Ralph M. Scott

The influence of patients' age and tumor grade on the prognosis of carcinoma of the cervix.

Many factors can influence the prognosis of cancer of the cervix. They range from clinical staging, various histologic cell types, to extensions into the endometrium. Very little is known about the influence of the patients‐ age and constitutional status of the host (patient) on the prognosis of cervical cancer. Over the past several years, we have been observing that when cancer of the cervix occurs in the relatively young patient, they tend to be more aggressive and inspite of the usual accepted treatment, the majority of them do not survive their disease. From 1969 to 1974, 561 patients with proven invasive squamous cell carcinoma of the cervix were treated by irradiation only in the Department of Radiation Therapy, University of Maryland Hospital. Of these, 94 patients were studied and their ages ranged from 23 to 39 years. They were staged following FIGO guidelines and subject to the usual irradiation treatment for cervical cancer. All patients are eligible for a minimum five‐year follow‐up and the absolute five‐year disease‐free survival is as follows: Stage I, 70.2%, (33/47); Stage II, 54%, (14/26); Stage III, 17%, (3/18) and Stage IV, 0%, (0/3). One of the most interesting features observed in Stage I and II disease is distant disease; 26% for Stage I and 42% for Stage II. Further analysis of our result for Stage I and II shows that tumor grading may be responsible for poor outcome. Three Grade systems were used for the study and the result clearly shows that Grade III or poorly differentiated squamous cell carcinoma had the poorest five‐year survival; for example, survival for Stage I disease is 43% and 44% for Stage II. Analysis of the failures following the treatment suggests that about 50% of patients with Grade III disease have already had distant disease by the time the diagnosis was made. Recommendations for futher appropriate treatment is suggested.

Irradiation of nasopharyngeal carcinoma: correlations with treatment factors and stage.

Eighty patients with nasopharyngeal carcinoma were treated with radiotherapy in the Radiation Center at the University of Louisville from January 1955 to December 1980. Among the patients were 70 whites, nine blacks and one Chinese; their ages ranged from eight to 82 years. There was a 40% recurrence rate within the nasopharynx, and a 29% recurrence rate within neck nodes. The five year survival and relapse-free survival rates of the entire group were 36 and 33%, respectively. Forty-nine patients died of cancer, four patients died of intercurrent disease and eight patients were lost to follow-up. Nineteen patients are alive and free of disease. Factors considered in this study included tumor and nodal status, the presence of cranial neuropathy, the size and area irradiated, and dose delivered. Primary site relapse was not demonstrated to be dependent on T group or nodal status, but was likely to be related to inadequacy of original treatment volume and dose. A higher survival was noted with our lymphoepithelioma category (p = .056).

Value of multi-planar CT images in interactive dosimetry planning of intracavitary therapy

A method of intracavitary treatment planning and dosimetry analysis which uses multi-planar reconstructed computerized tomography (CT) images is presented. The aim of the method is to improve ability to precisely locate clinical reference points, to fully define pertinent anatomic structures and to provide dose distributions and their relationship to these structures in multiple planes. Our approach is based on interactive treatment planning and point dose display on sagittal and coronal reconstructed CT images as well as the usual transaxial image. The advantages of clinical evaluation of isodoses directly on multi-planar CT images are assessed. These include precise anatomic and dose relationships between the cervix and paracervical structures, the bladder, rectum and pelvic node-bearing sites. Problems of image magnification, blurred images and inadequate resolution attendant to orthogonal radiographs, which are the basis of current techniques, are minimal. Analysis and results of the method and a comparison with the technique of orthogonal radiographs are presented for a demonstration case.

Treatment of stage IIIB carcinoma of the cervix. Improvement in local control by radium needles implant to supplement the dose to the parametrium

From 1971 to 1974 at the University of Maryland Hospital a total of 53 cases Stage III B cancer of the cervix (FIGO) were treated by a technique consisting of total pelvis irradiation (4000–5000 rad/4–5 weeks) plus a boost to the affected parametrium up to 5500 rad/5 1/2 weeks followed by usual Fletcher‐Suit intrauterine and vaginal radium. An overall absolute three year survival rate (NED) of 49% (26/53) was obtained. Local failure and especially parametrial failure was 51% (27/53). All local failure occurred within one year after the completion of the therapy. Further analysis showed that all local and parametrial failure cases at the time of radium insertion had evidence of residual disease in parametria as well as midline lesion under EUA. Because of the findings suggestive of inadequate radium dosage, a group of patients treated from 1975 to early 1976 who were diagnosed jointly by Gynecologic and Radiation Oncologists as Stage III B (FIGO) had a radium needle implant to the affected parametrium as a booster to the routine radium. Whole pelvis irradiation was given to 4000–5000 rad/4–5 weeks and pelvic wall boost to 5500 rad/5 1/2 weeks as usual prior to radium therapy. 18 cases of Stage IIIB cervical CA. were treated by radium needles implant in conjunction with protruding tandem and have had a careful follow‐up ranging from 15 months to 36 months. Fourteen of 18 cases treated in this fashion showed a complete disappearance of the neoplastic disease (14/18 = 78%). One case was lost to follow‐up and three cases showed local failure within 6 months after therapy (4/18 = 22%). Technique and dosimetry with less than expected complications will be discussed in detail.

Radiation treatment of primary carcinoma of the female urethra.

Because of the rarity of the primary carcinoma of the female urethra, there has been limited experience of individual institutions in management of this disease. Treatment by radiation alone requires radium implant skill in early cases and individualized consideration for integrating external and internal irradiation in more advanced cases. From 1961 to 1975 a total of 16 women with histologically verified primary urethral carcinoma were given radiation treatment at the University of Maryland Hospital. Six of 16 patients were primarily treated for palliation only and 10 were receiving curative radiation treatment. The results show an excellent local control in anterior urethral disease (3/3), entire urethral disease (2/3) and urethral disease with involvement of vulva and/or vagina (3/3). Bladder neck, parametrial, inguinal lymph node, or paraortic involvement represents a poor prognosis and failure is close to 100%. Eight of 10 patients who were treated with aggressive radium alone or combination of external irradiation and interstitial therapy show complete control of disease (80%). Total dosage between 5500 to 6500 rad appears to be adequate to control the disease. Palliative treatment by irradiation alone can only offer a short term symptom‐free result, and should be considered as an occasional alternative modality of choice.

Retreatment of very late recurrent invasive squamous cell carcinoma of the cervix with irradiation. II: Criteria for patients' selection to achieve the success

Very late recurrent invasive squamous cell carcinoma of the cervix (over 10 years) after successful initial radiation treatment is a very rare occurrence (∼0.5%). Even though the treatment of choice has been radical surgery, there are a number of patients in whom surgery was regarded as undesirable. Ten such patients were reirradiated for these late recurrences after the full course of irradiation some 10 or more years ago. Six patients (six of ten) survived disease‐free several years, while the remainder experienced relief of their symptoms. Factors determining success and failure are: (1) the extent of the recurrence (clinical stage); (2) the degree of tumor necrosis; (3) status of normal surrounding tissues; and (4) radiation treatment and doses, integration and individualization of the external beam and brachytherapy. Criteria for patient selection and treatment technique are discussed.

Management of late second or late recurrent squamous cell carcinoma of the cervix uteri after successful initial radiation treatment

Abstract Late second or late recurrent squamous cell carcinoma of the cervix uteri after successful initial radiation treatment is a very rare disease. Surgery is generally accepted as the treatment of choice for late second or recurrent invasive cervical cancer. We have re-irradiated six of eight patients with very late invasive cervical cancer; three survived more than 5 years with no evidence of disease (NED); two achieved good palliative results without major complications. The treatment of choice for second in situ cervical cancer is surgery with excellent results. It is felt that there is a definite need for continued follow-up over many years, especially in the young age group to obtain early diagnosis and effective treatment.

Adenocarcinoma of the uterine corpus following irradiation for cervical cancer

Abstract A series of eight cases with an adenocarcinoma of the uterine corpus occurring 5 to 23 years following radiotherapy for cervical cancer is presented and the literature is reviewed. Abnormal vaginal bleeding was the presenting symptom in only 2 of 8 patients and in only 30.7% of 26 collected cases. In none of the 8 patients was the cancer confined to the uterine corpus. Intraabdominal spread or distant metastasis was documented in 5 of 8 patients and in 12 of 26 collected cases (46%). Survival was extremely poor. Regardless of treatment, all 8 patients died of cancer. The longest survival was 5 years and 1 month. Among 29 collected cases from the literature including present series, only 3 survived 5 years or longer without recurrence and 68.9% of those ( 20 29 ) died of the cancer at the time of publications. These unusual clinical features and the grave outcome may simply indicate the advanced cancer at diagnosis and are believed due to delay in diagnosis resulted from infrequent alarming symptom (vaginal bleeding) in these patients. Postradiation stenosis of the cervical canal and/or obliteration of the upper vagina appear to be the main obstacle.

Basic data on tissue-equivalent compensators for 4-mv x-rays

Abstract The compensator technique to correct for irregular and sloping body surfaces was examined for 4 MV X-rays. Thickness ratios for tissue-equivalent compensators were determined from central axis depth dose measurements and ratios were obtained for various compensator-to-surface distances. Use of a single thickness ratio to compensate over a range of field sizes, at different depths and for various deficit thicknesses was examined; agreement within ±4% was achieved between central axis depth doses of the compensated and normally incident beams. Similar agreement down to a depth of 20 cm. was obtained between isodose distributions of a normally incident beam and an obliquely incident beam that was compensated for a non-uniform thickness of missing material. Errors in depth doses caused by a failure to correct for the reduced compensator thickness were also assessed.

Parametrial implants in the treatment of stage IIIB carcinoma of the cervix. II. Analysis of success and failure.

Local failure (in the cervix and pelvic wall) continues to be a major reason for poor results following conventional radiation treatment of Stage IIIB (FIGO) carcinoma of the cervix. Attempting to minimize this local failure, in 1975 and early 1976, the Radiation Therapy Department, University of Maryland Hospital, began using a parametrial implant technique in a selected group of patients who had met the criteria for implant in Stage IIIB carcinoma of the cervix. Essentially, prior to radium implant, all patients received whole‐pelvis irradiation (4000–5000 rad TP/four to five weeks) plus an appropriate parametrial boost to the affected side (pelvic wall to 5500 rad/over five and a half weeks). Two types of radium were given: 1) a protruding tandem with parametrial implant by means of radium needles; and 2) a radium implant to the lower segment of uterus and affected parametrium plus a vaginal colpostat in cases of severe shortening (or absence) of the uterine cavity or when we were unable to identify the uterine cavity. A total of 31 cases were treated with one or the other of these techniques and have been followed for a minimum of three years. Results show an absolute disease‐free survival rate of 64.5% (20 of 31) with a determinate disease‐free survival rate of 71.4% (20 of 28). The overall local control rate is 84% (26 of 31). Analysis of local and paraaortic failures as well as distant metastases and complications are presented in detail.