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Ninety-six patients with cancer of the tonsillar region in all stages were studied to compare full-course radiation therapy with surgical salvage to planned radiation and surgery. Full-course radiation therapy was effective in controlling T1 and T2 tumors without neck node involvement. Combined therapy was much more effective in treating T3 tumors with neck node disease. Patients with T4 tumors did poorly regardless of therapy.

The treatment of 102 patients with squamous cell carcinoma of the pyriform sinus seen at the University of Virginia Medical Center from 1958 through 1977 is reviewed. Eight-seven cases form the basis for this report. Surgery alone, radiation alone and combination of the two were the treatment modalities utilized for the patients in this study. The overall 3 year, no evidence of disease determinate survival was (37%). Recent literature has suggested that preoperative radiation obscures tumor margins with a decrease in survivals as compared to postoperative irradiation. Though the number of patients in both the preoperative (27) and postoperative (7) groups are small, our data suggests similar survivals. In addition, when pathology was examined, no tumor margins were transected in the preoperative irradiation group and only 5/23 patients had margins classified as close. The incidence of postoperative complications was not significantly difference between the combination therapy and surgery only groups. It is concluded that preoperative irradiation does not compromise the resection of adequate tumor margins nor significantly increase postoperative complications.

This disease is often thought to be primarily a surgical lesion, which carries the suggestion that radiation be reserved for surgical failures or for very early lesions. Other opinions name radiation as the primary mode of treatment. In an effort to improve the cure rate, combination therapy such as preoperative radiation followed by surgery is here suggested.

Revue retrospective de 10 etudes (la plus ancienne datant de 1939-51) sur l'interet de l'irradiation preoperatoire

Advances in the treatment of stage 0 to III superior sulcus tumors mandate greater accuracy in establishing tissue diagnosis, assessing tumor extent, and staging. Currently, this is best accomplished by a combination of PA chest radiography, MRI, and needle biopsy. MRI is superior to other single imaging modalities for the overall assessment of local tumor extent, bone invasion, mediastinal invasion, and perhaps in the future, determining radiosensitivity. In patients with superior sulcus tumors, evaluation of the brain, liver, and skeleton for metastases may be advisable prior to treatment with preoperative radiation and radical surgical resection.

Preoperative irradiation was given to 58 selected patients with adenocarcinoma of the rectum to decrease local recurrence and to improve survival. The irradiation was well tolerated without increasing operative complications. At a median follow-up of 25 months, the local failure rate appeared to be improved. Evaluation of increased length of survival will require longer follow-up. Results suggest that preoperative irradiation can safety decrease local recurrence of rectal carcinoma in patients believed to be at higher risk for local recurrence.

In order to study, autoradiographically, DNA synthesis in tumors, kidneys containing renal carcinomas were for the first time perfused with normothermic oxygenated blood with an addition of radioactively labelled thymidine. Tumor cells preserve the ability of synthesizing DNA in spite of an unavoidable postoperative ischemia. In most cases the incorporation of 3H-TdR was inhibited significantly after preoperative irradiation with a total dose of 1,600 rad applicated 48 h before operation.

Thirty-seven patients with advanced carcinoma of the tonsil were treated by a planned combination of radiation and surgery, utilizing 4500 rad preoperative radiation followed in 4–6 weeks by surgical excision of the primary tumor and in continuity neck dissection(s). Factors analyzed in this cooperative study include anatomic extent of the tumor, technique of radiation therapy and surgery, significance of residual tumor, and complications of the combined treatment. Our results reveal a 2 year disease-free rate of 71%.

As reported previously, it remains our conclusion that the radical neck dissection can be performed expediently in a reasonable period of time, usually without the need of blood replacement, and is not characterized by major physiologic disability or wound complications secondary to the neck dissection alone. The presence of preoperative radiation, composite resections entering the oral cavity or pharynx, and systemic disease or debilitation, however, vastly enhance the risk of significant life threatening complications and prolong hospitalization; therefore, the use of postoperative radiation therapy in combined treatment, the use of planned fistulas and generally accepted reconstructive techniques, and a careful evaluation of the methods and technique for protection of the carotid artery are recommended.

It appears that combined preoperative radiation and surgery continue to offer the best survival results in patients with superior sulcus tumors. Patients with involvement of the brachial plexus, Horner's syndrome, rib invasion, and ipsilateral neck node metastases are still candidates for combined modality therapy, with expectations of survival of about 30 to 40 per cent. However, those presenting with invasion of vertebrae, involvement of subclavian vessels, and mediastinal lymph node metastases do poorly. In this latter group, treatment by high-dose external radiation alone may prove to be as effective as combined modality treatment.

Our interest at Memorial Sloan-Kettering Cancer Center in preoperative radiation dates back to the late thirties and early forties where the accepted practice under the late Dr. George Binkley was to give patients with cancer of the rectum preoperative radiation therapy three to four weeks prior to operation. In the late forties and early fifties the emphasis was on the surgical approach and the routine preoperative radiation therapy was abandoned, except for questionably operably lesions. When it became apparent that the extended surgical approach alone did not improve survival we reviewed the early experience with preoperative radiation from 1939–1951. This experience is summarized in tables 1, 2 and 3, where it seems apparent that the patients with the poorest prognosis, that is the Dukes’ C lesions those with nodal metastases benefited materially from preoperative radiation (2). Thus in 1957 we resumed preoperative radiation therapy for patients with any but the most superficial cancers of the rectum. In 1960 we began to randomize patients. Because these were almost all patients seen in private offices and it was in the days before informed consent we randomized patients purely on the basis of an odd or even birth date. This allowed us to discuss with the patient his treatment program immediately without having to wait for an outside randomization. We continued this program through 1967. In 1972 we evaluated our results, which are shown in tables 4, 5 and 6, which indicated there was no difference in survival with or without preoperative radiation therapy (3).

Twenty-three patients with high malignancy grade soft tissue sarcoma received irradiation (about 40 Gy) followed by surgery. The follow-up time was 62 months or more in all patients. The local recurrence rate was 9 per cent (2/23). One of the patients was reoperated and is living free of disease, giving a local control rate of 95 per cent. Thirty per cent (7/23) of the cases developed distant metastases and died of the disease. Delayed wound healing was observed in 2 cases which was possibly due to the radiation therapy. Since surgery was regarded non-radical in 5 cases, the local control obtained by the combined radiation therapy and surgery is good and should be the subject for further investigations.

We examined the records of 118 patients with squamous cell carcinoma of the anterior two-thirds of the tongue treated during a 15 year period between 1958 and 1972 at The Norwegian Radium Hospital. They were staged according to the UICC 1978 system. Preoperative irradiation was employed in all patients, either with a radium needle implant or with external high energy irradiation or both. After a median delay of 3 months, surgical resection of the residual infiltrate was carried out. Histological examination of the resected tongue specimen was reported negative for residual tumor in 72 % of T 1 N 0 , 48 % of T 2 N 0 , and 29 % of T 3 N 0 patients. The local control of the tumor of the tongue after negative post-irradiation histology was 91 % for T 1 N 0 68 % for T 2 N 0 , and 50 % for T 3 N 0 patients. The local control of the tumor of the tongue after positive post-irradiation histology was 89 % for T 1 N 0 , 43 % for T 2 N 0 , and 30% for T 3 N 0 patients. Surgery was, therefore, most effective in preventing local recurrence in the earlier stages. The local control of the neck after negative post-irradiation histology was 72 % for T 1 N 0 , 53 % for T 2 N 0 , and 3 out of 4 for T 3 N 0 patients. The local control of the neck after positive post-irradiation histology was 22 % for T 1 N 0 , 43% for T 2 N 0 , and 50 % for T 3 N 0 patients. More extensive use of external beam irradiation was noted in patients with advanced tumors. The five year survival of patients with negative post-irradiation histology was, for T 1 N 0 65% absolute and 73% relative; for T 2 N 0 53% absolute and relative; for T 3 N 0 50% absolute and relative. The five year survival of patients; with positive post-irradiation histology was, for T 1 N 0 39% absolute and 59% relative; for T 2 N 0 29% absolute and 40 % relative; for T 3 N 0 30 % absolute and relative. The difference observed between the groups of patients with negative and positive post-irradiation histology with respect to the control of the tumor in the neck and to the survival were statistically significant for T 1 N 0 patients.

• Between 1962 and 1972, 190 patients with squamous cell carcinoma of the hypopharynx were seen; 162 received primary treatment at our clinic. Of the 162 lesions, 117 (72%) originated in the pyriform sinus. The most frequent symptom was pain in the throat (87 patients, 54%). One hundred twenty six patients (78%) had tumors extending beyond the hypopharynx (T 3 lesions), and 108 patients (67%) had cervical metastasis (stage III or IV). Treatment modalities included surgical excision in 82 patients, radiation in 39, planned combination of preoperative radiation followed by surgery in 18, radiation plus neck dissection in 15, and surgery plus postoperative radiation in eight. Sixty-nine patients (43%) had recurrent tumor. Recurrences were equally frequent in the primary site and the neck. Comparison of treatment modalities showed no differences in overall recurrence. Surgery alone or in combination with radiation reduced the incidence of local recurrence; however, when recurrences were analyzed in relation to stage of lesion, preoperative or postoperative radiation and surgery offered no advantage over surgery alone in reducing local or neck recurrence or in overall survival rate. Treatment by radiation alone was associated with a poorer survival. For the entire group, three-year survival was 52% and five-year survival was 47%. ( Arch Otolaryngol 102:716-721, 1976)

Fifty-five selected patients with previously untreated squamous cell carcinoma of the head and neck regions were studied in a randomized, prospective manner. The three treatment categories were primary radiation (Gp R), primary surgery (Gp S), and preoperative radiation of 4000 rads in four weeks (Gp R/S). The local control rates for the 44 evaluable patients with a two-year minimum followup were 24%, 39%, and 43%, respectively. Further treatment attempts in patients failing initial therapy yielded local control rates of 35%, 39%, and 43% for Gp R, Gp S, and Gp R/S, respectively. None of the local control rates nor the corresponding survival curves were significantly different at P < 0.10. However, the group sizes were sufficiently small that true differences might not have been detected. Postoperative complications were higher in the primary radiation failures subsequently operated upon compared to the primary surgery group (P = 0.07). A table is included in which the types of postoperative complications are listed and enumerated according to treatment regime.

Between January 1950 and December 1981, 32 patients with chemodectomas of the temporal bone were treated at the University of Iowa Hospitals and Clinics. Thirteen patients were treated with surgery alone, 15 with radiation therapy alone, one with preoperative radiation therapy and surgery, and three with surgery and postoperative radiation therapy. In general, the patients treated with radiotherapy alone or combined therapy (radiotherapy group) had more advanced tumors than those treated with surgery alone (surgery group). For the surgery group, the initial local control rate was 46% and the ultimate local control rate 84% following salvage with additional surgery, 31% developed complications, and 78% survived 10 years. For the radiotherapy group, 84% had local tumor control, 11% developed complications, and 77% survived 10 years. These results demonstrate that radiation therapy is an effective treatment modality for chemodectomas of the temporal bone.

I have used this procedure for over 7 years on approximately 150 radical neck dissections and have experienced no complications related to the use of this stapler, and operative time has been reduced. Approximately one third of these neck dissections have been done on patients who later received radiation therapy. In addition, approximately one third received preoperative radiation therapy. No problems with increased complications or recurrences in the area where the staples remain have been noted. This procedure has been discussed with radiation therapists at the University of Florida, where most of the patients received radiation therapy, and no increase in the complication rate or recurrence rate in this area of the neck was noted.

One hundred ten patients with predominantly advanced laryngeal carcinoma were treated in the period 1969-1978 with planned preoperative radiation therapy followed by surgery. Site distribution was: 63 supraglottic, 26 glottic, 15 transglottic and 6 subglottic. There were 4 Stage II patients, 66 Stage III and 40 Stage IV. Preoperative radiation therapy consisted of Telecobalt irradiation to a total dose of 25 Gy given to a target volume encompassing the larynx and regional neck nodes, given in 5 equal daily fractions of 5 Gy in 5 consecutive days. Surgery was performed 2 days later. Total laryngectomy was performed on 48 patients, total laryngectomy with neck dissection on 55 patients, supraglottic laryngectomy on 5 and supraglottic laryngectomy with neck dissection on 2 patients. Crude actuarial 5 and 10 year survival probability for the whole group is 71 and 61%, respectively. The corrected 5 and 10 year survival is 75%. For patients with T/sub 3/-T/sub 4/-N/sub 0/ tumors 5 and 10 year survival probability is: crude 65 and 58%, and corrected 70% respectively. For T/sub 3/-T/sub 4/-N/sub +/ crude: 75 and 60% and corrected: 78%. Of 110 patients, one died postoperative, three died of intercurrent disease, five died as a result of secondmore » malignancy, and 23 died of their larynx carcinoma: 12/23 because of locoregional failure, and 11/23 because of distant metastasis. We concluded that short intensive preoperative radiation therapy and surgery offer a high cure rate in the treatment of advanced resectable laryngeal carcinoma. The merits of this technique are outlined in the text.« less

The treatment of tumor recurrences after irradiation alone and after operation and post- or preoperative radiation is one of the most difficult problems that radiologists encounter. It is obvious that in these situations surgery should be considered first. The general experience shows that the chance of surgery is limited. With the exception of small localized recurrences, the operative procedure is often mutilating and has, in many patients, only a small probability of cure and is associated with a high risk. In addition, many patients are either very old or their general condition is so poor that surgery cannot be considered. Finally, many patients refuse extensive and mutilating surgery.

Although it is a major surgical effort removal of the bladder can be done with reasonable safety. In our opinion cystectomy and urinary diversion by an ileal conduit can be performed as a conjoined procedure without need for staging to reduce risks. Mortality up to 3 months postoperatively was 3.9 per cent and the major complication rate for surviving patients was 18.6 per cent. Minor complications occurred in 28.7 per cent of all patients but were treated easily. We did not note increased morbidity after radical cystectomy compared to other types of cystectomy. A higher complication rate was noted in patients who had undergone preoperative radiation treatment, and wound infection rate was higher in patients with neurogenic bladder dysfunction and chronic cystitis. The advantages of 1-stage compared to 2-stage cystectomy would include the fact that it eliminates the need for a second operation, saves considerable expense by virtue of shortened hospitalization and an earlier resumption of the patient's productivity, achieves early removal of the malignancy, decreases the chances of infection by avoiding a second laparotomy in the presence of a stoma and allows better exposure in the absence of previous ureteroileal anastomoses.

Specific problems exist when partial laryngectomy is considered the treatment of choice after radiotherapy: 1. the therapeutic benefit of preoperative radiation in the surgical therapy of laryngeal carcinoma; 2. the management of persistent or recurrent laryngeal carcinoma after full-dose radiation therapy when a partial operation with all its advantages would suffice clinically; 3. the influence of radiation on postoperative complications.

A review was made of 240 women with endometrial carcinoma who were treated at the University Hospital in Seattle, Washington, between 1961 and 1979. The most common predisposing factor was a history of exogenous hormones, elicited in 46.7%. As predicted, such patients exhibited a more favorable outcome. Twelve percent of patients developed recurrent disease, and the vagina was the most common site of recurrence. However, 85% of patients with vaginal recurrence had received preoperative radiation therapy. Nodal sampling was a phase of the primary surgical treatment of the disease in 41 of the 240 patients. An effort to focus on this issue was made by including in a separate review 26 additional patients similarly managed in 1980 and 1981, thereby raising to 67 the total number of patients with nodal sampling. Fifty-nine of these patients had Stage I endometrial cancer. In these patients, histologic grade of tumor and depth of invasion determined at the time of operation appear to serve as reasonable predictors of nodal involvement.

The present investigation reaffirms our observation that removal of a C3H mouse mammary adenocarcinoma results in a perturbation of tumor cells in a metastatic focus. An increase occurs in the proportion of cells undergoing DNA synthesis (labeling index, LI), and a decrease occurs in the proportion demonstrating estrogen receptor (ER index; ERI). The changes are transient but of sufficient duration and magnitude to produce an increase in the size of a distant tumor. This study was conducted to determine whether cytoreduction of a primary tumor by irradiation would produce a similar change in metastatic tumor cells and whether preoperative radiation would obtund the effect of primary tumor removal. The administration of a maximum tolerated dose of radiation (50 Gy) to a primary tumor produced a significant (p less than 0.001) increase in LI and decrease in ERI of a lesser magnitude than that observed following surgical removal of the primary tumor, but still sufficient to enhance the growth of a metastatic focus. Whereas, there was almost a 50% increase in LI in a metastasis 1 and 3 days following removal of a primary tumor the increase was only 13% three days after radiation. There was a 20% decrease in ERI 3 days following radiation and a 37% decrease at that time following tumor removal. Preoperative irradiation of a primary tumor 1, 3, or 5 days prior to tumor removal, obtunds the increase in LI and decrease in ERI following operation. Radiation the day before surgery was most effective because the changes in a distant focus occurring as a result of the radiation and of the surgery were prevented. The clinical relevance of these observations deserves further consideration.

Summary: A retrospective analysis of 91 patients with endometrial carcinoma is presented with emphasis on important factors in relation to survival. Patients with Stage 1 carcinoma were treated with a standardized mode of preoperative radiation and extended abdominal hysterectomy. An 87.1% 5-year survival rate was obtained for patients with well differentiated lesions, with only 1 patient developing a vault metastasis. The assessment of residual tumour after intracavity radiotherapy proved reliable in predicting prognosis and should prove of benefit in directing additional therapy for endometrial carcinoma.

Experience with 47 patients with head and neck carcinoma operated after preoperative megavoltage irradiation of about 3 000 rads over 3 weeks is reported. The 3-year survival for the series was 25/47 (53%), for the cases of Stages I--II 13/19 (68%) and Stages III--IV 12/28 (43%). Neoplastic cells could not be detected in 18% of the cases at operative biopsy. The remaining neoplastic cells were considered to be degenerated and non-vital in 14%, but in 68% of the cases the histological examination revealed a viable neoplasm. Changes in the macroscopic appearance did not correlate very well with the histological findings. Disadvantages of the irradiation were so minimal that the authors consider the general application of preoperative radiation in the therapy of head and neck malignancies to be the treatment of choice.

At the University of Virginia Hospital, patients undergoing preoperative irradiation for carcinoma in the head and neck region are usually scheduled for surgery four to six weeks after completion of therapy. Since preoperative irradiation produces no significant difference in the operative difficulty or postoperative morbidity, it is assumed that the vascularity of the area has returned to the pre-treatment level. Thermography is being used to quantitatively gauge the amount of vascularity and thus, help predict the optimum time for surgery. Thermography is obtained at two-week intervals after a pre-treatment baseline and is carried out for eight weeks after completion of therapy. During therapy the vascularity as determined by thermography is noted to increase to a maximum at approximately three to four weeks or 3 to 4,000 rads. Following completion of treatment, the vascularity subsides gradually and returns to the pre-treatment level at four to six weeks after completion of therapy.

A study of the effectiveness of preoperative radiation as an adjuvant for surgery for patients with invasive bladder carcinoma revealed a subpopulation of patients having advanced disease who could not benefit from radiation treatment. The effect of such a group of patients on the efficiency of 2 common nonparametric tests is investigated here. Both Gehan's tests and Greenwood's tests were shown to have a very low efficiency when compared with a parametric test when this group of patients is present.

Bone labeling studies with fluorochrome markers (oxytetracycline and DCAF) were carried out in fifteen dogs in which the posterior portion of the ninth rib was transferred, by means of microvascular anastomoses, to a defect fashioned in the mandible. Seven of the dogs received preoperative radiation of the mandible in order to study the performance of the revascularized graft in radiated tissue. In nine animals the bone grafts were labeled in the subperiosteal, the cortical and the endosteal parts, as opposed to the non-labeling of conventional free bone grafts. Determination of the linear bone formation rate in seven dogs (five non-radiated and two radiated), with the use of a scanning microscope photometer, showed no significant difference between the growth rate in the grafts and that in three other skeletal sites studied.

One hundred and sixteen patients with Stage I endometrial carcinoma were treated by hysterectomy with or without preoperative radiation therapy. Survival was slightly but not significantly increased in the group who received preoperative irradiation. The survival rates were identical when examination of the hysterectomy specimen showed no residual tumor or tumor limited to the endometrium after radiation, but survival was significantly poorer when myometrial extension was present. The incidence of complete tumor sterilization was considerably higher in uteri removed more than 5 weeks following the completion of radiation therapy. When residual tumor was present after radiation, its histologic characteristics were seldom altered from those observed in material obtained before treatment, and bizarre radiation changes were seen almost exclusively in benign endometrial glands. Our data indicate that carcinomas limited to the endometrium are frequently sterilized by preoperative radium but that survival is not changed appreciably in these cases. Tumors with myometrial extension, which have a poorer prognosis, appear to be considerably less frequently sterilized by the techniques employed in this series. Implications for therapy based on these histologic data are presented.

The effect of preoperative radiation therapy on the pseudocapsule of experimental rat soft-tissue sarcomas has not been histologically evaluated in a controlled study. The irradiated animal showed marked thickening of the capsular structure surrounding the sarcoma. Everywhere morphologically distinct from the tumor, there was no evidence of tumor invasion into or through this capsular structure. The membrane was consistently thicker and more hyalinized than in the control animals. The nonirradiated animals showed a minimal pseudocapsular structure with a characteristic tumor penetration. Irradiation produced distinct histologic changes in the pseudocapsule. Although assumed on the basis of clinical observations alone, irradiation-induced pseudocapsule has not previously been demonstrated in an experimental model of soft-tissue sarcoma.

If there were a method of predicting which larynges have been cured by radiotherapy, unnecessary surgery and loss of function might be avoided. In a large series of patients with advanced cancer of the larynx treated by high-dose preoperative radiotherapy, the apparent sterilization of the primary tumor and metastatic lymph nodes was studied. The results are compared with results from other large series. The present study indicates that at least 40% of patients would avoid laryngectomy. Further, clinical response following radiotherapy gives an excellent indication of which patients would be cured by radiotherapy. The delay of surgery in those cases that developed recurrence did not result in a high complication rate. This policy—radiotherapy with surgery for salvage of recurrences—has achieved a control rate comparable to that achieved by high-dose preoperative radiotherapy and surgery.

In the period from January, 1936, to June, 1942, 40 patients with breast carcinoma were treated with x-ray (250 kv.) before, rather than after, operation. All were reexamined annually, and in all but four cases contact was maintained until the present time or until death. It is now possible to report that 7 (17.5%) of the 40 patients are living 20 years after the diagnosis of breast carcinoma was established. The diagnoses were confirmed by biopsy in all but four advanced cases. Two case histories given in some detail illustrate the effects of the radiation on the tumor and justify the use of radiation first in order to reduce the danger of disseminating tumor cells during the subsequent surgery. It is believed that modern radiologic techniques may overcome former objections to preoperative irradiation and that this plan deserves more extensive trial.

P REOPERATIVE irradiation of endometrial carcinoma has been widely adopted as a valuable therapeutic means of improving the end results of treatment of this disease. The plan of irradiation, total tumor dose, and sequence of the therapy differ considerably in various clinics, The recovery rate also varies according to the thoroughness of the plan of treatment and the meticulous precision with which the plan is executed. According to Stowe,l’ microscopic study of uteri removed following such irradiation reveals persistence of apparently viable tumor in from 12.5 to 89 per cent of cases. It is assumed, therefore, that the dose of irradiation delivered to the tumor in comparable clinical groups and pathological grades is the important factor. Improvement of radiation technique at the Radiumhemmet in .Stockholm was credited by Heyman as increasing the cure rate of endometrial carcinoma from 44.6 per cent to 61.9 per cent. Studies aimed at evaluating a form of therapy must define the irradiation dose delivered to the tumor, the microscopic grade of the tumor under consideration, and the clinical extent of the disease at the time therapy was begun. In this way we can evaluate the efficacy of such a plan of treatment by comparing the end results thus obtained with end results obtained in treating tumors similar in extent and cell type by other methods. If inadequate irradiation dosage is delivered to the tumor-bearing area, then very little benefit is to be expected from the preoperative therapy, and such findings should not be used to support the contention that such treatment does not add to the surgical removal of the organs. The present study was undertaken to evaluate a specific technique, previously described,lO of irradiating the uterus, parametria, and pelvic lymphatic areas, and to report the effect on the tumor and determine in particular the cure rate in those patients in whom active tumor could no longer be demonstrated on serial section of the removed organ and its appendages.

Biologists, in the laboratory, see cancer cells as individual entities while physicians, in the clinic, see them as tumor masses. A mathematical model is described which bridges the relationship between the observations in the clinic and the underlying movements of the individual tumor cells. For this purpose the model is developed according to the protocol of an actual study of patients with cancer of the endometrium and includes the effect of preoperative radiation treatment in reducing the visible size of the tumor. In this way it is possible to obtain a quantitative estimate of the radiation effect. The model is also used to estimate the motility of tumor cells in vivo and this is compared with measurements obtained in the laboratory. A short discussion is presented of how mathematical models could become useful tools for bridging the gap between discovery in the laboratory and application in the clinic.

A biologic basis of preoperative radiation treatment has been presented and the various factors governing its application have been discussed in detail.

Two hundred and fifty-seven patients treated at the Toronto General Hospital for carcinoma of the endometrium were evaluated with regard to results from operation, operation and preoperative radiation, and radiation alone. A comparison was made with the results reported from the same hospital in the period from 1929 to 1944. In the past, we have favored the combined therapy with preoperative radiation and operation, but the present findings cast doubt upon the efficacy of preoperative radiation. There was a 69.8 per cent five-year survival for operation alone and a 67.9 per cent five-year survival with operation plus preoperative radiation. The patients treated by radiotion alone had a 41.3 per cent five-year survival. The use of preoperative intrauterine radiation did not reduce the vault recurrence rate in this series.

In the experience of the surgeon who most frequently treats patients with cancer of the head and neck, many of the recommended reconstruction procedures fail to satisfy the need for a simple, dependable, and rapid technic for cosmetic and functional restoration. The trend toward the use of preoperative radiation, and the attendant high incidence of failure of primary wound healing, make the development of efficient means of reconstructing large defects even more mandatory. To this end, the extended shoulder flap offers several advantages over methods of reconstruction currently used, the most important ones being the proximity of the vascular base of the pedicle to the areas to be reconstructed, the relatively few operations required with its use, the relative ease with which the technical aspects of management of the flap can be mastered, and the minimal cosmetic deformity at the donor site. It can be used to reconstruct any defect of the head and neck region, including those defects that extend past the midline.

In 1960, the Head and Neck Service and the Department of Radiation Therapy of the Memorial Hospital Center, New York, N. Y., instituted a controlled clinical study to determine the value of preoperative irradiation in the prevention of recurrence after radical neck dissection. To avoid a significant delay in surgery as well as complications, a tissue dose of 2,000 rads to the subcutaneous tissues of the neck was chosen. This was given by 5 treatments, each of 400 R in air, on five successive treatment days immediately preceding the operation. All therapy was administered through one large lateral field which covered the whole neck and included the primary except when it was in the maxilla, the palate, or the nasopharynx. The Allis-Chambers betatron was employed, with an electron beam of 18 Mev maximum energy. Patients born on an odd day received preoperative radiation, while those born on an even day did not, thus constituting a control group. It was agreed at the outset of the study that the patients in ...

The possible benefits of preoperative radiation therapy on patients with operable carcinoma of the uterine corpus are examined. The clinical sample studied included only patients adequately treated in essentially the same environment over a 15 year period. It included 111 patients subjected to immediate operation and 124 patients who received preoperative radiation therapy. Analysis of the patient material in the two series, according to various biologic characteristics, showed only minor variations. Investigation of the results of treatment from survival statistics showed a more favorable result in patients receiving preliminary radiation. This was most apparent when results in patients with anaplastic lesions or large uteri were compared.

Evidence suggests that some therapeutic modality in addition to the present standard surgical treatment of cancer of the rectum will be necessary if long-term survival is to be improved. The use of preoperative irradiation is under continuing investigation. The results of several studies, using both moderate and high dosage preoperative radiation, are reviewed. A reduced incidence of lymph node metastases in the specimens from irradiated patients is common to all these studies.

Since 1963, a total of 117 patients with cancer of cervical and thoracic esophagus were subjected to combined treatment with preoperative radiation and surgery, and the results obtained with this group were compared to those of surgery alone in 229 cases. Curative resectability of the radiation group increased up to 65.1 percent against the comparable 25.8 percent of the nonradiation group. The five-year survival rate of the radiation groups was increased up to 25 percent as compared to 13.6 percent of the nonradiation group. Our method of preoperative radiation was discussed in relation to the curative resection and changes in the mode of lymph node metastasis from pathologic standpoints. Our method of combined treatment for the esophageal cancer with preoperative radiation and surgery is an effective method of treatment at present, in order to extend the operative indication and curative resection, thus improving the results of the postoperative long-term survival rate.

This study was carried out to determine the merit of contralateral supraomohyoid neck dissection in the clinically negative neck. When performed in conjunction with a standard radical neck dissection on the ipsilateral side, a yield of 2.8 percent pathologically positive nodes (5 of 177) was obtained in the contralateral neck. Little difference was noted in the yield of midline lesions versus unilateral lesions which approached the midline (3 and 2.6 percent, respectively). Similarly, the yield with preoperative radiation was close to that of the nonradiated group (3 and 2.7 percent, respectively). Additionally, in 1.7 percent of patients (3 of 177) with both clinically and pathologically negative nodes, metastases later developed in the contralateral neck, which indicates that the dissection is not necessarily effective in preventing future disease. The contralateral supraomohyoid neck dissection in the treatment of malignancies of the oral cavity, pharynx, and larynx does not appear to be of significant therapeutic value.

Extensive clinical experience has demonstrated the efficacy of external beam radiotherapy for selected patients with radioresponsive bladder cancers. Patients who achieve a complete clinical response within 6 months of completion of radical radiotherapy enjoy a 45%–69% survival at 5 years, as opposed to 6%–14% for patients with unresponsive tumors (Bloom et al. 1982; Quilty and Duncan 1986; Hope-Stone et al. 1984). This relationship between tumor radioresponsiveness and prognosis also holds true for patients undergoing combined preoperative radiation followed by planned cystectomy.

At the 91st Annual Meeting of the Triological Society in Palm Springs, Fla, Richard L. Fabian, MD, Harvard Medical School, Boston, reported reconstructing the hypopharynx and cervical esophagus with the pectoralis major myocutaneous flap. He sought to determine whether or not a one-stage reconstruction could be achieved utilizing this approach. Twenty-two patients were included in his analysis, which included five patients who had an esophageal stenosis following laryngectomy and 17 patients who underwent primary reconstruction after extended laryngectomy. Analysis of results demonstrated that preoperative radiation therapy did contribute to a somewhat more complicated postoperative course. The technique involves partially placing a tube in the skin island of the flap and suturing it to the remaining pharyngeal mucosa, then using a salivary bypass tube to place a stent in the area. The lower incidence of failure and complete absence of mortality prompted Dr Fabian to conclude that this is a viable

It is the opinion of the authors that there are changes at the periphery of many of the malignant lesions of the cervix which show no clinical evidence of such change and even on staining of the vagina by the Schiller method do not show any abnormalities. However, these changes can be discovered by the proper colpomicroscopic investigation and cytologic determinations. The realization of this possibility may lead to the discovery of these changes early and, therefore, lead to cure of the patients before invasive lesions develop. The authors believe that because of these changes preoperative radiation therapy in invasive cancer and possibly even in the microinvasive lesions would aid in the destruction of these peripheral zones and, therefore, increase the favorable prognosis of the patient. The main emphasis, however, is on proper postoperative follow-up which should include cytological determination and possibly colpomicroscopy. J. Edward Hall