Quality indicators for hyperthermia treatment: Italian survey analysis

AIM

Nowadays, no Quality Indicators (QI) have been proposed for Hyperthermia treatments. Starting from radiotherapy experience, the aim of this work is to adapt radiotherapy indicators to Hyperthermia and to propose a new specific set of QI in Hyperthermia field.

MATERIAL AND METHODS

At first, radiotherapy quality indicators published in literature have been adapted to hyperthermia setting. Moreover, new specific indicators for the treatment of hyperthermia have been defined. To obtain the standard reference values of quality indicators, a questionnaire was sent to 7 Italian hyperthermia Institutes with a list of questions on physical and clinical hyperthermia treatment in order to highlight the different therapeutic approaches.

RESULTS

Three structure, five process and two outcome QI were selected. It has been possible to adapt seven indicators from radiotherapy, while three indicators have been defined as new specific indicators for hyperthermia. Average values used as standard reference values have been obtained and proposed.

CONCLUSION

The survey performed on 7 Italian centres allowed to derive the standard reference value for each indicator. The proposed indicators are available to be investigated and applied by a larger number of Institutes in which hyperthermia treatment is performed in order to monitor the operational procedures and to confirm or modify the reference standard value derived for each indicator.

Hypofractionated Radiation Therapy for Inoperable Advanced Stage Non-small Cell Lung Cancer

Aims and Background

Inoperable advanced stage lung cancer is usually treated by radiation therapy. Although a minority of patients may achieve prolonged survival with aggressive therapeutic approaches, most patients present with adverse prognostic factors that do not allow curative treatment. For these cases palliation of symptoms becomes the main treatment purpose, and short treatment schedules are commonly employed.

Methods

Fifty-two inoperable patients with stage IIIB or IV non-small cell lung cancer (NSCLC) were treated with a hypofractionated schedule of radiotherapy. Initially all patients received 20 Gy in five fractions, and approximately one month after irradiation completion patients underwent clinical and radiological evaluation. Those that achieved a >50% reduction in tumor load and respiratory symptoms were submitted to a second similar short course of radiotherapy.

Results

Thirty-three (63%) patients received only one course of radiotherapy. After the first evaluation, 19 patients (37%), all stage IIIB, fulfilled the criteria to receive a total dose of 40 Gy. Survival rates at one and two years were 33% and 0%, respectively, in the group of patients that received 20 Gy, and 52% and 21% respectively, in the group treated with 40 Gy. Two-year survival rates were 10% for stage IIIB and 0% for stage IV patients. Among the patients that were irradiated with a dose of 20 Gy, a subjective reduction of dyspnea and cough and remission of hemoptysis were observed in 97%, 82% and 80% cases, respectively. Complete remission of dyspnea and coughing was observed in 17 (89%) and 14 (74%) patients treated with two irradiation courses. Only mild toxicity was recorded.

Conclusions

Our treatment schedule achieved symptom control in the majority of patients. Early evaluation after 20 Gy allowed selection of responsive patients that could benefit from more prolonged treatment.

Concomitant Radiotherapy with Protracted 5-fluorouracil Infusion in Locally Advanced Carcinoma of the Pancreas: A Phase Ii Study

Aims and Background

To evaluate the efficacy of combined radiation therapy and continuous infusion of 5-fluorouracil in patients with locally advanced carcinoma of the pancreas.

Methods

Between January 1992 and June 1999, 31 patients with locally advanced adenocarcinoma of the pancreas were treated in our Institute. In 20 patients, the tumor (65%) was located in the head of the pancreas and in 11 (35%) in the body or tail; 13 cases also showed involved nodes. Radiation therapy consisted in a median dose of 63 Gy in 33-36 fractions applied to the tumor and regional lymph nodes. Chemotherapy with 5-fluorouracil in continuous infusion, 250 mg/m2 daily, was administered in the first and fifth week of the radiation therapy. Thereafter, 22 patients received 3-10 cycles of adjuvant chemotherapy with same doses. Median follow-up of the series was 20 months. The toxicity of the treatment was scored according to WHO criteria. All patients underwent nutritional assessment at the time of radiochemotherapy.

Results

The median overall survival was 15.2 months (range, 4-42). At restaging, 17 cases (55%) showed no change and 14 (45%) a partial remission. At the end of radiochemotherapy in 8 (26%) of the cases there was indication for pancreatectomy, which was executed in 4 patients. At the time of the study, 2 patients (6.4%) were surgically proven disease free. Eleven of the 13 cases (85%) presenting involved nodes showed that the enlarged lymph nodes had disappeared. Nineteen patients (61%) are alive with clinical evidence of disease and 2 cases are alive with liver metastases; 8 patients (26%) died for disease. In 74% of cases there was complete pain control. Tolerance to the regimen was good. Nutritional assistance was evaluated and was found to be correlated to survival.

Conclusions

The results of the series confirm a good tolerance with low acute toxicity. Tumor down-staging and resectability rates were high, together with prolonged survival and a good quality of life.

Patterns of CT lung injury and toxicity after stereotactic radiotherapy delivered with helical tomotherapy in early stage medically inoperable NSCLC

OBJECTIVE

To evaluate toxicity and patterns of radiologic lung injury on CT images after hypofractionated image-guided stereotactic body radiotherapy (SBRT) delivered with helical tomotherapy (HT) in medically early stage inoperable non-small-cell lung cancer (NSCLC).

METHODS

28 elderly patients (31 lesions) with compromised pulmonary reserve were deemed inoperable and enrolled to undergo SBRT. Patterns of lung injury based on CT appearance were assessed at baseline and during follow up. Acute (6 months or less) and late (more than 6 months) events were classified as radiation pneumonitis and radiation fibrosis (RF), respectively.

RESULTS

After a median follow-up of 12 months (range, 4-20 months), 31 and 25 lesions were examined for acute and late injuries, respectively. Among the former group, 25 (80.6%) patients showed no radiological changes. The CT appearance of RF revealed modified conventional, mass-like and scar-like patterns in three, four and three lesions, respectively. No evidence of late lung injury was demonstrated in 15 lesions. Five patients developed clinical pneumonitis (four patients, grade 2 and one patient, grade 3, respectively), and none of whom had CT findings at 3 months post-treatment. No instance of symptomatic RF was detected. The tumour response rate was 84% (complete response + partial response). Local control was 83% at 1 year.

CONCLUSION

Our findings show that HT-SBRT can be considered an effective treatment with a mild toxicity profile in medically inoperable patients with early stage NSCLC. No specific pattern of lung injury was demonstrated.

ADVANCES IN KNOWLEDGE

Our study is among the few showing that HT-SBRT represents a safe and effective option in patients with early stage medically inoperable NSCLC, and that it is not associated with a specific pattern of lung injury.

Role of radiotherapy for high grade gliomas management

We have analyzed the therapeutic standard options for high grade gliomas, with particular attention to the different radiation therapy modalities and techniques and their application considering the natural history of the disease. Of the several therapeutic options, surgical resection remains the initial treatment of choice for patients with high grade glioma; of all adjuvant treatments tested, radiotherapy offers the greatest magnitude of survival benefit, so radiotherapy, which must be started within 6 weeks of surgery, is mandatory for practically all patients with high grade gliomas. In this paper we perform an overview considering the integration between the different therapeutic modalities, with particular attention to the radiation therapy role in the management of high grade gliomas.

Management of oncologic transplant recipient: the profile of the radiation oncologist

Long-term survival after organ transplantation is increasing. As a result, many physicians may encounter various solid organ cancers during follow up. We review papers who address their attention on those malignancies and their treatment. Aim of this work is to discuss the role of radiotherapy especially when helped by new technologies in the management of brain, skin, head and neck, lung, breast, prostate and anal cancer. In our institution we are used to treat such patients by Helical Tomotherapy in order to avoid graft and to limit high risk toxicity. As example, we include a scalp and pelvic irradiation in which high dose conformality is linked to best organ sparing.

A new therapy for kidney injury: regeneration

Because of progressive population ageing and epidemic diffusion of type 2 diabetes mellitus in industrialized Countries, we are attending a growing incidence of end stage renal disease. This phenomenon has induced researchers to study potential alternative methods of renal function replacement. Actually, only dialytic methodics and renal transplant make possible survival of patients with terminal uremia, but both these therapeutic approaches show important limitations. The ideal solution would be represented by the possibility to "regenerate" the injured organ. This is the purpose of Regenerative Nephrology, a new medical domain which tries to develop new therapies through stimulation and induction in humans of regenerative processes already observed in other species, like reptiles and fishes. Such an ambitious and fascinating purpose requires a deep knowledge of the intricate networks which regulate the production of the hormones and mediators involved in the tissue regenerative processes. In this field the kidney embryonic development phases can represent a fundamental study model to acquire information about the reparative mechanisms of the structure and function of this excretory organ.

The erythropoietin and regenerative medicine: a lesson from fish

BACKGROUND

Erythropoietin (EPO), the main haematopoietic growth factor for the proliferation and differentiation of erythroid progenitor cells, is also known for its angiogenic and regenerative properties.

MATERIALS AND METHODS

In this study, we aimed to test the regenerative effects of EPO administration in an experimental model of Sea bass (Dicentrarchus labrax) subjected to amputation of the caudal fin.

RESULTS

Erythropoietin-treated fishes (3000 UI of human recombinant EPO-alpha immediately after cutting and after 15 days) showed an increased growth rate of their fins compared with those untreated (anova variance: P: 0.01 vs. P: 0.04). By analysing fin length at established times (15 and 30 days after cut), EPO-treated fishes always showed an increased length compared with untreated ones (T-15: 1.1 +/- 0.2 vs. 0.7 +/- 0.2 cm, P: 0.03; T-30: 1.9 +/- 0.3 vs. 1.2 +/- 0.2 cm, P: 0.01). Moreover, exogenous EPO administration induced an enormous increase in EPO-blood levels at each observation time (T-15: 2240 +/- 210 vs. 16.7 +/- 1.8 mU mL(-1), P < 0.001; T-30: 2340 +/- 190 vs. 17.1 +/- 1.9 mU mL(-1), P < 0.001), whereas these levels remained quite unmodified in untreated fishes. Immunochemical analyses performed by confocal laser scanning microscopic observations showed an increased expression of EPO-receptors and PECAM-1 (an endothelial surface marker of vessels sprout) in the regenerating tissue, whereas no signs of inflammation or fibrosis were recognisable.

CONCLUSIONS

All these findings confirm EPO as a new factor involved in regenerative processes, also suggesting a potential, future utility for new therapeutical applications in the field of human regenerative medicine.

Involvement of cPLA2 Inhibition in Dexamethasone-Induced Thymocyte Apoptosis

Various molecular mechanisms have been suggested to be involved in dexamethasone induced thymocyte apoptosis. In this study we show that pharmacological inhibition of cytoplasmic PLA2 in mouse thymocytes for 18 h with arachidonyl trifluoromethyl ketone (AACOCF3) (10 μM) and palmitoyl trifluoromethyl ketone (PACOCF3) (10 μM) induced a drastic increase of thymocyte apoptosis comparable to that observed following Dex (10−7 M) treatment, while inhibition of secretory PLA2 with p-bromophenacyl bromide (pBPB) (20 μM) did not. AACOCF3-induced thymocyte apoptosis, similarly to Dex-induced thymocyte apoptosis, was eliminated by cell pre-treatment with the PI-PLCβ inhibitor, U73122, but not by the PC-PLC inhibitor D609. These observations were corroborated by the ability of AACOCF3, like Dex, to induce a rapid and transient increase in DAG generation. In addition, AACOCF3-induced apoptosis involved the activation of the acidic sphingomyelinase (aSMase) but not of the neutral sphingomyelinase (nSMase), as evaluated by measurements of enzyme activity in cell extracts following thymocyte exposure to AACOCF3 and by the ability of monensin to inhibit AACOCF3-induced thymocyte apoptosis. In addition, the AACOCF3 apoptotic effect resulted in an early increase of ceramide levels. AACOCF3-induced thymocyte apoptosis involved the activation of caspase 3, and cell pre-treatment with a caspase 3 inhibitor prevented AACOCF3-induced apoptosis. These observations suggest that cPLA2 inhibition may have a role in Dex-induced thymocyte apoptosis and highlight the importance of cPLA2 activity in thymocyte survival.

Stage III non small lung cancer (NSCLC): Docetaxel (D), gemcitabine (G), and cisplatin (C) as induction chemotherapy, an Italian phase I study

18201

Background: Based on the several clinical trials, combined modality therapy became the standard of care for patients with stage III NSCLC “unresectable” with good performance status (Kathy S. Albain, Educational Book ASCO 2006, 453–461; Thomas E. Stinchcombe, Oncologist 2006, 11, 809–823). The most effective induction chemotherapy has yet to be determined. The objective of this prospective phase I study was to define the maximum tolerated dose (MTD), and to evaluate the activity and safety of one of the third generation triplets as a full dose neoadjuvant regimen in patients (pts) with unresectable Stage III NSCLC. Methods: In this study, chemotherapy-naïve pts with stage IIIA-N2 bulky and IIIB (except malignant pleural effusion) NSCLC were eligible. Inclusion into the trial and treatment decisions were done by multidisciplinary panel involving surgeons, medical oncologists and radiotherapists. All drugs were given intravenously on days 1 and 8, and repeated every 3 weeks up to 2 cycles followed by concurrent chemoradiation. D (30–35 mg/m2) was given first, followed by C (35 mg/m2) and G (1000 mg/m2). Results: From Jan ‘06 to Jul ‘06 twelve eligible pts were enrolled, 10/2 m/f gender; median age 63 (50–72), 1 patient with ECOG PS 0, 11 pts with PS 1; 5 pts with stage IIIA-N2 bulky, 7 pts with stage IIIB NSCLC; nine pts were smokers. All pts were evaluable for toxicity. Toxicity grade 3–4 by CTC criteria was: grade 3 neutropenia in 2/3 patients and grade 3 thrombocytopenia in 1/3 patients on the second dose level of chemotherapy (i.e. docetaxel 35 mg/m2), and was considered dose-limiting. Of 9 pts treated at the MTD (i.e. docetaxel 30 mg/m2), only 1 patient developed grade 4 neutropenia and 1 patient grade 3 thrombocytopenia; 3 patients (30%) had grade 2 neutropenia and grade 2 stomatitis. Of 12 evaluable pts for response, after induction chemotherapy eighty-three percent of patients (9/12 pts) had an objective response and 16,6% (2/9 pts) stable disease. Phase II is continuing for larger patient accrual. Conclusions: The recommended doses for further phase II studies are D (30 mg/m2) followed by C (35 mg/m2) and G (1000 mg/m2) every 3 weeks. This regimen is well tolerated and effective, and appears to be an excellent choice for stage III NSCLC.

No significant financial relationships to disclose.

Elderly and poor prognosis patients with high grade glioma: hypofractionated radiotherapy

AIM

To evaluate efficacy of short-course radiotherapy in elderly and/or poor performance status patients with high grade glioma.

MATERIALS AND METHODS

Twenty-one patients with high grade astrocytoma were selected in our Institute to receive hypofractionated radiotherapy. We considered two radiotherapy treatment arms: in arm I there were 22 patients treated with 60 Gy in 30 fractions at 5 fractions per week; in arm 2 there were 21 patients who received hypofractionated radiotherapy course of 30 Gy in 10 fractions at 5 fractions per week.

RESULTS

In arm1 the median survival time was 8.2 months and the 1 year overall survival was 36%; in arm 2 the estimated median survival was 6.2 months and the 1 year overall survival was 23%. Treatment was without acute toxicity.

CONCLUSIONS

In our experience, hypofractionated radiotherapy seems to be a reasonable treatment option for poor prognosis patients with high grade astrocytoma. It is well tolerated and can reduce the overall treatment time without negative effects on survival compared with conventional fractionation.

Use of probiotics for prevention of radiation-induced diarrhea

AIM: To investigate the efficacy of a high-potency probiotic preparation on prevention of radiation-induced diarrhea in cancer patients.

METHODS: This was a double-blind, placebo-controlled trial. Four hundred and ninety patients who underwent adjuvant postoperative radiation therapy after surgery for sigmoid, rectal, or cervical cancer were assigned to either the high-potency probiotic preparation VSL#3 (one sachet t.i.d.,) or placebo starting from the first day of radiation therapy. Efficacy endpoints were incidence and severity of radiation-induced diarrhea, daily number of bowel movements, and the time from the start of the study to the use of loperamide as rescue medication.

RESULTS: More placebo patients had radiation-induced diarrhea than VSL#3 patients (124 of 239 patients, 51.8%, and 77 of 243 patients, 31.6%; P < 0.001) and more patients given placebo suffered grade 3 or 4 diarrhea compared with VSL#3 recipients (55.4% and 1.4%, P < 0.001). Daily bowel movements were 14.7 ± 6 and 5.1 ± 3 among placebo and VSL#3 recipients (P < 0.05), and the mean time to the use of loperamide was 86 ± 6 h for placebo patients and 122 ± 8 h for VSL#3 patients (P < 0.001).

CONCLUSION: Probiotic lactic acid-producing bacteria are an easy, safe, and feasible approach to protect cancer patients against the risk of radiation-induced diarrhea.

Current radiotherapic procedures and preservation of salivary function in patients with head and neck cancer

Head and neck tumours have poor prognosis: with surgery and radiotherapy, local control is achieved but is associated with damage to speech and swallowing function. Conventional 2-D radiotherapy is based on one fraction of 1.8-2.0 Gy per day; increasing the number of fractions, a higher dose can be administered, with an increase in local control. Today, conventional treatment can be replaced by new techniques: with 3-D Conformal Radiotherapy, higher doses of radiation can be delivered to cancer cells while reducing the amount of radiation received by surrounding healthy tissues: Intensity Modulated Radiation Therapy permits an irregular dose distribution that conforms exactly to the volume of the target, increasing local tumour control and survival and decreasing radiation-induced side-effects.

Local recurrence in breast cancer after conservative surgery: timing of radiotherapy and sequencing of chemotherapy

BACKGROUND

A randomized trial was conducted to determine (a) the role of radiotherapy and chemotherapy on local control and (b) to determine the timing of radiotherapy for early-stage breast cancer.

MATERIALS AND METHODS

Five hundred and ninety patients were treated with both conservative surgery and radiotherapy (group A). The average time interval between surgery and radiation was 90 days for 452 patients and over 90 days for 138 patients. One hundred and ninety-four patients underwent adjuvant therapy based on CMF regimens (group B).

RESULTS

Among 396 patients of group A, 8.1% had local failure; we observed 7.2% local recurrences in 363 patients who received therapy before 90 days and 18.2% in patients who received therapy after 90 days. Among patients of group B, 7.7% had local failure; for patients who underwent radiotherapy before 90 days, the local recurrence rate was 6.6%, compared with 12.3% for patients who underwent therapy more than 90 days after surgery.

CONCLUSION

In patients who are eligible to receive chemotherapy, it is possible to administer radiotherapy after systemic treatment, while in patients who have to be treated with radiotherapy more then 90 days after breast surgery, chemotherapy can reduce the local failure rate.

Prophylaxis of diarrhoea in patients submitted to radiotherapeutic treatment on pelvic district: personal experience

Diarrhoea is a severe side-effect of radiotherapy on the pelvic area. It is due to acute enteric damage. We aimed at determining the ability of a highly concentrated freeze-dried living bacteria compound (VSL/3) to reduce these side-effects in 190 patients receiving radio therapy on the pelvic area. A total of 95 patients received radiotherapy alone and 95 were also administered VSL/3 bags, at doses of one bag three times a day beginning on the first day of the radiotherapy treatment. The same diet was indicated for both groups. All patients were irradiated for 6 to 7 weeks, with Linac X-6 MV or 15 MV through a box multiportal technique with the lower limit of the fields below the obturator foramina, upper limit at L5-S1, lateral limit 1.5 cm beyond the innominate hip. The total radiated dose ranged from 60 to70 Gy for a daily dose of 180 cGy. Gastroenteric toxicity was rated in WHO degrees. Two patients receiving radiotherapy alone had to discontinue the treatment due to acute enteritis. Toxicity was found in 52 (50.6%) patients with radiotherapy alone vs 36 (30.5%) patients receiving VSL/3. None of them had to discontinue radiotherapy. Toxicity of degrees 3 or 4 was found in 28 patients receiving radiotherapy alone vs 7 with VSL/3. These preliminary data suggest the effectiveness of VSL/3 in preventing the occurrence of diarrhoea in patients submitted to radiotherapy with a direct and indirect improvement of their quality of life and a good tolerance.

Radiation therapy for oncological emergencies

AIMS AND BACKGROUND

Radiation therapy holds a fundamental role in oncological emergencies such as superior vena cava syndrome, spinal cord compression and endocranial hypertension. The purpose of our study was, by comparing schedules of treatment, to confirm the efficacy of hypofractionated radiation therapy.

METHODS

From January 1994 to December 1998, 43 patients with superior vena cava syndrome, 37 patients with metastatic spinal cord compression and 108 patients with endocranial hypertension secondary to metastasis were treated at our institution. In the group of patients with superior vena cava syndrome, radiotherapy schedules were: 4 Gy x 5 to a total dose of 20 Gy (23 patients) and 3 Gy x 10 to a total dose of 30 Gy (20 patients). In the group of patients with spinal cord compression, radiation schedules were: 3 Gy x 10 to a total dose of 30 Gy (15 patients); 4 Gy x 5 to a total dose of 20 Gy (12 patients); a single fraction of 8 Gy in 10 cases, repeated after 1 week in 7 responder cases to a total dose of 16 Gy. 5 out of 37 patients were underwent to laminectomy plus stabilization of the spine and post-operative radiotherapy. In the group of patients with endocranial hypertension, radiotherapy schedules were: 6 Gy x 2 to a total dose of 12 Gy (53 patients), repeated after 4 weeks in 34 responder patients and 3 Gy x 10 to a total dose of 30 Gy (55 patients).

RESULTS

The patients with superior vena cava syndrome, revaluated after 4 weeks at the end of treatment, obtained a partial remission of symptomatology in 73.9% with 20 Gy and in 75% with 30 Gy. The patients with spinal cord compression obtained symptomatic relief in 73.3% with 30 Gy, in 66.6% with 20 Gy and in 70% of cases treated with 8 Gy. The patients with endocranial hypertension obtained symptomatic relief in 64.1% with 12 Gy and in 63.3% with 30 Gy.

CONCLUSION

Histology, pretreatment and performance status were important prognostic factors for the response to therapy. Our results demonstrated no significant difference among different schedules of radiotherapy and confirmed the importance of radiotherapy for oncological emergencies: it improves the quality of life and, in responding patients, is associated with a longer survival time.

Prognostic features and treatment outcome in patients with nasopharyngeal carcinoma: an experience of 20 years

BACKGROUND

The best treatment of Nasopharyngeal Carcinoma (NPC) is still an open question. The purpose of this retrospective study was to determine risk factors that affect locoregional control and treatment outcome of NPC patients after radiotherapy, with or without chemotherapy.

METHODS

Between January 1976 and December 1996, 66 consecutive patients (stage I = 0; stage II = 13; stage III = 32; stage IV = 21) were given definitive radiotherapy at a single Institution. Concurrent or adjuvant chemotherapy was also given to 14 of them (21%). Multivariate analysis was performed to evaluate age, T stage, N stage, radiotherapy dose, histology, chemotherapy bone of skull erosions or cranial nerve palsies and base of skull involvement as prognostic factors of locoregional control and overall survival.

RESULTS

By the end of January 2000, after a median follow-up of 66 months and a minimal follow-up of 36 months, the event-free overall survival rate of 5 years was 48% and the overall survival 54%. Risk factor analysis revealed that radiotherapy dose, age and stage were the most important factors for overall survival of these patients. The 5 year overall survival was 89% for stage II and 49% for stage III-IV (p = 0.004), 62% for dose higher than 60 Gy and 20% for dose below 60 Gy (p = 0.007), 62% for age below 65 years and 36% for age higher than 65 years (p = 0.027). The concurrent or adjuvant chemotherapy did not have prognostic significance.

CONCLUSIONS

We confirm the need to determine the risk factors in patients with NPC. The choice of treatment, whether radiotherapy alone, at dose > 60 Gy, or radiotherapy plus chemotherapy, should be made after identification of patients with high risk disease, suitable for the combined modality.

Radiotherapy alone in elderly patients with medically inoperable stage IIIA and IIIB non-small cell lung cancer

BACKGROUND

We have analysed our experience with medically inoperable IIIA and IIIB elderly patients (aged > or = 70 years), treated with radiotherapy alone, to better define the potential benefit of this approach.

MATERIALS AND METHODS

From 1992 to 1995, 41 patients with NSCLC (Non Small Cell Lunc Cancer), stage III, aged > or = 70 years were irradiated with curative intent.

RESULTS

Median follow-up was 20 months (range 9-53). The 2 year OS (Overall Survival) and DFS (Disease Free Survival) were respectively 27% and 14.6% for all patients. Patients presenting weight loss > 10% experienced 14% OS at 24 months compared to 58% for those without weight loss (p = 0.0027). A 64% OS at 24 months was seen in patients with tumor size less than 4 cm compared to 7% of patients with tumor size > 4 cm (p = 0.0009).

CONCLUSION

Radiotherapy is a good management for locally advanced NSCLC in the elderly patients assuring good quality of life, high rates of relief of symptoms and OS and DFS similar to those obtained with chemotherapy and chemotherapy plus radiotherapy.

[Exclusive radiotherapy in stage III esophageal cancer]

BACKGROUND

The purpose of the report is to evaluate the role of radiotherapy in the treatment of stage III esophageal carcinoma and to analyze the influence of site, extension, grade of dysphagia and histology on local control and survival.

METHODS

Twenty males and 6 females were submitted to external beam therapy with 4-6 MV X-rays and received 60-70 Gy in fractions of 180 cGY to 200 cGy per day, 5 days a week. Radiation therapy technique was two posterior oblique portals and a single anterior field at 100 cm SAD. After 4500 cGy portals were coned down, holding the spinal cord dose below 4500 cGy.

RESULTS

Global response to therapy was 73.1%. Median survival was 11 months. The 2-year survival rate was 12.5% in patients with lesions smaller than 5 cm and 5.5% for those with lesions greater than 5 cm. Patients with grade 2 dysphagia had a median survival of 16 months, those with grade 1, 11 months and 2 patients with grade 0, 4 and 9 months. In all patients mild to moderate esophagitis was observed. Two patients developed esophagotracheal fistula.

CONCLUSIONS

Exclusively radiotherapy cannot be considered the treatment of choice in III stage patients. Primary chemoradiotherapy may emerge as the treatment of choice for cancer of the esophagus.

Relapse and late complications in early-stage Hodgkin's disease patients with mediastinal involvement treated with radiotherapy alone or plus one cycle of ABVD

BACKGROUND AND OBJECTIVE

Patients affected by Hodgkin's disease (HD) in pathologic stage IA-IIA have a strong possibility of remission and long-term survival when treated with radiotherapy to extended fields. However, 20-30% of cases relapse in the five years following treatment and consequently need further therapy. This study examines the occurrence of relapse and other complications in patients with pathologic stage IIA Hodgkin's disease and mediastinal involvement treated in different ways: radiotherapy alone vs radiotherapy plus one cycle of adriamycin, bleomycin, vinblastine and dacarbazine (ABVD).

DESIGN AND METHODS

Our series consisted of 73 HD patients with mediastinal involvement treated by the Department of Radiation Oncology and the Hematology Department of "La Sapienza" University of Rome from 1983 to 1989. The patients were randomized into two groups according to their initial treatment. The first group contained 37 patients treated, initially, with supradiaphragmatic radiotherapy and para-aortic irradiation (STNI); the second group was made up of 36 patients treated, initially, with supradiaphragmatic radiotherapy and para-aortic irradiation (STNI) combined with one course of adriamycin, bleomycin, vinblastine and dacarbazine (ABVD). For 28 (38%) of the patients, the follow-up period was longer than 10 years. The average follow-up period was 114 months (range 22-174 months). Overall survival and relapse-free survival were assessed using the Kaplan and Meier method, while differences were tested by the log-rank test.

RESULTS

We recorded twelve cases of relapse after initial treatment. The period of time which elapsed between the end of treatment and the evidence of relapse ranged from 6 to 51 months, with an average of 22 months. Ten relapses occurred in the STNI group and two in the ABVD/STNI group. No statistically significant differences emerged between the two groups in the overall survival analysis but did in the relapse-free survival analysis (p<0.01). In the group treated with ABVD and STNI one patient developed acute non-lymphocytic leukemia and another patient treated at the age of 44 developed primary breast cancer. X-ray-related asymptomatic pulmonary fibrosis was observed in 12 patients: 10 cases in the STNI and ABVD group and 2 cases in the group treated with RT alone. The other sequelae of combined CT/RT treatment in our study were thyroid dysfunction (2 cases, hypothyroidism), whereas the sequela of RT treatment was cardiac disease (2 cases).

INTERPRETATION AND CONCLUSIONS

We conclude that one cycle of ABVD and radiotherapy in early-stage HD patients with mediastinal involvement may reduce the risk of relapse. Moreover, the combination of low-toxicity CT and RT, administered preferably to limited fields, in patients who have not undergone laparotomy could be a valid alternative to current treatment for early-stage HD. However, additional data and a longer follow-up are mandatory in order to evaluate late toxicity and the potential risk of treatment.

Radiotherapy in classic Kaposi's sarcoma (CKS): experience of the Institute of Radiology of University "La Sapienza" of Rome

Between 1992 and 1995 24 histologically demon strated Kaposi's. Sarcoma in 14 HIV negative patients were treated at the Institute of Radiology of the University "La Sapienza" of Rome. All patients underwent irradiation with 60CO in three different fractionations: 800 cGy in 1 fraction in 2 (8%) cases, 2000 cGy in 5 fractions in 18 (75%) and 300 cGy in 10 fractions in 4 (17%). Complete response was obtained in 13/24 (54%), partial response in 9/24 (38%), no change in 2/24 (8%). In 2 cases there were out field relapses 2 and 3 months after the end of therapy, and one patient presented with a field recurrence at 4 months. The median duration of local control was 19.5 months (range 4-40 months). All patients had complete remission of symptoms. Our results seem to confirm the effectiveness of radiotherapy in the local control and palliation of symptoms of CKS.

Radiotherapy in the symptomatic treatment of the oncological patients

This paper presents an overview on the palliative use of radiotherapy in the treatment of cancer patients. The aim of symptomatic treatment is to improve the patient's quality of life through the control of local symptoms, without serious disturbance of the life style. Radiotherapy can control many symptoms like metastasis bone pain hematological disorders and other.

HIV-HCV RNA loads and liver failure in coinfected patients with coagulopathy

BACKGROUND AND OBJECTIVE

The aim of this study was to measure contemporaneously HCV-RNA load, HIV-RNA load and CD4+ lymphocyte count in HCV/HIV coinfected patients with coagulopathy and to examine the relationship between these parameters and the liver failure.

DESIGN AND METHODS

A cross-sectional study was performed on 54 patients with severe coagulopathy: 39 HCV/HIV coinfected and 15 HCV+/HIV- comparable for age and HCV exposure time. HCV-RNA and HIV-RNA load, CD4+ lymphocyte count, biochemical and ultrasonographic parameters were evaluated at the time of entry to the study.

RESULTS

Mean HCV-RNA load was significantly higher in coinfected patients (643,872 717,687 copies/mL) than in HCV+/HIV- (mean 161,573 276,896 copies/mL) (p = 0.01). The 39 HCV/HIV coinfected patients had a mean HIV-RNA load of 205,913 456,311 copies/mL (range 4,000-2,500,000) and a mean CD4+ lymphocyte count of 206.5171/microL (range 5-693). Five of the 39 (12.8%) coinfected patients had liver failure. In these five patients the mean HCV-RNA load (770,200 996,426 copies/mL) was high but not significantly different from that in the 34 HCV+/HIV+ patients (623,496 682,239 copies/mL) without liver failure (p = 1.0). Coinfected patients with liver failure had a significantly higher HIV-RNA load (mean 764, 599 978,542 copies/mL) and lower CD4+ lymphocyte count (mean 52.655. 6/microL) than those observed in coinfected patients without liver failure (p = 0.007 and p = 0.03, respectively). A significant inverse correlation was found between CD4+ lymphocyte count and HIV-RNA load (r = -0.37, p = 0.01).

INTERPRETATION AND CONCLUSIONS

HCV-RNA load is significantly higher in HIV+ than in HIV- patients with coagulopathy. Liver failure was found only in the HCV/HIV coinfected patients with severe immunodepression, expressed either by low CD4+ lymphocyte count or by high HIV-RNA load.

Long-lasting response to vinorelbine in unresectable non-small cell lung carcinoma: a case with concomitant good quality of life

The authors observed a long-lasting response to uninterrupted vinorelbine treatment in a 72-year-old patient with a stage IIIB unresectable non-small cell carcinoma. The progressive tumor mass reduction was assessed by computed tomographic scans over a 2-year period. In the literature, data of randomized trials confirm that the appeal of single-agent vinorelbine therapy in elderly patients is also good for the patient's quality of life during treatment.