Killian-jamieson diverticulum: the rarer cervical esophageal diverticulum.

Killian-Jamieson (K-J) diverticulum is a rare cervical oesophageal diverticulum, less commonly encountered compared with Zenker's diverticulum (ZD). We report a case of K-J diverticulum in a 52-year-old lady who presented with sensation of lump in the neck and food stuck in the throat of 5 years duration. Esophagogram showed a large rightsided pharyngoesophageal diverticulum which was confirmed on endoscopy. The patient underwent a diverticulopexy and recovered without complications. Her symptoms had improved. In this report, we review the literature and describe our surgical technique.

Radical radiotherapy with high-dose-rate brachytherapy for uterine cervix cancer long-term results.

The aim of this is to report the results of radical radiotherapy in carcinoma of the cervix treated by high-dose rate (HDR) intracavitary brachytherapy and external beam radiotherapy (XRT) at a single centre in Singapore. This is a retrospective analysis of 106 consecutive cases with histologically proven cervical cancer, treated by HDR brachytherapy and XRT at the Mount Elizabeth Hospital from 1990 to 1993. External beam radiotherapy to the pelvis was delivered with 6 MV photons, to 45-50.4 Gy in 1.8 Gy fractions. High-dose-rate brachytherapy comprised two to three applications of an intrauterine tandem with paired ovoids, to a median dose of 18 Gy to point 'A', carried out during XRT. All 106 patients completed treatment. Their ages ranged from 32 to 80 years (median 57 years). Most patients presented with stage II or III disease (44 and 37%, respectively) and with squamous cell carcinoma (91%). Median follow-up time was 59 months (range 2-169 months). The 5-year relapse-free survival rate across all stages was 71%. The corresponding overall survival rate was 69%. Local control was achieved in 86 patients (81%); six patients had residual disease (6%), and 14 patients had local recurrence (13%). Fourteen patients developed metastatic disease (13%). On univariate analysis, tumour stage, haemoglobin level, number of brachytherapy treatments and overall treatment time were found to be prognostic factors for overall survival. Late complications were mild (Radiation Therapy Oncology Group score 1-2), except for one patient with grade 4 rectal toxicity. The complication rates were 8, 14 and 45%, respectively, for the rectum, bladder and vagina (stenosis). The use of two to three fractions of HDR intracavitary brachytherapy in addition to pelvic XRT achieves good outcomes.

2nd FY Khoo Memorial Lecture. Brachytherapy--one man's meat, a personal journey in radiation oncology.

The Lecture covers the author's personal experience in brachytherapy in radiation oncology, beginning with low-dose rate (LDR) treatments using 226Ra "hot" sources, in the 1960s and early 1970s, through manual afterloading for treating gynaecological cancers with the same sources in the 1970s and 1980s, to high-dose rate (HDR) remote afterloading on a microSelectron HDR machine, from 1989 on. This progression in brachytherapy is discussed, and specific applications to various tumour sites are presented, including long-term results of a personal series of 106 patients with cancer of the uterine cervix, treated with radiotherapy incorporating HDR brachytherapy. The Lecture rounds off with an unusual case of equine sarcoid, treated with a postoperative implant, using 192Ir LDR brachytherapy.

Radical radiotherapy for carcinoma cervix--preliminary experience with the microSelectron high dose rate machine.

Radiotherapy for uterine cervix carcinoma is an accepted treatment for all stages of invasive malignancy. The radiation modality is usually a combination of brachytherapy and external beam therapy for all except the most extensive tumours (stage IV--FIGO). Satisfactory results have been obtained in the Singapore General Hospital using low dose-rate radium applications in combination with cobalt teletherapy. Five year actuarial survival rates of 86.7% were obtained for FIGO stage I, 65.0% for stage II, 41.4% for stage III, 4.9% for stage IV with an overall rate of 54.0% for all stages. Corresponding 10-year rates were: 79.6%, 60.2%, 35.2%, 0% and 48.2%. Preliminary results of primary radiotherapy in 36 patients with cervical carcinoma treated by high dose-rate brachytherapy (microSelectron HDR) combined with 6MVP photons from a Siemens linear accelerator are presented. The patients were registered at the Mount Elizabeth Oncology Centre from November 1989 to December 1990 inclusive. The morbidity from high dose-rate therapy appears lower (9.1% for vaginal stenosis, 6.1% for non-severe proctitis) than for the radium series (4.1% and 20.8%) although the major complication rate appears similar (3% vs 2.8% respectively). The total failure rate is also lower at 19.4% for the HDR patients compared to 33.5% for the radium group. However, these rates are not strictly comparable as the HDR series consists of a small number of patients with limited follow-up. In the light of the data indicating acceptable morbidity with significant rate of early failure, the HDR brachytherapy doses have been increased whilst keeping within the limits set by other centres.

Bone scintigraphy in nasopharyngeal carcinoma.

One hundred and forty-three patients (Group 1) with histologically proven nasopharyngeal-carcinoma (NPC) had bone scintigraphy with 99Tcm methylenediphosphonate (MDP) or dihydroxypropanediphosphonate (DPD) within 2 months of the initial diagnosis. A further 162 patients (Group 2) had bone scans during the course of follow-up if there were symptoms of bone pain or evidence of metastases at other sites. Twenty-three per cent (33/143) of the newly diagnosed NPC patients (Group 1) had evidence of bone metastases. Of these 143 patients, 101 were T0-T2, 16 were T3 and 25 were T4. Thirty-six patients had no neck nodes (NO), 44 were N1, 25 N2 and 38 N3. Of the 162 patients in Group 2, 96 (59%) had a positive bone scan. The commonest sites for bony metastases from NPC were the spine, ribs, pelvis and lower limbs in order of frequency. There is a highly significant association with the nodal stage but no association with the UICC T staging which is not adequate in nasopharyngeal carcinoma. In our part of the world, bone metastases from NPC are a common cause of an abnormal bone scan.

Lung cancer metastases--management.

Distant metastases from lung cancer is a common occurrence in a common malignancy. Almost every organ may be involved but the extra-thoracic sites posing common clinical problems are brain metastases, cord compression, painful bone metastases or pathological fractures, nodal spread and liver involvement. A review of the records of 225 lung cancer patients referred to the Therapeutic Radiology Department, Singapore General Hospital, during the calender year 1985 showed a metastatic rate of 13.8% at referral. On subsequent follow up, an additional 49 patients (21.7%) developed metastases clinically. The organs involved were bone (21 patients), spinal cord (21 patients), brain (18 patients), liver (13 patients), other lung (7 patients) and other sites (17 patients). The management of metastases to the brain, bone and liver, and spinal cord compression will be discussed.

Conservation breast treatment: a viable option locally.

Conservation treatment in carcinoma of the breast is a viable option in the West but is still an uncommon practice locally. Many reasons have been put forth, including the late stage of the tumour we see and the small breast size. This paper presents 25 cases treated by lumpectomy and irradiation with satisfactory cosmetic results, although the follow-up period is short. The introduction of this technique may encourage women to seek treatment earlier, without the fear of losing their breasts.

Hyperthermia with radiotherapy.

The use of hyperthermia together with radiotherapy in the treatment of relatively radioresistant tumours has been widely studied. In this preliminary non control study we used a 8MHz RF capacitive heating machine together with temperature probes inserted into the tumours under local anaesthesia. 27 patients with advanced post-radiation tumour recurrences as well as known radioresistant tumours were selected for treatment with hyperthermia and radiation. 7 patients withdrew from the study because of their intolerance to heat. 3 patients received superficial skin burns. Of the 20 patients studied, we were able to obtain moderate hyperthermia in most cases. 2 patients showed complete responses and 13 partial responses, giving rise to a total response rate of 75%. Some of the technical difficulties in achieving satisfactory hyperthermia are discussed. These include insertion of multiple probes into the body and the problem of achieving uniform heating of the tumour. Advances in hyperthermia can be expected with the development of improved methods of heat delivery and temperature measurements. However, presently methods of heat delivery can be improved by careful adjustment of the heating applicators and manipulation of cooling pads to avoid areas of excessive heating. Further clinical trials should be carried out to establish the optimum technique of hyperthermia.

Radiotherapy of early glottic cancer Singapore, 1978-1981.

This study analyses the results of primary radiotherapy for 44 patients with early glottic cancer (Tis, T1 stage) given at the Therapeutic Radiology Department, Singapore General Hospital during the 4-year period from 1978 to 1981. Irradiation was delivered using cobalt teletherapy with free set-ups, and without "air-gap" compensation. Total doses of 55Gy to 64Gy were given in daily fractions of 1.8Gy, treating five times a week. The crude 5-year survival rate for Tis/T1a tumours was 88.9% and for T1b lesions, 81%. On correcting for deaths from intercurrent disease, the survival rates improved to 95.5% and 92.6% respectively. In 33 cases where the quality of voice after radiation was assessed, 15 patients (45.4%) retained good voice quality with an additional 11 patients (33.3%) having acceptable voice quality. In seven cases the voice after radiation was rated as poor. Nine patients had local recurrence, giving a rate of 20.4%. One other patient had cervical node metastasis and subsequently developed lung secondaries. Surgery, solely or with re-irradiation, was an effective treatment for local recurrence. Re-irradiation alone failed to control any case with recurrence.

Advanced colorectal carcinoma--5 year survival of 76 cases treated at the Department of Therapeutic Radiology, Singapore General Hospital.

The results of 76 cases of advanced colorectal carcinoma treated at the Department of Therapeutic Radiology, Singapore General Hospital, from 1977 to 1978, are presented. All cases had "Curative" Surgery and were given adjuvant radiotherapy or chemotherapy or both. All were adenocarcinoma and had lymph node involvement as well as tumour infiltration through the bowel wall. 44 cases of rectal carcinoma were given radiotherapy to the pelvis followed by I/V 5-fluorouracil for at least one year. 32 cases of colon cancer were given I/V 5-fluorouracil for at least one year. 20 of these cases had cancer of the sigmoid colon and were given pelvic irradiation as well. The five year actuarial survival rates were 27.8% for rectal cancer and 24.3% for colon cancer.

Radiotherapy of carcinoma of the uterine cervix in Singapore, 1973-1975.

The results of 322 patients with uterine cervix carcinoma treated by radiotherapy at the Singapore General Hospital in the 3-year period from 1973 to 75 are presented. Two hundred seventy-nine patients were treated with a combination of intracavitary radium, using Fletcher-Suit applicators and cobalt teletherapy; the remaining 43 patients received only cobalt teletherapy. One hundred thirty-four patients (41.6%) presented with FIGO Stage III disease. Only 46 patients (14.3%) presented with Stage I disease, showing that patients tended to present late in the disease course. Five-year actuarial (uncorrected) survival rates of 86.7% for Stage I, 65.0% for Stage II, 41.4% for Stage III and 4.9% for Stage IV were obtained with corresponding 10 year rates of 79.6%, 60.2%, 35.2% and 0%. The overall 5 and 10 year survival rates were 54.0% and 48.2%, respectively. The survival rates "flattened off" at about 7-8 years, reflecting late deaths after the fifth anniversary of treatment. Non-severe complications consisted mainly of chronic proctitis (41.3%) and vaginal stenosis (20.8%). Major complications were intestinal stricture (1.2%) and fistula formation (1.6%).

Testicular disease in Singapore children with acute leukemia.

A study was made on testicular leukaemia developing in children treated for leukaemia in the Department of Paediatrics, Singapore General Hospital over the past 6 years. Of the 44 cases of acute leukaemia treated, 24 were males, and 6 developed testicular leukaemia, all occurring in patients with acute lymphoblastic leukaemia. Half the cases developed testicular relapse while on chemotherapy with the other half developing it after all chemotherapy was stopped. There is a place for prophylactic radiotherapy to the testis. Testicular biopsy should be considered early in high risk groups.

A report of 21 cases of malignant lymphoma treated by radiotherapy.

In 1971, 21 new patients with malignant lymphoma were treated at the Therapeutic Radiology Department, Singapore General Hospital. 17 patients completed their courses of radiotherapy. Of the 17 patients given radical treatment, 5 were of Hodgkin's disease and 12 of Non-Hodgkin's disease. The 5-year survival for the group with Hodgkin's disease is 80% (4/5). The 5-year survival for the group with Non-Hodgkin's disease in 41.6% (5/12).

Adjuvant combination chemotherapy for osteosarcoma.

The management of patients with osteosarcoma in Singapore has for many years been an unrewarding task for the attending physicians. Encouraged by reports of long-term survivals with adjuvant cytotoxic chemotherapy appearing in 1975, orthopaedic surgeons and radiation therapists at the Singapore General Hospital undertook a program of combination chemotherapy in moderate doses for osteosarcoma patients with localised disease treated by ablative surgery. A few who refused surgery had irradiation of the primary tumour.

Radiotherapy in treatment of nasopharyngeal carcinoma.

Nasopharyngeal Carcinoma is one of the most prevalent malignancies treated by radiotherapy in Singapore. Planning of the radiation fields for this condition is difficult because of the proximity of anatomical structures that are vulnerable to irradiation, such as the eyes, brain stem and cervical cord. However, the treatment results have shown progressive improvement. The treatment technique currently used utilized cobalt as well as caesium teletherapy units. Of the 104 cases treated in 1970 using this technique, the overall absolute 5 years survival rate with no evidence of disease is 30.8%. For Stage I cases, the rate is 62.5%. The prognosis is significantly better for the female than the male and is also related to age.