Radiation therapy in the multimodal management of Ewing's sarcoma of bone: report of the Intergroup Ewing's Sarcoma Study

This paper is a progress report on the role of radiation therapy (RT) in local tumor control and the decreased incidence of pulmonary metastasis in 251 patients entered in the Intergroup Ewing's Sarcoma Study. All were followed for more that 1 year, and their RT records were reviewed. Doses to the primary tumor in the range of 4,500--6,500 rad were administered over approximately 5 to 6 weeks in combination with 4 drugs, i.e., vincristine (VCR), dactinomycin (DAC), cyclophosphamide (CY), and adriamycin, or only the first 3. One group of patients received the 3 drugs and bilateral pulmonary irradiation (approximately 1,500 rad in 2 wk). Preliminary analysis showed a local primary tumor control of approximately 90%. Patients with lesions in the pelvis and humerus had local failure rates of 13% (7 of 54) and 21.4% (6 of 28), respectively. The treatment groups differed significantly in the incidence of pulmonary metastasis. Patients treated with the 4 drugs (regimen 1) had a 14% incidence, whereas 42% of those treated with only 3 drugs (regimen 2) developed pulmonary metastases. Of all patients treated with 3 drugs and pulmonary irradiation (regimen 3), 18% showed lung metastases. The study indicated that intensive chemotherapy and RT significantly improved the local control and survival of patients with localized Ewing's sarcoma. However, the high incidence of metastasis indicated the need for more effective systemic chemotherapy for further improvement of treatment results. More studies are needed so we can define the volume to be treated and the optimal dose of irradiation to determine a therapeutic strategy that will yield optimal survival and tumor control with the fewest sequelae.

Multimodal therapy for the management of primary, nonmetastatic Ewing's sarcoma of bone: an Intergroup Study

A randomized study of 264 children and adults with previously untreated localized Ewing's sarcoma of bone was undertaken between 1973 and 1978 by 83 institutions of three national study groups: Children's Cancer Study Group, Southwest Oncology Group, and Cancer and Leukemia Group B. The Intergroup Study was designed to determine if the addition of adriamycin (ADR) or bilateral pulmonary radiotherapy (RT) to vincristine, dactinomycin, and cyclophosphamide (VAC therapy) would improve survival and reduce local recurrences and metastases. All patients received RT to the primary lesion, and the survival rate after 3 years was 65%. The most effective treatment regimen was VAC plus ADR; 74% of the patients were free of disease at 2 years. The lengths of disease-free status and survival of patients treated with VAC plus ADR or VAC plus RT did not differ. However, both regimens were significantly superior to treatment with VAC alone. The addition of ADR or bilateral pulmonary RT to VAC was highly advantageous to patients with nonpelvic primaries. Bone and lung were the major sites of distant relapse, but the addition of bilateral pulmonary RT showed no advantage over that of ADR in reducing the occurrence of lung metastases. These recent results should eliminate some of the pessimism that has accompanied a diagnosis of Ewing's sarcoma, although distant metastases continued to be a major reason for failure in the control of this tumor. Survival of these patients can be improved through well-controlled clinical trials designed to determine optimal adjuvant chemotherapy and treatment of the primary lesion.

Sarcomas of bone in childhood: pathologic aspects

Some sarcomas of bone are not characteristically childhood tumors. Within the context of osteosarcomas, telangiectatic and parosteal (juxtacortical) variants deserve recognition. Among chondrosarcomas, which ordinarily are not tumors that occur in children, the mesenchymal variant should be recognized in children especially, this lesion may be extraosseous. Fibrous histiocytoma and its malignant variant have recently emerged as morphologically specific lesions, occasionally osseous, among other spindle cell tumors. Ewing's sarcoma, which is predominantly of osseous origin, consists of undifferentiated fragile cells. The elaborate spectrum of topographic, cytologic, nuclear, and other morphologic features that fall within the designation Ewing's sarcoma are described.

Squamous carcinoma of the base of the tongue: a clinicopathologic study of 81 cases

Ninety-one patients were treated for squamous cell carcinoma of the base of the tongue between 1960 and 1974. Eighty-one of those patients were treated in a consistent manner, either by radiotherapy alone or preoperative radiotherapy plus total en bloc excision with a radical neck dissection. Eighteen patients were treated by radiotherapy alone (1800-7900 rads) to the primary site and bilaterally to the neck. Fifteen of these patients died within five years. Sixty-three patients were treated with preoperative irradiation (1800-7900 rads) followed by total primary excision with ipsilateral neck dissection. This latter group had a 50% five-year survival. Death due to uncontrolled tumor occurred within five years, whereas death after five years postinitial therapy was due to unrelated reasons. Unfavorable prognostic features were poor differentiation of the tumor, lack of histologic evidence of radiation-induced regression of the tumor, and more than three neck lymph node metastases in the initial neck dissection. Cox regression analysis showed that absence of histologic response to therapy was associated with a failure rate 4.05 times higher than that seen in patients whose tumors did respond. Primary tumor size did not affect prognosis as long as the tumor was technically resectable. Primary recurrences occurred in at least 20% of cases regardless of the presence or absence of surgical margin involvement.

Contribution of CT to quantitative radiation therapy planning

The contribution of computed tomography (CT) in radiotherapeutic treatment of lung cancer was evaluated. Radiation therapy ports prepared for 50 patients on the basis of routine diagnostic radiographs and without CT scan information were reviewed after CT scanning. Of 50 patients, 13 (26%) required alteration of treatment ports on the basis of the additional CT scan information. In 11 patients (22%) the changes resulted in an increase in field size to cover the tumor adequately, and in two patients (4%-) the field size was reduced to spare normal tissue. A three-phase study was completed to evaluate the impact of CT on quantitative parameters of two-dimensional treatment plans on 25 of the 50 patients. Treatment plans in the absence of CT scan and without lung transmission correction were compared with treatment plans where CT information was used and lung transmission corrections were performed. Numerical results for local efficiency and nonuniformity factor were compared for conventional, CT unoptimized, and CT optimized plans. Of the 25 patients, 14 (56%) had poorer local efficiency and 16 (64%) had nonuniformity factor exceeding 5% when treatment was planned without CT information. CT-optimized plans improved local efficiency in 16 (64%) of 25 patients and reduced nonuniformity to within 5% in 21 (84%). It is suggested that in the treatment planning of patients with lung cancer, CT scan information is essential for accurate determination of dose distribution and optimization of therapy.

Prognostic parameters in radiotherapeutic management of localized carcinoma of the prostate

A series of 215 patients with carcinoma of the prostate localized to the pelvis received radical radiotherapy. Treatment results have been correlated with the tumor stage, tumor size defined independently from stage, doses of radiation and histological grade. The following ranges from 2 to 13 years (median 5 years). Local recurrence was observed in 6.6 percent of stage B, 16.1 per cent of stage C and 20 per cent of stage D1 cases. Eighty per cent of the patients with stage B disease, 56 per cent with stage C and 0 per cent with stage D1 survived 5 years free of disease. Tumors less than 2 cm. in diameter were controlled uniformly, while tumors more than 2 cm. in diameter showed an over-all local control rate of about 85 per cent. Increasing size resulted in a higher incidence of distant metastases. A dose of 6,500 rad (180 to 200 rad per day) appears adequate for tumors less than 2 cm. in diameter and stage B tumors, while higher stage tumors require doses of 7,000 rad (180 to 200 rad per day). Most high grade tumors and massive tumors of any grade fail outside the pelvis.

Radiotherapy (2500 rad) for testicular leukemia: local control and subsequent clinical events: a Southwest Oncology Group study

The effectiveness of radiotherapy, 2500 rad over two weeks, in treating leukemic infiltrates of the testicles was studied in 38 boys who met the requirements for tissue conformation of testicular involvement and examination of the bone marrow. The study group was heterogeneous with respect to specific histology and prior therapy. Complete regression of testicular infiltrates was confirmed by repeated biopsy examinations of 32 of 33 patients undergoing the procedure. The single treatment failure occurred in a boy with acute myelogenous leukemia. In all other patients, local disease control following radiotherapy persisted throuthout the remainder of the clinical course. Three of 5 children, however, showed evidence of reseeding of the testicle as a part of the relapse process at post-mortem examination. Statistical analysis of data from the 35 patients with acute lymphocytic leukemia showed the subsequent course of the disease with respect to next relapse, involving either bone marrow (BM) or the central nervous system (CNS), to be dependent on the acute leukemia prognostic group, as determined by age and peripheral white blood cell count (WBC) at the time of diagnosis, and timing of extramedullary disease (EMD). Patients with poor prognosis at the time of diagnosis and EMD afterward had a 3.8 times greater risk of a subsequent BM or CNS relapse than did patients with good or average prognosis and no EMD at any time (P = 0.07). Of the candidate prognostic factors examined with repect to survival, only the number of prior BM relapses was of statistical significance (P = 0.044). Children with two or more prior BM relapses had the worst prognosis for survival from testicular relapse, with a death risk of 3.6 times greater per unit of time than that of children with no or one prior BM relapse. Protective BM and CNS rescue therapy was recommended for those otherwise in complete remission (CR) at the time of testicular relapse. The median times to next relapse for patients receiving both BM and CNS recue therapy and for patients given CNS recue only were 42+ and seven weeks, respectively ( P = 0.09). The type of rescue received did not appear to affect survival time following testicular CR.

Intergroup Ewing's Sarcoma Study: local control related to radiation dose, volume, and site of primary lesion in Ewing's sarcoma

One hundred ninety-three patients with localized Ewing's sarcoma treated at participating instutitions of the Intergroup Ewing's Sarcoma Study form the basis for this report. All patients received radiation therapy to the primary lesion and were randomized to receive vincristine, actinomycin-D, and cyclophosphamide (VAC) plus adriamycin (Regimen I); VAC alone (Regimen II); or VAC and bilateral pulmonary irradiation (Regimen III). Local control was achieved in 96% of the patients in Regimen I, and 86% of the patients in both Regimens II and III. The median duration of follow up was 83 weeks and median survival time was 172 weeks. Incremental doses of irradiation did not result in significant changes in the rate of local control of primary lesions. The local control rate was the same (92%) for tumors treated by means of whole-bone irradiation or with at least 5 cm of free margin around the lesion. The local control rate decreased to 79% for lesions treated with less than 5-cm margin. Excellent control was obtained for lesions involving the skull or spine (100%), and distal bones (fibula, 96% and tibia, 91%). Less favorable control rates were noted for pelvic and humeral lesions (84% and 79%, respectively). Bilateral pulmonary irradiation for subclinical disease played a role in lowering the incidence of lung metastases from 38% to 20% for patients treated with VAC. Lung metastases were similarly decreased (10%) when adriamycin was added to VAC chemotherapy.

Analysis of failures after definitive irradiation for epidermoid carcinoma of the nasopharynx

From 1955 to 1976, 111 patients were treated with definitive radiotherapy for epidermoid carcinoma of the nasopharynx. There was a definite correlation between recurrence at the primary site and T-stage; 9.5% of T1-2 patients, 38.1% of T3 patients and 54.1% of T4 patients had local recurrences. Similarly, failure in the neck correlated with N-stage, being negligible for N0 and N1 but 28.6% for N2 and 36.1% for N3. The incidence of distant metastases had no correlation with T-stage but correlated very closely with N-stage. The patients were grouped into four T and N categories, T1-2 N0-1, T1-2 N2-3, T3-4 N0-1, and T3-4 2-3. The five year relapse-free survival for the T1-2 N0-1 category was 69% but was only about 20% for each of the other three categories. The major cause of poor survival for the T3-4 N0-1 category was recurrence at the primary site, whereas for the T1-2 N2-3 and T3-4 N2-3 categories, it was the high incidence of distant metastases, approximately 50%. Recommendations are to increase dose at the primary site for T3-4 N0-1 patients and to institute clinical trials testing adjuvant chemotherapy for patients with neck stages N2 and N3.

Field shaping for electron-beam radiation therapy

A system for designing electron-beam treatment fields of any shape and size using the low-melting alloy Lipowitz's metal is described. An individualized shield is produced for each patient. The shields are designed to be mounted on any of the six cone sizes provided with the Varian Clinac 18 linear accelerator but should be adaptable to most accelerators which use cones for electron-beam collimation. Materials are reusable upon completion of treatment.

Effects of irradiation on mixed müllerian tumors of the uterus

A retrospective study of 54 patients with histologically proven malignant mixed müllerian tumors of the uterus was undertaken with main emphasis on the evaluation of the effects of irradiation on pelvic tumor control. The tumors were staged according to the FIGO classification for endometrial carcinoma and 24 were classified as Stage I, 10 as Stage II, 13 as Stage III and seven as Stage IV. Patients with Stage I and II were treated with surgery alone (9 patients, three surviving) or preoperative intracavitary irradiation (13 patients, eight surviving) or preoperative combination of intracavitary and external irradiation (12 patients, six surviving). Five patients with Stage III and IV were treated with surgery alone, two were treated with a combination of irradiation and surgery and 11 with radiation alone. None of these patients survived. In seven patients showing no residual tumor in the uterine specimen after irradiation, no pelvic failures were noted, whereas seven of 17 (41.2%) with residual tumor developed pelvic recurrences. In patients with Stage I treated with surgery alone, three out of six recurred in the pelvis whereas only three of 17 (17%) receiving preoperative irradiation developed pelvic recurrences. However, in Stage II six of eight patients treated with preoperative irradiation failed in the pelvis. Correlation with the doses of irradiation given to the uterus or the pelvic lymph nodes indicate that with doses below 5000 rads a significantly higher number of pelvic recurrences take place, whereas these are uncommon with doses over 6000 rads. The difference in pelvic recurrences between dosage levels is not, however, statistically significant. It is suggested that patients with Stage I and II malignant mixed müllerian tumors of the uterus should be treated with preoperative radiation and total hysterectomy with bilateral salpingo-oophorectomy. Patients with more advanced disease have extremely poor prognosis and should be treated with radiation therapy alone. This tumor has a high propensity to spread through lymphatics and hematogenous metastases are seen in approximately 75% of the patients. Because of this dissemination, significant improvements in survival rate will not be seen until effective cytotoxic agents are available.

Irradiation alone or in combination with surgery in stage IB and IIA carcinoma of the uterine cervix: A nonrandomized comparison

This is a report of a nonrandomized comparison of treatment results of 244 patients with stage IB carcinoma of the uterine cervix treated by radiation alone and 92 treated with preoperative radiation and surgery and 77 patients with stage IIA treated by radiation alone and 24 treated with a combination of radiation and surgery. The techniques of irradiation and types of operation are described in detail. The five-year tumor free actuarial survival for the patients with stage IB treated either with irradiation alone or combined with surgery was approximately 85% and the ten-year survival, 78%. For stage IIA the tumor free actuarial five-year survival without tumor was 73% and for ten years, 60%. In the 244 patients treated with radiation alone, there were ten central failures (4%) usually combined with distant metastasis. Further, 16 of these patients (6.5%) developed parametrial recurrence, in all but one instance associated with distant metastasis. In the 92 patients with stage IB treated with combined therapy, there were three local recurrences (3.8%), two of them combined with parametrial failures and six parametrial recurrences (6.5%), all of them concomitant with distant metastasis. Of the 77 patients with stage IIA treated by irradiation alone, there was one central recurrence alone and five local and parametrial recurrences, all of them associated with periaortic nodes or distant metastasis. Four additional patients had parametrial recurrences only concurrent with distant metastasis. Of the 24 patients treated with irradiation and surgery, there were two parametrial recurrences combined with distant metastasis (8.2%). There was no significant difference in the survival or recurrence rate of the patients treated with either method. In the group treated with combined therapy, patients with stage IB who showed evidence of microscopic residual tumor after irradiation had a failure rate of approximately 42% (8/18) in contrast to only 8.6% (6/70) in those with negative specimens. In stage IIA there were three failures in eight patients with residual tumor in the specimen in contrast to only two of 16 with negative specimens (12.5%). Major complications were comparable in both groups (radiation alone approximately 8.7% and irradiation combined with surgery approximately 14%), the difference is not statistically significant. The most frequent minor complication in patients treated with radiation alone was vaginal fibrosis (30 patients--9%) or vaginal vault necrosis (10 patients--3%).

Preliminary observations on the effect of glucan in combination with radiation and chemotherapy in four murine tumors

The efficacy of glucan in combination with local radiation therapy was measured using three solid murine tumors of differing abilities to induce a host defense. Using the KHT fibrosarcoma which induces no measurable host defense, glucan did not improve tumor-free survival over radiation alone; the combination produced a marginal improvement in tumor-free survival in animals bearing the highly immunogenic EMT-6 tumor. The most marked improvement in tumor-free survival was found with the mildly immunogenic 6C3HED lymphosarcoma. The efficacy of glucan in combination with BCNU chemotherapy was measured using the disseminated AKR transplantable leukemia; the combination yielded a high level of cures compared to no survival for either agent alone. Using the AKR transplantable leukemia in an F1 model, the effect of amphotericin B (AmB) alone or in combination with BCNU was tested. AmB or BCNU alone had little or no curative effect when tested in (AKR X DBA)F1 mice, but 56% of mice were cured when combined therapy was employed. When tested in (AKR X C57BL)F1 or (AKR X A)F1 mice, a small fraction was cured with AmB alone while about 90% were cured with either BCNU alone or the combination.

Efficacy of CT-assisted two dimensional treatment planning: analysis of 45 patients

A method is presented for quantitatively assessing the impact of CT assistance in treatment planning for radiation therapy. A three-phased analysis of treatment plans for 45 patients was undertaken. Nonuniformity and local efficiency of dose delivered were compared without and with the utilization of CT information. Good agreement between the objective assessment of treatment plans and independent subjective optimization of the plans by a radiotherapist support the validity of this technique. On the basis of nonuniformity of dose, 31 of the 45 cases were planned more poorly in the absence of CT information. The addition of CT information permitted optimization by the physician in 25 of the 45 patients. Twenty-three of these showed improved local efficiency (92%). This study indicates that measurable improvements in treatment plans are available by taking advantage of CT information. These were greatest in the brain, lung, and retroperitoneum in this small group of patients.