Intraoperative radiation therapy as part of planned monotherapy for early-stage breast cancer.

INTRODUCTION: Adjuvant whole breast radiation therapy has developed into the standard of care for patients following a lumpectomy for early-stage breast cancer. However, there is recent interest in intraoperative radiation therapy (IORT) to minimize toxicity while still improving local control beyond surgical resection and anti-estrogen therapy alone. MATERIALS AND METHODS: All patients were evaluated pre-operatively in a multidisciplinary clinic setting at a community hospital for suitability for breast conservation therapy. A total of 109 patients were reviewed receiving 110 IORT treatments. Patients were followed with clinical breast examinations and mammography as clinically indicated. RESULTS: At a median follow-up of 29.9 months, 2/110 (1.8%) patients experienced a local failure. One patient (0.9%) experienced a regional failure. Local control, disease-free survival and overall survival at 3 years were 98.9% (95%CI 92.2-99.8), 97.2% (95%CI 88.9-99.3), and 96.0% (95%CI 84.9-99.0), respectively. Five-year local control, disease-free survival, and overall survival rates were 96.3% (95%CI 84.7-99.2), 94.6% (95%CI 83.2-98.3), and 92.5% (95%CI 80.4-97.3), respectively. Patient self-reported cosmetic outcome was available for 51 patients, with all patients reporting being either very pleased, pleased, or satisfied with their cosmetic outcome, and no patients reported being dissatisfied or worse. CONCLUSIONS: The results of our series suggest the feasibility of utilizing IORT in a community-based cancer center with a high degree of local control, and patient satisfaction with regard to cosmesis. While the results of this series suggest that IORT may be a promising modality, longer follow-up is warranted to better understand exactly which clinicopathological features can predict long-term locoregional disease control.

Use of electronic brachytherapy to deliver postsurgical adjuvant radiation therapy for endometrial cancer: a retrospective multicenter study.

BACKGROUND: This retrospective, multicenter study evaluated the feasibility and safety of high-dose rate electronic brachytherapy (EBT) as a postsurgical adjuvant radiation therapy for endometrial cancer. METHODS: Medical records were reviewed from 41 patients (age 40-89 years) with endometrial cancer (Federation of International Gynecology and Obstetrics stages IA-IIIC) treated at nine centers between April 2008 and October 2009. Treatment included intracavitary vaginal EBT alone (n = l6) at doses of 18.0-24.0 Gy in 3-4 fractions and EBT in combination with external beam radiation therapy (EBRT, n = 25) at a total radiation dose range of 40.0-80.4 Gy. Doses were prescribed to a depth of 5 mm from the applicator surface and to the upper third (n = 15) and the upper half (n = 26) of the vagina. RESULTS: Median follow-up was 3.8 (range 0.5-12.0) months. All 41 patients received the intended dose of radiation as prescribed. Adverse events occurred in 13 of 41 patients and were mild to moderate (Grade 1-2), consisting primarily of vaginal mucositis, rectal mucosal irritation and discomfort, and temporary dysuria and diarrhea. There were no Grade 3 adverse events in the EBT-only treatment group. One patient, who was being treated with the combination of EBT and EBRT for recurrent endometrial cancer, had a Grade 3 adverse event. No recurrences have been reported to date. CONCLUSION: Electronic brachytherapy provides a feasible treatment option for postoperative adjuvant vaginal brachytherapy as sole radiation therapy and in combination with EBRT for primary endometrial cancer. Early and late toxicities were mild to moderate.

Phase III, double-blind study of depot octreotide versus placebo in the prevention of acute diarrhea in patients receiving pelvic radiation therapy: results of North Central Cancer Treatment Group N00CA.

PURPOSE: To assess the effectiveness of depot octreotide for the prevention of diarrhea during pelvic radiation therapy. PATIENTS AND METHODS: Patients receiving pelvic radiation therapy (planned minimum dose, 45 Gy; 1.7 to 2.1 Gy daily) were eligible for the study. From May 10, 2002, through October 14, 2005, 125 patients were randomly allocated in a double-blind fashion to receive octreotide (100 microg, administered subcutaneously on day 1, followed by depot octreotide, 20 mg, administered intramuscularly on days 2 and 29; n = 62) or to receive a placebo (n = 63). RESULTS: Grade 0, 1, 2, and 3 diarrhea were observed in 18%, 31%, 31%, and 21% of patients in the octreotide arm, respectively, and in 25%, 32%, 22%, and 21% of patients in the placebo arm, respectively (P = .64). Grade 0, 1, 2, and 3 abdominal cramps were observed in 32%, 45%, 21%, and 2% of patients receiving octreotide, respectively, and in 51%, 24%, 21%, and 5% of patients receiving the placebo, respectively (P = .053). Some patient-reported symptoms were worse in the octreotide group, including nocturnal bowel movements (70% v 45%; P = .004), clustering of bowel movements (90% v 69%; P = .004), and bleeding with bowel movements (57% v 35%; P = .01). CONCLUSION: As administered in this study, octreotide did not decrease diarrhea during pelvic radiation therapy. Some gastrointestinal symptoms were worse in patients treated with octreotide. Octreotide is not indicated for prevention of diarrhea during pelvic radiation therapy.

Internal mammary lymph node (IMN) coverage by standard radiation tangent fields in patients showing IMN drainage on lymphoscintigraphy: therapeutic implications.

The purpose of this report is to evaluate the variability in coverage of the internal mammary nodal chain (IMN) by standard radiation tangential fields in those patients with medial drainage on lymphoscintigraphy. Twenty-two patients who showed lymphoscintigraphic IMN drainage underwent radiation simulation planned with computed tomography (CT). Standard tangent fields were placed and CT scans were reviewed to assess IMN inclusion and correlation with presternal fat thickness. Of the 22 patients who showed IMN drainage on lymphoscintigraphy, 10 (45%) had lateral primary lesions, 9 (41%) had medial lesions and 3 (14%) had subareolar lesions. Of these 22 women, 4 (19%) had the IMN completely within the standard tangent fields. Twelve women (55%) had only partial coverage of the IMN and the remaining 6 women (27%) had the IMN region completely outside. Presternal fat thickness greater than 10 mm was less likely associated with complete IMN coverage than fat thickness 10 mm or less, P = 0.001. Lymphoscintigram drainage to the IMN in breast cancer patients may suggest an increased risk of IMN involvement. Our data show that a majority (73%) of these patients had complete or partial incidental inclusion of the IMNs with standard tangents, which may in part explain the historically low IMN failure rate.

Resection followed by radiosurgery for advanced juvenile nasopharyngeal angiofibroma: report of two cases.

OBJECTIVE AND IMPORTANCE: Experience with the management of juvenile nasopharyngeal angiofibroma (JNA) by gamma knife radiosurgery is limited. We report control of the disease in two patients with advanced-stage JNA treated with primary resection followed by gamma knife stereotactic radiosurgery of residual disease. CLINICAL PRESENTATION: An 18-year-old man presented with chronic sinusitis, worsening headaches, diplopia, and left-sided facial numbness. A second patient, a 19-year-old man, presented with recurrent epistaxis and nasal congestion. Magnetic resonance imaging findings and endoscopic evaluation in each patient were consistent with advanced-stage JNA. INTERVENTION: One patient underwent craniofacial resection with approximately 3.0 cm(3) of residual tumor in the region of the cavernous sinus. The other patient underwent preoperative embolization followed by a lateral rhinotomy for tumor resection with approximately 4.7 cm(3) of residual tumor in the right infratemporal fossa. In an attempt to limit radiation to surrounding normal brain, residual tumor in both patients was treated with gamma knife stereotactic radiosurgery. Control of disease was documented by magnetic resonance imaging more than 24 months after treatment. CONCLUSION: Short-term control of late-stage JNA was achieved by use of a strategy of primary surgical resection followed by gamma knife radiosurgery of residual tumor in two patients. Establishing the effectiveness and safety of this strategy over conventional methods of managing advanced JNA will require future prospective studies.

Lymphoma of the nasal cavity and paranasal sinuses: treatment and outcome of early-stage disease.

The records of 23 patients diagnosed and treated at the Massachusetts General Hospital for extranodal non-Hodgkin's lymphoma of the paranasal sinus and nasal cavity were reviewed. The majority of patients were Ann Arbor stage I and approximately evenly divided in T1 or T2 (n = 10) and T3 or T4 (n = 13). Eight patients had nasal-type NK/T cell and 15 patients had diffuse large B-cell lymphoma (DLBCL). The patients with nasal-type NK/T cell lymphoma predominately involved the nasal cavity (5/8), whereas the DLBCL more often had the paranasal sinuses as the primary site (12/15). All patients received radiation as part of their treatment. Only three patients received chemotherapy as part of their initial treatment for three cycles using a cyclophosphamide, doxorubicin, vincristine, and prednisone-based regimen. By coincidence, the estimated overall survival (OS) and disease-free survival rates for both 5 and 10 years were all the same for all analyses. The OS for the entire group at 10 years was 78%. Significant prognostic factors were Ann Arbor stage IEA versus IIEA ( p = 0.0001) and T stage with (T1 or T2) versus (T3 or T4) (p = 0.0243). Combining Ann Arbor stage and T stage created a highly significant prognostic variable (IEA & [T1 or T2], IEA & [T3 or T4], IIEA & [T1 or T2], IIEA & [T3 or T4]) at p = 0.0001, regardless of site or histology. Patients with local-regional disease appear to be well controlled with radiation alone, but distant failure remains a problem. A combined-modality approach with local-regional radiation and systemic chemotherapy is recommended for these patients.

Effect of concurrent radiation therapy and chemotherapy on pulmonary function in patients with esophageal cancer: dose-volume histogram analysis.

PURPOSE: The pulmonary effects of concurrent radiation therapy and chemotherapy were studied in patients enrolled in a phase I trial for esophageal cancer. MATERIALS AND METHODS: Pulmonary function tests were performed prospectively before and after combined-modality therapy (oxaliplatin, 5-fluorouracil, and radiation therapy) in 20 patients with esophageal cancer. Cumulative and differential lung DVH analysis from 0 to 5400 cGy in 25-cGy intervals was performed for the last 15 patients. Correlation between radiation exposure in various dose ranges and percent reduction in pulmonary function tests was calculated as an exploratory analysis. RESULTS: Significant reductions in carbon monoxide diffusion capacity corrected for hemoglobin (12.3%) and total lung capacity (2.5%) were evident at a median of 15.5 days after radiation therapy. DVH analysis revealed that the single dose of maximum correlation between lung volume radiation exposure and lung function reduction was less than 1000 cGy for all pulmonary functions. The percent lung volume that received a total dose between 700 and 1000 cGy maximally correlated with the percent reductions in total lung capacity and vital capacity, and the absolute lung volume that received a total dose between 700 and 1000 cGy maximally correlated with the percent reductions in total lung capacity, vital capacity, and carbon monoxide diffusion capacity. DISCUSSION: Significant declines in carbon monoxide diffusion capacity and total lung capacity are evident immediately after the administration of conformal radiation therapy, oxaliplatin, and 5-fluorouracil for esophageal cancer. Other lung functions remain statistically unchanged. The percent or absolute lung volume that received a total dose between 700 and 1000 cGy may be significantly correlated with the percent decline of carbon monoxide diffusion capacity, total lung capacity, and vital capacity. These associations will be evaluated further in a follow-up study.

Outcome with postmastectomy radiation with transverse rectus abdominis musculocutaneous flap breast reconstruction.

The effects of radiation on the outcome of patients undergoing transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction have not been extensively studied. Concern still exists of a possible negative impact secondary to irradiation as related to control of disease, cosmetic outcome, and flap viability. Thirty-six patients underwent both a modified radical mastectomy (MRM) with TRAM flap reconstruction and irradiation to the chest wall to include the TRAM flap and/or regional nodes either before reconstruction or after TRAM flap reconstruction. Fifteen patients had all of their treatment and follow-up at our institution and were retrospectively reviewed to assess treatment and outcome. During a median follow-up of 36 months there were no local-regional failures. One patient at Stage IIIA failed with distant metastases 3 years after treatment. One patient had a flap loss from a nonhealing wound after reconstruction performed 2 years after MRM and radiotherapy. Only one patient expressed dissatisfaction with the cosmetic outcome. Patients undergoing MRM with TRAM flap reconstruction and irradiation before or after reconstruction can achieve excellent local-regional control and satisfactory cosmesis. Risk of flap loss is low. Further follow-up is needed for assessing longer-term outomes in this patient group. Larger prospective studies are necessary for more definitive conclusions.