SUMMARY OBJECTIVE: The aim of this study was to perform dosimetric analysis of radiotherapy (RT) plans with or without elective nodal irradiation (ENI) and estimate whether the increase in mean doses (MDs) in the heart and lungs with ENI may lead to late side effects that may surpass the benefits of treatment. METHODS: The dosimetric analysis of 30 treatment plans was done with or without ENI. The planning and dose-volume histograms were analyzed, and the impact on the mortality of cardiovascular and lung cancer was estimated based on the correlation of the dosimetric data with data from population studies. RESULTS: RT with ENI increased the doses in the lungs and heterogeneity in the plans compared to breast-exclusive RT. When the increase in MDs is correlated with the increase of late side-effect risks, the most important effect of ENI is the increased risk of lung cancer, especially in patients who smoke (average increase in absolute risk=1.38%). The increase in the absolute risk of cardiovascular diseases was below 0.1% in the all the situations analyzed. CONCLUSIONS: ENI increases the heterogeneity and the doses at the lungs. When recommending ENI, the risks and benefits must be taken into account, considering the oncology factors and the plan of each patient. Special attention must be given to patients who smoke as ENI may lead to a significant increase in MD in the lung and the increased risk of radiation-induced lung cancer may surpass the benefits from this treatment.

É sabido que o envelhecimento da população do mundo durante o século XX e no início deste novo século constitui um desafio de primeira ordem para as nações, especialmente no campo socioeconômico. Um aspecto importante do envelhecimento populacional global é que, para grupos de idade mais avançada, a prevalência das doenças degenerativas também é maior, incluindo as doenças malignas. No universo de pacientes portadores de câncer, por outro lado, metade destes receberá radioterapia em algum momento de sua doença e suas características individuais podem influenciar, de alguma forma, o prognóstico, a indicação e as doses diárias de prescrição dos tratamentos. Neste contexto, a assistência à saúde do idoso portador de câncer deve ser vista como um importante desafio, principalmente devido a dois fatores: uma maior procura de tratamentos, em termos quantitativos, e características fisiológicas peculiares a esta população, que podem influenciar na tomada de decisões terapêuticas. Esta revisão propõe uma discussão sobre alguns aspectos relevantes tanto da fisiologia dos idosos, que pode influenciar o curso do tratamento irradiante, quanto de alguns avanços técnicos da radioterapia, que podem, por sua vez, beneficiar estes pacientes, oferecendo menor toxicidade e maior eficiência e rapidez, por exemplo.

It is known that the aging of the world population during the twentieth century and the beginning of this new century is a first-order challenge for nations, especially in the socio-economic field. An important aspect of the aging of global population is that, for older age groups, the prevalence of degenerative diseases is also higher, including malignancies. On the other hand, among the population of patients with cancer, half of these patients will receive radiation therapy at some point in their illness and their individual characteristics can somehow influence the prognosis, the indication and daily doses of treatment prescriptions. In this context, the health assistance for the elderly patient with cancer should be seen as an important challenge, mainly due to two factors: an increased demand for treatments, in quantitative terms, and physiological characteristics unique to this population, which can influence the therapeutic decision-making. This review proposes a discussion of some relevant aspects of both the physiology of the elderly, which may influence the course of radiation therapy, as well as of some technical advances in radiotherapy, which can in turn benefit these patients by offering, for example, lower toxicity, greater effectiveness and speed.

OBJETIVO: Relatar os resultados de tratamento de pacientes com câncer de pulmão de pequenas células com doença limitada (CPPC-DL), num período de dez anos, numa única instituição, para controle de qualidade e comparação com dados de literatura. MATERIAIS E MÉTODOS: Entre janeiro de 1992 e dezembro de 2002, 101 pacientes portadores de CPPC-DL completaram tratamento em nossa instituição. Seus resultados foram revistos e incluíram quimioterapia, radioterapia, a seqüência dos dois tratamentos e o uso de irradiação profilática cerebral (PCI). A radiação foi administrada com dose mediana de 45 Gy em 1,8 a 2 Gy por fração. A dose mediana de PCI foi de 25 Gy em dez frações. RESULTADOS: O seguimento mediano foi de 50,6 meses e a idade mediana dos pacientes foi de 63 anos. Houve 85 mortes confirmadas, 5 pacientes foram perdidos de seguimento e 11 estavam vivos. O tempo de sobrevida mediano foi de 11 meses, a sobrevida global em dois e cinco anos foi de 25,5% e 10%, respectivamente. Não houve diferença significante na sobrevida global em dois ou cinco anos segundo a idade e sexo dos pacientes. Também não houve diferença significante na sobrevida global entre os pacientes que realizaram PCI ou não, ou foram tratados em dois períodos diferentes (1997-2002 vs. 1992-1996). CONCLUSÃO: Os resultados de tratamento dos pacientes portadores de CPPC-DL na nossa instituição refletem as constantes mudanças no manuseio do CPPC. Nossa sobrevida global em dois anos de 25,5% é semelhante a outros resultados uni-institucionais publicados, mas menor que os resultados de 47% a 54% recentemente publicados por grupos cooperativos.

OBJECTIVE: To report the results of the treatment of patients with small-cell lung cancer with limited disease (SCLC-LD) in a single institution during a 10-year period, for quality assurance and comparison with data from the literature. MATERIALS AND METHODS: Between January 1992 and December 2002, 101 patients with SCLC-LD completed treatment at our institution. The outcomes were reviewed and included chemotherapy, radiotherapy, the sequence of the two treatments, and the use of prophylactic cranial irradiation. Radiation was delivered with a median dose of 45 Gy in 1.8 to 2 Gy per fraction. The median dose of the prophylactic cranial irradiation was 25 Gy in 10 fractions. RESULTS: Average follow-up was of 50.6 months and the average age of the patients was 63 years. There were 85 confirmed deaths, 5 patients were lost to follow up and 11 patients were alive. The median survival time was 11 months, the overall survival at 2 and 5 years was 25.5% and 10% respectively. There were no significant difference in overall survival at 2 or 5 years according to the age and sex of the patients. In addition, there were no statistical difference in overall survival among patients who had prophylactic cranial irradiation or not, or who were treated in two different periods (1997-2002 vs. 1992-1996). CONCLUSION: The results of the treatment of SCLC-LD patients in our institution reflect the constant changes in the management of SCLC. The 2-year's 25.5% overall survival seen in our institution is similar to reports published from other single institution, but lower than the 47% to 54% recently published results from cooperative groups.

OBJETIVO: Analisar, retrospectivamente, os resultados da radioterapia externa (RT) combinada a braquiterapia de alta taxa de dose (BATD), adjuvantes à cirurgia para o carcinoma de endométrio. MATERIAIS E MÉTODOS: Avaliamos 141 pacientes tratados com RT e BATD adjuvantes à cirurgia, no período de janeiro de 1993 a janeiro de 2001. RT pélvica foi realizada com dose mediana de 45 Gy, e BATD realizada na dose mediana de 24 Gy, em quatro inserções semanais de 6 Gy. A idade mediana das pacientes foi de 63 anos e a distribuição por estádio clínico (EC) foi: EC I (FIGO), 52,4%; EC II, 13,5%; EC III, 29,8%; EC IV, 4,3%. RESULTADOS: Com seguimento mediano de 53,7 meses, a sobrevida livre de doença (SLD) em cinco anos foi: EC I, 88,0%; EC II, 70,8%; EC III, 55,1%; EC IV, 50,0% (p = 0,0003). A sobrevida global em cinco anos foi: EC I, 79,6%; EC II, 74,0%; EC III, 53,6%; EC IV, 100,0% (p = 0,0062). Fatores que influíram na SLD foram grau histológico e histologia seropapilífera. Dos 33 casos que apresentaram recidiva da doença, em 13 (9,2%) esta ocorreu na pelve, vagina ou cúpula vaginal. RT + BATD do fundo vaginal permitiram o controle da doença em 90,8% dos casos. CONCLUSÃO: A RT exerce papel fundamental no controle loco-regional do câncer de endométrio e permite excelentes taxas de cura nos estádios iniciais. Para os estádios mais avançados, a falha terapêutica tende a ser a distância, sugerindo a necessidade de complementação terapêutica sistêmica, com introdução de novas modalidades de tratamento, em particular a quimioterapia.

OBJECTIVE: To review the results of adjuvant external beam radiation therapy (EBRT) combined with high-dose rate brachytherapy (HDR-BT) for the treatment of endometrial carcinoma. MATERIALS AND METHODS: We retrospectively evaluated 141 patients treated with EBRT and HDR-BT after surgery between January 1993 and January 2001. EBRT was performed with a median dose of 45 Gy, and HDR-BT was performed with a median dose of 24 Gy, with four weekly insertions of 6 Gy. The median age of the patients was 63 years and the disease stage distribution was: CS I (FIGO), 52.4%; CS II, 13.5%; CS III, 29.8%; CS IV, 4.3%. RESULTS: With a median follow-up of 53.7 months, the disease free survival (DFS) at five years was: CS I, 88.0%; CS II, 70.8%; CS III, 55.1%; CS IV, 50.0% (p = 0.0003). Global survival after five years was: CS I, 79.6%; CS II, 74.0%; CS III, 53.6%; CS IV, 100.0% (p = 0.0062). Factors affecting the DFS were histological grade and serous-papillary histology. Recurrence of the disease was observed in 33 cases, 13 (9.2%) of these occurred in the pelvis, vagina or vaginal vault. EBRT + HDR-BT of the vaginal vault allowed disease control in 90.8% of the cases. CONCLUSION: Radiation therapy is essential for loco-regional control of endometrial cancer and can achieve excellent cure rates in the initial stages. In more advanced stages, therapeutic failure frequently appears as distant metastases suggesting the need for complementary systemic therapy using new treatment modalities, particularly chemotherapy.

OBJETIVO: Análise comparativa da resposta bioquímica em pacientes submetidos à teleterapia exclusiva ou associada à braquiterapia de alta taxa de dose para tumores localizados da próstata. MATERIAIS E MÉTODOS: De novembro de 1997 a janeiro de 2000, 74 pacientes foram submetidos à teleterapia com 45 Gy e reforço com braquiterapia de alta taxa de dose com irídio-192 e dose de 16 Gy em quatro inserções (BT). Estes foram comparados a 29 pacientes submetidos à teleterapia com 45 Gy e reforço com arcoterapia e dose mediana de 24 Gy (RT) entre outubro de 1996 e fevereiro de 2000. Nos dois grupos houve associação ocasional de hormonioterapia neoadjuvante. Sobrevida atuarial livre de doença em três anos (SB3) e fatores prognósticos pré-tratamento da resposta bioquímica, como o antígeno prostático-específico inicial (PSAi), escore de Gleason da biópsia de próstata (EG) e estádio clínico (EC), foram analisados. RESULTADOS: O seguimento mediano foi de 25 meses para o grupo RT e 37 meses para o BT. Na análise atuarial, a SB3 foi de 51% e 73% (p = 0,032) para RT e BT, respectivamente. Na análise estratificada pelo PSAi, a SB3 para RT e BT foi de 85,7% e 79,1% (p = 0,76) para PSAi < 10 ng/mL e de 38% e 68% (p = 0,023) para PSAi > 10 ng/mL, respectivamente. Quando estratificado pelo EG, a SB3 para RT e BT foi de 37% e 80% (p = 0,001) para EG < 6 e 78% e 55% para EG > 6 (p = 0,58); estratificando-se pelo EC, a SB3 para RT e BT foi de 36% e 74% (p = 0,018) para EC < T2a e 73% e 69% para EC > T2a (p = 0,692), respectivamente. O risco relativo bruto de recidiva bioquímica foi de 2,3 (95% IC: 1,0-5,1) para os pacientes tratados com RT, em relação à BT; quando ajustado pelo PSAi e EG, o risco relativo de recidiva bioquímica foi de 2,4 (95% IC: 1,0-5,7). CONCLUSÃO: A modalidade de tratamento foi fator prognóstico independente de recidiva bioquímica, com maior controle bioquímico associado à BT. Nossos resultados preliminares sugerem que o maior benefício com BT foi obtido nos pacientes com PSAi > 10 ng/mL, EC < T2a e EG < 6.

OBJECTIVE: To compare the biochemical response in patients with locally advanced prostate cancer treated with external beam radiation therapy alone or in combination with conformal brachytherapy boost. MATERIALS AND METHODS: From November 1997 to January 2000, 74 patients received 45 Gy of pelvic external irradiation and four were treated with high dose rate iridium-192 conformal boost implants of 4 Gy each (BT). These were compared with 29 other patients treated with 45 Gy of pelvic external irradiation followed by a 24 Gy of bilateral ARC boost (RT) from October 1996 to February 2000. Some patients received neoadjuvant androgen deprivation therapy. Three-year actuarial biochemical control rates (BC3) and pretreatment biochemical response predictors such as prostate-specific antigen pretreatment (PSAi), Gleason score (GS) and clinical stage (CS), were evaluated. RESULTS: Median follow-up was of 25 months for the RT group and 37 months for the BT group. BC3 was 51% versus 73% (p = 0.032) for RT and BT, respectively. Comparisons of biochemical control by treatment group stratified by PSAi showed that BC3 for RT versus BT was 85.7% versus 79.1% (p = 0.76) for PSAi < 10 ng/mL and 38% versus 68% (p = 0.023) for PSAi > 10 ng/mL, respectively. For patients with GS < 6, BC3 was 37% versus 80% (p = 0.001) for RT versus BT and, for patients with GS > 6, BC3 was 78% versus 55% (p = 0.58) for RT versus BT, respectively. For patients with CS < T2a, BC3 was 36% versus 74% (p = 0.018) for RT versus BT and, for patients with CS > T2a, BC3 was 73% versus 69% (p = 0.692) for RT versus BT, respectively. The relative risk of biochemical relapse was 2.3 (95% IC: 1.0-5.1) for patients in RT group compared to the BT group. When adjusted for PSAi and GS, the relative risk of biochemical relapse was 2.4 (95% IC: 1.0-5.7). CONCLUSION: The treatment modality was an independent prognostic factor for biochemical relapse, with a significant improvement in the biochemical control with BT. These early results suggest that this treatment was most beneficial in patients with PSAi > 10 ng/mL, CS < T2a and GS < 6.