Soft-tissue simulation of the breast for intraoperative navigation and fusion of preoperative planning

Computational preoperative planning offers the opportunity to reduce surgery time and patient risk. However, on soft tissues such as the breast, deviations between the preoperative and intraoperative settings largely limit the applicability of preoperative planning. In this work, we propose a high-performance accurate simulation model of the breast, to fuse preoperative information with the intraoperative deformation setting. Our simulation method encompasses three major elements: high-quality finite-element modeling (FEM), efficient handling of anatomical couplings for high-performance computation, and personalized parameter estimation from surface scans. We show the applicability of our method on two problems: 1) transforming high-quality preoperative scans to the intraoperative setting for fusion of preoperative planning data, and 2) real-time tracking of breast tumors for navigation during intraoperative radiotherapy. We have validated our methodology on a test cohort of nine patients who underwent tumor resection surgery and intraoperative radiotherapy, and we have quantitatively compared simulation results to intraoperative scans. The accuracy of our simulation results suggest clinical viability of the proposed methodology.

Efficacy of Endometrial Cancer Follow-up Protocols: Time to Change?

OBJECTIVE

 The aim of the present study was to analyze relapse rates and patterns in patients with endometrial cancer with the aim of evaluating the effectiveness of current follow-up procedures in terms of patient survival, as well as the convenience of modifying the surveillance strategy.

METHODS

 Retrospective descriptive study including all patients diagnosed with endometrial cancer relapse at the Department of Gynecology and Obstetrics of the Complejo Hospitalario Insular-Materno Infantil de Canarias, between 2005 and 2014.

RESULTS

 Recurrence was observed in 81 patients (10.04% of the sample); 66.7% of them suffered relapse within 2 years and 80.2% within 3 years after the termination of the primary treatment; 41.9% showed distant metastases while the rest corresponded to local-regional (40.7%) or ganglionar (17.4%) relapse; 42% of these were symptomatic; 14 patients showed more than 1 site of relapse. Relapse was detected mainly through symptoms and physical examination findings (54.3%), followed by elevated serum marker levels (29.6%), computed tomography (CT) images (9.9%) and abnormal vaginal cytology findings (6.2%). No differences in global survival were found between patients with symptomatic or asymptomatic relapse.

CONCLUSION

 Taking into account that the recurrence rate of endometrial cancer is low, that relapse occurs mainly within the first 3 years post-treatment and that symptom evaluation and physical examination are the most effective follow-up methods, we postulate that a modification of the current model of hospital follow-up should be considered.

Does iatrogenic tumor rupture during surgery have prognostic implications for the outcome of uterine sarcomas?

OBJECTIVE

Tumor rupture during surgery is a risk factor for recurrence of sarcomas in other locations. However, the independent impact of rupture on prognosis is uncertain in uterine sarcomas. The aim of this study was to evaluate whether uterine rupture impacts outcomes in patients with uterine sarcoma.

METHODS

A retrospective analysis was carried out of all consecutive patients with uterine sarcoma managed at the Department of Gynecology and Obstetrics of the Complejo Hospitalario Universitario Insular-Materno Infantil of the Canary Islands, Spain between January 1990 and December 2016. Inclusion criteria included all patients with histologically proven uterine sarcoma. Exclusion criteria included patients with endometrial carcinoma (non-sarcomatous) and carcinosarcomas. During this period, 1981 patients were diagnosed with a uterine malignancy; 1799 were excluded because of a diagnosis of endometrial carcinoma and 85 patients were excluded for a diagnosis of carcinosarcoma. Thus, the final sample included 97 patients with uterine sarcoma (4.9%). These included leiomyosarcoma, endometrial stromal sarcoma, adenosarcoma, and liposarcoma. Surgical resection was the primary treatment, including open, laparoscopic and vaginal surgery. Survival rates were analyzed using the Kaplan-Meier method.

RESULTS

The median age was 52 years (range 25-90); 49.5% (48) were pre-menopausal. Distribution per histological type was: 46.4% (45) leiomyosarcoma, 23.7% (23) high-grade endometrial stromal sarcoma, 17.5% (17) low-grade endometrial stromal sarcoma, 11.3% (11) adenosarcoma, and 1% (1) liposarcoma. Uterine leiomyoma was the most frequent pre-operatively suspected diagnosis (49.5%). Iatrogenic rupture of the tumor during surgery occurred in 25.3% of cases (23). International Federation of Gynecology and Obstetrics stages I-II and III-IV were identified in 74.2% (72) and 25.8% (25) of patients, respectively. The median tumor size was 8 cm (range 2-40). The recurrence rate was 47.8% (11) for patients with intra-operative tumor rupture and 25% (17) for patients without uterine rupture (p=0.03). Disease-free survival rates at 1, 2, and 5 years for patients with uterine rupture were 72.7%, 55.4%, and 13.9%, respectively, with a median time of 39 months (95% CI 2.9 to 75). For those patients without uterine rupture, disease-free survival rates at 1, 2, and 5 years were 84.8%, 76.1%, and 71.3%, respectively, with a mean time of 208.6 months (95% CI 169 to 248.3) (p=0.01). Multivariate analysis showed that stage, histological type, and iatrogenic tumor rupture during surgery were all independent prognostic factors for overall survival (OR 7.9, 95% CI 1.6 to 38.2, p=0.01); OR 5.3, 95% CI 2.1 to 13, p<0.0001; and OR 2.6, 95% CI 1.1 to 6.5, respectively, p=0.03).

CONCLUSION

Considering that uterine sarcomas, especially leiomyosarcomas, often occur in pre-menopausal women as bulky tumors requiring laparotomy and that they are rarely diagnosed pre-operatively, efforts should be made to avoid iatrogenic uterine rupture during surgery as it impairs patient survival.

New biological markers in the decision of treatment of head and neck cancer patients

Head and neck squamous cell carcinoma is the sixth most common cancer type worldwide. Also the 5-year survival rate of less than 50 % seems to be lower than other cancer types. There are some reasons behind this high mortality rate; one of them is the lack of knowledge about the biology and genomic instability behind the carcinogenic processes. These biological features could condition the failure of frontline treatment, in which case rescue treatment should be used, representing an overtreatment for the patients. For years many biological factors have been tested as prognostic and predictive factors in relation to treatment with a modest success. To find appropriate tests which could be used in the context of the individualized treatment decision, we have reviewed new biological markers, not only in tumor tissue, but also in normal tissue from head and neck carcinoma patients.

Long-term control of refractory hemorrhagic radiation proctitis with ozone therapy

CONTEXT

Persistent or severe hemorrhagic radiation proctitis (HRP) has limited therapeutic options.

OBJECTIVES

To describe our experience with ozone therapy (O3T) in the management of refractory HRP.

METHODS

Patients (n=17; median age 69 years [range 42-80 years]) previously irradiated for prostate or uterine cancer and suffering persistent or severe HRP without response to conventional treatment were enrolled to receive an O3/O2 gas mixture via rectal insufflations and topical application of ozonized oil. Most of the patients (83%) had Grade 3 or Grade 4 toxicity. Median follow-up post-O3T was 40 months (range 3-56 months).

RESULTS

Endoscopic treatments required were: 43 (median 1; range 0-10) pre-O3T; 17 (median 0; range 0-8; P=0.063) during O3T; and five (median 0; range 0-2; P=0.008) during follow-up. Hemoglobin levels were 10.35g/dL (7-14g/dL) pre-O3T and 13g/dL (9-15g/dL) (P=0.001) post-O3T. Median toxicity grades were 3 (range 2-4) pre-O3T, 1 (range 0-2; P<0.001) at the end of O3T, and 0 (range 0-1; P<0.001) at the last follow-up.

CONCLUSION

Persistent advanced HRP was significantly improved with O3T. The addition of O3T can be useful as a complementary treatment in the long-term management of HRP and, as such, merits further evaluation.

Plasminogen activator inhibitor-1 (PAI-1) expression in relation to hypoxia and oncoproteins in clinical cervical tumors

PURPOSE

Explore the role of plasminogen activator inhibitor-1 (PAI-1) in cervical cancer and its relationship to hypoxia and the expression of p53, Ku70/80, and cyclin D1.

MATERIAL AND METHODS

The expression of PAI-1, cyclin D1, and p53, together with tumor oxygenation, were determined in 43 consecutive patients suffering from localized cervical carcinoma. Oncoprotein expression was determined by immunohistochemistry. Tumor oxygenation was measured using a polarographic probe system, "pO2 histography."

RESULTS

PAI expression was considered negative in 32.6% and overexpressed in 18.6% of cases. Cyclin D1 showed a median expression of 5.0 (range 0-70). We observed a positive association between PAI expression and altered p53 (p = 0.049) and cyclin D1 (p = 0.020). An inverse association was detected between PAI and Ku70/80 expression (p = 0.042). Cyclin D1 staining increased according to tumor volume (r = 0.314, p = 0.009). We did not observe a significant association between PAI and hypoxia or other clinicopathological parameters.

CONCLUSION

The present results show that PAI-1 overexpression is associated with nonhomologous end-joining DNA repair down-regulation (low Ku70/80 expression) and with increased p53 and cyclin D1 expression, and they suggest that PAI-1 plays a role in the tumor behavior in cervical carcinoma.

Prediction of normal tissue toxicity as part of the individualized treatment with radiotherapy in oncology patients

Normal tissue toxicity caused by radiotherapy conditions the success of the treatment and the quality of life of patients. Radiotherapy is combined with surgery in both the preoperative or postoperative setting for the treatment of most localized solid tumour types. Furthermore, radical radiotherapy is an alternative to surgery in several tumour locations. The possibility of predicting such radiation-induced toxicity would make possible a better treatment schedule for the individual patient. Radiation-induced toxicity is, at least in part, genetically determined. From decades, several predictive tests have been proposed to know the individual sensitivity of patients to the radiotherapy schedules. Among them, initial DNA damage, radiation-induced apoptosis, gene expression profiles, and gene polymorphisms have been proposed. We report here an overview of the main studies regarding to this field. Radiation-induced apoptosis in peripheral blood lymphocytes seem to be the most promising assay tested in prospective clinical trials, although they have to be validated in large clinical studies. Other promising assays, as those related with single nucleotide polymorphisms, need to be validated as well.

BCL-2, in combination with MVP and IGF-1R expression, improves prediction of clinical outcome in complete response cervical carcinoma patients treated by radiochemotherapy

OBJECTIVES

To investigate whether BCL-2 expression would improve MVP/IGF-1R prediction of clinical outcome in cervix carcinoma patients treated by radiochemotherapy, and suggest possible mechanisms behind this effect.

METHODS

Fifty consecutive patients, who achieved complete response to treatment, from a whole series of 60 cases suffering from non-metastatic localized cervical carcinoma, were prospectively included in this study from July 1999 to December 2003. Follow-up was closed in January 2011. All patients received pelvic radiation (45-64.80 Gy in 1.8-2 Gy fractions) with concomitant cisplatin at 40 mg/m2/week doses followed by brachytherapy. Oncoprotein expression was studied by immunohistochemistry in paraffin-embedded tumour tissue.

RESULTS

No relation was found between BCL-2 and clinicopathological variables. High MVP/IGF-1R/BCL-2 tumour expression was strongly related to poor local and regional disease-free survival (P<0.0001), distant disease-free survival (P=0.010), disease-free survival (P<0.0001), and cause-specific survival (P<0.0001). NHEJ repair protein Ku70/80 expression was significantly repressed in tumours overexpressing all three oncoproteins (P=0.047). No differences were observed in proliferation (Ki67 expression) or P53 alteration.

CONCLUSIONS

BCL-2, MVP, and IGF-1R overexpression were related to poorer clinical outcome in cervical cancer patients who achieved clinical complete response to radiochemotherapy. The NHEJ repair protein Ku70/80 expression could be involved in the regulation of these oncoproteins.

Combined low initial DNA damage and high radiation-induced apoptosis confers clinical resistance to long-term toxicity in breast cancer patients treated with high-dose radiotherapy

Background

Either higher levels of initial DNA damage or lower levels of radiation-induced apoptosis in peripheral blood lymphocytes have been associated to increased risk for develop late radiation-induced toxicity. It has been recently published that these two predictive tests are inversely related. The aim of the present study was to investigate the combined role of both tests in relation to clinical radiation-induced toxicity in a set of breast cancer patients treated with high dose hyperfractionated radical radiotherapy.

Methods

Peripheral blood lymphocytes were taken from 26 consecutive patients with locally advanced breast carcinoma treated with high-dose hyperfractioned radical radiotherapy. Acute and late cutaneous and subcutaneous toxicity was evaluated using the Radiation Therapy Oncology Group morbidity scoring schema. The mean follow-up of survivors (n = 13) was 197.23 months. Radiosensitivity of lymphocytes was quantified as the initial number of DNA double-strand breaks induced per Gy and per DNA unit (200 Mbp). Radiation-induced apoptosis (RIA) at 1, 2 and 8 Gy was measured by flow cytometry using annexin V/propidium iodide.

Results

Mean DSB/Gy/DNA unit obtained was 1.70 ± 0.83 (range 0.63-4.08; median, 1.46). Radiation-induced apoptosis increased with radiation dose (median 12.36, 17.79 and 24.83 for 1, 2, and 8 Gy respectively). We observed that those "expected resistant patients" (DSB values lower than 1.78 DSB/Gy per 200 Mbp and RIA values over 9.58, 14.40 or 24.83 for 1, 2 and 8 Gy respectively) were at low risk of suffer severe subcutaneous late toxicity (HR 0.223, 95%CI 0.073-0.678, P = 0.008; HR 0.206, 95%CI 0.063-0.677, P = 0.009; HR 0.239, 95%CI 0.062-0.929, P = 0.039, for RIA at 1, 2 and 8 Gy respectively) in multivariate analysis.

Conclusions

A radiation-resistant profile is proposed, where those patients who presented lower levels of initial DNA damage and higher levels of radiation induced apoptosis were at low risk of suffer severe subcutaneous late toxicity after clinical treatment at high radiation doses in our series. However, due to the small sample size, other prospective studies with higher number of patients are needed to validate these results.

Role of CD4 and CD8 T-lymphocytes, B-lymphocytes and Natural Killer cells in the prediction of radiation-induced late toxicity in cervical cancer patients

PURPOSE

To analyse the role of in vitro radio-induced apoptosis of lymphocyte subpopulations as predictive test for late effects in cervical cancer patients treated with radiotherapy.

METHODS AND MATERIALS

Ninety-four consecutive patients and four healthy controls were included in the study. Toxicity was evaluated using the Late Effects Normal Tissue-Subjective, Objective, Management, and Analytic (LENT-SOMA) scale. Peripheral blood lymphocyte subpopulations were isolated and irradiated at 0, 1, 2 and 8 Gy, and then collected 24, 48 and 72 h after irradiation. Apoptosis was measured by flow cytometry.

RESULTS

Radiation-induced apoptosis increased with radiation dose and time of incubation, and data fitted to a semi-logarithmic model defined by two constants: α (percentage of spontaneous cell death) and β (percentage of cell death induced at a determined radiation dose). Higher β values in cytotoxic T-lymphocytes (CD8) and bone cells (B-lymphocytes) were observed in patients with low bowel toxicity (hazard ratio (HR) = 0.96, p = 0.002 for B-cells); low rectal toxicity (HR = 0.96, p = 0.020; HR = 0.93, p = 0.05 for B and CD8 subpopulations respectively); low urinary toxicity (HR = 0.93, p = 0.003 for B-cells) and low sexual toxicity (HR = 0.93, p = 0.010 for CD8-cells).

CONCLUSIONS

Radiation-induced CD8 T-lymphocytes and, for the first time, B-lymphocytes apoptosis can predict differences in late toxicity in cervical cancer patients.

Radiation induced apoptosis and initial DNA damage are inversely related in locally advanced breast cancer patients

Background

DNA-damage assays, quantifying the initial number of DNA double-strand breaks induced by radiation, have been proposed as a predictive test for radiation-induced toxicity. Determination of radiation-induced apoptosis in peripheral blood lymphocytes by flow cytometry analysis has also been proposed as an approach for predicting normal tissue responses following radiotherapy. The aim of the present study was to explore the association between initial DNA damage, estimated by the number of double-strand breaks induced by a given radiation dose, and the radio-induced apoptosis rates observed.

Methods

Peripheral blood lymphocytes were taken from 26 consecutive patients with locally advanced breast carcinoma. Radiosensitivity of lymphocytes was quantified as the initial number of DNA double-strand breaks induced per Gy and per DNA unit (200 Mbp). Radio-induced apoptosis at 1, 2 and 8 Gy was measured by flow cytometry using annexin V/propidium iodide.

Results

Radiation-induced apoptosis increased in order to radiation dose and data fitted to a semi logarithmic mathematical model. A positive correlation was found among radio-induced apoptosis values at different radiation doses: 1, 2 and 8 Gy (p < 0.0001 in all cases). Mean DSB/Gy/DNA unit obtained was 1.70 ± 0.83 (range 0.63-4.08; median, 1.46). A statistically significant inverse correlation was found between initial damage to DNA and radio-induced apoptosis at 1 Gy (p = 0.034). A trend toward 2 Gy (p = 0.057) and 8 Gy (p = 0.067) was observed after 24 hours of incubation.

Conclusions

An inverse association was observed for the first time between these variables, both considered as predictive factors to radiation toxicity.

Amifostine modulates radio-induced apoptosis of peripheral blood lymphocytes in head and neck cancer patients

Head and neck cancer is treated mainly with surgery and radiotherapy. Xerostomia and mucositis are common adverse effects of radiation therapy. One of the strategies aimed at decreasing radiation toxicity is the use of radioprotective agents, such as amifostine. We previously reported that radio induced apoptosis of peripheral blood lymphocytes was statistically associated with normal tissue toxicity in the form of severe xerostomia. The aim of the present study was to explore the effects of amifostine on the radiation-induced apoptosis of peripheral blood lymphocytes from patients suffering head and neck cancer. Eighteen consecutive patients with squamous cell carcinoma of the head and neck were included in the study. Peripheral blood lymphocytes were isolated before and after the treatment with amifostine. Then, cells were irradiated at 0, 1, 2 and 8 Gy during 24 hours. Apoptosis was measured by flow cytometry using annexin V/propidium iodide. As expected, radio-induced apoptosis values fitted to a semi logarithmic equation as follows: RIA = β ln(Gy) + α. The administration of amifostine prior to radiation therapy modulates radio-induced apoptosis of peripheral blood lymphocytes: 13.68 vs. 13.37 (P = 0.027), 19.11 vs. 17.64 (P = 0.001) and 30.70 vs. 28.84 (P = 0.001), before and after the administration of the drug for 1, 2 and 8 Gy respectively. α and β decreased significantly after the administration of the drug: 13.58 vs. 12.99 (P = 0.009) and 8.21 vs. 7.53 (P = 0.017), respectively. Our results provide new information about the biological actions of amifostine in vivo.

Prediction of clinical toxicity in locally advanced head and neck cancer patients by radio-induced apoptosis in peripheral blood lymphocytes (PBLs)

Head and neck cancer is treated mainly by surgery and radiotherapy. Normal tissue toxicity due to x-ray exposure is a limiting factor for treatment success. Many efforts have been employed to develop predictive tests applied to clinical practice. Determination of lymphocyte radio-sensitivity by radio-induced apoptosis arises as a possible method to predict tissue toxicity due to radiotherapy. The aim of the present study was to analyze radio-induced apoptosis of peripheral blood lymphocytes in head and neck cancer patients and to explore their role in predicting radiation induced toxicity. Seventy nine consecutive patients suffering from head and neck cancer, diagnosed and treated in our institution, were included in the study. Toxicity was evaluated using the Radiation Therapy Oncology Group scale. Peripheral blood lymphocytes were isolated and irradiated at 0, 1, 2 and 8 Gy during 24 hours. Apoptosis was measured by flow cytometry using annexin V/propidium iodide. Lymphocytes were marked with CD45 APC-conjugated monoclonal antibody. Radiation-induced apoptosis increased in order to radiation dose and fitted to a semi logarithmic model defined by two constants: α and β. α, as the origin of the curve in the Y axis determining the percentage of spontaneous cell death, and β, as the slope of the curve determining the percentage of cell death induced at a determined radiation dose, were obtained. β value was statistically associated to normal tissue toxicity in terms of severe xerostomia, as higher levels of apoptosis were observed in patients with low toxicity (p = 0.035; Exp(B) 0.224, I.C.95% (0.060-0.904)). These data agree with our previous results and suggest that it is possible to estimate the radiosensitivity of peripheral blood lymphocytes from patients determining the radiation induced apoptosis with annexin V/propidium iodide staining. β values observed define an individual radiosensitivity profile that could predict late toxicity due to radiotherapy in locally advanced head and neck cancer patients. Anyhow, prospective studies with different cancer types and higher number of patients are needed to validate these results.

Prediction of clinical toxicity in localized cervical carcinoma by radio-induced apoptosis study in peripheral blood lymphocytes (PBLs)

Background

Cervical cancer is treated mainly by surgery and radiotherapy. Toxicity due to radiation is a limiting factor for treatment success. Determination of lymphocyte radiosensitivity by radio-induced apoptosis arises as a possible method for predictive test development. The aim of this study was to analyze radio-induced apoptosis of peripheral blood lymphocytes.

Methods

Ninety four consecutive patients suffering from cervical carcinoma, diagnosed and treated in our institution, and four healthy controls were included in the study. Toxicity was evaluated using the Lent-Soma scale. Peripheral blood lymphocytes were isolated and irradiated at 0, 1, 2 and 8 Gy during 24, 48 and 72 hours. Apoptosis was measured by flow cytometry using annexin V/propidium iodide to determine early and late apoptosis. Lymphocytes were marked with CD45 APC-conjugated monoclonal antibody.

Results

Radiation-induced apoptosis (RIA) increased with radiation dose and time of incubation. Data strongly fitted to a semi logarithmic model as follows: RIA = βln(Gy) + α. This mathematical model was defined by two constants: α, is the origin of the curve in the Y axis and determines the percentage of spontaneous cell death and β, is the slope of the curve and determines the percentage of cell death induced at a determined radiation dose (β = ΔRIA/Δln(Gy)). Higher β values (increased rate of RIA at given radiation doses) were observed in patients with low sexual toxicity (Exp(B) = 0.83, C.I. 95% (0.73-0.95), p = 0.007; Exp(B) = 0.88, C.I. 95% (0.82-0.94), p = 0.001; Exp(B) = 0.93, C.I. 95% (0.88-0.99), p = 0.026 for 24, 48 and 72 hours respectively). This relation was also found with rectal (Exp(B) = 0.89, C.I. 95% (0.81-0.98), p = 0.026; Exp(B) = 0.95, C.I. 95% (0.91-0.98), p = 0.013 for 48 and 72 hours respectively) and urinary (Exp(B) = 0.83, C.I. 95% (0.71-0.97), p = 0.021 for 24 hours) toxicity.

Conclusion

Radiation induced apoptosis at different time points and radiation doses fitted to a semi logarithmic model defined by a mathematical equation that gives an individual value of radiosensitivity and could predict late toxicity due to radiotherapy. Other prospective studies with higher number of patients are needed to validate these results.

Constitutive gene expression profile segregates toxicity in locally advanced breast cancer patients treated with high-dose hyperfractionated radical radiotherapy

Breast cancer patients show a wide variation in normal tissue reactions after radiotherapy. The individual sensitivity to x-rays limits the efficiency of the therapy. Prediction of individual sensitivity to radiotherapy could help to select the radiation protocol and to improve treatment results. The aim of this study was to assess the relationship between gene expression profiles of ex vivo un-irradiated and irradiated lymphocytes and the development of toxicity due to high-dose hyperfractionated radiotherapy in patients with locally advanced breast cancer. Raw data from microarray experiments were uploaded to the Gene Expression Omnibus Database (GEO accession GSE15341). We obtained a small group of 81 genes significantly regulated by radiotherapy, lumped in 50 relevant pathways. Using ANOVA and t-test statistical tools we found 20 and 26 constitutive genes (0 Gy) that segregate patients with and without acute and late toxicity, respectively. Non-supervised hierarchical clustering was used for the visualization of results. Six and 9 pathways were significantly regulated respectively. Concerning to irradiated lymphocytes (2 Gy), we founded 29 genes that separate patients with acute toxicity and without it. Those genes were gathered in 4 significant pathways. We could not identify a set of genes that segregates patients with and without late toxicity. In conclusion, we have found an association between the constitutive gene expression profile of peripheral blood lymphocytes and the development of acute and late toxicity in consecutive, unselected patients. These observations suggest the possibility of predicting normal tissue response to irradiation in high-dose non-conventional radiation therapy regimens. Prospective studies with higher number of patients are needed to validate these preliminary results.

Major vault protein may affect nonhomologous end-joining repair and apoptosis through Ku70/80 and bax downregulation in cervical carcinoma tumors

PURPOSE

We investigated the relationship between major vault protein (MVP) expression, the nonhomologous end-joining (NHEJ) repair gene Ku70/80, and related genes involved in the regulation of apoptosis and proliferation to shed light on the possible causes of genetic instability, tumor progression, and resistance to oncologic treatment in patients with clinical cervical cancer.

METHODS AND MATERIALS

One hundred sixteen consecutive patients with localized cervix carcinoma were prospectively included in this study from July 1997 to Dec 2003. Patients were staged according to the tumor, node, metastasis (TNM) classification. Forty patients had Stage I disease, 45 had Stage II, and 31 had Stage III/IVA. Most patients had squamous tumors (98 cases) and Grades II (52 cases) and III (45 cases) carcinomas. Expression of MVP, Ku70/80, Insulin-Like Growth Factor-1 receptor (IGF-1R), BCL2-associated X protein (BAX), B-cell CLL/lymphoma 2 (BCL-2), p53, and Ki67 was studied by using immunohistochemistry in paraffin-embedded tumor tissue.

RESULTS

Tumors overexpressing MVP (65 of 116 cases) showed low levels of Ku70/80 (p = 0.013) and BAX expression (p < 0.0001). Furthermore, low Ku70/80 expression was strongly related to suppressed BAX (p < 0.001) and, to a lesser extent, upregulated BCL-2 (p = 0.042), altered p53 (p = 0.038), and increased proliferation (p = 0.002).

CONCLUSION

We hypothesize that an early regulatory mechanism favors homologous or NHEJ repair at first, mediated by vaults along with other factors yet to be elucidated. If vaults are overexpressed, NHEJ repair may be suppressed by means of several mechanisms, with resultant genomic instability. These mechanisms may be associated with the decision of damaged cells to survive and proliferate, favoring tumor progression and reducing tumor response to oncologic treatment through the development of resistant cell phenotypes. Additional clinical studies are necessary to test this hypothesis.

Radiation-induced DNA damage as a predictor of long-term toxicity in locally advanced breast cancer patients treated with high-dose hyperfractionated radical radiotherapy

This 14-year-long study makes a novel contribution to the debate on the relationship between the in vitro radiosensitivity of peripheral blood lymphocytes and normal tissue reactions after radiation therapy. The aims were (1) to prospectively assess the degree and time of onset of skin side effects in 40 prospectively recruited consecutive patients with locally advanced breast cancer treated with a hyperfractionated dose-escalation radiotherapy schedule and (2) to assess whether initial radiation-induced DNA damage in peripheral blood lymphocytes of these patients could be used to determine their likelihood of suffering severe late damage to normal tissue. Initial radiation-induced DNA double-strand breaks (DSBs) were assessed in peripheral blood lymphocytes of these patients by pulsed-field electrophoresis. Acute and late cutaneous and subcutaneous toxicity was evaluated using the Radiation Therapy Oncology Group morbidity score. A wide interindividual variation was observed in toxicity grades and in radiation-induced DNA DSBs in peripheral blood lymphocytes (mean 1.61 +/- 0.76 DSBs/Gy per 200 MBp, range 0.63- 4.08), which were not correlated. Multivariate analysis showed a correlation (P < 0.008) between late toxicity and higher prescribed protocol dose (81.6 Gy). Analysis of the 29 patients referred to 81.6 Gy revealed significantly (P < 0.031) more frequent late subcutaneous toxicity in those with intrinsic sensitivity to radiation-induced DNA DSBs of >1.69 DSBs/Gy per DNA unit. Our demonstration of a relationship between the sensitivity of in vitro-irradiated peripheral blood lymphocytes and the risk of developing late toxic effects opens up the possibility of predicting normal tissue response to radiation in individual patients, at least in high-dose non-conventional radiation therapy regimens.

Predictive factors in advanced head and neck cancer treated by radio-chemotherapy and hypoxia modification

6085

Background: Anemia and tumor hypoxia are known factors for resistance to radio-chemotherapy (RT-CT). In a previous report we have suggested that spinal cord stimulation (SCS) can modify tumor oxygenation and regional blood flow in head and neck cancer (HNC). The aim of the present prospective study was to test the predictive value of pO2 measurement in HNC treated by RT-CT and hypoxia modification using SCS. Methods: Twelve male patients with advanced HNC were analyzed. Stage IVb-IVa: 8–4; mean age 58 + 7.6 years (46–70). Scheduled therapy was hyperfractionated RT (120 cGy/fraction, two fractions/day, total dose 81.6 Gy) from a Co- 60 source, and tegafur 800 mg/day. SCS devices were placed before RT-CT under local anesthesia. During treatment, SCS was connected from 20–30 min before to 20–30 min after each radiotherapy session. Before treatment, they were assessed: Hemoglobin levels and tumor oxygenation pre-SCS and pos-SCS (measured by a polarographic probe system ‘pO2 Histograph‘), expressed as median-pO2, and the fraction of pO2 values less than 5 mmHg (HF5) and less than 2.5 mmHg (HF2.5). Correlations were assessed using Pearson and Spearman tests, and actuarial survival using Kaplan-Meier estimates and Log-rank test. Results: Hemoglobin levels were correlated with oxygenation pre-SCS and pos-SCS: median-pO2 (p=0.005 and p=0.011), HF5 (p=0.048 and p=0.005) respectively. Anemia was associated with more advanced stage (IVb vs IVa, p=0.022), higher HF5 pos-SCS (p=0.028) and lower disease-free survival (p=0.019). The HF2.5 pos-SCS was adversely correlated with the 2 years actuarial: disease-free survival (p=0.027), cause-specific survival (p=0.008) and overall survival (p=0.008). HF2.5 was also correlated with hematocrit (p=0.044). Conclusions: Low hemoglobin levels and anemia are associated with more hypoxic and more advanced tumors. Pre-treatment tumor hypoxia (assessed by the fraction of pO2 values less than 2.5 mmHg during-SCS) is a strong predictive factor for survival in advanced HNC. Patients with highly hypoxic tumors should be selected for more aggressive treatments. Partially supported by: Grant ‘FUNCIS: PI 31–98‘. Scientific supervision was carried out by GICOR.

No significant financial relationships to disclose.

Cerebral blood flow increase in cancer patients by applying cervical spinal cord stimulation

INTRODUCTION

Generally, high-grade gliomas and head and neck tumors have decreased loco-regional blood flow resulting in reduced delivery of chemotherapy and oxygen, as well as an increases in radiation resistance to radiotherapy. The aim of this study was to analyze the effect of cervical spinal cord electrical stimulation (cSCS) on cerebral blood flow in patients with those tumors.

PATIENTS AND METHODS

We have evaluated 27 cancer patients with 12 with high grade gliomas and 15 with advanced head and neck tumors, who had cSCS devices placed after tumor diagnoses and before the commencement initiating of radio-chemotherapy. They were 12 high grade gliomas and 15 advanced head and neck tumors. Before and after cSCS, cerebral blood flow was assessed bilaterally by transcranial Doppler.

RESULTS

During cSCS there was a significant (p<0.001) increase in systolic (mean > 22%) and diastolic (> 29%) blood-flow velocities in both, healthy and tumor middle cerebral arteries. The analyses by subgroup of tumors showed similarly significant outcomes findings.

CONCLUSIONS

The results suggest that neuro-stimulation spinal cord electrical stimulation can increase cerebral blood flow in cancer patients. The implication is that this technique could be useful in modifying locoregional ischemia in brain tumors thus improving the outcomes of after radio-chemotherapy. Further research is in progress to confirm the advantages of the technique.

Electrical spinal cord stimulation during radiotherapy and temozolomide in high grade gliomas. A phase II report

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Background: Ischemia-hypoxia in high grade gliomas (HGG) turns tumor cells more aggressive and more resistant to radiotherapy (RT) and temozolomide (TMZ). Higher glucose metabolism pre-treatment has been correlated with better response to TMZ using 18-FDG-PET. In preliminary works, we have reported that electrical spinal cord stimulation (SCS) can modify loco-regional oxygenation, blood flow and metabolism in HGG. The aim of this study was to evaluate tumor response and toxicity in HGG using SCS during RT plus TMZ. Methods: 10 patients (males/females: 8/2; median age: 51 years (30–68)) were enrolled in this trial. Tumors were 6 glioblastomas and 4 relapsed anaplastic gliomas. Diagnosis was after complete resection (1), subtotal resection (6), biopsy (1) or MRI + PET (2 relapsed HGG). Tetrapolar electrode for SCS was percutaneously inserted on the posterior surface of the cervical spinal cord at C2-C4 level. RT was at 2 Gy/fraction, 5 fractions/week, total dose 60 Gy (40 Gy in previously irradiated tumors). TMZ was administered at 75 mg/m2 daily during RT, followed by at least 6 cycles of adjuvant TMZ at 200 mg/m2. Tumor response was evaluated by CT and PET. Results: After concurrent RT+TMZ, CT showed: 5 partial response (PR), 3 complete response (CR), 2 stable disease (SD). After 6 adjuvant cycles of TMZ, CT (median 10 months after surgery) showed: 4 PR, 3 CR, 3 progression disease (PD). PET showed post-surgical residual tumor in the 9 evaluated patients. After 6 cycles of TMZ, PET showed: 4 CR, 2 PR (they obtained delayed CR after 12 and 18 cycles of TMZ), PD n = 2, and two patients without PET assessment (1 with PR in CT, and 1 without tumor in CT). For the study group median overall survival (OS) was 22 months (95% CI = 14–30) and for glioblastomas 16 months (95% CI = 6–26). For relapsed anaplastic gliomas mean OS was 37 months (95% CI = 22–52). One patient did not finish scheduled adjuvant TMZ and only one patient experienced hematological toxicity with neutropenia G-I and thrombopenia G-III. Conclusions: Electrical SCS during RT+TMZ did not increase toxicity. Preliminary data about tumor response and OS seem to be encouraging and they support further research. Supported by Grants: FUNCIS 03/09 and ISCiii, RTICCC C03/10.

No significant financial relationships to disclose.

Modification of glucose metabolism in brain tumors by using cervical spinal cord stimulation

OBJECT

In previous studies the authors have shown potential increases in locoregional blood flow and oxygenation in tumors by using electrical cervical spinal cord stimulation (SCS). In the present report they demonstrate the effect of cervical SCS on brain tumor metabolism, as assessed using [18F]fluorodeoxyglucose-positron emission tomography (FDG-PET).

METHODS

Cervical devices were inserted in 11 patients who had high-grade gliomas, six of which had recurred. While the SCS device was deactivated, each patient underwent an initial FDG-PET study to clarify the clinical status. A second FDG-PET study was performed later the same day while the stimulation device was activated to determine the effect of cervical SCS on glucose metabolism. All 11 patients were invaluable for this PET study. Basal glucose metabolism was higher in the tumor than in the peritumoral areas (p = 0.048). There was a significant increase in glucose uptake during cervical SCS in both the tumor (p = 0.035) and the peritumoral (p = 0.001) areas, with measured increases of 43 and 38%, respectively. The estimated potential maximal residual activity of the first FDG dose's contribution to the activity on the second scan was 18.5 +/- 1% or less.

CONCLUSIONS

This PET study is the first in which is described the effect of cervical SCS on glucose metabolism in brain tumors and supports previous study data indicating a modification of locoregional blood flow and oxygenation by cervical SCS. These results open up new approaches to modifying the effect of radiochemotherapy in the treatment of malignant brain tumors.

[Conservative treatment with chemotherapy and radiotherapy in bladder cancer invading the muscle: preliminary results of a prospective study]

OBJECTIVE

To analyze the possibility and safety of conservative treatment of muscle-invasive bladder cancer and to identify the prognostic factors for survival.

METHODS

A total of 33 patients with invasive bladder cancer, clinical stages T2-4NxM0, were treated with aggressive transurethral resection (TUR) followed by three cycles of neoadjuvant methotrexate, cisplatin and vinblastine (MCV) chemotherapy and radiotherapy (60 Gy to the bladder). Cystectomy was recommended to patients without complete response to TUR and MCV chemotherapy.

RESULTS

31 of the 33 patients included in the study completed the protocol and were evaluable. The clinical complete response rate to TUR and MCV chemotherapy was 68% (21/31 Pts.). With a median follow-up of 39 months (range 12-78), 25/31 patients (81%) are alive and 24 (77%) have functioning preserved bladders. Four out of 31 patients (13%) developed distant metastases. The 5-year overall survival and disease free interval was 74.6% and 53.5%, respectively. By multivariate analysis response after TUR and chemotherapy (p = 0.022) was the more important risk factor associated with survival.

CONCLUSION

These results indicate that MCV chemotherapy followed by radiotherapy may be effective in preserving bladder function in a high number of patients, with a survival rate comparable to that reported after cystectomy. The true efficacy of neoadjuvant chemotherapy remains to be proven by ongoing randomized trials.

Prognostic factors affecting leukemia relapse after allogeneic BMT conditioned with cyclophosphamide and fractionated TBI

Between June 1985 and May 1992, 94 consecutive patients with acute myeloid leukemia (AML = 28), acute lymphoblastic leukemia (ALL = 27) and chronic myelogenous leukemia (CML = 39), were transplanted using genotypically HLA-identical marrow donors. All were conditioned with cyclophosphamide (CY) plus 12 Gy fractionated TBI. Graft-versus-host disease (GVHD) prophylaxis consisted of cyclosporin A alone in nine patients and methotrexate-cyclosporin A in 85 patients. Forty-eight patients developed grades II-IV acute GVHD and 24 of 68 patients who survived at least 100 days developed chronic GVHD. The 5-year actuarial probability of survival, event-free survival and relapse were 41 +/- 5%, 37 +/- 5% and 37 +/- 6%, respectively. In multivariate analysis, an increased risk of leukemia relapse was associated with (1) absence of chronic GVHD (P = 0.017), (2) advanced disease at transplant (P = 0.034) and (3) diagnosis of AML (P = 0.047). Our results confirm that disease status at transplant and chronic GVHD are the more important risk factors associated with leukemia relapse, and suggest that CY-TBI has only a partial role in eradicating leukemia in AML.

[A comparative study in rectal adenocarcinoma: preoperative or postoperative radiotherapy]

PURPOSE

To compare the results of preoperative and postoperative radiotherapy in rectal adenocarcinoma, in terms of overall survival and disease-free survival.

PATIENTS AND METHODS

From 1989 to 1993, 52 patients with clinically operable rectal cancer were retrospectively analyzed. Two groups were compared: Patients in Group I received postoperative radiotherapy and those in Group II preoperative radiotherapy. Patients with a Karfnosky index > 70%, no evidence of distant disease and no major systemic problems were included in this study.

RESULTS

The overall 5-year actuarial survival was 75% in Group I and 83% in Group II. The 5-year disease-free survival was 52% in Group I compared to 86% in Group II, a statistically significant difference (p = 0.025). A reduction in all Dukes' stages was observed in the preoperative radiation group, allowing preservation of the anorectal function in an increased number of patients.

CONCLUSIONS

We observed better results with preoperative radiotherapy and conclude that this treatment might be justified in rectal carcinoma.