Carcinoma of the colon: irradiation by delayed split whole-abdominal technique

Locally advanced and recurrent colon cancer was treated by irradiating first the pelvis and two hours later the upper abdomen. Curative treatment consisted of 4,000-5,000 rad (40-50 Gy) in 200-rad (2-Gy) fractions to the pelvis and 3,000 rad (30 Gy) in 150-rad (1.5-Gy) fractions to the upper abdomen. Palliative treatment consisted of 2,100 rad (21 Gy) in 300-rad (3-Gy) fractions to the liver, 3,000 rad (30 Gy) in 150-rad (1.5-Gy) fractions to the upper abdomen, and 4,000-5,000 rad (40-50 Gy) in 200-rad (2-Gy) fractions to the pelvis. Treatment was tolerated well, and acute toxicity was limited. Seven of the 11 patients treated curatively remain free of abdominal disease after 10-35 months; median survival among 9 patients treated palliatively was 9 months.     

Management of prostate carcinoma. Combination of pelvic lymphadenectomy, temporary Ir-192 implantation, and external irradiation

Forty patients with prostate adenocarcinoma had bilateral pelvic lymphadenectomy, temporary Ir-192 implantation, and external irradiation. With the implant, the prostate received less than or equal to 3,000 rad (30 Gy) for A2 and B1 and 3,500 rad (35 Gy) for B2 and C lesions in 40-45 hours. Ten days to 2 weeks later, 4,000 rad (40 Gy) external irradiation was given in 4-5 weeks using AP and PA parallel opposed fields, a "box," or rotation. Patients with positive nodes were given 5,000 rad (50 Gy) to the pelvis with a midline block at 4,000 rad (40 Gy) so that the prostate received 7,000-7,500 rad (70-75 Gy). All patients were free of local recurrence. Treatment was tolerated well, with rapid regression and few complications.     

Paraaortic lymph node irradiation in cervical carcinoma without prior lymphadenectomy

A study of complications associated with paraaortic irradiation was undertaken in patients with uterine cervical cancer who had not undergone prior lymphadenectomy. Between 1975 and 1984, 29 highly selected patients received paraaortic irradiation as part of their definitive treatment for cervical carcinoma. Paraaortic fields were irradiated to a total dose of 4,200-5,000 rad (42-50 Gy), in fractions of 150-180 rad (1.5-1.8 Gy). An anteroposterior-posteroanterior technique was generally used. All fields were treated every day. There were no instances of small-bowel obstruction or other major complications, surgical procedures, or deaths caused by paraaortic irradiation. Eleven patients (38%) have no evidence of recurrent disease 23-120 months after completion of therapy. Paraaortic irradiation was well tolerated in this patient group without prior staging lymphadenectomy. Thus, in selected patients and with appropriate techniques, paraaortic irradiation for cervical carcinoma may be used with relative safety.     

Irradiation of para-aortic lymph node metastases from carcinoma of the cervix or endometrium. Preliminary results

Twenty-two patients with biopsy-proved para-aortic lymph node metastases from carcinoma of the cervix (15 patients) or endometrium (7 patients) received a median dose of 5,000 rad/25 fractions. Para-aortic nodal metastases were controlled in 77% of cases. Control was significantly lower following radical retroperitoneal lymph node dissection than less extensive sampling procedures. Obstruction of the small bowel developed in 3 patients with tumor recurrence in the para-aortic region. Eight of the 10 patients who were disease-free at 2 years received greater than 5,000 rad. Three patients were still alive without disease at 129, 63, and 60 months, respectively. The 5-year disease-free survival rate was 40% for cervical cancer and 60% for endometrial cancer: in the former group, it was significantly different depending on whether the para-aortic nodes were irradiated (40%) or not (0%). The authors suggest that 5,000-5,500 rad in 5-5.5 weeks is well tolerated and can control aortic nodal metastases in cervical and possibly endometrial cancer.     

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.     

Hepatocellular carcinoma: pilot trial of treatment with Y-90 microspheres

The potential use of yttrium-90 glass microspheres in the treatment of hepatocellular carcinoma was assessed in a pilot study of seven patients. The Y-90 microspheres were injected via a hepatic artery catheter. In this group of patients, no toxicity was observed for absorbed doses of between 5,000 and 10,000 cGy to the liver and up to 32,000 cGy to the tumor itself. Tumor response was seen only at the higher absorbed doses. The new Y-90 glass microspheres can safely deliver large doses of internal radiation to hepatic tumors as long as extrahepatic shunting can be excluded. Extrahepatic shunting will be the main limitation to this form of radiation therapy.     

Pediatric patient exposures from CT examinations: GE CT/T 9800 scanner

This report presents Computed Tomography Dose Index (CTDI) values for typical CT examinations of children for a GE CT/T 9800 scanner and compares them with measured entrance skin absorbed doses of pediatric patients under clinical situations. Pediatric entrance skin absorbed doses were 1.1-2.4 rad (cGy) for chest and abdomen examinations, 2.0-3.4 rad (cGy) for pediatric head examinations, and 3.2-4.2 rad (cGy) for infant (less than or equal to 6 months) head examinations. CTDI measurements in a cylindrical Lucite head phantom predicted typical pediatric absorbed doses to within about 5% for chest and abdomen examinations and to within about 15% for head examinations, when corrections for amperage differences are taken into account.     

Interstitial radiation therapy for hepatic metastases: sonographic guidance for applicator placement

A new technique is reported for the treatment of hepatic metastases using sonography-directed percutaneous placement of a 14-gauge needle applicator and a high-intensity "remote afterloading" iridium-192 (Ir-192) source for interstitial radiation therapy. The results with six patients show that the procedure is easily performed, patient tolerance is good, and there is minimal disruption of the patient's lifestyle. Hospitalizations have been less than 24 hr. Partial response or stable disease in the liver was observed in all six patients. Tumoricidal doses up to 5000 rad (cGy) in a single treatment with durations from 7 to 41 min were achieved in small volumes (less than 25 cm3) with no clinically significant toxicity on follow-up evaluations from 2-6 months. The technique appears to ablate discrete metastatic tumor deposits in the liver.     

Strontium-89 therapy: measurement of absorbed dose to skeletal metastases

We report measurements of absorbed dose to vertebral metastases in ten patients referred for 89Sr therapy for disseminated prostatic carcinoma. Patients received a tracer dose of 85Sr at the time of 89Sr treatment and metastatic strontium retention was monitored scintigraphically for 6 mo. Metastatic 85Sr activity corrected for tissue attenuation was measured using the conjugate view principle, with special care taken to eliminate errors due to the selection of the metastatic region of interest. Metastatic volume was determined from high resolution CT images, and density inferred from Hounsfield number using the QCT bone mineral calibration of Genant and Cann. The mean absorbed dose was 850 rad/mCi (23 cGy/MBq) with a range from 220-2260 rad/mCi (6 to 61 cGy/MBq). The wide range found was consistent with the variation expected to arise due to differences in strontium renal plasma clearance (range 0.1-11.81/day) and extent of skeletal metastatic disease (varying from two small metastases to a superscan on [99mTc]MDP images) among the patients studied.     

Local thrombolytic therapy for hepatic artery thrombosis following chemotherapy infusion catheter placement

Nine patients with hepatic artery thrombosis subsequent to catheter placement (four surgical and five percutaneous) for hepatic arterial infusion chemotherapy were treated with local thrombolytic therapy. The thromboses were located in the common hepatic, proper hepatic and hepatic arteries. Thrombolytic therapy was instituted within seven days of catheter placement, at a rate of 5,000 to 20,000 units/hour (streptokinase) or 5,000 to 15,000 units/hour (urokinase) for 15 to 64 hours. All patients had repeat angiography and 99mTc-MAA hepatic artery perfusion scintigraphy after the infusion. In eight of the patients, thrombolytic therapy resulted in dissolution of the thrombus and recanalization of the hepatic artery. In three of these patients, rethrombosis occurred within a few days, and was attributed to underlying arterial abnormalities. The other five had documented continued hepatic arterial patency allowing completion of the chemotherapy course. The patient who did not respond to the lytic therapy had developed extensive collateral flow through the gastroduodenal artery to the liver.     

Gastroduodenal obstruction from ovarian cancer: imaging features and clinical outcome

OBJECTIVE: The purpose of this study was to describe the imaging features and clinical significance of gastroduodenal obstruction from ovarian cancer. MATERIALS AND METHODS: Eleven women with symptomatic gastroduodenal obstruction were identified over a 3-year period of prospective clinicoradiological review of cases managed in a specialist gynaecological oncology unit, during which period 438 women with ovarian cancer were managed. Imaging features were verified by surgery, intervention and clinicoradiological follow-up for a minimum of 12 months or until death. Management and outcome were independently reviewed by a medical oncologist not involved in primary care. RESULTS: The frequency of gastroduodenal obstruction was 2.5% (11 of 438 women). Disease stages of these women at initial diagnosis were: stage II (four women), stage III (six), stage IV (one). Histology was grade 3 in eight of the 11 women. Symptomatic gastroduodenal relapse occurred at 9-103 months after initial diagnosis (median 20 months). There were five cases of predominant involvement of the gastric body and six of the gastric outlet and duodenum. In six cases, focal mass disease resulted in obstruction, in two cases there was diffuse gastric invasion, and in three cases encysted malignant ascites in the lesser sac caused gastric compression/obstruction - the 'squashed stomach syndrome'. Diagnosis of obstruction was with CT in 10 of 11 cases. Palliative interventional procedures relieved symptoms in these three cases, surgery was performed in three cases and the remainder were treated with chemotherapy and other palliative measures. Two women are alive and well at 16 and 38 months who had loculated ascitic disease. Otherwise median survival was 5 months after symptomatic gastroduodenal involvement. CONCLUSIONS: Gastroduodenal obstruction is rare in women with ovarian cancer. Identification and drainage of encysted lesser sac ascites as its cause may be associated with long term survival, otherwise the prognosis is poor. CT accurately demonstrates the level and cause of obstruction and gives information about the wider extent of recurrent disease.     

The systemic fibrinolytic effect of low-dose intraarterial streptokinase: observations in 12 patients. Work in progress

The systemic hematological effects of low-dose intraarterial streptokinase were studied in 12 patients with angiographic evidence of thrombosis. Streptokinase was administered at 5,000 U/hr; this rate was increased in the absence of clinical response or a systemic effect, which was defined as a thrombin time greater than twice that of the control time and/or a fibrinogen concentration less than 30% that of the control concentration. Eight patients experienced a systemic effect with final infusion rates of 7,500 to 20,000 U/hr over 20 to 72 hours, while 4 patients had no evidence of a systemic effect at 5,000 to 10,000 U/hr over 18 to 138 hours. A systemic effect could not be predicted based on infusion rates or durations, and the presence of a systemic effect was not predictive of hemorrhagic complications or thrombolytic effect in our small series. These results suggest that a systemic effect is frequently encountered with this form of therapy and is of uncertain clinical relevance.     

Chordoma: role of radiation therapy

The treatment of 21 patients with a diagnosis of chordoma seen over a 20-year period is described. The 13 men and eight women (ratio 1.6:1) ranged in age from 7 to 82 years (average, 50 years). Eleven chordomas arose from the clivus; the others originated in the sacral region (three patients), thoracic spine (one), cervical spine (three), and lumbar spine (three). Primary treatment consisted of surgery, reserving radiation therapy for recurrence in the majority of patients. Radiation doses, delivered with megavoltage equipment, ranged between 5,000 cGy delivered over 5 weeks and 6,600 cGy over 6 1/2 weeks. Irradiation produced significant tumor control, with remission of symptoms from 1 to 6 years. The combination of high-dose radiation therapy and complete or subtotal surgical resection offers the best chance for prolonged survival in this group of patients.     

Enhancement of radioiodine treatment of small-pool hyperthyroidism with antithyroid drugs: kinetics and dosimetry.

(131)I-Iodide is the treatment of choice in most cases of hyperthyroidism, with a standard 7,000-cGy (rad) thyroid absorbed dose generally resulting in an incidental blood absorbed dose of less than 10 cGy (rad). However, in approximately 15% of patients there is a small, rapidly secreted thyroid iodine pool (small-pool patients) and, based on theoretic calculations, an incidental blood absorbed dose of up to 150 cGy (rad) could result. In such small-pool patients, continuing antithyroid drugs (ATDs) at a reduced dosage during (131)I therapy should inhibit the formation of (131)I-labeled levothyroxine and triiodothyronine and thereby reduce the protein-bound (131)I-iodine concentration in blood and the blood absorbed dose. METHODS: To test this hypothesis, thyroid and blood time-activity data were measured and absorbed doses were calculated for an (131)I tracer administered to small-pool hyperthyroid patients (n = 9) not receiving ATDs (off ATDs) and then receiving ATDs (on ATDs). RESULTS: The blood absorbed dose (cGy/37 MBq [rad/mCi] administered) was reduced from 2.54 +/- 0.91 (mean +/- SD) without ATDs to 1.27 +/- 0.54 with ATDs (P < 0.0001), whereas the thyroid absorbed dose was unchanged (1,870 +/- 700 vs. 2,080 +/- 1,080). The blood absorbed dose for an administered (131)I activity required to deliver a standard prescribed absorbed dose of 7,000 cGy (rad) to the thyroid therefore was reduced by over 50% with ATDs, from 11.3 +/- 6.5 to 4.9 +/- 2.8 cGy (rad) (P < 0.001). CONCLUSION: Continued administration of ATDs during (131)I therapy thus can effectively reduce extrathyroid radiation in small-pool patients without significantly reducing the target tissue (i.e., thyroid) dose.     

High-activity intraluminal 192iridium endocurietherapy for treatment of esophageal cancer

Intraluminal endocurietherapy (ECT) with high-activity 192Iridium administered via catheter following megavoltage external-beam radiotherapy, allows delivery of 8,000-10,000 rad to the target volume without exceeding the normal tissue radiation tolerances of surrounding vital structures. The endocurietherapy does not require surgery, general or local anesthesia. The technique is accurate, cost-effective, and allows safe delivery of higher radiation doses than could be tolerated by multiple-field external-beam megavoltage radiotherapy techniques alone. In a pilot Phase-1 toxicity study of six patients treated with minimum tumor doses of 8,000 rad, the majority of patients developed benign esophageal stricture 2-6 months following ECT which was managed by dilatation or gastrostomy. No patients developed esophageal perforation. Local tumor control was excellent, but a high proportion of patients developed distant metastatic disease.     

Radioiodine-131 therapy for well-differentiated thyroid cancer--a quantitative radiation dosimetric approach: outcome and validation in 85 patients.

For almost five decades, 131I treatment of thyroid cancer has been based empirically on administered activity rather than on actual radiation doses delivered. In 1983, we defined radiation dose thresholds for successful treatment. This report is concerned with the subsequent validation of those thresholds in 85 patients. The successful ablation of thyroid remnants occurred after a single initial 131I administration in 84% of inpatients and in 79% of outpatients when treatment was standardized to a radiation dose of at least 30,000 cGy (rad). Administered activities low enough to permit outpatient therapy could be used in 47% of the patients. Lymph node metastases were treated successfully in 74% of patients with a single administration of 131I calculated to deliver at least 8,500 cGy (rad). For athyrotic patients with nodal metastases only, success was achieved in 86% of patients at tumor doses of at least 14,000 cGy (rad). These success rates are equal to or better than those reported with empiric methods of 131I administration. The individualized treatment planning selectively allocates hospitalization and higher exposures to 131I to those patients who require them.     

Radiotherapy of dural arteriovenous malformation in the cavernous sinus

Six patients with dural arteriovenous malformation (DAVM) in the cavernous sinus were treated by irradiation. The region of the abnormal vascular network was irradiated with a 10 MV linear accelerator; the total dose given ranged from 3,200 to 5,100 cGy (150-200 cGy per day, 750-1,000 cGy per week). All patients responded favorably to the treatment, with three of the six having no residual symptoms or signs of disease. Postradiotherapy angiography confirmed the complete disappearance of the shunts in two of the three patients. No significant side effects were observed during the follow-up period, which ranged from 10 months to four years. Radiotherapy is considered to be a useful treatment method for DAVM, especially for those patients having shunts from the meningeal branches of the internal carotid artery.     

Ovariopexy and the treatment of Hodgkin's disease

Between 1979 and 1989 a total of 113 women underwent treatment for Hodgkin's disease at the Department of Radiation Oncology of the University of Erlangen-Nürnberg. Only 17 female patients of child bearing age received total lymphoid irradiation including pelvic and inguinal nodes. 15/17 patients underwent prophylactic bilateral oophoropexy during staging laparotomy: ten had lateral, five had midline ovarian transposition. Reproductive and ovarian function was investigated in 13 patients--all in complete remission after a minimum follow-up of three years--by menstrual history and serum levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), prolactin (PRL), testosterone, dehydroepiandrosteronsulfate (DHEAS), androstendion, estradiol, progesterone, 17-OH progesterone, sexual hormone binding globulin (SHBG), free androgen index (FAI). Thyroid function was assessed by measuring thyroxine (T4), triiodothyronine (T3), thyroxine stimulating hormone (TSH) and thyroxine binding globulin (TBG). Normal cyclic ovarian activity was found in seven out of nine patients following lateral oophoropexy (including one pregnancy), but only in one out of four cases after midline fixation. Median calculated dose was 325 cGy (range 260 to 500 cGy) to the laterally fixed ovaries and 490 cGy (range 390 to 500 cGy) for midline transposition. We conclude, if ovarian protection is required prior to pelvic radiation, lateral oophoropexy should be preferred.     

Recurrent tumors of the head and neck, pelvis, and chest wall: treatment with hyperthermia and brachytherapy

Cancer that recurs after surgery and radiation therapy remains a major problem. The claimed effectiveness of thermobrachytherapy in patients with this problem prompted the present study. Forty-six lesions (20 head and neck, 18 pelvic, seven chest wall, and one limb sarcoma) in 38 patients were treated with interstitial hyperthermia that sandwiched the use of Ir-192 with the aim of delivering 2,000-6,000 cGy, depending on prior dose and tissue tolerance. Complete regression occurred in 19 (54%) of 35 evaluable cases. More than 58,000 measured temperature points were analyzed to develop a representative quantitative measure, the "modal thermal dose," that represented the temperature reported most often during heating sessions. The pattern was plotted in each case. No significant relation was found between heating patterns and tumor response. Of all the prognostic factors studied, the radiation dose was the most significant, with a complete response rate being 78% when the total radiation dose exceeded 6,000 cGy, compared with 8% when the dose was lower than 5,000 cGy (P less than .005). The tumor volume also was important, with smaller lesions responding much better than larger ones (P = .1).     

Stage III thymoma: results of postoperative radiation therapy

The results of postoperative radiation therapy in 12 patients with stage III thymoma treated during 1966-1986 were reviewed. Surgical therapy consisted of total resection in one, subtotal resection in seven, and biopsy only in four. Megavoltage irradiation in the dose range of 3,000-5,600 cGy was employed, with nine patients receiving a dose of at least 5,000 cGy. The local control rate was 67%. The actuarial observed and adjusted 5-year survival rates were 57% and 75%, respectively. These results indicate that postoperative radiation therapy is an effective therapeutic modality in the control of stage III thymoma.