Progress in radiotherapy.

The 100 years which have elapsed since W.C. Röntgen discovered the x-rays in 1895 have given us a large body of knowledge about the sue of ionizing radiation, and also taught us enough to allow for a statement that there is still much room for improvement. Even if it is always difficult to look into the future, it seems today that such improvements in the first hand may imply sophistications of already existing methods. This will not be without impact. For Europe, it is estimated that improvements in radiotherapy will raise the cure rates in all cancer patients by a substantial figure. It is the purpose of this communication to try to describe such future improvements. Another at least equally important factor would be to make this treatment modality available to all patients who are considered to benefit from it.

Gliomas of the anterior visual pathway in children. Tumour behaviour and effect of treatment.

An analysis of 16 cases of optic glioma in childhood is presented. All tumours were astrocytomas of the juvenile pilocytic of type low malignancy. In 7 of 13 patients with involvement of the chiasm there was a significant progression of tumour during the follow-up period, including 4 cases with fatal outcome. Patients under 5 years of age had a more unfavourable course than older children, but at the same time they had received lower doses of radiotherapy. The 5 patients treated with an absorbed dose of 39 Gy or more are alive without signs of progression 7-20 years after treatment. It is concluded from this material and from a survey of literature that many cases of optic glioma in childhood do not have a benign course. Guidelines for treatment are proposed.

Surgery alone or combined with radiation therapy in esophageal carcinoma.

Two patient-materials with esophageal carcinoma are analyzed: a group of 22 patients who, during the period 1971-1974, were treated with esophageal resection followed by esophagogastrostomy or colonic interpolation; a second group of 28 patients from 1975-1978, who were treated in the same way, but also given either preoperative or postoperative radiation therapy, or both. Surgical mortality was about the same in the two groups: 25-32%. The group given radiation therapy had a one-year survival rate of 50%, as compared with 23% in the group treated solely with surgery. All 24 patients given combined therapy, with all or part of the absorbed dose of 24-47 Gy given preoperatively, showed vital cancer in resected specimens. Vital cancer was found in the periesophageal nodes in only six patients (25%), however; patients given no preoperative radiation therapy had tumor in 20 of 26 cases (77%; P less than 0.01). Celiac nodes were resected at laparotomy; when malignancy was found, the celiac region was irradiated postoperatively. This finding does not appear to exclude long-term survival, as two patients with metastases to the celiac nodes at operation are alive 16 and 20.5 months following surgery. Simple compared to troublesome dissection gives a better rate of survival. The spleen was unintentionally injured in 21 patients at laparotomy and had to be removed. One-year survival was better in patients with intact spleen, especially in those who also had radiation therapy. Patients with resected spleen succumbed from metastases more often than from mediastinal recurrence, as compared with the patients with intact spleen.

Hodgkin's disease irradiated with the inverted-Y technique.

Thirty-four patients with Hodgkin's disease were treated with the inverted-Y technique. Target absorbed dose was 40 Gy given in a split-course schedule to all but one patient. Only one recurrence occurred. Seventeen patients remained symptom-free after treatment and another 9 were rescued by further therapy. Eight patients died. All 7 patients in stages I and II are alive. In stage III A more patients with upper abdominal disease remained symptom-free after treatment than patients with lower abdominal disease. Of 7 patients in stage III B, 5 died. Actuarial survival at 10 years was significantly better for patients without systemic symptoms. Radiation side effects were mild. One serious complication occurred, acute gastrointestinal ulceration in the patient given the total dose in one series. No permanent symptom-producing side effects from liver, kidneys, spinal cord or bone marrow occurred.

Improvements in the radiotherapy of medulloblastoma, 1946-1975.

The prognosis in medulloblastoma has often been reported to be gloomy, and five-year survival rates of approximately 25% are often reported. In recent years, however, some centers have published results that indicate a possible cure rate of 60% or even more. During the years 1946-1975, 50 children received radiotherapy for medulloblastoma at the University Hospital, Lund, Sweden. During this period the target volume had been defined in three different ways, whereas the target-absorbed dose had not differed. When only the demonstrated tumor was treated, the ten-year survival rate was 5%. If the spinal subdural space also was included, it rose to 25%, and when the whole subdural space was treated in addition to the demonstrated tumor, the projected ten-year survival rate was 53%. It is apparent that the target volume in the radiotherapy of medulloblastoma should include not only the demonstrated tumor but also the whole subdural space from the tip of the frontal lobes down to and including the second sacral segment. The size of the target-absorbed dose to be aimed at is not settled, but should consider not only the cure rate but also the performance status of the survivors. It seems from the present series that an absorbed dose of 45 Gy in not more than 30 fractions over six weeks to the demonstrated tumor and 30 Gy in 20 fractions over four weeks to the subdural space resulted in a fair frequency of tumor healing and minimal side effects. The delivery of this complicated treatment demands a high degree of precision in the technique. In this material the performance status of the children was not affected by the radiation treatment.

CVP-remission-maintenance in stage I or II non-Hodgkin's lymphomas: preliminary results of a randomized study.

The effect of adjuvant combination chemotherapy when given to non-laparotomized patients in remission after radiotherapy in stage I or II non-Hodgkin's lymphoma was studied in a prospective randomized multicenter study. Locally extended field radiotherapy was given to a target absorbed dose of 40 Gy in 20 fractions. Fifty-five patients who were in complete remission 6 weeks after conclusion of radiotherapy were randomized to either no further therapy or to 9 cycles of CVP (cyclophosphamide + vincristine + prednisolone). The relapse-free survival at 30 months was 41% for patients without and 86% for patients with adjuvant chemotherapy (p = 0.02). The survival was the same for both treatment arms, being 90% at 30 months. Fifteen patients have relapsed, 14 of them with extensions and 1 with a recurrence within the radiation target volume. Analysis of subgroups showed that adjuvant chemotherapy in the present series significantly prolonged the relapse-free survival in diffuse histiocytic lymphoma.