M. F. Osti

Radiological assessment of necrosis in glioblastoma: variability and prognostic value.

Abstract In a previous study, we found that the extent of necrosis was the only radiological feature which correlated significantly with survival in patients with glioblastoma. The aim of this paper was to evaluate the variability and prognostic value of the extent of the necrotic area as seen on contrast-enhanced MRI and CT in a larger series. We studied 72 patients who underwent surgical removal of supratentorial glioblastomas and had CT and/or MRI with contrast medium before surgery; 38, all undergoing the same treatment (surgery plus radiotherapy), were followed clinically. Necrosis within the tumour varied greatly, ranging from none (only 1 case) to involvement of 76 % of the tumour. Survival data in the subgroup suggested that only patients with a small area of necrosis (less than 35 % of the tumour) had a significantly longer survival time. When necrosis involved more than 35 % of the mass, patients had a shorter survival time, without any further correlation with the extent of necrosis.

Comparision between transrectal ultrasonography and computed tomography with rectal inflation of gas in preoperative staging of lower rectal cancer

Abstract. Computed tomography with rectal air insufflation was compared with transrectal ultrasonography (TRUS) in 63 patients. The CT protocol involved pre- and postcontrast scans with 5 mm slice thickness following air insufflation in IV antiperistaltic agent. Of the patients, 79 % were scanned in the prone position. Results of the preoperative examinations were compared with the histological findings. The CT examination had an accuracy rate of 74 %, predicting perirectal spread with a sensitivity of 83 % and a specificity of 62 %, whereas the corresponding figures for TRUS were 83, 91 and 67 %. The accuracy, sensitivity and specificity of CT and TRUS for nodal involvement were 57, 56, 57, 66, 68 and 64 %-respectively. These findings confirm that TRUS is more accurate than CT in local tumour (T) staging and in detecting nodal (N) spread. However, the appropiate CT technique shows spread of tumour outside the rectal wall and locoregional lymph nodes with reasonable accuracy. Lymphatic spread correlated with nodal size. TRUS and CT correctly staged only 57 and 43 %, respectively, of cases with nodal metastases with maximum diameter of 5 mm. TRUS sometimes overstaged perirectal growth of tumour in 7 patients, due to inflammation (5 patients) or incorrect positioning of the ballon in relation to the tumour surface (2 patients).

Radiation therapy of spinal metastases: results with different fractionations.

Aims and background Local radiotherapy plays an important role in the palliative treatment of all skeletal metastases, particularly those of the spine, with the purpose to obtain pain relief and prevent pathologic fractures or vertebral collapse. Methods From June 1991 to October 1993, 95 patients with a total of 103 sites of spinal metastases were treated at the Institute of Radiology of the University of Rome “La Sapienza”. Fractionations and total doses were divided as single fractions of 800 cGy, hypofractionated multiple fractions for a total dose of 20 Gy administered in 4-5 days, and conventional multiple fractions for a total dose of 30-40 Gy in 2-4 weeks. An evaluation of the efficacy of the different radiation treatments was performed with the use of a simplified descriptive pain scale. Results Seventy-three (70.9%) of 103 treatments were evaluables. An overall response rate of 82.2% was obtained: complete in 38.3% and partial in 43.8%, irrespective of total dose, fractionation and location of irradiated spinal metameres. The analysis of results did not show significant differences between the treatment courses. Conclusions We confirm that radiation therapy has a major role in the management of pain control and prevention of fractures in patients with spinal metastases. Hypofractionated and single fraction treatments showed equal efficacy compared to more prolonged therapy, with an advantage for the patient and the radiation therapy institution.

Supratentorial glioblastoma: Neuroradiological findings and survival after surgery and radiotherapy

Few studies have attempted to correlate neuroimaging with outcome in patients with glioblastoma. Our aim was to evaluate the relationship between neuroradiological findings and survival in these patients. We studied 18 consecutive patients with glioblastoma who had undergone surgery and radiotherapy. We assessed the following features, using preoperative CT and/or MRI: tumour size, extent of necrotic area within the mass, extent of perifocal oedema and contrast enhancement. The mean survival was 14.2 ± 5 months (range 6–22). The extent of radiological evidence of necrosis within the mass correlated significantly with survival time, whereas tumour size, perifocal oedema and contrast enhancement did not.

Acute toxicity in 14 patients with locally advanced head and neck squamous cell carcinoma treated with concurrent cetuximab and radiotherapy

PurposeThe authors report acute toxicity in 14 patients with locally advanced head and neck squamous cell carcinoma treated with radiotherapy and cetuximab.Materials and methodsData collection was performed prospectively on patients treated from September 2007 to March 2009. Treatment consisted of 64.8–70 Gy radiotherapy in conventional fractions and cetuximab.ResultsTwo out of 14 patients did not complete the planned combined treatment; radiotherapy was temporarily suspended in six other patients. Seven of 12 patients received cetuximab until the end of radiotherapy. Treatment breaks were principally due to severe acute cutaneous or mucous toxicity. Any grade acneiform rash occurred in all patients. In-field G3-4 cutaneous toxicity occurred in five (36%) patients and G3-4 mucous toxicity in seven (50%). One patient died of sepsis.ConclusionsIn our experience, severe acute toxic reactions are common in patients treated with radiotherapy and concurrent cetuximab, resulting in frequent breaks or incomplete treatment with potential reduction in disease control.RiassuntoObiettivoScopo del nostro lavoro è stato riportare i dati relativi alla tossicità acuta in 14 pazienti affetti da carcinoma squamoso localmente avanzato del distretto testa-collo trattati con radioterapia e cetuximab in contemporanea.Materiali e metodiLa raccolta dei dati è stata effettuata in modo prospettico relativamente ai pazienti trattati da settembre 2007 a marzo 2009. Lo schema di trattamento consisteva nella radioterapia per una dose totale di 64,8–70 Gy con frazionamento convenzionale associata al cetuximab.RisultatiIn 2 dei 14 pazienti il trattamento combinato pianificato non è stato completato; la radioterapia è stata temporaneamente interrotta in altri 6 pazienti. In 7 dei 12 pazienti che hanno ricevuto la terapia combinata il cetuximab è stato somministrato fino al termine della radioterapia. Le interruzioni sono state principalmente imputabili all’insorgenza di tossicità cutanea o mucosa severa. In tutti i pazienti è comparso rash cutaneo di tipo acneiforme; tossicità cutanea di grado 3–4 si è verificata in 5 (36%) pazienti mentre tossicità mucosa di grado 3–4 si è avuta in 7 (50%) pazienti; un paziente è deceduto per sepsi.ConclusioniNella nostra esperienza gli effetti tossici acuti di entità severa nei pazienti trattati con radioterapia e cetuximab concomitante sono stati comuni implicando interruzioni frequenti della terapia o l’impossibilità di completare il trattamento con potenziale minor efficacia sul controllo della malattia.

External-beam radiotherapy and/or HDR brachytherapy in postoperative endometrial cancer patients: clinical outcomes and toxicity rates

PurposeThe objectives of this study were to evaluate local disease control, overall survival (OS), disease-free survival (DFS) and local relapse-free survival (LRFS) in patients with endometrial cancer undergoing adjuvant vaginal brachytherapy (VBT)±external-beam radiotherapy (EBRT).Materials and methodsFrom September 2007 to February 2011, 40 patients with endometrial cancer were retrospectively analysed. Surgery consisted of total hysterectomy and bilateral salpingo-oophorectomy without node dissection (16 patients) or with bilateral pelvic node dissection (24 patients). The stage distribution was as follows: two IA, nine IB, 12 IC, five IIA, eight IIB, two IIIA and two IIIC. Thirty-four patients underwent EBRT and VBT. Six patients received VBT alone.ResultsMedian follow-up was 26 months. The 5-year OS and DFS were 96.4% and 86.9%, respectively. No local recurrence was observed. Four patients presented distant disease (three had lung metastases and one had hepatic node metastases). Acute EBRT-related toxicities were seen in 15 (38%) patients. We recorded late toxicities in 14 patients (35%). There was no evidence of grade 3–4 toxicity.ConclusionsAdjuvant EBRT and/or VBT in patients with endometrial cancer showed good outcomes in terms of local disease control, with an acceptable toxicity profile.RiassuntoObiettivoL’obiettivo dello studio è stato di valutare il controllo locale, la sopravvivenza globale (OS), la sopravvivenza libera da malattia (DFS) e la sopravvivenza libera da recidiva locale in pazienti con cancro dell’endometrio sottoposti a brachiterapia (BRT)±radioterapia (RT) a fasci esterni adiuvante.Materiali e metodiDa settembre 2007 a febbraio 2011, quaranta pazienti con tumore dell’endometrio sono state analizzate. La chirurgia consisteva nell’isterectomia totale e annessiectomia bilaterale senza linfadenectomia (16 pazienti), o con linfadenectomia pelvica (24 pazienti). Lo stadio patologico era: 2 IA, 9 IB, 12 IC, 5 IIA, 8 IIB, 2 IIIA e 2 IIIC. Trentaquattro pazienti avevano ricevuto RT pelvica e BRT. Sei pazienti avevano ricevuto solo brachiterapia.RisultatiIl follow-up mediano è stato di 26 mesi. L’OS e la DFS a 5 anni sono state 96,4% e 86,9%, rispettivamente. Nessuna paziente presentava recidiva locale. Quattro pazienti manifestavano metastasi a distanza: (3 pazienti: malattia polmonare; 1 paziente: linfonodi epatici metastatici). Gli effetti tossici acuti sono stati osservati nel 38% dei pazienti e quelli tardivi nel 35%. Nessuna tossicità di 3–4 grado è stata rilevata.ConclusioniLa RT pelvica e/o BRT adiuvante hanno mostrato un buon controllo locale di malattia con tossicità accettabile nei pazienti con cancro dell’endometrio.

Curative radiotherapy in patients with anal cancer: clinical outcomes and prognostic factors in a single-institution experience

PurposeOur aim was to retrospectively analyse a series of patients with anal cancer treated with curative intent at a single institute in terms of survival and local disease control.Materials and methodsForty-two patients with anal cancer were treated with primary radiotherapy with or without concurrent chemotherapy. The influence of the prognostic factors on overall (OS), disease-free (DFS), disease-specific (DSS), colostomy-free (CFS) and metastasis-free (MFS) survival was evaluated.ResultsNine patients had stage I, 15 stage II, four stage IIIA and 14 stage IIIB disease. Tumour progression/ persistence occurred in five patients (12%). The 5-year OS, DSS, DFS, CFS and MFS were 72.7%, 84.2%, 85.7%, 81.1% and 87.1%, respectively. On univariate analysis, T stage emerged as highly significant for OS, DSS, CFS and DFS, whereas N status was a significant prognostic factor for DSS. On multivariate analysis, T stage was a significant prognostic factor for OS and CFS.ConclusionsOur data support the view that combined chemoradiation treatment of anal cancer is feasible and may provide survival benefits with an acceptable rate of adverse effects. We should consider T and N stages as important prognostic factors for survival.RiassuntoObiettivoIl nostro obiettivo era quello di analizzare retrospettivamente una serie di pazienti con cancro anale trattati con intento curativo, in termini di sopravvivenza e controllo locale.Materiali e metodiQuarantadue pazienti con cancro anale sono stati trattati con radioterapia +/− chemioterapia concomitante. è stato valutato l’impatto dei fattori prognostici su sopravvivenza globale (OS), sopravvivenza libera da malattia (DFS), sopravvivenza specifica di malattia (DSS), sopravvivenza libera da colostomia (CFS) e sopravvivenza libera da metastasi (MFS).RisultatiLo stadio di malattia era: 9 pazienti stadio I, 15 pazienti stadio II, 4 pazienti stadio IIIA, e 14 stadio IIIB. La progressione/persistenza di malattia si è verificata in 5 pazienti (12%). I valori di OS, DSS, DFS, CFS, MFS a 5 anni sono stati 72,7%, 84,2%, 85,7% 81,1% e 87,1%, rispettivamente. All’analisi univariata, il T è emerso come fattore prognostico significativo per l’OS, DSS, CFS e DFS, mentre l’N è risultato significativo per la DSS. All’analisi multivariata, il T è risultato un fattore significativo per l’OS e la CFS.ConclusioniI nostri dati confermano che la radiochemioterapia nel cancro anale è fattibile e può fornire un beneficio di sopravvivenza con tossicità accettabili. Dovremmo considerare il T e l’N come importanti fattori prognostici per la sopravvivenza.

The Role of Restaging Laparotomy in Hodgkin'S Disease

The role of restaging laparotomy (RL) in Hodgkins disease was studied in 41 patients. Two patients were in clinical stage I, 16 in clinical stage II, 13 in clinical stage III and 10 in clinical stage IV. Eight cases had previously received radiation therapy alone, 26 chemotherapy and 7 combined chemo-, and radiotherapy. The patients were divided into 2 groups, depending on the results of the preoperative clinical reevaluation. Group 1 included 20 patients with suspicion of persistent disease; in 6 (30%) RL was positive. Group 2 consisted of 21 cases with clinical appearance of complete response; RL was positive in one case (4.7%). The results of the comparison confirm the high rate of false positive findings in CT and lymphography. RL appears as a valuable procedure in patients with positive or doubtful clinical findings at reevaluation after radical therapy, in order to reduce the risk of unnecessary treatment.

30 Gy single dose stereotactic body radiation therapy (SBRT): Report on outcome in a large series of patients with lung oligometastatic disease

OBJECTIVES To evaluate the local control (LC) and long term adverse effects in a series of patients with lung metastases who received 30 Gy in single dose with stereotactic technique. MATERIALS AND METHODS Between December 2008 and April 2016, a total of 166 lung metastases in 129 patients affected by oligometastatic disease were treated at our Institution with stereotactic body radiotherapy (SBRT). Mainly, the primary tumors were non small-cell lung cancer and colorectal cancer (45.2% and 28.8%, respectively). Prognostic factors were also assessed. RESULTS The median follow-up was 38 months. Local progression occurred in 24 (14.4%) lesions in 21 patients. Intra-thoracic progression (new lung lesions or thoracic lymph node metastases) occurred in 59 (45.7%) patients. Forty-five (34.8%) patients had distant progression after a median time of 14 months. The 3- and 5-years local relapse-free survival (LPFS) were 80.1% and 79.2% (median not reached), respectively. One-hundred forty-eight patients were evaluated for late toxicity (follow-up >6 months): 51 (34.4%) patients had grade ≤2 fibrosis, 11 (7.4%) patients experienced grade 3 fibrosis. Two (1.3%) cases of rib fracture occurred. One case of toxic death (grade 5) has been reported. Median OS was 39 months. At the univariate analysis, lesion diameter ≤18 mm correlated significantly with a longer LPFS (p = 0.001). At the multivariate analysis, lesion diameter <18 mm was predictive for longer LPFS (p = 0.006). Also, oligometastases from primary colorectal cancer was a significant predictive factor for worse LPFS (p = 0.041) and progression-free survival (p = 0.04). CONCLUSIONS To our knowledge, the current study represents the largest series on the use of SBRT 30 Gy single dose for lung metastases. Our results confirm the effectiveness and safety of this schedule administered in selected oligometastatic patients. Further prospective series could better validate these results.

Two Cases of Capecitabine-Induced Ileitis in Patients Treated with Radiochemotherapy to the Pelvis and Review of the Literature

Colorectal cancer is the third most common cancer in the Western World. Locally advanced disease is treated with a preoperative approach with the purpose to improve local control and to make possible a sphincter saving surgery. Preoperative treatment mainly consists of RT alone (short-course) or RCT (long-course) [1, 2]; in the concomitant strategy, RT is usually associated with capecitabine, an oral fluoropyrimidine that is a prodrug of 5fluoruracil. The most common side effects of capecitabine include nausea, vomiting, hand-foot syndrome, and mucositis. Serious adverse effects are bowel obstruction and perforation [3]. It is proven the higher incidence of gastrointestinal toxicity in patients treated with RCT respect the sole RT [1, 2]; in particular, concomitant administration of 5-FU lead to a significant increase in G ≥ 2 diarrhea. We report two cases of ileitis in two patients affected by locally advanced rectal cancer treated with preoperative RCT and concomitant capecitabine. A review of the literature shows only one other case of this rare capecitabine-related side effect during pelvic irradiation [4]. Case Report 1