Children and youth's biopsychosocial wellbeing in the context of energy resource activities

BACKGROUND

Children and youth emerge as key populations that are impacted by energy resource activities, in part because of their developmental vulnerabilities, as well as the compounding effects of energy systems on their families, communities, and physical environments. While there is a larger literature focused on fossil fuel emissions and children, the impacts of many aspects of energy systems on children and youth remain under examined and scattered throughout the health, social science, and environmental science literatures.

OBJECTIVES

This systematic interdisciplinary review examines the biological, psychosocial, and economic impacts of energy systems identified through social science research - specifically focused on household and industrial extraction and emissions - on children and youth functioning.

METHODS

A critical interpretive search of interdisciplinary and international social sciences literature was conducted using an adaptive protocol focusing on the biopsychosocial and economic impacts of energy systems on children and youth. The initial results were complemented with a purposeful search to extend the breadth and depth of the final collection of articles.

DISCUSSION

Although relatively few studies have specifically focused on children and youth in this context, the majority of this research uncovers a range of negative health impacts that are directly and indirectly related to the development and ongoing operations of natural resource production, particularly oil and gas, coal, and nuclear energy. Psychosocial and cultural effects, however, remain largely unexamined and provide a rich avenue for further research.

CONCLUSIONS

This synthesis identifies an array of adverse biopsychosocial health outcomes on children and youth of energy resource extraction and emissions, and identifies gaps that will drive future research in this area.

"That was the Last Time I Saw my House": The Importance of Place Attachment among Children and Youth in Disaster Contexts

Place attachment is important for children and youth's disaster preparedness, experiences, recovery, and resilience, but most of the literature on place and disasters has focused on adults. Drawing on the community disaster risk reduction, recovery, and resilience literature as well as the literature on normative place attachment, children and youth's place-relevant disaster experiences are examined. Prior to a disaster, place attachments are postulated to enhance children and youth's disaster preparedness contributions and reinforce their pre-disaster resilience. During a disaster, damage of, and displacement from, places of importance can create significant emotional distress among children and youth. Following a disaster, pre-existing as well as new place ties can aid in their recovery and bolster their resilience moving forward. This framework enriches current theories of disaster recovery, resilience, and place attachment, and sets an agenda for future research.

Planning for disaster resilience in rural, remote, and coastal communities: moving from thought to action

Disaster resilience is the cornerstone of effective emergency management across all phases of a disaster from preparedness through response and recovery. To support community resilience planning in the Rural Disaster Resilience Project (RDRP) Planning Framework, a print-based version of the guide book and a suite of resilience planning tools were field tested in three communities representing different regions and geographies within Canada. The results provide a cross-case study analysis from which lessons learned can be extracted. The authors demonstrate that by encouraging resilience thinking and proactive planning even very small rural communities can harness their inherent strengths and resources to enhance their own disaster resilience, as undertaking the resilience planning process was as important as the outcomes.The resilience enhancement planning process must be flexible enough to allow each community to act independently to meet their own needs. The field sites demonstrate that any motivated group of individuals, representing a neighborhood or some larger area could undertake a resilience initiative, especially with the assistance of a bridging organization or tool such as the RDRP Planning Framework.

Like a fish out of water: reconsidering disaster recovery and the role of place and social capital in community disaster resilience

In this paper we draw on the findings of a critical, multi-sited ethnographic study of two rural communities affected by a wildfire in British Columbia, Canada to examine the salience of place, identity, and social capital to the disaster recovery process and community disaster resilience. We argue that a reconfiguration of disaster recovery is required that more meaningfully considers the role of place in the disaster recovery process and opens up the space for a more reflective and intentional consideration of the disorientation and disruption associated with disasters and our organized response to that disorientation. We describe a social-psychological process, reorientation, in which affected individuals and communities navigate the psychological, social and emotional responses to the symbolic and material changes to social and geographic place that result from the fire's destruction. The reorientation process emphasizes the critical importance of place not only as an orienting framework in recovery but also as the ground upon which social capital and community disaster resilience are built. This approach to understanding and responding to the disorientation of disasters has implications for community psychologists and other service providers engaged in supporting disaster survivors. This includes the need to consider the complex dynamic of contextual and cultural factors that influence the disaster recovery process.

Sequestering of Suffering

This article is a critical discourse analysis of the local print-news media coverage of the recovery process in two rural communities following a devastating forest fire. Two hundred and fifty fire-related articles from the North Thompson Star Journal (2003) were analyzed. Results revealed a neoliberal discursive framing of recovery, emphasizing the economic-material aspects of the process and a reliance on experts. A sequestering of suffering discourse promoted psychological functionalism and focused attention on a return to normalcy through the compartmentalization of distress. The dominant ' voice' was male, authoritative, and institutionalized. Implications for disaster recovery and potential health consequences are discussed.

Radiosurgery for skull base malignancies and nasopharyngeal carcinoma

PURPOSE

Patients with skull base lesions present a challenging management problem because of intractable symptoms and limited therapeutic options. In 1989 we began treating selected patients with skull base lesions using linac stereotactic radiosurgery. In this study the efficacy and toxicity of this therapeutic modality is investigated.

METHODS AND MATERIALS

Forty-seven patients with 59 malignant skull base lesions were treated with linac radiosurgery between 1989 and 1995. Eleven patients were treated for primary nasopharyngeal carcinoma using radiosurgery as a boost (7 Gy-16 Gy, median: 12 Gy) to the nasopharynx after a course of fractionated radiotherapy (64.8-70 Gy) without chemotherapy. Another 37 patients were treated for 48 skull base metastases or local recurrences from primary head and neck cancers. Eight of these patients had 12 locally recurrent nasopharyngeal carcinoma lesions occuring 6-96 months after standard radiotherapy, including one patient with nasopharyngeal carcinoma who developed a regional relapse after radiotherapy with a stereotactic boost. Lesion volumes by CT or MRI ranged from 0 to 51 cc (median: 8 cc). Radiation doses of 7.0 Gy-35.0 Gy (median: 20.0 Gy) were delivered to recurrent lesions, usually as a single fraction.

RESULTS

All 11 patients who received radiosurgery as a nasopharyngeal boost after standard fractionated radiotherapy remain locally controlled (follow-up: 2-34 months, median: 18). However, one patient required a second radiosurgical treatment for regional relapse outside the initial radiosurgery volume. Thirty-three of 48 (69%) recurrent/metastatic lesions have been locally controlled, including 7 of 12 locally recurrent nasopharyngeal lesions. Follow-up for all patients with recurrent lesions ranged from 1 to 60 months (median: 9 months). Local control did not correlate with lesion size (p = 0.80), histology (p = 0.78), or radiosurgical dose (p = 0.44). Major complications developed after 5 of 59 treatments (8.4%), including three cranial nerve palsies, one CSF leak, and one trismus. Complications were not correlated with radiosurgical volume (p = 0.20), prior skull base irradiation (p = 0.90), or radiosurgery dose > 20 Gy (p = 0.49).

CONCLUSION

Stereotactic radiosurgery is a reasonable treatment modality for patients with skull base malignancies, including patients with primary and recurrent nasopharyngeal carcinoma. The dose distribution obtained with stereotactic radiosurgery provides better homogeneity than an intracavitary implant when used as a boost for nasopharyngeal lesions, especially lesions which involve areas distant to the nasopharyngeal mucosa.

Gastrointestinal cancer after treatment of Hodgkin's disease

PURPOSE

This study aimed to quantify the risk of gastrointestinal cancer following Hodgkin's disease treatment according to age at treatment, type of treatment, and anatomic sites.

METHODS AND MATERIALS

Cases were identified from the records of 2,441 patients treated for Hodgkin's disease between 1961 and 1994. Follow-up averaged 10.9 years, representing 26,590 person-years of observation. Relative risks (RR) for gastrointestinal cancer incidence and mortality were computed by comparison with expected annualized rates for a general population matched for age, sex, and race.

RESULTS

Gastrointestinal cancers developed in 25 patients. The incidence RR was 2.5 [95% confidence interval (CI), 1.5-3.5] and mortality RR was 3.8 (CI, 2.4-4.7). Sites associated with significantly increased risks included the stomach [RR 7.3 (CI, 3.4-13.8)], small intestine [RR 11.6 (CI, 1.9-38.3)], and pancreas [RR 3.5 (CI, 1.1-8.5)]. Risk was significantly elevated after combined modality therapy, RR 3.9 (CI, 2.2-5.6). The risk after radiotherapy alone was 2.0 (CI, 1.0-3.4), not a statistically significant elevation. The RR for gastrointestinal cancer was greatest after treatment at young age and decreased with advancing age. It was significantly elevated within 10 years after treatment [RR 2.0 (CI, 1.1-3.5)] and increased further after 20 years [RR 6.1 (CI, 2.5-12.7)]. Risk assessed by attained age paralleled risk according to age at treatment. Fifteen cases of gastrointestinal cancers arose within the irradiation fields.

CONCLUSION

Patients treated for Hodgkin's disease are at modestly increased risk for secondary gastrointestinal cancer, especially after combined modality therapy and treatment at a young age. Risk was highest more than 20 years after treatment, but was significantly elevated within 10 years. Gastrointestinal sites with increased risk included the stomach, pancreas, and small intestine.

The accuracy of dose localization for an image-guided frameless radiosurgery system

A compact X-band accelerator mounted on a robotic arm is under development for frameless stereotaxic radiosurgery. The therapy beam is aimed at the lesion by an imaging system comprised of two diagnostic x-ray cameras that view the patient during treatment. Patient position and motion are measured by the cameras and communicated in real time to the robotic arm for beam targeting and patient motion tracking. The tests reported here measured the pointing accuracy of the therapy beam and the present targeting and tracking capability of the imaging system. The results show that the system achieves the same level of targeting precision as conventional frame-based radiosurgery.

Linear accelerator-based stereotaxic radiosurgery for brain metastases:the influence of number of lesions on survival

PURPOSE

To evaluate the influence of the number of brain metastases on survival after stereotaxic radiosurgery and factors that affect the risk of delayed radiation necrosis after treatment.

MATERIALS AND METHODS

Between March 1989 and December 1993, 120 consecutive patients underwent linear accelerator-based stereotaxic radiosurgery for brain metastases identified by computed tomography (CT) or magnetic resonance imaging (MRI) scans. The influence of various clinical factors on outcome was assessed using Kaplan-Meier plots of survival from the date of radiosurgery, and univariate and multivariate analyses.

RESULTS

The median survival time was 32 weeks. Progressive brain metastases, both local and regional, caused 25 of 104 deaths. Patients with two metastases (n = 30) or a solitary metastasis (n = 70) had equivalent actuarial survival times (P = .07; median, 37 weeks; maximum, 211+ weeks). Patients treated to three or more metastases (n = 20) had significantly shorter survival times (P < .002; median, 14 weeks; maximum, 63 weeks). Prognostic factors associated with prolonged survival included a pretreatment Karnofsky performance status > or = 70% and fewer than three metastases. Delayed radiation necrosis at the treated site developed in 20 patients and correlated with prior or concurrent delivery of whole-brain irradiation and the logarithm of the tumor volume.

CONCLUSION

Survival duration is equivalent for patients with one or two brain metastases and is similar to that reported for patients with a solitary metastasis managed by surgical resection and whole-brain irradiation. Survival after radiosurgery for three or more metastases was similar to that reported for whole-brain irradiation.

Thermal treatment parameters are most predictive of outcome in patients with single tumor nodules per treatment field in recurrent adenocarcinoma of the breast

PURPOSE

In previously reported studies using radiation therapy (XRT) and hyperthermia (HT) for treatment of superficial metastases from adenocarcinoma of the breast, we have identified several pretreatment and treatment parameters that correlated with rate of initial complete response (ICR) recorded at 3 weeks and duration of local control (DLC). These parameters include minimal intratumoral temperature, Tmin, and the temperature exceeded by 90% of the measured intratumoral temperatures, T90. Recently, others have shown that thermal dose defined as the cumulative time of isoeffective treatments with T90 = 43 degrees C (CUM EQ MIN T90 43) was predictive of complete response in superficial tumors. We have assessed the prognostic value of several formulations of this parameter for both ICR and DLC in a relatively uniform patient population treated with XRT-HT.

METHODS AND MATERIALS

The corresponding EQ MIN T90 43 were calculated for 332 HT treatments in 111 HT fields in 83 patients who started treatment between October 1982 and May 1992. Each field contained only one measurable superficially located nodular tumor recurrence or metastasis from adenocarcinoma of the breast that was treated with XRT-HT, had mapped or multiple point temperatures recorded, and had at least one posttreatment follow-up evaluation. The thermal doses from all treatments delivered to a field were added to obtain the total thermal dose, SUM EQ MIN T90 43. Logistic and life-table multivariate analyses were performed to determine which pretreatment parameters (including initial T-stage, prior XRT, and tumor volume at the time of HT) and treatment parameters (including XRT dose, Tmin, T90, thermal dose, and hormonal therapy) best correlated with ICR and DLC.

RESULTS

Of the treatment parameters tested, SUM EQ MIN T90 43 had the strongest correlation with both ICR (p = 0.0002) and DLC (p = 0.0014). Also, SUM EQ MIN T90 43 contributed to the best multivariate models predictive of ICR and DLC.

CONCLUSION

For this relatively uniform patient population, we have confirmed that SUM EQ MIN T90 43 is the treatment parameter most strongly correlated with not only response following XRT-HT, but also duration of local control. This formulation of thermal dose should permit prescriptions to be written for HT treatments. Prospective trials designed to confirm this thermal dose relationship are to be encouraged.

Prostate specific antigen after radiotherapy for prostate cancer: a reevaluation of long-term biochemical control and the kinetics of recurrence in patients treated at Stanford University

PURPOSE

We evaluated prostate specific antigen (PSA) evidence for control of prostatic cancer after irradiation.

MATERIALS AND METHODS

We studied 110 patients for whom more than 2 PSA measurements were obtained to establish trends and the initial measurement was done between April 1985 and January 1988.

RESULTS

A total of 42 patients (38%) had stable, normal PSA levels with followup averaging 12.4 years (range 4.4 to 24.8). Increasing clinical stage or Gleason score correlated significantly with risk for PSA relapse, as did pretreatment PSA level. Short PSA doubling times were associated with distant metastasis rather than with local recurrence.

CONCLUSIONS

We found that irradiation durably controlled 38% of prostatic cancers of various stages and grades and is unlikely to accelerate tumor growth.

Control of prostate cancer with radiotherapy: long-term results

The long-term outcome for 1,245 patients with carcinoma of the prostate treated with external beam radiation therapy is presented. The median survival for all patients without evidence of distant metastases but irrespective of T stage of the primary tumor, histopathological grade or lymph node status was 10 years compared to 15 years for an age-matched cohort of California men. The cause specific survival at 15 years was 52%. The data base is subdivided into a series of subsets that demonstrate the impact of T stage, Gleason pattern score and lymph node involvement on long-term outcome. The best results were shown in stages T1 and T2a cases with histopathologically proved negative lymph nodes. Survival at 15 years was 53%, which was essentially identical to the 55% survival rate of an age-matched cohort. The actuarial survival at 15 years for all stages T1 and T2N0M0 cancer patients was 45% compared to 56% for an age-matched cohort.

Radiotherapy for prostatic cancer: patient selection and the impact of local control

OBJECTIVE

To analyze the long-term results of external beam radiation therapy in patients under the age of sixty treated with early-stage prostate cancer. A comparison is also made between patients with early-stage, node-negative disease and those with locally advanced node-negative prostate cancer.

METHODS

In this retrospective study, 54 patients who were treated with external beam radiation, when under the age of sixty with Stanford stage T1a and T1b (equivalent to urologic stage B1), are compared to 75 patients with similar staged disease who were sixty to seventy years old at time of treatment. In addition, 17 men who underwent open lymph node dissection with Stanford stage T1a and T1b N0M0 (equivalent to urologic stage B1, pathologic node negative) were compared to 30 patients with Stanford stage T3N0M0 (equivalent to urologic stage C, pathologic node negative) prostatic carcinoma.

RESULTS

Patients under the age of sixty with clinically staged early prostate cancer exhibited a similar rate of local and metastatic control when compared to men treated when sixty to seventy years of age. Overall survival was not different than the expected survival in both groups. In patients with laparotomy-proven node-negative prostate cancer, those with locally advanced tumors had a poorer rate of local control, disease-specific survival, freedom from relapse, and survival when compared to patients with early-stage disease.

CONCLUSIONS

These results suggest that men under sixty years old are candidates for radiotherapy, and these results are comparable to those attained with prostatectomy. Treatment approaches for controlling bulky local disease in patients without lymph node metastases have a potential to improve local control that may have an impact on survival.

Radiation induced height impairment in pediatric Hodgkin's disease

PURPOSE

To quantitate the impairment in skeletal growth from radiation treatment, we reviewed height measurements among children with Hodgkin's disease irradiated at Stanford University Medical Center between 1965 and 1986.

METHODS AND MATERIALS

One hundred and twenty-four children with Hodgkin's disease, in whom long-term follow-up data were available, became the subjects for this analysis. They all had baseline height measurements within 1 year of radiation treatment, a final height measurement beyond age 15 for boys and 13 for girls, and a minimum time interval between baseline and final measurement of 2 years. A baseline and final percent height, as compared to a reference standard, was calculated for each patient. The difference between these two figures was used to assess height impairment. The study group was divided into age and treatment groups and a comparative analysis between these groups was performed.

RESULTS

Height impairment was most severe among children who were given high dose radiation to the entire spine when pre-pubertal in age. These patients demonstrated a 7.7% (p < 0.0001) average height impairment, which equates to a height loss of 13 cm or two standard deviations of the U.S. population mean. Pubertal and post-pubertal patients given similar heavy treatment as well as pre-pubertal patients given light treatment also demonstrated some impairment of skeletal growth, however, the loss was not deemed clinically significant. Comparison of standing versus sitting height impairment did not show evidence of disproportionate final growth impairment.

CONCLUSION

Treatment regimens that use low doses of radiation for pediatric Hodgkin's disease are thus not associated with clinically significant impairment of skeletal growth, as measured by standing and sitting heights.

Prostate-specific antigen kinetics after external beam irradiation for carcinoma of the prostate

PURPOSE

A mathematical model that describes the kinetics of prostate-specific antigen measured in patients who received therapeutic doses of radiation therapy is presented. The clinical implications of the model are also investigated.

METHODS AND MATERIALS

Data from 122 patients treated at Stanford University between December 1985 and December 1990 were used. The general form of the model contains five parameters, two associated with a decreasing exponential, two with a rising exponential and one additional constant. A nonlinear steepest-descent procedure that minimized chi-squared was used to determine the parameters producing the best fit to a patient's data. The correlation of the model parameters with clinical findings was investigated using standard statistical techniques including multivariate life-table and logistic regression.

RESULTS

The data for all patients could be fit with either a decreasing exponential with or without the additional constant (nonrelapsing pattern with two or three parameters) or with a decreasing plus rising exponential (relapsing pattern with three or four parameters). In no instance were all five parameters of the general model required to describe a patient's data. Three of 61 patients with nonrelapsing patterns experienced clinical relapse, whereas 36 of 61 patients with relapsing patterns did. The logarithm of the initial prostate-specific antigen level and the corresponding model parameter correlated with T-stage and Gleason score. Among the patients with relapsing patterns, the nadir in antigen level occurred within 2 years of the start of treatment and the time to nadir, as calculated from the model parameters, was associated with the probability of clinical relapse. In no instance was the rate of initial decline ever exceeded by the rate of subsequent rise.

CONCLUSION

The model is capable of describing the kinetics of prostate-specific antigen levels found in patients after receiving radiation therapy. The parameters derived from the model are strong correlates with clinical findings and patient outcome.

Predictors of survival after a positive post-irradiation prostate biopsy

PURPOSE

Considerable debate persists in the urologic oncology literature with regard to the optimum management of patients with a positive post-irradiation prostate biopsy. This analysis characterizes a group of such patients who have had a favorable course without intervention.

METHODS AND MATERIALS

Between 1956 and 1991, 116 patients have had a positive prostate biopsy 12 or more months post-irradiation without hormonal intervention or evidence of distant relapse. The population had an age range of 42 to 82 years (median - 61). American Joint Committee on Cancer stages included 1 T1, 70 T2, 44 T3, and 1 T4. Median actuarial survival for the entire population was 14.4 years (range = 2.2-21.5 years) from presentation and 5.2 years from re-biopsy.

RESULTS

Fifty-one of the 116 patients developed metastases subsequent to re-biopsy and 65 remain free from distant relapse. Among these 65 patients, 50 remain alive and otherwise well, 11 have died of other causes, and only four have succumbed to their local disease. The best predictor of distant relapse subsequent to re-biopsy was digital rectal exam. Forty-one of the 51 patients later developing metastases had an abnormal digital rectal exam compared to 37 of 65 with sustained distant control (p = .01).

CONCLUSION

These data demonstrate that long-term, disease-free (other than re-biopsy) survival is common following a "positive" post-irradiation biopsy without intervention especially among patients with a normal digital rectal exam. Therefore, routine re-biopsy without clinical indications is not a useful practice.

Computed tomography assessment of splenic size as a predictor of splenic weight and disease involvement in laparotomy staged Hodgkin's disease

PURPOSE

To evaluate how well splenic size predicts the risk of splenic Hodgkin's disease and to assess how accurately splenic dimensions on computerized tomographic scans predict spleen size and involvement by Hodgkin's disease.

METHODS AND MATERIALS

Splenic weights were obtained from laparotomies performed on 897 patients who presented with Hodgkin's disease and were compared with histologic involvement using logistic regression. Splenic dimensions were measured from preoperative computerized tomographic scans in 94 of these patients, and unidimensional splenic measurements [length (L), width (W), thickness (T)] and their products were compared with splenic weight at laparotomy using linear regression.

RESULTS

Hodgkin's disease involved 42% of the spleens at laparotomy and 31% of those assessed by computerized tomography. Splenic weight averaged 198 +/- 5 g (range 40-2000 g). Weight and involvement were greater with "unfavorable" histologies (mixed cellularity, lymphocyte depletion, and unclassified Hodgkin's disease: 229 +/- 12 g; 62.7% involved) than with "favorable" histologies (nodular sclerosing, lymphocyte predominant, and interfollicular Hodgkin's disease: 191 +/- 5 g; 37.8% involved). Splenic weight was the strongest independent risk factor correlated with Hodgkin's disease in univariate and multivariate analyses in all patients and the only identifiable univariate risk factor among those with computerized tomographic scans. For most patients, however, splenic weight poorly predicted involvement: The probability of involvement never fell below 20% and exceeded 80% when splenic weight exceeded 270 g with unfavorable histologies or 685 g in favorable histologies. Spleens of average weight had a probability of involvement of 36% with favorable histologies, 70% with unfavorable histologies. Unidimensional measurements of the spleen on computed tomography correlated poorly with splenic weight, but their product correlated well (Correlation coefficients: L: 0.73; W: 0.65; T: 0.78; [0.344485 x L x W x T]: 0.94).

CONCLUSIONS

Splenic weight is the strongest factor correlating with the risk of splenic involvement by Hodgkin's disease and can be accurately estimated from three-dimensional measurements on computed tomographic scans, but not from unidimensional measurements. However, splenic weight is not a sensitive predictor of involvement of the spleen by Hodgkin's disease. Therefore, treatment approaches to Hodgkin's disease must be based upon intermediate risks of splenic involvement for most clinically staged patients.

Major histocompatibility complex class I and class II antigen expression in diffuse large cell and large cell immunoblastic lymphomas. Absence of a correlation between antigen expression and clinical outcome

The major histocompatibility complex (MHC) class I (HLA-A, B, C) and class II (HLA-DR) antigens are involved in cell-to-cell recognition and in regulating the immune response. Others have shown previously that MHC class I and class II antigens may be absent in a subset of malignant lymphomas, prompting the hypothesis that the absence of MHC antigen expression may be one of the mechanisms involved in the growth and dissemination of malignant lymphomas (by allowing a neoplasm to escape immune surveillance). To address this hypothesis, we analyzed MHC class I and class II (HLA-DR) antigen expression by diffuse large cell and large cell immunoblastic lymphomas in 88 and 117 patients, respectively, using frozen sections and the monoclonal antibodies W6/32 (HLA-A, B, C), anti-beta 2-microglobulin, and L203 (HLA-DR). Although there were no statistically significant clinical differences by MHC class II antigen expression, a small group of patients with MHC class I antigen-negative lymphomas were significantly younger (P = 0.03), less often had small neoplasms (P = 0.03), and were treated with doxorubicin-based chemotherapy more frequently (P = 0.04) than those with antigen-positive lymphomas. However, neither MHC class I nor class II antigen expression by the lymphomas consistently correlated with patient survival or freedom from relapse. This lack of correlation was true for all patients assessed, as well as for the subsets of patients with B-cell lymphomas, T-cell neoplasms, or those treated with doxorubicin-based chemotherapy. In accordance with previously published studies, stage, presence of B symptoms, and treatment with doxorubicin-based chemotherapy were of prognostic importance in univariate or multivariate analyses for survival or freedom from relapse. The findings may be considered evidence against the hypothesis that the absence of MHC class I or II antigen expression by malignant lymphomas plays a role in their tumorigenicity. However, we cannot completely exclude the possibility that the therapies used for this group of patients may have obscured any effect that MHC antigen expression exerts on prognosis.

Temperature differentials between treatment and pretreatment temperatures correlate with local control following radiotherapy and hyperthermia

PURPOSE

To evaluate the influence of pretreatment tumor temperatures and the temperature differential between treatment and pretreatment temperatures on local tumor control in patients who underwent combined radiation therapy and hyperthermia.

METHODS AND MATERIALS

Mapped intratumoral temperatures were measured immediately prior to and during hyperthermia in 138 hyperthermia fields among 59 patients with nodular (60 fields) or diffuse (78 fields) superficially-located tumors. In the nodular subgroup there were 40 fields with adenocarcinomas (31 breast, two prostate, seven other primary sites), six melanomas, nine squamous cell carcinomas, and five other histologies. The fields with diffuse tumor involvement consisted of 77 adenocarcinomas (67 breast, 10 other) and one melanoma. The maximum, minimum, and average temperatures were determined for both the pretreatment (pTmax, pTmin, pTave) and treatment (Tmax, Tmin, Tave) distributions and the differences, Dm = Tmin-pTmax, and Da = Tmin-pTave, computed. These quantities were averaged over treatments to produce the corresponding mean quantities for each hyperthermia field. Univariate and multivariate analyses were performed to determine treatment and pretreatment parameters which best correlated with the duration of local control.

RESULTS

Pretreatment tumor temperatures were significantly lower than the oral temperatures with mean pTmax, mean pTmin, and mean pTave of 36.2 degrees C, 34.2 degrees C, and 35.4 degrees C, respectively. For the adenocarcinomas with diffuse involvement within the hyperthermia field, the covariates best correlating with local control duration on univariate analysis were concurrent radiation dose (p = 0.0026), Dm (p = 0.009), pTmax (p = 0.012) and Da (p = 0.036). Lower pTmax and larger Dm and Da were predictive for longer local control. In multivariate analyses, all thermal parameters lost power, however, the best model included Dm which was significant at the p = 0.040 level. For the nodular subgroup, nonthermal parameters and dichotomized thermal parameters were of prognostic significance for local control.

CONCLUSION

For fields diffusely involved with adenocarcinoma significant correlations with duration of local control have been demonstrated both for a) low pretreatment temperatures and b) large differentials between treatment and pretreatment intratumoral temperatures. These correlations were also found in a dichotomized description for fields with nodular tumors. The results support the concept that pretreatment hypothermic conditions can lead to an increase in thermal sensitization and may help explain the excellent clinical results noted in the treatment of superficial tumors with radiation and hyperthermia. Further exploitation of this approach by planned cooling of superficially-located recurrent tumors prior to hyperthermia treatment warrants investigation.

Prostate specific antigen after external beam radiotherapy for prostatic cancer: followup

Between 1986 and 1989, 117 patients with pretreatment and serial posttreatment prostate specific antigen values received external beam radiotherapy at our hospital. Followup ranged from 0.6 to 5.9 years (mean 2.7). No patient had hormonal manipulation before distant recurrence. Biochemical relapse, defined as an increasing prostate specific antigen level after treatment, was observed in 44 patients. To date 30 of these 44 patients (68%) have had clinical relapse. The prognostic factors of advanced local stage, high Gleason score and high elevations of pretreatment prostate specific antigen values predicted for biochemical relapse and subsequent clinical failure. The interval between biochemical and clinical relapse was 156 +/- 46 days. Biochemical relapse is an important end point that can be used to determine the effect of treatment in prostatic cancer research.

Correlation of thermal parameters with outcome in combined radiation therapy-hyperthermia trials

Many studies utilizing combined hyperthermia (HT) and radiation therapy (XRT) in the treatment of advanced or recurrent malignancies have reported a correlation between some measure of the minimum temperature achieved and outcome. Previous reported studies at Stanford have demonstrated a statistically significant correlation between the duration of local control and Tmin, the mean over treatments of the minima of (a) measured intratumoral temperatures in fields which contained diffuse or nodular tumours, or (b) measured interstitial temperatures in fields treated for microscopic residual disease. Recently, T90, the mean of the temperatures above which 90% of all measured intratumoral temperatures fall, has been proposed as an alternative characterization of the efficacy of the HT treatment that reportedly has a superior correlation with outcome. To test this hypothesis, T90 was computed by two different methods for three groups of patients treated at Stanford with XRT-HT for superficially located tumor recurrences. Tmin was found to be strongly correlated with T90 calculated by both methods. All three thermal parameters correlated with complete response at 3 weeks and with local control, although Tmin usually demonstrated the strongest correlation.

Stereotactic radiosurgical treatment of brain metastases

In a series of 33 patients with reasonably controlled primary cancers, stereotactic radiosurgery was used to treat 52 brain metastases. After a mean radiological follow-up time of 5.5 months, six lesions (12%) had stabilized in size, 26 (50%) were significantly reduced, and 15 (29%) had disappeared. One large melanoma metastasis progressed relentlessly despite treatment. Five lesions (9%) had decreased in size slightly before enlarging. In two of these lesions, biopsy revealed only necrosis. In almost all cases, treatment was associated with decreased peritumoral edema. However, a group of patients with large metastases and extensive prior brain irradiation has been identified in whom prolonged symptomatic cerebral edema poses a problem. It is concluded that radiosurgery is a viable alternative to surgical resection for some cases of brain metastasis.

The importance of local control in the treatment of prostatic cancer

In a retrospective analysis of 946 patients with prostatic carcinoma treated with external beam radiotherapy between 1958 and 1989 at Stanford University Hospital the 15-year actuarial clinical local control rate was 77.8 +/- 3.3% for Stanford stage T1, 61.3 +/- 4.4% for stage T2 and 64.9 +/- 4.8% for stage T3 disease. Overall, there was improvement in disease-specific survival without a significant alteration in survival in patients who achieved clinical local control. For the 50 Stanford stage T1 cases with local control on clinical examination and a positive post-treatment biopsy a decrease in disease-specific survival was observed. There was no difference in disease-specific survival for comparable stage T2 or T3 cases. In an analysis of patients who underwent ultrasound guided prostatic biopsy performed after irradiation the trend of prostate specific antigen was more important than biopsy results in predicting which patients would have relapse.

Critical reassessment of second-look exploratory laparotomy for epithelial ovarian carcinoma. Minimal diagnostic and therapeutic value in patients with persistent cancer

From 1979 to 1984, 88 women with epithelial ovarian cancer were treated with surgery and chemotherapy, achieved a clinical complete response, and then had "second-look" exploratory laparotomy to assess the pathologic status of their disease. Persistent cancer was found in 50 (57%) patients: 34 of 50 (68%) had gross tumor, which was larger than 2 cm in 12 (24%) and smaller than 2 cm in 22 (44%), and 16 (32%) had microscopic disease. Salvage therapy was as follows for these patients: whole abdominal irradiation, 29 (58%); chemotherapy, 17 (34%); intraperitoneal chromic phosphate, 1 (2%); and no further therapy, 3 (6%). With a follow-up time of 4 to 8 years, 7 (14%) patients are alive without evidence of cancer, 7 (14%) are alive with disease, 35 (70%) are dead of disease, and 1 (2%) has died of treatment complications. At 5 years, the relapse-free rate was 18% and the survival rate was 25%. Seventy-two parameters of suspected prognostic significance and 64 potential sites of tumor involvement were correlated with survival in a univariate analysis. The factors favorably affecting survival included the following: lower grade; microscopic tumor versus gross disease at second-look laparotomy; removal of the uterus; removal of the omentum; pelvic and paraaortic lymph node biopsy; negative results of a right diaphragm biopsy; and radiation therapy at Stanford University Medical Center, Stanford, California. There was no survival advantage for whole abdomen irradiation compared with chemotherapy or for the patients who had their disease successfully debulked at second-look laparotomy. The above factors and others were evaluated by multivariate regression. The best model (P = 0.000004) for predicting survival included largest tumor mass (P = 0.0002), operative blood loss (P = 0.002), perioperative blood transfusion (P = 0.003), and grade (P = 0.004). The detection of persistent ovarian cancer by second-look exploratory laparotomy should identify a subgroup of patients whose conditions can be salvaged by a second-line therapy. Unfortunately, that subgroup is small (8%) and an effective salvage therapy remains to be identified.

Second cancers in long-term survivors of Ewing's sarcoma

Previous reports suggest an increased risk of a second cancer, primarily osteosarcoma, in survivors of Ewing's sarcoma. In a retrospective review of 25 long-term irradiated survivors of Ewing's sarcoma, the incidence of second cancers was determined. The patients were free of disease for more than three years (except for one patient who developed a second cancer 2.5 years after diagnosis), with a median follow-up period of 7.6 years. All received megavoltage radiation to the primary tumor. Twenty-four of the 25 patients were treated with chemotherapy. Second cancers developed in two patients. Acute myelogenous leukemia (AML) developed in a seven-year-old 15 months after treatment. An osteosarcoma developed within an irradiated field in a 13-year-old three years after treatment. The actuarial risk of developing a second cancer at five years is 8% whereas the actuarial risk of developing a bone sarcoma is 4%. Genetic factors may play a role in the development of AML in patients with Ewing's sarcoma. Megavoltage radiation, particularly doses greater than 60 Gy, as well as alkylating agent chemotherapy may contribute to the risk for bone sarcoma. The risk of a second cancer after successful treatment of Ewing's sarcoma is similar to that expected for survivors of all childhood cancers.

Parameters predictive for complications of treatment with combined hyperthermia and radiation therapy

Pretreatment and treatment related factors were reviewed for 996 hyperthermia sessions involving 268 separate treatment fields in 131 patients managed with hyperthermia for biopsy confirmed local-regionally advanced or recurrent malignancies to ascertain parameters associated with the development of complications. A subset of 249 fields were identified in which multipoint or mapped temperature data were available for at least one treatment session per field. A total of 198 fields involved superficially located tumors (less than or equal to 3 cm from the surface), whereas 51 fields involved more deeply located tumors. Most of these patients had received extensive prior therapy: 77% had surgery, 75% chemotherapy, 65% radiation therapy and 28% hormonal therapy. They were treated with hyperthermia in conjunction with radiation therapy (244 fields) or hyperthermia alone (5 fields). The hyperthermia treatment objectives were to elevate intratumoral temperatures to a minimum of 43.0 degrees C for 45 minutes while maintaining maximum normal tissue temperatures to less than or equal to 43 degrees C and maximum intratumoral temperatures to less than or equal to 50 degrees C. The hyperthermia was given within 30 to 60 minutes following radiation therapy without the administration of additional analgesics. Hyperthermia treatment regimens using radiative electromagnetic, ultrasound, or radiofrequency interstitial techniques were individualized, with 3 to 4 days between hyperthermia treatments and an average of 3.6 treatments (range 1-14; standard deviation 2.2) utilized per field. A total of 38 complications in 33 treatment fields were noted; an incidence of 27/198 (13.6%) for fields with superficially located tumors, and 6/51 (11.8%) in fields with more deeply located tumors. Univariate analyses demonstrated statistically significant correlations between the maximum tumor temperature (p = 0.0005), average of the maximum tumor temperatures (p = 0.0006), the average of the % tumor temperatures greater than 43.5 degrees C (p = 0.0071), and the average number of hyperthermia treatments (p = 0.033), with the development of complications. The average of the maximum measured tumor temperature for fields without complications was 44.6 degrees C compared with 45.9 degrees C for fields with complications. The complication rate increased from 7.5% (9/120) in fields that received one or two hyperthermia treatments to 18.6% (24/129) in fields that received greater than two hyperthermia treatments. Multivariate logistic regression analyses revealed the best bivariate model predictive of the development of complications included average of the maximum tumor temperature and the number of treatments per field (p = 0.00012 for the bivariate model).(ABSTRACT TRUNCATED AT 400 WORDS)

Thermoradiotherapy for residual microscopic cancer: elective or post-excisional hyperthermia and radiation therapy in the management of local-regional recurrent breast cancer

A Phase I/II study was undertaken to investigate the efficacy and side effects of combined hyperthermia and radiation therapy in the management of presumed or known microscopic residual tumors. Between February 1985 and March 1991, 262 fields in 89 patients with local-regional recurrent breast cancer were treated with externally administered hyperthermia and radiation therapy. Thirty-eight fields were treated for microscopic residual disease following excisional biopsy of nodular recurrences and 224 fields were treated electively for areas at high risk for local recurrences adjacent to fields with macroscopic residual disease. Mechanically mapped temperatures were monitored throughout the field in all treatments. All patients had at least one follow-up evaluation at three weeks or more following completion of treatment. The majority of the fields were in patients who had had extensive prior therapy including radiation therapy (54%), chemotherapy (71%), and hormonal therapy (51%). All fields received hyperthermia (1-6 treatments: average 1.74) and radiation therapy (average dose: 42.4 Gy); concurrent hormonal therapy was administered in 37% of the treatments and no fields received concurrent chemotherapy. The treatments were well tolerated, no life-threatening complications were noted. Averages for all fields of the minimum, maximum, and average measured interstitial temperatures were 40.2 degrees C, 45.3 degrees C, and 42.8 degrees C, respectively. The three-year actuarial local-control rate for all 262 treated fields was 68%. Parameters characterizing the initial breast cancer, the patient and tumor at the time of hyperthermia, and the treatment were studied in univariate and multivariate analysis for correlation with duration of local control within the hyperthermia treatment field. Parameters in the best five covariate model correlating with the duration of local control included: estrogen receptor status of the initial breast cancer; initial T-stage; time from initial breast cancer to first failure; age at hyperthermia; and concurrent radiation dose (p-value for model less than 0.000001). Six covariate models adding anatomic site of disease, field type, mean minimum temperatures, and mean percent temperatures greater than or equal to 40 degrees C all resulted in improved models. Randomized controlled studies stratifying for these pretreatment parameters are felt warranted to confirm the value of adjuvant hyperthermia in the elective treatment of areas of high risk for local-regional recurrent breast cancer and in fields following surgical excision of recurrent disease, particularly in patients in whom full dose radiation therapy cannot be safely administered.

Stereotaxic radiosurgery for brain metastases: the importance of adjuvant whole brain irradiation

Stereotaxic radiosurgery delivered from a modified 4 MV linear accelerator was used to treat 47 brain metastases in 27 patients at Stanford. Response was assessed in 41 lesions. Histopathologies included adenocarcinoma (24 lesions), renal cell carcinoma (9 lesions), melanoma (6 lesions), and squamous cell carcinoma (2 lesions). Follow-up ranged from 1.0-16.5 months, with a median of 5.0 months. Radiographic local control was achieved in 88% of the lesions. Three patients developed enlarging contrast-enhancing lesions in the radiosurgical field; one of these was biopsied and revealed necrosis with no viable tumor. Adjuvant whole brain irradiation (10 patients) was associated with regional intracranial control in 80% of patients. This was statistically superior (p = 0.0007) to the regional intracranial control rate achieved when radiosurgery alone was employed (6 patients). Most patients reported resolution of their neurologic symptoms, and were able to discontinue dexamethasone without impairment of neurologic function.

External beam radiotherapy for incidental adenocarcinoma of the prostate discovered at transurethral resection

This paper updates the results of 89 patients treated between 1967 and 1989 for incidental carcinoma discovered at transurethral resection of the prostate (Stanford stage T0 or AJC-UICC stage T1) with external beam irradiation. Twenty-two patients had Stanford T0 focal (less than 5% involvement of the prostatic chips) and 67 presented with Stanford T0 diffuse (5% or more involvement). Follow-up ranges from 4 months to 25.1 years, with a mean follow-up of 9.8 years. The actuarial local control for Stanford T0 focal is 100%, and 70% for Stanford T0 diffuse at 15 years. There was no difference in survival between Stanford T0 diffuse and T0 focal and the expected survival of an age-matched control population. Patients who were treated when younger than 65 had a similar local control and distant relapse when compared to those treated when 65 or older. There was no difference in local control, freedom from relapse, or disease-specific survival when the 38 patients who received irradiation to the prostate only are compared with the 29 who also received pelvic irradiation for Stanford T0 diffuse carcinoma. Patients with a Gleason score of 6 or more, when compared with those with a score of 5 or less, experienced more distant relapses and similar local control, suggesting that patients with a high grade tumor have occult metastases at presentation.

Radiation treatment of prostate bone metastases and the biological considerations

This contribution on the biology and management of bone metastases from prostatic cancer is divided into three parts. The first details a study conducted at Stanford University on the prevention of bone metastases in the lumbar spine, in patients in whom the lumbar spine has been irradiated coincidental to the radiation treatment of the paraaortic lymph nodes. The incidence of metastases was significantly reduced in 71 patients in whom the apparently normal lumbar spine was irradiated, as compared to the incidence of metastases in 65 patients who received no lumbar irradiation. The implications of these observations on developing strategies for early, or preemptive, irradiation for bone metastases are discussed. In the second part, the optimum radiation dose and fractionation scheme for the palliation of overt bone metastases is addressed. Drawing largely from the work of Arcangeli et al., a total dose of 40-50 Gy*, fractionated at 2 Gy per day, seems to be the regimen of choice for enduring pain relief for most patients with prostatic metastases to bone. Finally, the recent utilization of strontium-89 in the palliation of advanced bone metastases is addressed. *The Gy is the current international unit of radiation. 1Gy = 100 Rad; 1cGy (centigray) = 1 Rad.

The clinical significance of a positive post-irradiation prostatic biopsy without metastases

To define the prognostic value of a post-irradiation prostatic biopsy, the outcome of 203 previously irradiated patients who underwent post-treatment biopsy was analyzed. The majority of patients were selected for biopsy based on an abnormal digital rectal exam or elevated prostate specific antigen. Patients with distant metastases found at the time of biopsy were excluded from further analysis. One hundred thirty-nine (139) of these had a positive biopsy and 64 were negative. Those with a positive biopsy tended to present with more locally-advanced (Stage B2/C) tumors (61%) compared to those with negative biopsies (42%). The 10- and 15-year survival and cause-specific survival from the time of initial presentation were similar for both groups. However, those with a negative biopsy had a more favorable survival and cause-specific survival from the time of post-treatment biopsy and were less likely to develop distant metastases than the positive biopsy group. These data suggest that a positive prostatic biopsy is associated with a greater likelihood of subsequent distant relapse and decreased survival following biopsy relative to patients with negative biopsies. Since a positive post-treatment biopsy is more likely among patients presenting with locally-advanced disease, perhaps more aggressive initial therapy (i.e., interstitial boost or hyperthermia) would benefit this subgroup.

Medulloblastoma: freedom from relapse longer than 8 years--a therapeutic cure?

Seventy-seven patients presenting with medulloblastoma between 1958 and 1986 were treated at Stanford University Medical Center and studied retrospectively. Multimodality therapy utilized surgical extirpation followed by megavoltage irradiation. In 15 cases chemotherapy was used as adjunctive treatment. The 10- and 15-year actuarial survival rates were both 41% with an 18-year maximum follow-up period (median 4.75 years). There were no treatment failures after 8 years of tumor-free survival. Gross total removal of tumor was achieved in 22 patients (32%); the surgical mortality rate was 3.9%. No significant difference was noted in the incidence of metastatic disease between shunted and nonshunted patients. The classical form of medulloblastoma was present in 67% of cases while the desmoplastic subtype was found in 16%. Survival rates were best for patients presenting after 1970, for those with desmoplastic tumors, and for patients receiving high-dose irradiation (greater than or equal to 5000 cGy) to the posterior fossa. Although early data on freedom from relapse suggested a possible beneficial effect from chemotherapy, long-term follow-up results showed no advantage from this modality of treatment. The patterns of relapse and survival were examined; 64% of relapses occurred within the central nervous system, and Collins' rule was applicable in 83% of cases beyond the period of risk. Although patients treated for recurrent disease could be palliated, none were long-term survivors. The study data indicate that freedom from relapse beyond 8 years from diagnosis can be considered as a cure in this disease. Long-term follow-up monitoring is essential to determine efficacy of treatment and to assess survival patterns accurately.

Non-small cell lung cancer: treatment results at a USAF referral center

The treatment results of 197 consecutive patients with non-small cell carcinoma of the lung managed at David Grant USAF Medical Center between January 1978 and September 1985 were reviewed. Patients were staged according to 1983 AJCC criteria as follows: 52 stage I, 28 stage II, and 117 stage III. Five-year survival and freedom from relapse (FFR) were 24% and 32%, respectively, for the entire population. Survival and FFR by stage were: stage I, 68% and 77% (5-year); stage II, 32% and 43% (5-year); and stage III, 10% and 10% (3-year), respectively.

Thyroid diseases after treatment of Hodgkin's disease

BACKGROUND AND METHODS

Thyroid disease, especially hypothyroidism, is common in patients with Hodgkin's disease who have been treated with irradiation. We reviewed the records of 1787 patients (740 women and 1047 men) with Hodgkin's disease who were treated with radiation therapy alone (810 patients), radiation and chemotherapy (920 patients), or chemotherapy alone (57 patients) at Stanford University between 1961 and 1989. Among these patients, 1533 were alive at the last follow-up, and 254 had died of causes other than Hodgkin's disease. (Four other patients were excluded from the analysis because they had undergone thyroidectomy before treatment for Hodgkin's disease. The thyroid was irradiated in 1677 patients. Follow-up averaged 9.9 years.

RESULTS

A total of 573 patients had clinical or biochemical evidence of thyroid disease. Among the 1677 patients whose thyroid was irradiated, the actuarial risk of thyroid disease 20 years after treatment was 52 percent, and it was 67 percent at 26 years. Hypothyroidism was found in 513 patients. A total of 486 patients received thyroxine therapy for elevated serum thyrotropin concentrations and either low free thyroxine (208 patients) or normal free thyroxine values (278 patients); 27 had transient elevations of the serum thyrotropin level that were not treated. Graves' hyperthyroidism developed in 30 patients (2 of whom had not undergone thyroid irradiation), and ophthalmopathy developed in 17 of these patients. Ophthalmopathy developed in four other patients with Graves' disease during a period of hypothyroidism (n = 3) or euthyroidism (n = 1). The risk of Graves' disease was 7.2 to 20.4 times that for normal subjects. Silent thyroiditis with thyrotoxicosis developed in six patients. Forty-four patients were found to have single or multiple thyroid nodules, 26 of whom underwent thyroidectomy. Six of the 44 had papillary or follicular cancers. Among the patients who did not undergo operation, 12 had small functioning nodules, 4 had cysts, and 2 had multinodular goiters. The actuarial risk of thyroid cancer was 1.7 percent. The risk of thyroid cancer was 15.6 times the expected risk.

CONCLUSIONS

High risks of thyroid disease persist more than 25 years after patients have received radiation therapy for Hodgkin's disease, reinforcing the need for continued clinical and biochemical evaluation. Prolonged follow-up confirms an elevated risk of thyroid cancer and Graves' disease as well as hypothyroidism in these patients.

A model of prostatic carcinoma tumor kinetics based on prostate specific antigen levels after radiation therapy

Serial prostatic specific antigen values (PSA) were determined on 42 patients receiving definitive radiation therapy for localized adenocarcinoma of the prostate. The PSA declined exponentially in 25 patients. None of these patients experienced metastases. The PSA initially declined then increased exponentially in 17 patients. The rate of decline was similar to the rate of rise in all 17 patients. Five of these patients had distant metastases (P less than 0.02) within 2 years of treatment. The PSA values after radiation therapy were employed to formulate a model of tumor kinetics. This model predicts the mean duration of G0. This parameter is correlated with the development of distant metastases within 2 years of treatment. For those patients at low risk for relapse, the mean G0 is calculated to be 22.5, and 13.6 weeks for those who have relapsed or are at high risk for relapse.

Hyperthermia and radiation therapy of local-regional recurrent breast cancer: prognostic factors for response and local control of diffuse or nodular tumors

Over the past decade, hyperthermia has been extensively studied as an adjuvant to radiation therapy in the management of local-regional metastases from adenocarcinoma of the breast. A retrospective review of our experience from July 1982 to January 1990 identified 241 fields in 89 patients which satisfied the following criteria: biopsy confirmation of recurrent or metastatic adenocarcinoma of the breast; involvement of the chest wall and/or regional lymph nodes with diffuse or nodular metastases; treatment which included radiation therapy and externally administered hyperthermia during which mechanically-mapped and/or multipoint normal tissue and intratumoral temperatures were monitored; and at least one follow-up evaluation at 3 weeks or more after completion of treatment. The majority of fields were in patients who had extensive prior treatment including radiation therapy (68%), chemotherapy (86%), and hormonal therapy (58%). Treatment consisted of radiation therapy (average dose: 39.88 Gy) and hyperthermia (1-12 treatments; average 3.12); concurrent chemotherapy or hormonal therapy were also administered in 3% and 32% of the fields, respectively. Parameters characterizing the initial breast cancer, the patient and tumor at the time of hyperthermia, and the treatment were studied in univariate and multivariate analyses with complete response rate at the time of maximum tumor regression and duration of local control as endpoints. The treatments were well tolerated with no life-threatening complications noted. The means for all fields of the mean minimum, mean maximum, and mean average measured intratumoral temperatures were 40.3 degrees C, 44.6 degrees C, and 42.4 degrees C, respectively. At 3 weeks following completion of radiation therapy, response rates were: complete response (52%), partial response (8%), no response (17%), and continuing regression (monotonic regression to less than 50% of initial volume) was noted in 22% of the fields. At the time of maximum tumor regression local control was noted in 72% of the fields. Five parameters correlated with higher complete response in univariate and multivariate analysis: lower T-stage of the initial breast cancer; at the time of hyperthermia age less than 50 years, Karnofsky status greater than 95%, and the absence of distant metastases; and the use of concurrent hormonal therapy. The absence of a family history of breast cancer and concurrent radiation dose greater than or equal to 25 Gy significantly correlated with higher complete response in the univariate but not in the best multivariate models.(ABSTRACT TRUNCATED AT 400 WORDS)

Computer-assisted work station timing analysis of instrument labor efficiency

Labor use ratings assigned to instruments by the Workload Recording Method (WRM) do not change with batch size or walk-away time use. The authors evaluated the effect of both on the labor use of the analyzers Paramax B6100 (Baxter Paramax, Irvine, CA) and Ektachem 700 (Eastman Kodak, Rochester, NY) by timing all worked and walk-away intervals on both instruments. Extrapolation of the data to a workload of slightly more than 1.1 million tests showed that reapportionment of tests to various batch sizes caused Paramax-Ektachem labor cost differences to fluctuate between $37,254 and $34,995. When the minimum usable walk-away interval length was varied from 1 to 20 minutes, Ektachem savings over Paramax increased from $8,700 to $61,400. The WRM predicted a constant $29,050 labor cost advantage for Ektachem over Paramax. If other instruments show similar labor use characteristics with respect to batch size and walk-away utility, laboratory managers who do not consider these factors may fail to select the most cost-effective instruments for their laboratories.

Interleukin 1 beta initially sensitizes and subsequently protects murine intestinal stem cells exposed to photon radiation

Interleukin 1 (IL-1) has been shown to prevent early bone marrow-related death following total-body irradiation, by protecting hematopoietic stem cells and speeding marrow repopulation. This study assesses the effect of IL-1 on the radiation response of the intestinal mucosal stem cell, a nonhematopoietic normal cell relevant to clinical radiation therapy. As observed with bone marrow, administration of human recombinant IL-1 beta (4 micrograms/kg) to C3H/Km mice 20 h prior to total-body irradiation modestly protected duodenal crypt cells. In contrast to bone marrow, IL-1 given 4 or 8 h before radiation sensitized intestinal crypt cells. IL-1 exposure did not substantially alter the slope of the crypt cell survival curve but did affect the shoulder: the X-ray survival curve was offset to the right by 1.01 +/- 0.06 Gy when IL-1 was given 20 h earlier and by 1.28 +/- 0.08 Gy to the left at the 4-h interval. Protection was greatest when IL-1 was administered 20 h before irradiation, but minimal effects persisted as long as 7 days after a single injection. The magnitude of radioprotection at 20 h or of radiosensitization at 4 h increased rapidly as IL-1 dose increased from 0 to 4 micrograms/kg. However, doses ranging from 10 to 100 micrograms/kg produced no further difference in radiation response. Animals treated with saline or IL-1 had similar core temperatures from 4 to 24 h after administration, suggesting that thermal changes were not responsible for either sensitization or protection. Mice irradiated 20 h after IL-1 had significantly greater crypt cell survival than saline-treated irradiated controls at all assay times, which ranged from 54 to 126 h following irradiation. The intervals to maximum crypt depopulation and initiation of repopulation were identical in both saline- and IL-1-treated groups, suggesting that IL-1 altered absolute stem cell survival but not the kinetics of repopulation.

Two or six hyperthermia treatments as an adjunct to radiation therapy yield similar tumor responses: results of a randomized trial

From March 1984 to February 1988, 70 patients with 179 separate treatment fields containing superficially located (less than 3 cm from surface) recurrent or metastatic malignancies were stratified based on tumor size, histology, and prior radiation therapy and enrolled in prospective randomized trials comparing two versus six hyperthermia treatments as an adjunct to standardized courses of radiation therapy. A total of 165 fields completed the combined hyperthermia-radiation therapy protocols and were evaluable for response. No statistically significant differences were observed between the two treatment arms with respect to tumor location; histology; initial tumor volume; patient age and pretreatment performance status; extent of prior radiation therapy, chemotherapy, hormonal therapy, or immunotherapy; or concurrent radiation therapy. The means for all fields of the averaged minimum, maximum, and average measured intratumoral temperatures were 40.2 degrees C, 44.8 degrees C, 42.5 degrees C, respectively, and did not differ significantly between the fields randomized to two or six hyperthermia treatments. The treatment was well tolerated with an acceptable level of complications. At 3 weeks after completion of therapy, complete disappearance of all measurable tumor was noted in 52% of the fields, greater than or equal to 50% tumor reduction was noted in 7% of the fields, less than 50% tumor reduction was noted in 21% of the fields, and continuing regression (monotonic regression to less than 50% of initial volume) was noted in 20% of the fields. No significant differences were noted in tumor responses at 3 weeks for fields randomized to two versus six hyperthermia treatments (p = 0.89). Cox regression analyses were performed to identify pretreatment or treatment parameters that correlated with duration of local control. Tumor histology, concurrent radiation doses, and tumor volume all correlated with duration of local control. The mean of the minimum intratumoral temperatures (less than 41 degrees C vs. greater than or equal to 41 degrees C) was of borderline prognostic significance in the univariate analysis, and added to the power of the best three covariate model. Neither the actual number of hyperthermia treatments administered nor the hyperthermia protocol group (two versus six treatments) correlated with duration of local control. The development of thermotolerance is postulated to be, at least in part, responsible for limiting the effectiveness of multiple closely spaced hyperthermia treatments.

Radiation therapy for localized prostate cancer. Justification by long-term follow-up

In the series presented here, survival patterns at 15 years after radiotherapy for patients with clinical stage A carcinoma of the prostate did not deviate significantly from those of an age-matched peer group. For patients with clinical stage B disease (nodular disease that did not exceed involvement of one lateral lobe), survival was only 5% less at 15 years than for the age-matched group of California men. This was in spite of the fact that the lymph node status and the true incidence of capsular penetration were unknown. Moreover, the patients were not stratified by histopathologic grade or by either acid phosphatase or prostate-specific antigen values. If one were to restrict the patients to those with intermediate and low Gleason scores, normal acid phosphatase, and low prostate-specific antigen values, it is likely that there would have been no difference between the survival of those with prostatic cancer and their age-matched peers. As one deviates from these conservative selection criteria and includes patients with more advanced stages, the likelihood of achieving 15-year survival diminishes. With radiation treatment, however, patients whose disease, by clinical examination, extends beyond the prostate and who seem too advanced for radical prostatectomy still may have a 20 per cent to 30 per cent chance of 15-year survival.

Prostate specific antigen after irradiation for prostatic carcinoma

The clinical significance of serum prostate specific antigen after primary irradiation for adenocarcinoma of the prostate is uncertain. Between September 1986 and December 1987 serial prostate specific antigen values were determined in 43 patients before and after definitive radiation therapy. The study group included 6 patients with stage T0d, 10 with stage T1, 11 with stage T2 and 16 with stage T3 disease, with a mean pre-treatment prostate specific antigen level of 49.2 +/- 10.8. For all patients the first post-treatment prostate specific antigen level was less than the pre-treatment level. One patient failed locally with recurrent prostatic cancer that invaded the rectum. The 6 patients who failed with symptomatic metastases had an increasing prostate specific antigen level 2 to 7 months before detection of recurrence. Based on the absolute value and trend of the prostate specific antigen, patients were described as being at high, intermediate or low risk for distant metastases. Of 9 high, 6 intermediate and 28 low risk patients 4 (44%), 2 (33%) and 0 (0%) have experienced recurrent disease (p = 0.0025). We conclude that serial post-irradiation prostate specific antigen values may be useful in the early identification of patients at risk for treatment failure.

Reduction of spinal metastases after preemptive irradiation in prostatic cancer

For this study, 136 patients treated at Stanford University Hospital for prostatic cancer between 1971 and 1980 were selected for review. The patients had received no prior therapy, and had no evidence of bone metastases at time of radiation treatment based on radiographic studies and bone scan. Of this group, 71 patients received extended-field irradiation (paraaortic and pelvic fields), and 65 patients received pelvic irradiation. The pelvic field was treated to 50 Gy and the paraaortic field received 45 Gy to 60 Gy. All patients subsequently underwent routine follow-up examinations and studies at Stanford University Hospital: 1,513 follow-up X rays, bone scans, and CT-scans were analyzed for site-specific recurrence. The follow-up ranged from 14 months to 16 yrs from the time of initial treatment, with a mean follow-up of 7 yrs. Lower extremities and ribs were found to be the most common sites of bone metastases. Irradiation of the lumbar spine to a dose of 35 to 60 Gy, coincidental to irradiation of the paraaortic lymph nodes prevented or delayed the development of lumbar spine metastases. The potential mechanism and clinical implications are discussed.

Development of total-skin electron therapy at two energies

Total-Skin Electron Therapy (TSET) modalities have been developed at two energies on a Varian Clinac 1800. The physical criteria for the beams were determined mainly from the requirement of continuing the Stanford treatment technique, which was 12 Total-Skin Electron Therapy portals combined in six pairs. The penetration of the lower energy mode matches that previously obtained at Stanford on the Varian Clinac 10, (about 4 mm for the 80% isodose contour in the 12-field treatment). The penetration of the higher energy mode is about 8 mm at the 80% contour. The Total-Skin Electron Therapy modes necessarily use electrons produced by the two standard electron-beam modes of lowest energy, nominally 6 and 9 MeV. Measurements to verify the beam specifications were carried out with diodes, a variety of ionization chambers, and a specially constructed circular phantom for film dosimetry. Initially, the penetration of the Total-Skin Electron Therapy beams was too large to match our criteria, so two methods of reducing it were explored: (a) the energies of the electron beams produced by the machine were reduced (which also reduced the energies of the corresponding standard electron modes) and (b) a large polymethylmethacrylate degrader (2.4 m X 1.2 m) 1 cm thick was placed just in front of the patient plane. Acceptable Total-Skin Electron Therapy beams could be produced by either method and the latter was finally used. The use of the standard dose monitoring system for the Total-Skin Electron Therapy modes considerably simplifies the daily treatment delivery as well as the implementation. However, the need for reasonable dose rates at the treatment plane (3.5 meters beyond the isocenter) requires dose rates of 24 Gy/min at the isocenter. Nevertheless, it is possible to use the internal dose monitor provided the problems associated with high dose rates (recombination and amplifier saturation) are addressed. Solutions to these problems involved switching the primary and back-up dose monitors, increasing the collecting voltage on the ion chambers, and calibrating the dose monitor so that 1 unit = 1 cGy at the patient rather than at the isocenter.