Jerold P. Green

PRIMARY RADIATION THERAPY IN THE TREATMENT OF ANAL CARCINOMA

From 1966 to 1981, 47 patients with a diagnosis of anal carcinoma were irradiated. This group was composed of 23 males and 24 females, with age ranging from 38-84 years (average 64.4 years). The average age of the males was eight years less than the females. Of the 47 patients, 39 had an intact anal canal following biopsy and were treated with curative intent. Thirty-one of these 39 had no evidence of nodal metastasis (N0) and eight had groin, pelvic and/or para-aortic nodal disease. Only three patients were treated with pre-irradiation chemotherapy; all had locally advanced disease. Five patients were treated preoperatively and 34 were treated definitively with cancericidal doses of irradiation. Acute radiation reactions requiring a rest-break were noted in 28% of patients, but all were managed as outpatients without untoward chronic sequelae. Chronic complications were noted in 13 patients, including two patients who required colostomy for severe anal stenosis and two who required A-P resection for large painful ulcers. Two of these four patients had received part of their treatment with an interstitial implant and one had an excessively high dose of perineal irradiation. Twenty-eight of 35 patients (80%) treated with irradiation alone have remained locally controlled without further treatment. An additional four have been salvaged by surgery. Only three patients had interstitial implants as part of their treatment course. Actuarial survival at five years for the N0 patients and the group as a whole are 95.6 and 79.3%, respectively. It is concluded that external beam irradiation alone, properly fractionated to cancericidal doses, can control anal carcinoma with acceptable morbidity rates and without the use of either chemotherapy or interstitial implants in most cases. There is also a strong correlation suggesting that anal intercourse and male homosexuality play a significant role in the etiology of this disease.

Efficacy of radiation therapy alone for limited squamous cell carcinoma of the anal canal

From 1973-1986, thirty-five patients with limited squamous cell carcinoma of the anal canal underwent definitive radiation therapy only. There were twenty females and fifteen males with average ages of 65 and 53 years, respectively. Twelve of the fifteen males were admittedly homosexual. The primary lesions were less than 5 cm in maximum dimension and were confined to the anal canal. Two patients presented with regional adenopathy. Chemotherapy was not used in any case. Treatment plans were individualized but usually included whole pelvis and boost external beam irradiation. The average tumor dose was 6395 cGy (range 4525-7550 cGy). One interstitial Ir-192 implant was performed. Local control was 77% (27/35) following radiation therapy alone. Seven of the eight failures were salvaged surgically, five by abdominoperineal resection and two by local excision, for an overall rate of 97% (34/35). The 5-year actuarial disease-free survival is 92%. Only two patients have disseminated and/or died of neoplasm. Anal continence was retained in 80% (28/35). Early and late complication rates were acceptable.

Anal carcinoma: current therapeutic concepts.

Abstract The generally preferred method of treatment of epidermoid carcinoma of the anus and anorectum has basically been surgical, although there have been instances of cure by radiation therapy alone. Techniques of radiotherapy have greatly improved, permitting high level irradiation to the anorectum while preserving good rectal function. Recent reports of the use of combined surgery and irradiation have shown dramatic results and have begun to change the concept of a strictly surgical approach to this disease. Thirty-eight patients treated by a combined approach in a community hospital setting from 1966 to 1979 were studied. The entire spectrum of epidermoid carcinoma, from highly malignant cloacogenic carcinoma to well differentiated squamous cell carcinoma, is included. Initially all patients had an accurate histologic diagnosis from adequate biopsy material followed by radiation therapy. Adjuvant chemotherapy was not used in this series. Determination of necessary surgical therapy, ranging from local excision to radical abdominoperineal resection, was delayed until maximal effects of irradiation were realized. Gallium scanning proved useful because many of the lesions and their metastases were gallium positive. Results have been excellent, with a high overall cure rate. Many patients subsequently needed little or no further surgery.

Prostatic carcinoma: limited field irradiation

This is a retrospective study of 251 patients with histologically proven adenocarcinoma treated primarily with limited field radiotherapy techniques, under the principle direction of authors JMV and JPG, between 1968 and 1981 in San Francisco, California. All patients are followed for a minimum of 3 years; mean follow-up is 7.3 years. Routine clinical staging procedures included: H&P, digital prostate exam, cystoscopy, biopsy, blood studies including serum acid phosphatase, and imaging studies including chest X ray, IVP, bone survey or radionucleotide bone scan, and in recent years, pelvic CT scans. Twelve patients are Stage A1, 37-Stage A2, 50-Stage B, 140-Stage C1 and 12-Stage C2. Ninety percent of all cases and 85% of Stage C patients were treated with limited fields to the prostate and periprostatic volume only. Total doses were prescribed at midplane or isocenter and were generally 6500-7000 cGy, daily doses of 180-200 cGy, 5 days per week. Actuarial 5- and 10-year survival rates are: entire population-69% and 47%; Stage A1-74% and 50%; Stage A2-81% and 67%; Stage B-84% and 53%; Stage C1-63% and 42%; Stage C2-32% and 11%. The 5- and 10-year disease-free actuarial survivals are: entire population-71% and 50%; Stage A1-89% and 74%; Stage A2-82% and 69%; Stage B-71% and 52%; Stage C1-67% and 44%; Stage C2-0%. Sites of recurrence, alone or as a component of the failure pattern are: 37 (15%) local, 11 (4%) symptomatic regional recurrence (lower extremity edema, pelvic pain/sciatica, hydroureteronephrosis), and 87 (35%) distant metastasis. Seven (3%) had unknown sites of failure. Local-regional failure occurred in 42% of Stage C2 patients. Concomitant hormonal therapy has no survival impact on Stage C1 patients and poorly differentiated histology is associated with decreased determinate and disease-free survival rate of 5 years. Complications correlate with treatment technique, being more frequent with single field per day treatment plans. In patients treated with multiple fields per day or rotational plans, complications occur in less than 8% of patients and major complications have not occurred.

Postirradiation induration as a prognosticator. A retrospective analysis of squamous-cell carcinomas of the oral cavity and oropharynx.

Abstract The authors analyzed retrospectively 49 cases of squamous-cell carcinoma of the oral cavity and oropharynx followed for a minimum of two years after irradiation. There was no correlation between predictability of tumor control by irradiation at the primary site and the presence or absence of residual local induration. The immediate postirradiation clinical assessment of tumor regression in this anatomic site should therefore not be used in making therapeutic decisions or in predicting curability.

Radiotherapeutic management of locally advanced carcinoma of the breast.

Carcinoma of the breast is responsive to irradiation, and we have validated this conclusion by our experience. Considering the advanced stage of the disease presented in this series of 27 cases, we may also conclude that radiation therapy offers a highly successful chance of local as well as regional nodal disease control for long periods of time in the large majority of these unfortunate women. The treatment, when carefully planned and executed, is well tolerated; indeed, it permits post‐irradiation conservative or even radical surgery should the lesion become operable.

Nasopharyngeal Carcinoma: A Study Examining Asian Patients Treated in the United States

1972 to 1991, 126 Asian patients with nasopharyngeal carcinoma underwent definitive radiation therapy for locoregional disease: 86 men, 40 women. Median age was 50. All patients received external-beam irradiation with cobalt 60 or 4–18 MV x-rays. Local recurrence, regional recurrence, and distant metastases were 22%, 11%, and 23%, respectively. Local recurrence progressively increased with increasing T stage, but doses in those who recurred did not differ from the group as a whole. Regional recurrence was not associated with T or N stage or dose. Patients with N2 disease had the highest distant metastatic rate. The 5− and 10-year overall survival rates were 54% and 38%, respectively. Of age, gender, and histology, only age less then 50 was found to be favorably prognostic. No severe long-term complications were observed, and acute reactions were acceptable. Our survival results are comparable with results found both in Asia and North America. Nonetheless, altered fractionation techniques and/or other radiation modalities should be further explored to improve locoregional control.

Phantom Dosimetry Study of Shaped Cobalt-60 Fields in the Treatment of Hodgkin's Disease

In recent years there has been a decided trend among radiation therapists to treat localized Hodgkins disease in an increasingly more radical manner. This has included not only higher doses, but also the use of larger treatment portals. A technic of treating the upper torso has evolved in which all the lymph node-bearing areas of the cervicothoracic region are treated in continuity by a single portal. This is accomplished by interposing appropriately shaped lead blocks in the treatment beam to shield such vital structures as lung and cervical spinal cord. The technic has been referred to as the “cervicothoracic bath” or more commonly as the “mantle.” Although this treatment method is very much in vogue at the present time, there has been little published work pertinent to the dosimetry of such shaped fields. The study reported here was performed to satisfy some misgivings in the calculation of doses with the mantletype field. Materials and Methods The Alderson phantom man used in this study is representa...