内窥镜下微波固化术治疗鼻咽癌放疗后鼻咽腔内复发患者的疗效

背景与目的:局部复发鼻咽癌的治疗是一个临床难题.再程放疗可治愈部分患者,但会带来明显后遗症.本研究旨在评价内窥镜下微波固化术治疗鼻咽癌放疗后鼻咽腔内复发患者的疗效.方法:选取1994年8月至2005年4月中山大学肿瘤防治中心采用内镜下微波同化术治疗的局部复发(rT1)鼻咽癌病例55例,分析其无局部进展生存率及总生存率.结果:本组病例中位随访时间为102.1个月(22.4～153.9个月).放疗后局部复发的中位时间为22.1个月(6.5～125.6个月).微波固化术后鼻咽局部再复发5例.5年无局部进展生存率和总生存率分别为90.7%和93.6%.55例患者均无术中并发症.1例患者术后出现鼻咽溃疡,1个月后愈合.结论:内窥镜下微波同化术治疗选择性的局部复发鼻咽癌(rT1)患者可取得较好的生存率及局控率且并发症少,是目前治疗局部复发鼻咽癌患者的一种操作简便易行、疗效较理想的救援性治疗方法.     

Outcome of fractionated stereotactic radiotherapy for 90 patients with locally persistent and recurrent nasopharyngeal carcinoma

PURPOSE: Local recurrence remains one of the major causes of failure in nasopharyngeal carcinoma (NPC). Stereotactic radiosurgery and fractionated stereotactic radiation therapy (FSRT) have recently evolved as a salvage option of NPC. This study was conducted to review the treatment outcome after FSRT for NPC. METHODS AND MATERIALS: Between September 1999 and December 2005, 90 patients with persistent (Group 1: n = 34, relapse within 6 months of RT) or recurrent (Group 2: n = 56, relapse beyond 6 months) NPC received FSRT using multiple noncoplanar arcs of 8-MV photon to the target. Median FSRT dose was 18 Gy in three fractions (Group 1) or 48 Gy in six fractions (Group 2). Median follow-up was 20.3 months. RESULTS: Complete response rate after FSRT was 66% for Group 1 and 63% for Group 2. One-, 2-, and 3-year disease-specific survival (DSS) and progression-free survival (PFS) rates for all patients were 82.6%, 74.8%, 57.5%, and 72.9%, 60.4%, 54.5%, respectively. Three-year local failure-free survival, DSS, and PFS rates were 89.4%, 80.7%, and 72.3% for Group 1, and 75.1%, 45.9%, and 42.9% for Group 2, respectively. Multivariate analysis showed that recurrent disease and large tumor volume were independent factors that predicted poorer DSS and PFS. Seventeen patients developed late complications, including 2 with fatal hemorrhage. CONCLUSIONS: Our results indicate that FSRT is effective for patients with persistent and recurrent NPC. Compared with reported results of radiosurgery, FSRT provides satisfactory tumor control and survival with a lower risk of complications and it may be a better treatment for local failures of NPC.     

Initial clinical experience with frameless radiosurgery for patients with intracranial metastases

PURPOSE: To review the initial clinical experience with frameless stereotactic radiosurgery (SRS) for treating intracranial metastatic disease. METHODS AND MATERIALS: Sixty-four patients received frameless SRS for intracranial metastatic disease. Minimum follow-up was 6 months with none lost to follow-up. Patients had a median of 2 metastases and a maximum of 4. The median number of isocenters was 2 with median arcs of 10 and median dose of 17.5 Gy. Thirteen patients were treated for progressive/recurrent disease after surgical resection or whole brain radiotherapy (WBRT). Fifty-one patients were treated with frameless SRS as an an adjunct to initial treatment. Of the total treated, 17 were treated with SRS alone, 20 were treated with WBRT plus SRS, 16 were treated with surgical resection plus SRS, and the remaining 11 were treated with surgical resection plus WBRT plus SRS. RESULTS: With a median actuarial follow-up period of 8.2 months, ultimate local control was 88%. The median time to progression was 8.1 months. The median overall survival was 8.7 months. Of the 17 patients treated with SRS alone, 86% had ultimate local control with mean overall survival of 7.1 months. Of the 13 patients who received surgical resection plus SRS without WBRT as primary treatment, there was 85% ultimate local control with an overall survival of 10.3 months. Three patients treated with initial surgery alone had recurrence treated with SRS 2-3 months after resection. All these patients obtained local control and median survival was >10 months. Of the 13 patients who received WBRT followed by SRS as boost treatment, 92% had local control and mean overall survival was 7.3 months. Of 7 patients who received SRS after recurrence after WBRT, 100% had local control with median survival of 8.2 months. For 8 patients who received surgery followed by WBRT and SRS, local control was 50%; however, ultimate intracranial control was achieved in 7 of 8 patients with repeat SRS and surgical resection. The overall survival in this group of patients was 14.7 months. No patient had a serious (Grade 3 or higher) complication requiring intervention. CONCLUSIONS: Frameless optically guided radiosurgery is less invasive, can be performed as a standard radiotherapy-based simulation procedure, and maintains submillimetric accuracy. Our initial results with frameless SRS for metastatic disease suggest survival times and local control (88%) eqiuvalent to frame-based methodologies. Practical noninvasive delivery makes treatment and potential retreatment to avoid WBRT more feasible.     

Treatment Outcome with Brachytherapy for Recurrent Nasopharyngeal Carcinoma

Background: To evaluate the treatment outcome and major late complications of all patients with recurrentnasopharyngeal carcinoma (NPC) treated with intracavitary brachytherapy (ICBT) in Hospital Kuala Lumpur.Materials and Methods: This retrospective study was conducted at the Department of Radiotherapy and Oncology,Hospital Kuala Lumpur, Malaysia. All patients with histologically confirmed recurrent NPC in the absence ofdistant metastasis treated in the period 1997-2010 were included in this study. These patients were treated withICBT alone or in combination with external beam radiotherapy (EBRT). Treatment outcomes measured werelocal recurrence free survival (LRFS), disease free survival (DFS) and overall survival (OS). Results: Thirty threepatients were eligible for this study. The median age at recurrence was 56 years with a median time to initiallocal recurrence of 27 months. Majority of patients were staged as rT1-2 (94%) or rN0 (82%). The proportionof patients categorised as stage III-IV at first local recurrence was only 9%. Twenty one patients received acombination of ICBT and external beam radiotherapy while 12 patients were treated with ICBT alone. Medianinterval of recurrence post re-irradiation was 32 months (range: 4-110 months). The median LRFS, DFS andOS were 30 months, 29 months and 36 months respectively. The 5 year LRFS, DFS and OS were 44.7%, 38.8%and 28.1% respectively. The N stage at recurrence was found to be a significant prognostic factor for LRFS andDFS after multivariate analysis. Major late complications occurred in 34.9% of our patients. Conclusions: Ourstudy shows ICBT was associated with a reasonable long term outcome in salvaging recurrent NPC althoughmajor complications remained a significant problem. The N stage at recurrence was a significant prognosticfactor for both LRFS and DFS.     

Salvage stereotactic radiosurgery effectively treats recurrences from whole-brain radiation therapy

BACKGROUND.

The purpose of the current study was to examine overall survival (OS) and time to local failure (LF) in patients who received salvage stereotactic radiosurgery (SRS) for recurrent brain metastases (BM) after initial management that included whole‐brain radiation therapy (WBRT).

METHODS.

The records of 1789 BM patients from August 1989 to November 2004 were reviewed. Of these, 111 underwent WBRT as part of their initial management and SRS as salvage. Patients were stratified by Radiation Therapy Oncology Group (RTOG) recursive partitioning analysis class, primary disease, dimension of the largest metastases and number of BM at initial diagnosis, and time to first brain recurrence after WBRT. Overall survival, survival after SRS, and time to local and distant failure were analyzed.

RESULTS.

The median OS from the initial diagnosis of BM was 17.7 months. Median survival after salvage SRS for the entire cohort was 9.9 months. Median survival after salvage SRS was 12.3 months in patients who had their first recurrence >6 months after WBRT versus 6.8 months for those who developed disease recurrence ≤6 months after (P = .0061). Primary tumor site did not appear to affect survival after SRS. Twenty‐eight patients (25%) developed local recurrence after their first SRS with a median time of 5.2 months. A dose <22 grays and lesion size >2 cm were found to be predictive of local failure.

CONCLUSIONS.

In this study, patients who recurred after WBRT and were treated with salvage SRS were found to have good local control and survival after SRS. WBRT provided good initial control, as 45% of these patients failed >6 months after WBRT. Those with a longer time to failure after WBRT had significantly longer survival after SRS. Cancer 2008. © 2008 American Cancer Society.     

A phase II study of capecitabine in patients with recurrent and metastatic nasopharyngeal carcinoma pretreated with platinum-based chemotherapy

To evaluate the efficacy and toxicity of capecitabine as a salvage chemotherapy regimen in Chinese patients with recurrent or metastatic nasopharyngeal carcinoma (NPC) previously treated with platinum-based chemotherapy, 17 patients with recurrent or metastatic NPC previously treated with platinum-based chemotherapy as adjuvant or palliative treatments received oral capecitabine at a dose of 1.25 G/m(2) twice daily in 3-week cycles consisting of 2 weeks of treatment followed by rest period of 1 week. Seven patients had local recurrence, seven had distant metastases, one had loco-regional recurrence, and two had both local/regional recurrence and distant metastases. Patients received a median number of three cycles of capecitabine (range: 1-6). The median follow-up was 7.5 months (range: 3-25.3). All patients were included in the efficacy and adverse events analysis. Three patients (17.6%) achieved partial response and one patient (5.9%) achieved complete response, with an overall response rate of 23.5% (95% confidence interval, 7-50%). The duration of response's were 4.2, 5, 6+, and 23.1+ months. Nine patients (52.9%) had stable disease whereas four (23.5%) had progressive disease. The median time to progression was 4.9 months. The median survival was 7.6 months. Five patients are still alive with an estimated 1-year survival rate of 35%. Treatment-related adverse events were generally mild except hand-foot syndrome which occurred in 58.8% of patients. Capecitabine is an effective salvage regimen in patients with recurrent and metastatic NPC. Capecitabine as a single agent or in combination with other chemotherapeutic agents or treatment modalities should be further studied in NPC.     

局部复发鼻咽癌三维适形放疗初步观察

目的:探索三维适形放疗(3demensionalconformalradiationtherapy3DCRT)技术在局部复发鼻咽癌再程放疗中的应用。方法:1998年4月～1999年10月,采用3DCRT技术治疗局部复发鼻咽癌26例。其中低分化鳞癌25例,低分化腺癌1例。按92’福州分期标准再分期:T1N0M04例,T2N0M08例,T3N0M09例,T4N0M05例。密集肿瘤区(grosstumorvolumeGTV)最大径1.0～5.0cm(平均3.1cm)。全组病例均采用每次5～7个固定适形野照射,计划靶区(planningtargetvolumePTV)平均最大剂量、最小剂量、平均剂量分别为104.1±1.3%、92.1±2.8%、99.2.±1.7%。时间-剂量-分次处方:65～70Gy/26～28次,共5～5.5周。随访8～26个月,中位随访时间17个月。结果:再程放疗后随访期内靶区边缘复发2例,颈淋巴结复发3例,远处转移2例,死亡4例。随访期内肿瘤局部控制率88.5%(23/26),84.6%(22/26)患者生存,76.9%(20/26)无瘤生存。再程放疗所致急性放射反应少而轻。累计后遗症发生率19.2%(5/26),放射性功能损害发生率15.4%4/26。结论:三维适形放疗技术用于局部复发鼻咽癌具有明显的剂量分布优势。初步临床观察结果表明,这一放疗新技术用于局部复发鼻咽癌肿瘤局部控制率高、放射反应和后遗症较少,远期疗效和后遗症尚有待观察。     

The role of Gamma Knife Radiosurgery in the management of unresectable gross disease or gross residual disease after surgery in ependymoma

SummaryPurpose/Objective To evaluate the efficacy and the toxicity of Gamma Knife (GK)-based stereotactic radiosurgery (SRS) in the management of gross disease in ependymoma.Materials and methods Eight patients with 13 ependymomas were treated with GK-based SRS in our institution for gross disease. Five patients were treated for recurrent disease that developed after surgery and external beam radiotherapy (EBRT), two received SRS to the gross disease after surgery and EBRT, and one received SRS alone (in a 1.3 year old child). Median EBRT dose was 54.4 Gy (range 50–55.8 Gy). Median SRS dose was 14 Gy (range 12–20 Gy). Seven of eight (87.5%) patients had SRS to a single lesion and one of eight (12.5%) patients had treatment to six tumors in three different sessions.Results The median follow up was 30.2 months (range 8–65.4 months). Out of the eight patients treated with SRS, six (75%) were alive, four (50%) were alive with no recurrence, two (25%) were alive with recurrence, and two (25%) died of recurrent disease. Both patients treated with SRS as a boost were alive and without recurrence. Out of the five patients who received SRS as salvage treatment, three (60%) were alive, two (40%) were alive without recurrence, two (40%) developed distant failure, and three (60%) had in-field control. Two patients who received SRS to their brainstem lesions developed symptoms related to radionecrosis and were successfully treated with steroid with good control of symptoms.Conclusions GK-based SRS appears to be a feasible and safe treatment modality for patients with ependymoma with unresectable gross disease or gross residual disease after surgery. SRS provides reasonable local control but out-of-field tumor progression remains an issue. For patients who receive SRS as a boost, the local control appears to be excellent. This paper has been presented in the American Society for Therapeutic Radiology and Oncology Meeting in Denver, CO in October 2005.     

Endoscopic microwave coagulation therapy for early recurrent T1 nasopharyngeal carcinoma

The result of reirradiation in recurrent T1 (rT1) nasopharyngeal carcinoma (NPC) is unsatisfactory. We sought to study the efficacy and complications of endoscopic microwave coagulation therapy (MCT) in salvaging rT1 NPC after primary radiotherapy. Between August 1994 and April 2005, 55 patients with rT1 NPC were treated with endoscopic MCT. With a median follow-up of 102.1 months, 52 of 55 patients are still alive. Five patients had local failure after retreatment. The overall survival and local progression-free survival were 100% (95% CI, 99.4% to 100%) and 94.5% (95% CI, 94.1% to 94.9%) at 2 years, respectively, and 93.6% (95% CI, 93.5% to 94.4%) and 90.7% (95% CI, 90.2% to 91.2%) at 5 years. The common complications of endoscopic MCT were mild postoperative pain and headache. Nasopharyngeal necrosis was transient in one patient and subsided in 1 month. Endoscopic MCT achieved significant survival and tumour control without severe complications in selective rT1 NPC.     

The residual mediastinal mass following radiation therapy for Hodgkin's disease

Thirty-two patients with mediastinal involvement by Hodgkin's disease (HD), treated with an isocentric technique of extended-field radiation therapy (RT) with or without chemotherapy, are described. Twenty-nine patients (91%) had a complete response to therapy and four patients subsequently relapsed, with a median follow-up of 54 months. Five of seven patients not in continuous complete remission were salvaged, with one additional salvage therapy. Ten patients had persistent mediastinal masses at 1 year, following completion of planned therapy; only one of these has had recurrent disease. Of those who achieved complete response, only one patient has had disease recurrence in the mediastinum. We conclude that extended-field RT, using an isocentric technique, provides excellent local disease control in HD; however, persistent mediastinal widening after therapy is frequent, and additional therapy should not be given in the absence of conclusive evidence of disease progression.     

Bladder-sparing, combined-modality approach for muscle-invasive bladder cancer: a multi-institutional, long-term experience

BACKGROUND: The authors evaluated their long-term experience with combined-modality, conservative treatment in patients with muscle-invasive bladder cancer. METHODS: In total, 121 patients with T2, T3, or T4 bladder cancer (mean age, 63 years; ratio of men to women, 3:1) underwent induction by transurethral resection (TUR) of the tumor and received 2 cycles of neoadjuvant chemotherapy followed by radiotherapy (RT) (n = 43 patients) or radiochemotherapy (RCT) (n = 78 patients). Six weeks after RT or RCT, responses were evaluated by restaging TUR. Patients who achieved a complete response (CR) were observed at regular intervals. In patients who had persistent or recurrent invasive tumor, further treatment was recommended. RESULTS: Local response evaluation by restaging TUR was possible in 119 patients, and 102 of those patients (85.7%) achieved a CR. After a median follow-up of 66 months (range, 6-182 months), no local or distant disease recurrences were observed in 67 of 102 complete responders (65.7%), 17 of 102 complete responders (16.7%) experienced superficial local disease recurrence, and 18 of 102 complete responders (17.6%) had a muscle-invasive relapse. The 5-year tumor-specific, overall, and bladder-intact survival rates were 73.5%, 67.7%, and 51.2%, respectively. Treatment modality, tumor classification, and resection status after initial TUR had an impact on survival rates (P = .04, P = .02, and P = .02, respectively). CONCLUSIONS: The current results indicated that conservative combined treatment is a reasonable alternative to radical cystectomy in selected patients with muscle-invasive bladder cancer.     

局限性残留、复发鼻咽癌的鼻内镜进路救援性外科治疗

背景与目的:对于放疗后鼻咽局限性残留、复发鼻咽癌,二程放疗可以使部分患者得到长期局部控制,但其放射性后遗症也相当严重:而救援性外科手术在取得相仿甚至更优疗效的同时,避免了这些放射性后遗症.然而,传统开放式手术进路创伤大,术野欠清晰,难以按肿瘤外科原则进行连续、整块切除.本研究旨在探索一种新的微创性鼻内镜进路的复发鼻咽癌外科治疗方法.方法:从2004年9月至2007年1月,25例放疗后鼻咽局限性残留或复发鼻咽癌患者在中山大学肿瘤防治中心进行经鼻内镜鼻咽切除术,将鼻咽肿瘤和足够的安全边缘连续、整块切除.观察其疗效和并发症.结果:25例患者均在鼻内镜进路下按肿瘤外科手术原则进行根治性整块切除,仅1例切缘阳性,鼻咽创面愈合良好,均未追加术后放疗.中位随访时间13个月(3～31个月),1例原位残留,3例术后原位复发,无远处转移和死亡.1年总生存率100%,无局部复发生存率达86.0%.无张口、吞咽、发音困难和其他手术并发症发生,无围手术期死亡.结论:鼻内镜进路鼻咽癌救援手术能充分暴露鼻咽以及咽旁间隙浅部,能将鼻咽残留、复发病灶按肿瘤外科原则进行连续、整块根治性切除,并发症少而轻,近期疗效满意.     

KX2-361: a novel orally bioavailable small molecule dual Src/tubulin inhibitor that provides long term survival in a murine model of glioblastoma

Stereotactic radiosurgery (SRS) is frequently used for Cushing’s disease (CD) after failed pituitary surgery. Management of patients with persistent CD after failed SRS is complex, as the alternative therapeutic options harbor significant risks. The outcomes of repeat pituitary radiosurgery, however, have not been described. We sought to determine the outcomes of repeat SRS in patients with CD. We pooled data from five institutions participating in the International Gamma Knife Research Foundation for patients with recurrent or persistent CD?≥?12 months after initial SRS. Patients were included in the study if they had ≥?6 months endocrine follow-up after repeat SRS. Twenty patients were included in the study. Repeat single-session SRS was performed 1.3–9.7 years after initial SRS. Median endocrine follow-up was 6.6 years (1.4–19.1 years). Median margin dose was 20 Gy (range 10.8–35 Gy). Endocrine remission after second SRS was noted in 12 patients (60%), with a median time to remission of 6 months (range 2–64 months). Biochemical recurrence occurred in two patients (17%) after initial remission. Overall, the cumulative rates of durable endocrine remission at 5 and 10 years were 47 and 53%, respectively. Two patients (10%) experienced adverse radiation effects, including transient visual loss and permanent diplopia. Repeat SRS achieves lasting biochemical remission in approximately half of patients with CD refractory to both prior microsurgery and SRS. Because of the morbidity of refractory or recurrent CD, repeat SRS should be considered for carefully selected patients with hypercortisolism confirmed one or more years after initial SRS.     

Relapse Patterns and Outcomes Following Recurrence of Endometrial Cancer in Northern Thai Women

Background: The aim of this study was to analyze the patterns of relapse and survival outcomes in NorthernThai women with recurrent endometrial cancer (EC). Materials and Methods: Medical records were abstractedfrom EC patients who underwent primary surgery from 1999 to 2012. Data on clinicopathologic variables, sitesof first recurrence, time to relapse of disease, and overall survival (OS) was analyzed. Associations betweenthe clinicopathological variables and the rates of disease recurrence were determined. Results: Among 1,204reviewed records, 42 eligible patients were identified with recurrent disease. The median age was 55 years andthe median follow-up time was 26.0 months. The median times to recurrence (TTR) after completion of theinitial treatment in the group of local relapse (LR) and distant/combined sites of recurrence (DCSR) was 6.6(95% CI=4.6 to 8.6 months) and 16.9 months (95% CI=5.6 to 28.2 months), respectively (p=0.36). The 2-yearsurvival and 3-year survival probability in the group of LR was 54.2% (95% CI=27.2 to 81.3%) and 34.7% (95%CI=9.2 to 60.2%), compared to 50.4% (95% CI=41.1 to 59.7%) and 42.1% (95%CI= 24.1 to 60.1%) for thosewith DCSR. Distant recurrence was the most frequent pattern of relapse. Overall survival was not significantlydifferent in patients with local relapse when compared to those with DCSR (p=0.69). Conclusions: Patients withrecurrence of EC after primary treatment had a worse prognosis and clinical aggressiveness. LR and DCSRoccurred most during the first three years. The common sites of relapses were vaginal cuff, pelvis, and lungs.No significant clinicopathological predictor for survival outcomes was identified.     

Repeat high-dose external beam irradiation for in-breast tumor recurrence after previous lumpectomy and whole breast irradiation

PURPOSE: To determine whether excision of an in-breast tumor recurrence (IBTR) plus 5000 cGy in 25 fractions to the new operative area is both tolerated and effective as treatment for an IBTR after previous lumpectomy and whole breast irradiation.METHODS AND MATERIALS: Thirty-nine women with an IBTR after lumpectomy and breast irradiation for invasive carcinoma (n = 31) or ductal carcinoma in situ (n = 8) were treated with excision of the IBTR and radiotherapy (RT), 5000 cGy in 25 fractions, to the operative area using electrons of appropriate energy. The interval from completion of the first course of RT to diagnosis of the IBTR ranged from 16 to 291 months (median 63).RESULTS: The repeat course of RT to the new operative area was well tolerated in all patients, and no late sequelae occurred other than skin pigmentation changes. Eight patients, including 2 with suspicious bone scans at the time of IBTR, developed distant metastases, and 7 died 21-71 months (median 48) after retreatment. One patient was alive with distant metastases at 27 months after retreatment. Four of the 8 patients who developed distant metastases also had a second IBTR, and 3 died with persistent disease in the breast. An additional 4 patients, for a total of 8, had a second IBTR. Three were alive and free of disease after mastectomy, and 1 was alive and free of disease after mastectomy and additional RT for chest wall recurrence. An additional patient developed recurrence in the axilla 9 months after reirradiation and was treated with surgery; she died free of disease at 63 months. One patient underwent mastectomy for suspected persistent disease 2 months after completion of repeat RT; no evidence of recurrent tumor was found in the removed breast. Thus, 30 women (76.9%) had an intact breast free of tumor at death or at last follow-up 1-180 months (median 51.5) after reirradiation. Using the Kaplan-Meier life table analysis, the estimated overall and disease-free 5-year survival rate for the 39 patients was 77.9% and 68.5%, respectively.CONCLUSION: For select patients with an IBTR after lumpectomy and breast irradiation, excision of the IBTR followed by repeat external beam RT to the operative area may be an acceptable alternative to mastectomy.     

Locally recurrent nasopharyngeal carcinoma.

PURPOSE: To assess the outcome of and determine prognostic factors for locally recurrent nasopharyngeal carcinoma (NPC) in patients treated with a second course of radiotherapy (RT). MATERIALS AND METHODS: From 1982 to 1995, 186 NPC patients, who had initially been treated in the Department of Radiation Oncology, Chang Gung Memorial Hospital-Linkou, developed local recurrence in the nasopharynx and were re-treated with RT (>/=20 Gy). The time from the initial RT to re-treatment ranged from 8 to 136 months (median: 23 months). All patients were treated with external RT and conformal radiotherapy was used in 35 patients after 1993. Fifteen received radiosurgery as a boost treatment. The RT dose at the nasopharyngeal tumor area ranged from 20 to 67.2 Gy (median 50 Gy). Eighty-two patients received one to eight courses of cisplatin-based chemotherapy in addition to RT. RESULTS: The 1-, 3- and 5-year survival was 54.9, 22. 1 and 12.4%, respectively. Patients whose tumor relapsed later than 2 years after the first treatment had a better survival than those with earlier relapse (3-year survival: 30.1 vs. 10.8%; P=0.015), but the difference became insignificant in patients who received >/=50 Gy. Patients without evidence of intracranial invasion or cranial nerve palsy had better survival than those with such lesions (3-year survival: 30.9 vs. 3.7%; P=0.006). A re-treatment dose >/=50 Gy yielded better survival (3-year survival: 22.8 vs. 18.5%; P=0.003). Addition use of radiosurgery may improve survival. The use of chemotherapy did not improve survival. Conformal radiotherapy resulted in significantly fewer severe complications than conventional RT. CONCLUSIONS: A repeat course of RT for locally recurrent NPC successfully prolongs survival in a significant number of patients. Intracranial invasion and/or cranial nerve palsy and re-treatment dose affect the prognosis, with a dose of >/=50 Gy significantly improving survival. Radiosurgery boost may also improve survival. Our preliminary data indicates that conformal radiotherapy may decrease the severity of radiation-induced complications. However; longer follow-up and larger sample size is necessary to document the findings.     

Efficacy of high-dose chemotherapy or standard salvage therapy in patients with recurrent medulloblastoma

The efficacy of high-dose chemotherapy (HDC) or standard salvage therapy was evaluated in patients with recurrent medulloblastoma (MBL) using retrospective chart review of all patients with recurrent MBL treated at Duke University Medical Center between 1995 and 2005 and who had undergone HDC with or without radiotherapy (RT) or standard salvage therapy after relapse. A total of 30 patients were diagnosed with recurrent MBL after standard RT alone or chemotherapy with RT. Nineteen patients (7 who received no RT before recurrence [group A] and 12 who received definitive RT before recurrence [group B]) underwent surgery and/or induction chemotherapy followed by HDC plus autologous stem-cell rescue. Eleven patients (group C) underwent standard salvage therapy. Six of seven group A patients also received standard RT just before or after recovery from HDC, and 5 of 12 group B patients received adjuvant palliative focal RT post-HDC. At a median follow-up of 28 months, three of seven patients in group A are alive and disease-free at >or=34, >or=110, and >or=116 months, respectively, post-HDC. All patients in groups B and C have died of tumor, at a median of 35 months and 26 months from HDC and standard salvage therapy, respectively. HDC or standard salvage therapy was ineffective in our patients with recurrent MBL who had received standard RT before recurrence. The favorable impact of HDC on disease control in the two long-term survivors cannot be clearly established due to the cofounding effect of definitive RT postrecurrence.     

Re-irradiation of nasopharyngeal carcinoma with intensity-modulated radiotherapy.

BACKGROUND AND PURPOSE: To evaluate the treatment outcome in patients with locally recurrent nasopharyngeal carcinoma (NPC) treated with intensity-modulated radiation therapy (IMRT). MATERIALS AND METHODS: Between October 2001 and May 2004, 31 patients with locally recurrent NPC received re-irradiation using IMRT. The rT classification distribution was 3 for rT1, 5 for rT2, 9 for rT3, and 14 for r T4. Median time from first course of radiotherapy to re-irradiation was 51 months. IMRT was performed using step-and-shoot method with nine 4-6 MV photon fields and median prescribed dose was 54 Gy (range: 50-60 Gy). Additional treatments included cisplatin-based induction chemotherapy in 68% and radiosurgery boost with a single dose which ranged from 8.5 to 12.5 Gy in 32%. Median follow-up time was 11 months. RESULTS: After re irradiation, 58% of patients had complete regression of primary tumor. One-year loco-regional progression-free, distant metastasis-free and overall survival rates were 56, 90, and 63%, respectively. Significantly better 1-year local progression-free rate was observed in rT1-3 than r T4 tumor (100 vs. 35%). Grade 3 late toxicities, mostly ototoxicity/cranial neuropathy, occurred in six patients (19%). One-year actuarial rates of late toxicities were 70% for all grades and 25% for Grade 3. CONCLUSION: Our preliminary results showed that good control of rT1-3 NPC can be achieved using IMRT with a dose between 50 and 60 Gy, whereas the outcome for r T4 tumor remained poor. Late toxicities were common but incidence of severe toxicities was relatively low.     

Salvage reirradiation for recurrent glioblastoma with radiosurgery: radiographic response and improved survival

Purpose To determine the radiographic and clinical efficacy of stereotactic single dose radiosurgery (SRS) and fractionated stereotactic radiotherapy (FSRT) as salvage therapy for glioblastoma (GBM) at recurrence. Methods Thirty-six patients with pathologically proven recurrent GBM were treated with salvage reirradiation by either SRS or FSRT between March of 2001 and August of 2006. Thirty-one patients had an initial diagnosis of GBM. Five patients had a malignant transformation. All patients had received radiotherapy with a dose of 50–60 Gy, a median 13.6 months prior to reirradiation (range: 0.8–119 months). At the time of recurrence, 26 patients were treated with SRS with a median dose of 18 Gy (range: 12–20 Gy). FSRT was performed in ten patients with a dose of 36 Gy in six fractions, twice weekly. Follow-up included MRI and clinical examination every 2 months. Results Median survival time after SRS was 8.5 months, compared to 7.4 months after FSRT (P = 0.81). Of 26 patients treated with SRS, radiographic tumor response or stable disease was observed in eight (35%) patients and tumor progression was seen in 18 (65%) patients. Of 10 patients treated by FSRT, radiographic tumor response or stable disease was observed in four (40%) patients and tumor progression was observed in four (40%) patients (two lost to follow-up). Patients who responded to treatment had statistically improved survival compared to non-responders, with median survival of 15.8 vs. 7.3 months (P < 0.05). Conclusion Salvage reirradiation with SRS or FSRT for recurrent GBM results in radiographic response in a proportion of patients. Survival was significantly improved among patients who either responded or had stable disease after salvage reirradiation, compared to non-responders. Further study is warranted to investigate the method and time of reirradiation for recurrent GBM.