Treatment Of Pelvic Tumors Research Articles

A comparison of dosimetry and clinical outcomes in patients receiving photon external beam therapy to the pelvis: A two-year experience with 6MV and 10MV photon energies in cervical cancer patients at Parirenyatwa Radiotherapy Centre in Harare, Zimbabwe.

e18768 Background: Radiotherapy efficacy depends on the ability of the treatment machine to deliver optimal radiation dose to target volume while sparing normal tissue using different techniques. The photon energy determines penetrative power. Higher photon energies are generally preferred over low photon energies when treating deep tumours using 3-dimensional conformal radiotherapy (3DCRT). In most low income settings, availability of higher energies (≥10MV) is limited. Elsewhere protocols do not recommend use of lower energies for deep pelvic tumours. There is paucity of data comparing 10MV and 6MV photon energy plans and outcomes for treatment of pelvic tumours with 3DCRT. This study aimed to compare dosimetric and clinical tumour outcomes between the two photon energies which are available in our setting when treating locally advanced cervical cancer (LACC). Methods: We retrospectively analysed medical records for LACC patients who received definitive concurrent chemoradiotherapy (CCRT) at Parirenyatwa Group of Hospitals Radiotherapy Centre for the period between 1st January 2017 and 31st December 2018. Patient’s treatment plans were stratified into two arms according to the photon energies used (10MV and 6MV) and their respective dosimetric and clinical tumour outcomes at three months post-treatment were compared. Results: A total 875 cervical cancer patients were seen during the study period, of these 82 met the inclusion criteria and were evaluated. Out of these, 20(24.4%) and 62(75.6%) patients were planned and/or treated with 10MV and 6MV photon energy respectively. The differences in minimum doses to the planned target volume and dose homogeneity index between the two photon energies were statistically significant (p-values 0.027 and 0.028 respectively), whereas the other dosimetric parameters (maximum & average doses to the planned target volume, conformity index and maximum doses to rectum, bladder, femoral heads and bowel) were not statistically significant (p-values of 0.245, 0.309, 0.130, 0.19, 0.35 and 0.42, and 0.16 respectively). Complete clinical tumour response at 3 months post treatment was 95% in the 10 MV arm compared to 91% in the 6 MV arm. Conclusions: This study showed that the dosimetric and clinical tumour outcomes in LACC patients receiving 3DCRT definitive CCRT using 10MV or 6MV photon energy in our setting are comparable. Follow-up prospective studies to further characterise the application of these photon energies in resource constrained settings is recommended.

A novel and innovative device to retract rectum during radiation therapy of pelvic tumors.

An effective radiotherapy treatment entails maximizing radiation dose to the tumor while sparing the surrounding and normal tissues. With the advent of SBRT with extreme hypo‐fractionation in treating tumors including prostate where ablative dose is delivered in smaller number of fractions, rectum remains a dose‐limiting organ and at the risk of rectal toxicity or secondary cancer. The same limitation of rectal toxicity exists for high‐dose rate (HDR) treatments of cervical, endometrial, or prostate cancer when creating even a short distance between the anterior rectal wall and field of radiation is ideal in delivering ablative dose to the target. An effective solution to such problem is to physically displace rectum as the organ at risk. This research presents an organ retractor device that is designed to displace the rectum away from the path of radiation beam employing a Nitinol shape memory alloy that is designed for displacing the rectum upon actuation. A control system regulates the motion in a reproducible and safe manner by creating the desirable shape in moving the anterior rectal wall. The study finds the novel organ retractor device to be a promising tool that can be applied in a clinical setting for minimizing dose to the rectum during treatment of pelvic tumors, and creating the potential to deliver an ablative dose to tumor volume or to escalate the dose when needed.

Диагностика острой бивентрикулярной сердечной недостаточности в ОРИТ у больной с синдромом малого сердечного выброса после хирургического лечения опухоли малого таза с тромбозом левой подвздошной вены, нижней полой вены и правых отделов сердца в условиях искусственного кровообращения.

Описанный клинический случай острой правожелудочковой недостаточности (ОПЖН), проявившейся при малоинвазивном мониторинге гемодинамики синдрома малого сердечного выброса, демонстрирует вариант развития бивентрикулярной сердечной недостаточности и необходимость проведения расширенного гемодинамического мониторинга у хирургических больных с высоким риском развития послеоперационных осложнений. На сегодняшний день необходимость оценки сердечного выброса у больных в ОРИТ не вызывает сомнений, однако выбор метода мониторинга, предоставляющего дополнительные возможности, составляет одну из немаловажных задач для реаниматолога и может существенно влиять на диагностический поиск причин гемодинамической нестабильности больного. Также данный случай представляет интерес, поскольку не связан с основными описанными в литературе патологическими процессами, приводящими к развитию ОПЖН.<br> Ключевые слова: синдром малого сердечного выброса; острая правожелудочковая недостаточность; бивентрикулярная сердечная недостаточность. HTML

RADIOLOGY OF UROLOGICAL COMPLICATIONS AFTER TREATMENT OF PELVIC TUMORS. PART II. URINARY LEAKS AND URETERAL INJURIES

Urinary leaks and ureteral injuries under treatment of pelvic tumors are the difficult and unsettled clinical diagnostic problem. For their radiodiagnostics using different imaging techniques, primarily computed tomography. About application magnetic resonance imaging (MRI) is less well knows. The possibilities MRI to diagnostic of urinary leaks and ureteral injuries and ureterostegnosis are illustrated in the article; we discuss the limitation of method requiring additional use of other radiological methods. A literature search on the topic of research was carried out on the databases PubMed and eLIBRARY.

RADIOLOGY OF UROLOGICAL COMPLICATIONS AFTER TREATMENT OF PELVIC TUMORS. PART I. URINARY FISTULAS

Urinary fistulas complicating treatment of pelvic tumors are the clinical diagnostic problem that needs research and decision. The top-priority radiological method for diagnostic urinary fistulas is computed tomography. About application magnetic resonance imaging (MRI) is less well knows. The possibilities MRI to diagnostic of urinary fistulas are illustrated in the article; we discuss the limitation of method requiring additional use of other radiological methods. A literature search on the topic of research was carried out on the databases PubMed and eLIBRARY.

Protective efficacy of vitamin B12 combined with far-infrared radiation on radiation-induced skin damage in the treatment of pelvic tumours

Objective: To determine the protective efficacy of vitamin B12 combined with far-infrared radiation on radiation-induced skin damage in the treatment of acute and chronic pelvic tumours. Methods: One hundred patients requiring radiation therapy were randomly assigned to one of two groups: 50 patients were assigned to the control group and received usual care; the 50 patients assigned to the experimental group were, in addition to usual care, given vitamin B12 (0.25 mg/mL) injections to radiation-sensitive perineal skin and subsequently treated with far-infrared radiation beginning the first day of radiotherapy. Far-infrared radiation treatment was performed at a light distance of 40 cm at a temperature of 28°C to 32°C for 25 min twice per day. Results: The incidence of acute skin reactions in the two groups was statistically different (P<0.05). The incidences of grades I, II, III and IV radiation-induced skin damage in the experimental group were 60.0%, 30.0%, 10.0% and 0%, respectively; in contrast, the incidences in the control group were 26.0%, 54.0%, 18.0% and 2.0%, respectively. Grades II to IV skin reactions in the experimental group were remarkably less severe than those of the control group. When a radiation treatment dose of <40 Gy was used, the incidences of acute radiation-induced dermatitis in the control and experimental groups were 66% and 34%, respectively (P<0.05). Conclusion: Vitamin B12 combined with far-infrared radiation had a markedly protective effect on acute radiation-induced skin damage in the treament of pelvic cancers. Moreover, the treatment improved patient quality of life and was clinically valuable.

Hip transposition as a limb salvage procedure following the resection of periacetabular tumors

One of the most difficult problems in tumor surgery is the treatment of pelvic tumors, particularly those in the periacetabular region. This retrospective study serves to analyze clinical and functional outcome of the new surgical technique of hip transposition. Sixty-two patients were analyzed (chondrosarcoma 15, Ewing's sarcoma or PNET 26, osteosarcoma 14, synovial cell sarcoma 2, others 5) and clinical, oncological, and functional outcome were evaluated. The surgical procedure focused on hip transpositions Type I (n = 9), Type IIa using the MUTARS attachment tube (n = 36), and Type IIb using the MUTARS attachment tube with a proximal femur endoprosthesis and bipolar cup (n = 17). In 53 patients (85.5%), wide margins were achieved. The 1- and 5-year overall survival rates were 96.4% and 80.5%, respectively. The 5-year (10 years) overall survival was 82.1% (82.1%) for Ewing's sarcoma, 60.1% (40.6%) for osteosarcoma, and 92.3% (46.2%) for chondrosarcoma. Wound healing problems were observed in 14 cases, deep infection in 20 cases. The mean Musculoskeletal Tumor Society (MSTS) score was 62% (18.6 Pts ± 3.73). Hip transposition can be considered as an easy and safe surgical procedure to employ in order to achieve good functional outcome in periacetabular tumors.

Dose de tolérance à l’irradiation des tissus sain : les testicules

Although there is very little evidence for direct irradiation of the testes, they may receive significant doses, especially in the treatment of pelvic tumors in adults and in pediatrics. The exocrine function of the testis seems to be more sensitive to radiotherapy. There is a risk of sterility, even after low doses of radiation. In the adult or the child who has reached puberty, we should propose a self-preservation of semen prior to radiotherapy. In pre-pubescent children, the problem is more delicate. In all cases, it is necessary to limit the dose to the testicles without affecting the coverage of tumour volume. Patients and/or their caregivers should be systematically informed of the risk of infertility related to irradiation.

Preoperative needle biopsy and immunohistochemical analysis for gastrointestinal stromal tumor of the rectum mimicking vaginal leiomyoma

Accurate preoperative diagnosis for gastrointestinal stromal tumor (GIST) was obtained using the endoscopic approach in about 50% of the cases. Preoperative assessment is quite important in reproductive women for the treatment of pelvic tumor. We report the first case of GIST of the rectum that was accurately diagnosed with preoperative needle biopsy from the vaginal wall. The case was a 38-year-old woman who presented with a history of genital bleeding. Internal examination revealed a round and elastic mass (7 x 7 cm) in the left pelvic cavity. The biopsy specimen from the left sidewall of the vagina using a manually manipulated biopsy needle showed strong reaction for CD34 and CD117 (c-KIT). The patient underwent low anterior resection of the rectum, tumor resection, and partial resection of the posterior vagina. Preoperative biopsy with vaginal approach might be helpful to make a diagnosis for pelvic tumor of unknown origin and unknown malignant potential.

Transverse Retubularized Ileal Vaginoplasty: A New Application of the Monti Principle—Preliminary Report

ObjectiveThe surgical management of the absence of the vagina is a complex problem and constitutes a significant technical challenge. Herein we present our successful experience with vaginal reconstruction by the use of a modified ileal segment according to the Monti principle. MethodsSix patients aged from 23 to 41 years (mean 33 years) were referred to our institution for vaginal stenosis. In our series, ileum has been used to create the neovagina: the isolated segment has been longitudinally detubularized and transversally retubularized in order to configure the roof of the neovagina. ResultsThe mean operating time was 220min. No intra-operative complication occurred. The mean follow-up of this series was 16 months. At the latest follow-up, all patients had patent moist neovaginas, but excessive vaginal mucous was not a problem in any patient in our series. ConclusionsNeovaginal creation using isolated ileal segments according to the Monti channel principle provide excellent tissue for vaginal replacement, providing excellent patient satisfaction and relatively low morbidity. Cosmetic, functional and anatomical results were encouraging. In our opinion our technique may be indicated for all cases of vaginal absence: congenital abnormalities in the pediatric population, vaginal stenosis after treatment of pelvic tumors, severe vaginal scarring secondary to chronic inflammatory disease or in case of secondary correction after failure gender surgery.

Operative Treatment of Pelvic Tumors

Hideaki E. Takahashi, Tetsuro Morita, Tetsuo Hotta, and Akira Ogose, editors. Tokyo: Springer-Verlag; 2003. 216 pages. $119.00. This concise textbook on the operative treatment of pelvic tumors represents the thirty-year experience of the senior editor and author, Dr. H.E. Takahashi, at the Niigata University Medical Hospital in Japan. Dr. Takahashi (who has some forty years of experience in the operative treatment of musculoskeletal tumors) and his contributors have done a very nice job of organizing a concise, readable, and generally well-illustrated surgical text. This single-volume textbook is tastefully constructed …

Association of rectal toxicity with thermal dose parameters in treatment of locally advanced prostate cancer with radiation and hyperthermia

Purpose: Although hyperthermia has been used for more than two decades in the treatment of pelvic tumors, little is known about the potential impact of heat on rectal toxicity when combined with other treatment modalities. Because rectal toxicity is a concern with radiation and may be exacerbated by hyperthermia, definition of the association of thermal dose parameters with rectal toxicity is important. In this report, we correlate rectal toxicity with thermal dose parameters for patients treated with hyperthermia and radiation for prostate cancer.Methods and Materials: Thirty patients with T2b-T3b disease (1992 American Joint Committee On Cancer criteria) enrolled in a Phase II study of external beam radiation ± androgen-suppressive therapy with two transrectal ultrasound hyperthermia treatments were assessed for rectal toxicity. Prostatic and anterior rectal wall temperatures were monitored for all treatments. Rectal wall temperatures were limited to 40°C in 19 patients, 41°C in 3 patients, and 42°C in 8 patients. Logistic regression was used to estimate the log hazard of developing National Cancer Institute Common Toxicity Criteria Grade 2 toxicity based on temperature parameters. The following were calculated: hazard ratios, 95% confidence intervals, p values for statistical significance of each parameter, and proportion of variability explained for each parameter.Results: Gastrointestinal toxicity was limited to Grade 2. The rate of acute Grade 2 proctitis was greater for patients with an allowable rectal wall temperature of >40°C. In this group, 7 of 11 patients experienced acute Grade 2 proctitis, as opposed to 3 of 19 patients in the group with rectal wall temperatures limited to 40°C (p = 0.004). Preliminary assessment of long-term toxicity revealed no differences in toxicity. Hazard ratios for acute Grade 2 proctitis for allowable rectal wall temperature, average rectal wall Tmax, and average prostate Tmax were 9.33 (p = 0.01), 3.66 (p = 0.03), and 2.29 (p = 0.08), respectively. A model combining these three parameters explained 48.6% of the variability among groups.Conclusion: Rectal toxicity correlates with maximum allowable rectal wall temperature, average rectal wall Tmax, and average prostate Tmax for patients undergoing transrectal ultrasound hyperthermia combined with radiation for treatment of advanced clinically localized prostate cancer. Further definition of this association of thermal dose parameters with rectal toxicity in treatment of pelvic malignancies with hyperthermia should advance the goal of delivering thermal therapy in an effective yet safe manner.

Salvage of the limb and gait analysis in the treatment of pelvic tumor without prosthesis

Salvage of the limb and gait analysis in the treatment of pelvic tumor without prosthesis

VAGINAL REPLACEMENT IN CHILDREN AND YOUNG ADULTS

Purpose Absence of the vagina in the pediatric population most commonly results from congenital abnormalities, such as the Mayer-Rokitansky syndrome but it may also be seen after treatment for pelvic tumors, such as rhabdomyosarcoma, and in patients who have had previous gender reassignment. We review our experience using bowel for vaginal replacement in a group of children and young adults to assess outcome and satisfaction. Materials and Methods From 1980 to 1996 we evaluated 31 patients 1 to 20 years old who required vaginal replacement. Presenting diagnoses included mullerian failure (the Mayer-Rokitansky syndrome) in 20 patients, androgen insensitivity syndrome in 5, rhabdomyosarcoma in 3, penile agenesis in 1, cloacal exstrophy in 1 and 1 previously separated conjoint twin. A questionnaire was given to 26 of the 31 patients to assess postoperative sexual function and satisfaction. Results A total of 33 bowel segments in 31 patients were used for vaginal reconstruction, including sigmoid colon in 20, ileum in 8 and cecum in 5. Of the 31 patients 20 were sexually active, 8 were married and 3 had been previously married and divorced. Only 1 patient described chronic dyspareunia. Three patients were on chronic home dilation, while 4 required sanitary pads for vaginal secretions. There were 8 complications in the 31 patients, including stenosis of the bowel segment in 6. Three patients required a second procedure after total stenosis of the small bowel vagina (2) and prolapse of the neovagina (1), which required retroperitoneal fixation. Conclusions Experience with this group of patients leads us to believe that isolated bowel segments provide excellent tissue for vaginal replacement. Furthermore, we believe that colon segments, particularly sigmoid, are preferable to small bowel for creation of the neovagina. In many instances the small bowel mesentery may be too short to provide an adequate, tension-free anastomosis in the perineum, particularly in obese patients. Our results would also suggest that sexual activity is more compatible with isolated bowel segments for vaginal replacement than with any of the more traditional methods, such as passive dilations and split thickness skin graft vaginoplasty.

Transvaginal sonography, color flow imaging, computed tomographic scanning, and CA 125 as a routine follow-up examination in women with pelvic tumor: detection of recurrent disease.

We were trying to determine whether transvaginal sonography combined with color flow imaging should be used routinely for detecting recurrent pelvic tumors in patients treated for pelvic cancer. Eighteen patients who had completed their treatment for pelvic tumor were examined every 6 months by gynecologic examination, a CT scan, serum CA 125 levels, and transvaginal sonography with color flow imaging. Laparotomy or fine-needle biopsy was performed when a recurrent pelvic mass was observed or suspected on CT scans or transvaginal sonography. In nine of 18 patients a recurrent pelvic tumor was observed or suspected on CT scans or on transvaginal sonography. A recurrent pelvic tumor was diagnosed on laparotomy in five patients. In four patients, only a fine-needle biopsy was performed and only two of them had positive results. The highest sensitivity and specificity for detecting recurrent pelvic tumors were achieved by transvaginal sonography (100 and 91%, respectively) and by color flow imaging (86 and 100%, respectively). Intratumoral blood vessels were detected in all cases with recurrent pelvic tumors, and in only one of these cases the PI was high. We recommend a routine follow-up with transvaginal sonography in women completing their treatment for pelvic tumors. When a recurrence of tumor is only suspected on transvaginal sonography, color flow imaging may be used as an additional diagnostic tool.

Benefits expected from simple conformal radiotherapy in the treatment of pelvic tumours

In 20 patients with invasive bladder cancer suitable for radical radiotherapy, a simple conformal planning technique has been compared with conventional beam arrangements in terms of normal tissue sparing. The median treatment volume for the group was reduced from 2275 to 1416 cm 3 by the introduction of conformal planning. More specifically, in 13 20 patients (65%) the percentage volume of rectum irradiated to 90% of the isocentric dose was reduced by more than 30%, although the extent of rectal sparing varied greatly between patients. Overall, conformal planning appeared to be less successful at reducing the volume of large and small bowel irradiated to high dose. However, the data suggest that considerable benefit can be expected for those patients most at risk of morbidity by virtue of high bowel volumes included within the treatment length. A randomised trial is now being set up to determine the clinical impact of this planning technique in terms of reduced bowel morbidity.

Vascular injury in the mouse rectum after irradiation and cis-diamminedichloroplatinum (II).

The rectum is a major critical organ in the radiation treatment of pelvic tumours in patients. Late radiation-induced lesions such as ulceration, stenosis, fibrosis and fistulae can be both severe and distressing and are extremely difficult to treat. A better understanding of the pathogenesis of radiation damage in this organ might provide clues towards therapeutic possibilities to prevent such injury. Suitable animal models have been developed (Black et al, 1980; Hubmann, 1981; Terry et al, 1983). It has been suggested that radiation damage in the microvasculature plays a key role in the onset of late damage in the rectum (Trott, 1984; Breiter & Trott, 1986). The present experiments were aimed at investigating functional changes in the rectal microvasculature at various times after irradiation given with or without cisdiamminedichloroplatinum (II) (c-DDP). These results were related to previously published histological alterations after such treatment (Dewit et al, 1987). Specific pathogen-free inbred ma...

Preliminary technical, experimental and clinical results of the use of the HPLR 27 system for the treatment of deep-seated tumours by hyperthermia.

Based on the theoretical deep penetration of radio frequencies, we have developed several 27.12 MHz ridged wave guides, with large apertures, and filled with circulating deionized water. Different low impedance matching networks have been tested and a 0-800 W power generator has been designed for this particular clinical use. This can be driven easily by a microcomputer which is used to regulate the temperature at depth by varying the sequencing time and/or by adjusting the RF power. The complete system, known as HPRL 27, is manufactured by Sairem Ets. Studies of the spatial power density distributions show a relatively homogeneous RF field for an aperture greater than 30 X 14 cm. Preliminary heating patterns studied in phantoms indicate the possibility of treating volumes greater than 2000 cm3 within the 50 per cent isotherm. Maximum heating is observed between 2 and 5 cm deep with passive cooling, and between 3 and 6 cm deep with active cooling, in which case the 50 per cent isotherm is situated between 2 and 10 cm deep. Preliminary phase I clinical results on 20 patients with pelvic or thoracic carcinomas show the possibility of heating deep-seated tumours to above 42 degrees C with a good patient tolerance. Temperature is controlled by implantable catheters or in the case of pelvic heating, by inserting catheters into the vagina, the rectum and the bladder. This new device is well adapted for the treatment of pelvic tumours.

Ileal Loop in the Treatment of Radiation-Treated Pelvic Malignancies: A Comparative Review

Critical analysis of ureteroileal diversion in the treatment of pelvic tumors in which prior radiation therapy was administered has prompted us to review our experience with ileal loops after patients have been irradiated. Between 1970 and 1975, 136 adults underwent ureteroileal bypass. Of these patients 36 had preoperative irradiation for various pelvic malignancies, 44 had malignancies but no irradiation and 56 were operated upon for neurogenic bladders. Major morbidity in the irradiated group included wound infections (33 per cent), ureteroileal urinary leaks (19.4 per cent) and paralytic ileus (13.9 per cent). The average postoperative hospital stay for this group was 8 to 11 days longer than that of the other 2 groups. In contrast, however, the overall incidence of reoperations for various complications in the irradiated group was only 11 per cent, compared to 25 per cent in the group not given preoperative radiation and 30.4 per cent of those operated upon for neurogenic bladders. Most significantly, none of the patients in the irradiated group required re-exploration and surgical correction of ureteroileal urinary fistulas. Comparison of these results to those reported in the literature is favorable. The ileal loop remains a simple and viable operative technique in patients requiring urinary diversion for pelvic malignancies previously irradiated.

ROENTGEN-RAY INTOXICATION

An increasing amount of experimental data has been accumulating which indicates clearly that the intestinal epithelium is peculiarly sensitive to the hard roentgen rays that are used so much in modern therapy. In the light of this knowledge, we wish to review some of the scattered and incomplete observations in human cases, as we believe the evidence is convincing that the intestinal epithelium in man is likewise sensitive to the hard or short wave length roentgen rays. If this is an established fact, we must use care in the exhibition of roentgen rays when the small intestine is exposed to irradiation; for example, in the treatment of pelvic tumors. There can be little doubt that the small intestine can be injured by roentgen-ray therapy in human beings, and it is certain that any such injury is serious. We know that roentgen-ray skin burns or ulcers are very chronic, and we