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ABSTRACT: Aim. To present a retrospective analysis of results of definitive radiotherapy for rectal cancer. Material and methods. Forty-one consecutive patients with rectal cancer (32% primary, 61% pelvic recurrence and 7% after R2 resection) who could not be treated with surgery underwent external beam radiotherapy. A median tumour dose of 64 Gy was given with 1.8-2.5 Gy per fraction using 2D or 3D technique. In 46% of patients, concurrent 5-Fu-based chemotherapy was given. The median follow-up was 54 months. Results. Clinical complete response was achieved in 39% of patients. Five-year cumulative incidence of local failure, overall survival and cancer specific survival were 76%, 26% and 30%, respectively. Of 11 patients with local control, in five cases the tumour was larger than 5 cm and in the other five the tumour was fixed. Two patients, regarded as locally controlled had non-progressive tumour without local symptoms at the last follow-up of 54 and 118 months post-radiotherapy. Late toxicity occurred in 22% of patients, all with acceptable severity. There was no bowel obstruction requiring surgery despite that in 18 patients the small bowel dose was > 60 Gy to a mean volume of 51 cm(3). Conclusion. Definitive radio(chemo)therapy provides a chance for local control even in patients with large fixed or recurrent rectal cancer.
Acta oncologica (Stockholm, Sweden) 08/2012; · 2.27 Impact Factor
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ABSTRACT: Elective nodal irradiation (ENI) is not recommended in PET-CT-based radiotherapy for NSCLC despite a low level of evidence to support such guidelines. The aim of this investigation is to find out whether omitting ENI is safe.
Sixty-seven patients treated within a frame of a previously published prospective trial of the value of PET-CT were included in the analysis. Seventeen (25%) patients received ENI due to higher initial nodal involvement and in the remaining 50 patients (75%) with N0-N1 or single N2 disease ENI was omitted. Isolated nodal failure (INF) was recorded if relapse occurred in the initially uninvolved regional lymph node without previous or simultaneous local recurrence regardless of the status of distant metastases.
With a median follow-up of 32 months, the estimated 3-year overall survival was 42%, local progression-free interval was 55%, and distant metastases-free interval was 62%. Three patients developed INF; all had ENI omitted from treatment, giving a final result of three INFs in 50 (6%) patients treated without ENI. In this group of patients, the 3-year cause-specific cumulative incidence of INF was 6.4% (95% confidence interval: 0-17%).
The omission of ENI appears to be not as safe as suggested by current recommendations.
Radiotherapy and Oncology 05/2012; 104(1):58-61. · 5.58 Impact Factor
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ABSTRACT: To evaluate prospectively how positron emission tomography (PET) information changes treatment plans for non-small-cell lung cancer (NSCLC) patients receiving or not receiving elective nodal irradiation (ENI).
One hundred consecutive patients referred for curative radiotherapy were included in the study. Treatment plans were carried out with CT data sets only. For stage III patients, mediastinal ENI was planned. Then, patients underwent PET-CT for diagnostic/planning purposes. PET/CT was fused with the CT data for final planning. New targets were delineated. For stage III patients with minimal N disease (N0-N1, single N2), the ENI was omitted in the new plans. Patients were treated according to the PET-based volumes and plans. The gross tumor volume (GTV)/planning tumor volume (PTV) and doses for critical structures were compared for both data sets. The doses for areas of potential geographical misses derived with the CT data set alone were compared in patients with and without initially planned ENI.
In the 75 patients for whom the decision about curative radiotherapy was maintained after PET/CT, there would have been 20 cases (27%) with potential geographical misses by using the CT data set alone. Among them, 13 patients would receive ENI; of those patients, only 2 patients had the PET-based PTV covered by 90% isodose by using the plans based on CT alone, and the mean of the minimum dose within the missed GTV was 55% of the prescribed dose, while for 7 patients without ENI, it was 10% (p = 0.006). The lung, heart, and esophageal doses were significantly lower for plans with ENI omission than for plans with ENI use based on CT alone.
PET/CT should be incorporated in the planning of radiotherapy for NSCLC, even in the setting of ENI. However, if PET/CT is unavailable, ENI may to some extent compensate for an inadequate dose coverage resulting from diagnostic uncertainties.
International journal of radiation oncology, biology, physics 07/2011; 80(4):1008-14. · 4.59 Impact Factor
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ABSTRACT: Proper target volume delineation is a crucial stage of treatment planning, so any error introduced in this process is a systematic
error and cannot be quantified and/or detected by modern treatment technologies, unlike other sources of geometrical uncertainties.
All steps of target definition should be standardized. In non-small cell lung cancer radiotherapy, there are specific problems
related to the definition of all three consecutive target volumes recommended by ICRU: gross tumor volume (GTV), clinical
target volume (CTV), and planning target volume (PTV). In GTV delineation, the proper imaging, e.g., standardized way of the
use of CT and PET-CT, and continuous radiological training of radiation oncologists are emphasized. For CTV, we still lack
robust data on the margin which is necessary to expand around GTV of the tumor and pathologic lymph nodes to adequately account
for microscopic spread. Additionally, elective nodal irradiation is still a source of controversies. For PTV definition, major
increase in technologies is involved. It leads in some cases to improvement of the tumor coverage and sparing of organs at
risk, but as this process is expensive and time consuming, it might not be always beneficial.
06/2011: pages 187-200;
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ABSTRACT: To prospectively assess the cardiopulmonary morbidity and quality of life in patients with non-small cell lung cancer (NSCLC) treated with postoperative radiotherapy (PORT) in comparison to those not receiving PORT.
From 2003 to 2007, 291 patients entered the study; 171 pN2 patients received 3D-planned PORT (PORT group), 120 pN1 patients (non-PORT group) did not. One month after surgery, all patients completed EORTC QLQ C-30 questionnaire and had pulmonary function tests (PFT); cardiopulmonary symptoms were assessed by modified LENT-SOM scale. Two years later, disease-free patients repeated the same examinations. The differences between baseline values and values recorded at two years in QLQ, LENT-SOM and the PFT of the two groups were compared.
In the whole cohort, the rate of non-cancer related deaths was 5.3% and 5.0% in PORT and non-PORT group, respectively. Ninety-five patients (47 - PORT group, 48 - non-PORT group) were included into the final analysis. The differences in the QLQ and cardiopulmonary function (LENT/SOM, PFT) between both groups were insignificant. The forced expiratory volume in one second was on average 12.2% and 1.3% better in the PORT and the non-PORT group, respectively, p=0.2.
Our findings support the hypothesis about insignificant morbidity of 3D-planned PORT.
Radiotherapy and Oncology 10/2010; 98(2):238-43. · 5.58 Impact Factor
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ABSTRACT: To explore the utility of tumour regression grading (TRG, the amount of residual tumour cells in relation to extension of fibrosis) after chemoradiation of rectal cancer.
Of 131 patients who received preoperative chemoradiation in the frame of the randomized trial, pathological complete response (pCR, TRG0), good regression (TRG1), moderate regression (TRG2), and poor regression (TRG3) were recorded in 17%, 31%, 31%, and 22% of patients, respectively.
The rates of ypN-positive category for TRG0, TRG1, TRG2, and TRG3 groups were 5%, 23%, 45%, and 46%, respectively, p=0.001. When ypT-category and TRG were evaluated by the logistic regression analysis, only ypT-category remained significant for independent prediction of the risk for mesorectal nodal metastases, p=0.006. The 4-year (median follow-up) disease-free survival (DFS) for TRG0, TRG1, TRG2, and TRG3 groups were 91%, 67%, 54%, and 47%. When patients with persistent disease (TRG1 vs. TRG2 vs. TRG3) were analyzed separately, TRG had no prognostic value for DFS, p=0.402.
TRG in patients with residual cancer had no prognostic value for the incidence of nodal disease and for DFS. Our findings and literature data question the need for the inclusion of TRG assessment into a routine pathological report.
Radiotherapy and Oncology 06/2010; 95(3):298-302. · 5.58 Impact Factor
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ABSTRACT: The benefit of whole brain radiotherapy (WBRT) for RTOG RPA (Radiation Therapy Oncology Group Recursive Partitioning Analysis) class 3 patients with brain metastases is not well established. The aim of this study was to determine whether WBRT has any benefit in terms of symptoms palliation in such patients. Evaluation of patients' preferences for WBRT, changes in performance and neurological status were secondary aims.
Ninety-one RTOG RPA class 3 patients were included. All patients received WBRT (20 Gy in 5 fractions) and were asked to complete a questionnaire about their symptoms before and one month after WBRT. The patient's symptom checklist comprised 17 items scored from 0 to 3; a higher score meant a greater symptom intensity. The mean scores at baseline and after treatment were compared. Karnofsky performance status (KPS) and neurological status before and one month after WBRT were also recorded. Patients were asked to express their preference as to the WBRT undergone.
Forty-three (47%) patients completed both symptom checklists. The mean scores on the symptom checklist were 18.21 and 21.09 at baseline and one month after WBRT, respectively (p = 0.02). The KPS was estimated after WBRT in 42 patients: 57% of patients improved, 26% worsened, and 17% did not change from the baseline KPS score (p = 0.06). Neurological status did not change from baseline to one month after WBRT (p = 0.44). Only 7% of respondents would not have consented to the WBRT undergone.
Our results challenge the palliative value of the WBRT in RPA class 3 patients.
Acta oncologica (Stockholm, Sweden) 04/2010; 49(3):382-8. · 2.27 Impact Factor
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ABSTRACT: Despite an increasing use of chemotherapy in the palliative setting for lung cancer, the role of palliative thoracic radiotherapy should not be disregarded. It offers quick and efficient palliation, with improvement observed in approximately two-thirds of treated patients. There is evidence that the short and long radiotherapy schedules are equally effective for poor performance patients. Higher radiation doses delivered via protracted schedules give a modest survival benefit for good performance patients. The current review covers the issues related to the use of palliative thoracic radiotherapy, such as total dose, fractionation, delayed versus immediate use, external-beam radiotherapy versus endobronchial brachytherapy, combination with chemotherapy, re-irradiation and palliation with radiation in small-cell lung cancer.
Expert Review of Anti-infective Therapy 04/2010; 10(4):559-69. · 2.65 Impact Factor
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ABSTRACT: Lung cancer is the leading cause of cancer mortality with the median age of incidence being 69 years in males and 67 years in females. Radiochemotherapy (RT-CHT) is indicated in locally advanced non-small-cell lung cancer and limited-stage small-cell lung cancer; however, a significant under-representation of the elderly has been observed in patient recruitment in cancer treatment trials. In the last decades of the 20th Century, studies showed that elderly patients achieved the best quality-adjusted survival with radiotherapy alone, but recent trials have found that fit elderly patients benefit from concurrent RT-CHT, although with more short-term toxicity. Age alone should not exclude fit patients and deprive them of the standard treatment. Using tools, such as comprehensive geriatric assessment, a patient's tolerance to therapy can be assessed and monitoring can be performed. This review will focus on RT-CHT treatment in elderly patients with nonoperable stage III non-small-cell lung cancer and limited-stage small-cell lung cancer exclusively.
Expert Review of Anti-infective Therapy 10/2009; 9(10):1405-11. · 2.65 Impact Factor
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ABSTRACT: Thoracic radiotherapy and prophylactic cranial irradiation (PCI) in combination with chemotherapy is an established standard of treatment of limited-disease (LD) small-cell lung cancer (SCLC). Both types of radiotherapy increase 3-year survival by approximately 5%, as shown in the meta-analyses. There is some evidence that earlier commencement of thoracic radiotherapy for good performance status LD-SCLC patients results in better outcome. Total dose, fractionation type and irradiation volume are still matter of debate. The ongoing Phase III randomized trials aim to answer the question of total dose in LD-SCLC. For PCI, in LD-SCLC a standard dose of 25 Gy in ten fractions should remain a standard, as has recently been demonstrated. The PCI in extensive-disease SCLC improves survival at the expense of worsening of short-term health-related quality of life. There is evidence that consolidation thoracic radiotherapy may be of value in extensive-disease SCLC. The recently initiated prospective trials may answer this question.
Expert Review of Anti-infective Therapy 10/2009; 9(10):1379-87. · 2.65 Impact Factor
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ABSTRACT: The combination of radiotherapy and chemotherapy is considered to be a standard approach for patients with locally advanced, stage III non-small-cell lung cancer. The current state of the art of combined radiochemotherapy supported by evidence-based data is presented. As shown in the meta-analyses, the concurrent radiochemotherapy gives a superior outcome in terms of survival compared with sequential delivery of both modalities. This is obtained at the expense of higher toxicity, which makes further intensification of radiochemotherapy challenging. Eligibility of patients with non-small-cell lung cancer for such an approach is limited. The new methods to improve treatment results, such as selection of proper strategies, incorporation of molecular agents into combined treatment and radiotherapy technique modifications are discussed.
Expert Review of Anti-infective Therapy 10/2009; 9(10):1389-403. · 2.65 Impact Factor
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ABSTRACT: To determine the efficacy of accelerated hypofractionated three-dimensional conformal radiotherapy (3D-CRT) with dose-per-fraction escalation for treatment of stage III non-small cell lung cancer (NSCLC).
Between 2001 and 2007, 173 patients with stage III NSCLC were treated using accelerated 3D-CRT and the simultaneous boost technique. Initially, the total dose of 56.7 Gy (including 39.9 Gy to the elective area) was delivered over 4 weeks in fractions of 2.7 Gy (1.9 Gy to the elective area). The dose-per-fraction escalation study commenced after the outcomes of 70 patients had been evaluated. The dose per fraction was increased from 2.7 through 2.8 Gy (level 1 escalation) to 2.9 Gy (level 2 escalation); the total dose increased, respectively, from 56.7 Gy through 58.8 Gy to 60.9 Gy. The dose to the elective area and the overall treatment time remained unchanged. Fit patients received two to three courses of chemotherapy before radiotherapy.
The 2- and 3-year overall survival rates were 32 and 19%, respectively (median survival = 17 months). Of the patients, 7% had grade III acute esophageal toxicity and 6% had grade III or greater late pulmonary toxicity. Two of the nine patients who received the level 2 escalation (60.9 Gy) died of pulmonary toxicity. The study was terminated at a dose of 58.8 Gy and this schema was adopted as the institutional policy for treatment of stage III NSCLC.
Although dose escalation with accelerated hypofractionated 3D-CRT was limited, the results and toxicity profiles obtained using this technique are promising.
Journal of thoracic oncology: official publication of the International Association for the Study of Lung Cancer 08/2009; 4(7):853-61. · 4.55 Impact Factor
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International journal of radiation oncology, biology, physics 06/2009; 74(1):322; author reply 322-3. · 4.59 Impact Factor
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ABSTRACT: To evaluate the dose-response relationship for a wide range of doses lower than 50 Gy delivered to the hilar and mediastinal lymph node stations from incidental irradiation in 220 patients with non-small-cell lung cancer (NSCLC) treated with three-dimensional conformal radiotherapy. The endpoint was isolated nodal recurrence (INR) in stations that were initially negative.
The individual responses of 2596 nodal stations were analyzed. Different fractionation schedules were used in different patients. Total prescribed tumor doses ranged from 52 Gy to 74 Gy given over 16-56 days. There were 1198 nodal stations (46%) within and 1398 stations beyond the elective nodal irradiation (ENI) volumes. The INR incidence was estimated for six dose levels ranging from 5 +/- 5 Gy to > or = 56 Gy.
There were a total of 25 INRs in 17 patients (8%). The incidence of INR within the electively treated volumes was 0.58%, compared with 1.28% in nodal stations beyond the ENI. Almost 80% of the INRs occurred during 10 months of follow-up. A strong dose-response relationship was seen for the lower "incidental" doses, most of which were less than 50 Gy. As the dose increased from 5 +/- 5 Gy to 40 +/- 5 Gy, the rate of freedom from INR increased from 12% to 76% (p = 0.005).
There is evidence of a dose-response relationship between a reduction in the rate of INR and doses lower than 50 Gy. This suggests that incidental irradiation can eradicate at least some subclinical metastases in regional lymph nodes.
International journal of radiation oncology, biology, physics 05/2009; 73(5):1391-6. · 4.59 Impact Factor
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Lucyna Kepka
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ABSTRACT: Patients aged 70 years and older accounted for 42% of all lung cancer deaths in Poland in 2005. Although the incidence of lung cancer in elderly people is growing in Poland, like in other developed countries, the standards of treatment for this subset of population are not well established. Prospective elderly-specific trials concerning curative treatment are lacking. The results from prospective trials including elderly participants show similar effectiveness as in younger population at the expense of higher toxicity. Selection bias may limit the ability to generalize results of clinical trials to the entire population of elderly people. Methods of curative treatment (surgery, radiotherapy, chemotherapy as adjuvant for non-small cell lung cancer and basic treatment for limited-stage small cell lung cancer) are discussed. Some treatment options and modifications of standard strategies which are particularly promising in elderly patients, as VADS surgery, stereotactic radiotherapy or abbreviated treatment for SCLC, are presented.
Pneumonologia i alergologia polska: organ Polskiego Towarzystwa Ftyzjopneumonologicznego, Polskiego Towarzystwa Alergologicznego, i Instytutu Gruzlicy i Chorob Pluc 02/2009; 77(2):166-72.
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ABSTRACT: To assess doses received by mediastinal and hilar lymph node stations (LNS) delineated according to published recommendations when "standard" two-dimensional (2D) elective fields are applied and to assess doses to critical structures when fields are designed using 2D and three-dimensional (3D) treatment planning for elective irradiation.
LNS were delineated on axial CT scans according to existing recommendations. For each case and tumor location, 2D anteroposterior-posteroanterior (AP-PA) elective fields were applied using the AP-PA CT topograms. From the 2D portal fields, 3D dose distributions were then calculated to particular LNS. Next, 3D plans were prepared for elective nodal irradiation for tumors of different lobes. Doses for critical structures were compared for 2D and 3D plans.
LNS 1/2R, 1/2L, 3A, 3P, 5, 6, and 8 were not adequately covered in a substantial part of plans by standard 2D portals when guidelines for delineation were strictly followed. The magnitude of the lack of coverage increased with margin application. There was a trend for a higher yet probably still safe dose delivered to lung for 3D plans compared with 2D plans with a prescription dose of 45 Gy.
2D fields did not entirely cover LNS delineated according to the recommendations for 3D techniques. A strict adherence to these guidelines may lead to larger portals than traditionally constructed using 2D methods. Some modifications for clinical implementation are discussed.
International journal of radiation oncology, biology, physics 12/2008; 73(5):1397-403. · 4.59 Impact Factor
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ABSTRACT: Thoracic radiotherapy (RT) is an integral part of the management of small-cell lung cancer (SCLC) because its administration provides a survival benefit in patients with limited-stage disease. However, there are many areas of controversy with respect to the delivery of curative RT, and these include definition of the target to be irradiated. A current area of concern is defining what the RT portal must encompass with respect to the mediastinal lymph nodes; that is, whether one should electively treat all mediastinal nodes, or selectively include those with some clinical risk for harboring disease, or perhaps omit elective nodal irradiation altogether. The purpose of the present report is therefore to address the concepts underlying elective or selective nodal irradiation as it applies to SCLC, looking at clinical, imaging, and RT reports to help define the parameters appropriate to treating individual patients.
International Journal of Radiation OncologyBiologyPhysics 11/2008; 72(2):327-34. · 4.11 Impact Factor
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ABSTRACT: Lymphatic spread is an important pathway of progression in non-small-cell lung cancer (NSCLC), along with local spread and distant metastasis. The probability of lymph node (LN) involvement is dependent on the site of the primary tumor, stage, and histology. Elective nodal irradiation (ENI) is the irradiation of clinical and radiological uninvolved LN to account for microscopic tumor invasion in these LNs because we have not been able to determine the extent of LN spread accurately. The clinical value of ENI is uncertain. The impact of ENI is dependent on many (staging-, treatment-, and patient-related) factors. The purpose of this report is to analyze the current status of ENI and to provide comprehensive in-depth analysis and guidance on how to generally approach this issue in NSCLC.
International Journal of Radiation OncologyBiologyPhysics 11/2008; 72(2):335-42. · 4.11 Impact Factor
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ABSTRACT: To estimate the doses of incidental irradiation in particular lymph node stations (LNS) in different extents of elective nodal irradiation (ENI) in 3D-conformal radiotherapy (3D-CRT) for non-small cell lung cancer (NSCLC). METHODS; Doses of radiotherapy were estimated for particular LNS delineated according to the recommendations of the University of Michigan in 220 patients treated using 3D-CRT with different (extended, limited and omitted) extents of ENI. Minimum doses and volumes of LNS receiving 40 Gy or more (V40) were compared for omitted vs. limited+ extended ENI and limited vs. extended ENI.
For omission of the ENI the minimum doses and V40 for particular LNS were significantly lower than for patients treated with ENI. For the limited ENI group, the minimum doses for LNS 5, 6 lower parts of 3A and 3P (not included in the elective area) did not differ significantly from doses given to respective LNS for extended ENI group. When the V40 values for extended and limited ENI were compared, no significant differences were seen for any LNS, except for group 1/2R, 1/2L.
Incidental irradiation of untreated LNS seems play a part in case of limited ENI, but not in cases without ENI. For subclinical disease the delineation of uninvolved LNS 5, 6, and lower parts of 3A, 3P may be not necessary, because these stations receive the substantial part of irradiation incidentally, if LNS 4R, 4L, 7, and ipsilateral hilum are included in the elective area while this is not case for stations 1 and 2.
Acta oncologica (Stockholm, Sweden) 02/2008; 47(5):954-61. · 2.27 Impact Factor
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ABSTRACT: To estimate retrospectively the rate of isolated nodal failures (INF) in NSCLC patients treated with the elective nodal irradiation (ENI) using 3D-conformal radiotherapy (3D-CRT).
One hundred and eighty-five patients with I-IIIB stage treated with 3D-CRT in consecutive clinical trials differing in an extent of the ENI were analyzed. According to the extent of the ENI, two groups were distinguished: extended (n = 124) and limited (n = 61) ENI. INF was defined as regional nodal failure occurring without local progression. Cumulative Incidence of INF (CIINF) was evaluated by univariate and multivariate analysis with regard to prognostic factors.
With a median follow up of 30 months, the two-year actuarial overall survival was 35%. The two-year CIINF rate was 12%. There were 16 (9%) INF, eight (6%) for extended and eight (13%) for limited ENI. In the univariate analysis bulky mediastinal disease (BMD), left side, higher N stage, and partial response to RT had a significant negative impact on the CIINF. BMD was the only independent predictor of the risk of incidence of the INF (p = 0.001).
INF is more likely to occur in case of more advanced nodal status.
Acta Oncologica 02/2008; 47(1):95-103. · 3.33 Impact Factor
