The 1989 patterns of care study for prostate cancer: five-year outcomes.

PURPOSE: Five-year results from the 1989 patterns of care study (PCS) for prostate cancer are now ready for analysis. The PCS was initiated to determine national averages for treatments and examine outcomes prospectively; the 1989 prostate study is the first to have collected pre- and post-treatment serum PSA data. METHODS AND MATERIALS: Six hundred patients treated with radiotherapy with curative intent for prostate cancer at 71 separate institutions in the year 1989 made up the study population. Three hundred ninety-one cases were fully analyzable. Pretreatment patient and tumor characteristics were as follows: of the 391 analyzable, 255 had pretreatment PSA values obtained, and 245 had a Gleason's sum (GS) reported. Three hundred fifty-eight were Caucasian, 24 African-American, and 3 Hispanic (also 6 unknown). One hundred three patients had PSA < 10, 60 had PSA 10-19, and 92 presented with PSA >20. Ninety-seven patients were from Radiation Therapy Oncology Group (RTOG), Community Cancer Centers (CCC), or teaching institutions; 141 patients were from other hospital-based, nonteaching institutions; and 153 were from freestanding radiation oncology facilities. Seventy-one patients were T1, 203 T2, and 100 T3/4. Twenty-four out of 391 patients also received neoadjuvant hormone therapy. Survival curves were constructed using Kaplan-Meier methods, and differences between groups were tested for significance using the log-rank test. For cumulative incidence curves, Gray's test was used to investigate failure distributions between groups. The variables entering Cox model for multivariate analysis included age, race, T stage, pretreatment PSA, and GS. A patient was considered a PSA failure if the treating radiation oncologist reported it as such. RESULTS: With a median follow-up of 5.7 years, the 5-year biochemical no evidence of disease (bNED) and overall survival were 56% and 79% respectively for Stage T1, 52% and 81% for T2, and 36% and 63% for Stages T3 and T4 combined. As expected, higher pretreatment PSA, GS, and T stage were all prognostic of poorer outcome. On univariate analysis, bNED survival was adversely impacted by T stage (p = 0.009), pretreatment PSA (p = 0.0035), and by the GS (p = 0.0038). Cause-specific failure was significantly lower for higher T stage (p = 0.014), GS (p = 0.001), and also pretreatment PSA (p = 0.0004). Overall survival was significantly lower in patients with higher T stage (p = 0.047) or GS (p = 0.0191), but not pretreatment PSA (p = 0.284). On multivariate analysis, pretreatment PSA was found to be statistically significant in association with bNED survival, and GS was associated with overall survival, cause-specific survival, and distant metastasis. Few late complications were reported: 13/391 and 13/391 Grade 2-3 gastrointestinal (GI) and genitourinary (GU) complications respectively, with two patients having required surgery with or without a permanent colostomy. CONCLUSION: For a representative cross-section of institutions in the United States, radiotherapy achieved high rates of bNED and CSS in selected groups of prostate cancer patients. When studied retrospectively, increased pretreatment PSA was a strong predictor of both biochemical failure and death due to prostate cancer. New strategies for patients with high-stage, high-grade tumors and/or pretreatment PSA >20 deserve testing.

Combined low-dose-rate brachytherapy and external beam radiation for cervical cancer: experience over ten years.

Cervical cancer was treated with a combination of external beam and intracavitary radiation during a 10-year period at Wayne State University. Data were collected for 216 patients treated radically with external beam radiation (EBRT) and low-dose-rate brachytherapy for cervical cancer between 1980 and 1991 at Wayne State University. Patient distribution by stage was IB, 20.8%; IIA, 7.4%; IIB, 26.9%; IIIA, 1.8%; IIIB, 40.7%; and IVA, 2.3 %. Survival curves were constructed using Kaplan-Meier methods and differences between groups were tested for significance using the log-rank test. Multivariate analysis was done using the Cox proportional hazards model. With a median follow-up of 114 months, actuarial disease-free survival for all patients was 60% at 5 years and 55% at 10 years. Actuarial 5-year survival for Stage IB was 79%; for Stage II, 59%; and for Stage III, 53%. There were 14/216 (6%) of patients with severe late complications. On univariate analysis, race was found to be statistically significant, with Caucasian patients having better survival than African American (P = 0.03). The survival for patients treated in shorter overall times was significantly higher (P<0.001), especially with treatment completion in under 58 days. The stepwise Cox multivariate analysis provided the following significant results: race (African American vs. Caucasian; P = 0.04, RR = 1.6), Stage (II vs. I, P = 0.004, RR = 2.6), Stage (III vs. I; P = 0.004, RR = 2.5), and overall treatment time (P = 0.006, RR = 1.62). Rates of local control, survival, and complications among women treated with combined external beam and intracavitary radiation for cervix cancer were similar to those of prior retrospective studies.

Three dimensional conformal neutron radiotherapy for prostate cancer.

The conditions for safe and effective conformal neutron radiotherapy have been established at Wayne State University.

Permanent I-125 brain stem implants in children.

Between 1988 and 1997, 28 children have had iodine-125 implants for CNS tumors performed in our institution. Ten had stereotactic implantation in the brain stem region, and nine had the diagnosis of brain stem glioma (8 diffuse pontine, 1 midbrain tumor). Their ages ranged from 1.8 to 12 years. All patients had histological confirmation of malignancy (7 high-grade glioma, 2 low-grade glioma, 1 PNET). Diffuse pontine glioma patients received external beam radiation (50 Gy) followed by a fractionated stereotactic boost of 3 Gyx4 fractions. After 4-6 weeks, patients were reevaluated for stereotactic interstitial I-125 therapy. The planned implant dose was 82.9 Gy to the enhancing tumor (4 cGy per h). Preliminary results indicated that no surgical complications were associated with the catheter placement. Four patients have died (7-9 months from diagnosis) and four patients remain alive (5-38 months from diagnosis, median 10 months). Two autopsies confirmed the presence of progressive glioblastoma multiforme and intralesional necrosis. In one patient who received an implant alone for midbrain LGA, necrosis without tumor was found on biopsy after 36 months. He was successfully treated with hyperbaric oxygen therapy. The implementation of permanent I-125 implants appears to have a role in the management of pediatric CNS malignancy. This study confirms the results of previous reports regarding the safety of stereotactic interstitial brachytherapy in the brain stem. Tumor control for patients with high-grade brain stem glioma remains poor even with high focal radiation doses.

The influence of race on the efficacy of curative radiation therapy for carcinoma of the prostate.

The purpose of this study was to examine the effect of race on the outcome of patients treated curatively with external beam irradiation for carcinoma of the prostate. The study was performed between January 1980 and December 1993 of 1,529 men with prostate cancer. Similar percentages of Caucasian men (CM) and African-American men (AAM) had localized disease (stages T1 and T2) and advanced stage disease (stage T3). There was no difference in crude survival by race (P = .13). At 5 years, crude survival by race was 75% for CM and 73% for AAM. At 10 years, the crude survivals, were 50% and 40%, respectively. Disease-specific survival rates were equivalent for AAM and CM (P = .66). The 5-year disease-specific survival was 83% for CM and 85% for AAM. At 10 years, the disease-specific survival was 65% for CM and 69% for AAM. There was no difference in disease-specific survival by race when stage-for-stage comparisons were made. Among those patients referred for curative radiation therapy, AAM and CM had a similar age, stage, and grade distribution. This study demonstrated that there was no difference in disease-specific survival between CM and AAM treated curatively with radiation for prostate cancer.

Hyperbaric oxygen therapy for radiation-induced brain injury in children.

BACKGROUND: Radiation-induced necrosis (RIN) of the brain is a complication associated with the use of aggressive focal treatments such as radioactive implants and stereotactic radiosurgery. In an attempt to treat patients with central nervous system (CNS) RIN, ten patients received hyperbaric oxygen treatment (HBOT). METHODS: Patients presented with new or increasing neurologic deficits associated with imaging changes after radiotherapy. Necrosis was proven by biopsy in eight cases. HBOT was comprised of 20-30 sessions at 2.0 to 2.4 atmospheres, for 90 minutes-2 hours. Sites of RIN included the brain stem (n = 2), posterior fossa (n = 1), and supratentorial fossa (n 7). Histologic types included brain stem glioma (n = 2), ependymoma (n = 2), germinoma (n = 2), low grade astrocytoma (n = 1), oligodendroglioma (n = 1), glioblastoma multiforme (n = 1), and arteriovenous malformation (n = 1). RESULTS: Initial improvement or stabilization of symptoms and/or imaging findings were documented in all ten patients studied and no severe HBOT toxicity was observed. Four patients died, with the cause of death attributed to tumor progression. Five of six surviving patients were improved by clinical and imaging criteria; one patient was alive with tumor present at last follow-up. CONCLUSIONS: HBOT may prove to be an important adjunct to surgery and steroid therapy for CNS RIN.

The elemental composition of tumors: kerma data for neutrons.

The elemental composition of a variety of tumor samples, including squamous cell lung carcinoma, sarcoma, adenoid cystic carcinoma, melanoma, and rectal carcinoma have been measured by combustion analysis. Hydrogen, carbon, nitrogen, and oxygen content have been determined. Using the elemental neutron kerma data published in ICRU Report #46 the neutron kerma factors for the various tumor samples have been calculated in the energy range 11 eV to 29 MeV. The average neutron kerma values for all tumor samples are approximately 6%-7% lower than those for average soft tissue in the energy range of interest in fast neutron therapy (energies > 1 MeV).

Differences in dosimetry and toxicity between definitive and postprostatectomy radiation therapy.

PURPOSE: To compare the volumes of normal tissue irradiation and toxicity in patients treated with definitive radiation therapy or postprostatectomy radiation therapy. MATERIALS AND METHODS: Results were analyzed prospectively in 49 patients who underwent definitive or postprostatectomy radiation therapy after three-dimensional conformal treatment planning. Dose-volume histograms and the effective area irradiated were analyzed. Patient charts were reviewed and scored for acute and chronic toxicity. The mean bladder volume was 200 mL in the definitive group and 226 mL in the postprostatectomy group. The mean rectal volume was 87 mL in the definitive group and 81 mL in the postprostatectomy group. RESULTS: The dose to 25% of the rectal volume was 91% and 86% in the definitive and postprostatectomy groups, respectively. The dose to 25% of the bladder volume was 89% in the definitive group and 82% in the postprostatectomy group. The incidence of acute and chronic gastrointestinal and chronic genitourinary toxicity was similar in both groups, but acute genitourinary toxicity in the postprostatectomy group was significantly lower (P = .026). The volume of normal tissue irradiated was similar in both groups. Also, similar doses were delivered to the normal tissue. CONCLUSION: Differences in acute genitourinary toxicity are most likely secondary to radiation-induced prostatitis. Postprostatectomy radiation therapy is safe and is not associated with increased toxicity.

Enhancement of prostate tumor volume definition with intravesical contrast: a three-dimensional dosimetric evaluation.

PURPOSE: To assess the impact of intravesical contrast during computed tomography (CT) simulation on prostate tumor volume definition and dose distribution. METHODS AND MATERIALS: Sixteen patients with localized adenocarcinoma of the prostate underwent CT-based virtual simulation in preparation for definitive radiotherapy. Patients were immobilized with a foam cradle and an initial CT was performed after oral but without intravesical contrast (noncontrast scan). A second scan was performed following administration of intravesical contrast (contrast scan). Beam apertures were designed on the noncontrast scans and digitized into the contrast scan file. Beam apertures were also designed on the contrast scans. Isodose plans were generated for several beam apertures and arrangements. RESULTS: There was enhanced visualization of the prostate at the cephalad portion of the field for 15 of the 16 cases. The mean differences between the noncontrast and contrast volumes was significant (p = 0.0001). The mean percent underdosage to the prostate ranged from 3.9% to 18.6%, depending upon the target volume and beam arrangement. CONCLUSION: This study demonstrates the necessity of using intravesical contrast for defining the location of the prostate during CT simulation. The underestimation of the extent of the prostate when omitting intravesical contrast leads to significant underdosage. The value of intravesical contrast is most evident when small (prostate only) conformal fields are used.

Clinical strategies for improving the radiotherapeutic management of prostate cancer.

The goal of treatment of localized and locally advanced prostate cancer is to cure without causing unacceptable complications. The recognition that cure rates for localized and locally advanced prostate cancer treated with traditional means are far lower than previously estimated (1-4) has provided the impetus to seek improved local therapies. In particular, 3D conformal radiation therapy (3D-CRT) and the combination of radiation and hormone therapy are promising. Advances in these and other areas are discussed below.

Trends in primary surgical and radiation therapy for localized breast cancer in the Detroit Metropolitan area 1973-1992.

PURPOSE: The purpose of this report is to describe trends in primary surgical and radiation therapy for localized breast cancer from 1973 through 1992 among residents of the Detroit Metropolitan area. METHODS AND MATERIALS: Data on surgical and radiation therapy procedures for women with local stage breast cancer were obtained from the population-based Metropolitan Detroit Cancer Surveillance System (MDCSS). RESULTS: Women age 75 years and older were treated less aggressively than younger women (< age 75) as evidenced by higher rates of simple mastectomy or no treatment among older women. Younger women (< age 75) were more likely to have had optimal breast conservation therapy which consisted of partial mastectomy, axillary lymph node dissection (ALND), and radiation therapy, than were women who were older than 75. Partial mastectomy has increased proportionally from 4% of all breast cancer surgeries in the time period 1973 to 1977, to 39% of all surgeries from 1988 through 1992. CONCLUSION: A marked difference in surgical treatment of breast cancer exists for younger vs. older women. Despite changes in surgical treatment trends for breast cancer, a large proportion of women who are candidates for conservative therapy continue to undergo mastectomy.

Musculoskeletal complications of neutron therapy for prostate cancer.

The purpose of this study was to investigate the cause of hip complaints following conformal neutron therapy delivered by opposed lateral and oblique anterior ports to treat prostate cancer. Twenty-seven patients with hip complaints following neutron or mixed neutron and photon therapy for prostate cancer had 34 magnetic resonance imaging (MRI) studies 3-39 (mean 15.3) months following treatment; for comparison, 13 similarly treated patients without hip complaints were imaged 1-32 (mean 13.8) months post-treatment; 25/40 imaged patients received concurrent nonsteroidal hormone therapy. Coronal and axial images of the hips/pelvis were obtained utilizing T1 weighted spin echo and fat suppressed inversion recovery (STIR) sequences. Signal amplitude (SA) of involved muscles was measured on the STIR images and normalized to that of the psoas outside the treatment field. Hip complaints ranged from mild soreness or motion limitation to severe pain and limitation of ambulation; presence and severity of symptoms (sx) were significantly related to neutron dose (P = 0.020 and 0.0001) but not to hormone therapy (each P > 0.17). Normalized SA of the obturator muscles differed significantly with neutron dose (P = 0.013), the presence, and the severity, of sx (P = 0.0002 and 0.0007); estimated extent of abnormal muscle also differed significantly with neutron dose (P = 0.039), presence, and severity, of sx (P = 0.00004 and 0.0007); [hormone treatment had a profound effect on SA (P = 0.0001) and extent (P = 0.005) which was independent of sx (P = 0.10 and 0.14, respectively) and neutron dose (P = 0.33 and 0.32, respectively)]. Subcutaneous changes localized lateral to the greater trochanter were seen in all, and edema of the subjacent gluteus muscles in many, symptomatic hips; only 4/13 asymptomatic hips showed subcutaneous changes, 6 had mild gluteus edema. Avascular necrosis of the femoral head was seen in 5 symptomatic hips, with marked acetabular necrosis in 3 of these; small joint effusions were seen in 8 symptomatic hips; asymptomatic hips had no significant bone or joint abnormalities. Neutron therapy for prostate cancer designed to spare the rectum results in significant dose-dependent, musculoskeletal complications which are well demonstrated by MRI. SA abnormalities of irradiated muscle correlate significantly with neutron dose and both presence and severity of hip sx. Protocol modifications have been implemented to reduce these complications. MRI provides an objective means to assess both complications and the success of new protocols in ameliorating them. Concurrent hormone therapy has a profound effect on muscle changes on MRI which is independent of neutron dose and sx.

Hip stiffness following mixed conformal neutron and photon radiotherapy: a dose-volume relationship.

PURPOSE: To determine the relationship between dose, volume, and the incidence of hip stiffness in patients who received conformal neutron irradiation for prostate cancer. METHODS AND MATERIALS: A series of dose-searching studies using neutron irradiation for prostate cancer were performed to determine the optimal dose, fraction size, field size, technique, and proportions of photon and neutron dose. Neutron doses ranged from 9 to 20 Gy and photon doses ranged from 0 to 38 Gy. Data were analyzed by using a hip stiffness grading scale. RESULTS: Hip stiffness was recorded on follow-up examination in 30% of patients (40 out of 132) treated with fast neutrons or mixtures of fast neutron and photon radiation for prostate cancer. Hip stiffness was categorized as none (Grade 0, 92 patients), mild (Grade 1, 24 patients), moderate (Grade 2, 10 patients), or severe (Grade 3, 6 patients). The incidence of hip stiffness differed significantly by dose and volume in the five dose levels studied (p < 0.001). CONCLUSIONS: By using a mixture of conformal neutron and photon irradiation and limiting the total neutron dose to less than 13 Gy, hip stiffness toxicity could be reduced to acceptable levels.

Cloning and DNA sequence of plasmid determinant iss, coding for increased serum survival and surface exclusion, which has homology with lambda DNA.

Escherichia coli K12 cells carrying a cloned 1.4 kb HindIII fragment from plasmid ColV2-K94, showed increased survival in guinea pig serum. The recombinant plasmid also conferred group II surface exclusion, i.e. the cells were reduced in recipient ability towards the incoming plasmid R538drd in conjugation experiments. Southern blotting suggested homology with bacteriophage lambda DNA and to the insertion element IS2. Determination of the DNA sequence of the fragment demonstrated the presence of a truncated IS2 (165 bp), separated by 250 bp from a 900 bp stretch of homology with lambda DNA, beginning within the Rz gene and continuing in the rightward direction on the lambda map. A 97 amino acid open reading frame (ORF) adjacent to Rz and on the opposite strand, remained intact in iss, with several amino acid changes. The ORF in iss is preceded by sequences resembling prokaryotic ribosome binding sites and promoters.

Comparison of 16S rRNA sequences from the family Pasteurellaceae: phylogenetic relatedness by cluster analysis.

The taxonomy of the family Pasteurellaceae has remained controversial despite investigations of biochemistry, serology, and nucleic acid relatedness. In an attempt to resolve some of this confusion, we have partially sequenced the 16S rRNAs of seven members of the family, representing all three genera. The sequences were aligned, similarity scores calculated, and single, average and complete linkage cluster analysis of the resulting distance matrix performed. In this way, an evolutionary branching pattern of these closely related species was reconstructed, and the approximate phylogenetic position of the family determined. Actinobacillus (Haemophilus) actinomycetemcomitans clustered with Haemophilus instead of Actinobacillus, supporting transfer of this species to the genus Haemophilus. Thus cluster analysis of phylogenetic relatedness was found to be particularly useful for studying closely related organisms, and could be performed using a microcomputer.

Synthetic oligodeoxynucleotide probes for the rapid detection of bacteria associated with human periodontitis.

Analysis of the subgingival microflora has recently implicated Actinobacillus (Haemophilus) actinomycetemcomitans and several black Bacteroides species in the aetiology of juvenile, adult and rapidly progressing periodontitis. Rapid bacteriological diagnosis has been hampered by the slow growth and fastidious nature of these bacteria. To construct diagnostic probes, dideoxy sequencing of the 16S rRNA molecules from A. (H.) actinomycetemcomitans, Haemophilus aphrophilus, Bacteroides gingivalis, Bacteroides intermedius subgroup II, Bacteroides asaccharolyticus and several closely related species was performed. Next, oligodeoxynucleotides, complementary to defined regions of the 16S rRNA exhibiting considerable evolutionary divergence, were synthesized for use as molecular probes. In a dot-blot hybridization assay, all strains from each of the species for which probes were constructed were correctly identified, with a detection limit of less than 5 x 10(3) organisms. No cross-hybridization to closely related species (except for H. aphrophilus and Haemophilus paraphrophilus) or contaminating bacteria was observed. Using a modified DNA/RNA hybridization technique, the detection could be performed in less than 12 h, as compared to 2-3 weeks using conventional bacteriological procedures.

Nonselective enrichment for yeast adenine mutants by flow cytometry.

The expression of certain adenine biosynthetic mutations in the yeast Saccharomyces cerevisiae results in a red colony color. This phenomenon has historically provided an ideal genetic marker for the study of mutation, recombination, and aneuploidy in lower eukaryotes by classical genetic analysis. In this paper, it is reported that cells carrying ade1 and/or ade2 mutations exhibit primary fluorescence. Based on this observation, the nonselective enrichment of yeast cultures for viable adenine mutants by using the fluorescence-activated cell sorter has been achieved. The advantages of this approach over conventional genetic analysis of mutation, recombination, and mitotic chromosomal stability include speed and accuracy in acquiring data for large numbers of clones. By using appropriate strains, the cell sorter has been used for the isolation of both forward mutations and chromosomal loss events in S. cerevisiae. The resolving power of this system and its noninvasiveness can easily be extended to more complex organisms, including mammalian cells, in which analogous metabolic mutants are available.