Adjuvant Radiotherapy For Stage Research Articles

Racial Disparity in Accessibility and Outcomes of Adjuvant Radiotherapy in Stage I High Intermediate Risk Endometrial Adenocarcinoma: A National Database Study

<h3>Purpose/Objective(s)</h3> Based on PORTEC-2 study in 2010, vaginal brachytherapy (VB) was found to be non-inferior to whole pelvic radiation (WPRT) in terms of survival and loco-regional control with a more favorable toxicity Profile. VB is now the preferred choice of adjuvant treatment in patients with high-intermediate risk (HIR) endometrial cancer, especially those with negative Lymphovascular space invasion. In this study we assessed the accessibility and outcomes of this recommended regimen in the different groups of race/ethnicity. <h3>Materials/Methods</h3> The Surveillance, Epidemiologic, and End Results (SEER) database was used to identify patients who met PORTEC-2 inclusion criteria. All patients underwent surgery followed by either vaginal brachytherapy (VB) or whole pelvic radiation (WPRT). Patients with stage I disease, grade 1 with ≥ 50% myometrial invasion (MI), grade 2 with any invasion, and grade 3 with < 50% MI were included in the analysis. Patients were excluded if any lymph nodes were examined or involved, if they received any chemotherapy. Lymphovascular space invasion was not available in the database. HIR endometrial adenocarcinoma was defined as the presence of 2 of the following: age>60, grade 3, and ≥50% myometrial invasion. Radiation status was extracted from the SEER Radiation/Chemotherapy database. Race/ethnicity was defined as non-Hispanic White (NHW), non-Hispanic Black (NHB), Hispanic and others/unknown. Cox regression analysis was performed to calculate hazard of cancer specific death and overall death both before and after counting for race/ethnicity with following variables in the model: grade, radiation status, myometrial invasion. <h3>Results</h3> Between 2005- 2015, 571 patients met PORTEC-2 inclusion criteria of whom 349 (61.1%) and 222 (38.9%) received WPRT and VB, respectively. Rate of VB was 38.9% overall, 41.1% in NHW however 29.0% in H and only 27.0% in NHB (p<0.05). There was no difference in grade and myometrial invasion between the study groups nor within categories of race/ethnicity (p=0.21 and 0.89, respectively). Cox regression analysis revealed an overall 66% decrease in the hazard of cancer specific death in the VB group as compared to WPRT group (HR=0.34, 95% CI: 0.16-0.73, p<0.01); this decrease was 67% in non-Hispanic White subjects (HR=0.33, 95% CI: 0.12-0.86, p<0.05) however no significant change was noted in NHB (HR=0.55, 95% CI: 0.11-2.67, p=0.45). Moreover, after adjusting for confounding variables, hazard of cancer specific death in NHB was 2.62 times higher than NHW (HR=2.62, 95% CI: 1.22-5.62, p=0.01). <h3>Conclusion</h3> Administration of VB following surgery has become significantly more popular after publication of the PORTEC-2 results however racial disparity exists against both accessibility to and outcomes of this treatment modality. Being a NHB is a risk factor for lack of accessibility as well as failure to respond to PORTEC-2 regimen; future studies on genetic predispositions are recommended.

Adjuvant Radiotherapy in Stage II Endometrial Cancer: Selective De-intensification of Adjuvant Treatment

AimsRisk stratification, including nodal assessment, allows for selective de-intensification of adjuvant radiotherapy in stage II endometrial cancer. Patterns of treatment and clinical outcomes, including the use of reduced volume ‘mini-pelvis’ radiotherapy fields, were evaluated in a population-based study. Materials and methodsAll patients diagnosed with pathological stage II endometrial cancer between 2000 and 2014, and received adjuvant radiotherapy in a regional healthcare jurisdiction were reviewed. Registry data were supplemented by a comprehensive review of patient demographics, disease characteristics and treatment details. The Charlson Comorbidity Score was calculated. Survival and recurrence data were analysed. ResultsIn total, 264 patients met the inclusion criteria. Most patients had endometrioid histology (83%); 41% of patients had International Federation of Gynecologists and Obstetricians grade 1 disease. Half (49%) had surgical nodal evaluation; 11% received chemotherapy. Most patients (59%) were treated with full pelvic radiotherapy fields ± brachytherapy. Seventeen per cent of patients received mini-pelvis radiotherapy ± brachytherapy, whereas 24% received brachytherapy alone. Five-year recurrence-free survival was 87% for the entire cohort, with no significant difference by adjuvant radiotherapy approach. Only one patient receiving mini-pelvis radiotherapy ± brachytherapy recurred in the pelvis but outside of the mini-pelvis field. Recorded late toxicity rates were highest for full pelvis radiotherapy + brachytherapy. ConclusionRisk stratification in a real-world setting allowed for selective de-intensification of adjuvant radiation with equivalent outcomes for stage II endometrial cancer. Mini-pelvis radiotherapy combined with brachytherapy is effective in highly selected patients, with the potential to decrease toxicity without compromising local control. Brachytherapy should be considered in low-risk stage II patients.

Prognostic Value of Radiotherapy and Chemotherapy in Stage I-III Merkel Cell Carcinoma.

PurposeMerkel cell carcinoma (MCC) is a highly malignant cancer associated with dismal survival outcomes. Surgery is the cornerstone for the management of MCC, but the benefit of radiotherapy (RT) and chemotherapy (CT) is still controversial. We aimed to investigate the prognostic value of RT and CT in the management of stage I-III MCC patients using the Surveillance, Epidemiology, and End Results (SEER) database.MethodsPatients with a histopathological diagnosis of MCC between 2010 and 2016 were included. The primary endpoint of this study was overall survival (OS). The prognostic significance for OS was analyzed by Cox proportional hazard regression model.ResultsA total of 1,691 patients were identified in the SEER database. Over half of the patients had received RT (56.7%), and 9.8% of the patients were documented to have received CT. The median OS for the entire cohort was 66.0 months, and the 5-year OS rate was 53.8%. In the multivariate analysis, receiving RT was associated with significantly improved OS (P < 0.001), while receiving CT significantly negatively impacted OS (P = 0.010). In stage III patients who underwent treatment based on surgical resection, RT was still demonstrated to be a positive factor (P = 0.002), while CT had no significant association with OS in the univariate analysis (P = 0.295).ConclusionsThe current data in the SEER database are consistent with earlier studies supporting the benefit of adjuvant RT for stage I-III MCC patients, but caution should be taken regarding the routine use of CT. For stage III MCC patients, the value of adjuvant CT needs to be confirmed in future studies.

82: A Population-Based Study of Outcomes in Adjuvant Radiotherapy for Stage II Endometrial Carcinoma

82: A Population-Based Study of Outcomes in Adjuvant Radiotherapy for Stage II Endometrial Carcinoma

Adjuvant Radiotherapy Improved Survival in Stage I to II Low-Grade Endometrial Stromal Sarcoma: A Retrospective Study of 152 Cases.

ObjectiveLow-grade endometrial stromal sarcoma (LG-ESS) is a rare gynecological tumor. Whether adjuvant radiotherapy benefits survival in patients with resected early-stage ESS remains controversial. This study was designed to explore the role of adjuvant radiotherapy in stage I to II LG-ESS.MethodsWe retrospectively reviewed patients with stage I to II LG-ESS in our center from Jan. 1998 to Feb. 2018. All patients underwent a total hysterectomy and postoperative radiotherapy was administrated based on clinical and pathological characteristics.ResultsA total of 152 patients with stage I to II resected LG-ESS were included. Forty patients received adjuvant radiotherapy (RT group) while 112 patients did not receive adjuvant radiotherapy (no RT group). The baseline characteristics of the two groups were comparable, except that the proportion of stage II patients in the RT group was higher than that in the no RT group (32.5% vs. 11.6%, in RT vs. no RT groups, respectively; p = 0.003). For both patient groups, median overall survival was not reached. The median disease-free survival (DFS) was 144 months. Radiotherapy was associated with significantly improved DFS (92 months vs. not reached in RT vs. no RT groups, respectively; p = 0.008) and pelvic failure-free survival (PFFS) (92 months vs. not reached in RT vs. no RT groups, respectively; p=0.004). Subgroup analysis revealed that RT benefited survival most among patients with stage IB to IIB disease. Adjuvant radiotherapy significantly reduced the pelvic recurrence rate (10.0%, 4/40 vs. 28.6%, 32/112, p = 0.018). No radiotherapy-induced grade 4 to 5 toxicity was observed.ConclusionFor patients with stage I to II LG-ESS, adjuvant radiotherapy showed significant improvement in DFS and PFFS with tolerable adverse effects, especially in patients with stage IB to IIB disease.

ES22.02 A Milestone in Locally Advanced NSCLC

Stage III NSCLC encompasses locally advanced tumours with infiltration of locoregional nodes and central thoracic structures and accounts for about a third of newly diagnosed NSCLC[1]. It represents the most advanced stage of NSCLC in which treatment is delivered with curative intent, but eventually more than 60% of patients die from their disease. Stage III NSCLC patients must strictly be discussed in a multidisciplinary tumor board, whereat the definition of resectability suffers from a certain heterogeneity across centers. Resectability is usually defined by the degree of invasion of lymph nodes, most often excluding multilevel or bulky N2 and N3 disease as well as invasion of the oesophagus, aorta and myocardium. Controversy exists on the role of surgery in stage III NSCLC since two large randomized trials investigated either induction chemoradiation therapy followed by resection versus radiotherapy[2], or induction chemotherapy followed by resection versus radiotherapy[3]. Both studies failed to demonstrate a difference in survival[2-5], however these treatment strategies are evidence-based and can be pursued in restectable NSCLC[6]. In the surgical scenario, randomised trials and meta-analyses have consistently shown that either adjuvant or neoadjuvant chemotherapy added to surgery results, with a better survival than surgery alone[7,8]. Adding preoperative radiotherapy to chemotherapy in patients with stage IIIA/N2 NSCLC did not improve the clinical outcome in a phase 3 randomised trial[9]. The role of adjuvant radiotherapy in stage IIIA/N2 after neoadjuvant chemotherapy followed by surgery has been evaluated in a unique randomized trial with awaited results (Lung ART, NCT00410683). Early NSCLC stages offer a theoretical unique curative scenario for the development of immunotherapy strategies, with limited disease volumes, a relative immune system preservation as well as unique opportunities for the investigation and assessment of new biomarkers. Perspectives, rational, hopes and ongoing attempts to combine immunotherapy in the surgical setting or alternatively complementary to chemoradiation will be discussed, with a focus on locally advanced disease. 1. Detterbeck FC. The eighth edition TNM stage classification for lung cancer: What does it mean on main street? J Thorac Cardiovasc Surg 2018;155:356-9. 2. Albain KS, Swann RS, Rusch VW, et al. Radiotherapy plus chemotherapy with or without surgical resection for stage III non-small-cell lung cancer: a phase III randomised controlled trial. Lancet 2009;374:379-86. 3. van Meerbeeck JP, Kramer GW, Van Schil PE, et al. Randomized controlled trial of resection versus radiotherapy after induction chemotherapy in stage IIIA-N2 non-small-cell lung cancer. J Natl Cancer Inst 2007;99:442-50. 4. O'Rourke N, Roque IFM, Farre Bernado N, Macbeth F. Concurrent chemoradiotherapy in non-small cell lung cancer. Cochrane Database Syst Rev 2010:CD002140. 5. Auperin A, Le Pechoux C, Rolland E, et al. Meta-analysis of concomitant versus sequential radiochemotherapy in locally advanced non-small-cell lung cancer. J Clin Oncol 2010;28:2181-90. 6. Postmus PE, Kerr KM, Oudkerk M, et al. Early and locally advanced non-small-cell lung cancer (NSCLC): ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2017;28:iv1-iv21. 7. Group NM-aC. Preoperative chemotherapy for non-small-cell lung cancer: a systematic review and meta-analysis of individual participant data. Lancet 2014;383:1561-71. 8. Group NM-aC, Arriagada R, Auperin A, et al. Adjuvant chemotherapy, with or without postoperative radiotherapy, in operable non-small-cell lung cancer: two meta-analyses of individual patient data. Lancet 2010;375:1267-77. 9. Pless M, Stupp R, Ris HB, et al. Induction chemoradiation in stage IIIA/N2 non-small-cell lung cancer: a phase 3 randomised trial. Lancet 2015;386:1049-56. Stage III NSCLC , chemoradiation, neo-adjuvant immunotherapy

The role of adjuvant radiotherapy in stage I endometrial cancer: A single-institution outcome

ObjectivePostoperative radiotherapy for early endometrial cancer has been investigated in several randomized trials. These trials demonstrate that it reduces loco-regional recurrence, but has no impact on overall survival. The aims of this study were to better understand the role of adjuvant radiotherapy and determine predictors for loco-regional recurrence or development of distant metastasis. Materials and methodsA retrospective medical records review was performed on patients with surgical stage I endometrial cancer treated at Taipei Veterans General Hospital between 2006 and 2013. Multivariable analysis was conducted using Cox regression for prognostic predictors. ResultsA total of 337 patients were identified. The estimated five-year overall survival and loco-regional recurrence-free survival were 96.3% and 97.9% in the non-radiotherapy group, and 91.6% and 97.1% in the radiotherapy group (p = 0.06 overall survival, p = 0.956 loco-regional recurrence-free survival). Multivariable analysis revealed that elevated preoperative serum Cancer Antigen 125 (CA-125) level (hazard ratio (HR) = 2.54), age older than 60 years old (HR = 3.34), and depth of myometrial invasion > 50% (HR = 3.37) were significant factors in overall survival. Elevated preoperative CA-125 level (HR = 5.37), age older than 60 years (HR = 6.57), positive lymphovascular space invasion (HR = 50.20), and adjuvant radiotherapy (HR = 0.05) were independent predictors of loco-regional recurrence-free survival. For distant metastasis, deep myometrial invasion was a significant risk factor. ConclusionsPostoperative radiotherapy delivery is an independent predictor for loco-regional recurrence-free survival but has no impact on overall survival in this population. Preoperative CA-125 level is a risk factor for loco-regional recurrence, and deep myometrial invasion was correlated with distant metastasis.

Adjuvant radiotherapy for Stage I seminoma: A Single-institutional experience.

There is no consensus regarding the management of Stage 1 seminomas following inguinal orchiectomy. In this study, we evaluated the treatment results and treatment-related toxicity for patients with Stage 1 seminomas treated with adjuvant radiotherapy (RT) at a single institution. Sixty-five patients who underwent adjuvant RT following orchiectomy for Stage 1 seminomas between January 1996 and December 2007 were retrospectively reviewed. The age, tumor location, histopathological type, stage, tumor size, RT field, and radiation dose were recorded for all patients. The patients' ages ranged from 17 to 61 years (median, 37 years). Sixty-three patients (97%) were diagnosed with classical seminoma and the remaining two patients (3%) had spermatocytic seminoma. After orchiectomy, 37 patients (57%) received para-aortic RT and 28 patients (43%) received dog-leg field RT. RT was applied with 1.8-2 Gy/day fractionation and the median RT dose was 26 Gy (range, 20-38). Follow-up ranged from 0.3 to 18 years (median, 9.5 years). Local control had been achieved in all patients and all of them were alive with no evidence of disease. Fifty-one patients (77%) had at least 5 years of follow-up and 27 patients (41%) had at least 10 years of follow-up. Overall survival at 10 years was 100%. Although retrospective in nature, this single-institutional study provides useful information about the outcomes and toxicities associated with adjuvant RT in patients with Stage 1 seminomas reporting excellent disease control and survival rates at the expense of acceptable toxicity.

Radiotherapy for stage I seminoma of the testis: Organ equivalent dose to partially in-field structures and second cancer risk estimates on the basis of a mechanistic, bell-shaped, and plateau model.

The aim of the current study was to (a) calculate the organ equivalent dose (OED) and (b) estimate the associated second cancer risk to partially in-field critical structures from adjuvant radiotherapy for stage I seminoma of the testis on the basis of three different nonlinear risk models. Three-dimensional plans were created for twelve patients who underwent a treatment planning computed tomography of the abdomen. The plans for irradiation of seminoma consisted of para-aortic anteroposterior and posteroanterior fields giving 20 Gy to the target site with 6 MV photons. The OED of stomach, colon, liver, pancreas, and kidneys, that were partially included in the treatment volume, was calculated using differential dose-volume histograms. The mechanistic, bell-shaped, and plateau models were employed for these calculations provided that organ-specific parameters were available for the subsequent assessment of the excess absolute risk (EAR) for second cancer development. The estimated organ-specific lifetime risks were compared with the respective nominal intrinsic probabilities for cancer induction. The mean OED, which was calculated from the patients' treatment plans, varied from 0.54 to 6.61 Gy by the partially in-field organ of interest and the model used for dosimetric calculations. The difference between the OED of liver derived from the mechanistic model with those from the bell-shaped and plateau models was less than 1.8%. An even smaller deviation of 1.0% was observed for colon. For the rest organs of interest, the differences between the OED values obtained by the examined models varied from 8.6% to 50.0%. The EAR for stomach, colon, liver, pancreas, and kidney cancer induction at an age of 70 yr because of treatment of a typical 39-yr-old individual was up to 4.24, 11.39, 0.91, 3.04, and 0.14 per 10 000 persons-yr, respectively. Patient's irradiation was found to elevate the lifetime intrinsic risks by 8.3%-63.0% depending upon the organ of interest and the model employed for risk analysis. Radiotherapy for stage I seminoma of the testis may result in an excess risk for the appearance of secondary malignancies in partially in-field organs. The organ- and model-dependent second cancer risk assessments of this study may be of value for patient counseling and follow-up.

Adjuvant radiotherapy in stage 1 seminoma: Evaluation of prognostic factors and results of survival.

The purpose of this study was to evaluate the prognostic factors affecting overall survival (OS), cause-specific survival (CSS), progression-free survival (PFS), and survival among patients undergoing adjuvant radiotherapy (RT) for stage-1 seminoma. Between August 1997 and May 2013, 68 patients diagnosed with stage-1 seminoma were retrospectively evaluated. The median age was 39 (24-74) years. All patients received adjuvant RT after inguinal orchiectomy. Fifty-eight (85.3%) patients received paraaortic RT; 10 (14.7%) received dog-leg field RT. The median RT dose was 23.4 (23.4-30.6) Gy. The median follow-up period was 77.5 (6.7-198.5) months. During the follow-up period, two patients developed distant metastasis, and none developed local recurrence. Two patients died from seminoma, and three died for other reasons. The 5, 10, and 15-year OS rates were 94.7%, 89.6%, and 89.6%, respectively. The 5, 10, and 15-year CSS rates were 98.5%, 96%, and 96%, respectively. The 5, 10, and 15-year PFS rate was 96.1%. The univariate analysis showed that only histological subtype was significant for OS. The 10-year survival rate was 100% among patients with seminoma histology, 90.8% among patients with a classic seminoma histology, and 50% among patients with an anaplastic seminoma histology (P < 0.001). A multivariate analysis showed that the anaplastic seminoma was a negative prognostic indicator for OS (P = 0.042). Adjuvant RT resulted in excellent long-term survival and local control in patients with stage-1 seminoma after orchiectomy. During a short follow-up, secondary malignancy (SM) and late cardiovascular morbidity were not observed. Despite those results, concern of SM and late cardiovascular morbidity remains.

Survival benefit of adjuvant radiotherapy in stage III and IV bladder cancer: results of 170 patients.

Background:Radical cystectomy (RC) with or without neoadjuvant chemotherapy is the standard treatment for muscle-invasive bladder cancers. However, the locoregional recurrence rate is still significantly higher for locally advanced cases post-RC. The underuse of postoperative radiotherapy (PORT) in such cases after RC is related mainly to a lack of proven survival benefit. Here we are reporting our long-term Egyptian experience with bladder cancer patients treated with up-front RC with or without conformal PORT.Patients and methods:This retrospective study included 170 locally advanced bladder cancer (T3–T4, N0/N1, M0) patients who had RC performed with or without PORT at Damietta Cancer Institute during the period of 1998–2006. The treatment outcomes and toxicity profile of PORT were evaluated and compared with those of a non-PORT group of patients.Results:Ninety-two patients received PORT; 78 did not. At median follow-up of 47 months (range, 17–77 months), 33% locoregional recurrences were seen in the PORT group versus 55% in the non-PORT group (P<0.001). The overall distant metastasis rate in the whole group was 39%, with no difference between the two groups. The 5-year disease-free survival for the whole group of patients was 53%±11%, which was significantly affected by additional PORT, and 65%±13% compared with 40%±9% for the non-PORT group (P=0.04). The pathological subtypes did not affect 5-year disease-free survival significantly (P=0.9). The 5-year overall survival was 44%±10%. Using multivariate analysis, PORT, stage, and extravesical extension (positive surgical margins) were found to be important prognostic factors for locoregional control. Stage and lymph node status were important prognosticators for distant metastasis control.Conclusion:PORT was found to be a safe and effective tool in decreasing local recurrence rates and improving disease-free survival.

Adjuvant Radiotherapy for Stage I Endometrial Cancer: An Updated Cochrane Systematic Review and Meta-analysis

The role of adjuvant radiotherapy in stage I endometrial cancer has changed in recent years. This updated Cochrane systematic review aimed to reexamine the efficacy and toxicity of adjuvant radiotherapy vs no treatment in stage I endometrial cancer. We searched various databases including The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and the Specialised Register of the Cochrane Gynaecological Cancer Review Group (CGCRG) for randomized controlled trials that met the predefined inclusion criteria. The primary outcome was overall survival (OS); secondary outcomes were endometrial cancer-specific survival, locoregional recurrence, distant recurrence, and toxicity. Hazard ratios (HRs) were estimated and pooled if possible; otherwise, dichotomous data were extracted. All statistical tests were two-sided. Of the eight included trials, seven trials (3628 women) compared external beam radiotherapy (EBRT) and no EBRT (or vaginal brachytherapy [VBT]), and one trial (645 women) compared VBT and no additional treatment. EBRT statistically significantly reduced locoregional recurrence compared with no EBRT (or VBT alone) (HR = 0.36, 95% confidence Interval [CI] = 0.25 to 0.52; P < .001), but this did not translate into an improvement in OS (HR = 0.99, 95% CI = 0.82 to 1.20; P = .95), endometrial cancer-specific survival (HR = 0.96, 95% CI = 0.72 to 1.28; P = .80), or distant recurrence rates (risk ratio = 1.04, 95% CI = 0.80 to 1.35; P = .77). EBRT was associated with an increased risk of severe acute toxicity, severe late toxicity, and reduced quality of life scores. EBRT reduces the risk of locoregional recurrence but has no statistically significant impact on cancer-related deaths or OS. However, EBRT is associated with clinically and statistically significant morbidity and a reduction in quality of life.

Adjuvant radiotherapy for stage I endometrial cancer.

This is an updated version of the original Cochrane review published in Issue 2, 2007. The role of radiotherapy (both pelvic external beam radiotherapy (EBRT) and vaginal intracavity brachytherapy (VBT)) in stage I endometrial cancer following hysterectomy remains controversial. To assess the efficacy of adjuvant radiotherapy following surgery for stage I endometrial cancer. We searched The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and the Specialised Register to end-2005 for the original review, and extended the search to January 2012 for the update. We included randomised controlled trials (RCTs) that compared post-operative adjuvant radiotherapy (either EBRTor VBT, or both) versus no radiotherapy or VBT in women with stage I endometrial cancer. Two review authors independently assessed trials and extracted data to a specifically designed data collection form. The primary outcome was overall survival. Secondary outcomes were endometrial cancer-related deaths, locoregional recurrence and distant recurrence. Meta-analyses were performed using Cochrane Review Manager Software 5.1. We included eight trials. Seven trials (3628 women) compared EBRT with no EBRT (or VBT), and one trial (645 women) compared VBTwith no additional treatment. We considered six of the eight trials to be of a high quality. Time-to-event data were not available for all trials and all outcomes.EBRT (with or without VBT) compared with no EBRT (or VBT alone) for stage I endometrial carcinoma significantly reduced locoregional recurrence (time-to-event data: five trials, 2965 women; Hazard Ratio (HR) 0.36, 95% Confidence Interval (CI) 0.25 to 0.52; and dichotomous data: seven trials, 3628 women; Risk Ratio (RR) 0.33, 95% CI 0.23 to 0.47). This reduced risk of locoregional recurrence did not translate into improved overall survival (time-to-event data: five trials, 2,965 women; HR 0.99, 95% CI 0.82 to1.20; and dichotomous data: seven trials, 3628 women; RR 0.98, 95% CI 0.83 to 1.15) or improved endometrial cancer-related survival (time-to-event data: five trials, 2965 women; HR 0.96, 95% CI 0.72 to 1.28; and dichotomous data: seven trials, 3628 women; RR 1.02, 95% CI 0.81 to 1.29) or improved distant recurrence rates (dichotomous data: seven trials, 3628 women; RR 1.04, 95% CI 0.80 to 1.35).EBRT did not improve survival outcomes in either the intermediate-risk or high-risk subgroups, although high-risk data were limited, and a benefit of EBRT for high-risk women could not be excluded. One trial (PORTEC-2) compared EBRT with VBT in the high-intermediate risk group and reported that VBT was effective in ensuring vaginal control with a non-significant difference in loco-regional relapse rate compared to EBRT (5.1% versus 2.1%; HR 2.08, 95% CI 0.71 to 6.09; P = 0.17). In the subgroup of low-risk patients (IA/B and grade 1/2), EBRT increased the risk of endometrial carcinoma-related deaths (including treatment-related deaths) (two trials, 517 women; RR 2.64, 95% CI 1.05 to 6.66) but there was a lack of data on overall survival. We considered the evidence for the low-risk subgroup to be of a low quality.EBRT was associated with significantly increased severe acute toxicity (two trials, 1328 patients, RR 4.68, 95% CI 1.35 to 16.16), increased severe late toxicity (six trials, 3501 women; RR 2.58, 95% CI 1.61 to 4.11) and significant reductions in quality of life scores and rectal and bladder function more than 10 years after randomisation (one trial, 351 women) compared with no EBRT.One trial of VBT versus no additional treatment in women with low-risk lesions reported a non-significant reduction in locoregional recurrence in the VBT group compared with the no additional treatment group (RR 0.39, (95% CI 0.14 to 1.09). There were no significant differences in survival outcomes in this trial. EBRT reduces the risk of locoregional recurrence but has no significant impact on cancer-related deaths or overall survival. It is associated with significant morbidity and a reduction in quality of life. There is no demonstrable survival advantage from adjuvant EBRT for high-risk stage I endometrial cancer, however, the meta-analyses of this subgroup were underpowered and also included high-intermediate risk women, therefore we cannot exclude a small benefit in the high-risk subgroup. EBRT may have an adverse effect on endometrial cancer survival when used to treat uncomplicated low-risk (IA/B grade 1/2) endometrial cancer. For the intermediate to high-intermediate risk group, VBT alone appears to be adequate in ensuring vaginal control compared to EBRT. Further research is needed to guide practice for lesions that are truly high risk. In addition, the definitions of risk should be standardised.

Physician and patient factors influencing management recommendations in stage I testicular seminoma: A survey among radiation oncologists in the United States.

225 Background: Post-orchiectomy adjuvant radiotherapy (RT) for stage I seminoma is associated with long-term toxicity, and management strategies with a lower treatment burden achieve the same excellent cure rate. Because studies suggest that radiation oncologists in the United States (U.S.) continue to recommend RT for these patients, we sought to identify factors associated with management recommendations. Methods: We conducted a one-time internet-based survey among 578 randomly selected U.S. radiation oncologists specialized in genitourinary oncology. Results: Response rate was 45% (n = 261). Forty-nine percent of respondents worked in university-affiliated practices. Sixty-two percent of respondents always/usually recommended adjuvant RT for stage I seminoma patients, whereas 21% always/usually recommended surveillance and 3% always/usually recommended chemotherapy. One-third (33%) expressed concerns that patients who relapsed during surveillance could not be salvaged, and 97% recommended against surveillance if they felt a patient was unreliable for regular follow-up. Although 88% of physicians were aware of a risk of second malignant neoplasms (SMN) after adjuvant RT, 85% underestimated the magnitude of this risk. Only 20% of physicians were aware of a possible association between sub-diaphragmatic RT and an increased risk of cardiovascular disease. Compared to physicians not typically recommending RT, physicians who always/usually recommended RT were more likely to believe that patients may not be salvaged at relapse during surveillance (p = 0.008) and were less aware of the association between RT and SMN (p = 0.04). Conclusions: Respondents who always/usually recommend post-orchiectomy RT for stage I seminoma patients are more likely to underestimate late RT morbidity and to believe surveillance is associated with increased mortality. Given the equivalent efficacy and reduced morbidity of surveillance compared to RT, our findings underscore the need for ongoing physician education to increase appropriate clinical implementation of surveillance strategies. No significant financial relationships to disclose.

Long-term results of adjuvant radiotherapy in stage I endometrial cancer

Two hundred sixty-three patients with stage I endometrial adenocarcinoma, who were treated with postoperative radiotherapy between 1978 and 1998, were analyzed retrospectively. According to the 1988-FIGO staging system, the disease was stage IA in 19, stage IB in 128, and stage IC in 116 patients. One hundred and ninety-seven patients were treated with external and intracavitary irradiation, 45 patients with external radiotherapy and 21 patients with vaginal brachytherapy.

Palliation of dysphagia with radiotherapy for exophytic base tongue metastases in a case of renal cell carcinoma

Base tongue involvement is a rare presentation of lingual metastases from renal cell carcinoma. A 48-year-old gentleman was treated with open radical nephrectomy and adjuvant radiotherapy for Stage II Furhman grade I clear cell carcinoma of the left kidney at an outside hospital. He presented metachronously 5 years later with progressive dysphagia and change of voice. Clinicoradiological evaluation revealed a large exophytic mass in the oropharynx with epicenter in the right base of tongue. Metastatic workup revealed widespread dissemination to multiple organs and bone. In view of predominant symptom of dysphagia, base tongue metastasis was treated with protracted course of palliative radiotherapy to a dose of 50 Gy in conventional fractionation over 5 weeks. This resulted in excellent and durable response at the base tongue lesion (till the time of last follow-up). Radiation therapy is an acceptable palliative strategy for advanced lingual metastasis as it produces prompt relief of pain, bleeding, and dysphagia.

What is the value of routine follow-up in stage I seminoma after paraaortic radiotherapy?

Routine posttreatment surveillance is recommended after adjuvant radiotherapy for stage I seminoma. However, systematic studies on the value of follow-up in these patients are missing. This report addresses the efficiency of routine follow-up in stage I seminoma with particular reference to the mode of detection of relapse and the costs of posttreatment screening. All follow-up investigations of a prospectively followed cohort of 675 patients with stage I seminoma treated with PA radiotherapy were analyzed with respect to the first indications of relapse, patterns of recurrence, risk factors of relapse, and cost-efficiency of the different technical examinations of the follow-up schedule over a 10-year period. With a median time to follow-up of 61 months, recurrence was diagnosed by symptoms or physical examination in 14 out of 26 relapsing patients. Among the technical follow-up investigations abdominopelvic imaging had the highest detection rate for relapse, while thoracic imaging and marker analysis were inefficient. Abdominal sonography had the highest cost-efficiency of all technical follow-up investigations, while computed tomography (CT) scans were responsible for approximately 60% of all costs. The authors failed to identify risk factors predictive of relapse after adjuvant irradiation. Routine technical investigations during follow-up after PA radiotherapy for stage I seminoma yield only a low detection rate of relapse from cancer. The data presented here provide no evidence for the value of technical follow-up beyond the 3rd year after treatment or routine screening of the chest. Thorough physical examination of the patients should be encouraged. Patients should be informed about potential symptoms indicative of recurrence. Restrictive use of abdominopelvic CT scans will reduce exposure to ionizing radiation and considerably increase the cost-efficiency of follow-up.

Increased Human Chorionic Gonadotropin Due to Hypogonadism after Treatment of a Testicular Seminoma

Alfa-fetoprotein (AFP) and serum human chorionic gonadotropin (hCG) are reliable markers of testicular cancer, and treatment of a relapse is often initiated on the basis of marker increase alone. Slightly increased hCG concentrations have occasionally been misinterpreted to indicate a relapse, leading to inappropriate chemotherapy (1). We describe a seminoma patient in whom a relapse was suspected 10 years after therapy because the patient had increased hCG concentrations found to be caused by hypogonadism-induced pituitary hCG secretion. A 27-year-old man underwent left radical orchiectomy and adjuvant radiotherapy for stage I testicular seminoma in the early 1990s at Helsinki University Central Hospital. The patient had a preoperative serum hCG of 0.5 IU/L (upper reference limit 0.7 IU/L) and AFP <1 IU/L (upper reference limit 9 IU/L). Atrophy of the nonmalignant testicle was suspected on the basis of preoperative ultrasound findings, but the serum testosterone concentration, 10.2 nmol/L, was within the reference interval (10–38 nmol/L), whereas follicle-stimulating hormone (FSH) concentration was increased, at 28 …

Genetic counselling following paternal therapeutic irradiation

We discuss a patient who received adjuvant radiotherapy for stage I seminoma. He was advised to avoid conception for 6 months following treatment. However, his partner became pregnant only shortly after he completed his radiotherapy (i.e. with sperm that had been irradiated). We estimated the dose received by the remaining testis as 30 cGy. Here, we review the information available to advise patients on the risks to the fetus from paternal preconception irradiation. For the population, a doubling dose for hereditary effects of 1 Gy has recently been reaffirmed (United Nations Scientific Committee on the Effects of Atomic Radiation 2001). However, a range of animal studies suggest conception with postmeiotic sperm carries a greater risk of genetic damage than conception with sperm derived from irradiated stem cells. We have attempted to quantify the risks in this particular case. Lead shielding of the testes may reduce radiation received from the primary beam, but internal scatter still produces a risk. In male patients who are potentially fertile, the best advice remains to delay conception after radiotherapy for as long as 6 months. Our case illustrates the need to reinforce such advice.

Adjuvant radiotherapy in stage I seminoma: Is there a role for further reduction of treatment volume?

An analysis was performed to determine whether a cranial reduction of the portals to the T11/T12 junction instead of the common T10/T11 junction would alter the outcome of patients with stage I seminoma. Of 163 consecutive patients with newly diagnosed testicular seminoma referred to the authors’ institution between April 1992 and April 1999, 80 patients with stage I seminoma were treated with cranially reduced para-aortic treatment fields reaching from the top of T12 to the bottom of L4. Median total dose was 20.0 Gy (range, 19.8–27.2 Gy). Patients were followed-up by the use of CT in regular intervals. After a median follow-up of 7.1 years (range, 4.1–11.1 years), four patients (5%) had relapsed resulting in an actuarial 5-year relapse-free survival of 95%. No patients relapsed within the cranially reduced treatment volume above the top of T12. The cranial reduction of the para-aortic treatment fields resulted in a median reduction of treatment volume of 16% (range, 13–21%). The achieved median reduction in treatment volume of 16% appears to be relevant and is not associated with an increased relapse rate. This approach is recommended in analogy to the surgical approach in NSGCT to further minimize the risk of radiation-related late effects.