Fractionated stereotactic radiotherapy in patients with acromegaly: an interim single-centre audit

AIM

To evaluate the effect of fractionated stereotactic radiotherapy (FSRT) in acromegaly in a retrospective analysis.

PATIENTS AND METHODS

Thirty-four patients (17 females, median 43 years (range 30-74)) with acromegaly were treated with FSRT (conformal dynamic arcing, dose 54 Gy, 27-30 fractions) between January 1998 and April 2007. Of the 34 patients, 32 had undergone transsphenoidal adenotomy, and 28 were on medical therapy before FSRT. Patients on medical therapy continued this during and after the irradiation. The treatment was gradually decreased/withdrawn after careful assessment.

RESULTS

Magnetic resonance scanning of the pituitary gland 34 months (median, range 11-95) after irradiation showed stable or reduced volume of the remaining tumour tissue in 31 of 34 patients (91%). Seventeen patients (50%) were biochemically controlled (normalised nadir GH during oral glucose tolerance test and IGF1 <+2 S.D.) 30 months after FSRT (median, range 6-60), and ten of them had true biochemical remission (off medical therapy) 30 months after FSRT (median, range 12-69). Of 28 patients with one or more functioning pituitary axes before irradiation, 8 (29%) developed further deficit of one or two pituitary axes 48 months (median, range 6-102) after FSRT. Of 34 patients, 20 still required medical treatment for acromegaly at the end of this study, mainly those with a short follow-up period after irradiation.

CONCLUSION

The FSRT seems promising in terms of treatment of acromegaly. Longer follow-up is, however, needed to assess the overall efficacy and safety of FSRT for acromegaly.

Vaginal rupture caused by transvaginal ultrasonography in follow-up for ovarian cancer

Vaginal rupture is a rare complication of hysterectomy. It is, among others, related to age and the incidence is higher in postmenopausal women. The rupture can occur spontaneously or in relation to clinical follow-up. In ovarian cancer the follow-up after surgery includes clinical examination, cancer antigen (CA)-125, and transabdominal and transvaginal ultrasonography. We experienced vaginal rupture in three patients with ovarian cancer. All patients had undergone surgery for ovarian cancer and were receiving chemotherapy. The rupture occurred shortly after transvaginal ultrasonography, performed by separate radiologists specialised in ultrasonography. All patients had acute surgery without any complications. Caution should be taken when performing transvaginal ultrasonography in hysterectomised patients and the complication of vaginal rupture should always be borne in mind.

Phase II study on stereotactic body radiotherapy of colorectal metastases

Surgical resection provides long term survival in approximately 30% of patients with colorectal carcinoma (CRC) liver metastases. However, only a limited number of patients with CRC-metastases are amendable for surgery. We have tested the effect of stereotactic body radiotherapy (SBRT) in the treatment of inoperable patients with CRC-metastases. Sixty-four patients with a total number of 141 CRC-metastases in the liver (n = 44), lung (n = 12), lymph nodes (n = 3), suprarenal gland (n = 1) or two organs (n = 4) were treated with SBRT with a central dose of 15 Gy x 3 within 5-8 days. Median follow-up was 4.3 years. After 2 years, actuarial local control was 86% and 63% in tumor and patient based analysis, respectively. Nineteen percent were without local or distant progression after 2 years and overall survival was 67, 38, 22, 13, and 13% after 1, 2, 3, 4 and 5 years, respectively. One patient died due to hepatic failure, one patient was operated for a colonic perforation and two patients were conservatively treated for duodenal ulcerations. Beside these, only moderate toxicities such as nausea, diarrhoea and skin reactions were observed. SBRT in patients with inoperable CRC-metastases resulted in high probability of local control and promising survival rate. One toxic death and few severe reactions were observed. For the majority of patients, the treatment related toxicity was moderate.

Comparing different error-conditions in film dosemeter evaluation

In the evaluation of a film used as a personal dosemeter it may be necessary to mark the dosemeters when possible error-conditions are recognised, such as errors that have an influence on the ability to make a correct evaluation of the dose value. In this project a comparison has been carried out to examine how two individual monitoring services, IMS [National Institute of Radiation Hygiene, Denmark (NIRH) and National Research Centre for Environment and Health, Germany (GSF)], from two different EU countries mark their dosemeters. The IMS are different in size, type of customers and issuing period, but both use films as their primary dosemeters. The error-conditions examined are dosemeters exposed to moisture or light, contaminated dosemeters, films exposed outside the badge, missing filters in the badge, films inserted incorrectly in the badge and dosemeters not returned or returned too late to the IMS. The data are collected for the year 2003 where NIRH evaluated approximately 50,000 and GSF approximately 1.4 million film dosemeters. The percentage of film dosemeters is calculated for each error-condition as well as the distribution among eight different employee categories, i.e. medicine, nuclear medicine, nuclear industry, industry, radiography, laboratories, veterinary and others. It turned out, that incorrect insertion of the film in the badge was the most common error-condition observed at both IMS and that veterinarians, as the employee category, generally have the highest number of errors. NIRH has a significantly higher relative number of dosemeters in most error-conditions than GSF, which perhaps reflects that a comparison is difficult due to different systemic and methodical differences between the IMS and countries, e.g. regulations and monitoring programs etc. Also the non-existence of a common categorisation method for employee categories contributes to make a comparison like this difficult.

Aspects of harmonisation of individual monitoring for external radiation in Europe: conclusions of a EURADOS action

Following the publication of the EU Council Directive 96/29, EURADOS coordinated two working groups (WGs) for promoting the process of harmonisation on individual monitoring of occupationally exposed persons in Europe. An overview of the major findings of the second WG is presented. Information on the technical and quality standards and on the accreditation and approval procedures has been compiled. The catalogue of dosimetric services has been updated and extended. An overview of national regulations and standards for protection from radon and other natural sources in workplaces has been made, attempting to combine the results from individual monitoring for external, internal and workplace monitoring. A first status description of the active personal dosemeters, including legislative and technical information, and their implementation has been made. The importance of practical factors on the uncertainty in the dose measurement has been estimated. Even if a big progress has been made towards harmonisation, there is still work to be done.

Phase-II study on stereotactic radiotherapy of locally advanced pancreatic carcinoma

BACKGROUND AND PURPOSE

The majority of patients with pancreatic cancer have advanced disease at the time of diagnosis and are not amenable for surgery. Stereotactic radiotherapy (SRT) may be an alternative treatment for patients with locally advanced disease. The effect of SRT was investigated in the present phase-II trial.

PATIENTS AND METHODS

Twenty-two patients with locally advanced and surgically non-resectable, histological proven pancreatic carcinoma were included into the trial. The patients were immobilized by the Elekta stereotactic body frame (SBF) or a custom made body frame. SRT was given on standard LINAC with standard multi-leaf collimator. Central dose was 15 Gyx3 within 5-10 days.

RESULTS

Evaluation of response was found to be very difficult due to radiation and tumour related tissue reaction. Only two patients (9%) were found to have a partial response (PR), the remaining had no change (NC) or progression (PD) after treatment. Six patients had local tumour progression, but only one patient had an isolated local failure without simultaneous distant metastasis. Median time to local or distant progression was 4.8 months. Median survival time was 5.7 months and only 5% were alive 1 year after treatment. Acute toxicity reported 14 days after treatment was pronounced. There was a significant deterioration of performance status (P=0.008), more nausea (P=0.001) and more pain (P=0.008) after 14 days compared with base-line. However, 8 of 12 patients (66%) improved in performance status, scored less nausea, pain, or needed less analgesic drugs at 3 months after treatment. Four patients suffered from severe mucositis or ulceration of the stomach or duodenum and one of the patients had a non-fatal ulcer perforation of the stomach.

CONCLUSIONS

SRT was associated with poor outcome, unacceptable toxicity and questionable palliative effect and cannot be recommended for patients with advanced pancreatic carcinoma.

Optic neuritis: chemokine receptor CXCR3 and its ligands

AIM

To study the involvement of the chemokine receptor CXCR3 and its ligands (CXCL9/Mig, CXCL10/IP-10, CXCL11/ITAC) in optic neuritis (ON).

METHODS

30 patients with ON and 10 non-inflammatory neurological disease controls were included. The patients underwent a phlebotomy, lumbar puncture, and MRI scan. CXCR3 expression was studied on blood and cerebrospinal fluid (CSF) T cells by flow cytometry. CXCL9, CXCL10, and CXCL11 were measured in plasma and CSF by ELISA.

RESULTS

CSF concentrations of CXCL10, but not of CXCL9 and CXCL11, were significantly higher in ON patients than in controls. CSF concentrations of CXCL10 correlated with the CSF leucocyte count in ON patients, and CXCR3 expressing cells were significantly enriched in the CSF.

CONCLUSION

These data show that the CSF concentration of the CXCR3 ligand CXCL10 is selectively increased in CSF from ON patients, and CXCR3 positive cells are recruited to the subarachnoid space.

Three-dimensional anal endosonography may improve staging of anal cancer compared with two-dimensional endosonography

PURPOSE

Three-dimensional (3-D) endosonography is a new method of staging anal carcinoma that has not yet been validated in comparison with two-dimensional (2-D) endosonography, the latter using only a single scan plane. The aim of this study was to investigate the differences between the two endosonographic techniques.

METHODS

Thirty patients with an endosonographically detectable anal tumor were examined with a 10 MHz rotating endoprobe. Cross-sectional images of the anal sphincters were stored on a 3-D system during retraction of the endoprobe through the anal canal. Afterwards, any projection could be reconstructed. Cross-sectional images (2-D) were compared with reconstructed projections (3-D) according to five parameters concerning tumor spread and presence of regional lymph nodes. In this study, a scale of 0 to 5 points on critical issues was used; ideally, the results should be identical in 2-D and 3-D endosonography.

RESULTS

The 3-D method detected a median of 5 diagnostic findings, compared with a median of 4 findings with the 2-D method ( P = 0.001). In eight patients the lateral tumor margin was visualized only by 3-D endosonography. The median number of lymph nodes visualized in 3-D was 1 (range, 0-13), in 2-D the median number was 0 (range, 0-6), P = 0.002.

CONCLUSIONS

Use of 3-D endosonography in patients with anal carcinoma improves detection of perirectal lymph nodes and may improve that of tumor invasion, compared with 2-D endosonography. This may affect local tumor staging and thus planning of treatment. A study with histopathologic correlation is needed to verify this endosonographic study.

Quality control and reliability of reported doses

Results of performance tests verifying the dosimetric properties of dosimetric systems are published in various reports (e.g. IAEA and EURADOS). However, there is hardly any information in the open literature relating to the uncertainty in a dose measurement or in the annual dose, which is increased by failure of the evaluation or data management system, damage of the dosemeter itself or by the loss of dosemeter. In this article, an attempt is made to estimate the importance of the above-mentioned conditions. This is achieved by sending questionnaires to about 200 approved dosimetric services in Europe. In total 88 questionnaires were returned and analysed. In the questionnaires, the frequency of occurrence of the various error conditions were investigated. Participants were also asked to evaluate the impact of the error condition from a dosimetric point of view and what countermeasures are taken. The article summarises all responses and compares different sources of errors according to their impact on the uncertainty of the resulting dose and gives a comprehensive overview on quality control actions and reliability on reported doses from European dosimetric services.

No rules without exception: long-term complete remission observed in a study using a LH-RH agonist in platinum-refractory ovarian cancer

OBJECTIVE

Second-line chemotherapy in platinum/paclitaxel-resistant ovarian cancer induces an objective response in <15% and third-line chemotherapy results in responses less than 10%. Chemotherapy always results in side effects with the risk of a low quality of life. Endocrine therapy is used world-wide among chemo-resistant ovarian cancer. Tamoxifen is a standard palliative treatment in many centers. LH-RH (luteinizing hormone-releasing hormone) agonists have also demonstrated activity among patients with ovarian cancer in several studies with response rates of 9-12% and disease stabilization in 15-26% of these women.

METHODS

In this retrospective study 32 patients with ovarian cancer who had relapsed after platinum/paclitaxel-based first-line chemotherapy and had exhausted all standard treatments received LH-RH analogue Leuprorelin depot 3.75 mg sc once a month until tumor progression.

RESULTS

One patient (3%) had a complete response, with remission time over 3 years. Two patients (6%) reached partial response with remission time of 3 and 4 months. Four patients (12%) remained stable for a mean time of 7 months (range 4-12 months). The remaining 25 patients (78%) had progressive disease. The treatment was well tolerated, and no major toxicity has been reported.

CONCLUSION

This study showed that LH-RH agonist Leuprorelin has only a limited effect in patients pretreated with platinum-based chemotherapy.

[Infants with colic. A heterogenous group possible to cure? Treatment by pediatric consultation followed by a study of the effect of zone therapy on incurable colic]

INTRODUCTION

The aim of the study was to investigate and treat infants with colic by conventional medicine followed by an investigation of the effect of reflexological treatment.

MATERIAL AND METHODS

The investigation was prospective, followed by a randomised, single-blind, double-controlled, prospective study of reflexological treatment with an interview and diary. Sixty-three infants aged 1-3 months referred by general practitioners with crying for > 90 minutes a day were given a paediatric examination and intervention. The cause of crying was discovered in 33 infants: Vitamin D (5), elimination of cow's milk protein (3), and anal stenosis (3); counselling on feeding, sleep, reduction of stimulation, and avoidance of passive smoking (22). Thirty infants without the benefit of paediatric consultation were randomised to three groups for a duration of two weeks: A: Presumed non-effective reflexological treatment vs B: Presumed effective reflexological treatment vs C: No treatment--only observation. The most important parameter was the number of crying hours over 24 hours. Cure was defined as crying for less than or equal to 30 minutes.

RESULTS

Examination by the paediatrician: Thirty-three of 63 infants benefited with a reduction in crying of less than 90 minutes and 13 of these infants were cured. The randomised study: In group C (control), none of the patients was cured. In groups A and B (presumed non-effective reflexological treatment and presumed effective treatment), half the patients were cured, which was significantly better than in group C. There was no significant difference between groups A and B, but B seemed better than group A. B was significantly better than C.

DISCUSSION

Infantile colic had a significant cure rate at paediatric consultation and the children who did not benefit from this intervention had a significantly better outcome after reflexological treatment than had the observation group. Further investigations in reflexological treatment in infants are recommended.

Pulsed dose rate (PDR) brachytherapy as salvage treatment of locally advanced or recurrent gynecologic cancer

PURPOSE

Pulsed dose rate (PDR) brachytherapy is a new treatment option permitting dose distribution optimization in interstitial implants. It possesses the advantage of equipment simplification and radiation protection to the staff, compared to the manually afterloading technique. This study presents the first clinical results from The Finsen Center with PDR-brachytherapy in patients with locally advanced or recurrent gynecologic cancer.

METHODS AND MATERIALS

Between June 1993 and August 1996, 34 patients with gynecologic malignancies (22 pelvic recurrences, 12 primary locally advanced) have been treated with external irradiation, four-field box technique, to 46 Gy/23 fractions, 5 F/week and 192Ir-interstitial PDR-brachytherapy in pulses of 0.6 Gy, one pulse per hour to a total of 30 Gy. The Martinez Universal Perineal Interstitial Template applicator was used for all implantations.

RESULTS

The overall complete response rate was 74%. At median 14 months follow-up (range 3-40) 15 patients were alive with no evidence of disease. Seven of 14 patients with a second recurrence or progressive disease were still alive. The overall 1- and 2-year survival was 71% and 63%, respectively. There was no difference in survival probability when stratifying the patients by primary diagnosis (recurrent vs. primary advanced), relapse locations (central vs. central + pelvic wall mass) or treatment volume. Seventeen chronic grade III complications were observed in 10 patients. Large treatment volumes significantly correlated to severe gastrointestinal complications. Fifteen of 17 chronic grade III complications were observed in patients treated for recurrent disease.

CONCLUSION

PDR-brachytherapy in combination with external irradiation is an effective treatment option for patients with locally advanced or recurrent gynecologic cancer, although substantial toxicity is observed in patients with large treatment volumes and recurrent disease.

Pulsed dose rate (PDR) brachytherapy of anal carcinoma

BACKGROUND AND PURPOSE

With radiotherapy of anal carcinomas, sphincter preservation can be obtained at survival rates similar to those obtained with radical surgery. By combining external beam irradiation with interstitial irradiation, superiority over standard external irradiation has been obtained. With the introduction of pulsed dose rate equipment, where a single high activity source moves through catheters, a more individualized dose distribution and a further elimination of radiation exposure to the staff can be achieved.

MATERIALS AND METHODS

Between June 1993 and November 1994, 17 patients with anal carcinoma (T1:4, T2:4, T3:6, T4:3) have been treated at the Finsen Center. The treatment consisted of three-field external irradiation 46 Gy/23 fractions with five fractions a week to the anal canal and regional pelvic lymph nodes. Seven to 33 days after completion of external irradiation, the tumorspace was given 25.2 Gy PDR brachytherapy with 42 pulses of 0.6 Gy, one pulse every hour.

RESULTS

One isolated local recurrence has been noted 13 weeks after implantation. One additional local recurrence was seen in a patient with concomitant hepatic and inguinal recurrence. In three patients inguinal recurrence had occurred, two of these patients were irradiated without any further evidence of disease, and one patient with a primary advanced tumour, had local failure. So far necrosis has been observed in 13 patients within 1-49 weeks (median 16 weeks) after implantation. Eight of these patients required colostomy. No relation was observed between the number of implanted needles and the occurrence of necrosis.

CONCLUSIONS

The results indicate that the treatment is highly effective, but with substantial toxicity.

A dominated and resistant subpopulation causes regrowth after response to 1,3-bis(2-chloroethyl)-1-nitrosourea treatment of a heterogeneous small cell lung cancer xenograft in nude mice

In order to address the question of the influence of a primarily chemoresistant tumor cell subpopulation on the progression of a heterogeneous tumor after cytotoxic therapy, in vitro established human small cell lung cancer cell lines of a 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU)-sensitive (592) and a resistant (NYH) tumor were used to produce mixed solid tumors in nude mice. Mixtures of 592/NYH (9:1 and 1:1) were inoculated s.c. After 3-4 weeks of tumor growth, the mice were stratified according to tumor size and randomized to treatment with BCNU 40 mg/kg i.p. (10% of lethal dose) or no treatment. Tumor growth curves were used to calculate the effect of the treatment, and changes in the relative proportions of 592 and NYH in the mixed tumors were monitored by flow cytometric DNA analysis by which the two cell lines were distinguishable due to differences in DNA content. A significant response was demonstrated in the 9:1 mixed tumors in which only 592 cells were detectable at the start of the treatment. The response was short and less pronounced compared with tumors containing only 592. In the regrowing tumors after treatment, only NYH was detected. In untreated 9:1 mixed control tumors, only 592 cells were detectable throughout the entire observation period. It is substantiated that the 592 cells were able to inhibit the growth of the NYH cells completely when grown together in 9:1 mixed tumors. This was not the case in the 1:1 mixed tumors. The 1:1 mixed tumors did not respond to BCNU, although 592 was eradicated. These results indicate that resistant and undetectable (dominated) subpopulations in heterogeneous tumors may be responsible for relapse and that the fractional size and the growth characteristics of the resistant subpopulation may determine the magnitude of the clinical response to cytotoxic treatment.

Doxorubicin sensitivity pattern in a panel of small-cell lung-cancer cell lines: correlation to etoposide and vincristine sensitivity and inverse correlation to carmustine sensitivity

The aim of our investigations is to evaluate whether the sensitivity patterns of small-cell lung-cancer (SCLC) cell lines in vitro can be used in evaluating new drugs and in selecting drugs for the optimization of combination therapy. In our attempts to obtain a panel of cell lines demonstrating differential patterns in sensitivity, we have developed three SCLC lines exhibiting different types of multidrug resistance (MDR). In the present investigations we compared the sensitivity patterns shown by five wild-type SCLC lines and three MDR lines in response to six different types of drugs: doxorubicin, cytarabine, carmustine, cisplatin, vincristine, and etoposide. In the wild-type SCLC cell lines, the range of variation in sensitivity to all drugs was within a factor of 10. Cell lines showing low sensitivity to doxorubicin also exhibited low sensitivity to etoposide and vincristine, and vice versa. In contrast, the pattern of sensitivity to carmustine was almost the opposite of that to doxorubicin. A tendency to an inverse relationship between doxorubicin and carmustine sensitivity was also observed when doxorubicin sensitivity was reduced in near stationary cells and in cells exposed to the metabolic inhibitor 2-deoxy-D-glucose. In agreement with the pattern observed for the wild-type lines, all of the MDR sublines demonstrated collateral sensitivity to carmustine. As to cytarabine, the wild-type lines expressed a sensitivity pattern similar to that shown in response to doxorubicin. Interestingly, the opposite pattern was found in the MDR lines, as all three demonstrated cytarabine hypersensitivity. The combination of alkylating agents and "MDR" drugs are of proven clinical benefit in the treatment of solid tumors, as is the combination of anthracycline and cytarabine in acute myeloid leukemia. The experimentally derived sensitivity data on cytarabine, alkylating agents, and MDR drugs (i.e., etoposide, doxorubicin, vincristine) thus resemble the clinical experience with these drugs, and we conclude that the use of a clonogenic assay on the described panel of SCLC cell lines can give valuable information for the selection of agents for combination therapy.

In vitro circumvention of anthracycline--resistance in Ehrlich ascites tumour by anthracycline analogues

In previously reported studies, acquired experimental resistance and cross resistance to anthracyclines are related to decreased drug accumulation and retention. The decreased accumulation seems to depend on a cellular mechanism for active drug efflux. N-Acetyl-daunorubicin (N-acetyl-DNR) has demonstrated the ability to increase drug accumulation and to overcome experimental resistance to daunorubicin (DNR) in resistant cells. In the present in vitro study 25 different anthracycline analogues were tested for their influence on [3H]DNR accumulation in resistant cells. At equimolar concentrations (5 microM) four of the analogues enhanced [3H]DNR accumulation more than 200%. Increasing the concentration of the analogues 3-20-fold, 12 of the compounds could enhance [3H]DNR accumulation above 200%. No specific structural changes separated those 12 compounds from the 13 analogues with no or minor effect. The lipid solubility of the 25 analogues was examined by measuring the partition coefficient in octanol/phosphate and pentanol/phosphate buffer (pH 7.45). A good correlation was demonstrated between increased lipid solubility of the analogues and their effect on [3H]DNR accumulation in resistant cells. Further studies demonstrated that N,N-dibenzyl-DNR was able to potentiate cytotoxicity of DNR in resistant cells. It is concluded that several anthracycline analogues are able to reverse resistance, but it is not possible from the chemical structure to predict which analogue results in enhanced [3H]DNR accumulation in resistant cells.

Antitumor activity of the two epipodophyllotoxin derivatives VP-16 and VM-26 in preclinical systems: a comparison of in vitro and in vivo drug evaluation

The epipodophyllotoxines VP-16 and VM-26 are chemically closely related. VM-26 has been found to be considerably more potent than VP-16 in vitro in a number of investigations. Although the drugs have been known for greater than 20 years, they have not been compared at clearly defined equitoxic doses on an optimal schedule in vivo and it has not been clarified as to whether a therapeutic difference exists between them. A prolonged schedule is optimal for both drugs; accordingly we determined the toxicity in mice using a 5-day schedule. The dose killing 10% of the mice (LD10) was 9.4 mg/kg daily (95% confidence limits, 7.4-11.8) for VP-16 and 3.4 (2.5-4.5) mg/kg daily for VM-26. In vitro, we found VM-26 to be 6-10 times more potent than VP-16 in a clonogenic assay on murine tumors P388 and L1210 leukemia and Ehrlich ascites. This pattern was also demonstrated in a multidrug-resistant subline of Ehrlich selected for resistance to daunorubicin (Ehrlich/DNR+), as it was 30 times less sensitive than Ehrlich cells to both VP-16 and VM-26. Using 90%, 45%, and 22% of the LD10 on the same murine tumors in vivo, we found that the effect of the two drugs was equal as evaluated by both the increase in life span and the number of cures. The drugs were also compared in nude mice inoculated with human small-cell lung cancer lines OC-TOL and CPH-SCCL-123; however, they were more toxic to the nude mice and only a limited therapeutic effect was observed. In conclusion, the complete cross-resistance between the two drugs suggests that they have an identical antineoplastic spectrum. VM-26 was more potent than VP-16 in vitro; however, this was not correlated to a therapeutic advantage for VM-26 over VP-16 in vivo.