Prostate cancer and elective nodal radiation therapy for cN0 and pN0-a never ending story? : Recommendations from the prostate cancer expert panel of the German Society of Radiation Oncology (DEGRO).

For prostate cancer, the role of elective nodal irradiation (ENI) for cN0 or pN0 patients has been under discussion for years. Considering the recent publications of randomized controlled trials, the prostate cancer expert panel of the German Society of Radiation Oncology (DEGRO) aimed to discuss and summarize the current literature. Modern trials have been recently published for both treatment-naïve patients (POP-RT trial) and patients after surgery (SPPORT trial). Although there are more reliable data to date, we identified several limitations currently complicating the definitions of general recommendations. For patients with cN0 (conventional or PSMA-PET staging) undergoing definitive radiotherapy, only men with high-risk factors for nodal involvement (e.g., cT3a, GS ≥ 8, PSA ≥ 20 ng/ml) seem to benefit from ENI. For biochemical relapse in the postoperative situation (pN0) and no PSMA imaging, ENI may be added to patients with risk factors according to the SPPORT trial (e.g., GS ≥ 8; PSA > 0.7 ng/ml). If PSMA-PET/CT is negative, ENI may be offered for selected men with high-risk factors as an individual treatment approach.

Staging anal cancer: prospective comparison of transanal endoscopic ultrasound and magnetic resonance imaging.

PURPOSE: The staging of anal cancer is extremely important for therapy and prognosis. Transanal endoscopic ultrasound and magnetic resonance imaging are routinely applied. The aim of this prospective comparative study is to evaluate whether tumor staging is concordant between these techniques. METHODS: Forty-five anal cancer patients underwent endoscopic ultrasound and magnetic resonance imaging. Histological confirmation was obtained in all patients. The two test methods were compared with the kappa concordance index and sensitivity for the initial method of tumor detection was calculated. For six patients who were operated upon because of tumor progression, the results were evaluated against the histological tumor stage. RESULTS: High concordance was found in the assessment of tumor size and nodal status (kappa index 0.63 and 0.77). Cancer patients were correctly identified with 100% sensitivity (45/45) by endoscopic ultrasound and with 88.9% (40/45) sensitivity by magnetic resonance imaging. In the six operated patients, T stage was correctly assessed in four of six patients by endoscopic ultrasound and in three of six patients by magnetic resonance imaging. CONCLUSION: The results of endoscopic ultrasound strongly coincide with those of magnetic resonance imaging. Endoscopic ultrasound may be superior to magnetic resonance imaging for detection of small superficial tumors. However, magnetic resonance imaging is needed for N staging.

[Recurrence rate following adjuvant strontium-90 brachytherapy after excision of conjunctival melanoma]. / Rezidivhäufigkeit nach Exzision von Bindehautmelanomen und adjuvanter Strontium-90-Kontaktbestrahlung.

BACKGROUND: Because of the high local recurrence rates after excision of conjunctival melanomas, adjuvant local chemotherapy or irradiation is recommended. Strontium-90 brachytherapy is one radiotherapeutic option due to its low penetration depth. METHODS: 15 patients with conjunctival melanoma were treated with adjuvant strontium-90 brachytherapy after tumour excision. The treatment was fractionated into 9 irradiation sessions with 6 Gy each. The mean follow-up was 35 months (12-60 months). RESULTS: Seven patients (46%) had no recurrence during the follow-up. Three patients (20%) had a recurrence in the treated or adjacent area. Eight patients (53%) developed new tumours in non-treated areas. CONCLUSIONS: Strontium-90 brachytherapy is a useful adjuvant in the treatment of conjunctival melanomas. Regular ophthalmoscopic controls are necessary because of the high rate of new tumours in non-irradiated areas, especially in cases with primary acquired melanosis.

[Endoresection following proton beam irradiation of large uveal melanomas]. / Endoresektion von grossen uvealen Melanomen nach Protonenbestrahlung.

PURPOSE: Large uveal melanomas located close to the optic nerve and/ or to the fovea have an unfavourable prognosis with regard to visual preservation and eye retention, due to the high incidence of radiation and tumour necrosis induced complications. Endoresection of the tumour after proton beam irradiation, is an alternative approach, aiming to reduce the incidence of ocular morbidity caused by tumour necrosis after sole radiotherapy. PATIENTS AND METHODS: 32 patients with large uveal melanomas (mean tumour thickness: 9.1 mm, mean tumour volume: 0.77 cc), received a primary proton beam irradiation (60 CGE) and underwent subsequent endoresection via a 3-port pars plana vitrectomy. The median pretreatment visual acuity was 0.2. The mean follow-up was 13.9 months. RESULTS: The postoperative visual acuity after 12 months was 0.12 (median, mean visual acuity loss 0.08). The probability of developing radiation retinopathy or papillopathy within the first year after treatment was 35% and 28% respectively and the probability of enucleation was 9% within the first postoperative year. No tumour recurrences were observed and 2 patients developed liver metastases. CONCLUSIONS: Endoresection following irradiation of large uveal melanomas located close to the optic nerve and/ or the fovea seems to be a useful and safe alternative to the traditional irradiation or enucleation. The incidence of complications following our approach seems to be lower when compared to radiation alone, where tumour necrosis is a substantial problem.

Adjuvant and salvage radiotherapy after radical prostatectomy.

BACKGROUND: Following radical prostatectomy, between 15 and 60% of all patients with pT3 prostate cancer experience persistence or increasing levels of prostate-specific antigen (PSA) as a sign of tumor persistence or progression within 5 years. Retrospective studies have shown a rate of 35-55% of positive biopsies from the vesicourethral anastomosis in this situation. Best treatment for these disease conditions is under debate, current strategies include adjuvant radiotherapy (RT), 'wait-and-see' and salvage RT or hormone therapy for increasing PSA. RESULTS: A number of retrospective studies have shown an increased rate of local control and 'freedom from treatment failure' following adjuvant RT with doses in the range of 50-60 Gy. However, no survival benefit could be demonstrated by now. Results of three major phase III studies are pending. In case of persisting or increasing PSA levels following radical prostatectomy, 30-70% of these patients will reach an undetectable PSA level after conformal RT with total doses of 60-70 Gy, which will stay undetectable or at least stable within the next 2-5 years in about 50% and therefore offering a chance of cure. When starting RT, PSA should be as low as possible (<2 ng/ml). With higher PSA levels the chance of achieving an undetectable PSA again decreases below 35%. High Gleason scores of 8-10, seminal vesicle involvement and a short PSA doubling time are adverse prognostic factors. Severe late side effects of conformal RT are infrequent (<3%). In contrast, hormonal treatment is of palliative nature in the long run, with a median time to development of metastases of 4-7 years, and can be offered to patients with progressive disease after RT. CONCLUSIONS: Adjuvant RT following radical prostatectomy for pT3 prostate cancer offers higher local control rates and an increase in 'freedom from treatment failure', but no prolongation of survival has yet been shown. In the situation of increasing PSA levels after radical prostatectomy, salvage RT seems to offer a chance of cure in selected patients, although it is difficult to draw firm conclusions because of generally too short follow-up times.

[Primary radiotherapy of recurrent Merkel cell carcinoma of the eyelid. Case report and review of the literature]. / Primäre Strahlentherapie eines rezidivierenden Merkel-Zell-Karzinoms des Lides. Kasuistik und Literaturübersicht.

BACKGROUND: Despite an increasing number of reports Merkel-cell-carcinoma still is a rare neoplasm. Reports on radical radiotherapy are sparse. PATIENT AND METHOD: We report on a successful radical radiotherapy of a recurrent Merkel-cell-carcinoma of the eyelid in an 84-year old woman, using a hypofractionated treatment of 50 Gy with 70 kV-X-rays, 10 fractions of 5 Gy within 5 weeks. RESULT: Rapid and complete remission was achieved, with no signs of local or distant failure 24 months after the end of therapy. CONCLUSION: The case reported on highlights the radiosensitivity of this tumor and the role of radiotherapy not merely as salvage procedure.

Low acute toxicity of radiotherapy and radiochemotherapy in patients with cancer of the anal canal and HIV-infection.

Although not an AIDS-defining malignancy, anal cancer is an evolving problem in HIV-infected patients. Treatment-tolerance to radiotherapy as well as to chemotherapy is supposed to be reduced in patients with HIV-infection. From January 1995 to January 1997, four patients with epidermoid cancer of the anal canal and a long history of HIV-infection but without symptoms of AIDS or repeated severe infections were treated with radiotherapy (n = 1) or radiochemotherapy (n = 3). External beam radiotherapy with 45 Gy to the tumor and pelvic as well as inguinal lymphatic drainage was administered. In tumors larger than T2 N0 lesions an additional boost of 9 Gy was given. Chemotherapy consisted of 5-fluorouracil 1000 mg/m2/24 h, d 1-4 two cycles and Mitomycin C either 1 x 15 mg/m2, d 1 in the first, or 2 x 10 mg/m2, d 1, in the first and fifth week of radiotherapy. Acute reactions were mild to moderate in all patients and all but one treatment could be given as scheduled (1 patient with a delay of 4 days). No excessive acute reactions were seen. Because of the short follow-up, late reactions and local control are not yet evaluable.