Wilms' tumor in an adult: a case report and review of the literature

Wilms' tumor in an adult is extremely rare, with less than 250 cases reported in the world literature. Treatment guidelines for pediatric Wilms' tumor are well established; those for adults are not. This article presents the case of a 19-year-old male diagnosed with Wilms' tumor after complaints of hematuria. He was categorized as Stage IV after nephrectomy and received post-operative radiotherapy and chemotherapy consisting of Vincristine, Adriamycin, and Actinomycin-D. Two years later he was found to have metastases to brain and lungs. He was treated with radiotherapy and bone marrow transplantation, and died of septic shock. The literature regarding Wilms' tumor in adults is reviewed, and current therapy is discussed.

HIV incidence among injecting drug users in New York City syringe-exchange programmes

BACKGROUND

There have been no studies showing that participation in programmes which provide legal access to drug-injection equipment leads to individual-level protection against incident HIV infection. We have compared HIV incidence among injecting drug users participating in syringe-exchange programmes in New York City with that among non-participants.

METHODS

We used meta-analytic techniques to combine HIV incidence data from injecting drug users in three studies: the Syringe Exchange Evaluation (n = 280), in which multiple interviews and saliva samples were collected from participants at exchange sites; the Vaccine Preparedness initiative cohort (n = 133 continuing exchanges and 188 non-exchangers, in which participants were interviewed and tested for HIV every 3 months; and very-high-seroprevalence cities in the National AIDS Demonstration Research (NADR) programme (n = 1029), in which street-recruited individuals were interviewed and tested for HIV every 6 months. In practice, participants in the NADR study had not used syringe exchanges.

FINDINGS

HIV incidence among continuing exchange-users in the Syringe Exchange Evaluation was 1.58 per 100 person-years at risk (95% CI 0.54, 4.65) and among continuing exchange-users in the Vaccine Preparedness Initiative it was 1.38 per 100 person-years at risk (0.23, 4.57). Incidence among non-users of the exchange in the Vaccine Preparedness Initiative was 5.26 per 100 person-years at risk (2.41, 11.49), and in the NADR cities, 6.23 per 100 person-years at risk (4.4, 8.6). In a pooled-data, multivariate proportional-hazards analysis, not using the exchanges was associated with a hazard ratio of 3.35 (95% CI 1.29, 8.65) for incident HIV infection compared with using the exchanges.

INTERPRETATION

We observed an individual-level protective effect against HIV infection associated with participation in a syringe-exchange programme. Sterile injection equipment should be legally provided to reduce the risk of HIV infection in persons who inject illicit drugs.

Radiation therapy for pituitary adenomas. A retrospective study of the University of Louisville experience

A retrospective analysis of treatment outcome was performed on patients treated with radiation for pituitary adenomas at the University of Louisville from January 1988 to December 1992. The study population included 27 patients. Twenty received radiation as a component of their initial treatment while seven received radiation as part of their treatment for recurrent disease. Nineteen patients were treated with post-operative radiation, and eight were treated with radiation alone. Follow-up interval ranged from 1 month to 109 months, with a median of 28 months. All three patients with stage I disease were controlled with radiation alone (1/3) or combined surgery and postoperative radiation (2/3), whereas six of eight stage II patients had disease control following surgery and postoperative radiation. Both patients with stage III adenomas treated with radiation alone had local control, whereas local control was achieved in six of seven with post-operative radiation. Three of five patients with recurrent disease had local control with radiation alone, whereas both patients undergoing surgery and postoperative radiation had local control. This retrospective analysis supports previous findings that radiation therapy alone or combined with transphenoidal resection is effective in long-term control of pituitary adenomas. It further suggests that immediate radiation therapy may be superior to radiation for surgical or medical failures.

High-risk personal networks and syringe sharing as risk factors for HIV infection among new drug injectors

In a cross-sectional study of 174 new injecting drug users (IDUs) in New York City who had injected for < or = 6 years, we examined whether those who both share syringes and have personal risk networks that include high-risk injectors are particularly likely to be infected with HIV. Subjects were street recruited between July 1991 and January 1993, were interviewed about their risk behaviors in the prior 2 years and their personal risk networks with other IDUs in the prior 30 days, and were tested for HIV; 20% were HIV seropositive. Among those who both shared syringes and had a personal risk network member who injected more than once a day, 40% were HIV seropositive (versus 14% for others, p < 0.001). In simultaneous multiple logistic regression, the interaction of both sharing syringes and having a personal risk network member who injected more than once a day remained independently and significantly associated with being HIV seropositive (OR, 3.57; 95% CI, 1.22, 10.43; p < 0.020), along with Latino race/ethnicity and exchanging sex for money or drugs. These findings suggest that the combination of sharing syringes with having a high-risk personal network is a risk factor for HIV infection among new IDUs. Studies of risk factors for HIV infection among new IDUs and interventions to reduce the spread of HIV among them should focus on their risk networks as well as their risk behaviors.

Syringe-mediated drug sharing among injecting drug users: patterns, social context and implications for transmission of blood-borne pathogens

Drug injectors are at risk for infection with human immunodeficiency virus (HIV) and other blood-borne pathogens through the exchange of (infected) blood resulting from unhygienic injecting practices. Research attention and public discussion have focused primarily on the sharing of syringes and needles. While the focus on syringe sharing has sparked important interventions (bleach distribution, syringe exchange) it may have obscured the social relationship in which injecting equipment is used. Drug sharing plays a crucial role in the social organization of the drug using subculture. In this paper, various drug sharing practices and other distinguishable aspects of the injecting process-collectively termed Syringe-Mediated Drug Sharing (SMDS)-are described. All of these behaviors may put injecting drug users (IDUs) at risk for infection. The purpose of this paper is to stimulate scientific inquiry into SMDS behaviors and the social contexts which shape them. Descriptions are based primarily on field studies in Rotterdam and New York City. Recommendations for safer injecting training and education are proposed, as are directions for future research.

Risk factors for human immunodeficiency virus seroconversion among out-of-treatment drug injectors in high and low seroprevalence cities. The National AIDS Research Consortium

From 1988 to 1991, 6,882 drug injectors in 15 US cities were interviewed and had serum samples collected. The interviews and samples were analyzed for determination of significant predictors of human immunodeficiency virus (HIV) seroconversion in the 10 low seroprevalence cities and the five high seroprevalence cities. The unit of analysis was the period of observation between consecutive paired interviews/blood samples. In Cox proportional hazards regression, significant predictors of seroconversion in the low seroprevalence cities were: not being in drug treatment, injecting in outdoor settings or abandoned buildings, using crack cocaine weekly or more frequently, engaging in woman-to-woman sex, being of non-Latino race/ethnicity, and city seroprevalence. Predictors in high seroprevalence cities were: injecting with potentially infected syringes, not being in drug treatment, and having a sex partner who injected drugs. These findings suggest that HIV may be concentrated in sociobehavioral pockets of infection in low seroprevalence cities. For reducing HIV transmission, these results suggest: 1) in low seroprevalence cities, localized monitoring to detect specific emerging sociobehavioral pockets of infection, and quick implementation of appropriate targeted interventions if necessary; 2) in high seroprevalence cities, relatively more emphasis on locality-wide outreach and syringe-exchange projects to reduce risky behavior; and 3) in both types of cities, considerable expansion of drug treatment programs.

Results of irradiation in patients with high-grade gliomas evaluated by magnetic resonance imaging

Evidence shows that most high-grade gliomas are a diffuse process. Prior studies reported a median survival with surgery and postoperative radiotherapy of 8.6 months for glioblastoma multiforme (GBM) and 36.2 months for anaplastic astrocytoma (AA). Since MRI delineated the glioma better than CT scan, using MRI-based radiotherapy treatment planning allows for more precise treatment volumes. We retrospectively reviewed the records of the first 36 patients with malignant glioma, who had a presurgery MRI-based radiotherapy treatment planning. These patients were diagnosed between January 1986 and February 1991. Minimum follow up was 14 months and median survival was 15.4 months for GBM (7-42 months) and 27.4 months for AA (7-53 months). We feel that the trend for increased median survival in GBM (15.4 vs 8.6 months) is partly due to better definition of the tumor volume by using MRI. Larger studies are needed to confirm this finding.

Self-reports of HIV risk behavior by injecting drug users: are they reliable?

While most studies of AIDS risk behavior rely on self-reports, few studies have assessed the reliability of these reports. The present study examines self-reports of drug-related and sexual risk behavior among pairs of injecting drug users (IDUs) recruited from the streets in New York City. Since both members of the pair were interviewed, it was possible to compare their responses in order to assess reliability. Subjects reported on their contacts' demographic data (age, gender, race/ethnicity) and on shared risk behaviors, including syringe sharing. Despite the private and/or illegal nature of AIDS risk behaviors, IDU subjects were generally reliable in their reports of both demographic and AIDS risk behaviors.

Radiation therapy for pancreatic cancer: a retrospective study of the University of Louisville experience

Although multiple regimens and approaches have been used in attempts to treat pancreatic cancer, the 5-year disease-free survival is dismal. With an increase in incidence of pancreatic cancer over the past 35 years, researchers continue their efforts to find an effective treatment for this aggressive disease. Between January 1983 and January 1993, we treated 77 patients with radiotherapy for pancreatic cancer. Only 35 of these patients had localized adenocarcinoma and were treated for cure. In this group of 35 patients, 5 received < 4,000 cGy (mean survival of 5.6 months) and 30 received > or = 4,000 cGy (mean survival of 14.7 months). Twenty-four of these 30 received > or = 5,000 cGy, resulting in a mean survival of 15.4 months, and 17 of these 24 received > or = 6,000 cGy, with a mean survival of 15.7 months. Some palliation of symptoms was achieved in 57% of all patients. These results at the University of Louisville Brown Cancer Center are comparable to other published results, but the prognosis for patients with pancreatic cancer remains bleak.

Operational issues in syringe exchanges: the New York City tagging alternative study

It is estimated that 50% of the approximate 200,000 intravenous drug users (IDUs) in New York City (NYC) are infected with HIV. Syringe exchange, a common method of HIV prevention in many countries was legalized in NYC in 1992. As syringe exchange has gained public support and the number of functioning exchangers has grown in the country, more attention has been given to the study of operational characteristics of syringe exchanges. Syringe exchanges may be considered health service delivery organizations, and the specific methods of service delivery may greatly influence their effectiveness in reducing HIV risk behavior among injecting drug users. Improving operational characteristics of syringe exchanges requires both careful data collection, in order to reduce ambiguity in interpretation, and methods for cumulating knowledge, so that previous learning experiences need not be repeated with each new exchange. We report here on the practice of marking ("tagging") syringes distributed by exchanges in NYC during the period from 1990 through 1994. During this period the NYC exchanges operated illegally as underground exchanges, and then received legal status and expanded greatly. Developing regulations that reflect the reality of the program operations while allowing for monitoring and oversight is a complicated process, especially when implemented in states that maintain paraphernalia and prescription laws and where "unauthorized" possession of injection equipment remains a criminal activity under existing legal statutes. The particular situation in NYC which required the revision of existing regulations during a period of rapid program expansion and implementation of a large system of syringe exchange further illustrates the multiple pressures which accompany such a process. In order to implement meaningful regulations which maximize the public health benefits of syringe exchange programs on an individual and community level, recommendations are made.

Use of magnetic resonance imaging in central nervous system tumors

MRI provides additional information about tumor location, extent, and margins. MRI was used in 158 patients with CNS tumors for treatment planning from 1985-89 and they were studied in a prospective manner. The most common site was cerebrum (73 pts), then extradural spinal axis (21 pts) posterior fossa (17 pts), brain stem (14 pts) and pituitary (13 pts), etc. The most common histological primary tumor was glioblastoma multiform (25 pts), then low grade astrocytoma (22 pts), anaplastic astrocytoma (14 pts), pituitary tumor (13 pts), medulloblastoma (9 pts), ependymoma (7 pts), and germ cell tumors (6 pts). Twenty-nine patients had metastasis to the brain. A majority of the patients with CNS tumors had the studies using Gadolinium-DTPA. Of the patients with CNS tumors, 120 (76%) had better information based on the MRI, which improved the treatment planning (using the three dimensional images) and field arrangement. In 89 patients (56%) the MRI was very decisive in the treatment volume and field arrangement. In 31 patients (20%) the MRI was beneficial and confirmed the treatment plan. MRI provides important additional information for radiation therapy planning.

Pediatric astrocytomas. The Louisville experience: 1978-1988

PURPOSE

The purpose of this study is to retrospectively analyze all pediatric patients with the diagnosis of astrocytoma treated either definitively or postoperatively in our department from 1978 through 1988. Grade, age, T-stage, tumor location, and extent of resection are individually analyzed as prognostic indicators of overall survival.

MATERIALS AND METHODS

Pediatric astrocytoma patients (grades I-IV) diagnosed by CT-guided biopsy or surgical resection were assessed. Patients were treated with external beam radiotherapy to involved fields using 4- or 6-MV photons. Daily doses ranged from 1.5 to 2.0 Gy; total doses from 41.4 to 66 Gy. Treatment was given to 17 patients (9 male, 8 female), aged 18 years and younger: 11 patients had low-grade (I & II) astrocytoma with incomplete margins; 3 patients had anaplastic astrocytoma; and 3 patients had glioblastoma multiforme.

RESULTS

Overall survival at 140 months was 63%. Median follow-up of patients living NED was 69 months, with a range of 39-140 months. Nine of the eleven (82%) low-grade patients survived NED; 1 of 3 anaplastic patients is NED at 44 months follow-up; 1 died of intercurrent disease at 80 months; the third died of disease at 49 months. All three glioblastomas succumbed to local disease at 9, 15, and 27 months from diagnosis. Univariate analysis showed only grade to be prognostically significant (p < .03) in determining overall survival.

CONCLUSION

Postoperative radiotherapy for unresected or partially resected low-grade astrocytomas produces excellent local control. Higher grade astrocytomas require further investigational studies to improve survival and local control. Grade is prognostically significant with respect to overall survival.

Use of P-32 in stage III epithelial carcinoma of the ovary

From 1982 through 1989, 56 patients with Stage III epithelial carcinoma of the ovary received intraperitoneal chromic phosphate following chemotherapy and second look (52 pts) or as the only postsurgical management (4 pts). Median follow-up was 48 months (range of 24 to 108 months). The 4 patients treated following primary surgery with P-32 without chemotherapy had microscopic abdominal disease (3 pts) or complete reduction of gross abdominal disease (1 pt), and their 5-year survival was 100%. Of the 52 patients treated with P-32 following PAC chemotherapy, 23 were pathologic negative, 15 had microscopic residual, and 14 had gross residual at second look. The 5-year survival following second look was 75% for negative, 48% for microscopic, and 32% for gross residual. There were 4 Grade 3 GI complications (7%). There were no complications in the 38 patients who received the P-32 within 12 hr of surgery. The use of P-32 as an adjuvant for Stage I and II epithelial carcinoma of ovary has been found to be effective in prior GOG trials. We have expanded the selection criteria in patients with Stage III carcinoma to include those who can be surgically reduced to microscopic residual at primary surgery or second look following chemo reduction. Because of multiple prognostic variables affecting survival in Stage III ovarian cancer, a randomized study with control arm would be necessary to draw firm conclusions regarding the effectiveness of P-32. The 5-year survival in this group of patients compares favorably to published reports.

Consistent condom use in relationships between seropositive injecting drug users and sex partners who do not inject drugs

OBJECTIVES

To study how condom use in injecting drug users' (IDU) relationships differs according to whether they are HIV-infected, and to whether their sex partner is an IDU.

DESIGN AND METHODS

A total of 317 street-recruited IDU were HIV-antibody tested and interviewed about 421 relationships with particular sex partners.

RESULTS

Condoms were consistently (100%) used in sex between partners (during the previous 30 days) in 33% of these relationships, and their use was significantly more frequent in relationships of seropositive IDU and in relationships with non-IDU partners. In relationships between seropositive IDU and non-IDU, consistent condom use was reported to be high (68%); this remained unchanged under multivariate controls.

CONCLUSIONS

Self-reported condom use by IDU in New York, with its relatively mature epidemic, appears to be concentrated where it may most reduce the spread of HIV to non-IDU heterosexuals, i.e., in relationships between infected IDU and non-IDU partners. Differential condom use by serostatus and by partners' drug injection should be incorporated into mathematical models of the HIV epidemic. Causes of the high level of condom use in this subset of relationships may include drug injector altruism and pressure by sex partners; prevention programs should develop ways to use both of these factors to motivate increased condom use.

The relevance of drug injectors' social and risk networks for understanding and preventing HIV infection

Focusing on the social environment as well as the individual should both enhance our understanding of HIV transmission and assist in the development of more effective prevention programs. Networks are an important aspect of drug injectors' social environment. We distinguish between (1) risk networks (the people among whom HIV risk behaviors occur) as vectors of disease transmission, and (2) social networks (the people among whom there are social interactions with a mutual orientation to one another) as generators and disseminators of social influence. These concepts are applied to analyses of data from interviews with drug injectors in two studies. In the first study drug injectors' risk networks converge with their social networks: 70% inject or share syringes with a spouse or sex partner, a running partner, or with friends or others whom they know. Qualitative data from interviews with injectors in the second study also show that the social relationships between drug injectors and members of their risk network are often based on long-standing and multiplex relationships, such as those based on kinship, friendship, marital and sexual ties, and economic activity. In the first study the vast majority of injectors, over 90%, have social ties with non-injectors. Injectors with more frequent social contacts with non-injectors engage in lower levels of injecting risk behavior. Risk settings may function as risk networks: injectors in this study who inject at shooting galleries are more likely than those who do not to rent used syringes, borrow used syringes and inject with strangers. Since the adoption of a network approach is relatively new, a number of issues require further attention. These include: how to utilize social networks among drug injectors to reduce risk through peer pressure; how to promote risk reduction by encouraging ties between injectors and non-injectors; and how to integrate biographical and historical change into understanding network processes. Appropriate methodologies to study drug injectors' networks should be developed, including techniques to reach hidden populations, computer software for managing and analyzing network data bases, and statistical methods for drawing inferences from data gathered through dependent sampling designs.

Implications of directly observed therapy in tuberculosis control measures among IDUs

Tuberculosis (TB) is a rapidly growing problem among injecting drug users (IDU), especially those infected with human immunodeficiency virus. The authors review IDUs' responses to current TB control strategies and discuss the implications of their findings for the proposed implementation of directly observed therapy (DOT), a method for ensuring that patients take prescribed medication. Field workers carried out 210 ethnographic interviews with 68 IDUs in a Brooklyn, NY, community during 1990-93. Case studies suggested that many IDUs are uninformed about TB and often misinformed about their personal TB status. Ethnographic interviews and observations indicated that the threat of TB-related involuntary detainment may lead IDUs to avoid TB diagnostic procedures, treatment for TB, or drug abuse treatment, and to avoid AIDS outreach workers and other health-related services. IDUs who tested positive for the purified protein derivative (PPD) of TB sometimes have left hospitals before definitive diagnoses were made, because of a perceived lack of respectful treatment, fear of detention, or lack of adequate methadone therapy to relieve the symptoms of withdrawal from drugs. Current TB diagnosis and treatment systems are, at best, inadequate. The threat of TB-related detention discourages some IDUs from seeking any type of health care. There is an urgent need to educate IDUs about TB and to educate and sensitize health care providers about the lifestyles of IDUs. DOT may help in servicing this difficult-to-serve population, particularly if techniques are incorporated that have been developed for other successful public health interventions for IDUs.

Syringe-mediated drug-sharing (backloading): a new risk factor for HIV among injecting drug users

BACKGROUND

In syringe-mediated drug-sharing (backloading), injecting drug users (IDU) use their syringes to mix drugs and to give measured shares to other IDU by squirting drug solution into the syringes of other IDU. Backloading has been discussed as a potential HIV risk factor, but its role as an HIV transmission route has not been established empirically.

METHODS

Six hundred and sixty IDU who had injected drugs in the previous 2 years were street-recruited from Bushwick, New York City through chain referral, tested for HIV antibody and interviewed about sexual and drug-risk behaviors.

RESULTS

Receiving drugs via backloading in the previous 2 years was reported by 24.5% of the subjects. These subjects had significantly higher HIV seroprevalence than those who did not receive drugs by backloading (odds ratio, 2.2; 95% confidence interval, 1.5-3.1). Backloading remained positively and significantly associated with HIV seropositivity in stepwise logistic regression, and in a series of simultaneous logistic models controlling for sociodemographic variables and for sexual and drug risk variables.

CONCLUSIONS

Backloading can be a route of HIV transmission among IDU and should be incorporated into risk-factor studies and HIV transmission modeling. Many IDU who avoid other high-risk drug-injection practices may overlook the risk of backloading. HIV prevention programs should warn IDU against syringe-mediated drug-sharing and work together to develop ways to avoid it.

Phase I-II study of multiple daily fractions for palliation of advanced head and neck malignancies

PURPOSE

To assess palliation of advance head and neck malignancies with the use of rapid hyper fractionation studies similar to the RTOG 85-02.

MATERIALS AND METHODS

37 patients with 39 lesions were entered into the non-randomized Phase I-II protocol, between 1984 and 1991. Previously untreated malignancies were present in 24 lesions, primary recurrent diseases in six patients, metastasis to the head and neck in five patients and skin primaries in the remaining two cases. At presentation 15 of 37 patients (or 17 of 39 lesions) were in operable due to poor medical status, eight patients were considered technically in operable due to extent of disease, 10 patients had distant metastasis and four patients refused surgery. The protocol uses twice a day fraction (370 cGy per fraction) for 2 consecutive days totalling 1,480 cGy per course. Three courses were given at 3-week intervals for a final tumor dose of 4,440 cGy in twelve fraction over 8-9 weeks.

RESULTS

Eleven of 39 lesions had complete response; 19 lesions had partial response; 4 lesions had no response; 3 lesions progressed under treatment. Response could not be assessed in two patients. The average survival after completion of therapy was 4.5 months ranging from 2 weeks to 31 months. Palliation was achieved in 33 of 39 lesions. The acute reactions were minimal and no late or long term complications were noted.

CONCLUSION

The absence of significant complications with reasonable response in the high rate of palliation suggests that this rapid hyper fractionation palliation study should be studied for further evaluation.

Complications in the use of intra-abdominal 32P for ovarian carcinoma

From 1982 through 1989, 94 patients at the University of Louisville with ovarian neoplasm had abdominal instillation of 15 mCi chromic 32P as part of their management. The timing of the 32P was immediately postoperative in 55 patients and delayed greater than 24 hr in 39 patients. This is an analysis of factors contributing to gastrointestinal (GI) complications. GI complications were graded according to RTOG guidelines. There was a total of 11 GI complications grade 3 or worse for an overall incidence of 12%. Factors analyzed include timing of 32P delivery, age, stage, number of previous surgeries, use of Hyskon at surgery, addition of external beam radiation, and subsequent use of chemotherapy. There were significantly fewer complications when 32P was given on the same day as surgery than when 32P administration was delayed more than 12 hr following surgery (4% vs 21%), P = 0.007. This difference held significance when adjusted for the number of previous surgeries, use of Hyskon, external beam radiation, and stage. None of the other factors had a significant effect on complication rate. There have been no incidences of contamination even though 32P instillation in the immediate post-operative period had increased risk of contamination due to wound leakage or reoperation. In our experience, the delivery of 32P in the immediate postoperative period resulted in a significant reduction in abdominal complications.

Incidence of complications with mini vaginal culpostats in carcinoma of the uterine cervix

Between 1980 and 1987, 298 patients with carcinoma of the uterine cervix were treated at the University of Louisville Department of Radiation Oncology. Of these, 197 (66.1%) were treated for cure by radiotherapy alone: 36 by external beam alone and 161 by external beam and tandem and ovoid applications. The F.I.G.O. staging of the 161 patients was 82 (50.1%) Stage IB, 9 (5.6%) Stage IIA, 40 (24.9%) Stage IIB, and 30 (18.6%) Stage III. The usual treatment was whole pelvis irradiation followed by two intracavitary applications using the Fletcher Suit Applicators of tandem and ovoids in 79/161 patients (49%), a 3-M Mini Applicator (Fletcher Suit Delcos Applicator) in 52/161 patients (32.3%), and a 3-M Mini Applicator with Caps in 30/161 patients (18.6%). The incidence of grade 3-4 gastrointestinal or genitourinary complications as defined by the RTOG was 19.3% (31/161). Various treatment parameters were analyzed to define possible contributing factors. Grade 3-4 complications were seen in 7.6% (6/79) of patients treated with the standard ovoid Fletcher system, 26.9% (14/52) treated with the mini-ovoid system, and 36.6% (11/30) treated with the mini-ovoid system with caps (p = .0006). Although trends were noted, neither the vaginal surface dose (VSD) from the ovoids nor the addition of the external beam dose to the VSD (total vaginal surface dose = TVSD) were significant independent variables (p = 0.19 and = 0.133, respectively). The TVSD was significant when comparisons were made between different ovoid systems (p = 0.05 for less than 12,000 cGy and p = 0.004 for greater than 12,000 cGy). In this study, the 3-M mini applicator was associated with a significant increase in grade 3-4 complications as compared to the Standard Fletcher Suit Applicator.

Irradiation and free tissue transfer in head and neck cancer

The aim of this study was to analyze the effects of surgery, irradiation, and free tissue transfer in locally advanced head and neck cancer patients. Forty-one patients with head and neck cancer were treated with surgery, irradiation, and free tissue transfer for reconstruction from 1977 to 1987. The age range was 38 to 78 years with a median age of 61. Patients were staged using the AJCC (1978) staging system. Eighty-four percent of the patients were in stage III or IV. The common sites of primary tumors were the oral cavity (22) and oropharynx (10). Forty patients had squamous cell carcinoma and 1 patient had basal cell carcinoma. Six patients had preoperative irradiation, and the rest had postoperative irradiation. The most common surgical procedures were partial glossectomy and neck dissection (17 patients) and wide excision of the primary and neck dissection (17 patients). The most common types of free tissue transfer were dorsalis pedis (13 patients) and scapular flaps (6 patients). The primary site was controlled in 22 patients (54%) and the neck in 36 patients (88%). Three patients (7.3%) had flap failure which required further surgical management. Eighteen patients are living with no evidence of disease with a median follow-up of 18 months (5-101 months), 10 patients are living with disease with a median follow-up of 9 months (3-40 months), 9 patients are dead of disease with a median survival of 13 months (6-54 months), and 4 patients are lost for follow-up. This study shows that free tissue transfer before or after irradiation is of benefit with few complications.

Glioblastoma multiforme in adults: results of treatment

One hundred and thirty adult patients with brain tumors were treated in the Department of Radiation Oncology, Brown Cancer Center, University of Louisville School of Medicine from 1973 to 1980. Forty-one patients (39%) were diagnosed with glioblastoma multiforme. Forty-two percent of the patients were in the age group of 51-60 years. There were 24 males and 27 females. Forty-seven percent of the patients had partial resection, 27% had total excision and 26% had biopsy only. The radiation dose ranged from 4400 to 6600 rad with a median dose of 5500 rad. The median survival was 8.5 months, (range 3 to 120 months), 38% of patients survived one year or more and 10% survived 2 years or more. A detailed review of the current policy of treatment and of the ongoing clinical trials is done in this paper.

Medulloblastoma: results of treatment

Fourteen patients with a diagnosis of medulloblastoma were treated in the Department of Radiation Oncology, University of Louisville School of Medicine from 1973 to 1979. The age of these patients ranged from 2 to 47 years with a median of 9 years. Twelve of them were 15 years or younger. All patients received craniospinal radiation after surgery, with a boost to the primary site by reduced field. The median dose to the primary was 4736 rads (range 3600 to 5600 rad). The median follow-up was 29.5 months. Six patients have died, and four of those six patients lived more than two years. Eight patients are alive to the last follow-up with a median survival of 29 months. Eight of 14 patients had local control and one patient developed distant metastasis. A brief review of the literature is done in this paper.

Budd-Chiari syndrome secondary to hepatic vein thrombus from Wilm's tumor. Case report and literature review

We describe a case of Budd-Chiari Syndrome in a 6-year-old boy secondary to Wilm's tumor. The patient had a right nephrectomy and mediastinotomy with removal of the tumor from the right atrium, inferior vena cava, and hepatic vein. Postoperatively, the patient had chemotherapy consisting of Actinomycin-D to be followed by radiation to the tumor bed to a total dose of 2000 rads in 10 fractions by using AP/PA field on 6 MeV Linear Accelerator. Currently, the child is receiving combination chemotherapy.

Evaluation of unplanned interruptions in radiotherapy treatment schedules

One of the major radiobiological interests has been to maximize the effectiveness of the time-dose relationship in the clinical setting. Current explorations include altered fractionation schedules, multiple daily fractions and hypofractionation. Patient compliance to standard radiotherapy treatment schedules is taken for granted. To evaluate the true rate of compliance, the charts of all new patients treated from July 1, 1984 through June 30, 1985 were reviewed. The overall incidence of unplanned interruptions was 54% (361/668). The frequency of interruptions is significantly higher in patients treated to the primary site as compared to those treated for metastasis (59.8% and 35.6% respectively). The duration of the interruptions varied: 12.7% of the patients missed only 1 day, 25% missed 2 to 5 days, 38% had interruptions totalling 6-15 days, and in 24% the total exceeded 15 days. The most frequent cause of the unplanned interruptions was a rest resulting from unusually adverse tissue reactions (46.8%-169/361). Although this study has documented that unplanned interruptions are a major problem, the impact on local control and survival cannot be determined from our data. A retrospective review of multi-institutional studies such as those conducted by the Patterns of Care or RTOG might show that one of the major causes of failure is unplanned interruptions.