Intensity modulated radiotherapy as neoadjuvant chemoradiation for the treatment of patients with locally advanced pancreatic cancer

Background

To evaluate outcome after intensity modulated radiotherapy (IMRT) compared to 3D conformal radiotherapy (3D-RT) as neoadjuvant treatment in patients with locally advanced pancreatic cancer (LAPC).

Materials and methods

In total, 57 patients with LAPC were treated with IMRT and chemotherapy. A median total dose of 45 Gy to the PTV__baseplan and 54 Gy to the PTV__boost in single doses of 1.8 Gy for the PTV__baseplan and median single doses of 2.2 Gy in the PTV__boost were applied. Outcomes were evaluated and compared to a large cohort of patients treated with 3D-RT.

Results

Overall treatment was well tolerated in all patients and IMRT could be completed without interruptions. Median overall survival was 11 months (range 5–37.5 months). Actuarial overall survival at 12 and 24 months was 36?% and 8?%, respectively. A significant impact on overall survival could only be observed for a decrease in CA 19-9 during treatment, patients with less pre-treatment CA 19-9 than the median, as well as weight loss during treatment. Local progression-free survival was 79?% after 6 months, 39?% after 12 months, and 13?% after 24 months. No factors significantly influencing local progression-free survival could be identified. There was no difference in overall and progression-free survival between 3D-RT and IMRT. Secondary resectability was similar in both groups (26?% vs. 28?%). Toxicity was comparable and consisted mainly of hematological toxicity due to chemotherapy.

Conclusion

IMRT leads to a comparable outcome compared to 3D-RT in patients with LAPC. In the future, the improved dose distribution, as well as advances in image-guided radiotherapy (IGRT) techniques, may improve the use of IMRT in local dose escalation strategies to potentially improve outcome.     

Simultaneous integrated boost intensity-modulated radiotherapy in esophageal carcinoma

Purpose

The safety and efficacy of using simultaneous integrated boost intensity-modulated radiotherapy (SIB-IMRT) for patients with esophageal squamous cell carcinoma were evaluated in a single-institution phase II setting.

Methods and materials

Between June 2007 and October 2009, 45 patients underwent concurrent chemoradiotherapy (n?=?27) or radiotherapy alone (n?=?18). Two planning target volumes (PTV) were defined for the SIB: PTV_C and PTV_G, with prescribed doses of 50.4 Gy to the PTV_C (1.8 Gy/fraction) and 63 Gy to the PTV_G (2.25 Gy/fraction), both given in 28 fractions.

Results

At a median follow-up interval of 20.3 months, the 3-year overall survival (OS) and progression-free survival (PFS) rates were 42.2 and 40.7?%, respectively. The median overall survival time was 21 months; locoregional control rates were 83.3?% at 1 year and 67.5?% at 3 years. According to CTCAE (version 3.0) criteria, none of the patients developed grade 4–5 toxicity. The most common grade 2 and 3 radiation-related toxicity was radiation esophagitis, occurring in 64?% of all patients (but only 13?% as grade 3). No patient developed grade >?2 pulmonary complications.

Conclusion

SIB-IMRT is a feasible therapeutic approach for esophageal carcinoma patients and provides encouraging locoregional control with a low toxicity profile. Further investigations should focus on dose escalation and optimization of the combination with systemic therapies.     

Efficacy and toxicity of (chemo)radiotherapy for primary subglottic cancer

Background and purpose

Primary subglottic cancer is a rare malignancy. We investigated the efficacy and toxicity of radiotherapy for subglottic cancer.

Patients and methods

Nineteen patients with primary squamous cell carcinoma of the subglottis received radiotherapy, 14 of whom also underwent chemotherapy. Of the 19 patients, 15 received definitive radiotherapy to the gross tumors with total doses of 70–70.2 Gy in 35–39 fractions, and 4 underwent preoperative radiotherapy with total doses of 37.8–55.8 Gy in 21–31 fractions, followed by total laryngectomy.

Results

Of the 19 patients, 5 developed local progression and 2 developed distant metastasis at the median follow-up period of 5 years. The 5-year local control and disease-free rates were 74 and 63%, respectively. Three patients died of tumor progression, and the 5-year overall and disease-free survival rates were 80 and 63%, respectively. Regarding acute toxicities, transient mucositis and dermatitis of grade 3 or lower were observed in all patients, but there were no late toxicities of grade 3 or higher.

Conclusion

Radiotherapy is a safe and effective treatment for patients with primary squamous cell carcinoma of the subglottis. The use of chemotherapy together with radiotherapy may enhance treatment efficacy and contribute to larynx preservation through good local control.     

Radiation therapy for angiosarcoma of the scalp

Background and purpose

Wide surgical excision is the standard treatment for angiosarcoma of the scalp, but many patients are inoperable. Therefore, we investigated the outcome of radiation therapy for angiosarcoma of the scalp.

Patients and methods

Seventeen patients with angiosarcoma of the scalp underwent radiation therapy with total scalp irradiation. Four patients had cervical lymph node metastases, but none had distant metastases. A median initial dose of 50 Gy in 25 fractions was delivered to the entire scalp. Subsequently, local radiation boost to the tumor sites achieved a median total dose of 70 Gy in 35 fractions.

Results

Fourteen of the 17 patients developed recurrences during the median follow-up period of 14 months after radiation therapy; 7 had recurrences in the scalp, including primary tumor progression in 2 patients and new disease in 5, and 12 patients developed distant metastases. The primary progression-free, scalp relapse-free, and distant metastasis-free rates were 86, 67, and 38?% at 1 year and 86, 38, and 16?% at 3 years, respectively. Thirteen patients died; the overall and cause-specific survival rates were both 73?% at 1 year and 23 and 44?% at 3 years, respectively. The median survival time was 16 months. There were no therapy-related toxicities ≥?grade 3.

Conclusion

Total scalp irradiation is safe and effective for local tumor control, but a dose of ≤?50 Gy in conventional fractions may be insufficient to eradicate microscopic tumors. For gross tumors, a total dose of 70 Gy, and >?70 Gy for tumors with deep invasion, is recommended.     

Nonmetastatic pancreatic cancer

Purpose

The role of radiotherapy (RT) for nonmetastatic pancreatic cancer is still a matter of debate since randomized control trials have shown inconsistent results. The current retrospective single-institution study includes both resected and unresected patients with nonmetastasized pancreatic cancer. The aim is to analyze overall survival (OS) after irradiation combined with induction chemotherapy.

Patients and methods

Of the 73 patients with nonmetastatic pancreatic cancer eligible for the present analysis, 42 (58%) patients had adjuvant chemoradiotherapy (CRT), while 31 (42%) received CRT as primary treatment. In all, 65 (89%) had chemotherapy at any time before, during, or after RT, and 39 (53%) received concomitant CRT. The median total dose was 50?Gy (range 12–77?Gy), while 61 (84%) patients received >40?Gy.

Results

With a median follow-up of 22 months (range 1.2–179.8 months), 14 (19%) are still alive and 59 (81%) of the patients have died, whereby 51 (70%) were cancer-related deaths. Median OS and the 2?year survival rate were 22.9 months (1.2–179.8 months) and 44%, respectively. In addition, 61 (84%) patients treated with >40?Gy had a survival advantage (median OS 23.7 vs. 17.3 months, p?=?0.026), as had patients with 4 months minimum of systemic treatment (median OS 27.5 vs. 14.3 months, p?=?0.0004).

Conclusion

CRT with total doses >40?Gy after induction chemotherapy leads to improved OS in patients with nonmetastatic pancreatic cancer.

     

Radiotherapy with or without chemotherapy in the treatment of anal cancer: 20-year experience from a single institute

Purpose

To report the efficacy and toxicity of radio(chemo)therapy (RCT) in the management of squamous cell anal carcinoma (SQ-AC) and to evaluate the prognostic factors influencing the outcomes.

Patients and methods

A consecutive cohort of 138 patients with cT1-4, cN0-3, cM0 SQ-AC were treated with RCT between 1988 and 2011 at our department. Median follow-up time for surviving patients from the start of RCT was 98 months (range, 1–236 months). Patients were treated with a median radiation dose of 56 Gy (range, 4–61 Gy). Concurrent chemotherapy was administered to 119 patients (86%).

Results

The survival rates at 2, 5, and 10 years were 88?±?3, 82?±?4, and 59?±?6%, respectively, with a median overall survival (OS) of 167 months. The cumulative incidence for local recurrence at 2 and 5 years was 8?±?2 and 11?±?3%, respectively. The median disease-free survival (DFS) and colostomy-free survival (CFS) times were 132 and 135 months, respectively. In 19 patients (14%), a distant metastasis was diagnosed after a median time of 19 months. In the multivariate analysis, UICC (International Union Against Cancer) stage I-II, female gender, Eastern Cooperative Oncology Group (ECOG) performance status of 0–1, and good/moderate histologic differentiation (G1–2) were significantly associated with a better OS, DFS, and CFS. Conformal radiotherapy planning techniques were significantly associated with a lower cumulative incidence of local recurrence (11?±?3% vs. 38?±?19% at 5 years, p?=?0.006). A higher radiation dose beyond 54 Gy was not associated with an improvement in outcome, neither for smaller—(T1/T2) nor for larger tumors (T3/T4).

Conclusion

RCT leads to excellent outcomes—especially in patients with stage I/II and G1/G2 tumors—with acceptable toxicity. The probable advantages of high-dose radiotherapy should be considered carefully against the risk of a higher rate of toxicity. Future studies are needed to investigate the role of a more intensified (systemic) treatment for patients with unfavorable prognostic factors such as T3/T4, N+, and/or poor cell differentiation.     

Prognosis of primary central nervous system lymphoma treated with radiotherapy alone

Purpose

Standard treatment for patients with primary central nervous system (CNS) lymphoma involves combining high-dose methotrexate-based chemotherapy and radiation. However, chemotherapy is sometimes contraindicated, and radiotherapy alone becomes the only option. We retrospectively investigated the clinical outcomes of primary CNS lymphoma patients treated with radiotherapy alone.

Materials and methods

Between 1983 and 2006, 35 patients (median age 69 years, range 37–89 years) with primary CNS lymphoma were treated with radiotherapy alone. Of these, 74 % had an Eastern Cooperative Oncology Group performance status (PS) of 2–4. Most patients (91 %) received whole-brain irradiation with or without irradiation boost to the tumor site (median dose 50 Gy, range 22–50 Gy); remaining patients received partial brain irradiation.

Results

Median follow-up time was 20 (range 1–152) months, median survival time was 20 months, and the 1- and 2-year overall survival rates were 65 and 32 %, respectively. Median survival in patients aged <70 and ≥70 years was 26 and 10 months, respectively (p = 0.01).

Conclusion

Median survival with radiotherapy alone was 20 months. Patients aged <70 years have a better prognosis than those ≥70 years.     

Radiotherapy in pediatric pilocytic astrocytomas

Purpose

We evaluated clinical outcomes in the subset of patients who underwent radiotherapy (RT) due to progressive pilocytic astrocytoma within the Multicenter Treatment Study for Children and Adolescents with a Low Grade Glioma HIT-LGG 1996.

Patients and methods

Eligibility criteria were fulfilled by 117 patients. Most tumors (65?%) were located in the supratentorial midline, followed by the posterior fossa (26.5?%) and the cerebral hemispheres (8.5?%). Median age at the start of RT was 9.2 years (range 0.7–17.4 years). In 75 cases, external fractionated radiotherapy (EFRT) was administered either as first-line nonsurgical treatment (n?=?58) or after progression following primary chemotherapy (n?=?17). The median normalized total dose was 54 Gy. Stereotactic brachytherapy (SBT) was used in 42 selected cases.

Results

During a median follow-up period of 8.4 years, 4 patients (3.4?%) died and 33 (27.4?%) experienced disease progression. The 10-year overall (OS) and progression-free survival (PFS) rates were 97 and 70?%, respectively. No impact of the RT technique applied (EFRT versus SBT) on progression was observed. The 5-year PFS was 76?±?5?% after EFRT and 65?±?8?% after SBT. Disease progression after EFRT was not influenced by gender, neurofibromatosis type 1 (NF1) status, tumor location (hemispheres versus supratentorial midline versus posterior fossa), age or prior chemotherapy. Normalized total EFRT doses of more than 50.4 Gy did not improve PFS rates.

Conclusion

EFRT plays an integral role in the treatment of pediatric pilocytic astrocytoma and is characterized by excellent tumor control. A reduction of the normalized total dose from 54 to 50.4 Gy appears to be feasible without jeopardizing tumor control. SBT is an effective treatment alternative.     

Limb-sparing management with surgical resection,external-beam and intraoperative electron-beam radiation therapy boost for patients with primary soft tissue sarcoma of the extremity

Background or purpose

A joint analysis of data from three contributing centres within the intraoperative electron-beam radiation therapy (IOERT) Spanish program was performed to investigate the main contributions of IORT to the multidisciplinary treatment of high-risk extremity soft tissue sarcoma (STS).

Methods and materials

Patients with an histologic diagnosis of primary extremity STS, with absence of distant metastases, undergoing limb-sparing surgery with radical intent, external beam radiotherapy (median dose 45 Gy) and IOERT (median dose 12.5 Gy) were considered eligible for participation in this study.

Results

From 1986–2012, a total of 159 patients were analysed in the study from three Spanish institutions. With a median follow-up time of 53 months (range 4–316 years), 5-year local control (LC) was 82?%. The 5-year IOERT in-field control, disease-free survival (DFS) and overall survival (OS) were 86, 62 and 72?%, respectively. On multivariate analysis, only microscopically involved margin (R1) resection status retained significance in relation to LC (HR 5.20, p?p?=?0.001) and higher IOERT dose (≥?12.5 Gy; HR 0.32, p?=?0.02) retained a significant association in multivariate analysis.

Conclusion

From this joint analysis emerges the fact that an IOERT dose ≥?12.5 Gy increases the rate of IOERT in-field control, but DFS remains modest, given the high risk of distant metastases. Intensified local treatment needs to be tested in the context of more efficient concurrent, neo- and adjuvant systemic therapy.     

Does high-dose radiotherapy benefit palliative lung cancer patients?

Background and purpose

The present analysis compares two palliative treatment concepts for lung cancer in terms of overall survival.

Patients and methods

Survival data from 207 patients were used in a retrospective analysis. All patients received palliative treatment comprising either 25 Gy applied in 5 fractions or 50 Gy in 20 fractions. A subgroup analysis was performed to compare patients with a good–fair vs. poor overall condition.

Results

Median survival times were 21 weeks (range 6–26 weeks) for patients treated with 25 Gy in 5 fractions and 23 weeks (range 14.5–31.5 weeks) for patients treated with 50 Gy in 20 fractions (95?% confidence interval, CI; p?=?0.334). For patients with a good–fair overall condition, median survival times were 30 weeks (21.8–39.2 weeks) for 25 Gy in 5 fractions and 28 weeks (14.2–41.8 weeks) for 50 Gy in 20 fractions (CI 95?%, p?=?0.694). In patients with a poor overall condition, these values were 18 weeks (14.5–21.5 weeks) and 21 weeks (13.0–29.0 weeks), respectively (CI 95?%, p?=?0.248).

Conclusion

The palliative treatment concept of 25 Gy applied in 5 fractions is sufficient for radiation of lung cancer, given that there was no obvious survival improvement in patients treated with the higher total dose regimen.     

High-dose radiotherapy alone for patients with T4-stage laryngeal cancer

Background and purpose

The purpose of this retrospective study was to report on the efficacy of radiotherapy alone in patients with T4-stage laryngeal cancer and to establish the prognostic value of (a) the size and location of the extralaryngeal tumor extensions and (b) of emergency tracheostomy.

Patients and methods

A group of 114 patients were treated with definitive radiotherapy between 1990 and 1996. The piriform recess was involved in 37 cases (33?%), the base of the tongue and glosso-epiglottic vallecula in 34 cases (30?%), and the hypopharyngeal wall in 10 cases (9?%). In 16 cases (14?%), emergency tracheostomy was performed before radiotherapy. The mean total dose was 68 Gy (range, 60–77.6 Gy). The mean treatment time was 49 days (range, 42–74 days).

Results

Actuarial 3-year local control (LC) was noted in 42?% of patients, disease-free survival (DFS) in 35?%, and overall survival (OS) in 40?%. The best prognosis was for the lesion suspected of cartilage infiltration: 56?% 3-year LC. The worst results were noted in the cases with massive infiltrations spreading from the larynx through the hypopharynx: 13?% 3-year LC. Emergency tracheostomy before radiotherapy was significantly connected with the worst treatment results (p?=?0.000): 3-year LC in patients with tracheostomy was 0?% vs. 48?% in patients without tracheostomy.

Conclusion

Conventional radiotherapy of T4 laryngeal cancer is a method of treatment with limited effectiveness. The efficacy of radiotherapy is dependent on the location and extent of extralaryngeal infiltrations. Emergency tracheostomy is a prognostic factor connected with the worst prognosis.     

Outcome after Radiofrequency Ablation of Sarcoma Lung Metastases

Purpose

Resection is the mainstay of management in patients with sarcoma lung metastases, but there is a limit to how many resections can be performed. Some patients with inoperable disease have small-volume lung metastases that are amenable to thermal ablation. We report our results after radiofrequency ablation (RFA).

Methods

This is a retrospective study of patients treated from 2007 to 2012 in whom the intention was to treat all sites of disease and who had a minimum CT follow-up of 4 months. Treatment was performed under general anesthesia/conscious sedation using cool-tip RFA. Follow-up CT scans were analyzed for local control. Primary tumor type, location, grade, disease-free interval, prior resection/chemotherapy, number and size of lung tumors, uni- or bilateral disease, complications, and overall and progression-free survival were recorded.

Results

Twenty-two patients [15 women; median age 48 (range 10–78) years] with 55 lung metastases were treated in 30 sessions. Mean and median tumor size and initial number were 0.9 cm and 0.7 (range 0.5–2) cm, and 2.5 and 1 (1–7) respectively. Median CT and clinical follow-up were 12 (4–54) and 20 (8–63) months, respectively. Primary local control rate was 52 of 55 (95 %). There were 2 of 30 (6.6 %) Common Terminology Criteria grade 3 complications with no long-term sequelae. Mean (median not reached) and 2- and 3-year overall survival were 51 months, and 94 and 85 %. Median and 1- and 2-year progression-free survival were 12 months, and 53 and 23 %. Prior disease-free interval was the only significant factor to affect overall survival.

Conclusion

RFA is a safe and effective treatment for patients with small-volume sarcoma metastases.     

Timing of radiotherapy following breast-conserving surgery: outcome of 1393 patients at a single institution

Background

The role of postoperative radiotherapy in breast-conserving therapy is undisputed. However, optimal timing of adjuvant radiotherapy is an issue of ongoing debate. This retrospective clinical cohort study was performed to investigate the impact of a delay in surgery–radiotherapy intervals on local control and overall survival.

Patients and methods

Data from an unselected cohort of 1393 patients treated at a single institution over a 17-year period (1990–2006) were analyzed. Patients were assigned to two groups (CT+/CT?) according to chemotherapy status. A delay in the initiation of radiotherapy was defined as >?7 weeks (CT? group) and >?24 weeks (CT+ group).

Results

The 10-year regional recurrence-free survival for the CT? and CT+ groups were 95.6 and 86.0?%, respectively. A significant increase in the median surgery–radiotherapy interval was observed over time (CT? patients: median of 5 weeks in 1990–1992 to a median of 6 weeks in 2005–2006; CT+ patients: median of 5 weeks in 1990–1992 to a median of 21 weeks in 2005–2006). There was no association between a delay in radiotherapy and an increased local recurrence rate (CT? group: p?=?0.990 for intervals 0–6 weeks vs. ≥?7 weeks; CT+ group: p?=?0.644 for intervals 0–15 weeks vs. ≥?24 weeks) or decreased overall survival (CT? group: p?=?0.386 for intervals 0–6 weeks vs. ≥?7 weeks; CT+ group: p?=?0.305 for intervals 0–15 weeks vs. ≥?24 weeks).

Conclusion

In the present cohort, a delay of radiotherapy was not associated with decreased local control or overall survival in the two groups (CT?/CT+). However, in the absence of randomized evidence, delays in the initiation of radiotherapy should be avoided.     

Survival and prognostic factors after moderately hypofractionated palliative thoracic radiotherapy for non-small cell lung cancer

Background

Survival and prognostic variables in patients with advanced or metastatic non-small cell lung cancer (NSCLC) requiring thoracic palliative radiotherapy using a moderately hypofractionated regime (13–15?×?3 Gy) were evaluated.

Methods

From March 2006 to April 2012, 120 patients with a physician estimated prognosis of 6–12 months were treated with this regime using CT-based 3D conformal radiotherapy. We collected data on patient characteristics, comorbidities, toxicity, and treatment parameters.

Results

Radiotherapy was completed as prescribed in 114 patients (95.0?%, premature termination 5.0?%). Acute grade 3 toxicity was seen in 6.4?% of patients. The median survival of all patients was 5.8 months. Nonmetastatic patients survived significantly longer than patients with metastatic disease (median 11.7 months vs 4.7 months, p?=?0.0001) and 18.6?% of nonmetastatic patients survived longer than 2 years. In 12.7?% radiotherapy started less than 30 days before death and 14.2?% of patients received radiotherapy within 14 days before death. In the multivariate analysis, good general condition, nonmetastatic disease, and a stable or improved general condition at the end of radiotherapy were significant. The treatment parameters, age, and comorbidities were not statistically significant.

Conclusion

Our data confirm considerable effectiveness of 13?×?3 Gy with conformal radiotherapy for patients with locally confined NSCLC not fit for radical treatment and raise doubt for this regimen in metastatic patients and ECOG ≥?2 when burden, acute toxicity, and resources are considered.     

Salvage radiotherapy with or without concurrent chemotherapy for pelvic recurrence after hysterectomy alone for early-stage uterine cervical cancer

Purpose

Treatment outcomes of patients with pelvic recurrence after hysterectomy alone for uterine cervical cancer who received salvage radiotherapy (RT) with or without concurrent chemotherapy were investigated.

Methods

Salvage RT for recurrent cervical cancer confined to the pelvic cavity after hysterectomy alone was received by 33 patients. The median interval between initial hysterectomy and recurrence was 26 months. Whole-pelvic irradiation was delivered to median dose of 45?Gy, followed by a boost with a median dose of 16?Gy to the gross tumor volume. Cisplatin-based concurrent chemotherapy was administered to 29 patients.

Results

The median follow-up period was 53 months for surviving patients. Most patients (97.0%) completed salvage RT of ≥45?Gy. Complete response (CR) was achieved in 23 patients (69.7%). Pelvic sidewall involvement and evaluation with positron-emission tomography-computed tomography were significantly associated with CR. The 5?year progression-free survival (PFS), local control (LC), distant metastasis-free survival (DMFS), and overall survival (OS) rates were 62.7, 79.5, 72.5, and 60.1%, respectively. Initial International Federation of Gynecology and Obstetrics stage, pelvic sidewall involvement, and CR status were significant factors for PFS and OS rates in multivariate analysis. The incidence of severe acute and late toxicities (≥grade 3) was 12.1 and 3.0%, respectively.

Conclusion

Aggressive salvage RT with or without concurrent chemotherapy for recurrent cervical cancer confined to the pelvic cavity was feasible, with promising treatment outcomes and acceptable toxicities. However, even more intensive novel treatment strategies should be investigated for patients with unfavorable prognostic factors.

     

Concurrent and adjuvant temozolomide-based chemoradiotherapy schedules for glioblastoma

Aim

To investigate the impact of nonstandard concomitant temozolomide (TMZ) administration in two prospective phase II studies for glioblastoma (GBM).

Patients and methods

From October 2000 to June 2008, 104 patients were enrolled in two studies: 25 in RT-TMZ-10.00 and 79 in RT-TMZ-01.04. Adjuvant radiotherapy (RT) was used with a total dose of 59.4 Gy (1.8 Gy/day). Patients received concomitant TMZ (75 mg/m²/day) from Monday to Friday during the first and last weeks of RT in the RT-TMZ-10.00 study and from Monday to Friday during all weeks of RT in the RT-TMZ-01.04 trial. Adjuvant TMZ (200 mg/m²) was administered for 5 days every 28 days.

Results

Median progression-free (PFS) and overall survival (OS) were 9 and 16 months, respectively, with no significant difference between the two groups (p?=?0.5 and 0.14, respectively). The 2- and 5-year OS rates were 32 and 3?%, respectively, and similar to those observed with standard treatment regimens.

Conclusion

Our data support the hypothesis that adjuvant TMZ is more important than concomitant chemotherapy (CH) and that RT is the more important element of the concomitant treatment schedule.     

Protocol-based image-guided salvage brachytherapy

Purpose

To assess the overall clinical outcome of protocol-based image-guided salvage pulsed-dose-rate brachytherapy for locally recurrent prostate cancer after radiotherapy failure particularly regarding feasibility and side effects.

Patients and methods

Eighteen consecutive patients with locally recurrent prostate cancer (median age, 69 years) were treated during 2005–2011 with interstitial PDR brachytherapy (PDR-BT) as salvage brachytherapy after radiotherapy failure. The treatment schedule was PDR-BT two times with 30 Gy (pulse dose 0.6 Gy/h, 24 h per day) corresponding to a total dose of 60 Gy. Dose volume adaptation was performed with the aim of optimal coverage of the whole prostate (V₁₀₀ >?95?%) simultaneously respecting the protocol-based dose volume constraints for the urethra (D_0.1 cc <?130?%) and the rectum (D_2 cc <?50–60?%) taking into account the previous radiation therapy. Local relapse after radiotherapy (external beam irradiation, brachytherapy with J-125 seeds or combination) was confirmed mostly via choline-PET and increased PSA levels. The primary endpoint was treatment-related late toxicities—particularly proctitis, anal incontinence, cystitis, urinary incontinence, urinary frequency/urgency, and urinary retention according to the Common Toxicity Criteria. The secondary endpoint was PSA-recurrence-free survival.

Results

We registered urinary toxicities only. Grade 2 and grade 3 toxicities were observed in up to 11.1?% (2/18) and 16.7?% (3/18) of patients, respectively. The most frequent late-event grade 3 toxicity was urinary retention in 17?% (3/18) of patients. No late gastrointestinal side effects occurred. The biochemical PSA-recurrence-free survival probability at 3 years was 57.1?%. The overall survival at 3 years was 88.9?%; 22?% (4/18) of patients developed metastases. The median follow-up time for all patients after salvage BT was 21 months (range, 8–77 months).

Conclusion

Salvage PDR-brachytherapy of the prostate following local failure after radiation therapy is a treatment option with a low rate of genitourinary side effects and no late gastrointestinal side effects. The treatment efficacy in the first 3 years is promising.     

Xerostomia after radiotherapy

Purpose

Xerostomia is a debilitating side effect of radiotherapy in patients with head and neck cancer. We undertook a prospective study of the effect on xerostomia and outcomes of sparing one or both parotid glands during radiotherapy for patients with squamous cell carcinoma of the head and neck.

Methods and materials

Patients with locally advanced squamous cell carcinoma of the head and neck received definitive (70 Gy in 2 Gy fractions) or adjuvant (60–66 Gy in 2 Gy fractions) curative-intent radiotherapy using helical tomotherapy with concurrent chemotherapy if appropriate. Group A received <?26 Gy to the left and right parotids and group B received <?26 Gy to either parotid.

Results

The study included 126 patients; 114 (55 in group A and 59 in group B) had follow-up data. There were no statistically significant differences between groups in disease stage. Xerostomia was significantly reduced in group A vs. group B (p?=?0.0381). Patients in group A also had significantly less dysphagia. Relapse-free and overall survival were not compromised in group A: 2-year relapse-free survival was 86% vs. 72% in group B (p?=?0.361); 2-year overall survival was 88% and 76%, respectively (p?=?0.251).

Conclusion

This analysis suggests that reducing radiotherapy doses to both parotid glands to <?26 Gy can reduce xerostomia and dysphagia significantly without compromising survival. Sparing both parotids while maintaining target volume coverage and clinical outcome should be the treatment goal and reporting radiotherapy doses delivered to the individual parotids should be standard practice.