Ototoxicity evaluation in medulloblastoma patients treated with involved field boost using intensity-modulated radiation therapy (IMRT): a retrospective review

Abstract\ud \ud Background\ud Ototoxicity is a known side effect of combined radiation therapy and cisplatin chemotherapy for the treatment of medulloblastoma. The delivery of an involved field boost by intensity modulated radiation therapy (IMRT) may reduce the dose to the inner ear when compared with conventional radiotherapy. The dose of cisplatin may also affect the risk of ototoxicity. A retrospective study was performed to evaluate the impact of involved field boost using IMRT and cisplatin dose on the rate of ototoxicity.\ud \ud \ud Methods\ud Data from 41 medulloblastoma patients treated with IMRT were collected. Overall and disease-free survival rates were calculated by Kaplan-Meier method Hearing function was graded according to toxicity criteria of Pediatric Oncology Group (POG). Doses to inner ear and total cisplatin dose were correlated with hearing function by univariate and multivariate data analysis.\ud \ud \ud Results\ud After a mean follow-up of 44 months (range: 14 to 72 months), 37 patients remained alive, with two recurrences, both in spine with CSF involvement, resulting in a disease free-survival and overall survival of 85.2% and 90.2%, respectively.\ud Seven patients (17%) experienced POG Grade 3 or 4 toxicity. Cisplatin dose was a significant factor for hearing loss in univariate analysis (p < 0.03). In multivariate analysis, median dose to inner ear was significantly associated with hearing loss (p < 0.01). POG grade 3 and 4 toxicity were uncommon with median doses to the inner ear bellow 42 Gy (p < 0.05) and total cisplatin dose of less than 375 mg/m2 (p < 0.01).\ud \ud \ud Conclusions\ud IMRT leads to a low rate of severe ototoxicity. Median radiation dose to auditory apparatus should be kept below 42 Gy. Cisplatin doses should not exceed 375 mg/m2.This study was supported by Instituto Israelita de Responsabilidade Social\ud (IIRS) of Hospital Israelita Albert Einstein (HIAE)

Peculiaridades da radioterapia em idosos Peculiarities of radiotherapy in the elderly

É sabido que o envelhecimento da população do mundo durante o século XX e no início deste novo século constitui um desafio de primeira ordem para as nações, especialmente no campo socioeconômico. Um aspecto importante do envelhecimento populacional global é que, para grupos de idade mais avançada, a prevalência das doenças degenerativas também é maior, incluindo as doenças malignas. No universo de pacientes portadores de câncer, por outro lado, metade destes receberá radioterapia em algum momento de sua doença e suas características individuais podem influenciar, de alguma forma, o prognóstico, a indicação e as doses diárias de prescrição dos tratamentos. Neste contexto, a assistência à saúde do idoso portador de câncer deve ser vista como um importante desafio, principalmente devido a dois fatores: uma maior procura de tratamentos, em termos quantitativos, e características fisiológicas peculiares a esta população, que podem influenciar na tomada de decisões terapêuticas. Esta revisão propõe uma discussão sobre alguns aspectos relevantes tanto da fisiologia dos idosos, que pode influenciar o curso do tratamento irradiante, quanto de alguns avanços técnicos da radioterapia, que podem, por sua vez, beneficiar estes pacientes, oferecendo menor toxicidade e maior eficiência e rapidez, por exemplo.<br>It is known that the aging of the world population during the twentieth century and the beginning of this new century is a first-order challenge for nations, especially in the socio-economic field. An important aspect of the aging of global population is that, for older age groups, the prevalence of degenerative diseases is also higher, including malignancies. On the other hand, among the population of patients with cancer, half of these patients will receive radiation therapy at some point in their illness and their individual characteristics can somehow influence the prognosis, the indication and daily doses of treatment prescriptions. In this context, the health assistance for the elderly patient with cancer should be seen as an important challenge, mainly due to two factors: an increased demand for treatments, in quantitative terms, and physiological characteristics unique to this population, which can influence the therapeutic decision-making. This review proposes a discussion of some relevant aspects of both the physiology of the elderly, which may influence the course of radiation therapy, as well as of some technical advances in radiotherapy, which can in turn benefit these patients by offering, for example, lower toxicity, greater effectiveness and speed

Unintended irradiation of internal mammary chain – Is that enough?

AimTo evaluate the unintentional coverage of the internal mammary chain (IMC) with tangential fields irradiation to the breast, and its relation with the type of surgery employed.BackgroundThe dose distribution in regions adjacent to the treatment targets (mammary gland or chest wall), with incidental irradiation of the IMC, could translate into clinical benefit, due to the proximity of these regions.Materials and methodsOne hundred and twelve consecutive conformal radiotherapy plans were correlating the average dose to the IMC with the type of surgery employed, the extent of disease and the irradiation techniques.ResultsThe mean doses to IMC after modified radical mastectomy (MRM), modified radical mastectomy with immediate reconstruction (MRM[[ce:hsp sp="0.25"/]]+[[ce:hsp sp="0.25"/]]R), and breast conservative surgery (BCS) were 30.34[[ce:hsp sp="0.25"/]]Gy, 30.26[[ce:hsp sp="0.25"/]]Gy, and 18.67[[ce:hsp sp="0.25"/]]Gy, respectively. Significant differences were identified between patients who underwent MRM or MRM[[ce:hsp sp="0.25"/]]+[[ce:hsp sp="0.25"/]]R over BCS (p[[ce:hsp sp="0.25"/]]=[[ce:hsp sp="0.25"/]]0.01 and 0.003, respectively), but not between MRM and MRM[[ce:hsp sp="0.25"/]]+[[ce:hsp sp="0.25"/]]R (p[[ce:hsp sp="0.25"/]]=[[ce:hsp sp="0.25"/]]0.88). Mean doses to IMC were greater in patients with T3–T4 tumors when compared with more initial stages (≤T2) (p[[ce:hsp sp="0.25"/]]=[[ce:hsp sp="0.25"/]]0.0096). The lymph node involvement also correlated with higher average doses to IMC (node positive: 26.1[[ce:hsp sp="0.25"/]]Gy[[ce:hsp sp="0.25"/]]×[[ce:hsp sp="0.25"/]]node negative: 17.8[[ce:hsp sp="0.25"/]]Gy, p[[ce:hsp sp="0.25"/]]=[[ce:hsp sp="0.25"/]]0.0017).ConclusionsThe moderate dose level to the IMC in the unintentional irradiation scenario seems to be insufficient to treat the subclinical disease, although it could have an impact in patients undergoing mastectomy

Fatores prognósticos e tratamento de pacientes com metástases cerebrais

O desenvolvimento de metástases cerebrais é um evento muito freqüente no paciente com câncer, sendo a neoplasia maligna mais prevalente do sistema nervoso central (SNC). O tratamento médico destes pacientes inclui: 1) Medidas inespecíficas, tais como cuidados clínicos gerais (por exemplo, o uso de corticosteróide e drogas anticonvulsivantes, entre outros); 2) Medidas específicas gerais (que tratam todos os possíveis focos de doença no SNC, como radioterapia cerebral total e quimioterapia); e 3) Medidas específicas focais (que tratam somente os focos macroscópicos da doença cerebral, como radiocirurgia estereotáxica e neurocirurgia). Embora o aparecimento de metástases cerebrais represente uma situação clínicadramaticamente negativa, a crença que associa o diagnóstico desta entidade com uma sentença de morte iminente deve ser revista, pois dependendo dos fatores prognósticos associados, certamente a sobrevida dos pacientes pode variar desde semanas até anos. Esta revisão tem foco de discussão na influência que a correta valorização de possíveis fatores prognósticos pode exercer na escolha adequada da terapia para pacientes com metástases cerebrais, no sentido de maximizar benefícios, em termos de qualidade e tempo de sobrevida. A observação dos fatores prognósticos na avaliação do tratamento de metástases cerebrais, certamente uma forma de estadiamento desta entidade, pode ser um importante aliado do paciente na busca de algo além da mera paliação de sua doença.</jats:p

Bladder (ICRU) dose point does not predict urinary acute toxicity in adjuvant isolated vaginal vault high-dose-rate brachytherapy for intermediate-risk endometrial cancer

PURPOSE: High-dose-rate brachytherapy (HDR-BT) alone is an adjuvant treatment option for stage I intermediaterisk endometrial cancer after complete surgical resection. The aim of this study was to determine the value of the dose reported to ICRU bladder point in predicting acute urinary toxicity. Oncologic results are also presented. MATERIAL AND METHODS: One hundred twenty-six patients were treated with postoperative HDR-BT 24 Gy (4 × 6 Gy) per ICRU guidelines for dose reporting. Cox analysis was used to identify variables that affected local control. The mean bladder point dose was examined for its ability to predict acute urinary toxicity. RESULTS: Two patients (1.6%) developed grade 1 gastrointestinal toxicity and 12 patients (9.5%) developed grades 1-2 urinary toxicity. No grade 3 or greater toxicity was observed. The mean bladder point dose was 46.9% (11.256 Gy) and 49.8% (11.952 Gy) for the asymptomatic and symptomatic groups, respectively (p = 0.69). After a median follow-up of 36.8 months, the 3-year local failure and 5-year cancer-specific and overall survival rates were 2.1%, 100%, and 94.6%, respectively. No pelvic failure was seen in this cohort. Age over 60 years (p = 0.48), lymphatic invasion (p = 0.77), FIGO histological grade (p = 0.76), isthmus invasion (p = 0.68), and applicator type (cylinder × ovoid) (p = 0.82) did not significantly affect local control. CONCLUSIONS: In this retrospective study, ICRU bladder point did not correlate with urinary toxicity. Four fractions of 6 Gy HDR-BT effected satisfactory local control, with acceptable urinary and gastrointestinal toxicity

Validating the SIR: a better prognostic score index for patients with brain metastases treated with stereotactic radiosurgery

Objective: The aim of this paper is to validate the score index forsurvival in patients treated with stereotactic radiosurgery, using aclassification prepared to better evaluate the prognosis of patientswith brain metastasis submitted to stereotactic surgery, re-evaluatingsurvival of patients and reviewing the medical literature. Methods:Data from 100 patients with brain metastases treated with stereotacticradiosurgery at a single institution, between July 1993 and February2000, were retrospectively analyzed. The prognostic factors andscores studied were age, Karnofsky performance status, extracranialdisease status, number of brain lesions, volume of the largest lesion,primary tumor type, treated or not with whole brain radiation therapy,SIR, and RPA. Kaplan-Meier actuarial survival curves for subsets werecalculated and compared by log-rank test. Complete and backwardelimination Cox models were utilized to identify the prognostic factorsand scores independently associated with survival. Results: Karnofskyperformance status, extracranial disease status, volume of the largestbrain lesion, RPA, and SIR were significantly correlated with prognosisin Kaplan-Meier survival analysis. Applying Cox models, significancewas observed for KPS and volume of the largest lesion (p < 0.0001and p = 0.0182, respectively), as well as for SIR and RPA when testedindividually (p < 0.0001 and p = 0.0002, respectively). However, whentesting SIR and RPA together, only SIR reached independent statisticalsignificance (p < 0.0001). Conclusion: SIR classification demonstrateda better accuracy in predicting survival time than RPA. SIR was testedin other centers, showing superior accuracy and applicability than theRPA, thus validating this score