Radical Adjuvant Radiotherapy Research Articles

Can Bcl-XL expression predict the radio sensitivity of Bilharzial-related squamous bladder carcinoma? a prospective comparative study

BackgroundLocal pelvic recurrence after radical cystectomy for muscle invasive bilharzial related squamous cell carcinoma accounts for 75% of treatment failures even in organ confined tumors. Despite the proven value of lymphadenectomy, up to 60% of patients undergoing cystectomy do not have it. These factors are in favor of adjuvant radiotherapy reevaluation. objectives: to evaluate the effect of adjuvant radiotherapy on disease free survival in muscle invasive bilharzial related squamous cell carcinoma of the urinary bladder and to test the predictability of radio-sensitivity using the anti apoptotic protein Bcl-XL.MethodsThe study prospectively included 71 patients, (47 males, 24 females) with muscle invasive bilharzial related squamous cell carcinoma of the bladder (Stage pT2a-T3N0-N3M0) who underwent radical cystectomy in Assiut university hospitals between January 2005 and December 2006. Thirty eight patients received adjuvant radiotherapy to the pelvis in the dose of 50Gy/25 fractions/5 weeks (Group 1), while 33 patients did not receive adjuvant radiotherapy (group 2). Immunohistochemical characterization for bcl-xL expression was done. Follow up was done every 3 months for 12 to 36 months with a mean of 16 ± 10 months. All data were analyzed using SPSS version 16. Three years cumulative disease free survival was calculated and adjusted to Bcl-XL expression and side effects of the treatment were recorded.ResultsThe disease free cumulative survival was 48% for group 1 and 29% for group 2 (log rank p value 0.03). The multivariate predictors of tumor recurrence were the positive Bcl-XL expression (odd ratio 41.1, 95% CI 8.4 - 102.3, p < 0.0001) and radiotherapy (odd ratio 0.19, 95% CI 0.05 - 0.78, p < 0.02). With Cox regression, the only independent multivariate predictor of radio-sensitivity was the Bcl-XL expression with odd ratio 4.6 and a p value < 0.0001. All patients tolerated the treatment with no life threatening or late complications during the period of follow up.ConclusionsAdjuvant radiotherapy for muscle invasive bilharzial related squamous cell carcinoma of the urinary bladder has potential effectiveness and minor side effects. Moreover, Bcl-XL expression is a valuable tool for predicting those who might not respond to this adjuvant treatment.

Osteopontin Plasma Levels in Head and Neck Cancer Patients During Radiotherapy

Osteopontin Plasma Levels in Head and Neck Cancer Patients During Radiotherapy

Primary salivary gland-type lung cancer: Surgical outcomes

Primary salivary gland-type lung cancer is rare, and little is known about the role of surgery. The aim of this study was to analyze surgical role and outcome for primary salivary gland-type lung cancer. Between October 1995 and June 2008, 48 patients underwent surgical treatment for primary salivary gland-type lung cancer. Medical records were analyzed for age, sex, tumor histopathology, location, surgical resection, tumor grade, clinical outcome, and survival. There were 31 male and 17 female patients, with an average age of 41.1 ± 15.2 years. Mucoepidermoid carcinoma was diagnosed in 26 patients, adenoid cystic carcinoma was diagnosed in 20 patients, and epithelial–myoepithelial carcinoma was diagnosed in 2 patients. The operative procedure included (bi) lobectomy ( n = 15, 31.2%), sleeve lobectomy ( n = 13, 27.1%), tracheal resection ( n = 8, 16.7%), pneumonectomy ( n = 7, 14.6%), and carinal resection ( n = 5, 10.4%). There was no operative mortality, and minor morbidity occurred in eight patients. Incomplete resection occurred in eight patients, and six of them received postoperative radiotherapy. Of incompletely resected patients, cancer recurrence was found in three patients, and all were in the adjuvant radiotherapy group. Overall, cancer recurred in 11 patients (22.9%), and 4 of them were treated by repeated surgical resection and were alive and disease-free at the conclusion of this study. The overall 5-year and 10-year survival rates after operation were 97.6 and 86.7%. Surgical resection of primary salivary gland-type lung cancer was an effective treatment with low operative morbidity, and expected long-term survival. Repeated surgical resection may be considered an effective treatment modality in some cases of recurrence.

Psychometric validation of the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Endometrial Cancer Module (EORTC QLQ-EN24)

Aim A validation study was conducted to evaluate the psychometric properties of the European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire-Endometrial Cancer Module (EORTC QLQ-EN24). This module was designed to assess disease and treatment specific aspects of the quality of life (QoL) of patients with endometrial cancer. Methods Two hundred and sixty-eight women with endometrial cancer were recruited in different phases of treatment: after pelvic surgery (Group 1); during adjuvant chemotherapy and/or radiotherapy (Group 2); after completion of treatment (Group 3). Patients completed the EORTC QLQ-C30, the endometrial cancer module and a short debriefing questionnaire. Results Multi-trait scaling analyses confirmed the hypothesised scale structure of the QLQ-EN24. Internal consistency reliability was good with Cronbach’s alpha coefficients ranging from 0.74 to 0.86 (lymphoedema 0.80, urological symptoms 0.75, gastrointestinal symptoms 0.74, body image problems 0.86 and sexual/vaginal problems 0.86). Convergent and discriminant validity did not show any scaling errors for the subscales. The QLQ-EN24 module discriminated well between clinically different groups of patients. All items exhibited a high completion rate with less than 2% missing values except for the sexuality items (19%). Conclusion The validation study supports the reliability, the convergent and divergent validity of the EORTC QLQ-EN24. This newly developed QLQ-EN24 module is a useful instrument for the assessment of the QoL in patients treated for endometrial cancer in clinical trials.

Total treatment burden in stage I seminoma patients.

4534 Background: Concern has been expressed that stage I seminoma surveillance patients are exposed to an increased burden of treatment due to the need for combination chemotherapy (ChT) during salvage management. To address this issue, we reviewed the total treatment burden in patients with stage I seminoma managed on a surveillance protocol or adjuvant radiation (RT). Methods: Between 1981 and 2004, of 764 stage I seminoma patients, 484 were managed by surveillance and 280 by adjuvant RT. First relapse on surveillance was managed by RT alone, with ChT for more extensive recurrence; a policy akin to the management of de- novo stage II seminoma. All patients with second relapse were managed with ChT. Relapse after adjuvant RT were treated with ChT with exceptional cases (isolated inguinal relapse) receiving RT alone. We assigned total treatment burden according to initial management strategy after orchiectomy by defining episodes of treatment i.e. 1 episode was a course of RT or 3 cycles of BEP chemotherapy (or equivalent) or surgery (e.g. retroperitoneal lymphadenectomy). Results: Median follow-up for the surveillance and adjuvant RT group was 79 and 102 months, respectively. Overall survival at 5 and 10 yrs was 98% and 95%, respectively. Only 1 patient died of seminoma. In surveillance patients, 72 relapsed [72/484 (15%)]. Of these, 56 were treated with RT (5 second relapses), 15 with ChT (1 second relapse), and 1 surgery. Second relapse was treated with ChT in all cases. Relapse after adjuvant RT occurred in 14 patients [14/280 (5%)], 10 of whom received salvage ChT and 4 further RT with no second relapses. In total 20 (4%) and 10 patients (4%) were treated with ChT in the surveillance and adjuvant groups, respectively. In total, surveillance patients underwent 78 episodes of treatment (56 RT, 21 ChT, 1 surgery) compared to 294 in adjuvant patients (284 RT, 10 ChT). Conclusions: Surveillance with RT for first relapse as a management strategy reduces the overall burden of treatment in stage I seminoma patients. We saw no evidence for increased exposure to chemotherapy in patients managed with surveillance, with marked reduction in the use of radiotherapy in this population of young patients. No significant financial relationships to disclose.

Treatment strategy of pituitary invasive prolactinomas

To discuss the treatment strategy of invasive prolactinomas (IPs) involving the cavernous sinus. Data from 80 patients with IPs treated in our institutions were reviewed retrospectively. The criteria utilized included: (1) invasion of the cavernous sinus by tumor, corresponding to Grade III-IV according to the classification of Knosp; (2) serum prolactin level > 9.1 nmol/L; (3) clinical signs of hyperprolactinemia and mass effect. Among the 80 patients who met the criteria: 21 patients received bromocriptine as primary treatment (Group A); 21 patients initially received bromocriptine and then accepted microsurgery or irradiation (Group B); 38 patients had initially undergone transcranial or transsphenoidal microsurgery and then received bromocriptine or adjuvant radiotherapy (Group C). Eleven patients underwent gamma knife radiotherapy. In 57 patients (12 cases of Group A, 16 cases of Group B, 29 cases of Group C), the tumors on MRI had almost completely disappeared after an average follow-up period of 62 months, and in the other 23 patients, residual tumor involved the cavernous sinus. Visual symptoms improved in 33 patients while deteriorated in 7 patients. Serum prolactin level of 52 patients had in normal range after treatment (10 cases of Group A, 11 cases of Group B, 31 cases of Group C) and 7 patients were more than 9.1 nmol/L. Nine patients had symptoms of hypopituitarism. For IPs, individualized treatment methods are advocated in which dopamine agonist medications are effective as first-line therapy. It is necessary to take dopamine agonist after operation and close observation is mandatory. Gamma knife surgery is an option to treat the residual tumor involving the cavernous sinus.

Desmoplastic neurotropic melanoma

Several studies have suggested that desmoplastic neurotropic melanoma (DNM) is associated with higher local recurrence rates than other types of melanoma. The authors investigated the local recurrence rates for patients with DNM after surgery alone or surgery followed by radiotherapy (RT). One hundred twenty-eight patients with DNM were treated at the Sydney Melanoma Unit and the Sydney Cancer Center from 1996 to 2007. All patients underwent local excision, 27 patients also received RT. For both groups, clinical and pathologic features, treatment details, and local recurrence data were analyzed. The median age at diagnosis was 65.5 years. The ratio of men to women was 2.7:1. The head and neck was the most common location (51%). The median Breslow thickness was 4 mm, and 99% of patients had Clark Level IV or V primary tumors. Patients who received adjuvant RT had thicker tumors (P = .003), deeper Clark level invasion (P < .001), and narrower excision margins (P < .001). There were 8 local recurrences, including 6 (6%) in the surgery only group and 2 (7%) in the adjuvant RT group. A positive margin (P < .001) and head and neck location (P = .03) were significant predictors of local recurrence. The local recurrence rate in this series was lower than the rates reported in historic control groups and in the authors' previous temporal cohort. The results indicated that clear surgical margins are of paramount importance in minimizing local recurrence; when margins are compromised, the addition of RT may reduce local recurrence rates compared with historic controls. A prospective randomized trial is needed to quantify the risk reduction with adjuvant RT.

Adjuvant Radiotherapy for Pathologically Advanced Prostate Cancer

Despite a stage-shift to earlier cancer stages and lower tumor volumes for prostate cancer, pathologically advanced disease is detected at radical prostatectomy in 38% to 52% of patients. However, the optimal management of these patients after radical prostatectomy is unknown. To determine whether adjuvant radiotherapy improves metastasis-free survival in patients with stage pT3 N0 M0 prostate cancer. Randomized, prospective, multi-institutional, US clinical trial with enrollment between August 15, 1988, and January 1, 1997 (with database frozen for statistical analysis on September 21, 2005). Patients were 425 men with pathologically advanced prostate cancer who had undergone radical prostatectomy. Men were randomly assigned to receive 60 to 64 Gy of external beam radiotherapy delivered to the prostatic fossa (n = 214) or usual care plus observation (n = 211). Primary outcome was metastasis-free survival, defined as time to first occurrence of metastatic disease or death due to any cause. Secondary outcomes included prostate-specific antigen (PSA) relapse, recurrence-free survival, overall survival, freedom from hormonal therapy, and postoperative complications. Among the 425 men, median follow-up was 10.6 years (interquartile range, 9.2-12.7 years). For metastasis-free survival, 76 (35.5%) of 214 men in the adjuvant radiotherapy group were diagnosed with metastatic disease or died (median metastasis-free estimate, 14.7 years), compared with 91 (43.1%) of 211 (median metastasis-free estimate, 13.2 years) of those in the observation group (hazard ratio [HR], 0.75; 95% CI, 0.55-1.02; P = .06). There were no significant between-group differences for overall survival (71 deaths, median survival of 14.7 years for radiotherapy vs 83 deaths, median survival of 13.8 years for observation; HR, 0.80; 95% CI, 0.58-1.09; P = .16). PSA relapse (median PSA relapse-free survival, 10.3 years for radiotherapy vs 3.1 years for observation; HR, 0.43; 95% CI, 0.31-0.58; P<.001) and disease recurrence (median recurrence-free survival, 13.8 years for radiotherapy vs 9.9 years for observation; HR, 0.62; 95% CI, 0.46-0.82; P = .001) were both significantly reduced with radiotherapy. Adverse effects were more common with radiotherapy vs observation (23.8% vs 11.9%), including rectal complications (3.3% vs 0%), urethral strictures (17.8% vs 9.5%), and total urinary incontinence (6.5% vs 2.8%). In men who had undergone radical prostatectomy for pathologically advanced prostate cancer, adjuvant radiotherapy resulted in significantly reduced risk of PSA relapse and disease recurrence, although the improvements in metastasis-free survival and overall survival were not statistically significant. Trial Registration clinicaltrials.gov Identifier: NCT00394511.

Adjuvant radiotherapy and survival outcomes in early-stage endometrial cancer: A multi-institutional analysis of 608 women

Objective. The role of post-operative radiotherapy (RT) in women with early-stage, low to intermediate risk cancer of the uterine corpus remains controversial. The primary objective of this analysis was to evaluate the survival outcomes of women with early-stage endometrial cancer treated with surgery alone or surgery followed by RT. Methods. Data from two institutions were collected from 1990 to 2003. The 608 eligible women had FIGO stage IA to IIA endometrial cancer and underwent primary surgery ± RT. Univariate and multivariate analyses of pertinent variables were performed for the end points of disease-free survival (DFS) and overall survival (OS). Results. The median age for all women was 64 years. RT was delivered to 133 women (22%). Unfavorable histologic grade ( P < 0.0001) and stage ( P < 0.0001) were significantly more prevalent in the adjuvant RT group. At a median follow-up of 5.2 years, 26 pelvic (11 vaginal) and 16 distant failures occurred along with 110 deaths (with no significant differences between women undergoing surgery alone or followed by RT). Adjuvant RT, younger age, and lower stage predicted for improved DFS and OS on multivariate analysis. Stratified analysis revealed that adjuvant RT conferred a survival benefit in women with stage IC or IIA disease. Conclusions. Adjuvant RT was associated with improved disease-free and overall survival in women with higher risk disease. Despite significantly worse disease characteristics among women in the adjuvant RT group, the analyzed end points were equivalent among the two groups. These findings suggest that adjuvant radiotherapy has a significant benefit in reducing mortality and disease progression in early-stage carcinoma of the uterine corpus.

Treatment of stage I seminoma: A 15-year review

Purpose To review the treatment and outcomes in patients with stage I seminoma after orchidectomy. Methods A retrospective chart review of all patients with stage I seminoma referred for initial treatment during the last 15 years was performed. Initial treatment approaches and outcomes were analyzed. Comparisons were made between patients treated with adjuvant radiotherapy and those receiving no adjuvant therapy (surveillance group). Results A total of 150 patients with stage I seminoma was seen between 1989 and 2003. Median age at diagnosis was 37.5 years (range 19–79), with a median follow-up of 54 months (range 1–162). Of the patients, 71% were treated with adjuvant radiotherapy, and 29% were placed on a surveillance protocol. The 5-year relapse-free survival and overall survival for the entire group were 95% and 100%, respectively. The 5-year relapse-free survival for the adjuvant radiotherapy group was 100% compared with 79% for the surveillance group ( P < 0.001). Of the 6 patients who had a relapse, 5 were salvaged with radiation, but 1 required chemotherapy as well. One patient who had a relapse is currently refusing treatment for recurrence. Conclusions Our results confirm the excellent prognosis for patients with stage I seminoma and indicate that surveillance does not compromise survival. This result adds to the evidence that surveillance is a good option for many patients and also supports our current approach, which favors surveillance for most patients with stage I seminoma after orchidectomy who are willing to go on our surveillance protocol.

Adjuvant Therapy in Rectal Cancer: What is the Truth?

It’s just like deja vu. Japanese surgeons have often been dismissive of the value of adjuvant treatment for gastric cancer reported from Europe and America (1,2) because of differences in the degree of lymph node dissection between Japan and Europe/America (3). In contrast, Japanese surgeons may be surprised and delighted at the results of the National Surgical Adjuvant Study of Colorectal Cancer (NSAS-CC) of postoperative adjuvant chemotherapy for rectal cancer published in this issue of the JJCO (4), the results of which have not been so exciting for European and American oncologists. Such differences have resulted from attitudes towards the basic surgical procedures and the strategy of postoperative adjuvant treatment for rectal cancer. In Europe and America, adjuvant therapy for rectal cancer has included radiotherapy as a standard. In Japan, postoperative chemotherapy has been the primary treatment mainly because of excellent outcomes of surgery including autonomic nerve-preserving D3 dissection (lateral lymphadenectomy). The latest National Comprehensive Cancer Network (NCCN) guidelines prescribe preoperative concomitant radiotherapy and chemotherapy (FU – LV or Capecitabine) and postoperative chemotherapy (FU – LV or FOLFOX or Capecitabine) or, when preoperative chemoradiotherapy was not given, postoperative concomitant radiotherapy and chemotherapy (FU – LV or FOLFOX or Capecitabine) (5). The use of chemotherapy has been based on the evidence of postoperative adjuvant chemotherapy in colon cancer, not rectal cancer. As for radiotherapy, local recurrence was reduced but the survival rate not increased in most reports. In the USA, postoperative radiotherapy following surgery for rectal cancer has been used from the beginning for local control. A randomized controlled trial of MOF therapy and postoperative adjuvant radiotherapy using surgery alone as the control arm has been performed (NSABP R-01 study). The 5 year disease-free survival (DFS) and overall survival (OS) rates were significantly higher in the MOF therapy group. Local control was significantly better in the postoperative adjuvant radiotherapy group, but DFS and OS were not (6). Although these findings did not clarify the significance of postoperative adjuvant radiotherapy, the 1990 NCI Consensus Development Conference defined chemotherapy + postoperative adjuvant radiotherapy as a standard postoperative adjuvant therapy for stage II and III rectal cancer (7). The subsequent NSABP R-02 study concluded that postoperative adjuvant radiotherapy did not improve the prognosis of rectal cancer. This study used the MOF therapy group, which was effective compared with the surgery alone group in the NSABP R-01 study, as the control. It investigated MOF versus MOF + postoperative adjuvant radiotherapy, MOF versus 5-FU/LV, and 5-FU/LV versus 5-FU/LV + postoperative adjuvant radiotherapy. No significant differences were noted in DFS or OS between the groups treated with adjuvant chemotherapy alone and chemotherapy + adjuvant radiotherapy after surgery. Disease free survival was significantly higher in the 5-FU/LV group when compared with MOF, but there was no difference in OS (8). These findings had a great impact on postoperative adjuvant radiotherapy, and the American Society of Clinical Oncology (ASCO) initiated discussion on the role of postoperative adjuvant radiotherapy. A subsequent meta-analysis performed by the Colorectal Cancer Collaboration Group confirmed that postoperative adjuvant radiotherapy significantly reduced local recurrence, but showed no significant difference in OS (9). Since it was clarified that postoperative adjuvant radiotherapy did not improve the prognosis of rectal cancer, the emphasis turned to the role of preoperative adjuvant radiotherapy. Various trials on the role of preperative adjuvant radiotherapy for rectal cancer have been reported, but a final conclusion is not yet reached. Two recent meta-analyses have shown that preoperative adjuvant radiotherapy reduces local recurrence rates by almost 50% and overall mortality by 2–10% (9, 10). Preoperative radiotherapy with higher biologically effective doses (of at least 30 Gy) have shown a larger reduction than either preoperative radiotherapy with lower doses or postoperative radiotherapy. However, the trials included in these meta-analyses all started before the broad introduction of total mesorectal excision (TME) surgery. The only randomized trial of TME with or without preoperative radiotherapy was that conducted by the Dutch Colorectal Cancer Group. After 2 years follow-up the estimated local recurrence rates were 2.4% with preoperative radiotherapy and 8.2% without preoperative radiotherapy. This relative reduction of local control For reprints and all correspondence: Hiroya Takiuchi, Internal Medicine II, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan. E-mail: in2028@poh.osaka-med.ac.jp

Adjuvant combination chemotherapy and radiotherapy versus radiotherapy alone in the treatment of early stage cervical cancer after radical hysterectomy

5156 Background: This study was conducted to retrospectively evaluate the benefits and risks of adjuvant pelvic radiotherapy (RT) versus combination pelvic radiotherapy and chemotherapy (RCT) in the treatment of early stage cervical cancer patients with adverse prognostic factors following radical hysterectomy and pelvic lymphadenectomy. Methods: Fifty patients were eligible for inclusion. Adverse prognostic factors were identified as: stromal invasion greater than half the cervical length, lymphovascular space involvement, lower uterine segment involvement, positive resection margins, positive margins with 5mm of resection, positive parametrial margins, clinical tumor diameter greater than half the cervical size, and positive pelvic lymph nodes. All patients were diagnosed and treated at a single institution from 1992–2002. Results: Twenty-nine patients were treated with adjuvant RT and 21 patients were treated with adjuvant RCT. Progression free interval was 62.9 months in the adjuvant RT group compared to 30.4 months in the RCT group. The 2-year survival in the RT group was 96.6% versus 81% in the RCT group. Overall survival was 69 months in the adjuvant RT group versus 35 months in those treated with RCT. Eight (27.5%) patients recurred in the RT group and 10 (47.6%) recurred in the RCT group: 8 (27.5%) patients had pelvic recurrence in the RT group; 7 (33.3%) patients recurred locally in the RCT group. Five patients died in the RT group, 4 (13.8%) of disease; 6 (28.6%) patients died of disease in the RCT group; none died of treatment related complications. Grade 3 toxicity was experienced in 24.1% of the patients who received adjuvant RT compared to 28.6% in the RCT group. Conclusions: There was no increase in overall survival and progression free interval by the addition of adjuvant chemotherapy to irradiation. Consideration should be given to limiting chemotherapy administration due to its adverse side effects and cost without a decrease in cancer recurrence or mortality. Further information for treatment with adjuvant chemotherapy in addition to adjuvant irradiation should be obtained from randomized controlled trials. No significant financial relationships to disclose.

Adjuvant and salvage radiotherapy after radical prostatectomy for prostate cancer

Purpose The optimal role of radiotherapy (RT) to the prostate bed after radical prostatectomy (RP) is the subject of much debate. In this study, the results of adjuvant RT (ART) and salvage RT (SRT) were compared. Methods and materials A total of 146 lymph node-negative patients were treated postoperatively after RP with RT to the prostate bed between 1987 and 1998. Of these, 75 patients had an undetectable prostate-specific antigen (PSA) level and were treated with ART for adverse pathologic features only to a median dose of 60 Gy (range 51–70). A positive margin was identified in 96%, and two of the three with negative margins had seminal vesicle involvement (SVI). SRT was administered for either a persistently detectable PSA level after RP ( n = 27) or for a delayed rise in PSA ( n = 44) to a median dose of 70 Gy (range 60–78). Adjuvant androgen ablation was given to 37 patients; 2 who had received ART and 35 had who received SRT. The median duration of androgen ablation was 24 months. The primary end point was freedom from biochemical failure (bNED), which was considered to be an undetectable PSA level. The median follow-up was 53 months for all patients: 68 months for the ART patients and 35 months for the SRT patients. Results For the ART group, 8 patients subsequently developed a rising PSA level. The 5-year bNED rate was 88%. SVI was the strongest predictor of outcome, with a 5-year bNED rate of 94% for those without SVI and 65% for those with SVI ( p = 0.0002). SVI was the only significant factor in Cox proportional hazards regression analysis in the ART cohort. For the SRT group, 20 patients developed a rising PSA level after RT. The 5-year bNED rate was 66% for all SRT patients, and 43% and 78% in those with a persistently detectable PSA and those with a delayed rise in PSA, respectively. In the Cox proportional hazards regression analysis, this subdivision of SRT was statistically significant. Moreover, when the Cox model included all patients and variables, the timing of RT (ART vs. SRT) was an independent correlate of bNED, as was androgen ablation. Conclusion For RP patients with high-risk pathologic features, the timing of postoperative RT and the PSA status after RP were strong determinants of outcome. Because of the potential confounding factors, direct comparisons of ART and SRT are problematic; however, ART is extremely effective and offers the surest approach for maintaining biochemical control.

PSA based review of adjuvant and salvage radiation therapy vs. observation in postoperative prostate cancer patients

Because of the uncertainties regarding the efficacy of postoperative radiation therapy for early prostate cancer, treatment strategies following radical prostatectomy include: (1) observation alone in high-risk patients, (2) adjuvant radiation therapy (PSA undetectable) in high-risk patients, or (3) salvage radiation therapy for biochemical and clinical recurrence. Fifty-two patients treated with postoperative radiation therapy in either an adjuvant setting (13) or for salvage (39) were retrospectively reviewed. The actuarial biochemical disease-free survival (bNED) rates following radiation therapy were calculated using the life-table method. Univariate and multi variate analyses were used to define the clinical factors that predict biochemical failure following postoperative radiation therapy. In addition, the bNED survival rate for 36 high-risk surgery patients who were simply observed following prostatectomy was determined. The 3-year bNED survival rate for the adjuvant radiation group was 85% compared with 27% for salvage radiation and 43% for the observation group. These results are statistically significant. Factors that predict biochemical failure following postoperative radiation therapy include preoperative PSA level, pre-radiation therapy PSA level, and seminal vesicle involvement. At our institutions, adjuvant radiation therapy was a superior strategy compared with either observation alone or salvage radiation therapy for high-risk postoperative prostate cancer patients. Int. J. Cancer (Radiat. Oncol. Invest.) 90, 29–36 (2000). © 2000 Wiley-Liss, Inc.

PSA based review of adjuvant and salvage radiation therapy vs. observation in postoperative prostate cancer patients

Because of the uncertainties regarding the efficacy of postoperative radiation therapy for early prostate cancer, treatment strategies following radical prostatectomy include: (1) observation alone in high-risk patients, (2) adjuvant radiation therapy (PSA undetectable) in high-risk patients, or (3) salvage radiation therapy for biochemical and clinical recurrence. Fifty-two patients treated with postoperative radiation therapy in either an adjuvant setting (13) or for salvage (39) were retrospectively reviewed. The actuarial biochemical disease-free survival (bNED) rates following radiation therapy were calculated using the life-table method. Univariate and multi variate analyses were used to define the clinical factors that predict biochemical failure following postoperative radiation therapy. In addition, the bNED survival rate for 36 high-risk surgery patients who were simply observed following prostatectomy was determined. The 3-year bNED survival rate for the adjuvant radiation group was 85% compared with 27% for salvage radiation and 43% for the observation group. These results are statistically significant. Factors that predict biochemical failure following postoperative radiation therapy include preoperative PSA level, pre-radiation therapy PSA level, and seminal vesicle involvement. At our institutions, adjuvant radiation therapy was a superior strategy compared with either observation alone or salvage radiation therapy for high-risk postoperative prostate cancer patients. Int. J. Cancer (Radiat. Oncol. Invest.) 90, 29-36 (2000).

Benefits of adjuvant radiotherapy after radical resection of locally advanced main hepatic duct carcinoma

Purpose: The objective of this study was to determine the benefits of adjuvant radiotherapy after radical resection of locally advanced main hepatic duct carcinoma (Klatskin tumor). Methods and Materials: We conducted a retrospective review of 63 patients who underwent surgical resection of Stage IVA Klatskin tumor. Of the 63 patients, 47 had microscopic tumor residue (RT1). Twenty-eight of the 47 patients with RT1 were treated by adjuvant radiotherapy and the remaining 19 patients were treated exclusively by surgical resection. Seventeen of the 28 patients with RT1 were treated by both intraoperative radiotherapy (IORT) and postoperative radiotherapy (PORT); of the remaining 11 patients with RT1, 6 underwent resection and IORT, and 5 underwent resection and PORT. Results: The major complication and 30-day operative death rates were significantly lower in the radiation group (9.5% and 0.0%, respectively) than in the resection alone group (28.5% and 9.5%, respectively). Of the eight 5-year survivors with RT1, 6 had adjuvant radiotherapy and the remaining 2 had resection alone. Adjuvant radiotherapy for patients with RT1 yielded significantly (p = 0.0141) higher 5-year survival rates (33.9%) than in the resection alone group (13.5%). The best 5-year survival rate (39.2%) was found in patients who underwent a combination of IORT and PORT after resection. The local-regional control rate was significantly higher in the adjuvant radiation group than in the resection alone group (79.2% vs. 31.2%). Conclusion: Our data clearly suggest the improved prognosis of patients with locally advanced Klatskin tumor by integrated adjuvant radiotherapy with IORT and PORT to complete gross tumor resection with acceptable treatment mortality and morbidity.

Postoperative adjuvant therapy for stage II non–small-cell lung cancer

Background. Stage II non–small-cell lung cancer is regarded as one of the early lung cancers. Although resection, including the mediastinal lymph nodes, is currently regarded as the standard treatment, the survival rate of this disease is not encouraging. It is well known that the most common causes of death are locoregional recurrences or distant metastases, or both. However, the best adjuvant treatment to improve survival is as controversial an issue as ever.Methods. This study was designed as a randomized, blinded, two-armed study with operation and adjuvant radiotherapy in one arm, versus operation and adjuvant mitomycin C (10 mg/m2), vinblastin (6 mg/m2), and cisplatin (100 mg/m2) (MVP) chemotherapy in the other arm. We assigned 57 resected patients with pathologic proven stage II non-small cell lung cancer to the groups according to our eligibility criteria.Results. The most common pattern of recurrence was distant metastases, and nearly all the recurrences (17 of 18 patients) in both groups were found within 2 years after operation. The rates of the locoregional and distant metastases were 3.6% and 46.4% in the adjuvant radiotherapy group and 6.9% and 10.3% in the adjuvant chemotherapy group (p = 0.018). The 5-year disease-free survival rates were 52.0% in the adjuvant radiotherapy group and 74.0% in the adjuvant chemotherapy group (p = 0.16, log-rank test). The 2-year, 5-year, and 6-year survival portions were 60.3%, 56.5%, and 28.3% in the adjuvant radiotherapy group, and 82.8%, 70.1%, and 60.1% in the adjuvant chemotherapy group (p = 0.01, p = 0.17, and p = 0.03, Z-test). The difference of the actuarial survival between these two groups was somewhat significant (p = 0.09, log-rank test).Conclusions. Our results suggest that the addition of adjuvant MVP chemotherapy may reduce the distant metastasis rates and prolong the survival of the surgically resected stage II non–small-cell lung cancer patients.

Adjuvant Radiotherapy for Squamous Cell Carcinoma of the Tongue Base: Improved Local-Regional Disease Control Compared with Surgery Alone

Purpose: The purpose of this retrospective study is to present the results of postoperative adjuvant radiotherapy after primary surgery for squamous cell carcinoma of the tongue base and to compare these results to those obtained with surgery alone. Methods: Between 1974 and 1993, continuous-course postoperative radiotherapy was delivered to 24 patients (Adjuvant Radiotherapy Group). Results were compared to those from a group of 55 patients treated with surgery alone (Surgery Group). Results: Characteristics of the two groups were similar, except that a larger proportion of patients in the Adjuvant Radiotherapy Group had higher pathologic TNM stages. Ipsilateral neck control (87% vs. 68%, p = 0.04), contralateral neck control (100% vs. 76%, p = 0.002), relapse-free survival (64% vs. 46%, p = 0.04), and control above the clavicles (80% vs. 48%, p = 0.007) were significantly higher in the Adjuvant Radiotherapy Group compared to those in the Surgery Group (5-year figures shown). Conclusion: The use of adjuvant radiotherapy after surgical resection of tongue base squamous cell carcinoma significantly decreased the rate of local-regional recurrence and improved relapse-free survival compared with surgery alone but did not alter cause-specific or overall survival.

Sarcomas near extremity joints in adults.

There are technical difficulties in resecting soft tissue sarcomas extending to or crossing a joint. The objective of this study was to determine the rate of amputation and local recurrence rate for these sarcomas and compare them with the respective rates for overall extremity sarcomas. Retrospective review of 78 patients with sarcoma near a joint compared with 215 patients with extremity sarcomas accrued during the same period, 1977-1994. Of these 78 patients, 64 were in the lower and 14 in the upper extremity. Most common histologic subtypes were malignant fibrous histiocytoma (15/78, 19%), synovial sarcoma (11/78, 14%), liposarcoma (11/78, 14%), and leiomyosarcoma (10/78, 13%). The surgical treatment consisted of local excision in 10 (13%), wide excision in 56 (72%), and amputation in 12 (15%). Adjuvant radiation was given to 26 patients. Local recurrence was noted in 20% (16/78) patients. The incidence of local recurrence in the surgery alone group (n = 52) was 15% (8/52) and in the surgery plus adjuvant radiation group (n = 26) it was 31% (8/26); P = 0.11. Of the 16 patients with local recurrence, 9 (56%) required amputation. The 5-year and 10-year survival rates for the entire group of patients were 68% and 60% respectively. On multivariate analysis survival varied according to grade (P = 0.05) and tumor size (P = 0.02). Amputation was finally required in 27% (21/78) for local control of the disease. The local recurrence rate was 20%. These rates appear to be somewhat higher than those reported in our overall extremity sarcoma series and those in most modern series of overall extremity sarcomas, but the 5- and 10-year survival rates are similar to those of the latter.

Silicone Stents in the Management of Inoperable Tracheobronchial Stenoses: Indications and Limitations

Various stent models have been developed for the treatment of inoperable stenoses of the central airways caused by external compression. Increasing use is made of the silicone stents designed by Dumon. We tested their technical feasibility, tolerance, and long-term efficacy in relieving respiratory symptoms in patients referred for endoscopic palliation of malignant disease. All procedures were performed under general anesthesia with the use of the rigid bronchoscope. We inserted 38 stents in 31 patients (median age, 67 years; 25 men and 6 women) whose airways showed residual obstruction of > 50 percent of the lumen after laser resection of endobronchial tumor and/or mechanical dilatation of extrinsic compressions. Stent placement and removal--where necessary--were easy in all patients, but five stents inserted in three patients with short (< or = 2.5 cm) and conical stenoses migrated, necessitating emergency removal. In 27 of the remaining 28 patients, stent tolerance was excellent; 1 proximal tracheal stent (< 1 cm below the vocal cords) had to be removed because of otalgia and dysphagia. One lethal hemoptysis occurred within hours after a repeated laser therapy and removal of an indwelling stent. No other serious complications occurred. Immediate and lasting relief of dyspnea and improvement in performance status (Karnofsky scale, activity index) was achieved in 90 percent (28/31) of patients (p < 0.01). The influence of adjuvant radiotherapy on local tumor recurrence and survival was analyzed in a subgroup of ten patients with stage IIIB squamous cell carcinoma with comparable performance status. Five did not undergo adjuvant radiotherapy (group A) and five did (group B). In group A, four of five stents were occluded by tumor recurrence above or below the stent after a median follow-up of 2 months; in group B, zero of five were occluded (p < 0.05) after 4 months. Median survival was 4 months in group A and 6 months in group B; the difference did not reach significance. The silicone stents designed by Dumon are easily inserted and removed; they are also well tolerated and very efficacious in relieving respiratory symptoms caused by extrinsic airway compression. Short and conical stenoses present limitations for their use due to increased risk of migration. Combined treatment with laser resection, stent insertion, and subsequent radiotherapy is necessary to prevent local tumor recurrence and may improve survival.