Dental extractions and radiotherapy in head and neck oncology: review of the literature.

Management of irradiated patients with cancer in the head and neck region represents a challenge for multidisciplinary teams. Radiotherapy promotes cellular and vascular decrease that results in a low response rate in the healing. Consequently, surgical procedures in irradiated tissues present high rates of complication. Osteoradionecrosis (ORN) is the most severe sequelae caused by radiotherapy. It is associated with previous extractions especially those carried out post-irradiation. The management of this side effect is difficult and can result in bone or soft tissue loss, affecting the quality of life. The literature regarding dental extractions performed before and after head and neck radiotherapy was evaluated, focusing on indications, criteria, surgical techniques and adjunctive therapies such as antibiotics and hyperbaric oxygen. Osteoradionecrosis can be minimized by oral evaluation and care prior to irradiation and healing time which allows tissue repair until the commencement of radiotherapy. In dental extractions realized after irradiation, minimal trauma, alveolectomy, primary alveolar closure and adjunctive therapies are recommended. Patients must be evaluated before radiation therapy and at that time all unrestorable teeth and/or teeth with periodontal problems must be extracted to reduce the post-radiotherapy exodontias that contribute to ORN. Once dental extractions become unavoidable after irradiation, additional care is needed.

Needle displacement during high-dose-rate afterloading brachytherapy boost and conventional external beam radiation therapy for initial and local advanced prostate cancer.

PURPOSE: To determine the displacement of needles (ND) and its impact in the outcome of initial and locally advanced prostate cancer treated with conventional external beam radiation therapy (EBRT) and fractionated transrectal ultrasound-guided high-dose-rate afterloading brachytherapy (HDR-BT) as a boost. METHODS AND MATERIALS: From 03/97 to 08/98 a total of 47 patients were eligible for study entry. Patients with 1992 AJCC clinical stage T3a or less and prostatic volume

Radiosurgery for brain metastases: who may not benefit?

PURPOSE: To select a group of patients with brain metastases for whom stereotactic radiosurgery (SRS) may not be beneficial. PATIENTS, MATERIALS, AND METHODS: Actuarial survival of 87 patients with brain metastases treated with SRS between July 1993 and May 1999 was retrospectively analyzed under stratification by the Score Index for Stereotactic Radiosurgery for Brain Metastases (SIR). To identify the group of patients most likely to survive less than 6 months after SRS, Cox model survival curves were calculated for all SIR values, and Kaplan-Meier survival curves were calculated for two SIR subsets (0-5 and 6-10) and were compared by log-rank test. RESULTS: Overall median survival after SRS was 6.88 months. The stratification of patients into two SIR subsets (0-5 and 6-10) sustained statistical significance regarding survival with p = 0.0001. The median survival time for the group of patients with SIR between 0 and 5 was 4.52 months (95% confidence interval of 2.82 to 5.84 months). Survival probability at 6 months for this group of patients with poor prognosis was 35.6%. CONCLUSION: Patients with brain metastases and SIR of 5 or lower have an expected median survival of less than 6 months after treatment with radiosurgery. Thus, radiosurgery may not be beneficial for this group of patients.

Intracoronary brachytherapy in the treatment of in-stent restenosis. Initial experience in Brazil.

Intracoronary brachytherapy using beta or gamma radiation is currently the most efficient type of therapy for preventing the recurrence of coronary in-stent restenosis. Its implementation depends on the interaction among interventionists, radiotherapists, and physicists to assure the safety and quality of the method. The authors report the pioneering experience in Brazil of the treatment of 2 patients with coronary in-stent restenosis, in whom beta radiation was used as part of the international multicenter randomized PREVENT study (Proliferation REduction with Vascular ENergy Trial). The procedures were performed rapidly and did not require significant modifications in the traditional techniques used for conventional angioplasty. Alteration in the radiological protection devices of the hemodynamic laboratory were also not required, showing that intracoronary brachytherapy using beta radiation can be incorporated into the interventional tools of cardiology in our environment.

High-dose-rate brachytherapy in the treatment of uterine cervix cancer. Analysis of dose effectiveness and late complications.

PURPOSE: This retrospective analysis aims to report results of patients with cervix cancer treated by external beam radiotherapy (EBR) and high-dose-rate (HDR) brachytherapy. METHODS AND MATERIALS: From September 1992 to December 1996, 138 patients with FIGO Stages II and III and mean age of 56 years were treated. Median EBR to the whole pelvis was 45 Gy in 25 fractions. Parametrial boost was performed in 93% of patients, with a median dose of 14.4 Gy. Brachytherapy with HDR was performed during EBR or following its completion with a dose of 24 Gy in four weekly fractions of 6 Gy to point A. Median overall treatment time was of 60 days. Patient age, tumor stage, and overall treatment time were variables analyzed for survival and local control. Cumulative biologic effective dose (BED) at rectal and bladder reference points were correlated with late complications in these organs and dose of EBR at parametrium was correlated with small bowel complications. RESULTS: Median follow-up time was 38 months. Overall survival, disease-free survival, and local control at 5 years was 53.7%, 52.7%, and 62%, respectively. By multivariate and univariate analysis, overall treatment time up to 50 days was the only statistically significant adverse variable for overall survival (p = 0.003) and actuarial local control (p = 0.008). The 5-year actuarial incidence of rectal, bladder, and small bowel late complications was 16%, 11%, and 14%, respectively. Patients treated with cumulative BED at rectum points above 110 Gy(3) and at bladder point above 125 Gy(3) had a higher but not statistically significant 5-year actuarial rate of complications at these organs (18% vs. 12%, p = 0.49 and 17% vs. 9%, p = 0.20, respectively). Patients who received parametrial doses larger than 59 Gy had a higher 5-year actuarial rate of complications in the small bowel; however, this was not statistically significant (19% vs. 10%, p = 0.260). CONCLUSION: This series suggests that 45 Gy to the whole pelvis combined with four fractions of 6 Gy to point A with HDR brachytherapy is an effective and safe fractionation schedule in the treatment of Stages II and III cervix cancer if realized up to 50 days. To decrease the small bowel complications, we decreased the superior border of the parametrial fields to the S2-S3 level and the total dose to 54 Gy.

A comparison of radiotherapy or radiochemotherapy with symptomatic treatment alone in patients with advanced head and neck carcinomas.

The choice of palliative treatment and the prognostic factors in unresectable head and neck cancer cases continue to be controversial. In the present study we compared the survival rates of untreated stage IV head and neck cancer patients with cases managed prospectively at A.C. Camargo Hospital for Cancer with neoadjuvant chemotherapy, concomitant chemotherapy or radiotherapy alone. Previous results had shown that while the type of treatment did not influence survival rates (P = 0.706), tumor response to treatment (whether complete, partial or none) significantly influenced survival (P = 0.00002). In the present study we compared the survival rates in the groups with untreated patients (who remained untreated until death) with the same demographic and clinical characteristics of patients receiving treatment. We found that there was a significant difference between the survival rates of the untreated group and those of the treated groups that was independent of the type of treatment performed (P < 0.00001) or the tumor response to treatment (P < 0.0001).

Radiosurgery for brain metastases: a score index for predicting prognosis.

PURPOSE: To analyze a prognostic score index for patients with brain metastases submitted to stereotactic radiosurgery (the Score Index for Radiosurgery in Brain Metastases [SIR]). METHODS AND MATERIALS: Actuarial survival of 65 brain metastases patients treated with radiosurgery between July 1993 and December 1997 was retrospectively analyzed. Prognostic factors included age, Karnofsky performance status (KPS), extracranial disease status, number of brain lesions, largest brain lesion volume, lesions site, and receiving or not whole brain irradiation. The SIR was obtained through summation of the previously noted first five prognostic factors. Kaplan-Meier actuarial survival curves for all prognostic factors, SIR, and recursive partitioning analysis (RPA) (RTOG prognostic score) were calculated. Survival curves of subsets were compared by log-rank test. Application of the Cox model was utilized to identify any correlation between prognostic factors, prognostic scores, and survival. RESULTS: Median overall survival from radiosurgery was 6.8 months. Utilizing univariate analysis, extracranial disease status, KPS, number of brain lesions, largest brain lesion volume, RPA, and SIR were significantly correlated with prognosis. Median survival for the RPA classes 1, 2, and 3 was 20.19 months, 7.75 months, and 3. 38 months respectively (p = 0.0131). Median survival for patients, grouped under SIR from 1 to 3, 4 to 7, and 8 to 10, was 2.91 months, 7.00 months, and 31.38 months respectively (p = 0.0001). Using the Cox model, extracranial disease status and KPS demonstrated significant correlation with prognosis (p = 0.0001 and 0.0004 respectively). Multivariate analysis also demonstrated significance for SIR and RPA when tested individually (p = 0.0001 and 0.0040 respectively). Applying the Cox Model to both SIR and RPA, only SIR reached independent significance (p = 0.0004). CONCLUSIONS: Systemic disease status, KPS, SIR, and RPA are reliable prognostic factors for patients with brain metastases submitted to radiosurgery. Applying SIR and RPA classifications to our patients' data, SIR demonstrated better accuracy in predicting prognosis. SIR should be further tested with larger patient accrual and for all patients with brain metastases subjected or not to stereotactic radiosurgery.

Melanoma de coróide: conservaçäo de olhos com placas de cobalto-60 / Choroidal melanoma: eye preservation by cobalt-60 plaque therapy

Säo apresentados os resultados de tratamento de 28 pacientes portadores de malanoma da coróide tratados por braquiterapia com placas de cobalto-60. O tamanho dos tumores variou de 2,1 a 15mm em altura e de 9,0 a 22mm no maior diâmetro basal. Para análise dos resultados os pacientes foram subdivididos em 2 grupos: grupos I, com 19 pacientes portadores de tumores de mais de 8mm em altura; e grupo II, com 9 pacientes portadores de tumores de até 8mm de altura. Os resultados quanto à conservaçäo do globo ocular foram melhores no grupo I (78,9/100) que no grupo II (33,3). Todos os olhos enucleados tiveram confirmaçäo do diagnóstico clínico por anátomo-patológico. Dois pacientes do grupo II foram a óbito. Ambos eram portadores de outros tumores malignos sistêmicos previamente ao diagnóstico do melanoma da coróide. Pode-se questionar as hipóteses de tumor metastático ocular ou de dupla patologia tumoral nesses casos. A complicaçäo ocular mais frequente foi a retinopatia da irradiaçäo (39,3/100) seguida da catarata (28,6/100)

[Linear accelerator radiosurgery]. / Radiocirurgia por acelerador linear.

Radiosurgery is the precise radiation of a known intracranial target with a high dose of energy, sparing the adjacent nervous tissue. Technological advances in the construction of linear accelerators, stereotactic instruments and in computer sciences made this technique easier to perform and affordable. The main indications for radiosurgery are inoperable cerebral vascular malformations, vestibular and other cranial schwannomas, skull base meningiomas, deep seated gliomas and cerebral metastases. More recently, the development of fraccionated stereotactic radiotherapy increased the spectrum of indications to bigger lesions and to those adjacent to critical nervous structures. We present our initial experience in the treatment of 31 patients. An adequate control of the neoplastic lesions was obtained and the adequate time of observation is still needed to evaluate the results in arteriovenous malformations.

Prognostic factors in glottic carcinoma clinical stage I and II treated by surgery or radiotherapy.

INTRODUCTION: Decision making regarding selection of treatment for early glottic carcinoma remains controversial. This study was undertaken to assess the impact of such factors as patient age, stage of tumor, site and size of characteristic of the lesion, and other characteristics relative to disease free and overall survival rates. PATIENTS AND METHODS: The records of 145 consecutive patients with stage I and II glottic carcinomas treated between 1954 and 1990 were reviewed retrospectively. Surgery was performed on 50 patients (34.5%), and irradiation therapy was performed on 95 (65.5%). Cox's regression model was used to estimate the hazard ratios of recurrence and death. RESULTS: Median follow-up was 69.3 months. Death due to cancer or treatment complications occurred in 29 patients, whereas 25 patients died due to causes not related to cancer. Five-year rates for overall survival and disease-free intervals were 94.6% and 70.8%, respectively. Tumor control was achieved by initial surgery or irradiation in 78% and 69.5%, respectively. T stage and vocal cord mobility in this series were not associated with prognosis. Arytenoid involvement intended to indicate a worse prognosis. Other site involvement such as anterior commissure had no prognostic impact. DISCUSSION: Although stage I and II glottic cancers represent a heterogenous group, survival rates after surgery or radiotherapy vary relatively little. Death due to occurred in 17.9% of patients included in this series, whereas 17.2% died due to causes not related to cancer. Local recurrence following irradiation (29.5%) occurred more frequently than following surgery (10%). The choice of treatment modality for stage I and II glottic cancer should be justified by patient preference, involvement of anterior commissure, and impairment of vocal cord mobility and should not be a contraindication to radiotherapy.

A randomized trial of neoadjuvant vs concomitant chemotherapy vs radiotherapy alone in the treatment of stage IV head and neck squamous cell carcinoma.

Treatment results of irradiation as a single treatment for advanced stage IV unresectable head and neck cancer remains uniformly poor and apparently has not changed with the most recent improvements in oncological care. Despite several negative results of randomized studies, neoadjuvant or concomitant chemotherapy and radiotherapy seems to improve the number of complete responses and also the duration of disease-free survival. The present study was designed to determine the feasibility, potential risks and benefits of the two methods of combined treatment and radiotherapy alone on the management of advanced unresectable squamous cell carcinoma of the upper respiratory and digestive system. From 1983 to 1986, 90 patients entered the trial. Thirty patients were randomized to each study group: radiotherapy alone (70 Gy); neoadjuvant chemotherapy (vinblastine, mitomycin, cisplatin, and bleomycin) and radiotherapy; concomitant chemotherapy (cisplatin and bleomycin) and radiotherapy. An increased frequency of complete responses (33%) was seen in patients treated with the two different combinations of chemotherapy and irradiation compared to irradiation alone (10%). However, toxicity was more common in patients treated with the two modalities of combined treatment and there were no differences in overall survival rates (P = 0.706).

Braquiterapia no tratamento do cancer da mama - resultados preliminares. / Braquitherapy in the treatment of breast cancer - preliminary results

Os autores apresentam 22 casos de carcinoma de mama tratados por irradiacao exclusiva, demostram sua tecnica e tecem comentarios comparativos entre o tratamento irradiante exclusivo e o cirurgico

A ultra-sonografia na avaliacao do tratamento de massas abdominais. / Ultrasonics in evaluation of treatment in abdominal tumor

Os autores apresentam sua experiencia,utilizando a ultrassonografia em 50 pacientes com tumores abdominais determinando as relacoes da massa tumoral com orgaos adjacentes. Sao apresentados os resultados obtidos com o metodo, durante e apos o tratamento, e suas correlacoes com outros exames