CT Derived Hounsfield Unit: An Easy Way to Determine Osteoporosis and Radiation Related Fracture Risk in Irradiated Patients

Background: We aimed to evaluate osteoporosis, bone mineral density, and fracture risk in irradiated patients by computerized tomography derived Hounsfield Units (HUs) calculated from radiation treatment planning system.

Methods: Fifty-seven patients operated for gastric adenocarcinoma who received adjuvant abdominal radiotherapy were included in the study group. Thirty-four patients who were not irradiated after surgery comprised the control group. HUs of T12, L1, L2 vertebral bodies were measured from the computerized tomographies imported to the treatment planning system for all the patients. While the measurements were obtained just after surgery and 1 year later after surgery in the control group, the same measurements were obtained just before irradiation and 1 year after radiotherapy in the study group. Percent change in HU values (Δ%HU) was determined for each group. Vertebral compression fractures, which are the consequence of radiation induced osteoporosis and bone toxicity were assessed during follow-up.

Results: There was no statistical significant difference in HU values measured for all the vertebrae between the study and the control group at the onset of the study. While HU values decreased significantly in the study group, there was no significant reduction in HU values in the control group after 1 year. significant correlation was found between Δ%HU and the radiation dose received by each vertebra. Insufficiency fractures (IFs) were observed only in the irradiated patients (4 out of 57 patients) with the cumulative incidence of 7%.

Conclusions: HU values are very valuable in determining bone mineral density and fracture risk. Radiation treatment planning system can be utilized to determine HU values. IFs are common after abdominal radiotherapy in patients with low vertebral HU values detected during radiation treatment planning. Radiation dose to the vertebral bones with low HU values should be limited below 20 Gy to prevent late radiation related bone toxicity.

Stereotactic Radiotherapy in Recurrent Glioblastoma: A Valid Salvage Treatment Option

BACKGROUND

Glioblastoma (GBM) is a dismal disease. Recurrence is inevitable despite initial surgery and postoperative temozolomide (TMZ) and radiotherapy. Salvage surgery is the standard treatment in selected patients. Chemotherapy, biological agents, and re-irradiation are other treatment approaches available. Stereotactic radiotherapy (SRT) is nowadays a common treatment as a salvage treatment option.

MATERIALS AND METHODS

We reviewed the files of 132 GBM cases treated between 2010 and 2018. All patients received TMZ and radiotherapy after surgery or biopsy. Among the patients who had recurrence, we identified 42 cases treated with salvage SRT. The CyberKnife robotic system was used to administer SRT.

RESULTS

While the median follow-up time for all patients was 16 months (range 1-123), the median follow-up time for patients treated with SRT after initial diagnosis was 26.5 months (range 9-123). The median follow-up time after SRT was 10 months (range 2-107). SRT was performed in a median of 3 fractions (range 2-5). The median prescription dose was 20 Gy (range 18-30). While the median actuarial survival after initial diagnosis for patients treated with salvage SRT was 30 months (range 9-123), it was only 14 months (range 1-111) for patients who could not be treated with salvage SRT (p = 0.001). The median survival time after SRT was 12 months, and 1- and 2-year survival rates were 48 and 9%, respectively. The time to progression after SRT was 5 months (range 1-62), and 6-month and 1-year progression-free survival rates were 50 and 22%, respectively. Patients with longer time to recurrence >12 months had longer overall survival with respect to the ones having recurrence <12 months (p < 0.001). Salvage surgery had been performed in 7 out of 42 patients before SRT. These reoperated patients had significantly worse survival after SRT when compared to the patients who underwent SRT alone (p = 0.02). SRT was well tolerated and there was no grade III/IV toxicity.

CONCLUSIONS

SRT is a viable salvage treatment option for recurrent GBM. SRT provides acceptable local control and survival benefit for recurrent GBM cases. SRT can be considered especially in patients with long time to recurrence.

Volumetric decrease of pancreas after abdominal irradiation, it is time to consider pancreas as an organ at risk for radiotherapy planning

Background

Volumetric shrinkage of normal tissues such as salivary glands, kidneys, hippocampus are observed after radiotherapy. We aimed to assess the alterations in pancreatic volume of patients who received abdominal radiotherapy and define pancreas as an organ at risk for radiation treatment planning.

Material-methods

Forty-nine patients operated for gastric adenocarcinoma who received adjuvant abdominal radiotherapy were in the study group, 27 patients with early stage disease who did not need adjuvant treatment after surgery comprised the control group. An experienced radiologist contoured the pancreas of all the patients from computed tomographies imported to the planning system obtained either for radiation planning purpose or for follow-up after surgery. The same procedure was repeated one year later for both groups. Measured volume of the pancreas was expressed in cm³.

Results

Mean pancreatic volumes were similar in both groups at the onset of the study, 51,34 ± 20,33 cm³, and 50,12 ± 23,75 cm³ in the irradiated and the control groups respectively (p = 0,63). One year later, mean pancreatic volumes were significantly decreased in each group; 22,48 ± 10,53 cm³, 44,18 ± 23,08 cm³ respectively, p < 0,001. However, the decrease in pancreatic volume was significantly more pronounced in the irradiated group in comparison to the control group, p < 0,001.

Conclusion

Volumetric decrease in normal tissues after radiotherapy is responsible for loss of organ function and radiation related late side effects. Although pancreas is a radiation sensitive organ losing its volume and function after radiation exposure, it is not yet considered as an organ at risk for radiation treatment planning. Pancreas should be contoured as an organ at risk, dose-volume histogram for the organ should be created, and safe organ doses should be determined. This is the first study declaring pancreas as an organ at risk for radiation toxicity and the necessity of defining dose constraints for the organ.

Osteoporosis development and vertebral fractures after abdominal irradiation in patients with gastric cancer

Background

Decrease in bone mineral density, osteoporosis development, bone toxicity and resulting insufficiency fractures as late effect of radiotherapy are not well known. Osteoporosis development related to radiotherapy has not been investigated properly and insufficiency fractures are rarely reported for vertebral bones.

Methods

Ninety-seven patients with gastric adenocarcinoma were evaluated for adjuvant treatment after surgery. While 73 out of 97 patients treated with adjuvant chemoradiotherapy comprised the study group, 24 out of 97 patients with early stage disease without need of adjuvant treatment comprised the control group. Bone mineral densities (BMD) of lumbar spine and femoral neck were measured by dual energy x-ray absorptiometry after surgery, and one year later in both groups.

Results

There was statistically significant decline in BMDs after one year in each group itself, however the decline in BMDs of the patients in the irradiated group was more pronounced when compared with the patients in the control group; p values were 0.02 for the decline in BMDs of lumbar spine, and 0.01 for femoral neck respectively. Insufficiency fractures were observed only in the irradiated patients (7 out of 73 patients) with a cumulative incidence of 9.6%.

Conclusions

Abdominal irradiation as in the adjuvant treatment of gastric cancer results in decrease in BMD and osteoporosis. Insufficiency fracture risk in the radiation exposed vertabral bones is increased. Calcium and vitamin D replacement and other measures for prevention of osteoporosis and insufficiency fractures should be considered after abdominal irradiation.

Pre- and post-surgery treatments in rectal cancer: a long-term single-centre experience

BACKGROUND

Our study evaluated long-term survival outcomes in rectal cancer patients treated with preoperative radiotherapy, and the impact on survival of concomitant and postoperative adjuvant chemotherapy (ctx), among other prognostic factors.

METHODS

The study included 196 patients [median age: 58 years (range: 20-86 years); 63.0% men] with locally advanced rectal carcinoma and, in some cases, resectable liver metastasis. Rates of distant metastasis and local recurrence and of 5-year distant metastasis-free survival (dmfs) and overall survival (os) were determined.

RESULTS

The 5-year os rate was 57.0%, with a median duration of 81.5 months (95% confidence interval: 73.7 months to 89.4 months), and the 5-year dmfs rate was 54.1%, with a median duration of 68.4 months (95% confidence interval: 40.4 months to 96.4 months). Prognostic factors for higher os and dmfs rates were downstaging (p = 0.013 and p = 0.005 respectively), radiotherapy dose (50 Gy vs. 56 Gy or 45-46 Gy, both p = 0.002), and concomitant ctx use (p = 0.004 and p = 0.001) and type (5-fluorouracil-leucovorin-folinic acid vs. tegafur-folinic acid, p = 0.034 and p = 0.043). Adjuvant ctx after neoadjuvant long-term concomitant chemoradiotherapy (ccrt) and surgery was associated with better 5-year os rates for postoperative T0-T3 disease (p = 0.003) and disease at all lymph node stages (p = 0.001).

CONCLUSIONS

Our findings revealed a favourable survival outcome with long-term fractionated irradiation and concomitant 5-fluorouracil-based ctx, achieving 5-year os and dmfs rates of 57.0% and 54.1% respectively. Preoperative administration of radiotherapy (50 Gy) and postoperative adjuvant ctx were associated with a significant survival benefit. Radiation doses above 50 Gy and the interval between ccrt and surgery had no significant effect on survival.

Is there any role of intravenous iron for the treatment of anemia in cancer?

BACKGROUND

Anemia is a major cause of morbidity in patients with cancer resulting in poor physical performance, prognosis and therapy outcome. The aim of this study is to assess the efficacy of intravenous (iv) iron administration for the correction of anemia, for the prevention of exacerbation of anemia, for decreasing blood transfusion rates, and for the survival of cancer patients.

METHODS

Patients with different solid tumor diagnosis who received iv iron during their cancer treatment were evaluated retrospectively. Sixty-three patients with hemoglobin (Hgb) levels between ≥ 9 g/dL, and ≤ 10 g/dL, and no urgent need for red blood cell transfusion were included in this retrospective analysis. The aim of cancer treatment was palliative for metastatic patients (36 out of 63), or adjuvant or curative for patients with localized disease (27 out of 63). All the patients received 100 mg of iron sucrose which was delivered intravenously in 100 mL of saline solution, infused within 30 min, 5 infusions every other day. Complete blood count, serum iron, and ferritin levels before and at every 1 to 3 months subsequently after iv iron administration were followed regularly.

RESULTS

Initial mean serum Hgb, serum ferritin and serum iron levels were 9.33 g/dL, 156 ng/mL, and 35.9 μg/dL respectively. Mean Hgb, ferritin, and iron levels 1 to 3 months, and 6 to 12 months after iv iron administration were 10.4 g/dL, 11.2 g/dL, 298.6 ng/mL, 296.7 ng/mL, and 71.6 μg/dL, 67.7 μg/dL respectively with a statistically significant increase in the levels (p < 0.001). Nineteen patients (30 %) however had further decrease in Hgb levels despite iv iron administration, and blood transfusion was necessary in 18 of these 19 patients (28.5 %). The 1-year overall survival rates differed in metastatic cancer patients depending on their response to iv iron; 61.1 % in responders versus 35.3 % in non-responders, (p = 0.005), furthermore response to iv iron correlated with tumor response to cancer treatment, and this relation was statistically significant, (p < 0.001).

CONCLUSIONS

Iv iron administration in cancer patients undergoing active oncologic treatment is an effective and safe measure for correction of anemia, and prevention of worsening of anemia. Amelioration of anemia and increase in Hgb levels with iv iron administration in patients with disseminated cancer is associated with increased tumor response to oncologic treatment and overall survival. Response to iv iron may be both a prognostic and a predictive factor for response to cancer treatment and survival.

Whole-brain radiation therapy for brain metastases: detrimental or beneficial?

Stereotactic radiosurgery is frequently used, either alone or together with whole-brain radiation therapy to treat brain metastases from solid tumors. Certain experts and radiation oncology groups have proposed replacing whole-brain radiation therapy with stereotactic radiosurgery alone for the management of brain metastases. Although randomized trials have favored adding whole-brain radiation therapy to stereotactic radiosurgery for most end points, a recent meta-analysis demonstrated a survival disadvantage for patients treated with whole-brain radiation therapy and stereotactic radiosurgery compared with patients treated with stereotactic radiosurgery alone. However the apparent detrimental effect of adding whole-brain radiation therapy to stereotactic radiosurgery reported in this meta-analysis may be the result of inhomogeneous distribution of the patients with respect to tumor histologies, molecular histologic subtypes, and extracranial tumor stages between the groups rather than a real effect. Unfortunately, soon after this meta-analysis was published, even as an abstract, use of whole-brain radiation therapy in managing brain metastases has become controversial among radiation oncologists. The American Society of Radiation Oncology recently recommended, in their “Choose Wisely” campaign, against routinely adding whole-brain radiation therapy to stereotactic radiosurgery to treat brain metastases. However, this situation creates conflict for radiation oncologists who believe that there are enough high level of evidence for the effectiveness of whole-brain radiation therapy in the treatment of brain metastases.

Survival in gastric cancer in relation to postoperative adjuvant therapy and determinants

AIM: To evaluate survival data in patients with gastric cancer in relation to postoperative adjuvant therapy and survival determinants

METHODS: A total of 201 patients (mean ± SD age: 56.0 ± 11.9 years, 69.7% were males) with gastric carcinoma who were operated and followed up at Lutfi Kirdar Kartal Training and Research Hospital between 1998 and 2010 were included in this retrospective study. Follow up was evaluated divided into two consecutive periods (before 2008 and 2008-2010, respectively) based on introduction of 3-D conformal technique in radiotherapy at our clinic in 2008. Data on patient demographics, clinical and histopathological characteristics of gastric carcinoma and the type of treatment applied after surgery [postoperative adjuvant treatment protocols including chemoradiotherapy (CRT) and chemotherapy (CT), supportive therapy or follow up without any treatment] were recorded. The median duration and determinants of local recurrence free (LRF) survival, distant metastasis free (DMF) survival and overall survival were evaluated in the overall population as well as with respect to follow up years [1998-2008 (n = 127) vs 2008-2010 (n = 74)].

RESULTS: Median duration for LRF survival, DMF survival and overall survival were 31.9, 24.1 and 31.9 mo, respectively in patients with postoperative adjuvant CRT. No significant difference was noted in median duration for LRF survival, DMF survival and overall survival with respect to treatment protocols in the overall population and also with respect to followed up periods. In the overall population, CT protocols FUFA [5-fluorouracil (400 mg/m²) and leucovorin-folinic acid (FA, 20 mg/m²)] (29.9 mo) and UFT^® + Antrex^® [a fixed combination of the oral FU prodrug tegafur (flouroprymidine, FT, 300 mg/m² per day) with FA (Antrex^®), 15 mg tablet, two times a day] (42.5 mo) was significantly associated with longer LRF survival times than other CT protocols (P = 0.036), while no difference was noted between CT protocols in terms of DMF survival and overall survival. Among patients received CRT, overall survival was significantly longer in patients with negative than positive surgical margin (27.7 mo vs 22.4 mo, P = 0.016) in the overall study population, while time of radiotherapy initiation had no significant impact on survival times. Nodal stage was determined to be independent predictor of LRF survival in the overall study population with 4.959 fold (P = 0.042) increase in mortality in patients with nodal stage N2 compared to patients with nodal stage N0, and independent predictor of overall survival with 5.132 fold (P = 0.006), 5.263 fold (P = 0.027) and 4.056 fold (P = 0.009) increase in the mortality in patients with nodal stage N3a (before 2008), N3b (before 2008) and N2 (overall study population) when compared to patients with N0 stage, respectively.

CONCLUSION: Our findings emphasize the likelihood of postoperative adjuvant CRT to have a survival benefit in patients with resectable gastric carcinoma.

Risk of endocrine pancreatic insufficiency in patients receiving adjuvant chemoradiation for resected gastric cancer

BACKGROUND

Adjuvant radiotherapy combined with 5-fluorouracil based chemotherapy has become the new standard after curative resection in high risk gastric cancer. Beside many complications due to surgery, the addition of chemotherapy and radiotherapy as adjuvant treatment may lead to both acute and late toxicities. Pancreatic tissue irradiation during this adjuvant treatment because of incidental and unavoidable inclusion of the organ within the radiation field may affect exocrine and endocrine functions of the organ.

MATERIALS AND METHODS

Fifty-three patients with gastric adenocarcinoma were evaluated for adjuvant chemoradiotherapy after surgery. While 37 out of 53 patients were treated postoperatively due to either serosal or adjacent organ or lymph node involvement, 16 patients without these risk factors were followed up regularly without any additional treatment and they served as the control group. Fasting blood glucose (FBG), hemoglobin A1c (HBA1c), insulin and C-peptide levels were measured in the control and study groups after the surgery and 6 months and 1 year later.

RESULTS

At the baseline there was no difference in FBG, HbA1c, C-peptide and insulin levels between the control and the study groups. At the end of the study there was a statistically significant decline in insulin and C-peptide levels in the study group, (7.5 ± 6.0 vs 4.5 ± 4.4 IU/L, p: 0.002 and 2.3 ± 0.9 vs 1.56 ± 0.9 ng/ml, p: 0.001) respectively.

CONCLUSIONS

Adjuvant radiotherapy in gastric cancer leads to a decrease in beta cell function and insulin secretion capacity of the pancreas with possible diabetes risk. Radiation-induced pancreatic injury and late effects of radiation on normal pancreatic tissue are unknown, but pancreas is more sensitive to radiation than known. This organ should be studied extensively in order to determine the tolerance doses and it should be contoured during abdominal radiotherapy planning as an organ at risk.

Co-existence of gastrointestinal stromal tumors with other primary neoplasms

BACKGROUND/AIMS

Gastrointestinal stromal tumors (GISTs) are the most common primary mesenchymal neoplasms of the tubular gastrointestinal tract (GI). Here, we present a series of 32 patients diagnosed with a primary neoplasm in addition to GIST, from six different institutions in Turkey.

METHODOLOGY

In total, 200 patients with GIST were evaluated; 32 patients with both GISTs and other primary malignancies were identified.

RESULTS

This study included 20 men and 12 women median age 66.5 years (range 43-78). GIST was incidentally found intra-operatively in 12 of the cases. All patients underwent surgery. Detection of the GIST was synchronous in 19 cases, metachronous in 7 cases and preceded the GIST diagnosis in 6 cases. The median time before follow-up evaluation ranged from 4 to 80 months.

CONCLUSIONS

To our knowledge, no cases of GISTs co-existing with leiomyosarcoma of the spermatic cord and larynx tumors have been reported previously. The prevalence of malignancies in this subpopulation of GIST patients is significantly higher than the prevalence of malignancies in the healthy Turkish population. The high occurrence rate of additional primary malignancies in GIST patients has focused the attention of clinical oncologists on this problem, and may imply a common genetic mechanism for their etiology.

Lhermitte's sign: Review with special emphasis in oncology practice

Lhermitte's sign (LS) is characterized by electric shock like sensation, spreading along the spine in a cervico-caudal direction and also into both arms and legs, which is felt upon forward flexion of the neck. It is a myelopathy resulting from damage to sensory axons at the dorsal columns of the cervical or thoracic spinal cord and a well-known clinical sign in neurology practice. Patients with cancer may present with LS due to various causes either related to the tumor itself or to its treatment. Spinal cord tumors, radiotherapy and chemotherapy are possible causes of LS observed in oncology practice. While LS is observed with a frequency of 3.6-13% in large patient groups receiving radiotherapy for head and neck and thoracic malignancies, the true incidence of chemotherapy and spinal cord tumor induced LS is unknown with only few reported cases in the literature. In the present article, various pathologies causing Lhermitte's sign are reviewed with special emphasis on the implications of this sign in oncology practice.

Efficacy of iodopovidone pleurodesis and comparison of small-bore catheter versus large-bore chest tube

BACKGROUND

To evaluate the efficacy of iodopovidone as an agent for pleurodesis in malignant pleural effusion (MPE) and to compare the efficacy of small-bore catheter (Pleuracan, Braun, Melsungen, Germany) and conventional large-bore chest tube in pleural fluid drainage and sclerotherapy.

METHODS

Patients with MPE were prospectively consecutively randomized into two groups between August 2004 and February 2007: pleurodesis via conventional (32F) chest tube (group 1) and small-bore catheter (group 2), both using iodopovidone. After 3 months' follow-up, response rates (complete or partial), complication rates, and duration of procedures within whole group, group 1, and group 2 were compared. Statistical analyses were performed by Mann-Whitney U, chi(2), and Fisher's exact test.

RESULTS

Forty-three pleurodeses were performed in 41 patients. The response was complete in 26 (60.5%) and partial in 12 (27.9%), and the overall success rate was 88.4%. The response rate was not associated with the type of inserted tube (P = .750), pleural fluid pH (P = .290), or pleural fluid lactate dehydrogenase (P = .727). In group 1 (n = 20), 12 demonstrated complete and 6 demonstrated partial response, with a 90% success rate; success was 86.9% in group 2, with complete response in 14 and partial response in 6 patients. Success rates were similar in the two groups (P = 1.000). Of 43 procedures, complications were observed in 14 (32.5%), and complication rates were 35% and 30.4% in groups 1 and 2, respectively (P = .750). The most frequent complication was pain (16.2%), followed by fever, subcutaneous emphysema, dyspnea, and hypotension.

CONCLUSION

Iodopovidone is an effective, inexpensive, safe, and easily available alternative in chemical pleurodesis in MPE. The success rates of pleurodesis were found to be similar regardless of the type of the tube inserted.

Does the addition of COX-2 inhibitors alter the resistance to aromatase inhibitors?

11511

Background: This study aimed to investigate whether the addition of COX-2 inhibitor to aromatase inhibitor alter the resistance to aromatase inhibitor, developed during first or second line hormonal treatment of estrogen (ER) and/or progesterone receptor (PR) positive metastatic breast cancer cases. Methods: ER and/or PR positive breast cancer patients with known high baseline CA 15–3 levels due to the tumor and receiving a first or second line (after first line tamoxifen) aromatase inhibitor due to soft tissue (lymphatic tissue, skin) or bone metastasis were evaluated in this study. A recurrent increase in CA 15–3 levels without tumor progression following an initial decrease in CA 15–3 levels was observed in 7 patients and this was considered as resistance to the aromatase inhibitor. For this reason, a COX- 2 inhibitor was added to either letrozole (5/7) or anastrozole (2/7) treatment. The aromatase inhibitor and COX-2 inhibitor combination (celecoxib 200 mg bid, 5/7 cases; rofecoxib 50 mg od, 2/7 cases) was used for 3 months. CA 15–3 levels and tumor response of these 7 cases was re- evaluated at the end of 3 months. Results: None of the seven cases had a decrease in CA 15–3 levels following the 3 months of aromatase inhibitor plus COX-2 inhibitor combination treatment, instead all cases had their levels increased. In addition, none of the 7 cases had clinical or radiological tumor response, all had tumor progression. Treatment was continued by either third line hormone treatment (4/7) or chemotherapy (3/7). Conclusions: COX-2 inhibitors are suggested to potentiate endocrine treatment since the overexpression of COX-2 contributes to the increased expression of aromatase in the breast tumor tissue. Thus, the combination of an aromatase inhibitor and a COX-2 inhibitor may be useful in the hormonal treatment of breast cancer. However, present study failed to demonstrate alteration of the developed aromatase resistance by the addition of a COX-2 inhibitor.

No significant financial relationships to disclose.

Late term renal complications related to chemoradiotherapy in patients with gastric cancer

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Background: The aim of this study is to evaluate late term renal complications of the combined treatment with chemoradiotherapy, according to the scheme of McDonald et al, in patients diagnosed with gastric cancer, after radical curative surgery. Methods: Totally 44 patients who administered to our clinic between years 2003 and 2004, with the diagnosis of gastric cancer, and with the age-adjusted creatinine clearance test (CCT) results within normal range, were enrolled into the study. Surgical procedure was subtotal gastrectomy in 34 patients (63,6%), and total gastrectomy in 16 patients (36,4%). Total 4600 cGy radiotherapy was administered to all patients through parallel-opposed AP-PA fields in 23 fractions concomitant with chemotherapy according to the scheme of McDonald et al. One year after the completion of the treatment, a technetium 99-m renal scintigraphy (DMSA) and CCT were performed to all patients whose renal functions were within normal limits. Results: Median age in the study was 52 (22–78). 34 patients (77,3%) were male and 10 (22,7%) were female. TNM stages were stage II in 15 (34,1%), IIIA in 21 (47,7%), IIIB in 4 (9,1%), and IV in 4 cases (9,1%). CCT measured 1 year after the treatment was low in 13 patients (29,6%), and within normal range in 31 patients (70,4%). Renal scintigraphy revealed damage at one pole in 32 patients (72,7%), damage at bilateral renal poles in 8 patients (18,3%), and it was normal in 4 patients (9%). Renal damage was higher in left kidneys than right kidneys (89,9% vs. 15,4%). There was a correlation between CCT values and scintigraphical findings. Damage in bilateral renal poles was higher in cases with low CCT than in cases with normal values (85,7% vs. 15,4). In general, there were no statistically significant relationship between late term renal complications and sex, and grade III treatment-related gastrointestinal toxicity. However, the relationships with age, extent of surgery reached statistical significance (p=0.009, and =0.006). Renal damage was notably higher in older patients, and in patients who underwent total gastrectomy. Conclusions: Since postoperative chemoradiotherapy is a novel modality for the treatment of gastric cancer, more studies are required in order to evaluate chronic toxicities.

No significant financial relationships to disclose.

Tumour Lysis Syndrome in Solid Tumours

Tumour lysis syndrome (TLS) is an oncological emergency that results from massive cytolysis of malignant cells with a sudden release of their cellular contents, such as intracellular ions and metabolic by-products, into the systemic circulation. This syndrome is common in tumours with rapid cell turnover and growth rates, and in bulky tumours with high sensitivity to antineoplastic treatments. It is, therefore, a well-recognised clinical problem in haematological malignancies. It is rarely observed in solid tumours. Here, published studies are reviewed, beginning with the first report of TLS in solid tumours. Reported solid TLS cases are evaluated according to their common features and differences, and their similarities with those seen in haematological malignancies. Basic principles for the prevention and management of TLS are mentioned, with particular emphasis on solid tumours.

Endoscopic scoring of late gastrointestinal mucosal damage after adjuvant radiochemotherapy

AIM: To evaluate late effects of chemoradiation on gastrointestinal mucosa with an endoscopic scoring system and compare it to a clinical scoring system.

METHODS: Twenty-four patients going to receive chemoradiation after gastric surgery underwent endoscopy four wk after surgery and one year after the chemoradiation finished. Upper gastrointestinal findings were recorded according to a system proposed by World Organisation for Digestive Endoscopy (OMED) and clinical scoring was done with RTOG-EORTC radiation morbidity scoring systems.

RESULTS: There was no significant endoscopic difference in gastric and intestinal mucosa after chemoradiation (P > 0.05) and there was no association between endoscopic scores and clinical scores. Endoscopic changes were minimal.

CONCLUSION: Late effects after chemoradiation in operated patients with gastric cancers can be evaluated with an endoscopic scoring system objectively and this system is superior to clinical scoring systems.

Preoperative radiation in combination with uracil/tegafur (UFT) and mitomycin C (MMC) in locally advanced rectal adenocarinoma

13512

Background: Preoperative chemoradiation has become the standard treatment approach not only for tumor downstaging, but also for adjuvant treatment of locally advanced rectal adenocarcinomas (Sauer et al. NEJM 2004). The most commonly used chemotherapeutic agent with preoperative radiation is either bolus or infusional 5-fluorouracil (5-FU). These combinations produce pathologic complete responses in the range of 10–30%. Continuous infusion of 5-FU has proven to be superior to bolus 5-FU, when given during radiation. However widespread use of continuous infusion 5-FU has been limited by the need for an indwelling venous catheter and portable infusion pump. UFT acting like infusional 5-FU, offers the advantage of oral administration. Response to preoperative chemoradiation is associated with higher sphincter preservation and survival rates. UFT, MMC (a hypoxic cell cytotoxin) combination during preoperative radiation may improve the response rates. The aim of this study is to assess the efficacy (pCR) and toxicity of this combination. Methods: 26 patients with biopsy proven non metastatic rectal adenocarcinoma were included. Clinical T and N stages, determined by pelvic MRI were; 10/26 cT3, 16/26 cT4, 10/26 cN0, and 16/26 cN+. Pelvic radiotherapy was administered with 6 or 15 MV photons to 46 Gy in 23 fractions over 5 weeks, with four field technique in prone position. During radiotherapy, patients received UFT, 300 mg/m2 divided in two daily doses, five days a week, from Monday to Friday, starting on the first day, ending on the last day of radiation, together with bolus injection of MMC, 10 mg/m2, once in the morning of the first day of radiaton. Surgery was performed 6 or more weeks after the radiation treatment has ended. Results: Acute grade III/IV toxicity was observed in 6 out of 26 patients. Diarrhea, 3 grIII, 1 grIV. Neutropenia, 1 grIII. Dermatitis, 1 grIII. Tumor downstaging was observed in 16 patients out of 26 (62%). Nodal sterilization was obtained in 11 patients out of 16 (69%), with a pathologic complete response in 3 out of 26 patients (11%). Conclusions: Preoperative radiation concurrent with UFT and MMC has a good activity, with manageable acute toxicity.

No significant financial relationships to disclose.

Encapsulating peritonitis and familial Mediterranean fever

AIM: To investigate the relationship between encapsulating peritonitis and familial Mediterranean fever (FMF).

METHODS: The patient had a history of type 2 diabetes and laparoscopic cholecystectomy was performed one year ago for cholelithiasis. Eleven months after the operation she developed massive ascites. Biochemical evaluation revealed hyperglycemia, mild Fe deficiency anemia, hypoalbuminemia and a CA-125 level of 2700 IU. Ascitic evaluation showed characteristics of exudation with a cell count of 580/mm³. Abdominal CT showed omental thickening and massive ascites. At exploratory laparotomy there was generalized thickening of the peritoneum and a laparoscopic clip encapsulated by fibrous tissue was found adherent to the uterus. Biopsies were negative for malignancy and a prophilactic total abdominal hysterectomy and bilateral salpingooophorectomy were performed.

RESULTS: The histopathological evaluation was compatible with chronic nonspecific findings and mild mesothelial proliferation and chronic inflammation at the uterine serosa and liver biopsy showed inactive cirrhosis.

CONCLUSION: The patient was evaluated as sclerosing encapsulating peritonitis induced by the laparoscopic clip acting as a foreign body. Due to the fact that the patient had FMF the immune response was probably exaggerated.

Total-body irradiation before bone marrow transplantation for acute leukemia in first or second complete remission. Results and prognostic factors in 326 consecutive patients

AIM

In order to assess the influence of total-body irradiation (TBI) on the outcome and incidence of complication after bone marrow transplantation (BMT), we retrospectively analyzed our patients treated for acute leukemia and conditioned with TBI prior to BMT.

PATIENTS AND METHODS

Between 1980 and 1993, 326 patients referred to our department with acute non-lymphoblastic leukemia (ANLL, n = 182) and acute lymphoblastic leukemia (ALL, n = 144) in complete remission underwent TBI either in single dose (190 patients: 10 Gy administered to the midplane, and 8 Gy to the lungs [STBI]) or in 6 fractions (136 patients: 12 Gy on 3 consecutive days, and 9 Gy to the lungs [FTBI]) before BMT. The male-to-female ratio was 204/122 (1.67), and the median age was 30 years (mean: 30 +/- 11, range: 3 to 63). The patients were analyzed according to 3 instantaneous dose rate groups: 118 patients in the LOW group (< or = 0.048 Gy/min), 188 in the MEDIUM group (> 0.048 and < or = 0.09 Gy/min), and 20 in the HIGH group (> 0.09 cGy/min). Conditioning chemotherapy consisted of cyclophosphamide (CY) alone in 250 patients, CY and other drugs in 54, and 22 patients were conditioned using combinations without CY. Following TBI, allogeneic and autologous BMT were realized respectively in 118 and 208 patients. Median follow-up period was 68 months (mean: 67 +/- 29, range: 24 to 130 months).

RESULTS

Five-year survival, LFS, RI and TRM rates were 42%, 40%, 47%, and 24%, respectively. Five-year LFS was 36% in the STBI and 45% in the FTBI group (p = 0.17). It was 36% in the LOW group, 42% in the MEDIUM group, and 30% in the HIGH group (p > 0.05). Five-year RI was 50% in STBI, 43% in FTBI, 55% in LOW, 41% in MEDIUM, and 44% in HIGH groups (STBI vs. FTBI, p = 0.48; LOW vs. MEDIUM, p = 0.03; MEDIUM vs. HIGH, p = 0.68). TRM was not influenced significantly by the different TBI techniques. When analyzing separately the influence of fractionation and the instantaneous dose rate either in ANLL or ALL patients, no difference in terms of survival and LFS was observed. Fractionation did not influence the 5-year RI both in ANLL and ALL patients. However, among the patients with ANLL, 5-year RI was significantly higher (58%) in the LOW group than the MEDIUM group (31%, p = 0.001), whereas instantaneous dose rate did not significantly influence the RI in ALL patients. The 5-year TRM rate was significantly higher in allogeneic BMT group both in ANLL (37%) and ALL (37%) patients than those treated by autologous BMT (ANLL: 15%, ALL: 18%; p = 0.002 and 0.02, respectively). The 5-year estimated interstitial pneumonitis (IP) and cataract incidence rates were 22% and 19%, respectively, in all patients. IP incidence seemed to be higher in the HIGH group (46%) than the MEDIUM (19%, p = 0.05) or LOW (25%, p = 0.15) groups. Furthermore, cataract incidence was significantly influenced by fractionation (STBI vs. FTBI, 29% vs. 9%; p = 0.003) and instantaneous dose rate (LOW vs. MEDIUM vs. HIGH, 0% vs. 27% vs. 33%; p < 0.0001). Multivariate analyses revealed that the best factors influencing the survival were 1st CR (p = 0.0007), age < or = 40 years (p = 0.003), and BMT after 1985 (p = 0.008). The RI was influenced independently only by the remission status (p = 0.0002). On the other hand, the TRM rate was lower in patients who did not experience graft-vs.-host disease (GvHD, p < 0.0001), and in those treated after 1985 (p = 0.0005). GvHD was the only independent factor involved in the development of IP (p = 0.01). When considering the cataract incidence, the only independent factor was the instantaneous dose rate (p = 0.0008).

CONCLUSION

The outcome of BMT patients conditioned with TBI for acute leukemia was not significantly influenced by the TBI technique, and TRM seemed to be lower in patients treated after 1985. On the other hand, cataract incidence was significantly influenced by the instantaneous dose rate.