- Email: [email protected]
Chemotherapy for the head & neck
Proceedings
of the 35th Annual ASTRO
Meeting
115
1. The identification of drugs commonly used in the management of head and neck cancer, their customary dosing and side effects. 2. The impact of induction and/or adjuvant chemotherapy combined with surgery and radiation therapy as defined by randomized trials, including a discussion of the Head & Neck Contracts program and the recent Intergroup adjuvant trial. 3. The development of larynx/function preservation treatment programs, including a review of the Memorial Hospital experience with larynx preserlration and the Veterans Administration larynx preservation study. 4. The evolving role of chemotherapy as part of innovative combined modality programs, especially in patients with unresectable disease. The rationale and utility of sequential versus concomitant/alternating chemotherapy-radiation strategies, and relevant randomized clinical trials comparing the different strategies will be discussed. 5. The appropriate application of chemotherapy in the palliative setting, including a discussion of the relative merits of single-agent versus combination chemotherapy.
405 INTRAOPERATIVE
RADIOTHERAPY
CURRENT STATUS - 1993
Timothy J. Kin&la, M.S., M.D.1, Peter Johnstone, M.D.2, and William F. Sindelar, M.D., Ph.D.3 tDepartment of Human Oncology, University of Wisconsin Medical School, Madison, WI 53792 zRadiation Oncology Branch, National Cancer Institute, Bethesda, MD 20852 3Surgety Branch, National Cancer Institute, Bethesda, MD 20852 Intraoperative radiotherapy (IORT) continues to be an area of considerable experimental and clinical interest as a potentially innovative modality for the treatment of certain cancers. IORT involves the use of a large single dose (usually 15-25 Gy) of electron or orthovoltage x-my irradiation delivered to a tumor (or tumor bed following resection) and adjacent areas of potential microscopic spread. IORT may improve the therapeutic ratio of tumor control to normal tissue toxicity for two main reasons: (1) it allows direct visualization of the tumor and the consequent precise definition of the target volume; and (2) direct oppositional treatment permits exclusion of all or part of dose-limiting normal tissues. The technical aspects of IORT including types of applicators, applicator dosimetry, field matching techniques, field verification, and IORT couch will be illustrated. Based on long term (5 year) follow-up of large animal studies assessing normal tissue toxicity principally from the National Cancer Institute and Colorado State University, it appears that major blood vessels, bone, bladder wall, esophagus, trachea and retroperitoneal soft tissues will tolerate IORT doses to 20-25 Gy without significant clinical sequelae. Hollow viscera such as the bile duct, ureter and small bowel will not tolerate clinically relevant doses. (15-25 Gy). Peripheral nerve may have an intermediate tolerance of 15 Gy. Interestingly, a few IORT-included sarcomas of bone and nerve have been seen recently in these long term normal tissue studies in dogs which merits close observation as clinical studies mature. Recent information on these late effects studies will be highlighted. Clinical studies of IORT have shown greatest promise in locally advanced recurrent rectal cancer. These studies carried out at the Massachusetts General Hospital (MGH) and Mayo Clinic will be updated. Additionally, the trials from the NC1 and RTOG involving IORT f external beam irradiation following resection of locally advanced gastric and pancreas cancer and retroperitoneal sarcomas will be reviewed. The use of IGRT as a “boost” for locally advanced lung cancer will be examined based on the technical approach and the limited clinical data available to date. Long Term (>5 year) Follow-up of the NC1 clinical trials will be highlighted. Acute and late effects of IORT on normal tissues in humans will be presented along with the limited autopsy data which confums many of the conclusions from the large animal trials. Finally, the “future” directions of IORT will be discussed.
406 MEDICAL LEGAL ASPECTS OF RADIATION ONCOLOGY Terry J. Wall, M.D. Radiology and Nuclear Medicine, Topeka, KS 66601-1353 The theoretical basis of, and practical experience in, legal liability in the clinical practice of radiation oncology is reviewed, with a view to developing suggestions to help practitioners limit their exposure to liability. New information regarding the number, size, and legal theories of litigation against radiation oncologists is presented. The most common legal bases of liability are then explored in greater detail, including “malpractice,” and informed consent, with suggestions of improving the specialty’s record of documenting informed consent. Collateral consequences of suffering a malpractice claim (i.e., the National Practitioner Data Bank) will also be briefly discussed.
of the 35th Annual ASTRO
Meeting
115
1. The identification of drugs commonly used in the management of head and neck cancer, their customary dosing and side effects. 2. The impact of induction and/or adjuvant chemotherapy combined with surgery and radiation therapy as defined by randomized trials, including a discussion of the Head & Neck Contracts program and the recent Intergroup adjuvant trial. 3. The development of larynx/function preservation treatment programs, including a review of the Memorial Hospital experience with larynx preserlration and the Veterans Administration larynx preservation study. 4. The evolving role of chemotherapy as part of innovative combined modality programs, especially in patients with unresectable disease. The rationale and utility of sequential versus concomitant/alternating chemotherapy-radiation strategies, and relevant randomized clinical trials comparing the different strategies will be discussed. 5. The appropriate application of chemotherapy in the palliative setting, including a discussion of the relative merits of single-agent versus combination chemotherapy.
405 INTRAOPERATIVE
RADIOTHERAPY
CURRENT STATUS - 1993
Timothy J. Kin&la, M.S., M.D.1, Peter Johnstone, M.D.2, and William F. Sindelar, M.D., Ph.D.3 tDepartment of Human Oncology, University of Wisconsin Medical School, Madison, WI 53792 zRadiation Oncology Branch, National Cancer Institute, Bethesda, MD 20852 3Surgety Branch, National Cancer Institute, Bethesda, MD 20852 Intraoperative radiotherapy (IORT) continues to be an area of considerable experimental and clinical interest as a potentially innovative modality for the treatment of certain cancers. IORT involves the use of a large single dose (usually 15-25 Gy) of electron or orthovoltage x-my irradiation delivered to a tumor (or tumor bed following resection) and adjacent areas of potential microscopic spread. IORT may improve the therapeutic ratio of tumor control to normal tissue toxicity for two main reasons: (1) it allows direct visualization of the tumor and the consequent precise definition of the target volume; and (2) direct oppositional treatment permits exclusion of all or part of dose-limiting normal tissues. The technical aspects of IORT including types of applicators, applicator dosimetry, field matching techniques, field verification, and IORT couch will be illustrated. Based on long term (5 year) follow-up of large animal studies assessing normal tissue toxicity principally from the National Cancer Institute and Colorado State University, it appears that major blood vessels, bone, bladder wall, esophagus, trachea and retroperitoneal soft tissues will tolerate IORT doses to 20-25 Gy without significant clinical sequelae. Hollow viscera such as the bile duct, ureter and small bowel will not tolerate clinically relevant doses. (15-25 Gy). Peripheral nerve may have an intermediate tolerance of 15 Gy. Interestingly, a few IORT-included sarcomas of bone and nerve have been seen recently in these long term normal tissue studies in dogs which merits close observation as clinical studies mature. Recent information on these late effects studies will be highlighted. Clinical studies of IORT have shown greatest promise in locally advanced recurrent rectal cancer. These studies carried out at the Massachusetts General Hospital (MGH) and Mayo Clinic will be updated. Additionally, the trials from the NC1 and RTOG involving IORT f external beam irradiation following resection of locally advanced gastric and pancreas cancer and retroperitoneal sarcomas will be reviewed. The use of IGRT as a “boost” for locally advanced lung cancer will be examined based on the technical approach and the limited clinical data available to date. Long Term (>5 year) Follow-up of the NC1 clinical trials will be highlighted. Acute and late effects of IORT on normal tissues in humans will be presented along with the limited autopsy data which confums many of the conclusions from the large animal trials. Finally, the “future” directions of IORT will be discussed.
406 MEDICAL LEGAL ASPECTS OF RADIATION ONCOLOGY Terry J. Wall, M.D. Radiology and Nuclear Medicine, Topeka, KS 66601-1353 The theoretical basis of, and practical experience in, legal liability in the clinical practice of radiation oncology is reviewed, with a view to developing suggestions to help practitioners limit their exposure to liability. New information regarding the number, size, and legal theories of litigation against radiation oncologists is presented. The most common legal bases of liability are then explored in greater detail, including “malpractice,” and informed consent, with suggestions of improving the specialty’s record of documenting informed consent. Collateral consequences of suffering a malpractice claim (i.e., the National Practitioner Data Bank) will also be briefly discussed.