The potential role of hypofractionated accelerated radiotherapy to cosmesis for stage I-II breast carcinoma: a prospective study.

PURPOSE: To evaluate the acute and late effects as well as the cosmetic results of an accelerated hypofractionated radiotherapeutic schedule in breast cancer irradiation. METHODS: Fifty-four patients with stage I-II invasive breast cancer receiving postoperative radiotherapy (RT) after lumpectomy and axillary node dissection were studied. All patients received RT with 6 MV linear accelerator with a total tumor dose of 53 Gy (Equivalent dose-EQD2- 60 Gy), 2.65 Gy per fraction, in 20 fractions. Acute and late effects as well as cosmetic results were assessed using the European Organization for Research and Treatment of Cancer and Radiation Therapy Oncology Group (EORTC-RTOG) Cosmetic Rating System. RESULTS: By the end of RT 66.7% of the patients developed no toxicity, while 24.1% showed grade 1 and 9.3% grade 2 acute skin toxicity. After 6 months 90.7% of women showed grade 0 late toxicity while 100% of women recovered completely 2 years after RT. There was no local or distant recurrence during 5-year follow up. CONCLUSION: The accelerated hypofractionated schedule appears to be an acceptable alternative to the traditional longer RT schedules, without late toxicity.

Limitations of quantitative bone-mass measurements using assessments of first-order statistics of grey-level histograms in plain radiographs.

PURPOSE: To evaluate the quality assurance of image-processing techniques in plain radiographs of skeletal structures. MATERIAL AND METHODS: Twenty-two patients were studied, each with one osteolytic metastasis. Accuracy and precision of tube voltage and timer were confirmed. The mean value of grey-level histograms in plain radiographs (MVGLHs) was assessed. The deviation was monitored after five sets of sequential X-rays retaining the same settings for each radiograph. RESULTS: Deviation was significantly higher in anatomical areas of thorax (21.2%) and abdomen (42.4%), while the consistency of MVGLH for weight-bearing bones was satisfactory with a maximum deviation of 2.9% (P<0.001, Kruskal-Wallis test). CONCLUSION: Assessment of MVGLH in plain radiographs is a reliable method for the extremities and generally for regions without superimposed movable tissues.

Primitive neuroectodermal tumour in a 60-year-old man: a case report and literature review.

Primitive neuroectodermal tumour (PNET) is very rare, especially in adults. We report a 60-year-old man presented with a PNET. The symptoms at the time of diagnosis were intense headache, Broca's aphasia and right hemiparesis. Only an open biopsy was performed. Irradiation of the primary tumour was the main treatment (total tumour dose 59.8 Gy) because of serious haematological side effects due to chemotherapy. The patient tolerated radiation therapy extremely well and his neurological symptoms were improved. 1 month after completion of radiotherapy, MRI showed no regression of the tumour. Clinical deterioration was observed 10 months after the initial diagnosis and the patient died 2 months later. In cases of PNET, initial therapy is surgical bulk reduction whenever possible. Irradiation of the cerebrospinal axis is justified as a routine treatment but, owing to the radioresistance of the tumour, the addition of multiregimen chemotherapy appears to improve survival, according to the literature.

Impact of inguinal dissection on prognosis of early-stage squamous cell carcinoma of the vulva--a retrospective analysis.

BACKGROUND: Inclusion of inguinal lymphadenectomy in the surgical procedure is a potential prognostic factor for squamous cell vulvar carcinoma. PATIENTS AND METHODS: A total of 33 women with early-stage squamous cell vulvar carcinoma were analyzed retrospectively. Before the establishment of FIGO criteria in 1983, 17 patients with stage I and 2 patients with stage II were evaluated clinically without inguinal lymphadenectomy. All patients underwent post-operative radiotherapy with a median dose of 45 Gy to the pelvis (vulva included) and boost dose to the vulva ranging from 10 to 20 Gy. Factors assessed for prognostic value included age, inguinal lymph node dissection, differentiation grade, and total irradiation dose to the vulva and pelvis. RESULTS: The log-rank test and the univariate regression analysis revealed that all above factors except irradiation dose decreased the overall survival. In the multivariate regression analysis, differentiation grade and the absence of inguinal dissection were independent predictors for decreased survival with a relative risk up to 2.6 (95% CI = 1.3, 5.6) and 2.7 (95% CI = 1.31, 5.44), respectively. CONCLUSION: Clinical evaluation of inguinal lymph node involvement is inadequate and node dissection is definitely the only appropriate surgical procedure for vulvar carcinoma.

Intraoperative hyperthermia and chemoradiotherapy for inoperable pancreatic carcinoma.

The aim of this study was to evaluate the tolerability and the possible clinical benefit of intraoperative hyperthermia combined with multischedule chemotherapy and bypass surgery for the palliative treatment of inoperable pancreatic cancer. Ten patients with unresectable adenocarcinoma of the pancreas received preoperative chemotherapy [5-fluorouracil (5-FU)], bypass surgery and postoperative chemotherapy (5-FU, doxorubicin and cisplatin) plus sandostatin and radiotherapy (45 Gy, 25 fractions, 5 days a week). A single session of intraoperative hyperthermia was performed, by using a waveguide-type applicator (433 MHz). The tumour region was heated to 43-45 degrees C for up to 60 min, while 500 mg 5-FU was infused simultaneously through the gastroduodenal into the splenic artery. Postoperative recovery was uneventful for all patients. A brief instrument was developed for evaluating patients' quality of life. Chemotherapy-related toxicity included myelosuppression, vomiting, alopecia and increase in blood urea nitrogen (BUN), creatinine, SGOT and SGPT. Glucose and amylase determinations remained within normal limits throughout the whole treatment. There was a significant improvement before and 1 month after combined treatment in Eastern Cooperative Oncology Group (ECOG) status (1.8 +/- 0.4), Scott-Huskinsson pain scale (3.2 +/- 0.8) and quality of life score (30.5 +/- 6.7). No progressive disease was noticed and the median overall survival was 11 (SE = 2.4) months. There was also a significant (P = 0.002, Wilcoxon test) decrease in values of both serum carcinoembryonic antigen (CEA) and carbohydrate antigen (CA19-9), from 7.6 +/- 1.3 ng/mL and 875.7 +/- 104.8 U/mL to 3.5 +/- 0.7 ng/mL and 65.3 +/- 14.1 U/mL respectively. The first clinical results suggest a potential advantage of using combined intraoperative hyperthermia, chemotherapy and postoperative radiotherapy in the palliative treatment of the adenocarcinoma of the pancreas. The whole procedure seems to be free of perioperative morbidity, while the chemotherapy toxicity was rather moderate. However, the preliminary nature limits the general applicability of our results.

Intraoperative hyperthermia in conjunction with multi-schedule chemotherapy (pre-, intra- and post-operative), by-pass surgery, and post-operative radiotherapy for the management of unresectable pancreatic adenocarcinoma.

The aim of this study was to evaluate the potential role of intraoperative hyperthermia (IOHT) in the management of stage IV pancreatic adenocarcinoma. Twenty-seven patients (group A) received pre-operative chemotherapy (5-FU), by-pass surgery with intraoperative bolus infusion of 5-FU and post-operatively multi-agent chemotherapy plus sandostatin and external beam irradiation (45Gy, 25 fractions, 5 days a week). In a non-randomized way, 10 patients (group B) received an additional single session of IOHT (43-45 degrees C, 1h) performed directly on the tumour using a waveguide applicator (433MHz) with interstitial measurements of temperature measured. A brief instrument was developed for evaluating patients' quality of life. No progressive disease (PD) was noticed in group B vs 11% (3/27) of PD in group A. There was also a significant increase of overall survival (OS) in group B vs A patients (p = 0.029, log-rank test). Moreover, there was a significant improvement for group B vs A patients regarding Karnofsky performance status (p < 0.001, Mann-Whitney test), pain score (p < 0.001, Mann-Whitney test) and quality of life score (p = 0.031, Mann-Whitney test). A significant correlation was noticed between OS and thermal parameters such as average T(min) (p = 0.043), average T(max) (p = 0.027) and cumulative minutes T(90) >or= 44 degrees C (p < 0.001). Combined IOHT with chemotherapy (pre-, intra- and post-operative) and external beam post-operative radiotherapy seem to have a potential benefit in the management of unresectable adenocarcinoma of the pancreas, concerning local response, OS and quality of life. Further clinical studies to evaluate the benefit of IOHT suggested in this study are warranted.

A short radiotherapy course for locally advanced non-small cell lung cancer (NSCLC): effective palliation and patients' convenience.

In order to facilitate patients with symptomatic locally advanced NSCLC, especially those coming from remote areas we have employed two palliative RT schedules. The first (S1) is the well known from Medical Research Council (MRC) randomized studies 2 x 8.5 Gy one week apart and the second (S2) is a two-day RT schedule: three fractions of 4.25 Gy are given on the first day and two fractions of 4.25 Gy on the second day. The records of 92 patients were reviewed (48 for S1 and 44 for S2). Patients, disease characteristics and results were similar for both groups; rates of symptom disappearance were for S1 and S2, respectively: cough 24 and 20%, hemoptysis 60 and 67%, chest pain 57 and 64% and dyspnoea 55 and 45% The overall condition improved in 39 and 36%, respectively. The median palliation time in days was in S1 and S2, respectively: cough 70 and 66, haemoptysis 133 and 139, chest pain 68 and 62 and dyspnoea 74 and 69 days. The median survival was 25 weeks in both S1 and S2 groups (P=0.89 log-rank test). At 52 weeks (one year), ten (21%) and seven (16%) of the patients were alive in S1 and S2 groups, respectively. At 104 weeks, the corresponding figures were two (4%) and two (4.7%) for S1 and S2. Our results are in accordance to those reported in literature regarding the safety and efficacy of palliative hypofractionated radiotherapy schemes. Their use in selected patients could be cost-effective and convenient for patients especially those coming from remote areas.

Minor prognostic factors in squamous cell vulvar carcinoma.

PURPOSE OF THE STUDY: To evaluate minor prognostic factors in a patient population with squamous cell vulvar carcinoma, with particular attention to age, smoking, obesity and parity. METHODS: A total of 50 women with invasive squamous cell vulvar carcinoma were retrospectively analyzed. Factors assessed for prognostic value included age, obesity, diabetes, hypertension, smoking and parity. RESULTS: The log-rank test and the univariate regression analysis revealed that all factors decreased the overall survival. In the multivariate regression analysis only age, obesity, smoking and parity were independent predictors for survival. The relative risk of death for elderly and patients, obese smokers, and patients with more than three deliveries was 1.008, 1.159, 1.411 and 2.532, respectively. Hypertension and diabetes seemed to be questionable prognostic factors. CONCLUSION: Smokers, patients who had more than three children, body mass index >27, and were older than 73 years had a poorer survival rate.

Dermatitis during radiation for vulvar carcinoma: prevention and treatment with granulocyte-macrophage colony-stimulating factor impregnated gauze.

The aim of this study was to determine the effectiveness of granulocyte-macrophage colony-stimulating factor (GM-CSF) impregnated gauze in preventing or healing radiation-induced dermatitis. Sixty-one patients were irradiated for vulvar carcinoma. Thirty-seven applied steroid cream at irradiated areas throughout radiotherapy (Group A) and 24 patients applied additionally GM-CSF impregnated gauze (40 micrcog/cm2 of skin-irradiated area, twice per day) in addition to the steroid cream, after 20 Gy of irradiation (Group B). The score of skin reactions (P=0.008, chi2 test) and the time interval of radiotherapy interruption (P=0.037, Mann-Whitney U test) were statistically significantly reduced in Group B patients. Multivariate analysis of variance showed for this group not only a significant reduction in the Sum of Gross Dermatitis Scoring (P<0.001, adjusted for Duration of Dermatitis) but also a significant reduction of the healing time (P=0.02, adjusted for Sum of Gross Dermatitis Scoring). The pain grading was less (P=0.014, chi2 test) and pain reduction was noticed sooner after the application of GM-CSF impregnated gauze (P=0.0017, Mann-Whitney U test). Multivariate logistic regression analysis showed that the only significant effect on dermatitis score is due to Body Mass Index (P=0.034) and the application of GM-CSF (P=0.008). GM-CSF impregnated gauze can be effective in preventing and healing radiation-induced dermatitis and in reducing the interruption intervals of radiotherapy for vulvar carcinomas.

Cytoreductive surgery combined with intraoperative chemo-hyperthermia and postoperative radiotherapy in the management of advanced pancreatic adenocarcinoma: feasibility aspects and efficacy.

BACKGROUND/PURPOSE: The aim of our study was to evaluate the feasibility and the efficacy of cytoreductive surgery (CS) with intraoperative chemo-hyperthermia in the management of advanced stage IVA (T4N0M0) pancreatic cancer. METHODS: From August 1995 through March 1996, seven patients with unresectable adenocarcinoma of the pancreas underwent CS, with preoperative chemotherapy (5-fluorouracil [FU] for 96 h), plus 45-Gy external beam postoperative irradiation with a 6-MeV linear accelerator (1.8 Gy per fraction, 5 days per week). A single session of intraoperative hyperthermia was performed with a waveguide-type applicator operating at 433 MHz, and temperature was measured by inserting a flexiguide needle catheter carrying a thermometry probe with three measuring points into the tumor. The tumor region was heated to 43 degrees C-45 degrees C for up to 60 min, while 5-FU 500 mg was injected simultaneously through the gastroduodenal artery into the splenic artery (intraoperative regional chemotherapy). RESULTS: Postoperative recovery was uneventful for all patients. After the combined treatment, there was a significant decrease in the values of both serum carcinoembryonic antigen (CEA; P = 0.017, Wilcoxon test) and carbohydrate antigen (CA)19-9 ( P = 0.016; Wilcoxon test), from 7.6 +/- 1.5 ng/ml CEA and 869.6 +/- 126.9 U/ml CA to 3.5 +/- 0.8 ng/ml CEA and 104.7 +/- 35.4 U/ml CA19-9. Moreover, there was a significant improvement ( P = 0.016; Wilcoxon test) in Eastern Cooperative Oncology Group performance status, pain score, and body mass index. The median overall survival was 18.5 (SE, 1.8) months. CONCLUSIONS: Our preliminary clinical results suggest the tolerability and the considerable potential advantage of using cytoreductive resection with preoperative chemotherapy, intraoperative chemo-hyperthermia, and external beam postoperative radiotherapy for the management of advanced adenocarcinoma of the pancreas.

Postoperative tailored radiotherapy for locally advanced breast carcinoma during pregnancy: a therapeutic dilemma.

A 45-year-old woman with breast carcinoma was found to be pregnant during postoperative radiotherapy. The pregnancy was desired. We performed in vivo and phantom radiation dosimetry. No effects on the embryo or treatment disadvantages for the patient were expected. Thirty-six months post partum the baby is healthy and the mother is free of disease.

A benign-looking subcutaneous metastasis from squamous cell cervical carcinoma: A case report and review of the literature.

A 30-year-old woman with a stage IIIB grade 3 squamous cell cervical carcinoma and pelvic lymph node metastases was treated with external beam radiotherapy and intracavitary brachytherapy. One month after the completion of the treatment, a rubbery, movable, and painless mass appeared in the lower third and outer aspect of her right thigh. The overlying epidermis was intact. The whole clinical picture and CT scan image indicated a benign tumor. Biopsy revealed a nonkeratinizing, grade 2-3, squamous cell carcinoma similar to the primary cervical tumor. She then received six cycles of chemotherapy (cis-platinum and 5-fluorouracil) with transient partial response. The patient died one year after the diagnosis of the disease. This is the 29th case of cutaneous metastasis from a cervical carcinoma, the seventh localized on the leg, but the first solitary one with a benign-looking appearance reported since 1855. The possible mechanism of this rare metastasis is debated and the literature is reviewed.

Radiation therapy alone for growth hormone-producing pituitary adenomas.

We present our experience in the treatment of growth hormone (GH)-producing pituitary adenomas using irradiation alone. Between 1983 and 1991, 21 patients suffering from GH-secreting pituitary adenomas were treated with radiotherapy alone. Two bilateral opposing coaxial fields were used in 10 patients and in the remaining 11 a third frontovertex field was added. Treatment was given in 1.8-2 Gy daily fractions and total dose ranged between 45 and 54 Gy. Treatment was given using a cobalt unit. Four patients treated with somatostatin prior to and 14 patients treated after the end of radiotherapy experienced symptom relief for 6-28 weeks. The 5-year actuarial rate of disease control was 72%. Five out of six failed patients had macroadenomas. Hypopituitarism was observed in 5/21 (24%) patients. Whereas RT alone is effective in the treatment of microadenomas, this is not true for large infiltrative macroadenomas.

CT and MR of pineal region tumors.

Magnetic Resonance (MR) imaging features of pineal region tumors were analyzed in 14 oncologic cases. The tumors were classified as germ-cell tumors, glial tumors, pineal parenchymal tumors, meningiomas, and cysts. They demonstrated different MR signal characteristics on precontrast scans and nodular or ring type enhancement with occasional central lucencies, except for benign cysts, which have not shown enhancement. MR images were useful in defining the relationship of the tumor to the posterior third ventricle, sylvian aqueduct, vein of Galen, and tentorium. Although CT can demonstrate in more evident fashion displacement of the original pineal calcification as well as tumor calcifications, MR imaging demonstrates different signal characteristics in germinomas and pineoblastomas which can be a useful adjunct in the evaluation and differential diagnosis of these tumors.