G. Aragón

Chordoma: results of radiation therapy in eighteen patients.

Between 1975 and 1990, eighteen patients with a histologically proven diagnosis of chordoma were treated at our institution. All patients initially underwent a surgical procedure and were referred for irradiation due to residual disease or postsurgical relapse. The mean dose administered was 50.1 Gy (range, 29.9-64.8 Gy). Eight patients were treated according to a hyperfractionated schedule. The overall actuarial 5-year survival and 5-year progression-free survival were 38% and 17%, respectively. The progression-free interval was longer for patients receiving doses greater than 48 Gy when compared with doses below 40 Gy (actuarial 5-year progression-free survival of 31 +/- 35% vs. 0%, respectively; p = 0.04). We conclude that in the treatment of chordoma, the administration of high radiation doses may increase the disease-free interval. The objective response and dose-response relationships were analyzed in twelve patients for whom sequential CT scans were available.

Phase II study of radiochemotherapy with uft and low-dose oral leucovorin in patients with unresectable rectal cancer

PURPOSE To determine the activity and evaluate the toxicity of uracil and tegafur in a 4:1 molar concentration (UFT) plus low-dose leucovorin administered concomitantly with pelvic irradiation in patients with unresectable or recurrent rectal cancer. METHODS AND MATERIALS Thirty-five patients (22 with primary unresectable tumors and 13 with locally recurrent tumors) were enrolled in the trial. Thirty-five patients were evaluable for toxicity and 32 of these were evaluable for clinical response. Patients received 300 mg/m2/day UFT and 30 mg/day leucovorin on days 8-35 concomitantly with pelvic radiotherapy, to a total dose of 45 Gy. RESULTS Eight of the 35 (23%) patients developed Grade 3 diarrhea and were treated with radiotherapy alone after this event. Of the 22 patients with unresectable primary tumors, 17 underwent surgery, and resection was feasible in 15 cases (88%). Of the 32 patients evaluable for clinical response, 4 (13%) had a complete clinical response (CR) and 22 (69%) a partial response (PR). A complete pathologic response was observed in 3 cases (18%) and, a PR in 11 cases (65%). CONCLUSION The response rates achieved with this schedule seem comparable to those obtained with 5-FU and radiotherapy. These results warrant further evaluation of this combination in patients with unresectable or locally advanced tumors.

Conjunctival intraepithelial and invasive squamous cell carcinomas treated with strontium-90

Twenty-seven patients with malignant epithelial tumors of the conjunctiva were treated between 1967 and 1987. Histological diagnosis was intraepithelial epithelioma in 15 cases (56%) and squamous cell carcinoma in 12 (44%). All patients were treated with a strontium-90 source on cup-shaped applicators of different sizes according to the extension of the tumor. Surface dose ranged from 60 Gy in a single treatment to 140 Gy in 7 fractions, depending on the thickness of the lesion. Fifteen patients were previously untreated, 7 were irradiated after some type of surgical treatment and 5 were treated for recurrence after multiple surgical excisions. Follow-up period ranged from 2 to 15 years. No patient died of his tumor. There were four local recurrences, three of them in patients with intraepithelial carcinoma. Two of the recurrences were salvaged with a new beta-ray treatment and the other two with enucleation. Since 1981, standard policy was to irradiate the entire conjunctiva in patients with diagnosis of intraepithelial epithelioma. Five patients developed cataracts. Considering the high primary control rate and minimal morbidity, strontium irradiation should be considered as a first-choice treatment for conjunctival tumors.

Candida Infection of Cerebrospinal Fluid Shunt Devices: Report of Two Cases and Review of the Literature

Summary¶ Use of CSF shunt devices is a common practice in neurosurgery, and infection of the shunt is the most frequent complication. In spite of the fact that bacteria are the most widely implicated pathogens, reports of fungal infections, especially due to Candida sp., have increased in recent years. Their reported frequency ranges between 6% and 17%. Many factors have been implicated in the pathogenesis of Candida meningitis, such as broad spectrum antibiotics used in the treatment of a bacterial meningitis, steroids and indwelling bladder and intravenous catheters. The treatment of Candida meningitis still consists of systemic antifungal agents and removal of the shunt.

Prognostic factors for local control, regional control and survival in oropharyngeal squamous cell carcinoma

We have performed univariate and multivariate analysis to identify the clinical and treatment-related prognostic factors in a series of 254 patients with newly diagnosed, histologically proven, oropharyngeal squamous cell carcinoma treated with radical radiation therapy. The probabilities of local control, regional control, disease-free survival (DFS) and adjusted survival (AS) were calculated using the Kaplan-Meier method and differences between curves were evaluated by the Mantel-Cox test. The obtained significant variables in the univariate analysis were analysed using the Cox proportional hazards model. In the Cox multivariate analysis, four variables significantly influenced local control probability in the following order: tumour diameter, N stage, alcohol intake and weight loss. N stage significantly influenced the probability of regional control. Five variables influenced both DFS and AS: N stage, tumour diameter, weight loss, alcohol intake and tumour origin within the posterior oropharyngeal wall.

Radiation therapy in craniopharyngiomas

Eighteen patients with cranipharyngiomas, who were studied and treated between 1970-1980, are presented. Each patient was treated with surgery and radiotherapy (50-60 Gy). Six patients were treated with radiotherapy because the tumor recurred after surgery. An extensive representation of the clinical symptomatology typical of this tumor was seen. In 3 patients an improvement in visual symptoms was demonstrated; in 11 the headaches and vomiting were controlled after treatment. The 18 treated patients are still alive without evidence of progression of the tumor, after a period of 2 to 12 years. Our experience supports the contention that conservative surgery coupled with radical radiotherapy remains the treatment of choice for the craniopharyngioma.

Intracranial tumors with risk of dissemination in neuroaxis

The experience of the Radiotherapy Service, Clínica Puerta de Hierro, Madrid (Spain), in the treatment of intracranial tumors with risk of neural axis dissemination is analyzed. In 15 years (1964-1979) 415 primary central nervous system tumors were studied and treated; 67 corresponded to tumors with risk of meningeal dissemination. Clinical dissemination in cerebrospinal fluid was proven in 14 patients. The actuarial survival of 10 years for patients with neural axis dissemination, without prophylactic treatment to the neuroaxis, is 14% with an average survival of 10.5 months. In approximately 20% of meduloblastomas, ependymal and pineal region tumors, meningeal metastases at some distance from the primary tumor can take place. Patients at risk wtih these types of neoplasia must be identified, and an adequate radical therapeutic focus devised, not only for the primary tumor, but also for the risk of dissemination.

Salvage brachytherapy and salvage surgery for recurrent oropharyngeal carcinoma following radiotherapy

We reviewed 21 patients who underwent salvage treatment after a biopsy of proven locally recurrent carcinoma of the oropharynx. Two of these patients underwent a second salvage treatment after failure of the first. Treatment was performed with Ir192 interstitial implant in 17 cases (13 rT1 and 4 rT2); by surgery in five cases (3 rT1, 1 rT2, 1 rTx), including two patients who had relapsed after salvage treatment with Ir192 implant; and by hyperfractionated external beam irradiation plus concomitant Tegafur chemotherapy in one case (rT3). The primary tumour was controlled in four of the 17 cases (23 per cent) treated with Ir192 implant. Of these four patients, two remained disease-free 42 and 59 months after treatment, one died of nodal metastases eight months after treatment and another of distant metastases 19 months after treatment. Four of the five cases (80 per cent) treated with surgery, including two patients who relapsed after salvage brachytherapy, remained free from local, regional and distant relapse 21, 25, 31 and 56 months after treatment.

Episcleral iridium-192 wire therapy for choroidal melanomas.

PURPOSE To evaluate the effectivity of high-dose episcleral iridium-192 wires in the treatment of choroidal melanoma. METHODS AND MATERIALS In 1983, the Departments of Radiation Oncology and Ophthalmology at the Clínica Puerta de Hierro, Madrid, Spain, initiated a clinical study using removable episcleral iridium-192 wires in the treatment of choroidal melanoma. Sixty-six evaluable patients were treated from January 1983 through July 1992. Two patients had a small sized tumor (3%), 28 had a medium sized tumor (42%), and 36 patients had a large tumor (54%). The mean follow-up was 40 months (6-118 months). The dose to the apex of the tumor ranged from 66 to 97 Gy (mean 76.6 Gy), and the doses at 2 mm depth ranged from 77 to 433 Gy (mean 200 Gy). RESULTS Tumor regression or stabilization was observed in 53 of the 66 patients (90%). Visual acuity improved following treatment in 5 out of 54 patients (9%), remaining unchanged in 30 out of 54 (56%), and decreased in 19 out of 54 (35%) patients. The remaining seven patients had undergone enucleation. Late complications have been documented in 20 out of 66 patients (30%), including 6 patients in whom enucleation was required because of radiation-related complications. The probability of survival and survival free of local progression was 93% at 5 years and 79% at 10 years. The probability of retaining the treated eye is 82% after the fifth year posttreatment. CONCLUSIONS Treatment of choroidal melanomas with episcleral iridium-192 wires is as effective as treatment with other radioactive applications. We feel that our results using iridium-192 wires are comparable to the other methods. However, we think that our technique is simple to implement, relatively inexpensive, and well tolerated.

Influence of Boost Technique (External Beam Radiotherapy or Brachytherapy) on the Outcome of Patients with Carcinoma of the Base of the Tongue

We reviewed 90 patients with squamous cell carcinoma of the base of the tongue. Fifty-three patients were treated with external beam radiotherapy alone (3 T1, 11 T2, 21 T3, and 18 T4 tumors) and thirty-seven patients were treated with external beam radiotherapy plus brachytherapy boost (4 T1, 15 T2, 11 T3, and 7 T4 tumors). For patients with T1, T2 and T3 primaries, the actuarial 3-year local relapse-free survival was 42% following external beam radiotherapy alone and 67% following external beam radiotherapy plus brachytherapy (p < 0.05). The actuarial 3-year cause specific survival for these T-stages was 37% for patients treated with external beam radiotherapy alone and 53% for patients treated with external beam radiotherapy plus brachytherapy (p = 0.1). In the Cox multivariate analyses restricted patients with T1, T2 and T3 staged tumors, treatment modality was the only predictor for local control but no influence on specific survival was found. The trend towards significant differences in specific survival found in the univariate comparison of both treatment modalities was probably due to the significantly higher number of N-positive patients treated with external beam radiotherapy alone. When all stages were included in the Cox analysis, low hemoglobin level, invasion of deep muscle, number of palpable nodes, and history of weight loss significantly influenced the outcome. Soft tissue necrosis occurred more frequently in patients treated with external beam radiotherapy plus brachytherapy (33% vs. 10%, p = 0.52).