Nursing care of the patient receiving high dose rate brachytherapy.

Over the past few decades, a significant increase in the incidence of lung cancer has occurred. In the majority of patients, the failure to cure lung cancer is related in part to an inability to obtain locoregional control of the disease. Remote afterloading high dose rate (HDR) brachytherapy has tremendous potential as a way to increase treatment to the primary site of lung cancer and to improve palliative management of recurrent disease when conventional treatments have failed. Because remote afterloading is used, the medical staff is not exposed to ionizing radiation, and since the duration of treatment is short, HDR brachytherapy is convenient for the patient and can be delivered on an outpatient basis. Fifty-two patients were treated endobronchially for carcinoma of the lung at Parkview Regional Oncology Center in Fort Wayne, IN, between May 1, 1988, and September 1, 1990. Nursing care during treatment and recovery of these patients will be discussed in this paper.

Unresectable non-oat cell carcinoma of the lung: definitive radiation therapy.

Between 1976 and 1983, 267 patients with non-oat cell carcinoma of the lung were treated with radiation therapy alone. One hundred thirty-four patients had squamous cell carcinoma; 69, large cell carcinoma; and 64, adenocarcinoma. Stage III carcinoma was diagnosed in 87% of the patients. Total radiation dose was less than 45 Gy in 69 patients (low dose group), 45-55 Gy in 161 (middle dose group), and 55-65 Gy in 37 (high dose group); dosage was 180-200 cGy daily, 5 days per week. Minimum follow-up was 3 years (median, 6 years). Tumor control within the radiation fields was achieved in 12%, 43%, and 78% of the low, middle, and high dose groups, respectively. A complete response rate of 13%, 23%, and 35% and an overall response of 43%, 71%, and 86% were seen in the low, middle, and high dose groups, respectively. The 5-year recurrence-free survival rate for all patients was 7% and was dependent on radiation dose and tumor response. This study indicates that tumor control and complete response rates are improved with a radiation dose of 55-65 Gy and that complete responders have improved survival.

Radiation therapy for nonsquamous tumors of the head and neck.

Recent advances in the understanding of the natural history and modes of spread of the nonsquamous malignancies of the head and neck region have delineated an important role for radiotherapy in their management. The indications for primary radiotherapy include malignant lymphoma of the thyroid, idiopathic midline granuloma, midline malignant reticulosis, extramedullary plasmacytomas, esthesioneuroblastomas, and locally aggressive benign tumors, such as glomus tumors, angiofibromas, and hemangiomas. Although the traditional treatment for malignant melanoma is surgery, indications are emerging for high-dose radiotherapy, either as the only modality or in addition to surgery. Combined radiotherapy and chemotherapy is the treatment choice for nonHodgkin's lymphomas of the Waldeyer's ring and for Ewing's sarcomas. High-grade soft tissue sarcomas and salivary gland malignancies are best treated with surgery and postoperative radiotherapy. The use of megavoltage photons and electrons, custom-made blocks delineating the treatment volume, tissue compensators, patient immobilization devices, and simulator-aided treatment planning are mandatory to achieve loco-regional control and to minimize the treatment-related morbidity.

Limb salvage in extremity soft-tissue sarcoma: combined modality therapy.

Thirty-two consecutive patients with high-grade soft-tissue sarcoma of an extremity were treated preoperatively with concomitant intra-arterial infusion of Adriamycin (doxorubicin) (10 mg/m2 daily for 10 days) and radiotherapy (2500 rad [25 Gy] in 10 fractions in 2 weeks). En bloc resection was then performed. Postoperatively, depending on the surgical specimen findings, radiotherapy was given to a dose ranging from 5000 rad (50 Gy) in 5 weeks to 6000 rad (60 Gy) in 6 weeks equivalent continuous schedules. No residual tumor was found in 28% of the surgical specimens and only minimal tumor in 41%. A functionally intact limb was preserved in 30 patients (94%). Local recurrence developed in one patient (3%). The actuarial overall survival at three years was 70% and disease-free survival 57%.

Preirradiation chemotherapy for advanced head and neck carcinomas.

Twenty-six patients with locally advanced squamous cell carcinoma of the head and neck region were treated with combination chemotherapy (cisplatin, bleomycin sulfate, and vincristine sulfate) prior to radiotherapy (RT). The chemotherapy produced a 65% major response rate, all partial responses. Significant hematologic toxic effects occurred in only two patients and severe renal toxic effects were not seen. Concurrently, 20 additional patients with locally advanced cancers were treated with high-dose RT along. Weight loss at the completion of RT and normal tissue reactions were similar in both groups. Complete tumor resolution occurred in 45% of RT-alone patients and 42% of patients completing combined-modality therapy. No difference in recurrence-free survival was seen. Despite minimal additional morbidity and a high response rate, this preirradiation chemotherapy regimen demonstrated no major impact on complete response rate or on long-term recurrence-free survival.

Patterns of cancer recurrence in the postoperatively irradiated neck.

Data from 92 patients with stage III or IV squamous cell carcinoma of the head and neck treated with surgery and planned postoperative radiotherapy were analyzed to determine the incidence and patterns of tumor recurrence. Overall, recurrent tumor in the cervical region developed in 19 patients (21%). Of these, eight were in the neck alone and 11 in both the neck and the primary site. All recurrences were in the ipsilateral cervical region and none in the contralateral neck. The presence of two or more metastatic nodes at the time of surgery correlated with tumor recurrence and decreased survival. Extracapsular tumor spread increased the recurrence rate. Our data suggest that postoperative radiotherapy decreases ipsilateral cervical tumor recurrence in only those patients with more than two metastatic lymph nodes, and contralateral neck recurrence in all patients.

Cancer of the glottis: prognostic factors in radiation therapy.

The authors conducted a multivariate analysis of the prognostic factors in 96 patients with early glottic cancer treated by radiation therapy. Of these, 73 had T1 and 23 had T2 tumor. The primary tumor was controlled in 82% of T1 and 74% of T2 lesions. Actuarial five-year survival rates were 87% for T1 and 74% for T2. Carcinoma of the anterior commissure associated with bilateral vocal cord involvement, subglottic tumor extension, persistent or recurrent laryngeal edema, and impaired cord mobility was found to adversely influence the prognosis. The data suggest that irradiation is the treatment of choice for glottic cancer limited to the vocal cords or with minimal extension to the anterior commissure or supraglottic larynx.

Postoperative radiotherapy for persistent tumor at the surgical margin in head and neck cancers.

Seventy-two patients with a carcinoma of the head and neck, who were treated with surgery and postoperative irradiation, were reviewed to determine the local recurrence rates and survival in patients with inadequate surgical margins. Tumor recurrence rate was 31% for patients with microscopic tumors at resection margins and 50% for those with macroscopic tumor. Actuarial 3-year survival for these patients was 71% and 43%, respectively. All 4 patients who were irradiated later than 6 weeks after surgery developed recurrent malignancy despite the resection margins being free of tumor. Excluding these patients the 3-year survival for R0 patients was similar to that of R1 patients. It is concluded that postoperative irradiation is effective in patients with tumor at the surgical margins. It is suggested that the time interval between surgery and radiation therapy be limited to less than 6 weeks. Radiation dose prescriptions for various clinical situations are discussed.

Work in progress: intra-arterial P-32 chromic phosphate for prevention of postoperative liver metastases in high-risk colorectal cancer patients.

Eight patients with locally extensive colorectal cancer were treated with colloidal P-32 chromic phosphate via the superior mesenteric artery following resection to prevent development of liver metastases. Less than 2% of the injected dose was found in the right atrial blood following the first pass through the liver and less than 1% in the urine. Therapy was tolerated well by all patients, with no acute complications. Long-term follow-up is needed to determine the effect of P-32 on the liver and the frequency of hepatic metastases.

Carcinoma of the esophagus: sites of failure.

A clinico-pathologic study of 173 patients with esophageal cancer was done. The median survival for all patients was 6.4 months. Persistent tumor in esophagus at the time of death was present in 78% of patients treated with radiation alone. Metastases to mediastinal, intraabdominal and supraclavicular nodes were found in 73%, 49% and 20% of patients respectively. Systemic metastases were found in 57% of patients, liver being the most common site. In 15% of patients, fistulae developed between esophagus and trachea or bronchus because of direct extension of the primary tumor. Local and regional tumor caused the death of 111 patients, whereas distant metastases led to death in only 27 patients. This study confirms the extensive intra- and extrathoracic spread of malignancy in a majority of patients with cancer of the esophagus.

Brain stem gliomas: an autopsy study of 25 cases.

The study analyzed the extent of tumor at autopsy in 25 patients with a brainstem glioma. Primary tumor in the pons comprised the majority of cases, followed by medulla and midbrain. Histologically, 48% of the tumors were glioblastoma multiforme. The tumor spread was found to be dependent on the site of origin and the grade. Pontine tumors involved the adjacent structures more extensively than the tumors of midbrain and medulla. Contiguous cephalad and caudad involvement was frequent with Grade III and Grade IV tumors. The extent of meningeal involvement was limited to those surrounding the main tumor mass. It is concluded that in the treatment of brainstem gliomas, irradiation through fields limited to the brainstem, adjoining temporal lobes, cerebellum, and proximal spinal cord would be adequate.

Complications of postoperative and preoperative radiation therapy in head and neck cancers. A comparative study.

The complications of planned postoperative irradiation in 60 consecutive patients treated between 1975 and 1979 are compared with those seen in 92 patients treated with preoperative irradiation between 1968 and 1974. The overall rate of complications requiring additional hospitalization was 15% (nine patients) in the postoperative radiotherapy group as compared with 54% (50 patients) in the preoperative radiotherapy group. A statistically significant increase in acute complications was noted in the latter group (46 vs three, 50% vs 5%). Delayed complications occurred with similar frequency in both groups. The three-year survival was comparable between similar patients of each group treated with either of the two modalities. We favor postoperative irradiation because of decreased acute complications and comparable survival. Modifications of the treatment technique are suggested to minimize the overall rate of complications.

Thyroid carcinoma.

Differentiated thyroid carcinoma was studied with regard to mode of presentation, initial findings, treatment and survival. The classic signs, symptoms, physical and scan findings were found to be present in approximately 70% of the patients. Thirty percent of the patients had either unusual presentations or findings. Prognosis was found to be dependent on age of presentation more than any other factor. The effects of neck metastasis, extracapsular invasion and recurrent laryngeal nerve involvement on long-term survival are studied in detail. patients with prior exposure to radiation were found to have more extensive disease and require more extensive surgery but ultimately had the same prognosis for 15-year cure. Treatment for distant metastatic disease by surgery, radioactive iodine and external radiation all resulted in long-term survival in certain cases.

An analysis of factors in the successful management of cancer of tonsillar region.

A total of 117 consecutive primary cancers of the tonsillar region was irradiated at the University of Illinois Hospitals from 1955 to 1973. Results with 94 patients treated with radiotherapy alone and 23 with a combination of surgery and radiotherapy were analyzed. The modalities of radiation used were electron beam, 22 meV photons and Cobalt-60. Lymph node metastases were noted in 70% of the patients at the initial examination. In patients treated with radiation alone the determinant 5-year survivals were 42% without and 20% with nodal involvement. In the absence of node disease, survivals were 100% in T1, 60% in T2, 37.5% in T3 and 25% in T4 lesions. The significance of age, sex, histological differentiation, extent of the tumor, modality of treatment and the incidence of second primary were analyzed. Time dose relationships and factors influencing the prognosis are discussed and the literature is reviewed.