Postgraduate Medicine
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Radiotherapy for bronchogenic carcinoma Anthony T. Farina, Stephen J. Alderman & Richard J. Carella To cite this article: Anthony T. Farina, Stephen J. Alderman & Richard J. Carella (1978) Radiotherapy for bronchogenic carcinoma, Postgraduate Medicine, 63:2, 117-123, DOI: 10.1080/00325481.1978.11714756 To link to this article: http://dx.doi.org/10.1080/00325481.1978.11714756
Published online: 07 Jul 2016.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [Australian Catholic University]
Date: 31 August 2017, At: 02:46
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4th of six articles • Despite numerous clinical and therapeutic stratagems, the management of patients with bronchogenic carcinoma remains a formidable challenge with many unresolved issues. Except for patients with very small or early peripheral tumors, cures are few even when the disease is discovered in the asymptomatic stage. An analysis of any series of 100 consecutive unselected cases of primary lung cancer explains why prognosis is dismal and why the results of expert surgery, radiotherapy, and chemotherapy are so frustratingly poor. In 70 ofthe lOO cases the tumor will be inoperable because of distant metastases, widespread local disease, or medical contraindications to major surgery. Of the other 30 cases, the tumor will be partially resectable or unresectable in 15 and completely resectable in 15, and only four of the lOO patients, ali from the group with completely resectable tumors, will be alive without evidence of disease after five years. This distribution, with only slight variation, is reproducible from series to series. A breakdown of any such series of patients with bronchogenie carcinoma into subpopulations may aid physicians in making wise decisions as to the usefulness of radiotherapy. The group of 70 patients with inoperable tumors will be composed of 40 who have distant metastases or medical contraindications to surgery and 30 with extensive local disease. In the operable group will be ten patients with unresectable tumors and five with incompletely resectable lesions. Resection for cure will be performed in 15 of the 100 cases. For the latter group of patients with limited local disease, the evidence strongly suggests that surgery is indeed the treatment of choice. Data on Length of Survival After Surgery or Radiotherapy
In a collected series of al most 2, 700 patients with completely resectable lung cancer who were treated surgically at leading institutions in the 1960s, the mean five-year survival rate was 26% (table 1).•-s In a smaller collected series of patients treated by ionizing radiation in doses calculated to be curative, the corresponding figure was 20%, not too far behind. 6-B ..,.
Vol. 63 • No. 2 • February 1978 • POSTGRADUATE MEDICINE
radiotherapy for bronchogenic . carc1noma Anthony T. Farina, MD Stephen J. Alderman, MD Richard J. Carella, MD New York University Medical Center New York Catholic Medical Center of Brooklyn and Queens Jamaica, New York
consider What is the treatment of choice for inoperable or nonresectable Jung cancer? Which manifestations of Jung cancer may be alleviated by palliative radiotherapy? What is the role of radiotherapy in the management of patients with distant metastases?
117
radlotherapy for lung cancer table 1. five-year survival rates in large series of cases of resectable lung cancer
Downloaded by [Australian Catholic University] at 02:46 31 August 2017
Series (senior au thor)
Year
SUrgery Ochsner, Brock2 Galofré3 Thompson 4 Paulson5
1966 1964 1964 1967 1967
RlldlolheriiPY Bignan• Morrison• Sm art'
1967 1963 1966
Numberof patients
Flve-year survlval rate(%) 25 32
728
264 685 256 764 2,697
33.4
62 28
13 7.2 22.5 20
27.3 15.2 26
_.1Q_ 130
table 2. four-year survivors among 58 patients with bronchogenic carcinoma treated by surgery or radiotherapy in randomized trial* Histologie type of lesion Squamoua cali Adenocarcinome Qat celland anaplastie
'Data of Morrison and
Number of four-year aurvlvora Surgery
Radiotherapy
6of20 1 of 10
1 of 17 Oof 2 1 of 9
7of30
2of28
associeras' (1963).
Evidence of clear superiority of surgery over radiotherapy for lung cancer came from a 1963 report by Morrison and associates7 describing a randomized study of 58 patients with proved carcinoma of the lung who were treated at Hammersmith Hospital, London, by either radical surgery or radical (megavoltage) radiotherapy. Seven of 30 patients treated surgically and two of 28 receiving radiotherapy survived for four years (table 2). In a breakdown ofthe cases by histologie type of tumor, surgery gave significantly better results than radiotherapy in the cases of squamous cell carcinoma. Among the patients with anaplastie lesions, the results of surgery and of radiotherapy were virtually the same. lt
118
appeared from the trial that surgery was the better method of treatment of operable squamous cell carcinoma of the lung. Then again, if only partial resection of lung cancer is possible, it is probably wise merely to obtain tissue for histologie confirmation of the diagnosis, foregoing extensive surgery, and to treat the patient by radiotherapy. Guttmann 9.1o reported a
Of any series of 100 prlmary lung cancers, 70 will be Inoperable when the dlagnosls la made and 15 of the other 30 will be completely resectable. Only four of the 100 patients will be allve wlthout evidence of dlsease after flve years. two-year survival rate of 28% for 95 patients receiving radical radiotherapy, without further surgery, after exploratory thoracotomy and confirmatory biopsy, and a two-year survival rate of ll% for 103 patients receiving radical radiotherapy after partial resection of lung cancer. The difference is statistically significant. Also, operative mortality of partial resection of lung cancer is appreciable. In the collected series of almost 2, 700 patients und ergoing complete resection, operative mortality was 6% to 10%, but Paulson5 in 1967 reported an operative mortality of 33% among 591 patients undergoing partial resection of lung cancer. In cases of oat cell carcinoma of the lung, complete resection is rarely achieved and the duration of survival is slightly better with radiotherapy than with surgery. Results of the National Cooperative British Studyll reported in 1969 showed a mean survival time of 199 days for 71 patients treated surgically for oat cell carcinoma, compared with a mean survival ti me of 293 da ys for 73 patients with oat cell carcinoma receiving radiotherapy. In the past 15 years there have been great improvements in diagnostic techniques which should facilitate a decision not to
POSTGRADUATE MEDICINE • February 1978 • Vol. 63 • No. 2
Dr Farina and Dr Carena are in the division of radiation oncology, department of radiology, New York University Medical Center. Dr Alderman is in the department of radiation oncology, Catholic Medical Center of Brooklyn and Queens, Jamaica, New York.
Downloaded by [Australian Catholic University] at 02:46 31 August 2017
Anthony T. Farina
Stephen J. Alderman
proceed with thoracotomy in cases of incompletely resectable neoplasms.
Surgery Alone Vs Radlotherapy Followed by Surgery About one third of patients with carcinoma of the lung have extensive localized disease when the diagnosis is made. ln the mid l960s there was great hope that radiotherapy followed by surgery would lead to greater local containment of disease and would prolong survival time. Encouraged by preliminary data from an uncontrolled study conducted in 1961 by Bloedorn and associatesl2 at the University of Maryland, the Committee for Radiation Therapy Studies 13 established an ad hoc committee which designed a prospective protocol to determine the benefits of combined therapy for cancer confined to one lung and the mediastinum. In groups of patients comparable for age, extent of disease, and general medical condition, it was clearly demonstrated that radiotherapy cannot convert an inoperable lesion to a resectable one and thereby increase survival time appreciably. The survival rate among the patients treated by surgery was nearly identical to that among the patients treated by irradiation plus surgery, and operative mortality in the latter group was grea ter. There is one situation in which preoperative radiotherapy has proved to be beneficiai, and that is malignant tumor in the
Vol. 63 • No. 2 • Februauy 1978 • POSTGRADUATE MEDICINE
Richard J. Carella
superior sulcus, or Pancoast tumor. Paulson •4 in 1956 began a program of combined therapy in which 3,000 rads in ten fractions was delivered to the tumor and a margin of apparently normal tissue before surgery. Patients then rested for three to four weeks before undergoing extensive surgical ablation, en bloc, of the upper lobe, involved chest wall, ribs, portions of the bodies and transverse processes of the
Studles publlshed ln the past 15 years have polnted up differences ln the outcome of surgery vs radlotherapy for lung cancer relatlng to both tumor cell type and the extent of local dlsease or metastasls. The decision of when to settle for conflrmatory blopsy and forego extensive surgery la lnfluenced by these data. thoracic vertebrae, and the last three cords of the brachial plexus. This method of management resulted in improved survival rates at two, five, and ten years. Although the benefit of combined therapy was great, the group of patients with this type of lung cancer constituted a small fraction of the total cases. Patients with extensive local disease who are not poor surgical risks and do not have evidence of distant metastasis at the time of diagnosis make up a large, unsorted group. They comprise nearly
119
radiotherapy for lung c a n c e r - - - - - - - - - - - - - - - table 3. contraindications to radical radiotherapy for lung cancer
Downloaded by [Australian Catholic University] at 02:46 31 August 2017
Absolute Extrathoracic metastases Malignant pleural effusion Paralysis of one vocal cord Relative Mediastinal pain Supraclavicular metastases Paralysis of a hemidiaphragm Tumor volume requiring field size>200 sq cm Oat cell carcinoma
half-45%-of all patients with lung cancer, including the one third whose disease is clinically inoperable and the 15% whose disease is thought to be operable but is found at thoracotomy to be unresectable ( 10%) or partially resectable (5%). About 5% to 8% survive for five years with treatment. Although 20% of these patients will benefit from radiotherapy, it is a grim fact that two out of five will be dead in six months. lt is in this group of patients that the use of radiotherapy must be especially judicious. Because proleptic survival time is short, subjecting these patients routinely to a six-week course of intensive radiotherapy in the vain hope of cure is wrong. It is important to select for radiotherapy those patients for whom cure or at !east prolongation of !ife is more than a mere glimmer of hope.
Contralndlcatlons to Radlotherapy The absolute contraindications to intensive radiotherapy for lung cancer are extrathoracic metastases, malignant pleural effusion, and paralysis of one vocal cord (table 3). The latter two have consistently foretold poor possibility of survival. Other grave signs that tend to speak against curability with radiation and must be taken as relative contraindications to intensive radiotherapy are mediastinal pain, metastases to supraclavicular nodes, paralysis of a hemidiaphragm, a tumor volume requiring a field larger than 200 sq cm, and oat cell carcinoma.
120
Split-Course Technique When it is determined that patients may benefit from aggressive radiotherapy, heavy doses determined by extent and location of the neoplastic process are required when conventional techniques are used. In about 20% of the patients, evidence of extrathoracic spread of the disease will appear during treatment. Fifteen percent will be unable to complete the therapy for other reasons, and another 15% will show evidence of distant metastases within a mon th after treatment. Because of these sad facts, a split-course technique has become popular. lt consists of administration of 3,000 rads in two weeks, a three- to four-week rest, and administration of another 3,000 rads in two weeks. With use of this technique, patients seem to tolerate treatment better and physicians can better identify those whose disease will go on inexorably to dissemination and who consequently will not benefit from more highdose local radiotherapy. lt should be pointed out that these patients will have re-
When lt ls determlned that a patient may beneflt from radlotherapy, a split-course technique may be tolerated better than conventlonal treatment. lt conslsts of glvlng 3,000 rads ln two weeks, waltlng for three to four weeks, and then glvlng another 3,000 rads. ceived a reasonable dose for palliation during the first part of the split-course technique, ie, 3,000 rads in two weeks.
Orthovoltage Vs Megavoltage Radiotherapy Roswit and associatesls in 1968 published data accumulated from a national Veterans Administration Hospital study of radiotherapy for lung cancer that showed little benefit in terms of length of survival from less than megavoltage radiotherapy
POSTGRADUATE MEDICINE • February 1978 • Vol. 63 • No. 2
Downloaded by [Australian Catholic University] at 02:46 31 August 2017
(figure 1). This randomized study was impeccab1y done. The subjects were men with squamous cell carcinoma, 90% of whom bad bad exp1oratory thoracotomy and then no more than biopsy. After one year, 22% of those receiving orthovo1tage radiotherapy and 16% of those not treated by this means were alive. These findings constituted powerful evidence that treatment of lung cancer with ionizing radiation did not alter survival time appreciably, and the study gave rise to a do-nothing attitude toward patients with extensive local squamous cell carcinoma of the lung that was judged inoperable. The doses used cannot be considered adequate. By comparison of data on orthovoltage and megavoltage radiotherapy, it becomes evident that the effect on survival time is dose-related. The data to support radiotherapy as a means of altering favorably the natural course of bronchogenic carcinoma derive from many published series in which megavoltage radiotherapy (radical radiotherapy) was used (table 4).1S-2o Radlotherapy as Palllatlon Another category of patients with lung cancer who may benefit from tadiotherapy is made up of"medically inoperable" cases. Typically the patients are indigent and have a long history of cigarette smoking and alcoholism. Such patients already have poor pulmonary function and rarely are able to finish a course of intensive radiotherapy. If indeed a patient's general condition is poor, we advise a palliative regimen that may be tolerable. In certain cases, if the outlook for more than palliation is reasonably good, we ad vise more intensive radiotherapy. In most cases we use the split-course technique. In the reporting of results of treatment of bronchogenic carcinoma, there is unwarranted grea ter emphasis on length of survival than on local or regional control of disease and improvement of the quality of remaining life. Radiotherapy bas
Vol. 63 • No. 2 • February 1978 • POSTGRADUATE MEDICINE
Figure 1. One-year survival rates in unresectable squamous cell carcinome of lung with and without orthovoltage radiotherapy (
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Radiotherapy for bronchogenic carcinoma Anthony T. Farina, Stephen J. Alderman & Richard J. Carella To cite this article: Anthony T. Farina, Stephen J. Alderman & Richard J. Carella (1978) Radiotherapy for bronchogenic carcinoma, Postgraduate Medicine, 63:2, 117-123, DOI: 10.1080/00325481.1978.11714756 To link to this article: http://dx.doi.org/10.1080/00325481.1978.11714756
Published online: 07 Jul 2016.
Submit your article to this journal
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [Australian Catholic University]
Date: 31 August 2017, At: 02:46
Downloaded by [Australian Catholic University] at 02:46 31 August 2017
4th of six articles • Despite numerous clinical and therapeutic stratagems, the management of patients with bronchogenic carcinoma remains a formidable challenge with many unresolved issues. Except for patients with very small or early peripheral tumors, cures are few even when the disease is discovered in the asymptomatic stage. An analysis of any series of 100 consecutive unselected cases of primary lung cancer explains why prognosis is dismal and why the results of expert surgery, radiotherapy, and chemotherapy are so frustratingly poor. In 70 ofthe lOO cases the tumor will be inoperable because of distant metastases, widespread local disease, or medical contraindications to major surgery. Of the other 30 cases, the tumor will be partially resectable or unresectable in 15 and completely resectable in 15, and only four of the lOO patients, ali from the group with completely resectable tumors, will be alive without evidence of disease after five years. This distribution, with only slight variation, is reproducible from series to series. A breakdown of any such series of patients with bronchogenie carcinoma into subpopulations may aid physicians in making wise decisions as to the usefulness of radiotherapy. The group of 70 patients with inoperable tumors will be composed of 40 who have distant metastases or medical contraindications to surgery and 30 with extensive local disease. In the operable group will be ten patients with unresectable tumors and five with incompletely resectable lesions. Resection for cure will be performed in 15 of the 100 cases. For the latter group of patients with limited local disease, the evidence strongly suggests that surgery is indeed the treatment of choice. Data on Length of Survival After Surgery or Radiotherapy
In a collected series of al most 2, 700 patients with completely resectable lung cancer who were treated surgically at leading institutions in the 1960s, the mean five-year survival rate was 26% (table 1).•-s In a smaller collected series of patients treated by ionizing radiation in doses calculated to be curative, the corresponding figure was 20%, not too far behind. 6-B ..,.
Vol. 63 • No. 2 • February 1978 • POSTGRADUATE MEDICINE
radiotherapy for bronchogenic . carc1noma Anthony T. Farina, MD Stephen J. Alderman, MD Richard J. Carella, MD New York University Medical Center New York Catholic Medical Center of Brooklyn and Queens Jamaica, New York
consider What is the treatment of choice for inoperable or nonresectable Jung cancer? Which manifestations of Jung cancer may be alleviated by palliative radiotherapy? What is the role of radiotherapy in the management of patients with distant metastases?
117
radlotherapy for lung cancer table 1. five-year survival rates in large series of cases of resectable lung cancer
Downloaded by [Australian Catholic University] at 02:46 31 August 2017
Series (senior au thor)
Year
SUrgery Ochsner, Brock2 Galofré3 Thompson 4 Paulson5
1966 1964 1964 1967 1967
RlldlolheriiPY Bignan• Morrison• Sm art'
1967 1963 1966
Numberof patients
Flve-year survlval rate(%) 25 32
728
264 685 256 764 2,697
33.4
62 28
13 7.2 22.5 20
27.3 15.2 26
_.1Q_ 130
table 2. four-year survivors among 58 patients with bronchogenic carcinoma treated by surgery or radiotherapy in randomized trial* Histologie type of lesion Squamoua cali Adenocarcinome Qat celland anaplastie
'Data of Morrison and
Number of four-year aurvlvora Surgery
Radiotherapy
6of20 1 of 10
1 of 17 Oof 2 1 of 9
7of30
2of28
associeras' (1963).
Evidence of clear superiority of surgery over radiotherapy for lung cancer came from a 1963 report by Morrison and associates7 describing a randomized study of 58 patients with proved carcinoma of the lung who were treated at Hammersmith Hospital, London, by either radical surgery or radical (megavoltage) radiotherapy. Seven of 30 patients treated surgically and two of 28 receiving radiotherapy survived for four years (table 2). In a breakdown ofthe cases by histologie type of tumor, surgery gave significantly better results than radiotherapy in the cases of squamous cell carcinoma. Among the patients with anaplastie lesions, the results of surgery and of radiotherapy were virtually the same. lt
118
appeared from the trial that surgery was the better method of treatment of operable squamous cell carcinoma of the lung. Then again, if only partial resection of lung cancer is possible, it is probably wise merely to obtain tissue for histologie confirmation of the diagnosis, foregoing extensive surgery, and to treat the patient by radiotherapy. Guttmann 9.1o reported a
Of any series of 100 prlmary lung cancers, 70 will be Inoperable when the dlagnosls la made and 15 of the other 30 will be completely resectable. Only four of the 100 patients will be allve wlthout evidence of dlsease after flve years. two-year survival rate of 28% for 95 patients receiving radical radiotherapy, without further surgery, after exploratory thoracotomy and confirmatory biopsy, and a two-year survival rate of ll% for 103 patients receiving radical radiotherapy after partial resection of lung cancer. The difference is statistically significant. Also, operative mortality of partial resection of lung cancer is appreciable. In the collected series of almost 2, 700 patients und ergoing complete resection, operative mortality was 6% to 10%, but Paulson5 in 1967 reported an operative mortality of 33% among 591 patients undergoing partial resection of lung cancer. In cases of oat cell carcinoma of the lung, complete resection is rarely achieved and the duration of survival is slightly better with radiotherapy than with surgery. Results of the National Cooperative British Studyll reported in 1969 showed a mean survival time of 199 days for 71 patients treated surgically for oat cell carcinoma, compared with a mean survival ti me of 293 da ys for 73 patients with oat cell carcinoma receiving radiotherapy. In the past 15 years there have been great improvements in diagnostic techniques which should facilitate a decision not to
POSTGRADUATE MEDICINE • February 1978 • Vol. 63 • No. 2
Dr Farina and Dr Carena are in the division of radiation oncology, department of radiology, New York University Medical Center. Dr Alderman is in the department of radiation oncology, Catholic Medical Center of Brooklyn and Queens, Jamaica, New York.
Downloaded by [Australian Catholic University] at 02:46 31 August 2017
Anthony T. Farina
Stephen J. Alderman
proceed with thoracotomy in cases of incompletely resectable neoplasms.
Surgery Alone Vs Radlotherapy Followed by Surgery About one third of patients with carcinoma of the lung have extensive localized disease when the diagnosis is made. ln the mid l960s there was great hope that radiotherapy followed by surgery would lead to greater local containment of disease and would prolong survival time. Encouraged by preliminary data from an uncontrolled study conducted in 1961 by Bloedorn and associatesl2 at the University of Maryland, the Committee for Radiation Therapy Studies 13 established an ad hoc committee which designed a prospective protocol to determine the benefits of combined therapy for cancer confined to one lung and the mediastinum. In groups of patients comparable for age, extent of disease, and general medical condition, it was clearly demonstrated that radiotherapy cannot convert an inoperable lesion to a resectable one and thereby increase survival time appreciably. The survival rate among the patients treated by surgery was nearly identical to that among the patients treated by irradiation plus surgery, and operative mortality in the latter group was grea ter. There is one situation in which preoperative radiotherapy has proved to be beneficiai, and that is malignant tumor in the
Vol. 63 • No. 2 • Februauy 1978 • POSTGRADUATE MEDICINE
Richard J. Carella
superior sulcus, or Pancoast tumor. Paulson •4 in 1956 began a program of combined therapy in which 3,000 rads in ten fractions was delivered to the tumor and a margin of apparently normal tissue before surgery. Patients then rested for three to four weeks before undergoing extensive surgical ablation, en bloc, of the upper lobe, involved chest wall, ribs, portions of the bodies and transverse processes of the
Studles publlshed ln the past 15 years have polnted up differences ln the outcome of surgery vs radlotherapy for lung cancer relatlng to both tumor cell type and the extent of local dlsease or metastasls. The decision of when to settle for conflrmatory blopsy and forego extensive surgery la lnfluenced by these data. thoracic vertebrae, and the last three cords of the brachial plexus. This method of management resulted in improved survival rates at two, five, and ten years. Although the benefit of combined therapy was great, the group of patients with this type of lung cancer constituted a small fraction of the total cases. Patients with extensive local disease who are not poor surgical risks and do not have evidence of distant metastasis at the time of diagnosis make up a large, unsorted group. They comprise nearly
119
radiotherapy for lung c a n c e r - - - - - - - - - - - - - - - table 3. contraindications to radical radiotherapy for lung cancer
Downloaded by [Australian Catholic University] at 02:46 31 August 2017
Absolute Extrathoracic metastases Malignant pleural effusion Paralysis of one vocal cord Relative Mediastinal pain Supraclavicular metastases Paralysis of a hemidiaphragm Tumor volume requiring field size>200 sq cm Oat cell carcinoma
half-45%-of all patients with lung cancer, including the one third whose disease is clinically inoperable and the 15% whose disease is thought to be operable but is found at thoracotomy to be unresectable ( 10%) or partially resectable (5%). About 5% to 8% survive for five years with treatment. Although 20% of these patients will benefit from radiotherapy, it is a grim fact that two out of five will be dead in six months. lt is in this group of patients that the use of radiotherapy must be especially judicious. Because proleptic survival time is short, subjecting these patients routinely to a six-week course of intensive radiotherapy in the vain hope of cure is wrong. It is important to select for radiotherapy those patients for whom cure or at !east prolongation of !ife is more than a mere glimmer of hope.
Contralndlcatlons to Radlotherapy The absolute contraindications to intensive radiotherapy for lung cancer are extrathoracic metastases, malignant pleural effusion, and paralysis of one vocal cord (table 3). The latter two have consistently foretold poor possibility of survival. Other grave signs that tend to speak against curability with radiation and must be taken as relative contraindications to intensive radiotherapy are mediastinal pain, metastases to supraclavicular nodes, paralysis of a hemidiaphragm, a tumor volume requiring a field larger than 200 sq cm, and oat cell carcinoma.
120
Split-Course Technique When it is determined that patients may benefit from aggressive radiotherapy, heavy doses determined by extent and location of the neoplastic process are required when conventional techniques are used. In about 20% of the patients, evidence of extrathoracic spread of the disease will appear during treatment. Fifteen percent will be unable to complete the therapy for other reasons, and another 15% will show evidence of distant metastases within a mon th after treatment. Because of these sad facts, a split-course technique has become popular. lt consists of administration of 3,000 rads in two weeks, a three- to four-week rest, and administration of another 3,000 rads in two weeks. With use of this technique, patients seem to tolerate treatment better and physicians can better identify those whose disease will go on inexorably to dissemination and who consequently will not benefit from more highdose local radiotherapy. lt should be pointed out that these patients will have re-
When lt ls determlned that a patient may beneflt from radlotherapy, a split-course technique may be tolerated better than conventlonal treatment. lt conslsts of glvlng 3,000 rads ln two weeks, waltlng for three to four weeks, and then glvlng another 3,000 rads. ceived a reasonable dose for palliation during the first part of the split-course technique, ie, 3,000 rads in two weeks.
Orthovoltage Vs Megavoltage Radiotherapy Roswit and associatesls in 1968 published data accumulated from a national Veterans Administration Hospital study of radiotherapy for lung cancer that showed little benefit in terms of length of survival from less than megavoltage radiotherapy
POSTGRADUATE MEDICINE • February 1978 • Vol. 63 • No. 2
Downloaded by [Australian Catholic University] at 02:46 31 August 2017
(figure 1). This randomized study was impeccab1y done. The subjects were men with squamous cell carcinoma, 90% of whom bad bad exp1oratory thoracotomy and then no more than biopsy. After one year, 22% of those receiving orthovo1tage radiotherapy and 16% of those not treated by this means were alive. These findings constituted powerful evidence that treatment of lung cancer with ionizing radiation did not alter survival time appreciably, and the study gave rise to a do-nothing attitude toward patients with extensive local squamous cell carcinoma of the lung that was judged inoperable. The doses used cannot be considered adequate. By comparison of data on orthovoltage and megavoltage radiotherapy, it becomes evident that the effect on survival time is dose-related. The data to support radiotherapy as a means of altering favorably the natural course of bronchogenic carcinoma derive from many published series in which megavoltage radiotherapy (radical radiotherapy) was used (table 4).1S-2o Radlotherapy as Palllatlon Another category of patients with lung cancer who may benefit from tadiotherapy is made up of"medically inoperable" cases. Typically the patients are indigent and have a long history of cigarette smoking and alcoholism. Such patients already have poor pulmonary function and rarely are able to finish a course of intensive radiotherapy. If indeed a patient's general condition is poor, we advise a palliative regimen that may be tolerable. In certain cases, if the outlook for more than palliation is reasonably good, we ad vise more intensive radiotherapy. In most cases we use the split-course technique. In the reporting of results of treatment of bronchogenic carcinoma, there is unwarranted grea ter emphasis on length of survival than on local or regional control of disease and improvement of the quality of remaining life. Radiotherapy bas
Vol. 63 • No. 2 • February 1978 • POSTGRADUATE MEDICINE
Figure 1. One-year survival rates in unresectable squamous cell carcinome of lung with and without orthovoltage radiotherapy (
