Results of surgery and irradiation or irradiation alone for pituitary adenomas

Summary A retrospective analysis was performed on the clinical course of all patients with pituitary adenomas treated at the Radiation Oncology Center, Mallinckrodt Institute of Radiology, Washington University Medical Center, St. Louis, Missouri. Of 212 patients treated from April 1954 through December 1982, 70 were treated with radiotherapy alone (XRT), 121 began immediate post-operative XRT (2–6 weeks) and 20 received XRT following surgical failure. Several sub-groups of adenomas were identified and analyzed, including secreting versus non-secreting adenomas (33.0% secreting) and by clinical syndrome; 27% with amenorrhea/galactorrhea, 18.4% acromegalic, Cushing's disease in 6.1% and 3.3% with Nelson's syndrome. The median follow-up time from the data of diagnosis for those patients alive at the time of last follow-up was 11.9 years (range 3.0 to 30.0 years). Actuarial overall and disease-free survival was analyzed up to 25 years. The 10-year overall and disease-free survival was 77.8 and 75.3% for those patients treated with XRT alone, 86.4 and 87.2% for those treated with immediate post-operative XRT and 100.0 and 87.5% for those who were irradiated after surgical failure. Complications related directly to XRT occurred in only five patients. One patient had documented central nervous system radionecrosis, two had visual complications, and tumor necrosis with hemorrhage occurred in the other two patients. In conclusion, overall survival for all patients did not significantly differ from an age, sex and race matched population. Control of local disease was greater for those patients receiving surgery and post-operative XRT than for those receiving XRT only. XRT salvage of surgical failures was possible. Treatment with XRT results in a low complication rate. Supported by the American Cancer Society Clinical Oncology Career Development.     

Antiangiogenic therapies: is VEGF-A inhibition alone enough?

Although available targeted therapies provide some clinical efficacy, a need remains for antiangiogenic therapies with alternative mechanisms in order to provide better outcomes and the ability to circumvent resistance. Inhibition of multiple VEGF targets may produce enhanced efficacy and more durable responses through synergistic effects, and prevent the development of escape mechanisms. Inhibition of VEGF-A, VEGF-C and VEGF-D with broad-spectrum VEGF receptor-2 (VEGFR-2) inhibitors, such as the novel protein therapeutic CT-322, may result in increased efficacy and prevent or delay acquired resistance and metastatic spread often seen with VEGF-A inhibition alone. Therefore, panoramic inhibition of VEGFR-2 may be a better approach to more effective antiangiogenic therapy. This article focuses on pivotal data on VEGF/VEGFR inhibitors currently in use, as well as newer agents in development.     

Stage III and localized stage IV breast cancer: Irradiation alone vs irradiation plus surgery

One hundred forty-seven patients with non-inflammatory, Stage III and IV breast cancer were treated with irradiation alone (54 patients) or with a combination of irradiation and mastectomy (93 patients). In the T₃ category, the local failure rate was 45% ($\text{5}\text{11}$) for the irradiation alone patients vs 12% ($\text{3}\text{25}$) for the irradiation plus surgery patients; in the T₄ category these figures were 65% ($\text{28}\text{43}$) vs 13% ($\text{9}\text{68}$), respectively. Corresponding local failure rates by size of primary tumor were 50% ($\text{2}\text{4}$) vs 15% ($\text{5}\text{29}$) for tumors 0–5 cm, 43% ($\text{9}\text{21}$) vs 14% ($\text{6}\text{45}$) for 5–8 cm tumors, and 75% ($\text{22}\text{29}$) vs 54% ($\text{1}\text{20}$) for tumors ≥8 cm. The rates of regional failure for the two treatment methods were compared according to N stage; they were 9% ($\text{2}\text{23}$) for irradiation alone vs 11% ($\text{8}\text{76}$) for irradiation plus surgery in the N_0–1 category, and 58% ($\text{18}\text{31}$) vs 18% ($\text{3}\text{17}$), respectively, for the N_2–3 category. A dose response analysis for patients with tumors greater than 5 cm treated with irradiation alone did not show a decrease in local failure rate with increasing total tumor dose over a range of 4000 to 7000 rad, suggesting that doses in this range are too low for these large tumors. Since a significant late complication rate has been reported with doses higher than this, patients with non-inflammatory, but large (>5 cm) tumors, should be treated with a combination of surgery and irradiation whenever possible to achieve maximum local-regional control with a minimum probability of complications. In 36 patients with inflammatory carcinoma, the rates of local and regional failure were 52% ($\text{15}\text{29}$) and 38% ($\text{11}\text{29}$), respectively, for patients treated with irradiation alone, and 14% ($\text{1}\text{7}$) and 29% ($\text{2}\text{7}$), respectively, for patients receiving irradiation plus surgery. Since none of these differences were statistically significant, one cannot conclude that surgery should necessarily play a role in the treatment of inflammatory carcinoma.     

Esthesioneuroblastoma: a meta-analysis and review

Our objective was to review recent developments in diagnosis, staging, and treatment of esthesioneuroblastoma (ENB). A meta-analysis of publications between 1990 and 2000 was carried out, and studies were classified according to their main subject: origin/aetiology of ENB, histopathological diagnosis, and treatment. Data so far point to the basal progenitor cells of the olfactory epithelium as the origin of ENB. Histopathological diagnosis remains difficult and is based on results of antigen expression detected through a panel of antibodies by immunohistochemistry. RT-PCR of HASH expression could be a specific marker of ENB. Overall and disease-free survival at 5 years averaged 45% (SD 22) and 41% (SD 21) in the studies included in the meta-analysis. Survival in Hyams' grades I-II was 56% (SD 20) compared with 25% (SD 20) in grades III-IV (odds ratio 6.2). In patients with metastases in cervical lymph nodes (on average 5% of the total) survival was 29%, compared with 64% for patients with N0 disease (odds ratio 5.1). Survival according to treatment modalities was 65% for surgery plus radiotherapy, 51% for radiotherapy and chemotherapy, 48% for surgery, 47% for surgery plus radiotherapy and chemotherapy, and 37% for radiotherapy alone. The histopathological grading according to Hyams and the presence of cervical lymph-node metastases emerged as prognostic factors. A combination of surgery and radiotherapy seems to be the optimum approach to treatment. The exact role of chemotherapy in treatment protocols is still unclear. The role of elective neck dissection is unclear.     

Targeted therapies of cancer: angiogenesis inhibition seems not enough

The therapeutic potential of targeting tumor endothelium to induce tumor regression is now widely recognized. Tumors obtain their blood supply by the formation of new vasculature and the incorporation of pre-existent vessels. Since anti-angiogenic therapy prevents formation of neovasculature, vessels in more matured stages are not affected by such therapies. Therefore, additional vascular targeting therapy, which aim at regression of existent tumor vasculature, seems an attractive approach to effectively deprive tumors from blood supply. In this review we present an overview of different strategies to target tumor endothelium. In addition, we discuss the pitfalls of anti-angiogenic therapies in clinical settings.     

Radiotherapy after breast-conservation surgery: how much is enough?

The National Surgical Adjuvant Breast Project (NSABP) clinical trials have demonstrated that breast conservation surgery (lumpectomy), axillary dissection, and breast irradiation for women with Stage I and II invasive breast carcinoma provide disease-free survival and overall survival rates equivalent to modified radical mastectomy. Breast irradiation following lumpectomy decreases the incidence of in-breast tumor recurrence compared to lumpectomy alone. The addition of adjuvant systemic therapy appears to further decrease the incidence of in-breast tumor recurrence. Irradiation of the internal mammary and supraclavicular nodal regions is not indicated for patients with Stage I and II carcinoma. Similarly, irradiation of the axilla after axillary dissection is not indicated.     

Cancer consultation preparation package: changing patients but not physicians is not enough.

PURPOSE: This study evaluated a cancer consultation preparation package (CCPP) designed to facilitate patient involvement in the oncology consultation. PATIENTS AND METHODS: A total of 164 cancer patients (67% response rate) were randomly assigned to receive the CCPP or a control booklet at least 48 hours before their first oncology appointment. The CCPP included a question prompt sheet, booklets on clinical decision making and patient rights, and an introduction to the clinic. The control booklet contained only the introduction to the clinic. Physicians were blinded to which intervention patients received. Patients completed questionnaires immediately after the consultation and 1 month later. Consultations were audiotaped, transcribed verbatim, and coded. RESULTS: All but one patient read the information. Before the consultation, intervention patients were significantly more anxious than were controls (mean, 42 v 38; P = .04); however anxiety was equivalent at follow-up. The CCPP was reported as being significantly more useful to family members than the control booklet (P = .004). Patients receiving the intervention asked significantly more questions (11 v seven questions; P = .005), tended to interrupt the physician more (1.01 v 0.71 interruptions; P = .08), and challenged information significantly more often (twice v once; P = .05). Patients receiving the CCPP were less likely to achieve their preferred decision making style (22%) than were controls (35%; P = .06). CONCLUSION: This CCPP influences patients' consultation behavior and does not increase anxiety in the long-term. However, this intervention, without physician endorsement, reduced the percentage of patients whose preferred involvement in decision making was achieved.     

嗅神经母细胞瘤诊断与治疗的临床分析

目的探讨鼻腔嗅神经母细胞瘤的诊断治疗方法及预后的相关因素。方法回顾性分析我院1994年1月-2010年5月收治的嗅神经母细胞瘤12例,改良Kadish分期A期1例,B期5例,C期3例,D期3期。含手术的综合治疗6例,单独手术4例,单独放疗1例,单独化疗1例。结果全组患者5年总生存率（OS）为90.9%,5年无病生存率（DFS）为74.1%。A、B期和C、D期患者的5年OS分别为100%和80.0%（χ²=1.20,P=0.27）,5年DFS分别为100%和44.4%（χ²=4.07,P=0.04）。有淋巴结转移和无淋巴结转移患者的5年OS分别为66.7%和100%（χ²=2.67,P=0.10）,5年DFS分别为33.3%和87.5%（χ2=4.88,P=0.03）。综合治疗与单一治疗的5年OS分别为100%和80.0%（χ²=1.20,P=0.27）,5年DFS分别为83.3%和62.5%（χ2=0.35,P=0.88）。结论嗅神经母细胞瘤的早期诊断较难,该病的治疗以综合治疗疗效较好,放疗是该病重要的治疗手段,该病预后与疾病分期及淋巴结转移情况相关。