Significantly lower frequency of relapse, incidence of pulmonitis and pericarditis, leukopenia and thrombocytopenia stage IV and longer recurrence-free survival were reported after acceleration of multifractionation of STD of 1.35Gy was used for treatment of patients with primary Hodgkin's disease, as compared with standard fractionation. When STD was reduced to 1.2Gy (modified multifractionation), subtotal exposure of lymph nodes was followed by a significant drop in frequency and severity of leukopenia and thrombocytopenia stage III-IV. The latter complications, rates decreased further, with perspective response to therapy, as irradiation was limited to that of areas exposed during modified multifractionation.
To update the 2005 Cancer Care Ontario practice guidelines for the diagnosis and treatment of adult patients with a suspected or confirmed diagnosis of extradural malignant spinal cord compression (MESCC).
A review and analysis of data published from January 2004 to May 2011. The systematic literature review included published randomized control trials (RCTs), systematic reviews, meta-analyses, and prospective/retrospective studies.
An RCT of radiation therapy (RT) with or without decompressive surgery showed improvements in pain, ambulatory ability, urinary continence, duration of continence, functional status, and overall survival. Two RCTs of RT (30 Gy in eight fractions vs. 16 Gy in two fractions; 16 Gy in two fractions vs. 8 Gy in one fraction) in patients with a poor prognosis showed no difference in ambulation, duration of ambulation, bladder function, pain response, in-field failure, and overall survival. Retrospective multicenter studies reported that protracted RT schedules in nonsurgical patients with a good prognosis improved local control but had no effect on functional or survival outcomes.
If not medically contraindicated, steroids are recommended for any patient with neurologic deficits suspected or confirmed to have MESCC. Surgery should be considered for patients with a good prognosis who are medically and surgically operable. RT should be given to nonsurgical patients. For those with a poor prognosis, a single fraction of 8 Gy should be given; for those with a good prognosis, 30 Gy in 10 fractions could be considered. Patients should be followed up clinically and/or radiographically to determine whether a local relapse develops. Salvage therapies should be introduced before significant neurologic deficits occur.
The risk of cardiac injury with hypofractionated whole-breast/chest wall radiation therapy (HF-WBI) compared with conventional whole-breast/chest wall radiation therapy (CF-WBI) in women with left-sided breast cancer remains a concern. The purpose of this study was to determine if there is an increase in hospital-related morbidity from cardiac causes with HF-WBI relative to CF-WBI.
Between 1990 and 1998, 5334 women = 80 years of age with early-stage breast cancer were treated with postoperative radiation therapy to the breast or chest wall alone. A population-based database recorded baseline patient, tumor, and treatment factors. Hospital administrative records identified baseline cardiac risk factors and other comorbidities. Factors between radiation therapy groups were balanced using a propensity-score model. The first event of a hospital admission for cardiac causes after radiation therapy was determined from hospitalization records. Ten- and 15-year cumulative hospital-related cardiac morbidity after radiation therapy was estimated for left- and right-sided cases using a competing risk approach.
The median follow-up was 13.2 years. For left-sided cases, 485 women were treated with CF-WBI, and 2221 women were treated with HF-WBI. Mastectomy was more common in the HF-WBI group, whereas boost was more common in the CF-WBI group. The CF-WBI group had a higher prevalence of diabetes. The 15-year cumulative hospital-related morbidity from cardiac causes (95% confidence interval) was not different between the 2 radiation therapy regimens after propensity-score adjustment: 21% (19-22) with HF-WBI and 21% (17-25) with CF-WBI (P=.93). For right-sided cases, the 15-year cumulative hospital-related morbidity from cardiac causes was also similar between the radiation therapy groups (P=.76).
There is no difference in morbidity leading to hospitalization from cardiac causes among women with left-sided early-stage breast cancer treated with HF-WBI or CF-WBI at 15-year follow-up.
Waiting for radiation therapy (RT) in Ontario has been a major problem for the past decade. In 1996, the Toronto-Sunnybrook Regional Cancer Centre (TSRCC) initiated a Rapid Response Radiotherapy Program (RRRP) to provide timely palliative RT for symptom relief of patients with terminal cancer.
This study reviews the clinical activity of the RRRP over the past 8 years to evaluate if we are meeting the objectives of the program.
From the TSRCC oncology patient information system (OPIS) database, we retrieved the number of patients referred to the RRRP, their demographics, diagnosis and treatment for the calendar years 1996 to 2003 inclusive. We calculated the time interval between referral to consultation, consultation to simulation and the percentage of cases who started RT on their initial consultation for all new cases referred to the RRRP.
From 1996 to 2003, the number of cases seen in consultation increased from just over 200 cases annually in the first 2 years to about 500 cases per year in the last 4 years, for a total of 3,290. There were 1,792 (54%) men and 1,498 (46%) women; median age was 69 years (range, 21-95 years). Breast, lung, genitourinary and gastrointestinal primaries accounted for over 80% of all referrals. The majority was referred for palliative treatment of symptomatic bone (70%) or brain (14%) metastases. The dose fractionation for bone metastases was a single 8-Gy fraction in 45%, 20 Gy in five fractions in 42%, 30 Gy in ten fractions in 4% and other dose fractionations in 9%. Nearly 90% were seen within 2 weeks of referral (38% within 1 week). Eighty-five percent were simulated on the day of their initial consultation. Sixty percent started their RT treatment on the day of their consultation visit. The overall median interval from referral to treatment was 8 days.
Over the past 8 years, the annual number of new cases referred to the RRRP has doubled. The overall median interval from referral to consultation was 8 days. Sixty percent were simulated, planned and started treatment on the day of their initial consultation. We therefore are meeting our goal of providing rapid access to palliative RT for symptomatic cancer patients.
PURPOSE: We hypothesized that administration of the angiotensin type 1 (AT1) receptor antagonist, L-158,809, to young adult male rats would prevent or ameliorate fractionated whole-brain irradiation (WBI)-induced cognitive impairment. MATERIALS AND METHODS: Groups of 80 young adult male Fischer 344 x Brown Norway (F344xBN) rats, 12-14 weeks old, received either: (1) fractionated WBI; 40 Gy of gamma rays in 4 weeks, 2 fractions/week, (2) sham-irradiation; (3) WBI plus L-158,809 (20 mg/L drinking water) starting 3 days prior, during, and for 14, 28, or 54 weeks postirradiation; and (4) sham-irradiation plus L-158,809 for 14, 28, or 54 weeks postirradiation. An additional group of rats (n = 20) received L-158,809 before, during, and for 5 weeks postirradiation, after which they received normal drinking water up to 28 weeks postirradiation. RESULTS: Administration of L-158,809 before, during, and for 28 or 54 weeks after fractionated WBI prevented or ameliorated the radiation-induced cognitive impairment observed 26 and 52 weeks postirradiation. Moreover, giving L-158,809 before, during, and for only 5 weeks postirradiation ameliorated the significant cognitive impairment observed 26 weeks postirradiation. These radiation-induced cognitive impairments occurred without any changes in brain metabolites or gross histologic changes assessed at 28 and 54 weeks postirradiation, respectively. CONCLUSIONS: Administering L-158,809 before, during, and after fractionated WBI can prevent or ameliorate the chronic, progressive, cognitive impairment observed in rats at 26 and 52 weeks postirradiation. These findings offer the promise of improving the quality of life for brain tumor patients.
The study is based on data on 1756 patients with cervical cancer treated as combined (remote + contact) and only the contact exposure with low, medium and high dose rate. For comparative radiobiological evaluation of reactions of irradiated tissues there were used the following radiobiological models: factor time-dose-fractionation, the cumulative radiation effect, linear- quadratic model in the variant of biologically effective dose. Survival of cervical cancer patients undergone combined radiation treatment was determined by the stage of disease. In particular, the survival of patients with Stage IB cervical cancer was significantly higher than in Stages IIB and IIIB, while in Stage IIB was significantly higher than in Stage IIIB. Long-term results of radiation treatment of patients with Stage IB1 (T1b1N0M0) and Stage IIB (T2bN0M0) cervical cancer did not depend on whether the contact radiation exposure was combined or single. The most preferred component of radiotherapy in women suffering from cervical cancer was brachytherapy with high dose rate.
The study is based on data on 306 patients with endometrial cancer treated as combined (remote + contact) and only the contact exposure with low, medium and high dose rate. For comparative radiobiological evaluation of reactions of irradiated tissues there were used the following radiobiological models: factor time-dose-fractionation, the cumulative radiation effect, linear- quadratic model in the variant of biologically effective dose. Survival of endometrial cancer patients undergone combined or only the contact radiation treatment was determined by the stage of disease. In particular, the survival of patients with Stage IB endometrial cancer (combined radiation treatment) was significantly higher than in Stage IC, while in Stage IB (contact radiation treatment) was significantly higher than in Stages IC and IIB. Long-term results of radiation treatment of patients with all Stages of endometrial cancer were significantly better by 16% when only the contact radiation treatment was performed. The most preferred component of radiotherapy in women suffering from endometrial cancer with severe comorbidities was brachytherapy with high dose rate both in the combined and only contact irradiation.
To report initial mortality findings from the Collaborative Ocular Melanoma Study (COMS) randomized clinical trial of pre-enucleation radiation of large choroidal melanoma.
Patients were evaluated for eligibility at one of 43 participating centers in the United States and Canada. Eligible consenting patients were assigned randomly at the time of enrollment to standard enucleation or to external radiation of the orbit and globe prior to enucleation. Eligibility was confirmed at the COMS Coordinating Center, Echography Center, and Photograph Reading Center. Adherence to the radiotherapy protocol was monitored at the Radiological Physics Center. The diagnosis of choroidal melanoma was confirmed following enucleation by a three-member Pathology Review Committee. Patient accrual began in November 1986 and was completed in December 1994; 1,003 patients enrolled. Patients have been followed at annual clinical examinations. Cause of death was coded by a Mortality Coding Committee whose members were not involved in the care of COMS patients; the clinical trial was monitored by an independent Data and Safety Monitoring Committee.
A total of 1,003 patients were enrolled; 506 were assigned to enucleation alone and 497 to pre-enucleation radiation. Treatment groups were well balanced on baseline characteristics. Only nine patients were found to be ineligible after enrollment, seven in the interval between randomization and enucleation and two after enucleation based on histopathology. All but nine patients were treated as assigned; in only six of 491 eyes treated with pre-enucleation radiation was there a major deviation from the radiotherapy protocol. With 5-year outcome known for 801 patients enrolled (80%), the estimated 5-year survival rates and 95% confidence intervals (CIs) were 57% (95% CI, 52% to 62%) for enucleation alone and 62% (95% CI, 57% to 66%) for pre-enucleation radiation. Among the baseline covariates evaluated, only age and longest basal diameter of the melanoma affected the prognosis for survival to a statistically significant degree. The risk of death among patients treated with pre-enucleation radiation relative to those treated with enucleation alone after adjustment for baseline characteristics of patients, eyes, and tumors was 1.03 (95% CI, 0.85 to 1.25). Of 435 deaths classified by the Mortality Coding Committee, 269 patients had histologically confirmed melanoma metastases at the time of death. Estimated 5-year survival rates for this secondary outcome were 72% (95% CI, 68% to 76%) for enucleation alone and 74% (95% CI, 69% to 78%) for pre-enucleation radiation.
No survival difference attributable to pre-enucleation radiation of large choroidal melanoma, using the COMS fractionation schedule, has been demonstrated to date in this randomized trial. The trial had statistical power of 90% to detect a relative difference in mortality rates between the two treatment arms of 20% or larger. A smaller difference is possible, but a clinically meaningful difference in mortality rates, whether from all causes or from metastatic melanoma, is unlikely.
Comment In: Am J Ophthalmol. 1998 Jun;125(6):865-79645725
Department of Radiation Oncology, BC Cancer Agency Vancouver Centre, Vancouver, BC, Canada; Département de radio-oncologie, CSSS de Gatineau-Hôpital de Gatineau, Gatineau, QC, Canada. Electronic address: firstname.lastname@example.org.
The objective of this study was to determine if use of a rectal retractor (RR) in high-dose-rate intracavitary brachytherapy for cervical cancer reduces rectal dose parameters.
We reviewed data obtained from patients treated with intracavitary brachytherapy for cervical cancer with and without an RR. Treatment plans for each brachytherapy fraction were separated into two groups; R group with use of an RR and P group with use of vaginal packing. Dose-volume parameters for high-risk clinical target volume (HR-CTV), rectum, sigmoid, small bowel, and vaginal surface were collected for each fraction. Rectal D2cc and International Commission on Radiation Units & Measurements (ICRU) rectal point doses were compared between groups using Student's t tests. Predictors of higher rectal D2cc were determined by univariate and multivariate regression analyses.
Four hundred sixty-three brachytherapy fractions from 114 patients were used for analysis, 377 fractions with a RR (R group) and 86 with vaginal packing only (P group). Both groups were similar except for slightly higher mean HR-CTV and mean bladder volume in P group. Both mean ICRU rectal point dose (241.1 vs. 269.9 cGy, p = 0.006) and rectal D2cc (240.6 vs. 283.6 cGy, p
This population-based study describes the treatment of early glottic cancer in Ontario, Canada and assesses whether treatment variations were associated with treatment effectiveness.
We studied 491 T1N0 and 213 T2N0 patients. Data abstracted from charts included age, sex, stage, treatment details, disease control, and survival.
The total dose ranged from 50 to 70 Gy, and the daily dose ranged from 1.9 to 2.8 Gy. In 90%, treatment duration was between 25 and 50 days. Field sizes, field reductions, beam arrangement, and beam energy varied. Late treatment breaks occurred in 13.6% of T1N0 and 27.1% of T2N0 cases. Local control was comparable to other reports for T1N0 (82% at 5 years), but was only 63.2% in T2N0. Variables associated with local failure in T1N0 were age less than 49 years (relative risk [RR], 3.21; 95% confidence interval [CI], 1.49-6.90) and >3 treatment interruption days (RR, 2.43; 95% CI, 1.00-5.91). In T2N0, these were field reduction (RR, 2.33; 95% CI, 1.23-4.42) and late treatment breaks (RR, 2.19; 95% CI, 1.09-4.41).
Some aspects of treatment for early glottic cancer were associated with worse local control. Problems with protracted treatment are of particular concern, underscoring the need for randomized studies to intensify radiotherapy.