Expression of Tumor-mediated CD137 ligand in human colon cancer indicates dual signaling effects.

CD137-targeting immune therapy, which activates anti-tumor T effector cell responses, seems to be an attractive concept in clinical oncology. Recent evidence has demonstrated that tumor cells besides T cells and antigen-presenting cells are able to express CD137 and CD137L. Here we aimed to identify CD137/CD137L expression in established colon cancer cell lines and primary tumors (UICC stages I-IV) from patients with documented long-term follow-up. CD137/CD137L expression was highly upregulated in early to late-stage tumors while the inverse was observed in patient-derived peripheral blood mononuclear cells. High CD137L expression within primary tumors was mediated by tumor cells and significantly correlated with the occurrence of distant metastases and shortened survival in advanced stages of disease (UICC stage IV). Interestingly, induced tumor cell signaling via CD137L on its surface in vitro resulted in dual effects: (i) reduced tumor cell proliferation suggesting inhibitory signaling in all investigated cancers and (ii) increased epithelial-to-mesenchymal transition signaling events. Taken together CD137/CD137L expression was stage-dependently upregulated with shortened survival in patients with highly CD137L-expressing tumors. Our clinical and experimental data suggest that colon cancer cells predominantly express CD137L and thereby have negative impact on overall survival through a process of reverse signaling. Beside agonistic CD137 antibody therapy to foster T effector cell responses, CD137L-mediated intervention strategies may become instrumental to circumvent relapsed tumor growth through induced epithelial-to-mesenchymal transition and consecutive metastases formation.

Upregulated Heat Shock Proteins After Hyperthermic Chemotherapy Point to Induced Cell Survival Mechanisms in Affected Tumor Cells From Peritoneal Carcinomatosis.

In patients with peritoneal carcinomatosis cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) represents a promising treatment strategy. Here, we studied the role of hyperthermic chemotherapy on heat shock protein (HSP) expression and induction of tumor cell death and survival. HSP27, HSP70, and HSP90 combined with effects on tumor cell proliferation and chemosensitivity were analyzed in human colon cancer. Hyperthermic chemotherapy resulted in significant HSP27/HSP70 and HSP90 gene/protein overexpression in analyzed HT-29/SW480/SW620 colon cancer cells and peritoneal metastases from patients displaying amplified expression of proliferation markers, proliferating cell nuclear antigen and antiapoptotic protein Bcl-xL. Moreover, functionally increased chemoresistance against 5-fluorouracil/mitomycin C and oxaliplatin after hyperthermic chemotherapy points to induced survival mechanisms in cancer cells. In conclusion, the results indicate that intracellular HSP-associated antiapoptotic and proliferative effects after hyperthermic chemotherapy negatively influence beneficial effects of hyperthermic chemotherapy-induced cell death. Therefore, blocking HSPs could be a promising strategy to further improve the rate of tumor cell death and outcome of patients undergoing HIPEC therapy.

Influence of hypoxia and irradiation on osteopontin expression in head and neck cancer and glioblastoma cell lines.

BACKGROUND: Tumor hypoxia is a known risk factor for reduced response to radiotherapy. The evaluation of noninvasive methods for the detection of hypoxia is therefore of interest. Osteopontin (OPN) has been discussed as an endogenous hypoxia biomarker. It is overexpressed in many cancers and is involved in tumor progression and metastasis. METHODS: To examine the influence of hypoxia and irradiation on osteopontin expression we used different cell lines (head and neck cancer (Cal27 and FaDu) and glioblastoma multiforme (U251 and U87)). Cells were treated with hypoxia for 24 h and were then irradiated with doses of 2 and 8 Gy. Osteopontin expression was analyzed on mRNA level by quantitative real-time RT-PCR (qPCR) and on protein level by western blot. Cell culture supernatants were evaluated for secreted OPN by ELISA. RESULTS: Hypoxia caused an increase in osteopontin protein expression in all cell lines. In Cal27 a corresponding increase in OPN mRNA expression was observed. In contrast the other cell lines showed a reduced mRNA expression under hypoxic conditions. After irradiation OPN mRNA expression raised slightly in FaDu and U87 cells while it was reduced in U251 and stable in Cal27 cells under normoxia. The combined treatment (hypoxia and irradiation) led to a slight increase of OPN mRNA after 2 Gy in U251 (24 h) and in U87 (24 and 48 h) cell lines falling back to base line after 8 Gy. This effect was not seen in Cal27 or in FaDu cells. Secreted OPN was detected only in the two glioblastoma cell lines with reduced protein levels under hypoxic conditions. Again the combined treatment resulted in a minor increase in OPN secretion 48 hours after irradiation with 8 Gy. CONCLUSION: Osteopontin expression is strongly modulated by hypoxia and only to a minor extent by irradiation. Intracellular OPN homeostasis seems to vary considerably between cell lines. This may explain the partly conflicting results concerning response prediction and prognosis in the clinical setting.

Inhibition of N-Myc down regulated gene 1 in in vitro cultured human glioblastoma cells.

AIM: To study short dsRNA oligonucleotides (siRNA) as a potent tool for artificially modulating gene expression of N-Myc down regulated gene 1 (NDRG1) gene induced under different physiological conditions (Normoxia and hypoxia) modulating NDRG1 transcription, mRNA stability and translation. METHODS: A cell line established from a patient with glioblastoma multiforme. Plasmid DNA for transfections was prepared with the Endofree Plasmid Maxi kit. From plates containing 5 × 10(7) cells, nuclear extracts were prepared according to previous protocols. The pSUPER-NDRG1 vectors were designed, two sequences were selected from the human NDRG1 cDNA (5'-GCATTATTGGCATGGGAAC-3' and 5'-ATGCAGAGTAACGTGGAAG-3'. reverse transcription polymerase chain reaction was performed using primers designed using published information on ß-actin and hypoxia-inducible factor (HIF)-1α mRNA sequences in GenBank. NDRG1 mRNA and protein level expression results under different conditions of hypoxia or reoxygenation were compared to aerobic control conditions using the Mann-Whitney U test. Reoxygenation values were also compared to the NDRG1 levels after 24 h of hypoxia (P < 0.05 was considered significant). RESULTS: siRNA- and iodoacetate (IAA)-mediated downregulation of NDRG1 mRNA and protein expression in vitro in human glioblastoma cell lines showed a nearly complete inhibition of NDRG1 expression when compared to the results obtained due to the inhibitory role of glycolysis inhibitor IAA. Hypoxia responsive elements bound by nuclear HIF-1 in human glioblastoma cells in vitro under different oxygenation conditions and the clearly enhanced binding of nuclear extracts from glioblastoma cell samples exposed to extreme hypoxic conditions confirmed the HIF-1 Western blotting results. CONCLUSION: NDRG1 represents an additional diagnostic marker for brain tumor detection, due to the role of hypoxia in regulating this gene, and it can represent a potential target for tumor treatment in human glioblastoma. The siRNA method can represent an elegant alternative to modulate the expression of the hypoxia induced NDRG1 gene and can help to monitor the development of the cancer disease treatment outcome through monitoring the expression of this gene in the patients undergoing the different therapeutic treatment alternatives available nowadays.

Modulation of carbonic anhydrase 9 (CA9) in human brain cancer.

Hypoxia is a crucial factor in tumour aggressiveness and its treatment resistance, particularly in human brain cancer. Tumour resistance against radiation- and chemo- therapy is facilitated by oxygenation reduction at tumour areas. HIF-1α regulated genes are mostly responsible for this type of resistance. Among these genes, carbonic anhydrase isoform 9 (CA9) is highly overexpressed in many types of cancer especially in high grade brain cancer like GBM. CA IX contributes to tumour environment acidification by catalyzing the carbon dioxide hydration to bicarbonate and protons, leading to the acquisition of metastasic phenotypes and chemoresistance to weakly basic anticancer drugs and therefore to inadequate application of radio-therapeutic or chemotherapeutic anti-cancer treatment strategies. Inhibition of this enzymatic activity by application of specific chemical CA9 inhibitors (sulphonamide derivative compounds) or indirect inhibitors like HIF-1α inhibitors (chetomin) or molecular inhibitors like CA9-siRNA leads to reversion of these processes, leading to the CA9 functional role inhibition during tumourigenesis. Hypoxia significantly influences the tumour microenvironment behaviour via activation of genes involved in the adaptation to the hypoxic stress. It also represents an important cancer prognosis indicator and is associated with aggressive growth, malignant progression, metastasis and poor treatment response. The main objective in malignant GBM therapy is either to eradicate the tumour or to convert it into a controlled, quiescent chronic disease. Sulfonamide derivative compounds with CA9 inhibitory characteristics represent one of the optimal treatment options beside other CA9 inhibitory agents or chemical inhibitory compounds against its main regulating transcription factor which is the hypoxia induced HIF-1α when applied against human cancers with hypoxic regions like GBM, bearing potential for an effective role in human brain tumour therapeutic strategies. Glycolytic inhibitors, when added in controlled doses under hypoxia, lead to a reduced accumulation of HIF-1α and can function as indirect hypoxia regulated genes inhibitors like CA9. These may be used as alternative or in conjunction with other direct inhibitors like the sulphonamide derivate compounds, chetomin or specific siRNAs, or other different chemical compounds possessing similar functionality making them as optimal tools for optimized therapy development in cancer treatment, especially against human brain cancer. Further experimental analysis towards the tumour stage specific inhibitory CA9 characteristics determination are necessary to find the optimal therapeutic solutions among the different available modalities; whether they are direct or indirect chemical, molecular or natural inhibitors to be able to set up successful treatment approaches against the different human tumour diseases.

Dose-response relationship for radiation-induced pneumonitis after pulmonary stereotactic body radiotherapy.

PURPOSE: To evaluate dosimetric factors predictive for radiation-induced pneumonitis (RP) after pulmonary stereotactic body radiotherapy (SBRT). MATERIALS AND METHODS: A retrospective analysis was performed based on 59 consecutive patients treated with cone-beam CT-based image-guided SBRT for primary NSCLC (n=21) or pulmonary metastases (n=54). The majority of patients were treated with radiosurgery of 26 Gy to 80% (n=29) or three fractions of 12.5 Gy to 65% (n=40). To correct for different single fraction doses, local doses were converted to 2 Gy equivalent normalized total doses (NTDs) using α/ß ratio of 3 Gy for RP. Dose-volume parameters and incidences of RP ≥ grade II SWOG were fitted using NTCP models. RESULTS: Eleven patients developed RP grade II. With an average MLD of 10.3±5.6 Gy to the ipsilateral lung, a significant dose-response relationship was observed: the MLD was 12.5±4.3 Gy and 9.9±5.8 Gy for patients with and without development of RP, respectively. Additionally, volumes of the lung exposed to minimum doses between 2.5 and 50 Gy (V(2.5)-V(50)) were correlated with incidences of RP with a continuous decrease of the goodness of fit for higher doses. CONCLUSIONS: The MLD and V(2.5)-V(50) of the ipsilateral lung were correlated with incidences of RP after pulmonary SBRT.

Radiotherapy in adrenocortical carcinoma.

Adrenocortical carcinoma (ACC) is a rare malignancy, and patients with ACC have a poor prognosis. Even after radical surgery, up to 85% of patients develop recurrent disease. Systemic treatment options still have limited efficacy. Because the role of radiotherapy is not defined well and because ACC often is considered radioresistant, the authors reviewed the available data on radiotherapy for ACC. Original articles and reviews were identified using a PubMed search strategy that included the period up to July 2008. Ten articles were identified that covered radiotherapy in a total of 129 patients with ACC (64 patients received postoperative irradiation, and 65 patients received palliative therapy for advanced disease). In addition, 26 patients were identified in the German ACC Registry who received palliative radiotherapy. Furthermore, patterns of failure after adjuvant radiotherapy were investigated, and the authors provided recommendations for patient selection, treatment planning, and treatment protocols. In an adjuvant setting, postoperative radiotherapy was able to prevent local recurrence in the majority of patients. In those with advanced disease, a response to radiotherapy was observed in 57% of patients who received palliative radiotherapy. Therefore, the authors concluded that radiotherapy may play an important role in the care of patients with ACC. Until better evidence is available, the authors recommended the following approach: Adjuvant radiotherapy to the tumor bed should be considered in patients at high risk for local recurrence (eg, incomplete/R1 resection); a total dose of >40 grays (Gy) with single fractions of 1.8 Gy to 2 Gy should be administered (including a boost volume to reach from 50 Gy to 60 Gy in individual patients); and radiotherapy in a palliative setting may be used for symptomatic metastases to bone, brain, or vena cava obstruction. With state-of-the-art technology, acute and long-term toxicities mostly were mild to moderate. However, the authors concluded that prospective investigations would be required to fully define the therapeutic potential of this important treatment option.

Absence of GAPDH regulation in tumor-cells of different origin under hypoxic conditions in - vitro.

BACKGROUND: Gene expression studies related to cancer diagnosis and treatment are important. In order to conduct such experiment accurately, absolutely reliable housekeeping genes are essential to normalize cancer related gene expression. The most important characteristics of such genes are their presence in all cells and their expression levels remain relatively constant under different experimental conditions. However, no single gene of this group of genes manifests always stable expression levels under all experimental conditions. Incorrect choice of housekeeping genes leads to interpretation errors of experimental results including evaluation and quantification of pathological gene expression. Here, we examined (a) the degree of GAPDH expression regulation in Hep-1-6 mouse hepatoma and Hep-3-B and HepG2 human hepatocellular carcinoma cell lines as well as in human lung adenocarcinoma epithelial cell line (A-549) in addition to both HT-29, and HCT-116 colon cancer cell lines, under hypoxic conditions in vitro in comparison to other housekeeping genes like beta-actin, serving as experimental loading controls, (b) the potential use of GAPDH as a target for tumor therapeutic approaches was comparatively examined in vitro on both protein and mRNA level, by western blot and semi quantitative RT-PCR, respectively. FINDINGS: No hypoxia-induced regulatory effect on GAPDH expression was observed in the cell lines studied in vitro that were; Hep-1-6 mouse hepatoma and Hep-3-B and HepG2 human hepatocellular carcinoma cell lines, Human lung adenocarcinoma epithelial cell line (A-549), both colon cancer cell lines HT-29, and HCT-116. CONCLUSION: As it is the case for human hepatocellular carcinoma, mouse hepatoma, human colon cancer, and human lung adenocarcinoma, GAPDH represents an optimal choice of a housekeeping gene and/(or) loading control to determine the expression of hypoxia induced genes in tumors of different origin. The results confirm our previous findings in human glioblastoma that this gene is not an attractive target for tumor therapeutic approaches because of the lack of GAPDH regulation under hypoxia.

Oxygen-dependent regulation of NDRG1 in human glioblastoma cells in vitro and in vivo.

NDRG1 is a member of the N-myc downregulated gene (NDRG) family. Its induction occurs via diverse physiological and pathological conditions (hypoxia, cellular differentiation, heavy metal, N-myc, neoplasia) which modulate NDRG1 transcription, mRNA stability and translation. Hypoxia, among other factors, induces NDRG1 expression and plays an important role in its regulation of expression. To date, the complete detailed function of this protein in humans remains unknown. Hypoxia represents a common feature of solid tumors. In our study, differences in NDRG1 expression between different WHO grades of astrocytic tumors were comparatively examined in vivo in human low-grade astrocytoma (WHO grade 2) and glioblastoma (WHO grade 4) at both the protein and mRNA level by Western blot analysis and semi-quantitative RT-PCR, respectively. Furthermore, the same proteins were determined in vitro in U373, U251 and GaMG human glioblastoma cells using the same methods. HIF-1alpha protein and mRNA regulation under hypoxia was also determined in vitro in U251, U373 and GaMG cells. This regulation was shown at the same levels in vivo in human low-grade astrocytoma (WHO grade 2) and glioblastoma which showed a higher NDRG1 overexpression level in glioblastoma than in low-grade astrocytoma. siRNA- and iodoacetate (IAA)-mediated downregulation of NDRG1 mRNA and protein expression in vitro in human glioblastoma cell lines showed a nearly complete inhibition of NDRG1 expression when compared to the results obtained due to the inhibitory role of glycolysis inhibitor IAA. Hypoxia responsive elements (HREs) bound by nuclear HIF-1alpha in human glioblastoma cells in vitro under different oxygenation conditions and the clearly enhanced binding of nuclear extracts from glioblastoma cell samples exposed to extreme hypoxic conditions confirmed the HIF-1 Western blotting results. Due to its clear regulatory behavior under hypoxic condition in human tumor cells, NDRG1 represents an additional diagnostic marker for brain tumor detection, due to the role of hypoxia in regulating this gene, and it can represent a potential target for tumor treatment in human glioblastoma.

Egr-1 is not upregulated in response to hypoxic and oxygenation conditions in human glioblastoma in vitro.

The early growth response factor 1 (Egr-1) gene (also known as krox24, NGFI-A, TIS8 or zif268) belongs to a family of immediate early response genes. This family of proteins contains a conserved zinc finger DNA-binding domain and can bind to a GC-rich sequence in the promoter region of target genes. Egr-1 expression is rapidly and transiently activated in many different cell types during development. In adult tissues, a variety of signals, including serum, growth factors, cytokines and hormones, stimulate Egr-1 expression. In several studies, it was demonstrated that the transcription factor Egr-1 is regulated by hypoxia, and it is hypothesized that Egr-1 is responsible for the hypoxia-induced regulation of the N-Myc downregulated gene 1 (NDRG1) in human tumor cells. In the present study, Egr-1 regulation was examined in the human glioblastoma cell lines U373, U251, GaMG and U87-MG under extreme hypoxic aeration conditions (0.1% O2) for 1, 6 and 24 h, 24-h extreme hypoxia with reoxygenation for 24 and 48 h, respectively, as well as oxygenated conditions (21% O2 and 5% CO2) in vitro. Protein and mRNA levels were detected in the lysates by Western blotting and RT-PCR, respectively. Egr-1 expression under hypoxic conditions was compared with the well-known and characterized hypoxia-induced gene regulator hypoxia-inducible factor-1α (HIF-1α) in parallel experimental sets. Cells incubated for 24 h with 100 µM desferroxamine served as a positive control for hypoxia, and ß-tubulin and ß-actin were used as loading controls. The experimental data indicate that Egr-1 was not upregulated under extreme hypoxic conditions (0.1% O2) or by reoxygenation after hypoxia in different glioblastoma cells in vitro. In conclusion, the regulation of Egr-1 in reaction to hypoxic development, at both the protein and mRNA levels, is not a general phenomenon. In contrast to previously published data, no Egr-1 regulatory events were observed in glioblastoma under hypoxic conditions in vitro. We suggest that Egr-1 regulation in human tumors in reaction to hypoxia could be a cell-specific post-translational event. Therefore, at least in glioblastoma, HIF-1α can be considered a major regulator of NDRG1 under hypoxic conditions. Further extensive analysis of tumor cells from different origins under similar physiological conditions is necessary to increase our knowledge of the conditions and functional role of Egr-1 in the regulation of hypoxia-induced gene expression.

Intra-fractional uncertainties in image-guided intensity-modulated radiotherapy (IMRT) of prostate cancer.

PURPOSE: To evaluate intra-fractional uncertainties during intensity-modulated radiotherapy (IMRT) of prostate cancer. PATIENTS AND METHODS: During IMRT of 21 consecutive patients, kilovolt (kV) cone-beam computed tomography (CBCT) images were acquired prior to and immediately after treatment: a total of 252 treatment fractions with 504 CBCT studies were basis of this analysis. The prostate position in anterior-posterior (AP) direction was determined using contour matching; patient set-up based on the pelvic bony anatomy was evaluated using automatic image registration. Internal variability of the prostate position was the difference between absolute prostate and patient position errors. Intra-fractional changes of prostate position, patient position, rectal distension in AP direction and bladder volume were analyzed. RESULTS: With a median treatment time of 16 min, intra-fractional drifts of the prostate were >5 mm in 12% of all fractions and a margin of 6 mm was calculated for compensation of this uncertainty. Mobility of the prostate was independent from the bony anatomy with poor correlation between absolute prostate motion and motion of the bony anatomy (R2=0.24). A systematic increase of bladder filling by 41 ccm on average was observed; however, these changes did not influence the prostate position. Small variations of the prostate position occurred independently from intra-fractional changes of the rectal distension; a weak correlation between large internal prostate motion and changes of the rectal volume was observed (R2=0.55). CONCLUSION: Clinically significant intra-fractional changes of the prostate position were observed and margins of 6 mm were calculated for this intra-fractional uncertainty. Repeated or continuous verification of the prostate position may allow further margin reduction.

Rapid detection of the hypoxia-regulated CA-IX and NDRG1 gene expression in different glioblastoma cells in vitro.

Hypoxia-inducible factor-1 (HIF-1) is a key regulator of tumor cell hypoxia. It regulates the expression of several genes related to oxygen homeostasis in response to hypoxic stress. Carbonic anhydrase IX (Ca-IX) has been found to be a stable marker of acute or chronic hypoxia. N-Myc down-regulated gene 1 (NDRG1) has been shown to possess more specific characteristics for clinical analysis and identification purposes. HIF-1 activates gene expression of the two genes and promotes tumor cell survival under hypoxic conditions. Herein, we modified a flow cytometry protocol to separate NDRG1- and CA-IX-negative and -positive cells in vitro to sort chronically hypoxic cells from glioblastoma tumors. The FITC-anti-CA-IX fluorescence differed between positive and negative cells by a factor of 60-160 in U373, U87-MG, U251 and GaMG, respectively. A clear effect of the O2 concentration on CA-IX expression was visible in GaMG and U251 cell lines whereas U373 showed a less differentiated pattern. NDRG1 expression was present in U373, U251 and GaMG with the lowest expression rate in GaMG. It was stable over 48 h of reoxygenation after 24 h of extreme hypoxia (0.1% O2). During reoxygenation NDRG1 was relatively stable in the four tumor cell lines with the lowest expression in GaMG. An oxygen- and time-dependent elevation of nuclear HIF-1alpha binding on HRE was displayed. FACS analysis of CA-IX and NDRG1 expression may be a new approach to determining the hypoxic state of tumor cells. However, an extensive analysis of other hypoxia-regulated genes in different tumors is required to identify additional markers for the detection of the oxygenation state in human tumors in order to tailor effective tumor-specific therapeutic strategies.

Nonrigid patient setup errors in the head-and-neck region.

PURPOSE: To investigate the magnitude and clinical relevance of relative motion/nonrigid setup errors in the head-and-neck (H&N) region. MATERIAL AND METHODS: Eleven patients with tumors in the H&N region were immobilized in thermoplastic head masks. Patient positioning was verified using a kilovoltage cone-beam CT (kv CBCT) prior to 100 treatment fractions. Five different regions of interest (ROIs) were selected for automatic image registration of planning CT and verification CBCT: (1) the whole volume covering planning CT and CBCT, (2) the skull, (3) the mandible, (4) C1-C3, and (5) C4-C6. Differences were calculated describing relative motion between the ROIs. RESULTS: The 3-D patient setup error was 3.2 mm +/- 1.7 mm based on registration of the whole volume. No systematic relative motion (group mean errors <0.5 mm and <0.5 degrees ) between planning and treatment for any ROI was observed. Mobility was largest for the skull and the mandible relative to C4-C6 with 3-D displacements of 4.7 mm +/- 2.5 mm and 4.4 mm +/- 2.5 mm. Relative rotations were largest around the left-right axis (nodding) between C1-C3 and C4-C6 with maximum 11 degrees . No time trend of relative motion was observed. Margins for compensation of relative motion ranged between 5 mm and 10 mm. CONCLUSION: The simplification of the patient as a rigid body was shown to result in significant errors due to relative motion in the H&N region. Margins for compensation of relative motion exceeded margins for compensation of patient positioning errors.

Influence of retrospective sorting on image quality in respiratory correlated computed tomography.

PURPOSE: To evaluate the influence of retrospective sorting on image quality in four-dimensional respiratory correlated CT. MATERIALS AND METHODS: Twelve patients with intrapulmonary tumors were examined using a 24-slice CT-scanner in helical mode. Images were reconstructed after retrospective sorting based on five algorithms: amplitude-based sorting with definition of peak-exhalation and peak-inhalation separately/locally for all breathing cycles (LAS) and globally for the time of image acquisition (GAS). Drifts of the breathing signal were corrected in dc-GAS. In phase-based (PS) and cycle-based (CS) algorithm the projections were sorted relative to time. Motion artifacts were scored by a radiologist. The tumor volumes were measured using automatic image segmentation. RESULTS: Averaged over all breathing phases, LAS and PS achieved significantly improved image quality and lowest tumor volume variability compared to GAS, dc-GAS and CS. Imaging redundancy of 5s was not sufficient for GAS and dc-GAS: missing corresponding amplitude positions in one or several breathing cycles resulted in incomplete reconstruction of peak-ventilation images in 11/12 and 10/12 patients with GAS and dc-GAS, respectively. Limiting the analysis to mid-ventilation phases showed GAS and dc-GAS as the most reliable algorithms. CONCLUSIONS: LAS and PS are suggested as a compromise between image quality and radiation dose.

Efficacy of adjuvant radiotherapy of the tumor bed on local recurrence of adrenocortical carcinoma.

CONTEXT: Local tumor recurrence is common in adrenocortical carcinoma (ACC) and is the most frequent cause for reoperation. Although radiotherapy is often considered ineffective in the treatment of ACC, the limited number of available studies does not support this statement. OBJECTIVE: The objective of the study was investigation of adjuvant tumor bed irradiation in the treatment of ACC. DESIGN: We performed a retrospective analysis. PATIENTS: The German ACC Registry (n = 285) was screened for patients who had received tumor bed radiotherapy in an adjuvant setting (no macroscopic evidence for residual disease after surgery). Fourteen patients without distant metastases (World Health Organization stage I, one patient; stage II, seven; stage III, three; and stage IV, three) were matched with 14 patients for resection status, adjuvant mitotane treatment, stage, and tumor size. Median follow-up of patients still alive (n = 15) was 37 months. MAIN OUTCOME MEASURE: Survival without local recurrence and disease-free survival was the main outcome measure. RESULTS: Local recurrence was observed in two of 14 patients in the radiotherapy group and in 11 of 14 control patients. The probability to be free of local recurrence 5 yr after surgery differed significantly [79% (95% confidence interval, 53-100) vs. 12% (0-30); P < 0.01]. However, disease-free and overall survival were not significantly different between the two groups. Acute adverse events related to radiotherapy were mostly mild. One patient developed a partial Budd-Chiari syndrome. CONCLUSION: These data from the largest series of ACC patients treated with adjuvant tumor bed irradiation suggest that radiotherapy is effective in reducing the high rate of local recurrence in ACC. A randomized trial in high-risk patients is needed to further evaluate the efficacy of radiotherapy as an adjuvant treatment option in ACC.