Total lymphoid irradiation for pretransplant immunosuppression: nine year follow-up.

Total lymphoid irradiation (16 to 30 Gray units) was given to 12 patients (8 who had rejected previous grafts). We found a fall in T and B cell counts with a reversal of CD4/CD8, and a decrease in mitogeneic and allogeneic responses with recovery to pretransplant levels in 24 to 36 months. The total lymphoid irradiation patients (on low dose prednisone and cyclosporine) had nine year graft and patient survival rates of 50% and 81.5%, respectively, versus 56% and 69.8% for 65 patients on conventional immunosuppression. Complications included viral (7) and fungal (1) infections, immunological thrombocytopenia (3), hypothyroidism and radiation pneumonitis and pericarditis (1 each), and there were no non-skin malignancies. There was only one episode of acute rejection in the group with total lymphoid irradiation as compared to 18 in the other group. We believe that total lymphoid irradiation provides effective immunosuppression and has the potential for reducing and possibly eliminating other immunosuppressants.

Interstitial hyperthermia and iridium-192 treatment alone vs. interstitial iridium-192 treatment/hyperthermia and low dose cisplatinum infusion in the treatment of locally advanced head and neck malignancies.

PURPOSE: To determine whether the addition of low dose platinum infusional chemotherapy adds to the effectiveness of interstitial hyperthermia/iridium-192 management of locally advanced head and neck malignancies. METHODS AND MATERIALS: From 1987 to 1993, 36 patients with locally advanced head and neck malignancies were treated locally with interstitial hyperthermia and iridium-192 as part or all of their management. Twenty-two of the above-mentioned patients also received low dose infusional cisplatinum chemotherapy at 20 mg/M2 per day during the time of the implant. No patient received greater than 100 mg/M2 total dose. Implant times ranged from 38.5 to 134 h and total doses delivered with the radiation implants ranged from 15 to 39.9 Gy. Average implant volume was 50 cc. Twenty-three patients received external beam irradiation supplementation in a dose range from 25.2 to 64 Gy. RESULTS: Median follow-up for the entire group was 8, months with 7 months for the chemotherapy group vs. 12 months for the no-chemotherapy group. Freedom from relapse rates for the chemotherapy group vs. the no-chemotherapy group were 70% at 41 months vs. 63% at 60 months, p = not significant (p = NS). Overall survival by Life Table Analysis was 28% for the chemotherapy group at 41 months vs. 31% for the no-chemotherapy group at 60 months (p = NS). Complete response (CR) rates were 93% for the chemotherapy group vs. 86% for the no-chemotherapy group. Seven patients in the chemotherapy group had recurrent disease and four patients in the no-chemotherapy group were being treated for recurrent disease. Complication rates were similar in both groups, with two patients in the chemotherapy arm requiring hyperbaric oxygen treatments and one patient in the no-chemotherapy arm requiring hyperbaric oxygen treatments (for soft tissue necrosis). CONCLUSION: It appears that low dose platinum infusional chemotherapy can be added safely to patients receiving interstitial iridium-192 implants along with interstitial hyperthermia for head and neck malignancies. Although there appears to be a trend toward better freedom from relapse by adding chemotherapy, a larger trial and longer follow-up will be necessary to prove statistical significance. Further research in these areas is recommended in the form of a randomized prospective study.

Electron beam versus photon beam radiation therapy for the treatment of orbital lymphoid tumors.

Shielding the lens of the eye while treating orbital lymphoid tumors and achieving a relatively homogeneous dose can be a dosimetric challenge. There are many clinical cases of tumors close to one or both eyes, where it is desirable to spare the lens as much as possible. We will show isodose curves comparing direct anterior fields using various electron beam energies to a single 6 mv photon beam to a multifield combination. The presence of an eye shield in a photon beam may impair the dose distribution at the back of the eye to an undesirable degree. The strong in-depth dose drop-off in electrons and the ease with which the beam can be intercepted suggests that an electron beam with an eye shield may offer advantages. We designed a suspended movable lens shield .8 cm wide with a height of 4.5 cm made of cerrobend surrounded by a brass cylinder mounted to a thin plexiglass plate to insert into a Varian electron 6 x 6 cone. A 1.5 cm gap between block and eye surface was used. Verification of dose distribution under the lens shield was obtained by film dosimetry.

Axillary-subclavian vein thrombosis following combination chemotherapy and radiation therapy in lymphoma.

Four patients with deep venous thrombosis of the upper extremity (DVTUE) following combined modality therapy (mantle radiotherapy and chemotherapy) for either Hodgkin's disease or non-Hodgkin's lymphoma were seen at Stanford University Medical Center between March 1980 and April 1984. A total of 235 patients had received similar combined modality therapy during this time period. Three patients presented with acute onset of DVTUE and were anticoagulated. One patient who was referred with a several month history of DVTUE was observed closely after diagnostic evaluation revealed no evidence of recurrent Hodgkin's disease. All patients remained without evidence of their original lymphoma and had developed adequate venous collateralization. These cases of DVTUE were felt to be treatment related, a previously unreported late complication of combined irradiation and chemotherapy. Methods of diagnosis and therapeutic options are discussed.

The potential benefits of therapeutic splenectomy for patients with Hodgkin's disease and non-Hodgkin's lymphomas.

Thirty-four patients with Hodgkin's disease and non-Hodgkin's lymphoma underwent therapeutic splenectomies to improve hematologic tolerance for chemotherapy. The mean age was 40 years; there were 16 males and 18 females. Fourteen had Hodgkin's disease, 19 had non-Hodgkin's lymphoma, and 1 had malignant histiocytosis. Nineteen had palpable splenomegaly, 19 had marrow involvement and 20 had splenic involvement by lymphoma. The following data were analyzed before and after splenectomy: mean white blood cell count (WBC) and platelet count on planned first day of cycle, delay ratio of chemotherapy delivery and percent maximal dose rate. Thirteen patients had non-Hodgkin's lymphoma, splenomegaly and positive bone marrow and showed significant benefit in all of the aforementioned parameters. Of the patients with prior irradiation, only those who completed their radiation greater than six months prior to splenectomy showed benefit. Ten patients had Hodgkin's disease, negative bone marrow and no splenomegaly. This group showed significant improvement in mean platelet count but more limited benefit in delay ratio and percent maximal dose rate. Thus, selected patients with lymphoma who are experiencing delays in chemotherapy because of poor count tolerance may benefit from splenectomy.