Conserving large populations of lions - the argument for fences has holes.

Packer et al. reported that fenced lion populations attain densities closer to carrying capacity than unfenced populations. However, fenced populations are often maintained above carrying capacity, and most are small. Many more lions are conserved per dollar invested in unfenced ecosystems, which avoid the ecological and economic costs of fencing.

The Practice of Paediatric Radiation Oncology in Low- and Middle-income Countries: Outcomes of an International Atomic Energy Agency Study.

AIMS: Childhood cancer survival is suboptimal in most low- and middle-income countries (LMICs). Radiotherapy plays a significant role in the standard care of many patients. To assess the current status of paediatric radiotherapy, the International Atomic Energy Agency (IAEA) undertook a global survey and a review of practice in eight leading treatment centres in middle-income countries (MICs) under Coordinated Research Project E3.30.31; 'Paediatric radiation oncology practice in low and middle income countries: a patterns-of-care study by the International Atomic Energy Agency.' MATERIALS AND METHODS: A survey of paediatric radiotherapy practices was distributed to 189 centres worldwide. Eight leading radiotherapy centres in MICs treating a significant number of children were selected and developed a database of individual patients treated in their centres comprising 46 variables related to radiotherapy technique. RESULTS: Data were received from 134 radiotherapy centres in 42 countries. The percentage of children treated with curative intent fell sequentially from high-income countries (HICs; 82%) to low-income countries (53%). Increasing deficiencies were identified in diagnostic imaging, radiation staff numbers, radiotherapy technology and supportive care. More than 92.3% of centres in HICs practice multidisciplinary tumour board decision making, whereas only 65.5% of centres in LMICs use this process. Clinical guidelines were used in most centres. Practice in the eight specialist centres in MICs approximated more closely to that in HICs, but only 52% of patients were treated according to national/international protocols whereas institution-based protocols were used in 41%. CONCLUSIONS: Quality levels in paediatric radiotherapy differ among countries but also between centres within countries. In many LMICs, resources are scarce, coordination with paediatric oncology is poor or non-existent and access to supportive care is limited. Multidisciplinary treatment planning enhances care and development may represent an area where external partners can help. Commitment to the use of protocols is evident, but current international guidelines may lack relevance; the development of resources that reflect the capacity and needs of LMICs is required. In some LMICs, there are already leading centres experienced in paediatric radiotherapy where patient care approximates to that in HICs. These centres have the potential to drive improvements in service, training, mentorship and research in their regions and ultimately to improve the care and outcomes for paediatric cancer patients.

Need for radiotherapy in low and middle income countries ­ the silent crisis continues.

About 57% of the total number of cancer cases occur in low and middle income countries. Radiotherapy is one of the main components of cancer treatment and requires substantial initial investment in infrastructure and training. Many departments continue to have basic facilities and to use simple techniques, while modern technologies have only been installed in big cities in upper-middle income countries. More than 50% of cancer patients requiring radiotherapy in low and middle income countries lack access to treatment. The situation is dramatic in low income countries, where the proportion is higher than 90%. The overall number of additional teletherapy units needed corresponds to about twice the installed capacity in Europe. The figures for different income level groups clearly show the correlation between gross national income per capita and the availability of services. The range of radiotherapy needs currently covered varies from 0% and 3-4% in low income countries in Latin America and Africa up to 59-79% in upper-middle income countries in Europe and Central Asia. The number of additional radiation oncologists, medical physicist, dosimetrists and radiation therapists (RTTs) required to operate additional radiotherapy departments needed is 43 200 professionals. Training and education programmes are not available in every developing country and in many cases the only option is sending trainees abroad, which is not a cost-effective solution. The implementation of adequate local training should be the following step after establishing the first radiotherapy facility in any country. Joint efforts should be made to establish at least one radiotherapy facility in countries where they do not exist, in order to create radiotherapy communities that could be the base for future expansion.

High dose-rate endobronchial irradiation in malignant airway obstruction.

We evaluated the effectiveness of high dose rate (HDR) endobronchial irradiation for palliation of malignant airway obstruction. Between May 1989 and February 1992, 39 patients were treated in our department. Thirty-two patients (82 percent) had primary lung neoplasms and 7 (18 percent) had metastatic disease. Thirty-three patients (85 percent) had prior external irradiation (either alone or in combination with chemotherapy), and 9 patients (23 percent) received laser excision before treatment. Of the 39 patients, 14 (36 percent) presented with hemoptysis, 20 (51 percent) with cough, 15 (38.5 percent) had dyspnea, and 15 patients (38.5 percent) had pneumonia or atelectasis. There were 57 applications performed in the 39 patients. Patients with hemoptysis had 93 percent complete response (CR), 20 percent with cough had CR; 60 percent improved (partial response [PR]); no response was seen in 20 percent. Atelectasis and pneumonia resolved in 20 percent of patients. Eighteen patients (46 percent) underwent a second procedure and were evaluated for objective response; 34 percent had CR, 44 percent had PR, and 22 percent did not respond. There were two acute (one bronchospasm, one pneumothorax) and three late (two strictures, and one exsanguination) complications. In our experience, HDR was highly effective in the palliation of airway symptoms caused by malignant tumors, with acceptable toxicity.

Salvage therapy for non-Hodgkin's lymphoma with a combination of dexamethasone, etoposide, ifosfamide, and cisplatin.

A total of 30 consecutive patients with refractory or relapsing non-Hodgkin's lymphoma (NHL) were treated with a combination of dexamethasone, etoposide (VP-16), ifosfamide, and cisplatin (DVIP). In all, 9 subjects (30%) showed a partial response and 10 (33%) achieved a complete response (CR) lasting from 2.5 to 24+ months. Aggressive histology, no prior therapy with VP-16, a CR to previous chemotherapy, and a treatment-free interval of greater than 6 months prior to the present study were associated with the high CR rate. DVIP caused pronounced myelosuppression (median granulocyte nadir and median platelet nadir, 380/mm3 and 73.000/mm3, respectively), but no drug-related death occurred. We conclude that DVIP is an effective salvage combination, especially in aggressive NHL, that produces acceptable toxicity.

Total skin electron irradiation in mycosis fungoides dose and fractionation considerations.

This study was undertaken to analyze the influence of total skin dose and dose-fractionation schedules on the response rate, survival and skin toxicity of patients with mycosis fungoides [MF] treated with total skin electron irradiation [TSEI]. From 1979 to 1992, 40 patients with MF were treated with TSEI using a modified Christie Hospital technique. Mean follow-up time was 48 months [median 20 months]. 37/40 patients completed TSEI; three died due to non-treatment-related conditions during therapy. 34/37 [92%] treated patients achieved complete remission [CR] and 16/40 [40%] are alive with no evidence of disease. Over the years, changes in dose-fractionation schedules were made and correlated with the pattern of CR and skin toxicity. The 5-year actuarial survival [Stanford staging] was 84% in Stages IA-IB [all Stage IA patients are alive] and 59% in Stage II. The probability of survival of Stage III-IV patients was 30% at 30 months. Late skin toxicity was mild to moderate in 60% and severe in 25% of patients. A reduction of the total dose and dose-per-fraction resulted in an acceptable CR rate and a significantly lower toxicity. TSEI is effective in early stage MF. Skin control and late skin toxicity seem to be dose-fractionation-schedule related. For the early stages, the optimal treatment schedule seems to be 24-30 Gy to the whole skin surface in 2.4-3.0 Gy fractions, given twice weekly over a period of four to six weeks. Total doses of 24-30 Gy at 2.4-3.0 Gy per fraction yielded comparable skin control rates with lower skin toxicity.

Total skin electron irradiation: efficacy in early mycosis fungoides.

The rare, indolent, but lethal malignancy, mycosis fungoides (MF), is amenable to durable remissions if treated topically at an early stage with nitrogen mustard, PUVA, or radiotherapy. A modification of conventional therapeutic irradiation which utilizes electron beams rather than photons, has been in use since 1951. This method, termed total skin electron irradiation (TSEI), has achieved consistently good CR rates (95-100%) at a variety of centres in the U.S.A., England, France, and Italy, despite troublesome differences in staging systems. In northern Israel we have treated 37 MF patients with TSEI during the past 13 years. All 21 of our early stage patients achieved CR, which is no longer regarded as an unusual result. However, most workers in the field acknowledge that issues of optimal dosing and curative potency remain unresolved.

Total skin electron irradiation in mycosis fungoides: comparison between a modified Christie Hospital translational technique and the Stanford technique.

Seventy-one patients with mycosis fungoides (MF) were treated by Total skin electron irradiation (TSEI) using either a modified Christie Hospital translational technique (44 pts) or a six dual-field Stanford technique (27 pts). There was no statistical difference in response rate, disease-free survival and overall survival between the two irradiation techniques. However, the Stanford technique was significantly less toxic than the modified Christie Hospital technique.

Emerging concepts of women's development. Implications for psychotherapy.

This article highlights the essence of the new theories concerning the development of girls and women. The discussion centers on the implications for reinterpretation of women's actual lives, women's mental health, and the conduct of outpatient psychotherapy with adolescent girls and women.

Intensive chemotherapy using cisplatin and fluorouracil followed by radiotherapy in advanced head and neck cancer.

This protocol was designed to achieve an improvement in the overall and disease-free survival in locally advanced, previously untreated carcinoma of the head and neck. 53 patients (pts) with locally advanced Stages III and IV, MO squamous cell carcinoma of the nasopharynx, larynx, paranasal sinuses, oral cavity, oropharynx, hypopharynx and one of unknown origin were treated with intensive chemotherapy followed shortly thereafter by radiotherapy. Induction chemotherapy consisted of two cycles of cisplatin 100 mg/m2 over 60 min on day 1, plus 5FU 1000 mg/m2 continuous infusion over 24 h on days 2-5, with a 10-day interval between the two cycles, followed by definitive radiotherapy after 10 days. The overall response rate to chemotherapy was 79%, with a 28% complete response (CR) rate and a 51% partial response (PR) rate. The overall CR rate after radiotherapy was 70%. With a median follow-up period of 48 months, the 5-year actuarial survival and disease-free survival rates were 67% and 45%, respectively. No difference was found in the survival probability of pts with carcinoma of the nasopharynx, larynx or other primary sites. The survival of pts with a performance status (PS) < or = 1 was better than pts with PS > 1, 72% versus 51% (not significant). The survival probability of complete responders to chemotherapy was superior than the survival of non-complete responders to chemotherapy, 100% versus 54% [P = 0.001]. The main toxicity was mucositis during radiotherapy. In conclusion, this treatment regimen demonstrated a high CR rate and survival probability in pts with locally advanced and mostly inoperable head and neck cancer.

Bilateral calcaneal intraosseous lipomas: a case report.

A case of bilateral intraosseous calcaneal lipomas in a 40-year-old man is presented. Because of the benignancy and the virtually diagnostic appearance of this lesion radiographically, a bone biopsy was not performed. This may be the first case of bilateral involvement of the calcaneous by intraosseous lipomas.

Malignant thymoma associated with progressive systemic sclerosis.

A 65-year-old man manifested certain features of scleroderma several years before discovery of malignant thymoma. Following tumor resection, the signs and symptoms of scleroderma did not improve, and the patient experienced the abrupt onset of renal failure with malignant hypertension 7 months after the operation. The scleroderma renal crisis caused terminal renal failure, which was treated by chronic hemodialysis. This is the second reported case of thymoma associated with progressive systemic sclerosis (PSS). The authors suggest that thymoma and various immunologic disorders have a common etiologic factor which has not yet been found. This case emphasizes that thymectomy frequently has little effect on the course of the immunologic disease. The implications of the association of thymoma and PSS are discussed.

Reduction of the rectal dose in gynecological brachytherapy: modification to the Fletcher-Suit applicator.

The dose to the anterior rectal wall is a known limiting factor for the delivery of radical doses of radiation to the uterine cervix with brachytherapy. We developed a modification to the Fletcher-Suit afterloading applicator, consisting of two small inflatable balloons attached to the posterior end of each colpostat. The balloons are connected to catheters that emerge from the vagina attached to the colpostat's handles. The balloons were affixed to the colpostats with a plastic adaptor and are inserted empty. After an anterior radiograph is taken, the balloons are filled with radiological contrast material and a lateral orthogonal film is made. This lateral film taken with the balloons filled with contrast typically shows a significant posterior displacement of the anterior rectal wall away from the vaginal sources. The International Commission on Radiation Units (ICRU) rectal point is then determined 5 mm beyond the posterior boundary of the opacified balloons. We have performed 90 applications using this device, including brachytherapy applications for cervical cancer, as well as vaginal applications for endometrial carcinoma following TAH-BSO. On average, the ICRU rectal point was displaced 14 mm away from the colpostats, thus reducing the dose rate by 60% and resulting in an average dose sparing of about 1000 cGy to the anterior rectal wall.

Implementing a tantalum wire mesh to increase the skin dose in low-energy electron irradiation of the chest wall.

Radiation treatment of the post-mastectomy chest wall is performed in our institution by straight-on electron irradiation. The chest-wall thickness is measured and the beam energy is chosen so that the chest wall is treated to therapeutic doses, while sparing the underlying lung tissue. The most commonly chosen energies are 6 and 9 MeV. The skin dose should be 90% of the dose prescribed to the chest wall, which is higher than can be achieved with 6- and 9-MeV beams because of the low surface dose. The addition of a bolus slab during part of the treatment can correct for this; however, the added depth means that a higher energy has to be chosen, which will increase the lung dose (the higher the electron energy, the slower the falloff of the electron depth-dose curve). A mesh of a high-Z material above the skin gives rise to obliquely scattered and low-energy electrons that effectively spoil the buildup zone. Dosimetric measurements of a Tantalum (Ta) mesh were performed using a dose scanner in a water tank and a film inserted in a humanoid phantom during a simulated treatment. Measurements were also done for the clinically relevant cases of oblique beam incidence and with the mesh placed 1 cm above the surface. The measurements demonstrate the spoiling of the buildup zone, while having only a moderate influence on the dose distribution beyond the dose maximum. The mesh also changes the absolute dose. In a fractionated regime, the first part of the treatment would be without the mesh, adding it only during the latter fractions. The total dose distribution gives 90% to the skin, while leaving the depth-dose characteristics beyond the dose maximum virtually unchanged.

A simple oral cone attachment for the Varian linear accelerator.

Lesions in the oral cavity are often treated with two opposed lateral fields. These include a significant amount of normal healthy tissue whose radiation tolerance is dose-limiting. The tumor dose can be boosted to tumorcidal levels by brachytherapy or by small electron fields directed straight on the lesion. We have developed a simple attachment to the standard electron applicator of the Varian Clinac 1800 that allows irradiation of small electron fields through acrylic tubes-the oral cones. These tubes have been evaluated in terms of depth dose and field profiles for 6, 9, 12, 16, and 20 MeV electrons using film for relative dosimetry. At these small field sizes there are significant changes in output factors, in the depth dose as well as in the effective size of the field, and a thorough dosimetric evaluation is imperative prior to treatment. The attachment can be manufactured locally at low cost. For reasons of patient safety the assembly is collapsible. In clinical practice the cone is directed directly on the tumor. For deep-seated lesions we use a penlight and a mirror for positioning.

Weight loss counseling in primary care.

Caring for the overweight client requires a multifaceted approach. The nurse practitioner can help clients lose weight by providing them with strategies for reducing calorie intake, maintaining a healthy, balanced diet, exercising more, and developing positive behavioral and attitudinal changes. Weight reduction programs need to be individualized and clients should be periodically reassessed for changes in behaviors, eating patterns, and goals. Success in weight loss and maintenance requires a lifelong commitment to behavioral and nutritional changes. The goal of this article is to improve the clinician's understanding of the overweight person and to assist health care providers in counseling clients in weight reduction and maintenance.

[Osteoradionecrosis of the jaws].

9 patients with osteoradionecrosis of the mandible were treated during 1975-1994. All primary tumor had received high dose external radiation or brachytherapy, using iridium-192 sources. In 6 patients the complication was triggered, shortly before or after irradiation, by surgical interventions such as tooth extraction, or by the presence of an infected focus in the mandible. The complications were treated conservatively, including 2 cases by hyperbaric oxygen. The value of prevention is emphasized.

[Preservation of the larynx in advanced cancer--experiences at the Oncology Department, Rambam Medical Center, Haifa].

The effectiveness of sequential chemo-radiotherapy in preserving the larynx in advanced laryngeal carcinoma was assessed. 4 unselected patients (19 men and 2 women, mean age 60 years) with advanced squamous cell carcinoma of the larynx (T3-4/N0-3) received induction chemotherapy consisting of 2-3 cycles of cisplatin (100 mg/m2) and 5-fluorouracil (1000 mg/m2/day) as a continuous infusion on days 1-5, followed by definitive radiotherapy: 50 Gy to the whole neck, 70 Gy to the larynx and clinically involved nodes, using a combination of 6 MV photons and 9-12 MeV electrons. 19 of the 21 patients responded to combined therapy but there was no response to induction therapy in 2 (10%) and 2 did not complete therapy due to severe toxicity. At a mean follow-up of 40 months, 7 had undergone total laryngectomy (33%), for an overall 5-year laryngeal preservation rate of 66%. Reasons for total laryngectomy in 2 patients were no response, and in 5 tumor recurrence. Mean survival was 39 months (range 11-46 months); at last follow-up, 17 of 21 were alive and disease-free, 11 of whom had a functional larynx (65% of survivors). 2 had died due to disease progression and due to a cardiovascular event. Sequential chemo-radiation allows laryngeal preservation in about 2/3 of surviving patients without compromising survival.

[Multimodal management of bone sarcomas in children].

Osteogenic sarcoma and Ewing's sarcoma are the most common malignant bone tumors in childhood and adolescence. Marked improvement in prognosis and long-term survival have been achieved using combined modality protocols. We present a retrospective analysis of our experience with combined therapy of malignant bone tumors in children. Among 20 (ranging in age from 6-16, mean 11.4 years) with Ewing's sarcoma, 14 (70%) had complete remission by the end of treatment, 5 (25%) had partial response and 1 did not respond. The overall 10-year actuarial survival was 64%. Of the 10 with osteogenic sarcoma, 5 (50%) fully responded and are alive, 4 (40%) died after a partial or no response and 1 is receiving second-line therapy after partial response to primary treatment. The 10-year actuarial survival was 37.5% and the efficacy of combined modality therapy was demonstrated. However, further efforts are needed to arrive at optimal treatment for improved outcome.

Telephone triage. A common sense approach.

Can you accurately assess a patient's condition over the telephone? Can you determine which patients should be seen in the ED or the office, and which patients can follow your advice for home treatment? Telephone triage can save time and money--if it's done effectively.