Radiation therapy in urinary cancer: state of the art and perspective

Invasive urinary tumours are relatively rare, and their treatment may cause important changes in urinary, sexual and social functions. A systematic review of external radiation therapy studies in urinary cancers was performed. This synthesis of the literature is based on data from meta-analyses, randomised and prospective trials and retrospective studies. There are few controlled clinical trials using adjuvant or radical radiotherapy with or without chemotherapy in cancer of the kidney, ureter and urethra. There are several reports on multimodality treatment in invasive bladder cancer: intravesical surgery and neoadjuvant chemotherapy to radiotherapy or concomitant radiochemotherapy with organ preservation. The conclusions reached for renal cancer are controversial, and data on cancers of the urethra and ureter are few and inconclusive. Sufficient data now exist in the literature to demonstrate that conservative management with organ preservation is a valuable alternative to radical cystectomy, the traditional gold standard, in invasive bladder cancer.

Role of external radiation therapy in urinary cancers

Invasive urinary tumors are relatively rare and their treatment may cause important changes in urinary, sexual, and social functions. A systematic review of external radiation therapy studies in urinary cancers has been carried out. This synthesis of the literature is based on data from meta-analysis, randomized and prospective trials, and retrospective studies. There are few controlled clinical trials using adjuvant or radical radiotherapy +/- chemotherapy in kidney, ureter, and urethra cancers; there are several reports of muscle-invasive bladder cancer using multimodality treatment: intravesical surgery and neo-adjuvant chemotherapy to radiotherapy or concomitant radiochemotherapy with organ preservation. The conclusions reached for renal cancer are controversial; urethra and ureter cancers data are few and inconclusive; sufficient data now exist in literature to demonstrate that conservative management with organ preservation, for muscle-invasive bladder cancer, is a valid alternative to radical cystectomy, viewed as the gold standard.

[Radiotherapy alone in endometrial neoplasms. The authors' own experience]

INTRODUCTION

Adenocarcinoma of the endometrium is the most common invasive genital malignancy in women and the majority of the cases are in stage I (80-85%) at the time of diagnosis. Total abdominal hysterectomy with bilateral salpingo-oophorectomy is the treatment of choice for most patients with uterine carcinoma. However, a number of women with endometrial cancer cannot undergo surgical treatment because of poor medical conditions. In these patients, who cannot tolerate surgery, radiation therapy is the only effective alternative. It is performed either as external treatment plus intracavitary brachytherapy or as brachytherapy alone. This retrospective study reports our data on survival, complications and local control in a consecutive series of patients treated with curative radiotherapy.

MATERIAL AND METHODS

From January, 1985, to December 1995, at the Radiotherapy Department of "Casa Sollievo della Sofferenza" Hospital in San Giovanni Rotondo (Foggia, Italy), 60 patients were treated with combined external beam radiation therapy (ERT) and high-dose-rate intracavitary brachytherapy (HDR-BRT) or with high dose rate intracavitary brachytherapy alone. The average age of patients was 69 years (range 50-90). FIGO stage distribution was: 41 patients in stage I, 11 in stage II and 8 in stage III. The ERT was given by means of 6-8 MV linear accelerator, with conventional technique (with two opposed AP-PA pelvic fields in 15 patients, with the four fields-box technique in 41 patients) and a daily fraction to a total dose of 45-50 Gy. HDR-BRT was delivered by means of an HDR remote afterloading unit, containing a linear source of 192-Iridium (370 Gbq). The dose was specified to Point A in 32 patients and to uterine outline in 26. 2-3 intracavitary insertions (mean dose 6-8 Gy per fraction) were performed with weekly intervals.

RESULTS

At the time of the analysis, all the patients were available for follow-up. Median follow-up was 25 months. 60% of patients were alive and well with no evidence of disease; 3.3% were alive with disease; 20% had died of this and 16.7% of other diseases. Five-year actuarial specific survival, obtained with the Kaplan and Meier method, was 77.7% in stage I, 90% in stage II, and 75% in stage III. Local relapses were observed in 14 patients. Complications (grade 2-3) scored with the French-Italian Glossary, were gastrointestinal in 10% of cases and genital in 6.6%.

CONCLUSIONS

Radical radiotherapy achieved acceptable specific survival, local control and complications rates in patients with medically or surgically inoperable uterine carcinomas. Complications and survival rates, in our experience, are consistent with the literature data. The treatment is comfortable for the patients, because there is no need for long immobilization and it can frequently be performed on an outpatient basis. Besides, the completely standardized procedure was carried out easily with remote control allowing maximal radiation protection.

[Preliminary results of preoperative radiotherapy schedule in the treatment of rectal tumors]

From March, 1988, to October, 1993, fifty-six consecutive patients with rectal adenocarcinoma in clinical stage T3NxM0, underwent preoperative radiation therapy at the "Casa Sollievo della Sofferenza" Hospital of San Giovanni Rotondo (Italy). The patients were treated with the four-field technique with 6 to 8 MV X photons on the pelvis. The dose given was 36 Gy in 12 fractions of 3 Gy each. Surgery was performed 2-3 weeks after completion of radiotherapy. Six patients were excluded from this study for metastatic involvement of the liver found at surgery. 48% of 50 assessable patients underwent abdominoperineal resection and 52% anterior resection. 68% of patients were in pathologic stage pT0-3 pN0 and 32% in pT0-3 pN1-2. Metastatic nodes were found in 16 patients (32%) (11 pN1 and 5 pN2). 4% of patients achieved a complete response. The follow-up ranged 24 to 91 months (mean: 46 months). None of the 50 patients died during the postoperative period and the specific morbidity was 26%. Side-effects, requiring surgery, were found in 4% of patients (1 retroperitoneal fibrosis and 1 small bowel occlusion). The incidence of local relapse was 8%. The overall survival at 5 years, in all stages, calculated with the Kaplan and Meyer method, was 76.5%. The disease-free survival rate was 81.1% in all stages: 94.1% in pT0-3 pN0 patients and 54.1% in pT0-3 pN1-2 patients. The disease-free survival rate related to nodal involvement was 72.7% in pN1 patients and 20% in pN2 patients. Our experience confirms the effectiveness of preoperative radiation therapy to improve local control in rectal cancer patients. In the future, it will be useful to assess the impact on prognosis of the schedules using chemotherapy, different fractionation of radiotherapy, delayed surgery and biological predictors of response to irradiation.

[High-dose brachytherapy in endobronchial neoplastic stenoses]

Form March, 1991, to September, 1995, twenty-nine patients with endobronchial neoplastic stenosis were treated with high dose rate (HDR) brachytherapy at the Casa Sollievo della Sofferenza Hospital in San Giovanni Rotondo (Foggia, Italy). Fifteen patients had hemoptysis, 10 dyspnea, 6 constant cough and 6 lung atelectasis. The total dose, specified at 1 cm from the source, ranged 5 to 21 Gy and the fraction doses 5 to 15 Gy. Fourteen of 29 patients (48%) died. The mean survival is 7 months, with the follow-up ranging 1 to 22 months. Subjective responses were achieved in 78.4% of cases, with 67.6% complete and 10.8% partial remission rates. Complete remission of hemoptysis was observed in 100% of patients. Dyspnea improved in 70%, cough in 46.4% and atelectasis in 83.2%. Endoscopic findings, 1 month after the end of brachytherapy, showed a response in 79.4% of patients. The complication rate was 13.8% (1 tracheoesophageal fistula, 2 pulmonary hemorrhages and 1 cavitary necrosis). Even though the number of treated patients is small, our experience confirms the efficacy of HDR endobronchial brachytherapy in the palliation of lung cancer-related symptoms. Literature data show that brachytherapy improves the quality of life in the patients with poor prognosis who are otherwise untreatable. The HDR technique is more accurate than the LDR technique and therapy is better tolerated also because execution time is shorter. Prospective clinical trials are needed to investigate the most effective total doses and fractionations and to better define the role of brachytherapy in the curative treatment of lung cancer.

[An in-vivo dosimetric study of the scattered radiation during the treatment of breast carcinoma]

In the last decade, radiation therapy has been increasingly used to treat breast cancer conservatively and some authors showed their concern about the radiogenic effects of irradiation outside the treated area. Our aim was to measure the scattered dose to the contralateral breast, thyroid and gonads during radiation therapy after conservative breast surgery. Thermoluminescent dosimeters, LiF Mn Ti (3 x 3 x 0.9 mm3), were used to measure scattered radiations outside the treated area. They were positioned on the skin of the patients in small (2 cm in diameter and 1 cm thick) perspex holders. Each measurement was performed once per treatment and six dosimeters were used--two on the contralateral breast, one on the midpoint of the medial side and one on the midpoint of the lateral side; two on thyroid lobes and two on the pelvis. The minimum dose to the contralateral breast (p < 0.002) and the maximum dose to the gonads (p < 0.003) were significantly higher in the 60Co group than in the LINAC6 group. The mean values of the minimum doses to the contralateral breast were significantly different (p < 0.007) in the whole series when beam area values were lower or higher than the median value (176 cm2). In the whole series the beam area and the minimum dose to the contralateral breast were correlated (Pearson, p < 0.001); the beam area and the minimum dose to the contralateral breast (p < 0.005), the gantry angle for the lateral beam and the minimum dose to the contralateral breast (Spearman, p < 0.001) exhibited statistically significant correlations. Of 30 patients, 16 were irradiated with 60Co (group A) and 14 with LINAC6 (group B). In group A the average scattered dose to the contralateral breast ranged 0.53-2.15 Gy, 0.66-1.91 Gy in the thyroid, 0.14-0.19 Gy in the gonads. In group B the average scattered dose to the contralateral breast ranged 0.36-2.07 Gy, 0.53-0.98 Gy in the thyroid and 0.08-0.12 Gy in the gonads. In the LINAC6 group the beam area and the minimum dose to the thyroid exhibited a statistically significant correlation (p < 0.009), as well as the beam area and the maximum dose to the gonads (p < 0.006), the beam area and the minimum dose to the gonads (p < 0.02), the gantry angle of the lateral beam and the minimum dose to the contralateral breast (p < 0.02). In the 60Co group no correlation was statistically significant, except for the correlation between the beam area and the minimum dose to the gonads (p < 0.001). Our experience confirms the scattered dose to depend on head treatment, beam area, gantry angle and wedge angle. Finally, the literature on this subject is reviewed.

[High dose brachytherapy in gynecologic neoplasms. Review of the literature]

The paper reports the historical origins of remote afterloading systems in intracavitary radiotherapy, together with the results and complications of high dose rate brachytherapy in gynecological tumours. High dose rate therapy achieves the same results as low dose rate therapy but has the advantage of making treatment more comfortable for patients.

A retrospective study of graduates of a coordinated internship/master's degree program

The coordinated dietetic internship/master's degree program (CDI/MDP) was formed in 1965 as a consortium of three hospitals and a university combining a hospital internship and graduate degree program. As of 1984, there were 317 graduates. The purpose of this study was to determine the employment, professional activity, and further education profiles of graduates in a 20-year period. The critical path method (CPM) was used as the blueprint for the 6-month project in which 267 questionnaires were sent and 152 were returned. Findings on areas of practice of graduates of the CDI/MDP indicated that their employment generally follows the same rankings as those found in previous studies of internship, CUP, and Plan IV programs, except for greater frequency of employment in education. Activities in professional associations were notable, with many graduates serving as officers or committee members. Twenty-one percent of respondents have earned or are in the process of pursuing study beyond the master of science earned with the internship. This may indicate that students interested in completing an internship/master's program have a strong achievement orientation or that they have an unusually high regard for education. Our findings provide valuable data for understanding the career impact of advanced education combined with the internship.

Mean transit time, forced expiratory volume and age in healthy male smokers and non-smokers

We studied 67 healthy males aged 20-30 years, 29 of them non-smokers and 38 smokers. In smokers, forced expiratory volume (FEV), 1 s forced expiratory volume (FEV1) and peak flow (PF) were significantly lower than in non-smokers, while the FEV1/FEV ratio, flows and mean transit time (MTT) compared well. MTT appeared directly related to age and negatively to FEV1/FEV, with no difference between the two groups, but MTT was directly related to FEV in non-smokers and negatively in smokers. Multiple regression analysis, MTT = a + b(FEV)+c(age), showed that parameters b and c were significantly different between smokers and non-smokers and, in the former, parameter b was negative. In non-smokers the effects of age and FEV on MTT were roughly the same, but in smokers MTT was influenced above all by age, probably because MTT measured the effects of continued smoking.