Radiotherapy and collagenosis: is it safe? A case report of reirradiation in a patient with scleroderma

Historically, scleroderma and other collagenous diseases have been considered a relative contraindication to radiation. The literature has few studies describing poor outcomes and cosmesis in this situation and there are almost no data concerning about reirradiation and colagenosis. The authors describe a case of a patient with a soft tissue sarcoma in the arm submitted to conservative surgery. They describe the outcome, cosmesis and function of this rare twice-irradiated scleroderma patient.

Impacto da nutrição enteral na toxicidade aguda e na continuidade do tratamento dos pacientes com tumores de cabeça e pescoço submetidos a radioterapia com intensidade modulada / Impact of enteral nutrition on acute toxicity and treatment continuity in head and neck cancer patients submitted to intensity-modulated radiotherapy

OBJETIVO: Analisar o impacto da terapia nutricional enteral na manutenção do peso corpóreo e na necessidade de replanejamento e/ou interrupção da radioterapia em pacientes com câncer de cabeça e pescoço submetidos a radioterapia de intensidade modulada (IMRT). MATERIAIS E MÉTODOS: Foram analisados, retrospectivamente, os pacientes submetidos a IMRT entre janeiro de 2005 e outubro de 2008, com a inclusão de 83 casos. RESULTADOS: A idade mediana foi de 58,6 anos. Em apenas em cinco pacientes (6 por cento) houve interrupção do tratamento, que variou de 4 a 18 dias, e em 19 casos (23 por cento) houve necessidade de replanejamento. A terapia nutricional enteral foi instituída antes do início da radioterapia em 16 pacientes (19 por cento). Perda de peso > 5 por cento ocorreu em 58 casos (70 por cento), sendo mais prevalente no grupo de pacientes em que a terapia nutricional enteral não foi instituída pré-radioterapia. Na comparação entre os grupos não houve diferença significativa na realização de replanejamento (25 por cento versus 21 por cento; p = 0,741) ou na ocorrência e duração da interrupção da radioterapia. CONCLUSÃO: A terapia nutricional enteral tem um claro ganho na manutenção do peso corporal, porém, não houve um benefício na realização da gastrostomia percutânea endoscópica ou da sonda nasoenteral em relação à interrupção e ao replanejamento da radioterapia.

OBJECTIVE: The present study was aimed at analyzing the impact of enteral nutrition on the maintenance of body weight and on the necessity of replanning and/or interruption of treatment of head and neck cancer patients undergoing intensity-modulated radiotherapy (IMRT). MATERIALS AND METHODS: Cases of patients submitted to IMRT in the period from January 2005 to October 2008 were retrospectively reviewed, and 83 of them were included in the study. RESULTS: Median patients' age was 58.6 years. Only five patients (6 percent) had their treatment interrupted for a period ranging from 4 to 18 days, and in 19 cases (23 percent) required replanning. Enteral nutrition was initiated before the radiotherapy in 16 patients (19 percent). Weight loss of > 5 percent was observed in 58 patients (70 percent), with a higher prevalence in the group of patients who had not received pre-radiotherapy enteral nutrition. No significant difference was observed between the groups regarding the necessity of radiotherapy replanning (25 percent versus 21 percent; p = 0.741) and necessity and duration of treatment interruption. CONCLUSION: Enteral nutrition is of a great value in the body weight maintenance, but no benefit was observed with the performance of endoscopic percutaneous gastrostomy as compared with radiotherapy interruption/replanning.

Tumor fibroso solitário na pele: relato de caso / Solitary fibrous tumor of the skin: case report

O tumor fibroso solitário (TFS) é uma neoplasia benigna muito rara, derivada de células mesenquimais. Há relatos de casos deste tumor em diversos sítios pleurais ou extrapleurais, sendo a região cutânea e subcutânea localizações ainda mais incomuns. O prognóstico, na maioria dos casos, é bom, mas o comportamento pode ser agressivo. O diagnóstico clínico diferencial é importante na prática diária do cirurgião plástico, pois não raramente aparecem lesões tumorais dos componentes do revestimento cutâneo, com características semelhantes ao TFS - consistência fibro elástica e não aderência a planos profundos - que devem ser bem conhecidas e diferenciadas de neoplasias malignas, para que o tratamento adequado seja instituído.

Solitary fibrous tumor (TFS) is a very rare benign tumor, derived from mesenchymal cells. There are reports of cases of this tumor in different pleural or extra-pleural’s sites, and the skin is even a more unusual spot. The prognosis in most cases is good, but the behavior in few cases can be aggressive. The differential diagnosis is important in the daily practice of plastic surgeons. There are several lesions well known with similar characteristics to TFS in skin layers: fibro elastic consistency, not adhered to deep planes. Those lesions should be differentiated from malignant neoplasms, so that proper treatment is instituted.

Impacto da adição da temozolamida à radioterapia no tratamento de crianças portadoras de tumor de tronco cerebral / Impact of the addition of temozolomide to radiotherapy in the treatment of children with brain stem tumors

OBJETIVO: Analisar o impacto da adição da temozolamida à radioterapia em tumores de tronco cerebral em crianças. MATERIAL E MÉTODO: Entre 2000 e 2005 foram analisadas, retrospectivamente, 64 crianças com tumor do tronco cerebral. Dessas crianças, 32 receberam temozolamida(grupo 1) e 32 não a receberam (grupo 2). RESULTADOS: A idade mediana no grupo 1 foi de 8,2 anos e no grupo 2 foi de 7,5 anos. A localização tumoral era predominantemente difusa (53%) emambos os grupos. Todos os pacientes receberam radioterapia com doses superiores a 50 Gy. No grupo1 foram ministrados nove ciclos, em média, de quimioterapia (3û14 ciclos). O tempo de progressão de doença foi de 7,9 meses no grupo 2 versus 13,8 meses no grupo 1. A sobrevida global foi de 8,8 meses (0,3û30,9 meses) no grupo 1 e de 14,6 meses (4,3û33 meses) no grupo 2. CONCLUSÃO: A utilização da temozolamida após a radioterapia proporcionou aumento da sobrevida, deseis meses em média, nos pacientes pediátricos com tumor do tronco cerebral.

OBJECTIVE: To analyze the impact of adding temozolomide to radiotherapyin pediatric brain stem tumors. MATERIAL AND METHOD: Between 2000 and 2005, 64 children with brain stem tumor were analyzed: 32 received temozolomide (group 1) and 32 did not(group 2). RESULTS: The median age of patients in group 1 was 8.2 year-old and in group 2 was 7.5 year-old. The predominant tumoral localization was diffuse (53%) in both groups. All of the patients were submitted to radiotherapy. In group 1, the median number of temozolomide cycles was 9 (3û14 cycles). Time of disease progression was 7.9 months in group 2 versus 13.8 months in group 1. Overall survival was 8.8 months (0.3û30.9 months) in group 1 and 14.6 months (4.3û33 months) in group 2. CONCLUSION: In our institution,adding temozolomide to radiotherapy increased the overall survival in approximately six months in brain stem pediatric tumors.

Biochemical Relapse for Prostate Cancer Following Radical Prostatectomy: Salvage Radiotherapy Without HormonalTherapy

Objectives: This paper aims to study biochemical control, hormonal therapy-free survival, and prognostic factors related tosalvage radiation for prostate cancer patients submitted to radical prostatectomy (RP) without hormonal therapy (HT) before orduring radiation. Materials and Methods: from August 2002 to July 2004, 39 prostate cancer patients submitted to RPpresented biochemical failure after achieving PSA nadir (<0.2ng/ml). All patients were submitted to three-dimensional conformalexternal beam radiation therapy (3DC-EBRT) and no patients had received HT. Median age was 62 years, median preoperativePSA was 9.4ng/ml, median Gleason Score was 7. We defined PSA rise above 0.2 as biochemical failure after surgery. Median3DC-EBRT dose was 70Gy, and biochemical failure after EBRT was defined as three consecutive rises in PSA or a single risesufficient to trigger HT. Results: Biochemical non-evidence of disease (BNED) in 3 years was 72%. PSA doubling time (PSADT)lower than 4 months (p=0.04), and delay to salvage EBRT (p=0.05) were associated to worse chance of successful salvagetherapy. Late morbidity was acceptable. Conclusion: Expressive PSA control (72% BNED / 3years) could be achieved withsalvage radiotherapy in well-selected patients. The importance of PSADT was confirmed, and radiotherapy should be started asearly as possible. Follow-up is somewhat short, but it is possible to conclude that it is possible to achieve a long interval freefrom hormonal therapy with low rate of toxicity, avoiding or at least delaying morbidity related to hormonal treatment.radiotherapy

Radioterapia adjuvante no tratamento do câncer de endométrio: experiência com a associação de radio-terapia externa e braquiterapia de alta taxa de dose / Adjuvant radiation therapy for the treatment of endometrial cancer: experience with combination of external radiation therapy and high-dose rate brachytherapy

OBJETIVO: Analisar, retrospectivamente, os resultados da radioterapia externa (RT) combinada a braquiterapia de alta taxa de dose (BATD), adjuvantes à cirurgia para o carcinoma de endométrio. MATERIAIS E MÉTODOS: Avaliamos 141 pacientes tratados com RT e BATD adjuvantes à cirurgia, no período de janeiro de 1993 a janeiro de 2001. RT pélvica foi realizada com dose mediana de 45 Gy, e BATD realizada na dose mediana de 24 Gy, em quatro inserções semanais de 6 Gy. A idade mediana das pacientes foi de 63 anos e a distribuição por estádio clínico (EC) foi: EC I (FIGO), 52,4 por cento; EC II, 13,5 por cento; EC III, 29,8 por cento; EC IV, 4,3 por cento. RESULTADOS: Com seguimento mediano de 53,7 meses, a sobrevida livre de doença (SLD) em cinco anos foi: EC I, 88,0 por cento; EC II, 70,8 por cento; EC III, 55,1 por cento; EC IV, 50,0 por cento (p = 0,0003). A sobrevida global em cinco anos foi: EC I, 79,6 por cento; EC II, 74,0 por cento; EC III, 53,6 por cento; EC IV, 100,0 por cento (p = 0,0062). Fatores que influíram na SLD foram grau histológico e histologia seropapilífera. Dos 33 casos que apresentaram recidiva da doença, em 13 (9,2 por cento) esta ocorreu na pelve, vagina ou cúpula vaginal. RT + BATD do fundo vaginal permitiram o controle da doença em 90,8 por cento dos casos. CONCLUSÃO: A RT exerce papel fundamental no controle loco-regional do câncer de endométrio e permite excelentes taxas de cura nos estádios iniciais. Para os estádios mais avançados, a falha terapêutica tende a ser a distância, sugerindo a necessidade de complementação terapêutica sistêmica, com introdução de novas modalidades de tratamento, em particular a quimioterapia.

Conventional External Beam Radiation Therapy and High Dose Rate Afterloading Brachytherapy as a Boost for Patients Olderthan 70 years

The treatment options for patients with non metastatic prostate cancer range from observation, radical prostatectomy, radiationtherapy, hormonal therapy to various combination of some to all of them. Objective: We evaluated the impact on biochemicalcontrol of disease (bNED), acute and late intestinal (GI) and urological (GU) morbidity for a group of patients older than 70years presenting initial or locally advanced prostate cancer treated with fractionated high dose rate brachytherapy (HDRB) asa boost to conventional external beam radiation therapy (RT) at the Department of Radiation Oncology from Hospital do CâncerA. C. Camargo, São Paulo, Brazil. Methods: A total of 56 patients older than 70 were treated from March, 1997 to June,2002. All patients had prior to HDRB a course of RT to a median dose of 45 Gy. HDRB doses ranged from 16 Gy to 20 Gy, givenin 4 fractions. Results: The median age of the patients was 74.4 years (range 70-83) and the median follow-up 33 months(range 24 to 60). The 5-year actuarial bNED rate was 77%. Acute GU and GI morbidity G1-2 were seen in 17.8% and 7.1% ofpatients, respectively. Late G1 or G2 GU morbidity was seen in 10.7% of the patients, while late G3 morbidity was observedin 7.1% of the patients, represented by urethral strictures. Conclusion: this group of patients had similar bNED rates whencompared to literature, with acceptable morbidity rates.

External Beam Radiotherapy Boosted With High Dose Rate Brachytherapy in Completely Resected Uterine Sarcomas. Is This a Treatment Option?

Uterine sarcoma (US) is a relative rare tumor, whichaccounts for only about 3-5% of all uterine cancers.Aggressive cytoreductive surgery at the time of the initialdiagnosis with maximum tumor debulking may lead toa prolonged survival or cure. OBJECTIVE: to identifyand review the role of adjuvante external beam radiationtherapy (EBRT) associated with high dose ratebrachytherapy (HDRB) in the management of patientspresenting US with complete resection. MATERIAL ANDMETHODS: this study is a retrospective analysis of 23patients with US treated from 10/92 to 03/03, withsurgery, external beam radiation therapy (EBRT) andhigh dose rate brachytherapy (HDRB). The inclusioncriteria for study participation included: histologicallyproven and graded US, completely resection of tumor,Karnofsky status 60–100, absence of significant infection,and recovery from recent surgery. RESULTS: The medianage of patients was 62 years (range 39-84); ten-yearactuarial disease-free and overall survivals were 42.2%and 63.4%, respectively. On univariate analysis,predictive factors for disease-free survival (DFS) wereage at initial presentation (p=0.0268), parity (p= 0.0441),tumor grade (p= 0.0095), cervical or vaginal invasion(p=0.0014) and node dissection at time of surgery (p=0.0471). On multivariate analysis, the only predictivefactor was cervical or vaginal invasion (p= 0.048), hazardratio of 4.7. CONCLUSION: it is quite likely that neitherradiotherapy nor chemotherapy alone will appreciablyimprove survival in US. If radiation therapy providesbetter locoregional tumor control, hematogenousmetastases will assume an even greater proportion oftreatment failures. Unfortunately, our small andheterogeneous group analyzed precludes any definitiveconclusions about the impact of HDRB associated to EBRTradiation therapy on recurrence or survival.

Tratamento conservador ocular dos melanomas de coróide com braquiterapia utilizando placas de iodo-125 / Conservative treatment of choroidal melanomas using iodine brachytherapy

OBJETIVO: Avaliar, retrospectivamente, o resultado do tratamento conservador do melanoma de coróide, por meio de braquiterapia, usando placas episclerais de iodo-125 (modelo 6711, Amershan). MATERIAIS E MÉTODOS: Foram avaliados 49 pacientes portadores de melanoma de coróide tratados no Hospital do Câncer, São Paulo, SP, de março de 2001 a janeiro de 2003. Os seguintes parâmetros foram analisados e correlacionados ao controle local e sobrevida: sexo, idade, dimensões da lesão, tempo de tratamento e doses no ápice e base das lesões. RESULTADOS: Com diâmetro máximo da base do tumor de 17 mm e altura máxima de 12 mm, observamos que as doses na base do tumor variaram de 213 a 463 Gy (mediana de 347 Gy) e no ápice, de 51 a 250 Gy (mediana de 91 Gy). As taxas de preservação ocular, sobrevida livre de doença e conservação ocular, atuariais em dois anos, foram de 96 por cento, 93,5 por cento e 96,3 por cento, respectivamente. Através de análise univariada, o único fator prognóstico para controle local nesta análise foi a altura do tumor menor que 6 mm (p = 0,0348). CONCLUSÃO: A braquiterapia levou a uma taxa bastante satisfatória de controle local, confirmando que a altura do tumor é um dos fatores prognósticos importantes desse parâmetro.

OBJECTIVE: To retrospectively evaluate the results of conservative therapy using episcleral iodine-125 (model 6711, Amershan) plaque for brachytherapy of choroidal melanoma. MATERIALS AND METHODS: We evaluated 49 patients with choroidal melanoma treated at "Hospital do Câncer", São Paulo, Brazil, from March 2001 to January 2003. The following clinical parameters were analyzed and correlated with local control and survival rate: gender, age, lesion dimension, treatment duration, as well as doses in apex and base of the tumors. RESULTS: The maximum diameter and height of the base of the tumors treated were 17 mm and 12 mm, respectively. Doses at those points ranged from 213 to 463 Gy (median: 347 Gy) and 51 to 250 Gy (median: 91 Gy), respectively. The actuarial rates of ocular preservation, disease free survival and ocular preservation in 2-years were 96%, 93.5% and 96.3%, respectively. A tumor height < 6 mm was the only predictive factor for local control (p = 0.0348) in the univariate analysis. CONCLUSION: Brachytherapy achieved a very satisfactory rate of tumor local control, confirming that tumor height is one of the most important predictive factors for local control.

Avaliação da resposta bioquímica no câncer inicial de próstata: experiência uninstitucional comparando teleterapia exclusiva ou associada à braquiterapia de alta taxa de dose / Evaluation of biochemical response on early prostate cancer: comparison between treatment with external beam radiation alone and in combination with high-dose rate conformal brachytherapy boost

OBJETIVO: Análise comparativa da resposta bioquímica em pacientes submetidos à teleterapia exclusiva ou associada à braquiterapia de alta taxa de dose para tumores localizados da próstata. MATERIAIS E MÉTODOS: De novembro de 1997 a janeiro de 2000, 74 pacientes foram submetidos à teleterapia com 45 Gy e reforço com braquiterapia de alta taxa de dose com irídio-192 e dose de 16 Gy em quatro inserções (BT). Estes foram comparados a 29 pacientes submetidos à teleterapia com 45 Gy e reforço com arcoterapia e dose mediana de 24 Gy (RT) entre outubro de 1996 e fevereiro de 2000. Nos dois grupos houve associação ocasional de hormonioterapia neoadjuvante. Sobrevida atuarial livre de doença em três anos (SB3) e fatores prognósticos pré-tratamento da resposta bioquímica, como o antígeno prostático-específico inicial (PSAi), escore de Gleason da biópsia de próstata (EG) e estádio clínico (EC), foram analisados. RESULTADOS: O seguimento mediano foi de 25 meses para o grupo RT e 37 meses para o BT. Na análise atuarial, a SB3 foi de 51 por cento e 73 por cento (p = 0,032) para RT e BT, respectivamente. Na análise estratificada pelo PSAi, a SB3 para RT e BT foi de 85,7 por cento e 79,1 por cento (p = 0,76) para PSAi < 10 ng/mL e de 38 por cento e 68 por cento (p = 0,023) para PSAi > 10 ng/mL, respectivamente. Quando estratificado pelo EG, a SB3 para RT e BT foi de 37 por cento e 80 por cento (p = 0,001) para EG < 6 e 78 por cento e 55 por cento para EG > 6 (p = 0,58); estratificando-se pelo EC, a SB3 para RT e BT foi de 36 por cento e 74 por cento (p = 0,018) para EC < T2a e 73 por cento e 69 por cento para EC > T2a (p = 0,692), respectivamente. O risco relativo bruto de recidiva bioquímica foi de 2,3 (95 por cento IC: 1,0-5,1) para os pacientes tratados com RT, em relação à BT; quando ajustado pelo PSAi e EG, o risco relativo de recidiva bioquímica foi de 2,4 (95 por cento IC: 1,0-5,7)...

OBJECTIVE: To compare the biochemical response in patients with locally advanced prostate cancer treated with external beam radiation therapy alone or in combination with conformal brachytherapy boost. MATERIALS AND METHODS: From November 1997 to January 2000, 74 patients received 45 Gy of pelvic external irradiation and four were treated with high dose rate iridium-192 conformal boost implants of 4 Gy each (BT). These were compared with 29 other patients treated with 45 Gy of pelvic external irradiation followed by a 24 Gy of bilateral ARC boost (RT) from October 1996 to February 2000. Some patients received neoadjuvant androgen deprivation therapy. Three-year actuarial biochemical control rates (BC3) and pretreatment biochemical response predictors such as prostate-specific antigen pretreatment (PSAi), Gleason score (GS) and clinical stage (CS), were evaluated. RESULTS: Median follow-up was of 25 months for the RT group and 37 months for the BT group. BC3 was 51% versus 73% (p = 0.032) for RT and BT, respectively. Comparisons of biochemical control by treatment group stratified by PSAi showed that BC3 for RT versus BT was 85.7% versus 79.1% (p = 0.76) for PSAi < 10 ng/mL and 38% versus 68% (p = 0.023) for PSAi > 10 ng/mL, respectively. For patients with GS < 6, BC3 was 37% versus 80% (p = 0.001) for RT versus BT and, for patients with GS > 6, BC3 was 78% versus 55% (p = 0.58) for RT versus BT, respectively. For patients with CS < T2a, BC3 was 36% versus 74% (p = 0.018) for RT versus BT and, for patients with CS > T2a, BC3 was 73% versus 69% (p = 0.692) for RT versus BT, respectively. The relative risk of biochemical relapse was 2.3 (95% IC: 1.0–5.1) for patients in RT group compared to the BT group. When adjusted for PSAi and GS, the relative risk of biochemical relapse was 2.4 (95% IC: 1.0–5.7)...

Single institutional retrospective analysis: treatment of choroidal melanomas with cobalt-60 brachytherapy

Purpose: To evaluate the autcome pf patients with choroidal melanoma treated with conservative therapy with brachytherapy (episcleral Co-60 plaque therapy) at the "Hospital do Cancer"São Paulo, Brazil. Methods: We evaluated 102 patients consecutively treated from January, 1999 to June, 1999. Median age, maximum tumor base diameter and apex size were 55.5 years, 9.75 and 5mm, respectively. Dose s at the base of the tumor, including 1 mm of sclera, ranged from 157 to 487 Gy (median 284.5 Gy) and to the apex from 37 to 220 Gy (median 106 Gy). Results: The crude eye preservation rate with conservative therapy alone was 78.5 percent. Five-year overall actuarial survival rate was 92.2 percent and eye conservation rate was 78 percent. Side effects were mostly and uncomplicated retinopathy in 39/102 patients (38.2 percent); macular degeneration or scarring led to poor central vision in 31/102 patients (30.3) of cases. Conclusion: Our experience with cobalt-60 plaque brachytherapy achieved a satisfatory rate of local tumor control, despite the oversized base diameters of theated tumors.

Hemangioma vertebral sintomático tratado com radioterapia exclusiva: relato de caso e revisão da literatura / Treatment of symptomatic vertebral hemangioma by radiotherapy: case report and review of the literature

Neste trabalho descrevemos a apresentação clínica e dos exames de imagem, bem como a utilização da radioterapia exclusiva, em um caso de hemangioma vertebral sintomático. Após três meses de seguimento, houve melhora parcial da dor. Recomendamos dose total de 40 Gy, em frações diárias de 2 Gy. Em seguida é apresentada revisão da literatura.