- Email: [email protected]
Rebuttal
685
Correspondence following single and multifractionated irradiation. fnr. J. Rudiur. Oncol. Biol.
Phvs. 6~1539-1544.
1980.
6. Tureason, I., Nitter.
G.: The response of pig skin to sidgle and fractionated high dose-rate and continuous low dose-rate “‘Csirradiation-l. Experimental design and results. Inr. 1. Radiur. Oncol.
Biol. Phys. 5~835-844, 1979. 7. Turesson. I., Nottcr, G.: The response of pig skin to singIF_.and
fractionated high dose-rate and continuous low dose-rate “‘Cs-irradiation-Ill. Re-evaluation of the CRE svstem and the TDF system according to the present findings. inr. /: Rudiar. Oncol. Biol. Phys. 5:1773-1779, 1979. 8. Withers, H.R.: IsoefTect curves for various proliferative tissues in experimental animals. In Time Dose Relationships in Clinical Rudiorherapy. W.L. Caldwell and D.D. Talbert (Eds.). Madison, Madison Printing and Publishing Co. 1975, Pp. 30-38. 9. Withers, H.R., Peters, L.J., Kogelnik. H.D.: The pathobiology of late effects of irradiation. In Rudiution Biology in Cuncer Research. R.E. Meyn and H.R. Withers (Eds.). New York, Raven Press. 1980. Pp. 439-448.
question the conclusion the authors reach on this otherwise dismal survival rate when at the end of their analysis, they conclude that radiotherapy to the neck and mediastinum is an adequate form of treatment for this disease. Obviously it is not; it would be hard to envision ever doing this badly with our more advanced combination chemotherapeutic programs centering around Adriamycin. Admittedly, no one has had a significantly large series of Adriamycin combinationtreated patients to date, but it is difficult to understand how the authors feel that their current management with radiotherapy for Stage I and II thyroid lymphoma could in any way be described as “adequate.” RONALD L. STEPHENS, M.D. Associate Professor of Medicine Co-Director, Division of Clinical Oncology The University of Kansas 39th and Rainbow Blvd. Kansas City, KS 66103
1. Souhami. L., Simpson, W.J.. Carruthers, J.S.: Malignant :_Lymphoma of the thyroid gland. Int. /. Radio!. Oncol. Biol. Phys. 6: 1143-I
147. 1980.
RADIOTHERAPY OF THE LOMBOAORTIC LYMPH NODES IN CARCINOMA OF THE CERVIX UTERI REBUTTAL To rhe
We present a radiation technique whereby lomboaortic lymph nodes (LAN) can be treated to 5000 rad in 5 weeks with a 1000 rad booster dose, if necessary, without significant complications. The delivery of radiation to the LAN is difficult because of the closenessof radiosensitive organs such as the aorta, vena cava inferior, renal vessels and the pancreas. In order to reduce the dose to these organs, and to the bowels and kidneys, we have established the exact treatment volume by pyelography and lymphography. The kidneys can be protected by using anterior and posterior fields; the penumbra of the radiation beam is cut with lead blocks. At the posterior field, the spinal cord is protected by a narrow lead shield. The main problem, however, is with the small bowel tolerance of 5000 rad in 6 weeks;’ the bowel must therefore be protected. By placing the patient in a prone position, the bowel moves forward. However, it does not move forward enough to be placed outside of the laterlly projected field. We have the patient lie prone on a table with an opening for the abdomen, with supports for the patients’chest and hips. This allows the bowel to move away from the vertebral body. leaving a space of 2-3 cm. The LAN to be treated are within this volume. The kidneys do not come into this field and are thus protected. It is possible that the caudal pole may be tangentially irradiated, but only 2O-25%. which is clearly within an acceptable range. Radiation is delivered in 3000 rad laterally; the kidneys and bowel receive doses within tolerance level. This technique requires precision, but not complicated apparatus. We have used this technique for a year without any complications; however, more time is necessary before we can make any definite conclusions. Editor:
To rhe Ediror: We regret that in his haste to condemn the use of external radiation for Stage I and II thyroid lumphoma, Dr. Stephens2 has misread the data presented in our article in the September 1980 issue of the Journal’: the survival rate for all patients was 35%; the 7%’ survival rate at five years to which Dr. Stephens refers represents the survival from the date of recurrence of those patients who relapsed. However, we concur with Dr. Stephens’ point about the necessity for adopting a more aggressive approach to the initial management of patients with thyroid lymphomas. To date, no study has demonstrated better survival rates for patients with Stage I and “localized” Stage II extranodal non-Hodgkin’s lymphoma treated by combination chemotherapy than by radiation alone. The validity of this approach is borne out by our results in the small sub-group of patients with Stage I and “localixed” Stage II disease who received irradiation to the neck and mediastinum - all are alive with no evidence of recurrent disease. To us, this seems sufficient evidence that radiotherapy alone is an adequate form of treatment for this selected group of patients. In patients with more extensive disease, it is clear that neck and mediastinal radiation is not adequate treatment. Combination chemotherapy, alone or following external radiation to relieve respiratory or superior vena cava obstruction. should be undertaken unless there are contraindications. One must no! forget that many of these patients are elderly (4096 were over 70 years of age) and often have other serious diseases which may preclude the administration of effective chemotherapy.
L. SOUHAMI. M.D. W.J. SIMPSON. M.D., FRCP (C) J.S. CARRUTHERS. M.D. Dept. of Radiation Oncology and Pathology Princess Margaret Hospital 500 Sherbourne St. Toronto, Ontario M4X I K9 Canada
W. JULIER. M.D. B. FORSTER. M.D. Division of Therapeutic Radiology County Hospital. Oradea, Romania I. Abbatucci, J.S., Bloquel. J., Quint, R., Boussel, A., Viallaneix, J.P.: Techniques do r~lkcolbalth~rapie Radicale. Paris, L’expansion Scientifique, 1968.
Critique of “Malignant Lymplm& of tbe Thyroid Gland,” L. Soulmmi et al., Int. J. RadIIt. Oncol. Biol. Phys. 6: 1143-1147, 1980 To rhe Editor: The article by Souhami et al.’ in the September I980 issue of the Journal is an interesting contribution to the natural history of thyroid lymphoma. This descriptive study does contribute to our understanding of this disease. However, it is not surprising that in the eight patients autopsied in the authors’ series. all eight had evidence of disseminated lymphoma. In addition, the use of radiotherapy for local management resulted in a five year survival rate of only 7%. One has to
I. Stephens, R.: Letter to the editor. Inr. J. Radiaf. Oncol. Viol. Phys. 7: ooo-ooO, 1981. 2. Souhami. L.. Simpson, W.J., Carruthers, J.S.: Malignant lymphoma of the thyroid gland. Inr. J. Radio!. Oncol. Biol. Ph,vs. 6: I I43- I 147. 1980.
Critique of “Microwave Power Absorption DitTerences Between Normal and Malignant Tksue,” W.T. Jones et al., lnt. J. Radirt. Oncol. Biol. Phys. 6: 681-687, 1980 .
To /he Edifor: In their article in the June issueof the Journal. Joines er al.’ apparently conclude that selective power absorption occurs in
Correspondence following single and multifractionated irradiation. fnr. J. Rudiur. Oncol. Biol.
Phvs. 6~1539-1544.
1980.
6. Tureason, I., Nitter.
G.: The response of pig skin to sidgle and fractionated high dose-rate and continuous low dose-rate “‘Csirradiation-l. Experimental design and results. Inr. 1. Radiur. Oncol.
Biol. Phys. 5~835-844, 1979. 7. Turesson. I., Nottcr, G.: The response of pig skin to singIF_.and
fractionated high dose-rate and continuous low dose-rate “‘Cs-irradiation-Ill. Re-evaluation of the CRE svstem and the TDF system according to the present findings. inr. /: Rudiar. Oncol. Biol. Phys. 5:1773-1779, 1979. 8. Withers, H.R.: IsoefTect curves for various proliferative tissues in experimental animals. In Time Dose Relationships in Clinical Rudiorherapy. W.L. Caldwell and D.D. Talbert (Eds.). Madison, Madison Printing and Publishing Co. 1975, Pp. 30-38. 9. Withers, H.R., Peters, L.J., Kogelnik. H.D.: The pathobiology of late effects of irradiation. In Rudiution Biology in Cuncer Research. R.E. Meyn and H.R. Withers (Eds.). New York, Raven Press. 1980. Pp. 439-448.
question the conclusion the authors reach on this otherwise dismal survival rate when at the end of their analysis, they conclude that radiotherapy to the neck and mediastinum is an adequate form of treatment for this disease. Obviously it is not; it would be hard to envision ever doing this badly with our more advanced combination chemotherapeutic programs centering around Adriamycin. Admittedly, no one has had a significantly large series of Adriamycin combinationtreated patients to date, but it is difficult to understand how the authors feel that their current management with radiotherapy for Stage I and II thyroid lymphoma could in any way be described as “adequate.” RONALD L. STEPHENS, M.D. Associate Professor of Medicine Co-Director, Division of Clinical Oncology The University of Kansas 39th and Rainbow Blvd. Kansas City, KS 66103
1. Souhami. L., Simpson, W.J.. Carruthers, J.S.: Malignant :_Lymphoma of the thyroid gland. Int. /. Radio!. Oncol. Biol. Phys. 6: 1143-I
147. 1980.
RADIOTHERAPY OF THE LOMBOAORTIC LYMPH NODES IN CARCINOMA OF THE CERVIX UTERI REBUTTAL To rhe
We present a radiation technique whereby lomboaortic lymph nodes (LAN) can be treated to 5000 rad in 5 weeks with a 1000 rad booster dose, if necessary, without significant complications. The delivery of radiation to the LAN is difficult because of the closenessof radiosensitive organs such as the aorta, vena cava inferior, renal vessels and the pancreas. In order to reduce the dose to these organs, and to the bowels and kidneys, we have established the exact treatment volume by pyelography and lymphography. The kidneys can be protected by using anterior and posterior fields; the penumbra of the radiation beam is cut with lead blocks. At the posterior field, the spinal cord is protected by a narrow lead shield. The main problem, however, is with the small bowel tolerance of 5000 rad in 6 weeks;’ the bowel must therefore be protected. By placing the patient in a prone position, the bowel moves forward. However, it does not move forward enough to be placed outside of the laterlly projected field. We have the patient lie prone on a table with an opening for the abdomen, with supports for the patients’chest and hips. This allows the bowel to move away from the vertebral body. leaving a space of 2-3 cm. The LAN to be treated are within this volume. The kidneys do not come into this field and are thus protected. It is possible that the caudal pole may be tangentially irradiated, but only 2O-25%. which is clearly within an acceptable range. Radiation is delivered in 3000 rad laterally; the kidneys and bowel receive doses within tolerance level. This technique requires precision, but not complicated apparatus. We have used this technique for a year without any complications; however, more time is necessary before we can make any definite conclusions. Editor:
To rhe Ediror: We regret that in his haste to condemn the use of external radiation for Stage I and II thyroid lumphoma, Dr. Stephens2 has misread the data presented in our article in the September 1980 issue of the Journal’: the survival rate for all patients was 35%; the 7%’ survival rate at five years to which Dr. Stephens refers represents the survival from the date of recurrence of those patients who relapsed. However, we concur with Dr. Stephens’ point about the necessity for adopting a more aggressive approach to the initial management of patients with thyroid lymphomas. To date, no study has demonstrated better survival rates for patients with Stage I and “localized” Stage II extranodal non-Hodgkin’s lymphoma treated by combination chemotherapy than by radiation alone. The validity of this approach is borne out by our results in the small sub-group of patients with Stage I and “localixed” Stage II disease who received irradiation to the neck and mediastinum - all are alive with no evidence of recurrent disease. To us, this seems sufficient evidence that radiotherapy alone is an adequate form of treatment for this selected group of patients. In patients with more extensive disease, it is clear that neck and mediastinal radiation is not adequate treatment. Combination chemotherapy, alone or following external radiation to relieve respiratory or superior vena cava obstruction. should be undertaken unless there are contraindications. One must no! forget that many of these patients are elderly (4096 were over 70 years of age) and often have other serious diseases which may preclude the administration of effective chemotherapy.
L. SOUHAMI. M.D. W.J. SIMPSON. M.D., FRCP (C) J.S. CARRUTHERS. M.D. Dept. of Radiation Oncology and Pathology Princess Margaret Hospital 500 Sherbourne St. Toronto, Ontario M4X I K9 Canada
W. JULIER. M.D. B. FORSTER. M.D. Division of Therapeutic Radiology County Hospital. Oradea, Romania I. Abbatucci, J.S., Bloquel. J., Quint, R., Boussel, A., Viallaneix, J.P.: Techniques do r~lkcolbalth~rapie Radicale. Paris, L’expansion Scientifique, 1968.
Critique of “Malignant Lymplm& of tbe Thyroid Gland,” L. Soulmmi et al., Int. J. RadIIt. Oncol. Biol. Phys. 6: 1143-1147, 1980 To rhe Editor: The article by Souhami et al.’ in the September I980 issue of the Journal is an interesting contribution to the natural history of thyroid lymphoma. This descriptive study does contribute to our understanding of this disease. However, it is not surprising that in the eight patients autopsied in the authors’ series. all eight had evidence of disseminated lymphoma. In addition, the use of radiotherapy for local management resulted in a five year survival rate of only 7%. One has to
I. Stephens, R.: Letter to the editor. Inr. J. Radiaf. Oncol. Viol. Phys. 7: ooo-ooO, 1981. 2. Souhami. L.. Simpson, W.J., Carruthers, J.S.: Malignant lymphoma of the thyroid gland. Inr. J. Radio!. Oncol. Biol. Ph,vs. 6: I I43- I 147. 1980.
Critique of “Microwave Power Absorption DitTerences Between Normal and Malignant Tksue,” W.T. Jones et al., lnt. J. Radirt. Oncol. Biol. Phys. 6: 681-687, 1980 .
To /he Edifor: In their article in the June issueof the Journal. Joines er al.’ apparently conclude that selective power absorption occurs in