Immunotherapy and radiotherapy for older patients with locally advanced rectal cancer unfit for surgery or decline surgery: a practical proposal by the International Geriatric Radiotherapy Group

The standard of care for locally advanced rectal cancer is total neoadjuvant therapy followed by surgical resection. Current evidence suggests that selected patients may be able to delay or avoid surgery without affecting survival rates if they achieve a complete clinical response (CCR). However, for older cancer patients who are too frail for surgery or decline the surgical procedure, local recurrence may lead to a deterioration of patient quality of life. Thus, for clinicians, a treatment algorithm which is well tolerated and may improve CCR in older and frail patients with rectal cancer may improve the potential for prolonged remission and potential cure. Recently, immunotherapy with check point inhibitors (CPI) is a promising treatment in selected patients with high expression of program death ligands receptor 1 (PD- L1). Radiotherapy may enhance PD-L1 expression in rectal cancer and may improve response rate to immunotherapy. We propose an algorithm combining immunotherapy and radiotherapy for older patients with locally advanced rectal cancer who are too frail for surgery or who decline surgery.

Clinical treatment planning in gynecologic cancer

Treatment planning in gynecologic cancer is a complicated and difficult procedure. It requires an adequate preoperative assessment of the true extent of the patient's disease process and oftentimes this can be achieved not only by conventional studies but must employ surgical exploratory techniques in order to truly define the extent of the disease. However, with contemporary sophisticated treatment planning techniques that are now available in most contemporary departments of radiation oncology, radiation therapy is reemerging as an important and major treatment technique in the management of patients with gynecologic cancer.

Cytokine profiles in patients receiving wide-field + prostate boost radiotherapy (xRT) for adenocarcinoma of the prostate

As a result of the association between ionizing irradiation and the induction of inflammatory and fibrogenic cytokines, circulating levels of IL-1alpha, macrophage colony stimulating factor (M-CSF) and TGFbeta were measured in a group of 37 patients who presented with well-defined adenocarcinoma of the prostate and were treated with wide-field pelvic (WFP) + prostate boost (PB) radiotherapy (xRT) according to RTOG protocols 94-08 and 94-13. First and foremost, patients with prostate cancer (PC) were found to have a significantly (p<0.05) elevated plasma level of the three cytokines prior to treatment. Moreover, during WFP + PB xRT, these circulating cytokine levels were further elevated, the elevation occurring in the form of cyclic waves; the concurrent waves of elevated IL-1alpha and M-CSF preceding that of TGFbeta. In addition to providing support for the existence of a humoral response to xRT in patients receiving WFP + PB xRT, the data demonstrated a significant correlation between the integral radiation dose (ID) and the temporal expression and magnitude of plasma IL-1alpha, M-CSF and TGFbeta levels in patients that had received 1-5 fractions (1.8-9Gy) of WFP + PB xRT. Thereafter, the appearance of elevated waves of cytokine expression in the patient's plasma continued independent of additional fractions of WFP + PB xRT.

Micronuclei in lymphocytes of prostate cancer patients undergoing radiation therapy

To further verify the applicability of the micronucleus (MN) assay in biodosimetry, we measured the MN yield in cytokinesis-blocked (CB) peripheral blood lymphocytes (PBL) of eight prostate cancer (PC) patients. These patients had no previous chemotherapy or radiotherapy (xRT). They were treated with standardized schemes of fractionated pelvic xRT. Before xRT, and at one random time-point during the course of xRT, blood samples were collected from each patient for the following purposes: (1) to verify the relationship between the MN yield in PBL and the estimated equivalent (EQ) total-body absorbed dose; and (2) to evaluate the individual differences of ex vivo radiation dose-response (1-4 Gy) relationship of MN yield in PBL before xRT. The number of xRT fractions, cumulative tumor dose, and EQ total-body absorbed doses of these patients represented a wide range. We found in PBL of these patients that (1) MN yield (Y) increased linearly with the estimated EQ total-body absorbed dose as Y=14.6+9.2D (R(2)=0.7, p=0.007); the distributions of MN yield were overdispersed; the ratio of relative increment of MN yield per 1000 binucleated (BN) PBL ranged from 0.9 to 8.2 (median: 4.1) folds above that of the respective baseline levels; and (2) before xRT, the MN yields also increased linearly with the ex vivo radiation dose; at each radiation dose level, the distributions of MN yield were overdispersed in most patients. In two of the three patients with xRT-induced early side effects (cystitis, diarrhea), the MN yield in PBL induced by ex vivo irradiation before xRT was significantly higher than in the other patients without xRT-induced side effects. These findings suggest that MN yields in CB PBL can be used as an in vivo biodosimeter. Since the differences in individual ex vivo radiation dose-response relationship of MN yield in PBL before xRT appeared to be significant, our preliminary results also suggest that it may be possible to identify individual intrinsic radiosensitivity before the start of xRT.

Effect of ex vivo hyperthermia on radiation-induced micronuclei in lymphocytes of cancer patients before and during radiotherapy

To investigate the effect of ex vivo hyperthermia (HT) and 137Cs-irradiation on micronucleus (MN) production in cytokinesis-blocked lymphocytes, we obtained the peripheral blood samples from the same cancer patients (n=6) before and during fractionated partial-body radiotherapy (xRT). The whole blood cultures were heated at 43.5 degrees C for 60 min, followed by 137Cs irradiation (0-4 Gy). The control cultures from the same patients were incubated at 37 degreesC after being exposed to radiation. The lymphocytes were then stimulated with PHA. Cytochalasin B was applied at 44 h, and lymphocytes were harvested at 72 h. MN frequency was determined on Giemsa-stained slides. We found that in patients before xRT, HT (43.5 degrees C) significantly increased the MN yield (mean+/-SEM) in unirradiated lymphocytes from 15.6+/-2.8 (37 degrees C) to 39.7+/-10.9. Further, in patients either before or during xRT, when the lymphocytes were treated with HT (43.5 degrees C) and combined with ex vivo irradiation, the MN yield (Y) could be estimated by a linear equation Y=C+alphaD. Our findings indicate that as measured by the MN production in cytokinesis-blocked lymphocytes, HT alone at 43.5 degrees C++ induced DNA damage. Moreover, it enhanced the radiation-induced cytogenetic damage. Therefore, the application of HT may impair the T-cell function in cancer patients who are receiving radiotherapy. 1998 Elsevier Science B.V.

Reliability of finger stick capillary blood for the lymphocyte micronucleus assay

Compared with peripheral blood sampling, capillary blood collecting by finger stick is less traumatic and more convenient. To assess the sensitivity and reliability of capillary blood for the lymphocyte micronucleus (MN) assay, this study was performed in three sample groups, i.e. healthy donors (n = 3), cancer patients before treatment (n = 7), and cancer patients who were undergoing fractionated partial-body radiotherapy (n = 9). For each group, we measured three intra-individual variables, i.e. micronucleus (MN) frequency, binucleate (BN) index, and micronucleated BN index of lymphocytes obtained from capillary blood and the corresponding peripheral blood. Our results indicated that in all three sample groups, the differences in these variables between capillary blood and peripheral blood either before or after ex vivo 137Cs irradiation (2 Gy) were insignificant. Since capillary blood is more accessible than peripheral blood, we believe that it is a reliable source for the lymphocyte MN assay especially when venipuncture is not convenient.

External beam radiation for retinoblastoma: results, patterns of failure, and a proposal for treatment guidelines

PURPOSE

To analyze treatment results and patterns of failure following external beam radiation for retinoblastoma and propose treatment guidelines according to specific clinical variables.

METHODS AND MATERIALS

We analyzed 27 patients (34 eyes) with retinoblastoma who received external beam radiation as initial treatment at Hahnemann University Hospital from October 1980 to December 1991 and have been followed for at least 1 year. Of the 34 eyes, 14 were Groups I-II (Reese-Ellsworth classification), 7 were Group III, and 13 were Groups IV-V. Doses ranged from 34.5-49.5 Gy (mean 44.3 Gy, median 45 Gy) in 1.5-2.0 Gy fractions generally delivered through anterior and lateral wedged pair fields.

RESULTS

At a mean follow up of 35.2 months (range 12-93 months), local tumor control was obtained in 44% (15 out of 34) of eyes with external beam radiation alone. Salvage therapy (plaque brachytherapy, cryotherapy, and/or photocoagulation) controlled an additional 10 eyes (29.5%), so that overall ocular survival has been 73.5%. Local tumor control with external beam radiotherapy alone was obtained in 78.5% (11 out of 14) of eyes in Groups I-II, but in only 20% (4 out of 20) of eyes in Groups III-V. A total of 67 existing tumors were identified prior to treatment in the 34 treated eyes and local control with external beam radiation alone was obtained in 87% (46 out of 53) of tumors measuring 15 mm or less and in 50% (7 out of 14) of tumors measuring more than 15 mm. When analyzing patterns of failure in the 19 eyes that relapsed, a total of 28 failure sites were identified and consisted of progression of vitreous seeds in seven instances (25% of failure sites) recurrences from previously existing tumors in 10 instances (36% of failure sites) and development of new tumors in previously uninvolved retina in 11 instances (39% of failure sites).

CONCLUSIONS

1) We find that external beam radiation to a dose of 45 Gy in fractions of 1.5 to 2.0 Gy provides adequate tumor control in retinoblastoma eyes Groups I-II (Reese-Ellsworth classification) or tumors measuring 15 mm in diameter or less. Eyes in more advanced group staging or containing tumors larger than the 15 mm seem to require higher radiation doses. We propose treatment guidelines for external beam radiation of retinoblastoma that specifically take into account the important clinical variables of tumor stage and patient age. 2) External beam radiation does not prevent the appearance of new tumors in clinically uninvolved retina. Therefore, the traditional belief that external beam radiation can treat the retina "prophylactically" should be seriously questioned. Due to this finding and their significant less morbidity, focal treatment modalities (plaque brachytherapy, photocoagulation, and/or cryotherapy), when clinically feasible, should be considered the treatment of choice for intraocular retinoblastoma. External beam radiation should be considered only when focal treatment modalities are not clinically indicated.

Thermoradiotherapy for brain tumors. Three cases of recurrent malignant astrocytoma and review of clinical experience

Three patients with symptomatic, recurrent supratentorial malignant astrocytoma were retreated with combined interstitial iridium-192 brachytherapy (RT) and hyperthermia (HT): 50 Gy at 50 cGy/h was delivered 10 mm outside the computed tomography (CT) enhancement border through stereotactically placed plastic tubes, and 915-MHz microwave antenna heating was done for 60 min within 30 min either before or after irradiation. Invasive thermometry data were obtained from the tumor and adjacent brain tissue. The patients tolerated the treatment well and two thirds improved. All patients developed cerebral edema, one also developed scalp infection, and another patient developed meningeal infection. Exceeding the expectancy without treatment, overall survival was 7, 12, and 15 months. On autopsy, two of the patients' brains revealed no active tumor in the treated regions, but one displayed tumor in untreated parts. The HT-RT treatment was very effective, but the original tumor extent was not apparent by the CT imaging technique. A postimplant resection approach may be advisable to minimize postimplant edema. Our data are in agreement with the available literature on more than 400 patients. However, our aim of extending survival decisively could not be realized.

In vivo isocenter dose in two hip prosthesis patients

Hip prostheses may cause irradiation dose inhomogeneities in conventional four-field target volumes to the pelvis. Two patients, with bilateral and unilateral prostheses, were subjected to thermoluminescent dosimetry measurements in the prostatic urethra during 24 MV photon portal exposures. The results suggested a 13% decrease in absorbed dose only for conventional four-field beam geometry with bilateral prostheses, as compared to oblique four-field beam geometry or unilateral prosthesis. This supports the suggestion that beam technique modifications may be warranted for patients with hip prostheses.

Primary advanced and local recurrent head and neck tumors: effective management with interstitial thermal radiation therapy

Thirty-seven patients with 18 primary advanced or persistent, 16 local recurrent, and three local metastatic tumors of the head and neck were treated with a combination of interstitial low-dose iridium-192 radiation therapy and interstitial 915-MHz microwave hyperthermia supplemented by external radiation therapy. Twenty-eight lesions received an additional external radiation dose of 21-61 Gy. Interstitial hyperthermia was applied immediately before Ir-192 was placed and after its removal for 45-60 minutes at 41 degrees C-44 degrees C. Follow-up ranged from 4 to 45 months. At 3 months, complete remission occurred in 25 lesions (68%); partial remission, in nine (24%); and no change or progressive disease, in three (8%). At 12 months of follow-up in 32 lesions, local control was achieved in 23 (72%), with the patients alive, and in four (12%), with the patients dead. There were five local recurrences, one of which occurred after complete response. Lesion type, tumor volume, radiation dose, and thermal quality at high minimum temperature were identified as prognostic factors influencing complete remission. The combined treatment was well tolerated.

Radiotherapy of retinoblastoma. A review of 63 children treated with different irradiation techniques

This is a retrospective review of treatment results in 63 children with retinoblastoma (RB) who received therapeutic irradiation from January 1975 to June 1988. Patient ages ranged from birth to 5 years with a mean age of 12.5 months. Three treatment groups were identified. In Group A, episcleral plaque was the only irradiation modality. In this group, 24 patients and 25 eyes with tumors of Reese-Ellsworth Stages I to III, and selected Stage VB tumors were irradiated using eye plaques. Twenty-two of 25 (88%) eyes are without evidence of disease (NED), and all patients are alive. Two eyes were enucleated for recurrent RB. Two of 23 eyes developed minimal cataracts. In Group B, external-beam was the only irradiation modality. Twelve patients with 21 involved eyes comprise this group. Thirteen eyes received EBRT alone. Seventy-seven percent of 13 eyes have NED. Four eyes developed cataracts. Three of 13 eyes required enucleation for progression of disease; one of these was Stage IVA and two of them were Stage VA. For Group C, external-beam plus episcleral plaque was used. Twenty-seven patients and 51 eyes with advanced retinoblastoma were included in this group. Episcleral plaque was used in 29 eyes as a salvage procedure for recurrent RB, or in selected cases was used as a boost after initial external beam irradiation. Fifteen of 29 eyes (52%) remain with NED with useful vision, and nine developed cataracts. Enucleation was performed in 14 eyes for recurrent RB. The authors conclude that radiation therapy has a major role in the management of RB due to its ability to control even advanced disease, allowing preservation of vision in a significant number of patients.

Initial results of phase I/II interstitial thermoradiotherapy for primary advanced and local recurrent tumors

Since January 1986 in a phase I/II study, 45 lesions (30 head and neck, 11 pelvic, and 4 other lesions) in 44 patients (24 men, 20 women; age 18-81 years) received a combination of interstitial Ir-192 radiotherapy (IRT) and interstitial 915 MHz MW hyperthermia (IHT) supplemented by external radiation (ERT). In June 1989, evaluation was performed for lesions with minimum follow-up (FU) of 6 months and FU periods between 6 and 39 months (mean: 16 months, SD +/- 9). The tumors comprised 21 advanced primary (AP) lesions without prior ERT, 18 local recurrent (LR) and 6 local metastatic (LM) lesions with variable prior treatment modes; 24 lesions had received prior ERT between 40 and 70 Gy, 23 chemotherapy and 30 prior surgery. The mean dimensions of 42 lesions were 4.5 X 4.0 X 3.0 (cm3) with tumor volumes ranging from 12 to 135 cm3 (mean: 54 cm3, SD +/- 35); 3 lesions had extensive tumor volumes greater than 225 cm3. IHT was applied immediately prior to and/or after low-dose Ir-192 IRT (20-30 Gy) for 60 min at temperatures between 41 and 44 degrees C. ERT (40-50 Gy) was always given for AP and LM lesions, but variably applied for previously irradiated LR lesions, thereby avoiding the cumulative radiation dose exceeding 110 Gy per site. IRT doses ranged from 17-48 Gy (mean: 26.8 Gy, SD +/- 8) at a dose rate of 25-70 cGy/h (mean: 42 cGy/h, SD +/- 12). Thirty-three lesions received additional ERT of 30-56 Gy (mean: 46.5 Gy, SD +/- 9). Total radiation dose (IRT + ERT dose) ranged from 31 to 82 Gy (mean: 61 Gy, SD +/- 18). The hyperthermia systems of Lund/Buchler 4010 and Clini-Therm Mark VI/IX with thermistor or fiber-optic thermometry devices were employed. Initial response at 3 months FU showed 31 (69%) lesions complete response (CR), 10 (22%) partial response (PR), and 4 (9%) no change (NC). Long-term response of 30 lesions at 12 months FU revealed a total of 27 (90%) with local control (LC) and 3 (10%) in-field recurrences. Six patients died prior to 12 months FU, three with LC and three with progressive disease. So far 10 (22%) patients have developed distant metastases. Acute side-effects occurred in 15 lesions (33%) resulting in 12 (27%) long-term complications with 3 lesions (7%) requiring surgery.(ABSTRACT TRUNCATED AT 400 WORDS)

Superficial chest wall recurrences of breast cancer: prognostic treatment factors for combined radiation therapy and hyperthermia

Forty-nine patients with chest wall recurrences of breast carcinoma received radiation therapy and 915-MHz microwave hyperthermia for 95 lesions. Follow-up ranged from 3 to 39 months, with five patients dying before 6 months follow-up. At 1 month follow-up, 49 (52%) of 95 lesions showed complete response; 28 (29%), partial response; and 18 (19%), no change. At 6 or more months follow-up, 54 (67%) of 81 lesions demonstrated local control; 10 (12%), partial response; six (7%), no change; and 11 (14%), local-regional recurrences. Superficial blisters occurred in 24 (25%) of 95 lesions, whereas long-term complications (deep necrosis, subcutaneous burns) occurred in seven (7%) lesions. Relapse occurred in 16 (17%) lesions, seven after initial complete response and nine after partial response. Several prognostic treatment factors were identified: applied radiation dose (greater than 30 Gy, P less than .01), size of tumor (less than 6 cm diameter, P less than .001), minimum tumor temperature (greater than 41 degrees C, P less than .001), and status of disease (M0 or M1 vs M2, P less than .001). Treatment complications were correlated with maximum temperatures (greater than 45 degrees C, P less than .001). In summary the palliative treatment concept proved to be safe and effective.

Analysis of treatment results in 36 children with retinoblastoma treated by scleral plaque irradiation

This is a retrospective analysis of treatment results in 36 patients with retinoblastoma treated by the Radiation Oncology Department of Hahnemann University Hospital and the Division of Oncology of Wills Eye Hospital between January 1975 and December 1986. There were 14 females and 22 males; ages ranged from 2 months to 4 1/2 years of age at presentation. Leukocoria was the most common clinical sign of presentation. These patients were treated with external beam radiation therapy in combination with scleral plaque irradiation in 20 patients and with scleral plaque alone in 16 patients. Cobalt-60, Iodine-125, Iridium-192, and Ruthenium-106, scleral plaques were used. The dose delivered to the mid plane of the globe was 40 Gy and the scleral dose adjacent to the plaque was in the range of 180-200 Gy. The treatment was successful in 30 of 36 patients. Complications of radiation therapy were minimal in patients treated by scleral plaque alone. The advantages of this treatment modality are discussed.

Recurrence of posterior uveal melanoma after 60Co episcleral plaque therapy

The authors analyzed the clinical and follow-up data on 277 selected patients with primary choroidal or ciliochoroidal melanoma who were treated with 60Co plaque radiotherapy between 1976 and 1982. Local recurrence of the irradiated melanoma developed in 39 (14%) patients during the follow-up interval. The 5-year tumor recurrence rate (Kaplan-Meier) was estimated to be 12%. Multivariate prognostic factor analysis (Cox proportional hazards modeling) identified the largest linear tumor dimension and proximity of the posterior margin of the tumor to the optic nerve head as predictors of recurrence. The 5-year survival rate of patients whose tumors recurred (58%) was significantly (log-rank test P = 0.0023) worse than that of patients whose tumor remained clinically controlled (82%).

The treatment of primary intraocular malignancy

This paper will summarize much of the information derived in an association between The Department of Radiation Oncology of Hahnemann University Hospital and the Oncology Service of Wills Eye Hospital of Thomas Jefferson University, a collaborative effort for the treatment of primary intraocular malignancies that has spanned the last dozen years. In that time we have treated malignant intraocular melanoma by radioactive eyeplaque brachytherapy and have begun to develop a similar program for treatment of recurring retinoblastoma. These experiences will be described.

Interstitial stereotactic irradiation of astrocytomas

History, rationale, methods, and problems of irradiation of astrocytomas by stereotactic implantation technique are briefly outlined. The literature indicates that this method appears to be suitable to help increase survival and improve quality of life for high-grade glioma patients.

Oral slough caused by dentifrice detergents and aggravated by drugs with antisialic activity

A unusual type of oral desquamation appeared as grayish-white gelatinous membranes on the floor of the mouth, lips, vestibules, and gingiva in a 50-year-old woman. The painless desquamation was caused by synthetic dentifrice detergents (foaming agents) and was exacerbated by the patient's use of drugs with antisialic action.

Development of neural elements in apical portions of cat primary and permanent incisor pulps

Pulp development was studied with light and electron microscopy in apical portions of cat primary and permanent incisors at various stages of development in order to qualitatively assess hypothesized differences during maturation. Primary and permanent tooth pulps passed through similar stages up to when the primary teeth began to resorb. At that point permanent tooth pulps continued to develop in complexity relative to myelinated axons and developed thin epineurial sheaths. Although the stages were similar in several regards, the time needed by the permanent tooth pulps to reach each stage was considerably greater than for the primary tooth pulps. It is of interest that the young permanent teeth had only a small portion of their final complement of nerves in spite of their relatively complete development. Individual axons, especially myelinated axons, appeared more immature in younger primary and permanent teeth. This suggests a less mature sensory capability for erupting primary teeth as compared to fully developed primary teeth as well as for erupting and young permanent teeth compared to old permanent teeth.

Cation-dependent structures associated with membranes in the rat central nervous system

As observed by high magnification electron microscopy, potassium ions induce osmiophilia at the extracellular side of triple layered plasma membranes in the central nervous system of the rat. In contrast, sodium ions induce a widening of the intracellular lamina of these membranes, and do not result in observable extracellular deposits. The observations suggest the existence of potassium and sodium ion-selective structures associated with opposite surfaces of the neuron membrane. Use of the fixative vehicle as a cytochemical reagent is proposed.

Natural desensitization of exposed tooth roots in dogs

With scanning electron microscopy, electron microprobe elemental analysis, and an objective method for eliciting responses to electrical stimuli, exposed tooth root surfaces in dogs were found to become naturally desensitized with time, perhaps because of the formation of acquired pellicle.

Brain Extracellular Space and Membrane Morphology Variations with Preparative Procedures

When considering extracellular space and plasma membrane structure in the brain, duration of postfixation in osmium tetroxide and embedding procedure are equally as important as the dehydrating agent employed. The use of ethanol instead of acetone for dehydration does not adequately explain the finding of a 5-30 nm space instead of apposed membranes. In this investigation it was found that postfixation for 3 h stabilized the tissue sufficiently so that ethanol or acetone dehydration followed by Vestopal W, Epon 812, or Araldite 502 embedding produced similar results, and apposed, triple-layered plasma membranes were prevalent. In contrast, when postfixed for a shorter time, namely 90, 45 or 30 min, ethanol dehydration followed by Epon embedding resulted in the common ‘20-nm’ extracellular space and only partially triple-layered plasma membranes. The same tissue dehydrated with acetone and Vestopal embedded looked much like the equivalent 3-h postfixed material, i.e. it had apposed, triple-layered plasma membranes. When acetone dehydration and Epon embedding, or ethanol dehydration and Vestopal embedding were used with tissue of short postfixation time, the results were comparable. Apposed membranes interspersed with erratic amounts of extracellular space were common and plasma membranes tended to show an indistinct outer leaflet. Taken together the results indicate that the presence of apposed triple-layered plasma membranes is at least as valid as the common finding of a 20-nm space and partially tri-laminar membranes.