Brace L. Hintz

Patterns of recurrence following curative resection alone for adenocarcinoma of the rectum and sigmoid colon.

Two‐hundred‐four patients with previously untreated adenocarcinoma of rectum, rectosigmoid, and sigmoid colon were retrospectively evaluated to determine patterns of recurrence following curative resection. Seventy‐eight (38%) subsequently developed recurrent disease. Of these, 40% (31/78) presented with local recurrence alone, 28% (22/78) with regional recurrence, 15% (12/78) with concomitant local recurrence and distant metastasis, and 17% (13/78) with distant metastasis alone. The degree of tumor anaplasia and depth of tumor penetration into the bowel wall influenced the rate of local recurrence. Through five years local recurrence without clinical evidence of distant metastasis was the most common cause of death. Need for adjuvant radiation therapy is discussed.

Radiation tolerance of the vaginal mucosa.

Abstract Sixteen patients with cancer of the vagina that were controlled locally for a minimum of eighteen months after teletherapy (T) or brachytherapy (B) or both (T & B), were analyzed for radiation tolerance of the vaginal mucosa. The site of vaginal necrosis did not always coincide with the site of the tumor. The posterior wall appeared more vulnerable than the anterior or lateral walls. For the distal vaginal mucosa, necrosis requiring surgical intervention occurred following combined T & B, if summated rad exceeded 9800. The upper vagina tolerated higher dosages. No patient required surgery for upper vaginal necrosis even though summated (T & B) dosage up to 14,000 rad was applied. Placing radioactive needles on the surface of the vaginal cylinder with or without interstitial perinea) needles should be avoided. Further accumulation of data is needed to define these vaginal mucosa tolerance limits more closely.

Influence of exploratory celiotomy on the management of carcinoma of the cervix. A preliminary report.

The policy of treating patients with Stages IB and IIA carcinoma of the cervix by radical hysterectomy and pelvic lymphadenectomy led to the initiation of laparotomy staging of carcinoma of the cervix in 1970. Two‐hundred twenty patients were subjected to surgical staging at which time bilateral aortic lymphadenectomies and biopsies of perirectal and perivesical spaces were done. If these were negative, radical hysterectomy and pelvic lymphadenectomy were performed in patients with surgical Stage IB and IIA. Para‐aortic node involvement was seen in 7%, 14%, 18%, and 19% in patients with Stages IB, IIA, IIB, and IIIB, respectively, in the context of the surgical material being heavily weighed in favor of early stage disease. The methods of management in these patients were designed according to the findings at exploratory celiotomy. Twenty‐one patients were found to have positive para‐aortic nodes and received en bloc pelvis and para‐aortic irradiation. Four patients are alive and well at 63,23,20, and 19 months, respectively. One patient is alive with disease at 18 months. Two died from other causes at 34 and three months. There was no difference in the survival of the two groups of patients among 75 with negative para‐aortic nodes, who received either pelvic irradiation alone or pelvic and para‐aortic irradiation on the basis of possible presence of subclinical disease not dissected at the time of surgery.

Carcinoma of the tonsillar area treated with external radiotherapy alone

Seventy patients with carcinoma of the tonsillar area were treated with radiation therapy alone, all with a minimum follow-up of 3 years. Seventeen patients with stages I and II developed six recurrences and three were salvaged by surgery. Fifty-three patients with stages III and IV developed 24 recurrences, and only three could be salvaged by surgery. We conclude that radiation therapy is adequate for stages I and II carcinoma of the tonsillar area. Local control rate is satisfactory and surgical salvage is acceptable. Patients with advanced disease, Stages III and IV, have a poor survival rate with radiotherapy alone. Local recurrence is high and surgical salvage is inadequate. We have decided to offer selected patients with stages III and IV tonsillar carcinoma planned combined radiotherapy and surgery, in an effort to improve the survival rate.

Observations on the treatment of mediastinal masses in Hodgkin's disease emphasizing site of failure.

Of 244 patients with Hodgkins disease, 126 (52%) had an abnormal mediastinum. Sixty-four patients were treated with radiation, 36 with radiation and chemotherapy, and 25 with chemotherapy alone as an initial treatment. Twenty of 52 (38%) with stage I or II who received initially radiation alone relapsed, and 70% (14 of 20) of them were salvaged with chemotherapy. Therefore, the ultimate failure rate was 12% (6 of 52). Forty percent (8 of 20) of these patients failed within or at the margin of the radiation portal, and 60% failed predominantly outside of the radiation field. Even though we did not treat the whole lung prophylactically, there was only one true peripheral lung recurrence. Nine of 20 (45%) recurred in more than one site. Of 36 patients treated with combined radiation and chemotherapy, 21 patients had stage I, II, or IIIA disease. Of these, two patients relapsed. Of 86 patients with accessible x-ray films, 30 patients had large masses with a ratio of mass to transverse diameter greater than .33 at the broadest level. Fifty-six patients had small masses. Survival at 96 months in patients with stages I-IIIA with either large or small masses is 94% (p = 0.80). Their relapse-free survival at 96 months is 79% for large masses and 95% for small masses (p = 0.18). The site of relapse is discussed in detail in the text. There were five treatment-related deaths; three patients died of acute myelogenous leukemia. Our data do not support the role of whole-lung prophylactic irradiation or initial combined radiotherapy and chemotherapy in patients with large mediastinal masses.

Systemic absorption of conjugated estrogenic cream by the irradiated vagina.

Abstract Previous authors have documented systemic absorption of vaginal estrogenic creams (VEC) in nonirradiated postmenopausal women. Our present study demonstrates that postmenopausal women who have received pelvic irradiation for carcinoma of the uterine cervix absorb a conjugated equine estrogenic vaginal cream (Premarin) comparably to nonirradiated controls. Postabsorptive plasma elevations of estrone and estradiol are sufficient to cause depression of plasma luteinized hormone. Therefore, if systemic estrogen is contraindicated for other medical reasons in postirradiated patients, vaginal cream does not provide safety. On the other hand, if estrogen therapy is deemed necessary, physiological (luteal phase) plasma estrogen levels will develop with either vaginal or oral use. Convenience and patient acceptance might suggest prescribing oral preparations for postirradiation vaginitis. Metabolic conversion products differ according to route of administration. Since controversy prevails as to which estrogen metabolites carry less risk of neoplasia in liver, breast, and endometrium, no preferred type of estrogen preparation nor route of administration can be specified at this time.

Stage I grade III endometrial carcinoma: Evaluation of treatment and recommendations for management

Abstract A review of 36 patients with Stage I Grade III endometrial carcinoma has been presented. Patients were treated with preoperative external beam megavoltage for a total of 5400 rad in 6 weeks, followed by total abdominal hysterectomy and bilateral salpingoorophorectomy 6 weeks after completion of irradiation. Fifteen of the 36 patients have died or have disseminated disease at present. These 15 patients had large amounts of residual tumor with deep muscle invasion in the resected specimen following the preoperative external beam megavoltage irradiation and hysterectomy. Consideration needs to be given to the use of adjuvant multiagent chemotherapy for those patients with gross residual disease in the resected specimen, in attempt to improve survival.

Prostate-specific antigen—all that rises is not refractory

After the initiation of androgen suppression in men with prostate cancer, the serum prostate-specific antigen (PSA) level generally declines. A subsequent PSA rise during that suppression usually reflects the presence of a significant component of hormonally refractory prostate cancer. We report a patient with a rising PSA level and elevated testosterone level after depot leuprolide in whom the PSA level subsequently declined with administration of bicalutamide.

Radiotherapy Planning for Simulation of Prostate Cancer: Computerized Tomographic Scanning vs. Conventional Radiographic Localization

A computerized tomographic localization protocol for prostate cancer treatment planning is described. In 23 patients, this new method is compared to localization using conventional orthogonal radiographic simulation with contrast media in the rectum, bladder, and urethra. Advantages of the CT localization protocol include enhanced ability to delineate the tumor extension, particularly for superior, lateral, anterior, and posterior spread. Accurate CT localization of the inferior border of the target volume has also been demonstrated to be feasible, thereby avoiding the need for invasive urethral, bladder, and rectal manipulations.

Vocal Cord Carcinoma-Reply

In Reply. —We realize that our approach to in situ vocal cord carcinoma (VCC) is controversial, and we did not intend at this time to imply strong advocacy of a watchful waiting policy outside the confines of a research setting. The main purpose of our article was to present data—gathered from patients with VCC who were supervised by one group of physicians within a controlled environment—to illuminate the natural course of in situ laryngeal carcinoma and to note advantages and disadvantages of both the immediate treatment and watchful waiting approaches. We did not discuss psychological issues in the original article, however. Anyone who deals with patients can appreciate the great psychosocial difficulties inherent in leaving noninvasive lesions untreated after the referring physician has already told the patient that he has cancer. It is certainly less stressful for the physician—and for the patient—to engage in immediate, definitive therapy for in situ lesions. We