Martin B. Levene

Analysis of cosmetic results following primary radiation therapy for stages I and II carcinoma of the breast.

Abstract In 31 cases of Stages I or II carcinoma of the breast treated by primary radiation therapy, the cosmetic results were analyzed with regard to the details of treatment. Three principal treatment factors were identified which influenced the cosmetic outcome: (1) the extent and location of the biopsy procedure, (2) the time/dose factors of the radiation therapy and (3) the technique of the radiation therapy. Cosmetic results were lessened when the biopsy procedure included a wide resection of adjacent breast tissue or when the biopsy scar was obvious. Increasing doses of external beam radiation were associated with greater degrees of retraction and fibrosis of the treated breast. All 6 patients who received 6000 rad by external beam had significant retraction and fibrosis while patients who received 5000 rad rarely showed significant changes. Local boost doses by interstitial implantation did not diminish the cosmetic outcome. All patients were treated using supervoltage equipment without bolus and skin changes secondary to treatment were infrequent. Seventeen patients developed localized areas of fibrosis and skin changes at the matchline between adjacent radiation fields. Recommendations are made for improved cosmetic results based on these findings.

Visual Complications following Irradiation for Pituitary Adenomas and Craniopharyngiomas

Of 55 patients with pituitary adenomas or craniopharyngiomas treated with irradiation, a retrospective study revealed that 5 sustained a visual loss compatible with radiation damage to the optic nerve. No patient who received less than 250 rads/day fractions showed such visual loss. Within the range of total dosages used in this series, total dose was not an important determinant of this complication. The time to occurrence of visual disturbance ranged from 5 to 34 months following therapy.

Results of treating stage III carcinoma of the breast by primary radiation therapy.

One hundred sixteen patients with stage III carcinoma of the breast were treated by primary radiation therapy. The 5‐year actuarial survival and relapsefree survival were 25% and 22%, respectively. The 5‐year actuarial probability of local tumor control for the entire group was 64%. In patients undergoing an excisional biopsy and an interstitial implant of the primary tumor area, local control was 100%. In patients who had either an excisional biopsy or an implant, the 5‐year actuarial probability of local control was 77% and 76%, respectively. In contrast, in patients having neither an excisional biopsy nor an implant, local control was only 41%. In patients receiving a total dose of greater than 6000 rad, from external beam treatment or from external beam plus an interstitial implant, the local control was 78% compared to 39% in patients receiving a total dose of less than 6000 rad. Forty‐one patients received some form of adjuvant therapy. Both local control and relapse‐free survival were improved in patients receiving chemotherapy as the sole adjuvant and in patients receiving chemotherapy combined with an endocrine ablative procedure. However, patients treated with only an endocrine ablative procedure had no improvement in survival nor in local control. These results indicate that primary radiation therapy can provide local control in a high proportion of patients with stage III carcinoma of the breast and suggest that chemotherapy is effective in improving both local control and survival in these patients. Cancer 43:985–993, 1979.

Radiation therapy as initial treatment for early stage cancer of the breast wiithout mastectomy

This report describes 150 patients with clinical stage I and II carcinoma of the breast treated at four institutions—Yale University School of Medicine, Harvard Medical School‐Joint Center for Radiation Therapy, Hahnemann Medical College, Jefferson Medical College—with radiotherapy only following excisional biopsy. Closely similar treatment policies were followed at all four centers, 4500–5000 rads minimum tumor dose being delivered to the entire breast and axillary, supraclavicular and internal mammary nodes. Forty‐six of 49 stage I patients treated are alive without disease, the actuarial relapse‐free survival being 91% at 5 years. Of the 101 stage II patients, 75 are alive without disease with a relapse‐free actuarial survival of 60% at 5 years. Local failure has occurred in 10 patients (9 stage II and 1 stage I, 6.6%), 5 of whom are disease‐free following mastectomy. The results obtained in this study are comparable to those of conventional surgery. It is our conclusion that mastectomy is not a necessary part of the treatment of small breast cancers, that radiation without mastectomy is an acceptable alternative with far superior cosmetic and functional results. Adjuvant chemotherapy should be considered particularly in stage II patients in view of their 40% relapse rate.

A modified three-field technique for breast treatment

Radiation therapy of breast cancer commonly uses three high-energy photon fields. The supraclavicular field and the two tangential fields are often matched on the skin. An analysis of the dose distribution in the matchline region shows a dose of up to 200% of the prescribed dose over the width of 8 mm at 3 cm depth. This is a result of the beam divergence and the complex geometry. A modification of the treatment technique has reduced the dose to less than 140% of the prescribed dose over approximately 4 mm. The modified technique uses a shielding block which covers the caudad half of the supraclavicular field and makes the caudad edge vertical. The cephalad edges of the two tangential fields are defined by a shielding block, which hangs vertically from the treatment head regardless of gantry and collimator position. This block obstructs a small portion of the radiation field and defines a vertical field edge. These three vertical field edges are brought into coincidence by adjustment of couch turntable angle and longitudinal couch position. The nearly perfect geometric match in three dimensions achieved in this manner further improves the cosmetic results after radiation treatment of breast cancer.

Radiation therapy of early carcinoma of the breast without mastectomy

The results of the treatment of 176 patients with early breast cancer, using radiation therapy without mastectomy are reported. The likelihood of local recurrence was 5% for Stage I patients and 7% for Stage II patients. Local control was significantly greater in those patients receiving an iridium implant (1/73 vs. 10/111, P less than .05). The cumulative survival probability at five years is 96% for Stage I and 68% for Stage II. Local control with good cosmetic results is greatly influenced by surgical and radiotherapeutic technique. Gross tumor resection with careful reapproximation of the breast tissue and well‐placed incisions facilitates the radiation therapy. Homogeneous external beam radiation to the breast and draining lymph nodes (4500–5000 rads) and supplemental local radiation to the sites of the primary lesion (in this series using interstitial implantation) are recommended.

Radiation Therapy of Thalamic, Midbrain and Brain Stem Gliomas

The case histories of 40 patients with gliomas of the thalamus and midbrain (Group I) or caudal brain stem (Group II) were reviewed to determine the effect of radiation therapy on neurologic functional status and survival. Nine of 14 (64%) patients in Group I demonstrated an improvement in functional status following radiotherapy, as did 19 of 26 (73%) patients in Group II. Eight (57%) patients in Group I and 10 (38%) patients in Group II are alive with no evidence of disease after periods of 12 to 65 months following completion of treatment. Acturial survival data indicate a better survival rate in Group I patients. Based on our findings, an aggressive and potentially curative attempt with use of radiation therapy for gliomas of the thalamus, midbrain, and brain stem is justified.

Computer-Controlled Radiation Therapy

Radiation therapy is often hampered in important body regions by the need to transit sensitive normal tissues which act as dose-limiting barriers. Computer-controlled radiation therapy permits the simultaneous variation of multiple treatment parameters during irradiation of the patient, producing improved dose distributions with the potential for improved local control. Equipment used for this purpose includes a Mevatron XII linear accelerator, redesigned for automatic control, and a PDP 11/45 minicomputer. Dose distributions are shown and potential clinical gains discussed.

A computer-controlled radiation therapy machine for pelvic and para-aortic nodal areas

Abstract A computer-controlled radiation therapy technique has been developed to treat cancer of the uterine cervix that has extended to the pelvic and pare-aortic lymph nodes. During five longitudinal scans with a 4 cm wide 8 MV X ray beam, conformation of the high dose region to the target volume was achieved primarily by varying the other field dimensions. Treatment planning and dose calculation were performed in three dimensions. Conventional two-dimensional planning in a series of transverse planes through the patient was combined with a mathematical normalization of dose in the longitudinal direction to attain uniform dose throughout the target volume and to fulfill criteria for protection of critical organs. The resulting dose distributions were compared, in detail, with those resulting from conventional treatment techniques. It was concluded that the computer-controlled therapy scheme offered the potential of reducing the probability of complications, for the same target dose, by lowering the doses to small bowel, duodenum, kidneys, liver and spinal cord.

Treatment of carcinoma of the breast by radiation therapy

One hundred and fifty patients with carcinoma of the breast were treated by radiation therapy without mastectomy. Seventy‐seven patients had excisional biopsy of the breast mass while the remainder had incisional biopsy or needle biopsy. There has been 100% local control in patients with Stage I or Stage II disease. The local control rate in Stage III is 67.5%. Those patients who had excisional biopsy had a significantly lower incidence of local recurrence than did those in whom the tumor was left in situ. The cumulative survival probability at five years is 100% for Stage I, 65% for Stage II and 26% for Stage III. Recommendations are made concerning axillary node sampling and adjuvant chemotherapy for patients treated by this technique.