The influence of radiotherapy in advanced head and neck cancer was investigated by autopsy of head and neck patients who had had carotid artery rupture. Twenty-five cases of head and neck cancer revealed carotid artery rupture among the 255 head and neck cases autopsied from 1972 to 1985. The rate of carotid artery rupture in hypoharyngeal cancer was 8/32 (25%); in oral cancer 8/55 (14.5%), and in other cancers 9/165 (5.4%). In localization of ruptured arteries there were 9 cases of common carotid artery, 14 cases of external carotid artery, one case of internal carotid artery, and one unknown. These cases were irradiated using more than 70Gy. The following reasons for carotid artery rupture were suspected: 1. There was a tumor with deep ulceration and necrosis near the vessel. 2. The wall of the artery had radiation angitis. 3. The artery wall was necrotic because of invasion by the tumor. 4. Thrombosis developed with ensuant rupture of the artery. Radiotherapy for advanced cancer of the head and neck is necessary to control pain and as palliative treatment, but to avoid rupture of the carotid artery, pain clinic techniques and chemotherapy as palliative treatment for this kinds of terminal condition should be also be considered.

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A new CT-linked treatment planning system, called a CT simulator has been developed. This system consists of a CT scanner, multi-image monitors, a treatment planning computer and a laser-beam field projector. With this system, the patient lying on the CT couch can be totally planned within 30 minutes from the CT scanning untill the field projection. Many CT images can be planned simultaneously and many threedimensionally reconstructed images are available in this system. The laser-beam field projector makes it possible to project any kind of the field outlines over the skin of a patient. This system enables us to make optimum use of CT information and prepare practical three-dimensional treatment planning.

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From October 1977 to April 1987, 42 patients with carcimoma of the tongue received combined treatment with interstitial irradiation (radium implant) and chemotherapy (bleomycin or peplomycin), and were followed up for more than two years. Sixteen of these patients were treated in association with external irradiation. Local tumors recurred in 11%(1/9) of T1, 21%(4/19) of T2, 30.7%(4/13) of T3, and one (1/1) of T4 tumors. Sixty percent of local tumors recurred within two years and twenty percent recurred over five years. Eighty percent of the local recurrences were at the centers of the original primary lesions. The local tumor control rate at two years was 76%(32/42). Eight of the ten patients who had recurrences at the primary sites had salvage surgery and irradiation. Five patients were rescued and the final local tumor control rate was 88%(37/42). Four patients had radio-osteonecrosis, and fourteen had soft tissue necrosis.

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From 1974 to 1987, at the National Sapporo Hospital, seventy-two cases of multiple primary malignant neoplasms in the esophagus have been registered, representing 11.9% of 606 esophageal carcinomas patients. Among these 72 cases, five patients had triple and two had quadruple primary malignancies. The number of cancer cases thus totaled 81. As a result, 41 other cancers (51% of all) occurred synchronously (the interval between the esophagus and the other primary occurrences was within one year) and 73 (90% of all) were within five years of the time the esophageal cancer was detected. The most common sites of additional primary malignancies were the head and neck, and the stomach. The number of observed cancers of the tongue, the oral cavity, and the pharynx, other the esophagus, was extremely high, compared to the number expected on a person-years basis. Therefore it is necessary to keep careful track of a patient's progress to ascertain the incidence of multiple primary malignant neoplasms.

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From August 1976 to December 1987, thirty-one patients with carcinoma of the biliary system were treated with intraoperative radiation therapy (IORT). A single dose ranging from 18 to 35Gy (average 24.3Gy) with an 8 to 20MeV electron beam was delivered. In combination with IORT, postoperative external beam irradiation was applied to fifteen patients in doses ranging from 20 to 54Gy (average 37.8Gy). Tumor lesions were surgically resected by macroscopically curative or subcurative intent on sixteen patients. The median survival time of all patients was 6 months and actuarial survival was 32% at 1 year, 22% at 2 years, and 13% at 3 years. The survival of patients with carcinoma of the bile duct was 40% at 1 year compared with 18% for those with carcinoma of the gallbladder. Patients treated by IORT in combination with postoperative irradiation survived longer than those treated by IORT alone (10 months versus 2 months median survival). Difference between survival of the two groups was statistically significant (p<0.01). After tumor resection, IORT with a dose of about 20Gy combined with postoperative doses ranging from 40 to 50Gy was considered to be feasible without causing severe adverse reactions.

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The Chuuseibu (Western Region in Japan) Radiation Oncology Group did a retrospective study of radiotherapy used in 1977 and 1987 for lung cancer in this area. Information about lung cancer treated with radiation in 1977 or 1987 was obtained from questionnaires answered by 36 institutions. Of these, 26 gave information for both 1977 and 1987, and eight gave information for 1987 only. The two remaining institutions did not provide enough information for analysis. The number of patients with lung cancer treated by radiation in one year increased from 631 to 1004. In 1987, among these patients, 46%, 26%, 18%, and 6% had squamous cell carcinoma, adenocarcinoma, small cell carcinoma, and large cell carcinoma, respectively. The percentage of patients with adenocarcinoma was slightly higher in 1987 than 10 years earlier. The number of patients for whom the cancer was resected increased from 85 to 200. Of these, 53%, 30%, 7%, and 6% had, respectively, squamous cell carcinoma, adenocarcinoma, small cell carcinoma, and large cell carcinoma. These percentages changed only slightly during the 10 years. In 1977, radiotherapy was administered preoperatively to 47% of the patients and postoperatively to 52%; in 1987, radiotherapy was postoperative for 75% of the patients. The number of patients for whom the cancer was not resected also increased, from 546 to 804. Of these, 44%, 26%, 21%, and 7% had, respectively, squamous cell carcinoma, adenocarcinoma, small cell carcinoma, and large cell carcinoma. The percentage of patients with adenocarcinoma was up from 18% in 1977. In 1987, 31% of the patients with non small cell carcinoma were treated by radiotherapy alone, and 29% were treated by radiation followed by chemotherapy. The use of both treatments in this order increased from 17% in 1977. In 1987, 65% of the patients with small cell carcinoma were treated with chemotherapy followed by radiation; 33% of such patients received the same treatment in 1977. Concurrent radiotherapy plus chemotherapy was administered to 30% of such patients in 1977, but to only 9% in 1987.

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This report discusses the effects on normal brain tissue of radiotherapy in relation to age and irradiation dose as determined from whole-brain sections of the autopsied brains with tumors. Twenty four patients (7 glioblastomas, 2 benign gliomas, 12 brain metastases, 2 malignant lymphomas, and 1 pituitary adenoma) older than 65 years (aged), and 17 younger than 65 years (non-aged) were treated by cobalt-or linear accelerator radiotherapy. Nine patients without brain disease (4 aged and 5 non-aged) were used as a control group. The histological findings were evaluated by grading the small and capillary vessels, fibrinoid necrosis, and myelination in the white matter in whole-brain sections. Those findings were compared to the irradiation doses within all radiation fields in whole-brain sections corresponding to CT scans. Hyalinization of the small vessels was observed within the postradiation 12 months in fields exposed to total doses of less than 800 neuret. Hyalinization of the capillary vessels was greater in the irradiated group than in the control group. Demyelination was observed within the postradiation 12 months in fields irradiated by more than 800 neuret in aged patients and in fields irradiated by less than 800 neuret in non-aged patients. Fibrinoid necrosis was observed after the post-radiation 12 months in fields irradiated by less than 800 neuret in aged patients and in fields irradiated by more than 800 neuret in non-aged patients. It is worth noting that in non-aged patients with brain tumors, adverse effects of radiotherapy on vessels and parenchyma were very high even in low-dose radiation areas; and in aged patients fibrinoid necrosis, which indicates irreversible damage of vessels, was observed in low-dose radiation areas.

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The efficacy of radiation therapy on metastatic brain tumors from lung cancer was evaluated in 73 patients treated in our department of Gunma University Hospital over the past 10 years. Radiation therapy without concomitant therapy was effective in 74% of all cases, and the minimal total dose required for regression of clinical symptoms was 40 Gy. Pretreatment characteristics associated with favorable prognosis for survival were identified as follows; performance status of 1-3, age>60 years, controlled primary lesions, metastatic lesion limited to the brain, total dose≥40Gy, and histology of adenocarcinoma. Especially, patients with no other lesion than brain metastasis had survival rates of 38% for one year and 9% for two years. Two fractionation schedules (2Gy/fraction and 3Gy/fraction five times per week) were evaluated. The latter schedule resulted in a high incidence of early radiation injury or brain atrophy. The score analysis of radiation effects and results for metastatic brain tumors from lung cancer was useful in evaluating the method of radiation therapy.

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Fifty-one previously untreated patients with limited-stage small cell lung cancer were treated from January 1979 to August 1987. The 51 patients (46 males and 5 females) had a median age of 62 years (range 44-81). Forty-six received combined multidrug chemotherapy (CT) plus radiotherapy (RT) to the thorax. The others were treated with RT alone (four patients), or CT alone (one patient). All patients were evaluated for response, with a median follow-up of 56 months. Twenty-seven (53%) achieved CR and 16 (31%) PR. The median survival time was 15 months and the 5-year survival rate was 26%. Of the responders, 30 (73%) had relapses. The 5-year relapse-free survival rate was 21%(median duration of response: 9 months). Fifteen (37.5%) patients developed locoregional recurrence, including six who had failure at the margin of the radiation field. Infield recurrence was seen more frequently in patients who received less than 40Gy (60%), and less frequently in those who received 40Gy or more (25%). We suggest that it may be important for all of the originally involved lung and mediastinum, rather than just the demonstrable residual disease after chemotherapy, to be irradiated. We also recommend that the radiation field be established before chemotherapy, to reduce failure at margins of the field.

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