Multimodality Treatment Of Patients Research Articles

Prevention and Treatment of Local Breast Cancer Recurrence Using 6.3 MeV Fast Neutrons

The study included 138 breast cancer patients, who received the complex treatment and radiotherapy alone with the use of 6.3 MeV fast neutrons generated within U-120 cyclotron. Neutron therapy used for the prevention of local recurrence was shown to be effective in multimodality treatment of patients with locally advanced breast cancer, and in cases with locally advanced tumor recurrences it is often the only treatment to prolong life of breast cancer patients.

Decision Making in Lung Cancer – How Applicable are the Guidelines?

Modelling demand for radiotherapy is contingent on the uniform application of clinical practice guidelines. However, decision making in lung cancer is a complex process requiring the integration of multimodality treatment in patients who frequently have underlying comorbidities. Population studies have shown that guideline adherence in lung cancer is modest, ranging from 44 to 52%. The application of guideline treatment decreases with increasing age and the presence of comorbidities. Patient and clinician attitudes also impact on this. In some regions, sociodemographic factors, such as lower income and non-White race, have been associated with a lack of guideline treatment. One of the major barriers in treating lung cancer patients according to guidelines is the mismatch between the clinic population and those enrolled in clinical trials from which evidence is derived. The lung cancer clinic population often consists of patients who are older, have multiple comorbidities and are of borderline performance status, all characteristics that are usually exclusion criteria for clinical trials. Hence, there is uncertainty not only about the magnitude of benefit, but also potential toxicities of guideline treatment. Further research is necessary in order to define the best treatment in these patients and thus increase the applicability of guidelines to the general lung cancer population. Lung cancer is an extreme example of the difficulties in translating evidence into clinical practice. The applicability of guidelines to specific cancer populations will affect the modelling of demand for radiotherapy and other treatment modalities.

Комплексное лечение пациентов с немелкоклеточным раком легкого и односторонней диссеминацией по париетальной плевре

Комплексное лечение пациентов с немелкоклеточным раком легкого и односторонней диссеминацией по париетальной плевре

Multimodal treatment of patients with advanced cervical cancer

Local progressive tumor growth involving the urinary tract with no distant metastases is known to be one of the features of cervical cancer in the advanced stages. Approximately 68 % of patients in stage T3-T4 have various uroevolution disorders. The severity of their condition often is caused by an increasing renal failure or a fever, those are associated with obstructive pyelonephritis and often are interpreted as the carcinogenic intoxication. Therefore, any special antineoplastic therapy methods are considered as unpromising even for patients without concomitant diseases. The authors conducted a retrospective analysis of 11 patients with the treatment of advanced non-metastatic cervical cancer, which included both surgery and neoadjuvant polychemotherapy (PCT). Our results demonstrate the advisability of multimodal phasing treatment of those patients, compared with palliative radiotherapy and symptomatic treatment.

Perioperative radiotherapy is associated with improved survival among patients with synovial sarcoma: A SEER analysis.

We examined the outcomes of synovial sarcoma (SS) patients in a national database. We identified 1,189 patients from the Surveillance, Epidemiology, and End Results (SEER) database with data on site and extent of surgery. We excluded patients diagnosed before 1990, <18 years, or lacking pathologic confirmation. Using Kaplan-Meier and Cox proportional hazards analyses, we determined predictors of overall (OS) and disease-specific survival (DSS). The mean age was 41, 49.3% were female, and 82.2% were white. Radiotherapy (RT) was administered to 57.5%. On multivariable analysis, age at diagnosis, sex, race, anatomic site, SEER summary stage, tumor size, surgery type, and RT predicted OS. Similar predictors of DSS were identified. The hazard ratio (HR) for OS was 0.65 (95% CI 0.48-0.88) in favor of RT and 0.62 (95% CI 0.45-0.86) for DSS. Five-year OS improved 8.4 ± 1.0% with RT (P=0.003), and five-year DSS improved 7.7 ± 1.0% with RT (P=0.015). In the largest study to date examining the role of RT in synovial sarcoma, we observed that RT was associated with a statistically significant improvement in oncologic outcome among SS patients. These data support the use of RT in the multi-modality treatment of patients with SS.

Role of surgery in multi-modality treatment for carcinomatous pleuritis in patients with non-small cell lung cancer.

To evaluate the role of surgery in the treatment of the patients with non-small cell lung cancer with pleural dissemination. The clinical records of 25 patients (mean age 69 years) diagnosed with carcinomatous pleuritis during a thoracotomy by pathological examination and followed by surgery between 1994 and 2012 were reviewed. The treatment modality, including surgery, the clinicopathologic characteristics and 5-year survival were analyzed. There were 16 adenocarcinomas, 6 squamous cell carcinomas and 3 large cell carcinomas. Surgery included resection of the main tumor by partial resection in 10 cases, segmentectomy in 2 cases, lobar resection in 12 cases and bilobectomy in 1 case. Intrathoracic irrigation was performed in 20 cases. The pathological N status was N0/N1/N2/Nx: 10/6/7/2. Fifteen patients received adjuvant therapy. The overall 5-year survival rate was 22.2 %. The 5-year survival rates of the N0, N1 and N2 groups were 36.0, 16.7 and 14.3 %, respectively (p = 0.0068). Nine patients lived more than 3 years including 5 in N0, 3 in N1 and 1 in N2. Surgery should not be excluded from the multi-modality treatment of patients with carcinomatous pleuritis because there are some patients who could benefit from surgery especially if they are in N0 status.

Safety and Efficacy of Targeted Therapy for Renal Cell Carcinoma With Brain Metastasis

BackgroundBrain metastases are associated with a poor prognosis in patients with renal cell carcinoma (RCC). The role of targeted therapy in this setting is not well established. The primary objective was to assess overall survival (OS) and neurologic events in patients with brain metastasis treated with targeted agents. Patients and MethodsPatients with RCC treated with targeted agents for brain metastasis between 2002 and 2012 were retrospectively identified. Kaplan-Meier methodology and a Cox proportional hazards model were used to analyze the association between clinical features and OS. ResultsOf 65 patients identified, 52 (80%) were treated with antiangiogenic agents and 13 (20%) received inhibitors of mTOR (mechanistic target of rapamycin [serine/threonine kinase]); 57 (88%) had local therapy for brain metastasis, including surgery in 3 (5%), radiation therapy in 36 (55%), and both surgery and radiotherapy in 18 (28%). Median follow-up was 12.3 months (1.1-58.8). Median treatment duration for targeted therapy as first-line therapy was 3.4 months (0.3-31.9). The median OS was 12.2 months (95% CI, 8.0-15.5). The risk group according to the Memorial Sloan Kettering Cancer Center (MSKCC) stratification (P = .001), the histology subtype (clear vs. other) (P < .0001), and the number of brain lesions (1 vs. ≥ 2) (P = .004) correlated with OS on multivariate analysis. Neurologic complications were identified in 5 patients (8%), including 2 with radiation necrosis and 3 with brain metastasis hemorrhage. ConclusionThe use of targeted agents in the multimodal treatment of patients with RCC and brain metastasis was not associated with excessive neurologic adverse events. Clear cell histology, favorable MSKCC risk status, and solitary brain metastasis are associated with more favorable OS.

Comparison of hypofractionated radiation with temozolomide to the current standard of care in the treatment of glioblastoma: Results from a single institution.

2089 Background: The multimodality treatment of patients with glioblastoma (GBM) includes adjuvant radiation with concomitant chemotherapy. At this time the optimal radiation fractionation is yet t...

Quality of life as a primary endpoint in ovarian cancer trials

Multimodal treatment of patients with advanced ovarian cancer consists of radical debulking surgery and a combination of platinum and taxane chemotherapy. Although this approach is highly effective and potentially curative, most women will relapse, which can be treated effectively but is rarely cured. 1 du Bois A Reuss A Pujade-Lauraine E Harter P Ray-Coquard I Pfisterer J Role of surgical outcome as prognostic factor in advanced epithelial ovarian cancer: a combined exploratory analysis of 3 prospectively randomized phase 3 multicenter trials: by the Arbeitsgemeinschaft Gynaekologische Onkologie Studiengruppe Ovarialkarzinom (AGO-OVAR) and the Groupe d'Investigateurs Nationaux Pour les Etudes des Cancers de l'Ovaire (GINECO). Cancer. 2009; 115: 1234-1244 Crossref PubMed Scopus (1037) Google Scholar In this context, quality of life is an important outcome measure. Unfortunately, few detailed analyses of quality of life have been done in large first-line treatment trials for ovarian cancer: primary publications traditionally focus on efficacy data and, typically, only outline results of quality of life are presented. Detailed description of health-related quality of life could help clinicians and patients with respect to making informed treatment decisions. 2 Luckett T King M Butow P Friedlander M Paris T Assessing health-related quality of life in gynecologic oncology: a systematic review of questionnaires and their ability to detect clinically important differences and change. Int J Gynecol Cancer. 2010; 20: 664-684 Crossref PubMed Scopus (47) Google Scholar Carboplatin plus paclitaxel once a week versus every 3 weeks in patients with advanced ovarian cancer (MITO-7): a randomised, multicentre, open-label, phase 3 trialA weekly regimen of carboplatin and paclitaxel might be a reasonable option for first-line treatment of women with advanced ovarian cancer. Full-Text PDF

Radical nephroureterectomy for pathologic T4 upper tract urothelial cancer: can oncologic outcomes be improved with multimodality therapy?

To report the outcomes of patients with pathologic T4 UTUC and investigate the potential impact of peri-operative chemotherapy combined with radical nephroureterectomy (RNU) and regional lymph node dissection (LND) on oncologic outcomes. Patients with pathologic T4 UTUC were identified from the cohort of 1464 patients treated with RNU at 13 academic centers between 1987 and 2007. Oncologic outcomes were stratified according to utilization of perioperative systemic chemotherapy and regional LND as an adjunct to RNU. The study included 69 patients, 42 males (61%) with median age 73 (range 43-98). Median follow-up was 17 months (range: 6-88). Lymphovascular invasion was found in 47 (68%) and regional lymph node metastases were found in 31 (45%). Peri-operative chemotherapy was utilized in 29 (42%) patients. Patients treated with peri-operative chemotherapy and RNU with LND demonstrated superior oncologic outcomes compared to those not treated by chemotherapy and/or LND during RNU (3Y-DFS: 35% vs. 10%; P = 0.02 and 3Y-CSS: 28% vs. 14%; P = 0.08). In multivariate Cox regression analysis, administration of peri-operative chemotherapy and utilization of LND during RNU was associated with lower probability of recurrence (HR: 0.4, P = 0.01), and cancer specific mortality (HR: 0.5, P = 0.06). Pathological T4 UTUC is associated with poor prognosis. Peri-operative chemotherapy combined with aggressive surgery, including lymph node dissection, may improve oncological outcomes. Our findings support the use of aggressive multimodal treatment in patients with advanced UTUC.

Efficiency of bacterial lysates in multimodality therapy of children of early age with viral croups

The paper presents the results of studying the features of the cytokine status and indicators of local immunity of children with acute respiratory viral infection, proceeding with the manifestations of the syndrome of croup, and an evaluation of the efficiency of using bacterial lysates in a multimodality treatment of patients. It has been corroborated that edematous and hypersecretory variants of croup proceed against a background of a considerable intensification of a systemic inflammatory response and a decrease of the factors of local immunity; whereas the spasmodic variant – develops against a background of the physiologic level of cytokines and an increase of the factors of local immunity in the acute period of the disease. The use of bacterial lysates in multimodality therapy of patients with the edematous variant of the syndrome of croup is accompanied with an insignificant decrease in the level of cytokines, whereas with the hypersecretory variant the content of cytokines decreases almost 4-5 times. Against a background of the intake of bacterial lysates with the edematous variant the activity and content of the factors of local immunity rises somewhat, but their level remains lower than the indicators of the control group, with the hypersecretory variant their level reaches the indicators of healthy children. The results of the research enable to recommend bacterial lysates to be used in multimodality therapy of patients afflicted with the hypersecretory variant of croup that will promote a more rapid normalization of the systemic inflammatory reaction and a stimulation of the production and activation of the factors of local immunity in sick children.

Natural orifice translumenal endoscopic surgery (NOTES) second-look peritoneoscopy for staging of limited peritoneal carcinomatosis

BackgroundOver the past decades, staging laparoscopy evolved as a useful tool in multimodality treatment of patients with abdominal malignancies, especially for detection of incurable peritoneal and liver metastasis. Natural orifice translumenal endoscopic surgery (NOTES) is a new, evolving technique which represents the next logical progression in minimally invasive surgery and has theoretical advantages in comparison with standard laparoscopic surgery. A review of the current literature revealed a continuous increasing number of fundamental and clinical studies addressing NOTES approach in multimodal management of oncologic patients. Technical possibility to use this new minimally invasive approach for oncological resection of abdominal malignancies was proved by some investigators. HypothesisNOTES can be used as an alternative method for staging patients with limited peritoneal carcinomatosis and may have better results compared to current imaging techniques for small diameter metastatic disease. ConclusionsWith the continuous development of the NOTES techniques and technology, the second-look peritoneoscopy by NOTES may become an alternative method for staging in patients with peritoneal carcinomatosis. Nevertheless, NOTES is at a very early stage of its development, and its implementation in oncologic surgery should be made very caution, and only after careful evaluation.

Association of surgical resection and survival in patients with malignant primary osseous spinal neoplasms from the Surveillance, Epidemiology, and End Results (SEER) database

Malignant osseous spinal neoplasms are aggressive tumors associated with poor outcomes despite aggressive multidisciplinary measures. While surgical resection has been shown to improve short-term local disease control, it remains debated whether surgical resection is associated with improved overall survival in patients with malignant primary osseous spinal neoplasms. The aim of this manuscript is to review survival data from a US cancer registry spanning 30 years to determine if surgical resection was independently associated with overall survival. The SEER registry (1973-2003) was queried to identify cases of histologically confirmed primary spinal chordoma, chondrosarcoma, osteosarcoma, or Ewing's sarcoma of the mobile spine and pelvis. Patients with systemic metastasis were excluded. Age, gender, race, tumor location, and primary treatments were identified. Extent of local tumor invasion was classified as confined within periosteum versus extension beyond periosteum to surrounding tissues. The association of surgical resection with overall survival was assessed via Cox analysis adjusting for age, radiotherapy, and tumor invasiveness. 827 patients were identified with non-metastatic primary osseous spinal neoplasms (215 chordoma, 282 chondrosarcoma, 158 osteosarcoma, 172 Ewing's sarcoma). Overall, median survival was histology specific (chordoma, 96 months; Ewing's sarcoma, 90 months; chondrosarcoma, 88 months; osteosarcoma, 18 months). Adjusting for age, radiation therapy, and extent of local tumor invasion in patients with isolated (non-metastatic) spine tumors, surgical resection was independently associated with significantly improved survival for chordoma [hazard ratio (95 % confidence interval; 0.617 (0.25-0.98)], chondrosarcoma [HR (95 %CI); 0.153 (0.07-0.36)], osteosarcoma [HR (95 %CI); 0.382 (0.21-0.69)], and Ewing's sarcoma [HR (95 %CI); 0.494 (0.26-0.96)]. In our analysis of a 30-year US population-based cancer registry (SEER), patients undergoing surgical resection of primary spinal chordoma, chondrosarcoma, Ewing's sarcoma, or osteosarcoma demonstrated prolonged overall survival independent of patient age, extent of local invasion, or location. Surgical resection may play a role in prolonging survival in the multi-modality treatment of patients with these malignant primary osseous spinal neoplasms.

Aggressive local treatment containing intraoperative radiation therapy (IORT) for patients with isolated local recurrences of pancreatic cancer: a retrospective analysis

BackgroundTo evaluate the use of intraoperative radiation therapy (IORT) in the multimodality treatment of patients with isolated local recurrences of pancreatic cancer.MethodsWe retrospectively analyzed 36 patients with isolated local recurrences of pancreatic cancer who have been treated with a combination of surgery, IORT and EBRT. Median time from initial treatment to recurrence was 20 months. All patients were surgically explored. In 18 patients a gross total resection was achieved, whereas the other half received only debulking or no resection at all. All patients received IORT with a median dose of 15 Gy. Additional EBRT was applied to 31 patients with a median dose of 45 Gy, combined with concurrent, mainly gemcitabine-based chemotherapy.ResultsMedian follow-up in surviving patients was 23 months. Local progression was found in 6 patients after a median time of 17 months, resulting in estimated 1- and 2-year local control rates of 91% and 67%, respectively. Distant failure was observed in 23 patients, mainly in liver or peritoneal space. The median estimated progression-free survival was 9 months with 1- and 2-year rates of 40% and 26%, respectively. We found an encouraging estimated median overall survival of 19 months, transferring into 1- and 2-year rates of 66% and 45%. Notably 6 of 36 patients (17%) lived for more than 3 years. Severe postoperative complications were found in 3 and chemoradiation-related grade III toxicity in 6 patients. No severe IORT related toxicity was observed.ConclusionCombination of surgery, IORT and EBRT in patients with isolated local recurrences of pancreatic cancer resulted in encouraging local control and overall survival in our cohort with acceptable toxicity. Our approach seems to be superior to palliative chemotherapy or chemoradiation alone and should be further investigated in a prospective setting specifically addressing isolated local recurrences of pancreatic cancer.

Positron emission tomography for the assessment of survival after subsequent surgery in multimodality treatment for patients with locally advanced esophageal squamous cell carcinoma.

e14636 Background: Recent studies imply that positron emission tomography with fludeoxyglucose F 18(FDG-PET) correlates with histopathologic response and survival in patients with esophageal cancer undergoing neoadjuvant chemoradiotherapy (CRT) followed by surgical resection. To evaluate the rating system of FDG-PET after the completion of neoadjuvant CRT for the assessment of histopathologic response and prognosis inthe multimodality treatment of patients with esophageal cancer. Methods: Seventy patients (58 men, 12 women; median age, 61 years) with locally advanced esophageal squamous cell carcinoma who received neoadjuvant CRT underwent FDG-PET before chemoradiotherapy and transthoracic en bloc esophagectomy in evaluation of pathologic response to CRT and postoperative survival. Lack of FDG uptake was defined as primary tumors with SUVmax at least 2.5, and FDG-PET complete response after CRT (PET-CR) was defined as SUVmax&lt;2.5 or SUVmax&lt;3 with mild hyper metabolic activity around the primary tumor. Results: After CRT, lack of FDG uptake was noted 34 patients, PET-CR was noted 49 patients and pathological CR was noted 31 patients. PET-CR indicated stronger correlation with postoperative survival than lack of FDG uptake and rate of decrease in SUV. PET-CR and pathologic CR predicted for improved outcomes (3-year disease free survival 70.3% vs 42.6% P=0.0032; log-rank test, 76.4% vs 37.6% P=0.0008; log-lank test). But on multivariate analysis using the Cox proportional hazards model, only pathologic CR was found to be correlated with post-CRT disease free survival (HR 0.190, 95%CI 0.049-0.73, P=0.017). Conclusions: To evaluate the value of FDG-PET for the assessment of prognosis in the multimodality treatment for patients with locally advanced esophageal squamous cell carcinoma, we tried different rating system of FDG-PET but no recommendation was made for the use of FDG-PET.

Retroperitoneal lymphadenectomy and resection for testicular cancer: an update on best practice

Clinical stage I testicular nonseminomatous germ cell tumours (NSGCTs) are highly curable. Following orchidectomy a risk-adapted approach using active surveillance (AS), nerve-sparing retroperitoneal lymph node dissection (nsRPLND) and primary chemotherapy is recommended by the current guidelines. Clinical stage I is defined as negative or declining tumour markers to their half-life following orchidectomy and negative imaging studies of the chest, abdomen and retroperitoneum. Active surveillance can be performed in low-risk and in high-risk NSGCTs with an anticipated relapse rate of about 15% and 50%. The majority of patients will relapse with good and intermediate prognosis tumours which have to be treated with three to four cycles chemotherapy. About 25-30% of these patients will have to undergo postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) for residual masses. Primary chemotherapy with one or two cycles of cisplatin (Platinol), etoposide and bleomycin (PEB) is a therapeutic option for high-risk clinical stage I NSGCT associated with a recurrence rate of only 2-3% and a minimal acute and long-term toxicity rate. nsRPLND, if performed properly, will cure about 85% of all high-risk patients with clinical stage I NSGCT without the need for chemotherapy. PC-RPLND forms an integral part of the multimodality treatment in patients with advanced testicular germ cell tumours (TGCTs). According to current guidelines and recommendations, PC-RPLND in advanced seminomas with residual tumours is only indicated if a positron emission tomography (PET) scan performed 6-8 weeks after chemotherapy is positive. In nonseminomatous TGCT, PC-RPLND is indicated for all residual radiographic lesions with negative or plateauing markers. Loss of antegrade ejaculation represents the most common long-term complication which can be prevented by a nerve-sparing or modified template resection. The relapse rate after PC-RPLND is around 12%, however it increases significantly to about 45% in cases with redo RPLND and late relapses. Patients with increasing markers should undergo salvage chemotherapy. Only select patients with elevated markers who are thought to be chemorefractory might undergo desperation PC-RPLND if all radiographically visible lesions are completely resectable. PC-RPLND requires a complex surgical approach and should be performed in experienced, tertiary referral centres only.

Micrometastases in Sentinel Lymph Nodes: Not Getting Lost in Translation

Advances in technology have led to increasingly minimally invasive procedures and an increased ability to detect very small amounts of disease. With sentinel lymph node (SLN) biopsy, initial concerns about false-negative results are now balanced with concerns of clinical false-positive results, defined as instances when small amounts of disease have no downstream clinical consequences. The evolution in carefully defining what constitutes clinically meaningful disease and necessary treatments is nicely illustrated in breast cancer. SLNs are considered positive if tumor cells meet a size threshold of 0.2 mm or 200 cells, although disease that is detected by cytokeratin immunohistochemistry alone (without confirmatory hematoxylin and eosin staining) still has somewhat unclear implications. Further, even in the setting of unequivocal disease in SLNs, there are increasing data to support not completing an axillary lymph node dissection (ALND). Most notably, practicechanging results from the American College of Surgeons Oncology Group Z0011 trial effectively demonstrated that ALND did not significantly affect overall or disease-free survival, heralding excellent locoregional control from multimodality treatment of patients with T1/2 invasive breast cancer and positive SLNs who are treated with lumpectomy, radiation therapy (including the low axilla), and adjuvant systemic therapy. 1

Embolization and radiosurgery for arteriovenous malformations

The treatment of arteriovenous malformations (AVMs) requires a multidisciplinary management including microsurgery, endovascular embolization, and stereotactic radiosurgery (SRS). This article reviews the recent advancements in the multimodality treatment of patients with AVMs using endovascular neurosurgery and SRS. We describe the natural history of AVMs and the role of endovascular and radiosurgical treatment as well as their interplay in the management of these complex vascular lesions. Also, we present some representative cases treated at our institution.

Recent advancements in multimodality treatment of gliomas.

Gliomas account for the vast majority of malignant adult brain tumors. Even though tremendous effort has been made to optimize treatment of patients with high-grade glioma, the prognosis remains poor, especially for patients with glioblastoma. The dismal prognosis conferred by these tumors is in part caused by the tendency to diffusely infiltrate into neighboring brain tissue, but also by the inherent resistance of these tumors to both chemotherapy and radiation. This article reviews the recent advancements in multimodality treatment of patients with gliomas, both in the primary and recurrent setting, with an emphasis on the emerging targeted therapies. Moreover, the external beam radiotherapy options, including intensity modulated radiotherapy and particle (proton and carbon ion) radiotherapy are reviewed.

6527 POSTER Post- Chemoradiotherapy Standardized Uptake Value of FDG-PET as a Significant Predictor of Survival After Subsequent Surgery in Multimodality Treatment for Patients With Locally Advanced Esophageal Squamous Cell Carcinoma

6527 POSTER Post- Chemoradiotherapy Standardized Uptake Value of FDG-PET as a Significant Predictor of Survival After Subsequent Surgery in Multimodality Treatment for Patients With Locally Advanced Esophageal Squamous Cell Carcinoma