Survey of current practices from an international task force for gynecological stereotactic ablative radiotherapy.

BACKGROUND: Stereotactic Ablative Radiotherapy (SABR) is an effective treatment that improves local control for many tumours. However, the role of SABR in gynecological cancers (GYN) has not been well-established. We hypothesize that there exists considerable variation in GYN-SABR practice and technique. The goal of this study is to describe clinical and technical factors in utilization of GYN-SABR among 11 experienced radiation oncologists. MATERIALS AND METHODS: A 63 question survey on GYN-SABR was sent to 11 radiation oncologists (5 countries) who have published original research, conducted trials or have an established program at their institutions. Responses were combined and analyzed at a central institution. RESULTS: Most respondents indicated that salvage therapy (non-irradiated or re-irradiated field) for nodal (81%) and primary recurrent disease (91%) could be considered standard options for SABR in the setting of inability to administer brachytherapy. All other indications should be considered on clinical trials. Most would not offer SABR as a boost in primary treatment off-trial without absolute contraindications to brachytherapy. Multi-modality imaging is often (91%) used for planning including PET, CT contrast and MRI. There is a wide variation for OAR tolerances however small bowel is considered the dose-limiting structure for most experts (91%). Fractionation schedules range from 3 to 6 fractions for nodal/primary definitive and boost SABR. CONCLUSIONS: Although SABR has become increasingly standard in other oncology disease sites, there remains a wide variation in both clinical and technical factors when treating GYN cancers. Nodal and recurrent disease is considered a potential indication for SABR whereas other indications should be offered on clinical trials. This study summarizes SABR practices among GYN radiation oncologists while further studies are needed to establish consensus guidelines for GYN-SABR treatment.

Impact of tumor volume-directed involved field radiation therapy integrated in the management of recurrent ovarian cancer.

OBJECTIVES: Assess the role of involved field radiation therapy (IFRT) in recurrent ovarian cancer. METHODS: Thirty-five patients with a diagnosis of epithelial ovarian cancer received radiation therapy at LUMC between 1991 and 2001. Of these, 20 received tumor volume-directed IFRT for localized extraperitoneal recurrences (either as consolidation following debulking surgery or as attempted salvage if unresectable) and form the basis of this report. All patients were heavily pretreated with multiple chemotherapy regimens. Eleven patients had optimal debulking of their recurrences prior to radiation. IFRT was primarily with external beam (median dose 50.4 Gy). Appropriate statistical analyses evaluated association among disease-free (DFS), overall survival (OS), local recurrence-free (LRFS), and various prognostic factors. LRFS was defined as freedom from in-field recurrences and was considered as a measure of effectiveness of radiotherapy. RESULTS: Of 20 patients, 17 had a complete response after RT. The actuarial LRFS, OS, and DFS at 5 years from date of radiation were 66%, 34%, and 34%, respectively. The LRFS at 3 years was 89% for those with optimal resection vs. 42% for those with gross residual/unresectable tumor, which was significantly better (P = 0.04). The corresponding 3-year DFS was 72% vs. 22% and 5-year OS was 50% vs. 19%, respectively. Acute complication of RT was mild, half had Grade 1-2 gastrointestinal (GI) toxicity, three patients had Grade 3-4 late GI effects. CONCLUSION: IFRT is effective in controlling localized recurrences of ovarian cancer, especially after they are optimally debulked (89% local control and 50% 5-year overall survival in this subgroup), and is relatively well tolerated in these heavily pretreated patients.

Pre-treatment serum levels of tumour markers in metastatic breast cancer: a prospective assessment of their role in predicting response to therapy and survival.

The value of pre-treatment serum tumour marker levels in 85 consecutive patients of newly diagnosed metastatic breast cancer was prospectively assessed for predicting response to therapy and survival. The markers studied were carcinoembryonic antigen (CEA), orosomucoid (ORO), erythrocyte sedimentation rate (ESR), C reactive protein (CRP), ferritin (FERR), human milk fat globule membrane 1 and 2 (HMFG1 and 2), CA 15-3 and NCRC-11. There was no correlation between serum marker levels and response to therapy. Only serum concentrations of CRP (P = 0.02), FERR (P = 0.001), HMFG1 (P = 0.004) and HMFG2 (P = 0.04) were predictive for survival. The prognostic significance of HMFG1 was restricted to a minority of patients (7%) with extreme values of these serum markers.

Primary germ cell tumours of the mediastinum.

Twenty nine cases of primary mediastinal germ cell tumours (MGCT) were seen at the Tata Memorial Hospital over a 16--year period (1974-1989). There were 5 benign MGCT occurring predominantly in females (80%), with these patients having an excellent result after surgery with all patients disease free at an median follow-up of 27 months. Malignant MGCT occurred only in males and demonstrated wide variation in response to treatment depending upon whether the tumour was seminomatous or non-seminomatous. There were 11 Seminomas, 5 Embryonal carcinomas, 5 Endodermal sinus tumours and 3 Teratocarcinomas. The diagnosis was established by surgical exploration or by biopsy of a lymph node or chest wall nodule in 20 patients. Four patients had needle biopsy. Seminomatous MGCT received radiotherapy as their main treatment modality and did well with 75% of the patients alive without disease at an average follow up of 33 months. The non-seminomatous MGCT could be divided into two groups. The mean survival for patients receiving cisplatinum based chemotherapy was 14 months as compared to the group not receiving such therapy where the survival was only 5.3 months. However, because of the advanced disease at presentation even in the group receiving cisplatinum chemotherapy, a long term complete response rate of only 20% could be achieved.

Cervical approach for repair of congenital tracheo-esophageal fistula presenting in an adult.

Congenital tracheo-esophageal fistula without esophageal atresia was diagnosed on barium swallow radiography and esophagoscopy findings in an adult patient presenting with difficult in swallowing. The fistulous opening seen on the anterior wall of the esophagus led to the trachea. On bronchoscopy, the tracheal opening was located posteriorly 5 cm below the vocal cords. Successful repair was undertaken via a left cervical approach. The anatomical and developmental basis for the preferred approach is discussed with a brief literature review on the subject.