T. Chung

Controversy in the management of optic nerve glioma

The records of 16 patients with optic nerve glioma treated between 1961 and 1984 were reviewed. All patients except two had extension of tumor beyond the chiasm to the hypothalamus, adjacent brain and/or along the posterior optic tract. Eleven of 16 cases were biopsy‐proven, two patients had craniotomy and visual inspection but no biopsy was performed, and in two cases the biopsy was not diagnostic.

External beam radiotherapy for carcinoma of the prostate

Five hundred nineteen patients with prostate cancer were seen in the Radiation Oncology Division of the State University of New York (SUNY) Health Science Center, Syracuse, New York, between 1969 and 1981. The results for the 239 patients treated with radical intent are reported here. All patients received 60 to 70 Gy to the prostate with megavoltage beam irradiation; 142 with a small field (10 × 10 cm) 360° rotational technique for Stage A, B, or C disease and 69 with a four‐field pelvic brick technique (followed by a boost to the prostate) for Stage A through C and Dl disease. Twenty‐eight patients were treated postoperatively for residual disease after radical prostatectomy or for recurrent tumor. The minimum follow‐up time was 5 years. Actuarial 5‐year and 7‐year survival rates for Stage A (n = 34), B (n = 100), C (n = 63), and Dl (n = 14) were 91% and 76%, 86% and 75%, 67% and 40%, and 46% and 36%, respectively. The corresponding 5‐year and 7‐year relapse‐free survival rates were 72% and 65%, 77% and 60%, 46% and 28%, and 38% and 25%. The local tumor control rates at 5 years were 91%, 85%, 77%, and 62% for Stage A, B, C, and Dl, respectively. In our experience, there was no significant difference in relapse‐free survival rates for patients who underwent transurethral resection (TURP) versus those who did not (67% versus 78% for Stage B [P > 0.25] and 38% versus 47% for Stage C [P > 0.25], respectively). Also there was no significant difference in relapse‐free survival rates between large and small field techniques (64% versus 77% for Stage B [P > 0.25] and 56% versus 41% for Stage C [P > 0.25], respectively). The 5‐year and 7‐year actuarial survival rates were 90% and 71%, respectively, for the 15 patients with residual tumor and 58% and 33%, respectively, for the 13 patients treated for postprostatectomy recurrence. Severe complications were documented in only nine patients (3.7%) and mild to moderate complications in 53 patients (22%). Larger fields did not cause a higher rate of complications, although small fields were tolerated better than large fields; the significant acute reaction rate was 27% for large field techniques versus 11% for small field techniques [P > 0.01]. These results confirm that external beam irradiation is an effective treatment for prostate cancer.

Resection and Permanent I-125 Brachytherapy Without Whole Brain Irradiation for Solitary Brain Metastasis from Non-small Cell Lung Carcinoma

We assessed a treatment plan of local therapy (resection and placement of permanent low dose-rate I-125 seeds) without whole brain irradiation in 15 patients with solitary brain metastasis (SBM) from primary non-small cell lung cancer between January, 1991 and May, 1996. Thirteen lesions were confirmed as solitary by MRI scan, and 2 patients had CT scan only.With median follow up of 14 months, 3 patients remain alive at 6, 33, and 62 months post-resection. Median survival is 14 months for all patients and 26 months for patients with SBM as the only site of disease. Five tumors failed in the brain: 2 solitary recurrences adjacent to the site of SBM, 2 multiple metastases outside the primary site, and 1 multiple recurrence including the primary site. No failures were seen with SBM <2.5 cm. Only 2 of 13 patients with SBM confirmed with MRI experienced relapses elsewhere in the brain. Recurrence rates both adjacent and outside the area of the initial brain lesion are similar to studies employing resection plus whole brain irradiation (WBI), and the patient is spared the acute and potential late toxicity of WBI. This approach may be considered for selected patients with solitary brain metastases (SBMs), although further experience with larger patient numbers is needed.

Carcinoma of the anterior tongue.

We have reviewed 126 patients with squamous cell carcinoma of the anterior tongue. Our experience suggests that carcinoma of the anterior tongue is a highly aggressive disease. It is no less aggressive and dangerous than carcinoma of the posterior tongue. The clinically negative neck is a problem. Many clinical stage I and II cancers are, in fact, stage III when analyzed by the pathologist. This difficulty in clinical staging results in a significant management problem when stage III carcinomas are treated as stage I and stage II disease. Management, if it is to cure, must be aggressive. An adequate, wide surgical resection will control early carcinoma of the anterior tongue. Advanced cancers of the anterior tongue, clinical stages III and IV, should be widely excised; the cervical lymph nodes on the side of the primary lesion must be treated by surgery and radiation therapy. Treatment of the opposite side of the neck is indicated based on a high rate of metastases to contralateral lymph nodes in this series. Those patients treated with irradiation who had recurrence did so predominantly at the primary site of disease. Patients treated surgically tended to have recurrence in the regional cervical lymphatics.

Treatment results of combined high-dose preoperative radiotherapy and surgery for oropharyngeal cancer.

Fifty‐eight patients receiving planned high‐dose preoperative radiotherapy followed by en bloc oro‐mandibular‐cervical resection for oropharyngeal cancer were reviewed. These patients received continued close observation and care from both the Otolaryngology and Radiotherapy services. In light of the ongoing controversy of preoperative vs. postoperative radiotherapy, we present our data demonstrating the value of preoperative radiation.

Use of computerized axial tomography of the head and neck region

The use of the computerized axial tomography has been well received in the field of otolaryngology. Five cases are presented illustrating the capability of the total body scanner (Delta scanner) to contribute to radiologie diagnosis below the level of the base of the skull. The advantages of non‐invasibility and three dimensionality are compared to the disadvantages of added cost, added radiation exposure, comparatively long exposure time and relatively poor detail.

Radiotherapy for nasolacrimal tract epithelial cancer

PURPOSE Tumors of the lacrimal sac are rare and have traditionally been treated surgically. We investigated the use of irradiation for treatment. METHODS AND MATERIALS Three consecutive patients with primary epithelial cancer of the nasolacrimal apparatus were treated with irradiation. A tumor dose of 52-66 Gy was delivered with conventional fractionation to fields limited to the primary site and immediately surrounding tissues. RESULTS Local tumor control was achieved in all three patients. Two patients subsequently developed metastatic cervical adenopathy; both were controlled with irradiation to the neck. One of these two died of distant metastases. Two patients are alive and well at 13 years and at 26 months. CONCLUSION We conclude that epithelial lacrimal sac tumors are controllable by radiation therapy and with a good cosmetic result. Poorly differentiated lesions require elective cervical nodal irradiation.

Enhanced apoptosis and radiosensitization by combined 13-CIS-retinoic acid and interferon-α2a; role of RAR-β gene

Abstract Purpose: Combined use of 13- cis -retinoic acid (cRA) and interferon-α2a (IFNα) induced significant radiosensitization in human cervical cancer ME-180 cell line, whereas it failed to achieve similar radiation enhancement in HeLa cells. The differential radiosensitization could be from the difference of retinoic acid receptor (RAR) expression because RAR-β was highly expressed in ME-180 cells in contrast to the HeLa cells where RAR-β was not detectable. We examined the role of this gene in mediating radiosensitization by cRA and IFNα, and explored the mechanism of radiation-induced cell killing. Methods and Materials: Human cervical cancer cell lines, ME-180 and HeLa, were treated with cRA and IFNα followed by radiation. Apoptosis and radiosensitization were quantitated by TUNEL assay ( in situ DNA nick end labeling) and colony-forming ability of surviving cells. The cells were transfected with bcl-2 gene and RAR-β gene to test the role of these genes in mediating radiosensitization and apoptosis. Results: Synergistic radiosensitization and apoptosis was observed by combined use of cRA and IFNα with radiation in ME-180 cells which express high level of RAR-β mRNA, whereas these were not seen in HeLa cells where RAR-β mRNA is not detectable. Both radiosensitization and apoptosis were abolished by bcl-2 gene in ME-180 cells. RAR-β gene transfection induced similar radiation enhancement and apoptosis in HeLa cells. Conclusion: Apoptosis and radiation response were enhanced in the cells with high level of RAR-β mRNA expression. The RAR-β gene appears to mediate the radiation-induced apoptosis by cRA and IFNα. These findings indicate that presence of RAR-β in the cancer cells could be exploited for patient selection in using these drugs for apoptosis and radiosensitization.

Interruption of Combined Therapy: A Factor in Decreased Survival

Occasionally, during the course of combined (radiation plus surgery) treatment of head and neck malignancies, the patient experiences a profound response to radiotherapy alone and elects to decline the second phase of treatment, namely, surgery. After a variable interval, radiotherapy is reinstituted to a “curative” level. A series of 14 laryngeal and oropharyngeal carcinomas, treated in this disjointed fashion, has been examined with respect to long-term survival. The prognosis is extremely unfavorable, thus supporting a basic philosophy of continuing with the prescribed surgical treatment despite a dramatic response to noncancericidal doses of radiotherapy. The site and stage of tumor, radiation dosage, interval to completion of therapy, and incidence of local and distant metastases are examined. It appears that every effort should be made to provide continuity in the combined therapeutic protocol if the advantages of this mode of therapy are to be effective.