外阴癌临床治疗309例报告

目的　分析外阴癌不同治疗方法的结果 ,并探讨其复发转移的特征。方法　采用回顾性研究的方法 ,对 30 9例外阴癌的临床治疗结果进行分析。结果　 30 9例患者总的 5年生存率为6 7.9% ,Ⅰ、Ⅱ、Ⅲ及Ⅳ期的 5年生存率分别为 86 .9%、82 .5 %、5 9.2 %和 43.6 %。总的治疗失败率为49 .8% (其中 2年内失败者占 6 9.5 % ) ;复发部位依复发时间不同而异 ,83.6 %的腹股沟、盆腔及远处转移发生在治疗后 2年内 ,外阴局部复发占 2年后治疗失败的 81.1%。外阴癌复发转移与年龄无关。Ⅰ期癌各种治疗方法的生存率及治疗失败率差异无显著性。Ⅱ期癌外阴根治性切除 腹股沟清扫术生存率较高 (P <0 .0 5 ) ;腹股沟淋巴结阳性者 ,手术治疗的失败率显著低于放疗 (P <0 .0 5 ) ;腹股沟淋巴结阴性者 ,两种治疗方式差异无显著性 ;腹股沟预防照射剂量Dm达 6 0Gy者 ,失败率显著低于剂量Dm <6 0Gy者 (P <0 .0 5 )。结论　早期外阴癌应施行外阴根治性切除 ,加施预防性淋巴清扫或腹股沟足量放疗 ;对中晚期患者 ,争取切除原发灶及行腹股沟淋巴清扫 ,并辅以术前、术后放疗。     

Irradiation in carcinoma of the vulva: factors affecting outcome

Purpose: This report reviews the increasing role of radiation therapy in the management of patients with histologically confirmed vulvar carcinoma, based on a retrospective analysis of 68 patients with primary disease (2 in situ and 66 invasive) and 18 patients with recurrent tumor treated with irradiation alone or combined with surgery.Methods and Materials: Of the patients with primary tumors, 14 were treated with wide local excision plus irradiation, 19 received irradiation alone after biopsy, 24 were treated with radical vulvectomy followed by irradiation to the operative fields and inguinal–femoral/pelvic lymph nodes, and 11 received postoperative irradiation after partial or simple vulvectomy. The 18 patients with recurrent tumors were treated with irradiation alone. Indications and techniques of irradiation are discussed in detail.Results: In patients treated with biopsy/local excision and irradiation, local tumor control was 92% to 100% in Stages T1-3N0, 40% in similar stages with N1-3, and 27% in recurrent tumors. In patients treated with partial/radical vulvectomy and irradiation, primary tumor control was 90% in patients with T1-3 tumors and any nodal stage, 33% in patients with any T stage and N3 lymph nodes, and 66% with recurrent tumors. The actuarial 5-year disease-free survival rates were 87% for T1N0, 62% for T2-3N0, 30% for T1-3N1 disease, and 11% for patients with recurrent tumors; there were no long-term survivors with T4 or N2-3 tumors. Four of 18 patients (22%) treated for postvulvectomy recurrent disease remain disease-free after local tumor excision and irradiation. In patients with T1-2 tumors treated with biopsy/wide tumor excision and irradiation with doses under 50 Gy, local tumor control was 75% (3 of 4), in contrast to 100% (13 of 13) with 50.1 to 65 Gy. In patients with T3-4 tumors treated with local wide excision and irradiation, tumor control was 0% with doses below 50 Gy (3 patients) and 63% (7 of 11) with 50.1 to 65 Gy. In patients with T1-2 tumors treated with partial/radical vulvectomy and irradiation, local tumor control was 83% (14 of 17), regardless of dose level, and in T3-4 tumors, it was 62% (5 of 8) with 50 to 60 Gy and 80% (8 of 10) with doses higher than 60 Gy. The differences are not statistically significant. There was no significant dose response for tumor control in the inguinal–femoral lymph nodes; doses of 50 Gy were adequate for elective treatment of nonpalpable lymph nodes, and 60 to 70 Gy controlled tumor growth in 75% to 80% of patients with N2-3 nodes when administered postoperatively after partial or radical lymph node dissection. Significant treatment morbidity included one rectovaginal fistula, one case of proctitis, one rectal stricture, four bone/skin necroses, four vaginal necroses, and one groin abscess.Conclusions: Irradiation is playing a greater role in the management of patients with carcinoma of the vulva; combined with wide local tumor excision or used alone in T1-2 tumors, it is an alternative treatment to radical vulvectomy, with significantly less morbidity. Postradical vulvectomy irradiation in locally advanced tumors improves tumor control at the primary site and the regional lymphatics in comparison with reports of surgery alone.     

Recurrent epidermoid cancer of the anus

Of 83 patients with recurrent epidermoid cancer of the anus, 67 had tumors in the anal canal and 16 had tumors at the anal margin. Local pelvic or perineal recurrence after abdominoperineal resection of tumors in the canal had a poor prognosis. Median survival after combination chemotherapy and megavoltage irradiation was 14 months. With irradiation alone, median survival was 7 months, although nearly half of these patients had been treated with orthovoltage techniques. Untreated patients with visceral metastases had a median survival of 8 months, but no improvement in survival was seen after treatment with chemotherapy. In contrast, patients who had metastases in inguinal lymph nodes had a 55% 5-year survival rate after inguinal dissection. Patients with tumors at the anal margin did not have visceral metastases. This is an important difference between tumors arising in the canal and those arising at the anal margin. Local excision was satisfactory treatment for 90% of the patients who had local recurrence in the perianal skin; abdominoperineal resection was rarely required. Inguinal lymph node metastases from margin cancer are uncommon, but three of five such patients survived 5 years after groin dissection. A combination of 5-fluorouracil, mitomycin C, and radiation therapy was used for patients with pelvic recurrence after abdominoperineal resection of epidermoid cancer of the anal canal. In this study, there was no evaluation of the role of megavoltage irradiation alone at the recommended doses of 5500 to 6000 rad for these patients. Some patients with visceral metastases respond to combination chemotherapy, but median survival is not improved; evaluation of new chemotherapeutic regimens is required. Patients with canal tumors metastatic to inguinal nodes should be treated by groin dissection as their prognosis is relatively good. Local recurrence of tumors at the anal margin can be satisfactorily treated by further local excision; those patients with margin tumors metastatic to inguinal nodes require groin dissection.     

Prophylactic inguinal-femoral irradiation as an alternative to primary lymphadenectomy in treatment of vulvar carcinoma

In a complete geographic series of 294 cases of primary vulvar carcinomas prophylactic inguinal-femoral irradiation was used as a standard postoperative therapy. Inguinal lymph node dissection was performed in only 27 cases (9%) and was not part of the standard surgery. The histology was squamous cell carcinoma in 269 cases (92%). The primary surgery was total vulvectomy, partial vulvectomy, or local resection of the tumor. The main type of radiotherapy was adjuvant inguinal irradiation. Two separate, symmetrical and rectangular inguinal fields were irradiated with combined photon and electron beams. In the complete series 127 recurrences (43%) were recorded. Local (24%) and regional recurrences (19%) were most frequent. Type of surgery was not associated with the risk of tumor recurrence. The 5-year overall survival rate was 53% and the relapse-free survival (RFS) rate was 55%. Tumor grade was significantly (P=0.007) associated with the RFS. The inguinal RFS rate was 75% both for patients treated with adjuvant inguinal irradiation without lymphadenectomy and patients treated with primary lymph adenectomy +/- inguinal irradiation. Postoperative complications were recorded in 22%. Postoperative complications occurred most frequently in the subgroup undergoing inguinal lymphadenectomy. Chronic lymph edemas were the most serious late tissue reactions.     

A case of advanced rectal carcinoma with multiple lung metastases responding to irinotecan combined with 5-fluorouracil and l-leucovorin (IFL) as neoadjuvant chemotherapy (NAC)

A 53-year-old man, admitted for inguinal hernia, complained of body weight loss in a preoperative condition check. We examined the digestive tract and diagnosed stage IV advanced rectal carcinoma with multiple lung metastases. It caused ileus, so emergency colostomy was performed. After that his general condition recovered, and two cycles of neoadjuvant chemotherapy (NAC) by irinotecan combined with 5-fluorouracil and l-leucovorin (IFL) therapy were performed on an outpatient basis. Lung metastatic nodules disappeared. We established a diagnosis of down staging for stage IIIa, and performed a lower anterior resection with D 2 lymph node dissection to allow a curability-A resection. The pathological effect of NAC was Grade 2. Post-operatively, two cycles of IFL therapy were then performed. There has been no sign of recurrence, and no adverse effects by chemotherapy have been seen during this treatment. Thus, NAC by IFL therapy can be one of the useful treatment approaches for patients with advanced rectal cancer.     

Surgical management of vulvar cancer.

Vulvar cancer is an uncommon disease, marked by typical long delays in diagnosis due to lack of awareness by doctors and patients. The most common histology is squamous, although melanoma, sarcoma and adenocarcinoma occur less frequently. The predictable spread pattern of vulvar cancer to regional then distant lymphatics has allowed for improvements in survival largely due to radical surgical intervention. However, the significant morbidity from radical surgery has led to the search for better prognostic indicators and complementary therapeutic modalities to modify the extent of surgery in both early and advanced disease. En bloc radical vulvectomy and bilateral inguinal-femoral lymphadenectomy are rarely performed today: an early invasive stage has been defined where only limited excision is required. The extent of and the indications for inguinal lymphadenectomy for various clinical tumors and role of separate incisions have been clarified. When disease has spread to more than one inguinal node, adjuvant radiotherapy has replaced pelvic lymphadenectomy as the standard. Inguinal radiotherapy without groin dissection does not appear to be adequate therapy for most patients. The use of chemotherapy and radiation to shrink large tumors to allow surgical resection continues to be evaluated but has demonstrated excellent results to date. The utility of newer techniques of sentinel node mapping is also being evaluated in squamous cancers and melanoma to limit the extent of lymphadenectomy in patients with clinically normally lymph nodes.     

Ⅰ期睾丸精原细胞瘤术后综合治疗进展

 精原细胞瘤约占睾丸生殖细胞瘤的40 %,其中大多数为临床Ⅰ期,长期以来经睾丸高位切除术及术后同侧髂血管及腹主动脉旁淋巴结照射是其经典治疗方式,近年来不少肿瘤学家提出单纯腹主动脉旁照射、卡铂化疗及术后单纯随访取得了与同侧髂血管及腹主动脉旁照射同样的近期疗效,且患者不良反应明显减少,但远期疗效尚不明确。     

Preoperative chemoradiation for advanced vulvar cancer: a phase II study of the Gynecologic Oncology Group

Purpose: To determine the feasibility of using preoperative chemoradiotherapy to avert the need for more radical surgery for patients with T₃ primary tumors, or the need for pelvic exenteration for patients with T₄ primary tumors, not amenable to resection by standard radical vulvectomy.Methods and Materials: Seventy-three evaluable patients with clinical Stage III–IV squamous cell vulvar carcinoma were enrolled in this prospective, multi-institutional trial. Treatment consisted of a planned split course of concurrent cisplatin/5-fluorouracil and radiation therapy followed by surgical excision of the residual primary tumor plus bilateral inguinal–femoral lymph node dissection. Radiation therapy was delivered to the primary tumor volume via anterior-posterior–posterior-anterior (AP–PA) fields in 170-cGy fractions to a dose of 4760 cGy. Patients with inoperable groin nodes received chemoradiation to the primary vulvar tumor, inguinal–femoral and lower pelvic lymph nodes.Results: Seven patients did not undergo a post-treatment surgical procedure: deteriorating medical condition (2 patients); other medical condition (1 patient); unresectable residual tumor (2 patients); patient refusal (2 patients). Following chemoradiotherapy, 33/71 (46.5%) patients had no visible vulvar cancer at the time of planned surgery and 38/71 (53.5%) had gross residual cancer at the time of operation. Five of the latter 38 patients had positive resection margins and underwent: further radiation therapy to the vulva (3 patients); wide local excision and vaginectomy necessitating colostomy (1 patient); no further therapy (1 patient). Using this strategy of preoperative, split-course, twice-daily radiation combined with cisplatin plus 5-fluorouracil chemotherapy, only 2/71 (2.8%) had residual unresectable disease. In only three patients was it not possible to preserve urinary and/or gastrointestinal continence. Toxicity was acceptable, with acute cutaneous reactions to chemoradiotherapy and surgical wound complications being the most common adverse effects.Conclusion: Preoperative chemoradiotherapy in advanced squamous cell carcinoma of the vulva is feasible, and may reduce the need for more radical surgery including primary pelvic exenteration.     

Postoperative adjuvante Strahlentherapie der Vulva und Vagina

It is widely accepted that adjuvant local radiotherapy of the vulva is indicated for limited resection, deep invasion (>5 mm) and close (<1 cm) or positive surgical margins. Other factors in favour of postoperative radiation therapy are lymph vessel invasion and large tumour size. Adjuvant irradiation of the groins is indicated in patients with positive lymph nodes, in particular in high risk patients (≥2 positive nodes and clinically suspect or fixed ulcerated groin nodes), for whom pelvic radiotherapy should be added to inguinal radiotherapy. In patients with clinically negative nodes, the invasion depth is the most important factor to be taken into account to decide whether adjuvant radiation therapy of the groin is required. The importance of surgical treatment for patients with vaginal cancer, in particular for locally advanced disease, is limited. Adjuvant radiation therapy is therefore rarely performed in these patients and little clinical evidence is available. Adjuvant radiotherapy may therefore be applied, analogue to vulvar cancer, in the few surgical patients with close or positive resection margins and in those patients with positive lymph nodes.     

Surgical treatment of scirrhous carcinoma of the stomach

In surgical treatment of scirrhous gastric carcinoma, the important points are as follows: Extensive resection of the stomach should be performed. Left epigastric evisceration and extensive dissection of lymph nodes including the para-aortic nodes should be done for sufficient extirpation of the tissues around the stomach. Adjuvant therapy is recommended for intensive chemotherapy immediately after surgery and for postoperative long-term maintenance therapy. Development of a combined therapy which takes into account the characteristics of scirrhous gastric cancer is hoped for in the future.     

Clinicopathologic characteristics and prognostic factors in 10 783 patients with gastric cancer

Background. Although the results of gastric cancer treatment have markedly improved, this disease remains the most common cause of cancer death in Korea. Methods. Clinicopathologic characteristics were analyzed for 10 783 consecutive patients who underwent operation for gastric cancer at the Department of Surgery, Seoul National University Hospital, from 1970 to 1996. We also evaluated survival and prognostic factors for 9262 consecutive patients operated from 1981 to 1996. The clinicopathologic variables for evaluating prognostic values were classified as patient-, tumor-, and treatment-related factors. The prognostic significance of treatment modality [surgery alone, surgery + chemotherapy, surgery + immunotherapy + chemotherapy (immunochemosurgery)] was evaluated in patients with stage III gastric cancer (according to the International Union Against Cancer TNM classification of 1987). For the assessment of lymph node metastasis, both the number of involved lymph nodes and the ratio of involved to resected lymph nodes were analyzed, as a quantitative system. Results. The mean age of the 10 783 patients was 53.5 years and the male-to-female ratio was 2.07 : 1. Resection was performed in 9058 patients (84.0% resection rate). The 5-year survival rates were 55.9% for all patients and 64.8% for patients who received curative resection. Age, sex, preoperative hemoglobin and albumin levels, type of operation, curability of operation, tumor location, Borrmann type, tumor size, histologic differentiation, Lauren's classification, perineural invasion, lymphatic invasion, vascular invasion, depth of invasion, number of involved lymph nodes, ratio of involved to resected lymph nodes, and distant metastasis had prognostic significance on univariate analysis. Radical lymph node dissection, with more than 25 resected lymph nodes improved survival in patients with stage II and IIIa disease. As postoperative adjuvant therapy, immunochemotherapy was most effective in patients with stage III disease. Patients with identical numbers of lymph nodes -either the number of involved lymph nodes or the number of resected lymph nodes- were divided according to their ratios of involved-to-resected lymph nodes. In each numeric group, there were significant survival differences according to the ratio of involved-to-resected lymph nodes. However, patients who had the same involved-to-resected lymph node ratio did not show significant differences in survival rate according to either the number of involved or the number of resected lymph nodes. On multivariate analysis, curability of operation, depth of invasion, and ratio of involved to resected lymph nodes were independent significant prognostic factors. Conclusions. Curative resection, depth of invasion, and lymph node metastasis were the most significant prognostic factors in gastric cancer. With regard to the status of lymph node metastasis, the ratio of involved to resected lymph nodes had a more precise and comprehensive prognostic value than only the number of involved or resected lymph nodes. Early detection and curative resection with radical lymph node dissection, followed by immunochemotherapy, particularly in patients with stage III gastric cancer should be the standard treatment in principle, for patients with gastric cancer. Received for publication on Apr. 13, 1998; accepted on Oct. 22, 1998     

新辅助化疗治疗进展期胃癌1 例

1 例59岁男性患者诊断为胃癌。胃周围、腹腔干多发肿大淋巴结。行CT检查考虑局部进展期胃癌（cT4,cN2,cM0）,因考虑患者的病情与年龄情况,给予mFOLFOX7 方案化疗2 个周期:OXA100mg/m2ivd 1（2hr ）,CF400mg/m2ivd 1（2hr ）,5-FU 2 400mg/m2civd 1（46hr ）。 复查CT肿物明显缩小,胃周围、腹腔干肿大淋巴结缩小。根据RECIST评价病情考虑为PR。行全胃切除+D2 淋巴结清扫+ 胰尾部分切除+ 脾切除术。术后病理分期为pT4N2M0ⅢB 期。mFOLFOX新辅助化疗成功的治疗此例胃癌患者,但是其在进展期胃癌治疗中的作用,仍需进一步的临床研究证实。无法达到R0 切除以及无远处转移的局部进展期胃癌患者可考虑行新辅助化疗。      

A case of advanced esophageal cancer with extensive lymph node metastases successfully treated with multimodal therapy

Advanced esophageal cancer patients with extensive lymph node metastases show extremely poor prognosis and the long-term outcome is poorer with the involvement of more lymph nodes. We report here a long-surviving case of advanced esophageal cancer with histologically 34 lymph node metastases, in which surgical resection with three-field lymphadenectomy followed by adjuvant chemotherapy and radiotherapy was performed. A 53-year-old male was diagnosed as advanced middle esophageal cancer with multiple regional lymph node metastases such as paraesophageal, pretracheal, tracheobronchial and bifurcational lymph nodes and three intramural metastatic lesions. Subtotal esophagectomy with three-field lymphadenectomy was performed for the tumor. Histopathologically, the tumor was poorly differentiated squamous cell carcinoma and 34 lymph nodes including ligamentum arteriosum lymph nodes and pretracheal lymph nodes were proved to be metastatic. Numerous tumor cells were found in the lymphatic vessels near the metastatic lymph nodes. Chemotherapy [3000 mg of 5-fluorouracil (5-FU), 50 mg of cisplatin (CDDP) and 30 mg of methotrexate (MTX)] was administered in two courses, followed by radiation therapy (field size 21 x 20 cm in mediastinum, 10 MV X-rays, 2 Gy/fr, 5 fr/week, total 46 Gy). Subsequently, 1000 mg of 5-FU and 200 mg of CDDP were administered every 3-4 months without any significant toxicities. The patient has been alive and well without recurrence for 5 years following operation. For treatment of advanced esophageal cancer with extensive lymph node metastases, a wide resection of the tumor and regional lymph nodes should be performed, followed by adjuvant chemotherapy and radiotherapy.     

A case of successfully treated lower rectal cancer with both inguinal lymph nodes by chemoradiotherapy

We report a case of successfully treated lower rectal cancer with both inguinal lymph nodes by chemoradiotherapy. A 59-year-old man presented with anal pain. A colonoscopy revealed primary rectal cancer. The histological diagnosis was well to moderately differentiated adenocarcinoma. A computed tomography showed metastases to pararectal, both inguinal lymph nodes and right external iliac. After a ileostomy construction was done, he was treated with intensity modulated radiotherapy (a total 50.4 Gy) and chemotherapy with FOLFOX. The primary tumor had completely disappeared, and metastases to lymph nodes showed a remarkable shrinkage after the chemoradiotherapy. Nine months after radiation therapy, however, multiple lung and liver metastases were observed by a computed tomography, which were treated by systemic chemotherapy with FOLFOX and bevacizumab. The primary tumor and metastases to lymph nodes are still controlled well for 2 years after the initial chemoradiotherapy.     

Management of Clitoral Melanoma Presenting as an Exophytic Clitoral Mass: A Case Report and Review of the Literature

Primary mucosal melanomas of the female genital tract account for one percent or less of all cases of melanoma with even fewer originating in the clitoris. Given the rarity of diagnosis of clitoral melanoma, there is a paucity of data guiding management. There is no supporting evidence that radical vulvectomy (with or without inguinal lymphadenopathy) is associated with improved disease-free or overall survival compared to partial vulvectomy or wide local excision. Additionally, there is no data to evaluate the role of sentinel lymph node biopsy or extensive lymphadenectomy in clitoral melanoma, however previous evidence demonstrates the utility of regional lymph node sampling in predicting survival in women with female genital tract mucosal melanoma. Adjuvant therapy considerations are often extrapolated from their use in treating cutaneous melanomas, including immune checkpoint inhibitors and other immunotherapy agents. Adjuvant radiation therapy has limited utility except in cases of bulky, unresectable disease, or when inguinal lymph nodes are positive for metastasis. The 52 year-old patient presented in this review was diagnosed with locally invasive advanced stage clitoral melanoma presenting as an exophytic clitoral mass. She underwent diagnostic primary tumor resection, which demonstrated ulcerative melanoma with spindle cell features extending to a Breslow depth of at least 28 mm. She subsequently underwent secondary wide local excision with groin sentinel lymph node biopsy, and adjuvant treatment with pembrolizumab. This article also emphasizes the importance of a multidisciplinary team involving gynecologic oncology, medical oncology, radiology, and pathology for management of this rare type of primary mucosal melanoma of the female genital tract.     

Effect of Neoadjuvant Chemotherapy on Axillary Lymph Node Positivity and Numbers in Breast Cancer Cases

Background: The aim of this study is to compare the numbers of axillary lymph nodes (ALN) taken out by dissection between patients with breast cancer operated on after having neoadjuvant chemotherapy (NAC) treatment and otherswithout having neoadjuvant chemotherapy, and to investigate factors affecting lymph node positivity. Materials and Methods: A total of 49 patients operated due to advanced breast cancer after neoadjuvant chemotherapy and 144 patients with a similar stage of the cancer having primary surgical treatment without chemotherapy at the general surgery clinic of Ondokuz Mayis University Medicine Faculty between the dates 01.01.2006 and 31.10.2012 were included in the study. The total number of lymph nodes taken out by axillary dissection (ALND) was categorized as the number of positive lymph nodes and divided into variables to be compared were analysed using the program SPSS 15.0 with PResults: Median number of dissected lymph nodes from the patient group having neoadjuvant chemotherapy was 16 (16-33) while it was 20 (5-55) without chemotherapy. The respective median numbers of positive lymph nodes were 5 ( 0-19) and 10 (0-51). In 8 out of 49 neoadjuvant chemotherapy patients (16.3%), the number of dissected lymph nodes was below 10, and it was below 10 in 17 out of 144 primary surgery patients. Differences in numbers of dissected total and positive lymph nodes between two groups were significant, but this was not the case for numbers of breast cancer having neoadjuvant chemotherapy may be less than without chemotherapy. This may not always be attributed to an inadequate axillary dissection. More research to evaluate the numbers of positive lymph nodes are required in order to increase the reliability of staging in the patients with breast cancer undergoing neoadjuvant chemotherapy.     

Curative resection of advanced gastric cancer responding to preoperative chemotherapy--a case report

A 56-year-old male was admitted for treatment of advanced gastric cancer. The patient was diagnosed as having an unresectable advanced gastric cancer because cancer cells had invaded the pancreas head and there were metastatic lymph nodes. The patient underwent preoperative chemotherapy (FLEP: intra-arterial infusion of CDDP, ETP and intravenous infusion of 5-FU, LV). The primary tumor and metastatic lymph nodes were reduced by three course of chemotherapy. The patient underwent curative resection and survived without recurrence for 14 months after operation. Preoperative chemotherapy using FLEP was performed in 15 patients with unresectable primary advanced gastric cancer. This therapy resulted in significantly higher survival times. In conclusion, FLEP has been shown to be effective for unresectable advanced gastric cancer.     

Size Does Matter: Can we Reduce the Radiotherapy Field Size for Selected Cases of Anal Canal Cancer Undergoing Chemoradiation?

AimsChemoradiation is the standard of care for the treatment of anal canal cancer, with surgery reserved for salvage. For tumours with uninvolved inguinal nodes, it is standard to irradiate the inguinal nodes prophylactically, resulting in large field sizes, which contribute to acute and late toxicity. The aim of this single-centre retrospective study was to determine if, in selected cases, prophylactic inguinal nodal irradiation could be avoided.Materials and methodsBetween August 1998 and August 2004, 30 patients with biopsy-proven squamous cell anal canal cancer were treated with chemoradiation using one phase of treatment throughout. A three-field beam arrangement was used without attempting to treat the draining inguinal lymph nodes prophylactically. The radiotherapy dose prescribed was 50 Gy in 25 daily fractions over 5 weeks. Concomitant chemotherapy was delivered with the radiation using mitomycin-C 7–12 mg/m² on day 1 and protracted venous infusional 5-fluorouracil 200 mg/m²/day throughout radiotherapy.ResultsAll patients had clinically and radiologically uninvolved inguinal and pelvic nodes and all had primary lesions that were T3 or less. The median age at diagnosis was 65 years (range 41–84). The median follow-up was 41 months (range 24–113). The mean posterior field size was 14 × 15 cm and the mean lateral field size was 12 × 15 cm. All patients achieved a complete response. Ninety-four per cent of patients (28/30) were alive and disease free. The two patients who died did so of unrelated causes and were disease free at death. Four patients relapsed and all were salvaged with surgery; two for local disease requiring abdominoperineal resection, one with an inguinal nodal relapse requiring inguinofemoral block dissection and one for metastatic disease to the liver who underwent liver resection.ConclusionsThis single-centre retrospective study supports the treatment for selected cases of anal canal cancer with smaller than standard radiation fields, avoiding prophylactic inguinal nodal irradiation. Hopefully this will translate into reduced acute and late toxicity. In future studies we would suggest that consideration is given as to whether omission of prophylactic inguinal nodal irradiation for early stage tumours should be explored.     

A case of long survival in Stage IV gastric carcinoma responding to combination treatment with paclitaxel and 5- fluorouracil followed by surgical resection

A 62-year-old female with epigastric pain was diagnosed with Type 4 gastric cancer upon detailed examination. Abdominal computed tomography(CT)revealed metastasis to the paraaortic lymph node and ascites at pelvis, and aspiration cytology of the ascites through vagina was positive(CY1). The clinical stage was determined as T4(panc) N1H0P0CY1M1(LYM), cStageIV. Three courses of neoadjuvant chemotherapy combined with paclitaxel and 5-fluorouracil( FT therapy)were performed. FT therapy showed a substantial reduction of the size of metastatic lymph nodes by sequentialCT examination, which was evaluated as partial response. Surgical resection consisted of total gastrectomy, and D2 lymph node dissection was performed. Operative cytology of ascites proved negative. The pathologic effect on primary lesion and metastatic lymph nodes was diagnosed as Grade 2. Although the prognosis of gastric cancer with carcinomatous peritonitis is poor, we here reported a patient with StageIV gastric cancer who markedly responded to FT therapy, which made surgical resection possible with the anticipation of extended survival. FT therapy may be a useful method for a patient with StageIVgastric cancer.     

Severe gastric and duodenal ulcer after chemotherapy of mFOLFOX6 and bevacizumab

A 74-year-old female had metastatic left inguinal lymph nodes 20 months after rectal amputation for cancer, and an attempt to adapt chemotherapy of mFOLFOX6/bevacizumab was made after resection of the nodes. She felt nausea 2 days and continued 1 week after starting chemotherapy. Then, an endoscopic examination revealed both active gastric and duodenal ulcers. Clipping and proton pump inhibitor medication was started. The ulcers healed to the healing stage at 18 days and to the scar stage at 28 days. Gastrointestinal complications often occur after chemotherapy, but severe ulcers are rarely reported. The chemotherapy included anti-VEGF antibody, but the ulcers have healed back to normal.