Use Of External Beam Radiotherapy Research Articles

Use of External Beam Radiotherapy Is Associated With Reduced Incidence of Second Primary Head and Neck Cancer: A SEER Database Analysis

Patients with head and neck cancer have a significant risk of developing a second primary cancer of the head and neck. We hypothesized that treatment with external beam radiotherapy (RT) might reduce this risk, because RT can eradicate occult foci of second head and neck cancer (HNCA). The data of patients with Surveillance, Epidemiology, and End Results Historic Stage A localized squamous cell carcinoma of the oral cavity, larynx, and pharynx were queried using the Surveillance, Epidemiology, and End Results database. For patients treated with or without RT, the incidence of second HNCA was determined and compared using the log-rank method. Cox proportional hazards analysis was performed for each site, evaluating the influence of covariates on the risk of second HNCA. Between 1973 and 1997, 27,985 patients were entered with localized HNCA. Of these patients, 44% had received RT and 56% had not. The 15-year incidence of second HNCA was 7.7% with RT vs. 10.5% without RT (hazard ratio 0.71, p <0.0001). The effect of RT was more profound in patients diagnosed between 1988 and 1997 (hazard ratio 0.53, p <0.0001) and those with pharynx primaries (hazard ratio 0.47, p <0.0001). On multivariate analysis, RT was associated with a reduced risk of second HNCA for pharynx (p <0.0001) and larynx (p = 0.04) tumors. For oral cavity primaries, RT was associated with an increased risk of second HNCA in patients treated before 1988 (p <0.001), but had no influence on patients treated between 1988 and 1997 (p = 0.91). For localized HNCA, RT is associated with a reduced incidence of second HNCA. These observations are consistent with the eradication of microscopic foci of second HNCA with external beam RT.

Should we perform surgery on late invasive vulvar cancer?

Vulvar cancer is an uncommon disease representing 3–5% of female genital tract malignancies. Squamous cell cancer accounts for approximately 90% of all primary vulvar malignancies. The incidence of in situ cancer has almost doubled over the past 30 years. The overall rate of invasive squamous cell cancer has remained relatively stable. Radical vulvectomy and en bloc groin dissection with pelvic lymphadenectomy have been considered standard treatment for all patients who have operable disease. In locally advanced vulvar cancer, partial resection of the urethra, vagina, anus or exenteration when necessary, has also been applied with severe post-surgical complications, poor quality of life and unsatisfactory survival rates. Chemoradiation followed by tailored surgery represents an attractive therapeutic option for advanced cases, to avoid ultraradical surgery and improve patient outcome. Chemotherapy has also been used in neoadjuvant therapy and in palliative treatment of patients with distant metastases. Numerous series have reported on the use of external beam radiation, often with concomitant chemotherapy, to shrink the primary tumor. Chemoradiation facilitates more limited resection of the tumor bed and lymphadenectomy on an individual basis, and initial response rates are approximately 90%. With the experience now accrued, preoperative chemotherapy with radiation should be regarded as the first-choice treatment for patients with advanced vulvar cancer.

Effective Treatment of Locally Advanced Endocrine Tumors of the Pancreas with Chemoradiotherapy

Background/Aims: The use of chemoradiation in the management of locally advanced pancreatic endocrine tumors has not been reported in the medical literature. Patients with unresectable tumors are often included in trials of systemic chemotherapy, and use of external beam radiation has been only described in few case reports. Given the sensitivity of pancreatic endocrine tumors to cytotoxic agents including streptozocin, doxorubicin and 5-FU, we have hypothesized that the combination of concurrent and sequential chemotherapy and radiation will yield higher response rates than acheivable with chemotherapy alone. Methods: Six patients with locally advanced pancreatic endocrine tumors were treated with a protocol consisting of radiation concurrent with infusional 5-FU (or capecitabine) along with induction and consolidation chemotherapy (streptozocin and doxorubicin). We retrospectively determined the objective radiographic response rate. Results: The objective response rate was 80%. With a median follow-up of 29 months, all six patients in the study have had continued reduction in tumor size from the time of the first posttreatment scan to the most recent scan. None of the patients have experienced local or metastatic disease progression. Treatment was well tolerated with minimal toxicity. Conclusion: The combination of concurrent and sequential chemoradiotherapy appears to be a highly effective treatment for locally advanced pancreatic endocrine tumors.

Current Management Strategies for Intraocular Retinoblastoma

Survival rates for retinoblastoma patients have increased dramatically over the last century, with documented 5-year survival figures reaching 87-99% in developed countries. During the last decade, there has been a dramatic paradigm shift in the treatment approach for intraocular retinoblastoma, emphasising chemoreduction protocols and minimising the use of external beam radiation. The recognition of the increased risk for second non-ocular cancers with external beam radiation contributed to the growing emergence of chemotherapy. Although chemoreduction protocols vary slightly between institutions, many centres are currently treating intraocular retinoblastoma with carboplatin, vincristine and etoposide as a three-drug regimen given in two to six cycles. Clinical studies have demonstrated that systemic chemotherapy must be combined with other modalities, such as laser treatment and cryotherapy, for adequate tumour control and many eyes with advanced intraocular disease require salvage therapy with radiation or enucleation. Therefore, modern centres treating retinoblastoma continue to manage patients with a variety of modalities, individualising the therapy according to the patient's presentation and clinical course.

Early use of a phosphodiesterase inhibitor after brachytherapy restores and preserves erectile function

To investigate whether the early use of phosphodiesterase inhibitors (PDEIs) after brachytherapy (BT) is associated with better erectile function, as of men potent before BT 38-70% have erectile dysfunction afterward. We evaluated a prospectively created database of 2500 patients who had had BT at our institution since 1992. We measured baseline age, cancer stage, Gleason grade, prostate specific antigen (PSA) level at diagnosis, implant type, use of neoadjuvant and adjuvant hormonal suppression therapy, use of external beam radiotherapy in conjunction with interstitial therapy, and follow-up PSA levels. Men were stratified by their use of PDEIs at <1 year (early group) or >1 year after implantation (late group). We excluded all men who did not have baseline Sexual Health Inventory for Men (SHIM) scores and at least one follow-up SHIM score; the latter were obtained at 6-month intervals after BT. Data were analysed using the Mann-Whitney U-test. In all, 210 men met the inclusion criteria; 85 began using PDEIs within a year of BT, and 125 started after a year. The mean time to PDEI use was 191 days in the early and 595 days in the late group. The median age was 62 years in the early and 63 years in the late group (P = 0.02). Baseline Gleason scores did not differ, nor did PSA levels between the groups. Of men in the early group, 48% received neoadjuvant and/or adjuvant hormonal suppression therapy, vs half of men in the late group. Baseline SHIM scores were not significantly different, nor were scores at the first two follow-up assessments, but the scores at 18-36 months after BT were significantly different. The early use of PDEIs after BT is associated with a significant improvement in and maintenance of erectile function compared with late use. Men undergoing BT should be encouraged to use PDEIs early after implantation, to preserve erectile function.

Role of Androgen Ablation with Low-Dose-Rate Brachytherapy in the??Treatment of Prostate Cancer

Androgen ablation is often used in addition to low-dose-rate brachytherapy in the treatment of prostate cancer, particularly for disease with adverse features. We report a single-institution experience and analysis of the role of androgen ablation with brachytherapy in patients with prostate cancer. A cohort of 189 consecutive patients receiving low-dose-rate brachytherapy for prostate cancer at our institution who had demographic, disease and treatment information and a minimum of 2 years of follow-up available, constituted the analysis study group. This cohort was divided into two major categories based on the use of androgen ablation. Using two successive prostate- specific antigen (PSA) rises above 1 ng/mL as the definition of failure, biochemical failure-free survival (BFFS) curves were constructed for the androgen ablation and no-androgen ablation groups and compared using the log rank test; additionally, a multivariate analysis of all major disease and treatment factors was performed using the Cox proportional hazards model. These analyses were conducted for the whole cohort as well as for subgroups defined by the use of external beam radiotherapy (EBRT). The 4-year BFFS in the androgen ablation versus no-androgen ablation groups was 76% versus 70% (p = 0.230) for the whole cohort, 75% versus 62% (p = 0.182) for EBRT patients, and 75% versus 82% (p = 0.764) for no-EBRT patients. For the whole cohort, the use of EBRT was the only factor reaching significance on multivariate analysis (p = 0.040). When analysing the EBRT and no-EBRT subgroups separately, no factor, including androgen ablation, reached significance on multivariate analysis. In our study, addition of androgen ablation conferred no biochemical control advantage when added to low-dose-rate brachytherapy for the treatment of patients with prostate cancer.

Spatial aspects of combined modality radiotherapy

Background and purpose A combined modality radiotherapy (CMRT) incorporates both external beam radiotherapy (EBT) and targeted radionuclide therapy (TRT) components. The spatial aspects of this combination were explored by utilising intensity modulated radiotherapy (IMRT) to provide a non-uniform EBT dose distribution. Patients and methods Three methods of prescribing the required non-uniform distribution of EBT dose are described, based on both physical and biological criteria according to the distribution of TRT uptake. The results and consequences of these prescriptions are explored by application to three examples of patient data. Results The planning procedure adopted allowed IMRT plans to be produced that met the prescription requirements. However, when the treatment was planned as a CMRT, compared with the use of EBT alone, more satisfactory target doses could be achieved with lower doses to normal tissues. The effects of errors in EBT delivery and in the functional data were found to cause a non-uniform prescription to tend towards the uniform case. Conclusions The methods and results are relevant for more general biological treatment planning, in which IMRT may be used to produce dose distributions prescribed according to tumour function. The effects of delivery and dose calculation errors can have a significant impact on how such treatments should be planned.

Management and Outcome of Patients With Malignant Salivary Gland Tumors

Refined imaging technology, the use of external beam radiation, neutron beam therapy, and chemotherapy, has altered management strategies for patients with salivary gland malignancies during the past 2 decades. Although treatment remains primarily surgical, optimal therapeutic regimens have yet to be fully realized. The purpose of this investigation is to report our experience with the management of patients with a variety of malignant salivary gland neoplasms that were treated with various combinations of surgery, radiation, and chemotherapy and to review treatment outcome in an effort to identify predictors of survival and locoregional control. The records of all patients with malignant salivary gland tumors presenting for treatment at our institution between 1992 and 2002 were retrospectively reviewed. Variables were collected and outcome measures were defined in terms of overall survival, disease-free survival, and locoregional control. Descriptive statistics were compiled and statistically evaluated. Survival was described using the Kaplan-Meier method. Prognostic factors were assessed using the Cox proportional hazards model. Clinical and reconstructive factors were reviewed. Eighty-five patients (35 males and 50 females) ranging in age from 16 to 89 years (mean, 58.6 years) met the criteria for inclusion in the study. The majority of tumors were located in the parotid gland (n = 42), with a significant minority located in the minor salivary glands (n = 29), followed by the submandibular gland (n = 8) and the sublingual gland (n = 6). Mucoepidermoid carcinoma was the most common neoplasm (n = 40). More than half of the patients presented in early-stage disease (stage I = 36, stage II = 17, stage III = 8, stage IV = 25). All patients were treated with surgery as the primary modality. Neck dissection was performed in 29% of patients, and more than half (56%) were treated with adjuvant external beam radiation therapy to a dose of 50 to 70 Gy. Patients were, in general, immediately reconstructed at the time of ablation using composite free tissue transfer when appropriate, local/regional rotational flaps, or maxillary obturators. The disease-free survival rate and locoregional control rate at 5 years were 77% and 86%, respectively. Stage (P = .0017), grade (P = .00044), cervical lymph node metastasis (P = .03), and age (P = .01) proved to make a statistically significant contribution when describing outcome. Neither site (P = .5), the presence of positive margins (P = .3), nor perineural invasion (P = .7) had a significant impact on survival. The treatment of salivary gland malignancies remains primarily surgical, although adjunctive radiotherapy may play an important role in those patients with advanced-stage disease. This study confirms the contributions of stage, grade, age, and cervical metastasis for describing survival. The benefits of combined modality therapy awaits prospective clinical trials.

Causes of chemoreduction failure in retinoblastoma and analysis of associated factors leading to eventual treatment with external beam radiotherapy and enucleation

Purpose To evaluate the causes of chemoreduction failure in retinoblastoma and to analyze the associated factors for eventual treatment with external beam radiotherapy and enucleation. Design Prospective noncomparative case series. Participants Seventy-one patients with 105 eyes with intraocular retinoblastoma that underwent chemoreduction therapy between October 1998 and January 2003. Intervention A 6-treatment cycle of chemoreduction therapy with vincristine, etoposide, and carboplatin was administered at monthly intervals. Unresponsive disease was defined as persistence of retinal tumors, vitreous seeds, or subretinal seeds after the second treatment cycle, with no appreciable sign of regression. Eyes with unresponsive disease were enucleated after the second treatment. Eyes that responded to chemoreduction therapy received focal treatment, including indirect laser photocoagulation, transpupillary thermotherapy, cryotherapy, and ruthenium 106 episcleral plaque radiotherapy after the second chemoreduction treatment, if necessary, to achieve complete tumor regression. Recurrence was defined as the regrowth of retinal tumors, vitreous or subretinal seeds after an initial favorable response, and regression. Recurrent retinal tumor, vitreous seeds, or subretinal seeds were treated with focal treatments and 2 to 3 additional chemoreduction treatments. When these methods failed or were not applicable, external beam radiotherapy and/or enucleation was administered. Main outcome measures The use of external beam radiotherapy and enucleation for chemoreduction failure, which was defined as unresponsive or recurrent disease. Results The mean follow-up was 25.7 months (range: 6–49). Ten of 105 eyes (9.5%) with unresponsive disease were enucleated after the second treatment. Of the remaining 95 eyes, 42 (44.2%) developed recurrence after chemoreduction. Recurrent disease failing to be treated successfully by other methods was treated with external beam radiotherapy in 26 of 95 eyes (27.4%) and enucleation in 22 of 95 eyes (23.2%). External beam radiotherapy was successful in preventing enucleation in 20 of 26 eyes (76.9%). Overall, the globe salvage rate was 69.5%, ranging from 36.1% for Reese–Ellsworth group V disease to 87.0% for groups I to IV disease. Histopathologically, 29 of 31 enucleated eyes (93.5%) had poorly differentiated or moderately differentiated retinoblastoma. Using multivariate logistic regression analysis, factors predictive of eventual treatment with external beam radiotherapy were female gender ( P = 0.010), presence of subretinal seeds ( P = 0.023), and a greater number of chemoreduction treatments ( P = 0.027). By multivariate analysis, the factors associated with the need for eventual treatment with enucleation were recurrence of retinal tumors ( P = 0.004), presence of vitreous seeds ( P = 0.008), greater tumor thickness ( P = 0.015), presence of subretinal fluid ( P = 0.040), and older patient age ( P = 0.042). Conclusions Chemoreduction failure in this article was defined as unresponsive or, more commonly, recurrent retinoblastoma. Older patient age, greater tumor thickness, presence of vitreous seeds and subretinal fluid at baseline, and retinal tumor recurrence after chemoreduction were factors associated with the need for enucleation.

Episcleral plaque brachytherapy for retinoblastoma.

The purpose of this study was to report our experience using episcleral plaque brachytherapy (EPBRT) to treat retinoblastoma and to demonstrate its applicability in multimodality treatment. We treated 26 tumors in 25 eyes from a group of 21 children with unilateral (n = 4) or bilateral (n = 17) retinoblastoma. The group comprised 8 girls and 13 boys; the median age was 25 months (range: 2-64 months) at the time of EPBRT. Iodine-125 ((125)I) was used for all applications. The median dose was 44 Gy (range: 35-47.6 Gy). EPBRT was administered primarily at the time of relapse after primary chemotherapy or radiation therapy. For eyes treated with EPBRT, the eye preservation rate was 15/25 with a median follow-up of 47 months (range: 2-198 months); the lesion control rate was 25/26 with a median follow-up of 13 months (range: 1-140 months). The median time to additional whole-eye treatment after EPBRT was 12 months (range: 2-105 months). Similar to previously reported series, EPBRT shows a high rate of successful tumor control as a primary treatment for retinoblastoma, as well as a secondary therapy at the time of relapse. EPBRT also allows for a clinically significant delay in the time to additional measures for the affected eye. Therefore, EPBRT should be considered as a form of local ophthalmic therapy that avoids or delays the use of external-beam radiotherapy, especially for patients primarily treated with chemotherapy who might require consolidation therapy.

Effect of cigarette smoking on biochemical outcome after permanent prostate brachytherapy

Purpose Recent studies have suggested that cigarette smoking may be associated with an increased risk of death from prostate cancer. In this study, we evaluated the effect of cigarette smoking on the presentation and biochemical outcome after permanent prostate brachytherapy for prostate cancer. Methods and materials A total of 582 patients underwent brachytherapy with generous periprostatic margins using either 103Pd or 125I with or without supplemental external beam radiotherapy between April 1995 and September 2000. Of the 582 patients, 178 (30.6%) had never smoked, 306 (52.6%) were former smokers, and 98 (16.8%) were current smokers. The median patient age was 67.9 years, and the median follow-up was 54.5 months. No patient was lost to follow-up. No patient underwent routine seminal vesicle biopsy or pathologic lymph node staging. The clinical, treatment, and dosimetric parameters evaluated included tobacco status, age, clinical stage, Gleason score, pretreatment prostate-specific antigen level, risk group, percentage of positive biopsies, ultrasound volume, isotope used, planning volume, hormonal status, use of external beam radiotherapy, and postimplant dosimetry (percentage of target volume receiving 100%, 150%, and 200% of the prescribed dose and percentage of prescribed dose covering 90% of the target volume). Biochemical outcome was determined using the American Society for Therapeutic Radiology and Oncology consensus definition. Results No differences in the clinical, treatment, or dosimetric parameters were identified, except that current smokers were statistically younger than those who had never smoked or former smokers (65.9 vs. 67.8 vs. 68.3 years, respectively, p = 0.016). Specifically, no relationship was discerned between tobacco history and risk group, supplemental external beam radiotherapy, choice of isotope, or use of hormonal therapy. The overall biochemical freedom from progression survival rate at 7 years was 96.2%, 95.6%, and 91.6% for patients who had never smoked, former smokers, and current smokers, respectively ( p = 0.126). When stratified by risk group and hormonal status, tobacco consumption did not predict outcome, although a trend for poorer biochemical progression-free survival was noted in current smokers. The median prostate-specific antigen level for hormone-naive and hormonally manipulated disease-free patients was <0.1 ng/mL. In multivariate Cox regression analysis, Gleason score, pretreatment prostate-specific antigen level, risk group, and hormonal status were predictors of biochemical outcome. Conclusion In this prostate brachytherapy cohort, tobacco consumption did not predict for risk group stratification or treatment approach. Although no statistically significant difference was found in biochemical progression-free survival, a trend for poorer biochemical outcome was demonstrated in current smokers.

Tumeurs de la rétine

This article reviews the various facets of retinoblastoma: definition, incidence, epidemiology, modes of discovery, clinical patterns, diagnostic clues, and differential diagnosis. Management is discussed, a recent trend being decreased use of external-beam radiation therapy; enucleation and conservative treatment are defined. The article also covers pathologic and cytogenetic findings, as well as external-beam radiation therapy, cryotherapy, photocoagulation, brachytherapy, and thermochemotherapy. Follow-up and genetic counselling are discussed. Extra-ocular retinoblastoma is reviewed, with emphasis on causes and management. Finally, other retinal tumours are briefly reviewed: combined hamartoma of the fovea and retinal pigment epithelium, benign congenital hypertrophy of the retinal pigment epithelium, retinal astrocytoma, and retinal capillary angioma.

External Beam Radiotherapy in the Management of Differentiated Thyroid Cancer

No randomised trials have addressed the use of external beam radiotherapy (EBRT) in the treatment of differentiated thyroid cancer. The indications for EBRT, the technique and recommended dose all remain controversial. We included patients treated with EBRT with curative intent from two cancer centres between 1988 and 2001. Data were collected from hospital notes, radiotherapy prescriptions and local cancer registry. The indications for treatment in the 41 identified patients were macroscopic residual disease 23 (56%), microscopic residual disease 10 (25%), Hurthle cell variants 3 (7%), multiple lymph-node involvement 3 (7%) and other 2 (5%). Delivered doses ranged from 37.5-66 Gy over 3-6.5 weeks. Rate of local recurrence and overall survival at 5 years were as follows: papillary 26% and 67%; follicular 43% and 48%; well differentiated 21% and 67%; focus of poor differentiation/Hurthle cell variants 69% and 32%; complete excision 25% and 61%; residual disease 37% and 59%; EBRT total dose < 50 Gy 63% and 42%; 50-54 Gy 15% and 72%; > 54 Gy 18%, and 68%. The results in this study are consistent with previous retrospective studies of EBRT. The wide range of indications and doses used with radical intent highlights the lack of clinical and radiobiological data on the response of differentiated thyroid cancer to EBRT. Despite the small study size, the 5-year local recurrence results indicate a possible dose response within the dose range used.

Is there a difference in outcome between stage I–II endometrial cancer of papillary serous/clear cell and endometrioid FIGO Grade 3 cancer?

Purpose: Several reports in the literature have shown that, compared with endometrioid adenocarcinoma, patients with papillary serous (PS) and clear cell (CC) histologic features do worse. However, it is unclear whether the outcome of PS/CC cancer is different from that of poorly differentiated endometrioid cancer. The purpose of this study was to compare the outcome between PS/CC and endometrioid International Federation of Gynecology and Obstetrics (FIGO) Grade 3 cancer and was limited to patients with Stage I–II uterine carcinoma. Methods and Materials: Between November 1987 and September 1999, 83 patients with Stage I endometrial cancer and Stage II occult endometrial cancer were treated with simple hysterectomy and high-dose-rate intravaginal brachytherapy. Forty-one patients (49%) had FIGO Grade 3 endometrioid tumors (Group 1) and 42 (51%) had PS/CC histologic features (Group 2). The mean age was 63 years (range 30–89). Comprehensive surgical staging was done in 23 (28%) of 83 patients. Capillary space-like invasion (CSLI) was seen in 24 (29%) of 83 patients. The median dose of intravaginal brachytherapy when used alone was 21 Gy in 3 fractions. Additional external beam radiotherapy was given to 42 (51%) of 83 patients to 45 Gy. The two groups were balanced with regard to age, race, comprehensive surgical staging, amount of myometrial involvement, CSLI, lower uterine segment involvement, cervical involvement, and use of external beam radiotherapy. The median follow-up was 46 months (range 4–147). Results: The pattern of relapse was as follows: vagina/pelvis in 5 of 14 patients, lungs in 8 of 15, intra-abdominal in 4 of 12, and supraclavicular lymph nodes in 1 of 14. One of the four intra-abdominal disseminations was in Group 1 and the other three in Group 2 ( p = 0.6). The 5-year vaginal/pelvic control, disease-free survival (DFS), and overall survival (OS) rate was 93% (95% confidence interval [CI] 87–99%), 79% (95% CI 69–89%), and 74% (95% CI 64–85%), respectively. No significant difference in outcome was found between Groups 1 and 2. The 5-year vaginal/pelvic control rate was 97% (95% CI 91–100%) in Group 1 compared with 90% (95% CI 81–99%) in Group 2 ( p = 0.2). The 5-year DFS rate was 79% (95% CI 64–95%) in Group 1 vs. 78% (95% CI 65–92%) in Group 2 ( p = 0.6), and the 5-year OS rate was 71% (95% CI 55–87%) in Group 1 vs. 79% (95% CI 66–92%) in Group 2 ( p = 0.3). The influence on outcome of age, race, comprehensive surgical staging, CSLI, amount of myometrial invasion, cervical involvement, lower uterine segment involvement, and presence of pure PS or CC histologic features was evaluated. On multivariate analysis, only CSLI correlated with poor DFS ( p = 0.04; relative risk 3, 95% CI 1–9) and OS ( p = 0.02; relative risk 3, 95% CI 1–6). Conclusion: On the basis of the results of this study, no significant difference in outcome exists between patients with Stage I–II endometrial cancer with PS/CC histologic features and those with similar stage disease, but with FIGO Grade 3 endometrioid histologic features. CSLI was the only independent predictor of poor DFS and OS.

External-beam radiotherapy in the management of liver metastases

This review discusses the importance of palliation of liver metastases. Although colorectal cancer comprises the majority of patients with metastatic liver disease, a number of other malignancies can be involved. Palliation of metastatic disease to liver has generally not included the use of external-beam radiotherapy because of restricted liver tolerance to radiotherapy. However, more recently, treatment policies have evolved to more generous use of palliative radiotherapy with utilization of tumor boost doses to partial liver volumes. This has resulted in improvement in palliation and a suggestion of improved survival with higher radiotherapy doses, which have been well tolerated by small volumes of liver. Semin Oncol 29:196-201. Copyright 2002, Elsevier Science (USA). All rights reserved.

Side effects and quality of life after inadvertent radiation overdosage in brachytherapy of head-and-neck cancer

Purpose: By comparing our old (DP5, in use from 1978 to 1994) and new (Plato, Nucletron) dose planning system, we found that the old system underestimated doses by 20–25%. To study the possible consequences for the patients treated between 1978 and 1994, all who were still alive were invited to undergo an examination with respect to side effects and quality of life (QOL).Methods and Materials: The degree of overdosage was calculated by comparing the isodose distribution generated on the two dose planning systems. Eighty-four patients were then invited to undergo an examination with respect to side effects and QOL. The side effects were scored according to the LENT SOMA system and QOL according to European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire-Core 30 (QLQ-C30), and EORTC Quality of Life Questionnaire-Head & Neck 35 (QLQ-H&N35).Results: The mean overdosage of brachytherapy was 19.3%. No association was found between overdosage and side effects or QOL. For implants in the lateral border of the tongue, we found a statistically significant correlation between osteoradionecrosis and the following parameters: linear activity, total activity, dose rate, and extrapolated response dose. By multivariate analysis, only total implanted activity and the use of lead protection during brachytherapy were found to be of prognostic significance with respect to development of osteoradionecrosis.Conclusion: The incidence of side effects after brachytherapy at the Norwegian Radium Hospital seems to have been somewhat higher in the period under investigation than at other institutions. There may be several explanations, including the use of external beam radiotherapy before brachytherapy and departure from the Paris system among others. However, the side effects were not associated with the overdosage that was the basis for the study. As opposed to the general consensus of opinion, long-term QOL was found to be worse after brachytherapy than after external beam radiotherapy. This calls for increased awareness and a systematic prospective registration of the long-term side effects of brachytherapy.

The utility of external beam radiation and intracystic 32P radiation in the treatment of craniopharyngiomas.

The management of craniopharyngiomas has historically been controversial in terms of the extent of initial surgical resection and the use of additional treatments. Various options include radical excision versus a more conservative surgical approach followed by external beam radiation; most recently, intracystic 32P radiation has been used in selected patients. We reviewed our experience with 25 patients with craniopharyngiomas treated between 1984 and 1999 to assess the effectiveness of external beam radiation and intracystic 32P radiation therapy in preventing progression and recurrence of local disease. All patients underwent surgery as a component of initial therapy for their histologically-proven craniopharyngiomas. Fifteen patients additionally received external beam radiation. Forty-five percent of patients who underwent incomplete resections followed by external beam radiation required additional therapy. In contrast, 80% of patients who had incomplete resections without post-operative external beam radiation required further treatment. Seven patients had intracystic 32P colloid injections. Neither of the two patients receiving 32P intracystic radiation as part of their initial therapy needed further treatment. Only one of the five patients receiving 32P intracavitary radiation for disease progression following initial therapy required further intervention. Of the remaining four patients, three enjoyed responses to treatment and one had stable disease. Our observations support the use of external beam radiation for prevention of tumor progression in adults unable to receive a complete surgical resection. Our results additionally suggest that intracystic 32P radiation results in control of cystic components of craniopharyngiomas in the majority of cases.

Effect on local control and survival of electron beam intraoperative irradiation for resectable pancreatic adenocarcinoma

Purpose: To assess the impact on local control and survival of intraoperative radiotherapy (IORT) in resectable pancreatic adenocarcinoma. Methods and Materials: The outcome of 127 patients surgically treated with curative intent combined with IORT was compared with the therapeutic results of 76 patients treated with surgery as exclusive treatment. Results: Operative mortality and morbidity were similar in IORT and no-IORT patients. In 49 patients with locally limited disease (Stage I–II; LLD), IORT ( n = 30) reduced the local failure rate and significantly prolonged time to local failure (TTLF), time to failure (TTF), and overall survival (OS) with respect to surgery alone ( n = 19). The multivariate analyses, stratifying patients by age, tumor grade, resection margins, chemotherapy, and external-beam radiotherapy use, confirmed the independent impact of IORT on outcome. In patients with locally advanced disease (Stage III–IVA; LAD), IORT had an impact on local failure rate and on TTLF when combined with beam energies of greater than 6 MeV, whereas no effect on TTF and OS was observed. Conclusion: IORT did not increase operative mortality and morbidity and achieved a significant improvement in local control and outcome in patients with LLD. In patients with LAD, beam energies greater than 6 MeV prolonged TTLF.

Conventional radiation therapy of cervical cancer.

This review of the present literature about the conventional management of patients with definitive radiotherapy for invasive carcinoma of the cervix will focus on advances in the use of external-beam radiation therapy (EBRT) as well as in the administration of low-dose-rate brachytherapy for the delivery of radiotherapy. Important concepts discussed include: techniques and dose fractionation for EBRT; newer imaging modalities for administration of EBRT; construction of the midline shield for external irradiation of the pelvic nodes following brachytherapy; the role of elective para-aortic nodal external radiotherapy; and the adequate number of brachytherapy applications needed to impact on patient outcome. Considerable attention will be given to multi-institutional clinical data (e.g., the Patterns of Care Study and the Radiation Therapy Oncology Group) to illustrate advances in radiotherapy of patients with cervical carcinoma.

Conventional radiation therapy of cervical cancer

This review of the present literature about the conventional management of patients with definitive radiotherapy for invasive carcinoma of the cervix will focus on advances in the use of external-beam radiation therapy (EBRT) as well as in the administration of low-dose-rate brachytherapy for the delivery of radiotherapy. Important concepts discussed include: techniques and dose fractionation for EBRT; newer imaging modalities for administration of EBRT; construction of the midline shield for external irradiation of the pelvic nodes following brachytherapy; the role of elective para-aortic nodal external radiotherapy; and the adequate number of brachytherapy applications needed to impact on patient outcome. Considerable attention will be given to multi-institutional clinical data (e.g., the Patterns of Care Study and the Radiation Therapy Oncology Group) to illustrate advances in radiotherapy of patients with cervical carcinoma. Semin. Surg. Oncol. 16:242–246, 1999. © 1999 Wiley-Liss, Inc.