[Exclusive radiotherapy in stage III esophageal cancer]. / Radioterapia esclusiva nel cancro dell'esofago stadio III.

BACKGROUND: The purpose of the report is to evaluate the role of radiotherapy in the treatment of stage III esophageal carcinoma and to analyze the influence of site, extension, grade of dysphagia and histology on local control and survival. METHODS: Twenty males and 6 females were submitted to external beam therapy with 4-6 MV X-rays and received 60-70 Gy in fractions of 180 cGY to 200 cGy per day, 5 days a week. Radiation therapy technique was two posterior oblique portals and a single anterior field at 100 cm SAD. After 4500 cGy portals were coned down, holding the spinal cord dose below 4500 cGy. RESULTS: Global response to therapy was 73.1%. Median survival was 11 months. The 2-year survival rate was 12.5% in patients with lesions smaller than 5 cm and 5.5% for those with lesions greater than 5 cm. Patients with grade 2 dysphagia had a median survival of 16 months, those with grade 1, 11 months and 2 patients with grade 0, 4 and 9 months. In all patients mild to moderate esophagitis was observed. Two patients developed esophagotracheal fistula. CONCLUSIONS: Exclusively radiotherapy cannot be considered the treatment of choice in III stage patients. Primary chemoradiotherapy may emerge as the treatment of choice for cancer of the esophagus.

Brachytherapy for squamous cell carcinoma of the lip. The experience of the Institute of Radiology of the University of Rome "La Sapienza".

AIMS AND BACKGROUND: Cancer of the lip is the most common malignancy occurring in the oral cavity. The aim of our retrospective study was to review the results of patients with lower lip squamous cell carcinoma who were treated with radiotherapy. METHODS & STUDY DESIGN: From 1970 to 1992, 57 patients with squamous cell carcinoma of the lower lip were treated at the Institute of Radiology of the University of Rome "La Sapienza" with low-dose rate interstitial brachytherapy. According to the UICC 1992 TNM classification, the disease stage was T1 in 27 (47%) cases, T2 in 20 (35%) and T3 in 10 (18%); 8 patients (14%) were cN+. The median tumor dose was 62 Gy (range, 44-96): 10 patients (18%) received a total dose < 50 Gy, 28 (49%) between 50 and 70 Gy, and 19 (33%) > 70 Gy. The cN+ cases were irradiated to total doses of 65-70 Gy on the involved station. All patients obtained complete remission. RESULTS: The actuarial overall survival rates at 3, 5 and 10 years were 95%, 76% and 53%; actuarial disease-free survival at 3, 5 and 10 years was 84%, 81%, and 81%, respectively. Actuarial cause-specific survival was 98%, 88% and 84% at 3, 5 and 10 years, respectively. Actuarial local control rate was 90% at 3 and 5 years, rising to 94% with salvage surgery. Local-regional control was obtained in 90% and 86% of patients at 3 and 5 years, and in 93% and 89% of cases, respectively, following surgery. Five of 11 deaths were due to local-regional or distant disease recurrence. CONCLUSIONS: Tumor stage and positivity of regional nodes were the only predictive factors of survival and disease control. Radiation-induced morbidity was very low, and all patients considered their cosmetic outcome at least satisfactory.

Postoperative combined radiohyperthermia in Astler-Coller stages B2 and C distal rectal cancer.

Pelvic perineal recurrence rate is the major therapeutic problem after curative surgery of extraperithoneal rectal cancer, after lower anterior resection as well as abdomino-perineal resection: local failure rate is high, particularly for stages B2-C. Radiotherapy alone or in combination with chemotherapy proved to be an useful adjunct to surgery. Postoperative radiotherapy, with 40 to 50 Gy doses, has shown local improvement, but causing intestinal damaging. There is now evidence that hyperthermia enthances radiation effects, by killing radioresistant acid tumor cells. In order to give high postoperative radiation doses, without intestinal damage, and to kill acid tumor cells by hyperthermia, we developed a device, able both to displace intestinal loops and to produce combined hyperthermia. From 1993 to 1995, four patients with Astler-Coller stages B2 (2 patients), C1 (1 patient) and C2 (1 patient) distal cancer, were operated by Hartmann's procedure and treated with postoperative radio-hyperthermia with our device. Overall radiation dose delivered in the pelvic area was of 65 Gy, associated with three heating sessions at 43 degrees C for 30 minutes. Pelvic infection occurred in one patient; all pelvic byopsies were negative and no bowel damage was found. Three patients underwent recanalization, one had anasthomotic leackage. The C1 and C2 stage patients died from hepatic metastasis, 18 and 11 months after recanalization; one B2 stage patient is still under treatment and the other is alive and disease free 13 months after recanalization. Our technique allows to give high postoperative radiation doses, without small intestine damage, and to give a good hyperthermia for better control of local failure.

[Radiotherapy of bone tumors. Analysis of a historic series and review of the literature]. / La radioterapia dei tumori ossei. Analisi di una casistica storica e revisione della letteratura.

The authors report a series of patients with osteosarcoma or Ewing's sarcoma irradiated 1968-1988 at the Institute of Radiology of "La Sapienza" University, Rome. Twelve of 17 osteosarcoma patients (71%) died and 5 are alive, with a median survival of 13 months. Seven of 12 Ewing's sarcoma patients (58%) died and 5 are alive (42%), with a median survival of 67 months. These results are similar to those of most contemporary series in the literature; the long follow-up of our series allowed us to calculate actuarial survival rates at 5, 10 and 15 years of 41%, 34% and 17%, respectively, in osteosarcoma patients and 75%, 45% and 34% for those with Ewing's sarcoma. The review of the literature on the management of bone tumors high-lights the importance of new developments and technologies to improve the life expectancy of these patients. The authors discuss the role of modern imaging techniques in defining tumor margins and predicting treatment-induced tumor regression and the research into new therapeutic approaches. Multimodality combinations and new schedules appear promising tools to improve prognosis and to reduce side-effects, thus stressing the need of combined efforts of surgeons, radiotherapists and chemotherapists. State-of-the-art radiotherapy can further increase local control with higher total doses to the lesion and selectively sparing adjacent normal tissues, thanks to 3D treatment planning of hadron beam equipment.

[The esthetic results in patients undergoing postoperative radiotherapy in breast carcinoma]. / Risultati estetici nelle pazienti sottoposte a radioterapia postoperatoria nel carcinoma mammario.

INTRODUCTION: Early stage breast cancer (pT-T2, N0, N+, M0) is generally treated with conservative surgery followed by radiation therapy, which procedures yield similar results to radical surgery. We studied the effects of irradiation on residual breast parenchyma in patients submitted to quadrantectomy and complementary irradiation. MATERIAL AND METHODS: 331 patients (Stage T1, T2, N0, M0) submitted to quadrantectomy and axillary dissection 1980-1993, were examined. The tumor was localized in external quadrants in 257 cases and in internal ones in 74 cases. Radiotherapy was given with 4-6 MV photon beams produced by a linear accelerator; the total dose to the breast was 50 Gy with a 10 Gy boost to tumor bed. All the patients were submitted to follow-up mammography at 6 months, one and two years after the end of radiotherapy. Parenchymal density was evaluated on an arbitrary scale from 0 to 3. We also considered the following other parameters: skin thickness, calcifications, cysts and possible signs of recurrence. RESULTS: Trabecular patterns were unchanged in 41 patients (grade 0) and slightly changed in 67 (grade 1); 135 patients had grade 2 and 90 grade 3 changes. 254 patients had skin thickening. All the changes disappeared at 2-3 years' follow-up. The patients with bigger breasts had poorer cosmetic results. CONCLUSIONS: It is very important to assess irradiation-induced tissue changes to detect any early recurrence of breast carcinoma. All radiation-induced changes decrease over time, which confirms the good tolerance and the good cosmetic results of complementary irradiation for breast cancer

Radiotherapy for T1 carcinoma of the glottis.

AIMS AND BACKGROUND: The management of patients with T1 carcinoma of the glottic larynx is controversial, because surgery and radiation therapy are reported to be effective treatments. Several studies have shown radiotherapy to be safe and effective, with a high percentage of voice preservation and minimal complications, but most Italian physicians prefer to surgically treat such patients. METHODS: From 1980 to 1990, 36 patients with stage I squamous cell glottic carcinoma were treated with radiotherapy alone at the institute of Radiology of University of Rome "La Sapienza". In all patients the irradiation fields were limited to the larynx, with field size ranging from 4 x 4 cm to 7 x 7 cm. Total tumor doses ranged between 51 and 70 Gy (median 60 Gy) with a mean number of 30 fractions of 2 to 3 Gy per fraction (3 or 5 fractions per week). RESULTS: After a median follow-up of 98 months, we observed an overall survival rate at 5 years of 91.4% and actuarial 10-year survival of 85.7%. Local control was achieved in 97.1% of cases, with an event-free survival of 94.2% at 5 and 10 years. No major complications like necrosis or persistent edema of the larynx were observed. Minor complications like dysphonia (8%) and dysphagia (5.5%) were temporary; laryngeal function was completely preserved at the end of therapy. Final voice quality ranged from good to excellent. CONCLUSIONS: Our series confirms that radiation therapy has a major role in the management of early glottic cancer, with results comparable to surgical approaches and with better voice preservation.

[Radiotherapy in the treatment of tumors of the nasopharynx in advanced stage]. / Radioterapia nel trattamento dei tumori della rinofaringe in stadio avanzato.

This series consists of 25 patients affected with nasopharyngeal carcinoma in an advanced stage (T3-T4) treated at the Radiation Oncology department of the Institute of Radiology, University "La Sapienza", Rome, from 1978 through 1988. The patients were irradiated with X-rays produced by a LinAc with 4 MeV energy, for a total dose of 60/75 Gy on tumor and 50/60 Gy on nodes. In 7 cases radiation therapy was combined with chemotherapy. Actuarial survival at 60 months was 47%; patients with T3 cancer treated with a total tumor dose over 65 Gy showed a significant statistical increase of survival. Adjuvant chemotherapy did not produce statistically significant increase of survival. Radiation therapy was the treatment of choice in nasopharyngeal carcinoma in an advanced stage, whereas the role of chemotherapy remains questionable, even though a bad prognosis requires aggressive and combined treatment.

Radiation treatment of testicular relapse in acute lymphoblastic leukemia.

Ten patients with testicular relapse among 128 cases of acute lymphoblastic leukemia are reported. At the time of the initial diagnosis of leukemia all patients with later testicular relapse showed one or more risk factors as predictive for leukemic infiltration of the testicles. All patients except one, who underwent orchiectomy and died 11 weeks after surgical intervention, received radiation therapy with doses ranging from 12 to 20 Gy and chemotherapy. The local control was excellent. Average survival time from testicular relapse to death was 68 weeks in 8 of 9 patients treated by irradiation and chemotherapy. One patient is still alive without signs of disease after 6 years.