Prophylaxis of Oral Mucositis with Iodine Solution during Concurrent Chemoradiation of Head and Neck Cancer: Preliminary Results of a Double-Blind, Randomized Controlled Trial.

OBJECTIVE: This study aims to evaluate the clinical efficacy of an in-house iodine solution (IS) mouthwash for the prophylaxis of concurrent chemoradiation (CCRT) induced oral mucositis (OM) in head & neck cancer (HNC) patients. METHODS: This prospective, double-blind, randomized controlled trial was conducted on 20 HNC patients, being treated with definite or postoperative CCRT, at the Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand. The patients were randomly assigned (1:1) to the treatment group or the control group. Patients in the treatment group gargled IS three times daily after meals, while patients in the control group gargled normal saline solutions (NSS). Assessment of OM was performed before starting CCRT, once a week during CCRT, and 4 weeks after CCRT was completed. The primary outcome was Oral Mucositis Assessment Scale (OMAS). RESULTS: The mean weekly OMAS, pain score, and impact on swallowing score were not statistically significant in patients who rinsed with IS mouthwash compared to those who received NSS (p > 0.999 in every week). There was no difference in the mean onset to OM (all grades) (p = 0.704), and the mean duration of OM (all grades) (p = 0.365). Severe OM (WHO grade 3-4) occurred in three patients [IS=2, NSS=1] with the median onset of 45.50 & 33.00 days (p = NA), and the duration of 8.00 & 57.00 days (p = NA) in the IS and NSS groups, respectively. Oral candidiasis occurred in one patient from the NSS group while no secondary infection of oral mucosa was observed in the patients receiving IS mouthwash. CONCLUSION: The study could not reach statistically significance to show that IS mouthwash was effective in of prevention CCRT-induced OM. Further study with a larger number of participants is encouraged.

Comparision of Different Radiotherapy Planning Techniques for Breast Cancer after Breast Conserving Surgery

Objectives:To compare different radiotherapy planning techniques for breast cancer after breast conserving surgery. Materials and methods: Eighteen patients with breast cancer who underwent breast conserving surgery were selected. For each patient four different whole breast irradiation techniques including Tan, fIMRT, iIMRT and VMAT were compared to the conventional tangential technique (Tan). Results: Mean maximum point dose (Dmax) for Tan, fIMRT, iIMRT and VMAT were 110.17% (±1.87), 105.89% (±1.13), 106.47% (±0.92) and 106.99% (±1.16) (p<0.001). Mean minimum point dose (Dmin) from Tan was 84.02% (±3.68) which was significantly higher than those from fIMRT, iIMRT and VMAT which were 76.57% (±11.4), 67.69 %( ±19.20) and 80.69% (±7.06) (p<0.001). Only the mean V95 of fIMRT was significantly less than Tan (p=0.01). Mean percentage of volume receiving ≥ 20 Gy (V20Gy) and mean doses of the ipsilateral lung were 17.09% and 953.05 cGy, 16.60% and 879.20 cGy, 14.79% and 772.26 cGy, 15.32% and 984.34 cGy for Tan, fIMRT, iIMRT and VMAT. Only iIMRT had a significantly lower mean V20Gy and the mean dose to ipsilateral lung in comparison with Tan. Significantly, high mean doses to the contralateral breast (498.07 cGy, p<0.001) were observed in VMAT. Conclusion: The conventional tangential technique provides adequate dose coverage but resulted in high dose-volumes. The iIMRT and fIMRT had significantly smaller high dose-volumes and better conformity. VMAT demonstrated excellent dose homogeneity and conformity but an increased low-dose volume outside the target should be of concern.

Survival Analysis of Glioblastoma Multiforme

Introduction: To evaluate the survival of Glioblastoma Multiforme (GBM). Material and Methods: Patients with a pathological diagnosis of Glioblastoma Multiforme (GBM) between 1 January 1994 and 30 November 2013, were retrospectively reviewed. Inclusion criteria: 1) GBM patients with confirmed pathology, 2) GBM patients were treated by multimodality therapy. Exclusion criteria: 1) GBM patients with unconfirmed pathology, 2) GBM patients with spinal involvement, 3) GBM patients with incomplete data records. Seventy-seven patients were treated by multimodality therapy such as surgery plus post-operative radiotherapy (PORT), post-operative Temozolomide (TMZ) concurrent with radiotherapy (CCRT), post-operative CCRT with adjuvant TMZ. The overall survival was calculated by the Kaplan-Meier method and the log-rank test was used to compare the survival curves. A p-value of ≤ 0.05 was considered to be statistically significant. Results: Seventy-seven patients with a median age of 53 years (range 4-76 years) showed a median survival time (MST) of 12 months. In subgroup analyses, the PORT patients revealed a MST of 11 months and 2 year overall survival (OS) rates were 17.2%, the patients with post-operative CCRT with or without adjuvant TMZ revealed a MST of 23 months and 2 year OS rates were 38.2%. The MST of patients by Recursive Partitioning Analysis (RPA), classifications III, IV, V, VI were 26.8 months, 14.2 months, 9.9 months, and 4.0 months, (p <0.001). Conclusions: The MST of the patients who had post-operative CCRT with or without adjuvant TMZ was better than the PORT group. The RPA classification can be used to predict survival. Multimodality therapy demonstrated the most effective treatment outcome. Temozolomide might be beneficial for GBM patients in order to increase survival time.

Maximum Diameter of Intracranial Metastatic Lesions as a Prognostic Factor in Patients Following Whole Brain Radiotherapy.

PURPOSE: To evaluate whetehr maximum diameter of intracranial metastatic lesions may be a prognostic factor in intracranial metastatic patients receiving whole brain radiotherapy. MATERIALS AND METHODS: The records of 114 cases who between January 2005 and December 2007 were retrospectively reviewed. There were 85 who met the inclusion criteria. RESULTS: In these 85, the oneyear overall survival rate was 16.5% and the median survival time was 125 days. Median survival in relation to recursive partitioning analysis (RPA) classes I, II and III were 216, 133 and 85 days. Logrank tests of initial prognostic factors were significant for RPA classifications, Karnofsky Performance Status(KPS), maximum diameters of intracranial metastatic lesions and presence of necrotic centers. The median survivals with a maximum diameter of the largest intracranial metastatic lesion <3cm and ≥3cm were 162 days and 104 days (p=0.027). Multivariate analysis also showed a statistical significance for maximum diameter of intracranial metastatic lesions and presence of necrotic centers. CONCLUSIONS: Maximum diameters of intracranial metastatic lesions could be used as a prognostic factor in patients receiving whole brain radiotherapy and may help radiation oncologists to make decisions on treatment plans.

Outcomes of Preoperative Chemoradiotherapy and Combined Chemotherapy with Radiotherapy Without Surgery for Locally Advanced Rectal Cancer.

PURPOSE: To evaluate the treatment outcomes of patients with locally advanced rectal cancer treated with preoperative concurrent chemoradiotherapy (CCRT) or combined chemotherapy together with radiotherapy (CMTRT) without surgery. MATERIALS AND METHODS: A total of 84 patients with locally advanced rectal adenocarcinoma (stage II or III) between January 1st, 2003 and December 31st, 2013 were enrolled, 48 treated with preoperative CCRT (Gr.I) and 36 with combined chemotherapy and radiotherapy (CMTRT) without surgery (Gr.II). The chemotherapeutic agents used concurrent with radiotherapy were either 5fluorouracil short infusion plus leucovorin and/or capecitabine or 5fluorouracil infusion alone. All patients received pelvic irradiation. RESULTS: There were 5 patients (10.4%) with a complete pathological response. The 3 yearoverall survival rates were 83.2% in Gr.I and 24.8 % in Gr.II (p<0.01). The respective 5 yearoverall survival rates were 70.3% and 0% (p<0.01). The 5 yearoverall survival rates in Gr.I for patients who received surgery within 56 days after complete CCRT as compared to more than 56 days were 69.5% and 65.1% (p=0.91). Preoperative CCRT used for 12 of 30 patients in Gr.I (40%) with lower rectal cancer demonstrated that in preoperative CCRT a sphincter sparing procedure can be performed. CONCLUSIONS: The results of treatment with preoperative CCRT for locally advanced rectal cancer showed comparable rates of overall survival and sphincter sparing procedures as compared to previous studies.

Treatment interruption during concurrent chemoradiotherapy of uterine cervical cancer; analysis of factors and outcomes.

BACKGROUND: To evaluate factors which effect treatment interruption during concurrent chemoradiotherapy (CCRT) and overall survival in patients with uterine cervical cancer stage IB2-IVA in Srinagarind Hospital. MATERIALS AND METHODS: Between January 2006 and December 2007, 107 patients with stage IB2-IVA as FIGO staging, 2000, were treated with CCRT in Srinagarind Hospital. Factors which caused treatment interruptions and impacted on overall survival were reviewed and analyzed. RESULTS: Twenty of 107 patients had treatment interruption during CCRT in patients with uterine cervical cancer stage IB2-IVA in Srinagarind Hospital. The causes of treatment interruption were as follows: hematologic toxicity was found in 16 of 20 cases, 12 cases with grade 2 and 4 cases with grade 3; three of 20 cases had gastrointestinal toxicities, 1 case with grade 2 and 2 cases with grade 3; one case had grade 3 skin toxicity. The mean total treatment time of the uninterrupted and interrupted groups were significantly different (78.98 days vs 161.80 days, p <0.001). The patients who could tolerate ≥5 cycles of cisplatin administration had significantly higher mean white blood counts (WBC) (9,769 cells/ mm3 vs 7,141 cells/mm3, p=0.02). The mean initial hemoglobin (Hb) in the uninterrupted group was significantly higher than the interrupted group (11.5 mg% vs 10.3 mg%, p=0.03). Other factors including age, KPS, initial platelets, initial serum creatinine levels showed no statistical significance. The 3-year overall survival of the uninterrupted group was better than in the interrupted group (78.6% vs 55.0%, p=0.03). CONCLUSIONS: The initial Hb and WBC levels were significantly correlated with treatment interruption during CCRT in patients with uterine cervical cancer. The 3-year overall survival of the uninterrupted group was significantly better than interrupted group. These factors may then be used indirectly to predict the outcomes of treatment.

Comparisons between the KKU-model and conventional rectal tubes as markers for checking rectal doses during intracavitary brachytherapy of cervical cancer.

BACKGROUND: To compare the KKU-model rectal tube (KKU-tube) and the conventional rectal tube (CRT) for checking rectal doses during high-dose-rate intracavitary brachytherapy (HDR-ICBT) of cervical cancer. MATERIALS AND METHODS: Between February 2010 and January 2011, thirty -two patients with cervical cancer were enrolled and treated with external beam radiotherapy (EBRT) and intracavitary brachytherapy (ICBT). The KKU-tube and CRT were applied intrarectally in the same patients at alternate sessions as references for calculation of rectal doses during ICBT. The gold standard references of rectum anatomical markers which are most proximal to radiation sources were anterior rectal walls (ARW) adjacent to the uterine cervix demonstrated by barium sulfate suspension enema. The calculated rectal doses derived from actual anterior rectal walls, CRT and the anterior surfaces of the KKU-tubes were compared by using the paired t-test. The pain caused by insertion of each type of rectal tube was assessed by the visual analogue scale (VAS). RESULTS: The mean dose of CRT was lower than the mean dose of ARW (Dmean0-Dmean1) by 80.55±47.33 cGy (p-value<0.05). The mean dose of the KKU-tube was lower than the mean dose of ARW (Dmean0-Dmean2) by 30.82±24.20 cGy (p-value<0.05). The mean dose difference [(Dmean0-Dmean1)-(Dmean0-Dmean2)] was 49.72±51.60 cGy, which was statistically significant between 42.32 cGy -57.13 cGy with the t-value of 13.24 (p-value<0.05). The maximum rectal dose by using CRT was higher than the KKU-tube as much as 75.26 cGy and statistically significant with the t-score of 7.55 (p-value<0.05). The mean doses at the anterior rectal wall while using the CRTs and the KKU-tubes were not significantly different (p-value=0.09). The mean pain score during insertion of the CRT was significantly higher than the KKU-tube by a t-score of 6.15 (p-value<0.05) CONCLUSIONS: The KKU-model rectal tube was found to be an easily producible, applicable and reliable instrument as a reference for evaluating the rectal dose during ICBT of cervical cancer without negative effects on the patients.

Survival rate of early stage endometrioid adenocarcinoma of endometrium treated at Srinagarind Hospital.

PURPOSE: To evaluate the survival outcome of early stage endometrioid adenocarcinoma of the endometrium with risk factors for locoregional recurrence treated with combined pelvic external beam radiotherapy (EBRT) and vaginal brachytherapy (VBT) after comprehensive surgery. MATERIALS AND METHODS: Post-operative radiotherapy by pelvic EBRT and VBT for early stage endometrioid endometrial carcinoma resulted in excellent pelvic control with acceptable complications. This study showed no significant relationships between age, stage, histologic grade and LVSI and overall survival rate. RESULTS: The 5-year overall survival rate (OS) of early stage endometrioid type of endometrial carcinoma was 85.7%. Acute toxicity occurred in 38.1% of the patients, all of whom were grade 1 or 2. Total late toxicity developed in 42.9% of study group, in which 36.99% of them were grade 1-2 and 4.76% were grade 3-4. CONCLUSIONS: Post-operative radiotherapy by pelvic EBRT and VBT is acceptable for early stage endometrioid endometrial carcinoma, independent of age, stage, histologic grade and LVSI.

Palliative treatment of advanced cervical cancer with radiotherapy and thai herbal medicine as supportive remedy - analysis of survival.

BACKGROUND: To evaluate outcomes using a Thai herbal medicine, Vilac Plus (G716/45) with standard radiotherapy in comparison with historic controls from literature reports of the results of treatment in stage IIIB cervical cancer. MATERIALS AND METHODS: Between March 2003 and June 2005, thirty patients with advanced cervical cancer stage IIIB-IV who had a poor performance status were treated by palliative radiotherapy along with an adjuvant daily dose of 15-30 ml of Thai herbal tonic solution (Vilac Plus G716/45) administered orally three times after meals as an additional supportive therapy. The results were analyzed from the aspect of the overall survival rates with curves estimated by the Kaplan-Meier method. RESULTS: The median follow -up time for stage IIIB was 4.2 years with a range of 7.9 months - 6.1 years. The overall 1, 3, and 5 year survival rates for stage IIIB were 88%, 60% and 52%. CONCLUSIONS: The overall 5 year survival rate for stage IIIB with a poor performance status was 52% when compared with 34-54.8% for historic controls. The combined complementary palliative radiotherapy (CCPR) had low rates of radiation morbidity. It was a simple technique and feasible for developing countries. The pilot study was limited by the small number of patients and further research will be necessary to assess interrelated and confounding factors in treatment of cervical cancer patients.

High dose rate Cobalt-60 after loading intracavitary therapy of the uterine cervical carcinoma in Srinagarind Hospital, analysis of residual disease.

OBJECTIVES: To evaluate residual disease in uterine cervical cancer patients treated with teletherapy using combined high dose rate Cobalt-60 brachytherapy. MATERIALS AND METHODS: A retrospective study of uterine cervical cancer patients, FIGO stages IB-IVB (International Federation of Gynecologists and Obstetricians recommendations), treated by radiotherapy alone between April 1986 and December 1988 was conducted and the outcomes analysed. The patients were treated using teletherapy 50 Gy/25 fractions, five fractions per week to the whole pelvis together with HDR Cobalt -60 afterloading brachytherapy of 850 cGy/fraction, weekly to point A for 2 fractions. RESULTS: The study covered 141 patients with uterine cervical cancer. The mean age was 50.0 years with a range of 30-78 years. The mean tumor size was 4.1 cm in diameter (range 1-8 cm). Mean follow - up time was 2.94 years (range 1 month-6.92 years). The overall incidence of residual locoregional disease was 3.5%. Residual disease, according to stage IIB, IIIB and IVA was present in 2.78%, 3.37% and 50.0%. It was noted that there was no evidence of residual disease in stage IB and IIA cases. CONCLUSION: Combined teletherapy along with high dose rate Cobalt -60 brachytherapy of 850 cGy/fraction, weekly to point A for 2 fractions resulted in overall 3.5% residual disease and a 96.5% complete response. The proposed recommendation for improving outcome is initiation of measurements for early detection of disease.

Results of multidisciplinary therapy of squamous cell carcinoma of the buccal mucosa at Srinagarind Hospital, Thailand.

OBJECTIVE: Review the clinical presentation and treatment of buccal carcinoma and compare it to the results of treatment as per survival rate. MATERIAL AND METHOD: The authors reviewed the medical records of newly diagnosed seen between 1995 and 2005 at the Division of Plastic Surgery and the Department of Radiotherapy, Srinagarind Hospital, Faculty of Medicine, Khon Kaen University Patients previously treated elsewhere or those whose lesions secondarily involved the buccal mucosa were excluded. RESULTS: The authors reviewed the medical records of 107 buccal carcinoma patients (94 females and 13 males) averaging 67 years of age. The 5-year survival rates of patients with Stage I (5.6%), 11 (6.5%), III (12.1%), and IVa (75.7%) were 67%, 43%, 47%, and 26%, respectively. A combined modality treatment (surgery and radiation or chemotherapy) was used to treat the advanced stage (III and IV) patients. The rate of incomplete therapy was high (47.78%). In the group that completed the protocol (i.e., neoadjuvant, surgery, and post operative radiation), there were five patients for whom the 5-year survival seemed higher than the patients who followed the standard treatment of surgery and post-operative radiation but it was not statistically significant. CONCLUSION: The treatment of buccal carcinoma requires a multidisciplinary team approach because most of the patients are elderly and present with an advanced stage. If treatment continues through to completion of the protocol, the survival rate would increase.

High dose rate cobalt-60 afterloading intracavitary therapy of uterine cervical carcinomas in Srinagarind hospital - analysis of complications.

OBJECTIVES: To evaluate complications in uterine cervical cancer patients treated with teletherapy combined with high dose rate(HDR) cobalt-60 brachytherapy. MATERIALS AND METHODS: A retrospective study of uterine cervical cancer patients, stages IB-IVB (International Federation of Gynecologists and Obstetricians recommendations), treated by radiotherapy alone between April 1986 and December 1988 was conducted. The patients received teletherapy 50 Gy / 25 fractions, five fractions per week to the whole pelvis together with HDR Cobalt -60 afterloading brachytherapy of 850 cGy/ fraction weekly to point A for 2 fractions. RESULTS: The study subjects were 141 patients with uterine cervical cancer. The mean age was 49 years with a range of 30-78. The mean tumor size was 4.1 cms in diameter (range 1-8 cms ). Mean follow-up time was 2.9 years (range 1 month - 6.9 years). The treatments resulted in a 96.5% complete response rates but morbidity rates of grade 1 and grade 2 radiation proctitis of 27.0%, and 10.6 %. The grade 1 and grade 2 radiation cystitis were 1.4%, and 1.4 %. At the level of grade 3 radiation complications, 0.71% of radiation proctitis and 0.71% small bowel obstruction were observed. The mean onset time to develop radiation proctitis after complete treatment was 15 months with a range of 6-61 months, for radiation cystitis was 30 months (range 9 - 47 months) and for small bowel obstruction was 53 months in the one case it occurred. CONCLUSION: Combined teletherapy along with high dose rate Cobalt -60 brachytherapy of 850 cGy/ fraction, weekly to point A for 2 fractions for uterine cancer demonstrated a slightly higher incidence of grade 2 radiation proctitis. Therefore, treatment using HDR-60 brachytherapy less than 850 cGy per fractionation for decreasing the grade 2 and grade 3 radiation morbidity is recommended.

High dose rate cobalt-60 afterloading intracavitary therapy for cervical carcinoma in Srinagarind hospital - analysis of survival.

OBJECTIVE: To evaluate the actuarial survival rates in uterine cervical cancer patients treated with teletherapy combined with high dose rate (HDR) cobalt-60 brachytherapy. MATERIALS AND METHODS: A retrospective study of uterine cervical cancer patients, stages IB-IVB (International Federation of Gynecologists and Obstetricians recommendations or FIGO), treated by radiotherapy alone between April 1986 and December 1988 was conducted. The patients were treated with teletherapy 50Gy/25 fractions, five fractions per week to the whole pelvis, together with HDR cobalt-60 afterloading brachytherapy of 850 cGy/ fraction, weekly to point A for 2 fractions. RESULTS: The study analysed the records of 141 patients with uterine cervical cancer with a mean age of 50.0 years (range 30-78). The mean tumor size was 4.1 cm in diameter (range 1-8). Mean follow-up time was 2.94 years (range 1 month - 6.92 years). The 5 year actuarial survival rates for patients with small size tumors less than 2 cm in diameter and tumor sizes larger than 2 cm in diameter were 100% and 63.2%. The overall 5 year survival rate was 63.3%. For cancer stages IB, IIB, IIIA and IIIB they were 100%, 80.3%, 100% and 54.8% and for squamous cell carcinoma and adenocarcinoma were 58.3% and 31.2%. CONCLUSION: Combined HDR cobalt-60 brachytherapy and external beam radiotherapy provide a useful modality in the treatment of uterine cervical cancer, feasible for developing countries. The approach demonstrated a slightly elevated radiation morbidity but was most effective in early stages and with small tumor sizes less than 2 cm in diameter.

AIDS-related primary central nervous system lymphoma: prolonged remission associated with highly active antiretroviral therapy.

A 36-year-old HIV-seropositive man developed progressive confusion and unilateral tremor of the hand. His medical history included cryptococcal meningitis and CMV colitis. CT scan revealed a single hyperdense mass with minimal peripheral enhancement at the region of the cerebral peduncle and pons, causing obstructive hydrocephalus. He was treated with ventriculo-peritoneal shunt and cranial radiotherapy. He also received treatment with highly active antiretroviral therapy (HAART). A CD4+ cell count was increased from 2 to 345 cells/mm3. He returned to normal function for about 32 months after treatment.