Merrill I. Feldman

New surgical approach to minimize radiation‐associated small bowel injury in patients with pelvic malignancies requiring surgery and high‐dose irradiation. A preliminary report

Complications associated with small bowel intolerance to radiation therapy at doses higher than 4500 to 5000 cGy have been the limiting factor in delivering pelvic radiation either as an adjuvant to surgery or alone in the treatment of pelvic malignancies. Despite numerous surgical, medical, and radiation therapy technical measures to minimize small bowel injury, none have been uniformly successful in eliminating this problem. With the availability of a new synthetic absorbable mesh, a pelvic sling can be placed at the time of exploration or definitive surgery aimed at suspending the small bowel out of the pelvis. Preliminary work in animal models has shown the mesh sling to be well‐tolerated and successful. Barium‐contrast simulation studies of seven patients with pelvic malignancies requiring resectional surgery and postoperative radiation therapy in whom the mesh sling was placed at the time of surgery demonstrate total exclusion of the small bowel from the pelvic radiation treatment field. All patients have been followed for at least 4 months since mesh placement, and to date no complications have occurred. It is possible that this technique of bowel exclusion will permit the delivery of larger doses of radiation therapy in patients with pelvic malignancies aiming at more effective local and regional control of cancer without increased complications from radiation‐associated small bowel injury.

Improvement of in vitro mitogen proliferative responses in non-Hodgkin's lymphoma patients exposed to fractionated total body irradiation.

Patients with non‐Hodgkins lymphomas who failed to respond to chemotherapy were treated with low dose fractionated total body irradiation (TBI). Prior to, during and after scheduled therapy, their clinical status was evaluated and peripheral blood studies were performed to enumerate EAC and E rosetting cells and to measure proliferative responses to mitogens. Peripheral blood abnormalities were present prior to TBI using these in vitro assays. Patients who obtained clinical remissions following therapy had restoration of mitogen proliferative responses, whereas patients who showed no response or progressive disease had no change in their ability to proliferate in response to mitogens. Normalization of EAC and E rosetting profiles often occurred regardless of clinical response. These data indicate that low dose fractionated TBI produces clinical and in nitro detectable immunological changes. Furthermore, they show that improvement in mitogen responsiveness correlates best with good clinical responses.

New surgical method to prevent pelvic radiation enteropathy

Pelvic radiation doses exceeding 4,000–4,500 cGy are known to be associated with acute and chronic radiation enteropathy. This same radiation dose is, at the same time, only moderately effective in the elimination of microscopic malignancy, let alone gross clinical disease. Numerous medical and surgical attempts to minimize this complication have been uniformly unsuccessful. With the availability of a new synthetic, absorbable, polyglycolic acid mesh, an intestinal sling surgical procedure has been devised to exclude the small bowel from the pelvis and subsequent radiation fields. Twenty-five patients have been treated by this new technique with only one complication presenting as a fungal infection. Small-bowel barium contrast studies in 16 patients referred for postoperative radiation demonstrated 13 satisfactory exclusions of the small bowel from the translateral pelvic irradiation field. In 16 evaluable patients, three had unsatisfactory exclusion two of which were due to technical error. This has permitted high-dose (5,500–6,500 cGy) radiotherapy to the critical treatment volume without posttreatment complication. Mean follow-up time is 14.8 months. Several patients have been reexplored demonstrating complete absorption of the mesh without fibrinous adhesions or other foreign body reaction. It is concluded that this new technique of small bowel exclusion will permit the routine delivery of much higher doses of radiation in patients requiring improved local-regional control of their pelvic cancers and without morbidity from radiation-associated small bowel injury.

A combined treatment program for the management of locally recurrent breast cancer following chest wall irradiation.

Locally recurrent breast cancer involving the previously irradiated chest wall and skin is a difficult but manageable problem. A detailed oncological evaluation is initially undertaken to determine the extent of local and systemic disease. Local infection, if present, is controlled by topical therapy with 0.5% silver nitrate in conjunction with well‐planned, aggressive radiotherapy to the areas of tumor recurrence. Concomitant, hormonal, and/or cytotoxic chemotherapy is administered if evidence of systemic involvement is detected. Biopsies of the ulcer margin are performed with surgical excision and débridement as indicated, followed by sequential skin grafting. Seven patients are presented in whom circumferential ulcer biopsies, radiation therapy, skin grafting, and topical silver nitrate therapy were carried out with control and resolution of local symptoms in all cases. It is not essential to have initial tumor control in order to insure graft take. This program has particular application to the poor risk surgical patient, with or without evidence of systemic disease.

Adenocarcinoma of the cecum: Analysis of 106 cases

The natural history of surgically treated adenocarcinoma of the cecum has not been well defined. This report is a retrospective study of 106 patients followed for a median time of 25 months after hemicolectomy. The overall median survival rate was 73 months and the median disease‐free survival rate was 37 months; 22 of 106 patients failed locally (21%). In addition, 7 of these 22 patients had distal failure. Thus, there appears to exist a group of patients likely to benefit from adjuvant radiotherapy. Whether total abdominal irradiation or locoregional radiotherapy is the method of choice needs to be further defined.

Adjunctive therapy with interstitial irradiation for prostate cancer

Thirty patients with clinically localized adenocarcinoma of the prostate underwent simultaneous staging pelvic lymphadenectomy and interstitial irradiation. Patients were followed for eighteen to forty-five months with regard to progression of disease and development of long-term complications. Upstaging to Stage D1 by virtue of discovering pelvic node involvement was noted in 16 patients (53.3 per cent). Subsequent disease progression (defined as development of bone or soft tissue metastasis) was seen in 9 of 16 upstaged patients with an average time to progression of 12.2 months. Three Stage D1 patients have died with an average time to death of 19.6 months. Only 1 patient whose lymphadenectomy was negative has experienced disease progression, and none has died. Adjuvant chemotherapy (cyclophosphamide and doxorubicin hydrochloride) was given to 9 upstaged patients, in only 3 did disease progress. In contrast, in 6 of 7 upstaged patients not receiving chemotherapy metastatic disease developed, with an average time to progression of 10.3 months. In an attempt to improve local tumor control achieved by interstitial irradiation alone, 18 patients received additional external beam radiation therapy to the prostate, in doses ranging from 2,000 to 4,000 rad. There were sixteen long-term complications in the 30 patients, 75 per cent of which were seen in patients receiving added external beam irradiation.

The use of lasers in the treatment of cholangiocarcinoma

SummarySix of seven patients were treated with external beam radiation, iridium-192 internal radiation and neodymium-YAG laser therapy via a percutaneous transhepatic tract for relief of biliary obstruction. After laser therapy, the transhepatic catheters were removed and patients remained tube-free and non-jaundiced for periods ranging from 1 to 20 months.

Automatic processing of periapical films

Abstract A simple, reliable, and effective means of automatically processing any number of exposed periapical dental films, using a modified Rinn plastic film mount and standard emulsions such as the Kodak periapical Radia-Tized films (Estar base) or Dupont Cronex, is described. The advantages to a busy clinic, hospital, or office are clearly obvious.

IMAGE-INTENSIFICATION FLUOROSIALOGRAPHY.

Abstract Image-intensification fluorosialography is a more satisfactory method than those previously used for making a detailed radiographic examination of the salivary structures. Direct control of the procedure is possible. The method should be used routinely in sialographic examination.

Biological effects evaluated as a function of patient thickness, beam quality, SSD,and treatment schedule.

Continuing efforts are being made by clinical radiotherapists to evaluate radiation complications to normal tissue and organs by specific time‐dose parameters. Currently, the NSD concept of Ellis is receiving wide application in the literature in the reporting of radiation complications and normal tissue tolerances. To afford an easy and broad application of the NSD concept to the evaluation of physiological, functional, or structural changes, the authors have evolved mathematical expressions for the calculations of NSD as a function of patient thickness, beam energy, SSD, and treatment schedule involving coplanar field arrangements whether the fields are treated alternately or simultaneously. Several interesting aspects evolving from the concepts of treatment planning in terms of the NSD or biological effects indicate that: 1) for beam energies above 22 MeV, treatment is more ideally performed by treating only one field per day, since the depth of electronic equilibrium provides more effective sparing of superficial organs and tissues; 2) large‐field therapy, such as the total nodal irradiation of Hodgkinss disease, can be more effectively treated in terms of tissue sparing by higher energy beams than cobalt‐60 or 4‐MeV for practically all patient dimensions; 3) a new concept of integral biological dose, the “gram‐ret,” is proposed, which represents the quantitation of total biological effect; 4) a series of tables with multiplication factors programmed on a digital computer is presented, which very quickly make available the NSD in any fractionated radiation treatment cycle to any plane of the body as a function of the beam energy, SSD, patient thickness, and continuous or split‐course therapy schedule.