History Of Previous Irradiation Research Articles

Radiation-induced meningiomas: A case-control study at single center institution

BackgroundOur understanding of radiation induced meningiomas (RIM) is limited. It has been suggested that RIM harbor more aggressive cellular pathology and must be observed vigilantly. However, the actual recurrence rates of RIM compared to the sporadic meningiomas has yet to be defined. ObjectiveWe employ a single center case-control study to retrospectively assess recurrence rates between RIM (n = 12) and sporadic meningiomas (n = 118). MethodsThe criteria for the RIM group included the following: 1) History of intracranial clinical-dose radiation 2) Initial pathology other than meningioma, 3) Radiation administered greater than 5 years prior to meningioma onset. Recurrence rates, extent of resection and outcomes were analyzed. ResultsThere was a significant difference in recurrence rates between the RIM group and sporadic meningioma: 50% vs. 5% respectively, p = 0.004. There was no significant difference in race, preoperative tumor volume, extent of resection, Ki67, or age between the two groups. Multivariate analysis demonstrated that size (OR 0.95 95%CI (0.92–0.99)), extent of resection (OR 1.08 95%CI (1.01–1.14)), WHO grade (OR 160.24 95% CI (6.32–74509)) and history of previous radiation (OR 1.28 95%CI (1.01–1.62)) were independent risk factors for recurrence. RIM patients had significantly higher proportion of atypical or malignant histology compared to sporadic patients (p < 0.0001). ConclusionRIM patients may have a higher predisposition for tumor recurrence than patients with sporadic RIM. The use of Ki67 indices may help identify patients with a higher risk of tumor recurrence. Prospective studies focusing on newly diagnosed patients with RIM may help identify an optimal surveillance and treatment plan.

Heterotopic ossifications: role of radiotherapy as prophylactic treatment.

Heterotopic ossification (HO) is abnormal formation of lamellar bone in soft tissue; the most frequent causes are total hip arthroplasty and trauma. Severe cases can lead to ankilosis with important impact on quality of life. Surgery is the elective treatment, but, especially in high-risk patients, it is important to prevent the re-formation of HO and, in these cases, radiotherapy (RT) can play an important role. we retrospectively analyzed a mono-institutional casistic of 30 patients (31 sites) at high risk for HO development, treated with surgery and pre- or postoperative RT. The majority of patients received a single RT fraction of 7Gy, median age was 62, with a prevalence of male and hip as most frequently involved site. Radiological studies and clinical examination were performed in all patients during the follow-up period to evaluate both treatment efficacy and acute or late toxicity. With a median follow up of 67months, 23 patients had a complete response (CR) with excellent results in term of joint mobility. Two patients with CR showed a relapse of HO in the same site 19 and 12months after treatment, respectively. Seven patients (22,6%) had a partial response (PR) to RT. One patient who reached CR had a history of previous irradiation in the same site 16years before. No acute or late reactions have been reported. Our data confirm safety and efficacy of RT in preventing HO, especially in high-risk patients, preferring a single fraction of 7Gy.

Risk factors for radiotherapy incidents: a single institutional experience

We aimed to analyze risk factors for incidents occurring during the practice of external beam radiotherapy (EBRT) at a single Japanese center. Treatment data for EBRT from June 2014 to March 2017 were collected. Data from incident reports submitted during this period were reviewed. Near-miss cases were not included. Risk factors for incidents, including patient characteristics and treatment-related factors, were explored using uni- and multivariate analyses. Factors contributing to each incident were also retrospectively categorized according to the recommendations of the American Association of Physicists in Medicine (AAPM). A total of 2887 patients were treated during the study period, and 26 incidents occurred (0.90% per patient). Previous history of radiotherapy and large fraction size were identified as risk factors for incidents by univariate analysis. Only previous history of radiotherapy was detected as a risk factor in multivariate analysis. Identified categories of contributing factors were human behavior (50.0%), communication (40.6%), and technical (9.4%). The incident rate of EBRT was 0.90% per patient in our institution. Previous history of radiotherapy and large fraction size were detected as risk factors for incidents. Human behavior and communication errors were identified as contributing factors for most incidents.

Urosymphyseal Fistulas Resulting From Endoscopic Treatment of Radiation-induced Posterior Urethral Strictures

To describe the inciting events leading to urosymphyseal fistulas (UFs) and pubic osteomyelitis (PO) in patients who had radiation-induced urethral strictures. We retrospectively reviewed patients who underwent simultaneous pubic debridement, simple cystectomy, and urinary diversion for refractory UF and PO from 2014 to 2016. We investigated inciting events leading to UF, as well as patient presenting symptoms, diagnosis, management, and outcomes. Five patients were identified over a 2-year period. All patients had a previous history of radiation for prostate cancer. The median age was 67 years. All patients developed UF and PO after endoscopic intervention for urethral stricture. The number of endoscopic interventions per patient for stricture ranged from 1 to 7, including serial dilation, balloon dilation, and urethrotomy. Sterile urine cultures were obtained before all endoscopic interventions. All patients had pelvic pain with ambulation and recurrent urinary tract infections at presentation. Patients were diagnosed using a combination of retrograde urethrography and magnetic resonance imaging. Simultaneous pubic debridement with simple cystectomy and diversion was used for management in all cases. One patient died postoperatively with the remainder recovering well without PO or fistula recurrence, with a median follow-up of 16 months. UF can occur as a complication of endoscopic treatment of posterior urethral stricture in patients with a history of radiation therapy for prostate cancer. This study demonstrates that UF and PO may develop even with minimally traumatic procedures and sterile urine. All patients treated for posterior stricture must be considered at risk of development of fistulas and osteomyelitis.

Association Between Postoperative Complications After Immediate Alloplastic Breast Reconstruction and Oncologic Outcome

IntroductionMastectomy with immediate reconstruction is associated with increased complications when compared with mastectomy without reconstruction. Postoperative complications have been associated with worse oncologic outcome in other cancers. We examined the association between postoperative complications after immediate reconstruction and oncologic outcome. MethodsThis retrospective study included all women undergoing mastectomy and immediate alloplastic reconstruction for breast cancer between the years 2009 and 2016. Data collected included demographics, cancer and treatment characteristics, type of surgery, postoperative complications, and outcome. Association between postoperative complications and oncologic outcome was examined using Cox regression analysis. ResultsBetween January 2009 and December 2016, 227 women underwent mastectomy with immediate alloplastic reconstruction. One hundred eighty-six (82%) were done for breast cancer. Most (148; 80%) had infiltrating carcinoma. The mean age was 48.8 years (range, 21-77 years). Forty-seven (25%) had a previous history of radiation. Fifty-four (29%) had neoadjuvant treatment. Complications occurred in 83 (45%) of the women. Fifty-five (30%) needed revisional surgery (closure of wound, debridement, exchange or removal of implant, and evacuation of hematoma). Complications were associated with older age and previous radiation history (57% vs. 40% in women with no previous radiation; P = .04). The mean follow-up was 1138 days. Twenty-five (12%) women developed recurrence during follow-up. There was no association between presence of postoperative complications and recurrence of cancer. ConclusionsPostoperative complications were not associated with worse oncologic outcome in this study. The study may be limited by the relatively short follow-up.

Post-operative therapy following transoral robotic surgery for unknown primary cancers of the head and neck

ObjectivesOur primary objective is to describe the post- operative management in patients with an unknown primary squamous cell carcinoma of the head and neck (HNSCC) treated with trans-oral robotic surgery (TORS). Materials & MethodsWe conducted a retrospective multi-institutional case series including all patients diagnosed with an unknown primary HNSCC who underwent TORS to identify the primary site from January 1, 2010 to June 30, 2016. We excluded those with recurrent disease, ≤6months of follow up from TORS, previous history of radiation therapy (RT) to the head and neck, or evidence of primary tumor site based on previous biopsies. Our main outcome measure was receipt of post-operative therapy. ResultsThe tumor was identified in 26/35 (74.3%) subjects. Post-TORS, 2 subjects did not receive adjuvant therapy due to favorable pathology. Volume reduction of RT mucosal site coverage was achieved in 12/26 (46.1%) subjects who had lateralizing tumors, ie. those confined to the palatine tonsil or glossotonsillar sulcus. In addition, for 8/26 (30.1%), the contralateral neck RT was also avoided. In 9 subjects, no primary was identified (pT0); four of these received RT to the involved ipsilateral neck nodal basin only without pharyngeal mucosal irradiation. ConclusionSurgical management of an unknown primary with TORS can lead to deintensification of adjuvant therapy including avoidance of chemotherapy and reduction in RT doses and volume. There was no increase in short term treatment failures. Treatment after TORS can vary significantly, thus we advocate adherence to NCCN guideline therapy post-TORS to avoid treatment-associated variability.

Single fraction radiotherapy is more acceptable than multi-fraction radiotherapy to palliate the metastatic bone pain

One of the main goals of palliative radiation treatment is the relief of pain or dysfunction caused by the bone metastasis. Most patients achieve pain relief after irradiation. The striking clinical observation is that some patients experience symptom relief within 24hrs after the irradiation. This quasi experimental study was carried out in the department of Oncology, BSMMU from January 2014 to June 2014 with the intention to compare the role of single fraction and multiple fraction radiotherapy in the management of bone secondaries as regard as potency for pain relief. A total of 100 patients with age up to 70 years and of any sex having cytologically or histologically proven malignant diseases with the painful bone metastases in single or multiple sites without pathological fracture were selected for the study. They had no history of previous radiotherapy on the treatment site. Patients were divided in to two Arm A and Arm B with 50 patients in each arm. Arm A was treated with single (8 Gy) fraction radiotherapy and Arm B was treated with multiple fraction (30 Gy) radiotherapy i.e. 300 cGy per fraction in 10 fractions, 5 days a week for two weeks by telecobalt or orthovoltage machine. 44 patients in Arm A &amp; 46 patients in Arm B completed the study. Onset of pain relief after completion of 4th week radiation were 68% in Arm A and 67.4% in Arm B . It was observed that, after 8th week of radiation 81.8% in Arm A and 86% in Arm B were relieved from pain. According to histological typing, 45% in Arm A &amp; 52% patients in Arm B had complete response; 40% in Arm A &amp; 37% patients in Arm B had partial response and overall distribution of no response of patient in Arm A was 18% and in Arm B was 7%. Metastatic bone pain represents one of the major indications in the external beam radiation therapy today.The disease can be efficiently treated by the use of either single fraction or multifraction radiotherapy without any significant difference in response to rate and early toxicities.Bangladesh Med J. 2016 Sep; 45 (3): 151-155

Osteosarcoma prognostic nomograms for predicting the 10-year probability of mortality and recurrence.

11020 Background: The multidisciplinary approach in treatment of osteosarcoma has been well established and well adopted nationwide. This study combined the clinical prognostic factors at initial presentation into a nomogram to predict local control (LC), metastasis free survival (MFS), and overall survival (OS) for patients with non-metastatic bone osteosarcoma. Methods: We reviewed 397 osteosarcoma patients treated from 1995 to 2014. Patients with metastatic disease at diagnosis or limited follow up were excluded, resulting in 283 cases for analysis. Clinical and pathologic variables were recorded. Predictive variables included age at diagnosis, gender, previous radiation history, site, tumor size, histologic subtype, histologic grade, extra-osseous extension (EOE), lymphovascular invasion (LVI), necrosis rate and margin. The multivariate Cox proportional hazards regression was used to analyze survival outcomes and risk variables. Results: At 10 years, LC was 70.4% (95% confidence interval, CI: 64.0%-76.7%), MFS was 64.7% (95% CI: 58.1%-71.3%), and OS was 61.5% (95% CI: 54.9%-68.1%). Multivariate Cox model identified age (p = 0.033), site (p = 0.020), EOE (p = 0.017), LVI (p = 0.011), and margin (p = 0.039) were correlated with LC; age (p = 0.028), tumor size (p &lt; 0.001), histologic grade (p = 0.039), and LVI (p = 0.014) were correlated with MFS; whereas age (p &lt; 0.001), prior radiation history (p = 0.010), tumor size (p = 0.002), histologic subtype (p = 0.012), EOE (p = 0.002), and LVI (p = 0.001) were associated with OS. The nomograms were drawn on the basis of the Cox regression model and were internally validated using bootstrapping, with predictive accuracy of ±7.2% for 10-year LC, ±7.4% for 10-year MFS, and ±7.5% for 10-year OS. Conclusions: Nomograms have been developed to predict the 10-year local-control failure, recurrence and death. We suggest that this tool at presentation may be useful for individualized risk evaluation, patient counseling, and making clinical decisions.

Latissimus Dorsi Flap Breast Reconstruction-A Nationwide Inpatient Sample Review.

The latissimus dorsi (LD) myocutaneous flap has been a long term standard for breast reconstruction. The variable indications for the LD flap have not been statistically examined because of the relative infrequency of its use by any single surgeon or institution. The Nationwide Inpatient Sample data set was queried for all patient encounters involving a LD myocutaneous flap procedure. The study population was further restricted to female patients with a history of breast cancer or previous mastectomy. Demographics, Charlson Comorbidity Index scores, previous radiation history, and additional simultaneous procedures were extracted. Analysis was performed using nonparametric correlation coefficients and linear regression models. In total, 2304 LD breast reconstruction hospitalizations were identified between 2008 and 2010. Average patient age was 52.1 years, average hospital length of stay (LOS) was 2.8 days, bilateral latissimus reconstruction was performed in 252 (10.9%) patients, and 1414 patients (61.4%) were delayed reconstruction. Previous irradiation was present in 389 (16.9%) patients and was correlated with delayed reconstruction (P < 0.001).Younger age was associated with bilateral latissimus reconstructions (P < 0.05), contralateral free flap reconstruction (P < 0.0001), and combination with implants or tissue expanders (both P < 0.0001).After adjustment for age and Charlson Comorbidity Index, increased LOS was observed in patients undergoing contralateral free flap reconstruction (+1.29 days, P < 0.05) and immediate reconstruction (mastectomy, +0.39 days unilateral, P < 0.05; +0.64 days, bilateral, P < 0.001). The use of tissue expanders and implants were found to decrease hospital LOS (bilateral implant, -0.65 days, P < 0.001; bilateral expander, -0.72 days, P < 0.001), likely from confounding comorbidities. Charlson Comorbidity Index was strongly related to LOS (+0.08 days per point, P < 0.005), whereas age was not statistically significant when considered with comorbidity. The LD is most commonly used for delayed or salvage breast reconstruction, with particular utility in irradiated patients. Younger patients tend to undergo more involved LD variants with bilateral reconstructions and expanders or implants. After adjusting for comorbidity, age and the use of bilateral latissimus flaps with implants or expanders have no adverse impact on LOS.

Previous External Beam Radiation Treatment Exposure Does Not Confer Worse Outcome for Patients with Differentiated Thyroid Cancer.

Radiation exposure, especially in childhood, is known to increase the risk for the development of thyroid cancer. However, the prognosis of patients with thyroid cancer with a history of radiation treatment exposure remains unclear. One hundred and sixteen patients with a previous history of radiotherapy in the head and neck region were identified from an institutional database of 3664 patients with differentiated thyroid cancer treated between 1986 and 2010. Using the Kaplan-Meier method, disease-specific survival and recurrence-free survival were compared between patients with (RT; n = 116) and without (No RT; n = 3509) a prior history of radiation exposure. The median ages of the RT and No RT cohorts were 52 and 47 years. The median follow-up for both groups was 54 months. Patients who had a prior history of radiation treatment exposure were more likely to be male (38.8% vs. 26.9%; p = 0.005) and older than 45 years of age (67.2% vs. 53.9%; p = 0.005). Other patient, tumor, and treatment characteristics were similar between the groups. There was no difference in the five-year disease-specific survival of the RT and No RT patients (97.4% vs. 98.7%; p = 0.798). The five-year recurrence-free survival was also similar between the RT and No RT patients (97.8% vs. 94.9%; p = 0.371). The findings suggest that differentiated thyroid cancer patients with a history of prior radiation treatment exposure have similar outcomes to those with no history of head and neck radiation exposure.

Very Low, Real-Time Rate of Urinary Retention after Intradetrusor Botox&amp;lt;sup&amp;gt;&amp;amp;reg&amp;lt;/sup&amp;gt; for Non-Neurogenic Overactive Bladder

Introduction: According to the most recent AUA/SUFU guidelines, intradetrusor onabotulinumtoxinA (BTN/A) is a standard, evidence strength grade B, third line treatment option for refractory non-neurogenic overactive bladder (OAB). Urinary retention is the most common clinically significant reported side effect ranging from 5.4% to 43% in previous studies. The aim of this study was to investigate the real-time rate of urinary retention in patients treated with BTN/A for refractory non-neurogenic OAB in a multi-institutional study. Methods: Retrospective chart review identified 71 patients who were treated with 100U BTN/A for refractory non-neurogenic OAB from August 2011 to July 2015 at two institutions. Using a flexible cystoscope, 100U Botox&reg reconstituted with 10 ml normal saline was administered. Injections of 1 ml (10 units/ mL) were administered in 10 evenly distributed sites sparing the trigone. Pre and post BTN/A post-void residuals (PVR) were reviewed. Urinary retention was defined as PVR > 200 mL requiring clean intermittent catheterization (CIC). Results: After exclusion, the study group consisted of 66 patients with a mean age of 67 years and 30% were men. Mean pre and post-procedural PVR were 14.06 mL and 69.21 mL. Eight patients (12.12%) were noted to have elevated PVR > 200 mL post injection however only one patient (female) required initiation of CIC. The rate of urinary retention was 1.5% (N = 1). There was no correlation with age, history of previous radiation, diabetes or prior use of a neuromodulator device. Conclusions: To the best of our knowledge, this is the first study to demonstrate a very low risk of real-time urinary retention rates in appropriately selected patients treated with BTN/A for refractory non-neurogenic OAB outside of a clinical trial setting.

Palliation of Ulcerative Breast Lesions with Radiation.

Patients with advanced breast cancer may experience ulcerative breast lesions. Breast cancer with ulcerative lesions has been shown to severely affect a patient's quality of life (QoL). The role of palliative radiation therapy (RT) in the management of ulcerative breast lesions needs to be further explored. We retrospectively reviewed the RT records for all patients who underwent palliative RT for breast cancer at our urban academic medical center. A total of 13 patients were identified, and we herein report their demographics, treatment characteristics, and clinical outcomes. The mean age of the patients receiving palliative RT for ulcerative breast cancer was 64 years. All patients had stage IV disease when they were evaluated for RT. The mean radiation dose received for palliative RT was 27.54 Gy in 11 fractions, with a median dose of 30 Gy in 15 fractions. Six (46%) patients had received prior RT to the same breast, with a median dose of 59.5 Gy in 31 fractions. Among these six patients, the average interval between initial RT and ulceration was 69.5 months. The median overall survival for the whole patient cohort since ulceration was 5 months and the mean survival did not differ between patients with previous history of RT and RT-naïve patients (4.50 vs. 4.57; p=0.95). Six out of the nine (69%) patients who received 30 Gy or more reported clinical improvement, whereas none of the four patients who received less than 30 Gy reported any benefit. There were no radiation-associated toxicities reported by patients. These data suggest that palliative RT (≥30 Gy) is an efficacious treatment for ulcerative breast cancer with minimal toxicity. Prior RT should not be a contraindication, as patients with previous history of RT have similar low toxicity rates compared to RT-naïve patients.

Transcorporal artificial urinary sphincter in radiated and non - radiated compromised urethra. Assessment with a minimum 2 year follow-up

ABSTRACTPurpose to assess the efficacy of transcorporal artificial urinary sphincter (AUS) implantation on continence for male stress urinary incontinence in cases of prior surgical treatment or/and radiation failure, and as a first option in radiation patients.Materials and Methods From March 2007 to August 2012, 37 male patients were treated with transcorporal AUS AMS™ 800. Twelve patients had primary placement of transcorporal cuff, a surgical option due to a previous history of radiation and 25 patients had secondary procedure after failure of AUS or urinary incontinence surgery. Functional urinary outcomes were assessed by daily pad use, 24-hour Pad-test and ICIQ-SF questionnaire. Quality of life and satisfaction were assessed based on I-QoL and PGI-I questionnaires.Results After a median of 32 months, the continence rate (0 to 1 pad) was 69.7%. Median pad test was 17.5g (0-159), mean ICIQ-SF score was 7.3/21 (±5.4) and mean I-QoL score was 93.9/110. A total of 88% of the patients reported satisfaction with the AUS. The 5-year actuarial revision-free for AUS total device was 51%. Patients for primary implant for radiation were not more likely to experience revision than non-radiation patients. Preservation of erections was reported in half of the potent patients.Conclusions Transcorporal AUS cuff placement is a useful alternative procedure option for severe male UI treatment, especially in patients with a compromised urethra after prior surgery or radiation. A high continence rate was reported and implantation as first option in radiation patients should be considered.

Rib cage deformity during two-stage tissue expander breast reconstruction in patient with previous radiotherapy: a case report

Patients undergoing two-stage breast reconstruction with tissue expander and a history of previous irradiation are predisposed to a various chest-wall deformations more than non-irradiated patients. If chest-wall depression with/without rib fracture is found intra-operatively, bigger implant should be used, with a subsequent radiologic evaluation. In the future, the development of a new, modified expander with a harder base could minimise such complications.

Early oral feeding after total laryngectomy: Outcome of 602 patients in one cancer center.

Pharyngocutaneous fistula (PCF) is the most frequent complication after total laryngectomy. However, delayed oral feeding and inserting a nasogastric tube has been considered as a safe practice among head and neck surgeons, and there is no general agreement on the initiation of the oral intake. The aim of the study is to determine the incidence of PCF after primary total laryngectomy in a large homogenous case series and to evaluate whether fistula and early oral feeding are related. Patients who underwent total laryngectomy/laryngopharyngectomy with primary closure of pharynx between 1990 and 2014 were reviewed. Patients who had a history of previous radiotherapy, chemotherapy or chemoradiotherapy, and patients who underwent more complex reconstruction techniques (e.g. pedicled or free flaps) for closure were excluded. In total, 602 patients underwent total laryngectomy (n=580) or total laryngectomy plus partial pharyngectomy (n=22). The overall PCF rate was 12%. In 582 of the 602 patients (99.8%), a nasogastric tube was not inserted. In 95.7% of the patients (576/602), oral feeding was started within 3 days of surgery. Among the patients who developed PCF (72/602), PCF rate was not significantly higher in early oral fed patients (69/582, 11.8%) than the patients with nasogastric tube insertion (3/20, 15%) (p=0.722). The low PCF rate in our study indicates that early oral feeding is a safe and effective method in primary total laryngectomy.

Thymoma 20 Years After Hodgkin’s Lymphoma Radiation Therapy: A Case Study

We present a case of a 48-year-old female who, over the course of 2 years, developed a recurrence of thymoma. She presented in 2013 with nausea and scalp pruritis, which progressed to generalized body pruritis. Examination was normal except for erythroderma noted on both arms and trunk sparing the lower limbs. A CT scan was performed which showed a 2.5 cm anterior mediastinal lymph node mass. A biopsy was performed which indicated a stage 2b thymoma. Her previous medical history was significant for a 1A nodular lymphocyte predominant Hodgkin’s lymphoma in 1992 for which she received mantle field radiation. Her presenting symptoms were thought to be of paraneoplastic origin. Thymectomy and excision of the pleural seeding occurred in 2013 with good results. A year later, a follow-up PET scan revealed a recurrence of her thymoma. Chemotherapy was started with good regression; however, in 2015 the thymoma had spread to the lungs, adjacent pleura and pericardium. Second line chemotherapy was initiated. This case report highlights the possible association between mantle field radiation for Hodgkin’s lymphoma leading to a future thymoma. It emphasizes the need to consider secondary malignancies in the differential diagnosis for patients presenting with unexplained symptoms and a previous history of radiation therapy. J Med Cases. 2016;7(4):153-154 doi: https://doi.org/10.14740/jmc2466w

Efficacy of Dose-Escalated Radiotherapy for Recurrent Colorectal Cancer

PurposeThis study aimed to evaluate the effects of radiotherapy (RT) on progression-free survival (PFS) for patients with recurrent colorectal cancer.MethodsWe reviewed the records of 22 patients with recurrent colorectal cancer treated with RT between 2008 and 2014. The median radiation dose for recurrent disease was 57.6 Gy (range, 45–75.6 Gy). Patients were divided into 2 groups according to the type of RT: patients underwent RT without previous history of irradiation (n = 14) and those treated with secondary RT (reirradiation: n = 8) at the time of recurrence.ResultsThe median follow-up period was 24.9 months (range, 4.5–66.6 months). Progression was observed in 14 patients (including 8 with loco-regional failure and 9 with distant metastases). Distant metastases were related to the RT dose (<70 Gy, P = 0.031). The 2-year loco-regional control (LRC), PFS, and overall survival (OS) rates were 74.6%, 45.1%, and 82.0%, respectively. The LRC rate was not different between the patients treated with RT for the first time and those treated with reirradiation (P = 0.101, 2-year LRC 79.5% vs. 41.7%). However, reirradiation was related to poor PFS (P = 0.022) and OS (P = 0.002). An escalated RT dose (≥70 Gy) was associated with a higher PFS (P = 0.014, 2-year PFS 63.5% vs. 20.8%).ConclusionSalvage RT for locally recurrent colorectal cancer can be offered when surgery is impossible. Dose-escalated RT shows a possible benefit in reducing the risk of progression.

Dose-Escalated Radiotherapy for the Treatment of Patients With Recurrent Colorectal Cancer.

See Article on Page 66-72 Local recurrence rates have markedly decreased in recent years as a result of changes in the surgical approach, such as a total mesorectal excision, as well as, neoadjuvant therapy for, the treatment of patients with colorectal cancer. For the treatment of patients with recurrent rectal cancer, a curative surgical resection of the local recurrence is considered the most important factor affecting the prognosis. However, such a resection is highly challenging as the surgical field has generally been anatomically disrupted and irradiated, and the tumor is typically adherent to or invasive into organs in the middle and low pelvis. And, such a resection is not always possible for all patients with recurrent rectal cancer, so the proper selection of patients for the surgery is very important [1,2]. If an R0 resection is impossible, chemotherapy or radiotherapy may be offered. In terms of optimizing radiotherapy, the tumors should receive a high total dose while sparing the surrounding normal tissue to avoid toxicity. Dose escalation has also been suggested as possibly being of benefit in the treatment of patients with rectal cancer [3]. Development of new radiotherapy techniques, such as three-dimensional conformal radiation therapy, intensity-modulated radiation therapy, and image-guided radiation therapy, has made feasible the delivery of higher doses of external beam radiation with acceptable morbidity. However, if the patient has previously undergone radiotherapy either before or after the primary rectal cancer surgery, determining the proper dose of radiation is challenging because the surrounding normal tissues may have already received doses near the organ- or endpoint-specific tolerance dose during the primary treatment [4]. Because re-irradiation for the treatment of patients with recurrent rectal cancer is mostly given with hyperfractionated (twice daily) chemoradiotherapy to a total dose of 30–40 Gy [4], dose-escalated radiotherapy usually can be performed only for those patients who have not previously undergone radiotherapy. The authors reviewed the records of patients who had been treated with palliative radiotherapy for locally recurrent colorectal cancers [5]. They reported that salvage radiotherapy, especially dose-escalated radiotherapy, for the treatment of such patients might be beneficial in that it might reduce the risk of progression. However, complete responses are rarely achieved even with high doses radiotherapy, and as expected, in this study, with one exception, dose-escalated radiotherapy was only offered to patients with no history of previous radiotherapy. In a clinical setting, the distinction between curative and palliative intent is often not clear and may depend on whether the patient is eligible for a curative resection after radiotherapy. Therefore, patients with recurrent rectal cancer should undergo adequate re-evaluation and have repeated discussions with a multidisciplinary team on topics such as dose-escalated radiotherapy, chemotherapy and surgical resection.

Palliation of ulcerative breast lesions with radiation.

199 Background: Patients with advanced breast cancer may experience ulcerative breast lesions. Breast cancer with ulcerative lesions has been shown to severely affect a patient’s quality of life (QoL). The role of palliative radiation therapy (RT) in the management of ulcerative breast lesions needs to be further explored. Methods: IRB-approval was obtained to retrospectively review the radiation treatment records for all patients who underwent palliative RT for breast cancer at our urban academic medical center. A total of 13 patients were identified, and we herein report their demographics, treatment characteristics, and clinical outcomes. Results: The mean age of the patients receiving palliative RT for ulcerative breast cancer was 64 years. All patients had stage IV disease when they were evaluated for RT. All patients received prior systemic chemotherapy with a mean of four chemotherapeutic agents, the most common of which was Capecitabine. The mean radiation dose received for palliative RT was 27.54 Gy in 11 fractions with a median dose of 30 Gy in 15 fractions. Six (46%) of the patients received prior RT to the same breast, with a median dose of 59.5 Gy in 31 fractions. Among these six patients, the average interval between initial RT and ulcerative breast lesion was 69.5 months. The median overall survival in all patients since ulcerative breast lesion was 5 months and the mean survival did not differ between patients with previous history of RT and RT-naïve patients (4.50 vs. 4.57; p = 0.95). Six out of the 9 (69%) patients who received ≥ 30 Gy reported clinical improvement, whereas none of the 4 patients who received &lt; 30 Gy reported any benefit. There were no radiation-associated toxicities reported by patients. Conclusions: These data suggest that palliative RT ( ≥ 30 Gy) is an efficacious treatment for ulcerative breast cancer with minimal toxicity. Prior RT should not be a contraindication as patients with previous history of RT have similar outcomes compared to RT-naïve patients.

Reconstruction of open wounds as a complication of spinal surgery with flaps: a systematic review.

OBJECT A systematic review of the available evidence on the prophylactic and therapeutic use of flaps for the coverage of complex spinal soft-tissue defects was performed to determine if the use of flaps reduces postoperative complications and improves patient outcomes. METHODS A PubMed database search was performed to identify English-language articles published between 1990 and 2014 that contained the following phrases to describe postoperative wounds ("wound," "complex back wound," "postoperative wound," "spine surgery") and intervention ("flap closure," "flap coverage," "soft tissue reconstruction," "muscle flap"). RESULTS In total, 532 articles were reviewed with 17 articles meeting the inclusion criteria of this study. The risk factors from the pooled analysis of 262 patients for the development of postoperative complex back wounds that necessitated muscle flap coverage included the involvement of instrumentation (77.6%), a previous history of radiotherapy (33.2%), smoking (20.6%), and diabetes mellitus (17.2%). In patients with instrumentation, prophylactic coverage of the wound with a well-vascularized flap was shown to result in a lower incidence of wound complications. One study showed a statistically significant decrease in complications compared with patients where prophylactic coverage was not performed (20% vs 45%). The indications for flap coverage after onset of wound complications included hardware exposure, wound infection, dehiscence, seroma, and hematoma. Flap coverage was shown to decrease the number of surgical debridements needed and also salvage hardware, with the rate of hardware removal after flap coverage ranging from 0% to 41.9% in 4 studies. CONCLUSIONS Prophylactic coverage with flaps in high-risk patients undergoing spine surgery reduces complications, while therapeutic coverage following wound complications allows the salvage of hardware in the majority of patients.