Is volumetric modulated arc therapy with constant dose rate a valid option in radiation therapy for head and neck cancer patients?

Background

Intensity-modulated radiotherapy (IMRT) improves dose distribution in head and neck (HN) radiation therapy. Volumetric-modulated arc therapy (VMAT), a new form of IMRT, delivers radiation in single or multiple arcs, varying dose rates (VDR-VMAT) and gantry speeds, has gained considerable attention. Constant dose rate VMAT (CDR-VMAT) associated with a fixed gantry speed does not require a dedicated linear accelerator like VDR-VMAT. The present study explored the feasibility, efficiency and delivery accuracy of CDR-VMAT, by comparing it with IMRT and VDR-VMAT in treatment planning for HN cancer.

Methods and materials

Step and shoot IMRT (SS-IMRT), CDR-VMAT and VDR-VMAT plans were created for 15 HN cancer patients and were generated by Pinnacle³ TPS (v 9.8) using 6 MV photon energy. Three PTVs were defined to receive respectively prescribed doses of 66 Gy, 60 Gy and 54 Gy, in 30 fractions. Organs at risk (OARs) included the mandible, spinal cord, brain stem, parotids, salivary glands, esophagus, larynx and thyroid. SS-IMRT plans were based on 7 co-planar beams at fixed gantry angles. CDR-VMAT and VDR-VMAT plans, generated by the SmartArc module, used a 2-arc technique: one clockwise from 182° to 178° and the other one anti-clockwise from 178° to 182°. Comparison parameters included dose distribution to PTVs (D_mean, D_2%, D_50%, D_95%, D_98% and Homogeneity Index), maximum or mean doses to OARs, specific dose-volume data, the monitor units and treatment delivery times.

Results

Compared with SS-IMRT, CDR-VMAT significantly reduced the maximum doses to PTV1 and PTV2 and significantly improved all PTV3 parameters, except D_98% and D_95%. It significantly spared parotid and submandibular glands and was associated with a lower D_mean to the larynx. Compared with VDR-VMAT, CDR-VMAT was linked to a significantly better D_mean, to the PTV3 but results were worse for the parotids, left submandibular gland, esophagus and mandible. Furthermore, the D_mean to the larynx was also worse. Compared with SS-IMRT and VDR-VMAT, CDR-VMAT was associated with higher average monitor unit values and significantly shorter average delivery times.

Conclusions

CDR-VMAT appeared to be a valid option in Radiation Therapy Centers that lack a dedicated linear accelerator for volumetric arc therapy with variable dose-rates and gantry velocities, and are unwilling or unable to sanction major expenditure at present but want to adopt volumetric techniques.

Long-term results of induction chemotherapy followed by concurrent chemotherapy and thoracic irradiation in limited small cell lung cancer

BACKGROUND

Small cell lung cancer (SCLC) is a chemoresponsive tumor but overall survival remains poor even in limited disease (LD). With the aim of eradicating chemoresistant tumor cells and reducing toxicity, we investigated in this phase II trial the feasibility and outcome of a sequential approach of induction chemotherapy (CT) followed, in responding patients with LD-SCLC, by intensified platinum-based CT and concurrent thoracic irradiation (TI).

MATERIALS AND METHODS

We treated 55 consecutive LD-SCLC patients with three 21-day cycles of cyclophosphamide, epiadriamycin and vincristine (CEV) as induction CT. In 44 (80%) patients there was an objective response and they received treatment intensification consisting of TI and concomitant CT with carboplatin and etoposide plus recombinant granulocite colony stimulating factor. Twenty-five (57%) patients were submitted to twice-daily thoracic irradiation (TDTI; 1.5 Gy per fraction, to a total dose of 45 Gy) and 19 (43%) to once-daily thoracic irradiation (ODTI; 2 Gy per fraction, to a total dose of 50 Gy).

RESULTS

Median follow up was 75 months (range, 42-102). Of 44 patients submitted to intensification with TI plus CT, 32 (73%) had a complete and 12 (27%) a partial response. Median overall survival of all 55 patients was 17 months with actuarial survival probabilities of 2 and 5 years, 32 and 25%, respectively. Analysis of patient sub-groups showed a 5-month median survival in non-responders, 19 in TDTI and 17 in ODTI patients, respectively. Two and 5 year survival probabilities were 0% in non-responders, 40 and 35% in TDTI and 39 and 21% in ODTI patients, respectively. At present, 13 of 44 responders are still alive, of which nine (20%) have been progression-free from 45 to 93 months (median 60). Treatment failure was registered in 31 (70%) of 44 patients who received both induction and intensification treatment. One-half of patients had intrathoracic recurrence, eight of which only local and the remaining seven local and distant. Fourteen (32%) patients had brain metastases. Grade 3-4 neutropenia occurred in 24 (55%) patients with no differences between treatment groups. Grade 3 esophagitis was registered in four (9%) patients: in 3/25 (12%) and 1/19 (5%) of those who received TDTI and ODTI, respectively (P=not significant). Acute radiation pneumonitis occurred in three (12%) patients submitted to TDTI. No clinically debilitating pulmonary fibrosis, permanent esophageal stricture or toxic death was observed.

CONCLUSIONS

In LD-SCLC patients late concurrent CT plus TI is feasible and effective. Our long-term results are similar to the best reported in the literature. Despite the high incidence of complete response obtained, however, one-half of the patients had intrathoracic relapse and one-third brain metastases.

Radiation-induced myelopathy in long-term surviving metastatic spinal cord compression patients after hypofractionated radiotherapy: a clinical and magnetic resonance imaging analysis

BACKGROUND AND PURPOSE

Hypofractionated radiotherapy is often administered in metastatic spinal cord compression (MSCC), but no studies have been published on the incidence of radiation-induced myelopathy (RIM) in long-term surviving patients. Our report addresses this topic.

PATIENTS AND METHODS

Of 465 consecutive MSCC patients submitted to radiotherapy between 1988 and 1997, 13 live patients (seven females, six males, median age 69 years, median follow-up 69 months) surviving for 2 years or more were retrospectively reviewed to evaluate RIM. All patients underwent radiotherapy. Eight patients underwent a short-course regimen of 8 Gy, with 7 days rest, and then another 8 Gy. Five patients underwent a split-course regimen of 5 Gy x 3, 4 days rest, and then 3 Gy x 5. Only one patient also underwent laminectomy. Full neurological examination and magnetic resonance imaging (MRI) were performed.

RESULTS

Of 12 patients submitted to radiotherapy alone, 11 were ambulant (eight without support and three with support) with good bladder function. In nine of these 11 patients, MRI was negative; in one case MRI evidenced an in-field relapse 30 months after the end of radiotherapy, and in the other, two new MSCC foci outside the irradiated spine. In the remaining patient RIM was suspected at 18 months after radiotherapy when the patient became paraplegic and cystoplegic, and magnetic resonance images evidenced an ischemic injury in the irradiated area. The only patient treated with surgery plus postoperative radiotherapy worsened and remained paraparetic. Magnetic resonance images showed cord atrophy at the surgical level, explained as an ischemic necrosis due to surgery injury.

CONCLUSIONS

On the grounds of our data regarding RIM in long-term surviving MSCC patients, we believe that a hypofractionated radiotherapy regimen can be used for the majority of patients. For a minority of patients, more protracted radiation regimens could be considered.

Regional node failure in patients with four or more positive lymph nodes submitted to conservative surgery followed by radiotherapy to the breast

A retrospective analysis was conducted to evaluate the incidence of nodal failure in a subgroup of patients who had T1-T2 breast cancer and four or more positive nodes. Sixty-four 5 patients ranging in age from 29 to 73 years (median, 51) received conservative surgery followed by radiotherapy to the breast between November 1980 and May 1995. Adjuvant chemotherapy was administered to 56 patients, 27 of whom were also treated with tamoxifen, which was used alone in 5 patients. Three patients received no adjuvant treatment. Sixty-two patients are evaluable for regional node failure. There were 10 nodal failures, 4 in the axillary and 6 in the supraclavicular regions, in 9 patients, at a median of 56.5 and 27 months, respectively. There was no internal mammary node failure. Median follow-up was 72.6 months. The 10-year probability of developing axillary and supraclavicular failure is 13.9 +/- 7.7% and 10.5 +/- 4.1%, respectively. Prognosis was better for patients with axillary and breast recurrence and worse when relapse was in the supraclavicular region. On the basis of our results and data already published in premenopausal patients, we believe that radiotherapy to the supraclavicular region should be considered in patients with four or more positive axillary nodes, after a complete dissection.

Allogeneic matched T-cell-depleted bone marrow transplantation for acute leukemia patients

PURPOSE

We evaluated the efficacy and toxicity of a conditioning regimen designed to overcome the increased risk of rejection and relapse associated with T-cell-depleted bone marrow transplants.

PATIENTS AND METHODS

Fifty-four patients with acute leukemia received an allogeneic T-depleted bone marrow transplant from an HLA-matched (n=52) or one locus mismatched (n=2) sibling donor between June 1989 and November 1993. Nineteen acute myeloid leukemia patients and 17 acute lymphoid leukemia patients were in complete remission, and 11 acute myeloid leukemia patients and 7 acute lymphoid leukemia patients were in relapse. Patients were preconditioned with hyperfractionated total body irradiation of 1.2 Gy three times a day on days -9 to -6 (total 14.4 Gy), 10 mg/kg thiotepa on day -5, 4 mg/kg rabbit antithymocyte globulin on days -4 to -1, and 50 mg/kg cyclophosphamide on days -3 and -2.

RESULTS

All patients were fully engrafted at a median of 15 days after transplant. No patient rejected the transplant or developed acute or chronic graft-versus-host disease. Of 19 patients with acute myeloid leukemia in complete remission, 14 survive. Four of the 11 patients with acute myeloid leukemia in relapse survive. Twelve acute myeloid leukemia patients died (three of relapse, eight of toxicity, one of other causes). Eleven of 24 patients with acute lymphoid leukemia (one treated in relapse) are alive in complete remission; the other 13 died (nine of relapse, four of toxicity). Interstitial pneumonia, the main cause of toxic death, occurred in 9.26% of total patients. The median follow-up time at this writing is 30 months.

CONCLUSIONS

The absence of rejection and graft-versus-host disease and the relatively low relapse and toxicity rates are evidence for the efficacy of our conditioning regimen.

Radiotherapy without steroids in selected metastatic spinal cord compression patients. A phase II trial

A phase II trial was planned to investigate the feasibility of radiotherapy (RT) without steroids in 20 consecutive patients with metastatic spinal cord compression (MSCC), no neurologic deficits, or only radiculopathy, and no massive invasion of the spine at magnetic resonance imaging (MRI) or computed tomography (CT). Aiming at an early diagnosis, MRI or CT was prescribed for all cancer patients with back pain and osteolysis, even when there were no signs of neurologic spinal compression. All patients were given 30 Gy in 10 fractions over 2 weeks with no steroids. Back pain and motor capacity were the parameters adopted to verify response to RT. Sixteen of 20 patients (80%) were able to walk without support, and 14 (70%) had no radiculopathy. Seventeen of 20 cases (85%) achieved relief from back pain. Regarding motor function, all patients (100%) responded to RT because the 16 patients able to walk without support at diagnosis did not deteriorate and the other 4, who needed support, became ambulatory without motor impairment. Median survival time was 14 months. Eight of 20 (40%) treated patients are still alive (14 to 36 months after end of RT), fully ambulatory, and free from relapse in the treated spine. Acute side effects were documented in only 2 patients (10%) and were managed without steroids. The results of this study suggest that RT without steroids is a feasible regimen for MSCC patients with good motor function. Elimination of steroids from the standard treatment for MSCC avoids cortisone side effects above all in those patients with diabetes, hypertension, peptic ulcer, and other steroid-sensitive medical problems.

[Testicular seminoma in stages I and II non-bulky. 16 years' experience]

From June 1977 through June 1993, ninety-five patients with testicular seminoma were treated in our center. This paper reports on 67 assessable patients--52 with stage I and 15 with non-bulky stage II disease. Median follow-up is 8 years (range: 4-16 years). Postorchiectomy radiotherapy consisted in 30 Gy (1.5 Gy/day) precautionary treatment to ipsilateral hemipelvis and paraaortic nodes (stage I) or 40-45 Gy to the same area plus 25.5-30 Gy prophylactic irradiation to mediastinum and supraclavicular fossae (stage II). Ten-year actuarial survival is 100%-96.8% +/- 2.2 considering deaths from other diseases. Ten-year disease-free survival is 95.3% +/- 2.6. The 3 relapsed patients were rescued with chemotherapy or radiotherapy (1 and 2 cases, respectively). Acute side-effects were nausea (30% of cases) and vomiting (18%) which disappeared after oral antiemetics. Late toxicity-asymptomatic osteolysis of the ipsilateral pubic region--was observed in 1 patient only (1.5%) who received cobalt therapy to inguinal canal and hemiscrotum (40.5 Gy in 27 fractions). The current diagnostic and therapeutic approaches to testicular seminoma are discussed. In stage I the conventional treatment is low-dose (20-25 Gy) subdiaphragmatic radiotherapy and a policy of surveillance is justified only for clinical trials. In non-bulky stage II disease lumboaortic and hemipelvic irradiation (36-40 Gy) is the treatment of choice whereas precautionary irradiation should not be given to the mediastinum. If abdominal CT scans show nodal metastases, chest CT is necessary for staging instead of chest X-ray films. When abdominal CT findings are negative or questionable, bi-pedal lymphography must be performed. Residual testis US should be the routine examination for the early diagnosis of metachronous contralateral seminoma. The semen should be tested for further storage and sexual functions should be accurately analyzed to distinguish between organic and psychologic causes. Although limited, our experience demonstrates the good prognosis of this condition and the optimal tolerance in testicular seminoma patients even with a radiotherapy regimen which is now considered suboptimal, though it was the standard about 10 years ago.

Radiation therapy of spinal cord compression caused by breast cancer: report of a prospective trial

Fifty-six breast cancer patients with metastatic spinal cord compression were consecutively treated with radiation therapy alone. All patients received steroids plus chemotherapy and/or hormonal therapy. Emergency radiation therapy was administered using a split-course regimen: 5 Gy for 3 days, stopped for 4 days and, only in responders, a further 3 Gy for 5 days (time dose fractionation 68). Median follow-up was 22 months (range, 4 to 52 months). Response and survival were assessed on the basis of, pretreatment and posttreatment walking capacity, presence of vertebral body collapse or osteolysis, presence of other metastatic sites apart from bone and chemotherapy and/or hormonal therapy. In 89% of patients with back pain the pain disappeared or lessened. Four of 6 cases (67%) with urinary dysfunction responded to radiation therapy. Of 35 cases with motor dysfunction at the time of diagnosis, 21 (60%) regained the ability to walk and another five (14%) who were able to walk with support at diagnosis did not deteriorate. All 21 cases without motor deficits before treatment maintained good motor performance after radiation therapy. Response to therapy was better in pretreatment walking than in nonwalking patients (97% vs 69%; p less than 0.02). Probability of duration of response at 1 year was 59% and 10% for posttreatment walking and nonwalking patients, respectively (p less than 0.0001). One year survival probability was 66% for posttreatment walking and 10% for posttreatment nonwalking patients, respectively (p less than 0.0001). Pretreatment and posttreatment ambulatory status were the most important prognostic factors.

Interstitial pneumonitis after hyperfractionated total body irradiation in HLA-matched T-depleted bone marrow transplantation

Interstitial pneumonia is one of the major causes of morbidity and mortality after bone-marrow transplantation. We here report a series of 58 patients suffering from hematological malignancies who received HLA-matched T-lymphocyte depleted bone-marrow transplants between July 1985 and January 1990. Interstitial pneumonia occurred in 7/58 patients (12%) and was fatal in six. Three different pre-bone-marrow transplantation conditioning regimens were employed. Total body irradiation was delivered according to a hyperfractionated scheme of 12 fractions given three per day 5 hr apart for 4 days. Twenty-three patients received 36 mg/Kg procarbazine, 1275 UL/Kg antithymocite globulin, 14.4 Gy hyperfractionated total body irradiation and 120 mg/Kg cyclophosphamide. Only one patient developed interstitial pneumonia, but two rejected the graft and 10 relapsed. As a consequence, the total hyperfractionated scheme was increased to 15,6 Gy, cyclophosphamide to 200 mg/Kg, antithymocite globulin to 3400 UL/Kg and procarbazine eliminated. There were three cases of interstitial pneumonia, no rejection and four relapses in the 17 patients who received this regimen. In the last 18 patients hyperfractionated total body irradiation was reduced to 15 Gy, cyclophosphamide to 100 mg/Kg, and 10 mg/Kg of the myeloablative agent thiothepa added to enhance the cytoreductive effect without significantly increasing extramedullary toxicity. Three cases of interstitial pneumonia, one relapse but no rejection were recorded. Our results demonstrate that the absence of graft-versus-host disease due to T-cell depletion, and radio-chemotherapy doses and schedules used for the conditioning regimen each contributed to reducing the risk of interstitial pneumonitis. Hyperfractionated total body irradiation therefore, seems to play an important role in lowering the incidence of this complication.

Lung damage following bone marrow transplantation after hyperfractionated total body irradiation

From July 1985 to December 1989, 72 evaluable patients aged between 6 and 51 (median age 27 years) suffering from haematological malignancies received an allogeneic bone marrow transplant (BMT) depleted of T-lymphocytes to reduce the risk of graft-versus-host-disease (GvHD); 57 were matched and 15 mismatched. Three different conditioning regimens were used in an effort to enhance cytoreduction without increase extramedullary toxicity. Mismatched patients were treated with more immunosuppressive regimens. Total body irradiation (TBI) was given in three doses per day, 5 h apart, over 4 days for a total of 12 fractions. The dose to the lungs was 14.4, 15.6 and 9 Gy according to the conditioning regimen. The incidence of interstitial pneumonia (IP) was 12.3% in matched and 46.7% in mismatched patients. Our results seem to indicate that lung toxicity is correlated with the intensity of the conditioning regimen, the stage of disease and, in mismatched patients, with the degree of human leucocyte antigen (HLA) disparity and the poor post-BMT reconstitution, rather than the radiotherapy dose delivered to the lungs. On the contrary, the hyperfractionated scheme adopted, the absence of GvHD and, perhaps, the post-TBI administration of cyclophosphamide all seem to have contributed to the low incidence of IP in our matched patients.

[Endocavitary curietherapy of tumors of the rhinopharynx after external radiotherapy]

We report our experience in the treatment of nasopharyngeal carcinoma with intracavitary curietherapy to cure small recurring carcinomas or residual local disease 2-6 weeks after completing external radiotherapy. Since 1984, 10 patients have received intracavitary radiotherapy with customized molds charged with Ir 192. Six of them received a boost dose because of residual disease and for local recurrence. The technique we employed to shape the molds is described, together with the mode of use and the doses to target volume. Due to both the small number of treated cases and the short follow-up, no significant conclusions could be drawn relative to survival time. However, it must be stressed that this therapeutic approach gives a high local control rate with no severe side-effects or sequelae.

[Pre- and postoperative radiotherapy of operable carcinoma of the rectum]

This was a non-randomized prospective study on the "sandwich" radiosurgical treatment of resectable rectal and rectosigmoid carcinomas. From December 1984 to December 1989, 100 patients were treated 86 of them are now evaluable. Mean follow-up was 38 months (range: 9-69). Surgery was abdomino-perineal resection in 33 cases and anterior resection in 53 cases. Radiotherapy was preoperative pelvic irradiation, with a single 500-Gy fraction, the day before surgery. To stages B2, C1 and C2 patients (Astler and Coller) postoperative radiotherapy was administered for a total dose of 4500 Gy (180 Gy/fraction, 5 fractions/week), with box technique, from a Co 60 unit or Linear Accelerator (photon 18 MV). Preliminary results indicate 8% (7/86) local recurrences and 9.3% (8/86) distant metastases. Five-year actuarial disease-free survival is 63.2% +/- 8 for stage B1, 55.6% +/- 19 for stage B2, and 40.2% +/- 13 for stages C1 + C2. Overall 5-year actuarial disease-free survival is 53% +/- 10. No lethal or severe complications were observed following treatment.

Radiation therapy in metastatic spinal cord compression. A prospective analysis of 105 consecutive patients

One hundred thirty consecutive patients with metastatic spinal cord compression (MSCC) were entered in a therapeutic protocol in which radiation therapy (RT) played the main role. When MSCC is diagnosed by clinical-radiologic methods such as myelography with or without computed tomography (CT) or magnetic resonance imaging (MRI), steroids are given and RT treatment started within 24 hours. When diagnostic doubts exist or stabilization is necessary, surgery precedes RT. Chemohormonal potentially responsive tumors are also treated with chemotherapy or hormonal therapy. Twelve patients (9.2%) underwent surgery plus RT, and 118 (90.8%) received RT alone. Thirteen (11%) early death patients were not evaluable. The 105 evaluable cases that received RT alone were analyzed. Median follow-up was 15 months (range, 4 to 38 months). Response among patients with back pain was 80%. In cases with motor dysfunction, 48.6% improved, and in 33 of 105 patients (31.4%) without motor disability there was no deterioration. Forty percent of patients with autonomic dysfunction responded to RT. Median survival time was 7 months with a 36% probability of survival for 1 year. The median duration of improvement was 8 months. The most important prognostic factor was early diagnosis. Radiosensitivity of tumor was only important in paraparetic patients in predicting response to RT. Complete myelographic block significantly diminished response to RT. Vertebral collapse did not influence response or survival.

[Role of lymphangiography and abdomino-pelvic CT in uterine tumors]

Between January 1983 and December 1987, 77 patients with cervical and endometrial carcinoma (40 and 37 cases, respectively) were studied with a diagnostic protocol which included lymphangiography and abdomino-pelvic CT. The only administered treatment was radiation since all patients were considered inoperable or had non-resectable disease. Median age was 55 years (range 29-77). Median follow-up was 44 months-minimum 24, maximum 72 months. Subdiaphragmatic nodes were considered as pathologic even when just one of the two techniques demonstrated their involvement. Radiotherapy doses and volumes varied according to these findings (45 Gy to pelvis as a precautional dose; 6-8 Gy booster dose in N1 cases; 45 Gy to the periaortic area in N4 cases). The two diagnostic techniques agreed as to the presence/absence of pathologic nodes in 50 (64.9%) and 12 (15.6%) patients, respectively. There was disagreement between CT and lymphangiographic findings in 12 patients (15.6%) as regards the pelvic area and in 8 patients as regards the periaortic area (10.4%; 5 of the 8 also figured in the pelvic group). Actuarial 5-year disease-free survival for both groups, summing up stages I, II and III, goes as follows: cervical carcinoma patients: 47% (N0 cases 56%, N1-N4 33%, p = 0.07) and endometrial carcinoma group: 74.5% (no difference was found between N0 and N1 cases). Higher diagnostic accuracy seems to be obtained when CT is combined with lymphangiography than when either of them is performed alone. Therefore, the combined use of the two techniques could have a precise diagnostic role.

[Radiotherapy of the breast after conservative surgery for primary carcinoma. Irradiation technic with matched fields]

The authors report their technique for breast radiotherapy following conservative surgery (quadrantectomy + axillary dissection). The breast and chest wall are irradiated with photons from a 60Co unit through two fixed opposing tangential fields. The posterior field edges must be parallel and coplanar to the chest wall. A routine treatment plan using simulator, pantograph and computerized console is standardized by mathematical formulae elaborated from geometric breast measurement parameters. Gammagraphies acquired prior to and during therapy allow verification and control of treatment parameters. For 35 patients the therapy plan as described was compared with that obtained by CT images. Our procedure proved valid and an accurate treatment plan could be elaborated even without CT images. The use of wedges, half-field blocks and the dose scattered to the contralateral breast are also discussed.

[Diagnostic-therapeutic integration in metastatic spinal cord compression. Analysis of a prospective study]

Metastatic Spinal Cord Compression (MSCC), an oncologic emergency, is a frequent complication of many neoplastic diseases in an advanced stage. Our experience is reported, which was obtained with a series of 61 patients following a diagnostic-therapeutic protocol aimed at early diagnosing MSCC and at assigning the major role in therapy to radiotherapy (RT) alone. Fifty-seven patients with an average follow-up of 13 months (range 4-26) were evaluable. Diagnosis was always made by means of myelography and/or myelography plus CT. In 50 cases the treatment consisted in RT alone and the remaining 7 patients had surgery before RT because of diagnostic doubts; in 1 case the patient was operated on because stabilization was necessary. A dose of 30 Gy was delivered, over 2 weeks, (TDF = 62) to those tumors which were considered as radiation-responsive and having a better prognosis (myeloma, lymphoma), whereas all the other histologies were given a split-course regimen (5 Gy x 3 days, stop x 4 days, +/- 3 Gy x 5 days; TDF = 68). All patients received medium or high doses of steroid depending on the degree of neurologic involvement. Patients with chemo/hormone-responsive primary tumors also received chemotherapy and/or hormone therapy. The clinical parameters considered in evaluating the response to treatment were backache, motor performance, and sphincter function. Respectively 86%, 47% and 44% of patients responded. Early diagnosis was the most important prognostic factor, whereas histology of the primary tumor was important in cases with severe neurologic damage only. The results obtained are similar to those reported in literature and confirm the value of the diagnostic-therapeutic approach used, which suggests continuing this trial.

Role of radiotherapy in metastatic spinal cord compression: preliminary results from a prospective trial

A non-randomized prospective trial in which radiotherapy (RT) alone played the major role in the treatment of metastatic spinal cord compression (MSCC) is reported. Diagnosis was formulated on myelography and/or myelography plus computed thomography (CT). Of 51 cases treated, 48 are evaluable. The therapy consisted of radiation alone (42 cases) or decompressive laminectomy followed by radiotherapy (6 cases). Surgery was performed when the site of the primary tumor was unknown. The group of patients who received radiotherapy alone (42 of 48 evaluable cases) are analysed in this report. Medium to high doses of steroids were administered to all patients depending on the gravity of the case. Patients with chemo- or hormone-responsive primary tumors also received chemotherapy and/or hormone therapy. Pain relief, assessed by comparing use of narcotics and minor analgesics before and after treatment, was achieved in 54% cases (confidence limits, CL = 38-69%). In 36% (CL = 22-51%) of patients back pain diminished to the point when only milder analgesics were necessary (partial remission). Motor performance, based on patients' ability to walk, improved in 48% cases (CL = 31-65%). The 19 patients who were ambulatory before RT, did not deteriorate after treatment. Sphincter function, evaluated by patient's need for indwelling catheter, improved in 3 of 7 automatic dysfunction cases. It was found that early diagnosis was more important than primary tumor type for predicting a good was found that early diagnosis was more important than primary tumor type for predicting a good prognosis. In fact, all ambulating patients responded to treatment independent of the radiosensitivity of the tumor histology.(ABSTRACT TRUNCATED AT 250 WORDS)

[Surgical and radiotherapeutic treatment in stage I endometrial adenocarcinoma. Retrospective analysis of 218 patients]

From April 1977 through April 1985, 218 stage I endometrial carcinomas were treated with radiosurgery or radiotherapy alone. Postoperative irradiation was external (60Co) in 131 and curietherapy in 27 patients. Twenty patients underwent preoperative curietherapy and 40 patients radiotherapy alone. Median follow-up was 5.6 years (range 3-11). The overall 5-year actuarial survival (Kaplan-Meier method) was 86.1% +/- 2.5. The 5-year D.F. actuarial survival was 95% +/- 4.9, 93.1% +/- 4.7, 88.4% +/- 2.9, respectively, for preoperative radiotherapy, postoperative curietherapy and postoperative external irradiation groups. The 5-year actuarial survival was 69.8% +/- 7.7 in the radiotherapy alone group. There was difference in survival among patients treated with radiotherapy alone as compared to those radiosurgically treated (P less than 0.001). Local and general recurrence rate was 8.2%; vaginal recurrences 2/218 (0.9%); pelvic recurrences 7/218 (3.3%); distant metastases 9/218 (4.1%). Overall side effects were observed in 20/218 patients (9.1%): grade I and II in 8.6% of cases, grade III in 0.9% of cases. The authors conclude that good results can be achieved with adjuvant radiotherapy both in high risk cases and in low risk cases, with minimal side effects.

[Radiotherapy of testicular seminoma. Stages I and II A, B]

From June 1977 through June 1987, 46 patients (36 evaluable) affected by stage I and II non-bulky testicular seminoma were treated with postoperative telecobaltotherapy (TCT). In stage I seminomas, radiotherapy was extended to the omolateral iliac and the para-aortic areas (total dose: 30 Gy over 4 weeks). In stage II seminomas, the subdiaphragmatic lymph nodes were irradiated with 40-45 Gy over 5-6 weeks; after an interval of one month the subdiaphragmatic lymph nodes were irradiated again with a total dose of 25 Gy over 3.5 weeks. Minimal follow-up lasted two years and maximum ten years (average: 5.5). Two (5.5%) recurrences occurred, but salvage radiotherapy and salvage chemotherapy respectively allowed a complete permanent remission. One patient died from a different neoplasia with no evidence of testicular involvement. The 5-year actuarial survival is 96.6 +/- 3.4. In 20% of the patients the side effects were nausea and/or vomiting, easily controlled. No late complications were observed.

Hyperfractionated total body irradiation for T-depleted HLA identical bone marrow transplants

Twenty patients suffering from malignant hemopathies (mean age 31.7 years) were given hyperfractionated total body irradiation (TBI) (120 cGy/3 fractions per day: total dose = 1440 cGy/4 days) as conditioning for T-depleted HLA identical allogeneic bone marrow transplantation. At an average of 12 months (range of 4.5-22 months) follow-up there were two cases of early death and two cases (11%) of rejection. There were no cases of acute or chronic graft versus host disease (GVHD) nor cases of interstitial pneumonitis. The average time for durable engraftment was 22 days. Disease-free survival at 12 months was 65%. To improve the results and further reduce the percent of rejection, the authors propose intensifying the immunosuppressive conditioning by increasing the cyclophosphamide dose and that of TBI so that a total dose of 1560 cGy is reached.

[Combined chemotherapeutic and radiotherapeutic treatment of limited pulmonary microcytoma]

Between 1978 and 1983, 34 patients (32 evaluable) suffering from limited small cell lung carcinoma (SCLC-L) were treated following the protocol polychemotherapy (CAV) plus thoracic cobalt teletherapy and "precautionary" cranial irradiation (30 Gy in 2 weeks). Minimum follow-up was 30 months. After induction chemotherapy there was complete remission (CR) in 20% of cases whereas at the end of induction chemo-radiotherapy there was complete remission (CR) in 44% (p less than 0.05) of cases. Median duration of the responds was 12 months. Total median survival is 15 months, median NED survival 32 months (6-90 months). Seven out of 14 CR patients received consolidated thoracic radiotherapy (Rt); 6 of these survived disease-free for over 2 years. No salvage therapy carried out has proved useful. Only in one patient (3%) brain metastasis occurred. Iatrogenic toxicity was also kept within limits of brain level. The role Rt plays in increasing the CR percentage, in drastically diminishing the incidence of brain metastasis, in improving the quality of life by increasing the disease-free interval must be emphasized. Finally it should be noted that only CR patients have the possibility to become "long survivors".

[Quadrant excision and radiotherapy in the treatment of early cancer of the breast]

One hundred twenty nine patients with T1 N0 M0 breast cancer were selectively treated with QUART. Mean age was 50 years. Ninety-eight patients (76%) were N- and 31 (24%) were N+. N+ cases received chemotherapy or Tamoxifen if R+. Patients evaluated are 95/129 in a 3 years average follow-up (range 2-7 years). Overall actuarial survival rate at 5 years is 88.9%. Three patients died; local relapses were 3/95 and metastases 3/95. Overall treatment tolerance was satisfactory and esthetic results were good.

[Treatment of stage I and II cervix carcinoma with radiotherapy alone or with combined radiation-surgery]

From 1975 to 1982, among 138 patients affected by stage IB and IIA-B cervical carcinoma, 93 were treated with radiotherapy and surgery, while 45 were treated with radiotherapy alone. 137Cs applied with individual "moulages" was used for uterine-vaginal brachycurietherapy, while telecobalt therapy was used in external beam radiotherapy. Surgery consisted of either a classical Wertheim-Meigs procedure or a hysterosalpingo-oophorectomy with pelvic lymphadenectomy. Dosage methods for remote-loading curietherapy with 137Cs are discussed. Actuarial survival at 5 years in the 56 patients in stage IB was 90.2% +/- 3; in the 37 patients in stage IIA was 75% +/- 5; and in the 45 patients in stage IIB was 46.2% +/- 7.5. Average follow-up was 6.5 years, with a minimum of 3 years. Survival results in patients undergoing radiotherapy alone were not substantially different. Causes for therapeutic failure were pelvic relapse in 9.4% of the cases, distant metastases in 3.6% and relapse plus metastases in 8.6% of the cases. Severe complications were seen in 2.8% of the cases; mild complications in 8.6% of the cases.