Cent 5-year Survival Research Articles

Patients' preferences for treatment after neoadjuvant chemoradiotherapy for oesophageal cancer.

After neoadjuvant chemoradiotherapy (nCRT) plus surgery for oesophageal cancer, 29 per cent of patients have a pathologically complete response in the resection specimen. Active surveillance after nCRT (instead of standard oesophagectomy) may improve health-related quality of life (HRQoL), but patients need to undergo frequent diagnostic tests and it is unknown whether survival is worse than that after standard oesophagectomy. Factors that influence patients' preferences, and trade-offs that patients are willing to make in their choice between surgery and active surveillance were investigated here. A prospective discrete-choice experiment was conducted. Patients with oesophageal cancer completed questionnaires 4-6 weeks after nCRT, before surgery. Patients' preferences were quantified using scenarios based on five aspects: 5-year overall survival, short-term HRQoL, long-term HRQoL, the risk that oesophagectomy is still necessary, and the frequency of clinical examinations using endoscopy and PET-CT. Panel latent class analysis was used. Some 100 of 104 patients (96·2 per cent) responded. All aspects, except the frequency of clinical examinations, influenced patients' preferences. Five-year overall survival, the chance that oesophagectomy is still necessary and long-term HRQoL were the most important attributes. On average, based on calculation of the indifference point between standard surgery and active surveillance, patients were willing to trade off 16 per cent 5-year overall survival to reduce the risk that oesophagectomy is necessary from 100 per cent (standard surgery) to 35 per cent (active surveillance). Patients are willing to trade off substantial 5-year survival to achieve a reduction in the risk that oesophagectomy is necessary.

Solid Pseudopapillary Tumors of the Pancreas: Case Presentation and Review of the Literature

Solid-pseudopapillary tumors of the pancreas are a rare pancreatic neoplasm that carries a 95 per cent 5-year survival rate. However, despite the excellent overall prognosis, aggressive variants been described that likely represent malignant degeneration in an otherwise indolent tumor. Therefore, surgical resection is indicated in all instances. We report a case in a young Hispanic woman, including appropriate work-up and operative intervention.

Isolated limb perfusion with melphalan in the treatment of malignant melanoma.

Seventy patients with invasive malignant melanoma confined to one limb were treated by isolated perfusion with 1-phenylalanine-dihydrochloride (melphalan) and regional lymphadenectomy between 1959 and 1979. Five patients were perfused twice. This treatment did not modify the results of appropriate local excision in early melanoma. Twenty-one patients with stage I disease have had 76 per cent 5-year survival. Forty-eight per cent of 29 patients with extensive local recurrent tumour showed marked tumour regression. Nine of these had subsequent local recurrence with a mean remission of 7 months. Survival in those who responded was 2 years longer than in those who did not. In 6 patients with slight local recurrence, and 19 patients with regional node metastases, response could not be assessed directly. Their 5-year survival was 52 per cent. There have been no deaths as a result of the procedure and no amputations. Mean postoperative hospital stay was 25 days. We conclude that this technique has a useful place in the palliation of extensive local recurrent melanoma.

Pathology and prognosis of carcinoma of the stomach.

Abstract The pathology and prognosis of 205 patients treated by total or partial gastrectomy for carcinoma of the stomach during the years 1951-5 have been evaluated. One hundred and sixteen patients (61 per cent) had a partial gastrectomy and 74 (39 per cent) had a total gastrectomy. The overall postoperative mortality was 25 per cent and this was greater for total than for partial gastrectomy. The crude survival rate was 19.4 per cent at 5 years and 11.4 per cent at 10 years. Carcinoma of the cardia had a worse prognosis than tumours at other sites. There were no 5-year survivors among patients with the linitis plastica type of carcinoma of the stomach. Tumours classified as poorly differentiated or anaplastic carcinoma had a poorer prognosis than well-differentiated adenocarcinomas. The amount of lymphocytic and plasma-cell infiltration of the tumour has a very significant effect on prognosis. Five out of the 7 patients with a heavy infiltrate of such cells survived over 5 years. Lymph-node involvement is the feature having the greatest influence on prognosis. There was a 40 per cent 5-year survival rate in the absence of node involvement and an 11 per cent 5-year survival rate with involved nodes. Patients with involved nodes surviving over 5 years had, on the average, fewer positive glands than those with involved nodes who survived for less than 5 years. No benefit follows from total rather than partial gastrectomy provided the cancer and regional lymph-nodes can be removed with the simpler procedure. Four case reports are presented to illustrate the difficulties in assessing the prognosis of gastric cancer.

Survival after hepatic resection for malignant tumours.

A retrospective analysis of 194 patients who underwent hepatic resection for primary or metastatic malignant disease from January 1962 to December 1988 was undertaken to determine variables that might aid the selection of patients for hepatic resection. Hepatic metastases were the indication for resection in 126 patients. The 5-year survival rate was 17 per cent. For patients with resected metastases from colorectal cancer (n = 104), the survival rate at 5 years was 18 per cent. The 5-year survival rate was 27 per cent when the resection margin was > 5 mm compared with 9 per cent when the margin was < or = 5 mm (P < 0.01). No patient with extrahepatic invasion, lymphatic spread, involvement of the resection margin or gross residual disease survived to 5 years, compared with a 23 per cent 5-year survival rate for patients undergoing curative resection (P < 0.02). The survival rate of patients with poorly differentiated primary tumours was nil at 3 years compared with a 20 per cent 5-year survival rate for patients with well or moderately differentiated tumours (P not significant). The site and Dukes' classification of the primary tumour, the sex and preoperative carcinoembryonic antigen level of the patient, and the number and size of hepatic metastases did not affect the prognosis. The 5-year survival rate for patients with hepatocellular carcinoma (n = 42) was 25 per cent. An improved survival rate was found for patients whose alpha-fetoprotein level was normal (37 per cent at 5 years) compared with those having a raised level (nil at 3 years) (P < 0.01). Involvement of the resection margin, extrahepatic spread and spread to regional lymph nodes were associated with an 8 per cent 5-year survival rate versus 44 per cent for curative resection (P < 0.005). The presence of cirrhosis, the presence of symptoms, and the multiplicity and size of the tumour did not affect the prognosis. The 5-year survival rate of 11 patients with hepatic sarcoma was 25 per cent. No patient with peripheral cholangiocarcinoma survived to 1 year in contrast to patients with hilar cholangiocarcinoma, all four of whom survived for more than 14 months.

Non-radical therapy for early gastric cancer.

To assess the potential benefit of R2 gastrectomy for patients with early gastric cancer, complications and long-term survival of patients who underwent conventional resection with limited lymphadenectomy (R1 gastrectomy) were analysed retrospectively. Resection margins of all 46 consecutive patients were free from tumour. Tumours were limited to the mucosa in 35 patients and infiltrated the submucosa in 11. Positive lymph nodes were found in two patients. The 30-day mortality was two patients, and cardiac and pulmonary complications occurred in five and six respectively. Anastomotic leakage developed in two patients. During 5 years of follow-up two patients died from tumour recurrence; one of these had lymph node metastases at the initial resection. Resection with limited lymphadenectomy for early gastric cancer results in a 91 per cent 5-year survival rate without the need for R2 gastrectomy with its probably higher morbidity and mortality.

Obstacles to organ donation.

Attitudes towards transplantation were investigated in national surveys of the general public (n = 1471), the medical profession (n = 590) and key clinical staff in units referring potential organ donors (n = 380). A clear majority of doctors would like to see more transplants. Only 16 per cent of doctors opposed them on cost grounds, and a 50 per cent 5-year survival rate is seen as more than adequate clinical justification. However, doctors are less supportive of liver and heart grafts than of kidney and cornea grafts. Few lay people would refuse donation of specific organs, but 30 per cent worry that doctors might be pressured into removal of organs when they are not sure the patient is dead. Religious or moral objection is rare. Intensive care unit staff felt the most important factor restricting organ harvest in their own units was dislike of adding to relatives' distress, followed by lack of training in approaching relatives and adverse media publicity. Only 11 per cent thought reservations on brain stem death a likely or possible influence. Enhanced public awareness of the need for transplants was seen as the most important means of increasing organ harvest. Required request would be controversial and perhaps impossible to implement. We conclude that the time, effort and expense involved in potential organ donation do not play a substantial part in limiting referral. Neither do reservations about brain stem death. Increased training of staff (both in communication skills and in the professional responsibility to encourage donation) and greater public awareness are seen as the twin foundations of a realistic approach to enhancing referral.

Adenocarcinoma of the Head of the Pancreas: Effects of Surgical and Nonsurgical Therapy on Survival—A Ten-Year Experience

A retrospective analysis of all patients treated for adenocarcinoma of the head of the pancreas from 1989 to 1998 was performed. Excluded were cancers in the body and tail, cystic neoplasms, ampullary tumors, and cancers of the duodenum and bile ducts. One hundred forty-five patients were reviewed, and 43 patients underwent pancreaticoduodenectomy. Data collected included the stage, lymph node status, surgical margins, adjuvant therapies, and survival. Statistical analysis was performed with Cox's Proportional Hazards Analysis and Log-Rank Life Table Analysis. The surgical population had a 21 per cent 3-year survival rate and a 7 per cent operative mortality rate. Median survival was: 1) the resection group versus no resection was 13.5 versus 3.1 months; 2) adjuvant therapy versus no therapy after resection was 16.1 versus 5.1 months; and 3) chemoradiation therapy versus no therapy for unresectable disease was 5.3 versus 1.8 months. The presence of positive surgical margins was found in 33 per cent of the surgical specimens and carried an increased mortality hazard ratio of 3.1. Patients with negative lymph nodes had a 15 per cent 5-year survival, versus 0 per cent with positive nodes. Seventy-three per cent of those resected had a T2 lesion, and 46 per cent of patients presented with metastatic disease. Surgical resection and adjuvant therapy significantly improves survival in patients with adenocarcinoma of the head of the pancreas. All patients who underwent resection as part of their therapy showed extended survival compared with chemoradiation therapy alone. Adjuvant chemoradiation improved survival when compared with surgery alone. Multimodality treatment in carcinoma of the head of the pancreas provides the best treatment option. However, better adjuvant therapies are needed.

Nucleolar organizer regions and prognosis in renal cell carcinoma

The prognostic significance of nucleolar organizer regions (NORs) in renal cell carcinoma (RCC) was evaluated. NORs were quantified in a series of 182 cases of RCC using the silver-colloid method. The cases were staged according to Robson's method (48 stage I, 26 stage II, 33 stage III, 75 stage IV) and mean NOR numbers for each tumour were correlated with survival over a 5-year period. Localized tumours (stages I and II) with low NOR numbers had an almost 100 per cent 5-year survival. Those patients with clinical evidence of metastases at presentation showed a high mortality, although those with low numbers of NORs had a significantly increased disease-free interval. Statistical analysis using the log rank test indicated NORs to be a significant predictor of survival over the whole series (P = 0.0001) and within each of Robson's stages (P = 0.0008 stage I, P = 0.0154 stage II, P = 0.0009 stage III, P = 0.0001 stage IV). Analysis of data using Cox's proportional hazard model showed mean NOR numbers to be independent of stage as a predictor of survival.

Testicular Seminoma: The M. D. Anderson Experience. An Analysis of Pathological and Patient Characteristics, and Treatment Recommendations

We treated 240 patients with testicular seminoma at our institution between January 1960 and December 1982. The over-all 5-year survival free of disease for these patients regardless of stage was 93.6per cent. The 165 patients (69per cent) with stage I disease had a 95.5per cent 5-year survival free of disease that remained constant at 20 years. Stage II cancer was diagnosed clinically in 62 patients (26per cent), while 13 (5per cent) presented with more advanced (stages III and IV) disease. The 5-year survival rate free of disease for all patients with stage II cancer was 85per cent. There were 14 pathological and patient characteristics analyzed, 4 of which were statistically significant. All but 1 of these factors (spermatic cord invasion) was related to tumor volume (stage, palpable mass and hydronephrosis). Based on the data of this retrospective review, the Canadian experience without prophylactic mediastinal irradiation and the development of effective chemotherapy, we recommend radiation therapy without prophylactic mediastinal irradiation for patients with stage I or IIA disease and chemotherapy for patients with stage IIB, III or IV disease. In an attempt to improve our results in the latter patients we recently instituted adjunctive radiotherapy for those with a persistent radiographic mass. Our current guidelines for the staging evaluation and followup of patients with this neoplasm also are discussed.

Prognostic Variables in Patients with Transitional Cell Carcinoma of the Renal Pelvis and Proximal Ureter

Recent technological advances in urological endoscopic surgery of the renal pelvis and proximal ureter via ureteroscopy or percutaneous nephroscopy have made it possible to consider parenchymalsparing procedures in patients with transitional cell carcinoma. To define the role of these procedures in the management of renal pelvic or proximal ureteral transitional cell carcinoma we analyzed retrospectively 31 patients who underwent nephroureterectomy for transitional cell carcinoma of the renal pelvis and/or proximal ureter. High grade upper urinary tract transitional cell carcinoma and a history of metachronous or synchronous bladder transitional cell carcinoma were independent adverse prognostic factors. However, patients with low grade upper urinary tract transitional cell carcinoma and no evidence of a urothelial field change had a 100 per cent 5-year survival rate. It would appear that parenchymal-sparing endoscopic techniques should be regarded with caution in patients with either high grade transitional cell carcinoma of the renal pelvis and proximal ureter or a history of bladder cancer.

Methods of Skeletal Reconstruction Following Resection of Lung Carcinoma Invading the Chest Wall

The 5 per cent of patients with carcinoma of the lung directly invading the chest wall present a challenge for treatment. Complete resection of all tumor, including the chest wall, should be done. Immediate reconstruction to prevent a flail chest ensures a smooth postoperative course. Excellent palliation and a 46 per cent 5-year survival rate can be achieved if there is no spread to mediastinal lymph nodes.

The Adrenal Gland and Renal Cell Carcinoma: Is Ipsilateral Adrenalectomy a Necessary Component of Radical Nephrectomy?

The ipsilateral adrenal gland may be involved by renal cell carcinoma through direct invasion or embolic metastases, and usually it is removed as part of the radical nephrectomy specimen. We reviewed retrospectively 44 patients with stage A and 8 patients with stage B renal cell carcinoma, 25 of whom had undergone ipsilateral adrenalectomy. The 5-year and 9-year survival of these 25 patients was 79 and 65 per cent, respectively, and was not statistically different from the 78 per cent 5-year and 9-year survival of those 27 patients who did not undergo ipsilateral adrenalectomy.These findings suggest that the ipsilateral adrenal gland need not be removed routinely as part of perifascial nephrectomy for renal cell carcinoma. Those patients who are found to have a contralateral adrenal lesion during preoperative evaluation should be spared bilateral adrenalectomy if there is no ipsilateral adrenal gland involvement at exploration. Those patients with lower pole lesions also need not undergo routine ipsilateral adrenalectomy. Preoperative computerized tomography scans will help to select those tumors that can be managed by perifascial nephrectomy with sparing of the ipsilateral adrenal gland.

Carcinoma of the Ureter: Natural History, Management and 5-Year Survival

We reviewed retrospectively 53 new cases of primary ureteral carcinoma. Each patient was staged pathologically and survival by operative procedure was compared. Depth of tumor invasion is the most accurate indicator of over-all outcome. Patients with stage A tumors had an 80 per cent 5-year survival rate, compared to only 33.3 per cent of the patients with stage C lesions. Patients also were divided into 2 groups: group 1 patients had a ureteral lesion only, and group 2 patients had a ureteral tumor and a second primary urothelial lesion. No difference was found in 5-year survival rates for patients in groups 1 (48.3 per cent) and 2 (47.7 per cent). Since prognosis for patients with low stage tumors was not enhanced by an aggressive operation a more conservative approach is indicated.

Bilateral Nephrectomy for Hypertension in Patients With Chronic Renal Failure on A Dialysis Program

During the last 6 years 33 bilateral nephrectomies have been performed for severe hypertension in patients with chronic renal failure on a dialysis program. Nephrectomy resulted in a prompt and sustained reduction in blood pressure, an improved sense of well-being and a gain of weight. Despite the fact that the mean hematocrit decreased from 25 to 18 per cent all patients thrived. The nephrectomy group showed an 85 per cent 5-year cumulative survival rate compared to 55 per cent in the non-nephrectomy group. There was 1 mortality and low morbidity. Simultaneous nephrectomy by 2 teams, using a posterior approach, proved more satisfactory than an anterior or bilateral flank approach. The indications for and arguments against bilateral nephrectomy are discussed.

Prostatic Involvement by Transitional Cell Carcinoma: Pathogenesis, Patterns and Prognosis

Prostatic involvement by transitional cell carcinoma of the bladder includes a spectrum of histologic patterns. Ductal only or ductal and acinar involvement occurs with or without stromal invasion. Stromal invasion may exist without glandular involvement. Invasive prostatic patterns are most frequent in the setting of high stage invasive bladder tumors and 5-year survival rates for these patients are low. Non-invasive in situ prostatic patterns are usually associated with low stage bladder tumors and 5-year survival approaches that predicted from radical cystectomy for low stage bladder tumor alone. When an invasive pattern is associated with a low stage bladder tumor the 5-year survival rate is determined by the prostatic lesion and is low.Although the survival rate is severely jeopardized by stromal prostatic invasion the prognosis is not hopeless. Preoperative radiotherapy followed by cystoprostatourethrectomy can be expected to produce a 20 per cent 5-year survival rate.

Personal experience in the surgical management of carcinoma of the stomach.

A consecutive series of 226 cases of carcinoma of the stomach has been studied. The policy of treatment has been consistent throughout and laparotomy was performed in 96-5 per cent of cases. The follow-up has been studied with regard to duration of symptoms, location and degree of spread of the tumour and different forms of operative treatment. Although Billroth I gastrectomy gave a 32 per cent 5-year survival rate for the less advanced tumours the overall survival remains, as in other series, depressingly low (8-5 per cent). Education of the public to present early would not appear to help the situation as survival was directly proportional to the duration of symptoms.

Carcinoma of the Bile Duct

The aim of surgical treatment is resection for cure but, except in tumors of the distal bile duct, this can be accomplished only rarely. Palliative bypassing or dilatation and intubation are worthwhile for the relief of pruritus and jaundice. There is a 30 per cent 5-year survival rate following pancreaticoduodenectomy for distal lesions.

Management of stage I and II adenocarcinomas of the uterine cervix on intact uterus.

MANAGEMENT OF STAGE I AND II ADENOCARCINOMAS OF THE UTERINE CERVIX ON INTACT UTERUSFELIX N. RUTLEDGE, M.D., AUGUSTO G. GUTIERREZ, M.D. and GILBERT H. FLETCHER, M.D.Audio Available | Share

PRIMARY LYMPHOMA OF THE LUNG: AN APPRAISAL OF ITS NATURAL HISTORY AND A COMPARISON WITH OTHER LOCALIZED LYMPHOMAS

SUMMARY AND CONCLUSIONS 1. Study of the Memorial Sloan-Kettering Cancer Center records and review of the literature revealed 77 cases of lymphosarcoma and 16 cases of reticulum cell sarcoma primary in the lung. Not one case of Hodgkin's disease could be accepted as primary in the lung. 2. The discovery of the disease is preceded by pulmonary symptoms lasting for months or years in about one half of the patients. In about one third of the patients, the disease is discovered on “routine” chest film. 3. The roentgenologic features of the disease are rather protean; they may mimic consolidation, inflammation, or carcinoma. 4. The diagnosis is difficult to make by bronchoscopy or sputum cytologic examinations, probably because bronchial obstruction and ulceration are not common. 5. Surgery and radiation therapy, either alone or in combination, effect a 45.2 per cent 5-year survival rate. 6. Local recurrences are frequent, regardless of the therapeutic modality employed initially. Fatal recurrences usually occur early; on the contrary those occurring late are usually controlled by radiation therapy. 7. Even though radiosensitive, these tumors should be treated initially by operation in view of the likelihood of repeated recurrences and the limited resistance of the lung to radiation. 8. Following adequate resection, “prophylactic” radiation therapy does not seem to be indicated. 9. The prognosis for localized lymphoma of the lung is better than that of the gastrointestinal tract and somewhat worse than that of the head and neck and bone. 10. It is suggested that the difference in survival of localized lymphoma in different regions is related to a variety of factors which lead to earlier diagnosis and therapy in some areas than in others.