Arthur D. Hamberger

Analysis of the severe complications of irradiation of carcinoma of the cervix: Whole pelvis irradiation and intracavitary radium

From January, 1967 to December, 1974, 325 patients with carcinoma of the uterine cervix were treated with a minimum of 4,000 rad whole pelvis irradiation plus intracavitary radium. These patients had large, sometimes massive, tumors. Generally, the larger the primary tumor the greater the amount of external irradiation delivered, with an appropriate reduction in the amount of intracavitary radium. Patients who had a positive lymphangiogram or a pre- or postirradiation hysterectomy or lymphadenectomy are not included in this analysis. All patients were followed for a minimum of 5 years. Local and regional failure rate in 193 patients receiving 4,000 rad whole pelvis irradiation plus radium was 1% and 4%, respectively, with a 3.1% incidence of severe complications. In 111 patients who received 5,000 rad whole pelvis irradiation plus radium, the local and regional failure rate was 3.5% and 4.5%, respectively, with a 10% incidence of severe complications. In patients who received 5,000 rad whole pelvis irradiation, complications were associated with unilateral parametrial boosts and with protruding vaginal sources. Of 21 patients who received 6,000 rad whole pelvis irradiation, three patients developed fistulae associated with high doses to the vagina delivered with protruding vaginal sources.

Treatment of intraperitoneal metastatic adenocarcinoma of the endometrium by the whole-abdomen moving-strip technique and pelvic boost irradiation

Between October 1961, and November 1978, 31 patients with intraperitoneal metastatic adenocarcinoma of the endometrium were treated by whole-abdomen moving-strip technique and pelvic boost irradiation. In 27 patients, with residual disease less than or equal to 2 cm, the corrected 5-year survival rate was 80%. The absolute 5-year survival rate was 63%. Within this group of 27 patients, the favorable prognostic trends were Stage III, incidental findings, and age less than 50 years. Tumor-reductive surgery to 2 cm or less residual disease was beneficial. Only one patient required operative correction for a complication of radiotherapy. The four patients who had residual disease greater than 2-cm disease died from tumor.

Optimal treatment for the technically resectable squamous cell carcinoma of the supraglottic larynx.

The charts of 431 patients with squamous cell carcinoma of the supraglottic larynx observed at the M. D. Anderson Hospital between January, 1954, and June, 1971, were analyzed. This study is concerned with those patients who had a technically resectable lesion. Emphasis is directed to the analysis of the effectiveness of primary irradiation instead of partial laryngectomy for those lesions which are technically suitable for a partial resection and to define the groups of patients which are best treated by combining surgery and planned postoperative irradiation.

Advanced squamous cell carcinoma of the oral cavity and oropharynx treated with irradiation and surgery.

One hundred and sixteen patients with advanced squamous cell carcinoma of the oral cavity and oropharynx were treated with irradiation and surgery. Failures were correlated with respect to tumor factors and treatment. Associated with failures are: (a) cut-through of disease at the primary site, (b) connective tissue involvement in the neck, (c) insufficient dose or use of a wedge pair, and (d) failure to give elective treatment to the neck. There is no significant difference in control in the pre- vs. the postoperative group. Combined treatment is indicated in those patients with a high risk of failure if treated by either modality alone.

Causes of Failure in Irradiation of Squamous-Cell Carcinoma of the Supraglottic Larynx

From 1948 through June 1971, 173 patients with squamous-cell carcinoma of the supraglottic larynx were treated by primary irradiation. The results were analyzed by staging of the primary lesions and specific extensions of disease. Primary irradiation of exophytic lesions of the supraglottic larynx offers a high control rate and preservation of the voice. Laryngectomy salvages a high percentage of the failures. In lesions of the suprahyoid epiglottis, moderate infiltration of the valleculae, although a cause of failure, is not a contraindication for primary irradiation as infiltration of the pre-epiglottic space is in lesions of the infrahyoid epiglottis.

Results of treatment of early stage I carcinoma of the uterine cervix with intracavitary radium alone.

A total of 151 patients with Stage I carcinoma of the uterine cervix received treatment with intracavitary irradiation alone between 1948 and 1971. All patients had a minimum follow‐up of five years. There were no local failures. No patient with microinvasive carcinoma (Stage IA) had a regional failure. A maximum of 4% (4/93) of patients with invasive cancer less than 1 cm in diameter (Stage IB‐Small Volume) had regional failures. The five year determinate survival rates for patients with Stage IA and IB (Small Volume) lesions were 100% and 96% respectively. The incidence of severe complications was low, with a fistula developing in only one patient. Treatment with intracavitary radium alone is sufficient for patients with invasive cancer less than 1 cm in diameter who have adequate anatomy that allows effective irradiation of the primary lesion and paracervical lymphatics.

Carcinoma of the cervical stump

This review is a retrospective analysis of 263 patients with carcinoma of the cervical stump treated at The University of Texas M. D. Anderson Hospital and Tumor Institute between 1963 and 1975. Symptomatology, stage distribution, and histology of carcinoma of the cervical stump showed no significant differences from cervical carcinoma of the intact uterus. Depending on the tumor stage, tumor volume, and distorted anatomy, treatment consisted of various combinations of intracavitary radium and transvaginal and external radiation. The 5-year survival was 100% in stage 0, 91% in stage I, 77% in stage II, 46% in stage III, and 37% in stage IV. The results achieved are similar to those in cervical cancer of the intact uterus. The complication rate was 30% and there were 9 (3.7%) deaths related to radiation complications.

The management of squamous cell carcinoma in cervical lymph nodes in the clinical absence of a primary lesion by combined surgery and irradiation

Sixty‐three patients who had either previously treated primary tumors or unknown primary tumors and developed metastatic cervical adenopathy in their previously untreated necks received the combination of surgery and megavoltage irradiation. Within two years, 12 patients died of intercurrent disease, nine patients died with distant metastastases only, and five patients had disease recur at a primary site. The remaining 37 patients were evaluable for control of neck disease; 26 patients had previous treatment to a primary head and neck cancer that was under control at the time cervical adenopathy was treated; and 11 patients had an unknown primary tumor that was believed to be in the head and neck area. The combination of pre‐ or postoperative irradiation and surgery controlled neck disease in 86% of the evaluable patients. Because of the extent of neck disease, these patients would have been at a high risk of failure in the treated area if only a single modality of treatment were used. Analysis of the data shows an association of extranodal connective tissue involvement with both a decreased rate of control within the treated area and distant metastases.

Preoperative radiotherapy for early endometrial carcinoma

A retrospective study was undertaken to compare the use of one versus two preoperative radium systems for early endometrial carcinoma. The charts of 73 patients treated between 1977 and 1980 were reviewed. No difference was noted between the two groups when compared for stage, grade, depth of myometrial invasion, and histologic type of tumor. One of thirty-eight (2.6%) patients in the one-radium group developed an isolated central recurrence; there were no central recurrences in the two-radium group. Total duration of therapy and total hospitalization for the one-radium versus the two-radium group were 17.6 and 15.3 days versus 77.0 and 17.3 days, respectively. Follow-up ranged from 48 to 84 months. Corrected survival figures are comparable to 94.6% for the one-radium group versus 100% for the two-radium group. These data suggest comparable effectiveness and morbidity between the two treatment regimens, with the single-radium application more efficient and cost effective.

The results of treatment of cervical adenopathy from squamous cell carcinoma of the head and neck with combined surgery and megavoltage irradiation

Sixty-four patients who developed metastatic cervical adenopathy in a previously untreated neck received treatment with a combination of surgery and megavoltage irradiation between January 1969 and December 1974 at the M.D. Anderson Hospital and Tumor Institute. Forty-four patients had had previous treatment to a primary head and neck cancer which-was under control at the time that the cervical adenopathy was treated. In 20 patients, the primary site was unknown but felt to be from the head and neck area. The results of treatment will be presented and analyzed with respect to clinical and pathological extent of neck disease. The possible significance of extranodal connective tissue involvement will be discussed.