Influence of fraction size, total dose, and overall time on local control of T1-T2 glottic carcinoma.

PURPOSE: To evaluate the influence of fraction size, overall time, total dose, and other prognostic factors on local control of T1 and T2 glottic carcinomas. METHODS AND MATERIALS: Between 1956 and 1995, 398 consecutive patients with early glottic carcinoma (315 T1 and 83 T2) were treated with once-a-day definitive radiotherapy at the University of California, San Francisco, and associated institutions. Treatment was delivered 5 days per week. Minimum tumor dose ranged from 46.6 to 77.6 Gy (median: 63 Gy). The fraction size was < 1.8 Gy in 146; 1.8-1.99 Gy in 128; 2.0-2.24 Gy in 62, and > or = 2.25 Gy in 62 patients. Overall time ranged from 34 to 75 days (median: 50 days). The majority of patients treated with a fraction size of 2.25 Gy completed therapy within 43 days. Median follow-up of all alive patients was 116 months (range 3-436 months). RESULTS: Five-year local control was 85% for T1 and 70% for T2 glottic carcinomas (p = 0.0004). For T1 lesions, within the dose and time range evaluated, there was no apparent relationship between fraction size, overall time, total dose, and local control on multivariate analysis. Treatment era was the only significant prognostic factor (p = 0.02), and anterior commissure (AC) involvement was of borderline significance (p = 0.056). Five-year local control was 77% for patients treated between 1956-1970, 89% for between 1971-1980, and 91% for between 1981-1995; 80% for patients with AC involvement and 88% for those without. For T2 lesions, prognostic factors for local control on multivariate analysis were: overall time (p = 0.003), fraction size (p = 0.003), total dose (p = 0.01), impaired vocal cord mobility (p = 0.02), and subglottic extension (p = 0.04). Five-year local control was 100% for T2 lesions treated with overall time < or = 43 days vs. 84% for overall time > 43 days; 100% for fraction size > or = 2.25 Gy vs. 44% for fraction size < 1.8 Gy; 78% for total dose > 65 Gy vs. 60% for total dose < or = 65 Gy; 79% for normal cord mobility vs. 45% for impaired cord mobility, and 58% for lesions with subglottic extension vs. 77% for those without. The severe complication rate for the entire group was low: 1.8%. CONCLUSIONS: Total dose, fraction size, and overall time were significant factors for local control of T2 but not T1 glottic carcinomas. Anterior commissure involvement was associated with decreased local control for T1 but not T2 lesions. For T1 lesions, local control improved over the treatment era. For T2 lesions, local control decreased with impaired cord mobility and subglottic extension.

Carcinoma of penis. Review of cases treated by surgery and radiation therapy 1960-1977.

Cases of squamous cell carcinoma of the penis treated by surgery and radiation therapy at Moffitt Hospital, University of California, and Mount Zion Hospital and Medical Center are reviewed. Only cases followed for more than three years or with autopsy findings are presented. For the primary lesion, over-all surgical control rate locally was 15/17 or 88 per cent. Over-all control rate with radiation therapy alone was 9/12 (75 per cent), and with surgical salvage 11/12 (92 per cent). Radiation therapy appears to be the treatment of choice for early stage lesions, reserving surgery for salvage. Prophylactic ilioinguinal lymph node dissection for N0 lesions is not warranted. The role of chemotherapy needs further investigation.

Metropolitan health policy development: barriers to implementation.

The complex health issues facing urban areas require effective public policy responses. Consistent with the call by the Institute of Medicine for local health policy development, a variety of groups within metropolitan areas have engaged in these efforts. This paper provides an exploratory analysis of a cross section of 25 health policy initiatives undertaken in Chicago from 1987 through 1994. Characteristics of these initiatives, their recommendations, and factors which served as barriers to implementation are identified. The barriers include: deficiencies in policy design, inadequate political support, organizational barriers, and resource constraints. Our findings are compared to other policy implementation research. Suggestions for improving the effectiveness of local policy development include: involving key individuals from the public and private sectors, maintaining a strategic perspective on achieving priority recommendations, including financial analysis and planning, developing an initial implementation plan, and securing political support.

Combination chemotherapy and radiotherapy for a locally advanced squamous cell carcinoma of the urethra: a case report.

A 68-year-old patient with advanced stage IVB squamous cell carcinoma of the urethra was treated successfully by combined radiation therapy to 5,580 cGy., and chemotherapy with 5-fluorouracil and mitomycin. Dramatic response in the size of the tumor was noted and on the last day of treatment there was no definite evidence of persistent disease. No surgery was performed except for urinary diversion. The patient remained without disease for 5.5 years clinically and pathologically. In this case the combination of radiation therapy and chemotherapy obviated the need for radical surgery. This clinical behavior is markedly similar to the behavior of anal canal carcinoma when using a similar regimen. Therefore, further clinical investigation for combined modality treatment is warranted.

Evaluation of the erythrocyte protoporphyrin test as a screen for elevated blood lead levels.

To study the effect of lowering the definition of an elevated blood lead level on the performance of the erythrocyte protoporphyrin screening test and the number of children who would require follow-up, we collected laboratory data from a screening program. The estimated sensitivity of an erythrocyte protoporphyrin level greater than or equal to 35 micrograms/dl for identifying children with elevated blood lead levels was 73% when we used 1985 Centers for Disease Control guidelines (elevated blood lead level greater than or equal to 25 micrograms/dl). Eight percent of the tests showed positive results. When we redefined an elevated blood lead level as greater than or equal to 15 micrograms/dl, the sensitivity estimate was reduced to 37% and the number of positive test results increased fourfold.