Mary E. Hebert

Initial clinical experience with the MammoSite breast brachytherapy applicator in women with early-stage breast cancer treated with breast-conserving therapy.

PURPOSE We present the results of the initial clinical testing of the MammoSite balloon breast brachytherapy applicator in women with early-stage breast cancer treated with breast-conserving therapy. METHODS AND MATERIALS Seventy patients were enrolled in a multicenter prospective trial testing the applicator for safety and performance. Fifty-four patients were implanted, and 43 patients were ultimately eligible for and received brachytherapy as the sole radiation modality after lumpectomy. Patients were staged T1N0M0 with negative pathologic margins and age >45 years. A dose of 34 Gy was delivered in 10 fractions over 5 days prescribed to 1 cm from the applicator surface using 192Ir high-dose-rate brachytherapy. A minimum skin-to-balloon surface distance of 5 mm was required for treatment. Device performance, complications, and cosmesis were assessed. RESULTS Computed tomography imaging post-balloon inflation showed 8, 14, and 21 patients with 5-6 mm, 7-9 mm, and >10 mm of skin spacing, respectively. Two patients were explanted because of inadequate skin spacing and 7 because of suboptimal conformance of the surgical cavity to the applicator balloon. One patient was explanted because of positive nodal status and another because of age. The most common side effects related to device placement included mild erythema, drainage, pain, and echymosis. No severe side effects related to implantation, brachytherapy, or explantation occurred. Side effects related to radiation therapy were generally mild with erythema, pain, and dry desquamation being the most common. At 1 month, 88% of patients were evaluated as having good-to-excellent cosmetic results. CONCLUSIONS The MammoSite balloon breast brachytherapy applicator performed well clinically. All eligible patients completed treatment. Side effects were mild to moderate and self-limiting. Skin-balloon surface distance and balloon-cavity conformance were the main factors limiting the initial use of the device.

Positron emission tomography in the pretreatment evaluation and follow-up of non-small cell lung cancer patients treated with radiotherapy: preliminary findings.

The purpose of this study was to prospectively evaluate positron emission tomography (PET) for delineating lung cancers preradiotherapy and to assess PETs ability to distinguish residual tumor from scarring following radiotherapy. Between April 1991 and October 1992, 20 patients underwent 18fluoro-2-deoxyglucose (18FDG) PET scanning of the chest prior to radiotherapy for lung cancer. Tumor volumes on chest x-ray (CXR) and computerized tomography (CT) scan were correlated with abnormalities on PET scans. Follow-up PET studies were compared to postradiotherapy chest x-ray and/or CT scans, and correlated with clinical outcome. Six of seven well-demarcated tumors showed increased uptake of 18FDG correlating with the CT/CXR tumor volume. Twelve poorly demarcated tumors demonstrated increased 18FDG uptake. In seven of 12, the CT/CXR abnormality correlated with changes on PET scan. In three of 12, CT/CXR abnormalities were larger than on PET, whereas in two of 12, abnormalities on PET extended outside the region of CT/CXR changes. The 13th patient in the poorly demarcated category had diffuse carcinoma in situ at the surgical margin that demonstrates increased 18FDG uptake, but was not visible by CT/CXR. Of 12 patients with follow-up studies, all had changes on CXR and/or CT that made it difficult to assess response. Four of 12 had a complete response by PET; all remain locally controlled. The remaining eight patients had either a partial response (n = 6) or no response (n = 2) by PET. Four of these eight patients remain alive and well 11-24 months after therapy. 18FDG PET may be useful for delineation of lung cancer volumes that are poorly defined by CXR and/or CT scan. The value of PET in differentiating tumor from fibrosis after radiotherapy for lung cancer remains to be established.

Serial Evaluation of Increased Chest Wall F-18 Fluorodeoxyglucose (FDG) Uptake Following Radiation Therapy in Patients With Bronchogenic Carcinoma

PURPOSE: Following radiation therapy for bronchogenic carcinoma, increased FDG accumulation within the irradiated tissue can be identified. This finding has not been well characterized. Therefore, we retrospectively evaluated the time course, frequency, and intensity of increased FDG uptake over a one-year period in patients who had been treated with radiation therapy. MATERIALS AND METHODS: Serial FDG-PET studies (n = 38) were performed in patients (n = 12) with bronchogenic carcinoma before and after radiation therapy. Regions of interest (ROIs) were placed in the chest wall and activity concentrations of posttherapy studies were compared to pretherapy studies. FDG uptake was also described qualitatively relative to mediastinal activity (1-4 scale) by two observers blinded from clinical information. RESULTS: Chest wall radiation port ROI uptake was 18% higher in the 2-month (P = 0.08), 40% higher in the 6-month (P = 0.003), and 32% higher in the 12-month (P = 0.04) posttherapy studies than in non-port ROIs. In 6 patients that clinically had radiation-induced chest wall fibrosis or pneumonitis, visual interpretation identified abnormal chest wall or pleural region FDG uptake in 5/6. In 2/6 patients without clinical chest wall fibrosis, abnormal, chest wall FDG uptake was seen. CONCLUSIONS: Radiation therapy occasionally causes modestly increased soft tissue FDG uptake within irradiated soft tissue in patients being treated for bronchogenic carcinoma, which persists for up to one year after therapy.

Anaphylactoid Reactions with Intraperitoneal Cisplatin

Objective: To report the occurrence of anaphylactoid reactions to intraperitoneal cisplatin in 3 patients. Case Summaries: While conducting a protocol evaluating the efficacy of intraperitoneal cisplatin and hyperthermia in the treatment of recurrent ovarian cancer, 3 patients were noted to exhibit anaphylactoid reactions. A 43-year-old woman received cisplatin 60 mg/m2 in 15 minutes during her sixth cycle of therapy. She developed pruritus, edema, and urticaria over both hands. The reaction subsided after treatment with diphenhydramine and dexamethasone. A 57-year-old woman received 400 mL (62.4 mg) of a cisplatin solution concentrated to deliver cisplatin 100 mg/m2 during her first attempted therapy. At this point, she developed whole body urticaria and pruritus with edema of the extremities. The reaction was aborted with diphenhydramine and dexamethasone. Despite premedication with dexamethasone prior to a second attempt at therapy, she again experienced similar symptoms after receiving 500 mL (78 mg) of cisplatin solution. A 55-year-old woman received 2 cycles of therapy with cisplatin 100 mg/m2 without difficulty. During her third cycle, she again received cisplatin 100 mg/m2 over 30 minutes and developed palmar pruritus, urticaria, and edema. Symptomatology resolved with diphenhydramine. Despite premedication with diphenhydramine and dexamethasone, she experienced generalized pruritus and urticaria, as well as headache and chest pain/tightness, after her next infusion. For both the second and third patients, symptomatology failed to resolve until the intraperitoneal cisplatin solution was withdrawn. Discussion: Anaphylactoid reactions have been described previously with cisplatin administration. No dose–rate effect has been reported, however. We observed 5 reactions in 3 patients that appear to be related to a high dose–infusion time ratio, indicating that dose and rate of infusion may be important factors in precipitating anaphylactoid reactions with cisplatin. Conclusions: We conclude that a high dose combined with a short infusion time increases the risk of anaphylactoid reactions with the administration of intraperitoneal cisplatin. There was no indication that the increase in anaphylactoid reactions was associated with the use of hyperthermia.

Multiple fraction-per-day radiotherapy for patients with brain stem tumors

Brain stem tumors are among the most resistant brain tumors to therapy. The majority progress within 18 months of diagnosis and treatment. Multiple-fraction-per-day (MFD) radiotherapy would theoretically allow higher total doses of radiotherapy to be delivered in order to improve local tumor control without increasing neurotoxicity secondary to treatment. Seventeen patients with brain stem tumors were evaluated and treated at Duke University Medical Center (DUMC) from 1985 to 1991 with a MFD regimen. Six patients were accrued to Pediatric Oncology Group (POG) Protocol 8495 and were not included in this analysis, leaving eleven patients for review. Local fields were treated with fraction sizes of 110 or 117 cGy twice daily. There were 3 patients who received a total of 60.5–68.2 Gy and 8 who received 70.2–71.5 Gy. Initial and follow-up CT and/or MRI studies were available for review on all but one patient. All patients had progression of disease and have died. Median time to tumor progression was 5.8 months. Median overall survival was 11.2 months. There was no significant influence upon time to tumor progression or survival by total radiation dose received. Patients were classified by imaging group per the criteria of Stroinket al. based on review of their pre-treatment CT or MRI scans. One patient had no initial films available, 2 were in Group II (no contrast was given to separate A or B), 3 in IIA, 4 in IIB, and 1 in III. Autopsy in 3 patients failed to demonstrate histologic evidence of injury attributable to radiotherapy. The results of this study fail to demonstrate a positive impact of MFD radiotherapy on the outcome of children with unresectable brain stem tumors.