Involved-site Radiotherapy Delineation Dilemmas in the Treatment of Adult Hodgkin Lymphoma: Turkish Society for Radiation Oncology Hematological Oncology, Pediatric Oncology and TBI Study Group Case-based Questionnaire Review (TROD 03-005).

AIMS: The International Lymphoma Radiation Oncology Group (ILROG) defined involved-site radiotherapy (ISRT) guidelines. These rules offer a certain variability that allows for autonomous decision-making in diverse clinical settings. However, this flexibility also gives rise to conflicts about the selection of treatment fields in the daily decision-making process. The aim of this study was to show the extent of interobserver variability when ILROG-ISRT recommendations were used in different clinical scenarios. MATERIALS AND METHODS: The 10-question survey used in our study consisted of two parts (part A and part B) and was prepared by four senior radiation oncologists experienced in the haemato-oncology field. The results were presented by stratifying according to clinical experience (<10 years, ≥10 years). Binomial tests (one-sided) were conducted to assess whether answers for each group and the whole group reached a consensus. RESULTS: Twenty-six radiation oncologists, 13 of whom had less than 10 years of experience and 13 seniors, participated in the survey. Eighty per cent of respondents thought ILROG did not bring sufficient solutions for all clinical scenarios but offered solutions in some cases. In different case-based scenarios, the consensus among the respondents decreased down to 38%. Senior radiation oncologists were found to have more doubts about the adequacy of current guidelines. CONCLUSIONS: ILROG guidelines allow for a high degree of variability in real-life clinical scenarios and different interpretation of the recommendations may lead to increased toxicity and recurrences. Therefore, there is a need for refinement in ISRT delineation strategies. On behalf of the Turkish Society for Radiation Oncology Hematological Oncology, Pediatric Oncology and TBI Study Group, we are planning to carry out further educational contouring sessions to detect the interobserver variability in real-life contouring cases.

The Practice of Paediatric Radiation Oncology in Low- and Middle-income Countries: Outcomes of an International Atomic Energy Agency Study.

AIMS: Childhood cancer survival is suboptimal in most low- and middle-income countries (LMICs). Radiotherapy plays a significant role in the standard care of many patients. To assess the current status of paediatric radiotherapy, the International Atomic Energy Agency (IAEA) undertook a global survey and a review of practice in eight leading treatment centres in middle-income countries (MICs) under Coordinated Research Project E3.30.31; 'Paediatric radiation oncology practice in low and middle income countries: a patterns-of-care study by the International Atomic Energy Agency.' MATERIALS AND METHODS: A survey of paediatric radiotherapy practices was distributed to 189 centres worldwide. Eight leading radiotherapy centres in MICs treating a significant number of children were selected and developed a database of individual patients treated in their centres comprising 46 variables related to radiotherapy technique. RESULTS: Data were received from 134 radiotherapy centres in 42 countries. The percentage of children treated with curative intent fell sequentially from high-income countries (HICs; 82%) to low-income countries (53%). Increasing deficiencies were identified in diagnostic imaging, radiation staff numbers, radiotherapy technology and supportive care. More than 92.3% of centres in HICs practice multidisciplinary tumour board decision making, whereas only 65.5% of centres in LMICs use this process. Clinical guidelines were used in most centres. Practice in the eight specialist centres in MICs approximated more closely to that in HICs, but only 52% of patients were treated according to national/international protocols whereas institution-based protocols were used in 41%. CONCLUSIONS: Quality levels in paediatric radiotherapy differ among countries but also between centres within countries. In many LMICs, resources are scarce, coordination with paediatric oncology is poor or non-existent and access to supportive care is limited. Multidisciplinary treatment planning enhances care and development may represent an area where external partners can help. Commitment to the use of protocols is evident, but current international guidelines may lack relevance; the development of resources that reflect the capacity and needs of LMICs is required. In some LMICs, there are already leading centres experienced in paediatric radiotherapy where patient care approximates to that in HICs. These centres have the potential to drive improvements in service, training, mentorship and research in their regions and ultimately to improve the care and outcomes for paediatric cancer patients.

The management of painful bone metastases with biphosphonates and palliative radiotherapy: a retrospective evaluation of 372 cases.

PURPOSE: The objective of this study was to evaluate the palliation of pain of bone metastases with biphosphonates and different radiotherapy protocols in 372 cancer patients. PATIENTS AND METHODS: Patients were treated with one of the 3 different radiotherapy protocols: 30 Gy in 10 fractions (group A), 20 Gy in 5 fractions (group B) and 8 Gy in a single fraction (group C). Two patient groups were studied: one with radiotherapy alone and the second with biphosphonates plus radiotherapy. The severity of pain was recorded before treatment. According to the pain relief, two different groups were defined: palliation rate<50% (limited palliation) and >50% (partial palliation), including complete pain relief. RESULTS: Overall limited and partial palliation rates were 20.2 and 79.8%, respectively (complete pain palliation 24.2%). In the group treated with both external radiotherapy and biphosphonates, limited and partial palliation rates were 19.5 and 80.4%, respectively (p=0.47). For 244 metastatic lesions treated with palliative radiotherapy alone, limited palliation rate was 20.4% and partial palliation rate 79.5%. No differences were detected between the groups with or without biphosphonates treatment in terms of pain palliation. According to the radiotherapy protocol, limited palliation rates in groups A, B, and C were 17.7, 20.3, and 28.5%, respectively (p=0.19, p=0.38, and p=0.26, respectively). Partial palliation rates were 82.2% in group A, 79.6% in group B and 71.4% in group C (p=0.42, p=0.21, and p=0.11, respectively). Similarly, no statistically significant differences were detected among the 3 radiotherapy schemes in terms of pain palliation. CONCLUSION: When combined with palliative radiotherapy, biphosphonates did not have any additive effects on pain palliation in the management of painful bone metastases. In addition, a single radiotherapy fraction provides equal pain palliation as multiple fractions.

Relapse patterns and related prognostic factors in patients with mobile tongue cancer treated with postoperative radiotherapy.

PURPOSE: To retrospectively assess prognostic factors and patterns of relapse in patients with oral tongue cancer treated by adjuvant radiotherapy (RT). PATIENTS AND METHODS: Between 1995 and 2005, 65 patients with stage II-IV oral tongue cancer were treated with postoperative adjuvant RT at our institution. The influence of multiple patient- and treatment-related factors on local and regional control, and overall survival (OS), locoregional failure- free survival (LRFFS) and cause-specific survival (CSS) were evaluated. Median patient follow-up was 74 months. RESULTS: Five-year disease-free survival (DFS), LRFFS and CSS rates were 56, 60 and 58%, respectively. During the study period 27 (41.5%) patients had locoregional failures. Seventeen of the recurrences were in the primary tumor region, 4 in the neck, 6 in both regions. Most of the local failures occurred in the first year (median 13 months, range 5-15). Gender, T stage, stage (AJCC TN stage), surgical margin, localization of tumor, and hemoglobin level had predictive value for improved local-regional control in univariate analysis. In total, 35 deaths occurred: 28 patients died of progressive disease, one patient died due to another primary tumor (esophageal cancer) and 6 patients died of other causes. CONCLUSION: Local failure was the most important problem concerning the final outcome. High local recurrence rates and poor survival rates are important issues in the management of oral tongue cancer. Further strategies should be directed to enhancing cure rates.

Evaluation of acute and late radiation morbidity in patients with gynaecologic malignancy using the RTOG criteria and Franco-Italian glossary.

PURPOSE: The purpose of this study was to evaluate acute and late radiation morbidity in patients with gynaecologic malignancy using the RTOG criteria and Franco-Italian glossary, and to compare the usefulness and disadvantages of each system. MATERIALS AND METHODS: Between February 2001 and February 2003, 107 patients with gynaecologic malignancy who received either radical or djuvant external radiotherapy +/- intracavitary brachytherapy or radiochemotherapy were enrolled in this study. The patients were evaluated before radiotherapy and weekly during radiotherapy for acute morbidity using the RTOG grading system and Franco-Italian glossary. Postradiotherapy evaluation was done one month after radiotherapy and at 3-month intervals thereafter. Median follow-up duration was 17 months. Morbidity was graded and recorded according to each scoring system. RESULTS: Median age was 46 years (range 37-82). Sixty-four patients (59.8%) had endometrial cancer. Radical radiotherapy was applied to 26 patients because of inoperability and 81 patients received postoperative radiotherapy. Biologically effective doses for the bladder, rectum and vagina were 98.39, 103.54 and 121.81, respectively, for late morbidity (BED3); 70.88, 72.84 and 80.92, respectively, for acute morbidity (BED10). According to the RTOG grading system acute morbidity rate for the genitourinary and gastrointestinal systems, and skin were 52.3%, 83.2% and 63.5%, respectively. Late morbidity rate for the bladder, colon-rectum, skin and vagina were 16.8%, 20.6%, 47.7% and 51.4%, respectively. The morbidity rate for the bladder, nonspecific abdominal, hematopoietic system, uterus-vulva-vagina, skin and rectum were 35.4%, 29.9%, 5.6%, 60.8%, 40.1% and 32.7%, respectively using the Franco-Italian glossary. In patients with carcinoma of the vulva--whose treatment fields were wider--acute morbidity rate according to RTOG criteria was higher (p = 0.057); photon energy (6 Mv rather than 1.25 MV) (p = 0.01) and treatment interruption of more than eight days (p = 0.019) were correlated with decreased long-term morbidity. According to the Franco-Italian glossary morbidity rates were higher in patients who received chemotherapy (p = 0.047), both external radiotherapy and brachytherapy (p = 0.022) and treatment interruption of less than eight days (p = 0.019). CONCLUSION: There is no common language between the RTOG grading system and Franco-Italian glossary for defining and scoring radiation morbidity. Up to date no standard and well-defined system has been developed for recording and reporting acute and late radiation morbidity in gynaecologic malignancy, but rather it depends on the subjective evaluation and experience of a radiation oncologist and subjective complaints of the patient, and sometimes on clinical findings. A standard and well-defined user friendly objective scoring system is needed to define and predict the morbidity rate more properly.

Intraoperative extracorporeal irradiation and re-implantation of involved bone for the treatment of musculoskeletal tumors.

The purpose of this trial is to evaluate the results of musculoskeletal tumors which is treated with limb salvage surgery and extracorporeal radiotherapy. Patients were treated with en-bloc resection followed by 50 Gy single dose extracorporeal irradiation and re-implantation of involved bone segments. Nine of fifteen were female and 6 were male, median age was 19. Tumor originated from tibia in 7 patients, femur in 3, humerus in 3, calcaneus in 1 and scapula in 1. Preoperative chemotherapy was given to 12 patients, 3 of them had not been treated previously. Median follow-up time of the survivors was 22 months (range 2-47 months); local recurrence and lung metastases occurred in one patient (local recurrence was away from the re-implanted bone segment), and lung metastases were reported in another 3 patients. Wound healing problems occurred in 4 patients and delayed union in 2 patients. Amputation was performed in 2 patients due to uncontrolled infection, and infected bone was replaced by a fibula graft in another patient. Treatment was successful in 12 patients where functional results were good in 9, excellent in 2 and not evaluated in 1. Limb salvage using en-bloc resection followed by intraoperative extracorporeal irradiation and re-implantation of involved bone is a useful and cheap reconstruction method in appropriately selected patients.

Treatment results and prognostic factors for cervical cancer patients treated by radiochemotherapy with weekly cisplatin.

OBJECTIVE: This retrospective trial aims to report the treatment results of patients with locally advanced cervical cancer treated by concomitant radiochemotherapy with weekly cisplatin. METHODS: Between October 1999 and December 2003, 81 patients with FIGO Stages IB-IVA were treated at Ege University Faculty of Medicine Department of Radiation Oncology by radiochemotherapy with weekly cisplatin (40 mg/m2). Intracavitary high-dose rate brachytherapy was applied to 76 patients (93.8%) and five patients (6.2%) were treated with external radiotherapy alone. Early and late side-effects of the treatment were analyzed according to RTOG-EORTC criteria. RESULTS: Median age was 55 years and the most frequent histology was epidermoid carcinoma. Median follow-up time was 42 months. Five-year overall, disease-free and local relapse-free survival rates were 69%, 77%, and 82%, respectively. The presence of low Hgb level (< 12 g/dl), bulky tumor (> 4 cm), poor performance status, pelvic nodal involvement and limited early response to treatment had a significant impact on the local failure rate. Prognostic factors influencing disease-free survival were bulky tumor, performance status, pelvic nodal status, pretreatment Hgb level and limited early response to treatment. A significantly higher 5-year overall survival rate was observed in patients with good performance status, without pelvic nodal involvement, normal pretreatment Hgb level and complete response to treatment. Grade 3-4 side-effects were not observed in any patients. The most frequent acute side-effects were leukopenia, anemia, nausea and vomiting. Long-term side-effects were observed in 54% of patients. CONCLUSION: This series suggests that radiochemotherapy with weekly cisplatin is an effective and a safe treatment in locally advanced cervical cancer.

Evaluation of anxiety levels during intracavitary brachytherapy applications in women with gynecological malignancies.

PURPOSE: To evaluate the anxiety levels of women treated for gynecological malignancies using intracavitary brachytherapy. METHODS: Anxiety levels prior to and after intracavitary brachytherapy application and factors influencing anxiety levels were evaluated. Women were evaluated for quality of life and psychological status before each brachytherapy application using the Hospital Anxiety and Depression Scale (HADS). Scores were grouped as follows: 0-7 = normal, 8-10 = borderline, 11-21 = abnormal. Women were also questioned about other factors which could affect anxiety levels such as marital status, education level, number of pregnancies and prior surgical history. RESULTS: Between January 2003 and August 2004, 146 women with a median age of 56 years were evaluated (range: 27-80). Eighty-six women had cervix uteri carcinoma and 63 had endometrial carcinoma. Sixty-seven women were premenopausal and 85 women were postmenopausal. The median pregnancy number was three (range = 0-10). Eighty-nine women had at least three children. Sixty-seven women had had previous operations. One hundred and twenty-five women were married and 24 women were unmarried or widowed. Before treatment, the anxiety scores were scored as normal in 49 (32%), borderline in 41 (28%), and abnormal in 59 (40%). Anxiety levels were lower in 69 women during the last application as compared with the pretreatment levels (p = 0.00). Marital status and pregnancy number showed a significant correlation with anxiety scores (p = 0.04). Age, level of education or having had a previous operation showed no significant correlation with anxiety level. CONCLUSION: These results indicate that intracavitary brachytherapy is associated with anxiety. Women need to be given detailed information before the brachytherapy application to reduce anxiety. Additional studies are needed to determine it.

Giant cell tumor of the bone with an asymptomatic huge solitary lung metastasis; case presentation and literature review.

A case concerning a man having giant cell tumor (GCT) of the leg and huge lung metastasis is presented. This case is discussed with a brief review of the relevant literature regarding detection and treatment of this care condition.

Changes of Ki-67 index in squamous cell carcinoma of the cervix during the early course of radiotherapy and prediction of prognosis.

PURPOSE: To determine whether changes in the Ki-67 index during the early course of radiotherapy could predict the prognosis in squamous cell carcinoma of the uterine cervix and be of value in clinical practice. MATERIALS AND METHODS: Biopsy specimens from 23 cases of histologically confirmed squamous cell carcinoma of the cervix were stained with anti-Ki-67 monoclonal antibody prior to radiotherapy and after 9 Gy. The correlation between the Ki-67 index, local control and distant metastasis was determined by Spearman's correlation test. RESULTS: Median age of the patients was 49. According to the FIGO staging system four patients had Stage IIA, 16 had Stage IIB, one had Stage IIIA and two had Stage IIIB disease. Among the whole group brachytherapy was applied to 17 patients (17/23) and weekly cisplatin (40 mg/m2) was applied to 15 patients (15/23). The mean Ki-67 index prior to radiotherapy and after 9 Gy for the entire group were 58.5% and 46.0%, respectively. The Ki-67 index after 9 Gy decreased in most of the patients (74%). During a median follow-up of 23 months four patients developed local recurrence and four patients developed distant metastasis. No significant correlation was detected among the local control and changes in Ki-67 index after 9 Gy, whereas there was a moderate correlation between distant metastasis and changes in Ki-67 index after 9 Gy (r = 0.51, p = 0.01). CONCLUSION: The Ki-67 index can be used safely as a proliferation marker in cervical carcinomas, and changes in the Ki-67 index during the early course of radiotherapy may predict the metastatic potential. However prospective studies including a large number of patients with long-term follow-up are necessary to confirm the clinical utility of this marker in cervical cancer.