Melvyn P. Richter

A prospective study of treatment techniques to minimize the volume of pelvic small bowel with reduction of acute and late effects associated with pelvic irradiation

The volume, distribution, and mobility of opacified pelvic small bowel (PSB) were determined by fluoroscopy and orthogonal radiographs in 150 consecutive patients undergoing pelvic irradiation. Various techniques including uteropexy, omental transposition, bladder distention, inclining the patient, and anterior abdominal wall compression in the supine and prone treatment position were studied for their effect on the volume and location of small bowel within the pelvis. Abdominal wall compression in the prone position combined with bladder distention was selected for further investigation because of its simplicity, reproducibility, patient comfort, and ability to displace the small bowel. Factors correlating with the volume of pelvic small bowel (PSB) included prior pelvic surgery, pelvic irradiation (XRT), and body mass index. After pelvic surgery, especially following abdominoperineal resection (APR), there was a greater volume of PSB which was also less mobile. The severity of acute gastrointestinal effects positively correlated with the volume of irradiated small bowel. Overall, 67% of patients experienced little or no diarrhea, 30% developed mild diarrhea, and no patient required treatment interruption. Late gastrointestinal effects correlated with the prior pelvic surgery and with the volume of small bowel receiving greater than 45 Gy. Small bowel obstruction was not observed in 75 patients who had no previous pelvic surgery. However, following pelvic surgery excluding APR, 2/50 patients and following APR, 3/25 patients developed small bowel obstruction.

The role of radiotherapy in the management of operable locally advanced breast carcinoma

The purpose of this study was to test the role of radiotherapy following total mastectomy, axillary dissection, and adjuvant systemic therapy in the management of operable locally advanced breast carcinoma.

The Postoperative Irradiation of Transitional Cell Carcinoma of the Renal Pelvis and Ureter

The role of adjuvant irradiation in the treatment of transitional cell carcinoma of the renal pelvis and ureter was reviewed. Between June 1966 and March 1981, 41 patients underwent curative resections. A poor risk group was identified, with 23 patients demonstrating disease greater than grade 2 or stage B. Postoperative irradiation was administered to 11 of 23 patients. Median patient followup was 40 months. Two-thirds of all failures occurred within the first 12 months and no failure was seen beyond 35 months. Patients with poor prognostic features had a 60 per cent failure rate compared to 11.8 per cent of the patients with good risk factors (p equals 0.023). The median survival of the 2 groups was 28 and 99 months, respectively (p less than 0.001). Outcome of the poor risk patients was analyzed whether or not the patient received postoperative irradiation. None of the irradiated patients failed with local disease only, while there was 1 patient with local and distant recurrence. In contrast, the nonirradiated group had 5 local failures and twice the number of failures over-all. Median survival of the irradiated and nonirradiated patients was 35 and 26 months, respectively. The number of patients treated is too small to permit valid statistical conclusions and indicates the need for a multi-institutional study to determine if these suggestive findings of improved local control will be corroborated and translate into an improved survival rate.

A pilot study of combined radiotherapy and chemotherapy for esophageal carcinoma

BETWEEN 9/80 AND 9/83, 20 PATIENTS WITH ESOPHAGEAL CARCINOMA were treated with combined radiotherapy and chemotherapy (5-FU and mitomycin). Thirteen patients with Stages I or II disease received definitive treatment consisting of 6000 rad in 6–7 weeks and 5-FU (1000 mg/m2/24 hours) as a continuous I.V. infusion for 96 hours starting on days 2 and 28. Mitomycin (10 mg/m2) was administered as a bolus injection on day 2. Palliative treatment (5000 rad plus above chemotherapy) was delivered to six patients with Stage III disease (two with extra-esophageal spread, four with distant metastases) and to one patient with an anastomotic recurrence following resection.Two of 13 definitively treated patients were not evaluable due to early death from intercurrent disease. Ten of 11 evaluable patients treated definitively are alive from 4–32 months; the median survival has not been reached at 17 months. Four of 11 evaluable patients treated definitively have relapsed, with only one relapsing within the irradiated field. Among the palliative and definitively treated patients, relief of dysphagia was seen in 16/17, and continued until the time of last follow-up or until death in 13/17. The treatment was well tolerated and no significant hematologic problems were incurred.This combination of radiation therapy with infusional 5-FU and mitomycin appears to be an effective and well-tolerated regimen in the treatment of esophageal carcinoma and is worthy of further study.

Quantitative lung scans for prediction of post-radiotherapy pulmonary function

Quantitative perfusion scans were used to predict the proportion of pulmonary function lost by inclusion of lung in radiotherapy fields. Nineteen patients receiving radiotherapy for carcinoma of the lung had pulmonary function evaluated by forced expiratory volume at 1 second (FEV1) prior to and following radiotherapy. FEV1 measurement followed initiation of radiotherapy from two to 18 months (mean: seven months). Prior to radiotherapy quantitative lung scans were performed with Tc-99m macroaggregated albumin. On images acquired by computer, the radiotherapy field was drawn as a region of interest (ROI) and the proportion of count within this ROI relative to total lung count was determined. The total FEV1 was apportioned by the ROI ratio of count excluded from radiation ROI to total count in lungs to predict the FEV1 expected to be remaining after radiotherapy. In only two cases was the measured post-therapy FEV1 less than predicted (and then, by only 2% and 5%, respectively). The data indicate that quantitative perfusion lung scans can be used to predict conservatively the pulmonary function that may be expected to remain post-radiotherapy. Therapy fields may be adjusted in patients with underlying compromised pulmonary function to conserve a pre-selected FEV1.