Management of thyroid carcinoma with radioactive 131I.

PURPOSE: To evaluate the role of radioactive 131I in the management of patients with well differentiated carcinoma of the thyroid. METHODS AND MATERIALS: Between 1965 and 1995, a total of 117 patients with well-differentiated carcinoma of the thyroid underwent either lobectomy or thyroidectomy followed by 100-150 mCi of 131I. RESULTS: With a median follow-up of 8 years, only four patients (3%) developed a recurrence of their disease. The 5-year actuarial survival was 97% with a 10-year survival of 91%. There were no severe side effects noted after 131I therapy. CONCLUSIONS: Radioactive 131I is a safe and effective procedure for the majority of patients with well-differentiated thyroid carcinoma. We currently recommend that all patients undergo a subtotal or total thyroidectomy followed by 131I thyroid scanning approximately 4 weeks after surgery. If the thyroid scan shows no residual uptake and all disease is confined to the thyroid, we recommend following patients with annual thyroid scans and serum thyroglobulin levels. If there is any residual uptake detected in the neck or if the tumor extends beyond the thyroid, we recommend routine thyroid ablation of 100-150 mCi of radioactive 131I.

Management of pterygium with surgery and radiation therapy. The North Florida Pterygium Study Group.

PURPOSE: To compare our results in the management of pterygium using a higher total dose with other reported results. METHODS AND MATERIALS: Between 1971 and 1991, 690 patients were treated with complete surgical excision followed by beta irradiation for primary or recurrent pterygium. Of these patients, 129 had two or more areas involving both eyes for a total of 825 lesions treated. Only 17 patients (2%) had temporal lesions with the rest of the patients having nasal pterygia. All patients underwent complete surgical resection of the pterygium before undergoing radiation therapy. One hundred forty-nine patients had undergone previous surgical resection alone but developed recurrence. After surgical excision, all patients were treated with Strontium-90 applicators starting immediately within 24 hr of surgery. Our standard policy was six weekly applications, each delivering a surface dose of 1000 cGy. The total dose delivered was 6000 cGy. Minimum follow-up was 1 year with a median of greater than 8 years. RESULTS: There were only fourteen recurrences (1.7%) out of a total of 825 lesions treated. Nine of the fourteen patients received suboptimal therapy undergoing less than five applications of Strontium-90. There were no major complications. CONCLUSION: The combination of surgical excision followed by adequate Strontium-90 applications is highly effective in the management of pterygium. The optimal total dose appears to be in the range of 2000 cGy to 6000 cGy.

Breast Cancer Screening Project in Northeast Florida.

The American Cancer Society--Duval Unit, in June, 1987, helped organize a community demonstration screening project involving all hospitals and institutions with mammography units in the area. A Northeast Florida Cooperative Breast Cancer Screening Group was formed comprised of physicians and administrators from each institution. A total of 1,200 women agreed to participate in the project and each underwent complete screening including education, instruction in self-examination, physical examination by a physician and mammography as indicated according to ACS guidelines. Of the study group, 1,032 women were eligible for mammography at a participating center, and 628 (61%) underwent a mammogram at no cost to them as instructed. Twenty four (4%) had definite abnormalities which led to biopsy and seven (1%) of them had malignant lesions. The medical community organized to provide breast cancer screening and follow-up with low-cost mammography.

Iodine 125 suture implants in the management of advanced tumors in the neck attached to the carotid artery.

Between 1975 and 1982, 38 patients with locally advanced head and neck cancer attached to the carotid artery underwent surgical excision followed by iodine 125 vicryl suture implant in the neck. Most patients had neck masses that were greater than 6 cm and stage IV disease without clinically evident distant metastases. Twelve patients had received no previous therapy while 26 underwent an implant for recurrent disease. The local control rate in the implant volume was 79%. The local and regional control rate in all head and neck sites was 53%. The mean survival was 11 months. The overall complication rate was 26%. There was no significant correlation of local control or complications with the minimum total dose, volume implanted, individual 125I seed strength, or total seed strength. In patients with large masses attached to the carotid artery, surgical resection followed by a 125I implant for residual disease is a viable alternative to resection of the carotid artery.

The role of radiation therapy in the management of stage III follicular lymphomas.

Between 1961 and 1982, 66 patients with stage III follicular small cleaved (FSC) and follicular mixed small cleaved and large cell (FM) lymphoma were treated at Stanford University. Treatment consisted of total-lymphoid irradiation (TLI) to a total dose of about 4,000 rad in 61 patients or whole-body irradiation (WBI) followed by boost irradiation to sites of involvement in five patients. In addition, 13 patients treated with TLI received adjuvant chemotherapy, consisting of six cycles of cyclophosphamide, vincristine, and prednisone (CVP). Median follow-up was 9.6 years. Kaplan-Meier actuarial survival at five, ten, and 15 years was 78%, 50%, and 37%, respectively. Freedom from relapse at five and ten years was 60% and 40% with no relapses after ten years. In a prospective randomized study of 16 patients who all underwent staging laparotomy comparing TLI with or without adjuvant chemotherapy with CVP, there was no significant difference in either survival or freedom from relapse between the two groups. Patients with limited stage III disease (without B symptoms, less than five sites of involvement, and maximum size of disease less than 10 cm) had an excellent prognosis with a 15-year survival and freedom from relapse of 100% and 88%, respectively. Radiation therapy may be a potentially curative modality in patients with stage III follicular lymphomas.

Analysis of non-Hodgkin's lymphomas with nodular and favorable histologies, stages I and II.

Between 1961 and 1980, 124 patients with Stages I and II nodular lymphocytic poorly differentiated (NLPD), nodular mixed histiocytic-lymphocytic (NM), nodular histiocytic (NH), or diffuse well-differentiated lymphocytic (DLWD) lymphoma according to the Rappaport classification were treated at Stanford University. Initial staging studies included lymphangiography in 91%, bone marrow biopsy in 93%, and diagnostic or staging laparotomy in 41% of patients. All patients were treated with megavoltage irradiation to either involved field (IF), extended field (EF), or total lymphoid fields (TLI) to a total dose of 3500-5000 rad. Median follow-up was 5.5 years. Kaplan-Meier actuarial survival at 5, 10, and 15 years was 84%, 68%, and 42%, respectively. Freedom from relapse at 5 and 10 years was 62% and 54%, respectively. In addition, there was a flattening of the relapse curve suggesting cure of approximately 50% of patients. Patients with NH had a significantly poorer survival (P = 0.03) while there were no differences among the other histologic groups. Freedom from relapse was higher in patients treated with TLI compared with those treated with IF or EF. However, a prospective study of 20 patients who all underwent staging laparotomy and were randomized to treatment with either IF or TLI revealed no significant difference in either survival or freedom from relapse. Utilizing multivariate analysis for the entire group, important prognostic factors included age, stage, histologic subtype, and treatment field.

Cranial nerve involvement in children with leukemia and lymphoma.

Between 1965 and 1982, 52 children with acute lymphoblastic leukemia or non-Hodgkin's lymphoma were found to have central nervous system involvement of their disease. Of this group, 20 developed clinically apparent cranial nerve paresis or palsy. The cranial nerve most frequently affected was No. VII. With therapy, 16 of the patients had objective control of their central nervous system disease. Among these 16 patients, cranial nerve palsies resolved completely in 14, and only two children were left with residual cranial nerve dysfunction. Seven patients received intrathecal chemotherapy before radiation therapy was instituted in an attempt to control their cranial nerve palsies. Cranial nerve palsy resolved in only two of these seven patients. However, the addition of whole-brain irradiation in the remaining five patients reversed cranial nerve dysfunction in four of them. The combination of intrathecal chemotherapy and central nervous system irradiation was successful in reversing cranial nerve dysfunction in 11 of 13 patients in whom central nervous system disease was ultimately controlled. As cranial nerve dysfunction is associated with distressing signs and symptoms, the combination of central nervous system irradiation and intrathecal chemotherapy is important palliative therapy to initiate promptly. Intrathecal therapy alone appears to be inadequate therapy for prompt and durable reversal of symptoms in this group of patients.

Diagnostic accuracies of clinical studies in patients with small cell carcinoma of the lung.

The diagnostic accuracy of clinical studies done in 38 patients with small cell carcinoma of the lung was analyzed by comparing the test results to autopsy findings. The chest radiograph was accurate in 31 of 38 patients (82%). The accuracy of the chest radiograph was higher in evaluating the lung parenchyma and mediastinum than in evaluating the hilum and pleura. Computerized tomographic brain scan was accurate in 11 of 12 patients. However, all the diagnostic studies used for assessing the liver, including physical examination, serum liver enzyme and bilirubin measurements, and radionuclide liver scan, were only moderately accurate. More accurate studies for detecting liver metastasis in patients with small cell carcinoma are needed.