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communications from the international radiation oncology community
Correspondence calculation is not in good agreement with measurement for water, there is unfortunately no reason to suppose that his RDF for other media are any more accurate. JEROMEA. MELI, PH.D. ALI S. MEIGOONI,PH.D. RAVINDERNATH, PH.D.
Yale University 333 Cedar St. New Haven, CT 065 10 1. Dale, R. G. Radial dose function (RDF). Int. J. Radiat. Oncol. Biol. Phys. (In press): 1989. 2. Meli, J. A.; Meigooni, A. S.: Nath, R. On the choice of phantom material for the dosimetry of 1921r sources. Int. J. Radiat. Oncol. Biol. Phys. 14:587-594: 1988.
HYPO-FRACIIONATION
To the Editor: In the March 1988 issue of International Journal of Radiation Oncoloav. Bioloav. Phvsics 14:577-579: 1988 the result of thirteen patients with cancerof cervix which were treated with high and low dose rates, once-a-week was represented from Nanavati Hospital, India as a brief communication. Both the clinical trends and radiobiological animal results point to the undesirability of using large doses per fraction, there is no disagreement about this point (I). To achieve low dose rate authors have used thick (several HVL of ““Co energy) lead attenuator between patient and diaphragm of the “Co unit (name not mentioned) having dimension more than the treated pelvic region of patient. The Compton scattered photons in sufficient quantity having energy well below several hundred KeV from lead attenator would give acute skin reaction. I believe this type of project should not be carried out on patients treating them as guinea pigs. RAMESHDESAI,PH.D., DIP.C.P., D1p.R.P.
Department of Radiation Oncology Nemazee Hospital University of Shiraz Iran I. Fowler, J. F. Non-standard fractionation in radiotherapy. Int. J. Radiat. Oncol. Biol. Phys. 10:755-759; 1984.
RESPONSE
To fhe Editor: Hypo-fractionation has a special place in clinical radiation oncology. Its utility in treating advanced cases has been amply demonstrated by our work and many others before us (I). It was feared that electron contamination due to attenuators may adversely affect the skin dose. However, a safe distance of more than 20 cm from the surface solved the problem, as is indicated in our results. Patients had comparable reactions in both groups. The name of the ‘Co teletherapy unit on which patients were treated is Gammarex-R. NAGRAJG. HUILGOL, M.D., D.G.O.
Division of Radiation Oncology Dr. Balabhai Nanavati Hospital S.V. Road, Vile Parle (West) Bombay-400 056 I. Dvivedi, M. S. Immediate results of weekly fractionation in external radiotherapy. Int. J. Radiat. Oncol. Biol. Phys. 4573-578. 1978.
OCCASIONAL
CASE REPORTS/COMMUNICATIONS THE INTERNATIONAL RADIATION ONCOLOGY COMMUNITY
FROM
To lhe Edim-: Case number one: Malignant lymphoma of the esophagus-a rare clinical disorder: Malignant lymphoma of the esophagus is a rare disorder and when it presents as a clinically solitary focus, as in this case, it has no special characteristics which permit it to be distinguished from more common esophageal tumors such as leiomyoma.
1655
Diagnosis depends upon thorough clinical and imaging workup and biopsy by either endoscopic means or direct thoracic surgical intervention. The notorious ability of non-Hodgkin’s lymphomas to both spread along vascular and lymphatic pathways and to appear randomly at distant body sites leads to reliance upon systemic chemotherapy. In the case of this 53 year-old man, who first presented in May of 1984. endoscopic biopsy was followed by 2 weeks of the standard COP regimen (Cytoxan, Vincristine, and Prednisone); subsequently, thoracotomy was accomplished with relatively wide local excision of the visible and palpable tumor mass. Nevertheless, because of the above-mentioned propensity for insinuous local spread of NHL beyond surgical margins, post-operative radiotherapy of the cervico-thoracic esophagus was elected. Treatment with ‘“Co at 80 cm SAD consisted of the administration of a tumor dose of 3,960 &y/22 fractions/33 days elapsed to a treatment volume which extended from the cricoid cartilage to the cardia of the stomach: anterior and two posterior oblique co-axial portals were used with multiple portals treated each day; radiotherapy was well tolerated. Because the tumor proved to be predominantly of the small cleavedcell type on histopathologic examination of the surgical specimen. it was elected to administer no further chemotherapy following completion of post-operative radiotherapy. Instead, traditional Chinese herbal prescriptions which have clinically demonstrated antitumor and immunoaugmentative properties were given and have been continued. The patient has now been followed for more than 3 years with no sign of recurrence and is in essentially good health at the time of the present writing. Case number two: An unusual case of second separate metachronous primary cancer with lengthy survival: A 34 year-old man presented with undifferentiated squamous cell carcinoma of the nasopharynx metastatic to lymph nodes in the upper neck on both sides in July of 1968. He was treated primarily with “‘Co at 60 cm SAD, receiving a tumor dose of 7.358 cGv/54 fractions/64 davs (NSD I788 ret: TDF IOI ). Parallel . elaosed . . opposed portals were used to treat the primary tumor. Treatment volume included not only the primary tumor but also the entire lymph node drainage on both sides of the neck: the neck was treated by means of anterior and posterior split beams. Complete eradication of neoplasm was achieved and the patient had no further clinical difficulty until 1974 when he suffered gastrointestinal hemorrhage and was subjected to surgery which included gastrectomy and splenectomy. Subsequently. he was again well until 1984 when he presented with an infiltrating squamous cell carcinoma of the left external ear canal extending to involve the auricle. Workup disclosed no evidence for metastatases from the original primary tumor and the histologic findings at the time of the biopsy of the left external canal were characteristic for a primary keratinizing integumental squamous cell carcinoma. A wide local excision was performed and radiation therapy was carried out postoperatively, using “‘Co at 60 cm SAD with anterior and posterior wedged beams. Treatment was confined to the site of the primary tumor with an adequate margin. A tumor dose of 60 Gy/30 fractions/44 days elapsed was received by the patient. Treatment was carefully planned so that tumor volume treated in the second instance was not within the first treatment volume. though a very close approach was necessary and the risks were recognized. Following completion of radiotherapy, which was well tolerated. the patient was placed on traditional Chinese medical herbal treatment according to the principles of bianzhon lunzhi (treatment specific for the established diagnosis): the prescription was developed to contain elements to counter both early local recurrence and secondary metastases (chronicity). or. as characterized in the traditional Chinese vernacular. treatment was given simultaneously to counteract both biao and ben. At the time of this report. the patient has survived over 19 years since his initial treatment and over 3 years since completion of radiotherapy to his second primary cancer. He is without evidence of either cancer and is able to live normally and care for himself. Statistics on cases such as this are difficult to come by. It is believed that the postulates for separate primary cancers stipulated by Warren and Gates have been fulfilled, to wit:
I. Each tumor must be malignant. 2. All tumors must be pathologically confirmed. 3. Metastases must be excluded. In spite of obvious risks in a situation like this one, we believe that a radical approach to a second primary cancer is warranted to gain the continuing benefit of extended survival for the patient. We also believe that the established antitumor and immunoaugmentative properties of traditional Chinese herbal medicines are useful. When properly prescribed, they can provide significant benefits to such patients: the patient in this case continues to receive a complex prescription for this purpose.
1656
I. J. Radiation Oncology 0 Biology 0 Physics
(Shi Guozhen, M.D., and Li Chuan’ai, M.D., collaborated in the initial presentation of this case.) ZHANG
FURONG,
M.D. Department of Radiotherapy The First Affiliated Hospital Henan Medical University Zhengzhou, The People’s Republic of China 1. Bush, R. S.; Ash, L. L. Primary lymphoma of the gastrointestinal tract. Radiology 92(6): 1349; 1969. 2. Caruso, R. N.; Berk, R. N. Lymphoma of the esophagus. Radiology 95(2):38 1; 1970. obser3. Butov, Y. P.; Yakimova, T. P. Lennert’s lymphoma-two vations. Issues Oncology 28(6):63; 1983. 4. Wu, B.-I., et al. Unusual presentations of malignant lymphomaanalysis of forty cases. China Cancer J. 7(3):2 11; 1985. 5. Million, R. R. Nasopharynx. In Fletcher, G. H., ed. Textbook of Radiotherapy, 3rd edition. Phila: Lea and Febiger; 1980:364. 6. Lichachev, Y. P. Spinal cord injuries secondary to radiation therapy. Med. Radiol. 8:27; 1983. 7. Chen, C. S.; et al. Clinical analysis of longterm survival of nasopharyngeal cancer treated with radiotherapy. China Radio]. J. 14(1): 47; 1980. 8. Tana, K.; Seng, K. Multiple primary cancers: cases of four separate primaries. J. Clin. Cancer 28: 1320; I98 I. FRACTION SIZE OR ACCELERATED
REPOPULATION?
To he Editor: In the March 1988 issue of this Journal I reported on the results of two different fractionation schemes in the treatment of Stage I glottic cancer (I). Specifically, it was reported that 7/28 patients failed treatment when utilizing 180 cGy fractions compared to O/28 patients treated with fractions of 200 cGy or greater. Withers et al. have reported on accelerated repopulation in head and neck cancer (2). Review of their data suggests that accelerated repopulation of clonogenic cells occurs after approximately 4 f 1 weeks. When our data are plotted as a scattergram (see Fig. I) note that there are no failures when treatment lasted less than 51 days. Taylor has analyzed
June 1989, Volume 16, Number 6
I
.
66 -
D
62-
BO-
A 2 OY -WCC... d
0 1.6 t3Y -*we.** . 1.6 QY -f~llur*
A
,.,,.I..,.I,,,,I,,,,l~,,~i,,,,l.,..l.,, 50 40
60
70
DAYS
Fig. I. these data and found that the dose to balance one days extension of treatment to be .5 1 Gy per day (std. error approximately .47 Gy per day) and using an alpha/beta ratio of 25 Gy the dose per day to compensate for extension of treatment is .37 Gy (given in 2 Gy fractions). Thus, it can be alternatively suggested that whereas a smaller fraction size was associated with more local failure this may have been a reflection of prolongation of overall treatment time with an attendant increase in the probability of failure because of accelerated repopulation. FRED SCHWAIBOLD, D.O. J. M. G. TAYLOR,PH.D. Cooper Hospital University Medical Center UCLA School of Medicine I. Schwaibold, Frederick: Scariato, Albert; Nunno, M.; Wallner, Paul E.; Lust& Robert A.; Rouby, Elida; Gorshein, Dov; Wenger, Jeffery. Cancer. Int. J. Radiat. Oncol. Biol. Phys. 14:451-454; 1988. 2. Withers, H. R.: Taylor, J. M. G.; Maciejewski, B. The hazard of accelerated tumor clonogen repopulation during radiotherapy. Acta Oncol. 27:Fasc. 2; 1988.
Yale University 333 Cedar St. New Haven, CT 065 10 1. Dale, R. G. Radial dose function (RDF). Int. J. Radiat. Oncol. Biol. Phys. (In press): 1989. 2. Meli, J. A.; Meigooni, A. S.: Nath, R. On the choice of phantom material for the dosimetry of 1921r sources. Int. J. Radiat. Oncol. Biol. Phys. 14:587-594: 1988.
HYPO-FRACIIONATION
To the Editor: In the March 1988 issue of International Journal of Radiation Oncoloav. Bioloav. Phvsics 14:577-579: 1988 the result of thirteen patients with cancerof cervix which were treated with high and low dose rates, once-a-week was represented from Nanavati Hospital, India as a brief communication. Both the clinical trends and radiobiological animal results point to the undesirability of using large doses per fraction, there is no disagreement about this point (I). To achieve low dose rate authors have used thick (several HVL of ““Co energy) lead attenuator between patient and diaphragm of the “Co unit (name not mentioned) having dimension more than the treated pelvic region of patient. The Compton scattered photons in sufficient quantity having energy well below several hundred KeV from lead attenator would give acute skin reaction. I believe this type of project should not be carried out on patients treating them as guinea pigs. RAMESHDESAI,PH.D., DIP.C.P., D1p.R.P.
Department of Radiation Oncology Nemazee Hospital University of Shiraz Iran I. Fowler, J. F. Non-standard fractionation in radiotherapy. Int. J. Radiat. Oncol. Biol. Phys. 10:755-759; 1984.
RESPONSE
To fhe Editor: Hypo-fractionation has a special place in clinical radiation oncology. Its utility in treating advanced cases has been amply demonstrated by our work and many others before us (I). It was feared that electron contamination due to attenuators may adversely affect the skin dose. However, a safe distance of more than 20 cm from the surface solved the problem, as is indicated in our results. Patients had comparable reactions in both groups. The name of the ‘Co teletherapy unit on which patients were treated is Gammarex-R. NAGRAJG. HUILGOL, M.D., D.G.O.
Division of Radiation Oncology Dr. Balabhai Nanavati Hospital S.V. Road, Vile Parle (West) Bombay-400 056 I. Dvivedi, M. S. Immediate results of weekly fractionation in external radiotherapy. Int. J. Radiat. Oncol. Biol. Phys. 4573-578. 1978.
OCCASIONAL
CASE REPORTS/COMMUNICATIONS THE INTERNATIONAL RADIATION ONCOLOGY COMMUNITY
FROM
To lhe Edim-: Case number one: Malignant lymphoma of the esophagus-a rare clinical disorder: Malignant lymphoma of the esophagus is a rare disorder and when it presents as a clinically solitary focus, as in this case, it has no special characteristics which permit it to be distinguished from more common esophageal tumors such as leiomyoma.
1655
Diagnosis depends upon thorough clinical and imaging workup and biopsy by either endoscopic means or direct thoracic surgical intervention. The notorious ability of non-Hodgkin’s lymphomas to both spread along vascular and lymphatic pathways and to appear randomly at distant body sites leads to reliance upon systemic chemotherapy. In the case of this 53 year-old man, who first presented in May of 1984. endoscopic biopsy was followed by 2 weeks of the standard COP regimen (Cytoxan, Vincristine, and Prednisone); subsequently, thoracotomy was accomplished with relatively wide local excision of the visible and palpable tumor mass. Nevertheless, because of the above-mentioned propensity for insinuous local spread of NHL beyond surgical margins, post-operative radiotherapy of the cervico-thoracic esophagus was elected. Treatment with ‘“Co at 80 cm SAD consisted of the administration of a tumor dose of 3,960 &y/22 fractions/33 days elapsed to a treatment volume which extended from the cricoid cartilage to the cardia of the stomach: anterior and two posterior oblique co-axial portals were used with multiple portals treated each day; radiotherapy was well tolerated. Because the tumor proved to be predominantly of the small cleavedcell type on histopathologic examination of the surgical specimen. it was elected to administer no further chemotherapy following completion of post-operative radiotherapy. Instead, traditional Chinese herbal prescriptions which have clinically demonstrated antitumor and immunoaugmentative properties were given and have been continued. The patient has now been followed for more than 3 years with no sign of recurrence and is in essentially good health at the time of the present writing. Case number two: An unusual case of second separate metachronous primary cancer with lengthy survival: A 34 year-old man presented with undifferentiated squamous cell carcinoma of the nasopharynx metastatic to lymph nodes in the upper neck on both sides in July of 1968. He was treated primarily with “‘Co at 60 cm SAD, receiving a tumor dose of 7.358 cGv/54 fractions/64 davs (NSD I788 ret: TDF IOI ). Parallel . elaosed . . opposed portals were used to treat the primary tumor. Treatment volume included not only the primary tumor but also the entire lymph node drainage on both sides of the neck: the neck was treated by means of anterior and posterior split beams. Complete eradication of neoplasm was achieved and the patient had no further clinical difficulty until 1974 when he suffered gastrointestinal hemorrhage and was subjected to surgery which included gastrectomy and splenectomy. Subsequently. he was again well until 1984 when he presented with an infiltrating squamous cell carcinoma of the left external ear canal extending to involve the auricle. Workup disclosed no evidence for metastatases from the original primary tumor and the histologic findings at the time of the biopsy of the left external canal were characteristic for a primary keratinizing integumental squamous cell carcinoma. A wide local excision was performed and radiation therapy was carried out postoperatively, using “‘Co at 60 cm SAD with anterior and posterior wedged beams. Treatment was confined to the site of the primary tumor with an adequate margin. A tumor dose of 60 Gy/30 fractions/44 days elapsed was received by the patient. Treatment was carefully planned so that tumor volume treated in the second instance was not within the first treatment volume. though a very close approach was necessary and the risks were recognized. Following completion of radiotherapy, which was well tolerated. the patient was placed on traditional Chinese medical herbal treatment according to the principles of bianzhon lunzhi (treatment specific for the established diagnosis): the prescription was developed to contain elements to counter both early local recurrence and secondary metastases (chronicity). or. as characterized in the traditional Chinese vernacular. treatment was given simultaneously to counteract both biao and ben. At the time of this report. the patient has survived over 19 years since his initial treatment and over 3 years since completion of radiotherapy to his second primary cancer. He is without evidence of either cancer and is able to live normally and care for himself. Statistics on cases such as this are difficult to come by. It is believed that the postulates for separate primary cancers stipulated by Warren and Gates have been fulfilled, to wit:
I. Each tumor must be malignant. 2. All tumors must be pathologically confirmed. 3. Metastases must be excluded. In spite of obvious risks in a situation like this one, we believe that a radical approach to a second primary cancer is warranted to gain the continuing benefit of extended survival for the patient. We also believe that the established antitumor and immunoaugmentative properties of traditional Chinese herbal medicines are useful. When properly prescribed, they can provide significant benefits to such patients: the patient in this case continues to receive a complex prescription for this purpose.
1656
I. J. Radiation Oncology 0 Biology 0 Physics
(Shi Guozhen, M.D., and Li Chuan’ai, M.D., collaborated in the initial presentation of this case.) ZHANG
FURONG,
M.D. Department of Radiotherapy The First Affiliated Hospital Henan Medical University Zhengzhou, The People’s Republic of China 1. Bush, R. S.; Ash, L. L. Primary lymphoma of the gastrointestinal tract. Radiology 92(6): 1349; 1969. 2. Caruso, R. N.; Berk, R. N. Lymphoma of the esophagus. Radiology 95(2):38 1; 1970. obser3. Butov, Y. P.; Yakimova, T. P. Lennert’s lymphoma-two vations. Issues Oncology 28(6):63; 1983. 4. Wu, B.-I., et al. Unusual presentations of malignant lymphomaanalysis of forty cases. China Cancer J. 7(3):2 11; 1985. 5. Million, R. R. Nasopharynx. In Fletcher, G. H., ed. Textbook of Radiotherapy, 3rd edition. Phila: Lea and Febiger; 1980:364. 6. Lichachev, Y. P. Spinal cord injuries secondary to radiation therapy. Med. Radiol. 8:27; 1983. 7. Chen, C. S.; et al. Clinical analysis of longterm survival of nasopharyngeal cancer treated with radiotherapy. China Radio]. J. 14(1): 47; 1980. 8. Tana, K.; Seng, K. Multiple primary cancers: cases of four separate primaries. J. Clin. Cancer 28: 1320; I98 I. FRACTION SIZE OR ACCELERATED
REPOPULATION?
To he Editor: In the March 1988 issue of this Journal I reported on the results of two different fractionation schemes in the treatment of Stage I glottic cancer (I). Specifically, it was reported that 7/28 patients failed treatment when utilizing 180 cGy fractions compared to O/28 patients treated with fractions of 200 cGy or greater. Withers et al. have reported on accelerated repopulation in head and neck cancer (2). Review of their data suggests that accelerated repopulation of clonogenic cells occurs after approximately 4 f 1 weeks. When our data are plotted as a scattergram (see Fig. I) note that there are no failures when treatment lasted less than 51 days. Taylor has analyzed
June 1989, Volume 16, Number 6
I
.
66 -
D
62-
BO-
A 2 OY -WCC... d
0 1.6 t3Y -*we.** . 1.6 QY -f~llur*
A
,.,,.I..,.I,,,,I,,,,l~,,~i,,,,l.,..l.,, 50 40
60
70
DAYS
Fig. I. these data and found that the dose to balance one days extension of treatment to be .5 1 Gy per day (std. error approximately .47 Gy per day) and using an alpha/beta ratio of 25 Gy the dose per day to compensate for extension of treatment is .37 Gy (given in 2 Gy fractions). Thus, it can be alternatively suggested that whereas a smaller fraction size was associated with more local failure this may have been a reflection of prolongation of overall treatment time with an attendant increase in the probability of failure because of accelerated repopulation. FRED SCHWAIBOLD, D.O. J. M. G. TAYLOR,PH.D. Cooper Hospital University Medical Center UCLA School of Medicine I. Schwaibold, Frederick: Scariato, Albert; Nunno, M.; Wallner, Paul E.; Lust& Robert A.; Rouby, Elida; Gorshein, Dov; Wenger, Jeffery. Cancer. Int. J. Radiat. Oncol. Biol. Phys. 14:451-454; 1988. 2. Withers, H. R.: Taylor, J. M. G.; Maciejewski, B. The hazard of accelerated tumor clonogen repopulation during radiotherapy. Acta Oncol. 27:Fasc. 2; 1988.