Early CT findings after interstitial radiation therapy for primary malignant brain tumors.

The CT findings after interstitial radiation therapy for brain tumors have not been extensively described. We evaluated retrospectively the CT scans of 13 patients who were treated with brachytherapy for malignant glioma. We found no typical CT appearance that differentiates recurrent tumor from radiation effect. After undergoing brachytherapy, eight of the 13 patients scanned demonstrated enhancement of brain tissue beyond the margins of the original enhancing tumor mass. In most cases, the pattern of enhancement diminished and extended more peripherally from the central necrotic area with time. We also report a new CT finding of focal calcification developing at the site of the radioactive implant.

Bone marrow transplantation for good-risk patients with leukemia in a university affiliated hospital.

Of the first 14 patients with acute or chronic leukemia to undergo bone marrow transplantation at our hospital, 9 (64%), all good-risk, are still alive in remission at 18 to 42 months of follow-up (mean, 29 months) with their Karnofsky performance status between 80% and 100%. The conditioning regimen of fractionated-dose irradiation and high-dose chemotherapy eradicated their disease; only two patients relapsed after transplantation. Toxicity was acceptable. Acute graft-versus-host disease developed in six patients (43%) (grade I or II in four, grade IV in two) and progressed to chronic graft-versus-host disease in four. Viral pneumonitis developed in three patients (21%), but none had idiopathic interstitial pneumonitis. The mean hospital charge was $54,355. These preliminary results suggest that good-risk patients with acute or chronic leukemia can be treated with bone marrow transplantation in a university affiliated hospital with appropriate staff and support facilities and achieve results comparable to those in research institutions at a competitive cost.

Sequential half-body irradiation (SHBI) and combination chemotherapy as salvage treatment for failed Ewing's sarcoma--a pilot study.

This study was undertaken to evaluate the toxicity of sequential half-body irradiation (SHBI) and combination chemotherapy (5-FU, VM-26 and BCNU) in patients who had failed primary aggressive therapy for their Ewing's sarcoma. A secondary goal was to evaluate the response of these previously treated patients to the combination of systemic radiation and multi-agent chemotherapy. The first patient in the study was treated with SHBI only and died 139 days following retreatment. Four subsequent patients successfully received the first cycle of combination chemotherapy. However, only one completed both upper and lower half-body irradiation while the remaining three patients, because of rapid progression of their disease, completed either the upper or the lower portion of their half-body irradiation (HBI). The time from retreatment to disease progression in these four patients ranged from 45 to 97 days (mean 79 days) and the time from retreatment to death ranged from 72 to 193 days (mean 126 days). The combination chemotherapy was tolerated well by all the patients, and the SHBI was accompanied by mild nausea and some vomiting within the first few hours following treatment. Failure to give the second half of the half-body irradiation and to complete further chemotherapy in three of the patients was a result of the progressive nature of the patients' disease and not to any limitations imposed by poor blood counts. Half-body irradiation provided good pain relief within 24 hours for all of the patients. Systemic radiation contributes to the palliative treatment of patients with failed Ewing's sarcoma, but appears to be relatively ineffective when the tumor burden is high.

Primary anterior mediastinal seminoma.

A review of the Mayo Clinic experience with primary anterior mediastinal seminomas involved 17 patients who had pure anterior mediastinal seminomas and four who had mixed germ-cell tumors containing seminomas. At follow-up, of the 17 patients with pure anterior mediastinal seminoma, nine had no evidence of disease and eight had died of metastatic disease. Of the four patients with mixed germ-cell tumor containing seminoma, two were alive at follow-up and two had died of metastatic disease. In the group with pure anterior mediastinal seminoma, these factors seemed to have been associated with a greater potential for progression of disease: older than 35 years of age, presentation with fever, superior vena caval syndrome, supraclavicular or cervical adenopathy, and roentgenographic evidence of hilar disease.

Hemangioendothelial sarcoma of bone.

Hemangioendothelial sarcoma of bone is a rare tumor. A series of 112 cases was studied to define the clinical and pathologic features of this disease. Of the various histologic features evaluated to define the ones most significant prognostically, the histologic grade of the lesions was the single feature that correlated best with disease-free survival. In this series, patients with multi-focal tumors did not have a better prognosis than patients with unicentric disease. Surgery remains the primary treatment for these patients. Radiotherapy may be useful for surgically inaccessible lesions of the axial skeleton. Too few patients have received adjuvant chemotherapy to evaluate its usefulness in this setting.

Pineal tumors in children and adolescents. Treatment by CSF shunting and radiotherapy.

Tumors of the pineal region account for 3% to 8% of pediatric intracranial tumors. The treatment of such tumors has been in a state of flux between conservative therapy (cerebrospinal fluid shunting and radiotherapy) and direct surgical removal. A brief history and review of the literature with analysis of both approaches is given, and the Mayo Clinic's experience with conservative treatment of tumors in the pineal region in patients 20 years old and younger (27 cases) is studied and analyzed. The series comprises 21 boys and six girls, with an age range of 1 to 20 years (mean 13.7 years). Follow-up examinations are complete and range from 1 to 24 years, with a mean follow-up period of 7.8 years. The median survival time for these patients treated with shunt and radiotherapy is 17.7 years. There was no mortality from treatment and complications were rare. The details of the clinical presentation, diagnostic findings, pathology, therapy, recurrence, and survival are presented. All patients under 6 years of age (six cases) had recurrences, 50% in other areas in the brain and 50% in the spinal cord, perhaps pointing to the need for whole-brain and spinal-axis irradiation in patients in this age group. The results of this study of the conservative approach form a standard against which results of any other type of therapy may be compared.

Tolerance of brain to multiple courses of radiation therapy. I. Clinical experiences.

Patients with recurrent brain tumours years after initial radiation therapy pose a difficult management decision. Should retreatment be performed with irradiation, which carries a risk of necrosis, or should retreatment be with less effective agents but without unnecessary risks? We present the results of retreatment of 32 patients at the Mayo Clinic and the Joint Center for Radiation Therapy. Clinical improvement was seen in all retreated patients. The median survival was 36 months after completion of the second course of irradiation. Eight patients (25%) were alive, free of disease, from 22 to 315 months after retreatment. Of the 11 patients alive at the time of analysis, eight were experiencing productive lives and three were suffering from severe neurological damage. Evidence of brain necrosis was observed in two patients (6%); however, only 10/21 patients underwent autopsy examinations. Reirradiation of patients with late recurrences of brain tumours may offer neurological improvement and prolonged survival without excessive risk of necrosis.

Malignant, predominantly lymphocytic thymoma with central and peripheral nervous system metastases.

Histologic features of an invasive mediastinal tumor found in a 25-year-old woman fulfilled the accepted criteria for diagnosis of predominantly lymphocytic thymoma. Histochemical and cell marker studies indicated that the neoplasm contained a preponderance of T lymphocytes. After surgical debulking of the mass, aggressive radiotherapy and chemotherapy eradicated all evidence of thoracic disease. However, six months after the initial diagnosis, rapid development of cranial nerve and brainstem metastases--without detectable recurrent disease elsewhere--resulted in the patient's death. Autopsy examination revealed the presence of peripheral nerve metastases as well. A review of the literature disclosed fewer than 10 cases of central nervous system metastasis from thymoma. In only two of these were there clinicopathologic features similar to those seen in this case.

Doxorubicin-enhanced skin reaction after whole-body electron-beam irradiation for leukemia cutis.

This is the first report of doxorubicin (Adriamycin) interacting with whole-body electro-beam irradiation to produce generalized toxic epidermal necrolysis. The patient was a 32-year-old woman with acute myelomonocytic leukemia and leukemia cutis. The severe dermatitis obscured clinical recognition of concomitant pseudomembranous colitis and contributed to the patient's death during management of toxic megacolon. Suggestions are made for minimizing this occurrence in future patients treated in a similar fashion.

Results of treating stage III carcinoma of the breast by primary radiation therapy.

One hundred sixteen patients with stage III carcinoma of the breast were treated by primary radiation therapy. The 5-year actuarial survival and relapse-free survival were 25% and 22%, respectively. The 5-year actuarial probability of local tumor control for the entire group was 64%. In patients undergoing an excisional biopsy and an interstitial implant of the primary tumor area, local control was 100%. In patients who had either an excisional biopsy or an implant, the 5-year actuarial probability of local control was 77% and 76%, respectively. In contrast, in patients having neither an excisional biopsy nor an implant, local control was only 41%. In patients receiving a total dose of greater than 6000 rad, from external beam treatment or from external beam plus an interstitial implant, the local control was 78% compared to 39% in patients receiving a total dose of less than 6000 rad. Forty-one patients received some form of adjuvant therapy. Both local control and relapse-free survival were improved in patients receiving chemotherapy as the sole adjuvant and in patients receiving chemotherapy combined with an endocrine ablative procedure. However, patients treated with only an endocrine ablative procedure had no improvement in survival nor in local control. These results indicate that primary radiation therapy can provide local control in a high proportion of patients with stage III carcinoma of the breast and suggest that chemotherapy is effective in improving both local control and survival in these patients.

Combined irradiation and surgery in the treatment of stage II carcinoma of the endometrium.

Between January 1969, and August 1975, 40 patients with pathologic Stage II carcinoma of the endometrium were treated at the Joint Center for Radiation Therapy. The treatment policy included external and intracavitary irradiation combined with surgery. The majority of patients received 4000 mg/hours of radium exposure using a Fletcher-Suit applicator and 4000 rad whole pelvis external irradiation, followed by hysterectomy and bilateral salpingooophorectomy. Median age of the patients was 61 years (39--88) and the median follow-up of the patients still alive was 69 months (29--102). Relapse-free 5-year survival corrected for intercurrent disease was 83% and uncorrected, 78%. Overall survival was 80%. Five patients had relapsing disease, three patients failed at distant sites only, one patient died of treatment related complications, and two failed locally and distantly. There were no failures in the pelvis alone. Although the relationshop between histologic grade and failure is not statistically significant, there were four failures among the 12 Grade III patients compared to two failures in 27 with Grades I and II. Similarly, 4 of 12 patients with gross cervical involvement developed relapsing disease, but only 2 of 28 failed with microscopic cervical involvement. This treatment policy yields excellent survival and continues to be our treatment recommendation.

Retroperitoneal germinoma marked by elevated serum lactic dehydrogenase.

A case of primary retroperitoneal germinoma is presented in which markedly elevated serum lactic dehydrogenase levels were present before diagnosis, but declined to normal with abdominal irradiation. It is the first report of lactic dehydrogenase serving as a tumor marker in germinoma.