Implications of quantitative tumor and nodal regression rates for nasopharyngeal carcinomas after 45 Gy of radiotherapy

PURPOSE

To quantitatively investigate the clinical implications of tumor regression rate (TRR-45) and nodal regression rate (NRR-45) of nasopharyngeal carcinomas (NPC) after receiving 45 Gy of radiotherapy (RT). The values, predictive values, and associated factors of TRR-45 and NRR-45 in NPC are analyzed.

METHODS AND MATERIALS

One hundred one patients with newly diagnosed NPC and who were curatively treated by RT alone were included in the study. Tumor volume and nodal volume before treatment and after 45 Gy were obtained from computed tomographic (CT) scans performed at those times and calculated with the assistance of a computer-based imaging analyzing system. TRR-45 (NRR-45) was defined as the ratio of reduced tumor (nodal) volume after 45 Gy to the initial tumor (nodal) volume. TRR-45 (NRR-45) values were stratified into three groups of slow (below 50%), moderate (between 50% and 75%), and rapid (above 75%) change. After conventional RT with 45 Gy, conformal RT for primary tumors was boosted to 70.2-72 Gy for T1-2 tumors, and 75.6-81 Gy for T3-T4 tumors. RT for residual neck masses was boosted by electron beam to 61-75 Gy.

RESULTS

The mean value of TRR-45 for all patients was lower than that of NRR-45 for the 78 patients with metastatic neck nodes (70% +/- 4.8% vs. 81% +/- 5%, p = 0.003). The 3-year actuarial neck control rate was better than the primary tumor control rate with statistical significance (98% vs. 85%, p = 0.009). No significant statistical differences concerning local control probability, nodal control probability, or survival rate were found among patients with slow, moderate, or rapid TRR-45 or NRR-45. T-stage was the only significant prognostic factor for locoregional control after multivariate analysis. Tumor volume and T-stage were found to have a statistically significant negative correlation with TRR-45. No associated factor was found to be significantly correlated with NRR-45.

CONCLUSION

Slow regression rates of the primary tumor or neck nodes in NPC after receiving 45 Gy of irradiation do not mean ultimately poor radiocurability, but may merely imply slow clearance of the cells damaged during irradiation. The different radiobiological behaviors of the regression rates during treatment, ultimate control probabilities, or associated factors for regression rates of NPC between primary tumors and neck nodes need to be further investigated.

Dermatofibrosarcoma protuberans: treatment results of 35 cases

BACKGROUND AND PURPOSE

This study evaluates the treatment results of patients with dermatofibrosarcoma protuberans.

PATIENTS AND METHODS

Between August 1987 and July 1998, 35 consecutive patients with pathologically proved dermatofibrosarcoma protuberans received surgery with or without radiation therapy. Their treatment results were analyzed retrospectively.

RESULTS

The patient ages ranged from 5 to 67 years (median 37 years). There were 24 males and 11 females. The anatomic sites of tumor were: trunk in 21, extremity in eight, and head and neck region in six. The maximal dimension of tumor ranged from 1.5 to 25 cm. Surgery techniques included local excision and wide excision with or without graft or flap. Adjuvant radiation therapy was given to 11 patients, with a dose ranging from 46 to 68 Gy (one pre-operative, ten post-operative). At a median follow-up of 50 months (range 11-131 months), there were 11 patients (nine patients without radiation therapy) who developed local failure. Salvage therapy (excision with or without radiation therapy) was given to all of them, and ten achieved disease control. Some patients had treatment-related moderate cosmetic or functional problems.

CONCLUSIONS

Dermatofibrosarcoma protuberans is a malignancy of a high cure rate, and adjuvant radiation therapy can reliably decrease the local recurrence rate and prevent mutilation and functional deficit caused by repeated surgery.

Multivariate analysis of pulmonary fibrosis after electron beam irradiation for postmastectomy chest wall and regional lymphatics: evidence for non-dosimetric factors

BACKGROUND AND PURPOSE

To evaluate the factors associated with pulmonary fibrosis after postmastectomy electron beam irradiation of chest wall and regional lymphatics in patients with breast cancer.

MATERIALS AND METHODS

From July 1987 through July 1994, 109 women with stage II and III breast cancer receiving modified radical mastectomies were managed by postoperative electron beam irradiation. Doses of 46 to 50.4 Gy were delivered to the chest wall covered with bolus, internal mammary nodes, supraclavicular nodes and axillary lymph nodes via 12 or 15 MeV single portal electron beam. Seventeen patients received additional 10-16 Gy surgical scar boost via 9 MeV electron beam. Comparison of pre-treatment and post-treatment chest X-ray films were used to monitor the development of pulmonary fibrosis.

RESULTS

Only Grade 1 radiation-induced late pulmonary toxicity was noted in 33 patients (29%). Twenty-six patients (24%) developed pulmonary fibrosis under unbolused chest wall. Lung fibrosis under bolused chest wall was noted in 11 patients (10%). Statistical difference (P<0.01) was noted between the incidence of fibrosis in these two sites. In multivariate analysis of lung fibrosis under unbolus-covered chest wall, the independent prognostic factors are low body mass index (BMI) (P<0.01), tamoxifen taking (P=0.03), and no treatment interruption (P=0.03). No independent factor was associated with lung fibrosis under bolus-covered chest wall in multivariate analysis.

CONCLUSIONS

In the analysis of pulmonary fibrosis induced by unbolused electron beam, BMI rather than body weight and body height is a strong prognostic factor. Tamoxifen and short overall time can predispose the development of lung fibrosis.

Intratumoral regional differences of DNA ploidy of gastrointestinal stromal tumors: a flow cytometric study

BACKGROUND

Mesenchymal neoplasms of the gastrointestinal tract remain controversial in regard to both diagnostic criteria and prognostic factors. In order to investigate whether DNA ploidy in a single area of a tumor can be representative of the entire tumor, multiple samples from the same tumor were analyzed in 79 cases of gastrointestinal stromal tumors.

METHODS

Forty-three male and 36 female patients, aged 11 to 80 years with stromal tumors of the GI tract were selected. Flow cytometric DNA ploidy analysis was done on tissue cut from paraffin blocks by using the modified technique of Hedley et al.

RESULT

All 34 benign stromal tumors displayed a concordant diploid DNA content. Eighteen (40%) of the 45 malignant stromal tumors (13 low-grade, 5 high-grade) were diploid. Aneuploid and polyploid DNA stemlines were found in 10 cases (43.4%) of low-grade stromal tumors, and in 17 cases (77.2%) of high-grade stromal tumors. DNA polyploidy was identified in 21 (46.7%) of 45 malignant stromal tumors. Also, aneuploid populations were accompanied by diploid populations.

CONCLUSION

DNA content correlated well with histologic category. Tumor aneuploidy was more frequently seen in tumors of advanced stage, but no relationship was seen between tumor stage and the presence of tumor heterogeneity. Differences in ploidy levels were thus not necessarily associated with apparent differences in histologic patterns. The mechanism responsible for regional differences in DNA ploidy in the same tumor remain unexplained. Several hypotheses are reviewed.

Healing of superior vena cava defect in mediastinal seminoma with invasion

We present an unusual case of mediastinal seminoma with direct intraluminal invasion into the superior vena cava (SVC) and extension to the right atrium. Magnetic resonance imaging demonstration of the SVC defect due to tumor invasion was important for determining treatment strategy because rapid posttherapeutic tumor regression may increase the risk of SVC rupture. Gradual healing of the SVC defect at the tumor entrance site was attained using a tailored treatment plan with radiotherapy and chemotherapy.

Concomitant boost radiation therapy for inoperable non-small-cell lung cancer: preliminary report of a prospective randomized study

PURPOSE

The radiation therapy results for patients with inoperable non-small-cell lung cancer (NSCLC) have been disappointing. Tumor dose escalation using concomitant boost technique (CBT) has been shown to improve local control in a few prospective studies. This trial was carried out to prospectively assess the radiation response and acute toxicity of CBT in comparison to the conventional treatment technique (CTT).

METHODS AND MATERIALS

Ninety-seven consecutive eligible patients were entered in this prospective clinical trial between November 1994 and February 1998. Patients were randomized to receive either CBT (43 patients) or CTT (54 patients) radiation therapy. These patients either refused chemotherapy or were judged as unsuitable for chemotherapy. Patients in the CBT group received 46.8 Gy in 26 fractions using large fields that encompassed the gross and occult disease. A concomitant boost of 18.2 Gy (0.7 Gy per fraction) was delivered to the gross disease using small fields with 1.5-cm margins. The small fields were treated concurrently with the large fields and the total dose to the tumor area was 65 Gy in 26 fractions. Patients in the CTT group received 70.8 Gy in 38 fractions. The acute toxicity between each group was compared. The response rate was analyzed and compared by treatment group, gender, age, stage, histology, initial Karnofsky performance score (KPS), severity of acute toxicity, and maximum body weight loss (MBWL) during treatment course.

RESULTS

The demographic parameters such as sex, age, and stage were evenly distributed in each treatment group. The majority of these patients had Stage IIIA and IIIB disease. Overall median treatment times were 39 days for the CBT group of patients and 62 days for the CTT group. No treatment-related mortality was found. There were 2 patients in the CTT group with acute RTOG Grade 3 lung toxicity, and no Grade 3 lung or esophageal toxicity was observed in CBT group. The response rates, assessed by radiographic images, were 69.8% and 48.1% for the CBT and CTT patients, respectively. Univariate and multivariate analysis revealed that patients in the CBT group, patients with better KPS, and patients with more severe acute toxicity had a higher response rate.

CONCLUSION

This study demonstrates that concomitant boost radiation therapy is tolerable, and produces a superior response rate than conventional radiation therapy for patients with inoperable NSCLC. The length of treatment was reduced from 38 to 26 treatment days, almost a 30% reduction.

Oral glutamine to alleviate radiation-induced oral mucositis: a pilot randomized trial

PURPOSE

To evaluate the influence of oral glutamine on radiation-induced oral mucositis in the radiotherapy of head and neck cancer.

METHODS AND MATERIALS

From July 1997 through June 1998, 17 patients with head and neck cancer receiving primary or adjuvant irradiation were randomized to either glutamine suspension (16 g in 240 ml normal saline) (n = 8) or placebo (normal saline) (n = 9) arm. Patients were instructed to swish the test solutions (30 ml) four times per day. All patients received half-mouth irradiation at least. Patients were treated 1.8 Gy per fraction daily, 5 days a week. We evaluated the grading of oral mucositis daily fraction at each day of treatment until 45 Gy/25 fractions. World Health Organization (WHO) step analgesic medication and body weight change were compared between the two arms.

RESULTS

The duration of objective oral mucositis > or = Grade 1 (p = 0.0097), Grade 2 (p = 0.0232), and Grade 3 (p = 0.0168) was shorter in the glutamine arm. Mean maximum grade of objective oral mucositis was less severe in the glutamine arm (1.6 vs. 2.6) (p = 0.0058). Glutamine did not reduce the duration and severity of subjective oral mucositis except for duration > or = Grade 3 (p = 0.0386). In the analysis of mean maximum WHO step of analgesic medication, there was no statistical difference (p = 0.5374) between the two arms. Mean body weight change was also not significantly different (p = 0.8070).

CONCLUSIONS

Oral glutamine may significantly reduce the duration and severity of objective oral mucositis during radiotherapy. It may shorten the duration of > or = Grade 3 subjective mucositis.

Computed tomography findings of bony regeneration after radiotherapy for nasopharyngeal carcinoma with skull base destruction: implications for local control

PURPOSE

To evaluate the response of bony destruction (BD) of the skull base following radiotherapy in nasopharyngeal carcinoma (NPC) and investigate the implications of bony regeneration (BR) on local control and its related factors.

METHODS AND MATERIALS

Ninety patients with NPC with skull base destruction clearly demonstrated on computed tomography (CT) were reviewed. These patients have completed the prescribed treatment and received regular CT follow-up. A total of 338 sets of CT images of the head and neck were reviewed. The tumor response and the appearance of BR in the previous destructive part of the skull base were recorded and analyzed. The tumor response was divided into complete, partial, or no response. BR was defined as recalcification or sclerotic change with partial or complete healing in the previous osteolytic bony defect. Local failure was confirmed either by pathological or merely by imaging studies showing progression of tumor in consecutive radiological pictures.

RESULTS

The distribution of specific sites of bony destruction (BD) in these patients included the sphenoid bone (68%), paracavernous sinus area (48%), petrous apex (47%), clivus (44%), pterygoid plates (20%), and others (7%). The CT showed 57 patients (63%) had BR. All were observed within 1 year after treatment. Sixty-two patients (69%) had complete tumor response after treatment. Analyzed by logistic regression method, tumor response after treatment was found to have a statistically significant correlation with BR (p = 0.0004). Most BR (55/57) was demonstrated in patients with complete tumor response. The 3-year actuarial local control rate was 54 % in these patients. The local control was quite different in the comparison of patients with BR versus those with persistent BD (77% vs. 21%, p < 0.0001). Multivariate analysis showed that patients with complete tumor response or with BR on imaging had statistically better local control than those without either of the two findings (p < 0.05).

CONCLUSION

Appearance of BR at previous destructive skull base following radiotherapy for NPC patients could be clearly demonstrated on CT. Bony regeneration significantly correlated with treatment response and local control. Although the underlying significance of BR was unknown, to predict the outcome after treatment, the appearance of BR shown on CT may imply the complete eradication of tumor in this area.

Postoperative radiotherapy for supratentorial malignant gliomas

From January 1988 to December 1996, sixty-five patients with histologically confirmed supratentorial malignant gliomas were treated with postoperative radiation therapy in our department. They were subjected to this analysis according to different clinical and pathologic parameters. The overall 1-year, 2-year survival rate was 57% and 23%, respectively. With univariate analysis, age, postoperative Karnofsky performance status, duration of symptoms, multiplicity of lesions and the extent of surgery were identified as significant prognostic factors. With multivariate analysis, postoperative Karnofsky performance status and the extent of surgery continued to show independent prognostic significance on overall survival.

Radiation therapy in primary central nervous system lymphoma

BACKGROUND

Treatment of primary central nervous system lymphoma (PCNSL) in Chinese individuals has rarely been reported. Therefore, this article presents our experience in managing PCNSL with radiotherapy.

METHODS

A thorough review was made of the medical records of 13 patients diagnosed with PCNSL at Kaohsiung Chang Gung Memorial Hospital from 1988 through 1997. The clinical characteristics, treatment modalities, and results were analyzed as well.

RESULTS

Thirteen patients diagnosed with PCNSL were identified, of which 10 cases originated in the brain whereas three were of spinal origin. Seven of the patients were man and six were women, with a mean age of 54.9 +/- 13.1 years (range 29 to 74 years). Diffuse large cell lymphoma (11 cases) was the most common histology. Limb weakness (11 cases) and headache (7 cases) were the most common complaints at presentation. Nine patients received radiation therapy alone and four patients received radiation therapy plus chemotherapy after surgical resection or biopsy. Follow-up computed tomography (CT) scans 3 to 4 months after the completion of radiotherapy revealed that nine patients (69%) had a complete response and four (31%) had a partial response. Local recurrence occurred in five patients (56%) treated with radiation therapy alone and in one patient (25%) treated with combined modalities. The overall actuarial survival rate was 54% at 2 years and 27% at 5 years.

CONCLUSION

Results in this study indicate that the initial response to radiotherapy is satisfactory. However, a local relapse frequently occurs. Future considerations should focus on new modes of treatment, such as three-dimensional conformal radiation therapy for dose escalation or a combination of chemotherapy and radiotherapy.

Local vaginal anesthesia during high-dose-rate intracavitary brachytherapy for cervical cancer

PURPOSE

To evaluate the clinical efficacy of local vaginal lidocaine application for pain relief during high-dose-rate (HDR) intracavitary brachytherapy for patients with cervical cancer, and to investigate sequential changes in serum levels of lidocaine during the procedures.

METHODS AND MATERIALS

This prospective study was designed to examine the analgesic effect, physical response, and side effects of local anesthesia during HDR intracavitary brachytherapy. Forty patients were enrolled. All patients received 10-15 MV X-rays to the pelvis with a total dose of 45-59.4 Gy 5-6 weeks before undergoing HDR intracavitary brachytherapy. All patients underwent first intracavitary brachytherapy under general anesthesia. These patients were randomly allocated to receive one of two different treatment protocols as follows: (1) treatment session - control session - treatment session - control session; or (2) control session - treatment session- control session - treatment session. In the treatment sessions, topical anesthesia was administered using 4 ml of 10% lidocaine solution sprayed liberally on the cervix and vagina during intracavitary brachytherapy. In the control sessions, a placebo was administered in the same manner during brachytherapy. The Hensche's applicators for brachytherapy were inserted into the cervix and vagina 5 min after lidocaine application. The visual analogue scale (VAS) was used to assess pain and discomfort during brachytherapy. Blood pressure and heart rates were measured to evaluate the physiological response. Another prospective study was then performed to investigate the sequential changes of serum lidocaine levels during the anesthetic procedure. Eleven additional patients with similar disease state and demographic characteristics were enrolled and blood samples were obtained before, and 5, 15, 30, and 45 min after the initiation of lidocaine application.

RESULTS

The mean VAS values recorded during the treatment sessions and control sessions were 49.9 +/- 24.1 versus 60.1 +/- 24.8, respectively. The value of VAS in the treatment session was significantly lower than that of the control session (p < 0.001). No statistically significant differences were found in the changes of blood pressure and heart rate and in the incidence of side effects during these two types of sessions (p > 0.05). In the drug-level study, serum levels of lidocaine reached a peak 5 min after the initiation of local anesthesia. The mean peak concentrations (Cmax) of lidocaine were 0.50 +/- 0.45 microg/ml.

CONCLUSION

Local vaginal anesthesia with 10% lidocaine solution can significantly decrease the degree of painful sensation during HDR intracavitary brachytherapy, and is safe to administer for the procedure for cervical cancer.

Impact of the extent of parametrial involvement in patients with carcinoma of the uterine cervix

PURPOSE

A scoring system is proposed to measure the extent of parametrial involvement and predict treatment outcome in patients with carcinoma of the uterine cervix.

METHODS AND MATERIALS

244 patients with FIGO Stage IIB (n = 146) or IIIB (n = 98) carcinoma of the uterine cervix were treated by radical radiotherapy from October 1987 to June 1992. Impact of the extent of parametrial involvement on outcome was studied. All patients were scored by the newly introduced scoring system described as follows: score 1, tumor extending <1/2 the distance to the pelvic side wall; score 2, tumor extending >1/2 the distance to the pelvic side wall but not to pelvic side wall; score 3, tumor extending to the pelvic side wall. The score in each patient was defined as the sum of the scores of both the left and right parametrial tumor extent.

RESULTS

There were 53, 47, 61, 34, 25, and 24 patients in score 1, 2, 3, 4, 5, and 6, respectively. All 244 patients were subdivided into three groups described as follows: score 1 and 2, group I; score 3 and 4, group II; score 5 and 6, group III. In univariate analysis, lower score groups had better overall survival rate (OS), disease-free survival rate (DFS), local control rate (LC), and distant metastasis-free rate (DMF) than higher score groups including groups I vs. II, II vs. III, or I vs. III. The differences were all statistically significant except for the difference of the DMF in group I vs. II. In multivariate analysis, score (range 1-6) was also statistically significant in OS (p < 0.0001), DFS (p = 0.0015), LC (p = 0.0032), and DMF (p = 0.0141).

CONCLUSIONS

The data suggested that the new scoring system defined by pelvic examination is a convenient, simple, and reliable method of measuring the degree of parametrial extension and predicting the outcome of patients with parametrial disease.

The correlation of acute toxicity and late rectal injury in radiotherapy for cervical carcinoma: evidence suggestive of consequential late effect (CQLE)

PURPOSE

To correlate the acute toxicity during pelvic irradiation and the development of late rectal injury following radiation therapy for cervical carcinoma.

METHODS AND MATERIALS

Two hundred and twenty patients treated with curative-intent radiation therapy between November 1987 and January 1992 were analyzed. Patients were treated initially with external beam irradiation, 40-44 Gy/20-22 fractions to whole pelvis, followed by high dose rate intracavitary brachytherapy, 7.2 Gy to point A for 3 fractions. Severity of diarrhea during radiation therapy was scored according to six criteria: fecal characteristics, frequency, onset, prescription of antidiarrheal agents, body weight loss during irradiation, and extramedical care needed. Patients were categorized as group ND (no obvious diarrhea), group MD (moderate diarrhea), and group SD (severe diarrhea) for sum score 0-1, 2-5, and > or = 6, respectively. The rate of radiation proctitis was expressed, analyzed, and compared with actuarial proctitis-free rate and prevalence.

RESULTS

1) According to the score, 76 (35%), 89 (40%), and 55 (25%) patients were categorized as group ND, group MD, and group SD, respectively. Distribution of patients and treatment characteristics among the three groups appeared similar. Patients treated with a larger field size, > or = 16.5 cm2, tended to have increased severity of diarrhea. 2) Overall, 103 patients (47%, 103 of 220) developed radiation proctitis. Twenty-one patients were in group ND (28%, 21 of 76), 43 in group MD (48%, 43 of 89), and 39 in group SD (71%, 39 of 55). 3) The five-year actuarial proctitis-free rate was 72, 52, and 29% for group ND, MD, and SD, respectively (p < 0.005). 4) Taking time evolution and recoverability into account, the effect of diarrhea on the prevalence of radiation proctitis remained statistically significant at the first through the fourth year after irradiation. 5) Severity of radiation proctitis and severity of diarrhea were not correlated (Spearman's rank correlation coefficient r(s) = 0.229, p = 0.098). 6) Cox's multivariate analysis revealed that severity of diarrhea was the only factor that significantly correlated with the development of radiation proctitis.

CONCLUSION

Patients with increased acute toxicity and diarrhea during radiation therapy of cervical carcinoma significantly increased the risk of late rectal injury. This result suggested that early excessive damage of acute-responding component of rectal wall may play an important role in the initiation of late rectal injury. Radiation proctitis can be accounted, in part, as a consequential late effect.

The prognostic factors of lung cancer patients with brain metastases treated with radiotherapy

PURPOSE

To analyze the prognostic factors of lung cancer with brain metastases (BM) and evaluate the role of cranial irradiation on survival.

METHODS AND MATERIALS

From 1987 to 1994, 159 lung cancer patients with CT scan documented BM were reviewed. All of them underwent cranial irradiation (median radiation dose: 30 Gy). Chemotherapy and surgery of BM were performed in 21 and 10 cases, respectively.

RESULTS

Overall median survival was 3.5 months and one year survival rate was 10.69%. Univariate analysis showed that the significant factors were performance status, age, total radiation dose to brain, BM as the first metastasis, neurosurgery, symptoms of urine/stool incontinence, and synchronous BM. Multivariate analysis indicated that (1) performance status (p = 0.0002), (2) total radiation dose (p = 0.0032), (3) BM as the first metastasis (p = 0.0449), (4) neurosurgery (p = 0.0233), (5) symptoms of urine/stool incontinence (p = 0.0002), and (6) the presence of a midline shift on cranial CT scans (p = 0.0063) were significant prognostic factors.

CONCLUSION

The prognosis of BM in lung cancer patients is extremely poor. Radiotherapy appears as an effective means of palliation with 75% overall symptomatic response rate. Higher radiation dose (> or = 30 Gy) and neurosurgery are associated with longer survival. Good performance status, BM as the first metastasis, absence of sphincter dysfunction, and midline shift on CT scans are favorable prognostic predictors. The role of midline shift is very interesting and needs to be explored further.

Combined-modality therapy for squamous carcinoma of the buccal mucosa: treatment results and prognostic factors

BACKGROUND

Reports on locoregional control and survival of squamous cell carcinoma of buccal mucosa are scarce in literature. In this study, a single institutions's experience of combined surgery and postoperative radiotherapy (RT) for buccal mucosal malignancy with favorable results was analyzed and presented. The prognostic factors on locoregional control were also discussed.

METHODS

From January 1988 to July 1994, 57 patients with squamous cell carcinoma of buccal mucosa treated by surgery and RT were reviewed. The distributions according to American Joint Committee on Cancer (AJCC) staging were: stage II, 6; stage III, 21; and stage IV, 30 patients. Total dose of RT at the buccal area ranged from 45 Gy to 68.4 Gy, median 61.2 Gy. Tumor-related factors (AJCC stage, T stage, histologic grading, pathologic tumor invasion to skin of cheek, adjacent bony structures, and regional lymph nodes) and treatment-related factors (surgical margin, radiation dose, and the time interval between operation and RT) were analyzed to determine their influence on locoregional control.

RESULTS

Three-year actuarial locoregional control rate, overall survival rate, and disease-specific survival rates were 64%, 55%, and 62%, respectively. Ten of these 22 patients (45%) with recurrent tumors were reoperated, but only 2 patients were successfully salvaged. Positive surgical margin and tumor invasion to skin of cheek were significantly poor prognostic factors on locoregional control by univariate analysis. In multivariate analysis, tumor invasion to skin of cheek was the only prognostic factor (p = .0014).

CONCLUSIONS

Locoregional failure was the major cause of death for squamous buccal mucosa cancers managed with surgery and RT. Few recurrences could be detected early and successfully salvaged. Skin of cheek involvement is an important prognostic factor for buccal mucosa cancers.

High-dose-rate intracavitary brachytherapy (HDR-IC) in treatment of cervical carcinoma: 5-year results and implication of increased low-grade rectal complication on initiation of an HDR-IC fractionation scheme

PURPOSE

To report the treatment results and rectal/bladder complications of cervical carcinoma radically treated with high-dose-rate intracavitary brachytherapy (HDR-IC). The current policy of using three-fraction scheme was examined.

METHODS AND MATERIALS

Between November 1987 and August 1990, 173 patients with cervical carcinoma were treated with curative-intent radiation therapy. Whole pelvic irradiation was administered with 10-MV X ray. Dose to the central cervix was 40-44 Gy in 20-22 fractions, following by pelvic wall boost 6-14 Gy in three to seven fractions with central shielding. 60Co sources were used for HDR-IC, and 7.2 Gy was given to Point A for three applications, 1-2 weeks apart. Duration of follow-up was 5-7.8 years.

RESULTS

Twenty-eight patients (16%) developed central-regional recurrences. Overall 5-year actuarial pelvic control rate was 83%. By stage, 5-year actuarial pelvic control rates were 94%, 87%, and 72% for Stages IB + IIA, IIB + IIIA, and IIIB + IVA, respectively. Thirty-one patients (18%) developed distant metastasis. Overall 5-year actuarial survival rate was 58%. By stage, 5-year actuarial survival rates were 79%, 59%, and 41% for Stages IB + IIA, IIB + IIIA, and IIIB + IVA, respectively. Sixty-six (38%) and 19 patients (11%) developed rectal and bladder complications, respectively. For rectal complication, the overall actuarial rate was 38% at 5 years. By grade, 5-year actuarial rectal complication rates were 24%, 15%, 4%, and 3% for Grades 1-4, respectively. Overall prevalence of rectal complications was 37% and 14% at 2 and 5 years, respectively. Prevalence of low-grade rectal complication (Grades 1 and 2) was dominant at 2 years (30%), but declined to 8% at 5 years. Prevalence of high-grade, severe rectal complication (Grades 3 and 4) remained steady at 2 and 5 years (7% and 6%, respectively). Five-year actuarial bladder complication was 9%. Five-year prevalence of bladder complication was 2%.

CONCLUSION

Using a three-fraction scheme, survival rate appeared comparable with the existing results of the low-dose-rate technique. The incidence of rectal complication with this scheme remained relatively high. The increased part of rectal complication was predominantly low grade. This result suggested that therapeutic gain with this scheme may not be good enough to circumvent its biologic disadvantage. Numbers of fractions >3 must be considered in future trials.

Effect of megestrol acetate and prepulsid on nutritional improvement in patients with head and neck cancers undergoing radiotherapy

BACKGROUND AND PURPOSE

Anorexia is a common problem in cancer patients who receive radiotherapy. In this current study, we attempt to determine the effect of megestrol acetate and prepulsid on appetite and nutritional improvement in patients with head and neck cancers undergoing radiotherapy.

MATERIALS AND METHODS

One hundred twenty-nine consecutive patients with head and neck cancers treated between July 1993 and June 1994 were prospectively randomized to receive either megestrol acetate, 40 mg qid (megace group), prepulsid, 5 mg tid (cisapride group), or a placebo treatment (control group) during radiotherapy. Before radiotherapy, body weight (kg), appetite score, performance status, biochemical parameters and hematological parameters were evaluated, and the above-noted clinical and biochemical parameters were assessed and recorded every other week. All patients received 6- 10 MV X-rays or Co-60 gamma-ray to head and neck region for a full course of radiotherapy, 61.2-75.6 Gy/7-9 weeks.

RESULTS

Forty-eight patients were enrolled in the megace group, 41 patients in the cisapride group, and 40 patients in the control group. At the 2nd, 4th, 6th and 8th week, as the radiation dose escalated, the megace group had significantly less body weight loss than did the cisapride and control groups (P = 0.045, 0.024, 0.006, 0.003, respectively). The appetite scores of the megace group were significantly higher than those of the cisapride and control groups (P = 0.0001). However, there were no statistically significant differences in the change of albumin level among these three groups at the 2nd, 4th, 6th and 8th week (P > 0.05, respectively).

CONCLUSIONS

Megestrol acetate can significantly decrease the degree of body weight loss, and can prevent the deterioration of appetite in patients with head and neck cancers receiving radiotherapy. However, prepulsid lacks the above-mentioned clinical benefits.

Patterns of distant metastases in nasopharyngeal carcinoma

The distant metastasis in nasopharyngeal carcinoma has remained the major cause of mortality and treatment failure despite better locoregional control of the disease in the past decades. Between 1987 and 1992, 125 out of 629 cases of nasopharyngeal carcinoma were found to have distant metastasis. The location of metastatic site, the timing and median survival were analyzed. The diagnosis of distant metastasis in the retrospective study was based on radiography, computed tomography, skeletal scintigraphy, abdominal sonography and pathology reports. The results showed that the frequencies of metastases were as follows: bone (75% of total metastatic patients), lung (46%), liver (38%), retroperitoneal lymph nodes (10%). Multiple organ involvement was high (57%). Most of the distant metastases (95%) occurred within 3 years after completion of radiotherapy, the first year (52%), the second year (23%) and the third year (20%). The median survival time from the discovery of distant metastasis was 11.2 months for bone metastasis, 16.3 months for pulmonary metastasis, and 3.2 months for hepatic metastasis. The results revealed that the skeletal system was the most common site of distant metastasis, followed by lung and liver. The incidence of retroperitoneal lymphadenopathy is higher than previous reports.

Topographic distribution of inguinal lymph nodes metastasis: significance in determination of treatment margin for elective inguinal lymph nodes irradiation of low pelvic tumors

PURPOSE

To study the distribution of gross inguinal lymph node metastasis and, in particular, its correlation with major pelvic bony structures on a simulation film.

METHODS AND MATERIALS

Thirty-seven cases of low pelvic tumors having gross inguinal lymph node metastasis that were treated with radiation therapy between November 1987 and December 1992 were segregated for study. The patient's nodes were palpated and marked with lead wire before the simulation film was assumed to be the origin of the previously uninfested node. A total of 84 such labeled nodes was taken. The geometric center of the usually round or elliptical node on the film was obtained from these 37 cases. These centers were transferred to and mapped collectively on a new simulation film showing major pelvic bony structures of left hemipelvis and upper femur.

RESULTS

Distribution of gross inguinal lymph nodes was found confined to the following area, as related to major pelvic bony structure: laterally, just abutting the tangential line that passes through lateral border of the femoral head; medially: 3 cm away from the body's midline axis; superiorly: 1 cm below the line that joins both upper borders of the femoral head; inferiorly: 2.5 cm below the low borders of ischial tuberosity. According to this rectangular boundary, three nodes were out of the field, nine nodes near the border less than 1 cm margin. This area adequately covered 86% (72 of 84) of the studied nodes.

CONCLUSION

Distribution study is important in determining the treatment margin. In general, an additional 1-2 cm beyond the area described above is the recommended treatment margin for elective inguinal lymph nodes irradiation with high confidence level of coverage.

[Distant metastasis after irradiation alone in carcinoma of the uterine cervix--the patterns and results]

From 1988 to May, 1992, there were 286 patients with pathology-proved carcinoma of the uterine cervix referred to Chang Gung Memorial Hospital, Kaohsiung to receive definite radiotherapy. Sixty-one (21%) patients were found to develop distant metastasis after radiotherapy for at least 2 years follow-up. By FIGO stage, the incidence of distant metastasis was as follows: I :2/39, II a:1/19, II b:20/118, III :34/101, IV a: 4/9. Eighty-five percent patients (52/61) began to develop distant metastasis within the first 2 years after radiotherapy. Twenty-three patients developed single organ metastasis, and 38 patients developed multiple organ metastasis. Lymph nodes (38 patients), lung (28 patients), bone (27 patients), and abdomen (20 patients) were the common sites of distant metastasis. Lymph nodes metastasis occurred most often at supraclavicular lymph nodes (15 patients), para-aortic lymph nodes (18 patients), and inguinal lymph nodes (5 patients). Spine (23 patients), especially the lumbar spine (20 patients) was the most common site of bony metastasis. Abdominal metastasis occurred in abdominal cavity (15 patients) or liver (5 patients). The incidence of metastasis within the first two years after radiotherapy was lung: 75% (21/28), bone: 62% (18/29), left supraclavicular lymph nodes: 60% (9/15), para-aortic lymph nodes: 72% (13/18), intra-abdominal cavity: 86% (13/15), liver: 66% (2/3), brain: 0% (0/4). The 2-year actuarial survival rate for the 61 patients after developing distant metastasis was 14%, with a median survival time of 6.4 months. There was no significant difference in survival when comparing patients with single organ metastasis and with multiple organ metastasis (p > 0.05), or patients with distant metastasis alone and with distant metastasis combined with local recurrence (p > 0.05). Otherwise, after distant metastasis twenty-three patients receiving chemotherapy or radiotherapy had a significantly higher 2-year survival rate than 38 patients receiving supportive care only after distant metastasis (34% vs. 2.4%, p < 0.05).

Management of anorexic patients in radiotherapy: a prospective randomized comparison of megestrol and prednisolone

Megestrol acetate and corticosteroid have been demonstrated to be effective in the treatment of anorexia in patients with advanced cancer. The purpose of this preliminary study is to evaluate the role of megestrol acetate and prednisolone in the treatment of anorexia induced during whole pelvis external irradiation. Fifty-two patients were randomized in this prospective study to either receive megestrol acetate (40 mg orally four times a day), prednisolone (10 mg orally three times a day), or placebo (1 tablet orally three times a day) for 21 consecutive days. Body weight, appetite, performance status, sense of well-being, and complications were assessed every 3 days. Both the megestrol acetate group and the prednisolone group showed improvement in body weight gain, appetite, performance status, and sense of well-being. Appetite improvement was statistically significant in the megestrol acetate group (P = 0.024) when compared with the placebo group. There were no complications during the 21-day trial.

Radiotherapy following simple hysterectomy in patients with invasive carcinoma of the uterine cervix

From January 1980 to December 1988, a total of 73 cases of invasive cervical cancer after simple hysterectomy were treated with radiotherapy. Seven patients were excluded due to incomplete treatment or loss of follow-up. Among the 66 patients, 52 had squamous cell carcinoma and 14 had adenocarcinoma or adenosquamous cell carcinoma. The patients were grouped as follows: group A, patients without gross residual tumor (n = 32); group B, patients with gross residual tumor (n = 23); and group C, patients with gross recurrent tumor (n = 11). All patients in groups A and B received radiotherapy immediately (within 4 months) following their simple hysterectomy. Patients in group C were treated six months to five years later. Different methods of radiotherapy were delivered during the two consecutive time periods. Before 1985, patients (n = 30) were irradiated with a dose of 45-50 Gy in the midpelvic plane, followed by a transvaginal boost of 30 Gy. After 1985, patients (n = 36) were treated with the same midpelvic dose, and boosted with 30 Gy by high-dose-rate brachytherapy. The overall five-year survival rate was 67%. The five-year survival rates were 81% in group A, 56% in group B, and 45% in group C. A low complication rate (10%) was obtained in our series.(ABSTRACT TRUNCATED AT 250 WORDS)