shown improved 3-month survival compared with placebo
. In the past, whether endoscopic variceal eradication
should be carried out in such patients remained unclear
due to the cost and the lack of survival benefit . With
the advance of molecular target therapies, the manage-
ment of variceal bleeding in such patients may be
changed. Although the experience is limited, we believe
the development of such new molecular target therapies
may prolong the survival of such patients. Furthermore,
more aggressive endoscopic therapy for such cases may
provide an improved outcome.
S. S. WU*
H. H. YEN*
C. Y. CHUNGy
*Department of Gastroenterology,
Changhua Christian Medical Center,
Changhua, Taiwan, ROC; yDepartment of
Oncology, Changhua Christian Medical
1 Amitrano L, Guardascione MA, Bennato R, Manguso F, Balzano A.
MELD score and hepatocellular carcinoma identify patients at
different risk of short-term mortality among cirrhotics bleeding
from esophageal varices. J Hepatol 2005;42:820e825.
2 Lang L. FDA approves sorafenib for patients with inoperable liver
cancer. Gastroenterology 2008;134:379.
3 Kadouchi K, Higuchi K, Shiba M, et al. What are the risk factors
for aggravation of esophageal varices in patients with hepato-
cellular carcinoma? J Gastroenterol Hepatol 2007;22:240e246.
4 Liu L, Cao Y, Chen C, et al. Sorafenib blocks the RAF/MEK/ERK
pathway, inhibits tumor angiogenesis, and induces tumor cell
apoptosis in hepatocellular carcinoma model PLC/PRF/5. Cancer
5 Abou-Alfa GK, Schwartz L, Ricci S, et al. Phase II study of
sorafenib in patients with advanced hepatocellular carcinoma.
J Clin Oncol 2006;24:4293e4300.
Salvage Radiotherapy for Local Relapse after Primary
Cryotherapy for Prostate Cancer
Sir d Thomson et al.  recently published an interesting
letter in Clinical Oncology about a patient treated with
salvage radiotherapy for local relapse after cryosurgical
ablation for prostate cancer. There is little experience
published about external beam radiotherapy as salvage
treatment of local relapses after cryotherapy for prostate
We would like to report four patients treated between
2004 and 2007 in this clinical scenario in the Radiation
Oncology Department of Hospital de l’Esperanc ¸a in Barce-
All of the patients were treated with primary cryother-
apy by the same urological team using the same technique.
In brief, under transrectal ultrasound guidance, cryoprobes
were placed using a percutaneous transperineal way to
cover the entire prostate gland. An argon-based cooling
system with urethral warming was used to freeze the
In all patients, local relapse was confirmed by endorectal
magnetic resonance imaging and by transrectal biopsy.
The median elapsed time between cryotherapy and the
initiation of salvage external beam radiotherapy was 15.25
months (range 7e28).
Patients underwent simulation and treatment in the
supine position with a full bladder and a knee support as
the immobilisation device. Computed tomography image
data sets for planning were acquired for three-dimensional
conformal radiation therapy using a 5 mm slice thickness.
The clinical target volume (CTV) was defined as the
prostate and seminal vesicles, and the planning target
volume (PTV) was defined with a CTV to PTV margin of
10 mm in all directions. Treatment verification was carried
out with skin tattoos and weekly electronic portal imaging.
The patients were irradiated with external beam radio-
therapy at 2 Gy/fraction using 18 MV photon beams. The
Table 1 e Patient characteristics and outcome
177T1c N0 M03þ2 4.62154þ 34.572GU 1
2 72T2a N0 M04þ3 20.3274þ 3 19 7436BF
373T1c N0 M02þ312.11113þ 31.97422BNED
4 78T2a N0 M0?101 28? 0,6776 10 BNED
CS, cryosurgery; EBRT, external beam radiotherapy; BNED, biochemically no evidence of disease; BF, biochemical failure; GU, genitourinary;
mean total radiation dose delivered in the target was 74 Gy
(range 72e76). No patient received androgen deprivation
therapy before or during radiotherapy.
Genitourinary and gastrointestinal acute and late toxic-
ity were scored using Radiation Therapy Oncology Group
After salvage radiotherapy, all patients had complete
resolution for palpable disease and one patient developed
biochemical failure as defined by the American Society for
Therapeutic Radiology and Oncology consensus definition.
Acute and late toxicity after external beam radiotherapy
was acceptable. Only one patient developed late proctitis
with slight intermittent rectal bleeding 12 months after
salvage treatment. In our series, no patient had urinary
incontinence or obstructive symptoms at the last follow-up.
Table 1 shows the characteristics of the patients and the
From our experience, it is suggested that salvage
three-dimensional conformal external beam radiotherapy
after cryotherapy failure for prostate cancer is a valid
treatment option with good local control and without
excessive morbidity. Additional data are necessary to
better assess the role of this salvage therapy in these
J. M. BANU ´Sy
*Institut d’Oncologia Radiotera `pica,
Hospital de l’Esperanc ¸a, Barcelona,
Spain; yInstitut Catala ` de Nefro-Urologia,
1 Thomson AH, Kulkarni S, Bahl A. Primary cryotherapy with
salvage external beam radiotherapy for locally recurrent pros-
tate cancer. Clin Oncol 2008;20:385.
2 McDonough MJ, Feldmeier JJ, Parsai I, et al. Salvage external
beam radiotherapy for clinical failure after cryosurgery for
prostate cancer. Int J Radiat Oncol Biol Phys 2001;51:
3 Burton S, Brown DM, Colonias A, et al. Salvage radiotherapy for
prostate cancer recurrence after cryosurgical ablation. Urology
Correction to Editorial on Thyroid Cancer Guidelines
Sir d We would like to make an important correction to
the editorial ‘Thyroid cancer guidelines d what’s new?’
In the conclusion it is stated that ‘each thyroid cancer
surgeon should operate on at least 10 to 20 cases of thyroid
cancer per year’. This is too high a number and should be
thyroid operations, rather than specifically thyroid cancer
cases. Thyroid cancer may be found incidentally in
a thyroidectomy specimen taken for a presumed benign
condition. The British Association of Endocrine and Thyroid
Surgeons (BAETS) suggests that about 25 thyroid operations
per year is required to maintain competency (U. Mallick,
pers. comm.). There might be minor variations in this
number depending upon regional case load. This is a useful
figure to work with when preparing for peer review. It is
also felt important that all thyroid surgeons are core
members of their local multidisciplinary team, and take
part in regular surgical audit, such as the one recommended
by the BAETS.
The editorial also states that UK thyroid cancer survival
figures are ‘some of the worst in Europe’. UK thyroid cancer
survival was seen to be worse than the European average in
the EUROCARE studies [2,3]. However, several factors,
including registration, staging and UK regional variation,
may be involved here. A Northern and Yorkshire Cancer
Registration and Information Service (NYCRIS) audit 
looked at 234 patients diagnosed with thyroid cancer in
1998 and 1999, which was before multidisciplinary man-
agement of thyroid cancer was widely established in the
UK. This showed that the 4-year survival rate for papillary
thyroid cancer was 97% and for follicular thyroid cancer was
94%. Although the follow-up was short and it was a regional
audit, this is above the EUROCARE average, in which overall
relative survival of patients diagnosed with thyroid cancer
in 1990e1994 was 86% at 1 year and 83% at 5 years.
*St. James’s Institute of Oncology, Leeds,
UK; yNorthern Centre for Cancer
Treatment, Newcastle, UK
1 Gerrard G, Gill V. Thyroid cancer guidelines e what’s new? Clin
2 The EUROCARE Working Group. EUROCARE-3: survival of cancer
patients diagnosed 1990e94 e
3 Venlecchia A, Francisci S, Brenner H, et al. Recent cancer
survival in Europe: a 2000e2002 period analysis of EUROCARE-4
data. Lancet Oncol 2007;8:784e796.
4 NYCRIS. Management of thyroid cancer in the Northern and
Yorkshire region 1998e99. NYCRIS Executive report 2004.
results and commentary. Ann