Equipment, staffing, and provision of radiotherapy in Lombardy, Italy: Results of three surveys performed between 2012 and 2016

INTRODUCTION:

Several efforts are being implemented at the European level to measure provision of up-to-date radiation treatments across the continent.

METHODS:

A snapshot survey involving all radiation oncology centers within Lombardy, Italy, was performed in 2012 and repeated in 2014 and 2016, in cooperation with regional governmental officers. Centers were asked to provide detailed information concerning all individual patients being treated on the index day, and to report data on available local resources.

RESULTS:

We observed an increase in the number of centers and of megavoltage units (MVU) (from 76 to 87, i.e., 8.7 MVU per million inhabitants in 2016). Mean number of MVU per center was 2.5. Average age of MVU increased from 5.3 to 7.5 years and patients on the waiting list also increased. Conformal 3D radiotherapy (RT) treatments decreased from 56% to 42% and were progressively replaced by intensity-modulated RT treatments (from 39% to 49%). Waiting times were overall satisfactory. Radiation oncologists treated on average 152 and radiation therapists 100 RT courses per year. Average reimbursement per course was €4,879 (range €2,476-€8,014).

CONCLUSIONS:

The methodology of snapshot survey proved feasible and provided valuable information about radiation oncology provision and accessibility in Lombardy.

Postsurgical Policy in Stage I Testicular Seminoma: Cost and Benefit of Prophylactic Irradiation in a Long-term Experience

The definitive cure rate for clinical stage I testicular seminoma is very close to 100%, and prophylactic irradiation of the regional lymph nodes is associated with a low morbidity. Nevertheless, in recent years a “wait-and-see” policy has been proposed by some researchers. We analysed the cost/benefit ratio of radiotherapy (RT) by review of the case histories of 299 patients treated at the Department of Radiotherapy of the Istituto Nazionale per lo Studio e la Cura dei Tumori in Milan from January 1968 to December 1989. The 5-year overall survival was 99% (97.5% at 10 years), while the 10-year disease-free survival was 96%. The recurrence rate was 2.3%, but no patient relapsed in the irradiated areas. Acute toxicity was very moderate with only 4 (1.3%) serious radiation sequelae occurring 6 to 27 years after treatment. However, 9 second malignancies (3%) were observed. Lastly, we have calculated the costs for our National Health Service comparing surveillance policy and prophylactic irradiation.

Nipple Discharge as a Sign of Preneoplastic Lesion and Occult Carcinoma of the Breast: Clinical and Galactographic Study in 103 Consecutive Patients

A clinical and galactographic investigation was carried out on 103 patients with hematic, serous-hematic, and serous nipple discharge. The age of the patients ranged from 18 to 72 years. A single papilloma was found in 20 cases, diffuse papillomatosis in 2 cases, atypical ductal hyperplasia in 8 cases, and ductal carcinoma in 4 cases (3 of these were infiltrating and 1 was noninfiltrating associated with a diffuse papillomatosis). Mammography gave no indications of carcinoma in any of the 4 cases. In the remaining 49 patients, pictures of ductal hyperplasia, periductal mastitis or sclerosis, sclerosing adenosis, or ductal ectasia were observed. The various types of lesions were often associated. Lacunae, stenosis, or occlusion of the ducts, evidenced by galactography, correlated well with the histologic findings of proliferative lesions of the ductal epithelium. Nevertheless, in practice, it should be the type of discharge that indicates surgery rather than galactographic or cytologic data, which appeared to have little diagnostic value. The frequency with which preneoplastic (or limit) lesions, and also nonsuspect carcinomas were found in patients with a significant nipple discharge confirm the importance of this symptom for a secondary prevention or early diagnosis of mammary neoplastic lesions originating from galactophorous ducts. Finally, complete resection of the galactophorous ducts must be considered as the best treatment in all patients with a suspicious nipple discharge that requires surgery.

Usefulness of Chest and Skeletal Survey to Assess the Time of Relapse in Breast Cancer

The pertinent radiographs of 151 patients treated with radical mastectomy who showed relapse in the chest and/or in the skeleton as first site were reevaluated. Diagnostic accuracy was calculated by comparing the first examination considered as positive with the previous ones reported as negative. For chest lesions the accuracy was 80 % (70 % for parenchymal nodular densities), with no difference between symptomatic and asymptomatic patients. For bone metastases retrospective evaluation confirmed the radiological report (i.e., the time of relapse), in 73.8 %, with a value of 89.7 % in symptomatic and 53.4 % in asymptomatic patients. The site of involvement and morphological characteristics of the lesions did not influence the diagnostic accuracy. Therefore chest examination and, for symptomatic patients, radiographic bone survey still represent a useful modality to assess the diffusion of breast cancer. For asymptomatic patients other modalities, such as bone scan and biochemical tests, should be utilized.

The Value of Radiotherapy in the Treatment of Vaginal Carcinoma

Herein we report the retrospective survey of 48 consecutive unselected cases of vaginal carcinoma, mainly treated with radiotherapy in our Institute from 1959 to 1970. In this series irradiation was delivered almost always with a single and continuous application of sources of radium 226. Radiumtherapy treatment varied according to the extension in surface of the neoplasm, the clinical stage and especially the vaginal step involvement, considering the length of the organ. Despite the very good immediate response, failures of treatment locally or in paravaginal and pelvic areas were frequently observed, and success of the treatment after a brief follow-up was poor. The actuarial survival was 41.6% and 33.3% at 3 and 5 years, respectively. Stage I cases showed at the follow-up better therapeutic results (48.6% survival at 5 years) than stage II and III cases (28.3%). The poorest results were observed in neoplasms extended to the whole vagina, and all these patients died within 4 years of the beginning of treatment. This report stresses that radiotherapy of vaginal carcinomas demands individualization and a properly planned therapeutic program that combines external irradiation with renewed techniques of low dose rate and continuous irradiation with radioactive sources.

Interventional Radiology and Radiotherapy for Inoperable Cholangiocarcinoma of the Extrahepatic Bile Ducts

Aims and background

To evaluate the effectiveness of external radiation therapy (ERT), alone or combined with endoluminal brachytherapy (BRT), following percutaneous transhepatic biliary drainage (PTBD) in the treatment of patients affected by inoperable cholangiocarcinoma.

Methods & study design

From September 1980 to June 1996, 130 jaundiced patients affected by inoperable cholangiocarcinoma were submitted to PTBD at the Division of Radiology C of the National Cancer Institute of Milan. Nineteen were excluded from the present analysis due to the short survival after PTBD (<30 days). The other 111 patients were divided into three groups according to the following therapy: no further treatment after palliative PTBD in 89 patients (80%, group 1); ERT in 10 patients (9%, group 2); ERT plus BRT in 12 patients (11%, group 3). All the ERT+BRT patients were enrolled after 1990 and were treated with high-energy photon beams followed by en-dobiliary insertion of one or two iridium-192 wires.

Results

Median overall survival among the 111 assessable patients was 126 days; for groups 1, 2 and 3 it was 108, 345 and 428 days, respectively. The patients submitted to radiotherapy (ERT alone or ERT+BRT) were evaluated by radiologic examinations after the end of radiation. In group 2, a partial remission in 3 cases, a progression of disease in 1 case, and no change in 6 cases were observed. Among the patients of group 3, complete remission in 5 and partial remission in 7 patients were achieved. In all the patients achieving complete remission, the PTBD could be removed.

Conclusions

The combination of ERT plus BRT improves survival and quality of life of the patients submitted to PTBD for cholangiocarcinoma. Under the technical point of view, radiation treatment is easy to perform, but much caution is required in defining clinical and planning target volumes. Moreover, drainage during the radiation treatment has to be submitted to a very meticulous surveillance.

Adjuvant Postoperative Radiotherapy in Locally Advanced Rectal and Rectosigmoidal Cancer

A pelvic recurrence is the cause of death in about 1/3 of radically operated patients for rectal and rectosigmoidal cancer without clinical evidence of distant metastases. Preoperative and postoperative radiotherapy are largely used to reduce the incidence of locoregional relapses and to improve disease-free and overall survival and quality of life. Benefits from radiotherapy have been widely demonstrated, and adjuvant postoperative radiotherapy is at present strongly recommended. Twenty-one patients with locally advanced (stage B2, B3, C) rectal (11 cases) and rectosigmoidal cancer (10 cases) were treated with postoperative radiotherapy at the National Cancer Institute of Milan from 1975 to 1978. The pelvis received a median dose of 4500 rad (range, 4000–5200 rad) in 5 to 7 weeks through AP, PA opposed fields; 6 patients received a boost of 1000 rad on the perineum. Median follow-up after surgery is 83 months (range, 24–63 months). Only 1 case (« 5%) had a pelvic recurrence, at the perineum. The expected recurrence rate after surgery alone is 40 %, and our favorable results after postoperative radiotherapy are comparable with recent data from other institutions. Radiotherapy side effects were moderate and transient; no late damages to small bowel were observed.

Treatment of Cancer of the Base of the Tongue and Glosso-Epiglottic Region: A Multicenter Italian Survey

BACKGROUND

The current treatment options for cancer of the base of the tongue and glosso-epiglottic region are surgery, radiotherapy, or a combination of both modalities. Comparisons between different modalities are not common in the literature, and a real standard of treatment has not yet been established. The purpose of our study was to evaluate the results of treatment in a large series of patients from 18 Italian institutions in relation to the main treatment adopted.

METHODS

The present study is a retrospective survey. The series was divided into a combined surgery group and a radiotherapy group. The Kaplan-Meier method and the log-rank test were used for survival calculations and comparisons.

RESULTS

Eight hundred patients were registered (25.7% stage III and 62% stage IV), 336 in the surgery and 372 in the radiotherapy group. Conventional fractionation was adopted in almost all cases. The five-year overall and disease free survival of the whole series was 32% and 38%, respectively. Survival was slightly better for patients with tumors of the glosso-epiglottic region than for those with a tumor of the base of the tongue. Five-year disease-free survival was 55% for patients treated with surgery +/- radiochemotherapy and 26% for those submitted to radiotherapy alone or in combination with chemotherapy. As far as the total dose and the treatment duration were concerned, only 26% of the patients of the radiotherapy group met the established criteria of adequacy, but in patients with adequate radiation the control rate was better only for small tumors (T1-T2).

CONCLUSIONS

The results in patients treated with surgery +/- postoperative radiotherapy were similar to or better than those reported in the best series in the literature. By contrast, the survival rate of irradiated patients was lower than those reported by other centers.

Epirubicin-Vinorelbine Intravenous Combination Followed by Oral Vinorelbine as First-Line Treatment in Metastatic Breast Cancer

Epirubicin and vinorelbine are considered active drugs in metastatic breast cancer. The optimal duration of a chemotherapy regimen for metastatic breast cancer patients is still unknown. Nevertheless, epirubicin has a dose-limiting cardiotoxicity. Vinorelbine is also available as oral formulation. In a multicenter phase II study, we analyzed the feasibility and the efficacy of a maximum of six cycles of i.v. epirubicin plus vinorelbine, followed by oral vinorelbine. We enrolled 30 patients with metastatic breast cancer. Each patient received epirubicin (75 mg/m2 on day 1) and vinorelbine (25 mg/m2 on days 1–8), every 3 weeks, for three cycles or six cycles in case of objective response or stable disease. When a clinical benefit was obtained, patients received oral vinorelbine (60 mg/m2 on days 1–8 every 3 weeks for three cycles). The regimen demonstrated to be active and well tolerated in metastatic breast cancer, and 6–8 months represented the optimal treatment duration. Maintenance therapy with oral vinorelbine was feasible, effective, safe and well accepted by the patients.

Brain Irradiation-Induced Lymphocytosis Predicts Response in Cancer Patients with Brain Metastases

Lymphocytopenia is one of the main toxicities of radiotherapy and its severity is related to the irradiation dose. The occurrence of lymphocytopenia depends on the body site of radiotherapy; it is most pronounced with pelvic irradiation, whereas the effect of brain irradiation on the lymphocyte count is to be elucidated. This preliminary study was performed to evaluate changes in lymphocyte number occurring during brain irradiation in cancer patients with brain metastases. The study included 50 patients who received brain radiotherapy for single or multiple brain metastases at a total dose of 30 Gy. Overall, no significant changes in mean lymphocyte number occurred during brain radiotherapy. However, when lymphocyte variations were assessed in relation to the clinical response of brain metastases, a significant increase in the mean number of lymphocytes was found in patients who achieved objective regression of brain metastases on brain irradiation. The mean lymphocyte number decreased in nonresponding patients, albeit without a statistically significant difference with respect to the pretreatment values. The results of this study show that the efficacy of radiotherapy in the treatment of brain metastases is associated with a significant increase in mean lymphocyte number. Therefore, evidence of brain irradiation-induced lymphocytosis may predict the efficacy of radiotherapy.

Response to neoadjuvant therapy in locally advanced rectal cancer: assessment with diffusion-weighted MR imaging and 18FDG PET/CT

The aim of this study was to evaluate the correlation between the changes of SUV(max) and of apparent diffusion coefficient (ADC) before and after neoadjuvant therapy, to enable us predict the therapy response, in patients with locally advanced rectal cancer (LARC). A total of 30 patients with LARC who underwent CRT were recruited for our study. All the patients underwent a whole body 18F-FDG-PET/CT scan and a pelvic MR examination including DW imaging for staging (PET/CT1 and RM1), and after the chemoradiation therapy (PET/CT2, and RM2). Histopathologic analysis of rectal specimen, according to tumor regression grade (Mandard's criteria) was used as the standard reference. MR and PET-CT images were analyzed, and measurements of ADC values and SUV(max) were taken. Diagnostic performance for selection of complete responders (TRG1-2) and overall diagnostic accuracy for each item were calculated. After neoadjuvant therapy, all patients were submitted to surgery. According to Mandard's criteria, 21 tumors showed complete (TRG1) or subtotal regression (TRG2) and were classified as responders; nine tumors were classified as non responders (TRG3, 4, and 5). In all the patients, mean value of SUV(max) in PET/CT1 was higher than those in PET/CT2 (P < 0.001), whereas mean ADC value was lower in RM1 than RM2 (P < 0.001), with a significant percentage decrease of values after the treatment (P < 0.005).The best predictors cut-off values for TRG response were SUV(max) of 4.4 and ADC of 1.28 × 10(3) mm(2)/s with sensitivity, specificity accuracy, negative predictive value, and positive predictive values of 77.3%, 88.9%, 80.7%, 61.5%, and 94.4%, respectively. We conclude from the overall data of this study that the absolute values of SUV(max) and ADC of rectal lesion after CRT were the best parameters to define the response to treatment, by differentiating fibrosis from viable tumor tissue.

Change in glucose metabolism measured by 18F-FDG PET/CT as a predictor of histopathologic response to neoadjuvant treatment in rectal cancer

PURPOSE

In order to analyze the changes of glucose metabolism by maximum standardized uptake value (SUVmax) of 18F-FDG PET/CT in patients with rectal cancer submitted to neoadjuvant radiochemotherapy (nRCT) and to correlate SUV changes with tumor regression grade (TRG).

METHODS AND MATERIAL

Three sequential 18F-FDG PET/CT studies were performed in 31 patients with rectal cancer at the following time point: before starting the treatment (PET/CT1), during the treatment (PET/CT2), and after completion of neoadjuvant treatment (PET/CT3). The SUVmax values of the rectal lesion in the PET/CT1 (SUV1), PET/CT2 (SUV2), and PET/CT3 (SUV3) were obtained; deltaSUV1 [(SUV1 - SUV2)/SUV1] and deltaSUV2 [(SUV1 - SUV3)/SUV1] were also calculated. Metabolic parameters were compared to TRG.

RESULTS

Significant differences in pathologic responder and non-responder patients were found only for SUV2 (6.4 ± 2.9 in responder and 10.7 ± 4.8 in non-responder patients, respectively; P = 0.006) and SUV3 (3.6 ± 1.4 in responder and 6.6 ± 2.1 in non-responder patients, respectively; P = 0.0009). The best predictor for TRG response was SUV3 (threshold of 4.4) with sensitivity, specificity, accuracy, negative predictive value, and positive predictive value of 77.3%, 88.9%, 80.7%, 61.5%, and 94.4%, respectively.

CONCLUSION

18F-FDG PET/CT is a reliable and accurate technique to assess the response to nRCT in rectal cancer. In our population, the absolute value of SUVmax after treatment was the best predictor of pathological response.

Concomitant chemoradiotherapy versus induction docetaxel, cisplatin and 5 fluorouracil (TPF) followed by concomitant chemoradiotherapy in locally advanced head and neck cancer: a phase II randomized study

BACKGROUND

Concomitant chemoradiotherapy (CT/RT) is the standard treatment of locally advanced squamous cell carcinoma of the head and neck (SCCHN). We evaluated the efficacy of induction docetaxel (Taxotere), cisplatin, and 5-fluorouracil (TPF) before CT/RT versus CT/RT alone.

PATIENTS AND METHODS

Patients with stage III-IVM0 SCCHN, Eastern Cooperative Oncology Group performance status of zero to one, were randomly assigned to receive CT/RT alone (arm A: two cycles of cisplatin 20 mg/m(2), days1-4, plus 5-fluorouracil 800 mg/m(2)/day 96 h continuous infusion, during weeks 1 and 6 of radiotherapy) or three cycles of TPF (arm B: docetaxel 75 mg/m(2) and cisplatin 80 mg/m(2), day 1, and 5-fluorouracil 800 mg/m(2)/day 96 h continuous infusion, every 3 weeks) followed by the same CT/RT. The primary end point was the rate of radiologic complete response (CR) at 6-8 weeks after the end of CT/RT.

RESULTS

A total of 101 patients were randomly allocated to the study (51 arm A; 50 arm B). CR rates were 21.2% (arm A) versus 50% (arm B). Median progression-free survival and overall survival were, respectively, 19.7 and 33.3 months (arm A) and 30.4 and 39.6 months (arm B). Hematologic and non-hematologic toxic effects during CT/RT were similar in the two arms.

CONCLUSION

Induction TPF followed by CT/RT was associated with higher radiologic CR in patients with locally advanced SCCHN with no negative impact on CT/RT feasibility.

Efficacy of HT 7 point acupressure stimulation in the treatment of insomnia in cancer patients and in patients suffering from disorders other than cancer

AIM

The induction of sleep would depend on interaction between gabaergic system and the pineal gland through its main hormone melatonin. Until few years ago benzodiazepines were the only drugs effective in the treatment of insomnia. Recently, however, both melatonin and acupressure have appear to be active in sleep disorders. The aim of study was to evaluate the efficacy of HT 7 point acupressure in insomnia.

METHODS

The study enrolled 25 patients affected by sleep disorders, 14 of whom had a neoplastic disease. They were treated by HT 7 stimulation for al least two consecutive weeks using a medical device named H7 Insomnia Control.

RESULTS

An improvement in the quality of sleep was achieved in 15/25 (60%) patients, with a more evident efficacy in cancer patients (11/14 [79%]).

CONCLUSION

This study confirms previous clinical data showing the efficacy of acupressure in the treatment of sleep disorders, particularly in cancer-related insomnia.

A progress study of 100 cancer patients treated by acupressure for chemotherapy-induced vomiting after failure with the pharmacological approach

AIM

The recent rediscovery of the natural traditional medical sciences has contributed to improve the treatment of the human diseases and, in particular, it has been shown that the pharmacological approach is not the only possible strategy in the treatment of nausea and vomiting, since bioenergetic approaches, such as acupressure and acupuncture, may also counteract the onset of vomiting due to different causes. Previous preliminary clinical studies had already suggested a possible efficacy of acupressure also in the treatment of chemotherapy-induced vomiting resistant to the classical antiemetic drugs. The aim of this study was to confirm these preliminary data.

METHODS

The study was performed in 100 consecutive metastatic solid tumour patients, who underwent chemotherapy for their advanced neoplastic disease, and who had no benefit from the standard antiemetic agents, including corticosteroids, antidopaminergics and 5-HT 3R-antagonists. Acupressure was made by a stimulation of PC6 acupoint.

RESULTS

The emetic symptomatology was reduced by acupressure in 68/100 (68%) patients, without significant differences in relation to tumour histotype. The lowest efficacy was observed in patients treated by anthracycline-containing regimens, without, however, statistically significant differences with respect to the other chemotherapeutic combinations.

CONCLUSION

This study confirms previous preliminary clinical results, which had already suggested the potential efficacy of acupressure in the treatment of vomiting due to cancer chemotherapy. Therefore, acupressure may be successfully included within the therapeutic strategies of cancer chemotherapy-induced vomiting.

A case-control study of Panicum Miliaceum in the treatment of cancer chemotherapy-induced alopecia

AIM

Alopecia still remains one of the most untreatable side-effects induced by cancer chemotherapy. According to the phytotherapeutic tradition, Panicum Miliaceum has been proven to be effective in the prevention of hair loss for different reasons. At present, however, there are no data about its possible efficacy in the treatment of cancer chemotherapy-induce alopecia. The aim of this study was to analyze the efficacy of Panicum Miliaceum in cancer patients treated with the most potent chemotherapeutic drugs in terms of hair loss, consisting of cisplatin (CDDP) and anthracyclines.

METHODS

This case-control study included 28 cancer patients concomitantly treated with Panicum Miliaceum and 56 patients receiving the same combinations of chemotherapy alone as a control group. Panicum Miliaceum was given orally at 300 mg (daily dose) 3 times per day, every day until the end of chemotherapy. The grade of hair loss was assessed by World Health Organization (WHO) criteria.

RESULTS

The percentage of alopecia of third grade observed in patients concomitantly treated with Panicum Miliaceum in association with CDDP-containing regimens was significantly lower than that found in those who received the chemotherapy only. The percentage was also lower under anthracycline-containing schedules, without, however, statistically significant differences. Panicum Miliaceum therapy was substantially well tolerated in all patients.

RESULTS

This preliminary study would suggest that the concomitant treatment with Panicum Miliaceum may be effective in preventing hair loss induced by CDDP-containing chemotherapies, whereas the benefit was lower in patients treated with anthracyclines. Future randomized studies will be necessary to confirm these preliminary

Quality indicators in radiotherapy

BACKGROUND AND PURPOSE

There is a widespread and increasing tendency to develop hospital performance indicators in the field of accreditation/certification systems and quality benchmarking. A study has been undertaken to develop a set of performance indicators for a typical radiotherapy Centre and to evaluate their ability to provide a continuous quality improvement.

MATERIALS AND METHODS

A working group consisting of radiation oncologists, medical physicists and radiation technologists under the coordination of experts in health technology assessment has elaborated a set of general indicators able to monitor performances and the quality level of a typical radiotherapy Centre. The work has been carried out through four steps: a preliminary set of indicators was selected; data on these indicators were collected in a number of Italian radiotherapy Centres and medical physics Services; problems in collection and analysis of data were discussed; a final set of indicators was developed.

RESULTS

A final set of 13 indicators is here presented. They concern general structural and/or operational features, health physics activities and accuracy and technical complexity of the treatment.

CONCLUSIONS

The indicators tested in a few Italian Centres of radiotherapy and medical physics Services are now ready to be utilized by a larger community.

Effect of acupressure on nausea and vomiting induced by chemotherapy in cancer patients

AIM

Corticosteroids, antidopaminergig agents and 5-HT3 antagonists are the most commonly used drugs in the treatment of chemotherapy-induced vomiting. Acupuncture and acupressure have also appeared to exert antiemetic effects. The aim of this study was to evaluate the efficacy of acupressure in the treatment of chemotherapy-induced vomiting resistant to the standard antiemetic therapies.

METHODS

The study included 40 consecutive advanced cancer patients with untreatable chemotherapy-induced vomiting. Colorectal cancer, lung cancer and breast cancer were the neoplasm most frequent in our patients. According to tumour histotype, patients received chemotherapeutic regimens containing the main emetic cytotoxic agents, including cisplatin and athracyclines. Acupressure was made by PC6 point stimulation for at least 6 h/day at the onset of chemotherapy.

RESULTS

The therapeutic approach was well accepted by the overall patients. An evident improvement in the emetic symptomatology was achieved in 28/40 (70%) patients, without significant differences in relation to neither tumor histotype, nor type of chemotherapeutic agent.

CONCLUSIONS

This preliminary study seems to suggest that a bioenergetic approach by acupressure on PC6 point may be effective in the treatment of chemotherapy-induced vomiting resistant to the conventional pharmacological strategies, as previously demonstrated for vomiting occurring during pregnancy.

Radiotherapy-induced lymphocytopenia: changes in total lymphocyte count and in lymphocyte subpopulations under pelvic irradiation in gynecologic neoplasms

Lymphocytopenia is one of the most negative biological prognostic factors in cancer patients. Lymphocytopenia may depend on tumor progression, or on various anticancer therapies. In particular, radiotherapy (RT) may induce direct lymphocyte damage. The present study was carried out to evaluate the influence of pelvic irradiation on lymphocyte number and lymphocyte subpopulations in patients with gynecologic tumors. The study included 40 patients affected by locally limited or advanced uterine tumors, who underwent pelvic irradiation for a total dose of 50.4 Gy. RT induced a significant decline in total lymphocyte number, with values lower than 500/mm3 in 29/40 (73%) patients and with a mean decrease of 71 +/- 4%. In the same way, T lymphocyte, CD4, CD8 and NK cell mean numbers significantly decreased under RT. The decline in NK and CD8 cells was limited to the first 2-3 weeks of irradiation, whereas that involving T lymphocytes and CD4 cells was progressive and persistent until the end of RT. Finally, the decline in total lymphocyte number was significantly greater in patients who had no tumor regression in response to RT. This study confirms that pelvic RT may induce severe lymphocytopenia which could negatively influence the efficacy of RT itself.

Endocrine effects of erythropoietin in cancer patients

The recent advances in the knowledge of the psychoneuroimmunological pathogenesis of human neoplasms have demonstrated the existence of feed-back mechanisms operating between interleukins and endocrine secretions, which play an important role in the regulation of the immune responses, including the anticancer immunity. In contrast, few studies only have been performed to investigate the possible relation between endocrine activities and hematopoietic growth factors. The present study was performed to analyze the acute endocrine effects of erythropoietin-alpha (EPO) on the main endocrine secretions. The study was carried out in 10 advanced solid tumor patients. EPO was injected subcutaneously at a dose of 10,000 U, and venous blood samples were collected before and 2, 4 and 6 h after EPO administration. No significant changes in mean serum levels of FSH, LH and TSH were seen in response to EPO. Cortisol and DHEAS concentrations increased after EPO injection, whereas those of PRL decreased, but none of these differences was statistically significant. Finally, mean serum levels of both growth hormone (GH) and somatomedin-C (IGF-1) significantly decreased after EPO administration. This preliminary study shows that EPO may inhibit GH secretion from the pituitary gland and IGF-1 production. Since GH would stimulate EPO release, the results of this study may suggest the existence of feedback mechanism operating between GH secretion and EPO production, with inhibitory effect of EPO on GH secretion, and stimulatory action of GH on EPO production. Therefore, this study would describe the first example of hemato-endocrine feedback mechanisms. Moreover, this study, by showing an inhibitory effect of EPO on IGF-1 secretion, would suggest a possible use of EPO in the medical oncology not only for the treatment of cancer related anemia, but also to counteract tumor growth by blocking IGF-1 production, which has been proven to be a growth factor for several tumor histotypes. Obviously, IGF-1 is not the only tumor growth factor, but it could play a fundamental role in the regulation of production and activity of several other tumor growth factors. In any case, this study describes the only acute endocrine effects of EPO. Therefore, further studies, by evaluating the endocrine effects of a chronic treatment with EPO, will be required to establish which may be its effect on IGF-1 endogenous production, and its consequence on survival time.

Enhancement of the efficacy of weekly low-dose taxotere by the long acting anti-prolactinemic drug cabergoline in pretreated metastatic breast cancer

In view of its potential action as a growth factor, the evidence of abnormally high blood levels of prolactin (PRL) is associated with a poor prognosis in metastatic breast cancer. Moreover, metastatic breast cancer-related hyperprolactinemia has proven to counteract the efficacy of cancer chemotherapy. The negative influence of high blood levels of PRL on the efficacy of chemotherapy in metastatic breast cancer has been confirmed by previous preliminary studies, showing that the concomitant administration of the anti-prolactinemic dopaminergic agent bromocriptine may enhance the therapeutic effect of chemotherapy. However, the clinical use of bromocriptine is limited by its short duration and gastrointestinal toxicity. Therefore, new anti-prolactinemic drugs, characterized by less toxicity and a longer duration of activity, such as Cabergoline (CBG), could be more appropriated to control PRL secretion in breast cancer. On this basis, a study was planned to evaluate the efficacy and tolerability of a concomitant administration of CBG with weekly low-dose Taxotere (TXT) in pretreated metastatic breast cancer under chemotherapy. The study group comprised 70 metastatic breast cancer patients (females), pretreated with at least one previous chemotherapeutic line containing anthracyclines, who were randomized to be treated with TXT alone or TXT plus CBG. TXT 25 mg/m2 was given i.v. at weekly intervals for at least 9 consecutive cycles. CBG was given orally at 0.5 mg once per week. Abnormally high pre-treatment levels of PRL were seen in 24/70 (34%) patients, 11 of whom were treated with TXT plus CBG, whereas the other 13 received TXT alone. CBG induced a complete normalization of the PRL levels in all patients within the first two weeks of therapy, whereas no normalization of PRL occurred spontaneously in patients treated with chemotherapy alone. The objective tumor regression rate was significantly higher in patients concomitantly treated with CBG than in those who received chemotherapy alone (31/34 vs 13/36, p < 0.05), and this difference was particularly evident in patients with high PRL levels prior to therapy (6/11 vs 2/13). No CBG-related toxicity occurred. On the contrary, chemotherapy-induced asthenia was significantly lower in patients concomitantly treated with CBG (5/34 vs 11/36, p < 0.05). This study shows that the chemoneuroendocrine therapy of weekly low-dose TXT plus the anti-prolactinemic drug CBG is a new, effective and well-tolerated therapy for metastatic breast cancer. It may also be recommended in heavily pretreated patients or in those with poor clinical status.

Biological response modifiers of cancer-related neuroendocrine disorders: efficacy of the long-term dopaminergic agonist cabergoline in the treatment of breast cancer-induced hyperprolactinemia

The evaluation of the biological status of cancer patients should not be limited only to investigation of immune reactivity, but should also include analysis of the endocrine condition, namely concerning those hormones which have appeared to be tumor growth factors, such as prolactin (PRL) for breast and prostate carcinomas. This statement is justified by the fact that the evidence of abnormally high serum concentrations of PRL has been proven to be associated with poor prognosis in breast and prostate cancer patients. Moreover, since hyperprolactinemia negatively influences the efficacy of anticancer therapies in breast cancer, it could be fundamental to achieve a normalization of PRL levels by long-acting dopaminergic agents, such as cabergoline. On this basis, a study was planned to evaluate the effect of cabergoline on PRL levels in hyperprolactinemic metastatic breast cancer subjects. The study included 20 hyperprolactinemic metastatic breast cancer subjects, who were randomized to receive no therapy or cabergoline at 0.5 mg/week orally for 4 consecutive weeks. Cabergoline therapy induced a normalization in all patients, whereas no spontaneous normalization of PRL levels occured in the control group. These results show that a weekly oral administration of the long-acting dopaminergic agent cabergoline is a well tolerated and effective treatment of metastatic breast cancer-related hyperprolactinemia. The possible prognostic impact of PRL normalization needs to be established by successive studies.

Biomodulation of cancer chemotherapy for metastatic colorectal cancer: a randomized study of weekly low-dose irinotecan alone versus irinotecan plus the oncostatic pineal hormone melatonin in metastatic colorectal cancer patients progressing on 5-fluorouracil-containing combinations

Recent advances in immunobiological knowledge have suggested the possibility of enhancing the therapeutic activity of various chemotherapeutic agents by a concomitant administration of anti-oxidant drugs and/or immunomodulating neurohormones. In particular, the pineal neurohormone melatonin (MLT), which is able to exert both antioxidant and immunomodulating effects, has been proven to enhance the efficacy of various chemotherapeutic drugs, namely cisplatin, anthracyclines and 5-fluorouracil, whereas at present there are no data about its possible influence on cytotoxic drugs effective in the treatment of colon cancer other than 5-fluorouracil, such as irinotecan (CPT-11). The present study was performed to evaluate the influence of a concomitant administration of MLT on CPT-11 therapeutic activity in metastatic colorectal cancer. The study included 30 metastatic colorectal cancer patients progressing after at least one previous chemotherapeutic line containing 5-fluorouracil, who were randomized to be treated with CPT-11 alone or CPT-11 plus MLT. According to a weekly low-dose schedule, CPT-11 was given i.v. at 125 mg/m2/week for 9 consecutive weeks. MLT was administered orally at 20 mg/day during the dark period of the day. No complete response was observed. A partial response (PR) was achieved in 2 out of 16 patients treated with CPT-11 alone and in 5 out of 14 patients concomitantly treated with MLT. Moreover, a stable disease (SD) was obtained in 5 out of 16 patients treated with CPT-11 alone and in 7 out of 14 patients treated with CPT-11 plus MLT. Therefore, the percent of disease-control achieved in patients concomitantly treated with MLT was significantly higher than that observed in those treated with chemotherapy alone (12 out of 14 vs 7 out of 16, p < 0.05). The only important toxicity was diarrhoea grade 3-4, which occurred in 6 out of 16 patients treated with CPT-11 alone and in 4 out of 14 patients treated with CPT-11 plus MLT, which required a 50% dose reduction. However, taken together, patients treated with CPT-11 at 50% of the planned dose showed a percent of disease control comparable to that achieved in patients who had no dose reduction (6 out of 10 vs 13 out of 20). This preliminary study shows that the efficacy of weekly low-dose CPT-11 in pretreated metastatic colorectal cancer patients may be enhanced by a concomitant daily administration of the pineal hormone MLT, according to the results previously reported for other chemotherapeutic agents. Moreover, since the dose reduction of CPT-11 does not influence its efficacy, the dose of CPT-11 for successive studies might be not greater than 70 mg/m2.

Psychooncology and cancer progression-related alterations of pleasure-associated neurochemical system: Abnormal neuroendocrine response to apomorphine in advanced cancer patients

OBJECTIVES

The clinical approach of the Psychooncology is generally limited to the investigation of the only psychological status of cancer patients, without taking into consideration the well demonstrated cancer progression-related psychoneuroendocrine alterations, namely consisting of a progressive decline in the pineal endocrine function and an anomalous activity of brain opioid system. The endocrine response to apomorphine, a dopaminergic agent, has been proven to reflect the dopaminergic sensitivity, which would be involved at least in part in pleasure-related neurochemical mechanisms. The present study was performed to analyze the endocrine response to apomorphine in metastatic cancer patients, as a preliminary approach to the investigation of pleasure-related neuroendocrine mechanisms in human neoplasms.

MATERIALS & METHODS

The study included 10 metastatic cancer male patients and 6 male volunteers as a control group. Apomorphine was given orally at 0.01 mg/kg body weight in the morning, and venous blood samples were collected before, and at 20, 60 and 120 minutes after apomorphine administration. The endocrine analysis consisted of the measurement of serum levels of GH, PRL and cortisol.

RESULTS

All cancer patients presented alterations involving one or more endocrine responses to apomorphine. GH and cortisol mean levels after apomorphine were significantly higher in controls than in cancer patients, whereas no substantial difference occurred in those of PRL.

CONCLUSIONS

This preliminary study, by showing an altered endocrine response to apomorphine in metastatic cancer patients, would suggest that cancer progression may be associated with an altered dopaminergic sensitivity. Because of the involvement of the dopaminergic system in pleasure-related neurochemical mechanisms, this finding would demonstrated that the decline in the perception of pleasure with cancer progression may depend not only on psychological factors, but also, at least in part, on psychochemical alterations occurring during the clinical course of the neoplastic disease.

Effects of IL-2 preoperative immunotherapy on surgery-induced changes in angiogenic regulation and its prevention of VEGF increase and IL-12 decline

BACKGROUND/AIMS

IL-2 preoperative immunotherapy has been proven to abrogate surgery-induced immunosuppression in cancer patients. In contrast, at present there are no data about the possible influence of IL-2 on angiogenesis-related molecular changes determined by the surgical operation. At present, it is known that VEGF (vascular endothelial growth factor) is the main endogenous angiogenic factor, whereas the antitumor cytokine IL-12 has appeared to play an anti-angiogenetic role. On this basis, a study was planned to evaluate the influence of IL-2 presurgical immunotherapy on the perioperative changes in VEGF and IL-12 secretions.

METHODOLOGY

The study was performed on 30 colorectal cancer patients undergoing radical surgery, who were randomly chosen to be treated with or without preoperative immunotherapy of IL-2 (12 million IU/day subcutaneously for 3 consecutive days prior to surgery). Serum levels of VEGF and IL-12 were measured by ELISA for blood samples collected before surgery, and at days 3, 7 and 10 of the postoperative period.

RESULTS

VEGF mean concentrations progressively and significantly increased during the postoperative period in patients treated with surgery alone. Mean values of VEGF were enhanced also in patients pretreated with IL-2, but VEGF increase observed in the IL-2 group was delayed, more transient and significantly lower with respect to that found in controls. IL-12 mean concentrations significantly decreased during the postoperative period only in the control patients, whereas in the IL-2-treated patients IL-12 postoperative mean values were not significantly lower than those found before surgery.

CONCLUSIONS

This preliminary study would suggest that IL-2 preoperative immunotherapy may abrogate surgery decline in IL-12 levels and reduce, although not completely prevent, VEGF increase during the postoperative period in surgically treated cancer patients. These results would suggest that IL-2 presurgical immunotherapy may counteract surgery-induced stimulation of the angiogenesis, by either opposing the decline in blood levels of the anti-angiogenetic cytokine IL-12, or reducing the increase in those of the angiogenic factor VEGF.

Effect of bicalutamide therapy on prolactin response to L-dopa in metastatic prostate cancer patients

OBJECTIVES

The secretion of prolactin (PRL), which is a growth factor for prostate cancer cell proliferation, has been proven to present profound alterations in advanced prostate cancer patients, consisting of abnormally elevated baseline levels and paradoxical response to L-dopa. Moreover, the efficacy of standard therapies for prostate cancer may be mediated at least in part by changes in PRL secretion. The present study was carried out to analyze the effects of the new antiandrogen agent bicalutamide on basal levels of PRL and on its response to L-dopa in metastatic prostate cancer patients.

MATERIAL & METHODS

The study included 10 metastatic prostate cancer patients. They were treated with bicalutamide at a dose of 50 mg/day orally. They were investigated with L-dopa test before therapy and after one month of treatment. L-dopa was given orally at 500 mg, by collecting blood samples before and at 60, 120 and 180 minutes after L-dopa administration. Serum levels of PRL were measured by the RIA method.

RESULTS

Abnormally basal levels of PRL were seen in 4/10 (40%) patients. Mean PRL basal levels decreased after bicalutamide therapy, without, however, significant differences. Before therapy, a paradoxical increase in PRL levels after L-dopa occurred in 4 patients, 3 of them showed basal concentrations of PRL within the normal range. Moreover, bicalutamide therapy significantly reduced PRL increase in response to L-dopa.

CONCLUSIONS

This study would suggest that the measurement of the only basal levels is not sufficient to define as normal the secretion of PRL in advanced prostate cancer, because of the possible existence of altered response to the dynamic tests for PRL secretion. Moreover, the study shows that the antitumor therapy with the new anti-androgen bicalutamide may reduce PRL secretion and improve its paradoxical secretion in response to L.-Dopa. Further studies will be required to better define the possible prognostic impact of changes in PRL secretion on the efficacy of treatments for metastatic prostate cancer.

Efficacy of bromocriptine in the treatment of metastatic breast cancer- and prostate cancer-related hyperprolactinemia

OBJECTIVE: Hyperprolactinemia is a frequent evidence occurring in both metastatic breast cancer and prostate cancer, and it has been proven to be associated with poor prognosis and reduced efficacy of the anticancer therapies. Therefore, the pharmacological control of cancer-related hyperprolactinemia could improve the prognosis of advanced breast and prostate carcinomas. Unfortunately, at present it is still controversial which may be the treatment of cancer-related hyperprolactinemia, which could depend at least in part on a direct autocrine production by cancer cells themselves. The present study was performed to evaluate the acute effects of the long-acting dopaminergic agonist bromocriptine on cancer-related hyperprolactinemia. METHODS: The study included 10 women affected by metastatic breast cancer and 10 men with metastatic prostate cancer, showing persistent hyperprolactinemia. Venous blood samples were collected before bromocriptine, and 2, 4, 10 and 24 hours after bromocriptine administration (2.5 mg orally) serum levels of PRL were measured with the double antibody RIA method. RESULTS: Bromocriptine induced a normalization of PRL levels in both groups of patients with breast and prostate cancers. Moreover, mean levels of PRL persisted significantly lower than those found before therapy during the whole 24-hour circadian period. DISCUSSION: This preliminary study shows that low-dose bromocriptine is sufficient to acutely normalize PRL secretion in both metastatic breast cancer and prostate carcinoma patients, irrespectively of the mechanisms involved in inducing cancer-related hyperprolactinemia. Therefore, low-dose bromocriptine could be recommended in association with the classical antitumor therapies in the treatment of metastatic breast cancer and prostate carcinoma patients showing cancer-related hyperprolactinemia, in an attempt to improve the efficacy of anticancer therapies themselves.

Efficacy of monochemotherapy with docetaxel (taxotere) in relation to prolactin secretion in heavily pretreated metastatic breast cancer

OBJECTIVES

Recent data have suggested that the efficacy of cancer chemotherapy does not depend only on tumor-related characteristics, but also on patient biological status, namely immune and endocrine functions. In particular, it has been shown that prolactin (PRL) is a growth factor for breast cancer, and abnormally high blood levels of PRL have been described in metastatic breast cancer patients. The present study was performed to evaluate the efficacy of chemotherapy with taxanes in relation to PRL blood levels in metastatic breast cancer.

MATERIAL & METHODS

The study included 20 metastatic breast cancer patients, who were treated with taxotere (100 mg/mq I.V. every 21 days) for at least 3 consecutive cycles. Serum levels of PRL were measured by RIA before the onset of treatment and at 21-days intervals.

RESULTS

The clinical response consisted of partial response (PR) in 6, stable disease (SD) in 7 and progressive disease (PD) in the remaining 7 patients. Abnormally high pre-treatment levels of PRL were seen in 7/20 patients. The percent of patients who had PD in response to chemotherapy was significantly high in patients with pre-treatment hyperprolactinemia than in those with normal blood levels of PRL before therapy.

CONCLUSIONS

This study shows that the evidence of abnormally high serum levels of PRL correlates with resistance to chemotherapy with taxanes in metastatic breast cancer. Therefore, a concomitant administration of anti-prolactinemic agents, such as bromocriptine, could enhance the efficacy of chemotherapy itself.

Long-term results of sequential chemotherapy-radiotherapy-chemotherapy in locally advanced squamous cell carcinoma of the uterine cervix

PURPOSE OF INVESTIGATION

In order to evaluate the impact of sequential chemotherapy-radiotherapy-chemotherapy on local control and survival, a follow-up study was carried out 12 years after the treatment of 22 patients with FIGO stage IIB-III squamous cell cervical cancer.

METHODS

Patients were submitted to three cycles of induction chemotherapy (cisplatin and bleomycin) followed by whole pelvis irradiation and central boost with endocavitary brachytherapy. Ten patients underwent three further cycles of chemotherapy after radiotherapy. All patients were maintained by regular follow-up. Only one patient was lost 48 months after treatment.

RESULTS

At the end of treatment complete response was obtained in 14 patients (63.5%). Four of these recurred locally, and one at also distance. Eight patients failed to obtain a complete response. Twelve patients died from disease and one patient died from other causes. Nine of 22 (41%) patients are alive without evidence of disease with a median follow-up of 134 months. Acute toxicity was mild, while two severe late complications were observed.

CONCLUSIONS

The achievement of complete remission at the end of treatment is important in terms of life expectancy. Further chemotherapy appears useful for patients who do not reach complete local remission after radiotherapy.

Treatment planning for radiotherapy in northern Italy: a survey by the National AIFB-AIRO Committee on 3D-Treatment Planning. Italian Association for Biomedical Physics. Italian Association for Radiation Oncology

BACKGROUND AND PURPOSE

A survey was performed in 1996 to investigate the structures and the process of radiation therapy treatment planning in clinical practice within northern Italy, with particular emphasis on the current and future implementation of 3D equipment and techniques.

MATERIALS AND METHODS

Of 57 existing radiation therapy (RT) centres covering a population of 25 million people (45% of the total population of Italy) and treating over 58,000 cancer patients (70% of the cancer cases in Italy) each year, 46 centres were deemed eligible for the survey; a questionnaire was sent to a medical physicist working in each eligible RT centre, 40 of whom responded, making the basis for this report.

RESULTS

A dedicated CT scanner was available in 25% of the responding centres and a total of 49 radiation therapy planning systems (RTPS) were reported; none of the RTPS were able to perform 3D calculations, but 50% of the centres had an advanced 2D or 2.5D system. Connection between CT scan and RTPS was by tape or disk in 62% of centres. Immobilization devices were used frequently for head and neck patients (88% of centres), but not for lung (16%) or prostate cancer (24%) patients; the number of contoured slices was largely variable, exceeding 10 in only about 30% of the responding centres. The average working time per patient seemed to closely reflect the number of slices used and the number of critical organs contoured. Finally, the majority of the responding physicists did not favour the use of more than 20 CT slices for 3D treatment planning, nor did they forecast a general spread of this technique in the next 2-3 years.

CONCLUSIONS

This survey has shown (1) a heterogeneous picture, with 20% of centres ready to implement 3D techniques and 20% of centres lacking the possibility of planning treatments and (2) a general difficulty in coping with the workload represented by 3D treatment planning.

Analysis of risk factors for mandibular bone radionecrosis after exclusive low dose-rate brachytherapy for oral cancer

BACKGROUND

Brachytherapy is widely adopted as an exclusive treatment of T1/T2 oral cancer with a high probability of definitive cure. Therefore, any major complication, like mandibular bone necrosis, should be avoided. Many risk factors, either clinical or technical, have been considered in the literature.

MATERIALS AND METHODS

One hundred consecutive interstitial iridium LDR treatments for early cancers of the tongue and floor of the mouth performed from January 1989 to November 1993 were reviewed. An analysis of some simple technical parameters (total dose, dose-rate, reference volume, linear activity, total reference kerma) was performed in order to identify the main physical risk factors. Moreover, total dose was recalculated as extrapolated responsive dose for normal tissue complications.

RESULTS

Bone necrosis was observed in 10 out of 100 patients with a median follow-up of 38 months. No significant incidence of this complication was observed when tumor site (mobile tongue versus floor of the mouth), dental status or total physical dose were considered. A significant correlation between the incidence of bone necrosis and two main parameters was found, i.e. dose-rate (P < 0.02) and reference volume (P < 0.05).

CONCLUSIONS

A threshold value may be suggested both for dose-rate (50 cGy/h) and reference volume (25,000 mm3). Bone necrosis is clearly related to both these parameters since most cases (i.e. 80%) were observed in the subgroup over the volume and dose-rate threshold.

Current controversies in the therapeutic approach to early breast cancer in the elderly

Over a 7-year period, in 408 patients aged 70 years or more, 413 early breast cancers were treated as follows: quadrantectomy, axillary dissection, and radiotherapy (QUART) in 142 patients, wide lumpectomy plus radiotherapy extended to the axilla in case of palpable nodes (WLRT) in 45 patients and wide lumpectomy alone in 221 patients. Postoperative tamoxifen was given to 251 patients and chemotherapy to 31. Mean follow-up was 54 months. Relapse free survival was similar at 5 years in the three groups (80%); at 10 years it was 80.8% in QUART, 61.3% in WLRT, 51.7% in WL. Locoregional recurrence, as first failure, occurred in 1.4% QUART, 6.5% WLRT and 15.2% WL. In our experience compliance with surgical day-hospital regimen was excellent, while postoperative radiotherapy created some problems, mainly among oldest patients. We support the role of radiotherapy for its positive impact on local control.

[Transcutaneous radiotherapy combined with low dose intraluminal brachytherapy in the treatment of non-operable neoplastic stenoses of the bile ducts]

Percutaneous biliary drainage is an excellent method to relieve the acute symptoms related to neoplastic stenoses of extrahepatic bile ducts. However, survival rates are low and the quality of life of these patients is poor. High dose irradiation--combined with external beams (ERT) and intraluminal brachytherapy (BRT) through percutaneous drainage--allows effective disease control and, therefore, not only higher survival rates but also a much better quality of life when drainage can be removed after bile duct stenosis resolution. March, 1990, through March, 1993, eleven patients (8 with extrahepatic cholangiocarcinomas and 3 with extrinsic tumors) were treated with combined ERT (40-60 Gy, 6-15 MV X-rays) and intraluminal BRT (6-25 Gy, 192Ir wire, LDR). In 8 patients the biliary stenosis was resolved, completely (CR) in 5 and partially (PR) in 3, as shown by posttreatment cholangiography. In 5 patients biliary drainage could be removed for an average 9 months' period; 3 of 11 patients did not respond to treatment at all (NR). Average overall survival was 14 months: 11 months for NR patients and 16.5 months for CR+PR patients. Treatment complications were acceptable: in two patients only treatment had to be discontinued, both during BRT. Two cases of high grade postirradiation stenosis were observed, both resolved with percutaneous cholangioplasthy.

[Ileal obstruction following radiosurgical treatment for rectosigmoid neoplasm]

A series of 191 patients submitted to adjuvant radiotherapy after surgery for rectal and rectosigmoid carcinoma from January, 1975, to December, 1990, has been analyzed to evaluate the incidence of high grade small bowel late toxicity (grades III/IV according to RTOG/EORTC scoring system). Surgical approach was abdominoperineal Miles resection in 92 patients, while a sphincter preserving bowel resection was performed in 99. The total radiation dose to the pelvis ranged from 40 to 60 Gy in 4 to 8 weeks, with conventional fractionation. Three different beams arrangements were used: two sagittal parallel opposite AP-PA fields in 106 patients, three fields (one posterior sagittal plus two parallel lateral fields) in 56, four fields (box technique) in 29. Fourteen patients (7.3%) developed sequelae grades III/IV: three of them died of toxicity. Average free interval between radiation and complication was 23 months (range: 4-87). The following risk factors were investigated: sex, age, type of surgery on primary rectosigmoid cancer, previous abdominal or pelvic surgery, radiation technique, treated volume, administered radiation dose. Dose was calculated as BED (time corrected biologically equivalent dose) according to the linear quadratic model. The only factors significantly related to late intestinal complications were the beam arrangement and, consequently, the treated volume. Detailed analysis showed that radiation sequelae developed in 12/106 (11.3%) patients treated with the two sagittal fields technique, while small bowel toxicity was observed in only 2/85 (2.3%) patients treated with the three--or four--fields technique. The difference is stastically significant (p < 0.05). Another significant correlation was the ratio between treated volume and late complications incidence observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Hyperfractionation versus conventional fractionation in oropharyngeal carcinoma: final analysis of a randomized trial of the EORTC cooperative group of radiotherapy

EORTC protocol 22791 compared once daily fractionation (CF) of 70 Gy in 35-40 fractions in 7-8 weeks, to pure hyperfractionation (HF) of 80.5 Gy in 70 fractions in 7 weeks using 2 fractions of 1.15 Gy per day, in T2-T3 oropharyngeal carcinoma (excluding base of tongue), N0,N1 of less than 3 cm. From 1980 to 1987, 356 patients were entered. In the final analysis (June 1990), the local control was significantly higher (p = 0.02 log-rank) after HF compared with CF. At 5 years, 59% of patients are local disease-free in the HF arm compared to 40% in the CF arm. The superiority of HF was demonstrated in patients staged T3N0,T3N1 but not in T2. The Cox model confirmed that the treatment regimen was an independent significant prognostic factor for locoregional control (p = 0.007 log-rank). This improvement of locoregional control was responsible for a trend to an improved survival (p = 0.08 log-rank). There was no difference in late normal tissue damage between the two treatment modalities.

[The results of definitive transcutaneous radiotherapy in the treatment of oropharyngeal neoplasms]

From January 1976 to December 1986, 199 patients with oropharyngeal cancer were submitted to definitive radiotherapy. Survival and local control were analyzed and related to different parameters--i.e, T and N categories, histopathologic grading, tumor location, patients age, and radiation dose. Fifty-six per cent of patients (111/199) died from neoplastic disease within 5 years. Local progression, recurrence or metastases were observed in 149 cases (75%). Ninety-three per cent of first failures (138/149) were related to residual disease or to locoregional relapse while distant metastases occurred in 14 patients only. The majority of locoregional failures (94%) appeared within 2 years, with a mean disease-free interval of 8 months. Tumor recurrence in the primary location was observed to be the first cause of failure in 78% of relapsed patients; moreover, it was the sole cause of failure in half of the unfavorable events. On the contrary, nodal relapse appeared in 38% of treatment failures and in 12% only it was the sole cause of failure. Overall and disease-free survival were observed to depend mainly on T and N categories, while histopathologic grading was seen to affect only early response rate. No significant differences were observed depending on tumor site and patients age. Local control rates depended on total radiation dose, but the difference between low dose (NSD less than 1700) and high dose (NSD greater than 1700) was significant only for T1 and T2 patients.