Gülyüz Atkovar

Postoperative radiotherapy in carcinoma of the cervix: treatment results and prognostic factors

In order to assess the role of postoperative radiotherapy and prognostic factors, 126 patients who were treated with radiotherapy after surgery for clinical early-stage carcinoma of the cervix were reviewed. All patients received external pelvic radiotherapy and 37 patients were treated with additional vaginal cuff irradiation. The 5-year overall survival, disease-free survival and locoregional control rates were 71.1, 69.9 and 78.1%, respectively. The 5-year disease-free survival rates were 40% for grade 3 vs. 75.4% for grade 1 tumours (p = 0.05), 76.5% for pathological stage IB versus 54.1% for pathological stage IIA (p = 0.04), 36.6% for node-positive patients versus 82.5% for node-negative patients (p = 0.0017), 54% for full thickness cervical invasion versus 100% superficial cervical invasion (p = 0.01), 34.8% for positive margins versus 78.1 for negative margins (p < 0.0001). After a multivariate analysis, tumour grade (p = 0.026) and presence of positive margins (p = 0.006) were found to independently influence the outcome. Grade II and III complication rate was 5.5% in all patients. In conclusion, postoperative radiotherapy should be used in patients treated with simple hysterectomy as well as those treated with radical hysterectomy with unfavorable pathological findings.

Results and complications of high dose rate and low dose rate brachytherapy in carcinoma of the cervix: Cerrahpaşa experience

PURPOSE To evaluate the results and complications of treatment with high dose rate (HDR) compared to low dose rate (LDR) brachytherapy in cervical carcinoma. METHODS Three hundred and seventy patients who were treated with external irradiation and intracavitary brachytherapy and followed for more than 2 years between 1978 and 1998 have been recently updated. The low dose rate group consisted of 77 cases treated between 1978 and 1982 and HDR group consisted of 293 cases treated between 1982 and 1998. All patients first received external irradiation with 60Co or 9-18 MV photons and a median dose of 54 Gy was given in 6 weeks. In the LDR group, intracavitary treatment was given with Manchester applicators loaded with radium (30 mg) in an intrauterine tube and 20 mg in vaginal ovoids. The dose delivered to point A was on average 32 Gy in one application. In the HDR group, a total dose of 24 Gy was given to point A in three insertions 1 week apart. The dose rate was 0.62 Gy at point A. RESULTS The 5-year pelvic control rate was found to be 73% in the HDR group, compared with 86% in the radium group for stage I cases. In stage IIB and IIIB cases, the rates were 68% and 45% for HDR and 65% and 53% for LDR, respectively. In all stages, there was no statistical difference in pelvic control and survival rates between the two groups. Overall incidence of late complications was found as 31.1% and 31.9% in HDR and LDR groups, respectively. The grade 2-4 late complication rate was 14% in the HDR group compared to 19% in the LDR group (P>0.05). CONCLUSION HDR brachytherapy in the management of the cervix appears to be a safe and efficacious approach. Pelvic control, survival and complications rates are quite similar when compared with LDR.

TREATMENT OF WILMS TUMOR: A Report from the Turkish Pediatric Oncology Group (TPOG)

Aim: To standardize diagnosis and treatment of childhood Wilms tumor (WT) in Turkey. Methods and patients: Between 1998 and 2006, WT patients were registered from 19 centers. Patients <16 years with unilateral WT whose treatment started in first postoperative 3 weeks were included. Treatments were stage I favorable (FH) and unfavorable histology (UH) patients, VCR + Act-D; stage IIA FH, VCR + Act-D; stage IIB FH, VCR + Act-D + radiotherapy (RT); stage III–IV FH, VCR + Act-D + adriamycin (ADR) + RT; stages II–IV UH tumors, VCR + Act-D + ADR + etoposide + RT. Results: 165/254 registered cases were eligible (bilateral, 5.9%) [median age 3.0 years; M/F: 0.99; 50/165 cases ≤2 years]. 9.7% cases had UH tumors. Disease stages were stage I 23.6%; IIA 36.4%; IIB 5.5%; III 22.4%; IV 12.1%. Cases >2 years had significantly more advanced disease. 1/11 cases with recurrent disease died; 2/165 had progressive disease, 2/165 had secondary cancers, and all 4 died. In all cases 4-year OS and EFS were 92.8 and 86.5%, respectively. Both OS and EFS were significantly worse in stage IV. Conclusions: Despite problems in patient management and follow-up, treatment results were encouraging in this first national experience with a multicentric study in pediatric oncology. Revisions and modifications are planned to further improve results and minimize short- and long-term side effects.

Ovarian ablation by radiation therapy: Is it still an option for the ablation of ovarian function in endocrine responsive premenopausal breast cancer patients?

Surgical or medical ovarian ablation is likely to be the treatment of choice at the current time, radiation ablation (RA) can be still a reasonable alternative. The efficacy and toxicity of radiation therapy (RT) for ovarian function suppression in 118 premenopausal breast cancer patients were retrospectively evaluated. The median age was 39 years (range 21-52 years). RT was given with either Co-60 or 15MV photons of the linear accelerator. The median total dose was 15Gy in 4 consecutive fractions (range 5Gy single fraction-36Gy in 18 fractions over 3.5 weeks). The endpoint for treatment efficacy was menstrual status. Amenorrhea was noted in 113 of 118 patients (96%) in 6 months following RA. Five patients (4%) who had still normal menstrual functioning after 6 months of RA underwent estradiol and follicle stimulating hormone measurements and were found to have premenopausal levels. No acute Grade 3 or 4 (according to the Radiation Therapy Oncology Group radiation morbidity scoring criteria) toxicities were noted. With a median follow-up of 24.5 months (range: 6-167), no late severe complications that could be attributable to RT were reported. RA should be considered as an option for endocrine responsive premenopausal breast cancer patients and can be easily delivered when postoperative or palliative irradiation is given.

The peripheral dose outside the applicator in electron beams of Oncor linear accelerator

In this study, the peripheral dose outside the applicator was measured using electron beams produced by an Oncor linear accelerator and compared with the data of the treatment planning system (TPS). The dose profiles have been measured, by using a water-equivalent slab phantom and a parallel plate ionisation chamber, at 6, 9 and 15 MeV energy levels in 5×5, 10×10, 15×15, 20×20 and 25×25 cm(2) applicators and at 0, 10 and 20° gantry angles; and at the surface, 0.2, 0.5, 1 cm and d(max) depth for each electron energy level. The peripheral dose has been determined with these profiles by normalisation at the field central beam axis (CAX). It has been noticed that, using a 10×10 cm(2) applicator, there is a 1.4 % dose peak on the surface 6 cm away from the field edge where the field CAX is at 100 %, at a gantry angle of 0° with 6 and 9 MeV electron beams; also for the 15 MeV electron beam there is a 2.3 % dose peak. It has been discovered that the peak dose approaches a minimum depending on the increase in depth and reaches 2.5-4 % depending on the growth of the field dimension. At gantry angles of 10 and 20°, 6 and 9 MeV electron beams created small peaks and a maximum dose could be reached at 0.2 and 1 cm depth. Electron beam of 15 MeV did not peak at depths of 0.2 and 1 cm at gantry angles of 10 and 20°. The measured peripheral dose outside the applicators has been compared with the data from a TPSs computer using the Pencil Beam algorithm; it has been stated that dose calculations can be made as far as 3 cm outside the field. In conclusion, the TPS is not sufficient to measure the peripheral dose outside the applicators, and this dose can only be determined by direct measurement.

Ventricular Ganglioneuroblastoma in an Adult and Successful Treatment with Radiotherapy

BACKGROUND Ganglioneuroblastomas (GNBs) are rare embryonic neoplasms in the spectrum of neuroblastic tumours and 80% of cases occur in the first decade. In adults, GNBs are usually located in the retroperitoneum, mediastinum and neck but intracranial GNBs are extremely rare. CASE REPORT A 34-year-old male applied to the Department of Neurology outpatient clinic with a two month history of headache and numbness in his legs. Detailed examinations and cranial CT were performed and showed a mass with a 5 cm diameter running from the third to the fourth ventricle. Referral to a neurosurgeon was performed for partial removal of the tumour, as the histological and immunohistochemical studies defined the diagnosis of GNB. Three months later, when the patient experienced dizziness, an MRI was performed, which showed a 4×3 cm ventricular mass, with hypointense characterisation in T1-weighted and hyperintense characteristics in T2-weighted and flair sequences. Afterwards, fractioned radiotherapy (54 Gy/30 fx) was chosen as the appropriate therapy. In the follow-up period, MRI was performed 3 months and 1 year after treatment, and revealed shrinkage of the tumour by at least 50%. Meanwhile the patients post-irradiation course was favourable. CONCLUSION Data following the use of radiotherapy as treatment for intracranial GNB showing favourable results has been reported.

Ovarian ablation by radiotherapy; is it still an option for the ovarian function suppression in endocrine responsive premenopausal breast cancer patients?.

CTRC-AACR San Antonio Breast Cancer Symposium: 2008 Abstracts Abstract #5137 Background ; Although surgical or medical ovarian ablation is likely to be the treatment of choice at the current time, radiation ablation (RA) can be still a resonable alternative. Data regarding the use of pelvic radiotherapy (RT) for ovarian ablation is very limited and in 10thSt Gallen consensus meeting, ovarian radiation was overwhelmingly rejected. In this retrospective study we evaluated the efficacy of RT for ovarian function suppression in 118 premenopausal breast cancer patients. Materials and Methods; 153 breast cancer patients had RA between the years 1979 and 2002 at the single center where this study was performed. 19 patients who received chemotherapy within 12 months of RA, and 16 patients who were lost to follow-up within 6 months following RA, were not included into the analyses. All patients were premenopausal and the median age at the initiation of RA was 39 years (range, 21- 52 years). 96 of 118 patients (82%) underwent RA for metastatic disease, 17 patients (14%) received RA as the systemic treatment after locoregional recurrences and 5 patients (4%) had RA as an adjuvant treatment. 97 patients (82%) received only RA as their systemic treatment, 20 patients (17%) had RA with tamoxifen and one patient (1%) had RA with aromatase inhibitors. RT was given with either Co-60 or 15 MV photons of the linear accelerator. A modified pelvic volume was irradiated with opposing anterior and posterior fields, and the dose was prescribed to midplane. The median total dose used for RA was 15Gy in 4 fractions (range 5Gy single fraction-36Gy in 18 fractions). Results; As the efficacy of RA, data regarding the menstrual status were collected. Amenorrhea was noted in 113 of 118 patients (96%) in 6 months following RA. 88 patients (75%) experienced amenorrhea in 2 months after pelvic RT. 5 patients (4%) who had still normal menstrual functioning after 6 months of RA had estrodiol and follicle stimulating hormone measurements. As they were found to have premenopausal levels, 3 of them received surgical and 2 of them received medical ablation. No acute Grade 3 or 4 (according to the Radiation Therapy Oncology Group radiation morbidity scoring criteria) toxicities were noted. With a median follow-up of 24,5 months (range; 6-167 months), no late severe complications that could be attributable to RT were reported. The total RT dose (more than 15Gy) were found to be significant on the rate of ovarian ablation with Mann Whithney U-test (p=0.02). Conclusion: Ovarian ablation was achieved with a rate of 96% without any major acute and late toxicity using pelvic RT. It should be considered as an option for endocrine responsive premenopausal breast cancer patients and can be easily delivered when postoperative or palliative irradiation is given. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5137.