Radiotherapy and surgery in 50 cases of osteosarcoma treated without adjuvant chemotherapy.

A consecutive series of osteosarcoma patients from one hospital is described. In 1962 radiotherapy with delayed surgery according to Cade was replacing surgery alone as the adopted treatment programme. Statistically the results were the same before and after this time with 5 out of 29 and 6 out of 21 patients, respectively, surviving 5 years. With radiation alone none out of eight survived. Surgery alone produced 3 out of 14 and radiation with delayed surgery 6 survivors out of 15. As surgery with or without radiotherapy is equally ineffective in controlling osteosarcoma a prospective randomized trial of the relative merits of chemotherapy and interferon as adjuvant therapy seems highly desirable.     

Stages IB and IIA carcinoma of the cervix treated by radiation and radical hysterectomy. Findings and results in 184 patients

Although the results of both radiotherapy and radical surgery for stages IB and IIA carcinoma of the cervix are good, a small percentage of cancers are resistant to radiation therapy. Combined radiation and surgery therefore seems an attractive alternative. A study of 184 patients in whom radium application was followed by radical abdominal hysterectomy and pelvic lymphadenectomy 6 weeks later is reported. The uncorrected 5-year survival rate of 85.7% is not significantly better than results obtained by surgery alone or radiotherapy alone. Some guidelines are suggested to rationalise individual treatment of these patients.     

Health related quality of life outcomes following surgery and/or radiation for patients with potentially unstable spinal metastases

BACKGROUNDCurrently there is no prospective pain and health related quality of life (HRQOL) data of patients with potentially unstable spinal metastases who were treated with surgery ± radiation or radiation alone.METHODSAn international prospective cohort multicenter study of patients with potentially unstable spinal metastases, defined by a SINS score 7 to 12, treated with surgery ± radiation or radiotherapy alone was conducted. HRQOL was evaluated with the numeric rating scale (NRS) pain score, the SOSGOQ2.0, the SF-36, and the EQ-5D at baseline and 6, 12, 26, and 52 weeks after treatment.RESULTSA total of 136 patients were treated with surgery ± radiotherapy and 84 with radiotherapy alone. At baseline, surgically treated patients were more likely to have mechanical pain, a lytic lesion, a greater median Spinal Instability Neoplastic score, vertebral compression fracture, lower performance status, HRQOL, and pain scores. From baseline to 12 weeks post-treatment, surgically treated patients experienced a 3.0-point decrease in NRS pain score (95% CI ?4.1 to ?1.9, p<.001), and a 12.7-point increase in SOSGOQ2.0 score (95% CI 6.3–19.1, p<.001). Patients treated with radiotherapy alone experienced a 1.4-point decrease in the NRS pain score (95% CI ?2.9 to 0.0, p=.046) and a 6.2-point increase in SOSGOQ2.0 score (95% CI ?2.0 to 14.5, p=.331). Beyond 12 weeks, significant improvements in pain and HRQOL metrics were maintained up to 52-weeks follow-up in the surgical cohort, as compared with no significant changes in the radiotherapy alone cohort.CONCLUSIONSPatients treated with surgery demonstrated clinically and statistically significant improvements in pain and HRQOL up to 1-year postsurgery. Treatment with radiotherapy alone resulted in improved pain scores, but these were not sustained beyond 3 months and HRQOL outcomes demonstrated nonsignificant changes over time. Within the SINS potentially unstable group, distinct clinical profiles were observed in patients treated with surgery or radiotherapy alone.     

Adjuvant postoperative radiation therapy for colonic carcinoma.

One hundred thirty-three patients with Stage B2, B3, and C colonic carcinoma had resection for curative intent followed by adjuvant postoperative radiotherapy to the tumor bed. The 5-year actuarial local control and disease-free survival rates for these 133 patients were 82% and 61%, respectively. Stage for stage, the development of local regional failure was reduced for patients receiving postoperative radiotherapy compared with a historic control series. Local recurrence occurred in 8%, 21%, and 31% of patients with Stage B3, C2, and C3 tumors who had radiation therapy, respectively, whereas the local failure rates were 31%, 36%, and 53% in patients treated with surgery alone. There was a 13% and 12% improvement in the 5-year disease-free survival rate in the patients with Stage B3 and C3 lesions who had radiotherapy compared with the historic controls. For patients with Stage C disease, local control and disease-free survival rates decreased progressively with increasing nodal involvement; however, local control and disease-free survival rates were higher in the patients who had radiotherapy than in those who had surgery alone. Failure patterns in the patients who had radiotherapy did not show any notable changes compared with those for patients who had surgery alone. Postoperative radiation therapy for Stage B3, C2, and C3 colonic carcinoma is a promising treatment approach that deserves further investigation.     

Conservative surgery without radiotherapy in the treatment of patients with early-stage invasive breast cancer. A review.

OBJECTIVE: The authors determined whether some patients with clinical stage I or II invasive breast cancer can be adequately treated by conservative surgery without radiotherapy. SUMMARY BACKGROUND DATA: Currently, there are many patients who are being treated in this manner in both academic and community hospitals. This approach is not as effective as either mastectomy or conservative surgery followed by radiotherapy in preventing local recurrence. However, there may be subsets of patients who might be adequately treated by surgery alone with acceptably low recurrence rates. METHODS: The authors reviewed retrospective studies of conservative surgery alone and of randomized trials comparing the results of treatment with and without postoperative radiotherapy. RESULTS: The local recurrence rate is unacceptably high when random patients are treated with conservative surgery without radiotherapy. More favorable results may be possible when relatively wide excisions are performed on selected postmenopausal patients with small lesions without an extensive intraductal component, lymphatic or blood-vessel invasion, and histologically negative axillary nodes. The role of tamoxifen in reducing the risk of breast recurrence is uncertain. Despite salvage therapy, some individuals may develop disseminated disease as a result of local recurrence. CONCLUSIONS: The authors believe that conducting carefully designed prospective studies of conservative surgery alone is reasonable for patients who are adequately informed of the potential risks of omitting radiation therapy. However, currently, patients should not be treated with conservative surgery alone (without radiotherapy) without such stringent guidelines.     

Surgical therapy and radiotherapy for carcinoma of the esophagus. Treatment results in 195 patients

Between 1963 and 1986, 195 patients with carcinoma of the esophagus were seen in the Department of Radiation Oncology at the University of Southern California School of Medicine. Of these 195 patients, 137 had unresectable or inoperable tumors and received radiotherapy. A combination of radiotherapy and surgical therapy was used in 46 patients, 9 patients were treated with surgery alone, and three with chemotherapy alone. Among the nonsurgical patients, 13 scored less than 50 on the Karnofsky scale, 25 had distant metastases, and 69 lost more than 10% of their body weight. The majority (94%) had squamous cell carcinoma and a few (6%) had adenocarcinoma. Fifty percent had middle esophageal lesions, 30% had lower lesions, and 20% had upper esophageal lesions. Stage I was diagnosed in 13%, II in 27%, III in 29%, and IV in 27%; the disease was not staged in 5%. The 5-year actuarial survival rate for all patients was 4% (median 32 weeks). The 5-year survival rate of the 46 patients with combination therapy was 18%, and it was 2% for the remaining 149 patients (p less than 0.001). These figures are independent of stage of disease. The 2-year survival rate by stage was as follows: I, 25%; II, 21%; III, 5%; and IV, 0% (p less than 0.001). Complete response was obtained in 18% and partial response in 41%. Complete response was dependent on the tumor stage. It was 40% for stage I disease, 23% for stage II, 11% for stage III, and 6% for stage IV disease. Similarly, a larger percentage (39%) of the 46 patients with combination surgical/radiation therapy had a complete response than of patients treated by either radiotherapy alone (n = 137, 12%) or surgery alone (n = 9, 11%). Complete response and initial performance status were important factors influencing survival (p less than 0.001). Surgery with adjuvant irradiation offered a better survival rate than radiotherapy or surgery used as single modalities. Treatment results for patients with advanced carcinoma of the esophagus remain poor.     

Postoperative Radiotherapy for Stage pT3 Carcinoma of the Prostate: Improved Local Control

Purpose

We determined whether radiotherapy after radical prostatectomy leads to improved results in patients with stage pT3 carcinoma of the prostate.

Materials and Methods

In a prospective nonrandomized study of 203 patients with clinical stage T2 prostate cancer treated with radical prostatectomy 88 underwent surgery alone, 89 received early postoperative radiotherapy generally because of pathological stage T3 disease and 26 received delayed radiotherapy for local recurrence. The disease was stage pT3N0/X in 135 patients.

Results

For patients with pathological stage T3 cancer actuarial local recurrence rates were significantly decreased in the early postoperative radiotherapy group compared to the surgery only group (p = 0.005), while actuarial metastatic rates (p = 0.6) and cause specific survival rates (p = 0.04) were not significantly different. Multivariate analysis for all patients in both groups identified adverse features of increased postoperative prostate specific antigen levels, seminal vesicle involvement, lack of postoperative radiotherapy and positive lymph nodes. Late toxicity was severe (Radiation Therapy Oncology Group grade 3 or 4) in 13 surgery only and 17 early postoperative radiotherapy group patients. Of those who were potent postoperatively the incidence of impotence in the early postoperative radiotherapy group was 89 percent compared to 59 percent in the surgery only group (p = 0.003). For patients treated with delayed radiation for clinical local recurrence the actuarial local control rate was 54 percent after 10 years.

Conclusions

Local radiotherapy appears to improve local control of stage pT3 cancer but has no impact on overall survival.     

The prognosis in osteosarcoma

Summary Multifactorial analysis of patients with osteosarcoma of the distal femur and proximal tibia, recorded in the Swedish Cancer Registry during 1958 through 1968, disclosed a 5-year survival of 15.1% for femoral osteosarcomas and 38.1% for tibial tumours. The prognosis was better in adults than in children and better in males than in females. Tumour size, soft tissue involvement, the presence of pathological fracture and the duration of symptoms before treatment influenced the prognosis. The best treatment for the tibial lesions was high amputation alone, whilst for the femoral tumours primary ablative surgery was not superior to combined high-dose radiotherapy and delayed amputation. The main cause for the higher survival rate for tibial neoplasms seemed to be the fact that they were less advanced on admission than those of the distal femur. The findings emphasize the importance of early diagnosis and treatment for improved survival.A Comparative Multifactorial Analysis of Osteosarcoma of the Distal Femur and Proximal Tibia Recorded in the Swedish Cancer Registry 1958 through 1968     

SO01NEOADJUVANT: RECTAL CANCER

Neoadjuvant therapy is given before surgery to improve resectability, local control and/or survival. Post‐operative radiation therapy for locally advanced rectal cancer has been long accepted, and since 1990 adding fluorouracil (5FU) chemotherapy became the NIH standard. However, trials then showed that pre‐operative radiotherapy followed by surgery improved local control over surgery alone, but had a less consistent effect on overall survival. The German trial (Sauer, NEJM, 2004, 351:1731) showed a 5 year local relapse rate of 6% for pre‐operative chemo‐radiotherapy and 13% for post‐operative chemo‐radiotherapy for T3 or T4 or node‐positive rectal cancer treated by TME. The EORTC 22921 trial (37% had TME) showed a similar reduction in local recurrence whether 5FU/leucovorin chemotherapy was given with pre‐operative radiotherapy, after pre‐operative radiotherapy plus surgery, or both (Bosset, NEJM, 2006, 355:1114). Trials show increased rates of complete pathological remission, increased acute toxicity, but no consistent effects on sphincter preservation rates or overall survival when chemotherapy is combined with pre‐operative radiation. Many questions remain. The TROG/AGITG trial compares pre‐operative radiotherapy as a short course (5 Gy X 5♯) or long course with chemotherapy (50.4 Gy plus 5 FU infusion), with accrual just completed. Ongoing phase III trials explore capecitabine, adding other drugs to 5 FU, and post‐operative adjuvant chemotherapy. Neo‐adjuvant pre‐operative radiation with concurrent chemotherapy, unless contra‐indicated by comorbidity, has become widely accepted for T3 or T4 or node‐positive rectal cancer based on MRI staging. Individual patient care is best planned by a multidisciplinary team.     

Carcinoma of the skin of the head and neck with perineural invasion

This is an analysis of 25 patients with carcinoma of the skin of the head and neck with clinical evidence of perineural invasion, who were managed with curative intent by radiotherapy alone (16) or surgery and radiotherapy (9). All patients had a minimum of 5 years of follow-up. Local control following treatment was observed in 20% of patients treated with radiotherapy alone and 38% of those treated with surgery and radiotherapy. Local control was diminished for recurrent lesions and for tumors that also invaded bone and/or cartilage. The 5-year absolute survival rates were 31% for patients treated with radiotherapy alone and 33% for those in the combined-treatment group. The incidence of significant complications was similar: 25% with radiotherapy alone and 33% with surgery and adjuvant radiotherapy.     

Ewing sarcoma/primitive neuroectodermal tumor of the chest wall: impact of initial versus delayed resection on tumor margins, survival, and use of radiation therapy

OBJECTIVE: To establish outcome and optimal timing of local control for patients with nonmetastatic Ewing sarcoma/primitive neuroectodermal tumor (ES/PNET) of the chest wall. METHODS: Patients < or =30 years of age with ES/PNET of the chest wall were entered in 2 consecutive protocols. Therapy included multiagent chemotherapy; local control was achieved by resection, radiotherapy, or both. We compared completeness of resection and disease-free survival in patients undergoing initial surgical resection versus those treated with neoadjuvant chemotherapy followed by resection, radiotherapy, or both. Patients with a positive surgical margin received radiotherapy. RESULTS: Ninety-eight (11.3%) of 869 patients had primary tumors of the chest wall. Median follow-up was 3.47 years and 5-year event-free survival was 56% for the chest wall lesions. Ten of 20 (50%) initial resections resulted in negative margins compared with 41 of 53 (77%) negative margins with delayed resections after chemotherapy (P = 0.043). Event-free survival did not differ by timing of surgery (P = 0.69) or type of local control (P = 0.17). Initial chemotherapy decreased the percentage of patients needing radiation therapy. Seventeen of 24 patients (70.8%) with initial surgery received radiotherapy compared with 34 of 71 patients (47.9%) who started with chemotherapy (P = 0.061). If a delayed operation was performed, excluding those patients who received only radiotherapy for local control, only 25 of 62 patients needed radiotherapy (40.3%; P = 0.016). CONCLUSION: The likelihood of complete tumor resection with a negative microscopic margin and consequent avoidance of external beam radiation and its potential complications is increased with neoadjuvant chemotherapy and delayed resection of chest wall ES/PNET.     

骨肉瘤患者延长生命保存肢体的临床研究(136例15年回顾)

作者１９８１～１９９６年共治疗骨肉瘤患者１３６例，随访５～１５年。２年生存率６１％，５年生存率２６．５％。作者首次在国内将大剂量顺铂全身化疗、双途径化疗以及ＤＳＡ介入化疗用于骨肉瘤术前化疗。在１３６例骨肉瘤患者中保肢手术８０例，其中开创放疗是国内首次开展。作者还对骨肉瘤的早期诊断、术前化疗、保肢手术以及肺转移瘤切除等问题提出了自己的看法。     

Verbesserung der lokalen Kontrolle bei Patienten mit aggressiver Fibromatose durch die Kombination von Chirurgie und Strahlentherapie

INTRODUCTION: The purpose of this retrospective analysis is to evaluate whether the combination of surgery and radiation therapy in patients with aggressive fibromatosis influences the therapeutic outcome. METHOD: Clinical, radiological and pathological results of 23 consecutive cases with histologically proven aggressive fibromatosis were retrospectively analyzed. The median follow-up was 59 months. RESULTS: Twelve patients received surgery alone for their first treatment, 10 patients had a combination of surgery and radiotherapy and 1 patient had radiochemotherapy. Of 23 patients 14 (63%) had one or more local recurrences and 9 (39%) were recurrence-free. The patients received a total of 50 treatments: 29/50 (58%) treatments were followed by a local recurrence and 21/50 (42%) were without relapse. Twenty-nine treatments with local recurrence consisted of 25/29 (86%) surgical treatments, 3/29 (10%) combinations of surgery and radiation therapy, and 1/29 (3%) radiochemotherapy. Of the patients who had only surgery for their first treatment, after one year 8 of 12 (66%) and after 5 years all patients had a local recurrence. In the group with surgery and radiotherapy, there was no recurrence after 1 year and 1 recurrence after 5 years (p = 0.0001). CONCLUSION: We recommend a complete tumor resection, without mutilating the patient. Radiation therapy in combination with surgery in contrast to surgery alone is an efficient treatment option for reducing local recurrence.     

Osteosarcoma: a review of 50 patients treated at the University of Alabama in Birmingham Medical Center between 1944 and 1975.

Only 12% of 50 patients lived 5 years or longer. Those who survived the longest were those with the tumor in the distal part of the lower extremity, with a well differentiated or chondroblastic tumor, or those who underwent radical surgery. Patients treated with surgery and chemotherapy lived about 1.5 months longer than those treated with sugery alone and about 1.2 months longer than those who had radiation included in the therapy. For a patient with a diagnosis of osteosarcoma, the prognosis was to be grave, no matter which methods of treatment were used.     

Treatment of choice for squamous carcinoma of the tonsillar fossa

The records of 160 patients with squamous cell carcinoma of the tonsillar fossa treated from 1968 through 1979 were reviewed. Biologic behavior, local and regional findings, and other prognostic factors were evaluated. patients were treated by either radiation alone (112 patients), radiation followed by planned neck dissection (31 patients), surgery alone (11 patients), or surgery combined with radiation (6 patients). Analysis of the data supports the recommendation that radiation be used as treatment for T1, T2, and early T3 lesions, whereas surgery alone or combined with radiation is best employed for advanced T3 or T4 tumors. Primary tumor control rates with radiation as the initial modality were 100% for T1 lesions, 89% for T2, 68% for T3, and 24% for T4. In addition, the control of cervical metastases with radiation therapy for patients with neck disease staged N0 through N3b was excellent (95%). In instances where a planned neck dissection was done 5 weeks after radiation, the control of cancer in the neck was 100%. The incidence of distant metastases was 10% and was not affected by the selection of therapy. The 2- and 5-year determinate survival figures for 112 patients treated with radiation therapy alone was 67% and 48% respectively, while 31 patients treated with radiation therapy followed by neck dissection achieved survival rates of 70% (2 year) and 58% (5 year). The criteria for selection of treatment are discussed.     

Long-term results of prospective trial of surgery alone with selective use of radiation for patients with T1 extremity and trunk soft tissue sarcomas

OBJECTIVE: We conducted a prospective trial to define the local recurrence rates for selected patients with T1 soft tissue sarcomas (STS) treated by surgery alone. SUMMARY BACKGROUND DATA: Retrospective data suggest that some patients with small STS can be safely treated by surgery alone. There are no defined criteria to select patients for such treatment. METHODS: Patients with T1 primary STS were treated with function-preserving surgery and microscopic assessment of surgical margins. Postoperative external-beam radiation was employed selectively for patients with microscopically positive (R1) final surgical margins. Patients who underwent resection with microscopically negative (R0) final margins did not receive radiotherapy. RESULTS: Eighty-eight eligible and evaluable patients were entered on this protocol between March 1996 and April 2002. Tumor sites included the extremities (n=60), and trunk (n=26). Fifty-one patients (58%) had high-grade STS; 60 (68%) had superficial (T1a) disease. Fourteen patients (16%) underwent R1 resection and were treated with postoperative radiation; 74 (84%) underwent R0 resection and were treated by surgery alone. The median follow-up was 75 months. Isolated local recurrences were observed in 11 patients (13%; 6 in R1 arm, 5 in R0 arm). In the R0 surgery-alone arm, the cumulative incidence rates of local recurrence at 5 and 10 years were 7.9% and 10.6%, respectively; and the 5- and 10-year sarcoma-specific death rates were 3.2% and 3.2%. CONCLUSION: Selected patients with primary T1 STS of the extremity and trunk can be treated by R0 surgery alone with acceptable local control and excellent long-term survival.     

Orchiectomy and delayed radiotherapy as treatment for prostatic carcinoma. A 10-year survey

One hundred and fifty patients with carcinoma of the prostate treated between 1967 and 1982 have been reviewed. Thirty-three patients were treated with stilboestrol alone, 36 by orchiectomy alone and in 81 cases radical radiotherapy was given to the prostate (and in 10 of the 81 cases to the regional and para-aortic lymph nodes) 5 or 6 months after orchiectomy. Although there was no significant difference between the results of those treated by stilboestrol alone and those treated by orchiectomy alone, in those patients receiving orchiectomy and delayed radiotherapy there was a significant improvement in survival. If patients with Stage D disease are excluded, this is a highly significant difference and indeed the survival in these patients does not differ significantly from the expected survival at this age. The 5-year survival rate of Stage D patients treated by this method was 35%.     

Fractionated Radiation Therapy in the Treatment of Cerebello-Pontine Angle Neurinomas: 12 Years of Experience in 29 Cases

The purpose of this research was to reevaluate long-term results of frationated radiation therapy (RT) in two previously published series of cerebello-pontine angle (CPA) neurinomas. From January 1986 to October 1995, 29 patients with stage III and IV CPA neurinomas were treated with external fractionated RT. One patient was irradiated on both sides and indications for radiotherapy were as follows: (a) poor general condition or old age contraindicating surgery, 16 cases; (b) hearing preservation in bilateral neurinomas after contro-lateral tumor removal, 6 cases; (c) partial resection or high risk of recurrence after subsequent surgery for relapse, 5 cases; (d) nonsurgical relapse, 3 cases. Most patients were irradiated with 6 to 10 MV photons. A three- to four-field technique with coplanar static beams and conformal blocks was used. Doses were calculated on a 95% isodose and were given 5 days a week for a mean total dose of 51 Gy (1.80 Gy/fraction). Median follow-up from RT was 66 months (7 to 120); 7 patients died, 2 with progressive disease, 5 from nontumoral causes. Two patients underwent total tumor removal after RT (1 stable and 1 growing tumor). On the whole, tumor shrinkage was observed in 13 patients (43.3%), stable disease in 14 (46.6%), and tumor progression in 3. Hearing was maintained in 4 out of 6 hearing patients. No patient experienced facial or trigeminal neuropathy. Long-term efficacy of fractionated RT is well documented in this series. Acute and delayed tolerance was excellent. Hearing can be preserved for a long time.     

Multimodal treatment of craniofacial osteosarcoma with high-grade histology. A single-center experience over 35 years

High-grade craniofacial osteosarcoma (CFOS) is an aggressive malignancy with a poor prognosis. Our goals were to evaluate treatment outcomes in those treated at a single referral institution over 35 years and to compare our results to the available literature. A retrospective analysis of all 42 patients treated between 1980 and 2015 at Oslo University Hospital, Norway, identified in a prospectively collected database, was conducted. Mean follow-up was 79.6 months. Overall survival at 2 and 5 years was 70.5 and 44.7%, respectively. The corresponding disease-specific survival rates were 73.0 and 49.8%. Treatment was surgery only in eight cases. Additional therapy was administered in 34 patients: chemotherapy in nine, radiotherapy in seven, and a combination of these in 18 cases. Stratified analysis by resection margins demonstrated significantly better survival at 2 and 5 years after radical surgical treatment. Neoadjuvant chemotherapy and subsequent adequate surgery resulted in better survival than surgery alone. Half of the patients either had a primary or familial cancer predisposition. This is the largest single-center study conducted on high-grade CFOS to date. Our experience indicates that neoadjuvant chemotherapy with complete surgical resection significantly improved survival, compared to surgery alone.     

Vascularized fibula with and without extracorporeal radiotherapy for limb salvage surgery in Indian patients

BackgroundReconstruction of segmental bone defects following resection of bone sarcomas is a challenging procedure. Vascularised fibula grafts alone or in combination with extracorporeal radiotherapy and reimplantation of tumor bone have long been established as a method of reconstruction of such defects, with satisfying results. Prompted by paucity of data on Indian patients, we report our experience with vascularised fibula graft for patients undergoing limb salvage surgery for sarcomas of bone.Material and methodsA total of 25 patients underwent the procedure from December 2008 to December 2014. Femur was the commonest site and osteosarcoma was the commonest diagnosis. Intercalary resection was done in 19 patients and arthrodesis in 6 patients. Vascularised fibula was used in combination with extra corporeally irradiated bone in eight patients, and alone in 17 patients.ResultsAll but one limb could be salvaged, and all but three patients had united at final follow up. Combination of extracorporeal radiotherapy and reimplantation with vascularised fibula fared better than vascularised fibula alone in terms of time to union (9.6 months vs 12.2 months) and rate of graft related complications (14.2% vs 62.5%).ConclusionReconstruction with VFG with or without ECRT has a good and predictable functional outcome. Though manageable with active intervention, complications were more commonly seen with vascularised fibula alone than a combination of the two techniques.