Patterns of recurrence following pelvic exenteration and external radiotherapy for locally advanced primary rectal adenocarcinoma

Background: Local recurrence remains the main site of failure after pelvic exenteration for locally advanced primary rectal adenocarcinoma. This is a report on the patterns of recurrence in a group of such patients treated with pelvic exenteration and radiotherapy. Methods: Between 1980 and 1992, we treated 49 patients. Thirty-one received preoperative radiotherapy (pre-RT), 4,500 cGy. Six weeks later, we performed posterior pelvic exenteration (PPE) in 21 patients, and total pelvic exenteration (TPE) in 10. Nine patients received postoperative radiotherapy (post-RT), 5,000 cGy after a PPE. Nine patients had surgery only, PPE (n=7) and TPE (n=2). Results: Surgical mortality occurred in 16% of those patients who received pre-RT. The median follow-up was 52 months. Recurrences occurred in 23% of those patients who received pre-RT (local, one; local/distant, one; distant, four); in 88% of those patients treated with surgery only (local/distant, four; distant, four); and in 11% of those treated with post-RT (distant, one). The 5-year survival for patients who received radiotherapy was 66 versus 44% for those treated with surgery only. Conclusion: Local control of locally advanced primary rectal adenocarcinoma requiring a pelvic exenteration is improved by the addition of radiotherapy. When recurrences do occur they are predominantly at extrapelvic sites.Results of this study were presented at The 48th Annual Cancer Symposium of the Society of Surgical Oncology, Boston, Massachusetts, March 23–26, 1995.     

Management of genital fistulas in patients with cervical cancer

Among 2096 patients treated for cervical cancer between 1985–1995, genital fistulas developed in 38 cases (1.8%). 16 patients were affected by rectovaginal, 13 patients had rectovesicovaginal and 9 patients had vesicovaginal fistulas. Median age at time of first presentation of the fistulas was 54.8 years. Fistula size ranged from 0.1 to 2.0 cm in diameter. Faecal or urinary leakage through the vagina (44.7%), bleeding (31.5%) and local pain (5.3%) were major clinical symptoms. 10 patients had surgery for the fistula, the remaining patients were managed conservatively. Accepted: 14 June 1996     

Can we use radiotherapy alone in the treatment of keloids?

Objective The use of radiation for the treatment of keloids has been the topic of debate for years. Methods In this study, 46 symptomatic cases were treated with ⁹⁰Sr-⁹⁰Y β-rays. Patients were given four fractions of 5 Gy per fraction either as weekly or twice weekly schedules. Results Radiation dose of 20 Gy given twice weekly in four fractions showed response in 92% of the cases as compared to 81% in those receiving four fractions of 5 Gy weekly. Conclusion Further studies with numerous dose fractionation schedules would open up new dimensions in the radiotherapy of keloids.     

Intracranial tumors during the 1st year of life

Twenty-eight patients with intracranial tumors symptomatic during the 1st year of life were managed from January 1970 to March 1988. Supratentorial location (19 cases) was dominant over the infratentorial. The most common histological type was astrocytoma; choroid plexus papilloma and ependymal tumors followed in frequency. Twenty-two infants (78.6%) had associated hydrocephalus. Macrocrania, vomiting, delayed milestones, and behavioral disturbances were the chief clinical manifestations. Four patients were admitted in extremely deteriorated condition and died preoperatively. Twenty cases underwent surgery for tumor removal with a 1-month mortality rate of 20%. Tumor excision provided permanent relief of hydrocephalus in the majority of the surviving cases. Five patients received conventional radiotherapy. Stereotactic brachytherapy yielded an excellent result in 1 case. Overall 13 cases are currently alive; 6 of them have survived longer than 6 years. Fourteen of the 15 patients who were dead at follow-up succumbed within 1 year after diagnosis.     

The EORTC treatment of early stages of Hodgkin's disease: the role of radiotherapy

Since 1964, the European Organisation for Research and Treatment of Cancer has conducted three subsequent clinical trials on clinical Stages (CS) I + II Hodgkin's disease (HD) in which 1059 patients have been entered. The first trial compared regional radiotherapy (RT) with mantle field or inverted Y, versus the same RT followed by a weekly injection of vinblastine for 2 years. The relapse free survival (RFS) and overall survival (S) were higher in patients treated by RT and chemotherapy (CT). This benefit, however, was significant only in patients with a mixed cellularity histologic type. The second trial compared the therapeutic efficacy of splenic irradiation versus splenectomy and found that in both arms, RFS and S were identical. Moreover, it was found that splenic involvement was correlated with an increased incidence of relapse in extranodal sites and in non irradiated lymphatic areas. In this trial, CT was given only to patients with poor histologic types, mixed cellularity or lymphocytic depletion. In the third trial, staging laparotomy was performed only to further delineate a good prognostic group which could be treated by RT alone. In this limited treatment group, there was no difference in RFS and S between mantle field and mantle field + para-aortic RT. In the extensive treatment group, total nodal irradiation (TNI) was compared with RT + MOPP. The RFS was slightly lower in the TNI arm, but there was no significant difference in S. The data of the 3 trials underline the importance of prognostic factors in the choice of optimal treatment and show that their significance depends upon the type of treatment. Multivariate statistical analyses showed that the main prognostic factors, which can help to identify the subsets of patients who can be treated by RT alone, are (1) systemic symptoms and elevated erythrocyte sedimentation rate (ESR), (2) the number of involved lymphatic areas, and (3) staging laparotomy. Extended RT (mantle + para-aortic + spleen treatment) gives satisfactory results in patients without systemic symptoms and/or elevated ESR and one or two involved sites, whereas TNI or combined modality treatment becomes mandatory for patients with 3 or more involved sites or splenic involvement and/or systemic symptoms. With proper adjustment of the irradiated volume, a very large proportion of CS I + II patients can be best treated by RT alone.     

Lung density as measured by computerized tomography: implications for radiotherapy

Accurate dose calculations for radiotherapy planning require a detailed knowledge of the internal anatomy of the patient both in terms of geometry and density. Computed tomography (CT) is presently the best means of providing these data. Fifty-eight patients who had scans of the thorax for radiotherapy planning were studied. The CT numbers were converted to relative electron densities and average lung densities were obtained for every patient. A linear correlation of lung density with age was found with the mean lung density of 0.35 at an age 5 years and 0.19 at an age of 80. The effect of scanning the patient under full inspiration, full expiration or normal shallow breathing conditions was analyzed. At the age of 5 years the expiration and inspiration average lung densities were 0.36 and 0.20, while at the age of 80 years they were 0.22 and 0.16, respectively. Respiratory volume changes were linearly correlated with changes in relative electron density. Differences in lung density between expiration and inspiration scans were found to demonstrate a similar trend with age as the relationship between vital capacity and age. The dosimetric and the possible clinical implications of lung density measurements for radiotherapy are considered. In particular, dose calculations were performed using scans taken under a number of different respiratory conditions. Doses calculated for a single cobalt-60 beam can differ by more than 25% when comparing a full inspiration scan to a normal breathing scan. A similar comparison for a parallel pair distribution on the lung yields a difference of about 3 % while a typical three field technique for treating cancer of the esophagus shows a difference of nearly 10%.     

放射疗法在整形美容中的应用策略

目的 探讨放射疗法在整形美容领域的正确应用，避免和预防并发症的发生。方法 回顾放射疗法在良性病和整形美容方面的应用历史，结合笔者的经验，总结了射线对人体的伤害效应和可能出现的并发症，分析了引起并发症的原因。结果 放射治疗在良性病和整形美容方面取得了一些成功经验，特别是对不适宜手术和药物治疗的患者，起到了独特的作用。但也有慢性皮炎、顽固性溃疡或发生癌变等较多的并发症发生。针对引起并发症的常见原因，提出了避免和预防并发症的对策。结论 应以循证医学为理论依据，科学地选择适应证，根据个体特点制定合理的、个性化的放疗计划。加强医护人员的技术培训和责任感，从而使患者获得最佳的治疗效果，避免和预防并发症的发生。     

Major resection for embryonal rhabdomyosarcoma of the biliary tree

Embryonal rhabdomyosarcoma of the biliary tree is a very rare tumor. Only 56 patients have been reported in the literature; 17 of them were long-term survivors. The recommended therapy is multidisciplinary: according to the Intergroup Rhabdomyosarcoma Study I and II (IRS I and II), the combination of major resection, chemotherapy, and radiation of the porta hepatis could improve the results. This report reviews our experience with four consecutive patients from a surgical point of view. We conclude that the classical definition of resectability cannot be applied to rhabdomyosarcomas of the biliary tree, because these polypoid tumors as a rule extend into the liver sectors and often affect both halves of the liver. Major resection with atypical reconstruction of the biliary tree is necessary in order to provide some promise of success. The problem of preoperatively determining the extent of the tumor is very important, as even intraoperative cholangiography cannot accurately demonstrate the true dimensions of the tumor in the sectorial bile ducts. The advantages and disadvantages of the procedures that come into question are discussed.     

Proposed definitions for isodose flatness and symmetry in clinical radiotherapy beams

In clinical radiotherapy it is important that beam intensity be as homogeneous as possible to reduce the probability of treatment failure. As an extension of the well established concepts of beam flatness and symmetry for characterizing radiotherapy beams, the concepts of isodose flatness and symmetry are introduced. The definitions are tested with actual data obtained from a Co-60 unit and a linear accelerator and results are presented. The concepts as defined appear to provide a useful quantitative indication of beam homogeneity.     

Multicentric extraabdominal desmoid tumour: A case report

The very rare condition of multicentric desmoid tumours involving two distant and apparently independent sites is reported in a 17-year-old man. The tumours grew simultaneously and reached approximately equal size. No evidence of familiar polyposis or any other feature of Gardner's syndrome were noted. The proximal desmoid tumour developed from the left hip region and extended into the femoral bone, whereas the distal mass was attached to the left popliteal fossa infiltrating the flexor muscles, the nerves and vessels. On the basis of the good results published recently in the literature and our own earlier experiences, the intralesional resection of the desmoid tumours was completed with postoperative fractionated radiotherapy.