Excimer laser coronary angioplasty and intracoronary radiation for in-stent restenosis: six-month angiographic and clinical outcomes.

BACKGROUND: The purpose of this study was to evaluate 6-month clinical and angiographic outcomes in patients treated with excimer laser coronary angioplasty (ELCA) and intracoronary radiation (ICR) for in-stent restenosis (ISR). METHODS: A consecutive series of 175 patients with ISR treated with ELCA+ICR (gamma and beta emitters) were compared to 33 patients with ISR treated with ELCA alone. Baseline characteristics were similar between groups. ELCA+ICR and ELCA-alone patients had similar lesion lengths (25.0+/-12.0 vs. 24.0+/-16.8 mm, P=NS) in predominantly saphenous vein grafts (SVG, 38% vs. 42%, P=NS). RESULTS: Procedural success was high (ELCA+ICR, 97.0% vs. ELCA alone, 98.5%, P=NS), with no perforations or acute vessel closures. ELCA+ICR therapy reduced target vessel revascularization (TVR; 27% vs. 64%, P<.0001) and major adverse cardiac events [MACE: death, myocardial infarction (MI), or TVR; 30% vs. 64%, P<.0001] compared to ELCA alone. Late loss was 0.66+/-0.90 mm in ELCA+ICR patients and 0.85+/-0.60 mm in ELCA-alone patients (P=NS). Angiographic binary restenosis (>50%) was significantly reduced with adjunctive ICR (28% vs. 54%, P=.014). CONCLUSION: Radiation therapy with ELCA significantly reduces angiographic binary restenosis at 6 months in patients with diffuse ISR, driven predominantly by reduced percutaneous TVR.

Permanent interstitial implantation using palladium-103: the New York Medical College preliminary experience.

Palladium-103 is a low energy photon emitter available for permanent interstitial implantation. Pd-103 has energy and safety characteristics similar to Iodine-125, but its initial peripheral dose rate is approximately three times greater. This may provide improved control of rapidly proliferating tumors. At the Westchester Campus of New York Medical College, 15 patients with residual or recurrent unresectable lesions were implanted with Pd-103. There were five males and 10 females with an age range of 41 to 93 years (median 58). Implanted sites included the chest wall, nasopharynx, vagina, and zygomatic region. Peripheral doses ranged from 55 to 203 Gy (median 107 Gy). A complete response was achieved in eight patients and a partial response in seven patients, for an overall response rate of 100%. We noted improved control with smaller volumes and peripheral doses at or above 115 Gy. No unusual skin or mucosal reactions were recorded. Possible advantages of Pd-103 as a substitute for I-125 include improved control of rapidly proliferating tumors and a more rapid clinical response of lesions. Disadvantages include current higher cost and an impracticality in maintaining a running inventory because of the short half-life of the isotope. Our experience suggests that Pd-103 is an attractive alternative to I-125.

Treatment of advanced transitional cell carcinoma of the bladder with irradiation and concomitant 5-fluorouracil infusion.

Twenty patients with advanced transitional cell carcinoma of the bladder were treated with radiation and concomitant continuous infusion of 5-fluorouracil with or without Mitomycin. Nineteen of 20 patients were assessed for response. Fourteen of 19 patients (74%) obtained a complete response within 3 to 6 months. An additional three patients (15%) acquired and maintained a complete response after local transurethral resection of the tumor and intravesical chemotherapy, raising the overall complete response (CR) rate to 17/19 (89%). Of the two patients with persistent disease, one is alive and well after salvage cystectomy. Eighteen of 20 patients were evaluated for survival with a median follow-up of 38 months. Seven patients remain alive and well 51 to 78 months, whereas three patients died from intercurrent disease. Eight patients died of either distant metastatic disease (7 patients) or regional disease (1 patient). An adjusted survival calculated by the Life Table Method was 53.6% at 5 years, whereas the overall survival was 39%. The combined modality therapy was well tolerated with no need for treatment interruption or reduction in dose. Late bladder complications include one patient with hemorrhagic cystitis, two patients with dysuria, and two with symptoms of irritable bladder. One patient required a colostomy for a chronic hemorrhagic proctitis. Bladder preservation was achieved in 19/20 patients.