0360-3016/791111951-06$02.00/O
Int. .I. Radiation Oncology Biol. Phys., Vol. 5, pp. 1951-1956 o Pergamon Press Ltd., 1979. Printed in the U.S.A.
* Original Contribution INTERSTITIAL .
BRACHYTHERAPY IN CANCER OF THE LUNG: A 20 YEAR EXPERIENCE
BASIL S. HILARIS,M.D.’ and NAEL MARTINI,M.D.2 Brachytherapy Service, Department Memorial Sloan-Kettering
of Radiation Therapy’ and Thoracic Service, Department of Surgery’, Cancer Center, 1275 York Avenue, New York, NY 10021
Interstitial
bracytherapy is used at Memorial Hospital to treat patients whose lung cancer is still localized to the chest but in whom the tumor cannot be resected either because of fixation or invasion of the major vessels, trachea or esophagus, or because restricted pulmonary reserve precludes extensive resection. This report presents the experience of 470 patients ivith non-oat cell lung cancer who were treated from 1956 to 1976 by permanent implantation. Local control of implanted unresectable lung cancer was obtained in about 80% of patients with Stage I and II disease and in 60% of patients with Stage III disease. Nearly 50% of all patients developed distant metastases. Twenty-four of 340 patients (7%) with localized disease in the thorax who were treated from 1956 to 1973 have survived for 5 years or more. The 5-year survival is: Stage I, 6113 patients (46%); Stage III, 181322 patients (7%). None of five patients with Stage II and of 53 patients with M, lesions, survived for 5 years. Lung cancer, Brachytherapy
lung, Interstitial
implantation
lung, Intraoperative
irradiation
lung.
clinical use.436 Since then with the combined efforts of the thoracic surgeons and the radiotherapists we have performed 700 implants for primary and metastatic carcinoma of the lung. The experience with primary non oat cell lung cancer provides the basis for this report.
INTRODUCTION
The conventional modalities used to treat lung cancer are surgery, external beam radiation, and chemotherapy. Surgical removal of lung cancer remains the only potentially curative treatment; however, the disease must still be early and localized with no metastases present. When the disease is advanced, surgical treatment alone is ineffective. Radical external radiotherapy has been of limited value in prolonging the survival. The limited success with radiation therapy results to a great extent from the technical difficulty in the delivery of the required high doses of radiation, even with complex treatment planning. At this time, there is no effective chemotherapy for lung carcinoma except in oat cell tumors. Intraoperative interstitial radiation at thoracotomy, theoretically would allow the administration of a high dose to a surgically exposed tumor, with minimal irradiation to adjacent normal structures. Intraoperative lung irradiation, using radon seeds, was employed for the first time, at Memorial Sloan-Kettering Cancer Center, in 1941.2 In 1955, modern afterloading interstitial techniques were introduced by Henschke.4 At approximately the same time, artificial radionuclides became available for
From 1956 through 1976, 470 patients with nonoat cell carcinoma of the lung were treated by intraoperative afterloading interstitial techniques at Memorial Sloan-Kettering Cancer Center. Any patient who had a non-resectable cancer at thoracotomy was usually accepted for implantation. Of the 470 patients, 417 had limited disease, confined to one hemithorax but non-resectable, and with no clinical or radiological evidence of distant metastases (MO lesions by the American Joint Committee staging system’). The remaining 53 patients had extensive disease with involvement outside the chest (Ml lesions) mainly of supraclavicular lymph nodes. In patients with limited disease, 51% (212 patients) had no regional lymph node metastases and 4% (205 patients) had metastatic cancer in regional nodes, 3% in the hilar lymph nodes and 46% in mediastinum. The majority of the patients were in the sixth and
Reprint requests to: Basil Hilaris, M.D., Memorial Sloan-Kettering Cancer Center, 1275 York Ave., N.Y.,
N.Y. 10021. Accepted for publication
METHODS
1951
AND MATERIALS
28 March 1979.
1952
Radiation Oncology 0 Biology 0 Physics
seventh decades of life. Their ages ranged from 31 to 81 years, with a median age of 65. There were 394 men and 76 women, a ratio of 5: 1. Epidermoid carcinoma was encountered in 350 patients, adenocarcinema in 113 patients, and giant and spindle cell carcinoma in 7 patients. Interstitial radiation therapy The entire tumor volume was implanted including any positive nodes and/or the corresponding portion of the chest wall if it was invaded. The intraoperative interstitial procedure added approximately 45 minutes to one hour to the operating time. During the period under study various radionuclides were employed: radon-222 in 189 patients, iridium-192 in 65 patients, gold-198 in 14 patients, and iodine-125 in 202 patients. The technique of interstitial implantation has been previously described.4,5
November-December 1979, Vol. 5, No. 11 and No. 12
involvement such as extension into the mediastinum with fixation or invasion of the major vessels, trachea or esophagus, extension to the chest wall or matted and fixed hilar or mediastinal lymph node metastases that technically were not resectable. Postoperative mortality Twenty patients died witin 30 days of treatment, an operative mortality of 4% (20/470). This is not significantly different from the expected operative mortality after exploratory thoracotomy alone. The median age in this group of patients was 68 years. Table 1 lists the cause of death in these 20 patients, none of which resulted directly from the implantation techniques. Table 1. Causes of postoperative
No. of patients
Cause of death
External radiation therapy Preoperative external beam therapy was employed routinely in superior sulcus tumors (41 patients). all other tumors received When indicated, postoperative irradiation to the primary tumor and to the regional lymph nodes. The supraclavicular nodes were irradiated only if the primary tumor was located in the apex of the lung, or if there was evidence of their involvement. Parallel opposed anterior and posterior portals were used to a midplane dose of 3000-4000 rad in 3-4 weeks. In recent years, compensating filters or shrinking fields have been employed to insure accurate dose distribution in areas such as the thoracic inlet and the supraclavicular fossae. Postoperative external beam radiotherapy was started 3-6 weeks following the date of surgery. Staging All patients were staged according to the surgical classification proposed by the American Joint Committee’; information obtained at bronchoscopy and thoracotomy and from pathology reports was used in the staging. Patients who were treated prior to 1973 were staged retrospectively, while the rest were staged prospectively. Reasons for unresectability In Stage I carcinoma, the reasons for unresectability were unrelated to cancer but resulted from the location of the tumor and the patient’s limitations in cardiopulmonary reserve, i.e.. a 4 cm. tumor that was confined to the lung but necessitated a pneumonectomy for removal in a patient who had inadequate lung function on the unaffected side. In the majority of the patients however the reasons for unresectability were related to the extent of tumor
mortality
Myocardial infarct Pulmonary embolus Pulmonary hemorrhage Bronchopleural fistula and sepsis Wound dehiscence Renal failure GI hemorrhage Brain metastases Ruptured abdominal aneurysm Suicide Total
7 2 3 2 1 1 1 1 1 1 20/470 (4%)
RESULTS
Patients with limited disease Survival was calculated from the date of first treatment, which coincided with the date of thoracotomy for most patients. All patients were included, including those who died postoperatively. Of the 417 patients, 197 (47%) survived for one year; 76 patients (18%) survived for two years. The determinate survival in patients treated with high-energy radionuclides (222Rn, lgsAu, and lg21r) was 37% at one year and 13% at two years. In patients treated with low-energy radionuclides (1251) survival was 47% at one year and 20% at two years. This difference in survival is statistically significant QKO.05). 340 patients with limited disease (MO) were available for five year evaluation; 24 of these patients survived for five or more years, a determinate survival of 7%. Figure 1 shows the determinate survival according to the surgico-pathological T classification. The Tl and T2 lesions were grouped together since too few
Interstitial
DETERMINATE
brachytherapy
in cancer
of the lung 0 B.S. HILARIS
AND
1953
N. MARTINI
DETERMINATESURVIVAL
SURVIVAL
\
\
No.1 \
\
\
\
\
)__-_-_4
36 Months
48
60
1
I____LL 12
after treatment
24 Months
MS
1155)
(148)
48
60
~__I___I_~J 36 after treatment
Fig. 1. Determinate survival according to surgicopathological T category in 417 patients with limited disease treated from 1956 through 1976. Figures in parentheses indicate the number of patients available for evaluation at the specified period.
Fig. 2. Determinate survival according to the surgicopathological findings of the dissected regional nodes. Figures in parentheses indicate the number of patients available for evaluation at the specified periods after treatment.
The determinate five year survival for Tl and T2 tumors was 6/43 (14%); and for T3 tumors 191297 (6%). Figure 2 shows the determinate survival according to the presence or absence of metastases in the mediastinal lymph nodes. The NO and Nl categories were evaluated together because of the small number of patients in the Nl category. The determinate five year survival for NO-N1 category was 10% (19/192); and for N2 category 3% (Y148).
Table 2 shows the determinate five year survival in the three histological groups; epidermoid, adenocarcinoma, and giant and spindle cell carcinoma. The overall five year determinate survival was 7%, 8% and 14%, respectively. The observed differences in the various groups are not statistically significant. The determinate 5-year survival in patients with Stage III disease limited to the chest (MO) was 7%. However, within this group, patients with superior
had small tumors.
Table 2. Determinate
5-year survival of 340 patients with limited disease (M,,). according to histological type Epidermoid
Surgico-pathological category Tl, T2
T3
Total
Adenocarcinoma
Giant and spindle cell carcinoma
No.
(%)
No.
(%)
NO, Nl N2
6111 0115
(35)
( 0)
Oil Oil0
( 0) ( 0)
NO, Nl N2
81141 4197
( 6) ( 4)
4124 1128
(17) ( 4)
115 012
181270
C7)
5163
( 8)
l/7
No.
(%)
(14)
1954
Radiation Oncology 0 Biology 0 Physics
Table 3. Determinate 5-year survival patients with limited disease (M,) Number Stage I and II Stage III Superior sulcus Other Total
November-December 1979, Vol. 5, No. 11 and No. 12
difference in local control in the various T and N categories. Local or regional recurrences were noted in 20% of patients (Table 5); 32% developed distant metastases and 12% had both local recurrence and distant metastases. Thus the overall recurrence rate was 32% (1 IO/340 patients) and the overall rate of distant metastases was 44% (H/340 patients). Patients with mediastinal lymph node involvement had a higher incidence of distant metastases (53%) than patients with negative mediastinal lymph nodes (38%). (Table 6) These differences are statistically significant. The most common sites of distant metastases were brain (21%), bone (17%), liver (8%) and contralateral lung (5%). The time interval between date of thoracotomy and date of first metastases is shown in Table 7.
in
Percent
6118
33
7141 1 l/281
17 4
241340
7
Table 4. Permanent local tumor control according surgico-pathological T and N categories. 340 patients with limited disease (M,)
to
N2
NO, Nl
sulcus lesions had a significantly higher survival rate than patients with tumors at other locations (17% vs.
Patients with extensive disease During the period under review, 53 patients with distant metastases were explored solely for palliative interstitial implantation. Nine of these patients had adenocarcinoma and 42 had epidermoid carcinoma. No deaths occurred in the immediate postoperative period. In the majority of patients there was extensive involvement of mediastinal nodes (N2); 19 patients were alive at the end of the first year after treatment, 6 at the end of the second year; 2 patients survived for 3 years, dying soon afterwards of distant metastases. The incidence of distant metastases in this group was 72% (38/53).
4%). Local control was achieved in 230 of 340 patients (68%) with limited disease available for evaluation for up to five years after treatment. Local control was defined as no evidence of recurrence in the treated area at the most recent followup or at death. This was determined by serial radiographic examinations, cytohistological studies when feasible and analysis of autopsy specimens when available. Local control was obtained in 78% of patients with Stage I and II disease and in 67% of patients with Stage III disease (Table 4). This difference is not significant (x2=0.47). There was also no apparent
DISCUSSION Our results indicate that localized lung cancer can be controlled by intraoperative interstitial irradiation in about 75%80% of the patients with Stage I and II cancers and in about 60% of the patients with mediastinal and/or chest wall involvement. Guttman3 and Rubin et al.,? have reported similar results using high doses of external beam ‘radiation. Certain degrees of selection of patients exist in the various including ours. If allowances for these reports, differences are made, Guttman’s, Rubin et al.‘s results
Surgico-pathological category
No.
(%)
No.
(%)
Tl T2
14/18
(78)
17125
(68)
T3
123074
(71)
761123
(62)
Total
137/192
(69)
931148
(63)
Table 5. Treatment
Surgico-pathological stage I II III All stages
failures according Patients at risk
to surgico-pathological
Locoregional recurrences
Distant metastases
stage Locoregional and distant failures
13 5 322
3 1 65
3 4 103
0 0 41
340
69(2&G)
110(32%)
41(12%)
in cancer of the lung 0 B.S.
Interstitial brachytherapy
Table 6. Incidence
HILARIS AND
of distant metastases in 340 patients limited disease (M,,) NO, Nl
Surgico-pathological category
No.
(%)
N.
MARTINI
1955
with
N2
No.
(%)
Tl 7118
(39)”
19125
(76)*
T3
661174
(38)**
591123
(48)**
Total
731192
(38)***.
78/148
(53)***
T2
*P
Int. .I. Radiation Oncology Biol. Phys., Vol. 5, pp. 1951-1956 o Pergamon Press Ltd., 1979. Printed in the U.S.A.
* Original Contribution INTERSTITIAL .
BRACHYTHERAPY IN CANCER OF THE LUNG: A 20 YEAR EXPERIENCE
BASIL S. HILARIS,M.D.’ and NAEL MARTINI,M.D.2 Brachytherapy Service, Department Memorial Sloan-Kettering
of Radiation Therapy’ and Thoracic Service, Department of Surgery’, Cancer Center, 1275 York Avenue, New York, NY 10021
Interstitial
bracytherapy is used at Memorial Hospital to treat patients whose lung cancer is still localized to the chest but in whom the tumor cannot be resected either because of fixation or invasion of the major vessels, trachea or esophagus, or because restricted pulmonary reserve precludes extensive resection. This report presents the experience of 470 patients ivith non-oat cell lung cancer who were treated from 1956 to 1976 by permanent implantation. Local control of implanted unresectable lung cancer was obtained in about 80% of patients with Stage I and II disease and in 60% of patients with Stage III disease. Nearly 50% of all patients developed distant metastases. Twenty-four of 340 patients (7%) with localized disease in the thorax who were treated from 1956 to 1973 have survived for 5 years or more. The 5-year survival is: Stage I, 6113 patients (46%); Stage III, 181322 patients (7%). None of five patients with Stage II and of 53 patients with M, lesions, survived for 5 years. Lung cancer, Brachytherapy
lung, Interstitial
implantation
lung, Intraoperative
irradiation
lung.
clinical use.436 Since then with the combined efforts of the thoracic surgeons and the radiotherapists we have performed 700 implants for primary and metastatic carcinoma of the lung. The experience with primary non oat cell lung cancer provides the basis for this report.
INTRODUCTION
The conventional modalities used to treat lung cancer are surgery, external beam radiation, and chemotherapy. Surgical removal of lung cancer remains the only potentially curative treatment; however, the disease must still be early and localized with no metastases present. When the disease is advanced, surgical treatment alone is ineffective. Radical external radiotherapy has been of limited value in prolonging the survival. The limited success with radiation therapy results to a great extent from the technical difficulty in the delivery of the required high doses of radiation, even with complex treatment planning. At this time, there is no effective chemotherapy for lung carcinoma except in oat cell tumors. Intraoperative interstitial radiation at thoracotomy, theoretically would allow the administration of a high dose to a surgically exposed tumor, with minimal irradiation to adjacent normal structures. Intraoperative lung irradiation, using radon seeds, was employed for the first time, at Memorial Sloan-Kettering Cancer Center, in 1941.2 In 1955, modern afterloading interstitial techniques were introduced by Henschke.4 At approximately the same time, artificial radionuclides became available for
From 1956 through 1976, 470 patients with nonoat cell carcinoma of the lung were treated by intraoperative afterloading interstitial techniques at Memorial Sloan-Kettering Cancer Center. Any patient who had a non-resectable cancer at thoracotomy was usually accepted for implantation. Of the 470 patients, 417 had limited disease, confined to one hemithorax but non-resectable, and with no clinical or radiological evidence of distant metastases (MO lesions by the American Joint Committee staging system’). The remaining 53 patients had extensive disease with involvement outside the chest (Ml lesions) mainly of supraclavicular lymph nodes. In patients with limited disease, 51% (212 patients) had no regional lymph node metastases and 4% (205 patients) had metastatic cancer in regional nodes, 3% in the hilar lymph nodes and 46% in mediastinum. The majority of the patients were in the sixth and
Reprint requests to: Basil Hilaris, M.D., Memorial Sloan-Kettering Cancer Center, 1275 York Ave., N.Y.,
N.Y. 10021. Accepted for publication
METHODS
1951
AND MATERIALS
28 March 1979.
1952
Radiation Oncology 0 Biology 0 Physics
seventh decades of life. Their ages ranged from 31 to 81 years, with a median age of 65. There were 394 men and 76 women, a ratio of 5: 1. Epidermoid carcinoma was encountered in 350 patients, adenocarcinema in 113 patients, and giant and spindle cell carcinoma in 7 patients. Interstitial radiation therapy The entire tumor volume was implanted including any positive nodes and/or the corresponding portion of the chest wall if it was invaded. The intraoperative interstitial procedure added approximately 45 minutes to one hour to the operating time. During the period under study various radionuclides were employed: radon-222 in 189 patients, iridium-192 in 65 patients, gold-198 in 14 patients, and iodine-125 in 202 patients. The technique of interstitial implantation has been previously described.4,5
November-December 1979, Vol. 5, No. 11 and No. 12
involvement such as extension into the mediastinum with fixation or invasion of the major vessels, trachea or esophagus, extension to the chest wall or matted and fixed hilar or mediastinal lymph node metastases that technically were not resectable. Postoperative mortality Twenty patients died witin 30 days of treatment, an operative mortality of 4% (20/470). This is not significantly different from the expected operative mortality after exploratory thoracotomy alone. The median age in this group of patients was 68 years. Table 1 lists the cause of death in these 20 patients, none of which resulted directly from the implantation techniques. Table 1. Causes of postoperative
No. of patients
Cause of death
External radiation therapy Preoperative external beam therapy was employed routinely in superior sulcus tumors (41 patients). all other tumors received When indicated, postoperative irradiation to the primary tumor and to the regional lymph nodes. The supraclavicular nodes were irradiated only if the primary tumor was located in the apex of the lung, or if there was evidence of their involvement. Parallel opposed anterior and posterior portals were used to a midplane dose of 3000-4000 rad in 3-4 weeks. In recent years, compensating filters or shrinking fields have been employed to insure accurate dose distribution in areas such as the thoracic inlet and the supraclavicular fossae. Postoperative external beam radiotherapy was started 3-6 weeks following the date of surgery. Staging All patients were staged according to the surgical classification proposed by the American Joint Committee’; information obtained at bronchoscopy and thoracotomy and from pathology reports was used in the staging. Patients who were treated prior to 1973 were staged retrospectively, while the rest were staged prospectively. Reasons for unresectability In Stage I carcinoma, the reasons for unresectability were unrelated to cancer but resulted from the location of the tumor and the patient’s limitations in cardiopulmonary reserve, i.e.. a 4 cm. tumor that was confined to the lung but necessitated a pneumonectomy for removal in a patient who had inadequate lung function on the unaffected side. In the majority of the patients however the reasons for unresectability were related to the extent of tumor
mortality
Myocardial infarct Pulmonary embolus Pulmonary hemorrhage Bronchopleural fistula and sepsis Wound dehiscence Renal failure GI hemorrhage Brain metastases Ruptured abdominal aneurysm Suicide Total
7 2 3 2 1 1 1 1 1 1 20/470 (4%)
RESULTS
Patients with limited disease Survival was calculated from the date of first treatment, which coincided with the date of thoracotomy for most patients. All patients were included, including those who died postoperatively. Of the 417 patients, 197 (47%) survived for one year; 76 patients (18%) survived for two years. The determinate survival in patients treated with high-energy radionuclides (222Rn, lgsAu, and lg21r) was 37% at one year and 13% at two years. In patients treated with low-energy radionuclides (1251) survival was 47% at one year and 20% at two years. This difference in survival is statistically significant QKO.05). 340 patients with limited disease (MO) were available for five year evaluation; 24 of these patients survived for five or more years, a determinate survival of 7%. Figure 1 shows the determinate survival according to the surgico-pathological T classification. The Tl and T2 lesions were grouped together since too few
Interstitial
DETERMINATE
brachytherapy
in cancer
of the lung 0 B.S. HILARIS
AND
1953
N. MARTINI
DETERMINATESURVIVAL
SURVIVAL
\
\
No.1 \
\
\
\
\
)__-_-_4
36 Months
48
60
1
I____LL 12
after treatment
24 Months
MS
1155)
(148)
48
60
~__I___I_~J 36 after treatment
Fig. 1. Determinate survival according to surgicopathological T category in 417 patients with limited disease treated from 1956 through 1976. Figures in parentheses indicate the number of patients available for evaluation at the specified period.
Fig. 2. Determinate survival according to the surgicopathological findings of the dissected regional nodes. Figures in parentheses indicate the number of patients available for evaluation at the specified periods after treatment.
The determinate five year survival for Tl and T2 tumors was 6/43 (14%); and for T3 tumors 191297 (6%). Figure 2 shows the determinate survival according to the presence or absence of metastases in the mediastinal lymph nodes. The NO and Nl categories were evaluated together because of the small number of patients in the Nl category. The determinate five year survival for NO-N1 category was 10% (19/192); and for N2 category 3% (Y148).
Table 2 shows the determinate five year survival in the three histological groups; epidermoid, adenocarcinoma, and giant and spindle cell carcinoma. The overall five year determinate survival was 7%, 8% and 14%, respectively. The observed differences in the various groups are not statistically significant. The determinate 5-year survival in patients with Stage III disease limited to the chest (MO) was 7%. However, within this group, patients with superior
had small tumors.
Table 2. Determinate
5-year survival of 340 patients with limited disease (M,,). according to histological type Epidermoid
Surgico-pathological category Tl, T2
T3
Total
Adenocarcinoma
Giant and spindle cell carcinoma
No.
(%)
No.
(%)
NO, Nl N2
6111 0115
(35)
( 0)
Oil Oil0
( 0) ( 0)
NO, Nl N2
81141 4197
( 6) ( 4)
4124 1128
(17) ( 4)
115 012
181270
C7)
5163
( 8)
l/7
No.
(%)
(14)
1954
Radiation Oncology 0 Biology 0 Physics
Table 3. Determinate 5-year survival patients with limited disease (M,) Number Stage I and II Stage III Superior sulcus Other Total
November-December 1979, Vol. 5, No. 11 and No. 12
difference in local control in the various T and N categories. Local or regional recurrences were noted in 20% of patients (Table 5); 32% developed distant metastases and 12% had both local recurrence and distant metastases. Thus the overall recurrence rate was 32% (1 IO/340 patients) and the overall rate of distant metastases was 44% (H/340 patients). Patients with mediastinal lymph node involvement had a higher incidence of distant metastases (53%) than patients with negative mediastinal lymph nodes (38%). (Table 6) These differences are statistically significant. The most common sites of distant metastases were brain (21%), bone (17%), liver (8%) and contralateral lung (5%). The time interval between date of thoracotomy and date of first metastases is shown in Table 7.
in
Percent
6118
33
7141 1 l/281
17 4
241340
7
Table 4. Permanent local tumor control according surgico-pathological T and N categories. 340 patients with limited disease (M,)
to
N2
NO, Nl
sulcus lesions had a significantly higher survival rate than patients with tumors at other locations (17% vs.
Patients with extensive disease During the period under review, 53 patients with distant metastases were explored solely for palliative interstitial implantation. Nine of these patients had adenocarcinoma and 42 had epidermoid carcinoma. No deaths occurred in the immediate postoperative period. In the majority of patients there was extensive involvement of mediastinal nodes (N2); 19 patients were alive at the end of the first year after treatment, 6 at the end of the second year; 2 patients survived for 3 years, dying soon afterwards of distant metastases. The incidence of distant metastases in this group was 72% (38/53).
4%). Local control was achieved in 230 of 340 patients (68%) with limited disease available for evaluation for up to five years after treatment. Local control was defined as no evidence of recurrence in the treated area at the most recent followup or at death. This was determined by serial radiographic examinations, cytohistological studies when feasible and analysis of autopsy specimens when available. Local control was obtained in 78% of patients with Stage I and II disease and in 67% of patients with Stage III disease (Table 4). This difference is not significant (x2=0.47). There was also no apparent
DISCUSSION Our results indicate that localized lung cancer can be controlled by intraoperative interstitial irradiation in about 75%80% of the patients with Stage I and II cancers and in about 60% of the patients with mediastinal and/or chest wall involvement. Guttman3 and Rubin et al.,? have reported similar results using high doses of external beam ‘radiation. Certain degrees of selection of patients exist in the various including ours. If allowances for these reports, differences are made, Guttman’s, Rubin et al.‘s results
Surgico-pathological category
No.
(%)
No.
(%)
Tl T2
14/18
(78)
17125
(68)
T3
123074
(71)
761123
(62)
Total
137/192
(69)
931148
(63)
Table 5. Treatment
Surgico-pathological stage I II III All stages
failures according Patients at risk
to surgico-pathological
Locoregional recurrences
Distant metastases
stage Locoregional and distant failures
13 5 322
3 1 65
3 4 103
0 0 41
340
69(2&G)
110(32%)
41(12%)
in cancer of the lung 0 B.S.
Interstitial brachytherapy
Table 6. Incidence
HILARIS AND
of distant metastases in 340 patients limited disease (M,,) NO, Nl
Surgico-pathological category
No.
(%)
N.
MARTINI
1955
with
N2
No.
(%)
Tl 7118
(39)”
19125
(76)*
T3
661174
(38)**
591123
(48)**
Total
731192
(38)***.
78/148
(53)***
T2
*P
