Presurgical Irradiation in Bronchogenic Carcinoma, Superior Sulcus Type

Shaw, Paulson, and Kee (6) in 1961 reported that a review of the survival rates of patients with bronchogenic carcinoma of the superior sulcus type revealed only one five-year survival without disease. In addition, they quoted Pancoast (4) and Walker (7) as stating that this tumor was radioresistant and that irradiation was of no avail. Our experience with bronchogenic carcinoma, superior sulcus type, prior to 1956 was rather discouraging. The average survival following various forms of surgery, irradiation, and combinations of both, ranged from ten to fourteen months, with the longest time being twenty-seven months. These frustrating results stimulated us to explore avenues of therapy other than the conventional ones and led to a program both theoretical and empirical in concept and design. We have previously reported the results of this approach (5, 6). In the 24 proved cases reported in April 1962 (5) resection was done prior to September 1961 and a full two-year evaluation can therefore be made at this time. In addition, this report will include cases admitted since the last report and a review of our original rationale in light of the present results and recent experimental evidence in this area. Protocol The program originally designed in 1956 is still being used with no essential revision. Our study includes all patients with a clinical diagnosis of bronchogenic carcinoma, superior sulcus type. The therapeutic regime to be described is attempted in all patients with the exception of those with evidence of distant disease. We have based our procedure on three basic concepts as follows: I. No Biopsy of Lesion: It was our studied opinion that a biopsy should not be done. The rationale behind this decision was as follows: A. A biopsy violates the natural barriers preventing the spread of the disease, potentially increasing the risk of both local and distant dissemination. B. Interference with normal barriers adversely influences the radiotherapeutic response, perhaps on the basis of inflammation, decreased vascular supply, and interference with immune mechanisms. C. The pathological confirmation can be made from the surgical specimen, provided the dose of irradiation is not too high. D. A high degree of accuracy of clinical diagnosis is possible in this particular lesion. II. Irradiation Therapy: The irradiation therapy was designed to serve as an adjuvant, rather than a curative approach. The dosage was selected with three objects in view. A. To sterilize the peripheral portions of the tumor only. Thus failures due to surgical spread of cells and incomplete removal of small portions of the periphery might be eliminated. B. To allow for recognizable residual tumor in the center for pathological confirmation. C. To minimize the possibility of interference with surgical procedures and complications. Our standard approach is to give a midplane tumor dose of 3,000 rads in ten treatments over twelve elapsed days, utilizing simple parallel opposing-field technics.