number of mediastinal lymph nodes as a prognostic factor in pn2 non small cell lung cancer a single centre experience and review of the literature

Lung cancer is one of the most common cause of cancer-related death for men and women in the world. The prevalent histology is non-small cell lung carcinoma (NSCLC), including squamous cell carcinoma, adenocarcinoma and large cell carcinoma (Moretti et al., 2009), with a 5year survival rate of 67% (stage IA) to <5% (stage IV) (End, 2006). Currently the most important predictor of survival in lung cancer is the stage (TNM) (Kligerman and Abbot, 2010; Goldstraw, 2009). Despite the new staging system (Kligerman and Abbot, 2010), stage III NSCLC remains a very heterogeneous disease , with a 5-year survival rate ranging from 35% to 5%. There are two major treatment targets for of patients with stage III : locoregional control and control of micrometastases, preventing distant metastatic disease (Penland et al., 2004; Bradley et al., 2005). The standard of care is represented by multimodality treatment, comprehending surgery for resectable disease, perioperative chemotherapy and radiation therapy (RT) for patients with pathological (p) N2 disease (Okamoto, 2008). In current TNM classification system, N category is defined exclusively by anatomic nodal location, though number of lymph nodes confirmed to be a fundamental prognostic factor as in other type of tumours. In our study, we assessed, in patients with stage III N2 category NSCLC disease, the prognostic value of the number of lymph nodes after multimodality treatment

Radioterapia: aspetti tecnici

Negli ultimi decenni c’è stata una grande evoluzione della radioterapia determinata dal progresso tecnologico delle apparecchiature. L’acceleratore lineare, strumento centrale del sistema, è un apparecchio che consente di produrre raggi X o elettroni di alta energia (4-20 MV) in grado di fornire dosaggi elevati anche nelle sedi profonde del corpo umano. Fino ai primi anni ’90, la pianificazione del trattamento radiante si basava su immagini radiografiche bidimensionali ed il campo veniva delimitato a punti di riferimento scheletrici. L’evoluzione della radiologia diagnostica ha consentito, con l’avvento della TC multistrato, la visualizzazione di immagini anatomiche dei tessuti molli e la successiva ricostruzione tridimensionale (3D). Nell’ultimo decennio i sistemi di pianificazione computerizzati del trattamento ed i recenti sistemi multi lamellari di collimazione dei raggi X, hanno permesso una migliore delimitazione dei campi di trattamento, individuando con precisione un bersaglio da trattare riducendo la dose ai tessuti sani circostanti. Più di recente, con la messa a punto di collimatori micromultilamellari, si è sviluppata una tecnica conformazionale molto sofisticata detta a modulazione di intensità (IMRT). Questa consente una più precisa delimitazione del campo definendo inoltre profili concavi o convessi in prossimità degli organi critici. Un ulteriore progresso di questa tecnica consente in alcuni moderni acceleratori lineari di ottenere immagini utilizzando raggi X di alta energia (IGRT). Tutto ciò permette di localizzare il bersaglio in tempo reale (4D) assicurando una precisa distribuzione della dose al tumore, evitando con sicurezza di danneggiare i tessuti critici. Ultimamente è stato sviluppato un apparecchio che accoppia un rivelatore TC ad un acceleratore lineare di 6Mv di energia con movimento elicoidale. Il sistema è chiamato tomo terapia ed il suo impiego clinico non è attualmente standardizzato. I primi risultati evidenziano un miglioramento della distribuzione della dose al tumore ed un elevato abbattimento del dosaggio agli orgni critici

Radiotherapy and chemotherapy in the conservative treatment of anal canal carcinoma

Aim: To evaluate the feasibility of conformal radiotherapy and concurrent chemotherapy in patients with anal canal carcinoma. Patients and Methods: Between 1990 and 2006, 83 patients affected by anal canal carcinoma were treated at the Radiotherapy Department of "La Sapienza" University of Rome. In all patients, a daily dose of 1.8 Gy, five times per week, was given for a total dose of 45 Gy for the whole pelvis (CTV1) and of 55-60 Gy for the tumor bed (CTV2). In 63 patients, chemotherapy consisted of two cycles of 5-fluorouracil (5-FU) and mitomycinC (MMC) or cisplatin delivery during the first and last week of radiotherapy. Results: The median follow-up time for all patients was 562 months. Treatment response was considered complete in 53 patients (63.8%) and partial in 30 patients (36.1%). Local tumor relapse was observed in 13 patients (15.6%). The probability of overall survival for all patients at 5 years was 75%: 39% in patients who underwent radiotherapy alone and 85% in patients who underwent radiochemotherapy (p=0.0013). Concerning acute toxicity, 9 patients developed grade 1 skin toxicity (10.8%), 35 grade 2 (42.1%), 26 grade 3 (31.3%) and 3 grade 4 (3.6%); eleven patients had grade 2 diarrhea (14.5%) and 2 grade 3 diarrhea (2.4%). Conclusion: This analysis suggests that the treatment scheme employed was effective for anal sphincter preservation and local control

Neoadjuvant strategy as initial treatment in resectable pancreatic cancer: concrete evidence of benefit.

Pancreatoduodenectomy remains the recommended treatment in potentially curative strategies for pancreatic carcinoma. Due to high local failure rates even after complete resection, a multi-modality treatment approach is paramount in the management of resectable disease. Despite there being insufficient evidence to recommend a specific neoadjuvant strategy, several studies have tested the use of preoperative chemoradiotherapy in this sub-group of patients, achieving promising results. The treatment is well-tolerated, with higher rates of negative margins and lower rates of lymph node positivity at resection, a decrease in local failure and benefit in overall survival. Considering the poor oncological results after primary surgical treatment, neoadjuvant strategy should be considered as a valid alternative in resectable pancreatic carcinoma

Management of persistent anal canal carcinoma after combined-modality therapy: a clinical review.

Anal canal carcinoma is a rare gastro-intestinal cancer. Radiochemotherapy is the recommended primary treatment for patients with non-metastatic carcinoma; surgery is generally reserved for persistent or recurrent disease. Follow-up and surveillance after primary treatment is paramount to classify patients in those with complete remission, persistent or progressive disease. Locally persistent disease represents a clinically significant problem and its management remains subject of some controversy.The aim of this systematic review is to summarise recommendations for the primary treatment of anal canal carcinoma, to focus on the optimal time to consider residual disease as genuine persistence to proceed with salvage treatment, and to discern how this analysis might inform future clinical trials in management in this class of patients. © 2014 Musio et al.; licensee BioMed Central Ltd

Multiple bone metastases from glioblastoma multiforme without local brain relapse: A case report and review of the literature

Extracranial metastases from glioblastoma multiforme (GBM) are a very rare event, even if an increasing incidence has been documented. We report the case of a young woman with primary GBM who developed bone metastases without local brain relapse. Because of persistent headache and visual disturbances, in March 2011 the patient underwent magnetic resonance imaging (MRI) evidencing a temporoparietal mass, which was surgically resected. Histology revealed GBM. She was given concomitant chemoradiotherapy according to the Stupp regimen. After a 4-week break, the patient received 6 cycles of adjuvant temozolomide according to the standard 5- day schedule every 28 days. In December 2011 she complained of progressive low back pain, and MRI showed multiple bone metastases from primary GBM, confirmed by histology. Cases of metastatic GBM in concurrence with a primary brain tumor or local relapse are more common in the literature; only a few cases have been reported where extracranial metastases from GBM occurred without any relapse in the brain. Here we report our experience

Pretreatment scalene node biopsy in cervical carcinoma

To evaluate incidence of scalene node metastases from carcinoma of the cervix, 20 patients had scalene fat-pad node biopsy. All cases were staged according to FIGO criteria and abdominal lymph nodes were studied by CT and lymphangiography. Scalene node metastases were found in 2 patients with clinically suspicious node and pelvic and paraaortic nodes involvement. Seven patients had sinus histiocytosis in scalene node biopsy and this seems related to a more favourable prognosis. From this study it appears that scalene node biopsy is not a routine procedure and should be performed in all patients with palpable supraclavicular masses or when paraortic nodes are involved

Therapeutic options for breast cancer treatment in patients previously irradiated for Hodgkin's disease: radical mastectomy or conservative surgery followed by reirradiation?

Patients undergoing radiotherapy for the treatment of Hodgkin' disease (HD) occurred at young age present a higher risk to develop second cancer compared to general population. Among the possible second tumours, breast cancer is the most frequent and the age at presentation is younger than the "classic" form. Patients at risk for second cancer undergo a strict follow-up permitting often to diagnose breast cancer at early stages (I-II). The aim of this work is to review the various therapeutic options for the treatment of breast cancer in patients previously irradiated for HD, with particular attention to the possibility of reirradiation of mammary tissue thanks to the new radiotherapy techniques developed in the last years. Clin Ter 2009; 160(4):311-31

Relationship of clinical and pathologic nodal staging in locally advanced breast cancer: current controversies in daily practice?

Systemic neo-adjuvant therapy plays a primary role in the management of locally advanced breast cancer. Without having any negative effect in overall survival, induction chemotherapy potentially assures a surgery approach in unresectable disease or a conservative treatment in technically resectable disease and acts on a well-vascularized tumor bed, without the modifications induced by surgery. A specific issue has a central function in the neo-adjuvant setting: lymph nodes status. It still represents one of the strongest predictors of long-term prognosis in breast cancer. The discussion of regional radiation therapy should be a matter of debate, especially in a pathological complete response. Currently, the indication for radiotherapy is based on the clinical stage before the surgery, even for the irradiation of the loco-regional lymph nodes. Regardless of pathological down-staging, radiation therapy is accepted as standard adjuvant treatment in locally advanced breast cancer

Chemoradiation as definitive treatment for primary squamous cell cancer of the rectum

In this report, we present a case of advanced squamous cell cancer located in the rectum of a 78-year-old woman treated with chemoradiation with curative intent. The patient showed a complete clinical response to chemoradiation; multiple biopsies were performed at the site of the previous mass 5 mo after the end of treatment and histological examination showed no residual tumour in the specimens. Surgical intervention was avoided and the patient was free of disease 12 mo after the diagnosis of cancer. Primary chemoradiation should be considered as the treatment of choice for this rare malignancy