Smoothed particle hydrodynamics implementation to enhance vertebral fracture finite element model in a cervical spine segment under compression

Spinal cord injuries (SCIs) can arise from compression loading when a vertebra fractures and bone fragments are pushed into the spinal canal. Experimental studies have demonstrated the importance of both fracture initiation and post-fracture response in the investigation of vertebral fractures and spinal canal occlusion resulting from compression. Finite element models, such as the Global Human Body Models Consortium (GHBMC) model, focused on predicting the initiation location of fractures using element erosion to model hard tissue fracture. However, the element erosion method resulted in a loss of material and structural support during compression, which limited the ability of the model to predict the post-fracture response. The current study aimed to improve the post-fracture response by combining strain-based element erosion with smoothed particle hydrodynamics (SPH) to preserve the volume of the trabecular bone during compression fracture. The proposed implementation was evaluated using a model comprising two functional spinal units (FSUs) (C5-C6-C7) extracted from the GHBMC 50th percentile male model, and loaded under central compression. The original and enhanced models were compared to experimental force-displacement data and measured occlusion of the spinal canal. The enhanced model with SPH improved the shape and magnitude of the force-displacement response to be in good agreement with the experimental data. In contrast to the original model, the enhanced SPH model demonstrated occlusion on the same order of magnitude as reported in the experiments. The SPH implementation improved the post-fracture response by representing the damaged material post-fracture, providing structural support throughout compression loading and material flow leading to occlusion.

Prediction of a positive circumferential resection margin at surgery following neoadjuvant chemotherapy for adenocarcinoma of the oesophagus

Background

A positive circumferential resection margin (CRM) has been associated with higher rates of locoregional recurrence and worse survival in oesophageal cancer. The aim of this study was to establish if clinicopathological and radiological variables might predict CRM positivity in patients who received neoadjuvant chemotherapy before surgery for oesophageal adenocarcinoma.

Methods

Multivariable analysis of clinicopathological and CT imaging characteristics considered potentially predictive of CRM was performed at initial staging and following neoadjuvant chemotherapy. Prediction models were constructed. The area under the curve (AUC) with 95% confidence intervals (c.i.) from 1000 bootstrapping was assessed.

Results

A total of 223 patients were included in the study. Poor differentiation (odds ratio (OR) 2·84, 95 per cent c.i. 1·39 to 6·01) and advanced clinical tumour status (T3-4) (OR 2·93, 1·03 to 9·48) were independently associated with an increased CRM risk at diagnosis. CT-assessed lack of response (stable or progressive disease) following chemotherapy independently corresponded with an increased risk of CRM positivity (OR 3·38, 1·43 to 8·50). Additional CT evidence of local invasion and higher CT tumour volume (14 cm3) improved the performance of a prediction model, including all the above parameters, with an AUC (c-index) of 0·76 (0·67 to 0·83). Variables associated with significantly higher rates of locoregional recurrence were pN status (P = 0·020), lymphovascular invasion (P = 0·007) and poor response to chemotherapy (Mandard score 4-5) (P = 0·006). CRM positivity was associated with a higher locoregional recurrence rate, but this was not statistically significant (P = 0·092).

Conclusion

The presence of advanced cT status, poor tumour differentiation, and CT-assessed lack of response to chemotherapy, higher tumour volume and local invasion can be used to identify patients at risk of a positive CRM following neoadjuvant chemotherapy.

FOLFOX and intensified split-course chemoradiation as initial treatment for rectal cancer with synchronous metastases

BACKGROUND

Optimal initial management of rectal carcinoma with synchronous metastases (RCSM) is controversial - both for patients being treated with curative and palliative intent. This study aims to evaluate the use of an upfront treatment strategy combining FOLFOX chemotherapy with split-course pelvic chemoradiation (FOLFOX + CRT) for patients with RCSM.

MATERIAL AND METHODS

An analysis of all patients who commenced treatment with FOLFOX + CRT at our institutions between January 2009 and June 2014 was performed. The regimen consisted of a total of 12 weeks of treatment with split-course pelvic chemoradiation (50.4Gy with concurrent oxaliplatin and 5-FU) alternating with FOLFOX chemotherapy. Restaging imaging was performed following treatment, with subsequent management as per local standard of care.

RESULTS

78 patients (15 with resectable liver-only metastases) were identified. 77 (99%) completed at least 45Gy of radiation and 87% completed ≥75% of planned dose intensity of both oxaliplatin and 5FU. Two (2.6%) patients died within 30 days of treatment. Rates of radiological complete or partial response for local and metastatic disease were 90% and 66%, respectively. 24% patients had radiological disease progression of metastatic disease. Median overall survival for patients with unresectable metastatic disease at baseline was 23 months (95%CI: 19-28). 12 patients underwent radical surgery to both the rectum and liver and had an estimated 3-year overall survival rate of 62% (95%CI: 37-100). For those patients who did not proceed to rectal surgery, only 7% required palliative re-irradiation or surgery at a later date and all >20months from initial treatment.

CONCLUSIONS

In patients with unresectable metastatic disease, FOLFOX + CRT provides durable pelvic control for the majority without the need for additional local treatment. For patients with an advanced primary tumor and synchronous resectable liver-only metastases, FOLFOX + CRT can be considered a feasible and tolerable upfront treatment option.

Safety, cost-effectiveness and feasibility of daycase paracentesis in the management of malignant ascites with a focus on ovarian cancer

BACKGROUND

Paracentesis for malignant ascites is usually performed as an in-patient procedure, with a median length of stay (LoS) of 3-5 days, with intermittent clamping of the drain due to a perceived risk of hypotension. In this study, we assessed the safety of free drainage and the feasibility and cost-effectiveness of daycase paracentesis.

METHOD

Ovarian cancer admissions at Hammersmith Hospital between July and October 2009 were audited (Stage 1). A total of 21 patients (Stage 2) subsequently underwent paracentesis with free drainage of ascites without intermittent clamping (October 2010-January 2011). Finally, 13 patients (19 paracenteses, Stage 3), were drained as a daycase (May-December 2011).

RESULTS

Of 67 patients (Stage 1), 22% of admissions and 18% of bed-days were for paracentesis, with a median LoS of 4 days. In all, 81% of patients (Stage 2) drained completely without hypotension. Of four patients with hypotension, none was tachycardic or symptomatic. Daycase paracentesis achieved complete ascites drainage without complications, or the need for in-patient admission in 94.7% of cases (Stage 3), and cost £954 compared with £1473 for in-patient drainage.

CONCLUSIONS

Free drainage of malignant ascites is safe. Daycase paracentesis is feasible, cost-effective and reduces hospital admissions, and potentially represents the standard of care for patients with malignant ascites.

Metabolic response of rectal cancer assessed by 18-FDG PET following chemoradiotherapy is prognostic for patient outcome

BACKGROUND

Complete pathological response has proven prognostic benefits in patients with locally advanced rectal cancer treated with neoadjuvant chemoradiotherapy. Sequential 18-FDG PET may be an early surrogate for pathological response to chemoradiotherapy.

OBJECTIVES

The aim of this study was to identify whether metabolic response measured by FDG PET following chemoradiotherapy is prognostic for tumor recurrence and survival following neoadjuvant therapy and surgical treatment for primary rectal cancer.

METHODS

Patients with primary rectal cancer treated by long-course neoadjuvant chemoradiotherapy followed by surgery had FDG PET performed before and 4 weeks after treatment, before surgical resection was performed. Retrospective chart review was undertaken for patient demographics, tumor staging, recurrence rates, and survival.

RESULTS

: Between 2000 and 2007, 78 patients were identified (53 male, 25 female; median age, 64 y). After chemoradiotherapy, 37 patients (47%) had a complete metabolic response, 26 (33%) had a partial metabolic response, and 14 (18%) had no metabolic response as assessed by FDG PET (1 patient had missing data). However, only 4 patients (5%) had a complete pathological response. The median postoperative follow-up period was 3.1 years during which 14 patients (19%) had a recurrence: 2 local, 9 distant, and 3 with both local and distant. The estimated percentage without recurrence was 77% at 5 years (95% CI 66%-89%). There was an inverse relationship between FDG PET metabolic response and the incidence of recurrence within 3 years (P = .04). Kaplan-Meier analysis of FDG PET metabolic response and overall survival demonstrated a significant difference in survival among patients in the 3 arms: complete, partial, and no metabolic response (P = .04); the patients with complete metabolic response had the best prognosis.

CONCLUSION

Complete or partial metabolic response on PET following neoadjuvant chemoradiotherapy and surgery predicts a lower local recurrence rate and improved survival compared with patients with no metabolic response. Metabolic response may be used to stratify prognosis in patients with rectal cancer.

The significance of size change of soft tissue sarcoma during preoperative radiotherapy

AIM

To assess the significance of change in tumour size during preoperative radiotherapy in patients with soft tissue sarcoma (STS).

METHODS

A retrospective review of 91 cases with STS was performed. Inclusion criteria were localised extremity and truncal STS with measurable disease, older than 18 years, treated with preoperative radiotherapy and wide local excision, in the period between January 1966 and December 2005. Patients with head and neck STS, or who received neoadjuvant chemotherapy were excluded. A difference in excess of 10% of the greatest tumour diameter of the pre-radiotherapy and the post-radiotherapy MRI scans was considered as change in tumour size.

RESULTS

Increase in tumour size was noted in 28 patients (31%) (Group 1). No change or decrease in size was observed in 63 patients (Group 2). There were no significance differences in local control or overall survival rates between the 2 groups. The estimated overall actuarial local recurrence free, event-free and overall survival rates were 90.5%, 64.4%, 62.9% in Group 1, and 85.7%, 60.8%, 68.9% in Group 2 respectively.

CONCLUSION

Increase in tumour size during preoperative radiotherapy for soft tissue sarcoma does not seem to associate with inferior local tumour control or compromise survival. Lack of reduction in tumour size is not necessarily a sign of lack of response to preoperative radiotherapy.

Intraoperative radiotherapy and colorectal cancer

Intraoperative radiotherapy (IORT) is a highly specialized component of multidisciplinary management of advanced and recurrent colorectal cancer. The aim of this review was to assess its role and effectiveness in the management of colorectal cancer. A literature search was performed using Medline, Embase, Ovid and Cochrane to identify English language studies which have used IORT in the multidisciplinary management of primary and recurrent colon and rectal cancers. Improved survival and local control in patients with involved surgical margins treated with IORT have been shown in many studies, but these results have been mainly from retrospective studies. There is associated morbidity from IORT. IORT does have a role in the management of colorectal cancer. Further research needs to be performed to optimize the application of this therapy.

The successful treatment of haemophagocytic syndrome in patients with human immunodeficiency virus-associated multi-centric Castleman's disease

Both virus-associated haemophagocytic syndrome (HPS) and human immunodeficiency virus-associated multi-centric Castleman's disease (HIV-MCD) induced by human herpesvirus-8 (HHV-8) are extremely rare. We therefore wished to investigate their occurrence together, and establish the degree of cytokine activation present. From a prospective cohort of individuals with HIV-MCD, we investigated the incidence and outcomes of HPS and measured 15 inflammatory cytokines and the plasma HHV-8 viral loads before and during follow-up. Of 44 patients with HIV-MCD with an incidence of 4.3/10,000 patient years, four individuals (9%) were diagnosed with HPS. All are in remission (range 6-28 months) following splenectomy, etoposide and rituximab-based therapy. Plasma HHV-8 levels were raised markedly at presentation (median 3,840,000 copies/ml). Histological samples from spleen, splenic hilar lymph nodes and bone marrow demonstrated increased phagocytosis by histiocytes and presence of HHV-8-infected plasmablasts outside the follicles. Surprisingly, many known inflammatory plasma cytokines were not elevated, although interleukin (IL)-8 and interferon-gamma were increased in all cases and IL-6 levels were raised in three of four patients. HPS in the setting of HIV-MCD is common and treatment can be successful provided the diagnosis is made appropriately. Systemic activation of cytokines was limited, suggesting that immunosuppressive therapy with steroids is not indicated in HHV-8-driven HPS.

Microarray coupled to quantitative RT-PCR analysis of androgen-regulated genes in human LNCaP prostate cancer cells

The androgen receptor (AR) mediates the growth-stimulatory effects of androgens in prostate cancer cells. Identification of androgen-regulated genes in prostate cancer cells is therefore of considerable importance for defining the mechanisms of prostate-cancer development and progression. Although several studies have used microarrays to identify AR-regulated genes in prostate cancer cell lines and in prostate tumours, we present here the results of gene expression microarray profiling of the androgen-responsive LNCaP prostate-cancer cell line treated with R1881 for the identification of androgen-regulated genes. We show that the expression of 319 genes is stimulated by 24 h after R1881 addition, with a similar number (300) of genes being significantly repressed. Expression of the upregulated genes, as well as of 60 of the most robustly downregulated genes, was carried out using quantitative RT-PCR (Q-RT-PCR) over a time-course of R1881 treatment from 0 to 72 h. Q-RT-PCR was also carried out following treatment with other AR agonists (dihydrotestosterone, estradiol and medroxyprogesterone) and antagonists (cyproterone acetate, hydroxyflutamide and bicalutamide). This study provides a comprehensive analysis of androgen-regulated gene expression in the LNCaP prostate cancer cell line, and identifies a number of androgen-regulated genes, not described previously, as candidates for mediating androgen responses in prostate cancer cells.

Accrediting radiation technique in a multicentre trial of chemoradiation for pancreatic cancer

Before a multicentre trial of 3-D conformal radiotherapy to treat cancer of the pancreas, participating clinicians were asked to complete an accreditation exercise. This involved planning two test cases according to the study protocol, then returning hard copies of the plans and dosimetric data for review. Any radiation technique that achieved the specified constraints was allowed. Eighteen treatment plans were assessed. Seven plans were prescribed incorrect doses and two of the planning target volumes did not comply with protocol guidelines. All plans met predefined normal tissue dose constraints. The identified errors were attributable to unforeseen ambiguities in protocol documentation. They were addressed by feedback and corresponding amendments to protocol documentation. Summary radiobiological measures including total weighted normal tissue equivalent uniform dose varied significantly between centres. This accreditation exercise successfully identified significant potential sources of protocol violations, which were then easily corrected. We believe that this process should be applied to all clinical trials involving radiotherapy. Due to the limitations of data analysis with hard-copy information only, it is recommended that complete planning datasets from treatment-planning systems be collected through a digital submission process.

The role of intraoperative radiotherapy in solid tumors

BACKGROUND

Combined multimodality therapy is becoming standard treatment for many solid tumors, but the role of intraoperative radiotherapy in the management of solid tumors remains uncertain. The aim is to review the indication, application, and outcomes of intraoperative radiotherapy in the management of nongynecological solid tumors.

METHODS

A literature search was performed using Medline, Embase, Ovid, and Cochrane database for studies between 1965 and 2008 assessing intraoperative radiotherapy, using the keywords "intraoperative radiotherapy," "colorectal cancer," "breast cancer," "gastric cancer," "pancreatic cancer," "soft tissue tumor," and "surgery." Only publications in English with available abstracts and regarding adult humans were included, and the evidence was critically evaluated.

RESULTS

Our search retrieved 864 publications. After exclusion of nonclinical papers, duplicated papers and exclusion of brachytherapy papers, 77 papers were suitable to assess the current role of intraoperative radiotherapy. The clinical application and evidence base of intraoperative radiotherapy for each cancer is presented.

CONCLUSIONS

Current studies in all common cancers show an additional benefit in local recurrence rates when intraoperative radiotherapy is included in the multimodal treatment. However, intraoperative radiotherapy may not improve overall survival and has significant morbidity depending on the site of the tumor. Intraoperative radiotherapy does have a role in the multidisciplinary management of solid tumors, but further studies are required to more precisely determine the extent of benefit.

Utility of 18-fluorodeoxyglucose positron emission tomography (FDG-PET) in the staging, radiotherapy planning and prognostication of anal cancer

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Background: Accurate inguinal and pelvic nodal staging in anal cancer is important for prognosis and planning of (chemo)radiation fields. There is strong evidence for the impact of FDG-PET in staging and management of cancer, with early reports of an increasing role in outcome prognostication for a number of tumours. We aimed to determine the impact of FDG-PET on the nodal staging, radiotherapy planning and prognostication of patients with primary anal cancer. Methods: Sixty-two consecutive patients with anal cancer referred to a single tertiary oncology centre between August 1997 and November 2005 were staged with conventional imaging (CIm), computed tomography, magnetic resonance imaging and chest x-ray and by FDG-PET. The stage determined by CIm and the proposed management plan was prospectively recorded and changes in stage and management as a result of FDG-PET assessed. Patients were treated using uniform radiotherapy technique and dose. The accuracy of changes and prognostication of FDG-PET was validated by subsequent clinical follow-up. Kaplan-Meier survival analysis was used to assess survival for the cohort and by FDG-PET and CIm stage. Results: The TNM stage group was changed in 23% (14/62) as a result of FDG-PET (15% up-staged, 8% down-staged). Fourteen percent of T1 patients (3/22), 42% of T2 patients (10/24) and 38% of T3–4 patients (6/16), assessed using CIm, had a change in their N or M stage following FDG-PET. Sensitivity for nodal disease by FDG-PET and CIm was 92% and 72% respectively. The staging FDG-PET scan altered management intent in 3% (2/62), and altered radiotherapy fields in 13% (8/62). Estimated 5 year overall survival and progression free survival (PFS) for the cohort was 77.3% (95% CI 55.3%-90.4%) and 72.2% (95% CI 51.5%-86.4%) respectively. Estimated 5 year PFS for FDG-PET and CIm staged N2–3 disease was 70% (95% CI 42.8%-87.9%) and 55.3% (95% CI 23.3%-83.4%) respectively. Conclusions: FDG-PET shows increased sensitivity over CIm for staging nodal disease in anal cancer and changes treatment intent or radiotherapy fields in a significant proportion of patients. Improved 5 year PFS for FDG-PET staged N2–3 disease could be consistent with more accurate nodal staging and radiotherapy targeting.

No significant financial relationships to disclose.

Managing metastatic prostate cancer

Prostate cancer is one of the most commonly diagnosed malignancies in the west. Most patients with metastatic or recurrent prostate cancer initially respond to androgen deprivation therapy, but almost all eventually progress. This review will focus on current treatment options for metastatic prostate cancer, with a focus on hormonal therapies, chemotherapy and treatment of bony disease, along with biological and targeted therapy.

Adjuvant and neoadjuvant therapy for gastric cancer using epirubicin/cisplatin/5-fluorouracil (ECF) and alternative regimens before and after chemoradiation

Chemoradiation is now used more commonly for gastric cancer following publication of the US Intergroup trial results that demonstrate an advantage to adjuvant postoperative chemoradiotherapy. However, there remain concerns regarding the toxicity of this treatment, the optimal chemotherapy regimen and the optimal method of radiotherapy delivery. In this prospective study, we evaluated the toxicity and feasibility of an alternative chemoradiation regimen to that used in the Intergroup trial. A total of 26 patients with adenocarcinoma of the stomach were treated with 3D-conformal radiation therapy to a dose of 45 Gy in 25 fractions with concurrent continuous infusional 5-fluorouracil (5-FU). The majority of patients received epirubicin, cisplatin and 5-FU (ECF) as the systemic component given before and after concurrent chemoradiation. The overall rates of observed grade 3 and 4 toxicities were 38 and 15%, respectively. GIT grade 3 toxicity was observed in 19% of patients, while haematologic grade 3 and 4 toxicities were observed in 23%. Our results suggest that this adjuvant regimen can be delivered safely and with acceptable toxicity. This regimen forms the basis of several new studies being developed for postoperative adjuvant therapy of gastric cancer.

Waldenstrom's macroglobulinemia: a retrospective analysis of 40 patients from 1972 to 2001

From 1972 to 2001 at St. Bartholomew's Hospital 40 untreated Waldenstrom's macroglobulinemia (WM) patients received either chlorambucil (n = 23); cyclophosphamide, vincristine, and prednisolone (CVP) (n = 5); fludarabine-based therapy (n = 5); or other combination chemotherapy (n = 7). Twenty-eight patients (70%) responded to first-line therapy with overall response rates as follows: chlorambucil, 17/23 (74%); CVP, 4/5 (80%); fludarabine-based regimen, 2/5 (40%); other combinations, 5/7 (71%). Twenty patients were treated at progression with chlorambucil, of whom 10 (50%) responded again, 6/13 having had chlorambucil initially, and 4/7 having had other therapy. Although there was a trend towards a survival advantage for patients who responded to chlorambucil, this difference was not statistically significant. At 6 and 11 years, overall survival was 36% v 18% and 15% v 0% for responders and nonresponders, respectively. The overall pattern was the same for patients treated initially with chlorambucil as with other therapy. This retrospective analysis confirms that chlorambucil is an effective first-line agent in WM and has activity when used at subsequent relapse.

Results of external beam radiotherapy alone for incompletely resected carcinoma of rectosigmoid or rectum: Peter MacCallum Cancer Institute experience 1981-1990

PURPOSE

To study the results of external beam radiotherapy treatment for incompletely resected nonmetastatic rectosigmoid and rectal carcinoma.

METHODS AND MATERIALS

A retrospective review was carried out of all patients (57) presenting to Peter MacCallum Cancer Institute from 1981 to 1990 with incompletely resected nonmetastatic rectosigmoid or rectal cancer who were treated with external beam radiotherapy. Three radiotherapy schedules were used: radical (50 to 60 Gy, 27 patients), high-dose palliative (45 Gy, 25 patients), and low-dose palliative (less than 45 Gy, 5 patients). Symptomatic response, overall survival, and the effect of prognostic factors on treatment outcome were evaluated. The median follow-up period for survivors was 49 months.

RESULTS

Symptomatic response rates were 83% and 79% for the radical and high-dose palliative groups respectively. The estimated median survival time from presentation for all patients was 16.4 months (radical 26.1 months, high-dose palliative 15.7 months). Patients with microscopic residual disease survived significantly longer than patients with macroscopic residual disease (estimated median survival time 30.7 months vs. 14.3 months, p = 0.013).

CONCLUSIONS

No dose response effect was seen between the radical group and high-dose palliative group. Microscopic residual disease at presentation was the only significant predictor of better survival. The conventionally fractionated course of 50 to 60 Gy was not significantly better in terms of palliation and overall survival than a shorter palliative course of 45 Gy. In future, preoperative chemoradiation should improve outcome by reducing the number of patients with incompletely resected cancer.

Pre-operative radiotherapy and chemotherapy for non-resectable rectal cancer

BACKGROUND

The treatment results of combined pre-operative radiotherapy and chemotherapy followed by surgery for patients with initially non-resectable primary rectal cancer were reviewed.

METHODS

Thirteen patients with locally advanced non-resectable rectal cancer were treated with pre-operative irradiation consisting of 50.4-54 Gy plus concomitant 5-fluorouracil (5-FU) delivered during the 1st and 5th weeks of radiotherapy.

RESULTS

Following pre-operative therapy, the resectability rate was 91%, with all but one patient undergoing complete resection. The pathologic complete response rate was 10%. The overall peri-operative and postoperative complication rate was 0.8 complications per patient. There was no postoperative mortality.

CONCLUSIONS

This early experience indicates that high resectability rates are achievable with pre-operative radiotherapy and chemotherapy for non-resectable rectal cancer while maintaining acceptable postoperative morbidity.

Radiotherapy treatment for isolated loco-regional recurrence of rectosigmoid cancer following definitive surgery: Peter MacCallum Cancer Institute experience, 1981-1990

PURPOSE

To assess the success of external beam radiation treatment in the management of loco-regional recurrence of rectosigmoid cancer.

METHODS AND MATERIALS

A retrospective analysis of 135 patients with locally recurrent rectosigmoid cancer presenting to Peter MacCallum Cancer Institute between January 1981 and December 1990 was undertaken. Patients were treated with three different dose ranges of radiotherapy: 50-60 Gy ("Radical" group), 45 Gy ("High-dose palliative" group), and <45 Gy ("Low-dose palliative" group). Symptomatic response rates and overall survival for each group were determined.

RESULTS

Symptomatic response rates of 85, 81, and 56% were achieved in the radical, high-dose palliative, and low-dose palliative groups, respectively. Estimated median survival times were 17.9, 14.8, and 9.1 months for the radical, high-dose palliative, and low-dose palliative groups, respectively.

Acute vascular embolus resulting from metastatic endocardial involvement with synovial sarcoma: report of a case and review of the literature

A rare case of metastatic soft tissue sarcoma (STS) involving the endocardium of the left ventricle of the heart is described. A 57-year-old man with a previously resected synovial sarcoma of the anterior abdominal wall presented 5 years later with an acute ischaemic arm resulting from tumour embolus. The treatment and outcome of the patient are outlined. Metastatic STS cardiac involvement and management of this complication are reviewed.

Postoperative radiotherapy for Dukes' B and C rectal cancer: Peter MacCallum Cancer Institute experience

This retrospective study reviews the outcome of patients with Dukes' B and C rectal cancer treated with adjuvant post-operative pelvic radiotherapy at the Peter MacCallum Cancer Institute from 1981 to 1990. Sixty-one patients (22 Dukes' B, 36 Dukes' C and 3 unknown stage) received a median dose of 50 Gy of pelvic irradiation. Locoregional relapse occurred in 33% of patients. Estimated median progression-free survival was 1.7 years with 46% surviving without progression at 2 years and 30% at 5 years. There was no difference according to Dukes' stage. The estimated median survival was 2.6 years, with no difference according to disease stage. These results with postoperative radiotherapy alone are inferior to results achievable by combination chemotherapy and radiotherapy as adjuvant therapy which should now be considered standard therapy following surgical resection for Dukes' B and C rectal cancer.

Limited small cell lung cancer: the effect of radiotherapy on local control following response to chemotherapy

The survival and rate of chest infield relapse was examined in 48 patients with limited disease small cell lung cancer (LSCLC) who had achieved complete (CR) or partial response (PR) following three courses of chemotherapy. During 1985-1986 chemotherapy consisted of carboplatin and etoposide and during 1986-1987, of etoposide, carboplatin, cyclophosphamide, and vincristine (ECCO). After three courses of chemotherapy, chest irradiation (50 Gy in 25 fractions over 5 weeks) was given to encompass the original tumor volume. Complete responders were also given prophylactic cranial irradiation, 30 Gy in 10 fractions over 2 weeks. Overall median survival of all patients receiving chest irradiation was 17 months from commencement of radiotherapy. The infield relapse-free survival at 24 months was 49% (95% confidence interval: 32-66%). Patients who had only achieved a PR at the time of irradiation were more likely to relapse in the chest than complete responders (p = 0.09). We conclude that local relapse remains a major cause of failure in patients with LSCLC in spite of sequential high dose radiotherapy given to patients who have responded to chemotherapy.