Leo E. C. M. Blank

ESTRO/EAU/EORTC recommendations on permanent seed implantation for localized prostate cancer

INTRODUCTION The last few years has seen an enormous increase in interest in the role of new transrectal ultrasound and template guided techniques for brachytherapy in localised prostate cancer. In the USA there has been a dramatic rise in the number of implants performed in the last five years. A similar rapid expansion is expected in Europe and this guidance is intended to indicate to those embarking on brachytherapy the factors which may be related to successful outcomes.

Combined treatment with radiation and hyperthermia inmetastatic malignant melanoma

In 24 patients with metastatic malignant melanoma, combined treatment with radiation and hyperthermia was administered to 38 localizations, radiation alone to 8 comparative localizations and hyperthermia alone to 3 localizations. Hyperthermia was administered during one hour by using a 433 MHz microwave generator. The heat treatment was given within 30 min following irradiation. Although an intratumoral temperature of 43 degrees C was aimed, considerable variations occurred during one session and from session-to-session. Radiation schedules consisted in either one large fraction (6-8 Gy) once a week in 14-21 days or two fractions (4-5 Gy) twice a week in 21 days. In the group of patients receiving irradiation once a week, three heat treatments were administered. In the twice-a-week radiation schedule, six heat sessions were given. The overall complete response (CR) rate in patients receiving combined treatment was 50%. In the group of patients treated with hyperthermia and irradiation schedules of 8 Gy per fraction, the CR rate was 83%. Irradiation alone achieved 38% CR rate but some of these CR relapsed during follow-up whereas the comparative area treated with radiation and heat remained under control at this time. The lesions treated with heat alone did not show any response to treatment. Enhancement of the acute skin reactions was generally observed. However, because the total doses were relatively low, this enhancement did not constitute a clinical problem. CR appears to occur more frequently in small tumor sizes. The highest and lowest temperature ever registered during any session of hyperthermia did not seem to correlate with the tumor response.

Chestwall recurrences of breast cancer: results of combined treatment with radiation and hyperthermia.

In 35 patients with chestwall recurrences of breast carcinoma, 45 lesions were treated with combined radiation and hyperthermia. The majority of the lesions received 6 fractions of 4 Gy, twice a week during 3 weeks. Hyperthermia was administered within 30 min after irradiation, aiming a tumor temperature of 43 degrees C during one hour. The percentage of complete response (CR) was 57%. In small lesions, the percentage of CR was 80%. The mean duration of the response was 7 months. Response rate increased with increasing temperature. Particularly, mean temperature and isoeffect thermal dose correlated very well with response rate. In nine cases, comparative lesions were treated with either radiation alone or radiation combined with hyperthermia. The response rates were 3/9 and 7/9, respectively. Acute skin reactions were enhanced by the combined treatment. However, late skin reactions were not increased. Although the prognosis of patients with chestwall recurrences is determined by the presence of distant metastases, local control remains an important objective. Combined treatment with radiation and hyperthermia offers the possibility of obtaining a high local control rate particularly in relatively small lesions.

Results of Deep Body Hyperthermia with Large Waveguide Radiators

The purpose of this report is to present results of work in progress on hyperthermia treatment planning and clinical application of a fourapplicator phased array hyperthermia system for heating of large and deepseated tumors.

A novel local treatment strategy for advanced stage head and neck rhabdomyosarcomas in children: results of the AMORE protocol

The AMORE protocol is a local treatment regimen for head and neck rhabdomyosarcomas (HNRMS), consisting of Ablative surgery, Moulage technique brachytherapy and surgical Reconstruction. The aim of AMORE is to intensify local treatment for children with HNRMS and to avoid external beam radiation therapy (EBRT) and its long-term sequelae. All children with primary irresectable, non-orbital HNRMS in whom EBRT was indicated, were evaluated for the feasibility of AMORE. In 20 children, AMORE was performed (15 with parameningeal disease and five with non-parameningeal disease). Complete remission was achieved in all 20 patients. Local complications were limited. 5 patients experienced a local relapse and 1 patient developed distant metastases. Estimated 5-year OS and EFS were 67.5 and 64.1% for the entire group, and 64.2 and 60.0% for the parameningeal subgroup. We conclude that the AMORE protocol is a feasible strategy, with a good local control rate. Long-term sequelae of EBRT might be avoided although, to date, the follow-up is too short for definitive conclusions regarding these sequelae.

Primary radiotherapy in progressive optic nerve sheath meningiomas: a long-term follow-up study

Background/aims To report the outcome of primary radiotherapy in patients with progressive optic nerve sheath meningioma (ONSM). Methods The clinical records of all patients were reviewed in a retrospective, observational, multicentre study. Results Thirty-four consecutive patients were included. Twenty-six women and eight men received conventional or stereotactic fractionated radiotherapy, and were followed for a median 58 (range 51–156) months. Fourteen eyes (41%) showed improved visual acuity of at least two lines on the Snellen chart. In 17 (50%) eyes, the vision stabilised, while deterioration was noted in three eyes (9%). The visual outcome was not associated with age at the time of radiotherapy (p=0.83), sex (p=0.43), visual acuity at the time of presentation (p=0.22) or type of radiotherapy (p=0.35). Optic disc swelling was associated with improved visual acuity (p<0.01) and 4/11 patients with optic atrophy also showed improvement. Long-term complications were dry eyes in five patients, cataracts in three, and mild radiation retinopathy in four. Conclusion Primary radiotherapy for patients with ONSM is associated with long-term improvement of visual acuity and few adverse effects.

Rectal Squamous Cell Carcinoma 11 Years After Brachytherapy For Carcinoma Of The Prostate

Although complications, such as prostatorectal fistula and rectal ulcer, following brachytherapy for prostate cancer have been documented previously, long-term complications have been less well investigated and documented. We report a case of radiation induced ulceration of a prostatorectal fistula, in which squamous cell carcinoma developed 11 years following implantation of iodine seeds for prostate cancer.

Brachytherapy in orbital tumors

PURPOSE To evaluate whether the use of iridium-192 brachytherapy would reduce the incidence of complications noted with external beam radiation therapy in patients with orbital tumors. METHODS AND MATERIALS This study is a retrospective review of a clinical series of 25 patients with various orbital tumors treated with brachytherapy between 1988 and 1995. RESULTS Patients were observed for an average of 40 months (range, 16-88 months) during which one patient died of metastatic disease and 24 patients are alive with no evidence of disease. Recurrent disease was observed in four patients. In 3 patients, exenteration was necessary and in 22 patients, the eye was preserved. The visual acuities after therapy ranged from no light perception to 20/20 (average, 20/40). CONCLUSIONS Since brachytherapy has been used as an alternative to exenteration, the results of this treatment have been excellent in most patients. However, in advanced disease, external radiation therapy or even mutilating surgery still remains inevitable.

Radiotherapy and hyperthermia.

72 patients with either unresectable or pelvic recurrence of colorectal cancer were treated with combined radiotherapy and locoregional hyperthermia. Radiation doses were 50 Gy or more in patients not previously treated with radiotherapy, and 32 Gy (8 x 4 Gy) in patients who had previously received radiotherapy. Hyperthermia was administered within 30 min of irradiation, and the aim was to give four to six sessions once or twice a week, intending to reach temperatures of at least 41 degrees C over 30 min. The mean of all the minimum (TMIN), maximum (TMAX) and median (TMED) intratumoral temperatures were 39.6, 41.1 and 40.2 degrees C, respectively. Toxicity during hyperthermia treatment consisted mainly of local pain within the heated field (33%) and general discomfort (17%). In 17% of the patients, the hyperthermic treatment was prematurely stopped. Palliation was achieved in 75% of patients with a mean duration of 12 months. The percentage of palliated patients was higher when higher radiation doses were administered. No correlation between palliative effect and thermal parameters was found. A computed tomography scan proved objective remission was obtained in 11 patients (15%). Median survival was 11 months, and 17% of the patients were alive at 3 years. The literature on combined radiotherapy and hyperthermia in colorectal cancer is reviewed. From this review and our own data, it is concluded that thermoradiotherapy is feasible. Acute and late toxicity are not major problems, although pain and general discomfort hamper hyperthermic treatment. The most disappointing fact is that, with the available hyperthermia equipment, the increase in intratumoral temperature does not reach, in general, the therapeutic range.

The AMORE Protocol for Advanced-Stage and Recurrent Nonorbital Rhabdomyosarcoma in the Head-and-Neck Region of Children: A Radiation Oncology View

PURPOSE A multidisciplinary approach, consisting of consecutive Ablative Surgery, MOld technique with afterloading brachytherapy and immediate surgical REconstruction (AMORE) applied after chemotherapy, was designed for children with rhabdomyosarcoma in the head-and-neck region. Analysis of the first 42 patients was performed. METHODS AND MATERIALS After macroscopically radical tumor resection, molds were constructed for each individual to fit into the surgical defect. The molds, made of 5-mm-thick layers of thermoplastic rubber, consisted of different parts. Flexible catheters were positioned between layers. After brachytherapy, the molds were removed. Surgical reconstruction was performed during the same procedure. RESULTS Dose to the clinical target volume varied from 40 to 50 Gy for the primary treatment (31 patients) and salvage treatment groups (11 patients). There were 18 females and 24 males treated from 1993 until 2007. Twenty-nine tumors were located in the parameningeal region, and 13 were located in the nonparameningeal region. Patient age at the time of AMORE was 1.2-16.9 years (average, 6.5 years). Follow-up was 0.2-14.5 years (average, >5.5 years). Eleven patients died, 3 with local recurrence only, 6 with local and distant disease, 1 died of distant metastases only, and 1 patient died of a second primary tumor. Overall 5-year survival rates were 70% for the primary treatment group and 82% for the salvage group. Treatment was well tolerated, and acute and late toxicity were mild. CONCLUSIONS The AMORE protocol yields good local control and overall survival rates, and side effects are acceptable.