American Brachytherapy Society (ABS) consensus guidelines for brachytherapy of esophageal cancer. Clinical Research Committee, American Brachytherapy Society, Philadelphia, PA.

INTRODUCTION: There is wide variation in the indications, treatment regimens, and dosimetry for brachytherapy in the treatment of cancer of the esophagus. No guidelines for optimal therapy currently exist. METHODS AND MATERIALS: Utilizing published reports and clinical experience, representatives of the Clinical Research Committee of the American Brachytherapy Society (ABS) formulated guidelines for brachytherapy in esophageal cancer. RESULTS: Recommendations were made for brachytherapy in the definitive and palliative treatment of esophageal cancer. (A) Definitive treatment: Good candidates for brachytherapy include patients with unifocal thoracic adeno- or squamous cancers < or = 10 cm in length, with no evidence of intra-abdominal or metastatic disease. Contraindications include tracheal or bronchial involvement, cervical esophagus location, or stenosis that cannot be bypassed. The esophageal brachytherapy applicator should have an external diameter of 6-10 mm. If 5FU-based chemotherapy and 45-50-Gy external beam are used, recommended brachytherapy is either: (i) HDR 10 Gy in two weekly fractions of 5 Gy each; or (ii) LDR 20 Gy in a single course at 0.4-1 Gy/hr. All doses are specified 1 cm from the midsource or mid-dwell position. Brachytherapy should follow external beam radiation therapy and should not be given concurrently with chemotherapy. (B) Palliative treatment: Patients with adeno- or squamous cancers of the thoracic esophagus with distant metastases or unresectable local disease progression/recurrence after definitive radiation treatment should be considered for brachytherapy with palliative intent. After limited dose (30 Gy) EBRT, the recommended brachytherapy is either: (i) HDR 10-14 Gy in one or two fractions; or (ii) LDR 20-25 Gy in a single course at 0.4-1 Gy/hr. The need for external beam radiation in newly diagnosed patients with a life expectancy of less than 3 months is controversial. In these cases, HDR of 15-20 Gy in two to four fractions or LDR of 25-40 Gy at 0.4-1 Gy/hr may be of benefit. CONCLUSION: ABS guidelines for esophageal brachytherapy now exist and will be updated by the ABS in the future, as clinical data using more uniform treatment techniques becomes available.

Phase III trial of thoracic irradiation with or without cisplatin for locally advanced unresectable non-small-cell lung cancer: a Hoosier Oncology Group protocol.

PURPOSE: Here we report the results of a phase III study, to evaluate whether the addition of cisplatin to radiation therapy (XRT) would improve progression-free survival or overall survival for patients with locally advanced unresectable non-small-cell lung cancer (NSCLC). PATIENTS AND METHODS: Two hundred forty patients with biopsy-proven unresectable NSCLC without distant metastases or lower-stage medically inoperable patients were randomized to one of two treatment arms. Arm A consisted of thoracic XRT alone, 60 to 65 Gy total tumor dose in daily fractions of 1.80 to 2.00 Gy; and arm B consisted of identical XRT with the addition of cisplatin 70 mg/m2 every 3 weeks for three cycles beginning on the first day of irradiation. RESULTS: Two hundred fifteen patients were eligible and assessable. The overall response rate was 50% on the combination arm versus 38% on the XRT-alone arm (P = .076). The median progression-free survival time was 23 versus 22 weeks, respectively (P = .0537). The median survival time was 43 weeks on the combination arm versus 46 weeks on the XRT arm (Poverall = .3469). The 1-, 2-, and 5-year survival rates were 43%, 18%, and 5% on the combination arm versus 45% 13%, and 2% on the XRT arm, respectively. CONCLUSION: Cisplatin, administered every 3 weeks, does not significantly improve response rate, progression-free survival, or overall survival when added to thoracic XRT for locally advanced unresectable NSCLC.

Nursing care of the patient receiving high dose rate brachytherapy.

Over the past few decades, a significant increase in the incidence of lung cancer has occurred. In the majority of patients, the failure to cure lung cancer is related in part to an inability to obtain locoregional control of the disease. Remote afterloading high dose rate (HDR) brachytherapy has tremendous potential as a way to increase treatment to the primary site of lung cancer and to improve palliative management of recurrent disease when conventional treatments have failed. Because remote afterloading is used, the medical staff is not exposed to ionizing radiation, and since the duration of treatment is short, HDR brachytherapy is convenient for the patient and can be delivered on an outpatient basis. Fifty-two patients were treated endobronchially for carcinoma of the lung at Parkview Regional Oncology Center in Fort Wayne, IN, between May 1, 1988, and September 1, 1990. Nursing care during treatment and recovery of these patients will be discussed in this paper.

Unresectable non-oat cell carcinoma of the lung: definitive radiation therapy.

Between 1976 and 1983, 267 patients with non-oat cell carcinoma of the lung were treated with radiation therapy alone. One hundred thirty-four patients had squamous cell carcinoma; 69, large cell carcinoma; and 64, adenocarcinoma. Stage III carcinoma was diagnosed in 87% of the patients. Total radiation dose was less than 45 Gy in 69 patients (low dose group), 45-55 Gy in 161 (middle dose group), and 55-65 Gy in 37 (high dose group); dosage was 180-200 cGy daily, 5 days per week. Minimum follow-up was 3 years (median, 6 years). Tumor control within the radiation fields was achieved in 12%, 43%, and 78% of the low, middle, and high dose groups, respectively. A complete response rate of 13%, 23%, and 35% and an overall response of 43%, 71%, and 86% were seen in the low, middle, and high dose groups, respectively. The 5-year recurrence-free survival rate for all patients was 7% and was dependent on radiation dose and tumor response. This study indicates that tumor control and complete response rates are improved with a radiation dose of 55-65 Gy and that complete responders have improved survival.

Radiation therapy for nonsquamous tumors of the head and neck.

Recent advances in the understanding of the natural history and modes of spread of the nonsquamous malignancies of the head and neck region have delineated an important role for radiotherapy in their management. The indications for primary radiotherapy include malignant lymphoma of the thyroid, idiopathic midline granuloma, midline malignant reticulosis, extramedullary plasmacytomas, esthesioneuroblastomas, and locally aggressive benign tumors, such as glomus tumors, angiofibromas, and hemangiomas. Although the traditional treatment for malignant melanoma is surgery, indications are emerging for high-dose radiotherapy, either as the only modality or in addition to surgery. Combined radiotherapy and chemotherapy is the treatment choice for nonHodgkin's lymphomas of the Waldeyer's ring and for Ewing's sarcomas. High-grade soft tissue sarcomas and salivary gland malignancies are best treated with surgery and postoperative radiotherapy. The use of megavoltage photons and electrons, custom-made blocks delineating the treatment volume, tissue compensators, patient immobilization devices, and simulator-aided treatment planning are mandatory to achieve loco-regional control and to minimize the treatment-related morbidity.

Advanced supraglottic carcinoma: a comparative study of sequential treatment policies.

Data from 131 consecutive patients with operable stage III or IV (American Joint Committee) supraglottic carcinoma were analyzed. Based on existing treatment policies at the time of presentation, patients received either preoperative radiation therapy (RT) (48 patients), surgery alone (42 patients), or postoperative RT (41 patients). Preoperative RT dose levels were either 2,000 rad in five fractions (33 patients) or 5,000 rad in 25 fractions (15 patients). Postoperative RT dosages were 5,000 to 6,000 rad in 6 to 6 1/2 weeks. Surgical procedures included either subtotal or total laryngectomy and radical neck dissection. Tumor control was achieved in 21 of 42 patients (50%) treated with surgery alone, 23 of 48 patients (48%) treated with preoperative RT, and 29 of 41 patients (71%) treated with postoperative RT (P = 0.005). The actuarial, recurrence-free survival at 5 years was 36% and 35%, respectively, in the surgery alone or preoperative RT groups as compared to 55% in postoperatively irradiated patients. The authors conclude that advanced but resectable supraglottic carcinomas may be best treated with surgery followed by RT, rather than with surgery alone or with combined preoperative RT and surgery.

Limb salvage in extremity soft-tissue sarcoma: combined modality therapy.

Thirty-two consecutive patients with high-grade soft-tissue sarcoma of an extremity were treated preoperatively with concomitant intra-arterial infusion of Adriamycin (doxorubicin) (10 mg/m2 daily for 10 days) and radiotherapy (2500 rad [25 Gy] in 10 fractions in 2 weeks). En bloc resection was then performed. Postoperatively, depending on the surgical specimen findings, radiotherapy was given to a dose ranging from 5000 rad (50 Gy) in 5 weeks to 6000 rad (60 Gy) in 6 weeks equivalent continuous schedules. No residual tumor was found in 28% of the surgical specimens and only minimal tumor in 41%. A functionally intact limb was preserved in 30 patients (94%). Local recurrence developed in one patient (3%). The actuarial overall survival at three years was 70% and disease-free survival 57%.

Preirradiation chemotherapy for advanced head and neck carcinomas.

Twenty-six patients with locally advanced squamous cell carcinoma of the head and neck region were treated with combination chemotherapy (cisplatin, bleomycin sulfate, and vincristine sulfate) prior to radiotherapy (RT). The chemotherapy produced a 65% major response rate, all partial responses. Significant hematologic toxic effects occurred in only two patients and severe renal toxic effects were not seen. Concurrently, 20 additional patients with locally advanced cancers were treated with high-dose RT along. Weight loss at the completion of RT and normal tissue reactions were similar in both groups. Complete tumor resolution occurred in 45% of RT-alone patients and 42% of patients completing combined-modality therapy. No difference in recurrence-free survival was seen. Despite minimal additional morbidity and a high response rate, this preirradiation chemotherapy regimen demonstrated no major impact on complete response rate or on long-term recurrence-free survival.

Patterns of cancer recurrence in the postoperatively irradiated neck.

Data from 92 patients with stage III or IV squamous cell carcinoma of the head and neck treated with surgery and planned postoperative radiotherapy were analyzed to determine the incidence and patterns of tumor recurrence. Overall, recurrent tumor in the cervical region developed in 19 patients (21%). Of these, eight were in the neck alone and 11 in both the neck and the primary site. All recurrences were in the ipsilateral cervical region and none in the contralateral neck. The presence of two or more metastatic nodes at the time of surgery correlated with tumor recurrence and decreased survival. Extracapsular tumor spread increased the recurrence rate. Our data suggest that postoperative radiotherapy decreases ipsilateral cervical tumor recurrence in only those patients with more than two metastatic lymph nodes, and contralateral neck recurrence in all patients.

Cancer of the glottis: prognostic factors in radiation therapy.

The authors conducted a multivariate analysis of the prognostic factors in 96 patients with early glottic cancer treated by radiation therapy. Of these, 73 had T1 and 23 had T2 tumor. The primary tumor was controlled in 82% of T1 and 74% of T2 lesions. Actuarial five-year survival rates were 87% for T1 and 74% for T2. Carcinoma of the anterior commissure associated with bilateral vocal cord involvement, subglottic tumor extension, persistent or recurrent laryngeal edema, and impaired cord mobility was found to adversely influence the prognosis. The data suggest that irradiation is the treatment of choice for glottic cancer limited to the vocal cords or with minimal extension to the anterior commissure or supraglottic larynx.

Postoperative radiotherapy for persistent tumor at the surgical margin in head and neck cancers.

Seventy-two patients with a carcinoma of the head and neck, who were treated with surgery and postoperative irradiation, were reviewed to determine the local recurrence rates and survival in patients with inadequate surgical margins. Tumor recurrence rate was 31% for patients with microscopic tumors at resection margins and 50% for those with macroscopic tumor. Actuarial 3-year survival for these patients was 71% and 43%, respectively. All 4 patients who were irradiated later than 6 weeks after surgery developed recurrent malignancy despite the resection margins being free of tumor. Excluding these patients the 3-year survival for R0 patients was similar to that of R1 patients. It is concluded that postoperative irradiation is effective in patients with tumor at the surgical margins. It is suggested that the time interval between surgery and radiation therapy be limited to less than 6 weeks. Radiation dose prescriptions for various clinical situations are discussed.

Work in progress: intra-arterial P-32 chromic phosphate for prevention of postoperative liver metastases in high-risk colorectal cancer patients.

Eight patients with locally extensive colorectal cancer were treated with colloidal P-32 chromic phosphate via the superior mesenteric artery following resection to prevent development of liver metastases. Less than 2% of the injected dose was found in the right atrial blood following the first pass through the liver and less than 1% in the urine. Therapy was tolerated well by all patients, with no acute complications. Long-term follow-up is needed to determine the effect of P-32 on the liver and the frequency of hepatic metastases.

Carcinoma of the esophagus: sites of failure.

A clinico-pathologic study of 173 patients with esophageal cancer was done. The median survival for all patients was 6.4 months. Persistent tumor in esophagus at the time of death was present in 78% of patients treated with radiation alone. Metastases to mediastinal, intraabdominal and supraclavicular nodes were found in 73%, 49% and 20% of patients respectively. Systemic metastases were found in 57% of patients, liver being the most common site. In 15% of patients, fistulae developed between esophagus and trachea or bronchus because of direct extension of the primary tumor. Local and regional tumor caused the death of 111 patients, whereas distant metastases led to death in only 27 patients. This study confirms the extensive intra- and extrathoracic spread of malignancy in a majority of patients with cancer of the esophagus.

Brain stem gliomas: an autopsy study of 25 cases.

The study analyzed the extent of tumor at autopsy in 25 patients with a brainstem glioma. Primary tumor in the pons comprised the majority of cases, followed by medulla and midbrain. Histologically, 48% of the tumors were glioblastoma multiforme. The tumor spread was found to be dependent on the site of origin and the grade. Pontine tumors involved the adjacent structures more extensively than the tumors of midbrain and medulla. Contiguous cephalad and caudad involvement was frequent with Grade III and Grade IV tumors. The extent of meningeal involvement was limited to those surrounding the main tumor mass. It is concluded that in the treatment of brainstem gliomas, irradiation through fields limited to the brainstem, adjoining temporal lobes, cerebellum, and proximal spinal cord would be adequate.

Radiation therapy for subclinical carcinoma in cervical lymph nodes.

Radiotherapy alone was used to treat 187 patients with a head and neck cancer and clinically uninvolved lymph nodes. Delayed lymph node metastases developed in 35 (19%) patients, and concomitant tumor at the primary site was present in 90% of them. In two (1%) of the 187 patients, delayed metastases developed in the irradiated nodes with the primary tumor controlled; both of these patients received a radiation dose of less than 5,000 rad. Metastases in supraclavicular and posterior cervical regions occurred in 4% of the patients; and these sites were not included in the original radiation fields. The following conclusions were reached: (1) a radiation dose of 5,000 rad or more can eradicate 99% of the subclinical carcinomas in lymph nodes; (2) whole-neck irradiation is not indicated in patients with N0 stage tumor; and (3) surgical resection of primary tumors alone, without added neck dissection, may be adequate if postoperative radiation therapy is planned.

Stomal recurrence. A critical analysis of risk factors.

Stomal recurrence developed in 5% of the 507 patients who underwent total laryngectomy for a squamous cell carcinoma. The most common site of the primary tumor was the glottis, followed by the supraglottic and pyriform sinus regions. Initial subglottic extension of the tumor and metastatic lymphadenopathy were the most significant risk factors. The primary tumor size, prior emergency tracheostomy, and conservation surgical procedures had no effect on the incidence of stomal recurrence. The median survival in patients with stomal malignant neoplasms was only five months. In high-risk patients, extended dissection or elective postoperative radiotherapy is recommended.

Complications of postoperative and preoperative radiation therapy in head and neck cancers. A comparative study.

The complications of planned postoperative irradiation in 60 consecutive patients treated between 1975 and 1979 are compared with those seen in 92 patients treated with preoperative irradiation between 1968 and 1974. The overall rate of complications requiring additional hospitalization was 15% (nine patients) in the postoperative radiotherapy group as compared with 54% (50 patients) in the preoperative radiotherapy group. A statistically significant increase in acute complications was noted in the latter group (46 vs three, 50% vs 5%). Delayed complications occurred with similar frequency in both groups. The three-year survival was comparable between similar patients of each group treated with either of the two modalities. We favor postoperative irradiation because of decreased acute complications and comparable survival. Modifications of the treatment technique are suggested to minimize the overall rate of complications.