Ewing's sarcoma: a trial of adjuvant chemotherapy and sequential half-body irradiation

The results of a pilot study using adjuvant chemotherapy and sequential half-body irradiation (HBI) for nonmetastatic Ewing's sarcoma are presented. Seventeen patients received Cyclophosphamide, Vincristine, and Adriamycin (8 cycles), followed by sequential radiation treatment of the upper (500 cGy) and lower (600 cGy) half body. Survival at 3 years was 49%. These results are contrasted with those for 18 concurrently treated patients who received standard adjuvant therapy. Overall 5-year survival and relapse-free survival for these 35 consecutive patients was 61 and 53%. The pilot protocol was given on an out-patient basis with limited and acceptable acute toxicology. Further study is necessary to determine the value of the pilot protocol.

Postoperative local abdominal irradiation for cancer of the colon above the peritoneal reflection

A retrospective analysis of 82 patients with cancer of the colon above the peritoneal reflection who received postoperative local abdominal irradiation was undertaken to assess the survival, patterns of failure, and toxicity of treatment. Forty-eight patients (adjuvant group) had a complete resection, but were felt to be at high risk for local relapse and received postoperative local abdominal irradiation. Thirty-four patients had gross residual disease following surgery. The 5-year actuarial survival and local relapse free survival were 67 and 67%, respectively, in the adjuvant group. In this group, local relapse was observed in 9 of 28 patients with Stage C disease in contrast to 3 of 20 patients with Stage B2 disease; 1 of 14 patients with lesions in the right colon failed locally compared to 11 of 35 patients with lesions in the left. Only 2 of the 34 patients with gross residual disease remained relapse free from 93% of patients having a component of local failure. The majority of the treatment morbidity was seen in patients with gross residual disease. Prospective randomized studies should be done to determine the efficacy of postoperative irradiation in patients with colon carcinoma who are at high risk for local recurrence following surgical resection.

Radical radiation therapy with 5-fluorouracil infusion and mitomycin C for oesophageal squamous carcinoma

Thirty-five patients with clinically staged non-metastatic squamous carcinoma of the oesophagus were treated with radiation combined with mitomycin C, and 5-fluorouracil (5-FUra) infusion. Twenty patients were planned for a split course regimen 2250-2500 cGy in 10 fractions and chemotherapy. This dose of radiation to be repeated with another course of chemotherapy after 4 weeks rest. Fifteen patients were planned for a single course 4500-5000 cGy in 20 fractions and a single course of chemotherapy. Thirty-one patients are available for a minimum follow-up of one year, 26 patients for a minimum follow-up of 2 years. All 35 patients are included in the survival and local relapse-free analysis. Survival at one year is 47% and at 2 years 28%. The local relapse-free rate at both one and 2 years is 48%. There was an improvement in survival and local relapse-free rate for the single course regimen compared to the split course; 2 years survival 48% versus 12% (p = 0.24) local relapse-free rate 79% versus 27% (p = 0.07). All patients receiving radiation and chemotherapy were compared with historical controls treated by radiation alone. This matching procedure was done independent of knowledge of outcome (two controls were matched/case). Patients were matched for age, sex. TNM stage, and total radiation dose. There was a significant difference in survival p = 0.004 and local relapse-free rate p = 0.05 for patients receiving radiation and chemotherapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Carcinoma of the tonsil: the effect of dose-time-volume factors on local control

Between 1970 and 1979, 372 patients with squamous cell carcinoma of the tonsil were treated with primary irradiation therapy, with salvage surgery for failures. The median age was 60 years and the male to female ratio was 2:1. The staging system used was the 1974 UICC TNM system. There were 47 T1 lesions (13%), 161 T2 lesions (43%), and 164 T3 lesions (44%). Regional nodes were not palpable in 173 (46%); 122 had N1 nodes (33%), 6 had N2 nodes (2%) and 71 had N3 nodes (19%). All patients received external beam radiation which was supplemented in 68 patients with a radioactive implant for disease into adjacent tongue. The overall survival for all patients was 38% at 5 years and 54% when corrected for intercurrent disease. Local control was 87% for T1 lesions, 68% for T2 lesions and 50% for T3 lesions. Regional control was 96% for N0, 67% for N1 and 37% for N2-3. A detailed dose-time-volume analysis revealed that increasing volume improved local control in T1 and T2 lesions (77% had local control if the volume was greater than 80 cm2 versus 53% if the volume was less than 80 cm2, p = 0.014), except for T3 lesions. Increasing the dose in the range of 5000 to 6500 rad had no significant effect on primary control in any stage of disease. The addition of a radioactive implant did not increase local control if disease extended into the tongue (57% local control if implant, 52% if no implant). This study demonstrates the significance of adequate treatment volume in local control for carcinoma of the tonsil. No significant dose response was found and subsequent surgery was not compromised when a moderate dose of radiation was used.

Primary radiation therapy for juvenile nasopharyngeal angiofibroma

Evidence is presented of the effectiveness and relative lack of serious toxicity of external beam megavoltage radiation therapy (RT) as primary treatment for juvenile nasopharyngeal angiofibroma. The importance of careful radiological evaluation of tumor extent prior to irradiation is stressed, and only moderate dose RT is required. Fifty-five patients have been treated by RT and followed for from 3 to 26 years. Forty-four of 55 patients (80%) had permanent tumor control following a single course of 3000 cGy to 3500 cGy over 3 weeks. Surgical resection or a second course of RT controlled the tumor in all 11 patients in whom regrowth occurred. Angiofibromas involute slowly after RT so that 50% of patients still had visible masses in the nasopharynx 12 months after treatment, but only 10% had any visible abnormality 36 months after RT. Retreatment was necessary only if symptoms recurred, and continued follow-up showed that most asymptomatic nasopharyngeal masses resolved completely. Acute and late toxicity rates were low. Two patients developed tumors in the head or neck following RT. There was no significant clinical impairment of growth or endocrine function. A single course of external beam megavoltage radiation to 3000 cGy in 3 weeks is an effective first treatment for patients with juvenile nasopharyngeal angiofibroma.

Radiotherapy for unusual tumors of the head and neck

The role of radiotherapy is discussed relative to the management of juvenile nasopharyngeal angiofibroma, glomus tumors of the middle ear region, ameloblastoma, extramedullary plasmacytoma of the head and neck, and soft tissue and bone sarcoma. Moderate doses of carefully applied irradiation are effective and can be safely utilized for these conditions.

Adjuvant radiation therapy for rectal adenocarcinoma

Adjuvant pelvic radiation is intended to reduce the incidence of pelvic tumor recurrence and improve the survival rates of patients who have "curative" resections for adenocarcinoma of the rectum. The results of trials of preoperative radiation of up to 2500 cGy in two weeks have been disappointing. However, studies with preoperative or postoperative radiation doses of 4500 cGy in five weeks or more suggest that the risk of pelvic recurrence can be reduced to 15 per cent or less, although follow-up in most studies is too brief to allow any comment on changes in survival rates. These promising results need to be confirmed, since most were not obtained in appropriately controlled studies. Although these higher radiation doses do appear to be safe when attention is paid to surgical and radiotherapy techniques, this also needs to be confirmed with larger numbers of patients and longer follow-up. While the studies suggest that higher radiation doses are more effective than lower doses, there is no agreement on whether radiation should be directed to the region of the primary tumor only, or also to the pelvic lymph nodes, nor whether radiation should be given before or after surgery. Although the use of adjuvant pelvic radiation is becoming more widespread, these and other questions need to be answered before adjuvant radiation can be considered standard therapy.

Total abdominal irradiation for cancer of the colon

A retrospective analysis of 55 patients treated with whole abdominal irradiation following surgical excision for cancer of the colon is presented. Three groups of patients were given whole abdominal irradiation, eight with gross residual tumor following surgery, 17 with peritoneal seeding, and 30 who had complete surgical excision of the tumor but were felt to be at high risk for relapse. Only one of the eight patients with gross residual tumor, and one of the 17 with peritoneal metastases, are currently alive and well, with the majority dying from local or peritoneal metastases. The 5 year actuarial survival for the 30 patients irradiated following complete surgical excision is 55%. The treatment was well tolerated and few complications were observed. It is concluded that whole abdominal irradiation is ineffective for the treatment of colon cancer if peritoneal metastases are present, or if gross residual tumor is left behind following surgery. A randomized controlled clinical trial is being organized to test whether total abdominal irradiation is of benefit in terms of survival in high risk colon cancer patients following complete surgical removal.

The treatment of glomus tumors in the temporal bone by megavoltage radiation

Forty-five patients with glomus tumors in the temporal bone region were treated by radiation therapy. Only three patients had recurrence or progression of tumor during the follow-up period of 3 to 23 years (median, 10 years). No patient died from uncontrolled glomus tumor. The majority of patients noted symptomatic relief after radiation, but objective neurologic deficits usually remained unchanged or showed only partial improvement. The most commonly used radiation dose was 3500 cGy tumor dose delivered in 15 fractions in 3 weeks by a homolateral wedge technique from megavoltage radiation apparatus. This dose is less than that usually recommended for glomus tumors. From these results and from review of the literature, it is suggested that a moderate radiation dose of 3500 cGy in 3 weeks is effective treatment for glomus tumors, even if complete tumor involution does not occur.

Ameloblastoma of the jaw. A reappraisal of the role of megavoltage irradiation

Ten patients with ameloblastoma of the jaw were treated with megavoltage irradiation between 1958 and 1982. Seven cases were treated with radiation alone and six responded initially. One patient subsequently recurred and was successfully salvaged surgically. Three patients were treated with combined radiation therapy and surgery. Carefully applied megavoltage irradiation has a useful role in the management of ameloblastoma, particularly in large maxillary tumors with associated destruction of the infrastructure of the maxillary antrum. It is apparent from this series, and from the literature, that the ameloblastoma is not an inherently radioresistant tumor.

Results of radical radiation for chondrosarcoma of bone

A retrospective analysis has been made of 38 radically treated patients with chondrosarcoma of bone treated with irradiation alone or with concurrent chemotherapy (nine patients) at the Princess Margaret Hospital (P.M.H.) between 1958 and 1981. This includes updated data on previously reported patients. No patient had complete surgery. Tumours in axial sites (25/38 patients) and presenting with pain (25/38 patients) predominate; both well known poor prognostic factors. There is also a greater proportion with unfavourable histology (mesenchymal, poorly differentiated, dedifferentiated) (13/38 patients) compared to other series. The 5 and 10 year actuarial survival rate was 41% and 36% respectively with a median survival of 46 months. The best results were obtained in the group with favourable histology (well and moderately differentiated) with 48% 5 year actuarial survival versus 22% in the unfavourable subgroup. The progression-free survival of the favourable group was 13/25 patients versus 2/13 for the unfavourable group (p less than 0.01). Distant metastasis were rare in the patients with favourable histology (1/24) compared to 5/13 of the unfavourable group. Nine patients were given concurrent chemotherapy and irradiation. To date, only 1/7 patients with favourable histology and combined treatment have had progressive disease (follow-up 8-83 months). Only two patients with unfavourable histology received combined chemotherapy and irradiation and both have relapsed. In conclusion, there is evidence to suggest chondrosarcoma is not radioresistant and irradiation should be considered when surgery would cause major unacceptable morbidity or be technically impossible. Early evidence suggests there may be a role for chemotherapy to supplement the effects of irradiation.

Gracilis myocutaneous flap for reconstructing perineal defects resulting from radiation and radical surgery

When high-dose radiotherapy for carcinoma of the rectum, cervix, vagina or vulva fails and subsequent surgical excision by extended abdominoperineal resection or exenteration is performed, healing is often greatly delayed, for many months, and a scarred, deformed perineum results. The introduction of myocutaneous flaps opened up a new field for reconstruction of defects in a number of areas. The authors used a gracilis myocutaneous flap in 15 patients for primary reconstruction following surgical resection for failed radiotherapy of a primary carcinoma (of the rectum in 6, the cervix in 7 and the vulva in 2) and as a secondary procedure in 2 patients, 1 with an unhealed perineum 4 months after irradiation and extended abdominal resection for carcinoma of the rectum, and the other with extensive perineal necrosis following radiotherapy and chemotherapy. The operative technique, which is relatively simple, is described and illustrated. Since all patients had received radiotherapy, the myocutaneous flap was used primarily and successfully to reduce morbidity and healing time. However, even without radiotherapy, the deformity following exenteration is unacceptable and reconstruction by the method described should probably be planned as part of this operation. Not only can primary healing be expected, but the neovagina has a relatively normal appearance with satisfactory sensation and function.

Cancer of the tonsil: results of radical radiation therapy with surgery in reserve

Three hundred seventy-two patients with squamous cell carcinoma of the tonsil were treated with primary irradiation of curative intent. Surgery was saved for subsequent treatment failure. The overall survival was 38 percent at 5 years. Local control was 63 percent for all patients. T1 and T2 lesions were controlled in 87 percent and 68 percent of patients, respectively, and T3 lesions were controlled in 50 percent of patients. Patients with healthy (N0) nodes and those with mobile nodes had a high degree of regional control, but fixed nodes were controlled in only 37 percent of patients with radiation alone. The most common site of treatment failure was in the primary tumor, which accounted for 45 percent of relapses, and isolated nodal relapses were present in only 24 percent of patients. Subsequent surgery was possible in 47 percent of patients in whom initial treatment failed. A higher degree of subsequent control was obtained with more aggressive surgery compared with simple local resection. There was a high rate of second respiratory tract malignancy, in fact, after 2 years, patients were dying more commonly of their second respiratory tract malignancies than of cancer of the tonsil.

Management of early supraglottic laryngeal carcinoma by irradiation with surgery in reserve

The results of radical radiotherapy with surgery in reserve for 136 patients with stage T1 and T2 NO supraglottic laryngeal carcinoma seen during a 20-year period are analyzed herein. Approximately one half of all patients were alive and well five years after treatment, while one fifth of patients died of supraglottic cancer. The cancer in two thirds of these patients was locally controlled by irradiation; of particular note was an 11% to 18% recurrence rate in patients whose necks were initially noted to be free of cancer. Analysis of the results of irradiation treatment disclosed a major reduction in nodal recurrence from the use of irradiation fields larger than 7 X 7 cm (3%, as compared with 19% with a smaller irradiation field). During the 20-year period of the study, there was a major reduction observed in tumor-related deaths; this is attributed to the use of larger irradiation fields and more aggressive use of surgery for irradiation failures. The results obtained are compared herein with the results of primary surgery, and conclusions are drawn as to the optimal management of early-stage supraglottic cancer.

Chordoma: the results of megavoltage radiation therapy

Twenty-four patients with chordoma who received one or more courses of megavoltage radiation therapy following biopsy or incomplete resection were reviewed. The uncorrected survival rate at five years was 62%, and at 10 years was 28%, but most patients had clinically detectable residual chordoma present at the time of death or last follow-up. The duration of symptomatic improvement following irradiation ranged from a few months to 18 years, median 3.5 years. Detailed dose-time and symptomatic response data for 56 patients from this series and from the literature who were treated by conventional daily fractionated megavoltage irradiation show no convincing evidence that symptomatic relief is more likely after high doses than after total doses of only 4000 to 5500 cGy. Patients are rarely cured of chordoma by partial tumor resection and conventional radiation. Four patients received multiple fractions of 100 cGy each day either as retreatment for recurrence, or as initial treatment. Symptomatic responses, and decreases in the size of tumor masses, were seen following total doses ranging from 2000 cGy/20 fractions/5 days/4 X 3 hourly fractions each day to 4000 cGy/40 fractions/12 days/4 X 3 hourly fractions each day. The short duration of follow-up in these patients prevents comparison with conventional fractionation. However, this technique presents one possible new approach for the treatment of chordoma.

Symposium on the diagnosis and treatment of common cancers. 3. Colorectal carcinoma

Current efforts to reduce the morbidity and mortality of colorectal adenocarcinoma are directed mainly to earlier diagnosis and the development of effective surgical adjuvant treatment. The most generally available screening technique is the identification of fecal occult blood, but numerous false-negative and false-positive findings, and the large population at risk, suggest that more effective but time-consuming screening methods, such as endoscopy, should be reserved for high-risk groups. More extensive pelvic and para-aortic lymph-node dissections for rectal adenocarcinoma have not resulted in consistently improved survival rates. Radiotherapy reduces the frequency of pelvic recurrence when given as either preoperative or postoperative adjuvant therapy for rectal cancer but has not yet produced any major improvement in survival. No effective adjuvant chemotherapy for colorectal adenocarcinoma has yet been identified. Primary radiotherapy can control a proportion of rectal carcinomas and may reduce the need for colostomy in some cases.

Carcinoma of the hypopharynx results of primary radical radiation therapy

The results of radiation therapy as applied to patients with squamous cell carcinoma of the hypopharynx seen during the period 1972-1976 at the Princess Margaret Hospital are presented. Approximately 2/3 of the patient population presented with disease involving the regional lymph nodes or with systemic metastases. Ninety percent (127/141) of all patients registered were treated primarily with radiation therapy with surgery reserved for the management of residual or recurrent disease only. Seventy-seven percent (98/127) of those who received radiation therapy were treated with radical intent. The uncorrected actuarial 5 year survival rate for those patients treated radically was 19%. Five year actuarial survival rates by the UICC TNM (1974) staging system, showed that nodal disease was the most significant determinant of survival. Five year survival rates were as follows: N0 36%; N1 20%; N2N30%. When considered within each nodal category the survival of the combined T1T2 group was not significantly different from the T3 category. Forty-five percent of those patients who failed with local or regional disease had an attempt at salvage surgery. Of these, 6/24 ultimately achieved local and regional control. Comparisons with other series in the literature are discussed and reasons for differences in published results are considered.

Supraglottic laryngeal carcinoma: an analysis of dose-time-volume factors in 410 patients

Four hundred and ten patients with supraglottic laryngeal carcinoma treated with moderate dose radical radiotherapy with surgery for salvage (RRSS) were analyzed in detail to determine optimal dose-time-volume parameters to be used in the treatment of each stage of supraglottic carcinoma. In the RRSS group 41% are alive and well at 5 years, 38% died of their tumor and 21% of intercurrent disease. Presence or absence of nodal disease has a major impact on survival. Local control is approximately 70% in T1, T2N0 patients and approximately 50% in T3 and T4N0 patients. Seventeen percent of T1 and T2N0 patients failed in the initially negative neck. Ten major complications (2.4%) have been seen. Local control by irradiation was not influenced by dose or field size. Regional control in the initially negative neck was markedly increased with the use of larger irradiation field sizes. Field sizes of less than 7 X 7 cm resulted in an 18% neck failure rate as compared to 3% with larger field sizes (p = 0.00005). This particularly applied to early stage disease. As a result of the use of larger irradiation field sizes giving reduced neck failure rates, improvement in survival has been seen in early stage supraglottic patients. The results are compared with published results. There is no statistically significant dose response curve in any stage of supraglottic cancer over the dose range 1650-2300 ret. Optimal treatment factors for supraglottic cancer are discussed.

0-7-21 radiotherapy in nodular melanoma

Fifty-four patients from August 1975 to March 1980 were treated with high dose per fraction (0-7-21) radiotherapy for malignant melanoma. The patients were subdivided into three clinical subtypes of disease: microscopic residual melanoma following surgery (22 patients), gross residual melanoma following surgery (nine patients), and recurrent melanoma (23 patients). Eighteen of 22 (82%) of patients treated for microscopic residual disease have been free of local recurrence to date. Ten of the 18 are alive and free of disease for up to 44 months following irradiation. Seven of nine (78%) patients treated for gross residual tumor have had no recurrence or progression of tumor in the irradiated volume, five of the nine achieved a complete remission and three are alive and free of disease at ten, 13, and 42 months, respectively. Twenty-three patients with recurrent melanoma were irradiated. Nine achieved a complete remission (39%) of tumor in the irradiated volume and three are alive and free of disease at up to 56 months following irradiation treatment. Three major complications of irradiation have been seen in the 54 patients treated. It is concluded that nodular melanoma is not a radioresistant tumor, large dose per fraction radiotherapy produces a high response rate of patients with measurable disease which is prolonged in some patients. The indications for radiotherapy in nodular melanoma are discussed and prospective studies of irradiation in melanoma are proposed.

Radical external beam radiation therapy for adenocarcinoma of the rectum

External beam megavoltage radiation therapy was used as primary treatment for 123 patients with rectal adenocarcinoma. Surgery was undertaken for some patients who had residual tumor. The overall five-year survival rate was 21 per cent. When patients were separated into those who presented with clinically mobile and those with clinically fixed rectal tumor masses, the survival rates were 38 per cent and 2 per cent, respectively. The primary tumor was controlled by radiation alone in 21 of 56 (38 per cent) patients who had mobile tumors but in only six of 67 (9 per cent) patients who had fixed tumors. Further investigation of high-dose primary radiation, with surgery reserved for patients with residual rectal carcinoma, may allow reduction of the number of patients who require abdominoperineal resection.