Prostate brachytherapy--the community hospital experience.

One of the options for treating localized carcinoma of the prostate includes the implantation of radioactive seeds under ultrasound guidance (brachytherapy). A community hospital-based prostate brachytherapy program was started in 1992. The overall survival and disease-free survival figures for the initial 100 patients treated in this program seem comparable to patients treated by radical prostatectomy or brachytherapy in larger series. The main side effects of brachytherapy included nocturia, daytime urinary frequency, dysuria, and proctitis. These side effects were transient and decreased to less than 10% by 12 to 24 months following implantation. Prostate brachytherapy can be effectively and safely provided in a community hospital setting.

Combined preoperative radiation and mitomycin/5-fluorouracil treatment for locally advanced rectal adenocarcinoma.

BACKGROUND: In the treatment of locally advanced rectal carcinoma, radiation therapy before surgery has been shown to decrease local recurrence rates, but has minimal effect on survival. Recently, chemotherapy in combination with preoperative radiation therapy has been shown to be effective for certain malignancies. We postulated that such combination therapy might improve the resectability of advanced rectal cancer. STUDY DESIGN: During a 4-year period we treated 20 patients with locally advanced adenocarcinoma of the rectum using a protocol of preoperative simultaneous pelvic irradiation (4,030-6,040 cGy) and infusion chemotherapy (5-fluorouracil 100 mg/m2 per day over 96 hours and mitomycin 10 mg/m2) followed by surgical resection. Effects of therapy on resectability, tumor size, recurrence and survival, and complications of treatment were evaluated. RESULTS: Minimal toxicity was observed and all patients completed their scheduled preoperative therapy. Reduction in tumor size after chemoradiation, as measured by CT scan, averaged 61% (range 20-100%). Twenty percent had a complete pathologic response to preoperative therapy, with no tumor found in the surgical specimen. Using Kaplan-Meier survival curves, the 5-year survival was estimated to be 64+/-11%, and cancer free and local pelvic control rates were 41+/-12% and 88+/-8% respectively. CONCLUSIONS: We believe that preoperative combination radiation and chemotherapy may provide significant benefit for patients with locally advanced rectal cancer, and that further, large scale studies of this treatment regimen are warranted.

Location of the prostatic apex and its relationship to the ischial tuberosities.

PURPOSE: Although modern computerized tomography scans have revolutionized the three-dimensional treatment planning for external beam radiation therapy for prostate cancer, the prostate apex is often difficult to precisely define. Some institutions routinely use the ischial tuberosities to define the lower border of external beam fields for prostate cancer, while others recommend a retrograde urethrogram. This study was undertaken to estimate the accuracy of using the bottom of the ischial tuberosities to define the lower border of the external beam fields for Stages T1, T2, and T3 prostate cancer. METHODS AND MATERIALS: The anatomic location of the apex of the prostate was determined in 153 implant patients either by direct surgical exposure of the prostate (133 patients) or by using transrectal ultrasound (20 patients). The prostate apex position relative to the ischial tuberosities was determined and plotted on a schematic of the bony pelvic structures drawn to scale. RESULTS: There was excellent agreement in the estimate of the location of the prostate apex between the two methods (surgery vs. ultrasound) used. The prostate apex was located above the ischial tuberosities in 152 of the 153 patients studied (99.3%). Seven of the 153 patients (4.6%) had a prostate apex which was less than 1.5 cm above the ischial tuberosities and 3 of the 153 patients (2%) had an apex-tuberosity distance of less than 1 cm. CONCLUSION: This study indicates that locating the inferior border of the external beam fields at the ischial tuberosity adequately treats at least 95.4% of all prostate patients with a margin of 1.5 centimeters or more below the prostate apex. In addition, the external beam policy of locating the inferior border at the ischial tuberosities has produced: (a) excellent 10-year clinical local control rates of 88% for Stage T1 and T2 patients and 82% for Stage T3 patients, and (b) 5-year and 10-year biochemical (normal prostate specific antigen) and clinical disease free survival rates for T1 and T2 patients which are similar to surgery.

Combined modality preoperative therapy for unresectable rectal cancer.

Locally advanced rectal cancer has been a surgical challenge because of fixation of the primary tumor to the boney pelvis or to other pelvic soft tissues. During a 12-month period seven patients with locally advanced adenocarcinoma of the rectum were treated preoperatively with simultaneous pelvic irradiation (4500-5040 cGy) and infusion chemotherapy (5-fluorouracil 1000 mg per m2 per day over 96 hours and mitomycin 10 mg per m2. Tolerance was reasonable and all patients underwent successful resection of the primary lesion. Two patients had a complete response to preoperative combined modality therapy with no cancer found in the surgical specimen. With a short follow-up period, all patients have experienced satisfactory healing and none have suffered local or distant recurrence. The results of this limited series are encouraging for future clinical trials.

Psychological predictors of survival in cancer patients undergoing radiation therapy.

In a prospective study to identify psychological factors affecting survival in cancer patients receiving radiation therapy, 101 consecutive patients were evaluated for anxiety, depression, and perception of the seriousness of the condition. In 3 years, the survivors were compared to the nonsurvivors. The survivors had significantly higher mean trait anxiety (p less than 0.05) than the nonsurvivors. State anxiety and depression scores also tended to be higher in the survivors (p less than 0.01). Self-assessment of the seriousness of their disease did not differentiate the two groups. The nonsurvivors had significantly more pain (p less than 0.05). Within the nonsurvivor group, survival time was negatively correlated with state anxiety (p less than 0.01), trait anxiety (p less than 0.02), and depression (p less than 0.01). In the nonsurvivors, women rated their condition to be significantly more serious than men (p less than 0.01). Female nonsurvivors tended to rate their condition to be more serious than female survivors (p less than 0.1), while male nonsurvivors rated their condition to be significantly less serious than male survivors (p less than 0.01). Only among female nonsurvivors did the seriousness rating correlate significantly with anxiety (p less than 0.01). The sex differences confirm our previous finding that men may tend to cope with cancer with more massive denial than women. We hypothesize that patients with higher anxiety and depression in the nonsurvivor group had a massive defensive failure, while those who had high anxiety levels in the survivor group had been more realistic about their disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Randomized trial of conventional versus high fractional dose radiation therapy in the treatment of advanced head and neck cancer.

A prospectively randomized clinical trial was undertaken to compare conventionally fractionated radiation therapy and high fractional dose irradiation in the treatment of advanced, surgically unresectable head and neck squamous cell carcinoma. Sixty-four patients were entered into the study between 1973 and 1979 and were randomized to receive either 200 rad daily to total tumor doses of 6000-7000 rad in 6-7 weeks, or 400 rad daily to a total of approximately 4400 rad in 2-3 weeks. The distribution of patients between the two fractionation schedules was comparable regarding site of the primary tumor, extent of disease, degree of histologic differentiation and performance status. Twenty-nine of 31 (94%) patients in the 200 rad group and 29 of 33 (88%) in the 400 rad group has Stage IV disease. Twenty-six in the former group and 30 in the latter completed radiation therapy as planned. Acute skin and mucosal reactions occurred earlier in patients treated with 400 rad daily, but were of equivalent intensity and well within acceptable levels in both groups. No increase in late adverse effects was seen with high daily doses. Palliation of tumor-related symptoms and extent of tumor control were comparable in the two groups. Actuarial five year disease-free survival rates were approximately 10% in both treatment groups with a mean follow-up period of 5 1/2 years. We conclude that high fractional dose irradiation is equivalent to conventionally fractionated radiation therapy in the treatment of advanced head and neck cancer.

Denial and helplessness in cancer patients undergoing radiation therapy: sex differences and implications for prognosis.

One hundred consecutive outpatients undergoing radiation therapy were prospectively studied using the Locus of Control Inventory designed by Rotter and a questionnaire covering various aspects of diagnosis, implications of disease, and details of therapy. The Locus of Control Inventory, which measures a person's belief that life's important events are controlled by personal effort (internality) as opposed to factors outside of one's control (externality), revealed a significant difference between men and women in this study. Although women were similar to the general healthy population, men expressed a greater sense of control as their radiation therapy progressed. Men were also more likely to characterize their illness as not very serious and to deny knowledge of their correct diagnoses or details of their treatment. With survival determined at two years following the study, it was found that living and deceased women had initially rated the seriousness of their illnesses appropriately, while deceased men had rated their illnesses as significantly less serious than women or surviving men. It is concluded that sexual differences in coping mechanisms may be accentuated by malignancy and men may actively deny their diagnosis and its implications. This amount of denial and sense of personal control in the face of a potentially fatal illness may indicate a need for more supportive clinical intervention for the radiation therapy patient.

Recurrent adenoid cystic carcinoma of the trachea: intraluminal radiotherapy.

Malignant neoplasms of the trachea are rare lesions, of which adenoid cystic carcinoma constitutes 30%. A case of extensive tumor recurrent after primary radiotherapy is presented. Surgical resection and radioisotope implantation were impossible. A method was devised for placement of intraluminal iridium 192 by casting six small hollow plastic tubes to the outer circumference of a Silastic endotracheal tube. This was an easy, safe, and effective method of delivering radiation to the trachea while sparing other vital structures and organs. Excellent tumor response and palliation were achieved. The literature is reviewed and the problems in diagnosis of this tumor are discussed. A comprehensive plan for early diagnosis is presented. All current methods of treatment are discussed, and the need for aggressive surgical management is stressed.

Anaplastic seminoma: an analysis of 77 patients.

Over a 28 year period, 77 patients with early stage anaplastic seminoma of the testis were treated by orchiectomy and lymphatic irradiation at three Army medical centers. With a median follow-up of 97 months, the 10 year actuarial survival is 96% of Stage I patients and 87% for Stage II patients. For patients with Stage I anaplastic seminoma no survival advantage can be demonstrated for adding mediastinal and supraclavicular irradiation versus para-aortic and pelvic irradiation alone. The addition of retroperitoneal lymphadenectomy to lymphatic irradiation increased the frequency of major gastrointestinal complications without significantly improving survival. Patients with anaplastic seminoma and elevated serum beta-subunit human chorionic gonadotrophin levels have a poor prognosis and should be considered for adjuvant combination chemotherapy. Anaplastic seminoma of the testis has a similar clinical presentation, response to therapy and prognosis compared to typical seminoma and should be managed in the same way.

The effect of penicillamine on radiation-induced pulmonary lethality in mice.

The collagen inhibitor D-penicillamine was evaluated as a potential radiation reaction preventive agent by studying its effect on deaths attributed to pulmonary damage in mice. Long-term administration of D-penicillamine at a rate of 100 mg/kg/day had no significant effect on the LD50/160 in mice following pulmonary irradiation.

Liposarcomas of the head and neck: a review of the literature and addition of four cases.

Liposarcomas of the head and neck are rare. There have been 25 previously reported patients in the literature. Four patients with head and neck liposarcomas, recently treated by the Head and Neck Surgery Service, Walter Reed Army Medical Center, are presented. Less than half of reported patients were noted to be living without evidence of disease. Prognosis generally corresponds to the cell type of the tumor. Intraoral, cheek and orbital tumors seem to have a worse prognosis compared to neck tumors. Wide local excision remains the treatment of choice. Advances in surgical techniques have allowed adequate therapy for most head and neck liposarcomas. Advanced lesions should be managed by conservative surgery and radical radiation therapy.

Endotracheal irradiation of adenoid cystic carcinoma of the trachea.

Management of advanced or recurrent primary tracheal neoplasms has been restricted to palliative external beam irradiation. A patient with recurrent adenoid cystic carcinoma of the trachea was recently treated again by combined external irradiation and endotracheal brachytherapy with iridium 192 sources; the results were dramatic without significant normal tissue toxicity. This endotracheal brachytherapy technique might be applied to tracheal tumors of different histology or more limited extent.

Beta-aminopropionitrile as a radiation reaction preventive agent.

Beta-aminopropionitrile (BAPN), an inhibitor of collagen maturation, was tested as a radiation reaction preventive agent (RRPA) using radiation-induced lung fibrosis in rats and mice as a model. Following pulmonary irradiation, treatment with BAPN significantly prevented an increase in collagen content as measured by hydroxyproline analysis. This effect persisted during BAPN maintenance for periods of up to 10 weeks but was lost when the drug was discontinued. BAPN administration did not increase the mouse lung LD50/160 in the drug doses employed in this study. Other possible RRPAs deserving further study include D-penicillamine and beclomethasone dipropionate.

Irradiation of advanced head and neck cancer with large daily fractions. Preliminary results of a prospectively randomized clinical trial.

The irradiation of locally advanced, inoperable, squamous cell caricinomas of the head and neck with conventional fractionation schedules using 200 rads/day has produced poor results. A prospectively randomized, clinical trial has been started comparing conventional with large daily fractions of 400 rads/day for 10-12 treatments. Results suggest that improved tumor control and survival rates might be obtained with the use of large daily fractions.

Radiation therapy of adrenal cortical carcinoma.

The role of radiation therapy in the management of adrenal cortical carcinoma has had little documentation in the literature. Fourteen patients with this malignancy were given 18 courses of palliative, preoperative or postoperative irradiation. The clinical results are presented. Significant palliation was obtained in all patients along with occasional long term local control of unresectable lesions.

Methotrexate and radiation therapy in the treatment of advanced head and neck tumors.

Ninety-six patients with advanced squamous cell carcinoma of the head and neck were randomized to treatment with intravenous methotrexate followed by radical irradiation or radiotherapy alone. No significant differences were demonstrated in local disease control or actuarial survival rates at three and five years. Some patients with local treatment failure were surgically salvaged.