10360-3016/92 $5.00+ .oO Copyrighta>1992Pergamon Press Ltd.
In/ J Radraion Oncolo~v B~ol Phys, Vol. 24. PP. 187-189 Printedin theU.S.A.All rightsreserved.
??Correspondence
RE: EDITORIAL
BY DR. DEUTSCH
RESPONSE
MINNE
AND
BONNETERRE
To the Editor: Drs. Minne and Bonneterre are to be congratulated for the diligence with which they read fine print. They have succeeded in detecting typographical errors which eluded the editors and typesetters, and for which the senior author must accept full responsibility. Table 3 in the article by Russell ef al. (I) appears to omit the percentage of patients receiving chest radiation alone who had T4 primary tumors. In actuality, the percentage omitted was for patients with Tl cancers, and the percentages given for TI, T2, and T3 lesions actually reflect the percentages for T2, T3, and T4 lesions, thus providing a whole new mechanism for the phenomenon known as “stage migration”. The accurate percentages are TI I I%, T2 38%, T3 23%, and T4 28%. Additionally. there is a typographical error in the N-stage column with the true percentage of N2 patients in the PCI arm being Sl%, not 61% as printed. The percentages do really add up to 100%. With these corrections, one can appreciate that the randomization succeeded in generating prognostically well matched groups. The first author, chastened by this experience, vows to proofread more assiduously in the future and apologizes to the readership of the Journal. Concerning side effects of cranial irradiation in the geriatric patients, I can only say that no gross neurological affects were reported. Detailed neuropsychiatric testing was not performed, and subtle alterations of intellectual function might well have gone undetected and unreported. With most of these patients (8 I%) developing non-brain extra-thoracic metastases, the validity of such testing might well be suspect because of the confounding effects of medications such as anti-emetics, sedatives, and narcotic analgesics.
To fhe Editor: In his editorial on breast preserving treatment, Melvin Deutsch focuses on a topic that is highly interesting for the radiation oncologist: the decreasing importance of radical surgery in breast cancer. As a radiation oncologist, I fully agree with his point of view. The reader of his editorial, however, might assume that the German physicians’ attitude toward breast preservation may be much more conservative than that of physicians in the United States. This does not reflect the real situation. Our study published in the previous issue restricted breast preservation to patients with pT1 pNO-breast cancer. It must be noted that this protocol was planned and begun in the early 1980s. During the last years, breast preservation has rapidly increased. Furthermore, we have to accept that some patients prefer mastectomy instead of a 5-week radiation course, although we would consider them as candidates for breast preservation. Melvin Deutsch has clearly stated what point has the strongest impact on treatment decision: the patient’s desire. Dr. R. SAUER Department of Radiation Oncology University of Erlangen Universit&sstr.27 8520 Erlangen. Germany
PROPHYLACTIC FOR LUNG
TO DRS.
CRANIAL IRRADIATION CANCER PATIENTS
ANTHONY H. RUSSELL, M.D.
To the Ediw: We were very interested in the article by Russell el al. (I) It raises the interesting question of the value of prophylactic cranial irradiation in patients with adenocarcinoma or large cell lung tumors in whom brain metastases may appear in 30% of the cases. We would like however to make a few comments. The distribution of the patients according to T stage was different in the two groupscranial irradiation vs. no irradiation-more patients in the radiation group had T4 tumors (26% vs probably 11%) @ < 10 - 4) (probably, since the percentage was missing). The same comment can be made about the N 3 stage more frequent in the “irradiation group” (p = 0,048) (however, the sum of the percentages in the radiation group was I 10%). It appears thus that the group of patients who received cranial irradiation had a poorer prognosis than the non-irradiated one-at least as far as T stage is concerned. The absence of difference on the incidence of brain metastasis and survival could be-at least in part-caused by the inbalance between the prognostic factors. The age of the patients was rather high-especially for a prophylactic irradiation-with I6 and 19% being more than 71 years old in each group. Did the authors observe some central system side effects after cranial irradiation?
Radiation Oncology Center Sacramento, CA 958 I9 I. Russell, A. H.; Pajak, T. E.; Selim, H. M.; Paradelo, J. C.; Murray, K.; Bansal, P.; Cooper, J. D.; Silverman, S.; Clement, J. A. Prophylactic cranial irradiation for lung cancer patients at high risk for development of cerebral metastasis: results of a prospective randomized trial conducted by the Radiation Therapy Oncology Group. lnt. J. Radiat. Oncol. Biol. Phys. 21:637-644;1991.
COMBINED
MODALITY RECURRENT
TREATMENT FOR LOCALLY RECTAL CANCER
To the Ediur: I read with great interest the article by Wong ef al. (3) in the October edition regarding combined chemoradiotherapy with 5FU and mitomycin C for locally recurrent rectal carcinoma. However, the therapeutic regimen and the consecutive results presented therein somewhat differ from our experiences. In 22 patients with advanced colorectal carcinoma (I 8 local recurrences and 4 primary tumors without distant metastases) and macroscopic residual tumor after surgical intervention we applied simultaneous chemoradiotherapy with a total dose of 50 Gy in 5 weeks plus chemotherapy in the first 2 weeks using 5-FU 500 mg/m’ on days l-5 and 8-12 as continuous 24 hr intravenous infusion and mitomycin C 5 mg/m’ on days 5 and 12. The 2-year local control rates were 42% and 2-year survival was 51%. All patients completed therapy. As side effects we observed 24% WHO grade 3 and 6% WHO grade 4 toxicities and a 15% incidence of late damage, in 6% requiring surgical intervention. The therapeutic regimen published by Wong et al. employs comparable daily doses of 5-FU but bolus instead of continuous application. Twice
J. F. MINNE, M.D. J. BONNETERRE, M.D., PH.D. Centre Oscar Lambret 1 rue Frederic Combemale BP 307-59020 Lille CCdex, France 1. Russell, A. H.; Pajak, T. E.; Selim, H. M.; Paradelo, J. C.; Murray, K.; Bansol, P.; Cooper, J. D.; Silverman, S.; Clement, J. A. Prophylactic cranial irradiation for lung cancer patients at high risk for development of cerebral metastasis: results of a prospective randomized trial conducted by The Radiation Therapy Oncology Group. lnt. J. Radiat. Oncol. Biol. Phys. 2 1:637-644; 199 I. I87
In/ J Radraion Oncolo~v B~ol Phys, Vol. 24. PP. 187-189 Printedin theU.S.A.All rightsreserved.
??Correspondence
RE: EDITORIAL
BY DR. DEUTSCH
RESPONSE
MINNE
AND
BONNETERRE
To the Editor: Drs. Minne and Bonneterre are to be congratulated for the diligence with which they read fine print. They have succeeded in detecting typographical errors which eluded the editors and typesetters, and for which the senior author must accept full responsibility. Table 3 in the article by Russell ef al. (I) appears to omit the percentage of patients receiving chest radiation alone who had T4 primary tumors. In actuality, the percentage omitted was for patients with Tl cancers, and the percentages given for TI, T2, and T3 lesions actually reflect the percentages for T2, T3, and T4 lesions, thus providing a whole new mechanism for the phenomenon known as “stage migration”. The accurate percentages are TI I I%, T2 38%, T3 23%, and T4 28%. Additionally. there is a typographical error in the N-stage column with the true percentage of N2 patients in the PCI arm being Sl%, not 61% as printed. The percentages do really add up to 100%. With these corrections, one can appreciate that the randomization succeeded in generating prognostically well matched groups. The first author, chastened by this experience, vows to proofread more assiduously in the future and apologizes to the readership of the Journal. Concerning side effects of cranial irradiation in the geriatric patients, I can only say that no gross neurological affects were reported. Detailed neuropsychiatric testing was not performed, and subtle alterations of intellectual function might well have gone undetected and unreported. With most of these patients (8 I%) developing non-brain extra-thoracic metastases, the validity of such testing might well be suspect because of the confounding effects of medications such as anti-emetics, sedatives, and narcotic analgesics.
To fhe Editor: In his editorial on breast preserving treatment, Melvin Deutsch focuses on a topic that is highly interesting for the radiation oncologist: the decreasing importance of radical surgery in breast cancer. As a radiation oncologist, I fully agree with his point of view. The reader of his editorial, however, might assume that the German physicians’ attitude toward breast preservation may be much more conservative than that of physicians in the United States. This does not reflect the real situation. Our study published in the previous issue restricted breast preservation to patients with pT1 pNO-breast cancer. It must be noted that this protocol was planned and begun in the early 1980s. During the last years, breast preservation has rapidly increased. Furthermore, we have to accept that some patients prefer mastectomy instead of a 5-week radiation course, although we would consider them as candidates for breast preservation. Melvin Deutsch has clearly stated what point has the strongest impact on treatment decision: the patient’s desire. Dr. R. SAUER Department of Radiation Oncology University of Erlangen Universit&sstr.27 8520 Erlangen. Germany
PROPHYLACTIC FOR LUNG
TO DRS.
CRANIAL IRRADIATION CANCER PATIENTS
ANTHONY H. RUSSELL, M.D.
To the Ediw: We were very interested in the article by Russell el al. (I) It raises the interesting question of the value of prophylactic cranial irradiation in patients with adenocarcinoma or large cell lung tumors in whom brain metastases may appear in 30% of the cases. We would like however to make a few comments. The distribution of the patients according to T stage was different in the two groupscranial irradiation vs. no irradiation-more patients in the radiation group had T4 tumors (26% vs probably 11%) @ < 10 - 4) (probably, since the percentage was missing). The same comment can be made about the N 3 stage more frequent in the “irradiation group” (p = 0,048) (however, the sum of the percentages in the radiation group was I 10%). It appears thus that the group of patients who received cranial irradiation had a poorer prognosis than the non-irradiated one-at least as far as T stage is concerned. The absence of difference on the incidence of brain metastasis and survival could be-at least in part-caused by the inbalance between the prognostic factors. The age of the patients was rather high-especially for a prophylactic irradiation-with I6 and 19% being more than 71 years old in each group. Did the authors observe some central system side effects after cranial irradiation?
Radiation Oncology Center Sacramento, CA 958 I9 I. Russell, A. H.; Pajak, T. E.; Selim, H. M.; Paradelo, J. C.; Murray, K.; Bansal, P.; Cooper, J. D.; Silverman, S.; Clement, J. A. Prophylactic cranial irradiation for lung cancer patients at high risk for development of cerebral metastasis: results of a prospective randomized trial conducted by the Radiation Therapy Oncology Group. lnt. J. Radiat. Oncol. Biol. Phys. 21:637-644;1991.
COMBINED
MODALITY RECURRENT
TREATMENT FOR LOCALLY RECTAL CANCER
To the Ediur: I read with great interest the article by Wong ef al. (3) in the October edition regarding combined chemoradiotherapy with 5FU and mitomycin C for locally recurrent rectal carcinoma. However, the therapeutic regimen and the consecutive results presented therein somewhat differ from our experiences. In 22 patients with advanced colorectal carcinoma (I 8 local recurrences and 4 primary tumors without distant metastases) and macroscopic residual tumor after surgical intervention we applied simultaneous chemoradiotherapy with a total dose of 50 Gy in 5 weeks plus chemotherapy in the first 2 weeks using 5-FU 500 mg/m’ on days l-5 and 8-12 as continuous 24 hr intravenous infusion and mitomycin C 5 mg/m’ on days 5 and 12. The 2-year local control rates were 42% and 2-year survival was 51%. All patients completed therapy. As side effects we observed 24% WHO grade 3 and 6% WHO grade 4 toxicities and a 15% incidence of late damage, in 6% requiring surgical intervention. The therapeutic regimen published by Wong et al. employs comparable daily doses of 5-FU but bolus instead of continuous application. Twice
J. F. MINNE, M.D. J. BONNETERRE, M.D., PH.D. Centre Oscar Lambret 1 rue Frederic Combemale BP 307-59020 Lille CCdex, France 1. Russell, A. H.; Pajak, T. E.; Selim, H. M.; Paradelo, J. C.; Murray, K.; Bansol, P.; Cooper, J. D.; Silverman, S.; Clement, J. A. Prophylactic cranial irradiation for lung cancer patients at high risk for development of cerebral metastasis: results of a prospective randomized trial conducted by The Radiation Therapy Oncology Group. lnt. J. Radiat. Oncol. Biol. Phys. 2 1:637-644; 199 I. I87
