Kenneth R. Stevens

Preoperative radiotherapy for adenocarcinoma of the rectosigmoid

Ninety‐seven patients with adenocarcinoma of the rectosigmoid have been treated with high dose (5000‐6000 rad) preoperative irradiation from 1960 through 1972 at the University of Oregon Health Sciences Center. Fifty‐seven were initially clinically resectable and 40 were initially inoperable. Forty of the 57 initially clinically resectable patients had “curative” resections and are at risk for more than 5 years. An increase in 5‐year survival (from 38% to 53%) and an absence of pelvic recurrence have occurred in those patients receiving preoperative irradiation and “curative” resection. Four of the 40 initially inoperable patients are alive without tumor. Three of the four survivors had irradiation and surgery; one had irradiation only. An additional four patients had no evidence of tumor at death. Tumor was totally sterilized by irradiation in nine patients and reduced to microfocal extent in an additional three of the 97 patients. Incidence of complications was no greater than has been reported in a surgical series from the same institution.

Anterior resection and primary anastomosis following high dose preoperative irradiation for adenocarcinoma of the recto‐sigmoid

Preoperative irradiation for adenocarcinoma of the rectum and sigmoid does not always limit the surgery to an abdominoperineal resection. From 1960 to 1976 anterior resection and primary anastomosis of the bowel has been performed in 13 patients with adenocarcinoma of the rectum and sigmoid whose tumor had been irradiated with 5000 rads with small pelvic fields. The inferior surgical resection line was within or very near the edge of the radiation field in 10 patients. In no instance was the superior resection line irradiated. Compared to a group of 79 patients treated with anterior resection only, the pre‐operatively irradiated patients had lower incidence of pelvic and anastomotic tumor recurrence, but a higher incidence of anastomotic leak and subsequent adhesions and intestinal obstruction. We stress that if irradiated rectum is considered for forming the anastomosis, a temporary “protective colostomy” should be strongly considered at the time of the surgery.

Limited epithelial carcinoma of the ovary treated with curative intent by the intraperitoneal installation of radiocolloids

Between January 1960 and September 1972, 104 patients with limited epithelial carcinoma of the ovary received intraperitoneal radiocolloid. Fifty‐six of these patients also received external beam radiation therapy to the pelvis (pelvic RT). Five‐year actuarial no‐evidence‐of‐disease survival rates were 95% for stage Iai, 82% for Iaii, 73% for Ib, 67% for Ic, 67% for IIa, 67% for IIb without gross residual tumor (GRT), 25% for IIb with GRT, and 50% for III with minimal or no GRT. The addition of pelvic RT following radiocolloid could not be shown to affect survival of patients with Stage I and IIa tumors. Small bowel complications were related to the use of pelvic RT, however, occurring in 2.2% of patients treated with radiocolloid alone and 24% of patients treated with colloid and pelvic RT (p < 0.005). In patients who underwent abdominal surgery following treatment of ovarian cancer, no excessive complication rate was observed. We conclude that for patients with stages Iaii through IIa, postoperative radiocolloid appears to provide the greatest chance of survival with the least chance of complication. For patients with Stage IIb and III lesions in whom there is minimal or no GRT, radiocolloid followed by pelvic RT produced survival rates comparable or superior to any other form of postoperative therapy. Cancer 42:2563–2571, 1978.

Pre-estrogen breast irradiation for patients with carcinoma of the prostate: a critical review

We studied 38 patients with prostatic cancer who received breast irradiation before oral estrogen administration. Our data are combined with those from other institutions to determine the effectiveness of pre-estrogen breast irradiation in minimizing gynecomastia and/or pain. Based on our review the incidence of estrogen-induced breast changes is 70%. Irradiation given before estrogen administration can prevent or minimize these changes in 89.3% of the treated patients. Histologic changes of gynecomastia are reviewed and recommendations for optimum radiation therapy technique are included.

Advanced squamous cell carcinoma of the maxillary sinus: Results of combined regional infusion chemotherapy, radiation therapy and surgery

Sequential intraarterial chemotherapy using bleomycin and methotrexate followed by high dose radiation and surgery was evaluated in 10 patients with stage III and IV squamous carcinomas of the maxillary sinus. Seven of 10 patients had extensive tumor necrosis in the surgical specimen, and no evidence of residual tumor was found in 4 of these patients. After a median follow up period of 24 months, there has been only one local recurrence in resected patients. Three patients died from pulmonary metastases. Although many unanswered questions remain regarding the efficacy of triple therapy for maxillary sinus malignancy, these results are encouraging and establish that surgical resection and healing are not compromised by preoperative chemotherapy and radiation.

Preoperative irradiation for osteogenic sarcoma

High‐dose preoperative irradiation with delayed disarticulation of an extremity involved with osteogenic sarcoma has resulted in a marked increase of tumor‐free survival in a small series of cases treated at the University of Oregon Medical School. Treatment was well tolerated without significant complications. The surgical specimen in most of the survivors contained no viable carcinoma after irradiation in the order of 10,000 rads. There is evidence that biopsy in suspected lesions should be performed without tourniquet to avoid flushing of the tumor cells from the marrow cavity. Discussion will include rationale for delayed surgery, possible influence of irradiation on immune factors, and techniques of irradiation.

External irradiation in the management of stage II endometrial carcinoma. A logical approach

Twenty‐nine patients with stage II endometrial carcinoma were reviewed and the possible risk factors involved in stage II disease are presented. Twenty‐four patients received external irradiation as part of their treatment with or without intracavitary or intravaginal radium and/or TAH BSO. The 5‐year actuarial survival in our series was 81.4%. The data showed that preoperative external irradiation can be effectively administered without undue complication. A strong argument against the traditional use of preoperative intracavitary radium is presented. Preoperative external irradiation administered with a 4‐field box technique to deliver a minimum dose of 5000 rad in 5–6 weeks to all of the structures at risk is the recommended treatment for stage II endometrial carcinoma.

Radiation management of bilateral retinoblastoma: Theneed to preservation

Abstract Thirty-four patients with retinoblastoma were treated in the Radiation Therapy Department of the University of Oregon Health Sciences Center from 1944 to 1978. Twenty-five of these patients had bilateral disease. Most patients were treated with megavoltage equipment and received doses of 5000 rad in 5 weeks. According to the lifetable method, five year survival was 67.6 % ; it increased to 85.7 % if patients who were treated with orthovoltage equipment were excluded. Seventy-one percent of evaluable patients had useful vision at 5 years; an additional two patients had useful vision for two years after radiation therapy. The value of even limited vision during this critical time of sensorimotor and psychological development is discussed. Orthovoltage equipment should not be used to irradiate patients with retinoblastoma.

Combined intraarterial chemotherapy, radiation therapy, and surgery for advanced squamous-cell carcinoma of the head and neck

From 1973 to 1978, 20 patients with T3 and T4 squamous cell carcinoma of the head and neck were treated according to a triple‐therapy protocol at the University of Oregon Health Sciences Center. Intraarterial chemotherapy (IAC) with bleomycin and methotrexate was given prior to high‐dose preoperative radiation therapy and then, when possible, the lesion was resected. The treatment results are presented. The initial clinical response to IAC and radiation correlated well with the findings in the pathologic examination of the resected specimen in 11 patients, but it did not correlate well with the subsequent clinical course of the patient. In view of the results of this pilot study, we do not feel that it is justified to continue IAC with bleomycin and methotrexate prior to conventional therapy in the very advanced and aggressive cancers of the head and neck. However, IAC might be justified in treating patients with operable Stage III carcinomas of the maxillary antrum.

A new technique for irradiating thoracic inlet tumors

Abstract Tumors of the thoracic inlet create a dilemma in radiation therapy treatment planning. It is difficult to give tumoricidal doses in this area because of the limitations of spinal cord tolerance. Opposed anterior-posterior fields, oblique fields and electron beam fields give inadequate dose distribution. A patient position and four-field treatment technique has been developed which allows us to give doses of 6000 + rad to tumors in the thoracic inlet, and limits the spinal cord dose to 4000 rad. A 25 MeV photon beam is used for opposed anterior-posterior and lateral fields. The lateral fields are treated with the patient supine, the upper arms are raised and rotated posteriorly, the scapula is pulled medially, the elbows are flexed, the forearms and hands are raised above and behind the head. Following the axis of the upper esophagus, the caudal end of the field is more posterior than the cephalad end of the field. As computerized axial tomography becomes available more readily and provides us with better knowledge of the anatomy in the thoracic inlet, this treatment position and technique may prove very useful.