Dosimetric study of pelvic proton radiotherapy for high-risk prostate cancer.

PURPOSE: To compare dose distributions in targeted tissues (prostate, seminal vesicles, pelvic regional nodes) and nontargeted tissues in the pelvis with intensity-modulated radiotherapy (IMRT) and forward-planned, double-scattered, three-dimensional proton radiotherapy (3D-PRT). METHODS AND MATERIALS: IMRT, IMRT followed by a prostate 3D-PRT boost (IMRT/3D-PRT), and 3D-PRT plans were created for 5 high-risk prostate cancer patients (n = 15 plans). A 78-CGE/Gy dose was prescribed to the prostate and proximal seminal vesicles and a 46-CGE/Gy was prescribed to the pelvic nodes. Various dosimetric endpoints were compared. RESULTS: Target coverage of the prostate and nodal planning target volumes was adequate for all three plans. Compared with the IMRT and IMRT/3D-PRT plans, the 3D-PRT plans reduced the mean dose to the rectum, rectal wall, bladder, bladder wall, small bowel, and pelvis. The relative benefit of 3D-PRT (vs IMRT) at reducing the rectum and rectal wall V5-V40 was 53% to 71% (p < 0.05). For the bladder and bladder wall, the relative benefit for V5 to V40 CGE/Gy was 40% to 63% (p < 0.05). The relative benefit for reducing the volume of small bowel irradiated from 5 to 30 CGE/Gy in the 3D-PRT ranged from 62% to 69% (p < 0.05). Use of 3D-PRT did not produce the typical low-dose "bath" of radiation to the pelvis seen with IMRT. Femoral head doses were higher for the 3D-PRT. CONCLUSIONS: Use of 3D-PRT significantly reduced the dose to normal tissues in the pelvis while maintaining adequate target coverage compared with IMRT or IMRT/3D-PRT. When treating the prostate, seminal vesicles, and pelvic lymph nodes in prostate cancer, proton therapy may improve the therapeutic ratio beyond what is possible with IMRT.

Association between operative closure type and acute infection, local recurrence, and disease surveillance in patients undergoing breast conserving therapy for early-stage breast cancer.

BACKGROUND: This study investigates the effect of full-thickness versus superficial closure of the breast parenchyma on the likelihood of subsequent infection and local recurrence after lumpectomy for early-stage breast cancer. In patients undergoing breast-conserving therapy (BCT), operative closure technique has been largely influenced by expected cosmetic outcome. However, the common practice of promoting postoperative fluid collection raises concerns about potential bacterial colonization, tumor cell migration, and impaired post-BCT surveillance. METHODS: From 1985 through 2004, operative closure technique was determined in 516 breasts in 580 women with stage T0-2N0-1 breast cancers undergoing BCT. Medical records were reviewed to determine closure technique, incidence of postoperative infection, and local recurrence characteristics. RESULTS: Median follow-up was 6.4 years from the completion of radiotherapy. The rate of acute infection was higher with the superficial closure technique: 11.7% (27/230) versus 5.2% (15/286) (P = .009). In T1-2 patients, there was no difference in the rate of local recurrence based on closure type: 5.6% (11/195) versus 3.5% (8/231) (P = .348). On multivariate analysis, acute infections and margin status were associated with increased local recurrence. Superficial closure was associated with larger recurrences less likely to be detected on mammogram. In stage T0-T2 patients, 80% of recurrent tumors after superficial closures were greater than 1 cm compared with no recurrent tumors greater than 1 cm after full-thickness closures (P = .005). In patients with superficial closure, 29% of recurrences in the tumor bed were initially detected on mammogram versus 100% in patients with deep closure (P = .003). CONCLUSIONS: Closure method was not predictive of local recurrence. Our findings regarding infection and post-treatment surveillance suggest, however, that full-thickness closure may be the preferred technique in BCT patients.

Dexrazoxane-associated risk for acute myeloid leukemia/myelodysplastic syndrome and other secondary malignancies in pediatric Hodgkin's disease.

PURPOSE: Pediatric Oncology Group (POG) studies 9426 and 9425 evaluated dexrazoxane (DRZ) as a cardiopulmonary protectant during treatment for Hodgkin's disease (HD). We evaluated incidence and risk factors of acute myeloid leukemia (AML)/myelodysplastic syndrome (MDS) and second malignant neoplasms (SMNs). PATIENTS AND METHODS: Treatment for low- and high-risk HD with doxorubicin, bleomycin, vincristine, and etoposide (ABVE) or dose-intensified ABVE with prednisone and cyclophosphamide (ABVE-PC), respectively, was followed by low-dose radiation. The number of chemotherapy cycles was determined by rapidity of the initial response. Patients were assigned randomly to receive DRZ (n = 239) or no DRZ (n = 239) concomitantly with chemotherapy to evaluate its potential to decrease adverse cardiopulmonary outcomes. RESULTS: Ten patients developed SMN. Six of eight patients developed AML/MDS, and both solid tumors (osteosarcoma and papillary thyroid carcinoma) occurred in recipients of DRZ. Eight patients with SMN were first events. With median 58 months' follow-up, 4-year cumulative incidence rate (CIR) for AML/MDS was 2.55% +/- 1.0% with DRZ versus 0.85% +/- 0.6% in the non-DRZ group (P = .160). For any SMN, the CIR for DRZ was 3.43% +/- 1.2% versus CIR for non-DRZ of 0.85% +/- 0.6% (P = .060). Among patients receiving DRZ, the standardized incidence rate (SIR) for AML/MDS was 613.6 compared with 202.4 for those not receiving DRZ (P = .0990). The SIR for all SMN was 41.86 with DRZ versus 10.08 without DRZ (P = .0231). CONCLUSION: DRZ is a topoisomerase II inhibitor with a mechanism distinct from etoposide and doxorubicin. Adding DRZ to ABVE and ABVE-PC may have increased the incidence of SMN and AML/MDS.

Delayed breast cellulitis: an evolving complication of breast conservation.

PURPOSE: Delayed breast cellulitis (DBC) is characterized by the late onset of breast erythema, edema, tenderness, and warmth. This retrospective study analyzes the risk factors and clinical course of DBC. METHODS AND MATERIALS: From 1985 through 2004, 580 sequential women with 601 stage T0-2N0-1 breast cancers underwent breast conserving therapy. Cases of DBC were identified according to accepted clinical criteria: diffuse breast erythema, edema, tenderness, and warmth occurring >3 months after definitive surgery and >3 weeks after radiotherapy. Potential risk factors analyzed included patient comorbidity, operative technique, acute complications, and details of adjunctive therapy. Response to treatment and long-term outcome were analyzed to characterize the natural course of this syndrome. RESULTS: Of the 601 cases, 16%, 52%, and 32% were Stage 0, I, and II, respectively. The overall incidence of DBC was 8% (50/601). Obesity, ecchymoses, T stage, the presence and aspiration of a breast hematoma/seroma, removal of >5 axillary lymph nodes, and arm lymphedema were significantly associated with DBC. The median time to onset of DBC from the date of definitive surgery was 226 days. Ninety-two percent of DBC patients were empirically treated with antibiotics. Fourteen percent required more invasive intervention. Twenty-two percent had recurrent episodes of DBC. Ultimately, 2 patients (4%) underwent mastectomy for intractable breast pain related to DBC. CONCLUSION: Although multifactorial, we believe DBC is primarily related to a bacterial infection in the setting of impaired lymphatic drainage and may appear months after completion of radiotherapy. Invasive testing before a trial of antibiotics is generally not recommended.

Whole-abdomen radiotherapy for non-Hodgkin's lymphoma using twice-daily fractionation.

PURPOSE: To report the tolerability and efficacy of twice-daily whole-abdomen irradiation (WAI) for non-Hodgkin's lymphoma (NHL). METHODS AND MATERIALS: Of 123 patients treated for NHL with WAI, 37% received previous chemotherapy, 28% received WAI as part of comprehensive lymphatic irradiation (CLI), and 32% received WAI for palliation. The median dose to the whole abdomen was 25.0 Gy, followed by a median tumor boost of 9.8 Gy in 58 patients. Fractionation was 1.0 Gy once daily (54%) or 0.8 Gy twice daily (46%). Blood counts were measured weekly. RESULTS: At a median follow-up of 4.3 years, local control was 72% and overall survival was 55% at 5 years. Median time of WAI was 42 days for once-daily treatment and 32 days for twice-daily treatment. Patients receiving twice-daily WAI did not have a significantly higher rate of acute side effects (e.g., nausea, diarrhea, platelet or red blood cell toxicity). Overall, acute thrombocytopenia was the most frequent side effect of treatment; 24 of 96 patients (25%) with available hematologic data had Grade 3+ toxicity. There was no acute Grade 3 gastrointestinal toxicity and no late small bowel obstruction. Multiple regression indicated that patients with four or less involved sites and disease size < or =6 cm had improved local control and overall survival. CONCLUSIONS: Twice-daily WAI using 0.8 Gy/fraction does not appear to have any greater toxicity compared with once-daily treatment using 1 Gy/fraction. Small doses per fraction (0.8-1 Gy/fx) are effective, tolerated well in the acute setting, and associated with a low rate of late toxicity.

Aneurysmal bone cyst.

OBJECTIVES: The purpose of this article is to discuss the natural history, treatment, and outcomes for patients with aneurysmal bone cysts (ABC). METHODS: Review of the pertinent literature. RESULTS: ABCs account for 1% to 2% of all primary bone tumors, usually present in the first 2 decades of life, and exhibit a slight female preponderance. The majority of patients are treated with curettage with local control rates ranging from approximately 70% to 90%. Almost all patients with recurrences are salvaged by one or more additional operations. A small subset of patients is treated with marginal or wide excision and almost all are locally controlled. A few patients with incompletely resectable, aggressive, and/or recurrent ABCs are treated with low-dose (26-30 Gy) radiotherapy (RT) and are locally controlled in approximately 90% of cases. CONCLUSIONS: The mainstay of treatment is surgery and most patients are cured with one or more operations. A small subset of patients with incompletely resectable, aggressive, and/or recurrent ABCs may be cured with low-dose RT.

Lethal midline granuloma-nasal natural killer/T-cell lymphoma.

PURPOSE: The purpose of this paper is to discuss lethal midline granuloma (LMG)-nasal natural killer (NK) T-cell lymphoma (LMG-NTL). METHODS: Literature review. RESULTS: LMG is a rare entity that usually arises in the nasal cavity, exhibits a male preponderance, and has a wide age range. The majority of LMGs are LMG-NTLs. The optimal treatment of LMG-NTL is unclear and is most likely moderate-dose radiotherapy. The prognosis for patients with LMG-NTL is significantly worse than for patients with other types of head and neck non-Hodgkin lymphomas (NHL). The 5-year survival rate is approximately 20% but may be higher, depending on whether patients with less aggressive forms of NHL are included. Initial local-regional disease progression is the predominant pattern of treatment failure. Late failures after 5 years are uncommon. CONCLUSIONS: LMG-NTL is a rare nasal NK/T-cell lymphoma that can be difficult to distinguish from other benign and malignant entities. Its clinical course, however, is extremely aggressive. The patterns of failure suggest a role for more aggressive local-regional treatment, as well as more effective chemotherapy.

Sinonasal undifferentiated carcinoma.

PURPOSE: The purpose of this paper is to discuss the treatment and outcomes for patients with sinonasal undifferentiated carcinoma. METHODS: Review of the pertinent literature. RESULTS: Most series contain a limited number of patients treated with various combinations of surgery, radiotherapy (RT), and chemotherapy. Follow-up periods for disease-free patients are sometimes relatively short. The majority of patients present with locally advanced tumors; 10% to 30% have clinically positive regional nodes. The risk of local-regional recurrence after treatment is probably 20% to 30% or higher, depending on the extent of disease. The likelihood of distant dissemination is approximately 25% to 30% and the cure rate varies from roughly 20% to 50%. Better outcomes are observed in patients treated with craniofacial resection combined with pre- or postoperative RT alone or with adjuvant chemotherapy. This is probably due, in part, to selection bias. Patients with incompletely resectable tumors are best treated with definitive RT and adjuvant chemotherapy. CONCLUSION: The optimal treatment is craniofacial resection combined with adjuvant RT alone or with chemotherapy. The risk of relapse is relatively high and the probability of cure is modest. Patients with incompletely resectable tumors may sometimes be cured with definitive chemoradiation.

Head and neck mucosal melanoma.

PURPOSE: The purpose of this article is to discuss the optimal treatment and outcomes for head and neck mucosal melanoma. METHODS: Review the pertinent literature. RESULTS: Head and neck mucosal melanoma is a rare entity comprising less than 1% for all Western melanomas. It usually arises in the nasal cavity, paranasal sinuses, and oral cavity. The optimal treatment is surgery. The likelihood of local recurrence after resection is approximately 50%. Radiotherapy (RT) reduces the likelihood of local failure but probably does not enhance survival, which is primarily impacted by advanced T stage and the presence of regional metastases. The 5-year survival rates vary from approximately 20 to 50%. Although the median time to relapse is roughly 1 year or less, late failures are common and cause-specific survival continues to decline after 5 years. CONCLUSION: The optimal treatment is surgery. Postoperative RT improves local-regional control but may not impact survival. Definitive RT may occasionally cure patients with unresectable local-regional disease or at least provide long-term palliation.

Adult head and neck soft tissue sarcomas.

BACKGROUND: The purpose was to determine the optimal treatment for adult patients with head and neck soft tissue sarcomas. METHODS: We conducted a review of the pertinent literature. RESULTS: Local control after surgery alone or combined with radiotherapy was obtained in approximately 60% to 70% of the patients. The probability of local control is influenced by histologic grade, tumor size, and surgical margins. Patients with high-grade tumors and/or positive margins have improved local control if adjuvant radiotherapy is used. Distant metastases occurred in 10% to 30% of patients. The 5-year overall and cause-specific survival rates varied from approximately 60% to 70% and are affected by age, histologic grade, previous treatment of tumor, invasion of deep structures, and adequacy of surgery. CONCLUSIONS: The optimal treatment for adult head and neck soft tissue sarcomas is surgery. Adjuvant radiotherapy improves outcomes for those with high-grade tumors and/or positive margins. Radiotherapy alone will cure a small subset of patients with unresectable tumors.

Merkel cell carcinoma: treatment and outcomes.

BACKGROUND: The purpose of the current study was to determine the outcomes of patients with previously untreated Merkel cell carcinoma of the skin who were treated with curative intent. METHODS: Between October 1984 and January 2002, 34 patients were treated with radiotherapy alone (2 patients) or combined with surgery (32 patients). Nine patients received adjuvant chemotherapy. Patients had follow-up for a median of 3.0 years (range, 0.3 to 18.5 yrs). Follow-up on living patients ranged from 2.2 to 18.5 years (median, 7.1 yrs). RESULTS: The 5-year outcomes were as follows: local control, 94%, locoregional control, 80%; freedom from distant metastases, 60%; cause-specific survival, 52%; and survival, 37%. No patient experienced a severe complication. CONCLUSIONS: Patients treated aggressively with surgery and locoregional radiotherapy have about a 50% chance of cure. Limited data suggest that definitive radiotherapy alone or after incomplete macroscopic resection may control locoregional disease in a significant subset of patients. The dominant site of failure was distant.

Breast-conserving therapy in patients with bilateral breast cancer: do today's treatment choices burn bridges for tomorrow?

PURPOSE: To determine how often initial treatment choices limit treatment options for subsequent breast cancer management in patients undergoing breast-conserving therapy (BCT), in particular with treatment of internal mammary nodes. METHODS AND MATERIALS: Between January 1985 and June 2001, 464 women with pathologic Stage 0, I, and II (T0-2, N0-1) breast cancer underwent BCT at our institution. All 464 patients had computed tomography-based treatment planning. In patients with bilateral breast cancer, the planning computed tomography scans were used to determine the impact initial radiation therapy fields had on treatment options for subsequent contralateral breast cancer. RESULTS: There were 500 breast cancers diagnosed in 464 patients. Thirty-six patients (8%) had bilateral breast cancer with 9 (2%) synchronous and 27 (6%) metachronous primaries. In 80 patients, the ipsilateral internal mammary nodes were explicitly treated. Initial breast cancer treatment choices impacted subsequent treatment decisions for the contralateral breast in only 2 of 464 patients (0.4%) in the study: 2 of 80 patients (2.5%) whose internal mammary nodes were treated, and 2 of 27 patients (7.4%) who developed metachronous bilateral breast cancer. CONCLUSIONS: Initial BCT, including internal mammary node irradiation, rarely compromised future contralateral breast-conserving therapy.

Skull base chordoma.

PURPOSE: Our purpose was to discuss the optimal treatment and outcomes for patients with skull base chordomas. METHODS: We reviewed the pertinent literature for this study. RESULTS: Skull base chordomas usually arise in the clivus and are rarely completely resectable. Therefore, most are treated with radiotherapy (RT). Because of the risk of severe late complications, the dose is often limited with conventional photon RT, and the probability of cure is low. Proton RT alone or combined with photon RT (proton/photon RT) offers the advantage of improved dose distribution and the ability to treat the tumor to a higher dose without exceeding normal tissue tolerance. The 10-year local control rate after proton/photon RT is approximately 40% to 50%. The probability of local control is related to minimum tumor dose and dose inhomogeneity. CONCLUSIONS: Skull base chordoma is a rare neoplasm that is rarely cured after surgery alone or combined with conventional RT. Proton/photon RT offers the advantage of increasing the tumor dose while minimizing the dose to normal tissues, thus reducing the risk of late complications. The optimal treatment may be photon/proton RT alone or combined with a gross total resection, when feasible.

Merkel cell carcinoma.

PURPOSE: To determine the natural history and treatment outcomes for patients with Merkel cell carcinoma. METHODS: Review of the literature. RESULTS: The probability of regional node involvement at presentation exceeds 50%; few patients present with distant metastases. Comprehensive treatment of the primary site and regional lymphatics with surgery or radiotherapy results in the highest likelihood of cure. The role of adjuvant chemotherapy remains investigational. CONCLUSION: The probability of regional dissemination at diagnosis is high. The optimal treatment is resection of the primary tumor and treatment of the regional lymphatics. Resection of all gross tumor should be accomplished followed by local-regional radiotherapy in most patients.

Inflammatory breast carcinoma: outcomes with trimodality therapy for nonmetastatic disease.

BACKGROUND: The objectives of this study were to summarize a single-institution experience in treating patients with inflammatory breast carcinoma (IBC) using trimodality therapy and to identify prognostic factors for outcome. METHODS: Sixty-one women underwent radiation therapy with curative intent for IBC between 1982 and 2001. All but five women received trimodality therapy. Neoadjuvant chemotherapy was given to the majority of women (n = 43 patients), although some received "up-front" surgery as first therapy (n = 18 patients). RESULTS: With a median potential observation time after diagnosis of 14 years, freedom from locoregional disease progression was 78%, freedom from distant metastasis was 45%, and the cause-specific survival rate was 47% at 5 years. Approximately 40% of the 56 patients who received trimodality therapy remained free of disease. Multivariate analysis demonstrated three factors that were found to be associated significantly with improved cause-specific survival: pathologic tumor size < 4 cm (P = 0.0001), up-front surgery (P = 0.0078), and local disease control (P = 0.0003). Factors that were found to be associated with better freedom from locoregional disease progression were pathologic tumor size (< 4 cm; P = 0.0157), age (> 55 years; P = 0.0596), and radiation dose (> or = 60 grays [Gy]; P = 0.0621). CONCLUSIONS: IBC is an aggressive disease that is treated effectively in select patients by multimodality therapy. Patient outcomes may be improved with therapies that result in better local and systemic control. Further studies are warranted to address the optimal sequence of trimodality therapy and the optimal administration of each agent.

Should decisions on internal mammary lymph node irradiation be based on current lymphoscintigraphy techniques for sentinel lymph node identification?

BACKGROUND: Treatment of internal mammary lymph node (IMN) metastases remains controversial because of the difficulty in predicting involvement, potential treatment-related morbidity, and questionable efficacy. Lymphoscintigraphy with sentinel lymph node biopsy offers a means to identify occult involvement of IMN, allowing appropriate patient selection for IMN treatment. METHODS: The authors retrospectively reviewed 262 lymphoscintigraphies (LS) of 248 patients treated at the University of Florida (Gainesville, FL) between 1998 and 2002. Tumor characteristics were assessed for their value in predicting IMN drainage and their association with IMN radiation. RESULTS: Lymph flow to the IMN was documented with LS in 23 of 262 tumor specimens (9%). Flow to the IMN was not correlated with any of the five factors: tumor location, tumor size, lymphovascular invasion, pathologic lymph node status, and laterality of the involved breast (right vs. left breast). Identification of IMN flow increased from 5.7% to 10.1% with the use of a deep injection technique. IMN radiotherapy was used more frequently in patients with larger tumors (15 of 188 in Tis/T1 vs. 31 of 70 in T2-T4; P<0.0001) and positive lymph nodes (17 of 91 in lymph node-negative patients vs. 28 of 66 in lymph node-positive patients; P<0.0001). In patients with T2N0 tumors (n=32), IMN radiotherapy was used more frequently with medial tumors (5 of 11 [45%]) than with lateral tumors (4 of 21 [19%]). CONCLUSIONS: The incidence of flow to the IMN documented with the current LS technique was low compared with other LS and extended radical mastectomy series. Histopathologic information was obtained for the sentinel IMN when IMN flow was identified on the LS. In the absence of histopathologic information, treatment decisions should continue to be based on clinical factors known to be correlated with occult IMN involvement.

Breast-conserving therapy (BCT) for early-stage breast cancer.

Several patient and tumor factors go into the decision process to determine whether a breast cancer patient is a good candidate for breast-conserving therapy. The patient must be seen by all disciplines before any therapeutic intervention. When used appropriately, breast-conserving therapy produces maximal disease control and improves quality of life in patients with early-stage breast cancer.

Valvular dysfunction and carotid, subclavian, and coronary artery disease in survivors of hodgkin lymphoma treated with radiation therapy.

CONTEXT: The majority of patients with Hodgkin lymphoma are young and highly curable. This necessitates concern for prevention, diagnosis, and optimal management of potential treatment-related complications. OBJECTIVE: To identify and quantify the incidence of and factors contributing to long-term cardiac and vascular complications after radiation therapy for Hodgkin lymphoma. DESIGN AND SETTING: Retrospective study comparing patients treated from 1962 to 1998 at a university-based referral center with a matched general population. PATIENTS: Four hundred fifteen consecutive patients who fulfilled the inclusion criteria of a minimum 2-year follow-up (median, 11.2 years) and whose radiation fields included the heart or carotid or subclavian arteries. MAIN OUTCOME MEASURES: Multivariable analyses of potential risk factors and observed-to-expected ratios for cardiac valve surgery, coronary artery bypass graft surgery, percutaneous coronary intervention, or both based on Surveillance, Epidemiology, and End Results (SEER) and National Hospital Discharge Survey (NHDS) data. RESULTS: Forty-two patients (10.4%) developed coronary artery disease at a median of 9 years after treatment, 30 patients (7.4%) developed carotid and/or subclavian artery disease at a median of 17 years after treatment, and 25 patients (6.2%) developed clinically significant valvular dysfunction at a median of 22 years. The most common valve lesion was aortic stenosis, which occurred in 14 valves. The observed-to-expected ratio for valve surgery was 8.42 (95% confidence interval [CI], 3.20-13.65) and the observed-to-expected ratio for coronary artery bypass graft surgery or percutaneous coronary intervention was 1.63 (95% CI, 0.98-2.28). At least 1 cardiac risk factor was present in all patients who developed coronary artery disease. The only treatment-related factor associated with the development of coronary artery disease was utilization of a radiation technique that resulted in a higher total dose to a portion of the heart (relative risk, 7.8; 95% CI, 1.1-53.2; P =.04). No specific treatment-related factor was associated with carotid or subclavian artery disease or valvular dysfunction. Freedom from any cardiovascular morbidity was 88% at 15 years and 84% at 20 years. CONCLUSIONS: Among patients treated with radiation therapy for Hodgkin lymphoma, there are statistically higher than expected rates of valve surgery and coronary revascularization procedures over the next 10 to 20 years. Coronary vascular disease is associated with higher radiation doses and traditional coronary heart disease risk factors. Noncoronary vascular disease and clinically important valvular dysfunction are less well understood complications at 15 to 20 years after radiation, requiring surveillance and further study.

Solitary plasmacytoma of bone and soft tissues.

PURPOSE: To define the optimal treatment and outcomes for patients with solitary plasmacytoma of bone and soft tissue. METHODS: Review of the literature. RESULTS: Solitary plasmacytomas are uncommon and account for less than 5% of plasma cell neoplasms. Solitary plasmacytomas of bone (SPB) usually occur in the vertebra and skull and are more common than extramedullary plasmacytomas (EMP) that almost always arise in the head and neck and may spread to regional lymph nodes. The optimal treatment is moderate-dose radiotherapy (40-50 Gy) and occasionally surgery. Adjuvant chemotherapy does not improve survival. Patients with EMP have a relatively low risk of progressing to multiple myeloma and have improved survival compared with those who present with SPB. CONCLUSION: Solitary plasmacytoma is an uncommon neoplasm that often arises in the head and neck. Optimal treatment is moderate-dose radiotherapy. Prognosis is relatively good and is better for patients with EMP compared with those presenting with SPB.

Radiation therapy for angiosarcoma.

BACKGROUND: Between 1964 and 1998, 19 patients with histologically proven angiosarcoma were treated with curative intent with radiation therapy. METHODS: Median follow-up was 37 months (range, 8-234 months). RESULTS: The actuarial 5-year absolute survival and local control rates were 51% and 50%, respectively. Of 12 patients who relapsed, 8 had isolated local recurrence as the first site of treatment failure, 2 had local (1 patient) or regional recurrence in conjunction with distant metastases, and 2 had distant metastases alone. Two of four patients who underwent further therapy for recurrent disease were successfully salvaged. CONCLUSIONS: Only the location of the primary tumor was a predictor of local control and absolute survival at 5 years. Angiosarcomas located on the scalp imply a dismal prognosis compared with those in other locations with the predominant pattern of failure being local recurrence. Patients should be treated aggressively with surgical resection and preoperative or postoperative radiation therapy.