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.     

The value of preoperative radiotherapy in operable mammary carcinoma

In a randomized trial preoperative radiotherapy (4500 rad to the breast, the internal mammary, the supraclavicular and the axillary lymph node regions) was compared to radical mastectomy followed either by no further treatment or by postoperative radiotherapy. The total number of patients was 960; 356 of these had a follow-up time of more than five years. Both preoperative and postoperative irradiation increased the disease-free survival, compared to survival in patients who were treated only by surgery. The patients who were irradiated preoperatively had significantly better survival rates than the control patients (p = 0.05). Compared to patients who were treated with surgery only the survival improvement was even more certain (p = 0.03). Patients whose tumors were located in the inner half of the breast seemed to benefit more from preoperative or postoperative irradiation than those with lateral tumors. This could support the hypothesis of the value of adequate irradiation of the internal mammary nodes.     

16例原发腮腺鳞癌的治疗与预后

目的回顾分析16例腮腺鳞癌的临床特点和治疗结果,研究原发腮腺鳞癌预后影响因素及恰当的治疗方案。方法搜集1984-2005年收治并经病理证实的原发腮腺鳞癌16例,其中T1期2例,T2期5例,T3期5例,T4期4例。NO期10例,N＋期6例,单一手段治疗组6例（单纯手术5例,单纯放疗1例）,综合治疗组（手术加放疗）10例。结果全组患者在病程中出现颈部淋巴结转移的概率为75%（12/16）,全组3和5年局部控制率、总生存率、无瘤生存率分别为45%和30%、58%和58%、36%和27%。T1～T2和T3～T4期的5年生存分别为100%和29%,（X^2=4．50,P= 0．034）。NO和N＋期的3年总生存率分别为80%和20%（X^2=8．70,P=0．003）,无瘤生存率分别为54%和0（X^2=9．83,P=0．002）。结论原发腮腺鳞癌颈部淋巴结转移概率和局部复发率均高,应该采用手术加放射的综合治疗;N＋期患者术后应该给予同侧全颈及锁骨上区放疗;手术治疗时未行颈清扫者应行同侧全颈及锁骨上区预防照射。     

Patterns of failure and results of preoperative irradiation vs radiation therapy alone in carcinoma of the pyriform sinus

From 1968 to 1977, 53 of 78 patients with carcinoma of the pyriform sinus completed planned therapy and were eligible for followup a minimum of two years. Of the 53, 35 (66%) were treated with high dose preoperative irradiation and surgery, while 18 (33 % ) were treated with radiation therapy alone. Preoperative irradiation averaged 5800 rad in $\text{5}\text{1}\text{2}$ weeks, whereas for irradiation alone doses ranged from 5700–7200 rad in 4–8 weeks (average 6400 rad in 6 weeks). Partial pharyngectomy, total laryngectomy and radical neck dissection usually followed preoperative irradiation within 4–6 weeks. Of all patients, 73 % presented with T3 or T4 primaries and 79 % had clinically positive neck nodes. Actuarial five year survival was 13% for irradiation alone group and 12% for the combined therapy group. All of the irradiation alone relapses and 85 % of the combined therapy relapses occurred within two years. Failure rates in the primary site were 30% for combined therapy and 72% for irradiation alone; the nodal failure rates were 51 % and 61 %, respectively. The radiation therapy fields for both groups were reviewed for adequacy of coverage of the known and potential tumor volume and of all the failures in the primary site and nodes, 17% were felt to be at the margin of the irradiated field. There was a 34% (12 of 35) rate of pharyngocutaneous fistulae with the combined therapy. Three of the 12 fistulae were a result of recurrent tumor and 2 of these had carotid rupture.     

Rectal cancer: Preoperative versus postoperative irradiation as a component of adjuvant treatment

The search for improved disease control and survival for resectable but high-risk rectal cancers has led to studies that combine all 3 modalities. For surgically resected, high-risk rectal cancers, postoperative chemoradiation has been shown to improve both disease control (local and distant) and survival (disease free and overall) and was recommended as standard adjuvant treatment at the 1990 National Institute of Health Colorectal Cancer Consensus Conference. Three randomized studies showed improved overall survival (OS) and local control for patients treated with postoperative irradiation and chemotherapy when compared with surgery alone or surgery plus irradiation control arms. These include 2 US trials, Gastrointestinal Tumor Study Group and Mayo/North Central Cancer Treatment Group (NCCTG) and a Norway trial. Although most preoperative external beam radiation trials show reductions in local relapse with the addition of preoperative EBRT to resection, only the large Swedish trial of 1,100 patients showed a survival improvement when compared with a surgery alone control arm for resectable primary rectal cancers. In a recent pooled analysis of 3 postoperative adjuvant rectal cancer trials (NCCTG 794751, NCCTG 864751, and GI Intergroup 0114) survival and disease relapse were dependent on both TN and NT stage of disease (N substage within T stage and T substage within N stage). Even among N2 patients (4 or more positive nodes), T substage influenced 5-year OS (T1-2, 69%; T3, 48%; and T4, 38%; P < .001). Ongoing randomized trials are being conducted for patients with high-risk, resectable primary rectal cancers. The intent is to help define optimal combinations of postoperative chemoradiation (US GI Intergroup), to test sequencing issues of preoperative versus postoperative chemoradiation (Germany trial), and to determine if concurrent and maintenance 5-FU and leucovorin add to the benefits found with preoperative irradiation (European Organization for Research and Treatment of Cancer). For subsequent trials, it may be preferable to perform separate studies, or a planned statistical analysis, for different risk groups of patients (low, intermediate, moderately high, and high), as defined in the rectal cancer pooled analysis.     

Radiation treatment for medulloblastoma: a review of 64 cases at a single institute

BACKGROUND: Although the optimal treatment mode for medulloblastoma is frequently discussed, results based on large series of cases, especially those treated in Asia, have rarely been reported. Our purpose was to evaluate the efficacy of postoperative radiation therapy, and to identify prognostic factors, in a relatively large cohort of patients with limited-stage medulloblastoma treated at a single institute in China. METHODS: Between January 1996 and April 2001, 69 patients with Chang stage M0/M1 medulloblastoma were referred to our hospital for radiation therapy after total or subtotal resection of the primary tumor. All patients received 30 Gy to the craniospinal axis followed by a 20-25 Gy boost to the posterior fossa (median fraction, 1.8 Gy). RESULTS: Sixty-four patients were followed for a median period of 38.5 months. The rates of 3-year and 5-year overall survival were 68.8% and 55.7%, respectively; corresponding disease-free survival were 57.8% and 51.4%, respectively. Patients who had received radiation treatment within 25 days after resection had a greater probability of 3-year survival (81.5% versus 59.5%; P = 0.11) and 3-year disease-free survival (74.1% versus 46.0%; P = 0.03) than patients who began radiation treatment later. No relationship was found between survival and age, sex or tumor size. CONCLUSIONS: This regimen was comparatively ineffective in preventing recurrence of postoperative medulloblastoma; however, we found that the interval between surgery and radiation is a significant prognostic factor for disease-free survival.     

Carcinoma of the superior pulmonary sulcus treated with surgery and/or radiation therapy

This is a retrospective analysis of 50 patients with carcinoma of the superior pulmonary sulcus, treated with curative intent at the University of Florida between October 1964 and October 1981. Treatment groups included preoperative radiation therapy and surgery (40 patients), radiation therapy alone (7 patients), and surgery with postoperative radiation therapy (3 patients). There was a minimum 2-year follow-up. Local control was obtained in 8 of 26 evaluable patients (31%) treated with preoperative radiation therapy and surgery, 2 of 6 patients treated with radiation therapy alone, and 0 of 2 patients treated with surgery and postoperative radiation therapy. Twelve (30%) of 40 patients receiving planned preoperative radiation therapy did not undergo definitive surgery. Absolute survival free of disease at 5 years by treatment group for patients at risk was 3 of 30 (10%) with preoperative radiation therapy and surgery, 0 of 3 with surgery and postoperative radiation therapy, and 2 of 7 with radiation therapy alone. Since one third of the patients who received low- to moderate-dose preoperative radiation therapy did not undergo definitive surgery, and since there is a small but significant survival with radiation therapy alone, it seems unwise to give moderate-dose preoperative radiation therapy, which implies an unfavorable radiation technique for the unresectable cases. The recommendation is to treat patients with lesions believed to be resectable by initial surgical resection followed by high-dose radiation therapy in selected patients with questionable margins or positive lymph nodes. Those patients with borderline or apparently unresectable lesions are recommended to be treated with radiation therapy alone.     

Influence of preoperative irradiation on failures of endometrial carcinoma with high risk of lymph node metastasis

From 1965-1980, 80 patients with adenocarcinoma of the endometrium, FIGO-AJC Stage I, Grade 3 and Stage II received preoperative radiation therapy. Thirty-three patients had Stage I, Grade 3 and 47 had Stage II. All patients were treated with preoperative radiation therapy (intracavitary application, external pelvic irradiation or both) followed by total abdominal hysterectomy and bilateral salpingo-oophorectomy. They were followed from 3-18 years (median, 6.2 years) after the completion of treatment and none was lost to follow-up. Overall 5-year actuarial disease-free survival was 75%. Preoperative external whole pelvic plus intracavitary irradiation gave the best 5-year survival of 83%; there were no failures after 20 months. In comparison to this group, survival for the intracavitary alone group was 64% at 5 years and 54% at 8 years. The 5-year survival of Stage II was 81% compared to 66% of the Stage I, Grade 3 group. Prognostic variables were analyzed and showed that the residual tumor in the specimen at the time of surgery after the preoperative irradiation was significantly correlated to a worse prognosis: patients who were found to have no residual tumor had a 5-year survival rate of 96% compared to 65% of those who were found to have residual tumor (p less than 0.01). Age, stage, methods of preoperative irradiation, dose of external pelvic irradiation or intracavitary application were not statistically significant prognostic factors. The grade of the tumor was suggestive as a prognostic variable. The most common failure site was the para-aortic lymph nodes independent of treatment methods and stage. Four patients developed complications possibly related to the radiation therapy. Our study suggests that preoperative external and intracavitary irradiation reduces the frequency of residual microscopic carcinoma and improves survival for patients with Stage I, Grade 3 and Stage II carcinoma of the endometrium.     

pT3N0M0期胸段食管鳞癌根治术后的预后因素

目的 探讨pT3N0M0期胸段食管鳞癌两野根治术后的预后及其影响因素。方法 胸段食管鳞癌行胸腹两野食管癌根治术后、分期为pT3N0M0者249例,中位年龄60岁（33~78岁）;胸上段39例、胸中段166例、胸下段44例,病变中位长度5 cm（2~12 cm）;术中无粘连者35例、轻度粘连者90例、重度粘连者124例;术中清扫淋巴结中位数9枚（1~27枚）;98例单纯手术、151例行术后辅助治疗。结果 249例中1、3、5年总生存率（overall Survival, OS）和无进展生存率（progression-free survival, PFS）分别为90.0%、68.7%、55.2%和82.1%、61.7%、5 3 . 9%。单因素分析结果显示：性别、肿瘤位置、病理分化程度和术前血红蛋白水平与O S 有关（P<0.05）;年龄、肿瘤位置和术中粘连程度与PFS有关（P<0.05）;多因素分析结果显示：肿瘤位置、术前血红蛋白水平、术前CT有纵隔小淋巴结（<1 cm）和清扫淋巴结数目是OS独立影响因素,肿瘤位置是影响PFS独立危险因素。术后辅助治疗对OS和PFS均无明显影响;但术前CT纵隔有小淋巴结（<1 cm）者,术后辅助治疗可以提高OS和PFS（P<0.05）。结论 pT3N0M0期胸段食管鳞癌胸腹两野根治术后,肿瘤位置影响OS和PFS,胸下段癌预后最好,胸上段癌预后最差;术中清扫淋巴结数多、术前CT纵隔无淋巴结者预后较好,反之预后较差;术前血红蛋白高者生存率低;而术后辅助治疗的价值有待证实。     

Radiation therapy for cutaneous squamous cell carcinoma involving the parotid area lymph nodes: dose and volume considerations

PURPOSE: The intraparotid and periparotid lymph nodes are the most commonly involved when skin cancer of the head and neck metastasizes beyond the primary site. We sought to report the clinical outcome of patients treated with radiation therapy for parotid-area metastases from cutaneous squamous cell carcinoma of the head and neck. METHODS AND MATERIALS: The records of 36 patients treated with radiation therapy for cutaneous squamous cell carcinoma involving the parotid-area lymph nodes were reviewed. All patients had clinically N0 necks and were without evidence of distant disease. Thirty patients (83%) were treated postoperatively after gross total tumor resection. Median dose to the parotid area was 60 Gy (range, 50-72 Gy). Treatment of clinically N0 necks consisted of surgical dissection (7 patients), irradiation (15 patients), and observation (14 patients). RESULTS: The 5-year estimate of local (parotid) control was 86% in patients treated using surgery with postoperative therapy and 47% in patients treated using radiation therapy alone. Three of 4 patients with tumors that relapsed locally after surgery and postoperative radiation received a dose of less than 60 Gy. Elective neck irradiation decreased the incidence of subsequent nodal failures from 50% to 0% and significantly improved neck control (p < 0.001). The 5-year overall survival rate was 63%. CONCLUSIONS: Surgery followed by radiation therapy to doses of at least 60 Gy results in effective local control for patients with parotid area metastasis from cutaneous squamous cell carcinoma. Routine irradiation of the clinically N0 neck is recommended.     

The role of brachytherapy in the management of oropharyngeal carcinomas: the Trento experience

AIMS: This study was undertaken to determine the outcome of patients with oropharyngeal cancer treated at the Radiotherapy Department of the Santa Chiara Hospital (Trento, Italy) with brachytherapy alone or combined with external beam radiotherapy (EBRT). MATERIAL AND METHODS: We retrospectively reviewed the medical records of 87 patients with squamous cell carcinoma of the oropharynx treated by radiation therapy between January 1986 and September 1999. The median age was 59 years and all patients had a minimum follow-up of one year. Tumor locations were 46 tonsillar region, 31 soft palate and 10 base of the tongue. The patients were staged as follows: 41 T1, 35 T2, 11 T3 with 70 N0, 9 N1 and 8 N2. They received either brachytherapy alone (14 patients) or a combination of external beam irradiation and brachytherapy (73 patients) using an afterloading iridium technique in a plastic tube. RESULTS: Overall primary tumor control, including salvage surgery, was 81/87 (93%). Control of metastatic cervical adenopathy was as follows: clinical stage N1, 5/9 patients; N2, 2/8 patients. The estimated five-year cause-specific survival and overall survival rates were 81% and 47%, respectively. After interstitial irradiation severe complications were limited to one case of osteoradionecrosis of the mandible and seven cases of mucosal ulcer. CONCLUSION: This study confirms that iridium-192 interstitial implant alone or as a boost after external beam irradiation is a safe and effective therapy in the management of oropharyngeal carcinomas.     

Management of Merkel cell carcinoma: case series of 36 patients

Merkel cell carcinoma is a rare, highly malignant skin tumor with a predisposition for local, nodal and distant recurrence which should be managed in a multimodal approach. Here, we performed a retrospective analysis of 36 patients, treated from 1984 to 1994. In patients with stage I disease, locoregional recurrence after surgery alone occurred in 65% compared to 43% after excision and adjuvant radiotherapy. Although the difference in disease-specific survival was not significant (67% versus 52% at 5 years), combination therapy conferred a benefit for locoregional control and relapse-free survival (88 versus 58 months). The majority of failures (54%) occurred within the draining lymph nodes that were not treated in the initial approach and locoregional recurrence was strongly associated with a later systemic relapse (50% versus 0%). Salvage after localized recurrence was achieved in 67% of resectable cases. The high rate of nodal recurrence after surgery alone warrants the use of elective nodal treatment in patients with stage I disease. Surgical resection of the primary tumor should be followed by postoperative radiotherapy to the primary site and draining lymph nodes. Even after locoregional recurrence, a substantial proportion of patients is able to achieve long-term disease-free survival, particularly after complete resection and adjuvant irradiation.     

Prognostic impact of complete remission after preoperative irradiation of tonsillar carcinoma: a retrospective analysis of the radiumhemmet data, 1980-1995

Purpose: This retrospective study was done to determine the outcome of patients with tonsillar carcinoma treated at Radiumhemmet, Karolinska Hospital, between January 1980 and December 1995 with radiotherapy alone or in combination with surgery. In addition the importance of tumor remission for patient survival was analyzed.

Methods and Materials: The analysis is based on 167 previously untreated patients with biopsy-proven, invasive tonsillar squamous cell carcinoma of the tonsillar region. All patients were consecutively admitted to the Department of General Oncology, Radiumhemmet, and treated with curative intent. The median follow-up time was 20 months. The median target dose was 64 Gy, delivered in fractions of 2 Gy 5 times weekly. Twenty-eight percent of the patients underwent surgery of the primary site and/or neck dissection after radiotherapy (RT).

Results: The overall local control rate for the whole patient group after radiotherapy was 79%. Probability of survival after 5 years for patients responding with complete remission (CR) was 43% and for patients with incomplete response (non-CR) 9%, (p < 0.0001). The survival in the non-CR group treated with combination therapy was 20 months longer than in patients receiving radiotherapy alone (p < 0.0001). There was no statistically significant difference in prediction of long-term survival when the patient population was stratified according to tumor differentiation grade, age, sex, nodal status, or treatment time.

Conclusion: The strongest clinical predictor of survival was the degree of tumor remission after RT. For the non-CR group receiving combination treatment including surgery there was a survival benefit as compared to patients treated with RT alone (p < 0.0001) although there were few long-term survivors in this patient group.     

Results of twice-a-day irradiation of squamous cell carcinomas of the head and neck

The results of twice-a-day irradiation for moderately advanced and advanced squamous cell carcinomas of the head and neck in 57 patients, treated at the University of Florida between March 1978 and July 1981, are reviewed. Fifty patients received irradiation alone to the primary site with or without neck dissection; 7 patients received preoperative irradiation (5040-6000 rad) followed in 4-6 weeks by resection of the primary tumor and neck dissection(s). Two 120 rad treatments were administered daily, with a 4-6 hour interval between fractions. External beam tumor doses were usually 7440-7680 rad when irradiation alone was used for the primary lesion; 2 of 3 T2 and 11 of 13 (85%) T3 lesions that received greater than or equal to 7440 rad remain locally controlled at 2-5 years' follow-up. External beam doses of 7440 rad controlled only 1 of 10 T4 cancers; higher doses controlled 3 of 8 T4 lesions. One severe complication of irradiation and 2 severe complications of salvage surgery have occurred in the group that received irradiation alone to the primary lesion. Five of the 7 patients who received planned combined preoperative irradiation plus surgery to the primary tumor were alive and free of disease at 2 years. Absolute disease-free survival at 2 years for the entire patient group was 23/57 (40%).     

Stage II carcinoma of the endometrium: results of therapy and prognostic factors

A retrospective analysis is reported of 116 patients with Stage II carcinoma of the endometrium treated definitively with combined radiation and total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO) or irradiation alone from January 1960 through December 1981. At 5 and 10 years, the overall survival for all patients was 71 and 52% and the disease-free survival was 73 and 69%, respectively. Of 90 patients in the combined therapy group, most received a preoperative intracavitary insertion (3500 mgh to the uterus and 2000 mgh to the upper vagina) and preoperative external beam pelvic irradiation (2000 cGy whole pelvis, additional 3000 cGy to parametria, with midline shield) followed in 4 to 6 weeks by a TAH-BSO. The 5 and 10 year disease-free survival for this group was 78 and 75%, respectively. The incidence of major complications was 7% for the combined therapy group. Twenty-six patients were treated with irradiation alone; most of them received two intracavitary insertions (5000 mgh to the uterus and 3000 mgh to the upper vagina) and external beam pelvic irradiation (2000 cGy whole pelvis, additional 3000 cGy to parametria). The 5 and 10 year disease-free survival was 53 and 45%, respectively. The incidence of major complications was 19%. Factors found to influence the prognosis were histologic grade of tumor, clinical and histologic degree of tumor involvement of the ectocervix, presence of residual tumor in the hysterectomy specimen and the depth of myometrial invasion.     

Analysis of the results of irradiation in the treatment of tonsillar region carcinomas

Five year follow-up data are presented for 215 patients with carcinomas of the tonsillar region, all of whom were treated by radiation therapy alone. Data are analyzed retrospectively to determine the factors associated with prognosis. As in many reports in the literature, prognostic factors regarding survival of the patients were: the initial tumor site (tumor extension to the base of the tongue was considered to be a bad prognosis factor); the initial tumor size and lymph node involvement (9.4% 5 year survival for T3N3 vs 73.7% 5 year survival for T1N0 cases); and histological type of differentiation (better prognosis for well differentiated carcinomas than for poorly differentiated tumors). Studies on the biological and volumetric data (the NSD value and target volume were calculated for each case) allowed a statistical and critical correlation between therapeutic results and physical characteristics of the radiation treatment.     

Postoperative borderline elevated CEA predicts for earlier relapse in patients with rectal cancer receiving adjuvant postoperative therapy

PURPOSE: The purpose of this study was to determine the impact of a borderline elevated postoperative carcinoembryonic antigen (CEA) on the duration of disease-free survival in patients with rectal cancer treated with postoperative adjuvant radiotherapy and chemotherapy. PATIENTS AND METHODS: A retrospective review was undertaken of 145 patients undergoing curative surgery for rectal adenocarcinoma (American Joint Committee on Cancer stages II and III) and treated with postoperative radiotherapy and chemotherapy from January 1994 to February 1997. Patients with known metastatic disease, with gross residual disease after surgery, or without an available postoperative CEA level before adjuvant therapy were not included. All patients were monitored for a minimum of 1 year or until death. The rates of relapse, disease-free survival and overall survival were estimated according to the Kaplan-Meier method. Univariate analyses for the endpoint time to relapse was carried out for the following potential prognostic factors: age, gender, American Joint Committee on Cancer stage, number of lymph nodes, perineural invasion, capillary-like space invasion, margin status, and postoperative CEA level (< or = 4.0 microg/L vs > 4.0 microg/L). A mulitvariate regression analyses was conducted with the Cox proportional hazards model. RESULTS: With a median follow-up of 45 months, the disease-free and overall survival rates at 2 years were 78% and 90% respectively. Eight patients were identified who expressed an elevated postoperative CEA (4.1-10.2 microg/L). Two patients had T3N0 tumors; one tumor was T4N0, four tumors were T3N1, and one was T4N1. The median time to first relapse in these eight patients was 26 months, compared with 69 months for the 137 patients with a postoperative CEA in the normal range (0-4.0 microg/L), (log-rank Chi-squared test = 4.92). As determined by a proportional hazards model, an elevated CEA remained an independent predictor (along with number of positive nodes) for early relapse. DISCUSSION: Postoperative CEA in patients undergoing curative surgery for rectal cancer provides additional prognostic information in those patients embarking on adjuvant postoperative therapy. An elevated CEA predicts for early relapse and may help define a high-risk subset of patients in whom more aggressive adjuvant therapies should be considered.     

External radiotherapy in the treatment of tonsillar carcinomas. Analysis of 183 cases

A retrospective analysis of 183 consecutive patients with tonsillar carcinoma observed from 1970 through 1984 and treated by external radiotherapy was carried out. The data were analyzed retrospectively to determine the factors affecting prognosis. Tumor size (T) and lymph node involvement (N) were found to be predominant prognostic factors. The difference in 5 year survival rate between T2 and T3 tumors was significant, and that between N1 and N3 was highly significant, whereas difference in survival could be found between N0 and N1 groups. The primary tumor was controlled by radiotherapy alone in 90% of cases of T1 lesions, 58% of T2, 37% of T3 and 11% of T4, and lymph node metastases was controlled in 70% of N1 cases, 0 of N2 and 15.5% of N3. Twenty-three patients underwent salvage surgery after radiotherapy had failed and the actuarial 5 year survival rate was 75% for stage I, 40% for stage II, 30% for stage III and 13% for stage IV.     

TNM因素对非小细胞肺癌治疗效果的影响

目的 探讨肺部原发肿瘤的大小、淋巴结不同区域的转移及有无远处转移对非小细胞肺癌(NSCLC)综合治疗效果的影响.方法 回顾性分析手术治疗的987例NSCLC患者的临床资料,将其中以手术+化、放疗的574例患者与单纯手术治疗的413例患者进行对比分析.结果 全组患者的1、3、5、10年生存率分别为87.7%、57.5%、54.6%和54.5%.其中综合治疗组的1年生存率高于单纯手术组(P<0.01).在T4患者中,手术+放疗组的5年生存率高于单纯手术组(P<0.05).在N0患者中,手术+化疗组、手术+放疗组与单纯手术组比较,1年生存率差异有统计学意义(均P<0.05);在N1患者中,手术+化疗组、手术+放化疗组与单纯手术组比较,1年生存率差异有统计学意义(P<0.01);在N2患者中,手术+化疗组与单纯手术组比较,1年和3年生存率差异均有统计学意义(均P<0.05).结论 对于NSCLC患者,以手术为主的综合治疗疗效优于单纯手术.对T4患者应加强术后局部放疗,对NO和N1患者应辅以适度化、放疗,对N2患者则应强调辅以足够的化疗.     

Comparison of outcomes of radical prostatectomy with and without adjuvant pelvic irradiation in patients with pathologic stage C (T3N0) adenocarcinoma of the prostate

Patients with localized adenocarcinoma of the prostate gland (CaP) are frequently (approximately 50%) found at radical prostatectomy to have extracapsular disease or positive surgical margins. The management of these patients is a subject of controversy because some question the impact of this manifestation of CaP on patient survival or disease-free survival. Between 1976 and 1991, 241 patients with pathologic stage C (T3N0) were treated in this medical center. Of these 241 patients, 201 (83%) received a planned postoperative pelvic irradiation consisting of 48 Gy given to the prostatic fossa, whereas 40 (17%) patients were treated with radical prostatectomy alone. The two study urologists selected these patients not to receive postoperative irradiation based on intraoperative findings and important prognostic factors. Comparison of treatment outcomes in these two treatment groups is a subject of this report. The 201 patients treated with surgery-radiotherapy (S+RT) combination had a higher pathologic stage, greater incidence of seminal vesicle involvement, p = 0.002, and higher mean and median preoperative prostate-specific antigen level, p < 0.0001, than the 40 surgery (S) alone patients. There was no significant difference in the incidence of higher Gleason's score by the treatment group, p = 0.14. In univariate analysis, there was no significant difference in survival, disease-free survival, and time to failure between the two treatment groups. In multivariate analysis after controlling for pathologic stage and Gleason's score, the 201 adjuvant radiotherapy patients were predicted to have recurrence at 68% (95% confidence interval 39%-118%) the rate of the 40 surgery-alone patients. Local recurrence with or without metastatic disease was found in 10% of surgery-alone patients as compared to 5% in those also receiving postoperative irradiation. Treatment tolerance was very good with minor radiotherapy complications only. There was no significant difference in the incidence of incontinence between the two treatment arms. In summary: (a) The use of moderate-dose postoperative radiotherapy was of low toxicity and it did not increase the incidence of incontinence. (b) Local recurrence was 5% in S+RT and 10% in S-alone patients. (c) In multivariate analysis, S+RT patients had 68% rate of recurrence of S-alone patients. (d) Adjuvant RT probably reduces the risk of recurrence in patients with poor prognostic factors. (e) These data need to be interpreted with caution because of the nonrandomized nature of the study.