Anthony J. Piro

Mediastinal Hodgkin's disease: A possible danger for intubation anesthesia: Intubation danger in Hodgkin's disease

Abstract In many centers, laparotomy and splenectomy is an important procedure in the staging and management of Hodgkins disease patients. Surgery usually is performed under general anesthesia with endotracheal intubation. Acute complications of such anesthesia in patients with mediastinal disease prompted a review of the anesthesia experience for any procedure in all Hodgkins disease patients seen at our center from April 1969 through December 1973. Acute life-threatening complications occurred in 5 of 74 intubation anesthesias carried out in untreated patients with mediastinal and/or hilar disease; no complications were seen in 24 anesthesias performed after radiation therapy of mediastinal disease, or in 78 anesthesias in patients without intrathoracic disease. The incidence of anesthesia complications was related to mediastinal mass size. Hodgkins disease patients with significant mediastinal masses should be treated before surgery whenever possible.

Palliation of hepatic metastasis

Between 1971 and 1975,55 patients underwent palliative radiation therapy for symptomatic hepatic metastasis. Most patients received 2400 rad in 300 rad fractions to the entire liver. There were 31 patients who received concomitant chemotherapy, and 14 who were prior chemotherapy failures. Ninety percent of the patients with symptomatic pain and liver enlargment and significant palliation of their symptoms. The median survival of the entire group was 4.5 months, while those patients experiencing an excellent response (21) had a median survival of 9 months. The median survival of patients having an excellent response to radiation is comparable to that of patients having regional arterial chemotherapy while incuring fewer complications. The overall complication rate of those patients completing therapy (50) was 12%.

An aggressive approach to marginally resectable lung cancer.

Between July 1968 and December 1974, 53 patients with lung cancer were planned for preoperative irradiation and surgery. All patients were considered clinically marginally resectable because of advanced local disease, 4 Stage II patients, with limited pulmonary reserve and 49 Stage III patients. Most patients received 3000 to 4000 rad followed in two weeks by thoracotomy. Forty‐six patients were explored and 38 were resectable. Twelve patients are alive with a median follow‐up of 48 months. The cumulative 5‐year survival of all resectable patients is 27%. The survival of patients with marginally resectable lung cancer treated by accelerated radiotherapy followed by aggressive surgery approaches the survival experience of patients with primary resectable lung cancer and is superior to such patients treated with radiation therapy alone.

Can pelvic irradiation be omitted in patients with pathologic stages IA and IIA Hodgkin's disease?

From April 1969 to December 1973, 81 unselected laparotomy‐staged IA and IIA patients with supradiaphragmatic Hodgkins disease were treated at the Joint Center for Radiation Therapy. Mantle and para‐aortic fields alone were treated to 3600‐4000 rads. Median follow‐up was 31 months. There were six relapses including three true recurrences, two extensions, and one extra‐nodal dissemination. Relapses were not related to histologic type. There were no pelvic or inguinal extensions. Disease‐free survival was 95% in stage IA patients and 86% in stage IIA patients. Only one patient died of disease, with an overall survival of 96%. These results indicate that mantle and para‐aortic irradiation is sufficient treatment for pathologic stage I and IIA supradiaphragmatic Hodgkins disease. Such treatment obviates the need for pelvic irradiation or combination chemotherapy without compromising the success of treatment.

An evaluation of total nodal irradiation as treatment for stage III a Hodgkin's disease

Between April 1969 and December 1974, 37 patients with surgically staged III A Hodgkins disease were treated with total nodal irradiation (TNI). Their probability of relapse‐free survival at 7 years is 51% and overall survival 82% with the majority of patients remaining disease free after retreatment with MOPP (10 of 16). In contrast, 21 stage III B patients treated with TNI and MOPP chemotherapy over the same time period have a relapse‐free survival of 74% and overall survival of 91%. Because of superior results in treating stage III B patients with combined modality treatment, we feel that a relapse‐free survival of 51% may not justify continuation of TNI as the only modality of treatment for patients with stage III A disease, and we have initiated a trial of combined radiation therapy and MOPP chemotherapy in these patients. The most effective treatment of stage III A Hodgkins disease, however, remains uncertain and depends both on the ultimate risk of combined modality treatment and the success of retreatment following relapse after radiation.

Stages IIB and IIIB Hodgkin's disease. Results of combined modality treatment

Between April 1969, and December 1974, 23 IIB and 26 IIIB surgically staged patients with Hodgkins disease were treated at the Joint Center for Radiation Therapy. Stage IIB patients received either mantle and para‐aortic‐splenic pedicle, or total modal irradiation (TNI) alone or with the addition of combination chemotherapy. Relapse‐free survival is 83% and overall survival 88%. Eleven patients received combination chemotherapy in addition to mantle and para‐aortic irradiation, and both the relapse‐free and overall survival are 100%. Of the stage IIIB patients, seven received TNI alone with four relapses, and 19 were treated with TNI and MOPP with two relapses. These relapse rates are significantly different (p less than 0.05). The relapse‐free and overall survival for all stage IIIB patients is 66% and 84% respectively. These data imply that irradiation alone is not adequate treatment for stage IIIB Hodgkins disease, and that with the addition of combination chemotherapy both the disease‐free and overall survival is similar to that of early stage Hodgkins disease without systemic symptoms. The ideal management of stage IIB Hodgkins disease is less certain; it is our plan to study the efficacy of combined modality treatment. Cancer 40:84–89, 1977.

Interaction between Radiation and Drug Damage in Mammalian Cells: I. Delayed Expression of Actinomycin D/X-Ray Effects in Exponential and Plateau Phase Cells

The survival characteristics of V79 Chinese hamster cells exposed to either X-radiation or actinomycin-D and subsequently treated with the other modality were studied. Exponentially growing cells were exposed to either 820 R, 50 kVp X rays or 3.0 μg/ml AMD for 30 min and the survivors were exposed to graded doses of the other agent 2, 3, and 7 days afterward. The previously irradiated cells did not differ in their response to subsequent AMD, whereas the cells which had survived AMD demonstrated a decrease in extrapolation number and

Interaction between radiation and drug damage in mammalian cells. II. The effect of actinomycin‐D on the repair of sublethal radiation damage in plateau phase cells

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Radiation therapy of Hodgkin's disease: Significance of splenic involvement

when exposed to X rays as compared to cells not previously treated with AMD. The X-ray two-dose response was studied in cells exposed to 3.0 μg/ml 3 days before. The AMD treated cells had a lower maximum recovery ratio than controls and subsequent survival with time between doses was lower than in controls. Similar experiments were done with stationary (plateau phase) V79 cells. The response of stationary cells to AMD after either similar d...

Radiotherapy and medical oncology: basis for cooperative relations.

The effect of actinomycin‐D (AMD) on radiation damage repair was studied in plateau phase V79 Chinese hamster cells. Sublethal radiation damage repair, as demonstrated by survival fluctuations following two x‐ray exposures separated by time, was observed in our plateau phase cells. Plateau phase cells exposed to 0.01–0.04 μg/ml AMD (a nontoxic regimen to 8 hours) between x‐ray exposures were less able to repair sublethal damage. If plateau phase cells were plated at low dilutions into fresh medium (conditions for resuming exponential growth) immediately after the first x‐ray dose, and exposed to 0.01–0.04 μg/ml AMD until the second dose, inhibition of sublethal damage repair and additional cell killing were observed particularly at 0.04 μg/ml AMD. It is suggested that radiation‐drug damage interactions should be studied in plateau phase cells and in cells resuming exponential growth after plateau phase (possibly analogous to “recruitment”), as well as in exponential phase cultures.