Aggressive Local Treatment Research Articles

Cushing's syndrome and chronic venous ulceration - a clinical challenge

Cushing's syndrome is a condition caused by high levels of glucocorticoids, or most commonly as a result of prolonged exposure to exogenous steroids. Clinical features include diabetes, hypertension, obesity, skin atrophy, immune suppression and delayed wound healing. We report a patient with iatrogenic Cushing's syndrome, in whom long-term topical steroid therapy was used to treat varicose eczema, which contributed to the development of type 2 diabetes, morbid obesity, sleep apnoea and chronic wound sepsis. In this case, repeated hospital admissions and systemic antibiotics were associated with considerable comorbidity. Aggressive local treatment, consisting of potassium permanganate soaks and irrigating gels, was highly effective in reducing the amount of exudate, pain and preventing from further deterioration of the patient's legs.

Recurrence Patterns and Survival for Patients With Intermediate- and High-Grade Myxofibrosarcoma

Myxofibrosarcoma (MFS) is a rare sarcoma with a predilection for multiple local recurrences (LR), for which optimal treatment has not been defined. We reviewed our experience to determine the impact of surgery and radiation therapy (RT) on pattern of recurrence, limb salvage, and overall survival (OS). Between 1995 and 2005, 36 patients with localized intermediate- or high-grade MFS were treated at our institution. Data on clinicopathologic features, treatments, and patient outcomes were reviewed and analyzed. Median age was 72.5 years (range, 42-96 years). Median tumor size was 7.5 cm, and 34 tumors (94%) were high grade. All patients underwent surgery at our institution, including re-resections in 20 patients (56%) after initial surgery elsewhere. Margins were microscopically positive in 9 patients (25%). RT was given to 28 patients (78%) pre - and/or postoperatively. After a median follow-up of 3.5 years (range, 0.4-12.4 years), 11 patients (31%) developed LR. There were no significant predictors for LR on univariate analysis, including margin status or use of RT. Limb salvage was ultimately achieved in only 5 of 11 LRs (45%) because of multiple subsequent LRs. Distant recurrence (DR) occurred in 6 patients (17%). Median and 4-year OS were 96 months and 65%, respectively. Seven patients (19%) died of tumor-related causes, 6 of whom had DRs. On univariate analysis, tumor size was associated with OS. Despite aggressive surgery and RT, intermediate- and high-grade MFS are associated with a high rate of LR that adversely affects limb preservation. More aggressive local treatment strategies are necessary.

Aggressive Local Treatment Containing Intraoperative Radiation Therapy (IORT) for Patients with Isolated Local Recurrences of Pancreatic Cancer

Aggressive Local Treatment Containing Intraoperative Radiation Therapy (IORT) for Patients with Isolated Local Recurrences of Pancreatic Cancer

Recurrence Patterns and Survival in Patients with Intermediate and High-grade Myxofibrosarcoma

MFS is a rare sarcoma with a predilection for multiple local recurrences (LR). In the absence of any large published series, optimal treatment has not been defined. We reviewed our experience to determine the impact of surgery and radiation therapy (RT) on pattern of recurrence, limb salvage, and overall survival (OS). Between 1995 and 2005, 36 patients with localized intermediate or high-grade MFS received treatment at Dana-Farber/Brigham and Women's Hospital Cancer Center (DFBWHCC). Data on clinicopathological features, treatments, and pt outcomes were reviewed. LR and OS rates were estimated using the Kaplan-Meier method. Comparisons of the difference in distributions were assessed by the log–rank test. Median age was 72.5 years (range, 42–96). Tumors were of high (n = 34) or intermediate (n = 2) grade. Median size was 7.5 cm (range, 0.7–22). Twelve patients (33%) had Stage II and 24 (67%) had Stage III disease. Disease sites were extremities (n = 32) and trunk (n = 4). All patients underwent surgery as part of initial treatment: 20 (56%) had re-resection at DFBWHCC after open biopsy or marginal resections elsewhere. One pt (3%) had amputation, the remainder had radical (n = 27, 75%) or wide (n = 8, 22%) excision. Final margins were microscopically positive in 9 patients (25%). RT was given to 28 patients (78%) either pre-operatively (n = 5; median, 50 Gy), postoperatively (n = 19; median, 62.5 Gy), or both (n = 4; median total, 64 Gy). Among the 8 patients who did not receive RT, 5 had negative surgical margins (mean, 1.5 cm; range, 0.5–3.5 cm), 2 had no residual tumor on re-excision, and 1 developed rapid LR before planned postoperative RT. One pt with a 22-cm MFS received preoperative chemotherapy (CT). No patients received adjuvant CT. After a median follow-up of 3.5 years (range, 0.4–12.4), 11 patients (30%) developed LR. Among those, median time to first LR was 21 mos (range, 6–48). The 4- year actuarial LR rate was 40%. Limb salvage was ultimately achieved for only 4 of 11 (36%) due to multiple LRs. The median number of LRs was 1 (range, 1–4). There were no significant predictors for LR on univariate analysis. Crude LR rates for patients treated with and without RT were 36% and 12%, respectively (p = NS); the rates for patients with positive and negative margins were 44% and 26%, (p = NS), respectively. Distant recurrence (DR) occurred in 6 patients (17%), most commonly in lung (n = 5). Among those 6 patients, median time to first DR was 21 mos (range, 4.8–97). Four of 6 DRs (67%) developed without any LR. Median OS was 96 mos and 4- year actuarial OS was 65%. Seven patients (20%) had tumor-related deaths, 6 of whom had DR. Despite aggressive surgery and RT, intermediate and high-grade MFS has a high rate of LR which adversely impacts limb preservation. More aggressive local treatment strategies are necessary.

A European treatment protocol for bone sarcoma in patients older than 40 years

10516 Background: EUROpean Bone Over 40 Sarcoma Study (EURO-B.O.S.S.) is the first prospective multicenter international study for patients 41 - 65 years old with high-grade bone sarcoma. Methods: Patients with HG Osteosarcoma (OS), HG sarcoma NOS (S), Fibrosarcoma, MFH, Leiomyosarcoma, Dedifferentiated Chondrosarcoma (DCh) were included. Chemotherapy: Combinations of cisplatin/doxorubicin (CDP 100mg/m2/ADM 60mg/m2), ifosfamide/CDP(IFO 6g/m2/CDP 100mg/m2) and IFO/ADM (IFO 6g/m2/ADM 60mg/m2) were repeated three times (9 cycles). Surgery was planned after 3 cycles. Methotrexate (8g/m2) was postoperatively added in poor responders. Immediate surgery was allowed and 9 cycles with CDP, ADM, IFO were postoperatively given. Results: In December 2007, 140 patients were registered (median age 51 years). OS (51%), S (16%), and DCh (11%) were the more frequent histotypes. Synchronous metastases in 30 (21%) patients, central location of tumor in 45 (32%). Surgical complete remission (SCR) was achieved in 84% of patients, (localized 91%, metastatic 37%) without difference among the histology groups. One surgical-related and one chemotherapy-related death were reported. Grade 4 WBC and PLT incidence was 55% and 17%.Renal toxicity and peripheral neurotoxicity were reported in 16% and 20% of patients. With a median follow-up of 25 months (4–68) 3 year OS was 58% (95%CI 48–68%) [7% (95%CI 0–19%) without SCR]. In patients with SCR, 3 year OS and EFS were 46% (95%CI 9–83%) and 0% in case of synchronous metastases and 69% (95%CI58–80%) and 45% (95%CI33–57%) for localized patients; 50% (95%CI 29–71%) and 40% (95%CI 20–59%) for patients with central tumor, 73% (95%CI61–85%) and 44% (95%CI31–57%) for those with extremity tumor; 68% (95%CI 52–83%) and 46% (95%CI 32–54%) for OS, 64% (95%CI 42–85%) and 48% (95%CI 25–71%) for S, 48% (95%CI 13–82%) and 27% (95%CI 1–54%) for DCh. Conclusions: The protocol is feasible, but the chemotherapy-related toxicity is remarkable. Surgical complete remission is the main factor influencing survival. Central location and synchronous metastases are negative prognostic factors, but 50% 3-year OS can be achieved with aggressive local and systemic treatment. Osteosarcoma and high-grade sarcoma NOS benefit from chemotherapy more than patients with dedifferentiated chondrosarcoma. No significant financial relationships to disclose.

Hyperthermia as an adjunctive treatment for soft-tissue sarcoma

The treatment for high-risk soft-tissue sarcomas (STSs) in adults remains a challenge for the multidisciplinary approach. Despite aggressive local treatment, high-risk STSs have a tendency for hematogenous spread, which is related, for each histologically distinct sarcoma, to risk factors, such as pathologic grade, size and location. The multimodality approach focuses on the combination of radiochemotherapy in a neoadjuvant or adjuvant setting, surgery being considered the mainstay of local treatment. Therefore, current clinical research aims include preoperative treatment to control systemic microscopic disease and to downsize the primary tumor mass. Within the past 20 years, the application of hyperthermia has been integrated in multimodal treatment strategies in several forms of advanced malignant tumors, as well as in STSs. Hyperthermia is of clinical interest in the temperature range of 40–43°C. Higher temperatures of 44–46°C are not clinically realistic. The rationale for the combination of cytotoxic drugs with regional hyperthermia in the treatment of STS is based upon experimental and clinical evidence that heat increases the killing of tumor cells by direct thermal toxicity and enhances the efficacy of some drugs, such as alkylating agents and platinum analogs. Moreover, recent results show that hyperthermia may be able to modulate the immune system by inducing the expression of heat-shock proteins. The approach of multimodality treatment in STS has used regional hyperthermia with systemic chemotherapy within a preoperative and postoperative strategy. The synergistic effect of hyperthermia with chemotherapy is also used in locoregional treatments, such as isolated limb perfusion and intraperitoneal chemotherapy.

Peritoneal Dissemination from Malignant Fibrous Histiocytoma of the Buttock: Unusual Metastases from a Rare Tumor

We report a case of malignant fibrous histiocytoma (MFH) of the right buttock with multiple metastases to the lung, bone, and small intestine. He received resection and end-to-end anastomosis of the jejunum for the jejunal metastatic tumor, and mass excision of the metastatic tumor of the left femur followed by closed reduction and internal fixation and palliative radiotherapy. In addition, he received palliative radiotherapy to the metastatic pulmonary tumor with suspicious invasion into the thoracic aorta. However, one month after the completion of the aggressive local treatments, metastatic tumors recurred in the abdominal cavity, an extremely unusual site, resulting in peritoneal dissemination. He died of progressive disease 5 months after the initial diagnosis.

Adjuvant hormone therapy after radiotherapy

Obviously, in low risk patients, excellent results are obtained with single-modality therapy (prostatectomy, external beam irradiation or brachytherapy). It is also clear that in high-risk patients who choose to be treated by radiotherapy the addition of androgen deprivation increases disease free survival and overall survival. However, in intermediate risk patients the choice is in between, and some benefit from more aggressive local treatment (surgery, combined surgery and radiotherapy or dose-escalation radiotherapy) while others take advantage of combined radiotherapy and short-term hormone therapy. According to the French guidelines recently updated by the CCAFU, SFRO, GETUG and SFP, each case must be discussed in a multidisciplinary approach, considering not only arguments from randomized trials but also other factors related to patients’ age, comorbidities, quality of life and patient perspective.

Is aggressive local treatment necessary for diffuse liver involvement in patients with progression of stage 4s neuroblastoma to stage 4?

Three patients with stage 4S neuroblastoma without MYC-N amplification who progressed to stage 4 with persistent liver involvement, were treated with iodine 131–meta-iodobenzylguanidine therapy, chemotherapy, and surgery. Successive histologic examination of the liver showed differentiation of the tumor in 2 patients and fibrosis in the third. One patient died of brain metastases at the age of 30 months. The other 2 patients are alive at 50 and 44 months. Diffuse liver involvement in patients with stage 4 progression of previous stage 4S without MYC-N amplification may differentiate after treatment. The aim of this report is to draw attention to major liver surgery that it may not be necessary in tumors without MYC-N amplification, despite the persistence of lesions in the liver.

Cancer of the external auditory canal and middle ear in Denmark from 1992 to 2001

In the context of the Danish Head and Neck Cancer Group, nationwide material from 1992-2001 was analyzed to study the extent and nature of the disease, evaluate treatment, compare staging systems, and examine prognosis and survival. Review of 68 consecutive cases: 47 squamous cell carcinoma, 10 basal cell carcinoma, and 11 other histologies. Moody (modified Pittsburgh) stages were T1 (26), T2 (9), T3 (8), T4 (23), Tx (2). Sixty-four patients were treated with curative intent: 24 primary radiotherapy, 18 primary surgery, and 22 combined. Surgery was limited to tumor excision and mastoidectomy and in 1 case temporal bone excision. Twenty-seven of 28 recurrences involved primary site. Kaplan-Meier analysis showed 5-year locoregional control of 48%, disease-specific survival 57%, and overall survival 44%. This nationwide study confirmed that local failure is the main problem, and future improvements should focus on more aggressive local treatment.

Rare metastases of recurrent cervical cancer to the pericardium and abdominal muscle

Pericardial metastasis from recurrent cervical cancer is very rare. There have been few case reports of such cases in which antemortem diagnoses were established. Cases of additional abdominal muscular metastasis have not been reported previously, although a small number of cases of additional skin metastasis have been reported. A 64-year-old woman with intermittent vaginal bleeding was referred under the clinical impression of cervical cancer. Further investigation revealed a cervical cancer (FIGO stage Ib), and she underwent a radical hysterectomy followed by adjuvant concurrent chemoradiation. During the post-operative follow-up period of 6 months, pericardial and abdominal muscular metastases were developed along with the symptoms of dry cough and dyspnea. We recommended a palliative pericardial window, but the patient rejected it. Although palliative radiation therapy and chemotherapy were performed for the control of the metastases, she expired due to cardiac failure 16 months after the operation. The prognosis of patients with pericardial and abdominal wall metastases from recurrent cervical cancer is usually poor because of the systemic dissemination of the disease. Aggressive local and systemic treatments may provide significant palliation of associated symptoms.

Striking response to intrathecal liposomal cytarabine in a patient with meningeal myelomatosis

A 63-year-old woman presented with right retro-orbital plasmacytoma. Magnetic resonance imaging (MRI; Fig 1A) confirmed a large, solid, well-delineated mass in the right orbit that was displacing the eyeball and upper extrinsic muscles downwards, without cerebral parenchyma involvement. Linear pachy-meningeal thickening extended to the right supraorbital and frontal dura, suggesting dural infiltration. The patient underwent fronto-temporal craniotomy. Histology and immunohistochemistry of the mass showed massive immunoglobulin (Ig) G-j plasma cell infiltration with 20% Ki-67 plasma cells. Bone marrow biopsy indicated 35% infiltration of monoclonal IgG-j plasma cells. Cerebral spinal fluid (CSF) was normal. Blood tests, including b2-microglobulin, were normal except for total protein (62 g/l), hypogammaglobulinaemia (4 g/l) and the presence of an IgG-j monoclonal component by serum immunofixation. Bence Jones protein was undetectable. A skeletal X-ray showed small osteolytic areas in the cranial vault and frontal–parietal area. Multiple myeloma (MM) was diagnosed. The patient underwent three cycles of Cy-VAD (cyclophosphamide, vincristine, adriamycin, dexamethasone) chemotherapy but, before the fourth, presented with a persistent headache. A MRI scan showed MM dural involvement. The CSF cell count was 18/mm with plasma cells and plasmablasts. Polymerase chain reaction amplification of IGH showed a monoclonal rearrangement in CSF. Meningeal myelomatosis was diagnosed. The patient received two intrathecal pushes of 50 mg liposomal cytarabine (SkyePharma, London, UK) at a 14-d interval, and dexamethasone (8 mg twice daily for 14 d). Her fever and headache rapidly disappeared. One month after encephalic radiotherapy (total dose 30 Gy), two more pushes of liposomal cytarabine were administered. Dexamethasone, radiotherapy and four injections of liposomal cytarabine were well tolerated. 18 months after diagnosis, disease assessment showed no serum monoclonal component, rare plasma cells in the bone marrow and no mass on cranial MRI (Fig 1B). Multiple myeloma involvement of the central nervous system is rare (Damaj et al, 2004; Fassas et al, 2004) and the outcome is extremely poor despite aggressive local and systemic treatment including high-dose chemotherapy (Pizzuti et al, 1997; Patriarca et al, 2001). As our patient had already been treated with dexamethasone in first-line treatment, intrathecal liposomal cytarabine alone seemed to ensure successful eradication of meningeal myelomatosis.

Impact of the smallest surgical margin on local recurrence in soft tissue sarcoma treated with surgery with or without radiotherapy: First ten year results of a prospective treatment protocol at Helsinki University Central Hospital

10064 Background: A single-institution experience using a prospective treatment protocol for soft tissue sarcoma (STS) of the extremity and trunk wall was reviewed. Special interest of smallest surgical margin on local control was taken. Methods: Between 1987 and 1997 361 patients with STS were treated by the STS Group at Helsinki University Central Hospital. Patients with borderline malignancies or metastatic disease were excluded leaving 270 patients to the present study. All patients included underwent surgery. Postoperative radiotherapy was administered if the smallest surgical margin was less than 2.5 cm when there was no natural barrier, irrespective of tumor grade. Results: With a median follow-up of 6.6 years, the 5-year local control for the whole study population was 76 %. On multivariate analysis, the smallest surgical margin in centimeters, adequacy of treatment according to protocol and postirradiation sarcoma were prognostic for local control. A margin of at least 2,5 cm yielded recurrence-free rate of 89 % at five years. Conclusions: Our findings show that size, depth and grade of the tumor, and patient`s age at diagnosis do not have independent prognostic effect on local control, nor has recurrent disease at referral. Instead, surgical margin in centimeters and adequacy of treatment according to protocol had independent prognostic value for local control. This is encouraging since these factors can be affected by aggressive local treatment. Soft tissue sarcomas should be referred to a specialized multimodality treatment group before biopsy or any surgery. A surgical margin of 2–3 cm yield a reasonable local control in STS even without radiotherapy. No significant financial relationships to disclose.

Malignancies of the Nasal Cavity and Paranasal Sinuses: Long-Term Outcome With Conventional or Three-Dimensional Conformal Radiotherapy

To evaluate the long-term clinical outcome and toxicity of conventional and three-dimensional conformal radiotherapy for malignancies of the nasal cavity and paranasal sinuses. Between January 1976 and February 2003, 127 patients with histologically proven cancer of the paranasal sinuses (n = 119) or nasal cavity (n = 8) were treated with preoperative (n = 61), postoperative (n = 51), or primary (n = 15) radiotherapy, using conventional (n = 74) or three-dimensional conformal (n = 53) techniques. No elective neck irradiation of the cervical lymph nodes was performed in N0 patients. Median follow-up was 5.6 years (range, 3-307 months) for all patients, and 7.3 years (range, 47-307 months) for patients still alive at the close-out date. The actuarial 5-year local control, overall survival, and disease-free survival rates were 53%, 54%, and 37%, respectively. Only 6 (5%) of all 127 patients and 4 (3%) of 122 originally N0 patients developed a regional failure in the neck. Distant metastasis occurred in 20% of patients. Both primary tumor extent and lymph node involvement were the most important prognostic factors, together with squamous cell carcinoma histology. Local failure remains the dominant cause of poor outcome for patients with sinonasal cancer, despite aggressive local treatment with combined surgery and radiotherapy in operable patients. Distant metastasis and certainly regional relapse were much less common sites of failure. Overall survival remains poor, suggesting the need for more efficacious local and possibly systemic therapy.

Long term disease-free survival resulting from combined modality management of patients presenting with oligometastatic, non-small cell lung carcinoma (NSCLC)

We report outcomes on 23 patients with oligometastastic (1 or 2 sites) NSCLC treated with aggressive local, regional, and systemic treatment. The results suggest that this is a favorable subset of patients who may benefit from such an approach, with a 22% rate of long-term survival. This treatment strategy is a departure from the usual practice of palliative-only therapy for all NSCLC patients presenting with metastatic disease.

A phase I/II trial of induction chemotherapy followed by concomitant docetaxel with concomitant boost radiotherapy (CBR) and amifostine for advanced head and neck cancer (HNC)

15525 Background: Concomitant chemo-radiation for head and neck cancer has emerged as the optimal method of treating advanced head and neck cancers, although the acute and late toxicities can be formidable. The addition of induction chemotherapy to concomitant chemo-radiation for head and neck cancer is designed to impact the incidence of distant metastasis while delivering aggressive local treatment. This trial evaluates the tolerability and effectiveness of induction chemotherapy followed by CBR with concurrent docetaxel and subcutaneous (SC) amifostine in locally advanced squamous cell carcinoma of the head and neck (SCCHN). Methods: Patients with stage III/IV nonmetastatic SCCHN received 3 cycles of primary chemotherapy with docetaxel and cisplatin, each at 75 mg/m2. Patients then received 4 weekly doses of docetaxel at 20 mg/m2 with concurrent CBR. SC amifostine was given at a dose of 500 mg in divided doses during each day of XRT. Results: The phase I component defined the MTD of concurrent docetaxel as 20 mg/m2 for 4 cycles during CBR. 18 patients are evaluated for response. No patient developed progressive disease during primary chemotherapy. Grade 3–4 mucositis was common, but all patients completed the planned concomitant docetaxel. At 6 months after treatment, 7/18 patients still used a feeding tube, though most have had them subsequently removed. Amifostine given by SC was well tolerated; 7 patients developed transient hypotension not requiring any intervention, with grade1 dermatitis and nausea reported. 2 patients discontinued amifostine due to rash or persistent hypotension. Conclusions: Response to induction chemotherapy was greater then 75% by radiological assessment, with no patient developing distant metastasis thus far. Local control has been excellent but side effects from docetaxel and CBR have necessitated prolonged use of feeding tubes for up to 6 months. SC amifostine has been well tolerated without significant side effects. This aggressive therapy is effective treatment for locally advanced SCCHN. No significant financial relationships to disclose.

Hirnmetastasen beim Lungenkarzinom

Cerebral metastases are a frequent complication of lung cancer. They often determine patients' prognosis and need urgent therapeutic intervention. Based on histologic type, former therapies, age and performance of the patient, the number of cerebral lesions and the extracerebral tumour activity, individualized treatments are applied. For patients who suffer from non-small cell lung cancer and a single CNS lesion the best results can be achieved if they are surgically resected or receive radiosurgery. Their survival time can be markedly increased in comparison to patients who undergo whole brain irradiation. If multiple metastases are seen in CT or MRI, whole brain irradiation is the therapy to choose. Furthermore it should be initiated if small cell lung cancer metastasizes to the brain. More aggressive local treatment options appear promising, but a clear role for them has not yet been defined. Systemic chemotherapy gains more attention in the treatment of small and non-small cell lung cancer with brain metastases. How to increase the efficacy through simultaneous application of chemo- and radiotherapy is tested in current trials. This article gives an overview on clinical presentation and diagnosis of cerebral metastases in lung cancer and reviews current treatment options.

Trends and predictors of aggressive therapy for clinical locally advanced prostate carcinoma

To determine the patterns and predictors of aggressive local therapies for patients with clinically advanced (cT3) prostate carcinoma, as the USA National Cancer Institute considers external beam radiotherapy (EBRT) to be the most appropriate treatment for these patients, and currently there is less evidence supporting the use of radical prostatectomy (RP). We used the Surveillance, Epidemiology and End Results (SEER) cancer registries to identify patients diagnosed with cT3 disease between 1995 and 2001. Sociodemographic and clinical data included patient age, race/ethnicity, marital status, SEER registry, year of diagnosis, tumour stage and grade, and treatment. Multivariate logistic regression was used to identify significant predictors of receiving (i) RP vs EBRT, (ii) any aggressive local treatment (RP or EBRT) or no treatment. Between 1995 and 2001, the proportion of men receiving aggressive local therapy for cT3 disease increased by 11% (58.4% to 69.4%), with a 20% increase in EBRT (40.3% to 60.2%) but a decline by half in RP (18.1% to 9.3%). Younger age was the strongest predictor of receiving RP rather than EBRT, and younger age with being married being a predictor of receiving aggressive local therapy (adjusted relative risk for marriage 1.33, 95% confidence interval 1.18-1.87). Black men were significantly less likely than non-Hispanic white men to receive aggressive therapy, with a relative risk of 0.56 (0.45-0.69). By 2001, 70% of patients with cT3 disease were receiving aggressive local therapy, with EBRT 6.5 times more common than RP. Clinical trials are needed to rigorously assess the effects of different local treatment strategies on clinical outcomes in men with cT3 prostate carcinoma.

Diffuse phlegmonous phlebitis after endovenous laser treatment of the greater saphenous vein

Endovenous laser treatment (EVLT) has become a valuable and safe option in the treatment of varicose veins. Although long-term results are lacking, most patients seem to benefit in the short-term from EVLT. Reported postoperative complications are limited, consisting usually of pain, ecchymosis, induration, phlebitis, or spot skin burn injuries. The most feared complication is an extension of the saphenous thrombus into the femoral vein, with possible pulmonary embolism. Here we report a septic thrombophlebitis after EVLT resulting in a phlegmonous infection of the whole leg that was treated by surgical drainage. Aggressive local therapy and antibiotic treatment resulted in complete resolution of symptoms and eventual satisfactory healing.

Hirnmetastasen beim Lungenkarzinom

Cerebral metastases are a frequent complication of lung cancer. They often determine patients' prognosis and need urgent therapeutic intervention. Based on histologic type, former therapies, age and performance of the patient, the number of cerebral lesions and the extracerebral tumour activity, individualized treatments are applied. For patients who suffer from non-small cell lung cancer and a single CNS lesion the best results can be achieved if they are surgically resected or receive radiosurgery. Their survival time can be markedly increased in comparison to patients who undergo whole brain irradiation. If multiple metastases are seen in CT or MRI, whole brain irradiation is the therapy to choose. Furthermore it should be initiated if small cell lung cancer metastasizes to the brain. More aggressive local treatment options appear promising, but a clear role for them has not yet been defined. Systemic chemotherapy gains more attention in the treatment of small and non-small cell lung cancer with brain metastases. How to increase the efficacy through simultaneous application of chemo- and radiotherapy is tested in current trials. This article gives an overview on clinical presentation and diagnosis of cerebral metastases in lung cancer and reviews current treatment options.