[Bone metastases or an insufficiency fracture? Oncology patients reporting pain or showing bone abnormalities on a scan]. / Ossale metastase of toch een insufficiëntiefractuur? Oncologische patiënten met botpijn of botafwijkingen op een scan.

A 71-year-old patient reported pain in the left hip 14 months after treatment with radiotherapy for a ypT3N1M0 rectal carcinoma, and a 61-year-old patient reported pain in the lower back with radiation to the buttocks 8 months after radiotherapy for a ypT3N2M0 rectal carcinoma. In both patients the initial diagnosis considered was bone metastasis. After MRI and nuclear bone scans, however, diagnoses of insufficiency fractures of the acetabulum and sacroiliac (SI) joints, respectively, were made. Insufficiency fractures of the SI joints or acetabula are a frequent complication of radiotherapy and should be considered in all oncology patients who present with sudden onset of back pain or lower back pain after radiotherapy. A MRI scan is the initial investigation of choice. Treatment is conservative, with analgesia and physiotherapy. Prognosis is good; symptoms disappear within 1 year in almost all patients.

Combination of biodegradable stent placement and single-dose brachytherapy is associated with an unacceptably high complication rate in the treatment of dysphagia from esophageal cancer.

BACKGROUND: For the palliative treatment of dysphagia, esophageal stent placement provides immediate improvement, whereas brachytherapy offers better long-term relief. OBJECTIVE: To evaluate safety and efficacy of concurrent brachytherapy and biodegradable stent placement. DESIGN: Prospective, single-arm study. SETTING: Two tertiary-care referral centers. PATIENTS: Nineteen consecutive patients with significant dysphagia resulting from unresectable esophageal cancer, with a life expectancy of more than 3 months. INTERVENTION: Single-dose brachytherapy (12 Gy) on day 1 followed by biodegradable stent placement on day 2. MAIN OUTCOME MEASUREMENTS: Intervention-related major complications (determined by an expert panel) and dysphagia. RESULTS: Nineteen patients (13 men, median age 66 years [interquartile range (IQR) 59-71] years) were included; 7 patients (37%) also received palliative chemotherapy. After inclusion of 19 patients, the study was ended prematurely because the safety threshold was exceeded. In total, 28 major complications occurred in 17 patients (89%). In 9 patients (47%), major complications were determined intervention-related (severe retrosternal pain with or without vomiting [n = 6], hematemesis [n = 1], recurrent dysphagia [n = 2]. Dysphagia scores decreased significantly from a median of 3 (IQR 3-4) to a median of 1 (IQR 0-3) after 1 month (P < .001). Despite adequate luminal patency in 17 patients (89%), normal diet could not be tolerated in 7 patients (37%) because of retrosternal pain and vomiting. LIMITATIONS: Lack of routine endoscopy or contrast esophagram to evaluate recurrent dysphagia during follow-up. CONCLUSION: Despite restoration of luminal patency, a combined treatment of brachytherapy and biodegradable stent placement cannot be recommended for the palliative treatment of esophageal cancer because of an unacceptably high intervention-related major complication rate.

Quality of life of patients after permanent prostate brachytherapy in relation to dosimetry.

PURPOSE: To investigate changes in quality of life (QoL) after permanent prostate brachytherapy and to correlate these changes with postimplant dosimetry based on magnetic resonance (MR) images. METHODS AND MATERIALS: For this study, 127 patients with low-stage prostate cancer and treated with brachytherapy received a QoL questionnaire at five time points: before treatment and at 4 weeks, 6 months, 1 year, and 2 years after treatment. The questionnaire included the RAND-36 generic health survey, the cancer-specific European Organization for Research and Treatment of Cancer (EORTC) core questionnaire, the tumor-specific EORTC prostate cancer module, and the American Urological Association symptom index. Postimplant dosimetry was based on registered T1 spin echo transversal, T2 turbo spin echo transversal, and T2 turbo spin echo sagittal MR images and CT images taken 4 weeks after implantation of the iodine-125 seeds. Calculated parameters were prostate volume, prostate volume receiving 100% (V100) and 150% (V150) dose, dose to 90% of the prostate volume (D90), maximum dose in 1-, 2-, and 5-cm3 rectum volume, distance between prostate and anterior rectum wall, and the maximum dose in 1%, 2%, and 5% urethra volume. Analysis of variance for repeated measures was used for comparison of the means of all variables in the different questionnaires. Linear regression analysis (stepwise) was used to investigate the correlations between QoL parameters and dosimetry parameters. RESULTS: On average, only the QoL at 4 weeks after implant was significantly different from (worse than) the QoL at the other time points. Regression analysis showed a significant correlation between changes in bowel problems and the maximum dose in 2-cm3 rectum volume, between changes in urinary symptoms and prostate volume, and between changes in urinary problems and the D90 value of the prostate. CONCLUSIONS: The QoL for patients with permanent prostate implants was worse in the first months after treatment but returned to baseline values 1 year after implant. Significant correlations were found between dose distribution and QoL.

Quality of permanent prostate implants using automated delivery with seedSelectron versus manual insertion of RAPID Strands.

BACKGROUND AND PURPOSE: To compare the quality of manually inserted RAPID Strand implants with automatically inserted selectSeed implants using volumetric and dosimetric parameters. PATIENTS AND METHODS: Patients with T1 to T2 prostate carcinoma were treated with brachytherapy. The (125)I seeds were implanted in the prostate in three different ways: manual insertion of RAPID Strands (R); insertion of selectSeeds using the seedSelectron (S); a combination of both techniques: manual insertion of RAPID Strands in the left half of the prostate and insertion of selectSeeds with the seedSelectron in the right half of the prostate (RS). The comparison is based on implant and target specific parameters. The implant specific parameters, V(100), homogeneity index (HI), and natural dose ratio (NDR), were determined at the time of implantation and four weeks later. MR images taken four weeks after the implantation were used for the calculation of the target specific parameters: D(90), HI, external index (EI), and conformation number (CN). RESULTS: We found no significant difference between the groups of implants (R, S, RS) for the implant specific parameters V(100), HI, and NDR at t(0) and neither at t(4w). For each group, the V(100) values decreased significantly with time between t(0) and t(4w). The target specific parameters D(90), HI, EI and CN were not significantly different between the groups. For the group of patients with both RAPID Strands and selectSeeds, we found a significant difference in D(90) between both halves of the prostate. CONCLUSIONS: The dosimetry parameters of a newly introduced implant technique using an automatic seed afterloader were not significantly different from the parameters of a manual insertion technique using RAPID Strands. Since either technique has its advantages and disadvantages regarding seed migration, physics quality assurance, efficiency, logistics, and ease of use, it was decided to use both techniques and to continue evaluations.

Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia from oesophageal cancer: multicentre randomised trial.

BACKGROUND: Both single-dose brachytherapy and self-expanding metal stent placement are commonly used for palliation of oesophageal obstruction due to inoperable cancer, but their relative merits are unknown. We undertook a randomised trial to compare the outcomes of brachytherapy and stent placement in patients with oesophageal cancer. METHODS: Nine hospitals in the Netherlands participated in our study. Between December, 1999, and June, 2002, 209 patients with dysphagia from inoperable carcinoma of the oesophagus or oesophagogastric junction were randomly assigned to stent placement (n=108) or single-dose (12 Gy) brachytherapy (n=101), and were followed up after treatment. Primary outcome was relief of dysphagia during follow-up, and secondary outcomes were complications, treatment for persistent or recurrent dysphagia, health-related quality of life, and costs. Analysis was by intention to treat. FINDINGS: Nine patients (six [brachytherapy] vs three [stent placement]) did not receive their allocated treatments. None was lost to follow-up. Dysphagia improved more rapidly after stent placement than after brachytherapy, but long-term relief of dysphagia was better after brachytherapy. Stent placement had more complications than brachytherapy (36 [33%] of 108 vs 21 [21%] of 101; p=0.02), which was mainly due to an increased incidence of late haemorrhage (14 [13%] of 108 vs five [5%] of 101; p=0.05). Groups did not differ for persistent or recurrent dysphagia (p=0.81), or for median survival (p=0.23). Quality-of-life scores were in favour of brachytherapy compared with stent placement. Total medical costs were also much the same for stent placement (8215) and brachytherapy (8135). INTERPRETATION: Despite slow improvement, single-dose brachytherapy gave better long-term relief of dysphagia than metal stent placement. Since brachytherapy was also associated with fewer complications than stent placement, we recommend it as the primary treatment for palliation of dysphagia from oesophageal cancer.