Adjuvant postoperative radiation therapy for colorectal carcinoma above the peritoneal reflection. II. Antimesenteric wall ascending and descending colon and cecum.

From 1970 to 1981, 50 patients had curative surgery for carcinoma of the cecum, ascending, or descending colon and were Stage greater than or equal to B2. In 15 cases, the lesion originated on the antimesenteric (posterolateral) bowel wall. Of seven cases (with minimum three-year follow-up) not receiving adjuvant postoperative regional irradiation, four recurred in the tumor bed/abdominal wall versus 0/3 irradiated patients. Similarly, the five-year survival was improved in the irradiated group (2/3) versus only 2/9 in the unirradiated group. Patients with transmural extension of right or left colon cancers originating on the anti mesenteric (posterolateral) bowel wall may have a high incidence of postoperative regional failure which may be decreased by adjuvant postoperative regional irradiation.

Postoperative radiation therapy for muscle-invading bladder carcinoma.

From 1974-1980, 15 patients with pT2-4 bladder carcinoma received adjuvant postoperative radiation therapy (XRT). The extent of initial surgery varied (six radical cystectomy, 5 partial cystectomy, four "total" transurethral resection). The planned XRT was 4,000-5,040 rads in 5-6 weeks to the pelvis (achieved in 14/15 patients) followed by a bladder boost in noncystectomized patients (achieved in 8/9). Survival at two years and five years was 54% (7/13 patients) and 27% (3/11 patients), respectively. Local-regional disease control (minimum two-year follow-up) was achieved in 7/11 (63%). Of seven patients alive at least two years later, small bowel complications (chronic diarrhea, obstruction) occurred in two; these latter patients each had had radical cystectomy. Adjuvant postoperative XRT may be useful in the multimodality management of patients with bladder carcinoma, especially those identified as high risk after pathologic staging and initial surgery. The poor regional control rate and relatively high incidence of complications seen in this and previous studies suggest that improved radiation technique is needed, both to ensure adequate coverage of the volume at risk and to minimize complications. Representative portals are shown to illustrate these features.

Curative surgery for adenocarcinoma of the pancreas/ampulla of Vater: the role of adjuvant pre or postoperative radiation therapy.

From 1972 to 1981, 7 patients received adjuvant external beam radiation therapy before (5 patients) or after (2 patients) a curative Whipple operation for adenocarcinoma of the pancreas (5 patients) or ampulla of Vater (2 patients). Via supervoltage, 4000-4520 rad/20-25 fractions/4-5 1/2 weeks were delivered to the tumor bed and draining lymphatics. Two patients (of 4 at risk) are 5-year survivors; 3 are alive-without-disease at 1-2 years follow-up. Distant metastases have developed to date in 3 patients. A marginal miss occurred at the edge of radiation portal in 1 patient, and no true in-field failures have occurred. Complications occurred in 2 patients. Because of the high incidence of local-regional failures after curative surgery alone for adenocarcinoma of the pancreas or ampulla of Vater, the above results suggest that adjuvant radiation therapy should be considered as a modality to potentially improve treatment results.

Long-term survivors after adjuvant pelvic irradiation in rectal and sigmoid carcinoma: an assessment of late results.

Twenty-six patients with adenocarcinomas of the rectum, rectosigmoid, or sigmoid colon given adjuvant pre- or postoperative pelvic radiation therapy followed at least 5 years were retrospectively reviewed to evaluate late tumor control and complication rates. The overall 7-year survival rate was 80 +/- 8% with B2,3 patients faring better than C2,3 (94 +/- 6% versus 43 +/- 19%, p less than 0.005). Local pelvic tumor control was achieved in 23/26 patients (88%); patients with high-stage (C2,3) or poorly-differentiated adenocarcinomas had a higher postirradiation pelvic relapse rate (3/11) versus low stage, well or moderately-well differentiated tumors (0/15). A major complication (none fatal) occurred in 2 of 26 patients (8%) and was not correlated with either irradiation dose nor volume. Long-term follow-up is now available on patients who received adjuvant pelvic irradiation for rectal or sigmoid carcinomas and indicates a high pelvic tumor control rate. The 8% major complication rate may be decreased in the future by more sophisticated irradiation treatment planning.

Adjuvant postoperative radiation therapy for colorectal carcinoma above the peritoneal reflection. I. Sigmoid colon.

From 1970-1981, 85 patients had curative sigmoid resections for adenocarcinoma and were eligible for postoperative adjuvant therapy. In a nonrandomized fashion, 10/28 B2,3 and 7/28 C2,3 patients received postoperative pelvic radiation therapy (4500-5100 rad/5-6 weeks). Compared to the 39 B2,3 or C2,3 patients not receiving adjuvant pelvic irradiation, those 17 who did demonstrated retrospectively an improved pelvic regional disease control rate (70 versus 91%) and an improved five-year survival for irradiated B2,3 cases versus unirradiated B2,3 cases. (100 versus 64%, P less than 0.05). C2,3 cases showed no survival advantage for pelvic irradiation. This retrospective analysis suggests that for sigmoid carcinoma patients, postoperative adjuvant pelvic irradiation may be beneficial in terms of improved regional disease control rates for B2,3 and C2,3 cases and also improved survival for B2,3 cases.

Primary and adjuvant radiation therapy in gallbladder and extrahepatic biliary tract carcinoma.

The natural history and pathways by which carcinomas of the gallbladder and extrahepatic bile ducts spread after attempted curative surgery offer a rationale for postoperative radiation therapy. We review: 1) the increasing use of primary-curative radiation therapy for these cancers, along with 2) the early results of innovative intraoperative irradiation and the transluminal insertion of radioactive sources into transhepatic catheters, 3) the efficacy of irradiation for metastases to the portahepatis, and 4) the overall effects of irradiation on the gallbladder and extrahepatic biliary system.

Medulloblastoma. The identification of prognostic subgroups and implications for multimodality management.

For 43 medulloblastoma patients who had five-and ten-year actuarial survival rates of 56%, prognostic factors of statistical significance included: T-stage (82% T1,2 versus 46% T3,4; P less than 0.02), M-stage (63% M0,1 versus 0% M2,3; P less than 0.03), and histopathologic tumor score (TS, based upon necrosis, desmoplasia, cytoplasmic processes, and mitoses) (81% TS less than or equal to 5 versus 41% TS greater than or equal to 6; P less than 0.05). Posterior fossa local control rates were also function of T-stage (90% T1,2 versus 38% T3,4) and TS (83% TS less than or equal to 5 versus 38% TS greater than or equal to 6). Combining TS with T-stage, patients fell into three prognostic and local control groups, which may have different future management implications: Small (T1,2) tumors of favorable (TS less than or equal to 5) histology had a 92% ten-year actuarial survival rate with 100% (8/8) local control; no change from current management is suggested. For the intermediate prognosis group (T1,2-TS greater than or equal to 6 or T3,4-TS less than or equal to 5 with 67% and 70% survival, respectively), increasing the irradiation dose alone may improve survival because these tumors exhibited an irradiation dose-response relationship. However, it is the poor prognosis group (T3,4-TS greater than or equal to 6 with 42% survival) which might be suitable for future adjuvant chemotherapy or radiosensitizer trials since there is no evidence that higher irradiation doses improve local control. This article identifies prognostic subgroups based on histologic type and TM staging in medulloblastoma patients which potentially may be utilized to improve therapeutic results, and confirms the value of staging patients with central nervous system malignancies.

Long-term survivors after preoperative pelvic radiation therapy for locally unresectable rectal and sigmoid carcinoma: an assessment of late results.

From 1972 to 1976, 11 patients received moderate-dose pelvic preoperative radiation therapy (4500-4600 rad +/- 500 rad boost) for initially unresectable rectal or sigmoid carcinoma. Of six patients subsequently explored, five had radical surgery and are alive without disease at least five years later. Comparison of the present long-term follow-up series with prior (short-term follow-up) series suggests that moderate-dose preoperative pelvic radiation therapy can convert many of these lesions to being resectable ones for which long-term survival-without-disease can be achieved. Attention to irradiation dose and field size is stressed, and a suggestion is made that patients whose tumors at final pathology still demonstrate extrarectal extension receive postoperative small-field boost irradiation.

Infratentorial glioblastoma: the role of neuraxis irradiation.

The patterns of clinical-and autopsy-documented tumor spread were evaluated for 15 patients with biopsy-proven infratentorial (8 cerebellar, 2 brainstem, 5 intramedullary spinal cord) glioblastoma. No patient developed clinical nor autopsy evidence of subarachnoid dissemination, even though no patient had received craniospinal axis irradiation. Fully 14 of the 21 previously reported patients with subarachnoid dissemination from infratentorial glioblastoma had this diagnosis made only at autopsy. The overall poor prognosis at present (8% 3-year survival from the present series and recent literature) along with the demonstrated pattern of local-regional aggressiveness as the major form of initial spread and post-irradiation recurrence, suggests that routine craniospinal axis irradiation may not be indicated for most patients with infratentorial glioblastoma.

Radiation therapy for small bowel carcinoma: report of three patients and review of the literature.

The potential role of radiation therapy in the management of localized small bowel carcinoma is reviewed based upon three patients irradiated at a major referral center and seven previously reported patients in the literature. The one patient irradiated postoperatively for gross residual disease has had local-regional disease control for 1.5 years. The two patients irradiated postoperatively in an adjuvant setting are alive disease at 3.8 and 0.5 years, respectively. Patients with unresectable disease (initially or at recurrence) have fared poorly. Patterns of tumor spread are reviewed, and recommendations on irradiation dose and volume are suggested.

Radiation tolerance of the spinal cord previously-damaged by tumor and operation: long term neurological improvement and time-dose-volume relationships after irradiation of intraspinal gliomas.

Of 26 patients with intramedullary spinal cord gliomas (9 astrocytomas, 5 glioblastomas, 12 ependymomas) seen at the Massachusetts General Hospital from 1962--1980, 24 were irradiated (21 initially and 3 after post-surgical recurrence). Those 19 patients who survived at least 1 year after completion of irradiation were evaluated for post-irradiation neurological changes. No patient developed radiation myelopathy. Return to a permanently and completely normal neurological status occurred for 33/51 (65%) of pre-irradiation neurological deficits. The major cause of post-irradiation neurological deterioration was tumor recurrence. Although 18/19 patients had their thoracic or lumbar spinal cords irradiated, each with field sizes greater than 10 cm, spinal cord doses approaching, equalling, or occasionally exceeding various definitions of spinal cord tolerance were tolerated well without evidence of radiation myelopathy. Spinal cords of patients with intramedullary gliomas, often with major neurological deficits prior to irradiation, may be treated safely to doses approaching or equalling spinal cord tolerance levels. These doses are expected to locally control most ependymomas and astrocytomas without an increased risk of radiation myelopathy. Caution should be observed if doses higher than this are contemplated in an attempt to cure a glioblastoma, because the 5% tolerance level of the damaged spinal cord remains to be defined.

Medulloblastoma in adults: improved survival with supervoltage radiation therapy.

During the period from January 1962--June 1979, 17 adults (greater than or equal to 16 years of age) received postoperative supervoltage neuraxis radiation therapy for medulloblastoma. An actuarial five- and ten-year survival rate of 46% was achieved, and the major site of recurrence postirradiation was in the posterior fossa. Compared to previous pediatric series, adults may demonstrate more visceral metastases and fare less well after tumor recurrence. Compared to prior series of adult patients, the demonstrated improved survival is attributed to increased doses delivered to the posterior fossa.

Radiation therapy for ureteral metastases from breast carcinoma.

Seven breast cancer patients received supervoltage radiation therapy in the Department of Radiation Medicine, Massachusetts General Hospital from 1970--1978 for ureteral-periureteral metastases. Urinary symptoms (flank pain, urgency, hematuria) disappeared completely and permanently for four of five patients; abnormal pyelograms returned completely to normal for three of three; and abnormal renal function tests for two of two. Six of seven patients survived at least one year after irradiation. Indications for irradiation, dose, and techniques are discussed.