Endobronchial brachytherapy for metastasis from extrapulmonary malignancies as an effective treatment for palliation of symptoms.

PURPOSE: Endobronchial metastasis (EBM) originating from primary cancers outside the lung is rare. External beam radiotherapy is often attempted for control of symptoms with variable effectiveness and retreatment is challenging if symptoms recur. There is limited documentation of high-dose-rate brachytherapy for EBM in the literature. METHODS AND MATERIALS: A prospective database was created from 2006 to 2015. Patients with EBM who received high-dose-rate brachytherapy were included. Cough, dyspnea, chest pain, and hemoptysis were assessed and graded (0-4) at the time of initial consult and in followup. Symptom-free survival and re-expansion were assessed. RESULTS: Thirty-five patients with EBM were identified. Most patients received three fractions of 700 cGy, and 17 patients had prior external beam radiotherapy. Median symptom-free and overall survival were 67 and 117 days. After brachytherapy, improvement in cough was documented in 75.0%, hemoptysis in 76.4%, dyspnea in 60.0% for a median of 3-6 months. Of the 22 patients who had subsequent chest imaging, re-expansion was documented in 32%. There were no significant toxicities reported. CONCLUSIONS: Brachytherapy appears effective in achieving durable symptom control of cough hemoptysis, and dyspnea in patients with EBM and should be considered routinely for palliation where available. Further studies are required to better characterize expected symptom improvement, lung re-expansion rates, and efficacy in comparison with other local treatments.

Effects of tobacco smoking on cancer and cardiovascular disease in urban black South Africans.

Demographic and lifestyle information from 9690 black patients diagnosed with cancer or cardiovascular disease was collected in an ongoing case-control study in Johannesburg, South Africa. Compared to never smokers, the odds ratio (OR) for lung cancer among current smokers was 16.3 (95% confidence interval (CI), 9.6-27.6) for men and 6.4 (95% CI, 4.0-10.4) for women. The corresponding OR for other smoking-related cancers was 4.6 (95% CI, 3.7-5.7) among men and 1.9 (95% CI, 1.6-2.2) among women, and for cardiovascular disease, 3.4 (95% CI, 2.1-5.4) among men and 1.5 (95% CI, 1.1-2.1) among women. Risks were higher among smokers than former smokers, and all risk estimates increased with increasing levels of smoking duration and intensity. Non-electric domestic fuel was associated with approximately 60% increase in the risk of smoking-related cancer, but not cardiovascular disease. Risks for cancers of cervix, oesophagus, oral cavity/pharynx, stomach, larynx, pancreas and anogenital region, as well as squamous cell carcinoma of skin were all significantly higher among current than never-smokers, with ORs ranging from 1.5 for cervix (95% CI, 1.2-1.8) to 14.7 for larynx (95% CI, 7.2-30). The risks of tobacco-related disease reported here are similar to that currently observed in Western countries, even though cigarette consumption is relatively low in this population.

A phase I study of concurrent cisplatin chemotherapy in patients with carcinoma of the cervix receiving pelvic radiotherapy.

The purpose of this study was to evaluate the maximum tolerated dose (MTD) of weekly cisplatin in a sample population of South African patients with cervical carcinoma, when given in combination with radical pelvic irradiation. Patients with cervical carcinoma stage IB2-IIIB (without hydronephrosis) received up to six cycles of cisplatin at weekly intervals. Groups consisting of three patients each were treated at each of the three predetermined dose levels of cisplatin (20, 25, and 30 mg/m(2)). Eighteen patients were treated and evaluated for toxicity. All the patients who received 20 mg/m(2) (n = 3) and 25 mg/m(2) (n = 3) cisplatin had no dose-limiting toxicity (DLT). Four of the 12 patients who were given cisplatin 30 mg/m(2) experienced DLT with rising serum creatinine and declining creatinine clearance. The minimum creatinine clearance was 22 mL/min. The highest serum creatinine was 174 mumol/L. This study showed that a weekly dose of 25 mg/m(2) of cisplatin was the MTD when used in combination with pelvic irradiation for this sample of patients. This dose is lower than the recommended dose of cisplatin 40 mg/m(2)/week. The patients in this study may have reduced tolerance to higher doses of cisplatin, when compared to patients from Western countries.

Aggressive fibromatosis--impact of prognostic variables on management.

OBJECTIVE: To determine the impact of prognostic variables on local control in patients with aggressive fibromatosis treated with or without radiation. MATERIALS AND METHODS: Forty-two patients presenting to the combined sarcoma clinic at Johannesburg Hospital with aggressive fibromatosis from 1990 to 2003 were analysed retrospectively. There were 14 males and 28 females. The lesions involved the head and neck in 6 cases (14%), the thorax in 6 (14%), the extremities in 19 (45%) and the abdomen in 11 (26%). Thirty-seven patients (88%) presented to the clinic for the first time, whereas 5 (12%) had recurrent disease at presentation. Fifteen patients (36%) underwent excision only, 15 (36%) had excision followed by postoperative radiation, 8 (19%) had biopsy only, and 4 (9%) had radiation only. The median dose of radiation was 60 Gy (range 9 - 70 Gy). RESULTS: One patient had local failure following excision and postoperative radiation therapy. The local control was 100% for surgery alone and 86% for surgery followed by postoperative radiation at > or = 24 months. On univariate analysis, age, sex, positive margins, primary or recurrent presentation, site of involvement and initial treatment did not affect local control significantly. Eight of 19 patients (42%) receiving radiation developed severe moist desquamation following treatment, and all these patients had doses of 60 Gy or more. CONCLUSION: Surgery with or without radiation therapy gave excellent local control. The addition of radiation therapy to surgery as well as other known prognostic parameters did not impact on local control. The morbidity of radiation treatment is considerable, as noted in this series, and adjuvant radiation therapy should therefore be considered only in situations where the risk of recurrence and the morbidity of re-excision are high.

Aggressive fibromatosis - impact of prognostic variables on management : general surgery

Objective. To determine the impact of prognostic variables on local control in patients with aggressive fibromatosis treated with or without radiation. Materials and methods. Forty-two patients presenting to the combined sarcoma clinic at Johannesburg Hospital with aggressive fibromatosis from 1990 to 2003 were analysed retrospectively. There were 14 males and 28 females. The lesions involved the head and neck in 6 cases(14); the thorax in 6 (14); the extremities in 19 (45) and the abdomen in 11 (26). Thirty-seven patients (88) presented to the clinic for the first time; whereas 5 (12) had recurrent disease at presentation. Fifteen patients (36) underwent excision only; 15 (36) had excision followed by postoperative radiation; 8 (19) had biopsy only; and 4 (9) had radiation only. The median dose of radiation was 60 Gy (range 9 - 70 Gy). Results. One patient had local failure following excision and postoperative radiation therapy. The local control was 100for surgery alone and 86for surgery followed by postoperative radiation at 24 months. On univariate analysis; age; sex; positive margins; primary or recurrent presentation; site of involvement and initial treatment did not affect local control significantly. Eight of 19 patients (42) receiving radiation developed severe moist desquamation following treatment; and all these patients had doses of 60 Gy or more. Conclusion. Surgery with or without radiation therapy gave excellent local control. The addition of radiation therapy to surgery as well as other known prognostic parameters did not impact on local control. The morbidity of radiation treatment is considerable; as noted in this series; and adjuvant radiation therapy should therefore be considered only in situations where the risk of recurrence and the morbidity of re-excision are high

Angiosarcomas--clinical profile, pathology and management.

Files of 8 patients with primary angiosarcomas treated in the Department of Radiation Oncology at the University of the Witwatersrand from 1982 to 1995 were identified. None of these patients had received prior radiotherapy or chemotherapy which would have predisposed them to the formation of an angiosarcoma. Slides of 6 patients were reviewed. Five of the 6 were confirmed as having angiosarcomas, while 1 patient was found to have a peripheral neuro-epithelial tumour. Four patients had angiosarcomas of the breast, while there was 1 patient each with angiosarcoma of the skin, intestine and brain. Complete excision was the primary modality of management whenever possible. Postoperative radiotherapy was given in cases of incomplete excision, patient refusal of radical surgery or gross tumour. Four patients died within 4 months of diagnosis. Three patients are alive (2 with no evidence of disease) 22-96 months after diagnosis. In 1 patient follow-up details were not available as he did not return for treatment. Angiosarcomas are aggressive malignant tumours arising from the endothelial cells. Complete surgical excision is the treatment of choice in the management of this aggressive disease, which has a poor prognosis.

Fractionated high dose rate intraluminal brachytherapy in palliation of advanced esophageal cancer.

PURPOSE: To optimize the dose of fractionated brachytherapy for palliation of advanced esophageal cancer. METHODS AND MATERIALS: One hundred and seventy-two patients with advanced esophageal cancer were randomized to receive 12 Gy/2 fractions (group A); 16 Gy/2 fractions (group B), and 18 Gy/3 fractions (group C) by high dose rate intraluminal brachytherapy (HDRILBT). Treatment was given weekly and dose prescribed at 1 cm from the source axis. Patients were followed up monthly and assessed for dysphagia relief and development of complications. RESULTS: Twenty-two patients died before completing treatment due to advanced disease and poor general condition. The overall survival was 19.4% at the end of 12 months for the whole group (A--9.8%, B--22.46%, C--35.32%; p > 0.05). The dysphagia-free survival was 28.9% at 12 months for the whole group (A--10.8%, B--25.43%, C--38.95%; p > 0.05). Forty-three patients developed fibrotic strictures needing dilatation (A--5 of 35, B--15 of 60, C--23 of 55; p = 0.032). Twenty-seven patients had persistent luminal disease (A--11, B--6, C--10), 15 of which progressed to fistulae (A--7, B--2, C--6; p = 0.032). There was no effect of age, sex, race, histology, performance status, previous dilation, presenting dysphagia score, presenting weight, grade, tumor length, and stage on overall survival, dysphagia-free, and complication-free survival (p > 0.05). On a multivariate analysis, brachytherapy dose (p = 0.002) and tumor length (p = 0.0209) were found to have a significant effect on overall survival; brachytherapy dose was the only factor that had an impact on local tumor control (p = 0.0005), while tumor length was the only factor that had an effect on dysphagia-free survival (p = 0.0475). When compared to other forms of palliation currently available (bypass surgery, laser, chemotherapy, intubation, external radiotherapy), fractionated brachytherapy gave the best results with a median survival of 6.2 months. CONCLUSIONS: Fractionated brachytherapy is the best modality for palliation of advanced esophageal cancer. It offers the best palliation to patient when compared to all other modalities currently available. The optimal brachytherapy dose ranges between 16 Gy in two fractions and 18 Gy in three fractions given a week apart.

Adenoid cystic carcinoma of the salivary glands: a review of 10 years.

A retrospective analysis was performed of 50 patients with adenoid cystic carcinoma who were seen in the Department of Radiation Oncology, University of Witwatersrand, Johannesburg, South Africa, in the past 10 years. There were 25 men and 25 women with a mean age of 52 years (age range, 21 to 88 years). Five patients had metastatic disease, and 17 had neural invasion. Thirty-four patients had surgery (11, complete; 23, microscopic residual). Sixteen patients had radiotherapy as initial management. The disease-free survival was 26%, overall survival was 29%, and local control was 30% at 10 years. Most recurrences occurred in the first 3 years. Nine patients had metastasis following treatment. The mean survival after metastasis was 15 months. Seven prognostic variables were analyzed using the log-rank test. There was no impact of age, site, type of salivary gland (major vs. minor), tumor stage, node positivity, or neural invasion on disease-free survival, overall survival, or local control. Extent of surgical resection (complete vs. microscopic residual) had a significant impact on disease-free survival and local control (P < 0.05) but no impact on overall survival (P > 0.05) because of the slow-growing nature of these tumors. Similarly, patients who had microscopic residual after surgery and were treated with radiotherapy did better than those who had biopsy and radiotherapy, although this was not significant statistically (P > 0.05). Thus, whenever possible, every attempt must be made to remove all microscopic tumor by surgery. Addition of postoperative radiotherapy with high-energy photons did not improve the locoregional control or survival in our series. There is a place for neutrons in the treatment of adenoid cystic carcinomas in advanced cases of inoperable or recurrent tumors, as a review of literature shows.

Symmetrical multifocal liposarcoma.

Multiple liposarcomas are extremely rare. We report on a patient with liposarcoma of the right lower limb who had undergone surgery and radiotherapy 4 years previously for a liposarcoma in the left lower limb. An outline of the management is discussed and a short review of available literature is given.

Role of radiotherapy in stage III invasive thymomas.

Twenty-five patients with malignant invasive stage III thymomas who underwent biopsy for tissue diagnosis were treated with primary radiotherapy (mean dose 46.36 Gy, range 32.4-58 Gy). These patients were followed up for a period of 10 years and survival/failure analysis was performed. Five prognostic variables were compared using the log rank test. There was no difference in survival between ages less than 50 and more than 50 years, presence or absence of myasthenia gravis, sex, histology and race. The mean follow-up was 39 months (range 1-86 months). The 5-year disease-free survival was 81% overall survival 72% and local failure rate 13%. Most local failures occurred in the first 3 months. Six patients died after a course of radiotherapy (2 intrathoracic relapse, 1 disseminated disease, 1 local failure and distant metastasis, 2 causes not related to disease). Hilar fibrosis was seen in 4 patients who are asymptomatic. No other complications were recorded. Radical external beam radiotherapy alone can give good results in malignant stage III invasive thymomas.

Radiotherapy for stage I and II testicular seminoma after orchidectomy.

A retrospective study was undertaken to evaluate the effect of irradiation on 65 patients with stage I, or II testicular seminomas treated at Hillbrow Hospital with irradiation following orchidectomy. Forty-seven patients presented with stage 1 and 9 with stage II disease. All patients received infradiaphragmatic irradiation. In addition 4 patients with stage II disease received prophylactic supradiaphragmatic irradiation. The 5-year overall and disease-free survival rate for all stages and for stage I and II compared favourably with other reports in the literature. The irradiation was well tolerated and severe long-term toxicity was rare. Seminomas were uncommon in black patients, of whom only 3 were seen in the 12-year period of this study.

Palliation of carcinoma of the oesophagus with brachytherapy and the Didcott dilator.

Forty-one patients with oesophageal cancer who developed strictures after high dose rate intraluminal brachytherapy were dilated using a slow continuous dilator (Didcott dilator). After dilatation, all patients were evaluated monthly for relief of dysphagia. At the end of the 1st month, 41 patients were evaluable: 28 had no dysphagia while 13 had improvement; at the end of the 2nd month, 40 were evaluable, 26 had no dysphagia while 14 had improvement; at the end of the 3rd month, 34 patients were evaluable, 24 had no dysphagia while 10 had improved. Three patients developed worsening of dysphagia owing to tumour recurrence among 32 patients who were evaluable at the end of the 4th month. Five patients developed worsening of dysphagia among the 26 patients who were evaluable at the 5th month due to tumour. These patients were dilated with the Didcott dilator and were treated with further brachytherapy. At the end of the 6th month, 14 patients were evaluable; seven had no dysphagia, while seven had improvement over their presenting dysphagia scores. Slow continuous dilatation using the Didcott dilator is very effective in the dilatation of strictures after high dose rate intraluminal brachytherapy. Dilatation is prolonged and sustained and a single dilatation is usually enough to maintain patency.

Toxicity in patients with testicular seminoma treated with radiotherapy. Different dose levels and treatment fields.

The aim of this study was to evaluate the acute and late effects of irradiation in 56 patients with stage I and II testicular seminomas. A retrospective study of patients' records was performed paying attention to the acute and late toxicity of radiation in relation to treatment fields and radiation doses. Treatment groups were compared using the chi squared-test. Mild to moderate nausea and/or vomiting was seen in 66% of patients and occurred equally independent of the treatment volume or radiation dose. Increased bowel frequency was seen in 59% and was more common when a larger treatment volume was used. Skin reactions increased with increase in treatment volume and dose (p = 0.046). Severe late complications were recorded in two patients (myocardial damage-1/4 at risk, duodenal ulcer-1/56 at risk). These could not be attributed solely to the irradiation as other contributing factors might play a role. Overall the data suggest that the risk of major posttreatment morbidity is minimal for patients with testicular seminoma treated with postoperative radiotherapy.

Carotid body tumour--a case for radiotherapy?

Carotid body tumours are rare tumours in the head and neck region. Treatment has been surgery with little or no role for radiotherapy. We describe 5 patients with carotid body tumours seen in our department in the last 10 years. Two patients were treated with postoperative radiotherapy after incomplete surgery, 2 had inoperable tumours and were treated with radiotherapy alone, and 1 had a complete excision and required follow-up only. In the 4 patients who received radiotherapy, the disease was stable in 1 patient at 1,1 years and progressive in 2 at 0,6 and 5,6 years respectively; 1 patient did not complete treatment. The patient who had surgery alone for a small tumour was free of disease at 1 year. Small carotid body tumours should be treated with surgery alone. When the tumour is large or the patient is older we propose radiotherapy as initial treatment because of the high morbidity of surgery. A review of the literature and the results with radiotherapy alone in varying doses support this view.

Jugulotympanic paragangliomas.

Eleven patients with glomus jugulotympanicum tumours were seen in our department between January 1983 and December 1993. Nine patients received a full course of radiotherapy with doses ranging from 35 to 54 Gy. Four patients were available for assessment after 48 months. All were alive and asymptomatic at the time of writing. In 4 other patients, pain had improved although cranial nerve function had not at the last follow-up (1-9 months). One patient died 1 month after treatment. Radiotherapy can provide long-term local control and survival in the treatment of glomus jugulotympanicum tumours. The details of clinical presentation, follow-up and the methods of investigation are presented together with a review of the literature.

Initial experience with telebrachytherapy treatment in palliation of advanced oesophageal cancer.

Ten patients with advanced metastatic squamous cell carcinoma of the middle third of the oesophagus were treated with palliative external radiotherapy and intraluminal brachytherapy. All patients had long lesions, 8-15 cm in length, and narrow lumens that did not allow the passage of a guidewire for dilatation. Improvement in dysphagia by more than 2 grades was seen in 9 of 10 patients. This finding was correlated with an increase in the size of the oesophageal lumen at the end of 6 weeks following treatment by barium swallow. No complications of treatment were noted in any patient. Low doses of external beam radiotherapy and high-dose-rate intraluminal brachytherapy can provide quick and effective palliation in advanced metastatic oesophageal carcinoma.