Combined laser therapy and endobronchial radiotherapy for unresectable lung carcinoma with bronchial obstruction.

Over a 4 year period, we refined a protocol for treatment of airway obstruction due to recurrent lung carcinoma. Patients undergo bronchoscopy with the Nd:YAG laser available on standby. If bronchial obstruction is found to be due to extrinsic compression, an endobronchial catheter is inserted for iridium 192 brachytherapy, treating a cylindrical volume 7.5 to 15 mm in radius. If an endobronchial lesion is found, the presence of complete versus partial bronchial obstruction determines the course of treatment. Total airway obstruction is treated with the laser until a channel is created and then an endobronchial catheter is placed for adjuvant endobronchial radiotherapy to treat a cylindrical volume 5 mm in radius. Partial airway obstruction is treated with an endobronchial catheter and radiotherapy alone. Segmental obstruction is also treated with a distally placed endobronchial catheter instead of the laser. Using this protocol, we hope to minimize risk to the patient by restricting the use of the laser with its inherent higher potential rate of complications to cases of total obstruction. In addition, we expect to prolong the duration of palliation with endobronchial radiotherapy. The laser is an excellent tool to reopen occluded bronchi, but it is relatively ineffective in producing long-term tumor control. Instead, we have found that placement of a temporary transtracheal endobronchial catheter for radiotherapy is a simple, low-risk procedure that can be safely performed even in critically ill patients. The endobronchial catheter can provide good to excellent long-term palliation for patients with both partially and totally obstructed endobronchial lesions or malignant extrinsic compression of major airways.

Impact of adjuvant chemotherapy on cosmesis and complications in stages I and II carcinoma of the breast treated by biopsy and radiation therapy.

Cosmesis and complication rates were examined in patients with early stage carcinoma of the breast treated by biopsy and radiation therapy with and without adjuvant chemotherapy in an attempt to determine the effect of chemotherapy upon these parameters. Between April 1, 1975 and June 1, 1980, 51 patients were treated with radiation therapy and adjuvant chemotherapy (XRT + ACT) and 83 patients with radiotherapy alone (XRT). Chemotherapy usually consisted of cytoxan, methotrexate and 5-fluorouracil for 6 or 12 cycles. Minimum follow-up was 36 months. Cosmetic results deteriorated with time in both groups but to a greater extent in the XRT + ACT group. At 36 months, excellent cosmetic results were obtained in 73 of the 83 patients (88%) in the XRT group compared to 37 of 51 patients (73%) in the XRT + ACT group (p = less than .05). Comparison of the two treatment groups revealed that complication rates were significantly increased in the XRT + ACT group. Of the 51 patients in the XRT + ACT group, 21 patients (41%) suffered complications compared to 8 (10%) of the 83 patients in the XRT group (p = less than .001). This difference in complication rates resulted primarily from an increased incidence in the XRT + ACT group of wet desquamation in the electron beam portal used to treat the internal mammary lymph nodes and a trend towards a higher incidence of spontaneous nonpathologic rib fractures, myositis and arm edema. An increased incidence of nonbreast primary cancers was not seen. Our preliminary conclusions are that adjuvant chemotherapy has a negative impact upon cosmesis and complication rates in patients being treated with definitive radiotherapy. However, cosmetic results remain satisfactory and complication rates are maintained at an acceptable level. Continued close follow-up will be required before definitive conclusions can be reached as to the overall incidence and severity of the changes noted.

Biopsy and definitive radiation therapy in Stage I and II adenocarcinoma of the female breast: analysis of cosmesis and the role of electron beam supplementation.

The cosmetic and functional outcome in 130 patients with Stages I and II carcinoma of the breast treated by biopsy and radiation therapy were evaluated. The cosmetic outcome was excellent in 107 patients (82%), acceptable in 17 patients (13%), and unacceptable in six patients (5%). Complete axillary dissection (CAD) was more morbid than limited axillary dissection (LAD) as a means of preradiotherapy staging of the axilla. The former was more often associated with breast edema, hematoma formation, and subsequent development of arm edema than the latter. A multivariate analysis revealed that the four most dominant variables associated with the attainment of an excellent cosmetic outcome were: 1) the performance of a conservative biopsy procedure; 2) small breast size (cup size A and B); 3) the use of electron energies equal to or less than 12 MeV; and 4) the presence of primary tumors less than or equal to 4 cm in diameter when adjusted for breast size. Postexternal beam supplementation to the area of the primary tumor was accomplished with electrons in 107 patients (82%) and with interstitial implantation in 23 patients (18%). Excellent cosmetic results were achieved in 97 of the 107 patients (91%) treated with electrons. The use of electrons appears to produce local control and cosmesis equal to that of interstitial implantation if specific indications and guidelines are followed, and is superior to implantation in certain clinical settings.

Biopsy and definitive radiation therapy in stages I and II carcinoma of the female breast.

One hundred-twenty patients with Stages I and II carcinoma of the female breast were treated by biopsy followed by definitive radiation therapy without mastectomy. The breast received 4500-5000 cGy (rad) using a 6 MV linear accelerator followed by a supplement to the area of the primary tumor of 2000 cGy (rad) using electrons in 99 patients (83%) and interstitial implantation in 21 patients (17%). Local recurrence was not recorded in the 43 patients with Stage I disease, while three of 77 patients (4%) with Stage II disease suffered a local recurrence. The actuarial five-year relapse-free survival was 91% and 60% in Stages I and II respectively. Cosmetic results were considered excellent by both physician and patient in the majority of cases. Axillary dissection was the recommended method of staging the axilla but was noted to be more morbid than axillary sampling. Electrons may be as effective as interstitial implantation as a means of supplementation following external beam therapy if specific guidelines are followed.