Is postoperative radiotherapy beneficial in the management of stage I-II squamous-cell carcinoma of the uterine cervix with negative metastatic nodes and positive parametrial involvement?: A retrospective review of 70 patients

Seventy patients having squamous-cell carcinoma of the uterine cervix FIGO Stage I-II with negative lymph nodes and positive parametrial involvement received postoperative radiotherapy following radical hysterectomy and pelvic lymphadenectomy. In 48 patients with microscopic parametrial invasion, the 5-year survival rate was 92%. The other 22 patients with macroscopic parametrial involvement had a 5-year survival rate of 75%. The overall recurrence rate was 13% (9 of 70). The sites of failure were 3 pelvic alone, 5 distant metastases alone, and 1 combined pelvis and para-aortic lymph node. All of those with recurrence were Stage-II cases. The absolute pelvic-control rate was 94.3% (66/70). Fifty-six percent of the patients experienced mild-to-moderate lymphedema. Severe complications requiring surgical intervention were observed in 6 patients (5 bowel obstructions and 1 femoral head fracture). A review of the literature suggests that early carcinoma can be successfully treated by surgery alone. Taking into consideration the risk and benefits involved, postoperative radiotherapy is not recommended for most cases with cervical carcinoma with negative lymph nodes and positive parametrial involvement in the present form, despite excellent local control. However, no definite conclusion can be drawn from this retrospective analysis.

Analysis of adenoid cystic carcinoma treated by radiotherapy

The records of 41 patients with adenoid cystic carcinoma of the head and neck region who had been treated with radiotherapy were reviewed. Local control was achieved in 72.3% in the cases with primary lesions at 5 years. The prognosis for tumors that arose in the major salivary glands was better than that for tumors that arose in the minor salivary glands; however, the difference was not statistically significant. In the minor salivary glands, early-stage tumors were well controlled with the use of radiation therapy alone. In spite of the high local control rate, the disease-free survival rate of the patients at 10 years was only 20.8%. Lung metastasis determined the prognosis.

Alveolar hydatid disease of the liver: computed tomography and transabdominal ultrasound with histopathological correlation

The appearances of alveolar hydatid disease of the liver (AHDL) on computed tomography (CT) and ultrasound (US) were retrospectively compared with histopathological appearances in 67 patients with 100 separate lesions. The radiological features were correlated directly with the pathological specimens obtained from each patient. We conclude that the CT appearances are more specific, but that US has a role to play in mass screening in endemic areas, and intraoperatively.

Feasibility of PACS based on 2 years experiences of Hokkaido University PACS

Some features of HU-PACS which is now just 2 years old are described with the results of clinical assessment on it. It is clear that many advancements in technology have made the HU-PACS to be a useful tool of clinical routines. The paper describes also problems of the system in future with general comments on technology assessment and cost benefit issues.

[MR imaging of hilar cholangiocarcinoma--comparative study with CT]

Magnetic resonance (MR) images of 18 cases of hilar cholangiocarcinoma were evaluated to compare the effectiveness of Gd-DTPA with that of high dose contrast enhancement computed tomography (HCE-CT) in detecting the primary tumor. The primary tumor was demonstrated as having slightly low intensity compared with liver parenchyma and high intensity compared with the dilated bile duct on T1 weighted images. In contrast, MRI using Gd-DTPA, which was carried out in five cases, revealed intense enhancement of the tumor. As the differentiation between cholangiocarcinoma and dilated bile duct was difficult, it was concluded that the use of Gd-DTPA improves the efficacy of MRI in diagnosing cholangiocarcinoma. Gd-DTPA was also effective in differentiating the growth pattern of the tumor: the infiltrating type was demonstrated as thickening of the wall of the bile duct, the polypoid type as a soft tissue mass in the bile duct. Contrast MRI study is effective for the detection of cholangiocarcinoma. It is also expected to be effective in the staging diagnosis of cholangiocarcinoma.

Concept of Hokkaido University picture archiving communication system

The basic concept of Hokkaido University picture archiving communication system (HU-PACS) for its design in hardware architecture and in its characteristic functions is reported. After almost 10 years, the concept was solidified as the opinion of most of the doctors of HU Hospital. Discussions with vendors were very helpful in providing technical or industrial expertise and equipment to effect this concept with the limited funds available.

Clinical experience--16 months of HU-PACS

Sixteen months experience with HU-PACS (Hokkaido University PACS) is reported. This report describes the hardware and software aspects of HU-PACS in its working state. Evaluation of the system is also reported, and usefulness of PACS concludes paper.

[Ultrasonography as a supplemental technique for the diagnosis of adhesion and invasion of abdominal tumors]

Diagnostic capability of ultrasonography (US) concerning with adhesion and/or invasion of the tumors to the surrounding tissues in the abdominal region including pelvis was evaluated in 54 patients with comparison to that of CT. All the lesions reached the surface of the organ and whether the adhesion or invasion of the lesion to the surrounding organ or tissue was a problem. All the patients underwent US and CT. US was performed not only in the usual real-time manner, but with "supplemental" techniques: respiration, drinking water, rectal infusion and bimanual examination. Accuracy of US reached 72% with one or some of those four US supplemental techniques, while accuracy of CT which yields only stable image was 30% (p less than 0.005 by chi 2 test). US with suitable supplemental techniques should be applied to those cases with suspected adhesion or invasion of the tumor in the abdomen, and when CT is not reliable to judge this problem.

[A randomized trial of single and multifraction radiation therapy for bone metastasis: a preliminary report]

From April, 1989 through January, 1990, a randomized trial was conducted to investigate the efficacy of single fraction radiation treatment (8, 10, 12, 15Gy) compared to a multifraction dose schedule (5Gy x 4, 5Gy x 5, 5Gy x 6) as a therapy for a bone metastasis. Both subjective and objective pain scores were used to measure the therapeutic results. A total of 31 patients participated in the trial and, for analysis, 27 of these patients were follow-up for more than 8 weeks after the start of the radiation therapy. The following statistics resulted. Of the single fraction series, symptomatic pain relief was obtained in 86% of the patients (12/14 treatment areas), and of the multifraction series, 92% (12/13). Further, a complete response was achieved in 57% (8/14) of the single fraction patients and 31% (4/13) of the multifraction patients, respectively. Between the two treatment regimens, no difference was found in the incidence of pain relief, speed of onset, or acute morbidity. Finally, no severe morbidity was seen in either arm.

[Radiotherapy of carcinoma of the uterine cervix--high dose rate intracavitary irradiation using a linear source arrangement]

We analyzed the records of 339 patients with squamous cell carcinoma of the uterine cervix. The patients were treated by irradiation alone in the period of 1973-1985 with external and high-dose rate intracavitary irradiation using linear source arrangement. The reason for using the linear source arrangement was to ensure the position of source as well as to simplify the technique of intracavitary irradiation. First, external irradiation was performed mainly with a dosage of 50Gy/25f four times a week or 50.4Gy/28f five times a week. Intracavitary irradiation was then carried out mainly with a dose of 30Gy/6f two times a week or 35Gy/7f two times a week and dose was indicated at point A. The 5-year survival rate of all 330 patients were 51.4%, and 55.1% for stage I (N = 19), 66.7% for stage II (N = 88), 47.1% for stage III (N = 212), 33.7% for stage IV (N = 20). Of the patients followed up for 24 months and found to have recurrence, 21.8% (39/179) had a recurrence in the pelvis and 22.1% (39/175) were found to have a distant metastasis. Of the patients followed up for over 24 months, 21.5% 932/149) developed intestinal complications and 12.2% (18/149) developed bladder complications. However complications Grade 2-4 were 5.4% for intestinal complications and 2.0% for bladder complications. From these results high-dose-rate intracavitary irradiation using a linear source arrangement was considered to be an effective treatment of carcinoma of the uterine cervix and to produce a standard results of treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cystic papillary carcinoma of the thyroid--sonographic-pathologic correlation]

Ultrasonographic findings of 13 patients with cystic papillary carcinoma (CPC) of the thyroid gland were reviewed retrospectively correlating with pathologic findings. A 4-6 cm oval cystic structure with a 2-3 cm pedunculated projection of mass into the lumen was the characteristic sonographic findings of CPC. However, other sonographic findings of CPC simulated adenoma, nodular goiter or follicular carcinoma. Pathological investigation revealed that malignant cells tended more to be located in intracystic pedunculated mass and/or pericystic region than in the cyst wall. In most of the cases cyst walls were chiefly composed of granulomatous tissue with scattered malignant cells. These findings indicate that the needle biopsy should be done under ultrasonographic guidance to obtain sufficient material for accurate cytologic and/or pathologic diagnosis, thereby reducing the number of false negative cases.

[Assessment of cisplatin in concurrent use with radiotherapy in esophageal carcinoma--joint research among nationwide multi-facilities, primary results. Research Committee for Radiation and Cisplatin Treatment of Esophageal Carcinoma]

The effect of cisplatin in concurrent use with radiotherapy for esophageal carcinoma has been assessed as a theme of joint research among nationwide 40 facilities for 18 months from October, 1985, to March, 1987. As the subjects, non-operative cases, recurrent cases and metastatic cases diagnosed as esophageal carcinoma were enrolled. Regimens in 4 kinds were used for treatment and CDDP was used concurrently with radiotherapy in all the regimens. The results of classifying and totalizing the effects in 73 cases, of whom the local effects were analyzed, turned out to be: CR-25 cases, CR rate being 34.2% and PR-33 cases, the effective rate being 79.5%. As a result of aggregating the effects by major axis of X-ray image, CR and effective rates were found as 60 and 90% in the cases with the axes less than 5 cm; 36 and 79% in the cases with axes more than 5 cm and less than 10 cm; and 19 and 76% in the cases with the axes more than 10 cm, all respectively.

[A case of icteric hepatoma which succeeded internal fistulation after radiotherapy]

A case of icteric hepatoma was treated by TAE, arterial chemoinfusion and photoirradiation to the hepatic hilum. The patient was successfully discharged after radiotherapy, which was most effective for internal fistulation of obstructed bile duct and decreasing the size of portal tumor thrombus.

[Ultrasonography of ganglions in the extremities]

Ultrasonography of 8 cases of cystic mass in extremities (7 ganglions, 1 popliteal cyst) were reviewed and evaluated. The lesions were demonstrated as round, oval or flattened shaped masses with no echo signal. However, in most cases, there was no sign of posterior echo enhancement, which may be the effect of posterior bony structure. It seemed important to handle probe with adequate palpation, which enables examiner to get further anatomical information.

[Cystic thyroid masses: ultrasonographic and pathologic correlation]

Forty-nine patients with 63 cystic thyroid masses who had undergone preoperative sonography were retrospectively reviewed. 52 lesions (83%) were benign and others (17%) were malignant. Among various sonographic findings of cystic thyroid masses, oval cystic lesions with polyp or dome like solid component projecting into the lumen were all diagnosed adenomatous goiter. Irregular cystic structures with more than 2 cm finger like pedunculated mass extended into and/or out of the lumen were all diagnosed papillary carcinoma. Small oval cysts (less than or equal to 1 cm) with strong echo were all diagnosed colloid goiter. The other sonographic type of cystic thyroid masses had somewhat malignancy (12-30%), not having characteristics which differentiate benign from malignant lesions. Pathologic findings of malignant lesions showed that cancer cells existed rather in pericystic portion than in cyst wall except for finger like solid component projecting into the lumen which was papillary carcinoma itself. Ultrasonically guided needle biopsy should be performed to get samples of above portions.

[Computed tomography of the kidney with diuretics--a method for avoiding artifacts due to nonionic contrast media]

We devised a method for avoiding beam-hardening artifacts, which interfere with enhanced CT images of kidney due to nonionic contrast medium. The radiographic effect and the frequency of beam-hardening artifacts on enhanced CT of kidney were studied by prospective comparison among three groups: a group of 20 patients examined with furosemide (f-d. CT), a group of 20 patients examined without diuretics (non-d. CT) and a group of 20 patients examined after water intake (w-d. CT). In all patients of f-d. CT group, the renal parenchyma from the cortex to the papilla was almost evenly enhanced, free from artifacts. The density of the renal papilla and pelvis in non-d. CT and w-d. CT groups was significantly higher than that in f-d. CT group, and artifacts were also observed in 14 (70%) of non-d. CT group and 12 (60%) of w.d. CT group, respectively. Satisfactory CT of kidney free from artifacts was obtained by f-d. CT, providing easy evaluation of renal pelvic or peripelvic lesions. In conclusion, this technique can be used in those pathologic cases of renal pelvis or peripelvic region, that are not clear on routine CT because of artifacts.

[CT of pulmonary eosinophilic granuloma]

CT findings of four cases of pulmonary eosinophilic Granuloma were discussed. In three cases, multiple nodular shadows or multiple cavitary lesions were observed in upper and middle lung field predominant. However, in one patient who had history of recurrent pneumothorax, CT revealed a honeycomb appearance and some bullous change as well. These findings seemed to represent a far advanced state of the disease. X-ray CT is excellent in demonstrating such pathological changes, and is indispensable in the diagnosis and follow up study of pulmonary eosinophilic granuloma.

Improved results in the treatment of nasopharyngeal carcinoma using combined radiotherapy and chemotherapy

A total of 77 patients with nasopharyngeal carcinoma were retrospectively reviewed for the effectiveness of combining chemotherapy (CT) with radical radiotherapy (RT). From 1972 to 1976, 26 patients were treated with a relatively short course of radical RT alone: 52-55 Gy/16 Fx/4 wk (study 1). From 1977 to 1982, 29 patients were also treated with radical RT alone, but with a more prolonged fractionation schedule: 65-70 Gy/26-28 Fx/6.5-7 wk (study 2). In 1983, the policy was to combine CT and RT. From 1983 to 1987, 22 patients received four to six courses of CMU regimen (consisting of cyclophosphamide, methotrexate, and UFT, a 5-fluorouracil analog) after completion of radical RT (study 3). The three studies were comparable with regard to patient characteristics: histologic type, stage, sex, and age distribution. There were no significant differences in survival and relapse figures between study 1 and study 2, but study 3 compared favorably with study 1 and study 2 in actuarial survival, relapse-free survival, relapse rate, and median relapse time. A mild nausea and transient granulocytopenia during CT was the only side effect encountered. In conclusion, the use of CT in combination with RT appeared to increase significantly the chance of long-term survival and probable cure.

The value of treatment planning using CT and an immobilizing shell in radiotherapy for paranasal sinus carcinomas

This article describes a method which uses CT scans and immobilizing shells radiation treatment planning (CT-assisted planning) for paranasal sinus carcinomas and the value of this method on the treatment outcome. Results of the treatment for 82 patients who had CT-assisted planning were compared with that of 88 patients who had no such treatment planning. It has been concluded that the combined use of CT and the shell in treatment planning permitted a 3-dimensional localization of both the tumor and critical normal structures with great accuracy, leading to an improved long-term survival and a reduced complication rate. The multivariate regression analysis for predicting significant prognostic factors also confirmed the valuable role of CT in terms of survival and primary tumor control. The actuarial 5-year survival rate was 51% in all patients, whereas, by using CT-assisted planning, it was improved to 61%. The improved survival was observed among the patients with tumors of the suprastructures where tumors were located adjacent to the critical organs (brain and eye). Major complications attributable to radiation have included instances of brain and ocular damage. CT-assisted planning, however, has been proven effective in avoiding brain necrosis and preserving eye sight.

[Radiotherapy of a pure seminoma of the testis]

Twenty-six cases of a pure seminoma of the testis that had been treated by postoperative radiotherapy have been reviewed. The overall 5-year survival rate was found to be 92.3%. Further, no severe adverse effects, including sterility, was found. Prophylactic mediastinal radiation is considered to be unnecessary, because supradiaphragmatic lymph node metastasis was seen in only 1 patient, who has remained disease-free 4.5 year after the treatment of a recurrence. Extranodal metastasis was seen 5 cases, 2 of these cases showing bone metastasis that was successfully treated, thereby achieving complete remission. A seminoma is considered to be one of the most curable malignant diseases, however, long-term follow up is a necessity since stage 1 seminoma has been found to show a generalized dissemination after a 16-year, disease-free interval.

[The role of radiotherapy in small cell lung cancer]

From 1974 to 1984, we have treated 70 patients with SCLC using radiotherapy (RT) alone or in combination with chemotherapy (CT). It was demonstrated that a heavy CT regimen causing a severe toxicity did not always cause good results. On the other hand, there was a long-term survivor in those patients who were treated with RT alone. Considering from our results as well as from reviews of literatures, it is evident that RT can reduce a significant number of local relapses but has little effect on systemic disease. Therefore, RT added to CT seems to improve a long-term survival specifically in those patients in whom CR is induced from CT. The characteristics of the long-term survivors treated with combined treatment are: limited disease, thoracic RT, good PS, only single site of metastases. In conclusion, there is no doubt that CT plays an important role in the management of SCLC. However, its efficacy is still far from desired, and a new type of CT is warranted.

[An analysis of needle biopsy under ultrasonography of the thyroid gland]

A multivariate analysis of 47 thyroid nodules and 34 diffuse goiters has been employed to determine the cause of failure in thyroid biopsy under ultrasonography. In the thyroid nodule cases, 30 percent were found to have been misdiagnosed or judged to be an inappropriate sampling. The most important factor leading to failure is a size of tumor. Only one fourth of the small tumors of less than 1 cm were correctly diagnosed and, in cases of a relatively large cystic tumor or a peripherally located nodule, an exact diagnosis was difficult, though 90 percent of the diffuse goiters were difficult, though 90 percent of the diffuse goiters were correctly diagnosed by this method. This result indicates that needle biopsy of the thyroid gland is reliable in cases of a diffuse goiter but problems remain to be resolved in cases of small or cystic tumors and peripherally located nodules.

[Contribution of CT and MRI to radiation therapy]

The contribution of CT to radiation therapy has been enormous. The most basic contribution has been that CT has made almost all malignant tumors visible, which has improved radiation therapy not only in the planning phase but also in the effect-estimating phase. As some examples, CT has improved the effects of radiation therapy for cancer of the maxillary sinus and of the uterine cervix, and the results from our department have already been published. The contribution of MRI to radiation therapy should be very great in future wherever MRI diagnostics are established. Even now, however, its ability to visualize cross-sectional anatomy in any area is an aid to radiation therapy both in planning and in estimating the degree of effect.

[Interstitial irradiation by 192Ir seed assemblies in fixed cervical lymph node metastases]

Eleven patients with fixed cervical lymph node metastases were treated using external irradiation followed by interstitial implants, 137Cs needles were used for one patient and 192Ir seed-assemblies for 10 patients. The local tumor responses were 4 CR, 6 PR and 1 NC. Acute tolerance was good, and there were no major late injuries except for one case of severe subcutaneous fibrosis. No morbidities such as local infection, bleeding or pulmonary injuries were encountered. Clear-cut dose control relationships were demonstrated; the local control of the nodes treated with intervals of more than one month between external and interstitial irradiation was poor. It is considered that adequate treatment is to give 40 Gy over 4 weeks by external irradiation first, then, after an interval of 2 weeks, to give 40-50 Gy over 4-5 days using 192Ir interstitial implants. The interstitial implants appeared to provide an improvement in local control and in the therapeutic ratio of fixed cervical lymph node metastases.

[Combined chemotherapy and radiotherapy in recurrent tumors of the head and neck region]

Over the past four years, 27 patients with recurrent tumors of the head and neck region have been treated with chemotherapy. The regimens used were BCMF (bleomycin 15 mg i.v. for 3 days, cyclophosphamide 500 mg i.v., methotrexate 50 mg i.v. and 5-fluorouracil 500 mg i.v.) and CMU (cyclophosphamide 350 mg/m2 i.v., methotrexate 30 mg/m2 i.v. and UFT 600 mg p.o. for 14 days). Of the 27 patients, eight were treated with combined radiation and chemotherapy, and either CR or PR was obtained. Nineteen patients were treated with chemotherapy alone, for which the response (CR + PR) rates were 8% (1/12) for BCMF and 43% (3/7) for CMU, respectively. No serious toxicities were observed as a result of these regimens. It was thus demonstrated that the CMU regimen was of great value in terms of improved response and minor toxicity in the treatment of head and neck tumors.

Early stage head and neck non-Hodgkin's lymphoma. The effect of tumor burden on prognosis

Treatment results were investigated in 113 previously untreated patients with clinical Stage I and II (Ann Arbor) non-Hodgkin's lymphoma of the head and neck. Fifty-six Waldeyer's ring, 34 other extranodal sites, and 23 cervical nodal lesions were included. The overall relapse-free survival at 5 years was 41%. Age and Ann Arbor stage influenced relapse-free survival. The results suggested that the tumor cell burden is a fundamental prognostic factor for patients with Waldeyer's ring disease and for patients with only cervical nodal disease. Abdominal relapse was most frequent, followed by generalized relapse. From 1981, patients were randomized in a clinical trial to receive either chemotherapy (cyclophosphamide, vincristine, and prednisone [CVP], five courses) or whole-abdominal irradiation (25 Gy/20 Fr) as an adjuvant therapy. Patients could not tolerate the whole-abdominal irradiation well. A significant improvement in survival has been obtained by adjuvant chemotherapy.

[Analysis of prognostic factors in the multidisciplinary treatment of maxillary sinus carcinoma]

In 247 patients with squamous cell carcinoma of the maxillary sinus, the logistic multiple regression analyses were employed to identify prognostic factors. Among various factors evaluated, use of CT scans in treatment planning (p less than .004), age (p less than .009), location of the tumor (p less than .011), T-stage (p less than .017), and free set-up in radiotherapy (p less than .052) proved to be significant factors independently predictive of survival. The most significant factor in improving survival rate was the use of CT scans in treatment planning which was initiated in 1980. Against our prediction, intra-arterial 5-Fu infusion combined with surgery and radiation did not yield favorable result when compared with combined surgery and radiation. Radiation was combined with surgery, high dose radiation of 50 to 55 Gy delivered in 16 fractions over 4 weeks seemed to show better local control than other dose-fractionations.

Long-term results of treatment with mild toxicities in small cell lung carcinoma

Results of treating small cell lung carcinoma with mild toxicities were investigated retrospectively. From 1974 to 1981, 38 patients were treated according to three institutional protocols: radiation alone (RAD), radiation with ifosfamide (IFOS), and radiation with adriamycin, vincristine, and cyclophosphamide (AOC). Of the three five-year survivors, two were treated with IFOS and one with RAD. The time period between admission and the beginning of radiotherapy was longer and the treatment field smaller in AOC than in the other two protocols. IFOS and RAD showed less toxicity. Our study indicated that IFOS and RAD should be regarded as curative treatments for limited disease and are suitable for patients who do not have sufficient bone marrow reserve.

Ultrasonographic measurement of tumor regression in radiation therapy

Ultrasonography was evaluated as a measurement procedure for investigating the tumor regression of cervical lymph nodes. Preliminary results suggested that interobserver compatibility in the measurement of nodes deteriorates when the diameter of the node is less than 15 mm. There was no systematic disparity between ultrasonographic and manual measurements. The tumor regression line fit the exponential line with a correlation coefficient of more than 0.95 in seven of 16 nodes. During the sequential examination, a central low-echo area suddenly appeared in one node at 15 Gy/6 Fr.

The role of radiotherapy in the management of maxillary sinus carcinoma

From 1971 to 1983, a total of 208 patients with maxillary sinus carcinomas were treated at Department of Radiology, Hokkaido University School of Medicine, 38 by Method I (radiation + surgery + intraarterial 5-fluorouracil [5-Fu] infusion), and 170 by Method II (radiation + surgery). Radiation doses ranged from 30 to 50 Gy over 3 to 5 weeks in Method I and 52 to 58 Gy over 4 weeks in Method II. Overall actuarial survival rate at 5 years was 45.6%. No statistical difference in survival rates was found between Method I and Method II. With respect to T stage, absolute 5-year survival rates were 100% (4/4) for T2, 49.5% (52/105) for T3, and 24.4% (11/45) for T4. From our data, no advantage in the use of intra-arterial 5-Fu infusion was demonstrated; the local failures in Method I developed earlier and more frequently than in Method II. The ultimate failures for all patients were 46.8%. Since 1980 when treatment planning by using computerized tomography scans and immobilization device was initiated, improvement in survival rate while reducing an incidence of eye complications has been accomplished.