L.A. Dawson

Prospective comparison of breast pain in patients participating in a randomized trial of breast-conserving surgery and tamoxifen with or without radiotherapy

PURPOSEnTo determine whether breast pain affects quality of life (QOL) after breast-conserving surgery and tamoxifen (TAM) with or without adjuvant breast radiotherapy (RT).nnnMETHODS AND MATERIALSnA randomized clinical trial was carried out at the Princess Margaret Hospital between 1992 and 2000 to evaluate the need for breast RT in addition to TAM in women >or=50 years treated with breast-conserving surgery for T1-T2N0 breast cancer. A companion study to assess breast pain was carried out during the last 2 years of the randomized clinical trial. The short-form McGill Pain Questionnaire (SF-MPQ), the European Organization for Research and Treatment of Cancer (EORTC) QOL (QLQ-C30) and EORTC breast cancer module (QLQ-BR23) questionnaires were completed by patients within 1 week of randomization in the randomized clinical trial (baseline) and at 3, 6, and 12 months.nnnRESULTSnEighty-six patients participated in the breast pain study; 41 received RT plus TAM and 45 received TAM alone. The median age was 70 years (range 51-80). The baseline pain and QOL scores were similar for the two groups. No significant difference was found between the two groups for each scale of the QLQ-C30 and QLQ-BR23 questionnaires at 3, 6, or 12 months (p >0.100), except that at 12 months, the score for role function (QLQ-C30) was higher in the RT plus TAM group than in the RT-only group (p = 0.02). At 3 months, the difference between the mean scores for the SF-MPQ was 0.553 (p = 0.47). At 12 months, the pain scores had decreased in both groups; the difference was 0.199 (p = 0.71). The number of breast operations or surgical complications did not correlate with breast pain in either group. Acute RT toxicity scores did not correlate with breast pain or QOL scores at 12 months.nnnCONCLUSIONnThese results suggest that breast RT does not significantly contribute to breast pain or adversely impact the QOL up to 12 months after treatment in postmenopausal patients with node-negative breast cancer who take TAM.

Retrospective study of palliative radiotherapy in newly diagnosed head and neck carcinoma.

PURPOSEnTo examine the patterns of care, outcomes, and prognostic factors for patients with head-and-neck cancer (HNC) treated with palliative radiotherapy (RT).nnnMETHODS AND MATERIALSnAn institutional HNC anthology and electronic patient records were used to identify patients with previously untreated HNC of mucosal or salivary gland origin who underwent palliative RT at our institution between July 2003 and June 2008. Overall survival was determined from the start date of RT to either the date of death or the date of last follow-up for living patients. The data were censored if the subject was either lost to follow-up or had not been seen for follow-up at our institution for ≥4 months.nnnRESULTSnWe identified 148 eligible patients. The median age was 72 years (range, 19-94). Of the 148 patients, 12 had Stage II-III, 39 Stage IVA, 36 Stage IVB, and 54 Stage IVC; for 7 patients, the stage was unknown. Oropharyngeal primary cancer (40) was the most common primary site. The Eastern Cooperative Oncology Group performance status was 0 in 15, 1 in 69, 2 in 40, 3 in 19, and 4 in 5 patients. The Adult Co-morbidity Evaluation-27 scale was 0 in 33, 1 in 47, 2 in 44, and 3 in 21. The median radiation dose was 50 Gy (range, 2-70), the median fraction number was 20 (range, 1-40), and the median total treatment time (including breaks) was 29 days (range, 1-80). At analysis, 108 patients (73%) had died, 20 (13.5%) were alive, and 20 (13.5%) had been censored. The median follow-up was 4.8 months, and the median survival time was 5.2 months. Information on the treatment response was available for 103 patients (70%). On multivariate analysis, the radiation dose was an independent predictor of both overall survival (hazard ratio 0.97, 95% confidence interval 0.96-0.99, p <.01) and treatment response (odds ratio 1.05, 95% confidence interval 1.01-1.08, p <.01).nnnCONCLUSIONnFor patients considered unsuitable for curative RT, the radiation dose might be an independent predictive factor for both overall survival and treatment response. Additional research is required to more effectively select those patients who might benefit from more aggressive treatment.

Adaptive Management of Liver Cancer Radiotherapy

Adaptive radiation therapy for liver cancer has the potential to reduce normal tissue complications and enable dose escalation, allowing the potential for tumor control in this challenging site. Using adaptive techniques to tailor treatment margins to reflect patient-specific breathing motions and image-guidance techniques can reduce the high dose delivered to surrounding normal tissues while ensuring that the prescription dose is delivered to the tumor. Several treatment planning and delivery techniques have been developed for use in the liver, including a margin to encompass the full breathing motion, mean position techniques, which evaluate the probability of tumor location during breathing, breath hold, gating, and tracking. Patient selection, clinical workflow, and quality assurance must be considered and developed before integrating these techniques into clinical practice.

Carcinoma of the Biliary Tract

The gallbladder and bile ducts share a common embryologic origin and are lined with a simple columnar epithelium. Most malignancies of the biliary tract are adenocarcinomas that arise from the malignant transformation of this columnar epithelium. Adenocarcinomas of the bile ducts are often referred to as cholangiocarcinomas. Malignant transformation can occur anywhere along the biliary system from the ampulla of Vater to the terminal intrahepatic bile ducts. Gallbladder cancers arise from the epithelium of the gallbladder or cystic duct. Intrahepatic cholangiocarcinoma (ICC) develops in bile ducts within the liver and proximal to the lobar hepatic ducts and hepatic duct confluence. Extrahepatic bile duct cancer develops in the biliary tree from the ampulla of Vater to the hepatic duct confluence. Extrahepatic bile duct tumors can be further subdivided into intrapancreatic cholangiocarcinoma, which are managed similarly to other periampullary malignancies (and are not discussed here), and proximal or hilar cholangiocarcinoma.