Local Palliative Radiotherapy Research Articles

RADT-33. ANALYSIS OF PATIENTS DIAGNOSED WITH ATYPICAL TERATOID RHABDOID TUMOR OF BRAIN AT TERTIARY CARE CENTER

Abstract Atypical Teratoid Rhabdoid Tumor (ATRT) of brain is highly malignant neoplasm with incidence of 1-2% among all pediatric CNS tumors characterized by mutations and subsequent inactivation of SMARCB1 (INI1, hSNF5) gene with dismal prognosis of about 6-18 months. On retrospective analysis of patients between 2010-2021 from Medical Record Department, only five cases of ATRT brain were retrieved. All patients were of pediatric age group (6 yr/F, 2yr/M, 6yr/F, 4yr/F, and 1yr/M – Median 4 yrs). On radiological findings, in four patients lesion was primarily in brain and in one patient with diffuse leptomeningeal enhancement. Three patients underwent craniotomy and gross total excision, and, in 2 patients only biopsy was done. In molecular analysis immunohistochemistry (IHC) markers were as follows. In all patients Vimentin and Synaptophysin were positive. EMA was positive in 3 patients, GPAP was positive in 3 patients, CD99 was positive in 2 patients, AE1 was positive in 2 patients. A specific marker for ATRT (INI1 loss) was seen in 3 patients. In other patients INI1 assessment could not be done. In two patients CSF cytology was negative, and, in all patients bone marrow examination was normal. One patient (4yr/F) received local radiotherapy with concurrent Vincristine based chemotherapy and lost to follow up (after 1 year of treatment). One patient (6yr/F) received vincristine based chemotherapy and local palliative radiotherapy and expired (after 1 month of treatment). One patient (6yr/F) received St Jude HR/IRS III protocol chemotherapy and craniospinal irradiation (CSI) and is still on follow up (total follow up period – 9 years). Two patients did not take any kind of treatment in whom one patient expired, another lost to follow up. Looking at rarity of tumors and with the review of literature, multiagent chemotherapy and Craniospinal irradiation seems to be promising approach for treatment of ATRT brain.

Clinical Outcomes Following Postoperative Cavity Stereotactic Radiosurgery for Brain Metastases

We evaluated outcomes of patients with brain metastases (BM) treated with surgical resection and postoperative cavity stereotactic radiosurgery (SRS) to identify which baseline characteristics and treatment factors may increase risk for local recurrence (LR). From June 2017 to December 2021, 68 patients underwent surgical resection for BM followed by single-fraction SRS (n = 15) or fractionated SRS (FSRS) in 3 (n = 24) or 5 (n = 29) fractions to the postoperative cavity using frameless LINAC-based technique. Patients treated with surgery alone or surgery with postoperative whole brain radiotherapy (WBRT) were excluded. Median prescription doses were 1600 cGy (range: 1440-1875) in 1 fraction, 2400 cGy (range: 2100-2700) in 3 fractions, and 3000 cGy (range: 2500-3000) in 5 fractions. Local control (LC) and overall survival (OS) were estimated by the Kaplan-Meier method. Cox proportional hazards models were used to compare groups. Median follow-up was 19.5 months (IQR: 9.0-34.7). Median patient age was 62.5 years (range: 24-80), and 38 (55.9%) patients were male. Primary tumors were lung (n = 29), including NSCLC (n = 28) and SCLC (n = 1), melanoma (n = 12), breast (n = 11), and other (n = 16). Median preoperative tumor maximal dimension was 3.5cm (range: 1.1-6.3). Median planning treatment volume (PTV) was larger in the FSRS group (26.2cc (range: 6.5-151.8)) than in the SRS group (7.7cc (range: 1.1-11.5)) (p<0.001). Median number of concurrently treated intact lesions was 0 (range: 0-13). Median time from surgery to SRS was 32 days (range: 14-77). Forty-eight (70.6%) patients were treated with immunotherapy or targeted therapy. Median OS was 22.3 months (95% CI: 14.4-30.9). The 1-year and 2-year OS rates were 70% and 48%, respectively. The 1-year and 2-year LC rates were 86% and 73%, respectively. Median time to LR was 8.4 months (95% CI: 4.4-11.0). Among the 14 patients with LR, 11 had undergone salvage therapy at last follow-up which included repeat SRS (n = 4), WBRT (n = 3), palliative local radiotherapy (n = 2), surgery followed by repeat SRS (n = 1), and systemic therapy (n = 1). Eleven (16.2%) patients ultimately underwent WBRT post-SRS for local and/or distant failure. No difference in LC was observed based on primary tumor, time interval between resection and SRS, PTV volume, prescription dose, or fractionation regimen (SRS v. FSRS). However, all LR in the 3-fraction group occurred in patients who received less than 2700 cGy. Favorable LC and OS outcomes were observed following postoperative cavity SRS for resected BM in a modern cohort with a large percentage of patients receiving immunotherapy or targeted therapy. No prognostic factors were identified for LC which may be attributable to the cohort size and small number of events observed. However, our findings suggest that patients who undergo 3-fraction FSRS should be treated to a total dose of 2700 cGy to maximize LC.

Phase II trial of durvalumab (MEDI4736) with/without tremelimumab for advanced hepatocellular carcinoma after palliative hypofractionated radiotherapy.

TPS630 Background: Hepatocellular Carcinoma (HCC) is among the most common types and leading causes of cancer death globally, and the incidence is on the rise. For patients with advanced hepatocellular carcinoma (HCC), immune checkpoint inhibitors (ICI) in combination with anti-angiogenic agents or other ICI improve survival compared with tyrosine kinase inhibition. Though ICI-based regimens can achieve prolonged responses in some patients and prolong overall survival, only a subset of patients achieve durable responses. There is an urgent need for strategies to overcome primary and acquired resistance. Many of these patients have symptomatic sites of disease which could benefit from local palliative radiotherapy. Radiotherapy also has the potential to elicit an abscopal immune response when combined with ICI. We hypothesize that combining Radiation Treatment (RT) with Durvalumab or the combination of Durvalumab + Tremelimumab (combination D+T in STRIDE regimen showed OS improvement in HIMALAYA trial in 1st line HCC) will achieve a meaningful response rate in advanced HCC patients after progression on other ICI-based therapies. Methods: This is an open label, single center, two-arm, non-comparative phase II trial. Key eligibility criteria are; histologically-diagnosed HCC with progression during or after prior PD-(L)1 checkpoint inhibitor immunotherapy and at least 1 RECIST 1.1-measurable tumor present which has not received RT or other local therapy prior to enrollment, ECOG 0-1, and Child Pugh score of A, B7, or B8. Patients are assigned sequentially to either single-agent durvalumab initiated starting 3 to 10 days after completing RT (25 Gy in 5 fractions to 1-5 sites of disease), at fixed dose of 1500 mg IV every 28 days, or a single fixed dose of tremelimumab of 300 mg IV administered on Day 1, initiated within 3-10 days of completing RT, in combination with durvalumab at fixed dose of 1500 mg IV every 28 days; for up to 24 months or until confirmed radiographic progression. The primary end point is overall response rate (ORR) and secondary endpoints include proportion of participants with adverse events, overall survival, progression free survival and duration of response. Exploratory endpoints include profiling of peripheral blood mononuclear cell immune cells and plasma biomarkers. We plan to accrue 30 patients to this study, 15 to each Arm, to evaluate ORR which would allow us to detect at least a 20% ORR, which would be a clinically meaningful improvement in efficacy in this population with otherwise poor treatment options assuming a statistical power of 87% and a directional 5% statistical significance level based upon an exact binomial test. The trial is open and enrolling. Clinical trial information: NCT04430452 .

Palliative Local Radiotherapy for Advanced Squamous Cell Carcinoma of the Head-and-Neck: Prognostic Factors of Survival.

A considerable number of patients with advanced head-and-neck cancer (SCCHN) receive palliative radiotherapy. This study aimed to identify prognostic factors for survival to facilitate personalized treatment for these patients. Ninety-two patients receiving palliative radiotherapy for SCCHN were retrospectively analyzed. Fourteen characteristics were evaluated for survival including age, gender, performance score, pre-radiotherapy hemoglobin, tumor site and stage, histologic grade, p16-status, equivalent dose in 2 Gy-fractions (EQD2), completion of radiotherapy, upfront surgery and systemic therapy. On univariate analysis, improved survival was significantly associated with pre-radiotherapy hemoglobin ≥12 g/dl (p=0.003), EQD2 >42.3 Gy (p=0.003) and completion of radiotherapy (p<0.001). In the multivariate analysis, hemoglobin levels remained significant (p=0.024). Trends were found for EQD2 (p=0.057) and completion of radiotherapy (p=0.093). Prognostic factors for survival were identified that can facilitate treatment personalization. The fact that higher EQD2 and completion of radiotherapy were associated with improved survival demonstrates the importance of close monitoring and care of these patients during radiotherapy.

Neoadjuvant docetaxel, cisplatin and ifosfamide (ITP) combination chemotherapy for treating penile squamous cell carcinoma patients with terminal lymph node metastasis

BackgroundChemotherapy may be a valuable treatment option as neoadjuvant treatment for locally advanced penile cancer according to some previous studies, but the rarity of the sample and the Lack of large-scale clinical trials hampered the attempt to establish a solid evidence base for its routine use. The purpose of this study was to evaluate the efficacy of the neoadjuvant chemotherapy combined with a ITP regimen including docetaxel, cisplatin and ifosfamide for treating advanced penile cancer patients.MethodsA total of 19 patients who were classified into advanced penile cancer (PN3) received neoadjuvant chemotherapy of ITP regimen from June 2009 to June 2016 in our hospital.ResultsAfter chemotherapy 12 patients had a partial response (PR), 5 had stable disease (SD) and progressive disease (PD) in 2 cases. The 12 responders underwent penectomy, bilateral inguinal lymphadenectomy (ILND) and pelvic lymph node dissection (LPLND). In contrast, 7 cases who were non-responsive received palliative local radiotherapy. After a median follow-up of 30.6 months, there was statistically significant improvement in median PFS and OS among patients who experienced an objective response to neoadjuvant chemotherapy (group A) compared with those patients who did not respond to chemotherapy (group B) (log-rank test; P < 0.001).ConclusionNeoadjuvant docetaxel, cisplatin and ifosfamide chemotherapy gave 63% (12/19) of patients who were diagnosed with stage n3 penile cancer the chance of radical resection of metastases, and their OS and PFS were significantly higher than those who could not be operated on and the therapeutic dose, toxic and side effects are acceptable in the Chinese Han population. Therefore, neoadjuvant ITP chemotherapy in the treatment of stage T3 penile cancer patients may have cheerful prospects in the Chinese Han population.

Spine Stereotactic Radiosurgery in the Treatment of Metastatic Pheochromocytoma: An Updated Case Series

Pheochromocytoma is a rare neuroendocrine tumor most frequently presenting with local disease. Despite aggressive primary treatment, up to 13.5% of patients may develop metastases with the axial skeleton as the most common site. Systemic therapy has historically been inadequate in controlling metastatic pheochromocytoma, thus local palliative radiotherapy has been explored to decrease local symptoms and disease burden. Potential radioresistance with standard fractionated radiation has led to increasing interest in stereotactic radiosurgery (SRS), which may provide more durable local control. Here we report an update on our institutional experience on spine stereotactic radiosurgery (SSRS) of pheochromocytoma spine metastases. A retrospective analysis on patients with metastatic pheochromocytoma treated with SSRS between 2000 and 2017 was performed. Seven patients with 16 treated spinal bone metastases were identified. Follow-up spine magnetic resonance imaging (MRI) was used to evaluate local control. Symptom data and imaging were reviewed to evaluate toxicity. Kaplan-Meier method was used to assess local control and overall survival (OS). Median follow up for treated lesions was 11 months (range 2.2 – 70.8 months). All patients underwent upfront surgical resection of their primary disease. Two patients presented with metastatic disease at the time of initial diagnosis, while the remaining five patients had a median time to first metastasis of 62.9 months (range 19.3 – 178 months). The median age at the time of SSRS treatment was 58 years (range 46 – 68 years). Most lesions were treated to a dose of 27Gy in 3 fractions (62.5%). Other fractionation schemes included 24Gy in 1 fraction (25%), 16Gy in 1 fraction (6.3%) and 18Gy in 3 fractions (6.3%). Treatment sites included the C-spine (18.8%), T-spine (37.5%), L-spine (31.3%) and sacrum (12.5%). The crude local control rate was 93.7%, with one thoracic spine lesion progressing 20.7 months after treatment with 24Gy in 1 fraction. Kaplan-Meier OS at 1 and 2 years after SSRS were 71.4% and 42.9% respectively. The most common toxicities included acute increase in pain and fatigue. There was one case of vertebral fracture in a C-spine lesion treated to 27Gy in 3 fractions, which was managed non-surgically. After updating our previous series with nearly double the number of patients and treated sites, the data continue to suggest SSRS is a safe and effective local treatment for spinal metastatic pheochromocytoma. The durable local control and short treatment course make this approach an attractive option for metastatic foci, where early treatment may manage local symptoms and potentially limit further disease spread. Future studies comparing SSRS with standard fractionation should be considered.

Apatinib Plus Radiation Therapy or Not in Chemotherapy-Refractory Recurrent or Metastatic Oral Squamous Cell Carcinoma: A Pilot Study

For patients (pts) with recurrent/metastatic oral squamous cell carcinoma (OSCC), treatment options are still unmet medical need. Apatinib, a new tyrosine kinase inhibitor targeting VEGFR-2, shows antitumor activity and manageable toxicities in multiple malignancies. This study aimed to explore apatinib alone or in combination with radiotherapy (RT) as second-line or beyond therapy in OSCC. Chemotherapy-refractory OSCC pts were recruited in this open-label exploratory study. Subjects were initially given 500 mg qd apatinib until disease progression or unacceptable toxicity. Dose reduction to 250 mg was allowed. Palliative local RT (GTV: 50-60 Gy/25-30 f; CTV: 40-50 Gy, 5 f/w) was given to Stage IVB pts who could tolerate concurrent RT. Herein, we reported the preliminary results at the cut-off date of Jan 10, 2018. Ten pts were treated between Jun 2017 and Nov 2017. The median age was 70 yrs; 30.0% were male; ECOG PS 0-1/2 was 70.0/30.0%; 40.0% had ≥ 2 lines of chemotherapy. All pts were evaluated for radiographic response and safety analyses. One (10.0%) pt had complete response (CR), 5 (50.0%) had partial response (PR), 2 (20.0%) had stable disease and 2 (20.0%) had progressive disease. The ORR was 60.0% and DCR was 80.0%. Among the 5 pts who received apatinib combined with RT, 1 CR and 4 PR were achieved. Seven (70%) pts experienced treatment related adverse events (TRAEs). Most TRAEs were in grade 1/2 and could be well-controlled by symptomatic treatments. The grade 3/4 AEs were hypertension (4/10, 40%), fistula (1/10, 10%), hand-foot skin reaction (1/10, 10%) and heart failure (1/10, 10%). The cases experienced fistula and heart failure were combination therapy treated pts. Fortunately, the symptoms were alleviated by administration interruption and symptomatic therapy. No treatment-related death occurred. Apatinib alone or plus RT is efficacious in pretreated OSCC pts, with acceptable toxic effects. Pts might benefit more from the combination therapy, but with high risk of fistula that should be cautiously managed. This study gives rationale clinical evidence to conduct further larger confirmatory clinical trials.

Pembrolizumab for recurrent/metastatic head and neck squamous cell carcinoma in an Asian population.

Head and neck squamous cell carcinoma (HNSCC) has a high prevalence and is a major cause of cancer deaths in Taiwan. However, there is still no effective salvage therapy that prolongs the life expectancy of patients with recurrent/metastatic (R/M) HNSCC. Immune checkpoint therapy that targets the programmed cell death protein 1 (PD-1) may provide clinical benefit for these patients. We analyzed 22 R/M HNSCC patients who received pembrolizumab, a monoclonal antibody against PD-1, as salvage therapy. Intravenous pembrolizumab was given at a fixed dosage of 100 or 200 mg every 3 weeks. Three patients also received local palliative radiotherapy, but no patients received chemotherapy or targeted drugs. Seventeen patients (77.3%) received at least 3 cycles of pembrolizumab. Based on Response Evaluation Criteria in Solid Tumors criteria (ver. 1.1), 2 patients (9.1%) had complete response, 5 (22.7%) had partial response, and 6 (27.3%) had stable disease, corresponding to a disease control rate of 59.1%. Four patients had confirmed disease progression, 2 of whom had continuous progression over the target lesion after shrinkage of other metastases. One patient developed immune-related pneumonitis that resolved quickly after steroid treatment. Another patient developed itchy skin rashes immediately after administration of pembrolizumab, and this was controlled by an antihistamine. There were no other severe adverse effects. Pembrolizumab is beneficial and well-tolerated for some patients with refractory R/M HNSCC. However, it is important to identify biomarkers to identify the most responsive patients when designing future trials.

Validation of a Score Developed to Estimate the 6-month Survival of Patients Treated with Palliative Local Radiotherapy for Advanced Lung Cancer.

To validate a score estimating the 6-month survival of lung cancer patients irradiated for locally advanced disease. The validation cohort of this study included 125 patients. The score for each patient was calculated by adding the points (6-month survival divided by 10) from the factors lymph node stage, distant metastasis and performance score. Patients were divided into three groups, 10-11 (N=36), 12-14 (N=69) and 15-17 points (N=20). Six-month survival of each group from the original study was compared to its corresponding group from this validation study. Six-month survival rates were 19% (10-11 points), 51% (12-14 points) and 75% (16-17 points) in the validation cohort (p<0.001) and 13%, 47% and 82% in the previous study (p<0.001). The group-by-group comparisons between both cohorts did not reveal any significant differences. The score was reproducible and valid for estimating the 6-month survival of lung cancer patients assigned to palliative thoracic radiotherapy.

486P Samarium-153 adjuvant to palliative local radiotherapy for bone metastases: Efficacy and complications

Background This study was undertaken for evaluation of the efficacy and complications of the bone-seeking radiopharmaceutical Samarium-153 (153Sm- EDTMP) added to local external beam radiotherapy (EBRT) for palliation of patients with metastatic bone pain. Methods Patients with multiple bone metastases and an estimated life expectancy of more than 3 months were eligible for this study, provided that they had a dominant localized pain for which palliative EBRT with local fields had been planned. Treatment was intravenous injection of 1.5 mCi (56 MBq)/kg of 153Sm-EDTMP, and local radiotherapy with 30 Gy in 10 fractions. Pain scoring was performed by the Farsi (Persian) version of Brief Pain Inventory (BPI), and response was categorized according to the International Consensus on Bone Metastases guidelines. Results Twenty-six patients (10 male, 16 female,) aged 30-80 years (mean 55 years) were enrolled in the study. Primary cancers were 15 breast, 7 prostate, and 4 others. Of the enrolled patients, 23 received the full treatment and were available for pain response evaluation. In these patients, overall response was 90% and there was 10% no response. 30% of the patients had a significant response with their pain score reducing to more than half. One patient (4.3%) experienced grade 3 leucopenia, and 1 patient grade 3 thrombocytopenia. All other patients experienced grade 0-2 of bone marrow toxicity. Conclusions 153Sm-EDTMP adjuvant to local radiotherapy resulted in higher overall response compared to the results of our studies on EBRT alone and Samarium alone in similar populations of patients, and to the results in literature. Samarium did not significantly add to the complications of radiotherapy alone. Clinical trial indentification 92-03-51-24776 Tehran University of Medical Sciences. Legal entity responsible for the study Radiation Oncology Research Center, Cancer Institute, Tehran University of Medical Sciences Funding Tehran University of Medical Sciences Disclosure All authors have declared no conflicts of interest.

486P Samarium-153 adjuvant to palliative local radiotherapy for bone metastases: Efficacy and complications

486P Samarium-153 adjuvant to palliative local radiotherapy for bone metastases: Efficacy and complications

Low dose palliative radiotherapy for refractory aggressive lymphoma

AimTo determine the efficacy of low-dose palliative radiotherapy in patients with refractory aggressive lymphoma. BackgroundThere are few reports on the administration of palliative radiotherapy to patients with aggressive lymphoma. Materials and methodsThe present study included 11 patients with 30 sites of aggressive lymphoma (diffuse large cell lymphoma, n=7; mantle cell lymphoma, n=2; follicular large cell lymphoma, n=1; and peripheral T cell lymphoma, n=1). The patients received local palliative radiotherapy after receiving a median of 4 chemotherapy regimens. The radiotherapy doses administered to the 30 sites were as follows: 8Gy, single fraction (n=27); 6Gy, single fraction (n=1); 4Gy, single fraction (n=1); and 4Gy, 2 fractions (n=1). ResultsThe complete response rate was 45% (5/11); the partial response rate was 36% (4/11). Toxicity occurred at one irradiated site (the mandibular), which showed temporal acute gingivitis; however, medication was not required. Retreatment was required for 3 sites on the head (parotid, face and mandible) due to persistent discomfort. None of the other sites (27/30) required retreatment. A patient with refractory DLBCL underwent radiotherapy (4Gy, single fraction) for hepatic hilar lymph node involvement but did not recover from jaundice and died of DLBCL. ConclusionsEight Gray single fraction radiotherapy was one of meaningful options for the treatment of refractory aggressive lymphoma in terms of its efficacy and the incidence of adverse events. The use of 8Gy single fraction radiotherapy is therefore recommended for achieving local control in patients with refractory aggressive lymphoma.

Efficacy and Complications of Samarium153-EDTMP Added to Palliative Local Radiotherapy for Bone Metastases

Efficacy and Complications of Samarium153-EDTMP Added to Palliative Local Radiotherapy for Bone Metastases

A rare case of scapular metastasis from bronchogenic carcinoma with ipsilateral malignant pleural effusion.

A rare case of scapular metastasis from bronchogenic carcinoma with ipsilateral malignant pleural effusion.

Neoadjuvant therapy combined with a BMP regimen for treating penile cancer patients with lymph node metastasis: a retrospective study in China.

Combination chemotherapy is emerging in the management of advanced penile cancer. However, evidence-based chemotherapeutic regimens in the current guidelines are lacking. The aim of this study was to evaluate the efficacy of preoperative neoadjuvant chemotherapy combined with a BMP regimen including bleomycin (BLM), methopterin (MTX) and cisplatin (DDP) for treating advanced penile cancer patients. We retrospectively audited the clinical and follow-up data of 24 penile cancer patients with fixed inguinal lymph node metastasis that were admitted in our hospital from 2001 to 2010 and received preoperative neoadjuvant chemotherapy. A total of 24 patients with advanced penile cancer (pN3) were recruited in this study. All patients received preoperative neoadjuvant chemotherapy combined with a BMP regimen. The average cycle of chemotherapy was two cycles (range 1-4 cycles). Among 24 adjuvant cases, 15 patients that responded to neoadjuvant chemotherapy underwent penectomy and inguinal lymphadenectomy. In contrast, nine cases did not respond to chemotherapy and received palliative local radiotherapy. Overall, the 1-, 2- and 5-year survival rates were 70.8, 50.0 and 45.8 %, respectively. The 5-year survival rate between the responder and non-responder groups was statistically significant (73.3 vs. 0 %, P < 0.001). Neoadjuvant chemotherapy combined with a BMP regimen followed by surgery is beneficial to patients with advanced penile cancer.

Palliative Local Radiotherapy in the Treatment of Tumor-stage Cutaneous T-cell Lymphoma/Mycosis Fungoides

To determine the efficacy of palliative radiotherapy in treating tumor-stage cutaneous T-cell lymphoma/mycosis fungoides (MF). From January 2008 to January 2013, a total of 11 patients with tumor-stage MF were treated with local radiation therapy in Peking Union Medical College Hospital. The median age of these patients was 53.36 ± 14.45 years. Female-male ratio was 1:1.2. The average course of disease was 10.82 ± 3.37 years. All the patients were treated with local electronic beam irradiation with a total median dosage of 48.55 ± 9.51 (40-74) Gy in an average of 24.55 ± 5.57 (20-40) fractions, 5 fractions per week. The median follow-up time was 55.27 ± 29.3 (13-103) months. No severe acute or chronic side effects of irradiation were observed. Complete clinical response (CR) rate of the radiated sites was 54.5% (6/11), partial response (PR) rate was 36.4% (4/11), and the overall response rate (CR+PR) was 90.9%. One patient showed no response. Local radiotherapy with psolaren plus ultraviolet A and/or interferon maintaining treatment is an effective palliative therapy in the treatment of tumor-stage MF patients.

An osteolytic metastasis of humerus from an asymptomatic squamous cell carcinoma of lung: a rare clinical entity.

Advanced lung cancer is complicated by skeletal metastases either due to direct extension from adjacent primaries or, more commonly, due to haematogenous dissemination of neoplastic cells. Lumber spine is the most common site for bony metastases in bronchogenic carcinoma. Proximal lone bones, especially humerus, are unusual sites for metastases from lung primaries. Small cell and large cell varieties of lung cancer are most commonly associated with skeletal dissemination. It is also unusual that an asymptomatic squamous cell carcinoma of lung presents with painful, soft tissue swelling with osteolytic metastasis of humerus which is reported in our case. Systemic cytotoxic chemotherapy, local palliative radiotherapy, adequate analgesia, and internal fixation of the affected long bone are different modalities of treatment in this advanced stage of disease. But the prognosis is definitely poor in this stage IV disease.

Outcome of a multimodal therapy of a recurrent adenocarcinoma arising from Caesarean section scar endometriosis—A case report

Background Endometriosis occurring in surgical scars is a well-described entity. Malignant transformation of endometriosis is a rare event, with most cases belonging to adenocarcinoma. The initial surgical treatment is a method of choice. Due to lack of therapeutic recommendations, adjuvant therapy and recurrence management are a great challenge for oncologists. Aim The aim of this paper was to present a long-term survival as the outcome of multimodal therapy in the patient with recurrent adenocarcinoma arising from Caesarean section scar endometriosis. Case We present the case of a woman with recurrent adenocarcinoma arising from Caesarean section scar endometriosis. The disease was first diagnosed in September 1997 at age 43. The patient underwent abdominal hysterectomy with tumour excision. Due to a local recurrence after 4 years, tumour excision with abdominal wall repair using a plastic mesh, regional lymphadenectomy, bilateral salpingo-ovariectomy and adjuvant radiotherapy for the pelvic region with local boost were performed; in addition hormontherapy with medroxyprogesterone was started. Because of a recurrent pelvic tumour, chemotherapy, further local palliative radiotherapy and brachytherapy were administered. Subsequently distant metastases in bilateral axillary lymph nodes were diagnosed and palliative radiotherapy was performed. The patient died of morbus neoplasmaticus generalisatus in September 2008. The follow-up period had been 132 months. Conclusion This paper is, to our knowledge, the only report in literature that presents a long-term survival as the outcome of multimodal therapy in the patient with this rare diagnosis. Further reports of new cases can help establish optimal treatment guidelines.

Primary Sinonasal Malignant Melanoma: A Clinicopathologic and Prognostic Study

We conducted a retrospective study to evaluate the clinicopathologic features and prognostic factors associated with primary sinonasal malignant melanoma. We reviewed the records of 10 patients-7 men and 3 women, aged 35 to 70 years (mean: 51.4)-who had been treated at our referral center over a 9-year period. The tumors were located in the nasal cavity in 7 patients and in a paranasal sinus in the other 3. Medial maxillectomy was performed in 4 patients, wide local excision in 3, and endoscopic excision in 2; the remaining patient, who had presented with a liver metastasis, received chemotherapy and palliative local radiotherapy. Two patients who presented with a neck node metastasis also underwent concurrent radical neck dissection. Follow-up ranged from 8 to 70 months (median: 25). Only 4 patients remained alive through the duration of follow-up. The 2- and 5-year survival rates were 60 and 40%, respectively. Based on the findings of our small study, we conclude that primary sinonasal malignant melanoma carries a generally poor prognosis despite aggressive treatment. The primary cause of death in our series was a distant metastasis (n = 5) despite adequate locoregional control in most cases. This finding confirms the aggressive nature of this disease. Other factors that appeared to be associated with a poor prognosis were (1) older age, (2) a primary tumor location in a paranasal sinus, (3) an advanced tumor stage, (4) an external approach to surgery, and (5) the absence of adjuvant radiotherapy.

Palliation by Low Dose Local Radiotherapy for Indolent Non-Hodgkin's Lymphoma

The efficacy of local palliative radiotherapy with a 2 x 2 Gy regimen (total dose: 4 Gy) in Non-Hodgkin's Lymphoma of indolent histology is assessed in a retrospective chart review. Between 2003 and 2005, 20 patients (10 men, 10 women, median age 71.5 years at treatment date, range, 33-81) were treated with 2 x 2 Gy over two days with palliative intent. Histologies were FL in 9 patients, CLL in 9 patients, MCL in 1 patient and MALT in 1 patient. Nine patients initially presented with stage 0-2 disease, ten patients with stage 3-4 disease and one unknown. ECOG status was 0-2 in 19 patients and ECOG 3 in one patient. 17 patients had received prior chemotherapy. The patients were treated to a total of 37 different sites, 5 of which were extranodal. 15 disease sites were less than 5 cm in maximum diameter, 15 sites were 5-10 cm, and 7 sites were larger than 10 cm. Clinical and radiographic data were used to assess local response. Response of less than 50% in largest tumor diameter was defined as stable disease. A response to the 2 x 2 Gy regimen was achieved in 15 patients (CR 10, PR 5, ORR 75%), 4 patients (stable 2, progression 2) had stable disease or progression and one patient had a mixed response (1 site CR and a later site stable disease). Among the 37 disease sites, ORR was 81% (CR 17, PR 13). Disease sites less than 5cm had an ORR of 80% (CR 9, PR 3, stable disease 3). Sites that were 5-10cm had an ORR of 80% (CR 5, PR 7, stable 2, progression 1). Sites larger than 10 cm had an ORR of 86% (CR 3, PR 3, progression 1). Of the 11 patients who presented with symptoms (pain/discomfort, leg edema, bleeding), 9 showed improvement in their symptoms after treatment. Among responding patients, the overall median follow-up time was 4.1 months. There was a median time between treatment and documented relapse of 6.1 months in patients with at least 1 site of relapse. A low dose regimen of 2 x 2 Gy is an effective palliative treatment for indolent lymphomas. Patients with smaller tumor bulk (>5 cm) appear more likely to respond with CR.