Lymphatic fistulas: obliteration by low-dose radiotherapy.

BACKGROUND: Lymphatic drainage from the surgical wound is an uncommon but challenging complication of surgical intervention. Protracted lymphorrhea contributes to morbidity, favors infections and results in a prolonged hospital stay. Treatment options include surgical ligation and, more conservatively, leg elevation, continuous local pressure, subatmospheric pressure dressings, and low-dose radiotherapy. This study examines the efficacy of low-dose radiotherapy. PATIENTS AND METHODS: 17 patients (19 fistulas) with lymphorrhea following vena saphena harvesting (n = 7), femoropopliteal bypass (n = 3), varicose vein surgery (n = 2), hip arthroplasty (n = 3; five fistulas), shunt surgery (n = 1), and piercing (n = 1) were referred for external radiotherapy. Depending on the depth of the fistula, orthovoltage (n = 12), electrons (4-11 MeV; n = 2) or photons (8 MV; n = 3) were used. Fractions between 0.3 Gy and 2 Gy were applied; the individual total dose depended on the success of the radiotherapy, i. e., the obliteration of the lymph fistula, and varied from 1 to 12 Gy. RESULTS: In 13 out of 17 patients complete obliteration of the fistula was achieved. Interestingly, this was achieved in nine of the ten patients irradiated with total doses of

Analysis of the prognostic impact of tumor embolization before definitive radiotherapy for cervical carcinoma.

PURPOSE: To assess whether embolization compromises the radiocurability of primary cervical cancer. METHODS AND MATERIALS: Two hundred fifty-four patients with primary cervical cancer (International Federation of Gynecology and Obstetrics [FIGO] stages IB: 47; II: 91; IIIB: 102; IV: 14) were treated with external beam irradiation and Ir-192 high-dose-rate brachytherapy over a period of 15 years. Of these, 24 patients (9.4%) (FIGO stages IB: 1; II: 8; IIIB: 12; IV: 3) had had bilateral embolization of the internal iliac arteries before referral. The median age of the entire cohort was 66 years (range, 34-85 years). Tumor size was >5 cm and paraortic nodes were enlarged (> or =1 cm) on pretreatment CAT scan in 39.4% and 9.1% of patients, respectively. All patients with hemoglobin levels (hb-l) < or =11 g/dL (28.3%) received packed red cell transfusions (PRCT) before and/or during radiotherapy in an attempt to maintain levels >11 g/dL throughout treatment. Cross-table tests were used to compare the distribution of FIGO stage, tumor size, lymph node status, and pretreatment and treatment hb-l of embolized and nonembolized patients. The impact of embolization, along with the above-listed tumor characteristics, on disease-specific survival (DSS), pelvic control (PC), and distant metastases-free survival (MFS) was determined by univariate and multivariate analyses. RESULTS: Embolized patients presented at a statistically significant younger median age (55 vs. 67 years; p = 0.003), with larger tumors (66.7% vs. 36.5%; p = 0.007), and lower pretreatment hb-l (75% vs. 23.5%; p < 0.001) than nonembolized patients. There was no significant difference in stage distribution or lymph node status, and although embolized patients responded better to PRCT (50% vs. 29.6%), this difference was not statistically significant. Univariate analysis showed a trend toward decreased DSS (p = 0.09) and PC (p = 0.07) for embolized patients but no effect on MFS, whereas all other variables tested were significantly correlated with DSS, PC, and MFS (all p < 0.001). In the multivariate model, tumor embolization, FIGO stage, and pretreatment hb-l ceased to impact significantly on outcome. Tumor size remained the most powerful independent predictor for all endpoints tested, followed by treatment hb-l. Paraortic node status was significantly correlated with DSS and MFS. CONCLUSION: Although a trend toward poorer DSS and PC was observed in embolized patients, no impact on radiocurability could be demonstrated in multivariate analysis after controlling for the major tumor characteristics and treatment hb-l.

Evaluation of the effect of routine packed red blood cell transfusion in anemic cervix cancer patients treated with radical radiotherapy.

PURPOSE: It is well established that anemia predicts diminished radiocurability in cervix cancer. However, the therapeutic benefit of measures to correct the anemia remains controversial. The objective of this study was to determine the impact of routine transfusion in patients with hemoglobin level (hb-l) < or =11 g/dl. METHODS AND MATERIALS: Since 1985, it has been departmental policy to attempt to correct hb-l < or =11 g/dl before and/or during radiotherapy by red blood cell transfusion (RBCT) in patients undergoing radical radiotherapy for primary cervix cancer. To assess the benefit of RBCT, the charts of 204 patients (FIGO: IB-IV) treated until 1997 were reviewed. Parameters analyzed for their impact on disease-specific survival (DSS), pelvic control (PC), and metastases-free survival (MFS) included pretreatment hb-l, treatment hb-l, stage, tumor size, and lymph node status. To determine any differences in outcome according to type of anemia, a separate analysis was performed, grouping patients by cause of anemia (tumor vs. other medical illness related). RESULTS: Each of the parameters tested was significantly correlated with the end points studied in univariate analysis. Patients whose hb-l were corrected (18.5%) had an outcome that did not differ significantly from that of nontransfused patients, whereas DSS, PC, and MFS (all: p < 0.001) were significantly decreased in nonresponders to RBCT. Subgroup analysis showed no impact of hb-l in patients with other medical illness-related anemia (n = 12). In multivariate analysis treatment, but not pretreatment, hb-l remained predictive for DSS, PC, and MFS. Persistent anemia was associated with a significantly increased risk of death (relative risk: 2.1) and pelvic failure (relative risk: 2.4) compared with nontransfused patients. If only patients with tumor anemia were considered, the respective risks increased (2.7; 3.6). None of the patients with other causes of anemia recurred, whether or not their hb-l was maintained. Assessment of the therapeutic gain in patients who responded to RBCT showed improved PC (p = 0.02) and a trend toward increased DSS (p = 0.06), but no effect on MFS after adjustment for tumor size and lymph node status. CONCLUSION: Treatment hb-l, in addition to tumor size and lymph node status, independently predicted outcome. Although our final multivariate analysis showed a therapeutic benefit for patients whose hb-l was corrected, the response to RBCT was disappointing. Results of our subgroup analysis suggest that the cause of anemia in patients with cervical cancer warrants in-depth investigation.