Stereotactic body radiotherapy in non-operable lung cancer patients

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Induction chemotherapy to weekly paclitaxel concurrent with curative radiotherapy in stage IV (M0) unresectable head and neck squamous cell carcinoma: a dose escalation study.

The purpose was to determine the maximum tolerated dose (MTD) of weekly paclitaxel with concurrent, daily irradiation in patients with unresectable head and neck squamous cell carcinoma previously submitted to induction chemotherapy. Patients with stage IV, and unresectable tumor and/or node/s were enrolled. Nine male patients were submitted to a course of paclitaxel 175 mg/m2 day 1 and cisplatin 75 mg/m2 day 2 given every 3 weeks for three courses. Curative radiotherapy (RT) started 3 weeks after the last cycle of chemotherapy with the goal of delivering a total dose of 66-70 Gy. During RT weekly paclitaxel was administered for 6 courses if feasible; paclitaxel was given according to a dose escalation schema in cohorts of three patients. Dose level A, 30 mg/m2; dose level B, 40 mg/m2; dose level C, 50 mg/m2. During weekly paclitaxel the major toxicity was mucositis that required a treatment break in two of three patients in dose level C; mucositis grade 4 required interruption of paclitaxel administration in all these patients. RT can be given in a continuous fashion with weekly paclitaxel after induction chemotherapy. The MTD of weekly paclitaxel was 40 mg/m2.

Ipsilateral supraclavicular lymph nodes metastases from breast cancer as only site of disseminated disease. Chemotherapy alone vs. induction chemotherapy to radical radiation therapy.

BACKGROUND: To define the role of radiotherapy (RT) in the treatment of ipsilateral supraclavicular lymph-nodes metastases (ISLM) from breast cancer as only site of disseminated disease, we started a prospective non-randomized clinical trial in 1989. Here we report the final results with a median follow-up of 8.75 years. PATIENTS AND METHODS: Thirty-seven patients (pts), with ISLM from breast cancer, were consecutively enrolled into two arms. Arm A (18 pts): chemotherapy (CT) for six courses. Arm B (19 pts): CT for three courses followed by RT to the site of ISLM at 'radical' dose of 50-60 Gy. RESULTS: In arm A, a median Time to Progression (TtP) of 7 months with a median Overall Survival (OS) of 28 months was recorded. In comparison, patients in arm B had a longer median TtP with 20 months as well as a better median OS with 41 months, respectively. An actuarial five-year disease-free survival of 5.5% was obtained in arm A vs. 21% in arm B. A statistically significant difference in TtP was demonstrated between the two groups (P = 0.01). CONCLUSIONS: These data demonstrate that a better event-free survival could be achieved in patients with ISLM submitted to induction CT and radical irradiation. This also translated into a longer survival although this did not achieve statistical significance. We want to stress the importance of local control by RT since it does imply that not all of these patients have micrometastases at the time of relapse in the supraclavicular fossa.

What is the best position of the arms in mantle field for Hodgkin's disease?

PURPOSE: To evaluate the best position of the arms in mantle field for Hodgkin's disease. METHODS AND MATERIALS: In 12 patients, with surgical clips placed at the time of an axillary dissection for breast cancer, the radiological projection of the clips according to three arm positions was prospectively evaluated: akimbo (A), extended (E), and up over the head (U). The surgical clips were arbitrarily separated into two groups: lower and upper. In each patient, the distance between the surgical clips and chest wall was measured, and the possibility of shielding the lungs and humeral heads was evaluated. RESULTS: The mean displacement of the lower clips away from the chest wall when the patients were in A, E, and U positions was 2.5, 3.0, and 4.6 cm, respectively. The upper group clips showed a lower difference in distance from chest wall. In the U position, there was always a clip of the lower group that projected over the humeral head, making it impossible to block this structure. CONCLUSION: In the A position, there is the possibility of blocking the humeral head, but it is necessary to irradiate more lung parenchyma. Type E treatment setup allows the shielding of both lung and humeral head, while maintaining adequate margins around the axillary nodes. In the U position, there is a greater possibility of shielding the lung parenchyma, but it is impossible to block the humeral heads.

Prognostic factors in ambulatory patients with inoperable locoregionally recurrent rectal cancer following curative surgery.

BACKGROUND: The optimal treatment for locoregionally recurrent rectal cancer after curative surgery has not yet been defined. The definition of prognostic factors could lead to the selection of an aggressive therapeutic approach in patients with favourable prognosis alone. PATIENTS AND METHODS: The records of thirty-nine ambulatory pts, 15 female and 24 male, with diagnosis of locoregionally recurrent rectal cancer (LRRC) after curative surgery and treated with radiotherapy were retrospectively analyzed. The following factors were analyzed for their ability to predict the clinical response and outcome for LRRC: age, sex, initial tumor grading, primary surgical approach, initial primary tumor stage according to Dukes' classification, disease free survival (time to primary surgery and detection of a LRRC), pelvic-perineal structure affected by recurrence, total radiation dose, chemotherapy with fluorouracil, symptomatic response to the therapy, locoregional symptomatic re-recurrence, systemic progression disease. RESULTS: In the univariate analysis, predictive factors for survival, were graded (G1-2 vs G3 p = 0.04), Dukes' stage at first diagnosis (A-B vs C p = 0.01), and site of pelvic-perineal recurrence (Pelvic mass alone yes vs no p = 0.01; Nerve and/or Osseous involvement yes vs no p < 0.001). Following therapy for LRRC, a better survival was observed in pts with a complete symptomatic response (complete remission vs partial remission vs no change p < 0.001), without a further locoregional symptomatic re-recurrence (re-recurrence, yes vs no p = 0.001) and/or appearance of metastatic disease (yes vs no p < 0.001).

Primitive sinonasal malignant mucosal melanoma: description of a case treated with radiotherapy (0-7-21 regimen).

Mucosal malignant melanoma (MMM) of the nasal cavity and paranasal sinuses is rare and has a poor prognosis. The rarity of MMM of the ethmoid is also noteworthy and primary treatment has been, till now, surgery and/or radiotherapy (RT). Here we report a case of MMM arising in the ethmoid of a caucasian man and treated with hypofractionated RT. A 32 year-old man presented with symptoms of cephalalgia, obstruction and nasal bleeding; a computed tomography (CT) showed a large mass that involved ethmoid, left orbit and roof of the nasal cavity. After biopsy, a MMM was found. Chest radiography demonstrated the presence of multiple lung metastases and still the patient was submitted to palliative radiotherapy according to 0-7-21 regimen with a total dose of 24Gy/3 fraction/21dd, dose per fraction 8Gy. The patient was asymptomatic one month after the end of RT and three months later a CT demonstrated a partial remission. The patient died 17 months after the initiation of RT for disseminated disease, without clinical signs of tumoral regrowth in the irradiated site. This case confirms the efficacy and the safety of 0-7-21 RT regimen; the absence of symptoms after 17 months and the poor prognosis encourage the use of RT as primary treatment for MMM of the head and neck.

Supraclavicular lymph node metastases (SLM) from breast cancer as only site of distant disease: has radiotherapy any role?

BACKGROUND: Supraclavicular lymph node metastases (SLM) as the only site of metastatic disease from breast cancer is a rare and a poor prognostic event. In order to evaluate the role of Radiotherapy (RT) with "radical dose" to the supraclavicular fossa, we carried out a non randomized clinical trial comparing systemic therapy alone to integrated and aggressive treatment (systemic therapy plus radiotherapy). The primary end-point was time to progression (TTP). The second end-point was the overall survival (OS). METHODS: From 1/1/1989 to 31/12/1994 37 patients (with or without the presence of locoregional disease) were enrolled into two arms, of the study, but were allowed, when giving their consent, to change the arm of the study which they had been originally allotted to. Arm A, 18 patients, 15 evaluable: chemo +/- hormonotherapy for 6 courses; after the second course, if local progression disease was present, the pts. were submitted to RT and removed from the study (3 patients). Arm B, 19 patients all evaluable: chemo +/- hormonotherapy for 3 courses followed by RT with "radical" dose. Results were analyzed on 30/11/1995 and no interim analysis was performed. The potential median follow up for all patients was 56.5 months (range 11-83 months): for Arm A 61 months (range: 12-82); for Arm B 53 months (range: 11-83). The two groups were homogeneous and balanced, without statistical differences. RESULTS: Median TTP was 12.5 months in Arm A and 19.5 months in Arm B (p = 0.064). Median overall survival (OS) was 27.5 months in Arm A and 48 months in Arm B. T-status to the time of the diagnosis was found to be independent prognostic factor for TTP (p = 0.0029). Disease-free interval from diagnosis to recurrence was found to be a significant prognostic factor for OS (p = 0.009). CONCLUSION: The results in Arm B demonstrated the opportunity of a long term control in this subset of patients. Therefore we suggest the start of a wider multicenter study in order to define the biological significance of SLM, its importance in staging breast cancer and to consider the optimum treatment.

Curative radiotherapy (RT) using limited RT treatment fields in elderly patients with non-small cell lung cancer in clinical stage IIIA.

We report a prospective phase II study utilizing limited radiotherapy (RT) treatment fields in elderly (greater than or equal to 75 years) patients (pts) with non-small cell lung cancer (NSCLC) in clinical stage IIIA. Sixteen good risk pts with histologically confirmed NSCLC in clinical stage IIIA, age greater than or equal to 75 years (yr) (range 75-83; median age 77) were entered in the study. All pts were treated with Limited RT fields (including T and N1-2 usually with a 1.5 cm, radiographic margin) and received a minimum of 54 Gy (range 54-62 Gy, median 60 Gy, dose/fraction 2 Gy/5 dd a week). All pts have been followed-up for a median time of 3.5 years (range 1.75-6.58). Median survival (MS) was 18 months (range 7-52 months). No acute and/or late significant toxicity was recorded. Univariate analysis showed a better survival in pts receiving a radiation dose greater than or equal to 60 Gy, with an MS of 34 vs 14 months (p=0.017) and in pts with Karnofsky Performance Status greater than or equal to 80, with an MS of 34 vs 12 months (p=0.0O2). There are scarce data available on survival in elderly pts with NSCLC in clinical stage IIIA. Pts submitted to 'standard' RT in unresectable NSCLC have a poor median survival time and 5-year survival rates. The results obtained in our pts encourage us to use 'limited' RT in elderly but the results require a phase III study before definitive recommendations can be made.