Irradiation treatment of laryngeal cancer in a patient with an implantable cardioverter-defibrillator (ICD)

Background: Due to an aging population the incidence of both cardiac and tumor-related illnesses is increasing. A problem may arise if radiotherapy is necessary in close anatomic proximity to an implantable cardioverter-defibrillator (ICD). These highly precise devices may respond to ionizing radiation with a loss of function or uncontrolled stimulation, with both effects being potentially life threatening. Available guidelines recommend the dose maximum to a pacemaker to be cumulative below 2 Gy. For most patients undergoing radiation therapy of the neck or of the chest this limit is exceeded, thus making a removal of the device and an implantation of an external ICD necessary. Case Report: A patient with severe cardiac problems underwent an implantation of an ICD. However, a recurrence of a laryngeal cancer was diagnosed. The irradiation dose after resection was 60 Gy to the tumor region and 50 Gy to the lymph nodes. Irradiation peakload to the ICD was calculated to be 2.5 Gy. This dose was verified with thermoluminescence measurements. The ICD was externally deactivated during the sessions of irradiation. Device checks demonstrated no malfunction. Conclusion: Even though the dose limits of the ICD of 2 Gy were exceeded, the device demonstrated a regular function during and after radiotherapy

Radio-chemotherapy as a preoperative treatment for advanced rectal cancer. Evaluation of down-staging and morbidity

Background: The standard therapy for patients with clinically resectable rectal cancer is generally considered to be surgery, If the patient is diagnosed with advanced disease, postoperative radiochemotherapy (RCT) is usually recommended. In our study we aimed to investigate and analyze the effectiveness and toxicity of preoperative pelvic radiotherapy in combination with 5-fluorouracil (5-FU) in locally advanced rectal cancer. Patients and Methods: From June 1999 to September 2001 we evaluated 50 consecutive patients {[}37 male and 13 female; average age 65.1 (range 46-79.5) years] with locally advanced rectal carcinoma. 32 patients were staged as uT3, 14 as uT4, and 4 as uT2. Regarding N-staging, 22 patients were diagnosed as ONO. 2 patients had distant metastases, with liver metastases in both instances. Conformal irradiation was performed with a box technique 4-field technique) with a dose of 45 Gy (5 x 1.8 Gy per week for a total of 25 sessions). From days 1-5 and 29-33, all patients received 5-FU (500 mg/m(2) per day, as a continuous i.v. injection). Results: Remission was observed in 28 patients (56%), with down-staging of at least one T-stage. A better success rate was achieved for patients with deep-seated tumors (64% of the patients in this group). Complete remission was observed in 4 patients (8.0%) and progression in 3 (6.0%). 15 patients had no detectable change in tumor staging (30.0%). A surgical R0 resection could be achieved in 43 patients, an R1 resection (minimal margins in 7. Side effects and toxicity (common toxicity criteria) of RCT included grade I-II dysuria in 5 patients (10%), grade I-II diarrhea in 20 patients (40%), and severe diarrhea in 2 patients (4.0%). Grade I-II skin reaction was noticed in 22 patients (44.0%), severe skin reaction only in 1 patient. Regarding acute postoperative morbidity, abscess and fistula formation was noted in 8 patients (16.0%), with anastomosis leakage in 7 (14%). Conclusion: Preoperative radiotherapy appears to be a feasible therapeutic approach with moderate toxicity and the potential to induce down-staging. The data presented in this study confirm the preliminary reports on this neoadjuvant treatment

Porphyrias associated with malignant tumors: Results of treatment with ionizing irradiation

Background: Porphyrin metabolism disorders, known as porphyria, represent inherited or acquired diseases. The development of porphyria due to light sensibility occurs especially with exposure to wavelengths in the range of 300-700 nm. Skin reactions and neurovisceral dysfunctions are known side effects of ionizing irradiation. It can be postulated that during or after ionizing irradiation treatment of patients affected with tumor and porphyria, severe side effects might appear, in contrast to patients without porphyria. This paper describes the treatment of 2 patients affected with tumor and concomitant porphyria. Patients: One female patient suffering from intermittent porphyria and breast cancer and one male patient suffering from porphyria cutanea tarda and bladder cancer were treated with ionizing irradiation (electrons and photons). No abnormalities nor any severe general or local side effects could be observed. Conclusion: Radiation therapy is not a `stimulating' factor in activating porphyria symptoms

Suboccipital lateral injection of intrathecal chemotherapy in a patient with mantle cell lymphoma

Background: Even today patients who suffer from mantle cell lymphoma have a poor prognosis, especially when the CNS is involved. To confirm the diagnosis of meningeosis lymphomatosa, asservation of the liquor cerebrospinalis is necessary. During this procedure, intrathecal chemotherapy may be given if there is clinical evidence of meningeosis. If lumbar puncture cannot be performed, a lateral suboccipital puncture may be an alternative approach. Patient and Methods: We report the case of a 65-year-old patient who suffered from mantle cell lymphoma stage IV. The patient presented with symptoms of progressive paraparesis of both legs and incontinence, with tumor mass intradural from the 12th thoracic vertebra to the level of S1. During irradiation, the patient developed symptoms of diffuse meningiosis lymphomatosa. The conventional lumbar puncture was impossible, because of tumor present in the thoracico-lumbar junction. Results: A suboccipital puncture was performed for both collecting cerebrospinal fluid and application of chemotherapy ( cytosine arabinoside/dexamethasone). This lead to remarkable improvement of the patient's clinical symptoms. Conclusion: The suboccipital cervical puncture was performed without complications. A variation of the intrathecal approach is described, which may serve as alternative when conventional lumbar puncture is not possible

Photofrin II as an efficient radiosensitizing agent in an experimental tumor

Background and Objective: The use of ionizing irradiation as radiation therapy (RT) for tumor treatment represents a well-established method. The use of photodynamic therapy (PDT), especially with Photofrin II, for tumor treatment is also known. Chemical modifiers enhancing the action of radiation therapy are well known and widely used in medicine. None of these compounds, however, is a selective radiosensitizer. Materials and Methods: Several series of animal experiments were performed, The highly differentiated human bladder cancer cell line RT4 was implanted subcutaneously in nude mice. The mice were injected 10 mg/kg Photofrin II and irradiated with 5 Gy. Results: Photofrin II has proved to be a chemical modifier of ionizing irradiation, enhancing the tumor doubling time (tumor growth) from 6.2 to 10.9 days in the control group with the use of irradiation and injection of porphyrin. Conclusion: Photofrin II shows a high activity as radiosensitizer and, in the future, can be used as a selective radiosensitizer for tumor treatment with ionizing radiation

Feasibility and morbidity of combined hyperthermia and radiochemotherapy in recurrent rectal cancer - Preliminary results

Background: The local recurrence rate of colorectal cancer has been significantly reduced due to the use of combined radiochemotherapy. Despite this improvement regarding locally advanced tumour recurrences, the treatment strategy for pre-treated patients remains difficult and unresolved. Patients and Methods: We analysed treatment and follow-up data of 14 patients with local recurrence of rectal cancer who were treated with radiation therapy (RT), chemotherapy (CT) and regional hyperthermia (RHT) from November 1997 to December 2001. Nine of these patients had received irradiation and CT (=pre-treated patients) in the past. For this group, 30.6-39.6 Gy RT, 5-fluorouracil (5-FU) as a continuous infusion over 5 days per week (350 mg/m(2)/24 h) combined with RHT twice a week was given. The 5 remaining patients (=not pre-treated) received conformal irradiation of 45 Gy with a boost between 9 and 14.4 Gy, combined with continuous infusion of 5-FU on days 1-4, and 29-33 (500 mg/m(2)/24 h), and RHT twice a week. Response to therapy was evaluated by means of computed tomography (CT) or magnetic resonance imaging (MRI) and by clinical follow-up. Results: Among 13 evaluated cases, the overall objective response rate was 54% (5 complete responses, 2 partial responses). At mean follow-up of 13.9 months (range 5-32 months) 7 patients were alive. Conclusion: The therapeutic regimen appears to be active in the treatment of local recurrences of rectal cancer. Larger-scaled studies are needed to evaluate the potency of hyperthermia in this therapeutic strategy

Suboccipital lateral injection of intrathecal chemotherapy in a patient with mantle cell lymphoma

Background: Even today patients who suffer from mantle cell lymphoma have a poor prognosis, especially when the CNS is involved. To confirm the diagnosis of meningeosis lymphomatosa, asservation of the liquor cerebrospinalis is necessary. During this procedure, intrathecal chemotherapy may be given if there is clinical evidence of meningeosis. If lumbar puncture cannot be performed, a lateral suboccipital puncture may be an alternative approach. Patient and Methods: We report the case of a 65-year-old patient who suffered from mantle cell lymphoma stage IV. The patient presented with symptoms of progressive paraparesis of both legs and incontinence, with tumor mass intradural from the 12th thoracic vertebra to the level of S1. During irradiation, the patient developed symptoms of diffuse meningiosis lymphomatosa. The conventional lumbar puncture was impossible, because of tumor present in the thoracico-lumbar junction. Results: A suboccipital puncture was performed for both collecting cerebrospinal fluid and application of chemotherapy ( cytosine arabinoside/dexamethasone). This lead to remarkable improvement of the patient's clinical symptoms. Conclusion: The suboccipital cervical puncture was performed without complications. A variation of the intrathecal approach is described, which may serve as alternative when conventional lumbar puncture is not possible

Cytokines levels, Severity of acute mucositis and the need of PEG tube installation during chemo-radiation for head and neck cancer - a prospective pilot study

<p>Abstract</p> <p>Background</p> <p>The purpose of this pilot study was to detect a correlation between serum cytokine levels and severity of mucositis, necessitating installation of a percutaneous endoscopic gastrostomy tube (PEG) in head and neck (H&N) cancer patients receiving combined chemo-radiation therapy.</p> <p>Patients and Methods</p> <p>Fifteen patients with H&N epithelial cancer were recruited to this study. All patients received radiotherapy to the H&N region, with doses ranging from 50-70 Gy. Chemotherapy with cisplatin, carboplatin, 5-fluorouracil and taxanes was given to high-risk patients, using standard chemotherapy protocols. Patients were evaluated for mucositis according to WHO common toxicity criteria, and blood samples were drawn for inflammatory (IL-1, IL-6, IL-8, TNF-α) and anti-inflammatory (IL-10) cytokine levels before and during treatment.</p> <p>Results</p> <p>A positive correlation was found between IL-6 serum levels and severity of mucositis and dysphagia; specifically, high IL-6 levels at week 2 were correlated with a need for PEG tube installation. A seemingly contradictory correlation was found between low IL-8 serum levels and a need for a PEG tube.</p> <p>Conclusion</p> <p>These preliminary results, indicating a correlation between IL-6 and IL-8 serum levels and severity of mucositis and a need for a PEG tube installation, justify a large scale study.</p

Postoperative irradiation for squamous cell carcinoma of head and neck: Retrospective comparison of accelerated radiochemotherapy and standard radiotherapy

Background: Comparison of accelerated radiochemotherapy (aRCT) and standard radiotherapy (sRT) in postoperative treatment after macroscopically complete resection of squamous cell cancers of head and neck. Material and Methods: 229 patients treated within the same period had either (no randomization) postoperative radiotherapy with conventional fractionation (60-70 Gy, 2.0 Gy per day) or received 2 fractions of 2.1 Gy per day, 8 times\textbackslash{}week, up to a total dose of 56.7 Gy with a treatment split after 2 weeks and simultaneous low dose cisplatin or carboplatin on treatment clays (cumulative dose >66 mg/m(2) or 550 mg/m(2) in 83% of patients). Results: 65 patients completed their course of twice-daily irradiations within a maximum of 35 days and therefore had aRCT; their 3-year locoregional tumor control (Kaplan-Meier estimate) was 86%, whereas that of 42 patients with prolonged twice-daily radiochemotherapy was 65% (p=0.0509). After sRT, i.e. 1 fraction daily and treatment time up to 45 days, locoregional tumor control was 67%, this result being significantly inferior to that after aRCT (p=0.0282). In multivariate analysis, pN stage, tumor site oral cavity/floor of mouth, high/moderate differentiation of squamous cell carcinoma and conventional surgery (versus CO2-laser surgery) were significantly predictive of locoregional failure. Whereas nodal status, the strongest prognostic factor, was evenly distributed among aRCT and sRT patients, there was a misbalance of 3 risk factors favoring the aRCT collective. Superior tumor control after aRCT was confirmed unilaterally for nearly each subgroup (significant for recurrent tumors, close margins, pN1/2a-b). For pN2c/pN3 nodal stage, the results after aRCT were by tendency worse than after sRT, possibly due to a particularly long interval between surgery and start of radio(chemo)therapy for the patients with aRCT (mean 58.0 days vs. 43.8 days, p=0.037). Among the total of patients the 3-year hazard for late toxicity Ill-IV was 31% after twice-daily treatment and 17% after conventionally fractionated radiotherapy (p=0.083). Conclusions:This retrospective analysis provides some evidence that accelerated radiotherapy with simultaneous chemotherapy is more potent than standard radiotherapy. However, as multivariate analysis misses significance and the influence of misbalance of some prognostic factors among aRCT and sRT patients remains unclear, only a randomized trial with stratification according to risk factors as well as a defined interval between surgery and initiation of RT can provide more evidence