Preoperative "chemoradiation" for stages II and III rectal carcinoma.

OBJECTIVE: To determine whether preoperative administration of combination chemotherapy and external beam irradiation ("chemoradiation") for patients with stage II or stage III rectal carcinoma had an impact on perioperative morbidity on oncologic outcome, as compared with patients not receiving preoperative chemoradiation. DESIGN: A group of patients with stage II or stage III rectal carcinoma receiving preoperative chemoradiation were followed up prospectively and compared in a nonrandomized fashion with an inception cohort group of similar patients. SETTING: Northwestern Memorial Hospital, Chicago, Ill, a tertiary care academic medical center. PATIENTS: Thirty patients with rectal carcinoma undergoing preoperative chemoradiation were compared with 56 patients not undergoing preoperative chemoradiation, and also with a subset group of 24 patients who received standard postoperative adjuvant chemoradiation. INTERVENTION: External beam radiation, 45 to 50 Gy, was delivered concurrently with fluorouracil and mitomycin 4 to 8 weeks prior to surgical resection. MAIN OUTCOME MEASURES: Patients were followed up at regular intervals for either tumor recurrence or death. In addition, the group receiving preoperative chemoradiation was evaluated for major preoperative morbidity. RESULTS: All patients agreeing to preoperative chemoradiation completed therapy. Perioperative major morbidity in this group (13%) was comparable to previously published results. Of the 56 patients with stage II or stage III rectal carcinoma not receiving preoperative chemoradiation, only 24 (43%) completed standard postoperative adjuvant chemoradiation. Patients receiving preoperative chemoradiation (n = 30), patients not receiving preoperative chemoradiation (n = 56), and the subset of the group not receiving preoperative chemoradiation who completed standard postoperative chemoradiation (n = 24) were followed up for a mean of 39 months, 31 months, and 32 months, respectively. Five-year actuarial local control rates were 96%, 83%, and 88%, respectively. Disease-free-survival rates were 80%, 57%, and 47%, respectively. Overall survival rates were 85%, 48%, and 78%, respectively. CONCLUSIONS: Preoperative chemoradiation in the treatment of stage II or stage III rectal carcinoma is well tolerated and not associated with an increase in subsequent perioperative major morbidity. In addition, local control, disease-free survival, and overall survival compare favorably with a nonrandomized inception cohort group of patients receiving standard postoperative adjuvant chemoradiation.

Early-stage breast cancer: arm edema after wide excision and breast irradiation.

PURPOSE: To determine the incidence of arm edema in women with early-stage breast cancer after breast-conserving surgery and irradiation. MATERIALS AND METHODS: Women aged 29-83 years (mean, 55.9 years) treated with breast-conserving surgery and irradiation (n = 183) underwent a series of measurements of the circumference of each arm. Patient and treatment factors were analyzed for predictive value. RESULTS: Arm edema developed in 35.0% (n = 64), and clinically significant edema developed in 17.5% (n = 32) of patients. Dissections that yielded 16 or more nodes led to a 44% actuarial incidence of edema and a 29% actuarial incidence of clinically significant edema. Clinically significant arm changes occurred in 19 of the 87 (22%) women older than 55 years and in 13 of the 96 (14%) women younger than 55 years (P = .002). Chemotherapy, breast radiation dose, and use of tamoxifen had no effect on development of edema. CONCLUSION: Axillary dissection producing more than 15 nodes and age older than 55 years are predictive of arm edema.

Technique for breast irradiation using custom blocks conforming to the chest wall contour.

A technique for the treatment of the breast and regional nodes is presented. The technique involves the use of tangential fields to treat the breast and chest wall. Customized blocks which conform to the slope of the chest wall are made for each tangent field. Simulation and treatment with this technique requires no special equipment. The setup is simple and quick. A three-field technique is also described using the custom half-beam blocks; this technique avoids the use of tangential field corner blocks, thus simplifying simulation and treatment.

Intraoperative radiation therapy in biliary tract cancer.

From 1983 to 1986, nine patients with advanced cancers of the proximal biliary tract were treated with intraoperative electron beam radiation therapy (IORT) following surgical resection or intubation. Five patients also received external beam radiation and four received chemotherapy. Early complications were minimal. Late complications included cholangitis, gastroduodenal ulceration, gastric outlet obstruction and portal vein thrombosis. Symptomatic recurrent or residual disease developed in eight patients with a median disease-free survival of 6 months. Seven patients failed locally; four recurred outside of the intraoperatively radiated field. The longest survivor is free of disease at 40 months; one patient is alive with disease at 30 months. Mean and median survivals were 16.8 months and 13 months respectively with 56 per cent 1-year survival. This was not different from a mean survival of 11 months and 46 per cent 1-year survival observed in 13 concurrent patients treated by external beam +/- 192Ir. Survival of six patients not treated by radiation was only 4.6 months (P = 0.3). Two thirds of patients had good or fair palliation. IORT has theoretical advantages for the treatment of locally advanced biliary cancer; preliminary results suggest useful palliation and potential long-term survival. Complications require ongoing evaluation and superiority to conventional treatment modalities has not been demonstrated.

Radiation therapy in the treatment of aggressive fibromatoses (desmoid tumors).

Twenty-five patients with aggressive fibromatoses (desmoid tumors) have been treated or followed in the Department of Radiation Medicine at the Massachusetts General Hospital between 1972 and 1982. Seventeen patients were treated by radiation, 4 for primary and 13 for recurrent disease. Seven patients were treated in conjunction with surgery. Partial or complete regression was achieved in 76%, and 59% are without evidence of disease (NED) at 9 to 94 months follow-up. Eight of ten patients treated primarily with radiation have achieved complete response without an attempt at resection (five) or have achieved stabilization (three) of their disease after some regression. Consistent complete control was seen with doses above 60 Gy. Periods to 27 months were required to observe complete responses. Only three failures within the radiation field were observed, two after low doses (22 and 24 Gy, respectively). Eight patients were seen after resection but with uncertain or histologically minimum positive margins, and were followed regularly and not treated. One patient has failed to date and is NED after resection. Radiation therapy is recommended in those situations where wide-field resection without significant morbidity is not possible for gross local disease. If minimally positive margins exist after resection in a patient who may be followed carefully, frequent follow-up and prompt treatment at recurrence may be an effective alternative to immediate radiation therapy.