Distant Metastasis-free Rates Research Articles

Comparing outcomes and cost in surgery versus watch & wait surveillance of patients with rectal cancer post neoadjuvant long course chemoradiotherapy.

Watch and wait (W&W) in complete clinical responders after neoadjuvant chemoradiotherapy has increasingly robust data supporting its oncological safety. Recently, studies have assessed the real-world costs of this strategy compared to surgical resection. Our aim was to compare our oncological safety and costs associated with operative and surveillance strategies to international literature. Data were retrospectively collected and analysed via electronic health records from March 2014 to March 2021 in Christchurch, New Zealand. Two cohorts were created based on intention to treat. All hospital events were recorded and costed, as well as oncologic outcomes. Our primary endpoints were the cumulative cost of both strategies, 3-year survival rate, and disease-free survival. Forty-eight patients were identified who had rectal cancers resected (OT) with a yPT0N0 pathology, and 42 who were on the wait-and-watch (W&W) audit after having a clinical complete response. After exclusions, we identified 38 OT and 23 W&W patients; the W&W group were more co-morbid (P = 0.05), had worse functional status (P = 0.008), higher BMI (P = 0.34) and more favourable clinical tumour staging (P = 0.01). The operative treatment (OT) group (n = 38) had more acute admissions (34% versus 13% in W&W, P = 0.08, OR 0.29). There was a 35.7% (n = 8 of 23) local recurrence in W&W and none in the OT group (P ≤ 0.001), with successful salvage in the W&W with local recurrence in 71.5% (n = 5 of 7). Three-year distant metastasis-free rate was 97.3% in the OT group and 90.9% in W&W (p = 0.05). Overall survival was 100% (W&W) and 94.7% (OT); (P = 0.019). Care in the OT group cost more than W&W, accounting for local regrowth management; $NZ70,759.56 versus $NZ47,905.52 (P = 0.014). This study found better oncological outcomes in the OT group, whilst the W&W group had reduced morbidity and acute bed days. The cost of wait and watch was approximately two-thirds that of operative treatment, even accounting for salvage procedures for local regrowth.

Intensity modulated radiation therapy in elderly patients with nasopharyngeal carcinoma

PurposeTo evaluate the outcomes in elderly patients with nasopharyngeal carcinoma (NPC) treated by intensity modulated radiation therapy (IMRT). Methods Patients with NPC aged ≥ 70 years old who received intensity-modulated radiation therapy ≥ 60 Gy were recruited into this study. The overall survival (OS), progression-free survival (PFS), cancer-specific survival (CSS), locoregional recurrence-free rate (LRFR) and distant metastasis-free rate (DMFR) were calculated using the Kaplan–Meier method. The Cox proportional hazards model was applied to perform multivariate analysis for independent prognosticators using meaningful variables from the univariate analysis.ResultsOne hundred ninety seven patients with NPC ≥ 70 years were recruited from the 4351 newly diagnosed NPC patients from January 2011 to December 2020. The 5-year OS, CSS, PFS, LRFR and DMFR were 59.6%, 78.9%, 51.3%, 91.6% and 78.9%, respectively. the plasma EBV DNA was the only prognostic factor for OS, the overall staging was the only prognostic factor for CSS, and plasma EBV DNA and N category were borderline significant factor for DMFR. We did not find any prognosticator for PFS and LRFR.ConclusionsThe survival after IMRT for elderly patients with NPC is suboptimal. Further study stratified by comorbidity and geriatric assessment is needed.

Timing of additional neoadjuvant chemotherapy in patients with locally advanced rectal cancer treated with neoadjuvant chemoradiotherapy and total mesorectal excision

BackgroundIn locally advanced rectal cancer (LARC), the optimal sequence of neoadjuvant chemotherapy in relation to neoadjuvant chemoradiotherapy and before total mesorectal excision is unknown.MethodsA total of 426 LARC patients, treated with neoadjuvant chemoradiotherapy followed by total mesorectal excision, between January 2010 and December 2018, were studied retrospectively. Patients were divided into induction and consolidation chemotherapy groups. Overall, disease-free, locoregional relapse-free, and distant metastasis-free survival rates for the 2 groups were compared. Multivariate analysis hazard ratios (HR) with 95% confidence intervals (CI) to identify survival predictors.ResultsMedian follow-up was 37 (range, 7–162) months. The 3-year overall, disease-free, locoregional relapse-free, and distant metastasis-free survival rates were 93.8%, 71.6%, 93.5%, and 74.4%, respectively. For those receiving either induction or consolidation chemotherapy, 3-year disease-free survival rates were 82.5% and 67.7%, respectively (P = 0.021), distant metastasis-free rates were 85.4% and 70.8%, respectively (P = 0.024), and both overall and locoregional relapse-free survival rates did not differ significantly. Absence of neural invasion was an independent predictor of disease-free (HR = 0.49, 95% CI 0.25–0.97, P = 0.04) and distant metastasis-free (HR = 0.49, 95% CI 0.25–0.98, P = 0.04) survival. Both ypTN stage III (vs.0-II) and consolidation (vs. induction) chemotherapy were independent predictors of disease relapse (HR = 1.95, 95% CI 1.47–2.58, P < 0.001; HR = 1.68, 95% CI 1.01–2.79, P = 0.046; respectively) and distant metastasis (HR = 2.04, 95% CI 1.51–2.76, P < 0.001; HR = 1.75, 95% CI 1.03–2.99, P = 0.04; respectively).ConclusionsLARC patients receiving neoadjuvant chemoradiotherapy and total mesorectal excision had better disease-free and distant metastasis-free survival, with induction rather than consolidation neoadjuvant chemotherapy.

Significance of mid-radiotherapy 18F-fluorodeoxyglucose positron emission tomography/computed tomography in esophageal cancer

Background and purposeMetabolic parameters evaluated by 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) are known as prognostic markers in various cancers. We aimed to validate the predictive value of mid-radiotherapy (RT) FDG PET/CT parameters in esophageal cancer. Materials and methodsEighty-three patients treated with RT with or without chemotherapy between 2015 and 2020 were included. PET parameters including metabolic tumor volume (MTV), total lesion glycolysis, and mean (SUVmean) and maximum standardized uptake value (SUVmax) were analyzed. Locoregional recurrence-free rate (LRFR) and distant metastasis-free rate (DMFR) were analyzed. ResultsThe median follow-up period was 10.5 months. Mid-RT SUVmax was significantly associated with LRFR (HR 1.07, p = 0.009) and DMFR (HR 1.13, p = 0.047) while mid-RT MTV was associated with DMFR (HR 1.06, p = 0.007). Treatment response after RT was associated with overall survival (HR, 1.52, p = 0.025). Further, treatment response was significantly associated with mid-RT SUVmax. The optimal cutoff value for mid-RT SUVmax in predicting LRFR and DMFR was 11 while cutoff value for mid-RT MTV was 15. The patients with mid-RT SUVmax ≤ 11 showed superior LRFR and DMFR compared to SUVmax > 11 (1-year LRFR; 73.4% vs. 48.4%, p = 0.028, 1-year DMFR; 74.6% vs. 40.7%, p = 0.007). The 1-year DMFR was significantly different between patients with mid-RT MTV ≤ 15 and >15 (1-year DMFR; 78.2% vs. 31.9%, p = 0.002). ConclusionTumor metabolism changes during RT can be a useful predictive tool for treatment response and recurrence in patients with esophageal cancer. Clinicians may consider early response evaluation with PET during RT for predicting prognosis information about prognosis.

Role of Esophagectomy after Chemoradiation Therapy in Patients with Locally Advanced Squamous Cell Carcinoma: A Comparative Analysis Stratified by Clinical Response to Chemoradiation Therapy.

PurposeThis study aimed to evaluate the long-term effect of esophagectomy in patients with esophageal squamous cell carcinoma (ESCC) by comparing the chemoradiotherapy (CRT)-only group and the trimodality treatment (TMT) group who received concurrent CRT followed by surgery.Materials and MethodsWe included 412 operable ESCC patients treated with TMT or CRT between January 2005 and December 2015. The oncological outcomes of the two groups were compared using a weighted Cox proportional-hazards model with inverse probability of treatment weighting (IPTW).ResultsThe median survival time was 64 and 32 months in the TMT (n=270) and CRT (n=142) groups, respectively (p < 0.001). After IPTW, the median overall survival (OS) remained significantly higher in the TMT group than in the CRT group (61 months vs. 32 months, p=0.016). Moreover, the TMT group showed a better local recurrence–free rate (LRFR; p < 0.001) and distant metastasis–free rate (p=0.007). In the subgroup of patients with clinical complete response (cCR), the OS was not significantly different between the two groups, both before and after IPTW adjustment (p=0.35 and p=0.93). However, among non-cCR patients, the OS was significantly higher in the TMT group (64% vs. 45%, p < 0.001).ConclusionIn patients with locally advanced ESCC, TMT was superior to CRT in terms of OS and LRFR. Such difference was more prominent in the non-cCR subgroup. In patients who achieved cCR, esophagectomy was effective in improving LRFR but not OS, suggesting that esophagectomy may be omitted in complete responders.

Assessment of safety margin after microwave ablation of stage I NSCLC with three-dimensional reconstruction technique using CT imaging

ObjectiveTo assess the ablative margin of microwave ablation (MWA) for stage I non-small cell lung cancer (NSCLC) using a three-dimensional (3D) reconstruction technique.Materials and methodsWe retrospectively analyzed 36 patients with stage I NSCLC lesions undergoing MWA and analyzed the relationship between minimal ablative margin and the local tumor progression (LTP) interval, the distant metastasis interval and disease-free survival (DFS). The minimal ablative margin was measured using the fusion of 3D computed tomography reconstruction technique.ResultsUnivariate and multivariate analyses indicated that tumor size (hazard ratio [HR] = 1.91, P < 0.01; HR = 2.41, P = 0.01) and minimal ablative margin (HR = 0.13, P < 0.01; HR = 0.11, P < 0.01) were independent prognostic factors for the LTP interval. Tumor size (HR = 1.96, P < 0.01; HR = 2.35, P < 0.01) and minimal ablative margin (HR = 0.17, P < 0.01; HR = 0.13, P < 0.01) were independent prognostic factors for DFS by univariate and multivariate analyses. In the group with a minimal ablative margin < 5 mm, the 1-year and 2-year local progression-free rates were 35.7% and 15.9%, respectively. The 1-year and 2-year distant metastasis-free rates were 75.6% and 75.6%, respectively; the 1-year and 2-year disease-free survival rates were 16.7% and 11.1%, respectively. In the group with a minimal ablative margin ≥ 5 mm, the 1-year and 2-year local progression-free rates were 88.9% and 69.4%, respectively. The 1-year and 2-year distant metastasis-free rates were 94.4% and 86.6%, respectively; the 1-year and 2-year disease-free survival rates were 88.9% and 63.7%, respectively. The feasibility of 3D quantitative analysis of the ablative margins after MWA for NSCLC has been validated.ConclusionsThe minimal ablative margin is an independent factor of NSCLC relapse after MWA, and the fusion of 3D reconstruction technique can feasibly assess the minimal ablative margin.

Particle Beam Radiation Therapy for Adenoid Cystic Carcinoma of the Nasal Cavity and Paranasal Sinuses.

Background: Sinonasal adenoid cystic carcinoma (SNACC) presents a challenge to oncologists due to its complex anatomy and poor prognosis. Although radiation therapy, either definitive or adjuvant to surgery, is an important part of the multidisciplinary management of SNACC, photon-based radiotherapy yielded suboptimal local control. The purpose of this study was to report the clinical results of a large patient cohort treated with particle beam radiation therapy.Methods: Patients with SNACC that received proton beam therapy (PBT), carbon-ion radiotherapy (CIRT) or a combination of CIRT and PBT between May 2015 and May 2019 were included in the analysis. Three patients were treated with PBT, 17 with CIRT and 18 received PBT and a CIRT boost. Overall survival (OS), progression-free survival (PFS), local control (LC), regional control (RC), and distant metastasis-free (DMF) rates were calculated using the Kaplan-Meier method. Toxicities were reported using the CTCAE (version 4.03).Results: A total of 38 patients were included in this analysis. Of these patients, 12 had recurrent disease, including 10 whose previous photon-based RT had failed. The most common primary tumor site was the maxillary sinus. Thirty-six patients (94.7%) suffered from locally advanced disease (T3-4). After a median follow-up of 27.2 months, the 3-year OS, PFS, LC, RC, and DMF rates were 96.7, 80.6, 90.0, 100, and 88.7%, respectively. No acute toxicities of grade 3 or above were observed. Two patients experienced grade 3 xerostomia or vision decreased, and one patient died of hemorrhage.Conclusion: PBT, CIRT or a combination of CIRT and PBT appeared to be a promising treatment option for SNACC and produced satisfactory local control and toxicity profile. Longer follow-up is needed to verify the long-term benefit of particle-beam radiation therapy (PBRT) for patients with SNACC.

MP50-15 CHROMOPHOBE RENAL CELL CARCINOMA – EVIDENCE FOR A NEW GRADING SYSTEM

You have accessJournal of UrologyKidney Cancer: Epidemiology & Evaluation/Staging/Surveillance I (MP50)1 Apr 2020MP50-15 CHROMOPHOBE RENAL CELL CARCINOMA – EVIDENCE FOR A NEW GRADING SYSTEM Svetlana Avulova*, John C. Cheville, Christine Lohse, Matvey Tsivian, R. Houston Thompson, Bradley C. Leibovich, and Aaron M. Potretzke Svetlana Avulova*Svetlana Avulova* More articles by this author , John C. ChevilleJohn C. Cheville More articles by this author , Christine LohseChristine Lohse More articles by this author , Matvey TsivianMatvey Tsivian More articles by this author , R. Houston ThompsonR. Houston Thompson More articles by this author , Bradley C. LeibovichBradley C. Leibovich More articles by this author , and Aaron M. PotretzkeAaron M. Potretzke More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000912.015AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: There is currently no consensus on a grading system for chromophobe renal cell carcinoma (chRCC), and currently the WHO recommends that chRCC is not graded. We sought to validate a previously reported 3-tiered grading system specific for chRCC and evaluate if coagulative tumor necrosis impacts its prognostic value. METHODS: A total of 266 patients were identified from an institutional registry who underwent radical or partial nephrectomy for unilateral, sporadic, nonmetastatic, chRCC between 1970 and 2012. A urologic pathologist, blinded to patient outcome, reviewed pathologic features including multifocality, tumor size, 2018 pT and pN classifications, coagulative tumor necrosis, sarcomatoid differentiation, and chRCC grade. Distant metastases-free (DMF) and cancer-specific (CS) survival rates were estimated using the Kaplan-Meier method and associations with these outcomes were evaluated using Cox proportional hazards regression models. RESULTS: Of the 266 patients, 195 (75%), 52 (20%), and 19 (7%) were classified as chRCC grade 1, 2, and 3 respectively. Median follow up for survivors was 11.0 (IQR 7.9-15.9) years. Univariable associations with DMF and CS survival included the presence of symptoms, tumor size, the 2018 pT/N classifications, coagulative tumor necrosis, sarcomatoid differentiation, and chRCC grade (Table). Among the 244 patients with chRCC grade 1 and 2, the presence of coagulative tumor necrosis was significantly associated with DMF and CS survival only for chRCC grade 2 (HR 28.93 and 17.96, p<0.001). DMF and CS survival rates for a proposed 4-tiered grade are presented in the Figure. CONCLUSIONS: While a previously reported 3-tier grading system for chRCC has prognostic value, the inclusion of coagulative tumor necrosis further stratifies outcomes among chRCC grade 2 patients, suggesting the utility of a 4-tiered chRCC grading system. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e759-e759 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Svetlana Avulova* More articles by this author John C. Cheville More articles by this author Christine Lohse More articles by this author Matvey Tsivian More articles by this author R. Houston Thompson More articles by this author Bradley C. Leibovich More articles by this author Aaron M. Potretzke More articles by this author Expand All Advertisement PDF downloadLoading ...

Management and Outcome of Local Regrowths in a Watch-and-wait Prospective Cohort for Complete Responses in Rectal Cancer.

To evaluate the management and oncological outcomes of rectal cancer patients with local regrowth in a watch-and-wait (W&W) program. Approximately 15%-30% of patients with a clinical complete response after (chemo) radiotherapy who undergo a W&W policy will experience a local regrowth. The risks of these local regrowths have not yet been fully established and main concerns include high postoperative morbidity, requirement of advanced surgery, and pelvic recurrence after regrowth treatment. All patients with a local regrowth after an initial W&W approach between January 2005 and March 2018 were retrospectively identified from 2 cohorts of rectal cancer patients with a clinical complete response after (chemo) radiotherapy. Type and outcome of regrowth treatment were assessed. Oncological outcome was assessed using Kaplan-Meier estimates. Eighty-nine out of 385 patients developed a local regrowth after a median of 9 (interquartile range 7-14) months. Median follow-up time was 28 (interquartile range 19-41) months. Eighty-four (94%) patients underwent surgical treatment of the local regrowth: total mesorectal excision was performed in 58 out of 84 (69%) patients and local excision was performed in 26 (31%) patients. The 2-year local recurrence-free rate, distant metastasis-free rate, disease-free survival, and overall survival in the patients undergoing surgical treatment were 97.8%, 91.8%, 90.3%, and 98.4%, respectively. The vast majority (97%) of patients with regrowth after a W&W policy were able to undergo treatment with curative intent for local regrowth. Uncontrolled pelvic disease was very rare.

Clinical Outcomes of Patients With Unresectable Cholangiocarcinoma Treated With Proton Beam Therapy.

To investigate the clinical outcomes and failure patterns of patients with unresectable cholangiocarcinoma (CC) who had been treated with proton beam therapy (PBT). The authors retrospectively examined 30 patients with unresectable CC who had undergone PBT between November 2015 and December 2017. Survival curves were plotted with the Kaplan-Meier method. Independent predictors of survival were identified by multivariate Cox proportional hazard regression analyses. Complications were assessed using the Common Terminology Criteria for Adverse Events v4.0. The median tumor size was 7 cm. Seventeen patients (56.7%) had regional lymph node metastases. The median radiation dose was 72.6 cobalt gray equivalents, and 23 patients (76.7%) received concurrent chemotherapy. The 1-year local control, regional control, and distant metastases-free rates were 88%, 86%, and 68%, respectively. The median overall survival and progression-free survival were 19.3 and 10.4 months, respectively. The median jaundice-free survival was 13 months, with a 1-year biliary tract infection (BTI)-free rate of 58%. Patients who received concurrent chemotherapy had a better median progression-free survival (12.1 vs. 4.7 mo). The most common form of acute toxicity from PBT was acute skin reactions which were rarely severe (grade III: 7% of patients). Three and 2 patients had grade III-IV toxicities and radiation-induced liver disease. There were no deaths caused by PBT or concurrent chemotherapy. PBT is clinically useful in patients with unresectable CC, even in the presence of large tumors or regional nodal metastases. Its use may induce durable symptom relief, without increasing acute or late toxicity.

Multicenter Retrospective Observational Research on the Outcome of Radical Radiation Therapy for Prostate Cancer with Metastases

Hormonal therapy is the standard treatment for prostate cancer with metastases, but the disease usually becomes castration-resistant several years later. Before prostate cancer becomes castration-resistant, irradiating both the prostate and metastases may increase the local control rate and decrease the distant metastasis rate. In this multi-center study, we investigated clinical outcome and toxicities of patients with prostate cancer with metastases in patients irradiated as the first-line treatment (group A) in comparison with those irradiated after acquiring resistance to hormonal therapy (group B). Between January 2005 and June 2018, 91 patients with prostate cancer with 1-10 bone and/or 1-10 lymph node metastases were treated by IMRT. The prescription doses were 30-74.8 Gy to metastatic lesions and 60-78 Gy to the prostate. Among them, 13 patients were irradiated with IMRT and proton. Seventy-two patients only had lymph nodes, 11 had only bone metastases, and 8 had both metastases. Median age was 68 years (range, 54–85 years) and median follow-up was 32 months (range, 3-138 months). Seventy patients were in group A and 21 patients were in group B. Overall survival (OS) and progression free survival (PFS) at 3 years were 92% and 81%, respectively. At 3 years distant metastasis-free (DMF) rate were 82% in 73 patients and the local control rate of irradiated lymph nodes and bone metastases were 96% in 61 patients. Late Grade 2 or higher radiation genitourinary toxicities were seen in 2/91 and radiation gastrointestinal bleedings were observed in 4/91. No other Grade 2 or higher toxicities were seen. All genitourinary toxicities were Grade 2. At 3 years, OS was 95% versus 81%, PFS was 90% versus 51%, DMF rate was 90% versus 55% and the local control rate of irradiated lymph nodes and bone metastases was 100% versus 81% in groups A and B, respectively (log-rank P= 0.1, 0.00003, 0.002 and 0.009, respectively). The median of PSA doubling time (DT), which was calculated between the day of PSA nadir and the last follow-up date, was 5 months in 37 evaluable patients. The PSA failure was more frequently seen in the group with PSA DT < 10 months (n=20) than in the groups with stable PSA group (n=8) and with PSA DT ≥ 10 months (n=9) (P = 0.0017). To irradiate both the prostate and metastases before prostate cancer becomes castration-resistant may increase PFS, DMF, and the local control rate of irradiated lymph nodes and bone metastases from prostate cancer and decrease distant metastases rate.

Intensity-modulated radiotherapy combined with sequential cisplatin and fluorouracil chemotherapy for locoregionally advanced nasopharyngeal carcinoma.

To investigate the efficacy and toxicity of intensity-modulated radiotherapy (IMRT) combined with induction-adjuvant cisplatin and fluorouracil (PF) in locoregionally advanced nasopharyngeal carcinoma (NPC).A total of 91 biopsy-proven NPC patients treated with IMRT were retrospectively analyzed. All patients received induction chemotherapy (IC) consisting of cisplatin 25 mg/m2 on day 1 to 3, and 5-Fu 2500 mg/m2 as an intravenous infusion over 120 hours every 3 weeks for 2 cycles. Adjuvant chemotherapy of the same regime was given 28 days after the end of IMRT.A total of 87 patients completed 2 cycles of IC. During adjuvant chemotherapy phase, 74.7% patients received at least 1 cycle. With a median follow-up time of 45 months (10–123 months), the 5-year local control, regional control, distant metastasis-free (DMF) and overall survival (OS) rates were 84.1%, 86.9%, 81.3%, and 74.4%, respectively. The 5-year local control rates for patients with Stage T1-2 and T3-4 was 94.6% and 76.5%, respectively (P = .045). The 5-year DMF rates for patients with N0-1 and N2-3 diseases were 90.6% and 73.3%, respectively (P = .072). During radiotherapy (RT), 24.2% patients suffered severe acute mucositis (grade 3–4). Severe late toxicities included cranial nerve palsy in 1 patient and grade 3 hearing impairment in 1 patient.IMRT combined with induction-adjuvant chemotherapy consisting of PF regimen is well tolerated and provides satisfactory local-regional control for locoregionally advanced NPC. Further treatment strategies to control distant metastasis are needed in the future.

Early Prediction of Response to Radiation Therapy Using Inter-Fractional 18F-FDG PET/CT in Esophageal Cancer

To identify whether early metabolic responses (based on 18F-FDG-PET/CT during radiotherapy [RT]) could predict treatment outcomes in esophageal cancer for implementation of FDG-PET-based adaptive treatment algorithm. A retrospective review of 21 patients with esophageal cancer who had a pre-treatment PET (PET1) and a mid-RT PET (PET2) after the 11 fractions of radiotherapy (Median 23.1 Gy, 2.1 Gy per fraction) between November 2015 and June 2017 was undertaken. Region of interest for each SUV calculation was delineated on the PET1 and PET2 scans using PET Edge (semi-automatic gradient-based delineation method). We calculated PET parameters including maximum and mean standardized uptake value (SUVmax and SUVmean), metabolic tumor volume (MTV), and total lesion glycolysis (TLG) between PET1 and PET2. At a median follow-up of 13 months (range, 1.6‒23.6), the 1-year overall survival and progression free survival was 79.0% and 34.4%. Among all patients, 4 patients developed loco-regional recurrences and 8 patients showed distant metastases. Overall 1-year loco-regional recurrence free rate was 76.9% and distant metastasis free rate was 60.6%. The relative changes of MTV (i.e., ΔMTV) were significantly associated with loco-regional recurrence (HR 0.98, 95% CI 0.96–1.00; p = 0.03). Conversely, relative changes of SUVmean (i.e., ΔSUVmean) were associated with risk of distant recurrence (HR 0.90, 95% CI 0.82–0.99; p = 0.02). The ideal cut-off value to distinguish responders from non-responders for ΔMTV and ΔSUVmean was statistically determined at ratio of 1.14 (MTV PET2/MTV PET1) and -35% (i.e., a 35% decrease). At the threshold 1.14, the MTV yielded a sensitivity of 60%, specificity of 94%, and accuracy of 86% for predicting a loco-regional recurrence. In addition, the ΔSUVmean yielded a sensitivity of 67%, specificity of 83%, and accuracy of 76% for prediction a distant metastasis with the threshold of 35% decrease. This study demonstrates that changes in tumor metabolic activity during radiotherapy based on FDG-PET could be used as a surrogate marker to predict RT response, recurrence, and prognosis in esophageal cancer. Furthermore, PET-based adaptive treatment algorithm to potentially allow a change of treatment plan in non-responding patients might even be applicable.

Radiation therapy for stage IVA uterine cervical cancer: treatment outcomes including prognostic factors and risk of vesicovaginal and rectovaginal fistulas.

PurposeTo evaluate the safety and efficacy of radiation therapy for stage IVA uterine cervical cancer and to identify an optimal radiation regimen.ResultsSeventeen of the 28 patients developed recurrence after radiation therapy (local recurrence in 10 and distant metastasis in 12). The local control and distant metastasis-free rates at 3 years in all patients were 61% and 49%, respectively. Fourteen patients died after radiation therapy, and all but 2 died of tumor progression. The disease-free, cause-specific, and overall survival rates at 3 years in all patients were 32%, 49%, and 45%, respectively, and the estimated median survival time was 32 months. Tumor size (P = 0.007) and involvement in the lower third of vagina (P = 0.006) were significant prognostic factors for local control. Older age (P = 0.018) and performance status (P = 0.020) were significant prognostic factors for distant metastasis. The presence of hydronephrosis was the sole significant prognostic factor for survival (P = 0.026). Only 2 patients developed grade 3 late toxicities (vesicovaginal fistula and radiation proctitis, respectively).Materials and MethodsTwenty-eight patients with stage IVA uterine cervical cancer received radiation therapy. All patients initially received external pelvic irradiation at a median dose of 50.4 Gy in 28 fractions. Twenty patients also received high-dose-rate intracavitary brachytherapy at a median dose of 22 Gy in 4 fractions. These fraction sizes were lower than conventional sizes. The total median dose for all 28 patients was 68.7 Gy.ConclusionsRadiation therapy is safe and effective for treatment of stage IVA uterine cervical cancer. The reduced radiation dose per fraction may contribute to the prevention of vesicovaginal fistula formation.

Early outcomes and impact of a hybrid IC/IS applicator for a new MRI-based cervical brachytherapy program

PurposeThe purpose of this study was to report early outcomes and assess the learning curve in a new MRI-based cervical brachytherapy program. MethodsWe accrued 33 patients prospectively, and only patients with ≥3 months' followup (n = 27) were assessed for disease control and toxicity. Eras were defined as first half and second half for the intracavitary (IC)-only era (n = 13 each), and the intracavitary/interstitial (IC/IS) era was separated by difference in applicator availability (n = 7). Dose to 90% of the high-risk clinical target volume (D90 HR-CTV) and minimum dose to the maximally irradiated 2 cubic centimeters (D2cc) to organs at risk were used to assess dosimetry. Statistics were performed with t tests and Kaplan–Meier method. ResultsMedian followup was 14.7 months. Median treatment duration was 50.5 vs. 57 days for patients treated with external beam radiation therapy at our institution vs. an outside institution (p = 0.03). One-year local control, noncervical pelvic control, distant metastasis–free rate, and overall survival were 84.0%, 96.0%, 78.5%, and 91.3%, respectively. When comparing the first half and second half eras of IC only, there were no differences in median D90 HR-CTV or D2cc of the bladder, rectum, or sigmoid. Comparing the entire IC era to the IC/IS era, median D90 HR-CTV trended higher from 88.0 Gy to 92.9 Gy (p = 0.11). D2cc rectum decreased from 69.3 Gy to 62.6 Gy (p = 0.01), and D2cc bladder trended lower from 87.5 Gy to 83.6 Gy (p = 0.09). ConclusionsThere was no significant difference between the first half and second half eras with IC-only MRI-based brachytherapy. Incorporation of an IC/IS applicator generated the greatest dosimetric improvement. Early results of the MRI-based brachytherapy program are favorable.

Application of intensity-modulated radiation therapy in the treatment of nasopharyngeal carcinoma.

The objective of the present study was to investigate the application values of the intensity-modulated radiation therapy (IMRT) and the three-dimensional conformal radiation therapy (3D-CRT) in the treatment of nasopharyngeal carcinoma (NPC). A total of 124 patients diagnosed with nasopharyngeal carcinomas were included into the study and randomly divided into the control group and the observation group, with 62 patients in each group. The 3D-CRT combined with postoperative chemotherapy were performed on the control group and the observation group received IMRT combined with postoperative chemotherapy, and then were followed up for a median duration of 25.5 months. Comparison of the survival analysis of the two groups showed no differences between them in terms of the total effective rate and effectiveness (P>0.05), or radiotherapy complications (P>0.05). In addition, no significant differences between the two groups were found in the follow-up local tumor control probability (TCP), regional lymph node control rate, distant metastasis-free rate, tumor-free survival rate, recurrence rate and overall survival rate (P>0.05). Furthermore, there was no difference between the two groups in the overall score of quality of life (P>0.05). The present study concludes that the IMRT and the 3D-CRT have almost the same short-term and long-term clinical effects in the treatment of nasopharyngeal carcinoma and both of them have high effectiveness and safety.

Radiation Therapy for Very Elderly Patients Aged 80 Years and Older With Squamous Cell Carcinoma of the Uterine Cervix.

We carried out a retrospective review to determine the role played by radiation therapy in the treatment of very elderly patients with uterine cervical cancer. Thirty elderly patients aged 80 years and older with squamous cell carcinoma of the uterine cervix, at clinical stages IB-IVA, underwent radiation therapy. Of these 30 patients, 6 received external irradiation alone and 24 received external irradiation and intracavitary brachytherapy. A total median dose of 69.0 Gy (range, 45.6 to 75.4 Gy) was delivered to the cervical tumors. No patients underwent chemotherapy. At a median follow-up time of 24 months, 7 patients had developed recurrences, including local recurrences in 3 and distant metastases in 5. The local control and distant metastasis-free rates were 88% and 79%, respectively, at 2 years. The disease-free, cause-specific, and overall survival rates were 69%, 77%, and 75%, respectively, at 2 years. Primary tumor size, T category, and clinical stage were found to be significant prognostic factors for distant metastasis. Age and primary tumor size were considered as being significant variables that affected survival. With the exception of a transient hematologic reaction, there were no therapy-related toxicities of grade ≥3. Radiation therapy was safe and effective regarding local control of uterine cervical cancer in elderly patients aged 80 years and older, and appeared to contribute to their prolonged survival. Curative radiation therapy should be considered as a viable treatment option, even in very elderly patients.

Influence of neutrophil-lymphocyte ratio on radiosensitivity and prognosis in patients with nasopharyngeal carcinoma

Objective To investigate the influence of neutrophil-lymphocyte ratio (NLR) on radiosensitivity and prognosis, the relationship between NLR and clinical features, and the clinical value of NLR in patients with nasopharyngeal carcinoma (NPC). Methods 2006 to 2011 in the cancer center of Zhongshan University admitted to the newly diagnosed nasopharyngeal cancer patients in 266 cases. The association of pretreatment NLR with radiotherapy doses 20, 40, and 60 Gy and therapeutic effect at 3 months after radiotherapy was analyzed, as well as the influence of NLR on overall survival (OS), local recurrence-free (LRF), and distant metastasis-free (DMF) rates. The Kaplan-Meier method was used to calculate survival rates and the log-rank test was used for survival difference analysis. Results NLR showed differences across patients with different T stages and sexes (P=0.039, 0.032). The patients with NLR≤3 had significantly higher OS, LRF, and DMF rates compared with those with NLR>3(P=0.004, 0.025, 0.045). As NLR increased, the radiosensitivity in patients with NPC was reduced gradually, and radiosensitivity showed a significant difference between sensitive group and moderately sensitive group (P=0.043). When the radiotherapy dose was 40 Gy, the tumor regression group had a lower NLR than the residual tumor group (P=0.025). Conclusions In patients with NPC, an increased pretreatment NLR is an adverse prognostic factor, and NLR can be used as a simple and convenient method to evaluate the prognosis of patients with NPC. Key words: Neutrophil-lymphocyte ratio; Nnasopharyngeal neoplasms; Radiosensitivity; Prognosis

Tumor Regression and Patterns of Distant Metastasis of T1-T2 Nasopharyngeal Carcinoma with Intensity-Modulated Radiotherapy.

PurposeTo study tumor regression and failure patterns in T1-T2 non-metastatic nasopharyngeal carcinoma (NPC) after intensity-modulated radiotherapy (IMRT).MethodsA retrospective analysis of 139 nasopharyngeal carcinoma patients treated with IMRT between January 2005 and December 2010 in our center was performed. According to the AJCC staging system, all primary lesions were attributed to T1 and T2. The prescription doses were 66 Gy at 30 fractions to gross tumor volume of the nasopharynx and the positive neck nodes, 60 Gy to high-risk clinical target volume and 54 Gy to low-risk clinical target volume. Patients staged III, IV A/B or II (lymph node measured 4 cm or more in diameter) received platinum-based chemotherapy.ResultsBy the end of radiotherapy, 7.2% (10/139), 23.7% (33/139), and 9.4% (13/139) of patients had residual lesions in the nasopharynx, cervical lymph nodes and retropharyngeal lymph nodes, respectively. The majority of patients had complete remission within 6 months of radiotherapy completion. Five months after IMRT, three patients with residual tumors in the cervical lymph nodes underwent surgery. Among these patients, two patients had positive pathological findings, and one patient had negative findings. With a median follow-up of 59 months, the 5-year overall survival, local control, regional control and distant metastasis-free rates were 87.8%, 96.7%, 94.9% and 89.1%, respectively. Fifteen patients developed distant metastases, representing the primary failure pattern.ConclusionsMost residual lesions that persisted after IMRT vanished completely in six months. Considering the potential damage to normal structures, clinicians should be cautious when considering the use of boost irradiation after radiotherapy. Distant metastasis was the primary cause of treatment failure, which was significantly higher in N2-3 patients than in N0-1. Additional studies to better understand distant metastases are needed.

Long-term Outcomes of Intensity Modulated Radiation Therapy for T1-T2 Nasopharyngeal Carcinoma

To evaluate the efficacy of the treatment for T1-T2 non-metastasis nasopharyngeal carcinoma (NPC) with intensity modulated radiation therapy (IMRT). We retrospectively analyzed 139 NPC patients treated by IMRT between January 2005 and December 2010 in our center, with a sex ratio of 3.2:1 (male 106: female 33). Median age was 49 years (18–73 years). According to the AJCC staging system, there were 16, 55, 38, and 30 patients with stage I, II, III, and IV disease. All patients received treatment with IMRT. Gross tumor volume (GTV) included the primary tumor and metastatic lymph nodes found in clinical and imaging examination. Clinical target volume (CTV) included the nasopharynx, retropharyngeal lymph node, skull base, anterior one-third of the clivus, pterygoid fossa, parapharyngeal space, the inferior sphenoid sinus, posterior one-third of the nasal cavity and the maxillary sinus, and drainage of the upper neck (levels II, III and Va) in N0 patients. In N1–N3 patients, levels II-V were included. The prescription doses were 66 Gy in 30 fractions to the GTV of nasopharynx and the positive neck nodes, 60 Gy to the high-risk CTV, and 54 Gy to the low-risk CTV. All patients were irradiated 1 fraction daily, 5 days per week. Patients staged III, IV A/B, or II (lymph node measured 4 cm or more in diameter) received platinum-based chemotherapy. All patients were evaluated weekly during RT, and every 3 months in the first 2 years after the completion of their treatment, every 6 months for the next 3 years, and annually thereafter. A statistical software package was used for statistical analysis. The Kaplan–Meier method was used to calculate local control (LCR), distant metastasis-free (DMF) and overall survival (OS) rates. With a median follow-up of 59 months (range, 13–98 months), the 5-year OS, LCR, region control, and DMF rates were 87.8%, 96.7%, 94.9%, and 89.1%, respectively. Seven patients had recurrences in the nasopharynx. Seven had recurrences in the regional lymph nodes and 15 had distant metastasis. The 5-year LCR for patients with T1 and T2 diseases were 94.9% and 97.7%, respectively (P=.664). The 5-year DMF rates for patients with N0, N1, N2, and N3 diseases were 95.7%, 100%, 89.5%, and 65.4%, respectively (P=.000). The 5-year OS rates for patients with N0, N1, N2 and N3 diseases were 95.7%, 100%, 79.8%, and 70.5%, respectively (P=.002). The treatment with IMRT for T1-T2 NPC is effective. Distant metastasis was the major reason for treatment failures, distant metastasis rate with N2-3 was prominently higher than N0-1. It is worthy of further studies controlling distant metastasis of the patients with N2-3.