[en] Purpose/Objective: With advances in 3D conformal therapy, daily variation in the position of the prostate poses increasing problems for radiation oncologists. In this study we attempt to define the optimal treatment position for patients with prostate cancer by measuring the range of movement of the prostate. Materials and Methods: Ten patients with biopsy proven adenocarcinoma of the prostate underwent prone and supine CT scans with IV and oral contrast. Foley catheters (FC) were placed in the urinary bladder, and renograffin was used to make the balloon radiopaque. AP/PA and lateral radiographs were taken for patients in the supine and prone position with either empty bladder (EB) or partially filled bladder (PFB, containing 60 cc of contrast medium). Measurements were taken from the Foley catheter (represents prostatic urethra), to the anterior rectal wall and pubic symphysis (PS). The rectal gas pattern was analyzed to evaluate the rectum-sparing effect. The false table top was not used. Results: For radiographs taken in the supine position, the FC was located 1.4 ± 0.5 cm from the PS in the case of PFB versus EB. In the prone position the variation was significantly less, with an increase in FC to PS distance of only 0.5 ± 0.3 cm for a PFB versus EB. The rectal gas pattern was also noted to vary, with a more expanded and rounded shape in the prone position. Conclusion: Most institutions treat patients with prostate cancer in the supine position. The previous rationale for treatment in the prone position has been small bowel sparing. Here, however, we show that prone treatment also minimizes the motion of the prostate. With less posterior margin required, 3D conformal treatment could be delivered with an additional 30-50% rectal sparing

[en] Purpose/Objective: To assess quality of life factors in patients receiving both initial and re-treatment with XRT for NSCLC.Materials and Methods: Over 600 patients with NSCLC were treated with primary XRT at the Medical College of Virginia (MCV) between 1990 and 1995. Twenty-six patients who initially received a median dose of 60 Gy (range = 50 to 66) were given re-treatment to a median dose of 30 Gy (range = 12 to 33) for worsening symptoms and/or radiographic progression. Sixteen patients received their initial therapy by split course, while 10 had continuous course XRT. The median interval between initial and re-treatment was 11 months (range = 1 to 51). All re-treatments were delivered twice per day at 1.5 Gy per fraction. The median total dose to this group was 90 Gy (range = 72 to 96). The observer portion of the Lung Cancer Symptom Scale (LCSS) was employed to score the effects of treatment on symptoms including loss of appetite, fatigue, cough, dyspnea, hemoptysis, and pain. The patients were noted to have experienced improvement, worsening, or no change following therapy. Survival analysis was completed using the Kaplan-Meier method, while the sign rank method compared survival with other factors. Results: Median follow-up was 22 months (range = 3 to 73). Fifteen patients have died of their disease, and 11 remain alive with disease. Patient characteristics at the time of first treatment included median age of 64 years (range = 39 to 77), median PS of 1 (92% with either 0 or 1), > 5% weight loss in 15%, and male to female ratio of 3.3 to 1. Stage breakdown was: I = 12%, II = 12%, IIIA = 38%, IIIB 19%, and IV = 19%. Squamous cell carcinoma was the most represented histology, found in 58%. The median number of LCSS symptoms at initial presentation was 1 (69% with 1 or 2). Sixty-one percent of the patients experienced relief in at least one of their pre-treatment symptoms. By the time of re-treatment, 100% of the patients had at least one complaint, and the median number of symptoms was 3 (69% with 2 or 3). After re-treatment, 51% of the patients had improvement in at least one symptom. Five of the patients died immediately after re-treatment and were not evaluable. Symptomatic relief after the first course of therapy did not predict palliation after the second course. Overall survival was 27 months and was independent of age (< versus > 65 years), stage (IIIA versus IIIB or IV), weight loss, presence of any one specific LCSS symptom, time during which initial therapy was given (< versus> 50 days), and fractionation of initial therapy (split versus continuous course). There was a statistically significant survival advantage in patients with a time to retreatment of more than 11 months (p = 0.03). Toxicity was limited to transient, mild esophagitis during the initial therapy, and no specific acute or late side effects were noted after re-treatment. Discussion: Here, we retrospectively describe a NSCLC population with good prognostic factors which underwent primary radiation therapy with a 61% symptomatic response. Subsequent re-treatment with XRT was feasible, well tolerated, and provided symptom relief in half of the patients. These results are consistent with our previously-published report on palliation rates in patients receiving short course therapy for advanced NSCLC, and we continue prospective accrual with the LCSS of all lung cancer patients treated at MCV

[en] PURPOSE/OBJECTIVE: To assess quality of life effects of radiation therapy on patients with brain metastasis. Not only is data on this subject rare, there is also no psychometrically tested brain metastasis symptom scale. We report data using a scale of our own design. MATERIALS and METHODS: Over 200 charts of patients treated for brain metastasis from various primary sites between 1990 and 1995 were reviewed. Seventy-two patients met the criteria for evaluation. They were all treated with radiotherapy and steroids. The majority of patients received a median dose of 30 Gy (Range 20 - 55) to the whole brain. Treatment over 40 Gy was delivered via a boost, either external beam or stereotactic. Pre and post-therapy symptoms of impaired vision, speech, sensation, motor strength, gait, cranial nerves, headache, seizure, lethargy, mentation, and nausea and vomiting were scored. Each symptom was evaluated separately. Following therapy, patients were noted to have improvement, no change, or worsening symptoms. Steroid and anti-seizure medication use pre and post-therapy were also recorded. RESULTS: Patient characteristics: median age is 62 (Range 27 - 82 years); Female: Male 1.4:1; Single: Multiple metastasis = 1:2.3. The primary sites included: lung=56%, breast=15%, unknown=11%, and various=18%. The histologies included: adenocarcinoma=26%, squamous cell carcinoma=21%, small cell carcinoma=15%, infiltrating ductal=14%, and various=24%. All patients had a minimum of one month post-treatment follow up (Range 1 - 24 mths). Sixteen patients are still living. Eighty-nine percent were symptomatic at presentation and 36% presented with only one symptom. The incidence of symptoms before treatment was: altered mentation=26%, decreased motor strength=26%, headache=24%, seizure=21%, altered gait=20%, nausea/vomiting=18%, speech deficit=15%, lethargy=11%, visual change=8%, altered sensation=7%, and cranial nerve deficits=3%. A statistically significant improvement in mentation (p<0.0001), motor strength (p<0.0001), headache (p<0.0001), seizure (p=0.0005), nausea/vomiting (p=0.0005), speech (p=0.001), and gait (p=0.0034) were present one month after the end of treatment. All patients were started on steroids before treatment. Attempts were made to wean the patients off steroids after therapy with only 25% still requiring steroid dosing after completion of treatment. All patients placed on anti-seizure medication before treatment continued usage indefinitely. CONCLUSION: The appearance of neurologic symptomatology impacts quality of life and is distressing for both patients and their families. Although life expectancy is not substantially prolonged in the majority of patients, treatment encompassing radiotherapy, steroids, and adequate supportive care offers a significant improvement in their quality of life. In this age of health care reform, where justification for palliative care is mandatory, quality of life, local control, and cost end-points are becoming as significant as survival end-points. The preservation of neurologic function or improvement in symptomatology is a definite indication of enhanced quality of life, as well as, limiting hospitalization or other costly interventions. Palliative care assumes a large role in the field of radiotherapy. Documentation of benefits derived from this treatment is lacking in patients treated for this intent. Our goal is to formalize this symptom scale and use it prospectively at our institution in the future

[en] Purpose/Objective: To prospectively determine symptom response in patients receiving radiation therapy for primary lung cancer. Materials and Methods: Thirty-three consecutive lung cancer patients were evaluated between March 1996 and February 1997 at the Medical College of Virginia satellite facility which serves a local community hospital. The LCSS, a validated quality of life scale, was used prospectively during the consultation and upon subsequent follow-up. The scale allowed scoring of symptom improvement, worsening, or stability following therapy. One patient declined therapy, while another was not offered XRT. The 31 remaining patients received a median dose of 54 Gy. Eleven patients received radiotherapy with curative intent to doses between 60 and 70 Gy, 5 small cell lung carcinoma (SmCCa) patients received 54 Gy consolidative therapy, and 13 patients received 15 to 30 Gy with palliative intent. Eight patients received chemotherapy as part of their initial treatment course, including all of those diagnosed with SmCCa. Twenty-one patients completed the LCSS at least once in the three month interval after therapy, while 6 died prior to follow-up, 2 were under treatment at the time of this analysis, and 2 were lost to follow-up. Survival analysis was completed using the Kaplan-Meier method. Results: Median follow-up was 4 months (range = 1 to 14), with an estimated median survival of 5 months. Fourteen patients died of lung cancer, 12 are alive with disease, 6 are alive without disease, and 1 died without disease. Patient characteristics were median age of 69 years (range = 43 to 91), male to female ratio of 4.5 to 1, mean weight loss of 12 pounds (range = 0 to 27), and mean duration of symptoms of 3 months (range = 0 to 12). Stage was: I 9%, II = 0%, IIIA = 6%, IIIB = 43%, IV = 27%, and limited stage SmCCa = 15%. Histology was: squamous cell carcinoma = 21%, adenocarcinoma = 23%, large cell carcinoma = 23%, poorly differentiated carcinoma = 15%, mesothelioma 3%, and SmCCa = 15%. The median number of LCSS symptoms at presentation was 4, and 94% of the patients presented with at least one symptom. The incidence of observer scored symptoms was: loss of appetite = 54%, fatigue = 79%, cough 79%, dyspnea = 73%, hemoptysis = 27%, and pain = 33%. Subjective reporting of pre-treatment symptoms revealed: loss of appetite = 51%, fatigue = 82%, cough = 73%, dyspnea = 70%, hemoptysis = 24%, and pain = 36%. There was a 96% rate of agreement between subjective and objective measures. When seen at first follow-up, the 21 evaluable patients scored subjective improvement in at least one symptom at a rate of 81%, while objective assessment at those same time points showed a palliation rate of 67%. The rate of agreement between subjective and objective measures of post-therapy symptoms was 68%, with the observer more likely to underestimate the gain defined by the patients' subjective scoring. Hemoptysis was the symptom most improved by therapy, followed by cough and loss of appetite. Discussion: Here we present early results of a prospective quality of life analysis in patients treated with radiotherapy for lung cancer. These objective palliation rates agree with our previously published retrospective data, though here the patients tend to perceive an even higher subjective rate of improvement than that which is evident to the examiner. To our knowledge this report contains the first data obtained in a prospective study using a validated quality of life scale on patients receiving radiotherapy for primary lung cancer. We continue prospective accrual of patients with the goal of allowing statistical analysis of symptom response to radiation in several different subgroups of patients with this disease

[en] Purpose: To measure symptom palliation in patients treated with radiation therapy for advanced nonsmall cell lung cancer (NSCLC). Methods and Materials: Five hundred thirty patients with NSCLC were treated at the Medical College of Virginia between 1988 and 1993. Sixty-three patients with the least favorable prognostic features received palliative radiation to 30 Gy in 10 or 12 fractions for symptoms related to the presence of intrathoracic tumor. The observer portion of the Lung Cancer Symptom Scale (LCSS) was employed in a retrospective chart review, scoring measures of appetite, fatigue, cough, dyspnea, hemoptysis, and pain. Results: In 54 evaluable patients, median survival was 4 months and was independent of age, stage, performance status, or histology. Ninety-six percent of the patients had at least one LCSS symptom at presentation. Fatigue was unaffected by therapy. Improvements in appetite (p = 0.68) and pain (p = 0.61) were not statistically significant. There was, however, a statistically significant reduction in cough (p = 0.01), hemoptysis (p = 0.001), and dyspnea (p 0.0003). Self-limiting acute side effects included transient esophagitis in 37% of patients, though no severe toxicities were noted. Conclusions: These results suggest symptomatic benefit from radiotherapy even in those NSCLC patients with advanced disease and a limited life expectancy. Treatment should be given to patients whose symptoms are most amenable to palliation. A site-specific quality of life instrument such as the LCSS should be included within any future clinical trial of NSCLC management so that symptom control may be scored as a treatment outcome in addition to disease-free survival