Anal cancer is a relatively uncommon malignancy. The goal of contemporary treatment of this disease is cure without the need for a colostomy. This retrospective study describes the outcomes of our patients treated in community-based radiation treatment centers. Medical records of 139 patients treated with definitive radiation therapy for locoregionally confined anal carcinoma between 1992 and 2008 were reviewed. Fourteen percent of patients underwent local excision of tumor, and the remaining patients underwent biopsy only. Eighty-eight percent underwent concurrent chemotherapy. Recorded data included technical and chemotherapeutic details of treatment, toxicities, disease progression, and whether a colostomy was required during the follow-up period. Overall (OS), progression-free (PFS), and colostomy-free (CFS) survival were calculated by Kaplan-Meier methods. The mean age was 64.8 years (range, 33-98 years), 73% of the patients were female, and 91% were white. The mean follow-up was 25.1 months with a range of 0.7 to 124.5 months. Eighty-four percent of patients presented with squamous cell carcinoma, 4% with cloacogenic carcinoma, 2% basaloid carcinoma, and 9% with mixed tumors. Fifteen percent of patients had T1 tumors, 51% T2 tumors, 24% had T3 tumors, 6% had T4 tumors, and 6% had no recorded T stage. The mean tumor size was 3.8 cm, with a range of 1-12 cm. Lymph nodes were assessed to be positive in 16% of patients, either by biopsy or suspected by radiographic or physical examination. Total prescription dose ranged from 22.1 to 69.4 Gy, with a median of 54 Gy. Most patients (68%) experienced acute complications, and 58% required a treatment break. Nineteen percent of patients experienced late complications. The 5-year OS, PFS and CFS were 52, 79, and 92%, respectively. There were 12 local recurrences (9%), and 10 patients developed distant metastases (7%). During the follow-up period, seven patients (5%) underwent a colostomy. Of these, 4 were salvage for local recurrence, and 2 due to ongoing side effects. A univariate analysis showed that performance status, tumor diameter, and T stage were statistically significant for OS. Performance status, T stage, tumor diameter, and treatment break predicted for PFS. There were no statistically significant predictors for CFS. Patients with anal carcinomas treated with radiation therapy as a component of their treatment regimen experience low rates of failure. While a significant number of patients experienced acute and late complications, only 2 such patients required a colostomy for symptomatic management.

With the advent of sophisticated radiation therapy techniques such as three-dimensional conformal treatment (3DRT) and intensity modulated radiation therapy (IMRT), it would be expected that the dose to the target area could be increased without a corresponding increase in complications. We performed a review of men treated for prostate cancer in a homogenous community-based setting over a period of 23 years to determine whether complications were reduced over the years as we introduced advanced technology into our centers. The medical records of 818 men who were treated with definitive radiation therapy to the intact prostate between 1982 and 2005 at three centers located in Southwest Florida were reviewed. All patients had localized disease and were treated with external beam radiation only. Gastrointestinal (GI) and genitourinary (GU) complications were scored retrospectively on a scale of 0 to 4 in accordance with the RTOG morbidity scoring criteria. Chi-squared tests, Fisher's Exact tests and a logistic regression were conducted using the SAS software package. The mean age was 73.3 years (range, 49–96 years). The mean follow-up was 6.5 years with a range, of 0.1 to 21.3 years. The mean prostate dose was 69.6 Gy (range, 14.4–81.8 Gy). For the 460 patients treated with conventional radiation therapy the mean dose was 68.3 Gy (range, 18.5–77.4). For patients treated with 3DRT the mean dose was 70.3 Gy (n = 273, range, 14.4–80.0), and for those with IMRT it was 74.9 Gy (n = 85, range, 65.0–81.8). Overall, 75.4% of patients experienced acute GU complications, with 12.5% experiencing Grades 3 or 4. Acute GI complications were experienced by 63.4%, with 6.3% Grades 3–4. Late GU complications were experienced by 15.5%, with 6.3% Grades 3–4. Late GI complications were experienced by 9.2% of patients with 3.2% Grades 3–4. Even though the dose increased with newer technology, the rate of complications was not significantly different for acute GI, acute GU, or late GU complications. For late GI complications, the rate decreased from 4.6% (Grades 3–4) for conventional RT to 1.5% for 3DRT to 1.2% for IMRT (p = .0369). On logistic regression with a model including area treated (pelvis vs prostate), year of treatment, modality, prostate dose, bladder dose, and rectal dose, rectal dose predicted for acute GI complications (p = .0178), and year predicted for acute GU (p = .0241) and late GU (p = .0345) complications. There were no significant predictors for late GI complications. Newer technologies, when introduced into community-based radiation treatment centers, allow higher doses to the prostate while maintaining or reducing morbidity.

From 21st Century Oncology, Fort Myers, FL. Presented as part of Chairman's Address for the 2006 Annual Meeting of the American College of Radiation Oncology, Orlando, Florida by James H. Rubenstein, MD, 21st Century Oncology, Fort Myers, FL. 21st Century Oncology, Fort Myers, FL. E-mail: [email protected]

PURPOSE:External beam radiation therapy (EBRT) alone for early stage, medically inoperable non-small cell lung cancer (MILC) can produce local disease control and sometimes cure. We have previously reported that higher EBRT doses result in improved disease control and, for patients with tumors > or =3.0 cm, improved survival. This report describes the impact of dose escalation with endobronchial brachytherapy boost during or following EBRT upon local disease control. METHODS AND MATERIALS:Medical records of 404 patients with MILC treated with radiotherapy alone were reviewed. Thirty-nine patients received a planned endobronchial brachytherapy boost during or following a course of EBRT. A matched-pair analysis of disease control and survival was performed by matching each brachytherapy patient to 2 EBRT patients from a reference group of the remaining patients. RESULTS:Endobronchial brachytherapy boost significantly improved local disease control over EBRT alone (58% vs. 32% at 5 years). The local control benefit for brachytherapy was found to be limited to patients with T(1-2) disease or tumors < or =5.0 cm. Among these patients treated with endobronchial boost, EBRT doses of > or =6500 cGy were necessary to optimize local disease control. No overall survival differences were observed at 3 years. Excess toxicity with brachytherapy was not observed. CONCLUSION:Endobronchial brachytherapy boost enhances local disease control rates in MILC treated with EBRT. Local control outcome is optimized when radical EBRT doses are used in conjunction with brachytherapy.

Purpose: To retrospectively review our experience using radiation therapy as a palliative treatment in ovarian carcinoma.Methods and Materials: Eighty patients who received radiation therapy for ovarian carcinoma between 1983 and 1998 were reviewed. The indications for radiation therapy, radiation therapy techniques, details, tolerance, and response were recorded. A complete response required complete resolution of the patient's symptoms, radiographic findings, palpable mass, or CA-125 level. A partial response required at least 50% resolution of these parameters. The actuarial survival rates from initial diagnosis and from the completion of radiation therapy were calculated.Results: The median age of the patients was 67 years (range 26 to 90 years). A median of one laparotomy was performed before irradiation. Zero to 20 cycles of a platinum-based chemotherapy regimen were delivered before irradiation (median = 6 cycles). The reasons for palliative treatment were: pain (n = 22), mass (n = 23), obstruction of ureter, rectum, esophagus, or stomach (n = 12), a positive second-look laparotomy (n = 9), ascites (n = 8), vaginal bleeding (n = 6), rectal bleeding (n = 1), lymphedema (n = 3), skin involvement (n = 1), or brain metastases with symptoms (n = 11). Some patients received treatment for more than one indication. Treatment was directed to the abdomen or pelvis in 64 patients, to the brain in 11, and to other sites in 5. The overall response rate was 73%. Twenty-eight percent of the patients experienced a complete response of their symptoms, palpable mass, and/or CA-125 level. Forty-five percent had a partial response. Only 11% suffered progressive disease during therapy that required discontinuation of the treatment. Sixteen percent had stable disease. The duration of the responses and stable disease lasted until death except in 10 patients who experienced recurrence of their symptoms between 1 and 21 months (median = 9 months). The 1-, 2-, 3-, and 5-year actuarial survival rates from diagnosis were 89%, 73%, 42%, and 33%, respectively. The survival rates calculated from the completion of radiotherapy were 39%, 27%, 13%, and 10%, respectively. Five percent of patients experienced Grade 3 diarrhea, vomiting, myelosuppression, or fatigue. Fourteen percent of patients experienced Grade 1 or 2 diarrhea, 19% experienced Grade I or 2 nausea and vomiting, and 11% had Grade 1 or 2 myelosuppression.Conclusions: In this series of radiation therapy for advanced ovarian carcinoma, the response, survival, and tolerance rates compare favorably to those reported for current second- and third-line chemotherapy regimens. Cooperative groups should consider evaluating prospectively the use of radiation therapy before nonplatinum and/or nonpaclitaxel chemotherapy in these patients. (C) 2001 Elsevier Science Inc.

The treatment of small-cell lung carcinoma (SCLC) requires the careful combination of chemotherapy and radiation therapy. To understand the factors involved in the outcome of these patients, the authors undertook a study of patients treated for limited stage SCLC. The charts of 194 consecutive patients treated at our facilities between 1986 and 1994 were reviewed. All patients underwent thoracic radiation therapy (TRT), 50% received prophylactic cranial irradiation (PCI), and all but one received chemotherapy. The probability of survival at 5 years was 14%, and the disease-free survival (DFS) was 17%. Patients receiving a combination of platinum and etoposide (PE) and Cytoxan (Bristol-Myers, Evansville, IN, U.S.A.), Adriamycin (Adria Laboratories, Dublin, OH, U.S.A.), and Vincristine (Eli Lilly, Indianapolis, IN, U.S.A.) (CAV) experienced a DFS at 3 years of 31%, versus 14% for CAV only and 18% for PE only (p = 0.004). In a multivariate survival analysis, only PCI (p = 0.001), having received PE and CAV (p = 0.01), and response to treatment (p = 0.001) were significant. Radiation dose and field size did not influence outcome. The combination of PE and CAV chemotherapy produced the best results in our series. Unanswered questions regarding the optimal TRT dose, field size, and timing of TRT await the results of ongoing randomized trials.

The treatment of small-cell lung carcinoma (SCLC) requires the careful combination of chemotherapy and radiation therapy. To understand the factors involved in the outcome of these patients, the authors undertook a study of patients treated for limited stage SCLC. The charts of 194 consecutive patients treated at our facilities between 1986 and 1994 were reviewed. All patients underwent thoracic radiation therapy (TRT), 50% received prophylactic cranial irradiation (PCI), and all but one received chemotherapy. The probability of survival at 5 years was 14%, and the disease-free survival (DFS) was 17%. Patients receiving a combination of platinum and etoposide (PE) and Cytoxan (Bristol-Myers, Evansville, IN, U.S.A.), Adriamycin (Adria Laboratories, Dublin, OH, U.S.A.), and Vincristine (Eli Lilly, Indianapolis, IN, U.S.A.) (CAV) experienced a DFS at 3 years of 31%, versus 14% for CAV only and 18% for PE only (p = 0.004). In a multivariate survival analysis, only PCI (p = 0.001), having received PE and CAV (p = 0.01), and response to treatment (p = 0.001) were significant. Radiation dose and field size did not influence outcome. The combination of PE and CAV chemotherapy produced the best results in our series. Unanswered questions regarding the optimal TRT dose, field size, and timing of TRT await the results of ongoing randomized trials.

Small cell anaplastic carcinoma of the prostate (SCCP) is a rare entity; a literature review disclosed fewer than 150 cases. SCCP has an aggressive course, and both local and distant failure is common. The optimal treatment method has not been clearly established. We review our experience with 7 patients, with attention paid to clinical and pathological details based on a review of the histological specimens. Three patients had mixed tumors of both SCCP and adenocarcinoma, 3 had pure adenocarcinomas that recurred as small cell, and 1 had pure small cell. Our series confirms the aggressive nature of the disease, with all patients dying of their disease < or = 42 months after diagnosis. All patients progressed locally, and at least 5 later developed distant metastases. Treatment with combination chemotherapy and/or hormones resulted in short-lived responses in most patients. We recommend use of hormonal manipulation and combination chemotherapy as well as surgery and/or radiation therapy to the prostate for local control and emphasize that histologic recognition of the entity is important for proper treatment.

Purpose: Prophylactic cranial irradiation (PCI) for the prevention of brain metastasis in small cell lung cancer remains controversial, both in terms of efficacy and the optimal dose-fractionation scheme. We performed this study to evaluate the efficacy of PCI at low doses.Methods and Materials: One hundred and ninety-seven patients were referred to our institution for treatment of limited stage small cell carcinoma of the lung between June 1986 and December 1992. Follow-up ranged from 1.1 to 89.8 months, with a mean of 19 months. Eighty-five patients received PCI.Results: Patients receiving PCI exhibited brain failure in 15%, while 38% of untreated patients developed metastases. This degree of prophylaxis was achieved with a median total dose of 25.20 Gy and a median fraction size of 1.80 Gy. At these doses, acute and late complications were minimal. Patients receiving PCI had significantly better 1-year and 2-year overall survivals (68% and 46% vs. 33% and 13%). However, patients with a complete response (CR) to chemotherapy and better Karnofsky performance status (KPS) were overrepresented in the PCI group. In an attempt to compare similar patients in both groups (PCI vs. no PCI), only patients with KPS greater than or equal to 80, CR or near-CR to chemotherapy, and treatment with attempt to cure, were compared. In this good prognostic group, survival was still better in the PCI group (p = 0.0018).Conclusion: In this patient population, relatively low doses of PCI have accomplished a significant reduction in the incidence of brain metastasis with little toxicity. Whether such treatment truly improves survival awaits the results of additional prospective randomized trials.

Patients unable to undergo a pancreatoduodenectomy for adenocarcinoma of the pancreas are often treated with radiation therapy. A randomized trial by the Gastrointestinal Tumor Study Group has shown an advantage in combining it with chemotherapy. A similar size retrospective study at a large community radiation therapy center assessed this finding in the nonprotocol setting. The study population consisted of 86 patients treated with primary radiation therapy between 1982 and 1992; 62 of them also received chemotherapy. The overall probability of survival was 39% and 13% at 12 and 24 months respectively. Patients receiving chemotherapy had a significantly (p = .018) longer survival (44% versus 25% at 12 months). Results confirm the Study Group's findings and suggest that they be applied to the community setting.

Purpose: For patients who are medically unable to tolerate a surgical resection for technically resectable non-small-cell lung carcinoma, radiation therapy is an acceptable alternative. We report on the effect of achieving local control of the primary tumor on survival end-points, and analyze factors that may influence local control.Methods and Materials: We reviewed the records of 152 patients with medically inoperable non-small-cell lung carcinoma treated at our institutions. All patients had technically resectable lesions and no evidence of metastatic disease. Treatment was delivered using megavoltage irradiation to doses ranging from 45 to 75 Gy.Results: For patients with tumors 3 cm or less, locally controlling the tumor significantly improved survival (p = .0371). Patients with Tl tumors had a higher probability of survival and disease-free-survival than patients with larger tumors if the primary tumor was locally controlled, but this survival advantage disappeared if the tumor was not controlled. Overall, patients with smaller tumors had a lower incidence of distant spread, but this association was maintained only when the primary tumor was controlled (36 month risk of 10%, 23%, and 57% for tumors < 3 cm, 3-4.9 cm, 5 cm or greater, respectively, p = .0027). For patients whose tumors were not controlled, there was no significant difference in the risk of distant dissemination by tumor size. Higher radiation doses influenced local control and metastatic spread. We observed no influence of the initial field size in the risk of local control and in the probability of survival.Conclusion: Radical radiation therapy is an effective treatment for small (T1 or < 3 cm) tumors when treated to doses of 65 Gy or more, and should be offered as an alternative to surgery in elderly or infirm patients. New therapeutic strategies to improve the local control rate should be considered for larger tumors, through the use of hyperfractionated treatment, endobronchial ''boost'' irradiation, and sensitizing chemotherapy agents.

Radiation therapy to control heterotopic bone formation does not appear to be commonly used in sites other than hips where effective control is evident following arthroplasty. Reported are the results in 12 sites in 10 patients including three with treatment to the elbow, humerus, and ulna. Ten sites received a radiation dose of 10.00 Gy, one 16.00 Gy, and one was treated to 20.00 Gy, all delivered in 2.00 Gy fractions. Preoperative and follow-up x-rays were reviewed and graded. There was no clinically significant regrowth of heterotopic bone. Five sites (42%) demonstrated mild regrowth or persistence following surgery with the other seven (58%) showing no evidence of heterotopic bone. No complications were seen. Radiation therapy is effective for the prevention of heterotopic bone after total hip arthroplasties as well as surgery for fractures to other areas.