Alex Hammond

Chemotherapy in Neuroendocrine/Merkel Cell Carcinoma of the Skin: Case Series and Review of 204 Cases

PURPOSE To study the use of chemotherapy for Merkel cell carcinoma (MCC) of the skin. PATIENTS AND METHODS Twenty-five cases of MCC were treated at the London Regional Cancer Center between 1987 and 1997. Thirteen cases treated with chemotherapy were reviewed with 191 cases from the literature. RESULTS At presentation, 24 patients had localized skin lesions (stage I) and one had locoregional involvement (stage II). Among the nine cases with recurrent nodal disease, six had chemotherapy as a component of salvage treatment. They were all free of disease at a median of 19 months (range, 12 to 37 months). In contrast, two patients who had salvage radiotherapy alone died of disease. Overall survival (OS) and disease-free survival (DFS) were 59% and 43%, respectively, at two years. Median OS and DFS were 29 months (range, 1 to 133 months) and 9 months (range, 1 to 133 months), respectively. Nodal disease developed in 12 (50%) of 24 patients with stage I disease, and distant metastases developed in six (25%) of 24. Including those from the literature, there were 204 cases treated with chemotherapy. Cyclophosphamide/doxorubicin (or epirubicin)/vincristine combination +/- prednisone was the most commonly used chemotherapy regimen (47 cases), with an overall response rate of 75.7% (35.1% complete, 35. 1% partial, and 5.4% minor responses). Etoposide/cisplatin (or carboplatin) was the next most commonly used regimen (27 cases), with an overall response rate of 60% (36% complete and 24% partial responses). The difference in response rate was not statistically significant (P =.19). Among the 204 cases, there were seven (3.4%) toxic deaths. CONCLUSION Chemoradiation for locally recurrent or advanced disease may be an option for patients with a good performance status.

Detection of circulating tumor cells in advanced head and neck cancer using the cellsearch system

Early detection of circulating tumor cells (CTCs) offers the possibility of improved outcome for patients with head and neck squamous cell cancer (HNSCC).

Pelvic fractures following irradiation of endometrial and vaginal cancers-a case series and review of literature.

PURPOSE To review the induction of pelvic fractures as a result of radiation therapy and to assess their management. MATERIALS AND METHODS The charts of patients with endometrial and vaginal cancers irradiated between 1991 and 1995 were reviewed. All patients were treated with megavoltage machines, energy ranging from cobalt to 25 MV photons. RESULTS We treated 336 patients, with a median follow-up duration of 28.9 months (range 0-73.3). Sixteen patients had symptomatic pelvic fractures. The 5-year actuarial incidence of symptomatic pelvic fracture was 2.1%. All patients had pain as the first symptom. The median time of onset was 11 months (range 4-46). Imaging studies of 37.5% (6/16) were initially interpreted to be recurrent malignancy. All patients were managed conservatively and nine patients showed radiological evidence of healing over a median time of 13 months (range 2-34). Six patients had specific drug treatment including provera, premarin, calcium supplements, or pamidronate. Of these, five healed. For the ten patients who did not have any specific treatment, only four showed signs of healing at the time of last follow-up. There was a trend toward earlier healing with specific drug treatment (P=0.11). CONCLUSIONS Fractures can easily be mistaken for metastatic lesions (37.5% in this series) which might be treated with further irradiation. Although not statistically significant, there was a trend towards early healing with drug therapy. More studies are required to generate quantitative data for dose-response relationships and to evaluate the effect of drug therapy on the healing of such fractures.

An early report on outcomes from computed tomographic-based high-dose-rate brachytherapy for locally advanced cervix cancer: A single institution experience

PURPOSE To report our experience using high-dose-rate (HDR) brachytherapy with computed tomographic (CT) imaging for locally advanced cervix cancer, using available resources to optimize the treatment. METHODS AND MATERIALS Fifty-seven women with cervix cancer were treated between September 2004 and March 2008. Patients received external radiotherapy, HDR brachytherapy (7 Gy x4) and concurrent chemotherapy. CT planning was done for each insertion. RESULTS Median age was 53 years (range, 29-89 years); majority (49%) had International Federation of Gynecology and Obstetrics stage IIB. The median follow-up was 22.6 months. There were 4 patients who required laser coagulation for rectal bleeding, and one patient required hemicolectomy for sigmoid stricture. There was no grade 3 or 4 genitourinary toxicity. The Kaplan-Meier overall survival, relapse free, central pelvic and pelvic control at 3 years was 86%, 62%, 89%, and 83%, respectively. Pelvic control for tumors 2 to 5 cm was 95% and 84% for tumors greater than 5 cm. CONCLUSIONS Our early experience confirms that CT-based HDR brachytherapy for cervix cancer achieves disease control comparable to other published series. At the same time, conformal avoidance of organs at risk allows for low rates of toxicity.

Evaluation of unified intensity-modulated arc therapy for the radiotherapy of head-and-neck cancer

PURPOSE Recently our group developed a unified intensity-modulated arc therapy (UIMAT) technique which allows for the simultaneous inverse-optimization and the combined delivery of volume-modulated arc therapy (VMAT) and intensity-modulated radiation therapy (IMRT). The aim of this study was to evaluate the dosimetric benefits of UIMAT plans for radiation treatment of complex head-and-neck cancer cases. METHODS AND MATERIALS A retrospective treatment planning study was performed on 30 head-and-neck cases, 15 of which were treated clinically with VMAT while the other 15 were treated with step-and-shoot IMRT. These cases were re-planned using our UIMAT technique and the results were compared with the clinically delivered plans. Plans were assessed in terms of clinically relevant metrics describing target volume coverage, dose conformity, and the sparing of organs at risk. RESULTS When compared to stand-alone VMAT or IMRT, UIMAT plans offered slightly better tumor volume coverage (Median D95: 98.1% vs. 97.5%, p=0.01) and similar dose conformity (Median CI: 0.69 vs. 0.69, p=0.09). More significantly, UIMAT plans had substantially lower doses to all organs at risk, including the spinal cord (Median D2%: 29.9Gy vs. 35.6Gy, p<0.01), brainstem (Median D2%: 21.2Gy vs. 25.6Gy, p<0.01), left parotid (Median DMean: 26.1Gy vs. 28.0Gy, p<0.01), and right parotid (Median DMean: 23.6Gy vs. 27.2Gy, p<0.01). The reduction in OAR doses did not result from the redistribution of dose to unspecified tissue. Furthermore, UIMAT plans can be delivered with comparable delivery times to VMAT (Median time: 135s vs. 168s, p=0.394) but with fewer monitor units (Median MU: 486 vs. 635, p<0.01). CONCLUSIONS Compared to stand-alone IMRT or VMAT, UIMAT was demonstrated to have a dosimetric advantage for the radiation treatment of head-and-neck cancer.