Ewing tumors of the chest wall: Local control and long-term outcomes

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Background: Primary sarcomas of the lungs and mediastinum are rare and few data are reported on treatment and results of therapy. Methods: We reviewed our experience from 1980 and 2008 including 31 patients (pts). Pts characteristics: median age 41 (19–80 y), male/female 19/12; symptoms at diagnosis: dyspnoea (42%), chest and shoulder pain (39%), cough (35%), hemophtoae (13%), discomfort (10%). 4 pts had a previous history of mediastinal radiation for Hodgkin's and non-Hodgkin's linfomas. 5 mediastinal tumours were located as follows: 2 in anterior part, 1 in posterior and 2 in the middle (sarcomas of the heart). 26 lung sarcomas presented as a singular mass in 23 cases and as a metastatic disease in 3. Results: In 20/31 cases the tumour was immediately resected (3 mediastinal masses and 17 lung sarcomas). In 8/31 cases only biopsy was possible. FNA was done in 25 pts. Neoadjuvant chemotherapy was performed in 4 cases (3 resected). Resection was complete in 11/23 cases and in 12/23 incomplete. The histology were: peripheral nerve tumour 7, leiomyosarcoma 4, MFH 2, fibrosarcoma 2, liposarcoma 1, angiosarcoma 2, undifferentiated sarcoma 1, solitary fibrous tumour 2, rhabdomyosarcoma 2, synovialsarcoma 2, pulmonary artery sarcoma 1, pleuropolmonary blastoma 1, malignant hemangiopericytoma 1, mixoid chondrosarcoma 1, ectopic osteosarcoma 1, aggressive fibromatosis 1. Only 4 pts received neoadjuvant chemotherapy, 11 adjuvant CT, 5 exclusive CT + RT for inoperable disease. Radiotherapy was completed in 26 pts (21 adjuvant). Local relapse or metastatic progression were recorded in 16/23 pts and 12 received one or more lines of palliative CT. Data about survival are disposable only for the more recently recorded pts (1998–2008: 17 pts). Of these only 8 are alive (2 with disease). Volume of disease, complete resection and grading are the dominant prognostic factors. Conclusions: Primary sarcomas of the lungs and mediastinum have a very severe prognosis. Surgical resection is the fundamental therapy, but in the future the role of neoadjuvant CT will increase.

No significant financial relationships to disclose.

Patterns of failure in squamous cell carcinoma of the vagina treated with definitive radiotherapy alone: what is the appropriate treatment volume?

The purpose of this study was to review treatment results, sites of failure, and complications in relation to the irradiation volume for carcinoma of the vagina treated with radiotherapy alone. A retrospective review of 65 patients with histologically confirmed squamous cell carcinoma of the vagina who received definitive radiotherapy was undertaken. The 5-year cause-specific survival rates were as follows: Stage I, 91%; Stage IIA (paravaginal extension), 90%; Stage IIB, 55%; Stage III, 89%; and Stage IVA, 62%. The pelvic disease control rates at 5 years were as follows: Stage I, 74%; Stage IIA, 90%; Stage IIB, 79%; Stage III, 89%; and Stage IVA, 67%. Recurrence in the pelvis occurred in 22% of patients. Eighty-five percent of pelvis recurrences were in the primary treatment field. Although pelvic control rates were not increased by use of larger treatment fields (>2,700 cm(3)), moderate acute and late effects were increased with these fields. Carcinoma of the vagina appears to have a different failure pattern than carcinoma of the cervix. The primary failure sites are the vagina and the paracolpal tissues and the inguinal nodes. Because of this, the superior edge of the pelvic fields does not have to extend above the bottom of the sacroiliac joints except with advanced lesions.

THE ROLE OF RADIOTHERAPY AND LIMB-CONSERVING SURGERY IN THE MANAGEMENT OF SOFT-TISSUE SARCOMAS IN ADULTS

The treatment of soft-tissue sarcomas has undergone significant changes over the past several decades. Previously, patients were often treated with surgery alone, which frequently necessitated amputation of the affected extremity. Less extensive, limb-sparing operations combined with adjuvant irradiation are now feasible for most patients without compromising the likelihood of cure.

Megavoltage radiotherapy for aneurysmal bone cysts

PURPOSE

An aneurysmal bone cyst (ABC) is a rapidly expansile and destructive benign tumor of bone that is usually treated by curettage and bone graft, with or without adjuvant treatment. For recurrent tumors, or tumors for which surgery would result in significant functional morbidity, does radiotherapy (RT) provide a safe and effective alternative for local control?

PATIENTS AND METHODS

Nine patients with histologically diagnosed aneurysmal bone cysts without other associated benign or malignant tumors were treated at the University of Florida with megavoltage RT between February 1964 and June 1992. The patients received local radiotherapy doses between 20 and 60 Gy, with 6 patients receiving 26--30 Gy. In 6 patients the diagnosis was made by biopsy alone; 3 underwent intralesional curettage before RT. Minimum follow-up was 20 months; 7 of 9 patients (77%) had follow-up greater than 11 years.

RESULTS

No patient experienced a local recurrence (median follow-up, 17 years). One patient required stabilization of the cervical spine 10 months after RT because of dorsal kyphosis from vertebral body collapse. No other significant side effects were experienced, and no patients developed secondary malignancies. Four patients were lost to follow-up: at 20 months, 11.5 years, 17 years, and 20 years after the initiation of treatment, none with any evidence of local recurrence. All of the patients who had significant pain before RT had relief of their symptoms within 2 weeks of completion of therapy.

CONCLUSIONS

Using modern-day RT, patients with recurrent or inoperable aneurysmal bone cysts can be treated effectively (with minimal toxicity) using a prescribed tumor dose of 26--30 Gy.

Adjuvant 32P in the treatment of ovarian carcinoma

The purpose of this study was to evaluate the efficacy of adjuvant 32P for patients with high-risk, early-stage ovarian carcinoma. Twenty-five patients underwent apparent complete resection followed by 32P (15 mCi) at the University of Florida between 1976 and 1993. Minimum and median follow-up times were 3 and 8 years, respectively. The rate of local control at 10 years was 83%. Four of the 5 patients who experienced recurrent disease had a component of intra-abdominal disease at the time of relapse. The absolute and cause-specific survival rates at 10 years were 68% and 82%, respectively. There were no severe acute complications. Five patients experienced significant late complications, including chronic abdominal cramping that was treated conservatively (3 patients) and small bowel obstruction necessitating surgical intervention (2 patients). Adjuvant 32P results in disease control and survival rates that are similar to those observed after adjuvant chemotherapy. However, the risk of late complications, particularly small bowel obstruction, is higher.

Consolidative 32P after second-look laparotomy for ovarian carcinoma

We report our experience with consolidative 32P after second-look laparotomy. Forty-three patients received consolidative 32P after platinum-based chemotherapy and a negative (39 patients, 91%) or positive (4 patients) second-look laparotomy. Thirty-one patients (72%) initially had stage III (30 patients) or stage IV (1 patient) disease; 28 patients (65%) had grade 3 tumors. Patients had follow-up from 3.5 to 14.9 years (median, 7.7 years); no patient was lost to follow-up. The 5-year rates of control of disease within the abdomen (local control) for the overall group and the subset of patients with stage II-IV disease and a negative second-look laparotomy were 65% and 69%, respectively. The corresponding 5-year survival rates were 78 and 81%, respectively. Multivariate analyses revealed that tumor found at second-look laparotomy significantly influenced the likelihood of local control and cause-specific survival. Acute side effects included cellulitis (1 patient) and ileus (3 patients). Two patients (5%) experienced severe late complications; both experienced small bowel obstruction that necessitated surgical intervention. Consolidative 32P appears to reduce the risk of recurrence and improve survival after negative second-look laparotomy. The risk of significant complications is low.

Outcome after radiotherapy of primary spinal cord glial tumors

Primary spinal cord tumors are rare, and treatment recommendations are therefore difficult. We reviewed a 22-year experience of postoperative radiotherapy for spinal cord tumors to elucidate prognostic factors and recommendations. Twenty-two patients with spinal cord tumors were treated from 1969-1991. Ten patients had ependymomas, of which two were high grade. Twelve had astrocytomas, of which 4 were high grade. Karnofsky status, age, extent of resection, tumor histology, grade, and radiation dose were evaluated, as well as degree of clinical improvement after treatment based on change in Karnofsky status. Ependymomas achieved 100% local control with postoperative radiotherapy. Grade and dose were of indeterminate significance because of these excellent results. High-grade astrocytomas all recurred and caused death. Disease recurred in 1 of 8 patients with low-grade astrocytic or mixed astrocytic tumors. The only prognostic variables of significance were histology, grade, and change in Karnofsky status after treatment. Radiation of primary spinal cord tumors is rare. In nearly all cases, local fields may be used. Improvement in Karnofsky status after radiotherapy may predict better survival. Treatment recommendations for these rare tumors are discussed.

Intracavitary radiotherapy for refractory dysfunctional uterine bleeding. A case report

BACKGROUND

Pelvic irradiation was once a common treatment for dysfunctional uterine bleeding (DUB). Today the majority of women with DUB are successfully treated with hormonal therapy; patients unresponsive to hormonal therapy may require endometrial ablation or hysterectomy. We present a patient with severe, intractable DUB and contraindications to surgery who was treated with intracavitary radiotherapy.

CASE

A 39-year-old, 150-cm-tall, 310-kg woman was referred for management of severe DUB refractory to medical management. The bleeding was successfully treated with intracavitary cesium. Hysterectomy was not recommended due to the operative risks posed by the patient's massive obesity. Because of technical difficulties during a previous dilation and curettage and the expense of long-term GnRH agonist therapy, the patient elected to undergo intracavitary radiotherapy.

CONCLUSION

In selected patients, intracavitary radiotherapy can be used to treat DUB when conventional therapy fails or is contraindicated.

The optimal dose of radiation in Hodgkin's disease: an analysis of clinical and treatment factors affecting in-field disease control

PURPOSE

The purpose of this study is to analyze the effect of radiation dose, as well as other clinical and therapeutic factors, on in-field disease control.

PATIENTS AND MATERIALS

The study population comprised 232 patients with Stage I and II Hodgkin's disease (HD) treated with curative intent at the University of Florida with radiotherapy (RT) alone (169 patients) or chemotherapy and radiotherapy (CMT) (63 patients). Sites of involvement and radiation doses were prospectively recorded and correlated with sites of disease recurrence.

RESULTS

Freedom from relapse and absolute survival rates at 10 years were as follows: 76% and 77%, entire group; 76% and 80%, RT group; 79% and 70%, CMT group; 85% and 78%, Stage I; and 71% and 77%, Stage II. Treatment failure occurred in 50 patients (22%) including in-field failure in 22 patients (9%). In-field failure was rare in electively treated sites. Multivariate analysis of clinical factors (tumor size, number of sites involved, B-symptoms, gender, histology, age, and site of involvement) and treatment factors (use of chemotherapy, number of cycles of chemotherapy, radiation dose, radiation treatment volume, and radiation treatment time) showed only tumor size (p = 0.0001) to be significantly correlated with in-field disease control. In RT patients, the in-field failure rate according to tumor size was as follows: 0% for < or = 3 cm; 4% for > 3 cm and < or = 6 cm; 23% for > 6 cm and < or = 9 cm; and 36% for > 9 cm. In CMT patients, the in-field failure rate was as follows: 0% for < or = 3 cm; 0% for > 3 and < or = 6 cm; 5% for > 6 cm and < or = 9 cm; and 26% for > 9 cm. In-field recurrence was not a predominant pattern of failure in RT patients with small tumors (< or = 6 cm); thus, the difference in in-field control in tumors < or = 6 cm between doses < or = 35 Gy (6%) and doses > or = 36 Gy (0%) was not statistically significant. In larger tumors (> 6 cm), in-field recurrence was a predominant pattern of failure; the in-field failure rate in RT patients with tumors > 6 cm of 30% for doses < or = 35 Gy was not significantly different from 25% for doses > 35 Gy. In moderately bulky tumors (> 6 cm and < or = 9 cm), the addition of chemotherapy did appear to increase in-field disease control; the in-field failure rate was 23% with RT and 5% with CMT (p = 0.07).

CONCLUSION

Our data do not demonstrate statistically significant evidence of increasing tumor control in HD with doses > 30 Gy. The data do show that increasing tumor size is associated with increased rates of in-field failure, and the addition of chemotherapy may improve in-field disease control in tumors > 6 cm. In-field recurrence in large tumors remains a predominant pattern of failure, however, and the role of radiation doses higher than 30-35 Gy in this high-risk subset warrants further study.

The impact of radiotherapy dose and other treatment-related and clinical factors on in-field control in stage I and II non-Hodgkin's lymphoma

PURPOSE/OBJECTIVE

To assess local (in-field) disease control, identify potential prognostic factors, and elucidate the optimal radiotherapy dose in various clinical settings of Stage I and II non-Hodgkin's lymphoma (non-CNS).

MATERIALS & METHODS

A total of 285 consecutive patients with Stage I and II non-Hodgkin's lymphoma were treated with curative intent, including 159 with radiotherapy (RT) alone and 126 with combined-modality therapy (CMT). Of these, 72 patients had low-grade lymphomas (LGL), 92 had intermediate or high-grade lymphomas (I/HGL), and 21 had unclassified lymphomas. Clinical and treatment variables with potential prognostic significance for in-field disease control, freedom from relapse (FFR), and absolute survival (AS) were evaluated by univariate and multivariate analyses.

RESULTS

The 5-, 10-, and 20-year actuarial AS rates were 73%, 46%, and 33% for patients with LGL and 64%, 44%, and 18% for patients with I/HGL, respectively. The 5-, 10-, and 20-year actuarial FFR rates were 62%, 59%, and 49% for patients with LGL and 66%, 57%, and 57% for patients with I/HGL, respectively. Significant prognostic factors identified by the multivariate analysis were age, tumor size, and histology for AS; tumor size and treatment for FFR; and only tumor size for in-field disease control. There were 95 total failures, with only 12 occurring infield. Most failures (65%) were in contiguous unirradiated sites. All 4 in-field failures in patients with LGL occurred after RT doses < 30 Gy, although none occurred in 10 patients with small-volume LGL of the orbit treated with doses < 30 Gy. The 8 in-field failures in patients with I/HGL were distributed evenly throughout the RT dose range; 5 occurred in patients treated with CMT, all with tumors > 6 cm, and 4 with less than a complete response (CR) to chemotherapy.

CONCLUSION

Our analysis suggests that the overwhelming problem in the treatment of non-Hodgkin's lymphoma is not in-field failure but, rather, failure in contiguous unirradiated sites. A dose of 20-25 Gy may be sufficient for small-volume LGL of the orbit. A dose of 30 Gy is sufficient for LGL in general, as well as for patients with nonbulky (< or = 6 cm) I/HGL treated with CMT who have a CR. However, patients with I/HGL treated with CMT for tumors > 6 cm and/or without a CR may benefit from doses > or = 40 Gy.

Radiotherapy in the management of orbital lymphoma

PURPOSE

This retrospective study reviews the treatment technique, disease outcome, and complications of radiotherapy used in the management of lymphoma involving the orbits.

PATIENTS & METHODS

Thirty-eight patients were treated between May 1969 and January 1995, with a median follow-up of 8.3 years. All patients had biopsy-proven orbital lymphoma. Twenty patients who had limited disease were treated with curative intent, and 18 patients who had known systemic disease were treated with palliative intent. Of the 20 patients treated with curative intent, 14 had low-grade and 6 had intermediate- or high-grade disease. None received chemotherapy. Most patients received treatment with 250 kVP or 60Co radiation, using either an en face anterior field or wedged anterior and lateral fields. Median treatment dose was 25 Gy. Lens shielding was performed if possible. For patients treated for cure, cause-specific survival and freedom from distant relapse were calculated using the Kaplan-Meier method.

RESULTS

Control of disease in the orbit was achieved in all but 1 patient, who developed an out-of-field recurrence after irradiation of a lacrimal tumor and was salvaged with further radiotherapy. In the patients treated curatively, the 5-year rate of actuarial freedom from distant relapse was 61% for those with low-grade and 33% for those with intermediate/high-grade disease (p = 0.08). Cause-specific survival at 5 years was 89% for patients with low-grade and 33% for those with intermediate/high-grade disease (p = 0.005). Two patients with low-grade disease had contralateral orbital failures; both were salvaged with further irradiation. Acute toxicity was minimal. Cataracts developed in 7 of 21 patients treated without lens shielding and 0 of 17 patients treated with lens shielding. No patient developed significant late lacrimal toxicity.

CONCLUSION

Radiotherapy is a safe and effective local treatment in the management of orbital lymphoma.

Preliminary experience with frameless stereotactic radiotherapy

PURPOSE

To report initial clinical experience with a novel high-precision stereotactic radiotherapy system.

METHODS AND MATERIALS

Sixty patients ranging in age from 2 to 82 years received a total of 1426 treatments with the University of Florida frameless stereotactic radiotherapy system. Of the total, 39 (65%) were treated with stereotactic radiotherapy (SRT) alone, and 21 (35%) received SRT as a component of radiotherapy. Pathologic diagnoses included meningiomas (15 patients), low-grade astrocytomas (11 patients), germinomas (9 patients), and craniopharyngiomas (5 patients). The technique was used as means of dose escalation in 11 patients (18%) with aggressive tumors. Treatment reproducibility was measured by comparing bite plate positioning registered by infrared light-emitting diodes (IRLEDs) with the stereotactic radiosurgery reference system, and with measurements from each treatment arc for the 1426 daily treatments (5808 positions). We chose 0.3 mm vector translation error and 0.3 degrees rotation about each axis as the maximum tolerated misalignment before treating each arc.

RESULTS

With a mean follow-up of 11 months, 3 patients had recurrence of malignant disease. Acute side effects were minimal. Of 11 patients with low grade astrocytomas, 4 (36%) had cerebral edema and increased enhancement on MR scans in the first year, and 2 required steroids. All had resolution and marked tumor involution on follow-up imaging. Bite plate reproducibility was as follows. Translational errors: anterior-posterior, 0.01 +/- 0.10; lateral, 0.02 +/- 0.07; axial, 0.01 +/- 0.10. Rotational errors (degrees): anterior-posterior, 0.00 +/- 0.03; lateral, 0.00 +/- 0.06; axial, 0.01 +/- 0.04. No patient treatment was delivered beyond the maximum tolerated misalignment. Daily treatment was delivered in approximately 15 min per patient.

CONCLUSION

Our initial experience with stereotactic radiotherapy using the infrared camera guidance system was good. Patient selection and treatment strategies are evolving rapidly. Treatment accuracy was the best reported, and the treatment approach was practical.

Medulloblastoma: time-dose relationship based on a 30-year review

PURPOSE

Time-dose relationships have proven important in many cancer sites. This study evaluates the time factors involved in the successful postoperative radiotherapy of medulloblastoma, based on a 30-year experience in a single institution.

METHODS AND MATERIALS

Fifty-three patients with medulloblastoma received postoperative craniospinal radiotherapy with curative intent between 1963 and 1993. Seven patients (13%) underwent biopsy alone, 28 patients (53%) had subtotal excision, and 18 patients (34%) had gross total excision. Eleven patients received adjuvant chemotherapy. The mean posterior fossa dose was 53.1 Gy; most patients received 54.0 Gy (range, 34.3 to 69.6 Gy). For 41 patients receiving once-a-day therapy, the mean dose was 50.6 Gy (range, 34.3 to 56.0 Gy). For 12 patients receiving twice-a-day therapy, the mean dose was 61.8 Gy (range, 52.6 to 69.6 Gy). Minimum follow-up was 2 years, and median follow-up was 10.7 years. Survival, freedom from relapse, and disease control in the posterior fossa were calculated using the Kaplan-Meier method, and multivariate analysis was performed for prognostic factors. Variables related to radiotherapy were examined, including dose to the craniospinal axis, dose to the posterior fossa, fractionation (once-a-day vs. twice-a-day), use of adjuvant chemotherapy, risk group [high (> or =T3b or > or =M1) or low (< or =T3a and M0-MX)], interval between surgery and radiotherapy (excluding patients receiving chemotherapy before radiotherapy), and duration of radiotherapy.

RESULTS

At 5 and 10 years, overall survival rates were 68 and 64%, respectively, and freedom-from-relapse rates were 61 and 52%, respectively. Rates of disease control in the posterior fossa at 5 and 10 years were 79 and 68%, respectively. At 5 years, absolute survival rates after biopsy alone, subtotal excision, and gross total excision were 43, 67, and 78%, respectively (p=0.04), and posterior fossa control rates were 27, 89, and 83%, respectively (p=0.004). Duration of the treatment course was the only radiotherapy-related variable with a significant impact on freedom from relapse and posterior fossa control. For patients whose radiation treatment duration was < or =45 days, posterior fossa control was 89% at 5 years, compared with 68% for those treated for >45 days (p=0.01). Duration of treatment also affected freedom from relapse at 5 years: < or =45 days (76%) compared with >45 days (43%), p=0.004.

CONCLUSION

Our study demonstrates that if adequate doses are used, then radiotherapy treatment duration will significantly affect the outcome in terms of control of disease in the posterior fossa and freedom from relapse. Fractions of at least 1.75 Gy given once a day, or a twice-a-day regimen should yield optimal local control results.

Treatment of unresectable or metastatic pediatric soft tissue sarcomas with surgery, irradiation, and chemotherapy: a Pediatric Oncology Group study

BACKGROUND

The objectives of this study were to compare vincristine/actinomycin D/cyclophosphamide/adriamycin (VACA) with VACA/plus imidazole carboxamide (DTIC) (VACAD) therapy in regards to complete/partial response and event free survival rates in children and adolescents with metastatic non-rhabdomyosarcoma soft tissue sarcomas (NRSTS) or previously chemotherapy-naive recurrent NRSTS or locally persistent gross residual tumor after surgery and radiation therapy.

PROCEDURES

Between 1986 and March 1994, 75 patients entered this randomized study comparing VACA and VACAD, given at 3 week intervals. Sixty-one patients were considered eligible and received chemotherapy and radiation therapy to the primary tumor and areas of metastases. Thirty-six patients had regional unresected (Group III) disease, and 25 had metastatic disease (Group IV) at time of accession. Thirty-six patients received VACA (11 were not randomized), and 25 received VACAD.

RESULTS

With a median follow-up of greater than 4 years, overall and event-free survival for all eligible patients are 30.6% and 18.4% respectively (S.E: 9.5% and 6.8%). There was insufficient evidence that DTIC offered any advantage to event free survival, but there was evidence for better outcome for patients in Group III disease in comparison to patients with Group IV disease, and for patients with a Grade 1 and 2 histology in comparison to Grade 3 lesions.

CONCLUSIONS

Combination chemotherapy with VACA and VACAD were insufficient to prevent recurrent or progressive disease in children and adolescents with high stage NRSTS. The use of vincristine/ifosfamide/doxorubicin with cytokine support is under study.

Ependymoma: results, prognostic factors and treatment recommendations

PURPOSE

To review the University of Florida experience in treating ependymomas, analyze prognostic factors, and provide treatment recommendations.

METHODS AND MATERIALS

Forty-one patients with ependymoma and no metastases outside the central nervous system received postoperative radiotherapy with curative intent between 1966 and 1989. Ten patients had supratentorial lesions, 22 had infratentorial lesions, and 9 had spinal cord lesions. All patients had surgery (stereotactic biopsy, subtotal resection, or gross total resection). Most patients with high-grade lesions received radiotherapy to the craniospinal axis. Low-grade intracranial lesions received more limited treatment. Spinal cord lesions were treated using either partial spine or whole spine fields.

RESULTS

Of 32 intracranial tumors, 21 recurred, all at the primary site; no spinal cord tumors recurred. Overall 10-year survival rates were 51% (absolute) and 46% (relapse-free); by tumor site: spinal cord, 100%; infratentorial, 45%; supratentorial, 20% (p = 0.002). On multivariate analysis, tumor site was the only factor that influenced absolute survival (p = 0.0004); other factors evaluated included grade, gender, age, duration of symptoms, resection extent, primary tumor dose, treatment field extent, surgery-to-radiotherapy interval, and days under radiotherapy treatment.

CONCLUSIONS

Patients with supratentorial or infratentorial tumors receive irradiation, regardless of grade. Craniospinal-axis fields are used when spinal seeding is radiographically or pathologically evident. Spinal cord tumors are treated using localized fields to the primary site if not completely resected. Failure to control disease at the primary site remains the main impediment to cure.

Radiotherapy for pediatric brain tumors

Brain tumors in children are a diverse group of diseases that require multidisciplinary and subspecialty expertise. Radiation therapy is an established treatment cornerstone for these pediatric tumors. Basic concepts of radiation biology and physics provide a framework for understanding the ongoing evolution in radiation delivery techniques and current treatment paradigms. Standard techniques of pediatric central nervous system radiotherapy are included in this review, as well as newer techniques including conformal therapy, stereotactic radiosurgery, and fractionated stereotactic radiotherapy. Examples are provided to illustrate differences in treatment approaches. The appropriate application of each technique is discussed, and then outcomes and treatment sequelae are compared.

Primary intracranial germ cell tumors: clinicopathologic review of 32 cases

Primary intracranial germ cell neoplasms are rare tumors and constitute a heterogeneous group. We have reviewed 32 cases, over a 21-year period, from the University of Florida. The cases include 22 germinomas, 6 mixed germ cell tumors, and 4 teratomas. The clinical presentations in these cases were more closely related to the location of the tumor, that is, pineal or suprasellar, rather than the histologic subtype. Neuroimaging evaluation was useful in distinguishing between germinomas, teratomas, and other mixed germ cell tumors (MGCTs), primarily by evaluation of cystic versus solid lesions (teratoma versus germinoma), contents of cysts (teratoma versus MGCT), and infiltrative nature of the tumors (MGCT), although cytologic-histopathologic confirmation remains necessary. Germinomas responded favorably to radiation therapy with survival periods of over 16 years; MGCTs were treated with combination chemotherapy and radiation, with a markedly poorer prognosis. This study underlines the critical significance of histopathologic evaluation of the tumor in determining therapeutic interventions as well as prognosis.

Benign meningiomas: primary treatment selection affects survival

PURPOSE

To examine the effect of primary treatment selection on outcomes for benign intracranial meningiomas at the University of Florida.

METHODS AND MATERIALS

For 262 patients, the impact of age, Karnofsky performance status, pathologic features, tumor size, tumor location, and treatment modality on local control and cause-specific survival was analyzed (minimum potential follow-up, 2 years; median follow-up, 8.2 years). Extent of surgery was classified by Simpson grade. Treatment groups: surgery alone (n = 229), surgery and postoperative radiotherapy (RT) (n = 21), RT alone (n = 7), radiosurgery alone (n = 5). Survival analysis: Kaplan-Meier method with univariate and multivariate analysis.

RESULTS

At 15 years, local control was 76% after total excision (TE) and 87% after subtotal excision plus RT (SE+RT), both significantly better (p = 0.0001) than after SE alone (30%). Cause-specific survival at 15 years was reduced after treatment with SE alone (51%), compared with TE (88%) or SE+RT (86%) (p = 0.0003). Recurrence after primary treatment portended decreased survival, independent of initial treatment group or salvage treatment selection (p = 0.001). Atypical pathologic features predicted reduced 15-year local control (54 vs. 71%) and cause-specific survival rates (57 vs. 86%). Multivariate analysis for cause-specific survival revealed treatment group (SE vs. others; p = 0.0001), pathologic features (atypical vs. typical;p = 0.0056), and Karnofsky performance status (> or = 80 vs. < 80; p = 0.0153) as significant variables.

CONCLUSION

Benign meningiomas are well managed by TE or SE+RT. SE alone is inadequate therapy and adversely affects cause-specific survival. Atypical pathologic features predict a poorer outcome, suggesting possible benefit from more aggressive treatment. Because local recurrence portends lower survival rates, primary treatment choice is important.

Radiotherapy for pituitary adenoma: long-term outcome and sequelae

PURPOSE

To review outcome and treatment sequelae in patients treated with external beam radiotherapy for pituitary adenomas.

METHODS AND MATERIALS

One hundred forty-one patients with pituitary adenomas received radiotherapy at the University of Florida and had 2-year minimum potential follow-up. One hundred twenty-one had newly diagnosed adenomas, and 20 had recurrent tumors. Newly diagnosed tumors were treated with surgery and radiotherapy (n = 98) or radiotherapy alone (n = 23). Patients with recurrent tumors received salvage treatment with surgery and radiotherapy (n = 10) or radiotherapy alone (n = 10). The impact of age, sex, presenting symptoms, tumor extent, surgery type, degree of resection, hormonal activity, primary or salvage therapy, and radiotherapy dose on tumor control was analyzed. Tumor control is defined by the absence of radiographic progression and stable or decreased hormone level (in hormonally active tumors) after treatment. Effect of therapy on vision, hormonal function, neurocognitive function, life satisfaction, and affective symptoms were examined. A Likert categorical scale survey was used for assessment of neurocognitive, life satisfaction, and affective symptom status. Survey results from the radiotherapy patients were compared with a control group treated with transsphenoidal surgery alone. Multivariate analysis used the forward step-wise sequence of chi squares for the log rank test.

RESULTS

At 10 years, tumor control for the surgery and radiotherapy group (S + RT) was 95% and not statistically different (p = 0.58) than for patients treated with radiotherapy alone (RT) (90%). Patients with prolactin- and ACTH-secreting tumors had significantly worse tumor control, as did patients treated for recurrent tumors. Multivariate analysis for tumor control revealed that only young age was predictive of worse outcome (p = 0.0354). Visual function was either unaffected or improved in most patients, although four patients developed visual loss due to treatment. Hormonal function was affected adversely in 46 of the 93 patients for whom detailed hormonal information was available. Neurocognitive function evaluation revealed that patients in the S + RT group were more likely (p = 0.005) to report difficulty with memory than those in the RT-alone or S-alone groups. No significant difference in life satisfaction or affective symptoms was evident.

CONCLUSIONS

Pituitary adenomas are well controlled by external beam radiotherapy, either alone or in combination with surgery. Visual symptoms often improve after treatment. Hormonal sequelae require medical intervention in many patients. Neurocognitive sequelae may be different among treatment groups.

Randomized study of intensive MOPP-ABVD with or without low-dose total-nodal radiation therapy in the treatment of stages IIB, IIIA2, IIIB, and IV Hodgkin's disease in pediatric patients: a Pediatric Oncology Group study

PURPOSE

To determine whether the addition of low-dose total-nodal irradiation (TNI) in pediatric patients with advanced-stage Hodgkin's disease who have received eight cycles of alternating mechlorethamine, vincristine, procarbazine, and prednisone (MOPP) and doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) will improve the event-free survival (EFS) and overall survival (OS) when compared with patients who have received chemotherapy only.

PATIENTS AND METHODS

At diagnosis, 183 children and adolescents with stages IIB, IIIA2, IIIB, and IV Hodgkin's disease were randomized to receive eight cycles of alternating MOPP-ABVD with or without low-dose TNI.

RESULTS

Of 183 patients, four were rendered ineligible before treatment was initiated. One hundred sixty-one of 179 patients (90%) were in complete remission (CR) at the completion of eight cycles of alternating MOPP-ABVD; 81 were in the chemotherapy-only group and proceeded to observation off therapy, whereas 80 of 161 were to receive combined modality therapy (CMT). Nine of 80 patients randomized at the time of diagnosis to receive CMT did not receive radiation (RT) because of a protocol violation, but were monitored for EFS and OS and included in all analyses. The estimated EFS and OS rates at 5 years for the 179 eligible patients are 79% and 92%, respectively. The actuarial EFS at 5 years was 80% for patients who received CMT and 79% for patients who received MOPP-ABVD only. The OS for the former group is estimated to be 87% and for the latter patients 96%. Age < or = 13 years of age at diagnosis and the attainment of a clinical CR after three cycles of chemotherapy were associated with a statistically significant improved EFS.

CONCLUSION

Our results indicate that after the delivery of eight cycles of MOPP-ABVD, the addition of low-dose RT does not improve the estimated EFS or OS in pediatric patients with advanced-stage Hodgkin's disease.

Pituitary adenomas: current methods of diagnosis and treatment

Pituitary adenomas are benign neoplasms that can be effectively managed by a variety of therapeutic options. The clinician's goal in managing patients with these tumors should be to minimize the morbidity of each intervention used in diagnosis and treatment. Standard diagnostic interventions include MRI, hormonal assessment, and tissue diagnosis. Therapies include transsphenoidal surgery, external-beam radiotherapy, newer stereotactic irradiation techniques, and medical management. Appropriate treatment selection requires detailed knowledge of the expected outcomes and side effects of each option. Newer and perhaps less toxic treatment techniques are evolving and require further evaluation.

Second malignancies after Ewing's sarcoma: radiation dose-dependency of secondary sarcomas

BACKGROUND

An excess risk of second malignancies has been reported in survivors of Ewing's sarcoma. We examined a multiinstitutional data base to reevaluate the risk among survivors of Ewing's sarcoma and to identify possible causal factors.

METHODS

Information was derived from a data base that included 266 survivors of Ewing's sarcoma. Cumulative incidence rates of second malignancies were calculated. Contributions of clinical features, type and dose of chemotherapy, and cumulative radiation dose to the risk of second malignancies were evaluated.

RESULTS

After a median follow-up duration of 9.5 years (range, 3.0 to 30), 16 patients have developed second malignancies, which included 10 sarcomas (five osteosarcomas, three fibrosarcomas, and two malignant fibrous histiocytomas) and six other malignancies (acute myeloblastic leukemia, acute lymphoblastic leukemia, meningioma, bronchioalveolar carcinoma, basal cell carcinoma, and carcinoma-in-situ of the cervix). The median latency to the diagnosis of the second malignancy was 7.6 years (range, 3.5 to 25.7). The estimated cumulative incidence rates at 20 years for any second malignancy and for secondary sarcoma were 9.2% (SD = 2.7%) and 6.5% (SD = 2.4%), respectively. The cumulative incidence rate of secondary sarcoma was radiation dose-dependent (P = .002). No secondary sarcomas developed among patients who had received less than 48 Gy, while the absolute risk of secondary sarcoma was 130 cases per 10,000 person-years of observation among patients who had received > or = 60 Gy.

CONCLUSION

The overall risk of second malignancies after Ewing's sarcomas is similar to that associated with treatment for other childhood cancers. The radiation dose-dependency of secondary sarcomas justifies modification in therapy to reduce radiation doses.

Radiotherapy for local control of aggressive fibromatosis

PURPOSE

To evaluate local control rates in patients treated with radiotherapy for aggressive fibromatosis.

METHODS AND MATERIALS

Fifty-three patients with histologically confirmed aggressive fibromatosis were treated with radiotherapy at the University of Florida between march 1975 and June 1992. The minimum length of follow-up was 2 years; 81% of the patients had follow-up for at least 5 years. The lesions arose in an extremity or limb girdle (39 patients), the trunk (10 patients), or the head and neck area (4 patients). Twenty-four patients were treated for gross disease and 29 for presumed microscopic residual disease after one or more operations. Patients were treated with total doses between 35 and 70 Gy; 83% of patients received 50 to 60 Gy.

RESULTS

Local control was achieved in 23 of 29 patients (79%) treated postoperatively for microscopic residual disease and in 21 of 24 patients (88%) treated for gross disease; gross disease was controlled in all 8 patients with previously untreated lesions and in 13 of 16 patients treated postoperatively for gross residual or recurrent disease. Overall, aggressive fibromatosis was locally controlled in 83% of treated patients. All nine treatment failures occurred in patients with extremity lesions 4 to 68 months after initiation of treatment. Three recurrences were in the irradiated field, two were out of the field, and four were at the field margin. Eight patients were salvaged with surgery alone or combined with postoperative radiotherapy. A functional limb was maintained in 38 of 39 patients with extremity or limb girdle lesions. Pathologic fracture occurred in three patients; two patients required rod fixation for treatment.

CONCLUSIONS

Radiotherapy is a valuable adjunct to surgery in the management of aggressive fibromatosis and can be used alone in patients with unresectable or inoperable disease.

Solitary plasmacytoma of bone and soft tissue

PURPOSE

This retrospective review evaluates the results of radiotherapy used for curative intent in the management of solitary plasmacytoma.

METHODS AND MATERIALS

Between August 1963 and January 1993, 37 patients with a solitary plasmacytoma were treated with curative intent at the University of Florida. Criteria for inclusion in the study were (a) a biopsy-proven plasmacytoma, (b) no tumor in the bone marrow on biopsy, and (c) no evidence of disseminated disease on skeletal survey. The primary site was osseous in 27 patients and extramedullary in 10 patients; 9 of the 10 extramedullary lesions were located in the upper respiratory passages. Treatment consisted of primary radiotherapy in all but one patient, who received surgical resection alone. Two patients also received adjuvant chemotherapy. The median radiation dose was 43.2 Gy in 1.8-Gy fractions. Absolute survival, progression to myeloma, and local control rates were calculated using the Kaplan-Meier method. A multivariate analysis was performed for prognostic factors predictive of absolute survival.

RESULTS

Multivariate analysis revealed tumor type (osseous vs. extramedullary) to be predictive of absolute survival (p = 0.12). Factors not predictive of survival were age, sex, use of chemotherapy, immunoglobulin level, and type of immunoglobulin elevated. Patients with osseous tumors had a lower survival rate than those with extramedullary tumors (55% vs. 80% at 10 years, p = 0.06). Multiple myeloma was more likely to develop in patients with osseous tumors (54% vs. 11% at 10 years, 100% vs. 33% at 15 years, p = 0.03). Of patients in whom multiple myeloma developed, those with osseous tumors had a poorer survival rate after development of myeloma (32% vs. 100% at 5 years, p = 0.11). Local relapse developed in 1 patient with an osseous tumor 10 months after treatment with 28.3 Gy in 14 fractions; this was controlled with an additional 28.3 Gy in 10 fractions. Local failure did not develop in any patient with an extramedullary tumor.

CONCLUSIONS

Radiotherapy is an effective local treatment for solitary plasmacytoma. Osseous tumors were found to have a poor prognosis compared with extramedullary tumors.

Current controversies in pediatric radiation oncology

Radiotherapy is commonly used in Ewing's sarcoma and pediatric soft-tissue sarcomas. In Ewing's sarcoma, radiotherapy appears to produce survival rates similar to surgery if used to treat the primary lesion, though the data remain subject to interpretation. When surgery is used to treat the primary lesions, postoperative irradiation should be given if the margins are less than wide, though the response to chemotherapy may also influence local control. In nonrhabdomyosarcoma soft tissue sarcomas, postoperative irradiation should be given if the margins are less than wide, with doses of 54 Gy at 1.8 Gy per day; this provides excellent local control.

Local control and functional results after twice-daily radiotherapy for Ewing's sarcoma of the extremities

PURPOSE

Radiotherapy (RT) has been the predominant local treatment for Ewing's sarcoma of bone at the University of Florida. Twice-daily hyperfractionated RT was initiated in 1982 to improve local control and functional outcome. This retrospective review compares the results of once-daily vs. twice-daily RT in patients with primary Ewing's sarcoma of an extremity, with emphasis on functional outcome.

METHODS AND MATERIALS

Between June 1971 and January 1990, 37 patients were treated at the University of Florida for nonmetastatic Ewing's sarcoma of bone with a primary lesion in an extremity. Three patients underwent amputation. Of 34 patients treated with RT, 31 had RT alone and 3 had a combination of RT and local excision. Before 1982, 14 patients received once-daily RT; since 1982, 17 patients have received twice-daily RT. Doses of once-daily RT varied from 47 to 61 Gy at 1.8-2 Gy per fraction. Doses of twice-daily RT varied, depending on the response of the soft-tissue component of the tumor to chemotherapy, and ranged from 50.4 to 60 Gy at 1.2 Gy per fraction. Some patients in the twice-daily RT group also received total body irradiation 1-3 months after local RT as part of a conditioning regimen before marrow-ablative therapy with stem cell rescue. They received either 8 Gy in two once-daily fractions or 12 Gy in six twice-daily fractions. The six patients who received surgery were excluded from local control analysis. Local control rates were calculated using the Kaplan-Meier (actuarial) method. Fifteen patients had a formal functional evaluation.

RESULTS

In the 31 patients treated with RT alone, the actuarial local control rate at 5 years was 81% for patients treated twice daily and 77% for those treated once daily (p = NS). No posttreatment pathologic fractures occurred in patients treated twice daily, whereas five fractures occurred in those treated once daily (p = 0.01). On functional evaluation, less loss in range of motion (15 degrees vs. 28 degrees of loss, p = 0.02) and a lesser degree of muscle atrophy (8% vs. 21% loss in muscle circumference, p = 0.0004) occurred with twice-daily than with once-daily RT. A trend toward less fibrosis and less local alopecia was seen in patients treated twice daily. Patients treated twice daily received a higher Musculoskeletal Tumor Society functional rating (determined by the Department of Orthopaedics) than those treated once daily (29.4 vs. 26.0, p = 0.15).

CONCLUSIONS

Local control rates were similar in the two groups (77% vs. 81%), but functional results were superior in the group treated twice daily.

Accelerated hyperfractionated radiotherapy for malignant gliomas

PURPOSE

To evaluate accelerated hyperfractionated radiotherapy for the treatment of malignant gliomas.

METHODS AND MATERIALS

Between April 1985 and June 1994, 70 adult patients with pathologically confirmed malignant glioma (75% glioblastoma multiforme, 25% anaplastic astrocytoma) suitable for high-dose therapy were selected for treatment with accelerated hyperfractionated radiotherapy, 1.5 Gy twice daily to a total target dose of 60 Gy. Two patients were excluded from analysis (one patient had a fatal pulmonary embolism after 18 Gy; one patient discontinued therapy after 28.5 Gy against medical advice and without sequelae or progression). The 68 patients in the study group had a median age of 52 years and a median Karnofsky performance status of 90. Stereotactic implant (125I) or stereotactic radiosurgery boosts were delivered to 16 patients (24%) in the study group. Minimum follow-up was 6 months.

RESULTS

Median survival was 13.8 months and median progression-free survival was 7.4 months. The absolute Kaplan-Meier survival rate was 16% at 2 years and 4% at 5 years. Multivariate analysis for the prognostic impact of age, gender, histology, Karnofsky performance status, symptomatology, surgical resection vs. biopsy, and boost vs. nonboost therapy revealed that Karnofsky performance status > or = 90, boost therapy, and surgical excision predicted significantly improved outcome. No severe toxicity occurred in patients treated with accelerated hyperfractionated radiotherapy alone, although 5% required steroids temporarily for edema. Progression occurred during treatment in one patient (1.5%).

CONCLUSION

This regimen of accelerated hyperfractionated radiotherapy is well tolerated and leads to results comparable with those of standard therapy. The rate of disease progression during treatment is significantly better (p = 0.001) than is reported for patients treated with standard fractionation, with or without chemotherapy. This regimen is a reasonable starting point for future trials and may have some advantages over standard fractionation.

Radiotherapy alone for carcinoma of the vagina: the importance of overall treatment time

PURPOSE

Review treatment results, complications, and the importance of overall treatment time for carcinoma of the vagina treated with radiotherapy alone.

METHODS AND MATERIALS

Between October 1964 and October 1990, 65 patients with histologically confirmed carcinoma of the vagina received definitive radiotherapy at the University of Florida. All patients had a minimum 2-year follow-up. Most patients were treated with a combination of external-beam radiotherapy and brachytherapy. The probability of pelvic control, cause-specific survival, and complications was calculated and multivariate analyses were performed. The log-rank test was used to determine significance levels between the curves.

RESULTS

The 5-year cause-specific survival rates were, Stage 0 (six patients), 100%; Stage I (17 patients), 94%; Stage IIA (six patients), 80%; Stage IIB (ten patients), 39%; Stage III (twn patients), 79%; and Stage IVA (six patients), 62%. The pelvic control rates at 5 years were: Stage 0, 100%; Stage I, 87%; Stage IIA, 88%; Stage IIB, 68%; Stage III, 80%; and Stage IVA, 67%. The parameters of stage, patient age, total dose to primary site, and overall treatment time were evaluated in a multivariate analysis. The single most important predictor of pelvic control was overall treatment time. If the entire course of radiotherapy (external beam + implant) was completed within 9 weeks (63 days), the pelvic control rate was 97%. The pelvic control rate was only 54% if treatment time extended beyond 9 weeks (p = .0003). The rate of severe complications was 12%, and the incidence increased with increasing total primary dose.

CONCLUSION

Radiotherapy alone can cure a significant proportion of patients with carcinoma of the vagina. Treatment should be completed without significant interruption, preferably within 9 weeks.

Stage III ovarian carcinoma: an analysis of treatment results and complications following hyperfractionated abdominopelvic irradiation for salvage

PURPOSE

Patients with persistent disease found at laparotomy following platinum-based chemotherapy for Stage III ovarian carcinoma have a remote chance of cure with second-line chemotherapy or conventional radiotherapy. To decrease relapse rates and improve tolerance, we have used twice-daily radiotherapy in 28 such patients.

METHODS AND MATERIALS

Twenty-eight patients with Stage III epithelial ovarian carcinoma were treated with curative intent at the University of Florida with hyperfractionated, continuous-course radiotherapy for persistent disease at laparotomy after administration of platinum-based chemotherapy. All patients received .8 Gy per fraction, twice daily, to a mean total dose of 30.2 Gy to the whole abdomen and pelvis; 20 patients had additional radiotherapy to the pelvis (mean, 14.54 Gy). All patients had undergone two to four (mean, 2.6) laparotomies for ovarian carcinoma and had received 6-28 (mean, 12) cycles of chemotherapy before irradiation.

RESULTS

With a 2-year minimum follow-up, survival rates at 1, 2, and 5 years were as follows: absolute survival, 79%, 50%, 21%; relapse-free survival, 52%, 36%, 19%. For the 11 patients with no evidence of gross residual disease after the second-look laparotomy, the absolute survival rates were 100%, 73%, and 27%. This was superior to the rates of 65%, 34%, and 18% for the 17 patients who had gross residual disease. Only two patients required treatment breaks. Four patients required surgical intervention for small-bowel obstruction, which in two cases revealed recurrent disease. Two patients died of treatment-related complications. Twenty-two of 23 failures occurred in the abdomen and/or pelvis.

CONCLUSION

Although most patients eventually relapse, a small percentage have had a prolonged disease-free interval. Since treatment was relatively well tolerated, escalation of the dose of hyperfractionated abdominopelvic irradiation is being investigated.

High-dose chemotherapy with marrow reinfusion and hyperfractionated irradiation for children with high-risk brain tumors

Between November 1990 and March 1993, nine pediatric patients with newly diagnosed brain tumors having a high risk of failure with standard treatment received high-dose thiotepa/cyclophosphamide chemotherapy followed by autologous bone marrow infusion and involved-field hyperfractionated radiation therapy. The presenting diagnoses were brainstem glioma (BSG) [6], parietal mixed high-grade oligodendroglioma-astrocytoma [1], thalamic anaplastic astrocytoma [1], and high-grade parietal glioma [1]. Following chemotherapy there were two partial responses, one minor response, three with stable disease, and one with progressive disease. Responses were not evaluated in two patients who had toxic deaths. Following radiation two patients, one with brainstem glioma and one with anaplastic mixed glioma, achieved complete remission. The overall survival is no better than conventional therapy.

Value of thallium-201 SPECT imaging in childhood brain tumors

Thallium-201 chloride single photon emission computed tomography (201Tl SPECT) has been proposed as a diagnostic tool in the assessment of patients with brain tumors. We performed SPECT scans coupled with magnetic resonance imaging (MRI) in children with brain tumors to determine the sensitivity and potential value of SPECT in neuro-oncology. Each patient was injected with 2.5-3.0 mCi of thallium chloride, followed by technetium-99m HMPAO (5-15 mCi) to assess cerebral perfusion. 201Tl uptake was imaged with triple-headed SPECT in 20/24 (83%) histologically and anatomically diverse neoplasms with MRI-measurable residual disease, including 13/16 (80%) posterior fossa tumors. 201Tl SPECT demonstrated uptake in tumors with MRI volumes ranging from 0.03 to 60 cm3. 201Tl SPECT imaging was not correlated with the following MRI features: gadolinium enhancement, necrosis, exophytic, unicentric and multicentric. 201Tl uptake was not detectable in patients with tumors of maldevelopmental origin or radionecrosis. It is suggested that 201Tl SPECT is an important imaging adjunct in the assessment of children with brain tumors.

Lhermitte's sign: incidence and treatment variables influencing risk after irradiation of the cervical spinal cord

PURPOSE

Lhermitte's sign is a relatively infrequent sequela of irradiation of the cervical spinal cord. In this study, we sought to determine whether various treatment parameters influenced the likelihood of developing Lhermitte's sign.

METHODS AND MATERIALS

Between October 1964 and December 1987, 2901 patients with malignancies of the upper respiratory tract were treated at the University of Florida. The dose of radiation to the cervical spinal cord was calculated for those patients who had a minimum 1-year follow-up. A total of 1112 patients who received a minimum of 3000 cGy to at least 2 cm of cervical spinal cord were included in this analysis.

RESULTS

Forty patients (3.6%) developed Lhermitte's sign. The mean time to development of Lhermitte's sign after irradiation was 3 months, and the mean duration of symptoms was 6 months. No patient with Lhermitte's sign developed transverse myelitis. Several variables were examined in a univariate analysis, including total dose to the cervical spinal cord, length of cervical spinal cord irradiated, dose per fraction, continuous-course compared with split-course radiotherapy, and once-daily compared with twice-daily irradiation. Only two variables proved to be significant. Six (8%) of 75 patients who received > or = 5000 cGy to the cervical spinal cord developed Lhermitte's sign compared with 34 (3.3%) of 1037 patients who received < 5000 cGy (p = .04). For patients treated with once-daily fractionation, 28 (3.4%) of 821 patients who received < 200 cGy per fraction developed Lhermitte's sign compared with 6 (10%) of 58 patients who received > or = 200 cGy (p = .02).

CONCLUSION

An increased risk of developing Lhermitte's sign was demonstrated for patients who received either > or = 200 cGy per fraction (one fraction per day) or > or = 5000 cGy total dose to the cervical spinal cord.

With modern imaging techniques, is staging laparotomy necessary in pediatric Hodgkin's disease? A Pediatric Oncology Group study

PURPOSE

To determine whether the information gained from staging laparotomy can be predicted by imaging and/or clinical factors in children with Hodgkin's disease.

PATIENTS AND METHODS

Between 1986 and 1991, 216 consecutive pediatric patients with Hodgkin's disease underwent laparotomy and were treated on two concurrent protocols in a multiinstitutional cooperative group. All patients had computed tomography (CT) of the chest, abdomen, and pelvis. Clinical factors studied included sedimentation rate, B symptoms, histology, number and location of involved sites, sex, mediastinal involvement, and age. Pretreatment CTs were centrally reviewed in 88 cases for the presence and size of both supradiaphragmatic and infradiaphragmatic lymph nodes, intrinsic spleen lesions, and splenic size. Models were generated that were predictive of any abdominal disease, splenic involvement, extensive splenic involvement, and upstaging at the laparotomy. False-positive and false-negative rates were calculated.

RESULTS

For the end point of any abdominal disease, a model based on B symptoms, histology, sedimentation rate, and number and location of involved sites was highly significant (P < .0001). However, the success in predicting abdominal disease in an individual patient was limited: false-negative rate, 26%; false-positive rate, 32%. Highly significant models based on clinical factors and/or radiographic findings were also generated to predict splenic involvement, extensive splenic involvement, and upstaging with laparotomy, but they also had high false-positive and false-negative rates.

CONCLUSION

Laparotomy findings cannot be predicted accurately in the majority of patients based on knowledge of CT findings and clinical factors.

Elective inguinal lymph node irradiation for pelvic carcinomas. The University of Florida experience

BACKGROUND

There is little published information pertaining to elective inguinal lymph node irradiation for carcinomas originating in the pelvis that place the inguinal lymph nodes at risk.

METHODS

Between October 1964 and October 1988, 164 patients with primary carcinomas originating in the pelvis that placed the inguinal lymph nodes at risk for subclinical disease received elective inguinal lymph node irradiation at the University of Florida. All patients had a minimum follow-up of 2 years from the start of radiation therapy. Primary sites included the penis, urethra, vulva, anal canal, distal rectum (within 4 cm of the verge), and the cervix or vagina when the tumor involved the distal one-third of the vagina. In 148 patients, both groins were clinically negative; in 16 patients, one groin was positive and the other negative by clinical examination. Treatment techniques were individualized according to the primary site. Tumor doses to the inguinal lymph nodes varied, although more than 70% of patients received 4500-5000 cGy (range, 2650-6780 cGy) over 5 weeks (range, 2-7 weeks) at 180-200 cGy per fraction. Patients were excluded from the analysis of disease control in the inguinal area if they died less than 2 years from treatment with the inguinal lymph nodes continuously disease free or if they experienced recurrence at the primary site with the inguinal lymph nodes clinically negative at the time of recurrence.

RESULTS

The inguinal lymph node control rate was 96% (101 of 105). No patient in whom recurrent disease developed in the inguinal lymph nodes underwent salvage therapy.

CONCLUSIONS

Elective irradiation of the inguinal lymph nodes is highly effective in controlling subclinical disease from carcinomas originating in the pelvis and can be accomplished with minimal acute or long-term complications.

Radiation therapy for giant cell tumor of bone

PURPOSE

Giant cell tumor of bone is usually treated with surgical curettage. For recurrent tumors, tumors that are inoperable because of location, and tumors that would require amputation or another radical procedure limiting function, does radiotherapy provide an alternative for local control?

METHODS AND MATERIALS

Sixteen patients with histologically confirmed, giant cell tumor of bone were treated at the University of Florida with irradiation between March 1973 and September 1988. Minimum follow-up was 32 months; 63% of the patients had follow-up for at least 5 years, 44% for greater than 10 years. All sites received doses of 35 Gy or more, and all were treated with megavoltage irradiation.

RESULTS

In 12 (75%) of 16 patients, the tumor was controlled locally with irradiation. The four failures occurred at 8, 13, 13, and 25 months following initiation of treatment. Surgical salvage was successful in all four failures for an overall local control rate of 100%. One patient developed pulmonary metastasis 1 month after surgical salvage and is alive without evidence of disease after multiple courses of chemotherapy, surgical resection, and whole-lung irradiation. All patients tolerated the treatment well with no severe or chronic complications. No secondary soft-tissue sarcomas have occurred within the irradiated areas.

CONCLUSION

Giant cell tumor of bone is not a radioresistant tumor as once believed, and complications seen with modern treatment regimens are minor.

Brainstem glioma: I. Pathology, clinical features, and therapy

Gliomas that arise in the brain stem have been associated with a poor prognosis. Diagnostic neuroimaging readily identifies the tumor as it extends between normal brainstem structures. Histologic sampling of tumor with stereotactic methods is notoriously unreliable in establishing a definitive prognosis. Clinical trials that incorporate high-dose chemotherapy, autologous bone marrow rescue, and irradiation hold promise of better tumor control by overcoming the inaccessibility of the central nervous system to standard doses of chemotherapy. We review the pathology, clinical features, neuroimaging features, and current therapeutic concepts relative to brainstem glioma. The pediatric neurologist has a pivotal role in identifying and monitoring children with this malignancy.

Pulmonary function tests after whole-lung irradiation and doxorubicin in patients with osteogenic sarcoma

PURPOSE

Because of the scarcity of information regarding long-term follow-up of pulmonary function after whole-lung irradiation, a prospective study was started at the University of Florida in 1979 to evaluate pulmonary function after treatment with whole-lung irradiation and doxorubicin in patients with osteogenic sarcoma.

PATIENTS AND METHODS

Between 1979 and 1984, 57 osteogenic sarcoma patients with no evidence of metastatic disease at diagnosis received adjuvant therapy consisting of whole-lung irradiation (with the heart shielded) followed by Adriamycin (doxorubicin; Adria Laboratories, Columbus, OH). The whole-lung irradiation schema was 1,600 cGy in 10 fractions with 8-MV x-rays via anterior and posterior fields. This was followed by five cycles of Adriamycin for a total dose of 450 mg/m2. Pulmonary function tests (PFTs) consisting of spirometry, lung volumes, and diffusing capacity were obtained before the whole-lung irradiation, at 6 and 12 months after irradiation, and at yearly intervals thereafter.

RESULTS

At the time of analysis, 28 of the 57 patients were available for study, with a mean follow-up of 42 months (range, 6 to 77 months). Follow-up pulmonary function testing revealed decreased forced vital capacity (FVC) and forced expiratory volume at 1 second (FEV1) during the first 6 to 12 months after whole-lung irradiation. These values returned to baseline during the second-year posttherapy and remained at baseline throughout the remainder of the follow-up period. Changes in lung volumes demonstrated a similar early trend, with significant decreases in total lung capacity (TLC) and functional residual capacity (FRC) at 6 to 12 months. These changes, however, did not improve significantly during the remainder of the follow-up period. Diffusing capacity of the lungs for carbon monoxide (DLCO) also reached a nadir at 6 to 12 months after whole-lung irradiation, with resolution by 2 years and maintenance of at least baseline values for the remainder of the follow-up period.

CONCLUSIONS

Treatment with whole-lung irradiation and Adriamycin, as given in this study, caused no significant sequelae, as demonstrated by pulmonary function testing during the mean follow-up period of 42 months, although a mild, transient restrictive ventilatory defect occurred at 6 to 12 months after treatment.

Local control and function after twice-a-day radiotherapy for Ewing's sarcoma of bone

Between February 1982 and December 1987, 39 patients with Ewing's sarcoma of bone have been treated at the University of Florida with a twice-a-day radiotherapy regimen to their primary lesion, 35 with radiation alone and 4 with a combination of radiation and surgery. Although three separate systemic regimens were used (standard risk, 1982-1987 [SR-1]; high-risk, 1982-1984 [HR-2]; and high-risk, 1985-1987 [HR-3]), the radiotherapy regimen remained constant through the years of the study. Those patients whose soft-tissue mass completely regressed after induction chemotherapy received 5040 cGy (as did patients with no soft-tissue mass at diagnosis), those who had 50% or greater resolution of the soft-tissue mass received 5520 cGy, and those who had less than 50% regression of the soft-tissue mass or progressive disease during induction chemotherapy received 6000 cGy. All patients were treated with 120 cGy twice a day and a 6-hr separation between fractions. Thirteen patients also received 800 cGy of total body radiotherapy (TBI) 1 to 3 months after local radiotherapy as part of their systemic treatment. In the 33 patients treated with radiotherapy alone who were eligible for local control analysis, there have been three local failures to date, all within the first 21 months after diagnosis. The 5-year local control rate was 88% for SR-1, 80% for HR-2, and 92% for HR-3. Local control was not related to total dose, but by design, the patients with the largest lesions and the poorest response to chemotherapy had the highest doses. In the 20 patients presenting with extremity primary lesions, there have been no pathologic fractures. In patients evaluated for limb function, the late effects have been minimal. The twice-a-day regimen used appears to produce good local control rates with improved long-term function as compared with once-a-day regimens.

The impact of pelvic recurrence and elective pelvic irradiation on survival and treatment morbidity in early-stage Hodgkin's disease

A retrospective analysis of patients with supradiaphragmatic Stage I-II Hodgkin's disease was performed to assess the impact of pelvic recurrence and elective pelvic irradiation on survival and treatment morbidity. One hundred twenty patients were treated with radiotherapy (RT) alone; 38 received total nodal (including pelvic) irradiation (TNI), 63 received modified total nodal (excluding pelvic) irradiation (MTNI), and 19 received involved-field or mantle irradiation only (less than MTNI). Thirty-three patients received combined-modality therapy. In laparotomy-staged (PS) patients treated with RT alone, the overall treatment failure rate was 13% after TNI, 24% after MTNI, and 43% after less than MTNI. The pelvic failure rate in PS patients was 0% after TNI, 9% after MTNI, and 29% after less than MTNI. Cause-specific deaths in patients treated with RT alone occurred in 10% following less than MTNI, 13% following MTNI, and 10% following TNI. Cause-specific deaths due to pelvic failure in patients treated with RT alone occurred in 5% following IF and 6% following MTNI, and also occurred in 7% of patients receiving combined-modality therapy. The potential disadvantages of elective pelvic irradiation in early-stage Hodgkin's disease include compromise of future tolerance of chemotherapy in the event of treatment failure, and infertility. Gonadal function was assessed in 67 patients less than 35 years old at the time of treatment. Compromise of gonadal function was correlated with the lack of special testicular shielding during pelvic irradiation and chemotherapy in the male, and with no oophoropexy before pelvic irradiation in the female. Twelve of 26 patients with recurrence after either less than MTNI or MTNI, with or without chemotherapy, were alive and without evidence of disease at greater than 2 years after completing salvage therapy, compared with 7 of 11 patients with recurrence after TNI.

Late follow-up of a short-term intensive regimen for Ewing's sarcoma

Twenty-two patients received a short-term intensive regimen for Ewing's sarcoma between November 1977 and December 1981. The regimen consisted of vincristine (1.5 mg/m2) on day 1, and doxorubicin HCl (75 mg/m2) plus cyclophosphamide (1,000 mg/m2) on day 2. Six cycles were given at 28-day intervals. Local irradiation was started shortly after cycle 2. Eight patients with lesions of expendable bones also underwent surgery as part of the treatment to the primary site, 4 at the end of chemotherapy and 4 at diagnosis. The 5-year event-free survival rate was 45% for all patients and 48% for those with localized disease at diagnosis. Two patients died of treatment-related toxicity. The most common form of failure was distant metastases, indicating that finding a better systemic treatment remains the problem in eradicating Ewing's sarcoma.

Long-term follow-up of radiotherapy for pituitary adenoma: the absence of late recurrence after greater than or equal to 4500 cGy

Recent literature has suggested that late recurrence of pituitary adenoma after radiotherapy is common. We hypothesized that late failures might be a result of inadequate dose (less than 4500 cGy). To investigate, we analyzed 105 patients treated at our institution between 1965 and 1986 (analysis, 2/89). The minimum observation time was greater than or equal to 5 years in 58% and greater than or equal to 10 years in 30% of the patients. All patients received megavoltage radiotherapy (range, 4200-5500 cGy; mean, 4821 cGy) at a mean dose per fraction of 172 cGy; 100 patients received greater than or equal to 4500 cGy tumor dose. Twenty-nine patients received radiotherapy alone, and 76 had postoperative radiotherapy after frontal craniotomy (20 patients) or transsphenoidal hypophysectomy (56 patients). At presentation, 71% of patients had extrasellar disease, 57% had visual field deficits, and 50% had endocrinopathy. Of patients treated postoperatively, 74% had gross residual disease. Four local failures occurred at 13, 16, 57, and 64 months after postoperative radiotherapy, all within the irradiated volume (tumor doses of 4700, 4715, 5000, and 5100 cGy). All four patients had presented with moderate to extensive extrasellar disease with visual field defects. Two of the four remain free of second recurrence at 7 and 13 years after salvage transsphenoidal hypophysectomy. The local control rate with radiotherapy (product-limit method) at 10 years was 100% in the radiotherapy-alone group and 92% in the postoperative radiotherapy group (95% for all patients). To prevent bias, seven patients who received bromocriptine, none of whom demonstrated a recurrence, were censored from the local control analysis at the initiation of the drug. No patient in this study suffered recurrence greater than 64 months after radiotherapy, with 31 patients (none with bromocriptine) observed 10 to 21 years. We conclude that treatment of pituitary adenoma with greater than or equal to 4500 cGy in 25 fractions can result in a high (greater than or equal to 90%) probability of stable long-term control.

Preoperative irradiation for soft tissue sarcomas of the trunk and extremities in adults

Between May 1978 and January 1987, 58 adult patients with previously untreated sarcomas of the trunk and extremities were treated with preoperative irradiation and surgery at the University of Florida. All patients had a minimum of 2 years of follow-up; 24 had a minimum of 5 years of follow-up. The preoperative dose was usually 5040 cGy, with 120-125 cGy per fraction delivered twice daily. Operations were performed 2 to 6 weeks after radiation therapy. Eight patients received adjuvant chemotherapy. The tumors were high grade in 52 (90%), measured greater than 10 cm in 45 (78%), and were extracompartmental in 49 (84%). The surgical margins were wide in 17, marginal in 31, and intralesional in 10 patients. A functional extremity was preserved in 47 of 54 patients who would have required an amputation had they been treated by operation alone. Five of 58 patients (9%) developed local failure; in three, the failure occurred outside of the irradiated volume. Survival rates (product-limit method) at 5 years according to grade and size of lesion were as follows: low grade, 100%; high grade, 10 cm or less in largest diameter, 68%; high grade, 11-20 cm, 39%. Data are insufficient for a 5-year analysis of high-grade lesions greater than 20 cm; to date, there are no 5-year survivors in these patients. Moderate and severe wound complications occurred in 16%. There were four pathological fractures in 52 long bones at risk.

Successful strategy for prevention of cytomegalovirus interstitial pneumonia after human leukocyte antigen-identical bone marrow transplantation

Cytomegalovirus (CMV) interstitial pneumonia is a frequent and often fatal complication of allogeneic bone marrow transplantation. Because therapy for CMV pneumonia was, until recently, largely ineffective, prophylactic methods were explored. This study shows that the strategy of using CMV seronegative blood products for seronegative patients with seronegative donors or weekly administration of intravenous immunoglobulin for all other patients reduced the attack rate of CMV pneumonia. The results of this study are put into the perspective of previously published data.

The incidence of myelitis after irradiation of the cervical spinal cord

To further define the tolerance of the cervical spinal cord, the dose of radiation to the cervical spinal cord was calculated for all 2901 patients with malignancies of the upper respiratory tract treated at the University of Florida between October 1964 and December 1987. To further define the population evaluated, certain criteria were used: (a) a minimum of 3000 cGy to at least 2 cm of cervical spinal cord and (b) a minimum of 1 year of follow-up, unless a neurological complication occurred before 1 year. A total of 1112 patients were evaluable, of which 2 (0.18%) developed radiation myelitis. One received 4658 cGy to the cervical cord at 172.5 cGy per day, and the other patient received 4907 cGy to the cord at 169.2 cGy per day. The risk of myelitis at each dose level was 0/124 at 3000-3999 cGy, 0/442 at 4000-4499 cGy, 2/471 at 4500-4999 cGy, and 0/75 at a cord dose of 5000 cGy or greater.

Clinical stage I and II endometrial carcinoma treated with surgery and/or radiation therapy: analysis of prognostic and treatment-related factors

This is an analysis of 266 patients with clinical stage I and II endometrial carcinoma treated with curative intent at the University of Florida between October 1964 and December 1980. There was a minimum 5-year follow-up. Thirty-nine patients who died of intercurrent disease less than 5 years from treatment were excluded from analysis of pelvic disease control and determinate disease-free survival. All patients were included in the analysis of complications. Pelvic disease control and determinate disease-free survival rates at 5 years were 91 and 88%, respectively, for stage I and 84 and 68% for stage II. There was no apparent difference in the rates of local control and survival or in the incidence of complications when comparing preoperative with postoperative radiation therapy. Tumor grade, stage, depth of myometrial invasion, and history of exogenous estrogen use or abnormal estrogen balance were of prognostic significance. Data on pelvic disease control, survival, and treatment complications are outlined, and management guidelines are discussed.