Prognostic factors and treatment outcomes of retinoblastoma in pediatric patients: a single-institution study

Purpose  Since 1997, our institute has used neoadjuvant chemotherapy for intraocular retinoblastoma. However, some of the patients showed signs of recurrence months to years later. We therefore attempted to determine the prognostic factors of treatment outcomes and survival in our patients. Methods  We reviewed 90 patients treated from 1997 to 2006. The following information was recorded: demographic and ophthalmological data, clinical classification, histopathological data, and treatment methods and outcomes. Results  Enucleation was avoided in two of 57 eyes in the unilateral group. Sixteen of 54 eyes in the bilateral group were salvaged by systemic chemotherapy with local treatment. There was no difference in histopathological findings between the two groups. Nine of 57 patients in the unilateral group demonstrated poor outcomes, compared with four of 27 in the bilateral group. Significant poor prognostic factors for survival were optic nerve head invasion, orbital involvement, abnormal results on bone marrow aspiration, lumbar puncture, bone scan, and group E or F classification. Conclusions  The 15% mortality rate in our patients is slightly higher than that reported in developed countries. Delayed diagnosis and treatment is the main cause of avoidable deaths. Improving education of both clinicians and parents would increase survival rates in this potentially fatal disease.     

A regional cooperative clinical study of radiotherapy for cervical cancer in east and south-east Asian countries.

PURPOSE: Radiotherapy differed widely in east and south-east Asia because of technical, cultural, and socio-economic differences. With the purpose of standardizing radiotherapy for cervical cancer in the region, an international clinical study was conducted. MATERIALS AND METHODS: Eleven institutions in eight Asian countries participated in the study. Between 1996 and 1998, 210 patients with stage IIIB cervical cancer were enrolled. Patients were treated with a combination of external beam radiotherapy (total dose, 50Gy) and either high-dose-rate (HDR) or low-dose-rate (LDR) intracavitary brachytherapy (ICBT) according to the institutional practice. The planned point A dose was 20-28Gy/4 fractions for HDR-ICBT and 30-40Gy/1-2 fractions for LDR-ICBT. RESULTS: Hundred patients were treated with HDR-ICBT and 110 were treated with LDR-ICBT. The ICBT doses actually delivered to point A ranged widely: 12-32Gy in the HDR group and 26-52.7Gy in the LDR group. The 5-year follow-up rate among the countries differed greatly, from 29% to 100%. The 5-year major complication rates were 6% in the HDR group and 10% in the LDR group. The 5-year overall survival rates were 51.1% in the HDR group and 57.5% in the LDR group. CONCLUSIONS: Although there were several problems with treatment compliance and patients' follow-up, the study suggests that the protocols provided favorable outcomes with acceptable rates of late complications in the treatment of advanced cervical cancer in east and south-east Asia.     

Concurrent chemoradiotherapy for T3–4 and N0–1 nasopharyngeal cancer: Asian multicenter trial of the Forum for Nuclear Cooperation in Asia

The aim of this study was to evaluate the toxicity and efficacy of radiotherapy concurrent with weekly cisplatin for T3–4 and N0–1 nasopharyngeal cancer. Between 2005 and 2010, 70 patients with nasopharyngeal cancer (T3–4 N0–1 M0, World Health Organization Type 2–3) from Vietnam, Indonesia, Malaysia and Thailand were registered. Patients were treated with 2D radiotherapy concurrent with weekly cisplatin (30 mg/m²). Neither adjuvant nor induction chemotherapy was given. Ninety-three percent of the patients completed at least four cycles of weekly cisplatin during radiotherapy. The median total doses for the primary tumor and positive lymph nodes were 70 and 66 Gy, respectively. The median overall treatment time of concurrent chemoradiotherapy was 52 days. No treatment-related deaths occurred. Grade 3–4 acute toxicities of mucositis, nausea/vomiting and leukopenia were observed in 34%, 4% and 4% of patients, respectively. With a median follow-up time of 52 months for the 40 surviving patients, the 3-year local control, locoregional tumor control, distant metastasis–free survival and overall survival rates were 80%, 75%, 74% and 80%, respectively. In conclusion, the current results illustrate that our concurrent chemoradiotherapy regimen was feasible, but disease control remained insufficient. Further research is encouraged in order to improve clinical outcomes.     

Chemotherapy in locally advanced nasopharyngeal carcinoma: an individual patient data meta-analysis of eight randomized trials and 1753 patients

OBJECTIVES: To study the effect of adding chemotherapy to radiotherapy (RT) on overall survival and event-free survival for patients with nasopharyngeal carcinoma. METHODS AND MATERIALS: This meta-analysis used updated individual patient data from randomized trials comparing chemotherapy plus RT with RT alone in locally advanced nasopharyngeal carcinoma. The log-rank test, stratified by trial, was used for comparisons, and the hazard ratios of death and failure were calculated. RESULTS: Eight trials with 1753 patients were included. One trial with a 2 x 2 design was counted twice in the analysis. The analysis included 11 comparisons using the data from 1975 patients. The median follow-up was 6 years. The pooled hazard ratio of death was 0.82 (95% confidence interval, 0.71-0.94; p = 0.006), corresponding to an absolute survival benefit of 6% at 5 years from the addition of chemotherapy (from 56% to 62%). The pooled hazard ratio of tumor failure or death was 0.76 (95% confidence interval, 0.67-0.86; p < 0.0001), corresponding to an absolute event-free survival benefit of 10% at 5 years from the addition of chemotherapy (from 42% to 52%). A significant interaction was observed between the timing of chemotherapy and overall survival (p = 0.005), explaining the heterogeneity observed in the treatment effect (p = 0.03), with the highest benefit resulting from concomitant chemotherapy. CONCLUSION: Chemotherapy led to a small, but significant, benefit for overall survival and event-free survival. This benefit was essentially observed when chemotherapy was administered concomitantly with RT.     

Clinical review 170: A systematic review and metaanalysis of the effectiveness of radioactive iodine remnant ablation for well-differentiated thyroid cancer

Radioactive iodine remnant ablation destroys residual thyroid tissue after surgical resection of papillary or follicular thyroid cancer. We systematically reviewed 1543 English references to determine whether remnant ablation decreases the risk of thyroid cancer-related death or recurrence after bilateral thyroidectomy for papillary or follicular thyroid cancer. In 13 cohort studies in which the analysis of thyroid cancer-related outcomes was statistically adjusted to a variable degree for prognostic factors or cointerventions, rates of recurrences of thyroid cancer-related outcomes were significantly decreased in the following: one of seven studies examining thyroid cancer-related mortality, three of six studies examining any tumor recurrence, three of three studies examining locoregional recurrence, and two of three studies examining distant metastases. Thyroid hormone suppressive therapy was not adjusted for in the majority of these analyses. In 18 cohort studies not adjusted for prognostic factors or interventions, the benefit of radioactive iodine ablation in decreasing the thyroid cancer-related mortality and any recurrence at 10 yr was inconsistent among centers. However, pooled analyses were suggestive of a statistically significant treatment effect of ablation for the following 10-yr outcomes: locoregional recurrence (relative risk of 0.31, 95% confidence interval, 0.2, 0.49) and distant metastases (absolute decrease in risk 3%, 95% confidence interval, risk decreases 1-4%). In conclusion, radioactive iodine ablation may be beneficial in decreasing recurrence of well-differentiated thyroid cancer; however, results are inconsistent among centers for some outcomes, and the incremental benefit of remnant ablation in low-risk patients treated with bilateral thyroidectomy and thyroid hormone suppressive therapy is unclear.     

Adjuvant radiotherapy in women with stage I endometrial cancer: a systematic review

OBJECTIVE: To review the literature regarding the role of adjuvant radiotherapy (RT) in women with stage I endometrial cancer in terms of survival and pelvic control. METHODS: A systematic search of MEDLINE, EMBASE and the Cochrane Library databases was conducted for studies evaluating RT (1966 to October 2005). RESULTS: Five randomized trials were identified that evaluated adjuvant external beam radiotherapy (EBRT) and/or intracavitary radiotherapy (ICRT) including one in which women had undergone complete surgical staging. No survival differences were identified; however, none of the studies were powered enough to show a survival benefit. In three studies reporting subgroup analyses, intermediate-risk subgroups (stages IA and IB, grade 3 or stage IC) who received RT had fewer pelvic recurrences compared to women not receiving RT. Unfortunately, none of the studies reported ultimate pelvic control as an outcome. CONCLUSIONS: RT is not recommended in low-risk patients (stages IA, IB, grades 1 and 2). It is reasonable to consider EBRT for intermediate-risk subgroup patients (stage IC, grades 1 and 2, or stages IA, IB, grade 3), regardless of surgical staging, to reduce the risk of pelvic recurrence. EBRT is recommended for high-risk patients (stage IC, grade 3). The benefits of EBRT need to be weighed against the toxicity of treatment. Patients should be informed of the benefits and risks of EBRT. Additional analysis including ultimate pelvic control in subgroups would be helpful. More clinical trials are warranted to further define the role of EBRT in subgroups of patients and to clarify the role of ICRT.