Joseph Newall

Non-Hodgkin's lymphoma of the brain: Can high dose, large volume radiation therapy improve survival? Report on a prospective trial by the Radiation therapy Oncology Group (RTOG): RTOG 8315

Between 1983 and 1987 the Radiation Therapy Oncology Group conducted a prospective phase II study to evaluate survival in primary non-Hodgkins lymphoma of the brain treated with whole brain irradiation to 40 Gy and a 20 Gy boost to tumor plus a 2 cm margin. Forty-one patients are reported. Full follow-up is available on 35/41 who have died. Six are alive at 8.8-67.2 months from start of radiation therapy with a median followup of 53.9 months. Overall median survival was 11.6 months from start of radiation therapy and 12.2 months from diagnosis, with 48% surviving 1 year and 28% surviving 2 years. Karnofsky Performance Status and age were significant prognostic factors. Patients with a Karnofsky Performance Status of 70-100 had a median survival of 21.1 months compared to 5.6 months for patients with a status of 40-60 (p less than .001). Fourteen patients less than 60 years of age had a median survival of 23.1 months, while 27 patients greater than or equal to 60 years of age had a median survival of 7.6 months (log-rank p = .001). Disease recurred in the brain in 25/41 (61%) of the patients, (21/41 in the brain only and 4/41 in the brain plus distant metastases). Despite high dose and large volume irradiation, primary Central Nervous System lymphoma still exhibits excessive mortality, especially in older patients. This paradox of the relative radioresistance of primary Central Nervous System lymphoma remains unresolved.

Role of radiation therapy in the management of meningioma.

Surgery is the accepted form of treatment of meningioma; the role of radiotherapy has not been clearly established. With this in mind, we have reviewed our experience with radiation therapy in the management of meningiomas at New York University Medical Center. Sixty-eight patients fell into three groups. Forty-three (Group A) underwent operation followed by radiation therapy, 14 patients (Group B) had radiation for recurrence after operation, and 11 patients (Group C) had radiation therapy as the primary treatment. In Group A, 41 of 43 are alive. During a follow-up of 1 to 10 years, only 2 have deteriorated. Five of 14 Group B patients showed neurological improvement and 7 showed deterioration, including 5 who died of tumor. All 11 patients in Group C are alive with follow-up periods of 3 to 6 years; 9 of these show improvement in neurological function. Eleven patients had malignant meningioma, of whom 8 are alive and stable. We present 4 case reports, including computed tomographic scans that show evidence of tumor necrosis after radiation therapy. Pathological verification of tumor necrosis is presented in 1 case. We believe that radiation therapy has an established role in the treatment of incompletely excised, recurrent, or malignant meningiomas and, in some cases, as the initial management of meningiomas. Indications for treatment and guidelines are presented.

Single-dose half-body irradiation for palliation of multiple bone metastases from solid tumors: Final radiation therapy oncology group report

This is the final analysis of Protocol #78–10 which explored increasing single‐doses of half‐body irradiation (HBI) in patients with multiple (symptomatic) osseous metastases. When given as palliation, HBI was found to relieve pain in 73% of the patients. In 20% of the patients the pain relief was complete; over two thirds of all patients achieved better than 50% pain relief. The HBI pain relief was dramatic with nearly 50% of all responding patients doing so within 48 hours and 80% within one week from HBI treatment. Furthermore, the pain relief was long‐lasting and continued without need of retreatment for at least 50% of the remaining patients life. These results compare favorably with those obtained by the Radiation Therapy Oncology Group (RTOG) using several conventional daily fractionated schemes on similar patients in a prior study (RTOG #74–02). HBI achieves pain relief sooner and with less evidence of pain recurrence in the irradiated area than conventionally treated patients. The most effective and safest of the HBI doses tested were 600 rad for the upper HBI and 800 rad for the lower or mid‐HBI. Increasing doses beyond these levels did not increase pain relief, duration of relief, or achieved a faster response; however, the increase in dose was associated with a definite increase in toxicity. Single‐dose HBI was well tolerated with no fatalities seen among 168 treated patients. A comprehensive premedication program has proven to decrease the acute radiation syndrome to very acceptable levels. There were excellent responses found in practically all tumors treated, but especially breast and prostate among which over 80% of all patients experienced pain relief, 30% in a complete fashion. Single‐dose HBI emerges as one of the safest, fastest, and more effective palliative tools for intractable cancer pain in modern radiation oncology. Cancer 58:29–39, 1986.

A role for radiotherapy in the treatment of solid and papillary neoplasms of the pancreas.

Solid and papillary neoplasms of the pancreas are rare tumors that usually occur in young women as enlarging abdominal masses. These lesions almost never metastasize but may be locally destructive. Although the usual treatment is surgery, the authors herein report a case that was treated solely by radiotherapy. They conclude that solid and papillary neoplasms of the pancreas are radiosensitive and can be successfully treated by radiation therapy.

Radiation therapy for intracranial germinoma: The case for limited volume treatment

Although radiation therapy has been universally accepted as the treatment of choice for primary intracranial germinomas, the optimal treatment technique continues to be a matter of controversy. Some authors advocate routine prophylactic craniospinal irradiation for all patients with localized intracranial germinomas whereas others have recommended partial brain fields. A retrospective analysis was performed on all 30 patients with tumors of the pineal and suprasellar regions irradiated at our institution between 1967 and 1987. Definitive histology was obtained in 23 patients. There were 13 germinomas and 10 non-germinomatous germ cell tumors. The 13 patients with biopsy proven germinomas constitute one of the largest modern series and will form the basis of this report. In all 13 patients, the tumor was confined to a single site within either the pineal region (9 patients) or the suprasellar region (4 patients). One patient with a pineal germinoma had CSF cytology positive for malignant cells and this patient was treated with craniospinal irradiation. Twelve patients were treated using partial brain fields encompassing either the tumor plus margin (10 patients) or the entire ventricular system followed by a boost to the primary tumor (2 patients). With the exception of one patient, all patients received a total dose between 4900 and 5500 cGy to the primary (median 5040 cGy). The patient receiving less (3960 cGy) suffered from both local and spine relapse 26 months after diagnosis. The remaining 12 patients were free of disease at 81 months median follow-up time. We suggest that for patients with biopsy proven pineal or suprasellar germinomas, irradiation of partial brain is sufficient and craniospinal irradiation should be administered only to those patients with disease involving more than one intracranial site, demonstrated meningeal seeding, or positive CSF cytology.

Pituitary adenoma: The efficacy of radiotherapy as the sole treatment

The management of patients with pituitary adenomas by radiotherapy alone, using modern techniques of evaluation and current standards of treatment, has not been examined. This is a retrospective review of 29 such patients with nonfunctional or prolactin secreting pituitary macroadenomas. Patients were analyzed by visual fields, hormone levels, and CT scans. All but one patient received a tumor dose of 4500 cGy in 4 to 5 weeks. The tumor was controlled in 26 of 28 (93%) patients for an observed period of 3 to 14 years. Seventeen of 21 (81%) patients with visual impairment experienced normalization or improvement, and seven of ten (70%) patients with hyperprolactinemia achieved normalization of their serum prolactin levels. Post-treatment CT scanning revealed persistent tumor in nine of 17 patients despite clinical improvement. We conclude that: (a) radiotherapy is an effective treatment for these tumors; (b) doses need not exceed 4500 cGy in 25 fractions; (c) radiation is effective for improving vision; (d) radiation can normalize hyperprolactinemia; and (e) tumor regression is variable and unrelated to observed symptom regression.

Glioblastoma in the older patient: how long a course of radiotherapy is necessary?

SummaryEighteen patients over 60 years old with a histologically proven diagnosis of glioblastoma multiforme were treated by a short radiotherapy course (3000 cGy midline dose by two opposed portals to the whole brain). Results in terms of survival and function appeared to be as good as with the standard course of six to seven weeks as reported in the literature.

The duration of local control of classic (non—AIDS-associated) Kaposi's sarcoma by radiotherapy

We report the short- and long-term responses to radiotherapy of 82 classic Kaposis sarcomas. Doses were prescribed ab initio and no attempt was made to discontinue treatment as soon as shrinkage was observed, as has been recommended by others. More than 50% of the lesions regressed completely and nearly all underwent some regression. Almost all recurrences were detected within 2 years of treatment and virtually all occurred in lesions that had not regressed completely within 2 weeks of radiotherapy. We conclude that classic Kaposis sarcoma should be treated with sufficient radiotherapy from the beginning to provide long-term control.

Carcinoma of the uterine cervix: The patterns of care study process survey

Abstract The Patterns of Care Study is currently investigating the management of patients with carcinoma of the cervix. This unique effort has required the development of a new method by which patients who have similar extent of disease are grouped. Patterns of care, for patients with similar disease, should be similar. Results indicate that there is substantial variation in care nationwide. The impact of this variation on outcome can provide the basis of educational efforts to improve the quality of patient care.

Computerized (axial) tomography in the serial study of cerebral tumors treated by radiation. A preliminary report.

The difficulty in evaluating the effectiveness of radiation therapy of primary cerebral tumors is well appreciated. Changes in tumor size and the presence or absence of edema or necrosis during or following treatment cannot be readily evaluated by present noninterventive roentgenographic methods. At New York University Medical Center, computerized (axial) tomography (CT) has been routinely used both before and after radiation therapy with the aim of assessing, by noninterventive means, tumor response, presence or absence of edema, or necrosis. A selected series of patients is presented with correlation of the clinical findings and CT‐scan results both before and after therapy. The significance of these findings and their implications in the management of cerebral tumors are discussed.