Surgical strategies in esophageal carcinoma with emphasis on radical lymphadenectomy.

From 1975 through 1988, 257 patients with carcinoma of the thoracic esophagus have been treated in our department. Operability was 90% (232/257); overall resectability, 77% (198/257), and for the operated group, 85% (198/232). Hospital mortality rate was 9.6% but decreased to 3% over the period 1986 to 1988. There were 65% squamous cell epitheliomas and 35% adenocarcinomas. Tumor, nodes, and metastases (pTNM) staging was as follows: stage I, 11.6%; stage II, 23.2%; stage III, 37.9%; stage IV, 27.3%. Overall survival rate was 62.5% at 1 year, 42.4% at 2 years, and 30% at 5 years. According to the pTNM staging, 5-year survival was 90% for stage I, 56% for stage II, 15.3% for stage III, and 0 for stage IV. There were no statistically significant differences according to tumor localization, pathologic type, sex, or age. Introducing extensive resection and extended lymphadenectomy seems to improve significantly survival in patients in whom an operation with curative intention was performed, the 1 year survival rate being 90.8% versus 72%; 2-year survival, 81% versus 46%; and 5-year survival, 48.5% versus 41% for radical and nonradical resections, respectively. Based on multivariate Cox regression analysis, only TNM stage and presence or absence of lymph nodes are important factors in predicting survival: stage 1 tumors have lower risk, and involvement of lymph nodes creates higher risk. Using this analysis, there was only for the patients with involved lymph nodes (N1) a significantly better prognosis when a radical lymph node dissection was performed (p = 0.0055). Barrett adenocarcinomas have no worse prognosis than other esophageal carcinomas, with a 5-year survival rate of 91.5% if lymph nodes are negative, and a 54% overall 5-year survival rate. Functional results after restoration of continuity with gastric tubulation were judged excellent to very good in 86.5% at 1 year, but infra-aortic anastomoses have a much higher incidence of peptic esophagitis: 53% versus 8% for cervical anastomoses. From this study it can be concluded that in experienced hands surgery today offers the best chances for optimal staging, potential cure, and prolonged high-quality palliation.     

Three-field lymphadenectomy for carcinoma of the esophagus and gastroesophageal junction in 174 R0 resections: impact on staging, disease-free survival, and outcome: a plea for adaptation of TNM classification in upper-half esophageal carcinoma

OBJECTIVE: To determine the impact of esophagectomy with 3-field lymphadenectomy on staging, disease-free survival, and 5-year survival in patients with carcinoma of the esophagus and gastroesophageal junction (GEJ). BACKGROUND: Esophagectomy with 3-field lymphadenectomy is mainly performed in Japan. Data from Western experience with 3-field lymphadenectomy are scarce and dealing with relatively small numbers. As a result, its role in the surgical practice of cancer of the esophagus and GEJ remains controversial. METHODS: Between 1991 and 1999, primary surgery with 3-field lymphadenectomy was performed in 192 patients, of whom a cohort of 174 R0 resections was used for further analysis. RESULTS: Hospital mortality of the whole series was 1.2%. Overall morbidity was 58%. Pulmonary complications occurred in 32.8%, cardiac dysrhythmias in 10.9%, and persistent recurrent nerve problems in 2.6%. pTNM staging was as follows: stage 0, 0.6%; stage I, 9.2%; stage II, 27.6%; stage III, 28.7%; and stage IV, 33.9%. Overall 3- and 5-year survival was 51% and 41.9%, respectively. The 3- and 5-year disease-free survival was 51.4% and 46.3%, respectively. Locoregional lymph node recurrence was 5.2%; no patient developed an isolated cervical lymph node recurrence. Five-year survival for node-negative patients was 80.2% versus 24.5% for node-positive patients. Five-year survival by stage was 100% in stages 0 and I, 59.1% in stage II, 36.8% in stage III, and 13.3% in stage IV. Twenty-three percent of the patients with adenocarcinoma (25.8% distal third and 17.6% GEJ) and 25% of the patients with squamous cell carcinoma (26.2% middle third) had positive cervical nodes resulting in a change of pTNM staging specifically related to the unforeseen cervical lymph node involvement in 12%. Cervical lymph node involvement was unforeseen in 75.6% of patients with cervical nodes at pathologic examinations. Five-year survival for patients with positive cervical nodes was 27.7% for middle third squamous cell carcinoma. For distal third adenocarcinomas, 4-year survival was 35.7% and 5-year survival 11.9%. No GEJ adenocarcinoma with positive cervical nodes survived for 5 years. CONCLUSIONS: Esophagectomy with 3-field lymph node dissection can be performed with low mortality and acceptable morbidity. The prevalence of involved cervical nodes is high, regardless of the type and location of tumor resulting in a change of final staging specifically related to the cervical field in 12% of this series. Overall 5-year and disease-free survival after R0 resection of 41.9% and 46.3%, respectively, may indicate a real survival benefit. A 5-year survival of 27.2% in patients with positive cervical nodes in middle third carcinomas indicates that these nodes should be considered as regional (N1) rather than distant metastasis (M1b) in middle third carcinomas. These patients seem to benefit from a 3-field lymphadenectomy. The role of 3-field lymphadenectomy in distal third adenocarcinoma remains investigational.     

Clinical outcome of epithelial tumors of the thymus

OBJECTIVE AND METHODS: We retrospectively reviewed treatment and clinical outcome of thymic epithelial tumors of 64 patients over a 20-year period. Clinical staging of the tumor was done by according to Masaoka classification. Histological diagnosis of the tumors was done by according to the second edition of the WHO histologic classification system for thymic epithelial tumors. Survival rate was calculated after Kaplan-Meire method. RESULTS: Median age of patients was 53.7 years (ranged from 16 to 81). There were 30 men and 34 women. Eighteen patients had auto-immuno diseases. Sixty-two patients underwent surgery. In 57 patients resection was complete (extended thymo-thymectomy), but in the other five incomplete. The operative approach was median sternotomy in 51 patients and video-assisted thoracoscopic surgery in 6. Stage II to IV patients had postoperative mediastinal irradiation. Stage III to IV patients had postoperative cisplatin (CDDP) based chemotherapy. Inoperable patients were treated by chemo-radiotherapy. There were 42 stage I, 7 stage II, 11 stage III, 3 stage IV a, 1 stage IV b. The 5-year/10-year survival rates were 93%/89%, 71%/71%, 68.5%/--in patients with stage I, II and III. There were 5 type A tumors, 8 type AB tumors, 11 type B1 tumors, 11 type B2 tumors, 9 type B3 tumors, 11 type C tumors, the respect 5-year survival rates were 100%, 100%, 87.5%, 60%, 85.7% and 90%. Masaoka stage II to IV patients classified in B2, B3 and C type except one case. CONCLUSION: Histologic type B2, B3 and C tumors may reflect the invasive nature. Masaoka staging system and the WHO histologic classification may help the assessment and treatment of patients with thymic epithelial tumor.     

Prognostic factors and long-term results after surgery for gallbladder carcinoma: a retrospective study of 127 patients

BACKGROUND: The surgical management of gallbladder cancer is controversial, especially as to the indications for reoperation, extended resection, and aggressive treatment in advanced tumor stages. METHODS: Records and follow-ups of 127 patients with gallbladder carcinoma who underwent surgery between 1980 and 1997 were examined according to the pTNM and Nevin staging systems. Factors predictive for survival were obtained from histopathologic staging and surgical procedures. RESULTS: Surgery for gallbladder cancer was associated with an overall 5-year survival rate of 6.6%. Curative resection was possible in 35.5% of cases, which resulted in 5-year survival rates of 20%. Noncurative surgery revealed poor prognosis, with median survival time limited to 3.2 months, independently of macroscopic or microscopic tumor residues. None of the latter patients survived longer than 24 months. Surgery of stage I/II cancer showed a 5-year survival rate of 64.5%. In stage III/IV tumors, resectability was only 20.4%. However, curative surgery in advanced stages significantly increased median survival from 3.2 to 19.4 months. CONCLUSIONS: Only complete tumor resection can provide long-term survival, even in advanced stages. Because negative surgical margins and UICC stage are the strongest predictors for survival, reoperation is required with all incidental findings above the T1b stage.     

Clinical analysis of 1,000 patients with prostate cancer

OBJECTIVES: Treatment outcomes for prostate cancer in our hospital were reported. MATERIALS AND METHODS: We analyzed 1,009 patients with prostate cancer treated at Niigata Cancer Hospital between 1983 and 2003. RESULTS: As for the clinical stage, 20 cases belonged to Stage I, 367 cases to Stage II, 269 cases to Stage III and 353 cases to Stage IV. The overall 5-year survival rate of the all 1,009 cases was 59.0%, comprising 78.2% for stage I, 82.0% for Stage II, 76.0% for Stage III and 30.0% for Stage IV cases. Disease-specific 5-year survival rates for Stage I, II, III and IV were 100%, 96.8%, 89.3% and 41.1% respectively. In Stage III patients, the radiotherapy (with endocrine therapy) group showed longer cause-specific survival than the endocrine therapy group (p = 0.0056). CONCLUSIONS: Our result suggest that the radiotherapy with endocrine therapy is useful for Stage III prostate cancer.     

Clinical pattern and pathologic stage but not histologic features predict outcome for bronchioloalveolar carcinoma

BACKGROUND: The histologic criteria defining bronchioloalveolar carcinoma (BAC) were recently revised, but it is unclear whether these criteria predict clinical behavior. This study determined the outcome of resected BAC in relationship to clinical and radiologic disease pattern, and pathologic features. METHODS: Between 1989 and 2000, 100 consecutive surgically treated patients with adenocarcinomas exhibiting various degrees of BAC features were retrospectively studied. Histology was reviewed; tumors were classified as pure BAC, BAC with focal invasion, and adenocarcinoma with BAC features. Clinical and radiologic pattern were classified as unifocal, multifocal, or pneumonic. Demographic data, tumor stage, and outcome were recorded. Survival was analyzed by the Kaplan-Meier method, and prognostic factors were determined by the log-rank test. RESULTS: Patient median age was 65, and 74% of the patients were female. Pure BAC, BAC with focal invasion, and adenocarcinoma with BAC features occurred in 47, 21, and 32 patients, respectively. Unifocal disease occurred in 64 patients, multifocal in 29, and pneumonic in 7. Seventy-one patients had stage I/II tumors, 22 had stage III/IV, and 7 patients had Stage X tumors. Overall 5-year survival was 74%. There was no significant difference in survival among the three histologic subtypes. The pneumonic pattern had significantly worse survival compared with unifocal and multifocal patterns. Pathologic stage predicted survival, with 5-year survivals for I/II and III/IV of 83.7% and 59.6%, respectively. CONCLUSIONS: Clinical pattern and pathologic stage, but not the degree of invasion on histologic examination predict survival. Multifocal disease is associated with excellent long-term survival after resection. The favorable survival of stage III/IV BAC indicates that the current staging system does not fully describe this disease in patients undergoing resection because of its distinct tumor behavior.     

Limited esophagogastrectomy for carcinoma of the cardia. Indications, technique, and results.

Between 1970 and 1988, 149 patients with carcinoma of the cardia were operated on at the Lahey Clinic. Of these patients, 127 (85%) underwent resection; 23 (18.1%) were of a palliative nature. More than 75% had Stage III and IV disease. One patient (0.8%) died within 30 days of the operation of a myocardial infarct. Two other patients failed to leave the hospital. Of 25 postoperative complications, 14 (11%) were considered major. Palliation of dysphagia was successful in 80% of patients. The actuarial 5-year survival rate was 22.4%. Of patients with Stage I and II disease, 36.6% survived for 5 years, and of patients with Stage III disease, 22.5% survived. No patient with Stage IV disease lived for longer than 1 year. It is concluded that limited esophagogastrectomy can be performed in most patients with carcinoma of the cardia with low mortality and morbidity and with satisfactory long-term survival.     

Predictors of survival after liver transplantation for hepatocellular carcinoma associated with Hepatitis C.

The efficacy of orthotopic liver transplantation (OLT) for hepatocellular carcinoma (HCC) associated with hepatitis C virus (HCV) is not well defined. This study examines the variables that may determine the outcome of OLT for HCC in HCV patients. From 1990 to 1999, 463 OLTs were performed for HCV cirrhosis. Of these patients, 67 with concurrent HCC were included in the study. Univariate and multivariate analyses considered the following variables: gender, pTNM stage, tumor size, number of nodules, vascular invasion, incidental tumors, adjuvant chemotherapy, preoperative chemoembolization, alpha-fetoprotein (AFP) tumor marker, lobar distribution, and histological grade. Overall OLT survival of HCV patients diagnosed with concomitant HCC was significantly lower when compared to patients who underwent OLT for HCV alone at 1, 3, and 5 years (75%, 71%, and 55% versus 84%, 76%, and 75%, respectively; P < 0.01). Overall survival of patients with stage I HCC was significantly better than patients with stage II, III, or IV (P < .05). Eleven of 67 patients developed tumor recurrence. Sites of recurrence included transplanted liver (5), lung (5), and bone (1). Twenty-four of 67 patients (36%) died during the follow-up time. Causes of deaths included recurrent HCC in 8 of 24 patients (12%) and recurrent HCV in 3 of 24 patients (4.5%), whereas 13 (19.5%) patients died from causes that were unrelated to HCV or HCC. Both univariate and multivariate analysis demonstrated that pTNM status (I versus II, III, and IV; P < .05) was a reliable prognostic indicator for patient survival. Presence of vascular invasion (P = .0001) and advanced pTNM staging (P = .038) increased risk of recurrence. Multivariate analysis showed that pretransplant chemoembolization and adjuvant chemotherapy reduced risk of death after OLT in HCC recipients. In conclusion, this study demonstrates the effectiveness of OLT for patients with HCC in a large cohort of chronic HCV patients. Advanced tumor stage, and particularly vascular invasion, are poor prognostic indicators for tumor recurrence. Early pTNM stage, adjuvant chemotherapy, and preoperative chemoembolization were associated with positive outcomes for patients who underwent OLT for concomitant HCV and HCC.     

Patient selection and factors affecting results following resection for hepatic metastases from colorectal carcinoma

Personal experience is reported of 47 consecutive liver resections for metastatic colorectal carcinoma treated in the I Clinica Chirurgica of the University of Rome for the purpose of contributing to treatment and evaluating the clinical factors and possible determinants of prognosis that could be potentially predictive of outcome and length of survival after liver resection: Duke's stage of primary colorectal cancer, synchronous or metachronous disease, number of hepatic lesions. Patients were classified according to the proposed staging system of the "Istituto Nazionale Tumori" in Milan. For Stage I and II patients the median survival time was 15 months, while in Stage III patients survival time was reduced to only 4.5 months. The 3- and 5-year survival rate was 20% and 12% respectively for Stage I patients; no patients at stage II or III survived more than 3 years.     

Twenty-year experience with liver transplantation for hepatocellular carcinoma

HYPOTHESIS: Liver transplantation (LT) has become the optimal treatment for stages I and II hepatocellular carcinoma (HCC). Based on our 20-year experience, changes in staging, techniques, and patient selection have improved survival over the past 20 years. Herein, we determine if pre-LT treatment for HCC alters the long-term outcomes in patients with HCC. DESIGN: Outcomes study. SETTING: Tertiary referral center. PATIENTS: We retrospectively reviewed prospectively collected data in a cohort of 92 patients who underwent LT for HCC between 1983 and 2003. MAIN OUTCOME MEASURES: Patient demographics, tumor stage in the explant liver, patient survival, and tumor recurrence data were analyzed. RESULTS: The average follow-up was 1052 (range, 0-6491) days. The average tumor size was 3.6 cm; 40% of tumors were multifocal and 60% unifocal. Of the 92 patients, 26% were classified as stage I; 42%, stage II; 24%, stage III; and 8%, stage IV. The overall 5-year survival rate was 50%, the 10-year survival rate was 32%, and the 15-year survival rate was 27%. Improvements in staging in the last 5 years reduced the number of patients with stages III and IV HCC from 39% to 19% and increased the 5-year survival rate to 69%. Tumor recurrence was relatively rare (13%); however, recurrence resulted in a poor prognosis (75% mortality rate; P = .02). The average time to recurrence was 458 (range, 179-1195) days. CONCLUSIONS: Liver transplantation for HCC results in excellent long-term survival for patients with stages I and II HCC, with relatively few patients dying from tumor recurrence. Improvements in preoperative staging have resulted in increased 5-year survival rates. Further refinements in pre-LT staging may increase the effectiveness of LT for HCC.     

Role of Surgery for Gallbladder Carcinoma with Special Reference to Lymph Node Metastasis and Stage Using Western and Japanese Classification Systems

The role of radical resection in the treatment of gallbladder carcinoma was examined with special reference to lymph node metastasis using two classifications: one proposed by the American Joint Committee on Cancer (AJCC) and the other by the Japanese Society of Biliary Surgery (JSBS). Histologic evaluations for the depth of tumor invasion (T), lymph node metastasis (N), stage, and follow-up for a mean period of 38 months (range 4-185 months) were completed in 52 patients with gallbladder carcinoma who underwent surgical resection from 1982 to 1997. The definition of T was similar in the two classifications. The extent of nodal involvement (N, AJCC; n, JSBS), stage, and survival were examined. In the absence of lymph node metastasis, the 5-year survival rate reached 71%. The 5-year survival rate in patients with involved nodes confined to the hepatoduodenal ligament, posterosuperior pancreaticoduodenal region, or along the common hepatic artery (N1 and part of N2 by AJCC; nl and n2 by JSBS) approximated 28%. In contrast, postoperative survival was poor in the presence of more extensive nodal involvement (rest of N2 by AJCC; n3 and n4 by JSBS), with no 2-year survivors. The definition of stage I was the same in both classifications, and all patients in this stage are alive. The 5-year survival rates in stages II and III by the AJCC were 70.7% and 22.4%, respectively, and those by JSBS 61.9% and 23.1%, respectively. Thus the survival rates in stages I to III were essentially similar irrespective of the staging system. Stage IV showed significantly worse survival than stage III by the JSBS classification. In contrast, the differentiation of stage IV from III by the AJCC was not significant because of the better survival in stage IV that contained any T with nodal involvement in the posterosuperior pancreaticoduodenal region and along the common hepatic artery. Radical resection should be considered for patients with stage I to III disease defined by either classification and applied to the tumor invasion up to T3 with nodal involvement confined to the hepatoduodenal ligament, posterosuperior pancreaticoduodenal region, and along the common hepatic artery. The role of radical surgery seems to be limited in patients with more extensive tumor invasion or lymph node metastasis.     

Thymoma needs a new staging system

Despite the wide use of the Masaoka staging system for thymoma, the distribution of survival by stage group is not well balanced. The new staging systems for testing were defined as follows: stage I was created by merging Masaoka's stages I and II, and stage IV remained unchanged. Stages II and III were defined as thymomas with invasive growth and the following combinations of tumor diameter and number of involved structures/organs. Scheme 1: stage II included tumors less than 10 cm in diameter and involving one neighboring structure/organ. Stage III included tumors with all combinations of diameter and number of involved structures/organs other than those in stage II. Scheme 2: stage II included tumors of all combinations other than those in stage III. Stage III included tumors 10 cm or more in diameter and involving two or more structures/organs. The survival curves were assessed for 138 patients treated at the National Cancer Center, Tokyo. The 10-year survival rates for each stage according to the Masaoka, Scheme 1, and Scheme 2 systems were as follows: stage I (100%, 100%, 100%), stage II (100%, 86%, 83%), stage III (70%, 64%, 34%), and stage IV (34%, 34%, 34%), respectively. The survival curves for Scheme 1 gave the most balanced distribution of survival in each staging group. By considering both tumor diameter and number of involved structures/organs, Masaoka's stages I-III could be rearranged with more balanced distribution of survival.     

External beam and intraluminal radiotherapy in the treatment of carcinoma of the esophagus

During a 10-year period, 46 patients with unresectable or inoperable carcinoma of the esophagus were treated with teletherapy-brachytherapy combination at the University of Southern California School of Medicine. Stage distribution was as follows: stage I, 5 (11%) patients; stage II, 23 (50%) patients; stage III, six (13%) patients; and stage IV, 12 (26%) patients. Thirteen patients were treated for recurrent disease, including 11 patients initially treated with teletherapy and two who had had surgical resection. Radiotherapy was given by teletherapy in 33 and brachytherapy in all 46 patients. An average tumor dose was 50 Gy with teletherapy and 20 Gy per application with brachytherapy. There were 25 patients who had more than one brachytherapy application. The 5-year actuarial survival rate for 28 patients with stage I or II disease was 12%, with a median of 13 months. This compared with no 5-year survivals and a median survival of 10 months for the 18 patients with stage III or IV disease. Failure at the primary site was seen in 16 (35%) patients. Complete response was seen in 20%, partial response in 76%, and no response in 4%. Treatment was well tolerated. Complications included esophageal stenosis in two patients and tracheoesophageal fistula in one. Teletherapy-brachytherapy combination is an effective treatment in the management of unresectable or inoperable carcinoma of the esophagus.     

The primary management of breast cancer: is breast conservation feasible for all patients?

A consecutive series of 411 patients with primary breast cancer treated by a consistent policy of breast conservation, regardless of tumour size, location, clinical stage or histological subtype, is reported. Actuarial 5-year survival was 84% for UICC Stage I, 73% for Stage II and 47% for Stage III/IV. The incidence of local recurrence at 5 years was 13% for Stage I, 12% for Stage II, and 26% for Stage III/IV. The probability of salvage mastectomy at 5 years was 5% for Stage I, 8% for Stage II, and 15% for Stage III/IV. Of local recurrences, 40% were managed with further breast conservation. Primary treatment with breast conservation results in satisfactory local control rates, 5-year survival and cosmesis, but the prevention, diagnosis and treatment of local recurrence within the conserved breast requires further evaluation.     

Carcinoma of the gallbladder--a clinical appraisal and review of 40 cases

Prognosis of 40 patients with gallbladder carcinoma who had undergone curative resection was investigated. Five-year survival rate calculated from Kaplan & Meier's method was 67% in 16 cases in Stage I, 43% in 8 cases in Stage II and 22% in 10 cases in Stage III, respectively. In 6 cases, classified as Stage IV, no case survived more than 2 years postoperatively. Most patients in Stage I had the tumors of papillary type in macroscopic appearance, papillary adenocarcinoma, and negative vascular and perineural invasions and showed better prognosis. In Stages II, III and IV, in contrast, most tumors were infiltrative or nodular type, tubular adenocarcinoma, and positive vascular and perineural invasions and demonstrated poorer prognosis. Patients in Stage I who had undergone simple cholecystectomy showed 5-year survival rate of 57%, and who underwent cholecystectomy with wedged resection of the gallbladder bed of the liver and regional lymphadenectomy (extended cholecystectomy) showed that of 100%. Extended cholecystectomy, therefore, is the procedure of choice in patients in Stage I. In patients in Stages II, III and IV, extended cholecystectomy yielded 5-year survival rate of 33%. More radical procedure or combined modality therapy must be indicated in advanced stage of the disease.     

Alveolar Cell Carcinoma of the Lung: A Retrospective Analysis of 205 Patients

From 1970 to 1986, survival of 205 patients with alveolar cell carcinoma was retrospectively studied. Analysis examined the predictive value of presenting symptoms and diagnostic screening results for pathological Stage III or IV disease (advanced) and survival. The lesion presented as a peripheral mass in 121 patients (59%) and as an infiltrate in 84 (41%). Follow-up data were available on 199 patients (97%). Variables analyzed included indices of background or risk factors, presenting symptoms, diagnostic test results, and clinical management. Seventy-nine patients (39%) had a histological diagnosis of advanced disease by TMN staging criteria. Of the 152 deaths (74%), 117 (77%) were related to the pulmonary carcinoma. Univariate analysis associated short-term and long-term anorexia, weight loss, generalized weakness, and profound dyspnea with advanced disease and ultimately with death due to cancer. Multivariate logistic regression analyses suggested that weight loss and dyspnea disclosed independent information about the likelihood of advanced disease for this population (p > 0.0003). Cox proportional hazard regression analyses of survival revealed a significant association between weight loss and death due to alveolar cell carcinoma after pathological stage was taken into account (p = 0.001). In this series, the 80 patients with Stage I disease had the best prognosis (5-year survival of 55%). There was no significant difference in disease-free survival between patients having wedge resection (N = 17) and those having lobectomy (N = 63) for Stage I disease.     

Adrenocortical carcinoma: surgical progress or status quo?

HYPOTHESIS: Outcome of patients with adrenocortical carcinoma (ACC) has improved with the advent of more widely available and higher quality imaging. Operative management strategies and use of adjuvant therapy have not changed. DESIGN: Retrospective review of patient histories, imaging studies, operative data, adjuvant therapy, and outcomes at a single institution. Follow-up was complete for a mean of 53 months. Data was compared with prior institutional experience. SETTING: Tertiary care referral center. PATIENTS: All patients undergoing operative management for ACC during the period from 1980 to 1996. MAIN OUTCOME MEASURES: Determinants of recurrence, survival, and the effect of adjuvant therapy on overall outcome. RESULTS: Fifty-eight patients (30 men, 28 women) with a mean age of 53 years underwent primary operative management for ACC. Functional tumors were identified in 27 patients (47%). Mean tumor size was 12.5 cm. Stage according to the TNM staging system (AJCC Cancer Staging Manual) at presentation was I (n = 0), II (n = 30), III (n = 7), and IV (n = 21). Surgical management included curative resection in 41 (71%), noncurative resection in 14 (24%), and open biopsy in 3 (5%). Perioperative mortality was 5%. Recurrence occurred in 30 patients (73%) with a median time to recurrence of 17 months. Five-year survival by the Kaplan-Meier method was 37%. Prognostic factors (P<.05) included functional status, stage, and chemotherapy in stage III/IV patients. When compared with our prior institutional experience (1960-1980), current patients were more likely to present with stages I to II (52% vs. 34%), have curative resections (71% vs. 50%), and have improved 5-year survival (37% vs. 16%). CONCLUSIONS: (1) Surgical resection remains the principal treatment for stage I to III disease. (2) Adjuvant therapy may improve survival in patients with stage III or IV disease. (3) Current patients were more likely to present at an earlier stage, undergo curative resections, and have improved 5-year survival than institutional historical comparisons.     

Gender differences in stage-adjusted bladder cancer survival

OBJECTIVES: Gender differences have been observed in the prognosis of patients with bladder cancer. It has also been suggested that these differences are caused by a worse stage distribution at diagnosis among women. The purpose of this study was to evaluate whether women with bladder cancer have a worse prognosis even after adjustment for disease stage at first presentation. METHODS: Data on patients with bladder cancer diagnosed between 1973 and 1996 and registered by one of the nine population-based Surveillance, Epidemiology, and End Results (SEER) cancer registries in the United States (n = 80,305) were obtained from the National Cancer Institute public domain SEER*Stat 2.0 package. Similar data on patients with bladder cancer diagnosed between 1987 and 1994 and registered by two population-based registries in the Netherlands (n = 1722) were obtained through the Comprehensive Cancer Centers, Amsterdam and South. Survival rates adjusted for mortality owing to other causes (ie, relative survival) were calculated for men and women within each category of the American Joint Committee on Cancer (SEER data) and TNM (Netherlands data) stage groupings.Results. In the United States, the 5-year relative survival rate of male patients with bladder cancer was calculated to be 79.5% (95% confidence interval 79.0% to 80.0%). Among women, the 5-year relative survival rate was significantly worse: 73.1% (95% confidence interval 72.2% to 74.0%). The male versus female 5-year survival rate among stage groups I, II, III, and IV was 96.5% versus 93.7%, 65.5% versus 59.6%, 58.8% versus 49.6%, and 27.1% versus 15.2%, respectively. The (sparser) data from the Netherlands were less conclusive. Women with Stage II and Stage IV disease fared worse than men but the reverse seemed to be true in Stage I disease. CONCLUSIONS: Female patients with bladder cancer have a worse prognosis than male patients. It is unlikely that the difference can explained entirely by the more frequent diagnosis of higher stages at first presentation among women.     

Locally advanced (stage III and IV) head and neck cancer: Westmead Hospital experience

Two hundred and fifty-one patients with Stage III and IV (UICC staging system) squamous cell cancers of the oral cavity, oropharynx, hypopharynx and larynx were assessed between January 1980 and December 1988 at Westmead Hospital. Of these, 50 patients received palliative treatment or were not treated and the remaining 201 patients received treatment with curative intent by various combinations of radiotherapy, surgery and chemotherapy. Thirty-nine operable cases were entered into a multimodality protocol initiated in April 1985, which consisted of induction chemotherapy (cisplatin 100 mg/m2 i.v. day 1, 5-fluorouracil 1000 mg/m2 per 24 h i.v. days 1-5, q3w x 2) followed by surgery and postoperative radiotherapy. The median follow-up for all 251 patients was 57 months. Actuarial 3-year survival rate for all 201 patients receiving radical treatment was 48% (Stage III 66%, Stage IV 36%; P less than 0.001). Overall actuarial local and nodal control rates at 3 years were 67% and 69%. Thirty-two of 201 patients (16%) developed distant metastases at a median time of 11 months. Twenty-one patients (10%) had a previous or subsequent second primary cancer. In the group of 39 protocol patients, overall actuarial survival, local and nodal control rates are 68%, 77% and 73% at 3 years. A group of 22 'protocol' patients was compared with a group of 22 patients treated prior to commencement of the protocol, matched as closely as possible on the basis of site, stage, age, sex and ECOG status.(ABSTRACT TRUNCATED AT 250 WORDS)     

Testicular seminoma: the M. D. Anderson experience. An analysis of pathological and patient characteristics, and treatment recommendations

We treated 240 patients with testicular seminoma at our institution between January 1960 and December 1982. The over-all 5-year survival free of disease for these patients regardless of stage was 93.6 per cent. The 165 patients (69 per cent) with stage I disease had a 95.5 per cent 5-year survival free of disease that remained constant at 20 years. Stage II cancer was diagnosed clinically in 62 patients (26 per cent), while 13 (5 per cent) presented with more advanced (stages III and IV) disease. The 5-year survival rate free of disease for all patients with stage II cancer was 85 per cent. There were 14 pathological and patient characteristics analyzed, 4 of which were statistically significant. All but 1 of these factors (spermatic cord invasion) was related to tumor volume (stage, palpable mass and hydronephrosis). Based on the data of this retrospective review, the Canadian experience without prophylactic mediastinal irradiation and the development of effective chemotherapy, we recommend radiation therapy without prophylactic mediastinal irradiation for patients with stage I or IIA disease and chemotherapy for patients with stage IIB, III or IV disease. In an attempt to improve our results in the latter patients we recently instituted adjunctive radiotherapy for those with a persistent radiographic mass. Our current guidelines for the staging evaluation and followup of patients with this neoplasm also are discussed.