The Role of Radiation Therapy on Medically Inoperable Clinically Localized Non-small Cell Lung Patients: London Regional Cancer Program (LRCP) Clinical Experience

Lung cancer is the most frequent cause of cancer death in both men and women in North America. In 2006, an estimated 22,700 Canadians will be diagnosed with lung cancer and 19,300 will die of it (Canadian Cancer Statistics 2006). Approximately 15-20% of NSCLC patients present with early or localized disease. Surgical resection of T1-2N0 NSCLC remains the treatment of choice for this population, and results in a 5-year survival rate of 50-70%. Patients deemed medically inoperable have been treated with non-surgical therapies, such as radiation therapy(RT), while some patients have simply been observed without any tumor therapy because of their co-morbid illnesses. Potential confounding issues in this patient population include some patients who are not referred to our Centre due to co-morbid disease, and some who are referred, but are not offered radical RT due to poor outcome expectations. In addition, patients may refuse treatment when offered. We have reviewed thepast 19 years’ experience at LRCP inmanagement of this group of patients

Endobronchial Carcinoid Tumour with Extensive Ossification: An Unusual Case Presentation

Carcinoid tumour is a well-known primary endobronchial lung neoplasm. Although calcifications may be seen in up to 30% of pulmonary carcinoid tumours, near complete ossification of these tumours is an unusual finding. Such lesions can prove diagnostically challenging at the time of intraoperative frozen section as the latter technique requires thin sectioning of the lesion for microscopic assessment. We present an unusual case of endobronchial carcinoid tumour with extensive ossification in a 45-year-old male. Preliminary intraoperative diagnosis was achieved through the alternative use of cytology scrape smears. The final diagnosis was confirmed after decalcification of the tumour. The prognostic implications of heavily ossified carcinoid tumours remain elusive. Long-term clinical follow-up of these patients is recommended

Post-Operative Extended Volume External Beam Radiation Therapy Is Safe for High Risk Esophageal Cancer Patients

Post-operative radiation therapy (RT) (1) and post-operative chemoradiation (2) have been used for esophageal cancer patients deemed high risk for recurrence after esophagectomy. Defining opitmal RT target volume after esophagectomy is difficult due to significant changes in patient anatomy and function. Some radiationon cologists advocated the inclusion of the anastomotic site within the irradiation volume due to concerns for potential increased relapse risk, while others did not subscribe to this practice due to concerns for increased treatment related toxicity. We have previously reported patient outcome benefit using extended volume RT In management with high risk esophageal cancer patients underwent esopagectomy(3). We have performed a Phase I study to evaluate the safety of subscription to this practice. (1). Folk et al, Surgery, 113:1993 (2). Bedard et al, Cancer, 91;2001 (3). Yu et al, Radiother & Oncol, 73;200

Extended vs. Small Field Irradiation in High Risk Post Esophagectomy Patients Receiving Combined Chemoradiation Therapy: A Decade Experience in Treatment of Esophageal Cancer

OBJECTIVE: To assess the impact of extended field irradiation with anastomotic coverage on local recurrence in high risk resected esophageal cancerpatients. METHODS: From 1989-1999, high risk resected esophageal cancer cases receiving post-resection chemoradiation were reviewed. Adjuvant chemotherapy consisted of four cycles of fluorouracil-based regimens. Loco-regional irradiation with or without coverage of anastomotic site had radiation a dose range from 45-60 Gyat 1.8-2.0 Gy/fraction given with initial anterior-posterior/posterior-anterior arrangement with either extended (with anastomotic coverage), or small (without anastomotic coverage) field followed by oblique fields for boost. RESULTS: One hundred eighty-eight charts were reviewed. Seventy-two patients were eligible for post-resection chemoradiation. Three patients had disease progression prior to therapy, and 69 patients were analyzed. The median age was 60 years (range 35-82 years) with 94% T2-3N1 and 65% were adenocarcinoma. As of January 2005 median followup was 30.5 months (range 3-142 months), the two-and five-year overall survival rates were 50% and 31%, respectively. First relapse rate after adjuvant therapy was 71% (n=49) and median time to relapse was about 30 months. Loco-regional relapse with small field was 25/35 (71.4%) and 2/14 (14.2%) with extended field (P\u3c0.001). Recurrence locally to anastomosis or adjacent site was 10/35 (28.6%) with small field and 0/14 (0%) with extended field (P=0.04). CONCLUSION: At a minimum of 5-year followup, there is significant decrease in loco-regional relapse with the use of extended field in high risk resected esophageal cancer patients. This important improvement trend deserves further exploration in prospective randomized clinical trials

Positron Emission Tomography-Computed Tomography Compared with Invasive Mediastinal Staging in Non-small Cell Lung Cancer: Results of Mediastinal Staging in the Early Lung Positron Emission Tomography Trial

IntroductionPatients with non-small cell lung cancer (NSCLC) require careful preoperative staging to define resectability for potential cure. 18Fluorodeoxyglucose positron emission tomography combined with computed tomography (18FDG PET-CT) is widely used to stage NSCLC. If the mediastinum is positive on PET-CT examination, some practitioners conclude that the patient is inoperable and refer the patient for nonsurgical treatment.MethodsIn this analysis of a previously reported trial comparing PET-CT with conventional imaging in the diagnostic work-up of patients with clinical stage I, II, or IIIA NSCLC, we determined the accuracy of PET-CT in mediastinal staging compared with invasive mediastinal staging either by mediastinoscopy alone or by mediastinoscopy combined with thoracotomy.ResultsAll 149 patients had mediastinal nodal staging at mediastinoscopy alone (14), thoracotomy alone (64), or both (71). The sensitivity of PET-CT was 70% (95% confidence interval [CI], 48–85%), and specificity was 94% (95% CI, 88–97%). Of 22 patients with a PET-CT interpreted as positive for mediastinal nodes, 8 did not have tumor. The positive predictive value and negative predictive value were 64% (95% CI, 43–80%) and 95% (95% CI, 90–98%), respectively. Based on PET-CT alone, eight patients would have been denied potentially curative surgery if the mediastinal abnormalities detected by PET-CT had not been evaluated with an invasive mediastinal procedure.ConclusionsPET-CT assessment of the mediastinum is associated with a clinically relevant false-positive result. Our study confirms the need for pathologic confirmation of mediastinal lymph node abnormalities detected by PET-CT

Hepato-bronchial fistula secondary to perforated sigmoid diverticulitis: a case report

Abstract Background Patients with diverticulitis are predisposed to hepatic abscesses via seeding through the portal circulation. Hepatic abscesses are well-documented sequelae of diverticulitis, however instances of progression to hepato-bronchial fistulization are rare. We present a case of diverticulitis associated with hepatic abscess leading to hepato-bronchial fistulization, which represents a novel disease course not yet reported in the literature. Case Presentation A 61-year-old Caucasian man presented with a history of unintentional weight loss and dyspnea both at rest and with exertion. He had a significant tobacco and alcohol misuse history. A massive right-sided pleural effusion was found on chest X-ray, which responded partially to chest tube insertion. A computed tomography scan of his thorax confirmed the presence of innumerable lung abscesses as well as a complex pleural effusion. An indeterminate tiny air pocket at the dome of the liver was also noted. A follow-up computed tomography scan of his abdomen revealed a decompressed hepatic abscess extending into the right pleural space and the right lower lobe. A sigmoid-rectal fistula was also revealed with focal colonic thickening, presumed to be the sequelae of remote or chronic diverticulitis. An interventional radiologist inserted a percutaneous drain into the decompressed hepatic abscess and the instillation of contrast revealed immediate filling of the right pleural space, lung parenchyma, and bronchial tree, confirming a hepato-bronchial fistula. After two concurrent chest tube insertions failed to drain the remaining pleural effusion completely, surgical lung decortication was conducted. Markedly thickened pleura were seen and a significant amount of gelatinous inflammatory material was debrided from the lower thoracic cavity. He recovered well and was discharged 10 days post-thoracotomy on oral antibiotics. The percutaneous liver abscess tube was removed 3 weeks post-discharge from hospital after the drain check revealed that the fistula and abscess had entirely resolved. Conclusions Refractory right-sided pleural effusion combined with constitutional symptoms should alert clinicians to search for possible hepatic abscess, especially in the context of diverticulitis. The rupture of an untreated hepatic abscess could lead to death from profound sepsis or rarely, as in this case, a hepato-bronchial fistula. Timely investigation and a multidisciplinary treatment approach can lead to improved patient outcomes

Adjuvant concurrent chemoradiation using intensity-modulated radiotherapy and simultaneous integrated boost for resected high-risk adenocarcinoma of the distal esophagus and gastro-esophageal junction.

Purpose: Multimodality therapy leads to improved outcomes for adenocarcinoma of the distal esophagus and gastroesophageal junction (GEJ) over surgery alone. At our institution, adjuvant chemoradiation (chemoRT) using IMRT and SIB is standard of care for resected high-risk disease. In this study, we review our experience with a recent cohort of patients treated in this manner. Methods and materials: We identified 18 patients with resected T3 and/or N1 adenocarcinoma of the distal esophagus and GEJ who received adjuvant chemoRT. A large elective volume (PTV1) and a smaller high-risk volume (PTV2) were irradiated simultaneously using IMRT and an SIB technique. All patients received concurrent chemotherapy. Relevant clinical outcomes are reported. Results: The median dose to 95% of PTV1 was 3747cGy and to 95% of PTV2 was 4876cGy. All RT was given in a median of 28 daily fractions. Four patients did not complete chemotherapy. At a median follow up of 952 days from the start of RT, 7 of 18 patients were dead; of these, 3 had developed local recurrence only; 3 had developed both local and distant recurrence; 1 died of a late toxicity, without recurrence. OS was 88% at 1year, 76% at 2 years and 58% at 3 years. Freedom from local recurrence was 88% at 1 year, 82% at 2 years and 82% at 3 years. Freedom from distant recurrence was 72% at 1 year, 67% at 2 years and 56% at 3 years. Toxicity was acceptable. Conclusions: Adjuvant concurrent chemoRT with IMRT and SIB is feasible for resected high-risk adenocarcinoma of the distal esophagus and GEJ. Our results describe how modern treatment techniques can be employed as part of a treatment paradigm that is neither commonly used nor commonly described in the literature

The Role of Radiation Therapy on Medically Inoperable Clinically Localized Non-small Cell Lung Patients: London Regional Cancer Program (LRCP) Clinical Experience

Lung cancer is the most frequent cause of cancer death in both men and women in North America. In 2006, an estimated 22,700 Canadians will be diagnosed with lung cancer and 19,300 will die of it (Canadian Cancer Statistics 2006). Approximately 15-20% of NSCLC patients present with early or localized disease. Surgical resection of T1-2N0 NSCLC remains the treatment of choice for this population, and results in a 5-year survival rate of 50-70%. Patients deemed medically inoperable have been treated with non-surgical therapies, such as radiation therapy(RT), while some patients have simply been observed without any tumor therapy because of their co-morbid illnesses. Potential confounding issues in this patient population include some patients who are not referred to our Centre due to co-morbid disease, and some who are referred, but are not offered radical RT due to poor outcome expectations. In addition, patients may refuse treatment when offered. We have reviewed thepast 19 years’ experience at LRCP inmanagement of this group of patients

Definitive Radiation Therapy Management for Medically Non-resectable Clinically Localised Non-small Cell Lung Cancer: Results & Prognostic Factors

The aim of this paper is to review the experience of radical radiation therapy and the prognostic factors of patient outcome for clinically localised, medically inoperable non-small cell lung cancer (NSCLC) patients. Clinically staged node-negative NSCLC patients who were not a surgical candidates due to co-morbid diseases but who were eligible for curative treatment, were reviewed in the London Regional Cancer Program (LRCP). This study population was treated between 1st Jan 1985 to 31st Jan 2004. Patients were excluded if they were previously treated with chest radiotherapy. Patients with localised disease, but who refused surgery, were also included in the study. Eligible patients received radiation therapy which was given via localised portals and underwent simulation prior to therapy. The dose prescription range was from 50 Gy in 2.5 Gy per fraction to 60 Gy in 2 Gy per fraction. Hazard ratios and P-values were determined for time to recurrence and patient survival. A total of 74 patients met the study eligibility criteria. The median age of the cohort was 70 years (range 38-92 years). The cohort consisted of 52 males and 22 females. 39/74 (53%) had a pathological diagnosis of squamous cell carcinoma. Clinical stages were 21 (28%) T1 , 40 (54%) T2 , and 13 (18%) T3 , respectively. 59/74 (78%) completed their planned radical radiotherapy but 15/74 declined radiotherapy. The median follow-up time was 17.6 months (range 0.4-123.6 months). For patients who completed radiotherapy, the two-year and five-year disease-free survival (DFS) rates were 38.1% and 11.4%. Overall survival (OS) two-year and five-year rates were 33.2% and 6.9%, respectively. The median DFS and OS for T1 , T2 , and T3 were 18.7, 14, 15 months; and 23.1, 18.5, 14.5 months, respectively. Patients who received radiotherapy compared to those who did not, had median lung cancer-specific survival (CSS) times of 21 months and 4.9 months (P\u3c0.001); OS times of 20 months and 5 months (P\u3c0.001), respectively. Tumour size had impact on patient survival in univariate (P=0.004) and multivariate (P=0.002) analyses. In conclusion, radical radiotherapy significantly improves survival for patients with medically inoperable clinically staged localised NSCLC, and tumour size is a predictor of patient outcome. The OS, CSS, and DFS rates for patients with tumour size greater than 6 cm are significantly worse than those with smaller size tumours