Research Archives

Prospective Randomized Comparison of the Effectiveness of Radiation Therapy and Local Steroid Injection for the Treatment of Plantar Fasciitis

By Tacoma Radiation on July 9th, 2015

Summary

Based on retrospective and prospective data, radiation therapy is effective for the treatment of plantar fasciitis. Local injections of corticosteroids are used to control pain when other conservative treatments have failed. We performed a randomized, prospective trial to compare the effects of radiation therapy with those of local corticosteroid injections. We show the superiority of radiation therapy concerning pain relief and recommend radiation therapy for treating plantar fasciitis.

Purpose

The purpose of this study was to conduct a randomized trial of radiation therapy for plantar fasciitis and to compare radiation therapy with local steroid injections.

Methods and Materials

Between March 2013 and April 2014, 128 patients with plantar fasciitis were randomized to receive radiation therapy (total dose of 6.0 Gy applied in 6 fractions of 1.0 Gy three times a week) or local corticosteroid injections a 1 ml injection of 40 mg methylprednisolone and 0.5 ml 1% lidocaine under the guidance of palpation. The results were measured using a visual analog scale, a modified von Pannewitz scale, and a 5-level function score. The fundamental phase of the study was 3 months, with a follow-up period of up to 6 months. Results: The median follow-up period for all patients was 12.5 months (range, 6.5-18.6 months). For the radiation therapy patients, the median follow-up period was 13 months (range, 6.5-18.5 months), whereas in the palpation-guided (PG) steroid injection arm, it was 12.1 months (range, 6.5-18.6 months). After 3 months, results in the radiation therapy arm were significantly superior to those in the PG steroid injection arm (visual analog scale, P<.001; modified von Pannewitz scale, P<.001; 5-level function score, P<.001). Requirements for a second treatment did not significantly differ between the 2 groups, but the time interval for the second treatment was significantly shorter in the PG steroid injection group (PZ.045).

Results

The median follow-up period for all patients was 12.5 months (range, 6.5-18.6 months). For the radiation therapy patients, the median follow-up period was 13 months (range, 6.5-18.5 months), whereas in the palpation-guided (PG) steroid injection arm, it was 12.1 months (range, 6.5-18.6 months). After 3 months, results in the radiation therapy arm were significantly superior to those in the PG steroid injection arm (visual analog scale, P<.001; modified von Pannewitz scale, P<.001; 5-level function score, P<.001). Requirements for a second treatment did not significantly differ between the 2 groups, but the time interval for the second treatment was significantly shorter in the PG steroid injection group (PZ.045).

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Evaluation of Outcomes in Gamma Knife Stereotactic Radiosurgery Treatment of Essential and Parkinsonian Tremor

By Tacoma Radiation on August 22nd, 2012

R. Sorum1,2, P. Shin2,3, A. Zemanek1, H. Wang1,2, M. McDonough1,2, K. Bergman1,2, K. Sanders1,2, N. Bittner1,2, A. Pittier1,2, D. Mastras1,2

1South Sound Gamma Knife, Tacoma, WA, United State of America
2Tacoma/Valley Radiation Oncology Centers, Tacoma, WA, United States of America
3South Sound Neurosurgery, Tacoma, WA, United Sates of America

Objective: The purpose of this study was to examine the outcomes of 39 patients (40 cases) with essential or Parkinsonian tremor who were treated with Gamma Knife stereotactic radiosurgery (GKSRS) via ventralis intermedius (Vim) thalamotomy.

Methods: A total of 40 cases of tremor were treated at our facility (South Sound Gamma Knife, Tacoma, WA). Thirty-five with benign essential tremor, three with Parkinsonian tremor, and two with both types of tremor were included. Using magnetic resonance imaging, the contra lateral Vim thalamic nucleus of the chosen treatment side was located and treated, receiving a single 4 mm shot of 130 Gy. These patients were followed by their radiation oncologist or neurosurgeon. A retrospective review of medical records including physical exams, writing samples and Archimedes spiral testing, in combination with patient phone interviews, was conducted to obtain data on treatment outcomes.

Results: In total, 39 patients with a median age of 77.5 years, received GKSRS for tremor. They had a median pre-treatment tremor duration of 13 years (range, 1.5-70). With a median follow-up period of 15.5 months (range, 3-64), a total of 33 patients (82.5%) responded to the treatment, as evidenced by lessening in their tremor severity. Of these patients, 24% had a complete response, with no residual tremor. The median time to response was 3.5 months (range, 0.1-12). One patient developed unilateral weakness in his lower extremity with evidence of significantly more thalamic edema on MRI than what is considered normal. He had corticosteroids prescribed and physical therapy that resolved this weakness over a short period of time.

Conclusion: GKSRS Vim thalamotomy at our institution was shown to provide relief from tremor at rates similar to other studies on this topic. This is a viable, safe and effective treatment option that is an alternative to deep brain stimulation in patients refractory to medication.

 

The Addition of Hyperthermia to Standard Radiotherapy Improves Both Local Control and Survival in Inoperable Pelvic Tumours: Results of Dutch Randomized Studies

By Tacoma Radiation on August 18th, 2012

Van Der Zee, D. Gonzalez Gonzalez, G.C. Van Rhoon, J.D.P. Van Dijk, W.L.J. Van Putten, A.A.M. Hart, and P.C.M. Koper

Background

Experimental research has shown that hyperthermia (HT) is an effective cell killing agent especially in a hypoxic, nutrient deprived and low pH environment. Such environmental conditions are commonly found to exist within malignant tumours. Hypoxic cells are known to be relatively radioresistant. So, the combination of radiotherapy (RT) and HT will result in at least complementary effects. The existing clinical data have confirmed the experimental data: in addition to promising results from many phases I-II clinical studies, the therapeutic gain by HT in addition to RT has been proven by randomised studies in head and neck cancer, malignant melanoma, recurrent breast cancer and glioblastoma multiforme. Advanced, inoperable tumours originating from the bladder, cervix, and rectum are characterized by disappointing local control rates following RT. For the patients concerned, a locoregional failure means that the situation, in general, has become incurable. One of the reasons for the relative radioresistance may be the existence of hypoxic areas. The effect of additional HT was investigated in these patient groups.

Materials and Methods

In the Netherlands, two randomised trials investigating the effect of HT in addition to standard RT, including patients with T3 and T4 bladder cancer, IIB-distal, IIIB and IV cervical cancer, and inoperable primary or recurrent rectal cancer, has recently been closed with a total of 358 patients included. The primary objective of both studies is whether additional HT will result in an increase in local control rate. Secondary objectives are acute and late toxicity, disease-free survival and overall survival. Following obtaining informed consent, patients were randomised 50% to RT alone and 50% to combined treatment. Three different systems for induction of HT were used: the B5D-2000 system, the Amsterdam 4-waveguide applicator system, and the Utrecht coaxial TEM applicator. For the three systems, similar energy distribution in human pelvic size phantoms has been demonstrated. The data from the two studies were combined.

Overall, patient and tumour characteristics are evenly distributed over the two treatment arms, except tumour stage which appears somewhat less favorable in the combined treatment arm. Radiotherapy was applied according to standard schedules, including brachytherapy for cervical cancer. Patients from institutes without hyperthermia facilities were irradiated at the referring institute. Hyperthermia was given once weekly, during the period of external RT, to a total of 5 treatments. The duration of each HT treatment was 60 minutes, following a heating period of maximum 30 minutes. There are no significant differences between the two treatment arms concerning the total RT doses applied. A relatively large number of patients in the combined treatment arm has not received HT treatments: 12% of the patients with cervical cancer and 17% of the patients with bladder cancer. Two patients in the RT-alone arm did receive HT-treatments. The analysis of results was done on the basis of the intention to treat principle.

Results

The preliminary results including total 298 patients with sufficient follow-up time show a significant improvement in local control rate by additional HT, from 37% to 58%. The addition of HT also resulted in better overall survival. At 3 years follow-up this was 24% following RT, and 30% following combined treatment. The effect of HT was most impressive in the group with cervical cancer (n=99), with significant improvement of both local control (+34) and overall survival (+29 at 3 years follow-up). In bladder cancer (n=85), the improvement in local control was temporary and not resulting in a better survival. In rectal cancer (n= 114), the improvement in local control seemed less and was not significant. The available data show no indication for enhanced radiation toxicity.

Conclusions

This study has shown that the addition of hyperthermia to standard radiotherapy of inoperable pelvic tumours improves both local control and survival. From the results of subgroup analysis, it was concluded to offer combined treatment standard to patients with tumours of the uterine cervix, stages IIB-distal, IIB and IV, and to develop new study protocols for patients with bladder and rectal cancer.

Evaluation of Outcomes in Gamma Knife Stereotactic Radiosurgery in Treatment of Trigeminal Neuralgia

By Tacoma Radiation on August 15th, 2012

P. Shin,1,3 R. Sorum,1,2 A. Zemanek,2 M. McDonough,1,2 K. Bergman,1,2 D. Mastras,1,2 K. Sanders,1,2 N. Bittner,1,2 A. Pittier,1,2 H. Wang.1,2

1South Sound Gamma Knife, Tacoma, WA, United State of America
2Tacoma/Valley Radiation Oncology Centers, Tacoma, WA, United States of America
3South Sound Neurosurgery, Tacoma, WA, United Sates of America

Objective: It is well documented that stereotactic radiosurgical lesioning of the trigeminal nerve entry is an effective treatment of trigeminal neuralgia [TN], and an appealing alternative to invasive treatments. This study details the outcomes of 79 cases.

Methods: This study consisted of a retrospective chart review of 79 cases in 73 patients treated with Gamma Knife stereotactic radiosurgery (GKSRS) at our facility. A single 4 mm shot of 75-85 Gy for primary treatment and 50-70 Gy for secondary treatment was delivered with the Leksell Gamma Knife 4C to the trigeminal nerve 4 to 7 mm from its origin from the brainstem while limiting the radiation dose to the brainstem to the 20% isodose line. Of those 79 cases, seven were secondary GKSRS treatments. Two patients had been lost to follow-up, leaving 71 patients available for analysis.

Results: Median follow-up was 30 months. Mean dose administered for primary treatment was 79.4 Gy (range, 75-85Gy); for secondary treatment it was 57.1 Gy (range, 50-70Gy). A total of 91.2% of patients undergoing their first GKSRS experienced pain relief following treatment at a median of 30 days post -treatment. Of this population, 32.3% of patients experienced a recurrence of symptoms, at an average of 11 months after treatment.  No significant differences were found between outcomes of subgroups including patients with multiple sclerosis, atypical TN, or those who had undergone previous surgical treatment for TN. There was no difference in outcome between the doses administered (75, 80, and 85Gy). For those patients receiving their second GKSRS for TN, there was an initial success rate of 71.4% with 40% of that population eventually having recurring symptoms.

Overall, 32.3% of patients developed some level of facial numbness. Of patients greater than 3 years post-treatment, (n=21), 52.4% experienced numbness, indicating a possible trend that this side effect may increase over time.

Conclusion: This study contributes to the growing body of research advocating that Gamma Knife stereotactic radiosurgery is an effective treatment of TN. Patient outcomes in terms of success of treatment are comparable to other studies. No significant predictor of recurrence or failure was found.