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van Iersel L, Li Z, Srivastava DK, Brinkman TM, Bjornard KL, Wilson CL, Green DM, Merchant TE, Pui CH, Howell RM, Smith SA, Armstrong GT, Hudson MM, Robison LL, Ness KK, Gajjar A, Krull KR, Sklar CA, van Santen HM, Chemaitilly W. Hypothalamic-Pituitary Disorders in Childhood Cancer Survivors: Prevalence, Risk Factors and Long-Term Health Outcomes. J Clin Endocrinol Metab 2019; 104:6101-6115. [PMID: 31373627 PMCID: PMC7296130 DOI: 10.1210/jc.2019-00834] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Accepted: 07/29/2019] [Indexed: 12/17/2022]
Abstract
CONTEXT Data on hypothalamic-pituitary (HP) disorders in systematically evaluated childhood cancer survivors are limited. OBJECTIVE To describe prevalence, risk factors, and associated adverse health outcomes of deficiencies in GH deficiency (GHD), TSH deficiency (TSHD), LH/FSH deficiency (LH/FSHD), and ACTH deficiency (ACTHD), and central precocious puberty (CPP). DESIGN Retrospective with cross-sectional health outcomes analysis. SETTING Established cohort; tertiary care center. PATIENTS Participants (N = 3141; median age, 31.7 years) were followed for a median 24.1 years. MAIN OUTCOME MEASURE Multivariable logistic regression was used to calculate ORs and 95% CIs for associations among HP disorders, tumor- and treatment-related risk factors, and health outcomes. RESULTS The estimated prevalence was 40.2% for GHD, 11.1% for TSHD, 10.6% for LH/FSHD, 3.2% for ACTHD, and 0.9% for CPP among participants treated with HP radiotherapy (n = 1089), and 6.2% for GHD, and <1% for other HP disorders without HP radiotherapy. Clinical factors independently associated with HP disorders included HP radiotherapy (at any dose for GHD, TSHD, LH/FSHD, >30 Gy for ACTHD), alkylating agents (GHD, LH/FSHD), intrathecal chemotherapy (GHD), hydrocephalus with shunt placement (GHD, LH/FSHD), seizures (TSHD, ACTHD), and stroke (GHD, TSHD, LH/FSHD, ACTHD). Adverse health outcomes independently associated with HP disorders included short stature (GHD, TSHD), severe bone mineral density deficit (GHD, LH/FSHD), obesity (LH/FSHD), frailty (GHD), impaired physical health-related quality of life (TSHD), sexual dysfunction (LH/FSHD), impaired memory, and processing speed (GHD, TSHD). CONCLUSION HP radiotherapy, central nervous system injury, and, to a lesser extent, chemotherapy are associated with HP disorders, which are associated with adverse health outcomes.
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Affiliation(s)
- Laura van Iersel
- Division of Endocrinology, St. Jude Children’s Research Hospital, Memphis, Tennessee
- Department of Pediatric Endocrinology, Wilhelmina Children’s Hospital, Utrecht, Netherlands
| | - Zhenghong Li
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Deo Kumar Srivastava
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Tara M Brinkman
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
- Department of Psychology, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Kari L Bjornard
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Carmen L Wilson
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Daniel M Green
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Thomas E Merchant
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Ching-Hon Pui
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Rebecca M Howell
- Department of Radiation Physics, University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Susan A Smith
- Department of Radiation Physics, University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Gregory T Armstrong
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Melissa M Hudson
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Leslie L Robison
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Kirsten K Ness
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Amar Gajjar
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Kevin R Krull
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Charles A Sklar
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hanneke M van Santen
- Department of Pediatric Endocrinology, Wilhelmina Children’s Hospital, Utrecht, Netherlands
| | - Wassim Chemaitilly
- Division of Endocrinology, St. Jude Children’s Research Hospital, Memphis, Tennessee
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
- Correspondence and Reprint Requests: Wassim Chemaitilly, MD, Department of Pediatric Medicine – Division of Endocrinology, St. Jude Children’s Research Hospital, MS 737, 262 Danny Thomas Place, Memphis, Tennessee 38105. E-mail:
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Gjyshi O, Ludmir EB, Pezzi TA, Boyce-Fappiano D, Dursteler AE, Mitin T, Lin SH. Evolving Practice Patterns in the Use of Prophylactic Cranial Irradiation for Extensive-Stage Small Cell Lung Cancer. JAMA Netw Open 2019; 2:e199135. [PMID: 31411707 PMCID: PMC6694387 DOI: 10.1001/jamanetworkopen.2019.9135] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
This survey study compares use of prophylactic cranial irradiation in patients with extensive-stage small cell lung cancer before and after the publication of a phase 3 trial that demonstrated no overall survival benefit for this therapy.
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Affiliation(s)
- Olsi Gjyshi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Ethan B. Ludmir
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Todd A. Pezzi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - David Boyce-Fappiano
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Amy E. Dursteler
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Timur Mitin
- Department of Radiation Medicine, Oregon Health & Science University, Portland
| | - Steven H. Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
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3
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Yuan X, Liu WJ, Li B, Shen ZT, Shen JS, Zhu XX. A Bayesian network meta-analysis of whole brain radiotherapy and stereotactic radiotherapy for brain metastasis. Medicine (Baltimore) 2017; 96:e7698. [PMID: 28834873 PMCID: PMC5571995 DOI: 10.1097/md.0000000000007698] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 06/04/2017] [Accepted: 07/06/2017] [Indexed: 11/26/2022] Open
Abstract
This study was conducted to compare the effects of whole brain radiotherapy (WBRT) and stereotactic radiotherapy (SRS) in treatment of brain metastasis.A systematical retrieval in PubMed and Embase databases was performed for relative literatures on the effects of WBRT and SRS in treatment of brain metastasis. A Bayesian network meta-analysis was performed by using the ADDIS software. The effect sizes included odds ratio (OR) and 95% confidence interval (CI). A random effects model was used for the pooled analysis for all the outcome measures, including 1-year distant control rate, 1-year local control rate, 1-year survival rate, and complication. The consistency was tested by using node-splitting analysis and inconsistency standard deviation. The convergence was estimated according to the Brooks-Gelman-Rubin method.A total of 12 literatures were included in this meta-analysis. WBRT + SRS showed higher 1-year distant control rate than SRS. WBRT + SRS was better for the 1-year local control rate than WBRT. SRS and WBRT + SRS had higher 1-year survival rate than the WBRT. In addition, there was no difference in complication among the three therapies.Comprehensively, WBRT + SRS might be the choice of treatment for brain metastasis.
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Affiliation(s)
- Xi Yuan
- Department of Radiation Oncology, Nanjing General Hospital of Nanjing Military Command, Medical School of Nanjing University
| | - Wen-Jie Liu
- Blood Purification Center, Zhongda Hospital, Southeast University, Nanjing, Jiangsu, China
| | - Bing Li
- Department of Radiation Oncology, Nanjing General Hospital of Nanjing Military Command, Medical School of Nanjing University
| | - Ze-Tian Shen
- Department of Radiation Oncology, Nanjing General Hospital of Nanjing Military Command, Medical School of Nanjing University
| | - Jun-shu Shen
- Department of Radiation Oncology, Nanjing General Hospital of Nanjing Military Command, Medical School of Nanjing University
| | - Xi-Xu Zhu
- Department of Radiation Oncology, Nanjing General Hospital of Nanjing Military Command, Medical School of Nanjing University
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4
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Verma V, Simone CB, Allen PK, Gajjar SR, Shah C, Zhen W, Harkenrider MM, Hallemeier CL, Jabbour SK, Matthiesen CL, Braunstein SE, Lee P, Dilling TJ, Allen BG, Nichols EM, Attia A, Zeng J, Biswas T, Paximadis P, Wang F, Walker JM, Stahl JM, Daly ME, Decker RH, Hales RK, Willers H, Videtic GMM, Mehta MP, Lin SH. Multi-Institutional Experience of Stereotactic Ablative Radiation Therapy for Stage I Small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2017; 97:362-371. [PMID: 28011047 PMCID: PMC10905608 DOI: 10.1016/j.ijrobp.2016.10.041] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Revised: 10/19/2016] [Accepted: 10/26/2016] [Indexed: 02/06/2023]
Abstract
PURPOSE For inoperable stage I (T1-T2N0) small cell lung cancer (SCLC), national guidelines recommend chemotherapy with or without conventionally fractionated radiation therapy. The present multi-institutional cohort study investigated the role of stereotactic ablative radiation therapy (SABR) for this population. METHODS AND MATERIALS The clinical and treatment characteristics, toxicities, outcomes, and patterns of failure were assessed in patients with histologically confirmed stage T1-T2N0M0 SCLC. Kaplan-Meier analysis was used to evaluate the survival outcomes. Univariate and multivariate analyses identified predictors of outcomes. RESULTS From 24 institutions, 76 lesions were treated in 74 patients (median follow-up 18 months). The median age and tumor size was 72 years and 2.5 cm, respectively. Chemotherapy and prophylactic cranial irradiation were delivered in 56% and 23% of cases, respectively. The median SABR dose and fractionation was 50 Gy and 5 fractions. The 1- and 3-year local control rate was 97.4% and 96.1%, respectively. The median disease-free survival (DFS) duration was 49.7 months. The DFS rate was 58.3% and 53.2% at 1 and 3 years, respectively. The median, 1-year, and 3-year disease-specific survival was 52.3 months, 84.5%, and 64.4%, respectively. The median, 1-year, and 3-year overall survival (OS) was 17.8 months, 69.9%, and 34.0% respectively. Patients receiving chemotherapy experienced an increased median DFS (61.3 vs 9.0 months; P=.02) and OS (31.4 vs 14.3 months; P=.02). The receipt of chemotherapy independently predicted better outcomes for DFS/OS on multivariate analysis (P=.01). Toxicities were uncommon; 5.2% experienced grade ≥2 pneumonitis. Post-treatment failure was most commonly distant (45.8% of recurrence), followed by nodal (25.0%) and "elsewhere lung" (20.8%). The median time to each was 5 to 7 months. CONCLUSIONS From the findings of the largest report of SABR for stage T1-T2N0 SCLC to date, SABR (≥50 Gy) with chemotherapy should be considered a standard option.
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Affiliation(s)
- Vivek Verma
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Charles B Simone
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Pamela K Allen
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Weining Zhen
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Matthew M Harkenrider
- Department of Radiation Oncology, Loyola University Stritch School of Medicine, Maywood, Illinois
| | | | - Salma K Jabbour
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, New Jersey
| | - Chance L Matthiesen
- Department of Radiation Oncology, Stephenson Cancer Center, University of Oklahoma, Oklahoma City, Oklahoma
| | - Steve E Braunstein
- Department of Radiation Oncology, University of California, San Francisco, School of Medicine, San Francisco, California
| | - Percy Lee
- Department of Radiation Oncology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Thomas J Dilling
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Bryan G Allen
- Department of Radiation Oncology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Elizabeth M Nichols
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland
| | - Albert Attia
- Department of Radiation Oncology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Jing Zeng
- Department of Radiation Oncology, University of Washington Medical Center, Seattle, Washington
| | - Tithi Biswas
- Department of Radiation Oncology, University Hospitals Siedman Cancer Center, Case Western Reserve University, Cleveland, Ohio
| | - Peter Paximadis
- Division of Radiation Oncology, Department of Oncology, Barbara Ann Karmanos Cancer Center, Wayne State University School of Medicine, Detroit, Michigan
| | - Fen Wang
- Department of Radiation Oncology, University of Kansas Medical Center, Kansas City, Kansas
| | - Joshua M Walker
- Department of Radiation Medicine, Oregon Health & Science University, Portland, Oregon
| | - John M Stahl
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut
| | - Megan E Daly
- Department of Radiation Oncology, University of California, Davis, Comprehensive Cancer Center, Sacramento, California
| | - Roy H Decker
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut
| | - Russell K Hales
- Department of Radiation Oncology and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Henning Willers
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Gregory M M Videtic
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Minesh P Mehta
- Miami Cancer Institute, Baptist Health South Florida, Coral Gables, Florida
| | - Steven H Lin
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas.
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Mason M, Giuliani M, Huang SH, Xu W, Hope A, Kim J, Bayley A, John Cho BC, Goldstein D, Jang RW, Ordonez BP, Wajstaub S, Waldron J, Dinniwell R, O'Sullivan B, Ringash J. Extra-pulmonary small cell carcinoma in the head and neck setting: the role of prophylactic cranial irradiation. Oral Oncol 2015; 51:e57-9. [PMID: 25865552 DOI: 10.1016/j.oraloncology.2015.03.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 03/25/2015] [Accepted: 03/26/2015] [Indexed: 11/18/2022]
Abstract
Head-and-neck small cell carcinoma (HN-SmCC) is a rare entity and there is limited data to support management decisions. The role of prophylactic cranial irradiation (PCI) remains controversial. A retrospective review of 21 consecutive HN-SmCCs was performed. No case received PCI. The 2-year overall survival, local, regional and distant control rates were 65%, 94%, 88%, and 76% respectively. Despite no patient receiving PCI, brain metastases were uncommon (n=2) and routine use of PCI is not justified in this population.
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Affiliation(s)
- Matthew Mason
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University Health Network, University of Toronto, Toronto, ON M5T 2M9, Canada
| | - Meredith Giuliani
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University Health Network, University of Toronto, Toronto, ON M5T 2M9, Canada
| | - Shao Hui Huang
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University Health Network, University of Toronto, Toronto, ON M5T 2M9, Canada
| | - Wei Xu
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON M5T 2M9, Canada
| | - Andrew Hope
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University Health Network, University of Toronto, Toronto, ON M5T 2M9, Canada
| | - John Kim
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University Health Network, University of Toronto, Toronto, ON M5T 2M9, Canada
| | - Andrew Bayley
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University Health Network, University of Toronto, Toronto, ON M5T 2M9, Canada
| | - B C John Cho
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University Health Network, University of Toronto, Toronto, ON M5T 2M9, Canada
| | - David Goldstein
- Department of Department of Otolaryngology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada M5T 2M9
| | - Raymond W Jang
- Division of Medical Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON M5T 2M9, Canada
| | - Bayardo Perez Ordonez
- Department of Pathology, University Health Network, University of Toronto, Toronto, ON M5T 2M9, Canada
| | - Sandra Wajstaub
- Department of Radiation Oncology, Cape Breton Cancer Centre, 1482 George Street, Sydney, NS B1P 1P3, Canada
| | - John Waldron
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University Health Network, University of Toronto, Toronto, ON M5T 2M9, Canada
| | - Robert Dinniwell
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University Health Network, University of Toronto, Toronto, ON M5T 2M9, Canada
| | - Brian O'Sullivan
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University Health Network, University of Toronto, Toronto, ON M5T 2M9, Canada
| | - Jolie Ringash
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University Health Network, University of Toronto, Toronto, ON M5T 2M9, Canada
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Patterson BC, Chen Y, Sklar CA, Neglia J, Yasui Y, Mertens A, Armstrong GT, Meadows A, Stovall M, Robison LL, Meacham LR. Growth hormone exposure as a risk factor for the development of subsequent neoplasms of the central nervous system: a report from the childhood cancer survivor study. J Clin Endocrinol Metab 2014; 99:2030-7. [PMID: 24606096 PMCID: PMC4037726 DOI: 10.1210/jc.2013-4159] [Citation(s) in RCA: 109] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
CONTEXT Cranial radiation therapy (CRT) predisposes to GH deficiency and subsequent neoplasms (SNs) of the central nervous system (CNS). Increased rates of SNs have been reported in GH-treated survivors. OBJECTIVE The objective of the study was to evaluate the association between GH treatment and the development of CNS-SNs. DESIGN The study was designed with a retrospective cohort with longitudinal follow-up. SETTING The setting of the study was multiinstitutional. PARTICIPANTS A total of 12 098 5-year pediatric cancer survivors from the Childhood Cancer Survivor Study, diagnosed with cancer prior to age 21 years, of whom 338 self-reported GH treatment, which was verified through medical record review. INTERVENTIONS INTERVENTIONS included subject surveys, medical records abstraction, and pathological review. OUTCOME MEASURES Incidence of meningioma, glioma, and other CNS-SNs was measured. RESULTS Among GH-treated survivors, 16 (4.7%) developed CNS-SN, including 10 with meningioma and six with glioma. Two hundred three survivors without GH treatment (1.7%) developed CNS-SN, including 138 with meningioma, 49 with glioma, and 16 with other CNS-SNs. The adjusted rate ratio in GH-treated compared with untreated survivors for development of any CNS-SN was 1.0 [95% confidence interval (CI) 0.6-1.8, P = .94], for meningiomas, 0.8 (95% CI 0.4-1.7, P = .61), and for gliomas, 1.9 (95% CI 0.7-4.8, P = .21). Factors associated with meningioma development included female gender (P = .001), younger age at primary cancer diagnosis (P < .001), and CRT/longer time since CRT (P < .001). Glioma was associated with CRT/shorter time since CRT (P < .001). CONCLUSIONS There was no statistically significant increased overall risk of the occurrence of a CNS-SN associated with GH exposure. Specifically, occurrence of meningiomas and gliomas were not associated with GH treatment.
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Affiliation(s)
- Briana C Patterson
- Department of Pediatrics (B.C.P., A.Mer., L.R.M.) Emory University/Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia 30322; Department of Public Health Sciences (Y.C., Y.Y.), University of Alberta, Edmonton, Alberta, Canada T6G 1C9; Department of Pediatrics (C.A.S.), Memorial Sloan-Kettering Cancer Center, New York, New York 10065; Department of Pediatrics (J.N.), University of Minnesota Medical School, Minneapolis, Minnesota 55454; Department of Epidemiology and Cancer Control (G.T.A., L.L.R.), St Jude Children's Research Hospital, Memphis, Tennessee 38105; Division of Oncology (A.Mea.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104; and Department of Radiation Physics (M.S.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030
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7
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Malchiodi E, Profka E, Ferrante E, Sala E, Verrua E, Campi I, Lania AG, Arosio M, Locatelli M, Mortini P, Losa M, Motti E, Beck-Peccoz P, Spada A, Mantovani G. Thyrotropin-secreting pituitary adenomas: outcome of pituitary surgery and irradiation. J Clin Endocrinol Metab 2014; 99:2069-76. [PMID: 24552222 DOI: 10.1210/jc.2013-4376] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
OBJECTIVE Our objective was to describe the effects of surgery and radiotherapy on hormonal control and tumor mass in short- and long-term follow-up of TSH-secreting pituitary adenomas (TSHomas). METHODS This was a retrospective multicenter study. RESULTS We collected data of 70 TSHomas (70% macroadenomas). The mean follow-up was 64.4 (range 3-324) months. Overall, 97% of patients were treated with surgery; in 27% of them radiotherapy was associated. After surgery, 75% of patients normalized thyroid function, 58% normalized both pituitary imaging and hormonal profile, 9% developed pituitary deficiencies, and 3% had tumor or hormonal recurrence, all within the first 2 years after surgery. Presurgical medical treatment did not significantly improve surgical outcome (63% vs 57%). Radiotherapy controlled hypersecretion in 37% of patients within 2 years, whereas 32% of patients developed new pituitary deficiencies from 18 to 96 months from treatment. At last follow-up, 80% of patients normalized thyroid function, whereas 20% were currently on medical treatment: 85% with somatostatin analog (SSA) alone and 15% with SSA combined with methimazole. Subjects who achieved disease control had surgery as the only treatment in 80% of cases and surgery combined with irradiation in 20%. CONCLUSIONS Surgery remains the first-choice treatment for TSHoma. If surgery is successful, recurrence is rare. When surgery is unsuccessful or contraindicated, SSA and radiotherapy are effective in controlling hyperthyroidism and tumor growth in the majority of patients. The effects of radiotherapy on TSH secretion and tumor mass are greater within the first years after treatment, whereas pituitary deficiencies may occur several years later.
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Affiliation(s)
- Elena Malchiodi
- Departments of Clinical Sciences and Community Health (E.M., E.P., E.F., E.S., E.V., I.C., M.A., P.B.P., A.S., G.M.), Neurological Sciences (E.M.) and BIOMETRA Department (A.G.L.), University of Milan; Endocrinology and Diabetology Unit (E.M., E.P., E.F., E.S., E.V., I.C., P.B.P., A.S., G.M.) and Unit of Neurosurgery (M.L.), Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, 20112 Milan, Italy; Istituto Clinico Humanitas IRCCS (A.G.L.), 20089 Rozzano, Italy; Unit of Endocrine Diseases and Diabetology (M.A.), San Giuseppe Hospital, Multimedica Group, 20123 Milan, Italy; Pituitary Unit, Department of Neurosurgery (P.M., M.L.), Istituto Scientifico San Raffaele, Università Vita-Salute, 20132 Milan, Italy; and GVM Care and Research, Maria Cecilia Hospital (E.M.), 48010 Cotignola, Italy
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8
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Devriendt D. [Treatment of brain metastases]. Rev Med Brux 2012; 33:371-376. [PMID: 23091944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Brain metastases (BC) are the cause of important mortality and morbidity in cancer patients. Corticoids and Whole Brain Radiotherapy (WBRT) remains the standard treatment but, at the long-term, the results are disappointing. In patients with a single metastase, the survival and the Quality of Life (QoL) can be improved by surgery combined with WBRT. Unfortunately, if surgery (S) is impossible because of the number and/or the site of the metastases or any contraindication for surgery, radiosurgery (RS) remains a good alternative choice. RS allows an excellent local control of the lesions and can be applied to several lesions at the same time. There is no advantage in in terms of survival between RS + WBRT and S + WBRT or RS alone. RS can therefore be recommended as a first treatment approach, namely when favourable prognostic factors are present. This approach allows to avoid WBRT and its potential toxicity, namely in long-term survival.
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Affiliation(s)
- D Devriendt
- Centre de Radiochirurgie par Gamma Knife, Hôpital Erasme, Bruxelles.
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9
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Yeazel MW, Gurney JG, Oeffinger KC, Mitby PA, Mertens AC, Hudson MM, Robison LL. An examination of the dental utilization practices of adult survivors of childhood cancer: a report from the Childhood Cancer Survivor Study. J Public Health Dent 2004; 64:50-4. [PMID: 15078062 DOI: 10.1111/j.1752-7325.2004.tb02726.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES This study characterized the self-reported dental utilization practice of long-term survivors of childhood cancer, a group at increased risk for treatment-induced dental abnormalities. METHODS 9,434 survivors and a comparison group of 3,858 siblings completed a 289-item survey that included a question on when their last dental visit occurred. RESULTS Within the last year 60.4 percent of survivors reported a dental visit. The groups less likely to report a recent dental visit include minority subjects, subjects with low levels of educational attainment, subjects with annual household incomes < dollar 20,000, and those without health insurance. No significant differences between survivors and siblings were seen. Male survivors exposed to cranial radiation were slightly more likely than other male survivors to report a recent dental visit (OR = 1.27, 95% CI = 1.12, 1.44). CONCLUSIONS The dental utilization practices among survivors of childhood cancer are below recommended levels, even among those at highest risk for dental abnormalities.
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Affiliation(s)
- Mark W Yeazel
- University of Minnesota Medical School, Department of Family Practice and Community Health, Mayo Medical Code 381, 420 Delaware Street, SE, Minneapolis, MN 55455, USA.
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10
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Oh HK, Chambers MS, Garden AS, Wong PF, Martin JW. Risk of osteoradionecrosis after extraction of impacted third molars in irradiated head and neck cancer patients. J Oral Maxillofac Surg 2004; 62:139-44. [PMID: 14762744 DOI: 10.1016/j.joms.2003.08.009] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE This study was performed to compare the risk of osteoradionecrosis (ORN) in head and neck cancer patients in whom 1 or more impacted third molars were extracted before radiotherapy with patients whose impacted third molars were left intact. PATIENTS AND METHODS Eighty-one patients were selected from the medical records from 1989 to 1998. Patients had at least 1 impacted third molar and received radiotherapy for a head and neck cancer. These patients were divided into 2 groups on the basis of preirradiation extraction: group 1, patients who had impacted third molars extracted before radiotherapy (n = 55), and group 2, patients whose impacted third molars were left intact before radiotherapy (n = 38). In 12 patients of combined groups 1 and 2, at least 1 but not all of the impacted third molars were extracted before radiotherapy. RESULTS Before radiotherapy, a total of 99 impacted third molars were extracted from the 55 patients in group 1 and a total of 55 impacted third molars were left intact in the 38 patients in group 2. After radiotherapy, a total of 7 impacted third molars were removed from 5 patients as treatment for infection (5 lower molars) or discomfort (2 upper molars). A total of 4 patients (2 from group 1 and 2 from group 2) developed ORN in the mandible. Of these 4 cases of ORN, 1 from group 1 appeared to be related to a dry socket that developed after preirradiation extraction of a lower impacted third molar, 1 from group 2 seemed to be related to infection of a lower impacted third molar after radiotherapy, and the remaining 2 cases appeared to be unrelated to an impacted third molar. CONCLUSION Because few patients in this study developed ORN, the study failed to demonstrate whether preirradiation extraction versus retention of impacted third molars affects the risk for ORN.
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Affiliation(s)
- Hee-Kyun Oh
- Department of Oral and Maxillofacial Surgery, College of Dentistry, Chonnam National University, South Korea.
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11
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Abstract
PURPOSE We have conducted a retrospective study of the use of whole brain irradiation (WBI) for melanoma patients with brain metastases. The purpose of the study was to obtain a description of the population offered this form of treatment, an overview of radiation doses and schedules, an assessment of palliative effect, and survival. METHODS AND MATERIALS A database of melanoma patients diagnosed with brain metastases was searched to identify patients who had received WBI and for whom adequate documentation existed. Data regarding demographics, treatment, and survival were compiled. RESULTS Information was obtained for 87 patients. Ninety-five percent of the patients received total doses of at least 30 Gy. The frequent use of corticosteroids during treatment made it difficult to assess palliative effect. However, 52% of all patients and 48% of symptomatic patients were able to discontinue corticosteroid therapy upon completion of irradiation, suggesting that some degree of control or palliation had been obtained. In the small number of patients with postradiotherapy imaging studies, it was not uncommon to see stability or shrinkage of tumors. The median survival of the entire group was 19 weeks. Improved survival was noted for patients who underwent resection of all brain metastases (45 weeks) and for those with no extracranial disease (54 weeks). CONCLUSION WBI may provide palliation for a portion of melanoma patients with brain metastasis. The outcome of these patients, however, is dominated by the aggressive nature of their systemic disease. These data serve as a baseline for comparison of new approaches for management of brain metastases from melanoma.
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Affiliation(s)
- J Ellerhorst
- Department of Melanoma/Sarcoma, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA
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12
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Verhoef L, van der Kogel A. A patient who developed necrosis of the temporal lobe after irradiation of the parotid gland for pleomorphic adenoma. Int J Oral Maxillofac Surg 2000; 29:155. [PMID: 10833156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
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13
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Cmelak AJ, Choy H, Shyr Y, Mohr P, Glantz MJ, Johnson DH. National survey on prophylactic cranial irradiation: differences in practice patterns between medical and radiation oncologists. Int J Radiat Oncol Biol Phys 1999; 44:157-62. [PMID: 10219809 DOI: 10.1016/s0360-3016(98)00557-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE Prophylactic cranial irradiation (PCI) in the treatment of small cell lung cancer (SCLC) patients remains controversial in the oncology community because of its potential for long-term toxicity and unproven survival benefit in randomized trials. A national survey of 9176 oncologists was conducted to characterize the use of PCI with regard to physician demographics, patient characteristics, and oncologists' beliefs. METHODS Data was collected via a questionnaire letter survey. Biographical data, treatment patterns, and clinical impressions were analyzed by the generalized linear model and generalized estimating equations method. RESULTS There were 1231 responders overall (13.4% of those surveyed), including 628 (51%) radiation oncologists (RO), 587 (48%) medical oncologists (MO), 8 (0.6%) surgical oncologists, and 8 (0.6%) from other oncology subspecialties. Of respondents, 74% overall recommend PCI in limited-stage patients, including 65% of MO and 82% RO (p = 0.001). Of responders who recommend PCI in limited-stage patients, 67% do so only after complete response to initial therapy. Only 30% of respondents recommend PCI for extensive-stage SCLC patients (p = 0.001), and 94% of these recommend PCI only when those patients have a complete response after initial therapy. Interestingly, 38% of responding MO feel that PCI improves survival of limited-stage patients, but only 11% believe PCI improves quality of life. Of the RO, 48% believe PCI improves survival in limited-stage SCLC, and 36% feel PCI improves quality of life (p < 0.05 and p < 0.01, respectively). MO responders believe PCI causes late neurological sequelae more often than do RO responders (95% vs. 84%, p < 0.05), with impaired memory (37%), chronic fatigue (19%), and loss of motivation (13%) as most commonly seen side effects. Only 1.5% overall, however, routinely obtain neuropsychiatric testing in PCI patients, and 42% overall never obtain them. CONCLUSION Results confirm that oncologic subspecialists have statistically significant differences in opinion regarding the use of PCI. However, these differences may not translate into large differences in clinical practice. Most oncologists continue to recommend PCI in limited-stage SCLC patients, despite many believing PCI may not provide a survival advantage nor improve quality of life.
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Affiliation(s)
- A J Cmelak
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN 37232-5671, USA
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14
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Kortmann RD, Timmermann B, Kühl J, Willich N, Flentje M, Meisner C, Bamberg M. HIT '91 (prospective, co-operative study for the treatment of malignant brain tumors in childhood): accuracy and acute toxicity of the irradiation of the craniospinal axis. Results of the quality assurance program. Strahlenther Onkol 1999; 175:162-9. [PMID: 10230458 DOI: 10.1007/bf02742358] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND It was the aim of the quality control program of the randomized trial HIT '91 (intensive chemotherapy before irradiation versus maintenance chemotherapy after irradiation) to assess prospectively the quality of neuroaxis irradiation with respect to the protocol guidelines and to evaluate acute toxicity with respect to treatment arm. PATIENTS, MATERIALS AND METHODS Data of 134 patients undergoing irradiation of the craniospinal axis were available. Positioning aids, shielding techniques, treatment machines, choice of energy, total dose and fractionation were evaluated. A total of 651 simulation and verification films were analyzed to assess the coverage of the clinical target volume (whole brain, posterior fossa, sacral nerve roots) and deviations of field alignment between simulation and verification of first treatment. Field matching between whole brain and adjacent cranial spinal fields was analyzed with respect to site and width of junction. Acute maximal side effects were evaluated according to a modified WHO score for neurotoxicity, infections, skin, mucosa and myelotoxicity. RESULTS In 91.3% of patients contemporary positioning aids and individualized shielding techniques were used to assure a reproducible treatment. In 98 patients (73.1%) linear accelerators and in 36 patients (26.8%) Cobalt machines were used. Single and total dose were administered according to the protocol guidelines in more than 90% of patients. In 20.2% of patients the cribriform plate, in 1.4% the middle cranial fossa and in 21.1% the posterior fossa and in 4.5% the 2nd sacral segment were incompletely encompassed by the treatment portals. Ninety-five percent of deviations of field alignment were less than 13.0 mm (whole brain) and 12 mm (cranial spinal field) with a random error between 4.9 and 7.6 mm (whole brain) and 6.9 mm and 9.9 mm (spinal canal), respectively. In 77.5% of patients the junctions between whole brain and cranial spinal fields were placed without a gap. A gap between 5 and 10 mm was left in 15 patients (18.7%), exceeding 10 mm in 3 patients. Acute neurotoxicity and skin reactions were mild, the rate of infections was low in both treatment arms. However, myelotoxicity resulted in interruptions of radiotherapy in 31.9% after intensive chemotherapy as compared to 20.0% without preceding chemotherapy. CONCLUSIONS In the HIT '91 trial a precise radiotherapy of craniospinal axis has been performed in the majority of patients. Our findings indicate that the high quality is possibly an important contributing factor for the therapeutic outcome. However, preceding intensive chemotherapy caused marked toxicity of subsequent irradiation leading to a high rate of interruptions. Our database is subject to a future analysis of recurrences.
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Affiliation(s)
- R D Kortmann
- Department of Radiotherapy, University of Tuebingen.
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15
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Coghlan KM, Magennis P. Cerebral radionecrosis following the treatment of parotid tumours: a case report and review of the literature. Int J Oral Maxillofac Surg 1999; 28:50-2. [PMID: 10065650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Radiotherapy is an accepted part of the treatment of malignant tumours of the parotid gland. The use of radiotherapy in benign parotid tumours, where spillage of tumour cells has occurred at operation, is more controversial. Radiotherapy to the parotid bed is not without morbidity. Complications may arise as a result of radiation damage to neighbouring structures and there is also potential to induce malignant disease. A patient, whose postoperative radiotherapy following resection of a pleomorphic salivary gland adenoma was complicated by cerebral necrosis, is discussed. The literature pertaining to morbidity of radiotherapy for parotid tumours is reviewed.
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Affiliation(s)
- K M Coghlan
- Oral and Maxillofacial Unit, The Royal London Hospital, England
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16
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Abstract
OBJECTIVE To investigate the oral health status of patients with nasopharyngeal carcinoma (NPC) after completion of radiotherapy. METHODS Thirty-three NPC patients (mean age 53 +/- 10 years) who had completed head and neck radiotherapy (3.6 +/- 3.1 years post-operation) were examined. Dental caries, periodontal status and oral mucosal lesions were recorded. Stimulated whole saliva (SWS) flow rate, pH, buffer capacity and carriage rate of carcinogenic micro-organisms were assessed. Jaw opening was measured. RESULTS Xerostomia was present in all patients, while 42% had candidiasis and 21% had limited jaw opening. The mean number of teeth present was 22, mean DMFT was 8.0, mean number of untreated root caries lesions was 1.4. Both saliva pH and buffering capacity were low while Streptococcus mutans and Lactobacillus spp. carriage were high. 52% of the patients had no dental care following radiotherapy. Although few patients expressed direct dissatisfaction, perceived level of information and of post-operative dental care was insufficient. CONCLUSIONS Post-irradiated NPC patients constitute a high-risk group for dental root caries and oral candidiasis. The carriage rate of Streptococcus mutans and Lactobacillus spp. in this NPC patient group was the highest among findings of other similar studies. This may be related to the inadequacy of dental care after radiotherapy. Head and neck radiotherapy was not associated with periodontal disease.
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Affiliation(s)
- E Schwarz
- Faculty of Dentistry, University of Hong Kong, China.
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Donoff RB, Todd R, Elovic A, Gallagher GT, Chou MY, Wong DT. Prediction of human oral cancer radiation responsiveness by histone (H3) mRNA in situ hybridization: a preliminary report. J Oral Maxillofac Surg 1998; 56:1410-6. [PMID: 9846539 DOI: 10.1016/s0278-2391(98)90406-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE Cell cycle kinetics are believed to be a key determinant in radiation responsiveness. However, histomorphologic analysis remains an unreliable method of identifying proliferating cells. In this study, the fraction of cells undergoing division within oral cancer biopsy samples was used to predict the responsiveness of the tumor to radiation therapy. PATIENTS AND METHODS Eighteen cases of T1 or T2 squamous cell carcinoma of the floor of the mouth with known clinical outcomes were identified. All were treated at the Massachusetts General Hospital with external beam radiation therapy alone. The fraction of proliferating cells was determined using in situ hybridization of histone (H3) mRNA expression. Tissue viability and mRNA status was verified using in situ hybridization for beta-actin mRNA expression. RESULTS Matching the fraction of oral tumor cells positively labeled for histone (H3) mRNA (histone labeling index or HLI) with the actual clinical outcome showed that the HLI of radioresponsive oral tumors (12 cases) was 0.336+/-0.185 (approximately 34%+/-19%), whereas that for radioresistant oral tumors (six cases) was 0.088+/-0.078 (approximately 9%+/-7.8%). Using t-test statistical analysis for unpaired samples showed that the difference in HLI between the two groups was significantly different (P=.0068). CONCLUSIONS It is concluded that the use of in situ detection of histone (H3) mRNA may be a useful adjunctive criterion in the choice of treatment for human oral cancer.
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Affiliation(s)
- R B Donoff
- Department of Oral and Maxillofacial Surgery, Harvard School of Dental Medicine, Massachusetts General Hospital, Boston, USA
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Haupt R, Novakovic B, Fears TR, Byrne J, Robinson LL, Tucker MA, Reaman GH. Can protocol-specified doses of chemotherapy and radiotherapy be used as a measure of treatment actually received? A CCG/NIH study on long-term survivors of acute lymphocytic leukemia. J Clin Epidemiol 1996; 49:687-90. [PMID: 8656231 DOI: 10.1016/0895-4356(96)00029-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
In a cohort of 593 long-term survivors of acute lymphocytic leukemia identified through the Children's Cancer Group (CCG), treatment abstracts were obtained and compared to protocol information on radiation therapy and intravenous chemotherapy. This was done in order to evaluate the actual compliance to protocol-specified treatment, and assess if protocol-specified doses can be used in studies of late effects of treatment. The compliance to protocol-specified type of treatment ranged between 95.3% (intrathecal methotrexate) and 98.6% (adriamycin) for chemotherapy, and between 94.1% (cranial radiation) and 97.0% (extended field radiation) for radiation. Concordance with the protocol-specified chemotherapy dose (+/- 25%) was 57.5% for adriamycin, 91.3% for daunomycin, and 48.5% for cyclophosphamide. When concordance was low, most patients received doses that were lower than expected. Concordance with chemotherapy was significantly lower for high-dose regimens than for low-dose regimens. Concordance with protocol-specified radiation dose (+/- 10%) was 87.4% for cranial radiation, 87.8% for spinal radiation, and 85.7% for extended field radiation. Concordance with treatment did not differ by gender, relapse status, or age at diagnosis. In this cohort of leukemia survivors, the validity of type of treatment was greater than the validity of dosage. Great care should be used when drawing conclusions about effects of treatment dosage. Although costly and time consuming, it appears that chart reviews are the most appropriate way to collect information about dose-related effects of therapy.
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Affiliation(s)
- R Haupt
- Department of Hematology/Oncology, G. Gaslini Children's Hospital, Genoa, Italy
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Abstract
In four groups of patients with acute lymphoblastic leukaemia, anthropometric variables were investigated every 3 months for 2 years. Group 1 (n = 7) was treated with a high-risk protocol, group 2 (n = 13) with a standard-risk protocol including cranial irradiation, group 3 (n = 13) with a standard-risk protocol without cranial irradiation and group 4 (n = 8) was followed after completion of treatment. A height retardation of 0.4-0.6 SD was observed during therapy in groups 1-3. A catch-up of 0.5 SD was found in group 4. The retardation of armspan was significantly larger than the retardation of sitting height when groups 1-3 were taken together. Head circumference was not affected. The anthropometric variables reflecting nutritional status showed a growth above normal during and after treatment. Corticosteroid medication and not cranial irradiation is the most likely explanation for our findings.
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Affiliation(s)
- R Y Tamminga
- Department of Paediatrics, University Hospital Groningen, The Netherlands
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