Unravelling oligometastatic disease from the perspective of radiation and medical oncology. Part I: non-small cell lung cancer and breast cancer

Oligometastatic disease (OMD) defines a cancer status that is intermediate between localized and widely spread metastatic disease, and can be treated with curative intent. While diagnostic imaging tools have considerably improved in recent years, unidentified micrometastases can still evade current detection techniques, allowing the disease to progress. The various OMD scenarios are mainly defined by the number of metastases, the biological and molecular tumour profiles, and the timing of the development of metastases. Increasing knowledge has contributed to the earlier and improved detection of OMD, underlining the importance of early disease control. In view of increasing OMD detection rates in current real-world clinical practice and the lack of standardized evidence-based guidelines to treat this cancer status, a board of experts from the Spanish Societies of Radiation Oncology (SEOR) and Medical Oncology (SEOM) organized a series of sessions to update the current state-of-the-art on OMD from a multidisciplinary perspective, and to discuss how results from clinical studies might translate into promising treatment options. This expert review series summarizes what is known and what it is pending clarification in the context of OMD in the scenarios of non-small cell lung cancer and breast cancer (Part I), and prostate cancer and colorectal cancer (Part II), aiming to offer specialists a pragmatic framework to help improve patient management (AU)

Unravelling oligometastatic disease from the perspective of radiation and medical oncology. Part II: prostate cancer and colorectal cancer

Oligometastatic disease (OMD) defines a status of cancer that is intermediate between localized and widely spread metastatic disease, and can be treated with curative intent. While imaging diagnostic tools have considerably improved in recent years, unidentified micrometastases can still escape from current detection techniques allowing disease to progress. The variety of OMD scenarios are mainly defined by the number of metastases, the biological and molecular tumour profiles, and the timing of the development of metastases. Increasing knowledge has contributed to the earlier and improved detection of OMD, underlining the importance of an early disease control. Based on increasing detection rates of OMD in the current real clinical practice and the lack of standardized evidence-based guidelines to treat this cancer status, a board of experts from the Spanish Societies of Radiation Oncology (SEOR) and Medical Oncology (SEOM) organized a series of sessions to update the current state-of-the-art on OMD from a multidisciplinary perspective, and to discuss how results from clinical studies may translate into promising treatment options. This experts’ review series summarizes what is known and what it is pending clarification in the context of OMD in the scenarios of Non-Small Cell Lung Cancer and Breast Cancer (Part I), and Prostate Cancer and Colorectal Cancer (Part II), aiming to offer specialists a pragmatic framework that might contribute to the improved management of patients (AU)

Unravelling oligometastatic disease from the perspective of radiation and medical oncology. Part I: non-small cell lung cancer and breast cancer.

Oligometastatic disease (OMD) defines a cancer status that is intermediate between localized and widely spread metastatic disease, and can be treated with curative intent. While diagnostic imaging tools have considerably improved in recent years, unidentified micrometastases can still evade current detection techniques, allowing the disease to progress. The various OMD scenarios are mainly defined by the number of metastases, the biological and molecular tumour profiles, and the timing of the development of metastases. Increasing knowledge has contributed to the earlier and improved detection of OMD, underlining the importance of early disease control. In view of increasing OMD detection rates in current real-world clinical practice and the lack of standardized evidence-based guidelines to treat this cancer status, a board of experts from the Spanish Societies of Radiation Oncology (SEOR) and Medical Oncology (SEOM) organized a series of sessions to update the current state-of-the-art on OMD from a multidisciplinary perspective, and to discuss how results from clinical studies might translate into promising treatment options. This expert review series summarizes what is known and what it is pending clarification in the context of OMD in the scenarios of non-small cell lung cancer and breast cancer (Part I), and prostate cancer and colorectal cancer (Part II), aiming to offer specialists a pragmatic framework to help improve patient management.

Conservative surgery, external radiotherapy, and HDR brachytherapy in a single fraction of 7 Gy in early breast cancer: long-term toxicity and esthetic assessment.

INTRODUCTION: The essential issue in conservative treatment is the quality in breast preservation. When risk factors for local relapse exist, a tumour bed boost is required, but the boost choice remains controversial. Prospectively, we studied long-term toxicity, cosmetic outcome and prognostic factors. MATERIALS AND METHODS: After conservative treatment, 115 patients received a single dose of 7 Gy HDR-brachytherapy (HDR-BT) boost between June 1996 and December 2005. Late toxicity was assessed using the LENT-SOMA scale. For esthetic assessment, a subjective scale was used for patients and a modified Fehlauer scale for physicians. Mean age was 56.6 years. Invasive ductal carcinoma (78 %) and lumpectomy (60 %) were predominantly reported. 48 % received chemotherapy (CT). RESULTS: Regarding toxicity, 39 % of patients reported breast pain, 75 % fibrosis, 56 % telangiectasias, 19 % lymphoedema, and 51 % retraction/atrophy. Concerning management, 22 % of patients with pain and 45 % with lymphoedema were treated. The esthetic result was found satisfactory by 96 % of the patients and 85 % of the physicians. Fibrosis was influenced by CT and a larger irradiated volume and telangiectasias by a greater implant volume. CONCLUSIONS: HDR-BT boost shows good cosmetic effects with acceptable toxicity. Patients overestimate the esthetic outcome. LENT/SOMA is useful to assess chronic toxicity.

Early-stage breast cancer conservative treatment: high-dose-rate brachytherapy boost in a single fraction of 700 cGy to the tumour bed.

BACKGROUND AND PURPOSE: Conservative treatment represents the current therapy for early-stage breast cancer. When risk factors for local relapse exist, a tumour bed boost is required. Retrospectively, we evaluated the prognostic factors influencing local recurrence (LR), overall survival (OS) and disease-free survival (DFS). MATERIAL AND METHODS: After conservative treatment, 210 patients received a single-dose HDR brachytherapy (HDRBT) boost between June 1996 and December 2005. Mean age was 57 years; 75% had invasive ductal carcinoma. The most frequent surgery was lumpectomy (55.7%); 39.4% were G3, 18.6% intraductal component >25% and only 22% had negative margins. RESULTS: With a mean follow-up of 85 months, at 5 and 10 years the OS was 93% and 88%, DFS 92% and 89%, and LR 3.6% and 5.3%, respectively. For LR, the risk factors were carcinoma in situ, N+ and involved margins, whereas for metastasis, the risk factors were T2 tumours, stage III, N+ and the presence of local recurrence. CONCLUSIONS: HDR-BT boost in one fraction is an effective, simple and safe method for reducing LR. The outpatient setting and shorter treatment duration represent undeniable advantages.

Granulocytic sarcoma of the right humerus in a non-leukaemia patient.

Granulocytic sarcoma (GS), an uncommon solid extramedullary tumour, should be considered even in the absence of leukaemia, as delay in diagnosis and treatment worsens the prognosis. We present a GS (single humeral bone lesion) in a non-leukaemia patient, treated with intensive AML (Acute Myeloid Leukaemia) chemotherapy and sequential radiotherapy, in complete response 26 months after diagnosis, confirmed by histopathology and without leukaemia progression.

Once-weekly dose of epoetinum alfa in cancer patients with anemia receiving radiotherapy

Introduction. Anaemia is present in 30%-90% of all patients with cancer, and its origin is multifactorial. Human recombinant erythropoietin has been shown to be useful in treating anemia in patients with cancer. The aim of this study was to evaluate the effectiveness of treatment of anaemia with epoetin alfa (EPO) given as a single weekly dose, and its repercussions on quality of life (QoL). Materials and methods. From January to October 2002, a total of 139 patients referred to our service for radiotherapy (RT) had anemia and received treatment with EPO as a single weekly dose of 40,000 IU subcutaneously, with oral iron supplement. If haemoglobin (Hb) values after 1 month of treatment did not increase by >=1 g/dl, the dose was increased to 60,000 IU/week. Treatment with EPO ended when Hb values reached >=14 g/dl or one month after the end of RT regardless of Hb values. QoL was evaluated with the Functional Assessment of Cancer Therapy-Anaemia subscale (FACT-An) and the Cancer Linear Analogue Scale (CLAS). Results. Mean Hb at the start of treatment with EPO was 11.49 ± 1.08 g/dl, and the mean value at the end of treatment was 14.52 ± 1.41 g/dl (p < 0.001). The mean increase in Hb was 2.97 ± 1.65 g/dl. Mean duration of treatment was 7.13 ± 2.91 weeks. In 11 patients (7.9%) the dose was increased after 4 weeks. In 84 patients (60.4%) EPO treatment was implemented before the commencing of RT. Mean Hb values in this group was 11.34 ± 1.11 g/dl at the start of EPO treatment, 12.69 ± 1.56 g/dl at the start of RT, 13.96 ± 1.54 g/dl at the end of RT and 14.68 ± 1.3 g/dl at the end of EPO treatment (p < 0.001). In 55 patients (39.6%) anaemia developed during RT and, therefore, EPO treatment was implemented after commencing of RT. In this group the mean Hb values were 12.29 ± 1.6 g/dl at the start of RT, 11.72 ± 1.01 g/dl at the start of EPO treatment, 13.97 ± 1.53 g/dl at the end of RT and 14.28 ± 1.54 g/dl at the end of EPO treatment (p < 0.001). Hemoglobin levels at the start of EPO were lower in patients who commenced EPO before RT (p < 0.05). In 60 patients who received combined RT and chemotherapy, mean Hb values were 11.42 ± 1.16 g/dl at the start of EPO and 13.98 ± 1.55 g/dl at the end of EPO (p < 0.005). In 75 patients who had received RT alone, the mean Hb values was 11.53 ± 1.05 g/dl at the start of EPO and 14.98 ± 1.17 g/dl at the end of treatment (p < 0.001). Patients treated with RT alone had higher Hb levels at the end of RT and at the end of EPO treatment than did patients who had received combined treatment (p < 0.005). The duration of EPO treatment was shorter in the group treated with RT alone than in the combined treatment group (6.41 ± 2.99 weeks versus 7.96 ± 2.67 weeks; p < 0.005). No significant differences were observed in FACT-An and CLAS scores at the beginning and the end of the study. Conclusions. Treatment with epoetin alfa as a single weekly dose significantly increased Hb levels in patients with cancer who were undergoing radiotherapy. The response was greater in patients treated with radiotherapy alone than in those receiving combined therapy. The duration of EPO treatment was shorter in the group treated with radiotherapy alone than in the combined treatment group

Early stage breast cancer conserving treatment: high dose rate brachytherapy boost to the tumour bed.

INTRODUCTION: The dose administered to the tumour bed is a risk-factor for local recurrence in localised breast cancer following breast-conserving surgery. MATERIALS AND METHODS: All patients (n=94) received 50 Gy external beam radiotherapy and one application of 700 cGy at 85% isodose with high dose rate brachytherapy. RESULTS: Of the cases, 84% were infiltrating ductal carcinoma; 31.2% were G3; 28% were intraductal component > 25%; 54% had margin < 1 cm or unknown. With a mean follow-up of 65 months (range: 36-107 months), the overall actuarial survival at 5 and 8 years was 93.2% and 84.2%, respectively; disease-free survival was 88.3% and 84.6%, respectively; local control was 92.2% and 88.75%, respectively. Local recurrence rate was 5.3%, and distant dissemination rate was 8.5%. Among the risk-factors analysed, only the presence of 4 or more lymph node involvement implied a higher risk for local recurrence (p =0.0001). For distant dissemination, the risk-factors were: 4 or more lymph nodes involved (p = 0.0001),G3 (p =0.029), tumour >3 cm (p = 0.001), irradiation volume with external beam radiotherapy (p =0.0001), and presence of local recurrence (p = 0.001). CONCLUSION: High dose rate brachytherapy is an effective method for reducing local recurrence, and increasing local control.

Early stage breast cancer conserving treatment: high dose rate brachytherapy boost to the tumour bed

Introduction. The dose administered to the tumour bed is a risk-factor for local recurrence in localised breast cancer following breast-conserving surgery. Materials and Methods. All patients (n=94) received 50 Gy external beam radiotherapy and one application of 700 cGy at 85% isodose with high dose rate brachytherapy. Results. Of the cases, 84% were infiltrating ductal carcinoma; 31.2% were G3; 28% were intraductal component > 25%; 54% had margin 3 cm (p = 0.001), irradiation volume with external beam radiotherapy (p = 0.0001), and presence of local recurrence (p = 0.001). Conclusion. High dose rate brachytherapy is an effective method for reducing local recurrence, and increasing local control

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