Jeannie J. Kinzie

Brain metastases: results and effects of re-irradiation

Re-irradiation for recurrent manifestations of brain metastases has been reported to be of benefit by either increasing the duration of survival or improving the quality of life. The records of 455 patients with brain metastases treated by radiation therapy at the University of Colorado Health Sciences Center from 1975 through 1986 were reviewed. Of these, 44 patients (9.7%) were re-irradiated because of suggestive neurological findings and/or imaging studies diagnostic of recurrent disease. The primary site distribution was as follows: lung (non-small cell)--15 (34%), lung (small cell)--9 (20%), melanoma--5 (11%), breast--4 (9%), genitourinary--4 (9%), unknown--4 (9%), lymphoma--2 (4%), and endometrium--1 (2%). Retreated patients received at least two courses of irradiation and one received three. The median interval between the first and second courses was 34 weeks (7.8 months). For the initial course of treatment, all patients were treated to the whole-brain with megavoltage X rays to a dose of 30-36 Gy (median 30 Gy) at 1.5 to 4.0 Gy/fraction (median 3.0 Gy/fraction). Retreatment also consisted of whole-brain irradiation (37/42 patients) to additional doses of 6-36 Gy (median 25 Gy) at 2.0 to 4.0 Gy/fraction (median 3.0 Gy/fraction). The total cumulative doses to the brain, therefore, varied from 38-75 Gy with a median of 60 Gy. Survival data were available for 42 of 44 patients retreated. All patients died with disease. The overall median survival following the initial course of irradiation was 40 weeks (9.2 months) with 10 patients (24%) living beyond 1 year. The median survival following retreatment, however, was only 8 weeks with one patient surviving greater than 1 year. Only 12 patients (27%) showed partial neurological improvement with re-irradiation and over one-half (55%) either failed to respond or deteriorated during or soon following retreatment. Brain necropsies were performed in 8 patients. Three of these had developed brain necrosis and two most likely died as a direct consequence. It is concluded that retreatment of brain metastases is seldom worthwhile. Survival is usually short and most importantly, the quality of survival frequently is not improved.

Use of ultrasound to guide radiation boost planning following lumpectomy for carcinoma of the breast

PURPOSE To determine if sonographic localization of the breast lumpectomy site is feasible and useful in boost planning. METHODS AND MATERIALS The operative beds following lumpectomy were localized by ultrasound in 22 patients (15-infiltrating ductal, 7-ductal carcinoma in situ; size: .4-2.0 cm). Twelve patients had two ultrasound examinations on different days for a total of 34 examinations. Twenty-one patients had their course of boost electron therapy planned using ultrasound to guide field placement. While the patient was in the treatment position, the surgical scar was placed at the machines isocenter. With the electron cone in place, the ultrasound transducer was placed within the cone on top of the surgical scar. The biopsy site was localized and the light field maneuvered so that its central axis would follow the axis of the transducer, transecting both the scar and biopsy site. RESULTS The operative bed was highly visible in 26 ultrasound examinations, visible in 7, and subtly visible in 1. Every biopsy site showed some hypoechoic area but most appeared as the mixed hypoechoic pattern. Ultrasound appearances were mixed or mostly hypoechoic (28), anechoic with irregular walls (4), and echoic (hypoechoic compared to parenchyma) (2). In two cases the surgeon placed surgical clips in the operative bed, and in both cases several of these clips could be identified at the margins of the operative bed as hyperechoic foci with shadowing. The mean depth of the operative bed was 21 mm (range 17-36 mm). In 12 patients, two ultrasound examinations were performed on different days, and the mean depth difference between these scans was 2 mm with a range of 0-5 mm. Among patients with two scans we found that both the location and appearance of the operative bed was highly reproducible. CONCLUSION Ultrasound can successfully be used to localize the biopsy site and facilitate boost field placement in patients treated with lumpectomy and radiation.

Spinal cord ependymomas treated with surgery and radiation therapy. A review of 11 cases.

Between 1971 and 1990, 11 patients with primary spinal cord ependymomas were treated with surgery and postoperative irradiation or surgery alone at the University of Colorado Health Sciences Center. Of the 11 patients, 6 (54%) were subclassified with myxopapillary ependymomas that were located in the lumbosacral region of the spinal cord: 2 patients underwent complete resections, 8 had subtotal resections, and 1 had a biopsy only; 8 patients received postoperative irradiation (range: 4,500–5,482 cGy) with 7 of 8 patients treated to involved spinal fields. With a mean follow-up of 7.4 years, 3 patients (27%) have developed recurrent disease, 2 in the combined treatment group, and 1 in the surgery alone group. The 5− and 10-year actuarial survival rates were 100% and 80%, respectively. Eight of nine patients (89%) demonstrated clinical improvement after postoperative irradiation which suggests that the irradiation may have contributed to the improvement. The present study supports the long-term survival of patients with spinal cord ependymomas. Results from this series and a review of the literature indicate that complete surgical resection is only possible in about one-quarter of cases. Local spinal irradiation should continue to be utilized when surgery is incomplete.

Survival results in adult patients treated for medulloblastoma

The records of all 27 adult patients (age, ≤ 16 years) diagnosed with cerebellar medulloblastoma between 1968 and 1986 were reviewed. Twenty‐four patients (89%) were treated with postoperative megavoltage irradiation. Twenty of these patients underwent craniospinal irradiation. Sixteen patients received greater than 5000 cGy to the posterior fossa (range, 2340 to 6600 cGy; median, 5490 cGy). Forty‐eight percent of patients also received adjuvant chemotherapy. A 5‐year and 10‐year actuarial survival rate of 48% was achieved. The use of adjuvant chemotherapy did not improve survival in this series. All relapses occurred within 35 months of diagnosis (median time to relapse, 23.5 months), except one patient who had a recurrence in the posterior fossa at 140 months. The posterior fossa was the most common site of treatment failure and represented 50% of all initial relapses. All survivors had no sequelae, except one in whom leukoen‐cephalopathy developed after craniospinal irradiation and intrathecal methotrexate administration. The survival results obtained in this series compare favorably with other reported modern adult medulloblastoma series.

Response to radiotherapy of head and neck tumors in AIDS patients

Initial manifestations of AIDS in the head and neck area occur frequently. In fact, up to 40 percent of patients may have involvement of the head and neck. The most common malignancies are Kaposis sarcoma and non-Hodgkins lymphoma. Since AIDS-related malignancies are a relatively new problem for radiation oncologists, optimal therapy for these neoplasms is unknown. A retrospective review of AIDS patients treated with radiotherapy has been performed. Fourteen patients were identified. Of these, five were treated for head and neck tumors (four for Kaposis sarcoma and one for non-Hodgkins lymphoma). Epidemic Kaposis sarcoma, as well as non-Hodgkins lymphoma, were seen to be as radioresponsive as the classical forms, but local control was difficult to achieve. Kaposis sarcoma tended to recur marginally and within the field. Nonetheless, we believe radiotherapy can offer significant palliation for AIDS patients with head and neck tumors. It is of utmost importance that the head and neck surgeon must be acutely aware of the common patterns of presentation of this disease.

Aids-related non-hodgkin's lymphoma: The outcome and efficacy of radiation therapy☆

The records of all 16 patients with AIDS-related lymphoma treated with radiation therapy at our institutions were reviewed. All patients were male with a median age of 32 years, and all but one had biopsy proven high-grade NHL. Eleven had lymphoma involving the central nervous system and five had lymphoma involving other sites. Seven of the 11 patients with CNS involvement had primary CNS lymphoma. All patients were treated with megavoltage X rays to doses ranging from 1050 cGy in 1 1/2 weeks to 5037 cGy in 6 weeks. Of those patients with CNS lymphoma, only one responded completely and four responded partially to irradiation. All patients died within a range of 0.2 to 5.3 months (median survival = 2.2 months) from starting radiation therapy. In contrast, 3 of 5 patients (60%) with NHL outside the CNS responded completely and 1 responded partially to involved-field irradiation. These patients survived a median of 12.6 months with one achieving long-term lymphoma-free survival at 40 months. This long-term survivor presented with Stage IE lymphoma as his only manifestation of AIDS. We conclude that AIDS-related lymphomas respond less favorably to radiation therapy than lymphomas in non-immunosuppressed patients. Furthermore, CNS lymphomatous involvement is an ominous occurrence in the AIDS patient. In our experience, cranial irradiation failed to provide significant palliation or survival prolongation in this group of patients. Instead, long-term survival is possible in AIDS patients with limited NHL outside the CNS, and it is in these patients that combination chemotherapy plus involved-field radiation therapy may play a curative role.

Treatment-related central nervous system toxicity: MR imaging evaluation with CT and clinical correlation

Thirteen patients with abnormal brain MR scans attributable to treatment-induced injury were retrospectively reviewed. All patients were treated with radiation therapy and 62% received chemotherapy. Five patients were graded as having severe white matter (WM) changes, four had moderate WM changes, and four had mild WM changes. CT was generally equivalent to MR in evaluation of severe and moderate WM abnormalities, whereas MR was superior to CT in detection of mild WM abnormalities. In general, the severity of changes depicted by MR/CT correlated with the extent of neurologic dysfunction. The most severe changes were seen in those patients treated with combination irradiation and chemotherapy.