Effective delivery of palliative radiotherapy: A prospective study

PURPOSE

The main goal of palliative radiotherapy is to reduce patient's discomfort. But sometimes patients do not receive any benefits from this treatment because of rapid worsening of their general condition. This prospective monocentric study assessed the effective delivery of palliative radiotherapy.

MATERIALS AND METHODS

From 1st December 2015 to 29th February 2016, all consecutive patients receiving palliative radiotherapy in our hospital were included. The primary endpoint was the effective delivery of palliative radiotherapy according to the initial prescription (total dose, overall treatment time and fractionation). The secondary endpoints were the number of treatment breaks, the clinical benefit, the number of deaths and the delays for admission in the palliative care unit.

RESULTS

Fifty-nine patients were included and 64 treatments were analysed. The treatment sites were: bone (70.3%) and brain (21.9%). The treatment goals were: pain control only (43.8%), decompression only (21.9%), pain control and decompression (32.8%), haemostatic aim (1.6%). Palliative treatment was achieved in 57 cases (89%). Temporary interruption of the radiotherapy treatment was necessary in six cases (9.4%; three for medical reason, three for logistic reason). The main reason of permanent interruption was worsening of performance status (seven cases). Palliation of symptoms (complete or partial responses) was obtained in 44 cases (68.8%). Seven patients (11.9%) died during the month after the end of the treatment. No delay or cancellation for admission in the palliative care unit were observed.

CONCLUSION

Palliative radiotherapy was completed as originally planned in 51 cases (79.9%) with a clinical benefit for 44 cases (68.8%). Radiation therapy must not be neglected as a palliative treatment at the end-of-life.

[Role of lymph node irradiation in breast cancer patients with negative pathologic node status after neoadjuvant chemotherapy: the René-Huguenin Cancer Center experience]

PURPOSE

Neoadjuvant chemotherapy generally induces significant changes in the pathological extent of disease. This potential down-staging challenges the standard indications of adjuvant radiation therapy. We assessed the utility of lymph node irradiation in breast cancer patients with pathological N0 status (pN0) after neoadjuvant chemotherapy and breast-conserving surgery.

PATIENTS AND MATERIALS

Among 1054 breast cancer patients treated with neoadjuvant chemotherapy in our institution between 1990 and 2004, 248 patients with clinical N0 or N1-N2 lymph node status at diagnosis had pN0 status after neoadjuvant chemotherapy and breast-conserving surgery. Cox regression analysis was used to identify factors influencing locoregional recurrence-free survival, disease-free survival and overall survival.

RESULTS

All 248 patients received breast irradiation, and 158 patients (63.7%) also received lymph node irradiation. With a median follow-up of 88 months, the 5-year locoregional recurrence-free survival and overall survival rates were respectively 89.4% and 88.7% with lymph node irradiation and 86.2% and 92% without lymph node irradiation (no significant difference). Survival was poorer among patients who did not have a pathological complete primary tumor response (pCR) (hazards ratio [HR]=3.05; 95% CI, 1.17 to 7.99) and in patients with N1-N2 clinical status at diagnosis ([HR]=2.24; 95% CI, 1.15 to 4.36). Lymph node irradiation did not significantly affect survival.

CONCLUSIONS

Relative to combined breast and local lymph node irradiation, isolated breast irradiation does not appear to be associated with a higher risk of locoregional relapse or death among breast cancer patients with pN0 status after neoadjuvant chemotherapy. These results need to be confirmed in a prospective study.

Inflammatory Breast Cancer: What Should Be the Locoregional Treatment after Primary Chemotherapy?

Purpose: The aim of this retrospective, mono-centric, study was to assess the benefit of breast surgery for inflammatory breast cancer (IBC).Patients and methods:From January 1st 1985 and December 31st 1999; out of 13180 patients diagnosed at the Institut Curie with non metastatic breast cancer, 280 (2%) were treated with curative intent for IBC with primary chemotherapy followed by either exclusive radiotherapy (118 patients, 51%) or surgery with or without radiotherapy (114 patients, 49%). Median follow-up of 11 years.Results:The two groups were comparable apart from a higher rate of tumors smaller than 70mm (43% vs 33%, p=0.003), a higher rate of clinical stage N2 (15% vs 5%, p=0.04) and fewer histopathologic grade 3 tumors (46% vs 61%, p<0.05) in the no-surgery group.The addition of surgery was associated with a significant improvement in locoregional disease control (p=0.04). At 5 years locoregional free interval was 79% in the surgery group vs 66 % in the exclusive radiotherapy group and at 10 years: 78 % vs 59 % respectively.In the univariate analysis, in addition to the absence of surgery (p=0.04), other prognostic factors associated with higher locoregional recurrence rates were: high clinical nodal stage (p=0.009), high histological nodal status (p=0.02) and the absence of taxanes in the neoadjuvant chemotherapy regimen (p=0.02). In the multivariate analysis, only the clinical N2 stage was associated with a higher rate of locoregional recurrences. There were no significant difference in overall survival (52% at 5 years, 38% at 10 years, p=0.32) or disease-free interval (at 5 years 32%, at 10 years 6%,p=0.35).Factors associated in univariate analyses with a decreased overall survival were age over 50 years, the absence of achievement of a clinical response ≥ 50%, absence of hormone receptors and the absence of taxanes in the neoadjuvant chemotherapy regimen.In multivariate analysis, only the absence of hormone receptors and either complete or partial clinical tumor response remained significant.Factors associated in univariate analyses with a higher rate of disease recurrences were the absence of achievement of a clinical response ≥ 50%, absence of hormone receptors and the absence of taxanes in the neoadjuvant chemotherapy regimen.In multivariate analysis, only the absence of hormone receptors and of clinical tumor response remained significant. Late toxicities were not significantly different between the two treatment groups except for a higher rate of fibrosis in the no-surgery group (p<0.0001), and more lymphedema in the surgery group (p=0.002).Conclusion:This study seems to confirm that the addition of breast surgery to radiotherapy should contribute to increase local control after induction chemotherapy. IBC, despite combined modality treatment, continues to suffer from dismal prognosis and efforts must be made to improve overall survival.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5120.

Is Exclusive Radiotherapy an Option for Early Breast Cancers with Complete Clinical Response after Neoadjuvant Chemotherapy?

Purpose: To determine whether exclusive radiotherapy (ERT) could be an option after complete clinical response (cCR) to neoadjuvant chemotherapy (NCT) for early breast cancers (EBC).Patients and methods: Between 1985 and 1999, 1477 patients received NCT for EBC considered to be too large for primary conservative surgery. Of 165 patients with cCR, 65 were treated by breast surgery (with radiotherapy) and 100 by ERT.Results: The two groups were comparable in terms of baseline characteristics, except for larger initial tumor sizes in the ERT group. There were no significant differences in overall, disease-free and metastasis-free survivals. Five-year and 10-year overall survivals were 91% and 77% in the no surgery group and 82% and 79% in the surgery group, respectively (p = 0.9). However, a non-significant trend towards higher locoregional recurrence rates (LRR) was observed in the no surgery group (31% vs. 17% at 10 years; p = 0.06). In patients with complete responses on mammography and/or ultrasound, LRR were not significantly different (p = 0.45, 10-year LRR: 21% in surgery vs. 26% in ERT). No significant differences were observed in terms of the rate of cutaneous, cardiac or pulmonary toxicities.Conclusion: Omission of breast surgery in patients who achieved cCR to NCT was not associated with an increased risk of distant metastases or death. However a trend towards an increased risk of locoregional recurrence was observed in the ERT group. Imaging modalities appear to be essential to monitor chemotherapy response and possibly select patients in whom ERT can be proposed.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4108.

Locally advanced breast cancer patients with negative pathological lymph node status after neoadjuvant chemotherapy and conservative surgery: Is lymph node irradiation necessary?

e11539

Background: The increased use of neoadjuvant chemotherapy (CT) in breast cancer (BC) management has raised new questions regarding the optimal locoregional treatment. The aim of this retrospective study was to compare the outcomes of BC patients (pts) with pathological N0 status (pN0) following primary CT and conservative surgery who received breast radiotherapy with or without lymph node irradiation. Methods: Between 1990 and 2004, 1054 patients received preoperative CT for locally advanced BC. Data from 248 pts (23.5%) with clinical N0 (164 pts) or N1-N2 (84 pts) lymph node status at diagnosis and pN0 status after primary CT were studied. Among them, 93 pts (37.5%) received breast irradiation alone and 155 pts (62.5%) underwent locoregional irradiation. Outcome was assessed in relation to lymph node recurrence, disease-free survival (DFS) and overall survival (OS). Results: Both groups were comparable in terms of baseline characteristics. With a median follow-up of 88 months, 3 pts experienced nodal recurrence in the breast irradiation alone group compared with 2 pts in the locoregional irradiation group (p>.05). Among the 164 N0 pN0 pts, the 5-year DFS and OS rates were respectively 84% and 89% vs 84% and 95%, according to whether they received (n=87) or not (n=77) lymph node irradiation(p>.05). Among the 84 N1-N2 pN0 pts, same outcome values did not show any significant difference according to group of treatment: 72% and 88% in 68 pts treated with locoregional irradiation vs 81% and 81% in 16 pts treated with breast irradiation alone (p>.05). Conclusions: Our results suggest that breast irradiation alone is not associated with a higher risk of regional recurrence in locally advanced BC pts with pN0 status after neoadjuvant chemotherapy. Whether this allows the omission of lymph node irradiation for such strategy should be addressed prospectively.

No significant financial relationships to disclose.

The differential response to chemotherapy of ovarian metastases from colorectal carcinoma

PATIENTS AND METHODS

All patients with metastatic (ovarian and extraovarian) CRC who underwent resection of ovarian metastases in our institution from April 1988 to August 2006 were analyzed and the response to preoperative chemotherapy was evaluated according to the RECIST criteria, and analyzed with respect to the sites of metastases (ovarian and extraovarian).

RESULTS

The studied population consisted of 23 women. At presentation, 20 patients had symptoms. Preoperative chemotherapy resulted in tumor control of measurable extraovarian metastases in 65% of cases. In contrast, no objective tumor response of ovarian metastases was observed, disease stabilization was obtained in only 3 patients (13%), and progression or occurrence of new ovarian metastases were observed in 20 patients (87%) (p=0.0005). With a median follow-up of 54 months [15-229], median overall survival was 30 months, and 3-year overall survival was 18%.

CONCLUSION

Ovarian metastases are less responsive to chemotherapy compared to other sites. As these "metastatic sanctuaries" often cause symptoms, surgical resection should always be considered for ovarian metastases, even in the case of associated extraovarian metastases.

[The role of radiotherapy in the management of patients with small cell lung cancer]

Small cell lung carcinomas are aggressive on account of their high and early risk of dissemination. They represent less than 20% of all lung cancers and only a third of these present with limited stage disease at diagnosis. Currently, treatment is based on synchronous thoracic irradiation and chemotherapy combining platinum salts and etoposide with or without other drugs. Because of the high risk of brain metastases, prophylactic cranial irradiation (PCI) is indicated in patients with a complete response and should be part of the standard management of these patients on the basis of a meta-analysis showing a 5% increase in survival at three years. In limited stage disease 5 year survival rates can reach 25% but the majority of patients will relapse. This progress is the consequence of a better combination of thoracic and cerebral irradiation and polychemotherapy. Even in extensive disease PCI reduces the risk of brain metastases and significantly improves overall survival. Many issues are subject to further clinical research concerning modalities of combination radio-chemotherapy, radiotherapy target volumes, optimum dosage, and the use of drugs in association with irradiation.

Partial purification of somatic and excretory-secretory products of adult Fasciola hepatica and their application for the serodiagnosis of experimental and natural fascioliasis using an ELISA

Six partially purified antigen fractions from adult Fasciola hepatica (three somatic tissues [Fhs] and three excretory products [Fhm]) were used in a micro-ELISA to monitor the serum antibody levels of an experimental rabbit F hepatica infection. Fhs 1 detected infection after 19 to 26 days and the titre remained significantly higher than that of the controls until day 103 of infection (end of experiment). Using Fhm 1 and Fhm 2, antibodies were detected between 12 and 19 days after infection. Fhm 2 distinguished infected from uninfected rabbits during the entire experimental period, whereas Fhm 1 did not. Excretory-secretory products of a low molecular weight were also antigenic and could differentiate between infected animals and controls. One hundred and nine sera from naturally infected cattle and uninfected controls were tested with the same antigens. Although antibody was detected, the results were inconsistent and further purification of the antigens may eventually improve the sensitivity of the method.

[Serodiagnosis of onchocerciasis by micro-ELISA using homologous somatic and metabolic antigens (excreted-secreted). Comparison with indirect immunofluorescence]

Using ELISA, we studied excreted-secreted (ES) antigens of adults O. volvulus obtained from nodules digested by collagenase and kept alive in vitro. It seems that only the female worms produce these antigens. They probably have a much higher specificity than somatic antigens (male or female worms extracts): a comparison was made in a study of 163 heterologous sera by ELISA. With this new sort of antigen the onchocerciasis serology seems to have a specificity not achieved until now. Its diagnosis value was studied with 61 proved onchocerciasis sera and 177 sera from people living in endemic areas. The percentages of positivity are 79 and 52 p. 100 respectively; the micro-ELISA is particularly advantageous for studying large numbers of sera and for seroepidemiology. We also compared the results obtained by the immunofluorescent antibody test using male and female O. volvulus and female D. viteae frozen sections. No significant differences were found in the study of these 3 antigens that have many non-specific fractions as all somatic antigens do.

[Serodiagnosis of human fasciolasis by micro-ELISA with reference to homologous somatic or excretory-secretory antigens. Comparison with an indirect immunofluorescent technic]

A new type of antigen constituted by excretory-secretory products (ES antigens) of adult Fasciola hepatica cyst alive in vitro is studied by the micro-ELISA method and compared with somatic antigens obtained from adult liver flukes. The results are practically the same (especially the sensitivity and the specificity of the test) but ES antigens seem to have more antigenicity. The results given by the ELISA method and by the IFAT (immunofluorescence antibody test) do not show any connection between the two tests, as the antigens employed are distinct, but IFAT gives a lightly inferior percentage of positivity to that obtained by ELISA.

[Serodiagnosis of onchocerciasis using micro-ELISA. Study of 450 sera and comparison with indirect immunofluorescence]

The microtest ELISA has been used for human Onchocerciasis serological study. The antigens employed were adult Onchocerca volvulus extracts, collected from dissected nodules, delipidized and cleared from human proteins by affinity Chromatography. Under the circumstances, the positivity limit of the test seems excellent (maximum )D: 0,23) defined with 171 negative sera, 66 of them taken from Africans. Specificity controls were studied with 56 heterologous sera; cross-reactions occurred with hydatidosis and especially wit various nematode infections, in particular loasis. With reagents and technical conditions used, the specificity limit of the test corresponds to an OD of 0,4 (measured with a 3 mm optical course). The diagnosis value of the test was verified by studying sera from 90 individuals wit a positive skin biopsy and with sera from 233 adults living in endemic areas. For all the infected people, the global percentage of positivity with ELISA is not greater than that with indirect immunofluorescent antibody test (85%). On the other hand, the micro-test ELISA seems slightly more sensitive in detection of high serological positivities. We did not find any statistically relationship presence and quantity of microfilarial worms in skin biopsy and positivity with the microtest ELISA. Likewise, in some polyinfested patients (with Onchocerca volvulus and Dipetalonema perstans or Wuchereria bancrofti), we did not observe any correlation between the results given the microtest ELISA and the quantity of microfilariae in the blood stream.