American Joint Cancer Committee Research Articles

2123: Primary Small Cell Carcinoma of the Esophagus -A Review of 20-Year Experience From One Institution

To retrospectively analyse the clinical features, treatment and prognosis of primary small cell carcinoma of the esophagus (ESCC) from our one institution within the past 20 years. From May 1985 through June 2005, 131 cases of SCEC were histopathologically diagnosed,accounting 1.2% of all diagnosed esophageal cancer cases of the institution . Pretreatment staging included medical history, physical examination in detail, chest x-ray, barium swallow, and chest and up abdominal CT scan abdominal ultrasound, blood rutin, blood biochemistry analyses including liver and renal function evaluation. Brain MRI and bone ECT scan were performed only in cases with suspected symptoms.118 cases were pathologically proved as ESCC from endoscope or surgical samples and 13 cases were diagnosed by cytology. The stage system of the American Joint Committee of Cancer (sixth Edition) was used. The methods of the Kaplan-Meier and Log-rank test were used for estimations and comparison of the median survival times(MTS)and overall survival rates (OS). The SPSS 10.0 software was adopted to forward analyse the prognostic factors by the model of Cox Regression with a entry probability for stepwise of 0.05 and removal one of 0.10. For all the 131 cases, the median age was 58 years old(33–82), with male-female ratio of 3.5:1. The clinical symptoms, signs as well as radiographs were similar to those of squamous-cell carcinoma of the esophagus. Fifty-three cases only received regional treatments or systematic chemotherapy (S ,R ,C ,S+R),78 cases received combined systematic chemotherapy with regional treatments (S+C, R+C, S+R+C). Through a median follow-up of 13 months(0.3–165months),111 cases had died, 10 cases were alive,10 cases were lost(8%). TNM stage (P=0.000) ,T stage(P=0.026), systematic chemotherapy(P=0.000) and radiotherapy(P=0.021) were identified as independent prognostic factors by multivariate analysis. The treatment results by stages were displayed in table 1. For the all group, the MST (95%CI), 1-year,2-year,3-year and 5-year OS (±S.E.)were 13 months (10–15 months), 51%±4%, 26%±4%,17%±3% and 13%±3%, respectively. The difference in OS between multi-modality therapy and mono-modality therapy were statistically significant(P=0.0004).Tab.1Stage and treatment results of SCECStageNo. of PtsMST (m)3-Year OS(%)I102946IIa202947IIb121633III50117IVa1469IVb2570 Open table in a new tab SCEC is similar to small-cell lung cancer (SCLC) in histopathology and biologic behavior. Systematic chemotherapy combine with local-regional treatments (radiotherapy and/or surgery) are considered as standard care for cases with early stage disease.

Multimodal imaging of esophagus and cardia cancer before and after treatment

Prognosis and treatment of esophagus and cardia cancer (ECC) depend on the precision with which the disease is staged according to the American Joint Committee of Cancer (AJCC) criteria. Imaging modalities normally used in clinical staging are esophagography, esophagoscopy, endoscopic ultrasound (EUS), computed tomography (CT) and positron emission tomography- CT fusion (CT-PET). The combination of these methods is crucial in determining not only the right diagnosis but also the stage and follow-up after multimodal treatment. The purpose of our investigation was to define the role of each imaging modality in determining the most appropriate treatment options in patients with ECC. Fifty-six patients with ECC diagnosed by X-ray of the upper digestive tract, endoscopy and biopsy were staged using EUS, chest and abdomen CT scan, and CT-PET. Thirty-four patients in stage II and 18 patients in stage III underwent surgery after neoadjuvant chemotherapy; four patients in stage IV were treated with the positioning of an endoprosthesis after chemoradiotherapy. In the 52 patients who had surgery, follow-up included digestive tract X-ray, endoscopy and CT of the chest and abdomen every 6-8 months for the first 3 years. CT-PET was only performed in patients with a clinical suspicion of recurrence and/or CT findings suspicious of persistent disease (12 cases). In all 56 patients, endoscopy, EUS, CT and CT-PET in combination were crucial in determining the site of disease, locoregional extent and depth of esophageal wall penetration (T), and any involvement of the mediastinal lymph nodes (N1), extrathoracic lymph nodes (M1) or hepatic metastases. In the locoregional staging of ECC before chemotherapy, we were able to differentiate T2-T3 from T4 in 40 patients; T4 disease was found in 12 potentially resectable cases. We were able to distinguish N0 from N1 in 12 patients. In four cases, the presence of small lymph node and/or liver metastases prompted positioning of an endoprosthesis. The specificity of CT in detecting small lymph nodes in the mediastinum was less than 50% while for CT-PET, it was more than 80%; EUS revealed sensitivity higher than 90% but a low specificity in seven cases. Only CT-PET revealed metastatic subdiaphragmatic lymph nodes (diameter <15 mm) in three cases. Presurgical restaging of the 18 patients (stage III) who had chemotherapy was based on endoscopy, EUS, CT of the chest and abdomen and CT-PET (only in suspected cases) and was compatible with surgery. Anastomotic recurrence was diagnosed in 16 patients by endoscopy with associated biopsy; any intramediastinal spread from anastomotic recurrences was evaluated by chest CT, and CT-PET in suspected cases. X-ray of the upper digestive tract and chest and abdomen CT scan are useful in preliminary evaluation of ECC. Endoscopy is particularly indicated for evaluating tumour morphology, taking biopsies for a histological diagnosis and the early diagnosis of anastomotic recurrences. EUS is indicated mainly for evaluating T stage before and after chemotherapy or chemoradiotherapy. CT-PET is extremely useful in identifying small mediastinal metastatic lymph nodes (N1) or extrathoracic lymph nodes (M1) and hepatic metastases (</=1 cm), which may escape multislice CT. PET alone is useful for identifying residual or recurrent tumour in the esophageal wall when an endoprosthesis is in place.

Morbidity and Cost Differences between Free Flap Reconstruction and Pedicled Flap Reconstruction in Oral and Oropharyngeal Cancer: Matched Control Study

To compare morbidity and cost in patients who underwent primary reconstruction with free tissue transfer with those with pectoralis major myocutaneous flap (PMMF) reconstructions after ablation of oral and oropharyngeal squamous cell carcinoma. Over a 6-year period, 36 patients had PMMF reconstructions and 127 patients had a variety of free flap (FRF) reconstructions after oral and oropharyngeal cancer ablation. Correction for confounding patient and disease variables was performed by matching all PMMF patients to a randomly selected cohort of FRF patients for age, sex, International Union Against Cancer-American Joint Committee on Cancer T category, tumour subsite, and radiotherapy status. This resulted in two groups of 32 patients each, with the flap reconstruction being the only variable. The following outcome variables were analyzed: operative time; blood loss; admission length, including intensive care unit and coronary care unit stay; complications; secondary interventions; readmissions; and feeding status. Cumulative costs of nursing care, hospital supplies and charges, surgeon's fees, and anesthesiologist's fees were calculated. Statistical analysis applied the paired Student's t-test and the chi-square test. Of all morbidity parameters, only operative time was significantly longer for FRF (p < .0001). Analysis of other outcome variables and costs showed no statistically significant differences (p > .05). There is no evidence that morbidity and cost differ between the pedicled flap and free tissue transfer reconstruction strategies, other than lengthier operating room time for FRF.

An improved classification of thin stage I melanomas using AJCC prognostic factors

7512 Background: Thin stage I cutaneous melanomas (≤ 1 mm, T1a and T1b) make up the majority of melanomas in SEER, and were under-represented in the cohort used by the American Joint Cancer Committee (AJCC) to develop the 2001 staging system. We examined prognostic factors to develop a classification for prognosis that could better discriminate among patients than the current AJCC dichotomous classification with 10 year survival of ∼88% for T1a and ∼83% for T1b. Methods: This study includes 27,963 patients diagnosed with thin melanomas between 1988 and 2001 from SEER, a population-based registry including 11 sites together representative of the United States population. A classification tree was developed to identify factors that identified patients at varying risk of melanoma-specific death. Multivariate Cox proportional hazard models were used to identify independent prognostic factors. Results: The overall ten year survival rate was 94.2%. The classification tree analysis identified two factors associated with survival, Clark level and ulceration (see rates in table below). As in the current AJCC staging system, the survival rates for patients with ulcerated melanomas were worse than, or similar to, the rates for non-ulcerated lesions at the next higher stage. In the multivariate survival analysis thickness, level, ulceration, age, sex, and anatomic site were significant independent prognostic factors. Nevertheless, the risk ratios for level and ulceration were significantly higher than those for the other factors. Conclusion: Prognosis differs among patients with thin melanomas and can be better specified than in the current AJCC staging system by using the full range of levels plus ulceration. No significant financial relationships to disclose.

DC therapy for metastatic melanoma.

Metastatic melanoma is a biological state reflecting the failure of the patient's immune system to eradicate residual melanoma cells, thus it defines a state of reduced immunocompetence. The prognosis for patients with locoregional recurrence — Stage III American Joint Cancer Committee (AJCC) is poor, with 60–75% having a 5-year survival following surgery. Of those with distant metastatic disease, the majority (95–98%) die in the same timespan [ 1. South Australian Cancer RegistryEpidermiology of cancer in South Australia. Incidence, mortality and survival 1977–1995. Incidence and Mortality. 1996; : 1995 Google Scholar ]. Conventional surgical therapies, chemotherapy, irradiation, and immunotherapy, have failed to change these outcomes. IL-2 has had therapeutic effects but, like IFN-a and IL-12, causes considerable toxicity. Recent advances in DC immunotherapy produced encouraging results. Several Phase I studies have been reported, and Phase III studies are underway.

E-31. The IASLC staging revision project

Following the last revision of the UICC TNM Staging for Lung Cancer in 1997 the IASLC decided that it should establish an International Committee to continue the work of Dr. Clifton Mountain and to inform future revisions. The committee has met on several occasions since its inaugural meeting in June 1999. The membership of the committee has been finalised (enclosed) to ensure representation of all disciplines treating lung cancer and all geographical regions. From its inception it was emphasised that we should seek to ensure that future revisions should be relevant to non-surgical specialities. We have built strong links with the UICC and those stakeholders who had traditionally been involved in this process, the American Joint Committee for Cancer and the Japan Lung Cancer Society. The UICC has now accepted that our committee will be the primary source of recommendations for the next revision of the TNM System due in 2007. We have established working parties to generate an Internationally agreed definition for “complete resection”, to create an Internationally agreed “Nodal Chart”, and, with our colleagues in the Pathology Section of the IASLC, to establish guidelines on the standards for processing pathological material. We have obtained funding for a S-year period and appointed Dr. John Crowley as our statistician and Cancer Research and Biostatistics (CRAB) in Seattle as the datacentre. Our Data Monitoring Group will be conducting their first site visit in July. We have finalised the dataset and data dictionary and are now actively recruiting data from any unit that can provide retrospective staging data on patients treated by all modalities from 1990 to 2002. We have already overtaken the size of database on which the last revision was based! We need the support of the membership of the IASLC. If you have any data please contact the datacentre directly, myself, or Member/Position Contact Details

Update on the use of sentinel node biopsy in patients with melanoma: who and how.

This review highlights the utility of sentinel lymph node biopsy for melanoma. The histopathologic status of the sentinel lymph node is acknowledged as the most powerful indicator of prognosis. Changes by the American Joint Committee for Cancer have not only incorporated the importance of ulceration in cutaneous melanoma, but have focused on the number of metastatic lymph nodes as well as whether the disease is macro- or micrometastatic. Specific technical aspects of the sentinel lymph node procedure are discussed, with emphasis on practical guidelines to minimize incorrect nodal staging.

T4 rectal cancer treated with preoperative chemoradiation to the posterior pelvis followed by multivisceral resection: patterns of failure and limitations of treatment

Purpose: To analyze the overall pattern of treatment failure and sites of pelvic disease recurrence relative to the radiation fields used in treating patients with clinically staged T4 rectal cancer with preoperative chemoradiation followed by multivisceral resection. Methods and Materials: Between 1990 and 1998, 45 patients with T4 rectal cancer were treated with preoperative chemoradiation. Clinical staging was according to the system of the American Joint Cancer Committee and was based on endoscopic ultrasonography, chemotherapy (CT), and physical examination. A diagnosis of T4 disease required evidence of invasion of a contiguous structure on CT ( n = 31) or endorectal ultrasonography ( n = 6), vaginal mucosal involvement on pelvic examination ( n = 6), or a combination of these findings ( n = 2). Chemoradiation was delivered with 18 MV photons using a 3-field belly-board technique. The median total dose was 45 Gy in all patients (range 45–63). Nine patients received a boost with external beam radiotherapy (EBRT) ( n = 5, 1.8–18 Gy), intraoperative RT ( n = 3, 10–20 Gy), or interstitial brachytherapy ( n = 1, 20 Gy). All patients received concurrent chemotherapy consisting of protracted venous infusion 5-fluorouracil (300 mg/m 2, 5 d/wk). Resection was not performed in 13 (29%) of the 45 patients because of metastases detected before resection or patient refusal. Multivisceral resection and pelvic exenteration was required in 21 (66%) and 11 (34%) of 32 patients, respectively. We compared the location of pelvic disease recurrence with the RT simulation films. The Kaplan–Meier method was used to calculate the 4-year actuarial pelvic and distant recurrent rates and the overall survival rate. Results: The median length of follow-up was 31.0 months for all patients and 40.0 months for patients alive at last follow-up. When only the resected cases were considered, the local recurrence rate was 20%. Distant metastases occurred in 44% of cases; the overall survival rate was 69%. When all patients were considered, the local recurrence rate was similar (24%), but the rate of distant recurrence (51%) was higher and the overall survival rate lower (50%). Pelvic disease was controlled in all 8 patients whose disease responded well to chemoradiation (either a histologically complete response or microscopic residual disease). Three of 4 patients with close or positive margins had pelvic recurrences despite intraoperative RT and brachytherapy. Nine of the 10 pelvic recurrences occurred in the radiation field. Elective external iliac nodal irradiation was not used, and nodal metastases were not seen in that region. In 1 case, marginal recurrence occurred in a common iliac node at the superior edge of the treatment field. Conclusions: Despite aggressive multimodality therapy including multivisceral resection, a high rate of pelvic and distant disease recurrence occurred in patients with clinically staged T4 disease. Regional disease recurred almost exclusively in the radiation field. The intraoperative RT and interstitial brachytherapy doses used did not prevent pelvic disease recurrence in patients with close or positive margins. Novel strategies such as higher preoperative doses of RT with or without altered fractionation or more effective radiosensitizers are needed to improve locoregional control in patients with T4 disease. Future strategies must also include more effective systemic therapy.

Sentinel node localization: do or dye alone?

The sentinel node concept is a revolutionary advance in cancer staging and has led to a flurry of research; the second biennial International Sentinel Node Conference has just been held. Sentinel node theory states that the sentinel node (or nodes) is the first lymph node to receive drainage from a tumour, having direct lymphatic connection with the tumour site. Histological scrutiny of such a node will determine whether metastasis to regional lymph node has occurred. The term was first coined by Cabanas in 1977 [1] in the context of penile carcinoma, but gained widespread interest in 1992 when Morton et al [2] applied the technique to patients with intermediate thickness malignant melanoma. The potential lies in those cancers where surgical excision of the tumour and regional draining lymph nodes are curative for early stage disease. However, elective regional nodal clearance (ELND) benefits only the minority of patients in this group who actually have occult regional lymph node metastases, and the technique itself has significant morbidity. Sentinel node biopsy (SNB) aims to improve management by targeting ELND to only those patients who will benefit from it. Interest has focused on malignant melanoma and breast carcinoma, but feasibility studies have been performed in vulval, cervical, head and neck, colorectal and gastric carcinoma. For the theory to apply, metastases should progress in a stepwise manner to the sentinel node first, rather than to nodes randomly, and this is thought to be true in melanoma where the incidence of skip metastases is less than 1% [2]. State-of-the-art technique requires sentinel node imaging and is a good example of a new application of ‘‘old’’ technology. In a modification of the lymphoscintigraphic techniques developed in the late 1970s, radiolabelled colloids (Tc nanocolloid in the UK) are injected in or around the tumour site, and drainage patterns and sentinel nodes are visualized with a gamma camera. The nodes are then marked on the skin surface and in theatre the surgeon uses patent blue dye to identify lymphatic tracks and sentinel nodes, guided by a hand-held gamma probe. Excised sentinel nodes are then sent for histological analysis and subsequent ELND is only performed on those whose sentinel nodes contain metastases. Good communication between radionuclide radiologist/physician, surgeon and histologist is essential. Do patients benefit? We do not have the full answer yet, but we are closest to it in melanoma. It has been fiercely debated whether patients with tumours of Breslow thickness 1–4 mm, of whom 20% will have occult nodal metastases, should have wide local excision (WLE) alone or ELND. A large multicentre trial (the American Intergroup Melanoma study) of WLE plus ELND vs WLE alone demonstrated significant survival benefit from WLE plus ELND in patients below 60 years, which was greatest for non-ulcerated melanomas 1–2 mm thick [3]. A similar World Health Organisation (WHO) trial of truncal melanomas 1.5–4 mm thick demonstrated significantly better 5-year survival rates in patients with nodal metastases at ELND compared with WLE alone (48.2% vs 26.6%) [4]. When lymphatic mapping and SNB are used to identify and stage nodal basins, those with negative sentinel nodes have a significantly better disease-free 3-year survival than those whose nodes are positive (88.5% vs 55.8%) [5]. With most centres reproducing high technical success rates in retrieving sentinel nodes, SNB is now a recognized staging procedure and the American Joint Committee for Cancer has revised its staging system for melanoma to include sentinel node status. The imminent results of the Multicenter Selective Lymphadenectomy Trial should tell us whether SNB prolongs 5-year survival. Whilst that trial’s co-ordinators wish to wait before declaring SNB the standard of care for early melanoma, the WHO has already done so [6]. In the USA, ELND has been the standard of care, despite it being unnecessary in about 80% of cases. If SNB is introduced to decide who are the 20% of patients who need to go on to ELND, the projected healthcare savings to the USA are $172 million per year [7]. In the UK, where the standard of care has been WLE and ‘‘watchful waiting’’, the sentinel node procedure costs the Received 29 January 2001 and accepted 22 February 2001. The British Journal of Radiology, 74 (2001), 475–477 E 2001 The British Institute of Radiology

Synovial sarcoma: a clinicopathologic, staging, and prognostic assessment.

Synovial sarcoma (SS) is a common soft tissue sarcoma (STS) with a propensity for young adults and notable sensitivity to chemotherapy (CT). This study provides a current clinicopathologic, staging, and prognostic assessment for SS. The problems with the current American Joint Committee for Cancer (AJCC) Staging System in relation to SS are discussed. Review of a prospective database supplemented by retrospective data. One hundred fifty patients were assessed; median age was 30 years and median follow-up was 52 months. Overall actuarial 5-year survival rate was 57%. Size trend, but not a cutoff of less than 5 cm versus > or = 5 cm, was a prognostic indicator (P <.001). The current AJCC/International Union Against Cancer Staging System differentiated prognosis less well than the recently proposed Royal Marsden Hospital Staging System. Age greater than 20 years at diagnosis implied worse prognosis. A local recurrence event was associated with a worse survival (P <.001). Therapeutic CT was administered to 55 patients. Eleven of 19 patients had an objective response to a combination of ifosfamide and doxorubicin. Four cases had complete response after CT. Twenty-one patients had pulmonary metastasectomy, with an actuarial 5-year survival rate of 23%. SS tends to affect young people. In this subtype of STS, size trend is the most significant influence on stage and hence survival; however, smaller SSs have an unexpectedly poor prognosis. Adequate local control may affect survival. SS is often chemosensitive, and given its poor prognosis, multicenter trials of adjuvant therapy are warranted.

Long-term disease-free survivors in metastatic undifferentiated carcinoma of nasopharyngeal type.

To review incidence and analyze profile of long-term complete responders among patients with undifferentiated carcinoma of nasopharyngeal type (UCNT) treated at a single institution. We present a cohort of 20 long-term unmaintained complete responders to chemotherapy for metastatic UCNT treated at the Institut Gustave Roussy between April 1978 and November 1996. A patient was considered a long-term survivor if he or she was disease-free for more than 36 months without treatment after obtaining a complete response by chemotherapy. Patient characteristics were as follows: sex, 17 men and three women; median age, 28 years (range, 9 to 62 years); median World Health Organization performance status, 1; and initial tumor-node-metastasis stage (International Union Against Cancer-American Joint Committee on Cancer, 1987) of T3 to T4, 60%, and of N2b to N3, 75%. Epstein-Barr virus serology was characteristic in 19 patients. Of 16 pretreated patients, 11 were pretreated by radiotherapy alone and five by chemotherapy and radiotherapy. Thirteen patients had metastatic relapses of locally controlled UCNT. Tumor sites were bone in 15 patients, lung in four, and liver (biopsy-proven) in two. Chemotherapy included the following: cisplatin, bleomycin, and fluorouracil in five patients; bleomycin, epirubicin, and cisplatin in seven patients; fluorouracil, mitomycin, epirubicin, and cisplatin in four patients; and fluorouracil, bleomycin, epirubicin, and cisplatin in one patient. Three patients were treated with platinum-based regimens before 1985. Patients received a median of six cycles (range, three to 13). Thirteen patients with bone metastases received consolidating radiotherapy. As of June 1999, 14 of 20 patients were still alive with no evidence of disease after treatment (disease-free survival time, 82+ to 190+ months), three patients died of other causes while in complete response at 61, 109, and 208 months after treatment, and three patients died of disease at 42, 89, and 115 months after treatment. Long-term complete responses were obtained in both bone and visceral disease. Our data support a curative role for chemotherapy in metastatic UCNT and are a major incentive to continue research for better combinations to increase the percentage of patients with metastatic UCNT who attain complete responses and long-term survival.

Stage I renal cell carcinoma. A clinicopathologic study of 82 cases.

Stage has been established as the most important predictor of prognosis in renal cell carcinoma. The predictive value of other morphologic features is less well established. Therefore, in this study we assessed morphologic parameters in 82 Robson stage I renal cell carcinomas. Insufficient numbers of T1 lesions were present in this series to permit a confident comparison of Robson staging with the Union Internationale Contre le Cancer-American Joint Committee on Cancer TNM (tumor, node, metastasis) staging. Morphologic parameters--including size, character of cytoplasm, nuclear grade, and pelvic invasion--were studied. Both univariate survival analysis and multivariate or tree-structured survival analysis (TSSA) were employed, with disease-free survival and actuarial survival as end points. Nuclear grade was the most important predictor of prognosis in stage I neoplasms by TSSA. Nuclear grade greater than 2 correlated with significantly shorter survival (p = 0.018). Stage I tumors measuring less than 5.0 cm by survival analysis (or 6.0 cm by TSSA) were associated with improved disease-free survival (p = 0.040), although TSSA indicated that the effect was pronounced only in low-grade neoplasms. The character of cell cytoplasm was not independent of nuclear grade (Kruskal-Wallis test, p = 0.028). The contingency table indicated disproportionate numbers of grade 4 mixed cell tumors, grade 3 granular cell tumors, and low-grade clear cell tumors. By TSSA, younger patients with low-grade but larger tumors had a poor clinical outcome. Elderly patients with high-grade tumors had the worst overall survival. None of the other clinical parameters or architectural pattern correlated with survival or disease-free survival. When nuclear grade was combined with tumor size and age at diagnosis in a decision tree, patients with stage I neoplasms were separated into favorable, intermediate, and poor prognosis groups.

Neoadjuvant chemotherapy consisting of cisplatin and continuous infusions of bleomycin and 5-fluorouracil for advanced head and neck cancer. The need for a new stratification for stage IV (MO) disease

A Phase II study of cisplatin (100 mg/m2 on day 1) and bleomycin (15 mg intravenous push day 1) followed by 5 days of continuous intravenous infusions of 5-fluorouracil (5-FU) (650 mg/m2/d) and bleomycin (16 mg/m2/d) repeated at 21-day intervals was performed in 54 previously untreated patients with nonmetastatic (M0), locoregionally advanced head and neck squamous cell carcinoma (SCC). The aim of this study was to increase the complete response rate to chemotherapy and to identify prognostic factors that may influence local control and disease-free survival. From April 1986 until August 1988, 5 patients with Stage III and 49 with Stage IV (International Union Against Cancer-American Joint Committee on Cancer 1986 [UICC-AJCC]) disease received this regimen. Thirty (61%) patients with Stage IV disease had bulky nodal disease (9 N2c and 21 N3) and 29 (53%) had T4 primary lesions. The response rate was 59% (95% confidence interval, 47% to 71%) and the complete response rate to chemotherapy was 13% (95% confidence interval, 0% to 26%). The response rate was greatly influenced by tumoral volume and performance status (PS). The complete response rate to chemotherapy was 40% for patients with Stage III disease (2 of 5 patients) versus 10% for patients with Stage IV disease (5 of 49 patients; P = 0.02). The response rate for patients with Stage III disease was 100% (5 of 5 patients) versus 55% for patients with Stage IV disease (27 of 49 patients; P = 0.14). For patients with Stage IV bulky nodal disease (N2c-N3), the response rate was 43% (13 of 30 patients) and the complete response rate to chemotherapy was 3% (1 of 30 patients) versus 68% (13 of 19 patients; P = 0.13) and 21% (4 of 19 patients; P = 0.07), respectively, for patients with Stage IV less than N2b disease. The local control rate after definitive therapy was 100% for patients with Stage III disease, 70% (17 of 24 patients) for patients with Stage IV less than N2b disease, and 17% (5 of 30 patients) for patients with bulky nodal disease (P = 0.0005). As of February 1991, with a median follow-up time of 38 months (range, 30 to 53 months), 4 of 5 patients with Stage III disease and 7 of 19 patients with Stage IV less than N2b disease were alive with no evidence of disease (37%) versus 0 of 30 patients with bulky nodal disease (P = 0.001).(ABSTRACT TRUNCATED AT 400 WORDS)

High Complete Response in Advanced Nasopharyngeal Carcinoma With Bleomycin, Epirubicin, and Cisplatin Before Radiotherapy

Undifferentiated carcinoma of nasopharyngeal type (UCNT) is a geographically endemic, Epstein-Barr virus-related carcinoma of epidermoid origin with reported 5-year survival rates of 15%-40% when treated with radiotherapy alone. Although UCNT can be well controlled locally by radiation therapy, in advanced nodal stage N3 [International Union Against Cancer-American Joint Committee on Cancer (UICC-AJCC, 1987)] the survival rate is below 20%, primarily because of metastatic spread in 80% of the fatalities. We report a pilot study of 41 patients with nonmetastatic, locoregionally advanced disease (85% of the patients had a nodal status greater than or equal to N2C-N3; 43% had T4 primaries), during which we used a combination of 100 mg of cisplatin/m2 on day 1, 15 mg of bleomycin by intravenous push and 12 mg/m2 by continuous infusion on days 1-5, and 70 mg of epirubicin/m2 on day 1 every 21 days for three cycles before definitive radiation therapy with 70 Gy for 7 weeks. Twenty-seven of 41 patients (66%; 95% confidence interval = 52.5%-80.5%) achieved a clinical complete response, and 40 of 41 (98%) had a major objective response after chemotherapy. Two deaths were treatment related, but side effects were moderate, and the overall treatment sequence was feasible. At the end of radiation therapy, all 39 assessable patients were in complete response, with a median follow-up of 21+ months (greater than 10-greater than 31); 33 (80%) patients had no evidence of disease. We believe that such a complete response rate in a high-volume disease with the use of combined modality treatment indicates a therapeutic gain in UCNT. Researchers performing a multicenter international controlled trial will test this hypothesis and compare local control, disease-free, and overall survival of the therapeutic sequence presented here with radiotherapy alone.

Clinical staging system for carcinoma of the oral cavity.

CA: A Cancer Journal for CliniciansVolume 18, Issue 3 p. 163-166 ArticleFree Access Clinical staging system for carcinoma of the oral cavity† First published: May/June 1968 https://doi.org/10.3322/canjclin.18.3.163 † Adapted from a publication of the AMERICAN JOINT COMMITTEE FOR CANCER STAGING AND END RESULTS REPORTING, February 1967. AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Volume18, Issue3May/June 1968Pages 163-166 RelatedInformation