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Bobić M, Huesa-Berral C, Terry JF, Kunz L, Schuemann J, Fisher DR, Maitz CA, Bertolet A. Monte Carlo dosimetric analyses on the use of 90Y-IsoPet intratumoral therapy in canine subjects. Phys Med Biol 2024; 69:165014. [PMID: 39053508 DOI: 10.1088/1361-6560/ad67a4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 07/25/2024] [Indexed: 07/27/2024]
Abstract
Objective.To investigate different dosimetric aspects of90Y-IsoPet™ intratumoral therapy in canine soft tissue sarcomas, model the spatial spread of the gel post-injection, evaluate absorbed dose to clinical target volumes, and assess dose distributions and treatment efficacy.Approach.Six canine cases treated with90Y-IsoPet™ for soft tissue sarcoma at the Veterinary Health Center, University of Missouri are analyzed in this retrospective study. The dogs received intratumoral IsoPet™ injections, following a grid pattern to achieve a near-uniform dose distribution in the clinical target volume. Two dosimetry methods were performed retrospectively using the Monte Carlo toolkit OpenTOPAS: imaging-based dosimetry obtained from post-injection PET/CT scans, and stylized phantom-based dosimetry modeled from the planned injection points to the gross tumor volume. For the latter, a Gaussian parameter with variable sigma was introduced to reflect the spatial spread of IsoPet™. The two methods were compared using dose-volume histograms (DVHs) and dose homogeneity, allowing an approximation of the closest sigma for the spatial spread of the gel post-injection. In addition, we compared Monte Carlo-based dosimetry with voxel S-value (VSV)-based dosimetry to investigate the dosimetric differences.Main results.Imaging-based dosimetry showed differences between Monte Carlo and VSV calculations in tumor high-density areas with higher self-absorption. Stylized phantom-based dosimetry indicated a more homogeneous target dose with increasing sigma. The sigma approximation of the90Y-IsoPet™ post-injection gel spread resulted in a median sigma of approximately 0.44 mm across all cases to reproduce the dose heterogeneity observed in Monte Carlo calculations.Significance.The results indicate that dose modeling based on planned injection points can serve as a first-order approximation for the delivered dose in90Y-IsoPet™ therapy for canine soft tissue sarcomas. The dosimetry evaluation highlights the non-uniformity of absorbed doses despite the gel spread, emphasizing the importance of considering tumor dose heterogeneity in treatment evaluation. Our findings suggest that using Monte Carlo for dose calculation seems more suitable for this type of tumor where high-density areas might play an important role in dosimetry.
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Affiliation(s)
- Mislav Bobić
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States of America
- Department of Physics, ETH Zurich, Zurich, Switzerland
| | - Carlos Huesa-Berral
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States of America
| | - Jack F Terry
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States of America
| | - Louis Kunz
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States of America
- Department of Physics, ETH Zurich, Zurich, Switzerland
| | - Jan Schuemann
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States of America
| | - Darrell R Fisher
- Versant Medical Physics and Radiation Safety, Richland, Washington, and University of Washington, Seattle, United States of America
| | - Charles A Maitz
- Department of Veterinary Medicine and Surgery, University of Missouri, Columbia, MO, United States of America
| | - Alejandro Bertolet
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States of America
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Brachytherapy in the Treatment of Soft-Tissue Sarcomas of the Extremities-A Current Concept and Systematic Review of the Literature. Cancers (Basel) 2023; 15:cancers15041133. [PMID: 36831476 PMCID: PMC9954233 DOI: 10.3390/cancers15041133] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 02/02/2023] [Accepted: 02/06/2023] [Indexed: 02/12/2023] Open
Abstract
INTRODUCTION Evidence on the use of brachytherapy in soft-tissue sarcoma (STS) is sparse. Therapy regimens are determined more by local interdisciplinary tumor conferences than by standardized protocols. Patient-specific factors complicate the standardized application of therapy protocols. The individuality of the treatment makes it difficult to compare results. MATERIALS AND METHODS A comprehensive literature search was conducted, whereby the literature from a period of almost 44 years (1977-2021) was graded and included in this systematic review. For this purpose, PubMed was used as the primary database. Search string included "soft-tissue sarcoma", "brachytherapy", and "extremity." Four independent researchers reviewed the literature. Only full-text articles written in English or German were included. RESULTS Of the 175 identified studies, 70 were eligible for analysis based on the inclusion and exclusion criteria. The key points to compare were local complications, recurrence rate and correlation with margins of resection, and the use of brachytherapy regarding tumor grading. CONCLUSION Brachytherapy represents an important subset of radiotherapy techniques used in STSs, whose indications and applications are constantly evolving, and for which a local control rate of 50% to 96% has been reported as monotherapy, depending on risk factors. However, the best benefit is seen in the combination of further resection and brachytherapy, and most authors at many other centers agree with this treatment strategy.
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Zöllner SK, Amatruda JF, Bauer S, Collaud S, de Álava E, DuBois SG, Hardes J, Hartmann W, Kovar H, Metzler M, Shulman DS, Streitbürger A, Timmermann B, Toretsky JA, Uhlenbruch Y, Vieth V, Grünewald TGP, Dirksen U. Ewing Sarcoma-Diagnosis, Treatment, Clinical Challenges and Future Perspectives. J Clin Med 2021; 10:1685. [PMID: 33919988 PMCID: PMC8071040 DOI: 10.3390/jcm10081685] [Citation(s) in RCA: 95] [Impact Index Per Article: 31.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 03/30/2021] [Accepted: 03/31/2021] [Indexed: 02/08/2023] Open
Abstract
Ewing sarcoma, a highly aggressive bone and soft-tissue cancer, is considered a prime example of the paradigms of a translocation-positive sarcoma: a genetically rather simple disease with a specific and neomorphic-potential therapeutic target, whose oncogenic role was irrefutably defined decades ago. This is a disease that by definition has micrometastatic disease at diagnosis and a dismal prognosis for patients with macrometastatic or recurrent disease. International collaborations have defined the current standard of care in prospective studies, delivering multiple cycles of systemic therapy combined with local treatment; both are associated with significant morbidity that may result in strong psychological and physical burden for survivors. Nevertheless, the combination of non-directed chemotherapeutics and ever-evolving local modalities nowadays achieve a realistic chance of cure for the majority of patients with Ewing sarcoma. In this review, we focus on the current standard of diagnosis and treatment while attempting to answer some of the most pressing questions in clinical practice. In addition, this review provides scientific answers to clinical phenomena and occasionally defines the resulting translational studies needed to overcome the hurdle of treatment-associated morbidities and, most importantly, non-survival.
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Affiliation(s)
- Stefan K. Zöllner
- Pediatrics III, University Hospital Essen, 45147 Essen, Germany;
- West German Cancer Center (WTZ), University Hospital Essen, 45147 Essen, Germany; (S.B.); (S.C.); (J.H.); (A.S.); (B.T.)
- German Cancer Consortium (DKTK), Essen/Düsseldorf, University Hospital Essen, 45147 Essen, Germany
| | - James F. Amatruda
- Cancer and Blood Disease Institute, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA 90027, USA;
| | - Sebastian Bauer
- West German Cancer Center (WTZ), University Hospital Essen, 45147 Essen, Germany; (S.B.); (S.C.); (J.H.); (A.S.); (B.T.)
- German Cancer Consortium (DKTK), Essen/Düsseldorf, University Hospital Essen, 45147 Essen, Germany
- Department of Medical Oncology, Sarcoma Center, University Hospital Essen, 45147 Essen, Germany
| | - Stéphane Collaud
- West German Cancer Center (WTZ), University Hospital Essen, 45147 Essen, Germany; (S.B.); (S.C.); (J.H.); (A.S.); (B.T.)
- German Cancer Consortium (DKTK), Essen/Düsseldorf, University Hospital Essen, 45147 Essen, Germany
- Department of Thoracic Surgery, Ruhrlandklinik, University of Essen-Duisburg, 45239 Essen, Germany
| | - Enrique de Álava
- Institute of Biomedicine of Sevilla (IbiS), Virgen del Rocio University Hospital, CSIC, University of Sevilla, CIBERONC, 41013 Seville, Spain;
- Department of Normal and Pathological Cytology and Histology, School of Medicine, University of Seville, 41009 Seville, Spain
| | - Steven G. DuBois
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA 02215, USA; (S.G.D.); (D.S.S.)
| | - Jendrik Hardes
- West German Cancer Center (WTZ), University Hospital Essen, 45147 Essen, Germany; (S.B.); (S.C.); (J.H.); (A.S.); (B.T.)
- German Cancer Consortium (DKTK), Essen/Düsseldorf, University Hospital Essen, 45147 Essen, Germany
- Department of Musculoskeletal Oncology, Sarcoma Center, 45147 Essen, Germany
| | - Wolfgang Hartmann
- Division of Translational Pathology, Gerhard-Domagk Institute of Pathology, University Hospital Münster, 48149 Münster, Germany;
- West German Cancer Center (WTZ), Network Partner Site, University Hospital Münster, 48149 Münster, Germany
| | - Heinrich Kovar
- St. Anna Children’s Cancer Research Institute and Medical University Vienna, 1090 Vienna, Austria;
| | - Markus Metzler
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, 91054 Erlangen, Germany;
| | - David S. Shulman
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA 02215, USA; (S.G.D.); (D.S.S.)
| | - Arne Streitbürger
- West German Cancer Center (WTZ), University Hospital Essen, 45147 Essen, Germany; (S.B.); (S.C.); (J.H.); (A.S.); (B.T.)
- German Cancer Consortium (DKTK), Essen/Düsseldorf, University Hospital Essen, 45147 Essen, Germany
- Department of Musculoskeletal Oncology, Sarcoma Center, 45147 Essen, Germany
| | - Beate Timmermann
- West German Cancer Center (WTZ), University Hospital Essen, 45147 Essen, Germany; (S.B.); (S.C.); (J.H.); (A.S.); (B.T.)
- German Cancer Consortium (DKTK), Essen/Düsseldorf, University Hospital Essen, 45147 Essen, Germany
- Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre, 45147 Essen, Germany
| | - Jeffrey A. Toretsky
- Departments of Oncology and Pediatrics, Georgetown University, Washington, DC 20057, USA;
| | - Yasmin Uhlenbruch
- St. Josefs Hospital Bochum, University Hospital, 44791 Bochum, Germany;
| | - Volker Vieth
- Department of Radiology, Klinikum Ibbenbüren, 49477 Ibbenbühren, Germany;
| | - Thomas G. P. Grünewald
- Division of Translational Pediatric Sarcoma Research, Hopp-Children’s Cancer Center Heidelberg (KiTZ), 69120 Heidelberg, Germany;
- Division of Translational Pediatric Sarcoma Research, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- Institute of Pathology, University Hospital Heidelberg, 69120 Heidelberg, Germany
- German Cancer Consortium (DKTK), Core Center, 69120 Heidelberg, Germany
| | - Uta Dirksen
- Pediatrics III, University Hospital Essen, 45147 Essen, Germany;
- West German Cancer Center (WTZ), University Hospital Essen, 45147 Essen, Germany; (S.B.); (S.C.); (J.H.); (A.S.); (B.T.)
- German Cancer Consortium (DKTK), Essen/Düsseldorf, University Hospital Essen, 45147 Essen, Germany
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Surgery versus stereotactic radiotherapy for treatment of pulmonary metastases. A systematic review of literature. Future Sci OA 2020; 6:FSO471. [PMID: 32518686 PMCID: PMC7273364 DOI: 10.2144/fsoa-2019-0120] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
It is not clear as to which is the best treatment among surgery and stereotactic radiotherapy (SBRT) for lung oligometastases. A systematic review of literature with a priori selection criteria was conducted on articles on the treatment of pulmonary metastases with surgery or SBRT. Only original articles with a population of patients of more than 50 were selected. After final selection, 61 articles on surgical treatment and 18 on SBRT were included. No difference was encountered in short-term survival between pulmonary metastasectomy and SBRT. In the long-term surgery seems to guarantee better survival rates. Mortality and morbidity after treatment are 0–4.7% and 0–23% for surgery, and 0–2% and 4–31% for SBRT. Surgical metastasectomy remains the treatment of choice for pulmonary oligometastases. Patients with metastatic cancer with a limited number of deposits may benefit from surgical removal or irradiation of tumor nodules in addiction to chemotherapy. Surgical resection has been demonstrated to improve survival and, in some cases, can be curative. Stereotactic radiotherapy is emerging as a less invasive alternative to surgery, but settings and implications of the two treatments are profoundly different. The two techniques show similar results in the short-term, with lower complications rates for radiotherapy, while in the long-term surgery seems to guarantee higher survival rates.
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Komatsu S, Demizu Y, Sulaiman NS, Terashima K, Suga M, Kido M, Toyama H, Tokumaru S, Okimoto T, Sasaki R, Fukumoto T. Space-making particle therapy for sarcomas derived from the abdominopelvic region. Radiother Oncol 2020; 146:194-199. [PMID: 32220700 DOI: 10.1016/j.radonc.2020.02.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 02/10/2020] [Accepted: 02/26/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The primary definitive treatment for abdominopelvic sarcomas (APSs) is resection, although incomplete resection has a negative prognostic impact. Although the effectiveness of particle therapy (PT) as a treatment for APS has already been demonstrated, its application for tumors adjacent to the gastrointestinal tract is frequently restricted, due to extremely low tolerance. Space-making PT, consisting of surgical spacer placement and subsequent PT, has been developed to overcome this limitation. MATERIALS AND METHODS Between June 2006 and June 2018, a total of 75 patients with 12 types of APS underwent space-making PT. RESULTS The 3-year local control rate of all patients was 90.3%. Fourteen surgery-related complications were observed in 12 patients (16%), and complications of Grade 3b or higher were observed in 3 patients. Ninety-five PT-related complications were seen in 66 patients (88.0%), and 13 patients (17.3%) had complications of Grade 3 or higher. The median V95% (volume irradiated with 95% of the treatment planning dose) of the gross tumor volume and clinical target volume were 99.9% and 99.5%, respectively. The median D95% (dose intensity covering 95% of the target volume) of the gross tumor volume/planned dose and clinical target volume/planned dose were 99.4%, and 99.1%, respectively. CONCLUSION The feasibility and effectiveness of space-making PT have been demonstrated via dosimetric evaluation, and our results indicate that this new strategy may potentially provide an effective and innovative treatment option for advanced APS.
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Affiliation(s)
- Shohei Komatsu
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, Japan.
| | - Yusuke Demizu
- Department of Radiology, Hyogo Ion Beam Medical Center, Tatsuno, Japan; Department of Radiation Oncology, Hyogo Ion Beam Medical Center Kobe Proton Center, Japan
| | | | - Kazuki Terashima
- Department of Radiology, Hyogo Ion Beam Medical Center, Tatsuno, Japan
| | - Masaki Suga
- Department of Radiation Physics, Hyogo Ion Beam Medical Center, Tatsuno, Japan
| | - Masahiro Kido
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, Japan
| | - Hirochika Toyama
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, Japan
| | - Sunao Tokumaru
- Department of Radiology, Hyogo Ion Beam Medical Center, Tatsuno, Japan
| | - Tomoaki Okimoto
- Department of Radiology, Hyogo Ion Beam Medical Center, Tatsuno, Japan
| | - Ryohei Sasaki
- Division of Radiation Oncology, Kobe University Graduate School of Medicine, Japan
| | - Takumi Fukumoto
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, Japan
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Tetta C, Londero F, Micali LR, Parise G, Algargoush AT, Algargoosh M, Albisinni U, Maessen JG, Gelsomino S. Stereotactic Body Radiotherapy Versus Metastasectomy in Patients With Pulmonary Metastases From Soft Tissue Sarcoma. Clin Oncol (R Coll Radiol) 2020; 32:303-315. [PMID: 32024603 DOI: 10.1016/j.clon.2020.01.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 10/23/2019] [Accepted: 11/14/2020] [Indexed: 10/25/2022]
Abstract
The lung is the preferred site of metastasis from soft tissue sarcoma (STS). This systematic review aims to evaluate the outcomes of stereotactic body radiotherapy (SBRT) and metastasectomy (MTS) for the treatment of lung metastases from STS. A systematic review was carried out according to the PRISMA protocol. PubMed, Medline, EMBASE, Cochrane Library, Ovid and Web of Knowledge databases were searched for English-language articles to December 2018 using a predefined strategy. Retrieved studies were independently screened and rated for relevance. Data were extracted by two researchers. In total, there were 1306 patients with STS: 1104 underwent MTS and 202 had SBRT. The mean age ranged from 40 to 55.8 years in the MTS group and from 47.9 to 64 years in the SBRT group. The cumulative death rate was 72% (95% confidence interval 59-85%) in the MTS group and 56% (38-74%) in the SBRT group. The cumulative mean overall survival time was 46.7 months (36.4-57.0%) in the MTS group and 47.6 months (33.7-61.5%) in the SBRT group. The cumulative rate of patients alive with disease was 5% (2-9%) in the MTS group and 15% (6-36%) in the SBRT group. Finally, the cumulative rate of patients alive without disease in the two groups was 19% (9-29%) and 20% (10-50%), respectively. Our study showed that local treatment of pulmonary metastases from STS with SBRT, compared with surgery, was associated with a lower cumulative overall death rate and similar overall survival time and survival rates without disease. By contrast, SBRT was associated with a higher survival rate with disease than MTS. Large randomised trials are necessary to confirm these findings and to establish whether SBRT may be a reliable option for early stage disease.
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Affiliation(s)
- C Tetta
- Rizzoli Orthopedic Institute, Bologna, Italy.
| | - F Londero
- Cardiovascular Research Institute Maastricht - CARIM, Maastricht University Medical Center, Maastricht, The Netherlands
| | - L R Micali
- Cardiovascular Research Institute Maastricht - CARIM, Maastricht University Medical Center, Maastricht, The Netherlands
| | - G Parise
- Cardiovascular Research Institute Maastricht - CARIM, Maastricht University Medical Center, Maastricht, The Netherlands
| | - A T Algargoush
- Cardiovascular Research Institute Maastricht - CARIM, Maastricht University Medical Center, Maastricht, The Netherlands
| | - M Algargoosh
- Cardiovascular Research Institute Maastricht - CARIM, Maastricht University Medical Center, Maastricht, The Netherlands
| | - U Albisinni
- Rizzoli Orthopedic Institute, Bologna, Italy
| | - J G Maessen
- Cardiovascular Research Institute Maastricht - CARIM, Maastricht University Medical Center, Maastricht, The Netherlands
| | - S Gelsomino
- Cardiovascular Research Institute Maastricht - CARIM, Maastricht University Medical Center, Maastricht, The Netherlands
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Iizumi T, Shimizu S, Numajiri H, Takei H, Yamada N, Mizumoto M, Ishikawa H, Okumura T, Sakurai H. Large Malignant Fibrous Histiocytoma Treated with Hypofractionated Proton Beam Therapy and Local Hyperthermia. Int J Part Ther 2019; 6:35-41. [PMID: 31773047 DOI: 10.14338/ijpt-18-00046.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 03/25/2019] [Indexed: 11/21/2022] Open
Abstract
Purpose Malignant fibrous histiocytoma (MFH) is one of the most common soft tissue sarcomas. The standard treatment is adequate surgical resection; in addition, radiation therapy plays a major role in perioperative treatment in most cases. Herein, we report the case of a patient with a large MFH who was successfully treated with combined proton beam therapy (PBT) and local hyperthermia (LH). Case Presentation A 60-year-old man presented with a 6×4-cm mass on his left thigh. Histopathology and immunohistochemistry indicated MFH, and he refused limb amputation. He received treatment with PBT at a dose at 72 GyE in 18 fractions. To cover the entire large target lesion, we used a patch-field protocol. He also concurrently received 7 courses of LH. The combination therapy achieved long-term local control without severe acute or late toxicity during the 7-year follow-up period. Conclusions This case suggests that the combination of PBT and LH may be an option as a limb-preserving treatment for large inoperable MFH in the extremities.
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Affiliation(s)
- Takashi Iizumi
- Department of Radiation Oncology and Proton Medical Research Center, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Shosei Shimizu
- Department of Radiation Oncology and Proton Medical Research Center, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Haruko Numajiri
- Department of Radiation Oncology and Proton Medical Research Center, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hideyuki Takei
- Department of Radiation Oncology and Proton Medical Research Center, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Noboru Yamada
- Department of Orthopedic Surgery, Fukushima Rosai Hospital, Iwaki, Fukushima, Japan
| | - Masashi Mizumoto
- Department of Radiation Oncology and Proton Medical Research Center, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hitoshi Ishikawa
- Department of Radiation Oncology and Proton Medical Research Center, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Toshiyuki Okumura
- Department of Radiation Oncology and Proton Medical Research Center, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hideyuki Sakurai
- Department of Radiation Oncology and Proton Medical Research Center, University of Tsukuba, Tsukuba, Ibaraki, Japan
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Proton beam therapy for renal pelvis and ureter cancer: A report of 5 cases and a literature review. Mol Clin Oncol 2019; 11:24-30. [PMID: 31289673 PMCID: PMC6547882 DOI: 10.3892/mco.2019.1861] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 04/17/2019] [Indexed: 11/05/2022] Open
Abstract
Standard treatment for localized renal pelvis and ureter cancer is surgery. Previously, the primary role of radiation therapy (RT) in cancer treatment was to control pain and hemostasis as palliative or as adjuvant therapy following surgery. In this report, we describe 5 patients with the disease treated with proton beam therapy (PBT) as curative treatment. Between September 2009 and July 2013, 5 males with renal pelvis (n=3) or ureter (n=2) cancer were treated by PBT with hypofractionated [72.6 Gy relative biological effectiveness (RBE)/22 fractions] or conventional [64-66 Gy (RBE)/32-33 fractions] fractionation. The median patient age was 72 years (range, 59-85 years). Three patients were deemed unfit for surgery. Local hypofractionated PBT was performed in 2 patients with T1-2N0M0 diseases, while prophylactic lymph node irradiation using a patch irradiation technique was performed for the remaining 3 patients, who had T3-4 disease. Two patients with T3-4 disease received chemotherapy prior to definitive PBT. No serious acute or late toxicities were observed in any patient. Local tumor control was achieved in 3 patients (60%); however, distant metastases were observed in 2 patients. Four of the five patients (80%) evaluated in the present study survived for >3 years. The data is limited; however, PBT appears to be a potential option for patients with renal pelvis or ureter cancer, especially for those who are unsuitable for radical surgery.
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Anwar MA, El-Baba C, Elnaggar MH, Elkholy YO, Mottawea M, Johar D, Al Shehabi TS, Kobeissy F, Moussalem C, Massaad E, Omeis I, Darwiche N, Eid AH. Novel therapeutic strategies for spinal osteosarcomas. Semin Cancer Biol 2019; 64:83-92. [PMID: 31152785 DOI: 10.1016/j.semcancer.2019.05.018] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 05/28/2019] [Accepted: 05/28/2019] [Indexed: 12/24/2022]
Abstract
At the dawn of the third millennium, cancer has become the bane of twenty-first century man, and remains a predominant public health burden, affecting welfare and life expectancy globally. Spinal osteogenic sarcoma, a primary spinal malignant tumor, is a rare and challenging neoplastic disease to treat. After the conventional therapeutic modalities of chemotherapy, radiation and surgery have been exhausted, there is currently no available alternative therapy in managing cases of spinal osteosarcoma. The defining signatures of tumor survival are characterised by cancer cell ability to stonewall immunogenic attrition and apoptosis by various means. Some of these biomarkers, namely immune-checkpoints, have recently been exploited as druggable targets in osteosarcoma and many other different cancers. These promising strides made by the use of reinvigorated immunotherapeutic approaches may lead to significant reduction in spinal osteosarcoma disease burden and corresponding reciprocity in increase of survival rates. In this review, we provide the background to spinal osteosarcoma, and proceed to elaborate on contribution of the complex ecology within tumor microenvironment giving arise to cancerous immune escape, which is currently receiving considerable attention. We follow this section on the tumor microenvironment by a brief history of cancer immunity. Also, we draw on the current knowledge of treatment gained from incidences of osteosarcoma at other locations of the skeleton (long bones of the extremities in close proximity to the metaphyseal growth plates) to make a case for application of immunity-based tools, such as immune-checkpoint inhibitors and vaccines, and draw attention to adverse upshots of immune-checkpoint blockers as well. Finally, we describe the novel biotechnique of CRISPR/Cas9 that will assist in treatment approaches for personalized medication.
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Affiliation(s)
- M Akhtar Anwar
- Department of Pharmacology and Toxicology, American University of Beirut, Beirut, Lebanon
| | - Chirine El-Baba
- Department of Biochemistry and Molecular Genetics, American University of Beirut, Beirut, Lebanon
| | - Muhammed H Elnaggar
- Biochemistry Department, Faculty of Science, Ain Shams University, Cairo, Egypt
| | - Yasmeen O Elkholy
- Microbiology Department, Faculty of Science, Cairo University, Giza, Egypt
| | - Mohamed Mottawea
- Faculty of Pharmacy, Modern University for Technology and Information, Cairo, Egypt
| | - Dina Johar
- Biomedical Sciences Program, Zewail University of Science and Technology, Giza, Egypt
| | | | - Firas Kobeissy
- Department of Biochemistry and Molecular Genetics, American University of Beirut, Beirut, Lebanon
| | - Charbel Moussalem
- Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Elie Massaad
- Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ibrahim Omeis
- Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Nadine Darwiche
- Department of Biochemistry and Molecular Genetics, American University of Beirut, Beirut, Lebanon.
| | - A H Eid
- Department of Pharmacology and Toxicology, American University of Beirut, Beirut, Lebanon; Department of Biomedical Sciences, Qatar University, Doha, Qatar.
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Okamoto K, Koga A, Tazume H, Noguchi R, Kumamoto S, Satoh H, Sueyoshi T, Fukui T. Early and Mid-Term Outcomes after Vascular Reconstruction for Patients with Lower-Extremity Soft-Tissue Malignant Tumors. Ann Vasc Dis 2018; 11:228-232. [PMID: 30116416 PMCID: PMC6094028 DOI: 10.3400/avd.oa.18-00027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Objective: To evaluate limb-salvage surgery including vascular resection for lower-extremity soft-tissue sarcomas and carcinomas for adult patients. Materials and Methods: Eight consecutive patients (median age, 59 years) who underwent vascular replacement during surgery for malignant tumors in the lower limbs between November 2006 and March 2018 were evaluated. Patient data were retrospectively obtained in a computerized database. Arterial and venous reconstructions were performed for seven patients, with one additional patient receiving venous reconstruction only. Autologous-vein (n=6) and synthetic bypasses were used for arterial repairs, whereas only autologous veins were implanted for venous repairs. Results: Morbidity was 62.5%, and in-hospital mortality was 12.5%. At a median follow-up of 24 months, the primary patency rates of arterial and venous reconstructions were 85.7% and 62.5%, respectively. Limb salvage was achieved in all cases. Conclusion: Early and mid-term bypass patency rates, the high percentage of limb salvage, and the oncologic outcome underline the efficacy of en bloc resection of soft-tissue tumors involving major vessels of the lower limbs. The anticipated need for vascular resection and reconstruction should not be a contraindication to sarcoma and carcinoma resections. However, efforts to achieve better control over systemic spread are required for long-term survival.
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Affiliation(s)
- Ken Okamoto
- Department of Cardiovascular Surgery, Kumamoto University Hospital, Kumamoto, Japan
| | - Ayumi Koga
- Department of Cardiovascular Surgery, Kumamoto University Hospital, Kumamoto, Japan
| | - Hirokazu Tazume
- Department of Cardiovascular Surgery, Kumamoto University Hospital, Kumamoto, Japan
| | - Ryo Noguchi
- Department of Cardiovascular Surgery, Kumamoto University Hospital, Kumamoto, Japan
| | - Sayahito Kumamoto
- Department of Cardiovascular Surgery, Kumamoto University Hospital, Kumamoto, Japan
| | - Hiroo Satoh
- Department of Orthopedic Surgery, Kumamoto University Hospital, Kumamoto, Japan
| | - Takanao Sueyoshi
- Department of Orthopedic Surgery, Kumamoto University Hospital, Kumamoto, Japan
| | - Toshihiro Fukui
- Department of Cardiovascular Surgery, Kumamoto University Hospital, Kumamoto, Japan
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11
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Castilho MS, Ferrigno R, Baraldi H, Novaes PERDS. Treatment of bone and soft tissue tumors of the limbs with conformal radiotherapy and intensity-modulated radiotherapy (IMRT). Rev Assoc Med Bras (1992) 2017; 63:477-480. [PMID: 28876420 DOI: 10.1590/1806-9282.63.06.477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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12
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Demizu Y, Jin D, Sulaiman NS, Nagano F, Terashima K, Tokumaru S, Akagi T, Fujii O, Daimon T, Sasaki R, Fuwa N, Okimoto T. Particle Therapy Using Protons or Carbon Ions for Unresectable or Incompletely Resected Bone and Soft Tissue Sarcomas of the Pelvis. Int J Radiat Oncol Biol Phys 2017; 98:367-374. [DOI: 10.1016/j.ijrobp.2017.02.030] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 12/31/2016] [Accepted: 02/14/2017] [Indexed: 10/20/2022]
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13
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Demizu Y, Mizumoto M, Onoe T, Nakamura N, Kikuchi Y, Shibata T, Okimoto T, Sakurai H, Akimoto T, Ono K, Daimon T, Murayama S. Proton beam therapy for bone sarcomas of the skull base and spine: A retrospective nationwide multicenter study in Japan. Cancer Sci 2017; 108:972-977. [PMID: 28182320 PMCID: PMC5448607 DOI: 10.1111/cas.13192] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Revised: 02/05/2017] [Accepted: 02/06/2017] [Indexed: 11/29/2022] Open
Abstract
We conducted a retrospective, nationwide multicenter study to evaluate the clinical outcomes of proton beam therapy for bone sarcomas of the skull base and spine in Japan. Eligibility criteria included: (i) histologically proven bone sarcomas of the skull base or spine; (ii) no metastases; (iii) ≥20 years of age; and (iv) no prior treatment with radiotherapy. Of the 103 patients treated between January 2004 and January 2012, we retrospectively analyzed data from 96 patients who were followed-up for >6 months or had died within 6 months. Seventy-two patients (75.0%) had chordoma, 20 patients (20.8%) had chondrosarcoma, and four patients (7.2%) had osteosarcoma. The most frequent tumor locations included the skull base in 68 patients (70.8%) and the sacral spine in 13 patients (13.5%). Patients received a median total dose of 70.0 Gy (relative biological effectiveness). The median follow-up was 52.6 (range, 6.3-131.9) months. The 5-year overall survival, progression-free survival, and local control rates were 75.3%, 49.6%, and 71.1%, respectively. Performance status was a significant factor for overall survival and progression-free survival, whilst sex was a significant factor for local control. Acute Grade 3 and late toxicities of ≥Grade 3 were observed in nine patients (9.4%) each (late Grade 4 toxicities [n = 3 patients; 3.1%]). No treatment-related deaths occurred. Proton beam therapy is safe and effective for the treatment of bone sarcomas of the skull base and spine in Japan. However, larger prospective studies with a longer follow-up are warranted.
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Affiliation(s)
- Yusuke Demizu
- Department of Radiology, Hyogo Ion Beam Medical Center, Tatsuno, Japan
| | - Masashi Mizumoto
- Department of Radiation Oncology, University of Tsukuba, Tsukuba, Japan
| | - Tsuyoshi Onoe
- Proton Therapy Division, Radiation and Proton Therapy Center, Shizuoka Cancer Center Hospital, Nagaizumi, Shizuoka, Japan
| | - Naoki Nakamura
- Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital East, Kashiwa, Chiba, Japan
| | - Yasuhiro Kikuchi
- Department of Radiation Oncology, Southern Tohoku General Hospital, Koriyama, Fukushima, Japan
| | | | - Tomoaki Okimoto
- Department of Radiology, Hyogo Ion Beam Medical Center, Tatsuno, Japan
| | - Hideyuki Sakurai
- Department of Radiation Oncology, University of Tsukuba, Tsukuba, Japan
| | - Tetsuo Akimoto
- Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital East, Kashiwa, Chiba, Japan
| | - Kota Ono
- Clinical Research and Medical Innovation Center, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Takashi Daimon
- Department of Biostatistics, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Shigeyuki Murayama
- Proton Therapy Division, Radiation and Proton Therapy Center, Shizuoka Cancer Center Hospital, Nagaizumi, Shizuoka, Japan
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14
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15
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Hoefkens F, Dehandschutter C, Somville J, Meijnders P, Van Gestel D. Soft tissue sarcoma of the extremities: pending questions on surgery and radiotherapy. Radiat Oncol 2016; 11:136. [PMID: 27733179 PMCID: PMC5062836 DOI: 10.1186/s13014-016-0668-9] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 07/13/2016] [Indexed: 12/18/2022] Open
Abstract
Soft tissue sarcomas are uncommon tumours of mesenchymal origin, most commonly arising in the extremities. Treatment includes surgical resection in combination with radiotherapy. Resection margins are of paramount importance in surgical treatment of soft tissue sarcomas but unambiguous guidelines for ideal margins of resection are still missing as is an uniform guideline on the use of radiotherapy. The present paper reviews the literature on soft tissue sarcomas of the extremities regarding the required resection margins, the impact of new radiotherapy techniques and the timing of radiotherapy, more particularly if it should be administered before or after surgical resection. This review was started by searching guidelines in different databases (National Guideline Clearinghouse, EBMPracticeNet, TRIP database, NCCN guidelines,…). After refinement of the query, more specific articles were found using MEDLINE, PubMed, Web of Science and Google Scholar. Used keywords include “soft tissue sarcoma”; “extremities OR limbs”; “radiotherapy”, “surgery”, “margins”, “local recurrence” and “overall survival”. Finally, the articles were selected based on the accessibility of the full text, use of the English language and relevance based on title and abstract. Literature demonstrates positive resection margins to be an important adverse prognostic factor for local recurrence of soft tissue sarcomas of the extremities. Still, no consensus is reached on the definition of what a good margin might be. The evolution of new radiation techniques, especially Intensity Modulated Radiotherapy, resulted in a s healthy surrounding tissues. However, the timing of radiotherapy treatment remains controversial as both preoperative and postoperative radiotherapy are characterised by several advantages and disadvantages.
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Affiliation(s)
- Fien Hoefkens
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | | | - Johan Somville
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.,Department of Orthopaedic Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Paul Meijnders
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.,Department of Radiotherapy, University Radiotherapy Antwerp UZA/ZNA, Antwerp, Belgium
| | - Dirk Van Gestel
- Department of Radiotherapy, University Radiotherapy Antwerp UZA/ZNA, Antwerp, Belgium. .,Department of Radiotherapy, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium.
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16
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Matsumine A, Tsujii M, Nakamura T, Asanuma K, Matsubara T, Kakimoto T, Yada Y, Takada A, Ii N, Nomoto Y, Sudo A. Minimally invasive surgery using intraoperative electron-beam radiotherapy for the treatment of soft tissue sarcoma of the extremities with tendon involvement. World J Surg Oncol 2016; 14:214. [PMID: 27514518 PMCID: PMC4982423 DOI: 10.1186/s12957-016-0968-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 08/02/2016] [Indexed: 11/21/2022] Open
Abstract
Background When a soft tissue sarcoma (STS) is located at the distal part of an extremity and involves the tendon, a wide excision usually causes severe functional disability. We therefore developed a minimally invasive surgical technique using intraoperative electron-beam radiotherapy (IOERT) to reduce the incidence of post-operative functional disability in patients with peri-/intra-tendinous STS. We assessed the clinical outcomes of the novel minimally invasive surgery. Methods The study population included five patients who received treatment for distal extremity STSs. After elevating the tumor mass, including the tendon and nerve from the tumor bed with a wide margin, a lead board was inserted beneath the tumor mass to shield the normal tissue. IOERT (25–50 Gy) was then applied, and the tumor excised with care taken to maintain the continuity of the tendon. Results In a desmoid patient, local recurrence was observed outside the irradiated field. No cases of neuropathy or bone necrosis were observed. The mean limb function score was excellent in all patients. None of the high-grade sarcoma patients had local recurrence or distant metastasis. Conclusions Although the current study is only a pilot study with a small number of patients, it shows that this minimally invasive procedure has the potential to become a standard treatment option for selected patients. Trial registration H17-250 (registered 2 November 2005) and H25-250 (modified from H17-250, registered 5 December 2013)
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Affiliation(s)
- Akihiko Matsumine
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan.
| | - Masaya Tsujii
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
| | - Tomoki Nakamura
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
| | - Kunihiro Asanuma
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
| | - Takao Matsubara
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
| | - Takuya Kakimoto
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
| | - Yuki Yada
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
| | - Akinori Takada
- Department of Radiology, Mie University School of Medicine, 2-174 Edobashi, Tsu city, Mie, 514-8507, Japan
| | - Noriko Ii
- Department of Radiology, Mie University School of Medicine, 2-174 Edobashi, Tsu city, Mie, 514-8507, Japan
| | - Yoshihito Nomoto
- Department of Radiology, Mie University School of Medicine, 2-174 Edobashi, Tsu city, Mie, 514-8507, Japan
| | - Akihiro Sudo
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
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17
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Zhang X, Huang WJ, Chen WW. Microwaves and Alzheimer's disease. Exp Ther Med 2016; 12:1969-1972. [PMID: 27698682 PMCID: PMC5038365 DOI: 10.3892/etm.2016.3567] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 07/25/2016] [Indexed: 01/12/2023] Open
Abstract
Alzheimer's diseases (AD) is the most common type of dementia and a neurodegenerative disease that occurs when the nerve cells in the brain die. The cause and treatment of AD remain unknown. However, AD is a disease that affects the brain, an organ that controls behavior. Accordingly, anything that can interact with the brain may affect this organ positively or negatively, thereby protecting or encouraging AD. In this regard, modern life encompasses microwaves for all issues including industrial, communications, medical and domestic tenders, and among all applications, the cell phone wave, which directly exposes the brain, continues to be the most used. Evidence suggests that microwaves may produce various biological effects on the central nervous system (CNS) and many arguments relay the possibility that microwaves may be involved in the pathophysiology of CNS disease, including AD. By contrast, previous studies have reported some beneficial cognitive effects and that microwaves may protect against cognitive impairment in AD. However, although many of the beneficial effects of microwaves are derived from animal models, but can easily be extrapolated to humans, whether microwaves cause AD is an important issue that is to be addressed in the current review.
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Affiliation(s)
- Xia Zhang
- Department of Neurology, Xuzhou Central Hospital, Xuzhou, Jiangsu 221009, P.R. China
| | - Wen-Juan Huang
- Department of Neurology, Xuzhou Central Hospital, Xuzhou, Jiangsu 221009, P.R. China
| | - Wei-Wei Chen
- Department of Neurology, Xuzhou Central Hospital, Xuzhou, Jiangsu 221009, P.R. China
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18
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Seo HS. Application of radiation technology in vaccines development. Clin Exp Vaccine Res 2015; 4:145-58. [PMID: 26273573 PMCID: PMC4524899 DOI: 10.7774/cevr.2015.4.2.145] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 06/10/2015] [Accepted: 06/20/2015] [Indexed: 12/11/2022] Open
Abstract
One of the earliest methods used in the manufacture of stable and safe vaccines is the use of chemical and physical treatments to produce inactivated forms of pathogens. Although these types of vaccines have been successful in eliciting specific humoral immune responses to pathogen-associated immunogens, there is a large demand for the development of fast, safe, and effective vaccine manufacturing strategies. Radiation sterilization has been used to develop a variety of vaccine types, because it can eradicate chemical contaminants and penetrate pathogens to destroy nucleic acids without damaging the pathogen surface antigens. Nevertheless, irradiated vaccines have not widely been used at an industrial level because of difficulties obtaining the necessary equipment. Recent successful clinical trials of irradiated vaccines against pathogens and tumors have led to a reevaluation of radiation technology as an alternative method to produce vaccines. In the present article, we review the challenges associated with creating irradiated vaccines and discuss potential strategies for developing vaccines using radiation technology.
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Affiliation(s)
- Ho Seong Seo
- Radiation Biotechnology Research Division, Advanced Radiation Technology Institute, Korea Atomic Energy Research Institute, Jeongeup, Korea
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19
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Ernst A, Anders H, Kapfhammer H, Orth M, Hennel R, Seidl K, Winssinger N, Belka C, Unkel S, Lauber K. HSP90 inhibition as a means of radiosensitizing resistant, aggressive soft tissue sarcomas. Cancer Lett 2015; 365:211-22. [PMID: 26044951 DOI: 10.1016/j.canlet.2015.05.024] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Revised: 05/20/2015] [Accepted: 05/29/2015] [Indexed: 01/27/2023]
Abstract
Radiotherapy is an essential part of multi-modal treatment for soft tissue sarcomas. Treatment failure is commonly attributed to radioresistance, but comprehensive analyses of radiosensitivity are not available, and suitable biomarkers or candidates for targeted radiosensitization are scarce. Here, we systematically analyzed the intrinsic radioresistance of a panel of soft tissue sarcoma cell lines, and extracted scores of radioresistance by principal component analysis (PCA). To identify molecular markers of radioresistance, transcriptomic profiling of DNA damage response regulators was performed. The expression levels of HSP90 and its clients ATR, ATM, and NBS1 revealed strong, positive correlations with the PCA-derived radioresistance scores. Their functional involvement was addressed by HSP90 inhibition, which preferentially sensitized radioresistant sarcoma cells and was accompanied by delayed γ-H2AX foci clearance and HSP90 client protein degradation. The induction of apoptosis and necrosis was not significantly enhanced, but increased levels of basal and irradiation-induced senescence upon HSP90 inhibition were detected. Finally, evaluation of our findings in the TCGA soft tissue sarcoma cohort revealed elevated expression levels of HSP90, ATR, ATM, and NBS1 in a relevant subset of cases with particularly poor prognosis, which might preferentially benefit from HSP90 inhibition in combination with radiotherapy in the future.
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Affiliation(s)
- Anne Ernst
- Clinic for Radiotherapy and Radiation Oncology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Heike Anders
- Clinic for Radiotherapy and Radiation Oncology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Heidi Kapfhammer
- Clinic for Radiotherapy and Radiation Oncology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Michael Orth
- Clinic for Radiotherapy and Radiation Oncology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Roman Hennel
- Clinic for Radiotherapy and Radiation Oncology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Karin Seidl
- Clinic for Radiotherapy and Radiation Oncology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Nicolas Winssinger
- Department of Organic Chemistry, NCCR Chemical Biology, University of Geneva, Geneva, Switzerland
| | - Claus Belka
- Clinic for Radiotherapy and Radiation Oncology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Steffen Unkel
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - Kirsten Lauber
- Clinic for Radiotherapy and Radiation Oncology, Ludwig-Maximilians-University Munich, Munich, Germany.
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20
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Weltman E, Marta GN, Baraldi HS, Pimentel L, Castilho M, Maia MAC, Lundgren MSFS, Chen MJ, Novaes PERS, Gadia R, Ferrigno R, Motta R, Hanna SA, Almeida W. Treatment of abdominal tumors using radiotherapy. Rev Assoc Med Bras (1992) 2015; 61:108-13. [DOI: 10.1590/1806-9282.61.02.108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
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21
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Navarria P, Ascolese AM, Cozzi L, Tomatis S, D'Agostino GR, De Rose F, De Sanctis R, Marrari A, Santoro A, Fogliata A, Cariboni U, Alloisio M, Quagliuolo V, Scorsetti M. Stereotactic body radiation therapy for lung metastases from soft tissue sarcoma. Eur J Cancer 2015; 51:668-74. [PMID: 25686482 DOI: 10.1016/j.ejca.2015.01.061] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 01/17/2015] [Accepted: 01/22/2015] [Indexed: 12/25/2022]
Abstract
PURPOSE To appraise the role of stereotactic body radiation therapy (SBRT) in patients with lung metastasis from primary soft tissue sarcoma. METHODS Twenty-eight patients (51 lesions) were analysed. All patients were in good performance status (1-2 eastern cooperative oncology group (ECOG)), unsuitable for surgical resection, with controlled primary tumour and the number of lung metastases was ⩽4. In a risk adaptive scheme, the dose prescription was: 30Gy/1fr, 60Gy/3fr, 60Gy/8fr and 48Gy/4fr. Treatments were performed with Volumetric Modulated Arc Therapy. Clinical outcome was evaluated by thoracic and abdominal computed tomography (CT) scan before SBRT and than every 3months. Toxicity was evaluated with Common Terminology Criteria for Adverse Events (CTCAE) scale version 4.0. RESULTS Leiomyosarcoma (36%) and synovial sarcoma (25%) were the most common histologies. Five patients (18%) initially presented with pulmonary metastasis, whereas 23 (82%) developed them at a median time of 51months (range 11-311months) from the initial diagnosis. The median follow-up time from initial diagnosis was 65months (5-139months) and from SBRT was 21months (2-80months). No severe toxicity (grades III-IV) was recorded and no patients required hospitalisation. The actuarial 5-years local control rate (from SBRT treatment) was 96%. Overall survival at 2 and 5years was 96.2% and 60.5%, respectively. At last follow-up 15 patients (54%) were alive. All other died because of distant progression. CONCLUSIONS SBRT provides excellent local control of pulmonary metastasis from soft tissue sarcoma (STS) and may improve survival in selected patients. SBRT should be considered for all patients with pulmonary metastasis (PM) and evaluated in a multidisciplinary team.
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Affiliation(s)
- Pierina Navarria
- Radiosurgery and Radiotherapy Department, Istituto Clinico Humanitas Cancer Center and Research Hospital, Rozzano, Milan, Italy
| | - Anna Maria Ascolese
- Radiosurgery and Radiotherapy Department, Istituto Clinico Humanitas Cancer Center and Research Hospital, Rozzano, Milan, Italy
| | - Luca Cozzi
- Radiosurgery and Radiotherapy Department, Istituto Clinico Humanitas Cancer Center and Research Hospital, Rozzano, Milan, Italy.
| | - Stefano Tomatis
- Radiosurgery and Radiotherapy Department, Istituto Clinico Humanitas Cancer Center and Research Hospital, Rozzano, Milan, Italy
| | - Giuseppe Roberto D'Agostino
- Radiosurgery and Radiotherapy Department, Istituto Clinico Humanitas Cancer Center and Research Hospital, Rozzano, Milan, Italy
| | - Fiorenza De Rose
- Radiosurgery and Radiotherapy Department, Istituto Clinico Humanitas Cancer Center and Research Hospital, Rozzano, Milan, Italy
| | - Rita De Sanctis
- Oncology and Haematology Department, Istituto Clinico Humanitas Cancer Center and Research Hospital, Rozzano, Milan, Italy
| | - Andrea Marrari
- Oncology and Haematology Department, Istituto Clinico Humanitas Cancer Center and Research Hospital, Rozzano, Milan, Italy
| | - Armando Santoro
- Oncology and Haematology Department, Istituto Clinico Humanitas Cancer Center and Research Hospital, Rozzano, Milan, Italy
| | - Antonella Fogliata
- Radiosurgery and Radiotherapy Department, Istituto Clinico Humanitas Cancer Center and Research Hospital, Rozzano, Milan, Italy
| | - Umberto Cariboni
- Thoracic Surgery Department, Istituto Clinico Humanitas Cancer Center and Research Hospital, Rozzano, Milan, Italy
| | - Marco Alloisio
- Thoracic Surgery Department, Istituto Clinico Humanitas Cancer Center and Research Hospital, Rozzano, Milan, Italy
| | - Vittorio Quagliuolo
- General Surgery Department, Istituto Clinico Humanitas Cancer Center and Research Hospital, Rozzano, Milan, Italy
| | - Marta Scorsetti
- Radiosurgery and Radiotherapy Department, Istituto Clinico Humanitas Cancer Center and Research Hospital, Rozzano, Milan, Italy
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22
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Chang UK, Lee DH, Kim MS. Stereotactic radiosurgery for primary malignant spinal tumors. Neurol Res 2014; 36:597-606. [DOI: 10.1179/1743132814y.0000000381] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Abstract
Background Primary tumors are rare and those localized to a single location offer the potential for cure. To achieve this, early recognition of the primary tumor and proper workup and treatment are essential. Methods The authors reviewed the literature and best practices to provide recommendations on primary spine tumor treatment. Appropriate workup of primary spine tumors and treatment algorithms are also discussed. Results Patients suspected of a primary spine tumor should undergo fine-needle aspirate biopsy following consultation with the surgical team to ensure the biopsy tract is surgically resectable should the need arise. Once pathology is confirmed, metastatic workup should be performed to guide the level of treatment. If a localized lesion with poor radiation and chemotherapeutic response is diagnosed, then en bloc resection may be required for cure. If en bloc resection is not feasible or metastatic lesions are present, then radiation and medical oncology specialists must work in conjunction with the surgical team to determine the best treatment options. Conclusions Patients with suspected primary tumors of the spine should be treated in a multidisciplinary fashion from the outset. With thoughtful management, these lesions offer the opportunity for surgical cure.
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Affiliation(s)
- Michelle J. Clarke
- Department of Neurosurgery, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Ehud Mendel
- Department of Neurosurgery and Orthopedics, Ohio State University, Columbus, Ohio
| | - Frank D. Vrionis
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
- Departments of Neurosurgery and Orthopedics, University of South Florida Morsani College of Medicine, Tampa, Florida
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Güleç A, Kütahya H, Karalezli N, Kacira B, Acar MA. Stewart Treves Syndrome: A Case Report. Oman Med J 2014; 29:e067. [PMID: 30838096 DOI: 10.5001/omj.2014.38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Angiosarcomas are malignant tumors, which originate from the vessel endothelium and resemble the vessel structure. Stewart-Treves syndrome is an angiosarcoma which in general, develops in female patients after mastectomy and axillary lymph node dissection and is associated with chronic lymphedema. The prognosis of this rare complication is very poor. We present the case of a 52-year-old female who had undergone mastectomy due to breast cancer and 13 years later required shoulder disarticulation due to Stewart-Treves syndrome.
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Affiliation(s)
- Ali Güleç
- Konya Training and Research Hospital, Department of Orthopaedics and Traumatology, PC 42090, Konya, Turkey
| | - Harun Kütahya
- Konya Beyhekim State Hospital Department of Orthopaedics and Traumatology, Konya,Turkey
| | - Nazım Karalezli
- Konya Necmettin Erbakan University Meram Medical Faculty Department of Orthopaedics and Traumatology, Konya, Turkey
| | - Burkay Kacira
- Konya Necmettin Erbakan University Meram Medical Faculty Department of Orthopaedics and Traumatology, Konya, Turkey
| | - M Ali Acar
- Selçuk University Medical Faculty Department of Orthopaedics and Traumatology, Konya, Turkey
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Abstract
Retroperitoneal soft-tissue sarcoma is an uncommon cancer of mesodermal origin, which is difficult to treat owing to its location and proximity to vital structures. Complete gross resection, often involving en bloc resection, is the standard of care as it represents the only treatment that improves overall survival. Unlike extremity sarcoma, retroperitoneal soft-tissue sarcoma tumor mortality is from local recurrence. Radiation therapy is the only adjuvant treatment that has improved local control in several institutional series. However, there remains no definitive prospective, randomized trial that establishes the role of adjuvant radiation versus no radiation. Owing to significant radiation morbidity with adjacent organs, especially the small bowel, there exists no consensus on radiation timing, delivery method or dosing. Recent and current protocols use preoperative external-beam radiation with or without a method of focal boost dosing. Methods of boost dosing include brachytherapy, intraoperative radiation therapy and intensity-modulated radiation therapy. Further studies are needed to definitively include radiation therapy in the standard treatment of retroperitoneal soft-tissue sarcoma and to find the optimal balance between acceptable radiation toxicity and effective local control in treatment protocols.
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Affiliation(s)
- Ching-Wei D Tzeng
- Surgical Oncology Research Fellow, Department of Surgery, University of Alabama-Birmingham, Birmingham, AL, USA.
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Lewin J, Puri A, Quek R, Ngan R, Alcasabas AP, Wood D, Thomas D. Management of sarcoma in the Asia-Pacific region: resource-stratified guidelines. Lancet Oncol 2013; 14:e562-70. [DOI: 10.1016/s1470-2045(13)70475-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Yadav P, Paliwal BR, Kozak K. Dosimetric comparison of photon and proton treatment techniques for chondrosarcoma of thoracic spine. Med Dosim 2013; 38:233-7. [DOI: 10.1016/j.meddos.2013.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Revised: 11/29/2012] [Accepted: 02/19/2013] [Indexed: 11/29/2022]
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Katonis P, Datsis G, Karantanas A, Kampouroglou A, Lianoudakis S, Licoudis S, Papoutsopoulou E, Alpantaki K. Spinal osteosarcoma. CLINICAL MEDICINE INSIGHTS-ONCOLOGY 2013; 7:199-208. [PMID: 24179411 PMCID: PMC3813616 DOI: 10.4137/cmo.s10099] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Although osteosarcoma represents the second most common primary bone tumor, spinal involvement is rare, accounting for 3%–5% of all osteosarcomas. The most frequent symptom of osteosarcoma is pain, which appears in almost all patients, whereas more than 70% exhibit neurologic deficit. At a molecular level, it is a tumor of great genetic complexity and several genetic disorders have been associated with its appearance. Early diagnosis and careful surgical staging are the most important factors in accomplishing sufficient management. Even though overall prognosis remains poor, en-block tumor removal combined with adjuvant radiotherapy and chemotherapy is currently the treatment of choice. This paper outlines histopathological classification, epidemiology, diagnostic procedures, and current concepts of management of spinal osteosarcoma.
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Affiliation(s)
- P Katonis
- Department of Orthopaedics, University Hospital, University of Crete, Heraklion, Greece
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29
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Yoon SS, Chen YL, Kambadakone A, Schmidt B, DeLaney TF. Surgical placement of biologic mesh spacers prior to external beam radiation for retroperitoneal and pelvic tumors. Pract Radiat Oncol 2013; 3:199-208. [DOI: 10.1016/j.prro.2012.06.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Revised: 06/19/2012] [Accepted: 06/20/2012] [Indexed: 11/25/2022]
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Yamada SM, Ishii Y, Yamada S, Goto Y, Murakami M, Hoya K, Matsuno A. Skull base osteosarcoma presenting with cerebrospinal fluid leakage after CyberKnife® treatment: a case report. J Med Case Rep 2013; 7:116. [PMID: 23622107 PMCID: PMC3668228 DOI: 10.1186/1752-1947-7-116] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Accepted: 03/12/2013] [Indexed: 11/26/2022] Open
Abstract
Introduction CyberKnife® radiation is an effective treatment for unresectable skull base tumors because it can deliver a highly conformational dose distribution to the complex shapes of tumor extensions. There have been few reports of severe complications with this treatment. This is the first published case report to our knowledge of cerebrospinal fluid leakage induced by CyberKnife® radiotherapy. Case presentation A skull base tumor was identified on magnetic resonance imaging in a 78-year-old Asian woman with a headache in her forehead. An endoscopic transnasal tumor resection was performed; however, the tumor, invading into the cavernous sinuses and optic canal, was not completely removed. During the subtotal resection of the tumor, no cerebrospinal fluid leakage was observed. Osteosarcoma was histologically diagnosed, and CyberKnife® radiation was performed to the residual tumor considering the aggressive feature of the tumor with a molecular immunology Borstel-1 index of 15%. Five months after the treatment, magnetic resonance imaging showed definite tumor shrinkage, and the patient had been living her daily life without any troubles. After another month, the patient was transferred to our clinic because of coma with high fever, and computed tomography demonstrated severe pneumocephalus. Rhinorrhea was definitely identified on admission; therefore, emergency repair of the cerebrospinal fluid leakage was performed using an endoscope. Dural defects at the bottom of the sella turcica were identified under careful endoscopic observation and fat tissue was patched to the dural defects. Follow-up computed tomography proved complete disappearance of air from the cisterns 2 weeks after the surgery, and the patient was discharged from our hospital without any neurological deficits. Conclusion CyberKnife® radiation is one of the effective treatments for skull base tumors; however, the risk of cerebrospinal fluid leakage should be considered when tumor invasion to the dura mater is suspected. Emergency surgical treatment is required when cerebrospinal fluid leakage is induced by the radiotherapy because the leakage is not expected to be healed by palliative treatments.
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Affiliation(s)
- Shoko Merrit Yamada
- Department of Neurosurgery, Teikyo University Chiba Medical Center, 3426-3 Anesaki, Ichihara-city, Chiba-prefecture 299-0111, Japan.
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Fogliata A, Scorsetti M, Navarria P, Catalano M, Clivio A, Cozzi L, Lobefalo F, Nicolini G, Palumbo V, Pellegrini C, Reggiori G, Roggio A, Vanetti E, Alongi F, Pentimalli S, Mancosu P. Dosimetric comparison between VMAT with different dose calculation algorithms and protons for soft-tissue sarcoma radiotherapy. Acta Oncol 2013; 52:545-52. [PMID: 22671576 DOI: 10.3109/0284186x.2012.689853] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND To appraise the potential of volumetric modulated arc therapy (VMAT, RapidArc) and proton beams to simultaneously achieve target coverage and enhanced sparing of bone tissue in the treatment of soft-tissue sarcoma with adequate target coverage. MATERIAL AND METHODS Ten patients presenting with soft-tissue sarcoma of the leg were collected for the study. Dose was prescribed to 66.5 Gy in 25 fractions to the planning target volume (PTV) while significant maximum dose to the bone was constrained to 50 Gy. Plans were optimised according to the RapidArc technique with 6 MV photon beams or for intensity modulated protons. RapidArc photon plans were computed with: 1) AAA; 2) Acuros XB as dose to medium; and 3) Acuros XB as dose to water. RESULTS All plans acceptably met the criteria of target coverage (V95% >90-95%) and bone sparing (D(1 cm3) <50 Gy). Significantly higher PTV dose homogeneity was found for proton plans. Near-to-maximum dose to bone was similar for RapidArc and protons, while volume receiving medium/low dose levels was minimised with protons. Similar results were obtained for the remaining normal tissue. Dose distributions calculated with the dose to water option resulted ~5% higher than corresponding ones computed as dose to medium. CONCLUSION High plan quality was demonstrated for both VMAT and proton techniques when applied to soft-tissue sarcoma.
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Affiliation(s)
- Antonella Fogliata
- Oncology Institute of Southern Switzerland, Medical Physics Unit,
Bellinzona, Switzerland
| | - Marta Scorsetti
- IRCCS Istituto Clinico Humanitas, Radiation Oncology,
Rozzano, Milan, Italy
| | - Piera Navarria
- IRCCS Istituto Clinico Humanitas, Radiation Oncology,
Rozzano, Milan, Italy
| | - Maddalena Catalano
- IRCCS Istituto Clinico Humanitas, Radiation Oncology,
Rozzano, Milan, Italy
| | - Alessandro Clivio
- Oncology Institute of Southern Switzerland, Medical Physics Unit,
Bellinzona, Switzerland
| | - Luca Cozzi
- Oncology Institute of Southern Switzerland, Medical Physics Unit,
Bellinzona, Switzerland
| | - Francesca Lobefalo
- IRCCS Istituto Clinico Humanitas, Radiation Oncology,
Rozzano, Milan, Italy
| | - Giorgia Nicolini
- Oncology Institute of Southern Switzerland, Medical Physics Unit,
Bellinzona, Switzerland
| | - Valentina Palumbo
- IRCCS Istituto Clinico Humanitas, Radiation Oncology,
Rozzano, Milan, Italy
| | - Chiara Pellegrini
- IRCCS Istituto Clinico Humanitas, Radiation Oncology,
Rozzano, Milan, Italy
| | - Giacomo Reggiori
- IRCCS Istituto Clinico Humanitas, Radiation Oncology,
Rozzano, Milan, Italy
| | - Antonella Roggio
- IRCCS Istituto Clinico Humanitas, Radiation Oncology,
Rozzano, Milan, Italy
| | - Eugenio Vanetti
- Oncology Institute of Southern Switzerland, Medical Physics Unit,
Bellinzona, Switzerland
| | - Filippo Alongi
- IRCCS Istituto Clinico Humanitas, Radiation Oncology,
Rozzano, Milan, Italy
| | - Sara Pentimalli
- IRCCS Istituto Clinico Humanitas, Radiation Oncology,
Rozzano, Milan, Italy
| | - Pietro Mancosu
- IRCCS Istituto Clinico Humanitas, Radiation Oncology,
Rozzano, Milan, Italy
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Duman BB, Gunaldi M, Ercolak V, Afsar CU, Sahin B, Erkisi IMK, Kara O, Paydas S, Gönlüsen G, Sertdemir Y. Retrospective analysis of 498 primary soft tissue sarcomas in a single Turkish centre. Asian Pac J Cancer Prev 2012; 13:4125-8. [PMID: 23098528 DOI: 10.7314/apjcp.2012.13.8.4125] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Soft tissue sarcomas (STS) must be managed with a team involving pathologists, radiologists, surgeons, radiation therapists and medical oncologists. Treatment modalities and demographic characteristics of Turkish STS were analysed in the current study. MATERIAL-METHODS Primary adult STS followed between 1999- 2010 in Cukurova University Medical Faculty Department of Medical Oncology were analyzed retrospectively. RESULTS Of the total of 498 patients, 238 were male and 260 female. The most seen adult sarcomas were leomyosarcoma (23%). Localization of disease was upper extremity (8.8%), lower extremity (24.7%), head-neck 8.2%, thoracic 8%, retroperitoneal 5.6%, uterine 12.4%, abdominal 10%, pelvic region 3.6 and other regions 10%. Some 13.1% were early stage, 10.2% locally advanced, 8.2% metastatic and 12.2% recurrent disease. Patients were treated with neoadjuvant/adjuvant (12%) or palliative chemotherapy (7.2%) and 11.4% patients did not receive chemotherapy. Surgery was performed as radical or conservative. The most preferred regimen was MAID combination chemotherapy in the rate of 17.6%. The most common metastatic site was lung (18.1%). The overall survival was 45 months (95%CI 30-59), 36 months in men and 55 months in women, with no statistically significant difference (p=0.5). The survival rates were not different between the group of adjuvant and palliative chemotherapy (respectively 28 versus 18 months) (p=0.06), but radical surgery at 37 months was better than 22 months for conservative surgery (p=0.0001). No differences were evident for localization (p=0.152). Locally advanced group had higher overall survival rates (72 months) than other stages (p=0.0001). CONCLUSION STS can be treated successfully with surgery, chemotherapy and radiotherapy. The survival rates of Turkish people were higher in locally advanced group; these results show the importance of multimodality treatment approach and radical surgery.
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Bölling T, Hardes J, Dirksen U. Management of bone tumours in paediatric oncology. Clin Oncol (R Coll Radiol) 2012; 25:19-26. [PMID: 22917543 DOI: 10.1016/j.clon.2012.07.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2009] [Revised: 03/07/2012] [Accepted: 05/17/2012] [Indexed: 11/29/2022]
Abstract
The management of bone tumours in paediatric oncology requires careful multidisciplinary planning due to the need for multimodal therapy approaches. The non-specific symptoms often lead to a delayed definitive diagnosis of a bone tumour. Imaging procedures are of major importance for an individualised and optimised treatment planning. They have to be carried out before any surgery, including biopsies. The introduction of multi-agent chemotherapy has led to a significant improvement in survival rates in patients suffering from Ewing's sarcomas and osteosarcomas. However, local therapy still remains indispensable in order to achieve long-term survival. For osteosarcoma, surgery remains the only adequate local therapy modality. Radiotherapy may be considered if surgery is not feasible. In these cases, high radiation doses need to be applied. The choice for local therapy modality is not as clear in patients with Ewing's sarcoma. Today, surgery is often preferred if a wide or at least marginal resection can be carried out. Additional radiotherapy is advised in patients with marginal/intralesional resection or poor histological response to induction chemotherapy. Definitive radiotherapy is recommended for inoperable lesions. In the future, new radiotherapy approaches, such as intensity-modulated radiotherapy or proton therapy, may yield better results with minor risks of late effects.
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Affiliation(s)
- T Bölling
- Department of Radiotherapy and Radiation Oncology, University Hospital of Münster, Münster, Germany.
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Cuneo KC, Riedel RF, Dodd LG, Harpole DH, Kirsch DG. Pathologic complete response of a malignant peripheral nerve sheath tumor in the lung treated with neoadjuvant Ifosfamide and radiation therapy. J Clin Oncol 2012; 30:e291-3. [PMID: 22869889 DOI: 10.1200/jco.2012.42.8797] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Kyle C Cuneo
- Duke University Medical Center, DUMC 91006, Durham, NC 27710, USA
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Chang UK, Cho WI, Lee DH, Kim MS, Cho CK, Lee SY, Jeon DG. Stereotactic radiosurgery for primary and metastatic sarcomas involving the spine. J Neurooncol 2012; 107:551-7. [DOI: 10.1007/s11060-011-0777-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2011] [Accepted: 11/29/2011] [Indexed: 10/14/2022]
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Nambiar D, Rajamani P, Singh RP. Effects of phytochemicals on ionization radiation-mediated carcinogenesis and cancer therapy. Mutat Res 2011; 728:139-57. [PMID: 22030216 DOI: 10.1016/j.mrrev.2011.07.005] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Revised: 07/27/2011] [Accepted: 07/28/2011] [Indexed: 02/01/2023]
Abstract
Ionizing radiation (IR)-induced cellular damage is implicated in carcinogenesis as well as therapy of cancer. Advances in radiation therapy have led to the decrease in dosage and localizing the effects to the tumor; however, the development of radioresistance in cancer cells and radiation toxicity to normal tissues are still the major concerns. The development of radioresistance involves several mechanisms, including the activation of mitogenic and survival signaling, induction of DNA repair, and changes in redox signaling and epigenetic regulation. The current strategy of combining radiation with standard cytotoxic chemotherapeutic agents can potentially lead to unwanted side effects due to both agents. Thus agents are needed that could improve the efficacy of radiation killing of cancer cells and prevent the damage to normal cells and tissues caused by the direct and bystander effects of radiation, without have its own systemic toxicity. Chemopreventive phytochemicals, usually non-toxic agents with both cancer preventive and therapeutic activities, could rightly fit in this approach. In this regard, naturally occurring compounds, including curcumin, parthenolide, genistein, gossypol, ellagic acid, withaferin, plumbagin and resveratrol, have shown considerable potential. These agents suppress the radiation-induced activation of receptor tyrosine kinases and nuclear factor-κB signaling, can modify cell survival and DNA repair efficacy, and may potentiate ceramide signaling. These radiosensitizing and counter radioresistance mechanisms of phytochemicals in cancer cells are also associated with changes in epigenetic gene regulation. Because radioresistance involves multiple mechanisms, more studies are needed to discover novel phytochemicals having multiple mechanisms of radiosensitization and to overcome radioresistance of cancer cells. Pre-clinical studies are needed to address the appropriate dosage, timing, and duration of the application of phytochemicals with radiation to justify clinical trials. Nonetheless, some phytochemicals in combination with IR may play a significant role in enhancing the therapeutic index of cancer treatment.
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Affiliation(s)
- Dhanya Nambiar
- Cancer Biology Laboratory, School of Life Sciences, Jawaharlal Nehru University, New Delhi, India
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Abstract
Musculoskeletal sarcomas are a heterogeneous group of malignant neoplasms derived from connective tissue. Sarcomas represent about 1% of cancer in adults. The annual incidence in adults in Europe is around 14,000 new cases of soft tissue sarcomas (STS) and 4,800 new cases of bone sarcomas. Musculoskeletal tumours arise anywhere in the body, although lower extremities are the most common site of appearance, followed by upper extremities, trunk, retroperitoneum and head and neck area. Adequate management of STS is a stimulating challenge for oncologists. The aim of treatment should be focused on four main aspects: improving survival, avoiding local recurrence, maximising organ function and, finally, minimising morbidity. Surgery, radiotherapy and, sometimes though increasingly, chemotherapy are the pillars on which rests the modern treatment of sarcomas. The optimal management of musculoskeletal tumour requires a multidisciplinary integration of these different approaches in treatment planning right from the initial diagnoses. Referring patients to qualified centres should be desirable to achieve the maximum probability of control and even cure for STS.
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Affiliation(s)
- Ángel Montero Luis
- FEA de Oncología Radioterápica, Hospital Universitario Ramón y Cajal, Madrid, Spain.
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New frontiers in the treatment of liposarcoma, a therapeutically resistant malignant cohort. Drug Resist Updat 2010; 14:52-66. [PMID: 21169051 DOI: 10.1016/j.drup.2010.11.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2010] [Accepted: 11/23/2010] [Indexed: 01/10/2023]
Abstract
The adipogenic origin-derived liposarcoma (LPS) family is the most common soft tissue sarcoma histological subtype. This group is composed of three categories as per the 2002 WHO guidelines: (1) well-differentiated and dedifferentiated liposarcoma (WDLPS/DDLPS); (2) myxoid and round cell liposarcoma (MLS and RCL); and (3) pleomorphic liposarcoma (PLS). While clustered together, these histological subtypes are widely diverse in their clinical, pathological, and molecular characteristics. In general, surgery still remains the mainstay of LPS therapy and the only approach offering the potential of cure. Effective therapeutic strategies for locally advanced and metastatic disease are currently lacking and are crucially needed. With the current gradually increasing knowledge of LPS genetic- and epigenetic-associated deregulations, the ultimate goal is to develop drugs that can specifically eliminate LPS cells while sparing normal tissues. This tumor-tailored target-orientated approach will hopefully result in a significant improvement in the outcome of patients suffering from these poor prognosis malignancies.
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Radiotherapy for soft tissue sarcoma of the proximal lower extremity. Sarcoma 2010; 2010:829498. [PMID: 20981344 PMCID: PMC2957855 DOI: 10.1155/2010/829498] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2010] [Accepted: 07/28/2010] [Indexed: 11/18/2022] Open
Abstract
Soft-tissue sarcoma (STS) is a histopathologically diverse group of tumors accounting for approximately 10,000 new malignancies in the US each year. The proximal lower extremity is the most common site for STS, accounting for approximately one-third of all cases. Coordinated multimodality management in the form of surgery and radiation is often critical to local control, limb preservation, and functional outcome. Based on a review of currently available Medline literature and professional experience, this paper provides an overview of the treatment of STS of the lower extremity with a particular focus on the modern role of radiotherapy.
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Cribb GL, Loo SCS, Dickinson I. Limb salvage for soft-tissue sarcomas of the foot and ankle. ACTA ACUST UNITED AC 2010; 92:424-9. [DOI: 10.1302/0301-620x.92b3.22331] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We evaluated the oncological and functional outcome of 27 patients who had limb salvage for a soft-tissue sarcoma of the foot or ankle between 1992 and 2007, with a mean follow-up of 7.5 years (1.05 to 16.2). There were 12 men and 15 women, with a mean age at presentation of 47 years (12 to 84). Referrals came from other hospitals for 16 patients who had previous biopsy or unplanned excision, and 11 presented de novo. There were 18 tumours located in the foot and nine around the ankle. Synovial sarcoma was the most frequent histological diagnosis. Excision was performed in all cases, with 16 patients requiring plastic surgical reconstruction with 13 free and three local flaps. Adjuvant treatment was undertaken in 20 patients, 18 with radiotherapy and two by chemotherapy. Limb salvage was successful in 26 of the 27 patients. There have been two local recurrences and two mesenchymal metastases. Four patients have died of their sarcoma and two of other causes. Function was evaluated with the Toronto Extremity Salvage Score and a mean overall score of 89.40 (52.1 to 100) was obtained. A questionnaire revealed that all surviving patients are able to wear normal shoes and none require a walking aid. Limb salvage can achieve good oncological and functional results with additional treatment.
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Affiliation(s)
- G. L. Cribb
- Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry SY10 7AG, UK
| | - S. C. S. Loo
- Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, Brisbane, Queensland, Australia 4102
| | - I. Dickinson
- The Wesley Hospital, Coronation Drive, Brisbane, Queensland, Australia 4066
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Yoon SS, Chen YL, Kirsch DG, Maduekwe UN, Rosenberg AE, Nielsen GP, Sahani DV, Choy E, Harmon DC, DeLaney TF. Proton-beam, intensity-modulated, and/or intraoperative electron radiation therapy combined with aggressive anterior surgical resection for retroperitoneal sarcomas. Ann Surg Oncol 2010; 17:1515-29. [PMID: 20151216 DOI: 10.1245/s10434-010-0935-1] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2009] [Indexed: 11/18/2022]
Abstract
BACKGROUND We sought to reduce local recurrence for retroperitoneal sarcomas by using a coordinated strategy of advanced radiation techniques and aggressive en-bloc surgical resection. METHODS Proton-beam radiation therapy (PBRT) and/or intensity-modulated radiation therapy (IMRT) were delivered to improve tumor target coverage and spare selected adjacent organs. Surgical resection of tumor and adjacent organs was performed to obtain a disease-free anterior margin. Intraoperative electron radiation therapy (IOERT) was delivered to any close posterior margin. RESULTS Twenty patients had primary tumors and eight had recurrent tumors. Tumors were large (median size 9.75 cm), primarily liposarcomas and leiomyosarcomas (71%), and were mostly of intermediate or high grade (81%). PBRT and/or IMRT were delivered to all patients, preferably preoperatively (75%), to a median dose of 50 Gy. Surgical resection included up to five adjacent organs, most commonly the colon (n = 7) and kidney (n = 7). Margins were positive for disease, usually posteriorly, in 15 patients (54%). IOERT was delivered to the posterior margin in 12 patients (43%) to a median dose of 11 Gy. Surgical complications occurred in eight patients (28.6%), and radiation-related complications occurred in four patients (14%). After a median follow-up of 33 months, only two patients (10%) with primary disease experienced local recurrence, while three patients (37.5%) with recurrent disease experienced local recurrence. CONCLUSIONS Aggressive resection of retroperitoneal sarcomas can achieve a disease-negative anterior margin. PBRT and/or IMRT with IOERT may possibly deliver sufficient radiation dose to the posterior margin to control microscopic residual disease. This strategy may minimize radiation-related morbidity and reduce local recurrence, especially in patients with primary disease.
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Affiliation(s)
- Sam S Yoon
- Division of Surgical Oncology, Department of Surgery, Massachusetts General Hospital, and Harvard Medical School, Boston, MA, USA.
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Abstract
Abstract
Objectives
The aim of this review was to examine gene therapy involving DNAzyme and siRNA encapsulation into chitosan nanoparticles, discussing the current and future status of this drug delivery system in enhancing drug delivery and cancer therapy.
Key findings
Cancer is a disease state in which the cells in our body undergo mutations at the genetic level and are transformed, acquiring the ability to replicate limitlessly. Conventional cancer treatment involves the use of surgery and cytotoxic chemotherapy and/or radiotherapy, which have the potential of harming normal, otherwise healthy, non-neoplastic cells. Newer forms of therapy such as immunotherapy and gene therapy have shown initial promise, but still require better ways to limit exposure to cancerous lesions in the body. As a result drug delivery systems have been developed in attempts to deliver therapeutics specifically to the target lesion site. One recent drug delivery system has revolved around the use of chitosan nanoparticle technology, where therapeutics are encapsulated into nanoparticles and targeted to tumours.
Summary
Though few, attempts at encapsulating therapeutics such as deoxyribozymes and small or short interfering RNA have been optimistic and encouraging.
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Affiliation(s)
- Mei Lin Tan
- Departments of Orthopaedics and Surgery, University of Melbourne, St Vincent's Hospital Melbourne, P.O. Box 2900, Fitzroy 3065, Australia
| | - Peter F M Choong
- Departments of Orthopaedics and Surgery, University of Melbourne, St Vincent's Hospital Melbourne, P.O. Box 2900, Fitzroy 3065, Australia
| | - Crispin R Dass
- Departments of Orthopaedics and Surgery, University of Melbourne, St Vincent's Hospital Melbourne, P.O. Box 2900, Fitzroy 3065, Australia
- Bone and Soft Tissue Sarcoma Service, Peter MacCallum Cancer Institute, Melbourne, Australia
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Lee JA, Kim MS, Koh JS, Kim MS, Kim DH, Lim JS, Kong CB, Song WS, Cho WH, Lee SY, Jeon DG. Osteosarcoma of the Flat Bone. Jpn J Clin Oncol 2009; 40:47-53. [DOI: 10.1093/jjco/hyp131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
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44
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Abstract
Soft tissue sarcomas, a rare and extremely low prevalence tumor, has no uniform treatment recommendation because there have been few randomized prospective trials to guide management. Recently, there have been surgical, medical, biologic, and genetic advances toward improved treatment. A multidisciplinary approach at specialized treatment centers should be sought because the skill set necessary to implement these advances can be provided and outcomes improved. Centralized care will be crucial to improving survival and functional outcome because it will allow for patients to be effectively entered into prospective randomized trials and create regional and national tissue banks to generate meaningful data.
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45
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Intensity-modulated radiation therapy for oropharyngeal cancer: Radiation dosage constraint at the anterior mandible. Oral Oncol 2009; 45:511-4. [DOI: 10.1016/j.oraloncology.2008.07.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2008] [Revised: 06/03/2008] [Accepted: 07/17/2008] [Indexed: 11/22/2022]
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García de Marcos JA, del Castillo-Pardo de Vera JL, Poblet E, Galdeano-Arenas M, Arroyo-Rodríguez S, Calderón-Polanco J, de Alava E. Clear cell sarcoma of the temporal region: case report, review of the literature, and genetic analysis. J Oral Maxillofac Surg 2009; 67:910-4. [PMID: 19304057 DOI: 10.1016/j.joms.2008.06.092] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2008] [Revised: 06/22/2008] [Accepted: 06/25/2008] [Indexed: 12/28/2022]
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Levine AM, Coleman C, Horasek S. STEREOTACTIC RADIOSURGERY FOR THE TREATMENT OF PRIMARY SARCOMAS AND SARCOMA METASTASES OF THE SPINE. Neurosurgery 2009; 64:A54-9. [DOI: 10.1227/01.neu.0000339131.28485.4a] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE
Spinal sarcomas pose unique treatment dilemmas because of the difficulty of achieving adequate surgical margins and/or delivering curative radiation doses (65 Gy) in close proximity to the spinal cord. This study used hypofractionated stereotactic radiosurgery (SRS) to deliver higher biologically effective doses to treat primary spinal sarcomas and spinal sarcoma metastases.
METHODS
Twenty-four patients with spinal or paraspinal sarcomas entered an Institutional Review Board-approved registry trial to evaluate SRS efficacy. They were assessed at regular intervals for pain control, disease progression, and complications for a minimum of 12 months or until death.
RESULTS
The median treatment dose for the spinal sarcoma lesions was 30 Gy at the 80% isodose in 3 fractions, with some variation based on tumor size, shape, and dose to adjacent critical structures. Seven patients were treated definitively; all had excellent pain relief and are alive with a mean follow-up period of 33 months. Two patients had complete tumor regression, 3 had partial regression, and 2 experienced recurrences and have been re-treated. Seven patients underwent resection and adjuvant SRS. One of 3 patients treated preoperatively had complete tumor regression, and none of the 4 patients treated postoperatively had a local recurrence with a mean follow-up period of 43.5 months. All 10 patients with sarcoma metastases to the spine (16 lesions) died, with a mean survival of 11.1 months from first spinal metastasis treatment. Complete pain relief was achieved in 8 patients, partial relief in 7 patients, and none in 1 patient. No patient developed radiation myelitis.
CONCLUSION
These preliminary results suggest that SRS may have a role in the definitive treatment of patients with primary spinal sarcomas who are deemed unresectable and as adjuvant treatment in those undergoing surgery and for palliation of sarcoma metastases.
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Affiliation(s)
- Alan M. Levine
- Department of Orthopedic Oncology, Alvin and Lois Lapidus Cancer Institute, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Cardella Coleman
- Department of Radiation Oncology, Alvin and Lois Lapidus Cancer Institute, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Sylvia Horasek
- Department of Orthopedic Oncology, Alvin and Lois Lapidus Cancer Institute, Sinai Hospital of Baltimore, Baltimore, Maryland
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48
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Abstract
Studies have demonstrated that chemotherapy alone is usually unsuccessful as exclusive therapy for osteosarcoma (Cancer 95:2202-2201, 2002). Information will be presented for situations where non-surgical alternatives could be considered as useful, if not necessary, adjuncts to chemotherapy. In the thorax these include treatment of pleural effusions, chest wall lesions, central lung or mediastinal osteosarcoma, as well as recurrences in patients with limited pulmonary reserve. Other situations include too many metastases to easily resect, axial osteosarcomas, bone metastases, liver and brain metastases. Non-surgical local control measures include radiation with chemotherapy for radiosensitization, bone-seeking radioisotopes (e.g., 153Sm-EDTMP, 223Ra), bisphosphonates, heat (radiofrequency ablation), freezing and thawing (cryoablation), and intracavitary or regional (aerosol) therapy. Because of the predictable and common pattern of pulmonary metastases in osteosarcoma, aerosol therapy also offers an attractive regional treatment strategy. Principles and use of aerosol cytokines (e.g., GM-CSF, IL-2), and aerosol chemotherapy with gemcitabin will be discussed. Individual cases illustrating strategy and techniques will be presented.
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Affiliation(s)
- Pete Anderson
- Children's Cancer Hospital, University of Texas MD Anderson Cancer Center, Unit 87, Pediatrics, 1515 Holcombe Blvd., Houston, TX 77030-4009, USA.
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Abstract
Osteosarcoma is the most common malignant primary bone tumor in children and adolescents. Current optimal treatment for osteosarcoma consists of multi-agent chemotherapy and aggressive surgical resection of all sites of disease involvement. The current national and international cooperative trial for patients with newly diagnosed osteosarcoma builds upon the backbone of cisplatin, doxorubicin, and methotrexate. This protocol is designed to clarify whether (i) the addition of ifosfamide and etoposide to postoperative chemotherapy with cisplatin, doxorubicin, and methotrexate improves the event-free survival and overall survival for patients with resectable osteosarcoma and a poor histologic response to 10 weeks of preoperative chemotherapy; and (ii) the addition of pegylated interferon-alpha-2b as maintenance therapy after postoperative chemotherapy with cisplatin, doxorubicin, and methotrexate improves the event-free survival and overall survival for patients with resectable osteosarcoma and a good histologic response to 10 weeks of preoperative chemotherapy. However, the optimal treatment strategy (or strategies) for patients with relapsed or metastatic disease has yet to be defined. This remains one of the persistent challenges in the treatment of osteosarcoma. Recent therapeutic advances have focused on circumventing chemotherapy resistance mechanisms, incorporation of non-classical agents into upfront therapy, targeting of the tumor micro-environment, and investigating the role of novel delivery mechanisms. In patients with localized disease the 5-year survival rate is at least 70%; patients with metastatic or recurrent disease have <20% chance of long-term survival despite aggressive therapies. These figures have changed little in the past 2 decades. This review focuses on the current therapy for osteosarcoma, and highlights emerging strategies that will hopefully change the outlook for patients with this disease.
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Affiliation(s)
- Alexander J Chou
- Department of Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, USA
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50
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Laskar S, Mallick I, Gupta T, Muckaden MA. Post-operative radiotherapy for Ewing sarcoma: when, how and how much? Pediatr Blood Cancer 2008; 51:575-80. [PMID: 18561167 DOI: 10.1002/pbc.21657] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Postoperative radiotherapy in Ewing family of tumors has undergone continuous evolution over the last few decades to establish its role in the combined modality management of these tumors. The process of evolution is still far from over. This review analyzes the evidence from major multi-institutional prospective trials as well as large retrospective institutional series in Ewing tumors to determine the current standards and controversies in postoperative radiation. The indications of PORT, radiation dose-fractionation, timing, target volumes and treatment planning, as well as the late effects are reviewed. A summary of evidence based consensus is presented and unresolved aspects are discussed. Pediatr Blood Cancer 2008;51:575-580. (c) 2008 Wiley-Liss, Inc.
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Affiliation(s)
- S Laskar
- Department of Radiation Oncology, Tata Memorial Hospital, Parel, Mumbai 400012, India.
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