Paul W. Scanlon

Radiotherapy of intracranial astrocytomas: analysis of 417 cases treated from 1960 through 1969.

In a review of 417 intracranial astrocytomas treated radiotherapeutically at the Mayo Clinic from 1960 through 1969, the well-known correlation of tumor grade with survival was verified. Totally unexpected was the finding that age was fully as important a discriminant as tumor grade. Another unexpected finding was that patients treated with biopsy only followed by radiation therapy did as well as or slightly better than those subjected to resection followed by postoperative radiotherapy. We could not verify the importance to survival of either large dose or large volume radiotherapy, which has been emphasized by some. Patients receiving less than 1400 rets did just as well as or slightly better than those receiving more than 1400 rets. With low grade astrocytomas, survival beyond 4 years was significantly worse (higher death rates) in the group receiving more than 1400 rets. This suggested the possibility of radiation damage with delayed manifestations. We also could not verify an increased effectiveness for the generally accepted use of total brain irradiation for high grade gliomas.

Ewing's Sarcoma: A Critical Analysis of 165 Cases

Ewings sarcoma is an entity among the malignant neoplasms of bone. Death can result from this tumor after many years, although the lesion usually produces death within two years after diagnosis. Despite the usually lethal effect of Ewings sarcoma, nearly 10 per cent of patients affected can be cured. Our data indicate that irradiation, ablative surgical treatment, or combinations of these can be curative. In the case of tumors of the extremities, amputation with or without preoperative irradiation appears to be the treatment of choice, but the evidence is not overwhelming. Patients who have metastatic processes sometimes can be cured by appropriate irradiation or surgical therapy.

Pleural effusion in lymphoma.

Pleural effusion in lymphoma is usually, but not invariably, a poor prognostic sign. The presence of underlying parenchymal lung involvement or a chylous type of effusion does not further alter the prognosis, but the presence of malignant cells in the fluid probably shortens survival. Obstruction of lymphatic drainage of the lung and pleura by enlarged mediastinal nodes, with resulting lymphedema of the pleural space, is probably the most common cause of nonchylous pleural effusion. In contrast to patients with metastatic carcinoma, pleural involvement by lymphoma is uncommonly the major factor in fluid formation. Radiation therapy to the mediastinum or to the affected hemithorax is more likely to relieve lymphomatous effusions than is intrapleural therapy or systemic chemotherapy alone.

A comparison of short-course, low-dose and long-course, high-dose preoperative radiation for carcinoma of the bladder

This retrospective study failed to detect a significant difference in survival rates between patients with bladder carcinoma who underwent cystectomy after short‐course, low‐dose radiation and those who underwent cystectomy after long‐course, high‐dose radiation. The authors were able to identify in the long‐course‐high‐dose group a subset of patients with an unusually good prognosis, but this advantage was not reflected in survival rates. The value of the ability of the long‐course‐high‐dose preoperative technique to identify a subgroup of patients with a relatively good survival rate remains to be determined. In terms of the current management of bladder cancer, this ability to identify a favorable subset of patients is probably not worth the cost and morbidity involved. If, however, adjuvant chemotherapy is to be considered, this ability might be valuable.

Split-dose radiotherapy: The original premise

Gertrude Stein tells us “a rose is a rose is a rose,” however it is apparent after perusal of the study by Marcia1 et al.’ on the effectiveness of and morbidity from split-dose techniques for carcinoma of the nasopharynx that one man’s opinion of split-dose methods does not necessarily correlate with another’s Their selection of daily doses of 300 rad to large volumes of the upper aerodigestive tract seems incomprehensible in the light of current practice. One has to go back to the 1930’s and 1940’s for examples of similar heavy-increment radiotherapy. Their conclusion, therefore, that the radiation morbidity from their type of heavy-increment split therapy is no less than that from conventional therapy comes as no surprise. Indeed, the surprise comes in the realization that their patients could “stay the course” and that their radiation morbidity was not greater. The flaw in the design of this study rests, I’m sure, not on their failure to appreciate the morbidity from a 300-rad, large-volume daily dose-although there certainly is no precedent in the current radiotherapeutic literature that would legitimatize this dose scheme-but on their inability to evaluate more than one variable in a randomly controlled study. In the design of the current study, Marcia1 et al.’ attempted to evaluate one variable-the split-and kept the overall time constant; therefore, inordinately large daily fractions were necessary in the remaining time. At the Mayo Clinic, experience with split-dose techniques dates from the late 1950’s. More than 8,500 patients have been treated with standard split-dose techniques (180 rad per day to large volumes and 200 rad per day to small volumes). One wonders why Marcia1 et al.’ did not select the dose rate that was used so successfully by us rather than the unorthodox and biologically unacceptable rate of 300 rad per day. Since the original inception of the split-dose methods 20 years ago by Sambrook, Holstie, myself, and others, the principal interest has centered on the effectiveness of such treatment-mistakenly so, in my opinion, since the entire raison d’etre is diminished radiation morbidity and not an overall increase in radiotherapeutic effectiveness. Nearly all the current papers that compare split-dose methods with conventional continuous methods attempt the comparison in terms of survival, local control, freedom of disease, and so forth, rather than in terms of the reduction in radiation morbidity or the increase in safety that split-dose methods reputedly afford. Those few studies that have attempted the latter comparison, such as the current one by Marcia1 et al.’ use time-dose relationships so at variance with the ordinary ones that a valid comparison is simply not possible. A comparable “Catch-22” situation existed in the 1950’s when the question of the effectiveness of cobalt teletherapy in comparison with that of the more conventional orthovolt methods arose and engendered much heated debate through the years as supervoltage techniques were being developed and improved. The question then of the comparative effectiveness of the two methods of treatment was caught up in the insoluble dilemma of whether one should add 10 to 30% to the cobalt dose range to adjust for the admitted biologic differences or whether equal doses of both should be employed for purposes of strict comparison. Obviously, those who believed in the equality of the two methods of treatment demanded that equal doses be compared; those favoring teletherapy insisted that the compensatory adjustment in dose be made and accounted for. Because this question could not be resolved, a satisfactory test comparison was never accomplished; however, after supervolt therapy had been in use for some time, its advantages were recognized and accepted by all. The situation today in the attempt to evaluate splitdose methods is similar. If one insists on one variable in the comparison-the split-and maintains equal overall times, one is forced to use a heavy-increment daily dose on both sides of the split. If one insists on using more reasonable daily dose fractions, the overall time has to be lengthened, a factor that by itself enhances the reduction

Intracavitary use of radium for treatment of atypical uterine bleeding in women of menopausal age

Abstract In the past 20 years there has been a marked decrease in the number of patients receiving the menopausal dose of radium at the Mayo Clinic. In our study, 364 patients of menopausal age received intracavitary treatment of 1,200 mg. hr. of radium during two 5 year periods. The major indications for such treatment were menorrhagia, metrorrhagia, menometrorrhagia, and postmenopausal bleeding. Endometrial carcinoma developed in 5 patients subsequent to their completed radium therapy. At the present time, the initial treatment for abnormal bleeding in women of menopausal age is dilatation and curettage. Should abnormal bleeding persist or recur, hysterectomy might be considered as a means of definitive therapy. The use of radium is reserved for a few selected patients and we anticipate a further decline in its use for atypical bleeding in women of menopausal age.