Concurrent radiation and chemotherapy for carcinoma of the cervix recurrent after radical surgery.

Results of salvage therapy in patients with carcinoma of the cervix, recurrent after primary surgery, have been dismal even when disease was apparently confined to the pelvis. Further surgery or radiation therapy cured only some with central pelvic disease alone who had recurred at intervals longer than 6 months after primary therapy. To try to improve the results of salvage therapy, we used a combination of concurrent chemotherapy, 5-Fluorouracil with or without Mitomycin-C, and radiation therapy. Seventeen patients were treated. Recurrent disease was present in the pelvis or pelvis and paraaortic nodes after radical surgery for Stage IB carcinoma of the cervix. Eight of seventeen (47%) are alive, disease-free, 21 to 58 months after therapy. Seven of the eight had biopsy proven recurrence. Five of eight had recurred within 9 months of primary surgery and 7/8 had a component of pelvic side wall disease. Thus the survivors had unfavorable prognostic features. Nevertheless, the use of concurrent radiation and chemotherapy produced an exceptionally high proportion of sustained complete remissions and possible cures.

Role of radiation therapy in localized non-Hodgkin's lymphoma.

Relapse occurs in 50% of patients receiving radiation for clinical stage (C.S.) I and II nodal and extranodal non-Hodgkin's lymphoma (N.H.L.). Prior to the introduction of intensive chemotherapy those failing primary control with irradiation and most of those who relapsed died of their disease with a resultant overall mortality of 50%. An analysis of Princess Margaret Hospital results with radiation for C.S. I and II N.H.L. between January 1967 and December 1978 revealed that tumour bulk, age, stage and histology were of independent prognostic significance. It was possible to group patients using combinations of these attributes so that each group encompassed only patients with similar outcomes. Such prognostic groups were identified separately within the low grade and the intermediate plus high grade categories of the Working Formulation. Patients with a high probability of cure with radiation were so defined. Also those patients in whom chemotherapy would be optimal initial therapy were also defined. Such patients were in the intermediate plus high grade histology groups. Thirty percent of all patients with low grade histology lymphoma had an actuarial survival of 83%, and relapse-free rate of 63% at 10 years. By implication, approximately 20% of all patients with these histologies seen at the Princess Margaret Hospital for the same time period achieved prolonged relapse-free survival by localized therapy. This is at variance with the implications of staging from studies where laparotomy and multiple bone marrow biopsies have been used. Such aggressive staging procedures suggest truly localised disease in only 5-6% of patients with low grade lymphoma. A significant relationship between radiation dose and disease control was demonstrated only for patients with intermediate and high grade lymphoma of medium or large bulk. A minimum tumour dose of 30 Gy was required for optimal local control with radiation.

Prognostic groups for management of localized Hodgkin's disease.

Two hundred fifty-two patients receiving radical irradiation for clinical stages I and II Hodgkin's disease between 1968 to 1977 had an actuarial ten-year survival rate of 78% and a relapse-free rate of 61%. Sixty-seven patients receiving chemotherapy followed by radiation had a 78% survival rate and a 63% relapse-free rate. Independent prognostic factors for survival and relapse were age, stage, and histology. Disease bulk was predictive only of relapse. Neither site of presentation above or below the diaphragm nor presence of mediastinal involvement was predictive for survival or relapse; however, patients with large mediastinal masses (greater than or equal to 10 cm absolute diameter) had a significantly higher intrathoracic failure rate with conventional mantle irradiation. Analysis of failure, according to age, clinical stage, and histologic type, showed three groups of patients defined according to the risk of relapse with radiation therapy: those with isolated upper cervical stage IA disease (group 1, relapse rate 8%), younger patients with localized stages I and II disease of favorable histologic type (group 2, relapse rate 35%), and older patients with extensive or symptomatic stages I and II disease of less favorable histologic type (group 3, relapse rate 70%). Subsequent analysis of radiation treatment volume indicates that the use of upper abdominal irradiation for patients in group No. 2 could yield results equivalent to those achieved with radiation therapy for surgically staged patients.

Neonatal ostomies.

Two methods of neonatal ostomy care, nonappliance and appliance, are discussed. Skin problems associated with stoma care, such as excoriation, fungal infections, and allergic reactions, are reviewed and a number of suggestions are made for the proper care of stomas in the newborn.

Results of treating Hodgkin's disease without a policy of laparotomy staging.

Results of the treatment of 780 primary patients with Hodgkin's disease at the Princess Margaret Hospital (PMH) between 1968 and 1977 are analyzed. Treatment decisions were based on the evaluation of the extent of disease by clinical methods. A marked improvement in relapse-free survival and overall survival was observed for 1973-1977 as compared to 1968-1972. This improvement did not result from differences in the distribution of important prognostic attributes (clinical stage, pathology, and age) between the two periods, and there was no improvement in our ability to rescue relapsed patients. Improved relapse-free and overall survival during the second period was observed for all stages in patients less than 50 years of age, but not in the older group. The improved survival of patients treated between 1973 and 1977 is attributed to more effective initial therapy, which reduced the fraction of patients who relapsed. These observations provide indirect evidence that relapse has a negative effect on prognosis, and that the initial treatment of patients with Hodgkin's disease should be designed to reduce the risk of relapse to a minimum without causing an unacceptable increase in late complications. The observed/expected incidence of acute leukemia and non-Hodgkin's lymphoma in the PMH series was increased to 41.9 and 13.9 respectively. The question of whether a policy of doing routine staging laparotomies improves the results of treatment of patients with Hodgkin's disease is considered only in general terms by comparing the total PMH series with the total Stanford Medical Center series of patients treated between 1968 and 1977. Relapse-free survival at 10 years is 48.9% and 66.8% respectively, at the two institutions, while overall survival at 10 years is identified.

Ovarian carcinoma: improved survival following abdominopelvic irradiation in patients with a completed pelvic operation.

A prospective, stratified, randomized study of 190 postoperative ovarian patients with Stages IB, II, and III (asymptomatic) presentations is reported. The median time of follow-up was 52 months. Patients in whom bilateral salpingo-oophorectomy and hysterectomy (BSOH) could not be completed because of extensive pelvic tumor had a poor prognosis which did not differ for any of the therapied tested. When BSOH was completed, pelvic plus abdominopelvic irradiation (P + AB) with no diaphragmatic shielding significnatly improved patient survival rate and long-term control of occult upper abdominal disease in approximately 25% more patients than pelvic irradiation alone or followed by adjuvant daily chlorambucil therapy. The effectiveness of P + AB in BSOH-completed patients was independent of stage or tumor grade and was most clearly appreciated in patients with all gross tumor removed. Chlorambucil added to pelvic irradiation delayed the time to treatment failure without reducing the number of treatment failures.

The Princess Margaret Hospital study of ovarian cancer: stages I, II, and asymptomatic III presentations.

An analysis of 231 patients with stages I, II, and asymptomatic III ovarian cancer, studied in a prospective randomized-stratified trial, is presented. None of the stage IA patients with well-differentiated tumors have had disease relapses; one fourth of the patients with poorly differentiated tumors have had disease relapses throughout the peritoneal cavity. There is therefore little justification for pelvic radiation alone as postoperative therapy for stage IA ovarian carcinoma. For stage IB, II, and asymptomatic III presentations, patients with an incomplete initial pelvic operation had poor survival characteristics with all tested therapies. For patients in whom the operation was completed, abdominopelvic radiation was superior to pelvic radiation alone or followed by chlorambucil, with respect to long-term survival and control of abdominal disease. The effectiveness of abdominopelvic radiation was independent of stage or histology. The value of abdominopelvic radiation was most strikingly seen in patients with no visible residual tumor.

Cancer of the mouth and lip.

Cancer of the lip and oral cavity are discussed, with emphasis on incidence, etiology, early diagnosis, treatment, curability, complications and after-care.

Pulmonary oil deposition in patients subjected to lymphography: Detection by thoracic photoscan and sputum examination.

During clinical trials of intralymphatic therapy with radioiodinated ethiodized oil (Lipiodol Ultra-Fluid; Ethiodol) [LUF-I(131)] for malignant disease involving lymph nodes, significant pulmonary deposition of radioactive material was demonstrated by thoracic scan in each of five cases treated. Radioactivity was detected in sputum obtained from two cases. Induced sputum specimens were subsequently obtained from patients undergoing lymphography. Fat demonstrated in sputum was confirmed as Lipiodol in one of six patients tested. Sputum examination and use of tracer doses of LUF-I(131) plus photoscanning are suggested as sensitive methods of assessing the incidence of oil deposition in the lungs of patients undergoing lymphography. Despite limitation of the volume of oil injected, monitoring of the infusion, and absence of radiographic evidence of contrast medium in the lungs, some degree of pulmonary oil deposition appears to be an inevitable result of lymphography. Further study of lung dosimetry is being undertaken by the authors before clinical usage of endolymphatic radioisotope therapy is expanded.