Analysis of skin dose distribution for the prediction of severe radiation dermatitis in head and neck squamous cell carcinoma patients treated with concurrent chemo-radiotherapy

BACKGROUND

We investigated whether the pattern of intensity-modulated radiotherapy (IMRT) dose distribution to the skin can be correlated with the development of G3/G4 radiation dermatitis (RD).

METHODS

A frequency-matched cohort analysis was perfomed on patients treated with IMRT and concurrent cisplatin or cetuximab. Risk ratios were obtained by fitting Poisson regression models.

RESULTS

The incidence of G3/G4 RD was 41.1% in 90 patients included (50% vs 36.6% in the cetuximab and cisplatin cohorts, respectively). In multivariate analysis, PS ≥ 1 and weight loss at RT completion >10 kg were the only factors that retained significance. The best dosimetric predictive accuracy was provided by 19.9 cc and 5.8 cc of skin ring 2 mm V50 and V60, respectively (AUC: 0.61 for both).

CONCLUSION

Along with clinical factors, the pattern of dose distribution to a ring structure localized 2 mm below the patient's surface may help predict the development of severe RD.

Is the social status a new prognostic factor in the Fournier's gangrene?

Fournier's gangrene is a life-threatening acute necrotizing fasciitis of perianal, genitourinary and perineal areas. Local symptoms are scrotal swelling, erythema of scrotal skin and pain with generalized constitutional symptoms. The gangrene may extends to abdominal wall, intra-abdominal structures, and even in the retroperitoneal tissues. Urgent surgical debridement is crucial to warrant a good outcome since delayed intervention carries a poor prognosis. We report the case of a not diabetic patient with Fournier's disease presented with severe sepsis and successfully treated with urgent deep debridement and reconstructive surgery. We propose the social status of the patient as a prognostic factor with high impact for survival rate.

Limited-Stage Small-Cell Lung Cancer Treated with Early Chemo-Radiotherapy: The Impact of Effective Chemotherapy

Aims and Background

Small cell lung cancer is characterized by an aggressive clinical course and a high sensitivity to both chemotherapy and radiotherapy. We present the Florence University experience in concurrent early radio-chemotherapy in patients affected by limited-stage small cell lung cancer, with particular emphasis on treatment safety, disease outcome and prognostic factors.

Methods and Study Design

Fifty-seven patients were treated between June 2000 and February 2005. All patients underwent platinum-based chemotherapy, administered intravenously following two different regimens, for at least three cycles. Eighteen patients (31.6%) received epirubicin and ifosfamide in 3-week cycles alternating with etoposide and cisplatin, administered on day 1 to 3; 39 patients (68.4%) received etoposide and cisplatin. A total of 6 cycles were planned. Radiotherapy was administered concurrently to the first cycle of etoposide and cisplatin.

Results

Clinical stage (P = 0.036) and number of chemotherapy courses (P = 0.009) emerged as the only significant death predictors at univariate analysis. Number of chemotherapy courses persisted as a significant death predictor also at multivariate regression analysis, with a reduced death risk for 5–6 chemotherapy cycles in comparison to 3–4 cycles (hazard ratio, 0.44). At a mean follow up of 38.5 months (standard deviation, 3.24 years; range, 6–164 months), considering the best overall tumor response achieved at any time during the whole treatment period, we obtained 32 complete responses (56.1%), 23 partial responses (40.3%) and 2 stable diseases.

Conclusions

Our analysis showed that concurrent early radio-chemotherapy in limited-stage small cell lung cancer treatment represents a safe and effective approach in patients. We confirmed the relevant impact on overall survival of effective chemotherapy delivery.

Non-Pegylated Liposomal Doxorubicin in Combination with Cyclophosphamide or Docetaxel as First-Line Therapy in Metastatic Breast Cancer: A Retrospective Analysis

Aims and background

Anthracyclines such as doxorubicin play a central role in the management of advanced breast cancer. Unfortunately, the clinical benefits of anthracyclines are limited by cardiotoxicity that can lead to the development of potentially fatal congestive heart failure. In order to limit anthracycline-related cardiotoxicity, liposomal formulations of doxorubicin have been developed. This retrospective analysis evaluated the experience obtained with non-pegylated liposomal doxorubicin as first-line therapy in 34 patients with metastatic breast cancer.

Methods

Patients received non-pegylated liposomal doxorubicin in combination with either cyclophosphamide (n = 14) or docetaxel (n = 20) for up to eight cycles, and efficacy and safety were assessed according to standard criteria.

Results

The overall response rate was 71%. The median progression-free survival was 8 months in patients receiving non-pegylated liposomal doxorubicin plus cyclophosphamide and 13.8 months in those receiving non-pegylated liposomal doxorubicin plus docetaxel (P = 0.2). The most commonly observed toxicities were grade 1–2 leucopenia, alopecia, nausea and vomiting; no grade 3–4 toxicities were observed. Overall, three patients (9%) experienced grade 1 cardiac toxicity.

Conclusions

Our results support the use of non-pegylated liposomal doxorubicin as an alternative to conventional doxorubicin formulations in combination regimens for the first-line therapy of metastatic breast cancer.

Limited-stage small-cell lung cancer treated with early chemo-radiotherapy: the impact of effective chemotherapy

AIMS AND BACKGROUND

Small cell lung cancer is characterized by an aggressive clinical course and a high sensitivity to both chemotherapy and radiotherapy. We present the Florence University experience in concurrent early radio-chemotherapy in patients affected by limited-stage small cell lung cancer, with particular emphasis on treatment safety, disease outcome and prognostic factors.

METHODS AND STUDY DESIGN

Fifty-seven patients were treated between June 2000 and February 2005. All patients underwent platinum-based chemotherapy, administered intravenously following two different regimens, for at least three cycles. Eighteen patients (31.6%) received epirubicin and ifosfamide in 3-week cycles alternating with etoposide and cisplatin, administered on day 1 to 3; 39 patients (68.4%) received etoposide and cisplatin. A total of 6 cycles were planned. Radiotherapy was administered concurrently to the first cycle of etoposide and cisplatin.

RESULTS

Clinical stage (P = 0.036) and number of chemotherapy courses (P = 0.009) emerged as the only significant death predictors at univariate analysis. Number of chemotherapy courses persisted as a significant death predictor also at multivariate regression analysis, with a reduced death risk for 5-6 chemotherapy cycles in comparison to 3-4 cycles (hazard ratio, 0.44). At a mean follow up of 38.5 months (standard deviation, 3.24 years; range, 6-164 months), considering the best overall tumor response achieved at any time during the whole treatment period, we obtained 32 complete responses (56.1%), 23 partial responses (40.3%) and 2 stable diseases.

CONCLUSIONS

Our analysis showed that concurrent early radio-chemotherapy in limited-stage small cell lung cancer treatment represents a safe and effective approach in patients. We confirmed the relevant impact on overall survival of effective chemotherapy delivery.

The impact of young age on breast cancer outcome

AIMS

We conducted a retrospective analysis in order to evaluate the impact of age on women aged less than 35 years affected by breast cancer.

MATERIALS AND METHODS

Between January 1972 and December 2006, 346 patients aged less than 35 years underwent adjuvant treatment at Florence University. The mean age of the patient population was 32 years (range 22-35): 76 patients were under 30 years old, the remaining were above 30 years old.

RESULTS

In our series, 215 patients received adjuvant radiotherapy to whole breast after conservative surgery, 131 patients underwent mastectomy without subsequent radiation therapy and 323 patients had lymphadenectomy; 191 patients received adjuvant chemotherapy, 73 with anthracycline-containing regimen. With a median time of 2.5 years (range 6 months to 27.6 years) local relapses were observed in 67 cases (19.4%). At the multivariate analysis of local disease-free survival, ductal and ductal plus lobular histotypes, having more than 3 positive nodes, and age emerged as independent significant relapse predictors (p = 0.018, p = 0.0005, p = 0.003 and p = 0.024, respectively). For the DSS analysis, the median follow-up was 6.8 years (range 0.6-36.7 years). At the multivariate analysis, age (p = 0.0038), positive nodes (p = 0.0035) and distant metastases (p < 0.0001) resulted to be independent death predictors. Patients younger than 30 had a worse prognosis. At the univariate analysis also local relapse resulted to be statistically significant (p = 0.0004).

CONCLUSIONS

Anthracycline-based chemotherapy seems to improve the outcome of these patients. However, there is an urgent need for tailored treatment investigations within the framework of randomized, controlled clinical trials.

Over-Treated Corneal Abscess May Be Toxic Keratopathy

Background/Aims

Keratitis, especially when long-standing and unresponsive to common antimicrobial treatment, leads to a suspicion of fungal aetiology.

Methods

Photographically documented case report.

Results

A 65-year-old man with diabetes was referred for corneal abscess unresponsive to antibiotic and antifungal treatment lasting 6 weeks. Corneal biopsy was performed following a 72-hour washout for identification of bacteria and fungi. Previously administered drops were withdrawn and only preservative-free artificial tears were maintained. Neither bacteria nor fungi were cultured. After 2 weeks, the clinical situation had conspicuously improved.

Conclusion

Over-treatment of corneal affections fearing mycosis may lead to toxic keratopathy.

The impact of young age on breast cancer outcome

AIMS: We conducted a retrospective analysis in order to evaluate the impact of age on women aged less than 35 years affected by breast cancer. MATERIALS AND METHODS: Between January 1972 and December 2006, 346 patients aged less than 35 years underwent adjuvant treatment at Florence University. The mean age of the patient population was 32 years (range 22-35): 76 patients were under 30 years old, the remaining were above 30 years old. RESULTS: In our series, 215 patients received adjuvant radiotherapy to whole breast after conservative surgery, 131 patients underwent mastectomy without subsequent radiation therapy and 323 patients had lymphadenectomy; 191 patients received adjuvant chemotherapy, 73 with anthracycline-containing regimen. With a median time of 2.5 years (range 6 months to 27.6 years) local relapses were observed in 67 cases (19.4%). At the multivariate analysis of local disease-free survival, ductal and ductal plus lobular histotypes, having more than 3 positive nodes, and age emerged as independent significant relapse predictors (p=0.018, p=0.0005, p=0.003 and p=0.024, respectively). For the DSS analysis, the median follow-up was 6.8 years (range 0.6-36.7 years). At the multivariate analysis, age (p=0.0038), positive nodes (p=0.0035) and distant metastases (p<0.0001) resulted to be independent death predictors. Patients younger than 30 had a worse prognosis. At the univariate analysis also local relapse resulted to be statistically significant (p=0.0004). CONCLUSIONS: Anthracycline-based chemotherapy seems to improve the outcome of these patients. However, there is an urgent need for tailored treatment investigations within the framework of randomized, controlled clinical trials.

Radiotherapy timing in 4,820 patients with breast cancer: university of florence experience

PURPOSE

To analyze the relationship between a delay in radiotherapy (RT) after breast-conserving surgery and ipsilateral breast recurrence (BR).

METHODS AND MATERIALS

We included in our analysis 4,820 breast cancer patients who had undergone postoperative RT at the University of Florence. The patients were categorized into four groups according to the interval between surgery and RT (T1, <60 days; T2, 61-120 days; T3, 121-180 days; and T4, >180 days).

RESULTS

On multivariate analysis, the timing of RT did not reach statistical significance in patients who received only postoperative RT (n = 1,935) or RT and hormonal therapy (HT) (n = 1,684) or RT, chemotherapy (CHT), and HT (n = 529). In the postoperative RT-only group, age at presentation, surgical margin status, and a boost to the tumor bed were independent prognostic factors for BR. In the RT plus HT group, age at presentation and boost emerged as independent prognostic factors for BR (p = 0.006 and p = 0.049, respectively). Finally, in the RT, CHT, and HT group, only multifocality was an independent BR predictor (p = 0.01). Only in the group of patients treated with RT and CHT (n = 672) did multivariate analysis with stepwise selection show RT timing as an independent prognostic factor (hazard ratio, 1.59; 95% confidence interval, 1.01-2.52; p = 0.045). Analyzing this group of patients, we found that most patients included had worse prognostic factors and had received CHT consisting of cyclophosphamide, methotrexate, and 5-fluorouracil before undergoing RT.

CONCLUSION

The results of our study have shown that the timing of RT itself does not affect local recurrence, which is mainly related to prognostic factors. Thus, the "waiting list" should be thought of as a "programming list," with patients scheduled for RT according to their prognostic factors.

Loco-regional recurrence in 2064 patients with breast cancer treated with mastectomy without adjuvant radiotherapy

INTRODUCTION

We investigated the incidence of loco-regional recurrence in a sub-group of patients who underwent mastectomy without adjuvant radiotherapy to evaluate the effect of each specific clinical or pathological parameter that could be associated with a higher local relapse rate.

PATIENTS AND METHODS

Two thousand and sixty-four patients were treated from January 1971 to December 2003 at the University of Florence.

RESULTS

At the time of analysis 18.3% of patients (378/2064) had isolated loco-regional failures. Univariate analysis showed an association of borderline statistical significance with pathological tumour size. Elderly age at diagnosis had a low incidence of local recurrence but the results did not reach statistical significant. The number of positive axillary lymph node did not show any influence for local recurrence.

CONCLUSION

In our series we noted a higher relapse rate only related to the pathological tumour size without any correlation with number of positive axillary nodes. Radiotherapy after mastectomy still remains controversial, but in our series the number of positive axillary lymph node did not seem enough to justify adjuvant treatment.

Computer-assisted diagnosis of postmenopausal osteoporosis using a fuzzy expert system shell

This paper shows how the AMDIS (Automated Medical Diagnosis with Intelligent Systems) integrated system can be employed to build a fuzzy medical expert system in the domain of postmenopausal osteoporosis. The fundamental aims of the expert system are to standardize knowledge and support physicians in the early detection of postmenopausal osteoporosis. A wide range of diagnostic situations has been considered for both categories of the disease, with judgments that range from disease is excluded to disease is definite. The salient aspects of the approach are the use of fuzzy logic as an analytic language for the representation and manipulation of knowledge and strategies and the integration of structured interview techniques and learning-by-example to address the knowledge acquisition task.