Anas M. El-Mahdi

I–125 interstitial implantation for prostate cancer. What have we learned 10 years later?

From 1975 to 1984, 120 patients were treated at Eastern Virginia Medical School with iodine‐125 (I–125) interstitial implantation and pelvic lymphadenectomy as the definitive therapy for stage A2‐C prostatic carcinoma. As might be expected, a higher incidence of local recurrence was seen with tumors at a more advanced stage but also with tumors of moderate and poor differentiation. Local tumor control in these groups did not compare favorably with patients externally irradiated during this period, of which 246 patients were available for study. Only 57% of recurrences with 1–125 were clinically evident by 5 years follow‐up with failures detected at up to 10 years, as opposed to the development of 91% of local recurrences by 5 years with external beam irradiation (P = 0.001), suggesting a later incidence of local recurrence with 1–125 therapy. Major complications attributable to local tumor recurrence were also more frequent in implanted patients (20% vs. 8%; P = 0.006). The incidence of distant metastasis increased significantly in patients who experienced local recurrences, i.e., 83% versus 18%, with the expected adverse affect on survival. Disease‐free survival by grade and stage showed a particular disadvantage for patients with moderately well and poorly differentiated tumors and stage C disease treated by 1–125 therapy. In conclusion, then, it appears that 1–125 interstitial implantation is well suited to only a select group of prostate cancer patients with well‐differentiated, early stage disease and in most cases does not provide results comparable with external beam irradiation.

Pelvic complications after definitive treatment of prostate cancer by interstitial or external beam radiation.

Radiation complications, after definitive treatment of localized prostatic carcinoma by either external beam or interstitial implantation with Iodine-125 seeds, are reviewed. Late serious complications to immediately adjacent structures of the anterior rectal wall, prostatic urethra, bladder neck, and external sphincter occurred with similar frequency in both treatment groups. However, late serious complications of the remotely adjacent structures of the bladder, urethra, distal ureters, and circumferential rectal wall occurred more frequently in the external beam treatment series, a reflection of the fact that larger tissue volumes were irradiated. Rectal ulceration, while occurring in both treatment groups, was amenable to surgical correction or underwent spontaneous healing only in the 125I group. At this point in our experience, morbidity from late radiation complications has been less among those patients having interstitial implantation for definitive treatment of localized prostatic carcinoma.

Prognosis in patients with local recurrence after definitive irradiation for prostatic carcinoma

Of 414 patients with Stage A2‐C disease, all with a minimum follow‐up period of 3 years, who have been definitively irradiated by external beam therapy or iodine‐125 (1–125) implantation for biopsy‐proven prostatic adenocarcinoma, 83 patients (20%) have experienced local recurrences. The incidence of distant metastasis was significantly higher in patients with local tumor recurrence (56 of 83; 68%), as compared with those with local control (64 of 331; 19%; P < 0.001). This difference remained significant within each tumor grade and stage. Subsequently, survival in patients with local recurrence was significantly shorter than in those with local tumor control (66% vs. 89% at 5 years; P = 0.001). Of the 83 patients with local tumor recurrence, 56 had local recurrence and distant metastasis, and 27 had local failure alone, with a median follow‐up of 76 months for the latter group. Fifteen of 83 patients with local recurrence (18%) developed major complications secondary to local disease. Three of the 83 (4%) patients were known to die of prostatic recurrence alone and another 11 of 83 (13%) as a result of some combination of local and distant disease. Therefore, in reference to the entire group of definitively irradiated patients, only 0.72% expired solely of complications associated with local tumor recurrence and an additional 2.7% expired of a combination of both local and distant disease.

Radiotherapeutic management of cancer of the glottis, University of Virginia, 1956-1971.

All patients with cancer of the glottis treated by radiotherapy with curative intent at the University of Virginia from 1956 through 1971 have been reviewed. Follow‐up is complete through December, 1973. Results are presented by both stage and treatment policy and indicate that with our present methods of management a high degree of local control is achieved. The complications of treatment are examined, particularly those arising as a result of combined radiotherapy and surgery. A small number of cases have been salvaged following local recurrence and these are described in detail. Particularly striking has been the effectiveness of radiotherapy in the treatment of advanced (Stage III and IV) lesions. In this group 58 percent of the patients survive with their larynges intact. Considering the poor general condition and advanced nature of the lesions in these cases this result is important and may indicate the nature of future trends in treatment, namely radiotherapy, with surgery held in abeyance until there is overt recurrence.

PROSTATE-SPECIFIC ANTIGEN AFTER RADIATION THERAPY: Prognosis by Pretreatment Level and Post-treatment Nadir

After external beam radiation therapy, pretreatment prostate-specific antigen (PSA) is the most powerful predictor of outcome as measured PSA (biochemical) failure. The post-treatment nadir levels of PSA that predict best for subsequent freedom from PSA failure are debatable, and many nadir levels have been proposed as targets. Although lower nadirs generally are associated with superior outcomes, the identification of a single absolute nadir level was not selected at a recent ASTRO consensus conference. Rather, three consecutive PSA rises above the nadir, with date of failure at the midpoint between the nadir and first rise, were selected as a more useful end point for treatment failure.

THE DURABILITY OF EXTERNAL BEAM RADIATION THERAPY FOR PROSTATE CANCER: CAN IT BE IDENTIFIED?

PURPOSEnWe establish criteria to identify a durable response to external beam radiation therapy by calculation of biochemical progression-free probability for patients who attained and maintained defined nadir prostate specific antigen (PSA) levels more than 5 years after treatment.nnnMATERIALS AND METHODSnA total of 460 patients were treated with external beam radiation monotherapy from 1976 to 1995. Patients with PSA less than 0.5 (group 1) or 0.5 to 1.0 (group 2) ng./ml. more than 5 years after treatment were identified. Treatment failure was defined as 3 consecutive increases in PSA after nadir. Progression-free probability after 60 months was calculated for each group. A comparison was also made to patients achieving the same nadir levels anytime after treatment.nnnRESULTSnFailure occurred at 133 months in 1 of 26 group 1 patients (4%) and at a median of 76 months in 5 of 26 group 2 patients (19%). At 10 years progression-free probability was 91% for group 1 compared to 72% for group 2 (p = 0.0575). These same nadir levels anytime after treatment were associated with higher failure rates of 55% for group 1 and 72% for group 2.nnnCONCLUSIONSnIf a PSA nadir of less than 0.5 ng./ml. was maintained 5 years after therapy, subsequent failure was rare. Although statistical significance was not reached (p = 0.0575), a higher failure rate was noted if the nadir PSA was 0.5 to 1.0 ng./ml. at 5 years. Thus, patients with PSA 0.5 to 1.0 ng./ml. require careful continued surveillance. Nadir levels less than 1.0 ng./ml. anytime before 5 years were associated with a substantial risk of subsequent progression.

Results of Irradiation of Tumors in the Region of the Pineal Body

The clinical findings and results of radiation treatment in 14 patients with tumors in the region of the pineal body are presented. The neurologic signs and symptoms improved significantly in 11 patients (79 per cent). The survival rate for five years or more was 50 per cent. Radiation therapy as the primary method of treatment is discussed.

Radiation control of microscopic pulmonary met ast ases in C3H mice

C3HBA adenocarcinoma cells injected intravenously into isogeneic C3H/HeJ mice result in the formation of visible lung colonies which are introduced as a model for pulmonary metastases. Visible lung colonies are both time dependent and injected cell number dependent. Control of the lung colonies at their microscopic (subclinical) stage is achieved by a single radiation dose of 2100 rads, which is far less than the dose necessary to control palpable primary tumors. An in vivo survival curve for the microscopic lung colonies irradiated with graded single doses is resented.

Alveolar rhabdomyosarcoma of the larynx: Case report and literature review†

We report the 11th well‐documented case of laryngeal rhabdomyosarcoma and only the second of laryngeal alveolar rhabdomyosarcoma. The optimum treatment of head and neck rhabdomyosarcoma has not yet been defined, but it appears that the ideal should consist of an aggressive multimodality approach. This includes surgical extirpation if it can be done without major morbidity, postoperative radiotherapy with a margin around known and suspected disease, and multiagent chemotherapy. Unlike most sarcomas, rhabdomyosarcoma (especially alveolar rhabdomyosarcoma) spreads by way of the lymphatic system as well as the blood stream. Inclusion of the draining lymphatics in the radiation field must be given strong consideration.

Combined treatment of advanced cancer of the laryngopharynx and cervical esophagus

Advanced cancer of the laryngopharynx and cervical esophagus is difficult to treat because of the malnutrition produced by pain and obstruction and the problems related to reconstruction. This paper presents the initial results of a regimen used in 14 patients in which there is rapid reversal of nutritional deficiencies, radical resection, and reconstruction using the gastric pull‐up technique and administration of postoperative radiotherapy. Excellent overall palliation and decreased hospitalization have been achieved using this regimen without diminishing chances for cure.