Roger E. Cupps

Giant-cell tumor: A study of 195 cases

This study of 195 patients with giant‐cell tumor reemphasizes the female predominance, the predilection for the region of the knee, and the extreme rarity of the tumor in patients with immature skeletons. One of the tumors occurred in a patient with Pagets disease of bone. There were 2 patients with 2 giant‐cell tumors each. Surgical treatment short of complete resection or amputation was followed by recurrence of benign giant‐cell tumor in 44.6% of cases. Adjunctive radiation or cautery did not decrease this rate. Primary en bloc resection or amputation was uniformly curative. Primary radiation therapy had very limited value. Sarcomas developed in 17 patients (8.7%) of the total; these lesions we have called malignant giant‐cell tumors. In 4 instances, zones of anaplastic sarcoma were found in otherwise typical giant‐cell tumors. The remaining 13 sarcomas were found in recurrent tumors, and in 11 of these, the primary treatment had included radiation. The evidence indicates that surgical removal is the best treatment and that radiation should be employed only for tumors that are unresectable because of their location.

Adjuvant radiation therapy for regional nodal metastases from malignant melanoma. A randomized, prospective study

After nodal metastasis from malignant melanoma, approximately 80% of patients die from disseminated disease. To clarify the role of radiation therapy (XRT) following node dissection, 56 patients with biopsy‐proven nodal metastasis participated in a randomized, prospective clinical trial which compares radiation therapy to the regional lymph node area following lymphadenectomy (27 patients) with lymphadenectomy alone (29 patients). Interesting differences in the survival curves (p = 0.09) and in the disease‐free interval curves (p = 0.08) for the two treatment groups proved to be attributable to imbalances in the age and nodal distributions in the treatment groups. Covariate analysis identified age and sex as the factors having the most significant (p < 0.04) effect on survival and identified the number of positive nodes as the covariate having the most significant (p < 0.02) effect on disease‐free interval. Treatment did not have a significant effect upon survival or disease‐free interval. Cancer 42:2206–2210, 1978.

Malignant lymphoma (so-called reticulum cell sarcoma) of bone.

The probability of 5‐year survival for 98 patients with “primary” skeletal lymphoma was 44%. For 81 additional patients with a similar skeletal lesion producing their initial clinical problem but found to have multifocal disease, the probability of 5‐year survival was 23%. Skeletal roentgenologic survey, sternal marrow aspiration, and probably lymphangiography should be employed in assessing such patients. Pulmonary involvement was extremely unusual. Radiation is the treatment of choice. Surgical ablation may be necessary for persistent or recurrent disease. Chemotherapy may be of value for patients with disseminated involvement.

Postradiation Sarcoma of Bone

Thirty-four additional cases of sarcoma developing in previously irradiated bone are documented, bringing the total Mayo Clinic experience in sarcoma appearing after radiation therapy to fifty-five instances. The sarcomas arose in normal bone within the radiation treatment field in eleven patients, while they arose in pre-existing bone lesions in sixteen patients. Osteogenic sarcoma and fibrosarcoma were most commonly diagnosed. The outlook in tumors of this nature is poor, the average survival being 1.14 years, with only two long-term survivors. Although a relationship has been established in experimental animals, a direct relationship between exposure to external radiation and the development of sarcoma is not established in man. There is no absolute proof that ionizing radiation caused any of these sarcomas. However, this and other significantly large series add to the mounting circumstantial evidence that the association between ionizing radiation and sarcoma is a real one. It must also be emphasized that this is a rare complication clinically.

Extramedullary Hematopoiesis Manifesting as a Symptomatic Pleural Effusion

The occurrence of extramedullary hematopoiesis in the pleura is rare and is usually asymptomatic. It is generally diagnosed on postmortem examination. Herein we describe a 61-year-old woman with agnogenic myeloid metaplasia who sought medical assessment because of progressive dyspnea. Thoracentesis yielded sanguineous fluid with 10% myeloblasts. A 99mTc bone marrow scan demonstrated increased tracer activity throughout both lungs, an outcome consistent with extramedullary hematopoiesis. Fine-needle aspiration and video-assisted thoracoscopy were considered but deferred because of the potential risk of profuse bleeding. Treatment with low-dose external beam irradiation to the left posterior pleura was successful. To date, no hemothorax has recurred.

Radiotherapy for large symptomatic hemangiomas

Between 1974 and 1988, 13 patients presented with large (3 to greater than 20 cm) symptomatic unresectable or partially resected hemangiomas. Tumor sites were extremities (five cases), vertebral bodies (three cases), face (two cases), pituitary fossa (one case), pelvic bones (one case), and bladder (one case). Symptoms included severe pain in eight patients, inability to use an extremity in five, vision problems in three, weakness in two, and hematuria with decreased urinary stream in one. Many patients had more than one symptom. Two of the cases were associated with life-threatening consumptive coagulopathies (Kasabach-Merritt syndrome). Therapy was delivered with both orthovoltage and megavoltage photons. Doses ranged from 6.25 to 40.0 Gy in 1.6- to 2.5-Gy fractions. Follow-up ranged from 2 to 15 years (median, 13 years). Tumor shrinkage was noted in 9 (82%) of the 11 cases in which tumor size data were collected before and after therapy. Complete response of tumor mass occurred in 4 (36%) of 11, partial response occurred in 5 (45%), and no response occurred in 2 (18%). No tumor grew after radiotherapy. Some relief in symptoms occurred in all 13 patients; 10 (77%) had complete resolution of symptoms. In both patients with life-threatening cytopenias, hematologic values returned to normal after treatment. Because the majority of the patients responded to all dose levels administered, no firm dose-response relationship was evident. However, objective (measurable) complete responses occurred in two (50%) of the four patients receiving doses of 30 Gy or greater compared with only two (29%) of the seven patients who received lesser doses. No long-term morbidity occurred. Radiotherapy of large unresectable and partially resected hemangiomas yields long-term relief of symptoms and tumor shrinkage in the majority of patients treated.

Definitive Radiation Therapy for Prostatio Carcinoma: Mayo Clinic Experience

Primary radiation therapy for clinically localized prostatic cancer is effective and safe. Of our 147 patients treated between 1964 and 1973, 144 were evaluated 5 years after the initial date of radiation therapy. At 5 years the over-all survival rate was 80 per cent and the rate of survival free of disease was 63 per cent. More than 70 per cent of the patients were free of progression 5 years after the date of the first radiation treatment. Analysis revealed a highly significant association between tumor grade and patient survival (p less than 0.001), and between tumor grade and the interval free of disease (p less than 0.002). The relationship between tumor stage and time to progression of disease also was significant (p approximately equal to 0.01) but there was no relationship between lower stage and longer survival. Of the 142 patients who completed treatment only 20 (14 per cent) had local recurrence of the prostatic cancer after radiation therapy, representing a local control rate of 86 per cent 5 years after treatment. A few of the patients underwent post-treatment prostatic biopsy after radiation therapy. If a biopsy is done for increased prostatic induration and the results are positive adjuvant treatment is recommended. In the absence of urologic symptoms of progressive induration of the prostate gland biopsy is not instrumental in predicting the course of the cancer.

Elective whole lung irradiation in the treatment of osteogenic sarcoma

Fifty‐three patients with histologically confirmed osteogenic sarcoma of bone and no clinical evidence of pulmonary metastases were divided into two equivalent groups: one received elective pulmonary irradiation of 1500 rads administered to both lung fields, and the other acted as a control group. There were no significant differences in either survival probabilities or the interval between treatment and the development of pulmonary metastases. Therefore, elective whole lung irradiation so administered was not found to be of value as a prophylactic measure in the treatment of osteogenic sarcoma. There were no recognized untoward reactions to the pulmonary irradiation.

Results of Radiotherapy for Chemodectomas

Between 1974 and 1988, 10 Mayo Clinic patients had unresectable, locally recurrent, or partially resected chemodectomas. Of these 10 tumors, 9 were confirmed pathologically, and 1 was diagnosed clinically. The chemodectoma was located in the jugular bulb in five patients, the middle ear in three, and the carotid body in two. The following symptoms were noted: tinnitus (in eight patients), loss of hearing (in six), hoarseness (in six), dysphagia (in four), pain (in three), and alteration of mental status (in one). Many patients had more than one symptom. Treatment was delivered with megavoltage photons and electrons; total doses ranged from 16.2 to 52 Gy (median, 46 Gy), and the daily doses ranged from 1.6 to 2.4 Gy. Follow-up among the nine survivors ranged from 3 1/2 to 16 years (median, 7 1/2 years). In one patient, the response could not be assessed because the patient died of renal failure 4 months after treatment. All nine assessable patients had decreased symptoms and objective control of the tumor (no evidence of progression of disease). Of the nine assessable patients, four had complete responses, one had a partial response, and four had stable disease. No patient experienced progression of disease after radiotherapy. We conclude that radiotherapy for chemodectomas yields successful results--namely, decreased symptoms and objective control of the tumor.

Radical Prostatectomy After Radiotherapy for Prostatic Cancer

We report on 18 patients with clinical stages B and C carcinoma of the prostate who underwent radiotherapy to the prostate, followed by radical retropubic prostatectomy and pelvic lymphadenectomy. Of the 18 patients only 2 (1 with grade 1 and 1 with grade 4 disease) had no residual local cancer at operation. Surgical morbidity was minimal in the 18 patients and only 3 patients had spread of the disease after the combined treatment. Radical retropubic prostatectomy after radiation therapy appears to be safe and effective treatment.