Faculty Bibliography

BACKGROUND: Ovarian transposition is a surgical maneuver used to protect ovarian function before delivery of gonadocidal doses of radiation therapy. Ovarian transposition has been performed in patients whose treatment includes pelvic radiotherapy as a part of management for Hodgkin's disease and other gynecologic malignancies. CASE: Laparoscopic ovarian transposition was performed on a 28-year-old female with rectal cancer. At 13-month follow-up from completion of chemoradiation treatments, normal menstrual cycles at regular monthly intervals are reported. FSH, LH, and progesterone levels obtained during the second half of menstrual cycles were within normal ranges. CONCLUSION: Ovarian transposition is an effective surgical procedure for preserving ovarian function in patients at risk of radiotherapy-induced ovarian failure. Laparoscopic techniques can be used to move the ovaries outside of the radiation portal. Consideration should be given for ovarian transposition for other abdominal and pelvic malignancies before onset of radiation treatments in patients who desire preservation of ovarian function.

We investigated how frequently the imaging procedure we use immediately prior to radiosurgery--triple-dose gadolinium-enhanced MR performed with the patient immobilized in a nonrelocatable head frame and 1-mm-thick MPRAGE (magnetization-prepared rapid gradient echo) images (SRS3xGado)-identifies previously unrecognized cerebral metastases in patients initially imaged by conventional MR with single-dose gadolinium (1xGado). Between July 1998 and July 2000, the diagnoses established for 47 patients who underwent radio-surgical procedures for treatment of cerebral metastases at The Gamma Knife Center of New York University were based initially on the 1xGado protocol. In July 1998, we began using SRS3xGado as our routine imaging protocol in preparation for targeting lesions for radio-surgery, using triple-dose gadolinium and acquisition of contiguous 1-mm Tl-weighted axial images. Because our SRS3xGado scans sometimes unexpectedly revealed additional metastases, we sought to learn how frequently the initial 1xGado scans would underestimate the number of metastases. We therefore reviewed the number of brain metastases identified on the SRS3xGado studies and compared the results to the number found by the 1xGado protocol, which had initially identified the brain metastases. Additional metastases, ranging from 1 to 23 lesions per patient, were identified on the SRS3xGado scan in 23 of 47 patients (49%). In 57% of the 23 patients, only one additional lesion was identified. The mean time interval between the 1xGado and the SRS3xGado scans was 20.6 days (range, 4-83 days), and the number of additional lesions detected and the time interval between two scans were negatively correlated (-0.11). The number of lesions detected on the SRS3xGado was associated only with the number of lesions on the 1xGado and not with any other patient or tumor pretreatment characteristics such as age, gender, largest tumor volume on the 1xGado, or number of days between the 1xGado and the SRS3xGado or prior surgery. The identification of additional lesions with SRS3xGado MR may have implications for patients who are treated with stereotactic radiosurgery alone (without whole-brain irradiation) with single-dose gadolinium imaging, in that unidentified lesions may go untreated. As a result of these findings we continue to use and advocate SRS3xGado scans for radiosurgery

There is a paucity of clinical data regarding radiation therapy in elderly patients. This is a retrospective study of all patients aged 80 years and older who underwent treatment with external beam irradiation at a single site. There were a total of 183 patients treated with 226 courses of therapy. The mean age was 84 years (range: 80-98 years). Fifty-eight percent of the patients were male. The treatment was deemed palliative in 51% and curative in 49%. The primary cancer diagnoses were: prostate 36, lung 28, breast 25, head and neck 23, gastrointestinal 21, hematologic 12, gynecologic 11, skin 11, genitourinary 9, unknown primary 6, central nervous system 1. The patients were able to complete the prescribed therapy in 173 of 226 courses (77%). Treatment breaks during the radiation courses were required in 81 (36%) of the courses. Radiation therapy can be safely administered to an elderly population with both curative and palliative intent with the expectation of completion in more than 80% of patients. The reasons for inability to complete therapy as prescribed are multifactorial, but careful patient selection and attention to comorbidity may optimize outcome. Further research is needed to better define these parameters.

PURPOSE: While the literature supports the use of radiation therapy for thyroid eye disease, it does not sufficiently describe in detail the results of radiation therapy for optic neuropathy associated with thyroid eye disease. The objective of this study is to quantify the changes in parameters of optic neuropathy after orbital irradiation for thyroid eye disease. METHODS AND MATERIALS: Twelve consecutive patients with optic neuropathy from thyroid eye disease were followed by a single neuro-ophthalmology practice and treated by one radiation oncologist with radiation therapy from 1991 through 1995. All cases were prospectively followed for visual acuity, color vision, mean deviation, and/or foveal sensitivity and afferent pupillary defect. All patients received 2000 cGy in 10 fractions with megavoltage irradiation to the orbits. RESULTS: Ten of 12 patients were evaluated for follow-up (one moved out of this country and one had a stroke, which confounded interpretation of examination results). An analysis was performed retrospectively while treatment and evaluation remained uniform. Five men and five women formed the basis of this study with a median age of 60 years (35-76 years). Nineteen eyes were evaluated for thyroid optic neuropathy. Improvement in optic nerve function occurred in eight of ten patients. Improvement was seen either during radiotherapy or within 2 weeks of completion. No long-term adverse effects were noted. CONCLUSION: This study objectively demonstrates improvement in optic neuropathy from radiation therapy for thyroid eye disease.

This study reports the outcome of 70 patients who were treated by a consistent treatment plan of surgery and postoperative radiotherapy (RT) for pituitary macroadenomas in the modern era [computed tomographic scan or magnetic resonance imaging (MRI), dopamine agonist therapy (DA) added as indicated, and immunohistochemical staining]. Sixty-two patients underwent transsphenoidal surgery (vs. transcranial surgery) and 61 received 45-Gy/25 fractions postoperatively (vs. other dose fractionation schemes). Twenty-four patients received DA for prolactin-secreting tumors. With a median follow-up of 8 years (range 2-15), 68 patients have experienced continuous control of their tumors. Most symptoms related to mass effect abated, while physiologic symptoms such as amenorrhea from markedly elevated prolactin levels tended to persist. Treatment-induced hypopituitarism occurred in 42% of the patients at risk. No patients in this series have died as a result of their pituitary tumor. No gross neuropsychologic dysfunction after treatment has been noted. While it is possible at this time with serial MRI to withhold postoperative RT and observe some patients who have had a 'gross total' resection of a macroadenoma, the therapeutic ratio for surgery and adjuvant radiotherapy for patients with nonfunctional tumors as well as select patients with secretory macroadenomas is favorable

The objective of this study was to evaluate the prognostic indices of lymphvascular space involvement (LVS), surgical substage and grade on recurrence and survival in patients with surgical stage I endometrial adenocarcinoma, who had received postoperative external beam radiation (ERT). The medical records of all patients who had surgical stage I endometrial cancer between January 1987 and December 1991 were reviewed. Prognostic indicators, ie LVS, surgical substage and grade were correlated with recurrence and survival by log-rank test. Recurrence and survival distributions were estimated using the product limit method. One hundred and twenty-two patients had surgical stage I endometrial cancer. Eight patients were excluded because of histologic types other than endometrioid adenocarcinoma. An additional 27 patients were excluded since they had surgical stage IA and grade 1 and had not received ERT. The remaining 87 patients who had surgical stage IB and IC and who had received ERT, are the focus of this study. Ten patients had recurrences, all of which were outside the prescribed field of radiation. Nine of 11 (82%) patients with LVS recurred and 8/11 (73%) patients with LVS died of disease (P = 0.0001). Surgical substage did not correlate with risk for recurrence (P < 0.51). Five-year survival for the study group was 92%. LVS correlated well with survival (P < 0.0001), while grade and surgical substage were not significant indicators of survival in these patients, with surgically documented early disease (P > 0.13 and P > 0.57). LVS appears to be an important prognostic indicator for both recurrence and survival in patients with surgical stage I endometrial adenocarcinoma who receive postoperative ERT

PURPOSE: To determine if postoperative external pelvic radiation (EBRT), without vaginal brachytherapy, is sufficient to prevent vaginal cuff and pelvic recurrences in patients with surgical Stage I endometrial adenocarcinoma (ACA). METHODS AND MATERIALS: The records of 122 patients with surgical Stage I endometrial cancer were reviewed. There were 87 patients with ACA who received EBRT alone and are the subject of this study. Their radiation records were reviewed. All patients underwent exploration, total abdominal hysterectomy, and bilateral salpingo-oophorectomy (TAH BSO), and pelvic and paraaortic lymph node sampling. They were staged according to the FIGO 1988 surgical staging system recommendations. Postoperatively, pelvic EBRT was administered by megavoltage equipment using four fields, to a total dose of 45 to 50.4 Gy. Actuarial survival and disease free survival were calculated according to Kaplan-Meier Method. RESULTS: Twenty-seven patients with Stage IA Grade 1 or 2 ACA with less than one-third myometrial invasion, who did not receive EBRT, and eight patients with histology other than adenocarcinoma (i.e., serous papillary, mucinous, etc.) were not included in the study. For the remaining 87 patients who are in the study group, the median follow-up was 52 months (range: 12-82 months). The 5-year overall survival for these 87 patients was 92%, with a disease-free survival of 83%. There were no tumor recurrences in the upper vagina or in the pelvis. Two patients developed small bowel obstruction (no surgery required), and one patient developed chronic enteritis. CONCLUSION: Adjuvant external pelvic radiation, without vaginal brachytherapy, prevents pelvic and vaginal cuff recurrences in surgical Stage I endometrial ACA.

Neurocrine, endocrine, and paracrine regulators are critical to the control of colonic secretion. These studies have investigated the inhibition of vasoactive intestinal polypeptide (VIP)-stimulated ion transport by peptide YY (PYY) and other Y-class effectors in rabbit distal colonic mucosa mounted in Ussing chambers. PYY decreased basal short-circuit current (Isc) but did not significantly change either basal Na+ or Cl- flux. PYY inhibited VIP-stimulated increases in Isc by up to 86% and abolished VIP-induced Cl- secretion. PYY decreased VIP-generated increases in Isc by a tetrodotoxin-insensitive mechanism. PYY inhibited cholera toxin-stimulated as well as forskolin-stimulated increases in Isc but failed to alter stimulation by 8-bromoadenosine 3',5'-cyclic monophosphate (8-BrcAMP). PYY decreased VIP-stimulated increases in tissue cAMP by 88% and forskolin-stimulated increases by 84%. PYY, neuropeptide Y (NPY), (Leu31,Pro34)-NPY, and pancreatic polypeptide (PP) all demonstrated potent inhibition of VIP-stimulated increases in Isc. PYY-(13-36) demonstrated little effect on VIP stimulation. Thus the rabbit distal colon possesses a novel Y-class receptor phenotype that demonstrates high affinity for all three PP-fold peptides, NPY, PYY, and PP.