Harvey A. Gilbert

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.

The Natural History of Papillary Transitional Cell Carcinoma of the Bladder and its Treatment in an Unselected Population on the Basis of Histologic Grading

Between 1950 and 1965, 365 patients were treated for transitional cancer of the bladder at our hospitals. A retrospective study was done, using clinical records and a histopathologic review to determine the long-term natural history of this population when treated conservatively. The natural history of 3 separate patient populations was discovered, based solely on the grading of the transurethrally resected fragments. Based on the grade on initial presentation these patients were divided into grades I, II and III. Of the patients 5 per cent in grade I, 16 per cent in grade II, 28 to 35 per cent in grade III not involving muscle and 83 per cent in grade III involving muscle died of bladder cancer. Ninety-seven patients (26 per cent) died of bladder cancer, 110 (31 per cent) died of other causes and 158 (43 per cent) have been alive more than 5 years (104 more than 10 years). Grade I tumors that progressed to a higher grade did so within 2 years of the initial diagnosis. Of the bladder cancer deaths 83 per cent occurred within 2 years of the initial diagnosis. Of 64 patients dying more than 5 years after presentation only 7 died of bladder cancer.

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.

Recurrences from malignant parotid salivary gland tumors

The clinical course of 130 patients treated for malignant parotid tumors at the three institutions have been reviewed. Fifty‐six of these 130 patients developed recurrences following their primary treatment by a surgical procedure. There were a total of 109 recurrences among these 56 patients. The average number of recurrences was two per patient. The average survival from first recurrence was 3.7 years, with the median survival 2 years. The range of survival was 0.5 to 17 years. Once recurrence developed, treatment was by surgery, radiation therapy, chemotherapy, or a combination. Of 56 patients with recurrence, 33 are dead and 9 patients are alive with disease. Fourteen patients are alive and well with no evidence of disease. These NED patients had an average number of 1.6 recurrences and a median survival to date of only 3 years. Our study indicates that for the majority of patients who develop recurrence, survival is relatively short and treatment is usually ineffective in three of four patients. The authors conclude that after a surgical procedure for malignant salivary gland tumors, a trial of wide field postoperative radiation therapy to high dose should be considered as part of the initial treatment.

A clinical appraisal of post‐irradiation biopsy in prostatic cancer

Twenty patients with adenocarcinoma of the prostate were reviewed clinically and by serial biopsy to demonstrate the spectrum of difficulties encountered. Only three patients recurred locally during their lifetime. In spite of positive biopsies, 17/20 patients had negative clinical exams at 2–7 years. Deaths were mainly secondary to disseminated disease. There is yet no good correlation between clinical evaluation and the biopsy response pattern. The significance of no residual tumor or fibrosis with scattered tumor nests on post‐irradiation biopsies has yet to be defined.

Radiation Damage to the Nervous System: a delayed therapeutic hazard

This volume represents a good overview of an important issue - late effects of radiation on the nervous system, a topic of interest to everybody who deals with neurooncologic problems. The book is well edited and includes almost all relevant subjects ranging from diagnostic and dosimetric considerations to treatment of radiation brain necrosis.

A new staging system for irradiation injuries following treatment for cancer of the cervix uteri

Abstract Four hundred six patients have been reviewed following radiation therapy for carcinoma of the cervix. The classification of radiation injuries is variable from institution to institution. Some classify injuries as early and late; others, acute and chronic. The grading of injuries usually depends on organ orientation. This is not helpful since the morbidity depends on the extent of surgery needed to correct the injury. This paper consists of a report of the number of injuries in our series, related to the stage of cancer, radiation dosage, recurrences, performance status, and survival. A staging system for irradiation injuries is proposed which has been helpful to us in analyzing and documenting our injuries more precisely. In addition, an analysis is made of the response of 100 surviving patients to a questionnaire regarding the effect of the cancer and treatment on the personal life and relationships of the patient to family, husband, and friends.

The detection of occult metastases with imaging studies

The detection of occult metastases from radionuclide and roentgenographic imaging studies is not optimum. Tables l-5 contrast the incidence of metastases in bone, lung, liver and brain with that found at post-mortem examination. The postmortem incidence of metastasis gives a guide to the highest estimate of possible metastasis at the time of diagnosis. 3.6,9.10.11,1-18.20.21,2&27 Cancer of the liver, esophagus, stomach and pancreas are excluded from this analysis because patients with these cancers survive less than 1 year, despite treatment. The apparent futility of our standard imaging studies to demonstrate occult metastatic disease at diagnosis was shown in a series of operable patients with cancer of the lung who died of intercurrent disease. Postmortem examination showed an unsuspected high incidence of metastatic disease despite an extensive pre-operative investigation.14 Thus far we have been concerned with the problem of underdiagnosing occult metastatic disease. There are also problems with overdiagnosing metastatic disease. Liver scanning is quite nonspecific. Findings that increase the possibility of detecting metastatic disease on liver scans are hepatomegaly, more than two abnormal liver function tests, and focal rather than diffuse abnormality on the liver scan. Hepatic arteriography adds little to the evaiuation of metastatic liver disease. Some conditions which produce abnormal liver scans can mimic metastatic disease, i.e., cirrhosis, benign tumors, large kidneys, supradiaphragmatic abscess and gallbladder fossa variationS.~.z.lz

Recurrence patterns in the non-seminomatous germinal testicular tumors

Abstract The authors have evaluated 80 consecutive patients with non-seminomatous testes tumor by studying local recurrence patterns in both surgical and irradiated regions to judge the relative effectiveness of these therapeutic modalities. Employing this analysis, there were 6 patients of 32 failures in the N0, N1–N2, N3 and N4 categories who migbt have benefited by more intensive irradiation to nodal areas because of a failure to disseminate in less than 1 year. In the N1–N2 patients, 12 of 14 successes were in the 3500–4500 rad region. Recommendations for treatment are as follows: 1. 1. Patients with negative nodes (N0) require adequate retroperitoneal node dissection alone. 2. 2. Patients with resectable histologically involved nodes (N1–N2) should probably receive post-operative radiotherapy to the involved retroperitoneal region with doses of 5000–5500 rad. 3. 3. Unresectable retroperitonal lymph node disease (N3) probably requires a systemic approach with localized irradiation administered to the involved nodes only. 4. 4. Patients presenting with supradipharagmatic disease (N4 or M1b & M1c) have disseminated tumor and radiotherapy is used for palliation of local masses not controlled by chemotherapy. 5. 5. Prophylactic mediastinal irradiation is not routinely indicated in any stage of the disease.

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.