Locally recurrent breast cancer: pulse dose rate brachytherapy for repeat irradiation following lumpectomy-- a second chance to preserve the breast

PURPOSE: To perform and assess the effectiveness of local excision of recurrent tumor followed by postoperative pulse dose rate (PDR) brachytherapy. MATERIALS AND METHODS: From 1994 to 2000, 17 patients who had small recurrent breast carcinomas after initially undergoing breast-conserving therapy (BCT), which included postoperative radiation therapy, were treated with local tumor excision and PDR brachytherapy. Recurrences occurred at a median time of 50 months (range, 11-208 months) after primary treatment. Eight patients underwent a combination of PDR brachytherapy (total dose range, 12.5-28.0 Gy) and external-beam radiation therapy (EBT) (total dose range, 12-30 Gy). Nine patients underwent radiation therapy with 40.2-50.0-Gy PDR brachytherapy only. The prescribed radiation dose was 0.5-1.0 Gy per pulse. Patients were examined for local tumor control and treatment-related side effects. RESULTS: Twelve of 17 patients had no local tumor at a median follow-up time of 59 months (range, 20-84 months); two of these patients showed signs of having distant disease. One patient died after a cerebral stroke without evidence of tumor. Four women treated with combined EBT and brachytherapy had secondary local tumor recurrences 4, 8, 8, and 11 months after therapy and had to undergo mastectomy. Despite having undergone radiation therapy previously, patients had side effects limited to moderate (grade 1-2) fibrosis. CONCLUSION: Local tumor excision combined with PDR brachytherapy for small local-regional tumor recurrences after primary BCT is feasible and well tolerated and might obviate mastectomy. Preliminary experiences are encouraging. Further studies are required for appropriate patient selection.     

Juvenile nasopharyngeal angiofibroma: efficacy of radiation therapy

From 1962 to 1984, 13 patients with juvenile nasopharyngeal angiofibroma (JNA) were treated with megavoltage radiation therapy. Follow-up ranged from 40 to 255 months (median, 136 months). Two patients received radiation therapy as the initial treatment; the other 11 patients had undergone unsuccessful previous surgical treatment (median, three resections). Gross tumor was evident at the start of radiation therapy in seven patients, and orbital, sphenoid sinus, or intracranial extension was noted in eight of 13 (62%). Doses ranged from 3,600 to 5,200 cGy (median, 4,800 cGy in daily fractions of 180-200 cGy). Tumor was controlled in 11 patients (85%) after irradiation. Two patients were treated with embolization for residual mass; both remained asymptomatic and without evidence of tumor 134 and 83 months after embolization, respectively. With the exception of xerostomia and caries, no significant chronic morbidity was seen. This review and other studies demonstrate that megavoltage radiation therapy is an effective and appropriate treatment for advanced and recurrent JNA; its routine use for early tumors remains controversial.     

Postoperative radiation therapy in the management of lung cancer

Postoperative radiation therapy for lung cancer is still controversial. In a 9-year period, 69 patients with non-oat-cell carcinoma of the lung (16% stage I, 26% stage II, and 58% stage III) received such therapy. The radiation dose was less than 5,000 cGy in 42 patients, 5,000-5,900 cGy in 16, and 6,000 cGy or more in 11; follow-up ranged from 24 to 64 months. Actuarial survival at 2 and 4 years was 50% and 16%, respectively, for squamous cell carcinoma, and 40% and 26% for adenocarcinoma. The 5-year survival for stages I, II, and III cancer was 29%, 17%, and 19%, respectively. Histologic findings and type of surgery did not affect survival, but the radiation dose apparently did. The 3-year survival for patients who received less than 6,000 cGy was 35%, compared with 73% for patients who received higher doses. In eight patients, treatment failed within the irradiated volume: all had received doses of less than 6,000 cGy, and the volume in three was judged to be inadequate.     

Orbital lymphomas and pseudolymphomas: treatment with radiation therapy

A retrospective analysis of 16 patients with orbital lymphoma or pseudolymphoma from 1961-1984 was undertaken to evaluate the use of radiation therapy. Pathologic assessment confirmed that four patients had benign pseudolymphoma, and 12 patients had true malignant lymphoma, including two with advanced disease at presentation. With a median follow-up of 4 years, the local control rate with radiation therapy was 100%, although the two patients with advanced disease died of lymphoma 26-33 months after irradiation. While doses of 1,600-2,000 cGy appear adequate for pseudolymphoma, for lymphoma a dose of 3,000-4,000 cGy is necessary. Subconjunctival lesions can be treated in a single anteroposterior field; retroorbital lesions require an additional lateral field.     

Transitional cell carcinoma of the urinary bladder: histologic clearance with combined 5-FU chemotherapy and radiation therapy. Preliminary results of a bladder-preservation study

Fourteen patients with transitional cell carcinoma of the urinary bladder were treated with 4,000 cGy of pelvic irradiation concurrent with two 96-hour infusions of 5-fluorouracil (5-FU). Three weeks after completion of this regimen, patients underwent repeat cystoscopy and deep-muscle biopsy at the site of their original neoplasms. Eight of 14 (57%) had no tumor left in the biopsy specimen, and they received an additional course of chemotherapy and radiation therapy to a total dose of 4,400 cGy to the pelvis and 6,000 cGy to the bladder. Five of the 14 had residual tumor in the biopsy specimen (one did not undergo biopsy) and went on to planned cystectomy. Two of the five had no tumor in the cystectomy specimen. Overall, ten of the 14 patients (71%) have been downstaged to a condition of P0 (no tumor) following 4,000 cGy and two courses of 5-FU. Of eight patients with retained bladders, seven remain well at a median follow-up of 7 months. At a range of follow-up of 3-21 months and a median of 7 months, 13 of 14 patients remain tumor-free. This regimen results in a greater percentage of downstaging than conventional irradiation alone, and may allow bladder preservation for those with radiation therapy- and chemotherapy-responsive tumors.     

Radiation therapy for stage I and II laryngeal cancer using 10 MV X-rays or cobalt-60 gamma-rays.

From 1970 to 1985, 117 patients with stage I and stage II carcinoma of the larynx (98 with glottic, 15 with supraglottic, and 4 with subglottic cancer) received radiation therapy. The patients were treated with (1) a 60Co machine equipped with 45-degree wedge filters, at a total dose of 6,000-7,000 cGy, 300 cGy per fraction, 3 days a week in the period from 1970-1974; (2) 10 MeV linear accelerator X-rays from 1975-1980, and (3) 10 MeV linear accelerator X-rays and/or the 60Co machine in the period from 1981-1985, at a total dose of 6,000-7,000 cGy, 5 days a week by parallel opposing portals without wedge filters. The 5-year local control rates by radiotherapy alone were 66%, 78%, and 83%, respectively, in the three periods, and the 5-year survival rates were 77%, 97%, and 96% following salvage surgery for recurrent disease. In the 1970-1974 period, four patients developed severe laryngeal edema, and two patients had total laryngectomy without local residual tumor. In the 1975-1985 period, 16 patients had local recurrence in five years, and in five of them the tumor exhibited verrucous-like histopathological findings. In the 1975-1980 period, local recurrence was considered to result from underdosing of lesions with 10 MV X-ray beams and split-course irradiation. In the last five years of the period, the 5-year local control rate for stage I and II carcinoma of the glottis, excluding verrucous-like carcinoma, reached 90% with 10 MV X-rays combined with 60Co gamma-rays.     

A pilot trial of high-dose-rate intraoperative radiation therapy for malignant pleural mesothelioma

PURPOSE: To report results of a phase II trial of high-dose-rate intra-operative radiation therapy (HDR-IORT) for malignant pleural mesothelioma (MPM). METHODS AND MATERIALS: Seven patients had extrapleural pneumonectomy with IORT (EPP/IORT) and 6 patients had pleurectomy/decortication with IORT (PD/IORT) between 1994 and 1996. IORT was delivered with 192Ir using a customized applicator with a remote afterloader. A median of 3 sites were treated to a median area of 143 cm2. A dose of 1500 cGy was prescribed at each site, with 1000 cGy delivered to the mediastinum. Postoperative external beam radiation therapy (EBRT) was given 3-5 weeks later. Median follow-up was 8 months (range, 1-84 months). RESULTS: Five patients developed local failure. Two-year local control and survival rates were 35% and 23%, respectively. Mortality was 2/13 (15%), 1 from each surgical group. Serious complications requiring further intervention occurred in 3/6 (50%) of the EPP/IORT group and 1/5 (20%) of the PD/IORT group. CONCLUSIONS: HDR-IORT after EPP for MPM is prohibitively toxic and has been abandoned, while its use with PD remains in question.     

Combined external and interstitial radiotherapy of vocal cord carcinoma

Since 1984 an Ir-192 source with a high dose rate has been used for interstitial implants, and since 1986 in the treatment of the tumor-bearing vocal cord in the organ-preserving management of larynx carcinoma. The combined percutaneous and interstitial treatment has been administered either as the primary treatment or after incomplete removal of the tumour. So fat 16 patients have been treated, two of them presented with tumours on both cords. All patients refused radical surgical interventions, four of them refused cord stripping too. The treatment method included external radiotherapy with a dose of 4600 to 5000 cGy to the larynx. One to two weeks after external XRT an interstitial implant into the vocal cord followed. Using two needles per cord, a boost dose of 1000 cGy was given to the tumour area. The median follow-up time is 21.3 months (range five to 49, calculated October 1990). So far no local or regional failures occurred. None of the patients had intra- or postoperative complications. All patients have preserved their voice. No severe late effects could be observed. The number of patients is very low, but the preservation of voice is high psychosocial value.     

First experiences with fission neutrons in the radiation therapy of cancer patients

16 patients have been treated until October 1987 at the mixed reactor beam of the RENT-facility in Munich-Garching. All of them received a single dose of 200 to 250 cGy after complete conventional radiotherapy and in same cases also surgery because of the lack of complete tumor resection or local tumor control after radiation control. The ages ranged from 40 to 84 years. The follow-up amounted between two and 28 months, 8.5 months on the average. The tumors selected appeared to be particularly suitable because of their growth in poorly perfused tissues, after the previous surgery and/or radiotherapy. All cases are briefly reported. The general experience from the very limited study is promising. The local effects to the tumor tissue so far are impressive. No severe side effects which could be related to the RENT-session were observed until now.     

Preoperative Radiation with Concurrent 5-Fluorouracil for Locally Advanced T4-Primary Rectal Cancer

PURPOSE: In cT4-rectal carcinoma disease-free margins often cannot be obtained by primary surgery, and even if total en bloc resection is accomplished, local failure remains high with surgery alone. Herein we report on the curative resectability rate, acute toxicities, surgical complications, local control and 5-year survival rates achieved with a more aggressive multimodality regimen, including preoperative radiochemotherapy. PATIENTS AND METHODS: Between 1/1990 and 12/1998, a total of 31 patients with cT4-rectal cancer were treated at our institution. All patients presented with tumor contiguous or adherent to adjacent pelvic organs. Eight patients had synchronous distant metastases. A total radiation dose of 50.4 Gy with a small-volume boost of 5.4 to 9 Gy was delivered (single dose: 1.8 Gy). 5-FU was scheduled as a continuous infusion of 1000 mg/m2 per 24 hours on days 1 to 5 and 29 to 33. Six weeks after completion of radiochemotherapy, patients were reassessed for resectability. RESULTS: After preoperative radiochemotherapy, 29/31 patients (94%) underwent surgery with curative intent. Resection of the pelvic tumor with negative margins was achieved in 26/31 patients (84%), 3 patients had microscopic residual pelvic disease. In 3/8 patients with distant spread at presentation a complete resection of metastases was finally accomplished. Toxicity of radiochemotherapy occurred mainly as diarrhea (NCI-CTC Grade 3: 23%), dermatitis (Grade 3: 16%) and leucopenia (Grade 3: 10%). Surgical complications appeared as anastomotic leakage in 3, wound infection in 2, fistula, abscess and hemorrhage in 1 patient, respectively. With a median follow-up of 33 months, local failure after curative resection was observed in 4 patients (19%), 3 patients (14%) developed distant metastases. The 5-year overall survival rate for the entire group of 31 patients was 51%, following curative surgery 68%. CONCLUSION: A combination of high-dose preoperative radiochemotherapy followed by extended surgery can achieve clear resection margins in more than 80% of patients with locally advanced cT4 rectal tumor. An encouraging trend evolves for this multimodality treatment to improve long-term local control and survival.     

Neutron boost irradiation of soft tissue and chondrosarcomas at the West German Tumour Centre in Essen

In this retrospective study, the results of postoperative neutron boost therapy for 40 soft tissue- and 18 chondrosarcomas are presented. In 65.5% and 34.5% of all cases, microscopic to macroscopic tumour residual was left postoperatively. Locally advanced and moderate to highly malignant tumours were found at surgery in 81% and 69%, respectively. Except for seven patients with a whole series of neutrons to 16 Gy, the other cases were treated with initially 40 to 50 Gy photons and a subsequent neutron boost of 4 to 6 Gy. The median follow-up was 29.3 and 36.2 months for the soft tissue- and chondrosarcomas. The actuarial three-year local control and overall survival rates were 69.3% and 91% for soft tissue- vs. 55.6% and 62.9% for chondrosarcomas. With regard to the extension of surgery (microscopic or macroscopic residual), local control rates of 80% and 60% for soft tissue- vs. 62.5% and 40% for chondrosarcomas were observed. The overall local failure rate was 32.8% with a median disease-free interval of ten respectively eleven months for soft tissue and chondrosarcomas. 17 out of 19 local recurrences were due to inadequate irradiation portals for the neutron boost or to insufficient total doses in the initially treated photon target volume.     

Therapeutic Outcome and Prognostic Factors in the Radiotherapy of Recurrences of Cervical Carcinoma Following Surgery

PURPOSE: To evaluate the efficacy of radiotherapy in patients with recurrences of cervical carcinoma. PATIENTS AND METHODS: 26 patients who underwent radiation therapy for recurrences of cervical carcinoma following surgery between 1989 and 1999 were retrospectively analyzed. 17 patients had inoperable or macroscopic residual tumor. Nine patients had a complete/microscopically incomplete tumor resection. Depending on tumor burden and location of the recurrence, external beam radiotherapy or a combination with brachytherapy was delivered to a total dose of 50-65 Gy. RESULTS: The 5-year overall survival was 28%, relapse-free survival 24%, pelvic control 48%. Therapeutic outcome was related to the margins of resection, location of recurrence and technique of radiotherapy. In case of surgery without residual or microscopic tumor, the 5-year survival rate was 67%, with macroscopic tumor no patient was alive after 37 months (p = 0.05). 5-year overall survival was 42% for central recurrences, 10% for recurrences with pelvic wall infiltration. Recurrences confined to the vagina or paravaginal tissue had a higher 5-year overall probability as compared to all other patients (57% vs. 14%). All patients treated with combined radiotherapy were alive, whereas all patients treated only with external radiotherapy were dead after 32 months (p = 0.01). CONCLUSION: The probability of controlling recurrence mostly depends on a small tumor burden with the possibility of brachytherapy and/or complete surgery. Aggressive treatment modalities like radiochemotherapy and/or higher radiation doses are needed, especially for recurrences with infiltration of the pelvic wall and/or with macroscopic tumor.     

Reirradiation for recurrent malignant brain tumor with radiotherapy or proton beam therapy

Background and purpose

Radiotherapy for recurrent malignant brain tumors is usually limited because of the dose tolerance of the normal brain tissue. The goal of the study was to evaluate the efficacy and feasibility of reirradiation for patients with recurrent malignant brain tumors.

Patients and methods

The subjects comprised 26 patients with recurrent malignant brain tumors treated with conventional radiotherapy (RT, n?=?8), stereotactic radiotherapy (SRT, n?=?10), and proton beam therapy (PBT, n?=?8) at our institute. Fifteen patients had glioblastoma, 6 had WHO grade 3 glioma, and 5 had other tumors. The dose of initial radiotherapy was 34.5–94.4 Gy. Different radiation schedules were compared using the equivalent dose in 2-Gy fractions.

Results

Reirradiation was completed in all patients without a severe acute reaction. The reirradiation doses were 30–60 Gy (median, 42.3 Gy) and the total doses for the initial and second treatments were 64.5–150.4 Gy (median, 100.0 Gy). Currently, 11 patients are alive (median follow-up period, 19.4 months) and 15 are dead. The median survival and local control periods after reirradiation of the 26 patients were 18.3 and 9.3 months, respectively. For the 15 patients with glioblastoma, these periods were 13.1 and 11.0 months, respectively. Two patients showed radiation necrosis that was treated by surgery or conservative therapy.

Conclusion

Reirradiation for recurrent malignant brain tumor using conventional RT, SRT, or PBT was feasible and effective in selected cases. Further investigation is needed for treatment optimization for a given patient and tumor condition.     

Die kombinierte Behandlung des lokal begrenzten Prostatakarzinoms mit HDR-Iridium-192-Nachlade-Brachytherapie und perkutaner Bestrahlung

BACKGROUND: The localized prostate cancer can be treated curatively by radiation therapy. The combined treatment of external beam irradiation and HDR-Iridium 192 remote brachytherapy allows higher radiation doses within the tumor without increasing radiation sequelae. PATIENTS AND METHODS: Patients of our clinic have been treated with this combined procedure since 1991. Between 1991 and 1994 15 patients received 2 x 9 Gy of high-dose-rate brachytherapy, followed by 36 Gy external beam irradiation (group A). Because of the frequent local failures in group A, the reference dose of external beam irradiation was increased to 50.4 Gy after brachytherapy between 1994 and 1996. RESULTS: Seven of 15 patients (47%) in group A developed a local recurrence after a median of 17 (13 to 30) months. In group B (20 patients) local failure occurred in 3 patients (15%) after 11, 16 and 32 months. CONCLUSION: The combined radiation therapy of localized prostate cancer cannot substitute radical prostatectomy completely, but it is a promising alternative in the curative treatment in selected patients.     

High-Dose-Rate (HDR) or Pulsed-Dose-Rate (PDR) Perioperative Interstitial Intensity-Modulated Brachytherapy (IMBT) for Local Recurrences of Previously Irradiated Breast or Thoracic Wall Following Breast Cancer

PURPOSE: In patients receiving salvage high-dose-rate (HDR) or pulsed-dose-rate (PDR) brachytherapy for a local recurrence on the chest wall or in the previously treated breast, clinical outcome and benefit were investigated. All patients had previously been treated with full-dose adjuvant external-beam irradiation (EBRT). Disease-free interval after salvage treatment, local tumor control and side effects were analyzed retrospectively. PATIENTS AND METHODS: Between 1996 and 2002, a total of 32 consecutive patients were treated. 13 patients initially treated with mastectomy and postoperative irradiation and 19 patients initially treated with breast-conserving surgery and postoperative irradiation developed a local recurrence. The mean dose of previous radiation therapy was 58 Gy (range, 42-64 Gy), applied by conventional fractionation. After implantation +/- surgery of recurrent disease and CT-based 3-D planning, 15 patients were irradiated with HDR-IMBT (intensity-modulated brachytherapy) with a mean dose of 28 Gy (range, 10-30 Gy, 2 x 2.5 Gy/day at 6-h daily interfraction interval) and 17 patients received PDR-IMBT with a mean dose 30 Gy (range, 10-45 Gy, 5 x 1 Gy/day at 2-h pulse intervals). Four patients underwent additional EBRT using a dose of 24-40 Gy electrons. Treatment was performed only on working days. RESULTS: After a mean post-implant follow-up of 19 months (range, 1-83 months), no signs of local recurrence were observed in 20 of the 32 patients. In twelve patients, local recurrence occurred after a mean follow-up of 13 months (range, 1-78 months). 20 of the 32 patients experienced an additional systemic progress. In one patient, an EORTC/RTOG grade 3 side effect (ulceration of the skin) was described, which was followed by a local recurrence 12 months posttherapeutically. CONCLUSION: Perioperative interstitial HDR/PDR-IMBT of localized breast or thoracic wall recurrences following previous full-dose EBRT appears to be a meaningful salvage treatment with acceptable toxicity.     

Palliative radiotherapy of brain metastases of solid tumors: experiences with high doses]

Results of palliative high dose irradiation in 145 patients with brain metastasis of various carcinomas are reported. All patients had whole brain irradiation by parallel opposed lateral fields with a midline dose of 13 to 14 x 300 cGy in 2,5 to three weeks. Patients with solitary brain metastasis received a local boost with 5 x 200 cGy. Twelve patients had also surgical excision of the brain metastasis. 39% of the patients had a marked improvement (good or very good neurological function class) and 30% had a moderate improvement. Neurologic function was stabilized in an improved state for 93% of the remaining survival time. This result corresponds to the observations of the RTOG in a randomized study of various doses, resulting in a standard dose of 10 x 300 cGy, but there is a small subgroup with a relatively favourable prognosis benefitting from surgery and irradiation or irradiation alone with a higher dose and conventional fractionation.     

Hepatic malignancies: improved treatment with intraarterial Y-90

An improved treatment method for hepatic malignancies with yttrium-90 incorporated into the matrix of glass microspheres was evaluated prospectively. Fifteen patients with 12 metastatic colorectal cancers, one carcinoid, one islet cell tumor, and one hepatoma were treated with three dose levels: 5,000 cGy (5,000 rad), ten patients; 7,500 cGy (7,500 rad), three patients; and 10,000 cGy (10,000 rad), two patients. Mean follow-up was 7 months (range, 2-12 months). Stable disease in the liver was seen in ten patients, four of whom had concurrent progression of extrahepatic disease, which resulted in two deaths. Two additional deaths were not directly related to the malignant process. Progression of liver disease was found in five patients, with three deaths occurring at 7-8 months. No procedural, hematologic, or pulmonary complications occurred. Late gastroduodenal ulceration occurred at 6-8 weeks in three patients who had histories of chronic alcohol abuse. This method of therapy seems to be feasible and efficient. Caution is necessary with high doses or with patients with a history of or predisposition to gastroduodenal ulcers.     

Giant cell tumors of bone: treatment with radiation therapy

Records of 15 patients with giant cell tumor of bone treated with radiation therapy over a 35-year period were reviewed; ten patients for whom follow-up information was available constituted the study group. One patient was treated by means of orthovoltage equipment only, a second, by both orthovoltage and megavoltage equipment (cobalt 60). The remaining eight were all treated with megavoltage to doses of 40-52 Gy in 24-30 fractions. Seven patients are alive without disease, with an average survival of 192 months (range, 48-360 months). Three patients died of uncontrolled local and distant disease (average survival, 52 months; range, 23-99 months): one with metastasis in the lungs at time of treatment and two after treatment. Although incidence of lung metastasis appears high, it may be due to patient selection because chemotherapy had failed in all three. Complications from irradiation in one surviving patient required surgical closure of a dural fistula 19 years after treatment. No radiation-induced sarcomatous transformations of controlled tumors were noted. These data suggest that giant cell tumor of bone can be well controlled by radiation therapy. Megavoltage irradiation should be considered in treating local disease not easily controlled by surgery in the axial skeleton. Complications are minimal, and normal function can be preserved in the treated areas.     

The management of soft tissue sarcomas in adults: surgery and postoperative radiotherapy.

Traditionally soft tissue sarcomas have been managed by surgery, because they were considered radioresistant. Experience has shown that the local recurrence rate after a simple excision is 90 per cent and 30 per cent after radical surgical procedures. The treatment of soft tissue sarcomas by radical ratiation therapy alone is also unrewarding-the local recurrence rate being 66 per cent. In order to preserve a functional limb, a selected group of patients was treated using a conservative surgical excision of the gross tumor (usually a simple "shelling out"), and immediate postoperative radiation therapy. The rationale for removing all gross tumor by conservative surgical excision is that the remaining subclinical disease can be destroyed with moderate doses of postoperative irradiation. In 70 patients with soft tissue sarcomas of the extremities, all local failures occurred in tumors of the fleshy parts with a recurrence rate of 17.2 per cent, independent of the histological type. In spite of generous radiation fields, 4 of the 12 local recurrences were outside of the irradiated volume, some more than 5 cm from the margin of the field. This documents the tendency of soft tissue sarcomas to spread along the fascial planes for a great distance. To avoid complications only part of the entire circumference of an extremity must be irradiated since a severe constricting fibrosis may result with varying degrees of edema distal to the irradiated volume when all of most of the circumference is irradiated. This retrospective review of patients treated for extremity lesions by conservative excision and postoperative radiotherapy shows that a functionnal limb can be preserved in 80 per cent of the patients.     

Intracranial germinoma: radiation therapy with tumor volume-based dose selection

PURPOSE: To prospectively investigate whether intracranial germinomas, except large ones, can be cured with radiation doses lower than 50 Gy and to determine 10-year follow-up results. MATERIALS AND METHODS: Between 1985 and 1995, 38 patients with intracranial germinoma diagnosed histologically or with established criteria were enrolled. Total radiation doses to the primary tumor site were 36 Gy after total removal, 40 Gy for tumors less than 2.5 cm in diameter, 45 Gy for those 2.5-4.0 cm, and 50 Gy for those greater than 4.0 cm, with 1.6-1.8-Gy daily fractions. Patients underwent irradiation of the primary tumor site or cerebrospinal axis (20-24 Gy), depending on findings at diagnosis. No chemotherapy was allowed. RESULTS: All patients completed radiation therapy. Thirty-five patients were treated according to protocol, and three with relatively slow tumor regression or presence of a cyst received additional radiation (5-7 Gy, 50-52 Gy total). Ten-year overall and relapse-free survival rates were 91% and 95%, respectively. Two patients developed meningeal dissemination, but none had local failure. Treatment complications included chordoma in one patient and internal carotid artery occlusion in another. No treatment-related decline of performance status was observed in the other patients. CONCLUSION: All tumor volume-based radiation doses were effective, without risk of local failure. Intracranial germinoma 4 cm or less in diameter can be cured with doses of 40-45 Gy. Investigation of further dose reduction seems worthwhile. Radiation therapy alone with these doses should be compared with ongoing chemotherapeutic protocols plus low-dose (24-30-Gy) irradiation in future studies.