Whole Abdominal Irradiation Research Articles

Outcome and patterns of failure in pathologic stage I-IV clear cell carcinoma of the endometrium: implications for adjuvant radiation therapy

Outcome and patterns of failure in pathologic stage I-IV clear cell carcinoma of the endometrium: implications for adjuvant radiation therapy

Surgery and postoperative radiation therapy in FIGO Stage IIIC endometrial carcinoma

Objective: To determine the outcome, pattern(s) of failure, and optimal treatment volume in Stage IIIC endometrial carcinoma patients treated with surgery and postoperative radiation therapy (RT). Methods: Between 1983 and 1998, 30 Stage IIIC endometrial carcinoma patients were treated with primary surgery and postoperative RT at the University of Chicago. All underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, sampling of pelvic lymph nodes (PLN), and peritoneal cytology. All were noted to have PLN involvement. Para-aortic lymph nodes (PALN) were sampled in 26 cases, and were positive in 14 cases (54%). Twenty women received whole-pelvic RT (WPRT) and 10 (WPRT), plus paraortic RT (extended-field RT, EFRT). One EFRT patient also underwent concomitant whole-abdominal RT (WART). Adjuvant vaginal brachytherapy (VB) was delivered in 10, chemotherapy in 5, and hormonal therapy in 7 patients. Results: At a median follow-up of 32 months, the actuarial 5-year disease-free and cause-specific survivals of the entire group were 33.9% and 55.8%, respectively. Overall, 16 women (53%) relapsed. Sites of failure included the pelvis (23%), abdomen (13%), PALN (13%), and distant (40%). Of the 7 pelvic failures, 4 were vaginal (3 vaginal only). Patients treated with VB had a trend to a lower vaginal recurrence rate (0/10 vs. 4/20, p = 0.12) than those not receiving VB. All 4 PALN failures were in women treated with WPRT (2 negative, 1 unsampled, and 1 positive PALN). None of the 10 EFRT patients (2 negative, 8 positive PALN) recurred in the PALN. No patient developed an isolated abdominal recurrence. Two patients developed significant RT sequelae: chronic diarrhea in 1 patient treated with WPRT and VB, and small bowel obstruction in 1 patient treated with EFRT. Conclusion: FIGO Stage IIIC disease comprises a small percentage of endometrial carcinoma patients but carries a poor prognosis. Our failure pattern suggests that the optimal adjuvant RT volume is EFRT, even in women with negative PALN sampling. VB should also be administered to improve local control. The low rate of abdominal recurrence does not support the routine use of WART in these women. Given the predominance of failure in distant sites, attention should be focused on the development of systemic chemotherapy protocols.

Prognosis for papillary serous carcinoma of the endometrium after surgical staging.

To investigate the pattern of failure and the prognosis following pathological staging for uterine papillary serous carcinoma (UPSC). A retrospective review was conducted of 22 patients with UPSC, treated between 1989 and 1998 at a single institution. All patients were surgically staged. Two patients with advanced disease received chemotherapy only. Two patients with early-stage disease were followed without further treatment. Eighteen patients received postoperative irradiation; eight patients received whole abdominal irradiation (WART), and the remaining 10 patients, pelvic irradiation (PRT). In addition, seven of these patients received vaginal cuff irradiation with low-dose-rate or high-dose-rate brachytherapy. Toxicity, pattern of failure, and survival were evaluated and compared to the literature. Seven patients (32%) developed distant metastases, three out of seven (42%) after WART. Four out of seven patients who had distant metastases died from disease progression during subsequent chemotherapy. All patients with distant metastases had locally advanced-stage disease at presentation (six stage III, one stage IV). Four patients with pelvic recurrences developed concurrent (2) and subsequent (2) distant metastases. Three patients had isolated distant metastases. No patient with early stage-disease (stage I and II) died from disease progression. Pathological staging should be performed for all patients with UPSC to determine the prognosis as well as to tailor the treatment. The role of abdominal irradiation in the treatment of UPSC is yet to be determined; however, such an approach may not be necessary for the control of disease for patients with early-stage (I and II) disease. Patients with locally advanced-stage (stage III) disease are at risk of local regional failures and distant metastases despite WART. Therefore, the benefit of WART for advanced-stage disease is also questionable. Paclitaxel-based chemotherapy is currently being investigated in this setting.

Early stage uterine papillary serous carcinoma of the endometrium

BACKGROUND Uterine papillary serous carcinoma (UPSC) is an aggressive subtype of endometrial cancer, behaving like ovarian epithelial cancers and having a predilection for transperitoneal relapse. Within this subtype of uterine cancers, predictors of outcome and the role of adjuvant therapies have not been firmly established, to the authors' knowledge.. METHODS Between 1985–1995, 78 patients who had International Federation of Gynecology and Obstetrics (FIGO) Stage I, II, or IIIa UPSC (based on positive washings only) were seen at the British Columbia Cancer Agency. During this time, the authors had a policy of offering adjuvant pelvic, paraaortic and whole-abdominal radiotherapy (WART) to these patients. Fifty-eight patients received adjuvant WART, and 20 received lesser or no adjuvant therapy. The authors undertook a retrospective analysis of pathology with quantification of the percentage of papillary serous component (% PSC) and p53 expression. Pathology was retrieved and reviewed on 62 patients; p53 staining was performed on blocks from the hysterectomy specimen in 46 cases. Pathologic parameters, stage, and adjuvant therapy were correlated with clinical outcome in a multivariate analysis. RESULTS Median follow-up was 52 months (3–139 mos) and the 5-year disease-specific survival rate was 66.2%. The 58 patients who received adjuvant WART had a significantly better 5-year disease-specific survival than those 20 patients who did not, 74.9% versus 41.3% (P = 0.04). Multivariate analysis showed that % PSC and p53 were not significant predictors of outcome for early stage UPSC. Of the factors examined, only FIGO stage and WART significantly predicted improved outcome (P = 0.02 and 0.04, respectively). CONCLUSIONS The current study demonstrated a significant difference in the outcomes of patients who had FIGO Stage I compared with Stage II UPSC. In the current series of patients, the authors were not able to predict outcome based on % PSC or p53 expression. The current study results with WART were promising, and WART merits further study. Cancer 2001;91:752–7. © 2001 American Cancer Society.

Prognosis for papillary serous carcinoma of the endometrium after surgical staging

Abstract.Nguyen NP, Sallah S, Karlsson U, Vos P, Ludin A, Semer D, Tait D, Salehpour M, Jendrasiak G, Robiou C. for papillary serous carcinoma of the endometrium after surgical staging.Background: To investigate the pattern of failure and the prognosis following pathological staging for uterine papillary serous carcinoma (UPSC).Patients and methods: A retrospective review was conducted of 22 patients with UPSC, treated between 1989 and 1998 at a single institution. All patients were surgically staged. Two patients with advanced disease received chemotherapy only. Two patients with early-stage disease were followed without further treatment. Eighteen patients received postoperative irradiation; eight patients received whole abdominal irradiation (WART), and the remaining 10 patients, pelvic irradiation (PRT). In addition, seven of these patients received vaginal cuff irradiation with low-dose-rate or high-dose-rate brachytherapy. Toxicity, pattern of failure, and survival were evaluated and compared to the literature.Results: Seven patients (32%) developed distant metastases, three out of seven (42%) after WART. Four out of seven patients who had distant metastases died from disease progression during subsequent chemotherapy. All patients with distant metastases had locally advanced-stage disease at presentation (six stage III, one stage IV). Four patients with pelvic recurrences developed concurrent (2) and subsequent (2) distant metastases. Three patients had isolated distant metastases. No patient with early stage-disease (stage I and II) died from disease progression.Conclusion: Pathological staging should be performed for all patients with UPSC to determine the prognosis as well as to tailor the treatment. The role of abdominal irradiation in the treatment of UPSC is yet to be determined; however, such an approach may not be necessary for the control of disease for patients with early-stage (I and II) disease. Patients with locally advanced-stage (stage III) disease are at risk of local regional failures and distant metastases despite WART. Therefore, the benefit of WART for advanced-stage disease is also questionable. Paclitaxel-based chemotherapy is currently being investigated in this setting.

Early stage uterine papillary serous carcinoma of the endometrium

Uterine papillary serous carcinoma (UPSC) is an aggressive subtype of endometrial cancer, behaving like ovarian epithelial cancers and having a predilection for transperitoneal relapse. Within this subtype of uterine cancers, predictors of outcome and the role of adjuvant therapies have not been firmly established, to the authors' knowledge. Between 1985-1995, 78 patients who had International Federation of Gynecology and Obstetrics (FIGO) Stage I, II, or IIIa UPSC (based on positive washings only) were seen at the British Columbia Cancer Agency. During this time, the authors had a policy of offering adjuvant pelvic, paraaortic and whole-abdominal radiotherapy (WART) to these patients. Fifty-eight patients received adjuvant WART, and 20 received lesser or no adjuvant therapy. The authors undertook a retrospective analysis of pathology with quantification of the percentage of papillary serous component (% PSC) and p53 expression. Pathology was retrieved and reviewed on 62 patients; p53 staining was performed on blocks from the hysterectomy specimen in 46 cases. Pathologic parameters, stage, and adjuvant therapy were correlated with clinical outcome in a multivariate analysis. Median follow-up was 52 months (3-139 mos) and the 5-year disease-specific survival rate was 66.2%. The 58 patients who received adjuvant WART had a significantly better 5-year disease-specific survival than those 20 patients who did not, 74.9% versus 41.3% (P = 0.04). Multivariate analysis showed that % PSC and p53 were not significant predictors of outcome for early stage UPSC. Of the factors examined, only FIGO stage and WART significantly predicted improved outcome (P = 0.02 and 0.04, respectively). The current study demonstrated a significant difference in the outcomes of patients who had FIGO Stage I compared with Stage II UPSC. In the current series of patients, the authors were not able to predict outcome based on % PSC or p53 expression. The current study results with WART were promising, and WART merits further study.

FIGO Stage IIIC Endometrial Carcinoma With Metastases Confined to Pelvic Lymph Nodes: Analysis of Treatment Outcomes, Prognostic Variables, and Failure Patterns Following Adjuvant Radiation Therapy

Abstract Objectives. This study was undertaken to evaluate the prognostic significance of isolated positive pelvic lymph nodes on survival and to analyze other prognostic variables, overall survival, and failure patterns in surgically staged endometrial carcinoma patients with positive pelvic lymph nodes and negative para-aortic lymph nodes following radiation therapy (RT). Methods. Between January 1, 1987, and December 31, 1997, 782 women underwent primary treatment for uterine cancer at Indiana University Medical Center. Through a review of the medical records, we identified 58 patients with pathologic stage IIIA, 27 patients with pathologic stage IIIB, and 77 patients with pathologic stage IIIC endometrial carcinoma. Patients with pathologically positive or unsampled para-aortic lymph nodes and patients who received preoperative radiation therapy were excluded, leaving a study group of 17 patients with nodal metastases confined to pelvic lymph nodes. Thirteen patients received adjuvant pelvic RT using AP-PA or four-field technique. A median dose of 5040 cGy was delivered. Four patients received whole abdominal irradiation (WAI) delivering a median dose of 3000 cGy. Two patients received vaginal cuff boosts of 1000 and 3560 cGy to 0.5 cm from the vaginal surface mucosa via Cs-137 brachytherapy. Two patients also received adjuvant chemotherapy ( cis -platinum and doxorubicin) and/or hormonal therapy (megestrol acetate). Disease-free and overall survivals were estimated using the Kaplan–Meier method of statistical analysis and prognostic variables were analyzed using the log-rank test. Results. With a median follow-up of 51 months the actuarial 5-year disease-free survival was 81% and the actuarial 2-year and 5-year overall survival rates were 81 and 72%, respectively. Univariate analysis revealed that positive peritoneal cytology in conjunction with positive pelvic lymph nodes imparts a greater risk of recurrence and decreased overall survival. There were no pelvic and/or upper abdominal failures, but there were recurrences in the para-aortic lymph nodes (two patients) and distantly (two patients). Conclusion. Surgery followed by postoperative pelvic RT is a viable treatment option for pathologically staged stage IIIC endometrial carcinoma with disease confined to the pelvic lymph nodes. Failures in the para-aortic region suggest a possible role for extended-field RT. Patients with positive peritoneal cytology in conjunction with nodal metastasis fared poorly with pelvic RT. Studies evaluating the efficacy of WAI are ongoing. Finally, substages within FIGO stage IIIC are recommended in an effort to better understand and define treatment strategies which might be appropriate for these patients.

Ovarial cancer: best timing and applications of debulking surgery

Ovarian Cancer is the fifth leading cause of death in women in the United States and the most common cause of death in women with gynaecological malignancies in most Western countries. Despite the significant advances in surgery, chemotherapy and radiotherapy, the resulting overall 5-year survival is about 40-50% [1]. In addition, millions of women remain fearful and concerned about being diagnosed with this too often fatal disease. While early detection improves the chances that ovarian cancer can be treated successfully, early cancers of the ovaries rarely cause symptoms that women would notice, or the symptoms are mistaken for menopausal ailments or intestinal illness. As a result, almost 75% of women with ovarian cancer are not diagnosed until the disease is advanced in stage with only 15-20% chances of reaching 5-year survival. Investigative efforts for the new millennium involve the areas of basic science and translational research, genetic susceptibility and prevention, diagnostic imaging, screening and diagnosis and, finally, therapy. Unfortunately, at present, results of treatment are still far from optimal. Integration of surgery with chemotherapy are crucial in the treatment of ovarian cancer and the recommended treatment strategy for patients with advanced ovarian cancer is radical cytoreductive surgery followed by 6 cycles of platinum-based combination chemotherapy [2]. The role of whole-abdominal radiation therapy in the treatment of ovarian cancer is still controversial. In particular, evidence that radiation therapy is curative in patients with advanced disease is lacking while severe toxicity is reported [3]. Critics of this modality have argued that the dose of radiation that can be safely delivered is low and unlikely to eradicate more than microscopic disease. Despite the fact that during the last two decades the cytoreductive ability of gynaecological oncologists has increased and an higher response rate to platinum-based chemotherapy can be obtained, the state of the art treatment fails to cure the vast majority of patients with advanced disease. In order to minimise the tumour burden before chemotherapy, cytoreductive (or debulking) surgery is usually performed upfront. Possible benefits from upfront cytoreductive surgery include: (a) improvement of tumour response to further therapy due to improved tumour perfusion and increased growth fraction. Smaller tumour masses require fewer cycles of chemotherapy with less chance of induced drug-resistance. Clones of phenotypically resistant cells may be removed also; (b) immediate treatment, or prevention of complications arising from tumour masses, i.e. bowel obstruction and ascites; (c) enhancement of the immunological competence of the patient. The immunogenicity of ovarian cancer has been demonstrated in vivo and cytoreduction may help the patient to mobilise her own immune response to the cancer [4]; (d) psychological benefit to the patient of knowing that the tumour bulk has been removed [5]. Several non randomised studies showed improved survival of patients with less than 1 cm diameter of residual tumour after primary surgery, as compared with patients with larger lesions. In a case-control study of patients with minimal residual disease, . Eisenkop et al. reported a longer survival for patients whose small lesions were completely resected rather than for those patients whose similar lesions were not completely removed [6]. Conversely, both Hoskins [7] and Hacker [8] reported that, despite optimal cytoreduction, the survival of patients with large intra-abdominal metastases before resection was significantly worse than that observed in patients with initially small intra-abdominal lesions. These observations suggested that intrinsic tumour factors are of prognostic importance in addition to residual disease after cytoreduction and also raised the question of whether cytoreduction has a significant effect on survival among patients with the same size tumours and the same intrinsic prognostic factors. Moreover, the problem still under debate is whether the observed survival benefits for cytoreduced patients are a function of surgical skill, tumour biology or both.

FIGO Stage IIIC Endometrial Carcinoma with Metastases Confined to Pelvic Lymph Nodes: Analysis of Treatment Outcomes, Prognostic Variables, and Failure Patterns Following Adjuvant Radiation Therapy

Objectives. This study was undertaken to evaluate the prognostic significance of isolated positive pelvic lymph nodes on survival and to analyze other prognostic variables, overall survival, and failure patterns in surgically staged endometrial carcinoma patients with positive pelvic lymph nodes and negative para-aortic lymph nodes following radiation therapy (RT).Methods. Between January 1, 1987, and December 31, 1997, 782 women underwent primary treatment for uterine cancer at Indiana University Medical Center. Through a review of the medical records, we identified 58 patients with pathologic stage IIIA, 27 patients with pathologic stage IIIB, and 77 patients with pathologic stage IIIC endometrial carcinoma. Patients with pathologically positive or unsampled para-aortic lymph nodes and patients who received preoperative radiation therapy were excluded, leaving a study group of 17 patients with nodal metastases confined to pelvic lymph nodes. Thirteen patients received adjuvant pelvic RT using AP-PA or four-field technique. A median dose of 5040 cGy was delivered. Four patients received whole abdominal irradiation (WAI) delivering a median dose of 3000 cGy. Two patients received vaginal cuff boosts of 1000 and 3560 cGy to 0.5 cm from the vaginal surface mucosa via Cs-137 brachytherapy. Two patients also received adjuvant chemotherapy (cis-platinum and doxorubicin) and/or hormonal therapy (megestrol acetate). Disease-free and overall survivals were estimated using the Kaplan–Meier method of statistical analysis and prognostic variables were analyzed using the log-rank test.Results. With a median follow-up of 51 months the actuarial 5-year disease-free survival was 81% and the actuarial 2-year and 5-year overall survival rates were 81 and 72%, respectively. Univariate analysis revealed that positive peritoneal cytology in conjunction with positive pelvic lymph nodes imparts a greater risk of recurrence and decreased overall survival. There were no pelvic and/or upper abdominal failures, but there were recurrences in the para-aortic lymph nodes (two patients) and distantly (two patients).Conclusion. Surgery followed by postoperative pelvic RT is a viable treatment option for pathologically staged stage IIIC endometrial carcinoma with disease confined to the pelvic lymph nodes. Failures in the para-aortic region suggest a possible role for extended-field RT. Patients with positive peritoneal cytology in conjunction with nodal metastasis fared poorly with pelvic RT. Studies evaluating the efficacy of WAI are ongoing. Finally, substages within FIGO stage IIIC are recommended in an effort to better understand and define treatment strategies which might be appropriate for these patients.

Long-term evolution of renal function in patients with ovarian cancer after whole abdominal irradiation with or without preceding cisplatin

The upper limit of the natural decline in creatinine clearance is 1 ml/min/year. To define the loss of renal function, we started a long-term assessment of patients with ovarian cancer treated by whole abdominal irradiation (WAI) with preceding cisplatin chemotherapy (CDDP) and second-look laparotomy (SLL). We analyzed the creatinine clearance over time of 56 patients treated from 1982 to 1988 for ovarian cancer. Thirty-one of 56 patients had received WAI after their initial surgery, and 25 of 56 patients had undergone CDDP therapy followed by SLL, and then WAI after their initial surgery. Median follow-up was 99 months (7-156). Twenty of 56 patients accepted our invitation for additional assessment of tubular function, nine of the 31 patients without CDDP therapy and SLL, and 11 of the 25 patients with CDDP followed by SLL and WAI. Ten of twenty patients had received four to six cycles CDDP, 80 mg/m2/cycle, and one patient nine cycles. The median total dose for each kidney was 1450 cGy (480-1690). The mean creatinine clearance decreased from 84 ml/min to 66 ml/min. Seventy-six percent of the 25 patients who had undergone CDDP therapy, SLL and WAI had declines of more than 1 ml/min/year, 64% of these patients of more than 2 ml/min/year. For the 31 patients who had received WAI after their initial surgery, the corresponding numbers were 71% and 55%, respectively. The tubular function of the 20 patients who had undergone the additional investigations was not impaired. The decline in renal function after WAI is more pronounced than in healthy subjects. The treatment with cisplatin and SLL prior to WAI does not seem to contribute to this loss of kidney function.

Uterine Papillary Serous Carcinoma: Evaluation of Long-Term Survival in Surgically Staged Patients

Objective.Earlier studies have demonstrated that the uterine papillary serous carcinoma (UPSC) variant of endometrial carcinoma has a high recurrence rate, even when disease is apparently confined to the uterus. The current study evaluated survival in patients with surgically staged UPSC.Methods.Patients with UPSC were identified from surgical pathology files and charts were retrospectively reviewed. Only patients who had undergone a TAH–BSO, lymph node dissection, and peritoneal cytology were included.Results.The FIGO stages of the 36 patients were 12 Stage I (4 IA, 4 IB, 4 IC), 2 Stage IIB, 13 Stage III (5 IIIA, 8 IIIC), and 9 Stage IV. Of the 14 Stage I/II patients, 6 did not receive adjuvant therapy, 5 received whole pelvic radiation (WPXRT), and 3 received whole abdominal radiation therapy (WART); after a median follow-up interval of 50 months only 2 (14%) of these Stage I/II patients have developed a recurrence. Both of the recurrences were in Stage IC patients who received radiation; 1 recurred in the radiation field. Of the 5 Stage IIIA patients, 3 patients declined therapy and 2 were treated with WART; 3 patients, including the 2 who received radiation therapy, are alive without disease. Of the 8 Stage IIIC patients, 2 declined postoperative therapy, 2 received WART, and 4 received WPXRT with an extended field to include paraaortic nodes. Four of the 6 Stage IIIC patients treated with curative intent are without evidence of disease and 1 died of unrelated causes after a median follow-up interval of 48 months. Both of the Stage IIIC patients who declined treatment recurred. Of the 9 patients with Stage IV disease, 8 have died of disease.Conclusion.Women with UPSC have a good prognosis when surgical staging confirms that disease is confined to the uterus (Stage I/II). Surgical findings can also be used to tailor adjuvant radiation treatments. Further study is required to define the optimal treatment for women with metastatic UPSC.

WART revisited: the treatment of epithelial ovarian cancer by whole abdominal radiotherapy.

The present study investigated outcomes for 78 women with epithelial ovarian carcinoma treated by whole abdominal radiotherapy (WART) after cyto-reductive surgery at Westmead Hospital between 1980 and 1993. These patients had 5-year relapse-free and overall survival rates of 52 and 55%, respectively. The median follow-up was 7.5 years. Fifty-eight of the 78 women fulfilled the criteria as defined by the Princess Margaret Hospital's intermediate risk' category. These patients had both a relapse-free and overall survival rate of 62% at 5 years (P = 0.001 as compared with the remaining 20 women). Mild gastrointestinal upset was common during radiotherapy. Five women did not complete treatment. Late toxicity (grade 3 or more, using the Radiotherapy Oncology Group (RTOG) system) occurred in eight women, and five women required surgery for intestinal complications (6.4%). There were no deaths due to late side effects. In conclusion the results are consistent with those of other series in the treatment of epithelial ovarian cancer by adjuvant WART. When compared to a similar-stage disease treated with cisplatin-based chemotherapy, there is no evidence to support the exclusive use of chemotherapy.

Respiration-induced motion of the kidneys in whole abdominal radiotherapy: implications for treatment planning and late toxicity

Purpose: Whole abdominal radiotherapy (WAR) has potential utility in the management of several malignancies. The limited radiation tolerance of the kidneys is an important consideration in the design of WAR fields. Although renal blocking is standard for WAR, few guidelines exist in the literature to factor respiration-induced kidney motion into the design of these blocks. Methods: Radiographs were obtained to measure kidney excursion under forced respiratory conditions in eight patients (14 visualized kidneys). Intravenous contrast was administered and AP films were obtained at maximum inspiration and expiration. Renal excursion was measured relative to a horizontal reference line at the bottom of the L3 vertebral body. The kidney position on the actual treatment simulation film was also determined using this technique. Treatment isodose distributions through the kidneys were obtained for a sample patient using phantom measurements and two blocking schemes: AP/PA and PA only. These provided quantification of the actual dose received by the kidney in a typical WAR treatment. Results: In the worst case scenario, the left kidney block required an additional 10 mm above and 15 mm below the renal silhouette on the simulation film in order to account for all phases of respiration. The corresponding values for the right kidney were 2 mm and 19 mm, respectively. The dose received by the kidney under the center of the block was 20% of prescribed using AP/PA blocks and 50% of prescribed using PA blocks only. However, portions of ‘blocked’ kidney received up to 90% of the prescribed dose with either technique. Conclusions: Although kidney motion under forced respiratory conditions is not representative of typical treatment conditions, the data highlight the possibility of renal movement during treatment. This is particularly important in light of the significant dose (20 to 50%) delivered to the kidney under the center of the kidney block in typical treatments. Given the potential for overdosage of this critical organ, careful prospective documentation of renal function is warranted in patients receiving WAR.

22115 years later: The results of whole abdominal irradiation (WAI) of ovarian cancer patients after platinol-chemotherapy and second-look-laparotomy

22115 years later: The results of whole abdominal irradiation (WAI) of ovarian cancer patients after platinol-chemotherapy and second-look-laparotomy

497 Respiration induced motion of the kidneys: Implications for block design in whole abdominal radiotherapy (WAR)

<h3>Purpose</h3> Whole abdominal radiotherapy (WAR) is frequently used in the treatment of tumors of the ovary and endometrium. The limited radiation tolerance of several critical organs, especially the kidneys, is an important consideration in the design of WAR fields. Although renal blocking is standard for WAR, few guidelines exist in the literature to factor respiration-induced kidney motion into the design of these blocks. <h3>Methods</h3> Radiographs were obtained to measure kidney excursion under forced respiratory conditions in 6 patients (10 visualized kidneys). Intravenous contrast was administered and AP films were obtained at maximum inspiration and expiration. A horizontal reference line was drawn at the bottom of the L3 vertebral body and the excursion of each kidney was determined relative to this line. The kidney position on the actual treatment simulation film was also determined using this technique. These excursion movements were incorporated into the design of an idealized block to account for all phases of respiration. <h3>Results</h3> The range of excursion for the left kidney was 1–32mm and for the right kidney was 3–14mm. In a worst case scenario, the left kidney block required an additional 14mm above and 32mm below the renal silhouette on the simulation film. The corresponding values for the right kidney were 17mm and 10mm, respectively. <h3>Conclusions</h3> Although kidney motion under forced respiratory conditions is not representative of typical treatment conditions, the data highlight the possibility of significant renal movement during treatment. These factors must be kept in mind when customizing renal blocks.

Adjuvant continuous infusion 5-FU, whole-abdominal radiation, and tumor bed boost in high-risk stage III colon carcinoma: A southwest oncology group pilot study

Results of a combined modality adjuvant pilot program of low-dose continuous-infusion 5-fluorouracil, whole-abdominal radiation, and tumor bed boost in patients with colon cancer with involved nodes and serosal involvement are presented. Forty-one eligible patients with completely resected T3N1-2M0 colon cancer (modified Astler-Coller C2) were treated with 5-fluorouracil (5-FU) at a dose of 200 mg/m2/day by continuous infusion and 30 Gy of concomitant whole-abdominal radiation in 1 Gy fractions. An additional 16 Gy boost to the tumor bed was administered in 1.6 Gy fractions. After completion of combined modality treatment and a 21-day rest period, patients received 4 days of 5-FU at a dose of 1000 mg/m2 by continuous infusion every 28 days for nine cycles. Five-year disease-free and overall survival estimates were 58 and 67%, respectively, for all T3N1-2 patients. Five-year disease-free and overall survival estimates for the 19 patients with four or fewer nodes were both 61%. Five-year disease-free survival and overall survival estimates for the 20 patients with more than four involved nodes were 55% and 74%, respectively (the exact number of involved nodes were unknown for two patients). Disease-free and overall survival estimates for patients treated with 5-FU and radiation compare favorably to the 5-FU plus levamisole arm of the intergroup adjuvant colon study (Int 0035/SWOG 8591) in patients with more than four positive nodes where the 5-year disease-free and overall survival estimates were 35% and 39%, respectively. Disease-free and overall survival estimates for patients with four or fewer nodes in the 5-FU plus levamisole arm of the intergroup study were 64 and 68%, which is not markedly different from results obtained with radiation and 5-FU in the current study. There were no treatment-related fatalities. Seventeen percent of patients had severe and 7% had life-threatening toxicity of any kind. One patient had an acute partial bowel obstruction and two patients had chronic low grade enteritis. Continuous infusion 5-FU and whole-abdominal radiation with tumor bed boost should be further investigated in a larger trial of T3N1-2 colon cancer.

The treatment of epithelial ovarian cancer.

The treatment and long-term survival of patients with ovarian cancer varies by stage. At present, five-year survival for patients with early-stage disease ranges from 50 to 95 percent, while five-year survival for patients with advanced-stage disease is less than 25 percent. Several new drugs with significant activity in advanced-stage ovarian cancer offer hope for increased long-term survival in the future. This article reviews the current and experimental approaches to the treatment of all stages of ovarian cancer.

73 Salvage whole abdominal irradiation (WAI) following second-look laparotomy in patients with ovarian cancer

73 Salvage whole abdominal irradiation (WAI) following second-look laparotomy in patients with ovarian cancer

A randomized trial comparing single-agent carboplatin with carboplatin followed by radiotherapy for advanced ovarian cancer: a North Thames Ovary Group study.

To determine in a randomized trial of advanced ovarian carcinoma whether consolidation therapy with whole-abdominal radiotherapy (RT) after chemotherapy improves survival and disease-free survival compared with the continued chemotherapy. Two hundred fifty-four patients with advanced epithelial ovarian cancer (stages IIB to IV) were entered onto a study of five monthly courses of 400 mg/m2 of carboplatin. One hundred seventeen patients with residual disease of 2 cm or less at second-look laparotomy or laparoscopy were then randomized to receive consolidation therapy, either five further courses of carboplatin at the same dosage or whole-abdominal RT (24 Gy). There was no control arm. Chemotherapy was well tolerated and was usually administered on an outpatient basis. Myelosuppression that was sufficient to delay chemotherapy occurred in only 3% of 1,418 courses analyzed. The main toxicity of carboplatin was nausea and vomiting, but this was easier to control than that with cisplatin. Although RT was well tolerated in the majority of the 58 patients, one patient who had been found to have multiple adhesions at second-look surgery developed fecal fistulae post-RT that resulted in the patient's death from peritonitis. Median survival for the whole group from date of surgery was 25 months. No statistical difference was found in either survival or disease-free survival between those patients who received consolidation chemotherapy and those who were treated with abdominal RT. Prognostic factors used to assess survival were stage, histology, amount of residual disease after primary surgery, and presence of tumor at second-look surgery. There seems to be no significant advantage for consolidation whole-abdominal RT compared with the continuation of the same chemotherapy in the management of advanced epithelial carcinoma of the ovary, even when no macroscopic residual disease is apparent at second-look surgery.

Recurrent Stage I Endometrial Adenocarcinoma in the Nonirradiated Patient: Preliminary Results of Surgical "Staging"

Recurrent endometrial carcinoma, even when clinically confined to the vagina or pelvis, is associated with poor survival. Pelvic radiotherapy for patients with localized recurrences who have not been previously irradiated has not been highly effective. Our hypothesis was that local salvage therapy fails because a significant number of patients have occult, subclinical distant metastases at the time of relapse. In order to accurately assess disease status at the time of the recurrence, we prospectively evaluated eight patients with recurrent disease limited to the vagina/pelvis by physical examination, routine laboratory tests, and radiologic imaging. All patients underwent a "staging" procedure which included laparotomy, selective pelvic/periaortic lymphadenectomy, peritoneal biopsies, and washings. Three (37.5%) of eight patients had upper abdominal disease found at laparotomy (95% confidence interval 0.11 to 0.71). Presence of subclinical metastases was associated with larger tumor size (⩾ 2 cm) and elevated serum CA 125 antigen levels. Treatment was modified in three patients according to the results of surgical staging. One patient was treated with chemotherapy while two patients received whole-abdominal radiation in addition to pelvic fields. Seven of eight patients are alive 21 to 61 months following salvage therapy. Three (43%) of seven patients treated with radiotherapy suffered nonneoplastic bowel obstruction requiring laparotomy at 3, 6, and 15 weeks following completion of radiation therapy. Since 37.5% of patients with recurrent endometrial carcinoma clinically confined to the pelvis had occult upper abdominal disease, surgical reassessment may be warranted, especially in those with elevated serum CA 125 levels or large tumors. Our limited sample size precludes any definitive conclusions regarding our data. Further research will determine the frequency of subclinical metastases and the value of serum CA 125 levels in assessing disease status.