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Second malignancies in treated cancer patients
552
CLINICAL RADIOLOGY
SECOND MALIGNANCIES IN TREATED CANCER PATIENTS N. E. D A Y and J. M. K A L D O R
International Agency for Research on Cancer, Lyon, France Both cytotoxic drugs and radiation when used for cancer therapy have the potential to induce new primary cancers. An approach to this problem is to exploit the material in population-based cancer registries, the advantages being the large number of cases available for study and extended follow-up of uniform quality. The disadvantage is the lack of detailed treatment information kept by most registries, but much of this information can be obtained on selected individuals by a search of clinical records, using a case-control approach. A n example of this approach has been an international study of the carcinogenic effect of the radiation treatment of cervix cancer. Earlier studies based on smaller numbers and less extensive follow-up had given incomplete or even misleading results. Similar studies are now being undertaken of second primaries following Hodgkin's disease, ovarian and testicular cancer. The following excesses of second cancers were observed which were probably treatment related: following Hodgkin's disease, leukaemia, lung, breast, bladder, skin, bone; following ovarian cancer, leukaemia, bladder, non-Hodgkin's lymphoma, bone, connective tissue and possibly large intestine; following testicular cancer, leukaemia and non Hodgkin's lymphoma. The nature of the treatments leading to these excesses is currently under investigation using a case control approach. The power of this approach is illustrated by results from the German Democratic Republic, where use of cancer registry material from 1960-82 has demonstrated a dose related leukaemogenic effect of cyclophosphamide used for treating ovarian and breast cancer.
THE LATE EFFECTS OF TREATING CANCER IN CHILDREN DOROTHY PEARSON
Christie Hospital & Holt Radium Institute, Manchester There has been an improvement in the survival of children treated for malignant disease in the past 20 years. As both radiotherapy and chemotherapy may have more effect on the normal tissues which are still actively growing it is important to document the effects on these tissues as the child progresses into adult life. The long term survivors treated before the era of chemotherapy by surgery and radiotherapy are now all adults, and the late effects of their treatment will be described in the normal tissues which had to be irradiated. In some instances there is the possibility of treatment for some of the late effects, particularly those of endocrine organs. Knowledge of these late effects can in some instances lead to modifications in treatment techniques, with the promise of fewer effects in the future. It is still too early to document all the possible late effects of intensive chemotherapy, and also whether combination treatment with chemotherapy and radiotherapy may increase the late effects as compared with radiotherapy alone, but what information is available will be discussed. Finally the development of second malignancies in these children will be described and the genetic and treatment factors discussed.
IATROGENIC DISEASE OF THE BRACHIAL PLEXUS AFTER RADIOTHERAPY J. C O O K E , D. COOKE* and C. P A R S O N S
Royal Marsden Hospital and *St Thomas' Hospital, London The brachial plexus is difficult to examine directly as it is hidden between the bone and muscles at the root of the neck. The consequence of plexus damage from either locally invasive metastatic caremoma of the breast or from post-irradiation fibrosis can be shown clinically but it may be difficult even with most careful neurological assessment to differentiate these conditions. Until recently radiological study of this region was limited to the use of plain films and angiography to demonstrate bony or vascular anatomy. Improvement in the spatial resolution of computed tomography has allowed more accurate imaging of the patient with plexus pathology. We examined the normal and abnormal axillae in 30 patients with carcinoma of the breast treated with radiation to assess, firstly, the normal plexus and its relations. We then graded the diseased side according to extent, severity and character of the abnormality and correlated this with the dose, fields and fractionation of radiotherapy.
GLYN EVANS M E M O R I A L LECTURE
Chairman: The President WHITHER RADIOTHERAPY? W. M. ROSS
Newcastle General Hospital & Royal Victoria infirmary, Newcastleupon- Tyne Tribute is paid to Dr Glyn Evans as a radiotherapist of the old school who showed the way forward. The record of radiotherapists and oncologists, and of the departments in which they work, is examined so as to indicate the scope for further progress, and the methods by which such progress will be made in a sound academic and scientific manner. The organisational arrangements appropriate to these advances will be reviewed in an attempt to portray new surgical clinical oncology at the end of the century.
RADIOIAGNOSTIC P R O F F E R R E D PAPERS
Chairman: Dr J. O. M. C. Craig (London) BALLOON DILATATION OF O E S O P H A G E A L STRICTURES A. G R U N D Y
St George's Hospital and Medical School, London Dilatation of oesophageal strictures by radiologically guided dilatation catheters is gaining acceptance as an alternative to conventional bougienage. Large dilatation catheters, developed from angioplasty catheters, are now available with a diameter of up to 20 mm. The technique of balloon dilatation under radiological control is described and the results of this method of treatment in a series of 17 patients over an 18 month period are presented. Strictures due to reflux oesophagitis were present in six patients, four had strictures due to previous radiotherapy, three had postoperative strictures and four patients had achalasia. The age range was from 49 to 88 years. Five patients had dilatation performed on more than one occasion. Balloon dilatation has advantages over conventional bougienage. It is a safe procedure, has good patient toleration, can be performed as a day case and is readily repeatable.
UNHEEDED W A R N I N G S J E A N M. G U Y
Yeovil District Hospital, Somerset For the 25 years prior to the setting up of the British X-ray and Radium protection committee, there had been numerous warnings of the dangers of radiation, beginning with Sir Joseph Lister's address to the British Association in 1896. The therapeutic use of radiation inevitably implies damage to patients' tissues; however, in its early years, diagnostic radiology was dangerous for patient and operator. Hamburg's radiation martyrs' memorial carries names of only some of the British men and women damaged or killed by the radiation they were using to help others. This radiation is invisible, inaudible and impalpable and its effects are delayed, so the causal association with 'dermatitis', tissue necrosis and tumours was not easily appreciated. Without the means to measure X-ray output, or to regulate it, protective measures could be only empirical. Recommendations for protection of staff and patients were unenforcable until well defined professional groups of X-ray manufacturers, technicians and physicians were established. This paper deals with first hand accounts of radiation damage and attempts made to prevent it in diagnostic radiology before 1921. EXTRA-CORPOREAL SHOCK WAVE LITHOTRIPSY, THE ST THOMAS'S EXPERIENCE J. P E M B E R T O N , J. B O W L E S , A. T A N Q U E R A Y , K. E. D. S H U T T L E W O R T H , M. I. B U L T I T U D E and E. L. H. P A L F R E Y
St Thomas' Hospital, London The first lithotripter for the use of National Health Service patients was opened at St Thomas' Hospital, London in March 1985. Patients referred were assessed both surgically and radiologically. Stag-horn calculi were initially excluded from primary lithotripter treatment, By April 1986 1000 patients had received treatment and it is envisaged this report will include details of the first 1500. Of these 77 patients were treated on a day care basis for other hospitals and the remainder were
CLINICAL RADIOLOGY
SECOND MALIGNANCIES IN TREATED CANCER PATIENTS N. E. D A Y and J. M. K A L D O R
International Agency for Research on Cancer, Lyon, France Both cytotoxic drugs and radiation when used for cancer therapy have the potential to induce new primary cancers. An approach to this problem is to exploit the material in population-based cancer registries, the advantages being the large number of cases available for study and extended follow-up of uniform quality. The disadvantage is the lack of detailed treatment information kept by most registries, but much of this information can be obtained on selected individuals by a search of clinical records, using a case-control approach. A n example of this approach has been an international study of the carcinogenic effect of the radiation treatment of cervix cancer. Earlier studies based on smaller numbers and less extensive follow-up had given incomplete or even misleading results. Similar studies are now being undertaken of second primaries following Hodgkin's disease, ovarian and testicular cancer. The following excesses of second cancers were observed which were probably treatment related: following Hodgkin's disease, leukaemia, lung, breast, bladder, skin, bone; following ovarian cancer, leukaemia, bladder, non-Hodgkin's lymphoma, bone, connective tissue and possibly large intestine; following testicular cancer, leukaemia and non Hodgkin's lymphoma. The nature of the treatments leading to these excesses is currently under investigation using a case control approach. The power of this approach is illustrated by results from the German Democratic Republic, where use of cancer registry material from 1960-82 has demonstrated a dose related leukaemogenic effect of cyclophosphamide used for treating ovarian and breast cancer.
THE LATE EFFECTS OF TREATING CANCER IN CHILDREN DOROTHY PEARSON
Christie Hospital & Holt Radium Institute, Manchester There has been an improvement in the survival of children treated for malignant disease in the past 20 years. As both radiotherapy and chemotherapy may have more effect on the normal tissues which are still actively growing it is important to document the effects on these tissues as the child progresses into adult life. The long term survivors treated before the era of chemotherapy by surgery and radiotherapy are now all adults, and the late effects of their treatment will be described in the normal tissues which had to be irradiated. In some instances there is the possibility of treatment for some of the late effects, particularly those of endocrine organs. Knowledge of these late effects can in some instances lead to modifications in treatment techniques, with the promise of fewer effects in the future. It is still too early to document all the possible late effects of intensive chemotherapy, and also whether combination treatment with chemotherapy and radiotherapy may increase the late effects as compared with radiotherapy alone, but what information is available will be discussed. Finally the development of second malignancies in these children will be described and the genetic and treatment factors discussed.
IATROGENIC DISEASE OF THE BRACHIAL PLEXUS AFTER RADIOTHERAPY J. C O O K E , D. COOKE* and C. P A R S O N S
Royal Marsden Hospital and *St Thomas' Hospital, London The brachial plexus is difficult to examine directly as it is hidden between the bone and muscles at the root of the neck. The consequence of plexus damage from either locally invasive metastatic caremoma of the breast or from post-irradiation fibrosis can be shown clinically but it may be difficult even with most careful neurological assessment to differentiate these conditions. Until recently radiological study of this region was limited to the use of plain films and angiography to demonstrate bony or vascular anatomy. Improvement in the spatial resolution of computed tomography has allowed more accurate imaging of the patient with plexus pathology. We examined the normal and abnormal axillae in 30 patients with carcinoma of the breast treated with radiation to assess, firstly, the normal plexus and its relations. We then graded the diseased side according to extent, severity and character of the abnormality and correlated this with the dose, fields and fractionation of radiotherapy.
GLYN EVANS M E M O R I A L LECTURE
Chairman: The President WHITHER RADIOTHERAPY? W. M. ROSS
Newcastle General Hospital & Royal Victoria infirmary, Newcastleupon- Tyne Tribute is paid to Dr Glyn Evans as a radiotherapist of the old school who showed the way forward. The record of radiotherapists and oncologists, and of the departments in which they work, is examined so as to indicate the scope for further progress, and the methods by which such progress will be made in a sound academic and scientific manner. The organisational arrangements appropriate to these advances will be reviewed in an attempt to portray new surgical clinical oncology at the end of the century.
RADIOIAGNOSTIC P R O F F E R R E D PAPERS
Chairman: Dr J. O. M. C. Craig (London) BALLOON DILATATION OF O E S O P H A G E A L STRICTURES A. G R U N D Y
St George's Hospital and Medical School, London Dilatation of oesophageal strictures by radiologically guided dilatation catheters is gaining acceptance as an alternative to conventional bougienage. Large dilatation catheters, developed from angioplasty catheters, are now available with a diameter of up to 20 mm. The technique of balloon dilatation under radiological control is described and the results of this method of treatment in a series of 17 patients over an 18 month period are presented. Strictures due to reflux oesophagitis were present in six patients, four had strictures due to previous radiotherapy, three had postoperative strictures and four patients had achalasia. The age range was from 49 to 88 years. Five patients had dilatation performed on more than one occasion. Balloon dilatation has advantages over conventional bougienage. It is a safe procedure, has good patient toleration, can be performed as a day case and is readily repeatable.
UNHEEDED W A R N I N G S J E A N M. G U Y
Yeovil District Hospital, Somerset For the 25 years prior to the setting up of the British X-ray and Radium protection committee, there had been numerous warnings of the dangers of radiation, beginning with Sir Joseph Lister's address to the British Association in 1896. The therapeutic use of radiation inevitably implies damage to patients' tissues; however, in its early years, diagnostic radiology was dangerous for patient and operator. Hamburg's radiation martyrs' memorial carries names of only some of the British men and women damaged or killed by the radiation they were using to help others. This radiation is invisible, inaudible and impalpable and its effects are delayed, so the causal association with 'dermatitis', tissue necrosis and tumours was not easily appreciated. Without the means to measure X-ray output, or to regulate it, protective measures could be only empirical. Recommendations for protection of staff and patients were unenforcable until well defined professional groups of X-ray manufacturers, technicians and physicians were established. This paper deals with first hand accounts of radiation damage and attempts made to prevent it in diagnostic radiology before 1921. EXTRA-CORPOREAL SHOCK WAVE LITHOTRIPSY, THE ST THOMAS'S EXPERIENCE J. P E M B E R T O N , J. B O W L E S , A. T A N Q U E R A Y , K. E. D. S H U T T L E W O R T H , M. I. B U L T I T U D E and E. L. H. P A L F R E Y
St Thomas' Hospital, London The first lithotripter for the use of National Health Service patients was opened at St Thomas' Hospital, London in March 1985. Patients referred were assessed both surgically and radiologically. Stag-horn calculi were initially excluded from primary lithotripter treatment, By April 1986 1000 patients had received treatment and it is envisaged this report will include details of the first 1500. Of these 77 patients were treated on a day care basis for other hospitals and the remainder were