Long-term morbidity after curative radiotherapy for carcinoma of the bladder. A retrospective study

48 patients with muscle invasive bladder cancer were asked by a mailed questionnaire concerning post-radiotherapy functional status, urological and intestinal complaints. All patients had received curative pelvic irradiation (greater than or equal to 1750 reu) nine to 133 months prior to the investigation. Eleven patients had recurrent or persistent disease and four (36%) of these patients had severe hematuria. The urinary morbidity of the 37 patients without evidence of disease varied between 24 and 38%, but only 3 to 8% of these patients experienced severe disturbances. Four patients (9%) had to undergo bowl resection due to severe radiation damage in the intestines. In conclusion, slight morbidity after curative radiation treatment is to be expected in about 30% of patients surviving more than six months. Severe complications may be expected in 10% of the patients. Serious complaints from the urologic tract, especially hematuria, indicate recurrent or persistent disease rather than a late radiation effect.     

膀胱癌术后放疗与第二原发直肠恶性肿瘤的关联性研究:一项基于大队列的回顾性研究

目的 探讨膀胱癌术后放疗与发生第二原发肿瘤直肠癌风险的关系。方法 从美国国立癌症研究所肿瘤监测、流行病学和结果数据库(SEER)(1975—2017)中纳入符合标准的膀胱癌患者75 120例。第二原发肿瘤定义为膀胱癌治疗后5年以上发生的直肠癌,第二原发肿瘤直肠癌的累积发病率通过Fine-Gray竞争风险回归进行估计。用泊松回归评估放疗患者与未放疗患者中直肠癌的相对风险。结果 在75 120例患者中,70 045例(92.4%)为白人,中位年龄65.8岁(54~74岁)。2 236例(3%)接受了术后放疗,72 884例(97%)仅接受了手术治疗。在放疗和非放疗患者中,30年随访期间直肠癌的累积发生率分别为0.93%和0.43%(P=0.004)。在竞争风险回归分析中,接受放疗与发生直肠癌明显相关(HR=1.86;95%CI 1.26~2.74,P=0.009)。直肠癌放疗相对风险(RR)随着直肠癌诊断时间越早增加越显著(1975—1985 v.s.1985—1994:RR=2.59;95%CI 1.20~4.86,P＜0.001),放疗时年龄越小发生第二原发肿瘤的概率越大(≤50岁vs.＞50岁:RR=7.89;95%CI 2.97~21.30,P＜0.001);使用泊松分布计算放疗患者直肠第二肿瘤相对风险均更高(RR=2.20;95%CI 1.45~3.18,P＜0.001),诊断日期调整后,放疗患者直肠第二肿瘤风险仍更高(RR=1.77;95%CI 1.17~2.57,P=0.009)。结论 膀胱癌放疗后发生直肠癌的风险增加,应积极随诊检查尽早发现膀胱癌放疗后相关的第二原发肿瘤直肠癌。     

Intraarterial 5-FU-infusion and simultaneous radiotherapy as palliative treatment of recurrent rectal cancer.

Palliative treatment of recurrent rectal cancer remains to be a challenge. From 1989 to 1991 13 patients with recurrent rectal cancer were treated with intraarterial infusion of 5-Fluorouracil and simultaneous radiotherapy in a palliative intent. Seven patients had received postoperative adjuvant radiotherapy with 56 to 60 Gy. Three patients had been treated with systemic chemotherapy. Radiotherapy of the recurrence was performed with 19.8 to 30.6 Gy in the pre-irradiated patients and with 50.4 to 59.4 Gy in the others. One complete remission, three partial remissions and nine minor responses were observed. Three patients had complete pain relief after the treatment, in the remaining patients major pain reduction was achieved. Palliation lasted from three to twelve months (median: five months). Our results indicate that locoregional chemo- and radiotherapy are a effective modality in recurrent rectal cancer.     

Visualisation of bladder cancer using (11)C-choline PET: first clinical experience

Fluorine-18 fluorodeoxyglucose (FDG), the most widely used radiopharmaceutical in positron emission tomography (PET) for oncological purposes, is unsuitable for imaging of bladder cancer owing to high excretion into the urine. More specific PET radiopharmaceuticals which are not excreted into urine would be welcome. Carbon-11 labelled choline (CHOL) is a new radiopharmaceutical potentially useful for tumour imaging and is not excreted into the urine. We prospectively studied the visualisation of bladder cancer using CHOL PET. Eighteen patients with bladder cancer and five healthy volunteers were included. Bladder cancer was first diagnosed by transurethral resection or by biopsy of the tumour. Next, PET images were performed before surgical treatment by cystectomy. The histopathological findings after cystectomy were used as the gold standard. PET images were performed on either an ECAT 951/31 or an ECAT Exact HR+ system. Attenuation-corrected PET images were obtained after injection of 400 MBq CHOL. PET images were analysed by two independent physicians using visual analysis and calculation of the standardised uptake value (SUV). In the normal bladder wall, the uptake of CHOL was low, and the bladder margin was only outlined by minimal urinary radioactivity, if present. In ten patients the tumour was detected correctly by CHOL PET, with an SUV of 4.7+/-3.6 (mean+/-SD). One false positive CHOL PET scan was seen in a patient with an indwelling catheter for 2 weeks prior to the PET scan. In two patients, lymph node metastases were detected by CHOL PET. A micrometastasis <5 mm was not visualised with CHOL PET. In seven patients, no residual tumour was found after surgery. In six of seven patients CHOL PET imaging was negative. In situ carcinoma, dysplasia and a non-invasive urothelial tumour (pTa) remained undetected in three of these six patients. Minimal to no urinary tract radioactivity was seen in 22/23 subjects. Non-specific uptake of CHOL was observed in the small bowel, rectum and prostate gland. CHOL uptake in bladder cancer was avid, visualising the tumour in the virtual absence of urinary radioactivity. No uptake of CHOL was seen in pre-malignant lesions or in small non-invasive tumours. Our results warrant further research into the value of CHOL PET in the clinical management of patients with bladder cancer.     

Curative radiotherapy in patients with anal cancer: clinical outcomes and prognostic factors in a single-institution experience

Purpose

Our aim was to retrospectively analyse a series of patients with anal cancer treated with curative intent at a single institute in terms of survival and local disease control.

Materials and methods

Forty-two patients with anal cancer were treated with primary radiotherapy with or without concurrent chemotherapy. The influence of the prognostic factors on overall (OS), disease-free (DFS), disease-specific (DSS), colostomy-free (CFS) and metastasis-free (MFS) survival was evaluated.

Results

Nine patients had stage I, 15 stage II, four stage IIIA and 14 stage IIIB disease. Tumour progression/ persistence occurred in five patients (12%). The 5-year OS, DSS, DFS, CFS and MFS were 72.7%, 84.2%, 85.7%, 81.1% and 87.1%, respectively. On univariate analysis, T stage emerged as highly significant for OS, DSS, CFS and DFS, whereas N status was a significant prognostic factor for DSS. On multivariate analysis, T stage was a significant prognostic factor for OS and CFS.

Conclusions

Our data support the view that combined chemoradiation treatment of anal cancer is feasible and may provide survival benefits with an acceptable rate of adverse effects. We should consider T and N stages as important prognostic factors for survival.     

Does one size fit all? Adaptive radiotherapy for bladder cancer: A feasibility study

IntroductionAdaptive techniques to deliver radiotherapy to the bladder may ensure treatment accuracy whilst sparing organs at risk. This study assesses the frequency of when an alternative plan to the current standard may be beneficial and establish the treatment resource implications of adaptive techniques. Assess the variation in accuracy of skeletal surrogate compared to the target. Additionally describes a training package for therapeutic radiographers evaluating CBCT datasets for adaptive techniques.MethodsA library of three plans was created for each patient, small, standard and large. Weekly CBCT and planar imaging data were acquired from 10 bladder cancer patients receiving radical radiotherapy. Bladder volumes from weekly CBCT were compared to the planning scan. Image registration was performed using bone and soft tissue structures on the CBCT images. A database of images was created to develop competency assessment and a training package.ResultsMatching to a skeletal surrogate may under estimate movement of the target. Bladder volume can vary significantly during the course of treatment, even in the presence of bladder preparation protocols. The additional time required to implement this technique is 4 min per fraction compared to standard treatment with planar imaging.ConclusionsThis feasibility study is a useful process to facilitate the implementation of adaptive techniques. However a limitation of this study is the low number of CBCT datasets evaluated. The advent of IGRT and adaptive techniques gives increased confidence to reduce margins, consequently facilitating hypo-fractionation, and may provide a gain in linear accelerator efficiency and reduce the number of hospital visits for the patient. CBCT paired with a development programme for therapeutic radiographers is an effective and efficient means of implementing adaptive radiotherapy.     

A retrospective study of the results of postoperative radiotherapy of hypernephroma

Retrospectively the patients were analyzed, postoperatively irradiated because of a hypernephroidal kidney carcinoma during the years 1978 to 1988. With a total number of 44 patients 12 were in stage I (Robson), 13 in stage II, 17 in stage III and 2 in stage IV. The probabilities for a tumor-free survival of five years were 81%, 59% and 30% for the stages I to III. The local recurrence rate was 7%, caused by exclusion of clinically negative lymph-nodes from irradiation field. In addition to survival probabilities the complication rate of radiotherapy is analyzed too. To this additionally to analysis of symptoms of a possible side-effect the nuclear medical investigation of function of the remaining kidney was done in 9 selected tumor-free patients being irradiated in different techniques. A normal function was found in all cases. No severe side-effects can be shown in irradiated patients. Consequently the postoperative radiotherapy in hypernephroma is a supportive therapy of advanced tumor stages without severe side-effects. Further and greater planned analyses are necessary to comprehend prognostic factors.     

Radiologic examination in gastric cancer. A retrospective study of 188 patients

The accuracy in the diagnosis of gastric cancer was investigated in 188 histologically proven cases, including 12 cases of early gastric cancer. One hundred and sixty-five of 167 patients (99%) were recorded radiologically as having a gastric lesion. The initial diagnosis was carcinoma in 144 patients (86%), and benign lesion in 21 cases (13%). In 2 cases (1%) no abnormalities were seen. In 3 out of 9 patients with a partial gastrectomy (33%) an incorrect diagnosis was made. In 11 of 12 patients with early gastric cancer the radiologic examination revealed abnormal findings, but 7 of these were incorrectly interpreted as benign. A retrospective analysis of the radiologic examination in which no malignancies were reported showed that inadequacy of the examination technique and misinterpretation of radiologic signs of malignancy were the main causes of failure in diagnosing of malignancy. The rate of misinterpretation of malignancy as a benign lesion (13%) justifies the endoscopic control of every radiologically detected abnormality. The high sensitivity in detecting a lesion indicates, however, that a biphasic radiologic examination is a safe screening method in gastric cancer. Endoscopy with biopsy showed a lesion in 156 out of 160 patients (98%), but in 11 of these (7%) the initial examination did not yield histologic proof of malignancy. In 4 patients (2%) no abnormalities were observed by endoscopists. One hundred and forty-nine patients were examined with both radiology and endoscopy with biopsy. A malignant lesion with recognition of its malignant character was defined in 144 cases (97%).     

A pilot study of accelerated fractionation in the radiotherapy of invasive carcinoma of the bladder.

24 patients with muscle invasive carcinoma of the bladder were treated in a pilot study of twice daily fractionation at radiation doses of 1.8-2.0 Gy per fraction to total doses of 54-64 Gy to the bladder and 39.6-44 Gy to the whole pelvis. The treatment aim was to give 32 fractions in 22 days. The interfraction interval was a minimum of 6 h. The principle objective was to record acute and late tolerance, but local control and survival data is also presented. Acute radiation morbidity was scored according to the RTOG system. Grade 2 large bowel effects were seen in 52% of patients, Grade 3 effects in 26% and there was one Grade 4 and one Grade 5 effect. The mean duration of effect was 4.5 weeks although the more severe reactions were also more protracted. Grade 2 urinary effects occurred in 30% and Grade 3 in 17% of patients. The mean duration of effect was 7.2 weeks. There were no Grade 4 or 5 acute urinary effects. Late radiation morbidity was scored according to the EORTC/RTOG system and was assessable in 16 cases who survived more than 6 months. There were two cases (12%) of Grade 1 bowel toxicity, two cases of Grade 1 and three of Grade 2 urinary toxicity. There were no cases of late skin effects. Actuarial analysis at 2 years shows a local control probability of 56% and survival probability of 35%.     

局部晚期非小细胞肺癌同步加量调强放疗的回顾性分析

目的 分析采用同步加量调强放疗(SIB-IMRT)技术治疗局部晚期非小细胞肺癌(NSCLC)的疗效及安全性.方法 回顾分析2008年1月至2011年6月在我院胸部放疗科行SIB-IMRT治疗的局部晚期NSCLC 78例,其中,ⅢA期45例,ⅢB期33例.处方剂量为PTV 50.4 ～64.0 Gy/28 ～33次,单次剂量为1.8～2.1 Gy;IGTV为60.0 ～ 74.3 Gy/28 ～ 33次,单次剂量为2.0～2.5 Gy.主要观察指标为总有效率(ORR)、局部控制率(LCR)、总生存率(OS)、无疾病进展生存率(PFS)及3级及以上食管和肺损伤.结果 78例患者均按计划完成根治性放疗,IGTV剂量≥60 Gy.67例(85.9％)患者接受以顺铂或卡铂为基础的第三代细胞毒药物两药联合方案化疗,其中17例(21.8％)为同步放化疗,50例(64.1％)为序贯放化疗.全组ORR为69.2％,其中CR 11例(14.1％),PR 43例(55.1％),SD 22例(28.2％),PD 2例(2.6％).截至2012年10月,失访6例,随访率92.3％.72例可随访患者中已死亡50例,22例存活.1、2、3年局部控制率分别为88.4％、54.7％、28.6％,中位PFS为15.3个月(2.3 ～46.8个月),中位OS为27.3个月(5.8 ～49.3个月).1、2、3年无进展生存率分别为50.7％、27.6％、21.1％;1、2、3年总生存率分别为87.5％、56.6％、30.3％.在同步放化疗与非同步放化疗亚组中,中位OS分别为32.8个月和24.1个月,1、2、3年总生存率分别为94.7％、73.7％、47.3％和83.0％、50.5％、23.9％(x2=3.946,P＜0.05).全组共发生急性放射性食管损伤59例(75.6％),治疗相关性肺损伤(TRP)21例(26.9％),其中3级及以上放射性食管损伤19例(24.4％),3级及以上放射性肺损伤9例(11.5％).随访1年后,2例(2.6％)出现晚期3级肺损伤,食管无3级及以上晚期不良反应.结论 SIB-IMRT照射技术治疗局部晚期NSCLC疗效确切,安全性良好,值得临床进一步开展大样本前瞻性随机对照研究.     

A retrospective study of marital discord in pilots: the USAFSAM experience

This exploratory retrospective multi-case study investigates marital discord in USAF pilots as part of an overall concern with mission safety. Seventeen USAF School of Aerospace Medicine (USAFSAM) cases involving marital distress were reviewed, using a standardized format. Duration of martial discord ranged from 1-10 years with an average of 2.25 years. The most frequent problem noted was one of communication, with authoritarian or controlling styles predominating. The second most frequent conflict concerned occupational demands; both pilots and spouses complained about frequent work-related separations. Nine of ten distressed outcomes (i.e., separated or divorced) were initiated by the wife. We speculate that a pilot with an inflexible communication style who is not cognizant of his or her spouse's emotional needs is likely to exacerbate marital problems. The notion that marital distress may adversely affect a pilot's attention, generating performance decrements, underscores the importance of investigating elements of marital harmony in the pilot population. Based on our study and review of the literature, we suggest the USAF employ programs that: a) recognize the spouse's contribution to mission safety; b) increase spouse's awareness of mission requirements; c) enhance couple's communication; and d) improve stress management skills.     

A retrospective study of the role of radiotherapy in the treatment of soft-tissue sarcoma

One hundred and forty patients with soft-tissue sarcoma were seen between 1965 and 1974 and the pathology has been reviewed in 93 cases. One hundred and eight patients were treated radically. Their overall survival rate was 53% at 5 years and 41% at 10 years. Overall local control was 63% but primary local control varied considerably with treatment, being highest for those receiving surgery and post-operative radiotherapy. The poor prognosis of patients with paravertebral tumours is confirmed.