 vs. 7.5 months; P = 0.0058). Conclusions High dose conformal radiotherapy to ≥70 Gy with chemotherapy for high-grade CNS neoplasms appears safe but survival remains suboptimal. Within glioblastoma patients, temozolomide provided statistically significant survival improvement over no chemotherapy.     

Pulsed reduced dose-rate radiotherapy: a novel locoregional retreatment strategy for breast cancer recurrence in the previously irradiated chest wall,axilla, or supraclavicular region

Purpose Reirradiation of breast cancer locoregional recurrence (LRR) in the setting of prior post-mastectomy radiation poses a significant clinical challenge due to the high risk for severe toxicity. In an attempt to reduce these toxicities, we have developed pulsed reduced dose-rate radiotherapy (PRDR), a reirradiation technique in which a series of 0.2 Gy pulses separated by 3-min time intervals is delivered, creating an apparent dose rate of 0.0667 Gy/min. Here we describe our early experience with PRDR. Patients and methods We reirradiated 17 patients with LRR breast cancer to the chest wall, axilla, or supraclavicular region using PRDR. The median prior radiation dose was 60 Gy. We delivered a median PRDR dose of 54 Gy (range 40–66 Gy) in 1.8–2.0 Gy per fraction. Eight patients received concomitant low dose capecitabine for radiosensitization. The median treatment volume was 2,084 cm³ (range 843–7,881 cm³). Results At a median follow-up of 18 months (range 4–75 months) only 2 patients have had tumor failure in the treatment region. Estimated 2-year local control rate is 92%. Treatment was well tolerated with 4 patients experiencing grade 3 acute skin toxicity. Despite a median cumulative dose of 110 Gy (range 80–236 Gy), there has been only one grade 3 and one grade 4 late toxicity. Conclusions With a median follow-up of 18 months, PRDR appears to be an effective method to reirradiate large volumes of previously irradiated tissue in selected patients with locoregional chest wall, axilla, and supraclavicular recurrences. Presented in part at the 2007 ASCO/ASTRO/ASBS Breast Cancer Symposium, San Francisco, CA, USA, September 7–8, 2007.     

A multi-institutional retrospective analysis of external radiotherapy for mucosal melanoma of the head and neck in Northern Japan

PURPOSE: A multi-institutional retrospective study was performed in northern Japan to analyze the outcome of external radiotherapy as the definitive treatment modality for localized mucosal melanoma of the head and neck. PATIENTS AND METHODS: Thirty-one patients with localized mucosal melanoma of the head and neck treated by external radiotherapy at nine institutions of the Northern Japan Radiation Therapy Oncology Group between 1980 and 1999 were enrolled in this study. Radiotherapy alone was performed in 21 patients, and the remaining 10 patients received postoperative radiotherapy for gross residual tumors. The fraction size of radiotherapy varied from 1.5-13.8 Gy, with the total dose ranging from 32-64 Gy (median, 50 Gy). The follow-up periods ranged from 1-214 months (median, 16 months). RESULTS: Complete or partial responses were observed in 9 patients (29%) and 18 patients (58%), respectively. Local recurrence occurred in 13 patients (41.9%) and distant metastasis occurred in 11 patients (35.5%). Most incidences of local recurrence and distant metastasis developed within 2 years after the initial treatment. Overall cause-specific survival rates of patients at 1 and 3 years were 73% and 33%, respectively. Univariate analysis showed that high dose per fractionated radiotherapy doses (>or=3 Gy) was associated with better prognosis for both local control (p = 0.048) and survival (p = 0.045). Multivariate analysis indicated that age (better prognosis in younger patients, p = 0.046) was the only significant factor. Radiotherapy for gross residual lesions after surgery did not seem to impact the significant gain of local control and survival. We observed two fatal late complications of mucosal ulcer and bleeding in the high dose per fractionated radiotherapy group. CONCLUSION: Radiotherapy at a dose of 3 Gy or more per fraction was effective in gaining local control in patients with localized mucosal melanoma of the head and neck, and subsequently better survival was possible, especially in younger patients.     

Single and hypofractionated stereotactic radiotherapy with CyberKnife for craniopharyngioma

Craniopharyngiomas are slow-growing tumors found in the suprasellar region, with especially high incidence in Japanese children. Due to the location, proximity and adhesiveness of the tumor to adjacent critical structures, these tumors remain a significant clinical challenge. The purpose of this study was to evaluate the clinical outcome of single and hypofractionated stereotactic radiotherapy (SRT) with CyberKnife for craniopharyngioma. Forty-three patients (21 men and 22 women; median age 44 years; range 3–85 years) were treated at two institutions. Three cases were treated in a single fraction to a marginal dose of 13–16 Gy. The other 40 cases were treated in 2–5 fractions to a marginal dose of 13–25 Gy. Tumor volumes ranged from 0.09 to 20.8 cm³ (median 2.0 cm³). Toxicities were evaluated with the Common Terminology Criteria for Adverse Events version 4.0. The median follow-up period was 40 months (range 12–92 months). The 3-year overall survival and local control rates were 100 and 85%, respectively. In-field cyst enlargement was observed in 9 patients. These tumors had significantly larger volumes (mean 6.9 cm³; 95% confidence interval, CI, 2.8–10.9 cm³) than the 34 controlled tumors (2.9 cm³; CI 1.5–4.3 cm³) (P = 0.02). Out-field tumor regrowth was observed in 4 patients. No radiation-induced symptomatic visual disorder or brain necrosis was observed. Hypopituitarism was observed in only 1 patient. Single and hypofractionated SRT using CyberKnife produced high tumor control rates with minimal complications. Hypofractionated SRT may be useful for protecting the visual nerve and neuroendocrine function, especially for tumors located near the optic pathways and for large tumors.     

CT-guided radioactive seed implantation for recurrent rectal carcinoma after multiple therapy

The recurrent carcinoma has been difficult to manage after surgery and radiotherapy, extensive resection of locally recurrent rectal cancer is associated with significant morbidity and mortality. Re-irradiation, even in combination with chemotherapy has shown very short survival. We assess the feasibility and efficacy of CT-guided interstitial permanent brachytherapy with ¹²⁵I or ¹⁰³Pd seeds for recurrent rectal cancer after multiple treatments. Fifteen patients with locally recurrent rectal carcinoma received ¹²⁵I or ¹⁰³Pd seed implants under CT guidance. The minimal peripheral dose of seed implants was 110–165 Gy (median 150 Gy). Two weeks after seed implantation, a 50 Gy of stereotactic radiotherapy was given to one patient; four patients received 2–4 cycles of chemotherapy. A median follow-up was 8 months (range 4–50 months). The duration of pain-free survival was 0–50 months (median 7 months). Local control was maintained for 3–50 months (median 7 months). The 1- and 2-year local controls were 16.2 and 8.1%, respectively. Eleven patients died: two (18.2%) of local recurrence, seven (63.6%) of local recurrence and metastases, and two (18.2%) of metastases. Four patients (26.7%) survived the median survival was 9 months. The 1- and 2-year actuarial overall survival rates were 42.9% and 10.7%, respectively. One patient (7.6%) experienced a grade 4 toxic event; there was no associated neuropathy. CT-guided radioactive seed implantation is feasible and safe as a salvage or palliative pain relief treatment for patients with recurrent rectal cancers after surgery and radiotherapy.     

Conservative treatment with transurethral resection, neoadjuvant chemotherapy followed by radiochemotherapy in stage T2-3 transitional bladder cancer

Purpose Organ preservation has been investigated in patients (p) with infiltrating transitional cell carcinoma (TCC) of the bladder over the past decade as an alternative to radical cystectomy. This is a trimodal schedule study, including transurethral resection of bladder tumor (TURB), neoadjuvant chemotherapy and concomitant radiochemotherapy (RTC). Patients and methods From April 1996 until August 2005, 29 evaluable patients (p) with T2-T3NXM0 bladder cancer were enrolled. After a transurethral resection of bladder tumor (TURB), we administered 2 cycles of induction chemotherapy with CMV (15 p) or Gemcitabine-Cisplatin (14 p) followed by radiotherapy 45 Gy 1.8 Gy/fraction and two cycles of concomitant cisplatin 70 mg/m². 2–3 weeks later, a cystoscopy with tumor-site biopsy was performed. If complete histological response, p were treated with consolidation radiotherapy until 64.8 Gy. For p with residual or recurrent tumor, cystectomy was performed. Results We included 28 men and 1 women (median age 63, range 39–72 years) with PS (ECOG) 0–1. The stage was: 21 p T2; 6 p T3a; and 2 p T3b. Toxicity was higher in CMV compared with Gem-Cis: grade 3/4 neutropenia 4/15 (26%) vs 1/14 (7%); febrile neutropenia 3/15 (20%) vs 1/14 (7%); grade 3/4 trombocytopenia 2/15 (13%) vs 1/14 (7%). Toxicities with concomitant RCT were low-moderate: urocystitis (26%) and enteritis (18%). Response: microscopically complete TURB was obtained in 20 p (69%), but not in 9 p (31%) (7 microscopic, and 2 macroscopic residual tumor). We found a complete histologic response after induction RCT in 25 p (86%). After a median follow-up of 69.4 months (m) (range: 8–97.7), there were 8 deaths, with a overall survival of 72%. Furthermore 14 of 29 p (48%) were alive with intact bladder, and median survival time with intact bladder was 63.6 m (50.1–77.2); were predictive of best outcome T2 stage vs T3 (p<0.0001), and complete histologic resection in initial TURB vs residual tumor (p=0.0004). Conclusions Combined treatment provide high response rates and can be offered as an alternative option to radical cystectomy in selected patients with TCC. Patients with T2 stage and complete histologic resection in initial TURB had the best outcome. Radiotherapy Oncology Unit . CROASA, S.A.     

Dose–volume factors predicting radiation pneumonitis in patients receiving salvage radiotherapy for postlobectomy locoregional recurrent non-small-cell lung cancer

Background The correlation between treatment-related factors and lung toxicity has not been sufficiently evaluated in salvage radiotherapy. Methods Twenty-one patients with recurrent non-small- cell lung cancer (NSCLC) after lobectomy received salvage radiotherapy to a total dose of 46–60 Gy. The effects of radiotherapy parameters on the development of radiation pneumonitis (RP) were examined using dose–volume histograms. Results Grade 1 RP was observed in 4, grade 2 in 2, and grade 3 in 1 patient. Patients who developed RP had a significantly higher value in V dose (V13, V20) parameters and mean lung dose (MLD) than those who did not develop RP. Concerning G2 or higher RP, 3 patients who developed ≥G2 RP had a significantly higher value in V20, V13, and MLD than the remaining patients with P values of 0.01, 0.015, and 0.016, respectively. The mean V20, V13, and MLD in these 3 patients were 27%, 29.3%, and 14.8 Gy, respectively, whereas the mean V20, V13, and MLD in the remaining 18 patients were 15.8%, 18.3%, and 8.8 Gy, respectively. Three of 6 patients with a V20 ≥20% developed ≥G2 RP whereas this did not occur in the remaining patients (P = 0.015). Similarly, 3 of 6 patients with a V13 ≥23% developed ≥G2 RP whereas this did not occur in the remaining patients (P = 0.015). Conclusions These data suggest that a somewhat lower V dose value or MLD, as compared with the setting of definitive radiotherapy, could be a surrogate for RP in patients undergoing salvage radiotherapy for recurrent NSCLC.     

Weekly docetaxel with concomitant radiotherapy in patients with inoperable oesophageal cancer

Abstract Introduction: To evaluate the efficacy and tolerability of weekly docetaxel concurrent with radiotherapy in inoperable oesophageal cancer patients. Material and methods: Thirty-four oesophageal cancer patients with co-morbid medical conditions, locally advanced tumours (T4) or advanced age (older than 75 years) received docetaxel (20 mg/m² weekly) plus concurrent radiotherapy (2 Gy daily, to a total dose of 66 Gy). Twenty-two patients (64%) were stage III, 19 of whom had T4 tumours. Results: Twenty-seven patients (79%) completed the planned chemoradiotherapy treatment. Nine patients (26%) achieved a complete response and 8 (24%) achieved a partial response, for an overall response rate of 50%. Median survival was 6 months, and 1-year survival was 35%. Patients with T4 tumours had significantly shorter survival than other patients: 5 months for T4 tumours vs. 11 months for T1–3 (p=0.04). Grade 3–4 oesophagitis occurred in 6 patients (17%). There were two treatment-related deaths due to radiation pneumonitis. Conclusions: Docetaxel plus concurrent radiotherapy is active in poor-prognosis oesophageal cancer patients, with a lower incidence of severe oesophagitis than with cisplatin-based chemoradiotherapy regimens. This schedule can be considered, especially in patients with non-T4 tumours who are not candidates for oesophageal resection.     

Hypofractionated radiotherapy in the treatment of diffuse intrinsic pontine glioma in children: a single institution’s experience

We report herein our institutional experience in the treatment of diffuse intrinsic pontine glioma (DIPG) with a hypofractionated external-beam radiotherapy schedule. Between April 1996 and January 2004, 22 patients (age 2.9–12.5 years) with newly diagnosed DIPG were treated by hypofractionated radiation therapy delivering a total dose of 45 Gy in daily fractions of 3 Gy, given over 3 weeks. No other treatment was applied concomitantly. Fourteen of the 22 patients received the prescribed dose of 45 Gy in 15 fractions of 3 Gy, and 2 patients received a total dose of 60 and 45 Gy with a combination of two different beams (photons and neutrons). In five cases the daily fraction was modified to 2 Gy due to intolerance, and one patient died due to serious intracranial hypertension after two fractions of 3 Gy and one of 2 Gy. Among 22 children, 14 patients showed clinical improvement, usually starting in the second week of treatment. No grade 3 or 4 acute toxicity from radiotherapy was observed. No treatment interruption was needed. In six patients, steroids could be discontinued within 1 month after the end of radiotherapy. Median time to progression and median overall survival were 5.7 months and 7.6 months, respectively. External radiotherapy with a radical hypofractionated regimen is feasible and well tolerated in children with newly diagnosed DIPG. However, this regimen does not seem to change overall survival in this setting. It could represent a short-duration alternative to more protracted regimens.     

Treatment with high marginal dose is mandatory to achieve long-term control of skull base chordomas and chondrosarcomas by means of stereotactic radiosurgery

Chordomas and chondrosarcomas of the skull base are rare. Since total resection of these tumors is difficult, adjuvant radiotherapy is necessary. This study was performed to evaluate the effect of stereotactic radiosurgery (SRS) for skull base chordomas and chondrosarcomas and to determine the optimal marginal dose for these tumors. Fourteen patients with histologically proven chordomas or chondrosarcomas underwent 16 sessions of SRS using gamma knife. The marginal doses ranged from 10 to 20 Gy (mean, 15 Gy). Lower marginal doses of 12 Gy on average (range, 10–12.5 Gy) were applied to four patients since they underwent prior fractionated radiotherapy, and partial treatment for which parts of tumors were excluded from planned target volume because of their proximity to critical structures was also applied to four patients. The whole tumors were covered with higher marginal doses of 18 Gy on average (range, 16–20 Gy) for six patients. The mean follow-up period was 65 months. Progression-free survival (PFS) rates at 3 and 5 years after SRS was 53 and 43%, respectively. Five-year PFS rates for patients who underwent SRS with higher and lower marginal doses were 80 and 14%, respectively, which were significantly different (P = 0.005). Tumor progression after partial irradiation mainly occurred from sites where delivered doses were reduced. Sufficient marginal doses at least 16 Gy appeared crucial. Proper combination with surgical resection to detach tumors from critical structures and to reduce tumor volume is necessary to completely deliver sufficient marginal doses for SRS.     

直肠癌手术前后辅助放疗疗效比较

［目的］探讨比较术前单次、术前４０Ｇｙ放疗及术后放疗对直肠癌疗效的影响。〔方法）１２７例病理证实的直肠癌患者, 于１９９０年 ４月至 １９９４年 １２月随机分为 ３组,分别为术前单次组 ３９例,术前４０Ｇｙ组 ４３例和术后放疗组 ４５例。术前放疗组中病理 若属Ｔ_３期以上,则加用术后放疗。术前单次组放疗剂量为５Ｇｙ－６Ｇｙ／次,放疗后４８ 小时内手术。术前４０Ｇｙ组中位剂量为４０Ｇｙ／２０ 次（２０Ｇｙ－ ４０Ｇｙ）,放疗后休息 ４周手术。术后放疗组中位剂量为 ５５．１Ｇ ｙ／２９次（３０Ｇｙ－ ６３Ｇｙ／１５次～ ３５次）,手术放疗间隔为 ３～ ４ 周。［结果］全部病例中位随访７８个月,３组中位生存期分别为５５、５８、４７个月,Ｋａｐｌａｎ Ｍｅｉｅｒ法计算３年及５年生存率分别为 ７４．３％、４８７％,６７．４％、４８９％和６２２％、４２２％。局部复发率分别为１２．８％、２３．１％,１４．０％、２３．３％和２２．２％、２８．９％。单因素Ｌｏｇ ｒａｎｋ检验术前放疗２组３年局部复发率低于术后放疗（Ｐ＜０．０５）。５年局部复发率和生存率无差别。［结论］适当剂量的术前放 疗较术后放疗具有更高的局控率和较低的副反应。     

Postoperative radiotherapy in cranial ganglioglioma

Summary We performed an institutional database search for patients with ganglioglioma in order to evaluate postoperative radiotherapy in the light of our experience. This search identified 5 patients with a mean age of 23.3 (range, 9–54 years) treated between April 1994 and April 2003. The latter date was chosen to allow a minimum follow-up of 1 year at the time of our analysis. Median follow up was 7 years (range, 1.5–11 years). Gross total tumor resection could only be achieved in one case, while other four patients had been referred after subtotal tumor excisions. All patients were treated postoperatively with conventionally fractionated (1.8–2 Gy/day) external beam radiotherapy (EBRT) to a total dose of 54–60 Gy. Patients were treated with megavoltage beams using Co⁶⁰ or 6-MV photons. None of the patients were lost to follow up with a median follow up time of 80 months (range, 5.5–122.5 months) and all patients were alive with no evidence of disease at last follow-up. We believe that long term follow-up is necessary to observe the relapse patterns and the significance of postoperative radiotherapy needs to be further evaluated with large patient numbers to remark a conclusive statement.