Are intraoral customized stents still necessary in the era of Highly Conformal Radiotherapy for Head & Neck cancer? Case series and literature review.

AIM: To evaluate the dose sparing efficacy of intraoral customized stents in combination with IGRT/VMAT in Head & Neck cancer patients. BACKGROUND: Despite advances in high-dose conformal radiotherapy (RT) techniques, adverse effects (such as oral mucositis) during and after RT often require temporary suspension of treatment and affect the quality of life in survivors. Intraoral customized stents can decrease radiation doses in healthy tissues and minimize damage from radiations. At the best of our knowledge the clinical impact of such devices in combination with VMAT (volumetric modulated arc therapy) is not reported in the literature. CASES DESCRIPTION: Three Head & Neck cancer patients were submitted to image guided (IG) RT/VMAT in their treatment protocol. Dose distribution with and without the use of an intraoral stent was compared in each patient. Mean radiation doses proved to be lower in all patients, especially in the subsite: oral cavity. CONCLUSIONS: There are several reports on the efficacy of IS during RT for Head & Neck cancer. Despite technological advances, the combination between high conformal RT and intraoral stents could still play a role in the management of this kind of patients. This strengthens the usefulness of the individualization of treatments and multidisciplinary approach.

Complete recovery from paraparesis in spinal cord compression due to extramedullary haemopoiesis in beta-thalassaemia by emergency radiation therapy.

Extramedullary haemopoiesis (EMH) is a complication commonly associated with beta-thalassaemia intermedia; it is frequently asymptomatic but can sometimes lead to symptomatic tumour-like masses. No guidelines or common consensus are available in literature regarding the different treatment strategies and only single cases have been reported. We describe a case of spinal cord compression due to intrathoracic EMH masses treated with combined radiotherapy and hydroxyurea.

Target registration errors with surface imaging system in conformal radiotherapy for prostate cancer: study on 19 patients.

PURPOSE: Accurate patient setup is a prerequisite for conformal radiotherapy (3D-CRT) and is based on various methods, including surface imaging systems. To evaluate the validity of a surface imaging system (AlignRT), we analysed setup reproducibility of a cohort of patients. MATERIALS AND METHODS: Nineteen patients affected by prostate adenocarcinoma were enrolled in this study. We acquired 653 surface images and 99 digital portal images (DPI). Setup errors were found by matching surface images with computed tomography (CT) and DPI images. RESULTS: The setup errors from the threshold of 5 mm detected by AlignRT along the Y, Z and X axes occurred in 47.4%, 42.1% and 5.3% of patients, respectively. For the threshold of 3 mm, shifts along the Y, Z and X axes were observed in 68%, 69% and 10%, respectively. Comparing AlignRT and DPI, we found a statistically significant difference in the detection of shifts along the Y and Z axes. For a threshold ≥ 5 mm, the two systems provided corresponding setup errors along the Y and Z axes, whereas along the X axis, the threshold was not necessary. CONCLUSIONS: AlignRT is an accurate technique for setup in 3D-CRT prostate cancer patients, especially along the lateral direction.

Induction chemotherapy followed by concurrent chemoradiotherapy in advanced head and neck squamous cell carcinoma.

BACKGROUND: A phase II study was carried out to investigate an induction regimen with cisplatin, paclitaxel followed by radiotherapy concurrent with weekly cisplatin for locally advanced squamous cell carcinoma of the head and neck. PATIENTS AND METHODS: Stage III-IV disease patients were eligible. Two cisplatin (100 mg/m2) and paclitaxel (175 mg/m2) courses were administered every 21 days followed by standard fractionated external beam radiotherapy (approximately 70 Gy), concomitant to weekly cisplatin (30 mg/m2). RESULTS: Thirty-five patients were enrolled: over 70% had unresectable disease with bulky lesions. Grade 3-4 neutropenia developed in 14% and G3 mucositis in 23%. Locoregional control was achieved in 51%. Median time to progression and overall survival were 10,7 and 17 months respectively; 2- and 3-year survival rates were 30% and 25% respectively. CONCLUSION: Our induction two-drug regimen followed by chemoradiotherapy with concurrent weekly cisplatin was well tolerated with low acute toxicity and good locoregional control and survival rate.

CT-MRI image fusion for delineation of volumes in three-dimensional conformal radiation therapy in the treatment of localized prostate cancer.

The objective of this study was to assess the utility of CT-MRI image fusion software and compare both prostate volume and localization with CT and MRI studies. We evaluated the differences in clinical volumes in patients undergoing three-dimensional conformal radiation therapy for localized prostate cancer. After several tests performed to ensure the quality of image fusion software, eight patients suffering from prostate adenocarcinoma were submitted to CT and MRI studies in the treatment position within an immobilization device before the start of radiotherapy. The clinical target volume (CTV) (prostate plus seminal vesicles) was delineated on CT and MRI studies and image fusion was obtained from the superimposition of anatomical fiducial markers. A comparison of dose-volume histograms relative to CTV, rectum, bladder and femoral heads was performed for both studies. Image fusion showed a mean overestimation of CTV of 34% with CT compared with MRI. Along the anterior-posterior and superior-inferior direction, CTV was a mean 5 mm larger with CT study compared with MRI. The dose-volume histograms resulting from CT and MRI comparison showed that it is possible to spare a mean 10% of rectal volume and approximately 5% of bladder and femoral heads, respectively. This study confirmed an overestimation of CTV with CT images compared with MRI. Because this finding only allows a minimal sparing of organs at risk, considering the organ motion during each radiotherapy session and the excellent outcomes of prostate cancer treatment with CT based target identification, we are still reluctant to reduce the CTV to that identified by MRI.

Small cell carcinoma of the esophagus: a case report and review of the literature.

We present a case of small cell esophageal carcinoma (SCEC) treated with alternated chemotherapy (including cisplatin, etoposide, vincristine, cyclophosphamide and doxorubicin) and irradiation (36 Gy) followed by surgery. Despite a pathological complete response, the patient died of regional disease recurrence 29 months after the diagnosis. We reviewed the available literature on SCEC with regard to the incidence, clinical symptoms, radiological signs, diagnostic workup, therapeutic modalities and prognosis of this malignancy.

Basic and clinical research for the new radiotherapy.

Basic research has allowed the full knowledge of the underlying mechanisms of the use of radiotherapy in cancer treatment. However, in spite of the crop of radiobiological studies, the impact on clinical research in last years has been relatively little. Within the recent research in man, studies on altered dose fractionations, combined radiation and chemotherapy together with the development of sophisticated technology have allowed the use of new methods of radiotherapy while those existing have been optimized.

Topical role of brachytherapy: economic and organizational aspects.

Brachytherapy for the recent technological advances, represents a fundamental "therapeutic step" in a multidisciplinary approach based on surgery, external beam radiotherapy and chemotherapy, if necessary. The various professionals involved, each within their personal skills, participate in the formulation of a correct therapeutic program. The widespread use of high dose rate brachytherapy leads to consider that the machines should be supplied to major radiotherapy centers only, because the procedure requires the combination with external beam radiotherapy.

Surgery or radiotherapy for early stages carcinomas of the glottic larynx.

AIMS AND BACKGROUND: The choice of treatment in limited squamous cell carcinoma of the glottic larynx often depends on individual and tumor factors. Data of the literature clearly show that surgery and radiotherapy tend to give identical results in terms of survival. We examined 196 cases of T1-T2/N0 cancers of the glottic larynx. We review the literature and discuss the indications and the efficacy of the various available treatments. METHODS AND STUDY DESIGN: 196 consecutive cases of T1-T2/N0 cancers of the glottic larynx were examined. In 54.5% the tumor was confined to the vocal cord; in 38.2% it extended to the anterior commissure, in 4.6% to the arytenoid cartilage and in 2.5% to the floor of the ventricle. We performed partial laryngeal surgery in 41.3% (81 cases). Radiotherapy alone was employed in 58.6% (115 cases). RESULTS: In T1a and T1b cases there was no statistically significant difference in 5-year disease-free survival. In T2 cases the NED survival of patients who underwent partial laryngectomies (90% of cases) was significantly better (P <0.05) than among patients given radiotherapy (73%). NED survival at 5 years in patients with the primary tumor on a vocal cord, ventricle or anterior commissure was 78%, 80% and 81%, respectively, with no statistically significant difference among the various sites. It is possible that involvement of the anterior commissure exposes patients to greater risk of recurrence when radiotherapy alone is used (5 out of 23 cases, 21.7%, compared to 3 out of 52 cases, 5.7%, among our surgically treated patients). CONCLUSIONS: When the tumor is confined to the vocal cord and mobility is not impaired (T1a), surgery and radiotherapy give comparable results, and the latter yields a better functional outcome. When the anterior commissure is involved, recurrences appear to be less likely after surgery. In T2 glottic carcinoma, surgery gives better results than radiotherapy alone. In any event, the choice of treatment should be patient-specific and based on a careful analysis of the factors involved in each case.

Small cell carcinoma of the esophagus.

Small cell carcinoma of the esophagus (SCEC) is a rare tumor with its particular biologic features, distinct from squamous and glandular carcinoma of esophagus. Although initial symptoms can be similar (with metastatic dissemination and paraneoplastic syndromes at presentation more frequent in SCEC), differences in age and sex distribution, tumor location, radiological and endoscopic findings, clinical course and prognosis have been observed between SCEC and other esophageal malignancies. SCEC should be considered a systemic disease, and by analogy to bronchogenic small cell carcinoma, multimodality approach including chemotherapy is recommended. In patients with limited disease, irradiation or surgery should be offered after induction chemotherapy to manage local disease. However, optimal treatment schedule has not yet been defined. In the future, registration of all SCEC cases and careful analysis of prognostic factors in the larger multi-institutional series could contribute to further progress in treatment outcome.

Results of hypofractionated stereotactic re-irradiation on 13 locally recurrent nasopharyngeal carcinomas.

Thirteen patients with locally recurrent, previously-irradiated nasopharyngeal carcinoma were treated with linac-based hypofractionated stereotactic radiotherapy (24 Gy in two or four fractions). One- and 3-year overall survival were 54 and 31%. Three patients were free of disease at 30, 34 and 65 months. No severe acute or late complications were seen.

Brachytherapy and local control.

Locoregional control of primary tumor is fundamental to cure since only in one third of patients the onset of distant metastases is the major cause of therapeutic failure. Thus recently, all therapeutic approaches aimed at the enhancement of locoregional control have been considered with growing interest. More particularly, brachytherapy alone or in combined modality therapy as an important option in the local treatment of various malignant tumors, has been widely used; this being related to the now available information on dose-rate, remote after-loading procedures, the new, safe and handy radionuclides and computerized dosimetry systems which allow a more accurate and rapid dose calculation. These advances have led to a wider application of brachytherapy. Together with the classical indications for head and neck and cervical tumors, brachytherapy plays now a well-established role in the treatment of breast, brain, gastrointestinal, genitourinary, soft tissue lung and eye tumors.

Combined modality therapy for laryngeal and hypopharyngeal cancer.

In recent years, the improvement in results in terms of survival in the treatment of laryngeal and hypopharyngeal cancer at the same stage has been rather poor. Therefore, oncologists have tried to improve the quality of life through a decrease in morbidity while not decreasing the treatment efficacy. In particular, the objective was to preserve with noninvasive procedures the anatomy and function of the larynx and hypopharynx while not affecting the possible cure. The refinement on diagnostic, surgical and anesthetic procedures, the potential of modern radiotherapy, the acquisition of new knowledge in medical oncology have allowed the planning of combined modality therapy protocols aimed at organ preservation in many patients. Concurrent radiation and chemotherapy in patients with locally advanced disease is a clinical problem still under study. Results of some phase I and III studies have shown the efficacy of radiochemotherapy, at times with a non negligible toxicity involving healthy tissues, but with a real effective improvement in survival and organ preservation in laryngeal and hypopharyngeal cancer.

[Radiotherapy of non-neoplastic diseases: the situation in Piedmont]. / La radioterapia delle affezioni non neoplastiche: la situazione in Piemonte.

The authors report the results of a census among the Piedmont region radiation therapy departments during the period 1980-1991 concerning non antineoplastic radiotherapy. Eight out of eleven centers respond to the questionnaire. During the period considered 36,480 patients were treated, with an annual mean of 4056; the number of treated patients varies from 1.2% to over 71.3% in the different centers when compared to the number of neoplastic patients. Arthrosis, osseous angioma, cheloides and verruca were the most treated diseases. Plesioroentgentherapy and roentgentherapy were normally employed; telecesium and telecobalt therapy were also used; only two centers used electron beams or brachytherapy. The doses of radiotherapy were not uniform; also patients' information and follow-up criteria were quite different in the various centers. The authors conclude with a guidelines for future radiotherapy in benign diseases.

The cost of hyperthermia: nine years experience at the Radiation Therapy Department of the Turin University.

BACKGROUND: In this paper the authors try to quantify the expenditure for the equipment, staff, treatment per patient and research, sustained at the Radiation Therapy Department of the University of Turin for the treatment of cancer with hyperthermia, METHODS: Two hyperthermic computerized devices are available: the SAPIC SVO3 multifrequencies system (915, 434 and 2-30 MHz) for external hyperthermia, and the SACEM system. working only with the frequency of 915 MHz, for interstitial and intracavitary heating. From September 1983 to December 1991, 408 patients have been treated with hyperthermia, for a total number of treated sites of 483; 2960 heating sessions were performed, with a average of six sessions per patient. RESULTS: The overall cost of our "hyperthermia project" was about 2,000,000,000 Italian liras; the equipment cost was estimated at 1,258,650,000 Liras (839,100 US$), and the cost per treatment and per heat session at about 3,985,200 (2676 US$) and 664,200 liras (443 US$), respectively. The cost of the research program can be estimated in 175,000,000 liras (116,666 US$). The National Health System provides for a partial reimbursement of 2,000,000 liras (1,333 US$) for each course of hyperthermia. Taking into account the mean expected life expectancy and increasing purchases for replacement of equipment, these costs increase 10% each year. As regards the cost-benefit problem, using the Rees formula it varies from 1112 US$ when hyperthermia is used as elective treatment to 3380 US$ when hyperthermia is used as palliative treatment. CONCLUSIONS: Hyperthermia is, in our experience, an expensive therapy.

[The exclusive radiotherapy of tumors of the paranasal sinuses. A retrospective analysis of 73 cases]. / La radioterapia esclusiva dei tumori dei seni paranasali. Analisi retrospettiva di 73 casi.

Seventy-three cases of paranasal sinus tumors observed between 1980 and 1991 were retrospectively analyzed. Our series consisted of 50 men and 23 women aged 43 to 83 years. Histology demonstrated 33 squamous cell carcinomas, 20 adenocarcinomas, 10 undifferentiated carcinomas, 3 mucoepidermoid carcinomas, 3 adenoid-cystic carcinomas, 2 osteosarcomas, 1 fibrosarcoma and 1 melanoma. All patients were untreated. The lesions from maxillary sinus consisted of 3 T2, 13 T3 and 39 T4 tumors; 50 cases were N0 and 5 N+. "Central" neoplasms consisted of 6 stage I, 7 stage II and 5 stage III lesions. All patients underwent irradiation (with 60Co) with two angled fields or three fields -2 opposing lateral and 1 anterior. Critical structures were shielded when possible and wedges were used to optimize dose distribution. Locoregional lymph nodes were treated in N+ cases only. Dose distribution was studied on CT images. All patients received a total dose of 54-72 Gy (mean: 61.4, median: 62 Gy) with 1.8-2 Gy/day fractions for 5 days/week. After irradiation 27/73 (30.8%) complete responses were observed. Local control at 6 months was obtained in 17/73 cases (23.3%) and it was correlated with the total dose. Actuarial survival rates at 3 and 5 years were 27.9% and 21.8%, respectively. At the multivariate analysis, the only significant variable was the stage; no correlations were found with sex, histology and site. During follow-up, lymph node metastases were observed in 4/66 initially N0 cases. Distant metastases were found in 10/73 patients (13.7%) and secondary lesions in 8/73 (11%). Severe complications were observed in 7/73 cases (9.6%).

[Radiotherapy results in the treatment of malignant tumors of the nasal fossa and vestibule]. / Risultati della radioterapia nel trattamento dei tumori maligni della fossa nasale e del vestibolo.

The authors report their personal experience in the treatment of malignant tumors of the nasal cavity and vestibule with irradiation alone or combined with surgery. From January 1976 to December 1989 we treated 40 patients with 22 squamous cell carcinomas, 12 adenocarcinomas or other glandular types, and 6 other histologic types of lesions: 23 patients received irradiation alone and 17 patients were treated with surgery and postoperative irradiation. The protocol included surgery as the treatment of choice: irradiation alone was administered to inoperable tumors or to the patients refusing surgery; postoperative irradiation was given when macroscopic or microscopic residual disease was observed after surgery or to particular histologic types. In the whole series of patients, 3- and 5-year local control rates were 70% and 50%, respectively; better results were obtained in the patients receiving the combined treatment (64% at 5 years) than in the patients receiving irradiation alone (43% at 5 years). Disease stages (I and II versus III and IV) were the only statistically significant prognostic factor; worse results in irradiated patients might be due to the higher rate of advanced lesions in this group. Salvage therapy (irradiation in 8 cases, surgery in 2 and chemotherapy in 1) was successfully performed in 5 of 11 treated patients. The 3- and 5-year overall survival rates were 88% and 70%, respectively. Severe complication rate was lower than 10% (3 cases only).

Carcinoma of the external auditory meatus and middle ear. Results of the treatment of 28 cases.

AIMS: The authors report their experience on the treatment of 28 cases of middle ear (3) and external auditory meatus (EAM) cancers (25) with surgery and/or radiation therapy. According to histologic type, there were 23 squamous cell carcinomas, 4 basal cell carcinomas and 1 adenocystic carcinoma. METHODS: Surgery alone was performed in 2 cases, surgery combined with radiotherapy in 11 cases, and radiotherapy alone in 15 cases. Postoperative radiation therapy dose ranged between 4500 and 5500 cGy; the definitive dose was 6000-7000 cGy. The median follow-up was 61 months. RESULTS: Complete response rate 6 weeks after the end of the treatment, evaluated by CT scan, was 85.7% (24/28). Definitive local control was obtained in 20/28 cases for the primary site and in 26/28 cases for the neck. Nine of the 10 recurrences were retreated with low-dose radiotherapy combined with surgery, chemotherapy or hyperthermia. A new local control was obtained in 2 cases. Four patients were lost during the follow-up at 13, 14, 17 and 23 months after the end of the treatment. The survival rate was 54% (13/24); disease-free survival was 50% (11/22). CONCLUSIONS: Despite a not very aggressive treatment, our results are quite good.

[Invasive thermometry and prognostic thermometry in radiological hyperthermia]. / Termometria invasiva e termometria previsionale in ipertermia radiologica.

The term radiological hyperthermia is used to describe the exposure of biological tissues to temperatures just above physiological ones, namely between 42 and 45 degrees C. A machine for hyperthermia (SAPIC SV03 produced by Aeritalia, Caselle, Turin) is been experimentally used at the authors' institute. The present study aims to analyse the technical and qualitative aspects of temperature control using invasive and previsional thermometry. The term invasive thermometry is used to describe the insertion of small teflon catheters into the biological body through which thermometric probes are introduced to control deep temperature. Previsional thermometry is the phrase used to describe the computer simulation of hyperthermic treatment, starting from knowledge of the tissue to be heated and the type of applicator used. The simulated treatment and the real temperature measured are then compared in order to optimize the treatment used.