Interstitial iridium-192 implantation combined with external radiotherapy in anal cancer: ten years experience.

PURPOSE: To report our experience in the use of interstitial iridium-192 implantation combined with external radiotherapy in anal cancer. METHODS AND MATERIALS: From 1984 to 1994, 79 patients with anal cancer were treated with radical intent using radiotherapy (plus chemotherapy) at Beatson Oncology Centre, Glasgow, Scotland. The mean and median age at presentation were 68 and 70 years, respectively (range 34-85) with a male-to-female ratio of 0.39. The histologic distribution was as follows: 48 squamous, 16 basaloid, 14 adenocarcinoma, and 1 basal cell carcinoma. The T stages were: 8 T1, 40 T2, 26 T3, and 5 T4 lesions. Twelve (15%) patients had nodal involvement at presentation. All patients underwent interstitial implantation using iridium-192 as part of the initial treatment. Seventy-six patients were treated with external radiotherapy followed by implant with a mean delay of 37 days after the end of radiotherapy. Twelve patients also received chemotherapy with 5-fluorouracil and mitomycin-C concurrently with external radiotherapy. Follow-up ranged from 6 to 123 months, with a median of 37 months. RESULTS: Seventy-nine patients were analyzed to assess local control, survival, and complications. A complete response rate of 91% (72 of 79) was achieved after planned radiation treatment. At the end of external radiotherapy, 29% (22 of 76) had achieved complete response, 58% (7 of 12) with chemotherapy and 23% (15 of 64) without it. Local control was achieved in 62 of 79 (78%) patients and 8 of 17 (47%) local failures were salvaged by abdominoperineal resection. Five patients developed inguinal node failure; four of these were salvaged. Overall, 10% of all patients developed distant metastasis as the first site of failure and 25% failed at any site after salvage therapy. Time to unsalvageable relapse was significantly different on comparing T stage (p = 0.005) and histology (p = 0.029) of tumor. Major complications requiring surgical intervention were seen in six (7.5%) patients. Anal function preservation with local control was possible in 56 of 79 (71%) patients. CONCLUSION: We report excellent results with radiotherapy in T1 and T2 lesions. The role of chemoradiotherapy as radical treatment of anal cancer should be defined in the context of locally advanced tumors.

Interstitial iridium-192 implantation for recurrent and/or locally advanced head and neck cancer.

We report our experience with the use of interstitial iridium-192 implantation in the management of patients with recurrent and locally advanced squamous cell carcinoma of the head and neck. Between June 1992 and July 1998 this technique was employed in the management of two groups of patients: (1) a primary group, comprising 42 patients who had presented for the first time with advanced head and neck disease, and had therefore not undergone any previous treatment; and (2) a salvage group of 16 patients with recurrent disease previously treated with external beam radiotherapy (four received therapy to the neck, one to the cheek, eight to the tongue and three to the floor of the mouth). The follow-up in each group was short, ranging from 3 to 56 months. The overall response in the primary group was 38/42 (90%). A complete response was achieved in 35/42 (83%). In the salvage group, the overall response was 13/16 (81%); 4/16 (25%) showed a complete response and 9/16 (56%) a partial response. The estimated percentage surviving at 1 year for patients with primary disease is 70% (95% confidence interval (CI) 54-86). For those receiving salvage therapy the estimated percentage surviving at 1 year is 45% (95% CI 19-71).

Primary gastrointestinal lymphoma--disease spectrum and management: a 15-year review from north India.

OBJECTIVE: To analyze retrospectively the disease spectrum and outcome of primary gastrointestinal lymphoma (PGIL) in a tertiary referral center in north India. MATERIAL: Seventy five patients presenting with PGIL between January 1971 and December 1985 were evaluated. RESULTS: The 49 males and 26 females were aged 3.5-69 years (mean 34) at presentation. Abdominal pain, weight loss and vomiting were cardinal symptoms at presentation; the stomach was the most common site of involvement. Histologically, a majority of patients were classified as having diffuse poorly-differentiated lymphocytic lymphoma (46.7%) and diffuse histiocytic type (30.7%). Twenty seven (36%) patients had stage I disease, 31 (40%) stage II, 11 (14.7%) stage III, and 6 (8%) stage IV. At laparotomy, primary resection and anastomosis was carried out in 66 patients, while only biopsies were taken in nine. Forty eight patients received adjuvant radiation with or without chemotherapy. The mean follow-up was 3.9 years (range 1-14). The 5-year actuarial survival was 34%, 25% and 16% for stages I, II, and higher-stage disease, respectively. The survival was significantly better (p < 0.01) for gastric location (44%) compared to other sites (24%). CONCLUSION: PGIL was more common in the 3rd and 4th decades of life, with the stomach being the predominant site of involvement. Survival was better among patients with stages I and II disease, and gastric location of lesion.

Carcinoma of the esophagus presenting with esophagocutaneous fistula--a case report.

An interesting manifestation of carcinoma of the esophagus, hitherto undescribed is reported. The patient at the time of diagnosis had presented with an esophagocutaneous fistula. He was treated by feeding jejunostomy and local palliative radiotherapy and showed good clinical improvement. The extreme rarity of such a presentation is highlighted.

Occult carcinoma esophagus metastatic to spine producing paraplegia--a case report and review of literature.

An extremely rare case of asymptomatic squamous cell carcinoma of the esophagus metastatic to the spine leading to paraplegia is reported. The rarity of such an event signifies the relationship between hypercalcaemia and carcinoma of the esophagus. Its occurrence as a second silent primary neoplasm and its association with a negative esophagogram is highlighted.

Target localization and toxicity in dose-escalated prostate radiotherapy with image-guided approach using daily planar kilovoltage imaging.

Dose escalation with intensity-modulated radiation therapy (IMRT) for carcinoma of the prostate has augmented the need for accurate prostate localization prior to dose delivery. Daily planar kilovoltage (kV) imaging is a low-dose image-guidance technique that is prevalent among radiation oncologists. However, clinical outcomes evaluating the benefit of daily kV imaging are lacking. The purpose of this study was to report our clinical experience, including prostate motion and gastrointestinal (GI) and genitourinary (GU) toxicities, using this modality. A retrospective analysis of 100 patients treated consecutively between December 2005 and March 2008 with definitive external beam IMRT for T1c-T4 disease were included in this analysis. Prescription doses ranged from 74-78 Gy (median, 76) in 2 Gy fractions and were delivered following daily prostate localization using on-board kV imaging (OBI) to localize gold seed fiducial markers within the prostate. Acute and late toxicities were graded as per the NCI CTCAEv3.0. The median follow-up was 22 months. The magnitude and direction of prostate displacement and daily shifts in three axes are reported. Of note, 9.1% and 12.9% of prostate displacements were ≥ 5 mm in the anterior-posterior and superior-inferior directions, respectively. Acute grade 2 GI and GU events occurred in 11% and 39% of patients, respectively, however no grade 3 or higher acute GI or GU events were observed. Regarding late toxicity, 2% and 17% of patients developed grade 2 toxicities, and similarly no grade 3 or higher events had occurred by last follow-up. Thus, kV imaging detected a substantial amount of inter-fractional displacement and may help reduce toxicity profiles, especially high grade events, by improving the accuracy of dose delivery.

Local thermo-radiotherapy in carcinoma cervix: improved local control versus increased incidence of distant metastasis.

In 1986, 50 patients with stages II and III carcinoma of the cervix were entered into this prospective randomized study. Twenty-five cases (Group I) were treated only by radical radiation whereas remaining 25 cases (Group II) received local hyperthermia in addition to radical radiation. Hyperthermia was delivered by intracavitary brachyhyperthermia approach using an endotract applicator. Both the groups were followed up for a minimum period of 18 months. Group II patients achieved better local control (14 out of 20 evaluable cases) than the Group I patients (11 out of 22 evaluable cases). A disturbing observation was the increased incidence of distant metastasis in Group II (4 out of 23 cases) as compared to Group I (1 out of 23 cases), though most of them remained disease free locally. The increasing use of hyperthermia in the management of various cancers needs to be reviewed in this context.

Side-effects of local hyperthermia: results of a prospectively randomized clinical study.

In 1986, 25 patients with stage II and III carcinoma of the cervix were treated by a combination of radiation and local hyperthermia using an endotract intravaginal applicator. Another 25 patients were treated with radiation alone. Both groups were followed up for a minimum period of 18 months. The acute and long-term toxicity of local hyperthermia was closely monitored. Our study shows that whereas local hyperthermia adds significantly to the local control achieved with radiation alone, it is not in any way associated with any significant short- or long-term toxicity, and does not enhance the radiation reactions.

Ewing's sarcoma of the foot bones: an analysis of seven cases.

Seven cases of Ewing's sarcoma presenting with primary lesions of the foot bones are described. Difficulty and delay in making the initial diagnosis are the hallmarks of the problems encountered at this site. Although radiation therapy plays an important role for control of disease in Ewing's sarcoma, surgery along with chemotherapy appears to give better results. Lesions of the forefoot are amenable to surgery; however, no guidelines are available in the literature for hindfoot lesions. Chemotherapy has revolutionized the outcome, and its use along with surgical intervention is recommended in all cases of Ewing's sarcoma of foot bones.