5-year Cause-specific Survival Rates Research Articles

198Au grain implantation for early tongue cancer in patients of advanced age or poor performance status

Brachytherapy using 198Au grains is minimally invasive and the only curative treatment for early tongue cancer in patients of advanced age or poor performance status available in our institution. From March 1993 to February 2008, 198Au grains were used to treat a group of 96 Stage I–II tongue cancer patients who could not undergo surgery or brachytherapy using 192Ir pins because of an advanced age (≥75 years) or poor performance status (≥2). The patients were followed for 3.9 ± 3.3 years, and the cause-specific survival and local control rates were determined. Survival analyses were performed using the Kaplan-Meier method, and univariate and multivariate analyses were performed using the Cox proportional hazard model. The results were compared with those for a group of 193 early tongue-cancer patients who underwent treatment using iridium pins. The 5-year cause-specific survival and local control rates of the 198Au grains group were 71% and 68%, respectively, both of which were 16% lower than the corresponding rates for the 192Ir pins group. Our study demonstrated that as the last curative treatment available, 198Au grain implantation could be used to achieve moderate treatment results for early tongue cancer in patients of advanced age or poor performance status.

Endoscopic submucosal dissection for early gastric cancer in the remnant stomach after gastrectomy

Endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) after surgical gastrectomy is a technically difficult procedure because of the limited working space in the remnant stomach as well as the presence of severe gastric fibrosis and staples under the suture line. We evaluated clinical results including long-term outcomes to determine the feasibility and effectiveness of ESD for EGC in the remnant stomach of patients after gastrectomy. Retrospective study. National Cancer Center Hospital, Tokyo, Japan. We investigated patients undergoing ESD for EGC in the remnant stomach from 1997 to 2011. We examined the patient characteristics, endoscopic findings, technical results, adverse events, and histopathologic results including curability and evaluations of Helicobacter pylori gastritis in addition to the rates of local recurrence, metachronous gastric cancer, overall survival, and cause-specific survival. A total of 128 consecutive patients with 139 lesions had previously undergone 87 distal (68%), 25 proximal (19.5%) and 16 pylorus-preserving gastrectomies (12.5%). The median period from the original gastrectomy to the subsequent ESD for EGC in the remnant stomach was 5.7 years (range 0.6-51 years), the median tumor size was 13 mm (range 1-60 mm), and the median procedure time was 60 minutes (range 15-310 minutes). There were 131 en bloc resections (94%), with curative resections achieved for 109 lesions (78%); 22 lesions (16%) resulted in non-curative resections, and 8 lesions (6%) had only a horizontal margin positive or had inconclusive results. A total of 118 patients (92%) were assessed as H pylori gastritis-positive, with 7 patients (5%) negative. Adverse events included 2 cases of delayed bleeding (1.4%) and 2 perforations (1.4%), with 1 patient requiring emergency surgery. The 5-year overall and cause-specific survival rates were 87.3% and 100%, respectively, during a median follow-up period of 4.5 years (range 0-13.7 years), with no deaths from EGC in the remnant stomach. Single-center, retrospective study. ESD for EGC in the remnant stomach of patients after gastrectomy was a feasible and effective therapeutic method and should become the standard treatment in such cases, based on the favorable long-term outcomes.

Mohs resection and postoperative radiotherapy for head and neck cancers with incidental perineural invasion

PurposeTo update our experience treating cutaneous squamous cell carcinoma (SCC) and basal cell carcinomas (BCC) of the head and neck with incidental perineural invasion (PNI) using Mohs resection followed by radiotherapy (RT). We compare outcomes between head and neck patients with incidental PNI who received Mohs surgery and those who did not. Materials and methodsFrom 1987 to 2009, 36 patients were treated with Mohs resection followed by postoperative RT; 82 patients were treated with resection other than Mohs followed by postoperative RT. ResultsThe 5-year overall survival and cause-specific survival rates for patients who received Mohs resection plus RT and those who received a non-Mohs resection plus RT were 53% versus 56% (p=0.809) and 84% versus 68% (p=0.0329), respectively. The 5-year local control rates for Mohs and non-Mohs patients were 86% versus 76% (p=0.0606), respectively. The 5-year local–regional control and freedom from distant metastases rates for the Mohs group were 77% and 92%, respectively. The 5-year overall neck control, neck control with elective neck RT, and neck control without elective RT treatment rates for the Mohs group were 91%, 100%, and 82% (p=0.0763), respectively. The rate of grade 3 or higher complication in the Mohs group was 22%, which included bone exposure (N=3), cataract (N=2), chronic non-healing wound (N=2), wound infection (N=1), fistula (N=1), and/or radiation retinopathy (N=1). ConclusionsMohs surgery appears to result in improved local control and cause-specific survival in patients with incidental PNI who receive postoperative RT. Elective nodal RT improves regional control in patients with SCC.

Is endoscopic submucosal dissection an effective treatment for operable patients with clinical submucosal invasive early gastric cancer?

Gastrectomy with lymph node dissection is the gold standard curative treatment for clinical submucosal invasive early gastric cancer (cSM EGC), but a relatively small number of operable patients with cSM EGC have undergone endoscopic submucosal dissection (ESD) instead because they refused surgery. The aim of this study was to determine the effectiveness of ESD in these operable patients. The therapeutic outcomes of ESD were retrospectively assessed for 38 patients with 38 operable cSM EGC lesions who initially refused surgery at the National Cancer Center Hospital, Tokyo, from January 1999 to December 2008. The en bloc resection rate was 84.2% (32 lesions) and the complete (R0) resection rate was 63.2% (24 lesions). A total of 33 lesions (86.8%) involved submucosal invasion on pathology. Resection was non-curative in 34 patients (89.5%), 22 of whom (64.7%) underwent subsequent gastrectomy after the need for such surgery was carefully explained to them again. The median follow-up period was 73.2 months (range 3-115 months). Local recurrence was detected in one patient, distant metastasis in two patients, and both local recurrence and distant metastasis were detected in one patient. None of these four patients with recurrence (10.5%) had undergone surgery when their recurrent disease was detected and all of them died from gastric cancer. The 5-year cause-specific survival rate for all patients was 91.8%. The 5-year cause-specific survival rate for all patients was lower than the previously reported rate of 96.7% for pathologically submucosal invasive EGC patients after gastrectomy; therefore, ESD appears to have been an ineffective treatment for operable patients with cSM EGC.

A Clinical Study of 37 Cases of Major Salivary Gland Carcinomas

Thirty-seven cases of major salivary gland carcinomas, treated in our hospital during the past 16 years from July 1995 to June 2011, were studied and reviewed histopathologically and statistically. They comprised 27 cases with parotid carcinomas and 10 cases with submandibular carcinomas. Thirty-five patients had undergone surgery, followed by chemotherapy in 7 patients and radiation therapy in 20. Because of the advanced ages of two patients in their 90’s with submandibular carcinoma, they were treated with radiation alone. The mean age of the group was 62.1 years. There was no difference based on sex and the side of occurrence. The mean duration of the complaint was 33.6 months, and the mean tumor diameter was 34.6 mm. The results of cytological examinations from 35 cases with fine-needle aspiration biopsy delivered a sensitivity of 62.9% and a false-negative rate of 37.1%. Histopathological findings revealed the numbers of carcinoma ex pleomorphic adenoma as the greatest in all cases, salivary duct carcinoma in parotid carcinomas and also carcinoma ex pleomorphic adenoma in submandibular carcinomas. The mean operation time was 171.7 minutes and the mean intraoperative blood loss was 125.5 ml. In both parameters there was a statistically significant correlation. The complication with the highest postoperative rate was facial nerve palsy (37%). The 5-year cause-specific survival rate (CSS) was 78.5% in all cases, and 80.7% in parotid carcinomas and 72.9% in submandibular carcinomas, although these latter rates were without statistical significance. On the other hand according to the classifications of the stage of the cancer, the 5-year CSSs were 100% for Stage I, 80% for Stage II, 50% for Stage III, and 71.2% for Stage IV. Furthermore patients with parotid carcinomas with facial nerve palsy at the first time of diagnosis or in the category of the high malignancy group revealed significantly bleaker survival rates than those without.

Population‐based 10‐year oncologic outcomes after low‐dose‐rate brachytherapy for low‐risk and intermediate‐risk prostate cancer

The objective of this study was to report the rates of disease-free survival (DFS), cause-specific survival (CSS), and overall survival after low-dose-rate (LDR) prostate brachytherapy (PB). Data from 1006 consecutive patients with prostate cancer who received LDR-PB and underwent implantation on or before October 23, 2003 were extracted from a prospective database on November 11, 2011. The selected patients had low-risk (58%) or intermediate-risk (42%) disease according to National Comprehensive Cancer Network criteria. The Phoenix threshold was used to define biochemical relapse. Sixty-five percent of patients received 3 months of neoadjuvant androgen-deprivation therapy (ADT) and 3 months of concomitant ADT. Univariate and multivariate analyses are reported in relation to patient, tumor, and treatment variables. The median follow-up was 7.5 years. By using Fine and Gray competing risks analysis, the 5-year and 10-year actuarial DFS rates were 96.7% (95% confidence interval, 95.2%-97.7%) and 94.1% (95% confidence interval, 92%-95.6%), respectively. When applied to the whole cohort, none of the usual prognostic variables, including dose metrics, were correlated with DFS. However, in both univariate and multivariate models, increasing dose was the only covariate that correlated with improved DFS for the subset of men (N = 348) who did not receive ADT (P = .043). The actuarial 10-year CSS rate was 99.1% (95% confidence interval, 97.3%-99.7%). The overall survival rate was 93.8% at 5 years (95% confidence interval, 92%-95.1%) and 83.5% at 10 years (95% confidence interval, 79.8%-86.6%). Only age at implantation (P = .0001) was correlated with overall survival in multivariate analysis. In a consecutive cohort of 1006 men with National Comprehensive Cancer Network low-risk and intermediate-risk prostate cancer, the actuarial rate of recurrent disease after LDR-PB was approximately 3% at 5 years and 6% at 10 years.

Analysis of late toxicity associated with external beam radiation therapy for prostate cancer with uniform setting of classical 4-field 70 Gy in 35 fractions: a survey study by the Osaka Urological Tumor Radiotherapy Study Group

We aimed to analyse late toxicity associated with external beam radiation therapy (EBRT) for prostate cancer using uniform dose-fractionation and beam arrangement, with the focus on the effect of 3D (CT) simulation and portal field size. We collected data concerning patients with localized prostate adenocarcinoma who had been treated with EBRT at five institutions in Osaka, Japan, between 1998 and 2006. All had been treated with 70 Gy in 35 fractions, using the classical 4-field technique with gantry angles of 0°, 90°, 180° and 270°. Late toxicity was evaluated strictly in terms of the Common Terminology Criteria for Adverse Events Version 4.0. In total, 362 patients were analysed, with a median follow-up of 4.5 years (range 1.0–11.6). The 5-year overall and cause-specific survival rates were 93% and 96%, respectively. The mean ± SD portal field size in the right–left, superior–inferior, and anterior–posterior directions was, respectively, 10.8 ± 1.1, 10.2 ± 1.0 and 8.8 ± 0.9 cm for 2D simulation, and 8.4 ± 1.2, 8.2 ± 1.0 and 7.7 ± 1.0 cm for 3D simulation (P < 0.001). No Grade 4 or 5 late toxicity was observed. The actuarial 5-year Grade 2–3 genitourinary and gastrointestinal (GI) late toxicity rates were 6% and 14%, respectively, while the corresponding late rectal bleeding rate was 23% for 2D simulation and 7% for 3D simulation (P < 0.001). With a uniform setting of classical 4-field 70 Gy/35 fractions, the use of CT simulation and the resultant reduction in portal field size were significantly associated with reduced late GI toxicity, especially with less rectal bleeding.

The Role of Postoperative Radiation Therapy in the Treatment of Meningeal Hemangiopericytoma—Experience From the SEER Database

The aim of this study was to examine the effect of postoperative radiation therapy (RT) on cause-specific survival in patients with meningeal hemangiopericytomas. The Surveillance, Epidemiology, and End Results database from 1990-2008 was queried for cases of surgically resected central nervous system hemangiopericytoma. Patient demographics, tumor location, and extent of resection were included in the analysis as covariates. The Kaplan-Meier product-limit method was used to analyze cause-specific survival. A Cox proportional hazards regression analysis was conducted to determine which factors were associated with cause-specific survival. The mean follow-up time is 7.9 years (95 months). There were 76 patients included in the analysis, of these, 38 (50%) underwent gross total resection (GTR), whereas the other half underwent subtotal resection (STR). Postoperative RT was administered to 42% (16/38) of the patients in the GTR group and 50% (19/38) in the STR group. The 1-year, 10-year, and 20-year cause-specific survival rates were 99%, 75%, and 43%, respectively. On multivariate analysis, postoperative RT was associated with significantly better survival (HR = 0.269, 95% CI 0.084-0.862; P=.027), in particular for patients who underwent STR (HR = 0.088, 95% CI: 0.015-0.528; P<.008). In the absence of large prospective trials, the current clinical decision-making of hemangiopericytoma is mostly based on retrospective data. We recommend that postoperative RT be considered after subtotal resection for patients who could tolerate it. Based on the current literature, the practical approach is to deliver limited field RT to doses of 50-60 Gy while respecting the normal tissue tolerance. Further investigations are clearly needed to determine the optimal therapeutic strategy.

Treatment outcome of high-dose image-guided intensity-modulated radiotherapy using intra-prostate fiducial markers for localized prostate cancer at a single institute in Japan

BackgroundSeveral studies have confirmed the advantages of delivering high doses of external beam radiotherapy to achieve optimal tumor-control outcomes in patients with localized prostate cancer. We evaluated the medium-term treatment outcome after high-dose, image-guided intensity-modulated radiotherapy (IMRT) using intra-prostate fiducial markers for clinically localized prostate cancer.MethodsIn total, 141 patients with localized prostate cancer treated with image-guided IMRT (76 Gy in 13 patients and 80 Gy in 128 patients) between 2003 and 2008 were enrolled in this study. The patients were classified according to the National Comprehensive Cancer Network-defined risk groups. Thirty-six intermediate-risk patients and 105 high-risk patients were included. Androgen-deprivation therapy was performed in 124 patients (88%) for a median of 11 months (range: 2–88 months). Prostate-specific antigen (PSA) relapse was defined according to the Phoenix-definition (i.e., an absolute nadir plus 2 ng/ml dated at the call). The 5-year actuarial PSA relapse-free survival, the 5-year distant metastasis-free survival, the 5-year cause-specific survival (CSS), the 5-year overall survival (OS) outcomes and the acute and late toxicities were analyzed. The toxicity data were scored according to the Common Terminology Criteria for Adverse Events, version 4.0. The median follow-up was 60 months.ResultsThe 5-year PSA relapse-free survival rates were 100% for the intermediate-risk patients and 82.2% for the high-risk patients; the 5-year actuarial distant metastasis-free survival rates were 100% and 95% for the intermediate- and high-risk patients, respectively; the 5-year CSS rates were 100% for both patient subsets; and the 5-year OS rates were 100% and 91.7% for the intermediate- and high-risk patients, respectively. The Gleason score (<8 vs. ≥8) was significant for the 5-year PSA relapse-free survival on multivariate analysis (p = 0.044). There was no grade 3 or 4 acute toxicity. The incidence of grade 2 acute gastrointestinal (GI) and genitourinary (GU) toxicities were 1.4% and 8.5%, respectively. The 5-year actuarial likelihood of late grade 2–3 GI and GU toxicities were 6% and 6.3%, respectively. No grade 4 GI or GU late toxicity was observed.ConclusionsThese medium-term results demonstrate a good tolerance of high-dose image-guided IMRT. However, further follow-up is needed to confirm the long-term treatment outcomes.

Definitive radiation therapy for squamous cell carcinoma of the pharyngeal wall

PurposeTo analyze the results of definitive radiation therapy (RT) for squamous cell carcinoma of the pharyngeal wall. Methods and MaterialsBetween 1964 and 2009, 170 patients were treated with definitive RT; all living patients had a 1.7-year minimum follow-up. ResultsThe 5-year rates of local control and ultimate local control were the following: T1, 93% and 93%; T2, 84% and 91%; T3, 60% and 62%; and T4, 44% and 44%. Multivariate analysis revealed stage I-II tumors, female gender, and altered fractionation were associated with improved local-regional control. The 5-year cause-specific and overall survival rates were the following: I, 88% and 50%; II, 89% and 57%; III, 49% and 31%; IV, 35% and 21%; and overall, 50% and 31%, respectively. Fatal complications occurred in 9 patients (5%). ConclusionsLocal-regional control and survival are related to extent of disease and treatment technique. Although outcomes have improved in recent years, the morbidity of treatment is significant and a substantial proportion of patients die due to cancer.

Prognostic features, human papillomavirus status, and epidermal growth factor receptor expression in oral squamous cell carcinoma in young adults

PurposeThere is still debate in literature about the survival outcomes of patients who have cancer of the oral cavity when young. Hence the aims were (1) to estimate disease-free survival, overall survival, and cause-specific survival in patients who developed oral cavity squamous cell carcinoma between 18 and 40 years of age and (2) to assess the clinicopathologic factors including detection of human papillomavirus and epidermal growth factor receptor (EGFR) overexpression in primary lesions affecting recurrence. MethodsThis is a retrospective case-note review and reevaluation of histopathologic slides of patients treated more than 25 years. Descriptive statistics, Cox proportional hazard models, and Kaplan-Meier survival curves were used for statistical analysis. ResultsA total of 62 patients were treated, with mean follow-up of 11.4 years. Forty-five were oral tongue tumors and 43 had stage I or II disease. The 5-year disease-free survival was 73.5%. The 10-year overall survival and cause-specific survival rates were 81.8% and 83.4%, respectively. Smoking and alcohol intake were not seen as risk factors in this population. Multivariate modeling identified only nodal involvement as significantly associated with overall survival and only extracapsular spread as significantly associated with locoregional recurrence. At 5 years after treatment, the cause-specific survival was 100% for patients with low EGFR expression and 81.1% for patients with high EGFR expression (hazard ratio for high vs low, 3.1; 95% confidence interval, 0.4–406.9; P = .46). Human papillomavirus was not detected in all but 2 tumor specimens. ConclusionsSurvival outcomes are quite good in young patients with oral cancer.

Breast Conservation Therapy: The Influence of Molecular Subtype and Margins

To evaluate treatment results and prognostic factors, especially margin status and molecular subtype, in early-stage breast cancer patients treated with breast conservation therapy (BCT). The records of 1,058 Stage I or II breast cancer patients treated with BCT (surgical excision plus radiotherapy) at Duke University Medical Center, Durham, North Carolina, from 1985-2005 were retrospectively reviewed. Conventional receptor analyses were used as surrogate markers for molecular subtype classification (luminal A, luminal B, Her2 positive, and basal like). Actuarial estimates of overall survival (OS), cause-specific survival (CSS), failure-free survival, and locoregional control (LRC) were computed by use of Kaplan-Meier plots. We analyzed prognostic variables for significance using Cox proportional hazards univariate and multivariate analysis. The study was approved by the Duke University Medical Center Institutional Review Board. The median age of the patients was 56 years (range, 18-89 years). Of the patients, 80% had T1 disease and 66% N0 disease pathologically. With a median follow-up of 9.8 years, an in-breast recurrence developed in 53 patients and 10 patients had nodal failure. For all patients, the 10-year CSS rate was 94%; LRC rate, 94%; and failure-free survival rate, 88%. Luminal A patients had a CSS rate of 95% and LRC rate of 99%. Basal-type patients appeared to do worse, with regard to both CSS rate (74%) and LRC rate (76%), but the numbers were small and the difference was not statistically significant. LRC rates of patients with negative margins (widely negative, close, and extent of margin not known) were virtually identical (93%, 96%, and 94%, respectively). Those with positive margins appeared to fare slightly worse based on LRC rate (88%), but again, the numbers were small and the difference was not statistically significant. BCT remains the treatment of choice for early-stage breast cancer patients irrespective of molecular subtype. Negative margins of excision are desirable, but the width of the negative margin does not influence outcome.

Mediastinoscopy-assisted esophagectomy for esophageal cancer in patients with serious comorbidities

We evaluated the results of mediastinoscopy-assisted esophagectomy (MAE), performed for esophageal cancer patients with comorbidities, versus those of thoracoscopic esophagectomy (TSE), performed for esophageal patients with or without comorbidities. Among 153 patients who underwent esophageal cancer surgery at our hospital, 17 (11.1%) underwent MAE and 37 (24.2%) underwent TSE. Many of the MAE group patients had pulmonary (P < 0.001), cardiovascular (P = 0.031), or hepatic (P = 0.0029) diseases preoperatively, and these comorbidities frequently overlapped (P < 0.0001). The %VC and FEV(1)/FVC were lower (P = 0.0099 and P = 0.0057, respectively), and the ICG-R15 and serum level of HbA1c were higher (P = 0.0014 and P = 0.043, respectively) in the MAE group. There were no differences in postoperative complications or in the modified Clavien classification between the groups. There was no mortality in either group. After MAE, 5 (29.4%) patients died of other diseases. The 5-year overall survival rate after MAE was poorer than that after TSE (56.1 vs. 71.8%), but the 5-year cause-specific survival rates were similar in the two groups. MAE is feasible for esophageal cancer patients with serious comorbidities and may decrease morbidity and mortality.

Radiotherapy for mucosa-associated lymphoid tissue lymphoma of the ocular adnexa

Methods: Twenty-one patients with MALT lymphoma of the ocular adnexa were treated with radiotherapy alone at a dose ranging from 30 to 54Gy. The disease arose from the conjunctiva in 15 patients (9 with bilateral involvement), and from the retrobulbar space in 6 patients (1 with bilateral involvement). Results: All patients with MALT lymphoma achieved a CR or unconfirmed CR (CRu). The 5-and 10-year overall survival rates of all patients with MALT lymphoma were 100% and 90%, respectively. The 5-and 10-year cause-specific survival rates were 100% and 100%, respectively. In all patients with delayed toxicity, the radiation dose was more than 40Gy. Conclusions: Excellent local control and survival can be achieved for patients with MALT lymphoma of the ocular adnexa using radiotherapy alone. ACTA MEDICA NAGASAKIENSIA 56: 49－52, 2011

Long-term outcomes of intraluminal brachytherapy in combination with external beam radiotherapy for superficial esophageal cancer

The aim of this study was to assess the long-term outcomes of combining high-dose-rate intraluminal brachytherapy (IBT) with external beam radiotherapy (EBRT) for superficial esophageal cancer (SEC). From 1992 to 2002, 87 patients with T1N0M0 thoracic esophageal cancer received IBT in combination with EBRT. Of these, 44 had mucosal cancer and 43 had submucosal cancer. For patients with tumor invasion within the lamina propria mucosa, IBT alone was performed (n = 27). IBT boost following EBRT was performed for patients with tumor invasion in the muscularis mucosa or deeper (n = 60). No patient received chemotherapy. The median follow-up time was 94 months. For mucosal cancer, the 5-year locoregional control (LRC), cause-specific survival (CSS) and overall survival (OS) rates were 75, 97 and 84%, respectively, and 49, 55 and 31%, respectively, for submucosal cancer. Tumor depth was a significant factor associated with LRC (p = 0.02), CSS (p < 0.001) and OS (p < 0.001) by univariate analysis. Multivariate analysis revealed that tumor depth was the only significant predictor for OS (p = 0.003). Late toxicities of grade 3 or higher in esophagus, pneumonitis, pleural effusion and pericardial effusion were observed in 5, 0, 0 and 1 patients, respectively. Grade ≥3 events of cardiac ischemia and heart failure after radiotherapy were observed in 9 patients, and history of heart disease before radiotherapy was the only significant factor (p = 0.002). There was a clear difference in outcomes of IBT combined with EBRT between mucosal and submucosal esophageal cancers. More intensive treatment should be considered for submucosal cancer.

Comparison of efficacy and safety of low-dose-rate vs. high-dose-rate intraluminal brachytherapy boost in patients with superficial esophageal cancer

PurposeTo compare the efficacy and the incidence of complications of high-dose-rate (HDR) and low-dose-rate (LDR) intraluminal brachytherapy (IBT) boost after external beam radiation therapy in patients with superficial esophageal cancer. Methods and MaterialsFifty-four consecutive patients with Stage I thoracic esophageal squamous cell carcinoma who were treated with definitive radiotherapy using IBT between 1991 and 2007 were studied retrospectively. LDR-IBT and HDR-IBT were performed for 19 and 35 patients, respectively. After external beam radiation therapy of 56–60Gy with a conventional fractionation, LDR-IBT (5Gy×2) or HDR-IBT (3Gy×3) was given within 2 weeks. The median follow-up was 47 months (7–151 months). ResultsOverall, the 5-year overall survival, cause-specific survival (CSS), and locoregional control (LRC) rates were 61%, 86%, and 79%, respectively. The 5-year overall survival, CCS, and LRC rates did not differ significantly between the LDR-IBT and HDR-IBT groups (68% vs. 58% (p=0.50), 83% vs. 85% (p=0.63), and 84% vs. 75% (p=0.42), respectively). Salvage treatment was given in 8 locally recurrent patients, and 6 patients were rescued. The Grade ≥2 late morbidities of esophagus and heart/lung were observed in 5 patients (4 in the LDR-IBT group and 1 in the HDR-IBT group) and 2 patients (one from each group), respectively. ConclusionsIn view of the safety profile and effectiveness, our results encourage the continued adoption of HDR-IBT as radiation boost in medically inoperable or elderly superficial esophageal cancer patients undergoing definitive radiotherapy.

Multimodality Local Therapy for Retroperitoneal Sarcoma

Soft-tissue sarcomas of the retroperitoneum are rare tumors comprising less than 1% of all malignancies. Although surgery continues as the mainstay of treatment, the large size of these tumors coupled with their proximity to critical structures make resection with wide margins difficult to achieve. The role and timing of radiotherapy are controversial. This study updates our institutional experience using multimodality local therapy for resectable retroperitoneal sarcoma and identifies prognostic factors impacting disease control and survival. Between 1974 and 2007, 58 patients with nonmetastatic retroperitoneal sarcoma were treated with surgery and radiation at the University of Florida. The median age at radiotherapy was 57 years old (range, 18-80 years). Forty-two patients received preoperative radiotherapy and 16 received postoperative radiotherapy. Nineteen patients received 1.8 Gy once daily and 39 patients received 1.2 Gy twice daily. Variables analyzed for prognostic value included age, grade, kidney involvement, histology, de novo versus recurrent presentation, tumor diameter, margin status, radiotherapy sequencing (preoperative vs. postoperative), total radiation dose, fractionation scheme, and treatment era. The 5-year overall survival, cause-specific survival, and local control rates were 49%, 58%, and 62%, respectively. Nearly two-thirds of disease failures involved a component of local progression. On multivariate analysis, only margin status was significantly associated with improved 5-year local control (85%, negative margins; 63%, microscopic positive margins; 0%, gross positive margins; p < 0.0001) and 5-year overall survival (64%, negative margins; 56%, microscopic positive margins; 13%, gross positive margins; p = 0.0012). Thirty-one Grade 3 or greater toxicities were observed in 22 patients, including two treatment-related deaths (3%). For retroperitoneal sarcoma, local control remains a challenge and combined-modality therapy may be associated with significant acute and late morbidity. Our patterns of failure data suggest that improvements in local control may translate into a survival benefit.

A Population-based Study of Cervix Cancer: Incidence, Management and Outcome in the Canadian Province of Saskatchewan

Aims To document the incidence, management and outcome of uterine cervix cancer in the Canadian province of Saskatchewan. To compare provincial results of low dose rate (LDR) and high dose rate (HDR) brachytherapy in this population. Materials and methods We carried out a retrospective population-based cohort study of all uterine cervix cancer cases in Saskatchewan diagnosed between 1985 and 2001. We used data from the provincial cancer registry for incident cases, the provincial death registry for vital status information and chart reviews for treatment and toxicity information. Results In total, 714 cases of uterine cervix cancer were identified. Stage distribution was IA 22.7%, IB 31.8%, II 19.1%, III 18.4%, IV 6.8%; 81.2% were squamous cell carcinoma, 13.4% adenocarcinoma, 1.5% adenosquamous, 0.9% small cell and 3.1% other. The annual crude incidence rate of uterine cervix cancer in Saskatchewan ranged from 6.5 to 12.3% between 1985 and 2001. The 5-year cause-specific survival rate ranged from 100% for stage IA1 to 22% for stage IV. One hundred and seven patients were treated with LDR and 37 with HDR with similar stage distribution. The 5-year cause-specific survival rate was 56% for HDR and 67% for LDR ( P = 0.72). For 43 patients managed with external beam radiotherapy alone, outcome was poor for stage IIB to IIIB. The most common acute toxicities of radiation treatment were diarrhoea (60%) and abdominal cramps (12.5%). The common chronic toxicities were vaginal stenosis (5.5%) and small bowel obstruction (4%). Conclusions Our population-level outcomes are in keeping with published observed results and provide some of the first Canadian population-level data on HDR and LDR outcomes. We found no significant different in cause-specific survival between patients managed with HDR and LDR, although interpretation is limited by patient numbers. Our results for external beam radiotherapy alone emphasise the vital role brachytherapy plays in the management of cervical cancer.

165 Outcomes of Esophagogastric Junction Adenocarcinomas Initially Treated by Endoscopic Resection

Outcomes of Esophagogastric Junction Adenocarcinomas Initially Treated by Endoscopic Resection Hiromitsu Kanzaki, Ryu Ishihara, Noriya Uedo, Sachiko Yamamoto, Yoji Takeuchi, Koji Higashino, Hiroyasu Iishi Department of Gastrointestinal Oncololy, Osaka Medical Center for Cancer and Cardiaovascular Diseases, Osaka, Japan Introduction: Few studies have reported the outcome of Siewert type II adenocarcinomas treated by endoscopic resection (ER). We used ER as initial treatment for esophagogastric junction (EGJ) cancers 5cm in diameter and confined the mucosal layer in preoperative staging. Aims & Methods: A total of 1578 gastric or esophageal adenocarcinomas were treated by ER from April 2000 to December 2007. The data for the patients and lesions were stored consecutively in a database. Fifty-seven EGJ cancers in 53 patients from the database met our inclusion criteria. The inclusion criteria were; (1) histrogically proven adenocarcinoma; (2) tumor center within 1cm above and 2cm below the junction (Siewert type II cancer); (3) no lymph node or distant metastases; and (4) clinically diagnosed as mucosal cancer 5cm. Treatment outcomes of EGJ cancers after ER were compared with those of non-EGJ gastric cancers. And long-term survival of EGJ cancers after the treatment was investigated. Results: In the cases of EGJ cancers, ER was completed in all lesions. Thirteen of the 53 patients received additional surgical resection of the stomach with lymph node dissection because of the risk of lymph node metastasis, based on submucosal deep invasion revealed by histological examination of resected specimens. Two patients received photodynamic therapy. The other patients were followed-up with no additional treatment. The complete resection rate for EGJ cancers (58%: 33/57) was significantly lower than that for gastric cancers (76%: 1162/1521) (P 0.03). Diagnostic accuracy for the invasion depth of EGJ cancers (63%: 36/ 57) was significantly lower than that for gastric cancers (85%: 1275/1505) (P 0.001). Major complications of ER included perforation (2cases) and postoperative bleeding (2cases). All complications were successfully treated by endoscopy. All patients with EGJ cancer were followed-up until their death, or until January 2009. Local recurrences were observed during follow-up in two patients, but no lymph node or distant metastases were observed. All local recurrences were successfully treated by additional ER. Five deaths were identified after a mean observation period of 1396 775 days. However, no patient died of esophageal or gastric cancer. The overall 3-year and 5-year survival rates for all patients were 95.5% and 87.9%, respectively. The causespecific 3-year and 5-year survival rates for all patients were both 100%. Conclusion: Additional surgical resection was required in some patients because of the lower preoperative diagnostic accuracy for the depth of EGJ cancers. However, the overall and cause-specific survival rates for patients with EGJ cancer were favorable, and the complications were acceptable. Endoscopic resection is suitable for the initial treatment of patients with EGJ cancers confined to the mucosal layer at preoperative staging.

Does the revised International Federation of Gynecology and Obstetrics staging system for endometrial cancer lead to increased discrimination in patient outcomes?

Recent changes were made to the International Federation of Gynecology and Obstetrics (FIGO) staging system for endometrial cancer. The objective of this study was to compare survival outcomes for patients who were staged according to the 1988 FIGO staging system versus the 2009 FIGO staging system. Data were obtained from the Surveillance, Epidemiology, and End Results Program for the years 1998 to 2006. Patients who had a diagnosis of adenocarcinoma of the uterus with complete staging information were included. Patients were staged according to the 1988 and 2009 FIGO staging systems, and Kaplan-Meier estimates were derived for cause-specific survival (CSS). Univariate and multivariate analyses using Cox proportional hazards models were used to identify the factors associated with survival. In total, 47,284 patients were included. The median follow-up was 37 months. The 5-year CSS rates for patients who had 2009 FIGO stage IA and IB disease were 96.6% and 89.9%, respectively (P < .0001). After accounting for age, grade, and race, this survival difference remained significant (hazard ratio [HR], 1.97; 95% confidence interval [CI], 1.74-2.24; P < .0001). Patients who had 1988 FIGO stage IIA disease had a 5-year CSS rate similar to that of patients who had 1988 FIGO stage IC disease (88.6% vs 89.9%, respectively; P = .09). Patients who had positive pelvic washings had a 5-year CSS rate similar to that of patients who had stage IIIA disease according to the 2009 FIGO system (74.2% vs 72.1%, respectively; P = .37). The 5-year CSS rate for patients who had stage IIIC1 disease was significantly improved compared with that for patients who had stage IIIC2 disease (68.2% vs 57.3%, respectively; P < .0001). In the multivariate model, the survival difference remained (HR, 1.49; 95% CI, 1.26-1.76; P < .0001). The 2009 staging system for endometrial cancer produced better discrimination in CSS outcomes compared with the 1988 system.