Comparative effectiveness of new treatment modalities for localized prostate cancer through patient-reported outcome measures

Purpose

There is scarce comparative effectiveness research on the new treatment modalities for localized prostate cancer. We aim to compare through Patient-Reported Outcome Measures (PROMs) the impact of active surveillance, robot-assisted radical prostatectomy (RARP), intensity-modulated radiotherapy (IMRT), and real-time brachytherapy, considering side effects (incontinence, irritative/obstructive urinary symptoms, sexual dysfunction and bowel symptoms) and physical and mental health.

Materials and Methods

Prospective cohort of men diagnosed with clinically localized prostate cancer (age 50-75y, T1-T2, and low risk including Gleason 3 + 4 in T1c) from 18 Spanish hospitals, followed up to 24 months. Treatment decisions were jointly made by patients and physicians (n = 572). The Expanded Prostate cancer Index Composite (EPIC-26) and Short-Form 36 (SF-36v2) were administered through telephone interviews before and three, six, 12, and 24 months after treatment. To account for correlation among repeated measures, generalized estimating equation models were constructed. All analyses were performed with propensity score weights to solve treatment selection bias.

Results

The PROMs completion rate at 24 months was 95.0 %. Active surveillance entails the fewest side effects, but with significant sexual (0.4 standard deviations [SD], p < 0.001) and physical health deterioration (0.5 SD, p < 0.001); and moderate mental health improvement (0.4 SD, p = 0.001) at 24 months. Compared with active surveillance, RARP presented greater urinary incontinence (p = 0.030), and IMRT and real-time brachytherapy worse bowel symptoms (p = 0.027 and p = 0.007) at 24 months.

Conclusions

Most side effects of the new treatment modalities seem to be limited to short-term deteriorations, except for moderate-large urinary incontinence in patients who had undergone RARP and moderate bowel deterioration in patients treated with IMRT or with real-time brachytherapy. Furthermore, patients under active surveillance, IMRT, and real-time brachytherapy showed a moderate improvement in mental health.

Antimicrobial efficacy of a very stable hypochlorous acid formula compared with other antiseptics used in treating wounds: in-vitro study on micro-organisms with or without biofilm

BACKGROUND

Many antiseptics have been used to treat wounds.

AIM

To compare the microbicidal efficacy of ClHO (Clortech®) with other antiseptics used on wounds, healthy skin and mucous membranes.

METHODS

The microbicidal efficacy of 13 antiseptic products on eight micro-organisms (three Gram-positive; three Gram-negative; two yeasts) inoculated on organic germ-carriers was studied. In addition, the loss of efficacy against Staphylococcus aureus and Pseudomonas aeruginosa with biofilm was assessed with the six best-performing products.

FINDINGS

Chlorhexidine (1%) had the highest microbicidal effect at 1 min. At 5 min, 500 and 1500 mg/L ClHO showed similar, or better, activity than the other antiseptics studied. The ClHO concentration of 300 mg/L achieved this same efficacy at 10 min. The product that lost the most efficacy due to biofilm was 1% chlorhexidine, while 1% PVP-I and ClHO at either 300 or 500 mg/L were moderately affected by biofilm. The most effective in the presence of biofilm was ClHO at 1500 mg/L.

CONCLUSIONS

ClHO at medium-low concentrations (300 or 500 mg/L) is a good antiseptic that can be used on wounds and mucous membranes for 5-10 min. Lower concentrations of ClHO, as well as of the other antiseptics studied, were less effective or more altered by the biofilm. ClHO at a concentration of 1500 mg/L is very effective in the presence or absence of biofilm that can be used on healthy skin for 5 min.

Correction to: Morphological MRI-based features provide pretreatment survival prediction in glioblastoma

The original version of this article, published on 15 October 2018, unfortunately contained a mistake. The following correction has therefore been made in the original: The name of Mariano Amo-Salas and the affiliation of Ismael Herruzo were presented incorrectly.

Morphological MRI-based features provide pretreatment survival prediction in glioblastoma

OBJECTIVES

We wished to determine whether tumor morphology descriptors obtained from pretreatment magnetic resonance images and clinical variables could predict survival for glioblastoma patients.

METHODS

A cohort of 404 glioblastoma patients (311 discoveries and 93 validations) was used in the study. Pretreatment volumetric postcontrast T1-weighted magnetic resonance images were segmented to obtain the relevant morphological measures. Kaplan-Meier, Cox proportional hazards, correlations, and Harrell's concordance indexes (c-indexes) were used for the statistical analysis.

RESULTS

A linear prognostic model based on the outstanding variables (age, contrast-enhanced (CE) rim width, and surface regularity) identified a group of patients with significantly better survival (p < 0.001, HR = 2.57) with high accuracy (discovery c-index = 0.74; validation c-index = 0.77). A similar model applied to totally resected patients was also able to predict survival (p < 0.001, HR = 3.43) with high predictive value (discovery c-index = 0.81; validation c-index = 0.92). Biopsied patients with better survival were well identified (p < 0.001, HR = 7.25) by a model including age and CE volume (c-index = 0.87).

CONCLUSIONS

Simple linear models based on small sets of meaningful MRI-based pretreatment morphological features and age predicted survival of glioblastoma patients to a high degree of accuracy. The partition of the population using the extent of resection improved the prognostic value of those measures.

KEY POINTS

• A combination of two MRI-based morphological features (CE rim width and surface regularity) and patients' age outperformed previous prognosis scores for glioblastoma. • Prognosis models for homogeneous surgical procedure groups led to even more accurate survival prediction based on Kaplan-Meier analysis and concordance indexes.

An exception to the rule "no association between antibiotic resistance and decreased disinfectant microbicidal efficacy": Orthophthalaldehyde (OPA) and Pseudomonas aeruginosa isolated from ICU and paraplegic patients

BACKGROUND

Antibiotic resistance and decreased susceptibility to disinfectants are not usually associated in microorganisms, but we have found an exception to this rule: P. aeruginosa versus orthophthalaldehyde (OPA).

METHODS

Bactericidal effect of OPA was measured at 10 minutes on endodoncy files contaminated with an ATCC strain (control) or 206 strains of P. aeruginosa recently isolated from 206 ICU and paraplegic patients in a tertiary university hospital, in two consecutive years.

RESULTS

Differences in bactericidal effect of OPA were found between the strains isolated each year (decreased susceptibility in the first period), but in both years the statistical differences (p < 0.05) were maintained according to whether the strains were "susceptible" to antibiotics, "resistant" (to one family of antibiotics) or "multi-resistant" (resistant to more than one family of antibiotics), exhibiting a reduction in their OPA susceptibility in parallel to an increase of their antibiotic resistance. In contrast, there were no differences depending on the type of sample (sputum, urine, faeces, pharynx) or of patient (paraplegic or ICU: adult, newborn, burn). Finally we selected 15 strains with an OPA effect below 3.5 log10 at 10 minutes and repeated the study with an OPA exposure of 15 minutes. In these conditions OPA showed a total bactericidal effect on these P. aeruginosa strains.

CONCLUSIONS

There was an association between antibiotic resistance and decreased OPA susceptibility. This normally does not require an increase in disinfection time, but, for endoscope disinfection or instruments from colonized/infected patients with resistant/multiresistant P. aeruginosa, we consider it better to use 15 min of OPA. Regular tests (e.g., once every 12 months) with germ-carriers, should be performed to assess ecological changes in susceptibility to high level disinfectants and must include not only ATCC strains, but also recently isolated microorganisms with different antibiotic sensitivities (susceptible, resistant and multi-resistant).

Glioblastoma: does the pre-treatment geometry matter? A postcontrast T1 MRI-based study

BACKGROUND

The potential of a tumour's volumetric measures obtained from pretreatment MRI sequences of glioblastoma (GBM) patients as predictors of clinical outcome has been controversial. Mathematical models of GBM growth have suggested a relation between a tumour's geometry and its aggressiveness.

METHODS

A multicenter retrospective clinical study was designed to study volumetric and geometrical measures on pretreatment postcontrast T1 MRIs of 117 GBM patients. Clinical variables were collected, tumours segmented, and measures computed including: contrast enhancing (CE), necrotic, and total volumes; maximal tumour diameter; equivalent spherical CE width and several geometric measures of the CE "rim". The significance of the measures was studied using proportional hazards analysis and Kaplan-Meier curves.

RESULTS

Kaplan-Meier and univariate Cox survival analysis showed that total volume [p = 0.034, Hazard ratio (HR) = 1.574], CE volume (p = 0.017, HR = 1.659), spherical rim width (p = 0.007, HR = 1.749), and geometric heterogeneity (p = 0.015, HR = 1.646) were significant parameters in terms of overall survival (OS). Multivariable Cox analysis for OS provided the later two parameters as age-adjusted predictors of OS (p = 0.043, HR = 1.536 and p = 0.032, HR = 1.570, respectively).

CONCLUSION

Patients with tumours having small geometric heterogeneity and/or spherical rim widths had significantly better prognosis. These novel imaging biomarkers have a strong individual and combined prognostic value for GBM patients.

KEY POINTS

• Three-dimensional segmentation on magnetic resonance images allows the study of geometric measures. • Patients with small width of contrast enhancing areas have better prognosis. • The irregularity of contrast enhancing areas predicts survival in glioblastoma patients.

Tumour heterogeneity in glioblastoma assessed by MRI texture analysis: a potential marker of survival

OBJECTIVE:

The main objective of this retrospective work was the study of three-dimensional (3D) heterogeneity measures of post-contrast pre-operative MR images acquired with T₁ weighted sequences of patients with glioblastoma (GBM) as predictors of clinical outcome.

METHODS:

79 patients from 3 hospitals were included in the study. 16 3D textural heterogeneity measures were computed including run-length matrix (RLM) features (regional heterogeneity) and co-occurrence matrix (CM) features (local heterogeneity). The significance of the results was studied using Kaplan-Meier curves and Cox proportional hazards analysis. Correlation between the variables of the study was assessed using the Spearman's correlation coefficient.

RESULTS:

Kaplan-Meyer survival analysis showed that 4 of the 11 RLM features and 4 of the 5 CM features considered were robust predictors of survival. The median survival differences in the most significant cases were of over 6 months.

CONCLUSION:

Heterogeneity measures computed on the post-contrast pre-operative T₁ weighted MR images of patients with GBM are predictors of survival.

ADVANCES IN KNOWLEDGE:

Texture analysis to assess tumour heterogeneity has been widely studied. However, most works develop a two-dimensional analysis, focusing only on one MRI slice to state tumour heterogeneity. The study of fully 3D heterogeneity textural features as predictors of clinical outcome is more robust and is not dependent on the selected slice of the tumour.

Evaluation of the utilization of external radiotherapy in the treatment of localized prostate cancer in Andalusia, Spain

BACKGROUND

Around 27,000 new cases of prostate cancer are diagnosed every year in Spain and 5400 die from this disease. Radiotherapy (RT), alone or combined, has proven to be effective as initial treatment in patients with localized disease. Our objective was to evaluate the use of external beam RT (EBRT) in our region, comparing the indication rate and irradiation rate and examining variability in its application among hospitals.

METHODS

We conducted a review of RT guidelines and indication studies for prostate cancer (% expected irradiation). Data were gathered from all twelve public healthcare centers in Andalusia (Spain) on RT-treated prostate cancer patients during 2013 (% actual irradiation) and from nine of the centers on RT discharge reports. Information was classified according to type of hospital, tumor risk category and RT treatment (technique, dosage, volume, toxicity).

RESULTS

The estimated RT rate was 67 % (1289/1917), 43 % were aged > 70 years, 44.7 % had ECOG performance status of 0); 44.7 % had high-risk tumors; 57 % underwent RT associated with hormone therapy; 70 % of patients receiving RT were treated with 3D planning (30 % IGRT); and doses were 70-76 Gy in 70 % of cases and >76 Gy in 10.7 %. Acute gastrointestinal and genitourinary toxicities were < grade 2 in 79 and 89 % of patients, respectively. An irradiation rate significantly below the mean for the study was found in four provinces. There was a significant difference among provinces in the distribution of risk groups.

CONCLUSIONS

Underutilization of EBRT was estimated to be around 30 % in prostate cancer patients, with an elevated variability in irradiation rates among hospitals related to differences in available technology and in the distribution of patients with different risk levels. These data should be a matter of concern to regional health managers, given the negative and measurable impact on the survival of patients.

Uroncor consensus statement: Management of biochemical recurrence after radical radiotherapy for prostate cancer: From biochemical failure to castration resistance

Management of patients who experience biochemical failure after radical radiotherapy with or without hormonal therapy is highly challenging. The clinician must not only choose the type of treatment, but also the timing and optimal sequence of treatment administration. When biochemical failure occurs, numerous treatment scenarios are possible, thus making it more difficult to select the optimal approach. Moreover, rapid and ongoing advances in treatment options require that physicians make decisions that could impact both survival and quality of life. The aim of the present consensus statement, developed by the Urological Tumour Working Group (URONCOR) of the Spanish Society of Radiation Oncology (SEOR), is to provide cancer specialists with the latest, evidence-based information needed to make the best decisions for the patient under all possible treatment scenarios. The structure of this consensus statement follows the typical development of disease progression after biochemical failure, with the most appropriate treatment recommendations given for each stage. The consensus statement is organized into three separate chapters, as follows: biochemical failure with or without local recurrence and/or metastasis; progression after salvage therapy; and treatment of castration-resistant patients.

Estimating preferences for treatments in patients with localized prostate cancer

PURPOSE

Studies of patients' preferences for localized prostate cancer treatments have assessed radical prostatectomy and external radiation therapy, but none of them has evaluated brachytherapy. The aim of our study was to assess the preferences and willingness to pay of patients with localized prostate cancer who had been treated with radical prostatectomy, external radiation therapy, or brachytherapy, and their related urinary, sexual, and bowel side effects.

METHODS AND MATERIALS

This was an observational, prospective cohort study with follow-up until 5 years after treatment. A total of 704 patients with low or intermediate risk localized prostate cancer were consecutively recruited from 2003 to 2005. The estimation of preferences was conducted using time trade-off, standard gamble, and willingness-to-pay methods. Side effects were measured with the Expanded Prostate Index Composite (EPIC), a prostate cancer-specific questionnaire. Tobit models were constructed to assess the impact of treatment and side effects on patients' preferences. Propensity score was applied to adjust for treatment selection bias.

RESULTS

Of the 580 patients reporting preferences, 165 were treated with radical prostatectomy, 152 with external radiation therapy, and 263 with brachytherapy. Both time trade-off and standard gamble results indicated that the preferences of patients treated with brachytherapy were 0.06 utilities higher than those treated with radical prostatectomy (P=.01). Similarly, willingness-to-pay responses showed a difference of €57/month (P=.004) between these 2 treatments. Severe urinary incontinence presented an independent impact on the preferences elicited (P<.05), whereas no significant differences were found by bowel and sexual side effects.

CONCLUSIONS

Our findings indicate that urinary incontinence is the side effect with the highest impact on preferences and that brachytherapy and external radiation therapy are more valued than radical prostatectomy. These time trade-off and standard gamble preference assessments as well as the willingness-to-pay estimation could be useful to perform respectively cost-utility or cost-benefit analyses, which can guide health policy decisions.

Infrastructures, treatment modalities, and workload of radiation oncology departments in Spain with special attention to prostate cancer

AIM

The purpose of the study was to describe infrastructures, treatment modalities, and workload in radiation oncology (RO) in Spain, referred particularly to prostate cancer (PC).

METHODS

An epidemiologic, cross-sectional study was performed during 2008-2009. A study-specific questionnaire was sent to the 108 RO-registered departments.

RESULTS

One hundred and two departments answered the survey, and six were contacted by telephone. Centers operated 236 treatment units: 23 (9.7 %) cobalt machines, 37 (15.7 %) mono-energetic linear accelerators, and 176 (74.6 %) multi-energy linear accelerators. Sixty-one (56.4 %) and 33 (30.5 %) departments, respectively, reported intensity-modulated radiation therapy (IMRT) and image-guided RT (IGRT) capabilities; three-dimensional-conformal RT was used in 75.8 % of patients. Virtual simulators were present in 95 departments (88.0 %), 35 use conventional simulators. Fifty-one departments (47.2 %) have brachytherapy units, 38 (35.2 %) perform prostatic implants. Departments saw a mean of 24.9 new patients/week; the number of patients treated annually was 102,054, corresponding to 88.4 % of patients with a RT indication. In 56.5 % of the hospitals, multidisciplinary teams were available to treat PC.

CONCLUSIONS

Results provide an accurate picture of current situation of RO in Spain, showing a trend toward the progressive introduction of new technologies (IMRT, IGRT, brachytherapy).

Consensus on the regional lymph nodes irradiation in breast cancer

Standard locoregional treatment of early-stage breast cancer currently consists of the conservative surgery and sentinel lymph node biopsy. In the event of positive sentinel node biopsy, an axillary level I-II lymphadenectomy should be carried out. However, recent publications have increasingly supported a tendency not to apply the surgical lymphadenectomy, but simultaneously, it has been developed a new role of regional radiotherapy, even if there is only 1-3 axillary lymph nodes involved. Given these new trends, radiation oncologists are facing the dilemma with regard to deciding about regional irradiation of breast cancer. For such purpose, The Spanish Group of Breast Cancer Radiation Oncology (GEORM as per its Spanish acronym) decided to reach a consensus to issue the respective guidelines for such types of cases. GEORM Managing Commission, gathering 13 members of different Spanish regional communities, issued a questionnaire including different clinical situations. These questions were set as key questions seeking responses, which were answered by 66 % out of the 75 members of the group. Following the response, the guidelines were drafted based on the replies to the mentioned questionnaire. All the respective issues were discussed by means of a virtual platform. In this article, we show the levels of consensus for different clinical situations, depending on the number of nodes involved and the type of surgical procedure performed on the axillary lymph nodes. The ongoing evolution of the oncological treatments obliges the radiation oncologists to take decisions without any existing clarifying evidence, and therefore, the consensus is necessary, which can assist in the decision-making process by the practitioners in such kinds of clinical situations.

[1st National Meeting of Multidisciplinary Work in Oncogeriatrics: expert consensus document]

On 2nd of June 2011 the Institut Català d' Oncologia l'Hospitalet--Hospital Duran i Reynals hosted the first Meeting of Multidisciplinary Work in Oncogeriatrics. The reason for the meeting, which follows on from an initiative of the Medical Societies of Radiotherapy, Oncology, Geriatrics and Gerontology and Palliative Care and Medical Oncology, was to initiate a joint line of work among the different specialties that generally take part in the handling of the elderly patient suffering from oncologic pathologies. This document summarises the different subjects covered during the Meeting.

The white book of radiation oncology in Spain

The White Book of Radiation Oncology provides a comprehensive overview of the current state of the speciality of radiation oncology in Spain and is intended to be used as a reference for physicians, health care administrators and hospital managers. The present paper summarises the most relevant aspects of the book's 13 chapters in order to bring the message to a wider audience. Among the topics discussed are the epidemiology of cancer in Spain, the role of the radiation oncologist in cancer care, human and material resource needs, new technologies, training of specialists, clinical and cost management, clinical practice, quality control, radiological protection, ethics, relevant legislation, research & development, the history of radiation oncology in Spain and the origins of the Spanish Society of Radiation Oncology (SEOR).

Erlotinib and chemoradiation in patients with surgically resected locally advanced squamous cell carcinoma of the head and neck: a GICOR phase I trial

BACKGROUND

Standard treatment of advanced squamous cell carcinoma of the head and neck (SCCHN) is concurrent chemoradiation. Erlotinib is an oral tyrosine kinase inhibitor of epidermal growth factor receptor, which has shown activity in SCCHN. Phase I study aims to determine the maximum tolerated dose and dose-limiting toxicity (DLT) of adding erlotinib to chemoradiation therapy in patients with surgically resected locally advanced SCCHN.

PATIENTS AND METHODS

Inclusion criteria--SCCHN patients with T3 or T4 primary lesion (except T3N0 with negative resection margins); pathologic N2-N3 disease; poor prognostic findings; age 18-70 years; Eastern Cooperative Oncology Group performance status of zero to one; no evidence of metastasis; adequate organic function and written informed consent. Study design--dose-escalating phase I study with three cohorts of three to six patients each that received increasing doses of erlotinib (100-150 mg/day p.o.) and cisplatin (30-40 mg/m(2) i.v., day 1) for 7 weeks. Radiotherapy--standard regimen of 1.8 Gy daily (5 fractions/week) to a maximum total dose of 63 Gy in 7 weeks.

RESULTS

Thirteen male (median age: 57 years) were enrolled. Overall, the regimen was well tolerated. Two of three patients treated at dose level III (erlotinib: 150 mg/day; cisplatin: 40 mg/m(2)) developed DLT consisting of grade 3 infection and grade 3 mucositis. Other toxic effects included diarrhea, asthenia, and rash. Recommended dose for additional studies: erlotinib 150 mg/day p.o.; cisplatin 30 mg/m(2)/week i.v.

CONCLUSION

Erlotinib can be safely combined with chemoradiation without requiring dose reduction of chemo- or radiotherapy in this postsurgical population.

Quality-of-Life Impact of Primary Treatments for Localized Prostate Cancer in Patients Without Hormonal Treatment

Purpose

Earlier studies evaluating the effect on quality of life (QoL) of localized prostate cancer interventions included patients receiving adjuvant hormone therapy, which could have affected their outcomes. Our objective was to compare the QoL impact of the three most common primary treatments on patients who were not receiving adjuvant hormonal treatment.

Patients and Methods

This was a prospective study of 435 patients treated with radical prostatectomy, external-beam radiotherapy, or brachytherapy. QoL was assessed before and after treatment with the Short Form-36 and the Expanded Prostate Cancer Index Composite. Differences between groups were tested by analysis of variance. Distribution of outcome at 3 years was examined by stratifying according to baseline status. Generalized estimating equation models were constructed to assess the effect of treatment over time.

Results

Compared with the brachytherapy group, the prostatectomy group showed greater deterioration on urinary incontinence and sexual scores but better urinary irritative-obstructive results (−18.22, −13.19, and +6.38, respectively, at 3 years; P < .001). In patients with urinary irritative-obstructive symptoms at baseline, improvement was observed in 64% of those treated with nerve-sparing radical prostatectomy. Higher bowel worsening (−2.87, P = .04) was observed in the external radiotherapy group, with 20% of patients reporting bowel symptoms.

Conclusion

Radical prostatectomy caused urinary incontinence and sexual dysfunction but improved pre-existing urinary irritative-obstructive symptoms. External radiotherapy and brachytherapy caused urinary irritative-obstructive adverse effects and some sexual dysfunction. External radiotherapy also caused bowel adverse effects. Relevant differences between treatment groups persisted for up to 3 years of follow-up, although the difference in sexual adverse effects between brachytherapy and prostatectomy tended to decline over long-term follow-up. These results provide valuable information for clinical decision making.

Conservative treatment with transurethral resection, neoadjuvant chemotherapy followed by radiochemotherapy in stage T2-3 transitional bladder cancer

PURPOSE

Organ preservation has been investigated in patients (p) with infiltrating transitional cell carcinoma (TCC) of the bladder over the past decade as an alternative to radical cystectomy. This is a trimodal schedule study, including transurethral resection of bladder tumor (TURB), neoadjuvant chemotherapy and concomitant radiochemotherapy (RTC).

PATIENTS AND METHODS

From April 1996 until August 2005, 29 evaluable patients (p) with T2-T3NXM0 bladder cancer were enrolled. After a transurethral resection of bladder tumor (TURB), we administered 2 cycles of induction chemotherapy with CMV (15 p) or Gemcitabine-Cisplatin (14 p) followed by radiotherapy 45 Gy 1.8 Gy/fraction and two cycles of concomitant cisplatin 70 mg/m(2). 2-3 weeks later, a cystoscopy with tumor-site biopsy was performed. If complete histological response, p were treated with consolidation radiotherapy until 64.8 Gy. For p with residual or recurrent tumor, cystectomy was performed.

RESULTS

We included 28 men and 1 women (median age 63, range 39-72 years) with PS (ECOG) 0-1. The stage was: 21 p T2; 6 p T3a; and 2 p T3b. Toxicity was higher in CMV compared with Gem- Cis: grade (3/4) neutropenia 4/15 (26%) vs 1/14 (7%); febrile neutropenia 3/15 (20%) vs 1/14 (7%); grade (3/4) trombocytopenia 2/15 (13%) vs 1/14 (7%). Toxicities with concomitant RCT were low-moderate: urocystitis (26%) and enteritis (18%).

RESPONSE

microscopically complete TURB was obtained in 20 p (69%), but not in 9 p (31%) (7 microscopic, and 2 macroscopic residual tumor). We found a complete histologic response after induction RCT in 25 p (86%). After a median follow-up of 69.4 months (m) (range: 8-97.7), there were 8 deaths, with a overall survival of 72%. Furthermore 14 of 29 p (48%) were alive with intact bladder, and median survival time with intact bladder was 63.6 m (50.1-77.2); were predictive of best outcome T2 stage vs T3 (p < 0.0001), and complete histologic resection in initial TURB vs residual tumor (p = 0.0004).

CONCLUSIONS

Combined treatment provide high response rates and can be offered as an alternative option to radical cystectomy in selected patients with TCC. Patients with T2 stage and complete histologic resection in initial TURB had the best outcome.

Phase I/II study of concurrent erlotinib and chemoradiation for post-resected locally advanced squamous head and neck cancer (HNSCC): A GICOR study

16544

Background: Concurrent chemoradiation is considered the optimal treatment for advanced HNSCC, including post-resected status. Erlotinib is an oral EGFR TKI, with activity in recurrent and metastatic HNSCC.The Spanish Group of Clinical Research in Radiation Oncology (GICOR) leads a phase I/II study to determine the maximum tolerated dose (MTD) and dose-limiting toxicity (DLT) of adding erlotinib (e) to chemoradiation to patients (p) with surgically resected locally advanced HNSCC Methods: p had surgically resected advanced HNSCC, with a least one of the following criteria: T3 or T4 primary lesion (except T3N0 with negative resection margins), pathologic N2-N3 disease, and poor prognostic findings (i.e. extranodal spread, positive resection margins, perineural or perivascular involvement). Additional eligibility criteria included: age 18–70 y; life expectancy = 12 w; PS 0–1; no evidence of metastasis; adequate organic function; and written informed consent. Dose-escalating phase I study consisted on 3 cohorts of 3–6 p each, with increasing doses of erlotinib (100–150 mg po qd) and cisplatin (30–40 mg/m2, iv, d 1) for 7 w. Radiotherapy was delivered as a fixed standard regimen of daily 1.8 Gy (5 fractions/w) to a total dose of 63 Gy in high risk areas along 7 w. Results: By the time of this analysis, 7 p have entered the phase I component of the study. Median age: 52 y; male 100%. Complete data for 4 pats included in cohort 1 (e 100 mg/d, c 30 mg/m2) are available. One p withdrew prematurely the study due to a grade 2 toxicity (not considered DLT) and was considered unevaluable by the Scientific Committee. Among evaluable p, 2 developed mucositis (1g.3), vomiting (g.1) and nausea (g.1). All p developed skin rash (mild in all the cases). Haematological toxicities were single cases of anaemia, leukopenia and thrombocytopenia (g.1). All 3 p completed 7 weeks of treatment and no dose reduction was required. No DLT as per protocol has been described and study went subsequently further to cohort 2. Conclusions: This study demonstrates the safe addition of erlotinib to chemoradiotherapy in the treatment of this p population. Full data from the phase I study will be presented.

No significant financial relationships to disclose.

Damage assessment in gastric cancer treatment with adjuvant radiochemotherapy: calculation of the NTCP's from the differential HDV of the organs at risk

OBJECTIVE

To calculate the Normal Tissue Complication Probabilities (NTCP) for the liver, right kidney, left kidney and spinal cord, as well as the global Uncomplicated Tumour Control Probability (UTCP) in gastric cancer patients who underwent a treatment with radiotherapy after radical surgery in our environment.

MATERIAL AND METHOD

In April 2000, a postoperative chemotherapy (QT-RT) protocol started in the province of Malaga for Gastric Adenocarcinomas with postsurgical stage II or higher (pT3-4 and/or pN+). This clinical protocol served as a base for our NTCP and UTCP retrospective theorical study. A virtual simulation and a 3D planning were made in all cases. The differential HDV, selected for each patient were obtained for the 4 organs at risk (OR). Hystograms reduction was made by the Kutcher and Burman's Effective Volume method. NTCP calculations by Lyman's models. The following variables were calculated: maximal dose for each organ (Dmax), Effective Volume (Veff), TD50 (Veff/Vref); NTCP for each organ of the patient; global UTCP for each patient. Differences between the 2 treatment techniques were analysed (2-field versus 4-field technique). For the NTCP calculations the computer application Albireo 1.0(R) was used.

RESULTS

29 patients to assess with an average age of 54 +/- 10 years (range: 38-71); 65.5% men/34.5% women. The technique used was the field technique AP-PA in the 51.7% (15) and with 4 fields in 48.3% (14) of the cases. The global damage is estimated in 16% with a range between 0 and 37%. This goes up to 25% with the 2-field technique, with a wide range between 2 and 48% and it remains reduced to 4%, within a range between 0 and 12% when 4 fields are used. There were significant differences concerning the estimated damage probability (NTCP) on liver, spinal cord and left kidney, depending on the use of two or four fields.

CONCLUSION

NTCP and the global UTCP values of the organs at risk allow to compare a technique net benefit from another in each particular case, although in our theoretical study the comparison was done among the patients. It is important to stress that the calculations of the TCP and NTCP have a limited quantitative signification but they are useful and beneficial in order to decide between treatment plans when they are supported by the clinical knowledge.

[Neoadjuvant treatment with cisplatin, 5-FU and folinic acid in advanced head and neck cancer]

From May to February 1992, 32 patients diagnosed as advanced cancer of the head and neck were included in a program of neoadjuvant treatment with cisplatin, 5-FU, and folinic acid, followed by radiotherapy (45 at 70 Gy) and/or surgery. Twenty patients were considered fully evaluable; their global response rate was 75% (7 complete responses and 8 partial responses). Five patients had no appreciable response or progression. Radiotherapy after chemotherapy enhanced the response, yielding complete responses in 4 patients and partial response in 1. Toxicity was moderate, except for mucositis (9 cases grade 3-4), despite high doses of drugs and radiotherapy. Given the clinical results, this combination may be promising as a first-line treatment against advanced cancer of the head and neck.