Hypofractionated helical intensity-modulated radiotherapy of the prostate bed after prostatectomy with or without the pelvic lymph nodes - the PRIAMOS trial.

BACKGROUND: While evidence on safety and efficacy of primary hypofractionated radiotherapy in prostate cancer is accumulating, data on postoperative hypofractionated treatment of the prostate bed and of the pelvic lymph nodes is still scarce. This phase II trial was initiated to investigate safety and feasibility of hypofractionated treatment of the prostate bed alone or with the pelvic lymph nodes. METHODS/DESIGN: A total of 80 prostate cancer patients with the indication for adjuvant radiotherapy will be enrolled, where 40 patients with a low risk of lymph node involvement (arm 1) and another 40 patients with a high risk of lymph node involvement (arm 2) will each receive 54 Gy in 18 fractions to the prostate bed. Arm 2 will be given 45 Gy to the pelvic lymph nodes additionally. Helical Tomotherapy and daily image guidance will be used. DISCUSSION: This trial was initiated to substantiate data on hypofractionated treatment of the prostate bed and generate first data on adjuvant hypofractionated radiotherapy of the pelvic lymph nodes. TRIAL REGISTRATION: ClinicalTrials.gov; NCT01620710.

Safety and efficacy of thoracic external beam radiotherapy after airway stenting in malignant airway obstruction.

PURPOSE: We retrospectively evaluated the outcome and toxicity of external beam radiotherapy (EBRT) after airway stents were placed in patients treated for malignant airway obstruction. METHODS AND MATERIALS: Between 2004 and 2009, we performed airway stenting followed by EBRT in 43 patients for symptomatic primary lung cancer (n = 31) or other thoracic malignancies (n = 12). The median time interval between stent placement and first irradiation was 14 days. A median total dose of 50 Gy was delivered. Sixty-seven percent of the patients had reduced performance status (Karnofsky performance score, ≤70). RESULTS: EBRT had to be stopped prematurely in 16 patients (37%), at a median total dose of 17 Gy, for various reasons. In this group of patients, the survival was poor, with a median overall survival (OS) of only 21 days. Twenty-seven patients (63%) completed radiotherapy as planned, with a median OS of 8.4 months. Fourteen of 43 patients (33%) developed at least one Common Terminology Criteria for Adverse Event of grade 3 to 5. The most common event was a malignant restenosis of the stent leading to asphyxia (n = 7), followed by fistula formation (n = 4), necrosis (n = 3), mediastinitis with abscess (n = 1), secondary nonmalignant airway stenosis (n = 1), and hemoptysis (n = 1). With the exception of one event, all events were associated with a local progression of the tumor. CONCLUSIONS: Although the long-term prognosis for patients with malignant airway obstruction is poor, airway stenting combined with EBRT offers a possible therapeutic option, achieving fast relief of acute respiratory distress with an associated antitumor effect, resulting in a potential survival benefit. However, due to local advanced tumor growth, increased rates of adverse events are to be expected, necessitating careful monitoring.

Kyphoplasty in patients with multiple myeloma a retrospective comparative pilot study.

BACKGROUND: This retrospective study of 73 myeloma patients with painful vertebral lesions compares clinical and radiomorphological outcomes up to 2 years after additional kyphoplasty, radiation therapy or systemic treatment only. METHODS: We assessed pain, disability and radiomorphological parameters by visual analogue scale (VAS 0-100), Oswestry Disability Index and by re-evaluating available follow-up X-rays, respectively, in patients that were treated according to a clinical pathway. RESULTS: After 2 years the VAS score was reduced in all groups by 66 ± 8.2 (kyphoplasty), 35 ± 10.5 (radiation therapy) and 38 ± 20.5 (systemic therapy only). Only after kyphoplasty we observed a significantly reduced Oswestry Disability Index after 1 year (P < 0.001). Vertebral height remained stable after kyphoplasty (P = 0.283), in contrast to a progressive height loss in the other groups (P = 0.013 and P = 0.015 for radiation and systemic therapy only, respectively). Two years after kyphoplasty and radiotherapy the overall vertebral fracture incidence was significantly decreased as compared to the group after systemic therapy only (9.7% of all thoracic and lumbar vertebrae had new vertebral fractures after systemic therapy only, 2% after kyphoplasty (P < 0.001), 4.8% after radiation (P = 0.032)). CONCLUSION: Additional kyphoplasty was more effective than additional radiation or systemic therapy in terms of pain relief, reduction of pain associated disability and reduction of fracture incidence of the entire lumbar and thoracic spine.

Radiotherapy.

Solitary plasmocytoma occurring in bone (solitary plasmocytoma of the bone, SBP) or in soft tissue (extramedullary plasmocytoma, EP) can be treated effectively and with little toxicity by local radiotherapy. Ten-year local control rates of up to 90% can be achieved. Patients with multiple myeloma often suffer from symptoms such as pain or neurological impairments that are amenable to palliative radiotherapy. In a palliative setting, short treatment schedules and lower radiation doses are used to reduce toxicity and duration of hospitalization. In future, low-dose total body irradiation (TBI) may play a role in a potentially curative regimen with nonmyeloablative conditioning followed by allogenic peripheral blood stem cell transplantation.

Radiotherapy of solitary plasmacytoma.

Solitary plasmacytoma of the bone (SBP) or extramedullary plasmacytoma (EP) are rare neoplasms amenable to local radiotherapy. In this retrospective analysis, we report the University Heidelberg experience in the treatment of solitary plasmacytoma. From 1995 to 2008, 18 patients were treated with local radiotherapy. Ten patients suffered from SBP, eight patients showed a single extramedullary lesion. Local radiotherapy with a median dose of 45 Gy yielded excellent local control with only one patient suffering from local relapse. SBP and EP had significantly different 5-year multiple myeloma-free survival rates of 36.8% and 86.7%, respectively. However, no significant difference in overall survival could be detected. Radiotherapy can achieve excellent local control of solitary plasmacytoma. Progression to multiple myeloma, especially in the case of SBP, remains to be addressed by further studies.

Palliative total skin electron beam therapy (TSEBT) for advanced cutaneous T-cell lymphoma.

Our aim was to analyze the effectiveness of palliative total skin electron beam therapy (TSEBT) in the management of advanced cutaneous T-cell non-Hodgkin's lymphoma (CTCL). Eighteen patients (median age 59 years) with advanced and therapy-refractory CTCL in stages IIB-IV were treated with TSEBT for the first time. The most common histological subtype was Mycosis fungoides (72%). All patients suffered from lymphoma-associated symptoms. Median daily fractions of 1 Gy were administered up to a median total dose of 25 Gy. The median follow-up period was 11 months. Nine patients (50%) achieved a complete response and seven patients (39%) had a limited response. The actuarial one-year progression-free survival was 24%. Four patients (22%) had continuing remission over a median period of six months. Lymphoma associated symptoms were improved in 16 patients (89%). The median overall survival after receiving TSEBT was 12 months, resulting in an actuarial one-year overall survival of 48%. Treatment related acute effects (grade 1 or 2) were observed in all patients during radiation therapy. Transient grade 3 epitheliolyses developed in five patients (28%), late skin effects (grade 1 and 2) in 16 patients (89%), and hypohidrosis was seen in six patients (33%). We conclude that TSEBT is a very efficient and tolerable palliative treatment for patients with advanced CTCL.

Activation of telomerase by ionizing radiation: differential response to the inhibition of DNA double-strand break repair by abrogation of poly (ADP-ribosyl)ation, by LY294002, or by Wortmannin.

PURPOSE: Telomerase activity represents a radiation-inducible function, which may be targeted by a double-strand break (DSB)-activated signal transduction pathway. Therefore, the effects of DNA-PK inhibitors (Wortmannin and LY294002) on telomerase upregulation after irradiation were studied. In addition, the role of trans-dominant inhibition of poly(ADP-ribosyl)ation, which strongly reduces DSB rejoining, was assessed in comparison with 3-aminobenzamide. METHODS AND MATERIALS: COM3 rodent cells carry a construct for the dexamethasone-inducible overexpression of the DNA-binding domain of PARP1 and exhibit greatly impaired DSB rejoining after irradiation. Telomerase activity was measured using polymerase chain reaction ELISA 1 h after irradiation with doses up to 10 Gy. Phosphorylation status of PKB/Akt and of PKCalpha/beta(II) was assessed by western blotting. RESULTS: No telomerase upregulation was detectable for irradiated cells with undisturbed DSB rejoining. In contrast, incubation with LY294002 or dexamethasone yielded pronounced radiation induction of telomerase activity that could be suppressed by Wortmannin. 3-Aminobenzamide not only was unable to induce telomerase activity but also suppressed telomerase upregulation upon incubation with LY294002 or dexamethasone. Phospho-PKB was detectable independent of irradiation or dexamethasone pretreatment, but was undetectable upon incubations with LY294002 or Wortmannin, whereas phospho-PKC rested detectable. CONCLUSIONS: Telomerase activation postirradiation was triggered by different treatments that interfere with DNA DSB processing. This telomerase upregulation, however, was not reflected by the phosporylation status of the putative mediators of TERT activation, PKB and PKC. Although an involvement of PKB in TERT activation is not supported by the present findings, a respective role of PKC isoforms other than alpha/beta(II) cannot be ruled out.

Telomerase activity in peripheral blood mononuclear cells after whole body irradiation.

Telomerase activity in vitro represents a radiation-inducible function. To test this effect after irradiation in vivo, we measured telomerase activity in peripheral blood mononuclear cells (PBMC) of 25 patients with leukemia or lymphoma before and 1 h after whole body irradiation. Telomerase activity of the patients was compared to telomerase activity in PBMC of 15 healthy volunteers. Peripheral blood of the patients was taken before and 1 h after the first fraction of whole body irradiation (2 Gy). Blood samples of the volunteers were irradiated ex vivo with 2 Gy. After Ficoll-Paque density gradient centrifugation telomerase activity of 10(4) PBMC per sample was measured using the telomerase PCR ELISA method. No age-dependence of telomerase activity was detected for both the volunteer and the patient group. Telomerase activity in patients was not statistically significantly increased compared to healthy individuals, and this parameter was also no prognostic factor for patient survival. After whole body irradiation an induction of telomerase activity was observed for only 7 patients (28%), or in PBMC of 2 volunteers (13%), respectively. In patients with radiation-inducible telomerase activity, a slightly better survival was indicated, but this difference did not reach statistical significance. The feasibility to assess in vivo radiation-induction of telomerase activity in PBMC of leukemia or lymphoma patients was demonstrated. An unexpectedly low number of whole body irradiated patients displayed this phenotype, and the treatment impact of telomerase upregulation in PBMC upon radiation exposure needs to be further analyzed.

Long-term results and predictive factors of three-dimensional conformal salvage radiotherapy for biochemical relapse after prostatectomy.

PURPOSE: Salvage radiotherapy (RT) is used to treat patients with biochemical failure after radical prostatectomy (RP). Although retrospective series have demonstrated that salvage RT will result in biochemical response in approximately 75% of patients, long-term response is much lower (20-40%). The purpose of this study was to determine prognostic factors related to the prostate-specific antigen (PSA) outcome after salvage RT. METHODS AND MATERIALS: Between 1991 and 2004, 171 patients received salvage RT at the University of Heidelberg. Patient age, margin status, Gleason score, tumor grading, pathologic tumor stage, pre-RP and pre-RT PSA levels, and time from RP to rise of PSA were analyzed. RESULTS: Median follow-up time was 39 months. The 5-year overall and clinical relapse-free survival were 93.8% and 80.8%, respectively. After RT serum PSA decreased in 141 patients (82.5%). The 5-year biochemical relapse-free survival was 35.1%. Univariate analysis showed following statistically significant predictors of PSA recurrence after RT: preoperative PSA level (p = 0.035), pathologic tumor classification (p = 0.001), Gleason score (p < 0.001), tumor grading (p = 0.004), and pre-RT PSA level (p = 0.031). On multivariate analysis, only Gleason score (p = 0.047) and pre-RT PSA level (p = 0.049) were found to be independently predictive of PSA recurrence. CONCLUSIONS: This study represents one of the largest retrospective studies analyzing the outcome of patients treated with salvage RT at a single institution. Our findings suggest that patients with Gleason score <7 and low pre-RT PSA levels are the best candidates for salvage RT, whereas patients with high-grade lesions should be considered for additional treatment (e.g., hormonal therapy).

Radiotherapy for orbital lymphoma : outcome and late effects.

PURPOSE: To analyze the effectiveness of radiotherapy in the management of orbital non-Hodgkin's lymphoma (NHL). PATIENTS AND METHODS: 42 patients (median age 64.5 years) were reviewed retrospectively. The median follow-up period was 58 months. 26 patients had stage IE orbital lymphoma (22 indolent, four aggressive NHLs). 16 patients had advanced NHLs in stages II-IV with orbital involvement (eleven indolent, five aggressive NHLs). The median radiation dose was 40 Gy (20-46 Gy) for indolent lymphoma and 44 Gy (20-48 Gy) for aggressive lymphoma. Patients with stage IE were treated with at least 30 Gy. RESULTS: The 5-year local control rate for patients with stage I was 100%, the 5-year overall survival 91%. Two distant relapses were found, but no lymphoma-related death was detected. The 5-year local control rate for patients in stages II, III, and IV was 80%. Two local failures were detected. The 5-year overall survival for the advanced stages was 47%, nine patients with stages III and IV died due to systemic progression of lymphoma. Acute, radiotherapy-related complications grade 3/4 were not observed. Late effects grade 1/2 were documented in 45%. Six patients, treated with doses of > 36 Gy, developed grade 3 complications (four cataract, two dryness). CONCLUSION: Radiotherapy alone yields excellent local control and overall survival rates in orbital lymphoma stage IE. Local irradiation is also well tolerated and effective in advanced NHL stages with orbital infiltration. Doses of > 36 Gy resulted in an increase of late complications.

Outcome and late complications of radiotherapy in patients with unicentric Castleman disease.

Castleman disease is a rare lymphoproliferative disorder. Surgery is considered standard therapy for the unicentric type. However, case reports have documented favorable responses to radiotherapy. The aim of this study was to analyse the clinical outcomes of five patients with unicentric Castleman disease treated with radiotherapy between 1991 and 2005. Mediastinal lymph nodes were the most common site of disease (four patients). Three patients were treated with radiotherapy alone, two patients with surgery and radiotherapy. Patients were treated with radiotherapy doses ranging from 40 Gy to 50 Gy. The median follow-up was 12 months (range, 3-175 months). During follow-up only one patient had progressive disease and died of Castleman disease. At the time of last follow-up two patients were in complete remission, one patient in partial remission, and one patient had stable disease. One patient showed serious acute and late toxicities. At the end of radiotherapy a paraneoplastic pemphigus vulgaris occurred, and eight to 11 months after radiotherapy a stenosis of the esophagus, of the left bronchus, and of the trachea due to scars. The study shows that unicentric Castleman disease is successfully treated with radiotherapy. However, for detection of possible complications as pemphigus vulgaris or stenosis of the esophagus or trachea an accurate follow-up is necessary.

Retrospective evaluation of combined modality treatment and prognostic factors in patients with esophageal cancer.

The influence of prognostic factors and combined modality treatment on survival was evaluated retrospectively for 156 patients with esophageal cancer receiving radiotherapy in different modalities between 1991 and 2001 at the University of Heidelberg and the Universitätsklinikum Mannheim. Forty-six patients (29.5%) were treated with radiotherapy alone, 74 patients (47.4%) had combined radiochemotherapy and 36 patients (23.1%) were operated on after receiving neoadjuvant radiochemotherapy. The median follow-up time was 10 months. Female patients showed a significantly better overall survival compared with male patients (p=0.031), younger patients (age 60 years) (p=0.02). Patients with hemoglobin concentration>13.4 g/dl before therapy (median hemoglobin concentration) had a significantly better overall survival than patients with lower hemoglobin concentration (p=0.044). Patients who received combined radiochemotherapy (with or without operation) had a survival advantage compared with radiotherapy alone. Overall survival after neoadjuvant treatment followed by operation was significantly better than in the two other groups, median survival times were 20 vs. 9 (RCHT) vs. 8 months (RT) (p=0.003). The data presented show for the first time that hemoglobin concentration in addition to gender and age was a prognostic factor for patients with esophageal cancer. A low hemoglobin value was a negative predictor.

Abrogation of radiation-inducible telomerase upregulation in HPV16 E6 transfectants of human lymphoblasts.

BACKGROUND: Telomerase activity in a human lymphoblastoid cell line with wild-type p53 status (TK6) was previously shown to be rapidly induced by ionizing radiation doses as low as 10 cGy. Since this low-dose response was absent in a closely related cell line overexpressing a mutant form of p53 (WTK1), the putative involvement of p53 was further investigated using stable human papillomavirus 16 (HPV16) E6 transfectants of these cell lines. The E6 product mediates rapid degradation of wild-type p53, but has also been found to upregulate telomerase. MATERIAL AND METHODS: Telomerase activity in HPV16 E6 transfectants of the human lymphoblastoid cell lines TK6 and WTK1 was measured by PCR/ELISA and was quantified using internal standards (titration by cell number) run within each separate assay. Mean telomere length was determined by Southern hybridization of terminal restriction fragments with a biotin-labeled telomeric DNA probe. RESULTS: The TK6E6 and the WTK1E6 cells exhibited higher baseline telomerase activities than the parental cells. This was also accompanied by increased telomere lengths. Radiation exposure (up to 10 Gy) was unable to significantly further enhance telomerase activities, although the dynamic range of the assay would have allowed to record higher signals. CONCLUSION: The lacking radiation induction of telomerase activities in the E6 transfectants could reflect saturation, if E6 and radiation would share a common pathway of telomerase upregulation. Present evidence from the literature, however, suggests that E6 mediates telomerase reverse transcriptase (TERT) subunit transcriptional activation, whereas radiation signals to posttranscriptional/posttranslational control of telomerase activity. Therefore, the present data enforce the previous hypothesis of a p53 dependence of telomerase upregulation by low doses of radiation and its abrogation, likely due to p53 degradation, in E6-expressing cells.