Clinical outcome of postoperative radiotherapy with or without chemotherapy in adult glioblastoma multiforme in Ramathibodi Hospital: a retrospective study.

OBJECTIVE: To identify the treatment outcome of glioblastoma multiforme (GBM) in Ramathibodi Hospital from overall survival rate and related prognostic factors. MATERIAL AND METHOD: Medical records of patients with histological diagnosis of GBM treated at Radiation Oncology Division, Radiology Department, Ramathibodi Hospital between 2000 and 2010 were reviewed and available data extracted for evaluation of treatment outcome. RESULTS: There were 47 patients with mean age at diagnosis of 51.9 years (range from 18 to 82 years). Surgery (partial 76.6%, total 12.8%, and biopsy 10.6%) followed by postoperative radiotherapy (mean dose 52 gray) was the treatment of choice with or without concurrent and adjuvant Temozolomide (TMZ). With median follow-up time of 0.9 years, the median survival of the patients was 2.1 years (95% CI 1.08-7.36), whereas one and two-year overall survival rates were 78.0% and 57.8%, respectively. In univariate analysis, persistent neurological deficit after surgery and presenting symptom of visual disturbance were identified to lower overall survival while multivariate analysis, younger age, and higher radiation dose were identified as favorable prognostic factors to improve overall survival. Re-surgery or re-irradiation in some selected cases of recurrent or progressive disease was considered as a choice for palliative treatment. CONCLUSION: Proper management of GBM patient was surgical removal and postoperative radiotherapy with or without chemotherapy. Proper palliative treatment modality was considered in selected cases of recurrent or progressive disease.

Linac-based stereotactic radiosurgery and fractionated stereotactic radiotherapy for vestibular schwannomas: comparative observations of 139 patients treated at a single institution.

Stereotactic radiosurgery (SRS) and fractionated stereotactic radiotherapy (SRT) have been recognized as an alternative to surgery for small to medium sized vestibular schwannoma (VS). This study analysed and compared the outcomes of VS treated with the first Thailand installation of a dedicated Linac-based stereotactic radiation machine using single-fraction radiosurgery (SRS), hypofraction stereotactic radiotherapy (HSRT) and conventional fraction stereotactic radiotherapy (CSRT). From 1997 to 2010, a total of 139 consecutive patients with 146 lesions of VS were treated with X-Knife at Ramathibodi hospital, Bangkok, Thailand. SRS was selected for 39 lesions (in patients with small tumors ≤3 cm and non-serviceable hearing function), whereas HSRT (79 lesions) and CSRT (28 lesions) were given for the remaining lesions that were not suitable for SRS. With a median follow-up time of 61 months (range, 12-143), the 5-year local control rate was 95, 100 and 95% in the SRS, HSRT and CSRT groups, respectively. Hearing preservation was observed after SRS in 75%, after HSRT in 87% and after CSRT in 63% of the patients. Cranial nerve complications were low in all groups. There were no statistically significant differences in local control, hearing preservation or complication between the treatment schedules. In view of our results, it may be preferable to use HSRT over CSRT for patients with serviceable hearing because of the shorter duration of treatment.

Preliminary experience of CyberKnife treatment of lung metastasis: the question about real clinical benefit.

OBJECTIVE: Evaluate the effectiveness of radiotherapy plan and physical parameters including local tumor response and clinical outcome of lung metastasis in patients who received CyberKnife treatment at Ramathibodi Hospital. MATERIAL AND METHOD: Six cases with twenty lesions of lung metastasis patients were evaluated for tumor response after having received CyberKnife treatment. The prescribed radiation dose was calculated approximately to biological equivalent dose (BED) around 60 to 100 gray (Gyz). The response of each lesion to treatment was evaluated from roentgenographic study during follow-up period along with adverse event, status of patients, and disease. RESULTS: At the third month after treatment, roentgenographic partial response (PR, 50% decrease in size) was demonstrated in eight lesions and stable disease (SD, unchanged size) in eight lesions with no complete response (CR, disappearance of tumor) detected. Progressive disease (PD, 25% increase in size) of six treated lesions was detected during the follow-up period. At the time of report, two patients were alive and still received palliative chemotherapy, two patients died from uncontrolled progressive metastases and failed palliative chemotherapy, and two patients lost follow-up after progressive metastases with unknown surviving status. No severe adverse event was observed. The treatment planning parameters demonstrated borderline of radiation dose homogeneity, and conformality coverage of the target volume. CONCLUSION: This preliminary report aimed to provide the idea of choosing the appropriate lung metastasis patient to receive CyberKnife treatment that must strictly clarify the real clinical benefit of each selected case to achieve the best outcome from this special treatment procedure.

The clinical results of pediatric brain tumors treated with Linac-based stereotactic radiosurgery and radiotherapy.

OBJECTIVE: Stereotactic radiosurgery (SRS) and fractionated stereotactic radiotherapy (FSRT) for brain tumor is increasingly acceptable worldwide. In Thailand, the first Linac-based stereotactic radiation machine was implemented at the Radiosurgery Center, Ramathibodi Hospital since 1997. This is the first study in Thailand to report the results of pediatric brain tumor patients treated with SRS and FSRT MATERIAL AND METHOD: The clinical outcome of 39 pediatric patients treated with SRS/FSRT between 1998 and 2010 was retrospectively reviewed. RESULTS: The median follow-up time was 26 months (range, 1 to 154 months). The local progression free survival (LPFS) at one and five years after SRS/FSRT for all patients was 87.5% and 54.2%, respectively. The 5-year LPFS by tumor histology was as follow, pituitary adenoma 100%, meningioma 100%, ependymoma, and low-grade astrocytoma 75%, and craniopharyngioma 68.6%. High-grade tumor had the worst LPFS and the median LPFS of this group was only 12 months. On univariate analysis, low-grade tumor (pituitary adenoma and menigioma) and small tumor volume (< 10 ml) were the factors that correlated significantly with good local control. After multivariate analysis, small tumor volume was the only factor associated with good LPFS (HR = 2.35, p = 0.042). No other radiation complication except panhypopituitarism was reported. CONCLUSION: SRS/FSRT in pediatric brain tumor is technically feasible, with minimal acute side effects. SRS/FSRT plays an important role for the small low-grade tumor

Preliminary experience of CyberKnife treatment of primary non-small cell lung cancer.

OBJECTIVE: Provide the effectiveness of treatment protocol, radiotherapy plan, technique, and early clinical results of inoperable primary non-small cell lung cancer (NSCLC) in patients who received CyberKnife treatment at Ramathibodi Hospital. MATERIAL AND METHOD: Six cases of inoperable primary NSCLC patients were evaluated for tumor response after having received CyberKnife treatment. The prescribed radiation dose was 45 gray (Gy) in three consecutive fractions for peripherally located tumor and 50 Gy in five fractions within two weeks for centrally located tumor (biological equivalent dose, BED, 112.5 Gy 10, and 100 Gy 10, respectively). The response to treatment was evaluated from roentgenographic study during follow-up period along with clinical outcome and adverse event. RESULTS: Overall response after the treatment was demonstrated in five cases with roentgenographic complete response (CR, disappearance of tumor) and partial response (PR, 50% decrease in size) in two and three cases, respectively without any severe adverse event. The treatment planning parameters demonstrated the effectiveness of radiation dose homogeneity and conformity coverage of the target volume. CONCLUSION: This preliminary report has provided the effectiveness of treatment plan and local tumor controlled without severe adverse event for primary inoperable NSCLC patients receiving CyberKnife treatment.

Expression of hormonal receptor in patients with metastasizing pleomorphic adenoma of the major salivary gland; a clinicopathological report of three cases.

BACKGROUND: Metastasizing pleomorphic adenoma is an uncommon malignant tumor of the salivary gland demonstrating benign epithelial and modified myoepithelial elements intermingling with tissue of mucoid, myxoid, or chondroid appearance that inexplicably manifests local or distant metastasis. OBJECTIVE: To determine the expression of hormonal receptor in the patients with metastasizing pleomorphic adenoma of the major salivary gland. MATERIAL AND METHOD: Medical records, clinical and pathologic findings of three patients who were diagnosed as metastasizing pleomorphic adenoma were reviewed. The immunohistochemical stains for estrogen receptor, progesterone receptor, and Ki-67 were performed. RESULTS: Three cases of metastasizing pleomorphic adenoma, clinically presenting as painless, gradually enlarged cervical lymph nodes were reported. The pathologic examinations of the cervical lymph nodes are morphologically and immunohistologically identical to the sialoadenectomy specimen. Immunohistochemical stains show positive reactivity to progesterone receptor but negative reactivity to estrogen receptor in both mesenchymal and epithelial components of pleomorphic adenoma. CONCLUSION: These are the first reported cases of metastasizing pleomorphic adenoma of the major salivary glands associated with expression of progesterone receptor in both specimens of sialoadenectomy and lymph node biopsy. This finding supports the pathogenesis of benign metastasis of tumor. However, the role of hormonal receptor in the pathogenesis and treatment of salivary metastasizing pleomorphic adenoma should be further investigated.

Relief of radiation-induced oral mucositis in head and neck cancer.

This study was a prospective, randomized clinical trial carried out to explore the efficacy of payayor in the prevention and relief of radiation-induced oral mucositis compared with benzydamine. Sixty patients with head and neck cancer, who have started to receive radiotherapy and met predetermined criteria, were randomly assigned into each group to use assigned products 3 times a day from the first to the last day of radiation. The first group used glycerin payayor, a Thai prepared herbal product, by dripping it into the mouth. Another group rinsed their mouths with benzydamine hydrochloride. The World Health Organization Mucositis Grading System was used to assess oral status every week and 2 weeks after radiation. Comparison of time to the onset, pain, severity, xerostomia, postponement of treatment, satisfaction of the solution, and body weight between the 2 groups was performed by t test. The average time to the onset of oral mucositis in the payayor group was significantly later, and its severity and pain score were less than those of the benzydamine group throughout the study period. Significantly higher satisfaction with the solution and higher body weight at the end of the study were shown in the payayor group. Payayor seemed to be superior to benzydamine for preventing and relieving radiation-induced oral mucositis.

Association between multidrug resistance-associated protein 1 and poor prognosis in patients with nasopharyngeal carcinoma treated with radiotherapy and concurrent chemotherapy.

ATP-binding cassette (ABC) multidrug transporters have been associated with chemoresistance, which is a major obstacle in attempts to improve clinical outcome of patients with nasopharyngeal carcinoma (NPC). In this study, we investigated 3 ABC multidrug transporters including MDR1, MRP1, and BCRP for their potential as prognostic indicators in patients with NPC. We examined the protein expression profiles of MDR1, MRP1, and BCRP in NPC tissues from 60 patients with advanced stages who were treated with radiotherapy and concurrent chemotherapy. The clinicopathologic features, patterns of treatment failure, and survival data were compared with the transporter expression. Univariate analyses were performed to determine the prognostic factors that influenced treatment failure and patient survival. We found that MRP1 expression was strongly predictive of both 5-year survival (P = .025) and disease-free survival (P < .001). However, neither MDR1 nor BCRP expression was correlated with the clinicopathologic parameters. Interestingly, the incidence of recurrence and metastasis for patients in the MRP1-positive group was significantly higher than that in the MRP1-negative group (P = .003). With multivariate analysis, MRP1 expression at the time of diagnosis before the treatment was identified as an independent prognostic factor for both 5-year survival (P = .041) and disease-free survival (P = .001). MRP1 expression can therefore be used as a potent molecular risk factor and a guide for chemotherapeutic regimens in patients with advanced stages of NPC.

Fractionated stereotactic radiotherapy in residual or recurrent nasopharyngeal carcinoma.

The aim of this study was to evaluate results of fractionated stereotactic radiotherapy (FSRT) in patients with residual or recurrent nasopharyngeal carcinoma (NPC) in terms of local progression-free (LPFS) and overall survival (OS) rate and complications after treatment. There were 32 residual or recurrent NPC patients treated with FSRT using linac-based radiosurgery system. Time from the previous radiotherapy to FSRT was 1-165 months (median, 15). Two patients were treated for the second and one for the third recurrence. Thirteen patients (40.6%) also received chemotherapy with FSRT. Tumor volume ranged from 6.2-215 cc (median, 44.4). Average FSRT dose was 17-59.4 Gy (median, 34.6) in 4-25 fractions (median,6) in 1-5.5 weeks (median, 3). Median follow-up time was 25.5(3-67) months. LPFS rate at 1 and 3 years after FSRT was 67.8% and 37.9%. OS rate at 1 and 3 years was 89.7% and 71.2%. If all patients who had tumor progression with no further follow-up were assumed dead, the OS rate at 1 and 3 years would be 75.0% and 37.9%. Univariate analysis showed better local tumor control in patients with tumor volume

Postoperative radiotherapy with high dose rate iridium 192 mould for prevention of earlobe keloids.

BACKGROUND: A 50% to 80% recurrence rate of earlobe keloids can occur following a simple excision. Many modalities, including radiotherapy, have been suggested to reduce the postoperation recurrence. OBJECTIVE: The aim of the present study was to determine the efficacy of postoperative radiotherapy by a high dose rate Iridium 192 mould in the prevention of earlobe keloids recurrence. MATERIAL AND METHOD: Between March 1999 and March 2003, 22 patients with 24 earlobe keloids were treated by radiotherapy immediately following surgical excision. A dose of 15 Gray in 3 fractions was delivered at a point placed 5 mm from the axis of the Iridium sources. RESULTS: From the 22 patients with 24 keloids who were treated, 15 patients with 16 keloids were followed for a minimum of 6 months. Recurrence occurred in two keloids (12.5%). There were no severe adverse effects. CONCLUSION: Postoperative radiotherapy by high dose rate Iridium 192 mould was an effective prevention of earlobe keloids recurrence. It was well tolerated and did not present any significant side effects.

High-dose-rate interstitial brachytherapy in the management of carcinoma of the uterine cervix and other gynecologic malignancies.

OBJECTIVE: To report technique and experience of high-dose-rate (HDR) interstitial brachytherapy in the treatment of cervical carcinoma and other gynecologic malignancies. MATERIAL AND METHOD: Between April 2003 and October 2004, ten patients (7-cervical carcinoma, 3-vaginal stump carcinoma) were treated with interstitial implant. Indications for implant include previous hysterectomy and previous pelvic radiation. Patient characteristics, implant technique, and initial outcomes were reported. RESULTS: Transperineal interstitial implant was performed using fluoroscopy-guided technique. Brachytherapy dose/fraction ranged from 500-750 cGy for 1 to 6 fractions. Combined external beam radiation was given in 8 patients. After 5-21 months follow-up, all the patients were alive. Local control was achieved in 9 patients. One patient had persistent disease at the implant site. No acute complication from the procedure or serious late complication was observed. CONCLUSION: Interstitial implant can be a treatment option in patients with gynecologic malignancies who have limitations with standard intracavitary insertion. This technique is feasible, providing good local control without serious complications. However, long-term follow-up is needed.

Acute effects of postmastectomy radiotherapy after immediate TRAM flap reconstruction in breast cancer patients.

OBJECTIVES: To study the acute effects of radiotherapy after mastectomy and immediate transverse rectus abdominis myocutaneous (TRAM) flap reconstruction in breast cancer patients treated at Ramathibodi Hospital. MATERIAL AND METHOD: Between January 2004 and March 2005, ten breast cancer patients (age 32-51 years) were treated with postoperative radiotherapy after mastectomy and immediate TRAM flap reconstruction. Medical records of these patients were retrospectively reviewed. Radiotherapy was delivered to the chest wall and reconstructed TRAM flap using 6-MV x-ray or Cobalt-60. The total dose was 45 to 50.4 Gy delivered in 25 to 28 fractions. Patients were evaluated weekly during the course of radiation and then at 1 and 2 months after treatment completion to determine acute effects or toxicities of radiation. RESULTS: During radiation, 3 patients developed erythema or mild hyperpigmentation of the skin, and 4 developed moderate hyperpigmentation. Three patients who were treated with Cobalt-60 and/or bolus to the chest wall developed skin desquamation (1 dry desquamation, 2 moist desquamation). No patient required a treatment break because of acute side effects. One patient who received chemotherapy after radiation developed recalled moist desquamation. CONCLUSION: Radiotherapy after mastectomy and immediate TRAM flap reconstruction is well tolerated and is not associated with increased acute complication or radiation interruption. The authors have noticed that chemotherapy given after radiation was related to severe skin reaction, so it should be used with caution.

Reduced recurrence of late hemorrhagic radiation cystitis by WF10 therapy in cervical cancer patients: a multicenter, randomized, two-arm, open-label trial.

BACKGROUND AND PURPOSE: To evaluate the efficacy and the safety of WF10 as adjunct to standard treatment in the management of late hemorrhagic radiation cystitis compared to standard treatment alone. PATIENTS AND METHODS: Cervical cancer patients with Grade 2 or 3 late hemorrhagic radiation cystitis, were randomized and treated with WF10 0.5 ml/kg body weight, diluted in physiological saline or 5% dextrose water 250 ml, intravenous infusions over 2 h on 5 consecutive days, every 3 weeks for 2 cycles plus standard treatment (WF10 group) or standard treatment alone (control group). Fifty patients in each group were evaluated by questioning; urinalysis and cystoscopy during a 1 year follow up. RESULTS: At week 7, 37 patients (74%) in the WF10 group and 32 patients (64%) in the control group showed complete resolution in objective hematuria (P = 0.28). Significantly lower use of antibiotics (P = 0.002) and antispasmodics (P < 0.001) was found in the WF10 group. Among the responders, 24 patients (77%) in the control group experienced recurrent objective hematuria, whereas in the WF10 group only 17 patients (47%) experienced a recurrence (P = 0.01). Recurrence of objective hematuria occurred significantly faster in the control group as evidenced by Kaplan-Meier and log-rank statistics (P = 0.004), suggesting a long-term effect of WF10. Cystoscopy, at the end of the treatment period and after the one year follow up showed overall improvement without significant difference between two groups. No severe toxicity was monitored. CONCLUSIONS: WF10 therapy is a safe, non-invasive and convenient method in the management of late hemorrhagic radiation cystitis. WF10 therapy, as adjunct to standard treatment, has significantly reduced recurrence of objective hematuria, compared to standard treatment alone, during a one year follow up.