Survival analysis of HDR brachytherapy versus reoperation versus temozolomide alone: a retrospective cohort analysis of recurrent glioblastoma multiforme

Objectives Tumour recurrence of glioblastoma multiforme (GBM) after initial treatment with surgical resection, radiotherapy and chemotherapy is an inevitable phenomenon. This retrospective cohort study compared the efficacy of interstitial high dose rate brachytherapy (HDR-BRT), re-resection and sole dose dense temozolomide chemotherapy (ddTMZ) in the treatment of recurrent glioblastoma after initial surgery and radiochemotherapy. Design Retropective cohort study. Setting Primary level of care with two participating centres. The geographical location was central Germany. Participants From January 2005 to December 2010, a total of 111 patients developed recurrent GBM after initial surgery and radiotherapy with concomitant temozolomide. The inclusion criteria were as follows: (1) histology-proven diagnosis of primary GBM (WHO grade 4), (2) primary treatment with resection and radiochemotherapy, and (3) tumour recurrence/progression. Interventions This study compared retrospectively the efficacy of interstitial HDR-BRT, re-resection and ddTMZ alone in the treatment of recurrent glioblastoma. Primary and secondary outcome measures Median survival, progression free survival and complication rate. Results Median survival after salvage therapy of the recurrence was 37, 30 and 26 weeks, respectively. The HDR-BRT group did significantly better than both the reoperation (p<0.05) and the ddTMZ groups (p<0.05). Moderate to severe complications in the HDR-BRT, reoperation and sole chemotherapy groups occurred in 5/50 (10%), 4/36 (11%) and 9/25 (36%) cases, respectively. Conclusions CT-guided interstitial HDR-BRT attained higher survival benefits in the management of recurrent glioblastoma after initial surgery and radiotherapy with concurrent temozolomide in comparison with the other treatment modalities. The low risk of complications of the HDR-BRT and the fact that it can be delivered percutaneously in local anaesthesia render it a promissing treatment option for selected patients which should be further evaluated

High dose rate brachytherapy as monotherapy for localised prostate cancer : a hypofractionated two-implant approach in 351 consecutive patients

BACKGROUND: To report the clinical outcome of high dose rate brachytherapy as sole treatment for clinically localised prostate cancer. METHODS: Between March 2004 and January 2008, a total of 351 consecutive patients with clinically localised prostate cancer were treated with transrectal ultrasound guided high dose rate brachytherapy. The prescribed dose was 38.0 Gy in four fractions (two implants of two fractions each of 9.5 Gy with an interval of 14 days between the implants) delivered to an intraoperative transrectal ultrasound real-time defined planning treatment volume. Biochemical failure was defined according to the Phoenix Consensus and toxicity evaluated using the Common Toxicity Criteria for Adverse Events version 3. RESULTS: The median follow-up time was 59.3 months. The 36 and 60 month biochemical control and metastasis-free survival rates were respectively 98%, 94% and 99%, 98%. Toxicity was scored per event with 4.8% acute Grade 3 genitourinary and no acute Grade 3 gastrointestinal toxicity. Late Grade 3 genitourinary and gastrointestinal toxicity were respectively 3.4% and 1.4%. No instances of Grade 4 or greater acute or late adverse events were reported. CONCLUSIONS: Our results confirm high dose rate brachytherapy as safe and effective monotherapy for clinically organ-confined prostate cancer

Functional recovery after implantation of artificial nerve grafts in the rat- a systematic review

<p>Abstract</p> <p>Purpose</p> <p>The aim of this study was to compare functional data of different nerve-gap bridging materials evaluated in rat experiments by means of a systematic review.</p> <p>Materials and methods</p> <p>A systematic review was conducted, searching MEDLINE, HTS and CENTRAL to identify all trials evaluating functional recovery of artificial nerve conduits in the rat model.</p> <p>Results</p> <p>There was a trend towards a favourable outcome of conduits coated with Schwann-cells compared to the plain synthetics. Histomorphometry, electrophysiology and muscle-weight correlated poorly with functional outcome.</p> <p>Conclusion</p> <p>Schwann-cell coated conduits showed promising results concerning functional recovery. Further standardization in outcome reporting is encouraged.</p

Computed Tomography-Guided Interstitial High-Dose-Rate Brachytherapy in the Local Treatment of Primary and Secondary Intrathoracic Malignancies

Introduction:Image-guided interstitial (IRT) brachytherapy (BRT) is an effective treatment option as part of a multimodal approach to the treatment of isolated lung tumors. In this study, we report our results of computed tomography-guided IRT high-dose-rate (HDR) BRT in the local treatment of inoperable primary and secondary intrathoracic malignancies.Methods:Between 1997 and 2007, 55 patients underwent a total of 68 interventional procedures for a total of 60 lung lesions. The median tumor volume was 160 cm3 (range, 24–583 cm3). Thirty-seven patients were men and 18 were women, with a median age of 64 years (range, 31–93 years). The IRT-HDR-BRT delivered a median dose of 25.0 Gy (range, 10.0–32.0 Gy) in twice-daily fractions of 4.0 to 15.0 Gy in 27 patients and 10.0 Gy (range, 7.0–32.0 Gy) in once-daily fractions of 4.0 to 20.0 Gy in 28 patients.Results:The median follow-up was 14 months (range, 1–49 months). The overall survival rate was 63% at 1 year, 26% at 2 years, and 7% at 3 years. The local control rate for metastatic tumors was 93%, 82%, and 82% and for primary intrathoracic cancers 86%, 79%, and 73% at 1, 2, and 3 years, respectively. Pneumothoraces occurred in 11.7% of interventional procedures, necessitating postprocedural drainage in one (1.8%) patient.Conclusions:In patients with inoperable intrathoracic malignancies, computed tomography-guided IRT-HDR-BRT is a safe and effective alternative to other locally ablative techniques

Epstein-Barr virus myelitis and Castleman's disease in a patient with acquired immune deficiency syndrome: a case report

<p>Abstract</p> <p>Introduction</p> <p>Few cases of Epstein-Barr virus myelitis have been described in the literature. Multi-centric Castleman's disease is a lymphoproliferative disorder that is well known for its associations with the human immunodeficiency virus, human herpes virus 8, and Kaposi's sarcoma. The concurrent presentation of these two diseases in a patient at the same time is extremely unusual.</p> <p>Case Presentation</p> <p>We describe the case of a 43-year-old Caucasian man with acquired immune deficiency syndrome who presented with fever, weight loss and diffuse lymphadenopathy, and was diagnosed with multi-centric Castleman's disease. He presented three weeks later with lower extremity weakness and urinary retention, at which time cerebrospinal fluid contained lymphocytic pleocytosis and elevated protein. Magnetic resonance imaging demonstrated abnormal spinal cord signal intensity over several cervical and thoracic segments, suggesting the diagnosis of myelitis. Our patient was ultimately diagnosed with Epstein-Barr virus myelitis, as Epstein-Barr virus DNA was detected by polymerase chain reaction in the cerebrospinal fluid.</p> <p>Conclusion</p> <p>To the best of our knowledge, this is the first case of multi-centric Castleman's disease followed by acute Epstein-Barr virus myelitis in a human immunodeficiency virus-infected patient. Clinicians caring for human immunodeficiency virus-infected patients should be vigilant about monitoring patients with increasing lymphadenopathy, prompting thorough diagnostic investigations when necessary.</p

Role of Brachytherapy in the Postoperative Management of Endometrial Cancer: Decision-Making Analysis among Experienced European Radiation Oncologists.

BACKGROUND There are various society-specific guidelines addressing adjuvant brachytherapy (BT) after surgery for endometrial cancer (EC). However, these recommendations are not uniform. Against this background, clinicians need to make decisions despite gaps between best scientific evidence and clinical practice. We explored factors influencing decision-making for adjuvant BT in clinical routine among experienced European radiation oncologists in the field of gynaecological radiotherapy (RT). We also investigated the dose and technique of BT. METHODS Nineteen European experts for gynaecological BT selected by the Groupe Européen de Curiethérapie and the European Society for Radiotherapy & Oncology provided their decision criteria and technique for postoperative RT in EC. The decision criteria were captured and converted into decision trees, and consensus and dissent were evaluated based on the objective consensus methodology. RESULTS The decision criteria used by the experts were tumour extension, grading, nodal status, lymphovascular invasion, and cervical stroma/vaginal invasion (yes/no). No expert recommended adjuvant BT for pT1a G1-2 EC without substantial LVSI. Eighty-four percent of experts recommended BT for pT1a G3 EC without substantial LVSI. Up to 74% of experts used adjuvant BT for pT1b LVSI-negative and pT2 G1-2 LVSI-negative disease. For 74-84% of experts, EBRT + BT was the treatment of choice for nodal-positive pT2 disease and for pT3 EC with cervical/vaginal invasion. For all other tumour stages, there was no clear consensus for adjuvant treatment. Four experts already used molecular markers for decision-making. Sixty-five percent of experts recommended fractionation regimens of 3 × 7 Gy or 4 × 5 Gy for BT as monotherapy and 2 × 5 Gy for combination with EBRT. The most commonly used applicator for BT was a vaginal cylinder; 82% recommended image-guided BT. CONCLUSIONS There was a clear trend towards adjuvant BT for stage IA G3, stage IB, and stage II G1-2 LVSI-negative EC. Likewise, there was a non-uniform pattern for BT dose prescription but a clear trend towards 3D image-based BT. Finally, molecular characteristics were already used in daily decision-making by some experts under the pretext that upcoming trials will bring more clarity to this topic

Reirradiation of head and neck cancer focusing on hypofractionated stereotactic body radiation therapy

Reirradiation is a feasible option for patients who do not otherwise have treatment options available. Depending on the location and extent of the tumor, reirradiation may be accomplished with external beam radiotherapy, brachytherapy, radiosurgery, or intensity modulated radiation therapy (IMRT). Although there has been limited experience with hypofractionated stereotactic radiotherapy (hSRT), it may have the potential for curative or palliative treatment due to its advanced precision technology, particularly for limited small lesion. On the other hand, severe late adverse reactions are anticipated with reirradiation than with initial radiation therapy. The risk of severe late complications has been reported to be 20- 40% and is related to prior radiotherapy dose, primary site, retreatment radiotherapy dose, treatment volume, and technique. Early researchers have observed lethal bleeding in such patients up to a rate of 14%. Recently, similar rate of 10-15% was observed for fatal bleeding with use of modern hSRT like in case of carotid blowout syndrome. To determine the feasibility and efficacy of reirradiation using modern technology, we reviewed the pertinent literature. The potentially lethal side effects should be kept in mind when reirradiation by hSRT is considered for treatment, and efforts should be made to minimize the risk in any future investigations

The role of radiotherapy in localised and locally advanced prostate cancer

For a patient suffering from non-metastatic prostate cancer, the individualized recommendation of radiotherapy has to be the fruit of a multidisciplinary approach in the context of a Tumor Board, to be explained carefully to the patient to obtain his informed consent. External beam radiotherapy is now delivered by intensity modulated radiotherapy, considered as the gold standard. From a radiotherapy perspective, low-risk localized prostate cancer is treated by image guided intensity modulated radiotherapy, or brachytherapy if patients meet the required eligibility criteria. Intermediate-risk patients may benefit from intensity modulated radiotherapy combined with 4–6 months of androgen deprivation therapy; intensity modulated radiotherapy alone or combined with brachytherapy can be offered to patients unsuitable for androgen deprivation therapy due to co-morbidities or unwilling to accept it to preserve their sexual health. High-risk prostate cancer, i.e. high-risk localized and locally advanced prostate cancer, requires intensity modulated radiotherapy with long-term (≥2 years) androgen deprivation therapy with luteinizing hormone releasing hormone agonists. Post-operative irradiation, either immediate or early deferred, is proposed to patients classified as pT3pN0, based on surgical margins, prostate-specific antigen values and quality of life. Whatever the techniques and their degree of sophistication, quality assurance plays a major role in the management of radiotherapy, requiring the involvement of physicians, physicists, dosimetrists, radiation technologists and computer scientists. The patients must be informed about the potential morbidity of radiotherapy and androgen deprivation therapy and followed regularly during and after treatment for tertiary prevention and evaluation. A close cooperation is needed with general practitioners and specialists to prevent and mitigate side effects and maintain quality of life