Adenocarcinoma of the pancreas is an extremely malignant neoplasm with a particular propensity to spread to the liver. In an effort to combine chemotherapy with high-dose local irradiation plus a modest dose of irradiation to suspected (subclinical) hepatic metastasis, patients with unresectable pancreatic carcinomas with no known distant metastasis were treated on a prospective multi-institutional Radiation Therapy Oncology Group (RTOG) Phase I/II trial. High total dose continuous radiation therapy to the pancreas (6120 cGy in 34 fractions over 7 weeks) and simultaneous prophylactic hepatic irradiation (PHI, 2340 cGy in 13 fractions for the last 2.5 weeks) were combined with administration of 5-fluorouracil 1000 mg/m2/day (maximum, 1500 mg) by intravenous continuous infusion for 5 days starting on day 1 and repeated on day 30 for 5 days, followed by a dose of 600 mg/m2 as a weekly bolus injection starting during week 9 for 6 months. In 18 months, 81 patients were enrolled in the study; 79 were evaluable with a minimum potential follow-up of 8.2 months. The patients ranged in age from 32 to 75 years (median, 64 years). Karnofsky performance status was 80 to 100 in 74% of patients. The tumor was confined to the head of the pancreas in 72% of patients. The planned radiation therapy for the pancreas was completed in 87% of patients, 80% received the planned PHI, and 85% completed the first two cycles of chemotherapy. Seventy-five percent of patients completed both treatments according to the protocol. Most patients who did not complete both treatments had tumor progression or refused additional therapy. During all cycles of chemotherapy and radiation therapy, 2 patients died of complications (Grade 5, 1 hepatic and 1 infection), 9 had life-threatening reactions (Grade 4, 7 hematologic, 1 neurologic, and 1 mucositis), and 31 patients had severe effects (Grade 3) according to the RTOG toxicity scale. Overall hepatic metastasis was documented in 32% (13% as the first site of failure), persistent or progressive pancreatic tumor was evident in 73%, and abdominal and extra-abdominal spread were reported in 27% and 8% of patients, respectively. Eighty percent (63 patients) died (median survival, 8.4 months). Although this study suggests that PHI may reduce the frequency of hepatic metastasis, failure to control the primary tumor and intraabdominal spread remain overwhelming.

A previously reported Phase I/II multimodality program for non-resectable hepatocellular cancer began with external beam-radiation and chemotherapy, followed by administration of I-131 antiferritin-specific radioimmunoglobulin and led to a 48% remission (7% complete remission and 41% partial remission). Survival and response depended on alpha fetoprotein status. AFP+ patients had a median survival of 5 months; AFP- patients had a median survival of 10.5 months. No acute effects occurred relative to treatment with radiolabeled antibody. A randomized prospective study was designed to compare full dose chemotherapy consisting of 60 mg/m2, doxorubicin and 500 mg/m2 of 5-fluorouracil administered every 3 weeks, to I-131 antiferritin administration every 8 weeks and allowed for crossover treatment if tumor progression occurred. Overall, radiolabeled antibody administration and full dose chemotherapy led to equivalent partial remission rates (22-30% vs 23-25%) and survival rates compared to chemotherapy (6 month median; AFP+ 5 months; AFP- 10 months). The most important new observations were the response in AFP- patients who, following chemotherapy failure, achieved remission using I-131 radiolabeled antibody (7/11) and a subset of patients (7%) who were treated with radiolabeled antibody and converted from non-resectable to resectable status followed by surgical excision.

Over a 31-month period, 100 patients with malignant hepatic tumors were preoperatively evaluated with three imaging techniques. The results of intravenously enhanced computed tomography (CT) scan, selective hepatic arterial contrast CT, and magnetic resonance imaging (MRI) were compared with operative findings. A total of 227 lesions were identified, with the sensitivity for tumor detection being arteriographically enhanced CT 94% (p less than 0.01), MRI 70%, and CT 66%. This advantage for arteriographically enhanced CT was most marked for lesions less than 1 cm in diameter (82% versus 20% for MRI and 5% for CT; p less than 0.01). Arteriographically enhanced CT was also most sensitive in assessing tumor margins. MRI was clearly superior to arteriographically enhanced CT or CT in detecting vascular involvement (85% versus 30% and 8%, respectively; p less than 0.01). No imaging technique was sensitive in determining extrahepatic involvement. Arteriographically enhanced CT was also best at predicting the operative procedure. The combination of arteriographically enhanced CT and MRI was the best predictor of true disease. We conclude that both arteriographically enhanced CT and MRI should be used for preoperative assessment of hepatic malignancies.

Four patients (three with hepatocellular carcinoma and one with colorectal carcinoma metastatic to the liver) previously treated with chemotherapy or radiotherapy or both in an attempt to reduce tumor bulk prior to surgical resection were examined by CT angiography (CTA). Areas of abnormal enhancement and irregular vessels simulating tumor involvement proved to be free of neoplasm at surgery. Perfusion abnormalities and vascular irregularity on CTA following radiotherapy or chemotherapy should not be automatically considered as neoplastic. Tissue confirmation in such cases should be obtained to rule out treatment related hepatic parenchymal changes.

Seventy-one patients with Hodgkin's disease who were initially treated at Johns Hopkins with radiation or radiation-chemotherapy from 1975--1980 had a five-year cumulative disease-free survival of I-A--100% (12 patients); II-A--85% (33 patients); II-B--83% (seven patients); III-A--75% (ten patients); and III-B--66% (nine patients). Fifty patients with mediastinal masses at the time of treatment demonstrated no marginal misses, two mediastinal recurrences (96% local control), and three lung disseminations. CT scan data yielded stage and treatment modification in 60% (9/15) of recent patients with mediastinal Hodgkin's disease. This demonstrates the need for routine thoracic scans and individual treatment planning in all mediastinal cases. Recommendations for combination treatment in early stage disease are made only for pericardial or extrathoracic chest wall extension based on CT scan findings, our low failure rates, radiation organ tolerances, and available relapse data in the literature, not arbitrary size designations from upright chest radiographs. It can be concluded that patients with mediastinal Hodgkin's disease require CT scan analysis to identify unusual patterns of presentations, sites at risk, and to allow for proper application of radiation portals and/or chemotherapeutic management.

Forty-four consecutive patients with potentially curable carcinoma of the prostate were localized with an Old Delft Simulator with the methods described by Bagshaw. The isocenter and the treatment portal were marked on the skin of the patient. Subsequently, the adequacy of the portal was checked by ultrasonography and/or CT scanning. Of 30 patients who underwent ultrasonography, five patients (17%) were found to have tumor extending beyond the initially simulated treatment portals. Using CT scanning, three of 22 patients were found to have tumor extending beyond the initially simulated portals. As a result, 1-2 cm were added to the initially simulated treatment portals for adequate coverage of the tumor volumes. Eight of our 44 patients underwent both studies and results were similar with ultrasonography and CT scanning. Only patients in the group presenting with clinical stage C disease had modifications of the initially simulated treatment portal. It is recommended that conventional simulation should be done first in order to establish the isocenter and treatment volume, which then should be confirmed by ultrasonography or CT scanning.

Eighty-six patients have received a definitive irradiation program for adenocarcinoma of the prostate from 1975 through March 1979.The technique of radiation consisted of treating the whole pelvis to a dose of 4000-4500 rad with a fractional dose of 180-200 rad per day.This was followed by a planned two week rest.Following this delay, the prostate is boosted with an arc rotation for an additional 2000-2400 rad.Five patients were Stage A, 27 Stage B, and 54 Stage C. Fifty-six patients were treated by radiotherapy alone and 30 patients by radiotherapy following surgical procedures.The results of treatment by delayed prostatic irradiation reveal an overall estimated disease free survival at 3 years of 75%.Estimated disease free survival for Stages A and B is 78.7%, and for Stage C, 65.0%.

A new treatment policy was instituted at The Johns Hopkins Hospital in 1975 in an attempt to improve survival and decrease treatment time and morbidity in patients with Stage III ovarian cancer. The treatment integrated isotopic therapy with a new technique of abdominal irradiation. Patients with minimal or no residual disease after thorough surgical staging received intra-abdominal “P followed 2 weeks later by split delayed abdominal irradiation. The abdomen was divided into upper and lower halves, separated by a calculated gap and treated through anterior-posterior (AP)-posterior-anterior (PA) portals. It was found that a 2 hour break interposed between the irradiation of the upper and lower abdomen reduced the acute symptoms of irradiation and allowed treatment to proceed without frequent interruptions; daily fractions consisted of 150 rad to the upper abdomen and 200 rad to the pelvis. Eight patients have been treated in the prescribed fashion and have been followed from 3 to 24 months post therapy. Seven of 8 patients (7/8) had no evidence of disease (NED) at this writing.