Treatment Of Benign Diseases Research Articles

Emerging technologies in radiation oncology and nuclear medicine: An overview of their use and regulation

In the past few years, radiation oncologists and nuclear medicine physicians have seen radiation medicine branch out into areas predominantly reserved for other specialties. Modalities such as intravascular brachytherapy (IVBT), also sometimes called coronary artery radiation therapy, have brought radiation back into the treatment of benign disease in a way that may not surprise older physicians but may be new and unexpected for many younger physicians. Intravenous radiopharmaceutical therapy could change the scope of these practices to more closely resemble

Robotic surgery and cancer: the present state, problems and future vision.

In the 1990s, laparoscopic surgery entirely changed the traditional style of surgical operations. Laparoscopic cholecystectomy has spread rapidly and is now established as the standard treatment. However, besides cholecystectomy, endoscopic procedures are still not applied so widely to a variety of surgical operations. This is because laparoscopic techniques, such as suturing or ligation, make it difficult for surgeons to perform other kinds of operations and thus greatly increase their mental and physical stress. It is necessary to introduce various advanced technologies such as: surgical robots, three dimensional (3D) images, computer graphics (CG), computer simulation technology and others. Surgical robots, including the AESOP, da Vinci and ZEUS systems, provide surgeons with technologically advanced vision and hand skills. As a result, such systems are expected to revolutionize the field of surgery. However, there have so far been few studies which discuss the indications of robotic surgery for tumors/cancer. Therefore, herein we review various studies published in English to focus on the application of robotic surgery to tumors/cancer. We point out that there are several problems to be solved for robot surgery: i) price of surgical robots, ii) training systems for surgeon, iii) coverage by medical insurance, iv) downsizing and v) navigation system. In conclusion, we believe that, in the near future as robotic technology continues to develop, almost all kinds of endoscopic surgery will be performed by this technology. It will replace traditional surgery not only in the treatment of benign diseases but also in malignant illnesses.

Laparoscopy for colorectal cancer.

The advantages of laparoscopy in the treatment of benign disease have been well demonstrated. Compared to open surgery, laparoscopy is associated with a shorter hospital stay, less ileus, decreased postoperative pain, earlier return to work, and better cosmesis. The role of laparoscopy for the cure of malignant disease, however, remains controversial. In order to elucidate the safety and efficacy of laparoscopy for malignancy, worldwide large controlled randomized trials were developed. While awaiting the results of large randomized trials, a review of the many published studies to date was undertaken demonstrating a high level of evidence of the superiority of laparoscopy over laparotomy in regard to short-term benefits, when performed by appropriately skilled surgeons in properly selected patients. The data also suggest similar or superior local recurrence and long-term survival rates. However, further follow-up and review of large, multicenter, randomized trials will be needed before widespread acceptance of the technique can be recommended.

Laparoscopy for rectal carcinoma: anterior resection.

Laparoscopic anterior resection is a technically demanding procedure with a steep learning curve. In expert hands, this procedure has a place in the operative armamentarium for the treatment of benign disease. Its application in the treatment of rectal carcinoma is more difficult to address. The evidence available suggests that laparoscopic anterior resection is a feasible and appropriate option for the treatment of rectal carcinoma. The skill and technology to perform the procedure are developing apace, and level 1 evidence to support its use is tantalizingly close. In this paper, we outline the development of the procedure, the operative approach, and the available evidence for its use in the treatment of rectal carcinoma.

Screen-detected prostate cancer and the insulin-like growth factor axis: results of a population-based case-control study.

Higher circulating levels of IGF-I have been associated with increased risk of prostate and some other cancers. Most research on prostate cancer has been based on men with symptoms or identified following treatment of benign disease. However, increasing numbers of cancer cases are now detected in asymptomatic men following prostate-specific antigen (PSA) tests. We therefore used a population-based case-finding exercise using the PSA test to examine whether associations between the IGF axis and cancer risk were apparent in this population. A matched case-control study was conducted among 7,383 men (50-70 years) receiving a PSA test as part of a case-finding exercise. Assays of IGF-I, IGF-II, IGFBP-2 and IGFBP-3 were performed on cases and 2 controls matched on age, recruitment center and calendar time. Analyses were based on 176 cases and 324 matched controls. The risk of prostate cancer increased across quartiles of IGF-I (highest vs. lowest quartile, OR = 2.34; 95% CI = 1.26-4.34; p(trend) = 0.02) and IGF-II (OR = 1.78; 95% CI = 0.94-3.15; p(trend) = 0.09). Controlling for smoking history and IGFBP-3 strengthened associations with cancer for both IGF-I (OR = 3.00; 95% CI = 1.50-6.01; p(trend) 0.005) and IGF-II (OR = 2.02; 95% CI = 1.07-3.84; p(trend) = 0.04) Associations between the IGFs and cancer risk were stronger for advanced cases. Our findings suggest that both IGF-I and IGF-II are associated with an increased risk of screen-detected prostate cancer.

Assessment of carcinogenic risks in radiotherapy of non-malignant diseases

Purpose/Objective: With the renewed interest in the treatment of benign diseases with radiotherapy, there is also concern about the risk of induction of malignancies. The carcinogenic risk can be estimated with the concept of effective dose introduced by the International Commission on Radiological Protection (ICRP). The objective of this study is to calculate effective doses for various non-malignant diseases and assess the risk for tumor induction, dependent on age and gender.Materials/Methods: According to the ICRP the average risk factor for fatal cancers is presently assumed to be 10 percent per Sv in the high dose region. The attributable lifetime risk is, however, considerably smaller at older age than earlier in life. In radiotherapy, the dose distribution will be inhomogeneous. Organ doses have been calculated using Monte Carlo radiation transport codes and anthropomorphic mathematical phantoms. The different susceptibilities for tumor induction in these organs, are approximated by tissue weighting factors. The effective dose has been derived as the sum of the products of the equivalent organ doses and their tissue weighting factors.Results: For Graves’ orbitopathy, for a square field, a target dose of 20 Gy and 5 MV photons, the effective dose is 65 mSv. Adjustment of the field to the conical outline of the orbit, with a slightly lower target dose of 16 Gy and 12 MV photons, resulted in an effective dose of 34 mSv. For radiotherapy to prevent heterotopic ossification with a target dose of 7 Gy, effective doses between 136 and 323 mSv and between 213 and 419 mSv are derived for a male and female phantom, respectively. Irradiation of the shoulder (omarthritis, target dose 12 Gy) performed in the absence or presence of thyroid protection, resulted in effective doses of 197 and 185 mSv, respectively, for the female gender. For treatment of the knee (gonarthrosis, target dose 6 Gy) the effective dose is 13 mSv.Conclusions: The calculation of effective doses for radiotherapy of benign diseases offers the possibility to optimize the irradiation procedure. On the basis of the average attributable risk factor, the estimated number of induced fatal tumors varies from 1 to 40 per 1000 patients. When irradiations are performed at older age the risk factor will be reduced by an approximate factor of three. Purpose/Objective: With the renewed interest in the treatment of benign diseases with radiotherapy, there is also concern about the risk of induction of malignancies. The carcinogenic risk can be estimated with the concept of effective dose introduced by the International Commission on Radiological Protection (ICRP). The objective of this study is to calculate effective doses for various non-malignant diseases and assess the risk for tumor induction, dependent on age and gender. Materials/Methods: According to the ICRP the average risk factor for fatal cancers is presently assumed to be 10 percent per Sv in the high dose region. The attributable lifetime risk is, however, considerably smaller at older age than earlier in life. In radiotherapy, the dose distribution will be inhomogeneous. Organ doses have been calculated using Monte Carlo radiation transport codes and anthropomorphic mathematical phantoms. The different susceptibilities for tumor induction in these organs, are approximated by tissue weighting factors. The effective dose has been derived as the sum of the products of the equivalent organ doses and their tissue weighting factors. Results: For Graves’ orbitopathy, for a square field, a target dose of 20 Gy and 5 MV photons, the effective dose is 65 mSv. Adjustment of the field to the conical outline of the orbit, with a slightly lower target dose of 16 Gy and 12 MV photons, resulted in an effective dose of 34 mSv. For radiotherapy to prevent heterotopic ossification with a target dose of 7 Gy, effective doses between 136 and 323 mSv and between 213 and 419 mSv are derived for a male and female phantom, respectively. Irradiation of the shoulder (omarthritis, target dose 12 Gy) performed in the absence or presence of thyroid protection, resulted in effective doses of 197 and 185 mSv, respectively, for the female gender. For treatment of the knee (gonarthrosis, target dose 6 Gy) the effective dose is 13 mSv. Conclusions: The calculation of effective doses for radiotherapy of benign diseases offers the possibility to optimize the irradiation procedure. On the basis of the average attributable risk factor, the estimated number of induced fatal tumors varies from 1 to 40 per 1000 patients. When irradiations are performed at older age the risk factor will be reduced by an approximate factor of three.

Laparoscopic tumor nephrectomy

Initially, laparoscopic surgery in urology was restricted to the treatment of benign diseases, whereas its role in the management of malignant disease was restricted to purely diagnostic procedures. Only recently has laparoscopy been introduced for the treatment of low stage renal cell carcinoma (RCC), and the data on both surgical efficiency and oncologic efficacy are very promising. Therefore, we present our experience with laparoscopic radical nephrectomy and data from literature. The technique of the transperitoneal approach is described in detail. Retroperitoneoscopy is a good alternative, however. Intact removal of the specimen within an organ bag to avoid tumor spillage is an important detail of our technique. Our experience amounts to radical nephrectomy in 121 patients. The indication was clinical stage T1-T2. Mean operative time and blood loss was 2.4 h and 154 ml, respectively. The rate of minor or major complications was 5% and 4%, respectively. There was no conversion to open surgery in any patient. Mean postoperative hospital stay was 6.1 days. Data on tumor control are available for 73 patients with a mean follow-up of 13.3 months. There was no recurrence within this period. Radical nephrectomy for low-stage RCC is associated with low morbidity and great surgical efficiency. The rates for local recurrences and metastases are low, tumor-specific survival is high. However, there is still a lack of long-term data on large series of patients. Despite this fact, laparoscopy is already widely accepted for this indication, and it is quite likely that it will become the standard treatment.

Radiotherapy for Graves’ Ophthalmopathyb

The interest in the treatment of benign diseases with radiation therapy has grown particularly in the Western part of the world. In 1996, a questionnaire was sent to 1348 institutes worldwide listed in the directory of the Society for Therapeutic Radiology and Oncology asking whether the respondents considered a list of 28 most common benign disorders as being a good indication for orbital radiotherapy.1 Questions concerned the frequency of such treatments and the treatment schedules used. The prevention of keloid formation was the most widely accepted indication, followed by Graves’ ophthalmopathy. Thus, radiotherapy for this orbital disorder is generally accepted and applied worldwide.

Radiotherapy of benign disorders

The radiation oncologist's primary concern is treatment of patients with malignant tumors but sometimes faces on occasion rare, non malignant disorders. The scarcity of disease incidence is reflected by the paucity of references for these diseases in the literature. This minimal exchange of information may make research and analysis difficult, tedious and not easily directed. Even with recognition of the risks of late skin injury, carcinogenesis, leukemogenesis and genetic damage from all ionizing radiation, radiation therapy also continues to be accepted treatment for benign diseases that do not respond to other methods of therapy. The purpose of this paper is to provide a short overview of the radiotherapy of most frequent benign disorders.

Estrogenic Activity of Tamoxifen on the Epithelium of Normal Mammary and Fibroadenoma in the Luteal Phase of the Menstrual Cycle

: Tamoxifen, an antiestrogenic drug used in adjuvant therapy in breast cancer, is in need of further studies to determine its effectiveness for treatment of benign disease and in cancer prevention. This study examines the effect of tamoxifen on the epithelium of fibroadenomas and its respective normal adjacent parenchyma by quantitative analysis of lysosomes. Tamoxifen was administered to 18 patients during the luteal phase of the menstrual cycle, thus reducing interference with the secretory activity of the corpus luteum. Biopsies were obtained from adjacent tissue and fibroadenomas were obtained during their surgical resection in 35 premenopausal women. Ages ranged from 15 to 37 years old and all patients had a regular cycle for at least 6 months. The patients were divided randomly into two groups: 17 from group A (control) and 18 from group B (tamoxifen) treated with tamoxifen, 20 mg/day between the 13th and 22nd day of the cycle. The tissue fragments were prepared according to the Gomori's cytochemical method using the acid phosphatase reaction. Lysosome counts were carried out with a light microscope and grid lenses at high magnification and the results were analyzed with the Mann–Whitney test. The epithelium of fibroadenoma had significantly more lysosomes than those seen in the epithelium of adjacent mammary parenchyma. The patients who received tamoxifen showed a statistically significant decrease in the number of lysosomes in the epithelium of mammary parenchyma and fibroadenoma, demonstrating an antiestrogenic effect.

Indications and treatment schedules for irradiation of benign diseases: a survey

Background: The interest in the treatment of benign diseases with radiotherapy has grown particularly in the Western part of the world. Questions about the effectiveness and risks of radiotherapy for these disorders have to be answered in the light of new information from clinical research, dose calculations and risk estimates. New indications for irradiation of non-malignant diseases, e.g. vascular disorders, such as macular degeneration and prevention of stent restenosis, are appearing. As a starting point for further discussions and publications in this area, the authors, with the help of the European Society for Therapeutic Radiology and Oncology (ESTRO), performed a survey of current practice and of opinion amongst ESTRO members. Methods: A questionnaire was circulated in 1996 to 1348 institutes listed in the 1995 ESTRO directory asking whether the respondents considered a list of the 28 most common benign disorders as being a good indication for radiotherapy. Details of the frequency of such treatments and of treatment schedules used were requested. Results and conclusions: A large variation in indications and treatment schedules was detected throughout the world. This variation confirms the inadequate information on which such treatments are based and stresses the importance of careful clinical studies and trials as well as clear understanding of any risks involved.

Epidemiology in Gastroenterology

A review of the literature on gastrointestinal epidemiology during the last 25 years shows a comprehensive contribution from Danish studies. This is partly explained by very favourable conditions in Denmark for epidemiological research, due to various valid registers and a long tradition for longitudinal population and patient cohorts. Data are presented on prevalence, incidence, demography, clinical risk factors, clinical course, and prognosis of various gastrointestinal disorders. Main emphasis is put on Danish studies, which are compared with international results. Present possibilities for prophylaxis against gastrointestinal diseases and delimitation of treatment of benign diseases are discussed. It is expected that research within gastrointestinal epidemiology in Denmark will increase in the coming years.

CNS tumor induction by radiotherapy: A report of four new cases and estimate of dose required

We have analyzed 60 cases of intra-axial brain tumors associated with antecedent radiation therapy. These include four new cases. The patients had originally received radiation therapy for three reasons: (a) cranial irradiation for acute lymphoblastic leukemia (ALL), (b) definitive treatment of CNS neoplasia, and (c) treatment of benign disease (mostly cutaneous infections). The number of cases reported during the past decade has greatly increased as compared to previous years. Forty-six of the 60 intra-axial tumors have been reported since 1978. The relative risk of induction of an intra-axial brain tumor by radiation therapy is estimated to be more than 100, as compared to individuals who have not had head irradiation.

Letter: FDA drug bulletin-radiation.

To the Editor.— In June 1974, the FDA Drug Bulletin published a short article on the delayed effects of head and neck radiation. 1 They quoted the studies in Israel and in New York on neoplastic development in persons having had x-ray epilation for tinea capitis. 2,3 On this basis, they concluded with the following paragraph, Today, with specific or alternative methods of treatment for benign disease, the indications for x-ray therapy are rare. With the knowledge that relatively low doses of radiation can be responsible for the development of benign and malignant tumors, caution in the use of ionizing radiation for benign disease is well justified. In response, on July 28, 1974, I wrote a letter to Caspar Weinberger, Secretary of the US Department of Health, Education, and Welfare, which said in part, . . . this slanted article could make the defense of medicolegal actions regarding the use of radiation therapy

On radiation cancer

The ten cases which had received roentgen therapy for benign diseases, such as chronic dermatitis, tuberculosis of the cervical nodes and others, were diagnosed as radiation-cancer during the recent five years. Five of them were found to be the cancer of the pharynx or hypopharynx, two being the cancer of the thyroid gland, one being the fibrosarcoma of the upper lip and one was duplicated cancer in the thyroid and larynx. The last case was a rarelycase of being caused by extravasated and retentio-ned thorotrast in the neck. All these cancers developed in the area where was primarily irradiated for the treatment of ben-ign disease. The latent period was from 13 to 32 years withe the average of 25 years. In regard to pathological findings, six were well differentiated squamous cell carcinoma in the pharynx, hypopharynx and larynx and three were papillary and follicular adenocarcinoma in the thyroid gland. Three were treated with radiation therapy only, five were operated upon and one case was treated with combined radiological and surgical therapy. Of ten cases, two had the local recurrence. The radiation cancer is one of the typical iat-rogenic diseases. The author cannot help reflecting with concern about the miserable facet of the pro-sperous modern medicine.

The surgical treatment of radiation dermatitis following irradiation of benign diseases

A survey is presented of plastic surgical techniques used in 80 patients with radiation dermatitis after exposure to x rays, either accidentally or for a benign disease. The patients illustrate that the use of radiation for treatment of benign disease may be disastrous. All 80 patients with radiation dermatitis had such symptoms from the dermatitis as pruritus, burning, and/or ulceration. The majority of the 80 patients had been given radiation treatment for lesions that were cosmetically unacceptable, in an attempt to improve the appearance of the patient, but the results indicate that it would have been better if the original lesions had been allowed to remain. In 46 irradiated patients (57%) in whom malignancy developed, the incidence of squamous and basal cell carcinoma was almost equal. The average and median time between exposure and diagnosis of malignancy was 27 yr; however, the range was from 9 to 40 yr and the standard deviation was 8.9 yr. In most instances the patients with radiodermatitis who later developed cancer had a history of recurrent ulceration. Surgical treatment consisted usually of excision of the affected area followed by grafting of the skin, although occasionally simple excision and closure were possible. Amputation and/or coveragemore » of the pedicle flap were required in many cases. Since deeper tissues were often severely damaged too, there was a high incidence of failure of the intital graft. There was much oozing from fine teleangiectatic vessels when excision was performed, and hematomas occurred frequently and contributed to the incidence of failure of grafts. Only 17 patients were considered to have made satisfactory recovery from the sequelae of radiodermatitis. (TCO)« less

Replacements of the esophagus

The esophagus may be replaced by various means. The skin tubes fashioned from the anterior thorax which were formerly used to restore continuity after esophageal resection have been superseded by more direct methods. Resection of the esophagus for both malignant and benign disease has become a common-place procedure. The ability to surgically remove many types of esophageal disease is well established. Some uncertainty still exists about the best method of restoring gastrointestinal continuity after esophageal resection. The stomach is admirably suited for use as an esophageal substitute. It is easily mobilized and has attributes which make its use favorable from most aspects. Its shortcomings are minimal even when it is used in the treatment of benign disease. Experience has shown that if the esophageal resection is extensive and the esophagogastrostomy is performed at a high level in the thorax, esophagitis is not a frequent development. The jejunum and colon are often used as esophageal replacements. The jejunum has certain limitations related both to its anatomically short vascular arcades and to certain physiologic and long term observations of patients undergoing these replacement procedures. The use of the colon presents fewer technical difficulties than does the jejunum, and is well suited for total or nearly total replacement of the esophagus. A discussion is presented here which questions the justification of the use of the colon or jejunum in the management of malignant disease of the esophagus. It is suggested instead that the stomach is a more satisfactory esophageal substitute in these instances. In the treatment of benign esophageal stenoses the colon or jejunum should find their greatest use as esophageal replacements.