Comparison of hematologic toxicity between 3DCRT and IMRT planning in cervical cancer patients after concurrent chemoradiotherapy: a national multi-center study.

PURPOSE: To compare the incidence and severity of acute and chronic hematologic toxicity (HT) in patients treated with three-dimensional conformal radiotherapy (3DCRT) and intensity modulated radiotherapy (IMRT) for curative treatment of cervical cancer and to ascertain the dosimetric parameters of two techniques associated with acute and chronic HT. MATERIALS AND METHODS: A total of 127 patients with cervical cancer receiving concomitant pelvic radiotherapy (RT) and cisplatin were evaluated. Pelvic bone marrow (BM) was contoured for each patient and divided into five sub-regions: lumbosacrum (LS), ilium (IL), lower pelvis (LP), pelvis (P), and whole pelvis (WP). The volume of each BM region receiving 10, 20, 30, and 40 Gy was calculated (V10, -V20, -V30, and -V40). The lowest level of hemoglobin, leukocyte, neutrophil, and platelet counts were obtained during chemoradiotherapy and six months after RT. The nadir values were graded according to Common Terminology Criteria for Adverse Events (version 3.0). RESULTS: Grade 2 or greater acute anemia, leukopenia, neutropenia, thrombocytopenia was observed in 2%, 41.5%, 12% ,and 0% in 3DCRT group and in 27%, 53%, 24.5%, and 4.5% in IMRT group, respectively. Grade 2 or greater chronic anemia, leukopenia, neutropenia, and thrombocytopenia was observed in 11%, 10%, 6%, and 0% in 3DCRT group and in 11%, 9%, 4.5%, and 0% in IMRT group, respectively. LS-V30, 40; IL-V10, 20, 30, 40; LP-V10, 20 ,40; P-V10, 20, 30, 40, and TP-V10, 20, 30, 40 were significantly reduced with IMRT planning compared to 3DCRT planning. Logistic regression analysis of potential predictors showed that none of the dosimetric parameters were significant for predicting acute and chronic HT. CONCLUSION: The present findings showed that IMRT planning reduced irradiated BM volumes compared to 3DCRT planning. However, no difference between the two techniques was observed in terms of acute and chronic HT. Further studies are needed to confirm these results.

The effects of simple and radical hysterectomy and radiotherapy on lower urinary tract symptoms and urodynamics.

PURPOSE: To evaluate effects of simple/radical hysterectomy, radiotherapy, and their combination on lower urinary tract symptoms (LUTS) and urodynamics. MATERIALS AND METHODS: Four groups were formed as simple hysterectomy; Group 1 (n = 20), Type-II hysterectomy; Group 2 (n = 11), Type-II hysterectomy + radiotherapy; Group 3 (n = 16), radiotherapy; Group 4 (n = 20). LUTS, bladder diary, pad test, Q-tip test, stress-test, urodynamics, bladder-wall-thickness measurement, King's Health Questionnaire (KHQ) performed prior and at six and 18 months after treatment. RESULTS: Pre-treatment prevalence of LUTS was higher in Group 1 and decreased at six and 18 months. LUTS increased in Groups 2, 3, and 4 at six months; some of the symptoms decreased to pre-treatment levels at 18 months. Quality of life improved in Group 1 and worsened in the others. Maximum bladder capacity increased in Group 1 and decreased in Groups 2 and 3. Bladder-wall-thickness, maximum detrusor pressures increased, urine sensation decreased in Groups 2 and 4. Maximum vesical pressure increased and compliance decreased in Groups 2 and 3. CONCLUSION: LUTS may decrease after simple hysterectomy. Radical hysterectomy and radiotherapy result in voiding dysfunction; however some of the symptoms may decrease to pre-treatment levels during follow-up.

Does pelvic lymph nodes irradiation using intensity modulated radiation therapy increase rectal and bladder toxicities in patients with prostate carcinoma?

PURPOSE: this study compared the radiation-related rectal (R) and bladder (B) toxicities in prostate carcinoma patients receiving additional pelvic lymph nodes (PLN) irradiation with those receiving prostate (P) and seminal vesicle (SV) irradiation only. METHODS: thirty-three patients treated with intensity modulated radiation therapy (IMRT) were included. RT doses ranged between 60- 66.6 Gy to SV, 74-77.7 Gy to P and 50.4- 60 Gy to PLN. Max acute R toxicity was graded by a physician according to the RTOG side effect criteria during the period from the initiation of therapy until the end of the third month. Max late R and B toxicities were graded 3 months after the completion of RT by a physician using the RTOG GI and urogenital toxicity score and by patients using EORTC QLQ - PR25 self questionnaire separately. The effects of R and B doses and additional PLN irradiation on acute and late R and B toxicities and compatibility of patient- and physician-graded toxicity scores were investigated. RTOG GI and urogenital toxicity scores and EORTC QLQ - PR25 self questionnaire results were correlated. RESULTS: significant factors for acute R toxicity were: max R; R volume receiving ≥ 68 Gy; and PLN irradiation. PLN irradiation was marginally significant for late R toxicity; the mean B dose was a significant factor for late B toxicity. CONCLUSION: the results of this study suggest that although PLN irradiation increased acute R toxicity, it has no effect on late R and B toxicity. Patient- and physician-evaluated late R and B toxicity scores were concordant.

Abdominal pillow for the sparing of small bowel in four-field conventional pelvic radiotherapy.

From 2003 through 2004, 88 patients with gynecological cancer were referred to Istanbul University Oncology Institute for pelvic radiation therapy. All patients underwent small bowel evaluation within the pelvic radiotherapy field in both the supine and prone positions with and without an abdominal pillow. The small bowel area included in radiation fields and intestinal movement were compared on PA films. All patients were treated by using the abdominal pillow. The median external beam pelvic radiation dose of 5040cGy (range, 3220-5400cGy) was administered. The mean distance of upward displacement of small bowel in the prone position on abdominal pillow compared with in the prone position alone and in the supine position was 3.6 cm (range, 0-14 cm) and 4.7 cm (range, 0-14 cm). Using the abdominal pillow, the mean small bowel area was reduced by 45% and 55% compared to the prone position alone and the supine position, respectively (p = 0.0001). In patients who had pelvic surgery intestinal movement was significantly reduced. The incidence of G1, G2 and G3 acute radiation toxicity was 18%, 36% and 3%, respectively. This study demonstrates that the small intestines can be displaced out of the radiation field by an abdominal pillow in the prone position. Also, this noninvasive technique provides for reduction of acute gastrointestinal morbidity.

The role of postoperative radiotherapy in node negative breast cancer patients with pT3-T4 disease.

AIMS: To evaluate the role of postmastectomy radiotherapy (PMRT) in patients with pT3-T4N0M0 breast cancer. METHODS: 156 patients with T3-T4N0M0 breast cancer were retrospectively analyzed. RESULTS: Locoregional recurrences were seen in 17 of 156 patients with a median time for development of 27 months (5.7-248.7 months). Two of 9 patients who were not treated with post-operative radiation therapy had locoregional recurrence as compared with 16 of 147 patients receiving radiotherapy. In multivariate analysis, presence of locoregional recurrence was the only significant prognostic factor for overall survival (18% vs. 86%, p<0.001, RR=9.05). The patients with a median number of dissected lymph nodes >or=10 had a significantly better locoregional disease free survival rate as compared with patients with dissected lymph nodes <10 (90% vs. 78%, p=0.04). Chest wall recurrences were clearly higher in patients without chest wall RT since 5 of 49 patients without RT had recurrences in the chest wall region while only 4 of 107 who received chest wall RT had recurrence. However receiving RT to peripherical lymphatic regions had no additional effect on reducing recurrences in these regions (5% vs. 4%). CONCLUSIONS: Due to the lack of phase III randomized trials directly addressing the role of postmastectomy radiotherapy in these stages, our series suggest that postmastectomy radiotherapy to the ipsilateral chest wall is recommended for patients with PT3N0 and T4N0 breast cancer. The need for irradiating axillary or supraclavicular region shall be neglected in patients who undergo sufficient axillary sampling.

Effectiveness of brachytherapy in the treatment of lip cancer: a retrospective study at the istanbul university oncology institute.

Stage T1 through T3 lip cancers can be treated primarily by brachytherapy (BRTX), with or without external radiotherapy (ERT), with adequate safety margins and good results. In this study, the outcomes of BRTX were reviewed for patients treated at the Brachytherapy Department of the Istanbul University Oncology Institute (IUOE). The medical records of 41 patients registered at IUOE with a diagnosis of lip cancer between 1988 and 2003 were reviewed. The median follow-up time was 88 months (24-160 mo). Among these patients, 21 patients with a primary tumor, 14 with tumors arising postoperatively, and 6 with postoperative recurrence of tumor were treated using BRTX. A total of 33 patients (80%) received BRTX alone and 8 (20%) received BRTX and ERT. The 10-year local control rate was 100%, 93%, and 67% for patients treated with BRTX alone, BRTX and surgery, and those treated for postoperative recurrence, respectively (P<.02). For patients treated with BRTX only and BRTX plus surgery, specific disease-free survival was 95% and 94%, respectively, and overall survival was 93% and 100%, respectively; these differences were not statistically significant. One patient with a postoperative recurrence who had been treated with BRTX died as a result of lip cancer. No patients developed any ulcerations, intra-oral complications, or mandibular necrosis. In the BRTX only group, 83% had excellent or good cosmetic results. In the surgery group, 62% had a contour deformity. In lip cancer management, BRTX results were comparable for local control, survival, and minimal late effects in normal tissue. This is in accordance with current reports in the medical literature. Satisfactory results were observed in patients with stage T1 and T2 lesions who had been treated with BRTX only and in patients with stage T3 lesions who had been treated with BRTX plus ERT, without a need for additional treatment modalities.

Prognostic factors and survival in patients with metastatic or recurrent carcinoma of the uterine cervix.

The aim of this study is to identify the impact of various prognostic factors on survival in patients with recurrent carcinoma of the uterine cervix. Fifty-two patients who were treated with platinum-based chemotherapy for recurrent or metastatic disease were retrospectively evaluated. Twenty-seven patients (90%) had received pelvic radiation as primary treatment. Out of 45 evaluable patients, two (4.4%) had complete response (CR), three (6.7%) had a continuous CR after additional surgical treatment and irradiation. Five patients (11.1%) had partial response (PR). The majority of patients had progressive response to treatment (22 patients, 48.9%). After a median follow-up period of 19 months, 31 patients (60%) had died. Progression-free survival after initial diagnosis was observed to have a significant association with response to chemotherapy for recurrent disease (Fisher two-sided P = 0.027). The median survival duration for relapsed disease was 11.8 months. Those with a longer disease-free interval ( 8 months vs.

Can preoperative lymphoscintigraphy be used as a guide in treatment planning of breast cancer?

PURPOSE: The purpose of this study was to map the lymphatic drainage patterns of breast cancer with lymphoscintigraphy to evaluate the variability of drainage and to determine whether lymphatic mapping can help to increase the certainty of breast cancer staging. MATERIALS AND METHODS: Fifty women with breast cancer (mean age, 49 years) were included in the study. Lymphoscintigraphy was performed with 1 mCi Tc-99m rhenium sulfide colloid in a 2-ml volume injected into the four quadrants of the peritumoral area using a 25-gauge needle. Ten-minute dynamic images and 2-hour delayed static images were obtained in the anterior and lateral positions using a gamma camera with a high-resolution collimator. All patients had a modified radical mastectomy and axillary dissection. The results were evaluated with histopathologic findings of the axilla. RESULTS: Six patients had excision biopsies before surgery. Of 13 patients with centrally located tumors, 84% had axillary lymphatic drainage, whereas 53% drained to internal mammary lymphatics. Of 23 patients with outer quadrant tumors, 4 showed no lymphatic drainage and all of them had metastatic tumor in the axillary lymph nodes. Axillary drainage was seen in 82% of patients and internal mammary lymphatic drainage in 23%. Of eight patients with inner quadrant tumors, one patient with no lymphatic drainage was found to have metastases in the axilla. In this group, 62% had axillary and 50% had internal mammary lymphatic drainage, and one patient had supraclavicular drainage. CONCLUSIONS: Lymphoscintigraphy indicates that drainage routes may vary, and thus it may play a guiding role in patients with breast cancer who need radiotherapy. In patients with internal mammary lymphatic drainage, the accuracy of radiotherapy planning may increase if internal mammary lymphoscintigraphy is added to the protocol. In patients with internal mammary drainage, obtaining an internal mammary lymphatic biopsy during surgery will also increase the accuracy of staging.

Electrophysiological findings in patients who received radiation therapy over the brachial plexus: a magnetic stimulation study.

Clinical and electrophysiological findings of 47 asymptomatic females who received radiation therapy (RT) over their brachial plexus region are presented and compared with 8 radiation-induced brachial plexopathy (RBP) and 4 neoplastic brachial plexopathy (NBP) patients. In the asymptomatic group, abnormal findings were more frequent in patients whose post-RT period was longer than 1 year. Flexor carpi radialis H reflex was delayed or absent in 19 patients (52%) in this subgroup of asymptomatic cases, as compared to only 2 (18%) of the patients with post-RT periods of less than 1 year. Magnetic cervical nerve root stimulation was performed in 16 asymptomatic cases, with the conclusion that there was no significant difference between the irradiated and non-irradiated sides with regard to latencies, amplitudes and areas of the muscle responses. In spite of this, muscle response amplitudes and areas on both sides were significantly lower than those obtained from healthy controls. It was postulated that this finding resulted from hypoexcitability to magnetic stimulation produced by slight nerve root damage. Any part of the brachial plexus could be affected in RBP and NBP patients. Myokymic discharges were found at a high rate (87.5%) in RBP group. Cervical magnetic nerve root stimulation may have a diagnostic value in these patients in localizing the nerve lesion over the brachial plexus.

Detection of HPV 16 and HPV 18 infection in patients with cervical neoplasia.

Definite types of human papillomaviruses (HPV) are considered an etiological factor in the occurrence of cervical carcinoma. Determining the persistence of some HPV types associated with cervical carcinoma is important in defining and following precancerous lesions. The most sensitive method in the determination of these viruses is polymerase chain reaction (PCR). Because of the convenience and the fastness it provides, cytological cervical material is preferred for the analysis. In our study infection with HPV 16 and HPV 18 was investigated in the cervical scrapes of 33 subjects with cervical carcinoma. The DNAs isolated from the samples were amplified by PCR. HPV 16 and HPV 18 types were identified by Southern Blot hybridization. The positivity rates for HPV 16 and HPV 18 in 33 subjects with cervical carcinoma were 54.5% and 45.4%, respectively. The corresponding value in the control group was only 5.5%. PCR combined with Southern Blot is the most sensitive method for scanning programmes and in defining and monitoring the risk groups for developing cervical neoplasia.

A comparison of body image, self-esteem and social support in total mastectomy and breast-conserving therapy in Turkish women.

As well as the medical outcomes of two distinct operations, namely total mastectomy and breast-conserving therapy, their impact on the psychic structuring of the patient may differ. A group of 40 woman with who had undergone mastectomy were therefore compared with another 40 with who had received breast-conserving therapy, with regard to the variables of body image, self-esteem and social support. The women who underwent breast-conserving therapy had a more positive body image (P < 0.001). The two groups showed a negligible difference with respect to self-esteem and social support (P > 0.05). A negative correlation was found between body image and social support (P < 0.05). Patients with total mastectomy therefore do have a more negative body image than patients receiving breast-conserving therapy. Self-esteem and social support in the postoperative period in two groups are comparable.

A new iridium applicator for vaginal vault irradiation.

A new disposable gynecologic applicator designed for postoperative vaginal vault brachytherapy is presented. The applicator is afterloading manually with iridium 192 wire. We have used this new applicator in more than thirty patients and recorded the following advantages: 1) There is no need to install expensive and complicated equipment; 2) Single use applicators are in sterile packages and are ready to use; 3) Applicator is easily and comfortably carried by patient; 4) There is no need for specific training to use the system; 5) There is no need for general anesthesia during application; 6) There is no need for patient immobilization during treatment; 7) There is no need for urinary catheterization during treatment; 8) Dose distribution is homogeneous; 9) Bladder and rectum doses are at acceptable levels; 10) Radioprotective measures needed to be taken are inexpensive. We believe that this new system could easily be used in every radiation oncology unit.

The role of adjuvant chemotherapy in the treatment of uterine sarcoma patients.

41 uterine sarcoma patients completed their post-operative adjuvant treatment at Istanbul University, Oncology Institute. Of these patients 23 had pelvic irradiation (RT group) and 18 had pelvic irradiation plus chemotherapy (RT + CT group). The 3 year survival rates of the two adjuvant treatment arms were 36% (RT group) and 66% (RT + CT group) (0.05 greater than p greater than 0.02). This difference is statistically significant. The 5 year survival rates were 18% (RT group) and 51% (RT + CT group) (0.1 greater than p greater than 0.05). Although the survival advantage at 5 years is not statistically significant because of the low number of patients, the use of adjuvant chemotherapy in uterine sarcomas seems to bring some survival benefit, probably by controlling subclinical distant disease.

[Electron irradiation of cervix cancer using a new transvaginal tube system attached to the betatron]. / Elektronenbestrahlung des Kollumkarzinoms mit einem neuen transvaginalen Tubussystem, das am Betatron angesetzt wird.

A new tube system for the betatron, which normally is only applied in percutaneous electron therapy, was developed at the Radiotherapeutic Department of the Medical Faculty of Istanbul. The new system allows to use the betatron also in transvaginal irradiation of the uterine cervix cancer. The authors describe the technical features of this system, its clinical application, and the results achieved. In great tumor centres where every type of malignant disease is treated, it is indispensable to dispose of the equipment necessary for certain very special cases, even if this equipment is not used frequently. In recent years, applicators for cavitary therapy and high voltage units for percutaneous therapy have been gradually substituted for the tube system employed in former times with orthovolt therapy units in intravaginal irradiation of cervical and vaginal carcinomas. There are cases, however, where the therapy techniques used nowadays are not sufficient or where a cavitary therapy should be used. Furthermore electrons which today can easily be produced for percutaneous surface therapy with linear accelerators can also be used for transvaginal therapy. We, too, have developed a new tube system which was attached to the betatron and used in intravaginal irradiation. This study describes the tube system, its clinical application, and the results achieved.