RESUMO
INTRODUCTION: Recent studies have questioned the relative benefit of radiotherapy (RT) for older patients with favorable breast cancer given the lack of survival benefit and marginal local control benefit. Despite the 2004 National Comprehensive Cancer Network (NCCN) guidelines advocating for the option of hormonal therapy alone, trends in utilization rates of RT in this group are not well-documented. We analyzed our institutional experience with implementation of the guidelines over time. MATERIAL AND METHODS: We identified 564 patients aged ≥ 60 years with favorable breast cancer treated with breast conserving surgery from 2000 to 2017. Patients met criteria for Cancer and Leukemia Group B (CALGB) 9343, Postoperative Radiotherapy in Minimum Risk Elderly (PRIME II), or the very-low risk cohort identified in the Toronto-British Columbia study. Multivariable logistic regression analysis was performed to assess the magnitude of association between omission status, grade, and tumor size while controlling for age and year of diagnosis. RESULTS: Overall RT omission rates were 17.6% prior to the 2004 NCCN update and 45% after the publication of the 10-year CALGB data in 2013. The overall RT omission rate was 29%. Patients with grade 1 to 2 histology (odds ratio, 3.2; 95% confidence interval, 1.3-7.7; P = .01) and tumors < 1 cm (odds ratio, 1.60; 95% confidence interval, 0.4-0.9; P = .007) were more likely to omit RT than those with higher grade or larger tumors. CONCLUSIONS: We observed a slight decrease in the use of RT over time, suggesting a move towards adoption of the NCCN guidelines. There remains a fundamental need to continue to individualize breast cancer care based on risk stratification and make evidenced-based treatment recommendations with equitable use of health care resources.
Assuntos
Neoplasias da Mama/terapia , Fidelidade a Diretrizes/estatística & dados numéricos , Mastectomia Segmentar , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Antineoplásicos Hormonais/normas , Antineoplásicos Hormonais/uso terapêutico , Neoplasias da Mama/diagnóstico , Neoplasias da Mama/patologia , Quimioterapia Adjuvante/normas , Quimioterapia Adjuvante/estatística & dados numéricos , Medicina Baseada em Evidências/normas , Medicina Baseada em Evidências/estatística & dados numéricos , Feminino , Fidelidade a Diretrizes/normas , Humanos , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Guias de Prática Clínica como Assunto , Padrões de Prática Médica/normas , Prognóstico , Radioterapia (Especialidade)/normas , Radioterapia (Especialidade)/estatística & dados numéricos , Radioterapia Adjuvante/normas , Radioterapia Adjuvante/estatística & dados numéricos , Medição de Risco , Resultado do TratamentoRESUMO
CONTEXT: Current American Thyroid Association (ATA) Management Guidelines for the treatment of differentiated thyroid cancer (DTC) stratify patients to decide on additional radioiodine (RAI) therapy after surgery, and to predict recurring/persisting disease. However, studies evaluating the detection of distant metastases and how these guidelines perform in patients with distant metastases are scarce. OBJECTIVE: To evaluate the 2015 ATA Guidelines in DTC patients with respect to 1) the detection of distant metastases, and 2) the accuracy of its Risk Stratification System in patients with distant metastases. PATIENTS AND MAIN OUTCOME MEASURES: We retrospectively included 83 DTC patients who were diagnosed with distant metastases around the time of initial therapy, and a control population of 472 patients (312 low-risk, 160 intermediate-risk) who did not have a routine indication for RAI therapy. We used the control group to assess the percentage of distant metastases that would have been missed if no RAI therapy was given. RESULTS: Two hundred forty-six patients had no routine indication for RAI therapy of which 4 (1.6%) had distant metastases. Furthermore, among the 83 patients with distant metastases, 14 patients (17%) had excellent response, while 55 (67%) had structural disease after a median follow-up of 62 months. None of the 14 patients that achieved an excellent response had a recurrence. CONCLUSIONS: In patients without a routine indication for RAI therapy according to the 2015 ATA Guidelines, distant metastases would initially have been missed in 1.6% of the patients. Furthermore, in patients with distant metastases upon diagnosis, the 2015 ATA Guidelines are an excellent predictor of both persistent disease and recurrence.
Assuntos
Adenocarcinoma Folicular/prevenção & controle , Endocrinologia/normas , Guias de Prática Clínica como Assunto , Câncer Papilífero da Tireoide/prevenção & controle , Neoplasias da Glândula Tireoide/terapia , Adenocarcinoma Folicular/diagnóstico , Adenocarcinoma Folicular/epidemiologia , Adenocarcinoma Folicular/secundário , Adulto , Idoso , Idoso de 80 Anos ou mais , Endocrinologia/métodos , Feminino , Seguimentos , Humanos , Radioisótopos do Iodo/uso terapêutico , Masculino , Pessoa de Meia-Idade , Organizações sem Fins Lucrativos/normas , Seleção de Pacientes , Radioterapia Adjuvante/métodos , Radioterapia Adjuvante/normas , Estudos Retrospectivos , Medição de Risco/métodos , Medição de Risco/normas , Fatores de Risco , Sociedades Médicas/normas , Câncer Papilífero da Tireoide/diagnóstico , Câncer Papilífero da Tireoide/epidemiologia , Câncer Papilífero da Tireoide/secundário , Glândula Tireoide/patologia , Glândula Tireoide/cirurgia , Neoplasias da Glândula Tireoide/diagnóstico , Neoplasias da Glândula Tireoide/epidemiologia , Neoplasias da Glândula Tireoide/patologia , Tireoidectomia/normas , Estados Unidos/epidemiologiaAssuntos
Radioisótopos do Iodo/uso terapêutico , Medicina Nuclear/normas , Cuidados Pós-Operatórios/normas , Guias de Prática Clínica como Assunto , Neoplasias da Glândula Tireoide/radioterapia , Neoplasias da Glândula Tireoide/cirurgia , Medicina Baseada em Evidências , Humanos , Compostos Radiofarmacêuticos/uso terapêutico , Radioterapia Adjuvante/normas , Resultado do Tratamento , Estados UnidosRESUMO
The nasal cavity and parasinusal cancer are rare (10% of tumors of the head and neck) and are mainly represented by squamous cell carcinoma of the nasal cavity or the maxillary sinus and adenocarcinoma of the ethmoid sinus (occupational disease, wood dust). The most common clinical sign is nasal obstruction, but tumors can also manifest as rhinorrhea and/or epistaxis (usually unilateral signs). A magnetic resonance imaging of the facial structure is systematic for staging before treatment. The treatment consists of a first surgery if the patient is operable with a resectable tumor. If it is not the case, the treatment consists of radiotherapy (RT) associated with chemotherapy (CT) according to the initial data (T3/T4 or N+). After first surgery, RT is indicated (except T1N0 with complete resection) associated with a CT based on postoperative data (capsular effraction or incomplete resection). Lymph node irradiation is considered case by case, but is indicated in any nodal involvement. RT must be an intensity modulated RT (IMRT), static or dynamic, and must be imagery guided (IGRT). According to ICRU 83, doses to organs at risk and target volumes must be carried. Finally, after a post-treatment baseline imaging between 2 and 4 months, monitoring will be alternated with the ENT surgeon every 2 or 3 months for 2 years, then every 4 to 6 months for 5 years.
Assuntos
Adenocarcinoma/radioterapia , Carcinoma de Células Escamosas/radioterapia , Neoplasias Nasais/radioterapia , Neoplasias dos Seios Paranasais/radioterapia , Radioterapia de Intensidade Modulada/métodos , Adenocarcinoma/diagnóstico , Adenocarcinoma/diagnóstico por imagem , Adenocarcinoma/terapia , Assistência ao Convalescente , Carcinoma de Células Escamosas/diagnóstico , Carcinoma de Células Escamosas/diagnóstico por imagem , Carcinoma de Células Escamosas/terapia , Terapia Combinada , Fracionamento da Dose de Radiação , Humanos , Irradiação Linfática , Neoplasias do Seio Maxilar/radioterapia , Cavidade Nasal , Neoplasias Nasais/diagnóstico , Neoplasias Nasais/diagnóstico por imagem , Neoplasias Nasais/terapia , Órgãos em Risco , Neoplasias dos Seios Paranasais/diagnóstico , Neoplasias dos Seios Paranasais/diagnóstico por imagem , Neoplasias dos Seios Paranasais/terapia , Lesões por Radiação/etiologia , Lesões por Radiação/prevenção & controle , Dosagem Radioterapêutica , Planejamento da Radioterapia Assistida por Computador , Radioterapia Adjuvante/métodos , Radioterapia Adjuvante/normas , Radioterapia Guiada por Imagem , Radioterapia de Intensidade Modulada/efeitos adversos , Radioterapia de Intensidade Modulada/normasRESUMO
IMPORTANCE: Evolving data on the effectiveness of postmastectomy radiation therapy (PMRT) have led to changes in National Comprehensive Cancer Network (NCCN) recommendations, counseling clinicians to "strongly consider" PMRT for patients with breast cancer with tumors 5 cm or smaller and 1 to 3 positive nodes; however, anticipation of PMRT may lead to delay or omission of reconstruction, which can have cosmetic, quality-of-life, and complication implications for patients. OBJECTIVE: To determine whether revised guidelines have increased PMRT and affected receipt of breast reconstruction. We hypothesized that (1) PMRT rates would increase for women affected by the revised guidelines while remaining stable in other cohorts and (2) receipt of breast reconstruction would decrease in these women while increasing in other groups. DESIGN, SETTING, AND PARTICIPANTS: Retrospective, population-based cohort study of Surveillance, Epidemiology, and End Results (SEER) data on women with stage I to III breast cancer undergoing mastectomy from 2000 through 2011. Our analytic sample (N = 62,442) was divided into cohorts on the basis of current NCCN radiotherapy recommendations: "radiotherapy recommended" (tumors > 5 cm or ≥ 4 positive lymph nodes), "strongly consider radiotherapy" (tumor ≤ 5 cm, 1-3 positive nodes), and "radiotherapy not recommended" (tumors ≤ 5 cm, no positive nodes). MAIN OUTCOMES AND MEASURES: We used Joinpoint regression analysis to evaluate temporal trends in receipt of PMRT and breast reconstruction. RESULTS: The 3 cohorts comprised 15,999 in the "radiotherapy recommended" group, 15,006 in the "strongly consider radiotherapy" group, and 31,837 in the "radiotherapy not recommended" group. [corrected]. Rates of PMRT were unchanged in the radiotherapy recommended (29.9%) and radiotherapy not recommended (7.4%) cohorts over the study period. Receipt of PMRT for the strongly consider radiotherapy cohort was unchanged at 26.9% until 2007. At that time, a significant change in the APC was observed (P = .01) with an increase in APC from 2.1% to 9.0% (P = .02) through the end of the study period, for a final rate of 40.5%. Breast reconstruction increased across all cohorts. Despite increasing receipt of PMRT, the strongly consider radiotherapy cohort maintained a consistent increase in reconstruction (annual percentage change, 7.4%) throughout the study period. This is similar to the increase in reconstruction observed for the radiotherapy recommended (10.7%) and radiotherapy not recommended (8.4%) cohorts. CONCLUSIONS AND RELEVANCE: Changes in NCCN guidelines have been associated with an increase in PMRT among patients with tumors 5 cm or smaller and 1 to 3 positive nodes without an associated decrease in receipt of reconstruction. This may represent increasing clinician comfort with irradiating a new breast reconstruction and may have cosmetic and quality-of-life implications for patients.
Assuntos
Neoplasias da Mama/radioterapia , Neoplasias da Mama/cirurgia , Atenção à Saúde/tendências , Mamoplastia/tendências , Mastectomia , Padrões de Prática Médica/tendências , Adulto , Idoso , Neoplasias da Mama/patologia , Atenção à Saúde/normas , Feminino , Fidelidade a Diretrizes/tendências , Humanos , Metástase Linfática , Mamoplastia/normas , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Guias de Prática Clínica como Assunto , Padrões de Prática Médica/normas , Radioterapia Adjuvante/normas , Radioterapia Adjuvante/tendências , Estudos Retrospectivos , Programa de SEER , Fatores de Tempo , Resultado do Tratamento , Carga Tumoral , Estados UnidosRESUMO
PURPOSE: To develop recommendations for the use of adjuvant vaginal cuff brachytherapy after hysterectomy and update previous American Brachytherapy Society (ABS) guidelines. METHODS AND MATERIALS: A panel of members of the ABS performed a literature review, supplemented their clinical experience, and formulated recommendations for adjuvant vaginal cuff brachytherapy. RESULTS: The ABS endorses the National Comprehensive Cancer Network guidelines for indications for radiation therapy for patients with endometrial cancer and cervical cancer and the guidelines on quality assurance of the American Association on Physicists in Medicine. The ABS made specific recommendations for applicator selection, insertion techniques, target volume definition, dose fractionation, and specifications for postoperative adjuvant vaginal cuff therapy. The ABS recommends that applicator selection should be based on patient anatomy, target volume geometry, and physician judgment. The dose prescription point should be clearly specified. Suggested doses were tabulated for treatment with brachytherapy alone, and in combination with external beam radiation therapy, when applicable. A properly fitted brachytherapy applicator should be selected that conforms to the vaginal apex and achieves mucosal contact with optimal tumor and normal tissue dosimetry. Dose prescription points may be individually selected but doses should be reported at the vaginal surface and at 0.5-cm depth. CONCLUSIONS: Recommendations are made for adjuvant vaginal cuff brachytherapy. Practitioners and cooperative groups are encouraged to use these recommendations to formulate their treatment and dose reporting policies. These recommendations will permit meaningful comparisons of reports from different institutions and lead to better and more appropriate use of vaginal brachytherapy.
Assuntos
Braquiterapia/instrumentação , Braquiterapia/normas , Guias de Prática Clínica como Assunto , Radioterapia Adjuvante/instrumentação , Radioterapia Adjuvante/normas , Neoplasias Vaginais/radioterapia , Neoplasias Vaginais/cirurgia , Feminino , Humanos , Cuidados Pós-Operatórios/normas , Estados UnidosRESUMO
When treating soft tissue sarcomas (STS) of the extremities, the major therapeutic goals are survival, local tumor control, optimal function, and minimal morbidity. Surgical resection of the primary tumor is the essential component of treatment for virtually all patients. However, local control by surgery alone is poor for the majority of patients with extremity lesions unless the procedure removes large volumes of grossly normal tissue (ie, widely negative margins are attained, because sarcomas tend to infiltrate normal tissue adjacent to the evident lesion). Thus, removal of the gross lesion by a simple excision alone is followed by local recurrence in 60% to 90% of patients. Radical resections reduce the local recurrence rate to 10% to 30%, but may compromise limb function. The combination of function-sparing surgery and radiation achieves better outcomes than either treatment alone for nearly all patients with STS. Because both surgical and radiation technique are critically important for optimizing local control of tumor and functional outcome, it is important to manage these patients in dedicated multispecialty clinics comprised of physicians with expertise in sarcomas, including orthopedic and general oncologic surgeons, radiation oncologists, medical oncologists, sarcoma pathologists, and bone and soft tissue diagnostic radiologists. Radiation therapy can be given by external beam radiation therapy (EBRT) or brachytherapy (BRT) or combination thereof. External beam radiation can be given either preoperatively or postoperatively. The clinical considerations and the outcome data that must be considered in choosing the most appropriate treatment technique for the individual patient are discussed.
Assuntos
Extremidades , Sarcoma/radioterapia , Sarcoma/cirurgia , Neoplasias de Tecidos Moles/radioterapia , Neoplasias de Tecidos Moles/cirurgia , Braquiterapia/normas , Terapia Combinada , Humanos , Recidiva Local de Neoplasia , Fototerapia/normas , Doses de Radiação , Radioterapia/efeitos adversos , Radioterapia/normas , Radioterapia Adjuvante/normas , Sarcoma/patologia , Neoplasias de Tecidos Moles/patologia , Resultado do Tratamento , CicatrizaçãoRESUMO
For patients with resectable rectal cancer treated with total mesorectal excision, the routine use of radiotherapy should be omitted for stage I of the disease and for lesions located higher than 10 cm from the anal verge. Preoperative radiotherapy may be considered for all patients with a lesion with deep perirectal fat infiltration located in the lower two thirds of the rectum. The other option is to offer postoperative radiotherapy for patients with a positive surgical margin, N+ stage disease, mesorectal tumour implants, high tumour grade, perineural invasion, extramuscular blood and lymphatic vessel invasion and with inadvertent tumour perforation. The lower risk of small bowel damage and probable higher efficacy are arguments for the use of preoperative radiotherapy instead of postoperative radiotherapy. The impairment of anorectal function appears to be most frequent late postirradiation sequel. The analysis of acute complications (including toxic deaths) compliance, cost and convenience favours 5 x 5 Gy preoperative irradiation with immediate surgery for patients with resectable tumours in comparison to other commonly used schemes of radiotherapy. These advantages should be weighed against approximately 1.5% risk of late neurotoxicity. There is no clear answer to the question whether preoperative conventional radio(chemo)therapy offers an advantage in sphincter preservation. To answer this question, the results of two ongoing randomised trials are awaited. For patients with unresectable cancers, long-term preoperative radio(chemo)therapy with delayed surgery is a preferable scheme. The total mesorectal irradiation should be employed for mid- and low-lying lesions. Therefore, during radiotherapy planning, a contrast enema should be used to identify the anorectal ring, anatomically corresponding with the lowest edge of the mesorectum.
Assuntos
Neoplasias Retais/radioterapia , Neoplasias Retais/cirurgia , Humanos , Período Pós-Operatório , Cuidados Pré-Operatórios , Tolerância a Radiação , Radioterapia Adjuvante/normas , Ensaios Clínicos Controlados Aleatórios como Assunto , Neoplasias Retais/patologia , Resultado do TratamentoRESUMO
Combined radiation therapy and chemotherapy are adjuvant treatments given after surgery to patients with rectal carcinoma. Because apoptosis seems to play a role in tumor response to radiotherapy, the current study investigates whether there is a correlation between the ratio of bcl-2 oncoprotein and bax expression in rectal adenocarcinoma and the clinical response to radiotherapy. Elective colectomy for primary rectal adenocarcinoma followed by adjuvant radiotherapy and chemotherapy was performed on 35 patients. Tumors were staged as B2 (n = 30) and C (n = 5), and were classified as radiation resistant (n = 19, group A) and radiation nonresistant (n = 16, group B). Immunohistochemical study, using the streptavidin-biotin complex technique and monoclonal antibody to bcl-2 and polyclonal antibody to bax protein was used on paraffin sections. Cases were considered positive if at least 5% of tumor cells displayed cytoplasmic staining for bcl-2 or bax. In each tumor, the bcl-2/bax ratio was calculated dividing the percentage of bcl-2-positive cells by the percentage of bax-positive cells. For statistical analysis, the Mann-Whitney rank sum test and Kruskal-Wallis analysis of variance test were used. Rectal tumors of group A displayed significantly greater bcl-2 immunoreactivity (40.2 +/- 4.2) compared with group B (20.2 +/- 3.8). In contrast, expression of bax protein was less in group A (30.3 +/- 3.3) compared with group B (41.3 +/- 2.3). The bcl-2/bax ratio was greater in group A (1.3 +/- 0.1) compared with group B (0.49 +/- 0.1), and was correlated with poor responsiveness to radiotherapy. The current study indicates that in patients with rectal carcinoma an elevated bcl-2/bax ratio in tissue specimens suggests increased tumor resistance to adjuvant radiotherapy. Thus, in such patients, the bcl-2/bax ratio may serve as a potential molecular marker for prediction of tumor prognosis.
Assuntos
Proteínas Proto-Oncogênicas c-bcl-2/análise , Proteínas Proto-Oncogênicas/análise , Neoplasias Retais/radioterapia , Adenocarcinoma/diagnóstico , Adenocarcinoma/tratamento farmacológico , Adenocarcinoma/radioterapia , Biomarcadores/análise , Terapia Combinada , Humanos , Imuno-Histoquímica , Prognóstico , Radioterapia Adjuvante/normas , Radioterapia Adjuvante/estatística & dados numéricos , Neoplasias Retais/diagnóstico , Neoplasias Retais/patologia , Falha de Tratamento , Proteína X Associada a bcl-2RESUMO
Medulloblastoma, a malignant tumor arising from the medullary velum, is the most common malignant brain tumor of childhood. Local extension into the cerebellar hemisphere, infiltration of the floor of the fourth ventricle, and seeding into the subarachnoid space are common. Early diagnosis and improved treatment consisting of surgery followed by radiation and chemotherapy for selected high-risk patients has contributed to a dramatic change in survival. This article reviews current treatment strategies and describes new therapies that have the potential to improve the outlook of children with medulloblastoma.