Interstitial high-dose-rate brachytherapy combined with cervical dissection on head and neck cancer.

BACKGROUND: The literature is scarce regarding the use of interstitial high-dose-rate brachytherapy (I-HDR) as adjuvant treatment of the cervical region, and most reports are focused on primary tumors of the mobile tongue and oropharynx. We evaluated the outcome and morbidity related to an institutional treatment policy, using I-HDR as the sole adjuvant treatment or in combination with external beam radiotherapy (EBRT) at the Departments of Radiation Oncology and Head and Neck Surgery, Hospital do Cancer, Sao Paulo, Brazil. METHODS: From October 1994 to December 2003, charts of 42 patients who had biopsy-proven cervical head and neck cancer, with a median follow-up of 36 months (range, 8-111 months), were reviewed. The median age of the patients was 55 years (range, 31-76 years), and the male/female ratio was 4.25:1.00. Thirty-five patients had previous irradiation with EBRT, with doses ranging from 30 Gy to 65 Gy (median, 52 Gy). The total dose of I-HDR ranged from 12 Gy to 48 Gy (median, 24 Gy), given in three to 14 fractions (median, 6 fractions) in 2 to 8 days (median, 4 days). RESULTS: The total treatment time ranged from 19 to 83 days (median, 35 days). The 5- and 8-year overall survival (OS) rates were 52.5% and 48.1%, respectively; and the relapse-free survival (RFS) rates were 48.5% and 38.1%, respectively. The only statistically significant prognostic factor for RFS and OS at 5 and 8 years was margin status (p = .0050). Four patients (9.5%) had late adverse side effects, such as local dehiscence (n = 2), local ulcer (n = 1), and extensive neck fibrosis (n = 1), not related to a higher dose to the skin or graft. CONCLUSION: These results suggest that I-HDR can be recommended in selected patients with first presentation lesions, local recurrences, or second primary carcinomas, even with a previous course of EBRT, but further studies are eagerly awaited to delineate the optimum schedule for this combination-treatment modality.

Comparison of low and high dose rate brachytherapy in the treatment of uterine cervix cancer. Retrospective analysis of two sequential series.

PURPOSE: This retrospective analysis aims to report on the comparative outcome of cervical cancer patients treated with low dose rate (LDR) and high dose rate (HDR) brachytherapy. METHODS AND MATERIALS: From 1989 to 1995, 190 patients were treated with low dose rate (LDR) brachytherapy (LDR group) and from 1994 to 2001, 118 patients were treated with high dose rate (HDR) brachytherapy (HDR group). FIGO stage distribution for the LDR group was Stage I: 6.3%; Stage II: 57.4%; and Stage III: 36.3% and for the HDR group Stage I: 9.3%; Stage II: 43.2%; and Stage III: 47.4%. All patients were treated with telecobalt external-beam radiotherapy (EBR). Median doses of LDR brachytherapy at Point A were 40 Gy and 50 Gy for patients treated with 1 and 2 implants, respectively. All patients from the HDR group were treated with 24 Gy in 4 fractions of 6 Gy to Point A. Survival, disease-free survival, local control, and late complications at 5 years, were endpoints compared for both groups. RESULTS: Median follow-up time for LDR and HDR groups was 70 months (range, 8-127 months) and 33 months (range, 4-117 months), respectively. For all stages combined, overall survival, disease-free survival, and local control at 5 years were better in the LDR group (69% vs. 55%, p = 0.007; 73% vs. 56%, p = 0.002; and 74% vs. 65%; p = 0.04, respectively). For clinical Stages I and II, no differences was seen in overall survival, disease-free survival, and local control at 5 years between the two groups. For clinical Stage III, overall survival and disease-free survival at 5 years were better in the LDR group than in the HDR group (46% vs. 36%, p = 0.04 and 49% vs. 37%, p = 0.03, respectively), and local control was marginally higher in the LDR group than in the HDR group (58% vs. 50%, p = 0.19). The 5-year probability of rectal complications was higher in the LDR group than in the HDR group (16% vs. 8%, p = 0.03) and 5-year probability of small bowel and urinary complications was not statistically different between the the LDR group and the HDR group (4.6% vs. 8.9%, p = 0.17 and 6% vs. 3%, p = 0.13, respectively). CONCLUSIONS: This comparative series suggests similar outcome for Stages I and II patients treated with either HDR or LDR brachytherapy. Lower overall and disease-free survival and marginally lower local control were observed for Stage III patients treated with HDR brachytherapy. Less late rectal complications were observed in the HDR group patients. These findings were probably the result of the relatively low HDR brachytherapy dose delivered at Point A.

External Beam Radiotherapy Boosted With High Dose Rate Brachytherapy in Completely Resected Uterine Sarcomas. Is This a Treatment Option?

Uterine sarcoma (US) is a relative rare tumor, whichaccounts for only about 3-5% of all uterine cancers.Aggressive cytoreductive surgery at the time of the initialdiagnosis with maximum tumor debulking may lead toa prolonged survival or cure. OBJECTIVE: to identifyand review the role of adjuvante external beam radiationtherapy (EBRT) associated with high dose ratebrachytherapy (HDRB) in the management of patientspresenting US with complete resection. MATERIAL ANDMETHODS: this study is a retrospective analysis of 23patients with US treated from 10/92 to 03/03, withsurgery, external beam radiation therapy (EBRT) andhigh dose rate brachytherapy (HDRB). The inclusioncriteria for study participation included: histologicallyproven and graded US, completely resection of tumor,Karnofsky status 60–100, absence of significant infection,and recovery from recent surgery. RESULTS: The medianage of patients was 62 years (range 39-84); ten-yearactuarial disease-free and overall survivals were 42.2%and 63.4%, respectively. On univariate analysis,predictive factors for disease-free survival (DFS) wereage at initial presentation (p=0.0268), parity (p= 0.0441),tumor grade (p= 0.0095), cervical or vaginal invasion(p=0.0014) and node dissection at time of surgery (p=0.0471). On multivariate analysis, the only predictivefactor was cervical or vaginal invasion (p= 0.048), hazardratio of 4.7. CONCLUSION: it is quite likely that neitherradiotherapy nor chemotherapy alone will appreciablyimprove survival in US. If radiation therapy providesbetter locoregional tumor control, hematogenousmetastases will assume an even greater proportion oftreatment failures. Unfortunately, our small andheterogeneous group analyzed precludes any definitiveconclusions about the impact of HDRB associated to EBRTradiation therapy on recurrence or survival.

Radiochemotherapy in the conservative treatment of anal canal carcinoma: retrospective analysis of results and radiation dose effectiveness.

PURPOSE: This retrospective analysis reports the results on patients with anal canal carcinoma treated by combined radiotherapy and chemotherapy. METHODS AND MATERIALS: Between March 1993 and December 2001, 43 patients with anal canal carcinoma were treated with radiochemotherapy at the Hospital do Cancer A.C. Camargo. Stage distribution was as follows: I, 3 (7%); II, 23 (53.5%); IIIA, 8 (18.6%); and IIIB, 9 (21%). The median age was 56 years (range, 36-77 years) with most patients being women (4:1). External radiotherapy (RT) was delivered at the whole pelvis followed by a boost at the primary tumor. The median dose of RT at the whole pelvis and at the primary tumor was 45 Gy and 55 Gy, respectively. Chemotherapy was carried out during the first and last 4 days of RT with continuous infusion of 5-fluorouracil (1000 mg/m(2)) and bolus mitomycin C (10 mg/m(2)). Median overall treatment time was 51 days (range, 30-129 days). Thirty-four patients (79%) did not receive elective RT at the inguinal region. Patient's age, tumor stage, overall treatment time, and RT dose at primary tumor were variables analyzed for survival and local control. RESULTS: Median follow-up time was 42 months (range, 4-116 months). Overall survival and colostomy-free survival at 5 years was 68% and 52%, respectively. Overall survival according to clinical stage was as follows: I, 100%; II, 82%; IIIA, 73%; and IIIB, 18% (p = 0.0049). Complete response was observed in 40 patients (93%). Local recurrence occurred in 9 (21%) patients, and of these, 6 were rescued by surgery. Local control with a preserved sphincter was observed in 34 patients (79%). According to the RT dose, local control was higher among patients who received more than 50 Gy at primary tumor (86.5% vs. 34%, p = 0.012). Inguinal failure was observed in 5 patients (15%) who did not receive inguinal elective RT. Distant metastasis was observed in 11 patients (25.6%). Temporary interruption of the treatment as a result of acute toxicity was necessary in 12 patients (28%). Four patients developed mild chronic complications. CONCLUSIONS: This analysis suggests that the treatment scheme employed was effective for anal sphincter preservation and local control; however, the incidence of distant metastases was relatively high. The clinical stage was the main prognostic factor for overall survival. Local control was higher in patients treated with doses of more than 50 Gy at primary tumor. The high incidence of inguinal failure implies the need for elective RT in this region.

Late urinary morbidity with high dose prostate brachytherapy as a boost to conventional external beam radiation therapy for local and locally advanced prostate cancer.

PURPOSE: Late urinary retention (UR) is a known complication that may occur when using high dose rate brachytherapy (HDR-B) to boost external beam radiation therapy (EBRT) when treating prostate cancer. However, the dosimetric, treatment and clinical factors associated with this complication are not well-known. MATERIALS AND METHODS: From March 1997 to March 2000 a total of 108 patients with local or locally advanced prostate adenocarcinoma were treated with EBRT (45 Gy) and HDR-B as a boost, when 16 to 20 Gy was given in 4 fractions twice daily. Median patient age was 68 years and median followup was 44 months (range 36 to 72). Each implant was performed using 8 to 18 needles with a median active length of 3 cm. Planning ultrasound target volume ranged from 23 to 65 cc. RESULTS: Biological effective doses for the urethral region ranged from 107 to 138 Gy3 (median 113). Crude and 5-year actuarial UR-free survival were 95.4% and 86.2%, respectively. Predictive factors for UR on univariate analysis were age more than 65 years (p = 0.0416), planning ultrasound target volume greater than 35 cc and active length of needles more than 3.5 cm (p = 0.0158). On multivariate analysis by Cox regression age was the only predictive factor (p = 0.027). CONCLUSIONS: HDR-B appears to offer a safe, reproducible and effective method of boosting conventional EBRT in patients with locally advanced prostate cancer. Results with this technology reveal late urinary morbidity rates paralleling those achieved with other forms of treatment, but further long-term followup is still needed to warrant a definitive conclusion.

Chemotherapy versus best supportive care in stage IV non-small cell lung cancer, non metastatic to the brain

Stage IV non-small cell lung cancer is a fatal disease, with a median survival of 14 months. Systemic chemotherapy is the most common approach. However the impact in overall survival and quality of life still a controversy. OBJECTIVES: To determine differences in overall survival and quality of life among patients with stage IV non-small cell lung cancer non-metastatic to the brain treated with best supportive care versus systemic chemotherapy. PATIENTS: From February 1990 through December 1995, 78 eligible patients were admitted with the diagnosis of stage IV non-small cell lung cancer . Patients were divided in 2 groups: Group A (n=31 -- treated with best supportive care ), and Group B (n=47 -- treated with systemic chemotherapy). RESULTS: The median survival time was 23 weeks (range 5 -- 153 weeks) in Group A and 55 weeks (range 7.4 -- 213 weeks) in Group B (p=0.0018). In both groups, the incidence of admission for IV antibiotics and need of blood transfusions were similar. Patients receiving systemic chemotherapy were also stratified into those receiving mytomycin, vinblastin, and cisplatinum, n=25 and those receiving other combination regimens (platinum derivatives associated with other drugs, n=22). Patients receiving mytomycin, vinblastin, and cisplatinum, n=25 had a higher incidence of febrile neutropenia and had their cycles delayed for longer periods of time than the other group. These patients also had a shorter median survival time (51 versus 66 weeks, p=0.005). CONCLUSION: In patients with stage IV non-small cell lung cancer, non-metastatic to the brain, chemotherapy significantly increases survival compared with best supportive care

Actinic rectitis--the role of colostomy

From 4132 patients treated with radiation therapy due to gynecological malignancy from 1974 to 1988, 527 (12.75%) developed some grade of actinic rectitis with clinical manifestation. The authors analyzed the efficacy of colostomy in the management of 10 women with actinic rectitis grades I and II (Sherman classification) submitted to clinical treatment without response. Pelvic radiation therapy, clinical findings, proctoscopy and rectal biopsy were the basis for the diagnosis and staging of the actinic rectitis. All colostomies were made in the transverse colon and the median follow up from colostomy to last review was 53 months. Eight patients had complete remission of clinical findings after colostomy, but one had recurrence of symptoms 2 years later. One patient had incomplete remission but with clinical improvement and one patient had tumor recurrence. From 8 patients with complete clinical remission, 2 had the colostomies closed, but in 1 was restored 3 months later due to rectum-vaginal fistula