Arif Aras

Effect of geometrical optimization on the treatment volumes and the dose homogeneity of biplane interstitial brachytherapy implants

BACKGROUND AND PURPOSE The isodose distributions of HDR stepping source brachytherapy implants can be modified by changing dwell times and this procedure is called optimization. The purpose of this study is to evaluate the effect of geometrical optimization on the brachytherapy volumes and the dose homogeneity inside the implant and to compare them with non-optimized counterparts. MATERIAL AND METHODS A set of biplane breast implants consisting of 84 different configurations have been digitized by the planning computer and volumetric analysis was performed for both non-optimized and geometrically optimized implants. Treated length (TL), treated volume (V100), irradiated volume (V50), overdose volume (V200) and quality index (QI) have been calculated for every non-optimized implant and compared to its corresponding geometrically optimized implant having a similar configuration and covering the same target length. RESULTS The mean TL was 74.48% of the active length (AL) for non-optimized implants and was 91.87% for optimized implants (P < 0.001). The mean QI was 1.83 for non-optimized implants and 2.17 for optimized implants (P < 0.001). The mean V50/V100 value was 2.71 for non-optimized implants and 2.65 for optimized implants (P < 0.001) and the mean V200/V100 value was 0.09 for non-optimized implants and 0.10 for optimized implants (P < 0.001). CONCLUSIONS By performing geometrical optimization it is possible to implant shorter needles for a given tumour to adequately cover the target volume with the reference isodose and thus surgical damage is reduced. The amount of healthy tissues outside the target receiving considerable radiation is significantly reduced due to the decrease in irradiated volume. Dose homogeneity inside the implant is significantly improved. Although there is a slight increase of overdose volume inside the implant, this increase is considered to be negligible in clinical applications.

The interaction between antioxidant status and cervical cancer: a case control study.

AIMS AND BACKGROUND To compare the antioxidant status of cervical cancer patients with healthy controls and to assess the antioxidant levels before and after radiotherapy or radiochemotherapy. METHODS AND STUDY DESIGN Antioxidant levels (glutathione, glutathione peroxidase, superoxide dismutase, and malondialdehyde) were measured in 35 patients with cervical cancer and 35 age-matched healthy controls. Blood samples were collected twice (before and after treatment) from cervical cancer patients and once from healthy control subjects. RESULTS In the patient group, pre-radiotherapy glutathione and glutathione peroxidase levels were significantly lower (P <0.01 and P <0.0001, respectively) than the control group. Pre-radiotherapy levels of superoxide dismutase were significantly higher in cancer patients (P <0.01). In general, no difference was observed between pre- and post-radiotherapy antioxidant levels in cancer patients. However, when post-radiotherapy glutathione levels were analyzed, patients who did not respond to treatment had significantly higher levels than those who did respond (P <0.01). CONCLUSIONS Levels of antioxidants significantly differed between the patients with cervical cancer and the controls, and no change in antioxidant levels was observed after treatment. Moreover, further studies evaluating the predictive value of glutathione levels on treatment response are warranted.

Evaluation of unusual and highly aggressive variant of endometrium cancer: nonendometrioid endometrium carcinoma of the uterus.

Aims To evaluate the survival and treatment outcomes of patients with nonendometrioid endometrium carcinoma after postoperative radiotherapy. Methods The records of 94 patients treated with postoperative radiotherapy (RT) between January 2005 and December 2011 were retrospectively reviewed. Postoperative RT was delivered with a dose of 45-50.4 Gy with 1.8 Gy daily fractions and brachytherapy was added to external RT for 62 patients with a dose of 3 × 6 Gy. Median follow-up time was 35 months (range 6-95 months). Results Median age was 63 years (range 43-83 years) and lymph node metastasis (LNM) was positive in 15 (16.0%) patients. The stage distribution of the patients was as follows: stage I, 58 (61.7%); stage II, 16 (17.0%); stage III, 18 (19.1%); stage IV, 2 (2.2%). Five-year locoregional control (LRC), disease-free survival (DFS), and overall survival (OS) rates were 92.3%, 68.2%, and 78.6%, respectively. In univariable analysis, it was determined that the factors affecting OS rates were stage (p = 0.003), presence of LNM (p = 0.003), and presence of lymphovascular space invasion (LVSI) (p = 0.007); factors affecting DFS rates were stage (p = 0.019), presence of LVSI (p = 0.002), and having LNM (p = 0.049); and the factor affecting LRC rates was tumor size (>5 cm) (p = 0.011). In subgroup analyses, among all stage I patients, the DFS rates were lower for those with histologic grade 3 tumors and more than ½ myometrial invasion. Conclusions Due to its rarity, the prognostic factors and outcomes of nonendometioid endometrium carcinoma are not fully understood. In our analysis, stage, LNM, and presence of LVSI were found to be the most important prognostic factors. In order to tailor the optimal treatment strategy, prospective studies are needed.

Treatment results and prognostic factors of patients with vulvar cancer treated with postoperative or definitive radiotherapy.

Purpose Vulvar cancer is a relatively uncommon type of gynecologic cancer. The aim of this study is to analyze the treatment results and prognostic factors of vulvar cancer. Methods Forty-four vulvar cancer patients treated between 2000 and 2011 at the Department of Radiation Oncology, Ege University Faculty of Medicine, were retrospectively reviewed. External radiotherapy (RT) was applied with 6-18 MV linear accelerators with 1.8 Gy daily fractions with a median total dose of 50.4 Gy (45-59.4 Gy) for postoperative cases and 64.8 Gy (range 54-66 Gy) for definitive cases. Statistical analyses were performed with SPSS 13.0. Results Among 44 patients with a median age of 68 years (range 28-86), 14 (31.8%) were treated with curative and 30 (68.2%) were treated with postoperative RT or radiochemotherapy (RCT). According to International Federation of Gynecology and Obstetrics staging, 11 (25%) had stage IB, 10 (22.7%) had stage II, 6 (13.6%) had stage IIIA, 5 (11.4%) had stage IIIB, and 12 (27.3%) had stage IVA disease. Within a median of 24 months (range 6-135) of follow-up, 11 (27.3%) patients had local recurrence, 8 had regional recurrence, 2 had both local and regional recurrence, and 6 had distant metastases. Five-year locoregional, disease-free, and overall survival rates were 45%, 40%, and 54%, respectively. Older age, poor tumor differentiation, positive surgical margin, and lymphovascular space invasion were found to be important prognostic factors for disease-related outcomes. Conclusions Prognosis of vulvar cancer remains poor even with a multidisciplinary approach. Molecular prognostic factors need to be defined for individualized treatment options to achieve better treatment results.

Adverse effects of endocrine therapy in breast cancer: single institute experience

Aim of the study The main purpose of this study is to assess the known adverse effects of adjuvant endocrine therapy for non-metastatic breast cancer patients and to present our single center experience with light of literature. Material and methods The breast cancer patients treated with adjuvant radiotherapy in Medical School of Ege University between January 2007 and December 2009 were evaluated for this trial after obtaining their acceptance. Vital findings, bone mineral densitometry, endometrium thickness measured with trans-vaginal ultrasonography, biochemical results including liver function tests and blood lipid profile (total cholesterol, HDL, LDL, VLDL, triglyceride) were recorded for each controls. Socio-demographic data, financial statuses, medical history, co-morbid diseases were obtained from first controls. Patients were followed without any local recurrence and distant metastases until June 2011. Results Endometrium thickness was not seen in AI using patients. As compared with tamoxifen group, lack of thickness in AI group was statistically significant (p = 0.000). When compared the values before AI, the number of patients who had osteoporosis was gradually increasing. The decrease was seen in the number of patients with osteopenia. The number of patients with normal lipid profile was gradually increasing up to the second evaluation for tamoxifen group (p = 0.000). On the other hand, the number of patients with hyperlipidemia was increasing for AIs group in follow-up period statistically (p = 0.006). Conclusions With the aid of careful patient follow and effective disease management strategies, the negative effect over the QoL can be minimized and also the greatest benefit from endocrine therapy can be obtained.

Evaluation of morbidity after external radiotherapy and intracavitary brachytherapy in patients with carcinoma of the uterine cervix or endometrium

PURPOSE The aim of the present study was to evaluate early and late radiation morbidity and to assess the factors influencing morbidity in patients with cervical or endometrial cancer treated by a combination of external radiotherapy (ERT) and intracavitary brachytherapy (IBRT). MATERIALS AND METHODS Early and late radiation morbidity were evaluated retrospectively using RTOG/EORTC criteria and Franco-Italian glossary in 771 patients treated between November 1992 and December 1999. RESULTS Four hundred and seven patients (52.8%) had endometrial carcinoma and 364 (47.2%) had carcinoma of the cervix. One hundred and fifty-four patients with cervical carcinoma were inoperable. In patients with endometrial carcinoma total doses at the vagina, bladder and rectum were 60.36 Gy, 56.2 Gy and 55.6 Gy respectively. Biologically equivalent doses (BED) for the same points were 79.35, 68.63 and 67.37, respectively for early effects and 123.67, 97.65 and 94.85, respectively for late effects. One hundred and sixty-nine patients (41.5%) developed acute morbidity, grade I and II bladder morbidity being the most common type and 85 patients (20.9%) developed late morbidity, grade I and II vaginal morbidity being the most common type. No grade IV morbidity was recorded. Total doses at the vagina, bladder and rectum in operated cervix cancer patients were 60.51 Gy, 56.53 Gy and 55.67 Gy, respectively. BED for the same points were 79.77, 69.36 and 67.52, respectively for early effects and 124.74, 99.3 and 95.17, respectively for late effects. Eighty patients (38.1%) developed early morbidity. Grade I and II bladder morbidity was the most common type. Sixty-five patients (30.9%) developed late morbidity, vaginal morbidity being the most common type. Total doses at the vagina, bladder and rectum in inoperable patients were 70.92 Gy, 66.71 Gy and 62.38 Gy, respectively. BED for the same points were 97.43, 89.64 and 81.63, respectively for early effects and 159.3, 143.16 and 126.56, respectively for late effects. Sixty patients (39%) developed acute morbidity which was grade I or II bladder morbidity in 95%. Ninety-five patients (61.7%) developed late morbidity which was grade I-III vaginal morbidity in 94%. CONCLUSION Patients with cervical or endometrial cancer can be treated safely by a combination of ERT and IBRT. However the patients should be assessed before, during and after treatment and at every period of follow-up using a standard and well-defined system in order to define and predict the morbidity rate.

RADIOTHERAPY IN KASABACH-MERRITT SYNDROME

Abstract A male infant was born with a 1 × 3 cm reddish lesion under his umbilicus which enlarged within a month and was associated with consumptive coagulopathy. A diagnosis of Kasabach-Merritt syndrome (KMS) was made. After no response to prednisolone and interferon-α treatment, 8 Gy of radiotherapy (2 Gy. day −1 ) was applied. The clinical status improved and the lesion decreased by 95%. This case illustrates the potential use of radiotherapy in the management of KMS. Radiotherapy is a relatively simple and inexpensive treatment modality which should be considered for lesions that have failed to respond to medical treatment.