Milton Raben

Positron emission tomography of patients with head and neck carcinoma before and after high dose irradiation

Background. Positron emission tomography (PET) with labeled fluorodeoxyglucose (FDG) demonstrates in creased tracer uptake in many neoplasms. This study was undertaken to define the patterns of FDG uptake in head and neck neoplasms before and after high dose irradiation.

Distinguishing tumor recurrence from irradiation sequelae with positron emission tomography in patients treated for larynx cancer.

PURPOSE Distinguishing persistent or recurrent tumor from postradiation edema, or soft tissue/cartilage necrosis in patients treated for carcinoma of the larynx can be difficult. Because recurrent tumor is often submucosal, multiple deep biopsies may be necessary before a diagnosis can be established. Positron emission tomography with 18F-2fluoro-2deoxyglucose (FDG) was studied for its ability to aid in this problem. METHODS AND MATERIALS Positron emission tomography (18FDG) scans were performed on 11 patients who were suspected of having persistent or recurrent tumor after radiation treatment for carcinoma of the larynx. Patients underwent thorough history and physical examinations, scans with computerized tomography, and pathologic evaluation when indicated. Standard uptake values were used to quantitate the FDG uptake in the larynx. RESULTS The time between completion of radiation treatment and positron emission tomography examination ranged from 2 to 26 months with a median of 6 months. Ten patients underwent computed tomography (CT) of the larynx, which revealed edema of the larynx (six patients), glottic mass (four patients), and cervical nodes (one patient). Positron emission tomography scans revealed increased FDG uptake in the larynx in five patients and laryngectomy confirmed the presence of carcinoma in these patients. Five patients had positron emission tomography results consistent with normal tissue changes in the larynx, and one patient had increased FDG uptake in neck nodes. This patient underwent laryngectomy, and no cancer was found in the primary site, but nodes were pathologically positive. One patient had slightly elevated FDG uptake and negative biopsy results. The remaining patients have been followed for 11 to 14 months since their positron emission studies and their examinations have remained stable. In patients without tumor, average standard uptake values of the larynx ranged from 2.4 to 4.7, and in patients with tumor, the range was 4.9 to 10.7. CONCLUSION Positron emission tomography with labeled FDG appears to be useful in distinguishing benign from malignant changes in the larynx after radiation treatment. This noninvasive technique may be preferable to biopsy, which could traumatize radiation-damaged tissues and precipitate necrosis.

Response of superior vena cava syndrome to radiation therapy

The treatment of a superior vena caval obstruction associated with a mediastinal mass is a true radiotherapeutic emergency. The heralding signs and symptoms and the morbidity of the syndrome justify beginning therapy before a pathologic diagnosis is established. In a series of 19 patients with superior vena cava syndrome, there was an excellent response to an initial high‐dose course of irradiation, consisting of 400 rads midplane for 3 days, then reduced to conventional daily fractionation. It is concluded that rapid high‐dose irradiation in the treatment of a superior vena cava syndrome is safe and effective.

Radiation therapy in the treatment of superior vena caval obstruction.

The obstruction of the superior vena cava by tumor is recognized as an acute or subacute oncologic emergency. Rapid high‐dose irradiation to the mediastinum is shown to be effective therapy for a superior vena caval obstruction. In our series 35 patients have been treated with rapid high‐dose irradiation between January 1971 and July 1977. The present treatment consists of 400 rad given in a daily midplane dose for 3 days, and then slowing to 150 rad mid‐plane per day to a total dose of 3000 rad over 15 fractions. There have been no instances of exacerbations of symptoms or severe complications from this treatment. There have been 2 failures of the 35 patients treated with this regimen. Both were shown at autopsy to have massive thrombi obstructing the superior vena cava. Six years of experience using this regimen has proven to be a safe and effective means of treatment for superior vena caval obstruction. Cancer 42:2600–2603, 1978.

Role of intracavitary cuff boost after adjuvant external irradiation in early endometrial carcinoma.

Management of early endometrial carcinoma often consists of surgicopathologic staging followed by adjuvant radiation therapy (RT) for patients at risk of local recurrence. While an intracavitary vaginal cuff boost (VCB) is commonly given after external beam radiation therapy, its effects on local control and complication rates are unknown. To assess these effects, we reviewed 157 patients with FIGO Stage I (n = 134) or incidentally diagnosed (n = 23) endometrial adenocarcinomas. After surgery and external radiation therapy, 103 patients (65.6%) received a vaginal cuff boost of 3000-5000 cGy surface dose (Group I) and 54 (34.4%) did not (Group II). One hundred and two Group I and 52 Group II patients were evaluable for analysis. Median follow-up was 78.0 months for Group I and 60.0 months for Group II. Despite a preponderance of poor prognostic factors in Group II, no significant difference in local failure was seen. A component of local failure was seen in 6 Group I patients (6.0%) and 4 Group II patients (7.7%), p = 0.74. Distant failure, reflecting more advanced disease, was higher in Group II (19.2%) than in Group I (9.0%). Late complications included rectal bleeding/proctitis in 18.6% of Group I patients and 3.8% of Group II patients (p = 0.01). Overall, grade 2 complications occurred in 27.5% and 15.4% of Group I and II patients, respectively (p = 0.09). No difference in frequency of grade 3 complications was evident. Based on this retrospective study, intracavitary vaginal cuff boost after surgery and postoperative external beam radiation therapy does not appear to improve local control in early endometrial adenocarcinoma. Its possible effect on complication rates is uncertain.

Metastatic carcinoma of the neck from an unknown primary

From 1974 to 1984, 31 patients with metastatic carcinoma to the neck from an unknown primary were treated with radiation therapy. On review, three groups were identified based on presentation and treatment. Group I consists of 19 patients treated with curative intent. They all presented with cervical adenopathy, 11 patients with N1 disease, 2 with Stage N2A disease, 1 with Stage N2B disease, 4 with N3A disease, and 1 with unknown stage. The majority of patients were treated with portals encompassing the nasopharynx, oropharynx, hypopharynx, and neck to a dose of 5000 rad followed by boosts of 1000-1500 rad. The overall 2-year NED survival in this group was 63% (12/19). The most significant prognostic factor was the stage of the metastatic nodes. The NED survival rate for the 14 patients with Stage N1 and N2 was 86% (12/14). Histology of the lesions was not an important factor in the outcome. In Group II there are six patients who received palliative treatment because of large, fixed, cervical nodes. Three of these patients (50%) died within 2 months of completion of treatment. Group III consists of six patients who presented with supraclavicular adenopathy. All had persistent or recurrent disease within 19 months. We have concluded that in patients with metastatic carcinoma to the cervical nodes from an unknown primary, radiation therapy to the neck and suspected areas of primary disease may play an important role in cure, particularly in early stage disease.

Brain Tumors in Children: Analysis of 136 Cases

Between 1960 and 1971, 137 children with inoperable or partially resectable brain tumors were treated in the Division of Therapeutic Radiology at Duke University. The treatment approach to each major type of tumor is discussed, including radiotherapy techniques and time-dose relationships. Results are presented with regard to survival time, complications of radiation, symptomatic relief and quality of survival. Particular emphasis is placed on the question of retreatment and tolerance of the brain to irradiation.

Prostate cancer: Comparison of retrograde urethrography and computed tomography in radiotherapy planning

PURPOSE To prospectively compare the role of retrograde urethrography and high-quality computed tomography during the treatment planning of patients with prostate cancer. METHODS AND MATERIALS Forty consecutive men with localized prostate cancer underwent planning computed tomography prior to stimulation. At the time of simulation we performed retrograde urethrography and compared the location of the inferior border of the urogenital diaphragm to the location of the ischial tuberosities and the prostate and base of the penis as seen on the computed tomography scan. RESULTS Interobserver identification of the prostatic apex varied in 70% of the cases. Perhaps due to this variability, attempts to place the inferior border of the treatment field in relation to the prostatic apex resulted in an inadequate margin (< 1 cm) beneath the urogenital diaphragm in 5%. In contrast, placing the inferior border at the ischial tuberosities or the base of the penis as seen on computed tomography insured an adequate margin for all patients. The distance from the urogenital diaphragm to the ischial tuberosities and, thus, the potential margin beneath the urogenital diaphragm was > 2 cm in 77%, while the distance from the urogenital diaphragm to the base of the penis was > or = 2 cm in only 43%. CONCLUSION This demonstrates the difficulty in reliably identifying the prostate on computed tomography. Nevertheless, by identifying the base of the penis, planning computed tomography provides adequate information to cover the target volume, and results in minimal overtreatment of normal structures. Urethrograms are not necessary if the computed tomography is properly used or if the ischial tuberosities are used as a standard inferior border, but they can reduce the length of urethra in the treatment volume which could potentially reduce complications.

Efficacy of Radionuclide Scanning in Patients With Lung Cancer

Ninety-two patients with histologically proved carcinoma of the lung were studied retrospectively to determine the usefulness of liver, brain, and bone imaging in their examination and treatment. Occult metastatic liver disease was observed in two (5.3%) of 38 asymptomatic patients, while four (6.6%) of 58 neurologically intact patients had abnormal brain scans. Eight (13.6%) of 59 asymptomatic patients had metastatic bone disease. Seven (18.4%) of 38 patients with no clinical evidence of metastatic disease to liver, brain, or bone had at least one type of abnormal radionuclide study. More than half (52.5%) of the patients studied had at least one abnormal scan exclusive of symptoms. Radionuclide imaging is a useful procedure in the initial evaluation and subsequent management of lung cancer.

Proton NMR relaxation times in the peripheral blood or cancer patients

The proton spin lattice relaxation time (T1) of serum and leucocytes of cancer patients and normal volunteers was measured using pulsed NMR techniques. There was no statistically significant difference in the serum T1 values of cancer patients relative to normal. An increase in T1 relative to normal values was detected in the white blood cells of patients with active leukaemia. In these patients T1 fell to normal levels after the initiation of treatment. The variation of leucocyte T1 with the course of the disease for five patients having leukaemia is presented.