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Sequelae, sequelae on the wall, which is the fairest modality of them all?
PII: SO360-3016(96)00438-5
EISEVIER
l
Editorial SEQUELAE,
SEQUELAE ON THE WALL, WHICH MODALITY OF THEM ALL?
STANLEY E. ORDER, M.D.,FACR*
IS THE
FAIREST
AND SARAH S. DONALDSON, M.D..FACR’
:LInstitute for Systemic Radiation Therapy, Cooper Hospital/University Medical Center. Camden. NJ; and ‘Department Radiation Oncology, Stanford University Medical Center. Stanford University, Palo Alto. CA
of
The original impetus for investigating the radiation therapy of benign disease was a committee of the National Academy of Science (NAS) that had concluded that the radiation therapy of benign disease was irresponsible, always cancer-inducing, and the worst modality to choose for benign disorders. The committee “lacked data,” and it was suggested that data accumulation and a national survey among the radiation oncology community would be useful. The first publication of a literature search with accompanying data was accomplished and published by the government (2). In the years that followed, the American College of Radiology (ACR) and The Inter Society Council of Radiation Oncology (ISCRO) supported a national treatment survey to determine the practice of benign disease treatment in the radiation oncology community. Following this, a formal structured text with the requirements of a legal consent for permission of treatment and brief summaries of the literature concerning the irradiation of benign diseases was published (3). There was no hesitation to point out unacceptable sequelae and both appropriate and inappropriate radiation treatment. In the latest text (4), a section is devoted to unattractive sequelae. However, in certain disorders, the Snow White of radiation remains preeminent in preventing blindness (pituitary tumors), inhibiting organ destruction (desmoid). preventing paralysis (hemangioma of the spinal cord), and allowing ability to ambulate (heterotopic bone formation). Yet. even in this era, in which vascular stenosis and restenosis can reduce longevity and in which surgery is used for short-term gain (l), there are those who are opposed to investigating radiation therapy for the inhibition of vascular stenosis. Those who look in the mirror and see unrealistic threats of cancer induction stemming from fallacious treatments of the past often disregard the features
of organ at risk, dose, age of patients. and the other lessons learned from the irradiation of benign disease. Certain principles are denied by this approach. and yet are clearly established in the literature. Pediatric radiation for benign disease is hazardous because of patient longevity and the increased opportunity for malignancy. The radiation dose and distribution must be carefully chosen to avoid secondary targets in the treatment field (Le., ovary. thyroid). The dose of radiation should be only that which is required to be effective. Finally, new studies require rigorous scientific discipline and institutional review board approved evaluations and would then provide accurate risk-benefit ratios. It is unrealistic for Sneezy and Sleepy to tell Snow White that the apple is poisoned unless they have evidence of undue sequelae. Age, longevity. dose. target tissue, and past history of the organ site for radiation treatment would indicate whether a good risk-benefit ratio favors radiation treatment of arterial stenosis and restenosis. In the endarterectomy studies for moderate symptomatic carotid stenosis, the surgical benefit was statistically proven for the first 3 years ( 1). In a multicenter 1599 patient study beyond 3 years, the stroke-free patients were equivalent with or without surgical intervention. Are we to concern ourselves about long-term risks when the dose of radiation is a single dose of 1O- I.5 Gy and limited to the heart or immediate vasculature in 60year-old patients? Thirty percent of the patients with carotid stenosis were dead in 8 years (1). The risk-benefit ratio needs to be evaluated by formal studies; only then will we know whether restrictive radiation to prevent stenosis or restenosis is acceptable. Current data indicate that the risk is higher for those who have no treatment. What is the fairest modality of them all for patients having stenosis and cardiac problems? We must evaluate the mirror of reality to determine this and move forward in the treatment of benign disease-not depend on fairy tales.
Reprint requests to: Dr. Stanley E. Order, Institute for Systemic Radiation Therapy. Cooper HospitalfLTniversity Medical Center,
Camden, NJ 08103. Accepted for publication 28 August 19% 969
970
I. J. RadiationOncology 0 Biology 0 Physics
Volume 36, Number 4, 1996
REFERENCES 1. European Carotid Surgery Trial&s Collaboration Group. Endarterectomy for moderate symptomatic carotid stenosis: Interim results from the MRC European Carotid Surgery Trial. Lancet 347:1591-1593; 1996. 2. Order, S. E. A review of the use of ionizing radiation for the treatment of benign diseases. Rockville, MD: US Department of Health, Education, and Welfare; 1977.
3. Order, S. E.; Donaldson, S. S. In: Brady, L. W.; Heilman, H. P., eds. Radiation therapy of benign diseases. A clinical guide. Heidelberg, Germany: Springer Verlag; 1990. 4. Order, S. E.; Donaldson, S. S. In: Brady, L. W.; Heilman, H. P., eds. Radiation therapy of benign diseases. A clinical guide. Heidelberg, Germany: Springer Verlag; 1996.
EISEVIER
l
Editorial SEQUELAE,
SEQUELAE ON THE WALL, WHICH MODALITY OF THEM ALL?
STANLEY E. ORDER, M.D.,FACR*
IS THE
FAIREST
AND SARAH S. DONALDSON, M.D..FACR’
:LInstitute for Systemic Radiation Therapy, Cooper Hospital/University Medical Center. Camden. NJ; and ‘Department Radiation Oncology, Stanford University Medical Center. Stanford University, Palo Alto. CA
of
The original impetus for investigating the radiation therapy of benign disease was a committee of the National Academy of Science (NAS) that had concluded that the radiation therapy of benign disease was irresponsible, always cancer-inducing, and the worst modality to choose for benign disorders. The committee “lacked data,” and it was suggested that data accumulation and a national survey among the radiation oncology community would be useful. The first publication of a literature search with accompanying data was accomplished and published by the government (2). In the years that followed, the American College of Radiology (ACR) and The Inter Society Council of Radiation Oncology (ISCRO) supported a national treatment survey to determine the practice of benign disease treatment in the radiation oncology community. Following this, a formal structured text with the requirements of a legal consent for permission of treatment and brief summaries of the literature concerning the irradiation of benign diseases was published (3). There was no hesitation to point out unacceptable sequelae and both appropriate and inappropriate radiation treatment. In the latest text (4), a section is devoted to unattractive sequelae. However, in certain disorders, the Snow White of radiation remains preeminent in preventing blindness (pituitary tumors), inhibiting organ destruction (desmoid). preventing paralysis (hemangioma of the spinal cord), and allowing ability to ambulate (heterotopic bone formation). Yet. even in this era, in which vascular stenosis and restenosis can reduce longevity and in which surgery is used for short-term gain (l), there are those who are opposed to investigating radiation therapy for the inhibition of vascular stenosis. Those who look in the mirror and see unrealistic threats of cancer induction stemming from fallacious treatments of the past often disregard the features
of organ at risk, dose, age of patients. and the other lessons learned from the irradiation of benign disease. Certain principles are denied by this approach. and yet are clearly established in the literature. Pediatric radiation for benign disease is hazardous because of patient longevity and the increased opportunity for malignancy. The radiation dose and distribution must be carefully chosen to avoid secondary targets in the treatment field (Le., ovary. thyroid). The dose of radiation should be only that which is required to be effective. Finally, new studies require rigorous scientific discipline and institutional review board approved evaluations and would then provide accurate risk-benefit ratios. It is unrealistic for Sneezy and Sleepy to tell Snow White that the apple is poisoned unless they have evidence of undue sequelae. Age, longevity. dose. target tissue, and past history of the organ site for radiation treatment would indicate whether a good risk-benefit ratio favors radiation treatment of arterial stenosis and restenosis. In the endarterectomy studies for moderate symptomatic carotid stenosis, the surgical benefit was statistically proven for the first 3 years ( 1). In a multicenter 1599 patient study beyond 3 years, the stroke-free patients were equivalent with or without surgical intervention. Are we to concern ourselves about long-term risks when the dose of radiation is a single dose of 1O- I.5 Gy and limited to the heart or immediate vasculature in 60year-old patients? Thirty percent of the patients with carotid stenosis were dead in 8 years (1). The risk-benefit ratio needs to be evaluated by formal studies; only then will we know whether restrictive radiation to prevent stenosis or restenosis is acceptable. Current data indicate that the risk is higher for those who have no treatment. What is the fairest modality of them all for patients having stenosis and cardiac problems? We must evaluate the mirror of reality to determine this and move forward in the treatment of benign disease-not depend on fairy tales.
Reprint requests to: Dr. Stanley E. Order, Institute for Systemic Radiation Therapy. Cooper HospitalfLTniversity Medical Center,
Camden, NJ 08103. Accepted for publication 28 August 19% 969
970
I. J. RadiationOncology 0 Biology 0 Physics
Volume 36, Number 4, 1996
REFERENCES 1. European Carotid Surgery Trial&s Collaboration Group. Endarterectomy for moderate symptomatic carotid stenosis: Interim results from the MRC European Carotid Surgery Trial. Lancet 347:1591-1593; 1996. 2. Order, S. E. A review of the use of ionizing radiation for the treatment of benign diseases. Rockville, MD: US Department of Health, Education, and Welfare; 1977.
3. Order, S. E.; Donaldson, S. S. In: Brady, L. W.; Heilman, H. P., eds. Radiation therapy of benign diseases. A clinical guide. Heidelberg, Germany: Springer Verlag; 1990. 4. Order, S. E.; Donaldson, S. S. In: Brady, L. W.; Heilman, H. P., eds. Radiation therapy of benign diseases. A clinical guide. Heidelberg, Germany: Springer Verlag; 1996.