乳腺癌保乳术后放疗疗效和美观效果

目的　观察乳腺癌保乳术后放疗的疗效和美观效果。方法　保乳术后全乳外照射和瘤床加量共10 9例,79例除应用高剂量率插植技术[T1期肿瘤用单排插植,针距为1.5cm ,T2期以上肿瘤用双排或三排插植;针距间单次剂量(DB) 10～12Gy ,靶区周边剂量为85 %DB]外,其中4 8例还经组织间插植加量放疗;30例除采用电子线常规外照射15Gy外,其中2 7例还经电子线外照加量放疗。全乳照射应用6MV直线加速器,采用双切线半野照射技术,靶区剂量为4 5～5 2Gy(平均4 8.6Gy)。采用医生评分与患者问卷方法评价美观效果。结果　5年生存率为93.8% ,局部复发率为6 .5 %。全组无放射性溃疡发生,5例出现位于插植针孔周围急性皮肤炎症。在经临床随访体检的75例中,医生打分和患者自评满意度为优的比例分别占87%和81% (P >0 .0 5 )。两组满意度医生总评为优的患者比例分别为81.2 %和85 .2 % (P >0 .0 5 )。结论　乳腺癌保乳术后放疗可降低术后复发率,并发症少。不同的瘤床加量放疗方法不影响美观满意度。     

Interstitial brachytherapy for salvage treatment of vaginal recurrences in previously unirradiated endometrial cancer patients

PURPOSE: To evaluate whether interstitial brachytherapy can effectively salvage vaginal recurrence from endometrial carcinoma. METHODS AND MATERIALS: Between September 1989 and September 2000, 13 previously unirradiated patients (mean age 70 years) with isolated vaginal recurrences from endometrial adenocarcinoma were treated with interstitial low-dose-rate brachytherapy with or without additional external beam radiotherapy. Brachytherapy was delivered using a modified perineal Syed template loaded with (192)Ir. The central cylinder was loaded with high-activity (192)Ir (n = 12) or (137)Cs (n = 1). RESULTS: The patients had initially presented with FIGO Stage I (n = 11) or III (n = 2) cancer. Vaginal recurrences were diagnosed at a mean interval of 27.5 months after hysterectomy (range 2-83). The patients were followed for a median of 60 months (range 15-105). Ten patients had recurrence at the vaginal apex and three had recurrence in the lower two-thirds of the vagina. The median time to recurrence was 22 months. The tumor size ranged from 1.5 to 6 cm (mean 2.2, median 2.5). Eleven of 13 patients received 45-50-Gy pelvic external beam radiotherapy, followed by a mean interstitial brachytherapy boost of 28.3 Gy (range 18-35). The 2 other patients received brachytherapy only of 40 Gy and 50 Gy, respectively. All tumors were locally controlled. Three (23%) of 13 patients had a relapse at distant sites (two in the paraaortic region and one in the liver). The overall 8-year actuarial disease-specific survival rate was 77%. Major (Grade 3 and 4) long-term morbidity occurred in 2 patients (15%) and included Grade 3 vaginal ulceration in 1 patient, and Grade 4 colovesical fistula requiring surgical intervention in 1 patient. Additional long-term morbidity included Grade 2 proctitis in 1 patient. CONCLUSION: Interstitial brachytherapy with or without supplementary external beam radiotherapy can effectively salvage vaginal recurrence from endometrial cancer with very favorable local control and overall survival and acceptable morbidity.     

160例Ⅱb期宫颈癌术前光子线+术中电子线照射的远期疗效分析

目的 分析官颈癌Ⅱb期患者应用术前外照射+192Ir腔内照射+手术及术中电子线照射的远期疗效.方法 对160例应用术前外照射+192Ir腔内照射+手术及术中电子线照射的宫颈癌Ⅱb期患者资料进行回顾分析.全部患者术前先全盆腔接受了20 Gy分10次外照射和192Ir近距离腔内放疗,1周后全盆腔接受了12 MeV电子线18～20 Gy照射.结果 随访率为98.1%.随访满5、10年患者分别为143、135例.5年和10年生存率、无瘤生存率、局部控制率分别为89.4%、86.3%、96.3%和84.4%、81.0%、95.0%.放射性直肠炎、膀胱炎发生率分别为5.0%、0.6%.放疗后肾孟积水、下肢水肿发生率分别为6.3%、1.3%.结论 宫颈癌Ⅱb期患者应用术前外照射+192Ir腔内照射+手术及术中电子线照射可提高患者生存率,且对肿瘤原发部位局部控制效果好,放疗副反应少.     

Nasopharyngeal carcinoma treated by radical radiotherapy alone: Ten-year experience of a single institution

PURPOSE: To report on our experience in the treatment of nasopharyngeal carcinoma (NPC) by radical radiotherapy alone in our institution during the last decade. METHODS AND MATERIALS: From January 1990 to May 1999, 905 NPC patients were treated and were studied retrospectively. Radical radiotherapy was given to this cohort by conventional technique in a routine dose of 70-72 Gy to the primary tumor and metastatic lymph nodes. In case of residual primary lesion, a boost dose of 8-24 Gy was delivered by either 192Ir afterloading brachytherapy, fractionated stereotactic radiotherapy, conformal radiotherapy, or small external-beam fields. RESULTS: The 5-year and 10-year local-regional control, overall survival, and disease-free survival rates were 81.7% and 76.7%, 76.1% and 66.5%, 58.4% and 52.1%, respectively. In case of residual primary lesions after a dose of 70-72 Gy of conventional external-beam radiotherapy (EBRT), an additional boost was able to achieve a local control of 80.8%, similar to that obtained with primary lesions that completely disappeared at 70-72 Gy (82.6%, p = 0.892). CONCLUSIONS: The treatment results of radical EBRT followed by a boost dose to the residual primary tumor for nasopharyngeal carcinoma in our institution are promising.     

Conferencia de Consenso sobre la braquiterapia en cáncer de mama en estadios iniciales

A controversy exists since decades ago on the role of overdosis after external radiotherapy in conservative treatment of initial breast cancer. There are five randomised studies and one meta-analysis comparing surveillance and local control of conservative treatment versus mastectomy. These studies demonstrate that a dose of 50 Gy of external radiotherapy after conservative surgery reduces the rate of recurrence from 35% to 10%. Recently, the first randomised study on the role of a 16 Gy overdosis after conservative surgery and external radiotherapy with 50 Gy has been reported. The conclusion of this EORTC-coordinated study is clear: overdosis reduces the risk of local recurrence, especially in patients under 50 years old. Another randomised study carried out in Lyon shows that aboost of 10 Gy reduces the rate of local recurrence (4.5% local recurrence without theboost versus) 3.6% of local recurrence with theboost, p=0,044). Therefore, these randomised studies confirm the utility of overdosing. However, there are still doubts on how to deliver this boost, and in particular when brachytherapy should be performed. This timely issue was the leitmotif to organize this consensus meeting in Spain.     

早期乳腺癌保乳术后全乳大分割照射同步瘤床加量的临床分析

目的：观察早期乳腺癌保乳术后全乳大分割照射同步瘤床加量的短期疗效与不良反应。方法64例早期乳腺癌患者保乳术后行两野切线全乳照射,全乳腺照射40．5 Gy／15 f,单次剂量2．7 Gy／f,同步瘤床推量至48 Gy／15 f,单次剂量3．2 Gy／f,总疗程3周,观察分析患者局部复发情况、美容效果及不良反应。结果中位随访时间17月,随访率为100％,无局部复发情况发生。3例患者表现乳腺中度胀痛;Ⅰ、Ⅱ、Ⅲ级急性皮肤反应发生率分别为17．2％、4．7％、1．6％;Ⅰ级血小板下降发生率与Ⅰ～Ⅱ级中性粒细胞减少发生率分别为1．6％、4．7％;放疗完成后4、7月美容优良率分别为90．6％、87．5％。结论早期乳腺癌保乳术后全乳放疗同步瘤床加量的短期疗效与以往常规放疗方式相似,缩短放疗时间,不会增加皮肤不良反应及降低美容效果。     

External beam irradiation plus (192)Ir implant after breast-preserving surgery in women with early breast cancer

PURPOSE: To provide more information for the clinician and to analyze the impact of the boost with brachytherapy on the local disease-free survival (LDFS), disease-free survival (DFS), specific overall survival (OS), and cosmesis, a retrospective study of external radiation therapy and (192)Ir implantation in early breast cancer at Institut Català d'Oncologia has been undertaken. PATIENTS AND METHODS: From 1986 to 1996, 530 patients were selected for this study with a median follow-up period of 39.5 months (range, 10-115 months). External radiation therapy (combined with brachytherapy) was administered postoperatively to the breast in all patients. Mean given dose was 48.7 Gy (range, 42-52 Gy) with external radiation therapy to the breast, and 16.8 Gy (range, 10-27 Gy) was the mean dose with brachytherapy. Variables have been tested for cosmesis. Univariate and multivariate analysis have also been carried out. RESULTS: Mean age of the patients was 54 years (range, 28-81 years). Stages were distributed as follows: 350 patients (66%) in Stage I, 173 in Stage II (32.8%), and 7 in Stage III (1.1%). Pathologic distribution was 445 patients with infiltrating ductal carcinoma (84%), 20 patients with infiltrating lobular carcinoma (4%), and 65 patients (12%) of a miscellaneous group. OS for the entire group was 89.4% and 85.9% at 5 and 7 years respectively. Probability of DFS was 81.7% and 70.1% at 5 and 7 years. The LDFS was 94.9% and 91.7% at 5 and 7 years. The MFS probability was 85.5% and 76.9% at 5 and 7 years, respectively. Univariate analysis demonstrated that age (older than 52 years), premenopausal status, moderate and high histologic grades (Grades II-III), and presence of intraductal comedocarcinoma were prognostic factors for local relapse. Multivariate analysis for local disease-free survival demonstrated that only perineural or muscular infiltration remain as prognostic factors. Tumor dose bed of 70 Gy or higher had a negative impact in breast subcutaneous fibrosis, whereas dose rate lower than 65 cGy/h was better for skin color at 2 years. CONCLUSION: We conclude that patients with early-stage breast cancer undergoing external radiotherapy and LDR brachytherapy can be effectively managed. Overall survival, long-term local control, and cosmetic control are excellent.     

鼻咽旁区插植配合体外放射治疗鼻咽癌

目的探讨鼻咽旁区插植近距离放射治疗技术在鼻咽癌治疗中的作用。方法初治鼻咽癌患者体外照射56～70Gy（T2期56～60Gy,T3期66～70Gy）后复查CT或MRI发现鼻咽旁区残留病例67例,以腔内+鼻咽旁区插植放射治疗增量,咽旁区在模拟机引导下插入1～4根施源管,采用荷兰核通公司生产的192Ir高剂量率近距离治疗机,放射剂量2.5～4.0Gy/次,2次/d,间隔>6h,总剂量12～20Gy,3～4?d完成。插植组与同期的类似病例（67例）配对进行研究。结果鼻咽旁区插植组和对照组的3年生存率分别为92.4%,84.5%（P>0.05);3年无局部复发生存率分别为97.0%、76.4%（P<0.05);3年无远地转移生存率分别为76.6%、69.1%（P>0.05)。鼻咽旁区插植组的晚期放射反应如口干、张口困难发生率均低于对照组。结论鼻咽旁区插植放射治疗可以显著提高鼻咽癌咽旁区残留的局部控制率,拓宽了鼻咽癌近距离放射治疗的适应证,是一种有效的补充治疗手段。     

乳腺癌瘤床插植(保乳)放射治疗59例

目的　探讨乳腺癌保乳手术加根治性放疗和瘤床间质放疗的治疗原则及近期疗效。　方法　59例各期乳腺癌患者施保乳手术(单纯肿瘤切除 腋淋巴结清扫术)、术中或术后瘤床插植HDR192Ir针管放疗±化疗。靶区一次性放疗8Gy。手术后2～4周再接受全乳腺外照射,乳腺用切线野在5周被照射50Gy。随访时间平均为37个月。　结果　59例患者全部存活,无一例出现局部复发。无明显放射反应。双乳对称,外形美观。　结论　早期乳腺癌患者接受保乳手术加根治性放疗可以取得满意的临床效果,可成为早期乳腺癌的常规治疗方法     

Intraoperative radiotherapy given as a boost after breast-conserving surgery in breast cancer patients

Conventional radiotherapy after breast-conserving therapy is confined to 50-55 Gy external beam radiation therapy (EBRT) to the whole breast and 10-16 Gy external boost radiation to the tumour bed or brachytherapy to the tumour bed. Local recurrence rate after breast-conserving surgery varies between 5 and 18%. External boost radiation can partially miss the tumour bed and therefore can result in local failure. Intra-operative radiotherapy (IORT) as a high precision boost can prevent a 'geographical miss'. From October 1998 to December 2000, 156 patients with stage I and stage II breast cancer were operated upon in a dedicated IORT facility. After local excision of the tumour, the tumour bed was temporarily approximated by sutures to bring the tissue in the radiation planning target volume. A single dose of 9 Gy was applied to the 90% reference isodose with energies ranging from 4 to 15 MeV, using round applicator tubes 4-8 cm in diameter. After wound healing, the patients received additional 51-56 Gy EBRT to the whole breast. No acute complications associated with IORT were observed. In 5 patients, a secondary mastectomy had to be performed because of tumour multicentricity in the final pathological report or excessive intraductal component. 2 patients developed rib necroses. In 7 patients, wound healing problems occurred. After a mean follow-up of 18 months, no local recurrences were observed. Cosmesis of the breast was very good and comparable to patients without IORT. Preliminary data suggest that IORT given as a boost after breast-conserving surgery could be a reliable alternative to conventional postoperative fractionated boost radiation by accurate dose delivery and avoiding geographical misses, by enabling smaller treatment volumes and complete skin-sparing and by reducing postoperative radiation time by 7-14 days.     

The 10-Year Local Recurrence and Partial Breast Radiotherapy for Early Breast Cancer Treated by Conservative Surgery

C onservative surgery for early breast cancer was proposed by Keynes in 1924 and has been one of the main therapeutic mea- sures. It has been confirmed by abundant literature that the efficacy of conservative surgery plus whole breast radiotherapy is the …     

乳腺癌根治术后单纯胸壁复发放疗和胸壁再复发的预后分析

目的 探究乳腺癌根治术后单纯胸壁复发(ICWR)患者的照射野及剂量选择,同时分析胸壁再复发的预后因素。方法 回顾性分析1998—2018年间解放军总医院第五医学中心和医科院肿瘤医院收治的乳腺癌改良根治术后ICWR患者 201例,患者术后均未行辅助放疗。胸壁复发后 48例(73.6%)患者接受手术治疗,155例(77.1%)患者接受放疗。无进展生存(PFS)率的计算采用Kaplan-Meier法和log-rank检验,多因素分析采用Cox回归法。胸壁再复发的计算采用竞争风险模型和Gray检验,多因素分析采用F&G回归法。结果 复发后中位随访时间92.8个月,5年PFS率为23.2%,5年胸壁再复发率为35.7%。多因素分析显示联合手术+放疗和复发间隔时间>12个月患者有较低的胸壁再复发率,复发间隔时间>48个月、联合局部+全身治疗及联合手术+放疗的患者有较高PFS率。155例患者ICWR后接受胸壁放疗,全胸壁照射+局部补量比全胸壁照射可以改善首次胸壁复发后的 5年PFS率(34.0%∶15.4%,P=0.004)。胸壁放疗剂量(≤60Gy∶>60Gy)对胸壁再复发率及PFS率无明显影响(P>0.05)。53例未手术患者胸壁瘤床剂量≤60Gy和>60Gy的 5年PFS率分别为9.1%和20.5%(P=0.061)。结论 乳腺癌根治术后ICWR患者局部放疗建议包括全胸壁照射+局部补量,复发灶剂量需加至60Gy,对未行手术切除者需>60Gy。ICWR患者仍有较高的胸壁再复发风险,需要探索更有效的治疗方法。     

Results of definitive irradiation in a series of 305 epidermoid carcinomas of the anal canal

PURPOSE: To evaluate our data concerning the prognostic factors for locoregional control, survival, late complications, and sphincter conservation in a series of epidermoid cancers of the anal canal without clinical evidence of metastasis. METHODS AND MATERIALS: Between June 1972 and January 1997, 305 patients were treated with curative-intent radiotherapy (RT). The T stage according to the 1987 International Union Against Cancer classification was T1 in 26, T2 in 141, T3 in 104, and T4 in 34. Forty-nine patients had nodal involvement at presentation. The pretreatment anal function score, according to our in-house system, was 0 for 22 patients, 1 for 182, 2 for 74, 3 for 7, and 4 for 11 patients; for 9 patients, scores were unavailable. The treatment started with external beam radiotherapy (EBRT) in 303 patients (median dose 45 Gy). After a rest period of 4-6 weeks, a boost of 20 Gy was delivered by EBRT in 279 patients and by interstitial (192)Ir brachytherapy in 17 patients. Seven patients received only one course of EBRT (mean dose 49.5 Gy), and 2 patients were treated with interstitial (192)Ir brachytherapy alone (55 Gy and 60 Gy). Concomitant chemotherapy (5-fluorouracil and either mitomycin C or cisplatin) was delivered to 19 patients. The mean follow-up was 103 months (median 84). RESULTS: At the end of RT, the local tumor clinical complete response rate was 96% for T1, 87% for T2, 79% for T3, and 44% for T4. Of the 61 locally progressive tumors, 27 (44%) were salvaged with abdominoperineal resection. The rate of local tumor relapse was 12%. Among 37 local tumor relapses, 20 (54%) were salvaged with abdominoperineal resection and one with interstitial (192)Ir brachytherapy. The overall local control rate (with or without salvage local therapy) was 84%. The local control rate with good anal function (score 0 or 1) was 56.5%. Of 181 available patients with their anus preserved, 94% had good anal function. For a subgroup of 15 patients with a tumor length of <2 cm and without nodal involvement, the clinical complete response rate after RT completion was 100%, the local control rate with or without local salvage treatment was 100%, and among 13 available patients with their anus preserved, the anal function score was good in 12 patients (92%). The 10-year disease-free survival rate was 74%. After multivariate analysis, three independent predictive factors significantly influenced disease-free survival: the interval between the two courses of RT (>38 days vs. < or =38 days, p = 0.0025), pretreatment anal function score (0 vs. 1 vs. 2 vs. 3 vs. 4, p = 4.4.10(-6)), and clinical complete response after RT completion (no complete response vs. complete response, p = 2.5.10(-14)). CONCLUSION: We confirm the excellent results with RT in T1 and T2 lesions. However, to improve survival without colostomy with good anal sphincter function, chemoradiotherapy should be preferred for tumors > or =2 cm in length and for locally advanced tumors.     

Management of soft tissue sarcomas in first isolated local recurrence: a retrospective study of 83 cases]

PURPOSE: To analyse the management and clinical outcome of patients treated for a first isolated local recurrence of soft tissue sarcoma (trunk or extremities) and to identify prognosis factors. PATIENTS AND MATERIAL: This is a retrospective study of 83 adult patients treated between 1980 and 1999. Mean tumor size was 6 cm. Most sarcomas were located in extremities (N =74), were deep (N =60), and proximal (N =53). Thirty involved nerves or vessels. Histologic subtypes were mainly grade 2 (42%) or 3 (36%) histocytofibrosarcomas (49%) and liposarcomas (20%). Surgical treatment of recurrences consisted in wide excision (32 cases), marginal resection (46 cases), five patients requiring amputation. Final results were R0 (N =33), R1 (N =47) or R2 (N =3) resection. Beside surgery, six patients received neoadjuvant and seven others adjuvant chemotherapy. Twenty-three patients received postoperative external beam radiotherapy (EBRT) (mean dose 55 Gy) and 26 interstitial (192)Ir low dose rate brachytherapy (BCT) (mean dose 45 Gy for BCT alone, 22 Gy when associated with EBRT), 19 patients being re-irradiated. RESULTS: Mean follow up was 59 months. Thirty-seven (45%) tumors relapsed, 62% locally as first event. Nineteen patients developed secondary distant metastases. Multivariate analysis showed only tumour depth (P =0.05) and re-resection for primary R1 resection for the recurrence (P =0.018) being independent prognosis factors for tumour control, radiotherapy (EBRT and/or BCT) being significant in univariate analysis (P =0.05). Overall survival rate was 73, 54, and 47% at respectively 3, 5 and 10 years, and was 65, 35 and 32% after a further local recurrence. Multivariate analysis showed trunk (P =0.0001) or inferior extremity locations (P =0.023), symptomatic (P =0.001), high grade (P =0.01), deep (P = 0.01) tumours, and the occurrence of a further local failure (P =0.004) as unfavourable characteristics for overall survival. CONCLUSION: Because of the high relapse rate in this series, a first isolated local recurrence of STS increases mainly the risk of a subsequent local relapse. Quality of local treatment for the first local relapse is decisive. When a conservative treatment is feasible, it should combine surgical resection and radiotherapy, brachytherapy being the best suited in previously irradiated patients. Efforts have to be pursued to increase quality of the treatment of primary tumours, at best performed in centers that have expertise in this field.     

Chemoradiation and brachytherapy in biliary tract carcinoma: long-term results

PURPOSE: To evaluate long-term effects of chemoradiation and intraluminal brachytherapy in terms of local control, disease-free survival, overall survival, and symptom relief in patients with unresectable or residual extrahepatic biliary carcinoma. METHODS AND MATERIALS: Twenty-two patients with unresectable (17 patients) or residual (5 patients) nonmetastatic extrahepatic bile tumors received external beam radiation therapy (39.6-50.4 Gy) between 1991 and 1997. In 21 patients, 5-fluorouracil (96-h continuous infusion, Days 1-4, 1,000 mg/m2/day) was administered. Twelve patients received a boost of intraluminal brachytherapy with 192Ir wires (30-50 Gy) 1 cm from the source axis. RESULTS: During external beam radiotherapy, 10 patients (45.4%) developed Grade 1 to 2 gastrointestinal toxicity. In patients with unresectable tumor who could be evaluated, the clinical response was 28.6% (4 of 14). Two patients showed complete response. In all 22 patients, median durations of local control, disease-free survival, and overall survival were 44.5 months, 16.3 months, and 23.0 months, respectively. Two patients who received external beam radiation therapy and intraluminal brachytherapy developed late duodenal ulceration. In patients with unresectable tumors, median survival was 13.0 months and 22.0 months in those treated with and without brachytherapy, with 16.7% and no 5-year survival, respectively (p=0.607). Overall 5-year survival was 18.0%: 40% and 11.7% in patients treated with partial resection and in those with unresectable tumor, respectively (p=0.135). CONCLUSION: This study confirmed the role of concurrent chemoradiation in advanced biliary carcinoma; the role of intraluminal brachytherapy boost remains to be further analyzed in larger clinical trials.     

The role of brachytherapy in early-stage nasopharyngeal carcinoma

To present the treatment results and assess the optimal radiation dose and the role of brachytherapy in early stage nasopharyngeal cancer (NPC).

One hundred eighty-three patients with Stage I and II (American Joint Committee on Cancer Staging System, 1987) NPC completed the planned radiotherapy in our institution from 1979 to 1991. In 133 patients, radiotherapy was given to the nasopharynx by external beam to 64.8–68.4 Gy. Further boost was done by high dose rate (HDR) brachytherapy for 5–16.5 Gy in one to three fractions. For the remaining 50 patients, a course of external radiotherapy to the nasopharynx for 68.4–72 Gy was given to nasopharynx. Age (>40 or not) sex, neck boost or not, brachytherapy, and irradiation dose were analyzed to determine significant factors that influence the probabilities of local control and actuarial survival.

The 5-year disease-specific survival was 85.8% and local control was 83%. Only the brachytherapy and irradiation dose significantly affected the results. The use of the brachytherapy had significant impact on overall survival and local control. Furthermore, we compared the prognostic effect of various radiation dosage among Group I of 50 patients (<72.5 Gy, no brachytherapy, excluding four patients who received brachytherapy), Group II of 71 patients (72.5–75 Gy; one to two fractions of brachytherapy), and Group III of 58 patients (>75 Gy; three fractions of brachytherapy). Five-year disease-specific survival rates of Group I, Group II, and Group III were 77, 95.5, and 82.4%, respectively. Five-year local control rates were: 73.7, 93.9, and 79.5%. We found that the Group II had the best actuarial survival and local control rate (log-rank test, p < 0.05). Most patients receiving brachytherapy encountered foul odor because of nasopharynx crust; 12 of them had palate or sphenoid sinus floor perforation or nasopharynx necrosis. None of the patients without brachytherapy experienced the same complications.

The optimal radiotherapy dose to the nasopharnyx area in early stage NPC may be within 72.5 to 75 Gy by our treatment protocol. A dose of more than 75 Gy did not have significant local control or survival advantage. The use of brachytherapy to elevate radiation dose had significant local control and survival benefit for early stage NPC patients, but the fractionation size should be decreased to reduce the complications.     

Reirradiation of nasopharyngeal carcinoma with intracavitary mold brachytherapy: an effective means of local salvage

PURPOSE: To assess the role of intracavitary mold brachytherapy in salvaging local failure of nasopharyngeal carcinoma (NPC). METHODS AND MATERIALS: The outcomes of 118 consecutive NPC patients with local failure treated with mold brachytherapy between 1989 and 1996 were retrospectively reviewed. Eleven patients received additional external radiotherapy. RESULTS: All molds were tailor-made, and the whole procedure was performed under local anesthesia. Pharyngeal recess dissection was routinely performed to allow direct contact of the radioactive source with the pharyngeal recess, a common site of local failure. Initially, the molds were preloaded with 192Ir wires, but since 1992, the sources have been manually afterloaded; the mold has also been redesigned for better conformity, ease of insertion, and radiation safety. Using brachytherapy alone, 50-55 Gy was given for recurrence in 4-7 days; for persistence, 40 Gy was administered. The overall complete remission rate was 97%. The rates of 5-year local control, relapse-free survival, disease-specific survival, overall survival, and major complication were 85%, 68.3%, 74.8%, 61.3%, and 46.9%, respectively. Major complications included nasopharyngeal necrosis with headache, necrosis of cervical vertebrae with atlantoaxial instability, temporal lobe necrosis, and palsy of the cranial nerves. The afterloaded mold was as effective as the preloaded version, but with fewer complications. CONCLUSIONS: Intracavitary mold brachytherapy was effective in salvaging NPC with early-stage local persistence or first recurrence.     

Optimizing surveillance mammography following breast conservation surgery.

AIMS: Prompt detection and treatment of local recurrence (LR) following breast conservation surgery (BCT) may improve subsequent survival. Following early reports demonstrating increased LR in the first years after surgery, a practice of surveillance mammography starting 1 year from diagnosis has become established. Increasing use of adjuvant chemotherapy with adriamycin-containing regimens has resulted in radiotherapy being postponed, so that the first mammogram coincides with the acute radiotherapy reaction, resulting in patient discomfort and poor quality films. We wished to determine if the 1-year mammogram could safely be omitted. METHODS: We reviewed 1151 consecutive patients treated with BCT for in situ, stage I or II disease over a 10-year period. All patients had clear resection margins and, where indicated, underwent axillary surgery and adjuvant treatment. This consisted of radiotherapy (40 Gy with a 5 Gy boost), chemotherapy and/or tamoxifen. RESULTS: Overall, the 5-year actuarial rate of local recurrence was 4.8%. The cumulative risk of LR at 12 months was 0.3% (three patients) and 1.9% (20 patients) at 24 months. This included all cases of high-grade DCIS (>30 mm in size) and all but one tumour with a Nottingham Prognostic index (NPI) of >6.0 which recurred locally. CONCLUSION: Even including those patients generally accepted to be at high risk of LR, the cumulative risk of LR was only 0.3% at 12 months from surgery. We now therefore schedule routine biennial mammography from time of surgery except for those with high risk of early local recurrence such as extensive, high-grade in situ disease.     

Breast-conservative surgery with close or positive margins: can the breast be preserved with high-dose-rate brachytherapy boost?

PURPOSE: To evaluate the likelihood of preserving the breast in women who show close or positive margins after conservative surgery for early breast carcinoma. METHODS AND MATERIALS: Since 1996, 125 women with less than 5 mm or positive margins and positive separate cavity margin sampling were entered in a prospective trial with high-dose radiotherapy. A standard dose of 50 Gy to the whole breast was followed by a high-dose-rate brachytherapy application delivering 3 fractions of 4.4 Gy in 24 hours. The median follow-up was 84 months. RESULTS: There were only seven local recurrences, with an actuarial local control rate of 95.8% at 5 years and 91.1% at 9 years. Actuarial overall and cause-specific survival rates were 92.6% and 95% at 5 years and 86.7% and 90.4% at 9 years, respectively. Late fibrosis was the most common complication, in 30% of patients, with good or excellent cosmetic results in 77%. The final result was that 95.2% of breasts were preserved. CONCLUSIONS: Close or positive-margin breast cancer can be well managed with a high-dose boost in a wide tumor bed by means of high-dose-rate brachytherapy. This technique can avoid mastectomy or poor cosmetic resection, with minimal risk of local or general failure.     

Dose Escalation by Intensity-modulated Radiotherapy Boost after Whole Pelvic Radiotherapy in Postoperative Patients of Carcinoma Cervix with Residual Disease

AimsExternal beam radiotherapy followed by brachytherapy is the standard treatment for patients with carcinoma cervix. However, for patients who come from peripheral hospitals after incomplete surgery, whole pelvic radiotherapy (WPRT) followed by boost with either vaginal vault brachytherapy if suitable or further external beam radiotherapy is recommended. This study was conducted to evaluate if it was possible to give a higher tumour dose using intensity-modulated radiotherapy for that group of patients who were not suitable for high dose rate vaginal vault brachytherapy because of gross disease after WPRT.Materials and methodsA prospective study was carried out from 2005 to 2010 in which 25 postoperative patients of cervical carcinoma with gross residual disease after WPRT of 46 Gy/23 fractions/4.5 weeks were included. Nine patients were treated with 20 Gy to the planning target volume and 30 Gy to the clinical target volume in 10 fractions; 16 patients were treated with 30 Gy to the planning target volume and 35 Gy to the clinical target volume in 15 fractions. The end points of this study were local control, survival and treatment-related toxicity.ResultsThe median follow-up was 38 months. The 3 year local control, progression-free survival and overall survival rates were 76, 74 and 67%, respectively. Late grade 2 rectal toxicity was seen in 11 patients. Grade 2 bladder toxicity occurred in two patients and grade 3 bowel toxicity in two patients. No other grade 3 or higher toxicity was seen.ConclusionInadequate and inappropriate surgery in invasive cervical cancer with resulting gross residual disease is common in India. It is possible to escalate the tumour dose by intensity-modulated radiotherapy boost after WPRT in postoperative cervical carcinoma patients with gross residual disease with low incidence of severe toxicity and excellent local control.