Palliative radiotherapy for brain metastases

Several studies have confirmed that results of different hypofractionated radiotherapy schedules for palliative purpose are similar to those of conventional higher doses. From 1992 to 1993, 56 consecutive patients with brain metastases were irradiated at our Institution. Three different schedules were used ranging between 18 and 40 Gy. Overall survival, clinical and radiological responses were evaluated with regard to schedules and prognostic characteristics of patient population. There were no significant differences between the treatments, even though patients with shorter estimated life expectancy were more likely to be irradiated with more hypofractionated radiotherapy. Short, cost effective treatments appear to be the best therapeutic option both for institution and patients in most palliative cases.     

Evolution of the diagnostic accuracy of CT in clinical staging of patients with Hodgkin's disease

From 1983 through 1989, 141 untreated patients with Hodgkin's disease underwent CT of the abdomen. They subsequently underwent staging laparotomy plus splenectomy and multiple biopsies of liver and lymph nodes, at the Institute of Radiology and Hematology, University "La Sapienza", Rome. CT results were compared with surgical findings to evaluate CT sensitivity, specificity, and overall accuracy. The cases from this series were divided into two groups depending on the characteristics of the CT scanners employed. From 1983 to 1985, 78 patients were examined with 2nd-generation CT units; from 1986 to 1989, 63 patients underwent CT performed with 3rd-generation scanners. The results from the two groups were analyzed according to these parameters. A total number of 622 biopsies were performed, of spleen, liver, and lymph nodes. CT sensitivity, specificity, and overall accuracy were: 22.9% (group I) vs 43.7% (group II), 83.1% vs 92%, and 68.4% vs 81.2% for lymph nodes; 28.1% vs 36.3%, 93.5% vs 98%, and 66.7% vs 87.3% for the spleen, and 12.5% vs 42.8%, 97.1% vs 98.2%, and 88.5% vs 92.1% for the liver. Our results demonstrate an obvious increase in reliability with newer units, even though a high percentage of false-negatives were still observed in our series, which caused understaging in 19.4% of cases vs 24.4% in group I.     

Hodgkin's disease of the nasopharynx: diagnostic and therapeutic approach with a review of the literature

The lymphoid tissues of Waldeyer's ring, including the nasopharynx, are rarely involved in Hodgkin's disease (HD). Between March 1977 and July 2001, about 2150 patients affected by HD were observed in our institute; 7 of them (0.32%), all male patients, had HD of the nasopharynx. They had no symptoms and blood tests were normal. All patients were treated with chemotherapy and/or radiotherapy and achieved complete remission. At a median follow-up of 72 months, they are alive and in continuous complete remission. We conclude that Hodgkin's disease of the nasopharynx is a rare and predominantly male disease with a particularly favorable prognosis. Bone marrow biopsy could be avoided. We believe that two to four cycles of a chemotherapeutic regimen and involved field radiotherapy at an intermediate-high dosage (25-30 Gy) could be the first line treatment for these patients.     

Neoadjuvant chemoradiation with concomitant boost radiotherapy associated to capecitabine in rectal cancer patients

Purpose

The primary end-points were complete pathological response and local control. Secondary end-points were survivals, anal sphincter preservation, and toxicity profile.

Methods

Patients with T3/T4 and or N+ rectal cancer (n?=?65) were treated with preoperative concomitant boost radiotherapy (55 Gy/25 fractions) associated to concurrent chemotherapy with oral capecitabine.

Results

All patients completed the programmed treatment. The complete pathological response was achieved by 17 % of the patients. Anal sphincter preservation surgery was possible for 86 % of the patients with low rectal cancer (≤5 cm from the anal verge). The T-stage and N-stage downstaging were achieved by 40 and 58 % of the patients, respectively. Circumferential radial margin was involved (close/positive) in eight patients. After a median follow-up of 26 months, local and distant recurrence occurred in two and 11 patients, respectively. The 3-year overall survival and disease-free survival were 86.8 and 81 %, respectively. Non-hematological?≥?grade 3 toxicities were observed in 15 % of the patients. On univariate analysis N-downstaging and positive circumferential radial margin were significantly associated with worse overall survival (p?=?0.003 and p?=?0.023, respectively), disease-free survival (p?=?0.001 and p?=?0.036, respectively), and metastasis-free survival (MFS) (p?=?0.001 and p?=?0.038, respectively).On multivariate analysis, the N-downstaging were significantly associated with better overall survival (OS) (p?=?0.022).

Conclusions

Our data support the efficacy of preoperative treatment for rectal cancer in terms of local outcomes. Radiation treatment intensification may have a biological rationale; longer follow-up is needed.     

A longitudinal study of the matrix changes induced in the intervertebral disc by surgical damage to the annulus fibrosus.

A 5 x 5-mm anterolateral incision was made in the annulus fibrosus (AF) of lumbar discs of 16 sheep; four animals of similar age not operated on were used as controls. The experimental animals were sacrificed 2, 4, 6, 8, 12, and 18 months postoperatively (PO), and the incised and adjacent lumbar discs were collected. Discs were dissected into four zones: AF (zones 1 and 2) and nucleus pulposus (NP) (zones 3 and 4) corresponding to the half of the AF in which the cut was made and its opposite half, and the complementary halves of the NP. Each zone was analyzed for moisture, proteoglycan (PG), collagen, and noncollagenous protein (NCP) content. The PG extractability, aggregation, and hydrodynamic size were also examined. The NP of injured discs showed a significant loss of PGs and collagen 8 months PO, but NCP levels increased. In the incised discs, PG aggregation initially declined but recovered to within control values 6-8 months PO. The NP of discs adjacent to the incised disc also showed time-dependent changes in matrix components that included loss of collagen and PG; however, the AF matrix remained essentially uneffected. Double immunodiffusion studies indicated that a sizeable proportion of the NCPs present in the injured discs (but not the adjacent lumbar discs) were derived from serum.     

Long-term outcome after multimodality treatment for stage III thymic tumors

BACKGROUND: Surgery remains the cornerstone of therapy for thymic tumors, but the optimal treatment for advanced, infiltrative lesions is still controversial. The introduction of multimodality protocols has substantially modified survival and recurrence rate. We reviewed our 13-year prospective experience with multimodality treatment of stage III thymoma and thymic carcinoma. METHODS: Since 1989 we have prospectively used a multimodality approach in 45 stage III thymic tumors. Sixteen patients (35%) had myasthenia gravis. Twenty-three patients (51%) had pure or predominantly cortical thymoma (group 1), 11 (24.5%) had well-differentiated thymic carcinoma (group 2), and 11 (24.5%) had thymic carcinoma (group 3). Tumors that were not considered radically resectable at preoperative workup underwent biopsy and induction chemotherapy (15 patients, 33%) followed by surgical resection; all patients were referred for adjuvant chemoradiotherapy. RESULTS: No operative mortality was recorded; 1 treatment-related death during adjuvant chemotherapy was observed in group 1. Complete resection was feasible in 91% of patients in groups 1 and 2 and 82% in group 3. The overall 10-year survival was 78%. Ten-year survival for groups 1 and 2 was 90% and 85%, respectively; 8-year survival for group 3 was 56%. During follow-up, tumor recurrence was noted in 3 patients (13%) from group 1, 3 (27%) from group 2, and 3 (27%) from group 3. CONCLUSIONS: Multimodality treatment with induction chemotherapy (when required) and adjuvant chemoradiotherapy offers encouraging results for stage III thymic tumors; the outcome is more favorable for cortical thymoma and well-differentiated thymic carcinoma.     

Radiotherapy for nonfunctioning pituitary adenomas: from conventional to modern stereotactic radiation techniques

The initial management of nonfunctioning pituitary macroadenomas (NFAs) is usually surgery; however, a significant proportion of NFAs may require further treatment. Radiotherapy is currently used in patients with residual tumour and achieves excellent long-term control, but there are concerns about potential late toxicity. Stereotactic radiotherapy, both in the form of radiosurgery or fractionated stereotactic radiotherapy, has been developed as a more accurate technique of irradiation with more precise tumour localization and consequently a reduction in the volume of normal tissue, particularly the brain, irradiated to high radiation doses. A review of the literature suggests that new radiation techniques offer safe and effective treatment for recurrent or residual pituitary adenomas; however longer follow-up is necessary to confirm the excellent tumour control and the potential reduction of long-term radiation toxicity. Currently, radiotherapy has an important role in patients with residual or progressive disease after surgery. Patients with small or no residual tumours after surgery may generally continue on a policy of surveillance without immediate irradiation, in order to avoid the potential toxicity of treatment.     

Long-term results of 60 patients with pathologic stage I & IIA Hodgkin's disease treated with exclusive mantle radiation therapy.

Between January 1972 and December 1982 60 patients with pathological stage IA and IIA Hodgkin's disease (HD) were submitted to Mantle irradiation only. Twenty-five were in stage I (32.1%) and 35 in stage II (67.9%). All patients were submitted to staging laparotomy. Cases with large mediastinal mass were excluded from this series. Delivered doses were 44 Gy in involved areas, 40 Gy on the mediastinum and 36 Gy on uninvolved sites. Twenty-four patients in stage I (96%) and 33 in stage II (94.2%) obtained complete remission. Actuarial 10- and 20-yr overall (OS) rates were 86% and 79.1%, respectively. Event-free (EFS) and relapse-free (RFS) survival rates at 10 and 20 yr were 67.5% and 62.1%, respectively. The occurrence of disease relapse resulted in the only statistical significant prognostic factor for OS in both univariate and multivariate analysis. Distant and extranodal recurrences were significantly (P<0.01) related to a reduced OS. On multivariate analysis stage was the only determinant factor for increased RFS. Extended field RT proved to be an effective curative modality for stage I HD patients, whereas 15 out of 33 patients in stage II relapsed requiring salvage therapy. Long-term analysis of survival and treatment-related morbidity rates will improve our knowledge and assist the physicians to choose the therapeutic option to offer to HD patients.