Endometrial adenocarcinoma treated with combined radiotherapy and surgery: 437 cases]

PURPOSE: To identify prognostic factors and treatment toxicity in a series of operable endometrial adenocarcinomas. PATIENTS AND METHODS: Between November 1971 and October 1992, 437 patients (pts) with endometrial carcinoma, staged according to the 1988 FIGO staging system, underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy without (n = 140) or with (n = 297) pelvic lymph node dissection. The chronology of RT was not randomized and depended on the usual practices of the surgical teams. Group I: 79 pts received preoperative uterovaginal brachytherapy (mean total dose [MD]: 57 Gy). Group II: 358 pts received postoperative RT (196 pts received vaginal brachytherapy alone [MD: 50 Gy], 158 pts had external beam pelvis RT [EPRT] [MD: 46 Gy over 5 weeks] followed by vaginal brachytherapy [MD: 17 Gy], and 4 pts had EPRT alone [MD: 46 Gy over 5 weeks]). The mean follow-up was 128 months. RESULTS: The 10-year disease-free survival rate was 86%. From 57 recurrences, 12 were isolated locoregionally. Multivariate analysis showed that independent factors decreasing the probability of disease-free survival were: histologic type (clear cell carcinoma, p = 0.038), largest histologic tumor diameter > 3 cm (p = 0.015), histologic grade (p = 0.008), myometrial invasion > 1/2 (p = 0.0055), and 1988 FIGO staging system (p = 9.10(-8)). In group II, the addition of EPRT did not seem to improve locoregional control. The postoperative complication rate was 7%. The independent factors increasing the risk of postoperative complications were FIGO stage (p = 0.02) and pelvic lymph node dissection (p = 0.011). The 10-year rate for grade 3 and 4 late radiation complications according to the LENT-SOMA scoring system was 3.1%. EPRT independently increased the 10-year rate for grade 3 and 4 late radiation complications (R.R.: 5.6, p = 0.0096). CONCLUSION: EPRT increases the risk of late radiation complications. After surgical and histopathologic staging with pelvic lymph node dissection, in a subgroup of intermediate risk patients (stage IA grade 3, IB-C and II), postoperative vaginal brachytherapy alone is probably sufficient to obtain a good therapeutic index. Results for patients with stage III tumor are not satisfactory.     

Stage I, grade III adenocarcinoma of the endometrium treated with surgery and irradiation. Sites of failure and correlation of failure rate with irradiation technique

Eighty-three patients treated with total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO) and adjuvant irradiation for Stage I, grade III adenocarcinoma of the endometrium were reviewed. At 5 years, the overall survival was 71%, and the disease-free survival (excluding patients dying of intercurrent disease) was 79%. The failure rates for pelvis alone, pelvis plus distant, and distant alone were 4.8%, 4.8%, and 10.8%, respectively. The most common site of failure was the upper abdomen; 12% of all patients had a failure at this site, either alone or in conjunction with failure at another site. The 24% rate of failure in 50 patients receiving a preoperative implant and external irradiation was not significantly different from the 15% failure rate in 33 patients whose adjuvant irradiation consisted of a preoperative implant only. For the patients who had both an implant and external irradiation, the dose of external irradiation had no correlation with the rate of failure. In contrast, the number of milligram-hours delivered to the uterus by the preoperative implant had a strong inverse correlation with the rate of failure, both for patients receiving an implant only and for those receiving an implant plus external irradiation. The data suggest the following: (1) a high-intensity preoperative uterine implant may be an important adjunct to surgery; and (2) external pelvic irradiation in addition to the implant does not seem to be any more beneficial than an implant alone.     

Locoregional recurrence of adenocarcinomas of the rectum treated with irradiation combined with or without excision surgery]

PURPOSE: Retrospective study to analyze the results of external beam radiation treatment with or without surgery for loco-regional recurrence of adenocarcinoma of the rectum following previous surgery without pre- or post-operative radiotherapy. PATIENTS AND METHODS: Between March 1973 and November 1991, 211 patients with loco-regional recurrence of rectum cancer were treated with external beam radiation treatment. Radical surgery was the only initial treatment modality. Surgical resection of local recurrence was done in 36 patients and only 17 patients could undergo complete resection. Forty-seven patients underwent radiotherapy (RT) combined with surgery and 164 received external beam radiation treatment alone to a mean total dose of 46 Gy. RESULTS: Among the 151 patients whose recurrence was revealed by pain, 64 (42%) were considered to have a complete symptomatic response after loco-regional treatment with radiosurgery or RT alone. The mean duration of response was 12 months. The 3-year overall survival rate was 16%. Five prognostic factors decreased the overall survival rate in multivariate analysis: high age, sex (male), concomitant distant metastasis, no tumor resection, and low total radiation dose with external beam radiation treatment alone. The 3-year overall survival rate for patients with completely resected recurrences was 39%. CONCLUSION: External beam RT treatment can only be considered a palliative symptomatic treatment. New techniques of early detection of local recurrence and new combined modalities approaches (radiation sensitizers or intra-operative radiotherapy) with surgical resection in some favorable cases should be studied.     

Functional outcome in patients treated with surgery and irradiation for soft tissue tumours.

One hundred five consecutive patients underwent surgical resection and adjuvant irradiation in treatment of soft tissue sarcoma or aggressive fibromatosis. All patients were entered in a prospective study evaluating functional outcome and 88 patients were examined at 12 months following surgery. Outcome was characterized using the Enneking system as well as documenting employment/recreational status and limb edema. Sixty-eight of 88 patients had functional scores of 21 or better (out of a possible total of 35). Forty-four patients were serially evaluated at 12 and 24 months and there was no difference in their outcome at the 2 time points. Univariate analysis demonstrated that large tumour size, postoperative complications, and neural sacrifice were associated with poor functional outcome.     

Role of brachytherapy in recurrent extremity sarcoma in patients treated with prior surgery and irradiation

The treatment options for recurrent extremity sarcoma following conservative surgery and irradiation are limited. Amputation is the treatment of choice offered for the majority of these patients. In a selected group of patients with recurrent sarcoma, we have investigated the role of brachytherapy along with function-preserving resection. From 1979 to 1988, 40 patients underwent resection and brachytherapy for recurrent extremity sarcoma. There were 23 males and 17 females. All of the patients received function-preserving resection and an afterloading temporary tumor bed implant. A median dose of 4500 cGy was delivered with a range from 3000 to 4800 cGy. The median follow-up was 36 months with a range of 12 to 120 months. The actuarial local control at 5 years is 68%. Five patients (12.5%) developed complications such as wound ulceration (4) and femoral fracture (1) requiring surgery. Five patients developed local failure and an additional two patients had both local and distant failure. All of the failures occurred in patients with more than two prior recurrences. This review suggests that brachytherapy can be used as an effective treatment option in selected patients with recurrent extremity sarcoma following prior surgery and irradiation with satisfactory limb preservation. The data also suggest that higher local control rates can be achieved with early brachytherapeutic intervention.     

Extracranial chordoma: Outcome in patients treated with function-preserving surgery followed by spot-scanning proton beam irradiation

PURPOSE: To evaluate the use of postoperative proton therapy (PT) in extracranial chordoma. PATIENTS AND METHODS: Twenty-six patients were treated. Gross total resection was achieved in 18 patients. Nine patients had cervical, 2 had thoracic, 8 had lumbar, and 7 had sacro-coccygeal chordomas. Thirteen patients had implants. PT was administered after function-preserving surgery, using a gantry and spot scanning, without or with intensity modulation (IMPT; 6 patients), and/or photon-based radiotherapy (RT, 6 patients). Median total dose was 72 cobalt Gray equivalent (CGE; range, 59.4-74.4), with means of 70.5 and 73.2 CGE for patients with and without implants. Median follow-up time was 35 months (range, 13-73 months). Adverse events were scored using the Common Terminology Criteria for Adverse Events grading system (version 3.0). RESULTS: At 3 years, actuarial overall survival (OS) and progression-free survival (PFS) rates were 84% and 77%, respectively. One patient each died of local failure (LF), distant failure (DF), suicide, and secondary tumor. We observed 5 LFs and 3 DFs; 3-year LF-free and DF-free survival rates were 86%. We observed four radiation-induced late adverse events (Grade 2 sensory neuropathy; Grade 3 subcutaneous necrosis, and osteonecrosis; and Grade 5 secondary cancer). In univariate analysis, implants were associated with LF (p = 0.034). Gross residual tumor above 30 mL was negatively associated with OS (p = 0.013) and PFS (p = 0.025). CONCLUSIONS: Postoperative PT for extracranial chordomas delivered with spot scanning offers high local control rates. Toxicity was acceptable. Implants were significantly associated with LF. Residual tumor above 30 mL impacted negatively on OS and PFS.     

Primary spinal cord tumors treated with surgery and postoperative irradiation

Between 1954 and 1979, 37 patients with a primary spinal cord tumor received postoperative irradiation after laminectomy. There were 26 intramedullary and 11 tumors of the conus/cauda equina. The 26 intramedullary tumors were divided as follows: 14 astrocytomas, eight ependymomas, three unbiopsied tumors, and one diffuse histiocytic lymphoma. Of the cauda equina tumors, 10 were ependymomas and one was an astrocytoma. Patients were followed until death or for a minimum of 4 years. The 5- and 10-year actuarial survivals for the entire group were 70 and 58%, respectively. Anatomic location of the tumor was the most important predictor of both survival and neurologic function. Patients with tumors of the cauda equina had superior neurologic function and a significantly better survival than those with tumors at other sites. Recurrent tumor was the cause of death in 82% of the patients dead at the time of analysis. Of the patients alive at the conclusion of the study, 10 were completely normal or had only mild neurologic deficit; the remaining 10 patients were severely disabled. Increasing radiation dose correlated with an increase in tumor control and survival. Of those receiving less than 40 Gy, 77% died of recurrent tumor, while 83% of those who received greater than 40 Gy are alive 4.1 to 28.9 years after treatment.     

Survival patterns in patients with carcinoma base of tongue treated with external beam irradiation and salvage surgery

Objective

The current study was designed to assess the treatment results and survival in the patients with carcinoma of base of tongue that were treated with primary radiotherapy, radiotherapy with chemotherapy and salvage surgery when indicated.

Design

A prospective study was carried out in 78 cases of carcinoma of the base of tongue between 1995 and 1999.

Methods

The majority of cases belonged to stage IV 60/78 (76.92%) as per AJCC staging. Radiotherapy in the dose of 60 Gy was given primarily to the patients with stage III tongue base cancer. Patients with early stage IV cancer were given split course radiotherapy followed by assessment for surgery. For the patients with advanced stage IV disease with poor general condition, palliative radiotherapy of 24 Gy with or without palliative chemotherapy was given. 15 patients were subjected to salvage surgery in the form of radical neck dissection alone (8 cases), extended total laryngectomy with neck dissection (3 cases), extended total laryngectomy (2 cases) and extended supraglottic laryngectomy with RND in 2 cases.

Results

Two and 5 years Kaplan — Meier actuarial survival rates were 45% and 10% respectively with local control rates equivalent to survival rates. All surviving patients maintained good function and quality-of-life with few tolerable side effects.

Conclusions

External beam radiotherapy with salvage surgery results in satisfactory local and regional control in stage III and IV carcinoma base of tongue.     

Quality of life in patients with ductal carcinoma in situ of the breast treated with conservative surgery and postoperative irradiation

Aim of the study: To evaluate the quality of life (QL) in patients with ductal carcinoma in situ of the breast treated with conservative surgery and postoperative irradiation.Material and methods: A selfcompleted questionnaire covering many disease, symptom, and treatmentspecific issues was administered to 106 conservatively treated patients affected by noninfiltrating breast cancer. The questionnaire was based on a series of 34 items assessing five main fields of posttreatment adjustment: physical well being, sexual adaptation, aesthetic outcome, emotional/psychological well being, relational behaviour. Furthermore, the patients were requested to evaluate the degree of information provided by the medical staff concerning surgical procedures and radiation therapy, and to evaluate the effects of the treatment on their social and overall life.Results: The questionnaire was completed by 83 patients (78%), who had a median followup of 54.5 months. This final sample had a median age of 50 years (range 29–88) at the time of treatment and 54 years (range 32–94) at the time of study. The patients claimed to be in good physical condition. Data relating to sexual life were provided by 93% of the sample. Some limitations in sexuality, some interference with sexual desire, and some modifications during intercourse were reported by 5, 6, and 5 patients, respectively. The subjective evaluations of the cosmetic results of the therapies were generally good. Only 13 patients (16%) reported the perception of a worsened body image. Fortysix percent of the sample (38 patients) declared that they felt tense, 48% (39 patients) nervous, 29% (38 patients) lonely, 59% (41 patients) anxious, and 41% (34 patients) depressed. Only seven patients (8%) declared that the treatment had had a bad effect on their social life, and 15 (18%) thought that their current life had been affected by the treatment. The amount of information received concerning the disease and treatment (surgery and radiotherapy) was considered sufficient by 79%, 75%, and 79% of the sample, respectively.Conclusions: This study revealed a good QL in patients treated with breast conservation and postoperative irradiation, with a preserved favourable body image and a lack of negative impact on sexuality. Radiation therapy did not lead to any significant additional problems capable of affecting the QL.     

Combined irradiation and surgery in the treatment of stage II carcinoma of the endometrium.

Between January 1969, and August 1975, 40 patients with pathologic Stage II carcinoma of the endometrium were treated at the Joint Center for Radiation Therapy. The treatment policy included external and intracavitary irradiation combined with surgery. The majority of patients received 4000 mg/hours of radium exposure using a Fletcher-Suit applicator and 4000 rad whole pelvis external irradiation, followed by hysterectomy and bilateral salpingooophorectomy. Median age of the patients was 61 years (39--88) and the median follow-up of the patients still alive was 69 months (29--102). Relapse-free 5-year survival corrected for intercurrent disease was 83% and uncorrected, 78%. Overall survival was 80%. Five patients had relapsing disease, three patients failed at distant sites only, one patient died of treatment related complications, and two failed locally and distantly. There were no failures in the pelvis alone. Although the relationshop between histologic grade and failure is not statistically significant, there were four failures among the 12 Grade III patients compared to two failures in 27 with Grades I and II. Similarly, 4 of 12 patients with gross cervical involvement developed relapsing disease, but only 2 of 28 failed with microscopic cervical involvement. This treatment policy yields excellent survival and continues to be our treatment recommendation.     

Outcome analysis of localized gastrointestinal lymphoma treated with surgery and postoperative irradiation

One hundred thirteen patients with localized gastrointestinal lymphoma treated by surgery and postoperative irradiation between 1967 and 1985 were reviewed. At 15 years, actuarial survival of this group was 40.6%, with a cause-specific survival of 69.2% and a relapse-free rate of 64%. Two-thirds of relapses occurred at distant sites. In Stage IA and IIA patients with no residuum or with positive resection margins, (N = 90) only site of involvement and stage predicted for relapse. Age, histologic subtype group, and depth of bowel wall invasion did not affect relapse risk. In the very favorable group (Stage IA, IIA, no residuum or microscopic residuum), 8.4% of patients with stomach lymphoma relapsed compared to 25% of patients with small bowel lymphoma. The risk of early relapse was higher in those with Stage IIA small bowel lymphoma than those with Stage IA small bowel lymphoma. We continue to recommend adjuvant abdominal irradiation for patients with Stage IA, IIA completely resected stomach lymphoma and Stage IA completely resected small bowel lymphoma. We recommend combined modality therapy for patients with completely resected Stage IIA small bowel lymphoma and all other localized gastrointestinal lymphoma where visible residual disease is present.     

Inflammatory bowel disease drastically affects the prognosis of patients treated for peritoneal metastases with combined cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: A multicenter study

Background

Complete cytoreductive surgery (CCRS) followed by hyperthermic intraperitoneal chemotherapy (HIPEC) is a validated treatment in selected patients with peritoneal metastases (PM) of intestinal origin. There is an increased risk of Colorectal Cancer (CRC) and Small Bowel Adenocarcinoma (SBA) in Inflammatory Bowel Disease (IBD). The feasibility and benefit of that surgical approach in IBD patients is unknown.

Microinvasive ductal carcinoma of the breast treated with breast-conserving surgery and definitive irradiation.

An analysis was performed of 39 consecutive women with microinvasive ductal carcinoma of the breast treated with breast-conserving surgery and definitive irradiation during the period 1977 to 1988. Microinvasive ductal carcinoma was defined as predominantly intraductal carcinoma with microscopic or early invasion. Surgical treatment of the primary tumor included excisional biopsy or wide resection. Axillary lymph node staging showed that 37 patients were pathologically node negative and two patients were pathologically node positive, each with only one positive lymph node. The median follow-up was 55 months (mean = 65 months; range = 25-135 months). The 5-year actuarial rate of overall and cause-specific survival were both 97%. The 5-year actuarial rate of freedom from distant metastases was 93%. Nine patients developed a recurrence in the breast; eight of the nine patients had isolated local only first failures, and one of the nine patients had a local recurrence simultaneously with distant metastases. The median time to local failure was 42 months (mean = 53 months; range = 20-116 months). Of the eight patients with local only first failure, seven patients have been salvaged with further treatment and remain free of disease at the time of last follow-up, and one patient has died of subsequent distant metastatic disease. Median follow-up after salvage treatment was 29 months (mean = 27 months; range = 0-54 months). Comparison of the patients with microinvasive ductal carcinoma with two control groups of intraductal carcinoma and invasive ductal carcinoma was performed. Although the rate of local failure was significantly higher for patients with microinvasive ductal carcinoma as compared to the two control groups, the rates of survival and freedom from distant metastases for patients with microinvasive ductal carcinoma were intermediate to the two control groups. Because of the high rates of survival and freedom from distant metastases and because of the ability to salvage patients with local recurrence, breast-conserving surgery and definitive irradiation should continue to be considered as an alternative to mastectomy for appropriately selected and staged patients with microinvasive ductal carcinoma of the breast.     

Prospective assessment of the endometrium in postmenopausal breast cancer patients treated with fulvestrant

This prospective study assessed the endometrial effects of fulvestrant, a pure estrogen-receptor antagonist, in postmenopausal women with breast cancer. This single-center study enrolled postmenopausal patients who had an intact uterus at baseline with progressive metastatic breast cancer on tamoxifen followed by an oral aromatase inhibitor (AI). Fulvestrant (250 mg) was administered every 28 ± 3 days via IM injection. Transvaginal ultrasonography (TVUS) was performed at baseline and after 3 months of therapy. Primary and secondary endpoints were changes from baseline in double endometrial thickness (DET) and uterine volume (UV), respectively. No interventions were performed on any asymptomatic uterine abnormalities that were detected at baseline. In total, 32 women were enrolled. Five patients had no repeat TVUS because of early progression before 3 months, leaving 27 evaluable patients for final analysis. After 3 months therapy, mean DET had significantly decreased by 23.08% (P = 0.010). Mean UV also decreased by 10.88%, although this change was not significant (P = 0.119). After 3 months of therapy, none reported vaginal bleeding, there were no changes noted in most of the uterine pathologies present at baseline and no new uterine abnormalities were detected. We observed that 3 months of fulvestrant treatment resulted in a significant decrease in endometrial growth and a non-significant decrease in UV in postmenopausal women with metastatic breast cancer previously exposed to tamoxifen and AIs. Furthermore, no new uterine pathologies were detected, indicating that fulvestrant behaves as a pure antiestrogen at the uterine level.     

Two case reports: Carcinoma of the cervix and carcinoma of the endometrium treated with radiotherapy after previous irradiation for benign uterine bleeding

In the 1940s, 1950s and 1960s, low closes of radiotherapy were used to treat benign uterine bleeding. The cases of two women who received this form of therapy and later developed gynaecological malignancies and had high-dose pelvic radiotherapy are presented. A 76-year-old woman with an International Federation of Gynecology and Obstetrics (FIGO) stage-IIB squamous cell carcinoma of the cervix received external beam radiotherapy and intra-uterine brachytherapy and a 77-year-old woman with a FIGO stage-IB endometrial adenocarcinoma received adjuvant postoperative pelvic radiotherapy. Both women had a significant past history of low-dose-rate intra-uterine irradiation for dysfunctional uterine bleeding. Therefore the theoretical question of carcinogenesis was raised, and also the practical questions of what dose had previously been given and what further dose could be safely given with regard to normal tissue tolerance.     

Nasopharyngeal cancer: study III. A review of 1206 patients treated with combined modalities

A combination of radiation therapy and chemotherapy was used in an attempt to improve the control of nasopharyngeal cancer (NPC). From 1979 through 1983, 1206 patients with histologically proven NPC were treated with routine radiation along with 5 combinations of drug or drugs in small to maintenance doses. The drugs used were: 1) cyclophosphamide p.o. (CTX), 2) methotrexate p.o. (MTX), 3) CTX + MTX, 4) bleomycin i.v. (BLM), and 5) cisplatin + BLM i.v. (BP). The actuarial survival rates and recurrence rates were chosen as endpoints for comparison to previous studies. The overall survival rate increased from 43.5% in study I, and 56% in study II to 70.6% in the present study. The recurrence rate declined to 13%, but was less impressive. The encouraging results were more obvious in groups of patients with bilateral large cervical lymph nodes, reaching statistical significance (p less than 0.01).     

Quality of life as predictor of survival: A prospective study on patients treated with combined surgery and radiotherapy for advanced oral and oropharyngeal cancer

Background and purpose

The relation between health-related quality of life (HRQOL) and survival was investigated at baseline and 6 months in 80 patients with advanced oral or oropharyngeal cancer after microvascular reconstructive surgery and (almost all) adjuvant radiotherapy.

Materials and methods

Multivariate Cox regression analyses of overall and disease-specific survival were performed including sociodemographic (age, gender, marital status, comorbidity), and clinical (tumor stage and site, radical surgical, metastasis, radiotherapy) parameters, and HRQOL (EORTC QLQ-C30 global quality of life scale).

Results

Before treatment, younger age and having a partner were predictors of disease-specific survival; younger age predicted overall survival. At 6 months post-treatment, disease-specific and overall survival was predicted by (deterioration of) global quality of life solely. Global health-related quality of life after treatment was mainly influenced by emotional functioning.

Conclusion

Deterioration of global quality of life after treatment is an independent predictor of survival in patients with advanced oral or oropharyngeal cancer.     

手术联合放疗治疗喉癌的疗效及预后因素分析

目的 探讨手术联合放疗治疗喉癌的疗效及影响预后的因素。方法 回顾性分析92例接受手术及术后放疗的喉癌患者的临床资料。Log-rank检验进行生存分析,Cox回归模型进行多因素分析。结果 92例喉癌患者的1、3、5、10年生存率分别为85.9％、72.6％、67.5％和60.9％,1、3、5、10年局部控制率分别为93.3％、81.3％、75.6％和57.6％。单因素分析结果显示,年龄、颈部淋巴结转移与喉癌患者的预后有关（P＜0.05）。Cox回归多因素分析显示,颈部淋巴结转移是影响喉癌患者预后的独立因素。结论 颈部淋巴结转移是影响喉癌患者手术联合放疗预后的独立因素。提高局部控制率、加强术后随访是提高生存率及改善生活质量的关键。