Biomedical subjects

W H Morrison

Publications and source records attributed to W H Morrison.

At least 55 records · Page 3Linked to original sources

PubMed1995

Postoperative radiation of free jejunal autografts in patients with advanced cancer of the head and neck.

BACKGROUND: Free jejunal autografts increasingly are being used to repair the pharynx after resections of head and neck carcinomas. Doses of greater than 45 Gy are generally considered to be above the tolerance of the small bowel, whereas the dose range for effective postoperative radiotherapy of advanced head and neck cancers is between 57.6 Gy and 63 Gy. Between July 1988, and December, 1992, 29 patients at the M. D. Anderson Cancer Center were treated with a combination of resection of the advanced head and neck cancer, reconstruction with free jejunal autograft, and postoperative radiation. Planned reductions in postoperative doses due to the presence of the jejunum within the field were not made. This retrospective study analyzes the outcome of these patients with attention to survival, local-regional control, and complications. METHODS: Twenty-seven of the 29 study patients had squamous cell carcinoma of the larynx or pharynx; 24 of these patients had Stage III or Stage IV disease. Two patients had recurrent papillary thyroid carcinoma. The median number of days from surgery to the start of radiation was 34. Radiation doses to the tumor bed ranged from 50 Gy to 72 Gy. The median doses to the tumor bed and the jejunal autograft were both 63 Gy. Surviving patients were followed from 12 to 68 months (median, 20 months) from the time of their surgery. RESULTS: The actuarial 2-year survival rate was 51%. Nine patients had local or regional recurrences above the clavicles. The 2-year local-regional control and freedom from relapse rates were 71 and 50%, respectively. The most severe complication during radiation was confluent mucositis in greater than 50% of the treated area, which developed in two patients. No patient developed a late complication related to the jejunal autograft. CONCLUSIONS: Postoperative radiation to free jejunal autografts used for pharyngeal reconstruction can be delivered safely. Doses in this setting of 57.6 Gy to 63 Gy depending on the anticipated risk of recurrence based on clinical, surgical, and pathologic findings are recommended. The presence of a free jejunal autograft did not require a reduction of the desired doses used for patients with postoperatively irradiated head and neck cancer.

Actuarial Analysis↗

PubMed1995

Hyperfractionated radiation in the treatment of squamous cell carcinomas of the head and neck: a comparison of two fractionation schedules.

PURPOSE: In 1984 we began treating patients with squamous cell carcinomas of the larynx and hypopharynx with hyperfractionated radiotherapy. Patients received 76.8 Gy in 1.2 Gy fractions twice daily, with a 4 h interfraction interval. In 1988, this schedule was modified in patients treated with shrinking field techniques. The dose per fraction was slightly reduced (while not changing the total dose), and the interfraction interval was increased to 6 h. The goal was to decrease toxicity while maintaining satisfactory local-regional control. This retrospective study analyzes the results of this schedule modification. METHODS AND MATERIALS: Two hundred thirty-six patients were included in the analysis. Distribution of patients by primary site and T stage was as follows: supraglottic larynx, 120 patients; hypopharynx, 70; true vocal cord, 24; and oropharynx, 22; T1, 5 patients; T2, 118; T3, 93; T4, 19; and Tx, 1. Ninety-nine patients presented with cervical nodal disease. Seventy-eight patients (group A), including 16 treated with induction chemotherapy, were treated throughout with 1.2 Gy fractions twice daily and a 4-h interfraction interval. Subsequently, 158 patients (group B), 57 of whom received chemotherapy, received 1.1 Gy fractions to 55 Gy, and then 1.2 Gy fractions to their boost volumes to 76.6 Gy. The interfraction interval was 6 h. Median follow-up was 91 and 35 months for group A and B, respectively. RESULTS: Two-year actuarial survival, local control, and ultimate local rates were 70%, 75%, and 85%, respectively. Differences between survival rates for group A and group B were not statistically significant, with 2-year rates of 66% and 72%, respectively. Overall local control rates at 2 years were 77% and 74%, respectively, for groups A and B (p = 0.22). However, there was a trend toward inferior results in group B patients with T3 disease (67% at 2 years compared to 76% in group A, p = 0.13). Confluent mucositis and persistent mucositis developed in 52% and 14% of group A patients, but only 37% and 4% of group B patients (p = 0.02 and p < 0.01, respectively). There was a near significant trend toward fewer late complications in group B who developed an 8% complication rate at 3 years compared to 15% of group A patients (p = 0.07). CONCLUSIONS: The net effect of reducing the dose per fraction to 1.1 Gy twice daily for fields covering gross disease and subclinical sites, and increasing the interfraction interval to 6 h was to reduce the incidence of both acute and late complications. Excellent overall local control rates (85%) for T2 lesions were achieved with both hyperfractionation regimens and we, therefore, continue to treat patients with T2 tumors with the modified schedule. The overall results in selected patients with T3 lesions was also satisfactory (69%), but as there was a trend towards poorer local control in patients treated with 1.1 Gy fractions, we recommend using 1.2 Gy for the entire treatment of these patients, while maintaining the 6 h interfraction interval to reduce the risk of late complications.

Adult↗

PubMed1995

Laryngeal preservation for advanced laryngeal and hypopharyngeal cancers.

OBJECTIVE: To compare a single institutional experience with combination chemotherapy and radiation for laryngeal preservation with historical age-, sex-, stage-, and site-matched controls who underwent laryngectomy for cancer of the larynx or hypopharynx. DESIGN: Fifty-five patients with stage III or IV laryngeal and hypopharyngeal squamous carcinoma were prospectively entered into a protocol to receive three cycles of cisplatin (+/- bleomycin sulfate) and fluorouracil and radiation therapy from 1986 to 1991 (group 1). Following two cycles of chemotherapy, the clinical tumor response was assessed and responders received a third cycle of chemotherapy followed by definitive radiation therapy. Nonresponders underwent surgical salvage. Two patients in the surgical control group were matched to each protocol patient (n = 110, group 2) regarding site, stage, sex, and age (+/- 7 years) without knowledge of patient outcome. SETTING: A tertiary cancer referral center, The University of Texas M. D. Anderson Cancer Center, Houston. RESULTS: Following chemotherapy, the tumor response rate for group 1 was complete in 38% and partial in 31%. With a median follow-up of 24 months (group 1) and 37 months (group 2), the Kaplan-Meier 2-year disease-specific survival for group 1 and 2 was 63% and 74%, respectively (P = .251). Among group 1 patients, 67% retained their larynges. Local recurrences were more frequent among the laryngeal preservation group (P = .001), whereas distant metastasis was more frequent among controls (P = .35). Thirty-three percent (18/55) of group 1 patients required total laryngectomy. Examining these subsets of patients showed that of the 67% (n = 37) of patients who retained their larynges, their 2-year survival was 56%, not significantly different from their respective controls (n = 74), 71%. Additionally, 2-year survival among the 18 group 1 patients who required salvage laryngectomy was 75% as compared with 80% for their matched controls (n = 36). CONCLUSIONS: These results document the results of chemotherapy and radiation therapy in the treatment of patients with advanced laryngeal and hypopharyngeal cancers in preserving the larynx. Although local control is significantly compromised among these patients, there is no compromise in overall survival when combined with prompt surgical salvage.

Antineoplastic Combined Chemotherapy Protocols↗

PubMed1995

Alterations in structure, chemistry, and biodegradability of grass lignocellulose treated with the white rot fungi Ceriporiopsis subvermispora and Cyathus stercoreus.

The white rot fungi Ceriporiopsis subvermispora FP-90031-sp and Cyathus stercoreus ATCC 36910 were evaluated for their ability to delignify Bermuda grass (Cynodon dactylon) stems and improve biodegradability. Compositional and structural alterations in plant cell walls effected by the fungi were determined by nuclear magnetic resonance spectroscopy, gas chromatography of alkali-treated residues, microspectrophotometry, and electron microscopy. Contaminating bacteria and fungi, which grew from unsterilized Bermuda grass stems, did not alter the improvement in grass biodegradability by either of the fungi from that of gas-sterilized stems. The biodegradation of stems by ruminal microorganisms, after treatment for 6 weeks with C. subvermispora or C. stercoreus, was improved by 29 to 32% and by 63 to 77%, respectively; dry weight losses caused by pretreatment with the fungi were about 20% over that in untreated, control stems. Both fungi preferentially removed aromatics to carbohydrates, and C. subvermispora removed proportionately more guaiacyl units than did C. stercoreus. Substantial amounts of ester-linked p-coumaric and ferulic acids were removed by both fungi, and about 23 and 41% of total aromatics (determined after 4 M NaOH direct treatment) were removed from the plant biomass after incubation with C. subvermispora and C. stercoreus, respectively. UV absorption microspectrophotometry indicated that ester-linked phenolic acids were totally removed from the parenchyma cell walls, and these cells were readily and completely degraded by both fungi. However, aromatic constituents were only partially removed from the more recalcitrant sclerenchyma cell walls, resulting in variation in electron density and random digestion pits after incubation with fiber-degrading bacteria.(ABSTRACT TRUNCATED AT 250 WORDS)

Basidiomycota↗

PubMed1994

Postoperative radiotherapy for cutaneous melanoma of the head and neck region.

PURPOSE: To assess the efficacy and toxicity of elective-adjunctive radiotherapy given in five 6-Gy fractions to patients with cutaneous melanoma of the head and neck at high risk for local-regional relapse. METHODS AND MATERIALS: From 1983 to August 1992, 174 patients (132 men and 42 women) were enrolled. The ages ranged from 16 to 89 years (median: 54 years). One group (n = 79) received elective irradiation after wide local excision of lesions > or = 1.5 mm thick, or Clark's level IV-V, a second group (n = 32) received adjunctive irradiation after excision of primary lesions plus limited neck dissection, and a third group (n = 63) received irradiation after neck dissection for nodal relapse. Each group had a projected local-regional recurrence rate of approximately 50%. The radiotherapy consisted of five fractions of 6 Gy each, specified at Dmax, delivered twice a week, to a total dose of 30 Gy in 2.5 weeks. Electron beams of appropriate energies were used whenever possible. Junction lines between adjoining fields were moved twice to minimize dose heterogeneity. Patients were seen at regular intervals to assess disease status and therapy-related complications. Patients who relapsed were treated as indicated by the clinical status. RESULTS: With a median follow-up of 35 months, 111 of 174 patients were alive. The disease recurred above the clavicles only in six patients, at distant sites in 58 patients, and both local-regionally and at distant sites in nine patients. The actuarial 5-year local-regional control (LRC) and survival rates for the whole group were 88% and 47%, respectively. The thickness of the primary lesion, presence of more than three positive nodes, and extracapsular extension did not influence the LRC rate after radiotherapy (range: 85-92%). However, lesion thickness strongly affected the 5-year survival rate of group 1 patients (i.e., 100% for < or = 1.5 mm thick, but Clark's level IV, 72% for > 1.5-4 mm, and 30% for > 4 mm). In groups 2 and 3, the 5-year survival rate of patients with > three involved nodes was lower than that of patients with one to three positive nodes (23% vs. 39%). The acute tolerance to adjunctive radiotherapy was excellent. Late radiation complications were observed in only three patients. These were moderate neck fibrosis, mild ipsilateral hearing impairment, and transient exposure of external auditory canal cartilage. CONCLUSION: The safety of this hypofractionated radiotherapy regimen in the management of cutaneous melanoma was established in this study. The overall 5-year actuarial LRC rate of 88% was much higher than that of our historical group and that reported in the literature (50%). The survival rate of patients with lesion of 1.5-4 mm thickness was also higher than that observed in other series. Based on these results a prospective randomized study to further define the role of adjunctive postoperative radiotherapy is planned.

Adolescent↗

PubMed1994

Postoperative radiation therapy for malignant tumors of minor salivary glands. Outcome and patterns of failure.

BACKGROUND: In the treatment of major salivary gland cancers, the addition of adjuvant postoperative radiation therapy for patients with high risk features has been shown to reduce the incidence of local failure. This retrospective study was done to determine the effectiveness of this approach for minor salivary gland cancers, to document patterns of failure, and to define prognostic variables for treatment outcome. METHODS: Between 1961 and 1990, 160 patients received postoperative radiation at the University of Texas M. D. Anderson Cancer Center (UTMDACC) after gross total removal of their tumors. These operations ranged from excisional biopsies to craniofacial resections with orbital exenterations depending on the original site and size of the tumor. The primary tumor site was in the oral cavity-oropharynx in 111 patients and in the nasal cavity or paranasal sinuses in 46 patients. The most prevalent histologic type was adenoid cystic carcinoma (71%). Microscopic positive margins were present in 64 (40%) patients. Half of the patients had pathologic evidence of perineural invasion. Radiation therapy techniques varied, depending on the site and extent of disease and the era of treatment. Doses ranged from 50 to 75 Gy (median, 60 Gy; mean 59.2 Gy). Follow-up for surviving patients ranged from 24 to 270 months (median, 110 months). RESULTS: Fifty-seven (36%) patients experienced disease relapse. Nineteen (12%) patients had a local recurrence: 6 within 5 years of treatment, 8 between 5 and 10 years, and 5 after 10 years. Regional failures occurred in 3 of 13 patients with initially node-positive disease but were uncommon (less than 5%) in patients with node-negative disease, regardless of elective neck treatments. Distant metastases developed in 43 patients, mostly (79%) within 5 years of treatment. Actuarial overall survival rates at 5, 10, and 15 years were 81%, 65%, and 43%, respectively. Complications occurred in 51 patients and were of three predominate types: hearing loss (26 patients), ocular injury (15 patients), and bone exposure/necrosis (12 patients). Improved techniques, including better immobilization, customized beam shaping, and treating multiple fields per day, have substantially reduced the risk of serious complications during the past decade. CONCLUSIONS: Postoperative radiation therapy is effective in preventing local recurrence in most patients with minor salivary gland tumors after gross total excision. When local failure occurs, it tends to be a late event. For most patients, the authors recommend a postoperative dose of 60 Gy in 30 fractions to the operative bed; if there is named nerve invasion, the path of the nerve is treated electively to its ganglion.

Adolescent↗

PubMed1994

Radiation-induced injury to the visual pathway.

Radiation-induced injury to the visual pathway was reviewed in a cohort of patients treated for various cancers of the nasal cavity and paranasal sinuses between 1969 and 1985. The study subjects consisted of 219 patients, 137 men and 82 women, in whom detailed records were available on the extent of orbital shielding, treatment plan for estimating doses delivered to various optic structures, and visual acuity follow-up information. There was a wide range in doses administered to various optic structures because patients with different primary lesion types were included and the radiotherapy techniques used varied during this era. The endpoint of the study was visual acuity < 20/100. The Cox proportional hazard model was used to assess the influence of various factors on the latent time to visual impairment and to fit the LQ model to the failure-time data. Actuarial curves showing the proportion of patients with visual impairment as a function of dose and time were generated. Corneal injury occurred in 24 of the 49 patients treated with the 3-field technique without any orbital shielding; variables affecting the incidence of cornea injury were total radiation dose and chemotherapy. Symptomatic retinopathy was diagnosed in 7 of 77 patients who received irradiation to a relatively large retinal surface, but no variables were found to correlate with this complication. Eight patients developed ipsilateral blindness due to optic neuropathy and 11 patients had bilateral visual impairment secondary to chiasm injury. The total radiation dose was identified as the predominant determinant. None of patients receiving a dose of < 50 Gy developed optic neuropathy or chiasm injury.(ABSTRACT TRUNCATED AT 250 WORDS)

Blindness↗

PubMed1993

Dosimetric evaluation of total scalp irradiation using a lateral electron-photon technique.

PURPOSE: To evaluate the radiation dosimetry of a new technique for total scalp irradiation. METHODS AND MATERIALS: A treatment technique described by Akazawa (1989) has been studied. During each fraction, two electron and two photon fields are treated. While most of the lateral scalp is treated with the electron fields, a rind of scalp close to the midsagittal plane is irradiated by parallel-opposed lateral photon fields. A wax bolus is used to build up skin dose and to protect the brain from electron dose. The dose distribution and dose-volume histograms were evaluated for different field arrangements using a 3-dimensional treatment planning system. After modifying the technique, in-vivo thermoluminescent dosimetry were used to evaluate the dose distributions for the first two patients. RESULTS: To compensate for the lack of dose from the opposed photon field at the junction, the technique was modified using overlapped fields instead of abutting fields. A field overlap of 3 to 4 mm between the electron and photon fields was found optimal. When used with the field junction shift of 1 cm midway through the treatment, this scheme resulted in a dose uniformity of -5% to +15% of the prescribed dose in the region of abutment. Results of the 3-dimensional dose calculation were supported by in-vivo thermoluminescent dosimetry on two patients. CONCLUSION: On the basis of computer dose calculations and in-vivo dosimetry. Akazawa's technique for scalp irradiation can be improved by using a 3 to 4 mm overlap of electron and photon fields. This modified technique is practical and produces clinically acceptable dosimetry.

Clinical Protocols↗

PubMed1993

Evaluation of the dose for postoperative radiation therapy of head and neck cancer: first report of a prospective randomized trial.

PURPOSE: This study was designed to determine in a prospective randomized trial the optimal dose of conventionally fractionated postoperative radiotherapy for advanced head and neck cancer in relation to clinical and pathologic risk factors. METHODS AND MATERIALS: Between January 1983 and March 1991, 302 patients were enrolled on the study. This analysis is based on the first 240 patients entered through September 1989, of whom 221 (92%) had AJC Stage III or IV cancers of the oral cavity, oropharynx, hypopharynx, or larynx. The patients were stratified by postulated risk factors and randomized to one of three dose levels ranging between 52.2 Gy and 68.4 Gy, all given in daily doses of 1.8 Gy. Patients receiving > 57.6 Gy had a field reduction at this dose level such that boosts were only given to sites of increased risk. RESULTS: The overall crude and actuarial 2-year local-regional recurrence rates were 25.4% and 26%, respectively. Patients who received a dose of < or = 54 Gy had a significantly higher primary failure rate than those receiving > or = 57.6 Gy (p = 0.02). No significant dose response could be demonstrated above 57.6 Gy except for patients with extracapsular nodal disease in the neck in whom the recurrence rate was significantly higher at 57.6 Gy than at > or = 63 Gy. Analysis of prognostic factors predictive of local-regional recurrence showed that the only variable of independent significance was extracapsular nodal disease. However, clusters of two or more of the following risk factors were associated with a progressively increased risk of recurrence: oral cavity primary, mucosal margins close or positive, nerve invasion, > or = 2 positive lymph nodes, largest node > 3 cm, treatment delay greater than 6 weeks, and Zubrod performance status > or = 2. Moderate to severe complications of combined treatment occurred in 7.1% of patients; these were more frequent in patients who received > or = 63 Gy. CONCLUSION: With daily fractions of 1.7 Gy, a minimum tumor dose of 57.6 Gy to the whole operative bed should be delivered with a boost of 63 Gy being given to sites of increased risk, especially regions of the neck where extracapsular nodal disease is present. Treatment should be started as soon as possible after surgery. Dose escalation above 63 Gy at 1.8 Gy per day does not appear to improve the therapeutic ratio.

Adult↗

PubMed1993

Chemoradiation therapy for anal cancer: radiation plus continuous infusion of 5-fluorouracil with or without cisplatin.

Chemoradiation therapy for anal cancer was carried out in 58 patients using low-dose, continuous infusion of 5-fluorouracil (5-FU) with or without continuous infusion of cisplatin (cDDP) and external beam irradiation (chemoXRT). Thirty-nine patients received 5-FU chemoXRT resulting in a local control rate of 50% in those receiving a total dose of < 45 Gy, 73% for those receiving 50-54 Gy, and 83% for those receiving > 60 Gy. The actuarial local control rate at 2 years was 77% after chemoXRT alone; overall local control was 67% at 5 years. In 18 patients receiving 5-FU plus cisplatin with radiation doses of 54-55 Gy, actuarial local control was 85% at 2 years. Fifteen patients failed chemoXRT, 13 of whom had abdominoperineal resection for salvage; the overall local control rate was 93% (54/58). The actuarial survival at 5 years was 81% for the 5-FU chemoXRT group and 94% at 2 years for the 5-FU plus cisplatin chemoXRT group; median follow-up was 54 and 20 months, respectively. Diarrhea and nausea were the most frequent early reactions and were ameliorated by limiting the duration of chemotherapy to 5 days/week and by using XRT techniques to exclude the small bowel from the radiation portal. Serious late radiation complications have not been observed and may be related to XRT fractionation and the use of protracted chemotherapy infusion. The absence of late morbidity coupled with the high local control rate by the use of this chemoXRT program is an area to investigate for improving the therapeutic ratio for the treatment of anal cancers.

Anal Gland Neoplasms↗

PubMed1993

Microbial delignification with white rot fungi improves forage digestibility.

Three wild-type white rot fungi and two cellulase-less mutants developed from Phanerochaete chrysosporium K-3 (formerly Sporotrichum pulverulentum) were tested for their ability to delignify grass cell walls and improve biodegradation by rumen microorganisms. Fungal-treated and control stems of Bermuda grass were analyzed for their content of ester- and ether-linked aromatics by using alkali extraction and gas chromatography, for in vitro dry weight digestion and production of volatile fatty acids in in vitro fermentations with mixed ruminal microorganisms, for loss of lignin and other aromatics from specific cell wall types by using microspectrophotometry, and for structural changes before and after in vitro degradation by rumen microorganisms by using transmission electron microscopy. P. chrysosporium K-3 and Ceriporiopsis subvermispora FP 90031-sp produced the greatest losses in lignin and improved the biodegradation of Bermuda grass over that of untreated control substrate. However, C. subvermispora removed the most lignin and significantly improved biodegradation over all other treatments. Phellinus pini RAB-83-19 and cellulase-less mutants 3113 and 85118 developed from P. chrysosporium K-3 did not improve the biodegradation of Bermuda grass lignocellulose. Results indicated that C. subvermispora extensively removed ester-linked p-coumaric and ferulic acids and also removed the greatest amount of non-ester-linked aromatics from plant cell walls. Microscopic observations further indicated that C. subvermispora removed esters from parenchyma cell walls as well as esters and lignin from the more recalcitrant cell walls (i.e., sclerenchyma and vascular tissues). C. subvermispora improved in vitro digestion and volatile fatty acid production by ruminal microorganisms by about 80%, while dry matter loss due to fungi was about 20% greater than loss in untreated control stems. The chemical and structural studies used identified sites of specific fungal attack and suggested mechanisms whereby improvement occurred.

Journal Article↗

PubMed1993

Effectiveness of combined induction chemotherapy and radiotherapy in advanced nasopharyngeal carcinoma.

PURPOSE: This prospective trial was conducted with the goal of achieving an improvement in both overall and progression-free survival in previously untreated patients with stage IV nasopharyngeal carcinoma who received an induction chemotherapy regimen of fluorouracil (5-FU) and cisplatin followed by radiotherapy. PATIENTS AND METHODS: From January 1985 to January 1990, 47 patients with T1-4N2-3M0 squamous cell carcinoma of the nasopharynx were treated at The University of Texas M.D. Anderson Cancer Center with two to three cycles of 5-FU (1,000 mg/m2 continuous infusion per day x 5 days) plus cisplatin (100 mg/m2 continuous infusion on day 1 only) followed by radiotherapy using the conventional time/dose schedule. RESULTS: The response rate to chemotherapy was 93.2% (20.5% complete response [CR]; 72.7% partial response [PR]), and the overall CR rate after radiotherapy was 86%. With a median follow-up period of 53 months, the 2-, 4-, and 6-year survival rates were 80%, 71.6%, and 67.4%; the overall treatment failure rate was 27%. Treatment was well tolerated and without significant acute or chronic toxic effects. CONCLUSION: The results of this prospective study demonstrate that 5-FU plus cisplatin followed by radiotherapy can induce a durable remission in a high proportion of patients with poor-prognosis stage IV nasopharyngeal carcinoma.

Adolescent↗

PubMed1990

Regional radiotherapy as adjuvant treatment for head and neck malignant melanoma. Preliminary results.

From 1983 through 1988, 83 patients with high-risk cutaneous malignant melanoma (primary lesion thicker than 1.5 mm or palpable lymphadenopathy) of the head and neck region were enrolled in a study designed to assess the efficacy of a few large doses of radiation (24 to 30 Gy in 4 to 5 fractions). The actuarial 2-year locoregional control rates for the three groups were 95%, 90%, and 83%, respectively. Corresponding survival rates were 80%, 71%, and 69%. The majority of failures were due to distant metastases. Locoregional control rates were better than those reported earlier with surgery alone for comparable patients. The treatment morbidity was minimal.

Adolescent↗

PubMed1990

Primary radiotherapy in the treatment of stage I and II oral tongue cancers: importance of the proportion of therapy delivered with interstitial therapy.

From January 1963 through December 1979, 103 patients with Stage T1N0 and T2N0 squamous cell carcinomas of the oral tongue were treated with definitive radiotherapy. The primary was Stage T1 in 18 patients and T2 in 85 patients. Therapy to the primary consisted of interstitial therapy only in 18 patients, 16-37 Gy in 2.4-4.0 Gy fractions followed by interstitial therapy to doses of 38-55 Gy in 31 patients, external therapy of 40-50 Gy with interstitial therapy of 20-40 Gy in 46 patients, and external beam only to doses of 45-82 Gy in 8 patients. Follow-up ranged from 2 to 290 months (median 159 months). Five of the 8 patients treated with external therapy alone and 6 of the 18 patients treated with interstitial therapy failed at the primary site. In those patients treated with a combination of external and interstitial therapy the 2-year local control rate was 92% for patients treated with external therapy to doses of less than 40 Gy combined with a moderately high dose of brachytherapy, compared with 65% for patients who received external therapy to doses of greater than or equal to 40 Gy with lower brachytherapy doses (p = .01). Conversely the risk of failure in the neck was directly related to the dose delivered by external beam therapy. In field recurrence occurred in 44% of patients receiving no therapy to the neck. 27% in those receiving less than 40 Gy, and 11% in those patients with neck treatment to greater than or equal to 40 Gy. Eleven of 87 (13%) of patients who were at risk for complications for greater than or equal to 24 months developed severe complications; severe complications were more likely to occur in the group who received most of their therapy with external beam irradiation. These data show that a high dose of interstitial therapy is necessary to secure optimum local control of early primary tongue cancer. Because of the high frequency of moderate to severe late complications in this series we have adopted a policy of initial surgery for most oral tongue cancers with postoperative radiotherapy if indicated by pathological features predictive of a high rate of local-regional failure.

Adult↗

PubMed1990

Concomitant boost radiotherapy schedules in the treatment of carcinoma of the oropharynx and nasopharynx.

Concomitant boost schedules are characterized by delivering the boost (10-12 fractions) as second daily treatments during rather than following the basic wide field irradiations. This results in shortening the overall time to administer 69-72 Gy from 7 1/2-8 weeks to 6 weeks, which we hoped would improve the tumor control rate by reducing the opportunity for tumor clonogens to regenerate during treatment. From August 1985 to August 1988, 79 patients with T2-4 carcinomas of the oropharynx (72 patients) or nasopharynx (7 patients) were treated according to 1 of the 3 variants of the concomitant boost technique. The median age of patients was 60 years (range: 19-84 years) and the male-to-female ratio was 2.6. The overall 2-year actuarial primary and nodal control rates by radiotherapy alone were 74% and 76%, respectively. The ultimate 2-year control rates after surgical salvage were 82% and 84%, respectively. If the boost given during the last 2-2 1/2 weeks of basic treatment, a slightly better primary control rate (p = 0.11) resulted than if the boost was delivered during the first 2-2 1/2 weeks or twice a week throughout the basic treatment. The 2-year actuarial primary control rate of the 13 patients receiving induction chemotherapy prior to radiotherapy was significantly lower than that of patients treated with radiation only (81% vs 34%, p = 0.01), but this could be partly attributed to a more advanced stage in the chemotherapy group. The acute mucosal reactions were, as expected, more severe than those observed with conventional fractionation. Fifty patients developed confluent mucositis covering more than half of the boost area. Such reactions lasted for more than 6 weeks in seven patients. Late complications, however, so far observed, have been few. Three patients experienced chronic mucosal tenderness, 1 chronic mucosal ulceration, 2 transient bone exposure, and 1 carotid rupture following salvage surgery. The results so far appear to be better than the outcome of conventional radiotherapy. Its real value will be determined in a prospective randomized study.

Adult↗

PubMed1990

The essential role of radiation therapy in securing locoregional control of Merkel cell carcinoma.

Between 1966 and 1987, 54 patients with non-disseminated Merkel cell carcinoma (MCC) were treated with curative intent at the University of Texas M. D. Anderson Cancer Center. The primary tumor site was in the head and neck in 38 patients. The majority of the patients (57%) were referred with locoregionally recurrent disease. For the whole group, survival was 30% after 5 years. Patients who presented with nodal involvement had a median survival of 13 months compared with 40 months for node-negative patients (p less than .04). Only 4/37 patients treated initially by surgery alone were locoregionally controlled, with a median time to recurrence of 4.9 months. Salvage with radiation therapy was attempted in 18 patients (after additional surgery in 14), but was successful in only four. The predominant failure pattern in this subgroup was distant metastases, occurring as a component of initial recurrence in 12/18 patients. Prior to 1982, the philosophy of initial therapy was to give postoperative irradiation only to patients with large primaries or nodal involvement. Subsequently, postoperative radiotherapy has been recommended routinely, and all five patients treated with this approach remain disease-free. In total, 31 patients (including 10 patients with gross disease) were irradiated at M. D. Anderson; only one developed an in-field locoregional recurrence as an initial site of failure. However, three marginal recurrences occurred. The median dose to the primary tumor, first echelon nodes, and supraclavicular nodes was 60, 51, and 50 Gy, respectively. Our current recommendation for initial treatment is excision of the primary tumor followed by irradiation with generous fields to include the primary tumor site and draining regional lymphatics to doses of 46-50 Gy in 2 Gy fractions. For gross unresected disease, 56-60 Gy is recommended. The role of adjuvant systemic therapy remains to be defined.

Adult↗

PubMed1990

Treatment selection for carcinoma of the base of the tongue.

Between 1974 and 1984, 173 patients were treated for squamous cell carcinoma of the tongue base. Fifty-four patients had T1 or T2 primaries, while 115 patients had T3 or T4 tumors (4 were not staged). Lymph node metastasis was present in 120 patients. Early primary tumors treated with surgery or radiotherapy had a control rate of 83% (5 of 6 tumors) and 89% (40 of 45 tumors), respectively. For advanced primary tumors, definitive radiotherapy produced a local control rate of 55% (42 of 76 tumors), compared with 79% (23 of 29 tumors) for surgery and postoperative radiotherapy. If primary control was obtained, the regional failure rate was less than 10%. Tumor growth patterns were predictive of the response to radiotherapy. The primary control rate at 2 years for 21 patients with exophytic tumors was 84% as opposed to 58% for 62 patients with ulcerative-infiltrative tumors (p = 0.04). Radiotherapy is effective for early stage or exophytic tumors, whereas for advanced or deeply invasive tumors combined therapy enhances local control.

Adult↗

PubMed1989

Hyperfractionated radiotherapy in the treatment of squamous cell carcinomas of the supraglottic larynx.

From January 1984 through December 1987, 41 patients with squamous cell carcinomas of the supraglottic larynx were treated with hyperfractionated radiotherapy at The University of Texas M. D. Anderson Cancer Center. Two patients had T1 primary tumors, 23 had T2, 15 had T3, and 1 had T4; 29 patients had no clinical evidence of nodal disease in the neck, 4 had N1, 5 had N2, and 3 had N3. Radiotherapy was delivered in 120 cGy fractions twice per day, with at least 4 hr between treatments. Total doses ranged from 7200 to 7900 cGy (median, 7680 cGy). Three patients had planned neck dissections before or after radiotherapy, and three patients with fixed vocal cord lesions were treated with preradiation chemotherapy. At the time of analysis, median follow-up was 22 months. Four patients have had failures at the primary tumor site. There has been one recurrence in the neck in a patient who also had a recurrence at the primary site. Three of the four patients with recurrences have been successfully treated with salvage surgery. Exclusive of surgical salvage, the actuarial disease-free local control rates above the clavicles in the 38 patients with T2 and T3 cancers were 96% at 1 year and 87% at 2 years. In comparison, the rates were 82% and 76% for a group of 98 patients with T2 and T3 lesions treated at this institution from 1970 to 1981 with 6500-7000 cGy given in 200 cGy fraction per day. As predicted, acute reactions were more severe but late complications were not increased in patients who received hyperfractionated radiotherapy compared with those treated by conventionally fractionated therapy. Only two patients have developed severe late complications one of whom required laryngectomy. Hyperfractionated radiotherapy appears to provide improved local control with a similar incidence of late complications when compared with conventionally fractionated therapy. To further improve the therapeutic ratio, our current protocol has been amended by reducing the large field dose per fraction to 110 cGy (with a 2 day protraction of overall time) and requiring a minimum interfraction interval of 6 hr.

Adult↗