Extensive soft tissue resection with autologous tissue closure for locally recurrent breast cancer: Lasting local control and acceptable morbidity

Introduction

Locoregional breast cancer recurrence can be detected at an advanced stage of the disease. To achieve local control for these larger local breast cancer recurrences, wide soft tissue resections with autologous tissue coverage of the defect is an option. The aim of this study was to assess the local control and morbidity of surgical salvage of patients with advanced local breast cancer recurrence using autologous tissue closure of the defect.

Material and methods

Eighty-eight patients were treated with wide soft tissue resections with autologous tissue coverage from 1993 to 2006. Two different operating techniques were used for closure of the defect; transposition of the greater omentum covered with split skin graft and the latissimus dorsi musculo-cutaneous flap. Demographic, treatment and mortality information were retrieved from original patients' files.

Results

Postoperatively 10 patients (11%) developed complications which required an additional operation. In patients treated with curative intent (n = 67) median disease-free interval after extensive surgery was 24 months and median survival was 45 months. In 42 patients (47% of all included patients) the first recurrence after extensive surgery was a locoregional relapse. The two surgical techniques did not differ in overall survival (p = 0.739) and local control.

Conclusion

Large soft tissue resection for extensive local relapse of breast cancer may result in lasting local control in half of the patients with acceptable morbidity.     

Challenging a dogma – Surgery yields superior long-term results for T1a squamous cell carcinoma of the glottic larynx compared to radiotherapy

Aims

The aim of this study was to compare laser surgery, conventional endoscopic surgery and radiotherapy in the treatment of early T1a glottic cancer.

Methods

We conducted a retrospective analysis of patients with early vocal cord cancer (who underwent either conventional surgery via endoscopy or laryngofissur, or primary radiotherapy) at the Medical University of Vienna. By univariate and multivariate Cox regression models the influence of treatment and other parameters on survival and locoregional control were analysed.

Results

337 Patients were analyzed with a mean follow-up period of 133.8 months. Overall survival rates where similar in all three treatment groups. Five-year, 10-year and 15-year estimates of disease specific survival for laser-treated patients were 100%, for conventional surgery were 100%, 98% and 98%, and for radiotherapy were 96%, 92% and 91%, respectively. Locoregional recurrences were observed after laser surgery in 10%, after conventional surgery in 13% and after radiotherapy in 30% of the patients treated. According to the log-rank test, time to relapse was significantly shorter for irradiated patients compared to patients who underwent surgery (p < 0.0001). Mortality caused by the laryngeal tumour was significantly higher in the radiotherapy group (p = 0.003).

Conclusion

Patients undergoing laser or conventional surgery have a significantly lower incidence of locoregional recurrences and longer disease-free intervals when compared to patients treated by radiotherapy.     

Equivalent survival in patients with advanced stage IB–II and III–IVA cervical cancer treated by adjuvant surgery following chemoradiotherapy

Objectives

To evaluate survival in patients with advanced cervical cancer who underwent surgery after concurrent chemoradiotherapy.

Methods

One hundred and forty-four patients with biopsy-proven stage IB–IVA cervical cancer underwent adjuvant surgery after concurrent chemoradiotherapy. Surgical resection was classified as curative (no evidence of remaining disease after surgery) or palliative (remaining disease after surgery). Endpoints were pelvic control, overall survival (OS) and disease-free survival (DFS) at 5 and 10 years. Analysis included tumour FIGO stage, type of surgery (curative versus palliative), pelvic control, response to chemoradiotherapy and lymphatic status.

Results

Tumour FIGO stages were IB–II in 91 cases and III–IVA in 53 cases. Surgery was curative in 127 cases. Pelvic control was achieved in 114 patients and was equivalent in stage IB–II and III–IVA patients. So far, 60 patients have died. The 5-year OS and DFS rates were, respectively, 57.6% [95% CI: 49.1–67.5] and 65% [95% CI: 56.2–75]. OS was significantly affected by the type of surgery (p < 2.10⁻¹⁶), the presence of tumoural residue (p = 0.002) and the pelvic lymphatic status (p < 0.001). DFS was affected by the pelvic (p = 0.02) and para-aortic lymphatic status (p = 0.009). No significant difference was observed between OS and DFS in stage IB–II and III–IVA patients, whereas a macroscopic tumoural residue was observed in, respectively, 30.9 and 52.2% of cases (p = 0.022).

Conclusion

Survival rates were equivalent between patients with IB–II and III–IVA cervical cancer, suggesting that adjuvant surgery following chemoradiotherapy may improve local control.     

A nomogram to predict loco-regional control after re-irradiation for head and neck cancer

Background and purpose

Loco-regionally recurrent head and neck cancer (HNC) in the setting of prior radiotherapy carries significant morbidity and mortality. The role of re-irradiation (re-RT) remains unclear due to toxicity. We determined prognostic factors for loco-regional control (LRC) and formulated a nomogram to help clinicians select re-RT candidates.

Material and methods

From July 1996 to April 2011, 257 patients with recurrent HNC underwent fractionated re-RT. Median prior dose was 65 Gy and median time between RT was 32.4 months. One hundred fifteen patients (44%) had salvage surgery and 172 (67%) received concurrent chemotherapy. Median re-RT dose was 59.4 Gy and 201 (78%) patients received IMRT. Multivariate Cox proportional hazards were used to identify independent predictors of LRC and a nomogram for 2-year LRC was constructed.

Results

Median follow-up was 32.6 months. Two-year LRC and overall survival (OS) were 47% and 43%, respectively. Recurrent stage (P = 0.005), non-oral cavity subsite (P < 0.001), absent organ dysfunction (P < 0.001), salvage surgery (P < 0.001), and dose >50 Gy (P = 0.006) were independently associated with improved LRC. We generated a nomogram with concordance index of 0.68.

Conclusion

Re-RT can be curative, and our nomogram can help determine a priori which patients may benefit.     

Anastomotic leakage as a risk factor for the long-term outcome after curative resection of colon cancer

Aims

Long-term outcome for curative colon cancer surgery may be impaired by anastomotic leakage, but most studies regard colon and rectal cancer patients as one group. The aim of this study was to determine whether anastomotic leakage following potentially curative resection for colon cancer is a risk factor for postoperative mortality and for long-term survival.

Patients and methods

Medical records of a cohort of 440 consecutive patients undergoing 445 curative resections for explicit colon cancer with primary anastomosis above the peritoneal reflection were reviewed. Therefore patients with rectal cancer were not included. Diagnosis of leakage was made by clinical features or abdominal CT-scans.

Results

The study population consisted of 266 men and the mean age was 68.6 years. Median follow-up time was 66.5 months. Anastomotic leakage occurred in 12 patients. Four of these died within 30 days after surgery compared to 15 of the remaining 428 patients without leakage (p < 0.001). The 5-year overall survival rate was 25% in patients with anastomotic leakage compared to 61.2% in those without leakage (p < 0.001). Excluding 30-day mortality, respective values were 33.3 and 63.7% (p = 0.02).

Conclusion

Although anastomotic failure after colon cancer surgery is rare, it is a very severe complication that not only impairs the perioperative morbidity and mortality but also significantly influences the long-term outcome negatively.     

Population-based outcomes of boost versus salvage radiosurgery for brain metastases after whole brain radiotherapy

Purpose

We conducted a retrospective population-based study to examine the survival outcomes in patients with brain metastases treated with salvage stereotactic radiosurgery (SRS), compared to boost SRS, after previous whole brain radiotherapy (WBRT).

Methods and materials

From January 2000 to June 2011, 191 patients treated with WBRT and SRS for brain metastases in British Columbia were studied. Patients were divided into a boost cohort and a salvage cohort. The criteria used to determine eligibility for SRS were: 1–3 metastases, ?4 cm size, Karnofsky performance status ?70, and control of extracranial disease.

Results

Diagnosis by primary site was 84 lung, 47 breast, 15 melanoma, 12 renal, 9 colorectal, and 24 other. There were 113 patients (59%) in the boost cohort and 78 patients (41%) in the salvage cohort. The median overall survival from WBRT for the whole population was 17.7 months: 12.1 months for the boost cohort and 22.7 months for the salvage cohort. There was no difference in median survival after SRS for the boost and salvage cohorts (11.2 vs. 11.2 months, p = 0.78).

Conclusions

In selected patients with brain metastases treated with WBRT, survival following salvage SRS is as good as survival after WBRT + boost SRS.     

Post-chemoradiation intraoperative electron-beam radiation therapy boost in resected locally advanced rectal cancer: Long-term results focused on topographic pattern of locoregional relapse

Background

Patients with locally advanced rectal cancer (LARC) have a dismal prognosis. We investigated outcomes and risk factors for locoregional recurrence (LRR) in patients treated with preoperative chemoradiotherapy (CRT), surgery and IOERT.

Methods

A total of 335 patients with LARC [?cT3 93% and/or cN+ 69%) were studied. In multivariate analyses, risk factors for LRR, IFLR and OFLR were assessed.

Results

Median follow-up was 72.6 months (range, 4–205). In multivariate analysis distal margin distance ?10 mm [HR 2.46, p = 0.03], R1 resection [HR 5.06, p = 0.02], tumor regression grade 1–2 [HR 2.63, p = 0.05] and tumor grade 3 [HR 7.79, p < 0.001] were associated with an increased risk of LRR. A risk model was generated to determine a prognostic index for individual patients with LARC.

Conclusions

Overall results after multimodality treatment of LARC are promising. Classification of risk factors for LRR has contributed to propose a prognostic index that could allow us to guide risk-adapted tailored treatment.     

Evidence for a synchronous operative approach in the treatment of colorectal cancer with hepatic metastases: A case matched study

Background

Traditionally, a staged operative approach has been used for patients with synchronous colorectal cancer and liver metastases in the U.K. With improved outcomes from hepatic resection the role of a synchronous operative approach needs re-evaluated.

Methods

32 consecutive patients with colorectal cancer and hepatic metastases that underwent a synchronous operative approach were individually case matched (according to: age; sex; ASA grade; type of hepatic and colonic resection) with patients that had undergone a staged approach. The following variables were analysed: operative blood loss; in hospital morbidity and mortality; duration of hospital stay; disease free and overall survival.

Results

Operative blood losses were: synchronous group, median 475 mL (range 150–850 mL) vs median 425 mL (range 50–1700 mL), (p > 0.050). There were no significant differences in morbidity: (34% synchronous group vs 59%, p = 0.690) with no recorded mortality. Synchronous group had a shorter hospital stay (median 12 days [range 8–21] vs 20 [range 7–51], p = 0.008). There were no statistical differences between synchronous and staged patients for disease free and overall survival: 10 months (95% CI 5.8–13.7) versus 14 (95% CI 12.2–16.3; p = 0.487) and 21% versus 24% at 5 years (p = 0.838).

Conclusion

This present study provides supporting evidence for synchronous operative procedures in patients with colorectal liver metastases.     

Melanoma of the anorectal region : The experience of the National Cancer Institute of Milano

Aims

This study describes the experience of the National Cancer Institute of Milano in the treatment of anorectal melanoma over the last 32 years.

Methods

The influence of different surgical approaches on local care and final outcome was investigated on 40 completely evaluable patients, followed for a median follow-up time of 75 months. The analysis was carried out by calculating and comparing overall survival, disease-free survival and cumulative incidence curves of disease recurrence.

Results

Thirty-one patients underwent radical surgery: nine abdominoperineal resections, four total rectal resections and coloendoanal anastomosis, and 18 local excisions. The remaining nine patients received palliative treatments. Median overall survival time for patients receiving non-radical treatments was poor: only 6 months. However, even when a radical surgery was undergone, the prognosis of patients with anal melanoma remains dismal. Local relapse incidence was 45.8% for the limited surgery group, but non-existent for the extended-surgery group (p = 0.007). However, the median disease-free survival time was 7 and 9 months for patients receiving limited or major surgery (p = 0.97). Overall survival was 17 months, irrespective of the adopted surgery.

Conclusion

Prognosis of anal melanoma remains poor. Final outcome is not influenced by modality of surgery. A limited but radical excision can be considered whenever possible while a major demolitive surgery should be applied only for therapy of advanced or bulky lesions.     

Neoadjuvant chemoradiation and pancreaticoduodenectomy for initially locally advanced head pancreatic adenocarcinoma

Background

The most accepted treatment for locally advanced pancreatic adenocarcinoma (LAPA) is chemoradiotherapy (CRT). We sought to determine the benefit of pancreaticoduodenectomy (PD) in patients with LAPA initially treated by neoadjuvant CRT.

Methods

From January 1996 to December 2006, 64 patients with LAPA (borderline, n = 49; unresectable, n = 15) received 5-fluorouracil-cisplatin-based CRT. Of the 64 patients, 47 had progressive disease at restaging. Laparotomy was performed for 17 patients, and PD was performed in 9 patients (resected group). Fifty-five patients had CRT followed by gemcitabine-based chemotherapy (unresected group).

Results

The median survival and overall 5 years survival duration of all 64 patients were 14 months and 12%, respectively. The mean delay between diagnosis and surgical resection was 5.5 months. Mortality and morbidity from PD were 0% and 33%, respectively. The median survival of the resected group vs. the unresected group was 24 months vs. 13 months. Three specimens presented a major pathological response at histological examination. No involved margins were found and positive lymph nodes were found in one patient. Resected patients developed distant metastases.

Conclusions

PD after CRT was safe and resected patients had interesting survival rates. However, resected patients developed metastatic disease and new neoadjuvant regimens are needed to improve the survival of these patients.     

Procedure volume of gastric cancer resections versus 5-year survival

Aim

We used nationwide, population-based data to examine associations between hospital and surgeon volumes of gastric cancer resections and their patients’ short-term and long-term survival likelihood.

Methods

The study uses 1997–1999 inpatient claims data from Taiwan's National Health Insurance linked to “cause of death” data for 1997–2004. The total cohort of 6909 gastric cancer resection patients were categorized by their surgeon's/hospital's procedure volume, and examined for differences in 6-month mortality and 5-year mortality (post 6 months), by procedure volume, using Cox proportional hazard regressions, adjusting for surgeon, hospital and patient characteristics. We hypothesized that surgeons’ case volume and age but not hospital volume will predict short-term and long-term survival.

Results

Adjusted estimates show that increasing surgeon volume predicts better 6-month survival (adjusted mortality hazard ratio = 1.3 for low-volume surgeons relative to very high-volume surgeons; p < 0.01) and 5-year survival (adjusted mortality hazard ratios = 1.3; p < 0.001 for low-volume; 1.2 with p < 0.01 for medium volume) and increasing surgeon's age (adjusted hazards ratio = 1.4 for age < 41 years relative to 41–50 years; p ≤ 0.001; 0.8 for ≥51 years relative to 41–50 years; p < 0.05). In hospital volume regressions, surgeon's age is a consistent and significant predictor, not hospital volume. Findings suggest a key role of experience in surgical skill and sensitivity for early stage diagnosis in gastric cancer survival.

Conclusions

Although a key study limitation is the lack of cancer stage data, the pattern of findings suggests that experienced surgeons have relatively better survival outcomes among gastric cancer patients.     

Cetuximab in combination with chemoradiotherapy in Chinese patients with non-resectable,locally advanced esophageal squamous cell carcinoma: A prospective,multicenter phase II trail

Background and purpose

This multicenter phase II trial investigated cetuximab combined with chemoradiotherapy in patients with esophageal squamous cell carcinoma (ESCC).

Material and methods

Eligible patients with non-resectable, locally-advanced ESCC received cetuximab 400 mg/m² loading dose on day 1; and on day 1 of the 2nd–7th weeks: cetuximab 250 mg/m², paclitaxel 45 mg/m², and cisplatin 20 mg/m², concurrent with 59.4 Gy/33 fractions of radiation therapy. Primary endpoint was clinical response rate. Secondary endpoints included overall survival (OS), progression-free survival (PFS), safety, and KRAS status.

Results

Of 55 patients enrolled, 45 completed therapy. Forty-four patients had a clinical response: 29 complete response and 15 partial response. One-year PFS and OS of 45 evaluable patients were 84.23% and 93.33%, respectively, and 2-year PFS and OS were 74.87% and 80.00%, respectively. Non-hematologic adverse events were generally grade 1 or 2; primarily rash (92.7%), mucositis (45.5%), fatigue (41.8%), and nausea (38.2%). Grade 3 hematologic adverse events included neutropenia (32.7%) and anemia (1.8%). No KRAS mutations were identified in 50 evaluated samples.

Conclusions

Cetuximab can be safely administered with chemoradiotherapy to patients with locally-advanced ESCC and may improve clinical response rate.     

Effect of preoperative chemotherapy on liver resection for colorectal liver metastases

Aim

To compare the effects of preoperative chemotherapy on liver parenchyma morphology, as well as morbidity and mortality after liver resection for colorectal liver metastases.

Methods

Prospectively collected data on 173 patients undergoing liver resection for CLM between 1/2003 and 9/2005 was analysed in three groups: A: preoperative oxaliplatin (Ox, n = 70); B: other chemotherapeutic agents (OC, n = 60); and C: surgery alone without chemotherapy (SA, n = 43). Blood transfusion, hospital stay, operative procedure, peak postoperative bilirubin levels, complications and histopathology of the resected liver were compared.

Results

Intra-operative blood transfusion requirement (34%) and biliary complications (16%) was higher in patients receiving oxaliplatin-based chemotherapy (p = 0.01 and p = 0.06, respectively). Oxaliplatin-based chemotherapy was also associated with sinusoidal dilatation of mild grade in 52.8% vs. 26.6% and 23.3% patients (p = 0.007 and p = 0.004) in other groups, respectively. Steatosis was similarly distributed across the study group. Postoperative mortality was 2, 1 and 4 patients, respectively (p = ns).

Conclusion

Oxaliplatin-based preoperative chemotherapy is associated with vascular alterations in the liver parenchyma without significantly increasing the risk of steatosis, or postoperative morbidity and mortality.     

Stereotactic radiotherapy of benign meningioma in the elderly: Clinical outcome and toxicity in 121 patients

Background and purpose

To investigate the outcome of definitive stereotactic-based radiotherapy in elderly patients (?70 years of age) with benign intracranial meningiomas.

Materials and methods

121 patients were treated with either fractionated stereotactic radiotherapy (FRTS; n = 74), hypofractionated FSRT (hFSRT; n = 35) or stereotactic radiosurgery (SRS; n = 12), depending on tumor size and location. Local control (LC), overall survival (OS), cause-specific survival (CSS), symptomatology and acute and late toxicity were assessed. The prognostic value of factors such as age, sex, tumor location, Karnofsky performance scale, target volume and radiotherapy schedule was examined.

Results

The median follow-up was 40 months (range, 12–124 months). LC, OS and CSS at 3 years were 98.3%, 92% and 99% and at 5 years they accounted 94.7%, 79% and 94.3%, respectively. We failed to identify any significant prognostic factor for outcome. Only Grade I–II toxicity was observed, whereas no new neurologic deficits or treatment-related mortality were encountered.

Conclusion

This is the first study to assess the outcome following radiotherapy in elderly patients with intracranial meningiomas. The high local control, the low toxicity and the lack of treatment-associated mortality make stereotactic radiotherapy an attractive option in an age population where neurosurgery is often correlated with some mortality.     

Significance of tumor recurrence before pulmonary metastasis in pulmonary metastasectomy for soft tissue sarcoma

Background

Resection for pulmonary metastasis from soft tissue sarcomas is an accepted method for treatment, but it is still debatable which patients will benefit from surgical intervention. To find an entity of patients benefiting from pulmonary metastasectomy, we reviewed our institutional experience.

Methods

Between 1990 and 2007, 23 patients with pulmonary metastases from soft tissue sarcomas underwent complete pulmonary resection. All patients had obtained locoregional control of their primary tumors. Various perioperative variables were investigated retrospectively to confirm the role of pulmonary metastasectomy and to identify possible prognostic factors for survival after metastasectomy.

Results

Overall survival rate after metastasectomy was 43% and 29% at 5 and 10 years, respectively. Disease-free survival rate was 9% at 1 year after pulmonary resection. On multivariate analysis, no tumor recurrence (neither locoregional recurrence nor extrapulmonary metastasis) before pulmonary metastasis provided a significantly favorable overall survival (P = 0.038). In addition, repeat metastasectomy for recurrent pulmonary metastasis also provided a favorable overall survival (P = 0.041).

Conclusions

Our data suggested that patients most likely to benefit from pulmonary metastasectomy for soft tissue sarcoma have no tumor recurrence before pulmonary metastasis. Furthermore, patients with repeat metastasectomy for recurrent pulmonary metastasis also presented a significantly longer survival.     

Advanced gastric cancer with or without peritoneal carcinomatosis treated with hyperthermic intraperitoneal chemotherapy: A single western center experience

Introduction

The aim of this article was to evaluate the role of hyperthermic intraperitoneal chemotherapy (HIPEC), associated or not to cytoreductive surgery (CS) in the treatment of different stages of advanced gastric cancer (AGC).

Patients and methods

Thirty seven patients with AGC who underwent 43 HIPEC from June 1992 to February 2007 were included. HIPEC used Mitomycin-C and Cisplatin for 60–90 min at 41–43 °C intra-abdominal temperature. The main endpoints were long-term survivals, morbidity and mortality rates.

Results

Eleven patients had no demonstrable sign of PC and constituted the Prophylactic-group, while 26 patients had macroscopic PC (PC-group). Five patients were Gilly 1 or 2 (nodules <0.5 cm) and 21 Gilly 3 or 4 (nodules ≥0.5 cm). In the PC-group a complete curative CS was achieved before HIPEC in 8 (PC-curative subgroup) and a palliative HIPEC in 18 patients (PC-palliative subgroup). The overall 30-days mortality was 5% (2 patients). Two patients in the Prophylactic group died within 6 months after hospital discharge (overall mortality 11%). The estimated risk of death per procedure was 9%. Ten patients (27%) presented one or more complications. The median survival was 23.4 months in the Prophylactic group, and 6.6 months in the PC-group (p < 0.05). The median survival in the PC-curative subgroup was 15 vs 3.9 months in the PC-palliative subgroup (p = 0.007). The median survival according to Gilly classification was significantly different (Gilly 1&2 vs Gilly 3&4, 15 vs 4 months respectively, p = 0.014). The global recurrence rates between the Prophylactic group and the PC-curative subgroup at 2 years were 36% vs 50% respectively. The median delay to recurrence was 18.5 vs 9.7 months respectively.

Conclusion

HIPEC might be useful to improve the survival in selected patients with ACG only when a complete cytoreduction can be achieved. Despite encouraging data, prospective studies, based on larger cohorts of patients are required to assess the role of this procedure as a prophylactic treatment in patients with AGC.     

Adjuvant chemoradiotherapy with or without intraoperative radiotherapy for the treatment of resectable locally advanced gastric adenocarcinoma

Purpose

To document the long-term efficacy of intraoperative electron radiotherapy (IOERT) followed by concurrent chemotherapy and external-beam radiotherapy (EBRT) in the management of locally advanced gastric cancer.

Materials and methods

A total of 97 consecutive patients with T3/4 or N+ gastric adenocarcinoma were enrolled. Fifty-one patients received adjuvant chemoradiotherapy (EBRT group) and 46 received IOERT (dose range, 12-15 Gy) followed by chemoradiotherapy (EBRT + IOERT group).

Results

The 5-year locoregional control rates were 50% and 35% in the two groups with or without IOERT, respectively (p = 0.04). Two patients had recurrence within the IOERT field in the EBRT + IOERT group and 14 patients recurred in the same area in the EBRT group (p = 0.02). Multivariate analyses revealed that adjuvant IOERT was an independent prognosticator for both local-regional control (p = 0.02) and disease-free survival (p = 0.05). G3/4 late toxicity was observed in 5 patients in the EBRT + IOERT group, but none in the EBRT group (p = 0.02).

Conclusions

Higher radiation dose may contribute to the improvement of local control, especially in the field encompassed by IOERT. The addition of IOERT to surgery and adjuvant chemoradiation deserves further investigation in a randomized trial.     

Trimodality therapy for stage IIIA non-small cell lung cancer: Benchmarking multi-disciplinary team decision-making and function

Objectives

Although the standard treatment for patients with stage IIIA non-small cell lung cancer (NSCLC) is chemoradiotherapy, some patients are considered for trimodality therapy [TT]. We analyzed outcomes for stage IIIA NSCLC, treated with TT and compared them with concurrent chemoradiotherapy [con-CRT].

Materials and methods

Patients treated between January 2007 and December 2011 were retrospectively analyzed. Not included were patients with sulcus superior tumors, unknown T/N-status, or recurrent disease after con-CRT followed by surgery. All patients were discussed at our multidisciplinary thoracic tumor board (MTB).

Results

Mean Charlson Comorbidity Index was 2 for TT and con-CRT patients. TT patients were younger (median TT = 56 years vs. con-CRT = 62 years; p = 0.001) and had less advanced cN-stage (TT cN2 = 41% vs. 83% for CRT; p < 0.001). 44% of TT patients had T4-stage vs. 12% of con-CRT patients. Median RT dose was lower for TT (50 Gy vs. 66 Gy; p = 0.001) and median RT planning target volume (PTV) in TT and con-CRT patients was 525 cm³ and 655 cm³ (p = 0.010), respectively. The majority of TT patients had a lobectomy (23/32). Median follow-up was 30.3 months (95% CI = 18.7–41.9) for TT and 51 months (95% CI = 24.9–77.4) for con-CRT. Median overall survival was not reached for TT and was 18.6 months (95% CI = 12.8–24.4) for con-CRT (p = 0.001). For PTV </≥ 500 cm³, median OS for TT was not reached/33.9 months and 29.1/17.1 months for con-CRT. TT patients with cN0/1 had better survival than those receiving con-CRT (p = 0.015), but those with cN2 did not (p = 0.158). The 90-day mortality from start of RT was 0% (0/32) for TT and 1.7% (1/58) for con-CRT. 90-day post-operative mortality for TT was 3.1% (1/32, event unrelated to TT).

Conclusions

Selected patients with IIIA NSCLC treated with TT had favorable long-term survival with acceptable short-term mortality. These outcomes support the decision-making and function of our MTB/treatment team. The role of TT in cN2 disease and large tumors merits further evaluation.     

Prognostic value of lymph node metastases and lymph node ratio in esophageal squamous cell carcinoma

Aims

Although the positive lymph node (LN) metastasis in patients with thoracic esophageal squamous cell carcinoma carcinoma (SCC) has been reported to be a risk factor to reduce long-term survival, only a few studies have so far evaluated the lymph node metastasis among this group of patients. The purpose of this study was to evaluate the impact of lymph node positivity and ratio on survival of esophageal SCC.

Methods

All patients undergoing esophagectomy at the Forth Hospital of Hebei Medical University between January 1986 and December 2002 were reviewed. Survival curves were estimated using the Kaplan-Meier method.

Results

Of 1325 patients with invasive cancer, had squamous cell cancer of the esophagus. Median overall survival (OS) of the entire group was 36.7 months and 5-year OS was 39.3%. The most significant prognostic factor for overall survival was the presence of positive LN (P < 0.01). Additionally, patients with zero involved LN had a 5-year survival of 49.1%, while patients with 1–3 positive LN and >3 positive LN had 5-year survival of 19.5% and 11.0%, respectively (P < 0.01). Finally, an increasing ratio of positive to examined LN was linearly associated with a worsening 5-year survival, patients with <25%, 25%–50% and >50% positive LN had 5-year survival of 47.53%, 14.6% and 8.9%, respectively (P < 0.01).

Conclusion

Increasing number of positive LN in patients with esophageal cancer and increasing ratio of metastatic to examine LN portend a poor prognosis. These factors should play an important role in predicting prognosis of patients.     

Feasibility of proton beam therapy for reirradiation of locoregionally recurrent non-small cell lung cancer

Background and purpose

Options are limited for patients with intrathoracic recurrence of non-small cell lung cancer (NSCLC) who previously received radiation. We report our 5-year experience with the toxicity and efficacy of proton beam therapy (PBT) for reirradiation.

Materials and methods

Thirty-three patients underwent PBT reirradiation for intrathoracic recurrent NSCLC at a single institution. All patients had had RT for NSCLC (median initial dose 63 Gy in 33 fractions), with median interval to reirradiation of 36 months. Median reirradiation dose was 66 Gy (RBE) in 32 fractions. Toxicity was scored with CTCAE v4.0, and survival outcomes were estimated using Kaplan–Meier.

Results

Thirty-one patients (94%) completed reirradiation. At a median 11 months’ follow-up, 1-year rates of overall survival, progression-free survival, locoregional control, and distant metastasis-free survival were 47%, 28%, 54%, and 39%. Rates of severe (grade ?3) toxicity were 9% esophageal, 21% pulmonary; 1 patient had grade 4 esophagitis, and 2 had grade 4 pulmonary toxicity. Nine patients experienced a second in-field failure.

Conclusions

PBT is an option for treating recurrent NSCLC. However, the rates of locoregional recurrence and distant metastasis are high and the potential for toxicity significant. The risks and benefits of PBT must be carefully weighed in each case.