Robert G. Parker

Sarcomas of the head and neck. Prognostic factors and treatment strategies

The authors reviewed 164 cases of head and neck sarcoma from adult patients seen at the University of California, Los Angeles (UCLA), between 1955 and 1988. The median follow‐up was 70 months. Multivariate analysis demonstrated that tumor grade, size, and surgical margin status were the most important independent prognostic factors. Thirty‐one percent (27 of 85) of patients with high‐grade lesions were free of disease versus 81% (44 of 55) with low‐grade lesions at last follow‐up. Sixty‐seven percent (50 of 76) of patients with lesions smaller than 5 cm were free of disease versus; 38% (33 of 88) with lesions larger than 5 cm. In 16 patients, low‐grade lesions, measuring less than 5 cm and with negative margins histologically, were controlled with surgery alone. For the 94 patients whose primary tumors were treated at UCLA, local control was achieved in 52% (26 of 50) of patients treated with surgery alone and 90% (20 of 22) with combined therapy (surgery and radiation therapy [RT] with or without chemotherapy). Seventy‐five percent (6 of 8) of patients with positive surgical margins treated with post‐operative RT achieved local control versus 26% (5 of 19) of patients receiving no additional treatment. In conclusion, surgery alone appears to be adequate treatment for small, low‐grade tumors and negative surgical margins. Patients with incomplete resection or high‐grade tumors should receive aggressive treatment–surgery and RT.

Fast neutron and mixed (neutron/photon) beam teletherapy for grades III and IV astrocytomas

A study was performed in order to assess the efficacy of using fast neutron irradiation, either alone or in conjunction with megavoltage photons, in treating Grades III and IV astrocytomas. The study encompasses fifteen patients with Grade III lesions and twenty‐two patients with Grade IV lesions. Various fractionation schemes are described. Only one patient is still alive at the present time. Regarding the other patients, the mean survival after completing therapy was 10.8 months for those patients with Grade III lesions and 7.5 months for those patients with Grade IV lesions. Particularly for Grade III lesions, the average survival was appreciably less than that of patients treated with photons alone. The treated patients also had no noticeable improvement in quality of survival when compared with the results of conventional photon irradiation. There was no appreciable difference in survival between the group treated with neutrons alone or with mixed (neutron/photon) irradiation. Autopsy data on fifteen patients showed gross tumor progression in only one instance, and this patient also had liver metastases. In the other fourteen cases, the gross tumor volume was replaced by coagulation necrosis. In general, there were some abnormal cells intermixed with the regions of coagulation. These cells are currently felt to be reactive astrocytes. Both a diffuse gliosis and a white matter demyelination were found in regions far from the tumor volume and this presumably is related to the ultimate cause of death.

Major salivary gland tumors: Treatment results and prognostic factors†

A retrospective review of 133 patients with major salivary gland carcinomas treated between 1955 and 1981 is presented. The majority of cases (104) originated in the parotid gland. The most common histological type was mucoepidermoid carcinoma (39 cases). Tumor‐free interval was longest for patients with acinic cell and mucoepidermoid carcinomas. In contrast, adenoid cystic carcinoma was poorly controlled, regardless of the form of treatment.

A Kinetic Evaluation of Blood—Brain Barrier Permeability in Human Brain Tumors with [68Ga]EDTA and Positron Computed Tomography

Twelve patients with primary and metastatic brain tumors were evaluated with [68Ga]ethylenediaminetetraacetate (EDTA) and positron computed tomography. Using a two-compartment tracer kinetic model, foward (K1) and reverse (k2) rate constants for molecular diffusion across the blood–brain barrier (BBB) were obtained and averaged 0.0029 ± 0.0016 (mean ± SD) ml/min/g for K1 and 0.0310 ± 0.0156 min−1 for k2. Most tracer kinetic models are based on the assumption that tissue radioactivity contains no vascular component or require independent measures of cerebral blood volume (CBV) which are then subtracted from the measure tissue activity. The model in this work differs from that approach by assuming a vascular compartment in the tissue kinetic data. This vascular parameter is estimated from sequential measurements of activity concentrations in regions with an intact BBB or from measurements of 68Ga concentrations in the plasma (the input function). Thus, this approach does not require the assumption of a zero vascular contribution, does not require a separate measurement of CBV, and uses the criteria of constrained estimation to provide estimates of the local CBV and molecular diffusion through the BBB. Estimates of the relative CBV of the lesions in four studies (three subjects) with [68Ga]EDTA correlated well with those obtained with the C15O hemoglobin technique (correlation coefficient of 0.97).

Conservation therapy for invasive lobular carcinoma of the breast

Earlier literature suggests a high incidence of multicentricity and bilaterality, with an overall poor prognosis, in patients with invasive lobular carcinoma of the breast. Consequently, there is considerable disagreement regarding appropriate local management of this disease. To determine the influence of invasive lobular histologic findings on local tumor control, disease‐free survival, and overall survival, the authors reviewed 60 patients with Stage I and II invasive lobular breast carcinoma treated with local tumor excision and radiation therapy between 1981 and 1987 (mean follow‐up, 5.5 years; range, 2.5 to 10 years). The 5‐year actuarial risk of locoregional recurrence was 5%, with two of three failures occurring in the regional lymphatics. The mean time to locoregional failure was 28 months. The 5‐year actuarial disease‐free survival (84%) and overall survival (91%) were comparable to those seen in several large series of similarly treated patients with invasive ductal carcinoma. Contralateral breast cancer occurred at a rate of approximately 0.6% per year. This study and a review of the literature suggest that breast conservation, with local resection and radiation therapy, is appropriate therapy for invasive lobular breast cancer.

Second primary cancers of the head and neck following treatment of initial primary head and neck cancers.

The risk of a second primary cancer arising in the head and neck, following surgical or radiation treatment of an initial primary cancer in the head and neck, was evaluated for 2,151 patients whose first cancers were diagnosed and treated at UCLA between 1955 and 1979. Based on follow-up data ranging from 5 to 30 years, the rate of development of second cancers of the head and neck was in excess of 2.5 per 1000 person-years at risk. There was no statistically significant difference in the frequency or post-treatment interval of second primary cancers related to the type of treatment of the first cancer, whether that was surgery, radiation therapy, or surgery plus radiation therapy.

Radiation therapy for Graves' ophthalmopathy: a retrospective analysis

A retrospective analysis of 29 patients with Graves ophthalmopathy treated from 1973-1986 was undertaken to evaluate the use of radiation therapy (RT). Most patients presented with advanced disease; 20 had been treated with steroids and 8 had undergone prior surgery with orbital decompression. Post-RT evaluation was performed by the patients Radiation Oncologist, Ophthalmologist, and Endocrinologist with a median follow-up period of 45 months. The overall assessment of the patients disease was judged as improved with respect to the majority of signs and symptoms in 48%. Soft tissue changes were relieved in 78% and proptosis reduced in 52%. Ophthalmoplegia responded poorly and was improved in only 24%. After RT, 26/29 (90%) of patients have had no further steroid requirements. Thirteen patients underwent surgery for residual signs/symptoms post radiation therapy, indicating that combined modality may be necessary in many patients with advanced disease.

Hyperbaric oxygen therapy for carcinoma of the cervix—Stages IIB, IIIA, IIIB and IVA: Results of a randomized study by the radiation therapy oncology group

Abstract A total of 65 patients with Stage IIB, IIIA, III3 or IVA carcinoma of the cervix were randomized to receive conventional radiation therapy in air or hyperbaric oxygen therapy with radiation at optimal schedules. Seven patients could not be evaluated. Of the 19 patients treated in oxygen, 14 (73%) were living or had died without evidence of disease. Of the 29 patients treated with radiation alone 15 (52%) were alive or had died without evidence of tumor. Two of 29 patients treated in air and 5 of 19 patients treated in oxygen were dead of complications or intercurrent disease. No significant difference in survival could be demonstrated.

Outcomes and factors impacting local recurrence of ductal carcinoma in situ

The optimal management of ductal carcinoma in situ (DCIS) remains controversial. Investigators have focused on identifying patients who are eligible for treatment by excision alone. A retrospective analysis of patients with DCIS treated by various modalities was conducted to compare outcomes and determine factors significant for local recurrence (LR).

Postoperative irradiation for the prevention of heterotopic bone: Analysis of different dose schedules and shielding considerations

Ninety-seven high risk hips were irradiated postoperatively for prevention of heterotopic bone (HTB) in the UCLA Department of Radiation Oncology from 1980 to 1988. Ninety-two hips in 82 patients were eligible for analysis with a minimum follow-up of 2 months and a median follow-up of 10 months. Forty-nine of the hips had porous coated ingrowth prostheses. From 1980 to 1986, 2 Gy fractions were used to deliver 20 Gy (8 hips), 12 Gy (1 hip), and 10 Gy (27 hips). Since December of 1986, 38 hips received 8 Gy in two increments and 18 hips received a single 7 Gy fraction. All porous ingrowth components were shielded with custom blocks. Six out of 92 hips developed clinically significant (Brooker grade 3 or 4 heterotopic bone). There was one clinically significant failure in 78 hips (1.3%) when irradiation was initiated before post-operative day (POD) #6 and shielding was properly placed. One clinical failure occurred in 38 hips which received 8 Gy in two increments. One clinical failure occurred out of the 18 hips treated with 7 Gy in one fraction. This failure could be related to block malposition. There were four clinical failures in the 36 hips treated with 2 Gy fractions to total doses of 10 Gy, 12 Gy, or 20 Gy. Three of these failures were associated with initiation of treatment after POD #5, and the fourth was related to block malposition. Unshielded trochanteric osteotomies resulted in five migrations and seven fibrous unions for a total non-osseous union rate of 12/36 (33%). Shielding of the remaining 28 trochanteric osteotomies resulted in a non-osseous union rate of 7% (0 migrations and 2 fibrous unions). There were no failures of union of components, and the only side effects noted in the series were the five trochanteric migrations. In conclusion, the use of 8 Gy in two increments or 7 Gy in one fraction was found to be as efficacious as conventional 2 Gy fractionation schemes with no increase in side effects. For optimal results, treatment should be implemented prior to POD #5 with shielding of the trochanteric osteotomy. Postoperative irradiation to prevent HTB can be used in hips with porous components using properly placed blocks to shield the porous region.