Audit: the use of radiotherapy for NSCLC in the UK.

A questionnaire on the management of NSCLC was sent to all clinical oncologists in the UK. Responses were received from 121 individuals with at least one representative response from each of 54 British radiotherapy units. Results were then discussed at an open meeting attended by a cross section of clinical oncologists; a synopsis of responses to the questionnaire and discussion at this meeting is contained in this report. A majority of respondents estimated treatment of NSCLC to make up 10%-25% of their work-load. Radical and palliative treatments could be clearly distinguished, and aims of treatment, selection criteria and radiotherapy schedules were consistent with recommendations in the published literature. More than 90% of treatments were with palliative rather than radical intent. Radical treatment schedules could be divided according to dose (< 50 Gy, 50-55 Gy and >55 Gy), number of fractions (< 20, 20, > 20 fractions), overall time < 4/52, 4/52, > 4/52), dose per fraction (> 2.75 Gy, 2.1-2.75 Gy, < or = 2 Gy) and target volume (tumour alone, tumour and hilar nodes, or tumour, hilar and mediastinal nodes). Divided thus, radical techniques fell into three broad groups, each of the three techniques supported by a body of literature. Choice of schedule could be related to a heterogeneous referral pattern and unresolved controversies, identified as debate on the value of treating mediastinal lymphadenopathy with high dose radiation, the value of 'subradical doses' of radiation for microscopic disease, and the relative importance of volume treated, total dose, dose per fraction and overall treatment time in achieving an optimal therapeutic ratio.(ABSTRACT TRUNCATED AT 250 WORDS)

Interstitial brachytherapy: past-present-future.

This article summarizes and reviews the development of brachytherapy from 1930 to 1990. Its purpose is to highlight the immense contribution made to its underlying science and clinical practice by Dr. Frank Ellis, who has been personally involved with it, in theory and in practice, for that whole half-century. A remarkable achievement in itself, but so much the more when it is seen beside his contributions to other aspects of radiation in the service of man. The early use of solid sources leads on to a discussion of manual afterloading and iridium. This leads on to a quick survey of the development of dosimetry. Thereafter clinical indications are briefly discussed and some published results tabulated. Lastly, some pointers to possible future development and benefits are discussed. Mention is also made of some continuing unresolved problems where new work could help to establish the most appropriate use of brachytherapy.

Problems associated with iridium-192 wire implants.

Three incidents are reported, from different radiotherapy centres, in which an implanted iridium-192 wire remained in the tissues of a patient after withdrawal of the plastic tubing in which it was contained. In each case the instrument used to cut the wire had probably formed a hook on the end of the wire which caused it to catch in the tissues. Detailed recommendations are made for avoiding such incidents in the future, the most important of which is that the patient should be effectively monitored after the supposed removal of all radioactive sources.

A randomized controlled trial of prophylactic cytotoxic chemotherapy in potentially curable breast cancer.

A randomized controlled trial of the value of oral adjuvant cytotoxic chemotherapy in the treatment of potentially curable breast cancer has been in progress in the Oxford Region since 1977. Eighty-seven patients were allocated to treatment with melphalan 0.2 mg/kg for 5 consecutive days every 6 weeks for 2 years; 98 patients were allocated to treatment with oral combination therapy consisting of melphalan 10 mg daily for 5 consecutive days, plus methotrexate 15 mg and 5-fluorouracil 250 mg on the first day, courses being repeated every 6 weeks for 2 years; and 88 patients were allocated to a control group which received no adjuvant chemotherapy. So far, 125 patients have suffered a recurrence of breast cancer and 85 have died. No statistically significant differences in outcome are apparent between the three treatment groups, although there is some indication of a beneficial effect of chemotherapy on disease-free interval in pre-menopausal women. Toxic effects of treatment, notably nausea, vomiting and bone marrow depression, have been moderately severe. In our view, the beneficial effects of current adjuvant cytotoxic chemotherapy, if any, are too modest to justify the suffering which such treatment can cause at a time when a woman with breast cancer might otherwise expect to feel physically well.

Interstitial radiotherapy in treatment of superficial tumours of the lower alveolar ridge.

An adaptation of a routine afterloading implant technique for local irradiation of small tumours of the lower alveolar ridge is described. The methods the authors have used for radiation dosimetry are explained and some clinical results in 12 such lesions are presented. The technique has the advantage that the need for mandibular resection may be avoided, although this procedure is still available if the primary treatment fails.

Intercomparison of iridium-192 wire used in interstitial radiation therapy.

The results of an intercomparison which took place in 1976 when 2 sets of 192Ir wire, one English, the other French, were exchanged and their activities measured by the producers, one standardizing laboratory and two radiation therapy centres. The average differences ranged from 0.7 to 3.2 per cent. The differences in the derivation of basal dose rate as defined in the Paris system, by the two radiation therapy centres, were also investigated.

An improved after-loading technique for perineal implants.

A technique is described for achieving better geometry in anal and perineal implants using iridium-192 wire sources. The special after-loading needles described have proved satisfactory in clinical use by the author for several years. The needles which are used for this technique can also be used for other tumour sites where a rigid line source is considered necessary.

The Paris system in interstitial radiation therapy.

As a result of almost 20 years' experience using 192Ir wires in interstitial radiation therapy, a new method of dose calculation has been evolved, which is especially suitable for the techniques employed. Because this system was developed and brought into routine use in Paris, it was called the Paris System. Its basic principles are outlined in this report and the manner in which it is used in clinical practise is explained.

A modified afterloading technique for small implants using iridium-192 wires for interstitial therapy.

A new method is described for small iridium-192 wire implants upon the skin of the face. The method is a miniaturisation of a technique described previously (Paine, 1972), and has the advantage that is results in less scarring and therefore a better cosmetic end-result than in the case when the more conventional wide-bore tubing is employed. This new method produces similar clinical results in terms of tumour cure to other methods, and a degree of after-loading helps in radiation protection.

Keloid scars: a new method of treatment combining surgery with interstitial radiotherapy.

A method is described for the treatment of the linear keloid scar, by surgical excision and post-operative irradiation delivered locally to the base of the sutured edges of the scar, by an iridium-192 wire. The wire is after-loaded into a plastic tube using the technique described by Paine (1972). A dose of 2000 rad is delivered at a point 2-5 mm from the axis of the wire, opposite its mid-point. Thirty cases have been treated by this method with a follow-up period of two years or longer; five recurrences were found at six months, and a further one by two years. No complications were observed. It is suggested that this represents a rather lower recurrence rate than has been achieved by other methods, and that the dose to the tissue surrounding the scar is less than that which would be the case with conventional superficial radiotherapy - an important consideration in the treatment of young patients, with benign conditions, by irradiation.

Treatment of connective tissue sarcomas by local excision followed by radioactive implant.

Thirty-two cases of connective tissue sarcoma were treated by local excision immediately followed by a radioactive implant, sometimes supplemented by external radiation. The method is effective in preventing local recurrence, and is particularly valuable for patients in whom persistent local recurrences following simple excision have occurred. The patient experiences little extra discomfort, and complications are unusual; hazard to staff is low. Long-term survival appears to be just as good in our series as in others in which radical surgery was used, the radical surgery has the disadvantages of greater operative morbidity and mortality, causes greater disfiguration, and may in any case be impossible for tumours in certain anatomical sites.