食管癌根治术后放射治疗的价值

目的　评价食管癌根治术后放射治疗的价值。方法　收治 2 6 5例食管癌根治术后放射治疗病人 ,均为鳞癌。 72 8% (193例 )的病人始于术后 8周以内。照射野包括双锁骨上区、纵隔、吻合口及胃左动脉淋巴结区。放疗剂量 4 5～ 5 5Gy。 94 %的病人放疗剂量为 5 0Gy ,放疗采用常规分割照射。结果　 2 6 5例病人总的 1、2、3、4、5年生存率为 81 5 %、6 3 0 %、5 0 9%、4 6 1%、39 5 %。肿瘤外侵阳性病人预后较外侵阴性病人差 (P <0 0 1) ,但肿瘤外侵阳性病人 5年生存率仍达 35 3%。淋巴结阳性病人预后极差 ,5年生存率仅 9% ,与淋巴结阴性的病人相比有显著差异 (P <0 0 0 5 )。本组死亡 139例 ,其中血行转移 5 2例(肺转移 18例、肝转移 14例、骨转移 8例、其它 12例 )占 37 4 % ,纵隔食管瘤床复发 +纵隔淋巴结转移 2 9例占 2 0 9% ,腹腔淋巴结转移 16例占 11 5 %。结论　①除淋巴结阳性病人外 ,食管癌根治术后预防性照射可降低局部区域复发 ,提高远期生存。②对淋巴结阳性病人 ,术后放疗疗效差。③无论肿瘤外侵情况如何 ,食管癌术后放射治疗均有价值 ,但肿瘤外侵阳性病人预后相对较差。④放疗区域应包括肿瘤瘤床和淋巴引流区。⑤术后放疗剂量Dt5 0Gy是合适的。     

Pretreatment apoptosis in carcinoma of the cervix correlates with changes in tumour oxygenation during radiotherapy

A relationship between hypoxia and apoptosis has been identified in vitro and in experimental tumours. The aim of this study was to investigate the relationship between apoptosis, hypoxia and the change in oxygenation during radiotherapy in human squamous cell carcinoma of the cervix. Forty-two patients with locally advanced disease underwent pretreatment evaluation of tumour oxygenation using an Eppendorf computerized microneedle electrode. Twenty-two of these patients also had a second evaluation of tumour oxygenation after receiving 40-45 Gy external beam radiotherapy. Paraffin-embedded histological sections were obtained from random pretreatment biopsies for all 42 patients. Apoptotic index (AI) was quantified by morphology on TUNEL stained sections. No correlation was found between pretreatment measures of AI and either the median pO2 (r = 0.12, P = 0.44) or percentage of values < 5 mmHg (r = -0.02, P = 0.89). A significant positive correlation was found between AI and the change in tumour oxygenation (ratio of pre:post-treatment % values < 5 mmHg) following radiotherapy (r = 0.61, P = 0.002). The lack of correlation between apoptosis and hypoxia may occur because the Eppendorf measures both acute and chronic hypoxia, and the relative ability of acute hypoxia to induce apoptosis is unknown. These results indicate that cell death via apoptosis may be a mechanism of tumour reoxygenation during radiotherapy.     

高剂量率~(192)Ir后装腔内加外照射治疗宫颈癌的远期疗效分析

目的　分析高剂量率192 Ir后装腔内加外照射治疗宫颈癌的远期疗效及并发症。方法　对12 8例Ⅱ、Ⅲ期放疗后宫颈癌进行了回顾分析。其中Ⅱ期 47例 ,Ⅲ期 81例。全盆腔外照射DT2 0Gy/ 10次 ,全盆中间挡铅 4cmDT2 0Gy～ 30Gy/ 10次～ 15次 ;后装A点剂量 48Gy～ 5 6Gy/ 6次～ 7次。 结果　 1、3、5年生存率分别为 91 6 1%、81 8%和 6 7 36 % ;Ⅱ、Ⅲ期 1、3、5年生存率无统计学差异 (P >0 .0 5 ) ;远期严重并发症的发生率 7 0 3% (9/ 12 8)。结论　高剂量率192 Ir后装腔内加外照射治疗宫颈癌疗效肯定 ,并发症少。盆腔局部复发仍是放疗失败的主要原因。     

食管癌术后放射治疗

目的评价Ⅰ～Ⅱ期食管癌根治术后放射治疗的价值。材料与方法１９８７年１月至１９９１年６月共收治１０３例术后病理为Ⅰ～Ⅱ期的食管癌。病人单纯手术７２例，术后放疗３１例，放疗剂量５０～６０Ｇｙ。结果术后随访≥５年，４７例复发，复发与ＴＮＭ分期有关，区域淋巴结和食管瘤床失败与食管原发部位有显著关系。单纯手术组，１，３，５年生存率为８７．５％、６９．４％、４１．７％；术后放疗组１，３，５年生存率为９０．３％、８３．９％、７４．２％，两组差异有显著性意义（Ｐ＜０．０１）。结论术后放疗复发率低，术后放疗组５年生存率高于单纯手术组。     

Results of radiotherapy alone in 581 patients with Stage II carcinoma of the uterine cervix

From January 1976 to December 1978, 581 previously untreated patients with Stage II carcinoma of the uterine cervix were treated by radiotherapy alone in nine departments of radiotherapy in France. This retrospective analysis was undertaken in an attempt to evaluate the therapeutic results and prognostically significant factors. The initial clinical staging and the therapeutic guidelines were as outlined at the U.T. M. D. Anderson Hospital in Houston; all our patients were treated by standardized protocols combining external beam irradiation and intracavitary irradiation with cesium sources. The overall locoregional control rate was 83.2%, with total disease control of 74.5%. Uncorrected actuarial survival rates are 76% at 3 years and 68% at 5 years. The incidence of severe posttherapeutic complications is 7.2%. Clinical substaging, patient's age at the time of the diagnosis, lymphangiogram findings, and tolerance to external irradiation were all found to have prognostic significance. According to those findings, the possibilities of improving the results are discussed.     

Postoperative adjuvant radiotherapy and 5-fluorouracil chemotherapy for rectal carcinoma

Postoperative combined modality therapy with radiotherapy and 5-fluorouracil (5FU) chemotherapy is an effective adjuvant approach that reduces locoregional and distant metastatic disease in patients with high-risk rectal carcinoma. However, this approach results in a treatment regimen of at least 6 months’duration. The present prospective study investigates the integration of radiotherapy and 5FU chemotherapy in a protocol designed to minimize toxicity and reduce the overall treatment time. A total of 40 patients with TNM stage II or III disease received postoperative radiotherapy at four fractions per week with weekly 5FU bolus injections delivered on the fifth non-radiotherapy day. Patients also received systemic chemotherapy with leucovorin both before and after pelvic irradiation, with the total treatment duration extending for only 18 weeks. Patients were able to complete radiotherapy in 90% of cases, while the delivery of full-dose chemotherapy was achievable in the vast majority. The incidence of haematologic and gastrointestinal toxicities requiring the cessation of treatment was acceptable. With a median follow-up of 20.9 months among surviving patients, the estimated progression-free and overall survival at 2 years were 71 % and 79%, respectively.     

Expression of the proapoptotic protein Bid is an adverse prognostic factor for radiotherapy outcome in carcinoma of the cervix

The Bcl-2 family of apoptotic regulators is thought to play an essential role in cancer development and influence the sensitivity of tumour cells to radiotherapy. Bid is an abundantly expressed Bcl-2 family protein playing a central role in various pathways of apoptosis by integrating and converging signals at the mitochondria. The relevance of apoptotic modulation by Bcl-2 and related proteins in tumour development and radiation response for human tumours remains undefined. Therefore, a study was made regarding the expression of Bid in patients with locally advanced cervix carcinoma who received radiotherapy. Bid expression was assessed using immunohistochemistry in pretreatment archival biopsies from 98 patients. The data were correlated with clinicopathologic characteristics and treatment outcome. Pretreatment tumour radiosensitivity data were available for 60 patients. Strong Bid expression was associated with a patient age less than the median of 52 years (P=0.034) and poor metastasis-free survival. In multivariate analysis, after allowing for stage, Bid expression was a significant prognostic factor for both disease-specific and metastasis-free survival (P=0.026). It is concluded that strong tumour Bid expression is associated with poor outcome following radiotherapy regardless of intrinsic tumour cell radiosensitivity, and is adverse prognostic for disease-specific and metastasis-free survival in younger patients.     

48例甲状腺癌术后放疗的临床分析

目的　评价甲状腺癌术后放疗疗效。方法　对 1991年 3月～ 1996年 9月间 ,接受术后放疗的48例甲状腺癌进行总结分析。照射范围 :对分化型者 (乳头状癌、滤泡状癌、髓样癌 )包括瘤床及双颈 ;对未分化型者 (未分化癌 )包括瘤床、双颈及上纵隔 ;采用60 Coγ线加深部 180kvX线或电子流照射 ,照射剂量DT45～ 6 5Gy/ 5 - 7周 ,常规分割照射。结果　全组总的 5年生存率为 81.3% ,其中分化型为 90 .5 % ,未分化型为 16 .7% ,两者比较有显著性差异 (P <0 .0 1)。死亡 9例 ,1例缘于局部复发 ,8例因为远处转移。结论　分化型甲状腺癌首选手术治疗 ,术后T4 N1者需补充放疗 ,未分化型者需采用放化疗综合治疗措施。     

Early cervical cancer treated with definitive or adjuvant radiotherapy: Improved survival with adjuvant radiotherapy attributable to patient selection

The optimum management of patients with early cervical cancer (Federation Internationale de Gynécologie Stages IB and IIA) remains controversial. We reviewed our radiotherapy practise and compared patients with early stage cervical cancer who had surgery and adjuvant radiotherapy (ART) to those that had definitive radiotherapy (DRT). One hundred and twenty‐seven patients were identified, 81 of these underwent ART and 46 underwent DRT. Patients who underwent DRT were significantly older and of poorer performance status than those who underwent ART. The 5‐year relapse‐free survival in the ART and DRT groups were 79 and 72%, respectively (P = 0.70). The corresponding 5‐year overall survival figures were 86 and 58% (P = 0.006). The difference was due to increased deaths from other causes in the DRT arm, 37 versus 7% (P = 0.0007.) The poorer overall survival of DRT patients was due to patient selection.     

Postoperative recurrence of solitary small hepatocellular carcinoma

The prognosis of hepatocellular carcinoma after hepatic resection remains poor. The major cause is postoperative recurrence, most frequently intrahepatic. During the past 7 years, we conducted a detailed study of recurrence after hepatectomy in 34 patients with solitary small hepatocellular carcinoma measuring no larger than 4 cm in diameter, in which 13 cases had postoperative recurrent tumors. and two cases were considered multicentric. Eighty-five percent of recurrences were diagnosed at 6–18 months after the operation. The cumulative recurrence rates were 61% at 5 years after operation. When analyzing the factors affecting recurrence, a significant difference was observed regarding tumor diameter. After recurrence, most patients underwent percutaneous ethanol injection treatment and/or transcatheter arterial chemoembolization and lipiodolization. Four patients died of progressive disease within 1 year after recurrence; the treatment thus seemed to have no effect. The other patients with recurrence remain alive with the disease. The overall cumulative survival rates in this series were 76% at 3 years and 60% at 5 years after operation. To obtain better results after hepatectomy, even for small hepatocellular carcinoma, careful, long-term follow-up evaluation is therefore necessary for the multidisciplinary treatment of the postoperative recurrence, as well as the early diagnosis of tumors in high-risk patients. © 1996 Wiley-Liss, Inc.     

Assessment of the deep resection margin during oral cancer surgery: A systematic review

The main challenge for radical resection in oral cancer surgery is to obtain adequate resection margins. Especially the deep margin, which can only be estimated based on palpation during surgery, is often reported inadequate. To increase the percentage of radical resections, there is a need for a quick, easy, minimal invasive method, which assesses the deep resection margin without interrupting or prolonging surgery. This systematic review provides an overview of technologies that are currently being studied with the aim of fulfilling this demand.A literature search was conducted through the databases Medline, Embase and the Cochrane Library. A total of 62 studies were included. The results were categorized according to the type of technique: ‘Frozen Section Analysis’, ‘Fluorescence’, ‘Optical Imaging’, ‘Conventional imaging techniques’, and ‘Cytological assessment’. This systematic review gives for each technique an overview of the reported performance (accuracy, sensitivity, specificity, positive predictive value, negative predictive value, or a different outcome measure), acquisition time, and sampling depth.At the moment, the most prevailing technique remains frozen section analysis. In the search for other assessment methods to evaluate the deep resection margin, some technologies are very promising for future use when effectiveness has been shown in larger trials, e.g., fluorescence (real-time, sampling depth up to 6 mm) or optical techniques such as hyperspectral imaging (real-time, sampling depth few mm) for microscopic margin assessment and ultrasound (less than 10 min, sampling depth several cm) for assessment on a macroscopic scale.     

The role of radiotherapy for thymic carcinoma

OBJECTIVE: The aim of this study is to evaluate retrospectively the role of radiotherapy for thymic carcinoma. METHODS: Between 1973 and 1998, 14 patients with thymic carcinoma were treated at Gunma Prefectural Cancer Center. Two patients who had hematogenous metastasis were excluded from this study, therefore 12 patients were analyzed. The Masaoka staging system was used; four patients were diagnosed with stage III disease and eight patients with stage IV disease. The pathological subtype according to the World Health Organization histological criteria for thymic tumors was squamous cell carcinoma (low-grade histology) in six cases and undifferentiated carcinoma (high-grade histology) in six. Ten patients underwent thoracotomy, and two patients underwent excisional biopsy without thoracotomy. Ten patients (83%) received radiotherapy as a curative intent, and the median dose was 60 Gy. Systemic chemotherapy was administered to four patients (33%), and the majority (75%) of the regimens contained cisplatin. RESULTS: The 3-year overall survival rate was 25%. Histological subtype (low-grade versus high-grade), surgical resection (complete versus incomplete), radiotherapy and chemotherapy were evaluated as prognostic factors in a univariate analysis. Low-grade histology and complete resection were good prognostic factors, although these were not statistically significant. Patients who received radiotherapy had a better outcome than those who did not. The major sites of recurrence were the pleura and pericardium. Recurrence within the radiation field was observed in one of seven patients in whom failure patterns could be evaluated. CONCLUSION: Complete resection is mandatory if possible. Radiotherapy plays an important role in treating thymic carcinoma in terms of reducing local recurrence and prolonging survival time. Establishment of an innovative treatment protocol that includes chemotherapy is necessary to control intrathoracic relapse and distant metastasis.     

Resection margin status in lumpectomy specimens of infiltrating lobular carcinoma

Aims.To study the status of resection margins in specimens from patients with infiltrating lobular carcinoma (ILC) treated with lumpectomy. Materials and methods.Sixty-six consecutive cases of ILC were compared with the same number of consecutive cases of infiltrating ductal carcinoma (IDC). All cases were treated with lumpectomy. Results.ILCs were divided into 42 cases of typical ILC, 15 variants of ILC (alveolar or solid types) and 9 cases of mixed ILC and IDC. These groups were associated with positive or close resection margins in 22 (52%), 5 (33%) and 3 (33%) cases, respectively. For the group of IDC with partial mastectomies, matched for patient's age and tumor size, positive or close resection margins were observed in 26%. ILCs, measuring less than 2 cm in greatest diameter and having low nuclear grade, had rates of positive or close margins comparable with those of IDC. Typical ILCs, measuring more than 2 cm in diameter, had rates of positive or close margins of 70%. All cases with a positive extensive intraductal component had positive margins. Furthermore, in all types of ILC, tumors with a high nuclear grade tended to be associated with a high rate of positive margins. Conclusions.The status of resection margins in lumpectomy specimens for infiltrating lobular carcinoma is related to the extensive intraductal component status, tumor size and grade, and the presence of variants of ILC or mixed ILC and IDC. Most of these factors can be determined preoperatively by mammography and histopathological evaluation of breast core biopsies, therefore, aiding in planning the surgical strategy of mastectomy.     

Predictors of tumor response in carcinoma of uterine cervix: data from tertiary cancer centre in India

Aim: The current study was a retrospective analysis to identify the predictors of tumor response among cervical cancer patients treated with chemoradiation and completed the intended treatment. Methods: Hundred and twenty eight patients who completed the intended therapy as per institute protocol evaluated. Patients were treated with external beam radiotherapy to a dose of 50 Gy in 27 fractions followed by 21 Gy in three sessions by intracavitory radiotherapy to point A. Postoperative patients received 16 Gy in two sessions. Predictors of tumor response after treatment were assessed using cox regression. Results: Median time to complete tumor response was 12.2 months. Clinical stage emerged as the independent prognostic factor. Patients who completed chemotherapy treatment in fewer than five cycles had a non-significant increased chance of tumor response compared to those completing in five or more cycles. Conclusion: Poor tumor response after treatment is largely explained by advanced disease stage at diagnosis. A strategy for early detection and access to screening facilities will improve outcome. Fewer chemotherapy cycles may be beneficial in patients with locally advanced carcinoma cervix.     

Water-filled balloon in the postoperative resection cavity improves dose distribution to target volumes in radiotherapy of maxillary sinus carcinoma

Postoperative radiotherapy is a major treatment for patients with maxillary sinus carcinoma. However, the irregular resection cavity poses a technical difficulty for this treatment, causing uneven dose distribution to target volumes. In this study, we evaluated the dose distribution to target volumes and normal tissues in postoperative intensity-modulated radiotherapy (IMRT) after placing a water-filled balloon into the resection cavity. Three postoperative patients with advanced maxillary sinus carcinoma w...     

Treatment of carcinoma of the uterine cervix by remotely controlled afterloading intracavitary radiotherapy with high-dose rate: A comparative study with a low-dose rate system

From September, 1974 through December, 1979, a total of 249 patients with carcinoma of the cervix uteri Stage IIb and III were randomly allocated to either remotely controlled high-dose-rate intracavitary radiotherapy or manual afterloading low-dose-rate therapy, with radiotherapy of 20 Gy in 2 weeks to Point A to whole pelvis and 40 Gy in 4 weeks to the parametria. The dose to Point A by intracavitary radiotherapy was 40–60 Gy with one or two fractions in the low-dose-rate group and 30 Gy for the high-dose-rate group by 3 fractions with a once a week schedule. The purpose of this paper is to compare the results between the groups and to clarify the problems in the high-dose-rate group clinically. The local control rate was higher in the high-dose-rate group; however, the complication rate was also higher in this group than in the low-dose-rate group. The dose schedule and the place of rectal dose measurement is discussed. The overall cumulative survival rate was nearly the same in both groups (55 % at 5 years), although some difference was noted in each stage. The most common cause of death was distant metastasis outside the pelvis and the second most common was intercurrent disease in Stage IIb and local failure in Stage III.     

不同方法后装治疗宫颈癌152例远期放疗反应分析

目的 :比较不同方法后装治疗宫颈癌的远期放疗反应 ,探讨各种方法的合理应用。方法 :三组后装治疗病人均采取宫腔、阴道分上的方法 ,并配合外照射治疗。A组C组参照曼彻斯特法参考点均取A点 ,A组宫腔阴道对A点剂量贡献比为 1∶1,C组宫腔阴道对A点剂量贡献比 1.5～ 2 .4∶1;B组参照巴黎方法 ,参考点均取源轴中心外 2cm处 ,宫腔阴道组织受量比为 1∶1。结果 :三组疗效基本相近 ,差异无显著性 (P >0 .0 5)。远期放疗反应以阴道粘连最为常见 ,A组 36 / 4 2 (85.71% ) ,B组 4 / 86(4 .6 5% ) ,C组 (4 .17% ) ,A组显著高于B组和C组 (P <0 .0 1) ,B组和C组差异无显著性 (P >0 .0 5)。结论 :宫颈癌腔内治疗疗效确切可靠 ,但在腔内治疗各种方法的灵活应用上有时需注意 ,如参考点的设置、宫腔阴道剂量配比等 ,在采取宫腔、阴道分上参考点均取A点时 ,应结合病变范围及机器情况调整增加宫腔阴道对A点的剂量比例 (勿取 1∶1,本院用 1.5～ 2 .4∶1) ,以减少直肠、膀胱并发症。     

Intensity-modulated radiotherapy following null-margin resection is associated with improved survival in the treatment of intrahepatic cholangiocarcinoma

Background

The current study is the first to examine the effectiveness and toxicity of postoperative intensity-modulated radiotherapy (IMRT) in the treatment of intrahepatic cholangiocarcinoma (ICC) abutting the vasculature. Specifically, we aim to assess the role of IMRT in patients with ICC undergoing null-margin (no real resection margin) resection.

Methods

Thirty-eight patients with ICC adherent to major blood vessels were included in this retrospective study. Null-margin resection was performed on all patients; 14 patients were further treated with IMRT. The median radiation dose delivered was 56.8 Gy (range, 50-60 Gy). The primary endpoints were overall survival (OS) and disease-free survival (DFS).

Results

At a median follow-up of 24.6 months, the median OS and DFS of all patients (n=38) were 17.7 months (95% CI, 13.2-22.2) and 9.9 months (95% CI, 2.8-17.0), respectively. Median OS was 21.8 months (95% CI, 15.5-28.1) among the 14 patients in the postoperative IMRT group and 15.0 months (95% CI, 9.2-20.9) among the 24 patients in the surgery-only group (P=0.049). Median DFS was 12.5 months (95% CI, 6.8-18.2) in the postoperative IMRT group and 5.5 months (95% CI, 0.7-12.3) in the surgery-only group (P=0.081). IMRT was well-tolerated. Acute toxicity included one case of Grade 3 leukopenia; late toxicity included one case of asymptomatic duodenal ulcer discovered through endoscopy.

Conclusions

The study results suggest that postoperative IMRT is a safe and effective treatment option following null-margin resections of ICC. Larger prospective and randomized trials are necessary to establish postoperative IMRT as a standard practice for the treatment of ICC adherent to major hepatic vessels.