Hypofractionated whole breast irradiation after IORT treatment: evaluation of acute toxicity and cosmesis

INTRODUCTION

Hypofractionated whole breast irradiation (HWBI) is the current standard of treatment after breast conservative surgery (BCS). Intraoperative radiotherapy (IORT) must be associated to WBI in patients showing high-risk factors of local recurrence in the definitive pathology report. The aim of this trial was to evaluate, for the first time, the acute toxicity and cosmesis of HWBI after photon-IORT.

MATERIALS AND METHODS

Twenty-six luminal breast cancer patients treated by BCS and IORT(20 Gy) were included between February and December 2019, in this prospective trial, of adjuvant HWBI (40.5 Gy/2.67 Gy/15 fractions). Acute toxicity (CTCAEv5.0) and cosmesis (Harvard scale), were assessed 3 months after treatment.

RESULTS

All patients completed their treatment without interruptions. All cases were evaluable 3 months after treatment showing no toxicity ≥ G3 and excellent/good cosmesis assessment in 88% of the patients.

CONCLUSION

HWBI seems to have similar acute toxicity and cosmesis results than conventionally fractionated WBI in combination to photon-IORT after BCS.

EAU-ESMO consensus statements on the management of advanced and variant bladder cancer-an international collaborative multi-stakeholder effort: under the auspices of the EAU and ESMO Guidelines Committees†

BACKGROUND

Although guidelines exist for advanced and variant bladder cancer management, evidence is limited/conflicting in some areas and the optimal approach remains controversial.

OBJECTIVE

To bring together a large multidisciplinary group of experts to develop consensus statements on controversial topics in bladder cancer management.

DESIGN

A steering committee compiled proposed statements regarding advanced and variant bladder cancer management which were assessed by 113 experts in a Delphi survey. Statements not reaching consensus were reviewed; those prioritised were revised by a panel of 45 experts before voting during a consensus conference.

SETTING

Online Delphi survey and consensus conference.

PARTICIPANTS

The European Association of Urology (EAU), the European Society for Medical Oncology (ESMO), experts in bladder cancer management.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Statements were ranked by experts according to their level of agreement: 1-3 (disagree), 4-6 (equivocal), 7-9 (agree). A priori (level 1) consensus was defined as ≥70% agreement and ≤15% disagreement, or vice versa. In the Delphi survey, a second analysis was restricted to stakeholder group(s) considered to have adequate expertise relating to each statement (to achieve level 2 consensus).

RESULTS AND LIMITATIONS

Overall, 116 statements were included in the Delphi survey. Of these, 33 (28%) statements achieved level 1 consensus and 49 (42%) statements achieved level 1 or 2 consensus. At the consensus conference, 22 of 27 (81%) statements achieved consensus. These consensus statements provide further guidance across a broad range of topics, including the management of variant histologies, the role/limitations of prognostic biomarkers in clinical decision making, bladder preservation strategies, modern radiotherapy techniques, the management of oligometastatic disease and the evolving role of checkpoint inhibitor therapy in metastatic disease.

CONCLUSIONS

These consensus statements provide further guidance on controversial topics in advanced and variant bladder cancer management until a time where further evidence is available to guide our approach.

Feasibility of a deep hyperthermia and radiotherapy programme for advanced tumors: first Spanish experience

BACKGROUND

Hyperthermia (HT) is used to increase the temperature of the tumor-sensitizing cells to the effects of radiation/chemotherapy. We aimed to assess the feasibility, tolerability and safety of hyperthermia treatment in a Radiation Oncology Department.

METHODS

Between June 2015 and June 2017, 106 patients and a total of 159 tumor lesions were included in a prospective study (EudraCT 2018-001089-40) of HT concomitant with radiotherapy (RT). Systemic treatment was accepted. HT was given twice a week, 60 min per session, during RT treatment by a regional capacitive device (HY-DEEP 600WM system) at 13.56 MHz radiofrequency.

RESULTS

Most lesions (138 cases, 86.8%) received all HT sessions planned. Thirteen lesions (12 patients) withdrew treatment due to grade ≥3 QMHT toxicity. All these 12 patients completed the prescribed radiotherapy and/or systemic treatment.

CONCLUSIONS

Regional hyperthermia is a feasible and safe technique to be used in combination with radiotherapy and systemic treatment.

Morphologic Features on MR Imaging Classify Multifocal Glioblastomas in Different Prognostic Groups

BACKGROUND AND PURPOSE

Multifocal glioblastomas (ie, glioblastomas with multiple foci, unconnected in postcontrast pretreatment T1-weighted images) represent a challenge in clinical practice due to their poor prognosis. We wished to obtain imaging biomarkers with prognostic value that have not been found previously.

MATERIALS AND METHODS

A retrospective review of 1155 patients with glioblastomas from 10 local institutions during 2006-2017 provided 97 patients satisfying the inclusion criteria of the study and classified as having multifocal glioblastomas. Tumors were segmented and morphologic features were computed using different methodologies: 1) measured on the largest focus, 2) aggregating the different foci as a whole, and 3) recording the extreme value obtained for each focus. Kaplan-Meier, Cox proportional hazards, correlations, and Harrell concordance indices (c-indices) were used for the statistical analysis.

RESULTS

Age (P < .001, hazard ratio = 2.11, c-index = 0.705), surgery (P < .001, hazard ratio = 2.04, c-index = 0.712), contrast-enhancing rim width (P < .001, hazard ratio = 2.15, c-index = 0.704), and surface regularity (P = .021, hazard ratio = 1.66, c-index = 0.639) measured on the largest focus were significant independent predictors of survival. Maximum contrast-enhancing rim width (P = .002, hazard ratio = 2.05, c-index = 0.668) and minimal surface regularity (P = .036, hazard ratio = 1.64, c-index = 0.600) were also significant. A multivariate model using age, surgery, and contrast-enhancing rim width measured on the largest foci classified multifocal glioblastomas into groups with different outcomes (P < .001, hazard ratio = 3.00, c-index = 0.853, median survival difference = 10.55 months). Moreover, quartiles with the highest and lowest individual prognostic scores based on the focus with the largest volume and surgery were identified as extreme groups in terms of survival (P < .001, hazard ratio = 18.67, c-index = 0.967).

CONCLUSIONS

A prognostic model incorporating imaging findings on pretreatment postcontrast T1-weighted MRI classified patients with glioblastoma into different prognostic groups.

Infrastructure and equipment for radiation oncology in the Spanish National Health System: analysis of external beam radiotherapy 2015-2020

PURPOSE

Planning for radiation oncology requires reliable estimates of both demand for radiotherapy and availability of technological resources. This study compares radiotherapy resources in the 17 regions of the decentralised Spanish National Health System (SNHS).

MATERIALS AND METHODS

The Sociedad Española de Oncología Radioterápica (SEOR) performed a cross-sectional survey of all Spanish radiation oncology services (ROS) in 2015. We collected data on SNHS radiotherapy units, recording the year of installation, specific features of linear accelerators (LINACs) and other treatment units, and radiotherapeutic techniques implemented by region. Any machine over 10 years old or lacking a multileaf collimator or portal imaging system was considered obsolete. We performed a k-means clustering analysis using the Hartigan-Wong method to test associations between the gross domestic regional product (GDRP), the number of LINACs per million population and the percentage of LINACs over 10 years old.

RESULTS

The SNHS controls 72 (61%) of the 118 Spanish ROS and has 180 LINACs, or 72.5% of the total public and private resources. The mean rate of LINACs per million population is 3.9 for public ROS, and 42% (n = 75) of the public accelerators were obsolete in 2015: 61 due to age and 14 due to technological capability. There was considerable regional variation in terms of the number and technological capacity of radiotherapy units; correlation between GRDP and resource availability was moderate.

CONCLUSION

Despite improvements, new investments are still needed to replace obsolete units and increase access to modern radiotherapy. Regular analysis of ROS in each Spanish region is the only strategy for monitoring progress in radiotherapy capacity.

Demand for radiotherapy in Spain

AIM

Assessing the demand for radiotherapy in Spain based on existing evidence to estimate the human resources and equipment needed so that every person in Spain has access to high-quality radiotherapy when they need it.

MATERIAL AND METHODS

We used data from the European Cancer Observatory on the estimated incidence of cancer in Spain in 2012, along with the evidence-based indications for radiotherapy developed by the Australian CCORE project, to obtain an optimal radiotherapy utilisation proportion (OUP) for each tumour.

RESULTS

About 50.5 % of new cancers in Spain require radiotherapy at least once over the course of the disease. Additional demand for these services comes from reradiation therapy and non-melanoma skin cancer. Approximately, 25-30 % of cancer patients with an indication for radiotherapy do not receive it due to factors that include access, patient preference, familiarity with the treatment among physicians, and especially resource shortages, all of which contribute to its underutilisation.

CONCLUSIONS

Radiotherapy is underused in Spain. The increasing incidence of cancer expected over the next decade and the greater frequency of reradiations necessitate the incorporation of radiotherapy demand into need-based calculations for cancer services planning.

Association between single-nucleotide polymorphisms in DNA double-strand break repair genes and prostate cancer aggressiveness in the Spanish population

BACKGROUND

Novel predictors of prognosis and treatment response for prostate cancer (PCa) are required to better individualize treatment. Single-nucleotide polymorphisms (SNPs) in four genes directly (XRCC5 (X-ray repair complementing defective repair in Chinese hamster cells 5) and XRCC6 (X-ray repair complementing defective repair in Chinese hamster cells 6)) or indirectly (PARP1 and major vault protein (MVP)) involved in non-homologous end joining were examined in 494 Spanish PCa patients.

METHODS

A total of 22 SNPs were genotyped in a Biotrove OpenArray NT Cycler. Clinical tumor stage, diagnostic PSA serum levels and Gleason score at diagnosis were obtained for all participants. Genotypic and allelic frequencies were determined using the web-based environment SNPator.

RESULTS

(XRCC6) rs2267437 appeared as a risk factor for developing more aggressive PCa tumors. Those patients carrying the GG genotype were at higher risk of developing bigger tumors (odds ratio (OR)=2.04, 95% confidence interval (CI) 1.26-3.29, P=0.004), present higher diagnostic PSA levels (OR=2.12, 95% CI 1.19-3.78, P=0.011), higher Gleason score (OR=1.65, 95% CI 1.01-2.68, P=0.044) and D'Amico higher risk tumors (OR=2.38, 95% CI 1.24-4.58, P=0.009) than those patients carrying the CC/CG genotypes. Those patients carrying the (MVP) rs3815824 TT genotype were at higher risk of presenting higher diagnostic PSA levels (OR=4.74, 95% CI 1.40-16.07, P=0.013) than those patients carrying the CC genotype. When both SNPs were analyzed in combination, those patients carrying the risk genotypes were at higher risk of developing D'Amico higher risk tumors (OR=3.33, 95% CI 1.56-7.17, P=0.002).

CONCLUSIONS

We believe that for the first time, genetic variants at XRCC6 and MVP genes are associated with risk of more aggressive disease, and would be taken into account when assessing the malignancy of PCa.

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.

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.

Anti-inflammatory effects of low-dose radiotherapy. Indications, dose, and radiobiological mechanisms involved

Low-dose radiotherapy (LD-RT) has been used for several benign diseases, including arthrodegenerative and inflammatory pathologies. Despite its effectiveness in clinical practice, little is known about the mechanisms through which LD-RT modulates the various phases of the inflammatory response and about the optimal dose fractionation. The objective of this review is to deepen knowledge about the most effective LD-RT treatment schedule and radiobiological mechanisms underlying the anti-inflammatory effects of LD-RT in various in vitro experiments, in vivo studies, and clinical studies.

Matrix metalloproteinases: potential therapy to prevent the development of second malignancies after breast radiotherapy

Radiotherapy is widely used in the treatment of patients with breast cancer, but ionizing radiation-induced carcinogenesis has been described in several studies. Matrix metalloproteinases (MMPs) are a wide family of proteases secreted by tumour and microenvironmental cells that are directly linked with invasion and metastasis through complete extracellular matrix (ECM) breakage. In the past decade, MMPs have been associated with other carcinogenesis steps, including tumour growth and angiogenesis promotion. Moreover, in vitro studies have demonstrated an enhanced migration, invasiveness, and angiogenic ability of cancer cells after radiation exposure through an increase in MMP activity. These findings are consistent with clinical observations of breast cancer metastases raised in bone, lung and brain tissues after radiotherapy. The aim of this review was to analyse the current state of research on MMPs and report new insights into the potential of MMP-targeted therapy in combination with radiotherapy to decrease the risk of radiation-induced second malignancies and to improve the overall survival of breast cancer patients.

In vitro differentiation characteristics of human skin fibroblasts: correlations with radiotherapy-induced breast fibrosis in patients

PURPOSE

To determine whether there is an association between dermal fibroblast differentiation characteristics in vitro and breast fibrosis developing in patients following radiotherapy for breast cancer.

MATERIALS AND METHODS

Three hundred and eighty-five patients had been characterized for the degree of breast fibrosis and the level of clinical risk factors for fibrosis as established by logistic regression. Early-passage fibroblasts from 79 patients with a high (HR) or low (LR) level of risk factors were studied in vitro. The percentage differentiated cells (%DC) 7 days after 0 and 8 Gy was scored, and unirradiated colonies were scored for the ratio of early:late fibroblast differentiation stages (E:L ratio).

RESULTS

%DC: For the 0 Gy data there was a significant interpatient variation (CoV = 55%, p = 0.0001). HR patients with breast fibrosis had a higher %DC compared with patients without (p = 0.017). E:L ratio: for HR patients there was a significant interpatient variation (82%, p = 0.0030) and a lower E:L ratio for patients with fibrosis compared with those without (p = 0.086), but for LR patients this relationship was reversed (p = 0.079)

CONCLUSIONS

There was a true interpatient variation in the in vitro parameters of fibroblast differentiation but insufficient correlation with observed fibrosis after radiotherapy for use as a predictive test.

Apoptosis in carcinoma of the bladder: relation with radiation treatment results

PURPOSE

Radiotherapy is widely used in the treatment of bladder cancer. The search for biological parameters that could select patients who will respond to radiation treatment has become essential. The aim of this study is to assess whether the pretreatment apoptotic index is useful in predicting local control and survival in a group of bladder cancer patients treated by radiotherapy.

METHODS AND MATERIALS

Fifty-five patients with invasive bladder carcinoma treated between 1983 and 1996 were included in this study. Radiotherapy was given to a median dose of 66 Gy, mean 63.28 Gy, in 1.8-2 Gy daily fractions. Apoptotic cells were studied in hematoxylin-eosin slides. Clinicopathological tumor characteristics were studied in relation to the apoptotic index, and as prognostic factors for local control and survival in both univariate and multivariate analysis.

RESULTS

Pretreatment apoptotic indexes were related to tumor stage, mitotic index, and Ki67 proliferation index. Five-year actuarial local control for the whole group was 45%. Patients with tumors showing low pretreatment apoptotic indexes had better local control (p < 0.037) and survival (p < 0.01) than highly apoptotic tumors. Tumor stage (T2 vs. T3-4) and the pretreatment apoptotic index were significant predictive factors for local control and survival in multivariate analysis.

CONCLUSIONS

The pretreatment apoptotic index is useful in predicting the clinical outcome of bladder cancer patients treated by radiotherapy. Assessment of biological tumor characteristics could allow the selection of patients for different treatment strategies.

Tumor proliferation, p53 expression, and apoptosis in laryngeal carcinoma: relation to the results of radiotherapy

BACKGROUND

Radiotherapy is used in the treatment of laryngeal carcinoma. The search for biologic parameters that could be used to identify patients who will respond to radiotherapy is crucial. The aim of this study was to determine whether the Ki-67 and p53 indices and the pretreatment apoptotic index would be useful in predicting local control and survival for a group of laryngeal carcinoma patients given postoperative radiotherapy.

METHODS

Fifty-seven patients with laryngeal carcinoma treated between 1988 and 1993 were included in this study. Postoperative radiotherapy was given to a mean dose of 57.7 gray (Gy) (range, 50-68; median, 60) in 2-Gy daily fractions. Ki-67 and p53 immunostaining were performed on paraffin-embedded tissue. Cells were evaluated for apoptosis using hematoxylin and eosin-stained slides. Clinicopathologic tumor characteristics were studied in relation to Ki-67, p53, and apoptotic indices, and as prognostic factors for local control and survival in both univariate and multivariate analysis.

RESULTS

The Ki-67, p53, and pretreatment apoptotic indices were not related to any clinicopathologic tumor characteristics. Five-year actuarial local control for the whole group was 47%. Patients with tumors that had low Ki-67 proliferation had better long term local control (P < 0.01). and survival (P < 0.03). p53 expression was not predictive of local control or survival in this study. Patients with tumors that had low pretreatment apoptotic indices had better local control (P < 0.049) and survival (P < 0.056) than patients with highly apoptotic tumors. Tumor extension and the pretreatment apoptotic index were significant predictive factors for local control and survival in multivariate analysis.

CONCLUSIONS

Ki-67 proliferation measurement and the pretreatment apoptotic index are useful in predicting the clinical outcome of laryngeal carcinoma patients referred for radiotherapy. The role of p53 oncoprotein determination in predicting these outcomes is unclear. Assessment of biologic tumor characteristics could aid in the selection of patients for different treatment strategies.

The role of Ki67 proliferation assessment in predicting local control in bladder cancer patients treated by radical radiation therapy

PURPOSE

To assess whether tumour proliferation as measured by Ki67 immunostaining has any predictive value for local control in bladder cancer patients treated by radiotherapy.

PATIENTS AND METHODS

Fifty-five patients suffering from infiltrating bladder carcinoma recommended for radical radiotherapy (66 Gy/6-7 weeks) were included in this study. Paraffin-embedded pre-treatment tumour sections were stained with the Ki67 antibody. The percentage of Ki67-positive nuclei was correlated with established prognostic factors, local control and survival.

RESULTS

The Ki67 index was not related to local control in our patients when the median was selected as the cut-off value. Patients with tumours with a very low (<27%) Ki67 index had better local control at 5 years (69%) than patients with tumours with greater (>27%) Ki67 expression indices (31.5%) (P<0.05; log-rank test).

CONCLUSIONS

Ki67 immunostaining was a feasible method to estimate tumour proliferation. Patients with very low proliferating tumours seemed to achieve better local control after fractionated radiotherapy compared to other patients. Further studies are needed with a greater number of patients to accurately define the role of Ki67 expression in predicting tumour repopulation during fractionated radiotherapy.

KI67 proliferation index in tumors of the upper urinary tract as related to established prognostic factors and long-term survival

OBJECTIVE

Nephroureterectomy is the standard treatment for tumors of the renal pelvis and ureter. Conservative management or indication of adjuvant treatment in these neoplasms is based mainly in histological grade and stage. The aim of this study is to assess the relation of Ki67 index with other established prognostic factors and to define its predictive value for long term survival, which could be useful in selecting the best treatment for each individual case.

METHODS

81 patients with urothelial tumors of the renal pelvis and ureter, diagnosed and treated between 1975 and 1993, comprised the present study. Ki67 immunostaining was performed in paraffin-embedded tissue. A cut-off limit of 20% was chosen. Tumor location, histological grade, histological pattern, local (T), nodal (N), vascular and perineural invasion and stage (TNM) were assessed in relation to the proliferation index and as prognostic criteria for survival in both univariate and multivariate analysis.

RESULTS

The Ki67 proliferation index was found to be related to grade (p < 0.001), T (T0 vs T1-4; p < 0.01), N (p < 0.038), TNM categories (stage 0 vs I-IV; p < 0.048) and perineural invasion (p < 0.01). There was a marginal relation to vascular invasion (p < 0.11). Survival was better for the patients with low proliferating tumors (90%) than for high proliferating ones (67%) (p < 0.02). In the multivariate analysis only T stage was statistically significant (p < 0.01) but a highly suggestive trend was found for the Ki67 index (p < 0.07).

CONCLUSIONS

Tumor proliferation assessed by Ki67 immunostaining is related to the progression of the disease and proved to be of predictive value for long-term survival in tumors of the renal pelvis and ureter. The Ki67 index is able to detect high-risk patients that could not be cured by radical surgery alone, raising the need for some type of aduvant treatment in these cases. The treatment predictive effect observed in low grade-low stage cases suggests its possible utility in patients managed conservatively.

Overexpression of p53 in transitional cell carcinoma of the renal pelvis and ureter. Relation to tumor proliferation and survival

BACKGROUND

Clinical management of patients with tumors of the upper urinary tract is based mainly on histologic grade and stage of the tumors. In recent years, tumor proliferation has also proved to be an important factor in determining the prognosis of these and other transitional cell tumors. The aim of this study was to assess the role of p53 in regulating cell proliferation and tumor progression and to define its value in predicting the long term survival of patients with these tumors. Such information could be of use in selecting treatment in individual cases.

METHODS

Eighty-three patients with urothelial tumors of the renal pelvis and ureter diagnosed and treated between 1975 and 1993 were included in this study. p53 immunostaining was performed on paraffin embedded tissue. Tumor location, histologic grade, histologic pattern, tumor proliferation by Ki-67, local (T classification), lymph node (N classification), vascular and perineural invasion, and clinical stage (TNM) were assessed in relation to p53 overexpression (Mann-Whitney U test and analysis of variance comparisons) and as prognostic factors for survival in both univariate analysis (log rank test) and multivariate analysis (Cox proportional hazards model).

RESULTS

Overexpression of p53 was related to tumor proliferation as assessed by Ki-67 (P < 0.01), T classification (Ta vs. T1-4; P < 0.01), N classification (P < 0.054), and TNM staging (Stage 0 vs. I-IV; P < 0.01). There was also a statistically significant relation to vascular (P < 0.002) and perineural invasion (P < 0.04). Fifteen-year actuarial survival for the whole group was 75%. Patients having tumors with low p53 overexpression (< 30% of stained nuclei) had a better survival rate (88%) than those having tumors with high (> 30%) p53 overexpression (65%) (P < 0.02), and this effect reached statistical significance with high grade (P < 0.02) and infiltrating tumors (P < 0.04). Patients with low p53 and Ki-67 expression had a 15-year survival rate of 100%; in contrast, patients with overexpression of both markers had a 15-year survival rate of 61% (P < 0.003). In a multivariate analysis, only T classification (P < 0.001) and p53-Ki-67 expression (P < 0.026) were statistically significant.

CONCLUSIONS

Overexpression of p53 is related to increased tumor proliferation and disease progression and is of value in determining the long term survival of patients with tumors of the renal pelvis and ureter. p53 immunostaining can be used to distinguish low risk patients in the theoretically unfavorable high grade, high stage group, and when used together with Ki-67 index, it is a predictive factor for survival.

Overexpression of p53 in transitional cell carcinoma of the renal pelvis and ureter. Relation to tumor proliferation and survival

BACKGROUND

Clinical management of patients with tumors of the upper urinary tract is based mainly on histologic grade and stage of the tumors. In recent years, tumor proliferation has also proved to be an important factor in determining the prognosis of these and other transitional cell tumors. The aim of this study was to assess the role of p53 in regulating cell proliferation and tumor progression and to define its value in predicting the long term survival of patients with these tumors. Such information could be of use in selecting treatment in individual cases.

METHODS

Eighty-three patients with urothelial tumors of the renal pelvis and ureter diagnosed and treated between 1975 and 1993 were included in this study. p53 immunostaining was performed on paraffin embedded tissue. Tumor location, histologic grade, histologic pattern, tumor proliferation by Ki-67, local (T classification), lymph node (N classification), vascular and perineural invasion, and clinical stage (TNM) were assessed in relation to p53 overexpression (Mann-Whitney U test and analysis of variance comparisons) and as prognostic factors for survival in both univariate analysis (log rank test) and multivariate analysis (Cox proportional hazards model).

RESULTS

Overexpression of p53 was related to tumor proliferation as assessed by Ki-67 (P < 0.01), T classification (Ta vs. T1-4; P < 0.01), N classification (P < 0.054), and TNM staging (Stage 0 vs. I-IV; P < 0.01). There was also a statistically significant relation to vascular (P < 0.002) and perineural invasion (P < 0.04). Fifteen-year actuarial survival for the whole group was 75%. Patients having tumors with low p53 overexpression (< 30% of stained nuclei) had a better survival rate (88%) than those having tumors with high (> 30%) p53 overexpression (65%) (P < 0.02), and this effect reached statistical significance with high grade (P < 0.02) and infiltrating tumors (P < 0.04). Patients with low p53 and Ki-67 expression had a 15-year survival rate of 100%; in contrast, patients with overexpression of both markers had a 15-year survival rate of 61% (P < 0.003). In a multivariate analysis, only T classification (P < 0.001) and p53-Ki-67 expression (P < 0.026) were statistically significant.

CONCLUSIONS

Overexpression of p53 is related to increased tumor proliferation and disease progression and is of value in determining the long term survival of patients with tumors of the renal pelvis and ureter. p53 immunostaining can be used to distinguish low risk patients in the theoretically unfavorable high grade, high stage group, and when used together with Ki-67 index, it is a predictive factor for survival.

Radiation-induced differentiation of human skin fibroblasts: relationship with cell survival and collagen production

The aim of this study was to determine whether significant inter-individual differences exist between skin fibroblast strains obtained from radiotherapy patients in both radiation-induced differentiation and collagen production in vitro, for use as potential parameters for a predictive assay for fibrosis following radiotherapy in patients. Morphological cell differentiation was determined 7 days after irradiation in seven early-passage primary human fibroblast cell strains and correlated with cell survival. Collagen production was measured in two cell strains by flow cytometry and incorporation of 3H-proline. There was a wide variation in the extent of radiation-induced differentiation for the seven cell strains, each showing a dose-related increase. The correlation between induced differentiation and cell survival was poor (r = 0.64) but statistically significant (p < 0.01). Collagen synthesis increased 7 days after irradiation for one cell strain (HF-48), as measured by incorporation of 3H-proline, but not in radiation sensitive AT-1 cells. The collagen I content of the two cell strains was assessed by flow cytometry but no significant differences were observed between the strains tested or with increasing dose. In conclusion, marked variations in radiation-induced fibroblast differentiation were observed between patients, this being an important criterion for a predictive assay.

The role of squamous cell carcinoma antigen in the management of laryngeal and hypopharyngeal cancer

BACKGROUND

The efficacy of squamous cell carcinoma antigen (SCC-Ag) in laryngeal cancer to predict those patients who will relapse after primary treatment (surgery or radiotherapy) and its utility to detect relapses early and thereby increase salvage rates and cure were assessed.

METHODS

Sixty healthy donors and 168 patients with laryngeal cancer were included in this prospective trial. Squamous cell carcinoma antigen was measured at diagnosis in all patients, 24 hours and 1 week after surgery in 113 patients and every 10 Gy of administered dose and 2 weeks after treatment in 49 patients primarily referred to radiotherapy. The marker was determined every 3-6 months during follow-up. All patients who relapsed had SCC-Ag studies before and after salvage treatment.

RESULTS

The selected cut-off value was 1.5 ngr/ml (mean value in control group, 0.65 + 2 standard deviation [0.38]). Seventy-eight percent of patients with cancer had elevated SCC-Ag values at diagnosis. Squamous cell carcinoma antigen was statistically related to TNM categories (T, P < 0.04; N, P < 0.05; Stage, P < 0.01). Seventy-five percent of those patients with previously elevated pretreatment values normalized after treatment. Incomplete surgical resection (P < 0.0001) or persistence of the disease after radiotherapy (P < 0.01) were related to high posttreatment values. Squamous cell carcinoma antigen was elevated in 88% of the patients who relapsed. In 55% of the recurrences, SCC-Ag was elevated 3 months before pathologic confirmation of relapse. Salvage by surgery or radiotherapy was effective in 70% of the patients. Squamous cell carcinoma antigen posttreatment values were the most important factor in predicting disease free survival (DFS) (P < 0.0001) and overall survival (P < 0.03).

CONCLUSIONS

Squamous cell carcinoma antigen is an excellent marker of residual disease after primary treatment that can lead to the addition of other therapeutic procedures (surgery and postoperative radiotherapy). The absence of posttreatment SCC-Ag is the best predictor of DFS, its presence detects recurrence in early stages, permitting salvage of an increased proportion of patients primarily referred for palliative treatment.

Cisplatin-ifosfamide as neoadjuvant chemotherapy in stage IIIB cervical uterine squamous-cell carcinoma

Survival in patients with advanced cervical cancer (stage III B) treated by radical radiotherapy is low. In this study we attempted to assess the efficacy of the cis-diamminedichloroplatinum(II) (CDDP)-ifosfamide combination as neoadjuvant chemotherapy in advanced cervical cancer. The treatment schedule was: 20 mg/m2 CDDP on days 1-5; 1.5 g/m2 ifosfamide on days 1-5; and 900 mg/m2 mesna on days 1-5. Courses were given every 28 days. Radiotherapy was given 15 days after the completion of chemotherapy. A total of 26 patients were entered in this trial. Of the 24 patients evaluable for response, 15 (62.5%) achieved at least a 50% reduction in tumor volume, 6 (25%) showed stable disease, and three (12.5%) had progressive disease. At 38 months (mean follow-up) after completion of radiotherapy, 13 of the 24 (54%) evaluable patients were disease-free; 73% of the patients responding to chemotherapy vs 22% of the nonresponders remained free of disease (Fisher's exact test: P less than 0.02). Major hematologic depression occurred in 2 of the 26 patients evaluable for toxicity. No CNS toxicity was detected. These results are superior to those obtained by radical radiotherapy alone. Future treatment should be directed toward improving response rates as the best way of increasing both local and distant long-term disease control in these patients.