Treatment of stage I lung cancer (T1N0M0, T2N0M0)

Patients with stage I lung cancer can be offered surgical treatment with an excellent prognosis for recovery and long-term cure. The recent revision of the staging definition has rearranged the prognostic categories, further improving the prognosis in Stage I disease by eliminating patients with a higher risk of recurrence. The most vexing issues remaining are the infrequency of diagnosis of lung cancer at this stage and the increasing incidence of lung cancer of all stages, even among nonsmokers. Economical screening, abolition of cigarette smoking, control of airborne environmental carcinogens, and the continued search for effective systemic treatment remain challenges for the future.     

Contralateral breast carcinoma: an assessment of risk and prognosis in stage I (T1N0M0) and stage II (T1N1M0) patients with 20-year follow-up

Among 644 patients with a small (T1) primary breast carcinoma who were followed up for a median of 18.2 years, subsequent contralateral breast carcinomas were detected in 57 of 610 women (9%) who had a contralateral breast at risk. The average annual hazard rate for contralateral carcinomas was 8/1000 patients at risk per year without significant fluctuations throughout the 20 years of follow-up. Recurrences were caused by 9 of 57 (16%) subsequent contralateral carcinomas, and 4 of the 57 patients (7%) died of recurrent contralateral carcinomas. Contralateral carcinomas were responsible for 5.1% (9 of 176) of all recurrences of breast carcinomas and 2.6% (4 of 153) of breast carcinoma deaths. Surveillance of the contralateral breast must continue throughout a patient's lifetime. Detection and treatment of subsequent lesions at an early stage is a beneficial result of follow-up, especially in women whose first carcinoma is likely to have been cured.     

Efficacy of treatment of mammary gland carcinoma stage T2N0M0

Results of treatment of 218 patients with mammary gland cancer (MGC) stage T2N0M0 were analyzed. Surgical intervention was performed using mastectomy according to Holstad, Patey, Madden methods or organpreserving operation was done. Surgical treatment was added by preoperative and postoperative radiation therapy (RTH). In several patients chemotherapy and hormonotherapy was administered. There was established that in MGC stage T2N0M0 mostly efficient procedures were mastectomy according to Madden method and radical resection of the organ. The surgical intervention extension and excision of I-III orders of lymphatic nodes worsens the prognosis. If after the operation RTH is administered the result of treatment improves.     

Predictors of recurrence in stage I (T1N0M0) breast carcinoma.

A ten-year follow-up study of 382 women with Stage I (T1N0M0) breast carcinoma revealed recurrence and/or death due to cancer in 16% of the patients. Among 134 patients (35%) with a primary tumor 1.0 cm or less in diameter (Group A), 7% had recurrences and 5% died of breast carcinoma. Recurrences were observed in 21% of the 248 women with a tumor 1.1-2.0 cm in diameter (Group B), and 15% died of disease. These differences in recurrence and mortality rates were statistically significant. All recurrences were due to infiltrating duct or lobular carcinoma which accounted for 91% of the 382 carcinomas. Most strongly linked to recurrence was the finding of tumor emboli in lymphatics of the breast. This was found in 23 Group B patients and ten of them (43%) died of disease. No recurrences were observed among the seven Group A patients with lymphatic emboli. Other features associated with a significantly increased risk of recurrence were poorly differentiated carcinoma, marked lymphoid reaction to tumor, and menarche before age 12 years or after age 14 years. No combination of variables proved to identify a subset of patients with an especially increased or low risk of recurrence. Stage I patients with lymphatic tumor emboli in the breast surrounding a carcinoma 1.1-2.0 cm in diameter have a sufficient risk for recurrence to warrant consideration of adjuvant systemic therapy. A very low risk of recurrence was observed for the following: any tumor 1.0 cm or smaller; and tubular, medullary or colloid carcinoma up to 2.0 cm.     

Prognosis in stage II (T1N1M0) breast cancer.

As part of a detailed study of prognostic factors in breast cancer, we have analyzed the ten year survival rates of 524 patients with primary invasive carcinomas 2.0 cm or less in diameter (T1). This report describes the subset of 142 patients (27%) who had metastases only in axillary lymph nodes (T1N1M0). All the patients were treated initially by at least a modified radical mastectomy. Factors associated with a significantly poorer prognosis were: axillary lymph node metastases suspected on clinical examination; perimenopausal menstrual status at diagnosis; tumor larger than 1.0 cm; prominent lymphoid reaction; infiltrating duct or lobular rather than medullary, colloid and tubular carcinoma; and blood vessel invasion. When compared with those patients with negative nodes (T1N0M0), the patients with one or more lymph node metastases had a significantly poorer prognosis. Generally, survival rates tended to diminish as the number of involved lymph nodes increased. In this respect, comparison of patients with one-three and four or more nodal metastases provided a significant discrimination of prognostic groups in the entire series. However, for patients with disease limited to Level I, the same discrimination was obtained comparing those with one-two and three or more positive nodes. In the subset with a single lymph node metastasis, the size of the metastasis (micro or less than or equal to 2 mm vs macro or greater than 2 mm) was not significantly related to prognosis. Lymph node metastases were significantly less frequent among tumors smaller than 1 cm and special tumor types (medullary, colloid, lobular and tubular). However, no factor proved to be a reliable predictor of the presence of axillary metastases for the single largest group consisting of patients with infiltrating duct carcinoma 1-2 cm in diameter.     

Treatment of modified Stage II (T1 N1 M0, T2 N1 M0) non-small cell bronchogenic carcinoma. A combined modality approach

Twenty patients with postsurgical, modified Stage II (T2 N1 M0, T1 N1 M0) non-small cell bronchogenic carcinoma were seen between 1974 and 1981 and were evaluated in a retrospective manner. Fifteen patients had T2 N1 M0 lesions, while 5 patients had T1 N1 M0 disease. Eight patients were treated with surgical resection alone, of whom seven had died, with a median survival of 12.0 months. Four patients received surgical resection and postoperative radiation therapy, of whom two have died, with a median survival not reached at 37 months. Eight patients were treated with surgical resection, radiation therapy, and adjuvant chemotherapy including cyclophosphamide (C), doxorubicin (A), methotrexate (M), and procarbazine (P). Six patients are alive and free of disease, with a median survival not yet reached at 72 months. There is a significant survival advantage for the 12 patients treated with combined modality therapy (surgical resection + radiation therapy; surgical resection + radiation therapy + chemotherapy) compared to the eight patients treated with SR alone (p less than 0.01), and for the eight patients receiving chemotherapy versus the 12 patients who did not (p less than 0.01). In spite of thorough clinical and surgical staging, patients with T1 and T2 primary tumors with N1 disease have a high relapse rate, predominantly in metastatic sites. Adjuvant radiation therapy and chemotherapy appear to benefit these patients with modified Stage II non-small cell bronchogenic carcinoma.     

Three dimensional conformal radiotherapy in patients with T2a-b,N0, M0 prostatic carcinoma

The current study was undertaken to evaluate the Prostate Specific Antigen (PSA) relapse free survival and the prognostic factors in a total of 38 patients with stages of T_2a-b, N₀, M₀ prostate carcinoma treated with three-dimensional conformal radiotherapy (3D-CRT). Mean 69.63 Gy was given with 3D-CRT, the mean follow up time was 13.89 months, and the mean prebiopsied PSA level was 25.12 ng/ml. The 2-year PSA relapse free survival was 47.37% for the entire group. The 2-year PSA relapse free survival rates were 100% and 44.74% for the patients with Gleason score ≤ 7 and greater than 7 (p ≤ 0.05). Patients with prebiopsied PSA level ≤ 10 ng/ml and the stages of T_2a or T_2b did not show any significant differences (p ≥ 0.05). Although the few case number and short term follow up, in this study 3D-CRT was a new effective technique to prostate cancer for our institutes and the Gleason score was important predictor of PSA relapse free survival. This revised version was published online in August 2006 with corrections to the Cover Date.     

Comparison of surgery and radiotherapy in T1 and T2 glottic carcinomas

We retrospectively studied 356 patients who received treatment for T1 and T2 glottic carcinomas. Two hundred and thirty patients were treated with surgery (200 by cordectomy, 15 by vertical partial laryngectomy, and 15 by subtotal laryngectomy). Radiotherapy was used to treat 126 patients. There were 206 T1 and 24 T2 lesions in the surgically treated group and 107 T1 and 19 T2 lesions in the radiotherapy group. Sixty-four patients received radiotherapy because it was the treatment of choice (scheduled radiotherapy) and 62 patients received radiotherapy because they had medical contraindications for surgery (default radiotherapy). Actuarial survival rates at 5 years were 84% for patients who underwent surgery and 78% for patients who underwent scheduled radiotherapy. In the surgically treated group, there were 10 local recurrences in 170 patients with tumors of the true vocal cord, eight recurrences in 36 patients with anterior commissure lesions, and 6 recurrences in 24 patients with tumors extending to the arytenoid. In the scheduled radiotherapy group, there were 7 local recurrences in 38 patients with true vocal cord tumors, 6 recurrences in 20 patients with anterior commissure tumors, and 5 recurrences in 6 patients with tumors extending to the arytenoid. We conclude that survival is similar in these patients whether they receive operative treatment or scheduled radiotherapy. However, in the radiotherapy group, local recurrences were more frequent in patients with tumors extending to the arytenoid. We advocate extended functional surgery for patients with T1 and T2 glottic lesions except for those with small tumors arising from the middle third of the vocal cord.     

Carbon dioxide laser salvage surgery after radiotherapy failure in T1 and T2 glottic carcinoma.

OBJECTIVES: Recurrent glottic carcinoma after radiotherapy (RT) may be managed by open neck or endoscopic surgery. The impact of endoscopic treatment with CO(2) laser for recurrent glottic carcinoma after RT is reported. METHODS: We present the oncologic and vocal outcomes of a retrospective study based on a series of 16 patients with rT1 and rT2 glottic carcinoma who were endoscopically managed between February 1995 and December 1999 after RT failure. All patients were males with a mean age of 68.7 years (range, 50 to 87 years). Before RT, the lesions had been staged as T1 N0 in 11 patients and T2 N0 in 5, and after RT as rT1 N0 in 12 and rT2 N0 in 4. According to the European Laryngological Society classification, a total of 9 transmuscular, 3 total, and 4 extended cordectomies were performed. Mean follow-up was 45 months (range, 9 to 79 months). RESULTS: Endoscopic salvage surgery was successful in 14 patients. One of them developed a second recurrence and was definitively cured with an additional endoscopic procedure. Two of the 16 patients had recurrent disease after salvage laser surgery and died due to progression of disease. Ultimate local control with laser alone at 3 years was 87.1%, according to the Kaplan-Meier method. Laryngeal preservation was obtained in all survivors after endoscopic rescue surgery. Voice analysis showed a clear correlation between the amount of vocal cord tissue resected and decrease of the vocal outcome. CONCLUSIONS: The present series indicates that selected recurrences after primary RT for T1 and T2 glottic carcinoma are eligible for endoscopic salvage surgery with oncologic results comparable to those with open neck procedures but with a lower complication rate and a favorable functional outcome.     

早期(T1N0M0)非小细胞肺癌外科治疗的探讨

目的：探讨肺叶切除术和楔形切除术对早期(T1N0M0)非小细胞肺癌(NSCLC)的疗效。方法：分析109例早期(T1N0M0)NSCLC病例的手术效果，其中楔形切除术51例(开胸组21例，胸腔镜组30例)，肺叶切除术58例；包括各治疗组间对术后并发症发生率、病死率、术后复发率、生存率及肺功能的评估。结果：各治疗组间肿瘤的组织类型、术后并发症发生率和病死率及后期肺功能差异无显著性。楔形切除组年龄偏大，慢性阻塞性肺病((COPD)发病率高，肺功能较差，与肺叶切除组相比，平均住院日明显减少，局部复发率增高，差异有统计学意义。1年生存率各组相似(开胸楔形切除组95％，胸腔镜楔形切除组95％，肺叶切除组91％)，5年生存率开胸楔形切除组58％，胸腔镜楔形切除组65％，肺叶切除组70％，差异有统计学意义(P=0．02)。结论：对有心肺功能损害的早期NSCLC病人，楔形切除术是一种可行的外科治疗；但由于局部复发率较高，只要病人心肺功能耐受，仍应首选肺叶切除术。     

Management of T3 N0 and T4 N0 glottic carcinomas: results of a national survey.

OBJECTIVE: A survey was undertaken to document the clinical management of T3 and T4 pure glottic primary carcinomas and the management of the N0 neck by otolaryngologists and radiation oncologists. STUDY DESIGN AND SETTING: This study represents the results of a national survey of 250 otolaryngologists and 250 radiation oncologists regarding management of T3 N0 M0 and T4 N0 M0 glottic carcinomas. RESULTS: Of the surveys sent, 208 completed questionnaires were received. Results of this survey suggest that 87% and 90% will treat the neck for a T3 N0 M0 and T4 N0 M0 glottic tumor, respectively, with a large number choosing to perform a radical neck dissection. CONCLUSIONS: A significant percentage of otolaryngologists perform neck dissections in the management of T3 N0 M0 and T4 N0 M0 glottic carcinomas. Given the relatively low risk of occult metastasis, potentially high morbidity associated with overtreatment, and the lack of a well-designed outcome study investigating treatment alternatives, a prospective randomized study is needed to address the issue.     

Treatment of stage II lung cancer (T1N1 and T2N1)

Adenocarcinoma and large cell carcinoma have a worse prognosis than squamous cell carcinoma in the T1N1 and T2N1 subsets. In addition, local failure is a major problem with squamous carcinoma, whereas the most common sites of first recurrence are systemic, especially the brain, in non-squamous cell carcinoma. It is clear that radiation therapy can prevent local recurrences. In addition, chemotherapy prolongs survival but systemic recurrences--especially in the brain--remain the major obstacle to improved cure rates.     

Management of stage T3 and T4 glottic carcinomas

Between 1959 and 1979, 242 patients with T3 and T4 lesions of the vocal cords were treated at our institution. Treatment consisted of total laryngectomy in all patients. Different modalities of regional node dissections were performed on 187 patients. In addition, 50 patients received irradiation with cobalt-60 postoperatively for specific features of the disease. In the group of 192 patients whose treatment consisted of surgery alone, 28 (14 percent) had recurrence in the neck and 10 (5 percent) had stomal recurrence. Of the patients treated with combined therapy, three (6 percent) had ipsilateral neck recurrences and one (2 percent) had stomal recurrence. For lesions staged N0, failure rates above the clavicles were 16 percent and 31 percent for patients with T3 and T4 lesions, respectively, in the group treated by surgery alone, 9 percent and 6 percent for patients with T3 and T4 lesions, respectively, in the combined therapy group. The rate of failure above the clavicles for lesions staged N+ was 32 percent in the group treated with surgery alone and 8 percent in the combined therapy group. In this study, a correlation was made between the failure rates above the clavicles and different clinical and histologic characteristics of the tumor, surgical findings, and the different modalities of cervical node dissection used. From analysis of the data, recommendations have been made for the selective treatment of patients with advanced glottic carcinomas.     

Modified stage I (T1N0M0, T2N0M0), nonsmall cell lung cancer: treatment results, recurrence patterns, and adjuvant immunotherapy

We analyzed 96 patients who had surgery with T1N0M0 or T2N0M0 nonsmall cell lung cancer (NSCLC) to identify survival rates and recurrence patterns in well-staged patients and to evaluate adjuvant therapy. Preoperative staging included chest x-ray, gallium 67 scanning, and bronchoscopy in all patients. At thoracotomy, multiple mediastinal lymph node sites were routinely sampled. The results included an operative mortality rate of 5.2%, and the actuarial 5-year survival rate of all patients was 70.0%. Survival of T1N0 (n = 44) and T2N0 (n = 47) patients was 72.1% and 68.3%, respectively (p = NS). Survival was not affected by type of surgery, cell type, sex, age, or race. Late death was due to recurrence in 12 patients, a new airway malignancy in three, and a noncancer problem in six. Disease recurred in 15 patients: four (9.1%) T1N0 patients versus 11 (23.4%) T2N0 patients, p less than 0.05. Recurrence was local in four patients and distant in 11. Second lung cancers developed in six patients at a mean interval of 65.7 months after resection. A prospective, randomized trial of systemic immunotherapy with bacillus Calmette-Guerin (BCG) skin scarification was carried out in 29 patients. Survival in those patients receiving BCG was 85.9% compared with 63.9% for control subjects (p = 0.075) and 69.6% for patients not in the study (p = 0.077). The following conclusions can be made: Resection for well-staged, modified stage I NSCLC results in a 5-year survival rate of 70%. Nearly half the deaths are unrelated to recurrence of the original cancer. Recurrences are more frequent in T2N0 patients, but there is no survival difference compared with T1N0 patients. Systemic recurrences are more frequent than local recurrences, and there is an appreciable incidence of second lung cancers. Adjuvant chemotherapy or radiation therapy does not seem justified, but systemic immunotherapy holds sufficient promise to warrant further investigation.     

Clinical trials of peripheral stage I (T1N0M0) non-small cell lung cancer

Debate continues regarding the choice of resection for peripheral stage I (T1N0M0) non-small cell lung cancer (NSCLC). Anatomic lobectomy has been considered the standard of care for resectable NSCLC; however, intriguing results of clinical trials have been reported with the use of sublobar resection as primary therapy of selected small peripheral lung cancers. Most modern clinical studies comparing lobectomy to sublobar resection of stage I NSCLC demonstrate equivalent survival, but local recurrence following sublobar resection appears to be greater. Low energy computed tomography screening programs for lung cancer have increasingly identified small peripheral lesions potentially amenable to effective therapeutic management with sublobar resection. We discuss the possible management scenarios for stage I NSCLC in this age of early computed tomography detection of lung cancer, more precise molecular biologic staging of the disease, optimized peri-operative management of the marginally resectable patient, and improved adjunctive treatment measures for local control following lung cancer resection.     

Results treatment of laryngeal cancer in T4N0M0 stage

Experience of treatment of 127 patients with cancerous laryngeal tumor in T4N0M0 stage was summarized. In 25 patients radiation therapy was done, in 16--chemoradiation treatment, in 42--surgical, in 44--the combined one. Difference between results of application of radiation therapy and chemoradiation treatment was not significant. After conduction of combined treatment with preoperative radiation the 5-year survival index had constituted (53.1 +/- 10.8)%. High efficacy of surgical prophylaxis of the regional metastases occurrence was noted in patients with stenosing laryngeal cancer. When radiation resistant laryngeal cancer is revealed it is necessary to study up the efficacy of surgical prophylaxis of the regional metastases occurrence in such patients.