Exclusive radical radiation therapy in breast carcinoma

We present the results of 186 breast cancer patients treated initially for locoregional disease by radiotherapy alone, combining cobalt therapy with external electron beam or interstitial iridium implants. According to the TNM classification, the patients were distributed as follows: 3 T1N0, 2 T1N1, 33 T2N0, 36 T2N1, 16 T3N0, 26 T3N1, 6 T3N2, 14 T4N0, 29 T4N1, 9 T4N2 and 12 T4N3. The 5- and 10-year survival rates (52.7% and 36.5%, respectively, for all patients) were directly correlated with the size and location of the breast tumor, and the extent of lymph node involvement. Locoregional recurrence was observed in 39.8% of the cases, metastasis alone in 26.8% of the cases, and a combination of local recurrence and distant metastasis in 14.5% of the cases. The local recurrences and metastases were directly correlated with the extent of locoregional involvement. Late complications and sequelae were mostly minor and occurred in less than 25% of the cases; severe sequelae occurred in no more than 2% of the cases. They depended on the initial tumor volume and the tumor dose. Our results, along with those in the literature, indicate that radiotherapy administered alone is a valid therapeutic option in breast cancer.     

Hyperthermia and radiation therapy in the treatment of recurrent Merkel cell tumors

A high incidence of local recurrence, spread to regional lymph nodes, and distant metastases has been reported after surgical excision of Merkel cell tumors (MCT). The use of postoperative radiation therapy and/or chemotherapy is reviewed from the literature. Despite adjuvant treatment, local tumor recurrences frequently develop. Two patients are presented with metastatic MCT recurrent in previously irradiated sites who had excellent clinical responses and local control following retreatment with local hyperthermia in conjunction with low to moderate dose radiation therapy. These patients represent the first reported use of hyperthermia in the management of MCT. The encouraging local responses described suggest a potential role for the use of hyperthermia and concomitant radiation therapy in the treatment of recurrent MCT.     

The role of radiation therapy in the treatment of glomus jugulare tumors.

The records of 14 patients who received irradiation for incompletely excised, inoperable or recurrent glomus jugulare tumors were retrospectively reviewed. Ages ranged from 12 to 66 years, and the male to female ratio was 1:3. With a follow-up time of 1.3 to 17.2 years (mean of 7.7 years), 11/14 remain clinically disease-free. Doses of at least 4000 rad are shown to be effective in controlling glomus jugular tumors.     

The role of radiation therapy in the treatment of testicular germ cell tumors.

Infradiaphragmatic radiotherapy remains the treatment of choice for patients with stage I and II (small volume) testicular seminoma. With this approach, the disease-free survival rate exceeds 90% to 95%, and the ultimate disease-free survival rate (including salvage) is 95% to 100%. Initial therapy for patients with large-volume stage II, III, and IV disease should include multiagent systemic chemotherapy. Involved field radiotherapy is recommended for these patients following the chemotherapy, especially in patients with residual masses larger than a few centimeters. Although not used frequently in the United States, infradiaphragmatic radiotherapy is a viable treatment option for patients with clinical stage I testicular nonseminomas. Such therapy results in approximately an 85% to 90% relapse-free survival rate, with an ultimate survival rate (including salvage) approaching 100%. Initial therapy for patients with stage II or greater disease generally should include chemotherapy and/or surgery. Radiotherapy is often useful as post-chemotherapy consolidation, especially for unresectable masses. For extra-gonadal seminomas, radiotherapy is useful as definitive therapy for small-volume disease and as consolidative therapy (postchemotherapy) for more advanced disease.     

质子放射治疗与儿童肿瘤

质子治疗技术在肿瘤治疗中的应用已日渐成熟,其优点是质子射线以Bragg峰的形式释放能量,其能量大、穿透力强、散射少、半影小,可以方便精确地调节剂量分布,使高剂量区集中于肿瘤部位而降低靶区外器官及周围正常组织受量.放射治疗对处于生长发育期儿童的长期影响较之成人更为突出,减少正常组织受量对于减轻儿童远期并发症是至关重要的.现就质子放射治疗的物理和生物学特性及其在儿童肿瘤中的临床应用作一综述.     

The role of radiation therapy in the treatment of early stage large cell lymphoma

Nineteen patients with localized non-Hodgkin's lymphoma large cell type classified by the international formulation in group D (5) and group G (14) were treated with extended field radiation therapy. These patients have been followed for 168 months with range from 12 to 168 months from initiation of treatment. In G category of the formulation, the overall survival is 83 per cent at 5 and 10 years and recurrence-free survival is 75 per cent at 10 years. Sixteen of the patients were stage I and three were stage II. Two patients died without evidence of recurrence. Four patients recurred and two of these died of disease. Thirteen of the 19 patients are alive and recurrence free. Bulk of disease had no apparent influence on the response to irradiation. We believe that the early pathological stage large cell lymphoma of the G and D type international formulation are appropriate candidates for radical radiation therapy and benefit from this approach to treatment.     

The current status of primary radiation therapy in the treatment of early breast cancer

Summary Primary radiation therapy, usually with limited surgery, is being used increasingly as an alternative to mastectomy in patients with early breast cancer. Results so far appear similar in terms of local control and overall survival. Current questions on patient selection, extent of surgery, radiation therapy technique, possible long-term complications, and the role of axillary dissection and of adjuvant therapy are reviewed. Though many questions remain, it is hoped that this alternative will contribute to improved survival along with breast preservation for improved quality of life. Address for reprints: Dr Nancy Tarbell Leslie, Joint Center for Radiation Therapy, Dept. of Radiation Therapy, Harvard Medical School, 50 Binney Street, Boston, MA 02115, USA.     

Primary radiation therapy for early breast cancer: The experience at the joint center for radiation therapy

The results of primary radiation therapy in 176 consecutive patients with clinical Stage I and II carcinoma of the breast were reviewed. Median follow-up time was 47 months. The overall breast relapse rate was 7%. Patients undergoing interstitial implantation had a significantly lower breast relapse rate (1%) than patients not undergoing implantation (11 %). Breast relapse was more common in patients undergoing incisional or needle biopsy (17 %), compared to patients treated after excisional biopsy (5 %). In patients undergoing excisional biopsy, but not interstitial implantation, breast relapse was related to external beam dose. Twelve percent of the patients who received less than 1600 ret dose relapsed in the breast, compared to none of the 19 patients who received more than 1700 ret dose. These results imply that supplemental irradiation to the primary tumor area is required following excisional biopsy of a primary breast cancer when 4500–5000 rad is delivered to the entire breast.     

The role of radiation therapy in the treatment of locally unresectable or metastatic carcinoid tumors

Forty-four patients irradiated for metastatic or unresectable carcinoid tumors at Memorial Sloan-Kettering Cancer Center from 1950 to 1986 were studied. The response to radiation was analyzed at four sites: epidural space (11 pts), brain (8 pts), bone (8 pts), and abdominal (17 pts). Although survival was generally poor, substantial palliation was achieved in most cases. No patient with brain metastases had progression of intracranial disease after radiation therapy (median dose: 3300 cGy); all died of progression of systemic metastases (median survival: 4 months). Infield control following radiation therapy for epidural and osseous metastases was achieved in 77% and 78% of sites, respectively, with median doses of 3000 cGy and 4000 cGy. Median survival for epidural and bone metastases was 11 and 13 months, respectively. In-field control was obtained in 62% of patients with intraabdominal disease (median dose: 2700 cGy). Among the subset of seven patients who were irradiated at ten sites of unresectable abdominal (non-hepatic) disease, the median survival was 23 months with 80% achieving a complete or partial response and 50% maintaining permanent in-field control. No dose-response relationship was demonstrated. Radiation therapy can achieve local control and symptomatic palliation in most patients with metastatic carcinoid tumors. Our current recommendation would be to treat non-hepatic sites with 4500-5000 cGy in 4-5 weeks. More rapid fractionation schemes could be used for patients with limited life expectancies.     

A quantitative study of MRI-based treatment planning for the percutaneous radiation therapy of brain tumors

This study examined to which extent treatment plans for brain tumors can be constructed with a commercial treatment planning system (TPS) based on MRI data only. CadPlan 6.4.7 was used as TPS. In particular, differences between MRT-based and conventional CT-based plans were examined systematically. The quantification of the retrospective evaluation was carried out by the point-wise dose difference and the gamma-distribution. In this study the gamma-distribution did not appear advantageous over the dose difference for the tolerance range (point-wise dose difference < 3%, distance criterion LLL 5 mm). The calculated dose distribution showed large differences (up to 103%) at the boundary of the treatment fields, in the regions of the head contour, and in areas with air inclusions and significant bone structures. The inner parts of the fields, and therefore the actual target volume, revealed only small deviations in the range of-2% in the homogeneous distribution.     

Intra-operative radiation therapy in tumors of the digestive tract

All the retrospective and prospective studies concerning IORT in tumors of the digestive tract tend to substantiate a significant improvement in local control without a significant increase in survival. Improvements in the results of IORT can be expected in the near future, and may occur on several fronts: - Technological improvements: advances in the development of IORT machines, with the construction of electron accelerators specifically designed for IORT; greater precision in the systems of collimation (asymmetric collimator, multiple leaves, computerization of the control of collimation); and increased adaptability of the localizers to each clinical situation and to each patients. - Increase in the biological effects of IORT: determination of the exact role of IORT in relation to other therapeutic methods, its integration into the global therapeutic strategy for cancer, and the optimization of IORT doses should all be studied in phase II and III trials. Interesting results are expected from the combination of different methods of preoperative, intraoperative, and postoperative radiotherapy with chemotherapy; the cumulative effect of radiosensitization and cytotoxicity can bring about both local control and treatment of the general disease. In addition, the combination of hypoxic cell radiosensitizers and IORT, a source of important cellular hypoxia as a result of single doses, appears promising. - Lastly, randomized studies in a larger number of patients with objectives and methodologies to be perfected will document the actual contribution of IORT to an increase in survival as part of an overall treatment strategy for digestive tumors. At present, the prognosis remains significantly related to systemic metastatic evolution; this can only be influenced by chemotherapy, whose efficacy remains to be demonstrated. As means for better control of systemic disease are discovered, the clear benefits of local control via IORT will assume increased importance.     

The role of post-operative radiation therapy in the treatment of malignant tumors of the parotid gland

Twenty-nine patients treated with postoperative radiotherapy for malignant tumors of the parotid gland were reviewed at the Joint Center for Radiation Therapy. Most patients were treated between 5,000 and 6,500 rad. All were treated because of microscopic residual disease, extra capsular extension, or tumor close to the facial nerve. The overall results showed one in-field failure, two marginal recurrences, and eight patients failed distantly. Poor prognostic factors included high-grade, extracapsular extension, and nodal involvement. We conclude that patients with malignant tumors of the parotid should be treated with postoperative radiation therapy if any of the bad prognostic signs are present. This may enable the surgeon to spare the facial nerve and obtain local control results equal to or better than more radical surgical procedures.     

Evidence-based radiation therapy for primary brain tumors

Radiation therapy for five primary brain tumors is discussed based on the results of prospective trials. Many randomized studies have revealed the usefulness of radiation and radiochemotherapy for treating malignant gliomas, and the ineffectiveness of many new treatments modalities. However, novel treatments should be tested further against this tumor. In low-grade gliomas, the usefulness of radiotherapy was shown but a dose-effect relationship was not observed in recent randomized studies. In medulloblastoma, the difficulty in reducing the dose to the cerebrospinal axis has been shown even in low-stage patients. On the other hand, reliable randomized studies are still lacking for germinoma and primary central nervous system lymphoma, and the usefulness of combination chemotherapy remains uncertain. In the future, more prospective studies are needed for primary brain tumors other than glioma. Establishment of IMRT and controlled studies to prove its efficacy are important in the field of neuro-oncology.     

Conformal radiation therapy for childhood CNS tumors

Radiation therapy plays a central role in the management of many childhood brain tumors. By combining advances in brain tumor imaging with technology to plan and deliver radiation therapy, pediatric brain tumors can be treated with conformal radiation therapy. Through conformal radiation therapy, the radiation dose is targeted to the tumor, which can minimize the dose to normal brain structures. Therefore, by limiting the radiation dose to normal brain tissues, conformal radiation therapy offers the possibility of limiting the long-term side effects of brain irradiation.In this review, we describe different approaches to conformal radiation therapy for pediatric central nervous system tumors including: A) three-dimensional conformal radiation therapy; B) stereotactic radiation therapy with arc photons; C) intensity-modulated radiation therapy; and D) proton beam radiation therapy. We discuss the merits and limitations of these techniques and describe clinical scenarios in which conformal radiation therapy offers advantages over conventional radiation therapy for treating pediatric brain tumors.     

Fractionated stereotactic radiation therapy for intracranial tumors

In stereotactic radio surgery, a single, large dose of radiation is delivered to a small, well-defined, stereotactically localized intracranial lesion. In contrast to conventional radiation therapy, in radio surgery no attempt is made to spare normal cells within the target volume by fractionating the tumor dose. In 1987, the authors began a program of fractionated stereotactic radiation therapy for selected tumors involving sensitive brain structures. Their objective was to improve the therapeutic index and study the feasibility of the fractionated technique. Fifteen patients were treated with a multifraction regimen typically consisting of six fractions of 700 cGy each, given on alternate days for 2 weeks (total tumor dose, 4200 cGy). All patients were treated with the dynamic stereotactic radio surgical technique. A head ring ("halo frame") was used for immobilization and setup during radiation treatments. At a median follow-up time of 27 months, the symptoms of the majority of the patients improved clinically; this improvement usually occurred within a few weeks after completion of the treatment. The radiologic response was much slower. Currently, only two patients have had complete radiologic disappearance of their lesions; the majority of the patients have only had a decrease in tumor size. The treatments were well tolerated by the patients and no acute complications were observed. One patient who had a vasogenic edema 11 months after treatment fully recovered after steroid therapy. Fractionated stereotactic radiation therapy is a feasible treatment technique and may prove to be useful for selected patients with intracranial tumors. Although the preliminary data are encouraging, this technique should still be considered experimental. A larger number of patients and a longer follow-up time are necessary to determine whether the results of this technique are actually better than those of conventional radiation therapy.     

The role of radiation therapy in thoracic tumors

Radiation plays an important role in the treatment of thoracic tumors. During the last 10 years there have been several major advances in thoracic RT including the incorporation of concurrent chemotherapy and the application of con-formal radiation-delivery techniques (eg, stereotactic RT, three-dimensional conformal RT, and intensity-modulated RT) that allow radiation dose escalation. Radiation as a local measure remains the definitive treatment of medically inoperable or surgically unresectable disease in NSCLC and part of a multimodality regimen for locally advanced NSCLC, limited stage SCLC, esophageal cancer, thymoma, and mesothelioma.     

Primary tumors of the trachea. Results of radiation therapy

From 1959 to 1986, 24 patients with primary malignant tumors of the trachea received radiotherapy as all or part of treatment. Common presentations included respiratory symptoms in 20 patients and hemoptysis in 15. Thirteen patients had squamous carcinomas with undifferentiated and adenoid cystic cancers in five and four patients, respectively. Overall actuarial survival was 45% at 1 year, 25% at 5 years, and 13% at 10 years. Survival was significantly correlated to histologic type (adenoid cystic versus squamous, P less than 0.03), but not to tumor extent or to patient age or sex. Local control was attained in 10 of 24 patients overall and was more frequent for patients with tumors localized to the trachea and for patients who were treated with combined surgery and radiotherapy. For the 18 patients treated with radiotherapy alone, complete response (CR) was seen to be significantly (P less than 0.001) related to dose: six of seven (86%) patients receiving greater than or equal to 6000 cGy attained CR versus one of 11 (9%) receiving less than 6000 cGy. Three patients developed complications related to radiotherapy. Radiotherapy can provide durable local control of localized tracheal tumors and should be considered for medically inoperable patients with localized tumors and for patients with high risk of recurrence after resection.