Percutaneous fractionated radiotherapy of the groin to eliminate lymphatic fistulas after vascular surgery.

BACKGROUND: Vascular surgery of the inguinal area can be complicated by persistent lymphatic fistulas. Rapid and effective treatment is essential to prevent infection, sepsis, bleeding, and possible leg amputation. Current data on irradiation of lymphatic fistulas lack recommendation on the appropriate individual and total dose, the time of irradiation, and the target volume. Presumably, a dose of 0.3-0.5 to 1-12 Gy should be sufficient for the purpose. Currently, radiotherapy is a "can" recommendation, with a level 4 low evidence and a grade C recommendation, according to the DEGRO S2 guidelines. As part of a pilot study, we analyzed the impact and limitations of low-dose radiation therapy in the treatment of inguinal lymphatic fistulas. PATIENTS AND METHODS: As a part of an internal quality control project, patients with lymphatic fistulas irradiated in the groin area after vascular surgery for arterial occlusive disease (AOD) III-IV, repair of pseudo aneurysm or lymph node dissection due to melanoma were selected, and an exploratory analysis on retrospectively collected data performed. RESULTS: Twelve patients (10 males and 2 females) aged 62.83 ± 12.14 years underwent open vascular reconstruction for stage II (n = 2), III (n = 1), and IV (n = 7) arterial occlusive disease (AOD), lymph node dissection for melanoma (n = 1) or repair of a pseudoaneurysm (n = 1). Surgical vascular access was obtained through the groin and was associated with a persistent lymphatic fistula, secreting more than 50 ml/day. Patients were irradiated five times a week up to a maximum of 10 fractions for the duration of the radiation period. Fraction of 0.4 Gy was applied in the first 7 cases, while 5 patients were treated with a de-escalating dose of 0.3 Gy. There was a resolution of the lymphatic fistula in every patient without higher grade complications. CONCLUSION: Low-dose irradiation of the groin is a treatment option for persistent lymphatic fistula after inguinal vascular surgery.

[Radiotherapeutic management of lymphatic fistulas : An effective but disregarded therapy option]. / Strahlentherapeutisches Management von Lymphfisteln : Eine effektive, aber wenig beachtete Therapieoption.

BACKGROUND: Lymphatic fistulas and lymphoceles are known complications after vascular surgery of the groin and after extended surgical interventions in the pelvic region. Unfortunately, conservative standard therapies are not always successful. OBJECTIVES: Evaluation of the therapeutic efficacy and related side effects of percutaneous low-dose irradiation in patients with lymphorrhea and definition of its importance. MATERIAL AND METHODS: Current presentation of previously published case series, reviews and guidelines. RESULTS: The use of low-dose irradiation therapy with single doses of 0.3-0.5 Gy leads to a cessation of the lymphatic flow in a high percentage of patients when standard therapies do not show a sufficient effect. With cessation of lymphorrhea irradiation should be terminated. Acute side effects have not been reported and the risk of tumor induction is almost negligible. CONCLUSION: Low-dose irradiation is an effective and very well-tolerated therapeutic alternative in the treatment of lymphatic fistulas and lymphorrhea when conservative therapies are unsuccessful.

Clinical response of pelvic and para-aortic lymphadenopathy to a radiation boost in the definitive management of locally advanced cervical cancer.

PURPOSE: Optimal treatment with radiation for metastatic lymphadenopathy in locally advanced cervical cancer remains controversial. We investigated the clinical dose response threshold for pelvic and para-aortic lymph node boost using radiographic imaging and clinical outcomes. METHODS AND MATERIALS: Between 2007 and 2011, 68 patients were treated for locally advanced cervical cancer; 40 patients had clinically involved pelvic and/or para-aortic lymph nodes. Computed tomography (CT) or 18F-labeled fluorodeoxyglucose-positron emission tomography scans obtained pre- and postchemoradiation for 18 patients were reviewed to assess therapeutic radiographic response of individual lymph nodes. External beam boost doses to involved nodes were compared to treatment response, assessed by change in size of lymph nodes by short axis and change in standard uptake value (SUV). Patterns of failure, time to recurrence, overall survival (OS), and disease-free survival (DFS) were determined. RESULTS: Sixty-four lymph nodes suspicious for metastatic involvement were identified. Radiation boost doses ranged from 0 to 15 Gy, with a mean total dose of 52.3 Gy. Pelvic lymph nodes were treated with a slightly higher dose than para-aortic lymph nodes: mean 55.3 Gy versus 51.7 Gy, respectively. There was no correlation between dose delivered and change in size of lymph nodes along the short axis. All lymph nodes underwent a decrease in SUV with a complete resolution of abnormal uptake observed in 68%. Decrease in SUV was significantly greater for lymph nodes treated with ≥54 Gy compared to those treated with <54 Gy (P=.006). Median follow-up was 18.7 months. At 2 years, OS and DFS for the entire cohort were 78% and 50%, respectively. Locoregional control at 2 years was 84%. CONCLUSIONS: A biologic response, as measured by the change in SUV for metastatic lymph nodes, was observed at a dose threshold of 54 Gy. We recommend that involved lymph nodes be treated to this minimum dose.

Manually after-loaded 192Ir low-dose rate brachytherapy after subtotal excision and flap reconstruction of recurrent cervical lymphadenopathy from head and neck cancer.

BACKGROUND: Treatment of extensive recurrent cervical lymph node metastases from previously irradiated head and neck cancer represents a difficult clinical challenge. We report the results of an approach of maximal surgical debulking and manually after-loaded intra-operative brachytherapy. PATIENTS AND METHODS: Seventy-four procedures were carried out at the Royal Marsden Hospital between 1979 and 2003. All patients had previously been treated with radical radiotherapy or chemoradiation. Patients underwent maximal surgical debulking, followed by brachytherapy to the tumour bed with low-dose rate (192)Ir to a dose of 60 Gy to the reference isodose using the Paris system. RESULTS: Overall and disease specific survival rates were 31% and 28% at two years and 23% and 17% at five years. Corresponding Loco-regional control rates were 37% and 23%, respectively. Fifty per cent of patients developed metastatic disease within 5 years of treatment. Best results were obtained with surgical excision, brachytherapy and reconstruction of the skin defect using a vascularised myo-cutaneous flap with in-field control rates of 72% at two years and 66% at 5 years. Nine per cent of patients developed fistulae, 4% had haemorrhage and 8% wound breakdown/infection. CONCLUSIONS: Maximal surgical debulking, including removal of overlying skin, and brachytherapy to the surgical tumour bed provides high levels of local control, and can be achieved with acceptable morbidity. Only a minority of patients achieve long-term survival because of the high risk of systemic relapse.

Lymphatic fistulas: obliteration by low-dose radiotherapy.

BACKGROUND: Lymphatic drainage from the surgical wound is an uncommon but challenging complication of surgical intervention. Protracted lymphorrhea contributes to morbidity, favors infections and results in a prolonged hospital stay. Treatment options include surgical ligation and, more conservatively, leg elevation, continuous local pressure, subatmospheric pressure dressings, and low-dose radiotherapy. This study examines the efficacy of low-dose radiotherapy. PATIENTS AND METHODS: 17 patients (19 fistulas) with lymphorrhea following vena saphena harvesting (n = 7), femoropopliteal bypass (n = 3), varicose vein surgery (n = 2), hip arthroplasty (n = 3; five fistulas), shunt surgery (n = 1), and piercing (n = 1) were referred for external radiotherapy. Depending on the depth of the fistula, orthovoltage (n = 12), electrons (4-11 MeV; n = 2) or photons (8 MV; n = 3) were used. Fractions between 0.3 Gy and 2 Gy were applied; the individual total dose depended on the success of the radiotherapy, i. e., the obliteration of the lymph fistula, and varied from 1 to 12 Gy. RESULTS: In 13 out of 17 patients complete obliteration of the fistula was achieved. Interestingly, this was achieved in nine of the ten patients irradiated with total doses of

Successfully treated lingual tonsillar metastasis from bronchial adenocarcinoma.

Tonsillar metastasis from neoplasms, including lung cancer, are extremely rare, and the prognosis for patients with tonsillar metastases is rather poor. We herein describe a case of long-term survival following radiation for lingual tonsillar metastasis from a bronchial adenocarcinoma. A 39-year-old male was diagnosed with adenocarcinoma of the right lung and was surgically treated. Four months after surgery, a mass arising from the lingual tonsil was noted at the root of the tongue and was pathologically diagnosed as metastasis from lung cancer. In addition, a computed tomography scan revealed a jugular lymphadenopathy, which was considered to be a metastasis from the tonsillar tumor. The tonsillar mass and jugular lymphadenopathy disappeared after external radiotherapy (50 Gy). The patient is alive without recurrence more than 8 years after treatment for tonsillar metastasis. This is the first report of successfully treated tonsillar metastasis from a malignant tumor.

Pagetoid reticulosis: a case report and review of the literature.

The histologic finding of a pagetoid epidermotropic growth pattern is associated with a variety of conditions that range from reactive to neoplastic in nature. Included among these conditions is the uncommon skin disorder pagetoid reticulosis. Pagetoid reticulosis may present clinically as a solitary, indolent plaque-like lesion. Conversely, it may manifest as a more generalized clinically aggressive disease. The generalized form may develop into systemic lymphoma, leading to severe morbidity and death. We present a case of pagetoid reticulosis of the perioral region, a rare anatomic site for this condition. Histopathologic and immunohistochemical findings were consistent with a diagnosis of isolated pagetoid reticulosis. This review discusses the nature of pagetoid reticulosis and addresses past and current concepts regarding the condition.

153Sm EDTMP for bone marrow ablation prior to stem cell transplantation for haematological malignancies.

This study examined the safety of adding 153Sm lexidronam to standard conditioning regimens in patients undergoing stem cell transplantation for marrow based haematological malignancies in whom total-body irradiation as part of conditioning was desirable but not feasible. Ten such patients were enrolled, seven with multiple myeloma. An escalating regimen of 19-45 GBq of 153Sm lexidronam was added 12-14 days prior to the standard transplantation regimen. Evaluation parameters included time to engraftment, status at day +100 by International Bone Marrow Transplant Registry (IBMTR) criteria and toxicity during this period. Absorbed marrow radiation doses were estimated using the MIRDOSE 3 program. No adverse events were attributable to 153Sm lexidronam. Of the seven patients with multiple myeloma, four achieved complete response, two partial response, and another had stable monoclonal band at 3 months post-transplant. One patient with Refractory Anaemic with Excess Blasts in transformation (RAEBt) died of a presumed fungal infection, whilst another with acute myeloid leukaemia relapsed, dying at day +153. A patient with low-grade lymphoma showed no evidence of residual disease at day +100. The total marrow absorbed dose was estimated to be 0.7+/-0.2 mGy x MBq(-1). Regional uptake was markedly non-uniform with poor uptake in the appendicular skeleton. Dose-limiting toxicity was not attained. At the activities used 153Sm lexidronam was not associated with additional toxicity in this population. Adequate absorbed radiation dose to appendicular marrow is unlikely to be deliverable by this approach alone.

[Pagetoid reticulosis]. / Pedzhetoidnyi retikulez.

Pagetoid reticulosis is a rare form of T-cell skin lymphoma. A case of this disease is reported.

[Radiotherapy of lymphatic fistula and lymphocele]. / Strahlentherapie von Lymphfisteln und Lymphozelen.

BACKGROUND: The treatment of persistent postoperative lymphatic fistulas or lymphoceles is often a problem. Approximately 2% of patients will develop lymphatic fistula after vascular surgery. This can require a long lasting conservative therapy. If spontaneous cure fails, a second operation with wound revision becomes necessary. We studied low-dose percutaneous radiotherapy to be used as an alternative treatment in addition to conservative or surgical therapy. PATIENTS AND METHODS: Between 1989 and 1998 29 patients (25 with lymphatic fistulas, 4 with lymphoceles) received radiation therapy. Depending on the depth of the fistula 27 patients were treated with electrons (7 to 18 MeV). Two other patients suffering of retroperitoneal lymphoceles received a treatment with photons (15 MV). In all patients the fractionation was 4- to 5 x 1.0 Gy/week and the dose ranged from 3 to 12 Gy depending upon the onset of the radiation therapy effect. RESULTS: In 27 of 28 evaluable patients a complete disappearance of the fistula or lymphocele was achieved by radiation during therapy or shortly afterwards. In 1 case no benefit was observed after a dose of 11 Gy. This patient required further surgery with wound exploration. CONCLUSION: Low dose percutaneous radiotherapy (up to 10 to 12 Gy) is effective to heal lymphatic fistulas and lymphoceles without complications. Individual dosage is required because doses even lower than 10 Gy may be effective. Radiation can be effective even after a failed conservative therapy or instead of surgery.

[Radiotherapy of cutaneous lymphomas]. / Radiothérapie des lymphomes cutanés.

Radiotherapy plays an important role in the treatment of cutaneous lymphomas. In the treatment of Mycosis fungoides, total skin electron beam radiation therapy is efficient for patients with limited and superficial forms of the disease. Radiotherapy is also efficient for the locally advanced forms of non-epidermotropic lymphomas. The palliative radiotherapy is indicated for advanced, nodular and treatment resistant forms of cutaneous lymphomas and for voluminous lymphadenopathies.

Rapid progression of squamous cell carcinoma of the cervix after hyperbaric oxygenation.

The role of hyperbaric oxygenation in the treatment of radiation-induced sequelae and chronic ulcer is well established. On the contrary, a possible cancer-causing or growth-enhancing effect by hyperbaric oxygenation was highly controversial. Herein, we present a 55-year-old Chinese woman with recurrent squamous cell carcinoma of the cervix on her left inguinal area. She received concurrent chemoradiation therapy followed by radical inguinal lymphadenectomy due to persistent tumor mass. The patient was complicated with severe radiation fibrosis and unhealed wounds, so she was treated with hyperbaric oxygenation (HBO). However, the patient died of complications of the disease after completing HBO therapy I month later and autopsy of the patient showed carcinomatosis of the abdominal cavity and lower abdominal wall. Because previous studies have been inconclusive regarding the effect of HBO on tumor cells, we reviewed the possible relation between the HBO and tumor cells.

Multicentre experience with combined hyperthermia and radiation therapy in the treatment of superficially located non-Hodgkin's lymphomas.

The combination of Radiation Therapy (RT) and Hyperthermia (HT) has proved to be an effective treatment for a wide variety of superficially located recurrences of different tumors, particularly those arising in previously irradiated areas. Few studies on the use of HT in the management of lymphomatous diseases have so far obtained interesting results. Eight patients with Non Hodgkin Lymphomas (LNH) - 4 with cutaneous lymphomas and 4 with nodal recurrences after RT-Chemotherapy (CHT) treatment treated in three different Italian institutions with combined RT and HT are here reported. Rt dose ranged from 15 to 40 Gy with different fractionations, on the basis of previously received treatment. Hyperthermia was delivered using 432 or 915 MHz external microwave applicators, according to extension and depth of the lesions and available equipment. All patients tolerated well the HT treatment, and in all cases average intratumoral temperatures were >42 degrees, with 3 out of 10 treated sites achieving the goal of average temperatures >42.5%. One patient, with recurrent NHL, is disease-free after 24 months from completion of combined therapy. Our results seem to confirm previous experiences, suggesting a role of HT/RT not only for palliative purposes in cutaneous lymphomas, but also as an adjunct to radiotherapy alone in selected patients with superficially located recurrences.

Complete AV block following mediastinal radiation therapy: electrocardiographic and pathologic correlation and review of the world literature.

The clinical, features, serial electrocardiograms, and autopsy findings of a patient with symptomatic complete AV block, who had received mediastinal radiation therapy 8 1/2 years previously, are presented. The cardiac histopathology disclosed immense fibrosis of the conduction system and of the atria and ventricles. The enormous amount of fibrosis was similar in location and intensity to that observed in our previously reported patient (Cohen et al., Arch Intern Med 1981; 141:676-679) who had undergone mediastinal radiation. We conclude that the severe fibrosis was primarily due to radiation, rather than secondary to atherosclerotic coronary artery disease, which also has been described as a consequence of mediastinal radiotherapy. This patient's serial electrocardiograms disclosed evidence of complete block both in the AV nodal area and infra His system, which correlated well with the histopathology. The characteristic clinical features of patients with symptomatic complete AV block post mediastinal radiation therapy are presented, along with a review of the world literature.

[Pulmonary metastases with a prolonged development. Two cases of thyroid cancers]. / Métastases pulmonaires d'évolution prolongée. A propos de deux cas de cancers thyroidiens.

The authors report two cases of differentiated carcinoma of the thyroid with pulmonary involvement showing as miliary shadowing radiologically which preceded the diagnosis of the thyroid neoplasm by 35 and 6 years respectively. The two patients had undergone cervical radiotherapy in infancy for lymphadenopathy whose aetiology had not been determined. The scintigraph with iodine 131 showed tht in two cases there was a bilateral and diffuse pulmonary uptake in keeping with pulmonary lesion of metastatic origin. Our observations recall the possibility of a slow evolution of pulmonary metastases and carcinoma of the thyroid and the role of cervical irradiation in the development of such cancers. With miliary shadowing a metastatic origin, in particular that of the thyroid, should be considered and in the majority of cases the proof could be supported using iodine 131 scintigraphy. The delay in appearance of pulmonary metastases during the course of cancer of the thyroid is variable. They occur most often after the initial diagnosis or more rarely preceding the discovery of a primary thyroid cancer. The pulmonary metastases may be asymptomatic. This neoplasm may benefit from a specific effective therapy and prolonged remissions have been described even with metastases.

Radiotherapy for mediastinal obstruction and intrathoracic lymphadenopathy in chronic lymphocytic leukemia.

Four of 65 patients (6%) with chronic lymphocytic leukemia (CLL) were treated by megavoltage teleradiotherapy for palliation of symptoms arising from mediastinal obstruction or intrathoracic lymphadenopathy. External beam irradiation was found to be effective treatment for these disease complications associated with CLL.

Radiotherapy compared to chemotherapy as initial treatment of angiocentric centrofacial lymphoma (polymorphic reticulosis).

Polymorphic reticulosis has recently been characterized as an angiocentric lymphoproliferative disorder of the peripheral T-lymphocytes. However, its treatment is still a matter of controversy. In order to study efficacy and toxicity of the primary treatment, we reviewed clinical features and therapeutic results in 29 patients seen at the Instituto Nacional de Cancerologia de Mexico. Nineteen patients received primary local irradiation and 10 patients primary combination chemotherapy. In the radiotherapy group, 14 (74%) patients achieved complete response, but only 4 (40%) did so in the primary chemotherapy group. Five patients in the latter group died of treatment-related complications. The 5-year actuarial survival rate was 70% in the irradiation group, while the 1-year survival rate was only 15% in the chemotherapy group. These data strongly suggest that, in polymorphic reticulosis, initial chemotherapy may be very toxic.