Comparison of extramedullary plasmacytomas with solitary and multiple plasma cell tumors of bone.

Patients with solitary osseous plasmacytomas (SOP) differ from those with extramedullary plasmacytomas (EMP) in that they are younger and the proportion of males is smaller. The median survival of the two groups is similar: 86.4 mo for SOP, and 100.8 mo for EMP. Progression-free survival, however, is much better for EMP. Only five EMP patients have progressed following initial radiation therapy: one developed a single bony lesion, two progressed to multiple myeloma, and two developed multiple EMP. Thus, 71% of EMP patients are progression free at 10 yr, and most deaths do not result from plasma cell neoplasia. In contrast, 13 SOP patients have progressed to develop additional osteolytic lesions, so that only 16% of SOP patients are progression free at 10 yr; death resulted from progression to multiple myeloma in most of these patients. In EMP patients the occurrence of involved lymph nodes at the time of diagnosis in seven, and initial relapse in regional nodes in three, suggest that consideration should be given to including regional lymph nodes in the radiation fields used to treat these patients.

Conventional fractionated radiotherapy for 51 patients with lentigo maligna and lentigo maligna melanoma.

Lentigo maligna (LM) and lentigo maligna melanoma (LMM) are distinct entities from other forms of melanoma, occurring predominantly on the skin of the head and neck in elderly people, having a slow growth rate and a low metastatic potential (10%). Twenty-three patients with LM were treated with conventional fractionated irradiation, 18 were locally controlled and two failed locally both of whom, however, were salvaged with further treatment. Three patients are not evaluable because of short follow-up time. Median time to complete regression of the lesion is seven months. Twenty-eight patients with LMM have been irradiated, 23 are locally controlled, two locally recurred (both retrieved with subsequent treatment), and three are inevaluable because of short follow-up time. One patient with a level 5 LMM has developed regional and distant metastases. It is concluded that irradiation is a simple effective method of treatment for this form of melanoma.

The quality of life of patients following treatment for laryngeal cancer.

One hundred and twenty-nine patients have been interviewed 9 to 15 months following treatment for laryngeal cancer to determine the post treatment quality of voice and life. The patients were subdivided into 3 groups, successfully irradiated T1 and T2 patients, (89 patients), successfully irradiated T3 and T4 patients (24 patients) and those treated by surgery (16 patients). Ninety-three percent of T1 and T2 patients and 79% of T3 and T4 patients are working following treatment as compared to 44% of the surgery patients. Ninety-eight percent of the T1 and T2 and 87.5% of the T3 and T4 patients were able to use the telephone normally as compared to 12% of the surgery patients. Similarly major differences between the successfully irradiated patients and the surgically treated patients in terms of ability to live a normal social life have been noted. The patients also rated their voice in terms of volume, pitch, ability to communicate, quality, rate of speech, flow of speech and dry throat. In every parameter of rating of the voice, with the exception of dryness of the throat, the successfully irradiated patients in all stage groupings had better ratings than the surgery group. Since, in Toronto, survival in advanced glottic and supraglottic cancer is the same using radical radiation with surgery in reserve as survival with primary surgery, it is concluded in view of the superior quality of voice and life in the successfully irradiated patients that irradiation with surgery in reserve is the optimal treatment for these patients. We also conclude that the measurement of quality of life in patients with cancer of the larynx is of vital importance in determining optimal treatment and that further studies in this area are indicated.

Radiotherapy for mucosal melanomas.

Twelve patients who were primarily irradiated at the Princess Margaret Hospital (PMH) for mucosal melanomas of the head and neck and 6 patients irradiated for mucosal melanomas of the vagina and anorectal region are reported. The PMH results of irradiation of mucosal melanomas of the head and neck are combined with the literature results for this type of melanoma. A total of 24 patients who had 25 areas irradiated are considered. The complete remission rate locally is 72% (18 of 25 areas treated). Seven of the 18 patients who achieved complete local remission subsequently relapsed locally (9 to 144 months post treatment); 11 are in maintained complete local remission (9 to 54 months). Four died of intercurrent disease without melanoma, 5 are alive and well post irradiation, one recurred regionally and was salvaged surgically and one died of distant metastases without local or regional relapse. Only 1 of 7 patients who failed to respond to irradiation was salvaged with subsequent surgery, the others all died very rapidly following unsuccessful irradiation. Analysis of local control versus fraction size revealed that 6 of 7 patients treated with a fraction size of 400 rad or more achieved complete remission as compared to 5 of 18 treated with a fraction size of 399 rad or less. The results of primary irradiation for mucosal melanomas of the head and neck are compared with the literature on radical surgery, it is concluded that in view of the poor results of radical surgery that large dose per fraction irradiation should be seriously considered as the initial treatment of choice for primary mucosal melanomas of the head and neck. Four patients with vaginal melanomas were treated at the PMH, all achieved complete remission locally, 2 recurred at 18 and 28 months, one is alive and well at 3 years and one died of intercurrent disease at 1 1/2 years. Two patients with anorectal melanoma had transient palliative benefit from irradiation. Since the treatment of both vaginal and thick (greater than 2 mm) anorectal melanoma is essentially palliative it is suggested that irradiation should be considered as an alternate treatment to radical treatment in these conditions.

Radiotherapy of Kaposi's sarcoma.

Between 1958 and 1983, 91 patients with Kaposi's sarcoma were referred to the Princess Margaret Hospital. Eight patients received no specific therapy immediately following their first assessment. Twenty-seven patients were treated by local field radiotherapy, of whom 17 entered complete remission and 6 have remained relapse-free. Fifty-six patients received extended field radiotherapy, usually a single fraction of 8 Gy megavoltage gamma-ray or photon therapy; 38 achieved completed remission, and 24 have remained relapse-free for a median duration of 3 years. The actuarial relapse-free survival for patients treated by local versus extended field radiotherapy significantly favors the extended field technique although the rates of relapse after complete remission has been achieved appear similar. Immunosuppression was present in 12 patients prior to the diagnosis of Kaposi's sarcoma; these patients had a similar response rate to radiation therapy to those who were not known to be immunosuppressed. A rationale for management, and radiation technique and dose are discussed. It is concluded that radiotherapy is an effective treatment for most forms of Kaposi's sarcoma.

Postoperative local abdominal irradiation for cancer of the colon above the peritoneal reflection.

A retrospective analysis of 82 patients with cancer of the colon above the peritoneal reflection who received postoperative local abdominal irradiation was undertaken to assess the survival, patterns of failure, and toxicity of treatment. Forty-eight patients (adjuvant group) had a complete resection, but were felt to be at high risk for local relapse and received postoperative local abdominal irradiation. Thirty-four patients had gross residual disease following surgery. The 5-year actuarial survival and local relapse free survival were 67 and 67%, respectively, in the adjuvant group. In this group, local relapse was observed in 9 of 28 patients with Stage C disease in contrast to 3 of 20 patients with Stage B2 disease; 1 of 14 patients with lesions in the right colon failed locally compared to 11 of 35 patients with lesions in the left. Only 2 of the 34 patients with gross residual disease remained relapse free from 93% of patients having a component of local failure. The majority of the treatment morbidity was seen in patients with gross residual disease. Prospective randomized studies should be done to determine the efficacy of postoperative irradiation in patients with colon carcinoma who are at high risk for local recurrence following surgical resection.

Carcinoma of the tonsil: the effect of dose-time-volume factors on local control.

Between 1970 and 1979, 372 patients with squamous cell carcinoma of the tonsil were treated with primary irradiation therapy, with salvage surgery for failures. The median age was 60 years and the male to female ratio was 2:1. The staging system used was the 1974 UICC TNM system. There were 47 T1 lesions (13%), 161 T2 lesions (43%), and 164 T3 lesions (44%). Regional nodes were not palpable in 173 (46%); 122 had N1 nodes (33%), 6 had N2 nodes (2%) and 71 had N3 nodes (19%). All patients received external beam radiation which was supplemented in 68 patients with a radioactive implant for disease into adjacent tongue. The overall survival for all patients was 38% at 5 years and 54% when corrected for intercurrent disease. Local control was 87% for T1 lesions, 68% for T2 lesions and 50% for T3 lesions. Regional control was 96% for N0, 67% for N1 and 37% for N2-3. A detailed dose-time-volume analysis revealed that increasing volume improved local control in T1 and T2 lesions (77% had local control if the volume was greater than 80 cm2 versus 53% if the volume was less than 80 cm2, p = 0.014), except for T3 lesions. Increasing the dose in the range of 5000 to 6500 rad had no significant effect on primary control in any stage of disease. The addition of a radioactive implant did not increase local control if disease extended into the tongue (57% local control if implant, 52% if no implant). This study demonstrates the significance of adequate treatment volume in local control for carcinoma of the tonsil. No significant dose response was found and subsequent surgery was not compromised when a moderate dose of radiation was used.

Ewing's sarcoma: a trial of adjuvant chemotherapy and sequential half-body irradiation.

The results of a pilot study using adjuvant chemotherapy and sequential half-body irradiation (HBI) for nonmetastatic Ewing's sarcoma are presented. Seventeen patients received Cyclophosphamide, Vincristine, and Adriamycin (8 cycles), followed by sequential radiation treatment of the upper (500 cGy) and lower (600 cGy) half body. Survival at 3 years was 49%. These results are contrasted with those for 18 concurrently treated patients who received standard adjuvant therapy. Overall 5-year survival and relapse-free survival for these 35 consecutive patients was 61 and 53%. The pilot protocol was given on an out-patient basis with limited and acceptable acute toxicology. Further study is necessary to determine the value of the pilot protocol.

Supraglottic laryngeal carcinoma: an analysis of dose-time-volume factors in 410 patients.

Four hundred and ten patients with supraglottic laryngeal carcinoma treated with moderate dose radical radiotherapy with surgery for salvage (RRSS) were analyzed in detail to determine optimal dose-time-volume parameters to be used in the treatment of each stage of supraglottic carcinoma. In the RRSS group 41% are alive and well at 5 years, 38% died of their tumor and 21% of intercurrent disease. Presence or absence of nodal disease has a major impact on survival. Local control is approximately 70% in T1, T2N0 patients and approximately 50% in T3 and T4N0 patients. Seventeen percent of T1 and T2N0 patients failed in the initially negative neck. Ten major complications (2.4%) have been seen. Local control by irradiation was not influenced by dose or field size. Regional control in the initially negative neck was markedly increased with the use of larger irradiation field sizes. Field sizes of less than 7 X 7 cm resulted in an 18% neck failure rate as compared to 3% with larger field sizes (p = 0.00005). This particularly applied to early stage disease. As a result of the use of larger irradiation field sizes giving reduced neck failure rates, improvement in survival has been seen in early stage supraglottic patients. The results are compared with published results. There is no statistically significant dose response curve in any stage of supraglottic cancer over the dose range 1650-2300 ret. Optimal treatment factors for supraglottic cancer are discussed.

Carcinoma of the hypopharynx results of primary radical radiation therapy.

The results of radiation therapy as applied to patients with squamous cell carcinoma of the hypopharynx seen during the period 1972-1976 at the Princess Margaret Hospital are presented. Approximately 2/3 of the patient population presented with disease involving the regional lymph nodes or with systemic metastases. Ninety percent (127/141) of all patients registered were treated primarily with radiation therapy with surgery reserved for the management of residual or recurrent disease only. Seventy-seven percent (98/127) of those who received radiation therapy were treated with radical intent. The uncorrected actuarial 5 year survival rate for those patients treated radically was 19%. Five year actuarial survival rates by the UICC TNM (1974) staging system, showed that nodal disease was the most significant determinant of survival. Five year survival rates were as follows: N0 36%; N1 20%; N2N30%. When considered within each nodal category the survival of the combined T1T2 group was not significantly different from the T3 category. Forty-five percent of those patients who failed with local or regional disease had an attempt at salvage surgery. Of these, 6/24 ultimately achieved local and regional control. Comparisons with other series in the literature are discussed and reasons for differences in published results are considered.

Results of radical radiation for chondrosarcoma of bone.

A retrospective analysis has been made of 38 radically treated patients with chondrosarcoma of bone treated with irradiation alone or with concurrent chemotherapy (nine patients) at the Princess Margaret Hospital (P.M.H.) between 1958 and 1981. This includes updated data on previously reported patients. No patient had complete surgery. Tumours in axial sites (25/38 patients) and presenting with pain (25/38 patients) predominate; both well known poor prognostic factors. There is also a greater proportion with unfavourable histology (mesenchymal, poorly differentiated, dedifferentiated) (13/38 patients) compared to other series. The 5 and 10 year actuarial survival rate was 41% and 36% respectively with a median survival of 46 months. The best results were obtained in the group with favourable histology (well and moderately differentiated) with 48% 5 year actuarial survival versus 22% in the unfavourable subgroup. The progression-free survival of the favourable group was 13/25 patients versus 2/13 for the unfavourable group (p less than 0.01). Distant metastasis were rare in the patients with favourable histology (1/24) compared to 5/13 of the unfavourable group. Nine patients were given concurrent chemotherapy and irradiation. To date, only 1/7 patients with favourable histology and combined treatment have had progressive disease (follow-up 8-83 months). Only two patients with unfavourable histology received combined chemotherapy and irradiation and both have relapsed. In conclusion, there is evidence to suggest chondrosarcoma is not radioresistant and irradiation should be considered when surgery would cause major unacceptable morbidity or be technically impossible. Early evidence suggests there may be a role for chemotherapy to supplement the effects of irradiation.

Total abdominal irradiation for cancer of the colon.

A retrospective analysis of 55 patients treated with whole abdominal irradiation following surgical excision for cancer of the colon is presented. Three groups of patients were given whole abdominal irradiation, eight with gross residual tumor following surgery, 17 with peritoneal seeding, and 30 who had complete surgical excision of the tumor but were felt to be at high risk for relapse. Only one of the eight patients with gross residual tumor, and one of the 17 with peritoneal metastases, are currently alive and well, with the majority dying from local or peritoneal metastases. The 5 year actuarial survival for the 30 patients irradiated following complete surgical excision is 55%. The treatment was well tolerated and few complications were observed. It is concluded that whole abdominal irradiation is ineffective for the treatment of colon cancer if peritoneal metastases are present, or if gross residual tumor is left behind following surgery. A randomized controlled clinical trial is being organized to test whether total abdominal irradiation is of benefit in terms of survival in high risk colon cancer patients following complete surgical removal.

Radical radiation therapy with 5-fluorouracil infusion and mitomycin C for oesophageal squamous carcinoma.

Thirty-five patients with clinically staged non-metastatic squamous carcinoma of the oesophagus were treated with radiation combined with mitomycin C, and 5-fluorouracil (5-FUra) infusion. Twenty patients were planned for a split course regimen 2250-2500 cGy in 10 fractions and chemotherapy. This dose of radiation to be repeated with another course of chemotherapy after 4 weeks rest. Fifteen patients were planned for a single course 4500-5000 cGy in 20 fractions and a single course of chemotherapy. Thirty-one patients are available for a minimum follow-up of one year, 26 patients for a minimum follow-up of 2 years. All 35 patients are included in the survival and local relapse-free analysis. Survival at one year is 47% and at 2 years 28%. The local relapse-free rate at both one and 2 years is 48%. There was an improvement in survival and local relapse-free rate for the single course regimen compared to the split course; 2 years survival 48% versus 12% (p = 0.24) local relapse-free rate 79% versus 27% (p = 0.07). All patients receiving radiation and chemotherapy were compared with historical controls treated by radiation alone. This matching procedure was done independent of knowledge of outcome (two controls were matched/case). Patients were matched for age, sex. TNM stage, and total radiation dose. There was a significant difference in survival p = 0.004 and local relapse-free rate p = 0.05 for patients receiving radiation and chemotherapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Radiation therapy for melanomas of the head and neck.

This report reviews experience with radiation therapy in 77 patients with melanoma of the head and neck, a lesion traditionally but incorrectly considered to be radiation-resistant. Thirteen patients with lentigo malignum and 18 patients with lentigo malignum melanoma have been primarily irradiated. In 11 of the 13 patients, the lentigo malignum has been locally controlled with no recurrence from 6 months to 5 years following treatment. One patient had a local recurrence and was salvaged with further radiation therapy, and one patient had residual tumor after irradiation and was salvaged with simple excision. Seventeen of 18 patients primarily irradiated had lentigo malignum melanomas that have been locally controlled from 6 months to 6 years after irradiation. One patient had a local recurrence and was salvaged by excisional surgery. There have been no deaths from lentigenous melanoma, and the cosmetic results of treatment are excellent. We concluded that radiation therapy is a simple, effective out-patient treatment for lentigo maligna and lentigo maligna melanoma. Nonlentigenous melanoma was irradiated after incisional biopsy in 6 patients; local control was obtained in 4 patients although 1 died of distant metastases. Fifteen patients were irradiated after excisional biopsy (margins inadequate); 14 of 15 had local control although 6 died of metastases. Only 2 of 16 patients irradiated for recurrent melanoma were controlled. Analysis of local control versus irradiation fraction size revealed that 17/24 (71%) achieved local control with a dose per fraction of greater than 400 rad as compared with 3 of 12 (25%) in those being irradiated with a dose of less than 400 rad per fraction. We concluded that nonlentigenous melanoma is not radiation resistant and that local excision followed by radiation therapy with a large dose per fraction deserves further study, particularly in melanomas of the head and neck where wide local excision is not possible due to age of the patient or location of the tumor. Nine mucosal melanomas have primarily irradiated and four have been locally controlled.

Verrucous carcinoma (Ackerman's tumor) of the larynx: diagnostic and therapeutic considerations.

Verrucous carcinoma (Ackerman's tumor) is a low-grade malignant lesion with distinct clinical and pathologic features, distinguishing it from other well-differentiated squamous cell carcinomas. Much of the confusion surrounding its natural history, response to therapy, and anaplastic transformation may be ascribed to the failure of critically reviewing accepted diagnostic criteria. A series of 44 patients with verrucous carcinoma of the larynx is presented, 18 of these being updated results of previously reported patients. Ackerman's tumor, although not radioresistant, seems less radiosensitive than ordinary squamous cell carcinoma. The tumor's rounded, pushing margins and inability to metastasize would seem to favor endoscopic removal, saving partial laryngectomy procedures for those lesions that cannot be managed endoscopically. Extensive lesions that would require total laryngectomy for complete removal of the tumor should be treated by primary radiotherapy. It is our belief that total laryngectomy should only be performed in large lesions that fail to respond to radiotherapy and whenever medical considerations preclude partial laryngectomy procedures.

Kaposi's sarcoma. An update on the results of extended field radiotherapy.

This report reviews the results of extended field radiotherapy (EFR) in the treatment of Kaposi's sarcoma. During the 22-year period that is under study, 54 patients with Kaposi's sarcoma were seen and 38 were treated with EFR. Thirty patients had spontaneous Kaposi's sarcoma and eight had received immunosuppressive therapy. Extended field radiotherapy is compared with both local methods of radiation and chemotherapy in the treatment of Kaposi's sarcoma. It was concluded that EFR is the treatment of choice because of its simplicity, high disease-control rate, and lack of complications in patients without systemic disease manifestations.

Cancer of the tonsil: results of radical radiation therapy with surgery in reserve.

Three hundred seventy-two patients with squamous cell carcinoma of the tonsil were treated with primary irradiation of curative intent. Surgery was saved for subsequent treatment failure. The overall survival was 38 percent at 5 years. Local control was 63 percent for all patients. T1 and T2 lesions were controlled in 87 percent and 68 percent of patients, respectively, and T3 lesions were controlled in 50 percent of patients. Patients with healthy (N0) nodes and those with mobile nodes had a high degree of regional control, but fixed nodes were controlled in only 37 percent of patients with radiation alone. The most common site of treatment failure was in the primary tumor, which accounted for 45 percent of relapses, and isolated nodal relapses were present in only 24 percent of patients. Subsequent surgery was possible in 47 percent of patients in whom initial treatment failed. A higher degree of subsequent control was obtained with more aggressive surgery compared with simple local resection. There was a high rate of second respiratory tract malignancy, in fact, after 2 years, patients were dying more commonly of their second respiratory tract malignancies than of cancer of the tonsil.

Histopathological study of radionecrosis in laryngeal carcinoma.

With modern radiotherapy techniques, clinical radionecrosis is uncommon following eradication of primary squamous cell carcinoma from the larynx. Histologic sections from 265 specimens, prepared by the technique of whole organ subserial step-sectioning were studied to determine the incidence and location of chondronecrosis and/or osteomyelitis in both irradiated and non-irradiated cases. Chondronecrosis occurred in only 1 of 41 early (pT1 - pT2) tumors but in 143 advanced tumors (pT - pT4) treated with radical radiotherapy and containing residual carcinoma, 27% had evidence of significant necrosis, compared with 24% of those not irradiated. Age, sex, tumor grade and previous laryngeal surgery did not appear to be significant factors in the development of necrosis in irradiated patients. The arytenoid cartilage was most frequently involved when chondronecrosis occurred in association with radiotherapy. Six total laryngectomy specimens (3%) were received from patients with symptoms of chondronecrosis and in whom no residual tumor was present. We conclude that although the incidence of clinical perichondritis is low, histologic chondronecrosis and/or osteomyelitis occurred in 26% of all the larynges studied. Radiotherapy appears to be a significant causative factor only in advanced supraglottic tumors.

Radiotherapy of early glottic cancer.

Patients (383) with stage Tis, Tla and Tlb NoMo glottic cancer are reviewed. Radiotherapy cured 93% of Tis patients and 86% of Tla and Tlb cases. Of all recurrences, 63% were cured. No patient with stage Tis died as a result of tumor and only 5% of stage Tla and Tlb died from tumor. Involvement of the anterior commissure or both vocal cords did not influence control rates by radiotherapy. Mobility of the vocal cord and size of radiotherapy field were significant factors influencing control by radiotherapy. Late recurrences and/or second primaries in the larynx following radiotherapy are rare. Second primaries in the respiratory tract (especially lung) are common and are as important a cause of death as laryngeal cancer in T1 cases. It is concluded that moderate dose radiotherapy with surgery for salvage is a highly effective method of management for early glottic cancer.

Prognostic significance of thyroid gland involvement in laryngeal carcinoma.

We reviewed 173 laryngeal specimens that included thyroid tissue received from patients undergoing laryngectomy between 1966 and 1980 for evidence of thyroid gland invasion. Twenty-three (14%) of the larynges demonstrated thyroid involvement. In 15 specimens, involvement of the thyroid gland was by direct extension, and in eight the thyroid was involved metastatically. The survival in this group of patients was poor, with 18 patients dying of their disease within three years. Subglottic extension of 10 mm or greater was noted in 21 of 23 patients, and local recurrence was noted in 15 of 18 patients dying of their disease. The importance of removing one or both lobes of the thyroid gland in advanced laryngeal cancer is restated, and a surgically aggressive approach to the paratracheal nodes is recommended in patients with extensive subglottic involvement.