Publications by authors named "Gokhan Yaprak"

17 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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http://dx.doi.org/10.1111/crj.13240DOI Listing
November 2020

CT Derived Hounsfield Unit: An Easy Way to Determine Osteoporosis and Radiation Related Fracture Risk in Irradiated Patients.

Front Oncol 2020 13;10:742. Epub 2020 May 13.

Department of Radiation Oncology, Kartal Dr. Lutfi Kirdar Education and Research Hospital, Istanbul, Turkey.

We aimed to evaluate osteoporosis, bone mineral density, and fracture risk in irradiated patients by computerized tomography derived Hounsfield Units (HUs) calculated from radiation treatment planning system. Fifty-seven patients operated for gastric adenocarcinoma who received adjuvant abdominal radiotherapy were included in the study group. Thirty-four patients who were not irradiated after surgery comprised the control group. HUs of T12, L1, L2 vertebral bodies were measured from the computerized tomographies imported to the treatment planning system for all the patients. While the measurements were obtained just after surgery and 1 year later after surgery in the control group, the same measurements were obtained just before irradiation and 1 year after radiotherapy in the study group. Percent change in HU values (Δ%HU) was determined for each group. Vertebral compression fractures, which are the consequence of radiation induced osteoporosis and bone toxicity were assessed during follow-up. There was no statistical significant difference in HU values measured for all the vertebrae between the study and the control group at the onset of the study. While HU values decreased significantly in the study group, there was no significant reduction in HU values in the control group after 1 year. significant correlation was found between Δ%HU and the radiation dose received by each vertebra. Insufficiency fractures (IFs) were observed only in the irradiated patients (4 out of 57 patients) with the cumulative incidence of 7%. HU values are very valuable in determining bone mineral density and fracture risk. Radiation treatment planning system can be utilized to determine HU values. IFs are common after abdominal radiotherapy in patients with low vertebral HU values detected during radiation treatment planning. Radiation dose to the vertebral bones with low HU values should be limited below 20 Gy to prevent late radiation related bone toxicity.
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http://dx.doi.org/10.3389/fonc.2020.00742DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7237579PMC
May 2020

Covid-19 outbreak in a major radiation oncology department; which lessons should be taken?

Radiother Oncol 2020 08 6;149:107-108. Epub 2020 Apr 6.

Dr. Lutfi Kirdar Kartal Training and Research Hospital, Department of Radiation Oncology, Turkey.

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http://dx.doi.org/10.1016/j.radonc.2020.03.044DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7194801PMC
August 2020

Prognostic factors for survival in patients with gastric cancer: Single-centre experience.

North Clin Istanb 2020 5;7(2):146-152. Epub 2019 Dec 5.

Department of Radiation Oncology, University of Health Sciences, Kartal Dr. Lutfi Kırdar Training and Research Hospital, Istanbul, Turkey.

Objective: We aimed to investigate survival outcomes and survival-related prognostic factors in gastric cancer patients who were followed-up or received adjuvant therapy in our center.

Methods: Patients with gastric cancer treated between 2005 and 2016 were evaluated retrospectively. We included 345 non-metastatic (stage I-III) gastric cancer patients in the study. The clinical, demographic, histologic data of the patients and treatment characteristics were obtained from the patient's files.

Results: While 50 patients were stage I, 94 patients were stage II, 201 patients were stage III. While 221 patients (64%) presenting with serosal or adjacent visceral organ invasion or with involved lymph nodes were treated with adjuvant chemoradiotherapy, 124 patients presenting with early-stage disease were followed after surgery. Median follow up time was 34 months (4-156 months). While the median overall survival (OS) was 51 months, median disease-free survival (DFS) was 35 months. Overall survival and disease-free survival rates for 1, 3 and 5 years were 85%, 55%, 45% and 72%, 49%, 38%, respectively. According to univariate analysis, tumor size, T stage (p<0.001), N stage (p<0.001), TNM stage (p<0.001), grade (p<0.001) and presence of lymphovascular invasion (p=0.005) were determined as prognostic factors that affect overall survival significantly. According to the multivariate analysis, only T and N stage (p<0.001) were determined as independent prognostic factors for overall survival.

Conclusion: Many different prognostic factors have been defined for gastric cancer. In concordance with the literature, we found T and N stages as prognostic factors in univariate and multivariate analysis.
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http://dx.doi.org/10.14744/nci.2019.73549DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7117626PMC
December 2019

Stereotactic Radiotherapy in Recurrent Glioblastoma: A Valid Salvage Treatment Option.

Stereotact Funct Neurosurg 2020;98(3):167-175. Epub 2020 Apr 3.

Department of Neurosurgery, University of Health Sciences, Dr. Lutfi Kırdar Kartal Training and Research Hospital, Istanbul, Turkey.

Background: Glioblastoma (GBM) is a dismal disease. Recurrence is inevitable despite initial surgery and postoperative temozolomide (TMZ) and radiotherapy. Salvage surgery is the standard treatment in selected patients. Chemotherapy, biological agents, and re-irradiation are other treatment approaches available. Stereotactic radiotherapy (SRT) is nowadays a common treatment as a salvage treatment option.

Materials And Methods: We reviewed the files of 132 GBM cases treated between 2010 and 2018. All patients received TMZ and radiotherapy after surgery or biopsy. Among the patients who had recurrence, we identified 42 cases treated with salvage SRT. The CyberKnife robotic system was used to administer SRT.

Results: While the median follow-up time for all patients was 16 months (range 1-123), the median follow-up time for patients treated with SRT after initial diagnosis was 26.5 months (range 9-123). The median follow-up time after SRT was 10 months (range 2-107). SRT was performed in a median of 3 fractions (range 2-5). The median prescription dose was 20 Gy (range 18-30). While the median actuarial survival after initial diagnosis for patients treated with salvage SRT was 30 months (range 9-123), it was only 14 months (range 1-111) for patients who could not be treated with salvage SRT (p = 0.001). The median survival time after SRT was 12 months, and 1- and 2-year survival rates were 48 and 9%, respectively. The time to progression after SRT was 5 months (range 1-62), and 6-month and 1-year progression-free survival rates were 50 and 22%, respectively. Patients with longer time to recurrence >12 months had longer overall survival with respect to the ones having recurrence <12 months (p < 0.001). Salvage surgery had been performed in 7 out of 42 patients before SRT. These reoperated patients had significantly worse survival after SRT when compared to the patients who underwent SRT alone (p = 0.02). SRT was well tolerated and there was no grade III/IV toxicity.

Conclusions: SRT is a viable salvage treatment option for recurrent GBM. SRT provides acceptable local control and survival benefit for recurrent GBM cases. SRT can be considered especially in patients with long time to recurrence.
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http://dx.doi.org/10.1159/000505706DOI Listing
May 2021

Acoustic diagnosis of elastic properties of human tooth by 320 MHz scanning acoustic microscopy after radiotherapy treatment for head and neck cancer.

Radiat Oncol 2020 Feb 17;15(1):38. Epub 2020 Feb 17.

Department of Physics, Bogazici University, Bebek, 34342, Istanbul, Turkey.

Background: On the elastic profiles of human teeth after radiotherapy for head and neck cancers, generation of dental complications, which may bring several side effects preventing the quality of life, has not well clarified. Thus, we aimed to show the applicability of using 320 MHz Scanning Acoustic Microscopy (SAM) in the evaluation of the tooth damage acoustically at the micrometer level following radiation therapy, and also in the determination of the safe dose limits to impede severe dental damage.

Methods: This prospective study was performed by SAM employed at 320 MHz by an azimuthal resolution of 4.7 μm resolving enamel and dentin. A total of 45 sound human third molar teeth collected between September 2018 and May 2019 were used for the acoustic impedance measurements pre- and post irradiation. Nine samples for each group (control, 2 Gy, 8 Gy, 20 Gy, 30 Gy and 60 Gy) were evaluated to acquire the acoustic images and perform a qualitative analysis. Scanning Electron Microscopy (SEM) images were obtained to establish a relationship between micromechanical and morphological characteristics of the teeth. Statistical analysis was conducted using the Student t-test succeded by Mann-Whitney U investigation (p < .05), while SEM images were assessed qualitatively.

Results: The analysis included 45 sound teeth collected from men and women 18 to 50 years old. Post irradiation micromechanical variations of human teeth were significant only in the radiation groups of 30 Gy and 60 Gy compared to pre-irradiation group for enamel (7.24 ± 0.18 MRayl and 6.49 ± 028 MRayl; p < 0.05, respectively). Besides, the teeth subjected to radiation doses of 20, 30 and 60 Gy represented significantly lower acoustic impedance values relative to non-irradiated group for dentin (6.52 ± 0.43 MRayl, 5.71 ± 0.66 MRayl and 4.82 ± 0.53 MRayl p < 0.05), respectively.

Conclusions: These results are evidence for a safe acoustic examination device which may be a useful tool to visualize and follow the safe dose limits to impede severe dental damage through the radiation therapy treatment for head and neck cancers.
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http://dx.doi.org/10.1186/s13014-020-01486-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7027275PMC
February 2020

Is stereotactic body radiotherapy an alternative to surgery in early stage non small cell lung cancer?

J BUON 2019 Jul-Aug;24(4):1619-1625

1Dr Lutfi Kirdar Kartal Training and Research Hospital, Department of Radiation Oncology, Istanbul, Turkey.

Purpose: To determine local control and overall survival of patients with medically inoperable early-stage non-small cell lung cancer (NSCLC) treated with stereotactic ablative radiotherapy.

Methods: Included were a total of 52 patients (7;13% females and 45;87% males) with medically inoperable early-stage NSCLC and who were treated with stereotactic ablative body radiotherapy (SBRT) by a CyberKnife robotic radiotherapy machine between 2009 and 2017. Depending on tumor size and location, median 45 Gy (30-60) were delivered in median 3 fractions (3-5) to Planning Target Volume. As regards the tumor-tracking system; X-Sight lung tracking system was used in 43 (83%) patients, gold fiducials in 4 (8%) patients, and X-Sight spine tracking system in 5 (9%) patients.

Results: The median age of patients was 67 years (54-86). Tumor was staged as cT1 in 38 (73%) patients and cT2 in 14 (27%) patients. Median follow up was found to be 23 months (10-84 months). Median survival time was 38 months and, 1-3-5 year survival rates were respectively 94%-53%-33.6%. Locoregional recurrence occurred in 8 (15%) patients and recurrence was local only in 4 (8%) patients, while it was regional only in 3 (6%) and distant only in 12 (23%) patients. During follow up, local, regional and distant recurrence was detected in 27 (52%) cases and median progression free survival was found to be 25 months. 1-3-5 year progression free survival was 71.2%-39%-26%, respectively. Grade 3 toxicity was observed in only one patient; no grade 4-5 toxicity was observed.

Conclusion: A high local control rate with no major toxicity was obtained by SBRT in the patients with medically inoperable early-stage NSCLC. In the near future, SBRT may be an alternative that has growing evidence to support comparable outcomes in selected stage I patients.
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March 2020

Pretreatment SUV value to predict outcome in patients with stage III NSCLC receiving concurrent chemoradiotherapy.

North Clin Istanb 2019 12;6(2):129-133. Epub 2019 Jun 12.

Department of Radiation Oncology, Biruni University, Medicana International Hospital, Istanbul, Turkey.

Objective: Stage III disease accounts for approximately one-fourth of all non-metastatic non-small cell lung cancer (NSCLC). The patients who are not candidates for curative resection are offered concomitant chemoradiotherapy. In this subgroup, which is difficult to manage, studies that address the role of PET-CT to predict outcome measures specifically for stage III NSCLC receiving concurrent chemoradiotherapy may help better risk stratification. This study aimed to assess whether baseline PET maximum standardized uptake value (SUV) value in stage III NSCLC treated with concurrent chemoradiotherapy would independently identify patients with high risk of progression and death.

Methods: The study population consisted of patients aged 18 years or more with unresectable stage III histologically or cytologically proven NSCLC who received concurrent chemoradiotherapy. From 2007 to 2014, medical records of patients admitted to our institution were retrospectively analyzed. Pretreatment PET-CT SUV values were recorded for each patient. These values were categorized as low or high according to the median SUV measure of the study population.

Results: A total of 175 patients were analyzed. The median follow-up time was 23 months (range 6-109). The PET-CT SUV values ranged from 3.5 to 46 with a median value of 14. The median overall survival was 25 months in SUV <14 and 18 months in SUV ≥14 group (p=0.023). The median progression-free survival was 16 months in SUV <14 and 11 months in SUV ≥14 group (p=0.033). Multivariate analysis revealed that both PET-CT SUV value (p<0.001) and age (p=0.016) were independent significant predictors for overall survival (OS).

Conclusion: The results of this study involving patients with stage III NSCLC receiving concurrent chemoradiotherapy provide evidence that suggests that high values of pretreatment SUV, an indicator of metabolic tumor burden, predicted a higher risk of disease progression and death.
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http://dx.doi.org/10.14744/nci.2019.02212DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6593921PMC
June 2019

Anal canal squamous cell cancer: surgıcal therapy, when?

Med Glas (Zenica) 2019 Aug 1;16(2). Epub 2019 Aug 1.

Department of General Surgery, Kartal Training and Research Hospital, Istanbul, Turkey.

Aim To describe a therapeutic approach, indications for abdominoperineal resection (APR), survival and oncological results for patients who received treatment in our surgical clinic for anal canal squamous cell cancer (SCC). Methods Patients were randomized into two groups according to the treatment method: Group 1- Chemoradiotherapy (CRT) without surgery, Group 2- CRT + APR. Results Eighteen patients with anal canal SCC were included in the study; 11 (61.1%) patients were in Group 1 and 7 (38.8%) in Group 2. Reasons for APR was as follows: three patients had insufficient CRT, two had recurrence after CRT, one had complete faecal incontinence and one patient had rectovaginal fistula. Overall five year survival (OS) and disease free survival (DFS) was 77.7% and 72.7%, respectively. Comparing two groups five year OS was 90.9% and 57.1%, whereas DFS was 81.8%, 57.1%, respectively (p=0.389 and 0.324, respectively). Conclusion Gold standard therapy for anal canal SCC is CRT. However, APR should be applied as an escape treatment for patients suffering from tumour progression, insufficient CRT and recurrence (30%).
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http://dx.doi.org/10.17392/1008-19DOI Listing
August 2019

Volumetric decrease of pancreas after abdominal irradiation, it is time to consider pancreas as an organ at risk for radiotherapy planning.

Radiat Oncol 2018 Dec 3;13(1):238. Epub 2018 Dec 3.

Department of Radiation Oncology, Dr. Lutfi Kirdar Kartal Education and Research Hospital, Istanbul, Turkey.

Background: Volumetric shrinkage of normal tissues such as salivary glands, kidneys, hippocampus are observed after radiotherapy. We aimed to assess the alterations in pancreatic volume of patients who received abdominal radiotherapy and define pancreas as an organ at risk for radiation treatment planning.

Material-methods: Forty-nine patients operated for gastric adenocarcinoma who received adjuvant abdominal radiotherapy were in the study group, 27 patients with early stage disease who did not need adjuvant treatment after surgery comprised the control group. An experienced radiologist contoured the pancreas of all the patients from computed tomographies imported to the planning system obtained either for radiation planning purpose or for follow-up after surgery. The same procedure was repeated one year later for both groups. Measured volume of the pancreas was expressed in cm.

Results: Mean pancreatic volumes were similar in both groups at the onset of the study, 51,34 ± 20,33 cm, and 50,12 ± 23,75 cm in the irradiated and the control groups respectively (p = 0,63). One year later, mean pancreatic volumes were significantly decreased in each group; 22,48 ± 10,53 cm, 44,18 ± 23,08 cm respectively, p < 0,001. However, the decrease in pancreatic volume was significantly more pronounced in the irradiated group in comparison to the control group, p < 0,001.

Conclusion: Volumetric decrease in normal tissues after radiotherapy is responsible for loss of organ function and radiation related late side effects. Although pancreas is a radiation sensitive organ losing its volume and function after radiation exposure, it is not yet considered as an organ at risk for radiation treatment planning. Pancreas should be contoured as an organ at risk, dose-volume histogram for the organ should be created, and safe organ doses should be determined. This is the first study declaring pancreas as an organ at risk for radiation toxicity and the necessity of defining dose constraints for the organ.
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http://dx.doi.org/10.1186/s13014-018-1189-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6276196PMC
December 2018

Osteoporosis development and vertebral fractures after abdominal irradiation in patients with gastric cancer.

BMC Cancer 2018 Oct 11;18(1):972. Epub 2018 Oct 11.

Department of Radiation Oncology, Biruni University Medicana International Hospital, Istanbul, Turkey.

Background: Decrease in bone mineral density, osteoporosis development, bone toxicity and resulting insufficiency fractures as late effect of radiotherapy are not well known. Osteoporosis development related to radiotherapy has not been investigated properly and insufficiency fractures are rarely reported for vertebral bones.

Methods: Ninety-seven patients with gastric adenocarcinoma were evaluated for adjuvant treatment after surgery. While 73 out of 97 patients treated with adjuvant chemoradiotherapy comprised the study group, 24 out of 97 patients with early stage disease without need of adjuvant treatment comprised the control group. Bone mineral densities (BMD) of lumbar spine and femoral neck were measured by dual energy x-ray absorptiometry after surgery, and one year later in both groups.

Results: There was statistically significant decline in BMDs after one year in each group itself, however the decline in BMDs of the patients in the irradiated group was more pronounced when compared with the patients in the control group; p values were 0.02 for the decline in BMDs of lumbar spine, and 0.01 for femoral neck respectively. Insufficiency fractures were observed only in the irradiated patients (7 out of 73 patients) with a cumulative incidence of 9.6%.

Conclusions: Abdominal irradiation as in the adjuvant treatment of gastric cancer results in decrease in BMD and osteoporosis. Insufficiency fracture risk in the radiation exposed vertabral bones is increased. Calcium and vitamin D replacement and other measures for prevention of osteoporosis and insufficiency fractures should be considered after abdominal irradiation.
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http://dx.doi.org/10.1186/s12885-018-4899-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6182865PMC
October 2018

Radiation field size and dose determine oncologic outcome in esophageal cancer.

World J Surg Oncol 2016 Oct 13;14(1):263. Epub 2016 Oct 13.

Department of Radiation Oncology, Bezmialem Vakif University Medical Faculty, Istanbul, Turkey.

Background: Locoregional recurrence is a major problem in esophageal cancer patients treated with definitive concomitant chemoradiotherapy. Approximately half of the patients fail locoregionally. We analyzed the impact of enlarged radiation field size and higher radiation dose incorporated to chemoradiotherapy on oncologic outcome.

Methods: Seventy-four consecutive patients with histologically proven nonmetastatic squamous or adenocarcinoma of the esophagus were included in this retrospective analysis. All patients were locally advanced cT3-T4 and/or cN0-1. Treatment consisted of either definitive concomitant chemoradiotherapy (Def-CRT) (n = 49, 66 %) or preoperative concomitant chemoradiotherapy (Pre-CRT) followed by surgical resection (n = 25, 34 %). Patients were treated with longer radiation fields. Clinical target volume (CTV) was obtained by giving 8-10 cm margins to the craniocaudal borders of gross tumor volume (GTV) instead of 4-5 cm globally accepted margins, and some patients in Def-CRT group received radiation doses higher than 50 Gy.

Results: Isolated locoregional recurrences were observed in 9 out of 49 patients (18 %) in the Def-CRT group and in 1 out of 25 patients (3.8 %) in the Pre-CRT group (p = 0.15). The 5-year survival rate was 59 % in the Def-CRT group and 50 % in the Pre-CRT group (p = 0.72). Radiation dose was important in the Def-CRT group. Patients treated with >50 Gy (11 out of 49 patients) had better survival with respect to patients treated with 50 Gy (38 out of 49 patients). Five-year survivals were 91 and 50 %, respectively (p = 0.013).

Conclusions: Radiation treatment planning by enlarged radiation fields in esophageal cancer decreases locoregional recurrences considerably with respect to the results reported in the literature by standard radiation fields (18 vs >50 %). Radiation dose is as important as radiation field size; patients in the Def-CRT group treated with ≥50 Gy had better survival in comparison to patients treated with 50 Gy.
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http://dx.doi.org/10.1186/s12957-016-1024-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5064926PMC
October 2016

Is there any role of intravenous iron for the treatment of anemia in cancer?

BMC Cancer 2016 08 20;16(1):661. Epub 2016 Aug 20.

Department of Oncology, Bezmialem Vakif University, Istanbul, Turkey.

Background: Anemia is a major cause of morbidity in patients with cancer resulting in poor physical performance, prognosis and therapy outcome. The aim of this study is to assess the efficacy of intravenous (iv) iron administration for the correction of anemia, for the prevention of exacerbation of anemia, for decreasing blood transfusion rates, and for the survival of cancer patients.

Methods: Patients with different solid tumor diagnosis who received iv iron during their cancer treatment were evaluated retrospectively. Sixty-three patients with hemoglobin (Hgb) levels between ≥ 9 g/dL, and ≤ 10 g/dL, and no urgent need for red blood cell transfusion were included in this retrospective analysis. The aim of cancer treatment was palliative for metastatic patients (36 out of 63), or adjuvant or curative for patients with localized disease (27 out of 63). All the patients received 100 mg of iron sucrose which was delivered intravenously in 100 mL of saline solution, infused within 30 min, 5 infusions every other day. Complete blood count, serum iron, and ferritin levels before and at every 1 to 3 months subsequently after iv iron administration were followed regularly.

Results: Initial mean serum Hgb, serum ferritin and serum iron levels were 9.33 g/dL, 156 ng/mL, and 35.9 μg/dL respectively. Mean Hgb, ferritin, and iron levels 1 to 3 months, and 6 to 12 months after iv iron administration were 10.4 g/dL, 11.2 g/dL, 298.6 ng/mL, 296.7 ng/mL, and 71.6 μg/dL, 67.7 μg/dL respectively with a statistically significant increase in the levels (p < 0.001). Nineteen patients (30 %) however had further decrease in Hgb levels despite iv iron administration, and blood transfusion was necessary in 18 of these 19 patients (28.5 %). The 1-year overall survival rates differed in metastatic cancer patients depending on their response to iv iron; 61.1 % in responders versus 35.3 % in non-responders, (p = 0.005), furthermore response to iv iron correlated with tumor response to cancer treatment, and this relation was statistically significant, (p < 0.001).

Conclusions: Iv iron administration in cancer patients undergoing active oncologic treatment is an effective and safe measure for correction of anemia, and prevention of worsening of anemia. Amelioration of anemia and increase in Hgb levels with iv iron administration in patients with disseminated cancer is associated with increased tumor response to oncologic treatment and overall survival. Response to iv iron may be both a prognostic and a predictive factor for response to cancer treatment and survival.
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http://dx.doi.org/10.1186/s12885-016-2686-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4992337PMC
August 2016

Whole-brain radiation therapy for brain metastases: detrimental or beneficial?

Radiat Oncol 2015 Jul 28;10:153. Epub 2015 Jul 28.

Department of Radiation Oncology, Dr. Lutfi Kirdar Kartal Education and Research Hospital, Cevizli, Istanbul, Turkey.

Stereotactic radiosurgery is frequently used, either alone or together with whole-brain radiation therapy to treat brain metastases from solid tumors. Certain experts and radiation oncology groups have proposed replacing whole-brain radiation therapy with stereotactic radiosurgery alone for the management of brain metastases. Although randomized trials have favored adding whole-brain radiation therapy to stereotactic radiosurgery for most end points, a recent meta-analysis demonstrated a survival disadvantage for patients treated with whole-brain radiation therapy and stereotactic radiosurgery compared with patients treated with stereotactic radiosurgery alone. However the apparent detrimental effect of adding whole-brain radiation therapy to stereotactic radiosurgery reported in this meta-analysis may be the result of inhomogeneous distribution of the patients with respect to tumor histologies, molecular histologic subtypes, and extracranial tumor stages between the groups rather than a real effect. Unfortunately, soon after this meta-analysis was published, even as an abstract, use of whole-brain radiation therapy in managing brain metastases has become controversial among radiation oncologists. The American Society of Radiation Oncology recently recommended, in their "Choose Wisely" campaign, against routinely adding whole-brain radiation therapy to stereotactic radiosurgery to treat brain metastases. However, this situation creates conflict for radiation oncologists who believe that there are enough high level of evidence for the effectiveness of whole-brain radiation therapy in the treatment of brain metastases.
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http://dx.doi.org/10.1186/s13014-015-0466-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4517629PMC
July 2015

SRS With or Without Whole-Brain Radiation Therapy for Those With 1 to 4 Brain Metastases: In Regard to Sahgal et al.

Int J Radiat Oncol Biol Phys 2015 Jul;92(4):947-8

Department of Radiation Oncology, Dr. Lutfi Kirdar Kartal Education and Research Hospital, Istanbul, Turkey.

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http://dx.doi.org/10.1016/j.ijrobp.2015.04.012DOI Listing
July 2015

Survival in gastric cancer in relation to postoperative adjuvant therapy and determinants.

World J Gastroenterol 2015 Jan;21(4):1222-33

Sevgi Ozden, Zerrin Ozgen, Hazan Ozyurt, Cengiz Gemici, Gokhan Yaprak, Huseyin Tepetam, Radiation Oncology, Dr. Lutfi Kirdar Kartal Training and Research Hospital, 34890 Istanbul, Turkey.

Aim: To evaluate survival data in patients with gastric cancer in relation to postoperative adjuvant therapy and survival determinants

Methods: A total of 201 patients (mean±SD age: 56.0±11.9 years, 69.7% were males) with gastric carcinoma who were operated and followed up at Lutfi Kirdar Kartal Training and Research Hospital between 1998 and 2010 were included in this retrospective study. Follow up was evaluated divided into two consecutive periods (before 2008 and 2008-2010, respectively) based on introduction of 3-D conformal technique in radiotherapy at our clinic in 2008. Data on patient demographics, clinical and histopathological characteristics of gastric carcinoma and the type of treatment applied after surgery [postoperative adjuvant treatment protocols including chemoradiotherapy (CRT) and chemotherapy (CT), supportive therapy or follow up without any treatment] were recorded. The median duration and determinants of local recurrence free (LRF) survival, distant metastasis free (DMF) survival and overall survival were evaluated in the overall population as well as with respect to follow up years [1998-2008 (n=127) vs 2008-2010 (n=74)].

Results: Median duration for LRF survival, DMF survival and overall survival were 31.9, 24.1 and 31.9 mo, respectively in patients with postoperative adjuvant CRT. No significant difference was noted in median duration for LRF survival, DMF survival and overall survival with respect to treatment protocols in the overall population and also with respect to followed up periods. In the overall population, CT protocols FUFA [5-fluorouracil (400 mg/m2) and leucovorin-folinic acid (FA, 20 mg/m2)] (29.9 mo) and UFT®+Antrex® [a fixed combination of the oral FU prodrug tegafur (flouroprymidine, FT, 300 mg/m2 per day) with FA (Antrex®), 15 mg tablet, two times a day] (42.5 mo) was significantly associated with longer LRF survival times than other CT protocols (P=0.036), while no difference was noted between CT protocols in terms of DMF survival and overall survival. Among patients received CRT, overall survival was significantly longer in patients with negative than positive surgical margin (27.7 mo vs 22.4 mo, P=0.016) in the overall study population, while time of radiotherapy initiation had no significant impact on survival times. Nodal stage was determined to be independent predictor of LRF survival in the overall study population with 4.959 fold (P=0.042) increase in mortality in patients with nodal stage N2 compared to patients with nodal stage N0, and independent predictor of overall survival with 5.132 fold (P=0.006), 5.263 fold (P=0.027) and 4.056 fold (P=0.009) increase in the mortality in patients with nodal stage N3a (before 2008), N3b (before 2008) and N2 (overall study population) when compared to patients with N0 stage, respectively.

Conclusion: Our findings emphasize the likelihood of postoperative adjuvant CRT to have a survival benefit in patients with resectable gastric carcinoma.
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http://dx.doi.org/10.3748/wjg.v21.i4.1222DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4306167PMC
January 2015

Risk of endocrine pancreatic insufficiency in patients receiving adjuvant chemoradiation for resected gastric cancer.

Radiother Oncol 2013 May 3;107(2):195-9. Epub 2013 May 3.

Department of Oncology, Dr. Lutfi Kirdar Kartal Education and Research Hospital, Turkey.

Background: Adjuvant radiotherapy combined with 5-fluorouracil based chemotherapy has become the new standard after curative resection in high risk gastric cancer. Beside many complications due to surgery, the addition of chemotherapy and radiotherapy as adjuvant treatment may lead to both acute and late toxicities. Pancreatic tissue irradiation during this adjuvant treatment because of incidental and unavoidable inclusion of the organ within the radiation field may affect exocrine and endocrine functions of the organ.

Materials And Methods: Fifty-three patients with gastric adenocarcinoma were evaluated for adjuvant chemoradiotherapy after surgery. While 37 out of 53 patients were treated postoperatively due to either serosal or adjacent organ or lymph node involvement, 16 patients without these risk factors were followed up regularly without any additional treatment and they served as the control group. Fasting blood glucose (FBG), hemoglobin A1c (HBA1c), insulin and C-peptide levels were measured in the control and study groups after the surgery and 6 months and 1 year later.

Results: At the baseline there was no difference in FBG, HbA1c, C-peptide and insulin levels between the control and the study groups. At the end of the study there was a statistically significant decline in insulin and C-peptide levels in the study group, (7.5 ± 6.0 vs 4.5 ± 4.4 IU/L, p: 0.002 and 2.3 ± 0.9 vs 1.56 ± 0.9 ng/ml, p: 0.001) respectively.

Conclusions: Adjuvant radiotherapy in gastric cancer leads to a decrease in beta cell function and insulin secretion capacity of the pancreas with possible diabetes risk. Radiation-induced pancreatic injury and late effects of radiation on normal pancreatic tissue are unknown, but pancreas is more sensitive to radiation than known. This organ should be studied extensively in order to determine the tolerance doses and it should be contoured during abdominal radiotherapy planning as an organ at risk.
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http://dx.doi.org/10.1016/j.radonc.2013.04.013DOI Listing
May 2013