John E. Munzenrider

Effect of preoperative irradiation on resectability of colorectal carcinomas

From 1968 to January 1, 1977, 44 patients with initially unresectable colorectal carcinoma were treated with preoperative radiotherapy and surgery. On presentation, unresectability was determined either clinically (26 patients) or by preradiotherapy laparotomy (18 patients). Preoperative irradiation consisted of 4500-5000 rad. After radiotherapy, 33 of 44 lesions were considered resectable. Seven of 33 patients underwent incomplete resection with mean survival of 17 months. Resection was complete in 26 of the 33 patients. Of the latter group (26), 18 patients are alive with no evidence of disease with minimum follow-up of 36 months. Detailed results are discussed.

Use of body scanner in radiotherapy treatment planning.

CT body scans obtained on 98 patients before, during, and after radiotherapy were evaluated for their utility in radiotherapy treatment planning and in follow‐up after radiotherapy. Twenty‐two patients were studied after irradiation. Four received additional treatment, and continuing or planned treatment was withheld from another four on the basis of CT data. Tumor extent was clearly delineated on CT scan in 48/76 cases (63%), suggestive in 25/76 (33%), and not seen in only three (4%). Utilizing CT data relative to all other available tests, in 75 patients, total treatment volume was altered in 34 (45%), tumor coverage was marginal or inadequate in 35 (47%), and volume of normal tissue irradiated was changed in 34 (45%). CT scan data was judged essential for treatment planning in 41, or 55%, of patients studied. Unsuspected areas of tumor involvement were seen in 32 of 75 cases (43%). Use of the CT scan as a patient contour for radiotherapy treatment planning and alternative techniques for inputting the CT data to treatment planning computers are discussed. A simple inexpensive device to accomplish this is described. Speculations are made regarding the impact of CT scanners on transverse axial tomography units and treatment simulators as well as the potential application of the technique in brachytherapy dose computation. Cancer 40:170–179, 1977.

Preoperative irradiation of primarily unresectable colorectal carcinoma.

A series of 44 patients with colorectal carcinomas considered unresectable on presentation received preoperative irradiation to a dose of 4500–5000 rad (175–200 rad/day). After a waiting period averaging 6.5 weeks, 38 patients underwent exploration. Complete resection was possible in 27 patients. Of these, 22 patients remained disease‐free with a median follow‐up of 27 months. While longer follow‐up periods are needed, the results indicate that the large percentage of unresectable and therefore surgically incurable colorectal carcinomas can be made resectable by preoperative irradiation, and a significant number of these may have been cured.

Radical radiation therapy of advanced lung cancer: evaluation of prognostic factors and results of continuous and split course treatment.

One hundred patients with inoperable (80) or unresectable (20) bronchogenic carcinoma without evidence of spread beyond the thorax and supraclavicular nodes were planned for radical radiotherapy. Seventy‐six patients received continuous irradiation (6000 rads in 30 treatments in 6 weeks, TDF 99) and 24 received split course therapy (2 courses of 2500 rads in 10 treatments with a 3 week break between courses, TDF 88). Forty‐three patients had squamous cell carcinoma or adenocarcinoma and were considered to have favorable prognostic factors, while 57 patients had unfavorable prognostic factors: undifferentiated large cell or small cell carcinoma, supraclavicular metastases, SVC obstruction, superior sulcus tumors, or bone erosion in continuity with the tumor. Ninety‐two patients completed the planned course of treatment. In patients completing treatment, local control of cancer within the irradiated volume was achieved in 58.5% of continuously irradiated patients and 45.4% of patients receiving split course therapy. Median survival was 1.2 months in patients not completing treatment and 12 months for the patients who completed treatment; 19% of the total group survived 3 years. Median and 3 year survivals of 14 months and 20.4% and of 9 months and 11% were observed for patients treated continuously and by the split course techniques, respectively. Corresponding survival figures for patients with favorable and unfavorable prognostic signs were 21 months and 26%, and 4 months and 11%, respectively. Implications of these data for treatment planning and patient selection for radical radiotherapy in bronchogenic carcinoma are discussed. Cancer 44:446‐456, 1979.

External irradiation and one radium application for carcinoma of the cervix

Abstract Between August 1968 and May 1976 at the Tufts-New England Medical Center, Boston, Massachusetts, 264 patients with carcinoma of the cervix on intact uteri were treated with external irradiation followed by one radium application. Of these patients, 78 presented with Stage 1,126 with Stage II, 51 with Stage III, and 9 with Stage IV disease. In a majority of patients, external irradiation was given with 60 Co when AP diameter was less than 17 cm, and with a 46 MeV Brown-Boveri Betatron when AP diameter was greater than 17 cm. A whole pelvic dose of 4000 rad was given for tumors smaller than 5 cm in size and 4500 rad for those larger than 5 cm. A dose was then given to the pelvic wall using 4 cm or 5 cm midline blocks. In Stage I disease, tumors of less than 2 cm received no pelvic wall irradiation and tumors greater than 2 cm and Stage HA patients received 1000 rad to both pelvic walls. In Stage IIB and IIIA disease, a dose of 1000 rad was given to the uninvolved pelvic wall and 1500 rad to the involved site. In Stage IIIB disease, after giving 1500 rad to the involved parametria, an additional 500 rad was given with a reduced field to the area of gross tumor in the parametrium. All patients had one radium application for 72 hr 7–14 days after completion of all external irradiation. There were no pelvic failures in Stage I patients, 856 in Stage IIA, 10/70 in Stage IIB, and 1752 in Stage III. The 5 year no evidence of disease (NED) actuarial survival was 100% in early Stage III (less than 1 cm), 90% in Stage III (greater than 1 cm), 79% in Stage IIA, 58% in Stage IIB, 42% in Stage III and 23% in Stage IV. There was no difference in survival or complications between patients who had tandem and colpostats and those who had protruding tandem.

Routine noninvasive hysterography in the evaluation and treatment of endometrial carcinoma

Abstract Hysterography is an important aid in the diagnosis and treatment of endometrial carcinoma. Using a noninvasive technique, no significant complications have occurred in 134 patients. Important information concerning site of origin, size, and extent of the tumor and uterine deformities has been obtained and has altered the treatment in 28% of the cases studied. The importance of having a knowledgeable observer to direct and interpret the study is stressed. The significance of possible transtubal and hematogenous spread is discussed.

Preoperative irradiation for carcinoma of the endometrium: indications and results.

Abstract One hundred thirty patients with carcinoma of the endometrium were treated preoperatively with external irradiation (4000 rad) and radium application (2500 mg/hr or 2000 rad). Criteria for preoperative irradiation included: large uterus [19], signs of myometrial invasion on hysterogram [50], cervical involvement [37], poorly differentiated or anaplastic carcinoma [13], adenosquamous cell carcinoma [10], or squamous cell carcinoma [1]. Hysterography was performed as part of the pretreatment work-up in 93 patients (71%). Diffuse, multiple or single large defects were observed in the fundus in 72%, 8% had defects in the lower uterine segment, and the remaining 20% showed no gross defects on hysterography. Eighty-seven (67%) had no residual tumor in the hysterectomy specimen, while residual carcinoma was seen in forty-three (33%). No local recurrence has developed in the pelvis or vagina. Six patients have developed extra-pelvic metastasis, and four have died of disease. Overall survival is 97% with follow-up of 1 to 6 years.

The value of supraclavicular area treatment in radiotherapeutic management of lung cancer

Records of 295 patients treated for carcinoma of the lung have been reviewed. 64 patients (21.7%) had a supraclavicular involvement at initial presentation, local control was achieved in that region in 26 out of 27 (96%) patients who received a minimum dose of 5,000 rads in 25 treatments. „Local control”︁ applies to complete disappearance of disease in that area with no subsequent recurrence at any time or until death of the patient. One patient had persistent disease despite a dose of 7,000 rads in 35 treatments. Elective supraclavicular irradiation was given to 79 patients, one of whom subsequently developed clinically detectable disease there. One hundred fifty‐three patients did not receive elective supraclavicular irradiation, and 21 (14%) subsequently developed supraclavicular disease, a statistically significant difference. Patients considered at higher risk for supraclavicular metastasis were selected for elective supraclavicular irradiation. Therefore, the markedly lower rate of involvement in the treated patients can be attributed to the irradiation given that group. Overall, supraclavicular nodes were present in 24.8%, 30.2%, 34.1%, and 31.5% of patients with squamous cell carcinoma, adenocarcinoma, and undifferentiated small and large cell carcinoma, respectively. Seventy‐six of 85 patients (89.4%) with supraclavicular involvement had hilar and/or mediastinal involvement at initial presentation. No significant difference in survival was observed between patients receiving supraclavicular, irradiation and those not receiving treatment to that area. Of 64 patients with initial supraclavicular involvement, there were 14, 9, and 5 survivors at 12, 18, and 24 months, respectively, with four patients surviving beyond 36 months.

A selective patient information system.

A patient information system is described in the light of present needs and possibilities. Current medical records shortcomings are in the areas of completeness, organization, timeliness, and retrievability. As part of the solution the use of an on‐line computer system in a Department of Therapeutic Radiology is described. Essentials for success include careful planning and having the medical staff input the data and use the computerized record as part of the patient record, not as a duplicate. Using the information retrievable with the computer to advantage will take research and education, because such information has not been readily available hitherto. Costs of the system are shown to be comparable to current manual record keeping due to recent dramatic improvements in cost‐performance of large mini‐computers. This kind of hardware, together with computer software such as “MUMPS,” has enabled us to enter every patient treated by the department on an on‐line basis since the initiation of the system in early 1972. Refinement of the medical data items is, however, still in progress, pointing up the fact that the start‐up effort of a computerized patient information system is only a small part of the work required to make it truly useful in the long run. Cancer 33:1653–1663, 1974.