Publications by authors named "Ayşe Nur Demiral"

12 Publications

  • Page 1 of 1

Prognostic factors in medically inoperable early stage lung cancer patients treated with stereotactic ablative radiation therapy (SABR): Turkish Radiation Oncology Society Multicentric Study.

Clin Respir J 2020 Nov 17;14(11):1050-1059. Epub 2020 Aug 17.

Faculty of Medicine, Radiation Oncology Department, Ankara University, Ankara, Turkey.

Objective: We identified factors influencing outcomes in patients with medically inoperable early stage lung cancer (MIESLC) treated with stereotactic ablative radiation therapy (SABR) at 14 centers in Turkey.

Materials And Methods: We retrospectively analyzed 431 patients with stage I-II MIESLC treated with SABR from 2009 through 2017. Age; sex; performance score; imaging technique; tumor histology and size; disease stage radiation dose, fraction and biologically effective dose with an α/β ratio of 10 (BED ); tumor location and treatment center were evaluated for associations with overall survival (OS), local control (LC) and toxicity.

Results: Median follow-up time was 27 months (range 1-115); median SABR dose was 54 Gy (range 30-70) given in a median three fractions (range 1-10); median BED was 151 Gy (range 48-180). Tumors were peripheral in 285 patients (66.1%), central in 69 (16%) and <1 cm from mediastinal structures in 77 (17.9%). Response was evaluated with PET/CT in most cases at a median 3 months after SABR. Response rates were: 48% complete, 36.7% partial, 7.9% stable and 7.4% progression. LC rates were 97.1% at 1 year, 92.6% at 2 years and 91.2% at 3 years; corresponding OS rates were 92.6%, 80.6% and 72.7%. On multivariate analysis, BED > 100 Gy (P = .011), adenocarcinoma (P = .025) and complete response on first evaluation (P = .007) predicted favorable LC. BED > 120 Gy (hazard ratio [HR] 1.9, 95% confidence interval [CI] 1.1-3.2, P = .019) and tumor size (<2 cm HR 1.9, 95% CI 1.3-3, P = .003) predicted favorable OS. No grade 4-5 acute side effects were observed; late effects were grade ≤3 pneumonitis (18 [4.2%]), chest wall pain (11 [2.5%]) and rib fracture (1 [0.2%]).

Conclusion: SABR produced encouraging results, with satisfactory LC and OS and minimal toxicity. BED > 120 Gy was needed for better LC and OS for large, non-adenocarcinoma tumors.
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November 2020

Dosimetric comparison of anterior posterior-posterior anterior 2-field three-dimensional conformal radiotherapy, 4-field three-dimensional conformal radiotherapy and "forward" plan intensity modulated radiotherapy techniques in female lymphoma patients irradiated to neck and mediastinum.

J Cancer Res Ther 2018 Oct-Dec;14(6):1389-1396

Department of Radiation Oncology, Dokuz Eylül University Medical Faculty, Izmir, Turkey.

Aim: Dosimetric comparison of three different techniques in female lymphoma patients who had radiotherapy (RT) to the neck and mediastinum.

Setting And Design: Retrospective clinical study.

Materials And Methods: Computerized tomography-simulator images of eight patients were obtained retrospectively. Using 6 MV-X photon energy, RT plans were formed with three different techniques (anterior posterior-posterior anterior 2-field three-dimensional conformal RT [AP-PA 2-field 3D-CRT], 4-field 3D-CRT and "forward" plan intensity modulated RT [FPIMRT]). Comparisons were in terms of homogeneity index (HI), conformity index (CI), and inhomogeneity coefficient for planning target volume (PTV); mean lung dose, V, V, V, V for lung; D, V, V, V for heart; D, V, V, V for breast; D for spine; D, V, V, V, V for thyroid.

Statistical Analysis Used: Since nonparametric tests had to be used due to the study population being < 30, Friedman and Wilcoxon signed-rank tests were implemented in trilateral and bilateral comparison of techniques, respectively. For statistical significance, P value was required to be <0.05.

Results: When FPIMRT was compared with AP-PA and 4-field techniques with respect to, HI (AP-PA/FPIMRT P: 0.017; 4-field/FPIMRT P: 0.03) and CI (AP-PA/FPIMRT P: 0.018; 4-field/FPIMRT P: 0.042), FPIMRT was more advantageous. In addition, FPIMRT was found more useful in terms of D (AP-PA/FPIMRT P: 0.012; 4-Field/FPIMRT P: 0.012) for spinal cord and D (AP-PA/FPIMRT P: 0.012; 4-field/FPIMRT P: 0.012) for thyroid.

Conclusion: FPIMRT was superior in terms of PTV homogeneity and conformity. However, it was observed that for normal tissues, FPIMRT was advantageous only for spinal cord and thyroid; but it was not the most advantageous technique for some of the dose-volume parameters of the breast, lung, and heart.
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February 2019

The Effect of Dose-Volume Parameters on Central Nervous System Relapse in Pediatric Patients with Acute Leukemia Receiving Prophylactic Cranial Irradiation.

Gulf J Oncolog 2017 May;1(24):24-29

Dept of Radiation Oncology, Dokuz Eylül Univ Faculty of Medicine, Izmir, Turkey.

Aim Of The Study: To investigate the effects of dosevolume parameters of brain parenchyma, optic nerves (ONs) and cribriform plate (CP), which were determined on central nervous system (CNS) control in pediatric leukemia patients who have undergone prophylactic cranial irradiation (PCI) at our department.

Patients And Methods: In the current study, the records of 14 patients were examined retrospectively. Along with the minimum and maximum doses for brain and CP, D95% (minimal dose received by the 95% volume of a structure) and V95% (percent volume of target receiving 95% of prescribed dose) could be obtained from the dose-volume histogram. Statistical analyses were conducted using the Mann Whitney test in SPSS-15.

Results: ALL/AML ratio was 9/5. CNS relapse was observed only in 2 patients. The minimum dose was 1249 (1100-1782) cGy, 1036 (547-1651) cGy, 856 (308-1460) cGy and 1234 (922-1727) cGy for brain parenchyma, right ON, left ON and CP, respectively. The value of D95%/D was 1.01 (1-1.06) and 0.99 (0.92- 1.06) for brain parenchyma and CP, respectively. V95% was 99.8 % (98.6%-100%) and 98.1% (80.5%-100%) for brain parenchyma and CP, respectively. The analyses revealed that none of the target tissue dose-volume parameters for PCI affected CNS relapse (p>0.05).

Conclusion: In our study; it was found that the dosevolume parameters of the brain, CP and ONs did not have any effect on CNS relapse. Along with the other clinical factors, the scarce number of patients included in the study might have concealed the effects of parameters related to RT.
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May 2017

A Diet Containing Beta-Hydroxy-Beta-Methylbutyrate, L-Glutamine and L-Arginine Ameliorates Chemoradiation-Induced Gastrointestinal Injury in Rats.

Radiat Res 2015 Oct 2;184(4):411-21. Epub 2015 Oct 2.

e  Multidisciplinary Laboratories, Dokuz Eylül University School of Medicine, Izmir, Turkey.

The aim of this study was to investigate the effects of a specific diet, containing beta-hydroxy-beta-methylbutyrate, L-glutamine and L-arginine (HMB/Glu/Arg), on chemoradiation-induced injuries of the rat gastrointestinal mucosa. Wistar albino rats were divided into 4 groups: control (n = 5); radiation (n = 14); 5-fluorouracil treatment (5-FU; n = 14); and radiation and 5-FU treatment (n = 14). Rats were fed either a standard diet or a specific diet (SpD) containing HMB/Glu/Arg supplementation for 7 days prior to radiation exposure and/or 5-FU treatment. The irradiated groups were exposed to an 1 Gy dose of 6 MV x rays delivered to the who-abdominal. The animals receiving 5-FU treatment were given a 100 mg/kg dose of the drug. In the radiation and 5-FU treatment group, the 5-FU was administered 30 min prior to irradiation. After irradiation and/or 5-FU treatment, feeding with either the standard rat diet or specific diet continued as before. All animals were sacrificed on day 4 after irradiation and 5-FU treatment. Data collected included microbiological, histological and immunohistochemical end points. We found that bacterial colony counts in the ceca and mesenteric lymph nodes of irradiated rats treated with 5-FU were significantly lower in the specific diet (SpD) group than in the standard diet group (P = 0.002-0.05). Morphometrically, gastric, duodenal and colonic mucosal injuries were less severe in the irradiated animals fed the specific diet, as well as the 5-FU-treated animals fed the specific diet, compared to the similarly treated standard diet groups. Apoptosis, measured by TUNEL, revealed significantly lower numbers of TUNEL positive cells in irradiated animals fed the specific diet, and irradiated animals treated with 5-FU and fed the specific diet compared to irradiated animals fed the standard diet, and irradiated animals treated with 5-FU and fed the standard diet. In the 5-Fu-treated and SpD group, the extent of apoptosis was significantly lower than that of the 5-Fu-treated and standard diet group in both the stomach and duodenum (P = 0.0001), but not in the colon. Apoptosis, measured by caspase 3 staining, was significantly less in all three organs of the SpD groups. In conclusion, these findings suggest that a diet supplemented with HMB/Glu/Arg may ameliorate the effect of radiation-induced gastrointestinal injury, coinciding with reduced bacterial growth.
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October 2015

Patterns of care for lung cancer in radiation oncology departments of Turkey.

Int J Radiat Oncol Biol Phys 2008 Dec 15;72(5):1530-7. Epub 2008 Aug 15.

Dokuz Eylul University Medical School, Department of Radiation Oncology, Izmir, Turkey.

Purpose: To determine the patterns of care for lung cancer in Turkish radiation oncology centers.

Methods And Materials: Questionnaire forms from 21 of 24 (87.5%) centers that responded were evaluated.

Results: The most frequent histology was non-small cell lung cancer (NSCLC) (81%). The most common postoperative radiotherapy (RT) indications were close/(+) surgical margins (95%) and presence of pN2 disease (91%). The most common indications for postoperative chemotherapy (CHT) were ">/= IB" disease (19%) and the presence of pN2 disease (19%). In Stage IIIA potentially resectable NSCLC, the most frequent treatment approach was neoadjuvant concomitant chemoradiotherapy (CHRT) (57%). In Stage IIIA unresectable and Stage IIIB disease, the most frequent approach was definitive concomitant CHRT (91%). In limited SCLC, the most common treatment approach was concomitant CHRT with cisplatin+etoposide for cycles 1-3, completion of CHT to cycles 4-6, and finally prophylactic cranial irradiation in patients with complete response (71%). Six cycles of cisplatin + etoposide CHT and palliative thoracic RT, when required, was the most commonly used treatment (81%) in extensive SCLC. Sixty-two percent of centers did not have endobronchial brachytherapy (EBB) facilities.

Conclusion: There is great variation in diagnostic testing, treatment strategies, indications for postoperative RT and CHT, RT features, and EBB availability for LC cases. To establish standards, national guidelines should be prepared using a multidisciplinary approach.
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December 2008

Clinical and prognostic features of plasmacytomas: a multicenter study of Turkish Oncology Group-Sarcoma Working Party.

Am J Hematol 2008 Sep;83(9):702-7

Department of Radiation Oncology, Faculty of Medicine, Gaziantep University, Gaziantep, Turkey.

To identify the outcomes of prognostic factors of solitary plasmacytoma mainly treated with local radiotherapy (RT). The data were collected from 80 patients with solitary plasmacytoma (SP). Forty patients (50.0%) received radiotherapy (RT) alone while 38 of them (47.5%) were treated with surgery (S) and RT. The median radiation dose was 46 Gy (range 30-64). The median follow up was 2.41 years (range 0.33-12.33). Ten-year overall survival (OS) and local relapse-free survival (LRFS) were 73% and 94%, respectively. The median progression-free survival (PFS) and multiple myeloma-free survival (MMFS) were 3.5 years and 4.8 years, respectively. On multivariate analyses, the favorable factors were radiotherapy dose of > or =50 Gy and RT + S for PFS and younger age for MMFS. For the patients with medullary plasmacytoma, the favorable factor was younger age for MMFS. RT at > or =50 Gy and RT + S may be favorable prognostic factors on PFS. Younger patients, especially with head-neck lesion and without pre-RT macroscopic tumor, seem to have the best outcome when treated with RT +/- S. Progression to MM remains as the main problem especially for older patients.
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September 2008

The variability of applicator position among high dose rate intracavitary brachytherapy applications in cervical cancer patients treated with ring & tandem applicators.

Tumori 2007 Sep-Oct;93(5):432-8

Kocaeli State Hospital Radiation Oncology Clinic, Kocaeli, Turkey.

Objective: To evaluate the interindividual and intraindividual applicator position variability in high dose rate ring and tandem intracavitary brachytherapy applications in locally advanced cervical cancer.

Patients And Methods: Eight patients with locally advanced cervical cancer formed the study population. They had been treated in Dokuz Eylül University Department of Radiation Oncology between the years 2000 and 2005 with high dose rate intracavitary brachytherapy using ring and tandem applicators. The 3-dimensional geometric variation of the applicator center in craniocaudal, mediolateral and anteroposterior directions was determined on the basis of bony reference points in 24 pairs of orthogonal films obtained in the conventional simulator. Then the following evaluations were performed: 1) the applicator position variability in all applications (interindividual variability), 2) the intraindividual applicator position variability relative to the first application, 3) the intraindividual applicator position variability relative to the average of three applications. Among the potential factors that might influence the reproducibility of ring and tandem applications, age, stage, the period between external radiotherapy and brachytherapy were evaluated by univariate analysis.

Results: Standard deviation of interindividual applicator variability was 3.83 mm in craniocaudal, 0.39 mm in mediolateral and 2.86 mm in anteroposterior directions. The standard deviation of intraindividual variability relative to the first application was 1.91 mm in craniocaudal, 0.4 mm in mediolateral, and 4.26 mm in anteroposterior directions. The standard deviation of intraindividual variability relative to the average of three applications was 0.95 mm in craniocaudal, 1.86 mm in mediolateral, and 1.24 mm in anteroposterior directions. According to univariate analysis, no factor influenced applicator position variability.

Conclusions: In order to extract definitive conclusions about factors that affect positional reproducibility of ring and tandem applicators, studies are needed that include larger numbers of patients.
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December 2007

The effect of socioeconomic factors on quality of life after treatment in patients with head and neck cancer.

Int J Radiat Oncol Biol Phys 2008 Jan 8;70(1):23-7. Epub 2007 Nov 8.

Department of Radiation Oncology, Dokuz Eylül University Medical School, Izmir, Turkey.

Purpose: To determine the effect of socioeconomic factors on quality of life (QoL) after treatment in patients with head and neck carcinoma (HNC).

Patients And Methods: The study population included 50 HNC patients seen in their control examinations after radiotherapy during a 2-month interval and who were willing to complete the Short-Form 36 QoL questionnaire. Socioeconomic, demographic, and tumor- and treatment-related factors were analyzed for their effect on physical component summary score (PCS) and mental component summary score (MCS) using the Mann-Whitney U test.

Results: All patients received radiotherapy, and 33 patients (66%) underwent surgery for the primary tumor and/or neck disease. Chemotherapy was given in 9 patients (18%). Mean PCS and MCS were 47.9 (range, 24.8-59.3) and 46.7 (range, 22-63.3) for the whole patient population. There was no significant factor affecting PCS. Education level of "middle school or higher," perceived economic status of "medium or higher," social security status of not being "absent or minimally covered," and unilateral type of neck surgery were found to increase MCS significantly. According to separate linear regression analyses performed for three socioeconomic variables, the most significant factor for MCS was social security status compared with education level and perceived economic status. It was the only parameter that retained its significance when all five parameters were combined in a linear regression model.

Conclusion: This study demonstrated that educational status, perceived economic status, and social security status showed a significant effect on the QoL of HNC patients after radiotherapy. When all variables were taken into account, only "social security status" remained significant.
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January 2008

Different clinical features of primary and secondary tumors in patients with multiple malignancies.

Tumori 2005 Jul-Aug;91(4):317-20

Akdeniz University Medical School, Department of Internal Medicine, Division of Medical Oncology, Antalya, Turkey.

Clinical features of the first and second primaries in patients with multiple malignancies have not been extensively studied. We compared patient and treatment characteristics of the primary malignancy in 48 consequent multiple primary cancer patients with those of the second primary in the same cohort. The second primaries comprised fewer breast cancers; 29.2% of primaries as opposed to 10.4% of second tumors were breast cancer (P = 0.049). In addition, primary tumors tended to be at a lower TNM stage than secondary tumors (P = 0.060). The median overall survival after the diagnosis of the first primary for the whole cohort was 22.3 years (95% CI, 2.0-42.5) and the median time to presentation of the second malignancy was 38 months after the diagnosis of the first primary (range, 0 to 384). Therefore, the prognosis of cancers in the multiple malignancy group appears to be good and they appear to have an indolent clinical behavior. Thus, we recommend a long screening time for secondary tumors after a curative treatment in patients with common cancers, taking into account the different occurrence patterns of second primaries with respect to first primaries.
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November 2005

Assessment of quality of life of nasopharyngeal carcinoma patients with EORTC QLQ-C30 and H&N-35 modules.

Int J Radiat Oncol Biol Phys 2005 Dec 19;63(5):1347-53. Epub 2005 Sep 19.

Turkish Oncology Group (TOG)--Head and Neck Cancer Working Party, Hacettepe University, Sihhiye, Ankara, Turkey.

Purpose: The current study reports on long-term quality of life (QoL) status after conventional radiotherapy in 187 nasopharyngeal carcinoma patients from 14 centers in Turkey.

Patients And Methods: Patients with the diagnosis of nasopharyngeal carcinoma, who were treated in 14 centers in Turkey with minimum 6 months of follow-up and were in complete remission, were asked to complete Turkish versions of EORTC QLQ-C30 questionnaire and the HN-35 module. Each center participated with the required clinical data that included age at diagnosis, gender, symptoms on admission, follow-up period, treatment modalities, radiotherapy dose, and AJCC 1997 tumor stage. Each patient's 33 QoL scores, which included function, global health status, and symptoms, were calculated as instructed in EORTC QLQ-C30 scoring manual. All of the scales and single-item measures range from 0 to 100. A high score represents a higher response level. Kruskal-Wallis and Mann-Whitney U nonparametric tests were used for comparisons.

Results: One hundred eighty-seven patients with median age of 46 years (range, 16-79 years) participated and completed the questionnaires. Median follow-up time was 3.4 years (range, 6 months-24 years). All patients have received external-beam radiotherapy. Beside external-beam radiotherapy, 59 patients underwent brachytherapy boost, 70 patients received concomitant chemotherapy, and 95 patients received adjuvant/neoadjuvant chemotherapy. Most of the patients in the analysis (75%) were in advanced stage (Stage III, n = 85 [45.4%]; Stage IV, n = 55 [29%]). Mean global health status was calculated as 73. Parameters that increased global health status were male gender, early-stage disease, and less than 4-year follow-up (p < 0.05). Functional parameters were better in males and in early-stage disease. Factors that yielded better symptom scores were short interval after treatment (10 scores), male gender (7 scores), and lower radiation dose (6 scores). Neoadjuvant or adjuvant chemotherapy did not have any effect on QoL, whereas concomitant chemotherapy adversely affected 5 symptom scores.

Conclusion: Quality of life is adversely affected in our nasopharyngeal carcinoma patients treated with combined therapies. The factors that adversely affect quality of life are advanced tumor stage, female gender, and long-term follow-up. Further controlled studies to evaluate both preradiotherapy and postradiotherapy status are necessary to clarify the contribution of each treatment modality to QoL.
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December 2005

Prognostic significance of hemoglobin concentration in nasopharyngeal carcinoma: does treatment-induced anemia have negative effect?

In Vivo 2003 Sep-Oct;17(5):483-7

Istanbul University, Oncology Institute, Department of Radiation Oncology, 34390 Capa, Istanbul, Turkey.

Purpose: To assess the value of hemoglobin concentration (HC) in predicting treatment outcomes in nasopharyngeal carcinoma (NPC) patients treated with chemotherapy (CT) and radiotherapy (RT).

Patients And Methods: Ninety-eight NPC patients treated with three courses of platinum-based neoadjuvant CT (NCT) and conventional RT were grouped as having normal HC (> or = 12.0 g/dl in females and > or = 13 g/dl in males), having mild anemia (MA) (13.0 g/dl > Hb > or = 11 g/dl in males, 12.0 g/dl > Hb > or = 11 g/dl in females) and having severe anemia (SA) (Hb < 11 g/dl). Massive decrease in HC (MDHC) was defined as > or = 1.5 g/dl decline with NCT. Along with other known risk factors (sex, age, histopathology, T stage, N stage, bilateral neck involvement, cranial nerve involvement and total RT time), the prognostic value of SA and MDHC were evaluated by Cox-regression.

Results: SA increased from 7 to 33% with NCT (p < 0.0001). Patients with SA had lower 5-year locoregional control (LRC) (49 vs. 73%, p = 0.03), disease-free survival (DFS) (42 vs. 68%, p = 0.01) and overall survival (OS) (43 vs. 69%, p = 0.01) rates than patients with normal HC or MA. The presence of MDHC worsened 5-year LRC (p = 0.002), DFS (p = 0.001) and OS (p = 0.02) rates. In multivariate analyses, MDHC and SA had pronounced effect on LRC and survival, respectively.

Conclusion: MDHC and SA adversely affect treatment outcome in NPC patients treated with CT and RT. This may favour concomitant scheduling of RT and CT over neoadjuvant setting. Correction of HC before RT can improve the efficacy of RT and should be further evaluated.
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May 2004

Amifostine-induced toxic epidermal necrolysis during radiotherapy: a case report.

Jpn J Clin Oncol 2002 Nov;32(11):477-9

Department of Radiation Oncology, Akdeniz University Medical School, Antalya, Turkey.

Amifostine is a phosphorylated aminothiol prodrug that can selectively protect normal tissues against the toxic effects of chemotherapy and radiotherapy. In clinical use amifostine is well tolerated and may rarely cause allergic reactions. Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are two closely related entities that present with severe acute mucocutaneous reactions most often triggered by drugs. There are only two case reports related to the use of amifostine during radiotherapy, one case with SJS and the other with SJS-TEN overlap. In this paper, a case with amifostine-induced TEN during radiotherapy is presented.
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November 2002