Permanent iodine-125 implant and external beam radiation therapy for the treatment of malignant brain tumors.

Survival data of 114 patients treated for malignant brain tumors with 125I interstitial radiation therapy at Henry Ford Hospital, Detroit, Mich. (1986-1990), are presented. The first 64 patients were treated with temporary 125I implants with a total prescribed dose of 60 Gy at a dose rate of 40 cGy/h. In order to reduce the risk of injury to the surrounding normal tissue associated with high-dose brachytherapy, a new approach was initiated using permanent implants with a lower dose rate; 50 patients were treated after surgical resection with permanent implantation of 125I seeds at a lower dose rate of 4-7 cGy/h, with a total dose of 10,000-12,000 cGy, and concurrent external radiation therapy of 5,000 cGy. The rationale of this protocol was to increase the effectiveness of the low-dose-rate implant by a concurrent 'daily' boost of external radiation, thus inhibiting the proliferation of tumor cells during the protracted low-dose radiation treatment. Survival was compared between groups with permanent and temporary implants in terms of effectiveness in tumor control as well as impact on clinical condition. Low-dose-rate implant with concurrent external radiation therapy seems to offer the best chance for long-term survival without deterioration in the clinical condition.     

Wound complications after resection and immediate postoperative brachytherapy in the management of soft-tissue sarcomas

Background: When used as the sole source of postoperative radiotherapy, brachyradiation therapy (BRT) (4,500–6,000 cGy) should be delayed beyond the fourth postoperative day to minimize wound complications. However, when 1,000–2,000 cGy BRT are given as a “boost” to the tumor bed, it is unclear if a similar treatment delay is necessary. The purpose of this review was to determine the incidence of wound complications when BRT (1,000–2,000 cGy) is administered ⩽48 h after soft-tissue sarcoma resection. Methods: The results of treatment in 21 patients with soft-tissue sarcomas of the extremity and superficial trunk treated with resection, immediate postoperative brachytherapy, and external beam radiation were reviewed. All patients were followed through the completion of radiation (median follow-up 30 months). A median of seven (range 3–24) after-loading catheters were placed at the time of resection and were loaded with iridium-192 a median of 2 days postoperatively to deliver 1,000–2,000 cGy radiation. Results: Eight patients (38%) experienced minor wound complications (seromas, wound separation, and flap edge necrosis) within 30 days of operation. There were no early complications that required reoperation or delayed further therapy. Conclusions: Brachytherapy (1,000–2,000 cGy) can be administered ⩽48 h postoperatively with a low risk of major wound complications. Minor wound complications are common but do not delay further treatment.     

Permanent I Interstitial Radiation Therapy in the Treatment of Non-GBM High-Grade Gliomas

This study evaluates prognostic factors influencing survival outcomes for 50 patients with permanent¹²⁵ iodine-125 implants in the primary treatment of non-GBM high-grade gliomas. Stereotactic treatment planning aimed to encompass the contrast-enhancing rim of the tumor visualized by CT, with an initial dose rate of 0.05 Gy/hour with ¹²⁵I, delivering 100 Gy at 1 year and 103.68 Gy at infinity. Survival was evaluated using the Kaplan–Meier method for unvariate analysis and the Cox regressional method for multivariate analysis. In addition to the implant, 31 patients received external radiation therapy (5000 to 6000 cGy) before the implant; 10 patients were implanted without additional external beam radiation, and 9 patients underwent external radiation therapy before implant placement. With a mean follow-up of 40.76 months (range 3.47–87 months); 1–, 3–, and 5-year survival were 78.5% (± .05%), 58.7% (± .07%), and 56.2% (± .07%) respectively. Since 56.2% of the patients were alive at 5 years, median survival has not been reached yet. Second surgery was performed following the implant in 19 patients. Findings were tumor recurrence in 11 patients (22.5%), radiation necrosis in 7 patients (14.3%), and brain abcess in 1 patient (2%). Age, sex, tumor location, side of brain, tumor volume, Karnofsky, and neurological status were correlated with survival outcome. Favorable prognostic factors were age younger than 45 years, superficial tumor location, and preoperative Karnofsky greater than 70. Surgical treatment of patients with non-GBM high grade gliomas combined with external beam radiation and permanent ¹²⁵I implants represent a valuable alternative for the treatment of patients with malignant gliomas, allowing patients good quality of life and long survival.     

Outcomes with brachytherapy based dose escalation for gleason 8 versus 9-10 prostate cancer: An NCDB analysis

IntroductionThe addition of brachytherapy (BT) in high risk prostate cancer is supported by Level 1 evidence. Whether all high risk patients benefit from BT to the same extent is unknown. The National Cancer Database (NCDB) was used to investigate overall survival (OS) differences between GS 8 and 9-10 treated with external beam radiation (EBRT) only or BT +/- EBRT.Materials and MethodsWe included localized prostate adenocarcinoma definitively treated with radiation between 2004-2014. Patients were stratified into various radiation treatment groups: EBRT 7560 - 8640 cGy, EBRT 5940 - 7540 cGy, and BT +/- EBRT. All EBRT only and BT +/- EBRT patients received ADT. A multivariable Cox proportional hazard model was used to assess OS. Propensity score matching was used to account for differences between groups. Median survival was determined based on Kaplan-Meier survival curves.Results30,698 patients were included. On multivariable analysis among GS 8 patients, BT was associated with improved OS compared to 7560 - 8640 cGy (HR–0.80 (95% CI 0.70-0.92, P = 0.002). In Gleason 9-10 BT did not result in improved OS compared to 7560 – 8640 cGy (HR- 0.91 (95% CI 0.79 – 1.05, P = 0.212). Results remained significant with propensity score matching and removing patients with medical comorbidities.ConclusionBT was associated with improved OS when compared to 7560 – 8640 cGy in GS 8, but not in Gleason 9-10 disease. This hypothesis generating study suggests there may be variable benefit with BT in high risk prostate cancer patients on OS. Future prospective studies are needed to investigate whether the benefit of BT is similar across all high risk prostate cancer patients.     

Interstitial brachytherapy for malignant brain tumors: preliminary results

The authors report their experience with interstitial brachytherapy in 46 patients with malignant brain tumors. Twenty-three patients received implants after external radiation for newly diagnosed malignant astrocytoma, as part of a randomized study (Group I). Eighteen patients received implants for recurrent malignant astrocytoma (Group II) and 3 for recurrent solitary cerebral metastasis from adenocarcinoma of the lung (Group III). Two additional patients received implants as part of their initial therapy for a radiation-induced malignant astrocytoma and a malignant fibrous histiocytoma. In all patients high-activity iodine-125 sources were implanted temporarily by a stereotactic technique. To date 50 patients have been entered in the randomized study with a maximum follow-up of 31 months. The small numbers and short follow-up preclude any conclusions regarding the efficacy of brachytherapy used as part of initial therapy. The median survival to date in the 23 patients in this group who received implants is 60 weeks. The median survival to date for the 18 patients who received implants for recurrent malignant astrocytoma is 44 weeks postimplant. Two of the three patients who received implants for recurrent solitary metastasis are alive at 41 and 49 weeks postimplant; a third died at 39 weeks postimplant. Significant complications attributable to interstitial brachytherapy have been observed in 10 of 46 patients (21.7%). A second operation for clinical and radiological deterioration was performed in 12 patients (26.1%) 8 to 105 weeks after brachytherapy. The authors conclude that interstitial brachytherapy is beneficial for selected patients with recurrent malignant astrocytoma and solitary recurrent metastasis.(ABSTRACT TRUNCATED AT 250 WORDS)     

The Role of Stereotactic Radiosurgery in the Management of Benign, Atypical, and Malignant Meningiomas

Stereotactic radiosurgery and fractionated Stereotactic radiotherapy (SR) offer precise localization of radiation dose (Gy) for the treatment of meningioma (M). For the multimodal treatment with preservation of function, SR is complementary to both microsurgery (S) and conventional external beam radiotherapy (XRT). The role of SR in the management of atypical and malignant meningiomas, however, remains unexplored. Fifty consecutive patients with meningioma: 18 males (60.1 +/– 2.3 years) and 32 females (56.9 +/– 2.2 years) (p = NS) received SR. Thirty-one patients had surgery 69.6 +/– 13.9 months (95% CI: 53.3–98.0) prior to SR. For patients having S, the incidence of atypical or malignant versus benign meningiomas (14 versus 17 patients) increased with age (p = 0.03). Twenty patients had XRT approximately 18 months prior to SR. For antecedent XRT, the range of doses was 3600–6400 cGy (median: 5040 cGy). Following failure of S and/or XRT, patients had SR. Compared to other series, the mean tumor volumes for SR were comparatively large: 9.8 +/– 1.3 cm³ (range 0.3–37.1 cm³). The median SR dose was 3500 cGy (range 540–5400 cGy) administered in seven fractions (range 1–30). Linear regression analysis showed a consistent method for fractionation: the number of administered fractions increased (p = 0.053) and the total dose increased (p = 0.054) with tumor size. During the interval for follow–up (17.9 +/– 2.9 months), one patient with malignant meningioma required surgery for progression 8 months after SR. In the remaining patients, post-SR MRIs showed control (unchanged or smaller tumor volume) regardless of histology. These results show that SR may provide control of M regardless of grade.     

Stereotactic Radiosurgery for Tonsillar Carcinoma

Background: Stereotactic radiosurgery (SRS) was developed for the treatment of patients with intracranial lesions; indeed, the stereotactic equipment is derived from neurosurgical tools. However, SRS may be feasible for any small lesions that can be targeted with Stereotactic apparatus. In this report we describe the use of SRS in treating a patient with a squamous cell cancer of the oropharynx. Methods: A 62-year-old man had received 65 Gray (Gy) postoperative radiation therapy for a floor of mouth cancer 3 years prior to this presentation. He had developed a second primary of his tonsil within the previous radiation portals. Because of a recent myocardial infarction he was unable to undergo salvage surgery or interstitial brachytherapy. He was unable to have intraoral cone electron beam treatment or contact brachytherapy because of severe trismus. He therefore underwent 30 Gy in 15 fractions of external beam radiation followed by a Stereotactic boost of 850 centigray (cGy) in one fraction. Results: The Stereotactic boost delivered a tumoricidal radiation dose while sparing the mandible and other vital structures. He tolerated the treatment well with a complete local tumor response. Conclusions: In selected patients, stereotactic radiosurgery is a viable option in the management of head and neck cancer.     

Brachytherapy of brain tumors.

Temporary implants of high-activity 125iodine sources have been used in the treatment of brain tumors since December 1979 at the University of California, San Francisco. For previously untreated patients who underwent external beam radiation therapy followed by implant boost, median survival from the date of diagnosis was 88 weeks for 34 patients with glioblastoma multiforme (GM) and 157 weeks for 29 patients with nonglioblastoma gliomas (NGM). For recurrent tumors treated with brachytherapy only, median survival from the date of the implant was 54 weeks for 45 patients with GM and 81 weeks for 50 patients with NGM. Finally, in 48 patients with recurrent tumors treated with combined hyperthermia and brachytherapy, median survival from the date of the implant was 46 weeks for 25 patients with GM and 44 weeks for 7 patients with metastases; 18-month survival was 65% for 16 patients with NGM. Brachytherapy appears to be a useful technique for the treatment of selected recurrent brain tumors and selected primary glioblastomas.     

Stereotactic interstitial brachytherapy of malignant astrocytomas with remarks on postimplantation computed tomographic appearance

Seventeen patients were treated with stereotactically implanted high activity iodine-125 seeds, 12 patients for recurrent malignant astrocytomas (Protocol I) and 5 patients for newly diagnosed glioblastomas (Protocol II). Total radiation dosage to the recurrent tumors in Protocol I, including prior external beam irradiation, averaged 13,500 cGy. In the follow-up period of 6 to 50 months, the survival rate was 93% at 6 months, 60% at 12 months, 50% at 18 months, and 38% at 24 months after implantation. In Protocol II, brachytherapy was used as an interstitial radiation boost to the conventional treatment of newly diagnosed glioblastomas. External beam therapy and interstitial brachytherapy provided 11,000 cGy to these tumors. In the follow-up period of 15 to 27 months, there was a 100% survival at 12 months, 75% at 18 months, and 25% at 24 months after implantation. Eight of our 17 patients required reoperation for persistent or recurrent mass lesions at 6 to 15 months postimplantation; 7 were found to harbor masses of radionecrosis containing nests of anaplastic astrocytes; 1 had frank tumor recurrence. Median survival in this group of patients requiring reoperation was 18.7 months postimplantation. In a review of postimplantation computed tomographic scans, significant mass effect and crossover of hypodensity or enhancement into the corpus callosum or opposite hemisphere were found to have prognostic significance; persistent areas of contrast enhancement and excessive peritumoral hypodensity did not.     

Evaluation of new putative tumor markers for melanoma

Background: The early diagnosis of recurrent melanoma can contribute to better outcome if the disease can be surgically resected or if the metastases are responsive to systemic therapies. Lipid-associated sialic acid (LASA-P) and the S-100 protein (S-100) were evaluated as tumor markers for melanoma with the goal of early detection of recurrence. Methods: Sixty-seven patients were identified who had levels of S-100 and LASA-P drawn during their clinical course. A multivariate regression analysis was performed to determine the significance of the serum markers in relation to other prognostic factors for melanoma. Results: After a median follow-up of 30 months, 58 patients had recurrences, and 49 patients died of disease. LASA-P elevation was not associated with the time to recurrence (p=0.2176) or survival (p=0.2507). S-100 positivity was a significant predictor of recurrence (p<0.0001) and survival (p=0.0059). The median time to recurrence for S-100-positive and S-100-negative patients was 7.6 and 33.8 months, respectively. The median survival time was 59.2 months for S-100-negative patients and 29.6 months for patients positive for S-100. Conclusions: Serum S-100 shows significant correlations to both time to recurrence and survival and could be useful in the clinical detection of malignant melanoma.Presented at the 47th Annual Cancer Symposium of The Society of Surgical Oncology, Houston, Texas, March 17–20, 1994.     

Malignant peripheral nerve sheath tumors: The St. Jude Children's Research Hospital experience

Background: Malignant peripheral nerve sheath tumors (MPNSTs) are uncommon in young patients. To contribute to the understanding of these tumors, we reviewed the records of all patients treated for PNSTs at one institution over a 30-year period. Methods: We reviewed the records of eight patients treated for benign PNSTs and 28 patients treated for 29 MPNSTs. We focused on the latter group, statistically testing several clinical factors for their significance in affecting survival. Results: Five-year survival in patients with MPNSTs was 39%. The most significant prognostic factor was gross tumor resectability (p=0.0004). Five-year survival for patients with resectable tumors was 65%, whereas no patient with unresectable disease survived >25 months. Tumor grade, site, and patient race were also significant factors by univariate analysis but were not significant when adjusted for resectability. Conclusion: Gross tumor resection is crucial in treating malignant PNSTs. Supplemental radiation therapy is recommended for positive microscopic margins. More effective treatment is still being sought for unresectable disease. Presented at the 47th Annual Cancer Symposium of The Society of Surgical Oncology, Houston, Texas, March 17–20, 1994.     

Permanent iodine-125 interstitial radiation therapy in the treatment of non-glioblastoma multiforme high-grade gliomas

BACKGROUND: This study evaluates prognostic factors influencing survival outcomes for 60 patients with permanent iodine-125 implants in the primary treatment of non-glioblastoma multiforme (GBM) high-grade gliomas. METHODS: Stereotactic treatment planning aimed to encompass the contrast-enhancing rim of the tumor visualized by CT, with an initial dose rate of 0.05 Gy/h with 125I, delivering 100 Gy at 1 year and 103.68 Gy at infinity. Survival was evaluated using the Kaplan-Meier method for univariate analysis and the Cox regressional method for multivariate analysis. In addition to the implant, 34 patients received external radiation therapy (5,000-6,000 cGy) before the implant; 13 patients were implanted without additional external beam radiation, and 13 patients underwent external radiation therapy before implant placement. RESULTS: With a mean follow-up of 77.6 months (range 3.5-164 months), 1-, 3-, 5- and 10-year survival were 86.7% (+/-0.05%), 60% (+/-0.07%), 50% (+/-0.07%) and 45.7% (+/-0.7%), respectively. The median survival time was 57 months. Second surgery was performed following the implant in 19 patients. Findings were tumor recurrence in 11 patients (22.5%), radiation necrosis in 7 patients (14.3%) and brain abscess in 1 patient (2%). Age, sex, tumor location, side of brain, tumor volume, Karnofsky score and neurological status were correlated with survival outcome. Favorable prognostic factors were age younger than 45 years, superficial tumor location and preoperative Karnofsky score greater than 70. RPA classification was used to define this group of patients. In RPA classes I and II (n = 43), 1-year survival was 93%, while 3-, 5- and 10-year survival was 67.4, 60.5 and 55.5%, respectively, and median survival time was 91 months. In RPA class III (n = 7), 1-year survival was 71.4%, while 3- and 5-year survival was 42.9 and 28.6%, respectively, and median survival time was 47 months. In RPA class IV (n = 10), 1-year survival was 60%, while 3-, 5- and 10-year survival was 50, 22.2 and 11.1%, respectively, and median survival time was 37 months. CONCLUSION: Brachytherapy with permanent implant of 125I appears promising in the treatment of primary non-GBM malignant gliomas. It improved survival time and reduced the incidence of complications and provided good quality of life. In order to further confirm these results, multicenter randomized prospective studies are needed. RPA analysis is a valid tool to define prognostically distinct survival groups. In this study, 2-year survival and median survival time were improved in all prognostic classes. This would suggest that selection bias alone does not account for the survival benefit seen with 125I implants. Further randomized studies with effective stratification are needed.     

Irreversible Electroporation in Locally Advanced Pancreatic Cancer: Potential Improved Overall Survival

Background

Locally advanced unresectable pancreatic adenocarcinoma (LAC) is characterized by poor survival despite chemotherapy and conventional radiation therapy. We have recently reported on the safety of using irreversible electroporation (IRE) for the management of LAC. The purpose of this study was to evaluate the overall survival in patients with LAC treated with IRE.

Methods

A prospective, multi-institutional evaluation of 54 patients who underwent IRE for unresectable pancreatic cancer from December 2009 to October 2010 was evaluated for overall survival and propensity matched to 85 matched stage III patients treated with standard therapy defined as chemotherapy and radiation therapy alone.

Results

A total of 54 LAC patients have undergone IRE successfully, with 21 women, 23 men (median age, 61 (range, 45–80) years). Thirty-five patients had pancreatic head primary and 19 had body tumors; 19 patients underwent margin accentuation with IRE and 35 underwent in situ IRE. Forty-nine (90 %) patients had pre-IRE chemotherapy alone or chemoradiation therapy for a median duration 5 months. Forty (73%) patients underwent post-IRE chemotherapy or chemoradiation. The 90 day mortality in the IRE patients was 1 (2 %). In a comparison of IRE patients to standard therapy, we have seen an improvement in local progression-free survival (14 vs. 6 months, p = 0.01), distant progression-free survival (15 vs. 9 months, p = 0.02), and overall survival (20 vs. 13 months, p = 0.03).

Conclusions

IRE ablation of locally advanced pancreatic tumors remains safe and in the appropriate patient who has undergone standard induction therapy for a minimum of 4 months can achieve greater local palliation and potential improved overall survival compared with standard chemoradiation–chemotherapy treatments. Validation of these early results will need to be validated in the current multi-institutional Phase 2 IDE study.

     

Bronchial resection margin length and clinical outcome in non-small cell lung cancer

Objective: Complete surgical resection with pathologic negative margin is associated with the best prognosis in early-stage non-small-cell lung cancer (NSCLC). However, the impact of the length of the bronchial margin remains unknown. This study aimed to determine whether an increased bronchial resection margin length is correlated with an improved disease-free and overall survival rate. Methods: A total of 3936 consecutive pulmonary resections were performed between 25 June 1992 and 31 December 2007 at Mayo Clinic Rochester. A subset consisting of 496 patients with completely resected lesions (R0-resection), and a documented bronchial margin length was analyzed retrospectively. Results: There were 340 men (68.5%) and 156 women (31.5%), with a mean age of 65.9 ± 10.6 years. All patients underwent anatomic lobectomy or larger resection. Final pathology confirmed complete resection without microscopic residual tumor (R0-resection) in all patients. Mean length of the bronchial resection margin was 23.3 ± 15.9 mm. Overall, 190 patients (38.3%) suffered from disease recurrence with local recurrence in 35 patients, distant recurrence in 101, and both local and distant recurrence in 54 patients. Overall 5-year and 10-year local recurrence-free survival was 72.5% (95% confidence interval (CI): 67.3–78.1) and 68.0% (95% CI: 62.1–74.4), distant recurrence free survival 61.0% (95% CI: 55.8–66.6) and 52.9% (95% CI: 46.7–60.1) and overall survival 50.0% (95% CI: 45.1–55.3) and 28.8% (95% CI: 23.8–34.7). Tumor size and N-stage were associated with a worse prognosis in terms of local and distant recurrence, as well as survival (p < 0.05). Histology was not significantly associated with local recurrence (p = 0.28), though adenocarcinoma relative to squamous cell carcinoma was associated with an increased risk of distant recurrence (p < 0.01). There was no significant association between type of surgical resection and local (p = 0.37) or distant recurrence (p = 0.37). Neither local (p = 0.56) or distant recurrence (p = 0.46), nor survival (p = 0.54) was associated with the bronchial margin length. In multivariate models including age, N-stage, and gender there were no significant overall associations of margin length (≤5, 6–10, 11–15, 16–20, >20 mm) and local recurrence (p = 0.51), distant recurrence (p = 0.33), or survival (p = 0.75). Conclusions: When complete surgical resection is achieved, the extent of the bronchial margin has no clinically relevant impact on disease-free and overall survival in NSCLC.     

Survival Outcomes of Patients with Colorectal Liver Metastases Following Hepatic Resection or Ablation in the Era of Effective Chemotherapy

The outcome of patients with colorectal liver metastases (CLM) undergoing surgical resection in the era of effective chemotherapy is not widely reported. In addition, factors associated with disease-specific survival (DSS) in a contemporary series of patients are not well defined. Clinical, pathologic, and outcome data for 64 patients with CLM treated by a single surgeon in a multidisciplinary setting from February 2002 to October 2007 were examined. Hepatic resection was combined with radiofrequency ablation (RFA) in 23 (36%) cases. Secondary or tertiary resection was undertaken in 12 (19%) patients. Synchronous CLM were noted in 25 (39%) cases. Neoadjuvant chemotherapy was given to 41 (64%) patients. Following hepatic resection, adjuvant chemotherapy was administered in 52 (81%) cases. There was one (2%) operative mortality. One or more complications were noted in 24 (38%) patients. Median length of hospital stay was 7 (2–7) days. Five-year DSS and overall survival were 72% and 69%, respectively. Bilobar disease (p < 0.001), local tumor extension (p = 0.02), response to neoadjuvant chemotherapy (p = 0.005), preoperative portal vein embolization (p = 0.05), number of hepatic lesions (p = 0.03), positive resection margin (p < 0.001), and node-positive primary disease (p = 0.001) were prognostically significant factors on univariate analysis. On multivariate analysis, bilobar disease (p = 0.02) and local tumor extension (p = 0.02) were the only two independent prognostic factors. We conclude that, in patients with CLM, a multidisciplinary approach encompassing an aggressive surgical policy achieves excellent 5-year survival results with acceptable operative morbidity and mortality. Bilobar disease and local extrahepatic extension of cancer appear to be independent prognostic factors for long-term survival.     

Can high-dose-rate brachytherapy prevent the major genitourinary complication better than external beam radiation alone for patients with previous transurethral resection of prostate?

Purpose

To compare the grade 3 genitourinary toxicity and oncological outcome for localized prostate cancer between high-dose-rate (HDR) brachytherapy and external beam radiation therapy (EBRT) alone in patients with previously undergone Transurethral resection of the prostate (TURP).

Materials and methods

From November 1998 to November 2008, 78 patients with a history of TURP underwent radiation therapy for localized prostate cancer. Of these, 59 were enrolled in this study. In this study, 34 patients underwent HDR brachytherapy and 25 patients underwent EBRT alone.

Results

Grade 3 genitourinary complication was observed in 8.8 % of HDR brachytherapy group and 44 % in EBRT alone group. Five-year urinary incontinence rate was 2.9 % in HDR brachytherapy and 24 % in EBRT alone group. The results showed that significant higher incidence of grade 3 genitourinary complication (p = 0.003) and urinary incontinence was the most significant (p = 0.023) in the EBRT alone group. Five-year biochemical survival rate was 82.4 % in HDR brachytherapy group and 72.0 % in EBRT alone group (p = 0.396).

Conclusions

In patients with prostate cancer who have previously undergone TURP, we observed that HDR brachytherapy was able to control prostate cancer with fewer GU morbidities and oncological outcomes that were similar to those associated with traditional EBRT alone. Moreover, HDR brachytherapy led to a decrease in major GU toxicity and also preserved the sphincter function more than that in TURP patients who underwent EBRT alone.     

Neoadjuvant Chemoradiotherapy for Adenocarcinoma of the Pancreas: Treatment Variables and Survival Duration

Background:For patients with potentially resectable pancreatic cancer, the poor outcome associated with resection alone and the survival advantage demonstrated for combined-modality therapy have stimulated interest in preoperative chemoradiotherapy. The goal of this study was to analyze the effects of different preoperative chemoradiotherapy schedules, intraoperative radiation therapy, patient factors, and histopathologic variables on survival duration and patterns of treatment failure in patients who underwent pancreaticoduodenectomy for adenocarcinoma of the pancreatic head.Methods:Data on 132 consecutive patients who received preoperative chemoradiation followed by pancreaticoduodenectomy for adenocarcinoma of the pancreatic head between June 1990 and June 1999 were retrieved from a prospective pancreatic tumor database. Patients received either 45.0 or 50.4 Gy radiation at 1.8 Gy per fraction in 28 fractions or 30.0 Gy at 3.0 Gy per fraction in 10 fractions with concomitant infusional chemotherapy (5-fluorouracil, paclitaxel, or gemcitabine). If restaging studies demonstrated no evidence of disease progression, patients underwent pancreaticoduodenectomy. All patients were evaluated with serial postoperative computed tomography scans to document first sites of tumor recurrence.Results:The overall median survival from the time of tissue diagnosis was 21 months (range 19–26, 95%CI). At last follow-up, 41 patients (31%) were alive with no clinical or radiographic evidence of disease. The survival duration was superior for women (P = .04) and for patients with no evidence of lymph node metastasis (P = .03). There was no difference in survival duration associated with patient age, dose of preoperative radiation therapy, the delivery of intraoperative radiotherapy, tumor grade, tumor size, retroperitoneal margin status, or the histologic grade of chemoradiation treatment effect.Conclusion:This analysis supports prior studies which suggest that the survival duration of patients with potentially resectable pancreatic cancer is maximized by the combination of chemoradiation and pancreaticoduodenectomy. Furthermore, there was no difference in survival duration between patients who received the less toxic rapid-fractionation chemoradiotherapy schedule (30 Gy, 2 weeks) and those who received standard-fractionation chemoradiotherapy (50.4 Gy, 5.5 weeks). Short-course rapid-fractionation preoperative chemoradiotherapy combined with pancreaticoduodenectomy, when performed on accurately staged patients, maximizes survival duration and is associated with a low incidence of local tumor recurrence.Presented at the 53rd Annual Cancer Symposium of the Society of Surgical Oncology, New Orleans, Louisiana, March 18, 2000     

Is iodine-125 seed strand brachytherapy suitable for ureteral carcinoma?

BackgroundLong-term conventional high-dose radiation therapy can lead to retroperitoneal fibrosis and nerve damage in patients with advanced ureteral carcinoma (UC). The purpose of this study is to evaluate the safety and efficacy of nephrostomy combined with iodine-125 seed strand (ISS) brachytherapy for the treatment of UC.Materials and methodsTwenty-one patients with UC were treated with nephrostomy combined with ISS brachytherapy. The following parameters were recorded: technical success rate, procedure time, complications, mean D90 (dose delivered to the 90% gross tumor volume), organ at risk (OAR) dose, local control rate (LCR), ureteral patency (UP), local tumor progression (LTP), and overall survival (OS). The hydronephrosis score (HS), visual analog score (VAS), Karnofsky score and maximum diameter (MD) were compared before and 8 weeks after the operation.ResultsThe technical success rate was 100%, with a mean procedure time of 54.6 min. Three cases (14.5%) had bladder implant metastasis but no other major complications, such as ureteral perforation, infection, or severe bleeding, occurred. The mean D90 and OAR doses were 50.7 and 3.8 Gy, respectively. LCR was 100% with 28.6% UP at the 8-week evaluation. During the mean follow-up of 16.6 months, LTP occurred in 4 cases (19.1%), and the median OS was 25.0 months (95% CI 21.3–28.5). The HS, VAS, Karnofsky score and MD showed significant changes (all P < 0.01).ConclusionUC can be safely and effectively treated by nephrostomy combined with ISS brachytherapy, a viable option for patients who cannot undergo or refuse surgical resection.     

Recurrent malignant gliomas: survival following interstitial brachytherapy with high-activity iodine-125 sources

The authors report survival data for the first 41 patients treated for recurrent malignant gliomas with interstitial brachytherapy at the University of California, San Francisco (1980-1984). Iodine-125 (125I) sources were temporarily implanted using stereotaxic techniques. The median survival period for 18 patients with recurrent glioblastomas was 52 weeks after brachytherapy; two patients are alive more than 5 years after brachytherapy. The median survival period for 23 patients with recurrent anaplastic astrocytomas is 153 weeks after brachytherapy, with 10 patients alive more than 3 years and four patients alive more than 4 years after brachytherapy. Both groups did significantly better (p less than 0.01) than groups of patients with the same diagnoses and similar general characteristics who were treated at recurrence with chemotherapy alone. Because of deterioration of their clinical condition and evidence of recurrence from computerized tomographic scans, 17 (41%) of 41 patients required reoperation 20 to 72 weeks after brachytherapy. Despite the invariable presence of apparently viable tumor cells mixed with necrotic tissue in the resected specimen, nine patients have survived more than 2 years after reoperation and two of the nine are still alive 4 years after reoperation. The authors conclude that brachytherapy with temporarily implanted 125I sources for well-circumscribed, hemispheric, recurrent malignant gliomas is effective and offers a chance for long-term survival even though focal radiation necrosis can seriously degrade the quality of survival in a minority of patients.     

Prostate-only Versus Whole-pelvis Radiation with or Without a Brachytherapy Boost for Gleason Grade Group 5 Prostate Cancer: A Retrospective Analysis

BackgroundThe role of elective whole-pelvis radiotherapy (WPRT) remains controversial. Few studies have investigated it in Gleason grade group (GG) 5 prostate cancer (PCa), known to have a high risk of nodal metastases.ObjectiveTo assess the impact of WPRT on patients with GG 5 PCa treated with external-beam radiotherapy (EBRT) or EBRT with a brachytherapy boost (EBRT + BT).Design, setting, and participantsWe identified 1170 patients with biopsy-proven GG 5 PCa from 11 centers in the United States and one in Norway treated between 2000 and 2013 (734 with EBRT and 436 with EBRT + BT).Outcome measurements and statistical analysisBiochemical recurrence-free survival (bRFS), distant metastasis-free survival (DMFS), and prostate cancer-specific survival (PCSS) were compared using Cox proportional hazards models with propensity score adjustment.Results and limitationsA total of 299 EBRT patients (41%) and 320 EBRT + BT patients (73%) received WPRT. The adjusted 5-yr bRFS rates with WPRT in the EBRT and EBRT + BT groups were 66% and 88%, respectively. Without WPRT, these rates for the EBRT and EBRT + BT groups were 58% and 78%, respectively. The median follow-up was 5.6 yr. WPRT was associated with improved bRFS among patients treated with EBRT + BT (hazard ratio [HR] 0.5, 95% confidence interval [CI] 0.2–0.9, p = 0.02), but no evidence for improvement was found in those treated with EBRT (HR 0.8, 95% CI 0.6–1.2, p = 0.4). WPRT was not significantly associated with improved DMFS or PCSS in the EBRT group (HR 1.1, 95% CI 0.7–1.7, p = 0.8 for DMFS and HR 0.7, 95% CI 0.4–1.1, p = 0.1 for PCSS), or in the EBRT + BT group (HR 0.6, 95% CI 0.3–1.4, p = 0.2 for DMFS and HR 0.5 95% CI 0.2–1.2, p = 0.1 for PCSS).ConclusionsWPRT was not associated with improved PCSS or DMFS in patients with GG 5 PCa who received either EBRT or EBRT + BT. However, WPRT was associated with a significant improvement in bRFS among patients receiving EBRT + BT. Strategies to optimize WPRT, potentially with the use of advanced imaging techniques to identify occult nodal disease, are warranted.Patient summaryWhen men with a high Gleason grade prostate cancer receive radiation with external radiation and brachytherapy, the addition of radiation to the pelvis results in a longer duration of prostate-specific antigen control. However, we did not find a difference in their survival from prostate cancer or in their survival without metastatic disease. We also did not find a benefit for radiation to the pelvis in men who received radiation without brachytherapy.