Table Of ContentMEDICAL RADIOLOGY
Diagnostic Imaging and Radiation Oncology
Editorial Board
1. W. Brady, Philadelphia . M. W. Donner, Baltimore
H.-P. Heilmann, Hamburg . F. Heuck, Stuttgart
Radiation Therapy
of Benign Diseases
A Clinical Guide
Stanley E. Order and Sarah S. Donaldson
Foreword by
Luther W. Brady and Hans-Peter Heilmann
With 103 Tables
Springer-Verlag Berlin Heidelberg New York
London Paris Tokyo Hong Kong
STANLEY E. ORDER, MD, ScD, FACR
Director Radiation Oncology
The Johns Hopkins Hospital
Baltimore, MD 21205, USA
SARAH S. DONALDSON, MD, FACR
Professor of Radiation Oncology
Stanford University
School of Medicine
Stanford, CA 94305, USA
MEDICAL RADIOLOGY· Diagnostic Imaging and Radiation Oncology
Continuation of
Handbuch der medizinischen Radiologie
Encyclopedia of Medical Radiology
ISBN- 13: 978-3-642-97162-4 e-ISBN -13: 978-3-642-97160-0
DOl: 10.1007/978-3-642-97160-0
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Foreword
The radiation therapist's primary concern is the treatment of patients with malignant dis
ease. However, there are definite indications for radiation treatment for benign diseases
that do not respond to conventional methods of treatment. It may be the treatment of
choice in the unusual instance of a life-threatening benign disease that cannot be surgi
cally or medically managed.
The present volume by Order and Donaldson represents a major statement on the uti
lization of radiation techniques in the management of benign disease.
The initial report of the Committee on Radiation Treatment of Benign Disease from
the Bureau of Radiological Health recommended that consideration be given to the
quality of radiation, the total dose, overall time, underlying organs at risk and shielding
factors before the institution of radiation therapy. Infants and children should be treated
with ionizing radiation only in very exceptional cases and after careful evaluation of the
potential risk compared with the expected benefit. Direct irradiation of the skin areas
overlying organs that are particularly prone to late effects such as the thyroid, eye, go
nads, bone marrow, and breast should be avoided. Meticulous radiation protection tech
niques should be used in all instances and the depth of penetration of the x-ray beam
should be chosen in accordance with depth of the pathologic process'.
The present volume is based on the American literature and the experience of Ameri
can radiologists and represents a significant and important contribution in this critical
and significant area of disease processes. The data indicate that radiation therapy con
tinues to be an important part in the treatment of a large number of benign conditions
where the benefits may greatly outweigh the risks which are frequently minimal.
LUTHER W. BRADY HANS-PETER HEILMANN
Philadelphia Hamburg
Contents
Prologue ..... . 1
Acknowledgement . 2
Standard of Care . . 3
Preface, Guidelines 7
Abortion ..... . 9
Acne ....... . 9
Acromegaly with Adenoma . . . 10
Adamantinoma (Ameloblastoma) 10
Aneurysmal Bone Cysts . . . . . . 14
Angiofibroma of the Nasopharynx. 18
Ankylosing Spondylitis . . . . 20
Anovulation .......... . 26
Arteriovenous Malformations. . 26
Arthritis ........ . .. .... 28
Rheumatoid Arthritis . . . . 28
Arthritis Reviews ..... . 29
Astrocytoma (Grade I-II) . 31
Bowen's Disease ........... . 32
Bronchial Adenomas ..... . 35
Bursitis, Synovitis and Tendinitis . . . 43
CarCinoid ............................... . . . . . . . . . .. 52
Complications of Treatment in Pituitary Tumors . . . . . . . . . . 55
Chemodectomas (Non-Chromaffin Paragangliomas) ....... . 55
Chordoma ........................ . 63
Choroid Plexus Papilloma . ..... . 65
Craniopharyngioma . . . . . . . . . . . . 66
Cushing's Disease ............ . 67
Cystic Hygroma, Lymphangioma. 67
Desmoid-Aggressive Fibromatosis . 71
Dupuytren's Contracture ..... . 74
Epithelial Hemangioendothelioma . . . . ...... 76
Erythroplasia of Queyrat . . . . 77
Extramammary Paget's Disease 79
Fibrosclerosis. . . 83
Fungal Infections ....... . 83
Giant Cell Tumor ....... . 84
Gynecomastia (Prostate Cancer Managed with DES) 88
Hemangioma. 89
Herpes Zoster .100
VIII Contents
Heterotopic Bone Formation . . . . . . . . . . . . . . . . · 103
Histiocytosis . . . . . . . . . . . . . . . . . . . . . . . . . .104
Hypersalivation in Amyotrophic Lateral Sclerosis .... · 112
Hypersplenism ......... . · 112
Hyperthyroidism . . . . . . . . . . . . . . . . . . . . . . . . .116
Hyperthyroid Ophthalmopathy. . . . . . . . . . . . . . . . .125
Immunosuppression, Lupus Nephritis, Multiple Sclerosis,
and Organ Transplantation. ...... .... . .132
Infectious Disorders . . . . . . . . . . . . . . . . . . . . · 139
Inflammatory Conditions . . . . . . . . . . . . . . . . . · 142
Arachnoiditis, Tendinitis, Sinusitis, Thyroiditis . . . . · 142
Inverted Papilloma. .147
Keloid .............................. . · .147
Lethal Midline Granuloma . . . . . . . . . . . . . . . . . . . · . 153
Polymorphic Reticulosis/Lymphomatoid Granulomatosis ... 153
Lymphoid Hyperplasia - Pseudotumor · 156
Me~n~oma . . . . . . . . . . . . . . . . . . . . . . . · 157
Mikulicz Syndrome . . . . . . . . . . . . . . . . . . . · 158
Myasthenia Gravis and Thymus Gland Abnormalities · 161
Neurofibroma .......... . · . 165
Optic Nerve Glioma ....... . · . 165
Osteoblastoma/Osteoid Osteoma ..... . · . 168
Otitis Media . . . . .169
Pancreatic Fistulae . . . . . . . . . . . . . . . · .170
Pancreatitis . . . . . . . . . . . . . . . . . . . . · .170
Paraganglioma (Chromaffin Positive) .... . · . . . . . ......... 170
Parotitis ...................... . · ................... 172
Peptic Ulcer ................... . · . . . . . . . ......... 175
Perifolliculitis Capitis Abscedens et Suffodiens . . . . .. . .. 179
Peyronie's Disease . · 180
Pinealoma ..... . · 185
Pituitary Adenomas . · 186
Plantar Fibromatosis . · 188
Plasmacytoma (Solitary) . · 189
Pterygium ........ . · 195
Pyogenic Granuloma .. .200
Salivary Gland Adenoma .200
Sarcoidosis . . . . . . . .201
Skin Disorders . . . . . .202
Therapeutic Castration .206
Thymus .. . .208
Tinea ... . .208
Tonsillitis . . .210
Tuberculosis · 211
Xanthoma . .212
Subject Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
Prologue
The purpose of this text is to provide a functional begins with a brief resume which is followed by ci
workbook for the radiation oncologist who faces on tations of pertinent literature both in explanatory
occasion rare, non-malignant disorders. The scarci tables and reference lists. The use of rad and Roent
ty of disease incidence is reflected in the paucity of gen is indiscriminately designated in the literature
reference for these diseases in the literature. This and the reviewers indicate to readers their need to
minimal exchange of information may make re read original scripts if such distinction is necessary.
search and analysis difficult, tedious and not easily An index is also provided to facilitate reference
directed. Through the cooperation of the American access. The resvlts of the survey, jointly conducted
College of Radiology 834 radiation oncologists by The American College of Radiology and the In
were canvassed in a national survey regarding treat ter Society Council for Radiation Oncology
ment of these benign disorders. Although benign by (lSCRO), are included for each of the disorders as
nomenclature, benign disorders may have grave they are reviewed. This book, although utilizing Eu
consequences, or even be malignant. Further confu ropean literature where appropriate, represents the
sion is created by more than a single nomenclature view of American radiation oncology in regard to the
for a given disorder. For example, asked if they management of benign diseases, including the medi
would treat polymorphic reticulosis, 86% of the on cal legal aspects of such therapy.
cologists surveyed were unwilling to treat the disor Many novel applications of radiation will chal
der. When asked, however, if they would treat le lenge our thoughts in the future. Even as this text
thal midline granuloma, only 17% of these radia goes to press, consideration of early radiotherapy
tion oncologists would not treat the disorder. for treatment of paraquat poisoning, for example,
Polymorphic reticulosis and lethal midline granulo has recently been discussed (Br J Radiology 61:
ma are the same disorder. In addition to nomencla 405, 1988). These investigators conclude that con
ture problems, decision making is rendered even trolled trials following identification of the subsets
more complicated for the radiation oncologist by at risk should be conducted to determine the bene
the relative rarity of these benign disorders. Unfa fit of adding radiotherapy to treatment protocols.
miliarity with sarcoid, for example, leads 92% of ra The conduct and documentation of controlled trials
diation oncologists to be unwilling to treat the dis for benign disorders would help greatly in the radi
order, while the literature, in fact, indicates that in ation oncologist's decision making. A general con
life-threatening situations, treatment may be appro sensus that radiation of tendinitis, bursitis and syn
priate and beneficial. ovitis provides benefit, for example, has no substan
The text begins with Standard of Care, a discus tiation in the literature and randomized trials now
sion of guidelines for the treatment of benign disor indicate no benefit accrues from treatment. We
ders, especially when treatment must take into ac must insist upon controlled trials for the radiation
count long-term effects and risk-benefit analysis. of benign disorders where questions of efficacy
The various benign conditions follow this introduc arise, as we do for more conventional radiation on
tory discussion in alphabetical order. Each disease cology.
Acknowledgement
We wish to acknowledge the leadership provided Marvin Elfin, LLB
by the American College of Radiology through the
efforts of Mr. John Curry and James Diamond, Marvin Ellin was born in Baltimore, Maryland. He
Ph.D., as well as the dedicated assistance of Su attended college at the University of Baltimore and
zanne Bohn, who in conjunction with the Inter So graduated from its Law School in 1953. He was ad
ciety Council for Radiation Oncology (ISCRO), mitted to the Bar the same year. Mr. Ellin is a spe
aided in coordinating and carrying out the exten cialist in medically related trials, and has repre
sive mailings, the collection and the preparation of sented surgeons and physicians who themselves
data for the National Survey for the Radiation suffered injury through professional negligence. He
Therapy of Benign Diseases. Marvin Ellin, an out has written and lectured at law schools, medical as
standing malpractice lawyer, presents the Standard sociations and hospitals on professional malprac
of Care section in lucid terms that should greatly tice and the prevention of patient injury. He was
aid those of us practicing radiation oncology. Two one of the first trial lawyers to utilize experts from
residents from Johns Hopkins, Drs. Catherine outside the United States, and has secured expert
North and Clinton Leinweber, contributed sections witness participation from specialists in England,
on bronchial adenoma and extramedullary hema Italy and Canada. He is admitted to practice before
topoiesis, respectively. Thanks to Mrs. Laverne Fair the Supreme Court of the United States, the Fourth
and Mrs. Edna Maciejczyk for the continual assis Circuit Court of Appeals, the Federal District
tance in the secretarial tasks. Finally, we extend our Court of Maryland, and the Court of Appeals of
most sincere appreciation to William L. Clark Maryland. He has previously served as an officer of
whose editorial assistance has been invaluable. the Bar Association and has frequently participated
as a lecturer in the continuing education series fea
tured by the American Bar Association, the City
and State Bar. In the chapter that follows, Mr. Ellin
shares his opinions regarding the proper applica
tion of standards of care in the radiation therapy of
benign disorders.
Standard of Care
Malpractice plaintiff, or that in his treatment of the plaintiff he
failed to exercise the care and skill ordinarily pos
The appellate courts have defined malpractice as sessed and exercised by others in the profession.
the failure of a practitioner to give and to exercise Although the Defendant was alleged to have deviat
that degree of care as would be practiced by a rea ed from acceptable standards by excessive radiation
sonably competent practitioner under the same or therapy given at too frequent intervals, the qualifi
similar circumstances. Simply stated, the appellate cations of the Defendant were not challenged by
courts have recognized the existence of standards of the Plaintiff. The Court found that the Defendant
care followed by competent specialists in the var did conform to the requisite standards of care in the
ious fields. Thus, malpractice is found where a pa administration of radiation treatment. The Court
tient's injury or death occurs as a result of a physi further noted that the testimony established that
cian's failure to use diagnostic and/or treatment even the exercise of the "highest degree of skill and
methods which would be followed by the majority care" may not avoid an adverse reaction by the pa
of competent physicians in the same field. tient. Thus, the Hazen case set the principle as early
as 1929 that, ultimately, the medical profession es
Standard of Care tablishes its own standard of care. The standard is
not one able to be determined by a judge or jury,
As applied to the specialty of radiation therapy, a since any court and jury would require the medical
therapist who renders radiation care must conform expert evaluation of the treatment modality and
to the standards which generally prevail in the spe treatment rendered in order to determine standard
cialty. Hazen v. Miller F.2d 394 (D.C. Cir., 1929) is of care. The fact that a patient suffers injury raises
an early case that demonstrates the medical profes no implication of negligence in most jurisdictions.
sion's establishment of standards of care. The ac Moreover, res ipsa loquitur, that is to say, "the inju
tion was brought by a patient who maintained that ry speaks for itself," which would establish a sug
she suffered severe injury due to radiation overex gestion of negligence, has been rejected, unless un
posure. The appellate court reversed the jury's usual circumstances occurred.
award to the patient of $15,000 and stated:
It is conceded that Dr. Hazen possessed the requisite
degree of skill and ability; that x-ray treatment was Negligence by Technical Error
the recognized treatment for tubercular glands; it
clearly appears that the length of time between expo Through error while applying 800 rad of electron
sures of the same area depends upon existing condi beam therapy to a patient, a technician adjusted the
tions and the judgment of the operator; that telan machine to 80,000 rad. The patient manifested
giectasis may occur even if the highest skill is burns of such intensity that under those circum
exercised in the treatment. stances it could not be said that the patient had an
Moreover, this decision contained the following adverse reaction or an idiosyncratic response to the
statement of law important to the issue of standards treatment rendered. It would follow that, absent the
of care: admission that the therapy had exceeded its in
As already observed, there is no evidence upon which tended dosage by 100 times, the extent and nature
it reasonably may be found that Dr. Hazen did not of the injury in such an extreme case would indi
exercise his best judgment and ability in treating the cate negligence.
4 Standard of Care
Individual Standards for the Specific Patient for the primary site had been without success, rec
ommended a biopsy of one of the lesions, if possi
Although the specialist must adhere to the stan ble. The radiotherapist noted that he would pro
dards of radiation therapy that prevail across the ceed with radiotherapy of 3600 rad over a period of
country, he is not deprived of utilizing his own par two and one-half weeks, if the biopsy were not able
ticular technique. Indeed, freedom in the exercise to be performed. Steroids continued to be adminis
of treatment may be pursued so long as the special tered to control the worsening symptoms. Some evi
ist's approach does not violate the safeguards and dence of improvement was noted. On April 19, a
the advances developed in the specialty and utilized neurosurgery consultation was obtained to evaluate
by colleagues under the same or similar circum the patient for a brain biopsy prior to radiotherapy.
stances. The neurosurgeon recommended that radiation
therapy and chemotherapy proceed without a brain
biopsy:
Negligence in Medical Judgment I do not feel that the risk of biopsy is indicated in this
patient in that there is no chance for surgical cure and
Carver v. The United States of America, 587 F. bilateral multiple lesions are likely metastasizing,
Supp. 794 (N.D., Cal. 1984) provides an example of though primary Res [reticulum cell sarcoma] of the
a medical malpractice action brought under the brain is a reasonable differential. Multiple abscesses
Federal Tort Claims Act. The action alleged that would likely be very positive on brain scan, as well as
physicians at a U.S. Army Medical Center had neg show surrounding inflammatory edema and shift.
ligently subjected patient Carver to radiotherapy, Prior to radiotherapy a third CT scan was per
thereby causing brain tissue damage. The history of formed on April 24. That scan was interpreted to
the case is as follows: show progression of the metastases observed on the
On April 1, 1979, the 56 year old patient was ad prior scan. Radiotherapy was begun the same day.
mitted to Letterman Army Medical Center with By April 26 the patient had improved. Radiation
complaints of staggering gait, clumsiness, left was completed on May 9 and another CT scan that
handed weakness, slurred speech and personality date showed improvement. The patient was dis
change. After one inconclusive CT scan, the patient charged on May 12, 1979.
was sent to the University of California Medical Following his discharge the patient lived at
Center for a second CT scan performed by a promi home. He gradually grew weaker. In late 1979 and
nent neuroradiologist. The CT scan was reported to early 1980 he was again admitted to Letterman Ar
indicate that the most likely diagnosis was multiple my Medical Center. In 1980 he was diagnosed as
metastatic neoplasm. possibly having multiple sclerosis. His physical and
Subsequently, an extensive work-up that in mental condition continued to deteriorate and he
cluded liver and spleen scan, lung tomograms, an was eventually placed in a convalescent home.
IVP, sigmoidoscopy, bronchoscopy and a bone The United States District Court of Appeals for
scan, failed to reveal the primary site of the cancer. the Northern District of California held that the
Consultations were also obtained with cardiology, Plaintiff failed to sustain the burden of proof by a
hematology-oncology, nuclear medicine, radiother preponderance of the evidence that the physicians
apy, neurosurgery, pathology, proctology, as well as failed to conform to the standard of care in pre
the diabetic and immunization clinics. During this scribing and administering radiotherapy. As this
period of search for the primary site, April 3 was a Federal Tort Claims case, the physicians indi
through April 23, the patient's condition steadily vidually were not Defendants in the suit. The Plain
declined. He had attacks of nausea and dizziness tiff in Federal Tort Claims cases is limited to a court
that were accompanied by ECG changes. He devel trial by judge without a jury.
oped diplopia which continued for three days and The Appeals Court held that the physicians exer
necessitated the use of Decadron. On April 11, the cised judgment involving a serious disease process.
patient developed hiccups and the dose of Deca Further, when weighing the possible benefits
dron was increased. The patient eventually received against the possible risks, the suit amounted to
Thorazine in an attempt to control his hiccups. nothing more than an ex post facto attack on the ex
From April 16 to 18, the patient continued to de ercise of medical judgment. The case was dismis
cline. He was considered for palliative radiother sed.
apy; a radiotherapy consultation was requested.
The radiotherapist, noting that the extensive search
