Preoperative irradiation and surgery for carcinoma of the base of the tongue

From 1960 through 1978, 101 patients with histologically proven epidermoid carcinoma of the base of the tongue were treated with preoperative irradiation and surgery at Washington University School of Medicine. Local and regional control at 3 years was achieved in 65% of the patients, and at 5 years in 57%. Sixteen percent of patients who suffered local or regional failure were salvaged by further surgery. Distant metastases developed in approximately 18% of patients and second malignancies developed in 20%. It appears that the combination of preoperative irradiation plus surgery provides substantial local control rates and survival for patients with base of tongue cancer in both early and moderately advanced stages.

Radiation therapy and hyperthermia in the treatment of superficial lesions: preliminary analysis: treatment efficacy, and reaction of skin, tissues subcutaneous

Superficial and measurable tumors were treated with hyperthermia and radiation therapy according to RTOG protocol 78-06. This study focuses on a subset of patients who were heated with microwaves. Eighty patients representing 88 lesions were treated between 1978 and 1981 with a schedule which allowed 48-96 hours to elapse between treatment sessions. The mean value of the average temperatures for individual lesions was 42.3 degrees C. The mean total radiation dose was 33.95 Gy. Skin reaction was examined in terms of the maximum score reported, using a modified Fowler scale. Erythema, the most common finding, was reported as the maximum skin reaction in 24% of the cases. Ulcerations and blisters occurred with frequencies of 18% and 7%, respectively. No reaction or desquamation was reported in 19% and 17% of the cases. Complete regression was noted in 48% of the treated lesions, partial regression in 17%, and no change in 24%. Twenty-five percent of the patients enjoyed sustained response for greater than 180 days. Refinement of hyperthermia treatment equipment and technique may result in less normal tissue reaction and improved clinical responses. In view of the encouraging initial results, we recommend aggressive pursuit of hyperthermia as a new treatment modality.

Role of radiation in the management of early vocal cord carcinoma

From 1952-1978, 177 patients with epidermoid carcinoma confined to the true vocal cords with normal mobility (T1NO) were treated with radiation alone. Five- and 10-year adjusted actuarial survival rates for all patients were 97 and 95%, respectively. The tumor recurred in the larynx and/or neck in 16% of patients with T1a (one cord involved) and 23% of the patients with T1b (both vocal cords involved) disease. Radiation failures were surgically salvaged in 89% of patients with T1a disease without anterior commissure involvement, in 60% of those with T1a disease with anterior commissure involvement and in 57% of those with T1b disease. Tumor was ultimately controlled in 97% of the patients with T1a and 90% of the patients with T1b disease. Voice was preserved in 93% of the patients with T1a disease and 77% of patients with T1b disease. Of 121 patients evaluated for voice quality, 77% had good and 22% had fair voice, while only one patient had poor quality of voice. Patients with fair or poor quality voice usually had had salvage hemilaryngectomy. We recommend radiation for all patients with early vocal cord carcinoma.

Late effects of treatment for Wilms' tumor

Twenty-six out of a total of 49 patients who were treated for Wilms' tumor at the Mallinckrodt Institute of Radiology between January 1960 and December 1975 have survived at least five years. The median follow-up time is 153 months (12 years, 9 months). One girl, who received pelvic irradiation, has not reached puberty at age 14, but the other 25 patients are currently in good health and have no major complaints or functional impairments at present. Twenty-one patients have, however, developed some complication at some time since treatment. Serious side-effects requiring hospitalization included one case of pericarditis and one of esophageal varices secondary to portal hypertension. Both these patients, however, had advanced tumors requiring aggressive treatment and their complications should be seen in perspective. There has also been one case of temporary low grade renal failure and one of transient hypertension. More common complications were 14 instances of scoliosis (only three have had any symptoms, however), five of osseous hypoplasia, three of soft tissue hypoplasia, three of liver damage and three of lung damage. There was one case of osteochondroma within a radiotherapy field. The factors pertaining to these complications and the anticancer therapy which preceded them are discussed in detail. We conclude that, whereas structural changes following modern radiotherapy for Wilms' tumor are very common, severe dysfunctions are infrequent. Even more extended periods of observation will be required before the total number of abnormalities is ascertained. However, the striking observation from this study is the lack of late functional effects.

Radiation therapy alone in the treatment of carcinoma of uterine cervix. I. Analysis of tumor recurrence

This is a retrospective analysis with emphasis on the patterns of failure in 849 patients with histologically proven invasive carcinoma of the uterine cervix treated with irradiation alone. In 281 patients with Stage IB tumors, the total incidence of pelvic failure was 6.4% (two without and 16 combined with distant metastasis). In 88 patients with Stage IIA, 12.5% failed in the pelvis (one without and ten combined with distant metastasis). The total pelvic failure rate in Stage IIB was 17.4% (22 without and 22 combined with distant metastasis). In 212 patients with Stage III, the overall pelvic failure rate was 35.8% (31 without and 45 combined with distant metastasis). Approximately 25% of the pelvic recurrences were central (cervix or vagina) and 75% parametrial. The overall incidence of distant metastasis was 13.5% for Stage IB, 27.3% for Stage IIA, 23.8% for Stage IIB, and 39.6% in Stage III. Higher doses of irradiation delivered to the medial and lateral parametrium with external beam irradiation and intracavitary insertions were correlated with a lower incidence of parametrial failures in all stages, except IB. In Stage IIA, medial parametrial doses below 9000 rad resulted in 10/78 = 12.8% pelvic failures, in contrast to one recurrence in 10 patients treated with doses over 9000 rad. In Stage IIB, doses below 9000 rad yielded a pelvic recurrence rate of 36/203 (17.7%) compared to 5/49 (10.2%) with higher doses. In Stage III there were 66/167 (39.5%) recurrences with doses below 9000 rad and 10/44 (22.7%) with larger doses. Statistically significant differences were observed among the Stage IIB (P = 0.02) and III patients (P = 0.005) respectively. The lateral parametrial dose also showed some correlation with tumor control, although the differences were not statistically significant. The survival in patients with Stage IIB and III was 10% higher in the patients treated with higher parametrial doses. However, the differences are not statistically significant. These results strongly suggest that higher doses of irradiation must be delivered to patients with Stage IIB and III, but improvement in tumor control must be weighed against an increasing number of complications. Factors other than the total doses of irradiation, such as the characteristics of the tumor and the quality of the intracavitary insertion influence the therapeutic results in irradiation of carcinoma of the uterine cervix. Other therapeutic approaches must be designed to improve the effect of irradiation in the tumor without further injury to the normal tissues. Hypoxic cell sensitizers, hyperthermia and high LET particles are under investigation.

Dose-response analysis for nasopharyngeal carcinoma: an historical perspective

Historical review of 118 patients with nasopharyngeal cancer treated in our institution from 1950--1978 showed a 20% improvement in tumor control for patients irradiated during the most recent period (1974--1978). This improvement was attributed to prescription of higher doses of radiation as well as improvements in technical accuracy and dose delivery to the tumor during that period. Rates of severe and mild complications were comparable and survival was not significantly altered over time despite improved tumor control. Within the range of doses delivered, there was no improvement in tumor control with increasing doses of radiation for small or large nasopharyngeal carcinomas. The dose-response analysis for tumor control was less than ideal because a number of prerequisites were lacking and because the study extended over a 28-year span during which there were significant changes in technology and physician orientation.

Long-term follow-up in radiation therapy of carcinoma of the vagina

A retrospective analysis of 134 patients with histologically confirmed carcinoma of the vagina is reported. Actuarial disease free 5-year survival was: Stage 0 (15 patients), 90%; I (39 patients), 90%; IIA (39 patients), 58%; IIB (21 patients), 32%; III (12 patients), 40%; IV (8 patients), 0%. Fifteen patients had carcinoma in situ; of these, 14 were controlled with interstitial or intracavitary therapy. Of 39 patients with Stage I carcinoma, 37 (95%) showed no evidence of vaginal or pelvic recurrence. Most of them received interstitial or intracavitary therapy or both; the addition of external beam irradiation did not significantly increase survival or tumor control. In Stage IIA (paravaginal extension) 22 of 34 (64.7%) patients were controlled with a combination of brachytherapy and external beam irradiation; only two of five (40%) treated with brachytherapy alone exhibited tumor control in the pelvis. Eight of 12 Stage III tumors were controlled in the pelvis. Only two of eight patients with Stage IV had no recurrence in the pelvis even with relatively high doses of irradiation. The dose of irradiation delivered to the primary tumor or the parametrial extension was critical in achieving successful results. The incidence of complications (9.7%) is correlated with the stage of the tumor and type of treatment given.

Computed tomography in definitive radiotherapy of prostatic carcinoma, part 2: definition of target volume

Pretreatment computed tomography (CT) scanning of the pelvis was performed in 100 consecutive patients with carcinoma of the prostate treated with external irradiation (82 patients) or interstitial I125 (18 patients). Treatment plan modifications prompted by CT scan findings were most frequent in patients with (clinical) involvement of the seminal vesicles in whom the conventional treatment planning often resulted in an underestimate of tumor volume. Seventeen of 32 (53%) such patients required an enlargement of treatment fields to adequately encompass the target volume. Using skeletal landmarks as reference, the dimensions of the prostate, seminal vesicles and the detectable tumor and their topographic relationships were systematically tabulated. These measurements provide a basis for the definition of the target volume in patients with carcinoma of the prostate in whom CT scans might not be available.

The risk of second primaries subsequent to irradiation for cervix cancer

A review of 1048 patients with cancer of the cervix treated with radiation, either alone or combined with surgery, disclosed 32 cases of second primary malignancies occurring from 1 to 16 years subsequent to treatment. Using the person years approach, the incidence rate of second primaries was 5.49 per 1000 person years, which is not significantly different from population based rates. The anatomic locations of the new malignancies and the times from treatment of the cervix cancer to diagnosis of a new primary are presented; the possible carcinogenic effects of radiation are discussed. In this group of patients, it was concluded that under the period of observation irradiation administered at therapeutic doses did not increase the probability of second malignancy in the pelvis or at other sites.

Large fraction radiotherapy plus misonidazole for treatment of advanced lung cancer: report of a phase I/II trial

From August 1978 through December 1979, 51 patients with advanced non-oat cell carcinoma of the lung were enrolled in a Phase I/II trial sponsored by the Radiation Therapy Oncology Group (RTOG) employing misonidazole (a 2-nitroimidazole) as a hypoxic cell sensitizer and radiation. The purpose of this study was to test drug and radiation tolerance and to assess the short term efficacy of this unconventional treatment. Tumor doses of 600 rad wer given twice weekly for three weeks for a total of 3600 rad, preceded four to six hours by misonidazole in a dose of 2 gm/m2 or 1.75 gm/m2, administered orally. Forty-nine patients were evaluable. Serious toxicity from this treatment was rare. Grade 2 or 3 peripheral neuro-toxicity occurred in eight of 24 patients (33%) with drug doses of 2 gm/m2 and in four of 26 patients (15%) who received 1.75 gm/m2. Grade 3 or 4 central nervous system toxicity occurred in two patients. Two patients developed serious late radiation complications: one patient had a transverse myelitis that appeared one year following delivery of 3600 rad to the spinal cord; a second patient developed a tracheoesophageal fistula and pericarditis eight months following treatment. Objective responses were reported in 67% of patients (complete in 18%); 70% of the patients died with a median survival time of nine months. Of 32 patients eligible for 12 month follow-up, 34% survived more than one year. Patterns of relapse after initial treatment and comparison with results from other RTOG trials using conventional fractionation are discussed.

Thoracic and elective brain irradiation with concomitant or delayed multiagent chemotherapy in the treatment of localized small cell carcinoma of the lung: a randomized prospective study by the Southeastern Cancer Study Group

A prospective randomized study was carried out to compare the effectiveness of concomitant or delayed multiagent chemotherapy combined with irradiation to the primary tumor and regional lymph nodes and to the brain in a group of 70 patients with histologically proven small cell undifferentiated carcinoma of the lung. Complete and partial response in both groups was comparable, and the overall survival was comparable. However, relapse-free survival was significantly higher in patients receiving concomitant chemotherapy and irradiation in comparison with the radiotherapy alone group. Disease-free survival was higher in the concomitant chemotherapy-radiotherapy patients, although survival was not significantly modified, probably because of suboptimal chemotherapy. The initial intrathoracic failure rate was 40.7% inthe concomitant chemotherapy-irradiation group, compared with 53.8% in the radiotherapy-alone patients. None of the patients receiving delayed chemotherapy following the radiotherapy recurrence showed significant tumor response to the drugs. The incidence of distant metastasis was slightly lower in the chemotherapy groups. Brain metastases were noted in 7% of the patients in both groups. Increased intrathoracic recurrences were noted in patients with lower doses of irradiation. Nine of 13 patients treated with inadequate portals developed intrathoracic recurrences in comparison to 13 of 40 treated with adequate irradiation fields. The study emphasizes the need for intensive chemotherapy and adequate radiation therapy to improve survival of patients with small cell undifferentiated carcinoma of the lung. Additional trials are necessary to assess the role of each modality in the management of these patients.

Endometrial extension of carcinoma of the uterine cervix: a prognostic factor that may modify staging

A retrospective review was done of 473 patients with histologically proven primary carcinoma of the uterine cervix on whom a dilatation and curettage (D & C) was performed during the initial workup. The pathologic features of the D & C specimens were classified as: (1) endometrial stomal invasion of cervical carcinoma; (2) tumor only, cervical carcinoma in D & C, normal endometrium absent; (3) admixture of normal endometrium and cervical carcinoma (contamination); (4) D & C negative for tumor. The patients were staged according to the FIGO classification. Eighty-two percent (388) of the patients were treated with radiation alone and the rest with a combination including surgical procedures (usually radical hystrectomy with lymphadenectomy). The three- and five-year survival rates were 10% to 20% lower for patients with D & C showing stromal invasion or tumor only than in patients with admixture or negative D & C. These results were coupled with an appreciably higher number of distant metastases in the patients with positive D & C and a lower incidence in patients with negative D & C. The authors suggest that endometrial extension of carcinoma of the uterine cervix may be an important factor in the staging classification of these patients and recommend that D & C always be done in the initial evaluation. Because of the high incidence of distant metastasis, effective adjuvant therapy must be developed to improve the present therapeutic results.

Endometrial extension of carcinoma of the uterine cervix: a prognostic factor that may modify staging

A retrospective review was done of 473 patients with histologically proven primary carcinoma of the uterine cervix on whom a dilatation and curettage (D & C) was performed during the initial workup. The pathologic features of the D & C specimens were classified as: (1) endometrial stomal invasion of cervical carcinoma; (2) tumor only, cervical carcinoma in D & C, normal endometrium absent; (3) admixture of normal endometrium and cervical carcinoma (contamination); (4) D & C negative for tumor. The patients were staged according to the FIGO classification. Eighty-two percent (388) of the patients were treated with radiation alone and the rest with a combination including surgical procedures (usually radical hystrectomy with lymphadenectomy). The three- and five-year survival rates were 10% to 20% lower for patients with D & C showing stromal invasion or tumor only than in patients with admixture or negative D & C. These results were coupled with an appreciably higher number of distant metastases in the patients with positive D & C and a lower incidence in patients with negative D & C. The authors suggest that endometrial extension of carcinoma of the uterine cervix may be an important factor in the staging classification of these patients and recommend that D & C always be done in the initial evaluation. Because of the high incidence of distant metastasis, effective adjuvant therapy must be developed to improve the present therapeutic results.

Local hyperthermia and irradiation in cancer therapy

The preliminary experience at the Mallinckrodt Institute of Radiology with hyperthermia and irradiation is reported and current issues in clinical application of heat are reviewed. Twenty-nine lesions were treated with 400 rad fractions given every 72 hr (twice weekly) for a total dose of 2400 to 4000 rad followed by hyperthermia (1450-MHz or 915-MHz microwaves, 42.0 degrees -43 degrees, 90 min, every 72 h). Eight of 12 recurrent epidermoid carcinomas of the head and neck showed complete regression (67%) and one more than 50% response. Of 5 metastatic melanoma nodules treated with irradiation an hyperthermia, 4 (80%) showed complete regression of the tumors an 1 almost complete response. Of 9 recurrent adenocarcinoma of breast nodules in the chest wall treated with 3200 to 4000 rad 5 lesions exhibited complete regression and 2 others about 80%. Of 6 lesions treated with 1500 rad and hyperthermia (RTOG protocol), 2 metastatic melanomas showed complete regression (CR) and 3 tumors exhibited partial regression. Of the 35 sites treated, 4 (11%) developed blisters, 7 (20%) erythema only, 3 (8%) moist desquamation and 27 (77%) dry desquamation. Additional clinical trials are in progress to assess the potential value of hyperthermia alone or combined with irradiation in the treatment of selected cancer patients.

Thoracic and elective brain irradiation with concomitant or delayed multiagent chemotherapy in the treatment of localized small cell carcinoma of the lung: a randomized prospective study by the Southeastern Cancer Study Group

A prospective randomized study was carried out to compare the effectiveness of concomitant or delayed multiagent chemotherapy combined with irradiation to the primary tumor and regional lymph nodes and to the brain in a group of 70 patients with histologically proven small cell undifferentiated carcinoma of the lung. Complete and partial response in both groups was comparable, and the overall survival was comparable. However, relapse-free survival was significantly higher in patients receiving concomitant chemotherapy and irradiation in comparison with the radiotherapy alone group. Disease-free survival was higher in the concomitant chemotherapy-radiotherapy patients, although survival was not significantly modified, probably because of suboptimal chemotherapy. The initial intrathoracic failure rate was 40.7% inthe concomitant chemotherapy-irradiation group, compared with 53.8% in the radiotherapy-alone patients. None of the patients receiving delayed chemotherapy following the radiotherapy recurrence showed significant tumor response to the drugs. The incidence of distant metastasis was slightly lower in the chemotherapy groups. Brain metastases were noted in 7% of the patients in both groups. Increased intrathoracic recurrences were noted in patients with lower doses of irradiation. Nine of 13 patients treated with inadequate portals developed intrathoracic recurrences in comparison to 13 of 40 treated with adequate irradiation fields. The study emphasizes the need for intensive chemotherapy and adequate radiation therapy to improve survival of patients with small cell undifferentiated carcinoma of the lung. Additional trials are necessary to assess the role of each modality in the management of these patients.

Prognostic factors in children with Ewing's sarcoma

Patient characteristics of 272 patients entered in a clinical trial conducted by the Pediatric Intergroup Ewing's Sarcoma Committee between June 1972 and November 1978 were examined for their relationship to prognosis. Prognosis was defined as disease-free survival time (time to local recurrence and/or metastatic disease) and overall survival time; all times were measured from the start of treatment. In a multivariate regression model, primary site of disease was the major variable that influenced prognosis, and patients with pelvic sites had the least favorable prognoses, followed by those with proximal and rib sites. The most favorable sites were distal and other. The median disease-free and survival times in weeks by primary site were, respectively: pelvis (69, 112), proximal (102, 141), rib (105, 109+), distal (226+, 240), and other (96+, 199+). Females had better prognoses than males; the median survival times were 197 and 147 weeks, respectively. An abnormal liver function as indicated by an abnormal serum glutamic-oxaloacetic transaminase value (greater than 45 IU) was a bad prognostic sign, although only 8 patients had this finding; their median survival time was 94 weeks. Patients who had resections had a slight advantage in survival compared with those having biopsies, though the difference favoring resection patients was not consistent for both sexes in any primary site. Individual characteristics of the patients that were of prognostic significance were: blood lymphocyte counts (high counts favorable), polymorphonuclear leukocyte counts (high counts unfavorable), and time from symptoms to diagnosis (times less than 1 mol favorable). Patients who received treatment 2 had significantly poorer prognoses than those given treatments 1 or 3. The median disease-free and survival times by treatment were (in wk): 1 (134, 198+), 2 (81, 120), and 3 (123, 182).