Beatriz E. Amendola

Radiation-associated sarcoma: A review of 23 patients with postradiation sarcoma over a 50-year period

Between 1934 and 1983, 23 patients with well-documented diagnosis of radiation-associated sarcoma (RAS) were seen at the University of Michigan Medical Center. The median latent period from irradiation to diagnosis of RAS was 13 years with a minimum latent period of 3 and a maximum of 34 years. All sarcomas originated in previously normal tissues within the irradiated field. Pathology slides available in all patients were reviewed by the same pathologist for the purpose of the study, and the diagnosis of sarcoma was confirmed histologically. There were five bone sarcomas and 18 soft tissue sarcomas. Thirteen patients developed radiation- associated sarcoma following megavoltage treatment with a minimum total radiation dose of 25 Gy in 2½ weeks. The other 10 patients received orthovoltage and/or brachytherapy irradiation alone or combined with external beam radiation. In this group, the radiation doses ranged from 25 Gy to 72 Gy except for one patient who received 8 Gy delivered by orthovoltage irradiation as treatment of knee arthritis. Four patients were originally treated for benign conditions. All the other patients (n = 19) received radiation therapy for a variety of primary malignancies including carcinoma of the cervix (n = 4), brain gliomas (n = 13), Wilms tumors (n = 2) and retinoblastomas (n = 2), among others.

Computed Tomography in the Evaluation of Carcinoma of the Ovary

Over a 26 month period, 34 patients with histologically proven ovarian malignancy were studied by computed tomography (CT). In nine patients, CT was obtained for evaluation of a pelvic or abdominal mass. Computed tomography was diagnostic of ovarian malignancy in seven and indeterminate regarding the origin of the tumor in two patients. Ten patients were evaluated by CT in order to rule out recurrent ovarian neoplasm. Disease free intervals prior to CT ranged from 6 to 36 months with an average of 18 months. In eight surgically proven cases, CT was true positive for recurrent tumor in six patients, true negative in one, and false positive in one. In 20 patients, serial CT examinations were valuable in the objective assessment of measurable tumor response following chemotherapy and radiation therapy. A major limitation of CT was its inability to detect peritoneal and liver surface implants smaller than 2 cm in size.

Lung Metastases Treated by CyberKnife® Image-Guided Robotic Stereotactic Radiosurgery at 41 Months

Objectives: Based on the reported success of stereotactic body radiotherapy in treating extracranial tumors, we used CyberKnife® (Accuray Incorporated, Sunnyvale, CA) to treat patients with metastatic lung cancer. Methods: This is a retrospective report of treatment details and outcomes of 35 patients, ranging in age from 33 to 91 years, with 69 histologically proven pulmonary metastases, treated by image-guided robotic stereotactic radiosurgery at the CyberKnife® Center of Miami, between March 2004 and August 2007. Tumor volumes ranged from 0.7 mL to 152 mL. Total doses ranged from 5 to 60 Gy delivered in one to four fractions with an equivalent dose range from 6 to 110 Gy NTD delivered in 2-Gy fractions assuming an α/β of 20 Gy. Results: All patients tolerated radiosurgery well with fatigue as the main side effect. Grade 3 and grade 4 pulmonary toxic reactions were observed in one patient who had undergone a repeat treatment. Of the 35 treated patients, 27 (77%) were still alive at a median 18-month (range 2–41 mo) follow-up. Local control was 71% with 25 tumors showing a complete response, 16 a partial response, and 7 stable with disease. Eight had progressive disease. Conclusions: The delivery of precisely targeted radiation doses to lung tumors in a hypofractionated fashion is feasible and safe. image-guided robotic stereotactic radiosurgery of pulmonary metastases with the CyberKnife® achieves good rates of local disease control with limited toxicity to surrounding tissues and in many cases may be beneficial for patients for whom surgery is not an option.

Episcleral plaque radiotherapy for retinoblastoma.

The authors report their preliminary results of episcleral plaque radiotherapy (cobalt 60, iridium 192, ruthenium 106, and iodine 125 plaques) in 50 selected patients with retinoblastoma. There were 97 plaque applications to 51 affected eyes in these 50 patients. The plaque was used as primary treatment in 15 eyes and as secondary treatment after failure of external beam radiotherapy, photocoagulation, and/or cryotherapy in 36 eyes. Vitreous seeding of tumor cells was evident ophthalmoscopically in 49 of the 51 eyes, negating the possibility of ultimate success by further photocoagulation or cryotherapy. In 18 patients, the contralateral eye had been enucleated and the remaining eye was being considered for enucleation because all other treatment modalities had failed. In 2 of these 18 patients (11%), the remaining eye was salvaged with plaque radiotherapy and some vision was preserved. In 33 eyes with less advanced tumors, 31 had some degree of vitreous seeding by tumor cells. The eye has been retained in all 33 of these patients and useful vision preserved in most. On the basis of these preliminary observations, the authors conclude that plaque radiotherapy can be used successfully as a primary treatment for selected cases of unilateral or bilateral retinoblastoma or as a supplemental treatment after other treatment methods have failed. The current indications for plaque radiotherapy and its advantages over other therapeutic modalities are discussed.

Early results of CyberKnife image-guided robotic stereotactic radiosurgery for treatment of lung tumors

Objective: To determine if image-guided robotic stereotactic radiosurgery (IGR-SRS) by CyberKnife achieves acceptable local control in resectable but medically inoperable patients with non-small cell lung cancer (NSCLC) or pulmonary metastasis, and to evaluate control rates and toxicity. Methods: Treatment details and outcomes were reviewed for 95 patients (age range 33–96 years) with 136 histologically proven cancers treated by IGR-SRS at the CyberKnife Center of Miami between March 2004 and March 2007. Tumor volumes ranged from 1.2 cc to 338 cc. Targeting was accomplished using combined skeletal alignment and real-time tracking via fiducials placed within the tumor. Total doses ranged from 15 to 67.5 Gy delivered in 1 to 5 fractions. Results: Of the 95 patients treated, 78 (82%) are still alive at 1 to 36 months post-treatment. Nineteen patients have died, four from disease other than cancer progression. All patients but one achieved at least partial response to treatment and tolerated radiosurgery well. For the majority of our patients, fatigue had been the main side effect. Conclusions: The delivery of precisely targeted high radiation doses with surgical precision to lung tumors in a hypo-fractionated fashion is feasible and safe. Image-guided robotic stereotactic radiosurgery (IGR-SRS) of lung tumors with the CyberKnife achieves excellent rates of local disease control with limited toxicity to surrounding tissues, and in many cases may be curative for patients for whom surgery is not an option.

The treatment of primary intraocular malignancy

This paper will summarize much of the information derived in an association between The Department of Radiation Oncology of Hahnemann University Hospital and the Oncology Service of Wills Eye Hospital of Thomas Jefferson University, a collaborative effort for the treatment of primary intraocular malignancies that has spanned the last dozen years. In that time we have treated malignant intraocular melanoma by radioactive eyeplaque brachytherapy and have begun to develop a similar program for treatment of recurring retinoblastoma. These experiences will be described.

Analysis of treatment results in 36 children with retinoblastoma treated by scleral plaque irradiation

This is a retrospective analysis of treatment results in 36 patients with retinoblastoma treated by the Radiation Oncology Department of Hahnemann University Hospital and the Division of Oncology of Wills Eye Hospital between January 1975 and December 1986. There were 14 females and 22 males; ages ranged from 2 months to 4 1/2 years of age at presentation. Leukocoria was the most common clinical sign of presentation. These patients were treated with external beam radiation therapy in combination with scleral plaque irradiation in 20 patients and with scleral plaque alone in 16 patients. Cobalt-60, Iodine-125, Iridium-192, and Ruthenium-106, scleral plaques were used. The dose delivered to the mid plane of the globe was 40 Gy and the scleral dose adjacent to the plaque was in the range of 180-200 Gy. The treatment was successful in 30 of 36 patients. Complications of radiation therapy were minimal in patients treated by scleral plaque alone. The advantages of this treatment modality are discussed.

CT findings in hepatoblastoma

Hepatoblastoma is the third most common intraabdominal malignant neoplasm in infants. Computed tomography of six patients with surgically proven hepatoblastoma was reviewed; abnormalities included large, diffuse, or multifocal liver masses with lower attenuation values than normal hepatic parenchyma after contrast enhancement. In three patients, areas of speckled or amorphous calcifications within the tumor were evident on CT, whereas calcification was present on conventional radiography in only one patient. In four of the six infants, CT demonstrated unresectable tumor by virtue of massive pansegmental involvement. Computed tomography is a useful tool for screening patients with suspected hepatoblastoma and for determining the anatomic extent of tumor and thus selecting a group of children for aggressive surgical excision.

Pineal tumors: analysis of treatment results in 20 patients

OBJECT The authors evaluate their results when using gamma knife surgery (GKS) in the management of patients with tumors in the pineal region. METHODS This is a retrospective clinical evaluation of 20 patients with primary tumors of the pineal region treated with GKS from November 1994 through August 2003. There were 13 germ cell tumors, two pineoblastomas, two low-grade gliomas, one primitive neuroectodermal tumor, one teratoma, and one pineocytoma. There were 10 male and 10 female patients. Their median age was 15.5 years (range 5-71 years). The median margin dose was 11 Gy (range 8-20 Gy). The median target volume was 3.1 cm3 (range 0.1-49.9 cm3). Five patients received sequential systemic chemotherapy and four underwent adjuvant conventional radiation therapy. Seventeen (85%) of 20 patients are alive with a median survival of 30.4 months (range 0--85.7 months). Two patients required retreatment. Three patients died: one of unrelated causes, one who presented with extensive local disease, and the other of meningeal carcinomatosis with local control of the primary tumor. No complications from GKS were noted. CONCLUSIONS This initial experience suggests that GKS is a valuable treatment modality for the management of pineal region tumors. This technique offers excellent local tumor control and minimal patient morbidity, allowing for immediate use of systemic chemotherapy and/or conventional radiation if indicated.

Lymphoma of the thyroid. Report of five cases and review.

Thyroid lymphoma is a rare disease seen most commonly in elderly women and associated with Hashimotos thyroiditis. Five cases of thyroid lymphoma seen and treated at Hahnemann University Hospital between 1979 and 1988 are retrospectively reviewed. All patients underwent a staging work- up, including chest radiograph, intravenous pyelography, abdomenal/pelvic computed tomogram (CT) scan and/or lymphangiogram, and bone marrow. An extensive review of the literature is presented. Risk factors for thyroid lymphoma are discussed, enabling the clinician to differentiate thyroid lymphoma from thyroid carcinoma. Thyroidectomy may be indicated in a small number of cases, provided that the patient has disease localized within the thyroid such that total gross resection can be achieved. It is proposed that patients with bad prognostic factors may benefit from the administration of chemotherapy initially before or after radiotherapy rather than using chemotherapy as salvage therapy. Irradiating the patient to the neck and mediastinum to 40 Gy, in 4–5 weeks, is recommended, except possibly for tumor that is extremely well localized in the neck. Finally, the necessity of a full staging work-up, including lymphangiogram and/or abdomenal/ pelvic CT is emphasized.