Preliminary results of clinical application of reactor fast neutrons in radiation and combined therapy of patients with laryngeal carcinoma

Since 1985 treatment of cancer patients on BR-10 reactor has been carried out in the Institute of Medical Radiology. Till May, 1989, 78 patients have received mixed gamma-neutron therapy and combined treatment (preoperative radiation therapy and surgery). Marked late local reactions (perichondritis) were observed only in three (7%) out of 42 patients treated with radical radiation therapy alone. 43 patients had a follow-up period of two years. Among them T2 tumors were registered in six (14%) cases, T3 in 28 (65%) cases, T4 in nine (21%) cases. Regional metastases were observed in 13 (30%) patients. 19 out of 27 patients (70%) treated with radical gamma-neutron therapy and 13 out of 16 patients (81%) treated with combined therapy using reactor fast neutrons as preoperative radiation therapy are alive two years without evidence of the disease.     

Increased salivary gland density on contrast-enhanced CT after head and neck radiation

In an attempt to determine whether radiation therapy leads to an increased density of salivary glands on subsequent contrast-enhanced CT, 109 CT scans from 78 patients with head and neck tumors were reviewed. The density of parotid and submandibular glands was subjectively evaluated (compared with adjacent muscle) and correlated with treatment including surgery, chemotherapy, and radiation. Density of the parotid and/or submandibular glands was found to be significantly associated with previous irradiation on contrast-enhanced scans (p less than .05). One or both glands were denser than normal in seven (44%) of 16 patients who received only radiation therapy and in eight (38%) of 21 who received chemotherapy and radiation therapy, compared with only two (10%) of 20 patients who received chemotherapy alone and two (4%) of 52 patients who received neither. The type or amount of irradiation, type of chemotherapy, or timing of the CT scan after the initiation of treatment was not found to be significant. We conclude that the density of the parotid and/or submandibular glands on contrast-enhanced CT is frequently increased after radiation therapy for tumors of the head and neck.     

Analysis of patients treated with radiotherapy in the year 1990.

We analyzed the patients treated with radiotherapy in Gunma University Hospital in 1990, to determine the characteristics of the practice of radiotherapy. During this period, 540 patients with various diseases received radiation therapy. Five hundred thirty-one (98.3%) of them had malignant tumors, and the remaining nine had benign diseases. Of the patients with malignant tumors, primary tumor of the head and neck (21.7%), and lung and mediastinum (13.0%) were most common. Four of nine patients with benign diseases had pterygium. Three hundred thirty-two patients (63%) had previously untreated malignant tumors. Curative radiotherapy was performed in 296 patients (56%), and palliative radiotherapy in 235 (44%). Of CRG patients, 43% were treated with radiation alone and 40% with surgery followed by radiotherapy. The proportion who received curative radiotherapy was the highest in patients with cervical cancer (80%). Twenty-four of 34 patients treated with intracavitary irradiation had cervical cancer. Interstitial irradiation was performed in nine patients. Four patients with pterygium were treated postoperatively with surface irradiation using an Sr-90 contact device. Radioactive iodine was administered to ten patients: eight thyroid cancer patients and two hyperthyroid patients.     

Radiotherapy, radiotherapy combined with surgery, radiotherapy combined with chemotherapy in the treatment of carcinoma of the pyriform sinus. A retrospective study]

A rectrospective analysis was performed of the results of 104 consecutive patients with carcinoma of the pyriform sinus, who underwent radiation therapy. Thirty-four patients underwent radical surgery and postoperative radiation therapy (group 1); 36 patients received radical radiation therapy alone (group 2); neoadjuvant chemotherapy was administered prior to full-dose radiation to 20 patients (group 3); 14 patients received palliative radiation therapy (group 4). Loco-regional control and survival rates at 5 years were 60.4% and 34.3% in group 1, 23.8% and 23.8% in group 2, 17.5% and 23.8% in group 3; no patients in group 4 survived at 5 years. Patients in group 1 experienced significantly better survival and local control than those in groups 2 and 3. No differences were observed between groups 2 and 3. Loco-regional recurrence was the main cause of failure in group 2 (69.4%) and 3 (70.0%). In group 1, 20.3% of cases developed distant metastases. Overall 5-year survival rate was 23.7%, confirming the poor prognosis of this disease. These results provide further support to the need of improving prevention and early diagnosis to improve both results and outcome in patients with carcinoma of the pyriform sinus.     

Long-term results of postoperative and primary radiotherapy of carcinoma of the salivary glands: importance of dosage and target volume]

Longterm results in 92 patients after primary or postoperative irradiation for carcinoma of the major or minor salivary glands of the head are analyzed. Target volume included the region of the primary tumor; ipsilateral cervical lymph nodes were included in patients with metastases of the lymph nodes. Target doses were 25 to 35 X 2.0 Gy or in some cases 16 to 18 X 3.30 Gy. Local control was 93% in tumors of limited extension (I), 84% in extensive but macroscopically complete resected tumors (II) and 26% in biopsied or partially resected tumors (III). There were no major complications. Recurrence in the lymph nodes were observed in less than 5% of the group I + II NO and could be controlled permanently by secondary surgery plus irradiation. According to the own and published results the following target volumes are adequate: region of the primary tumor in adenoid-cystic carcinoma NO plus the ipsilateral cervical-supraclavicular region in patients with other high grade cancers or evidence for metastases. Target doses between 5940 and 7020 cGy are recommended.     

Combined treatment of hypopharyngeal carcinoma

From 1978 through 1984, 120 patients with hypopharyngeal carcinomas were treated cooperatively by the University Hospitals of Erlangen. 120 out of these patients were men and 6 women. 96 patients (80%) suffered from cervical lymph node metastases, 91 (76%) were already in UICC stage IV. There were two cases with stage I, eight cases (7%) with stage II, and 19 cases (16%) with stage III. Among the 116 patients treated by causal therapy, 70 (60%) reached complete remission (CR), 34 (29.5%) partial remission (PR), and 12 (10.5%) were non-responders (NC,P). The cumulative survival at five years was 14% in 120 patients and 24% in 70 patients after CR. None of the patients with PR or NC survived more than two years. 111 patients were irradiated. Group 1: radiotherapy alone (41 patients), group 2: surgery and radiotherapy (47 patients), group 3: chemotherapy and radiotherapy (19 patients). The medium treatment period was 76, 107, and 141 days, respectively. The cumulative survival at five years was 3% in group 1, 28% in group 2, the survival at three years in group 3 was 14%. The results of postoperative radiotherapy, amounting to 36%, were better than the rate of 20% achieved by preoperative radiotherapy and surgery. A survival at five years of 46% was obtained after transoral microlaryngoscopic laser resection and postoperative irradiation, which was therefore superior to conventional operation techniques combined with radiotherapy (16%). Moreover, better functional and cosmetic results were achieved with this method. The prognosis is unfavorably influenced by a high stage, lymph node manifestations, and dedifferentiated tumor histology.     

Effect of misonidazole in preoperative irradiation for bladder cancer followed by total cystectomy

Between 1980 and 1984, 44 patients were treated for bladder cancer by preoperative irradiation of 40 Gy to the pelvic region followed by total cystectomy. These patients were prospectively divided into two groups at random. In 23 cases, 500 mg of misonidazole (MISO) was administered four hours prior to irradiation. Twenty-one patients were preoperatively treated by radiation alone. Most patients had histopathological grading of G3-4, and the distribution of T-factors in the two groups was comparable. Thirty-seven patients out of 44 underwent total cystectomy within three weeks after irradiation. pT-factors were carefully examined in resected specimens. Survival rates were calculated by the Kaplan-Meier method. The 5 year survival rate for T3 patients in the group treated by MISO combined with radiotherapy was 59%, while that for T3 patients in the radiation only group was 43%. A reduction in T-factors was observed in 9 of 17 T3 cases treated by MISO combined with radiation, and in one of 14 T3 cases treated by radiation alone. This finding was significant on chi-square test (p = 0.02). Since the survival rate of T3 patients with a reduction in T-factors by preoperative irradiation was superior to that of cases without reduction (70% vs. 43%), the combined use of MISO in preoperative irradiation seems to be useful for the treatment of T3 bladder cancer.     

Evidence for early and persistent impairment of salivary gland excretion after irradiation of head and neck tumours

Salivary gland scintigraphy with technetium-99m pertechnetate was used to follow changes in the excretion and uptake function of the major salivary glands until 1 year after irradiation. Twenty-five patients who received radiotherapy for head and neck tumours were included in the study. Seventy-nine salivary glands (39 parotid and 40 submandibular) were evaluated in relation to the average received radiation dose. Salivary gland scintigraphy was performed before and 1, 6 and 12 months after radiotherapy. For each gland the excretion response to carbachol, evaluated by calculation of the salivary excretion fraction (SEF), the cumulative gland uptake (CGU) and the absolute excreted activity (AEA) at various intervals after radiotherapy were compared with the baseline values. The excretion response decreased in 20 of 25 patients at 1 month after radiotherapy. One month after radiotherapy both SEF and AEA decreased significantly in relation to the radiation dose. These decreases in excretion parameters persisted during the follow-up period. Parotid excretion was affected significantly more than submandibular excretion. CGU values did not change significantly until 6 months after radiotherapy, but at 12 months a significant decrease related to radiation dose was observed. Xerostomia was assessed during radiotherapy and on the days of the scintigraphic tests. The incidence of xerostomia did not correspond to the effects observed in the scintigraphy studies. It is concluded that radiotherapy induces early and persistent impairment of salivary gland excretion, related to the radiation dose. This impairment is stronger in parotid glands than in submandibular glands.     

Clinical results of thermoradiotherapy of locally advanced and recurrent breast cancers--comparison of results with radiotherapy alone

From August 1979 through January 1988, 23 breast cancer patients with 25 tumors supposed to be refractory to conventional treatment were treated by thermoradiotherapy. Of the 25 tumors, 10 were locally advanced primary tumors [Group 1], 4 locally advanced recurrent tumors after operation more than 5 cm in maximum diameter [Group 2], and 11 locally recurrent tumors after radiotherapy [Group 3]. The present study was not a formal randomised-trial, but a historical-controlled study. The results were compared with tumors which were treated by radiation therapy alone between July 1962 and August 1979. The historical control groups comprised 11 tumors for Group 1, 17 for Group 2 and 19 for Group 3. Employing 4 types of heating devices (8, 13.56 MHz capacitive RF, 430, 2450 MHz microwave), hyperthermia was administered once or twice a week after irradiation, for 30-60 minutes per session, up to a total sessions of 2-9. Radiotherapy was delivered in fractions of 180 to 200 cGy per day, 5 days per week, up to 28-74.4 Gy in total, or in fraction of 400 cGy, two times per week, up to 28-60 Gy. Tumor temperatures were measured by inserting thermocouples into the tumors. The tumors that did not recur during follow-up of more than 3 months were regarded as locally controlled tumors, and the local control rate was calculated. The local control rate in Group 2 and the local response rate (CR + PRa) in Group 1 were higher than those of the historically controlled tumors. In Group 3, hyperthermia combined with lower total doses of irradiation showed a high local response rate similar to that by radiation therapy alone. Thus local hyperthermia in combination with radiation therapy seems to be more effective than radiotherapy alone for locally advanced and recurrent breast cancers.     

The value of and indications for radiotherapy in endometrial carcinoma

Today the endometrial carcinoma is the most frequent malignant tumor found in female genital tract. Endometrial carcinoma ought to be operated in all cases, if possible. Traditionally some form of adjuvant radiotherapy has been given. Despite the large number of patients treated by combined therapy over the last 30 years, surprisingly there is a lack of hard data on which to establish a theory for an improved outcome. It is generally accepted that the risk of local relapses in the vagina is lowered when postoperative vaginal irradiation is applied. The question of the value of additional external irradiation in stage I endometrial cancer still is unsettled. Only two prospective studies led to the conclusion that only patients with poorly differentiated tumors and with deep infiltration of the myometrium might benefit from additional external radiotherapy. Therefore a simple score for these risk factors is proposed enabling assignment into patient groups of similar risk on the base of a point system due to individual prognostic factors. With a score of one to two points prognosis is very good and adjuvant irradiation seems not to be necessary. With three to four points local vaginal irradiation is recommended, with five and more points additionally external beam irradiation to the pelvis should be given. This is necessary in more than the half of the operated cases of endometrial carcinoma. The indication for such a treatment has become more individual and "high risk" cases are treated more intensively, but "low risk" cases have to be excepted from unnecessary adjuvant therapy. In order to judge an individual case of endometrial cancer histopathologic prognosticators have to be considered. Typical adenocarcinomas have a five-year survival of more than 80%, but unfavourable subtypes (adenosquamous, clear-cell, serous-papillary carcinomas) of only 40%, respectively. Tumor grading and depth of myometrial invasion are of high importance for individual prognosis. The new histopathologic staging system of FIGO (1988) takes these items into account. Only patients with severe internal diseases should be treated with radiation therapy alone. Although radiation therapy alone can cure endometrial cancer (five-year-survival approximately 60%), the survival figures are poorer than for the operation (five-year survival 80%, respectively). It should be outlined that in inoperable cases radiotherapy is the best form of treatment.     

Local hyperthermia in the treatment of advanced tumors: curative and palliative effects

During the years of 1978 to 1981, a pilot study was conducted with 210 patients suffering from 235 tumors. The treatment included localized high-frequency hyperthermia alone or combined with radiotherapy and/or chemotherapy. The final evaluation of 164 tumors with different sites, sizes and histologic findings shows that even if the patients collective is unfavorably selected (nearly all tumors in an advanced stage), an increased palliative effect exceeding the clinical effect expected for radiotherapy alone was reached in 60 to 70% of all cases. 45% of the patients showed curative effects in the sense of an objectively improved tumor remission. At the same time, a significant reduction of local side effects of radiotherapy was achieved by the hyperthermic treatment. Localized hyperthermia until 42/43 degrees C has only a small rate of complications, even if it is applied in the abdominal region. Within the relatively short follow-up period, an increased rate of metastases after therapy combinations with hyperthermia was not observed.     

Adenoid cystic salivary gland carcinoma: treatment with irradiation and surgery

The records of 71 patients with adenoid cystic carcinoma of the salivary glands were reviewed to determine the dose response relationships for this aggressive tumor. Local control after treatment was determined for all patients and analyzed with respect to extent of surgery and dose of radiation. Of 70 patients who were available for evaluation of local control, 28 (40%) had a local recurrence and 42 (60%) did not. The highest control rates were found in patients who underwent both radiation therapy and surgery. Patients who received a dose equal to or greater than 6,000 rad (60 Gy) in addition to surgery had significantly higher local control rates than those who received less than 6,000 rad (60 Gy). Distant metastases developed in 50% of patients regardless of local control, with the following distribution: 39% lung, 19% bone, and 10% disseminated soft-tissue metastases. Lymph node involvement was rare. Implications for combined modality treatment are discussed.     

The management of stage I lymphomas of the B-cell type with special reference to the role of radiation therapy

Fifty-one patients with clinical stage I B-cell lymphomas were treated between 1980 and 1988. For the entire group, the actuarial 5-year survival rate and 5-year freedom from relapse rate were 78% and 64%, respectively. Primary site, tumor bulk and performance status were the prognostic factors. Twenty-three patients were intensively treated with local radiotherapy alone, because (1) they had histologically low grade (7 patients) or follicular large cell (1 patients) tumors, (2) Waldeyer's ring was the site of the primary (11 patients) or (3) the tumor was less than 4 cm in maximum diameter (4 patients). Among them, only one patient died due to lymphoma (5-year survival rate: 95%), and 19 remained disease free (5-year freedom from relapse rate: 80%). In contrast, of the remaining 23 patients treated with both radiation therapy and combination chemotherapy (VEMP or CHOP), the 5-year survival rate and 5-year freedom from relapse rate were 70% and 54%, respectively. These results suggest that high-risk patients should be treated with more aggressive combination chemotherapy as well as radiotherapy. However, low-risk patients with stage I B-cell lymphomas can be treated by local radiotherapy alone.     

Sparing of Contralateral Major Salivary Glands Has a Significant Effect on Oral Health in Patients Treated with Radical Radiotherapy of Head and Neck Tumors

BACKGROUND: Has a conscious exclusion of the contralateral major salivary glands (parotid, submandibular, and sublingual glands) a significant impact on the milieu of the oral cavity (saliva flow, pH, buffer capacity, and colonisation with Streptococcus mutans) in patients with ENT tumors receiving radical radiotherapy? PATIENTS AND METHODS: 20 consecutive consenting patients with ENT tumors were evaluated once before, weekly during, and 6 weeks after the end of treatment in regard to saliva flow, ph, buffer capacity, and colonisation with Streptococcus mutans. In 13 patients the major salivary glands on both sides were included in the treated volume, in seven patients the treatment portals excluded consciously the contralateral major salivary glands. RESULTS: The stimulated saliva flow decreases already during the 1st week of radiotherapy, the decrease follows the dose exponentially; the saliva flow is further reduced in the weeks after the end of treatment. The effect is less pronounced in patients with sparing of contralateral major salivary glands. The majority of patients with unilateral sparing of the major salivary glands retain the baseline value of buffer capacity, whereas buffer capacity of all patients with inclusion of all major salivary glands is markedly reduced with 20 Gy already, without signs of recovery when treatment has stopped. With unilateral salivary gland sparing the pH always remains basic, in bilaterally irradiated patients the pH changes from a mean of 7.3 to 5.8 during treatment. The colonisation with Streptococcus mutans varies little in both groups during the radiotherapy; after the end of therapy, it is higher in bilaterally irradiated patients. CONCLUSIONS: The conscious arrangement of irradiation portals in order to spare contralateral major salivary glands in patients with radical radiotherapy of ENT tumors has a significant influence on the oral environment: the stimulated saliva flow is higher, the buffer capacity retains the baseline value, the saliva pH remains basic, and the colonisation with Streptococcus mutans is reduced.     

Postoperative irradiation of carcinoma of the corpus uteri using the iridium afterloading technic

From 1981 to 1986 a prospective study was conducted of University of Vienna, 1st gynecology department, for 708 patients with operated and postoperatively irradiated endometrial cancer. These patients were treated by total hysterectomy, bilateral salpingo-oophorectomy and postoperative vaginal irradiation with high-dose-afterloading (iridium 192). A percutaneous irradiation (cobalt 60) was done in stage I cases only when myometrial infiltration was deep. Highly differentiated tumors with infiltration of the first and second third of the myometrium were treated by vaginal irradiation alone. Poorly differentiated tumors (G2, G3) with infiltration of the second and third third of the myometrium were treated by vaginal and percutaneous irradiation. A group of 125 cases with good prognosis (infiltration 1/3, G1) and with postoperative vaginal irradiation alone had the same five-year-survival of 83% as a group of 152 cases with bad prognosis (infiltration 2/3 and 3/3, G2 or G3) treated by vaginal and percutaneous irradiation. This result shows clearly the importance of additional irradiation of the pelvis in cases with bad prognosis factors. The incidence of radiation side effect in all 708 cases was: cystitis 4.6%, proctitis 5.2%, vaginal or rectal ulcers 1.4% and fistulas 0.2%. Cases with vaginal irradiation alone and with the optimal intravaginal fraction dose of 700 cGy (twice) had the lowest level of side effects: cystitis 3.8%, proctitis 2.1%, vaginal necrosis 0.7%, no further severe complications. None of the patients with postoperative vaginal irradiation alone had a vaginal recurrence. The incidence of recurrences in 708 patients was 1.6%. All recurrence cases in stage I (0.7%) had bad prognosis factors and were treated with vaginal and percutaneous irradiation. It is concluded that primary surgery of endometrial cancer should be followed by postoperative vaginal radiation. It appears that the remote afterloading treatment for vaginal radiation produces minimally complications and gives complete protection from radiation exposure to the medical staff. With additional external radiation in high-risk cases the same good result can be achieved as in cases with low-risk and vaginal radiation alone.     

Therapeutic profile of outpatient radiosurgery with the Gamma Knife system. Part 2: First clinical experiences

Summary Gamma Knife radiosurgery (GKRS) was applied in 500 consecutive treatments for 445 patients within 2 years. Indications were arterio-venous malformations (93 patients), schwannomas of cranial nerves (75 patients), meningiomas (79 patients; 73 of the tumors involving the skull base), pituitary adenomas (40 patients), craniopharyngiomas (13 cases), gliomas (13 cases), rare indications (12 cases), and brain metastases (126 patients). In arterio-venous malformations two complications were observed whereas two other patients underwent surgery due to intracranial hemorrhage in the latent period after GKRS. In all cases follow-up with MRI showed evidence of an active obliteration process. Out of 24 patients with a follow-up over 1 year, angiography revealed complete obliteration in 9 patients so far. A partial obliteration was evidenced by MRI in 15 cases. In benign tumors (meningiomas and vestibular schwannomas) tumor control rates of 88 % and 89 % were achieved, respectively. Treatment related side effects were mild and rare; no facial palsy occured after primary Gamma Knife treatment. GKRS was particularly effective in inoperable skull base meningiomas. Cerebral metastases were controlled in 89.5 % by a single Gamma Knife treatment. The mean survival period was 11.8 months. In patients receiving a single Gamma Knife treatment the mean survival time was 9.1 months. For patients undergoing multiple (up to 5) sessions of GKRS (because of new tumors) the mean survival period was 17.2 months. MRI showed evidence of adverse radiation reactions in 10/124 patients (8.1 %) which were symptomatic in 3 patients (0.8 %). The results obtained in patients with cerebral metastases emphasize that GKRS alone is as effective as the combined treatment of these lesions by surgery and fractionated radiotherapy. Our results demonstrated an attractively high therapeutic gain factor of Gamma Knife treatment in key indications of radiosurgery.      

Cervical lymph node metastases from an unknown primary tumor

From 1978 through August 1986, 32 patients with lymph node metastases of the neck and unknown primary tumor were treated at the Radiotherapeutic Hospital of the University Erlangen-Nürnberg. Most of the cases were large metastases from squamous cell carcinomas or anaplastic carcinomas. The patients were treated by surgery and postsurgical radiotherapy or radiotherapy alone. In nearly all patients the target volume comprised both sides of the neck including the median structures as well as the base of the tongue and the nasopharynx. A dose of at least 50 Gy was aimed at, which was given within five weeks by individual doses of 2 Gy each. The survival at three years is 70% and at five years 52%. Out of twenty patients irradiated with more than 50 Gy following lymph node extirpation or radical excision of the lymph nodes of the neck, sixteen are tumor-free. The five year survival of this group is 80%. The results of radiotherapy alone are unsatisfactory, because only two out of nine patients are alive with follow-up periods of less than one year. Two primary tumors were found after the end of treatment. Both were situated within the ORL areas beyond the ancient irradiation fields, and both were developed by patients who at first had only been treated by local irradiation. Half of the patients with lymph node metastases of the neck and unknown primary tumors can be cured by complete tumor excision and postsurgical irradiation. The target volume of radiotherapy comprises both sides of the lymph drainage area of the neck as well as the mucous membranes of the ORL region including nasopharynx and base of the tongue. The dose is at least 50 Gy which is given after surgery with conventional fractionation.     

The effect of radio- and chemotherapy on survival in advanced head and neck tumors

Inoperable cases of advanced squamous cell carcinomas in the head and neck area which have a very poor prognosis are often treated by a combined radio- and chemotherapy. Tumor remissions up to 70% are induced by both radiotherapy and chemotherapy alone; an increase of the survival time is not reported. The present randomized study investigates the efficacy of two therapy schemes, i.e. chemotherapy alone and chemotherapy combined with irradiation. Tumor remissions of 75% were achieved in 80 evaluable patients, the median remission period was four months and the median survival period eleven months. The survival curves do not show any dependence of the survial time on the size of tumor or metastases. Only responders had a significantly longer survival time than non-responders.     

Radiation-induced insufficiency fractures of the pelvis: evaluation with 99mTc-methylene diphosphonate scintigraphy.

99mTc-methylene diphosphonate (99mTc-MDP) bone scans in 80 patients, 30-80 years old (average, 62 years old) with uterine cancer who received high doses of radiation (10-60 Gy; average, 46 Gy) were reviewed retrospectively to evaluate the frequency of pelvic insufficiency fractures caused by radiotherapy and to study the appearance of the fractures on bone scans. Bone scans in 29 of 80 patients showed abnormalities in the pelvis: insufficiency fractures were identified in 27 patients (34%) and osseous metastases were found in two patients (3%). The fractures and metastases were diagnosed by CT and were confirmed by observing the patients' clinical courses. Fractures were identified in 27 (39%) of 69 postmenopausal women and in none of 11 premenopausal patients (p greater than .05). Fractures were found in 21 (84%) of 25 patients who had pelvic pain and in six (11%) of 55 patients who were asymptomatic (p greater than .001). Scintigrams in patients with fractures showed more than one fracture in most patients (85%), and fractures were often symmetric (67%). Scintigrams in two patients with osseous metastases showed increased activity in an iliac wing that was outside the radiation field. Our results suggest that a marked increase in insufficiency fractures occurs after radiation therapy, especially in postmenopausal patients. A symmetric area of increased uptake of radionuclide is a characteristic scintigraphic appearance of an insufficiency fracture.     

A comparison of treatment methods for germinal cell tumors of the testis other than pure seminoma

The results of three approaches to management of the regional lymphatics for Stage I and Stage II nonseminomatous testicular tumors were reviewed. For clinical Stage I disease, the results achieved with orchiectomy and radiation therapy alone are equal to those achieved with orchiectomy and lymphadenectomy. Although the results with preoperative radiotherapy and lymphadenectomy are slightly better, the lymphadenectomy almost always results in aspermia and infertility. The effectiveness of radiotherapy alone is determined by the volume of cancer. Local tumor control with irradiation is good if the tumor burden is relatively small. The local control rates, however, are diminished if the metastases are greater than 2 cm in diameter. The results with preoperative radiotherapy and lymphadenectomy for patients with clinical Stage II disease are superior to those achieved with either primary lymphadenectomy or radiotherapy alone.