Early prediction of response by ¹8F-FDG PET/CT during preoperative therapy in locally advanced rectal cancer: a systematic review.

AIM: To assess the predictive value of fluorine-18-fluorodeoxyglucose ((18)F-FDG) positron emission tomography/computed tomography (PET/CT) in early assessing response during neo-adjuvant chemoradiotherapy (CRT) in patients with locally advanced rectal cancer. MATERIALS AND METHODS: A systematic review was performed by search of MEDLINE Library for the following terms: "rectal carcinoma OR rectal cancer", "predictive OR prediction OR response assessment OR response OR assessment", "early OR ad interim", "therapy", "FDG OR (18)F-FDG", "PET OR PET/CT". Articles performed by the use of stand-alone PET scanners were excluded. RESULTS: 10 studies met the inclusion criteria, including 302 patients. PET/CT demonstrated a good early predictive value in the global cohort (mean sensitivity = 79%; mean specificity = 78%). SUV and its percentage decrease (response index = RI) were calculated in all studies. A higher accuracy was demonstrated for RI (mean sensitivity = 82%; pooled specificity = 85%) with a mean cut-off of 42%. The mean time point to perform PET scan during CRT resulted to be at 1.85 weeks. Some PET parameters resulted to be both predictive and not statistical predictive of response, maybe due to the small population and few studies bias. CONCLUSION: PET showed high accuracy in early prediction response during preoperative CRT, increased with the use of RI as parameter. In the era of tailored treatment, the precocious assessment of non-responder patients allows modification of the subsequent strategy especially the timing and the type of surgical approach.

A rare case of paraneoplastic cerebellar degeneration discovered by whole-body F-18 FDG PET.

A rare case of paraneoplastic cerebellar degeneration (PCD) in a 36-year-old woman is reported. She developed hyposthenia of the inferior limbs, diplopia, and disequilibrium in July 2001. Routine blood tests, tumoral markers, brain MRI, evoked potentials, and cerebrospinal fluid (CSF) examination were substantially normal. The clinical syndrome rapidly worsened in the following 2 months; she was wheelchair-bound with marked limb ataxia. CSF showed an increase of the IgG index with oligoclonal bands; brain MRI remained negative. The patient's serum and CSF were analyzed to detect antineuronal antibodies; anti-Yo antibodies were found that is typical of PCD. No tumor was found until April 2003; repeated CT scan, ultrasound, and mammographic examinations were negative. A further worsening in clinical symptoms was observed with a complete loss of autonomy (Rankin score 5) despite the performance of immunosuppressive therapy. In April 2003, an F-18 FDG PET scan visualized an area of abnormal uptake in the upper outer quadrant of the left breast. Interestingly, brain F-18 FDG uptake was normal. Suspicious microcalcifications were found on a new mammography and malignant cells were disclosed at cytology. The patient was operated on and final histologic examination revealed an infiltrating ductal breast cancer. In the reported case, F-18 FDG PET played a crucial role in detecting the unknown primary tumor in a young patient with PCD.

Information for patients with early-stage prostate cancer: a comparison of professionals' attitudes in Canada and Italy.

PURPOSE: To compare information priorities of Canadian to those of Italian health-care professionals in the context of early-stage prostate cancer. METHOD: Oncologists (radiation and medical), nurses, and radiation-therapy technologists in each country were surveyed. Respondents rated the importance of addressing each of 78 questions with a case-scenario patient using either three (Italian survey) or four (Canadian survey) categories; the most important category was defined as "essential" in both countries. At least 67% identical responses on a specific question was considered "agreement." RESULTS: Within each country, questions rated essential by most group members were similar across professions (all pairwise group correlations r>or=0.77, p<0.01); there was much less agreement within each profession between the countries (all pairwise comparisons of the amount of accounted-for variance F(max) >or=1.59, p<0.05). Amongst oncologists, Canadians agreed that 11 questions were essential versus two by the Italians; the Canadians disagreed on the essential nature of 29 questions versus nine by the Italians. More importantly, there was large variation within each group in both countries: individual Canadian oncologists identified from five to 69 questions essential and Italians from zero to 68; each of 75 questions was considered essential by some Canadian oncologists and each of all 78 by some Italians. Similar patterns were evident in the other professions. CONCLUSIONS: Within each profession, the Italians agreed that fewer questions were essential to address and disagreed on the essential nature of fewer questions than their Canadian counterparts. There was, however, marked individual variation in priorities within each profession in each country. Thus, information provided to individual patients in both countries likely differs as a function of the particular professionals seen, and seeing two professionals (from the same or different professions) likely results in confusion for patients.

Dislocation of small bowel volume within box pelvic treatment fields, using new "up down table" device.

PURPOSE: To present the impact of a novel minimization device, the up down table (UDT), on the volume of small bowel included within a 4-field pelvic irradiation plan. METHODS: A polystyrene bowel displacement standard mold was created and added to a customized vacuum cushion (Vac Lok) formed around the abdomen and legs of each patient in the prone position. Two hundred seventy-seven consecutive patients with pelvic malignancies treated with the UDT device were compared with 1 historic series (68 cases) treated at our division. Small bowel contrast dyes at the time of simulation were used in all patients. RESULTS: The average volume of small bowel within the planning target volume (high-dose volume, calculated with Gallagher method) was 100 cm(3) (median 49 +/- 114) in the series treated with standard box technique and 23 cm(3) (median 0 +/- 64) in the series treated with the UDT (p < 0.001). The average volume of small bowel included in any isodose (any-dose volume) was 505 cm(3) (median 447 +/- 338) and 158 cm(3) (median 69 +/- 207), respectively (p < 0.001). The incidence of G1, G2, and G3 acute enteric toxicity (Radiation Therapy Oncology Group criteria) in the UDT series was 16%, 15%, and 1.5%; in the standard box technique, it was 28%, 25%, and 3%, respectively (p < 0.05). The incidence of acute enteric toxicity directly correlated with the irradiated small bowel volume. In the UDT series, the 5-year actuarial incidence of G3 chronic enteric toxicity was 1.8%. The setup procedures, analyzed in 18 cases, revealed no systematic errors and a standard deviation equal to +/-5 mm for random errors. CONCLUSIONS: The UDT technique is comfortable, inexpensive, highly reproducible, and permits an almost full bowel displacement from standard radiotherapy fields.

The role of a conventional simulator in multileaf-plan simulation: a proposal.

Modern computer networks provide satisfying levels of data recording and verification between the treatment planning system (TPS) and the accelerators, while the main weakness of the preparation chain remains the simulation. When a conventional simulator is employed, it may adversely affect the three-dimensional treatment planning system (3DPS) process because of the difficulty to document the leaf positions on the simulator location films and on the patient's skin. With a conventional simulator, hard copies of the DRRs of each field and CT scans at isocenter level are needed. In an attempt to transfer more information displayed from a BEV perspective from the 3DPS to simulator radiographs, this study aimed to reduce the quality loss by using a 2D conventional simulator in a 3DPS process. We realized an acetate photocopy of TPS data for each field, from a BEV perspective, containing: DRR, wire frames of the PTV, organs at risk and MLC aperture. The photocopies, with an appropriate magnification factor to obtain a correct projective value (ratio 1:1) at isocenter level, are carefully placed on the radiographic images on the same hard copy which allows us to better understand possible setup errors and obliges us to correct these. The method provides reliable documentation, facilitates treatment verification, and fulfils the criteria for MLC simulation. It is accurate, simple, and very inexpensive.

[Quality radiotherapy in rectal cancer]. / La radioterapia di qualità nel cancro del retto.

The quality of radiotherapy significantly impacts on the results of treatment, in patients with rectal carcinoma, especially in terms of acute and late toxicity. Based on this assumption, the Italian Association of Radiation Oncology (AIRO) formulated a document aimed to define the standards of radiation treatment for rectal carcinomas. Two different levels of standard were described: a first level, considered as "minimal requirement", and a second level, considered as "optimal treatment". A retrospective evaluation, based on a questionnaire, revealed that in 1996, in most Italian Centers, patients affected by rectal carcinoma received radiation treatment within the first level of proposed standards. A subsequent analysis concerned the evaluation of the level of treatments applied in 2000. In this paper the radiotherapy standards proposed by the AIRO are described in the different phases of the radiation treatment.

Immobilization devices between routine and quality assurance.

AIMS AND BACKGROUND: To evaluate the impact of immobilization devices in reducing treatment errors and delivering high doses to limited target volumes. The clear advantages are matched with quality control necessity. METHODS: The Authors examine two fundamental aspects of the topic: 1) the immobilization of head and neck and the relative implications in reducing the skin-sparing at the build-up region; 2) the rationale and management of quality assurance procedures in the immobilization devices utilization, with a particular reference to pelvic radiation treatment. CONCLUSIONS: The immobilization devices utilization certainly leads to an optimization in the execution of radiation treatments. Nevertheless, in the choice for their routine use, the Authors suggest to follow some "conceptual rules" with the aim of successfully matching each of the discussed aspects connected with their utilization.

Radiation therapy of bone metastases in the elderly: a multicentric survey of the Italian "Geriatric Radiation Oncology Group".

External radiation therapy (ERT) has been reported to be the elective treatment of symptomatic bone metastases. A nationwide survey on the use of ERT in elderly patients with bone metastases has been conducted by the Italian "Geriatric Radiation Oncology Group" with a three-fold aim: define the state of the art of ERT, evaluate the analgesic efficacy and identify the optimal dosage and schedule, if any. 347 patients aged 70 or over, treated in 29 different institutions for a period of six months were analyzed. Conclusive results were: a significant pain relief achieved shortly after ERT completion; an improvement in the quality of life; a decrease in the dose of analgesics and consequently, a reduction in treatment-related costs. Unfortunately the optimal treatment schedule remains unidentified; ERT was neither aggressive nor toxic in this series of elderly patients.

Quality assurance procedures in radiotherapy of rectal neoplasms.

Major uncertainties which impact on pre- or postoperative radiotherapy of rectal neoplasms and operational measures taken to lower the risks in prescription, planning, delivery and follow-up of radiotherapy, are examined. In prescription, major problems related with the selection of treatment dose and volumes, are considered. In planning, irradiation techniques and systems for intestinal loop displacement from treatment site, are analyzed. In dose delivery, methods used to ensure treatment reproducibility and support care, are examined. Finally, in follow-up procedures used in the evaluation of disease progress, late side-effects, and life quality, are discussed.

[Volume of the irradiated small intestine during pelvic radiotherapy. Comparison of various calculation methods]. / Il volume dell'intestino tenue irradiato durante la radioterapia pelvica. Confronto tra diverse metodiche di calcolo.

In pelvic irradiation, the small bowel portion included in the planning treatment volume is one of the major factors of acute enteropathy. Three different methods are used to calculate the bowel volume: Gallagher's grid method and two systems based on specific algorithms using CT data. We compared the results of these different methods in a series of nine patients submitted to treatment volume planning simulation for pelvic irradiation, after oral barium administration. The small bowel volumes were calculated with the grid method on orthogonal radiographs. About one hour later, the patients were submitted to CT for radiotherapy planning. The small bowel regions to be irradiated were drawn manually on all CT slices on a Varian Cadplan 2.62 console. Two different algorithms were used to calculate the small bowel volumes: one of them based on polyhedral and the other on cylindric approximation. The average volumes, the variance and the determination coefficient with linear and polynomial regression were in substantial statistical agreement in the three series; the correlation index between the grid and the CT methods ranged 0.84-0.87. Therefore, the authors believe that enteric side-effects can be correlated with the irradiated small bowel volume, independent of the calculation method.

[Quality control in radiotherapy. Computerized management of the "total" oncologic follow-up]. / Il controllo di qualità nella radioterapia. La gestione informatizzata del follow-up oncologico "totale".

Since 1992, in the Rovigo Radiotherapy Department, we have computerized the management of oncologic follow-up to minimize all "non-medical" times during the different phases. System efficiency was analyzed and the results follow: 1) the absolute number of follow-up visits, compared with the standard reference year (1991), shows that we were able to double our "performance" within the time unit, with the same "resources"; 2) the average number of follow-up visits per malignancy within 6 months of the diagnosis and then every seventh month, approximated to the number of scheduled visits; 3) the number of cancer relapses in the patients who could not be submitted to a specific antiblastic treatment (a reversed efficacy indicators) progressively reduced from 13.7% to 12.6% and 10.4% respectively, in 1992, 1993 and 1994; 4) secondary lesion diagnosis, an indirect efficacy parameter, was found to be accurate; 5) the cost of follow-up per malignancy reduced, in 6 months' periods, especially in the cancers with easier clinical diagnosis (-32% for breast cancer, -50% for head and neck cancer), by as much as 43,639,000 Italian liras in 1994 (relative to 1993); 6) the scheduled visits began only 12 minutes late, as studied on 2,346 visits. To conclude, the computed management of medical records improves our Department's efficiency, with no additional cost for the patients.

[Cancer of the bladder. Results of radiotherapy after partial cystectomy]. / Il cancro della vescica. Risultati del trattamento radiante dopo cistectomia parziale.

The authors evaluate 374 patients treated by adjuvant radiotherapy after conservative surgery or radiotherapy alone for bladder carcinoma, from 1974 to 1982. The five year survival rate was 61, 39, 8 and 43 percent, respectively, for stages A (84 pts), B (154 pts), C (65 pts) and NOS (71 pts). Two homogeneous groups of patients staged B, treated by conservative surgery and adjuvant radiotherapy were evaluated: group I by "high" dose radiotherapy (TDF greater than 95), group II by "low" dose (TDF between 50 and 95); the five years survival rates were, respectively, 59% and 28% (P less than 0.05). It is discussed the value of treatment of the bladder carcinoma by high dose radiotherapy after conservative surgery.

[Whole-body irradiation for bone marrow transplantation]. / La irradiazione corporea totale per il trapianto di midollo osseo.

High dose total body irradiation is widely used in conditioning regimens to treat patients undergoing bone marrow transplantation. Radiation-related complications observed in 67 patients who received total body irradiation and their correlation with physiopathological mechanism of clinical manifestations are discussed. Interstitial pneumonitis occurred in 9 patients in our study (14%); the relationship between the incidence of interstitial pneumonitis and many factors such as irradiation treatment techniques, pre-graft chemotherapy, bone marrow malignant as well hereditary diseases, are discussed and related to a detailed literature review. Radiation techniques are different in leukemic and thalassemic patients.