Ferdinand A. Salzman

Single-dose electron beam irradiation in treatment and prevention of keloids and hypertrophic scars

Low megavolt electron beam irradiation was used on 354 sites in 199 patients at the Lahey Clinic either for palliation of symptomatic hypertrophic scars or as post-operative irradiation in an attempt to prevent formation or recurrence of hypertrophic scars. Electron energies used ranged from 1.5 to 3.5 MeV. The median age of the 59 male patients was 22 years and of the 140 female patients, 35 years. All patients had at least one follow-up visit, and the median follow-up was 35 months. Of the 294 sites treated for the first time, 272 (93%) were irradiated with a single fraction with a skin dose ranging from 2 to 20 Gy. Of the 85 sites in 63 patients without excision of symptomatic hypertrophic scars, single-dose electron beam irradiation was of clinically significant value in only 41 sites (48%). No patients have been treated without surgical excision since 1973. Because of a history of formation of hypertrophic scars elsewhere in the body, 13 patients with 19 incisions were treated prophylactically after operation for other diseases. All sites were irradiated with single doses ranging from 8 to 20 Gy, and hypertrophic scars did not subsequently develop in any patient. Altogether, 119 patients with 174 sites were irradiated after surgical excision of hypertrophic scars to prevent recurrence; 168 sites (97%) received single-fraction irradiation, and 161 received a dose of 8 Gy or greater, up to 15 Gy. No statistically significant differences were observed in complete success rates, ranging from 82 to 90% with doses of 9 Gy or greater.(ABSTRACT TRUNCATED AT 250 WORDS)

Radiotherapy for Kaposi's sarcoma

Between 1954 and 1976, 60 patients with Kaposis sarcoma were treated in the Department of Radiotherapy of the Lahey Clinic Foundation at the High Voltage Research Laboratory of Massachusetts Institute of Technology. Only 2 patients were free of clinical disease in the lower extremities at the time of initial presentation, and 40 patients (69%) had cutaneous lesions involving areas extending above the knees. Eight patients (13%) also presented with mucous membrane involvement in addition to skin disease.

Synchronous Field Shaping and Protection in 2-Million-Volt Rotational Therapy

This presentation is concerned primarily with certain irradiation technics evolved over the past eleven years of clinical radiotherapeutic experience with the 2-million-volt Van de Graaff electrostatic x-ray generator. Field shaping may be considered to have two objectives: that of conforming the shape of the beam of radiation to the known tumor volume and its possible extension and that of protecting adjacent normal areas by exclusion from the beam. In the absence of motion between patient and beam, the field may be given any desired shape depending upon the clinical problem and the philosophy of the radiotherapist. Accessory protective devices in such stationary-field therapy are usually modifications in the outline or dose distribution of the original field. Applied to 360° rotation of the patient, a fixed field is usually considered as necessarily symmetrical about the axis of rotation. The use of an accessory protective device in this situation requires in general that it also be shaped and rotate. T...

Rebound response after estrogen therapy for metastatic breast cancer.

The estrogen rebound response in metastatic breast cancer has been reported in the past as a rare and short‐lived phenomenon, not clearly associated with any aspect of the patients clinical profile. In this series, 25% of patients responding to estrogen therapy had a further response when they no longer received the hormone. The median duration of this palliation was a minimum of 18 months and was similar to that of the initial estrogen response. Patients with a rebound response had significantly longer disease‐free intervals before estrogen therapy and estrogen remissions than those who did not have a rebound response. These clinical factors may, therefore, be helpful in predicting the chances of a rebound response in any given patient. It is urged that patients be observed for objective improvement without therapy upon escape from estrogen palliation. Further palliative therapy should not be offered until definite progression of disease has been documented after any rebound response that occurs.

The Intravenous Cholangiographic Diagnosis of Partial Obstruction of the Common Bile Duct

IN AN ATTEMPT to evaluate the role of intravenous cholangiography in the diagnosis of partial obstruction of the common bile duct, to determine the relationship of common duct size to partial obstructions of the duct, and to establish criteria for roentgenographic diagnosis, we have reviewed our experiences of the past two and one-half years. Since a significant number of postcholecystectomy patients either exhibit the same symptoms as before operation or develop new symptoms, the problem is worthy of attention. The implications are: (a) that the gallbladder disease was not responsible for the precholecystectomy complaints, (b) that the surgical procedure was incomplete and should have gone beyond simple removal of the gallbladder and at times beyond removal of common duct calculi, or (c) that mechanical or inflammatory injury to the common bile duct may have taken place at the time of or shortly after cholecystectomy. Walters (1) in 1956, was of the opinion that the most frequent causes of pain after cho...

Megavolt Electron Irradiation for Localized Mycosis Fungoides

A retrospective analysis was carried out to evaluate the effectiveness of small field megavolt electron irradiation for localized mycosis fungoides. Only local field electron beam therapy was employed for limited disease reserving total skin electron irradiation for multiple lesions or diffuse disease covering at least 25 per cent of the entire body surface. Of the 14 patients with limited disease treated between 1964 and 1973 with the local field technique, 10 patients (71 per cent) are alive without evidence of disease at a minimum of 5 years. In contrast, of 200 patients with extensive cutaneous disease who received total skin electron irradiation, only 16 (8 per cent) were considered cured. It is concluded that early localized mycosis fungoides is potentially curable, and that limited field electron beam therapy with a relatively low total dose is adequate to obtain excellent response.

Field Shaping and Selective Protection in Megavolt Radiation Therapy

The availability of intense sources of megavolt radiation makes possible the treatment of regional as well as localized disease with more adequate doses. These new capabilities are often best exploited by the use of large treatment fields, carefully shaped to include known tumor and local extensions and to exclude uninvolved regions. This procedure results in a more uniform dose distribution and reduces the problems of overlap inherent in the multiple field approach. Field shaping, or field outline control, is accomplished by interposing sufficient thickness of absorbing material into the beam cross section. In addition, the beam may be intensity-modulated by filters to adjust for variations in the anatomical thickness. In our megavolt x-ray equipment a light-beam localizer is used to facilitate the placing of such absorbers and filters. Double-exposure radiographs are taken to confirm and record the field location and the position of these absorbers. Fields of typical shape used in both rotational and op...

A Multidisciplined Approach for the Treatment of Metastatic Carcinoma of the Breast: A Review of Five Years' Experience

We have reviewed our experience in a multidisciplined breast cancer clinic where we have utilized hormonal, ablative, and chemotherapetuci modalities. Our experience seesm to be similar to that of other groups in that oophorectomy treatment produces approximately a 61 per cent response (regression and arrest) rate, androgen therapy produces a 47 per cent response (regression and arrest) rate estrogen therapy produces a 40 per cent response (regression and arrest) rate, and ablative treatment produces approximately a 50 per cent response (regression and arrest) rate. Adrenalectomy and hypophysectomy showed similar response rates. Until it can be shown that hypophysectomy clearly offers enhanced benefits, this will not be utilized by our group except in those patients who cannot tolerate abdominal surgery (that is, patients with poor pulmonary reserve). Of interest is the high response rate (65 per cent) to ablative treatment in patients in whom disease exacerbates on additive hormonal treatment, with an increased duration of response and survival. Survival is increased in patients who are rebound responders after estrogen withdrawal. We expect to report data with future follow-up of this group of patients. New protocols will be instituted after review of the data in the hope of increasing clinical benefit and survival in this group of patients. Carcinoma of the breast accounts for almost 90,000 new cases of cancer a year, with metastases eventually developing in at least half of these patients. All physicians must be aware of the many complex problems associated with this disease and, hopefully, arrive at a logical approach for its control. We believe this can be achieved with a multidisciplined group approach as established at the Lahey Clinic Foundation.

Megavolt Electron Irradiation in the Treatment of Recurrent Carcinoma of the Breast on the Chest Wall

Low megavolt electron beam therapy was used to treat 68 women and one man with recurrent carcinoma of the breast on the chest wall. Photon irradiation had been used previously in 53 patients. Of the 63 patients who survived 2 months or longer after electron irradiation, 59 (94%) achieved a complete response. Persistent radiation ulcers developed in only 2 patients (3%). No other late radiation complications were observed. Nineteen patients (28%) survived 3 years after electron irradiation, with a median survival of 54 months. In this group, disease eventually recurred in all patients who received a calculated NSD of less than 1 400 ret; no disease recurred in the patients who received doses greater than 1 400 ret. It is concluded that megavolt electron irradiation is effective in the treatment of chest wall recurrence from carcinoma of the breast and is safe even in patients who have had a previous course of photon irradiation.

Clinical Safety in Low-Megavolt Electron Therapy

Low-megavolt electrons produced by accelerators offer clinical advantages over low-energy x rays in that they can be used to treat large-area superficial tumors and they yield more favorable dose distributions in depth. In electron therapy it is also important that special precautions be taken to eliminate the chance of an overdose, since the electron dose rates can be extraordinarily high. The accompanying x-ray background, which results in whole-body irradiation, should be kept below an average dose of 20 rads for a treatment series to avoid the production of irreversible blood changes. Electron therapy planning must take into account the gram rad dose due to both electrons and x rays (1). These considerations tend to limit the maximum electron energy used for total skin surface area treatment. In the low-megavolt energy range, the x-ray production efficiency increases in the forward direction approximately as the cube of the electron energy and directly with the atomic number of the material. The accom...