Management of advanced cervical metastasis using intraoperative radiotherapy.

Seventy-five patients who had advanced cervical metastasis with possible invasion of the deep muscles or carotid artery were approached with aggressive resection and intraoperative radiotherapy (IORT). All metastatic nodes were greater than 3 cm, 65% were fixed on clinical examination, and 35% involved the carotid artery. Forty-six (61%) of the patients had previously received irradiation. Fifteen of the patients required extended neck dissections with carotid resections and grafting. After the resection an average single dose of 2000 cGy of electron beam IORT was delivered. At 2 years, the local control rate within the IORT port was 68% and the absolute survival rate was 45%. Local control rates for close and microscopic margins (76% and 73%, respectively) were significantly better than the control rate for gross residual disease (25%, P < .05). The combination of extended neck dissection, including carotid artery resection if necessary, and IORT appears to offer improved control.

Effects of radiation on the use of hydroxyapatite for orbital reconstruction in the rabbit.

The gross and histopathologic effects of external beam radiation on host response to subperiosteal implantation of dense hydroxyapatite (HA) blocks along the superior orbital rim was investigated, using the rabbit as an experimental model. Three study groups were employed: those with no radiation, those receiving 500 cGy, and those receiving 1,500 cGy. The hydroxyapatite blocks were surgically implanted 2 weeks after administration of the radiation. The pathologic specimens, including the HA block and the neighboring bone segment, were harvested and examined at either the fourth or 12th postsurgical week. There was essentially no inflammatory reaction stimulated by the implanted HA blocks, nor was there any evidence of abnormal bone remodeling in the underlying orbital rim segments. The most secure bonding between the HA block and bone was found in the specimens having received either 500 cGy or 1,500 cGy and harvested at 12 weeks. We conclude that HA serves as an acceptable bone graft substitute in areas previously treated with radiation. The various properties of HA are also reviewed.

Intraoperative radiation therapy for recurrent head and neck cancer.

Forty-seven patients with recurrent head and neck cancer in a previously irradiated field were treated with surgical resection and intraoperative radiation therapy (IORT). Recurrent disease occurred at a median of 18 months from primary treatment, and was at the primary tumor site in 31 and metastatic to regional lymph nodes in 16. Recurrences were squamous cell carcinomas in 42 and adenoid cystic in five. Surgical resection left microscopic residual disease in 41 and gross residual in six. All patients received IORT with a median of 20 Gy. Two-year actuarial survival is 54.9%, and 15 patients are alive and disease free with a median survival of 29 months. Two-year actuarial local control is 61.5%. A trend toward increased survival (P less than 0.09) and local recurrence control (P = 0.05) was noticed when treating microscopic residual disease as opposed to gross residual disease. Perioperative mortality was seen in 8.5% and there was no increase in morbidity secondary to IORT. The authors believe that surgical resection and IORT is an effective treatment modality for head and neck cancers recurrent in previously irradiated fields and is adaptable to tertiary care hospitals.

Leg length discrepancy following irradiation for childhood tumors.

Leg length inequality developed in 12 of 67 children who were treated with radiation therapy to the kidney, abdomen, pelvis, or lower extremities. All these children survived childhood cancer to the age of skeletal maturity. Of the 12 with anisomelia, seven were symptomatic. There were significant relationships between the development of leg length inequality and the total dose of radiation to the pelvic area, asymmetric irradiation to the pelvis, and high-dose irradiation to the leg.

The effect of palliative radiation therapy on epidural compression due to metastatic malignant melanoma.

The efficacy of palliative radiation therapy in the treatment of spinal cord and cauda equina compression due to metastatic malignant melanoma was evaluated in 38 sites in 35 patients treated between 1970 and 1990. All patients had radiographic documentation of epidural compression. The median dose of radiation therapy was 2850 cGy (range, 500 to 4000 cGy), with daily fractions ranging from 200 to 800 cGy. Twenty-eight sites in 26 patients were evaluable 1 month after completion of radiation therapy, and symptoms responded completely in 11 of 28 (39%) sites. Fourteen sites (46%) showed a partial response of symptoms. Response lasting until death was documented in 21 of 26 patients (81%). Patients receiving a total dose of 3000 cGy or greater were more likely to achieve a complete response than those receiving less than 3000 cGy (62% versus 20%) by univariate (P = 0.025) and multivariate (P = 0.048) analyses. A treatment program of radiation therapy and corticosteroids is effective in palliating the symptoms of epidural compression due to metastatic malignant melanoma. It is recommended to deliver an accelerated course of radiation therapy to a dose of 3000 cGy or greater without exceeding spinal cord tolerance (e.g., 3000 cGy in ten fractions at 300 cGy per fraction).

Late orthopedic effects in children with Wilms' tumor treated with abdominal irradiation.

Between 1970 and 1984, 31 children with biopsy-proven Wilms' tumor received nephrectomy, chemotherapy, and abdominal irradiation and were followed beyond skeletal maturity. Three patients (10%) developed late orthopedic abnormalities requiring intervention. Ten children received orthovoltage irradiation, and all cases requiring orthopedic intervention or developing a scoliotic curve of greater than 20 degrees were confined to this group, for a complication frequency of 50%. Those children who developed a significant late orthopedic abnormality (SLOA) as defined were treated to a higher median dose (2,890 cGy) and a larger field size (150 cm2) than those who did not (2,580 cGy and 120 cm2). Age at irradiation, sex, and initial stage of disease did not appear to influence the risk of developing an SLOA. No child who received megavoltage irradiation developed an SLOA despite treatment up to 4,000 cGy or to field sizes of 400 cm2. We conclude that modern radiotherapy techniques rarely lead to significant late orthopedic abnormalities previously associated with abdominal irradiation in children with Wilms' tumor.

Adjuvant radiation therapy in endometrial carcinoma.

Between 1983 and 1987, 79 patients received radiation therapy in combination with surgery for cancer of the endometrium. The pathology in all cases was adenocarcinoma. Most cases had deep myometrial penetration with moderate or poor differentiation. More than two-thirds of the patients had stage I disease. Twenty-two patients received preoperative radiation, and 57 patients received radiation following surgery. There were 10 recurrences in the 79 patients treated. Most recurrences were from distant disease, and there was only one case of an isolated pelvic recurrence. Adjuvant radiation is well-tolerated, and the failure rate in the pelvis is low, even with aggressive lesions.

Skeletal sequelae of radiation therapy for malignant childhood tumors.

One hundred forty-three patients who received radiation therapy for childhood tumors, and survived to the age of skeletal maturity, were studied by retrospective review of oncology records and roentgenograms. Diagnoses for the patients were the following: Hodgkin's lymphoma (44), Wilms's tumor (30), acute lymphocytic leukemia (26), non-Hodgkin's lymphoma (18), Ewing's sarcoma (nine), rhabdomyosarcoma (six), neuroblastoma (six), and others (four). Age at the follow-up examination averaged 18 years (range, 14-28 years). Average length of follow-up study was 9.9 years (range, two to 18 years). Asymmetry of the chest and ribs was seen in 51 (36%) of these children. Fifty (35%) had scoliosis; 14 had kyphosis. In two children, the scoliosis was treated with a brace, while one developed significant kyphosing scoliosis after laminectomy and had spinal fusion. Twenty-three (16%) patients complained of significant pain at the radiation sites. Twelve of the patients developed leg-length inequality; eight of those were symptomatic. Three patients developed second primary tumors. Currently, the incidence of significant skeletal sequelae is lower and the manifestations are less severe than reported in the years from 1940 to 1970. The reduction in skeletal complications may be attributed to shielding of growth centers, symmetric field selection, decreased total radiation doses, and sequence changes in chemotherapy.

Mediastinoscopy incision site metastasis. Implications for radiotherapeutic treatment.

The risk of iatrogenic tumor seeding from mediastinoscopy is low. Reported is a case of mediastinoscopy incision site metastasis treated palliatively. The implications for radiotherapy treatment are discussed.

Palliative radiotherapy for metastatic malignant melanoma: brain metastases, bone metastases, and spinal cord compression.

The records of all patients receiving palliative radiotherapy for malignant melanoma metastatic to brain, to bone, or with spinal cord compression were reviewed. The median survival of 77 patients with brain metastases from the initiation of radiotherapy was 14 weeks. A statistically improved survival was observed only in the 10 patients who underwent subtotal to total resection of a solitary brain metastasis prior to radiotherapy (median = 36 weeks). No improved survival was observed in the 12 patients with a solitary brain metastasis treated by radiotherapy alone (median = 16 weeks). Multivariate analysis revealed that fraction size, total dose, patient age, sex, and duration of the interval between initial diagnosis and appearance of brain metastases did not significantly influence survival, but the use of chemotherapy was associated with a decreased survival. Twenty six patients with symptomatic and radiographic evidence of 39 bone metastases showed a palliative response rate of 85%. 18 of 20 bony lesions treated with high-dose-per-fraction (greater than or equal to 400 cGy) and 15 of 19 bony lesions treated with conventional fractionation (less than or equal to 300 cGy) were palliated. Total dose, patient age, sex, interval between initial diagnosis of malignant melanoma and the appearance of bone metastases, prior or concurrent chemotherapy, or lesion location did not significantly influence palliation. Seventeen patients were identified with symptomatic and myelographic evidence of spinal cord compression. Complete palliation was observed in 47% (8/17) and partial palliation was observed in 24% (4/17). The overall palliation response rate for neurologic symptoms due to spinal cord compression of 71% appeared to be independent of fraction size and total dose.

Inhibition of aflatoxin B1-induced cytotoxicity and binding to DNA in cultured rat liver cells by naturally occurring flavones.

For naturally occurring flavones, quercetin, fisetin, nobiletin, and tangeritin, protect cultured rat liver epithelial-like cells against aflatoxin B1-induced cytotoxicity and inhibit the binding of [3H] aflatoxin B1 to cellular DNA. The methoxy-substituted flavones, nobiletin and tangeritin, show greater protection against cytotoxicity than do the hydroxy-substituted compounds, quercetin and fisetin.