Results of radical perineal prostatectomy with adjuvant brachytherapy.

Retrospective analysis of outcome in 137 patients who underwent radical perineal prostatectomy and bilateral injection of gold-198 implants into the periprostatic tissues and/or neurovascular pedicles as treatment for prostatic adenocarcinoma was performed. Patients had undergone treatment between 1975 and 1985. Local recurrence developed in 22 patients (16.1%) and distant metastases developed in 33 (24.1%). Clinical and surgical staging of disease and Gleason grading of pathologic specimens were performed retrospectively. Kaplan-Meier local recurrence, freedom from relapse (FFR), and survival rates decreased with increasing stage and pathologic grade. With clinical staging, these rates were not statistically different from previous rates achieved with external beam radiation therapy, and with pathologic staging, they were not statistically different from previous rates achieved with prostatectomy. The authors conclude that (a) 5-year follow-up is inadequate to determine local control rates after prostatectomy; (b) use of implants did not improve local control, FFR, or survival rates of 10 years; and (c) method of staging probably has more effect on local control, FFR, and survival rates than does treatment modality.

Extended field irradiation for carcinoma of the uterine cervix with positive periaortic nodes.

Forty-three patients were treated with extended field irradiation for periaortic metastasis from carcinoma of the uterine cervix (FIGO stages IB-IV). Twelve patients (28%) remained continuously free of disease to the time of analysis or death from intercurrent disease, 20 (46%) had persistent cancer within the pelvis, 11 (26%) had persistent periaortic disease, and 23 (53%) developed distant metastasis. The actuarial 5-year survival rate was 32%. The results correlated well with the periaortic tumor burden at the time of irradiation. None of 19 patients (0%) with microscopic or small (less than 2 cm) periaortic disease had periaortic failures, compared to 29% (4/14) of those with moderate-sized (2-5 cm) disease and 70% (7/10) of those with massive (greater than 5 cm) periaortic metastasis. Similarly, the 5-year survival rates were 50% (6/12) with microscopic disease, 33% (2/6) with small gross disease, 23% (3/13) with moderate-sized disease, and 0% (0/10) with massive periaortic metastases. Only 10% (1/10) of patients whose tumor extended to the L1-2 level survived 5 years, compared with 31% (9/29) of those whose disease extended no higher than the L3-4 level. The periaortic failure rates correlated to some extent with the dose delivered through extended fields, although the difference was not statistically significant. Only 8% (1/13) of those who had undergone extraperitoneal lymphadenectomies developed small bowel complications, compared with 25% (7/29) of those who had had transperitoneal lymphadenectomies. The incidence of small bowel obstruction was 8% (1/13) following periaortic doses of 4000-4500 cGy, 10% (1/10) after 5000 cGy, and 32% (6/19) after approximately 5500 cGy. From this, we concluded that the subset of patients who would benefit most from extended field irradiation are those in whom the residual disease in the periaortic area measures less than 2 cm in size at the time of treatment, whose disease extends no higher than L3, and whose cancer within the pelvis has a reasonable chance of control with standard radiation therapy techniques.

A comparison of the roles of surgery and radiation therapy in the management of carcinoma of the female urethra.

Between 1939 and 1986, 42 patients with carcinoma of the female urethra were treated with surgery and/or radiation therapy at the University of Iowa. Ten patients were treated with surgery alone, 28 with radiation therapy alone, and 4 with combined surgery and radiation therapy. Seventeen patients (40%) developed persistent or recurrent disease at the primary site and 15 (36%) had failures in the inguinal nodes. The actuarial 5-year survival rate was 33.5%. Only 36% (10/28) of patients treated with radiation therapy had local failures, compared to 60% (6/10) of those treated with surgery alone. The best results were achieved with combined interstitial and external beam irradiation. Whereas 57% (8/14) of patients who were treated with combined interstitial and external beam irradiation were alive NED at 3 years, none of 7 patients (0%) treated with interstitial implants only and 2 of 7 patients (29%) treated with external beam irradiation alone were alive NED at 3 years. There was a significantly lower inguinal failure rate in patients who received treatment to the inguinal nodes (10%) than in those who did not receive inguinal area treatment (52%), and this translated into a superior 5-year survival for those patients (60% vs 18%). Survival rates did not correlate with histopathologic type in this series, although there were differences in the patterns of failure. Survival rates did correlate well with clinical stage.

The role of radiation therapy in the management of ependymomas of the spinal cord.

Twenty patients with biopsy-proven ependymomas of the spinal cord were treated between 1960 and 1984-7 with surgery only, 3 with radiation therapy only, and 10 with surgery and postoperative radiation therapy. Of these, 2 patients developed recurrent tumor at the primary site, 3 developed a recurrent tumor in the thecal sac, and 1 developed distant metastasis. The absolute 5- and 10-year survival rates were 95% (19/20) and 86% (12/14), respectively. None of 13 patients who were treated with radiation therapy only or combined surgery and postoperative radiation therapy developed recurrent tumor at the primary site, and none of 7 patients who received thecal sac irradiation developed thecal sac recurrences. In contrast, 2 of 7 patients (29%) treated with surgery alone developed recurrent tumor at the primary site, and 3 of 13 patients (23%) who received no thecal sac irradiation developed a recurrent tumor in the thecal sac. The failure rates following surgery were greatest in patients who had tumor removed in a piecemeal fashion (43%, 6/14). The results show that radiation therapy is probably not necessary if the tumor has been removed completely in an en bloc fashion. However, radiation therapy is needed if the tumor has been incompletely removed or removed in a piecemeal fashion. If the tumor has been removed in a piecemeal fashion, the radiation portals should be extended to include the thecal sac. Histologic subtypes influenced the pattern of recurrence. Myxopapillary ependymomas and high grade cellular ependymomas appear to be more likely to recur in the thecal sac. However, no big difference could be detected in local recurrence.

Preliminary results of a pilot study of pentoxifylline in the treatment of late radiation soft tissue necrosis.

Between September 1988 and August 1989, 12 patients with 15 sites of late radiation necrosis of the soft tissues were treated with pentoxifylline, a hemorrheologic agent that has been used to treat a variety of vasculo-occlusive disorders. Four of these necroses were located in the oromucosa, four in the mucosa of the female genitalia, and seven in the skin. At the time of analysis, 87% (13/15) of the necroses had healed completely, and one was partially healed. Furthermore, the time-course of healing with pentoxifylline was significantly less than the duration of nonhealing prior to pentoxifylline (average: 9 weeks vs 30 1/2 weeks). All patients had pain relief. These results indicate that pentoxifylline can contribute to the healing of soft tissue radiation necrosis. They also support the concept that late radiation injury in skin and mucosa is at least partly due to vascular injury.

The prevalence and severity of late effects in normal rat duodenum following intraoperative irradiation.

In humans, a portion of the duodenum is often at risk for radiation-induced complications following intraoperative radiation therapy for pancreatic carcinoma. To determine experimentally the prevalence and severity of late effects in the normal mammalian duodenum, 190 rats received single doses of 0, 15, 20, 25, 30, or 40 Gy orthovoltage X rays to temporarily exteriorized 3 cm circumferential segments of duodenum. The animals were killed 2, 6, 8, or 10 months later. Actuarial survival, change in body weight, and a radiation injury score based on eight histopathologic alterations were used as endpoints. Epithelial atypia, intestinal wall fibrosis, serosal thickening, and vascular sclerosis were the dominant histopathologic alterations at all dose levels throughout the 10-month observation period. The prevalence and severity of histologic radiation injury showed sigmoidal dose-response relationships with the plateaus starting at 20 Gy. Doses of 20 Gy or greater also resulted in a substantial loss of body weight and a high level of early deaths (20-80 days). All endpoints indicate that intraoperative doses of 20 Gy or greater are associated with unacceptable risks of late and irreversible complications.

The role of radiation therapy in the treatment of solitary plasmacytomas.

Between 1960 and 1985, 30 patients with solitary plasmacytomas were treated with radiotherapy at the University of Iowa: 13 patients with extramedullary plasmacytomas (EMP) and 17 with solitary plasmacytomas of bone (SPB). The local control rates were 92% for patients with EMP and 88% for those with SPB. Two of nine patients (22%) with EMP treated to the primary tumor only developed regional lymph node metastasis, indicating the need for elective irradiation of this area. The most common pattern of failure in both groups was progression to multiple myeloma. This occurred in 23% of the patients with EMP and 53% of those with SPB. The time course of progression to multiple myeloma differed for the two groups. All of those who progressed to multiple myeloma in the EMP group did so within 2 years, whereas a significant number of those in the SPB group progressed more than 5 years after initial therapy. None of five patients who received adjuvant chemotherapy in the SPB group progressed to multiple myeloma, compared to 75% (9/12) of the patients who did not receive chemotherapy.

The role of kilovoltage irradiation in the treatment of keloids.

This is a retrospective analysis of the results of kilovoltage irradiation given to prevent the regrowth of 203 keloids excised at the University of Iowa Hospitals and Clinics, Iowa City, Iowa, Lutheran Hospital in Moline, Illinois, and Mercy Hospital in Cedar Rapids, Iowa. We found that a minimum follow-up of 1 year is needed to evaluate the results of post-excisional kilovoltage x-ray therapy. A dose versus response effect was also observed. Although it is desirable to use the lowest possible dose of radiation that is likely to be effective, the likelihood of failure is too great to justify the routine use of doses of less than 900 cGy regardless of how they are fractionated or when they are given. It appears that the total dose of irradiation that is given to prevent the regrowth of an excised keloid is more important than when irradiation is started, the size of the largest fraction given, whether the irradiation is completed in 1 week or 3, or where the keloid has grown. When a small number of keloids were irradiated less than 1 year after they first appeared greater than or equal to 1500 cGy were sufficient to control 90% of them without re-excision.

A comparison of the roles of surgery and radiation therapy in the management of craniopharyngiomas.

Fifty-two patients with craniopharyngioma were seen between January 1961 and July 1986. Of these, 40 were treated with surgery alone, 8 with surgery and postoperative radiotherapy, and 3 with radiotherapy alone. One patient received no treatment. For the group treated with surgery alone, 33% (13/40) had local tumor control, 42.5% (17/40) developed major complications, and 71% (25/35) survived 5 years. With surgery and postoperative radiotherapy, 100% (8/8) had local tumor control, 25% (2/8) developed major complications, and 100% (7/7) survived 5 years. Two of the three patients treated with radiotherapy alone had local tumor control and the third was salvaged with surgery. The "complete resection" rate for 32 patients treated with radical surgery was 63% (20/32). Tumor control was achieved in 50% (10/20) of the patients treated with "complete resection" without radiotherapy, in 15% (3/20) of the patients treated with "incomplete resection" without radiotherapy, and in 100% (8/8) of the patients treated with "incomplete resection" and postoperative radiotherapy. In this series, doses of 5000-5500 cGy were as effective in achieving control as 5500-6000 or 6000-7000 cGy.

Intraoperative irradiation in a rat model: histopathological changes in irradiated segments of duodenum.

During intraoperative radiation therapy for carcinoma of the head of the pancreas in humans, a portion of duodenum is often at risk for radiation-induced complications because of its fixed anatomical position within the treatment field. This study was undertaken to determine the feasibility of using the rat as a model to determine the radiotolerance of normal mammalian duodenum. The procedures used to exteriorize and irradiate a selected segment of duodenum are described. Histopathologic changes in 5-cm segments of midduodenum were studied 14 and 28 days after 0, 30, 40, or 50 Gy X-radiation. Complete denudation of the epithelium and thickening of the muscularis and serosal layers occurred in all irradiated segments by day 14. By day 28, even though crypt and villus architectures were atypical, large areas of epithelial regeneration were seen in rats receiving 30 Gy. In contrast, complete denudation of the epithelium were still evident along most of the length of the irradiated segments in rats receiving 40 or 50 Gy. Serosal fibrosis was prominent in all irradiated animals, regardless of dose. These results indicate that radiation doses above 30 Gy carry high risks of complications. The rat is considered a suitable animal model.

Chemodectoma of the temporal bone: a comparison of surgical and radiotherapeutic results.

Between January 1950 and December 1981, 32 patients with chemodectomas of the temporal bone were treated at the University of Iowa Hospitals and Clinics. Thirteen patients were treated with surgery alone, 15 with radiation therapy alone, one with preoperative radiation therapy and surgery, and three with surgery and postoperative radiation therapy. In general, the patients treated with radiotherapy alone or combined therapy (radiotherapy group) had more advanced tumors than those treated with surgery alone (surgery group). For the surgery group, the initial local control rate was 46% and the ultimate local control rate 84% following salvage with additional surgery, 31% developed complications, and 78% survived 10 years. For the radiotherapy group, 84% had local tumor control, 11% developed complications, and 77% survived 10 years. These results demonstrate that radiation therapy is an effective treatment modality for chemodectomas of the temporal bone.

Inoperable adenocarcinoma of endometrium: radiation therapy.

Between 1960 and 1979, 41 patients with adenocarcinoma of the endometrium who were poor surgical risks were treated with radiation therapy at the University of Iowa. Local tumor control was achieved in 78% of the patients, 5% manifested complications, and 46% survived 5 years ("uncorrected" 5-year survival rate). Intercurrent disease was the major cause of death (54%), and intrauterine recurrence (22%) was the most frequent recurrence. Intraperitoneal spread (12%) occurred as commonly as hematogenous metastases (12%). Three of nine local failures occurred after 5 years. Local control rates correlated well with clinical stage, and the survival rates correlated well with the stage and grade of the tumor. Local tumor control was achieved in 95% of patients who received greater than 7,000 mg-h intracavitary radium, compared with 63% of patients treated with less than 7,000 mg-h.

Dosimetric aspects of a rotating beam splitter used in tangential field breast treatment.

A rotating beam splitter was designed and fabricated for use in treating tangential breast fields on an AECL Theratron-80 cobalt teletherapy unit. Its dosimetric properties were studied using a 0.6-cm3 Baldwin-Farmer ionization chamber with Keithley electrometer and a Scanditronix RFA-3 three-dimensional water phantom scanner with semiconductor detector. An aluminum plate, which held the semicircular rotating 5-HVL (half-value layer) lead block, extended to the phantom surface (80-cm source-surface distance). The beam was blocked directly along the central axis and also at distances up to 7.5 mm off-axis, corresponding to the projected extent of the 1.5-cm-diam source. The penumbra at the central ray and at each off-axis point was measured at dmax and at 5-cm depth in water. A reduction in the penumbra from 8 to about 2 mm for 20 X 20 cm2 beam was observed regardless of the off-axis distance of the block. Isodose distributions obtained for various field sizes indicated that the percent depth doses of the split fields agree well with the equivalent squares of the irradiated field sizes. Output measurements in water and in air indicated that scatter from the aluminum plate more than compensates for the reduction in backscatter factor, due to the decrease in irradiated area when the beam splitter is used. Isodose curves in various planes were obtained at clinically useful rotational angles of the beam splitter. Computer generated isodose curves have been obtained that match the measured curves to be used in treatment planning.

Dysgerminoma of the ovary.

Twenty-four patients with pure dysgerminoma of the ovary were treated at The University of Iowa Hospitals and Clinics between 1935 and 1985. Ten patients had stage I unilateral tumors, and all are free of disease from 20-455 months (median, 100 months). All patients treated by unilateral adnexectomy alone for stage IA disease survived. Nine of 11 patients with advanced disease whose therapy began or was completed at our institution are alive without disease from 12-204 months (median, 60 months). Three patients were referred with recurrent disease, and none survived.