Combined preoperative and postoperative radiation for bladder cancer. Results of RTOG/Jefferson Study

Ninety-two patients with bladder cancer have been treated with combined pre- and postoperative radiation in a Radiation Oncology Study Group (RTOG) Phase I-II study and at Thomas Jefferson University Hospital. Patients with invasive bladder cancer were entered into the study and given low-dose preoperative radiation (500 rad) to the whole pelvis, either on the day of or the day before cystectomy. Following surgery, patients were pathologically staged. Patients with stage B1 (T2) (grade 3 or 4), stage B2 and C (T3) tumors were given 4500 rad in 5 weeks postoperative radiation. Follow-up in the study ranges from a minimum of 24 months to 5 years, with a median of 36 months. Incidence of complications was 15% (14/92). The 4-year actuarial survival (Kaplan-Meier) by stage of disease is 68% for stage B1 (T2) (grade 3 or 4), 78% for stage B2, and 57% for stage C. These survival results appear to be better than those obtained with other approaches of adjuvant therapy and/or surgery in comparable histopathologically staged patients.

Is dose/time fractionation important in treating rectal cancer?

In a study to evaluate the effect of increasing dose per fraction on radiation response in rectal cancer, two groups of 29 patients each, matched for extent and size of disease, were evaluated. Group A was treated with conventional dose/fraction (180-200 cGy) X 5 days/week and Group B was treated with 250 cGy/fraction X 4 days/week. Total dose was reduced by 10% in Group B patients to allow comparison of biologically equivalent doses. Two categories of patients were analyzed in each group: patients receiving planned high dose preoperative radiation (4000-4500 cGy); and patients receiving high dose radiation for post-surgical recurrent tumors or locally advanced inoperable tumors (5500-6000 cGy). Tumor regression was markedly better in patients treated with the 250 cGy/fraction. Overall response (greater than 50% regression) was 35% (10/29) in Group A and 62% (18/29) in Group B. Nine of 10 patients in Group B, treated preoperatively, had greater than 50% regression in tumor size, with two patients having no evidence of disease on surgico-pathological evaluation. Six of 10 similar patients in Group A had greater than 50% tumor regression.

Results of adjuvant radiation therapy in cancer of the rectum. Thomas Jefferson University Hospital experience

From 1972 to 1981, 174 patients with cancer of the rectum surgically staged as B2 or C disease, underwent surgical resection of the tumors for cure. Eighty-eight patients received surgery only with no further adjuvant therapy, and the remaining 86 patients were treated with a combination of radiation and surgery. Twenty-nine patients received low-dose preoperative radiation (500 rad in one fraction); 26 patients received postoperative radiation (4500 rad in 5 weeks); and 31 patients received combined low-dose preoperative radiation (500 rad) and postoperative radiation (4500 rad in 5 weeks). This experience was analyzed to determine the patterns of failure and the impact of adjuvant therapy on survival. Patients undergoing surgery alone had a 26% incidence of local failure in the pelvis and a 57% incidence of distant metastasis. Patients receiving low-dose preoperative radiation had a reduction in the rate of distant metastasis (24%), but no effect on local failure (34%). On the other hand, patients receiving postoperative radiation had a reduction in the local failure rate (11%), with no effect on distant metastasis (50%). Patients who received the combined preoperative and postoperative treatment had a reduction in both the local recurrence rate (7%), and the rate of distant metastasis (13%), and these patients also had a substantial improvement in survival over surgery alone. Survival of patients undergoing surgery alone was 34% at 5 years and was not substantially different for patients undergoing low-dose preoperative irradiation (48%), or for patients receiving postoperative irradiation (29%). Survival in patients receiving combined preoperative and postoperative irradiation was substantially better (78%) than the other groups of patients.

Radiotherapy of stage I and II Hodgkin disease with inguinal presentation

Seventeen patients who presented with inguinal adenopathy were found to have stage I or II infradiaphragmatic Hodgkin disease. Sixteen were treated with an inverted-Y field (supplemented by mantle irradiation in 3) and 1 had irradiation of the involved field only. Two patients with stage IIB disease also received MOPP chemotherapy. Fifteen patients currently have no evidence of recurrence; one died of acute myelogenous leukemia 6 years after total nodal irradiation, while another died of cardiopulmonary disease but had no evidence of Hodgkin disease at autopsy. In one patient, progressive peripheral atherosclerosis developed in an irradiated inguinal area, requiring angioplasty. Patient characteristics and results of treatment are analyzed and implications for management presented.

Multimodality therapy of localized unresectable pancreatic adenocarcinoma

Eighty-eight patients with localized unresectable carcinoma of the pancreas were treated at Thomas Jefferson University Hospital between 1974 and 1981. Four treatment regimens were used which were sequential modifications of the technique based on the experience in the preceding group of patients. Each treatment changed the course of the disease, and as patterns of failure were identified, the treatment was altered to deal with them. Initially, all patients were treated with external beam radiation. Subsequently, Iodine-125 implantation was added to improve local control; low-dose preoperative radiotherapy to reduce the risk of peritoneal seeding; and adjuvant chemotherapy to reduce the risks of distant metastases. The addition of 125I implantation increased the local control from 22% to 81%, but did not increase the median survival, which was unchanged from 7 months. The addition of adjuvant chemotherapy increased the median survival from 7 months to 14 months, but had no impact on the control of the pancreatic tumor. Adjunctive chemotherapy and low-dose preoperative radiotherapy appear synergistic in reducing the risk of peritoneal seeding. The combination of 125I implantation, external beam radiation, and adjunctive chemotherapy is safe and effective. This regimen produces excellent local control with acceptable morbidity. This regimen produced a 30% survival at 18 months. The patterns of failure among these patients suggest future modifications of the technique.

Adjuvant radiation therapy for rectal cancer

Since 1976, 104 patients with rectal cancer have been treated with a new approach of combined pre- and postoperative radiation. All patients were given 500 rad preoperative irradiation on the day of or the day before surgery. Surgery in the majority of patients was an abdominal perineal resection. The disease was then staged pathologically according to Astler-Coller's modification of Duke's staging. Patients with early stage cancer (Stages A and B1) were followed with no further therapy. Patients with poor prognostic characteristics (Stages B2, C1, C2) were given postoperative pelvic irradiation (4500 rad in 5 weeks). Twenty-nine patients were found to have Stage A or B1 cancer and were followed with no further therapy. Of these 29 patients, 1 patient developed recurrence and one has died of metastatic disease. The excellent survival of patients with early tumors indicates that minimizing the role of adjuvant therapy in this group has not been detrimental to their survival. Fifteen were found to have liver metastases at laparotomy and had just a colostomy and palliative therapy. Sixty patients had Stage B2 and C disease. Thirty-one received postoperative irradiation as per protocol. Twenty-nine patients did not receive postoperative irradiation for a variety of reasons. Follow-up ranges from 1 to 7 years in these patients. Of the 29 patients with Stage B2 and C disease who should have but did not receive postoperative radiation, 10 patients (34%) have developed a recurrence in the pelvis, and 5 other patients (17%) have developed metastatic disease. Of 31 patients who received postoperative irradiation, only 2 patients (6%) developed a local recurrence and 4 patients (13%) have developed distant metastases. Survival at 3 years was 80% for patients receiving the combined treatment, as compared to 42% for those not receiving the postoperative part of the treatment protocol.

Rectal cancer: extent of disease and radiotherapeutic effects by computed tomography

The CT scans of 54 patients with carcinoma of the rectum were studied in an attempt to assess the value of computed tomography in the initial evaluation and therapeutic management of these patients. Thirty-five of the examined patients received full dose preoperative radiation therapy for sphincter preservation purposes, and had two or more computed tomography studies to delineate the progression of the disease and the response to radiotherapy. In 70% of these patients, changes in tumor size were demonstrated. Various aspects in the CT diagnosis of the primary or recurrent tumor extent, distant metastatic spread or involvement of surrounding tissues are discussed.

Preliminary results of RTOG phase I/II study of misonidazole and radiation for bladder cancer

Eleven patients were entered in a phase I/II study to evaluate the toxicity and effectiveness of the use of misonidazole with radiation in cancer of the bladder. The radiation fractionization used is shown in Figure 1. Misonidazole was administered in a dose of 1.5 g/m2, 4-6 hours before the radiation dose. The large radiation dose (400 rad) used with misonidazole was designed to obtain maximum enhancement of radiation sensitizer effect. Only minor misonidazole toxicity was observed. Tumor regression was dramatic, with 7/9 patients achieving complete regression of disease. Three patients however, developed severe small bowel complications, probably from the unconventional radiation fractionation used. In view of this high complication rate, this study was terminated.

Combined pre- and postoperative adjuvant radiotherapy for bladder cancer

Thirty-nine patients with invasive bladder cancer were treated using a new approach to adjuvant radiation therapy. All patients had histologic evidence of bladder muscle invasion on biopsy and were considered suitable for surgical resection. Low-dose preoperative radiation (500 rad) was delivered either on the day of or the day before cystectomy. In most instances, a radical cystectomy was performed and patients were then stratified according to pathologic stagings. Those patients with pathologically good prognostic indicators, Stage B1 low grade (I or II) disease, were followed up with no further treatment. Patients at high risk for local recurrence and pelvic lymph node involvement, Stages B1 high grade (III or IV), B2, and C, were given aggressive postoperative radiation (4,500 rad in five weeks). Patients with advanced disease, Stage D2, were given palliative therapy. All patients received the dose of preoperative radiation as planned. Preliminary results indicate that combined pre- and postoperative radiation in bladder cancer gives excellent local control of disease. A significant potential for improved long-term survival of patients has been observed.

Combined pre and postoperative radiation for carcinoma of the rectum

Since 1976, a new approach to adjuvant radiation therapy in carcinoma of the rectum has been used at Thomas Jefferson University Hospital. Seventy-eight patients with biopsy-proven invasive carcinoma of the rectum have been treated with low dose preoperative radiation, 500 rad given either on the day of or the day before surgery. Following surgery, the lesions were pathologically staged according to Astler-Coller's Modification of Duke's staging. Patients with good prognostic features (Stage A or B1) were followed with no further treatment while patients with poor prognostic characteristics (Stage B2, C1 and C2) were treated with aggressive postoperative pelvic radiation, 4500 rad delivered in five weeks. All patients entered into this study received the preoperative dose of 500 rad. Fifty-six patients underwent an A-P resection, four patients underwent a low anterior resection and ten patients had a combined abdominal transsacral resection. Eight patients were found to have liver metastasis at laparotomy and underwent a colostomy followed by palliative therapy. Twenty-nine patients were found to have early disease, Stage A or B1, and were given no further therapy. Of 41 patients with Stage B2 or C, 25 patients received the full course of postoperative radiation. Sixteen patients did not receive postoperative radiation for a variety of reasons. Follow-up in these patients ranges from six months to a maximum of 48 months with a median follow-up of 18 months. Sixty-nine of the total group of 78 patients are currently alive. Two patients with early tumor (Stage A or B1) have died of metastasis. One other patient with Stage A carcinoma died of unrelated causes. Two of the 25 patients receiving postoperative radiation developed metastatic disease, but none of the patients developed local recurrence in the pelvis. Six of 16 patients who should have received postoperative radiation, but did not recurred. Four of these six recurrences have been in the pelvis. Both the incidence of failure and the pattern of recurrence between these two groups of patients who did not receive postoperative radiation is suggestive of a better effect in the PR unrelated group. Survival of patients treated with this approach appears to be improved.

Combined pre- and postoperative adjuvant radiotherapy for bladder cancer: results of RTOG/Jefferson Study

This paper presents the results of adjuvant "sandwich" radiotherapy for bladder cancer in 65 patients treated in a Radiation Therapy Oncology Group (RTOG) phase II study and at Thomas Jefferson University Hospital. In this approach of adjuvant therapy, patients with clinical stages B or C bladder cancer were given low dose preoperative irradiation (500 rads) to the whole pelvis on the day before or on the day of surgery. Following cystectomy, patients were pathologically staged. Those with high grade (III or IV) stage B1 tumors or stages B2 or C were given 4500 rads in five weeks postoperative radiation. Thirty-four of these 65 patients were entered in the RTOG protocol and 31 in the Jefferson Study. TWenty patients had early lesions (stage 0, A or B1, grade I-II) and did not receive postoperative irradiation. Six patients had stage D cancer and were given palliative therapy. Of 39 patients eligible for postoperative irradiation, 29 received the full course of pre- and postoperative irradiation. Ten patients did not receive treatment. Follow-up ranged from six months to three years with a median of 18 months. Treatment was extremely well tolerated. Incidence of major complications was 6% (4/65). Local control of disease was excellent, with no failures in pelvis response. Actuarial survival at three years is 78%. At this preliminary analysis, these survival results appear to be better than those obtained with other approaches using preoperative irradiation and surgery.

Adjuvant radiotherapy with selective sandwich technique in treatment of rectal cancer: results of a continuing study

Sixty-two patients with carcinoma of the rectum were treated with "selective sandwich" adjuvant radiotherapy in a pilot study which began in September 1976 at Thomas Jefferson University Hospital. All patients received 500 rads preoperative irradiation on the day of or day preceding surgery. Following surgery, the lesions were staged pathologically according to Astler-Coller's modification of Dukes' staging. Patients with poor prognostic characteristics (Stages B2, C1, and C2) were treated with aggressive postoperative pelvic irradiation (4500 rads in five weeks). All 62 patients received the single preoperative dose of 500 rads. Forty-four patients underwent abdominoperineal resection, four patients, a low anterior resection, ten patients, a combined abdominotranssacral resection, and four patients found to have liver metastasis at laparotomy had colostomy followed by palliative therapy. Twenty-one patients found to have early disease (Stages A or B1) were given no further therapy. Of 37 patients with Stages B2 or C disease, 21 received postoperative irradiation. Follow-up ranged from 6 months to 36 months, with a median of 18 months. Of patients with Stage A or B1 disease, one patient has died with metastasis. Two of 21 patients receiving postoperative irradiation have developed metastatic disease; neither has failed in the pelvis. Of 16 patients who did not receive postoperative irradiation, three have had metastasis to the pelvis and two others have developed distant metastasis.

Adjuvant "sandwich" radiation therapy for bladder cancer

Preliminary results of a study using a new concept of adjuvant "sandwich" radiotherapy in bladder cancer are presented. In this approach low-dose preoperative irradiation (500 rads) is delivered prior to cystectomy, and then on the basis of histopathologic staging patients with superficial tumors (Stage A and B) are followed with no further treatment; patients with deeply invasive tumors (Stage B, Grade III or IV, B2 or C) are treated with high-dose postoperative irradiation (4,500 rads in five weeks); and patients with advanced or metastatic disease (Stage D) are treated palliatively. Eighteen patients were treated with this approach, and all patients have been followed for at least one year. Sixteen (89 per cent) are alive with no evidence of tumor. One patient died of distant metastasis, and 1 patient died of peritonitis without evidence of disease. Since recurrence is known to develop in 50 per cent of patients within the first year after treatment, the low rate of failure obtained using this approach of adjuvant "sandwich" radiotherapy with a minimum follow-up of one year appears to be promising. This approach ideally balances the risk versus benefit ratio of adjuvant therapy sparing patients with superficial tumors from unnecessary treatment while treating patients with more advanced disease aggressively.

Optimum fractionation for irradiation of carcinoma of the bladder. Experiments based on one case

A patient with multiple metastases of transitional cell carcinoma of the bladder to the skin and subcutaneous tissues proved a model where most of the biologic and host-related factors were constant. The effects of varying the physical factors of radiation dose and time were observed. The results indicate that fractionated irradiation at intervals of 48 h was more effective than at intervals of 24 h and that superfractionation (intervals of 5 h) was not an effective method for the treatment of this tumor. The possible reasons for this effect and the implication for the treatment of bladder carcinoma are discussed.