Preliminary result of using intensity modulated radiation therapy (IMRT) as a primary treatment for prostate cancer at Siriraj Hospital in Thailand: toxicity and biochemical outcomes.

Objective: This study is a retrospective study of the outcome and the incidence of the toxicity of using intensity-modulated radiation therapy (IMRT) as the primary treatment for prostate cancer at Siriraj Hospital. Methods: Hospital records and radiotherapy medical records of prostate cancer patients treated with IMRT as the primary treatment between July 2004 and May 2009 at Siriraj Hospital were all reviewed. Seventy-five prostate cancer patients were included in the study. Patient’s biochemical failure was established at the time of prostatic specific antigen progression above the post-treatment nadir value +2 ng/ml according to the Phoenix definition. Acute and Late toxicity were assessed and scored according to the Radiotherapy Oncology Group grading system. Results: The median follow up time was 25 months (range 3 – 63 months). The two years overall survival (OS) and freedom from biochemical failure rate (FFBF) were 93.7 and 95.8%, respectively. Five patients (6.6%) developed prostatic specific antigen failure according to the Phoenix definition. The incidences of grade  2 of acute and late gastrointestinal toxicity were 12% and 2.7%, respectively. The incidences of grade  2 of acute and late genito-urinary toxicity were 61.3% and 41.3%, respectively. Conclusion: This preliminary result of using IMRT as the primary treatment for prostate cancer provides good outcomes. The FFBF and OS are comparable with other studies. The incidences of acute and late gastrointestinal toxicity are acceptable, but the incidences of acute and late genito-urinary toxicity are higher than other studies.

Preoperative chemoradiation for locally advanced rectal cancer with capecitabine 2,000 mg/m2/day.

OBJECTIVE: Evaluate the efficacy and the tolerability of preoperative chemoradiation with high dose Capecitabine. MATERIAL AND METHOD: Fifteen patients with locally advanced resectable rectal cancer were treated with Capecitabine 2,000 mg/m2/day, orally 7 days/week concurrent with whole pelvic irradiation 45 Gy in 25 fractions/5 weeks. Patients underwent surgery in the following 4-6 weeks. RESULTS: After complete treatment, 11 patients (73%) underwent surgery. Ten patients (66%) had sphincter preservative surgery; three of them had primary tumors located in the lower rectum. Five patients had grade 2 and one patient had grade 3 diarrhea. No grade 4 toxicity was reported. CONCLUSION: Preoperative Capecitabine 2,000 mg/m2/day concurrent with whole pelvic irradiation were effective and well tolerated The potential dose limiting toxicity effect was the diarrhea.

Prevalence incidence and management of anemia in cancer patients treated in the radiation oncology division, Siriraj Hospital.

Objective: This study was designed to find the prevalence of anemia in cancer patients before radiotherapy and the incidence of anemia during radiotherapy treatment. The study also planned to identify factors that affect the incidence and prevalence of anemia and the management of anemia in the radiation oncology division, Siriraj Hospital. Methods: This study is designed prospectively to collect hemoglobin level and factors that might cause anemia in patients whom were treated with radiotherapy at Siriraj Hospital during April - June 2006. The eligible criteria were patients age > 18 years old, had a pathology confirmed to be malignancy, and had never been treated with radiotherapy before. Patients were excluded if they were not treated with radiotherapy, had skin/central nervous system or hematologic malignancies. In this trial, anemia was defined as Hb level < 12 g/dl for both genders. Results: It was found that the prevalence of anemia within 30 days before starting radiotherapy was 54.4% and the incidence of anemia during radiotherapy was 34.3%. The frequency of anemia, defined as the number of patients in the study in whom Hb <12.0 g/dL were found at least once either at enrollment or during the survey, was 66%. Previous chemotherapy was the main predicting factor for anemia before radiotherapy. Concurrent chemo-radiotherapy patients developed a higher incidence of anemia during the survey than patients with radiotherapy alone. The incidence of anemia was highest in gynecologic malignancy patients. Only 25/112 (22.3%) of anemic patients at initial evaluation received treatment for anemia. Most of the patients were treated with a blood transfusion and none was treated with erythropoietin. Our mean trigger hemoglobin level for treatment of anemia was 9.3 g/dl. Conclusion: Anemia is common in the patients who are treated with radiotherapy in our institute with the prevalence of anemia before starting radiotherapy as high as 54.4% especially in patients previously treated with chemotharapy. One-thirds of patients developed anemia during radiotherapy, with a higher incidence in gynecologic malignancy patients and patients who receive combined chemo-radiotherapy. The total frequency of anemia in patients treated in the Division of Radiation Oncology, Siriraj Hospital was as high as 66% before and during radiotherapy.

Effect of Amifostine to prevent radiotherapy-induced acute and late toxicity in head and neck cancer patients who had normal or mild impaired salivary gland function.

BACKGROUND: Amifostine has a potential role for salivary gland protection in head and neck cancer patients who had radiotherapy. MATERIAL AND METHOD: Sixty-seven head and neck cancer patients were randomized to receive radiotherapy or radiotherapy plus Amifostine. The efficacy of the treatment was determined by a questionnaire evaluating dryness of mouth and the oral comfort, the RTOG/EORTC acute/late radiation morbidity scoring criteria, collection of the whole saliva and the 99mTc-pertecnetate scintigraphy of the salivary glands. RESULTS: Amifostine significantly reduced the mean questionnaire scores from 6.49 to 3.73, the incidence of grade > or = 2 mucositis from 75% to 36% and acute xerostomia from 82% to 39%. The salivary gland function returned to normal at a rate of 36.3% in the Amifostine group versus 9.1% in the control group. CONCLUSION: Amifostine is effective in reducing the incidence and severity of acute mucositis, acute and late xerostomia in head and neck cancer patients.

Preoperative capecitabine with pelvic radiotherapy for locally advanced rectal cancer (phase I trial).

OBJECTIVE: Phase I multicenter study defined the maximal tolerated dose (MTD), dose-limiting toxicity (DLT) and safety profile of capecitabine in combination with preoperative radiation for patients with locally advanced rectal cancer (LARC). MATERIAL AND METHOD: Patients were treated with oral capecitabine (700, 800, 900, 1000, 1100 and 1200 mg/m2 twice daily continuously) plus preoperative whole pelvic irradiation (45-46 Gy in 23-25 fractions over 5-6 weeks). Surgery was performed at the median of 42 days after chemoradiation treatment. RESULTS: Twenty-seven patients were in this trial. Eighteen patients (3 per dose level) had received capecitabine from 700 mg/m2 twice daily to the highest dose level of 1200 mg/m2 twice daily. There were no grade 3/4 DLTs during dose escalation, a further nine patients were included at the highest capecitabine dose. Two of the twelve patients (16%) receiving capecitabine 1200 mg/m2 twice daily developed grade 3 diarrhea and discontinued treatment. There were no other grade 3/4 adverse events. After capecitabine chemoradiation, 24 of 27 patients (89%) received definite surgery. Primary and lymph node down staging occurred in ten patients (42%). Sphincter-sparing surgery was performed in seven patients (26%) and abdominal-perineal resection was performed in 17 patients (63%). CONCLUSION: Preoperative capecitabine chemoradiation based on continuous daily capecitabine is very well tolerated in patients with LARC. The authors did not reach the MTD in the present study.

Necessary for CT whole abdomen in post chemoradiation of rectosigmoid cancer stage 3: A comparative study.

Objective: To study the reliability of CT Scan interpretation in pre and post operative chemoradiation of rectosigmoid cancer. Methods: Retrospective review CT scan of 12 patients with diagnosis of rectosigmoid cancer stage 3 or more in pre and post operative chemoradiation were done by 2 radiologists. Data analysis included Maximum Wall Thickness, Distance of Lesion above Anal Verge, Perirectal Involvement, Regional node, Distant Metastasis. Chest radiograph (CXR), Endorectal Ultrasound (ERUS), Barium enema ( BE), Colonoscopy and treatment information were reviewed. Results: Reliability of TNM staging by CT scan interpretation were .66, .50 and .75, respectively total reliability is .75 and overall validation of CT scan staging is .40 with statistic significant at .05 reference with Pathological staging. Conclusion: There was CT scan interpretation reliability in pre and post chemoradiation for rectosigmoid cancer patients.

Chronic arsenicism and multiple skin cancers.

Abstract : We report a case of skin cancer who presented with an ulcerated nodule at left arm and finger. The patient was previously diagnosed Bowenûs disease at left calf one year ago, skin cancer at hand and foot nine years ago. He also received herbal medicine every month for 1 year since 50 years ago for herpes treatment. Multiple skin cancers were suspected to be induced by chronic arsenicism. High level of arsenic was identified from nails. Bowenûs disease at finger was treated with CO2 laser and squamous cell carcinoma at left arm was removed by surgical excision. Chronic arsenicism was treated by supportive care.

A young woman with rectal bleeding.

Rectal cancer is a common malignancy in Thailand. A case of 39-year-old female with rectal bleeding caused by adenocarcinoma of rectum is reported here. Successful treatment was achieved by preoperative chemoradiation therapy and low anterior resection. She is now symptom free and has good sphincter control. The history, physical examination, investigations, diagnosis and treatment are discussed.

Five-year follow-up in respectable breast cancer patients with “CMF” adjuvant chemotherapy and radiation.

From 1989 to 1991, there were 36 female breast cancer patients came to the Division of Radiation Oncology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University. All36 patients had surgical treatment involving either MRM or conservatiove breast surgery. The combination CMF regimen were given as the adjuvant chemotherapy for six cycles. (Cyclophosphamide 100 mg./m2 p.o. day 1-14, Methotrexate 40 mg./m2 i.v. day 1 and 8, 5-Fluorouracil 600 mg./m2 i.v. day 1 and 8; repeated on a 28-day cycle). Conventional radiation treatment was given to the chest wall and regional lymph nodes at 5,000 cGy/25 fractions, while those who had conservative breast surgery received booster doses of 1,000-1.600 cGy/5-8 fractions to the tumour bed. The follow-up period was ranged between 52 and 86 months (mean = 62.25 months). The disease-free survival rate was 66.66 percent (24 patients). Nine of 10 patients who had loco-regional and/or distant failure were premenopausal women. So the authors suggest that CMF chemotherapy is inadequate for controlling the disease because in premenopausal patients there is greater risk of recurrence and metastases than in post-menopausal patients. Anthracyclines-based combination chemotherapy should be considered for premenopausal breast cancer patients.