Radical Course Research Articles

Failure pattern following complete resection plus radiotherapy and temozolomide is at the resection margin in patients with glioblastoma

Glioblastomas (GBM) are highly motile cancers that invade through normal brain. In the absence of curative chemotherapy this invasion, beyond surgical and radiotherapy margins, to distant brain sites is thought to be an important cause of treatment failure. Paradoxically, studies analyzing failure patterns have consistently shown that the large majority of failures occur at the original tumor site. This conflict may be explained by the fact these cancers are often only sub-totally resected and radiotherapy and chemotherapies fail to control this significant local cancer burden. We analyzed the failure pattern in 20 consecutive patients with complete resection of the gadolinium-enhancing portion of GBM demonstrated on the immediate post-operative magnetic resonance study, and who underwent a radical course of radiotherapy and chemotherapy. We found that recurrences occurred only at the resection margin in 17 of 20 patients. Recurrences were exclusively distant in 2 of 20 patients and occurred at both the resection margin and a distant site in 1 of 20 cases. We found that even in cases of complete resection of the gadolinium-enhancing portion of GBM 85% of recurrences are localized to the resection margin.

Survival after chemotherapy and/or radiotherapy versus self-expanding metal stent insertion in the setting of inoperable esophageal cancer: a case-control study

BackgroundOur aim was to compare survival of the various treatment modality groups of chemotherapy and/or radiotherapy in relation to SEMS (self-expanding metal stents) in a retrospective case-control study. We have made the hypothesis that the administration of combined chemoradiotherapy improves survival in inoperable esophageal cancer patients.MethodsAll patients were confirmed histologically as having surgically non- resectable esophageal carcinoma. Included were patients with squamous cell carcinoma, undifferentiated carcinoma as well as Siewert type I--but not type II - esophagogastric junctional adenocarcinoma. The decision to proceed with palliative treatments was taken within the context of a multidisciplinary team meeting and full expert review based on patient's wish, co-morbid disease, clinical metastases, distant metastases, M1 nodal metastases, T4-tumor airway, aorta, main stem bronchi, cardiac invasion, and peritoneal disease. Patients not fit enough to tolerate a radical course of definitive chemo- and/or radiation therapy were referred for self-expanding metal stent insertion. Our approach to deal with potential confounders was to match subjects according to their clinical characteristics (contraindications for surgery) and tumor stage according to diagnostic work-up in four groups: SEMS group (A), Chemotherapy group (B), Radiotherapy group (C), and Chemoradiotherapy group (D).ResultsEsophagectomy was contraindicated in 155 (35.5%) out of 437 patients presenting with esophageal cancer to the Department of General and Abdominal Surgery of the University Hospital of Mainz, Germany, between November 1997 and November 2007. There were 133 males and 22 females with a median age of 64.3 (43-88) years. Out of 155 patients, 123 were assigned to four groups: SEMS group (A) n = 26, Chemotherapy group (B) n = 12, Radiotherapy group (C) n = 23 and Chemoradiotherapy group (D) n = 62. Mean patient survival for the 4 groups was as follows: Group A: 6.92 ± 8.4 months; Group B: 7.75 ± 6.6 months; Group C: 8.56 ± 9.5 months, and Group D: 13.53 ± 14.7 months. Significant differences in overall survival were associated with tumor histology (P = 0.027), tumor localization (P = 0.019), and type of therapy (P = 0.005), respectively, in univariate analysis. Treatment modality (P = 0.043) was the only independent predictor of survival in multivariate analysis. The difference in overall survival between Group A and Group D was highly significant (P < 0.01) and in favor of Group D. As concerns Group D versus Group B and Group D versus Group C there was a trend towards a difference in overall survival in favor of Group D (P = 0.069 and P = 0.059, respectively).ConclusionsThe prognosis of inoperable esophageal cancer seems to be highly dependent on the suitability of the induction of patient-specific therapeutic measures and is significantly better, when chemoradiotherapy is applied.

A pilot study of two radiation fractionation regimens in patients with cancer of the cervix, who were HIV positive and not on antiretroviral therapy

The Department of Radiation Oncology at the previously named Pretoria Academic Hospital (now the Steve Biko Hospital) undertook a pilot study between 2000 and 2001 of 20 patients who were human immunodeficiency virus-positive with locally advanced cancer of the cervix. At the time of the study, these patients were not on antiretroviral therapy, as per government policy. The patients were randomised into two arms. Six patients underwent a short palliative course of radiotherapy and 13 received a protracted and radical course of radiotherapy. One patient was lost to follow-up. Although the results were not statistically significant, the short course of palliative radiotherapy was adequate in terms of toxicity. As expected, the radical course was associated with a greater and more significant toxicity, because of the suppressed immune status of the participants.

Rectal Planning Risk Volume Correlation with Acute and Late Toxicity in 3-Dimensional Conformal Radiation Therapy for Prostate Cancer

The purpose of this study was to evaluate rectum motion during 3-Dimensional conformal radiation therapy (3D-CRT) in prostate cancer patients, to derive a planning volume at risk (PRV) and to correlate the PRV dose-volume histograms (DVH) with treatment complications.This study was conducted in two phases. Initially, the PRV was defined prospectively in 50 consecutive prostate cancer patients (Group 1) who received a radical course of 3-D CRT. Then, the obtained PRV was used in the radiotherapy planning of these same 50 patients plus another 59 prostate cancer patients (Group 2) previously treated between 2004 and 2008. All these patients' data, including the rectum and PRV DVHs, were correlated to acute and late complications, according to the Common Toxicity Criteria (CTC) v4.0.The largest displacement occurred in the anterior axis. Long-term gastrointestinal (GI) complications grade ≥ 2 were seen in 9.2% of the cases. Factors that influenced acute GI reactions were: doses at 25% (p 5 0.011) and 40% (p 5 0.005) of the rectum volume and at 40% of the PRV (p 5 0.012). The dose at 25% of the rectum volume (p 5 0.033) and acute complications ≥ grade 2 (p 5 0.018) were prognostic factors for long-term complications. The PRV DVH did not correlate with late toxicity. The rectum showed a significant inter-fraction motion during 3D-CRT for prostate cancer. PRV dose correlated with acute gastrointestinal complications and may be a useful tool to predict and reduce their occurrence.

Recording a patient diet over the radical course of radiotherapy for prostate cancer using a diet diary: a feasibility study

AbstractAims: To obtain an estimate of dietary fibre and fluid intake in Australian men undergoing prostate radiotherapy and to establish feasibility and patient compliance with recording normal diet without intervention during the radical course of radiotherapy.Methods: Eleven participants were enrolled and treated with 74–78 Gray (Gy) to the prostate over 8 weeks. Participants were instructed to record a diary of their food and fluid intake and bowel motions for the duration of treatment. Treating radiation therapists were instructed to initial the diet diary daily. Diet diaries were assessed for compliance by analysing the number of days over the treatment period and the number of diary pages submitted. The diet diaries were analysed for nutrient intake of fibre and fluids.Results: A total of 10 of 11 participants submitted a diet record for the full duration of treatment with a median compliance of 100% (range 90.4–100%) of days recorded. The mean (standard deviation) of fibre and fluids recorded in the diets were 21.5 g (5.5) and 2227.1 g (733.1), respectively.Conclusions: It is feasible for patients to record a diet diary over a radical course of prostate radiotherapy. In this study, most patients were highly compliant with submitting a diet record for each day during treatment.

SU‐GG‐J‐63: Evaluation of Treatment Shifts for Prostate and Rectum Patients Undergoing CBCT Guided IGRT Using KV CBCT

Purpose: We present results of a pilot study established to investigate protocol to access inter‐fraction setup errors for patients with rectal and prostate cancer receiving CBCT based IGRT. We also report on radiation skin doses to patients from a typical CBCT acquisition for daily patient positioning using previously established 2D reference radiochromic film dosimetry protocol. Method and Materials: Patients receiving radical course of IGRT based treatment using CBCT were eligible. Pre‐treatment 3D imaging of 20 patients in treatment position was acquired using kV CBCT on‐board imaging (OBI) system (v. 1.4, Varian Medical Systems, Palo Alto). Scans were preformed using Pelvis CBCT protocol. Reconstructed CBCT images obtained prior to treatment were co‐registered with planning CT data set using bony landmarks for rectal cancer patients and prostate soft tissue visibility and prostate contours for prostate cancer patients. For dose measurements we used 2D dosimetry protocol that employs XR‐QA radiochromic film. Results: Our measurements show that average displacements over investigated rectal cancer patient population was 3.68±1.51 mm in vertical, 3.18±2.0 mm in lateral and 1.59±1.34 mm in longitudinal direction with the maximum observed shift in lateral direction of 11 mm. Average displacements over prostate cancer population showed 2.29±1.69 mm in lateral, 3.36±2.06 mm in vertical, and 3.36±2.06 mm in longitudinal direction with the maximum shift observed in vertical direction of 18 mm. Measured anterior dose during CBCT amounts to 1.60 cGy in larger and up to 3.17 cGy in smaller patients, while the lateral dose was ranging from 1.63 cGy in larger and up to 2.68 cGy in smaller patients. Conclusion: Our investigation showed that 3D conformai therapy with reduced margin in all 3 directions can be used for prostate and rectal cancer patients undergoing daily CBCT based IGRT. However, this benefit must be weighted against dose delivered to patients during CBCT.

Between Reformstau and Länder Strangulation? German Co-operative Federalism Re-considered

Two features of German federalism have been the subject of much criticism in recent years, the veto power of the Bundesrat and the centralization of legislative competences. The former is made responsible for the (in)famous German ‘Reformstau’, the latter for severely limiting autonomous policy making at the Länder level. The paper argues that both complaints about the federal system are exaggerated. Neither does the bicameral structure completely block reforms, nor are the Länder immobilized by the corset of centralized legislation. Instead it will be argued that public opinion and electoral dynamics constrain political actors and provide them with few incentives to pursue a radical reform course or to embrace policy competition at the Länder level.

Geographical Variation in Radiotherapy Services Across the UK in 2007 and the Effect of Deprivation

Aims Modelling of demand has shown substantial underprovision of radiotherapy in the UK. We used national audit data to study geographical differences in radiotherapy waiting times, access and dose fractionation across the four countries of the UK and between English strategic health authorities. Materials and methods We used a web-based tool to collect data on diagnosis, dose fractionation and waiting times on all National Health Service patients in the UK starting a course of radiotherapy in the week commencing 24 September 2007. Cancer incidence for the four countries of the UK and for England by primary care trust was used to model demand for radiotherapy aggregated by country and by strategic health authority. Results Across the UK, excluding skin cancer, 2504 patients were prescribed 33 454 fractions in the audit week. Waits for radical radiotherapy exceeded the recommended 4 week maximum for 31% of patients (range 0–62%). Fractions per million per year ranged from 17 678 to 36 426 and radical fractions per incident cancer ranged from 3.0 to 6.7. Patients who were treated received similar treatment in terms of fractions per radical course of radiotherapy (18.2–23.0). Access rates ranged from 25.2 to 48.8%, nearing the modelled optimum of 50.7% in three regions. Fractions per million prescribed as a first course of treatment varied from 43.9 to 90.3% of modelled demand. The percentage of patients failing to meet the 4 week Joint Council for Clinical Oncology target for radical radiotherapy rose as activity rates increased ( r = 0.834), indicating a mismatch of demand and capacity. In England, a comparison between strategic health authorities showed that increasing deprivation was correlated with lower rates of access to radiotherapy ( r = −0.820). Conclusions There are substantial differences across the UK in the radiotherapy provided to patients and its timeliness. Radiotherapy capacity does not reflect regional variations in cancer incidence across the UK (3618–5800 cases per million per year). In addition, deprivation is a major unrecognised influence on radiotherapy access rates. In regions with higher levels of deprivation, fewer patients with cancer receive radiotherapy and the proportion treated radically is lower. This probably reflects late presentation with advanced disease, poor performance status and co-morbid illness. To provide an equitable, evidence-based service, the needs of the local population should be assessed using demand modelling based on local cancer incidence. Ideally this should include data on deprivation, performance status and stage at presentation. The results should be compared with local radiotherapy activity data to understand waits, access and dose fractionation in order to plan adequate provision for the future. The development of a mandatory radiotherapy data set in England will facilitate this, but to assist change it is essential that the results are analysed and fed back to clinicians and commissioners.

How Generic is I(nformation) T(echnology)?

Introduction A curriculum revolution has started to transform the Australian higher education sector, as several leading universities embarked on radical course reforms involving a reduction of discipline-based undergraduate course offerings in favour of a much smaller number of broad undergraduate courses integrating the humanities and science; for instance, the University of Western Australia plans to cut its undergraduate courses from seventy to six by the beginning of the 2009 academic year. Upon completion of a broad undergraduate degree, students can pursue specialised graduate courses (Slattery, 2008). The reform process has strong international parallels, as individual universities such as Harvard, and entire systems such as the European universities covered by the Bologna Accord, have embraced the cause of curriculum renewal; this renewal goes to the heart of teaching, learning and graduate competencies Victoria University has introduced a similar curriculum reform, albeit on a smaller scale. Beginning in semester 1/2009, it will offer a Degree, replacing a number of current specialist degrees. However, the Degree will be generic only up to a point that is, it will include a common first year and branch out into Degree specialisations in the second and third year; the specialisations will include Biotechnology, Chemistry, Food Science, Computing, Ecology, Community and others. The first year of the Degree will be rich in disciplinary breadth across the broad areas of the sciences, and in the second and third year intense disciplinary depth and/or professional expertise will be gained. The composition of the first year was subject to much debate, as representatives of the various specialisations fought to convince the program committee that theirs was an area of general interest and importance and therefore should be studied by all students. The arguments put forward by the computing experts were particularly compelling. Given that IT, or indeed computer science, underpins many of the scientific disciplines, it was only fitting that the development of computing skills should apply to all science students and that it should start in the first year of the Degree. This decision was supported by Microsoft Research Cambridge's report Towards 2020 Science (Microsoft Research, 2005). This report was the result of a workshop that invited an international group of natural and computer scientists to put together a roadmap for science, and particularly computing, over the next sixteen years before 2020. The central tenet was that computer science would transform science in two ways: as a tool for doing traditional science, and as a technique for performing experiments and creating models. Thus, the study has strongly identified the importance of mathematical, quantitative and computational and indeed IT skills to all students in science. It concluded that 'Scientists will need to be completely computationally and mathematically literate, and by 2020, it will simply not be possible to do science without such literacy' (Microsoft Research, 2005, p. 8). While information literacy skills have been recognised in most science course curricula, more advanced IT skills and digital literacy have been largely overlooked; yet, they are all-encompassing with applications that permeate various disciplines of science (Miliszewska, 2008). Thus IT should be regarded as a powerful facilitator to higher-level learning. How should this advanced IT literacy be developed? How can its relevance be maintained in a Degree? Is such literacy generic? The following sections discuss these issues and propose suggestions for introducing essential tools and technologies for tomorrow's scientists. The Need for IT Skills in Students Today's members of the skilled workforce are expected to display a broad range of skills including good communication and team working abilities, strong problem-solving and numeric proficiency and, most particularly, expertise in information technology. …

A survey of cancer patients undergoing a radical course of radiotherapy, to establish levels of anxiety and depression

AbstractThis research aims to establish the prevalence and aetiology of anxiety and depression in cancer patients within their first 2 weeks of a radical course of radiotherapy. Depression followed by anxiety is the two most frequent psychological disorders experienced by cancer patients. However, these two disorders are frequently undiagnosed and untreated in patients undergoing a course of radiotherapy possibly because the treatment side effects often simulate those of anxiety and depression; the consequences of this can be reduced patient prognosis and increased health care costs. A questionnaire was administered to a sample of 100 eligible cancer patients and this yielded a 68% response rate. The Hospital Anxiety and Depression (HAD) scale was integrated into the questionnaire to accurately establish levels of anxiety and depression in the respondents of the study. The study identified six respondents with clinically significant levels of anxiety (9%) and six with depression (9%); 21% (n = 14) of participants had higher than normal levels of anxiety and 21% for depression (n = 14). Correlations were then identified between levels of psychological distress and the four independent variables; age, diagnosis, adjuvant medication and pain. Four predisposing factors were established—breast cancer diagnosis, age range 40–50 years, the presence of pain and adjuvant chemotherapy regimes.

Radiotherapy in non-Hodgkin lymphomas

Most patients with localized non-Hodgkin lymphoma (NHL) who receive radiotherapy (RT) are treated with the intent of achieving local control of disease [1]. A palliative approach is used only when, due to the condition of the patient and/or the extent or location of the disease, a radical course of treatment carries no chance of local control. Knowledge of histology, extent and pattern of disease is essential to select the appropriate therapeutic strategy. Involved field RT is routinely used, whether for cure or local control. The recognition of the high risk for occult distant disease mandates the use of chemotherapy in all cases of diffuse large cell lymphoma or similar histologies. For localized disease, the initial decision for patients treated with curative intent is the use of a combined modality approach—chemotherapy and RT, or a local treatment alone with RT. The choice is predicated upon the inherent risk of occult distant disease, availability of curative chemotherapy and the potential need for local control. Patients with stage III and IV are routinely treated with chemotherapy alone. The aim of RT is to deliver an adequate dose of radiation to the target volume to ensure local control. The design for a proper course of RT must take into account the extent of disease, the appropriate margins, routes of lymphatic and possible extranodal spread, and the radiation tolerance of normal tissues and organs. Dose fractionation parameters must assure local control with acceptable acute and late toxicity. The technique should guarantee reproducibility of treatment on a daily basis. Custom-designed fields should be used to conform to the target volume while keeping the volume of irradiated normal tissues to a minimum. The use of CT simulation with delineation of target volumes including the gross tumour volume (GTV), the clinical target volume (CTV),which includes themicroscopic disease extent, and planning target volume (PTV), which takes into account variation in the locationof theGTVandCTV.Three dimensional conformal RT (3D CRT) or intensity modulated RT (IMRT) may be used to shape the dose distribution. It is important to note that when RT follows chemotherapy in CMTprotocols, RT is usually started 4–6 weeks following the last course of chemotherapy to minimize the drug–radiation sensitization effect.

Student resistance and teacher authority: the demands and dynamics of collaborative learning

The intersection among discourses of curriculum, pedagogy, and power are increasingly becoming the focus of research and analysis in southern African classrooms as the effects of apartheid, colonialism, and patriarchalism are critiqued for their influences on epistemic and pedagogic policies and practices. This article draws on feminist research on pedagogy to examine the dynamics of teacher and student relations in southern African university classrooms. In particular, it focuses on student resistance to engaging in collaborative work and with radical ideologies in course content. Drawing on case studies it shows that, despite feminist teachers subscribing to egalitarian ideals, when they encounter student resistance to democratic pedagogic strategies and radical course content they resort to normalizing and regulatory postures that reinstate teacher authority in the classroom.

Tolerability of Accelerated Chest Irradiation and Impact on Survival of Prophylactic Cranial Irradiation in Patients with Limited-stage Small Cell Lung Cancer: Review of a Single Institution's Experience

Evidence that has been published in the last decade indicates that in patients with limited-stage small-cell lung cancer (SCLC), hyperfractionated accelerated thoracic radiotherapy (RT) given twice daily and prophylactic cranial irradiation (PCI) have each separately improved survival. Concerns about the toxicities associated with these treatments and uncertainty about their impact on survival outside the trial setting may have restricted the extent to which they have been incorporated into standard treatment protocols. We have reviewed the experience at Peter MacCallum Cancer Centre to determine the tolerability of these treatments in routine practice and to determine their effects on survival. A retrospective review of patients with limited-stage SCLC receiving a radical course of thoracic RT between June 1998 and May 2002, including either conventional fractionation at 50 Gy for 5 weeks, or hyperfractionated accelerated RT at 45 Gy for 3 weeks. Patients achieving a complete response were offered PCI at 36 Gy in 18 fractions. The main outcomes recorded were RT toxicity (graded using CTCAE v. 3.0 and RTOG/EORTC late scoring criteria), response, relapse-free survival, and overall survival. Ninety patients were identified as having undergone radical-intent thoracic RT, with a median potential follow-up of 4.2 years. Fifty-seven patients (63%) were treated with hyperfractionated accelerated RT, and 33 (37%) were treated with conventional fractionation. Forty-six patients (51%) received PCI. Patients receiving hyperfractionated accelerated RT compared with conventional fractionation had higher rates of grade 3 and 4 esophagitis (14% versus 6%; p = 0.312), a higher rate of treatment interruptions (12% versus 3%; p = 0.250), and a higher hospital admission rate (39% versus 15%; p = 0.031). The majority of patients were able to complete the planned treatment, and there were no treatment-related deaths. Median survival for all patients from commencement of RT was 14.2 months (95% confidence interval [CI]: 11.9-18.1 months), and survival at 2 years was 24.8% (95% CI: 16.9-35.0%). On multifactor analysis, the only factor associated with longer survival was PCI (hazard ratio = 0.40; p < 0.001). Hyperfractionated accelerated RT was more toxic than conventional fractionation, but it was possible to deliver treatment as planned in the majority of patients. PCI was associated with improved survival. Both treatments can be incorporated into routine practice.

Multicentric epithelioid angiosarcoma of the spine: a case report of a rare bone tumor

Background context Epithelioid angiosarcoma (EA) is a high-grade sarcoma of vascular origin. EA is a rare variant of angiosarcoma. It is characterized by large cells with an epethelioid morphology. EA has been reported in sites like skin thyroid, adrenal gland, soft tissue, and rarely in bone. Purpose The current article describes a case of multicentric EA of the spine that presented simultaneously at T4 spine and the posterior one third of the left fourth rib. Study design/settings This study included a patient with a rare spinal tumor, which presented insidiously. Radiologically, the lesions were osteolytic with erosion of cortices. The tumor was composed of nests and cords of malignant cells with epithelioid morphology with areas of vascular differentiation, necrosis, and hemorrhage. Anastomosing vascular spaces lined by epithelioid endothelial cells suggested focal endotheliod differentiation. Methods Histopathological evaluation of the tumor obtained from en bloc resection of the fourth rib and specimen from decompression of the fourth thoracic vertebra was done. Immunohistochemistry showed positivity for endothelioid cell markers like CD31 and factor VIII related antigen. The authors point out the need for immunohistochemical evaluation after careful histological analysis for vascular differentiation for an accurate diagnosis of vascular bone tumors with epithelioid features so that an erroneous diagnosis of metastatic carcinoma can be avoided. EA occurs rarely in bone. EA is marked by the presence of large polygonal epithelioid malignant cells with marked cellular atypia and pleomorphism. The arrangement of the cells may mimic epithelial neoplasm. These types of lesions are a definite diagnostic challenge in bone biopsy. The tumor was treated with en bloc resection of the rib and decompression of the body of T4 spine, followed by megavoltage radiotherapy. Follow-up X-rays showed regression of the tumor at 2 years. CD31 is the most sensitive marker for EA. Even in the absence of obvious vascular differentiation, abundant intratumoral hemorrhage and intratumoral neutrophils are definite morphologic changes that should suggest a vascular origin. Results The patient was followed up for 2 years. A conservative surgical approach with a radical course of megavoltage radiotherapy could yield a good result in EA of bone. At the time of writing this report, there is no evidence of tumor recurrence. Conclusion It is important to differentiate EA from other tumors because the clinical course and treatment are specific for these conditions. Careful histologic and immunohistochemical analysis will clinch the diagnosis. Even though rare, we stress the importance to be aware of the existence of this tumor, which is essential for correct diagnosis.

Germinoma with synchronous lesions in the pineal and suprasellar regions

Germinomas represent the most frequent tumour type in the pineal region and the synchronous involvement of the suprasellar region, frequently termed bifocal disease, is increasingly recognised. The incidence, pathogenesis, histomorphological, radiological, clinical features, and management strategies are discussed. A 6-year-old girl presented with clinical features of hypothalamic-pituitary axis dysfunction. MRI showed two distinct lesions in the pineal and suprasellar regions. Tumour markers for germ cell tumours from blood and cerebrospinal fluid were within the normal range. The suprasellar lesion was biopsied and the histology revealed a germinoma. She received a radical course of radiotherapy covering the entire craniospinal axis (24 Gy/15#) followed by focal boost to the sites of primary disease (16 Gy/10#). Three months after the completion of treatment, the patient achieved a complete clinical and radiological response, which was maintained during the 13-month follow-up period. The optimum management of primary intracranial pineal and suprasellar (bifocal) germinomas still remains controversial. The definition as either localised or disseminated disease has major implications on required treatment and its associated late morbidity. Prospective studies with large cooperative groups worldwide and consensus meetings may reduce uncertainties regarding available management options.

Childhood glioblastoma multiforme of the spinal cord

Astrocytoma accounts for more than 50% of all central nervous system tumours diagnosed, with particular prevalence in the 15- to 34-year-old age bracket, rarely arising in younger children. In 1995, a 7-year-old boy presented in Emergency with a 3-day history of severe radicular back pain and associated muscle spasms, exacerbated by lying on his back. Both bone scan and plain X-rays were unremarkable; however, MRI showed a 3-cm space-occupying lesion at the level of T5-T6. The patient proceeded to biopsy and partial excision of the tumour through laminectomy, histology confirming an anaplastic astrocytoma (glioblastoma multiforme), St Anne Mayo grade 4. Treatment consisted of a radical course of radiotherapy alone, delivering a total dose of 44.8 Gy at 1.6 Gy per fraction. The treatment comprised of three phases using two oblique wedged fields on a 6 MV linear accelerator. The patient remains disease free 7 years post treatment, with the only effect noted being a slight kyphoscoliosis at the site of the laminectomy and radiation. This report highlights the efficacy of combined surgery and radiation therapy in the management of spinal cord glioblastoma multiforme in preventing tumour recurrence, with acceptable morbidity. Further evaluation of the treatment efficacy would be difficult because of the scarcity of such cases.

Intranasal Extrusion of the Endovascular Coil After Occluding Internal Carotid Artery for Massive Nasopharyngeal Bleeding

Serious sequelae can occur after radiation therapy for nasopharyngeal carcinoma, including paralysis of the cranial nerves, stricture of the pharynx, radiation myelitis, and necrosis with fatal hemorrhage. We report a case of spontaneous extrusion of the coils into the nasal cavity after endovascular internal carotid artery (ICA) occlusion for massive epistaxis related to cavernous carotid artery pseudoaneurysm, which developed after radiation therapy for nasopharyngeal carcinoma. A 32-year-old woman had nonkeratinizing differentiated nasopharyngeal carcinoma (T3 N0 M0, UICC staging) diagnosed in September 2001. She received 2 courses of chemotherapy consisting of 5-FU and cisplatin, followed by a radical course of radiotherapy, 4500 Gy for the nasopharynx and 7000 Gy for the neck in 35 fractions. Because a positron emission tomography scan taken 1 year after completion of treatment showed tumor recurrence, 4800 Gy in 40 fractions was additionally administered to the nasopharynx. http://www.entnet.org/journal/casereports/OTO-17.pdf/

Correction of systematic setup errors in prostate radiation therapy: How many images to perform?

The purpose of this study was to develop an evidence-based off-line setup correction protocol for systematic errors in prostate radiation therapy. Daily orthogonal electronic portal images were acquired from 30 patients. Field displacements were measured in the medial-lateral (ML), superior-inferior (SI), and anterior-posterior (AP) directions for each treatment fraction. The off-line protocol corrects the mean field displacement found from n consecutive images, starting at a particular fraction of treatment, with a fixed tolerance level. Simulations were performed with the measured data to determine (1) how many images ( n) should be averaged to determine the systematic error; (2) on which treatment fraction should the protocol be initiated; and (3) what tolerance level should be applied to determine whether the patient position should be corrected. Uncorrected systematic errors in the ML, SI, and AP directions were (mean position ± 1 standard deviation [SD]): −0.7 ± 2.2 mm, −1.5 ± 1.3 mm, and 1.4 ± 2.6 mm, respectively. Random errors (1 SD and range) were 1.9 mm (1.3–3.3), 1.5 mm (0.–4.1), and 1.8 mm (1.0–2.6), respectively. A correction based on a single image taken on the first fraction actually increased the systematic errors in the ML and SI directions compared with no correction. More accurate correction of systematic errors was achieved with increasing number of images averaged, with only small benefit after 5 images. With fewer images averaged, delaying the start of the protocol resulted in more accurate correction because of the influence of unrepresentative positions at early fractions. The number of corrections made on patients with small (<2 mm) systematic errors was minimized for tolerance values of 2 mm and n ≥ 5 images averaged. The optimal off-line setup correction protocol would be to shift the patient by the mean displacement of the first 5 portal images of a radical course of radiation therapy. A small tolerance level should be utilized with 2 mm giving good accuracy with minimal unnecessary shifts.

Victims' Rights in Criminal Trials: Prospects for Participation

Victims in common law jurisdictions have traditionally been unable to participate in criminal trials for a number of structural and normative reasons. They are widely perceived as ‘private parties’ whose role should be confined to that of witnesses, and participatory rights for such third parties are rejected as a threat to the objective and public nature of the criminal justice system. However, recent years have witnessed both a major shift in attitude in relation to the role of victims within the criminal justice system and a breakdown in the public/ private divide in criminal justice discourse. This article considers the standing of the victim within the criminal trial against the backdrop of such changes, and examines the arguments for a more radical course of reform that would allow victims to participate actively in criminal hearings as they are able to do in many European jurisdictions.

Neoadjuvant chemotherapy followed by concurrent chemo-radiation therapy in locally advanced nasopharyngeal carcinoma

To evaluate the efficacy and outcomes of neoadjuvant cisplatinum and epirubicin chemotherapy followed by concurrent cisplatinum chemotherapy with radiotherapy in patients with locally advanced nasopharyngeal carcinoma. One hundred ten patients (80 male, 30 female) with locally advanced nasopharyngeal carcinoma, staged according to the 1997 International Union Against Cancer/American Joint Committee on Cancer classification system as IIB (n = 9), III (n = 20), IVA (n = 32), and IVB (n = 49), World Health Organization types II (n = 25) and III (n = 85), were included in this protocol between January 1998 and July 2000 at King Faisal Specialist Hospital and Research Centre. Patients underwent two cycles of induction chemotherapy with cisplatinum 100 mg/m(2) and epirubicin 70 mg/m(2) on Days 1 and 21, followed by a radical course of radiotherapy (6,600 cGy in 6.5 weeks, 200 cGy/fraction) starting on Day 42, with three cycles of concurrent cisplatinum 25 mg/m(2) for 4 days on Days 42, 63, and 84. Of 110 patients included in this study, intracranial extension was present in 32 (29%), and nodal stage was N3 in 49 (45%). Complete remission and partial remission were achieved in 87 patients (79%) and 23 patients (21%), respectively. At a median follow-up for surviving patients of 37 months (22-55 months), 49 of 110 patients (44%) had failed treatment: 12 with local, 9 with regional nodes, 4 locoregional, 5 locoregional plus distant areas, and 19 with distant metastases. At the time of writing, 34 patients had died; all deaths were related to the patients' cancer except for 1 patient with treatment-related toxicity. Three-year actuarial overall survival, relapse-free survival, locoregional control, and distant metastasis-free survival rates were 89%, 78%, 88%, and 89% for patients with stage IIB; 71%, 70%, 89%, and 74% for stage III; 68%, 49%, 61%, and 77% for stage IVA; and 70%, 45%, 60%, and 69% for stage IVB, respectively. One patient received only one induction cycle; all others received two cycles; however, 9 of them required 20% reduction in the second cycle dose. Ninety patients (82%) completed two or more concurrent cycles of cisplatinum. Rates of Grade 3 and 4 reactions after induction chemotherapy were as follows: anemia 1% and 0%, leukopenia 8% and 4%, nausea 27% and 0%, vomiting 25% and 0%, and infection 4% and 4%, respectively. Acute Grade 3 and 4 reactions were also observed during chemoradiotherapy: anemia 1% and 0%, leukopenia 31% and 4%, nausea 35% and 0%, vomiting 26% and 2%, infection in 4% and 2%, mucositis in 49% and 0%, and skin reaction in 39% and 0%, respectively. Neoadjuvant chemotherapy followed by concurrent chemoradiotherapy is a safe and effective method of treatment for locally advanced nasopharyngeal carcinoma. Further investigations in prospective studies are required to evaluate this regimen.