Interstitial Irradiation Research Articles

Laser Therapy of Haemangiomas and Vascular Malformations – Techniques and Strategies

Summary Lasers have been used in the treatment of haemangiomas since the early 1980s. Several study groups have reported good results, others have been less enthusiastic and emphasized other treatments like cryosurgery. We reviewed our experience with the use of laser therapy in treating complicated haemangiomas of infants. During a 15-year period, 1117 infants with haemangiomas were treated with the Nd:YAG laser. The lesions reported were particular troublesome because of significant cosmetic disfigurement, maceration or ulceration, bleeding, and of potential functional impairment. Superficial findings were treated using was a transcutaneous application with local ice cube cooling to protect the overlying skin. All deep-seated lesions were treated with interstitial laser irradiation. In trachaeal haemangiomas endoscopic laser destruction is an alternative to tracheostomy with good functional results and comparable or less morbidity. Overall, excellent results were achieved in 41% of infants and good results occured in 51%. On the basis of our results we conclude that laser therapy may successfully prevent enlargement and promote involution of haemangiomas with minimal adverse effects. Therapy should be initiated as early as possible, when lesions are relatively flat, for optimal results.

Permanent Iodine-125 Interstitial Radiation Therapy in the Treatment of Non-Glioblastoma multiforme High-Grade Gliomas

Background: This study evaluates prognostic factors influencing survival outcomes for 60 patients with permanent iodine-125 implants in the primary treatment of non-glioblastoma multiforme (GBM) high-grade gliomas. Methods: Stereotactic treatment planning aimed to encompass the contrast-enhancing rim of the tumor visualized by CT, with an initial dose rate of 0.05 Gy/h with ¹²⁵I, delivering 100 Gy at 1 year and 103.68 Gy at infinity. Survival was evaluated using the Kaplan-Meier method for univariate analysis and the Cox regressional method for multivariate analysis. In addition to the implant, 34 patients received external radiation therapy (5,000–6,000 cGy) before the implant; 13 patients were implanted without additional external beam radiation, and 13 patients underwent external radiation therapy before implant placement. Results: With a mean follow-up of 77.6 months (range 3.5–164 months), 1-, 3-, 5- and 10-year survival were 86.7% (±0.05%), 60% (±0.07%), 50% (±0.07%) and 45.7% (±0.7%), respectively. The median survival time was 57 months. Second surgery was performed following the implant in 19 patients. Findings were tumor recurrence in 11 patients (22.5%), radiation necrosis in 7 patients (14.3%) and brain abscess in 1 patient (2%). Age, sex, tumor location, side of brain, tumor volume, Karnofsky score and neurological status were correlated with survival outcome. Favorable prognostic factors were age younger than 45 years, superficial tumor location and preoperative Karnofsky score greater than 70. RPA classification was used to define this group of patients. In RPA classes I and II (n = 43), 1-year survival was 93%, while 3-, 5- and 10-year survival was 67.4, 60.5 and 55.5%, respectively, and median survival time was 91 months. In RPA class III (n = 7), 1-year survival was 71.4%, while 3- and 5-year survival was 42.9 and 28.6%, respectively, and median survival time was 47 months. In RPA class IV (n = 10), 1-year survival was 60%, while 3-, 5- and 10-year survival was 50, 22.2 and 11.1%, respectively, and median survival time was 37 months. Conclusion: Brachytherapy with permanent implant of ¹²⁵I appears promising in the treatment of primary non-GBM malignant gliomas. It improved survival time and reduced the incidence of complications and provided good quality of life. In order to further confirm these results, multicenter randomized prospective studies are needed. RPA analysis is a valid tool to define prognostically distinct survival groups. In this study, 2-year survival and median survival time were improved in all prognostic classes. This would suggest that selection bias alone does not account for the survival benefit seen with ¹²⁵I implants. Further randomized studies with effective stratification are needed.

32/Brachytherapy HDR in interoperative breast cancer treatment

To present data from Linz, Austria, on survival and local control of a prospective treatment method and to demonstrate the safe use of combined external beam and interstitiallridium-192 HDR irradiation. This method has been transferred to Gynecological Clinic in Poznan, Poland, where the first implantation was performed in January 2004. a) Linz: Since 1984 HDR Ir-192 brachytherapy has been used to deliver an interstitial boost to the primary site in conservative breast cancer treatment. Until December 1995, 650 patients have been treated (T1: 434, T2: 216, N0: 467, N1: 183). Treatment method (after tumourectomy or quadrantectomy) included external beam irradiation of 45 to 50 Gy to the breast followed by an interstitial 10 Gy boost. Mean follow up of survivors: 105 months (range 36 to 189). b) Poznan: Ina 54 years old patient with breast cancer carcinoma ductale infiltrans G.2 pT2 tumourectomy was performed. In the same surgical session hollow needles where implanted into the tumour bed. Using an Iridium-192 source interstitial radiotherapy was delivered with a dose of 10 Gy as boost to the primary site. 5-years actuarial data for T1-2 tumours: Overall survival: 89.2%, local control: 96.9%, disease free survival: 86.4%, and disease specific survival: 92.8%. There were no severe complications, the cosmetic results are satisfactory (91% good to excellent after 5 years). The use of a HDR source in boosting the primary tumour site with a dose of 10 Gy in 1 fraction after external beam radiotherapy is a safe procedure; the impact on cosmetic results is minimal. Our 5-year local relapse rate of 3.1%and survival data are satisfactory and better compared to most of the results reported in literature. Therefore we will continue with the described prospective approach in Linz. The first implantation in Poznan was the kick off for further brachytherapy treatments in breast cancer patients. High dose rate implantantions in the treatment of breast cancer will continue at the Gynecological Clinic in Poznan, either as a boost or as the sole treatment of mammary glant carcinoma.

Safety and efficacy of concurrent interstitial radiation and hyperthermia in the treatment of progressive malignant brain tumors

High activity 125I brachytherapy has efficacy in selected recurrent malignant brain tumors, but limited efficacy and risk of radiation necrosis have prompted investigation of additional adjunctive therapies. This study aims to assess the toxicity of interstitial conductive hyperthermia used concurrently with 125I brachytherapy for the treatment of recurrent brain malignancies. Twelve patients with recurrent malignant brain tumors were implanted using afterloading catheters intended to deliver 50 Gy at the isodose line encompassing the enhancing tumor with a 5-mm margin and heated to 41.5 degrees C for 48 h. The average implant volume was 18 cc with 5.3 catheters containing 9.4 sources with a total activity of 265 mCi. Serious toxicities included 8 motor deficits, 2 mood alterations, 4 seizures and 2 catheter wound cerebrospinal fluid leaks. Median survival was 10.35 months with the best responses being 6 with stable disease and 2 with partial responses. Reoperation rate for radiation necrosis was 33%. Concurrent conductive thermoradiotherapy is feasible but is associated with serious toxicity. There is no suggestion of improved survival with thermoradiotherapy over brachytherapy alone. Given the degree of toxicity observed, alternative approaches to improving local control of these tumors are being explored.

Lymph node metastasis of early oral tongue cancer after interstitial radiotherapy

Purpose To examine the prognostic factors for lymph node metastasis after brachytherapy for early (T1-T2N0M0) oral tongue cancer. Methods and materials We reviewed the records of 571 patients (500 low dose rate and 71 high dose rate) treated at Osaka University Hospital between 1967 and 1999. Results Patients with lymph node metastasis had tumor with an average diameter of 26 ± 8 mm and a thickness of 9 ± 5 mm; for patients without lymph node metastasis, the corresponding dimensions were 23 ± 8 mm and 7.5 ± 4 mm ( p = 0.0004 and 0.001, respectively). After 5 years, the ulcerative (48%) and indurative/infiltrative (39%) types showed a higher ratio of nodal involvement than the exophytic (31%) and superficial (19%) types ( p <0.0001). Multivariate analysis showed ulceration ( p = 0.006) and a thickness of ≤6 mm ( p = 0.04) to be statistically significant predisposing factors for lymph node metastasis. The lymph node control rate was 68% in 1967–1979, 71% in 1980–1990, and 66% in 1990–1999; the corresponding successful salvage rates for lymph node metastasis were 43%, 33%, and 58% ( p = 0.04). Conclusion The appearance of the tumor, especially the presence or absence of ulceration and the diameter and thickness, are useful prognostic indicators for lymph node metastasis. Although the rates of lymph node metastasis did not change, the salvage outcome for recurrence after interstitial radiotherapy has recently improved.

Interstitial radiotherapy of the tumour of the base of the tongue

Interstitial radiotherapy of the tumour of the base of the tongue

Radiation damage to the normal monkey brain: experimental study induced by interstitial irradiation.

Radiation damage to normal brain tissue induced by interstitial irradiation with iridium-192 seeds was sequentially evaluated by computed tomography (CT), magnetic resonance imaging (MRI), and histological examination. This study was carried out in 14 mature Japanese monkeys. The experimental area received more than 200-260 Gy of irradiation developed coagulative necrosis. Infiltration of macrophages to the periphery of the necrotic area was seen. In addition, neovascularization, hyalinization of vascular walls, and gliosis were found in the periphery of the area invaded by the macrophages. All sites at which the vascular walls were found to have acute stage fibrinoid necrosis eventually developed coagulative necrosis. The focus of necrosis was detected by MRI starting 1 week after the end of radiation treatment, and the size of the necrotic area did not change for 6 months. The peripheral areas showed clear ring enhancement with contrast material. Edema surrounding the lesions was the most significant 1 week after radiation and was reduced to a minimum level 1 month later. However, the edema then expanded once again and was sustained for as long as 6 months. CT did not provide as clear of a presentation as MRI, but it did reveal similar findings for the most part, and depicted calcification in the necrotic area. This experimental model is considered useful for conducting basic research on brachytherapy, as well as for achieving a better understanding of delayed radiation necrosis.

Nonlinear photodynamic therapy. Saturation of a photochemical dose by photosensitizer bleaching.

Photodynamic therapy with total photobleaching of a photosensitizer was studied theoretically. The possibilities of having constant therapeutic dose within a large extent of a tissue and even of obtaining the maximal dose at a particular depth were considered. The use of both surface irradiation or interstitial irradiation were evaluated.

Spatial distribution of liposome encapsulated tin etiopurpurin dichloride (SnET2) in the canine prostate: Implications for computer simulation of photodynamic therapy

Photodynamic therapy (PDT) is a minimally invasive treatment that can be employed in many human diseases including prostate cancer. PDT for prostate cancer depends on the sequestration of a photosensitizing drug within the glandular tissue. The photosensitizer is subsequently activated by light (usually from a laser) and the active drug destroys tissue. Since prostate cancer is a multifocal disease, PDT must ablate the glandular prostate completely. This will depend on the precise placement of light sources in the prostate and delivery of a therapeutic light dose to the entire gland. Also, sources of light and their spatial distribution must be tailored to each individual patient. The uniform, therapeutic light distribution can be achieved by interstitial light irradiation. In this case, the light is delivered by diffusers placed within the substance of the prostate parallel to the urethra at a distance optimized to deliver adequate levels of light and to create the desired photodynamic effect. To help achieve the uniform light distribution throughout the prostate we have developed a computer program that can determine treatment effects. The program predicts the best set of parameters and the position of light diffusers in space, and displays them in graphical or in numerical form assuming a fixed attenuation coefficient. The two parameters of greatest importance in the computer simulation are attenuation coefficient and critical fluence. Both depend on the concentration of active drug within the prostate gland. It is necessary to know the nature of the spatial distribution of photosensitizer within the prostate to execute computer modeling of PDT with high precision. We found that the concentration of SnET2 is heterogeneous in nature, and is higher in the proximity of the glandular capsule. It is clear therefore that any future attempts of computerized modeling of this procedure must take into consideration the uneven sequestration of photosensitizer and the consequential asymmetrical necrosis of the prostate.

Tumor treatment by sustained intratumoral release of 5-fluorouracil: effects of drug alone and in combined treatments.

To evaluate an intratumoral polymer implant for sustained delivery of 5-fluorouracil (5-FU) in a mouse tumor model. 5-FU was incorporated into a polyanhydride-based polymer, bis(p-carboxyphenoxy)propane sebacic acid (CPP:SA) and implanted in RIF-1 mouse fibrosarcoma growing s.c. The effectiveness of treatment was evaluated by tumor growth delay. External beam radiation was 60Co gamma rays, and the source of interstitial radiation was implanted 125I seeds. A second drug, cis-diamminedichloroplatinum (cis-DDP), was administered by intraperitoneal injection or by osmotic pump. For drug/polymer implant alone, the tumor growth delay was proportional to the amount of drug in the implant. The 5-FU polymer implant was most effective when combined with cis-DDP or with acute or fractionated radiation, and in some cases, the effects of combined treatments were greater than additive. The most effective combination was intratumoral 5-FU and low-dose-rate radiation delivered from an interstitial radiation source. Results indicate that 5-FU can be effectively delivered by polymer implant and that this mode of delivery is particularly appropriate for combined treatments.

Treatment of a recurrent ocular squamous cell carcinoma in a horse with Iridium-192 implantation

A 7-year-old Selle français gelding was presented for a recurrent conjunctival tumour on the left eye. A previous histologic analysis revealed a conjunctival squamous cell carcinoma. As it was the third recurrence after surgical excision in a 1½-year period, we decided to perform interstitial radiotherapy combined with the surgical excision. Two Iridium-192 pins were implanted in the subcutaneous fascia of the lower eyelid over the tumor site and were removed 3 days later. No postoperative adverse reactions were observed. Twelve months postoperatively, there were no signs of local recurrence. Surgical excision combined with Iridium-192 therapy appeared to be an effective treatment in this case.

Organ preservation with interstitial radiation for base of tongue cancer.

Management options for squamous cell carcinoma of the base of tongue include surgical resection (often with adjuvant radiation), definitive external radiation and external combined with interstitial radiation. The reported series is a single institution experience with interstitial radiation for base of tongue cancer. Twenty patients were treated definitively with interstitial radiation as a boost to external radiation, and four patients were treated palliatively with interstitial radiation alone for recurrent base of tongue cancers or disease arising in a previously irradiated base of tongue. Patient, tumor, and treatment details were analyzed relative to disease control and posttreatment patient function. The 5-year actuarial local control, locoregional control, distant metastasis-free survival, overall disease-free survival, and actuarial overall survival of the definitively treated patients were 86%, 84%, 57%, 41%, and 30%, respectively. The 5-year actuarial rate of tolerating a normal diet was 86%, and all long-term survivors had normal speech function. Of the four patients treated palliatively with interstitial implant alone for recurrent disease (three patients), or a second primary cancer in a previously irradiated site (one patient), local control was obtained in three and long-term disease-free survival was obtained in one. Interstitial implantation combined with external radiation is associated with a high rate of disease eradication with preservation of speech and swallow function. Interstitial radiation alone can achieve effective palliation.

826 Poster Tumor control and functional outcome in cancer of the base of tongue — Radical surgery versus interstitial radiotherapy

826 Poster Tumor control and functional outcome in cancer of the base of tongue — Radical surgery versus interstitial radiotherapy

The Brain Tumor Cooperative Group NIH Trial 87-01: A Randomized Comparison of Surgery, External Radiotherapy, and Carmustine versus Surgery, Interstitial Radiotherapy Boost, External Radiation Therapy, and Carmustine

Abstract OBJECTIVE The objective of the Brain Tumor Cooperative Group NIH Trial 87-01 trial was to investigate the effect of additional implanted radiation therapy in newly diagnosed patients with pathologically confirmed malignant gliomas. METHODS The study involved a randomized comparison of surgery, external beam radiotherapy, and carmustine (BCNU) versus surgery, external beam therapy, interstitial radiotherapy boost, and BCNU in newly diagnosed malignant gliomas. 125I was chosen as best suited for this effort because it allowed preimplantation planning and postimplantation quality assurance review. Two hundred ninety-nine patients met the eligibility criteria and were randomized into the two arms of the study between December 1987 and April 1994. Follow-up continued for an additional 3 years. Twenty-nine patients were identified as having committed protocol violations and were excluded, resulting in 270 subjects in the Valid Study Group. One hundred thirty-seven patients received external beam radiation and BCNU, and 133 underwent the 125I implantation plus external beam radiation and BCNU therapy. RESULTS The overall median survival for the Valid Study Group was 64.3 weeks. The median survival for patients receiving additional therapy of 125I was 68.1 weeks, and median survival for those receiving only external beam radiation and BCNU was 58.8 weeks. The cumulative proportion surviving between the two treatment groups was not statistically significantly different (log-rank test, P = 0.101). As in other studies in the literature, age, Karnofsky score, and pathology were predictors of mortality. Additional analyses incorporating an adjustment for these prognostic variables, either in a stratified analysis or Cox proportional hazards model, did not result in statistically significant differences in the cumulative proportion of patients surviving between the two treatment groups. CONCLUSION We conclude that there is no long-term survival advantage of increased radiation dose with 125I seeds in newly diagnosed glioma patients.

The Brain Tumor Cooperative Group NIH Trial 87-01: A Randomized Comparison of Surgery, External Radiotherapy, and Carmustine versus Surgery, Interstitial Radiotherapy Boost, External Radiation Therapy, and Carmustine

The objective of the Brain Tumor Cooperative Group NIH Trial 87-01 trial was to investigate the effect of additional implanted radiation therapy in newly diagnosed patients with pathologically confirmed malignant gliomas. The study involved a randomized comparison of surgery, external beam radiotherapy, and carmustine (BCNU) versus surgery, external beam therapy, interstitial radiotherapy boost, and BCNU in newly diagnosed malignant gliomas. (125)I was chosen as best suited for this effort because it allowed preimplantation planning and postimplantation quality assurance review. Two hundred ninety-nine patients met the eligibility criteria and were randomized into the two arms of the study between December 1987 and April 1994. Follow-up continued for an additional 3 years. Twenty-nine patients were identified as having committed protocol violations and were excluded, resulting in 270 subjects in the Valid Study Group. One hundred thirty-seven patients received external beam radiation and BCNU, and 133 underwent the (125)I implantation plus external beam radiation and BCNU therapy. The overall median survival for the Valid Study Group was 64.3 weeks. The median survival for patients receiving additional therapy of (125)I was 68.1 weeks, and median survival for those receiving only external beam radiation and BCNU was 58.8 weeks. The cumulative proportion surviving between the two treatment groups was not statistically significantly different (log-rank test, P = 0.101). As in other studies in the literature, age, Karnofsky score, and pathology were predictors of mortality. Additional analyses incorporating an adjustment for these prognostic variables, either in a stratified analysis or Cox proportional hazards model, did not result in statistically significant differences in the cumulative proportion of patients surviving between the two treatment groups. We conclude that there is no long-term survival advantage of increased radiation dose with (125)I seeds in newly diagnosed glioma patients.

Improved Risk Stratification for Biochemical Recurrence after Radical Prostatectomy Using a Novel Risk Group System based on Prostate Specific Antigen Density and Biopsy Gleason Score

Previous studies have suggested that prostate specific antigen (PSA) density is a significant independent predictor of biochemical failure after primary therapy. We determined whether pathological PSA density using surgical weight of the radical prostatectomy specimen was an independent predictor of adverse pathological features or biochemical recurrence after radical prostatectomy. We also examined whether combining pathological PSA density with biopsy Gleason score improved risk stratification compared with serum PSA and biopsy Gleason score for predicting PSA recurrence after prostatectomy. Multivariate analysis was used to determine whether pathological PSA density was an independent predictor of adverse pathology or PSA recurrence after radical prostatectomy in 325 patients treated at a Veterans Affairs medical center. Cutoff points of pathological PSA density were generated to identify patients at various risks for biochemical recurrence. These cutoffs were combined with biopsy Gleason cutoff points 2 to 6, 7 and 8 to 10 to generate a risk stratification system that was compared with a previous risk stratification system using PSA and biopsy Gleason score cutoff points. The validity of the risk stratification system using pathological PSA density and biopsy Gleason score was evaluated in another cohort of 490 patients treated with radical prostatectomy at a tertiary care medical center. Pathological PSA density was an independent predictor of positive surgical margins (p <0.001), nonorgan confined disease (p <0.001), seminal vesicle invasion (p = 0.003) and biochemical recurrence after radical prostatectomy (p <0.001). The cutoff points for pathological PSA density of less than 0.3, 0.3 to 0.7 and greater than 0.7 ng./ml./gm. separated patients into 3 distinct groups at increasing risk for biochemical failure after radical prostatectomy (p <0.001). Pathological PSA density cutoffs combined with biopsy Gleason score cutoffs 2 to 6, 7 and 8 to 10 provided better risk stratification for biochemical failure than cutoffs based on a combination of PSA and biopsy Gleason score in patients treated at the Veterans Affairs (hazards ratio 3.04, confidence interval 2.25 to 4.11, p <0.001) and tertiary care (hazards ratio 2.38, confidence interval 1.78 to 3.18, p <0.001) medical centers. Pathological PSA density was a strong predictor of advanced pathology and biochemical failure after radical prostatectomy. Pathological PSA density combined with biopsy Gleason score defined a novel risk group system that improved risk stratification compared with a combination of PSA and biopsy Gleason score. These results were validated in another cohort of patients treated with radical prostatectomy at a tertiary care medical center. Further studies are required using PSA density values calculated from preoperative transrectal ultrasound measurements to determine whether a combination of PSA density and biopsy Gleason score provides significant pretreatment risk stratification.

Saving bladders with brachytherapy: implantation technique and results

Purpose : To analyze and report the treatment results of brachytherapy for solitary bladder cancer in the Arnhem Radiotherapy Institute. Methods and Materials : Between January 1983 and October 1998, 63 patients with a solitary bladder tumor were treated with a combination of transurethral resection, external beam radiotherapy (EBRT), and interstitial radiotherapy. The indications for bladder-conserving treatment were tumor ≤5 cm, T1G3 ( n = 14), T2G2 ( n = 8), T2G3 ( n = 37), and T3a ( n = 4). The prescribed implant dose was either 55 Gy (range 50–65 Gy) in combination with small pelvis external beam RT, 3–4 fractions of 3.5 Gy ( n = 58), or 30 Gy in combination with 20 fractions of 2 Gy external beam radiotherapy ( n = 5). Brachytherapy was performed with 2–8 137Cs needles until 1995 ( n = 48) and 2–5 afterloading catheters ( 192Ir) since 1996 ( n = 15). Follow-up cystoscopies were performed at 3-month intervals during the first 2 years, then every 6 months for 3 years, and annually after the fifth year. The median follow-up was 4.9 years. Results : Twenty patients developed local recurrences, of which 6 were “true in-implant recurrences,” 12 were in second bladder locations, and 2 were urethral recurrences. All recurrences developed within 2.5 years after treatment. Of these 20 patients, 13 underwent cystectomy: 6 stayed disease-free, 1 died of postoperative complications, 2 developed regional metastases, and 4 developed distant metastases. The 5-year disease-specific survival rate was 80% for patients with Stage T1 and 60% for those with Stage T2 disease. The local control rate was 70% in the whole patient population and 80% after salvage cystectomy. Forty-four bladders were saved. Acute complications were seen in 14 patients, and no significant late complications occurred. Conclusion : Using this treatment technique, a high cure rate with conservation of the bladder and only minor toxicity can be obtained in a selected patient population having a solitary tumor ≤5 cm.

Recurrent vulvar cancer.

Recurrent vulvar cancer occurs in an average of 24% of cases after primary treatment after surgery with or without radiation. The relatively few primary vulvar cancers, combined with the low proportion of recurrences, has made it difficult to perform randomized studies to document the most appropriate therapeutic modalities. Most reports are small retrospective studies and anecdotal reviews that have emphasized the importance of surgery and have led to new approaches with respect to chemoradiation. Traditionally, the most accepted treatment of vulvar cancer has been and continues to be surgery. Recently, radiation and chemotherapy have been combined with very encouraging results. The therapeutic modality used depends on the location and extent of the recurrence. Most recurrences occur locally near the original resection margins or at the ipsilateral inguinal or pelvic lymph nodes. Lateralized local vulvar recurrences treated with a wide radical local excision with inguinal lymphadectomy results in an excellent cure rate of 70%. With a central pelvic recurrence with antecedent radiotherapy involving the urethra, upper vagina, and rectum, total pelvic exenteration is indicated in a select group of patients with curative intent. Radiotherapy or chemoradiation concomitantly with wide radical local excision of an advanced vulvar has proven successful in avoiding an exenteration, with improved survival and less morbidity. Prospective and retrospective studies have shown excellent results using radiation or chemoradiation with wide radical local excision in patients with locally advanced disease in whom adequate resection margins are difficult to achieve (with a central lesion requiring exenteration) or with debilitating medical conditions that preclude surgery. In these patients, chemoradiation has shown favorable results when used before a wide local resection. In patients with advanced local disease, external beam and interstitial radiation has been used for palliative and curative intent with encouraging results. Regional recurrences to the inguinal and pelvic lymph nodes have been shown to have a poor prognosis with a high mortality rate. We recommend that inguinal recurrences without prior radiation therapy undergo excision followed by radiotherapy with chemosensitization. In patients with previous radiation to the inguinal lymph nodes, we try to avoid any excisional procedures because of the high rate of complications. We offer these patients brachytherapy for palliation. With pelvic recurrences, we recommended chemoradiation as the treatment modality. In the subset of patients with distant metastasis, chemotherapy may be offered; however, few studies have been performed to advocate any single combination. The literature supports the use of 5-fluorouracil or cisplatin as single agents or in combination to have sensitivity against squamous cells. There are few studies revealing improvement in 5-year survival, thus these patients may benefit from recruitment into research protocols.

The role of brachytherapy in the management of oropharyngeal carcinomas: the Trento experience.

This study was undertaken to determine the outcome of patients with oropharyngeal cancer treated at the Radiotherapy Department of the Santa Chiara Hospital (Trento, Italy) with brachytherapy alone or combined with external beam radiotherapy (EBRT). We retrospectively reviewed the medical records of 87 patients with squamous cell carcinoma of the oropharynx treated by radiation therapy between January 1986 and September 1999. The median age was 59 years and all patients had a minimum follow-up of one year. Tumor locations were 46 tonsillar region, 31 soft palate and 10 base of the tongue. The patients were staged as follows: 41 T1, 35 T2, 11 T3 with 70 N0, 9 N1 and 8 N2. They received either brachytherapy alone (14 patients) or a combination of external beam irradiation and brachytherapy (73 patients) using an afterloading iridium technique in a plastic tube. Overall primary tumor control, including salvage surgery, was 81/87 (93%). Control of metastatic cervical adenopathy was as follows: clinical stage N1, 5/9 patients; N2, 2/8 patients. The estimated five-year cause-specific survival and overall survival rates were 81% and 47%, respectively. After interstitial irradiation severe complications were limited to one case of osteoradionecrosis of the mandible and seven cases of mucosal ulcer. This study confirms that iridium-192 interstitial implant alone or as a boost after external beam irradiation is a safe and effective therapy in the management of oropharyngeal carcinomas.

Minimally invasive therapy for the treatment of breast tumours

Minimally invasive therapy has been explored as a potential means of treating breast tumours with minimal disruption to adjacent soft tissues. The purpose of this is to facilitate improved cosmesis and to offer treatment to women who are unfit for surgery. A number of treatment modalities including thermal therapies (intersitital laser photocoagulation, radiofrequency, focused ultrasound and cryotherapy), percutaneous excision and interstitial radiotherapy are being developed. The experience to date of each of these modalities is described and reviewed. Currently there are too few data to indicate the efficacy of these treatments although the preliminary data are encouraging. The need for large-scale studies examining the role of MIT in relationship to the overall management of breast cancer (including chemotherapy, radiotherapy, and the management of the axilla) and outcome is discussed.