[Postoperative radiotherapy of rectal carcinoma]

In the last 40 years, radiotherapy as gained a major role in the curative treatment of rectal carcinoma. Based on a reported incidence of local failure after surgery between 15% and 50%, in patients with T3-4 rectal cancer, postoperative radiation has been proposed in this group of patients. However, postoperative radiotherapy results associated with a relatively high incidence of acute and late toxicity and the reported improvement in local control attained statistical significance only in the MRC randomized trial. A recent publication suggests that postoperative radiation should probably be reserved to the subgroup of pT3 patients with unfavourable features. Postoperative radiation therapy is considered also for patients with G1-2 carcinoma treated with local excision, who do not show lymphatic or venous invasion, and for those with pT2 stage or pT1 carcinoma with involved resection margins.

Interphysician variability in defining the planning target volume in the irradiation of prostate and seminal vesicles

With the improvements in treatment accuracy the risk exists of over-reliance on the capability of the physician to estimate the extent of the tumour. We assessed the variability between six radiotherapists in defining the planning target volume (PTV) on CT slices for three prostate tumour cases. Percentage differences between measured volumes and mean values calculated for each case ranged from -53.64 to +60.48% (SD 36.00%). There is a considerable variation in delineating the PTV, both in the cranio-caudal direction and in the in-slice extension of the areas drawn on each slice (standard deviations ranged from 0.35 to 2.64 cm2). We also checked the uncertainty in the shape and position of the contours on each CT image. The analysis was performed on three slices of one test case. As we expected, the uncertainty seems largest for seminal vesicle slices and smallest for prostatic apex slices. These results endorse the need for uncertainty analysis of all departmental processes in order to define a detailed protocol and consequently to minimize the interphysician differences in PTV delineations.

Radiological findings when very small lung volumes are irradiated in breast and chest wall treatment

Acute pneumonitis following breast irradiation is a rare and transient phenomenon that can be easily managed by drugs. The aim of this study is to evaluate late sequelae on lung, after postoperative radiotherapy (RT) for breast cancer. We were concerned with investigating late radiological findings when very small lung volumes are involved in the irradiated volume. We studied 28 consecutive patients. They underwent clinical examination and all staging procedures before surgery, evaluation of pulmonary function with spirometry, postoperative chest x-ray and high resolution computed tomography (HRCT) of the lung before RT. Clinical examinations were usually performed every 3 months after RT. A second chest x-ray, HRCT and spirometry were carried out after nearly 7 months from the end of RT. We estimated the irradiated lung volume by measuring the area of the lung surface enclosed by the 50% isodose (LA50) in each profile. We found a significant correlation between LA50 and the score of radiological findings after RT. No correlations were found between other factors (i.e., adjuvant chemotherapy, age, weight, smoking) and lung fibrosis. No woman developed radiation pneumonitis syndrome or respiratory symptoms. Our results indicate that irradiation of the breast and/or chest wall is well tolerated if treatment planning is done accurately. The fibrosis likelihood is strongly correlated to the irradiated lung volume. The use of tangential fields limits radiological changes that can be detected only by HRCT examination and are not associated with clinical symptoms.

[Exclusive irradiation of clinically localized prostatic carcinoma: comparison with various techniques]

The frequency of prostate cancer is on the increase and many intracapsular tumors are diagnosed in asymptomatic and relatively young patients. Radiotherapy is an effective alternative to surgery when the technique which reduces the rate of acute reactions and late side-effects is chosen. On the other hand, dose distribution on the target volume and dose delivered to surrounding tissues (rectum and femoral heads) depend on several variables, namely irradiation technique, treatment planning simulation procedures and study and patient positioning. 5 by 5 mm CT studies of the prostate and/or seminal vesicles and the execution of retrograde urethrography to define the prostatic apex plan are essential steps of the simulation procedure. To compare the adequacy of various techniques, we analyzed several isodose distribution maps of nonconformational treatments, calculated by our radiotherapy planning system on the central slice. Arc and multiportal (3 or 4 fields) techniques were considered. The statistical analysis of our results demonstrated that the 4-field perpendicular technique permits better dose distribution to the target volume than the 3-field perpendicular technique; it also reduces the dose to the femoral heads. However, a combination of anterior irradiation with two oblique posterior fields is preferred in hip prosthesis patients. The comparison between arc and static multiportal techniques shows that the former gives a markedly lower dose (up to 50%) to posterior rectal wall. The bilateral arc appears to be the best technique, especially when the patient restraining device is good, because it permits homogeneous irradiation of the target volume, even at high doses, and marked reduction of the dose to the posterior rectal wall and femoral heads; consequently, treatment morbidity is lower.

An ICRU 50 radiotherapy treatment chart

We illustrate a radiotherapy treatment chart elaborated to fulfil the necessity for clarity in reporting information about radiotherapeutic treatment. The schematic configuration of the chart results from the experience and the cooperation of physicists, physicians and technicians, and an effort has been made to satisfy Levels 2/3 of the ICRU 50 recommendations. The chart has been divided into four sections corresponding to different kinds of information: a cover sheet, a section containing data about the treatment planning geometry and the console parameters adopted, a section showing dosimetric data, and a section showing treatment data. The chart seems to give a good level of accuracy in reporting treatment plan information.

Evaluation of most frequent errors in daily compilation and use of a radiation treatment chart

Between 1 March and 30 April (1994) we recorded the errors detected by the physician, the radiographer or the physicist during prescription, preparation and execution phases of 227 treatment plans. The radiation treatment modalities used were the following: (i) single or opposed fields, moulded or not; and (ii) multiple fields or kinetic techniques. The total number of sessions performed is 1613 with the cobalt unit and 2131 with the linear accelerator (total, 3744). The total number of wrong data is 155, consisting of 24/227 (10.5%) in compilation, 22/3744 (0.58%) in execution and 109/3744 (2.9%) in registration phases. The number of missing data is 140, consisting of 10/227 (4.4%) in compilation, 9/3744 (0.2%) in execution and 121/3744 (3.2%) in registration phases. Wrong data of compilation, even if in high rate (10.5%), were all found during the same compilation phase or at the first treatment, so that they did not alter the exactness of the treatment plan. Wrong and missing data, found in the registration phase (2.9% and 3.2%, respectively), depend on the repetition of daily treatment and on the registration of data on the chart after having digitized them on the display.

A cooperative study on ProMACE-CytaBOM in aggressive non-Hodgkin's lymphomas

Chemotherapy using cyclophosphamide, doxorubicin, etoposide, cytarabine, bleomycin, vincristine, methotrexate with leucovorin, and prednisone (ProMACE-CytaBOM) for patients with intermediate or high grade non-Hodgkin lymphomas (G, H and K according to the Working Formulation), was tested by the Gruppo Cooperativo Lombardo to confirm the activity of the regimen and to test the feasibility and safety of administering third-generation drug regimen in a cooperative group setting. Among 64 previously untreated patients, aged between 20 and 71 years, 7 had stage IB-IIB, 12 had stage IIIA-B, 45 (67%) had stage IVA-B. There were 44 complete remissions (CRs) (69%) and 14 partial remissions (22%); the difference between patients in stage I-II-III (84% complete remissions) and those in stage IV (62% complete remissions) was statistically significant. The median length of follow up was 20 months (range 1-60 months), with 56% of patients alive at 60 months and 53% of CRs patients free of disease at 60 months. Patients in stage I-II-III have the best survival and disease free survival compared to stage IV, 87% versus 42% and 72% versus 32% respectively (both with high statistical significance). Grade 3-4 (WHO) haematological toxicity was observed in 39% of patients, with 3 septic deaths. Two more patients died with chemotherapy related toxicity (1 stroke and 1 acute renal insufficiency). Administration of ProMACE-CytaBOM is a feasible and safe regimen although it presents moderate toxicity. ProMACE-CytaBOM may represent improved treatment for aggressive lymphomas, in terms of duration of response and survival, but a longer follow up is needed.

[The irradiated volume in stage III non-small-cell carcinoma of the lung. Comparison of outdated and new techniques]

March 1988 through April 1992, three hundred and ninety-six patients affected with bronchogenic carcinoma were treated at the Department of Radiation Oncology of the S. Anna Hospital, Como, Italy. A hundred and ten patients presenting stage-III non-small-cell lung carcinoma were evaluable. All evaluable patients underwent radiation therapy alone, with either palliative or curative purposes. Two main periods can be distinguished: in period A, before June 30th, 1990, treatment planning included conventional techniques, with no simulators; the patients were treated with opposing anteroposterior fields only. In period B, after July 1st, 1990, either the simulator alone was used or a simulator, a CT unit and a treatment planning computer system were combined; anteroposterior opposing fields or multiportal technique were used. Median overall survival was 10 months. Independent of treatment goals, the irradiated volume was markedly different in the patients treated in period A than in those treated in period B. A marked and statistically significant increase in survival was observed in group B. Survival also increased in patients treated with doses > 40 Gy, but only if treatment planning had used adequate technology and accuracy. To conclude, better survival can be achieved only by improving treatment accuracy and quality.

[Results of radiotherapy of supraglottic laryngeal carcinomas observed at the Division of Radiotherapy of the District Hospital of Varese]

The authors review the supraglottic laryngeal carcinomas examined in the Radiotherapy Department of the "Ospedale Regionale" of Varese, Italy, from 1979 to 1984. 255 patients have been monitored: 80 considered for radiotherapy alone and 77 for postoperatory radiotherapy treatment. The cumulative actuarial survival (pcs) after 60 months, for patients treated only with radiotherapy, is 0.66 +/- e.s. 0.07; for patients treated with post-operatory radiotherapy the cumulative actuarial survival (pcs) after 60 months is 0.49 +/- e.s. 0.11. The irradiation techniques are described and the results achieved fully discussed.

[Initial therapeutic evaluations of 141 patients with carcinoma of the breast under 40 years of age]

The Authors, considering 141 cases of patient women under 40, suffering from breast cancer, analyse the prognostic factors in relation to the different therapeutical approach, histologic type, dimensions of T, and presence or absence of metastases at the axillary lymph nodes. They, moreover, appraise the actuarial global survival with no disease (NED) of this group of patients as compared with the survival of women in more advanced age.