Scott L. Sailer

Ewing's sarcoma: surgical resection as a prognostic factor.

A retrospective review of 46 cases of Ewings (43) and extraosseous Ewings (3) sarcoma was performed to examine for prognostic factors. Follow-up ranged from 27 to 135 months with a mean of 77.6 months, 86% greater than 36 months. Nine (20%) patients presented with distant metastases, 98% received multiagent chemotherapy, and 98% received radiation therapy. Overall actuarial survival and local control at 5 years were .52 +/- .08 and .78 +/- .07, respectively. The freedom from relapse or treatment related mortality at 5 years was .46 +/- .08. In 12 (26%) patients, surgical resection of the involved bone or soft tissue was part of the initial treatment plan. Ninety-two percent (11/12) of these patients also received radiation therapy. In addition to surgical resection, tumor size (less than 500 cc vs. greater than or equal to 500 cc), primary site (central vs. other), and stage were also analyzed for prognostic significance, and where appropriate, were included in Cox multivariate analyses. Considering all patients, the 5-year actuarial survival was .92 +/- .08 vs. .37 +/- .09 for patients receiving and not receiving surgical resection, respectively (p = .001 by logrank, p = .02 by Cox). To make the groups more comparable, 8 patients with local failure and 5 patients with non-evaluable primary sites were excluded. After these exclusions, the presence or absence of surgical resection had decreased significance: .92 +/- .08 vs. .59 +/- .11, respectively; p = .01 by logrank, p = .07 by Cox. Only primary site remained statistically significant: .86 +/- .08 for noncentral sites vs. .38 +/- .16 for central sites, p less than .0002 by logrank, p = .0004 by Cox. Surgical resection when added to local irradiation has prognostic significance in this retrospective review. The reason for this is not clear, but may be related to a decrease in local failure after resection.

Carcinoma of the female urethra: a review of results with radiation therapy

Low stage female urethral carcinoma is curable by radiation therapy alone and is amenable to brachytherapy techniques whereby high doses of irradiation can be delivered safely. A 60 to 80 per cent 5-year survival rate with preservation of bladder function and control can be expected with good radiotherapeutic techniques. Except for stage Tis or early stage T1 lesions of the anterior urethra that can be treated with limited surgical excision, irradiation should be considered as an alternative to more extensive surgery for low stage bulky lesions. While there has been some success with radiation therapy alone for advanced disease, the cure rate probably can be improved with a combined approach using surgery, radiation therapy and possibly chemotherapy.

90Y radioembolization for neuroendocrine cancers liver metastases provides sustained therapeutic effect with minimal toxicity.

343 Background: Radioembolization (RE) is the delivery of radioactive microspheres (90Y) via the hepatic artery, which permanently implant preferentially in metastatic lesions, sparing adjacent normal liver. Metastatic neuroendocrine tumors in the liver are a common clinical problem which can be treated with RE. It is an outpatient procedure performed with increasing frequency worldwide for a variety of solid tumor types. METHODS A single institution retrospective review of all neuroendocrine patients treated with radioactive resin microspheres to control hepatic metastases. Details reviewed included: specifics of treatment and delivery, RECIST response at 3 and 6 months, acute and delayed radiation toxicities by CTC3ae, and analyses of tumor and radiation factors related to response and liver control. RESULTS A total of 56 patients; 26 male, 30 female, received a total of 85 separate treatments with resin 90Y microspheres. Treatment volume was all hepatic tumors with each treatment, usually selective whole liver in one fraction. Whole liver in 1 treatment comprised 86%, right lobe only in 10% and left lobe in 4%. Thirty-six patients (64.3%) received 1 treatment, 12 patients 2 fractions, 7 patients 3 fractions, and 1 patient 4 fractions. The median activity of 90Y delivered was 1.49 GBq (0.35 - 2.9 GBq). BSA approach was used for pretreatment activity calculations for all patients, with median of 100% planned activity delivered (26% - 147%). No grade 4 toxicities occurred, and only two grade 3 events were found (gastric ulcers). The median follow up is 24.2 mo. (1 - 93.4 mo.). RECIST at 3 and 6 months: CR 6.5%, SD 49.1%, PR 42.6% and PD 1.6%. Delivered activity (GBq) was associated with PR at 3 months (p=0.07, two-tailed t-test). CONCLUSIONS Our experience is consistent with other published reports confirming the efficacy and low toxicity of this liver-directed ablative approach for unresectable neuroendocrine carcinomas. Multiple treatments to the whole liver were well tolerated. The BSA method of pretreatment radioactivity estimation is useful and safe in this tumor type.

Liver Tolerance to Repeat 90Y-Microsphere Radioembolization

Purpose: Liver tolerance to multiple doses of Y90-microspheres is not known. Many patients (pts) are surviving long enough to be considered for a second and third liver treatments with internal radiation. Materials and Methods: The experience of a single center treating liver tumors with resin Y90-microspheres. Pts that received liver radiation prior to or after resin microsphere therapy were studied. Endpoints were toxicity, tumor response, shunting to lung, and effects on liver volume and function. The delivery activity of microspheres selected was not reduced below BSA dose calculation for patients without prior treatment. All patients received bilobar single session delivery. Results: A total of 38 pts; 14 women, 24 men, treated 6∕2003 to 9∕2006, with 33 pts receiving 2 courses and 5 pts with 3 courses of liver radiation. Retreatment with resin microspheres 26 pts, prior external beam radiation in 7 pts, prior glass microspheres in 2 pts, prior systemic radiotherapy in 2 pts, and prior stereotactic liver radiation in 1 pt. Liver function was stable and adequate in all patients after additional liver radiation, and no pts developed radiation-induced liver dysfunction (RILD) or veno-occlusive disease (VOD). The percentage of shunting to the lung decreased with retreatment. Conclusions: Repeated implantation in the liver with Y90-microspheres is safe in patients that have sufficient liver function and reserve based on known and accepted laboratory parameters already used for selection of microsphere therapy. No acute life-threatening, fatal, or late liver damage was observed, RILD or VOD. No specific dose reduction is recommended for retreatment of the liver.