[Adaptive IG-IMRT for prostate cancer]

BACKGROUNDS

Adaptive image-guided intensity-modulated radiation therapy (IG-IMRT) is a perspective method for the treatment of localized prostate cancer. Validate optimal protocols for IG-IMRT using kilovoltage cone-beam CT (CBCT) are required.

PATIENTS AND METHODS

Seventy-six patients with prostate cancer were treated using adaptive IG-IMRT. Based on the CBCT performed during the first 10 fractions of radiotherapy, an average prostate position in relation to the pelvic bones was determined in antero-posterior AP, supero-inferior SI, and right-left axes. An adapted treatment plan for the second phase of the treatment included an isocenter shift into its average position (correction of the systematic error sigma). A margin between a clinical and planned target volume (CTV-PTV) was adjusted according to the magnitude of random error sigma. During the second phase of radiotherapy, set-up of patients was performed daily on pelvic bones using kilovoltage skiagraphic imaging in two projections (kV-kV). Follow-up CBCTs were repeated once a week.

RESULTS

An average isocenter position differed from the position of a reference planning CT isocenter in at least one axis in 63 patients (83%). Major changes were recorded in AP axis - shift > or = 2 mm in 33 patients (43%), shift > or = 5 mm in 7 patients (9%). PTV for the second phase of radiotherapy was in the range of 6-10 mm in AP axis, 6-8 mm in SI axis, and 6 mm in RL axis. Mean sigma value in the AP axis was smaller in patients with a specific diet compared to patients without the diet (2.2 mm vs. 2.7 mm, p = 0.05). We evaluated 446 follow-up CBCT images from the second phase of radiotherapy (66 patients had 6 CBCT, 10 patients had 5 CBCT). Set-up error exceeding CTV-PTV margin occurred in 4 cases with no more than once per patient. Safety margin was sufficient in 72/76 patients (95%).

CONCLUSION

IG-IMRT protocol integrating CBCT and kV-kV imaging provided adequate coverage of the target volume and proved to be compatible with departmental workflow. Margin reduction around the CTV is a prerequisite for dose escalation aimed at a intraprostatic lesion.

[Prostate bed radiotherapy--when and what?]

BACKGROUNDS

Recently, prostate bed irradiation has, due to the results of randomized trials which confirmed its benefit in adjuvant treatment, become the standard treatment for patients with risk factors after radical prostatectomy. It is also irreplaceable in the treatment of biochemical progression caused by local recurrence. In most cases, the tumour is not visible on planning CT, so it is necessary to use all available information to define the target volume to treat all the sites where the recurrence could be present.

DESIGN

The aim of this review is to provide a compendium of radiotherapy after radical prostatectomy, its indications and especially the localization of recurrences, which implicates the clinical target volume definitions.

CONCLUSION

The treatment of prostate cancer requires close co-operation between urologists and radiation oncologists, especially now when the indication of radiotherapy includes patients with risk factors after radical prostatectomy where adjuvant treatment should be performed early after surgery. It is of the utmost importance to precisely define the target volume for radiotherapy to fully prevent local recurrence without unnecessary complications for the patient.

[Changes in target volumes definition by using MRI for prostate bed radiotherapy planning--preliminary results]

BACKGROUNDS

Magnetic resonance imaging (MRI) is used quite routinely in radiotherapy treatment planning in the primary radiotherapy of prostate cancer as it provides more contrast imaging of soft tissues in the small pelvis than planning CT, thanks to which it allows more exact delineation of target volumes and thus the saving of organs at risk We tried to verify whether it is possible to use MRI by analogy in the planning of prostate bed radiotherapy.

PATIENTS AND METHODS

Twentyone patients indicated for prostate bed radiotherapy were considered in this study. Here we present the preliminary results of 10 of them. Four patients were indicated for adjuvant, 6 for salvage radiotherapy. All the patients underwent, besides standard planning CT, MRI in the same position. Target volumes and organs at risk were delineated into CT,T1 and T2 MRI images - clinical target volume (CTV), planning target volume (PTV), urinary bladder and rectum. Based on the merging of images, the volumes delineated in MRI were copied into planning CT, where the evaluation was done. We evaluated the volumes of each structure, agreement in contouring with the help of the rate of union and intersection of the volumes and with Cohen's kappa, and 3D differences between volumes of CTV on CT, T1 and T2 MRI.

RESULTS

Statistically, volumes of CTV and PTV are not significantly different. The volume of the rectum is significantly smaller on T1 and also T2 MRI images. The index of agreement (union/intersection) is statistically significantly different from 1 for CTV and PTV as well. Cohen's kappa indicates moderate agreement for CTV CT and T1, T1 and T2 MRI, fair agreement for CTV CT and T2 MRI, and substantial agreement for PTV. In the superior and superolateral direction, the CTV volume on MRI in the central plane is smaller on T1 and T2 images. In the area of seminal vesicles (SV) the cranial border is similar on CT and MRI. In the superoposterior direction, the volume of CTV is smaller on CT than on T1 and T2 MRI, which means, that seminal vesicles are delineated larger in the posterior direction on MRI (about 0.24cm on T1; by about 0.20cm on T2 images). In the posterior direction, there are no differences in CTV on CT and T1 while on T2 the CTV is larger (a difference of 0.29 cm). In the posterolateral direction, CTV is smaller on T1 MRI than on CT on both sides, on the right as well as on the left.

CONCLUSION

Preliminary results suggest that clinical target volume defined with the help of MRI is shifted compared with CTV defined on planning CT. The agreement of CTV delineation by one radiation oncologist is moderate to fair and is similar to interobserver variability in the contouring of the prostate bed in the planning CT. MRI provides more contrast imaging of the anterior rectal wall, where we have confirmed the most differences in contouring. Moreover, it provides better imaging of local recurrences and seminal vesicles, where the most differences in our group of patients were seen in comparison with planning CT.

[Chronic gastrointestinal toxicity after external-beam radiation therapy for prostate cancer]

BACKGROUNDS

Chronic gastrointestinal (GI) toxicity is an important dose-limiting factor of prostate cancer treatment. Its incidence varies with the dose of radiotherapy and the external beam treatment technique; however, there are also other factors that should be considered. Despite all the efforts to diminish the incidence, chronic toxicity still remains an adverse event which can affect the quality of life in patients after prostate cancer radiotherapy.

DESIGN

The aim of this review is to provide a detailed description of chronic GI toxicity after external beam radiation therapy for prostate cancer, its causes, development, symptoms and incidence in different treatment techniques, and to compare the development of GI toxicity from the beginning of curative prostate cancer radiotherapy to now.

CONCLUSION

Thanks to up-to-date radiotherapy techniques, the incidence of chronic GI toxicity is relatively low despite high doses of about 80 Gy used in prostate cancer treatment. Further reduction of radiation complications could be achieved by using image-guided radiotherapy (IGRT), which enables more precise delivery of the radiation dose to the prostate, reduction of the margin around the clinical target volume (CTV) and the sparing of organs at risk.

[Use of PET/CT examination in head and neck cancer radiotherapy planning]

BACKGROUND

Using conformal techniques and IMRT in radiotherapy allows dose increase in the target volume and sparing of healthy tissues. In comparison with conventional techniques it requires more accuracy in the target volume delineation. It is important to use all relevant diagnostic methods to reduce the risk of relapse.The basic method is CT examination which allows the dose distribution to be calculated. New imaging dimensions are associated with PET (positron emission tomography), which supplements the morphological image (CT or MRI) with a functional view.The aim of this study was to evaluate the benefit of PET/CT fusion in radiotherapy planning for head and neck cancer.

PATIENTS AND METHODS

40 head and neck cancer patients treated by definitive radiotherapy were evaluated. The patient group consisted of 30 men and 10 women, with a median age of 56 years (range 34-81 years). Postoperative radiotherapy was used in 10 cases and 30 patients were irradiated without prior surgery. IMRT technique with simultaneous integrated boost was used with 6 MV photons.

RESULTS

Comparing diagnostic CT with planning PET/CT, there was no difference in tumour extent in 20 out of 40 patients. In 6 cases (15%) the nodal involvement was more extensive according to PET/CT while in 3 cases (7.5%) the nodal involvement was detected to be less extensive. In 2 patients (5%) the primary tumour was reclassified, in both cases towards tumour enlargement. Two patients with positive histopathological margin were PET/CT negative. PET/CT imaging resulted in a change in the target volume in 11 (27.5%) patients and the treatment strategy was changed in 3 cases.

CONCLUSION

We tested use of the PET/CT examination in radiotherapy treatment planning of the head and neck carcinoma and it was introduced as a standard clinical practice at our department.

[The progress in the treatment of cervical cancer--3D brachytherapy CT/MR-based planning]

Brachytherapy plays a major role in the therapeutic management of patiens with cervix cancer. The rapid dose fall-off provide a very high dose to the tumor, while relative sparing bladder, rektum, sigmoid and small bowel. The CT/MR-based planning provides better information on target and organ volumes and dose-volumes histograms in contrast to radiography-based planning, that provides doses only at selected points.

[Extended field radiotherapy and high-dose brachytherapy combined with chemotherapy in patients with locally advanced cervical carcinoma]

OBJECTIVE

Evaluation of results of extended field radiotherapy and high-dose rate brachytherapy combined with chemotherapy in patients with locally advanced cervical carcinoma.

TYPE OF THE STUDY

A retrospective study.

SETTING

Department of Oncology and Radiotherapy, University Hospital Hradec Králové.

METHODS

Forty five patients with stage IIB - IVA cervical cancer and radiologically suspicious pelvic and/or paraaortic lymph nodes were treated at the Dept. of Oncology and Radiotherapy Hradec Králové with pelvic and paraaortic radiotherapy, high-dose rate brachytherapy and concomitant chemotherapy with cisplatin or cisplatin and paclitaxel.

RESULTS

The 3-years disease free survival estimate was 64%. Hematological toxicity was the most limiting factor of concomitant chemotherapy. Late toxicity grade III and IV was observed in 7 patients. One patient underwent surgery due to ileus caused by lymphoma.

CONCLUSIONS

Concomitant chemoradiotherapy with paraaortic fields results in high tumor control but also significant acute and late toxicity. New techniques of radiotherapy, such as intensity modulated radiotherapy, may improve the therapeutic ratio.

[Chemotherapy intensity importance in concurrent chemoradiotherapy of locally advanced cervical cancer]

OBJECTIVE

Concurrent chemoradiotherapy with weekly cisplatin became a standard procedure in patients with locally advanced cervical carcinoma. The objective of this retrospective study was to evaluate the therapy toleration and the survival of patients with locally advanced cervical cancer treated with concurrent chemoradiotherapy with weekly cisplatin of 40mg/m2.

SUBJECT AND METHOD

From January 2000 to December 2004, 40 patients with locally advanced cervical cancer were treated with concurrent chemoradiotherapy with weekly cisplatin of 40mg/m2. Radical radiotherapy consisted of external beam radiotherapy 25 x 2 Gy to the pelvis, high-dose rate brachytherapy 6 x 4 Gy to the tumor, boost 7 x 2 Gy to the pelvic walls. 21 patients also recieved 22 x 2 Gy to the para-aortic lymphatic nodes.

RESULTS

Only 16 patients recieved full five doses of cisplatin. Causes of discontinuance of the chemotherapy: acute hematological toxicity with leukopenia (10), thrombocytopenia (1), anaemia (1), increased levels of creatinine (2), profuse vomiting (1), haematemesis (1). Stage dependent two-year overall survival (OS) was 72% (IIB) against 64% (III, IVA). Two-year disease-free survival (DFS) dependent on the number of cisplatin doses was 77% (> or = 3 doses) against 56% (<3 doses) in patients with IIB stage.

CONCLUSION

Acute hematological toxicity with leukopenia was the most frequent cause of discontinuance of the chemotherapy. The results of two-year OS and DFS show difference in dependence on the number of applied doses of chemotherapy. However, the difference was not significant due to a low number of patients subject to the study.

[Electroretinoraphic findings in age-related macular degeneration (ARMD) before and after radiotherapy]

Standard ERG examinations were performed in 61 patients with ARMD before and after radiotherapy. Before the radiotherapy, a significant decrease in the cone b- wave amplitude and a significant reduction of the sum of oscillatory potentials (OP1-OP4) were found. At 24 months after the first dose of radiotherapy, a significant decrease in the rod response and 30-Hz flicker response were described. A possible explanation for the findings is an influence of radiotherapy onto primary circulatory disturbances in the whole retina in ARMD.

[The results of radiotherapy 24 months after treatment by patients with age-related macular degeneration]

The authors evaluate results of the radiotherapy by age- related macular degeneration. 114 patients (123 eyes) were examined. According to the total dose, we have divided the patients in 3 groups. Group A (12 Gy) consisted of 68 patients (74 eyes) and group B consisted of 46 patients (49 eyes), group C was designated as a control group, consisting of 21 patients (22 eyes). They have been performed in Department of Ophthalmology of Teaching Hospital of Charles University in Hradec Králové from February 1999 to April 2003. All examinations were performed before and at 24 months- follow up the radiotherapy. Radiotherapy seems to be a very promising and efficient method for treatment of the wet form of ARMD.

[A case of an asynchronic triple tumorous disorder: a rectal adenocarcinoma, a carcinoma of the kidney and a prostatic adenocarcinoma--case report]

The authors describe occurence asynchronic tumor triplicity. In the year 1980 in 56 years old patient had histologically proven rectal adenocarcinoma and consequently was done radical Miles amputation of rectum. In December 1991 in the same patient was histologically proven well differentiated adenocarcinoma of prostate after transurethral resection of prostate. Prostate cancer was threated bilateral orchiectomy (March 1992) and consequently from April to June 1992 was done small-volume irradiation of pelvic by Betatron X-ray, box technique with dosage 70 Gy. In November 1992 there was done radical transperitoneal nephrectomy on right side for renal carcinoma. Histologically was proven moderately differentiated clear cell renal carcinoma. In August 1994 was found suspected pulmonary metastases, wich was proof on CT in the January 1995. Therapy was Imodin, Wobenzym, Vinblastin. Patient was died of generalisation renal cancer in the February 1998. The carcinoma of prostate and rectum wasn't found in the autopsy. The authors emphasize pertinence radical surgical access incuding multiplex malignant tumors and consider to carry out oncology screening in the all of patients with proven malignant tumor.

Weekly Paclitaxel Combined with Local Hyperthermia in the Therapy of Breast Cancer Locally Recurrent after Mastectomy – a Pilot Experience

BACKGROUND

The combination of chemotherapy and hyperthermia (HT) is a promising approach in the treatment of malignant tumors. In the present report we evaluate the efficacy and toxicity of a combination of weekly paclitaxel combined with local hyperthermia in breast cancer.

PATIENTS AND METHODS

7 patients were treated for inoperable local recurrence of breast cancer after mastectomy, irradiation, and chemotherapy or hormonal therapy. They weekly received paclitaxel (60-80 mg/m(2)) in 3-h infusions followed by local HT 41-44 degrees C for 45 min for 6-18 cycles.

RESULTS

Objective local response was observed in all treated patients (complete response in 4 patients and partial response in 3 patients). There were no grade 3 or 4 toxicities, neurologic toxicity or hypersensitivity reactions. Local tolerance to this regimen was also good, with only 4 patients developing mild transient erythema.

CONCLUSION

Our experience indicates that the combination of weekly paclitaxel and HT may be effective in the treatment of locally recurrent breast cancer after mastectomy.

Perioperative fractionated high-dose rate brachytherapy in the treatment of soft tissue sarcomas

The purpose of the study was to investigate the viability of perioperative fractionated high dose rate brachytherapy (HDR BT) for primary and reccurent soft tissue sarcomas (STS). From February 1998 through June 2002, 21 adult patients, 11 females and 10 males with either low grade or high grade soft tissue sarcomas were treated by perioperative HDR BT. Surgical margin was negative in 10 cases, close in 4 and positive in 4 in cases. In 3 cases it was not described. BT was used as a part of primary treatment in 10 cases and for the treatment of reccurent tumor in 11 cases. The localisation of the tumor was the extremity in 16 patients and the trunk in 5 patients. Ten patients were treated with HDR BT alone (total mean dose 40 Gy) and 11 were treated with combination of external beam radiotherapy (EBRT) (40-50 Gy) and brachytherapy (total mean dose 24 Gy). Hyperfractionation 2.4-3 Gy twice daily at 10 mm from the source was used for BT. Follow-up periods were between 7--48 months (median: 20 months). Local control in patients treated pro primary STS was 100%.The pulmonal metastases were a cause of death in one case, one patient was alive with dissemination and one patient was disease free after salvage surgery and chemotherapy for lung metastases. Local control was achieved only in 3 of 11 patients treated for reccurent tumor (27%). Six patients were disease free after salvage surgery, 2 patients died of disease progression, one patient died of toxicity of chemotherapy without evidence of disease and 2 patients are alive with distant metastases. Local control was achieved in 5 of 11 (45%) patients with positive, close or not stated surgical margin and in 5 of 10 (50%) patients with negative margin. Local control was 100% in patients treated by EBRT + BT, but only 20% in patients treated by BT alone. No infection or delayed wound healing has occurred after BT. Soft tissue necrosis was seen in 4 cases, subcutanous fistula in one case and peripheral nerve palsy in one case. Despite small number of patients and short follow up our study suggest that perioperative HDR BT is easy and promissing when used as a part of primary treatment for STS. The treatment results for recurrence are poor and in a lot of cases radical surgical approach should have been considered for the salvage.

[Asynchronous occurrence of three neoplastic diseases: chronic B-cell lymphatic leukemia, renal carcinoma and prostatic adenocarcinoma]

Authors present a case of three asynchronous malignancies in man working life-long in chemical industry. Course of diseases and their treatment are described: B chronic lymphatic leukaemia (B-CLL) (age of 55), conventional clear cell renal carcinoma (CRCC) (age of 61) and adenocarcinoma of prostate (CaP) (age of 72). B-CLL treatment was chlorambucil for 2 years and follow-up subsequently. CRCC treatment was radical transperitoneal nephrectomy. Due to locally advanced CaP bilateral orchiectomy and radical external beam radiotherapy were performed. Patients is alive 30 months without any signs of any malignity. Incidence of multiple malignancies and particularly triplicities are discussed in this article. Authors point out pertinence of radical therapeutic approach also in multiple malignancies and oncological screening not only in patients with heamatological malignancy, but considering it in all tumours.

[Radiotherapy in the treatment of ovarian epithelial carcinoma]

OBJECTIVE

Evaluation of the role of radiotherapy in the treatment of the epithelial ovarian cancer.

SUBJECT

Review.

SETTING

Department of Oncology and Radiotherapy, University Hospital, Charles University, Hradec Králové. Department of Obstetric and Gynaecology, Charles University, University Hospital, Hradec Králové.

SUBJECT AND METHOD

Discussion about current evidence of the effect of radiotherapy in the treatment of the epithelial ovarian cancer from literature.

CONCLUSION

Radiotherapy has proved its efficacy in adjuvant treatment of intermediate risk ovarian carcinoma. Contemporary radiotherapy attracts attention as consolidation or salvage treatment after chemotherapy. Radiotherapy can also be effective palliative treatment of chemorefractory tumours. Modern radiation technique is essential.

Conformal radiotherapy for prostate cancer--longer duration of acute genitourinary toxicity in patients with prior history of invasive urological procedure

The incidence and predictors of acute toxicity were evaluated in patients treated with three-dimensional conformal radiotherapy (3D-CRT) for localized prostate cancer. Between December 1997 and November 1999, 116 patients with T1-T3 prostatic carcinoma were enrolled in the study. Ninety patients were treated with 70 Gy and 26 patients with T3 tumors received 74 Gy. Of the 116 patients 42 (36.2%) had a prior history of invasive urological procedure (IUP) (transurethral resection of the prostate or transvesical prostatectomy for benign prostatic hyperplasia). Acute gastrointestinal (GI) and genitourinary (GU) symptoms were graded according to the EORTC/RTOG scoring system. Toxicity duration after the completion of 3D-CRT was recorded. The majority of patients experienced only mild or no (Grade 1) acute toxicities. Medications for GI and GU symptoms (Grade 2) were required by 28.4% and 12.9% of patients, respectively. Only one case of Grade 3 GI toxicity (0.9%) was observed. Seven patients (6.1%) experienced severe GU toxicity (Grade 3 or 4). No correlation was found between acute toxicity and age, stage, dose (70 Gy vs. 74 Gy), IUP and pelvic lymphadenectomy. A significant relationship was observed between the duration of acute GU toxicity and prior IUP. Symptoms persisted for more than 4 weeks in 51.9% and 26.0% of patients with and without a prior history of IUP, respectively (p = 0.02). The incidence of acute complications, associated with 3D-CRT for prostate cancer, was acceptable in our cohort of patients. A prior history of IUP resulted in a significantly longer duration of acute GU toxicity.

[Radiotherapy of age-related macular degeneration]

The authors evaluate results of the radiotherapy by age-related macular degeneration. They have been performed in Department of Ophthalmology of Teaching Hospital of Charles University in Hradec Králové from February 1999 to June 2000. Our group consisted of 23 patients (23 eyes), 10 males and 13 females in age from 41 to 83 years, with average of 69 yrs. They were evaluated 6 months after begin of radiotherapy. The patients were divided into 2 groups. 11 patients with the entry visual acuity 6/60-6/24 and 12 patients with the entry visual acuity 0.25/50-3/50. The study proved the fact that it is possible to treat the exudative form of age-related macular degeneration using radiotherapy.

Endovascular brachytherapy in the prevention of vascular restenosis

PURPOSE

To evaluate the technical feasibility and efficacy of endovascular brachytherapy for prophylaxis of restenosis after femoropopliteal percutaneous transluminal angioplasty (PTA).

MATERIALS AND METHODS

Ten patients with recurrence of stenosis in the femoropopliteal region underwent PTA followed by endovascular irradiation with Iridium-192 a high-dose rate after-loading technique. We used a single fraction of dose 12 Gy given in 3 mm from the source axis in the stenotic vessel segment.

RESULTS

During follow-up of 59-580 days restenosis occurred in four patients 111, 460, 472 and 580 days after irradiation. All other patients are without restenosis. No radiation-associated side effects were observed.

CONCLUSIONS

Endovascular brachytherapy of restenosis in the femoropopliteal region is technically feasible, and may be done as a part of the PTA. These encouraging results open the possibility of reduction of restenosis by the present method.

The current look at high-dose chemotherapy in breast cancer minireview

High-dose chemotherapy (HDC) in high-risk breast cancer is one of the possible approaches how to improve therapeutic results, eventually, to overcome the incurability of the disease. In recent randomized studies superiority of HDC to conventional therapy has not been unambiguously established. Nevertheless, many oncologists, as well as, patients are so convinced of HDC benefits, that they are not willing to take part in randomized studies. At an ASCO Annual Meeting (American Society of Clinical Oncology) in May 1999 in Atlanta - preliminary results of five large randomized studies phase III were presented (2 studies on metastatic breast cancer and 3 studies on high-risk breast cancer with more than 10 positive lymph nodes). The ASCO was informed of an investigation into serious scientific misconduct in a clinical trial that was presented in a plenary session of its Annual Meeting. The results of Dr. Bezwoda's research were presented at ASCO's Meeting as one of four plenary papers on the investigational therapy and was the only one to clearly indicate a survival benefit in the high-dose regimen. Preliminary results presented there, however, did not confirm the original hypothesis of the high efficacy of HDC. It is necessary to wait for definite results (within two or three years, because enrollment of patients either has been finished or is being finished just now) and several parameters may change. In view of hitherto results, some investigators think that there is no need to continue in similar intensive studies. Still some believe that different modifications of therapeutic regimens or new, less toxic drugs should be tested which may lead to more effective and safer HDC.

The role of chemotherapy in prostate cancer. Minireview

Hormonal therapy in disseminated prostate cancer is effective in 70-80% of patients and prolongs their lives of a mean 1-2 years. Sooner or later, androgen independence develops due to a multifactorial mechanism. A smaller part of patients may respond to second-line hormonal manipulations (antiandrogen withdrawal, adrenal enzymes synthesis inhibitors, corticosteroids). In hormone-refractory disease only about 30% of patients would respond to chemotherapy. In the standard chemotherapy the mostly used cytotoxic agents are anthracyclines, platinum derivatives, vinca alkaloids and cyclophosphamide. However, combined chemotherapy is not more effective than monotherapy. Conventional chemotherapy may improve especially the quality of life. The median survival in chemotherapy patients (6-12 months) is not significantly longer when compared with the best supportive care. In recent years the main concern has been focused on new cytotoxic drugs and different combinations with hormonal agents. In Phase II studies the combinations of estramustine with oral etoposide, estramustine with taxanes and alternating weekly regimens (doxorubicin, ketoconazole/estramustine, vinblastine) show higher response rates (53-69% of patients with prostate-specific antigen decline of more than 50%) and longer survival (13-19 months) than conventional chemotherapy.

Application of whole blood and peripheral blood progenitor cells (PBPC) and new strategies for rescue after intensive cyclic chemotherapy in high-risk breast cancer

The efficacy of autologous peripheral stem cells given as mobilized whole blood or leukapheresis product for hematopoietic rescue after intensive chemotherapy was studied in 34 consecutive female patients with high-risk breast cancer. All patients received six cycles of chemotherapy regimen EC (epirubicin 150 mg/m2 and cyclophosphamide 1250 mg/m2) at 14-day intervals. In the first cycle, chemotherapy was given on day 1, and 24 h later mobilization of PBPC was started with G-CSF at a dose of 5 microg/kg/day for 13 days. In all other cycles, G-CSF was given at the same dose from day 7. On days 11, 12, and 13, leukaphereses were performed, and whole blood was collected on day 14 (the peak incidence of colony-forming units-granulocyte-macrophage [CFU-GM] burst-forming units-erythrocyte [BFU-E], and colony-forming unit-granulocyte-erythrocyte-macrophage-megakaryocyte [CFU-GEMM]). The second cycle of chemotherapy was started on day 15, and 24 h later, whole blood (collected in the first cycle) was reinfused, and the same was done in the third cycle. In the fourth to sixth chemotherapy cycles, leukapheresis product was used for hematopoietic rescue. The median increment of absolute values in both whole blood and leukapheresis product was as follows: CD34+ cells over baseline was approximately 17.4-fold, CFU-GM was 85.3-fold, BFU-E was 95.9-fold, and CFU-GEMM was 44.2-fold. In the cycles with whole blood support, the mean values of applied progenitors per cycle were CD34+ cells 1.52 x 10(6)/kg, CFU-GM, 1.18 x 10(5)/kg, BFU-E 2.54 x 10(5)/kg, CFU-GEMM 0.31 x 10(5)/kg. In the courses with PBPC support, the mean values of progenitors were CD34+ 2.04 x 10(6)/kg, CFU-GM 1.59 x 10(5)/kg, BFU-E 2.87 x 10(5)/kg, and CFU-GEMM 0.34 x 10(5)/kg. Leukopenia in patients supported with whole blood versus leukapheresed PBPC was as follows: grade 4, 13/6 (38.2%/17.6%), grade 3, 19/23 (55.9%/70.6%), and grade 2, 1/4 (2.9%/11.8%), respectively. Thrombocytopenia was grade 4, 11/6 (32.4%/17.6%), grade 3, 10/7 (29.4%/20.6%), grade 2, 7/13 (20.6%/38.2%), and grade 1, 6/6 (17.6%/17.6%), respectively. The median follow-up analysis was at 24.6 (7-36) months. High-risk patients previously treated with surgery and adjuvant chemotherapy (n = 5) were not evaluated for response. In 21 patients with locally advanced or inflammatory breast carcinoma the response rate (RR) was 94%, CR was 90%, and PR was 15%. No response to therapy was observed in 1 patient. In 8 patients with metastatic disease, RR was 75%, there was no CR, and PR was 75%. Two patients died during therapy. Relapse-free survival (RFS) in the adjuvant group was 23.7 (range 12-36) months and in the group with locally advanced disease was 18.2 (range 7-27) months. In the group with metastatic disease, time to tumor progression (TTP) was 12.1 (range 1-16) months. Mean duration of hospital stay for whole blood reinfusion in the second and third chemotherapy cycles was 6.7 (range 5-8) days and for PBPC in the fourth to sixth cycles was 6.2 (range 4-8) days, which at p < 0.001 was not statistically significant.

Endovascular brachytherapy of transjugular intrahepatic portosystemic shunt

PURPOSE

To evaluate the technical feasibility and efficacy of endovascular brachytherapy with Iridium-192 in the prevention of restenosis caused by neointimal hyperplasia of transjugular intrahepatic portosystemic shunt (TIPS).

MATERIALS AND METHODS

The endovascular brachytherapy with high dose rate automatic afterloading system was performed in six patients with recurrent of stenosis of TIPS. We used a single dose fraction of 12 Gy delivered at 3 millimeter (mm) from the source axis to the stenotic vessel segment in five patients with spiral Z-stent, and 15 Gy at 5 mm in one patient with Wallstent.

RESULTS

Follow-up time ranged from 148 to 639 days. In one patient, restenosis occurred in the treated vessel segment, diagnosed 71 days after endovascular brachytherapy by doppler ultrasound. All other patients were, during the follow-up time, without restenosis in the irradiated vessel segment. Radiation-associated side effects were not observed.

CONCLUSIONS

Endovascular brachytherapy of TIPS is technically feasible and may be done as a part of the percutaneous revision of the shunt. This pilot study may be the largest experience of treating TIPS restenosis in humans to date. For definitive conclusions, a lot of studies are needed.