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Fraction size in radiotherapy of malignant melanoma remains a point of controversy. Among 139 patients treated at the University of Illinois Hospital in 1979-1988, 36 were considered potentially curable (not counting ocular melanomas); 20 were treated by the Princess Margaret Hospital (PMH) hypofractionated schedule using 800 cGy per fraction and achieved a permanency of local control lasting > 6 months since the beginning of radiotherapy in 10/22 (45.5%) courses. Comparable results were obtained in 11 patients treated by standard fractionation to at least threshold curative levels. A modification of PMH regimen in 5 patients (but with 13 courses) by decreasing fraction size to 400 cGy while keeping total dose and course duration unchanged, resulted in a 100% loss of focal control within 6 months. Patients considered incurable and irradiated by PMH schedule responded in 83% of courses compared to 51.4% response rate in patients irradiated with other schedules (except modified PMH regimen). Other aspects of melanoma management are analyzed.

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A non-weight-bearing porous-coated rod was implanted bilaterally in the proximal part of the humerus in thirty-five adult male mongrel dogs. In all of the animals, one limb was treated with radiation and the opposite limb served as the control. In twenty-one animals, the dose was 1000 centigrays (rads) and in fourteen, it was 500 centigrays. The strength of fixation and the volume fraction of ingrowth of bone were determined two, four, and eight weeks after the operation in the group that received 1000 centigrays and two and four weeks after the operation in the group that received 500 centigrays. Treatment with 500 centigrays had no significant effect on the strength of fixation or the amount of ingrowth of bone. In contrast, at two weeks, treatment with 1000 centigrays had reduced the strength of fixation to 50 per cent of the control value (p less than 0.01), although, at four and eight weeks, the strength of fixation was not significantly different than that in the control limb. The amount of ingrowth of bone in the irradiated limb was significantly reduced at two weeks (30 per cent of the control value) (p less than 0.01), four weeks (70 per cent of the control value) (p less than 0.05), and eight weeks (56 per cent of the control value) (p less than 0.05).

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Seventy-two patients with a carcinoma of the head and neck, who were treated with surgery and postoperative irradiation, were reviewed to determine the local recurrence rates and survival in patients with inadequate surgical margins. Tumor recurrence rate was 31% for patients with microscopic tumors at resection margins and 50% for those with macroscopic tumor. Actuarial 3-year survival for these patients was 71% and 43%, respectively. All 4 patients who were irradiated later than 6 weeks after surgery developed recurrent malignancy despite the resection margins being free of tumor. Excluding these patients the 3-year survival for R0 patients was similar to that of R1 patients. It is concluded that postoperative irradiation is effective in patients with tumor at the surgical margins. It is suggested that the time interval between surgery and radiation therapy be limited to less than 6 weeks. Radiation dose prescriptions for various clinical situations are discussed.

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The authors conducted a multivariate analysis of the prognostic factors in 96 patients with early glottic cancer treated by radiation therapy. Of these, 73 had T1 and 23 had T2 tumor. The primary tumor was controlled in 82% of T1 and 74% of T2 lesions. Actuarial five-year survival rates were 87% for T1 and 74% for T2. Carcinoma of the anterior commissure associated with bilateral vocal cord involvement, subglottic tumor extension, persistent or recurrent laryngeal edema, and impaired cord mobility was found to adversely influence the prognosis. The data suggest that irradiation is the treatment of choice for glottic cancer limited to the vocal cords or with minimal extension to the anterior commissure or supraglottic larynx.

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A clinico-pathologic study of 173 patients with esophageal cancer was done. The median survival for all patients was 6.4 months. Persistent tumor in esophagus at the time of death was present in 78% of patients treated with radiation alone. Metastases to mediastinal, intraabdominal and supraclavicular nodes were found in 73%, 49% and 20% of patients respectively. Systemic metastases were found in 57% of patients, liver being the most common site. In 15% of patients, fistulae developed between esophagus and trachea or bronchus because of direct extension of the primary tumor. Local and regional tumor caused the death of 111 patients, whereas distant metastases led to death in only 27 patients. This study confirms the extensive intra- and extrathoracic spread of malignancy in a majority of patients with cancer of the esophagus.

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The study analyzed the extent of tumor at autopsy in 25 patients with a brainstem glioma. Primary tumor in the pons comprised the majority of cases, followed by medulla and midbrain. Histologically, 48% of the tumors were glioblastoma multiforme. The tumor spread was found to be dependent on the site of origin and the grade. Pontine tumors involved the adjacent structures more extensively than the tumors of midbrain and medulla. Contiguous cephalad and caudad involvement was frequent with Grade III and Grade IV tumors. The extent of meningeal involvement was limited to those surrounding the main tumor mass. It is concluded that in the treatment of brainstem gliomas, irradiation through fields limited to the brainstem, adjoining temporal lobes, cerebellum, and proximal spinal cord would be adequate.

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Radiotherapy alone was used to treat 187 patients with a head and neck cancer and clinically uninvolved lymph nodes. Delayed lymph node metastases developed in 35 (19%) patients, and concomitant tumor at the primary site was present in 90% of them. In two (1%) of the 187 patients, delayed metastases developed in the irradiated nodes with the primary tumor controlled; both of these patients received a radiation dose of less than 5,000 rad. Metastases in supraclavicular and posterior cervical regions occurred in 4% of the patients; and these sites were not included in the original radiation fields. The following conclusions were reached: (1) a radiation dose of 5,000 rad or more can eradicate 99% of the subclinical carcinomas in lymph nodes; (2) whole-neck irradiation is not indicated in patients with N0 stage tumor; and (3) surgical resection of primary tumors alone, without added neck dissection, may be adequate if postoperative radiation therapy is planned.

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One hundred forty-nine lymphograms from patients with localized carcinomas of the prostate were interpreted by a referee radiologist without the benefit of clinical stage, grade of tumor, or the result of staging pelvic node dissection. The lymphogram was able to detect 30 of 35 (86%) positive nodal metastases and confirm 90 of 114 (79%) negative nodal biopsies. The internal iliac nodal biopsies were positive as a single finding in only 7 of 54 (13%) patients. The total external iliac nodal involvement was 41 of 54 (76%). High-grade prostate cancer patients have twice the incidence of positive nodal biopsies and lymphograms. Lymphography detected 43% of positive nodal patients with normal acid phosphatase and 69% of positive nodal patients with elevated acid phosphatase determinations. The lymphogram and tumor grade (prostate) are considered significant potential predictors of lymph node biopsy result. Finally, the incidence of nodal metastasis in localized prostatic cancer from surgical and histologically confirmed lymphogram series is reviewed with the concept of sensitivity and specificity of the lymphogram.

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A total of 117 consecutive primary cancers of the tonsillar region was irradiated at the University of Illinois Hospitals from 1955 to 1973. Results with 94 patients treated with radiotherapy alone and 23 with a combination of surgery and radiotherapy were analyzed. The modalities of radiation used were electron beam, 22 meV photons and Cobalt-60. Lymph node metastases were noted in 70% of the patients at the initial examination. In patients treated with radiation alone the determinant 5-year survivals were 42% without and 20% with nodal involvement. In the absence of node disease, survivals were 100% in T1, 60% in T2, 37.5% in T3 and 25% in T4 lesions. The significance of age, sex, histological differentiation, extent of the tumor, modality of treatment and the incidence of second primary were analyzed. Time dose relationships and factors influencing the prognosis are discussed and the literature is reviewed.

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The efficacy and safety of perfluoroctylbromide as a diagnostic contrast agent for direct lymphography was studied in mongrel dogs. This radiopaque perfluorocarbon has several advantages over Ethiodol. The liquid compound has injection times one-fifth of that required for Ethiodol. When dosages were three to four times that necessary for radiograms, the lungs of perfluoroctylbromide dogs tolerated the increase better than the Ethiodol dogs. Although the radiopacity is less, radiographs were acceptable. The less radiopacity of the fluoroctylbromide nodes may be of greater significance in the larger body of the human.

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Nineteen consecutive children are analyzed according to clinical stay, radiation dose (NSD), local control, and survival. The majority received 1600 to 1750 rets and courses of actinomycin during their radiation treatments. The favorable sites were the orbit, facial soft tissue, and the larynx. The primary site control rate was 89%, and the metastatic neck control rate was 80%. The 2-year survival was 70%, and the 5-year survival was 67%. Five children are alive and well 12 to 15 years after irradiation. Late sequelae are hypoplasia of the orbit and maxillary sinus.

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