Late Gastrointestinal Complications Research Articles

Long-term outcomes of laparoscopic gastrectomy for gastric cancer

BackgroundLaparoscopic gastrectomy (LG) has been established as a procedure for the treatment of gastric cancer. However, there have been few reports on the long-term outcomes of LG for gastric cancer. The aim of this study is to investigate the long-term outcomes of LG for gastric cancer. MethodsA total of 278 consecutive patients who underwent LG in our unit between January 1999 and December 2006 were included in this study. Survival, recurrence, and late gastrointestinal complications were analyzed. ResultsThe median follow-up period was 73.7 mo (6–165 mo). Distal gastrectomy was performed in 229 patients, total gastrectomy in 23 patients, proximal gastrectomy in 15 patients, and pylorus-preserving gastrectomy in 11 patients. Five-year overall and disease-specific survival rates were 91% and 99% for stage IA, 75% and 91% for stage IB, 72% and 88% for stage II, and 40% and 50% for stage III, respectively. Recurrences were detected in 15 (5.4%) patients, including 5 distant lymph node, 5 peritoneal, 4 hematogenous, and 1 locoregional recurrences. Bowel obstruction occurred in 4 (1.4%) patients, and gallstones developed in 37 (15%) patients. ConclusionsThis follow-up investigation suggested that LG for gastric cancer is a feasible procedure from the standpoint of long-term oncological outcome and postoperative complications.

High-dose-rate interstitial brachytherapy in combination with androgen deprivation therapy for prostate cancer: are high-risk patients good candidates?

To evaluate the effectiveness of high-dose-rate interstitial brachytherapy (HDR-ISBT) as the only form of radiotherapy for high-risk prostate cancer patients. Between July 2003 and June 2008, we retrospectively evaluated the outcomes of 48 high-risk patients who had undergone HDR-ISBT at the National Hospital Organization Osaka National Hospital. Risk group classification was according to the criteria described in the National Comprehensive Cancer Network (NCCN) guidelines. Median follow-up was 73 months (range 12-109 months). Neoadjuvant androgen deprivation therapy (ADT) was administered to all 48 patients; 12 patients also received adjuvant ADT. Maximal androgen blockade was performed in 37 patients. Median total treatment duration was 8 months (range 3-45 months). The planned prescribed dose was 54 Gy in 9 fractions over 5 days for the first 13 patients and 49 Gy in 7 fractions over 4 days for 34 patients. Only one patient who was over 80 years old received 38 Gy in 4 fractions over 3 days. The clinical target volume (CTV) was calculated for the prostate gland and the medial side of the seminal vesicles. A 10-mm cranial margin was added to the CTV to create the planning target volume (PTV). The 5-year overall survival and biochemical control rates were 98 and 87 %, respectively. Grade 3 late genitourinary and gastrointestinal complications occurred in 2 patients (4 %) and 1 patient (2 %), respectively; grade 2 late genitourinary and gastrointestinal complications occurred in 5 patients (10 %) and 1 patient (2 %), respectively. Even for high-risk patients, HDR-ISBT as the only form of radiotherapy combined with ADT achieved promising biochemical control results, with acceptable late genitourinary and gastrointestinal complication rates.

High-dose-rate brachytherapy in the treatment of uterine cervical cancer using cobalt-60 radionuclide source: Three years treatment outcome

Background: The Iridium-192 radionuclide source is commonly used for high-dose-rate brachytherapy of uterine cervical cancer. The cobalt-60 radionuclide source, which is more economical, is now available with dosimetric properties similar to iridium-192. Objective: To evaluate late gastrointestinal and genitourinary complications, and also the survival pattern in cervical cancer patients treated with cobalt-60 high-dose-rate brachytherapy, three years after treatment. Materials and Methods: Seventy patients, who were treated with high-dose-rate brachytherapy using the cobalt-60 radionuclide source were followed up for three years. All the patients received 45 Gy of external beam radiotherapy in 22 daily fractions, with 19.5 Gy from high-dose-rate brachytherapy, in three fractions, over three weeks, using the cobalt-60 radio nuclide source. The patients also received concurrent cisplatin-based chemotherapy. Late complications were assessed every three months, using Radiation Therapy Oncology Group (RTOG) late toxicity criteria. The pattern of disease control was also assessed. Results: Late complications in the bowel were, six (9%) grade 1, four (6%) grade 2, one (1%) grade 3, and one (1%) grade 4. The late complications affecting the bladder were 5 (7%) grade 1 and 1 (1%) grade 4. Twenty-eight patients (40%) were alive without disease, seven (10%) were alive with disease, seven (10%) died of persistent disease, four (6%) died of metastatic disease, while 24 (34%) were lost to follow-up. Conclusion: The late complications were similar to those reported for Iridium-192 as a source of high-dose brachytherapy. Cobalt-60 high-dose-rate brachytherapy is tolerable, effective, and economical for low resource settings.

Low-dose-rate Brachytherapy for the Treatment of Postprostatectomy Local Recurrence: A Phase II Trial

Treatment for patients with biochemical progression after radical prostatectomy (RP) and evidence of local recurrence usually consists of external beam radiotherapy. This a valid option, but not exempt from complications, and is demanding in terms of dose adjustment and definition of target vol. Low dose-brachytherapy (LDB) is an alternative option for patients with localized prostate cancer. The aim of this prospective study was to analyze the capacity of LDB to treat patients with local progression after RP in terms of toxicity and oncologic control. Fifty-two patients were treated for local prostate cancer relapse from April 2004 to December 2010. Only patients with more than 6 months follow-up were included n = 47. Median age was 69.6 years(54-77). The pathologic staging after at RP was 1(2.1%) pT0, 7(13.9%) pT2a, 12(25.5%) pT2b, 3(6.4%)pT2c, 12(25.5%) pT3a and 4(8.5%) pT3b. Local progression in all cases was confirmed by positive biopsy. The Gleason score (GS) on control biopsy ranged from 6-9, 21(44.7%) GS 6, 20(42.6%) GS 7 and 6 (12.7%) GS >7. The median follow-up was 29.5 months (6-60.5), and median time to biochemical progression 26 months. Median PSA before LDB was 1.8 ng/mL(range, 0.24-9.3). Real-time implantation was performed and connected seeds were used. Treatment dose planning was for 144 Gy to cover the anastomotic area. Median target volume was 9.6cc (2.8-23), seed activity 0.47mci, seeds per implant 43.7.The post implant median prostate and urethra D90 were 176 Gy and 115G respectively. All patients were assessed for acute and late gastrointestinal (GI) and genitourinary (GU) toxicity as defined by RTOG. Biochemical failure was defined using the Phoenix definition. All cases were hormone naive prior to LDB. Median hospital stay was 21h. There were no major perioperative complications. All patients were discharged without urethral catheter. Acute GI and GU complications grade 1 and 2 were 2(4.3%), 1(2.1%) and 15(31.9%) and 3(6.4%) respectively. Mild previous incontinence improved in 3 patients (6.4%). Late GI and GU complications grade 1 or 2 were 3 (6.4%), 1 (2.1%), and 3 (6.4%) and 1 (2.1%) respectively. With a median follow up of 40 months, biochemical relapsed-free survival at 2 and 5 years was 92.9% and 80.8%. At 2 years 61.8% and at 5 years 71.4% of patients had PSA < 0.5ng/mL. Eight patients had biochemical failure and one patient died, of prostate cancer related causes. Although longer follow up is needed, these promising results, with minimal morbidity and excellent biochemical response, lead us to believe that LDB is a valid salvage option for patients with local relapse after RP.

Late gastrointestinal (GI) complications in patients with stage I-II testicular seminoma treated with radiotherapy (RT).

4595 Background: For stage I-II testicular seminoma, RT is highly effective at eradicating disease in the abdominopelvic lymph nodes, but results in unnecessary exposure to normal tissues including the GI tract. The purpose of this study was to define the incidence and risk factors for late GI complications in this patient population. Methods: A retrospective review was performed of 251 patients with stage I-II testicular seminoma treated with curative intent RT at our institution from 1974-2009. All patients underwent orchiectomy and postoperative external beam RT to the involved and/or at-risk nodal basins. Potential late GI complications that were assessed included endoscopically-confirmed gastric or duodenal ulceration, small bowel obstruction (SBO), and biopsy-confirmed malignancy of the GI tract. Risks were estimated using the Kaplan-Meier (KM) technique and univariate/multivariate analyses were performed using the Cox proportional hazards model. Results: Median age at diagnosis was 36 years (range 18 – 80). Clinical stage was I (n=199) or II (n=52). Median abdominopelvic RT dose was 26 Gy (interquartile range 25 – 30). Median follow-up was 15 years (range 0.1 – 38). KM estimates for any GI complication (ulcer, SBO, or GI malignancy) at 10, 20, and 30 years were 7, 10 and 24%, respectively. Four patients died as result of a GI complication. KM estimates for ulcer at 10, 20, and 30 years were 4, 7, and 9%, respectively. Age at RT (Hazard Ratio [HR] 1.05, 95% Confidence Interval [CI] 1.00 – 1.10, p=0.03) and RT total dose (per Gy, HR 1.20, 95% CI 1.09 – 1.31, p&lt;0.01) were associated with risk of ulcer. KM estimates for SBO at 10, 20, and 30 years were 2%, 2%, and 3%, respectively. History of inflammatory bowel disease was associated with risk of SBO (HR 43, 95% CI 7-325, p&lt;0.01). KM estimates for GI malignancy at 10, 20, and 30 years were 0.5, 3 and 16%, respectively. Age at RT was associated with risk of GI malignancy (HR 1.07, 95% CI 1.02-1.14, p=0.01). Conclusions: In patients with stage I-II testicular seminoma treated with RT, late GI complications were a relatively uncommon, but clinically significant source of late morbidity. Use of low dose, limited field, and/or proton RT may reduce these risks.

Radiation sigmoiditis mimicking sigmoid colon cancer after radiation therapy for cervical cancer: the implications of three-dimensional image-based brachytherapy planning

External-beam radiation therapy with intracavitary high-dose-rate brachytherapy is the standard treatment modality for advanced cervical cancer; however, late gastrointestinal complications are a major concern after radiotherapy. While radiation proctitis is a well-known side effect and radiation oncologists make an effort to reduce it, the sigmoid colon is often neglected as an organ at risk. Herein, we report two cases of radiation sigmoiditis mimicking sigmoid colon cancer after external-beam radiation therapy with intracavitary high-dose-rate brachytherapy for uterine cervical cancer with dosimetric consideration.

Toxicity Associated With Postoperative Radiation Therapy for Prostate Cancer

To quantify gastrointestinal (GI) and genitourinary (GU) toxicity associated with postprostatectomy radiation and to determine the relationships between dosimetry parameters and medical comorbidities and toxicity. We reviewed the records of 233 prostate cancer patients irradiated after prostatectomy between 1987 and 2002. Ninety-nine patients were treated with a volumetric 3-dimensional conformal approach and 134 patients were treated conventionally. Acute and late GI and GU toxicity was recorded and the relationships between dosimetry parameters and comorbidities and toxicity were examined. Acute grade 2 to 3 GI toxicity was more common in the conventionally versus conformally treated patients (83% vs. 61%, P=0.01). The rates of acute grade 2 to 3 GU toxicity were not significantly different between the techniques. There were no acute grade 4 events. Most patients had no late GI toxicity (73% conformal and 75% conventional) and no late GU toxicity (64% conformal and 59% conventional). In an actuarial analysis, the 5-year rates of grade 2 to 4 GI and GU complications were not different between the treatment techniques. Two patients treated conventionally had late grade 4 complications. Hemorrhoids predicted for late GI toxicity, and renal stones and preirradiation urinary incontinence predicted for late GU complications. Delivery of 50 Gy to more than 38% of the rectal volume, 40 Gy to more than 58%, or 30 Gy to more than 72% was associated with an increased risk of late GI complications. Eighty-seven percent of the late GI complications occurred in patients with at least grade 2 acute GI toxicity. For prostate cancer patients treated with postoperative radiation, limited toxicity is seen with conventional or conformal techniques. The similar rates of toxicity between techniques may have been because of higher conformal median doses -70 Gy versus 62 Gy. Dose-volume parameters correlate with the risk of GI complications.

Commentary on "Late Gastrointestinal Complications of Inferior Vena Cava Filter Placement: Case Report and Literature Review"

Commentary on "Late Gastrointestinal Complications of Inferior Vena Cava Filter Placement: Case Report and Literature Review"

Commentary on "Late Gastrointestinal Complications of Inferior Vena Cava Filter Placement: Case Report and Literature Review"

Commentary on "Late Gastrointestinal Complications of Inferior Vena Cava Filter Placement: Case Report and Literature Review"

Late Gastrointestinal Complications of Inferior Vena Cava Filter Placement: Case Report and Literature Review

In current practice, inferior vena cava (IVC) filters are commonly used in the prevention of pulmonary embolism. Despite their widespread use, periprocedural as well as late complications do occur. Filter penetration of the IVC wall into surrounding structures, including bowel, is a known although rare complication. This complication may manifest with abdominal pain, gastrointestinal bleeding, duodenocaval fistula, or small bowel obstruction. The authors present a case of abdominal pain from duodenal penetration by a Greenfield IVC filter 13 years after insertion. A detailed operative description and pertinent review of the literature is provided.

Single-stage omental flap transposition: modality of an effective treatment for deep sternal wound infection

Deep sternal wound infection (DSWI) is an uncommon life-threatening complication of cardiac surgery performed through median sternotomy. Surgical treatment is considered complicated and challenging. We report our experience with a single-stage omental flap transposition in the treatment of the 14 consecutive patients who were diagnosed with DSWI within 3-16days after the primary cardiac surgery, between August 2001 and January 2008. The single-stage omental flap transposition was achieved within 70-135min, at four to eight hours after diagnosis of DSWI. The single-stage omental flap transposition was successfully applied and all 14 patients survived. They displayed a shortened intensive care unit stay (one to nine days) and hospital stay (19-36days). Follow-up was 100% complete (26-92months) and demonstrated rapid recovery, complete wound healing without fistula, and no late gastrointestinal complications. However, the very few complications found were slight numbness of anterior chest and minor paradoxical chest movement. We obtained satisfactory outcomes when treating the patients with DSWI by a single-stage omental flap transposition. Based on our solid experience, we recommend this procedure as an option for patients with DSWI, especially those who are not in a state of severe low cardiac output or malnutrition.

Intensity-modulated radiation therapy (IMRT) for prostate cancer: Toxicity and biochemical control in 183 Chinese patients from a single institution in Hong Kong.

101 Background: To report the biochemical outcome and the acute and late toxicities in 183 Chinese patients with clinically localized prostate cancer treated with IMRT. Methods: Between May 2001 and November 2009, 183 patients with clinically localized prostate cancer were treated with IMRT at the Prince of Wales Hospital. Median follow-up was 44 months (range 8.5 to 112 months).Treatment was planned using an inverse-planning approach, and the beams were delivered by dynamic multileaf collimation. Four-field box technique was used for pelvic irradiation (pelvic RT) if indicated in phase I and IMRT was used for prostate boost in phase II. The median age of the patients was 71.4 (range 45 to 82). According to the NCCN risk classification, 18 (9.8%), 47 (25.7%) and 118 (64.5%) patients belong to favorable, intermediate, and unfavorable risk group respectively. The median prescription dose of the planning target volume of the prostate gland (PTV-G) is 72Gy (range from 66 to 76Gy). 77 patients (42.1%) received pelvic RT. 129 patients (70%) received neoadjuvant hormone and 106 patients (57.9%) received adjuvant hormone. Acute and late toxicities were scored according to the Common Terminology Criteria for Adverse Events Version 4.02. Biochemical failure was defined according to the Houston definition (absolute PSA nadir plus 2ng/ml dated at the call). Results: The 5-year actuarial biochemical-failure free survival for patients in favorable, intermediate and unfavorable risk groups were 95%, 80%, and 83% respectively. 3 patients (1.6%) experienced grade 3 acute gastrointestinal (GI) toxicity. There were no grade 3 acute genitourinary (GU) toxicity. There was no grade 4 acute GI or GU toxicity. 14 patients (7.7%) developed grade 2 late GI toxicity and 8 patients (4.4%) developed grade 3 late GI toxicity. 5 patients (2.7%) developed grade 2 late GU toxicity and 5 patients (2.7%) developed grade 3 late GU toxicity. There was no grade 4 late GI or GU toxicity. Conclusions: These data demonstrate that IMRT for prostate cancer is feasible and safe in Chinese population. The early biochemical outcome is encouraging and the grade 3 late GI and GU complications were below 5%. No significant financial relationships to disclose.

Survivors of Childhood Cancer Have Increased Risk of Gastrointestinal Complications Later in Life

Children who receive cancer therapy experience numerous acute gastrointestinal (GI) toxicities. However, the long-term GI consequences have not been extensively studied. We evaluated the incidence of long-term GI outcomes and identified treatment-related risk factors. Upper GI, hepatic, and lower GI adverse outcomes were assessed in cases from participants in the Childhood Cancer Survivor Study, a study of 14,358 survivors of childhood cancer who were diagnosed between 1970 and 1986; data were compared with those from randomly selected siblings. The median age at cancer diagnosis was 6.8 years (range, 0-21.0 years), and the median age at outcome assessment was 23.2 years (5.6-48.9 years) for survivors and 26.6 years (1.8-56.2 years) for siblings. Rates of self-reported late GI complications (occurred 5 or more years after cancer diagnosis) were determined and associated with patient characteristics and cancer treatments, adjusting for age, sex, and race. Compared with siblings, survivors had increased risk of late-onset complications of the upper GI tract (rate ratio [RR], 1.8; 95% confidence interval [CI], 1.6-2.0), liver (RR, 2.1; 95% CI, 1.8-2.5), and lower GI tract (RR, 1.9; 95% CI, 1.7-2.2). The RRs for requiring colostomy/ileostomy, liver biopsy, or developing cirrhosis were 5.6 (95% CI, 2.4-13.1), 24.1 (95% CI, 7.5-77.8), and 8.9 (95% CI, 2.0-40.0), respectively. Older age at diagnosis, intensified therapy, abdominal radiation, and abdominal surgery increased the risk of certain GI complications. Individuals who received therapy for cancer during childhood have an increased risk of developing GI complications later in life.

591 LOW DOSE BRACHYTHERAPY WITH I125 IN PATIENTS WITH LOCAL PROSTATE CANCER RECURRENCE AFTER RADICAL PROSTATECTOMY

You have accessJournal of UrologyProstate Cancer: Localized III1 Apr 2010591 LOW DOSE BRACHYTHERAPY WITH I125 IN PATIENTS WITH LOCAL PROSTATE CANCER RECURRENCE AFTER RADICAL PROSTATECTOMY F.G. Gómez Veiga, A. Marino, I. Gómez, L.A. Castelo, J. Gonzalez Dacal, S. Breijo, D. Lopez, J. Ponce, A. Candal, and V. Chantada F.G. Gómez VeigaF.G. Gómez Veiga More articles by this author , A. MarinoA. Marino More articles by this author , I. GómezI. Gómez More articles by this author , L.A. CasteloL.A. Castelo More articles by this author , J. Gonzalez DacalJ. Gonzalez Dacal More articles by this author , S. BreijoS. Breijo More articles by this author , D. LopezD. Lopez More articles by this author , J. PonceJ. Ponce More articles by this author , A. CandalA. Candal More articles by this author , and V. ChantadaV. Chantada More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.863AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Treatment for patients with biochemical progression after radical prostatectomy (RP) and suspicion of local recurrence usually consists of external beam radiotherapy. This a valid option, but not exempt from complications, and is demanding in terms of dose adjustment and definition of target volumes. Low dose- brachytherapy (LDB) is an alternative option for patients with localized prostate cancer. The aim of this prospective study was to analyze the capacity of LDB to treat patients with local progression after RP in terms of toxicity and oncologic control METHODS 42 patients were treated for local prostate cancer relapse from April 2004 to July 2009. Median age was 69.2 years(54-76). The pathologic staging after at RP was 1(2.4%) pT0, 5(11.9%) pT2a, 7(16.7%), pT2b, 14(33.3%)pT2c, 11(26.2%) pT3a and 4(9.5%) pT3b. Local progression in all cases was confirmed by positive biopsy. The Gleason score (GS) on control biopsy ranged from 6-9, 20(47.1%) GS 6, 18(42.9%) GS 7 and 4 (9.5%) GS ≥8. Only patients with more than 6 months follow-up were included n=35. The median follow-up was 29.5 months (6-60.5), and median time to biochemical progression 26 months. Median PSA before LDB was 1.9 ng/mL(range 0.24-6.8). Real-time implant was realized using Variseed 7.2 program and Rapid Strand ®seeds were used. Treatment dose planning was for 144 Gy to cover the anastomotic area. Median volume prescription was 10cc (3.1-23), seeds activity 0.48mci, seeds per session 44.4, and median prostate and urethra d90 174Gy and 121G respectively. All patients were assessed for acute and late gastrointestinal (GI) and genitourinary (GU) toxicity as defined by RTOG. Biochemical failure was defined using the Phoenix definition. All cases were hormone naive prior to LDB. RESULTS Median hospital stay was 21h. There were no major perioperative complications. All patients were discharged without urethral catheter. Acute GI and GU complications grade 1 and 2 were 2(5.7%), 1(2.9%) and 14(40%) and 3(8.6%) respectively.Mild previous incontinence improved in 3 patients (8.6%). Late GI and GU complications grade 1 or 2 were 3 (8.8%), 1 (2.9%), and 3 (8.6%) and 1 (2.9%) respectively. With a median follow up of 29.5 months, biochemical relapsed-free survival was 88.6%, 4 patients had biochemical failure and one patient died, related to prostate cancer the cancer- free survival was 97%. CONCLUSIONS Although longer follow up is needed, these promising results, with minimal morbidity and excellent biochemical response, lead us to believe that LDB is a valid salvage option or patients with local relapse after RP A Coruna, Spain© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e232 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information F.G. Gómez Veiga More articles by this author A. Marino More articles by this author I. Gómez More articles by this author L.A. Castelo More articles by this author J. Gonzalez Dacal More articles by this author S. Breijo More articles by this author D. Lopez More articles by this author J. Ponce More articles by this author A. Candal More articles by this author V. Chantada More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Antiangiogenic agents and late anastomotic complications

Anticancer agents targeting circulating vascular endothelial growth factor (VEGF) (e.g., bevacizumab and aflibercept) are strong angiogenesis inhibitors. As such, they may hamper the healing process, notably in the early postoperative period. Whether antiangiogenic agents may be associated with late postoperative healing complications is less known. We reviewed three cases of patients with anastomotic complications under antiangiogenic treatment occurring more than 1 year after initial surgery and we conducted a review of the literature. We report the first case of delayed anastomotic leakage which occurred under aflibercept therapy 13 months after a bilioenteric anastomosis and two cases of delayed rectal anastomotic complications associated with bevacizumab treatment 18 and 78 months after surgery. Fifteen similar cases of late gastrointestinal anastomotic complications were found in the English literature. Antiangiogenic agents are probably not deleterious to a healed wound. However, they appear to be associated with an increased risk of complications in a subgroup of patients. According to the 18 cases reported, the main risk factors appear to be low anterior resection for rectal cancer, perioperative radiotherapy, and early postoperative leak which heals through the formation of abundant and hypervascularized granulation tissue.

Spontaneous rectovaginal fistula during bevacizumab therapy for ovarian cancer: a case report

Recent studies have demonstrated efficacy of bevacizumab for recurrent ovarian cancer, but few data on its use and gastrointestinal potential complications when administered as adjuvant chemotherapy after cytoreductive surgery are available. In this study, we report the first case of a rectovaginal fistula in this indication.

Combined modality treatment with bladder preservation for muscle invasive bladder cancer

Objective To evaluate the 5-year results of the following trimodal therapy for treatment of some selected cases of muscle invasive bladder cancer. Materials and Methods In this prospective study, we included 104 patients with transitional cell carcinoma (TCC) (T2 and T3a, N0, M0) who were amenable to complete transurethral resection. All patients received adjuvant chemo-radiotherapy (CRT) in the form of gemcitabine and cisplatin and conventional radiotherapy after the maximum resection of their tumors. Two weeks later, all cases had radiologic and cystoscopic evaluation. The patients who showed no evidence of the bladder tumors [complete response (CR)] went on to complete the CRT, while those with recurrent invasive tumors did not receive any more CRT and were assigned to have salvage cystectomy. Thereafter, all patients were subjected to a regular follow-up. Results This trimodal therapy was well tolerated in most of cases with no severe acute toxicities. Complete response was achieved in 78.8% of cases after the initial CRT, and tumor grade was found to be the most significant risk factor to predict this response ( P = 0.004). With a median follow-up of 71 months for patients with initial CR, 16.2% of cases showed muscle invasive recurrences, and multifocality was the only significant risk factor for their development ( P = 0.003). Meanwhile, superficial recurrences were detected in 8.1% of cases with initial CR and were successfully treated with transurethral resection and intravesical bacillus Calmette-Guerin (BCG). On the other hand, we reported distant metastasis in 24.3% of patients with initial CR, and tumor grade, stage and multifocality were the most significant risk factors for this complication ( P = 0.002, 0.031, 0.006). No cases of contracted bladder or late gastrointestinal complications were demonstrated in this series. The 5-year overall survival rate for patients with initial CR was 67.6%, and for all the patients in this study it was 59.4%. Conclusions This trimodal therapy can be considered as a treatment option for patients with localized muscle invasive TCC. The best candidates for such therapy are those with solitary T2, low grade tumors that are amenable to complete transurethral resection.

The Effects of Carbon Ion Irradiation Revealed by Excised Perforated Intestines as a Late Morbidity for Uterine Cancer Treatment

Clinical trials of carbon ion therapy have been performed due to the advantages of high-dose energy delivery with precise localization control to targeted organs and strong cell-killing activities to cancers. Perforated intestines as a late morbidity after carbon ion radiotherapy for uterine cancers were examined to reveal the biological characteristics of carbon ion for future applications for the treatment of gastrointestinal cancers. Between June 1995 and December 2004, 94 patients with carcinoma of the uterine cervix or corpus were treated with carbon ion therapy. Among them, 9 patients (9.6%) developed major late gastrointestinal (GI) complications. Four out of 9 patients had intestinal perforations excised operatively at our institute. The postoperative clinical courses and histopathological findings of the excised intestine were investigated. Carbon ion irradiation severely damaged smooth muscle layers by coagulation necrosis as well as atrophy of the intestinal epithelium and middle-sized arterial thromboses of the intestines. After evaluating late complications, the dose constraints on the GI tracts were set under 60 GyE to prevent major complications. Thereafter, the incidence of major GI complications markedly decreased. Our findings demonstrated the characteristic histopathological effects of carbon ion radiotherapy and thus are expected to facilitate future additional applications of carbon ion radiotherapy for the treatment of gastrointestinal cancers.

Dose escalation study of carbon ion radiotherapy for locally advanced carcinoma of the uterine cervix

To evaluate the toxicity and efficacy of carbon ion radiotherapy (CIRT) for locally advanced cervical cancer by two phase I/II clinical trials. Between June 1995 and January 2000, 44 patients were treated with CIRT. Thirty patients had Stage IIIB disease, and 14 patients had Stage IVA disease. Median tumor size was 6.5 cm (range, 4.2-11.0 cm). The treatment consisted of 16 fractions of whole pelvic irradiation and 8 fractions of local boost. In the first study, the total dose ranged from 52.8 to 72.0 gray equivalents (GyE) (2.2-3.0 GyE per fraction). In the second study, the whole pelvic dose was fixed at 44.8 GyE, and an additional 24.0 or 28.0 GyE was given to the cervical tumor (total dose, 68.8 or 72.8 GyE). No patient developed severe acute toxicity. In contrast, 8 patients developed major late gastrointestinal complications. The doses resulting in major complications were > or =60 GyE. All patients with major complications were surgically salvaged. The 5-year local control rate for patients in the first and second studies was 45% and 79%, respectively. When treated with > or =62.4 GyE, the local control was favorable even for the patients with stage IVA disease (69%) or for those with tumors > or =6.0 cm (64%). In CIRT for advanced cervical cancer, the dose to the intestines should be limited to <60 GyE to avoid major complications. Although the number of patients in this study was small, the results support continued investigation to confirm therapeutic efficacy.

Localized volume effects for late rectal and anal toxicity after radiotherapy for prostate cancer

To identify dosimetric parameters derived from anorectal, rectal, and anal wall dose distributions that correlate with different late gastrointestinal (GI) complications after three-dimensional conformal radiotherapy for prostate cancer. In this analysis, 641 patients from a randomized trial (68 Gy vs. 78 Gy) were included. Toxicity was scored with adapted Radiation Therapy Oncology Group/European Organization for the Research and Treatment of Cancer (RTOG/EORTC) criteria and five specific complications. The variables derived from dose-volume histogram of anorectal, rectal, and anal wall were as follows: % receiving > or =5-70 Gy (V5-V70), maximum dose (Dmax), and mean dose (D(mean)). The anus was defined as the most caudal 3 cm of the anorectum. Statistics were done with multivariate Cox regression models. Median follow-up was 44 months. Anal dosimetric variables were associated with RTOG/EORTC Grade > or =2 (V5-V40, D(mean)) and incontinence (V5-V70, D(mean)). Bleeding correlated most strongly with anorectal V55-V65, and stool frequency with anorectal V40 and D(mean). Use of steroids was weakly related to anal variables. No volume effect was seen for RTOG/EORTC Grade > or =3 and pain/cramps/tenesmus. Different volume effects were found for various late GI complications. Therefore, to evaluate the risk of late GI toxicity, not only intermediate and high doses to the anorectal wall volume should be taken into account, but also the dose to the anal wall.