Pancreatic cancer risk after treatment of Hodgkin lymphoma

BACKGROUND

Although elevated risks of pancreatic cancer have been observed in long-term survivors of Hodgkin lymphoma (HL), no prior study has assessed the risk of second pancreatic cancer in relation to radiation dose and specific chemotherapeutic agents.

PATIENTS AND METHODS

We conducted an international case-control study within a cohort of 19 882 HL survivors diagnosed from 1953 to 2003 including 36 cases and 70 matched controls.

RESULTS

Median ages at HL and pancreatic cancer diagnoses were 47 and 60.5 years, respectively; median time to pancreatic cancer was 19 years. Pancreatic cancer risk increased with increasing radiation dose to the pancreatic tumor location (Ptrend = 0.005) and increasing number of alkylating agent (AA)-containing cycles of chemotherapy (Ptrend = 0.008). The odds ratio (OR) for patients treated with both subdiaphragmatic radiation (≥10 Gy) and ≥6 AA-containing chemotherapy cycles (13 cases, 6 controls) compared with patients with neither treatment was 17.9 (95% confidence interval 3.5-158). The joint effect of these two treatments was significantly greater than additive (P = 0.041) and nonsignificantly greater than multiplicative (P = 0.29). Especially high risks were observed among patients receiving ≥8400 mg/m(2) of procarbazine with nitrogen mustard or ≥3900 mg/m(2) of cyclophosphamide.

CONCLUSION

Our study demonstrates for the first time that both radiotherapy and chemotherapy substantially increase pancreatic cancer risks among HL survivors treated in the past. These findings extend the range of nonhematologic cancers associated with chemotherapy and add to the evidence that the combination of radiotherapy and chemotherapy can lead to especially large risks.

ICRP publication 118: ICRP statement on tissue reactions and early and late effects of radiation in normal tissues and organs--threshold doses for tissue reactions in a radiation protection context

This report provides a review of early and late effects of radiation in normal tissues and organs with respect to radiation protection. It was instigated following a recommendation in Publication 103 (ICRP, 2007), and it provides updated estimates of 'practical' threshold doses for tissue injury defined at the level of 1% incidence. Estimates are given for morbidity and mortality endpoints in all organ systems following acute, fractionated, or chronic exposure. The organ systems comprise the haematopoietic, immune, reproductive, circulatory, respiratory, musculoskeletal, endocrine, and nervous systems; the digestive and urinary tracts; the skin; and the eye. Particular attention is paid to circulatory disease and cataracts because of recent evidence of higher incidences of injury than expected after lower doses; hence, threshold doses appear to be lower than previously considered. This is largely because of the increasing incidences with increasing times after exposure. In the context of protection, it is the threshold doses for very long follow-up times that are the most relevant for workers and the public; for example, the atomic bomb survivors with 40-50years of follow-up. Radiotherapy data generally apply for shorter follow-up times because of competing causes of death in cancer patients, and hence the risks of radiation-induced circulatory disease at those earlier times are lower. A variety of biological response modifiers have been used to help reduce late reactions in many tissues. These include antioxidants, radical scavengers, inhibitors of apoptosis, anti-inflammatory drugs, angiotensin-converting enzyme inhibitors, growth factors, and cytokines. In many cases, these give dose modification factors of 1.1-1.2, and in a few cases 1.5-2, indicating the potential for increasing threshold doses in known exposure cases. In contrast, there are agents that enhance radiation responses, notably other cytotoxic agents such as antimetabolites, alkylating agents, anti-angiogenic drugs, and antibiotics, as well as genetic and comorbidity factors. Most tissues show a sparing effect of dose fractionation, so that total doses for a given endpoint are higher if the dose is fractionated rather than when given as a single dose. However, for reactions manifesting very late after low total doses, particularly for cataracts and circulatory disease, it appears that the rate of dose delivery does not modify the low incidence. This implies that the injury in these cases and at these low dose levels is caused by single-hit irreparable-type events. For these two tissues, a threshold dose of 0.5Gy is proposed herein for practical purposes, irrespective of the rate of dose delivery, and future studies may elucidate this judgement further.

Evaluation of a probabilistic model for staging of oesophageal carcinoma

With the help of two experts in gastrointestinal oncology from the Netherlands Cancer Institute, Antoni van Leeuwenhoekhuis, a decision-support system is being developed for patient-specific therapy selection for oesophageal carcinoma. The kernel of the system is a probabilistic model describing the characteristics of oesophageal carcinoma and the pathophysiological processes of invasion and metastasis. Using data from 185 patients, an evaluation study of the model was conducted. We found that for 86% of the patients, the model established the stage of the patient's carcinoma correctly.

Treatment of malignancy arising in pilonidal disease

BACKGROUND

Malignant degeneration is a rare complication of pilonidal disease and is associated with a high recurrence rate and poor prognosis compared with regular nonmelanoma skin cancer. Treatment in our departments and in the international literature was evaluated.

METHODS

We analyzed the data from three patients with malignant degeneration who were treated in our departments and an additional 56 patients who were found after an extensive literature search.

RESULTS

A total of 47 males and 12 females, with a mean age of 52 years, were most frequently primarily treated with surgery. After a mean follow-up time of 28 months, 20% of all patients died with evidence of disease and an additional 10% died of unrelated causes. The overall recurrence rate was 39%, with a median time to recurrence of only 9 months. The local recurrence rate was lower when radiotherapy was added to surgical treatment alone (30% vs. 44%). Re-excision of local recurrence resulted in some long-term survivals.

CONCLUSIONS

Early diagnosis and treatment may lead to improvement of the relative poor prognosis. Surgical treatment should be tailored according to the locoregional extent. The high recurrence rate after surgical treatment can be reduced by the addition of radiotherapy. Although repeat surgery for recurrent disease may involve extensive resection and morbidity, this may result in prolonged survival.

[Second primary tumors in patients treated at an early age for Hodgkin's disease; consequences for the follow-up]

As curative treatment is now available for a substantial group of cancer patients, it is increasingly important to evaluate how late complications of treatment affect their long-term survival. Two recent publications summarize the second malignancies in survivors of Hodgkin's disease treated during adolescence or young adulthood. After more than 20 years' follow-up, the risk of solid tumours is still much greater in survivors of Hodgkin's disease than in the population at large. Age at treatment has a major effect on the occurrence of second malignancy. Reassuringly, the increased risk of solid tumours in patients who were less than 20 years of age seems to decrease as these patients grow older. The data of these studies suggest that chemotherapy may increase the risk of solid tumours from radiotherapy. Special alertness to symptoms of second malignancies is advised during follow-up after treatment for Hodgkin's disease, especially in patients treated below the age of 20.

Long-term risk of second malignancy in survivors of Hodgkin's disease treated during adolescence or young adulthood

PURPOSE

To quantify the long-term risk of second primary cancers (SCs) in patients diagnosed with Hodgkin's disease (HD) during adolescence or young adulthood.

PATIENTS AND METHODS

The risk of SCs was assessed in 1,253 patients diagnosed with HD before the age of 40 years and treated in two Dutch cancer centers between 1966 and 1986. The median follow-up duration was 14.1 years.

RESULTS

In all, 137 patients developed SCs, compared with 19.4 cases expected on the basis of incidence rates in the general population (relative risk [RR] = 7.0; 95% confidence interval, 5.9 to 8.3). The 25-year actuarial risk of SC overall was 27.7%. The RR of solid tumors increased greatly with younger age at the first treatment of HD, not only for breast cancer but also for all other solid tumors, with RRs of 4.9, 6.9, and 12.7 for patients first treated at ages 31 to 39 years, 21 to 30 years, and </= 20 years, respectively. Among patients first treated at the age of 20 years or younger, the RR of developing a solid tumor before the age of 40 years was significantly greater than the RR of solid tumor development at ages 40 to 49 years (RR = 27.9 v RR = 4.2; P =.0001). Patients who received salvage chemotherapy had significantly greater risk of solid cancers other than breast cancer than did patients whose treatment was restricted to initial radiotherapy or initial combined-modality treatment (RR = 9.4 and 4.7, respectively; P =. 004).

CONCLUSION

After more than 20 years of follow-up, the risk of solid tumors is still much greater in survivors of HD than in the population at large. Reassuringly, the greatly increased risk of solid tumors in patients who were young (</= 20 years of age) at the first treatment seems to decrease as these patients grow older. Our data suggest that chemotherapy may increase the risk of solid tumors from radiotherapy.

Controversies and consensus in the diagnosis, work-up and treatment of gastric lymphoma: an international survey

BACKGROUND

Variations in diagnostic criteria and staging procedures in cancer patients have important consequences for patient selection and often preclude meaningful comparison of published series. In gastric lymphoma, these effects will play a role, since diagnostic criteria are controversial. Moreover, staging procedures and therapeutic choices are influenced by insights from different clinical specialisms.

METHODS

To review the management of gastric lymphoma, formatted questionnaires were mailed to leading institutes with a special interest in this field in Europe, the United States and Japan.

RESULTS

Nineteen centers agreed to contribute. Minimum histological criteria varied among pathologists with a notable influence of the classification system used in the different countries. Detailed evaluation of the lymphoma distribution in the gastric wall and routine staging of the GI-tract differed between groups leaded by medical oncologists and gastroenterologists. This results in basically different patient selections and bias in treatment outcome. Similar effects were recorded for the role of gastric resection and radiotherapy.

CONCLUSIONS

This study gives insight in the basis of the decisions that result in different approaches in the management of gastric MALT-NHL and in the effects for patient selection and treatment results and may help in the design of future clinical trials.

High dose rate brachytherapy before external beam irradiation in inoperable oesophageal cancer

To induce fast relief of dysphagia in patients with oesophageal cancer high dose rate (HDR) brachytherapy was applied before external radiotherapy in a prospective study. Seventy-four patients with inoperable oesophageal cancer (36 squamous cell, 38 adenocarcinoma) were treated with a combination of 10 Gy HDR brachytherapy, followed by 40 Gy in 4 weeks external beam radiotherapy (EBRT), starting 2 weeks later. Tumour response, as measured by endoscopy and/or barium swallow, revealed complete remission in 21 and partial response in 38 patients (overall response rate 80%). Improvement of dysphagia was induced by brachytherapy within a few days in 39%, and achieved at the end of treatment in 70% of patients. Further weight loss was prevented in 39 of the 59 patients who presented with weight loss. Pain at presentation improved in 12 out of 25 patients. Median survival was 9 months. No differences in either response rate or survival were found in squamous cell or adenocarcinoma. Side-effects were either acute with minimal discomfort in 32 (42%) or late with painful ulceration in five patients (7%), occurring after a median of 4 months. A fistula developed in six patients, all with concurrent tumour. In conclusion, brachytherapy before EBRT was a safe and effective procedure to induce rapid relief of dysphagia, especially when combined with EBRT.

Modulation of toxicity following external beam irradiation preceded by high-dose rate brachytherapy in inoperable oesophageal cancer

To induce fast relief of dysphagia in inoperable oesophageal cancer, we applied high-dose rate (HDR) intraluminal irradiation followed by external irradiation (EBRT) in a phase II study. 15 patients (group A: n = 15; 10 men, 5 women; median age 66 years) were treated with 10 Gy HDR brachytherapy plus 40 Gy EBRT (15 fractions of 2.67 Gy). Severe side-effects were encountered in 60% of patients: 3 late ulceration, 2 pending fistula, 2 fistula and 2 patients with fatal haemorrhage after an interval of 6 months. Overall response was excellent: 9 complete remissions (60%) and 6 partial responses (40%). Because of the high toxicity rate, in a subsequent study (group B: n = 30; 23 men, 7 women; median age 66 years) the EBRT scheme was changed using smaller fractions (2.0 Gy) to reach the same total dose of 40 Gy. The complication rate (17%) was significantly reduced, while the overall response remained excellent (83%): 17 complete and 8 partial responses. The impressive change in complication rate of HDR brachytherapy and EBRT stresses the impact of the fraction per dose and illustrates the small therapeutic margins.

The current role of radiotherapy in colorectal cancer

During the last two decades, radiotherapy has become an integral part of the multidisciplinary approach in the treatment of patients with colorectal cancer. Currently, radiotherapy is seen mainly as an adjuvant therapy, sometimes in combination with chemotherapy, in a pre- or postoperative setting. Adjuvant radiotherapy alone leads to a significant reduction of local recurrence rates, but an impact on survival is seen only in subset analyses. Combined modality treatment can reduce local recurrence rates even further, and can also reduce the rate of distant relapses and increase survival. The acute toxicity of combined modality is considerably higher. Local radiation can also be use as a component of organ conserving local treatment for selected early lesions. Radiotherapy has been an important palliative treatment modality, diminishing symptoms in cases of inoperable primary rectal cancers or pelvic recurrences. The timing of radiation, surgery and chemotherapy has been under evaluation for years. For patients with locally advanced primary or recurrent malignancies (unresectable due to fixation), the preferred sequence is pre-operative irradiation with or without chemotherapy, followed by surgical resection. For mobile resectable lesions, sequencing issues are being tested in phase III randomised trials.

The volume effect in radiation-related late small bowel complications: results of a clinical study of the EORTC Radiotherapy Cooperative Group in patients treated for rectal carcinoma

PURPOSE

The purpose of this study was to quantify the correlation between irradiated small bowel volume and late occurring small bowel complications.

METHODS

Small bowel volumes in the high-dose region were measured using orthogonal barium films for 203 patients treated for rectal carcinoma with pelvic postoperative radiotherapy to 50 Gy in an EORTC multicentric study.

RESULTS

The 5-year estimate of late pelvic small bowel obstruction requiring surgery was 11%. No correlation between the irradiated small bowel volume and obstruction was detected. The actuarial 5-year estimate of chronic diarrhea varied from 31% in patients with irradiated small bowel volumes below 77 cm3 to 42% in patients with volumes over 328 cm3. This correlation was significant in the univariate and multivariate analysis (p = 0.025). The type of rectal surgery significantly influenced the incidence of chronic diarrhea and malabsorption, the actuarial 5-year estimate being 49% and 26% after low anterior resection and abdominoperineal resection, respectively (p = 0.04).

CONCLUSIONS

This study demonstrated that there is a volume-effect in radiation-induced diarrhea at a dose of 50 Gy in 25 fractions. No volume-effect for small bowel obstruction was detected at this dose-level in pelvic postoperative radiotherapy. A review of the literature data on small bowel obstruction indicates that the volume effect at this dose level can only be demonstrated in patients who were treated with extended field radiotherapy (estimated small bowel volume 800 cm3) after intra-abdominal surgery.

Surgical intervention for complications caused by late radiation damage of the small bowel: a retrospective analysis

We studied the records of 46 patients who had been operated on between 1974 and 1990 in The Netherlands Cancer Institute because of complications due to late radiation damage of the small bowel. Data were collected on preoperative history, surgical intervention, postoperative complications and survival. By means of Cox's proportional hazards regression analysis we sought to identify factors that contribute to complication-risk and survival. The following factors led to an increase in complication-risk: hypoalbuminemia, more than one laparotomy prior to irradiation and a short interval (< 12 months) between irradiation and surgical intervention. The following factors related to a poorer survival: incomplete resection of the primary tumor and a short interval (< 12 months) between irradiation and surgical intervention. The type of surgical intervention did not have cumulative prognostic value in relation to complication-risk or survival. As patients undergoing resections differed considerably from patients undergoing bypass-procedures, no conclusions could be drawn about the superiority of one technique over the other. We think that both types of intervention have their own field of indication.

The management of radiation-associated oesophageal carcinoma: a report of 16 cases

16 patients, presenting with squamous cell carcinoma in previously irradiated sections of the oesophagus, are described. Oesophagectomy could be performed in 2 patients, resulting in long-term disease-free survival (38 and 60 months after diagnosis). 14 patients were treated with palliative radiotherapy (external beam or intraluminal), oesophageal stenting, bougienage or chemotherapy. Although most patients previously received curative dosages of mediastinal irradiation, additional full courses of high-dose radiotherapy could be given on five occasions; no major complications were encountered and adequate palliation for up to 10 months was achieved. Similar results were observed after oesophageal stenting and/or bougienage. Relief of dysphagia following intraluminal radiotherapy or chemotherapy was only minimal (2 months or less). Median survival in the palliative treatment group was 6.5 months (range 2-27 months), which is in keeping with results observed in non-radiation-associated oesophageal carcinoma. We concluded that, in selected cases, both surgery and radiotherapy offer good prospects for patients with radiation-associated oesophageal cancer.

Postoperative radiotherapy for rectal and rectosigmoid cancer: the impact of total dose on local control

Between 1984 and 1988, 206 patients were treated with pelvic radiotherapy after macroscopically complete surgery for rectal or (recto)sigmoid cancer. Depending on an estimation of the amount of small bowel in the intended treatment volume a total dose was, in general, 45 or 50 Gy. An additional boost of 10 Gy was given to 6 patients because of microscopically involved surgical margins. For tumor stage B a statistically significant trend (p = 0.017) for higher local control with higher total dose was observed comparing patients treated with a total dose of 45 Gy or less, with more than 45 Gy but less than 50 Gy or with a total dose of 50 Gy or more. This finding illustrates the impact of total dose on local control for postoperative radiotherapy for rectal carcinoma.

The antibacterial activity of benzylpenicillin against Staphylococcus aureus ingested by granulocytes

Granulocytes that had ingested pre-opsonized Staphylococcus aureus for 3 min at 37 degrees C and then had been washed twice, were incubated in the presence of benzylpenicillin. The antibiotic showed a concentration-dependent effect on cell-associated S. aureus between 0.005 and 0.1 mg/l benzylpenicillin. The antibacterial effect on cell-associated S. aureus was equal to that on opsonized S. aureus in suspension. Microscopic studies with lysostaphin showed that the number of extracellular bacteria was negligible and that the decrease in the number of cell-associated bacteria reflected the true rate of intracellular killing of S. aureus. Contrary to the generally accepted opinion that benzylpenicillin does not act intracellularly in granulocytes, we were able to show intracellular antibacterial activity of benzylpenicillin against S. aureus under the experimental conditions we used.