The Effect of Active Release Technique on Hamstring Extensibility: A Critically Appraised Topic

CLINICAL SCENARIO

Hamstring extensibility plays a significant role in maintaining postural alignment essential for a functional musculoskeletal system. When hamstring extensibility is lacking, individuals are placed at a higher risk for developing various lumbar spine, pelvis, knee, and foot dysfunctions. Limited hamstring extensibility is common, occurring in as much as 40% of college students and 86% of the adult population. Therefore, it is essential to maintain hamstring extensibility, which can be aided by understanding intervention effectiveness for improving flexibility.

PURPOSE

To critically appraise the literature on the effectiveness of Active Release Technique (ART) for the treatment of hamstring extensibility deficits.

CLINICAL QUESTION

What is the effect of ART in a healthy population with or without hamstring extensibility deficits?

SUMMARY OF KEY FINDINGS

Three studies were included for critical appraisal. Two studies concluded a single treatment session of ART that individuals possessing limited straight leg raise range of motion experienced improved active knee extension, popliteal angle, and sit-and-reach test measures. In the third study, a single session of ART was effective at improving hamstring extensibility in males without hamstring extensibility dysfunction.

CLINICAL BOTTOM LINE

Based on the current level 1 and level 3 evidence, ART may be an effective treatment to produce acute increases in hamstring extensibility. Future research is still needed.

STRENGTH OF RECOMMENDATION

Level B evidence exists to support the use of ART to improve hamstring extensibility in the healthy population.

Tolerance and efficacy of dose escalation using IMRT combined with chemotherapy for unresectable esophageal carcinoma: Long-term results of 51 patients

PURPOSE

The optimal dose in esophageal cancer patients treated with definitive chemoradiation (CRT) remains debated. We herein report on the dosimetric results, treatment-related toxicities and long-term outcomes of escalated dose up to 60Gy delivered with intensity-modulated radiotherapy (IMRT).

MATERIALS AND METHODS

All consecutive patients that received a definitive CRT>50Gy for an unresectable esophageal carcinoma between 2010 and 2015 were retrospectively evaluated for this study. Methodology included data base search, delayed toxicity grading, statistical testing including frequency analysis and survival analysis.

RESULTS

A total of 51 patients were irradiated for a squamous cell carcinoma (86.3%) or an adenocarcinoma (13.7%). The median age at diagnosis was 62 years. Seven patients were simultaneously irradiated for another synchronous primary tumor. Forty-six patients (90.2%) received concurrent platin-based chemotherapy. The median prescribed doses were 60Gy (54-66) and 48Gy (44.8-56) delivered in 30 (27-35) fractions to the high and the low risks PTV respectively. The mean dose delivered to the lungs was 11.4Gy (IC 95%: 4.8-19.8), the median volumes receiving up to 20Gy (V20) and 30Gy (V30) were 13.5% (3.0-46.0) and 4.6% (0.7-19.8) respectively. The mean dose delivered to the heart was 13.9Gy (IC 95%:0.3-31.3) with a median V40 of 3.3% (0.0-25.0). One treatment-related death occurred within days after RT completion (neutropenic aplasia). After a median follow-up of 2.7 years (95% CI: 1.9-4.3), the 2-year overall survival, disease free survival and loco-regional control rates were 53.6%, 42.0% and 72.8% respectively. Delayed treatment related-toxicities ≤grade 3 occurred among 25 patients (62.5%) mostly esophageal stricture (79.2%).

CONCLUSION

We demonstrated in this study that dose escalation using IMRT in combination with platin-based chemotherapy as a definitive treatment for esophageal carcinoma is safe and results in higher loco-regional and control survival when compared to previously reported data.

[Definitive or neo-adjuvant chemoradiation in esophageal carcinoma?]

Management of resectable esophageal carcinoma is based on a multimodal treatment associating neo-adjuvant chemoradiation before surgery. This therapeutic sequence allows a disease-free survival rate at 2 years around 45% but remains associated with a high post-operative morbidity. In case of definitive chemoradiotherapy, the dose delivered to the macroscopic disease is a controversial topic since decades and the prognosis of patients treated in this setting at the dose of 50Gy remains poor. This article proposes a review of the main published data and the ongoing studies related to the management of these patients.

[Stereotactic hypofractionated radiation therapy as a bridge to transplantation for hepatocellular carcinoma: Case report of a complete pathological response and review of the literature]

Patients with hepatocellular carcinoma who are on liver transplant waiting list usually require local treatment to limit any risk of tumour growth. Historically percutaneous radiofrequency ablation or transarterial chemoembolization represented the major therapeutic alternatives. Depending on the size, or the topography of the lesion these two techniques may not be feasible. Radiation therapy under stereotactic conditions has recently emerged in the management of localized hepatocellular carcinoma as an alternative to the focused therapies performed to date. We herein report the case of a 43-year-old patient harbouring a complete histological response on explant after liver stereotactic irradiation and discuss its role in the management of hepatocellular carcinoma before liver transplantation.

[Postoperative external beam radiotherapy for medullary thyroid carcinoma with high risk of locoregional relapse]

PURPOSE

To assess the outcome of locally advanced medullary thyroid carcinoma treated with surgery and adjuvant external beam radiotherapy.

PATIENTS AND METHODS

Twenty-nine consecutive patients with non-metastatic medullary thyroid carcinoma treated in our institution between January 1995 and December 2012 were retrospectively evaluated. All underwent curative-intended optimal surgery, followed by external beam radiotherapy because of high risk of locoregional relapse. Twelve patients were stage III, 16 IVa and 1 IVb. Positive surgical margins were present in 11 cases (10 R1 and 1 R2). Median and average preradiotherapy serum calcitonin were 141pg/mL and 699pg/mL, respectively. Fourteen patients received 3D-conformal radiotherapy and 15 received intensity-modulated radiotherapy. Median prescribed dose was 63Gy to the high-risk volumes and 54Gy to the low-risk volumes. Treatment was delivered in 30 fractions. The median gap between surgery and radiotherapy was 1.9months. Median follow-up was 76.4months.

RESULTS

Kaplan-Meier estimates of 5-year locoregional relapse-free survival and overall survival were 79 and 96 %, respectively. Among the five locoregional relapses, two were related to a macroscopic metastatic cervical lymph node that was unfortunately not removed during the lymphadenectomy. Eight of ten patients with microscopic positive margins (R1) were controlled regarding the thyroidectomy bed. Eight patients had normal serum calcitonin after external beam radiotherapy, of whom only one developed a locoregional relapse during follow-up. Regarding the 21 patients with persistent positive serum calcitonin after treatment, only ten developed a macroscopic locoregional or distant relapse. One grade III and no grade IV acute morbidity were reported. Fifteen patients reported grade II chronic morbidity and no grade III/IV.

CONCLUSION

Maximal surgery followed by adjuvant external beam radiotherapy as a treatment for locally advanced medullary thyroid carcinoma provides a high rate of long-term locoregional control and overall survival with limited toxicity. Postoperative external beam radiotherapy should be considered when patients present features indicating a high risk of locoregional relapse.

[Systematic neck dissection in squamous cell carcinoma of the oral cavity]

OBJECTIVES

To evaluate the neck control after prior surgical management of patients with squamous cell carcinoma of the oral cavity and to quantify the ratio of patients among whom neck dissection did not have a real therapeutic value. To discuss the usefulness of the sentinel node biopsy in this group of patients.

METHOD

Retrospective analysis of patients with epidermoid carcinoma of the oral cavity who had systematically a neck dissection.

RESULTS

Thirty-nine files of patients have been processed. We found 45% patients classified pN0 (among whom about one half where classified pT4). With a mean follow-up of 19 months, we did not find any cervical lymph node relapse. Five patients died (13.5%) without any cervical disease.

CONCLUSION

The systematic cervical lymph node dissection remains the most effective means to obtain the neck control of squamous cell cancers of the oral cavity. It however was applied without therapeutic value for 45% of the patients of this series. The validation of the sentinel node concept as a method of cervical staging should make it possible to avoid this surgical procedure in more than one third of the cases.

Definitive chemo-radiotherapy (CRT) with folfox 4 or 5FU-cisplatin as first line treatment for patients (pts) with inoperable esophageal cancer (IEC): Final results of a randomized phase II study

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Background: The RTOG regimen of concurrent CRT with 5FU/CDDP represents the standard treatment of pts with IEC (Al- Sarraf JCO, 1997). As new combinations are required to improve survival, we launched a multicenter randomized phase II study to assess the feasibility and endoscopic complete response rate (ECRR) of combination CRT with Folfox 4 (arm A) or 5FU/CDDP (arm B) in pts with IEC. Methods: Radiotherapy (RT) was in both arms 50 Gy (2Gy/fraction) 5 days/ week for 5 weeks. In Arm A, pts received 6 biweekly cycles (cy): Oxaliplatin 85mg/m2 d1 and Leucovorin 200mg/m2 followed by 5-FU 400mg/m2 bolus and 600mg/m2 22h continuous infusion (C.I.) d1–2 ; the first 3 cy were delivered during RT, the 3 other after. Arm B: 4 cy were delivered: CDDP 75mg/m2 d1 followed by 5FU 1,000 mg/m2/d C.I. d1–4, the first two cy during RT and 2 other after RT. To be evaluable pts must have completed the concurrent CRT. Response evaluation (esophagoscopy + CT-scan) was done on week 15; ECRR was reviewed by an independent expert committee. Results: 97 pts (A/B= 53/44) were included and 95 treated: 19% adenocarcinoma, 81% squamous cell carcinoma; median age 59 [39–81] and PS 0–1: 98%. In arms A/B, 89/91% of pts completed the concurrent CRT and 75/70% the full treatment. Main NCI-CTC grade (G) 3–4 toxicities (% per pt) were in arms A/B: neutropenia 19/19, febrile neutropenia 12/5, neutropenic infection 2/7, esophagitis 8/14. Neurotoxicity: in arms A/B, 13%/ 2% of pts had G 2 and 46%/13% G 1 neuropathy, no G 3 neuropathy occurred. 47/40 pts (90%) were evaluable for response. In the ITT population, the ECRR was 44.7% and 30.0%, median TTP was 15.0 [9.9–18.9] / 9.5 [7.6- not reached (NR)] months (mos), median Event Free Survival was 11.6 [8.6–17.2]/ 7.8 [5.1–9.9] mos and the median overall survival was 22.7 [16.7-NR]/ 14.7 [9.2–17.2] mos, in arms A and B respectively. Conclusions: The new concurrent CRT with Folfox4 is a well tolerated and convenient combination with promising efficacy associated with very good survival results. Final data will be presented at the meeting. The study continues as a phase III trial.

No significant financial relationships to disclose.

Oncological outcome of ultra-low coloanal anastomosis with and without intersphincteric resection for low rectal adenocarcinoma

BACKGROUND

The value of ultra-low coloanal anastomosis (CAA) for rectal cancer is dependent on the oncological and functional results. The aim of this comparative study was to evaluate the long-term oncological outcome of CAA with or without intersphincteric resection (ISR) for low-lying rectal tumours.

METHODS

The study population comprised consecutive patients with low rectal cancer who underwent CAA in a single institution between 1977 and 2004. Patients were divided into two groups according to whether or not a partial ISR had been performed. Cox multivariate models were used for survival analysis.

RESULTS

Some 278 patients underwent CAA with curative intent; 173 had ISR and 105 had CAA without ISR. Mean follow-up was 66.8 months. The 5-year actuarial rate for local recurrence, regardless of tumour stage, was 10.6 per cent in the ISR group versus 6.7 per cent for CAA alone (P = 0.405), and the 5-year actuarial overall survival rate was 86.1 and 80.0 per cent respectively (P = 0.318). Cox multivariable analysis revealed that resection of the anal canal was not a prognostic factor for local or metastatic recurrence.

CONCLUSION

Sphincter-preserving surgery appears to be oncologically adequate for very low-lying rectal tumours.

Neo-adjuvant treatment with erlotinb in squamous cell carcinoma head and neck (SCCHN) patients before surgery provides an opportunity to find predictive factors of response

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Background: To date, neither immunohistochemistry (IHC) nor molecular analyses have identified prognostic markers of response to epidermal growth factor receptor (EGFR) tyrosine kinase (TK) inhibitors in SCCHN. Thus, the selection of patients who could benefit from such agents remains a challenge. We designed a ‘pilot’ clinical trial of patients (pts) with SCCHN pending first-line surgery of their disease. Methods: Pts with resectable SCCHN received erlotinib at 150mg/day during the period between pan-endoscopy and surgery. Pharmacokinetic (PK) samples were collected during treatment, which ceased the day before surgery. Results: Thirty five pts were recruited. All of them had resectable SCCHN: oral cavity (17 pts), oropharyngeal (7 pts), hypopharyngeal (5 pts), larygeal (6 pts). Thirty pts received full treatment with erlotinib and the main reason for discontinuation was rash. The median duration of treatment was 21 days (14–27). All pts were evaluated clinically and their tumors assessed radiologically before and after treatment. Out of 30 evaluable pts, 8 were considered as good responders (30–80% decrease in tumor size), 18 had stable disease and 2 had minor progression. Expected toxicities were observed: rash (grade 2/3 in 11 pts), diarrhea (grade 2 in 1 pt). All pts underwent surgery. The incidence of post-operative complications was similar to our historical series. No mutations in the catalytic domain of EGFR TK were found. All tumors were positive for EGFR by IHC. Correlative statistical analyses between PK, toxicity and response data are ongoing and will be presented. Neither over expression of EGFR nor other IHC markers alone were found to be good predictive markers of efficacy. Retrospective analysis of morphological and IHC evaluation in some cell cycle regulators (mainly p21) appeared to be predictive of erlotinib efficacy (sensitivity 87.5%, specificity 88%). Conclusions: Neo-adjuvant treatment with erlotinib in SCCHN pts is well-tolerated. This trial demonstrated a useful prospective method to potentially aid patient selection to improve the design of post-operative adjuvant treatment combinations.

No significant financial relationships to disclose.

Proposition de sélection et délimitation des volumes cibles microscopiques péritumoraux dans les cancers de la cavité buccale et de l'oropharynx (aires ganglionnaires exclues)

This article reviews the concept of selectivity in peritumoral microscopic disease to be included in the Clinical Target Volume (CTV) for elective treatment for oral cavity and oropharyngeal squamous cell carcinoma, using the local tumoral spread. The objective of the present article is to present a procedure for the delineation of the target volumes, required for an appropriate application of 3-DCRT and IMRT for head and neck cancers. These propositions are for the delineation of microscopic peritumoral target volumes when external beam irradiation is required. CTVs are illustrated on CT sections.

Concomitant radiochemotherapy or accelerated radiotherapy: Analysis of two randomized trials of the French Head and Neck Cancer Group (GORTEC)

In the early 1990s, when conventional radiotherapy (RT) was the standard of care in patients with locally advanced head and neck squamous cell carcinoma (HNSCC), two main options were being tested to improve the efficacy and the therapeutic ratio of RT. The first approach evaluated the effect of adding chemotherapy (CT) simultaneously to RT (RT-CT), while the second approach assessed the effect of modified fractionated RT. To answer these two questions, in 1994, the French Group for Head and Neck Oncology Radiotherapy (GORTEC) initiated two randomized trials. A total of 494 patients were entered in these two parallel phase III multicenter trials comparing conventional RT (70 Gy in 35 fractions) either with concomitant RT-CT (226 patients; 70 Gy in 35 fractions with three cycles of a 4-day regimen comprising carboplatin and 5-fluorouracil [5FU]) or with very accelerated RT (268 patients) delivering 64 Gy in 3 weeks. The 5-year overall survival (OS), specific disease-free survival (DFS), and local-regional control rates were improved in favor of simultaneous RT-CT, whereas local-regional control was significantly improved with accelerated RT, along with a marginal effect on OS and DFS. This increased antitumor efficacy was in both cases associated with a marked increase in acute RT-induced toxicity, which was more pronounced with accelerated RT, whereas late effects were marginally increased with the addition of CT and not influenced by accelerated RT. We conclude that both concomitant RT-CT and accelerated RT improved tumor control rates, as compared to conventional RT, along with increased but manageable toxicity. The two regimens are currently being tested in an ongoing randomized study and also being compared to moderately accelerated RT and concomitant CT.

Murine leukemia inhibitory factor enhances retroviral-vector infection efficiency of hematopoietic progenitors

We have investigated the in vitro effects of the cytokine leukemia inhibitory factor (LIF) on normal murine hematopoietic progenitors by measuring recovery and retroviral vector infection efficiency of 13-day posttransplant, spleen-colony-forming cell (CFU-S 13) in short-term culture. Up to a twofold increase in CFU-S13 recovery was observed, from 9.7 x 10(-5) cells in untreated controls to 17.8 to 19.5 x 10(-5) cells, depending on the concentration of LIF. Histologic analysis of spleen colonies from control and LIF-treated marrows demonstrated that there was no detectable alteration in the differentiative potential of CFU-S13. The efficiency of CFU-S13 infection was increased from 15% in untreated controls to 84% to 91% in LIF-treated marrows. Analysis of proviral integration sites in spleen colonies indicated that some CFU-S13 precursors were infected in the LIF-treated marrows.