Frank A. Beale

Supraglottic laryngeal carcinoma: an analysis of dose-time-volume factors in 410 patients.

Four hundred and ten patients with supraglottic laryngeal carcinoma treated with moderate dose radical radiotherapy with surgery for salvage (RRSS) were analyzed in detail to determine optimal dose-time-volume parameters to be used in the treatment of each stage of supraglottic carcinoma. In the RRSS group 41% are alive and well at 5 years, 38% died of their tumor and 21% of intercurrent disease. Presence or absence of nodal disease has a major impact on survival. Local control is approximately 70% in T1, T2N0 patients and approximately 50% in T3 and T4N0 patients. Seventeen percent of T1 and T2N0 patients failed in the initially negative neck. Ten major complications (2.4%) have been seen. Local control by irradiation was not influenced by dose or field size. Regional control in the initially negative neck was markedly increased with the use of larger irradiation field sizes. Field sizes of less than 7 X 7 cm resulted in an 18% neck failure rate as compared to 3% with larger field sizes (p = 0.00005). This particularly applied to early stage disease. As a result of the use of larger irradiation field sizes giving reduced neck failure rates, improvement in survival has been seen in early stage supraglottic patients. The results are compared with published results. There is no statistically significant dose response curve in any stage of supraglottic cancer over the dose range 1650-2300 ret. Optimal treatment factors for supraglottic cancer are discussed.

Treatment of epithelial carcinoma of the ovary: Operation, irradiation, and chemotherapy

This paper presents an interim analysis of 279 patients with epithelial carcinoma of the ovary who were entered into a prospective study started in April, 1971. One hundred and three patients were available for analysis three years after diagnosis. Apart from the survival differences by stage and treatment method, this study has shown that the completeness of the initial pelvic operation, in Stages II and III, is of greater prognostic importance than the stage. The importance of the features of the pelvic disease which interfere with the removal of all pelvic organs led the authors to conclude that factors other than stage should be considered in prescribing postoperative treatment. To date, the disease-free survival trends in Stages IB, II, and asymptomatic Stage III show that physicians should place much greater emphasis on the initial operative features when they are seeking the most effective combination of irradiation and chemotherapy. Analysis of failures shows that upper abdominal irradiation is more effective than daily chlorambucil in preventing progression of disease to that area. However, early evidence indicates that chlorambucil added to pelvic irradiation improves the control of pelvic disease. Improved methods of treatment have not yet been identified for early Stage I (IA) and advanced presentations (symptomatic Stages III and IV).

Management of advanced glottic cancer a 10 year review of the Toronto experience

Abstract This paper presents a detailed retrospective analysis of all patients with glottic cancer (with the exception of early vocal cord cancer) who were seen at the Princess Margaret Hospital from 1965 through 1974. 358 patients with this diagnosis were seen during this time period; Stage T2N0M0 comprised 46% of the total group, T3N0M0 :25%; 13% had nodal disease and 1.5% had distant disease at presentation. 293 patients were treated with radical radiotherapy; surgery was reserved for salvage of persistent or recurrent disease. The local control rate with radical radiotherapy was 66% for Stage T2N0M0 , 45% for Stage T3N0M0 and 56% for Stage T4N0M0 . 60% of the radiation failures were salvaged by surgery; surgical morbidity was low. The overall tumor control rates for the major stage groupings were 80% for Stage T2N0M0 , 69% for Stage T3N0M0 and 63% for Stage T4N0M0 . Of the survivors 82.5% of Stage T2N0M0 , 65% of Stage T3N0M0 and 90% of Stage T4N0M0 had an intact larynx and natural voice. Essential features of our management policy include moderate (but effective) dose radiotherapy combined with meticulous radiotherapy planning and careful follow-up to identify radiation failures. Our philosophy of treatment and its rationale emphasize preservation of the larynx and natural voice where possible, but without sacrificing survival.

Carcinoma of the tonsil: The effect of dose-time-volume factors on local control

Between 1970 and 1979, 372 patients with squamous cell carcinoma of the tonsil were treated with primary irradiation therapy, with salvage surgery for failures. The median age was 60 years and the male to female ratio was 2:1. The staging system used was the 1974 UICC TNM system. There were 47 T1 lesions (13%), 161 T2 lesions (43%), and 164 T3 lesions (44%). Regional nodes were not palpable in 173 (46%); 122 had N1 nodes (33%), 6 had N2 nodes (2%) and 71 had N3 nodes (19%). All patients received external beam radiation which was supplemented in 68 patients with a radioactive implant for disease into adjacent tongue. The overall survival for all patients was 38% at 5 years and 54% when corrected for intercurrent disease. Local control was 87% for T1 lesions, 68% for T2 lesions and 50% for T3 lesions. Regional control was 96% for N0, 67% for N1 and 37% for N2-3. A detailed dose-time-volume analysis revealed that increasing volume improved local control in T1 and T2 lesions (77% had local control if the volume was greater than 80 cm2 versus 53% if the volume was less than 80 cm2, p = 0.014), except for T3 lesions. Increasing the dose in the range of 5000 to 6500 rad had no significant effect on primary control in any stage of disease. The addition of a radioactive implant did not increase local control if disease extended into the tongue (57% local control if implant, 52% if no implant). This study demonstrates the significance of adequate treatment volume in local control for carcinoma of the tonsil. No significant dose response was found and subsequent surgery was not compromised when a moderate dose of radiation was used.

Whole abdominal irradiation by a moving-strip technique for patients with ovarian cancer

Abstract A technique of moving-strip irradiation of the whole abdomen was utilized in a randomized trial for patients with ovarian cancer. Subjects were classified as being in stages III, II and III and a bilateral salpingo-oophorectomy and hysterectomy had been completed. With regards both to 5-year survival and control of occult upper abdominal metastases, abdominopelvic irradiation using this technique was significantly better than pelvic irradiation alone or followed by chlorambucil therapy. The essential features of the technique used are (1) Therapy began with pelvic irradiation 2250 rad in 10 fractions followed immediately by a downward moving-strip that encompassed the entire abdomen and pelvis. (2) The dose to the moving-strip was 2250 rad in 10 fractions. (3) The superior border was placed above the diaphragm. This was confirmed on a radiograph taken in expiration. (4) No liver shielding was used. (5) Posterior renal shielding was used throughout (5-half value layer (HVL)). (6) The patients were treated while in a prone position; two fields were treated per day, using an isocentric technique. Serious or symptomatic late complications were rare and were amply justified by a survival gain of approximately 30%.

Carcinoma of the hypopharynx results of primary radical radiation therapy

The results of radiation therapy as applied to patients with squamous cell carcinoma of the hypopharynx seen during the period 1972-1976 at the Princess Margaret Hospital are presented. Approximately 2/3 of the patient population presented with disease involving the regional lymph nodes or with systemic metastases. Ninety percent (127/141) of all patients registered were treated primarily with radiation therapy with surgery reserved for the management of residual or recurrent disease only. Seventy-seven percent (98/127) of those who received radiation therapy were treated with radical intent. The uncorrected actuarial 5 year survival rate for those patients treated radically was 19%. Five year actuarial survival rates by the UICC TNM (1974) staging system, showed that nodal disease was the most significant determinant of survival. Five year survival rates were as follows: N0 36%; N1 20%; N2N30%. When considered within each nodal category the survival of the combined T1T2 group was not significantly different from the T3 category. Forty-five percent of those patients who failed with local or regional disease had an attempt at salvage surgery. Of these, 6/24 ultimately achieved local and regional control. Comparisons with other series in the literature are discussed and reasons for differences in published results are considered.

Cancer of the tonsil: Results of radical radiation therapy with surgery in reserve

Three hundred seventy-two patients with squamous cell carcinoma of the tonsil were treated with primary irradiation of curative intent. Surgery was saved for subsequent treatment failure. The overall survival was 38 percent at 5 years. Local control was 63 percent for all patients. T1 and T2 lesions were controlled in 87 percent and 68 percent of patients, respectively, and T3 lesions were controlled in 50 percent of patients. Patients with healthy (N0) nodes and those with mobile nodes had a high degree of regional control, but fixed nodes were controlled in only 37 percent of patients with radiation alone. The most common site of treatment failure was in the primary tumor, which accounted for 45 percent of relapses, and isolated nodal relapses were present in only 24 percent of patients. Subsequent surgery was possible in 47 percent of patients in whom initial treatment failed. A higher degree of subsequent control was obtained with more aggressive surgery compared with simple local resection. There was a high rate of second respiratory tract malignancy, in fact, after 2 years, patients were dying more commonly of their second respiratory tract malignancies than of cancer of the tonsil.