Successful Treatment of Adenoid Cystic Carcinoma with the Application of a High-Dose Stereotactic Body Radiotherapy Boost.

BACKGROUND: Adenoid cystic carcinoma (ACC) should be treated with a surgical procedure. Unfortunately, in some cases, such procedures are impossible to perform. In that event, radiotherapy can be used as a form of radical treatment, although ACC is established as a radio- and chemoresistant tumour. Therefore, unconventional fractionated radiotherapy needs to be considered. CASE PRESENTATION: Here, we present a case study of a patient with an unresectable tumour of the choanae and nasopharynx treated with a stereotactic radiotherapy boost in combination with conventional radiotherapy. We achieved complete clinical regression after application of a 1 × 18 Gy boost followed by conventional radiotherapy at 50 Gy in 25 fractions. The early and late tolerance of this treatment were positive. During the 2-year follow-up, local and distant recurrence were not detected. CONCLUSIONS: This case represents an individualized, modern and safe approach to unresectable ACC. This is one of the first cases to show the use of a combination of stereotactic and conventional radiotherapy in radical, conservative cancer treatment.

Radiation-free weekend rescued! Continuous accelerated irradiation of 7-days per week is equal to accelerated fractionation with concomitant boost of 7 fractions in 5-days per week: report on phase 3 clinical trial in head-and-neck cancer patients.

PURPOSE: To report long-term results of randomized trial comparing 2 accelerated fractionations of definitive radiation therapy assessing the need to irradiate during weekend in patients with head and neck squamous cell carcinoma. METHODS AND MATERIALS: A total of 345 patients with SCC of the oral cavity, larynx, and oro- or hypo-pharynx, stage T2-4N0-1M0, were randomized to receive continuous accelerated irradiation (CAIR: once per day, 7 days per week) or concomitant accelerated boost (CB: once per day, 3 days per week, and twice per day, 2 days per week). Total dose ranged from 66.6-72 Gy, dose per fraction was 1.8 Gy, number of fractions ranged from 37-40 fractions, and overall treatment time ranged from 37-40 days. RESULTS: No differences for all trial end-points were noted. At 5 and 10 years, the actuarial rates of local-regional control were 63% and 60% for CAIR vs 65% and 60% for CB, and the corresponding overall survival were 40% and 25% vs 44% and 25%, respectively. Confluent mucositis was the main acute toxicity, with an incidence of 89% in CAIR and 86% in CB patients. The 5-year rate of grade 3-4 late radiation morbidity was 6% for both regimens. CONCLUSIONS: Results of this trial indicate that the effects of accelerated fractionation can be achieve by delivering twice-per-day irradiation on weekday(s). This trial has also confirmed that an accelerated, 6-weeks schedule is a reasonable option for patients with intermediate-stage head-and-neck squamous cell carcinoma because of the associated high cure rate and minimal severe late toxicity.

Surgical treatment of dysplasia fibrosa and defectus fibrosus with bone allografts.

BACKGROUND: A common feature of dysplasia fibrosa and defectus fibrosus is the development of foci of disordered fibrous tissue in bone that tend to grow and displace regular bone tissue. The objective of this study was to evaluate the efficacy of surgical treatment with bone allografts in patients with fibrous dysplasia and fibrous defect of bone. MATERIAL AND METHODS: The study group consisted of 99 patients aged from 9 to 58 years (mean age 22 years), including 56 men and 43 women. A total of 145 surgical procedures were performed in this group at the Bone Tumour and Neoplasm Unit between 1999 and 2005. In all cases histopathological verification confirmed fibrous dysplasia or fibrous defect of bone. The follow-up period was from 1 to 5 years (mean 2.5 years). RESULTS: In 85 patients there were no recurrences. A total of 96 surgical procedures were performed in this group. The other 14 patients experienced recurrences and no graft remodelling. Forty-nine surgical procedures were performed in this group because of multiple (from 2 to 6) relapses of the tumours. CONCLUSIONS: 1. Resection surgery and filling the defect with bone graft in the basic tyep of treatment in fibrous dysplasia and bibrous defect of bone and leads to good outcomes. 2. Frozen cortico-cancelleous allografts are well incorporated and bone remodeling is not assocaited with inflammatory complications, resulting into good outcomes of the operative treatment.

Treatment and differential diagnosis of aneurysmal bone cyst based on our own experience.

BACKGROUND: Aneurysmal bone cyst was first described by Jaffe and Lichtenstein in 1942. Schajowicz in 1972 in his Histopathological Classification of Primary Bone Tumors (later modified by WHO in 1993) placed it in group IX - tumor-like lesions. Its etiology and pathogenesis is not completely clear. Aneurysmal bone cysts are usually found in older children and young adults, rarely before the age of 5 or after 30. The aim of the study is to evaluate aneurysmal cyst treatment outcomes in patients we have treated and present diagnostic difficulties, especially considering the giant cell tumor in differential diagnosis. MATERIAL AND METHODS: The study group consisted of 40 patients aged from 10 to 65 years (mean age 22 years), including 21 men and 19 women, who underwent surgery at the Bone Tumor and Neoplasm Unit between 1999 and 2006. The follow-up period varied from 2 to 78 months (mean 23 months). RESULTS: A single surgical procedure was performed in 25 patients. No recurrences were noted in this group. In the remaining 15 cases, the tumor relapsed between 2 and 72 months after surgery (mean 17 months). In 12 patients, the histopathological examination was inconclusive. The giant cell tumor of bone was considered as a second diagnosis in all these cases. CONCLUSIONS: 1. Surgical treatment of aneurysmal bone cysts enables radical excision of the lesion with same-time histopathological verification. 2. The basis of effective treatment of primary and recurring aneurysmal bone cysts consists in complete resection of all tissues lining the cyst and any of its components from the surrounding soft tissues. 3. An effective plan of surgical treatment of aneurysmal bone cyst aimed at reducing the risk of tumor recurrence relies crucially on precise determination of its size, characteristics and topography via imaging workup. 4. Relapses are most common in patients suffering from the aggressive or active form of aneurysmal bone cyst. 5. Tumor location in direct proximity of a joint and the presence of epiphyseal cartilage hinders complete resection of the lesion and gives rise to technical problems during surgery. 6. The diagnosis of aneurysmal bone cyst most often leads physicians to assume the presence of giant cell tumor. If this diagnosis is confirmed following surgery, the patient should be subjected to additional radiotherapy. 7. Patients suffering from aneurysmal bone cyst require a ling follow-up due to the possibility of late recurrence of the tumor.

Pattern analysis of acute mucosal reactions in patients with head and neck cancer treated with conventional and accelerated irradiation.

PURPOSE: To evaluate severity of acute mucosal reactions (AMR) caused by conventional (CF) and accelerated fractionation (AF) regimens using a modified Dische system and to analyze differences in incidence and severity of AMR according to frequency and regularity of scoring. METHODS AND MATERIALS: Sixty-six consecutive patients (33 CF, 33 AF) with head and neck cancer irradiated with 5 fractions in 5 days per week (CF) or with 7 fractions in 7 days (AF) to a total dose of 70 Gy. A modified Dische system was used for daily quantitation of AMR during radiotherapy until complete healing. RESULTS: Confluent mucositis (CM) was noted in 79% of patients in the CF group and 85% in the AF group. In 24% of the CF group and 18% of the AF group the CM presented a wave-like pattern. In 55% of CF and 67% of AF a classic triphasic pattern was noted. In 12 patients acute reactions did not transgress the level of spotted mucositis. The present study clearly shows that quantitation of the incidence and severity of acute mucosal effects strongly depends on frequent and regular scoring. A significant difference in the incidence of CM between the CF and AF groups was noted, mainly in weeks 4-6 of irradiation. When once-weekly irregular instead of daily scoring was evaluated, the incidence of CM was underestimated by approximately 20-36%. CONCLUSIONS: Acute mucosal reactions occur as a complex of morphologic and functional disorders with individual intensity, even among patients treated with the same fractionation regimen. In some cases they present a "wave-like" pattern during irradiation. Therefore, precise quantitation of acute effects requires regular and frequent scoring.

[Efficacy of primary and combined radiotherapy in locally advanced cancer of oropharynx and nasopharynx in III and IV stage]. / Ocena skutecznosci radioterapii i leczenia skojarzonego u chorych na raka czesci nosowej i ustnej gardla w stopniu III i IV klinicznego zaawansowania.

Aim of the study is evaluation of radiotherapy treatment in cancer of oropharynx and nasopharynx. Retrospective analysis was based on 283 patients in III and IV clinical stage of disease without distant metastases who were treated between 1989-2001. 201 patients were treated radiotherapy alone and 82 by combined modality: radiotherapy and chemotherapy. Induction chemotherapy and radiotherapy was used in 34 cases, concomitant chemoradiotherapy--25 and adjuvant chemotherapy and radiotherapy in 23 cases. Following methods of radiotherapy fractionation were used: accelerated in 35 cases, conventional--26, hyperfractionation--21. Accelerated treatment mainly was used in concomitant combined modality. Log-rank statistical analysis revealed better results of treatment for combined modality: radiotherapy and chemotherapy. Most effectiveness method of combined modality was concomitant radiochemotherapy. Locoregional control in 3 years observation interval was better for concomitant mode about 18% comparing to induction chemotherapy and radiotherapy and 30% to adjuvant chemotherapy and radiotherapy. Based on this data, the optimal mode of treatment in III and IV stage of oropharyngeal and nasopharyngeal cancer, especially with extensive nodal disease and extranodal involvement is concomitant treatment with accelerated fractionation dose of radiotherapy.

Evaluation of methods of bone defect reconstruction after iliac tumor resections.

Background. The goal of this article is to assess the treatment efficacy of partial shoulder arthroplasty after massive proximal humerus resection following pathological fracture or primary tumor, based on the authors' own clinical material. Material and methods. We analyzed 42 cases operated between 1997 and 2005, including 11 patients with primary tumors and 31 with pathological fracture or metastatic disease. A resection ranging from 6 to 12 cm was performed due to the presence of tumor and present or imminent pathological fracture. Partial shoulder arthroplasty was performed subsequently to bone resection. The follow-up time ranged from 2 months to 7 years. Outcome was assessed by X-ray imaging, clinical examination, and the Enneking functional scale. Results. Excellent and very good outcome were obtained in 37 cases, while in 2 cases the outcome was poor. 3 patients died within 7 days after surgery. Infectious complications occurred in 2 patients but resolved after conservative therapy. More than 90% of the patients expressed a positive subjective opinion. Conclusions. Partial shoulder replacement after massive proximal humerus resection was subjectively very acceptable for the operated patients. This high rate of good and excellent outcomes in clinical tests and imaging procedures confirms the usefulness of this method, and makes this kind of treatment a valuable alternative for both the patient and the orthopedic surgeon. Complications, whether early (death) or late (tumor recurrence) result from the normal biology of the tumor.

Treatment methods for neoplastic metastates and tumor-like changes in the bodies and epiphyses of long bones using polymethyl methacrylate cement and bone grafting.

Background. The objective of our study was to evaluate the stabilization of reconstructed long bones after metastatic tumor resection and defect filling with polymethyl methacrylate (PMMA) or bone allograft. Material and methods. We studied a group of 107 patients who underwent surgery between 1996 and 2004 (55 females and 46 males). A primary neoplasmatic focus was found after histopathological examination in 58 cases, in 29 the histopathology was not evident, and in 20 cases no neoplastic tissue was found. Metastases were found within the femur in 73 cases, in the humerus in 19 cases, and in the tibia in 15 cases. Stabilization was performed using the traditional AO method, intramedullary nailing, or DHS/DCS fixation. Results. Taking into consideration clinical and radiological assessment, outcomes varied from fair to good. Better outcome was obtained in cases treated by polymethyl methacrylate (PMMA) filling combined with intramedullary nailing or DCS/DHS than in cases treated with traditional AO plating. For tumor-like lesions, complete bone graft consolidation was found after bone allograft filling in 14 of 20 cases. Conclusions. The 2 methods of long bone stabilization mentioned above, combined with polymethyl methacrylate (PMMA) or bone allograft filling, is the method of choice. Deep frozen bone grafting is possible only in cases of total tumor resection with the possibility of non-malignant tumor. The effect of reconstruction, besides fair or good outcome, included improved quality of life, less consumption of analgesics, and in many cases successful avoidance of pathological fracture.

The own experience in femoral bone metastases treatment.

Background. The objective of this paper is an efficacy analysis of surgical treatment of femoral bone cancer metasases depending on surgical technique and tumor localisation.
Material and methods. 144 patients who underwent surgery in 1996-2002 were assesed. In 32 patients with proximal femur matastases tumor resection and angled plate stabilisation was made, 68 patients underwent THR.
In 20 patients with tumor situated in femoral shaft an intramedullary nailing was performed and the rest 14 patients were treated with plate (AO/ASIF) technique. In 10 patients with distal femoral metastases an angled condylar plate was used.The average follow-up time was 6 months.
Results. The surgery outcome was assesed by functional Enneking test. The cases with proximal femur metastases were assesed by Merle d'Aubigne classification. In cases after resection and subsequent THR very good results were found in 5 patients,good in 34, fair in 23 and bad in 6 patients according to Enneking scale. In Merle d'Aubigne classification the results were as follows:very good in 6, good in 30, fair in 26 and bad in 6 patients.
In the intramedullary nailing group the limb function was found good in 17, in 1 fair and bad in 2 patients. The limb function in patients who were operated using plate condylar or stright(AO/ASIF) plate technique was found fair.
Conclusions. The high patients satisfaction and high ratio of good and very good results in tests after modular THR(proximal femur metastases)and after intramedullary nailing(femoral shaft pathology)are methods of choice in those cases. AO plate stabilisation combined with bone cement augmentation is suitable for pathological fractures management.

The efficacy analysis of partial bone resection procedure in pathological fractures treatment (own experience).

Background. The objective of this paper is efficacy assesment of partial bone resection procedure with subsequent joint exchange as a method of skeletal cancer metastases and pathological fractures surgical treatment within hip and shoulder among patients in our own experience.
Material and methods. 79 patients operated between 1997 and 2002 were assesed.Group I - 68 cases with sceletal cancer metastases and pathological fracture of proximal femur.Group II - 11 patients with sceletal cancer metastases and pathological fracture of humerus.The patients underwent primary or secondary (after complications) partial resection procedure with subsequent joint prosthesis implantation.The range of femur resection was 6-17cm.Various types of total or partial hip and shoulder joint endoprostheses according to indication were used.Additional paliative radiotherapy of mathastases,bisphosphonians and analgetics were used according to the case.The average follow-up period was 9,6 months (0-3y). The efficacy analysis was based on Enneking limb function test and Merle d'Aubigne classification and X-ray analysis in patients with partial proximal femur resection.
Results. Group I-according to Enneking test in 41 patients very good and good results,fair in 22 and bad only in 5 cases were found.According to Merle'd Aubigne classification in 37 cases very good and good outcome was found.In 25 the outcome was fair and bad in 6 patients.The machanical instability complication assesed radiologically were found in 7 patients.
Conclusions. The partial bone resection with subsequent joint exchange procedure is positively assesed in patients subjective opinion and its high rate of very good and good results let us conclude this kind of surgery as a very good method in some types of pathological fracture treatment.However a massive bone and particullary soft tissue resection may produce higher incidence of mechanical complications - especially dislocations.