[Requirements and performance profile of the Paediatric Radiation Oncology Working Group (APRO): evaluation of the present situation and description of future developments]

BACKGROUND

Radiation therapy is an integral component in the management of childhood malignancies and undergoes a continuous process of optimization within the prospective trials of the GPOH. At present there are approximately 20 active protocols, some specifying radio-oncological study questions, in which about 500 to 600 children annually are given radiotherapy.

MATERIALS/METHODS

The Pediatric Radiation Oncology Working Group (APRO) of the German Society for Radiation Oncology (DEGRO) represents the organizational link between GPOH and DEGRO. Their activities range from phrasing guidelines of radio-oncological therapy, through writing a protocol for a prospective study on radiation-induced late effects (RISK--in co-operation with GPOH, 695 patients registered so far) and organizing meetings for information transfer, to implementing radio-oncology within the prospective studies of the GPOH by establishing study chairs for radio-oncology when radio-oncological questions are a primary focus and/or to function as a reference institution for quality assurance. These activities also include individual case consultations outside the study proper. Twice annually the members of the APRO meet for an update on current knowledge and future directions where a representative of the GPOH is invited to contribute special aspects of pediatric oncology.

CONCLUSIONS

In the future, modern technology (intensity modulated radiotherapy, proton therapy, inclusion of imaging in treatment planning) will be part of disease management in pediatric oncology. A working group for modern radiotherapy technology was established to enhance this development. Prospective studies of the GPOH with primary or secondary radio-oncological questions require the implementation of corresponding tasks (documentation, monitoring, etc.) in order to meet future demands on clinical trials and to achieve the aims of the protocol. Consequently adequate financial support is indispensable.

Radiochemotherapy with cisplatin and 5-fluorouracil after transurethral surgery in patients with bladder cancer

PURPOSE

To give an update on the long-term outcome of an intensified protocol of combined radiochemotherapy (RCT) with 5-fluorouracil (5-FU) and cisplatin after initial transurethral resection of bladder tumor (TURBT) with selective organ preservation in bladder cancer.

METHODS AND MATERIALS

One hundred twelve patients with muscle-invading or high-risk T1 (G3, associated Tis, multifocality, diameter >5 cm) bladder cancer were enrolled in a protocol of TURBT followed by concurrent cisplatin (20 mg/m(2)/day as 30-min infusion) and 5-FU (600 mg/m(2)/day as 120-h continuous infusion), administered on Days 1-5 and 29-33 of radiotherapy. Response to treatment was evaluated by restaging TURBT 4-6 weeks after RCT. In case of invasive residual tumor or recurrence, salvage cystectomy was recommended.

RESULTS

Ninety-nine patients (88.4%) had no detectable tumor at restaging TURBT; 71 patients (72%) have been continuously free from local recurrence or distant metastasis. Superficial relapse occurred in 13 patients and muscle-invasive recurrence in 11 patients. Overall and cause-specific survival rates for all patients were 74% and 82% at 5 years, respectively. Of all surviving patients, 82% maintained their own bladder, 79% of whom were delighted or pleased with their urinary condition. Hematologic Grade 3/4 toxicity occurred in 23%/6% and Grade 3 diarrhea in 21% of patients. One patient required salvage cystectomy due to a shrinking bladder.

CONCLUSION

Concurrent RCT with 5-FU/cisplatin has been associated with acceptable acute and long-term toxicity. Overall and cause-specific survival rates are encouraging. More than 80% of patients preserved their well-functioning bladder.

Mitochondrial OXPHOS functions in R1H rhabdomyosarcoma and skeletal muscles of the rat

The aim of the study was to determinate mitochondrial oxidative phosphorylation (OXPHOS) functions in rat rhabdomyosarcoma R1H (R1H) and rat skeletal muscles. For that purpose skinned fiber technique and multiple substrate inhibitor titration were adapted to tumor samples. In our animal tumor model (R1H) functional abnormalities of OXPHOS were found compared to skeletal muscles. In R1H the state 3 respiration of pyruvate + malate was decreased: 0.56 +/- 0.28 nmol O(2)/mg/min versus 2.32 +/- 1.19 nmol O(2)/mg/min, P < 0.001, whereas the state 3 respiration of succinate + rotenone was increased: 36 +/- 14% versus 19 +/- 11%, P < 0.001. In R1H the rotenone-insensitive respiration reached higher levels than the antimycin A-insensitive respiration, whereas in normal muscles the converse was observed. Additionally, the obvious difference between the CAT- and the antimycin A-independent respiration indicates an increased part of leak respiration in R1H. By now, the high feasibility of these techniques is appreciated for the investigation of muscles and prospectively for tumors, too.

Radiotherapy is effective for metastatic spinal cord compression in patients with epithelial ovarian cancer

Ovarian cancer patients developing metastatic spinal cord compression (MSCC) are extremely rare and account for only 0.4% of MSCC patients. Only very few case reports are available in the literature. This analysis evaluates seven ovarian cancer patients treated for MSCC with radiotherapy alone. Data of 1,852 MSCC patients irradiated between 1992 and 2005 were retrospectively reviewed. Seven patients were identified with epithelial ovarian cancer. These seven patients were evaluated for functional outcome, ambulatory status, local control of MSCC, and survival. The patients received either short-course radiotherapy (1 × 8 Gy or 5 × 4 Gy, n= 2) or long-course radiotherapy (10 × 3 Gy, 15 × 2.5 Gy, or 20 × 2 Gy, n= 5). Improvement of motor function occurred in three of the seven patients, in three of the five patients after long-course radiotherapy, and none of the two patients after short-course radiotherapy. Two of the five nonambulatory patients regained the ability to walk after radiotherapy. No further deterioration of motor function was seen in another three of the seven patients, in two of the five patients after long-course radiotherapy, and one of the two patients after short-course radiotherapy. Deterioration occurred in one of the seven patients, in none of the five patients after long-course radiotherapy, and one of the two patients after short-course radiotherapy. Patients died after a median interval of 4 months (range 1–7 months) following radiotherapy. A recurrence of MSCC did not occur. Radiotherapy alone is effective in improving or maintaining motor function in MSCC patients with ovarian cancer and should be administered if decompressive surgery is not indicated.

Survivin protein expression and hypoxia in advanced cervical carcinoma of patients treated by radiotherapy

BACKGROUND

Survivin is strongly overexpressed in the vast majority of cancers. Initial investigations suggest a role for Survivin in radiation resistance. In this study, we investigate the effect of Survivin expression on clinical outcome and its relationship to tumor oxygenation parameters, expression of Hif-1alpha and anemia in patients with advanced cervical cancers treated with radiotherapy.

MATERIAL AND METHODS

Biopsies of 44 patients with cervical cancers (Stage IIB: n=9; Stage IIIB: n=31; Stage IVA: n=4) treated with radiotherapy were assessed by immunochemistry for expression of Survivin. Relation of Survivin to pretreatment tumor oxygenation parameters (HF5, pO(2)), hemoglobin (hb) level, Hif-1alpha expression and clinical parameters were investigated.

RESULTS

Survivin expression was detected in all tumors of the 44 patients. Seven showed a strong expression and 37 have moderate Survivin expression. Patients whose tumors showed moderate Survivin expression had a 5-year overall survival of 66%. However, only one of the seven patients with strong Survivin expression was alive 45 months after treatment. In a Cox regression analysis, Survivin expression was correlated to poor overall survival (p=0.02, RR=3.3). There was no relationship between Survivin expression and pO(2) or HF5, but rather an inverse correlation with hemoglobin level (p=0.04). Furthermore, for six of the seven tumors with a high Survivin expression, Hif-1alpha was detected.

CONCLUSION

Survivin protein expression is linked with anemia and prognosis in advanced cervical carcinoma of patients treated by radiotherapy.

Immunohistochemical detection of osteopontin in advanced head-and-neck cancer: Prognostic role and correlation with oxygen electrode measurements, hypoxia-inducible-factor-1α-related markers, and hemoglobin levels

PURPOSE

The tumor-associated glycoprotein osteopontin (OPN) is discussed as a plasma marker of tumor hypoxia. However, the association of immunohistochemical OPN expression in tumor sections with tumor oxygenation parameters (HF5, median pO(2)), the hypoxia-related markers hypoxia-inducible factor-1alpha (HIF-1alpha) and carbonic anhydrase IX (CAIX), or hemoglobin and systemic vascular endothelial growth factor (VEGF) levels has not been investigated.

METHODS AND MATERIALS

Tumor tissue sections of 34 patients with advanced head-and-neck cancer treated with radiotherapy were assessed by immunochemistry for the expression of OPN, HIF-1alpha, and CA IX. Relationship of OPN expression with tumor oxygenation parameters (HF5, median pO(2)), HIF-1alpha and CA IX expression, hemoglobin and serum VEGF level, and clinical parameters was studied.

RESULTS

Bivariate analysis showed a significant correlation of positive OPN staining with low hemoglobin level (p = 0.02), high HIF-1alpha expression (p = 0.02), and high serum vascular endothelial growth factor level (p = 0.02) for advanced head-and-neck cancer. Furthermore, considering the 31 Stage IV patients, the median pO(2) correlated significantly with the OPN expression (p = 0.02). OPN expression alone had only a small impact on prognosis. However, in a univariate Cox proportional hazard regression model, the expression of either OPN or HIF-1alpha or CA IX was associated with a 4.1-fold increased risk of death (p = 0.02) compared with negativity of all three markers.

CONCLUSION

Osteopontin expression detected immunohistochemically is associated with oxygenation parameters in advanced head-and-neck cancer. When the results of OPN, HIF-1alpha, and CA IX immunohistochemistry are combined into a hypoxic profile, a strong and statistically significant impact on overall survival is found.

Effect of treatment with epoetin beta on short-term tumour progression and survival in anaemic patients with cancer: A meta-analysis

To assess the early effect of epoetin beta on survival and tumour progression in anaemic patients with cancer, data were pooled from nine randomised clinical trials comparing epoetin beta with placebo or standard care. Studies were not primarily designed to assess these end points. Follow-up was for treatment duration plus 4 weeks following therapy completion. All adverse events (AEs) were retrospectively reviewed blinded, for progression. Thromboembolic events were also assessed. Data analysis involved standard statistical tests. Overall, 1413 patients were included (epoetin beta, n=800; control, n=613; 56% haematological, and 44% solid). Median initial epoetin beta dose was 30 000 IU/week. Overall survival during months 0–6 was similar with epoetin beta and control (0.31 vs 0.32 deaths/patient-year). No increased mortality risk was seen with epoetin beta (relative risk (RR) 0.97, 95% CI: 0.69, 1.36; P=0.87). There was a significantly reduced risk of rapidly progressive disease for epoetin beta (RR 0.78, 95% CI: 0.62, 0.99; P=0.042). Epoetin beta was associated with a slightly higher frequency of thromboembolic events vs control (5.9% vs 4.2% of patients) but thromboembolic-related mortality was identical in both groups (1.1%). Epoetin beta provided a slight beneficial effect on tumour progression and did not impact on early survival or thromboembolic-related mortality.

Plasma osteopontin levels in patients with head and neck cancer and cervix cancer are critically dependent on the choice of ELISA system

BACKGROUND

The tumor-associated glycoprotein osteopontin (OPN) is discussed as a plasma surrogate marker of tumor hypoxia and as an indicator of the presence of pleural mesothelioma in asbestos-exposed individuals. The clinical introduction of plasma OPN measurements requires the availability of a reliable enzyme-linked immunosorbence assay (ELISA).

METHODS

We compared previously described and currently available ELISA systems on 88 archival plasma samples obtained from patients with head and neck or cervix cancer between 20 days before and 171 after the start of radiotherapy.

RESULTS

Median (range) plasma OPN levels were 667 (148.8-2095) ng/ml and 9.8 (3.5-189.5) ng/ml for a previously described and a newly marketed assay, respectively. Although results for different assays were significantly correlated (r = 0.38, p < 0.05, Spearman rank test), between-assay factors ranged from 2.0 to 217.9 (median 74.6) in individual patients. OPN levels in cervix cancer patients were comparable to those of head and neck cancer patients.

CONCLUSION

Commercially available OPN ELISA systems produce different absolute plasma OPN levels, compromising a comparison of individual patient data with published results. However, different assays appear to have a similar capacity to rank patients according to plasma OPN level. A review of literature data suggests that plasma OPN levels measured even with identical ELISA systems can only be compared with caution.

Postoperative concurrent radiochemotherapy versus radiotherapy in high-risk SCCA of the head and neck: Results of the German phase III trial ARO 96–3

5507

Background: Despite resection and postoperative irradiation high-risk (3 or more involved lymph nodes, extra-capsular disease and/or microscopically involved mucosal margins of resection) squamous cell carcinomas (SCCAs) of the head and neck frequently recur in the tumor bed. Postoperatively radiochemotherapy (RCT) with cis-Platin (CDDP)/5-FU versus radiotherapy (RT) alone was compared in a randomized trial. Methods: Between 5/97 and 12/04, 440 patients who had high-risk SCCAs of the head and neck were enrolled in this prospectively randomized phase III trial. Following resection and neck dissection, 214 patients were randomly assigned to RT (66 Gy/33 Fx/6.6 weeks) and 226 patients to identical RT plus CDDP (20 mg/m2 on day 1–5, 29–33) and 5-FU (600 mg/m2 on day 1–5, 29–33). Results: The 5 year local-regional control rate is 72.2 ± 3.7% following RT and 88.6 ± 2.4% for the RCT group (p = 0.00259; 5-year progression free survival 50.1 ± 4.0% and 62.4 ± 4.4% (p = 0.024) and 5-year overall survival 48.6 ± 4.4% vs. 58.1 ± 4.6% (p = 0.11). There was no difference in the 5 year incidence of distant metastases (19.3 ± 3.6% vs 25.5 ± 4.6%; p = 0.45). The incidence of grade 3+ acute toxicity was higher during RCT: mucositis 12.6% vs. 20.8% (p = 0.04), leucopenia 0% vs. 4.4% (p = 0.007). Conclusions: Acute toxicity is increased to an acceptable level by RCT. Postoperative RCT compared to RT improves locoregional control and progression free survival; thus survival as a trend is improved by 10% after 5 years. Supported by Deutsche Krebshilfe 70–2140.

No significant financial relationships to disclose.

[Role of radiation therapy on the use of primary ("neoadjuvant") systemic treatment of breast cancer]

BACKGROUND

The indications for primary ("neoadjuvant") systemic treatment (PST) for breast cancer have evolved over the last few years. PST is not only used in patients with locally advanced breast cancer (LABC) and inoperable tumors but also plays a role for operable tumors aiming at breast conservation and higher complete remission rates (ypCR). The contribution of radiotherapy and the optimal sequencing of chemotherapy, surgery and radiotherapy still have to be defined.

MATERIAL AND METHODS

Objectives and results of PST for inflammatory, locally advanced and operable breast cancer were analyzed according to tumor stage.

RESULTS

Radiotherapy following PST and surgery is the standard of care for inflammatory breast cancer, LABC and nonresectable lesions. Comparable results are achieved for good responders after PST receiving radiotherapy or surgery. The evaluation of a preoperative radiotherapeutic approach is complicated by different chemo- and radiotherapy regimens, continuation of chemotherapy after surgery and heterogeneous patient groups.

CONCLUSION

For LABC and inflammatory breast cancer the role of PST is well defined. For operable lesions, however, the value of preoperative radiotherapy still has to be established. This should be assessed within the framework of a clinical trial using standardized parameters for applying chemotherapy as well as radiation therapy.

Radiochemotherapy After Transurethral Resection for High-Risk T1 Bladder Cancer: An Alternative to Intravesical Therapy or Early Cystectomy?

Purpose

For high-risk T1 bladder cancer, the most important issue is how to restrict radical cystectomy to selective patients with a high likelihood of tumor progression and to choose an initial bladder-sparing approach in others without affecting survival. Radiotherapy or radiochemotherapy (RT/RCT) may help to strike a balance between intravesical treatment and early cystectomy.

Patients and Methods

Between 1982 and 2004, 141 patients with high-risk T1 bladder cancer (84 patients with T1 grade 3 [T1G3]; others with T1G1/2 and associated carcinoma-in-situ, multifocality, tumor diameter > 5 cm, or multiple recurrences) were treated with RT (n = 28) or platinum-based RCT (n = 113) after transurethral resection of bladder tumor (TURBT). Six weeks after RT/RCT, response was evaluated by restaging TURBT. Salvage cystectomy was recommended for patients with persistent disease and for tumor progression after initial complete response (CR). Median follow-up was 62 months; 65 patients have been observed for 5 years or more.

Results

CR was achieved in 121 of 137 patients (88%; four patients without restaging TURBT). Tumor progression for the entire group of 141 patients was 19% and 30% at 5 and 10 years, respectively (for 121 patients with CR, 15% and 29%; for 84 patients with T1G3, 13% and 29%, respectively). Disease-specific survival rates were 82% and 73% at 5 and 10 years (CR, 89% and 79%; T1G3, 80% and 71%, respectively). More than 80% of survivors preserved their bladder; 70.4% were “delighted” or “pleased” with their urinary function.

Conclusion

RT/RCT after TURBT with selective bladder preservation is a reasonable alternative to intravesical treatment or early cystectomy for high-risk T1 bladder cancer.

The integration of oral capecitabine into chemoradiation regimens for locally advanced rectal cancer: how successful have we been?

The aim was to review available literature on capecitabine-based chemoradiation regimens for the preoperative treatment of patients with locally advanced rectal cancer (LARC) and determine efficacy and safety data for capecitabine in this setting. Medical literature databases (Pubmed, Medline) and abstracts/posters presented at recent scientific congresses (ASCO, ASTRO, ESTRO and ECCO) were screened and critically analysed to identify relevant data. A number of phase I/II studies have demonstrated that capecitabine is effective and well tolerated in combination with preoperative radiotherapy in patients with LARC. Phase III studies are ongoing. Continuous oral administration of capecitabine (825 mg/m(2) twice daily for 7 days/week) is an effective regimen and has similar tolerability to the less dose-intensive intermittent regimens of capecitabine given 5 days/week followed by 2 day's rest or 14 days followed by 7 day's rest as used in systemic chemotherapy for patients with colorectal or breast cancer. Capecitabine chemoradiation is associated with a relatively low rate of grade 3/4 adverse events. Capecitabine simplifies chemoradiation and provides a convenient treatment option for both patients and health care professionals. Combining capecitabine with cytotoxic agents such as oxaliplatin and irinotecan has the potential to further improve antitumour efficacy in patients receiving preoperative chemoradiation. Data from phase I/II single-agent and combination capecitabine chemoradiation studies provide a clear rationale for replacing infusional 5-FU with oral capecitabine as part of chemoradiation for patients with LARC.

Radiotherapy in Ewing tumors of the vertebrae: Treatment results and local relapse analysis of the CESS 81/86 and EICESS 92 trials

PURPOSE

Treatment results in patients with Ewing tumors of the vertebrae enrolled in the Cooperative Ewing's Sarcoma Study (CESS) 81, 86, and the European Intergroup Cooperative Ewing's Sarcoma Study (EICESS) 92 trials were analyzed with special emphasis on radiation-associated factors.

PATIENTS AND METHODS

A retrospective analysis was performed on 116 patients with primary tumors of the cervical, thoracic, or lumbar vertebrae treated between 1981 and 1999. Furthermore, a relapse analysis was done on those patients who underwent radiotherapy and subsequently had a local recurrence.

RESULTS

A total of 64.6% of the patients received definitive radiotherapy; 27.5% of patients had surgery and radiotherapy. Only 4 patients (3.4%) underwent definitive surgery. Twenty-seven patients presented with metastases at diagnosis. 22.4% of the total group developed a local relapse. Among the subgroup with definitive radiotherapy, local recurrence was seen in 17 of 75 patients (22.6%). Event-free survival and survival at 5 years were 47% and 58%, respectively. Of the 14 evaluable patients with a local relapse after radiotherapy, 13 were in-field. No correlation between radiation dose and local control could be found.

CONCLUSION

Surgery with wide resection margins is rarely possible. The results after definitive radiotherapy in vertebral tumors are comparable to those of other tumor sites when definitive radiotherapy is given. Nearly all local relapses after radiotherapy are in-field.

Radiotherapy in multilocalized lymphedema-associated angiosarcoma

We report an 80-year-old woman, suffering from a recurrence of a multilocalized lymphedema-associated angiosarcoma of the right arm. The tumor consisted of solid tumor cell formations and "classical" spongiform tumor complexes. In the tumor periphery, pathological endothelial cell proliferates on pre-existing dilated lymphatic capillaries were detectable, which, together with immunohistology (CD 31+/Desmoplakin-1-2.17+/CD 34-), supported the diagnosis of lymphangiosarcoma. Complete remission was achieved under radioimmunotherapy (54 Gy/Interferon beta). A further recurrence 3 months later outside the primary therapy fields was successfully treated with radiotherapy alone. During a follow-up observation period of 3 years, there was neither local recurrence nor metastasis. This case demonstrates for the first time the long-lasting efficacy of photon radiation in a case of histologically-defined lymphangiosarcoma. Further studies should elucidate the suitability of radio monotherapy as first-line therapy in lymphedema-associated angiosarcoma with lymphatic endothelium-like immunohistology.

[Quantitative and qualitative investigations of salivary gland function in dependence on irradiation dose and volume for reduction of xerostomia in patients with head-and-neck cancer]

BACKGROUND AND PURPOSE

Radiation treatment of head-and-neck tumors mostly leads to a damage to the salivary glands and a consequential permanent loss of saliva. The aim of this investigation was to establish a modern three-dimensional conformal radiotherapy (3D-CRT) to show a decrease in severe xerostomia in contrast to the proven conventional technique (K-RT) with photons and electrons.

PATIENTS AND METHODS

Between April 2002 and September 2003, 32 patients (25 male, seven female, mean age: 58 years) with malignant tumors of the head and neck were included-after surgery or in case of inoperability with curative intent-in a prospective, nonrandomized study. 10/32 patients (31%) received K-RT with photons and electrons, and 22/32 patients (69%) 3D-CRT (six to eight photon portals). The quantity of saliva was measured as stimulated saliva flow rate (ml/5 min) prior to treatment, at the end, and 1, 6, and 12 months after termination of treatment. To find out the resulting mean dose of both parotid glands for every patient in Gray (D(mean) doses), the D(mean) doses of the ipsilateral and the contralateral parotid gland, determined by dose-volume histograms (DVHs), were averaged over. For calculation of the NTCP (normal tissue complication probability), the logistic model was used.

RESULTS

In the trend the stimulated salivary flow rates were higher in the group with 3D-CRT than in the group with K-RT during the whole observation period (at 10 weeks after the start of radiotherapy 3D-CRT vs. K-RT with 1.56 +/- 1.6 vs. 0.82 +/- 1.2 ml/5 min; p < 0.1). The patients treated with the K-RT had, on average, significantly higher averaged D(mean) values than those irradiated with 3D-CRT (p < 0.012). Patients, who were irradiated with 3D-CRT for tumors of the larynx or hypopharynx, showed, on average, significantly lower D(mean) values than patients, who were treated with 3D-DRT because of oral cavity or oropharynx carcinomas or with K-RT irrespective of the primary tumor site (p < 0,003). The resulting dose for 50% complication probability (TD(50)) of the salivary glands was 36.9 Gy (30.9-43.5 Gy; 95% confidence interval). The gradient k of the curve located in point TD(50) was 7.7 (4.8-15.8; 95% confidence interval).

CONCLUSION

Basically, 3D-CRT seems to be suitable as a standard for all patients with carcinomas of the oral cavity, oro- and hypopharynx. Especially in patients with tumors located in the larynx and hypopharynx, averaged D(mean) doses of both parotids during irradiation can be reached, to conserve salivary flow rates, which are similar to baseline flow rates.

Effects of Recombinant Human Erythropoietin (rHuEPO) on Tumor Control in Patients with Cancer-Induced Anemia

It is well recognized that anemia-induced tumor hypoxia is associated with a reduced sensitivity of tumors to radiation and some forms of chemotherapy. Thus, the correction of lower hemoglobin (Hb) concentrations with recombinant human erythropoietin (rHuEPO) can play an essential role by improving tumor oxygenation. Based on evidence from a number of trials, treatment with rHuEPO will effectively ameliorate anemia and improve quality of life. However, one of the most essential prerequisites for achieving this benefit is the use of rHuEPO in agreement with the evidence-based ASCO/ASH-guidelines recommending a target Hb concentration of 12 g/dl (7.44 mmol/l).

Organ-Sparing Treatment in Muscle-Invasive Bladder Cancer

BACKGROUND AND PURPOSE

Organ-sparing treatment of bladder cancer by a trimodality approach is feasible and effective. In this study, the results of a series of patients are reported, who were, in the majority, not suitable for major surgery.

PATIENTS AND METHODS

In the period from June 1995 through December 2003, 68 patients (64 males, four females) with urothelial bladder cancer were treated with curative intent. The median age was 68 years (range 42-82 years). Clinical T-category was 32x T2, 20x T3, and 16x T4. Transurethral resection was performed in all cases, and a complete TUR-BT (transurethral resection of bladder tumor) was attempted, if possible. Radiotherapy was administered in conventional fractionation (five fractions of 1.8 Gy per week) up to 50.4 Gy to bladder, and regional nodes and the whole bladder received a boost up to 54-59.4 Gy. 34 patients received concurrent cisplatin-based chemotherapy (25 mg/m(2) on days 1-5 and 29-33), and patients with impaired renal function were either treated with irradiation alone (n = 7) or received paclitaxel as alternative to cisplatin in a phase II protocol or on an individual decision (n = 27). The median follow-up was 34 months (range 2-104 months).

RESULTS

A histologically confirmed complete remission (CR) on restaging cystoscopy was observed in 40/46 patients (87%) who underwent restaging cystoscopy. CR rates were not significantly correlated to T-category (CR: 24/32 T2, 9/19 T3, and 9/16 T4 tumors) or clinical nodal status. Patients with non-radical resection and macroscopic residual tumor (R2 resection) achieved a CR in only 39% (12/31); this figure was significantly lower as compared to patients with radical R0 TUR-BT (CR: 15/16, 94%, p = 0.013) Furthermore, age and preexisting anemia had no impact on response. The overall survival of the whole group was 45% after 5 years, and survival according to clinical T-category was 62% for T2, 43% for T3, and 19% for T4 (p = 0.015). In eleven patients, local disease progression or relapse was observed. So far, only one salvage cystectomy has been performed, due to contraindications to surgery in the majority of patients.

CONCLUSION

The data obtained in this study confirm the high efficacy of TUR and radiochemotherapy for locally advanced bladder cancer.

Management of anemia in patients undergoing curative radiotherapy. Erythropoietin, transfusions, or better nothing?

BACKGROUND AND RESULTS

Anemia is a well-known risk factor for decreased local control and survival in patients undergoing curative radiotherapy. There is clear evidence from recent clinical investigations that anemia is an independent risk factor and hemoglobin (Hb) levels during radiotherapy are important (and not pretreatment Hb levels). The most likely explanation for the prognostic impact is the association with tumor hypoxia. An "optimal" Hb range with regard to tumor oxygenation seems to exist, and Hb levels < 11 g/dl and > approximately 15 g/dl impair tumor oxygenation but have (over a broader range) no significant impact on normal tissue oxygenation. There is some evidence from retrospective and prospective studies that the response to radiotherapy and the prognosis, especially in cervical cancers, might be improved if the Hb levels during radiotherapy can be maintained in the optimal range, either by transfusions or by erythropoietin. The effect of any antianemic therapy should be analyzed according to whether or not treatment was successful with regard to achieving optimal Hb levels during irrradiation. Erythropoietin is probably more effective in steadily increasing and stabilizing Hb levels, but bears the risk of overcorrection of Hb levels. The clinical relevance of erythropoietin receptors on tumor cells remains questionable.

CONCLUSIONS

Treatment of anemia with the objective of improving local control and survival in radiotherapy patients is probably more difficult and sophisticated than coping with symptoms of anemia or improving quality of life. Nevertheless, the potential of antianemic treatment is high on the basis of experimental and clinical data, and further clinical trials are warranted.

Prognosefaktoren beim operierten und adjuvant bestrahlten Zervixkarzinom

PURPOSE

To determine prognostic factors in patients with cervical cancer treated with surgery followed by radiotherapy.

PATIENTS AND METHODS

In a retrospective analysis, patients treated at the Department of Radiotherapy, University of Halle-Wittenberg, Germany, from 1980 through 1993 were evaluated for local control, survival and treatment sequelae with special emphasis on prognostic factors. 298 patients (age 23-81 years, median 46 years) with cervical cancers were treated with surgery followed by radiotherapy to a minimum of 50 Gy. 250 patients received radiotherapy after radical hysterectomy with pelvic lymphadenectomy and 48 patients after hysterectomy. Most of the cancers were squamous cell carcinomas (81%) with few adenocarcinomas (12.4%). Grading was G1/G2 in 28.9% of the patients and G3/G4 in 39.6%.

RESULTS

The 5-year overall survival was 68.8% for the whole group, 70.5% for squamous cell carcinomas (n = 241), 64.4% for adenocarcinomas (n = 37; not significant), 80% for G1/G2 tumors (n = 86), and 69% for G3/G4 carcinomas (n = 118; p = 0.074). Survival dependent on tumor size and positive nodes was 76.2% (n = 94) for pT1N0, 65.8% for pT1N+ (n = 31), 68.2% for pT2N0 (n = 62), and 41.4% for pT2N+ (n = 35). An impact of grading on 5-year survival was only found in patients with positive nodes: G1/G2N0 84% (n = 62) versus G1/G2N+ 64.8% (n = 23); G3/G4N0 79.6% (n = 71) versus G3/G4N+ 39.9% (n = 31). The number of positive nodes was the strongest prognostic factor. Multivariate analysis (Cox regression) established a risk factor of 3.06 (p < 0.01) for positive nodes, of 1.7 for grading G1/G2 versus G3/G4 (p = 0.087), and of 1.3 for tumor size (pT1 vs. pT2; p = 0.079). There were no differences in the clinical outcome between patients in stage pT1 with or without lymphadenectomy (75% [n = 130] vs. 79% [n = 39]).

CONCLUSION

In patients with cervical cancers treated with surgery and radiotherapy, positive nodes were an independent prognostic factor for local control and survival and should be an indication for additional chemotherapy. A value of lymphadenectomy for survival in this group of irradiated patients could not be established.

Radioprotective effects of amifostine in vitro and in vivo measured with the comet assay

PURPOSE

The authors investigated whether a potential radioprotective effect of amifostine (WR-2721) after in vitro or in vivo administration can be detected with the comet assay. Moreover, it was determined whether radioprotection by WR-2721 is dependent on the concentration of amifostine or alkaline phosphatase (AP, the enzyme which activates the prodrug). Furthermore, the authors tried to detect possible interindividual differences in radioprotection by amifostine.

MATERIAL AND METHODS

In vitro administration of amifostine: Freshly isolated lymphocytes from two healthy volunteers were incubated with different concentrations of AP (0-210 U/ml) and amifostine (0-5,000 microg/ml). IN VIVO ADMINISTRATION OF AMIFOSTINE: Blood samples were collected from six postoperative rectal cancer patients before and after intravenous administration of amifostine 500 mg (no pretreatment with radio- or chemotherapy). Leukocytes and lymphocytes were irradiated and repaired in vitro and investigated with the alkaline comet assay. The radioprotective effect was evaluated by calculating dose-modifying factors (DMFs) and the paired t-test.

RESULTS

Amifostine alone did not alter the radiation-induced DNA damage in vitro. The addition of at least 0.5-1 U/ml AP was required. A significant radioprotective effect (p < 0.05) was seen after administration of amifostine in vitro for all concentrations investigated (250-5,000 microg/ml, initial DNA damage). A comparable radioprotective effect after in vivo administration of 500 mg amifostine was measured with a mean DMF of 0.87. Interindividual differences were present in vivo and in vitro.

CONCLUSION

Amifostine 500 mg intravenously yields an adequate radioprotective concentration. The effect was only marginally improved by extreme concentrations of amifostine in in vitro experiments. The comet assay is capable of detecting small changes in radiosensitivity by amifostine.

Radiosensitization, after a combined treatment of survivin siRNA and irradiation, is correlated with the activation of caspases 3 and 7 in a wt-p53 sarcoma cell line, but not in a mt-p53 sarcoma cell line

Survivin, a member of the inhibitor-of-apoptosis family is an essential protein for regular mitosis and is involved in an anti-apoptotic pathway. In some studies, an association between survivin expression and radiosensitivity has been described for tumor cells, but the relationship between p53 and survivin regarding radioresistance remains to be clarified. In order to increase the effect of irradiation on two sarcoma cell lines, A-204 with wt-p53 and US 8-93 with mt-p53, siRNA was applied to knock down survivin expression. The effects of combined treatment of siRNA treatment and irradiation were investigated by clonogenic survival assay, measurement of activity of caspases 3 and 7, Western blot hybridization for survivin and p53, and morphological analysis of apoptosis. Survivin knock down caused radiosensitization in the cell line A-204 (wt-p53) with an enhancement factor of 1.8 at 2 Gy (p=0.05) and 2.5 at 4 Gy (p=0.02), respectively. No radiosensitization was found in the cell line US 8-93 (mt-p53), when clonogenic survival was analyzed. These findings were supported by an increase in activity (up to 5.2-fold) of caspases 3 and 7 in cell line A-204 (wt-p53), but not in cell line US 8-93 (mt-p53) after a combined treatment of siRNA and irradiation. Our findings suggest that the wt-p53-caspase pathway is of importance for the radiosensitization induced by targeting survivin, which may have an impact on future gene therapeutical treatments.