Editor's note

EDITOR'S NOTE The lead article by Harisiadis and Chang on medulloblastoma sets the dominant theme for this issue: the importance of staging and patterns of relapse. The overall 40% 5-year and 31% lo-year survival rates for medulloblastoma treated with radiation theranv obscure the high survival that has been achieved in the treatment of smaller lesions which have l&ited spread patterns. A new staging system is introduced in this article which is in the process of being adopted by the American Joint Committee for Cancer Staging and End Results Reporting. For T1 and Tz, MO medulloblastoma, survival rates of 90% and 75%) respectively, have been achieved with the use of full-dose radiation therapy. Bloom’s editorial briefly outlines his research experience with chemotherapy (vincristine, cyclophosphamide, methotrexate) and high LET beams of neutrons, and then points to new ways of coping with the overall 60% local failure rate in this disease. The mature study of mycosis fungoides by Hoppe, Fuks and Bagshaw is a classic report. Their concept of staging this unique disease according to the degree of skin involvement, the thickness of the lesions, and the nodal and visceral involvement, is essential to management and prognosis. Complete response rates and survival rates are much higher for limited plaque patients than for tumorous patients. The dose resnonse curve urovided indicates a 94% response rate for patients receiving 3000-3600 rad versus 18% for-those recei;ing 800-1000 rad. The most controversial material in this issue is Levi, Wiernik and O’Connell’s report of the randomized study of the treatment of favorable stages of Hodgkin’s disease, particularly the extranodal, or E, stage. The relapse-free survival for those patients who were treated with local-field irradiation and MOPP is 70% as onnosed to 34% for those who were treated bv extended field irradiation; this difference is statistically s&&cant. The failure patterns a peared ai mar inal recurrences in the group which received radiation therapy alone, particularly in tK ose patients wY-l o had lung and mediastinal involvement. Prosnitz’s editorial critiques this experienCe and discusses the origin of the E stage and how it affects the principles of radiation treatment. Of equal interest are the patterns of relapse found by Weller et al in Stages I and II Hodgkin’s disease patients who were treated with mantle irradiation; most relapses appeared as transdiaphragmatic extensions. At issue is the ability to salvage these patients with more radiation therapy and/or chemotherapy. The salvage rates of approximately 50% for the entire series of relapses and 83% for those whose first relapses were treated with combined MOPP and irradiation have many implications for future treatment. DeVita’s editorial addresses the topic of chemotherapy salvage after extended field radiation therapy failure versus an initially more aggressive combined approach for localized stages similar to the method reported by Levi et al. This provocative analysis led to the design of joint Radiation Therapy Oncology Group (RTOG) and Eastern Cooperative Oncology Grou (ECOG) trials for Stages I and II (E included) Hodgkin’s disease, which are designed to test these K_ gpotheses, but _ which as yet lhave not assessed enough patients to do so adequateiy. The management of Stages B and C nrostate cancer is of preat interest to the radiation theranv community. ThY report by Ngglia, Husseyand Johnson requires careful reading. The local control a&l survival rates in this study are comparable to those of other studies. The value ofhormonal treatment in locally advanced prostate cancer, particularly when hormones are used in combination with radiation therapy, is debatable. Despite the small difference in the rates of local control and survival between the group which received radiation therapy alone and the group which received radiation and hormonal treatment., hormonal treatment is advocated for more aggressive disease. The question of the justification for this approach, as well as the issue of the staging of this cancer (with special regard to paraortic and pelvic nodes), is elaborately discussed in Ray’s editorial. Other unique clinical reports concern the role of radiation in the treatment of cancer of the gall bladder and extrahepatic hiliary system (Kopelson et al), and in the treatment of residual and recurrent meningiomas (Friedman). The studies of Hill, Bush and Siemann regarding the variations in tumor control with different breathing tim.es of carbogen before treatment, and with fractionated doses, illustrate the problems of adjuvant treatments. The recently completed national RTOG study of carbogen breathing has proved to be negative’; an explanation for this result may be found in the aforementioned radiobiological studies. The studies in the radiation pathology of the lung by Moosavi et al and of the kidney by Glatstein et al provide some new findings that challenge existing views of the pathogenesis of radiation effects in these organs. Finally, the updated breast cancer reports of the Current Concepts in Cancer series, “The Search for the Ideal Surcrical Procedure in Breast Cancer”. deserve careful reading. Most of these renorts provide long-term foll:bw-up (beyond 10 years). Controv&sies in breast cancer never die, and unlike generals, do not seem to fade away. PHILIP RUBIN, M.D. EDITOR-IN-CHIEF

REFERENCE 1. Rubin, P., Marital, V., Hanley, J., Mann, S., Brady, L.: The national study on adjunctive oxygen breathing in the radiation treatment of head and neck and esophageal cancer: A Radiation Therapy Oncology Group study. To be published.