Adjuvant Radiotherapy for Gastric Carcinoma: 10 years Follow-up of 244 cases from a Single Institution

Background: Postoperative chemoradiotherapy (CRT) of gastric carcinoma improves survival among highriskpatients. This study was undertaken to analyse long-term survival probability and the impact of certaincovariates on the survival outcome in affected individuals. Materials and Methods: Between January 2000 andDecember 2005, 244 patients with gastric cancer underwent adjuvant radiotherapy (RT) in our institution. Datawere retrieved retrospectively from patient files and analysed with SPSS version 21.0. Results: A total of 244cases, with a male to female ratio of 2.2:1, were enrolled in the study. The median age of the patients was 52 years(range, 20-78 years). Surgical margin status was positive or close in 72 (33%) out of 220 patients. Postoperativeadjuvant RT dose was 46 Gy. Median follow-up was 99 months (range, 79-132 months) and 23 months (range,2-155 months) for surviving patients and all patients, respectively. Actuarial overall survival (OS) probabilityfor 1-, 3-, 5- and 10-year was 79%, 37%, 24% and 16%, respectively. Actuarial progression free survival (PFS)probability was 69%, 34%, 23% and 16% in the same consecutive order. AJCC Stage I-II disease, subtotalgastrectomy and adjuvant CRT were significantly associated with improved OS and PFS in multivariate analyses.Surgical margin status or lymph node dissection type were not prognostic for survival. Conclusions: PostoperativeCRT should be considered for all patients with high risk of recurrence after gastrectomy. Beside well-knownprognostic factors such as stage, lymph node status and concurrent chemotherapy, the type of gastrectomy wasan important prognostic factor in our series. With our findings we add to the discussion on the definition ofrequired surgical margin for subtotal gastrectomy. We consider that our observations in gastric cancer patientsin our clinic can be useful in the future randomised trials to point the way to improved outcomes.     

Adjuvant chemotherapy vs radiotherapy in high-risk endometrial carcinoma: results of a randomised trial

Patients with high-risk endometrial carcinoma (stage IcG3, IIG3 with myometrial invasion >50%, and III) receive adjuvant therapy after surgery but it is not clear whether radiotherapy (RT) or chemotherapy (CT) is better. We randomly assigned 345 patients with high-risk endometrial carcinoma to adjuvant CT (cisplatin (50 mg m(-2)), doxorubicin (45 mg m(-2)), cyclophosphamide (600 mg m(-2)) every 28 days for five cycles, or external RT (45-50 Gy on a 5 days week(-1) schedule). The primary end points were overall and progression-free survival. After a median follow-up of 95.5 months women in the CT group as compared with the RT group, had a no significant hazard ratio (HR) for death of 0.95 (95% confidence interval (CI), 0.66-1.36; P = 0.77) and a nonsignificant HR for event of 0.88 (95% CI, 0.63-1.23; P = 0.45). The 3, 5 and 7-year overall survivals were 78, 69 and 62% in the RT group and 76, 66 and 62% in the CT group. The 3, 5 and 7-year progression-free survivals were, respectively, 69, 63 and 56 and 68, 63 and 60%. Radiotherapy delayed local relapses and CT delayed metastases but these trends did not achieve statistical significance. Overall, both treatments were well tolerated. This trial failed to show any improvement in survival of patients treated with CT or the standard adjuvant radiation therapy. Randomised trials of pelvic RT combined with adjuvant cytotoxic therapy compared with RT alone are eagerly awaited.     

乳癌术后辅助放化治疗对远期生存的影响

本文回顾总结我院内科１９７７至１９８７年收治９８例Ⅱ、Ⅲ期乳癌术后病人辅助化疗及辅助放化治疗的远期疗效，该组５、１０年生存率７１．４％与４２．９％，较同期手术组Ⅱ、Ⅲ期病人５、１０年生存率６６．４％与２９．６％提高。在Ⅱ期病人中辅助化疗组５、１０年生存率９４．１％与７３．５％明显高于Ⅱ期放化治疗组５、１０年生存率６９．６％与２６．１％。Ⅲ期病人辅助化疗组与辅助放化组生存率相近似。     

Comparison of Effects of Hemoglobin Levels Upon Tumor Response among Cervical Carcinoma Patients Undergoing Accelerated Hyperfractionated Radiotherapy versus Cisplatin Chemoradiotherapy

Purpose: Blood hemoglobin levels are known to influence response to radiotherapy. This retrospectiveanalysis compared the effect of hemoglobin levels upon response to radiation among patients treated withradiation alone (by accelerated hyperfractionated radiotherapy) versus those treated with concurrent cisplatinchemoradiotherapy. Materials and Methods: Among patients treated for locally advanced carcinoma of thecervix (LACC) during 2009-10, a total of 60 fulfilled the eligibility criteria. In this time frame, external beamradiotherapy was delivered with either concurrent chemoradiotherapy (CRT, n=31) (45Gy over 25 fractions,with weekly cisplatin at 40mg/m2), or with accelerated hyperfractionated radiotherapy (AHRT, n=29) (20Gyover 10 daily fractions over the first two weeks, followed by 30Gy over 20 fractions over the next two weeks,with two fractions of 1.5Gy per day, without the use of chemotherapy). Mean weekly hemoglobin (MWH) levelsof all patients were calculated as the arithmetic means of weekly recorded blood hemoglobin levels. As perMWH, patients in both of the AHRT or the CRT groups were classified into two subgroups- those with MWHbetween 10-10.9g/dL, or with MWH>11g/dL. Complete response (CR) to external beam RT phase (prior tobrachytherapy) was declared after clinical examinations and computed tomography. The CR rate was noted forboth MWH sub-groups within each of the AHRT and CRT groups. Results: Within the AHRT group, patientswith MWH>11g/dL had a much better CR rate in comparison to those with MWH:10-10.9g/dL (80% vs. 21.1%)which was statistically significant (p 0.0045). Within the CRT group, there was no significant difference in theoutcomes within the MWH>11g/dL and MWH:10-10.9g/dL sub-groups ( CR rates of 80% vs. 61.9%, p=0.4285).Conclusions: The importance of maintaining a minimum hemoglobin level of 11g/dL during RT is much greaterfor patients treated with RT alone, than for patients treated with concurrent chemoradiotherapy. Enhancedhaemoglobin levels during RT may to an extent negate the ill-effects that may otherwise arise due to non-use ofconcurrent chemotherapy.     

直肠癌术后放疗（附45例分析）

放疗在直肠癌的综合治疗中占有重要地位,特别是术后预防照射能够起到减少复发提高生存率的作用.本文收集1970年2月至1989年12月治疗的45例直肠癌术后病例:术后预防照射25例和术后复发治疗的20例.两组病例的临床所见和病理检查结果大致相同,前者5年生存率为37%(7/19),后者仅有2例活过3年,可见术后预防照射的预后明显优于复发放疗者.所以对病期偏晚的直肠癌应做预防放疗,可望改善本病的预后.     

Adjuvant Modified FOLFOX-4 in Patients with Stage III Rectum Adenocarcinoma

Purpose: The aim of this study was to investigate efficacy and toxicity of a modified 5-fluorouracil (5-FU),folinic acid, oxaliplatin (mFOLFOX-4) regimen followed by infusional 5-FU concomitant with radiotherapy forcuratively resected stage III rectum adenocarcinoma patients. Patients and Methods: Between April 2005 andJuly 2009, 55 operated stage III rectum cancer patients were evaluated retrospectively. mFOLFOX-4 regimen(oxaliplatin 85 mg/m2 1st day, folinic acid 200 mg/m2 1st day, 5-FU 400 mg/m2 iv bolus 1st day, 5-FU 1600mg/m2 46 hours continuous infusion) was applied every 2 weeks. After four courses of mFOLFOX-4, 50.4 Gy(1.8 Gy in 28 fractions) radiotherapy with continuous 5-FU 200 mg/m²/day by infusion pump were given. Oncompletion of chemoradiation four more mFOLFOX-4 courses were given. Results: Median age of the patientswas 54 years (range 23-73 years). Low anterior resection was performed in 37 (67.3%) and abdominoperinealresection in 16 (29.1%) . Ten (18.2%) patients were at stage IIIA, 24 (43.6%) at stage IIIB and 21 (38.2%) atstage IIIC. Planned chemotherapy cycles were completed in 92.7% of patients. Grades 3-4 toxicity includedneutropenia (9.1%), febrile neutropenia (3.6%), anemia (3.6%), diarrhea (21.8%), neuropathy (9.1%), renaltoxicity (3.6%), hepatotoxicity (5.5%). Median follow-up time was 30 (9-57) months. Local recurrence anddistant metastasis was observed in 3 (5.5%) and 10 (18.2%) patients, respectively. Ten (18.2%) patients diedduring follow-up. Three years disease free survival and overall survival were 67.5% and 77.3%, respectively.Conclusion: mFOLFOX-4 following chemoradiotherapy with continuous 5- FU infusion is an effective and welltolerated adjuvant treatment for stage III rectal carcinoma patients.     

同期放化疗治疗局限期小细胞肺癌的临床观察

目的探讨三维适形放疗或调强放疗同期化疗与序贯放化疗治疗局限期小细胞肺癌的疗效及毒副作用。方法 45例局限期小细胞肺癌患者随机分成三维适形放疗或调强放疗加同步化疗组（同期组,23例）与化疗后再放疗组（序贯组,22例）。同期组在化疗的第l周期开始放疗,序贯组化疗4～6个周期后再进行放疗。两组患者化疗方案均为EP方案,均接受三维适形放疗或调强放疗,1次/天,1.8～2 Gy/次,5次/周,共28～31次,总剂量50.4～62 Gy。照射野包括原发病灶和转移淋巴结及邻近一站淋巴引流区。结果原发病灶总有效率同期组为95.7%,序贯组为86.4%;1～2级急性骨髓抑制发生率同期组为82.6%,3～4级同期组为8.7%,序贯组分别为77.3%、9.1%（P〉0.05）;1～2级放射性食管炎、放射性肺炎发生率同期组分别为78.2%、86.9%,序贯组为72.7%、81.8%（P〉0.05）;两组均无3、4级发生率。同期组和序贯组的12个月、18个月生存率分别为82.6%、69.5%和77.2%、36.3%（P=0.039）,局部复发率分别为8.6%和31.8%（P=0.023）。结论三维适形放疗或调强放疗加同期化疗局限期小细胞肺癌能为绝大多数患者耐受,有较好的近期疗效,是1种安全有效的治疗手段,值得进一步研究。     

术后辅助放化疗与单纯手术治疗在胃腺癌中的比较

Objective:Despite resection with curative intent,a majority of patients with gastric cancer will develop disease recurrence.Postoperative adjuvant chemo-radiotherapy increase the curability of surgery,prevent local recurrence and improve survival.Methods:Between December 2005 and February 2010,33 patients were eligible for the study,17 patients were randomly assigned for chemo-radiotherapy (GI) and 16 patients with surgery alone (GII).Patients in GI received chemotherapy (fluorouracil,425 mg/m 2/day,and leu...     

Hypofractionated or Conventionally Fractionated Adjuvant Radiotherapy After Regional Lymph Node Dissection for High-Risk Stage III Melanoma

AimsAdjuvant radiotherapy can be beneficial after regional lymph node dissection for high-risk stage III melanoma, as it has been shown to reduce the risk of recurrence in the node field. However, the optimal fractionation schedule is unknown and both hypofractionated and conventionally fractionated adjuvant radiotherapy are used. The present study examined the oncological outcomes of these two approaches in patients treated in an era before effective systemic immunotherapy became available.Materials and methodsThis retrospective cohort study involved 335 patients with stage III melanoma who received adjuvant radiotherapy after therapeutic regional lymph node dissection for metastatic melanoma between 1990 and 2011. Information on tumour characteristics, radiotherapy doses and fractionation schedules and patient outcomes was retrieved from the institution's database and patients' medical records.ResultsHypofractionated radiotherapy (median dose 33 Gy in six fractions over 3 weeks) was given to 95 patients (28%) and conventionally fractionated radiotherapy (median dose 48 Gy in 20 fractions over 4 weeks) to 240 patients (72%). Five-year lymph node field control rates were 86.0% (95% confidence interval 78.4–94.4%) for the hypofractionated group and 85.5% (95% confidence interval 80.5–90.7%) for the conventional fractionation group (P = 0.87). There were no significant differences in recurrence-free survival (RFS) (41.7%, 95% confidence interval 32.5–53.5 versus 31.9%, 95% confidence interval 26.1–38.9; P = 0.18) or overall survival (41.2%, 95% confidence interval 32.1–52.8 versus 45.0%, 95% confidence interval 38.7–52.4; P = 0.77). On multivariate analysis, extranodal spread was associated with decreased RFS (P = 0.04) and the number of resected lymph nodes containing metastatic melanoma was associated with decreased RFS (P = 0.0006) and overall survival (P = 0.01).ConclusionLymph node field control rates, RFS and overall survival were similar after hypofractionated and conventionally fractionated adjuvant radiotherapy. The presence of extranodal spread and an increasing number of positive lymph nodes were predictive of an unfavourable outcome.     

术前同步放化疗或放疗联合手术治疗宫颈癌的观察

目的观察术前同步放化疗或放疗联合手术治疗宫颈癌的疗效及毒副反应。方法39例宫颈癌患者分成同步放化疗组（22例）及单纯放疗组（17例）,同步放化疗组每周采用顺铂25mg／m^2,静脉点滴,同时进行放疗,化疗d1开始进行放疗,单纯放射治疗组仅行单纯放疗,方法同前。结果同步放化疗组的近期有效率95．5％,单纯放疗组82．3％,差异无显著性（P〉0．05）。同步放化疗组有较明显的骨髓抑制和消化道反应,但患者经治疗后均可耐受。手术切除率从术前治疗前的33.3％提高到89．7％,且不会增加手术并发症。结论宫颈癌未前同步放化疗或放疗有效率高,副作用稍增加,但能为手术创造更有利的条件,且不会增加手术难度、并发症。     

影响子宫内膜癌患者术后放疗效果的相关因素分析

目的 分析影响子宫内膜癌患者术后放疗效果的相关因素.方法 随机抽取行子宫内膜癌术后放疗患者80例,综合分析患者的年龄、病理分型分期、转移与否以及患者月经情况对术后放疗效果的影响.结果 80例患者随访2年,7例死亡,2年总生存率为91.3%,11例复发,复发率为13.8%,10例发生转移,转移率为12.5%.单因素分析结果显示:病理分期和淋巴结转移影响术后放疗效果(P<0.05);患者年龄、绝经与否以及病理分型与术后放疗效果不存在明显相关性(P>0.05).Logistic多因素分析显示,病理分期和淋巴结转移是患者术后放疗的独立危险因素(P<0.05);患者年龄、绝经与否以及病理分型与术后放疗效果无明显相关性(P>0.05).结论 子宫内膜癌病理分期和淋巴结转移是影响术后放疗效果的独立危险因素,值得关注.     

Adjuvant Radiotherapy in Stage II Endometrial Cancer: Selective De-intensification of Adjuvant Treatment

AimsRisk stratification, including nodal assessment, allows for selective de-intensification of adjuvant radiotherapy in stage II endometrial cancer. Patterns of treatment and clinical outcomes, including the use of reduced volume ‘mini-pelvis’ radiotherapy fields, were evaluated in a population-based study.Materials and methodsAll patients diagnosed with pathological stage II endometrial cancer between 2000 and 2014, and received adjuvant radiotherapy in a regional healthcare jurisdiction were reviewed. Registry data were supplemented by a comprehensive review of patient demographics, disease characteristics and treatment details. The Charlson Comorbidity Score was calculated. Survival and recurrence data were analysed.ResultsIn total, 264 patients met the inclusion criteria. Most patients had endometrioid histology (83%); 41% of patients had International Federation of Gynecologists and Obstetricians grade 1 disease. Half (49%) had surgical nodal evaluation; 11% received chemotherapy. Most patients (59%) were treated with full pelvic radiotherapy fields ± brachytherapy. Seventeen per cent of patients received mini-pelvis radiotherapy ± brachytherapy, whereas 24% received brachytherapy alone. Five-year recurrence-free survival was 87% for the entire cohort, with no significant difference by adjuvant radiotherapy approach. Only one patient receiving mini-pelvis radiotherapy ± brachytherapy recurred in the pelvis but outside of the mini-pelvis field. Recorded late toxicity rates were highest for full pelvis radiotherapy + brachytherapy.ConclusionRisk stratification in a real-world setting allowed for selective de-intensification of adjuvant radiation with equivalent outcomes for stage II endometrial cancer. Mini-pelvis radiotherapy combined with brachytherapy is effective in highly selected patients, with the potential to decrease toxicity without compromising local control. Brachytherapy should be considered in low-risk stage II patients.     

Adjuvant hormonal therapy for stage I endometrial cancer

Question

What is the role of hormonal therapy as adjuvant therapy in patients with stage i endometrial cancer?

Perspectives

There is little consensus on the role of adjuvant treatment for patients with stage i endometrial cancer. Although the use of hormonal therapy has been established in advanced disease, less agreement has emerged concerning the benefits of adjuvant hormonal therapy for patients with early-stage disease. The objective of the present evidence series was to review the existing literature on the role of hormonal therapy as adjuvant therapy in patients with stage i endometrial cancer.

Outcomes

Reports were sought that included at least one of the following outcomes: overall survival, disease-free survival, recurrence (local, or distant, or both), adverse effects, and quality of life. Because of the potential for long-term adverse effects with adjuvant hormonal treatment in this patient population, especially with regard to thromboembolic or cardiovascular events, the rates of non-cancer-related death were also of interest.

Methodology

The medline, embase, and Cochrane Library databases were systematically searched for randomized controlled trials, practice guidelines, systematic reviews, and meta-analyses. The resulting evidence informed the development of the clinical practice guideline. The systematic review with meta-analyses and practice guideline were approved by the Report Approval Panel of the Program in Evidence-Based Care, and by the Gynecology Cancer Disease Site Group (dsg).

Results

Nine randomized trials and one published meta-analysis comparing adjuvant hormonal therapy with no adjuvant therapy in women with stage i endometrial cancer constituted the evidence base. One trial reported a statistically significant survival benefit with adjuvant progestogen as compared with no further treatment (97% vs. 69%, p < 0.001). In that trial, the treatment group had a higher number of patients with less myometrial invasion, and a lower number of patients with advanced-stage disease. These differences in baseline characteristics between the randomized groups were considered to be clinically important. In addition, the results of that trial were not consistent with those of other trials, and the trial was a source of statistical heterogeneity when data were pooled across trials.In two of the nine randomized trials, statistically significant recurrence-free benefits were detected with adjuvant hormonal therapy as compared with no further therapy. In one trial, the difference between the rates of recurrence was 16%; however, the methodologic concerns related to that that trial limited its relevance. In the other trial, the difference between the rates of recurrence was 5%. In that trial, patients were at a high risk of recurrence. None of the remaining seven randomized trials reported any significant difference in recurrence rates between treatment groups.The meta-analysis identified in the literature detected no statistically significant recurrence-free or overall survival benefit associated with adjuvant hormonal therapy as compared with no adjuvant therapy [odds ratio (or): 1.05; 95% confidence interval (ci): 0.88 to 1.24). Those results are consistent with the results of the meta-analysis in the present report, which included an additional two trials (or: 1.10; 95% ci: 0.91 to 1.34).

Practice Guideline

Target Population

This clinical recommendation applies to women with newly diagnosed stage i endometrial cancer.

Recommendation

The available evidence does not demonstrate any benefit for adjuvant hormonal therapy. The use of hormonal therapy is not recommended as adjuvant treatment for patients with stage i endometrial cancer.     

Endometrial Carcinoma with Cerebellar Metastasis: A Case Report and Review of the Literature

Background: Endometrial cancer is the most common malignancy involving the female genital tract in the United States. There is a paucity of reports of brain metastases in this disease, and most of these reports emphasize that this pattern of dissemination is rare. Case: We present a case of a 63-year-old woman who had high-grade endometrial carcinoma treated with surgery and radiotherapy. She had three separate episodes of relapse in the lungs, the first two relapses being treated surgically. Chemotherapy was also administered following surgery for the first relapse. The third pulmonary recurrence was treated with chemotherapy and then consolidated with thoracic radiation. Four years from the date of diagnosis, and a few weeks after completion of thoracic radiotherapy, she had evidence of a solitary cerebellar metastasis. This was treated surgically and followed by whole brain irradiation. She died 6 months after this central nervous system diagnosis with systemic dissemination of her cancer. Conclusion: The existing literature on brain metastases from endometrial cancer is reviewed together with the patterns of spread of endometrial cancer. We call attention to the unusually long course of this patient. Partially successful treatment for metastatic disease may have predisposed eventual development of brain metastases. This occurrence reinforces reports emphasizing their increasing incidence in association with endometrial cancer.     

Concurrent Chemoradiotherapy Versus Radiotherapy Alone for Locoregionally Advanced Nasopharyngeal Carcinoma

Objective: To compare the clinical effects of concurrent radiochemotherapy with those of radiotherapy intreating locally advanced nasopharyngeal carcinoma (Stage III~IVa). Methods: A total of 95 patients sufferingfrom nasopharyngeal carcinoma (Stage III~IVa) were divided into two groups: concurrent radiochemotherapy(Group CCRT, n=49) and radiotherapy (Group RT, n=46). The two groups were both delivered conventionalfractionated radiotherapy, while Group CCRT also received three cycles of PF (DDP+5-Fu) or PLF (DDP+5-Fu+CF) chemotherapy. Results: The complete remission rate and total remission rate of Group CCRT werehigher than those of Group RT (Ⅹ2=4.72~7.19, P<0.05). The one-year overall survival (OS) rate calculated bythe life table method, was also higher than that of Group RT (Ⅹ2=4.24, P<0.05) as well as the 3-year OS rate,nasopharyngeal control rate and cervical lymph nodes’ control rate (Ⅹ2=4.28~4.40, P<0.05). In addition, the5-year OS and metastasis-free rates of Group CCRT were higher than those of Group RT and the differenceswere of statistical importance (Ⅹ2=3.96~8.26, P﹤0.05). However, acute toxicity was also obviously higher, thedifference in gastrointestinal reactions being statistically significant (Ⅹ2=11.70, P<0.05). Conclusion: This studydemonstrated that concurrent radiochemotherapy could improve the remission rate, overall survival rate andlocally control rate. The toxicity of concurrent radiochemotherapy could be tolerated by the patients.     

Adjuvant Therapy in Early‐Stage Endometrial Cancer: A Systematic Review of the Evidence,Guidelines, and Clinical Practice in the U.S.

Endometrial cancer is the most common gynecologic malignancy in the U.S., with an increasing incidence likely secondary to the obesity epidemic. Surgery is usually the primary treatment for early stage endometrial cancer, followed by adjuvant therapy in selected cases. This includes radiation therapy [RT] with or without chemotherapy, based on stratification of patients into categories dependent on their future recurrence risk. Several prospective trials (PORTEC‐1, GOG#99, and PORTEC‐2) have shown that the use of adjuvant RT in the intermediate risk (IR) and the high‐intermediate risk (HIR) groups decreases locoregional recurrence (LRR) but has no effect on overall survival. The ad hoc analyses from these studies have shown that an even larger LRR risk reduction was seen within the HIR group compared with the IR group. Vaginal brachytherapy is as good as external beam radiotherapy in controlling vaginal relapse where the majority of recurrence occur, and with less toxicity. In the high‐risk group, multimodality therapy (chemotherapy and RT) may play a significant role. Although adjuvant RT has been evaluated in many cost‐effectiveness studies, high‐quality data in this area are still lacking. The uptake of the above prospective trial results in the U.S. has not been promising. Factors that are driving current practices and defining quality‐of‐care measures for patients with early‐stage disease are what future studies need to address.