Josef Kovarik

High dose-rate microselectron molds in the treatment of skin tumors

PURPOSEnThe feasibility of high dose rate iridium afterloaded molds in the treatment of skin tumors.nnnMETHODS AND MATERIALSnExpanded silicone rubber and bronchial applicator tubes were used in the construction of various molds. The number of tubes used and the separation between them depends on the size and area to be treated. Source dwell position and time are set to follow Paterson-Parker rules. Single plane expanded silicone rubber molds between 15 X 15 mm and 60 X 70 mm were used in 120 different sites, and of the others, seven were perspex double molds, two were cylindrical applicators, and one was a partially shielded intranasal applicator. One hundred and thirty lesions of various site and histology were treated in all. After exclusion of treatments that were combined with either external beam or chemotherapy, 106 lesions (76 patients) were evaluated.nnnRESULTSnFull response was obtained in all but four basal cell carcinomas. The acute reaction ranged from moist desquamation (27 sites) to erythema only. Follow-up at 5 or more months revealed no changes whatever in 47 sites; 53 showed an excellent cosmetic outcome, although slight changes in pigmentation or minimal atrophy was demonstrable and 6 sites became noticeably atrophic with patchy pigmentation. For 9.6 months of average follow-up time, no recurrences have been observed.nnnCONCLUSIONnThe high-dose-rate iridium-loaded skin applicators offer the possibility of improved therapeutic ratio in the treatment of superficial skin tumors. With the availability of a high-dose-rate afterloader this technique is simple and straightforward.

Small cell neuroendocrine carcinoma of larynx: Case series and literature review

BACKGROUNDnPrimary small cell neuroendocrine carcinoma of larynx is a rare, aggressive type of malignancy. As only about 200 cases worldwide have been reported, any larger institutional experience is valuable. This study reports our experience in managing this rare entity.nnnMETHODSnOf the nine patients identified, three had metastatic cancer at the time of diagnosis. Four patients underwent radical treatment: one was managed surgically followed by adjuvant chemotherapy and consolidation radiotherapy; the remaining three were treated with neoadjuvant chemotherapy and definitive radiotherapy.nnnRESULTSnOf the 4 patients treated with radical intent, 1 was alive and disease free after 99 months, 2 died of metastatic disease after 22 and 26 months, and 1 was alive after 20 months with a diagnosis of recurrent disease.nnnCONCLUSIONnOur relatively small number of patients confirms other centres experiences. This cancer has a poorer prognosis than most other head and neck cancers. Although the logistics would be challenging, there is a need for international multicentre trials for this disease modelled on those performed for other cancers, as has been done for paediatric malignancies.

Spindle cell carcinoma of the head and neck region: treatment and outcomes of 15 patients

Introduction Spindle cell carcinoma of the head and neck is a rare entity and the evidence of optimal management is lacking. The objective of our study was to report the treatment and outcomes of 15 patients treated in a single institution over a seven year period. Materials and Methods A total of 15 patients (12 males and 3 females) with spindle cell carcinoma of the head and neck were treated between July 2007 to June 2014. In six patients the disease developed after previous radiotherapy. Of the 15 patients, five patients had their primary in the tongue, four in the paranasal sinuses, two in the hypopharynx, two in the vocal cords, and one each in the soft palate and the floor of mouth. Eleven patients were treated with radical intent (seven patients required surgery only and four were treated with combined modality). The remaining four patients were treated with palliative intent. Results Among 11 patients treated with radical intent eight are alive or died of non-oncological causes. The disease recurred locally in three patients and they died of the disease (two patients with locally advanced disease in the tongue and one patient with T1N0 tumour in the hypopharynx). Median overall survival (OS) was 18 months. Conclusion Surgery or surgery combined with radiotherapy has a real impact on the natural cause of spindle cell carcinoma of the head and neck region. Even locally advanced tumours can be controlled with aggressive treatment. The worst outcome is seen with the tongue as the primary site because of a high local recurrence rate.

Maintenance Therapy with Trastuzumab in Her2 Positive Metastatic Parotid Ductal Adenocarcinoma

Salivary ductal carcinomas (SDCs) are extremely rare and aggressive malignancies, accounting for approximately 6% of all salivary gland malignancies. One distinct feature is their resemblance to ductal carcinomas of breast. A significant percentage of SDCs overexpress Her2 and the use of targeted therapy with trastuzumab can be considered in these patients. We report a rare case of long term disease control with trastuzumab in Her2 positive metastatic parotid ductal carcinoma. Our case also highlights that isolated brain metastasis should be managed aggressively to allow optimal local control when systemic disease is under remission with trastuzumab. We have also reviewed the published literature on the use of trastuzumab in SDCs.

Early tolerance of different organs to fast fractionation in clinical practice

PURPOSEnTo assess the feasibility of accelerated hyperfractionated radiotherapy in the treatment of breast, abdominal cavity, and pelvic tumors.nnnMETHODS AND MATERIALSnBetween August 1989 and March 1993, 39 patients were treated in Portsmouth by an accelerated, hyperfractionated regimen giving 45 to 54 Gy three times a day over 12 days. Twenty patients had abdominal cavity or pelvic tumors and 19 patients breast carcinoma, 9 of whom were treated prophylactically after local excision.nnnRESULTSnNo local recurrence has been observed in the 19 patients with breast carcinoma, and out of the 20 with abdominal or pelvic tumors, 6 showed complete regression and so far no severe late damage has been observed. In those patients who had pelvic or abdominal tumors treated, the acute toxicity varied widely from minimal to very intensive. No surgical intervention was necessary and most reactions settled within a 6-week period.nnnCONCLUSIONnAccelerated fractionation by small increments is well tolerated by the breast, pelvic, and abdominal organs.

Palliative radiotherapy for locally advanced non-metastatic head and neck cancer: A systematic review

OBJECTIVESnThe objective of this systematic review was to identify and appraise the existing evidence of role of palliative radiotherapy for locally advanced non-metastatic head and neck cancer.nnnMETHODSnA systematic search of the literature was conducted using Medline, Embase and Cochrane databases and relevant references were included.nnnRESULTSnLiterature search revealed a wide variation in dose fractionation regimens. Reported outcomes showed high efficacy and low rate of significant side effects, except in studies utilising higher doses of radiotherapy where higher grade toxicities were seen. Reported median overall survival was in the range of 3.3-17u202fmonths, but most studies reported median survival of around 6u202fmonths.nnnCONCLUSIONSnThe choice of palliative radiotherapy varies significantly. This is in contrast to regimens of curative radiotherapy for locally advanced head and neck cancer, which are well standardised. Given the reported relatively short overall survival of this patient group, an ideal treatment should be of the shortest possible duration whilst ensuring effective palliation and minimal side effects. Future well designed trials are needed to evaluate quality of life and duration of side effects in addition to survival and severity of toxicities in this group of patients.

Palliative radiotherapy for locally advanced non-metastatic head and neck cancer: A survey of UK national practice

Glossary: TD = total dose [Gy]; d = dose per fraction [Gy]; a/b = alpha beta r fractions [Gy]. As highlighted in our systematic review on palliative radiotherapy for locally advanced head and neck cancer [1], there is a wide variation of dose fractionation regimes. We conducted an email based survey looking at the choice of dose fractionation of palliative radiotherapy in non-metastatic head and neck cancers across the UK. The primary objective was to describe the range of palliative radiotherapy dose fractionation regimens in use for head and neck cancer management across the United Kingdom. Lead clinicians at all 48 UK radiotherapy centres that treat head and neck cancers were approached via email asking their ‘choice of dose/ fractionation for high-dose palliative radiotherapy in non-metastatic head and neck cancers’. Non-responders were sent a reminder. Thirty-four centres (71%) responded. The survey showed a range of dose fractionations (some centres used more than one schedule) varying from 20 Gy in 5 daily fractions to 68 Gy in 34 fractions. The most commonly used regimen

Primary Concurrent Chemoradiation in Head and Neck Cancers with Weekly Cisplatin Chemotherapy: Analysis of Compliance, Toxicity and Survival

Introductionu2003Concurrent chemoradiation is the standard of care in inoperable locally advanced squamous cell head and neck cancers. The most widely accepted schedule of concomitant cisplatin is 100mg/m2 given on a 3 weekly basis but the optimal regime is unknown. Objectiveu2003The objective of this study is to assess the tolerability, compliance, and clinical outcomes of weekly cisplatin (40mg/m2). Methodsu2003During the period of January 2007–December 2009, we analyzed retrospectively 122 patients with histologically proven squamous cell carcinoma of head and neck (nasopharynx, oropharynx, larynx, hypopharynx, and oral cavity) treated with definitive chemoradiation. All patients received 63u2009Gy in 30 daily fractions with concomitant weekly cisplatin 40mg/m2. We assessed treatment toxicities and patient compliance. We estimated overall survival using the Kaplan-Meier method. Resultsu2003Sixty-eight percent of patients managed to complete all six cycles of chemotherapy while 87% of patients completed at least 5 cycles of weekly cisplatin. Incidence of grade 3/4 toxicity was as follows: mucositis 33%, dermatitis 41%, dysphagia 15%, mouth/neck pain 17%, neutropenia 2%, and renal impairment 3%. 53% patients required at least one hospital admission for symptom control. The 5-year overall survival rate was 60%. Conclusionu2003Concurrent chemoradiotherapy using weekly cisplatin at 40mg/m2 per week is an effective, well tolerated regimen allowing most patients to receive at least 5 cycles of chemotherapy. However, a phase III randomized control trial comparing the standard dose of 100mg/m2 cisplatin tri-weekly with a weekly regimen is needed to establish the long term clinical outcome.