TELE-CURIE-THERAPY Tele-Curie-Therapy May Be Defined As the Treatment of Malignant Tumors by Gamma Rays, from Radium at a Distan

TELE-CURIE-THERAPY BERNARD F. SCHREINER, M.D., F.A.C.S., MELVIN C. REINHARD, M.A., AND WILLIAM H. WEHR, M.D. (From the State Institute for the Study of Malignant Dbeaae, Bhffalo, N. Y., Burton T. Sim.pclon, M.D., Director) Tele-curie-therapy may be defined as the treatment of malignant tumors by gamma rays, from radium at a distance from the skin. Our conception of tele-curie-therapy is the use of large amounts of radium, from 1 to 5 grams, at distances of 5 to 10 cm. or more from the skin. The apparatus used in tele-curie-therapy are referred to as cannons, packs, or bombs. In this paper we shall refer to them as packs. Generally speaking, we may say that the more deeply situated the malignant process, the greater should be the distance between the radium and the skin. This is an application of a well known law of physics, which states that the greater the radium skin distance (RaSD), the greater the percentage depth dose, as shown in Table I, columns 3, 4, and 5. This table also shows that the intensity reaching the skin is less, the greater this distance. Therefore, in order to attain the re- quired dose, the treatment time must be prolonged, sometimes beyond practical limits. To reduce the time of exposure to a period which may be more easily tolerated, larger quantities of radium must be used. The use of large quantities of radium necessitates surrounding the radium by heavy lead walls which serve as a protection to the patient and worker, and also confine the beam to the size of the field chosen. The size of the field and its shape are dependent upon the individual case under consideration. It may be circular, square, or rectangular, ranging from 25 to 100 sq. cm. The primary filter should be 1.0 mm. platinum or its metallic equivalent ; also a secondary filter, placed at the bottom of the treatment cone, is essential. European collaborators in tele-curie-therapy include Regaud and Laborde of Paris, Cheval and hilayer of Brussels, Bervan and Sievert of Stockholm, and RLISSand Lazarus-Barlow of England. Among Americans are Failla of Memorial and Kaplan of Bellevue Hospital, New York City, Kelly and Burnam of Baltimore, Glasser of Cleveland, Schmitz and Cutler of Chicago, Widman of Philadelphia, Stenstrom of Minneapolis, and Reinhard, Schreiner, and Wehr of Buffalo. The dosage of tele-curie-therapy in the past has been recorded in milligram or gram hours. This is inadequate unless all the factors and conditions under which the treatments were given are stated: namely, filter, distance, amount and distribution of the radium, time of treatment and time interval between treatments, and rate of dosage. After a consideration of all the factors involved, it would seem that a unit of dosage for tele-curie-therapy is desirable. We have provisionally adopted the x-ray unit of intensity, the 380 TELE-CURIE-THERAPY 387 roentgen, as a unit of gamma ray intensity. This is now being investi- gated by some physicists, among whom are Glasser, Failla, and Mayneord. There is not complete agreement among these investigators that gamma rays can be measured as x-rays are, yet this unit does have certain advantages where it is used under fixed conditions.

TABLEI

New Pack Four-gram Pack

I Section I11 Sections RaSD 10 cm. 10 cm. 6 cm. 10 cm. 15 crn. Surface Intensity 63 r/gm. hr. 69 r/gm. hr. 86 r/gm. hr. 1 50 r/gm. hr. I 28.5 r/gm. hr. Depth Per cent Per cent Per cent Per cent Per cent 0 cm.. ... 100.0 100.0 100.0 100.0 100.0 1...... 88.8 91.o 87.5 91.0 91.0 2...... 76.5 80.0 71.5 76.0 80.5 3 ...... 65.3 72.5 59.1 65.1 71.0 4 ...... 55.0 67.6 49.3 56.1 62.0 5 ...... 46.6 64.0 41.3 49.0 54.0 6 ...... 40.0 60.8 34.7 42.4 47.5 7 ...... 33.3 58.0 29.1 36.7 42.0 8 ...... 29.5 55.0 24.6 31.8 36.7 9 ...... 25.6 51.6 21.3 27.5 32.3 10 ...... 22.2 48.0 18.7 24.0 28.5 11, ...... 19.9 43.8 16.6 21.3 25.7 12...... 16.7 39.3 14.9 19.0 23.5 13 ...... 13.3 35.0 13.3 17.3 21.2 14...... 12.2 31.2 12.0 15.6 19.3 15...... 10.5 27.8 10.8 14.2 17.5 16 ...... 8.6 25.0 9.8 13.0 16.2 17...... 7.1 22.2 8.9 11.8 14.8 18...... 5.9 20.1 8.0 10.8 13.5 19...... 4.8 18.5 7.3 10.0 12.3 20 ...... 3.8 17.0 6.7 9.1 11.5

* The surface intensities as listed include tissue scattering. The distribution of radiation on the skin and within the body has been determined, and results are recorded in the form of isodose charts (Fig, 1). These charts give the relative intensity at a given point of the beam of radiation at any depth. With these factors in mind, a discussion of the one-field treatment can be undertaken. This is best illustrated by a case record. A. B., No. 15093, white, male, aged fifty-three, farmer, was admitted Nov. 11, 1931. He had bruised his hand three or four years earlier; a scab formed, and was removed from time to time, but the lesion gradually increased in size. On the dorsum of the left hand there was now an ulcerating lesion measuring 4 X 4 om. The borders were markedly indurated. The growth involved the tendon sheaths. There were no palpable aleillary or epitroohlear nodes. Biopsy showed the tumor to be an epidermoid carcinoma. X-ray films were negative for bone involvement. Treatment was given with the four-gram radium pack at 6 cm. radium skin distance; field size 10 x 10 om., 430 r per day for five oonsecutive days for a total of 2150 r. When the patient w’&s last seen the tumor had regressed completely. The scar was smooth, soft, and not adherent. There has been no recurrence to date, three years and three months since admission. 388 B. F. SCHREINER, M. C. REINHARD, AND W. H. WEHR Where lesions are located at or near the surface, one field of application is sufficient, as shown in this case (Figs. 2 and 3). In the deeper seated tumors, such as those in the pharynx and naso- pharynx, where the diameter approximates 10 to 15 cm., it is possible, by choosing two or three ports of entry and planning by means of isodose curves, to irradiate thoroughly and heal some of these lesions. This is illustrated by the following case, which is an example of the thr ee-field technic.

FIQ.1. ISODOSECHART FOR SINQLE SECTION RADIUMPACK

H. H., No. 14992, white, male, aged fourteen, was admitted October 16, 1931, complaining of difficulty in breathing and swallowing. On the posterior pharyngeal wall, extending downward from the soft palate, was an indurated, Axed lesion, measuring 4 om. in diameter. There were palpable nodes in both sides of the neck. Biopsy revealed a transitional-cell epithelioma. Radium pack with a radium skin distance of 6 cm. and u field size of 5 X 5 om. was applied to the right and left sides of the neck, 670 r per treatment; the four-gram pack, at 10 cm. distance with a 10 X 10 centimeter Add, was applied to the posterior surface of the neck and occipital region, 250 r per treatment. Each area was treated every third day, rotating right, left, and posteriorly. The total skin dose was as follows: Right neck, 2680 r; left neck, 2680 r; posterior, 1500 r. The tumor dose was 2622 r. At the end of one month the tumor had disap- peared and the patient has remained well to the present date, three years and four months since admission. To illustrate the successful treatment of pelvic malignancy with packs arranged to radiate two fields simultaneously, we have chosen the following case : TELE-UURIE-THERAPY 389

A. V., No. 21322, white, female, aged fifty, was admitted to the hospital October 8, 1934, complaining of a yellowish vaginal discharge for two years, and a continuous foul- smelling, bloody discharge for seven months. There was an infiltrating epithelioma involving the cervix, fornices, and anterior vaginal wall. The uterus was fixed. Four fields were treated, two anteriorly and two posteriorly, alternating daily, each of the two fields receiving 500 r simultaneously every other day. Treatment was given over a period of twenty-five days, with three Sundays, on which no treatments were given, intervening; 5500 r were applied to each of the 4 skin areas. The tumor dose was 4598 r. Biopsies were made at weekly intervals and showed complete disappearance of the tumor within thirty-5ve days (Figs. 4 and 5). This patient is at present symptom-free. The

FIGS.2 AND 3. EPIDERMOIDCARCINOMA OF THE DOREUMOF THE LEFT HAND,BEFORE AND AFTER TREATMENTWITH THE 8INGLE SECTION RADIUMPACK There was an ulcerating lesion measuring 4 x 4 em. and involving the tendon sheaths cervix is hard and scarred. The uterus is freely movable, and there is no palpable involvement of the parametria. In the more deeply situated lesions, such as bladder, uterus, and rectum, the problem is more involved. Isodose charts for two or more fields from a radium pack clearly demonstrate that either the amount of radiation reaching a point at depth is, in a majority of cases, inadequate, or the time of treatment is so prolonged as to be almost prohibi- tive. In order to increase the intensity at a point at depth, the pack designed by Reinhard and Goltz was constructed. This pack seems to offer great possibilities in the healing of deep seated malignancies. This pack (Fig. 6) consists essentially of three separate and inde- pendent sections, so arranged as to radiate three separate skin areas simultaneously. Each contains 1.5 grams of radium, filtered by 1.0 mm. 1 The original description of this pack has been submitted to “Radiology” for publica- tion. FIQ.-4. A. v., NO. 21322, PHOTOMICROQRAPH 0%’ ORIQINAL BIOPSYSPECIMEN 8IIOWINO EPITHELIOMAOF CERVIX UTERI

FIQ.5. A. V., No. 21322, PHOTOMICROQRAPHOF BIOPSY SPECIMEN TAKEN THIRTY-FIVE DAYS AFTER THE BEQINNINQOF TREATMENTWITH THE TWO-FIELDRADIUM PACK, 8HOWINQ NO TUMORPRE6ENT

390 TELE-CURIE-THERAPY 39 1 platinum, distributed in a tray 3 X 6 cm., and radiates a skin area 5.0 X 9.0 em. at a radium skin distance of 10 cm. The secondary filter consists of 1.0 mm. copper and 1.0 mm. aluminum. The beams from the three sections are so angulated that the two outer beams converge on the middle beam below the surface of the skin. Due to this con- vergence there is a marked increase in the relative depth intensity over that of a single pack. This increase is greatest between 4 and 12 cm. below the surface (see Table I, columns 1 and 2 for the relative depth intensities from the three-section pack, compared with those from a single pack).

FIff. 6. THREE-CANNONPACK, SHOWING ARRANGEMENT OF FIELDS AND POSSIBLE ANQULATION OF TEE PACK AS A WHOLE The secondary filters were removed for this photograph

The accompanying isodose chart (Fig. 7) gives the ray distribution in the body, from the three-section pack. The intensity on the skin im- mediately beneath the center section is 69 r per gram hour. With the quantity of radium available in this pack, the rate of radiation is 1.72 r per minute, per field. While we have been using dosages of 400 to 500 r, delivered to each skin field, making a total of 1200 to 1500 r in a day, this may prove not to be the most desirable daily increment as we gain in experience. These treatments are planned so that treatment is continuous over a period of twenty-one to twenty-five days. Two case reports are given as examples of what can be accomplished by this method. 392 B. F. SCHREINER, M. C. EEINHARD, AND W. H. WEHR

II. B., No. 21545, white, male, aged forty-six, was admitted Nov. 5, 1934. Three years ago he had been treated for a bladder tumor. Since then he had had heniaturia st intervals, and this had incwased in the past three months. Cystoscopic examination revealed ulceration and thickening of the bladder wall. A diagnosis of an infiltrating carcinoma was made and confirmed microscopically. Six fields were treated, three anteriorly and three posteriorly, alternating daily, each of the three fields receiving 500 r simultaneously every other day. Treatment was given over a period of twenty-six daya with four Sundays intervening; 5500 r were applied to each of six fields. The tumor dose was 5060 r. At present the patient has no dysuria, frequency, or hcmaturia. The interior of the bladder is normal except for some scarring, two months after admission.

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FIQ. 7. ISODOBE CHART FOR THREE-SECTIONPACK

E. T., No. 21411, white, male, aged sixty-six, was admitted October 17, 1934. He had had an epidei-moid carcinoma removed from the anal ring in July 1933, and inguinal gland dissection in August 1933, with recurrence in September 1934, Examination showed an ulcerating, indurated lesion involving the anal ring; about 3 inches from the anal ring was a carcinoma of the rectum involving the lateral wall. Biopsy showed adenocarcinoma. Six fields were treated, three fields anteriorly and three fields posteriorly, alternating daily, each of the three fields receiving 400 r simultaneously every other day. Treatment covered a period of thirty days with four Sundays intervening; 5200 r were applied to each of the six fields. The tumor dose was 4641 P. Three months after admission there is no evidence of tumor tissue in the anal canal or rectum. TVe want to impress upon the reader that all the treatment given in these cases was external irradiation. We are justified in concluding, with the advancement of our knowl- edge of physical measurements and the biological reactions, that tele- curie-therapy has been increasingly beneficial.