Late radiation damage in prostate cancer patients treated by high dose external radiotherapy in relation to rectal dose.

A retrospective analysis of the incidence of radiation proctitis was performed in 154 patients with carcinoma of the prostate treated with external radiotherapy assisted by CT-scan planning from 1983 to 1985. An attempt was made to assess a dose-response relationship for proctitis. Multivariate Cox regression analysis showed that previous bowel disease or surgery, anterior rectal dose, and average rectal dose contributed to a higher risk of proctitis. The anterior rectal dose was the most important indicator. No statistically significant correlation was found for the posterior rectal dose. The actuarial 2-year incidence of moderate or severe proctitis was 22% for anterior rectal doses less than 70 Gy and 20% for anterior rectal doses between 70 and 75 Gy, but increased to 60% when the dose was more than 75 Gy. A dose effect relation was evident, with a sharp dose-response gradient around 75 Gy at the anterior rectal wall.

Carcinoma of the urinary bladder category T2,3NXM0 treated by 40 Gy external irradiation followed by cesium137 implant at reduced dose (50%).

Forty-eight bladder cancers T2NXM0 with bad prognostic factors and 42 T3NXM0 growths, suitable for interstitial treatment, were submitted to 40 Gy external irradiation immediately followed by Cae137 Implant at "reduced dose". Intercurrent death corrected 5-year survival for both groups was about 80%. The influence of previously identified bad prognosticators (more than one TUR, WHO grade 3, 4, vascular invasion in the biopsy specimen, pathological IVP) was nearly eradicated.

Late radiation injuries of the gastrointestinal tract in the H2 and H5 EORTC Hodgkin's disease trials: emphasis on the role of exploratory laparotomy and fractionation.

Out of 516 patients who entered in the two successive EORTC trials H2 and H5 for supra-diaphragmatic stages I and II Hodgkin's disease (HD), and who received an infra-diaphragmatic irradiation, 36 (7%) developed late radiation injuries of the gastrointestinal tract (GIT). Twenty-five patients presented with ulcers (stomach or duodenum), 2 with severe gastritis, 6 with small bowel obstruction or perforation and 3 patients had both an ulcer and bowel obstruction. A previous laparotomy played an important role. While the complication rate was 2.7% without any previous abdominal surgery, it was 11.5% after laparotomy (p less than 0.001). Fractionation was also found to be of importance in the occurrence of complications: three different weekly schedules were used -5 x 2 Gy, 4 x 2.5 Gy and 3 x 3.3 Gy; the GIT complication rates were 4, 9 and 22%, respectively (p less than 0.001). When combining laparotomy and fractionation, we found that the patients who were treated using 5 weekly fractions of 2 Gy without any prior laparotomy had a very low rate of late digestive complications (1%), whereas the patients who received 3 weekly fractions of 3.3 Gy after laparotomy presented a 39% complication rate. The other subgroups of patients were at an intermediate risk (from 5 to 13%) of late digestive injuries. Since most patients received 40 Gy with only very small variations, the influence of the radiation dose could not be investigated.(ABSTRACT TRUNCATED AT 250 WORDS)

Factors influencing the prognosis in bladder cancer.

In the categories T1, T2 and T3NxM0 bladder cancer, diameter not exceeding 5 cm, the treatment in the Rotterdam Radio-Therapy Institute consists of interstitial irradiation with needles containing radioactive material. The results of treatment and the role of additional external irradiation are discussed. Category T3NxM0 tumors diameter exceeding 5 cm are treated by external irradiation followed by cystectomy; the results are presented here. Factors influencing prognosis appeared to be degree of differentiation, number of transurethral resections (TURs) prior to definitive treatment, intravenous pyelography (IVP), vascular invasion, T category after preoperative irradiation, and postsurgical histopathologically-assessed T category (pT).

A multivariate analysis of prognostic factors in early stage Hodgkin's disease.

A multivariate analysis of the prognostic factors was carried out with a Cox model on 1,139 patients with clinical Stage I + II Hodgkin's disease included in three controlled clinical trials. The following indicators had been prospectively registered: age, sex, systemic symptoms, erythrocyte sedimentation rate (ESR), number and sites of involved lymph node areas, histologic type, clinical stage, pattern of presentation, results of staging laparotomy when performed, as well as the date and type of treatment. A linear logistic analysis showed that most of the indicators are interrelated. This emphasizes the necessity of a multivariate analysis in order to assess the independent influence of each of them. The two main prognostic indicators for relapse-free survival are systemic symptoms and/or ESR and number of involved areas. The only significant factor for survival after relapse is age. Sex has a small but significant influence on relapse-free survival. The relative influence of each indicator varies with the type of treatment and these variations may help in understanding the biologic significance of the indicators.

Carcinoma of the urinary bladder treated by interstitial radiotherapy.

Bladder cancers are usually only poorly radiosensitive and require a very high dose of radiation in order to become completely eradicated. Radioactive material inserted interstitially, however, can deliver an extremely high dose to the bladder malignancy and still spare vulnerable adjacent tissues and organs. Indications for implantation, treatment results, and prognosis are presented.

Non-seminoma testis treated by irradiation at the Rotterdamsch Radio-Therapeutisch Instituut: the risk of metastasis.

One hundred and thirteen patients with non-seminoma testis and without clinical evidence of distant metastasis (category M0) have been analyzed with regard to the risk of subsequent metastasis after subdiaphragmatic irradiation. Important prognostic factors were: histology (malignant teratoma intermediate (MTI), malignant teratoma undifferentiated (MTU), T-category (T4, T less than 4), clinical regional and juxta-regional subdiaphragmatic lymph node involvement (N0, N1,2, N3,4) and vascular invasion in the orchidectomy specimen (V-, V+). If vascular invasion was considered, the histological type MTI or MTU lost its prognostic impact. Categories T4 and N greater than or equal to 1 worsen prognosis and if vascular invasion could be observed metastasis-risk would be additionally increased. Watch-and-wait policy is probably most justified in categories T less than 4, N0, V-. Elective chemotherapy might be most justified in categories T4N0V+ and T less than 4N greater than or equal to 1V+.

Prostatic cancer treated by external irradiation at the Rotterdam Radiotherapy Institute.

Two-hundred-seventy-nine patients, mainly with prostatic cancer category T3NXM0 and T4NXM0 , have been treated by a full-course of external irradiation. Five- and 10-year survivals and relapse-free survivals are comparable to reports in literature. Complications in about 24% of all cases are acceptable but might be reduced in future by more sophisticated techniques. Important prognostic factors were the T-category of the primary, the histological grade according to WHO and according to Gleason, and to a lesser extent vascular invasion in the biopsy specimen and the diagnostic procedure: either transurethral resection or needle biopsy. Combinations of WHO-grade, Gleason-grade and T-category are possibly the best prognosticators . Persisting, positive transrectal cytology after the irradiation is probably an indicator of a slightly increased risk of metastasis. In spite of hormone therapy after evidence of metastasis, prognosis is poor and not significantly influenced by any pre-irradiation prognosticator.

Prognostic significance of erythrocyte sedimentation rate in clinical stages I-II of Hodgkin's disease.

A prospective study was undertaken in 1963 on the respective prognostic significances of erythrocyte sedimentation rate (ESR) and presence or absence of systemic symptoms in Hodgkin's disease. Six hundred seventy-six patients with clinical stages I or II were included in this study; 376 from 1963 to 1971 who were included in the H1 trial of the European Organization for Research and Treatment of Cancer (EORTC) and 300 who had been enrolled in the EORTC H2 trial from 1972 to 1976. All relevant data and long-term follow-up are available from 649 patients who were analyzed in this study. Multivariate analysis (Cox model) was carried out to assess the prognostic value of ESR independently of the other prognostic parameters and of the treatment. The results showed that of all the prognostic indicators studied, ESR is the one which has the highest correlation with relapse-free survival; however, initial ESR is not correlated with the probability of death after relapse. The presence or absence of systemic symptoms has less prognostic impact. Despite a close correlation between systemic symptoms and ESR, the two are not redundant and it is useful to combine both.

Cancer of the urinary bladder category T2, T3, (NxMo) treated by interstitial radium implant: second report.

Three-hundred-twenty-eight patients with bladder cancer category T2NxMo and 63 patients with category T3NxMo have been treated by 3 times 3.5 Gy external irradiation followed by a radium implant. Overall 5- and 10-year survival in the T2 category are 56%. In the T3 category they are 39% and 13%, respectively. The intercurrent death (i.e. without evidence of bladder malignancy) corrected actuarial survival percentage in the T2 category is 75% at 5 years and 69% at 10 years. The corresponding percentages in the T3 category are 62% and 59%. Prognosis is worsened by the following factors: more than 1 diagnostic transurethral resection, a pathological intravenous pyelography, non-papillary structure and poor degree of differentiation of the growth. Prognosis in category T3, as compared with category T2, is worse because of the prevalence of bad prognosticators in this T3 category. Therapeutic adaptation to these findings might improve prognosis in the future.

Carcinoma of the urinary bladder category T3NxMo treated by the combination of radium implant and external irradiation: second report.

Forty-one patients with bladder cancer, T3NxMo, with a diameter not exceeding 5 cm, were treated by 3 times 350 rad external irradiation, radium implant at reduced dose, and an additional 3000 rad external irradiation ("Radium 55%"). Survival is excellent where there is a high or medium degree of differentiation without vascular invasion in the biopsy specimen; prognosis is poor if a low degree of differentiation is combined with vascular invasion. The future therapeutic approach will be adapted to this finding.

Carcinoma of the urinary bladder T3NxMo treated by preoperative irradiation followed by simple cystectomy.

One hundred eighty-three patients with bladder cancer category T3NxMo (the diameter of the primary exceeding 5 cm), were treated by preoperative 40 Gy and simple cystectomy. Using only pretreatment information, the group with the best prognosis was characterized by a T3A-growth with a normal intravenous pyelography, with about a 75% cure rate. Before cystectomy, after irradiation the combination of a clinically assessed radiation-downstaged growth (T40GY less than 3) with normal urography, predicted the best chance of cure at about 80%. After cystectomy was performed, the best prognostic group could be most correctly identified: those patients with both microscopic downstaging of the primary ("P" less than 3) and no vascular invasion in the cystectomy specimen (CV-) combined with normal urography had an 81% chance of cure. This most favorable group constitutes 45% of all patients.

Radiation therapy of testicular non-seminomas.

The prognosis of 121 patients with a non-seminoma testicular tumor MTI or MTU was assessed. The clinical lymph node involvement and the T-category of the primary had a significant bearing on prognosis, which is completely determined by pulmonary relapse. The low-risk group (9% pulmonary relapse, all curable) is characterized by a primary category T1 or T2 with negative lymphangiography. The percentage of favorable patients is significantly higher if there is malignant teratoma intermediate (MTI) rather than malignant teratoma undifferentiated (MTU) histology. Systematic use of tumor markers (beta 1 -HCG and alpha fetoprotein), and perhaps an assessment of vascular invasion in the primary, might be useful to identify those patients in the unfavorable group who might benefit from elective chemotherapy.