Radiotherapy for benign diseases in Turkey: a patterns of care survey of the Turkish Society for Radiation Oncology (TROD 05-002).

PURPOSE: We aimed to investigate the patterns of radiotherapy (RT) care in cases of benign diseases in Turkey. METHODS: A questionnaire survey was sent to all radiation oncology (RO) departments in Turkey. The number of patients treated for benign disease between 2015 and 2020 was requested. A list of benign conditions was given, and information on the number of patients per disease, single and total doses prescribed, weekly fractions, radiation type, energy, and device was requested. RESULTS: Of the 138 RO departments, 29 (21%) responded. The data received concerned 15 (52%) university, 10 (34%) public, and four (14%) private hospitals. A total of 130,846 patients were treated with RT in these departments. Of these patients, 6346 (4.85%) were treated for benign conditions. The most common benign diseases treated with RT were meningioma (35%), plantar fasciitis (19%), schwannoma (16%), arteriovenous malformation (11%), and pituitary adenoma (7%). Most centers performed RT for paraganglioma, heterotopic ossification, vertebral hemangioma, and Graves' ophthalmopathy, but none treated arthrosis. Wide variations were observed across the departments. Radiosurgery for intracranial pathologies was performed intensively in four centers. By contrast, RT for plantar fasciitis was predominantly treated in five centers, one of which had more than 1000 patients. CONCLUSION: The ratio of patients who underwent RT for benign diseases in Turkey among all patients who underwent RT was 4.85%. The common pattern of RT in 72% of patients was radiosurgery for intracranial benign diseases, followed by low-dose RT for plantar fasciitis in 19%.

Tumor deposits: Prognostic significance in gastric cancer patients.

PURPOSE: Tumor deposits (TDs) are defined as satellite peritumoral nodules in the peritumoral adipose tissue of a primary carcinoma without histologic evidence of residual lymph node in the nodule. We aimed to investigate the relation between TDs and clinicopathological characteristics of gastric cancer and to evaluate the effect of TDs on prognosis. METHODS: One hundred and seven non-metastatic gastric cancer patients were enrolled. The relationships between positive and negative TDs with respect to clinicopathological characteristics, as well as disease free survival (DFS) and overall survival (OS), were analyzed. RESULTS: TDs were detected in 28 patients (26.2%). Advanced pT stage and pN stage were significantly higher in TDs-positive compared to TDs-negative patients (p=0.015 and p=0.037, respectively). No significant differences were identified between the groups in other clinicopathological variables such as gender, lymphovascular and perineural invasion. Recurrence and mortality rates were higher in the TDs-positive patients during follow-up of both groups (22/78.6% vs 38/48.1%, p=0.010 for relapse; 20/71.4% vs 3/38%, p=0.005 for mortality). The univariate analysis demonstrated shorter DFS and OS for TDs-positive compared to TDs-negative patients. In multivariate analysis, TDs-positive patients had 1.75-fold higher likelihood to develop recurrence, while the likelihood of death increased 1.99-fold (p=0.041 and p=0.020, respectively). CONCLUSION: TDs-positive gastric cancers demonstrate a more aggressive clinical course compared to TDs-negative. More effective treatment methods should be necessary for management of this subgroup of gastric cancer.

Early transient radiation-induced brachial plexopathy in locally advanced head and neck cancer.

AIM OF THE STUDY: Early transient brachial plexopathy following radiotherapy (RT) in patients with head and neck cancer may be underreported and associated with a dose-response. Our purpose was to determine the incidence of early transient radiation-induced brachial plexopathy (RIBP) in patients receiving primary RT (± chemotherapy) for locally advanced head and neck cancer (HNC). MATERIAL AND METHODS: Twenty-seven locally advanced HNC patients who have no finding of brachial plexopathy at the diagnosis were evaluated 3 times by a specifically developed 13-item questionnaire for determining early transient RIBP. The 54 brachial plexus in 27 patients were delineated and dose volume histograms were calculated. RESULTS: Median follow-up period was 28 (range: 15-40) months. The mean BP volume was 7.9 ±3.6 cm(3), and the mean and maximum doses to the BP were 45.3 (range: 32.3-59.3) Gy, and 59.4 (range: 41.4-70.3) Gy, respectively. Maximum dose to the BP was ≥ 70 Gy only in 2 nasopharyngeal cancer patients. Two (7%) early transient RIBP were reported at 7(th) and 8(th) month after RT under maximum 67.17 and 55.37 Gy, and mean 52.95 and 38.60 Gy RT doses. CONCLUSIONS: Two (7%) early RIBP were seen in the patient group, although brachial plexus maximum doses were ≥ 66 Gy in 75% of patients.

Prognostic factors of breast cancer brain metastasis.

In this editorial we comment on the article by Chen et al published in the recent issue of the World Journal of Clinical Oncology. Brain metastasis is one of the most serious complications of breast cancer and causes high morbidity and mortality. Brain metastases may involve the brain parenchyma and/or leptomeninges. Symptomatic brain metastases develop in 10%-16% of newly recognized cases each year, and this rate increases to 30% in autopsy series. Depending on the size of the metastatic foci, it may be accompanied by extensive vasogenic edema or may occur as small tumor foci. Since brain metastases are a significant cause of morbidity and mortality, early diagnosis can have significant effects on survival and quality of life. The risk of developing brain metastases emerges progressively due to various patient and tumor characteristics. Patient variability may be particularly important in the susceptibility and distribution of brain metastases because malignant blood must cross the brain barrier and move within the brain parenchyma. Some characteristics of the tumor, such as gene expression, may increase the risk of brain metastasis. Clinical growth, tumor stage, tumor grade, growth receptor positivity, HER2 positivity, molecular subtype (such as triple negative status, luminal/nonluminal feature) increase the risk of developing breast cancer metastasis. Factors related to survival due to breast cancer brain metastasis include both tumor/patient characteristics and treatment characteristics, such as patient age, lung metastasis, surgery for brain metastasis, and HER2 positivity. If cases with a high risk of developing brain metastasis can be identified with the help of clinical procedures and artificial intelligence, survival and quality of life can be increased with early diagnosis and treatment. At the same time, it is important to predict the formation of this group in order to develop new treatment methods in cases with low survival expectancy with brain metastases.

Circulating tumor cells as prognostic marker in pancreatic cancer.

In this editorial we comment on the article by Zhang et al published in the recent issue of the World Journal of Clinical Oncology. Pancreatic cancer is the fourth most common cause of cancer-related mortality and has the lowest survival rate among all solid cancers. It causes 227000 deaths annually worldwide, and the 5-year survival rate is very low due to early metastasis, which is 4.6%. Cancer survival increases with better knowledge of risk factors and early and accurate diagnosis. Circulating tumor cells (CTCs) are tumor cells that intravasate from the primary tumor or metastasis foci into the peripheral blood circulation system spontaneously or during surgical operations. Detection of CTC in blood is promising for early diagnosis. In addition, studies have associated high CTC levels with a more advanced stage, and more intensive treatments should be considered in cases with high CTC. In tumors that are considered radiologically resectable, it may be of critical importance in detecting occult metastases and preventing unnecessary surgeries.

Evaluation of acute hematological toxicity by machine learning in gynecologic cancers using postoperative radiotherapy.

Background: The aim of the study is to investigate the factors affecting acute hematologic toxicity (HT) in the adjuvant radiotherapy (RT) of gynecologic cancers by machine learning. Methods: Between January 2015 and September 2018, 121 patients with endometrium and cervical cancer who underwent adjuvant RT with volumetric-modulated arc therapy (VMAT) were evaluated. The relationship between patient and treatment characteristics and acute HT was investigated using machine learning techniques, namely Logistic Regression, XGBoost, Artificial Neural Network, Random Forest, Naive Bayes, Support Vector Machine (SVM), and Gaussian Naive Bayes (GaussianNB) algorithms. Results: No HT was observed in 11 cases (9.1%) and at least one grade of HT was observed in 110 cases. There were 55 (45.5%) cases with ≤grade 2 HT (mild HT) and 66 (54.5%) cases with grade ≥3 HT (severe HT). None of the patients developed grade 5 HT. Of 24 variables that could affect acute HT, nine were determined as important variables. According to the results, the best machine learning technique for acute HT estimation was SVM (accuracy 70%, area under curve (AUC): 0.65, sensitivity 71.4%, specificity 66.6%). Parameters affecting hematologic toxicity were evaluated also by classical statistical methods and there was a statistically significant relationship between age, RT, and bone marrow (BM) maximum dose. Conclusion: It is important to predict the patients who will develop acute HT in order to minimize the side effects of treatment. If these cases can be identified in advance, toxicity rates can be reduced by taking necessary precautions. These cases can be predicted with machine learning algorithms.

Prediction of Radiation Pneumonitis With Machine Learning in Stage III Lung Cancer: A Pilot Study.

BACKGROUND: Radiation pneumonitis (RP) is a dose-limiting toxicity in lung cancer radiotherapy (RT). As risk factors in the development of RP, patient and tumor characteristics, dosimetric parameters, and treatment features are intertwined, and it is not always possible to associate RP with a single parameter. This study aimed to determine the algorithm that most accurately predicted RP development with machine learning. METHODS: Of the 197 cases diagnosed with stage III lung cancer and underwent RT and chemotherapy between 2014 and 2020, 193 were evaluated. The CTCAE 5.0 grading system was used for the RP evaluation. Synthetic minority oversampling technique was used to create a balanced data set. Logistic regression, artificial neural networks, eXtreme Gradient Boosting (XGB), Support Vector Machines, Random Forest, Gaussian Naive Bayes and Light Gradient Boosting Machine algorithms were used. After the correlation analysis, a permutation-based method was utilized for as a variable selection. RESULTS: RP was seen in 51 of the 193 cases. Parameters affecting RP were determined as, total(t)V5, ipsilateral lung Dmax, contralateral lung Dmax, total lung Dmax, gross tumor volume, number of chemotherapy cycles before RT, tumor size, lymph node localization and asbestos exposure. LGBM was found to be the algorithm that best predicted RP at 85% accuracy (confidence interval: 0.73-0.96), 97% sensitivity, and 50% specificity. CONCLUSION: When the clinical and dosimetric parameters were evaluated together, the LGBM algorithm had the highest accuracy in predicting RP. However, in order to use this algorithm in clinical practice, it is necessary to increase data diversity and the number of patients by sharing data between centers.

Dosimetric comparison of single-arc/partial-arc volumetric modulated arc therapy and intensity-modulated radiotherapy for peripheral and central lung cancer.

AIM: The aim of this study is to compare the differences between intensity-modulated radiotherapy (IMRT) and single-arc/partial-arc volumetric modulated arc therapy (SA/PA-VMAT) techniques in locally advanced-stage non-small cell lung cancer (NSCLC). MATERIALS AND METHODS: Locally advanced 22 patients with NSCLC were evaluated retrospectively. Each patient underwent radiation therapy with either IMRT or SA-VMAT or 2PA-VMAT technique. Homogeneity index, conformity number, and dosimetric parameters were evaluated. RESULTS: Ten peripheral and 12 central lung tumors were evaluated. In the entire patient group, tV5-10-60, total mean lung dose (tMLD), iV5-10-30-50-60, iMLD, and esophagus Dmean and Dmax were lower in IMRT technique, cV5-10-20-30, kMLD, and medulla spinalis Dmax were lower in PA-VMAT technique, whereas iMLD is the highest in the SA-VMAT technique. In peripheral tumors, tV5-10-60, iV5-10-20-30-40-60, iMLD, and esophagus Dmean were lower in IMRT technique and kV5-10 was lower in the 2PA-VMAT technique. In central tumors, tV5-10, tMLD, iV5-60, iMLD, and esophagus Dmean and Dmax were lower in IMRT technique, whereas cV10-20 and medulla spinalis Dmax were lower in 2PA-VMAT, and all contralateral lung doses are high in the SA-VMAT technique (all P < 0.05). CONCLUSION: IMRT and VMAT techniques have different advantages in locally advanced lung cancer, and the use of those two techniques as a hybrid can provide a single collection of these advantages.

Comparison Between the Maximum Standard Uptake Value and the Ratio of Lymph Node to Primary Tumor Attenuation in Head and Neck Cancers: A Prospective Study.

OBJECTIVE: The study aimed to investigate the relationship between the ratio of lymph node attenuation to primary lesion attenuation on contrast-enhanced CT and the PET/CT standard uptake value (SUVmax) in head and neck squamous cell cancer (HNSCC). METHODS: Volunteers with advanced-stage, histopathologically proven HNSCC, indicated to have radiotherapy/chemoradiotherapy, were evaluated for CT and PET/CT for radiotherapy planning. The attenuation and SUVmax of the primary lesion and the largest, possibly metastatic lymph node, and the round index and volume of the lymph node were calculated. The relationship between lymph node/primary lesion attenuation and SUVmax ratios was investigated. The differences in CT findings between the SUVmax < and ≥3 groups were examined. RESULTS: Thirty-two cases with adequate diagnostic quality were studied. There was a very strong positive correlation between the primary lesion and lymph node attenuation (r=0.817, p<0.001), a strong correlation between the lymph node volume and SUVmax (r=0.681, p<0.001), and a moderate negative correlation between lymph node/primary lesion SUVmax and attenuation (r=-0.503, p=0.004). In patients with ≥3 SUVmax, lymph node volume and lymph node/primary lesion SUVmax were significantly higher, and the attenuation ratio was close to 1 (PPV 94.1, 86.3%, respectively). CONCLUSION: In HNSCC, the lymph node/primary lesion attenuation ratio can be used instead of SUVmax if supported by other conventional CT findings. Metastasis should be considered if lymph node attenuation is similar to primary mass attenuation and excluded if higher. CT attenuation rate can be used as a supportive finding if PET/CT cannot be performed or lymph node SUVmax is close to the acceptable cut-off for metastasis.

Evaluation of Prognosis in Nasopharyngeal Cancer Using Machine Learning.

BACKGROUND AND AIM: Although the prognosis of nasopharyngeal cancer largely depends on a classification based on the tumor-lymph node metastasis staging system, patients at the same stage may have different clinical outcomes. This study aimed to evaluate the survival prognosis of nasopharyngeal cancer using machine learning. SETTINGS AND DESIGN: Original, retrospective. MATERIALS AND METHODS: A total of 72 patients with a diagnosis of nasopharyngeal cancer who received radiotherapy ± chemotherapy were included in the study. The contribution of patient, tumor, and treatment characteristics to the survival prognosis was evaluated by machine learning using the following techniques: logistic regression, artificial neural network, XGBoost, support-vector clustering, random forest, and Gaussian Naive Bayes. RESULTS: In the analysis of the data set, correlation analysis, and binary logistic regression analyses were applied. Of the 18 independent variables, 10 were found to be effective in predicting nasopharyngeal cancer-related mortality: age, weight loss, initial neutrophil/lymphocyte ratio, initial lactate dehydrogenase, initial hemoglobin, radiotherapy duration, tumor diameter, number of concurrent chemotherapy cycles, and T and N stages. Gaussian Naive Bayes was determined as the best algorithm to evaluate the prognosis of machine learning techniques (accuracy rate: 88%, area under the curve score: 0.91, confidence interval: 0.68-1, sensitivity: 75%, specificity: 100%). CONCLUSION: Many factors affect prognosis in cancer, and machine learning algorithms can be used to determine which factors have a greater effect on survival prognosis, which then allows further research into these factors. In the current study, Gaussian Naive Bayes was identified as the best algorithm for the evaluation of prognosis of nasopharyngeal cancer.

Prediction of Survival and Recurrence Patterns by Machine Learning in Gastric Cancer Cases Undergoing Radiation Therapy and Chemotherapy.

PURPOSE: Radical surgery is the most important treatment modality in gastric cancer. Preoperative or postoperative radiation therapy (RT) and perioperative chemotherapy are the treatment options that should be added to surgery. This study aimed to evaluate the overall survival (OS) and recurrence patterns by machine learning in gastric cancer cases undergoing RT. METHODS AND MATERIALS: Between 2012 and 2019, the OS and recurrence patterns of 75 gastric cancer cases receiving RT ± chemotherapy at the Department of Radiation Oncology were evaluated by machine learning. Logistic regression, multilayer perceptron, XGBoost, support vector classification, random forest, and Gaussian Naive Bayes (GNB) algorithms were used to predict OS, hematogenous distant metastases, and peritoneal metastases. After the correlation analysis, the backward feature selection was performed as the variable selection method, and the variables with P values less than .005 were selected. RESULTS: Over the median 23-month follow-up, recurrence was seen in 33 cases, and 36 patients died. The median OS was 23 (min: 7; max: 82) months, and the disease-free survival was 18 (min: 5, max: 80) months. The most common recurrence pattern was hematogenous distant metastasis, followed by peritoneal metastasis. In this study, the most successful algorithms in the prediction of OS, distant metastases, and peritoneal metastases were found to be GNB with an accuracy of 81% (95% confidence interval [CI], 0.65-0.97, area under the curve [AUC]: 0.89), XGBoost with 86% accuracy (95% CI, 0.74-0.97, AUC: 0.86), and random forest with 97% accuracy (95% CI, 0.92-1.00, AUC: 0.97), respectively. CONCLUSIONS: In gastric cancer, GNB, XGBoost, and random forest algorithms were determined to be the most successful algorithms for predicting OS, distant metastases, and peritoneal metastases, respectively. To determine the most accurate algorithm and perhaps make personalized treatments applicable, more precise machine learning studies are needed with an increased number of cases in the coming years.

Risk factors of radiation pneumonitis in patients with NSCLC treated with concomitant chemoradiotherapy--Are we underestimating diabetes?--Turkish oncology group (TOG)/Lung cancer study group.

INTRODUCTION: To evaluate the clinical and dosimetric parameters that increase the risk of radiation pneumonitis (RP) in locally advanced non-small cell lung cancer (NSCLC) patients treated with concomitant chemoradiotherapy of nationwide multicentric data analysis. METHODS: All data of 268 patients who underwent definitive chemoradiotherapy were retrospectively collected from eight institutes participating in this study. Patient, tumor and treatment-related factors and dosimetric parameters were analyzed for grade ≥2 RP. The toxicity scoring system of The Radiation Therapy Oncology Group used for grading the severity of pneumonitis. A relationship with the risk of RP with potential predictive factors were evaluated by univariate and multivariate analyses. A recursive partition analysis (RPA) was applied to stratify patients according to the risk of developing RP. RESULTS: There were 90 (33.6%) patients who had grade ≥2 RP. The median time to pneumonitis after treatment was 4 months (range:1-6 months). In univariate analysis, diabetes mellitus (DM), use of cisplatin/etoposide, total and daily radiotherapy (RT) fraction dose, the planning target volume (PTV) size, mean lung dose, V5, V10 and RT technique were associated with the development of pneumonitis. In multivariate analysis, only DM (P = 0.008) was found to be independent risk factors for RP. According to RPA, the risk of developing RP was highest in patients with DM. CONCLUSIONS: In our study, besides the known dosimetric factors, DM was found to be the most important risk factor causing RP development in multivariate analysis and RPA. The risk is tripled compared to patients without DM.

CD105 (endoglin) expression as a prognostic marker of angiogenesis in squamous cell cervical cancer treated with radical radiotherapy.

INTRODUCTION: Increased levels of endoglin may represent a new reagent of active neovascularization and angiogenesis process in various cancer types. The prognostic value of tumor CD105 (endoglin) expression in cervical squamous cell cancer (CSCC) patients treated with radical radiotherapy (RT) ± chemotherapy was investigated. MATERIALS AND METHODS: CD105 (endoglin) expression was assessed by immunohistochemical methods in seventy patients, who were treated with radical RT ± chemotherapy for CSCC. The prognostic effects of CD105 on patient and treatment characteristics, local-regional control, and survival were assessed. RESULTS: The median follow-up was 24 (5-99) months for the whole cohort. The median CD105 microvessel density was 55.5 (range; 12-136). Age (≤61 vs. >61 years; P = 0.015), lymph node metastasis status (absent vs. present; P = 0.028), International Federation of Gynecology and Obstetrics stage (Ib-IIa vs. IIb-IVa; P = 0.036), cycles of concurrent chemotherapy (1-3 vs. 4-6 cycles; P = 0.001), and hemoglobin levels (≤10 g/dL vs. >10 g/dL; P = 0.006) appeared to associate significantly with overall survival on univariate analysis. DISCUSSION: No correlation was identified between the tumor CD105 (endoglin) expression and survival in CSCC patients treated with radical RT ± chemotherapy.

Multiple primary malignant neoplasms: A 10-year experience at a single institution from Turkey.

PURPOSE: The development of improved diagnostic techniques, increased survival, and life expectancy of cancer patients have all contributed to the higher frequency of multiple primary malignant neoplasms (MPMN). MPMN can be divided into two main categories: Synchronous MPMN (sMPMN) and metachronous MPMN (mMPMN). MATERIALS AND METHODS: 122 patients with MPMN analyzed retrospectively who were admitted to the Radiation Oncology Department of Eskisehir Osmangazi University Medical Faculty from January 2004 to December 2013. The patient characteristics and relation with overall survival (OS) were examined. RESULTS: The overall incidence of MPMN was found 1.2% in our institution. The median age was 59 (range: 29-80) years. Male:female ratio was 54.5:45.5%, and mMPMN:sMPMN ratio was 69.9:30.1%. The most common 3 cancers were head and neck (22%), breast (20%), and gastrointestinal (20%) for first primary; and gastrointestinal (22%), lung (19%), gynecologic tumors (15%) for second primary cancers, respectively. The median OS in patients with sMPMN and mMPMN were 30 (3-105) and 91 (4-493) months. 2, 3, and 5 years OS of patients with sMPMN were 86%, 75%, 63%, and with mMPMN were 92%, 88%, 80%, respectively (P < 0.005). CONCLUSION: OS was found longer in female patients with sMPMN (P < 0.05), and in all group with mMPMN (P < 0.005).

Influence of tumor volume on survival in patients irradiated for non-small-cell lung cancer.

PURPOSE: To investigate the importance of CT-defined total tumor volume (TTV) on overall survival (OS) in patients with unresectable or medically inoperable non-small-cell lung carcinoma (NSCLC). METHODS AND MATERIALS: Between 1991 and 1998, 150 evaluable patients with Stage I-IIIB NSCLC were treated with three-dimensionally planned conformal radiotherapy and curative intent at Duke University Medical Center. On the treatment-planning CT, the primary tumor and nodal volumes were identified and subsequently combined to form the TTV. The TTV was compared with the stage and outcome with respect to OS, local progression-free survival, and distant failure-free survival using the Kruskall-Wallis analysis of variance and Kaplan-Meier actuarial method. To account for the potentially confounding effects of therapeutic and patient-specific covariates on survival, the Cox proportional hazard regression model was used. RESULTS: The TTVs in patients with Stage I disease (median 19 cm3) were smaller than in patients with Stage II (median 80 cm3) or Stage III (median 97 cm3; p <0.001) disease. The Stage II TTVs were not significantly different from those of Stage III (post-hoc test according to Bonferroni). Prolonged OS was independently associated with a small TTV (<80 vs. >80 cm3 [median]; p = 0.01), young age (<60 vs. > or =60 years; p = 0.03), high Karnofsky performance status (< o r =70 vs. >70; p = 0.04), and female gender (p = 0.04). Both stage (p = 0.7) and T stage (p = 0.06) were of less importance for OS than was the TTV, according to multivariate modeling. Increased local progression-free survival (p = 0.001) and distant failure-free survival (p = 0.03) were independently associated with a small TTV (i.e., <80 cm3). The results were unchanged if the TTV was analyzed as a continuous variable. CONCLUSION: A strong independent association between a small CT-defined TTV and prolonged survival in patients with NSCLC selected for curative/definitive RT was found. Future therapeutic studies in NSCLC should consider stratifying/adjusting for differences in TTV to avoid confounding effects on survival from variations in the TTV at baseline.

Acute myeloblastic leukemia achieving complete remission with amifostine alone.

Amifostine, a phosphorylated thiol-amine, is known as a cytoprotective agent especially for cisplatin containing chemotherapies. Apart from the cytoprotective role, Amifostine could also be used in the treatment of hematologic malignancies such as myelodysplastic syndrome (MDS) and acute myeloblastic leukemia (AML), as a treatment option or for potentiating the effects of cytotoxic agents. We tried to use Amifostine in a patient with AML, which did not respond to conventional cytotoxic chemotherapy and aimed to publish the results. The patient was a 77-year-old male patient, he was diagnosed as AML by peripheral blood smear and bone marrow aspiration. Treatment commenced with low dose cytosine arabinoside (Ara-C) but the therapy should have ceased due to patient intolerance. The patient refused further therapy and he was offered to have Amifostine treatment. Amifostine was administered 200 mg/m2 three times a week, with ciprofloxacin, pentoxifyllin and dexamethasone. Dramatic response was obtained after 8 weeks of administration. Blast rate was reduced from 35 to 7% in bone marrow aspiration; pancytopenia was restored to normal levels. This remission was maintained through 8 more weeks. Amifostine treatment was restarted after he relapsed but this time he did not respond to the treatment and died of gastrointestinal bleeding on the 8th week of treatment.

Muscle metastasis as initial manifestation of epidermoid carcinoma of the lung.

Typical sites of squamous cell carcinoma of lung metastases include liver, brain, bones, pulmonary and adrenal glands. In advanced dissemination it can rarely involve the skeletal muscle. The patient in this case report was a 46-year-old man, with no significant medical history. He was admitted to hospital because of a large swelling on his left thigh. Investigations resulted in a diagnosis of primary squamous cell carcinoma of the lung. Biopsy of the left great adductor muscle produced similar pathology to that of the lung primary. This case report describes a skeletal muscle metastasis as the first sign of metastatic disease.

Comparison of radiation-induced oral mucositis scoring systems.

BACKGROUND: A number of oral toxicity scoring systems have been described, but their direct comparison has rarely been undertaken and little data exists. An impediment to mucositis research has been the lack of an accepted, validated scoring system. The objective of this study was to design a test and validation of scoring systems. MATERIALS AND METHODS: Forty-three patients with head and neck malignancies who had been irradiated were evaluated. Five different mucositis scoring systems (World Health Organization, Radiation Therapy Oncology Group, "Hickey", "Van der Schueren" and "Makkonen") were compared with each other. RESULTS: Daily mucositis scores demonstrated a high correlation among scoring systems (P < 0.05 and coefficient of correlation kappa and r = 0.5-0.95). Objective mucositis scores demonstrated a strong correlation with symptoms. CONCLUSIONS: All scoring systems were equally valid. The exact grading of mucositis is achieved by combining clinical information about pain and nutritional status with oral mucosal reactions.

Results of postoperative radiotherapy in the treatment of 29 uterine sarcoma patients.

AIMS AND BACKGROUND: The objective of this study was to evaluate the results of surgery combined with postoperative radiotherapy (RT) in patients with uterine sarcoma in order to describe the patterns of relapse and to define prognostic factors. METHODS: We report on 29 patients with uterine sarcoma (US) treated from 1980 to 1995; 18 patients with primary tumors were treated with surgery and adjuvant irradiation, while 11 patients with local recurrences (LR) after previous surgical resection received only radiotherapy. We evaluated the influence of stage, histology, grade, menopausal status, total radiation dose and brachytherapy on survival. Histological diagnosis was leiomyosarcoma in 13 patients (44.8%), endometrial stromal sarcoma in 10 patients (34.5%), and mixed mesodermal tumors in six patients (20.7%). Fifteen patients presented with stage I-II disease, three with stage III, and 11 with local recurrences. External pelvic RT was administered to all patients, in five patients combined with brachytherapy. The mean total dose was 54 Gy (SE 1.78). Univariate and multivariate analyses were carried out. RESULTS: Overall survival (OS) for the stage I-III group was 61.1% at two years and 33.3% at five years (median 29 months, SE 13.79). Disease-free survival (DFS) was 55.6% at two years and 33.3% at five years. Median DFS was 26 months (SE 14.85). In LR cases, median OS was only 10 months (SE 4.5). Multivariate analysis demonstrated that stage was the only prognostic factor after RT for US. CONCLUSIONS: These data suggest that postoperative and/or salvage RT has a questionable impact on disease-free and over-all survival because of the lack of homogeneity of stages in the series reported in the literature; it has, however, acceptable late side effects. Prospective multicenter trials including a statistically evaluable number of patients are necessary to further clarify the role of RT treatment programs for US.

Timing of thoracic radiotherapy in limited stage small cell lung cancer: results of early versus late irradiation from a single institution in Turkey.

BACKGROUND: It is standard treatment to combine chemotherapy (CT) and thoracic radiotherapy (TRT) in treating patients with limited stage small cell lung cancer (LS-SCLC). However, optimal timing of TRT is unclear. We here evaluated the survival impact of early versus late TRT in patients with LS-SCLC. MATERIALS AND METHODS: Follow-up was retrospectively analyzed for seventy consecutive LS-SCLC patients who had successfully completed chemo-TRT between January 2006 and January 2012. Patients received TRT after either 1 to 2 cycles of CT (early TRT) or after 3 to 6 cycles of CT (late TRT). Survival and response rates were evaluated using the Kaplan-Meier method and comparisons were made using the multivariate Cox regression test. RESULTS: Median follow-up was 24 (5 to 57) months. Carboplatin+etoposide was the most frequent induction CT (59%). Median overall, disease free, and metastasis free survivals in all patients were 15 (5 to 57), 5 (0 to 48) and 11 (3 to 57) months respectively. Late TRT was superior to early TRT group in terms of response rate (p=0.05). 3 year overall survival (OS) rates in late versus early TRT groups were 31% versus 17%, respectively (p=0.03). Early TRT (p=0.03), and incomplete response to TRT (p=0.004) were negative predictors of OS. Significant positive prognostic factors for distant metastasis free survival were late TRT (p=0.03), and use of PCI (p=0.01). Use of carboplatin versus cisplatin for induction CT had no significant impact on OS (p=0.634), DFS (p=0.727), and MFS (p=0.309). CONCLUSIONS: Late TRT appeared to be superior to early TRT in LS-SCLC treatment in terms of complete response, OS and DMFS. Carboplatin or cisplatin can be combined with etoposide in the induction CT owing to similar survival outcomes.