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Objectives The purpose of this study was to report on the clinical outcomes of patients treated at our institution for prostate cancer (PCa) who had been previously diagnosed as Human immunodeficiency virus (HIV) positive. Methods The authors conducted a retrospective study of 14 PCa/HIV patients who were being treated for PCa with external beam radiotherapy, brachytherapy, or a combination of the two. Each patient's prostate-specific antigen (PSA) level, CD4 count, and viral load were obtained before the initial radiation treatment and at the time of their most recent follow-up. In addition, 13 of 14 patients completed a quality of life survey with a social worker on staff and were examined by their radiation oncologist to assess the complications after treatment. Results Comparing pretreatment data with the data at last follow-up, only 1 patient's PSA level remained above 1.1 ng/mL. The average CD4 count remained stable, increasing from 523 to 577 cells/mm 3 , with the lowest final count at 200 cells/mm 3 . Viral load increased in only 2 of 14 patients. There were no unusual rectal, urinary, or sexual complications, and no infections related to treatment. Conclusions Based on changes in viral load and CD4 count, radiotherapy does not appear to have a long-term negative effect on the immune system. Treatment complications are consistent with HIV-negative patients, giving no evidence that the subset of PCa/HIV patients should be treated differently from PCa patients without HIV when considering radiation therapy. More investigation will be necessary before reliable mortality and morbidity data can be assessed.

Aim: To report 7 year results of ophthalmic plaque radiotherapy for exudative macular degeneration. Methods: In a phase I clinical trial, 30 patients (31 eyes) were treated with ophthalmic plaque irradiation for subfoveal exudative macular degeneration. Radiation was delivered to a mean 2 mm from the inner sclera (range 1.2–2.4) prescription point calculated along the central axis of the plaque. The mean prescription dose was 17.62 Gy (range 12.5–24) delivered over 34 hours (range 18–65). Early Treatment Diabetic Retinopathy Study (ETDRS) type standardised visual acuity determinations, ophthalmic examinations, and angiography were performed before and after treatment. Clinical evaluations were performed in a non-randomised and unmasked fashion. Results: At 33.3 months (range 3–4), 17 of 31 (55%) eyes had lost 3 or more lines of vision on the ETDRS chart, five (16%) had improved 3 or more lines, and the remaining nine (29%) were within 2 lines of their pretreatment visual acuity measurement. Overall, 45% of patients were within or improved more than 2 lines of their initial visual acuity. Five eyes developed macular scars, eight developed subsequent neovascularisation or haemorrhage, and three progressed through therapy. Two patients were lost to follow up. The most common finding of patients followed for 6 or more months (n = 18 of 29 (62%)) was regression or stabilisation of the exudative process. No radiation retinopathy, optic neuropathy, or cataracts could be attributed to irradiation. Conclusion: Ophthalmic plaque radiation can be used to treat exudative macular degeneration. At the dose and dose rates employed, most patients experienced decreased exudation or stabilisation of their maculas. No sight limiting radiation complications were noted during 7 year follow up. Owing to the variable natural course of this disease, a prospective randomised clinical trial should be performed to evaluate the efficacy of plaque radiation therapy for exudative macular degeneration.

Neovascular age-related macular degeneration is the most common cause of severe irreversible blindness in the Western world in people older than age 50. Laser photocoagulation is the only proven treatment for this disease; however, fewer than 20% of patients are eligible for this treatment because the majority of choroidal neovascularization membranes are not visible by ophthalmoscopy or angiography. In addition, many patients elect not to undergo this treatment because laser treatment of subfoveal neovascular membranes results in immediate and permanent central visual loss. Several treatments are under investigation, including external-beam radiation therapy. There are multiple publications of early trials using radiation therapy, but to date there is only one randomized published study. This article reviews these trials and summarizes the status of radiation therapy as a treatment for macular degeneration.

Objective To describe the first clinical experience with palladium-103 ( 103 Pd) ophthalmic plaque radiotherapy for choroidal melanoma. Design Phase-I (nonrandomized) clinical trial. Participants Eighty patients with uveal melanomas were diagnosed by clinical examination, found to be negative for metastatic disease, and offered 103 Pd radioactive plaque treatment. Nine patients were concurrently treated with microwave hyperthermia. Intervention Palladium-103 ophthalmic plaque radiotherapy was employed for each patient. Eye plaques were sewn to the episclera to cover the base of the intraocular tumor, radiation was continuously delivered over 5 to 7 days, and then the plaques were removed. A mean apical dose of 81 Gy was delivered. Main outcome measures The authors evaluated the ease of use of 103 Pd seeds within standard gold eye plaques. Patient-related outcomes were control of tumor growth, change in visual acuity, the development of radiation damage (retinopathy, optic neuropathy, and cataract), and metastatic disease. Results From September 1990 to December 1997, 80 patients were treated with 103 Pd and followed for an average of 38 months. Two patients were lost to follow-up. During this time, the authors found that 103 Pd seeds were equivalent to iodine-125 ( 125 I) with respect to plaque manufacture and ease of dosimetric calculations. Two patients in this series were treated for tumor recurrence after 125 I plaque radiotherapy. They both failed secondary 103 Pd treatment and were enucleated. When 103 Pd was used as a primary treatment, it controlled the growth of 75 of 78 tumors (96%). Overall, there have been six enucleations: three failures of primary treatment, two failures of retreatment, and one for neovascular glaucoma. Visual acuity evaluations at the 36-month follow-up visit (including the enucleated patients) revealed that 38% of eyes had decreased 3 or more lines of vision, and 77% were 20/200 or better. Conclusion Palladium-103 plaque radiotherapy can be used to treat uveal melanomas. Compared with 125 I, computerized dosimetry suggests a more favorable dose distribution with 103 Pd. Treatment of most patients resulted in tumor shrinkage and preservation of functional vision. The authors have noted no complications that might preclude the use of 103 Pd ophthalmic plaque radiotherapy for choroidal melanoma.

Purpose: To catalogue the presenting symptoms of patients with AIDS who are presumed to have primary central nervous system lymphoma (PCNSL). To document the palliative efficacy of cranial irradiation (RT) relative to the endpoints of complete and overall response for the respective symptoms. Methods: An analysis of 163 patients with AIDS-related PCNSL who were evaluated at nine urban hospitals was performed. These patients were treated for PCNSL after the establishment of a tissue diagnosis or on a presumptive basis after failing empiric treatment for toxoplasmosis. All patients were treated between 1983 and 1995 with radiotherapy (median dose-fractionation scheme = 3 Gy × 10) and steroids (>90% dexamethasone). Because multiple fractionation schemes were used, prescriptions were converted to biologically effective doses according to the formula, Gy 10 = Total Dose × (1 + fractional dose/α - β); using an α - β value of 10. Results: The overall palliative response rate for the entire group was 53%. In univariate analysis, trends were present associating complete response rates with higher performance status (KPS ≥ 70 vs. KPS ≤ 60 = 17 % vs. 5%), female gender (women vs. men = 29% vs. 8%), and the delivery of higher biologically effective doses (BED) of RT (Gy 10 > 39 vs.≤ 39 = 20% vs. 5%). In multivariate analysis of factors predicting complete response, both higher KPS and higher BED retained independent significance. A separate univariate analysis identified high performance status (KPS ≥ 70 vs. KPS ≤ 60 = 71% vs. 47%), and young age (≤ 35 vs. > 35 = 61% vs. 40%) as factors significantly correlating with the endpoint of the overall response. In multivariate analysis, high performance status and the delivery of higher biologically effective doses of irradiation correlated significantly with higher overall response rates. Conclusion: Most AIDS patients who develop symptoms from primary lymphoma of the brain can achieve some palliation from a management program that includes cranial irradiation. Young patients with excellent performance status are most likely to respond to treatment. The delivery of higher biologically effective doses of irradiation also may increase the probability of achieving a palliative response.

Preventing relapse in the neck is a major contemporary priority in cancers of the supraglottic larynx treated surgically. Previous studies have demonstrated that observing the clinically NO neck, or performing unilateral elective neck dissection, results in unacceptably high mortality. However, neither bilateral elective neck dissections nor postoperative bilateral elective neck irradiation have been uniformly embraced by head and neck oncologists because of fears that they would produce complications and damage the residual larynx. We undertook this study to evaluate the safety of postoperative neck radiotherapy, with the larynx shielded, after supraglottic laryngectomy. We treated 15 patients with T1–2, N0–3 disease by supraglottic laryngectomy followed by elective neck irradiation to a median dose of 56 Gy over 6 weeks. We shielded the residual larynx from irradiation because the primary margins were satisfactory in all of these patients. With follow-up periods ranging from 1.5 to 8.5 years (median 4.5 years), the incidence of complications was 0/15 (0%). The actuarial proportion of the patients who after 5 years remained free of relapse in the larynx was 100%, in the neck was 90%, and at distant sites was 80%. The cause-specific survival of the patients who initially presented with clinically N0–N1 necks was 100%, but with N2–N3 necks was only 20%. In conclusions, fears that postoperative irradiation would damage the residual larynx after supraglottic laryngectomy are quite unfounded when the larynx itself does not need to be irradiated and is shielded. Combining supraglottic laryngectomy with postoperative radiotherapy in this manner proved safe, with a cause-specific survival rate of 100% after 5 years in the patients without advanced neck disease. Better systemic therapy is necessary to help the patients with clinically advanced neck disease. Radiat. Oncol. Invest. 4:239–242, 1996. © 1997 Wiley-Liss, Inc.

Objective: Toxicity and safety study of concurrent cisplatin therapy and iodine 125 ( 125 I) brachytherapy. Background: Iodine 125 brachytherapy has an established role in surgically accessible recurrent tumors of brain. Cisplatin has antitumoral activity against glial neoplasms and has demonstrated sensitization of tumor to radiotherapy. Design/Methods: In 16 patients (age range, 13 to 68 years; median, 47 years), stereotactically placed catheters were afterloaded with 125 I sources. A median 50-Gy minimum treatment volume dose was delivered during a 100-hour period along with cisplatin (20 mg/m 2 per day for 5 days). Histologic diagnoses included glioblastoma multiforme (n=11), anaplasticastrocytoma (n=3), ependymoma (n=1), and anaplastic oligodendroglioma (n=1). Tumor volumes ranged from 7.0 to 73 cm 3 (median, 25 cm 3 ). Results: Early complications included headache (n=7), transient exacerbations of preexisting neurologic deficits (n=5), seizures (n=3), and nausea/vomiting (n=3). Late complications included steroid dependency (n=10), progressive dementia in the absence of recurrent tumor (n=1), and radiation-induced necrosis (n=9) requiring reoperation (n=9). Fifteen of 16 patients were assessable, with a median follow-up time of 9.5 months. Brachytherapy was discontinued in one patient owing to an acute subdural hematoma. A partial response was seen in five patients, disease remained stable in seven patients, and disease progressed in three patients. Conclusions: We conclude that 125 I brachytherapy with concurrent cisplatin therapy is associated with an acceptable level of toxic effects and warrants further investigation.

Purpose We report a case of a choroidal metastasis from an adenoid cystic carcinoma of the lung. Design Interventional case report. Methods A 40-year old man, 9 months' status postresection of a bronchial adenoid cystic carcinoma, was diagnosed by clinical evaluation and fine-needle aspiration biopsy and treated with palladium-103 ophthalmic plaque brachytherapy. Results This unusual patient with uveal metastasis from adenoid cystic carcinoma presented with decreased vision in the right eye and a diaphanous amelanotic choroidal tumor in the superotemporal macula. Ultrasound revealed a dome-shaped tumor that measured 4.0 mm in apical height and 11 × 10 mm in basal diameter. Fluorescein angiography revealed a double circulation and late intense subretinal fluorescence. Plaque brachytherapy provided local control and preservation of the eye. Conclusion Bronchogenic adenoid cystic carcinoma can metastasize to the choroid.

Purpose: To evaluate the effect of palladium 103 ( 103 Pd) ophthalmic plaque brachytherapy on patients with uveal melanoma. Background: Radioactive 103 Pd seeds have become available for plaque brachytherapy, and computer-aided simulations have compared the intraocular dose distribution of 103 Pd versus iodine 125 ( 125 I) plaques in patients with uveal melanoma. The use of the lower-energy radionuclide 103 Pd increased the radiation to the tumors and decreases irradiation of most normal ocular structures. Methods: The authors have begun a phase 1 clinical trial evaluating the effect of 103 Pd ophthalmic plaque radiotherapy on intraocular tumors. Uveal melanoma was diagnosed, and the patients were found to be negative for metastatic disease. All patients were given one 103 Pd radioactive plaque treatment, and six patients also were given adjuvant microwave hyperthermia. Results: Palladium 103 ophthalmic plaque radiotherapy was used to treat 23 patients with uveal melanoma. Patients were followed for up to 27 months (mean, 13.5 months). One eye was enucleated for progressive tumor enlargement (4 months after treatment). One patient died (of metastatic melanoma). Eight patients have lost greater than two lines of visual acuity, one has gained more than two lines. Fifteen patients (65%) were within two lines or had better than their preoperative visual acuity. Relating to the effect of treatment on visual acuity, 15 (65%) tumors were located equal to or less than 2 mm from the fovea. Conclusion: Palladium 103 ophthalmic plaque radiotherapy was noted to control the growth of uveal melanomas. Compared with other forms of plaque radiotherapy at this follow-up interval, the authors have noted no new complications, no difference in local control, and/or changes in tumor response to treatment. More long-term followup will be required to demonstrate differences between 125 I and 103 Pd ophthalmic plaque brachytherapy.

Purpose : To evaluate absorbable mesh for the suturing of afterloading chatters in patients with tumors involving the chest wall. Methods and Materials : Patients underwent thoracotomy and resection of tumor; a layer of absorbable mesh was then sutured to the tumor bed. Nylon flexiguide afterloading catheters were sutured into the mesh at about 1.5 cm distance from each other. A second layer of mesh was then sutured on top of the catheters. The chest wall was closed. Orthogonal radiographs and CT scans of the area of implants were done to verify catheter position in each patient on day 1 and on the last day of implant. Computer dosimetry by digitization of dummy sources was performed on each set of radiographs. The same seed for both sets of films was chosen as the origin of digitization. All seed coordinates were compared directly to offset for any rotation of the patient during the two sets of films. The distances were calculated from all seed positions to the origin, then tabulated and compared. Results : The distances agreed within a few millimeters (7–8 mm). The differences may be attributed to the patient's breathing and to the localization uncertainty. The resulting dose alteration was negligible. Conclusion : This technique appears to provide adequate anchorage of catheters with resulting constant seed position and dose distribution in areas of scant tissues or in surgical beds of considerable size.

Nicotinamide (NAM) has been shown to be an effective radiosensitizer in animal studies, but to date no clinical studies have substantiated this effect. Twenty-nine patients with brain metastases were randomized to receive NAM and external radiation therapy (RT) (n = 14) or irradiation alone (n = 15). NAM was started on day 1 at 3 g/day and continued until radiation was completed. The RT dose to the whole brain was 30 Gy in 10 fractions in 12–14 days. To evaluate response, a computed tomographic (CT) scan of the head was repeated 1 month post-treatment. Toxicity was graded from the skin, liver, and gastrointestinal tract. There were no toxicities observed at 39.0 g total dose of NAM. Median survival for the 29 patients, calculated by the Kaplan-Meier method, was 3.5 months for the NAM + RT group (14 patients) and 3.9 months for the RT alone group (15 patients). Eighteen patients were evaluable for 1 month tumor response by CT scan. Response rates were compared with Fisher's exact two-tailed test. There was no difference in complete response (CR) (P = 0.62) or CR + partial response (PR) (P = 1.000) between the two groups. Adjuvant NAM, given in doses of 3.0 g/day (39.0 g total dose) in the treatment of brain metastases, has shown no benefit in survival or response in this preliminary Study. © 1994 Wiley-Liss, Inc.

The purpose of this study was to assess the efficacy of a gross tumor volume (GTV) contouring protocol on interobserver variability between 4 physicians in positron emission therapy/computed tomography (PET/CT) treatment planning of head-and-neck cancer. A GTV contouring protocol for PET/CT treatment planning was developed utilizing 4 stages: Preliminary contouring on CT alone, determination of appropriate PET windowing, accurate image registration, and modification of CT contouring with correctly formatted PET/CT display and rules for modality disagreement. Two neuroradiologists and 2 radiation oncologists (designated as A, B, C, and D, respectively) were given a tutorial of PET/CT coregistered imaging individualized to their skill level, which included a step-by-step explanation of the protocol with clinical examples. Opportunities for questions and hands-on practice were given. The physicians were asked to re-contour 16 head-and-neck patients from Part I on PET/CT fusion imaging. Differences in volume magnitude were analyzed for statistical significance by analysis of variance (ANOVA) and paired t-tests (α < 0.05). Volume overlap was analyzed for statistical significance using Wilcoxon signed-rank tests (α < 0.05). Volume overlap increased significantly from Part I to Part II (p < 0.05). One previously significant difference between physicians disappeared with the protocol in place. The mean fusion volume of Physician C, however, remained significantly larger than that of Physician D (p < 0.01). This result is unchanged from Part I. The multidisciplinary contouring protocol significantly improved the coincidence of GTVs contoured by multiple physicians. The magnitudes of the volumes showed marginal improvement in consistency. Developing an institutional contouring protocol for PET/CT treatment planning is highly recommended to reduce interobserver variability.

The incidence of invasive anal squamous-cell carcinoma in patients with HIV is increasing. We report the outcome after combined chemoradiotherapy for anal squamous-cell carcinoma in HIV-infected individuals. Thirty-two HIV-positive patients treated at the St. Vincent’s Cancer Care Center for anal squamous-cell carcinoma from 1997 through mid 2005 were reviewed retrospectively. All patients also received highly active antiretroviral therapy. Treatment consisted of radiotherapy concurrent with 5-fluorouracil and mitomycin C in most patients. Overall survival, anal cancer-specific survival, local recurrence, and toxicity were assessed. Median time from completion of radiotherapy to last follow-up of surviving patients was 35 months. Five-year locoregional relapse, anal cancer-specific survival, and overall survival were 16 , 75, and 65 percent, respectively. In multivariate analysis, locoregional recurrence, cancer-specific survival, and overall survival were all significantly associated with tumor size. Overall survival was independently associated with high viral load and low CD4 count. Acute toxicity included: Grade 3 skin in 25 percent of patients, Grade 3 diarrhea: 28 percent, and Grade 3 or 4 hematologic toxicity in 21 and 48 percent, respectively. More than two-thirds of patients required radiotherapy interruption. There was no negative impact of chemoradiotherapy on viral load. Outcome after chemoradiotherapy for HIV-related anal squamous-cell carcinoma in the era of highly active antiretroviral therapy is comparable to outcome in patients without HIV. However, significant toxicity is seen with standard treatment regimens. Earlier diagnosis and risk-adapted therapy could lead to improved survival and decreased treatment-related morbidity.

Purpose To determine the feasibility of and patient outcomes using customized high-dose-rate (HDR) brachytherapy to boost the nasopharynx after external beam radiation therapy (EBRT) in patients with carcinoma of the nasopharynx. Methods and materials Patients with nonmetastatic squamous cell carcinoma of the nasopharynx were treated using EBRT followed by a HDR brachytherapy boost delivered via customized catheters in a noninvasive, accurate, and reproducible method under direct fiber-optic visualization. Local control (LC), disease-free survival (DFS), and overall survival (OS) were analyzed. We also measured the change in maximum oral aperture as an indication of temporomandibular joint dysfunction. Results Between March 1996 and July 2003, we treated 38 patients with this customized brachytherapy method. The procedure was well tolerated without any incidents of soft-tissue or bone necrosis and with minimal decrease of oral aperture. Median follow-up time was 47 months (range, 2–84 months); 35 patients had at least 1 year of follow-up. The 5-year actuarial rate of LC, DFS, and OS were 96.0%, 81.4%, and 92.7%, respectively. Conclusions The treatment has been well tolerated by all patients. The combination of conformal EBRT with our customized HDR brachytherapy boost has resulted in excellent local control to date, while minimizing temporomandibular joint dysfunction.

Purpose To investigate the clinical use of a commercially available gating system for minimizing respiratory-induced anatomic motion over a range of treatment sites. Methods and materials The gating system consists of a reflective marker placed on the patient's anterior surface. The motion of the marker is tracked using a camera interfaced to a computer. Gated intervals were defined that limited the motion of the diaphragm to less than 1 cm during free breathing. Patients underwent a computed tomography virtual simulation using a breath-hold technique. At the time of treatment, verification of patient position and gating interval were performed using electronic portal imaging. Results Between September 2000 and January 2002, 136 patients were simulated with respiratory gating. Of these, 108 patients were treated to 110 sites for a total of 2301 treatment sessions. Ninety-seven percent of patients completed their entire course of therapy with gated treatment delivery. Conclusions Respiratory gating is a practical and achievable solution for minimizing respiratory-induced target motion during both simulation and treatment. With proper patient selection and training, it can be successfully implemented in a clinical radiation therapy department.

Malignant chondroid syringoma, or mixed tumor of the skin, salivary gland type, is an uncommon neoplasm believed to originate in sweat glands. This neoplasm occurs mostly in women and is typically seen in the extremities and torso. A case of recurrent malignant chondroid syringoma of the right foot in a man aged 34 years is described with a review of pertinent literature. The surgically excised neoplasm was evaluated by routine histology, immunohistochemistry, and transmission electron microscopy. The malignant chondroid syringoma showed microscopic dermal satellite tumor nodules. Immunohistochemical staining was positive for keratin and S100 and negative for actin and p53. Ki-67 showed

Purpose: An evaluation of plaque-mounted diode-light transillumination (DLT) for localization of episcleral plaques beneath juxtapapillary tumors. Methods and materials: Two patients scheduled for radiotherapy for juxtapapillary melanomas were offered DLT as an additional method of ophthalmic plaque localization. Plaques were constructed by affixing 4 non-heat producing, light-emitting diodes with their apertures flush with the episcleral outer surface of the plaque’s rim. Bio-implantable epoxy was used to encapsulate the electronic components. Then the plaques were loaded with 103Pd seeds. After the eye-plaques were sewn to the episclera covering the base of the intraocular tumors; the diode-lights were illuminated, viewed and recorded. Photodocumentation of the relative position of the 4 lights around tumor’s base was obtained in both cases. Results: Digital images of plaque-mounted diode retro-transillumination were obtained. No evidence of diode-light toxicity was noted. Both tumors were found to be covered by the ophthalmic plaques. Conclusion: Juxtapapillary tumors are often difficult or impossible to visualize with standard transillumination techniques and have been associated with poor local control rates. We have developed plaque-mounted DLT in an effort to improve ophthalmic plaque localization. Retrobulbar transillumination was viewed by indirect ophthalmoscopy and recorded with video-imaging. This technique provides unique photographic documentation of episcleral plaque localization beneath juxtapapillary tumors.

PURPOSE: To evaluate ophthalmic plaque radiotherapy for the treatment of subretinal neovascularization associated with age-related macular degeneration. METHODS: In a prospective phase I clinical trial, we treated 23 patients (23 eyes) with ophthalmic plaque radiotherapy for subfoveal exudative macular degeneration. Palladium 103 ophthalmic plaque brachytherapy was delivered to a retinal apex dose of 1,250 to 2,362 cGy (rad). Early Treatment Diabetic Retinopathy Study type visual acuity determinations, ophthalmic examinations, and angiography were performed before and after treatment. Clinical evaluations were performed in a nonrandomized and unmasked fashion. RESULTS: Patients were followed up for a mean (±SD) of 19 ± 10.7 months (range, 3 to 37 months). Six months after radiation therapy, three (16%) of 19 eyes had lost 3 or more lines of best-corrected visual acuity; 12 months after radiation therapy, four eyes (31% of 13 eyes), and 24 months after radiation therapy, only two (22% of nine eyes) lost 3 or more lines of visual acuity. No eye suffered sudden irreversible loss of central vision. No radiation retinopathy, optic neuropathy, or cataract could be attributed to radiotherapy within this follow-up period. CONCLUSION: Ophthalmic plaque radiotherapy can be used to treat neovascular age-related macular degeneration. In contrast to external beam radiotherapy, ophthalmic plaque radiotherapy is a unilateral treatment, which allows a larger dose to be delivered to the macula with less irradiation of normal ocular structures. We have found no sight-limiting complications at the doses, dose rates, and follow-up evaluated in this study.

Purpose : Resectability, local control, and survival were evaluated in advanced stage nonsmall cell lung cancer treated with simultaneous chemoradiation therapy delivered in an accelerated, interrupted twice-a-day schedule. Methods and Materials : Forty-seven consecutive patients with Stage IIIA or IIIB nonsmall cell lung cancer, consenting to participation in the study, received cisplatin, 30 mg/m 2 for 3 days, etoposid, 80 mg/m 2 for 3 days, and 5-fluorouracil, 900 mg/m 2 for 4 days. Radiation therapy consisted of 2 Gy given twice a day for 5 days. Two weeks rest was planned between cycles. Patients were evaluated for resectability after the second cycle. Any patient with unresectable tumor received a third cycle of treatment. Results : Forty-seven patients were evaluable for acute toxicity : eighteen (38%) required an extended rest period for esophagitis or low blood count ; 3 (6%) had sepsis, of whom 1 (2%) expired. Three patients (6%) had multiple blood transfusions for low hemoglobin. Median follow-up is 23.6 months, with a range of 10-49 months. Nine patients (19%) failed locally ; 15 (32%) had local and distant failure ; 7 (15%) failed only at distant sites. Twelve patients (25.5%) are alive with no evidence of disease ; 4 patients were lost to follow-up with disease. The 2-year actuarial survival is 49%, and the 4-year is 28.2%. Conclusion : Simultaneous chemoradiation is well tolerated with acceptable toxicity. The overall 2- and 4-year actuarial survival is somewhat better than that reported in the literature. Resectability in Stage IIIB patients was not increased with this regimen nor was any surgical specimen free of cancer. The 47% distant failure rate is not different from those reported by others.

PURPOSE: Patients diagnosed as having anal cancer and human immunodeficiency virus (HIV)-positive disease were evaluated for response to treatment and its associated toxicity. METHODS: We studied nine HIV-positive patients with squamous-cell carcinoma of the anus. Among them, three patients had acquired immunodeficiency syndrome (AIDS). The stage of disease at presentation included: one Stage 0, two Stage I, two Stage II, and four Stage III patients. Seven patients received combined modality treatment,i.e.,radiation therapy and chemotherapy, and two patients received radiation therapy alone. The radiation therapy field included the pelvis and a conedown boost. Chemotherapy consisted of two cycles of 5-fluorouracil and mitomycin C. Patients have been followed from 2 to 42 (median, 8) months. RE-SULTS: Seven patients achieved a complete response clinically. All Stage I/II patients and one of four Stage III patients remain alive and have no evidence of disease. Radiation Therapy Oncology Group/European Organization for the Research and Treatment of Cancer Grades 3 and 4 skin toxicity were noted in six patients, and Grades 2 and 3 myelosuppression were noted in eight patients. The response rates achieved are comparable to the experience in non-HIV patients reported in the literature, but toxicity seems to be increased. CONCLUSION: It would seem reasonable to offer combined modality treatment to early stage, HIV-positive patients with good performance status and a history of minor opportunistic infections. The value of combined modality in AIDS patients and those who present with advanced stages of the disease is questionable.

Between March 1982 and October 1987, 375 fields in 187 patients with AIDS-related Kaposi's Sarcoma were treated in the Department of Radiation Oncology at the University of California in San Francisco (UCSF). Field sizes ranging from 2 x 2 cm to total skin received doses of 8 Gy in a single fraction to 15-40 Gy in 5-10 fractions. Seventy-four percent of the patients have died. Response to treatment was achieved in over 90% of treated fields, with a median time to progression of 21 months and an actuarial freedom from relapse at 6 months of 69% (97 patients alive). There was no difference in outcome regardless of the fractionation regimen used. Severe reactions were noted in 17% of treated fields, but this incidence was significantly lower when a single fraction of 8 Gy was used (p less than 0.001). Radiation therapy plays an important palliative role in this devastating disease. This review supports the use of a single 8 Gy fraction for all Kaposi's Sarcoma lesions of the skin. Further data regarding single fraction therapy for lesions of other sites are needed.

Objective To describe clinical experience with palladium 103 ( 103 Pd)ophthalmic plaque radiotherapy for choroidal hemangioma. Methods One course of 103 Pd ophthalmic plaque radiotherapy was usedin each of 5 patients with circumscribed choroidal hemangioma who had progressiveloss of vision due to subretinal exudation. A mean apex dose of 2900 cGy (2900rad) was delivered. Functional tests of outcome included best-corrected visualacuity. Anatomic results included changes in tumor height and subretinal fluiddocumented by ophthalmoscopy, fluorescein angiography, and ultrasonography. Results All patients had complete resolution of subretinal fluid with reattachmentof the retina. All tumors decreased in height (mean, 50%) after treatment.Three patients (60%) demonstrated improvement in visual acuity at the lastfollow-up, and in 1 patient vision remained stable with resolution of metamorphopsia.Twenty-four months after treatment, 1 patient whose visual acuity had recoveredfrom 20/160 to 20/32 had a loss of vision to 20/160 because of radiation maculopathy.For all patients, a mean visual acuity improvement of 2 lines was documented(95% confidence interval, 0.23-0.88). Mean follow-up was 18.6 months (range,6-29 months). Conclusions A single 103 Pd plaque radiation treatment was effective indecreasing tumor height, eliminating subretinal fluid, and improving visualacuity in patients with symptomatic circumscribed choroidal hemangiomas.

Objective To evaluate the use of 3-dimensional (3D) ultrasonography for the localization of episcleral eye plaques during the treatment of choroidal melanomas. Methods A series of 13 patients with choroidal melanoma were treated with radioactive palladium 103 seeds affixed into gold eye plaques. During surgery, 3D ultrasonography was performed with a commercially available system to evaluate the relative position of radioactive plaques secured beneath their intraocular tumors. This system consists of an automated, rotating, handheld, B-scan ultrasonographic probe operating at 10 MHz, a personal computer, and 3D imaging software. Results We measured the margins of the plaque extending beyond the tumor and the distance between the radioactive seeds and the tumor apex. We also evaluated the relationship between the plaque edge, the episclera, and the tumor's edges. While the plaques were well centered over the tumor in all cases, the plaque margins around the tumor were found to be variably sized. When comparing measurements taken at the time of plaque insertion with those taken at the time of plaque removal, we noted changes in the apical tumor height and in plaque centration. In the 1 patient with a juxtapapillary tumor, the posterior margin of the plaque was found to be displaced away from the sclera, or "tilted." Conclusions Three-dimensional ultrasonography offers a new method for ophthalmic plaque localization. Unique perspectives can be visualized through the use of computer-aided 3D reconstructions that permit the assessment of the relative position of the plaque to the optic nerve and the measurement of the distance between the in vivo radioactive seed and the tumor apex. Our experience suggests that when compared with 2-dimensional ultrasonography, 3D ultrasonography offers new capabilities that can be used to improve plaque placement and radiation dose calculations.

Since our first description and profile of patients with Kaposi's sarcoma (KS) in 1984, the relative rate of KS in patients with the acquired immunodeficiency syndrome has dropped from 34% to 20%. However, the absolute number is increasing. The pathogenesis of KS is still obscure, and its interaction with the human immunodeficiency virus infection remains unclear. Cause of death is usually opportunistic infections in both endemic and epidemic KS. The most common intraoral site is the palate, which is involved in 95% of our cases. The oral cavity may be the only or first site of KS, and therefore, becomes important in the diagnosis. More than 20% of our current patient population had the oral cavity as the initial site of manifestation. Because of functional impairment, bleeding, pain, or cosmetic reasons, treatment is frequently required. There are many modalities used, including chemotherapy, radiation, and laser resection. Radiation appears to be a most effective and practical control measure for oral KS.

Forty-five consecutive patients with chordoma or chondrosarcoma at the base of skull or cervical spine were treated at the University of California Lawrence Berkeley Laboratory (UCLBL) and University of California School of Medicine, San Francisco (UCSF) between November 1977 and October 1986. All patients had undergone a subtotal surgical resection. Twenty-three patients were treated definitively with charged particles, 13 patients were treated with photons and particles, and 9 patients were treated for recurrent disease. Total doses ranged from 36 to 80 Gray equivalent (GyE). Thirty-three patients are alive with a minimum followup of 1 year. The actuarial survival and local control for all patients at 5 years is 62% and 59%, respectively. Patients treated for primary disease had a 78% actuarial local control rate at 2 years, whereas the rate for patients with recurrent disease was 33%. Patients with smaller visible tumor volumes (less than 20 cc) had a significantly better local control rate than patients with larger tumor volumes (80% vs 33% actuarial rate at 5 years). Patients with chondrosarcoma had the highest local control rate, as did patients treated with particles alone. Complications included 3 patients with unilateral visual loss, two patients who became blind, and 4 patients with radiation injury to the brainstem.