High dose-rate afterloading in the treatment of cervical cancer of the uterus

From January 1981 to December 1983, 380 patients with cervical carcinoma of uterus were treated with high dose-rate intracavitary afterloading therapy (Ralstron-20B) and 60Co external irradiation. All of these cases have been followed over 3-5 years. The 5-year survival rates for Stages I, II, III, and IV were 100%, 81.5%, 73.9%, and 0% respectively. The over all 5-year survival rate was 79.1%. The results were comparable to that of conventional radium therapy in 1980 (5-year survival rate for radium group: Stage I 50%, Stage II 72.2%, Stage III 52.2%, Stage IV 0%). The moderate and severe rectal reactions in this series were 11.8% and 1.6% (radium group moderate 6.0%, severe 2.2%), which were higher than that of radium group. The incidence of bladder reaction was 7.1%. The problems of high dose-rate intracavitary therapy and the combination therapy with intracavitary and external irradiation are discussed in this paper.     

Effective Treatment of Stage I Uterine Papillary Serous Carcinoma with High Dose-Rate Vaginal Apex Radiation (192Ir) and Chemotherapy

Purpose: Uterine papillary serous carcinoma (UPSC) is a morphologically distinct variant of endometrial carcinoma that is associated with a poor prognosis, high recurrence rate, frequent clinical understaging, and poor response to salvage treatment. We retrospectively analyzed local control, actuarial overall survival (OS), actuarial disease-free survival (DFS), salvage rate, and complications for patients with Federation International of Gynecology and Obstetrics (FIGO) (1988) Stage I UPSC.Methods and Materials: This retrospective analysis describes 38 patients with FIGO Stage I UPSC who were treated with the combinations of radiation therapy, chemotherapy, total abdominal hysterectomy, and bilateral salpingo-oophorectomy (TAH/BSO), with or without a surgical staging procedure. Twenty of 38 patients were treated with a combination of low dose-rate (LDR) uterine/vaginal brachytherapy using ²²⁶Ra or ¹³⁷Cs and conventional whole-abdomen radiation therapy (WART) or whole-pelvic radiation therapy (WPRT). Of 20 patients (10%) in this treatment group, 2 received cisplatin chemotherapy. Eighteen patients were treated with high dose-rate (HDR) vaginal apex brachytherapy using ¹⁹²Ir with an afterloading device and cisplatin, doxorubicin, and cyclophosphamide (CAP) chemotherapy (5 of 18 patients). Only 6 of 20 UPSC patients treated with combination LDR uterine/vaginal brachytherapy and conventional external beam radiotherapy underwent complete surgical staging, consisting of TAH/BSO, pelvic/para-aortic lymph node sampling, omentectomy, and peritoneal fluid analysis, compared to 15 of 18 patients treated with HDR vaginal apex brachytherapy.Results: The 5-year actuarial OS for patients with complete surgical staging and adjuvant radiation/chemotherapy treatment was 100% vs. 61% for patients without complete staging (p = 0.002). The 5-year actuarial OS for all Stage I UPSC patients treated with postoperative HDR vaginal apex brachytherapy and systemic chemotherapy was 94% (18 patients). The 5-year actuarial OS for Stage I UPSC patients treated with HDR vaginal apex brachytherapy and chemotherapy who underwent complete surgical staging was 100% (15 patients). The 5-year actuarial OS for the 20 Stage I UPSC patients treated with combinations of pre- and postoperative LDR brachytherapy and postop WART was 65%. None of the 6 surgically staged UPSC patients treated with LDR radiation and WART/WPRT developed recurrent disease. For patients with FIGO Stage IA, IB, and IC UPSC who underwent complete surgical staging, the 5-year actuarial DFS by depth of myometrial invasion was 100, 71, and 40%, respectively (p = 0.006). The overall salvage rate for local and distant recurrence was 0%. Complications following HDR vaginal apex brachytherapy included only Radiation Therapy Oncology Group (RTOG) grade 1 and 2 toxicity in 16% of patients. However, complications from patients treated with WART/WPRT, and/or LDR brachytherapy, included RTOG grade 3 and 4 toxicity in 15% of patients.Conclusion: Patients with UPSC should undergo complete surgical staging, and completely surgically staged FIGO Stage I UPSC patients can be effectively and safely treated with HDR vaginal apex brachytherapy and chemotherapy. Both OS and DFS of patients with UPSC are dependent on depth of myometrial invasion. The salvage rate for both local and distant UPSC recurrences is extremely poor. Complications from HDR vaginal apex brachytherapy were minimal.     

High-dose-rate afterloading brachytherapy in carcinoma of the uterine cervix

The Brachytron has been used in the University of California at San Diego Medical Center since 1970 as one method of treating gynecological malignancies. This machine contains a high intensity cobalt 60 remote afterloading cycling source used for intracavitary brachytherapy. One hundred twenty-seven patients with epithelial carcinoma of the cervix are available for analysis of 5-year survival, and 176 are analyzed for treatment complications two years following therapy. Five year survival figures for FIGO-staged patients treated with external beam pelvic irradiation and intracavitary Brachytron treatments are as follows: Stage I, 89%; Stage II, 58%; Stage III, 33%, and two of five patients Stage IVa. Rectal complications graded moderate or severe (M, S) were dose-related and gradually decreased over the years as techniques improved. Complications from early results in 1970-1972 (24% M, 10% S) were reduced to lower levels in 1976-1979 (14% M, 4% S). The Brachytron offers the advantage of rapid dose delivery. Thus, patients can be treated in an outpatient setting, avoiding the cost of hospitalization and the risks of anesthesia. The Brachytron also offers virtually complete radiation safety to all attending medical personnel. With survival and complication figures similar to those reported for patients treated with conventional low-dose-rate brachytherapy, the Brachytron represents an effective alternate mode of therapy for uterine carcinoma.     

Patterns of failure and survival in locally advanced carcinoma of the uterine cervix treated with high dose-rate intracavitary irradiation system.

We retrospectively analyzed 71 patients with locally advanced carcinoma of the uterine cervix treated by irradiation using high dose-rate intracavitary brachytherapy between 1978 and 1985. Seven patients were Stage IIIa, 46 Stage IIIb, and 18 Stage IVa. Five-year survivals for Stage IIIa, IIIb, and IVa were 71.4, 60.9, and 16.7%, respectively. An analysis of patterns of failure demonstrated that loco-regional recurrences were observed in 1 (14.3%) for Stage IIIa, 6 (13.0%) for Stage IIIb, and 9 (50.0%) for Stage IVa. The incidence of recurrence outside the pelvis observed in Stage IIIb patients (7 para-aortic nodes, 5 distant metastases) was much higher than that of local recurrence. Five patients (7.0% of the total: 1 with Stage IIIa, 3 with Stage IIIb, 1 with Stage IVa) required surgery to manage the complications. These data suggest that a high dose-rate intracavitary irradiation system is an effective tool for the treatment of cervical cancer. Further efforts to control metastatic lesions outside the pelvis are required for patients with Stage IIIb. To increase a loco-regional control rate for patients with Stage IVa disease, it is important to give additional treatment such as chemotherapy in conjunction with radiation therapy.     

Prognosis of endometrial carcinoma stage I in two Swedish regions. A study with special regard to the effects of intracavitary irradiation with high dose-rate afterloading technique or with low dose-rate radium

A high dose-rate afterloading technique (60Co) was compared with a low dose-rate packing method (226Ra) in the treatment of endometrial carcinoma stage I. In all, 1,021 patients treated during the period 1977-1986 at two Swedish gynecologic oncology centers were analyzed regarding treatment set-up, histopathologic outcome in the operative specimens, recurrence rates, survival rates and radiation side effects. Complete tumor eradication in the operative specimen was achieved in 80% after radium therapy and in 60% after irradiation by the high dose-rate technique. The overall recurrence rate was 15.7% in the radium packing series and 11.5% after cobalt afterloading treatment. The risk of pelvic recurrences increased by 2.1-2.6 if hysterectomy was replaced by dilatation and curettage. The two radiation techniques seemed to be comparable with regard to the risk of both pelvic recurrences and distant metastases. The 5-year crude survival rates were 85% in the afterloading series and 82% in the radium series. The corrected survival rates were similar (90%) for the two techniques. Age, tumor grade and uterine size were significant prognostic factors with regard to the probability of death due to cancer. Early radiation reactions had quite similar rates in the two series, whereas late radiation reactions were more frequent in the high dose-rate afterloading group in the 10-12 Gy dose fraction range, but not in the 5-8 Gy range. The radium packing method seemed to give a higher frequency of tumor-free operative specimens in this study, but with regard to recurrence rates and survival probabilities the techniques were comparable. Since the different proportion of surgery in the two series and the histopathologic evaluation might have influenced the rate of local tumor eradication in the operative specimens and the risk of pelvic recurrences the results must be assessed with great caution and only a crude comparison of the two treatment techniques could be made.     

子宫内膜癌单纯放射治疗回顾性分析

90 patients with endometrial carcinoma treated from 1958 to 1984 by radiotherapy alone are presented. They constituted 18.7% of all cases of endometrial carcinoma treated in the same period. According to the clinical staging system of FIGO, there were 28.89% Stage Ia, 8.89% Stage Ib, 38.89% Stage II, 20% Stage III and 3.33% Stage IV lesions. In this series, 82 patients suffered from adenocarcinoma and 8 patients from adenoacanthoma. Two treatment regimens were adopted: 1. intracavitary Ra (137Cs or 60Co) as the major form of treatment supplemented by external irradiation in 82 patients (including 5 by intracavitary 137Cs afterloading), 2. external irradiation supplemented by intracavitary Ra (or 137Cs) radiation in 8 patients. The overall 5-year survival rate was 48.89% (Stage I 58.82%, Stage II 51.42%, Stage III 33.3% and Stage IV 0%). Complications were proctitis in 17 cases hematuria in 4 and rectovaginal fistula in 1. The 5 patients treated by intracavitary afterloading radiation with high doses at reference points A and F all survived for more than 5 years. This may imply a bright future for this form of radiotherapy in the treatment of endometrial carcinoma.     

Seminoma of the testis: a 22-year experience with radiation therapy

An analysis is presented of 188 patients with a histological diagnosis of seminoma testis, treated by radical orchiectomy and radiation therapy between 1960 and 1981 at the Cross Cancer Institute. Using the Walter Reed Hospital staging classification, 149 (79%) patients were Stage I, 34 (18%) were Stage II, and 5 (3%) were Stage III. The 5-year survival for all stages was 90%, and for Stage I was 98%, Stage II, 71%, and Stage III, 0%. All were treated primarily with radiation therapy. Prophylactic mediastinal radiation was not employed for Stage I, and was employed in half of Stage II patients. Eleven patients with Stage I relapsed, five in the mediastinum and/or neck nodes. Eight of 11 were cured with further treatment. Stage II patients were subdivided according to the presence or absence of a palpable abdominal mass. Palpable disease (Stage IIB) carried a poorer prognosis. Three of 20 patients without a palpable mass (Stage IIA) died of disease; there was an 82% five-year survival rate. Eight of 14 with a palpable mass (Stage IIB) were cured by radiotherapy; there was a 54% five-year survival rate. All five Stage III patients died within 1 year of diagnosis. Stage I and IIA seminoma is curable by radiation alone. Prophylactic mediastinal radiation is not indicated in either Stage I or IIA disease. Long term toxicity from radiation is not seen. Optimal treatment for Stage IIB disease is undetermined and new treatment regimens should be explored. Stage III disease requires primary chemotherapy.     

Postoperative vaginal radiation in endometrial cancer using a remote afterloading technique

Carcinoma of the endometrium is the most common malignancy of the female genital tract. In early stage endometrial cancer, surgery remains the primary mode of treatment while radiation therapy plays an adjuvant role. Prophylactic vaginal radiation has been shown to reduce significantly the incidence of vaginal recurrences. Between the years 1969-1976, 330 patients with FIGO Stages I and II endometrial cancer were treated according to a standard departmental policy in which 40 Gy of external radiation was given to high risk Stage I and all Stage II patients in combination with surgery and intravaginal radiation. Stage I was considered high risk if the tumor was of high grade or exhibited deep myometrial invasion. Vault radiation was delivered with a remote afterloading technique to a point .5 cm from the surface of the applicator; a total dose of 21 Gy was delivered in three fractions spaced two weeks apart over four elapsed weeks. With this regimen, the mucosal surface received a total equivalent dose of 40 Gy. These treatments were given on an outpatient basis without the need for any sedation or analgesics. All patients, regardless of stage, grade, or depth of myometrial invasion received adjuvant post-operative vaginal radiation. The minimum follow-up was 5 years, with a median follow-up of 8.5 years. The overall pelvic and/or vaginal recurrence rate was 2.7%. The incidence of vaginal complications was 3.7%. It appears that the remote afterloading treatment (RAT) for vaginal radiation is a very cost-effective therapeutic alternative, which produces minimal early or late complications and gives complete protection from radiation exposure to the medical staff. The advantages of a remote afterloading technique in delivering vaginal vault radiation in endometrial cancer are discussed in this paper.     

Patterns of radiotherapy practice for patients with squamous carcinoma of the uterine cervix: patterns of care study

PURPOSE: To determine the impact of research findings and evolving technology on the patterns of radiotherapy practice for patients with carcinoma of the uterine cervix. METHODS AND MATERIALS: Sixty-two radiation therapy facilities participated in the study after having been selected from a random sample, proportionally stratified according to practice type, of all United States facilities. Each facility submitted a list of patients treated during 1992-1994 with radiation for squamous carcinoma of the cervix. Cases for review were randomly selected from each institution after excluding those of patients who had distant metastases or initial hysterectomy. A total of 471 patients' records were reviewed in the treating institutions to obtain information about patients' characteristics, diagnostic evaluation, tumor extent, treatment approach, and radiotherapy techniques. RESULTS: Of the 61 facilities that treated eligible cases of intact cervical cancer during the 3-year survey period, 35 (57%) treated fewer than three eligible patients per year. Thirty-four (83%) of 41 non-academic facilities vs. 1 (5%) of 20 academic facilities treated fewer than three patients per year. FIGO stages were I, II, III, and IV in 32%, 40%, 24%, and 3% of patients, respectively. Computed tomography (CT) was the most common method of lymph node evaluation, but surgical evaluation, which was performed in 76 (16%) patients, had increased from previous surveys. Fields were designed using a dedicated simulator in 95% of patients; a dedicated CT unit was used for treatment planning in 119 (30%) cases. External beam irradiation was most often given using a four-field technique at 180 cGy per day on a 10-20 MV linear accelerator. The average daily fraction size had decreased from previous surveys, and 13% of patients were treated with daily doses of 170 cGy or less. Most patients were treated with a combination of external beam and low dose-rate (LDR) intracavitary irradiation. Of 425 patients who had treatment with curative intent that included brachytherapy, 362 (85%) had LDR brachytherapy, 45 (11%) had high dose-rate (HDR) brachytherapy, 3 had a combination of HDR and LDR, and 15 had incomplete information about the brachytherapy dose-rate. Forty-six (23%) of 197 patients with Stages I-IIA disease were treated with radiation followed by extrafascial hysterectomy. Of 111 patients treated with curative intent for Stage III-IV disease, 72 (65%) had a combination of external beam and intracavitary radiation therapy, 22 (20%) had external beam plus interstitial brachytherapy, and 17 (15%) were treated with external beam irradiation only. For patients who completed treatment with curative intent and did not have adjuvant hysterectomy or HDR brachytherapy, the median total dose at point A was 82.5 Gy. For all patients who completed treatment with radiation alone, the median total duration of treatment was 63 days; more than 70 days were taken to complete treatment in 33% of cases. Twenty-nine percent of patients received chemotherapy, usually concurrent with their radiation therapy. Only 27% of these patients were on investigational protocols. CONCLUSIONS: Greater participation in well-designed prospective trials might help clinicians address important clinical questions and reduce current inconsistencies in the use of adjuvant treatments. Radiation oncologists should take steps to avoid unnecessary treatment protraction and to improve patient compliance. Future studies will be needed to determine whether the small number of cases being treated in most nonacademic facilities will influence the outcome for patients with invasive cervical carcinoma.     

Carcinoma of the fallopian tube. Management and sites of failure

Thirty patients with adenocarcinoma of the fallopian tube, treated between 1950 and 1981, were studied. Median age was 55 years, and mean parity was 1.3. Bleeding or discharge occurred as a presenting complaint in 47% of patients, abdominal distention or mass in 50%, and pain in 30%. Lesions were staged using a system analogous to the International Federation of Gynecology and Obstetrics (FIGO) classification for ovarian carcinoma. Nine patients had Stage I disease; 11, Stage II; 7, Stage III; and 3, Stage IV. Histologic differentiation was Grade 1 in 39% of the patients, Grade 2 in 18%, and Grade 3 in 43%. Primary surgical treatment consisted of total abdominal hysterectomy and bilateral salpingectomy in 70% of the patients; 23% had more extensive surgery, whereas 13% had less extensive surgery. Three patients with Stage I tumors were treated with surgery alone, and the remainder received postoperative radiation, chemotherapy, or both. Survival was unrelated to grade, but highly dependent upon stage. Survival at 5 years was 56% for Stage I, 27% for Stage II, 14% for Stage III, and 0% for Stage IV. Four of five patients treated after surgery with a combination of cisplatin, doxorubicin, and cyclophosphamide (PAC) survived at least 3 years. Patterns of initial treatment failure showed 56% with a component of pelvic failure, 50% with a component of upper abdominal failure, and 44% with extraperitoneal metastases as a component of failure. These results suggest the need for aggressive postoperative adjuvant therapy targeted at upper abdominal and distant sites for metastasis in all lesions beyond Stage I.     

后装治疗子宫颈癌的临床报告

134 patients with carcinoma of the cervix treated by combination of intracavitary Cs-137 afterloading radiation and 8 Mv external X-ray irradiation from July 1983 to Nov. 1984 are reported. There were 1 Stage I, 78 Stage II, 53 Stage III and 2 Stage IV lesions. Of these patients, 94.8% had squamous cell carcinoma, 4.5% adenocarcinoma and 0.7% adeno-acanthoma. The total dose of intracavitary radiation at point A was 50 Gy +/- 20%. 40-45 Gy external irradiation was delivered to the parametria. The 3-year survival rates were 84.6% in Stage II and 67.9% in Stage III lesions, respectively. 48% of the 25 patients with cauliflower tumors died. Ten of 19 patients who died were due to extrapelvic metastasis. 9% of cases had rectal bleeding and 6% had hematuria after treatment although there was no recto-vaginal fistula within 3 years' follow-up.     

High-dose-rate remote afterloading intracavitary radiation therapy for cancer of the uterine cervix. A 20-year experience.

Retrospective analysis was performed on 1022 patients with squamous cell carcinoma of the uterine cervix who were treated with high-dose-rate remote afterloading intracavitary irradiation at the National Institute of Radiological Sciences, Angawa, Chiba-shi, Japan, from 1968 to 1982 in comparison with low-dose-rate intracavitary radiation therapy. The patient population consisted of 147 patients with Stage I disease, 256 patients with Stage II disease, 515 patients with Stage III disease, and 104 patients with Stage IV disease. Absolute 5-year survival rates for Stages Ib, IIa, IIb, IIIb, IVa, and IVb disease were 88.1%, 76.9%, 67.0%, 52.2%, 24.1%, and 13.3%, respectively. The rates of severe complication of Grades 3 and 4 were 4.1% for the rectosigmoid colon, 1.2% for the bladder, and 1.1% for the small intestine. In the case of Stage I to II disease, the optimal dose from intracavitary sources was suggested to be 2900 cGy +/- 200 cGy at point A, with 4 to 5 fractions of 600 to 700 cGy delivered over 4 to 5 weeks. These results suggested that high-dose-rate intracavitary radiation therapy provided clinical results comparable to those of a low-dose-rate technique.     

High-dose rate intracavitary therapy for carcinoma of the uterine cervix: I. General figures of survival and complication

From August 1978 through December 1982, a total of 200 patients with previously untreated carcinoma of the uterine cervix were treated using remote afterloading high-dose rate intracavitary therapy (RALS) at our department. According to the staging of UICC (1978), 8 patients were classified into Stage Ia, 22 Ib, 22 IIa, 53 IIb, 85 III, and 10 IV. Actuarial 5-year survival rates by Stage were 100% in Stage Ia, 86% Ib, 67% IIa, 72% IIb, 41% III, and 20% IV (p = 0.0001). Significant prognostic factors in Stage II were the value of hemoglobin (p = 0.0115) and age (p = 0.0431) by logrank test. Corresponding factors in Stage III were the value of hemoglobin (p = 0.0005) and total protein (p = 0.0036). Late complications after RALS developed in 22 patients (11%), that is, rectum 14 (7%), bladder 6 (3%), small intestine 4 (2%) and sigmoid colon 1 (1%). Severe complications requiring surgery were noted in 7 patients (4%). There was no fatal case attributable to complication. It is concluded that RALS is one of the most effective and safe means for the treatment of carcinoma of the uterine cervix based on our results.     

Results of radiation therapy in the treatment of epithelial carcinoma of the ovary

Between 1967 and 1976, 82 patients who had epithelial carcinoma of the ovary and were treated with surgery and postoperative radiation therapy, respectively, were studied. Of these patients, 35% had Stage I disease, 16% Stage II, 45% Stage III, and 4% Stage IV. Serous cystadenocarcinoma was the histologic cell type in 54% of the patients, and mucinous cystadenocarcinoma was involved in 24%. Of the tumors, 35% were Grade 1, 34% Grade 2, 18% Grade 3, and 13% were unspecified. Survival at five years was 96% for Stage I patients, 60% for Stage II, and 60% for Stage III. No stage IV patient survived past two years. Stage III patients with no palpable tumor prior to radiation therapy did well, with 80% alive at more than two years, while only 10% of Stage III patients with palpable tumors prior to radiation therapy are alive. Patients with Stage III disease treated by whole-abdominal irradiation with a pelvic boost did better than those who received 3,000 rad or less to the pelvis. Radiation therapy continues to be an important treatment modality in epithelial carcinoma of the ovary, particularly in patients with minimal tumor burden.     

Acute toxicity and preliminary clinical outcomes of concurrent radiation therapy and weekly docetaxel and daily cisplatin for head and neck cancer

OBJECTIVE: To examine the feasibility and efficacy of concurrent weekly docetaxel and radiation therapy as a definitive treatment for head and neck cancer (HNC). METHODS: Thirty-two patients with primary HNC, who were treated with concurrent weekly docetaxel and radiation therapy, were analysed. The distribution of the disease stage was as follows: Stage II, 18 patients; Stage III, 3 patients; Stage IVA, 7 patients; Stage IVB, 3 patients; the patient of cervical lymph node metastasis with unknown primary tumor was not assessable. The average total dose of radiotherapy was 67.5 Gy. Docetaxel (10 mg/m(2), intravenously, once a week) was given to all patients up to four cycles, and cisplatin (6 mg/m(2), intravenously, five times a week) was also administered to all patients for up to 3 weeks from the beginning of the radiation therapy. RESULTS: Only in two patients did the radiotherapy need to be temporarily interrupted due to the development of acute mucositis. Grade 3 toxicity was observed in six patients. Grade 4 acute mucositis was seen in one patient. The response rate was 100%, and complete response (CR) was observed in 30 patients (94%). At the time of the analysis, the 2 year local control and relapse-free rates in the 30 patients showing CR were 90 and 76%, respectively. CONCLUSIONS: Concurrent weekly docetaxel and radiation therapy did not affect the compliance of the patients for the radiation therapy, indicating that the acute toxicities were within acceptable limits.     

Intracavitary Irradiation of Carcinoma of the Cervix Stage Ib and IIA: A clinical comparison between a remote high dose-rate afterloading system and a low dose-rate manual system

The clinical results of a remote high dose-rate afterloading technique with individual three-dimensional treatment planning were compared with those of a manual low dose-rate technique for intracavitary irradiation of cervical carcinoma stage IB and II A. The rates of residual tumour at operation, local recurrence and survival were comparable with the two techniques. The rate of treatment complications was lower with the high dose-rate technique even when external irradiation was added. Better central shielding for external pelvic irradiation is possible when intracavitary irradiation is performed with higher accuraCY.     

Long-term results of high-dose-rate brachytherapy in the primary treatment of medically inoperable stage I-II endometrial carcinoma

PURPOSE: Total-abdominal hysterectomy and bilateral salpingo-oophorectomy (TAHBSO) is the gold-standard therapy for patients with endometrial carcinoma. However, patients with high operative risks are usually treated with radiation therapy (RT) alone. The goal of this study was to update our experience of high-dose-rate brachytherapy (HDRB), with or without external-beam irradiation (EBRT), for such patients. METHODS AND MATERIALS: Between 1984 and 2003, 38 patients with Stage I and Stage II adenocarcinoma of the endometrium considered high operative risk received RT as the primary treatment. The median age was 74.1 years. Before 1996, the local extent of the disease was assessed by an examination under anesthesia (EUA) and by EUA and magnetic resonance imaging (MRI) thereafter. Eight patients (21%) were treated with combined HDRB and EBRT, and 30 patients (79%) were treated with with HDRB alone. The median HDRB dose was 23.9 Gy, typically delivered in 3 fractions in a weekly schedule. The median EBRT dose was 42 Gy. RESULTS: At a median follow-up of 57.5 months for patients at risk, 11 patients (29%) have failed: 6 patients (16%) locally, 4 patients (10.5%) distantly, and 1 patient (3%) locally and distantly. Local failure was established by biopsy, and 4 patients were salvaged by TAHBSO. Higher stage and higher grade were both associated with increased failure rate. The 15-year disease-specific survival (DSS) was 78% for all stages, 90% for Stage I, and 42% for Stage II (p < 0.0001). The 15-year DSS was 91% for Grade I and 67% for Grade II and III combined (p = 0.0254). Patients with Stage I disease established by MRI (11 patients) and who received a total HDRB dose of 30 Gy had a DSS rate of 100% at 10 years. Four patients experienced late toxicities: 1 Grade II and 3 Grade III or IV. CONCLUSION: Medically inoperable Stage I endometrial carcinoma may be safely and effectively treated with HDRB as the primary therapy. In selected Stage I patients, our results are equivalent to that of surgery. We believe that the alternative option of HDRB as the primary therapy for selected Stage I endometrial carcinoma, even in patients with low operative risks, needs further evaluation.     

Primary lymphoma of the testis

Seventeen patients with initial presentation of lymphoma of the testis were evaluated at the Mayo Clinic between 1969 and 1979. The mean age of the patients was 69 years with 15 of the 17 patients age 60 or older at the time of diagnosis. All histologies were diffuse according to the Rappaport classification with 12 of 17 patients being histiocytic. Eleven patients were classified clinically as Stage I_EA, four as Stage II_EA and two as Stage IV according to the Ann Arbor classification. Eleven of the 15 Stage I_EA and II_EA patients were treated with radiation therapy alone with doses ranging from 2,600 to 4,000 rad. Eight of these 11 Stage I_EA patients experienced recurrence; in five of these eight, the first site of recurrence was Waldeyer's ring and adjacent structures. Four patients were treated initially with chemotherapy (one Stage I_E, one Stage II_E and two Stage IV). In all four patients the lymphoma recurred, in two patients in the central nervous system (CNS). The survival rate at two years was 73% in Stage I_EA patients and 25 % in Stage II_EA patients. There were no survivors at two years in those patients presenting with Stage IV disease.As patients with testicular lymphoma have a relatively high incidence of secondary involvement of Waldeyer's ring and the CNS, careful evaluation of these areas should be performed as part of the routine staging procedures. In view of the high incidence of secondary involvement of distant sites, systemic treatment should be given full consideration in addition to local irradiation as part of the initial treatment of patients with localized disease.