Adjuvant chemoradiation after laparoscopically assisted vaginal radical hysterectomy (LARVH) in patients with cervical cancer: oncologic outcome and morbidity.

PURPOSE: Compared to laparotomic surgery, laparoscopically assisted radical vaginal hysterectomy (LARVH) offers decreased blood loss during surgery and faster convalescence of the patient postoperatively, while at the same time delivering similar oncologic results. However, there is no data on outcome and toxicity of LARVH followed by (chemo)radiation. PATIENTS AND METHODS: A total of 55 patients (range 28-78 years) with cervical cancer on FIGO stages IB1-IIIA (Tables 1 and 2) with risk factors were submitted to either external beam radiotherapy alone [EBRT, n = 8 (14%), including paraaortic irradiation, n = 4 (2.2%); EBRT and brachytherapy (BT), n = 33 (60%); BT alone, n = 14 (25.5%)] or chemoradiation after LARVH. RESULTS: At a median follow-up of 4.4 years, the 5-year disease-free survival (DFS) was 81.8% with 84.5% overall survival (OS). Acute grade 3 side effects were seen in 4 patients. These were mainly gastrointestinal (GI) and genitourinary (GU) symptoms. Grade 4 side effects were not observed. CONCLUSION: With similar oncologic outcome data and mostly mild side effects, LARVH followed by (chemo)radiation is a valid alternative in the treatment of cervical cancer patients.

Radiation therapy for Gorham-Stout syndrome: results of a national patterns-of-care study and literature review.

PURPOSE: The German Cooperative Group on Radiotherapy for Benign Diseases conducted a national patterns-of-care study to investigate the value of radiation therapy (RT) in the management of Gorham-Stout syndrome. METHODS AND MATERIALS: In 2009 a structured questionnaire was circulated to 230 German RT institutions to assess information about the number of patients, the RT indication and technique, and the target volume definition, as well as accompanying treatments, outcome data, and early or late radiation toxicity. RESULTS: In November 2009 responses were available from 197 departments (85.6%): 29 university hospitals (14.7%), 89 community hospitals (45.2%), and 79 private RT offices (40.1%). Of these institutions, 8 (4.0%) had experience using RT, for a total of 10 cases in various anatomic sites. Four patients underwent irradiation postoperatively, and six patients received primary RT. The total doses applied after computed tomography-based treatment planning ranged from 30 to 45 Gy. After a median follow-up period of 42 months, local disease progression was avoided in 8 cases (80.0%). In 2 of these cases a progression occurred beyond the target volume. Acute and late toxicity was mild; in 4 patients RT was associated with Grade I side effects according to Radiation Therapy Oncology Group/European Organisation for Research and Treatment of Cancer criteria. The literature analysis of 38 previously published articles providing results after the use of RT in 44 patients showed stable or regressive disease in 77.3%. CONCLUSIONS: RT may prevent disease progression effectively in Gorham-Stout syndrome in 77% to 80% of cases. Total doses ranging from 30 to 45 Gy applied after computed tomography-based treatment planning are recommended.

[Fatigue and its determinants in radio-oncology]. / Fatigue und deren Determinanten in der Radioonkologie.

BACKGROUND: Fatigue is a common symptom among cancer patients, influencing their quality of life. The primary goal of his study was to identify parameters influencing fatigue, both prior to radiotherapy (RT) and changes in fatigue during RT. METHODS: 239 patients could be assessed prior to RT, 208 patients were reassessed at the end of RT. Measures comprised the Multidimensional Fatigue Inventory (MFI-20), the Resilience Scale (RS) and the SF-12 as a measure of health related Quality of Life (QoL). RESULTS: The sample revealed higher scores in the MFI and in the RS as well as lower scores in the SF-12 than normative samples. Fatigue increased significantly during RT. Fatigue at the beginning of RT was best predicted by the patients' resilience scores, changes of fatigue scores during RT depended on the patients' initial fatigue scores, the decrease in haemoglobin and the patients' experience with RT. CONCLUSIONS: Fatigue appears to be an important problem among cancer patients receiving RT. Resilience proved to powerfully predict the patients' fatigue at the beginning of RT. This result confirms other studies showing resilience to be an important psychological predictor of QoL and coping in cancer patients. The change of fatigue during RT is mainly related to disease- and treatment-related factors.

Benefit of a 17-year long-term bisphosphonate therapy in a patient with Gorham-Stout syndrome.

This case report of a 61-year-old woman suffering from Gorham-Stout syndrome shows osteolyses of the left pelvis, proximal femur and lumbar spine. The therapeutic regime has included two courses of percutaneous radiotherapy and also continuous application of bisphosphonates over 17 years. Despite this antiresorptive therapy, elevated urinary excretion of desoxypyridinoline has indicated the persistence of increased bone destruction. The radiological progression following bisphosphonate treatment was only moderate. However, physical disability is reduced, but without soaring handicaps suggesting that long-term bisphophonate therapy is a therapeutical option for this rare syndrome.

The need for psychosocial support and its determinants in a sample of patients undergoing radiooncological treatment of cancer.

OBJECTIVE: The primary goal of this study was to examine the need for psychosocial support in a consecutive sample of cancer patients undergoing radiotherapy (RT). Out of an initial sample of 250 patients, 239 patients could be assessed at the beginning of their RT. Two hundred eight patients were reassessed at the end of RT 4-8 weeks later. METHODS: Measures comprised the Hornheide Screening Instrument, the Multidimensional Fatigue Inventory, the Resilience Scale, and the Short Form 12 as a measure of health-related quality of life (QoL). Medical and radiological data were continuously registered. RESULTS: Within the sample, the need for psychosocial support as reflected in the screening instrument was high (>70%). Patients with the need for psychosocial support revealed significantly higher fatigue scores than patients who where not identified as needing psychosocial support. Furthermore, a negative correlation of the need for psychosocial support and QoL as well as resilience could be observed. QoL turned out to be the strongest predictor for the need of psychosocial support. CONCLUSION: The study confirmed that the need for psychosocial support is an important aspect in the treatment of cancer patients undergoing RT, which appeared to be powerfully predicted by the patients' health-related QoL. Fatigue turned out to be an important illness- and treatment-related factor that affects QoL. Psychological interventions for cancer patients should explicitly focus on decreasing patients' fatigue and increasing their resilience, thus improving their QoL.

Lymph edema of the lower extremities after lymphadenectomy and radiotherapy for cervical cancer.

PURPOSE: To assess the incidence of clinical lymph edema after lymphadenectomy and postoperative radiotherapy (RT). PATIENTS AND METHODS: From 1994-2002 192 patients with risk factors for recurrence received radiotherapy with FIGO I (58.8%), II (35.4%), III (4.2%) or IV (1.6%). RT consisted of teletherapy (10.4%), brachytherapy of the vaginal vault (20.8%) or a combination of both (68.8%). Additional chemotherapy was given in 69 patients (35.9%). Surgery comprised laparoscopically assisted radical vaginal hysterectomy (LARVH) (35.4%), radical abdominal hysterectomy (RAH) (48.4%), simple hysterectomy (HE) (11.5%) or exenteration (4.7%). RESULTS: 73 patients had lymph node metastases, 119 had negative lymph nodes. In patients with LARVH 6-74 (median 30) lymph nodes were removed, with RAH 3-70 (median 21 lymph nodes), and after HE or exenteration 5-50 (median 13 lymph nodes). 90 patients had 25 or less lymph nodes removed, 83 patients more than 25 lymph nodes removed. Prognostic factors, such as age, FIGO stages, histologic grading and type of histology were well balanced in these cohorts. 45 (23.4%) of all patients developed clinically relevant lymph edema of the lower limb with a median latency of 11 (1-121) months. When 25 or less lymph nodes were removed 17.8% of patients developed leg edema, when more than 25 lymph nodes were removed 32.5% of patients were diagnosed with lymph edema (p = 0.025). Radiotherapy and chemotherapy had no influence on the incidence of leg edema. Overall survival at 5 (10) years was independent of number of lymph nodes removed. CONCLUSION: The data suggest increasing rates of leg edema with increasing number of lymph nodes dissected independent of the type of radiotherapy and chemotherapy performed. The lymph node sampling policy should be planned carefully in respect to minimize the risk of leg lymph edema.

Stage-adjusted chemoradiation in cervical cancer after transperitoneal laparoscopic staging.

PURPOSE: To evaluate the impact of transperitoneal laparoscopic staging on choice of subsequent therapy including oncologic outcome and toxicity of chemoradiation after surgical staging. PATIENTS AND METHODS: 101 patients with cervical cancer FIGO IB1-IVB underwent chemoradiation after transperitoneal laparoscopic staging. RESULTS: 101 women (FIGO IB1-IVB) were laparoscopically staged. In 68/101 patients, pelvic and/or paraaortic lymph node metastases were confirmed histologically. Only 17/101 patients (17%) retained their original FIGO stage after laparoscopy. Laparoscopic staging and chemoradiation were well tolerated. Laparoscopic debulking of tumor-involved lymph nodes resulted in significantly improved overall survival. CONCLUSION: In patients with cervical cancer, laparoscopic staging led to an upstaging of 83% of cases with significant impact on therapeutic strategies. Nodal debulking prior to chemoradiation improves the prognosis of node positive women. Pretherapeutic laparoscopic staging should be the basis of the primary chemoradiation in patients with cervical cancer.

The influence of resilience on fatigue in cancer patients undergoing radiation therapy (RT).

PURPOSE: The primary goal of the study was to determine if resilience influences fatigue in a consecutive sample of cancer patients treated with radiotherapy (RT) at the beginning and at the end of the treatment. METHODS: Out of an initial sample of 250 patients, 239 could be assessed at the beginning of their RT. Two hundred and eight patients were reassessed at the end of RT 4-8 weeks later. Measures comprised the Resilience Scale (RS), the Multidimensional Fatigue Inventory (MFI), and the SF-12 as a measure of health related Quality of Life (QoL). Medical data were continuously registered. RESULTS: As hypothesized, the sample revealed higher scores in the MFI and lower scores in the SF-12 than normative samples. Resilience scores were higher than in the norm population. Fatigue increased during RT. Using multiple regression analyses, fatigue scores at the beginning of treatment were shown to be higher in inpatients and patients undergoing palliative treatment. Initial fatigue was best predicted by the patients' initial resilience scores. Changes of fatigue scores during RT depended on initial scores, decrease in Hb and the patients' experience with RT. Resilience could not be determined as a predictor of changes in fatigue during RT. CONCLUSIONS: The study confirmed that fatigue is an important problem among RT patients. Resilience turned out to powerfully predict the patients' fatigue at least early in RT. This result is in line with other studies, showing resilience to be an important psychological predictor of QoL and coping in cancer patients. On the other hand, resilience seems to have little influence on treatment related fatigue during RT.

Uterus necrosis after radiochemotherapy in two patients with advanced cervical cancer.

BACKGROUND: Simultaneous platinum-based radiochemotherapy is the standard of care for patients with advanced or node-positive cancer of the uterine cervix. A large body of literature concerning therapy-related acute and late morbidity is available. Chemoradiation-associated necrosis of the uterus has not been described so far. CASE REPORT: Two patients are reported who were treated by combined chemoradiation between 2004 and 2005 for histologically confirmed cervical cancer following laparoscopic staging. Both patients were diagnosed with squamous cell cancer of the cervix FIGO stage IIB (T2b pN1 pM1 LYM G2) and FIGO IIIA (T3a pN1 M0 G2), respectively. External-beam radiotherapy was applied in a 3-D-planned four-field technique, covering pelvic lymph nodes and primary tumor. Patient #1 received additional paraaortic irradiation. Patient #2 underwent 5 x 5 Gy brachytherapy covering the tumor. Simultaneously, cisplatin was given to both patients. Following chemoradiation, both patients developed pelvic pain and an elevation of C-reactive protein (CRP) in the presence of a normal leukocyte count. Both patients underwent relaparoscopy, and necrosis of the uterus combined with partial necrosis of the bladder was diagnosed in patient #1. Patient #1 underwent total supralevatoric exenteration and patient #2 laparoscopically assisted hysterectomy with bilateral salpingo-oophorectomy. CONCLUSION: In patients with persisting or incident pelvic pain, questionable findings in imaging techniques and/or elevated inflammation parameters following completion of chemoradiation for cervical cancer, differential diagnosis should include radiogenic necrosis of the uterus and other pelvic organs. Laparoscopy is an ideal technique to exclude or confirm this diagnosis.

Is there a benefit of pretreatment laparoscopic transperitoneal surgical staging in patients with advanced cervical cancer?

OBJECTIVE: At present, cervical cancer remains the only gynecologic tumor, which is staged by clinical examination according to FIGO. This is associated with a high percentage of over- and understaging of tumor extent. With the operative, especially laparoscopic staging, exact information about intraabdominal tumor spread, lymph node metastases, and involvement of adjacent organs is possible. However, the advantage of operative staging is still discussed controversially. The aim of this study is to describe the laparoscopic transperitoneal staging procedure in patients with cervical cancer and their oncologic outcome after primary chemoradiation. METHODS: From November 1994 to October 2003, 456 consecutive patients with histologically confirmed primary cervical cancer were admitted to the Department of Gynecology of the Friedrich-Schiller-University Jena, Germany. Out of these, 84 patients with locally advanced tumor (tumor size>or=4 cm) and/or lymph node involvement and/or tumor infiltration to bladder or rectum were selected by a standardized laparoscopic staging procedure for primary chemoradiation. Data of surgery, chemoradiation, and follow-up were analyzed retrospectively for these patients. RESULTS: The mean age of the patients was 54 years (26-80), and the mean body-mass-index was 24.8 (17.9-42.2). Preoperative clinical evaluation showed a stage distribution according to FIGO with stage IB1 in 15.5%, IB2 in 15.5%, IIA in 8.3%, IIB in 23.8%, IIIA in 8.3%, IIIB in 21.4%, IVA in 6%, and IVB in 1.2%. In 15 out of 84 (17.8%) patients, intraabdominal tumor spread was diagnosed by laparascopy. In 24 out of 84 (28.5%) patients, invasion of bladder and/or rectum was proven histologically after biopsy. In 60 out of 84 (71%) patients, lymph node metastases were confirmed histologically. In 2 out of 13 patients with FIGO-stage Ib1, skip metastases in infrarenal paraaortic lymph nodes were seen. Removal of more than 5 pelvic and/or more than 5 positive paraaortic lymph nodes was associated with significant improvement of overall survival. According to the histological findings following laparoscopic staging in 36 out of 84 (43%) patients, a higher tumor stage was diagnosed. If tumor involvement of lymph nodes is also included, an upstaging in 73/84 (87%) of patients has to be noted down. Downstaging was not necessary in any patient following laparoscopic evaluation. CONCLUSION: Only operative staging gives exact information about tumor extension in patients with locally advanced and/or nodal positive cervical cancer and allows individual treatment planning. This can be done successfully by a transperitoneal laparoscopic approach without serious adverse effects delaying chemoradiation. Debulking of tumor-involved lymph nodes significantly improves overall survival and should be performed prior to primary chemoradiation. Laparoscopic staging should be the basis for all treatment studies in order to group patients according to true tumor extent.

[A population-based study on variations in the use of adjuvant radiotherapy in breast cancer patients]. / Bevölkerungsbezogene Studie über die Anwendung adjuvanter Strahlentherapie bei Patientinnen mit Mammakarzinom.

AIM: The assessment of the compliance with consensus recommendations for adjuvant radiation therapy among women with breast cancer. The study is based on data obtained in a population-based cohort-study, which was performed to evaluate the quality of health care for patients with breast cancer. PATIENTS AND METHODS: About one million inhabitants live in the study region Eastern Thuringia, 2,031 cases with invasive breast cancer without distant metastasis (MO) or inflammatory spread were registered from 1995 to 2000. Out of these 1,700 with complete documentation of covariates were included in multivariate analysis. To examine the simultaneous influence of all clinical factors and "caseload" on the likelihood to receive adjuvant radiation therapy a logistic regression model was fitted for radiation therapy after mastectomy. In order to describe the impact of each individual clinic on treatment decision as "caseload" was replaced by the clinics with more than 30 primary treatments. RESULTS: Following breast conserving therapy (BCT) 90.6% of the patients received adjuvant radiation therapy. In the univariate analysis older age was negatively associated with the use of radiation therapy among women with BCT (Table 1). Furthermore, comorbid conditions were negatively associated with the use of radiation therapy. For all other cofactors no associations were found. Subsequent to mastectomy 33.0% of the women underwent radiation therapy (Table 2). Associations between the use of radiation therapy and age, tumor category, number of positive lymph nodes, multiple tumors, histologic differentiation grade, residual tumor as well as hormone receptor status were found. In the multivariate analysis only older age (>/= 70 years) was identified as negative indicator for the utilization of radiation therapy. Among patients with mastectomy increasing tumor size was a positive predictor on radiation therapy (Table 3). In addition more than three positive lymph nodes, multiplicity, poor histologic differentiation grade (G3/4), medial localization, and younger age (35-49 years) were positive predictors for the application of radiation therapy. For R-classification, hormone receptor status and comorbidity no influence on the use of radiation therapy was observed. Among clinics adjusted for case-mix variations in the compliance of treatment recommendation both following BCT and mastectomy were found (Figure 1). CONCLUSION: Following BCT compliance with treatment recommendations regarding radiation therapy was high. Women in older age or with comorbidities received less often radiation therapy. Subsequent to mastectomy indicators for the use of radiation therapy were identified. Among clinics differences in the adherence to treatment recommendations were observed.