Thoracic irradiation in 3weeks for limited-stage small cell lung cancer: Is twice a day fractionation really needed?

PURPOSE: Many Canadian institutions treat limited-disease small cell lung cancer with 40Gy in 15 fractions delivered once-a-day in 3weeks concomitantly with chemotherapy. This regimen is convenient and seems to be effective. Here, we report and compare with a literature review the outcomes of patients with limited-stage small cell lung cancer treated in our institution with this hypofractionated regimen. PATIENTS AND METHODS: From January 2004 to December 2012, patients with limited-stage small cell lung cancer treated curatively with platinum-based chemotherapy and concurrent thoracic radiotherapy at a dose of 40Gy in 16 fractions once-a-day were eligible for this review. RESULTS: Sixty-eight patients fit the analysis criteria, including ten patients with small pleural effusion. The median age was 66years old. After a median follow-up of 77months for those alive, the median survival was 28months. At 3 and 5years respectively, the locoregional control rates were 67 and 64%, while the overall survival rates were 40 and 35%. Prophylaxis cranial irradiation was delivered to 68% of the patients. Grade 2 and 3 acute esophagitis occurred in respectively 49 and 9% of the patients. There was no grade 4 radiation-induced toxicity. All patients, except for one, completed their thoracic irradiation course without interruption. CONCLUSION: Once-a-day hypofractionated radiation with concurrent chemotherapy followed by prophylactic cranial irradiation is a practical regimen. Based on our experience and the published literature, it appears to be similarly effective as regimens using twice-daily fractionation in 3weeks, or once-daily in 6 to 7weeks with higher radiotherapy doses. Further prospective comparisons of hypofractionation with the current recommendations are needed.

The challenge of scoring radiation-induced lung toxicity.

AIMS: The increasing use of curative radiation treatment in lung cancer mandates accurate assessment of late lung toxicity. The Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer (RTOG/EORTC) scoring schema combines clinical symptoms and radiological changes and may be confusing. Some have used a scoring scale modified from the National Cancer Institute Common Toxicity Criteria (NCI-CTC) version 2 scale based on symptoms only. Clinical data using these two different scales have been compared as if they give similar results. The present study compared the outcomes using the two scales in the same group of patients. MATERIALS AND METHODS: The medical records and imaging of patients with non-small cell lung cancer who received definitive radiotherapy were reviewed. Eligible patients had a minimum follow-up of 12 months with no clinical signs of local relapse. Radiation-induced lung toxicity was scored using the RTOG/EORTC and the NCI-CTC scales. RESULTS: In total, 50 patients were analysed. All patients developed radiographic abnormalities after curative radiotherapy. Grade 0, 1, 2 and 3 toxicity was 0, 28, 49 and 23%, respectively, according to the RTOG/EORTC scale and 86, 7, 7 and 0%, respectively, according to the NCI-CTC scale, showing that the inclusion of radiographic abnormalities changes and significantly upgrades the toxicity scores. CONCLUSION: After curative radiotherapy, all patients presented some radiographic abnormality. There was no correlation with lung symptoms. The assessment of radiation-induced lung toxicity differs depending on the scoring system used. Comparison of reports that use different scoring scales should be made with caution. A scale based on symptoms only, such as the NCI-CTC scale, may be more appropriate to evaluate long-term toxicity after curative radiotherapy for lung cancer.

Hyperfractionated external radiation therapy in stage IIIB carcinoma of uterine cervix: a prospective pilot study.

PURPOSE: Brazil has one of the highest incidence of carcinoma of the cervix in the world. Half of the patients have advanced stages at the diagnosis. Due to this large number of patients we decided to conduct a prospective pilot study to investigate the tolerance to and survival rate with hyperfractionated external radiotherapy only in patients with Stage IIIB carcinoma of the uterine cervix. METHODS AND MATERIALS: Between January 1991 and December 1993, 23 patients underwent hyperfractionated external beam radiotherapy without brachytherapy. All cases were biopsy proven squamous cell carcinoma of cervix clinically Staged as IIIB (FIGO). Hyperfractionation (HFX) was given with 1.2 Gy doses, twice daily at 6-h interval, 5 days/week, to the whole pelvis up to 72 Gy within 30 working days. Complications were evaluated by an adaptation ot the RTOG Radiation Morbidity Scoring Table graded as 1 = none/mild; 2 = moderate, and 3 = severe. RESULTS: Follow-up ranged from 27 to 50 months (median 40 months) on the 9 to 23 living patients at the time of the analysis in December 1995. There was no severe acute toxicity, but moderate acute reaction was high: 74%. The commonest site of complication was the intestine where severe late toxicity occurred in 2 of 23 (9%). Overall survival rate at 27 months was 48% and at 40 months was 43%. DISCUSSION: There is little information in literature about HFX in carcinoma of the cervix. This is the third published study about it and the one that gave the highest total dose with external HFX of 60 x 1.2 Gy = 72 Gy. Theoretically, through the linear quadratic formula this schedule of HFX would be equivalent to 30 x 2 Gy = 60 Gy of standard fractionation, both treatments given in 30 working days. HFX schedules must be tested to establish their safety. Present results suggest being possible to further increase the total dose in the pelvis with hyperfractionated irradiation.

Childhood Hodgkin's disease in Campinas, Brazil.

PURPOSE: Little clinical information about Hodgkin's disease in children is available from poor countries. The object of this study is to evaluate our data in Campinas, Brazil and hope "to make one dot on the geographic map of this disease more clear." PATIENTS AND METHODS: Between 1978 and 1988, 46 patients under the age of 17 years with biopsy-proven Hodgkin's Disease (HD) were referred for evaluation at Centro Boldrini in Campinas, São Paulo state, in Brazil. Thirty-seven of them were treated and followed-up only at this Center and are the subjects of this analysis. All the original histological slides were obtained, reviewed, and classified according to the Rye system. Staging procedures included exploratory laparotomy in 33 of 37 children, but none had lymphangiography. Treatment was individualized until January 1986 when the German protocol was adopted. RESULTS: Nineteen cases were classified as nodular sclerosis, 14 as mixed cellularity, and three as lymphocyte depleted. Mean age was 7 years; male/female ratio was 2:1. Fifty percent were advanced stages III and IV and 46% (17/37) had at least one of the systemic B symptoms. Mean follow-up was 81 months (range from 41 to 174 months). Five-year actuarial overall survival was 78%. Two children (5%) had acute myeloid leukemia at 25 and 49 months after diagnosis. CONCLUSIONS: Although distribution of histological subtypes of our cases is similar to other reports in developed countries, as well as percentage of advanced stages III/IV, our patients fared worse when compared to those reports. The reason for this continues to remain unclear but it does not seem to be related to histology subtypes.

[Brain metastasis. Palliative treatment with radiosurgery]. / Metástase cerebral. Tratamento paliativo com radiocirurgia.

This is a retrospective review of 52 patients with metastatic brain disease who underwent stereotactic radiosurgery at McGill University in Montreal. The radiosurgical treatment was performed with the dynamic rotation technique in which there is continuous and simultaneous movement of treatment couch and machine gantry of a 10 MV linac. All patients were treated with a single isocenter and a median dose of 1800 cGy was delivered. In 88% of the cases radiosurgery was given after failure from whole brain conventional irradiation. All 52 cases were assessed with brain CT post radiosurgery. The median follow up time was 6 months (range 1-37 months) and the response rate (partial or complete) was 64%. Only 4 patients (7%) developed late complications related to the treatment. These findings are similar to the literature. Stereotactic radiosurgery is a well tolerated, effective and minimally invasive treatment technique which has a high response rate in selected patients with small, well delineated metastatic brain lesion. Its definitive value as a single therapy or combined with whole brain conventional radiotherapy is being studied in prospective and randomized trials.

A irradiaçäo da cadeia mamária interna em câncer da mama / Irradiation of the internal mammary chain in breast cancer

A irradiaçäo de linfonodos da cadeia mamária interna (CMI) pode ser feita com um campo direto ou com os campos tangentes que irradiam a mama. Quando näo se dispöe de feixe de eletróns, o que é a regra no Brasil, o campo direto costuma irradiar uma área importante de mediastino, pulmäo e coraçäo, se o tumor for do lado esquerdo. A dose usual de 45 a 50 Gy em tais órgäos pode näo ser inócua, causando problemas a médio ou longo prazo, principalmente para as pacientes que väo receber quimioterapia adjuvante com drogas. Além disso, nos casos de tratamento conservador, em que a mama está presente, pode ser difícil a junçäo do campo direto com o campo tangente medial. A tentativa de irradiar a CMI por campos tangentes, entrando contralateralmente 3 cm com o campo tangente medial, pode acarretar perda completa ou dose incerta na CMI, além de irradiar demasiado o pulmäo. Por fim, com a indicaçäo frequente de quimioterapia adjuvante, muitos autores optam por näo irradiar a CMI. Este artigo faz consideraçöes sobre tais assuntos, voltando-se mais aos detalhes técnicos

Resultados em tratamentos de câncer: algumas definiçöes / Results in cancer treatments: some definitions

Nem sempre definiçöes de uso diário em oncologia - como disease free survival, freedom from relapse, relapse free survival, sobrevida atuarial ou por Kaplan-Meier, respostas objetivas, significância estatística com p<0,05 e outras - säo de fácil compreensäo e/ou imediata identificaçäo. Entretanto, é fundamental conhecê-las, para que possamos melhor interpretar textos sobre assuntos oncológicos e descrever nossos próprios dados em publicaçöes ou em apresentaçöes locais. Considerando a fragilidade e as deficiências de certas apresentaçöes científicas quando comparadas com a responsabilidade de suas conclusöes (ao, por exemplo, se concluir que um tratamento é significantemente melhor que o outro), os editores de revistas médicas e os próprios leitores deveriam ser rígidos nas definiçöes de critérios de respostas e curvas de sobrevida utilizados

[Axillary dissection in cancer of the breast: a conservative approach]. / Dissecção da axila no câncer da mama: um enfoque conservador.

It is common in oncology to have more than one alternative treatment for the same clinical situation. This is particularly true in breast cancer. Traditional treatments such as Halsted Radical Mastectomies are difficult to change. It is not uncommon to see this approach in Brazil, even in initial tumors, although it is considered unnecessary unless the pectoralis muscle is involved. Radical dissection of the axilla is another controversial issue in breast cancer today. Recent publications have given support to question the routine recommendation of axillary dissection in breast cancer. It is reasonable, under certain circumstances, not to perform axillary dissection or treat the axilla with other methods. Limited axillary dissection, for instance, may present good results with less risk of arm lymphedema. This paper illustrates this point showing preliminary results of 147 breast cancer patients with local tumor treated with conservative management. Half of the patients (74) had axillary surgery while the other 73 did not. Multivariate analysis using Cox's regression was performed and showed that axillary dissection did not change survival. This information confirms similar data published in the literature.

Radiotherapy in the treatment of vertebral hemangiomas.

Symptomatic vertebral hemangiomas are not common. Although radiotherapy has been used as treatment, the data are sparse concerning total dose, fractionation and results. We report nine patients with vertebral hemangioma treated with 3000-4000 rad, 200 rad/day, 5 fractions per week, followed from 6 to 62 months. Seventy-seven percent had complete or almost complete disappearance of the symptoms. Radiotherapy schedules are discussed.

Time, dose and fractionation factor as an indicator of fibrosis of the abdominopelvic subcutaneous tissue.

Ninety-six patients treated with irradiation for epidermoid carcinoma of the uterine cervix were evaluated for the occurrence of subcutaneous tissue fibrosis of the hypogastrium. They were retrospectively stratified according to time, dose and fractionation (TDF) factors of the subcutaneous tissue, total dose delivered and treatment techniques. In our study only the TDF value of the subcutaneous tissue was unequivocally related to the occurrence of fibrosis. The numerical value of the TDF was found to be 110, above which 88.2% of the patients displayed fibrosis.