Biomedical subjects
D H Hussey
Publications and source records attributed to D H Hussey.
Postoperative radiation therapy in clinical stage I endometrial cancer: corpus, cervical, and lower uterine segment involvement--patterns of failure.
PURPOSE: To evaluate involvement of the lower uterine segment (LUS) in adenocarcinoma of the endometrium and to identify patterns of treatment failure. MATERIALS AND METHODS: Two hundred four patients, aged 29-92 years, with endometrial carcinoma underwent surgery. Postoperative radiation therapy was administered for adverse histologic criteria, including deep myometrial invasion, high grade, or LUS involvement. RESULTS: The incidence of tumor involvement of the LUS was 19%; of the cervix, 14%; and of the corpus, 67%. Distant metastasis occurred in 3% of patients with LUS involvement and in 17% of patients with cervical involvement. The local recurrence rate was 50% among patients with LUS involvement with no other risk factors and no postoperative radiation therapy and was 3% among those who underwent radiation therapy (P = .023). CONCLUSION: Early local-regional spread may be the primary mechanism of treatment failure in tumor invasion of the LUS. Aggressive local management, including postoperative radiation therapy, may be necessary.
Patterns of care for carcinoma of the prostate gland: results of a national survey of 1984 and 1990.
BACKGROUND: The annual incidence of carcinoma of the prostate gland increased from an estimated 76,000 cases in 1984 to 200,000 in 1994. Part of this increase may be the result of increased detection. Management of the disease has also changed. To measure such changes, the American College of Surgeons conducted a patient care evaluation study of carcinoma of the prostate gland. STUDY DESIGN: Information was voluntarily submitted by cancer registrars on forms designed by a team of specialists. Data were received from 730 hospitals (of 2,000 hospitals invited for the study) on 14,716 patients with newly diagnosed adenocarcinomas of the prostate gland in 1984 and from 1,035 hospitals for 23,214 patients with carcinoma of the prostate gland in 1990. RESULTS: From 1984 to 1990, there was increased diagnostic use of the prostate specific antigen (PSA) test (from 5.1 to 66.4 percent of incident carcinomas) and transrectal ultrasound (TRUS) (0.9 to 19.7 percent). Use of the prostatic acid phosphatase assay declined from 62.4 to 47 percent. Although the proportion of early stage (0, I, II) disease increased for all racial or ethnic groups combined, the greatest increase was for whites (from 57.3 to 60.6 percent), while the increase for African-Americans was less (from 46.9 to 48.3 percent). The use of radical prostatectomy without radiation therapy or chemotherapy increased from 7.3 to 20.3 percent and the proportion of patients receiving no carcinoma-directed treatment decreased from 37.8 to 30 percent. Radiation therapy remained the same. Hormone therapy without radical prostatectomy declined from 24.4 to 19.7 percent. African-Americans had a lower five-year survival rate than whites, even when stratified for stage. CONCLUSIONS: The diagnostic use of the PSA test and TRUS increased markedly by 1990 and may have contributed to the increased diagnosis of carcinomas of the prostate gland and the earlier stage at diagnosis. The overall use of radical prostatectomy has increased and the proportion of patients receiving no treatment has decreased. African-Americans had a lower five-year survival rate than other groups, even when stage was controlled.
Cost-effectiveness of high-contrast-dose MR screening of asymptomatic brain metastasis.
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How many radiation oncologists will be needed under health care reform?
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Insurance coverage of patients with breast cancer in the 1991 commission on cancer patient care evaluation study.
BACKGROUND: Trends in the care of patients with cancer are monitored annually by the Commission on Cancer of the American College of Surgeons. In 1991 a patient care evaluation study of breast cancer was conducted, which among other questions examined the correlation of health insurance with type or quality of care delivered for breast cancer on a national basis. METHODS: The tumor registry system of the American College of Surgeons was used to obtain data on patients with breast cancer diagnosed in 1983 and 1990. Trends in diagnosis and treatment were correlated with the type of insurance or lack of insurance. RESULTS: Data were obtained from hospitals in 50 states on a total of 41,651 patients. The largest number of patients were covered by Medicare. Fewer than 5% were considered medically indigent. Medically indigent patients presented with higher stage disease and did not participate in a trend toward downstaging, which occurred between the two study years. The treatment of medically indigent patients appeared to be appropriate and comparable with better insured patients. Insurance type (health maintenance organization vs. private) did not affect stage, treatment, or outcome. Decisions to use controversial therapies, such as chemotherapy for stage I disease, did not appear to be financially driven. CONCLUSION: A nationwide pattern of care study for breast cancer indicates that medically indigent patients present with more advanced disease compared with better insured patients, but once the diagnosis is made, treatment and outcome have little to do with insurance type.
Implications of the anemia of chronic disorders in patients anticipating radiotherapy.
The authors assess prevalence of anemia in a population of patients anticipating radiation therapy. They also characterize the anemia and determine its relationship to stage, inflammation, and mortality. Blood counts were recorded for 81 of 103 patients surveyed during August 1988. When available, iron studies were used to characterize anemia. Stage, treatment, and 3-year mortality were obtained from tumor registry data. Many patients had anemia of chronic disorders. Therefore, 16 adults with solid tumors anticipating radiation therapy were evaluated with complete blood counts, iron studies, chemistries, erythropoietin, and measures of inflammation. Of 81 patients, more than half were anemic. Thirteen of 17 patients with anemia and with iron studies had anemia of chronic disorders. Two-thirds of patients with anemia had advanced cancer, versus one third of patients without anemia. Twice as many patients with anemia compared with those without anemia died within 3 years. Of 16 patients studied intensively, 4 had anemia, advanced cancer, and died within 6 months, whereas all 12 patients without anemia lived longer. The 4 patients with anemia had an elevated iron index (7.95), erythrocyte sedimentation rate (86 mm per hour), and C-reactive protein (4.48 mg/dL) versus those of 12 patients without anemia and 10 volunteers. Erythropoietin levels were not different significantly among groups. Anemia indicated a poor prognosis during and before radiotherapy, and anemia of chronic disorders was associated with advanced cancer and a short survival rate.
Cost-effectiveness of high-dose MR contrast studies in the evaluation of brain metastases.
PURPOSE: To investigate the cost-effectiveness of high-dose MR contrast studies in the management of brain metastases. METHODS: During the phase III clinical trial of high-dose contrast studies (0.3 mmol/kg), 11 of 27 patients were judged by the reviewers to have potential treatment changes based on the additional information provided by the high-dose studies. We retrospectively evaluated how many of these 27 patients had actual treatment changes because of the results of the high-dose study. Using the fee schedule at our institution, the cost-effectiveness was analyzed based on the cost savings from treatment changes and the additional expense of implementing the high-dose studies. RESULTS: A total of 3 craniotomies ($22,800 each) and 2 aggressive courses of radiation therapy ($1122 each) were avoided in 4 patients because of the additional lesions detected by the high-dose studies. This resulted in a treatment cost savings of $70,644. The extra expense for implementing the high-dose study is $9126 for a single injection in all 27 patients, $9295 for 2 separate injections completed in 1 visit in the 11 patients, and $11,154 for 2 separate injections completed in 2 separate visits. The cost savings in management (diagnosis and treatment) therefore ranged from $59,490 to $61,518 for all patients and from $2203 to $2278 per patient. CONCLUSION: Based on our limited data, the high-dose study seems to impact positively on the cost-effectiveness in the management of brain metastases. However, because our study had limitations, our results need to be confirmed with a larger patient population and a more standardized treatment approach and fee schedule.
1991 national survey of carcinoma of the breast by the Commission on Cancer.
A nationwide survey of patterns of care for carcinoma of the breast was conducted by the Commission on Cancer of the American College of Surgeons. Information regarding patient history, diagnostic tests, treatment, survival and disease status was obtained for 17,295 patients treated during 1983 and 24,356 patients treated during 1990. The results indicate that patients diagnosed in recent years (1990) are being treated at an earlier stage of the disease compared with the 1983 survey and the findings of earlier years, probably because of the use of mammography. Surgical treatment for conservation of the breast is being used more frequently, but modified radical mastectomy remains the most commonly used surgical treatment.
Acute and late reactions to radiation therapy in patients with collagen vascular diseases.
BACKGROUND: A commonly held belief is that patients with collagen vascular diseases (CVD) have a greater risk of radiation therapy complications than patients without CVD. This impression is based on anecdotal reports, however. METHODS: A group of 61 patients with CVD were compared with a matched control group of 61 patients without CVD. The CVD group included 39 patients with rheumatoid arthritis (RA), 13 with systemic lupus erythematosus (SLE), 4 with systemic sclerosis (scleroderma) (SSc), 4 with dermatomyositis, and 1 with polymyositis. The control group was matched with respect to age, sex, tumor site and histologic characteristics, treatment aim, general treatment method, radiation therapy technique, site irradiated, radiation dose, date of treatment, and follow-up. RESULTS: Overall, there was no significant difference between the CVD and control groups in terms of acute (11% versus 7%, respectively) or late complications (10% versus 7%, respectively). This was also true when only patients who were treated definitively were considered. Furthermore, none of the patients treated palliatively had complications. Three patients in the CVD group had fatal complications, compared with none in the control group. RA was associated with a slight increase in late complications in the definitively treated patients, whereas SLE was associated with a slight increase in acute reactions. No significant acute or late reactions were observed in the patients with SSc, dermatomyositis, or polymyositis. CONCLUSIONS: In general, these differences are less than expected and not statistically significant. Consequently, from these data, the authors could not show a significant increase in radiation therapy complications for patients with CVD.
Cervical cancer: application of MR imaging in radiation therapy.
PURPOSE: To evaluate magnetic resonance (MR) imaging in the planning of radiation therapy for patients with cervical cancer. MATERIALS AND METHODS: MR imaging was performed in 15 patients with predominantly advanced cervical carcinomas. Skin markings of the radiation ports were labeled with MR-detectable tubing and beads to assess the adequacy of port placement. Volume and extent of tumor at MR imaging were compared with those at physical and computed tomographic (CT) examinations. RESULTS: Tumor involvement of normal structures (parametrium, vagina, endometrium) was more extensive at MR imaging than at clinical examination in six patients (40%) and at CT in five patients (33%), resulting in modification of the radiation fields in eight patients (53%). Tumor size was larger on MR images than at clinical examination in 11 patients (73%). CONCLUSION: MR imaging can depict tumor volume and better delineate the extent of involvement than physical and CT examination. This can be useful for placement of radiation ports, especially when small boost fields are used.
Leptomeningeal carcinomatosis following craniofacial resection of an ethmoid tumor.
Leptomeningeal carcinomatosis (LMC) is a rare complication following treatment for head and neck cancer. In this paper, we report a case of LMC following surgery and localized radiation therapy for an ethmoid carcinoma, in which laceration of the dura during craniofacial resection may have provided an access for cancer cells into the cerebrospinal fluid (CSF). As a result, the patient developed LMC manifested as multiple spinal nerve root involvement. The patient died 3 months after the diagnosis of LMC. To avoid this type of complication, special care must be taken to prevent tears in the dura during craniofacial resection. Also, we recommend CSF examination be performed prior to radical surgery if there is any suspicion of meningeal invasion.
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.
Review of the manpower issue in radiation oncology.
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Three-dimensional viewing of and dosimetric calculations in Au-198 implants of the prostate.
A three-dimensional system for dosimetric calculation of radiation from interstitial brachytherapeutic implants was developed and was compared with conventional dosimetry performed with a commercial two-dimensional system. Software programs written for this study enabled the authors to place radioactive sources in the correct reconstructed anatomic locations, compute the isodose distribution around these sources, and display the isodose curves in their correct relationship to anatomic structures. Eight radiation oncologists evaluated the usefulness of both systems. Verification studies in phantoms and in 20 patients with gold-198 implants in the prostate gland showed that the experimental system was very accurate in volume reconstruction, seed localization, isodose distribution, point-dose calculation, and computation of dose-volume histograms. Although the dose depictions in the two systems matched almost exactly, statistically significant differences existed in interpretation of the dosimetric data generated by both systems. For example, the oncologists consistently believed that the dose to the prostate was lower when the three-dimensional system was used (P less than or equal to .0001).
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.
Morphometric studies in intraductal breast carcinoma using computerized image analysis.
A morphometric study was performed using computerized image analysis on the histologic specimens of 26 patients with intraductal carcinoma of the breast and 26 normal control patients. A significant incidence of necrosis (56%) was observed in the breast ducts containing intraductal carcinoma. This was characterized by one or more areas of necrosis surrounded by a rim of viable tumor cells. The mean diameter of the ducts containing intraductal carcinoma was 349 microns compared with a mean diameter of 90 microns for the normal ducts. The mean diameter of the ducts containing necrosis was 470 microns compared with a mean diameter of 192 microns for the ducts containing a solid pattern of intraductal carcinoma. Central necrosis occurred in 94% of the ducts more than 180 microns in radius, whereas only 34% of the ducts less than 180 microns in size contained necrosis. The width of the viable neoplastic tissue was less than 180 microns in 91% of the ducts. These results are analogous to the findings of Thomlinson and Gray in human lung tumor cords and provide indirect evidence for the existence of a hypoxic compartment in intraductal carcinoma of the breast. This could be an explanation for the higher local failure rate after conservative surgery and irradiation for infiltrating cancers containing an extensive intraductal component.