Arthur J. Gerdes

Fast neutron and mixed (neutron/photon) beam teletherapy for grades III and IV astrocytomas

A study was performed in order to assess the efficacy of using fast neutron irradiation, either alone or in conjunction with megavoltage photons, in treating Grades III and IV astrocytomas. The study encompasses fifteen patients with Grade III lesions and twenty‐two patients with Grade IV lesions. Various fractionation schemes are described. Only one patient is still alive at the present time. Regarding the other patients, the mean survival after completing therapy was 10.8 months for those patients with Grade III lesions and 7.5 months for those patients with Grade IV lesions. Particularly for Grade III lesions, the average survival was appreciably less than that of patients treated with photons alone. The treated patients also had no noticeable improvement in quality of survival when compared with the results of conventional photon irradiation. There was no appreciable difference in survival between the group treated with neutrons alone or with mixed (neutron/photon) irradiation. Autopsy data on fifteen patients showed gross tumor progression in only one instance, and this patient also had liver metastases. In the other fourteen cases, the gross tumor volume was replaced by coagulation necrosis. In general, there were some abnormal cells intermixed with the regions of coagulation. These cells are currently felt to be reactive astrocytes. Both a diffuse gliosis and a white matter demyelination were found in regions far from the tumor volume and this presumably is related to the ultimate cause of death.

Optic nerve glioma: The role of radiation therapy

Sixteen patients with optic nerve gliomas were treated with radiation therapy between 1962 and 1975. Surgical extirpation was not attempted. Fifteen patients had biopsies with histologic confirmation; one had a craniotomy without biopsy. With a follow‐up of 1 to 14 years, mean 6.3 years, 12 of the 16 patients are alive without evidence of disease. Vision was preserved or improved in all surviving patients. No patient who received 5000 rad or greater had a recurrence of his or her tumor, whereas four of seven patients receiving doses less than 5000 rad had recurrences and eventually died. We currently recommend 5000‐rad megavoltage photon irradiation, delivered with standard fractionation, for all patients with optic nerve gliomas.

The role of radiation therapy in the treatment of glomus jugulare tumors.

The records of 14 patients who received irradiation for incompletely excised, inoperable or recurrent glomus jugulare tumors were retrospectively reviewed. Ages ranged from 12 to 66 years, and the male to female ratio was 1:3. With a follow‐up time of 1.3 to 17.2 years (mean of 7.7 years), 11/14 remain clinically disease‐free. Doses of at least 4000 rad are shown to be effective in controlling glomus jugulare tumors.

Irradiation of Brain Metastases

A series of 124 patients with intracranial metastases, treated by irradiation, has been reviewed, retrospectively and prospectively, and the results are reported. Worthwhile palliation was obtained in 79 (63%) of the total number of patients with functional improvement documented in 52 (41%). The uncorrected mean survival was 4.7 months. The addition of surgery to irradiation did not improve results significantly in this series. Therefore, surgical removal should be performed on special indications such as rapidly progressing increase in intracranial pressure unresponsive to steroids or shunt, or if the etiology of the intracranial lesion is uncertain.

Are pelvic irradiation and routine staging laparotomy necessary in clinically staged IA and IIA Hodgkin's disease?

Thirty‐nine patients with clinically staged IA and IIA Hodgkins disease were treated with mantle plus paraaortic/splenic irradiation between 1968 and 1975. All patients had supradiaphragmatic presentations, and none had staging laparotomies. With a follow‐up time of 1 to 9 years, mean 4.3 years, the overall relapse‐free survival is 92% (100% for stage IA and 89% for stage IIA). The absolute relapse‐free 5‐year survival is 91% There were no pelvic recurrences. These data show that routine staging laparotomy and pelvic irradiation are not indicated for clinically staged IA and IIA Hodgkins disease with supradiaphragmatic presentations. The criteria for staging laparotomy in early‐stage Hodgkins disease are discussed. Cancer 40:2914‐2916, 1977.

High dose para-aortic lymph node irradiation for gynecologic cancer: technique, toxicity, and results

A technique for high dose (5600-6100 cGy) extended field irradiation to the para-aortic lymph nodes is described. Fourteen patients have been treated with this technique, of whom 10 have had histologic confirmation of para-aortic node metastases. With follow-up ranging from 11 to 78 months, 7 of 14 patients are alive and clinically cancer-free. Acute effects of extended field treatment on patient weight and circulating blood counts are analyzed, and late treatment morbidity assessed. The findings suggest that such treatment, executed with modern equipment and appropriate technique, is not significantly more hazardous than pelvic irradiation, and can result in a substantial probability of disease-free survival.

Preliminary clinical results from U.S. fast neutron teletherapy studies

Over 700 patients with cancer have been treated with fast neutron beams since 1972 in three U.S. programs at the M.D. Anderson‐TAMVEC (Houston and College Station, Texas), University of Washington (Seattle, Washington), and MANTA (Naval Research Laboratory, Washington, D.C.). Clinical applications are about to start at the Fermilab (Batavia, Illinois) and Cleveland Clinic‐NASA (Cleveland, Ohio). To date, studies have included: 1) effects of different treatment patterns and doses; 2) responses of several tumor types at many anatomic sites; and 3) acute and long‐term normal tissue tolerances. Responses of several cancers, such as extensive epidermoid carcinoma of the cervix and “fixed” metastatic cervical adenopathy, have been encouraging. In patients with glioblastoma multiforme, good tumor responses have not lengthened survival compared with that following conventional radiation therapy. Both local tumor control and “cure” have been compromised by the inclusion of patients with very extensive cancers. In general, treatment has been well tolerated. These preliminary studies provide the bases for planned clinical trials.

Preliminary results of fast neutron teletherapy of metastatic cervical adenopathy

Between September 21, 1973 and May 9, 1975, 36 patients with metastatic cervical adenopathy from cancers primarily arising in the pharynx or oral cavity, including six with bilateral cervical involvement, received fast neutron teletherapy at the University of Washington. At the conclusion of treatment, the masses were no longer palpable in nine of 42 (21%) heminecks and were reduced more than 50% in 23 (55%). In 12 patients with partial regression, the masses eventually disappeared, so that in all, 21 heminecks (50%) or 20 patients (56%) were controlled for periods up to 66 weeks. Fixed cervical masses were controlled in 11 of 23 (48%) patients. These results, which must be sustained for longer observation periods, are comparable to results reported in the literature. Treatment was well tolerated; therefore, doses can be raised to study the influence on tumor control.

Early assessment of normal tissue tolerance of fast neutron beam radiation therapy

Between September 10, 1973 and May 20, 1975, 94 selected patients were treated with fast neutron beams generated by bombarding an “intermediate” beryllium target with 21 MeV deuterons. The clinical material included: 58 patients with head and neck cancers; 27 patients with cerebral glioblastoma multiforme; and 9 patients with a variety of other neoplasms. Of the 67 patients treated only with neutron beams, 31 received two increments per week and 36 received three increments per week. The calculated doses in most patients were 1800 rad nγ (neutrons + gamma components) delivered in 6 weeks. Seventeen patients were treated with two increments of neutron beams and three increments of 60Co photons weekly to calculated total doses of 780–1050 rad nγ + 3360–3780 rad 60Coγ delivered over 50–54 days. Ten patients were treated with neutron beam “boosts” of 300–900 rad nγ in three to seven increments over 8–23 days following conventional radiation therapy. Treatment has been well tolerated, with only 9 of 94 patients not completing the anticipated course. In three of these, treatment was discontinued because of intercurrent problems. Except for those patients with glioblastoma multiforme, treatment complications have not been dose‐related. In four patients, complications probably were related to persistent cancer. Neutron beam irradiation may have been a factor in the neurologic deterioration of five patients with glioblastoma multiforme who did not complete treatment.

Peroral irradiation for limited carcinoma of the oral cavity

Abstract Eighteen patients with limited squamous cell carcinoma of the oral cavity were irradiated through a peroral cone between 1965 and 1975. All had primary lesions less than 3 cm in greatest dimension, and none had evidence of regional or distant metastasis. The local control rate with a follow-up time of 1–10 years was 100%. Peroral irradiation is recommended for patients who meet the following criteria: primary located in a site accessible to a cone; primary equal to or lesser than 3 cm in greatest dimension; no deep invasion of underlying tissues; no regional or distant metastasis; cooperative patient capable of remaining still during treatment.