Cihan Gani

Prospective evaluation of a hydrogel spacer for rectal separation in dose-escalated intensity-modulated radiotherapy for clinically localized prostate cancer

BackgroundAs dose-escalation in prostate cancer radiotherapy improves cure rates, a major concern is rectal toxicity. We prospectively assessed an innovative approach of hydrogel injection between prostate and rectum to reduce the radiation dose to the rectum and thus side effects in dose-escalated prostate radiotherapy.MethodsAcute toxicity and planning parameters were prospectively evaluated in patients with T1-2 N0 M0 prostate cancer receiving dose-escalated radiotherapy after injection of a hydrogel spacer. Before and after hydrogel injection, we performed MRI scans for anatomical assessment of rectal separation. Radiotherapy was planned and administered to 78 Gy in 39 fractions.ResultsFrom eleven patients scheduled for spacer injection the procedure could be performed in ten. In one patient hydrodissection of the Denonvillier space was not possible. Radiation treatment planning showed low rectal doses despite dose-escalation to the target. In accordance with this, acute rectal toxicity was mild without grade 2 events and there was complete resolution within four to twelve weeks.ConclusionsThis prospective study suggests that hydrogel injection is feasible and may prevent rectal toxicity in dose-escalated radiotherapy of prostate cancer. Further evaluation is necessary including the definition of patients who might benefit from this approach. Trial registration: German Clinical Trials Register DRKS00003273.

Pathological complete response and sphincter-sparing surgery after neoadjuvant radiochemotherapy with regional hyperthermia for locally advanced rectal cancer compared with radiochemotherapy alone

Purpose: To evaluate the influence of regional hyperthermia on rates of complete pathological response (pCR) and sphincter-sparing surgery in the context of an up-to-date radiochemotherapy protocol for locally advanced rectal cancer. Methods: Between 2007 and 2010, 106 patients with locally advanced cancer of the middle and lower rectum were admitted to neoadjuvant radiochemotherapy either with (n = 61) or without (n = 45) regional hyperthermia. A retrospective comparison was performed between two groups: 45 patients received standard treatment consisting of 5040 cGy in 28 fractions to the pelvis and 5-fluorouracil (RCT group) and 61 patients received the same treatment in combination with regional hyperthermia (HRCT group). Target temperature was 40.5°C for at least 60 min. Total mesorectal excision was performed routinely. Results: pCR was seen in 6.7% of patients in the RCT group and 16.4% in the HRCT group. Patients who received at least four hyperthermia treatments (n = 40) achieved a significantly higher pCR rate (22.5%) than the remaining 66 patients (p = 0.043). Rates of sphincter-sparing surgery were similar in both groups with 64% in the RCT group and 66% in HRCT. When considering only low-lying tumours located within 8 cm of the anal verge prior to treatment, the rate of sphincter-sparing surgery was 57% in the HRCT group compared with 35% in the RCT group (p = 0.077). Conclusion: The combination of regional hyperthermia and neoadjuvant radiochemotherapy may lead to an increased pCR rate in locally advanced rectal cancer. Patients with low-lying tumours especially may benefit when additional downsizing allows sphincter-preserving surgery.

Cervical Squamous Cell Lymph Node Metastases from an Unknown Primary Site: Survival and Patterns of Recurrence after Radiotherapy

Introduction The purpose of the present retrospective study was to review outcome and patterns of failure of patients who were treated with radiotherapy for cervical lymph node metastases from an unknown primary site (CUP). Patients and Methods Between 2000 and 2009, 34 patients diagnosed with squamous cell CUP were admitted to radiotherapy in curative intent. In 26 of 34 patients (76%) neck dissection was performed prior to radiotherapy, extracapsular extension (ECE) was seen in 20 of 34 patients (59%). Target volumes included the bilateral neck and panpharyngeal mucosa. Concomitant chemotherapy was applied in 14 of 34 patients (41%). Results After a median follow-up of 45 months for the entire group, 2 of 34 patients (6%) presented with an isolated regional recurrence, another 2 of 34 patients (6%) developed both local and distant recurrence, and 6 of 34 patients (18%) had distant failure only. Estimated overall survival after 2- and 5 -years was 78% and 63%. All patients with N1 or N2a disease (n=6) were disease free after 5 years. ECE, concomitant chemotherapy and involvement of neck levels 4 and 5 were associated with worse overall survival on univariate analysis. Conclusion Radiotherapy of the panpharynx and bilateral neck leads to excellent local control while distant metastases are the most frequent site of failure and prognostically limiting. Therefore intensified concomitant or sequential systemic therapies should be evaluated in future trials.

Zeitintervall zwischen neoadjuvanter Radiochemotherapie und Operation beim Rektumkarzinom

Ergebnisse In weniger als 3 Jahren wurden 265 Patienten aus 24 Zentren rekrutiert. Es zeigte sich hinsichtlich des primären Endpunkts kein signifikanter Unterschied zwischen den beiden Behandlungsarmen: pCR nach 7 Wochen 15%, nach 11 Wochen 17,4% (p = 0,5983). Die postoperative Morbidität im 11-Wochen-Arm war signifikant höher (44,5% vs. 32%; p = 0,04), bedingt durch internistische Komplikationen (32,8% vs. 19,2%; p = 0,01). Die Qualität der mesorektalen Resektion (TME) war im

Complete response after chemoradiotherapy for rectal cancer: what is the reasonable approach?

Abstract With the increasing use of preoperative treatment rather than upfront surgery, it has become evident that the response of rectal carcinoma to standard chemoradiotherapy (CRT) shows a great variety that includes histopathologiocally confirmed complete tumor regression in 10–30% of cases. Adaptive strategies to avoid radical surgery, either by local excision or non-operative management, have been proposed in these highly responsive tumors. A growing number of prospective clinical trials and experiences from large databases, such as the European Registration of Cancer Care (EURECCA) watch-and-wait database, or the recent Oncological Outcome after Clinical Complete Response in Patients with Rectal Cancer (OnCoRe) project, will provide more information on its safety and efficacy, and help to select appropriate patients. Future studies will have to establish appropriate inclusion criteria and optimize CRT regimens in order to maximize the number of patients achieving complete response. Standardized re-staging procedures have to be investigated to improve the prediction of a sustained complete response, and long-term close follow-up with thorough documentation of failure patterns and salvage therapies will have to prove the oncological safety of this approach.

Resolution of atelectasis during radiochemotherapy of lung cancer with serious implications for further treatment. A case report

Local failure is a major cause for low overall survival rates in advanced non small cell lung cancer (NSCLC). Among others, radioresistant tumor clones as well as geographical miss can explain these high local failure rates. One reason for geographical miss is a change of tumor related atelectasis in the course of radiotherapy. We present the case of a patient with UICC Stage IIIb NSCLC who presented with a large tumor related atelectasis. During definitive radiochemotherapy, the atelectasis resolved, which resulted in a massive tumor shift out of the planning target volume within 2 days. Without close monitoring by cone beam CTs and prompt replanning, this would have led to a geographical miss and relevant underdosage of the tumor. Furthermore, changes in anatomy and pulmonary function during treatment had implications for organs at risk and opened windows for dose escalation. We suggest at least biweekly CBCTs in patients with poststenotic atelectasis to ensure the rapid detection of geographical changes of the target and subsequent intervention if necessary.

Zeitintervall zwischen neoadjuvanter Radiochemotherapie und Operation beim Rektumkarzinom@@@Time interval between neoadjuvant radiochemotherapy and surgery in rectal cancer: Kein Einfluss auf die pathologische Komplettremissionsrate?@@@No impact on the pathologic complete response rate?

Ergebnisse In weniger als 3 Jahren wurden 265 Patienten aus 24 Zentren rekrutiert. Es zeigte sich hinsichtlich des primären Endpunkts kein signifikanter Unterschied zwischen den beiden Behandlungsarmen: pCR nach 7 Wochen 15%, nach 11 Wochen 17,4% (p = 0,5983). Die postoperative Morbidität im 11-Wochen-Arm war signifikant höher (44,5% vs. 32%; p = 0,04), bedingt durch internistische Komplikationen (32,8% vs. 19,2%; p = 0,01). Die Qualität der mesorektalen Resektion (TME) war im