RESUMO
PURPOSE: Definitive chemoradiotherapy (dCRT) is a treatment option with curative intent for patients with esophageal cancer that could result in late toxicities and affect health-related quality of life (HRQoL). This study aimed to review the literature and perform a meta-analysis to investigate the effect of dCRT on late toxicities and HRQoL in esophageal cancer. METHODS AND MATERIALS: A systematic search was performed in MEDLINE, EMBASE, and PsychINFO. Prospective phase II and III clinical trials, population-based studies, and retrospective chart reviews investigating late toxicity or HRQoL after dCRT (≥50 Gy) were included. The HRQoL outcomes were analyzed using linear mixed-effect models with restricted cubic spline transformation. Any HRQoL changes of ≥10 points were considered clinically relevant. The risk of toxicities was calculated using the number of events and the total study population. RESULTS: Among 41 included studies, 10 assessed HRQoL and 31 late toxicity. Global health status remained stable over time and improved after 36 months compared with baseline (mean change, +11). Several tumor-specific symptoms, including dysphagia, eating restrictions, and pain, improved after 6 months compared with baseline. Compared with baseline, dyspnea worsened after 6 months (mean change, +16 points). The risk of any late toxicity was 48% (95% CI, 33%-64%). Late toxicity risk of any grade for the esophagus was 17% (95% CI, 12%-21%), pulmonary 21% (95% CI, 11%-31%), cardiac 12% (95% CI, 6%-17%), and any other organ 24% (95% CI, 2%-45%). CONCLUSIONS: Global health status remained stable over time, and tumor-specific symptoms improved within 6 months after dCRT compared with baseline, with the exception of dyspnea. In addition, substantial risks of late toxicity were observed.
Assuntos
Neoplasias Esofágicas , Qualidade de Vida , Humanos , Estudos Prospectivos , Estudos Retrospectivos , Neoplasias Esofágicas/terapia , Quimiorradioterapia/efeitos adversos , Dispneia/etiologiaRESUMO
PURPOSE: Involved internal iliac and obturator lateral lymph nodes (LLNs) are a known risk factor for the occurrence of ipsilateral local recurrences (LLR) in rectal cancer. This study examined coverage of LLNs with routine radiation therapy practice in the Netherlands and associated LLR rates. METHODS AND MATERIALS: Patients with a primary tumor ≤8 cm of the anorectal junction, cT3-4 stage, and at least 1 internal iliac or obturator LLN with short axis ≥5 mm who received neoadjuvant (chemo)radiation therapy, were selected from a national, cross-sectional study of patients with rectal cancer treated in the Netherlands in 2016. Magnetic resonance images and radiation therapy treatment plans were reviewed regarding segmented LLNs as gross tumor volume (GTV), location of LLNs within clinical target volume (CTV), and received proportion of the planned radiation therapy dose. RESULTS: A total of 223 out of 3057 patients with at least 1 LLN ≥5 mm were selected. Of those, 180 (80.7%) LLNs were inside the CTV, of which 60 (33.3%) were segmented as GTV. Overall, 202 LLNs (90.6%) received ≥95% of the planned dose. Four-year LLR rates were not significantly higher for LLNs situated outside the CTV compared with those inside (4.0% vs 12.5%, P = .092) or when receiving <95% versus ≥95% of the planned radiation therapy dose (7.1% vs 11.3%, P = .843), respectively. Two of 7 patients who received a dose escalation of 60 Gy developed an LLR (4-year LLR rate of 28.6%). CONCLUSIONS: This evaluation of routine radiation therapy practice showed that adequate coverage of LLNs was still associated with considerable 4-year LLR rates. Techniques resulting in better local control for patients with involved LLNs need to be explored further.
Assuntos
Recidiva Local de Neoplasia , Neoplasias Retais , Humanos , Estudos Transversais , Recidiva Local de Neoplasia/patologia , Linfonodos/diagnóstico por imagem , Linfonodos/patologia , Neoplasias Retais/patologia , Recidiva , Estudos Retrospectivos , Estadiamento de NeoplasiasRESUMO
PURPOSE: To analyze the effect of radiation dose escalation to the primary tumor on local tumor control in definitive chemoradiation (dCRT) for patients with esophageal cancer. PATIENTS AND METHODS: Patients with medically inoperable and/or irresectable esophageal carcinoma, referred for dCRT, were randomly assigned between a standard dose (SD) of 50.4 Gy/1.8 Gy for 5.5 weeks to the tumor and regional lymph nodes and a high dose (HD) up to a total dose of 61.6 Gy to the primary tumor. Chemotherapy consisted of courses of concurrent carboplatin (area under the curve 2) and paclitaxel (50 mg/m2) in both arms once a week for 6 weeks. The primary end point was local progression-free survival. RESULTS: Between September 2012 and June 2018, 260 patients were included. Squamous cell carcinoma (SCC) was present in 61% of patients, and 39% had adenocarcinoma (AC). Radiation treatment was completed by 94%, and 85% had at least five courses of chemotherapy. The median follow-up time for all patients was 50 months. The 3-year local progression-free survival (LPFS) was 70% in the SD arm versus 73% in the HD arm (not significant). The LPFS for SCC and AC was 75% versus 79% and 61% versus 61% for SD and HD, respectively (not significant). The 3-year locoregional progression-free survival was 52% and 59% for the SD and HD arms, respectively (P = .08). Overall, grade 4 and 5 common toxicity criteria were 12% and 5% in the SD arm versus 14% and 10% in the HD arm, respectively (P = .15). CONCLUSION: In dCRT for esophageal cancer, radiation dose escalation up to 61.6 Gy to the primary tumor did not result in a significant increase in local control over 50.4 Gy. The absence of a dose effect was observed in both AC and SCC.
Assuntos
Adenocarcinoma/terapia , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Quimiorradioterapia/mortalidade , Neoplasias Esofágicas/terapia , Carcinoma de Células Escamosas do Esôfago/terapia , Adenocarcinoma/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Carboplatina/administração & dosagem , Relação Dose-Resposta à Radiação , Neoplasias Esofágicas/patologia , Carcinoma de Células Escamosas do Esôfago/patologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Paclitaxel/administração & dosagem , Prognóstico , Taxa de SobrevidaRESUMO
Introduction: Patient preferences are often not discussed in treatment decisions in oncology. We introduced an online values clarification method (VCM) to help newly diagnosed rectal cancer patients participate in shared decision making about short-course preoperative radiotherapy. Material and Methods: We offered a link to the VCM to a subset of consecutive patients before the pretreatment consultation with the radiation oncologist. Consultations were audiotaped and coded for expressions of patient preferences. Patients were asked to complete pre- and post-consultation questionnaires. Questionnaires assessed values clarity, decision regret and presence and impact of fecal incontinence and sexual problems. Results: Of 135 patients who had their consultation audiotaped and completed questionnaires, 35 received and accessed the VCM-link. Patients in the VCM-group slightly more often expressed preferences during consultations. Questionnaire data showed that patients in the VCM-group did not differ in how clear their values were, but experienced lower regret and less impact of treatment harms at 6 months follow-up; differences were non-significant but in the same direction at 12 months. Discussion: This is the first study to assess the effect of an adaptive conjoint analysis-based VCM on actual patient-clinician communication, and long-term decision regret and impact of treatment harms. Being explicitly invited to think about treatment benefits and harms seems to help patients to live with treatment consequences.
Assuntos
Tomada de Decisão Clínica/métodos , Tomada de Decisão Compartilhada , Participação do Paciente , Preferência do Paciente/psicologia , Neoplasias Retais/terapia , Idoso , Colectomia , Emoções , Incontinência Fecal/etiologia , Incontinência Fecal/psicologia , Feminino , Humanos , Masculino , Memória Episódica , Pessoa de Meia-Idade , Relações Médico-Paciente , Qualidade de Vida , Lesões por Radiação/etiologia , Lesões por Radiação/psicologia , Radio-Oncologistas , Radioterapia Adjuvante/efeitos adversos , Encaminhamento e Consulta , Disfunções Sexuais Psicogênicas/etiologia , Disfunções Sexuais Psicogênicas/psicologia , Inquéritos e QuestionáriosRESUMO
BACKGROUND AND PURPOSE: Small cell carcinoma of the esophagus (SCEC) is a rare subtype of esophageal cancer for which optimal treatment is unknown. We analyzed the impact of treatment factors on outcome in patients with nonmetastasized SCEC. METHODS: Patients with a histologically confirmed SCEC without distant metastases were analyzed in a nationwide multicenter retrospective cohort. All patients received radiotherapy as part of curative treatment between January 2000 and December 2014. Details on treatment and outcome were retrieved from individual charts. Cox regression analysis was used to determine prognostic factors for survival. RESULTS: Fifty-eight patients were analyzed. Median survival was 16 months (95% confidence interval, 11-21 mo). Infield recurrences occurred in 25%, distant metastases in 45%, and brain metastases in 12%. In total, 63% of patients developed a recurrence. Most recurrences (67%) occurred within 1 year. In univariable analyses an increased number of chemotherapy cycles (>3) and lower radiotherapy doses (<45 Gy) were associated with improved survival. T-stage, N-stage, treatment period, type of chemotherapy, prophylactic cranial irradiation, and age were not associated with survival. In multivariable analyses, only the number of chemotherapy cycles was associated with better survival (hazard ratio, 0.78; P=0.006). CONCLUSIONS: SCEC recurs frequently at distant sites after definitive chemoradiotherapy and usually within 1 year after curative treatment. With a dose of 45 to 50 Gy, infield recurrence rate was low. We found a relationship between number of received chemotherapy cycles and survival with best results obtained after at least 4 cycles of chemotherapy.
Assuntos
Adenocarcinoma/mortalidade , Carcinoma de Células Pequenas/mortalidade , Carcinoma de Células Escamosas/mortalidade , Quimiorradioterapia/mortalidade , Neoplasias Esofágicas/mortalidade , Recidiva Local de Neoplasia/mortalidade , Adenocarcinoma/secundário , Adenocarcinoma/terapia , Idoso , Carcinoma de Células Pequenas/secundário , Carcinoma de Células Pequenas/terapia , Carcinoma de Células Escamosas/secundário , Carcinoma de Células Escamosas/terapia , Neoplasias Esofágicas/patologia , Neoplasias Esofágicas/terapia , Feminino , Seguimentos , Humanos , Metástase Linfática , Masculino , Recidiva Local de Neoplasia/patologia , Recidiva Local de Neoplasia/terapia , Prognóstico , Estudos Retrospectivos , Taxa de SobrevidaRESUMO
PURPOSE: Hyperthermia treatment planning for deep locoregional hyperthermia treatment may assist in phase and amplitude steering to optimize the temperature distribution. This study aims to incorporate a physically correct description of bladder properties in treatment planning, notably the presence of convection and absence of perfusion within the bladder lumen, and to assess accuracy and clinical implications for non muscle invasive bladder cancer patients treated with locoregional hyperthermia. METHODS: We implemented a convective thermophysical fluid model based on the Boussinesq approximation to the Navier-Stokes equations using the (finite element) OpenFOAM toolkit. A clinician delineated the bladder on CT scans obtained from 14 bladder cancer patients. We performed (1) conventional treatment planning with a perfused muscle-like solid bladder, (2) with bladder content properties without and (3) with flow dynamics. Finally, we compared temperature distributions predicted by the three models with temperature measurements obtained during treatment. RESULTS: Much higher and more uniform bladder temperatures are predicted with physically accurate fluid modeling compared to previously employed muscle-like models. The differences reflect the homogenizing effect of convection, and the absence of perfusion. Median steady state temperatures simulated with the novel convective model (3) deviated on average -0.6 °C (-12%) from values measured during treatment, compared to -3.7 °C (-71%) and +1.5 °C (+29%) deviation for the muscle-like (1) and static (2) models, respectively. The Grashof number was 3.2 ± 1.5 × 105 (mean ± SD). CONCLUSIONS: Incorporating fluid modeling in hyperthermia treatment planning yields significantly improved predictions of the temperature distribution in the bladder lumen during hyperthermia treatment.
Assuntos
Hipertermia Induzida/métodos , Pelve/fisiopatologia , Neoplasias da Bexiga Urinária/terapia , Bexiga Urinária/fisiopatologia , Humanos , Neoplasias da Bexiga Urinária/patologiaRESUMO
BACKGROUND: Adequate tumor temperatures during hyperthermia are essential for good clinical response, but excessive heating of normal tissue should be avoided. This makes locoregional heating using phased array systems technically challenging. Online application of hyperthermia treatment planning could help to improve the heating quality. The aim of this study was to evaluate the clinical benefit of online treatment planning during treatment of pelvic tumors heated with the AMC-8 locoregional hyperthermia system. METHODS: For online adaptive hyperthermia treatment planning, a graphical user interface was developed. Electric fields were calculated in a preprocessing step using our in-house-developed finite-difference-based treatment planning system. This allows instant calculation of the temperature distribution for user-selected phase-amplitude settings during treatment and projection onto the patient's computed tomographic scan for online visualization. Online treatment planning was used for 14 treatment sessions in 8 patients to reduce the patients' reports of hot spots while maintaining the same level of tumor heating. The predicted decrease in hot spot temperature should be at least 0.5°C, and the tumor temperature should decrease less than 0.2°C. These predictions were compared with clinical data: patient feedback about the hot spot and temperature measurements in the tumor region. RESULTS: In total, 17 hot spot reports occurred during the 14 sessions, and the alternative settings predicted the hot spot temperature to decrease by at least 0.5°C, which was confirmed by the disappearance of all 17 hot spot reports. At the same time, the average tumor temperature was predicted to change on average -0.01°C (range, -0.19°C to 0.34°C). The measured tumor temperature change was on average only -0.02°C (range, -0.26°C to 0.31°C). In only 2 cases the temperature decrease was slightly larger than 0.2°C, but at most it was 0.26°C. CONCLUSIONS: Online application of hyperthermia treatment planning is reliable and very useful to reduce hot spots without affecting tumor temperatures.
Assuntos
Temperatura Alta , Hipertermia Induzida/métodos , Melanoma/terapia , Neoplasias Pélvicas/terapia , Planejamento da Radioterapia Assistida por Computador/métodos , Terapia Assistida por Computador/métodos , Neoplasias da Bexiga Urinária/terapia , Neoplasias do Colo do Útero/terapia , Feminino , Humanos , Hipertermia Induzida/efeitos adversos , Hipertermia Induzida/instrumentação , Melanoma/diagnóstico por imagem , Melanoma/tratamento farmacológico , Melanoma/radioterapia , Neoplasias Pélvicas/diagnóstico por imagem , Neoplasias Pélvicas/tratamento farmacológico , Neoplasias Pélvicas/radioterapia , Neoplasias da Bexiga Urinária/diagnóstico por imagem , Neoplasias da Bexiga Urinária/tratamento farmacológico , Neoplasias da Bexiga Urinária/radioterapia , Neoplasias do Colo do Útero/diagnóstico por imagem , Neoplasias do Colo do Útero/tratamento farmacológico , Neoplasias do Colo do Útero/radioterapiaRESUMO
BACKGROUND: The prognostic value of supraclavicular lymph node (SCN) metastases in esophageal cancer is not well established. We analyzed the prognostic value of SCN disease in patients after definitive chemoradiation (dCRT) for esophageal cancer. METHODS: We retrospectively analyzed 207 patients treated between 2003 and 2013 to identify the prognostic value of metastasis in the SCN on treatment failure and survival. All patients were treated with external beam radiotherapy (50.4 Gy in 28 fractions) combined with weekly concurrent paclitaxel 50 mg/m2 and carboplatin AUC2. RESULTS: Median follow-up for patients alive was 43.3 months. The median overall survival (OS) for all patients was 17.5 months. OS at one, three and five years was 67%, 36% and 21%, respectively. For patients with metastasis in a SCN, OS was 23.6 months compared to 17.1 months for patients without metastasis in the SCN (p = .51). In multivariate analyses, higher cT status, cN status and adenocarcinoma were found to be prognostically unfavorable, but a positive SCN was not (p = .67). Median OS and median disease-free survival for tumors with SCN involvement and N0/1 disease was 49.0 months and 51.6 months, respectively, compared to 14.2 months and 8.2 months, respectively, in patients with N2/3 disease. CONCLUSION: In esophageal cancer treated with dCRT, the number of affected lymph nodes is an important independent prognostic factor, whereas involvement of a SCN is not. Supraclavicular lymph nodes should be considered as regional lymph nodes and treated with curative intent if the total number of involved lymph nodes is limited.
Assuntos
Adenocarcinoma/mortalidade , Carcinoma de Células Grandes/mortalidade , Carcinoma de Células Escamosas/mortalidade , Quimiorradioterapia , Clavícula/patologia , Neoplasias Esofágicas/mortalidade , Linfonodos/patologia , Adenocarcinoma/secundário , Adenocarcinoma/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma de Células Grandes/secundário , Carcinoma de Células Grandes/terapia , Carcinoma de Células Escamosas/secundário , Carcinoma de Células Escamosas/terapia , Neoplasias Esofágicas/patologia , Neoplasias Esofágicas/terapia , Feminino , Seguimentos , Humanos , Metástase Linfática , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Prognóstico , Estudos Retrospectivos , Taxa de SobrevidaRESUMO
CONTEXT: Bladder cancer therapy remains suboptimal as morbidity and mortality remain high amongst those with non-muscle-invasive and muscle-invasive disease. Regional hyperthermia therapy (RHT) is a promising adjunctive therapy being tested in multiple clinical contexts. OBJECTIVE: The aim of this study was to systematically review the literature on the efficacy and toxicity of RHT. EVIDENCE ACQUISITION: This systematic review was registered with the PROSPERO database (Registration number: CRD42015025780) and was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. We queried PubMed, EMBASE, and Cochrane libraries. Two reviewers reviewed abstracts independently and a third reviewer arbitrated disagreements. The last search was performed on 28 August 2015. A descriptive analysis was performed and quality assessment was conducted using the Newcastle-Ottawa Quality Assessment Scale for observational studies, and the Cochrane Risk of Bias Assessment Tool for trials. EVIDENCE SYNTHESIS: We identified 859 publications in the initial search, of which 24 met inclusion criteria for full-text review. Of these, we were able to obtain data on the outcomes of interest for 15 publications. CONCLUSIONS: The review underscores the limited nature of the evidence; definitive conclusions are elusive. However, the promising results of RHT in the setting of intravesical chemotherapy, chemotherapy and radiotherapy show a trend towards legitimate efficacy.
Assuntos
Hipertermia Induzida , Neoplasias da Bexiga Urinária/terapia , Humanos , Resultado do TratamentoRESUMO
PURPOSE: An adaptive plan selection strategy can account for daily target volume variations for radiotherapy in rectal cancer patients. The aim was to quantify the daily dosimetric consequences of plan selection compared to a non-adaptive approach. MATERIALS AND METHODS: Ten patients with rectal cancer, treated with 25Gy in five fractions to the mesorectum and pelvic lymph nodes, were selected. The adaptive strategy was simulated by creating three plans per patient, with varying upper ventral PTV margins, and selecting the smallest PTV covering the entire mesorectum on every daily CBCT scan. Subsequently, mesorectum, bladder, and bowel cavity were delineated on these scans. Daily dose-volume histograms were calculated for both the adaptive and non-adaptive plan, with a ventral PTV margin of 20mm. Coverage of the mesorectum, defined as V95%>99%, was calculated, as well as bladder and bowel cavity V95% and V15Gy. RESULTS: In one patient, mesorectum coverage improved. A reduction in bladder V95% and bowel cavity V15Gy was found, of 6.9% and 18.4cm(3) (p<0.01), respectively. CONCLUSION: Plan selection for radiotherapy in rectal cancer can improve coverage of the target volume. Overall dosimetric sparing of bladder and bowel cavity was limited but could be beneficial for individual patients.
Assuntos
Planejamento da Radioterapia Assistida por Computador/métodos , Neoplasias Retais/radioterapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Tomografia Computadorizada de Feixe Cônico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Órgãos em Risco , Dosagem Radioterapêutica , Neoplasias Retais/diagnóstico por imagem , Neoplasias Retais/patologia , Carga TumoralRESUMO
The urinary bladder is a fluid-filled organ. This makes, on the one hand, the internal surface of the bladder wall relatively easy to heat and ensures in most cases a relatively homogeneous temperature distribution; on the other hand the variable volume, organ motion, and moving fluid cause artefacts for most non-invasive thermometry methods, and require additional efforts in planning accurate thermal treatment of bladder cancer. We give an overview of the thermometry methods currently used and investigated for hyperthermia treatments of bladder cancer, and discuss their advantages and disadvantages within the context of the specific disease (muscle-invasive or non-muscle-invasive bladder cancer) and the heating technique used. The role of treatment simulation to determine the thermal dose delivered is also discussed. Generally speaking, invasive measurement methods are more accurate than non-invasive methods, but provide more limited spatial information; therefore, a combination of both is desirable, preferably supplemented by simulations. Current efforts at research and clinical centres continue to improve non-invasive thermometry methods and the reliability of treatment planning and control software. Due to the challenges in measuring temperature across the non-stationary bladder wall and surrounding tissues, more research is needed to increase our knowledge about the penetration depth and typical heating pattern of the various hyperthermia devices, in order to further improve treatments. The ability to better determine the delivered thermal dose will enable clinicians to investigate the optimal treatment parameters, and consequentially, to give better controlled, thus even more reliable and effective, thermal treatments.
Assuntos
Hipertermia Induzida , Neoplasias da Bexiga Urinária/terapia , Animais , Humanos , Temperatura , TermometriaRESUMO
INTRODUCTION: Definitive chemoradiotherapy (dCRT) is standard care for localised inoperable/unresectable oesophageal tumours. Many surgical series have reported on distribution of lymph node metastases (LNM) in resected patients. However, no data is available on the distribution of at-risk LN regions in this more unfavourable patient group. This study aimed to determine the spread of LNM using FDG-PET/CT, to compare it with the distribution in surgical series and to define its impact on the definition of elective LN irradiation (ENI). METHODS: FDG-PET/CT images of patients with oesophageal cancer treated with dCRT (from 2003 to 2013) were reviewed to identify the anatomic distribution of FDG-avid LNs. Tumours were divided according to proximal, mid-thoracic or distal localisation. RESULTS: About 105 consecutive patients entered analysis. The highest numbers of FDG-avid LNs in proximal tumours were at LN station 101R (45%) and 106recL (35%). For mid-thoracic tumours at 104R (30%) and 105 (30%). For tumours located in the distal oesophagus, the most common sites were along the lesser curvature of the stomach (21%) and the left gastric artery (21%). Except for the supraclavicular and pretracheal nodes, there were no positive locoregional LNM found outside the standard surgical resection area. CONCLUSION: Our results show a good correlation between the distribution of nodal volumes at risk in surgical series and on FDG-PET/CT. The results can be used to determine target definition in dCRT for oesophageal cancer. For mid-thoracic tumours, the current target delineation guidelines may be extended based on the risk of node involvement, but more clinical studies are needed to determine if the potential harm of expanding the CTV outweighs the potential benefit.
Assuntos
Neoplasias Esofágicas/diagnóstico por imagem , Neoplasias Esofágicas/radioterapia , Fluordesoxiglucose F18 , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada/métodos , Compostos Radiofarmacêuticos , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias Esofágicas/patologia , Esôfago/diagnóstico por imagem , Esôfago/patologia , Feminino , Humanos , Metástase Linfática/diagnóstico por imagem , Metástase Linfática/radioterapia , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
BACKGROUND: The shared decision making (SDM) model states that patients' values and preferences should be clarified to choose a strategy that best fits the patient. This study aimed to assess whether values and preferences of rectal cancer patients are voiced and considered in deciding about preoperative radiotherapy (PRT), and whether this makes patients feel more involved in treatment decision making. METHODS: Pre-treatment consultations of radiation oncologists and patients eligible for PRT were audiotaped (N=90). Tapes were transcribed and coded to identify patients' values and treatment preferences. Patients filled in a post-consultation questionnaire on their perceived involvement in decision making (N=60). RESULTS: Patients' values were voiced for 62/611 of benefits/harms addressed (10%), in 38/90 consultations (42%; maximum 4 values per consultation), and most often related to major long-term treatment outcomes. Patients' treatment preferences were discussed in 20/90 consultations (22%). In 16/90 consultations (18%), the oncologists explicitly indicated to consider patients' values or preferences. Patients perceived a significantly more active role in decision making if their values or preferences had been voiced or considered. CONCLUSIONS: Patients' values and treatment preferences are voiced or considered in a minority of consultations. If they are, this increases patients' perceived involvement in the decision making process.
Assuntos
Tomada de Decisão Clínica/métodos , Participação do Paciente/métodos , Cuidados Pré-Operatórios/métodos , Neoplasias Retais/radioterapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Países Baixos , Participação do Paciente/estatística & dados numéricos , Neoplasias Retais/cirurgia , Encaminhamento e Consulta/estatística & dados numéricos , Inquéritos e QuestionáriosRESUMO
PURPOSE: Despite intravesical therapy with immunotherapy or chemotherapy intermediate and high risk nonmuscle invasive bladder cancer is associated with a high risk of recurrence and progression to muscle invasive bladder carcinoma. While intravesical hyperthermia combined with mitomycin C has proved effective to treat nonmuscle invasive bladder cancer, there is less experience with invasive regional 70 MHz hyperthermia and mitomycin C. Therefore, we examined the safety and feasibility of this treatment combination for intermediate and high risk nonmuscle invasive bladder cancer. MATERIALS AND METHODS: Between 2009 and 2011, 20 patients with intermediate and high risk nonmuscle invasive bladder cancer were treated with intravesical mitomycin C (40 mg) combined with regional hyperthermia. Treatment consisted of 6 weekly sessions followed by a maintenance period of 1 year with 1 hyperthermia-mitomycin C session every 3 months. Regional hyperthermia was administered using a 70 MHz phased array system with 4 antennas. Toxicity was scored using CTC (Common Toxicity Criteria) 3.0. RESULTS: The records of 18 of 20 patients could be analyzed. Median followup was 46 months. Of the 18 patients 15 (83%) completed the induction period of 6 treatments. Four patients (22%) discontinued treatment because of physical complaints without exceeding grade 2 toxicity. Toxicity scored according to CTC 3.0 was limited to grade 1 in 43% of cases and grade 2 in 14%. Mean T90 and T50 bladder temperatures were 40.6C and 41.6C, respectively. The 24-month recurrence-free survival rate was 78%. CONCLUSIONS: Treatment with regional hyperthermia combined with mitomycin C in patients with intermediate and high risk nonmuscle invasive bladder cancer is feasible with low toxicity and excellent bladder temperatures.
Assuntos
Hipertermia Induzida/métodos , Mitomicina/administração & dosagem , Neoplasias da Bexiga Urinária/terapia , Administração Intravesical , Adulto , Idoso , Idoso de 80 Anos ou mais , Antibióticos Antineoplásicos/administração & dosagem , Terapia Combinada , Progressão da Doença , Relação Dose-Resposta a Droga , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Invasividade Neoplásica , Projetos Piloto , Estudos Retrospectivos , Resultado do Tratamento , Neoplasias da Bexiga Urinária/patologiaRESUMO
BACKGROUND AND PURPOSE: Neoadjuvant chemoradiation (nCRT) followed by surgery is considered curative intent treatment for patients with resectable esophageal cancer. The aim was to establish hemodynamic aspects of changes in heart volume and to explore whether changes in heart volume resulted in clinically relevant changes in the dose distribution of radiotherapy. METHODS: A prospective study was conducted in patients who were treated with nCRT consisting of carboplatin and paclitaxel concomitant with radiotherapy (41.4 Gy/1.8 Gy per fraction). Physical parameters, cardiac volume on CT and Cone beam CT, cardiac blood markers and cardiac ultrasound were obtained. RESULTS: In 23 patients a significant decrease of 55.3 ml in heart volume was detected (95% CI 36.7-73.8 ml, p<0.001). There was a decrease in both systolic (mean decrease 18 mmHg, 95% CI 11-26 mmHg, p<0.001) and diastolic blood pressure (mean decrease 8 mmHg, 95% CI 2-14 mmHg, p=0.008) and an increase in heart rate with 6 beats/min (95% CI 1-11 beats/min, p=0.021). Except for Troponin T, no change in other cardiac markers and echocardiography parameters were observed. The change in heart volume did not result in a clinically relevant change in radiation dose distribution. CONCLUSION: Heart volume was significantly reduced, but was not accompanied by overt cardiac dysfunction. All observed changes in hemodynamic parameters are consistent with volume depletion. Adaptation of the treatment plan during the course of radiotherapy is not advocated.
Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Volume Cardíaco/efeitos da radiação , Quimiorradioterapia Adjuvante/métodos , Neoplasias Esofágicas/terapia , Idoso , Pressão Sanguínea/efeitos dos fármacos , Pressão Sanguínea/efeitos da radiação , Carboplatina/administração & dosagem , Volume Cardíaco/efeitos dos fármacos , Neoplasias Esofágicas/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Terapia Neoadjuvante , Paclitaxel/administração & dosagem , Estudos Prospectivos , Doses de Radiação , Dosagem RadioterapêuticaRESUMO
PURPOSE: Hyperthermia is the clinical application of heat, in which tumor temperatures are raised to 40°C to 45°C. This proven radiation and chemosensitizer significantly improves clinical outcome for several tumor sites. Earlier studies of the use of pre-treatment planning for hyperthermia showed good qualitative but disappointing quantitative reliability. The purpose of this study was to investigate whether hyperthermia treatment planning (HTP) can be used more reliably for online adaptive treatment planning during locoregional hyperthermia treatments. METHODS AND MATERIALS: This study included 78 treatment sessions for 15 patients with non-muscle-invasive bladder cancer. At the start of treatments, temperature rise measurements were performed with 3 different antenna settings optimized for each patient, from which the absorbed power (specific absorption rate [SAR]) was derived. HTP was performed based on a computed tomography (CT) scan in treatment position with the bladder catheter in situ. The SAR along the thermocouple tracks was extracted from the simulated SAR distributions. Correlations between measured and simulated (average) SAR values were determined. To evaluate phase steering, correlations between the changes in simulated and measured SAR values averaged over the thermocouple probe were determined for all 3 combinations of antenna settings. RESULTS: For 42% of the individual treatment sessions, the correlation coefficient between measured and simulated SAR profiles was higher than 0.5, whereas 58% showed a weak correlation (R of <0.5). The overall correlation coefficient between measured and simulated average SAR was weak (R=0.31; P<.001). The measured and simulated changes in average SAR after adapting antenna settings correlated much better (R=0.70; P<.001). The ratio between the measured and simulated quotients of maximum and average SARs was 1.03 ± 0.26 (mean ± SD), indicating that HTP can also correctly predict the relative amplitude of SAR peaks. CONCLUSIONS: HTP can correctly predict SAR changes after adapting antenna settings during hyperthermia treatments. This allows online adaptive treatment planning, assisting the operator in determining antenna settings resulting in increased tumor temperatures.
Assuntos
Hipertermia Induzida/métodos , Terapia Assistida por Computador/métodos , Neoplasias da Bexiga Urinária/terapia , Algoritmos , Antibióticos Antineoplásicos/administração & dosagem , Humanos , Masculino , Mitomicina/administração & dosagem , Radiografia , Estudos Retrospectivos , Neoplasias da Bexiga Urinária/diagnóstico por imagem , Neoplasias da Bexiga Urinária/patologiaRESUMO
OBJECTIVE: To assess clinicians' use of shared decision making (SDM) skills, enabling patient treatment evaluations (appraisals); and varieties of patient appraisals and clinicians' preceding and following utterances. METHODS: Two coders rated videotaped initial visits of 25 early-stage prostate cancer patients to their radiation oncologist. SDM skills were assessed using the Decision Analysis System for Oncology (DAS-O); appraisals and clinicians' utterances were labeled using qualitative methodology. RESULTS: Clinicians offered a treatment choice to 10 patients. They informed 15/25 about pros and 20/25 about cons of options. Patients expressed 67 appraisals (median/visit=2; range, 0-12). Half of appraisals were favorable and one-fourth was unfavorable toward treatment options. One-fifth referred to explicit tradeoffs. One-third of appraisals followed clinician requests; 58% followed clinician information. Clinicians approved almost half of appraisals. They contested, ignored or highlighted a minority. CONCLUSION: Clinicians infrequently offered patients a choice or explored appraisals. Most appraisals supported rather than challenged treatment options. Clinicians most often legitimized appraisals, thereby helping patients to feel good about the decision. Exploring appraisals may help patients in forming more stable preferences, thus benefiting patients in the long run. PRACTICE IMPLICATION: Clinicians should request patient appraisals and ascertain whether these seem well-informed before making treatment recommendations.
Assuntos
Tomada de Decisões , Participação do Paciente , Relações Médico-Paciente , Neoplasias da Próstata/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Atitude do Pessoal de Saúde , Técnicas de Apoio para a Decisão , Humanos , Masculino , Oncologia , Pessoa de Meia-Idade , Avaliação de Processos e Resultados em Cuidados de Saúde , Satisfação do Paciente , Pesquisa Qualitativa , Inquéritos e Questionários , Gravação em FitaRESUMO
PURPOSE: To evaluate treatment outcome of pulsed dose-rate brachytherapy (PDR) combined with external-beam radiotherapy (EBRT) for the treatment of prostate cancer. METHODS AND MATERIALS: Between 2002 and 2007, 106 patients were treated by EBRT combined with PDR and followed prospectively. Two, 38, and 66 patients were classified as low-, intermediate-, and high-risk disease respectively according to the National Comprehensive Cancer Network criteria. EBRT dose was 46 Gy in 2.0-Gy fractions. PDR dose was increased stepwise from 24.96 to 28.80 Gy. Biochemical disease free survival and overall survival were determined by the Kaplan-Meier method. Cumulative incidence of late gastrointestinal (GI) and genitourinary (GU) toxicity were scored, according to the Common Terminology Criteria for Adverse Events. RESULTS: The 3- and 5-year biochemical nonevidence of disease (bNED) were 92.8% (95% confidence interval [CI], 87.1-98.5) and 89.5% (95% CI, 85.2-93.8), respectively. Overall survival at 3 and 5 years was 99% (95% CI, 96-100) and 96% (95% CI, 90-100), respectively. The 3- and 5-year Grade 2 GI toxicity was 5.3% (95% CI, 0-10.6) and 12.0% (95% CI, 1.4-22.6), respectively. No Grade 3 or higher GI toxicity was observed. The 3- and 5-year Grade 2 or higher GU toxicity was 18.7% (95% CI, 10.3-27.1) and 26.9% (95% CI, 15.1-38.7), respectively. CONCLUSION: Results on tumor control and late toxicity of EBRT combined with PDR are good and comparable to results obtained with EBRT combined with high-dose-rate brachytherapy for the treatment of prostate cancer.
Assuntos
Braquiterapia/métodos , Neoplasias da Próstata/radioterapia , Idoso , Intervalo Livre de Doença , Trato Gastrointestinal/efeitos da radiação , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Neoplasias da Próstata/classificação , Neoplasias da Próstata/mortalidade , Neoplasias da Próstata/patologia , Radioterapia/métodos , Risco , Resultado do Tratamento , Sistema Urogenital/efeitos da radiaçãoRESUMO
PURPOSE: To investigate the development of gastrointestinal (GI) toxicity, genitourinary (GU) toxicity, erectile dysfunction, and International Prostate Symptom Score (IPSS) resolution in a cohort of patients treated with external-beam radiotherapy (EBRT) followed by a brachytherapy pulsed dose rate (PDR) boost. METHODS AND MATERIALS: Between 2002 and 2008, 110 patients were treated with 46-Gy EBRT followed by PDR brachytherapy (24.96-28.80 Gy). The investigated outcome variables, GI toxicity, GU toxicity, erectile dysfunction, and IPSS were prospectively scored at several time points during follow-up. Association between time (as continuous and categorical variable) and the outcome variables was assessed using generalized linear models. RESULTS: No statistically significant association was found between time (continuous) and GI toxicity (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.89-1.06), GU toxicity (OR, 0.97; 95% CI, 0.91-1.03), erectile dysfunction (OR, 1.06; 95% CI, 0.99-1.11), and IPSS (-0.11; 95% CI, -0.41-0.20). Also, no statistically significant association was found between these variables and time as a categorical variable. GU toxicity was associated with IPSS resolution (OR, 1.16; 95% CI, 1.09-1.24). Posttreatment IPSS was associated with pretreatment IPSS (0.52; 95% CI, 0.25-0.79). CONCLUSIONS: No accumulation of high-grade toxicity over time could be established for a group of patients treated with EBRT and PDR brachytherapy for prostate cancer, probably because high-grade late toxicity resolves with time. Also, differences in IPSS values among patients are smaller after treatment than before treatment.
Assuntos
Disfunção Erétil/etiologia , Trato Gastrointestinal/efeitos da radiação , Neoplasias da Próstata/radioterapia , Sistema Urogenital/efeitos da radiação , Idoso , Braquiterapia/efeitos adversos , Braquiterapia/métodos , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Dosagem Radioterapêutica , Fatores de TempoRESUMO
PURPOSE: To analyse the therapeutic effect and toxicity of re-irradiation (re-RT) combined with hyperthermia (HT) following resection or clinically complete remission (CR) of persistent locoregional recurrent breast cancer in previously irradiated area. METHODS AND MATERIALS: Between 1988 and 2001, 78 patients with high risk recurrent breast cancer underwent elective re-RT and HT. All patients received extensive previous treatments, including surgery and high-dose irradiation (> or =50Gy). Most had received one or more lines of systemic therapy; 44% had been treated for > or = one previous locoregional recurrences. At start of re-RT + HT there was no macroscopically detectable tumour following surgery (96%) or chemotherapy (CT). Re-RT typically consisted of eight fractions of 4Gy, given twice weekly. Hyperthermia was added once a week. RESULTS: After a median follow up of 64.2 months, three-year survival was 66%. Three- and five-year local control rates were 78% and 65%. Acute grade 3 toxicity occurred in 32% of patients. The risk of late > or = grade 3 toxicity was 40% after three years. Time interval to the current recurrence was found to be most predictive for local control in univariate and multivariate analysis. The extensiveness of current surgery was the most relevant treatment related factor associated with toxicity. CONCLUSIONS: For patients experiencing local recurrence in a previously radiated area, re-irradiation plus hyperthermia following minimisation of tumour burden leads to a high rate of local control, albeit with significant toxicity. The latter might be reduced by a more fractionated re-RT schedule.