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.     

Elective nodal failures are uncommon in medically inoperable patients with Stage I non-small-cell lung carcinoma treated with limited radiotherapy fields

PURPOSE: To review the outcome for 56 Stage I non-small-cell lung cancer treated definitively with three-dimensional conformal radiotherapy (3D-CRT) and to investigate the value of elective nodal irradiation in this patient population. METHODS AND MATERIALS: Between 1992 and 2001, 56 patients were treated with 3D-CRT for inoperable Stage I histologically confirmed non-small-cell lung cancer; 31 with T1N0 and 25 with T2N0 disease. All patients were treated with 3D-CRT to a median isocenter dose of 70 Gy (range 59.94-83.85) given in daily doses of 1.8 or 2 Gy. Prognostic factors were analyzed with respect to their impact on overall survival. Twenty-two patients received radiotherapy (RT) directed to elective regional lymphatics to doses of 45-50 Gy. The remaining 33 patients were treated to limited fields confined to the primary lung cancer with a margin. The patterns of failure were reviewed. RESULTS: The median follow-up was 20 months (range 6 months to 6 years). The actuarial local control rate was 88%, 69%, and 63%, at 1, 2, and 3 years, respectively. The actuarial cause-specific survival rate was 82%, 67%, and 51% at 1, 2, and 3 years, respectively. The actuarial overall survival rate was 73%, 51%, and 34% at 1, 2, and 3 years, respectively. The actuarial metastasis-free survival rate was 90%, 85%, and 81% at 1, 2, and 3 years, respectively. The RT dose was the only factor predictive of overall survival in our analysis. No statistically significant difference was noted in cause-specific or overall survival according to whether patients received elective nodal irradiation. Two of 33 patients treated with limited fields had regional nodal failure. CONCLUSION: Many patients with medically inoperable Stage I lung cancer die of intercurrent causes. The omission of the elective nodal regions from the RT portals did not compromise either the cause-specific or overall survival rate. Elective nodal failures were uncommon in the group treated with limited RT fields. A radiation dose 70 Gy was predictive of better survival in our population. We await the results of prospective trials evaluating high-dose RT in patients treated with RT alone for Stage I lung cancer.     

Carcinoma of the vulva: clinical results of exclusive and adjuvant radiotherapy

BACKGROUND: The aim of this study was to evaluate the historical cohort of 61 patients with carcinoma of the vulva, treated with radiation therapy from 1986 to 1997. PATIENTS AND METHODS: Twenty-seven patients were submitted to radiation therapy alone and 34 received radiotherapy post limited surgery in early stages and post radical vulvectomy in advanced stages. The dose range varied from 59 to 63 Gy in post-operative patients and 65 Gy to 71 Gy in curative patients. RESULTS: Five-year Overall Survival (OS) and Disease-Free Survival (DFS) for patients treated with irradiation alone and for those treated with post-operative radiotherapy were 50.8% and 69.7%, respectively, without significant statistical difference. For OS multivariate analysis showed statistical difference for stage and age variables, and for stage variable in the case of DFS. CONCLUSION: In early stage vulvar cancer patients OS and DFS are good, with high control rate and low incidence of adverse effect. In loco-regionally-advanced patients, especially in those with stage IV or with > 2 positive lymph nodes, the outcomes are poor.     

Survival advantage for prostate cancer patients treated with high-dose three-dimensional conformal radiotherapy.

PURPOSE: The value of treating prostate cancer has been questioned, and some insist that a survival benefit is demonstrated to justify treatment. Prospective dose-escalation studies with three-dimensional conformal radiotherapy technique have demonstrated improvement in biochemical freedom from disease and local control. We report the outcomes of high-dose treatment with three-dimensional conformal radiotherapy compared with low-dose treatment for biochemical freedom from disease, freedom from distant metastasis, cause-specific survival, and overall survival. PATIENTS AND METHODS: The study design was retrospective, involving pairs matched on independent prognostic variables in which each patient treated with low-dose radiotherapy was matched with a patient treated with high-dose radiotherapy. Outcomes were compared for two groups of patients: Group I: Three-dimensional conformal radiotherapy treatment--296 patients treated with more than 74 Gy matched on stage, grade, and prostate-specific antigen level, to 296 patients treated with less than 74 Gy. Group II: Three-dimensional conformal radiotherapy treatment--357 patients treated with more than 74 Gy matched on stage and grade to 357 patients treated with less than 74 Gy. RESULTS: Univariate analysis showed that dose is a significant predictor of biochemical freedom from disease, freedom from distant metastasis, and cause-specific survival for group I and biochemical freedom from disease, freedom from distant metastasis, cause-specific survival, and overall survival for group II. Multivariate analysis showed that dose is a significant independent predictor in group I for biochemical freedom from disease and freedom from distant metastasis and for biochemical freedom from disease, freedom from distant metastasis, cause-specific survival, and overall survival in group II. DISCUSSION: These data provide strong support for the definitive treatment of prostate cancer with high-dose (> 74 Gy) three-dimensional conformal radiotherapy. These doses can be safely delivered with three-dimensional conformal radiotherapy techniques. Various institutions and industry must collaborate to expand the technology allowing the use of high-dose three-dimensional conformal radiotherapy in the national practice beyond centers of technological excellence.     

Vulvar carcinoma

: Controversies exist regarding the use of radiation therapy in the treatment of vulvar carcinoma. A retrospective review was performed to evaluate our institution's experience with surgery and radiation for this disease.

: The medical records of 47 patients treated for squamous cell carcinoma of the vulva at out institution (1974–1992) were reviewed for TNM stage (AJCC criteria), treatment modality, and associated 5-year local control and survival based on Kaplan-Meier analysis.

: Twenty-eight patients (60%) presented with Stage I and II disease and their 5-year survival was 69%. Stage III patients accounted for 12 (25%) of the patients and their 5-year survival was 73%. Seven patients presented with Stage IV disease and five died within 13 months of diagnosis after predominantly palliative therapy. The 40 patients with Stages I, II, and III disease were treated aggressively and were further evaluated for treatment-modality-associated survival and local control. Radiation therapy was used as primary treatment in nine patients, or whom seven were treated with radiation alone and two were treated postoperatively after wide excision. Surgery alone was performed in 31 patients consisting of either radical vulvectomy (20 patients) or wide excision (11 patients). When comparing outcomes of radical vulvectomy vs. radiation therapy, we noted that the 5-year actuarial survivals were comparable (74% for either modality), despite the presence of more favorable prognostic factors in the group treated with radical vulvectomy. Patients treated with wide excision alone had a trend for a poorer 5-year actuarial survival (51%) and local control (50%).

: Radical vulvectomy offers good locoregional control and survival. This retrospective review further supports the use of radiation therapy with conservative surgery as an alternative treatment option for patients with vulvar carcinoma treated with curative intent. In contrast, the use of wide excision alone should be performed with caution due to a higher locoregional failure rate. The role of appropriately prescribed radiation therapy should be further investigated in prospective clinical trials.     

Radiotherapy Alone for Medically Inoperable Stage I Non-Small–Cell Lung Cancer: The Duke Experience

Purpose: To review our experience treating clinical Stage I non-small–cell lung carcinoma with radiotherapy alone using modern techniques and staging. The effect of dose and volume on outcome is to be analyzed.Methods: Between January 1980 and December 1995, 156 patients with Stage I medically inoperable non-small–cell lung cancer were irradiated at Duke University Medical Center and the Durham Veterans Administration Medical Center. Fifteen patients were excluded from analysis (7 treated with palliative intent, and 8 lost to follow-up immediately following radiation). Characteristics of the 141 evaluable patients were as follows: Median age 70 years (range 46–95); gender: male 83%, female 17%; institution: DUMC 65%, DVAMC 35%; T1N0 54%, T2N0 46%; median size 3 cm (range 0.5 to 8); pathology: squamous cell carcinoma 52%, adenocarcinoma 18%, large cell carcinoma 19%, not otherwise specified 11%; presenting symptoms: weight loss 26%, cough 23%, none (incidental diagnosis) 57%. All patients underwent simulation prior to radiotherapy using linear accelerators of ≥4 MV. No patients received surgery or chemotherapy as part of their initial treatment. The median dose of radiotherapy (not reflecting lung inhomogeneity corrections) was 64 Gy (50 to 80 Gy) given in 1.2 bid to 3 Gy qid fractionation. The majority of cases included some prophylactic nodal regions (73%).Results: Of the 141 patients, 108 have died; 33% of intercurrent death, 35% of cancer, and 7% of unknown causes. At last follow-up, 33 patients were alive (median 24 months, range 7–132 months). The 2- and 5-year overall survival was 39% and 13%, respectively (median 18 months). The corresponding cause-specific survival was 60%, and 32% (median 30 months). On multivariate analysis, significant factors influencing overall and/or cause-specific survival were age, squamous cell histology, incidental diagnosis, and pack-years of smoking. There was a nonsignificant trend towards improved cause-specific survival with higher radiotherapy doses and larger treatment volumes. On patterns of failure analysis, 42% of failures were local-only and 38% were distant-only. Regional-only failure occurred in 4 patients (7%), 3 of whom failed solely in an unirradiated nodal site. Analysis of factors correlating with local failure at 2 years was performed using a multinominal logistic regression analysis. Significant factors associated with a lower local failure included incidental diagnosis and absence of cough with a strong trend toward significance for higher radiotherapy dose (p = 0.07) and larger treatment volume (p = 0.08). Patients who were locally controlled had an improved cause-specific survival at 5 years over those who were not controlled (46% vs. 12%, p = 0.03). Grade III–V complications occurred in 2 patients (1.5%).Conclusion: Patients with clinical Stage I medically inoperable non-small–cell lung cancer treated with contemporary radiotherapy alone achieved a 5-year cause-specific survival of 32%. Uncontrolled lung cancer was the primary cause of death in these patients, and local failure alone represented the most common mode of failure (42%). Patients who were locally controlled had a significantly improved cause-specific survival over those who failed locally. Because higher doses of radiotherapy appear to provide improved local control, studies of dose escalation are warranted until dose-limiting toxicity is observed.     

Prognostic Factors in Invasive Squamous Cell Carcinoma of the Vulva Treated with Surgery and Irradiation

From 1958 through 1980, 113 women with invasive squamous cell carcinoma of the vulva were treated with vulvectomy. Postoperative irradiation was given with cobalt-60 beam or 10 MV photons from a linear accelerator from anterior fields including the vulva and groins, with the intention of delivering 40-52 Gy with 2-4 Gy/day at a depth of 0.5 cm or 2 cm. The overall corrected five-year survival rate was 68%. The prognosis was shown to worsen significantly with advancing stages (I/96%, II/75%, III/62% and IV/19%), increasing grades (G1/78%, G2/70% and G3/22%) and increasing size of the tumor (T1/90%, T2/71% and T3/37%), as it also did when there were signs of vascular invasion, multifocal tumors or positive nodes in the inguinal regions. Recurrences were diagnoses in 32% of the patients. With the less aggressive surgical approach used, combined with radiation therapy to eradicate subclinical disease, the morbidity rate was acceptable and the survival rate comparable to that reported after more aggressive surgery.     

Long-term results of hypofractionated radiotherapy and hormonal therapy without surgery for breast cancer in elderly patients.

BACKGROUND AND PURPOSE: To evaluate early and late reactions, local control, disease-free survival, cause-specific survival, and overall survival of elderly breast cancer patients treated with definitive once-a-week hypofractionated radiotherapy together with hormonal therapy. PATIENTS AND METHODS: Between 1987 and 1999, 115 patients with a median age of 83 presenting with 124 non-metastatic breast carcinoma were treated with definitive once weekly hypofractionated radiotherapy associated with hormonal therapy. The main reasons for adopting this schedule were patient refusal of surgery, very old age, locally advanced case, and/or comorbid disease. Radiation was delivered as once-a-week, 6.5 Gy for a total breast dose of 32.5 Gy in five fractions, followed with 1-3 fractions of 6.5 Gy to the tumour site. The median follow-up was 41 months. RESULTS: Neoadjuvant hormonal therapy led to 56% reduction of the tumour volume. Late reactions occurred in 46 patients; they were mild to moderate in 87% of these patients. The Kaplan-Meier rate was 52% of patients, with 6% experiencing grade 3 reactions. The 5-year local progression-free rate was 78%. The corresponding cause-specific survival was 71%, and was influenced by T classification, nodal status, oestrogen receptors and the total dose. The first three factors retained an independent prognostic impact on multivariate analysis. The 5-year overall survival was 38%. It was affected by the T classification, lymph node involvement and the performance status (PS). Using a multivariate analysis, only T classification and PS were identified as independent factors regarding overall survival. CONCLUSIONS: Definitive hypofractionated radiotherapy allows a good local control, with acceptable toxicity. This schedule associated with hormonal therapy is a good alternative to surgery in non-operable old patients and in case of patient refusal to surgery and to standard fractionation.     

Combination of radiotherapy and surgery for advanced cancer of the vulva]

From 1970-1985, seventy-six patients with advanced carcinoma of the vulva were treated. It accounted for 58.9% of all vulvar cancers seen in the same interval. According to the revised FIGO Staging System of Vulvar Cancer, 64 had Stage III, and 12 had Stage IV lesions. Fourty-eight patients had tumor extending to the distal urethra, vagina or anus. Fifty-one were treated by radiotherapy combined with radical vulvectomy and inguinal lymphadenectomy, 10 by surgery alone, 9 by radiotherapy alone and 6 by palliative radiotherapy. In 20 (55.6%) patients the tumor was reduced > or = 50% and in 4 (20%) patients the tumor completely disappeared after pre-operative radiation as shown in pathologic examination of the resected specimens. The 5-year survival rate was 46.9% for Stage III, 33.3% for Stage IV disease, with an over-all 5-year survival of 60.8% on the combined group. Surgery alone gave a 5-year survival rate of 30%. All the patients died of cancer within 5 years in the radiotherapy and palliative radiation groups. It is suggested that combined radiotherapy and surgery be preferred for advanced cancer of the vulva. Technique of encompassing the vulvar and inguinal areas needs to further studied and improved.     

The effect of anaemia on efficacy and normal tissue toxicity following radiotherapy for locally advanced squamous cell carcinoma of the head and neck.

PURPOSE: The aims of this analysis were to determine the effect of anaemia on loco-regional control, relapse-free survival, cause-specific survival, overall survival, and acute and late radiation therapy toxicity in patients with Stage III and IV squamous cell carcinoma of the head and neck treated with radiotherapy. PATIENTS AND METHODS: Between 1991 and 1998, 350 patients were randomly assigned to either conventional radiotherapy, (70 Gy in 35 fractions in 49 days) or to accelerated radiotherapy (59.4 Gy in 33 fractions in 24 days). Patients were divided into two groups according to their haemoglobin level: a normal haemoglobin group (>/=13 g/dl in males, >/=12 g/dl in females) and a low haemoglobin group (<13 g/dl in males, <12 g/dl in females). The influence of anaemia on cause-specific survival and the development of confluent mucositis independent of other variables was tested using Cox proportional hazards model. RESULTS: Of 350 patients recruited to the trial, 238 had haemoglobin measurements and were eligible for inclusion in this secondary analysis. One hundred and ninety-three were considered to have normal haemoglobin, and 45 patients were considered to be anaemic. There were significant differences between the groups in loco-regional control, relapse-free survival, cause-specific survival and overall survival, with hazards ratios of 0.56 (95% confidence interval (CI) 0.34-0.94), 0.57 (95% CI 0.35-0.92), 0.49 (95% CI 0.29-0.85) and 0.43 (95% CI 0.26-0.70) in favour of the normal haemoglobin group. Using Cox proportional hazards modelling, haemoglobin level was a significant predictor of cause-specific survival in addition to disease site, stage, and Eastern Cooperative Oncology Group status. There were no statistically significant differences between the groups in the development of acute or late reactions. CONCLUSION: Significant reductions in loco-regional control, disease-free survival, cause-specific survival and overall survival occur in the presence of anaemia. No significant differences in normal tissue toxicity have been identified in this analysis.     

Anal canal carcinoma: early-stage tumors < or =10 mm (T1 or Tis): therapeutic options and original pattern of local failure after radiotherapy

PURPOSE: To investigate the clinical history, management, and pattern of recurrence of very early-stage anal canal cancer in a French retrospective survey. METHODS: The study group consisted of 69 patients with Stage Tis and T1 anal canal carcinoma < or =1 cm treated between 1990 and 2000 (12 were in situ, 57 invasive, 66 Stage N0, and 3 Stage N1). The median patient age was 67 years (range, 27-83 years). Of the 69 patients, 66 received radiotherapy (RT) and 3 with in situ disease were treated by local excision alone without RT. Twenty-six patients underwent local excision before RT (12 with negative and 14 with positive surgical margins). Of the 66 patients who underwent RT, 8 underwent brachytherapy alone (median dose, 55 Gy), 38 underwent external beam RT (median dose, 45 Gy) plus a brachytherapy boost (median boost dose, 20 Gy), and 20 underwent external beam RT alone (median dose, 55 Gy). RESULTS: Of the 69 patients, 68 had initial local control. Of the 66 patients treated by RT, 6 developed local recurrence at a median interval of 50 months (range, 13-78 months). Four patients developed local failure outside the initial tumor bed. Of the 3 patients with Tis treated by excision alone, 1 developed local recurrence. No relation was found among prior excision, dose, and local failure. The 5-year overall survival, colostomy-free survival, and disease-free survival rate was 94%, 85%, and 89%, respectively. The rate of late complications (Grade 1-3) was 28% and was 14% for those who received doses <60 Gy and 37% for those who received doses of > or =60 Gy (p = 0.04). CONCLUSION: Most recurrences occurred after a long disease-free interval after treatment and often outside the initial tumor site. These small anal cancers could be treated by RT using a small volume and moderate dose (40-50 Gy for subclinical lesions and 50-60 Gy for T1).     

Multi-institutional randomized trial of external radiotherapy with and without intraluminal brachytherapy for esophageal cancer in Japan. Japanese Society of Therapeutic Radiology and Oncology (JASTRO) Study Group.

PURPOSE: With the aim of improving the results of treatment of esophageal cancer, we designed this multi-institutional, randomized trial to establish the optimal irradiation method in radical radiation therapy for esophageal cancer by clinically evaluating external irradiation alone and in combination with intraluminal brachytherapy. METHODS AND MATERIALS: The study population consisted of patients with squamous cell carcinoma who were expected to be successfully treated with radical radiation therapy. The patients who could be given intraluminal brachytherapy at the end of external irradiation of 60 Gy were stratified into 2 groups. Patients assigned to receive external irradiation alone received boost irradiation of 10 Gy/week on a schedule similar to the previous one, and with the same or smaller irradiation field. Intraluminal brachytherapy was performed, as a rule, with the reference dose point set at a depth of 5 mm of the esophageal submucosa, and a total of 10 Gy was irradiated at a daily dose of 5 Gy, on a once-weekly schedule with low-dose-rate or high-dose-rate brachytherapy equipment. RESULTS: A total of 103 patients were registered, 94 of whom were analyzable, with 8 ineligible, and 1 for whom complete information was unavailable. The overall cumulative survival rate was 20.3% at 5 years. The cause-specific survival rate was 31.8% at 5 years. The cause-specific survival rate at 5 years was 27% in the external irradiation alone group and 38% in intraluminal brachytherapy combined group. There was no significant difference between the 2 groups (p = 0.385). However, in the patients with 5 cm or less tumor length, the cause-specific survival rate was 64% at 5 years in the intraluminal brachytherapy combined group, which showed a significant improvement over 31.5% in the external irradiation alone group (p = 0.025). In the patients with Stage T1 and T2 disease, cause-specific survival rates tended to be better in the intraluminal brachytherapy combined group than in the external irradiation alone group (p = 0.088). In the patients with more than 5 cm tumor length or Stage T3-4 disease, there were no significant differences between the two groups by treatment methods (p = 0.290). The incidence of early and late complications did not differ according to whether intraluminal brachytherapy was used. CONCLUSION: For the purpose of establishing the usefulness of intraluminal brachytherapy, further prospective randomized studies are necessary to evaluate the efficacy in tumors with short length and those with shallow invasion, or to assess the usefulness of intraluminal brachytherapy, as additional irradiation in large advanced tumors have been shown to have disappeared by diagnostic imaging after chemoradiotherapy with 60 Gy/6w external irradiation.     

后程三维适形放射治疗食管癌的临床研究

目的：评价后程三维适形放射治疗食管癌的疗效。方法：从2003年5月-2005年5月，对70例经病理证实的食管癌患者随机分为对照组和治疗组各35例。对照组采用3个野等中心常规分割，总剂量70Gy，35分次，7周完成。治疗组前程照射方法同对照组，剂量40Gy，20分次，4周完成；后程采用三维适形照射3Gy／次，10分次，2周完成；总剂量70Gy，30分次，6周完成。结果：治疗组和对照组的近期有效率分别为88．6％和77．1％（P〈0．05），1、3年局控率分别为77．1％、57．1％和62．9％、31．4％（P〈0．05），1、3年生存率分别为68．6％、42．9％和54．3％、25．7％（P〈0．05）。两组毒副反应的差异无统计学意义。结论：三维适形放疗食管癌的近、中期结果优于常规方法，急性毒副反应无明显差别。     

前程加速放射治疗食管癌临床观察

目的　评价前程加速放射治疗食管癌的疗效。方法　自 1994年 1月至 1996年 2月 ,选择 10 6例食管癌患者 ,随机分为两组 :(1)前程加速放射治疗组 5 3例 ,放射治疗第 1,2周 ,每天 3Gy ,5次 /周 ,第 3 ,4周 ,每天 2Gy ,5次 /周 ,总剂量 5 0Gy/ 4周 ;(2 )常规放射治疗组 5 3例 ,每天 2Gy ,5次 /周 ,总剂量 60Gy/ 6周。 结果　前程加速组 5年局部控制率和 5年生存率明显高于常规放疗组 ,分别为 41.5 %比 18.9%和 18.7%比 9.7% ,放疗副作用两组无明显差别。结论　结果显示前程加速放射治疗能提高食管癌局部控制率和生存率。     

83 例外阴浸润性鳞癌的临床分析

目的分析外阴鳞癌的临床表现,总结治疗方法,评价手术和放化疗的疗效及愈后。方法对诊治的83例随访满1年的外阴鳞癌进行回顾性分析。结果83例外阴鳞癌患者中,95．2％有前驱疾患;Ⅰ期和Ⅱ期患者60例（72．3％）,Ⅲ期和Ⅳ期患者23例（27．7％）,平均发病年龄为56．2岁,其中55例患者绝经（66．3％）。手术78例,单纯放化疗5例。手术方式包括：外阴局部切除10例（12．8％）,单纯外阴切除4例（5．1％）,外阴局部根治37例（47．5％）,根治性外阴切除27例（34．6％）。51例（65．4％）合并单侧或双侧腹股沟股浅或深淋巴结的切除,术后辅以放化疗的有34例,其中1例术前行放化疗。完全缓解65例（78．3％）,未治愈并逐渐进展18例（21．7％）。复发11例（16．9％）。总体5年的缓解率为68．7％（57／83）。切缘或紧邻切缘阳性者即使术后辅予放射治疗,其复发率仍较高,为27．8％。肿瘤浸润超过5mm或累及真皮以下的患者,复发率高达34．6％。11例复发患者,1例手术,1例放疗,余9例均进行了手术联合放疗以及化疗的联合治疗,4例进展,7例缓解,但其中4例在5年内反复复发。结论外阴鳞癌早期病例占多数;主要治疗手段为手术治疗,术后放疗的意义待进一步观察;疾病分期与疗效相关;手术切缘不净和浸润较深的患者复发率高,复发病例总体疗效不佳。     

Gross tumor volume, critical prognostic factor in patients treated with three-dimensional conformal radiation therapy for non-small-cell lung carcinoma.

PURPOSE: Three-dimensional conformal radiation therapy (3D-CRT) has recently become widely available with applications for patients with non-small-cell lung cancer (NSCLC). These techniques represent a significant advance in the delivery of radiotherapy, including improved ability to delineate target contours, choose beam angles, and determine dose distributions more accurately than were previously available. The purpose of this study is to identify prognostic factors in a population of NSCLC patients treated with definitive 3D-CRT. METHODS AND MATERIALS: Between March 1991 and December 1998, 207 patients with inoperable NSCLC were treated with definitive 3D-CRT. Tumor targets were contoured in multiple sections from a treatment planning computed tomography (CT) scan. Three-dimensional treatment volumes and normal structures were reconstructed. Doses to the International Commission on Radiation Units and Measurements (ICRU) reference point ranged from 60 to 83.85 Gy with a median dose of 70 Gy. The median dose inhomogeneity was +/- 5% across planning target volume. Outcome was analyzed by prognostic factors for NSCLC including pretreatment patient and tumor-related factors (age, gender, race, histology, clinical stage, tumor [T] stage, and node [N] stage), parameters from our 3D-CRT system (gross tumor volume [GTV] in cm3), irradiation dose prescribed to isocenter, volume of normal lung exceeding 20 Gy (V20), and treatment with or without chemotherapy. The median follow-up time was 24 months (range, 7.5 months to 7.5 years). RESULTS: One and two-year overall survival rates for the entire group were 59% and 41%, respectively. Overall survival, cause-specific survival, and local tumor control were most highly correlated with the GTV in cm3. On multivariate analysis the independent variable most predictive of survival was the GTV. Traditional staging such as T, N, and overall clinical staging were not independent prognostic factors. Patients receiving ICRU reference doses > or =70 Gy had better local control and cause-specific survivals than those treated with lower doses (p = 0.05). Increased irradiation dose did not improve overall survival. CONCLUSIONS: GTV as determined by CT and 3D-CRT planning is highly prognostic for overall and cause-specific survival and local tumor control and may be important in stratification of patients in prospective therapy trials. T, N, and overall stage were not independent prognostic factors in this population of patients treated nonsurgically. The value of dose escalation beyond 70 Gy should be tested prospectively by clinical trial.     

Stage I Squamous Cell Carcinoma of the Vulva

Eighty-six patients with invasive squamous cell carcinoma of the vulva stage I were followed for 2 to 20 years after surgical treatment varying from local excision to radical vulvectomy with inguinal lymph node dissection. The results are presented and the prognosis discussed in relation to the radicality of the surgical intervention, the degree of tumour differentiation, the morphologic properties of tumour cell population, and the tumour host relationship. The most important prognostic factor seemed to be the radicality of the surgical intervention. To reduce patient morbidity in radical surgery while still achieving a comparable survival rate an operative approach with less than radical vulvectomy, inguinal dissections or pelvic lymphadenectomy, or both, is proposed for selected patients.     

Long term results of definitive radiotherapy for cervical carcinoma using four applications of high dose rate afterloading.

BACKGROUND: In definitive radiotherapy for cervical carcinoma, combined modality treatment using external beam radiotherapy and brachytherapy is standard. Although the optimal number of afterloading applications is controversial, the majority of authors recommend three applications. METHODS: In this study, the authors investigated the use of 4 applications with iridium-192 afterloading with a dose of 7.5 grays (Gy). Standardized radiotherapy doses were adapted to the individual tumor anatomy using a prospective schedule. RESULTS: In the 73 study patients, actuarial and tumor-related 5-year survival rates by T classification were: T1b: 30% (100% cause specific survival); T2a: 55% (76% cause specific survival); T2b: 50% (60% cause specific survival); T3a: 50% (67% cause specific survival); T3b: 39% (50% cause specific survival); and T4a: 40% (40% cause specific survival). Morbidity, graded according to the National Cancer Institute's Common Toxicity Criteria (CTC) were low: CTC Grade 1: 7 patients (7.6%); CTC Grade 2: 7 patients (7.6%); CTC Grade 3: 1 patient (1.4%); and CTC Grade 4: 1 patient (1.4%). In a multivariate analysis, the T classification was the only significant independent prognostic factor for actuarial survival, tumor related (cause specific) survival, local tumor control and freedom of metastatic disease. The number of afterloading applications was an independent prognostic factor for local tumor control. CONCLUSIONS: Based on the long term results of the current study, external beam radiotherapy combined with 4 afterloading high dose rate applications (total of 30 Gy) appears to be clinically feasible and results in satisfactory survival rates and few side effects.     

60例T4期梨状窝鳞状细胞癌的疗效分析

目的 总结T4期梨状窝鳞状细胞癌的治疗效果.方法 无远处转移的T4期梨状窝鳞状细胞癌初治患者60例,根据治疗方式分为4组:单纯放疗组(R组)15例,平均放疗剂量为67.9 Gy;单纯手术组(S组)7例,全部行非喉功能保留手术;术前放疗加手术组(R+S组)16例,平均术前放疗剂量为49.8 Gy,其中3例行喉功能保留手术;手术加术后放疗组(S+R组)22例,全部行非喉功能保留手术,平均术后放疗剂量为58.5 Gy.结果 本组患者3年生存率为38.7%,5年生存率为32.4%.R组、S组、R+S组和S+R组的5年生存率分别为8.7%、33.3%、29.2%和47.7%.综合治疗患者(R+S组和S+R组)与单一治疗患者(R组和S组)的5年生存率分别为41.7%和13.6%,差异有统计学意义(P=0.02).R+S组和S+R组的5年总体生存率分别为29.2%和47.7%,差异无统计学意义(P=0.228).R+S组和S+R组的并发症发生率分别为50.0%和31.8%,差异无统计学意义(P=0.258).结论 T4期梨状窝鳞状细胞癌仍以计划性综合治疗为标准治疗,可较多采用术后放疗.

Abstract：

Objective To evaluate the treatment results of T4 squamous cell carcinoma of the pyriform sinus. Methods Sixity patients with T4 cancer of the pyriform sinus were included in this retrospective analysis.Fifteen patients were treated with radiotherapy alone(Ra group) with 67.9 Gy.Seven patients were treated with surgery alone(S group) with no laryngeal function sparing surgery.Sixteen patients were treated with preoperative radiotherapy with 49.8 Gy followed by surgery including three cases with laryngeal function sparing surgery(R + S group).Twenty-two patients were treated with surgery followed by postoperative radiotherapy with 58.5 Gy(S + R group),and there was no laryngeal function sparing surgery in this group.The survival rate was calculated using Kaplan-Meier method. Results The overall 5-year survival rate for all patients was 32.4%,8.7% for R group,33.3% for S group,29.2% for R +S group,47.7% for S + R group,41.7% for combined therapy group(R + S group and S + R group) and 13.6% for single therapy group(S group and R group).There was a statistically significant difference between the two groups(P = 0.02) .The overall 5-year survival rates for R + S group and S + R group were 29.2% and 47.7%,respectively,with no significant difference(P =0.228).Surgery complications for R + S group was 50.0% and 31.8% for S + R group,with no significant difference(P = 0.258). Conclusions Combined therapy is the standard treatment modality for T4 squamous cell carcinoma of the pyriform sinus.Surgery with postoperative radiotherapy seems to be more advantageous.     

Vulvar carcinoma. The price of less radical surgery

BACKGROUND: The objective of this study was to determine whether modifications in the treatment of patients with vulvar carcinoma influence the rates of recurrence and survival. METHODS: Between 1982 and 1997, 253 patients with T1 and T2 invasive squamous cell carcinoma of the vulva were treated by essentially the same team of gynecologic oncologists, and 168 patients (Group I) underwent radical vulvectomy with en bloc inguinofemoral lymphadenectomy. Standard therapy was changed in 1993, and 85 patients (Group II) underwent wide local excision with inguinofemoral lymphadenectomy through separate incisions. The rates of recurrence and survival were compared between both groups. RESULTS: In Group II, the overall recurrence rate (33.3%) within 4 years was increased compared with Group I (19.9%; P = 0.03). In Group II, 5 of 79 patients (6.3%) developed fatal groin or skin bridge recurrences compared with 2 of 159 patients (1.3%) in Group I (P = 0.029); this did not result in a difference in overall survival. In Group II, 40 of 79 patients had tumor free margins measuring 8 mm, resulting in no local recurrences (P = 0.002). CONCLUSIONS: The current study showed that fatal recurrences in either the groin or the skin bridge were more frequent after wide local excision and inguinofemoral lymphadenectomy through separate incisions; however, probably due to lack of power, this did not result in shorter survival. In 40 of 79 patients, the histologic margins measured 相似文献