Alfred L. Goldson

Quality control parameters of intraoperative radiation therapy

We have tried to outline many of the factors which must be considered in the technical delivery of IORT and in subsequent evaluation of these patients. Unless careful attention is given to details of patient selection, surgery, pathology, radiation therapy and follow-up, it is likely that a vast morass of data will be obtained which will be very difficult to interpret. It is the hope of the IORT Working Group that other institutions using IORT will employ our recommendations with regard to dosimetry, follow-up, and the general technical approach. This will likely lead to an earlier understanding of the exact role of this modality in cancer therapy today.

lodine-131 Treatment of Hyperthyroidism in a Patient on Dialysis for Chronic Renal Failure

A 7- to 8-cm diffuse toxic goiter with associated symptoms of hyperthyroidism developed in a 38-year-old black female undergoing regular hemodialysis for renal failure. Our treatment of choice was an

Intraoperative radiotherapy for intracranial malignancies: A pilot study

Intraoperative radiotherapy (IOR) or “direct view” irradiation permits the delivery of a single exposure of high‐energy electrons to a surgically exposed tumor. Surgical exposure permits physical retraction of normal uninvolved tissues away from the IOR beam as well as the accurate assessment of the target volume. IOR represents a “supplement” or “boost” dose to conventional fractionated external beam irradiation that is administered postoperatively. This pilot study represents the clinical experience in the US using IOR for brain tumors. At Howard University Hospital, Washington, DC, 12 patients underwent surgical resection or decompression and 1500 cGy were delivered to the tumor bed intraoperatively. After surgical recovery, 5000 cGy in 25 fractions were delivered to the whole brain and an additional 500 cGy cone‐down boost were delivered to the tumor bed. This protocol was best tolerated when the cranial vault was decompressed. Two patients with meningioma are without evidence apparently NED at 8, 11, 12, and 15 months, respectively. A fifth patient died at 8 months NED from an accident. Three glioma patients died with disease at 3, 13, and 15 months, respectively. Two additional patients died 30 days after surgery. Indications, techniques, and clinical findings are presented.

Retrospective analysis of breast cancer among young African American females.

AbstractPurpose. To evaluate the patterns of failure, relapse-free survival and overall survival among African American breast cancer patients younger than 40 years. Patients and methods. We retrospectively reviewed the records of 124 African American breast cancer patients younger than 40 years who were registered with the Howard University Cancer Center Database between 1990 and 1999. One hundred and six patients were found eligible and subsequently included in this analysis. Ninety-eight percent of these patients were pre-menopausal and 30% had a documented family history of breast cancer. Patient distribution per stage is as follows: 19%, stage I; 61%, stage II; 16%, stage III and 4%, stage IV. Surgery was a component of treatment for 98% of the patients. Forty-six percent underwent mastectomy, 47% had breast-conserving surgery and 5% underwent biopsy only. Fifty-nine percent of the patients received adjuvant radiation and 56% were also treated with adjuvant chemotherapy. Median follow-up was 35 months (range of 4–126 months). Results. Locoregional only first failure rate was 6% while systemic failure occurred in 20% of these patients. Among 17 stage III patients, 50% developed distant metastasis. The 5-year overall survival for these patients was 73%, with relapse-free survival being numerically similar. Patients with early stage disease, stages I and II, were noted to have 5-year overall survival rates of 100 and 78–83%, respectively. Those who presented with stage III or stage IV disease had dismal 5-year overall survival rates of 25–29 and 0%, respectively. Multivariate analysis using the Cox proportional hazard model identified the presence of metastasis as a factor that significantly affects survival in these young African American females. Conclusion. These results show that African American females younger than 40 years with early stage breast cancer have local control and survival rates comparable to that of the general population. In contrast, young African American females in this study, with stages III and IV disease, appear to suffer a worse prognosis despite standard therapy. A larger series of young African American females with breast cancer, followed for a longer period of time, will be required to confirm a negative trend in survival.

Dynamic dose-shaping by gravity-oriented absorbers for total lymph node irradiation

Abstract Rotational therapy with gravity-oriented absorbers is proposed for better total lymph node irradiation (TLI). Two metal semicylinders are joined coaxially (face to face) to form a radiation absorber that is centrally suspended in the beam. During rotation this absorber is kept parallel to itself by gravity, like the riders of a Ferris wheel. The vertebrae remain continuously protected under the absorbers “shadow”. The circular full-dose region, achieved by ordinary rotation, is now transformed into a “horse-shoe” region embracing the spine anteriorly. The abdominal lymph nodes are thus irradiated while the spine and most of the normal tissue around the spine are protected. A similar technique is applied for the selective irradiation of the pelvic lymph nodes, which are confined in the two legs of an inverted V region.

Simple but sophisticated immobilization casts.

Abstract A fast and easy method of immobilization cast fabrication is described. There is no need for a special mold room or mold technologist, since either the radiotherapist or the radiation technologist is able to construct these casts in less than 10 min. A one-piece tbree-layer composite “casting blank” is used. A first sheet of resilient, water absorbable, non-allergenk open cell polyurethane foam, an inner layer of seven or more plaster splints, and a third outer layer of fibrous water absorbable cotton flannel comprise the composite casting blank. This paper outlines the steps in construction of this cast.

Intraoperative radiotherapy for pancreatic cancer — Requiem or revival?

From Whipple resection to RTOG-8505 Phase I/II intraoperative radiotherapy (IORT) study, the outlook for cure of adenocarcinoma of the pancreas has remained dismal. Modem day IORT enthusiasts looked to IORT as a possible ray of hope because of its unique application and because previous techniques using combinations of external beam irradiation, interstitial implants, plus or minus chemotherapy, had improved median survival of patients treated by by-pass procedures alone by only three to seven months. Early IORT techniques reported by Abe (1) and Goldson (2) using single doses of 2040 Gy alone produced six month median survival rates. The initial reports from Massachusetts General Hospital and the Mayo Clinic, using IORT as a “boost” dose in combination with external beam irradiation, gave some sense of promise with median survivals for unresectable pancreatic tumors of 13.5 months (4). Similar studies from other centers in Japan and the United States were not as good, with median survivals closer from eight to nine months. The RTOG-8505 Phase I/II IORT study for pancreatic cancer was supposed to set the numbers straight and confirm, in a multi-institutional study, that there was some improvement in median survival. Unfortunately, the study only demonstrated the feasibility of the technique and the acceptable morbidity, but no improvement in survival. The study, in my opinion, was well designed and user friendly. It combined the logic of using IORT as a safe “boost” dose, fractionated external beam irradiation to cover the entire pancreas and regional lymphatics, and I.V. 5-FU, a proven gastrointestinal tract chemotherapeutic agent for systemic coverage. The poor outcome only reflected the aggressive and insidious nature of pancreatic cancer. To shake our heads and close the chapter on IORT for pancreatic cancer at this point would be premature; other combinations should be evaluated. Don’t our medical oncology colleagues just rearrange the alphabetical order of their drug combinations and proceed to enter more patients onto protocol? Why shouldn’t we? At Howard University Hospital, we are performing a Phase I/II study combining the simultaneous delivery of IORT electrons with interstitial intraoperative hyperthermia followed by fractionated external beam irradiation (3). Initial findings show an improvement in median survival for this new protocol group over our previous group that received IORT plus external beam irradiation. Additional studies should consider combinations of IORT with Iodine125 seeds, Ferromagnetic seeds, monoclonal antibodies, and aggressive chemotherapy regimens. Now is the time to recall the troops and plan another attack.

Guidelines for comprehensive quality assurance in brachytherapy

Brachytherapy treatment techniques can provide significant improvement in local control and overall survival, but only when quality assurance can be guaranteed. In the absence of well-trained personnel and inadequate equipment undesirable results usually follow. To establish brachytherapy quality assurance, basic requirements for three predetermined subdivisions of clinical institutions will be forwarded. These are: (1) centers having minimum requirements to provide brachytherapy, (2) intermediate centers such as regional or community hospitals, and (3) optimal centers such as university hospitals and cancer centers. A minimum center would have no board certified radiation personnel, would make use of services of a gynecologist or surgeon, be limited to afterloading or remote afterloading techniques for uterus cancer, and quality control would be guaranteed by using simple treatment protocols with fixed intrauterine applicators. Additional quality assurance such as leak testing, etc. would be provided by a parent organization (W.H.O. or Optimal Center). An intermediate center would have at least one certified radiation personnel with expansion of brachytherapy techniques to interstitial implants with several isotopes. Like the minimum center, no teaching would be provided but some quality assurance policies would be performed at the center (e.g., autoradiographs). The optimal center would have a full complement of personnel, have total brachytherapy capabilities, have teaching programs for its staff and possibly the minimum and intermediate centers and be able to provide its own quality assurance. This presentation will highlight personnel needs, equipment requirements, academic activities, clinical experience with these systems and proposed quality assurance guidelines.