Gamma knife radiosurgery for trigeminal neuralgia: the initial experience of The Barrow Neurological Institute.

PURPOSE: To assess the efficacy and complications of Gamma Knife radiosurgery for trigeminal neuralgia. METHODS AND MATERIALS: The Barrow Neurological Institute (BNI) Gamma Knife facility has been operational since March 17, 1997. A total of 557 patients have been treated, 89 for trigeminal neuralgia (TN). This report includes the first 54 TN patients with follow-up exceeding 3 months. Patients were treated with Gamma Knife stereotactic radiosurgery (RS) in uniform fashion according to two sequential protocols. The first 41 patients received 35 Gy prescribed to the 50% isodose via a single 4-mm isocenter targeting the ipsilateral trigeminal nerve adjacent to the pons. The dose was increased to 40 Gy for the remaining 13 patients; however, the other parameters were unvaried. Outcome was evaluated by each patient using a standardized questionnaire. Pain before and after RS was scored as level I-IV per our newly-developed BNI pain intensity scoring criteria (I: no pain; II: occasional pain, not requiring medication; III: some pain, controlled with medication; IV: some pain, not controlled with medication; V: severe pain/no pain relief). Complications, limited to mild facial numbness, were similarly graded by a BNI scoring system. RESULTS: Among our 54 TN patients, 52 experienced pain relief, BNI score I in 19 (35%), II in 3 (6%), III in 26 (48%), and IV in 4 (7%). Two patients (4%) reported no relief (BNI score V). Median follow-up was 12 months (range 3-28). Median time to onset of pain relief was 15 days (range 0-192), and to maximal relief 63 days (range 0-253). Seventeen (31%) noted immediate improvement (

Brachytherapy in the treatment of thoracic tumors. Lung and esophageal.

Brachytherapy for carcinoma of the lung is most often performed using HDR remote afterloading equipment which delivers the treatment within the tracheal-bronchial tree in an outpatient setting. It provides excellent palliation, rapidly, and can also be selectively used with for curative intent. Permanent implantation using iodine seeds at the time of surgery improves the local control rate for those patients. Esophageal brachytherapy is performed as an intraluminal technique, most often using HDR equipment in an outpatient setting, and is used for palliation as a single modality and as a boost following chemo/radiation for curative patients. In this latter situation, the more aggressive therapy provides significantly better palliation than is possible with single-modality therapy.

Pulsed low dose rate brachytherapy for uterine cervix carcinoma.

PURPOSE: To analyze the outcome and complication rates for patients treated with curative-intent pulsed low dose rate (PLDR) brachytherapy and external beam radiation therapy (EBRT) for uterine cervical carcinoma. METHODS AND MATERIALS: Fifty-two patients have been treated, of whom 6 were excluded from analysis due to limited follow-up. Six patients were stage Ib, 3 were IIa, 11 IIb, 3 IIIa, 14 IIIb, 1 IVa, and 9 were treated for local recurrences following primary surgery for stage Ib disease. Thirty-six patients had squamous cell carcinoma, 8 adenocarcinoma, 1 adenosquamous, and 1 carcinosarcoma. Thirty-one had a staging laparotomy prior to radiation therapy. Brachytherapy was interstitial in 18 patients, and intracavity in 28. The median EBRT central pelvis dose was 45 Gy in 25 fractions. Median total prescribed doses (EBRT plus PLDR) were 75.8 Gy to the implant volume with interstitial, and 84.1 Gy to the A points with intracavitary, at a median dose rate of 0.55 Gy per pulse per hour. Six patients had laparotomy-documented periaortic node involvement, and received EBRT to this site, 45 Gy in 25 fractions. Thirty patients received concomitant weekly cisplatin chemotherapy (40 mg/m2). RESULTS: With a median follow-up of 25 months (range 6 to 55 months) actuarial 4-year disease-free survival (DFS) rates are 66% for the entire group: stage Ib 100%, stage II 69%, stage III/IVa 68%, and 43% in patients treated for recurrences after surgery for initial stage Ib disease. Pelvic nodes contained tumor in 13 of the 31 patients (41.9%) who underwent laparotomy, as did periaortic nodes in 6 (19.4%). Patients with negative pelvic nodes had a 4-year actuarial DFS of 75% versus 59% with positive pelvic (and negative periaortic) nodes, and 50% with positive periaortic nodes. Using the RTOG late radiation morbidity scoring criteria, there were no grade V complications. Grade IV complications occurred in 2 patients (4.3%). One was a rectovaginal fistula and the other a vesicovaginal fistula, each occurring subsequent to a biopsy revealing benign tissue. One patient (2.2%) had a grade III complication (frequent hematuria), and 5 (10.9%) had grade II complications. CONCLUSIONS: PLDR brachytherapy is a safe and effective brachytherapy method in the treatment of cervix carcinoma. It combines the physics benefits of dose optimization and the radiobiologic advantages of low dose rate brachytherapy. It eliminates radiation exposure to staff and visitors as well as the need for a source inventory. Although further follow-up will be required, it appears to provide outcome which compares favorably to other methods of brachytherapy delivery, and results in a low rate of complications.

Endoscopic brachytherapy.

Intraluminal radiation for the local control of bronchogenic carcinoma has recently undergone rapid technological progress. Remote afterloading of high intensity radiation sources into endoscopically placed multiple small catheters with computerized optimization of dosimetry is the state-of-the-art. Fractionated high dose rate (HDR) outpatient treatment has been shown to reduce airway obstruction and improve performance status and quality of life.

Remote afterloading brachytherapy for the local control of endobronchial carcinoma.

PURPOSE: The study was designed to, (a) standardize endobronchial brachytherapy and, (b) to evaluate the relief of obstructive signs and symptoms. METHODS: Patients with endobronchial carcinoma were treated on a protocol (n = 342) with remote afterloading brachytherapy. Group 1 patients were treated with medium dose rate and received 1000 cGy at 5 mm depth for three fractions (n = 47). Group 2 were treated with high dose rate, 1000 cGy to a 10 mm depth for three fractions (n = 144) and Group 3 received 750 cGy delivered to a 10 mm depth for three fractions (n = 151). Each group was divided into curative, palliative, and recurrent categories. Neodymium yttrium aluminum garnet photoresection was used in 24% of patients prior to brachytherapy. RESULTS: Evaluation consisted of symptom index scoring with weighted responses of hemoptysis 99%, obstructive pneumonia 99%, cough 85%, and dyspnea 86%. Obstruction improvement was 80% overall, curative 87%, palliative 84%, and recurrent 70% of mean pretreatment scores. Survival 10% alive, 88% expired, and 2% lost to follow-up. Cause of death was intrathoracic carcinoma 41%, metastatic carcinoma 38%, intercurrent disease 9%, and unknown cause 13%. Survival from diagnosis and first treatment was, respectively, for curative 10.8 and 9.5 months, palliative 14 and 5.6 months, and recurrent 25.6 and 6.2 months. Significant complications were fatal hemoptysis 7%, and radiation bronchitis and stenosis 11%. CONCLUSION: Endoluminal brachytherapy provides excellent palliation of the endobronchial portion of neoplastic disease.

Radiation bronchitis and stenosis secondary to high dose rate endobronchial irradiation.

PURPOSE: To describe a new clinical entity observed in follow-up bronchoscopies in patients who were treated with high dose rate and medium dose rate remote afterloading brachytherapy of the tracheobronchial tree. METHODS AND MATERIALS: Patients treated by protocol with medium dose rate, 47 patients receiving 1000 cGy at a 5 mm depth times three fractions, high dose rate 144 patients receiving 1000 cGy at a 10 mm depth for three fractions and high dose rate 151 patients receiving 750 cGy at a 10 mm depth for three fractions followed by bronchoscopy. RESULTS: Incidence of this entity was 9% for the first group, 12% for the second, and 13% for the third group. Reactions were grade 1 consisting of mild mucosal inflammatory response with a partial whitish circumferential membrane in an asymptomatic patient; grade 2, thicker complete white circumferential membrane with cough and/or obstructive problems requiring intervention; grade 3, severe inflammatory response with marked membranous exudate and mild fibrotic reaction; and grade 4 a predominant fibrotic reaction with progressive stenosis. Variables associated with a slightly increased incidence of radiation bronchitis and stenosis included: large cell carcinoma histology, curative intent, prior laser photoresection, and/or concurrent external radiation. Survival was the strongest predictor of the reaction. CONCLUSION: Radiation bronchitis and stenosis is a new clinical entity that must be identified in the bronchial brachytherapy patients and treated appropriately.

Fibrous histiocytoma cell line: chromosome studies of mouse and man.

A human cell line isolated from a lung metastasis of a malignant fibrous histiocytoma was studied chromosomally. The cell line had a modal chromosome number of 59 with multiple numerical and morphologic chromosome changes and marker chromosomes. A putative clone from this cell line had a modal number of 41 with exclusively acrocentric chromosomes and was clearly not human but mouse in origin.

Human cell lines that elaborate colon-stimulating activity for the marrow cells of man and other species.

We have established two human cell lines which elaborate colony-stimulating activity (CSA) for at least four species: man, mouse, rabbit, and dog. One, GCT, was isolated from a lung metastasis of a fibrous histiocytoma; the other, RC4, from a monocyte-enriched fraction of normal blood. Medium conditioned by either GCT or RC4 cells was more potent in stimulating human marrow growth in vitro than was monocyte-conditioned medium or human leukocyte feeder layers. Fractionation of cell-line-conditioned medium by Sephacryl S-200 chromatography indicated that the maximum activity of the CSA for human marrow cells is eluted within the range of 30,000-40,000 daltons. These cells lines provide a continuous source of large quantities of conditioned medium for purification of CSA. Moreover, the invariable growth-supporting activity for all species tested and the high potency of cell-line CSA facilitates studies of its elaboration and biologic effects.