Watch and wait approach following extended neoadjuvant chemoradiation for distal rectal cancer: are we getting closer to anal cancer management?

BACKGROUND: No immediate surgery (Watch and Wait) has been considered in select patients with complete clinical response after neoadjuvant chemoradiation to avoid postoperative morbidity and functional disorders after radical surgery. OBJECTIVE: The purpose of this study was to demonstrate the long-term results of patients who had a complete clinical response following an alternative chemoradiation regimen and were managed nonoperatively. DESIGN: This is a prospective study. SETTINGS: This study was conducted at a single center. PATIENTS: Seventy consecutive patients with T2-4N0-2M0 distal rectal cancer were studied. Neoadjuvant chemoradiotherapy included 54 Gy and 5-fluorouracil/leucovorin delivered in 6 cycles every 21 days. Patients were assessed for tumor response at 10 weeks from radiation completion. Patients with incomplete clinical response were referred to immediate surgery. Patients with complete clinical response were not immediately operated on and were monitored. MAIN OUTCOME MEASURES: The primary outcomes measured were the initial complete clinical response rates after 10 weeks and the sustained complete clinical response rates after 12 months from chemoradiotherapy. RESULTS: One patient died during chemoradiotherapy because of cardiac complications. Forty-seven (68%) patients had initial complete clinical response. Of these, 8 developed local regrowth within the first 12 months of follow-up (17%). Thirty-nine sustained complete clinical response at a median follow-up of 56 months (57%). An additional 4 patients (10%) developed late local recurrences (>12 months of follow-up). Overall, 35 patients never underwent surgery (50%). LIMITATIONS: This study is limited by the short follow-up and small sample size. CONCLUSION: Extended chemoradiation therapy with additional chemotherapy cycles and 54 Gy of radiation may result in over 50% of sustained (>12 months) complete clinical response rates that may ultimately avoid radical rectal resection. Local failures occur more frequently during the initial 12 months of follow-up in up to 17% of cases, whereas late recurrences are less common but still possible, leading to 50% of patients who never required surgery. Strict follow-up may allow salvage therapy in the majority of these patients (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A113.).

Increasing the rates of complete response to neoadjuvant chemoradiotherapy for distal rectal cancer: results of a prospective study using additional chemotherapy during the resting period.

OBJECTIVES: Addition of chemotherapy in the resting period between radiotherapy completion and response assessment during neoadjuvant treatment for distal rectal cancer could potentially increase rates of complete tumor regression. The purpose of this study was to evaluate toxicity rates and the impact of an extended neoadjuvant chemoradiation regimen on complete response rates. METHODS: Thirty-four consecutive patients with nonmetastatic distal rectal cancer were prospectively included. Patients were managed by 5,400 Gy of radiation and 5-fluorouracil/leucovorin-based chemotherapy given for three consecutive days every 21 days for six cycles (three cycles concomitant with radiotherapy). Tumor response assessment was performed at ten weeks from radiation completion. Patients with complete clinical response were strictly monitored and were not immediately operated on. Patients with incomplete clinical response were referred to surgery. RESULTS: Twenty-nine patients had completed 12 months of follow-up and were included in this preliminary analysis. Twenty-eight (97%) successfully completed treatment. Fifteen of 16 patients had Grade III toxicities that were skin-related (93%). Median follow-up was 23 months. Fourteen patients (48%) were considered as complete clinical responders sustained for at least 12 months (median, 24 months) after chemoradiation completion by clinical assessment alone. An additional five patients (17%) were considered as complete responders with ypT0 results after full-thickness local excision. Overall, the complete response rate was 65%. CONCLUSIONS: The addition of chemotherapy during the resting period after neoadjuvant chemoradiation is associated with acceptable toxicity and high tolerability rates. The considerably high rates of complete response in this preliminary series requires further follow-up, but they may provide valuable information for future prospective, randomized trials.

Radiosurgery with a linear accelerator in cerebral arteriovenous malformations.

OBJECTIVE: To evaluate results achieved with radiosurgery and complications of the procedure when treating arteriovenous malformations with linear accelerator. METHODS: This retrospective study was conducted between October 1993 and December 1996. Sixty-one patients with arteriovenous malformations were treated with radiosurgery utilizing a 6MV energy linear accelerator. Ages of the 32 female and 29 male patients ranged from 6 to 54 years (mean: 28.3 years). The most frequent initial symptom was cephalea (45.9%), followed by neurological deficit (36.1%). Cerebral hemorrhage diagnosed by image was observed in 35 patients (57.3%). Most arteriovenous malformations (67.2%) were graded Spetzler III and IV. Venous stenosis (21.3%) and aneurysm (13.1%) were the most frequent angioarchitecture changes. The dose administered varied from 12 to 27.5Gy in the periphery of the lesion. RESULTS: Out of twenty-eight patients that underwent conclusive angiography control, complete obliteration was achieved in 18 (72%) and treatment failed in 7 (absence of occlusion with more than 3 years of follow-up). Four were submitted to a second radiosurgery, and one of these has shown obliteration after 18 months of follow-up. DISCUSSION: Several factors were analyzed regarding the occlusion rate (gender, age, volume, localization, Spetzler, flow, embolization, total of isocenters, prescribed dose and chosen isodose) and complications (total of isocenters, localization, volume, maximum dose, prescribed dose and chosen isodose). Analyzed variables showed no statistical significance for obliteration of the vessel, as well as for treatment complications. The largest diameter of the arteriovenous malformation, its volume and the dose administered did not influence time of obliteration. CONCLUSION: Radiosurgery is effective in the treatment of arteriovenous malformations and can be an alternative for patients with clinical contraindication or with lesions in eloquent areas. In the studied variables no statistically significant correlation was observed between occlusion and treatment complications.

Patterns of failure and survival for nonoperative treatment of stage c0 distal rectal cancer following neoadjuvant chemoradiation therapy.

Neoadjuvant chemoradiation therapy (CRT) is the preferred treatment option for distal rectal cancer. Complete pathological response after CRT has led to the proposal of nonoperative approach as an alternative treatment for highly selected patients with complete clinical response. However, patterns of failure following this strategy remains undetermined. Three hundred sixty-one patients with distal rectal cancer were managed by neoadjuvant CRT including 5-FU, leucovorin, and 5040 cGy. Tumor response assessment was performed at 8 weeks following CRT. Patients with complete clinical response were not immediately operated on and were closely followed. One hundred twenty-two patients were considered to have complete clinical response after the first tumor response assessment. Of these, only 99 patients sustained complete clinical response for at least 12 months and were considered stage c0 (27.4%) and managed nonoperatively. Mean follow-up was 59.9 months. There were 13 (13.1%) recurrences: 5 (5%) endorectal, 7 (7.1%) systemic, and 1 (1%) combined recurrence. All 5 isolated endorectal recurrences were salvaged. Mean recurrence interval was 52 months for local failure and 29.5 months for systemic failure. There were five cancer-related deaths after systemic recurrences. Overall and disease-free 5-year survivals were 93% and 85%. Even though surgery remains the standard treatment for rectal cancer, nonoperative treatment after complete clinical response following neoadjuvant CRT may be safe and associated with good survival rates in a highly selected group of patients. Survival in these patients is significantly affected by systemic failure. Exclusive local failure occurs late after CRT completion and is frequently amenable to salvage therapy.

Treatment of childhood diffuse brain stem tumors: comparison of results in different treatment modalities.

BACKGROUND: Diffuse brainstem tumors in children are rare and its treatment is controversial. Although radiotherapy (RT) used to be the treatment of choice, results remained unsatisfactory. The association of RT with other therapies is common, but lacks scientific data regarding its efficacy. Comparison of results of irradiation alone versus combined treatment modalities is crucial in improving survival. METHOD: The authors reviewed twenty-four patients with diffuse brainstem tumors, with mean age of 7 years, treated from December 90 to November 99, at the University of Sao Paulo, Brazil. These patients were subdivided in four groups according to the treatment option at the onset of symptoms. Four patients were treated with radiation alone (total dose of 50 Gy to 62.4 Gy), 6 patients with chemotherapy and radiation, 8 with tamoxifen and radiation and 6 with tamoxifen, radiation and chemotherapy. The results of the different groups were them compared. FINDINGS: Clinical response was observed in 83.3% of our children, briefly followed by progressive disease. Mean survival was 17 months with no statistically significant differences among the groups. Four patients were alive at the end of the study, with a mean survival of 32.4 months, all of them received combined therapy, but with no statistically significant differences. CONCLUSIONS: Neither the association of radiation therapy with chemotherapy, tamoxifen nor both have showed survival improvement. The prognosis of these patients remains very poor and only investigational trials would justify a highly aggressive approach.

Long-term results of preoperative chemoradiation for distal rectal cancer correlation between final stage and survival.

Neoadjuvant chemoradiation treatment (CRT) has resulted in significant tumor downstaging and improved local disease control for distal rectal cancer. The purpose of the present study was to determine the correlation between final stage and survival in these patients regardless of initial disease stage. Two hundred sixty patients with distal (0-7 cm from anal verge) rectal adenocarcinoma considered resectable were treated by neoadjuvant CRT with 5-FU and leucovorin plus 5040 cGy. Patients with incomplete clinical response 8 weeks after CRT completion were treated by radical surgical resection. Patients with complete clinical response were managed by observation alone. Overall survival and disease-free survival were compared according to Kaplan-Meier curves and log-rank tests according to final stage. Seventy-one patients (28%) showed complete clinical response (clinical stage 0). One hundred sixty-nine patients showed incomplete clinical response and were treated with surgery. In 22 of these patients (9%), pathologic examination revealed pT0 N0 M0 (stage p0), 59 patients (22%) had stage I, 68 patients (26%) had stage II, and 40 patients (15%) had stage III disease. Overall survival rates were significantly higher in stage c0 (P=0.01) compared with stage p0. Disease-free survival rate showed better results in stage c0, but the results were not significant. Five-year overall and disease-free survival rates were 97.7% and 84% (stage 0); 94% and 74% (stage I); 83% and 50% (stage II); and 56% and 28% (stage III), respectively. Cancer-related overall and disease-free survival may be correlated to final pathologic staging following neoadjuvant CRT for distal rectal cancer. Also, stage 0 is significantly associated with improved outcome.

Radiotherapy alone in the treatment of uterine cervix cancer with telecobalt and low-dose-rate brachytherapy: retrospective analysis of results and variables.

PURPOSE: This retrospective analysis aims to report results and variables from patients with cervix cancer treated by radiation therapy alone with telecobalt and low-dose-rate brachytherapy (LDRB). METHODS AND MATERIALS: Between September 1989 and September 1995, 190 patients with histologic diagnosis of cervix carcinoma were treated with telecobalt for external beam radiotherapy (EBR), followed by one or two insertions of LDRB. Stage distribution according to patients was the following: IB, 12; IIA, 4; IIB, 105; and IIIB, 69. Median dose of EBR at whole pelvis was 40 Gy, and median parametrial doses for Stages II and III patients were 50 Gy and 60 Gy, respectively. Median doses of LDRB at point A for patients treated with one and two insertions were 38 Gy and 50 Gy, respectively. RESULTS: Median follow-up time was 70 months (range: 8-127 months). Overall survival, disease-free survival, and 5-year local control of patients at Stages I, II, and III were 83%, 78%, and 46%; 83%, 82%, and 49%; and 92%, 87%, and 58%, respectively. Overall incidence of late complications in the rectum, small bowel, and urinary tract was 15.3% (19/190), 4.2% (8/190), and 6.8% (13/190), respectively. The actuarial 5-year rectal, small bowel, and urinary incidence of late complications was 16.1%, 4.6%, and 7.6%, respectively. Clinical stage was the only significant variable for overall 5-year survival (p = 0.001), for disease-free survival (p = 0.001), and for local control (p = 0.001). Stage II patients more than 50 years old had better disease-free survival and local control at 5 years (p = 0.004). None of the analyzed variables influenced the actuarial 5-year incidence of late complications. CONCLUSIONS: Results of this series suggest that the use of telecobalt equipment for EBR with doses up to 50 Gy at whole pelvis, prior to brachytherapy, is an acceptable technique for radiation therapy alone in the treatment of cervix cancer, especially in developing countries, including Brazil, where telecobalt machines still prevail.

Preoperative chemoradiation therapy for low rectal cancer. Impact on downstaging and sphincter-saving operations.

BACKGROUND/AIMS: Multimodality treatment is the preferred strategy in the management of low rectal adenocarcinoma. Preoperative chemoradiation therapy (CRT) associated with radical surgery may result in significant tumor downstaging, local control of the disease and high rates of sphincter-saving operations. METHODOLOGY: One hundred consecutive patients with advanced and resectable distal rectal cancer treated either by surgery alone or by preoperative chemoradiation followed by surgery were reviewed. Both groups were similar in tumor and patients characteristics. Treatment strategy was randomly selected. RESULTS: Mean tumor size in Group 1 (surgery alone) was 6.1 cm and 3.3 cm in Group 2 (CRT). In Group 1 (surgery alone), nine patients had stage I (18%), 20 had stage II (40%) and 21 had stage III disease (42%). In Group 2 (CRT), 6 patients had stage 0 (12%), 21 had stage I (42%), 12 had stage II (24%) and 11 had stage III disease (22%). Furthermore, for each T (except for T0-1) the presence of lymph node (LN) metastasis was significantly more frequent in Group 1. In Group 2 (CRT), there was a mean reduction of 27% of the initial tumor size. This reduction was observed in 58% of patients in this group (CRT). Finally, sphincter-saving operations were more frequently performed in Group 2 (CRT) even though tumor differentiation and distance from the anal verge were similar in both groups. CONCLUSIONS: Preoperative CRT followed by radical surgery is an effective treatment strategy for distal rectal cancer resulting in significant tumor size reduction and downstaging. Consequently, these effects may be responsible for higher rates of sphincter-saving operations performed in this subset of patients.

Ototoxicity evaluation in medulloblastoma patients treated with involved field boost using intensity-modulated radiation therapy (IMRT): a retrospective review.

BACKGROUND: Ototoxicity is a known side effect of combined radiation therapy and cisplatin chemotherapy for the treatment of medulloblastoma. The delivery of an involved field boost by intensity modulated radiation therapy (IMRT) may reduce the dose to the inner ear when compared with conventional radiotherapy. The dose of cisplatin may also affect the risk of ototoxicity. A retrospective study was performed to evaluate the impact of involved field boost using IMRT and cisplatin dose on the rate of ototoxicity. METHODS: Data from 41 medulloblastoma patients treated with IMRT were collected. Overall and disease-free survival rates were calculated by Kaplan-Meier method Hearing function was graded according to toxicity criteria of Pediatric Oncology Group (POG). Doses to inner ear and total cisplatin dose were correlated with hearing function by univariate and multivariate data analysis. RESULTS: After a mean follow-up of 44 months (range: 14 to 72 months), 37 patients remained alive, with two recurrences, both in spine with CSF involvement, resulting in a disease free-survival and overall survival of 85.2% and 90.2%, respectively.Seven patients (17%) experienced POG Grade 3 or 4 toxicity. Cisplatin dose was a significant factor for hearing loss in univariate analysis (p < 0.03). In multivariate analysis, median dose to inner ear was significantly associated with hearing loss (p < 0.01). POG grade 3 and 4 toxicity were uncommon with median doses to the inner ear bellow 42 Gy (p < 0.05) and total cisplatin dose of less than 375 mg/m2 (p < 0.01). CONCLUSIONS: IMRT leads to a low rate of severe ototoxicity. Median radiation dose to auditory apparatus should be kept below 42 Gy. Cisplatin doses should not exceed 375 mg/m2.

High-dose cisplatin concurrent to conventionally delivered radiotherapy is associated with unacceptable toxicity in unresectable, non-metastatic stage IV head and neck squamous cell carcinoma.

Unresectable head and neck squamous cell carcinoma (HNSCC), non-metastatic, comprises a heterogeneous group of patients (pts), formed of stage III and IV pts. Since the available literature had not distinguished among these two groups, we prospectively addressed whether the recommended regimen involving cisplatin 100 mg/m2 concurrent to conventionally delivered radiotherapy (RT) is feasible in stage IV pts, based on the efficacy and safety of this regimen. A total of 30 pts were enrolled onto this study. Chemoradiation (CRT) consisted of RT 70 Gy, delivered in 35 daily fractions of 2 Gy, in 7 weeks, concurrent to cisplatin 100 mg/m2 on days 1, 22 and 43. Supportive treatment was provided as needed. Twenty-eight pts had tumors staged as T4 and 20 had N2 or N3 cervical involvement. The most common primary sites were the oral cavity and the oropharynx (23 pts). We observed six complete responses and 12 partial responses, with an overall response rate of 60%. A high rate of treatment-related toxicities was observed, with three deaths during CRT, and 26 pts suffering from one or more grade 3/4 toxicities, mainly dysphagia, mucositis, dermatitis, vomiting, infection or anemia. A prolonged treatment time was observed (63 days), as a result of unplanned treatment breaks. The lack of requirement of red blood cell transfusion was favorably related to the response to the treatment (93% vs. 50%, P=0.033). For the whole population, with a median follow-up of 20.8 months, the median progression-free survival (PFS) was 8.0 months, and the median overall survival (OS) was 17.3 months. Longer median PFS and OS were seen in responding pts (12.8 vs. 4.1 months, P=0.0001; and not reached (NR) vs. 10.4 months, P=0.0037, respectively), as well as in those pts not requiring red blood cell transfusion (12.8 vs. 3.9 months, P=0.0162; and NR vs. 10.4 months, P=0.0176, respectively). In conclusion, this concurrent CRT regimen is hardly delivered in stage IV, unresectable, locally advanced HNSCC pts, due to treatment-related toxicities and longer RT duration. As a subset of pts may benefit from this regimen, adequate patient selection and aggressive supportive measures are essential.

Peculiaridades da radioterapia em idosos / Peculiarities of radiotherapy in the elderly

É sabido que o envelhecimento da população do mundo durante o século XX e no início deste novo século constitui um desafio de primeira ordem para as nações, especialmente no campo socioeconômico. Um aspecto importante do envelhecimento populacional global é que, para grupos de idade mais avançada, a prevalência das doenças degenerativas também é maior, incluindo as doenças malignas. No universo de pacientes portadores de câncer, por outro lado, metade destes receberá radioterapia em algum momento de sua doença e suas características individuais podem influenciar, de alguma forma, o prognóstico, a indicação e as doses diárias de prescrição dos tratamentos. Neste contexto, a assistência à saúde do idoso portador de câncer deve ser vista como um importante desafio, principalmente devido a dois fatores: uma maior procura de tratamentos, em termos quantitativos, e características fisiológicas peculiares a esta população, que podem influenciar na tomada de decisões terapêuticas. Esta revisão propõe uma discussão sobre alguns aspectos relevantes tanto da fisiologia dos idosos, que pode influenciar o curso do tratamento irradiante, quanto de alguns avanços técnicos da radioterapia, que podem, por sua vez, beneficiar estes pacientes, oferecendo menor toxicidade e maior eficiência e rapidez, por exemplo.

It is known that the aging of the world population during the twentieth century and the beginning of this new century is a first-order challenge for nations, especially in the socio-economic field. An important aspect of the aging of global population is that, for older age groups, the prevalence of degenerative diseases is also higher, including malignancies. On the other hand, among the population of patients with cancer, half of these patients will receive radiation therapy at some point in their illness and their individual characteristics can somehow influence the prognosis, the indication and daily doses of treatment prescriptions. In this context, the health assistance for the elderly patient with cancer should be seen as an important challenge, mainly due to two factors: an increased demand for treatments, in quantitative terms, and physiological characteristics unique to this population, which can influence the therapeutic decision-making. This review proposes a discussion of some relevant aspects of both the physiology of the elderly, which may influence the course of radiation therapy, as well as of some technical advances in radiotherapy, which can in turn benefit these patients by offering, for example, lower toxicity, greater effectiveness and speed.

Operative versus nonoperative treatment for stage 0 distal rectal cancer following chemoradiation therapy: long-term results.

OBJECTIVE: Report overall long-term results of stage 0 rectal cancer following neoadjuvant chemoradiation and compare long-term results between operative and nonoperative treatment. METHODS: Two-hundred sixty-five patients with distal rectal adenocarcinoma considered resectable were treated by neoadjuvant chemoradiation (CRT) with 5-FU, Leucovorin and 5040 cGy. Patients with incomplete clinical response were referred to radical surgical resection. Patients with incomplete clinical response treated by surgery resulting in stage p0 were compared to patients with complete clinical response treated by nonoperative treatment. Statistical analysis was performed using chi2, Student t test and Kaplan-Meier curves. RESULTS: Overall and disease-free 10-year survival rates were 97.7% and 84%. In 71 patients (26.8%) complete clinical response was observed following CRT (Observation group). Twenty-two patients (8.3%) showed incomplete clinical response and pT0N0M0 resected specimens (Resection group). There were no differences between patient's demographics and tumor's characteristics between groups. In the Resection group, 9 definitive colostomies and 7 diverting temporary ileostomies were performed. Mean follow-up was 57.3 months in Observation Group and 48 months in Resection Group. There were 3 systemic recurrences in each group and 2 endorectal recurrences in Observation Group. Two patients in the Resection group died of the disease. Five-year overall and disease-free survival rates were 88% and 83%, respectively, in Resection Group and 100% and 92% in Observation Group. CONCLUSIONS: Stage 0 rectal cancer disease is associated with excellent long-term results irrespective of treatment strategy. Surgical resection may not lead to improved outcome in this situation and may be associated with high rates of temporary or definitive stoma construction and unnecessary morbidity and mortality rates.

Radiosurgery with a linear accelerator in cerebral arteriovenous malformations / Radiocirurgia com acelerador linear em malformações arteriovenosas cerebrais

OBJECTIVE: To evaluate results achieved with radiosurgery and complications of the procedure when treating arteriovenous malformations with linear accelerator. METHODS: This retrospective study was conducted between October 1993 and December 1996. Sixty-one patients with arteriovenous malformations were treated with radiosurgery utilizing a 6MV energy linear accelerator. Ages of the 32 female and 29 male patients ranged from 6 to 54 years (mean: 28.3 years). The most frequent initial symptom was cephalea (45.9 percent), followed by neurological deficit (36.1 percent). Cerebral hemorrhage diagnosed by image was observed in 35 patients (57.3 percent). Most arteriovenous malformations (67.2 percent) were graded Spetzler III and IV. Venous stenosis (21.3 percent) and aneurysm (13.1 percent) were the most frequent angioarchitecture changes. The dose administered varied from 12 to 27.5Gy in the periphery of the lesion. RESULTS: Out of twenty-eight patients that underwent conclusive angiography control, complete obliteration was achieved in 18 (72 percent) and treatment failed in 7 (absence of occlusion with more than 3 years of follow-up). Four were submitted to a second radiosurgery, and one of these has shown obliteration after 18 months of follow-up. DISCUSSION: Several factors were analyzed regarding the occlusion rate (gender, age, volume, localization, Spetzler, flow, embolization, total of isocenters, prescribed dose and chosen isodose) and complications (total of isocenters, localization, volume, maximum dose, prescribed dose and chosen isodose). Analyzed variables showed no statistical significance for obliteration of the vessel, as well as for treatment complications. The largest diameter of the arteriovenous malformation, its volume and the dose administered did not influence time of obliteration. CONCLUSION: Radiosurgery is effective in the treatment of arteriovenous malformations and can be an alternative for patients with clinical...

OBJETIVO: Analisar os resultados obtidos com radiocirurgia e as suas complicações do procedimento, no tratamento das malformações arteriovenosas com acelerador linear. MÉTODOS: Este é um estudo retrospectivo. Entre Outubro de 93 e Dezembro de 96, sessenta e um pacientes com malformações arteriovenosas foram tratados, utilizando um acelerador linear com 6MV de energia. As idades variaram de 6 a 54 anos (média: 28,3 anos), 32 pacientes mulheres e 29 pacientes homens. O sintoma inicial mais freqüente foi cefaléia (45,9 por cento), seguido de déficit neurológico (36,1 por cento). Hemorragia cerebral diagnostica por exame de imagem foi observada em 35 pacientes (57,3 por cento). A maioria das malformações arteriovenosas (67,2 por cento) eram graus III e IV de Spetzler. Estenose venosa (21,3 por cento) e aneurisma (13,1 por cento) foram as mais freqüentes alterações da arquitetura vascular. A dose administrada variou de 12 a 27,5Gy na periferia da lesão. RESULTADOS: Dos vinte e oito pacientes que se submeteram a controle angiográfico conclusivo, 18 tiveram obliteração completa (72 por cento) e 7 falharam ao tratamento (ausência de oclusão com mais de três anos de seguimento). Quatro pacientes foram submetidos a uma segunda radiocirurgia, e um paciente deste grupo apresentou obliteração em 18 meses de seguimento. DISCUSSÃO: Vários fatores foram analisados em relação ao grau de oclusão (sexo, idade, volume, localização, Spetzler, fluxo, embolização, total de isocentros, dose prescrita e isodose escolhida) e complicações (total de isocentros, localização, volume, dose máxima, dose prescrita e isodose escolhida). As variáveis analisadas não mostraram significância estatística para a obliteração do vaso, bem como para as complicações de tratamento. O maior diâmetro da malformação arteriovenosa, seu volume e a dose administrada não influenciaram no tempo de obliteração. CONCLUSÃO: Radiocirurgia é eficiente no tratamento das malformações arteriovenosas...

Validando o SIR: um melhor índice prognóstico para pacientes com metástases cerebraistratados com cirurgia estereotática / Validating the SIR: a better prognostic score index for patients with brain metastases treated with stereotactic radiosurgery

Objetivo: Validar o SIR (score index for survival in patients with brain metastasis treated with stereotatic radiosurgery) [índice de escore paraavaliar a sobrevida de pacientes com metástases cerebrais tratadoscom radiocirurgia estereotática], uma classificação elaborada paramelhor prever o prognóstico de pacientes com metástases cerebraistratados com radiocirurgia, reavaliar a sobrevida dos pacientes e revisara literatura médica. Métodos: Foram analisados dados de 100 pacientes com metástases cerebrais tratados com radiocirurgia estereotática um uma única instituição, entre julho de 1993 e fevereiro de 2002. Os fatores prognósticos e índices estudados foram: idade, índice de desempenho de Karnofsky, estado da doença extracraniana, número de lesões cerebrais, volume da maior lesão, tipode tumor primário, tratado ou não tratado com radioterapia cerebral total,SIR e RPA (Recursive Partitioning Analysis – classificação por análiserecursiva fragmentada). As curvas atuariais de sobrevida de Kaplan-Meier foram calculadas e comparadas. Os modelos Cox – completo e de eliminação retrógrada – foram utilizados para identificar os fatores prognósticos e índices, associados à sobrevida. Resultados: Ao analisar as curvas de sobrevida de Kaplan-Meier, o índice de desempenho de Karnofsky, o estado da doença extracraniana, o volume da maior lesão cerebral, a RPA e o SIR mostraram correlação significativa com o prognóstico. Aplicando os modelos de Cox, observou-se significância para índice de desempenho de Karnofsky (p < 0,0001) e volume da maior lesão (p = 0,0182), assim como para o SIR e paraa RPA, quando testados individualmente (p < 0,0001 e p = 0,0002). Contudo, testando SIR e RPA conjuntamente, só o SIR alcançou significância estatística independente (p < 0,0001). Conclusão: Ao reavaliar nossa casuística, a classificação SIR mostrou maior precisão do que a RPA para prever o tempo de sobrevida de pacientes com metástases cerebrais tratados com radiocirurgia.

Objective: The aim of this paper is to validate the score index forsurvival in patients treated with stereotactic radiosurgery, using aclassification prepared to better evaluate the prognosis of patientswith brain metastasis submitted to stereotactic surgery, re-evaluatingsurvival of patients and reviewing the medical literature. Methods:Data from 100 patients with brain metastases treated with stereotacticradiosurgery at a single institution, between July 1993 and February2000, were retrospectively analyzed. The prognostic factors andscores studied were age, Karnofsky performance status, extracranialdisease status, number of brain lesions, volume of the largest lesion,primary tumor type, treated or not with whole brain radiation therapy,SIR, and RPA. Kaplan-Meier actuarial survival curves for subsets werecalculated and compared by log-rank test. Complete and backwardelimination Cox models were utilized to identify the prognostic factorsand scores independently associated with survival. Results: Karnofskyperformance status, extracranial disease status, volume of the largestbrain lesion, RPA, and SIR were significantly correlated with prognosisin Kaplan-Meier survival analysis. Applying Cox models, significancewas observed for KPS and volume of the largest lesion (p < 0.0001and p = 0.0182, respectively), as well as for SIR and RPA when testedindividually (p < 0.0001 and p = 0.0002, respectively). However, whentesting SIR and RPA together, only SIR reached independent statisticalsignificance (p < 0.0001). Conclusion: SIR classification demonstrateda better accuracy in predicting survival time than RPA. SIR was testedin other centers, showing superior accuracy and applicability than theRPA, thus validating this score.

Conventional External Beam Radiation Therapy and High Dose Rate Afterloading Brachytherapy as a Boost for Patients Olderthan 70 years

The treatment options for patients with non metastatic prostate cancer range from observation, radical prostatectomy, radiationtherapy, hormonal therapy to various combination of some to all of them. Objective: We evaluated the impact on biochemicalcontrol of disease (bNED), acute and late intestinal (GI) and urological (GU) morbidity for a group of patients older than 70years presenting initial or locally advanced prostate cancer treated with fractionated high dose rate brachytherapy (HDRB) asa boost to conventional external beam radiation therapy (RT) at the Department of Radiation Oncology from Hospital do CâncerA. C. Camargo, São Paulo, Brazil. Methods: A total of 56 patients older than 70 were treated from March, 1997 to June,2002. All patients had prior to HDRB a course of RT to a median dose of 45 Gy. HDRB doses ranged from 16 Gy to 20 Gy, givenin 4 fractions. Results: The median age of the patients was 74.4 years (range 70-83) and the median follow-up 33 months(range 24 to 60). The 5-year actuarial bNED rate was 77%. Acute GU and GI morbidity G1-2 were seen in 17.8% and 7.1% ofpatients, respectively. Late G1 or G2 GU morbidity was seen in 10.7% of the patients, while late G3 morbidity was observedin 7.1% of the patients, represented by urethral strictures. Conclusion: this group of patients had similar bNED rates whencompared to literature, with acceptable morbidity rates.

Evolução neuropsicológica de pacientes com metástases cerebrais submetidos à radioterapia paliativa / Long term neuropsychological follow-up of patientswith brain metastasis treated with palliative whole-brain radiation therapy

Introdução: O tratamento radioterápico como modalidade terapêutica das metástases cerebrais está associado a um melhor controle local e diminuição da probabilidade de morte neurológica. Entretanto, há um número escasso de estudos na literatura investigando os efeitos deste tratamento, especialmente de radioterapia total de cérebro paliativa, no funcionamento cognitivo e na qualidade de vida dos pacientes que a ele se submetem. Objetivo: O presente estudo tem como objetivo investigar o funcionamento cognitivo de pacientes com metástases cerebrais antes e após o tratamento de radioterapia total de cérebro paliativa. Método: Os 13 pacientes incluídos foram submetidos a 30 Gy m 10 frações, totalizando 3000 cGy. Os testes neuropsicológicos selecionados avaliaram as funções mnésticas, atencionais, executivas, intelectuais e motoras. Resultados: Os principais resultados demonstraram prejuízo das funções executivas, atencionais e de memória episódica, após o tratamento de radioterapia total de cérebro, especialmente, em pacientes com 3 ou 4 metástases cerebrais. Conclusão: Estes achados foram discutidos levando-se em consideração os déficits cognitivos e localização das lesões.

Introduction: The radiation therapy as a treatment modality for brain metastasis is associated with better local control and reduction in neurological death. However, there is a lack of studies in the literature investigating the treatment effects especially of whole-brain radiation therapy on cognitive functions and quality of life in patients who underwent this treatment. Objective: The present study aimed at investigating the cognitive functioning of patients with brain metastases before and after palliative whole-brain radiation therapy. Methods: The 13 patients included in the study received 30 Gy in 10 fractions totaling 3000 cGy. The neuropsychological tests assessed memory, attention, executive functions and motor dexterity. Results: The main results showed impairment in executive, attentional and memory functions after treatment particularly in cases with 3 or 4 lesions in the brain. Conclusion: These findings are discussed in terms of the cognitive deficits and localization of the lesions.