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Predictive value of in vitro radiosensitivity parameters in head and neck cancers and cervical carcinomas: preliminary correlations with local control and overall survival.

PURPOSE: To determine whether in vitro radiosensitivity parameters are predictive of treatment outcome. METHODS AND MATERIALS: Biopsies were obtained from patients with head and neck cancers (57) and cervical carcinomas (20) and in vitro radiosensitivity parameters were obtained using the CAM plate assay. RESULTS: In most cases (75%) patients were treated with radiation alone. The median follow up was 461 days. When the whole group of head and neck cancers and cervical carcinomas was considered, patients with a SF2 value below 0.36 had a higher 2-year local control rate (93% versus 68%) and a higher 2-year survival rate (71% vs. 62%) than those with SF2 values above that threshold, but differences were not significant. These trends persisted when head and neck cancers were considered alone with a higher local control rate (86% vs. 67%) and a higher survival rate (75% vs. 52.5%) obtained for patients with a SF2 value below 0.36. When the alpha value was evaluated for the whole group of patients a significantly higher local control rate (80.5% vs. 40.5%) and overall survival rate (71% versus 37.5%) at 2 years were obtained for patients with alpha values above 0.07 Gy-1. When only the group of head and neck cancers was considered, local control rate was significantly higher (79% vs. 33%) but overall survival rate (65.5% vs. 33%) was not significantly higher for alpha values above 0.07 Gy-1. CONCLUSION: These results are encouraging but need to be confirmed with a larger number of patients with a longer follow-up.

Carcinoma, Squamous Cell↗

Local control versus dose or overall time: from coefficients to percentages.

When clinical results are analysed to find the treatment variables which affect the outcome, two types of multivariate analysis are done. Firstly, a determination of which variables are important is made: from age, gender, stage, histology, total dose, overall time, etc. Secondly, a quasi-biological model may be set up which includes those variables, e.g. Function (p) = Variable 1 + Variable 2 + ... + alpha x dose + beta x dose x (dose per fraction) - gamma x (overall time) where p is the probability of local control and "Function" is a logit or double-log function. The coefficients thus determined are often presented simply in raw form, or as ratios such as alpha/beta or gamma/alpha where any conversion factors from "Function (p)" to percentages are assumed conveniently to cancel out. However, it is mathematically possible to convert each coefficient directly into "percent change in local control per unit dose" (for alpha), or "percent per unit time" (for gamma), without recourse to the obvious convenience of the ratios. These converted values are more understandable than the coefficients themselves. They mean the rate of change of local control with (for example) total dose if overall time and dose per fraction were held constant; or rate of loss of local control with prolongation if total dose and dose per fraction were held constant. Even though heterogeneity may alter these slopes considerably from the theoretically maximum Poisson slopes, they still tell us what is happening averaged over the group of patients being studied, with often interesting insights.

Dose-Response Relationship, Radiation↗

Vaginal applicators (ovoids) for local control and alleviation of rectal complications of cervical cancers treated by brachytherapy.

PURPOSE: To assess the effects of vaginal applicators (ovoids) on dose distribution, local control and rectal complications in cervical cancers treated by brachytherapy. METHODS: From 1984 to 1992, 41 patients (15 stages I+II; 26 stages III+IV) were treated by high-dose-rate brachytherapy (20 Gy in 4 fractions) after external beam irradiation (36-56 Gy). Twenty-three patients were treated by standard application of both intrauterine tandem and ovoids, and 18 patients were treated by non-standard application. RESULTS: The five-year, local-relapse-free rates by standard application and tandem alone were 69 and 65% overall; 83 and 100% for stages I+II; and 62 and 49% for stages III+IV. Local control was related to tumor response following the external beam irradiation and initial tumor size by multivariate analysis. Rectal complications seen in patients followed for more than 1 year were 33% after standard application and 22% for tandem use alone. The rectal doses given for standard application (24 Gy) and tandem use (16 Gy) were significantly different. CONCLUSIONS: The ovoid sources did not always contribute to local control, and occasionally led to rectal complications. The optimization of brachytherapy was dependent on patients' anatomy, tumor size, and tumor response.

Adult↗

The influence of quantitative tumor volume measurements on local control in advanced head and neck cancer using concomitant boost accelerated superfractionated irradiation.

PURPOSE: Current methods to clinically define head and neck tumor bulk are qualitative and imprecise. Although the American Joint Committee on Cancer (AJCC) staging system is important for this purpose, limitations exist. This study will investigate the prognostic value of computed tomography (CT) derived tumor volume measurements in comparison to AJCC stage and other significant variables. MATERIALS AND METHODS: Seventy-six patients with advanced head and neck squamous cell carcinoma were treated with concomitant boost accelerated superfractionated irradiation. Doses ranged from 68.4-73.8 Gy (median 70.2 Gy). Good quality pretherapy CT scans were available in 51 patients. Total tumor volume (TTV) estimates were derived from these scans using digital integration of primary tumor and metastatic lymphadenopathy. Actuarial and multivariate statistical techniques were applied to analyze local control. RESULTS: Thirty-six-month local control was 63%. TTV ranged from 5-196 cm3 (median 35 cm3) for all cases, 5-142 cm3 (median 17 cm3) for those controlled, and 16-196 cm3 (median 47 cm3) for local failures. There was a significant increase in failures above 35 cm3. Univariate analysis found that TTV, T-stage, N-stage, and primary site were each significant prognostic variables. Local control for TTV < or = 35 cm3 was 92% at 36 months vs. 34% for TTV > 35 cm3 (p = 0.0001). Multivariate analysis, however, found that TTV, primary site, and sex were important as independent variables; T and N stage were not independently significant unless TTV was removed from the model. CONCLUSIONS: This study demonstrates the prognostic significance of TTV in advanced carcinoma of the head and neck. This variable appears to be a more predictive than AJCC clinical stage. Quantitative tumor volume measurements may prove to be a useful parameter in future analyses of head and neck cancer.

Carcinoma, Squamous Cell↗

Oxygenated and reoxygenated tumors show better local control in radiation therapy for cervical cancer.

The presence of hypoxic cells is one of the major factors affecting resistance against radiation therapy. In the clinical setting, little information exists as to the relationship between intratumoral oxygen partial pressure (pO(2)) and outcome. This study involved 30 consecutive patients with cervical cancer, who were treated with a combination of external and high-dose rate intracavitary irradiation. The pO(2) was measured before radiation therapy and at 9 Gy, using a needle-type polarographic oxygen electrode. The mean intratumoral pO(2) before radiation therapy was 17.3 +/- 10.8 mm Hg. The 3-year local control rates of patients with pO(2)< or = 20 mm Hg and pO(2) > 20 mm Hg before radiation therapy were 52% and 100%, respectively, representing a significant difference (P= 0.035). At 9 Gy, mean intratumoral pO(2) was 23.6 +/- 9.1 mm Hg, a significant increase compared to the value before radiation therapy (P= 0.006). The 3-year local control rates of tumors with pO(2)< or = 20 mm Hg and pO(2) > 20 mm Hg at 9 Gy were 35% and 93%, respectively, representing a significant difference (P= 0.001). The significantly better local control for oxygenated tumors at 9 Gy as well as before radiation therapy indicated that the oxygen effect and reoxygenation by radiation played an important role in local control in radiation therapy for cervical cancer.

Adenocarcinoma↗

Photodynamic therapy of orthotopic prostate cancer with benzoporphyrin derivative: local control and distant metastasis.

This is the first report of photodynamic therapy (PDT) in an orthotopic prostate tumor model and shows that PDT combined with surgery (tumor bed sterilization) gave significant local control of the primary tumor and significant reduction in distant metastases. By contrast, either treatment alone (surgery or PDT) gave relatively poorer local control, and PDT gave a significant increase in the mean number of lung metastases. The MatLyLu variant of the Dunning 3327 rat prostate cancer cell line, which has been selected to be metastatic to lymph nodes and lungs, was injected into the ventral lobe of the rat prostate. After 7 days, tumors were either treated by surgical removal of the ventral lobe, PDT with liposomal benzoporphyrin derivative monoacid ring A, or a combination of surgery, followed by PDT of the tumor bed. Results after 21 days showed a reduction in prostate tumor weight in all groups compared with controls, which became highly significant only for the combination group (17% of control mean tumor weight; P < 0.001; 7 of 13 clinical complete responses). The combination treatment also led to a reduction in lymph node metastasis and reductions in both the frequency and mean number of lung metastases compared with other treatment groups. The PDT-alone group, however, had a mean number of lung metastases per animal, which was nine times the control group and 34 times the combination group. These findings suggest that a tumor bed sterilization approach may be promising for locally advanced prostate cancer and suggest that factors other than local control may need to be evaluated when considering PDT for primary prostate cancer.

Adenocarcinoma↗

Loss of local control with prolongation in radiotherapy.

Twelve published clinical results of radical radiotherapy of head and neck cancer have been reviewed, seven of them with fresh multivariate analyses, to determine the magnitude of time factors relating local control to overall time. In all but two of the data sets a significant loss of local control was observed with prolongation. The median rate of loss was 14% in only 1 week, the range 3 to 25%. This corresponds to a median loss of 26% in 2 weeks (5-42%). These results are comparable with other, less detailed information. Whether these significant losses are due to proliferation of tumor cells or to other causes such as physician selection, it is clear that modest prolongation is associated with a lower chance of local control.

Head and Neck Neoplasms↗

The importance of local control in the treatment of prostatic cancer.

In a retrospective analysis of 946 patients with prostatic carcinoma treated with external beam radiotherapy between 1958 and 1989 at Stanford University Hospital the 15-year actuarial clinical local control rate was 77.8 +/- 3.3% for Stanford stage T1, 61.3 +/- 4.4% for stage T2 and 64.9 +/- 4.8% for stage T3 disease. Overall, there was improvement in disease-specific survival without a significant alteration in survival in patients who achieved clinical local control. For the 50 Stanford stage T1 cases with local control on clinical examination and a positive post-treatment biopsy a decrease in disease-specific survival was observed. There was no difference in disease-specific survival for comparable stage T2 or T3 cases. In an analysis of patients who underwent ultrasound guided prostatic biopsy performed after irradiation the trend of prostate specific antigen was more important than biopsy results in predicting which patients would have relapse.

Follow-Up Studies↗

Potential doubling time in head and neck tumors treated by primary radiotherapy: preliminary evidence for a prognostic significance in local control.

PURPOSE: The aim of the study was to determine preliminarily whether cell kinetic parameters evaluated using in vivo infusion of bromodeoxyuridine (BrdUrd) and flow cytometry, play a role as prognostic factors of loco-regional control in squamous cell head and neck carcinoma treated with radiotherapy. METHODS AND MATERIALS: Between April 1989 and December 1991, 42 patients with unresectable Stage II-IV squamous cell carcinoma of the oral cavity, pharynx or larynx were given an infusion of BrdUrd solution prior to primary tumor biopsy sampling at 4-6 hr later. The simultaneous labeling S-phase fraction (LI) and duration (Ts) as well as the estimated potential doubling time (Tpot) were measured using flow cytometric analysis of BrdUrd and DNA content. Twenty-six patients received standard radiotherapy (70 Gy/35 fractions/7 weeks) whereas 15 patients were treated with the concomitant boost technique (75 Gy/40 fractions/6 weeks). RESULTS: A complete set of flow cytometric data was available for 31 patients. The median value of LI, Ts, and Tpot were 9%, 9 hr and 5 days, respectively. Univariate analysis among the patients treated homogeneously by standard radiotherapy, indicated that local control was affected by Tpot value (p = 0.02). When the same analysis was performed for the patients treated with either standard radiotherapy or concomitant boost regimen, we found a p = 0.04. Thus, patients with a tumor Tpot value < or = 5 days had a significantly lower three-year local control than patients with Tpot > 5 days. Log-rank test univariate analysis showed, in addition, that nodal status was the strongest prognostic factor of local control (p = 0.005). Age, tumor stage, tumor site, performance status, grading, radiotherapy regimen, DNA ploidy and LI value were, instead, not significantly related to loco-regional control. Finally, when comparing the type of radiotherapy for tumors with Tpot < or = 5 days, we found a trend toward a better local control after concomitant boost regimen, with respect to standard regimen (p = 0.06). CONCLUSION: The present preliminary results suggest that Tpot could play a role as additional prognostic factor influencing the disease outcome in head and neck carcinoma treated by radiotherapy.

Actuarial Analysis↗

Radiogenetic therapy: on the interaction of viral therapy and ionizing radiation for improving local control of tumors.

Improving local tumor control is a goal of modern radiotherapy that will directly impact a majority of cancer patients. Numerous attempts to develop radiosensitizing agents have, however, met with limited clinical success. Recent advances in gene therapeutic approaches have allowed researchers to combine gene therapy with ionizing radiation to enhance tumor cell killing. In the following review, we discuss the current advances in the use of radiation-inducible promoters, the use of pro-drug converting enzymes, and cytotoxic cytokines to enhance the therapeutic efficacy of ionizing radiation.

Adenoviridae↗

Randomized study of local control and survival following radical surgery or radiation therapy in oral and laryngeal carcinomas.

From 1971 to 1975, 100 patients with glottic, supraglottic, and oral cavity lesions were prospectively randomized between primary radiation treatment and primary surgery. Local control and survival were similar with either treatment for lesions of the oral cavity or supraglottic larynx. Comparison between radiation alone and surgery alone for T1 and T2 glottic laryngeal lesions showed local control rates of 76% and 100% (P=0.32); after secondary salvage attempts, local control rates were 82% and 100%, respectively (P= 0.52). Neither result approached statistical significance. Successful radiation for early glottic larynx lesions resulted in superior deglutition and equivalent voice function compared to successful primary treatment with conservation laryngectomy. For oral cavity lesions, swallowing was impaired in the same percentage of radiated and operated patients, but fewer primary radiation patients had articulation difficulties. Among the patients with supraglottic larynx lesions, aspiration was not a problem with either radiation or surgery, but successful radiation perhaps maintained a slightly better voice quality.

Carcinoma, Squamous Cell↗

The impact of age on local control in women with pT1 breast cancer treated with conservative surgery and radiation therapy.

The aim of the study was to evaluate the importance of young age with regard to local control in a prospective cohort of 1085 women with pathological T1 tumours treated with breast conservative treatment (BCT). Patients were divided into two age groups: 40 years or younger, 7.8%, and older than 40 years, 92.2%. With a median follow-up of 71 months, the local recurrence rate was 10.6% in women < or =40 years, and 3.7% in older women. The local recurrence-free survival (LRFS) was significantly different for the two age groups, respectively 89%, < or =40 years, and 97.6%, >40 years (P=0.0046). A separate analysis showed a significantly decreased LRFS for young women with a positive family history, 75.4% versus 98.4% 5-year LRFS for older women. A worse LRFS for young women with a negative lymph node status was also observed, respectively 84% versus 98% 5-year LRFS (both P<0.001). In a multivariate analysis, taking into account the pre-treatment and treatment factors, age < or =40 years, was the only significant predictor of a decreased LRFS. Thus, young age is an important factor in relation to local control. In a subset analysis, this significant adverse effect of young age on outcome appears to be limited to the node-negative patients and those with a positive family history. To date, there is no evidence that young women with pT1 breast cancer, treated by mastectomy have an improved outcome when compared with those treated with conservative surgery and radiotherapy. Taking into account results from a subset analysis suggests that giving systemic therapy to a subgroup of women who are < or =40 years, node-negative and/or have a positive family history might give a better local control.

Adult↗

Computed tomographic volumetric analysis as a predictor of local control in laryngeal cancers treated with conventional radiotherapy.

BACKGROUND: There is still controversy regarding the appropriate management of large T2 and T3 laryngeal cancers, with some investigators finding little correlation between the current TNM staging system and tumour control following external beam radiotherapy. OBJECTIVE: To establish the utility of computed tomography (CT)-determined tumour volume as a predictor of local control of moderately advanced (T2 and T3) squamous cell carcinoma of the larynx. MATERIALS AND METHODS: A retrospective chart review and CT volumetric analysis were performed on 47 patients who were treated for T2 or T3 laryngeal squamous cell carcinoma with radiotherapy alone at the London Regional Cancer Centre between 1995 and 2000. Of these 47 patients, there were 30 with glottic tumours and 17 with supraglottic tumours. Forty-two males and five females were included in the analysis, with ages ranging from 40 to 84 years. Each patient's CT scan was redigitized, and the tumours were outlined by the chief investigator and by a head and neck radiologist using anatomy modelling software. Patient demographics, tumour characteristics, and tumour stage were analyzed, with local failure rates described and related to the variables through univariate and multivariate analyses. RESULTS: Tumour size ranged from 0.15 to 16.64 cm3, with a mean volume of 3.5 cm3. The local recurrence rate in this group of patients was 40% (19/47). Local control was correlated on multivariate analysis to tumour size for all patients combined (> 3 cm3 vs < 3 cm3; p = .003) and for glottic tumours alone (> 1 cm3 vs < 1 cm3; p = .001). A correlation was also demonstrated on multivariate analysis between local control and overall stage (p = .023), patient age (p = .029), and hypopharyngeal involvement (p = .032). CONCLUSIONS: There is a significant and independent relationship between CT-determined tumour volume and local recurrence in moderately advanced squamous cell carcinoma of the larynx treated with conventional radiotherapy. Based on these results and those of similar studies, CT should therefore become a routine part of the staging system for T2 tumours and above.

Adult↗

Anesthetic effectiveness of the supplemental intraligamentary injection, administered with a computer-controlled local anesthetic delivery system, in patients with irreversible pulpitis.

The purpose of this study was to determine the anesthetic effectiveness of the supplemental intraligamentary injection, administered with a computer-controlled local anesthetic delivery system, in mandibular posterior teeth diagnosed with irreversible pulpitis when the conventional inferior alveolar nerve block failed. Fifty-four emergency patients, diagnosed with irreversible pulpitis of a mandibular posterior tooth, received an inferior alveolar nerve block and had moderate to severe pain upon endodontic access. A computer-controlled local anesthetic delivery system was then used to administer intraligamentary injections of 1.4 ml of 2% lidocaine with 1:100,000 epinephrine. Success of the intraligamentary injection was defined as none or mild pain upon endodontic access or initial instrumentation. The results demonstrated that anesthetic success was obtained in 56% (30 of 54) of the patients. We concluded that when the inferior alveolar nerve block failed to provide profound pulpal anesthesia in mandibular posterior teeth of patients presenting with irreversible pulpitis, the intraligamentary injection administered with a computer-controlled local anesthetic delivery system was successful approximately 56% of the time.

Adult↗

Early glottic squamous cell carcinoma. Predictive value of MR imaging for the rate of 5-year local control with radiation therapy.

PURPOSE: To evaluate MR findings in early (T1 and T2 stages) glottic carcinomas and the predictive value of MR imaging for the rate of 5-year local control with radiation therapy. MATERIAL AND METHODS: Eighty-three patients with early glottic carcinomas were prospectively examined with MR at 1.5 T. MR investigation included unenhanced T1-weighted, T2-weighted, dynamic and contrast-enhanced T1-weighted images. Three patients with presumed advanced diseases on MR were initially treated with total laryngectomy and were excluded from the study. The remaining 80 patients were treated with radiation therapy with curative intent. Tumor detectability, size and relationship to the thyroid cartilage were determined on MR images. The MR findings were then correlated with the rate of local control. RESULTS: Forty-eight of 80 lesions (60%) were detected on MR imaging. All detected lesions but 1 demonstrated increased signal on T2-weighted images. The lesions were best delineated on dynamic images (statistically significant). The 5-year local control rate with radiation therapy was 72%. Univariate analysis revealed clinical T stage, MR detectability, tumor size and relationship to the thyroid cartilage as significant predictors. Multivariate analysis revealed that the relationship to the thyroid cartilage was an independent factor. CONCLUSION: MR provides prognostic information about the results of definitive radiation therapy. To evaluate the tumor extension in lesions detected on precontrast MR images, contrast-enhanced dynamic images should be obtained.

Adult↗

Decreased local control following radiation therapy alone in early-stage glottic carcinoma with anterior commissure extension.

PURPOSE: To assess the patterns of failure in the treatment of early-stage squamous cell carcinoma of the glottic larynx. PATIENTS AND METHODS: Between 1983-2000, 122 consecutive patients treated for early laryngeal cancer (UICC T1N0 and T2N0) by radical radiation therapy (RT) were retrospectively studied. Male-to-female ratio was 106 : 16, and median age 62 years (35-92 years). There were 68 patients with T1a, 18 with T1b, and 36 with T2 tumors. Diagnosis was made by biopsy in 104 patients, and by laser vaporization or stripping in 18. Treatment planning consisted of three-dimensional (3-D) conformal RT in 49 (40%) patients including nine patients irradiated using arytenoid protection. A median dose of 70 Gy (60-74 Gy) was given (2 Gy/fraction) over a median period of 46 days (21-79 days). Median follow-up period was 85 months. RESULTS: The 5-year overall, cancer-specific, and disease-free survival amounted to 80%, 94%, and 70%, respectively. 5-year local control was 83%. Median time to local recurrence in 19 patients was 13 months (5-58 months). Salvage treatment consisted of surgery in 17 patients (one patient refused salvage and one was inoperable; total laryngectomy in eleven, and partial laryngectomy or cordectomy in six patients). Six patients died because of laryngeal cancer. Univariate analyses revealed that prognostic factors negatively influencing local control were anterior commissure extension, arytenoid protection, and total RT dose < 66 Gy. Among the factors analyzed, multivariate analysis (Cox model) demonstrated that anterior commissure extension, arytenoid protection, and male gender were the worst independent prognostic factors in terms of local control. CONCLUSION: For early-stage laryngeal cancer, outcome after RT is excellent. In case of anterior commissure extension, surgery or higher RT doses are warranted. Because of a high relapse risk, arytenoid protection should not be attempted.

Adult↗

Improved local control with stereotactic radiosurgical boost in patients with nasopharyngeal carcinoma.

PURPOSE: Treatment of nasopharyngeal carcinoma using conventional external beam radiotherapy (EBRT) alone is associated with a significant risk of local recurrence. Stereotactic radiosurgery (STR) was used to boost the tumor site after EBRT to improve local control. METHODS AND MATERIALS: Forty-five nasopharyngeal carcinoma patients received a STR boost after EBRT at Stanford University. Seven had T1, 16 had T2, 4 had T3, and 18 had T4 tumors (1997 American Joint Commission on Cancer staging). Ten had Stage II, 8 had Stage III, and 27 had Stage IV neoplasms. Most patients received 66 Gy of EBRT delivered at 2 Gy/fraction. Thirty-six received concurrent cisplatin-based chemotherapy. STR was delivered to the primary site 4-6 weeks after EBRT in one fraction of 7-15 Gy. RESULTS: At a medium follow-up of 31 months, no local failures had occurred. The 3-year local control rate was 100%, the freedom from distant metastasis rate was 69%, the progression-free survival rate was 71%, and the overall survival rate was 75%. Univariate and multivariate analyses revealed N stage (favoring N0-N1, p = 0.02, hazard ratio HR 4.2) and World Health Organization histologic type (favoring type III, p = 0.002, HR 13) as significant factors for freedom from distant metastasis. World Health Organization histologic type (p = 0.004, HR 10.5) and age (p = 0.01, HR 1.07/y) were significant factors for survival. Late toxicity included transient cranial nerve weakness in 4, radiation-related retinopathy in 1, and asymptomatic temporal lobe necrosis in 3 patients who originally had intracranial tumor extension. CONCLUSION: STR boost after EBRT provided excellent local control in nasopharyngeal carcinoma patients. The incidence of late toxicity was acceptable. More effective systemic treatment is needed to achieve improved survival.

Adolescent↗

Carcinoma of the prostate: local control with external beam radiation therapy.

Local clinical control of the primary disease was evaluated in 209 patients with stage C adenocarcinoma of the prostate treated with definitive external beam radiation therapy and followed for a minimum of 2 years. Of these patients 92 per cent required no further prostatic operations for obstruction. Prostatectomy before therapy did not necessarily prevent later prostatic obstruction from occurring. Of 129 patients who had only a needle biopsy before irradiation 90 per cent had improvement of the obstructive and/or irritative symptoms as tumor regression occurred with therapy and these patients did not require a later prostatic operation for obstruction. Stricture formation occurred in 8 per cent of the patients and was not influenced by the type of preirradiation prostatic operation done. If transurethral resection was reuqired after irradiation it was technically more difficult but the morbidity was acceptable. The incidence of hematuria and incontinence was far less than that reported in non-irradiated patients with this disease. Most tumors exhibited a down-grading effect after irradiation. There were no deaths attributable to the treatment. Over-all, 83 per cent of the 209 patients had no urinary complaints after completion of therapy. From a urological viewpoint, good clinical local control is achieved in the patient with stage C adenocarcinoma of the prostate treated with external beam radiation therapy.

Adenocarcinoma↗