RESUMEN
Heterotopic ossification (HO) occurs in 42% of patients who have undergone total knee arthroplasty. Bone formation usually is found in the quadriceps expansion and causes minimal to no symptoms. Specific therapy usually is unnecessary, but cases have been reported in which manipulation under anesthesia or revision arthroplasty has been required. We report a small series of 5 patients (6 knees) who have undergone surgical intervention for HO of the knee with radiotherapy given postoperatively for prophylaxis against future HO. Although this series is small, it appears that the use of prophylactic radiation may reduce recurrence after resection of symptomatic HO after total knee arthroplasty. Further investigation is required to confirm these preliminary findings.
Asunto(s)
Artroplastia de Reemplazo de Rodilla/efectos adversos , Articulación de la Rodilla/efectos de la radiación , Osificación Heterotópica/prevención & control , Adulto , Anciano , Femenino , Humanos , Articulación de la Rodilla/diagnóstico por imagen , Masculino , Osificación Heterotópica/diagnóstico por imagen , Osificación Heterotópica/etiología , Osificación Heterotópica/cirugía , Cuidados Posoperatorios , Radiografía , Dosificación Radioterapéutica , Recurrencia , Estudios RetrospectivosRESUMEN
OBJECTIVE AND IMPORTANCE: The first case was recently reported of tumor seeding by glioblastoma multiforme (GBM) after stereotactic biopsy. This occurred despite radiosurgical treatment of the lesion post-biopsy. We report the first case of metastatic seeding along the needle biopsy tract of a GBM in which the tract was within the treatment field of subsequent fractionated radiation therapy. CLINICAL PRESENTATION: A 56-year-old man presented with left-sided focal motor seizures. An MRI showed an enhancing right cingulate gyrus lesion. INTERVENTION: A stereotactic biopsy of the lesion disclosed GBM. Radiation therapy was begun 25 days after biopsy and was completed 39 days thereafter. The biopsy tract received a minimum of 60 Gy. Subsequent magnetic resonance scanning showed the lesion to have doubled in size and evidence of enhancement along the biopsy tract. At surgery, specimens obtained from the biopsy tract, as determined using surgical navigation, revealed GBM. CONCLUSION: Seeding of the biopsy tract, radioresistance and the time interval until radiotherapy are the most likely explanations for tumor growth along the biopsy tract in this case. Consideration should be given for an early start to radiotherapy among those who undergo stereotactic biopsy for GBM. Further research will allow one to determine the radiosensitivity of these tumors and determine which patients may benefit from a radiosurgical or fractionated radiotherapy boost to the biopsy tract.
Asunto(s)
Biopsia/efectos adversos , Neoplasias Encefálicas/secundario , Glioblastoma/secundario , Giro del Cíngulo/patología , Siembra Neoplásica , Antineoplásicos Hormonales/uso terapéutico , Antitiroideos/uso terapéutico , Biopsia/métodos , Neoplasias Encefálicas/tratamiento farmacológico , Neoplasias Encefálicas/patología , Neoplasias Encefálicas/radioterapia , Neoplasias Encefálicas/cirugía , Terapia Combinada , Irradiación Craneana , Glioblastoma/tratamiento farmacológico , Glioblastoma/patología , Glioblastoma/radioterapia , Glioblastoma/cirugía , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Tolerancia a Radiación , Radiocirugia , Técnicas Estereotáxicas , Tamoxifeno/uso terapéuticoRESUMEN
PURPOSE: To evaluate the usefulness of whole brain radiotherapy (WBRT) and of the Radiation Therapy Oncology Group recursive partitioning analysis (RPA) for brain metastases among patients receiving stereotactic radiosurgery (SRS). METHODS AND MATERIALS: A retrospective analysis was performed on 135 patients who underwent linear accelerator (Linac) (n = 73) or Gamma Knife (n = 62) SRS for newly diagnosed brain metastases at the Cleveland Clinic Foundation between 8/89 and 12/98. Univariate and multivariate analyses were performed to evaluate the effects of age, primary site, control of the primary, interval to development of brain metastases (disease-free interval [DFI]), number of brain metastases, presence of extracranial metastases, Karnofsky performance status (KPS), treatment of brain metastases, and RPA class on overall survival. RESULTS: Application of the RPA classification revealed 29 patients fit the criteria for class I, 96 for class II, and 10 for class III. All of the patients underwent SRS. Fifty-seven patients also received WBRT at the time of initial presentation (SRS and immediate WBRT), and 78 patients received WBRT only if CNS relapse occurred (SRS alone). The median survival for all patients was 7.9 months (range: 1.1-90.1), and was 11.2 months for RPA class I compared to 6. 9 months for RPA classes II-III (p = 0.016). Median survival was 10. 5 months following SRS alone compared to 6.4 months following SRS and WBRT (p = 0.07). On univariate analysis, KPS >/= 80% (p = 0.002) and absence of systemic disease (p = 0.013) were also associated with longer survival, whereas control of the primary, DFI, and number of brain metastases did not have an impact. Multivariate analysis revealed only RPA class (p = 0.023) to be an independent predictor for overall survival, whereas treatment group (p = 0.079) was only marginally significant. At 2 years, immediate WBRT improved control at the original site of metastases (80% vs. 52%, p = 0.03) and prevention of new metastatic sites within the brain, 74% vs. 48% (p = 0.06). The 2-year intracranial disease-free survival was 60% following SRS and WBRT compared to only 34% following SRS alone (p = 0.03). CONCLUSIONS: Despite the inherent biases to select more favorable patients for SRS, the RPA class retains its prognostic value. Omission of WBRT from the initial management was not detrimental in terms of overall survival; however, progressive disease occurred in over 50% of patients treated in this manner. Further studies are required to determine which, if any, patients should be considered for SRS with WBRT held in reserve.
Asunto(s)
Neoplasias Encefálicas/radioterapia , Neoplasias Encefálicas/cirugía , Irradiación Craneana/métodos , Radiocirugia/métodos , Factores de Edad , Anciano , Análisis de Varianza , Sesgo , Neoplasias Encefálicas/secundario , Terapia Combinada , Supervivencia sin Enfermedad , Humanos , Estado de Ejecución de Karnofsky , Persona de Mediana Edad , Selección de Paciente , Estudios Retrospectivos , Análisis de Supervivencia , Factores de TiempoRESUMEN
Brain metastases are a common and devastating consequence of cancer and carry a poor prognosis. Nevertheless, physicians can serve their patients well by suspecting, detecting, and treating them appropriately.
Asunto(s)
Neoplasias Encefálicas/diagnóstico , Neoplasias Encefálicas/terapia , Metástasis de la Neoplasia/terapia , Antineoplásicos/uso terapéutico , Neoplasias Encefálicas/epidemiología , Neoplasias Encefálicas/secundario , Terapia Combinada , Irradiación Craneana , Diagnóstico Diferencial , Cefalea/etiología , Humanos , Examen Neurológico , Pronóstico , RadiocirugiaRESUMEN
The purpose of this study was to evaluate the outcome of treatment for patients with newly diagnosed nonsmall-cell lung cancer (NSCLC) with an isolated, single, synchronous brain metastasis. A retrospective review was performed evaluating any patient diagnosed between 1982 and 1996 at the Cleveland Clinic Foundation with NSCLC metastatic only to the brain. Patients with multiple brain metastases or with systemic metastases to any other organ were excluded. Survival was measured from the date of the first treatment for malignancy. All hospital records were thoroughly reviewed in a retrospective manner. Thirty-three patients were identified who met the study criteria. Twelve patients had primary disease limited to the lung and hilar nodes, and 21 had more advanced primary disease with involvement of the mediastinum. Treatment of the chest was considered aggressive in 13 patients and palliative in 15. The primary tumor was observed in 5 patients. The management of the brain metastasis was as follows: 21 patients underwent surgical resection and postoperative whole brain radiotherapy (WBRT), 5 underwent stereotactic radiosurgery (SRS) and WBRT, 3 had resection alone, 2 had SRS alone, and 2 underwent WBRT alone. The median overall and disease-free survival for all patients was 6.9 months and 3.3 months, respectively. Overall survival was markedly improved with the addition of WBRT (P = 0.002) and with the aggressive management of the primary tumor (P = 0.005). A total of 9 patients experienced CNS failure, including both patients receiving WBRT alone. CNS failures were divided as follows: 3 local, 5 distant, and 1 local and distant. Two of the 4 patients with a local failure were salvaged, and ultimate local control of the original brain metastasis was achieved in 93.6% of cases. Survival remains poor for patients with Stage IV NSCLC even when metastatic disease is limited to a single site within the brain; however, aggressive therapy of both the lung primary and the brain metastasis may provide a survival advantage. Excellent local control of single brain metastases was achieved with a combination of WBRT with either surgical resection or SRS.
Asunto(s)
Neoplasias Encefálicas/secundario , Carcinoma de Pulmón de Células no Pequeñas/terapia , Neoplasias Pulmonares/terapia , Adenocarcinoma/radioterapia , Adenocarcinoma/secundario , Adenocarcinoma/cirugía , Adenocarcinoma/terapia , Adulto , Anciano , Neoplasias Encefálicas/radioterapia , Neoplasias Encefálicas/cirugía , Neoplasias Encefálicas/terapia , Carcinoma de Pulmón de Células no Pequeñas/radioterapia , Carcinoma de Pulmón de Células no Pequeñas/secundario , Carcinoma de Pulmón de Células no Pequeñas/cirugía , Quimioterapia Adyuvante , Irradiación Craneana , Supervivencia sin Enfermedad , Femenino , Estudios de Seguimiento , Humanos , Neoplasias Pulmonares/radioterapia , Neoplasias Pulmonares/cirugía , Masculino , Neoplasias del Mediastino/patología , Neoplasias del Mediastino/terapia , Persona de Mediana Edad , Estadificación de Neoplasias , Cuidados Paliativos , Radiocirugia , Radioterapia Adyuvante , Inducción de Remisión , Estudios Retrospectivos , Terapia Recuperativa , Tasa de Supervivencia , Insuficiencia del Tratamiento , Resultado del TratamientoRESUMEN
PURPOSE: To evaluate the usefulness of neoadjuvant chemotherapy and radiation therapy before esophagectomy for invasive cancer of the esophagus or gastroesophageal junction (GEJ). MATERIALS AND METHODS: The authors conducted a retrospective analysis of 154 patients who underwent esophagectomy for invasive cancer between September 1, 1991, and December 31, 1995. The end points evaluated were overall, disease-free, local-regional relapse-free, and systemic relapse-free survival. RESULTS: Seventy of the 154 patients received neoadjuvant combined-modality therapy (CMT) consisting of concurrent cisplatin and fluorouracil administration and accelerated, hyperfractionated radiation therapy. The remaining 84 patients underwent immediate esophagectomy. With a median follow-up of 34.7 months, the 3-year overall, disease-free, and distant metastatic relapse-free survival rates were 38.0%, 41.9%, and 56.0%, respectively. Although neoadjuvant therapy did not appear to prevent distant metastases, there was a dramatic effect on local control. After CMT, the 5-year local control rate was 90% compared to 64% after surgery (P < .001). Tumors in the GEJ recurred more frequently (P = .01); however, multivariate analysis showed CMT was the only independent predictor of local control. Postoperative mortality was 15.7% after CMT versus 5.9% without CMT (P = .05). CONCLUSION: Local control of esophageal cancer is excellent following neoadjuvant chemotherapy and radiation therapy. However, the effects of CMT on overall and disease-free survival are less clear due to significant differences between the treatment groups.
Asunto(s)
Adenocarcinoma/terapia , Carcinoma de Células Escamosas/terapia , Neoplasias Esofágicas/terapia , Recurrencia Local de Neoplasia , Adenocarcinoma/mortalidad , Adenocarcinoma/secundario , Adenocarcinoma/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Carcinoma de Células Escamosas/mortalidad , Carcinoma de Células Escamosas/secundario , Carcinoma de Células Escamosas/cirugía , Quimioterapia Adyuvante , Cisplatino/administración & dosificación , Supervivencia sin Enfermedad , Fraccionamiento de la Dosis de Radiación , Neoplasias Esofágicas/mortalidad , Neoplasias Esofágicas/patología , Neoplasias Esofágicas/cirugía , Esofagectomía , Fluorouracilo/administración & dosificación , Humanos , Metástasis Linfática , Persona de Mediana Edad , Radioterapia Adyuvante , Radioterapia de Alta Energía , Estudios Retrospectivos , Tasa de SupervivenciaRESUMEN
Since the early decades of this century, radiation therapy has played an important role in the management of Wilms' tumor. Although in prior years the high radiation doses and eccentric field arrangements used in treatment were responsible for significant late toxicity, examination of long-term survivors and the important information obtained from the National Wilms' Tumor Studies (NWTS) and Societe Internationale d'Oncologie Pediatrique studies have now allowed us to tailor radiation fields and doses to provide high levels of local tumor control with minimal late effects. At present, most patients with NWTS stage III and stage IV tumors are offered radiotherapy as an integral component of their cancer management. Attempts to further refine selection criteria defining those patient groups who will benefit from radiation therapy are ongoing.