Crude 5-year Survival Rate Research Articles

Effects of Chlorambucil and Therapeutic Decision in Initial Forms of Chronic Lymphocytic Leukemia (Stage A): Results of a Randomized Clinical Trial on 612 Patients

In 1980, the French Cooperative Group on Chronic Lymphocytic Leukemia started a randomized clinical trial in which 612 good prognosis patients (stage A) received either no treatment (309 patients) or an indefinite course of chlorambucil at the daily dose of 0.1 mg/kg (303 patients). Overall survival appeared to be better in the untreated group (50 deceased patients compared with 62 in the chlorambucil group), but the difference was not significant (P = .21) even after adjusting for both prognostic and imbalanced factors (P = .09). The crude 5-year survival rates were 82% in the untreated group and 75% in the chlorambucil group. The action of chlorambucil appeared to be a complex phenomenon associating beneficial effects consisting in slowing down disease progression to stage B or C (P less than .01), and favoring disease remission with harmful effects given by a short survival after disease progression to stage B or C in the chlorambucil group and an increased incidence of epithelial cancers (33 v 19), as well as an excess of epithelial cancer deaths (13 v 3), in the chlorambucil group. As these results suggested an overall harmful effect of chlorambucil, we tried to define, within stage A patients, a group of patients with a low probability of disease progression. We showed that stage A patients with hemoglobin greater than or equal to 120 g/L and lymphocyte count less than 30 x 10(9)/L had a survival that was not significantly different (P = .46) from that of the age- and sex-matched French population. These patients, accounting for about 50% of all chronic lymphocytic leukemia patients, should not be treated unless disease progression is observed.

Effects of chlorambucil and therapeutic decision in initial forms of chronic lymphocytic leukemia (stage A): results of a randomized clinical trial on 612 patients. The French Cooperative Group on Chronic Lymphocytic Leukemia

In 1980, the French Cooperative Group on Chronic Lymphocytic Leukemia started a randomized clinical trial in which 612 good prognosis patients (stage A) received either no treatment (309 patients) or an indefinite course of chlorambucil at the daily dose of 0.1 mg/kg (303 patients). Overall survival appeared to be better in the untreated group (50 deceased patients compared with 62 in the chlorambucil group), but the difference was not significant (P = .21) even after adjusting for both prognostic and imbalanced factors (P = .09). The crude 5-year survival rates were 82% in the untreated group and 75% in the chlorambucil group. The action of chlorambucil appeared to be a complex phenomenon associating beneficial effects consisting in slowing down disease progression to stage B or C (P less than .01), and favoring disease remission with harmful effects given by a short survival after disease progression to stage B or C in the chlorambucil group and an increased incidence of epithelial cancers (33 v 19), as well as an excess of epithelial cancer deaths (13 v 3), in the chlorambucil group. As these results suggested an overall harmful effect of chlorambucil, we tried to define, within stage A patients, a group of patients with a low probability of disease progression. We showed that stage A patients with hemoglobin greater than or equal to 120 g/L and lymphocyte count less than 30 x 10(9)/L had a survival that was not significantly different (P = .46) from that of the age- and sex- matched French population. These patients, accounting for about 50% of all chronic lymphocytic leukemia patients, should not be treated unless disease progression is observed.

Postoperative vaginal irradiation with high dose rate afterloading technique in endometrial carcinoma stage I

A high dose rate ( 60Co) afterloading technique was used for postoperative prophylactic vaginal irradiation in a series of 404 women with endometrial carcinoma Stage 1. The total recurrence rate was 3.7% with 0.7% vaginal deposits. The crude 5-year survival rate for the complete series was 91.8% compared to 13.3% for those with recurrences. Depth of myometrial infiltration ( > 1 3 of the uterine wall) and nuclear grade were the most important prognostic factors;. Clinically significant late radiation reactions (bladder and/or rectum) were recorded in 6.9%. Dose per fraction and the size of the target volume were highly significantly related to the occurrence of both early and late radiation reactions. Vaginal shortening is closely related to the dose per fraction, length of the reference isodose, and the applicator diameter. The shape of the vaginal applicator versus the isodoses and the importance of the source train geometry and relative activity for dose gradient inhomogeneities within the target volume are discussed. Cumulative radiation effect (CRS) and linear-quadratic (LQ) calculations have been performed and related to tissue reactions within the target volume and in the risk organs. An alpha-beta quotient of 8.8 for vaginal shrinkage effect and 2.0 for late rectal complications are suggested on the basis of calculations using a maximum likelihood method for quantal radiation data.

Proximal extrahepatic bile duct tumors. Analysis of a series of 52 consecutive patients treated over a period of 13 years.

Fifty-two consecutive patients with proximal extrahepatic bile duct tumors were treated by one of us (J.G.F.) between 1974 and 1987 at Memorial Sloan-Kettering Cancer Center, New York, NY. Thirty-eight patients (73%) underwent palliative procedures aimed at relieving the biliary obstruction (group A) and 14 patients (27%) were operated on with curative intent (group B). The choice of the surgical procedure employed to relieve the biliary obstruction did not significantly influence the length of survival of patients in group A in whom the median survival was 13.5 months and the in-hospital mortality was 15.7%. Fifty percent of the patients in group B underwent major liver resections to macroscopically encompass the tumor. In this group, although 35% of the patients experienced major complications, no in-hospital mortalities were encountered and the median actuarial survival was 38 months. The projected and crude 5-year survival rates were 28% and 21%, respectively. Age, gender, extent of resection, microscopic status of margins of resection, and grade of the lesion did not affect the length of survival in patients in group B. Locoregional failure, either isolated or as a component of peritoneal failure, was detected in the 6 patients in whom the disease has recurred. Eighty-three percent of the patients in whom the disease has recurred were dead within 12 months of the diagnosis of recurrence. Two long-term survivors (14%) developed second primary tumors in the follow-up period.

Postoperative Vaginal Irradiation by A High Dose-Rate Afterloading Technique in Endometrial Carcinoma Stage I

A high dose-rate (cobalt-60) afterloading technique was used for postoperative vaginal irradiation in a series of 404 women with endometrial carcinoma stage I. The total recurrence rate was 3.7% with 0.7% vaginal lesions. The crude 5-year survival rate for the complete series was 91.8% compared to 13.3% for those with recurrences. Depth of myometrial infiltration (greater than 1/3 of the uterine wall) and nuclear grade were the most important prognostic factors. Clinically significant late radiation reactions (bladder and/or rectum) were recorded in 6.9%. The absorbed dose per fraction and the size of the treatment volume were significantly related to the occurrence of both early and late radiation reactions. Vaginal shortening was closely related to the dose per fraction, length of the reference isodose and the applicator diameter. The shape of the vaginal applicator versus the isodose contours and the importance of the source train geometry and relative activity for absorbed dose inhomogeneities within the treatment volume are discussed. Cumulative radiation effect (CRE) and linear-quadratic (LQ) calculations have been performed and related to tissue reactions within the target volume and in the risk organs. An alpha-beta quotient of 8.8 Gy for vaginal shrinkage effect and 2.0 Gy for late rectal complications are suggested on the basis of calculations using a maximum likelihood method for quantal radiation data.

Early gastric cancer: 52 cases of combined experience of two south australian teaching hospitals

Fifty-two patients with early gastric cancer are described. At presentation, the average age was 60 years and the male:female ratio was 3:2. The patients had presenting symptoms indistinguishable from those due to benign peptic ulcer disease. Endoscopic examination with multiple biopsies was the most accurate means of diagnosis, with an overall 93% detection rate. The tumours were located predominantly along the lesser curve (75%) and in the antrum (64%), with ulcerated or depressed lesions most common and flat lesions least common. Approximately 58% of lesions were of intestinal type, submucosal invasion was seen in 45% and lymph node metastases had occurred in 7% of cases. Lesser curve and antral lesions were more likely to be ulcerated. Ulcerated lesions were on average, the same size as non-ulcerated lesions. Body lesions were larger than antral lesions and lesions which had spread to the submucosa were larger than mucosal lesions. Diffuse-type lesions were more likely to be ulcerated than intestinal-type lesions and dysplasia was more commonly associated with intestinal-type lesions than with diffuse or mixed-type lesions. The crude 5-year survival rate was 80%, but only one death was associated with a recurrence of gastric cancer.

Cervico-facial adenoid cystic carcinoma: Study of 102 cases. Influence of radiation therapy

One hundred two patients with cervico-facial adenoid cystic carcinoma were treated with surgery alone, radiotherapy alone or both from 1951 to 1980. All the cases have a 5-year minimum follow-up. The local control rate is 55.5% at 5 years and 37.7% at 10 years. The 5-year local control rate is 44% with surgery alone, 65.8% with radiotherapy alone and 77.8% with post-operative radiotherapy. The difference between surgery alone and radiosurgical association is significant ( p < 0.01). The bone involvement diminished local control rate (32.2%/k 68.8%). The 5-year survival rate of the patients who recurred and have been retreated is 70.5%. The 5-year survival rate of the patients after the appearance of a metastasis is 38.1 % and 2 patients have survived more than 10 years. The NED 5-year survival rate is 48.8%. There is no significant difference in the NED 5-year survival rate according to sites or treatments. The crude 5-year survival rate is 70%, 51.4% at 10 years and 32.2% at 15 years. Our study shows that adenoid cystic carcinoma have a peculiar and slow evolution. Surgery with post-operative radiotherapy obtains the best local control. These results and the radiosensibility of these lesions allow us to propose an agressive treatment for the recurrence and the primary tumor of the directly metastatic patients.

Primary lymphoma of the thyroid: Clinical features, prognostic factors, and results of treatment

This study analyzes the results of 46 cases of biopsy-proven primary lymphoma of the thyroid, localized at diagnosis and treated at the Royal Marsden Hospital between 1948–1980. In all cases, disease was limited to the thyroid and cervical lymph nodes. There were 43 females and 3 males, with a mean age of 64.4 years (median 66 years; range 17–86). A short history (less than 3 months) of a neck mass and local compressive symptoms was the typical presentation. The majority of patients (91%) had adverse histologies, with diffuse histiocytic lymphomas being most common (78%). The overall crude 5-year survival rate was 40%, with 30% of patients surviving beyond 10 years. Disease-free and overall survival were virtually identical, indicating the ineffectiveness of salvage therapy. The important prognostic factors were: size of tumor, fixation, extra-capsular extension, and retrosternal involvement. Survival was not correlated with age, sex, histology, thyroid status, or stage of disease, as defined by the Ann Arbor classification. Patients who had total macroscopic removal of tumor had the highest rate of local control and long survival ( p < 0.005). No significant difference was seen between lobectomy, subtotal or total thyroidectomy, but 7 of 9 long-term survivors (58–129 months) have had total thyroidectomy. A radiotherapy dose to the tumor, of at least 40 Gy, was required to produce consistent local control in patients with unresected disease. The majority of patients who died had generalized disease. Only 52% of these patients were free of local recurrence. In view of the frequency of occult disseminated disease, adjuvant chemotherapy is one recommendation for patients with poor prognostic factors. For optimal local control, complete surgical eradication is recommended followed by high-dose local radiotherapy. The use of aggressive cytoreductive chemotherapy prior to radiotherapy is a possible alternative option which needs to be explored.

Adenocarcinoma of the uterine cervix.

Between 1958 and 1969, 251 patients were treated at Radiumhemmet in Stockholm for adenocarcinoma of the uterine cervix. The histologic specimens were reevaluated. In the 211 cases of pure adenocarcinoma, the 5-year survival rate was compared with that in the total of cervical epithelial malignancies. The rate was lower in the adenocarcinoma cases, with respective crude 5-year survival rates of 84%, 50%, and 9% in Stages I, II, and III. Two modes of treatment, irradiation alone or irradiation plus radical surgery, were used in Stages IB and IIA. The combined treatment gave significantly improved 5-year survival rates.

The treatment of malignant tumours of the maxillary antrum

The problems involved in the treatment of malignant tumours of the maxillary antrum are described and the need for a disciplined approach emphasised. The overall crude 5-year survival rate for this series of 43 cases was 49%. For the 34 patients suffering from carcinoma the rate was 44%. It is suggested that primary surgery be avoided because in the 23 cases treated by radiotherapy before major surgery the 5-year crude survival rate was 60.8%.

Unsuspected carcinoma of the prostate in suprapubic prostatectomy specimens: A Clinicopathological Study of 55 Consecutive Cases

Fifty-five cases of unsuspected carcinoma were found in 847 consecutive suprapubic prostatectomy specimens. All 55 patients have been followed for a minimum of 5 years. The crude 5-year survival rate is 54 per cent. Twenty-four of these patients were followed for 10 years, and their survival rate is 37 per cent. The differentiation and size of the cancer have a direct bearing upon the clinical outcome. The 5- and 10-year survival rates for patients with well differentiated cancers are 75 per cent and 47 per cent, respectively. The 5- and 10-year survival rates for those with less than well differentiated cancers are 33 per cent and 14 per cent, respectively. We have presented evidence that patients with small, well differentiated cancers discovered by suprapubic prostatectomy need not have secondary radical prostatectomy: We have no evidence that conservative therapy, i.e., estrogens or castration, alters the prognosis in this group. The indications are that secondary radical prostatectomy may be a rational approach for treating the moderately or poorly differentiated cancers and the large cancers discovered by suprapubic prostatectomy.

Invasive Bladder Cancer Treated by Radical External Radiotherapy

Fifty-three consecutive, unselected patients with invasive bladder cancer, Stage T2 to T3, treated by radical radiotherapy have been reviewed. Cystectomy was reserved for patients with significant worsening of disease during treatment, histologically confirmed persistent or recurrent invasive tumour after treatment, or patients with intolerable symptoms due to radiation cystitis. In 64% of our patients a favourable tumour response to radiotherapy was seen, while a further 31% showed disease progression either during or on completion of radiotherapy. Cystectomy was performed on 22% of patients, mainly for radiation cystitis, and was not associated with a significant operative mortality rate. The crude 5-year survival rate was 42%. We conclude that radical radiotherapy is as effective as other forms of treatment for invasive bladder cancer, but that there remains a need to identify those bladder tumours destined to respond poorly to radiotherapy at an earlier stage.

Invasive bladder cancer treated by radical external radiotherapy.

Fifty-three consecutive, unselected patients with invasive bladder cancer, Stage T2 to T3, treated by radical radiotherapy have been reviewed. Cystectomy was reserved for patients with significant worsening of disease during treatment, histologically confirmed persistent or recurrent invasive tumour after treatment, or patients with intolerable symptoms due to radiation cystitis. In 64% of our patients a favourable tumour response to radiotherapy was seen, while a further 31% showed disease progression either during or on completion of radiotherapy. Cystectomy was performed on 22% of patients, mainly for radiation cystitis, and was not associated with a significant operative mortality rate. The crude 5-year survival rate was 42%. We conclude that radical radiotherapy is as effective as other forms of treatment for invasive bladder cancer, but that there remains a need to identify those bladder tumours destined to respond poorly to radiotherapy at an earlier stage.

Prognostic factors in renal carcinoma. An evaluation of operative findings.

A consecutive series of 257 patients with renal carcinoma treated by radical nephrectomy is presented. The crude 5-year and 10-year survival rates for all patients were 47 and 31% respectively and for patients without distant metastases 62 and 50%. The importance of factors relating to prognosis was investigated with multivariate survival analysis. Metastases, nodal involvement and histological grade were strongly and independently associated with survival, but the influence of venous invasion was less important. When these factors are taken into consideration, direct extension, size and cell type of the tumour or sex and age of the patient give no significant additional prognostic information.

The prevalence and prognostic significance of argyrophil cells in colorectal carcinomas

The presence of argyrophil cells in the proliferative compartment of noncarcinoid carcinomas of the GI tract is well-documented; however, their prevalence and prognostic significance in colorectal carcinomas have never been systematically investigated and reported in the English literature. We applied the Churukian-Schenk argyrophil stain, a histochemical technique previously shown to be the most effective for demonstrating argyrophil cells, to 94 carcinomas of the colon and rectum from patients in whom a minimum 5-year follow-up was available. The 94 cases included 25 nonmucinous colonic and 25 nonmucinous rectal adenocarcinomas; 25 mucinous adenocarcinomas from all sites; and 19 undifferentiated carcinomas from all sites. Twenty control colorectal carcinoids all gave a positive argyrophil stain. Nineteen (20%) of the 94 carcinomas contained argyrophil cells as follows: adenocarcinoma of the colon, 52%; adenocarcinoma of the rectum, 16%; mucinous adenocarcinoma, 4%; and undifferentiated carcinoma, 5%. Crude 5-year survival rates were: carcinoids 80%; all carcinomas containing argyrophil cells, 37%; all without argyrophil cells, 27%. Chi-square between the later two groups was 0.723 (p less than 0.5). Because of the intrinsically poorer prognosis of mucinous and undifferentiated carcinomas, a comparison of survival rates was made excluding these tumors; chi-square was 0.095 (p less than 0.8). We conclude that argyrophil cells are commonly present in nonmucinous adenocarcinoma of the colon, but are less common in nonmucinous adenocarcinomas of the rectum and rare in mucinous and undifferentiated carcinomas. The presence of argyrophil cells did not influence prognosis in this series of cases.

The relationship between the extent of distal clearance and survival and local recurrence rates after curative anterior resection for carcinoma of the rectum.

With increasing use of low anterior resection, the length of rectum removed below the tumor is often less than the recommended 2 to 5 cm. It is important to know if this decreases the chance of cure. Between 1963 and 1975, 334 patients survived radical restorative operations for single rectal adenocarcinoma. The length of rectum below the tumor measured on fixed pinned-out pathologic specimens was 2 cm or less in 55 patients (group 1), 2 to 5 cm in 177 (group 2), and 5 cm or more in 102 (group 3). The Dukes' classification, histologic grade, and extent of local spread of the tumors were similar in the three groups. Overall crude 5-year survival rates for groups 1, 2, and 3 were 69.1%, 68.4%, and 69.6%, respectively. Corresponding cancer-specific death rates were 25.5%, 23.2%, and 21.6%. These rates were also similar in matching pathologic subgroups of the three main groups. Of 23 observed or suspected local recurrences, there were four recurrences in group 1 (7.3%), 11 in group 2 (6.2%), and eight in group 3 (7.8%). These results suggest that a margin less than 2 cm below a rectal carcinoma does not affect survival or local recurrence adversely.

T3 Bladder Cancer-the Case for Salvage Cystectomy

Seven hundred and four patients with bladder cancer treated by radiotherapy at the London Hospital between 1965 and 1974 have been followed for a minimum period of 5 years. Invasive tumours were usually treated by radical radiotherapy. Cystectomy was reserved for patients whose tumours did not respond to radiation, recurred later on, or who developed complications from radiotherapy. The crude 5-year survival rate for T3 tumours in this series was 38%--similar to that obtained in other centres using pre-operative radiation followed by cystectomy, but this overall figure conceals the important difference between 2 distinct tumour populations. Nearly half of these tumours appear to be radiosensitive, giving a 56% crude 5-year survival rate for T3 tumours. The remainder are radioinsensitive, with only a 17% crude 5-year survival rate for T3 tumours. When there is a good initial response to radiotherapy there would seem to be no necessity to insist upon cystectomy.

Long term results of radium therapy in cervical cancer

This paper reviews 649 patients with invasive cervical carcinomas; they were selected from among the overall number of patients who were treated from January 1959 to December 1970 and who for various reasons, received exclusively local treatment of the primary tumor with endocavitary curietherapy alone. The analysis was carried out with the intention of giving the long-term results of endocavitary curietherapy alone in the treatment of invasive cervical carcinoma. It also offers a contribution towards solution of the queries which still exist concerning the indications for endocavitary treatment in cervical cancer, and the questions connected with the optimal sequence of endocavitary irradiation with respect to external irradiation. To this end the following types of cases were excluded: carcinomas “in situ”; those with early stromatic invasion (≤ 0.3 cm); patients who were treated for relapse of the disease; patients who had surgery and/or external irradiation in association with endocavitary curietherapy; those few patients whose disease was initially at Stage IV. The endocavitary curietherapy adopted in these cases is a technique without rigid applicators that uses conventional 226Ra sources; an average of 7,500 nigh were administered in a single and continuous application with an average duration of 7 days. These were reduced to an average of 6,700 nigh in the case of cervical stump cancer. The crude 5-year survival rate, i.e. not corrected for natural mortality, calculated by the actuarial method, was 82.6% in Stage Ib “occ,” i.e. clinically undetectable, 64.8% in Stage Ib, 50.3% for Stage II and 29.8% in Stage III. In 155 601 patients with adequate follow-up the endocavitary treatment did not achieve local success (25.8% ). Local relapses, either alone or in association with pelvic relapse and/or a metastases in the medium and lower third of the vagina, comprised 43.9% of the overall failure causes found in relapsed patients. For lesions with a diameter greater than 6 cm it is unrealistic to expect a full-dose with endocavitary treatment in order to maximize the probability of controlling the primary tumor, since the primary lesion extends beyond the treatment isodose. This also applies to carcinomas of the cervical stump where the overall activity applicable is reduced and there are less favorable arrangement possibilities for the radioactive sources. In the Stage Ib “occ” cases, a conservative therapeutic approach can be proposed. In fact local treatment alone produces favorable results and nodal metastases are infrequent. In Stage III the physical examination alone often leads to errors when patients are classified; examination under general anesthesia should be considered compulsory.

Conservative treatment of carcinoma of the penis.

Sixty-five cases referred to one hospital between 1964 and 1977 were studied. Forty-one presented in Stages 1 or 2 and when treated by the Iridium mould technique gave a 12/13 (92.3%) crude 5-year survival rate, an improvement over the results of previous methods of treatment, including partial amputation. In Stage 3 radical amputation gave an 89% 5-year survival rate. Node dissection was reserved for inguinal nodes in Stages 1, 2 and 3 which failed to resolve after treating the primary tumour. Undifferentiated tumours and those with the microscopic "cord" pattern of growth did badly.

The results of surgical treatment for carcinoma of the rectum of St Mark's Hospital from 1948 to 1972.

The surgical treatment of 3163 patients seen at St Mark's Hospital with a single adenocarcinoma of the rectum in the years 1948-72 is described and the results analysed. In 2948 patients (93-2 per cent) the primary tumour was removed. The operative mortality fell from 7-0 per cent in the years 1948-52 to 2-1 per cent in 1968-72. The proportion of restorative operations has risen steadily over the years to a level of 41-1 per cent in the years 1968-72. There were 2410 operation survivors in the years 1948-67. The crude 5-year survival rate in the whole group was 47-1 per cent (corrected figure 56-7 per cent), and 56-6 per cent (corrected figure 68-4 per cent) for the 1931 survivors of radical operations. Comparison of results for patients surviving radical synchronous combined excision and radical anterior resection shows a significant difference in the two groups: in the former the crude 5-year survival rate was 52-7 per cent (corrected figure 63-8 per cent), and in the latter group the respective figures were 66-7 and 79-4 per cent. A higher proportion of Dukes' A and B cases and of low grade tumours are shown as the pathological background to the more favourable prognosis for patients surviving radical anterior resection.