Pentoxifylline and Vitamin E in Preventing Pneumonitis Using Stereotactic Ablative Radiotherapy in Previously Irradiated Patients

PURPOSE/OBJECTIVE(S)

Despite radiotherapeutic advancements, patients with non-small cell lung cancer (NSCLC) experience recurrence rates from 30-40% (1) (2). For these cases, stereotactic ablative radiotherapy (SABR) is an attractive retreatment option as studies have reported upwards of 96% local control rates at 3 years follow up (3) (4). However, thoracic reirradiation poses threat for radiation-induced pneumonitis. Particularly, the rate of grade 3 pneumonitis from institutional data was 30% in patients undergoing SABR for recurrent thoracic malignancies (4). Prior studies have tried to mitigate SABR toxicities with administration of pentoxifylline (Ptx) and vitamin E (VE), which has reduced lung damage in breast cancer patients (5) (6). The addition of Ptx and VE in retreatment of NSCLC may similarly reduce radiation-induced pneumonitis. The purpose of this study is to prospectively evaluate the efficacy of Ptx and VE in reducing grade 3 pneumonitis in patients undergoing SABR with loco-regionally recurrent lung cancer or new lung primary tumors in the setting of prior thoracic radiation. We hypothesize that these patients will experience rates of grade 3 pneumonitis lower than 30% at 3, 6, and 12-months post-treatment follow up.

MATERIALS/METHODS

Patients who received radiation for a prior thoracic malignancy with a diagnosis of a recurrent or new NSCLC were recruited from our institution. Ptx and VE were administered at the time of simulation, approximately 1 week prior to starting treatment and continued for 12 weeks after the completion of treatment. SABR was delivered using standard stereotactic techniques to a dose of 5000 cGy at 1000 cGy per fraction over 2 weeks. The following demographic information was collected: baseline performance status, time interval between initial radiation and retreatment radiation, central or peripheral recurrent tumor, and pre-treatment FEV1. Patients were assessed clinically and radiographically for grades of pneumonitis at 3, 6, and 12-months post treatment.

RESULTS

Demographic and follow-up data were collected from the initial cohort of 40 patients. There were no statistically significant correlations between pretreatment characteristics and pneumonitis. 92% of participants were medication compliant. Crude rates of pneumonitis at any time point were grade 1 (23%), grade 2 (10%), and grade 3 (2%). Only one of our patients experienced grade 3 pneumonitis. The rate of grade 3 pneumonitis in our Ptx and vitamin E treated cohort was significantly less than 30% at 3-months (p = 0.001), 6-months (p = 0.001), and 12-months (p = 0.014) post-treatment.

CONCLUSION

Thus, we conclude that Ptx and VE are safe interventions that may prophylactically reduce rates of grade 3 pneumonitis for patients receiving subsequent SABR for recurrent NSCLC. Additional studies should be performed to evaluate the use in of Ptx and VE in the retreatment setting.

Associations between earplug use and hearing loss in ROK military personnel

Introduction

The easiest way to prevent noise-induced hearing loss (NIHL) is to wear earplugs. The Republic of Korea (ROK) Ministry of National Defense (MND) is supplying earplugs to prevent NIHL, but many patients still suffer from this. We speculated that earplugs would have a high NIHL rate, depending on the rate of use of earplugs, regardless of the rate of supply. Therefore, we conducted this study to investigate the relationship between the use of earplugs and hearing loss by ROK military personnel.

Methods

The study used data from the Military Health Survey conducted in 2014–2015, which included 13 470 questionnaires completed by ROK military personnel. Hearing loss and earplug use were self-reported. Logistic regression analysis was used to assess associations between earplug use and hearing loss.

Results

The study sample included 13 470 ROK military personnel (response rate of 71.2%) (Army, 8330 (61.8%); Navy/Marines, 2236 (16.6%); and Air Force, 2904 (21.6%)). Overall, 18.8% of Korean military personnel reported that they always wore earplugs, and 2.8% reported hearing loss. In logistic regression analysis, there were significant differences in the rates of hearing loss associated with wearing earplugs sometimes (OR=1.48, 95% CI 1.07 to 2.05) and never wearing earplugs (OR=1.53, 95% CI 1.12 to 2.10). In subgroup analysis, in Air Force, non-combat branch, forward area and long-term military service personnel increased hearing loss was associated with not wearing earplugs.

Conclusion

Our study confirmed that within the ROK military, there is an association between hearing loss and lack of earplug use. In the ROK MND, Army, Navy/Marines and Air Force headquarters must provide guidelines for the use of earplugs during field training to protect military personnel’s hearings and, if necessary, need to be regulated or institutionalised.

Accident prevention activity and accident experience in the Republic of Korea military

Introduction

According to data released by the Korea National Statistical Office, the number of accidents has been decreasing since 2012. However, a considerable number of deaths related to safety accidents (23–46 deaths) are still reported annually. This study aimed to observe the correlation between accident prevention activities in the Republic of Korea (ROK) military and the incidence of safety accidents.

Methods

The study used data from the 2014–2015 Military Health Survey and included 13 618 responses (Army: 8414 (61.8%); Navy/Marine: 2262 (16.6%); Air Force: 2942 (21.6%)) from the ROK military personnel. Accident experiences and thoughts on accident prevention activities were self-reported. Multiple logistic regression analysis was used to examine the validity of accident prevention activity and accident experience.

Results

Of the 13 618 military personnel who responded, 12.0% reported experiencing safety accidents in the military and 1020 (7.5%) felt that accident prevention activities in the military were insufficient. On logistic regression analysis, we found a significant difference (insufficiency OR=1.56, CI 1.31 to 1.86). In particular, military personnel who belong to the Army and Navy were more likely to think that accident prevention activities were insufficient. In addition, military personnel who experienced falls/slips, crash, and laceration/puncture wound/amputation/penetrating wound accidents were more likely to think accident prevention activities were insufficient.

Conclusions

Our study found that accident prevention activities in the military and accident experiences were related. It is necessary for the ROK Ministry of Defense, Army, Navy and Air Force headquarters to re-evaluate their accident prevention systems.

Complementary cathodoluminescence lifetime imaging configurations in a scanning electron microscope

Cathodoluminescence (CL) spectroscopy provides a powerful way to characterize optical properties of materials with deep-subwavelength spatial resolution. While CL imaging to obtain optical spectra is a well-developed technology, imaging CL lifetimes with nanoscale resolution has only been explored in a few studies. In this paper we compare three different time-resolved CL techniques and compare their characteristics. Two configurations are based on the acquisition of CL decay traces using a pulsed electron beam that is generated either with an ultra-fast beam blanker, which is placed in the electron column, or by photoemission from a laser-driven electron cathode. The third configuration uses measurements of the autocorrelation function g⁽²⁾ of the CL signal using either a continuous or a pulsed electron beam. The three techniques are compared in terms of complexity of implementation, spatial and temporal resolution, and measurement accuracy as a function of electron dose. A single sample of InGaN/GaN quantum wells is investigated to enable a direct comparison of lifetime measurement characteristics of the three techniques. The g⁽²⁾-based method provides decay measurements at the best spatial resolution, as it leaves the electron column configuration unaffected. The pulsed-beam methods provide better detail on the temporal excitation and decay dynamics. The ultra-fast blanker configuration delivers electron pulses as short as 30 ps at 5 keV and 250 ps at 30 keV. The repetition rate can be chosen arbitrarily up to 80 MHz and requires a conjugate plane geometry in the electron column that reduces the spatial resolution in our microscope. The photoemission configuration, pumped with 250 fs 257 nm pulses at a repetition rate from 10 kHz to 25 MHz, allows creation of electron pulses down to a few ps, with some loss in spatial resolution.

CF₃-Substituted Mollugin 2-(4-Morpholinyl)-ethyl ester as a Potential Anti-inflammatory Agent with Improved Aqueous Solubility and Metabolic Stability

Although mollugin, the main ingredient of the oriental medicinal herb Rubia cordifolia, has considerable anti-inflammatory effects, it has poor aqueous solubility as well as poor metabolic and plasma stability. To overcome these shortfalls, various mollugin derivatives have been synthesized and evaluated for their ability to inhibit U937 monocyte cell adhesion to HT-29 colonic epithelial cells in TNF-α- or IL-6-induced models of colon inflammation. The 2-(4-morpholinyl)-ethyl ester of CF3-substituted mollugin (compound 15c) showed good water solubility, improved metabolic and plasma stability, and greater inhibitory activity than mesalazine in both the TNF-α- and IL-6-induced colonic epithelial cell adhesion assays, suggesting that 15c is a potential anti-inflammatory agent.

Enantioselective Synthesis of a Novel Thiazoline Core as a Potent Peroxisome Proliferator-Activated Receptor δ Agonist

The convergent and enantioselective synthesis of a highly potent human peroxisome proliferator-activated receptor delta agonist is presented. More specifically, the thiazoline structure, which constitutes the biosynthetically distinctive core structure of pulicatin (a secondary metabolite of symbiotic bacteria), was synthesized from a commercially available and inexpensive chiral pool of l-threonine.

Three-Dimensional Quantum Confinement of Charge Carriers in Self-Organized AlGaN Nanowires: A Viable Route to Electrically Injected Deep Ultraviolet Lasers

We report on the molecular beam epitaxial growth and structural characterization of self-organized AlGaN nanowire arrays on Si substrate with high luminescence efficiency emission in the deep ultraviolet (UV) wavelength range. It is found that, with increasing Al concentration, atomic-scale compositional modulations can be realized, leading to three-dimensional quantum confinement of charge carriers. By further exploiting the Anderson localization of light, we have demonstrated, for the first time, electrically injected AlGaN lasers in the deep UV band operating at room temperature. The laser operates at ∼289 nm and exhibits a threshold of 300 A/cm(2), which is significantly smaller compared to the previously reported electrically injected AlGaN multiple quantum well lasers.

Non-parental banding patterns in recombinant inbred line population of maize with SSR markers

We observed 3 types of non-parental banding patterns using simple-sequence repeat primers in a recombinant inbred line maize population developed from 2 inbred lines, Mo17 and KW7. We observed alleles that were not present in either of the parents, known as non-parental alleles. Although non-parental alleles are a consequence of genetic variation, they are less common in progenies derived from inbred lines. Generally, when non-parental alleles are encountered during genotyping analysis, they are either deleted from the analysis or considered to be missing data. However, before making a decision regarding how to treat non-parental alleles, it is important to understand the mechanism through which they form. There are a variety of potential reasons for the formation of non-parental bands, including recombination or mutation in the simple-sequence repeat region, residual heterozygosity in parental lines, or chromosomal aberrations resulting from rearrangements and transposons. In this article, we discuss the potential reasons behind the formation of the non-parental alleles observed in our data.

A novel compound VSC2 has anti-inflammatory and antioxidant properties in microglia and in Parkinson's disease animal model

BACKGROUND AND PURPOSE

Neuroinflammation through microglial activation is involved in the pathogenesis of neurodegenerative diseases including Parkinson's disease (PD), a major neurodegenerative disorder characterized by dopaminergic neuronal death in the substantia nigra. We examined our novel synthetic compound VSC2 for its anti-inflammatory properties towards development of a PD therapy.

EXPERIMENTAL APPROACH

We tested the effects of VSC2 on production of various NF-κB-dependent proinflammatory molecules and Nrf2-dependent antioxidant enzymes in BV-2 microglia and in vivo.

KEY RESULTS

The vinyl sulfone compound, VSC2, most effectively suppressed the production of NO in LPS-activated microglia. It also down-regulated expression of inducible NOS (iNOS), COX-2, IL-1β and TNF-α and inhibited nuclear translocalization and transcriptional activity of NF-κB. VSC2 increased total and nuclear Nrf2 levels, induced Nrf2 transcriptional activity and was bound to Keap1 with high affinity. Expression of the Nrf2-regulated antioxidant enzyme genes NAD(P)H quinone oxidoreducase-1 (NQO-1), haem oxygenase-1 (HO-1) and glutamylcysteine ligase (GCL) were up-regulated by VSC2. In the MPTP mouse model of PD, oral administration of VSC2 decreased the number of activated microglia in the substantia nigra, lowered the levels of iNOS, COX-2 and IL-1β, and protected the dopaminergic neurons. VSC2 also elevated the levels of NQO1, HO-1, GCL and Nrf2 in the nigrostriatal area.

CONCLUSIONS AND IMPLICATIONS

VSC2 has both anti-inflammatory and antioxidant properties and prevented neuroinflammation in microglia and in an animal model of PD. This suggests VSC2 as a potential candidate for PD therapy.

Discovery of vinyl sulfones as a novel class of neuroprotective agents toward Parkinson's disease therapy

Although the etiology of Parkinson's disease (PD) remains elusive, recent studies suggest that oxidative stress contributes to the cascade leading to dopaminergic (DAergic) neurodegeneration. The Nrf2 signaling is the main pathway responsible for cellular defense system against oxidative stress. Nrf2 is a transcription factor that regulates environmental stress response by inducing expression of antioxidant enzyme genes. We have synthesized novel vinyl sulfone derivatives. They exhibited a broad range of activities in inducing HO-1, whose gene expression is under the control of Nrf2. Among them, compound 12g was confirmed to activate Nrf2 and induce expression of the Nrf2-dependent antioxidant enzymes NQO1, GCLC, GLCM, and HO-1, at both mRNA and protein levels in DAergic neuronal cells. This was accompanied by protection of DAergic neurons in both in vitro and MPTP-induced in vivo models of PD. In addition, compound 12g effectively resulted in attenuation of the PD-associated behavioral deficits in the mouse model.

Abstract P2-05-20: Validation and comparison of CS-IHC4 score with a nomogram based on Ki67 index, Adjuvant! Online, and St. Gallen risk stratification to predict recurrence in early Hormone Receptor (HR)-positive breast cancers

Background: Recently, the information in the IHC score was reported to be similar to that in the 21-gene Genomic Health recurrence score (GHI-RS). The aim of this study is to develop a nomogram based on Ki67 index to predict recurrence and to validate the nomogram by comparison with CS-IHC4 as well as Adjuvant! Online and St. Galen risk stratification. In addition, we validated our nomogram with external cohort.

Methods: We retrospectively analyzed the clinicopathologic characteristics and outcomes of 1,070 postoperative HR-positive breast cancer patients between 2004 and 2007 at the Samsung Medical Center to determine recurrence-free survival (RFS). We constructed nomogram using Cox proportional hazard model and validated externally in a cohort of 1,028 at Seoul National University Hospital. A prognostic model that used classical variables, Adjuvant! Online, St. Gallen risk stratification, and the four IHC markers (IHC4 score) were created and assessed in our cohort by LR-χ2 test using the bootstrapping method.

Results: Nomogram showed an area under the receiver operating characteristic curve (AUC) of 0.70 (95% CI, 0.62–0.75) in the training set. The validation set showed a good discrimination with an AUC of 0.65 (95% CI, 0.58–0.72). In LR-χ2 test, the nomogram score was found to be more informative than the IHC4 with CS (LR-χ2 4.0539 [df1], 95% CI; 0.1038–8.004 for CS-IHC4 + nomogram score vs. CS-IHC4).

The study of new vacuum pressure measurement technique using ultrasonic acoustic impedance transducers

Ultrasonic sensors of 500 kHz frequency have been used to study the measuring of gas pressure in the range 1.33 × 10(3)-2.026 × 10(5) Pa. From the experimental data it was observed that amplitude of the transmitted ultrasound was dependent on gas pressure. The results confirm that by using appropriate instruments including sensors and electronic devices, pressure of the gas can be successfully measured by measuring the magnitude of the received signal. The proposed method is expected to be applied to develop as new vacuum pressure measurement instrument.

Distinct locomotive patterns of granulocytes, monocytes and lymphocytes in a stable concentration gradient of chemokines

The pattern of leukocyte locomotion can be changed in many pathological situations, but its accurate analysis is difficult because of technological limitation. In the present study, by using a newly developed time-lapse videomicroscopic technique, we have analyzed the locomotive patterns of leukocytes in a stable concentration gradient of chemokines. Granulocytes, monocytes, and lymphocytes were purified from adult human peripheral blood. Locomotive behavior of the leukocytes was analyzed by an optical assay using a microchannel producing a stable concentration gradient of chemokines. Videomicroscopic analysis showed distinct locomotive patterns of granulocytes, monocytes, and lymphocytes. Granulocytes were intrinsically motile, vigorously moving in random direction without any chemokine stimulation. Upon stimulation with CXCL8/IL-8, the speed of migration was increased from 13.3 +/- 2.8 to 19.4 +/- 2.5 microm/min (P = 0.002, n = 100) and they moved toward the chemokine, although many cells still wandered very much. Stimulation with CCL5/RANTES or CXCL12/SDF-1alpha induced similar changes in locomotive pattern. On the other hand, most lymphocytes did not polarize or move spontaneously without chemokine stimulation. Stimulation with CXCL12 induced directional migration in 37% of the lymphocytes at a speed of 9.6 +/- 1.6 microm/min (n = 100). The movement pattern of monocytes was similar to that of granulocytes in that they tend to become polarized and move spontaneously, but they moved at a very slow speed ranging from 3.9 to 4.2 microm/min even with chemokine stimulation. The new optical assay may be useful for many diagnostic as well as basic studies.

Respiratory syncytial virus infection induces matrix metalloproteinase-9 expression in epithelial cells

Increased gelatinolytic activity was observed in respiratory syncytial virus (RSV)-infected HEp-2 cells by using zymography. The anti-matrix metalloproteinase-9 (MMP-9) antibody specifically reduced the gelatinolytic activity suggesting that the increased gelatinolytic activity was due to the MMP-9. It was also supported by the results from immunofluorescent staining, treatment of MMP inhibitors, and RSV infection of the cell clones that were transfected with plasmids to express more MMP-9 and tissue type inhibitor of metalloproteinase-1 (TIMP-1). The gelatinolytic activity of extracellular MMP-9 in RSV-infected HEp-2 cells increased 1.5 +/- 0.2 fold compared with the control (p < 0.01). Cell surface MMP-9 expression was also clearly detected by immunofluorescent staining. Treatment with 1,10-phenanthroline (0.05 mM), ethylenediamine-tetraacetate (EDTA) (1.5 mM), and penta-O-galloyl-beta-D-glucose (PGG) (3.3 microM) inhibited RSV multiplication as well as syncytia formation. Furthermore, the average syncytia size increased when the cells expressing more MMP-9 were infected by RSV. In contrast, syncytia formation was inhibited in the cells manipulated to express TIMP-1. Thus, this study concludes that although RSV infection induces MMP-9, which can enhance the syncytia formation leading to RSV multiplication and spread it can be inhibited by MMP inhibitors.

Multimodality program involving stereotactic surgery in brain tumor management

Stereotactic and image guided surgery is becoming increasingly important in the management of brain tumors. Although there are several stereotactic modalities that have been reported to be of value, it is the combination of techniques in a multimodality approach that seems to show the most promise. Both frame-based and frameless guidance may facilitate glioma resection, allowing the optimal amount of resection while permitting avoidance of surrounding eloquent areas. Not only does this optimize resection, but leaving a minimal amount of gross tumor may provide a better bed for intracavitary chemotherapy. Deep tumors may be localized and approached through a small channel. Surgical exposure may be minimized to protect uninvolved areas of the brain. There is increasing evidence that patients operated with imaging guidance have a more benign course and more rapid discharge, perhaps with a lower incidence of adverse neurological sequelae. Stereotactic conformal radiotherapy allows a higher tumor dose while sparing uninvolved brain from radiation more efficiently than conventional radiation. Residual tumor may be treated with a boost of stereotactic radiotherapy. Stereotactic instillation of radioisotope may be used to treat cystic tumors. Stereotactic insertion of cannulae or radioisotope seeds permits efficient brachytherapy. Stereotactic surgery has moved beyond a subspeciality, so that every neurosurgeon might benefit from using stereotactic techniques in brain tumor management.

Phase I/II trial evaluating combined radiotherapy and in situ gene therapy with or without hormonal therapy in the treatment of prostate cancer--a preliminary report

PURPOSE

To report the preliminary results of a Phase I/II study combining radiotherapy and in situ gene therapy (adenovirus/herpes simplex virus thymidine kinase gene/valacyclovir) with or without hormonal therapy in the treatment of prostate cancer.

METHODS AND MATERIALS

Arm A: low-risk patients (T1-T2a, Gleason score <7, pretreatment PSA <10) were treated with combined radio-gene therapy. A mean dose of 76 Gy was delivered to the prostate with intensity-modulated radiotherapy. Arm B: high-risk patients (T2b-T3, Gleason score >or=7, pretreatment PSA >or=10) were treated with combined radio-gene therapy and hormonal therapy. Hormonal therapy was comprised of a 4-month leuprolide injection and 2-week use of flutamide. Arm C: Stage D1 (positive pelvic lymph node) patients received the same regimen as Arm B, with the additional 45 Gy to the pelvic lymphatics. Treatment-related toxicity was assessed using Cancer Therapy Evaluation Program common toxicity score and Radiation Therapy Oncology Group (RTOG) toxicity score.

RESULTS

Thirty patients (13 in Arm A, 14 in Arm B, and 3 in Arm C) completed the trial. Median follow-up was 5.5 months. Eleven patients (37%) developed flu-like symptoms (Cancer Therapy Evaluation Program Grade 1) of fatigue and chills/rigors after gene therapy injection but recovered within 24 h. Four patients (13%) and 2 patients (7%) developed Grade 1 and 2 fever, respectively. There was no patient with weight loss. One patient in Arm B developed Grade 3 elevation in liver enzyme, whereas 11 and 2 patients developed Grade 1 and 2 abnormal liver function tests. There was no Grade 2 or above hematologic toxicity. Three patients had transient rise in creatinine. There was no RTOG Grade 3 or above lower gastrointestinal toxicity. Toxicity levels were as follows: 4 patients (13%), Grade 2; 6 patients (20%), Grade 1; and 20 patients (67%), no toxicity. There was 1 patient with RTOG Grade 3 genitourinary toxicity, 12 patients (40%) with Grade 2, 8 patients (27%) with Grade 1, and 9 patients (30%) with no toxicity. No patient dropped out from the trial or had to withhold treatment because of severe toxicity.

CONCLUSIONS

This is the first trial of its kind in the field of prostate cancer that aims to expand the therapeutic index of radiotherapy by combining in situ gene therapy. Initial experience has demonstrated the safety of this approach. There is no added toxicity to each therapy used alone. Long-term follow-up and larger cohort studies are warranted to evaluate long-term toxicity and efficacy.

Important prognostic factors in patients with skull base erosion from nasopharyngeal carcinoma after radiotherapy

PURPOSE

To evaluate the long-term outcome and prognostic factors in patients with skull base erosion from nasopharyngeal carcinoma after initial radiotherapy (RT).

METHODS AND MATERIALS

From January 1985 to December 1986, 100 patients (71 males, 29 females) with a diagnosis of nasopharyngeal carcinoma were found on computed tomography (CT) to have skull base erosion. The mean age was 41 years (range 16-66). Ninety-six patients had World Health Organization type III undifferentiated carcinoma, and 4 had type I. The metastatic workup, including chest radiography, liver ultrasound scanning, and liver function test was negative. All patients underwent external beam RT (EBRT) alone to 66-80 Gy during 6-8 weeks. A daily fraction size of 2 Gy was delivered using 60Co or a linear accelerator. No patient received chemotherapy. All patients were followed at regular intervals after irradiation. The median follow-up was 22.3 months (range 2-174). Survival of the cohort was computed by the Kaplan-Meier method. The potential prognostic factors of survival were examined. Multivariate analyses were performed using the Cox regression model.

RESULTS

The 1, 2, 5, and 10-year overall survival rate for the cohort was 79%, 41%, 27%, and 13%, respectively. However, the subgroup of patients with both anterior cranial nerve (I-VIII) and posterior cranial nerve (IX-XII) involvement had a 5-year survival of only 7.7%. A difference in the time course of local recurrence and distant metastasis was observed. Both local recurrence and distant metastasis often occurred within the first 2 years after RT. However, local relapse continued to occur after 5 years. In contrast, no additional distant metastases were found after 5 years. The causes of death included local recurrence (n = 59), distant metastasis (n = 21), both local recurrence and distant metastasis (n = 1), and unrelated causes (n = 5). After multivariate analysis, complete recovery of cranial nerve involvement, cranial nerve palsy, and headache after irradiation were found to be independent prognostic factors in this cohort.

CONCLUSIONS

We present one of the longest follow-ups of patients with nasopharyngeal carcinoma invading the skull base. Our results demonstrate the importance of cranial nerve involvement, recovery of headache, and cranial nerve palsy. These factors should be carefully evaluated from the history, physical examination, and imaging studies. A subgroup of patients with skull base involvement had long-term survival after RT alone. The findings of this study are important as a yardstick against which more aggressive strategies, such as combined radiochemotherapy and altered fractionation RT can be compared.

The potential use of intensity modulated radiotherapy (IMRT) in women with pectus excavatum desiring breast-conserving therapy

The purpose of this study was to determine if intensity modulated radiation therapy (IMRT) offers a better treatment plan compared to conventional radiotherapy for patients with pectus excavatum desiring breast-conserving therapy and to assess the feasibility of simultaneous modulated accelerated radiation therapy (SMART) boost. A patient with pectus excavatum desired breast-conserving therapy for her early stage breast cancer. She underwent lumpectomy and axillary lymph node dissection followed by chemotherapy. She was then referred for radiotherapy. A breast board (Med-Tec) with aquaplast body cast was used to limit the movement of the patient, chest wall, and breasts before planning a computed tomography (CT) scan. IMRT including dose-volume histogram (DVH) was compared to that of the conventional plan using parallel opposed tangential beams with a 15-degree wedge pair. Forty-five gray was prescribed to the whole breast to each plan, while 50 Gy was prescribed to the tumor bed using IMRT with SMART boost in 25 fractions over 5 weeks. The coverage of the whole breast was adequate for both plans. IMRT allowed a more homogeneous dose distribution within the breast at the desired dose range. With IMRT there is less volume of ipsilateral lung receiving the radiation dose that is above the tolerance threshold of 15 Gy when compared to that of the conventional plan. However, there is more volume of surrounding normal tissues (the heart, spinal cord, and contralateral breast and lung) receiving low-dose irradiation when IMRT was employed. SMART boost was feasible, allowing a mean dose of 57 Gy to be delivered to the tumor bed simultaneously along with the rest of the breast in 5 weeks. IMRT is feasible in treating early breast cancer patients with pectus excavatum by decreasing the ipsilateral lung volume receiving high-dose radiation when compared to the conventional method. SMART boost shortens the overall treatment time that may have potential radiobiological benefit.

The role of DRE in the diagnosis of prostate carcinoma

DRE has been used as a diagnostic and screening tool for prostate cancer for decades. However these are based on Western data and its local applicability has yet to be verified. We held a Prostate Health Awareness Week in August 1998 and a total of 2086 men were screened. All men aged 50 years old and above were included for the study. The subjects were evaluated on DRE findings, PSA levels and if indicated a TRUS-guided biopsy results. We concluded that DRE per se might have limited role in the screening of prostate cancer in Malaysia. Screening using DRE and PSA combined are still recognized as the most cost-effective means. Neither DRE nor PSA alone has high enough specificity for diagnosis of prostate cancer cases. Combining DRE and PSA will definitely increase the specificity significantly.

Apoptosis and megakaryocytic differentiation during ex vivo expansion of human cord blood CD34+ cells using thrombopoietin

Thrombopoietin (TPO), the primary regulator of megakaryocytopoiesis, plays important roles in early haematopoiesis. Previously, we have demonstrated that TPO induces a characteristic pattern of apoptosis during ex vivo expansion of cord blood (CB) CD34+ cells. In this study, we have demonstrated that the TPO-induced apoptotic cells belong to the megakaryocytic (MK) lineage and that initially expanding MK progenitors declined along with the appearance of TPO-induced apoptosis. Human CB CD34+ cells were expanded in serum-free conditions with TPO. Multidimensional flow cytometry using simultaneous measurement of apoptosis and immunophenotyping showed that the TPO-induced apoptotic cells appeared in CD61+ fractions. Immunocytochemical analysis of the fluorescent activated cell-sorted fractions showed that the apoptosis-associated CD44low fraction expressed CD61. Clonogenic assay revealed 7.4 +/- 0.50-fold increase of total megakaryocyte colony-forming units (CFU-MKs) during the initial 9 d. Thereafter, the number of CFU-MKs decreased in parallel with the increase of apoptosis. When the MK colonies were subdivided according to size, the proportion of large colonies progressively decreased, while that of medium and small colonies increased. In particular, from d 6 small colonies became predominant. These results suggested that the MK progenitors matured as they expanded during ex vivo expansion with TPO and then proceeded to apoptosis.

A teleradiology case conference system

To investigate the use of teleradiology in the quality assurance programme of a multicentre radiotherapy practice, we installed image acquisition and display workstations at each of two affiliated radiation oncology clinics. A commercial diagnostic teleradiology system was successfully modified to suit the requirements of the radiotherapy subspecialty. The system allowed intersite transmission of images, access to high-resolution images from each site and, by use of laser film scanners, made accessible all types of radiation therapy image. Transmission speed and storage capacity were better than expected. Using the system, radiation oncology residents and staff reviewed 83 complex cases over eight months. Case presentation and discussion were enhanced. In the same period, 276 cases were reviewed by conference in person. Case conferences for quality assurance conducted with the teleradiology system influenced changes in treatment planning as effectively as those conducted in person. Equivalent treatment outcomes were produced. The teleradiology system facilitated quality assurance through review of patients' radiation treatments by allowing natural interactive consultation.

Intensity-modulated radiation therapy (IMRT) for prostate cancer with the use of a rectal balloon for prostate immobilization: acute toxicity and dose-volume analysis

PURPOSE

To report acute toxicity and to evaluate the relationship between dose-volume effects and acute toxicity in patients with localized prostate cancer, treated with intensity-modulated radiation therapy (IMRT).

METHODS AND MATERIALS

Acute toxicity (both lower gastrointestinal [GI] and genito-urinary [GU]) in 100 patients treated with IMRT definitively to a prescribed dose of 70 Gy were assessed using RTOG scoring criteria. A rectal balloon was used for prostate immobilization. Mean doses to seminal vesicles, prostate, bladder, and rectum were recorded. Average irradiated bladder and rectal volumes above 65, 70, and 75 Gy were assessed. A relationship between dose volume and clinical toxicity was evaluated. All patients completed the full duration of acute toxicity assessment.

RESULTS

Mean doses to the prostate and seminal vesicles were 75.8 and 73.9 Gy. This represents a moderate dose escalation. Acute GI toxicity profile was very favorable. Eleven percent and 6% of the patients had grade 1 and 2 GI toxicity, respectively, while 83% had no GI complaint. For GU complaints, 38% and 35% had grade 1 and 2 toxicity, respectively, while 27% had no complaints. There was no grade 3 or higher acute GI or GU toxicity. Mean doses to the bladder were 22.8, 23.4, and 26.1 Gy for grade 0, 1, and 2 GU toxicity, respectively (p = 0.132). There is no statistically significant relationship between acute GU toxicity and the bladder volume receiving > 65 Gy, > 70 Gy, or > 75 Gy. In evaluating acute GI toxicity, there are very few grade 1 and 2 events. No relationship was found between acute rectal toxicity and mean rectal dose or irradiated rectal volumes receiving more than 65, 70, and 75 Gy.

CONCLUSION

The findings are important with regard to the safety of IMRT, especially in reducing acute GI toxicity. Dose escalation with IMRT using a prostate immobilization technique is feasible. The findings are also important because they contribute to the clinical and dosimetric correlation aspect in the use of IMRT to treat prostate cancer. A larger cohort may be needed to determine if there is a relationship between acute GU toxicity and (a) mean bladder dose and (b) irradiated bladder volume receiving > 65 Gy, > 70 Gy, or > 75 Gy. A larger cohort of patients treated to a higher dose may be needed to show a relationship between dose volume and acute GI toxicity.

Intensity modulated radiation therapy (IMRT) following prostatectomy: more favorable acute genitourinary toxicity profile compared to primary IMRT for prostate cancer

PURPOSE

To report our initial experience on postprostatectomy IMRT (PPI), addressing acute genitourinary (GU) toxicity in comparison to primary IMRT (PI) for prostate cancer.

METHODS AND MATERIALS

From April 1998 to December 1999, 40 postprostatectomy patients were treated with intensity modulated radiation therapy (IMRT) to a median prescribed dose of 64 Gy (mean dose of 69 Gy). The Radiation Therapy Oncology Group (RTOG) scoring system was used to assess acute GU toxicity. Target volume and maximum and mean doses were evaluated. The mean doses to the bladder and irradiated bladder volume receiving >65 Gy were assessed. These were compared to those of 125 patients treated with PI to a prescribed dose of 70 Gy (mean dose of 76 Gy).

RESULTS

The acute GU toxicity profile is more favorable in the PPI group with 82.5% of Grade 0-1 and 17.5% of Grade 2 toxicity compared to 59.2% and 40.8%, respectively, in the PI group (p < 0.001). There was no Grade 3 or higher toxicity in either group. The target volume was larger in the PPI group, while the maximum and mean doses to the target were higher in the PI group. The mean dose delivered to the bladder was higher in the PPI group. The irradiated bladder volume receiving >65 Gy was significantly larger in the PI group (p < 0.001).

CONCLUSIONS

PPI can be delivered with acceptable ute GU toxicity. The larger PPI target volume may be related to the difficulty in delineating prostatic fossa. Despite a larger target volume and a higher mean dose to the bladder, PPI produced a more favorable acute GU toxicity profile. This may be related to a combination of lower mean and maximum doses and smaller bladder volumes receiving >65 Gy in the PPI group, as well as urethral rather than bladder irradiation. The findings have implications in the evaluation of IMRT treatment plan for prostate cancer, whereby the irradiated bladder volumes above 65 Gy may be more meaningful than the mean dose to the bladder. Longer term toxicity results are awaited.

Applying the equivalent uniform dose formulation based on the linear-quadratic model to inhomogeneous tumor dose distributions: Caution for analyzing and reporting

We apply the concept of equivalent uniform dose (EUD) to our data set of model distributions and intensity modulated radiotherapy (IMRT) treatment plans as a method for analyzing large dose inhomogeneities within the tumor volume. For large dose nonuniformities, we find that the linerar-quadratic based EUD model is sensitive to the linear-quadratic model parameters, alpha and beta, making it necessary to consider EUD as a function of these parameters. This complicates the analysis for inhomogeneous dose distributions. EUD provides a biological estimate that requires interpretation and cannot be used as a single parameter for judging an inhomogeneous plan. We present heuristic examples to demonstrate the dose volume effect associated with EUD and the correlation to statistical parameters used for describing dose distributions. From these examples and patient plans, we discuss the risk of incorrectly applying EUD to IMRT patient plans.

Properties of GST-CALM expressed in E. coli

Clathrin-coated vesicles (CCVs) are involved in protein and lipid trafficking between intracellular compartments in eukaryotic cells. CCVs are composed of clathrin and assembly proteins. The clathrin assembly protein lymphoid myeloid leukemia (CALM) gene, encodes a homologoue of the neuronal clathrin assembly protein AP180. In this study, we characterized the properties of the CALM expressed in E. coli. The molecular weight of bacterially expressed GST-CALM fusion protein was approximately 105 kD on SDS-PAGE. The CALM protein could promote clathrin triskelia into clathrin cages and could bind the preformed clathrin cage. However, 33 kD N-terminal domain of CALM could not bind pre-assembled clathrin cages, but assemble clathrin triskelia into clathrin cages. The CALM protein was bound to SH3 domain through N-terminal domain1, in vitro. The CALM protein is proteolyzed by caspase 3, caspase 8 and calpain through C-terminal domain.

The use of intensity modulated radiotherapy for the treatment of extensive and recurrent juvenile angiofibroma

These case series are presented to describe the application and advantages of intensity modulated radiotherapy (IMRT) for the treatment of extensive and/or recurrent juvenile angiofibroma. Two patients were diagnosed with recurrence at 11 and 13 months postoperatively, and one was surgically unresectable. The affected areas included the base of skull, cavernous sinus, pterygopalatine fossa, infratemporal fossa, posterior orbit and nasopharynx. Highly conformal IMRT was delivered with limited radiation doses to the optic nerves, optic chiasm, brainstem, brain, spinal cord, lens, retina, mandible, and parotid. The total dose delivered to the tumor varied from 3400 to 4500 cGy. The tumor shrunk radiographically in all three cases and there was no endoscopic evidence of disease in two cases at 15 months and 40 months. There was no acute toxicity. Late toxicity was limited to one episode of epistaxis and persistent rhinitis in one patient. In conclusion, IMRT provides several advantages over conventional radiotherapy in the treatment of recurrent juvenile angiofibroma.

Intensity modulated radiation therapy (IMRT): a new promising technology in radiation oncology

Intensity modulated radiation therapy (IMRT) is a new technology in radiation oncology that delivers radiation more precisely to the tumor while relatively sparing the surrounding normal tissues. It also introduces new concepts of inverse planning and computer-controlled radiation deposition and normal tissue avoidance in contrast to the conventional trial-and-error approach. IMRT has wide application in most aspects of radiation oncology because of its ability to create multiple targets and multiple avoidance structures, to treat different targets simultaneously to different doses as well as to weight targets and avoidance structures according to their importance. By delivering radiation with greater precision, IMRT has been shown to minimize acute treatment-related morbidity, making dose escalation feasible which may ultimately improve local tumor control. IMRT has also introduced a new accelerated fractionation scheme known as SMART (simultaneous modulated accelerated radiation therapy) boost. By shortening the overall treatment time, SMART boost has the potential of improving tumor control in addition to offering patient convenience and cost savings.

Distinct patterns of apoptosis in association with modulation of CD44 induced by thrombopoietin and granulocyte-colony stimulating factor during ex vivo expansion of human cord blood CD34+ cells

The insufficient number of haemopoietic stem cells (HSCs) in cord blood (CB) is the major potential limitation to widespread use of CB for marrow replacement. Cytokine-mediated ex vivo expansion has been proposed as a means of increasing the number of CB HSCs for transplantation. However, the biology of CB HSCs during cytokine-mediated ex vivo expansion, such as apoptosis or expression of adhesion molecules, has not yet been elucidated. We have investigated the patterns of apoptosis and CD44 expression on human CB CD34+ cells during ex vivo expansion. CD34+ cells isolated from human CB were cultured in a stroma-free liquid culture system with thrombopoietin (TPO), flt3-ligand (FL), stem cell factor (SCF), and/or granulocyte-colony stimulating factor (G-CSF). During the culture, for up to 5 weeks, apoptosis was measured by staining with 7-amino-actinomycin D (7-AAD) along with concurrent immunophenotyping of CD34 and CD44 with three-colour flow cytometry. In the cultures with TPO, an apoptotic fraction with down-regulated CD44 appeared from the fourth day up to the second week. G-CSF also induced apoptosis but in a different manner; the apoptotic fraction without down-regulation of CD44 appeared unremittingly for up to 5 weeks. FL did not induce apoptosis or down-regulation of CD44. These findings show that apoptosis is indeed involved in the regulation of CB CD34+ cells in ex vivo expansion and the patterns of apoptosis are dependent on the type of cytokines used. The distinct patterns of apoptosis suggest different mechanisms of TPO and G-CSF in inducing apoptosis, which still remains to be elucidated.

Smart (simultaneous modulated accelerated radiation therapy) boost: a new accelerated fractionation schedule for the treatment of head and neck cancer with intensity modulated radiotherapy

PURPOSE

To report the initial experience in the definitive treatment of head and neck carcinomas using SMART (Simultaneous Modulated Accelerated Radiation Therapy) boost technique. Radiation was delivered via IMRT (Intensity Modulated Radiotherapy). The following parameters were evaluated: acute toxicity, initial tumor response, clinical feasibility, dosimetry and cost.

METHODS AND MATERIALS

Between January 1996 and December 1997, 20 patients with primary head and neck carcinomas were treated with SMART boost technique. The treatment fields encompassed two simultaneous targets. The primary target included palpable and visible disease sites. The secondary target included regions at risk for microscopic disease. Daily fractions of 2.4 Gy and 2 Gy were prescribed and delivered to the primary and secondary targets to a total dose of 60 Gy and 50 Gy, respectively. Lower neck nodes were treated with a single conventional anterior portal. This fractionation schedule was completed in 5 weeks with 5 daily fractions weekly. Toxicity was evaluated by RTOG acute toxicity grading criteria, evidence of infection at immobilization screw sites, subjective salivary function, weight loss, and the need for treatment split. Mean follow-up was 15.2 months. Initial tumor response was assessed by clinical and radiographical examinations. Clinical feasibility was evaluated by the criteria: time to treat patient, immobilization, and treatment planning and QA time. In dosimetry, we evaluated the mean doses of both targets and normal tissues and percent targets' volume below goal. To evaluate cost, Medicare allowable charge for SMART boost was compared to those of conventional fractionated and accelerated radiotherapy.

RESULTS

ACUTE TOXICITY: None of the patients had a screw site infection and all patients healed well after completion of radiotherapy. Sixteen of 20 patients (80%) completed the treatment within 40 days without any split. Sixteen patients (80%) had RTOG Grade 3 mucositis while 10 patients (50%) had Grade 3 pharyngitis. Three of 20 patients (15%) had weight loss greater than 10% of their pretreatment weight. Ten patients (50%) required intravenous fluids, tube feeding or both. Nine patients (45%) reported moderate xerostomia with significant relief reported within 6 months. INITIAL TUMOR RESPONSE: 19 patients (95 %) had complete response (CR) while one had partial response (PR). The patient with PR had stable disease on imaging at 12 months follow-up. Two patients were found to have lung metastases at 2 months and 5 months follow-up. To date, there have been two local recurrences in the complete responders. Both patients had nasopharyngeal primary; one was retreated with radioactive Cesium-137 implant and the other died from the disease. CLINICAL FEASIBILITY: The average treatment time for a three-arc treatment was 17.5 minutes and 2.5 minutes for each additional arc. Eleven patients (55%) had four-arc treatment while six patients (30%) had five-arc treatment and three patients (15%) had three-arc treatment. Immobilization was reproducible within less than 2 mm. The treatment planning, QA and documentation prior to treatment averaged 2 days. DOSIMETRY: The mean doses to the primary and secondary targets were 64.4 Gy and 54.4 Gy, respectively; 8.9% of the primary target volume and 11.6% of the secondary target volume were below prescribed dose goal. The mean dose delivered to the mandible was 30 Gy, spinal cord 17 Gy, ipsilateral parotid 23 Gy, and contralateral parotid 21 Gy. COST: Total Medicare allowable charge for SMART boost was $7000 compared to $8600 (conventional) and $9400 (accelerated fractionation).

CONCLUSIONS

SMART boost technique is an accelerated radiotherapy scheme that can be delivered with acceptable toxicity. It allows parotid sparing as evidenced both clinically and by dosimetry. Initial tumor response has been encouraging. It is clinically feasible and cost saving. A larger population of patients and a long-term fol

Myeloid differentiation of human cord blood CD34+ cells during ex vivo expansion using thrombopoietin, flt3-ligand and/or granulocyte-colony stimulating factor

We investigated the phenotypic changes of human umbilical cord blood (CB) CD34+ cells during ex vivo expansion using thrombopoietin (TPO), flt3-ligand (FL), and/or granulocyte-colony stimulating factor (G-CSF). During ex vivo expansion of CD34+ cells isolated from human CB for up to 5 weeks, surface expression of molecules on the cultured cells including CD64 (Fc gammaRI), CD32 (Fc gammaRII), CD16 (Fc gammaRII), CD11b (MAC-1) and CD18 (beta2-integrin) was analysed by flow cytometry along with simultaneous measurement of apoptosis by 7-aminoactinomycin D staining method. CD64, CD32 and/or CD18 expressing cells appeared in the cultures both with and without the addition of G-CSF until the tenth day. However, without G-CSF, CD16+ fractions did not appear and CD11b+ fractions were not maintained. With G-CSF, the CD16+ or CD11b+ fractions appeared only from the second week. These results suggest that G-CSF is necessary for the late stage of myeloid maturation during which CD16 and CD11b are expressed.

Non-metastatic Ewing's sarcoma: twenty years of experience suggests that surgery is a prime factor for successful multimodality therapy

Eighty-five patients (37 female, 48 male; median age 14 years) with non-metastatic Ewing's sarcoma received definitive treatment at the University of Texas M.D. Anderson Cancer Center between 1969 and 1988. Multidisciplinary therapy was administered as follows: combination chemotherapy (CC) and local radiotherapy (XRT): 65 patients; CC, XRT and surgery, 19 patients; and XRT and surgery, 1 patient. This permitted a 10-20 year follow-up for 75% of our patients. The overall survival at 5 and 10-20 years was 46.1%, and 37.2%, respectively. At 5 years, 80.5% of live patients had control of local disease. The influence of sex, age, ethnicity, primary site, size, lactic dehydrogenase (LDH) level, presence or absence of systemic symptoms, and XRT dose (<60 Gy and </=60 Gy) was analyzed and was not found to be of prognostic significance in survival. The presence of a soft tissue mass at diagnosis was found to be a significant unfavorable prognostic variable. Nine of 11 patient who underwent resection after CC and/or XRT had residual tumor in the surgical specimen. Patients who received surgery as part of the planned treatment of their primary tumor had significantly better local control and disease-free survival than those who did not undergo resection. Complications in long-term survivors are described.

Clinical and financial issues for intensity-modulated radiation therapy delivery

Intensity-modulated radiation therapy (IMRT) is a term applied to a new technology that uses nonuniform radiation beams to achieve conformal dose distributions. This article reviews the use of a commercial system, the Peacock system, which uses a special multileaf collimator (MIMiC) to deliver the dose distribution using arc therapy and segmented fields, similar to a moving strip. Although initially designed for stereotactic radiosurgery, this system has been employed to treat various body sites. More than 300 patients have been treated at our institution in the past 4 years, mainly for cranial, head-and-neck, and prostate tumors. Presently, we treat 40 to 45 patients per day with this technology using two linear accelerators operating with 10 MV and 15 MV x-rays, as Peacock has become a standard therapy procedure. Cases are presented that show the unique ability of IMRT to deliver conformal dose distributions. Why this type of technology can become a standard procedure and why it is cost-effective therapy for both the institution and the patient are discussed.

Clear cell sarcoma of the kidney: an unusual presentation and review of the literature

PURPOSE

To describe a child with clear cell sarcoma of the kidney (CCSK) with an unusual presentation, including a primary tumor of the left kidney with metastases to the right kidney and soft tissues of the lower extremities, and to review the literature.

PATIENT AND METHODS

An 8-month-old infant presented with hypertension, an abdominal mass, and soft tissue masses in the left thigh and right foot. Imaging studies revealed a large left-sided renal tumor, left paravertebral soft tissue masses, and left thigh mass. At laparotomy, a lesion was noted in the lower pole of the contralateral kidney. CCSK with metastases to the contralateral kidney and to the soft tissues of left thigh, right foot, and left paravertebral region was diagnosed on histopathologic examination.

RESULTS

Multimodal oncologic treatment included surgery, chemotherapy, and radiotherapy. Three months after completion of therapy, a soft tissue lesion in the left arm and, later, soft tissue lesions involving multiple parts of the body developed. The patient died 18 months after diagnosis without clinical or radiographic evidence of bone involvement.

CONCLUSIONS

In a review of the literature, CCSK is most commonly associated with bone and lung metastases. Soft tissue involvement is uncommon. Metastasis to the contralateral kidney at initial diagnosis has not previously been reported. This case represents an unusual metastatic pattern of CCSK.

The Baylor College of Medicine experience with gold seed implantation

Advances in imaging technology and implant technique have led to the resurgent interest and practice of brachytherapy for the treatment of prostate cancer. Brachytherapy is a form of radiation treatment in which radioactive sources are placed directly into the tumor; it offers the advantage of maximizing the radiation dose delivered to the tumor while sparing the adjacent normal tissue. Permanent implants have become an important component of radiation delivery. Interstitial gold radioisotope (Au-198) implants for prostate cancer were introduced at Baylor College of Medicine in 1965. The rationale for using Au-198, instead of the two most commonly used radioisotopes, Palladium-103 (Pd-103) and Iodine-125 (I-125), is discussed, and the Baylor implant technique is compared to that used in other centers. Retrospective review divides the patient population into pre-ultrasound versus post-ultrasound eras. Dosimetric calculation and disease control with the Au-198 seed implant for prostatic cancer are reviewed for the two different eras; toxicity is evaluated in the post-ultrasound era only. In the pre-ultrasound era, 510 patients were treated with pelvic lymph node sampling and gold seed insertion of the prostate followed by external beam radiation. In the post-ultrasound era, 54 patients were treated definitively with ultrasound-guided transperineal Au-198 implant followed by external beam irradiation. A small group of 30 patients in the post-ultrasound era were evaluated for the efficacy of Au-198 re-implantation for locally recurrent disease.

Phase I-II study of combined 5-fluorouracil and cisplatin chemotherapy and altered fractionation radiotherapy for advanced squamous cell carcinoma of the cervix

Forty patients with advanced carcinoma of the cervix were prospectively treated by an intermodality approach using chemotherapy combination concomitant with split-course hyperfractionated radiation therapy (RT). Cisplatin (CDDP) (60 mg/m2) was administered before radiotherapy initiation followed by 5-fluorouracil (5-FU) (750 mg/m2) for 5 days during the first week of irradiation. The same schedule was repeated in the last week of the RT, with 5-FU administration (1,000 mg/m2) for only 3 days. RT consisted of 5,020 cGy to the pelvis, followed by two intracavitary applications for a total of 5,000-5,500 mg/h radium equivalent when possible: 140 cGy/fraction was administered in the morning and evening, with a 6-h interval. The remainder of the external beam radiation was delivered at a standard daily fractionation of 180 cGy/fraction to a total dose of 5,020 cGy. This regimen of RT with concomitant chemotherapy had minimal toxicity and did not cause significant prolongation of the treatment program. However, a high rate of late complications was noted in patients who had extended-field RT due to paraaortic lymph node involvement. Thirty-two patients had complete response (CR) (80%). 24 (75%) of whom have no evidence disease (NED), with a median follow-up of 24 months. Our study suggests that this regimen of combined chemotherapy and RT in this group of patients with poor prognosis is effective and well tolerated, with acceptable acute toxicity and late morbidity.

MOPP chemotherapy without irradiation as primary postsurgical therapy for brain tumors in infants and young children

Infants and young children who have brain tumors have a poor rate of survival and high treatment associated morbidity. A trial of mechlorethamine, vincristine (oncovin), procarbazine, and prednisone (MOPP) was performed to test the hypothesis that replacing radiotherapy with chemotherapy would improve survival and decrease long term morbidity of infants who have brain tumors. Between 1976 and 1988, 17 consecutive children less than 36 months old when diagnosed with medulloblastoma or ependymoma were treated with MOPP chemotherapy as primary therapy following surgical excision or biopsy of the tumor. Radiotherapy was reserved for recurrent disease. Ten of 17 children have survived without evidence of disease: medulloblastoma eight of 12 with median survival time of 10.6 years (range, 6.2 to 15.2 yrs); and ependymoma, 2 of 5 (at 13.0 and 16.0 yrs). Four of the 10 children with medulloblastoma and ependymoma who relapsed are now disease free at 7.5, 11.7, 12.2 and 13.5 yrs post relapse after receiving salvage therapy with cisplatin (n = 1) or irradiation (n = 3). All relapses occurred within 26 months of diagnosis. Data on growth demonstrated height less than the 5th percentile in all children who received cranial irradiation compared to 25 to 95th percentile for nonirradiated children. Intellectual ability for the group who did not require radiation was within normal range (mean IQ 100.1) and stable across annual assessments. Those who required radiation had lower IOs which continued to decline over time (mean IQ 85 at mean age of 5.8 years, declining to 63 at 10 years). In young children with brain tumors, primary chemotherapy with MOPP, omitting radiotherapy, provides improved neurodevelopmental outcome and survival.

Improvement in visual function in an eye with a presumed optic nerve sheath meningioma after treatment with three-dimensional conformal radiation therapy

The treatment of optic nerve sheath meningiomas (ONSM) is controversial. Radiation therapy has been used with some success in patients with progressive visual loss. We report a case of visual improvement in a patient with an optic nerve sheath meningioma and progressive visual field loss, treated with conformal radiotherapy.

Mixed neuronal-glial tumors (gangliogliomas) in children

Mixed tumors account for about 10% of the childhood central nervous system tumors. Studies of the most common tumor, the ganglioglioma, in patients of all ages suggest that optimal therapy is total gross resection. There are few studies on these tumors in children. In our institution between 1984 and 1993, 28 children with gangliogliomas (4 of which were anaplastic) and 4 children with dysembryoplastic neuroepithelial tumors were treated and followed. Fourteen had local subarachnoid involvement. Total gross resection was usually curative, regardless of histology. Subarachnoid involvement was not indicative of a poorer prognosis.

A comparison of intensity modulated conformal therapy with a conventional external beam stereotactic radiosurgery system for the treatment of single and multiple intracranial lesions

PURPOSE

To compare the stereotactic radiosurgery treatment plans generated by a conventional radiosurgery treatment system with the plan generated by a system using intensity modulated beams.

METHODS AND MATERIALS

Optimized conformal radiation treatment plans were generated for both single and multiple intracranial lesions using a conventional radiosurgery treatment-planning system computer and the Peacock treatment-planning computer. The Peacock system is a conformal therapy system that uses intensity modulated beams, back projection, and the simulated annealing optimization technique. The dose delivered to critical structures and the target volume were compared by means of dose volume histograms between plans generated by the two different systems. The Radiation Therapy Oncology Group (RTOG) stereotactic radiosurgery criteria were also used to evaluate each plan.

RESULTS

(a) For a single small target, radiosurgery plans generated by the conventional radiosurgery system and the Peacock system were comparable. (b) For two separate small targets, where nonoverlapping arcs could be used, plans generated by the two systems were also comparable. (c) For a single large (>4 cm) irregular-shaped target, the Peacock system appeared to be able to generate a treatment plan superior to that of the conventional radiosurgery system.

CONCLUSIONS

A treatment plan generated using intensity modulated beams appears to be superior to a multiple isocenter plan using a conventional radiosurgery system, for the treatment of a large irregular shaped intracranial target.

Long-term effects of radiotherapy administered in childhood for the treatment of malignant diseases

BACKGROUND

The use of radiotherapy for the treatment of childhood malignancy has improved long-term survival significantly, and many treated children now survive well into adulthood. As a consequence, long-term effects of childhood irradiation are being seen with increasing frequency.

METHODS

The medical records of 236 patients who had been treated for malignant disease with radiotherapy during childhood were examined to determine the long-term effect of the radiation on their growth and development.

RESULTS

Mean treatment dose was 35.5 Gy; mean age at treatment was 7.2 years; and mean follow-up was 14.5 years. Adjuvant chemotherapy was given to 82%. Some degree of bone deformity (usually with overlying soft-tissue hypoplasia) was seen in 40%; 21% developed some type of endocrine deficiency; 30% developed atrophic skin changes; and 7% developed second malignancies. The incidence of bone deformity and hormonal deficiency increased with the radiation dose; the incidence of second malignancy was independent of dose. Bone deformities were more common when radiation was administered before the age of 2 years.

CONCLUSIONS

The consequences of radiotherapy in childhood are significant and must be considered when planning treatment. Even when treatment is essential, families should be informed of the possibility of growth disturbance to prevent subsequent misunderstanding.

Treatment of secretory pituitary adenoma with radiation therapy

A retrospective review of 44 patients with secretory pituitary adenoma treated with radiation therapy (median total dose of 4,500 cGy with a median fraction size of 225 cGy) was performed to analyze response rates and possible variables associated with failure to respond and with complications. The treatment technique used for 75% of the patients was a combination field; an opposed-lateral fields technique was used for the remainder. Median follow-up was 78.5 months, with 59% followed up for more than 60 months and 34% for more than 120 months. Overall survival was 90%, and disease-free survival was 62%. Response rates were 86% for the group with prolactinoma, 67% for the group with acromegaly, and 50% for the group with Cushing disease; the overall response rate was 71%. Findings of suprasellar extension and those from treatment with opposed-lateral fields correlated significantly with failure to respond. A higher percentage of patients with invasive macroadenomas also failed to respond. More complications were found in patients treated with opposed-lateral fields, but the numbers were too small to reach significance. Radiation therapy remains an important adjunct for the treatment of many patients with secretory pituitary adenoma.

Allogeneic bone marrow transplantation for hematological malignancies following etoposide, cyclophosphamide, and fractionated total body irradiation

Forty-three patients received etoposide, cyclophosphamide, and fractionated total body irradiation before allogeneic marrow transplantation. Fifteen patients had chronic myelogenous leukemia in chronic phase or acute leukemia in first remission (standard risk) and twenty-eight patients with more advanced disease (high risk). All patients received etoposide 1,500 mg/m2 intravenously on day -8, cyclophosphamide 60 mg/kg/day intravenously on days -7 and -6, and total body irradiation at 170 cGy twice a day on days -3, -2, and -1. During the first 100 days 12 high risk patients (43%) died from causes unrelated to relapse while none of the standard risk patients died. Renal and hepatic dysfunction were also significantly increased during the first 14 days in the high risk group. The addition of 1,500 mg/m2 of etoposide to the cyclophosphamide and total body irradiation was well tolerated for patients with standard risk. However, the regimen was poorly tolerated with high mortality in patients with more advanced disease.

Intracranial ependymoma in children: analysis of prognostic factors

Between 1955 and 1986, 25 children (aged 2 weeks to 15 years) were treated for intracranial ependymoma at M.D. Anderson Cancer Center. Nine patients had supratentorial primaries (5 high-grade, 4 low-grade), and 16 had infratentorial primaries (9 high-grade, 7 low-grade). Five patients had gross complete resection and 20 had incomplete resection. Seven patients received craniospinal irradiation (25-36 Gy to the neuro-axis, 45-55 Gy to tumor bed), 12 received local field irradiation (29-60 Gy, median 50 Gy). Five infants had adjuvant chemotherapy without radiotherapy, and 6 children had post-radiotherapy adjuvant chemotherapy, and 12 patients had salvage chemotherapy with various agents and number of courses. Eight patients are alive, disease-free and without relapse from 1 year to 12 1/2 years from diagnosis (median 42 months). The primary failure pattern was local recurrence. The data suggest that 1) the long-term cure rate of children with ependymoma is suboptimal; 2) histologic grade may be of prognostic importance for supratentorial tumors; 3) prognosis appears worse for girls and infants under 3 years of age; 4) in well-staged patients routine spinal irradiation could be omitted; 5) the role of adjuvant chemotherapy is unclear.