Jaishanker Nautiyal

Patterns of failure following high-dose chemotherapy and autologous bone marrow transplantation with involved field radiotherapy for relapsed/refractory Hodgkin's disease

PURPOSE To evaluate the patterns of failure and outcome of patients undergoing high-dose chemotherapy and autologous bone marrow transplantation for relapsed/refractory Hodgkins disease with emphasis on the impact of involved-field radiotherapy. METHOD AND MATERIALS Fifty-four adult patients with refractory (25) or relapsed (29) Hodgkins disease underwent high-dose chemotherapy with either autologous bone marrow (32) or peripheral stem cell (23) transplantation. Twenty patients received involved-field radiotherapy either prior to (7) or following (13) high-dose chemotherapy. Patients treated prior to the high-dose chemotherapy received radiation to bulky or symptomatic sites, and those treated following the transplantation were treated to sites of disease persistence (10) or to consolidate a complete response (3). Twenty-six patients had purely nodal disease, 10 had lung involvement, 7 liver, 5 bone, and 3 bone marrow. A total of 147 sites were present prior to high-dose chemotherapy. Nineteen were bulky (> or = 5 cm), and 42 arose in a previous radiotherapy field. RESULTS Twenty-five of the 54 patients (46.3%) relapsed. Seventeen (68.0%) relapsed in sites of disease present prior to high-dose chemotherapy. Patients treated with involved-field radiotherapy had a lower rate of relapse in sites of prior disease involvement (26.3 vs. 42.8%) (p < 0.05) than those not treated with radiotherapy. Twenty-one patients had disease persistence following high-dose chemotherapy, of which 10 received involved-field radiotherapy and were converted to a complete response. Patients with disease persistence who received involved-field radiotherapy had a better progression-free survival (40.0 vs. 12.1%) (p = 0.04) than those who did not. Moreover, the patients converted to a complete response had similar progression-free and cause-specific survival as those patients achieving a complete response with high-dose chemotherapy alone. Of the initial 147 sites, 142 (97.3%) were amenable to involved-field radiation therapy. The addition of involved-field radiotherapy improved the 5-year local control of all sites (p = 0.008), nodal sites (p = 0.01), and sites of disease persistence (p = 0.0009). CONCLUSIONS Patients with relapsed/refractory Hodgkins disease undergoing high-dose chemotherapy and autologous bone marrow rescue have a high rate of relapse in sites of prior disease involvement. Involved-field radiotherapy is capable of improving the control of these sites, the majority of which are amenable to radiotherapy. In addition, the use of radiotherapy to sites of disease persistence following high-dose chemotherapy may improve the outcome of these patients.

Analysis of weekly complete blood counts in patients receiving standard fractionated partial body radiation therapy

PURPOSE Hematopoiesis is among the most sensitive systems in the body to radiation. Routine complete blood counts (CBCs) are common in clinical radiotherapy practice. Only a few studies have attempted to characterize the behavior of peripheral blood levels during partial body radiation therapy with field sizes smaller than those used in hemibody or total nodal irradiation. Such information is needed to identify which patients are at risk for cytopenia and require close monitoring. METHODS AND MATERIALS In 1993, 412 new patients were seen at Michael Reese Hospital for radiotherapy. A total of 972 weekly CBCs were identified for 155 patients receiving a minimum of 5 weeks of treatment for breast, prostate, lung, gynecological, or head and neck malignancies. Linear regression models were fitted to the weekly CBC values for those patients who had pretreatment CBC values recorded. Factors affecting starting levels, rates of decline, and nadirs during treatment were determined for leukocytes, platelets, and hemoglobin. RESULTS Leukocytes declined most dramatically during the first week of treatment (16% from pretreatment to Week 1 levels) and then at a rate of 3.3% per week from Week 1 to Week 7 (p < 0.001). Total mean leukocyte decrease over 7 weeks of therapy was 30%. Platelets declined 9% on average during the first week of therapy and then at a mean rate of 1.4% per week (p < 0.02). A statistically significant decrease in hemoglobin levels could not be detected. No difference in the rate of decrease could be found for different disease sites, age groups, or amount of marrow irradiated. The effects of chemotherapy were variable, depending on blood element and whether therapy was sequential or concomitant. The odds of a nadir < 2000 counts/mm3 for white blood count (WBC), < 50,000 counts/mm3 for platelets, and < 8.0 g/dl for hemoglobin were all well below 5%. A strong correlation existed between starting CBC values and nadirs; patients with lower Week 1 CBC levels were most likely to have the lowest nadirs. CONCLUSIONS Low CBC levels during radiation therapy are likely to be the result of other medical problems that cancer patients face. Regional irradiation with small field sizes (< 40% of total body marrow) typically used in clinical radiotherapy is unlikely to be the cause of marrow depression significant enough to warrant medical intervention. Blood levels taken during the first week of treatment (Week 1) can be used to determine risks of developing critical nadirs. Localized breast and prostate cancer patients are unlikely to require routine CBCs if initial levels are normal. Routine CBC levels on all radiation oncology patients without other reasons for hematopoietic depression requires reevaluation, as millions of dollars are spent on unnecessary testing. If weekly CBC blood levels are avoided in localized breast and prostate cancer patients, this alone could potentially result in a savings of as much as

Equivalent racial outcome after conformal radiotherapy for prostate cancer: a single departmental experience.

40 million a year nationally.

Potency probability following conformal megavoltage radiotherapy using conventional doses for localized prostate cancer

PURPOSE African-American (AA) men with prostate cancer present with advanced disease, relative to white (W) men. This report summarizes our clinical and biochemical control (bNED) rates after conformal radiotherapy (RT). In particular, we aim to characterize any race-based outcome differences seen after comparable treatment. PATIENTS AND METHODS We reviewed 893 patients (418 AA and 475 W) with clinically localized prostate cancer treated between 1988 and 1997. Neoadjuvant hormonal blockade was used in 22.5% of cases, and all patients received conformal RT to a median dose of 68 Gy (range, 60 to 74.8 Gy). Biochemical failure was defined according to the American Society of Therapeutic Radiology and Oncology consensus definition. Median follow-up was 24 months (range, 1 to 114 months). RESULTS The 5-year actuarial survival, disease-free survival, and bNED rates for the entire population were 80.5%, 70.0%, and 57.6%, respectively. When classified by prognostic risk category, the 5-year actuarial bNED rates were 78.7% for favorable, 57.7% for intermediate, and 39.8% for unfavorable category patients. AA men presented at younger ages and with more advanced disease. Controlled for prognostic risk category, AA and W men had similar 5-year actuarial bNED rates in favorable (78% v 79%, P: = .91), intermediate (52% v 62%, P: =.44), and unfavorable categories (36% v 45%, P: = .09). Race was not an independent prognostic factor (P: = .36). CONCLUSION Conformal RT is equally effective for AA and W patients. More research is needed in order to understand and correct the advanced presentations in AA men. These data suggest a need for early screening in AA populations.