Metaplastic breast cancer: A case report.

Metaplastic carcinomas of the breast are very rare and constitute less than 0.5% of all breast cancers. Breast metaplastic carcinomas are aggressive.They have worse prognosis compared to other breast cancers. We present a case diagnosed with metastatic breast cancer due to the rare occurrence of these tumours in treatment of which surgical chemotherapy, radiotherapy and hormonotherapy are employed together.

Meningeal carcinomatosis: an extremely rare involvement of urinary bladder carcinoma.

Meningeal carcinomatosis (MC) is a rare presentation of solid tumors, particularly breast cancer, lung cancer, and malignant melanoma. Recently, the incidence of MC has been reported to be increasing. It has a bad prognosis despite aggressive therapy. The usual clinical presentation is multifocal involvement of the neuraxis, with headache and radicular pain being the most common initial symptoms. The most frequent signs are motor deficits, altered mental status, and cranial nerve involvement. The treatment of MC remains controversial and no straightforward guidelines exist in the literature. MC from urinary bladder tumors is rare. In this case report, we present a 52-year-old male patient with meningeal metastasis from a primary urinary bladder carcinoma along with a review of the related literature. Free full text available at www.tumorionline.it

Long-lasting multiagent chemotherapy in adult high-risk Ewing's sarcoma of bone.

The outcome of Ewing's sarcoma depends on the anatomical site of the tumor. Studies conducted in high-risk patients are limited. We evaluated the outcome of high-risk Ewing's sarcoma patients that received long-term treatment protocol. Twenty-five patients (22 males, 3 females) with poor prognostic features were treated according to long-term Ewing's sarcoma protocol. Central-axis localization, inadequacy or unavailability of surgical resection, older than 15 years of age, are accepted as high-risk factors. The median age of patients was 23 years (range, 18-55). The tumor localization was pelvis (9), femur (1), tibia (1), fibula (1), maxilla (1), clavicle (1), vertebrae (5), metatarse (1), and ribs (5). Neoadjuvant chemotherapy was applied between weeks 0 and 6, local therapy on week 9, and adjuvant maintenance chemotherapy between weeks 11 and 41. All patients received neoadjuvant and adjuvant maintenance chemotherapy. Local therapy consisted of radiotherapy (32%), surgery alone (12%), or surgery and radiotherapy (56%). The median total treatment period was 10 months. The median follow-up was 25 months (range, 7-89). Three-year cumulative OS and DFS rates were 43% (95% CI, 28.5-57.85) and 40% (95% CI 23.63-52.19), respectively. The most common grade III/IV toxicities observed during the treatment protocol were neutropenia (16%) and gastrointestinal toxicities (16%). Our study indicated that long-term multiagent combination chemotherapy may result in better outcome in adult high-risk patients undergoing adequate surgical resection of the tumor and local radiotherapy. Further randomized studies are needed to assess the efficacy of this treatment protocol in patients with adequate surgical margins.

The management of gastric adenocarcinoma with postoperative chemoirradiation. A non-randomized comparison of oral UFT and 5-FU.

AIMS AND BACKGROUND: We assessed the therapeutic results and tolerability of postoperative chemoradiotherapy with either oral UFT or 5-fluorouracil for carcinoma of the stomach. METHODS AND STUDY DESIGN: Forty-six patients treated with chemoradiotherapy following total or subtotal gastrectomy for gastric carcinoma formed the cohort evaluated. The group included 39 males and 7 females whose ages ranged from 21 to 74 years (median, 53 years). In all patients, surgical therapy was the initial approach with a curative intent. The types of operations performed were total gastrectomy in 11 or subtotal gastrectomy in 35 patients. Radiotherapy began from 14 to 161 days after surgery (median, 55 days). Twenty patients received concomitant oral UFT (200 mg/m2), and 26 patients were given 5-fluorouracil (425 mg/m2, iv bolus) concurrently with irradiation consisting of one or two cycles, usually as a 3-day bolus at the start and last 3 days of irradiation therapy for radiosensitizing purposes. The patients were treated using either cobalt-60 or 6 MV photons, and irradiation doses delivered to the tumor bed and regional lymphatics ranged from 40 to 50 Gy (median, 46 Gy). RESULTS: Median follow-up for the entire group was 24 months (range, 2-67). The 2-year overall survival of the entire group of patients was 64%. The 2-year overall survival rates for 5-fluorouracil and oral UFT groups were 72% and 66%, respectively (P = 0.3). Treatment-related factors were reviewed to identify any impact on survival. Analyses included type of surgery and dissection, fraction size, the total dose of irradiation and the type of chemotherapy. A significant detrimental effect in survival in the patients treated with D2 dissection compared to the patients treated with D1 dissection was noted (P = 0.01). Overall grade II-III toxicity of oral UFT was significantly lower than 5-FU (4 patients vs 14 patients, P = 0.03). CONCLUSIONS: Concomitant use of oral UFT with radiation seems to be more tolerable and an equally effective regimen in the treatment of locally advanced gastric cancer compared with 5-fluorouracil. D2 dissection was found to have detrimental effects on survival in this cohort.

A dose-response analysis for classical Kaposi's sarcoma management by radiotherapy.

OBJECTIVE: To evaluate the dose-response relationship in classical Kaposi's sarcoma (CKS) patients treated with external beam radiotherapy. METHODS: Between 1993 and 2004, patients with CKS treated at the Department of Radiation Oncology, Gulhane Military Medical School, Ankara, Turkey were evaluated in this retrospective study. The median age at initial presentation was 60 years. First, we analyzed the overall response rates for normalized total dose 2Gy (NTD2Gy) of <20 Gy, 20 Gy, and >20 Gy. Secondly, we searched for whether better response rates could be obtained with the NTD2Gy of > or =20 Gy compared to the NTD2Gy of <20 Gy. RESULTS: There were 109 evaluable lesions in 18 patients. The median follow-up was 4 years. The overall response rates at the post-radiotherapy twelfth month were 88% for NTD2Gy of <20 Gy, 97% for 20 Gy, and 96% for NTD2Gy>20 Gy, which were not statistically different. The complete and partial response rates at 12 months were 93.2%, and 3.4% for NTD2Gy of > or =20Gy, and 64% and 24% for NTD2Gy of <20 Gy and these were statistically different (p=0.001). Late side effects of radiation therapy were acceptable in all but 4 patients with fibrosis and edema. CONCLUSION: This retrospective analysis showed that radiotherapy schedules with an NTD2Gy of 20 Gy and above by using local irradiation fields are effective in terms of complete response rates in the management of CKS compared to NTD2Gy of <20 Gy.

Acute renal toxicity of 2 conditioning regimens in patients undergoing autologous peripheral blood stem-cell transplantation. Total body irradiation-cyclophosphamide versus ifosfamide, carboplatin, etoposide.

OBJECTIVE: To compare acute renal toxicity of 2 conditioning regimens of total body irradiation/cyclophosphamide (TBI-Cy) and Ifosfamide, Carboplatin, and Etoposide (ICE). METHODS: Between August 1996 and February 2004, patients treated with autologous peripheral stem cell transplantation in the Department of Medical and Radiation Oncology, Gulhane Military Medical School, Ankara, Turkey with 2 different conditioning regimens was comparatively analyzed for acute renal toxicity in the early post-transplant period. Forty-seven patients received ICE regimen with 12 g/m2; 1.2 g/m2; and 1.2 g/m2 divided to 6 consecutive days, whereas 21 patients received 12 Gy TBI (6 fractions twice daily in 3 consecutive days) and 60 mg/m2/day cyclophosphamide for 2 days. RESULTS: Sixty-eight patients were evaluated in this study. There was no significant difference in baseline renal function between patients in the ICE and TBI-Cy groups. Eleven patients developed nephrotoxicity (23.4%) in the ICE group while one patient (4.8%) in the TBI-Cy group developed nephrotoxicity (p=0.06). Five out of 11 patients developing nephrotoxicity in ICE group required hemodialysis and subsequently 4 (8.5%) of them died. In contrast, one patient (4.8%) died due to nephrotoxicity despite hemodialysis in the TBI-Cy arm. CONCLUSION: This study reveals that the TBI-Cy conditioning regimen seems no more nephrotoxic than an ICE regimen particularly in patients who had used cisplatin prior to transplantation.

Heel spur radiotherapy and radiation carcinogenesis risk estimation.

PURPOSE: Radiotherapy is a nonsurgical alternative therapy of painful heel spur patients. Nonetheless, cancer induction is the most important somatic effect of ionizing radiation. This study was designed to evaluate the carcinogenesis risk factor in benign painful heel spur patients treated by radiotherapy. MATERIALS AND METHODS: Between 1974 and 1999, a total of 20 patients received mean 8.16 Gy total irradiation dose in two fractions. Thermoluminescent dosimeters (TLD(100)) were placed on multiple phantom sites in vivo within the irradiated volume to verify irradiation accuracy and carcinogenesis risk factor calculation. The 20 still-alive patients, who had a minimum 5-year and maximum 29-year follow-up (mean 11.9 years), have been evaluated by carcinogenic radiation risk factor on the basis of tissue weighting factors as defined by the International Commission on Radiological Protection Publication 60. RESULTS: Reasonable pain relief has been obtained in all 20 patients. The calculated mean carcinogenesis risk factor is 1.3% for radiation portals in the whole group, and no secondary cancer has been clinically observed. CONCLUSION: Radiotherapy is an effective treatment modality for relieving pain in calcaneal spur patients. The estimated secondary cancer risk factor for irradiation of this benign lesion is not as high as was feared.

The effects of tangential radiotherapy on lung clearance in breast cancer patients.

PURPOSE: The aim of this study was to investigate the effects of tangential radiotherapy (RT) on lung clearance in the patients with breast cancer by using (99m)Tc-DTPA aerosol scintigraphy. MATERIAL AND METHODS: Thirty-three female patients [non-smoker: 20, ex-smoker: 13] performed surgery and systemic chemotherapy for breast carcinoma [47+/-13 years] were included in the study. All patients underwent (99m)Tc-DTPA aerosol scintigraphy prior to RT (pre RT), midway through RT (mid RT) and after RT (post RT). Total dose was 50 Gy in modified radical mastectomy and 60 Gy in lumpectomy (2 Gy/fraction). Posterior dynamic images of lungs were obtained immediately after the inhalation of (99m)Tc-DTPA aerosol. RESULTS: Pulmonary function tests were normal in three measurements for all cases. In the ex-smokers, there was no significant difference among pre RT, mid RT and post RT clearance values in both lungs. Pre RT lung clearance in non-smoker group did not differ from that in ex-smokers. However, the lung clearance for non-smoker group showed significantly increase following RT. CONCLUSION: In this study, we observed that tangential radiotherapy caused an increase in the lung clearance in the cases of non-smokers even in non-irradiated lung, and that the effect of RT on lung clearance was closely depended on smoking habit before RT.

Management of pulmonary oligometastases by stereotactic body radiotherapy.

AIMS AND BACKGROUND: The aim of the study was to evaluate the feasibility, toxicity and effectiveness of active breathing control-guided stereotactic body radiotherapy in the management of pulmonary oligometastases. METHODS AND STUDY DESIGN: Between June 2010 and June 2012, 20 patients (13 males, 7 females) with 31 pulmonary metastases referred to the Department of Radiation Oncology, Gulhane Military Medical Academy were treated using active breathing control-guided stereotactic body radiotherapy. Response Evaluation Criteria in Solid Tumors and Common Terminology Criteria for Adverse Events were used in the assessment of treatment response and toxicity, respectively. RESULTS: Assessment of treatment response revealed complete response, partial response, stable disease, and progressive disease in 30%, 25%, 30%, and 15% of the patients, respectively. At a median follow-up of 14 months, local control was 85% and overall survival was 70%, with negligible treatment-related toxicity. CONCLUSIONS: Stereotactic body radiotherapy is safe and effective in the management of pulmonary oligometastases. It offers favorable treatment outcomes as a viable non-invasive therapeutic modality.

Dosimetric evaluation of intensity modulated radiotherapy and 4-field 3-d conformal radiotherapy in prostate cancer treatment.

OBJECTIVE: The purpose of this dosimetric study is the targeted dose homogeneity and critical organ dose comparison of 7-field Intensity Modulated Radiotherapy (IMRT) and 3-D 4-field conformal radiotherapy. STUDY DESIGN: Cross sectional study. MATERIAL AND METHODS: Twenty patients with low and moderate risk prostate cancer treated at Gülhane Military Medical School Radiation Oncology Department between January 2009 and December 2009 are included in this study. Two seperate dosimetric plans both for 7-field IMRT and 3D-CRT have been generated for each patient to comparatively evaluate the dosimetric status of both techniques and all the patients received 7-field IMRT. RESULTS: Dose-comparative evaluation of two techniques revealed the superiority of IMRT technique with statistically significantly lower femoral head doses along with reduced critical organ dose-volume parameters of bladder V60 (the volume receiving 60 Gy) and rectal V40 (the volume receiving 40 Gy) and V60. CONCLUSION: It can be concluded that IMRT is an effective definitive management tool for prostate cancer with improved critical organ sparing and excellent dose homogenization in target organs of prostate and seminal vesicles.

Dosimetric evaluation of critical organs at risk in mastectomized left-sided breast cancer radiotherapy using breath-hold technique.

AIMS AND BACKGROUND: The aim of the study was to evaluate the dosimetric impact of the active breathing control-moderate deep inspiration breath-hold (ABC-mDIBH) technique on normal tissue sparing in locally advanced left-sided breast cancer radiotherapy. METHODS AND STUDY DESIGN: Twenty-seven consecutive patients with left-sided locally advanced breast cancer referred to our department for adjuvant radiotherapy were enrolled in the study. Each patient was scanned at free breathing and ABC-mDIBH for radiation treatment planning. Two separate radiotherapy treatment plans were generated with and without ABC-mDIBH to investigate the dosimetric impact of ABC-mDIBH in breast cancer radiotherapy. RESULTS: Between June 2011 and February 2012, 27 consecutive patients with left-sided locally advanced breast cancer referred to our department for adjuvant radiotherapy were enrolled in the study. Dose-volume parameters of left anterior descending coronary artery, lungs, heart, contralateral breast, esophagus and spinal cord were significantly reduced with the use of ABC-mDIBH (P <0.001). CONCLUSIONS: Our study revealed that the use of ABC-mDIBH in the practice of locally advanced mastectomized left-sided breast cancer radiotherapy improves normal tissue sparing with the expected potential of decreasing treatment-related morbidity and mortality. Moreover, the resultant reduction achieved with ABC in doses to the left anterior descending coronary artery, which plays a central role in cardiac perfusion, may have implications for decreasing the potential of radiation-induced cardiac morbidity and mortality.

Image-guided positioning in intracranial non-invasive stereotactic radiosurgery for the treatment of brain metastasis.

AIMS AND BACKGROUND: The aim of the study was to examine the feasibility of non-invasive image-guided radiosurgery to improve patient comfort and quality of life in stereotactic radiosurgery planning and treatment of patients with brain metastasis. Precise immobilization is a rule of thumb for stereotactic radiosurgery. Non-invasive immobilization techniques have the potential of improved quality of life compared with invasive procedures. METHODS AND STUDY DESIGN: A total of 92 lesions from 42 patients with brain metastasis were included in the study. After immobilization with a thermoplastic mask and a bite-block unlike the invasive frame-based procedure, planning computed tomography images were acquired and fused with magnetic resonance images. After contouring, intensity-modulated stereotactic radiosurgery (IM-SRS) planning was done, and the patients were re-immobilized on the treatment couch for the therapy procedures. While patients were on the treatment couch, kilovoltage-cone beam computed tomography images were acquired to determine setup errors and achieve on-line correction and then repeated after on-line correction to confirm precise tumor localization. The patients then underwent single-fraction definitive treatment. RESULTS: For the 92 lesions treated, mean ± SD values of translational setup corrections in X (lateral), Y (longitudinal), and Z (vertical) dimensions were 0.7 ± 0.7 mm, 0.8 ± 0.7 mm, and 0.6 ± 0.5 mm, and rotational set-up corrections were 0.5 ± 1.1°, 0.06 ± 1.1°, and -0.1 ± 1.1° in X (pitch), Y (roll), and Z (yaw), respectively. The mean three-dimensional correction vector was 1.2 ± 1.1 mm. CONCLUSIONS: Non-invasive image-guided radiosurgery for brain metastasis is feasible, and the non-invasive treatment approach can be routinely used in clinical practice to improve patients' quality of life.

Linear accelerator-based stereotactic radiosurgery in recurrent glioblastoma: a single center experience.

BACKGROUND/AIM: Management of patients with recurrent glioblastoma (GB) comprises a therapeutic challenge in neurooncology owing to the aggressive nature of the disease with poor local control despite a combined modality treatment. The majority of cases recur within the high-dose radiotherapy field limiting the use of conventional techniques for re-irradiation due to potential toxicity. Stereotactic radiosurgery (SRS) offers a viable noninvasive therapeutic option in palliative treatment of recurrent GB as a sophisticated modality with improved setup accuracy allowing the administration of high-dose, precise radiotherapy. The aim of the study was to, we report our experience with single-dose linear accelerator (LINAC) based SRS in the management of patients with recurrent GB. METHODS: Between 1998 and 2010 a total of 19 patients with recurrent GB were treated using single-dose LINAC-based SRS. The median age was 47 (23-65) years at primary diagnosis. Karnofsky Performance Score was > or = 70 for all the patients. The median planning target volume (PTV) was 13 (7-19) cc. The median marginal dose was 16 (10-19) Gy prescribed to the 80%-95% isodose line encompassing the planning target volume. The median follow-up time was 13 (2-59) months. RESULTS: The median survival was 21 months and 9.3 months from the initial GB diagnosis and from SRS, respectively. The median progression-free survival from SRS was 5.7 months. All the patients tolerated radiosurgical treatment well without any Common Toxicity Criteria (CTC) grade > 2 acute side effects. CONCLUSION: Single-dose LINAC-based SRS is a safe and well- tolerated palliative therapeutic option in the management of patients with recurrent GB.

In vitro evaluation of head and neck radiation shields used to reduce exit dose.

PURPOSE: To determine the optimal thickness of protective oral radiation shields composed of an acrylic resin stent and a lead shield, which are used in head and neck radiotherapy to minimize undesired normal tissue radiomorbidity. MATERIALS AND METHODS: Intraoral acrylic resin stents and lead shields of different thicknesses were inserted into a specially designed human mandible phantom with thermoluminescent lithium fluoride dosimeter chips (TLD-100) placed on the buccal and lingual sites and exposed to irradiation of different energies. Fifty-cGy irradiation was performed and TLD-100 dose measurements were obtained for each irradiation type, acrylic resin stent thickness, and lead shield thickness. RESULTS: Acrylic resin stents with a 2-mm lead shield reduced 20% and 15% of the normal tissue dose for Co-60 and 6 MV X photon radiations, respectively, whereas the stents with a 4-mm lead shield achieved a higher reduction of the normal tissue dose (30% and 23% for Co-60 and 6 MV X photons, respectively). CONCLUSION: In protective oral radiation shields, acrylic resin stent thickness has little effect on the reduction of normal tissue dose, but lead shield thickness significantly effects the reduction of normal tissue dose.

Effect of dose-rate and lung dose in total body irradiation on interstitial pneumonitis after bone marrow transplantation.

The aim of this study is to evaluate the incidence of interstitial pneumonitis following fractionated total body irradiation conditioning for bone marrow transplantation with varying lung doses due to shielding technique and different dose-rates. Between 1987 and 2001, a total number of 105 patients have received total body irradiation conditioning for bone marrow transplantation for hematological malignancies at Gulhane Military Medical School. Twelve Gy fractionated total body irradiation was delivered in 6 fractions over 3 consecutive days with Co-60 teletherapy machine. Conditioning therapy included only cyclophosphamide (60 mg/ kg/day for two days) and total body irradiation. The median follow-up for patients was 12 months. Interstitial pneumonitis developed in 10 patients out of 105 patients (9.52%). The median total dose to lung was 9.60 Gy (8.88-10.90). The difference between total lung dose and interstitial pneumonitis was not significant. Pneumonitis development in the high dose-rate (>0.04 Gy/min) group versus low dose-rate (< or =0.04 Gy/min) group was statistically significant. Low dose-rate fractionated total body irradiation is a reliable conditioning program in bone marrow transplantation with effective lung sparing to avoid interstitial pneumonitis.