Hipolito Poussin-Rosillo

Once weekly total and subtotal skin electron beam therapy for kaposi's sarcoma

Although Kaposis sarcoma (KS) usually appears with solitary skin lesions, in a large percentage of these patients the disease progresses eventually to involve large extensive segments of the skin. In the past, the most frequently used approach is the irradiation of isolated lesions as they arose, hence the so‐called “chasing technique.” Since 1971, a technique of once weekly total skin electron beam therapy (TSEB) has been employed at Memorial Hospital for mycosis fungoides and other cutaneous malignancies involving large areas of the body. Four hundred rads once weekly for six to eight consecutive weeks are delivered to the entire skin surface by employing a 3.5 MeV electron beam. Twenty patients with KS treated by this technique have been followed for 12–98 months, median 48 months. Overall response is 100%; 17/20 (85%) obtained complete remission lasting 10–92 months (median 48 months).

Prognosticators in recurrent breast cancer. A 15-year experience with irradiation.

After initial surgery, 133 breast cancer patients, who did not receive postoperative radiation or chemotherapy, were subsequently irradiated for recurrences in the Department of Radiation Oncology, University of Maryland Hospital. All patients have been followed for a minimum of 5 years after the treatment of recurrences. An extensive analysis was done in search of prognosticators for outcome in recurrent breast cancer. Traditional prognostic factors, such as the initial axillary status, primary surgical procedure, initial menopausal status, time and site of recurrences, distant metastases and radiation dose and field issues, were investigated. No correlation was found between the initial axillary status and the overall prognosis after recurrence. The main prognosticators were: the size of the initial breast tumor, the radiation treatment for recurrences, and the presence of, or time to, distant metastases. Initial T1–T2 breast tumors were associated with a delayed onset of recurrences and a lower incidence of chest wall relapses; in turn, both the latter situations yielded the best outcome. Radiation doses of more than 4000 rad in 4 weeks delivered with locoregional fields achieved a local control rate of 72%, and the best 5‐year postrecurrence survival (57%). In 52% of the recurrent breast cancer patients, distant metastases were discovered; 70% of them occurred within 2 years from recurrence. The overall postrecurrence 5‐year survival for the entire series was 40%. Both the results achieved with radiation therapy and the need for a logical strategy to approach the problem of breast cancer recurrences are discussed. The situation for a large proportion of these patients is not hopeless, and many are salvagable. Combined modality approaches could offer the best possibilities of survival. However, the importance of radiation therapy in the management of these patients cannot be denied or ignored.

Treatment of advanced hodgkin's disease with chemotherapy and irradiation: Controlled trial of two versus three alternating, potentially non-cross-resistant drug combinations

From January 1979 to June 1983, 71 evaluable, previously untreated patients with advanced Hodgkins disease completed a randomized trial of two or three potentially non-cross-resistant drug combinations and low-dose radiotherapy to initially involved nodal regions (2,000 to 3,000 rads). All patients received nine cycles of alternating chemotherapy regimens and radiotherapy between cycles 6 and 7. Thirty-four patients received three combinations: lomustine, melphalan, vindesine (CAD), MOPP, and doxorubicin, bleomycin, vinblastine (ABV). The complete remission rate was 82 percent, partial remission rate 12 percent, and progression rate 6 percent. There were two relapses from complete remission and three deaths. Thirty-seven patients received MOPP and ABV plus dacarbazine (D). The complete remission rate was 78 percent, partial remission rate 16 percent, and progression rate 6 percent, with three relapses from complete remission and five deaths. Myelosuppression was more frequent with CAD/MOPP/ABV/radiotherapy, and nausea and vomiting with MOPP/ABVD/radiotherapy. The results for both are among the best reported, and CAD/MOPP/ABV/radiotherapy was more acceptable to patients.

A prospective randomized trial comparing once-a-week vs daily radiation therapy for locally-advanced, non-metastatic, lung cancer: A preliminary report☆

This is the first report of an on-going Phase III protocol for patients with locally-advanced, non-metastatic, measurable lung cancer. The study randomizes two arms: 6000 rad using 500 rad fractions once a week (1 X W) for 12 weeks with spinal cord (SC) protection at 3000 rad; and 6000 rad using 200 rad fractions daily (5 X W) for 6 weeks with SC protection at 4500 rad. Both arms use an initially large loco-regional field that is further reduced when tumor doses reach 3000 rad in (1 X W) arm and 5000 rad in (5 X W) arm. The protocol was activated April 1982; as of August 1984, it had accrued 100 patients of whom 68 were evaluable [29 (1 X W) and 39 (5 X W)]. There have been no major differences in tumor responses or failure patterns between the (1 X W) and (5 X W) arms; response rates have been 69 and 64%; CR 31 and 20%; total incidence of local failures 20 and 23%; and overall incidence of distant failures 34 and 43%, respectively. The (1 X W) arm has been far better tolerated with 76% of its patients free of any esophagitis and 97% without weight loss, as compared to only 33 and 67% in the (5 X W), respectively. The (1 X W) arm has not conveyed loss in tumor control effectiveness, in-treatment progression, or higher incidence of distant spread. Subacute and chronic complications have been minimal with either treatment. No fatal or life-threatening toxicities have occurred; the incidence of severe complications has been 7% in the (1 X W) arm and 8% in the (5 X W) arm. Nevertheless, the number of patients alive and at risk greater than or equal to 12 months is still relatively small; definitive statements regarding very late toxic reactions cannot yet be made. Compared to their protocyptes [a (1 X W) Pilot Study and the 6000 rad/6 weeks arm of RTOG Protocol 73-01], results in the present protocol arms have not been different from what was expected. Once a week RT yields results that appear no different from those achieved with conventional RT in lung cancer.

Once-a-week vs conventional daily radiation treatment for lung cancer: Final report

This is the final report of a prospective randomized clinical trial which began in 1982 and explored once-a-week hypofractionation in lung cancer patients with unresectable, non-metastatic, measurable, loco-regionally advanced disease. Stratification to this protocol has been done by histology, stage, and performance status categories. Patients with ipsilateral supraclavicular and/or brain metastases as the only evidence of distant spread, have been included in the study, but were stratified and analyzed separately. The two protocol arms were: (I) Conventional daily radiation [5 x W]-5 daily fractions of 2 Gy each to a total dose of 60 Gy in 6 weeks, protecting the spinal (SC) at 45 Gy and (II) Once-a-week radiation [1 x W]-one weekly fraction of 5 Gy each to a total tumor dose of 60 Gy in 12 weeks protecting the SC at 30 Gy. A total of 150 patients have been entered. Of these, 30 pts. are inevaluable, but the reasons of non-compliance, progression of disease or death due to intercurrent disease were of equal incidence in both groups. Of the 120 evaluable patients, 63 were treated 5 x W and 57 with 1 x W therapy. Complete tumor responses are similar in both arms with 1 x W pts demonstrating a numerical advantage (26% vs 17%). The average follow-up of the entire series is 3 yrs with a range of 12-66 months. Survival data is comparable in both groups with the 12 and 24 month actuarial survival of 49% and 23% for the 5 x W arm and 59% and 29% for the 1 x W arm. 1 x W patients continue to show a better tolerance than 5 x W pts. There are sufficient long-term survivors in both arms to assess chronic toxicity. The number of patients alive at 12, 18, and 24 months were 25, 11, and 5 for the 5 x W arm and 29, 16, and 7 for the 1 x W arm. No significant differences in late reactions have been noted. The longest surviving patient in the 1 x W arm is now 48 months after treatment.

Cancer of uterine cervix stage IB: Treatment results and prognostic factors

From 1969 through 1977, 210 patients with Stage IB carcinoma of the uterine cervix were treated at University of Maryland Hospital. Fifty‐six patients were treated by radical hysterectomy (S), 136 patients were treated by a full course of radiation therapy (RT) only and 18 patients received radiation treatment following radical surgery (S + RT). The 5‐year determinate survival rates were almost the same in the S group and RT alone group (79% and 77%, respectively). The 5‐year determinate survival rate in the S + RT group was 50%, which was statistical significantly lower than S alone or RT alone groups (P < 0.05). Several prognostic factors were analyzed in the radiated patients: the size of the primary lesion, location of the lesion within the cervix, tumor grade, age of the patients at the time of diagnosis, and complete blood count nadir during the course of radiation treatment. The only factor found to influence the prognosis was the size of the primary tumor. The patients with smaller tumors had a better prognosis; the absolute and determinate 5‐year survival rates were 80% and 82%, while the absolute and determinate survival rates in the large, fungating tumor replacing the entire cervix were 56% and 60%, respectively (P < 0.001). The complication rate was 22% in the RT alone, 22% in the S + RT, and 25% in the S alone groups.

Palliative half-body irradiation: Single and fractionated doses

SYSTEMIC HALF-BODY IRRADIATION (HBI) has been used extensively for the palliation of cancer pain. It has also been tried as an adjuvant therapy in patients with advanced locoregional tumors with a high propensity to disseminate and as consolidation therapy after primary systemic treatment. The limitations and toxicity of this technique have been studied extensively. Single doses of 600 rad to the upper half-body (UHB) and 800 rad to the lower half-body (LBH) have been found to achieve excellent palliative responses with an acceptable rate of complications.In order to determine the feasibility of increasing the dose of radiation delivered, a pilot study was conducted at the University of Maryland. Forty-four patients received palliative HBI. Of these, the first 36 patients received single doses to the UHB, mid-body (MB), or LHB using doses of 600 rad to the UHB and 800 rad to MB and LHB. The last consecutive eight patients received two fractions of 400 rad each, given 2–3 weeks apart.The pain response achieved by each group is similar; single dose achieved 84% complete and partial responses vs. the fractionated group, which achieved 87% complete and partial responses. The main difference between the two groups was the time necessary to achieve a response. The single dose group achieved improvement of their symptoms in 24–48 hours in approximately 70% of the patients who responded. The fractionated group achieved symptomatic response after the second dose of irradiation was given.The toxicity of both groups was similar. The acute radiation syndrome after half-body irradiation was controlled with a premedication program. Hematological toxicity was similar in both groups, and no cases of fatal radiation pneumonitis were seen. At the present time, it seems feasible to proceed with other fractionation schemes in order to try to increase the total dose delivered.

Subtotal-skin electron-beam therapy once a week for inflammatory breast carcinoma.

Subtotal-skin electron-beam therapy (SSEB) was employed once a week in the treatment of 22 patients with recurrent inflammatory breast carcinoma between 1971 and 1976. The entire upper torso received 400 rad once a week for 6 consecutive weeks, using 3.5-MeV electrons from a 6-MeV linear accelerator. Seventeen patients (77%) obtained complete response and 3 (14%) had partial response, for a total response rate of 91%. Remission lasted for six months or longer in 35% of those exhibiting complete response. Treatments were tolerated well. The authors suggest that this is an excellent palliative method of treating this rapidly progressive disease.