Moderately hypofractionated post-operative radiation therapy for breast cancer: preferences amongst radiation oncologists from countries in Latin America and the Caribbean.

Background: The safety and effectiveness of moderately hypofractionated post-operative radiation therapy for breast cancer were demonstrated by several trials. This study aimed to evaluate the current patterns of practice and prescription preference about moderately hypofractionated post-operative radiation therapy to assess possible aspects that affect the decision-making process regarding the use of fractionation in breast cancer patients in Latin America and the Caribbean (LAC). We also aimed to identify factors that can restrain the utilization of moderately hypofractionated post-operative radiation therapy for breast cancer. Materials an methods: Radiation oncologists from LAC were invited to contribute to this study. A 38-question survey was used to evaluate their opinions. Results: A total of 173 radiation oncologists from 13 countries answered the questionnaire. The majority of respondents (84.9%) preferred moderately hypofractionated post-operative radiation therapy as their first choice in cases of whole breast irradiation. Whole breast plus regional nodal irradiation, post-mastectomy (chest wall and regional nodal irradiation) without reconstruction, and post-mastectomy (chest wall and regional node irradiation) with reconstruction hypofractionated post-operative radiation therapy was preferred by 72.2% 71.1%, and 53.7% of respondents, respectively. Breast cancer stage, and flap-based breast reconstruction were the factors associated with absolute contraindications for the use of hypofractionated schedules. Conclusion: Even though moderately hypofractionated post-operative radiation therapy for breast cancer is considered a new standard to the vast majority of the patients, its unrestricted application in clinical practice across LAC still faces reluctance.

Curative treatment for stage IIIC2 cervical cancer: what to expect?

Background: Since the GOG125 study, treating radically patients with positive para-aortic lymph nodes has been a valid approach. Nevertheless, literature lacks data on how to better treat these patients since they are usually excluded from trials. In this study, we aimed to report the outcomes of patients with advanced cervical cancer and positive para-aortic lymph nodes (PAN) treated in a single tertiary/academic institution and try to identify variables that may impact survival. Materials and methods: We retrospectively reviewed patients with positive para-aortic lymph nodes treated in our institution. Demographic variables and treatment options were assessed and their impact on overall survival (OS), locorregional control, distant metastasis free survival, and para-aortic lymph node progression was analyzed. Results: We assessed 65 patients treated from April 2010 to May 2017. Median OS was 38.7 months. Median locorregional and para-aortic progression free survivals were not reached. Median distant metastasis progression-free survival was 64.3 months. Better ECOG performance status (p > 0.001), concurrent chemotherapy (p = 0.031), and brachytherapy (p = 0.02) were independently related to better overall survival. Conclusion: Patients with current stage IIIC2 cervix cancer may present long term survival. Treating positive PAN cervical cancer patients with concurrent chemoradiation including brachytherapy with curative intent should be standard. Poor PS and more advanced pelvic disease may represent a higher risk for worse outcomes. Distant metastases are still a challenge for disease control.

Results of consolidative radiotherapy for relapsed diffuse B-cell lymphoma.

Background: Recurrent diffuse large B-cell lymphoma (DLBCL) is a disease with high mortality. The standard of care involves autologous stem-cell transplantation (ASCT), which is not always feasible. We investigated the impact of radiotherapy as part of the salvage treatment for patients with relapsed disease. Materials and methods: Retrospective study of patients with recurrent DLBCL after chemotherapy and consolidative radiotherapy at a single institution. All patients were included if radiation was part of the first treatment. Results: Of 359 patients assessed between 2010 and 2017, 65 (18.1%) presented a recurrence, but only 62 received further treatment and were included in the study. Mean overall survival was 18.6 months since diagnosis and progression-free survival after first progression (PFS2) was 7.7 months. Patients were divided into two groups according to whether they did (24.8%) or did not (75.8%) receive radiation as part of their salvage treatment. Patients that did not receive R-CHOP (rituximab plus cyclophosphamide, doxorubicin hydrochloride, vincristine, and prednisone) in the first line were treated more with radiation in the second line (p = 0.02). Six patients with in-field relapse were re-irradiated. Only 4 patients received ASCT as part of their treatment for relapsed disease. There was no difference in outcomes. Conclusion: There is a place for radiotherapy in the treatment of relapsed DLBCL, particularly when patients do not receive ASCT. Radiotherapy is well-tolerated. More trials to assess the role of radiotherapy for these patients are needed.

Impact of radiation on tooth loss in patients with head and neck cancer: a retrospective dosimetric-based study.

OBJECTIVE: To characterize the dental adverse events after head and neck radiation therapy (HNRT) and to investigate the impact of regional radiation dose upon tooth loss outcomes. STUDY DESIGN: A retrospective dosimetric-based analysis was conducted to assess dental events affecting post-HNRT extracted teeth and the impact of 3 different radiation doses (<30 Gy, 30-60 Gy, and >60 Gy) upon tooth loss. In addition, post-HNRT extractions outcomes and mean parotid glands dosimetry and salivary changes were analyzed. RESULTS: Sixty-six patients who underwent HNRT were included in the analysis. Radiation caries was the most frequent (67.8%) post-HNRT dental adverse event, and maxillary molars ipsilateral to the tumor were lost earlier compared with the others (P < .001). The odds ratio for post-HNRT tooth extraction risk was approximately 3-fold higher for teeth exposed to >60 Gy (confidence interval, 1.56-5.35; P < .001), followed by an increased risk of delayed healing and osteoradionecrosis (ORN) in sites receiving doses above 50 Gy. CONCLUSIONS: Radiation caries was the major cause of dental extractions after HNRT, and the dosimetric analysis suggested that a high dose of radiation may negatively impact the dentition of survivors of head and neck cancer, increasing the risk of tooth loss and ORN.

Feasibility of SBRT for hepatocellular carcinoma in Brazil - a prospective pilot study.

BACKGROUND: The aim of the study was to evaluate the feasibility and safety of stereotactic body radiotherapy (SBRT) for the treatment of hepatocellular carcinoma in Brazil. SBRT is an evolving treatment in HCC patients not candidates to other local therapies. Its adoption in clinical practice has been heterogeneous, with lack of data on its generalizability in the Brazilian population. MATERIALS AND METHODS: We conducted a prospective pilot study involving HCC patients after failure or ineligibility for transarterial chemoembolization. Patients received SBRT 30 to 50 Gy in 5 fractions using an isotoxic prescription approach. This study is registered at clinicaltrials.gov NCT02221778. RESULTS: From Nov 2014 through Aug 2019, 26 patients received SBRT with 40 Gy median dose. Underlying liver disease was hepatitis C, hepatitis B and alcohol-related in, respectively, 50%, 23% and 19% of patients. Median lesion size was 3.8 cm (range, 1.5-10 cm), and 46% had multiple lesions. Thirty-two percent had tumor vascular thrombosis; median pretreatment alpha-fetoprotein (AFP) was 171.7 ng/mL (range, 4.2-5,494 ng/mL). 1y-local progression-free survival (PFS) was 86% (95% CI: 61% to 95%), with higher local control in doses ≥ 45Gy (p = 0.037; HR = 0.12). 1y-liver PFS, distant PFS and OS were, respectively, 52%, 77% and 79%. Objective response was seen in 89% of patients, with 3 months post-SBRT median AFP of 12 ng/mL (2.4-637 ng/mL). There were no grade 3 or 4 clinical toxicities. Grade 3 or 4 laboratory toxicities occurred in 27% of patients. CONCLUSION: SBRT is feasible and safe in patients unresponsive or ineligible for TACE in Brazil. Our study suggests doses ≥ 45 Gy yields better local control.

Safety and Feasibility Analysis of a Prospective Trial on Stereotactic Body Radiotherapy for Solitary Bone Plasmacytoma.

BACKGROUND: There have been reports on the use of hypofractionated stereotactic body radiotherapy (SBRT) for bone plasmacytomas, but no prospective data are available. We present the initial analysis of an ongoing prospective protocol on SBRT addressing the feasibility and safety of this treatment for solitary bone plasmacytomas. PATIENTS AND METHODS: A prospective cohort of SBRT for solitary bone plasmacytoma was developed. Patients could receive different doses depending on the index bone, from single fraction for skull base lesions, 24 Gy in 3 fractions for spine lesions, and 30 Gy in 5 fractions for other bones. Overall survival, bone events, local control, and progression to multiple myeloma (MM) were measured and compared to our retrospective cohort of patients treated with conformal standard-dose radiotherapy. Quality of life was assessed via the EORTC QLQ-C30 questionnaire, and toxicities were assessed by the CTCAE v5.0 criteria. After 1 year or the inclusion of 5-10 patients, a feasibility and safety analysis was programmed. RESULTS: Between April 2018 and April 2019, 5 patients were included. All were male, with a median age of 53.1 years. The median follow-up was 21.8 months. No patient had local progression, bone event, or died. Two patients had progressions to MM. The mean survival free of progression to MM was 18.6 months, compared to 19 months in the retrospective cohort; median values were not reached. There were no grade 3 toxicities. CONCLUSION: SBRT for plasmacytoma is safe and feasible. More robust data are awaited.

Hypofractionated radiotherapy in breast cancer: a 10-year single institution experience.

BACKGROUND: Moderately post-operative hypofractionated radiotherapy (HYPO-RT) for breast cancer is a safe and effective strategy as seen in large prospective trials. This study aimed to assess overall and disease-free survivals, local control, and acute and late toxicities in patients treated with HYPO-RT. MATERIALS AND METHODS: Data from patients submitted to post-operative HYPO-RT, with or without boost, were evaluated retrospectively. Demographic, disease, and treatment characteristics were collected. RESULTS: From March 2009 to December 2016, 393 patients were treated. Breast-conserving surgery was performed in 94.7%, immediate reconstruction after mastectomy in 6 (1.5%). Most patients (91.2%) had initial stage (0 to IIA), and chemotherapy was performed in 42.0%, HYPO-RT was mainly performed in 15 or 16 daily fractions of 267 cGy and 265 cGy, respectively. The median follow-up was 5.7 years. There were 25 deaths (6.4%) and 17 (4.3%) local recurrences. At 5 and 10 years, the overall survival, local control, and disease-free survival were, respectively, 96.0% and 79.3%, 99.2% and 94.9%, 96.6%, and 91.9%. Acute grade 3 or 4 dermatitis was observed in 0.9%. Late grade 1 or 2 occurred in less than 3% of the patients. CONCLUSION: HYPO-RT is a safe and effective radiotherapy regimen with excellent disease control and overall survival rates, with low acute and late toxicity rates.

Takotsubo syndrome induced by brachytherapy in a patient with endocervical adenocarcinoma.

BACKGROUND: Takotsubo syndrome (TTS), also known as stress cardiomyopathy, apical ballooning syndrome and broken heart syndrome, is characterized by acute-onset chest pain, electrocardiographic (ECG) abnormalities and reversible left ventricular (LV) disfunction in the absence of a culprit obstructive lesion in the coronary arteries; therefore, myocardial infarction is the most important differential diagnosis. Usually induced by emotional/physical stress, its treatment consists in hemodynamic support until complete and spontaneous recovery occurs, which is generally achieved within a few days to weeks. Cervical malignancies are an important public health issue in low/middle-income countries and, in the setting of locally advanced disease, concurrent chemoradiation followed by brachytherapy is considered the standard treatment, harboring curative potential. CASE REPORT: We report a case of a 38-year-old woman who underwent concurrent chemoradiotherapy and developed cardiopulmonary arrest in ventricular fibrillation during a brachytherapy session. Complementary tests disclosed altered ECG and cardiac biomarkers, no evidence of coronary artery obstruction, as well as LV disfunction consistent with TTS on echocardiogram and cardiac MRI. After few days of supportive therapy, complete recovery of heart function was observed. CONCLUSIONS: Especially for cancer patients, who usually experience intense emotional/physical stress intrinsically associated with their diagnosis and aggressive treatments, considering TTS as a differential diagnosis is warranted. Intracavitary brachytherapy procedure may represent a trigger for TTS.

What a difference a clip makes! Analysis of boost volume definition in radiation therapy for conservative breast surgery.

PURPOSE/OBJECTIVE(S): To evaluate the role of surgical clips placement in the definition of boost treatment volume. MATERIALS/METHODS: Clinical Target Volumes (CTV) were defined as: CTV Breast, CTV Quadrant (based on physical exam and pre-surgical images), CTV Boost, defined by clip plus margin (1 cm for 2 or more clips and 2 cm for 1 clip only) plus radiological changes, CTV NT (normal tissue), defined by CTV Quadrant minus CTV Boost and CTV MISS (CTV that would be outside the treatment volume), defined by CTV Boost minus CTV Quadrant. RESULTS: A total of 247 patients were included. Upper lateral quadrant was the most common clinical location (47.3%). The median number of clips used was three. The mean volumes were: CTV Breast:982.52 cc, CTV Boost:36.59 cc, CTV Quadrant:285.07 cc, CTV NT:210.1 cc and CTV MISS:13.57 cc. Only 50.6% (125) of the patients presented the CTV Boost completely inside the CTV Quadrant and in 47.3% (117), partially inside. Among patients with any CTV MISS, 80.3% (98) had 10% or more of CTV Boost outside the treatment volume. Regarding CTV MISS, there were no statistically significant differences between the groups with 1 clip versus 2 or more clips, nor between patients with or without reconstructive surgery. In average, the CTV Boost was 87% smaller than the CTV Quadrant. The whole quadrant irradiation would lead to unnecessary irradiation of 26% of normal breast tissue. CONCLUSION: Surgical bed clipping is up most important in the definition of the boost volume irradiation to ensure precision minimizing geographical miss and optimizing surrounding normal tissue sparing.

Clinical impact of adjuvant radiation therapy delay after neoadjuvant chemotherapy in locally advanced breast cancer.

BACKGROUND: and Purpose: Post-operative radiation therapy (PORT) is usually indicated for patients with breast cancer (BC) after neoadjuvant chemotherapy (NAC) and surgery. However, the optimal timing to initiation of PORT is currently unknown. MATERIAL AND METHODS: We retrospectively evaluated data from patients with BC who received PORT after NAC and surgery at our institution from 2008 to 2014. Patients were categorized into three groups according to the time between surgery and PORT: <8 weeks, 8-16 weeks and >16 weeks. RESULTS: A total of 581 patients were included; 74% had clinical stage III. Forty-three patients started PORT within 8 weeks, 354 between 8 and 16 weeks and 184 beyond 16 weeks from surgery. With a median follow-up of 32 months, initiation of PORT up to 8 weeks after surgery was associated with better disease-free survival (DFS) (<8 weeks versus 8-16 weeks: HR 0.33; 95% CI 0.13-0.81; p = 0.02; <8 weeks versus >16 weeks: HR 0.38; 95% CI 0.15-0.96; p = 0.04) and better overall survival (OS) (<8 weeks versus 8-16 weeks: HR 0.22; 95% CI 0.05-0.90; p = 0.036; <8 weeks versus >16 weeks: HR 0.28; 95% CI 0.07-1.15; p = 0.08). CONCLUSION: PORT started up to 8 weeks after surgery was associated with better DFS and OS in locally-advanced BC patients submitted to NAC. Our findings suggest that early initiation of PORT is critically important for these patients. However, the low numbers of patients and events in this study prevent us from drawing firm conclusions.

Reirradiation for locally recurrent breast cancer.

The aim of this study is to review the current status of reirradiation therapy (Re-RT) for locally recurrent breast cancer. The overall outcome of breast/chest wall Re-RT is difficult to assess because of the wide range of different treatments that a patient may have undergone and the patient's individual features. The local control and complete response rates were reported to be 43-96% and 41-71%, respectively. The combination of Re-RT and hyperthermia seems to be related to improved outcomes. Toxicity rates vary between studies, and Re-RT is generally well tolerated. Re-RT may be considered an option for patients with breast cancer relapse after prior irradiation. Further studies are needed to determine the best irradiation volume and treatment modality for patients with locally recurrent disease.

Effects of locoregional radiotherapy in patients with metastatic breast cancer.

OBJECTIVES: This study aims to assess the clinical outcomes of patients with metastatic breast cancer (MBC) who underwent local radiation therapy (RT) for the primary site. MATERIAL AND METHODS: Between 2005 and 2013, we retrospectively evaluated patients with MBC who received breast or chest wall RT with or without regional lymph node irradiation. RESULTS: 2761 patients with breast cancer were treated with RT. Of them, 125 women with stage IV breast carcinoma were included. The median follow-up was 15 months (ranging from 3.8 to 168 months), when 54.7% of the patients had died; local progression was observed in 22.8% of the patients. The mean overall survival (OS) and local progression free survival (LoPFS) were 23.4 ± 2.4 months and 45.1 ± 2.9 months, respectively. Three- and five-year overall survival rates were, respectively, 21.2% and 13.3%. Local progression free survival was the same, 67.3%, at three and five years, respectively. Karnofsky Performance Status (KPS) (p = 0.015), number of metastatic sites (p = 0.031), RT dose (p = 0.0001) and hormone therapy (p = 0.0001) were confirmed as independent significant variables correlated with OS. The variables that were independently correlated with LoPFS were the number of previous chemotherapy lines (p = 0.038) and RT dose (p = 0.0001). CONCLUSION: RT of the primary site in patients with MBC is well tolerated. The factors that presented positive impact on survival were good KPS, low disease burden (1-3 metastatic sites), and the use of hormone therapy.

Long-term outcomes of dose-escalated intensity modulated radiation therapy alone without androgen deprivation therapy for patients with intermediate and high-risk prostate cancer.

OBJECTIVE: The addition of androgen deprivation therapy (ADT) to conventional radiation therapy improves overall survival (OS) in intermediate- and high-risk prostate cancer. The benefit of ADT to added to dose-escalated radiotherapy is less clear. The aim of this study was to report disease control outcomes and to identify prognostic variables associated with favorable outcomes in patients with intermediate- and high-risk prostate cancer treated with dose-escalated radiation therapy without ADT. METHODS AND MATERIALS: From September 2001 to March 2010, 127 patients with intermediate- or high-risk prostate cancer were treated with dose-escalated radiation otherapy without ADT. Biochemical recurrence-free survival (bRFS), distant metastases-free survival (DMFS), prostate cancer-specific mortality, and OS were assessed. Univariate and multivariate analyses using Cox regression modeling were performed. RESULTS: The median follow-up was 6.5 years, and the 5-year estimated bRFS, DMFS, prostate cancer-specific mortality, and OS for all patients was 89%, 96.1%, 98.4%, and 96.9% respectively. On multivariate analysis, factors that predict bRFS include risk group and PSA nadir, and factors that predict DMFS include perineural invasion, risk group, and PSA nadir. CONCLUSIONS: Patients with favorable intermediate-risk cancer could likely be treated with dose-escalated radiation therapy without ADT. Patients with high-risk and unfavorable intermediate-risk cancer, perineural invasion, and PSA nadir ≥1ng/dL had worse outcomes and likely need distinct therapeutic approaches.

Laparoscopic extrafascial hysterectomy (completion surgery) after primary chemoradiation in patients with locally advanced cervical cancer: technical aspects and operative outcomes.

OBJECTIVE: This study aimed to evaluate the feasibility and safety of laparoscopic extrafascial hysterectomy and bilateral salpingo-oophorectomy after primary chemoradiation (CRT) in patients with locally advanced cervical cancer (LACC) without evidence of nodal metastasis. BACKGROUND: Currently, the standard of care for patients with advanced cervical cancer is concurrent CRT. There is an unequivocal correlation between presence of residual disease and risk of local relapse. Nevertheless, the importance of hysterectomy in adjuvant setting remains controversial. METHODS: Prospective study with patients affected by bulky LACC (International Federation of Gynecology and Obstetrics stage IB2 up to IIB) treated initially with radical CRT who underwent laparoscopic surgery 12 weeks after therapy conclusion. Inclusion criteria were absence of signs for extrapelvic or nodal involvement on initial imaging staging, as well as complete clinical and radiologic response. RESULTS: From January 2011 to March 2013, 33 patients were endoscopically operated. The mean age was 44 years (range, 21-77 years). Histologic finding revealed squamous cell carcinoma in 19 (60%) cases and adenocarcinoma in 14 (40%) cases. International Federation of Gynecology and Obstetrics stages distribution were as follow: 1B2, n = 3 (9%); IIA, n = 4 (11%); and IIB, n = 26 (80%). The mean pretherapeutic tumor size was 5.2 cm (range, 4-10.2 cm). Estimated blood loss was 80 mL (range, 40-150 mL), and mean operative time was approximately 104 minutes (range, 75-130 minutes). No casualty or conversion to laparotomy occurred. Hospital stay was in average 1.7 days (range, 1-4 days). Significant complication occurred in 12% of the cases; 2 vaginal vault dehiscence, 1 pelvic infection, and 1 ureterovaginal fistula. Nine (27%) patients had pathologic residual disease, and in 78% of these cases, histologic finding was adenocarcinoma (P = -0.048). All patients had free margins. After median follow-up of 16 months, all women have no signs of local recurrence. CONCLUSIONS: Laparoscopic extrafascial hysterectomy (completion surgery) after primary CRT in patients with apparent node-negative LACC is a feasible and safe strategy to improve tumor local control mainly in cases of adenocarcinoma.

Intensity-modulated radiation therapy for head and neck cancer: systematic review and meta-analysis.

BACKGROUND AND PURPOSE: Intensity-modulated radiation therapy (IMRT) provides the possibility of dose-escalation with better normal tissue sparing. This study was performed to assess whether IMRT can improve clinical outcomes when compared with two-dimensional (2D-RT) or three-dimensional conformal radiation therapy (3D-CRT) in patients with head and neck cancer. METHODS AND MATERIALS: Only prospective phase III randomized trials comparing IMRT with 2D-RT or 3D-CRT were eligible. Combined surgery and/or chemotherapy were allowed. Two authors independently selected and assessed the studies regarding eligibility criteria and risk of bias. RESULTS: Five studies were selected. A total of 871 patients were randomly assigned for 2D-RT or 3D-CRT (437), versus IMRT (434). Most patients presented with nasopharyngeal cancers (82%), and stages III/IV (62.1%). Three studies were classified as having unclear risk and two as high risk of bias. A significant overall benefit in favor of IMRT was found (hazard ratio - HR=0.76; 95% CI: 0.66, 0.87; p<0.0001) regarding xerostomia scores grade 2-4, with similar loco-regional control and overall survival. CONCLUSIONS: IMRT reduces the incidence of grade 2-4 xerostomia in patients with head and neck cancers without compromising loco-regional control and overall survival.

Fanconi anemia and vaginal squamous cell carcinoma.

Fanconi Anemia (FA) is an autosomal recessive disease characterized by chromosome instability, cellular hypersensitivity to DNA cross-linking agents, and increased predisposition to malignancies. We describe here a 28 year-old female with FA and vaginal squamous cell carcinoma treated by radiation therapy alone. The patient developed arm phlebitis, pulmonary fungal infection, and severe rectal bleeding, followed by hypocalcaemia, hypokalemia, vaginal bacterial and fungal infection, with subsequent leg and arm phlebitis, perineal abscess, and sepsis. The patient died 12 weeks later.

DNA repair gene excision repair cross complementing-group 1 (ERCC1) in head and neck squamous cell carcinoma: analysis of methylation and polymorphism (G19007A), protein expression and association with epidemiological and clinicopathological factors.

AIMS: To evaluate the associations of excision repair cross complementing-group 1 (ERCC1) (DNA repair protein) (G19007A) polymorphism, methylation and immunohistochemical expression with epidemiological and clinicopathological factors and with overall survival in head and neck squamous cell carcinoma (HNSCC) patients. METHODS AND RESULTS: The study group comprised 84 patients with HNSCC who underwent surgery and adjuvant radiotherapy without chemotherapy. Bivariate and multivariate analyses were used. The allele A genotype variant was observed in 79.8% of the samples, GG in 20.2%, GA in 28.6% and AA in 51.2%. Individuals aged more than 45 years had a higher prevalence of the allelic A variant and a high (83.3%) immunohistochemical expression of ERCC1 protein [odds ratio (OR) = 4.86, 95% confidence interval (CI): 1.2-19.7, P = 0.027], which was also high in patients with advanced stage (OR=5.04, 95% CI: 1.07-23.7, P = 0.041). Methylated status was found in 51.2% of the samples, and was higher in patients who did not present distant metastasis (OR = 6.67, 95% CI: 1.40-33.33, P = 0.019) and in patients with advanced stage (OR = 5.04, 95% CI: 1.07-23.7, P = 0.041). At 2 and 5 years, overall survival was 55% and 36%, respectively (median = 30 months). CONCLUSION: Our findings may reflect a high rate of DNA repair due to frequent tissue injury during the lifetime of these individuals, and also more advanced disease presentation in this population with worse prognosis.

Results of high dose-rate brachytherapy boost before 2D or 3D external beam irradiation for prostate cancer.

BACKGROUND AND PURPOSE: To evaluate biochemical control and treatment related toxicity of patients with localized adenocarcinoma of the prostate treated with high dose-rate brachytherapy (HDRB) combined with conventional 2D or 3D-conformal external beam irradiation (EBI). MATERIAL AND METHODS: Four-hundred and three patients treated between December 2000 and March 2004. HDRB was delivered with three fractions of 5.5-7 Gy with a single implant, followed by 45 Gy delivered with 2D or 3D conformal EBI. RESULTS: The median follow-up was 48.4 months. Biochemical failure (BF) occurred in 9.6% according to both ASTRO and Phoenix consensus criteria. Mean time to relapse was 13 and 26 months, respectively. The 5-year BF free survival using the ASTRO criteria was 94.3%, 86.9% and 86.6% for the low, intermediate and high risk groups, respectively; using Phoenix criteria, 92.4%, 88.0% and 85.3%, respectively. The only predictive factor of BF in the multivariate analysis by both ASTRO and Phoenix criteria was the presence of prostate nodules detected by digital palpation, and patients younger than 60 years presented a higher chance of failure using Phoenix criteria only. CONCLUSIONS: Treatment scheme is feasible and safe with good efficacy.

Treatment of childhood diffuse brain stem tumors: comparison of results in different treatment modalities.

BACKGROUND: Diffuse brainstem tumors in children are rare and its treatment is controversial. Although radiotherapy (RT) used to be the treatment of choice, results remained unsatisfactory. The association of RT with other therapies is common, but lacks scientific data regarding its efficacy. Comparison of results of irradiation alone versus combined treatment modalities is crucial in improving survival. METHOD: The authors reviewed twenty-four patients with diffuse brainstem tumors, with mean age of 7 years, treated from December 90 to November 99, at the University of Sao Paulo, Brazil. These patients were subdivided in four groups according to the treatment option at the onset of symptoms. Four patients were treated with radiation alone (total dose of 50 Gy to 62.4 Gy), 6 patients with chemotherapy and radiation, 8 with tamoxifen and radiation and 6 with tamoxifen, radiation and chemotherapy. The results of the different groups were them compared. FINDINGS: Clinical response was observed in 83.3% of our children, briefly followed by progressive disease. Mean survival was 17 months with no statistically significant differences among the groups. Four patients were alive at the end of the study, with a mean survival of 32.4 months, all of them received combined therapy, but with no statistically significant differences. CONCLUSIONS: Neither the association of radiation therapy with chemotherapy, tamoxifen nor both have showed survival improvement. The prognosis of these patients remains very poor and only investigational trials would justify a highly aggressive approach.