Application Of Radium Research Articles

Nasopharyngeal carcinoma: Results of treatment over a 27 year period, 1950 through 1977

In a retrospective study, 107 patients with squamous cell carcinoma of the nasopharynx were reviewed. One hundred six patients were treated primarily by radiation therapy and only one by surgery. The overall 5 year survival rate free of disease was 29 percent. Possible prognostic factors of age, sex, cancer stage, histopathology, and treatment were studied. The younger patients did significantly better. Patient's sex and clinical stage were not significant factors in this study. The patients with lymphoepitheliomas, anaplastic carcinomas, and those with poorly differentiated cell types did significantly better than those with more differentiated lesions. Fifty-five patients received irradiation therapy of 6,000 rads by external ports alone, and 51 patients received radiation therapy of 6,000 rads by external ports supplemented by 1,500 rads using an intracavitary radium applicator. The higher survival rate with the use of the supplementary dosage was only suggestively significant.

Applications of Carbon Dioxide Laser Surgery and Radiation: A Preliminary Report

Ten patients with advanced or recurrent squamous cell carcinomas of the upper airway were treated with a combination of carbon dioxide laser surgery and radiation therapy to evaluate the tolerance to rapid sequencing of both modalities in a variety of clinical situations. Other considerations were to accurately stage infiltrating tumors, to provide cytoreduction for T3 and T4 tumors, and to facilitate the optimal placement of intracavitary radium applicators. Because of minimal postoperative pain or dysfunction associated with the laser, patients were able to receive irradiation considerably sooner than with conventional surgery. Local tolerance was good to excellent in seven of the ten patients treated and, based on preliminary results, the combination would appear to offer advantages in curative approaches to advanced head and neck tumors.

The relationship between milligram-hours and dose to point A in carcinoma of the cervix.

The relationships between the Fletcher and Manchester methods in dosimetry of cancer of the uterine cervix were explored in order to compare dose prescriptions between the systems, to optimize the best features of both systems, and to establish the necessity for computerized dosimetry. A total of 91 Fletcher-Suit radium applications was analyzed by a linear least-square regression analysis to compare Point A and Point B doses of the Manchester system will milligram-hours of the fletcher system. Although moderately high correlations were found between milligram-hours of radium and doses at Point A and Point B, it was concluded that direct comparisons, particularly between individual patients, are fraught with dose uncertainties of clinical significance. In addition, the correlation between milligram-hours of radium and Point A dose was markedly affected by the position of the colpostats and tandem, thus making it difficult to formulate a simple conversion factor between the two systems.

Treatment of endometrial carcinoma with radiation therapy alone.

Of 393 patients treated at Tufts-New England Medical Center for endometrial carcinoma from 1968-1977, 66 patients underwent radiation therapy alone because of medical contraindications to surgery. The median age for this group was 70 years. The patient distribution was Stage I (39), Stage II (11), and Stage III and IV (16). Therapy consisted of pelvic irradiation to a dose of 4000-5000 rads followed by an intrauterine radium application (3000-5000 mg hr.) and a vaginal radium application (2000-4000 rads to the surface). Local control was achieved in 37 of 50 patients with Stages I and II disease with a three-year actuarial survival of 78%. Patients with Stages III and IV disease had a median survival of 15 months; 4 of 16 patients survived for 36 months. In this group of patients, bleeding pain, and vaginal discharge was palliated. Four patients in the series had treatment-related bowel complications requiring colostomy. This is an effective method of treatment for endometrial carcinoma patients who are not surgical candidates.

The value of radiometry in the treatment planning of inoperable carcinomas of the cervix (author's transl)

A retrospective study of 731 patients with carcinoma of the cervix in various stages showed that recurrences were most common in patients treated with combined local radium application and irradiation of the parametrium. The basis for radiation treatment planning had been radiometry after the radium application. A comparison of the position of the uterus as shown by this method with computer tomography carried out in 40 patients in the position used for irradiation showed that in more than half these patients there was a significant difference in the results. It therefore appears that it is necessary to determine the position of the uterus by computer tomography in all patients if the applicator deviates from the median line by more than 10 degrees and if the parametrium is not fixed. Frequently it is possible, at an advanced stage, to use a rotational method instead of repeated radium applications.

Surgical and combination therapy of cancer of the cervix uteri stages Ib and IIa

From 1974 to 1977, 211 consecutive women with carcinoma of the cervix stage Ib and IIa were referred to the Departments of Gynecology and Radiotherapy of the University Hospital, Odense. In 111 women the treatment was combination therapy, i.e., radium after the Stockholm-method (2100 rad two times with a 3-week interval) and extended hysterectomy with lymph node exeresis 6 weeks after the first application of radium. In 30 women treatment was exclusively with surgery, when age, weight, psyche, and tumor extension indicated. The third group of 70 women were treated with full radiation therapy because of advanced age, psychological reasons, or when medical disease contraindicated operation. Concerning survival all the women treated exclusively with surgery are still alive, and until now there seem to be no differences between the two other groups. If surgical and combined therapy were sufficient the urological and intestinal complications were few. The risk of central recurrence was eliminated, and normal sexual function could be preserved. It is recommended that treatment of cancer of the cervix be centralized. Specialized teams of gynecologists and radiotherapists are imperative if a high survival and quality of life is to be secured in women with early cervix cancer.

Carcinoma of the uterine cervix: review of experience at University of Kansas Medical Center.

A total of 211 patients with a diagnosis of carcinoma of uterine cervix, managed by radiotherapy at the University of Kansas Medical Center between 1969-1975 was reviewed. There were 90 patients in Stage I, 65 in Stage II, 43 in Stage III, and 13 with Stage IV disease. Squamous cell carcinoma was found to be the most common histologic type. Twenty-three patients had shown uterine extension of the disease; of these, eight had adenocarcinoma. The majority of the patients received external whole-pelvic telecobalt therapy followed by a variety of intracavitary radium applications. The combined dose to point A ranged from 5000-13,000 rad. There were 166 patients followed for five or more years. Overall five-year survival was 74% (124/166). Survival by stage: IA--92% (12/13); IB--88% (55/62); IIA2--74% (23/31); IIB--58% (14/24); IIIA&B--64% (18/28); and IV--25% (2/8). The overall three-year survival was 73% (155/211). Thirty-three patients (33/211 = 16%) developed local recurrence, and five of these patients were salvaged by surgery. Surgery for complications was required in nine patients. Rectovaginal and vesicovaginal fistulae occurred in three patients (1.5%). Local recurrence and complications vs. dose and system used were analyzed.

Postmenopausal bone mineral loss after treatment for malignant gynaecologic tumours.

Bone mineral content after treatment for malignant gynaecologic tumours was examined in women of fertile age. The treatment given was intracavitary radium applications followed by bilateral oophorectomy. In women who received oestrogen substitution the bone mineral content increased by one per cent a year, whereas nonsubstituted women lost 3 per cent of their initial bone mineral content per year. The findings suggest that oestrogen deficiency is the predominant cause of bone mineral loss initiated by this therapy.

A simple function describing the absorption in platinum for dose-rate calculations around radium applicators.

The diminution of exposure rate from radium gamma radiation by filtration through platinum can be described very accurately by gamma 0/(1 + mu0d) for wall thickness d from 0.2 mm to 4.0 mm (gamma 0 = 6.356 x 10(-5) A m2/kg2 or 8.869 R cm2 h-1 mg-1; mu0 = 1.501 cm-1). This function fits generally accepted data to within experimental error, to an accuracy not achieved by any single exponential factor. The expression is derived theoretically from a simple approximation to the spectral distribution of radium gamma radiation. With this type of transmission function, the expression for the exposure rate around linear radium sources in platinum tubes (generalized Sievert integral) is readily integrated in terms of elementary functions. Used in place of the Sievert integral in calculations of dose distributions, this new fomulation makes possible straightforward numerical evaluation and avoids the storage of tabulated values in computer programmes.

The treatment of inoperable endometrial cancer by means of intracavitary radiotherapy (author's transl)

Epidemiological data are presented to point out the importance of endometrial cancer and the role of primary irradiation. 650 patients with endometrial cancer, who could not be operated because of local tumor spread or contraindication to surgery were treated by primary irradiation at the Department of Radiotherapy of the 1st University-Clinic of Gynecology and Obstetrics in Vienna. 312 patients (48%) were alive after five years. Severe proctitis and/or cystitis was seen in 10,8% fistulas in 2% of the treated patients. These results were obtained with conventional intracavitary radium application.

Morbidity from large dose fractions in radiotherapy

Dr. Singh (1978; 1979) reported that when he treated patients with Stage III cancer of the cervix once weekly instead of with five fractions per week he achieved: (i) apparently equivalent tumour control rates; (ii) apparently equivalent acute responses in bowel; (iii) unacceptably severe late injuries of bowel in all 24 patients surviving one year after treatment. Since the radium applications were the same in the once-weekly and the five-times-weekly regimens, and since in both groups only the parametria were treated after radium insertion, the difference in late rectal complications between the two groups of patients presumably reflects a difference between the late biological effectiveness of the external beam treatments given before radium insertion, that is, between 4000 rad given as five fractional doses of 200 rad per week, and 2900 rad given as five fractions of 580 rad over a 28-day period.

Carcinoma of the Vagina

Twenty-two patients with Stage I through IV primary vaginal squamous cell carcinomas treated for cure with radiation therapy are reviewed, with particular emphasis on the relationship of dose to complications and local control. All but 2 patients received 4000 to 6000 rad whole pelvis irradiation plus at least one radium application. Local control was 91%, with an absolute 2-year disease-free survival of 82%. The degree of anaplasia was found to influence prognosis, with all local and distant failures resulting from high-grade lesions. The complication rate was modest, with no fistulae or serious bowel complications. An analysis of total dose (external plus radium) with respect to local failure and complications showed that no major complications occurred at a combined dose below 9000 rad. An analysis of the individual contributions of external irradiation and radium implants showed that all but one very minor complication occurred at a radium dose of 4000 rad or higher. From these data, overall treatment planning and total dose recommendations are made.

External irradiation and one radium application for carcinoma of the cervix

Between August 1968 and May 1976 at the Tufts-New England Medical Center, Boston, Massachusetts, 264 patients with carcinoma of the cervix on intact uteri were treated with external irradiation followed by one radium application. Of these patients, 78 presented with Stage 1,126 with Stage II, 51 with Stage III, and 9 with Stage IV disease. In a majority of patients, external irradiation was given with 60Co when AP diameter was less than 17 cm, and with a 46 MeV Brown-Boveri Betatron when AP diameter was greater than 17 cm. A whole pelvic dose of 4000 rad was given for tumors smaller than 5 cm in size and 4500 rad for those larger than 5 cm. A dose was then given to the pelvic wall using 4 cm or 5 cm midline blocks. In Stage I disease, tumors of less than 2 cm received no pelvic wall irradiation and tumors greater than 2 cm and Stage HA patients received 1000 rad to both pelvic walls. In Stage IIB and IIIA disease, a dose of 1000 rad was given to the uninvolved pelvic wall and 1500 rad to the involved site. In Stage IIIB disease, after giving 1500 rad to the involved parametria, an additional 500 rad was given with a reduced field to the area of gross tumor in the parametrium. All patients had one radium application for 72 hr 7–14 days after completion of all external irradiation. There were no pelvic failures in Stage I patients, 8 56 in Stage IIA, 10/70 in Stage IIB, and 17 52 in Stage III. The 5 year no evidence of disease (NED) actuarial survival was 100% in early Stage III (less than 1 cm), 90% in Stage III (greater than 1 cm), 79% in Stage IIA, 58% in Stage IIB, 42% in Stage III and 23% in Stage IV. There was no difference in survival or complications between patients who had tandem and colpostats and those who had protruding tandem.

Carcinoma of the uterine cervix. Results of treatment in 2 248 cases.

Data on the survival of 2 248 patients with cervical carcinoma, treated between1966 and 1972 at 3 oncologic centers in Cuba, are presented. Intracavitary radium application combined with external 60Co irradiation was the main treatment method. The most frequent complication was radiation proctitis, but fistulas occurred only in 1.6 per cent.

The dose—time relationship in the radiotherapy of carcinoma of the cervix uteri: An application of the CRE formalism

A correlation could be obtained between the likelihood of control of central and nodal disease and the corresponding local CRE levels attained in a group of 79 cases of carcinoma of the cervix uteri treated according to a multistage protocol involving a combination of external telecobalt irradiation and intracavitary radium application. A nodal CRE level of 1700 reu and a central CRE value of 2900 reu seemed to be optimal for control of modal metastases and central disease respectively. These CRE levels seemed to be well tolerated even if salvage surgery had to be performed.

Carcinoma of the vagina.

Twenty-two patients with Stage I through IV primary vaginal squamous cell carcinomas treated for cure with radiation therapy are reviewed, with particular emphasis on the relationship of dose to complications and local control. All but 2 patients received 4000 to 6000 rad whole pelvis irradiation plus at least one radium application. Local control was 91%, with an absolute 2-year disease-free survival of 82%. The degree of anaplasia was found to influence prognosis, with all local and distant failures resulting from high-grade lesions. The complication rate was modest, with no fistulae or serious bowel complications. An analysis of total dose (external plus radium) with respect to local failure and complications showed that no major complications occurred at a combined dose below 9000 rad. An analysis of the individual contributions of external irradiation and radium implants showed that all but one very minor complication occurred at a radium dose of 4000 rad or higher. From these data, overall treatment planning and total dose recommendations are made.

Interstitial therapy in gynecological cancer

Between January 1971 and May 1975, interstitial implants were performed in 81 patients with gynecologic malignancies. Patients were selected for treatment on the basis of having large residual tumor following external irradiation (5000 rads) and no cavity to accommodate adequate intracavitary radium application. All sites, histologies, and stages of disease were represented. There were 45 implants to the vagina, 24 to the cervix, 7 to the vulva or perineum, and 5 to the pelvic or groin nodes. The technique of treatment depended upon the location and size of disease. Local control of the tumor was achieved in 71.6% of the patients ( 58 81 ), with only four major complications. The results of treatment are presented in detail with regard to local control, survival, and complication.

Can treatment of carcinoma of the cervix be individualized?

Assessment of response of cervical cancers to irradiation by the conventional histological method of biopsies done during the course of radiotherapy in 51 Stage I and early stage II patients was discussed. The prediction of response to irradiation was based on the nuclear and cytoplasmic changes in the tumor cells. Two applications of intracavitary radium or external irradiation followed by intracavitary radium were given to the patients. Wertheim hysterectomy was done 4–6 weeks after irradiation in the former and 3–4 weeks after irradiation in the latter. The accuracy of the prediction was correlated with the presence of residual growth in the surgical specimens. The prediction based on biopsies done after intracavitary radium was found to be of significance. If the patient was treated initially by external irradiation, biopsy should only be taken after 5400 rad or on completion of the whole course. Validity of this study was discussed. It was concluded that it is possible to select patients who would respond poorly to irradiation for surgery.

Survival and complications in cervical cancer treated by pelvic and extended field radiation after paraaortic lymphadenectomy

Over a 3 year period, 49 patients with invasive cancer of the cervix underwent paraaortic lymphadenectomy. Of this group, 18 were stage lb, with cervix 3 cm or smaller, and were treated by radical hysterectomy. All had negative paraaortic nodes. The remaining 31 patients had more advanced disease and underwent radiation therapy in addition to the paraaortic lymphadenectomy. Thirteen patients with positive paraaortic nodes were treated with extended field radiation to the level of the diaphragms with 4,500 rad plus intracavitary radium applications. The remaining 18 patients with negative paraaortic nodes were treated to the fifth lumbar vertebra with 5,000 rad plus radium applications. The age of the patients and stage of the disease were similar for both groups. After 13-36 months of follow-up, the survival rate was 38% for patients with positive nodes compared to 72% for those with negative nodes. About half of both groups suffered complications. More study must be given to alternative treatments of advanced carcinoma of the cervix.

An improved cervical radium applicator.

Design improvements have retained the advantages of a previously described afterloading radium system, while facilitating insertion by minimizing the space required for passing the apparatus through the introitus. The mechanical integration of the parts of the apparatus results in smoother insertion, reliability of positioning, and less patient discomfort.