Maurice Greenberg

Malignant lymphoma of the uterine cervix

Three patients with primary malignant lymphoma of the uterine cervix are reported and the literature is reviewed. All of the patients in the current cases presented with irregular menstruation. Two patients were found to have diffuse histiocytic lymphoma, and one patient had diffuse mixed lymphoma. Histologic diagnosis was confirmed by outside expert pathologists in all cases. In spite of locally advanced disease according to FIGOs classification (Stage IVA‐2 and Stage IIB‐l), they responded well to external irradiation, and had control of tumor within the pelvis. All are alive at 13, 7, and 3 years, respectively, after the completion of irradiation. One patient developed disseminated disease 4.25 years after the completion of external irradiation, but was successfully treated with combination chemotherapy for 2 years, and is alive at 6.75 years after the completion of chemotherapy without disease. Review of the other 21 cases reported in the literature reveals that 14 were free of disease after treatment. The importance of distinguishing malignant lymphoma from undifferentiated carcinoma or sarcoma is emphasized since cervical malignant lymphoma can be successfully treated with irradiation in spite of locally advanced disease.

Local control and survival after external irradiation for adenocarcinoma of the prostate

From 1966 through 1978, 128 patients with biopsy-proven adenocarcinoma of the prostate underwent external irradiation to the entire pelvis followed by additional irradiation with a field that encompassed the entire prostate with generous margins. Local recurrence was diagnosed when palpable regrowth occurred and was confirmed by biopsy. Eighteen patients (14%) had local recurrence. Actuarial (life table) local recurrence rates, however, were 24% for both for Stage B and C patients. Actuarial five year survival was 100% for the 10 Stage A patients, 91% for the 25 Stage B, and 78% for the 93 Stage C patients. Actuarial five year disease-free survival was 59% for Stage B and 69% for Stage C patients. Local recurrence was affected by the total dose to the whole pelvis and the dose at the center of the prostate. Disease-free survival was influenced by differentiation. High dose external irradiation to the prostate and regional lymph nodes offers the greatest probability of long-term disease-free survival for patients with localized disease. Late bowel complications were seen in 14 patients (11%), two of whom required colostomies. Late urinary tract complications were observed in five patients (4%).

Mammary carcinoma developing after radiotherapy and chemotherapy for Hodgkin's disease

Two patients developed breast cancer after treatment of Hodgkins disease. Both had received mediastinal irradiation 13 to 15 years, respectively, before the diagnosis of breast carcinoma. One patient had synchronous bilateral breast cancer when the diagnosis was made. Discussed is the risk of mammary carcinoma as a second malignant neoplasm in patients treated for Hodgkins disease.

Twice-daily tapering dexamethasone treatment during cranial radiation for newly diagnosed brain metastases.

SummaryTwenty evaluable patients with newly diagnosed brain metastases underwent treatment with a novel dose/schedule of dexamethasone aimed at reducing steroid toxicity during palliative radiation therapy. All patients received twice daily dexamethasone starting at 8 mg bid for four days then 4 mg bid for four days then 2 mg bid until the last day of radiation therapy. The radiation prescriptions were not standardized varying from 2000 cGy/5 fractions to 5800 cGy/29 fractions. Fourteen patients received dexamethasone for a minimum of 24 hours before their first radiation treatment and 7 (50%) experienced improvement in neurologic symptoms/signs prior to starting radiation treatments. Fourteen patients completed the planned course of radiation and dexamethasone. Only 1 patient needed to restart dexamethasone within 30 days of finishing radiation because of steroid reversible neurologic deficits. Steroid toxicity was mild including hyperglycemia (1), candida esophagitis (1), steroid pseudorheumatism (2), peripheral edema (1) and steroid withdrawal syndrome (1). Only two toxic events were recorded in patients receiving steroids less than 21 days. Twice daily dexamethasone appears to provide good clinical results with minimal morbidity.

Stage III nodular lymphoreticular tumors (non-Hodgkin's lymphoma): results of central lymphatic irradiation.

Since 1969, 29 previously untreated patients with Stage III nodular malignant lymphoreticular (MLT) have received total central lymphatic (TCL) irradiation. The volume irradiated included the entire abdomen, Waldeyers ring, and preauricular nodes in addition to the usual regions encompassed by total nodal irradiation. Doses of 2000–3000 rads in three to six weeks were delivered to the nodal regions, liver, and spleen; fraction sizes ranged from 100 to 180 rads. Patients have been followed from one to ten years (median six years). The actuarial survival is 78% at five years, and the disease‐free survival is 61%. There is no difference in disease‐free survival of the patients with poorly differentiated lymphocytic vs. those with “histiocytic” or mixed cytology. Men and women had disease‐free survivals of 82% and 43%, respectively. The long‐term follow‐up of these patients indicates that prolonged disease‐free intervals are common after TCL irradiation, and some patients may be cured.

Reduced fractionation and the potential of hypoxic cell sensitizers in irradiation of malignant epithelial tumors

Abstract In recent years, there has been a resurgence of interest in hypofractionation associated with investigations of hyperbaric oxygen, high LET (linear energy transfer) radiations, and hypoxic cell radiosensitizers. With a view toward developing trials with irradiation and misonidazole, a review was undertaken of the experience with hypofractionation at the Medical College of Wisconsin. From 1971 through 1973 all patients were treated with 1, 2, or 3 fractions per week; a proportion received hypofractionation until 1976. Patients who were treated from 1965–1971 and 1974–1976 who received five fractions per week were compared. Two groups of patients were identified: 262 patients with inoperable, but localized carcinoma of the lung and 94 patients with squamous carcinomas of the oral cavity and oropharynx, all of whom received only external irradiation. The results in both groups show a significant reduction in tumor control probability with reduction in the number of fractions per week. A review of the available literature also indicates a decreased probability of tumor control with hypofractionation. Therefore, it may be necessary for hypoxic cell sensitizers to overcome a deficit imposed by reduced fractionation before a therapeutic benefit can be shown in prospective trials.

Correlation of treatment volume with milligram-hours for intracavitary applications for carcinoma of the cervix

Following the recommendations of the European Curietherapy Group, the three-dimensional dose distribution corresponding to various milligram-hour volumes has been analyzed according to its length, width, and height dimensions. Thus, it is possible to state the dimensions of a number of isodose surfaces for a dose prescription given in milligram-hours. Problems associated with the exact placement of the three-dimensional dose distribution in relation to the patients anatomy are discussed.