Efficacy, toxicities, and prognostic factors of stereotactic body radiotherapy for unresectable liver metastases.

INTRODUCTION: This study aims to determine the outcomes of stereotactic body radiotherapy (SBRT) for liver metastases in patients not eligible for surgery. METHODS: This study included 31 consecutive patients with unresectable liver metastases who received SBRT between January 2012 and December 2017; 22 patients had primary colorectal cancer and nine patients had primary non-colorectal cancer. Treatments ranged from 24 Gy to 48 Gy in 3 to 6 fractions over 1 to 2 weeks. Survival, response rates, toxicities, clinical characteristics, and dosimetric parameters were evaluated. Multivariate analysis was performed to identify significant prognostic factors for survival. RESULTS: Among these 31 patients, 65% had received at least one prior regimen of systemic therapy for metastatic disease, whereas 29% had received chemotherapy for disease progression or immediately after SBRT. The median follow-up interval was 18.9 months; actuarial in-field local control rates at 1, 2, and 3 years after SBRT were 94%, 55%, and 42%, respectively. The median survival duration was 32.9 months; 1-year, 2-year, and 3-year actuarial survival rates were 89.6%, 57.1%, and 46.2%, respectively. The median time to progression was 10.9 months. Stereotactic body radiotherapy was well-tolerated, with grade 1 toxicities of fatigue (19%) and nausea (10%). Patients who received post-SBRT chemotherapy had significant longer overall survival (P=0.039 for all patients and P=0.001 for patients with primary colorectal cancer). CONCLUSION: Stereotactic body radiotherapy can be safely administered to patients with unresectable liver metastases, and it may delay the need for chemotherapy. This treatment should be considered for selected patients with unresectable liver metastases.

Experience with the use of the Codonics Safe Label System(™) to improve labelling compliance of anaesthesia drugs.

The Codonics Safe Labeling System(™) (http://www.codonics.com/Products/SLS/flash/) is a piece of equipment that is able to barcode scan medications, read aloud the medication and the concentration and print a label of the appropriate concentration in the appropriate colour code. We decided to test this system in our facility to identify risks, benefits and usability. Our project comprised a baseline survey (25 anaesthesia cases during which 212 syringes were prepared from 223 drugs), an observational study (47 cases with 330 syringes prepared) and a user acceptability survey. The baseline compliance with all labelling requirements was 58%. In the observational study the compliance using the Codonics system was 98.6% versus 63.8% with conventional labelling. In the user acceptability survey the majority agreed the Codonics machine was easy to use, more legible and adhered with better security than the conventional preprinted label. However, most were neutral when asked about the likelihood of flexibility and customisation and were dissatisfied with the increased workload. Our findings suggest that the Codonics labelling machine is user-friendly and it improved syringe labelling compliance in our study. However, staff need to be willing to follow proper labelling workflow rather than batch label during preparation. Future syringe labelling equipment developers need to concentrate on user interface issues to reduce human factor and workflow problems. Support logistics are also an important consideration prior to implementation of any new labelling system.

Multicenter phase II study of gemcitabine and oxaliplatin in advanced nasopharyngeal carcinoma--correlation with excision repair cross-complementing-1 polymorphisms.

BACKGROUND: Nasopharyngeal carcinoma (NPC) is a platinum-sensitive cancer and excision repair cross-complementing group 1 (ERCC1) polymorphisms have been shown to predict survival in several cancers following platinum therapy. PATIENTS AND METHODS: This multicenter study evaluated the activity of oxaliplatin and prolonged infusion of gemcitabine ('GEMOX' regimen) in recurrent NPC. Baseline blood samples were genotyped for the presence of ERCC1-118 gene polymorphisms. RESULTS: Forty-two patients were recruited, of whom most (61%) had metastatic disease. Of the 40 patients evaluated for response, the respective overall response and disease control rates were 56.1% and 90.2%. At a median follow-up of 14.8 months, the respective median overall survival and time to progression were 19.6 months [95% confidence interval (CI) = 12.8-22 months] and 9 months (95% CI = 7.3-10 months). Grade 3-4 toxic effects were uncommon. The distribution of ERCC1-118 genotypes from 29 patients was C/C (n = 17, 40.5%), C/T (n = 10, 23.8%) and T/T (n = 2, 4.8%). No differences in survival or response rates were found between genotypes. CONCLUSIONS: GEMOX is active in the treatment of recurrent NPC. Detection of single-nucleotide gene polymorphisms from genomic DNA in peripheral blood is feasible in NPC and further studies are warranted.

Efficacy of combination chemotherapy with irinotecan (CPT-11) plus capecitabine in patients with metastatic or advanced colorectal carcinoma--a dual-centre phase II study: the MAC-6.

AIMS: A phase II trial was initiated to evaluate the efficacy and toxicity of combination chemotherapy with irinotecan (CPT-11) plus capecitabine in patients with metastatic colorectal cancer. PATIENTS AND METHODS: Patients received a combination of CPT-11 plus capecitabine. CPT-11 was infused intravenously on day 1 every 2 weeks and oral capecitabine was taken twice daily for 5 days every 7 days. Efficacy and toxicities were assessed. RESULTS: Between 2004 and 2005, 43 patients were enrolled. The overall response rate was 51.35%. With a median follow-up of 13 months, the median time to progression was 10 months (95% confidence interval 7.6-12.3 months); the median survival was 15 months (95% confidence interval 13.9-16.9 months). The most common grade 3 haematological and non-haematological toxicities were neutropenia (5.4%), diarrhoea (8.1%) and hand-foot syndrome (2.7%). CONCLUSIONS: CPT-11 plus capecitabine with a 14 day cycle showed a comparable response with international phase II data with a 3 weekly regimen and was well tolerated as a first-line palliative chemotherapy in patients with metastatic colorectal cancer. The data should be interpreted with caution due to the limited sample size and should be further confirmed by a phase III randomised trial.

Endoscopic submucosal dissection for the treatment of intraluminal gastric subepithelial tumors originating from the muscularis propria layer.

BACKGROUND AND STUDY AIMS: Subepithelial tumors of the stomach used to be considered as benign, but they do have malignant potential, especially when they originate from the muscularis propria layer. The aims of this study were to determine the feasibility of endoscopic submucosal dissection (ESD) for the removal of subepithelial tumors from the muscularis propria layer and to evaluate the efficacy and safety of ESD for this indication. PATIENTS AND METHODS: A total of 12 lesions in 11 patients were eligible for inclusion in the study during the period between December 2004 and February 2006. ESD using an insulated-tip knife was used to remove gastric subepithelial tumors from the muscularis propria where this was possible. Endoscopic mucosal resection using a suction and cap method ("EMR-c") was used to obtain a sufficiently large specimen for tissue diagnosis if complete resection by ESD was not possible. RESULTS: Nine tumors were resected completely by ESD (success rate 75 %). The mean tumor size as determined by endoscopic ultrasound as 20.7 mm (range 6 - 40 mm). The histological diagnosis was gastrointestinal stromal tumor for eight lesions and leiomyoma for four tumors. The mean operation time was 60.9 minutes (range 20 - 170 minutes), and the average blood loss was 30 ml. No patient developed perforation or massive hemorrhage requiring surgical treatment, and there were no other immediate postprocedure complications. CONCLUSIONS: ESD can be used for the resection of intraluminal gastric subepithelial tumors and could replace treatment by surgical resection in some cases. EMR-c is an alternative method that can be used to obtain sufficient tumor tissue for histological diagnosis if complete resection by ESD fails.

A pre-optimised dosimetry system using a rigid applicator for intracavitary treatment of cervical carcinoma.

AIMS: Tumour control and complication risk have been major concerns in the treatment of cervical carcinoma. A review of dose distribution for intracavitary treatment of cervical carcinoma revealed that modification of the Manchester dosimetry system is necessary for cases of narrow-sized vagina. A revised dosimetry system was introduced in the present study, with the objective of optimising the dose coverage for the parametrium while minimising the bladder and rectum dosage by restricting the rectal dose so as not to exceed 75% of the brachytherapy prescription dose. MATERIALS AND METHODS: A suitable-sized applicator was selected according to the patient's anatomy. The revised system is optimised based on the fixed geometry of the applicator. The system was therefore predefined and the distribution of the treatment dose already determined before application. The revised system was applied to 135 cases, involving 540 applications. The clinical outcome in terms of local tumour control and complication rates is reported. The differences between the revised system and the Manchester system in terms of dose coverage for the parametrium and the rectum dose were compared. RESULTS: The results showed that higher rectal and parametrial dosages were obtained with the Manchester system as compared with the revised system. Our study showed that over 50% of our patients would have received a rectal dose close to 100% of the point A dose if the Manchester system was applied, whereas it was restricted to below 75% using the revised system. Using the revised system, the significance of the parametrial dosage coverage in relation to local control was assessed: the mean dose to the rectum and the bladder as a percentage of point A was 65.7 +/- 5% (range 50-85%) and 66.4 +/- 14% (range 29-116%), respectively. The 5-year actuarial local failure-free survival rates were 90, 92.9, 86.8, 100, 69.7 and 0% for stages IB, IIA, IIB, IIIA, IIIB and IV (P < 0.0001), respectively. The 3-year actuarial complication rates (grade 3/4) for proctitis and cystitis were 1.4 and 0.5%, respectively. The dosage coverage for the parametrium was found to be significant (P = 0.029) in relation to local control for early-stage disease. CONCLUSIONS: The favourable local tumour control and low complication rates shown by our results indicate that the revised system presents an optimal dose distribution, particularly for the application of small ovoids, whereas morbidity was reduced to a lower level without compromising local control.

Treatment results of endometrial carcinoma with positive peritoneal washing, adnexal involvement and serosal involvement.

AIMS: To review the treatment results of patients with endometrial carcinoma having positive peritoneal washing (PPW), adnexal involvement, uterine serosal involvement, or all three. MATERIALS AND METHODS: The treatment records of patients who had undergone primary surgery for endometrial cancer without distant metastasis during 1990--2001 at the Department of Clinical Oncology, Tuen Mun Hospital, Hong Kong, were reviewed. Thirty-five patients were found to have involvement of positive PPW, adnexal involvement, uterine serosal involvement, or all three. Seven (20%) of them had gross or microscopic lymph-node metastasis. Thirty-three (94.3%) patients received adjuvant radiotherapy (28 whole-pelvic irradiation [WPI]; five abdominal radiotherapy [WART]). Two patients with solitary ovarian metastasis received chemotherapy, and one with isolated PPW also received adjuvant hormonal therapy. The median follow-up was 50.4 months (range 2.4-151.2 months). Multivariate analysis was carried out using the Cox regression proportional hazards model. RESULTS: Among the 28 patients with clinical or pathological node-negative disease (International Federation of Gynecology and Obstetrics [FIGO] stage IIIA), only two patients with solitary ovarian metastases developed recurrence. The 5-year actuarial disease-free survival (DFS) rates for the whole group and patients without lymph-node involvement were 77.9% and 91.7%, respectively. Five out of the seven patients with lymph-node involvement developed recurrences. Univariate analysis showed that lymph-node involvement (P < 0.0001) and high-grade disease (P = 0.011) were the significant poor prognostic factors. Multivariate analysis showed that lymph-node involvement was the only significant poor prognostic factor to predict poor 5-year DFS (P = 0.0001). Only one patient (3.7%) who had received WART developed grade 4 toxicity. CONCLUSIONS: This study showed that good treatment results could be obtained from patients with stage IIIA endometrial carcinoma without clinical or pathological lymph-node involvement after adjuvant radiotherapy, with acceptable late side-effects. The relative prognostic importance of individual IIIA involvement and the optimal adjuvant treatment remain to be determined.

Staging of nasopharyngeal carcinoma: suggestions for improving the current UICC/AJCC Staging System.

AIMS: To evaluate the current UICC/AJCC Staging System for nasopharyngeal carcinoma and to search for ways of improving the system. MATERIALS AND METHODS: This is a retrospective analysis of 2687 consecutive patients treated in five public centres in Hong Kong during the period 1996-2000. All patients were staged by computed tomography, magnetic resonance imaging, or both. The prognostic significance of the current stage assignment on various aspects of tumour control was evaluated. RESULTS: T-category, N-category and stage-group were all significant prognostic factors for major end points (P < 0.01). However, the distinction of prognosis between Stage I and II was insignificant (5-year cancer-specific survival being 92% vs 95%; P = 0.13). Multivariate analyses (corrected for age and sex) revealed lack of significance between T2a and T1 in hazards of local and distant failures, N3a and N2 in distant failure and subgroups of T1-2N0 in cancer-specific deaths. Corresponding down-staging of T2a to T1, N3a to N2, and subgroup T2N0 to stage I, resulted in more even and orderly increase in the hazard ratio of cancer-specific deaths (from 1 for stage I to 1.98 for II, 3.5 for III, 6.08 for IVA and 8.62 for IVB), better hazard consistency among subgroups of the same stage and more balanced stage distribution. CONCLUSIONS: The current UICC/AJCC Staging System could be further improved by the modifications suggested; validation of the current proposal by external data is urgently awaited.

CT verification of isocentre relocatability using stereotactic mask fixation system.

AIMS: This study introduces a non-invasive method based on computed tomography (CT) verification to ensure patients are accurately positioned before fractionated stereotactic radiotherapy. It enables quality control of mask positioning with reference to the CT images of the treatment plan. MATERIALS AND METHODS: A mask system, together with a dental impression moulded mouth bite, was used for patient immobilisation. In order to facilitate relevant image comparison, special alignment during CT localisation was discussed in the study. The accuracy of patient set-up was studied by assessing the isocentre position in relation to the patient's anatomical structure. The planning CT images were applied as a reference and the study was applied to 261 cranial applications. RESULTS: The results show that the mean and the maximum overall displacements at the isocentre were 0.7 and 2.5 mm, respectively. The mean and the maximum rotational displacement in the axial plane were 0.56 degrees and 2 degrees, respectively. The mean translational displacement and rotational displacement were close to zero when considering the direction of movement. CONCLUSIONS: The results indicate that the systematic error of the mask system and the verification method are minimal. Advantages of this technique include the simple set-up, three-dimensional quantification and short study time (10-15 min). It is therefore practical to implement on a routine basis. Investigation of the ability to relocate the mask is also recommended to justify the required safety margin between the clinical and planning target volumes.

Long-term results of endoscopic hemorrhoidal ligation: two different devices with similar results.

BACKGROUND AND STUDY AIMS: To evaluate the efficacy of two different endoscopic hemorrhoidal ligation (EHL) devices for symptomatic internal hemorrhoid. PATIENTS AND METHODS: From November 2000 to February 2001, 218 consecutive patients with symptomatic internal hemorrhoids were enrolled. A total of 109 patients were treated with an EHL device 9 mm in diameter (group A); the rest were treated with a device 13 mm in diameter (group B). The patients' clinical presentations were rectal bleeding and prolapse. The severity of the hemorrhoid was classified using Goligher's grading. RESULTS: All patients were treated for one session, and were followed from 19 to 24 months (mean 22.4 months). The number of band ligations averaged 2.59 in group A and 1.68 in group B. Most patients had their hemorrhoids reduced by at least one grade (82.8 % in group A and 90.8 % in group B). Rectal bleeding was controlled in 108 patients (99.1 %) in group A and 109 patients (100 %) in group B, while rectal prolapse was reduced in 93 patients (85.3 %) in group A and 99 patients (90.8 %) in group B. Eleven patients in group A and 12 in group B experienced anal pain after treatment, and eight patients in group A and six in group B had mild bleeding. The patients' subjective satisfaction rates were 90.8 % in group A and 93.6 % in group B. The 1-year recurrence rates were 3.9 % in group A and 2.3 % in group B. CONCLUSIONS: Both EHL devices can effectively treat symptomatic internal hemorrhoids. A device with a smaller diameter requires more band ligations, but appears equivalent with regard to treatment outcome and complications.

Sphenoid sinus mucocoele and cranial nerve palsies in a patient with a history of nasopharyngeal carcinoma: may mimic local recurrence.

We report the case history of a patient with a sphenoid sinus mucocoele detected by computed tomography and medical resonance imaging. The patient had a history of nasopharyngeal carcinoma, which was treated by radiotherapy more than 10 years previously. He presented with bilateral twelfth and sixth cranial nerve palsies. Local tumour recurrence was suspected. Further investigations showed that the cranial nerve palsies were caused by radiation damage and the sphenoid sinus mucocoele was an incidental finding. Sphenoid sinus mucocoele is a possible rare late complication of radiotherapy in patients with nasopharyngeal carcinoma.

Magnifying colonoscopy in differentiating neoplastic from nonneoplastic colorectal lesions.

OBJECTIVE: Because the medical management of persons with adenomatous colorectal polyps differs from that of those with hyperplastic polyps, accuracy of diagnosis is essential. This study reports our experience using a magnifying colonoscope combined with indigocarmine dye to diagnose colorectal polyps, emphasizing its ability to differentiate neoplastic from nonneoplastic lesions. METHODS: The materials consisted of 175 polyps. A 0.2% indigocarmine solution was sprayed, and the colonoscope zoom apparatus performed a magnified observation after an ordinary colonoscopy identified the lesions. The pit patterns were classified into six categories: I, II, III(L), IIIs, IV, and V according to Kudo's modified classification. RESULTS: The percentages of neoplastic changes in the lesions with pit pattern I, II, III(L), IIIs, IV, and V were 0, 12.2, 69.7, 80, 84.4, and 100%, respectively. The diagnostic sensitivity of neoplastic lesions was 93.8% and specificity was 64.6% when types I and II represented the pit pattern of nonneoplastic lesions and types III(L), IIIs, IV, and V represented neoplastic lesions. The overall diagnostic accuracy in differentiating neoplastic from nonneoplastic lesions was 80.1%. The diagnostic accuracy is not influenced by the size and shape of the lesions. The six neoplastic lesions that were misjudged to be nonneoplastic were histologically adenoma with only mild atypia. CONCLUSIONS: The pit pattern analysis of colorectal lesions by magnifying colonoscopy is a useful and objective tool for differentiating neoplastic from nonneoplastic lesions of the large bowel. In its current state of development, however, this technique is not a substitute for histology.

Endoscopic treatment of colorectal polyps and early cancer.

To analyze the efficacy and outcome of colonoscopic resection for colorectal neoplastic lesions, we retrospectively reviewed 338 colorectal lesions from 232 patients regarding the clinical profiles, colonoscopic findings, histological findings, complications, and outcome. Morphologically, these lesions were classified into three categories: pedunculated (n = 140), sessile (n = 176); and flat (n = 22). Histological findings of lesions included adenoma (n = 248), carcinoma in situ (n = 17), submucosal carcinoma (n = 2), hyperplastic polyp (n = 57), and inflammatory polyp (n = 14). Neoplastic lesions are generally larger than nonneoplastic lesions (chi2 test, P < 0.05). The incidence of carcinoma was 5.6% of 338 resected lesions. The rate of cancer or high-grade dysplasia in flat polyps was greater than in pedunculated and sessile polyps (13.6 vs 4.54 vs 5.71%; P < 0.05). There were no perforations or deaths after colonoscopic treatment, and only mild bleeding occured in two patients. To date, 19 patients with early colorectal cancer were treated successfully by endoscopy with no recurrence or metastasis. To reduce the incidence and mortality of colorectal cancer, colonoscopic resection is a simple and safe procedure for removing neoplastic lesions. Detailed histological examinations are essential to decide the indications of surgery.

Salvage radiation therapy for locally recurrent nasopharyngeal carcinoma.

PURPOSE: To study the treatment outcome in patients with locally recurrent nasopharyngeal carcinoma (NPC) and to explore whether a combination of high-dose-rate (HDR) intracavitary brachytherapy and external beam radiation therapy (ERT) could improve the therapeutic ratio. METHODS AND MATERIALS: Ninety-one patients with nonmetastatic locally recurrent NPC who were treated with curative intent during the years 1990-1999 were retrospectively analyzed. Eighty-two patients had histologically proven carcinoma. The remaining 9 had clinical and imaging features suggestive of local recurrence. The Ho's T-stage distribution at recurrence (rT) was as follows: rT1-37, rT2-14, rT3-40. Total equivalent dose (TED) was calculated by the linear-quadratic formula without a time factor correction. For those treated by combined-modality treatment (CMT), the TED was taken as the summation of the equivalent dose by ERT and the absolute dose delivered to floor of the sphenoid by brachytherapy. Eight patients were treated solely with brachytherapy, all receiving 24-45 Gy in 3-10 sessions. Forty-one patients were treated with ERT alone receiving a median TED of 57.3 Gy (range, 49.8-62.5 Gy). Forty-two patients were treated by CMT with a median equivalent dose of 50 Gy (range, 40-60 Gy) given by ERT and 14.8 Gy by brachytherapy (range, 3-29.6 Gy). Multivariate analyses were performed using the Cox regression proportional hazards model. RESULTS: The 5-year actuarial overall survival rate, disease specific survival rate and local failure-free survival (LFFS) rate for the whole group were 30%, 33. 3% and 37.8%, respectively. The 3-year LFFS rates of rT1, rT2, and rT3 diseases were 64%, 61.5%, and 18.4%, respectively (p = 0.001). Of the 8 patients treated with brachytherapy alone, 4 failed locally. Further analyses were concentrated on the ERT (41 patients) and CMT (42 patients) groups. The 3-year LFFS rates of rT1, rT2, and rT3 diseases were 66.7%, 66.7%, and 18.4%, respectively (p = 0.0008). Better local control for patients who received a TED of 60 Gy or greater was shown. The corresponding 3-year LFFS rates were 29% and 60% (p = 0.0004). Subgroup analysis on the ERT and CMT groups showed a 3-year LFFS rate of 33.5% and 57% (p = 0.003). ERT group had an excess of patients with rT3 disease. Further analysis was performed on the rT1-2 patients showing a trend toward improvement in local control in favor of the CMT group (3-year LFFS rates: CMT, 71.7%; ERT, 54%; p = 0.13). Multivariate analyses showed that rT stage (p = 0.002) and TED (p = 0.01; HR, 0.93; 95% confidence interval, 0.88-0. 98) remained significant. The 5-year major and central nervous system (CNS) complication-free rates were 26.7% and 47.8%. The following factors were found to be significant on univariate analyses for both complications in the ERT and CMT groups: (1) Modality of treatment: more complications with ERT group; and (2) rT stage. Multivariate analyses showed that the rT stage was significant for predicting the occurrence of major (p = 0.004) and CNS complications (p = 0.04). CONCLUSION: For rT1-2 local recurrences, CMT with at least 60 Gy TED is recommended. The high incidence of major late complications is of serious concern. Ways of improving the local control of Ho's rT3 disease and reducing the risk of late complications should be explored.

Salvage brachytherapy for patients with locally persistent nasopharyngeal carcinoma.

PURPOSE: Locally persistent nasopharyngeal carcinoma (NPC) carries an increased risk of local failure if additional treatment is not given. This study was conducted to evaluate the outcomes of patients with locally persistent NPC as treated by high-dose-rate (HDR) intracavitary brachytherapy, and to explore whether routine brachytherapy boost could improve the local control. METHODS AND MATERIALS: Eighty-seven patients with locally persistent NPC treated during 1990-1998 with HDR intracavitary brachytherapy were retrospectively analyzed. Fibreoptic nasopharyngoscopy was performed 3-6 weeks after completion of the primary external radiation therapy (ERT). Biopsies were only taken from suspicious areas. Those with complete regression of local disease were put on observation. Eighty-seven patients were shown to have persistent viable disease at a median time of 6 weeks post-RT. The distribution according to Ho's staging system at initial diagnosis was as follows: Stage I-8, II-33, III-41, IV-5; T1-19, T2-48, T3-20; N0-32, N1-22, N2-28, N3-5. CT scan for restaging was not performed after the documentation of persistent disease. Our policy was to treat all patients with persistent disease with brachytherapy irrespective of the extent of disease just prior to brachytherapy. They were treated with HDR intracavitary brachytherapy, with either cobalt sources or an iridium source, giving 22.5-24 Gy in 3 weekly sessions in all but 4 patients. This dose was prescribed at a distance of 1.5 cm from the center of the surface as defined by the sources in the first six patients and subsequently reduced to 1 cm for the others. Twelve patients were treated with neoadjuvant chemotherapy. To compare the efficacy of brachytherapy, another 383 consecutive nonmetastatic patients, treated with curative intent by ERT, during the years 1990-1993, were evaluated. Multivariate analysis was performed using the Cox regression proportional hazards model. RESULTS: The 5-year actuarial local failure-free survival (LFFS) rates and disease-specific survival rates for the brachytherapy group and ERT group were 85% and 76.6% (p = 0.15), and 72% and 67.8% (p = 0.2), respectively. The corresponding 5-year actuarial LFFS rates for T1, T2, and T3 disease were 94.7%, 88.2%, 67.4%, and 84.1%, 79.8%, 62.6%. In assessing the local control, only the T staging was significant on multivariate analysis (p = 0.0004). Other parameters such as age, sex, and persistence of disease (giving brachytherapy) were all nonsignificant. Complications were comparable between the two groups. In the persistent group, the local failure rates of the patients treated with and without neoadjuvant chemotherapy were 17% (2/12) and 13% (10/75) respectively. When analyzed according to different brachytherapy sources, the 5-year LFFS rates of the T1, T2, and T3 patients treated with iridium and cobalt sources were 100% vs. 85.7 (p = 0.19), 93.6% vs. 70% (p = 0.04), and 67.7% vs. 60% (p = 0.72). The difference was statistically significant for the T2 groups. When early T-stage (T1 and T2) patients were grouped together for analysis, the iridium group again showed a statistically significant improvement in 5-year LFFS rate when it was compared with the cobalt group (95.3% vs. 76.5%, p = 0.03) and the ERT alone group (95.3% vs. 81.5%, p = 0.03). The improvement of local control is attributed to a higher nasopharyngeal mucosal dose that is achieved by using small-size flexible applicators with an iridium source. It is interesting to note that the 5-year LFFS rates for the ERT alone group (T1: 84.1%, T2: 79.8%, T3: 62.6%) are comparable to the corresponding rates of the cobalt group. This information supports our speculation that an adequate booster treatment could compensate for inadequate primary treatment. The prognosis of patients with locally recurrent NPC is grave. Maximizing the local control is therefore crucial for the survival of the patients. (ABSTRACT TRUNCATED)

Total biological effect on late reactive tissues following reirradiation for recurrent nasopharyngeal carcinoma.

PURPOSE: To assess the additional damage of normal tissues attributable to reirradiation and the magnitude of partial recovery following the initial course. METHODS AND MATERIALS: Symptomatic late complication rates (excluding xerostomia) in 3635 patients receiving one course (Group 1) and 487 patients receiving two courses of external radiotherapy (Group 2) for nasopharyngeal carcinoma were retrospectively analyzed and compared. RESULTS: Group 2 had significantly lower actuarial complication-free survival rates than Group 1: 48% versus 81% at 5 years. The post-retreatment incidence was significantly affected by biologically effective dose (BED) (assuming an alpha/beta ratio of 3 Gy) of the first course: hazard ratio (HR) = 1.04 per Gy(3) (p = 0.01), but only marginally by that of the second course: HR = 1.01 per Gy(3) (p = 0.06). If the summated BED was taken as the dose unit, it was estimated that a total BED of 143 Gy(3) would induce a 20% incidence at 5 years, while the corresponding dose projected from Group 1 was 111 Gy(3). The gap effect was insignificant in the overall analyses, but a trend of decreasing risk with increasing interval was observed in patients with gap > or = 2 years: HR = 0.86 per year (p = 0.07). CONCLUSION: The major determinant of post-retreatment complication is the severity of damage during the initial course. The sum of total doses tolerated is higher than that expected with a single-course treatment, suggesting occurrence of partial recovery (particularly in those reirradiated after an interval of 2 years or more).

Radionecrosis of the temporal lobe: dynamic susceptibility contrast MRI.

We examined nine patients with histologically proven nasopharyngeal carcinoma (NPC), treated with radiotherapy, using dynamic susceptibility contrast MRI (DSC-MRI). In eight there was clinical evidence of radionecrosis of the temporal lobe, and one was examined for local recurrence in the nasopharynx. All patients had either high-signal finger-like or cystic lesions in the temporal lobes on T2-weighted images. Heterogeneous contrast enhancement occurred in all patients. Relative regional cerebral blood volume (rrCBV) mapping revealed marked hypoperfusion in all patients. One underwent bilateral temporal lobectomy and radionecrosis was confirmed histologically.