Patterns of failure in primary testicular non-Hodgkin's lymphoma.

Patterns of failure were analyzed in 30 patients with testicular non-Hodgkin's lymphoma: 16 had stage IE disease, ten had stage IIE, and four had stage IV. After orchiectomy, two of the 16 patients with stage IE disease received no additional therapy, one received multiagent chemotherapy, and 13 received pelvic and para-aortic radiation. Twelve patients with stage IE disease had progression, and the median time to progression was 12 months. Of the 14 patients with extratesticular involvement (stage IIE or IV), one (stage IV) received no treatment after orchiectomy, three (stage IIE) received para-aortic and pelvic radiation, and ten (seven stage IIE and three stage IV) received multiagent chemotherapy with or without radiation. Eight of the patients with stage IIE or IV disease had progression, and the median time to progression was 11 months. Widespread extranodal progression was observed in 17 of the 20 patients who had progression. The tendency of testicular lymphoma for early systemic progression suggests a need for multiagent chemotherapy in initial management.

Placebo-controlled trial of sucralfate for inhibiting radiation-induced esophagitis.

PURPOSE: To determine whether a sucralfate oral solution can prevent/alleviate radiation-induced esophagitis. PATIENTS AND METHODS: Patients included on this clinical trial were beginning thoracic radiation therapy to the mediastinum. Following stratification, they were randomized, in a double-blind manner, to receive a sucralfate solution or an identical-appearing placebo solution. Esophagitis was measured by physicians who used standard criteria and also by patients who used short questionnaires completed weekly during the course of the trial. RESULTS: A total of 97 assessable patients were entered onto this clinical trial. During the first 2 weeks of the study, two placebo patients (4%) stopped their study medication, compared with 20 sucralfate patients (40%). This was related to substantially increased incidences of gastrointestinal toxicity (58% of sucralfate patients v 14% of placebo patients; P > .0001). There was no substantial benefit from the sucralfate in terms of esophagitis scores. CONCLUSION: This oral sucralfate solution does not appear to inhibit radiation-induced esophagitis and is associated with disagreeable gastrointestinal side effects in this patient population.

Radiotherapy for large symptomatic hemangiomas.

Between 1974 and 1988, 13 patients presented with large (3 to greater than 20 cm) symptomatic unresectable or partially resected hemangiomas. Tumor sites were extremities (five cases), vertebral bodies (three cases), face (two cases), pituitary fossa (one case), pelvic bones (one case), and bladder (one case). Symptoms included severe pain in eight patients, inability to use an extremity in five, vision problems in three, weakness in two, and hematuria with decreased urinary stream in one. Many patients had more than one symptom. Two of the cases were associated with life-threatening consumptive coagulopathies (Kasabach-Merritt syndrome). Therapy was delivered with both orthovoltage and megavoltage photons. Doses ranged from 6.25 to 40.0 Gy in 1.6- to 2.5-Gy fractions. Follow-up ranged from 2 to 15 years (median, 13 years). Tumor shrinkage was noted in 9 (82%) of the 11 cases in which tumor size data were collected before and after therapy. Complete response of tumor mass occurred in 4 (36%) of 11, partial response occurred in 5 (45%), and no response occurred in 2 (18%). No tumor grew after radiotherapy. Some relief in symptoms occurred in all 13 patients; 10 (77%) had complete resolution of symptoms. In both patients with life-threatening cytopenias, hematologic values returned to normal after treatment. Because the majority of the patients responded to all dose levels administered, no firm dose-response relationship was evident. However, objective (measurable) complete responses occurred in two (50%) of the four patients receiving doses of 30 Gy or greater compared with only two (29%) of the seven patients who received lesser doses. No long-term morbidity occurred. Radiotherapy of large unresectable and partially resected hemangiomas yields long-term relief of symptoms and tumor shrinkage in the majority of patients treated.

External radiation therapy and transcatheter iridium in the treatment of extrahepatic bile duct carcinoma.

PURPOSE/OBJECTIVE: Review survival, prognostic factors, and patterns of failure in patients with extrahepatic bile duct (EHBD) carcinoma treated with external beam irradiation (EBRT) and transcatheter iridium. METHODS AND MATERIALS: The charts of 24 patients with EHBD cancer treated with EBRT and transcatheter boost were reviewed. All patients had transhepatic biliary tubes or endoprostheses placed. Two patients underwent hemihepatectomy with hepaticojejunostomy formation but had residual disease. Two patients had biopsy proven adenopathy. Five patients had Grade 1 adenocarcinoma, nine Grade 2, six Grade 3, and one Grade 4 disease. Median EBRT dose was 50.4 Gy delivered in 1.8 Gy/day fractions. Median transcatheter boost at 1 cm radius was 20 Gy. Nine patients received concomitant 5-Fluorouracil (5-FU) during EBRT. RESULTS: Median survival was 12.8 months (range 7.5 months to 9 years). Overall 2- and 5-year survival rates were 18.8 and 14.1%, respectively (three disease-free survivors > or =5 years). One patient is still alive without relapse 10 years from diagnosis and 5 years after liver transplantation for liver failure (no cancer in specimen, underlying sclerosing cholangitis). Two additional long-term survivors had no evidence of relapse 6.9 and 8.2 years after diagnosis. Histologic grade, lymph node status, cystic, hepatic, common hepatic or common bile duct involvement, surgical resection, radiation therapy dose, and chemotherapy did not significantly effect survival due to the number of patients analyzed. There was a trend towards improved survival with the addition of 5-FU chemotherapy (5-year survival in two of nine patients, or 22%). Eight of 24 patients (33%) demonstrated radiographic evidence of local recurrence. Distant metastases developed in 6 of 24 (25%) patients. The most common complications were tube related cholangitis (50%) and gastric/duodenal ulceration or bleeding (42%). CONCLUSION: External beam irradiation combined with a transcatheter boost can result in long-term survival of patients with EHBD cancer. Both distant metastases and local recurrence develop in 25-30% of patients despite irradiation. Survival may be improved by using chemotherapy in combination with EBRT to impact disease relapse (local and distant). Because there may be a dose response with irradiation, survival may also be improved by increasing the dose of radiation delivered by transcatheter boost. A Phase II trial is being developed using a combination of 45-50 Gy EBRT with concomitant 5-FU delivered by protracted venous infusion followed by a 25-30 Gy transcatheter boost.

Radiotherapeutic management of primary thyroid lymphoma.

The purpose of this study was to evaluate the radiotherapeutic management of 38 patients, with malignant lymphoma of the thyroid, seen at the Mayo Clinic between 1965 and 1979. There were 8 males and 30 females with ages ranging from 34 to 90 years (mean age of 65 years). A tissue diagnosis was made in all patients and tissue was available for reclassification under the "Working Formulation" in 31 of the 38 patients. Twenty-six patients had intermediate grade histology, four low grade and one indeterminate. Twenty patients were clinical Stage IE, 14 patients Stage IIE, one patient Stage IIIE, one patient Stage IV and two patients were unstaged. All patients were treated with approximately 4000 rad megavoltage irradiation (range 2400-6000 rad) to the neck only (10 patients) or neck and mediastinum (28 patients). Twenty patients received subdiaphragmatic radiotherapy and four patients received adjuvant chemotherapy. Median follow-up was 56 months with minimum follow-up of 30 months. Overall disease-free survival at five years was 59%. Of 14 patients who experienced a recurrence, 10 (71%) failed in two or more sites. The most common site of failure was in para-aortic lymph nodes. One year survival following recurrence was 29%; however, four of six patients receiving salvage therapy survived at least two years. Patients receiving radiation treatment to the neck and mediastinum and those with no gross residual disease at the initiation of radiotherapy were less likely to develop a recurrence. Patients receiving a planned break during the course of therapy did not have reduced overall disease-free survival. However, 4 of 20 patients (20%) who received split course therapy failed within the radiation fields compared to 2 of 18 patients (11%) who had no treatment break. Only 1 of 4 patients (25%) receiving adjuvant chemotherapy survived one year. Side effects of radiotherapy were minimal. We believe the radiotherapeutic management of clinical Stage IE and IIE primary thyroid lymphoma should include treatment of the neck, axillae and mediastinum to a dose of approximately 4000 rad using a continuous course technique. Additionally, gross total removal of the disease surgically may be beneficial.

External beam irradiation for retinoblastoma: patterns of failure and dose-response analysis.

Eighteen children with retinoblastoma (25 eyes) were treated with external beam radiation at the Mayo Clinic between January 1977 and January 1987; 15 eyes were in groups I to III and 10 were in groups IV and V (Reese-Ellsworth classification). The median number of tumors per eye was 3. Radiation therapy consisted of 4- or 6-MV photons. Doses varied from 39 to 51 Gy in 1.8- to 3.0-Gy fractions. Fourteen eyes were treated through lateral fields by anterior segment-sparing techniques, and 11 eyes were treated by an anterior approach with no attempt at anterior segment sparing. All patients survived (median follow-up, 31.5 months). Cataracts developed in five eyes at a median of 23 months, four in eyes treated with anterior segment-sparing techniques. Of the 15 group I to III eyes, 6 required additional treatment; 4 were salvaged with cryotherapy or photocoagulation and 2 were enucleated. Of the 10 group IV and V eyes, 8 required additional treatment; 4 were salvaged with cryotherapy or photocoagulation, 1 with persistent disease is being followed closely, and 3 were enucleated. Ten (71%) of the 14 eyes treated with anterior segment-sparing techniques required additional treatment (9 of the 10 for tumors anterior to the equator). Four (36%) of the 11 eyes treated with an anterior approach required additional treatment (3 of the 4 for tumors in the posterior pole of group IV or V eyes). Ninety percent of the tumors 10 disc diameters or smaller (1 disc diameter = 1.6 mm) were controlled independently of dose and fractionation used when they were not in the low-dose area of the anterior retina of an eye treated with an anterior segment-sparing technique. We find that use of lateral, anterior segment-sparing techniques has a high risk of anterior retinal tumor development and cataract formation and should be abandoned in favor of techniques that treat the entire retina. A dose of 45 Gy in 1.8-Gy fractions appears to be adequate for local control of tumors smaller than 10 disc diameters. Larger tumors may require additional treatment.

The results of radiotherapy for isolated elevation of serum PSA levels following radical prostatectomy.

Eleven patients were initially treated for localized prostate cancer with radical retropubic prostatectomy following negative pelvic lymph node dissection. Six or more months after surgery, these patients had elevated serum prostate specific antigen (PSA) levels. No patient had other clinical evidence of disease as determined by history, physical examination, bone scan, computed tomographic scan of the abdomen and pelvis, chest radiograph, complete blood cell count, and serum chemistry profile. These patients received prostate bed irradiation using 10-MV photons and a four-field technique. Doses ranged from 60.0 to 65.8 Gy in 1.8 to 2.0 Gy fractions. Levels of serum PSA were monitored and decreased initially in all treated patients. In two patients, levels of PSA increased after this initial decrease. In 7 of the 11 patients (64%), PSA levels decreased to less than or equal to 0.3 ng/mL at last measurement. Radiotherapy resulted in no severe toxicity. None of the patients had developed clinical evidence of disease at the time of this report. Isolated elevations of serum PSA after prostatectomy reflect residual disease, and radiotherapy appears to effectively decrease the PSA levels in most cases. This effect appears to be accomplished by killing locally residual or recurrent cancer in the postoperative tumor bed.

Analysis of failure following curative irradiation of gallbladder and extrahepatic bile duct carcinoma.

Twenty patients with carcinoma of the gallbladder (GB-4 patients) or extrahepatic bile ducts (EHBD-16 patients) received radiation therapy with curative intent between January, 1980 and December, 1982. All 20 received 4500-5000 rad in 180-200 rad fractions to the tumor and regional lymph nodes. A 1000 to 1500 rad external beam boost was delivered in 180-200 rad fractions in 10 patients who received external beam alone or concomitant 5-Fluorouracil (5-FU). Three of the four GB and 5 of the 16 EHBD patients received a transcatheter boost with 192-Iridium (192Ir) to a dose of 2000-2500 rad calculated at a 0.5-0.1 cm radius. An additional 2 patients with EHBD lesions received an intraoperative electron (IORT) boost of 1500-2000 rad in one fraction calculated to the 90% isodose. Survival and patterns of failure were analyzed by site and treatment method. All four patients with GB carcinoma are dead of disease at 5 1/2, 6, 9 and 10 months from the date of diagnosis respectively. Three of the four developed diffuse peritoneal carcinomatosis. Five of the 16 patients with EHBD carcinoma are alive with a median follow-up of 18 months (range 6-23 months). Four of the 5 patients received a transcatheter 192Ir or IORT boost and all are without evidence of disease. Four of 9 patients who had a subtotal resection with transection of tumor, dilatation of the bile ducts with probes or curettement of the bile ducts developed either diffuse peritoneal carcinomatosis (3 patients) or a recurrence in the surgical scar (2 patients). Local failure was documented in 3 of the nine patients treated with external beam alone +/- 5-FU, and has been documented in one of the seven patients who received an IORT or transcatheter 192Ir boost. Further experience is necessary to determine whether this aggressive treatment will result in long-term disease-free survival in these patients.

Hepatic duct stricture after radical radiation therapy for biliary cancer: recurrence or fibrosis?

Two patients with biliary cancer received radical radiation therapy. After treatment, both patients experienced episodes of biliary obstruction without definite evidence of progression of the tumor. These cases emphasize the importance of including radiation-induced biliary fibrosis in the differential diagnosis of hepatic duct stricture after radical radiation therapy.

Postoperative irradiation for tonsillar carcinoma.

From January 1975 through July 1987 at the Mayo Clinic, 16 patients received postoperative adjuvant radiation therapy for squamous cell carcinoma of the tonsil (pathologic stage I in 4 patients, stage III in 3, and stage IV in 9). Follow-up was continued for a minimum of 2 years or until death. At 5 years, overall survival was 74% and disease-free survival was 68% for the entire group of patients. The local-regional control rate at 5 years was 83% for 12 patients with pathologic stage III or IV disease; the 5-year disease-free survival rate was 74%. The results with use of postoperative irradiation for stage III or IV tonsillar cancer seem superior to those for a similar historical group of patients who underwent surgical treatment only. Because the number of patients was small and the analysis was retrospective, our study may have included some undetected bias.

Early-stage squamous cell carcinoma of the glottic larynx managed with radiation therapy.

Between January 1975 and December 1985, 45 patients with carcinoma in situ or invasive squamous cell carcinoma of the glottic larynx received radiation therapy at the Mayo Clinic. Local control in the entire group of 45 patients was 84% (in 6 of 6 with carcinoma in situ and in 32 of 39 with invasive cancers). Three of seven patients (43%) with local recurrences underwent successful larynx-preserving surgical procedures; thus, the rate of laryngeal preservation was 91%. In our study of several treatment factors, including the duration of treatment, type of treatment (continuous course versus split course), photon energy (60Co versus 4-MV photons versus 6-MV photons), total dose, and dose per fraction, we found that only total dose of 6,300 cGy or more was associated with significantly improved local control (in 35 of 38 patients [92%]). Two patients (4%) died of uncontrolled delayed nodal metastases, one of which was preceded by a local recurrence. Severe laryngeal edema developed in two patients, associated with recurrent glottic carcinoma in one of them. No larynx was lost because of complications. In our current treatment recommendations, patients receive a total dose of 6,300 cGy in 28 fractions of 225 cGy each, administered in a continuous course with use of 6-MV photons.

Locally recurrent non-small-cell lung cancer after complete surgical resection.

Between Jan. 1, 1976, and Dec. 31, 1985, at our institution, 37 patients who had undergone prior complete surgical resection of non-small-cell lung cancer received definitive thoracic radiation therapy (TRT) for locally recurrent disease. Of the 37 recurrences, 33 were in the pulmonary parenchyma or the hilar, mediastinal, or supraclavicular lymph nodes; the other 4 were in the chest wall. The initial stage of disease was I in 43%, II in 35%, and IIIA in 19%, whereas at the time of local recurrence, the stage was I in 8%, II in 11%, IIIA in 57%, IIIB in 22%, and IV in 3% (this patient had multiple pulmonary nodules encompassible within a single TRT field). The locally recurrent lesions were squamous cell carcinoma in 30%, adenocarcinoma or large-cell carcinoma in 46%, mixed types in 5%, and unknown type in 19%. All patients received megavoltage TRT, most often 4,000 cGy in 10 fractions administered in a split-course schedule. In addition, 15 patients received multiagent chemotherapy, usually a combination of cyclophosphamide, doxorubicin hydrochloride, and cisplatin or a regimen that included these drugs. The 2-year and 5-year survivals were 30% and 4%, respectively, and the median duration of survival was 13.7 months. Survival was not improved by the addition of chemotherapy. Approximately half of the patients had radiographic and symptomatic responses after TRT. Of 33 patients assessable for post-TRT patterns of failure, 46% had local failure only, 18% had local plus systemic failure, and 32% had systemic failure only. Two-thirds of the patients died as a direct consequence of progressive chest disease, despite receiving TRT.(ABSTRACT TRUNCATED AT 250 WORDS)

Results of radiotherapy for chemodectomas.

Between 1974 and 1988, 10 Mayo Clinic patients had unresectable, locally recurrent, or partially resected chemodectomas. Of these 10 tumors, 9 were confirmed pathologically, and 1 was diagnosed clinically. The chemodectoma was located in the jugular bulb in five patients, the middle ear in three, and the carotid body in two. The following symptoms were noted: tinnitus (in eight patients), loss of hearing (in six), hoarseness (in six), dysphagia (in four), pain (in three), and alteration of mental status (in one). Many patients had more than one symptom. Treatment was delivered with megavoltage photons and electrons; total doses ranged from 16.2 to 52 Gy (median, 46 Gy), and the daily doses ranged from 1.6 to 2.4 Gy. Follow-up among the nine survivors ranged from 3 1/2 to 16 years (median, 7 1/2 years). In one patient, the response could not be assessed because the patient died of renal failure 4 months after treatment. All nine assessable patients had decreased symptoms and objective control of the tumor (no evidence of progression of disease). Of the nine assessable patients, four had complete responses, one had a partial response, and four had stable disease. No patient experienced progression of disease after radiotherapy. We conclude that radiotherapy for chemodectomas yields successful results--namely, decreased symptoms and objective control of the tumor.

Radiotherapy for isolated increases in serum prostate-specific antigen levels after radical prostatectomy.

OBJECTIVE: To assess the outcome of radiotherapy in patients with increased serum prostate-specific antigen (PSA) levels 6 months or more after radical prostatectomy. DESIGN: In 27 Mayo Clinic patients, we examined the results of radiotherapy relative to various potentially prognostic factors during a median follow-up of 25 months. MATERIAL AND METHODS: All 27 patients had no nodal involvement at the time of prostatectomy and no clinical evidence of disease, as determined by history, physical examination, a radionuclide bone scan, computed tomography of the abdomen and pelvis, chest roentgenography, complete blood cell counts, and serum chemistry profiles. With use of 10-MV photons and a four-field approach, these patients received irradiation to the prostatic bed (60 to 67 Gy in 1.8- to 2.0-Gy fractions). RESULTS: Levels of PSA initially decreased in 24 of the 27 patients (89%). In 16 of the 27 patients (59%), the PSA level decreased to 0.3 ng/mL or less without hormonal intervention. "Freedom from failure" (defined as the actuarial chance of maintaining a PSA level of 0.3 ng/mL or less) was 58% at 2 years and 48% at 3 years. The response to salvage radiotherapy was more favorable in patients with no tumor spread into the seminal vesicles and those with serum PSA levels of less than 1.1 ng/mL at the beginning of radiotherapy than in those with seminal vesicle involvement or higher PSA levels. In addition, patients who received radiation doses of 64 Gy or more had more favorable responses than did those who received lesser doses. Radiotherapy resulted in no severe toxicity. No patient had clinical evidence of disease at the time of this report. CONCLUSION: Isolated increases in serum PSA after prostatectomy indicate the presence of residual or recurrent disease, and radiotherapy effectively decreases the PSA in approximately half the cases. This result is achieved by eradicating residual or recurrent cancer in the postoperative tumor bed.

Evaluation of serum prostate-specific antigen levels after postoperative radiation therapy for pathologic stage T3, N0 prostate cancer.

OBJECTIVE: To analyze freedom from progression of serum prostate-specific antigen (PSA) levels in patients who have received radiation therapy after radical prostatectomy for pathologic stage T3, N0 prostate cancer. DESIGN: We assessed the freedom from PSA progression after postoperative radiation therapy and its relationship to several potential prognostic factors during a median follow- up of 43 months. MATERIAL AND METHODS: Thirty Mayo patients received postoperative radiation therapy for pathologic stage T3, N0 prostate cancer between January 1988 and April 1993. Radiation therapy was initiated within 6 months after prostatectomy. Radiation doses ranged from 60 to 67 Gy. RESULTS: "Freedom from PSA failure" was defined as the actuarial risk of maintaining a serum PSA level at 0.3 ng/mL or less. The freedom from failure rate was 66% at 3 and 4 years. Prognostic factors significantly associated with an improved freedom from failure were a pre-radiation PSA level of 1.0 ng/mL or less and no seminal vesicle involvement. A trend toward an improved freedom from failure was noted in patients with low-grade (1 and 2) tumors in comparison with high-grade (3 and 4) tumors. Treatment-related morbidity was minimal. CONCLUSION: Radiation therapy after radical prostatectomy for pathologic stage T3, N0 prostate cancer seems to provide an improved freedom from PSA failure in comparison with that noted in other series of similar patients treated with radical prostatectomy only.

Radiation therapy for squamous cell carcinoma of the tonsil.

OBJECTIVE: To characterize the patient population referred for radiation therapy for tonsillar cancer and to assess the effectiveness of use of only radiation therapy in this population. DESIGN: We retrospectively reviewed the medical records of 21 patients referred to the Mayo Clinic in Rochester, Minnesota, from 1970 through 1988 for radiation therapy for squamous cell carcinoma of the tonsillar region. MATERIAL AND METHODS: The median age of the 21 study patients was 65 years (range, 45 to 92), and the male:female ratio was 12:9. In all patients, follow-up continued until death or for 2.25 to 16.25 years. Of the 21 patients, 17 had tumors that were either surgically unresectable or medically inoperable, and 20 had clinical stage III or IV disease. The median total dose of irradiation was 55 Gy. RESULTS: Local control of the tonsillar cancer was as follows: T2, four of five patients; T3, seven of seven; and T4, five of nine. Thus, the local control rate was 76%. No associations were discovered among local control, total dose of radiation therapy, dose per fraction, overall duration of treatment, age, sex, or reason for referral for radiation therapy. Control of metastatic cervical adenopathy was as follows: clinical stage N1, seven of seven patients; N2, six of seven; and N3, one of one. (Six study patients had no nodal involvement.) The estimated 5-year cause-specific survival and overall survival rates were 77% and 31%, respectively. CONCLUSION: This study substantiates the effectiveness of radiation therapy in patients with squamous cell carcinoma of the tonsil.

Lymph node-positive prostate cancer: evaluation of the results of the combination of androgen deprivation therapy and radiation therapy.

OBJECTIVE: To evaluate the outcome of patients with pathologic stage IV prostate cancer treated with androgen ablation plus external-beam radiation therapy. PATIENTS AND METHODS: Sixty consecutive patients treated between August 1986 and February 1995 with androgen ablation plus radiation therapy for stage IV (T1-4 N1 M0) adenocarcinoma of the prostate were selected for outcome analysis in this retrospective study. Bilateral pelvic lymphadenectomy was performed in 56 patients (93%). The 4 remaining patients had pelvic adenopathy on computed tomography, which was confirmed histologically in all patients. The median pretreatment prostate-specific antigen (PSA) level was 28.8 ng/mL (mean, 55 ng/ mL; range, 0.1-428 ng/mL). All patients received radiation therapy to the prostate, and 29 (48%) had pelvic node radiation. Biochemical failure was defined according to the American Society for Therapeutic Radiology and Oncology criteria of 3 successive increases in the PSA level. RESULTS: The median follow-up duration for surviving patients was 101.1 months (range, 20-134 months). Biochemical failure with (in 2 patients) or without (in 10 patients) clinically evident disease relapse was noted in 12 patients (20%). Four additional patients (7%) had clinical relapse without biochemical failure. Local recurrences were observed in 6 patients (10%), and this clinical impression was confirmed by biopsy in 4 patients. Thirteen patients (22%) died of causes related to prostate cancer. The biochemical relapse-free, clinical disease-free, overall, and cause-specific survival rates at 5 years were 82%, 84%, 76%, and 80%, respectively. CONCLUSIONS: This observational case series of patients treated with the combination of external-beam radiation therapy and permanent androgen ablation for pathologic stage IV prostate cancer suggests that the addition of androgen deprivation therapy to radiation therapy may improve disease outcome. In the absence of randomized trial results, these observations may be beneficial in clinical decision making.

Ovarian dysgerminoma: a retrospective analysis of results of treatment, sites of treatment failure, and radiosensitivity.

Thirty-five patients with a diagnosis of pure ovarian dysgerminoma underwent assessment at our institution between 1950 and 1984. The median age of these patients was 21 years (range, 8 to 41 years). The surgical pathologic stages of the tumors were as follows: stage IA1 in 18 patients, stage IA2 in 2, stage IB1 in 2, stage IC in 1, stage IIB in 2, stage III in 9, and stage IV in 1. The overall survival at 5, 10, and 20 years was 94.3%, 82.9%, and 82.9%, respectively, for all 35 patients and 100%, 83.9%, and 83.9%, respectively, for the 18 patients with stage IA1 lesions. The maximum interval from diagnosis to relapse was 3.7 years. All patients were under surveillance for a minimum of 2 years (median follow-up, 15.9 years). Of the 18 patients with stage IA1 disease, 16 did not receive prophylactic radiation therapy to the para-aortic lymph nodes, and in 6 of the 16 (38%) recurrent disease developed in this region. Five of these patients were salvaged with radiation therapy and one with radiation therapy and subsequent chemotherapy. No definite correlation was noted between the size or mass of the resected unilateral encapsulated tumor and the risk of development of recurrent disease. For patients with stage IA1 dysgerminoma who have undergone unilateral oophorectomy, two treatment options seem reasonable: (1) observation, with radiation therapy reserved for subsequent recurrence, or (2) prophylactic radiation therapy (2,000 cGy) to para-aortic and ipsilateral common iliac lymph nodes, which would preserve fertility.

Primary head and neck cancer. Histopathologic predictors of recurrence after neck dissection in patients with lymph node involvement.

OBJECTIVE: Retrospectively analyze several histopathologic variables that may predict neck recurrence after neck dissection. DESIGN: From 1970 through 1980, 284 patients with pathologically confirmed metastatic squamous cell carcinoma underwent neck dissection and received no adjuvant therapy. Kaplan-Meier evaluation estimated a 74% 2-year neck recurrence-free rate. After adjusting for the standard covariates of age, gender, neck stage, and tumor grade, we also controlled for the time-dependent covariates of primary recurrence, occurrence in the side of the neck not operated on, or development of new head and neck primary disease. SETTING: A large referral-based practice. RESULTS: The number of lymph nodes involved, invasion of vascular/lymphatic space, invasion of soft tissue, and desmoplastic lymph node pattern adversely affect neck recurrence. A desmoplastic stromal pattern was associated with almost a sevenfold increased risk of neck recurrence. To our knowledge, this finding has not been reported previously. CONCLUSION: Histopathologic evaluation of metastatically involved cervical nodes can identify patients with head and neck cancer who are at high risk for recurrence.

Radiotherapy treatment planning for prostate cancer in patients with prosthetic hips.

Patients diagnosed with prostate cancer may also have a prosthetic hip. When planning radiotherapy for these patients, one must consider the attenuation of the dose when the beam passes through the prosthetic hip. It is best to avoid administration of radiation to the target through the prosthesis. Example treatment plans are evaluated. The potential advantages and disadvantages of each plan are reviewed.