Curability Of Patients Research Articles

PRINCIPLES OF TREATMENT AND REHABILITATION OF PATIENTS WITH SCHIZOPHRENIA WITH CONCOMITANT DIABETES MELLITUS

In the course of the differentiated treatment and rehabilitation measures carried out, in the majority of patients with schizophrenia with concomitant diabetes mellitus, after a course of inpatient treatment, psychotic symptoms were completely or partially reduced, relative criticism of their condition was formed, and the subjective assessment of their quality of life improved significantly. The revealed differences in the frequency of rehospitalizations between the first (with a higher level of QoL at admission) and the second (with a lower level of QoL at admission) subgroups of patients indicate better curability of patients with an initially higher quality of life and the advisability of a differentiated (taking into account QoL) treatment and rehabilitation approach to patients. It is assumed that the further use of the proposed treatment and rehabilitation programs focused on a dynamic detailed (by spheres and sub spheres) study of the quality of life of patients will lead to an increase in the compliance of mentally ill patients, the prevention of stigmatization and self-stigmatization, an increase in long-term remissions, as well as an improvement in their quality of life and social adaptation. Keywords: stigmatization and self-stigmatization, spheres and sub spheres.

Radical antegrade modular pancreatosplenectomy enhances local control of the disease in patients with left-sided pancreatic cancer

BackgroundRadical antegrade modular pancreatosplenectomy (RAMPS) was developed to enhance curability in patients with left-sided pancreatic cancer. However, no evidence is available regarding the prognostic superiority of RAMPS compared with conventional distal pancreatectomy (cDP). Here, we aimed to assess the oncological benefit of RAMPS by comparing surgical outcomes between patients who underwent cDP and RAMPS with propensity score (PS) adjustment. MethodsClinical data of 174 patients undergoing cDP and RAMPS between 2009 and 2016 at two high-volume centers were analyzed with PS matching. Recurrence-free survival (RFS), overall survival (OS), and local recurrence rates were compared between patients who underwent cDP and RAMPS. ResultsThe cDP and RAMPS groups were successfully matched with baseline characteristics. No differences were found in the 3-year RFS and OS rates between the two groups (3-year RFS: cDP 46% vs RAMPS 40%, p = 0.451, 3-year OS: cDP 57% vs RAMPS 53%, p = 0.692). However, the 3-year local recurrence rate was lower in the RAMPS (10%) than that in the cDP group (34%) (hazard ratio 0.275, 95% confidence interval 0.090–0.842, p = 0.02). ConclusionRAMPS is oncologically superior to conventional procedure in achieving local control of the disease in patients with left-sided pancreatic cancer.

Curability of patients with lymph node metastases from extremity soft-tissue sarcoma.

Lymph node metastases (LNM) rarely occur in adult extremity soft-tissue sarcoma (STS), affecting approximately 5% of patients. To the authors' knowledge, few studies to date have evaluated the prognosis and survival of patients with LNM. A retrospective review was performed of a single-center, prospectively collected STS database. Demographic, treatment, and oncologic data for patients with STS of the extremity with LNM were obtained from clinical and radiographic records. Of 2689 patients with extremity STS, a total of 120 patients (4.5%) were diagnosed with LNM. LNM occurred most frequently among patients diagnosed with clear cell sarcoma (27.6%), epithelioid sarcoma (21.9%), rhabdomyosarcoma (17.3%), angiosarcoma (14.0%), and extraskeletal myxoid chondrosarcoma (9.3%). A total of 98 patients (81.7%) underwent LNM surgical resection. Patients with isolated LNM had a greater 5-year overall survival (57.3%) compared with patients with American Joint Committee on Cancer (AJCC) eighth edition stage IV STS with only systemic metastases (14.6%) or both LNM and systemic disease (0%; P<.0001). Patients with isolated LNM had an overall survival rate (52.9%) similar to that of patients with localized AJCC stage III tumors (ie, large, high-grade tumors) (49.3%) (P=.8). Patients with late, isolated, metachronous LNM had a 5-year overall survival rate (61.2%) that was similar to that of patients with isolated synchronous LNM at the time of presentation (53.6%) (P=.4). Many different types of STS develop LNM. Patients with extremity STS with isolated LNM should not be considered as having stage IV disease as they are according to the current AJCC eighth edition classification because they have significantly better survival than those with systemic metastases. Patients with isolated, late, metachronous LNM have a survival similar to that of patients with isolated synchronous LNM at the time of presentation. The results of the current study demonstrated that patients diagnosed with isolated lymph node metastases have a prognosis similar to that of patients diagnosed with localized American Joint Committee on Cancer stage III soft-tissue sarcomas, which also equates to a significantly better overall survival compared with patients with systemic metastases. Therefore, the authors recommend modifications to the most recent eighth edition of the American Joint Committee on Cancer staging system to clearly distinguish patients with isolated lymph node metastases to acknowledge their better prognosis compared with those with systemic metastases.

Diffusion-weighted MRI for preoperative prediction of histologic response in patients with borderline resectable pancreatic cancer; A prospective phase II study (DIFFERENT study)

Introduction: Preoperative prediction of histological response to neoadjuvant therapy is a remarkable findings for making decision of surgical resection in borderline resectable pancreatic cancer (BRPC) and locally advanced pancreatic cancer (LAPC). No prospective study reported investigating surrogate marker to predict their histological response to neoadjuvant therapy. Method: Twenty-eight patients with BRPC and LAPC who underwent diffusion-weighted magnetic resonance imaging (DW-MRI) prior to expected neoadjuvant chemotherapy and surgery were reviewed prospectively. Analyses for correlation between percent tumor cell destruction and the following was performed to investigate the parameter and cut off value: tumor size, whole tumor or vascular abutment site apparent diffusion coefficient (ADC) value of DW-MRI, maximum standardized uptake value of 18F-fluorodeoxyglucose positron emission tomography, carbohydrate antigen 19-9, and their change ratios or differences. The strong parameters were assessed for prediction ability of the therapeutic histological response and R0 curability. Result: Pre/post-treatment ADC value was correlated with tumor cell destruction rate among all parameters (R=0.630/0.714, P<0.001/<0.0001). The pre/post-treatment ADC cut-off value for discriminating between grade I and grade IIa and more after treatment was determined as 1.17/1.36x10-3 mm2/s and the sensitivity, 83/100%; specificity, 73/77%; accuracy, 75/82% for response, and the sensitivity, 63/75%; specificity, 75/80%; accuracy, 71/79% for R0 curability. The pre/post-treatment ADC cut-off value for discriminating between grade -3 mm2/s and the sensitivity, 92/100%; specificity, 63/81%; accuracy, 75/89% for response, and the sensitivity, 63/88%; specificity, 70/70%; accuracy, 68/75% for R0 curability. Conclusion: Post-treatment ADC value were confirmed to be a predictor of R0 curability in patients with BRPC and LAPC, and there was a significant correlation between the pre/post-treatment ADC value and histological tumor cell destruction rate.

High cure rates in Burkitt lymphoma and leukemia: a Northern Italy Leukemia Group study of the German short intensive rituximab-chemotherapy program

We evaluate the long-term results of a prospective clinical study enrolling more than 100 adult patients with Burkitt lymphoma/leukemia. Depending on extent of disease, treatment consisted of six to eight rituximab infusions and four to six courses of intensive chemotherapy (attenuated in patients aged >55 years) with high-dose methotrexate, fractionated ifosfamide/cyclophosphamide, other drugs in rotation, and intrathecal chemoprophylaxis. One-hundred five patients were treated (median age 47 years, range 17-78 years); 48% had Burkitt leukemia, 25% were older than 60 years, 37% had an Eastern Cooperative Oncology Group performance score >1, and 14% were positive for human immunodeficiency virus. The complete response rate and 3-year overall and disease-free survival rates were 79%, 67% and 75%, respectively, ranging from 100% to 45% for survival (P=0.000) and from 100% to 60% for disease-free survival (P=0.01) in patients with low, intermediate and high adapted International Prognostic Index scores. In multivariate analysis, only age (≤ versus >60 years) and performance status (0-1 versus >1) retained prognostic significance, identifying three risk groups with overall and disease-free survival probabilities of 88% and 87.5%, 57% and 70.5%, 20% and 28.5% (P=0.0000 and P=0.0001), respectively. The relapse rate was only 7% in patients treated with an intercycle interval ≤ 25 days. This regimen achieved 100% curability in patients with low adapted International Prognostic Index scores (21% of total), and very close to 90% in patients aged ≤ 60 years with performance score 0-1 (48% of total). Rapid diagnosis of Burkitt lymphoma/leukemia with prompt referral of patients to prevent clinical deterioration, and careful supervision of treatment without chemotherapy delay can achieve outstanding therapeutic results. ClinicalTrials.gov ID, NCT01290120.

Curability of Patients With Acute Myeloid Leukemia Who Did Not Undergo Transplantation in First Remission

The aims of this study were to quantify the prospects of salvage treatment of patients who did not undergo transplantation in first complete remission (CR1) and to assess the contribution of allograft in second complete remission (CR2) with respect to major risk groups. This evaluation can inform the decision whether to offer a transplant in CR1. Of 8,909 patients who entered the Medical Research Council AML10, AML12, and AML15 trials, 1,271 of 3,919 patients age 16 to 49 years who did not receive a transplant in CR1 relapsed. Of these patients, 19% are alive beyond 5 years compared with 7% of patients who relapsed after an allograft in CR1. Overall survival and the contribution of a transplant in CR2 were assessed overall and by cytogenetic risk group by using Mantel-Byar analysis. Fifty-five percent of patients who relapsed entered CR2. This percentage varied by risk group as follows: favorable (82%), intermediate (54%), adverse (27%), and unknown (53%), which resulted in 5-year survivals of 32%, 17%, 7%, and 23%, respectively. Sixty-seven percent of remitters received an allotransplant that delivered superior survival compared with patients who did not receive a stem-cell transplant (42% v 16%). A more-stringent assessment of a transplant by using delayed-entry (Mantel-Byar) analysis confirmed the benefit of transplant overall and within intermediate and adverse risk groups but not the favorable subgroup. Successful salvage treatment of patients who do not undergo transplantation in CR1 and relapse can be achieved in 19% of patients, which is improved by a transplant except in favorable risk disease. This result suggests that, for intermediate-risk patients in particular, equivalent overall survival can be achieved by delaying transplantation until after relapse, which would require many fewer transplants.

Value of splenectomy in patients with Siewert type II adenocarcinoma of the esophagogastric junction

The incidence of adenocarcinoma of the esophagogastric junction (AEG) has been increasing recently in both Western and Eastern countries. However, an optimal treatment strategy for Siewert type II AEG is still unclear. The aim of this study was to clarify the value of splenectomy in patients with Siewert type II AEG. From September 2002 to November 2011, 42 patients underwent total gastrectomy with D2 lymph node dissection for Siewert type II AEG and were included in this study. We used the index of estimated benefit from lymph node dissection (IEBLD) to assess the efficacy of lymph node dissection of each station. Surgical complications were graded by the Clavien-Dindo classification. The overall 5-year survival rate of the 42 patients was 57.5 %. The incidence of splenic hilar lymph node metastasis was 4.8 % and the 5-year survival rate of patients with splenic hilar lymph node involvement was zero. Consequently, the IEBLD of splenic hilar lymph nodes was zero. Postoperative morbidities occurred in 25 patients (59.5 %). Pancreas-related complications were the most frequently observed (28.5 %), followed by intraabdominal abscess (14.3 %) and anastomotic leakage (9.5 %). Splenic hilar lymph node dissection may be omitted without decreasing curability in patients with Siewert type II AEG, although a prospective study is necessary for more conclusive results.

Total resection of the right hepatic vein drainage area with the aid of three-dimensional computed tomography

We analyzed the feasibility and safety of our preliminary surgical approach for total hepatic resection of the right hepatic vein drainage area (THR-RHV) with the aid of three-dimensional computed tomography (3D-CT) guidance. Clinical findings and 3D-CT volumetry results were investigated in five patients who underwent THR-RHV for a hepatic malignant tumor close to the right hepatic vein (RHV). The mean estimated remnant liver volume after a conventional right lobectomy was 474 ml, whereas that after THR-RHV was 614 ml, indicating that 140 ml (13.8%) of additional liver volume had been preserved by performing THR-RHV. The median operative time, mean ischemic time, and mean blood loss during surgery were 406 min, 51 min, and 587 ml, respectively. Histological examinations confirmed a negative surgical margin in all five patients. The mean liver volume estimated by 3D-CT was 458 ml, whereas the mean actual resected liver volume was 468 g, resulting in a mean error ratio of 3.1%. THR-RHV allowed for a higher remnant liver volume than that after conventional right lobectomy of the liver, and proved feasible with acceptable perioperative results. This technique thus promotes both safety and curability for patients with a tumor close to the RHV.

High Incidence and Curability of Patients with Acute Myeloblastic Leukemia (AML) and t(8;21) Treated On a Uniform Protocol in Casablanca, Morocco.

Abstract 4713 BackgroundAML with t(8;21) is known to have a more favorable outcome when treated with adequate chemotherapy and supportive care. There have been minimal data on the characteristics and outcome of AML with this translocation in low-income countries. AimWe analyze the clinical and biological characteristics of a large population of children and adults with AML in Casablanca who had t(8;21) in relation to response, event-free (EFS) and overall survival (OS). MethodsFrom 4/1/03 to 3/31/09, eligible patients were treated on the AML-MA2003 protocol at a single center. For patients presenting with WBC>50,000, hydroxyurea (HU) was given for 4 days prior to initiation of standard induction. Treatment included two induction courses of cytarabine, 200 mg/m2/d (days 1-7) and daunomycin 50 mg/m2/d (days 1-3); consolidation was stratified by age: those '20 years had two courses of Capizzi high-dose cytarabine, 2 g/m2 q 12h (days 1-4) with L-asparaginase, 6000 units/m2 day 4; those >20 years had one or two courses of high-dose cytarabine, 1 g/m2 q 12h (days 1-4) with daunomycin 50 mg/m2/d (day 1-3), and maintenance with oral 6-mercaptopurine 60 mg/m2/d and weekly sc cytarabine 40 mg/m2 for 18 months. Events included death, relapse, progression, and abandonment. Results85 of 535 (15.8%) patients with karyotype results had t(8;21), including 40 with only t(8;21), 25 with additional loss of a sex chromosome, 5 with del (9), and 15 with other cytogenetic abnormalities. Characteristics of the t(8;21) group are shown in the Table. Five adults were ineligible for protocol therapy, due to secondary AML (n=1), refused (n=1) and early death (n=3). Of 33 children (age < 20 years), 28 completed all 4 courses of planned therapy. Five deaths occurred on therapy (1 failure, 4 toxicity) and 11/28 relapsed later, 8-14 months after end therapy. Of 47 adults who received the first induction course, 35 went on to 2nd induction, 34 received 1st consolidation, 22 completed both courses of induction and consolidation, and 20 completed maintenance. There were 12 deaths on therapy and 12 relapses after therapy completion. Overall, 30/80 patients did not complete prescribed therapy: 14 deaths, 1 failure, 4 abandonment, 11 complete remission). 7/8 children and 4/4 adults with t(8;21) had an early response (50% decrease in blasts) to HU. The complete remission rate (CR) after two courses of induction therapy was 91% for children and 72.5% for adults. The 2-year EFS and OS for the patients with t(8;21) was 32% (standard error [SE] 6.3%) and 59% (SE 7.3%) respectively. There was not a significant difference in 2-year EFS by sex (p=0.18), age ' 20 years vs older (p= 0.08), or presence of additional cytogenetic abnormalities accompanying the t(8;21) (p=0.98) Conclusionst(8;21) in Morocco occurred in 15.8% of cases, more frequently than the 7 to12% reported. It was associated with a high incidence of extramedullary disease, FAB M2, frequent deletion of a sex chromosome, preponderance of males, and young age. A third of these favorable-risk AML patients survive event-free 2 years from diagnosis despite the problem of abandonment of therapy and suboptimal supportive care.Table85 patients with t(8;21)All t(8;21)ChildrenAdultst(8;21) (%)8533 (38.8%)52 (61.2%)Median Age (yrs)25 (3-69)15 (3-20)34 (21-69)Male:Female1.361.061.94Median WBC (range)16.6 (0.9-237)25.0 (0.9-237)14.9 (1.6-64.7)WBC ≥ 50,00013 (15.3%)8 (24.2%)4 (7.7%)Extramedullary disease11 (12.9%)10 (30%)1 (1.9%)FAB M1/M2/other17 / 65 / 33 / 29 / 114 / 36 / 2t(8;21)/total AML85/535 (16%)33/122 (27.0%)52/413 (12.6%)t(8;21) + other anomalies45 (52.9%)16 (48.5%)29 (55.7%) Disclosures:No relevant conflicts of interest to declare.

Leukemia risk after adjuvant treatment of early breast cancer

Modern cancer treatment has substantially increased the survival and curability of patients with various malignancies. Therefore, favorable prognosis mandates for the evaluation of long-term complications of treatment. Since the late 1970s, adjuvant combination chemotherapy for operable breast cancer has come into widespread use. Several recent studies have estimated the risk of acute myeloid leukemia associated with these regimens. The purpose of this analysis is to discuss the risk of leukemia after early breast cancer therapy, the types of leukemia, and the relationship between the risk of leukemia and treatment with different cytotoxic agents (alkylating agents, antimetabolities, topoisomerase II inhibitors, dose-dense therapy, high-dose therapy and growth factor use) and radiotherapy.

Leukemia Risk after Adjuvant Treatment of Early Breast Cancer

Modern cancer treatment has substantially increased the survival and curability of patients with various malignancies. Therefore, favorable prognosis mandates for the evaluation of long-term complications of treatment. Since the late 1970s, adjuvant combination chemotherapy for operable breast cancer has come into widespread use. Several recent studies have estimated the risk of acute myeloid leukemia associated with these regimens. The purpose of this analysis is to discuss the risk of leukemia after early breast cancer therapy, the types of leukemia, and the relationship between the risk of leukemia and treatment with different cytotoxic agents (alkylating agents, antimetabolities, topoisomerase II inhibitors, dose-dense therapy, high-dose therapy and growth factor use) and radiotherapy.

Evaluation of serum CEA and CA19-9 levels as prognostic factors in patients with gastric cancer.

BACKGROUND: This clinicopathological study evaluated the utility of serum carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) 19-9 as predictors of locoregional recurrence and long-term disease-free survival in patients with gastric cancer.METHODS: During the period January 1989 to December 1994, 485 patients with primary gastric cancer were evaluated. Gastrectomies were performed in 434 patients. Prognostic factors were analyzed by the Kaplan-Meier method and multivariate analysis, using Cox regression.RESULTS: Elevated serum CEA and CA19-9 levels were observed in 92 of the 485 patients (19.0%), and in 95 of the 435 patients (21.8%), respectively, and both markers were elevated in 29 of these 435 patients (6.7%). Elevated serum CEA and CA19-9 levels correlated well with lymph node metastasis, lymphatic invasion, vessel invasion, stage grouping, depth of invasion, and curability. Patients with elevated serum CEA levels were at significantly higher risk of having all recurrence factors than were those with normal serum CEA levels. Patients with elevated serum CA19-9 levels were at significantly higher risk of having peritoneal metastases and distant metastases than were those with normal serum CA19-9 levels. A significant difference in the cumulative survival curves of patients was demonstrated between those with elevated and those with normal serum CEA or CA19-9 levels, even for patients at the same disease stage (stage III). Patients with elevated levels of both markers had a significantly worse prognosis than patients in whom the levels of both markers were normal. In patients who underwent gastrectomy, elevated serum CEA levels either preoperatively or within 3 weeks after gastrectomy were associated with significantly worse prognosis than were normal levels. When the cutoff level of serum CEA was increased to 10 ng/ml, serum CEA, age, lymph node metastasis, and surgical stage grouping were selected as independent prognostic factors by multivariate analysis of 14 prognostic factors, using Cox regression.CONCLUSION: Serum CEA and CA19-9 levels provide additional prognostic information in patients with primary gastric cancer. In particular, an elevated serum CEA level provides additional prognostic information and is a useful indicator of curability in patients who undergo gastrectomy. Serum CEA level is an independent prognostic factor in patients with primary gastric cancer.

LYMPHOHISTIOCYTIC ANAPLASTIC LARGE CELL LYMPHOMA STAGE I: Long-Term Survival after Resection Alone

A 17-year-old female presented with axillary lymphadenopathy, which, on biopsy, demonstrated an anaplastic large cell lymphoma of the lymphohistiocytic type (ALCL-LH). The tumor cells expressed the CD30 antigen and reacted with the ALK1 antibody, suggesting the presence of the nucleophosminanaplastic large cell lymphoma kinase (NPM/ALK) fusion protein. No other adenopathy was found. Following a wide excision of the lymph node and without postoperative treatment, the patient remains free of disease 5 years later. This case demonstrates the potential curability of patients with early stages of ALCL by local treatment.

Determinants of long term survival after surgery for cancer of the lung

BACKGROUND Even if some determinants of lung cancer (LC) prognosis have been established, their independent effect on long term survival remains to be seen. The objective of the current study was to identify the prognostic indicators of long term survival among LC patients treated by surgery. METHODS All patients with LC recorded at the Geneva Cancer Registry between 1977 and 1987 were analyzed by logistic regression, considering as cases (n = 98) those patients alive 10 years after their initial diagnosis and as controls (n = 330) all other patients, excluding those who did not undergo putative curative surgery. The effect of each prognostic factor was evaluated after accounting for age and gender (“crude” effect) and also for other a priori confounding factors (adjusted effect). Additional models considered two staging variables simultaneously to identify the strongest staging determinant. Results were presented as relative risk estimates of long term (≥10 years) survival. RESULTS Age, histology, and stage of disease significantly influenced prognosis regardless of the confounding factors considered. Gender also emerged as a discriminated factor in LC outcome, with a 2.1-fold increased chance (95% confidence interval, 1.6–3.5) of long term survival for women compared with men. Method of discovery, presence of symptoms, period of diagnosis, socioeconomic status, and tumor differentiation did not appear to be associated with long term survival. Extent and size of the tumor were found to be the most reliable prognostic staging factors, whereas adenopathy had no effect after accounting for extension. CONCLUSIONS The current population-based study quantifies the independent effect of the factors modifying the chances of curability in patients with LC. In particular, it provides additional evidence that gender strongly influences long term survival. Cancer 1999;86:2229–37. © 1999 American Cancer Society.

Determinants of long term survival after surgery for cancer of the lung

Even if some determinants of lung cancer (LC) prognosis have been established, their independent effect on long term survival remains to be seen. The objective of the current study was to identify the prognostic indicators of long term survival among LC patients treated by surgery. All patients with LC recorded at the Geneva Cancer Registry between 1977 and 1987 were analyzed by logistic regression, considering as cases (n = 98) those patients alive 10 years after their initial diagnosis and as controls (n = 330) all other patients, excluding those who did not undergo putative curative surgery. The effect of each prognostic factor was evaluated after accounting for age and gender ("crude" effect) and also for other a priori confounding factors (adjusted effect). Additional models considered two staging variables simultaneously to identify the strongest staging determinant. Results were presented as relative risk estimates of long term (>/=10 years) survival. Age, histology, and stage of disease significantly influenced prognosis regardless of the confounding factors considered. Gender also emerged as a discriminated factor in LC outcome, with a 2.1-fold increased chance (95% confidence interval, 1.6-3.5) of long term survival for women compared with men. Method of discovery, presence of symptoms, period of diagnosis, socioeconomic status, and tumor differentiation did not appear to be associated with long term survival. Extent and size of the tumor were found to be the most reliable prognostic staging factors, whereas adenopathy had no effect after accounting for extension. The current population-based study quantifies the independent effect of the factors modifying the chances of curability in patients with LC. In particular, it provides additional evidence that gender strongly influences long term survival.

Prospects with docetaxel in the treatment of patients with breast cancer

Docetaxel (Taxotere®) has been shown to be one of the most active cytotoxic agents in patients with breast cancer, achieving response rates of 41% when used as second-line treatment for metastatic breast cancer (34% in anthracycline-refractory patients) and 50–72% when used as first-line therapy. In both situations meaningful response durations of 7–8 months have been obtained. Based on these results, docetaxel is a promising candidate for new therapeutic strategies in patients with breast cancer. Studies comparing docetaxel with paclitaxel or anthracyclines in first-line therapy are ongoing. These studies should allow for an unequivocal definition of activity of docetaxel, yet not alter—as such—therapeutic strategies. A number of regimens are currently being explored combining docetaxel with anthracyclines, vinorelbine, 5-fluorouracil, cyclophosphamide and cisplatin. The preliminary conclusions are as follows: the main side-effect is non-cumulative neutropenia of short duration, and response rates are > 75%. Further, no cumulative cardiotoxicity has been observed with doxorubicin. The duration of response and length of the progression-free survival cannot yet be defined. Another option for combination chemotherapy is sequential combinations, the value of which has been demonstrated in advanced breast cancer as well as in the adjuvant setting. The short duration and non-cumulative character of docetaxel-induced neutropenia are good rationales for the use of dosedensified docetaxel-containing regimens. A dose of 100 mg/m 2/14 days can be used as single-agent therapy. A phase I trial combining cyclophosphamide at doses increased from 750 to 1200 mg/m 2 and docetaxel at doses increased from 66 to 100 mg/m 2 every 2 weeks, is ongoing; at the first dose-levels, the combination appears feasible although cumulative asthenia has been observed. Further, responses have been observed at all dose levels. The value of single-agent chemotherapy added to tamoxifen has been emphasised for stage I–II breast cancer in postmenopausal patients. A randomised phase III study comparing tamoxifen (20 mg/day for 5 years) and epirubicin (50 mg/m 2 days 1 and 8/28 days for 6 cycles) with the same regimen with epirubicin for 3 months followed by docetaxel (100 mg/m 2/21 days × 3) was initiated at the end of 1996. Thus, docetaxel is currently under study in most therapeutic situations to better define its impact on the prognosis and curability of patients with breast cancer.

Vulvar Cancer: The Evolution of Current Management Strategies

The treatment of vulvar cancer is evolving from the single incision “en bloc” highly morbid resection of the entire vulva, groin, and pelvic nodes for all stages of this disease. Currently, micro-invasive disease is treated conservatively by wide local excision, and stage 1 and 2 disease by wide local excision and superficial groin dissection. Vulvar tumours of all stages which by locanan or size preclude both a one cm surgical margin and the sparing of critical midline anatomy; clitoris, urethra or anal sphincter, can now be considered for primary irradiation rather than surgery. This approach may preserve the function and anatomic integrity of these important structures. Surgico-pathologic factors can greatly assist in identifying those post-surgical patients at higher than normal risk of relapse, so that they can receive targeted, adjunctive therapy.The extent of the psychological sequelae of the diagnosis and treatment of vulvar cancer is becoming known. Further information about these non-physical morbidities may help us to choose between the available treatment options, based on additional outcome measures including cost of treatment and patient preference.At this time, our clinical goal is to maintain cure and local control rates and to minimize morbidity in early disease, while we attempt to improve local control and curability for patients with advanced disease. This will be achieved by 1) limiting the amount of tissue treated/excised for patients with early stage/good prognosis disease and, 2) by minimizing the physical and psychologic morbidity, without sacrificing curability, for patients with advanced disease or with adverse risk factors.

Lymphadenectomy for Bladder Cancer

Experience with lymph node dissection in breast and colon cancer established the potential curability in patients whose tumor had spread to regional lymph nodes. Urologists began routinely including pelvic lymphadenectomy (PLND) with total cystectomy in the early 1930s, resulting in a significant decrease in local recurrence with acceptable morbidity and m~rtali ty.~,’~ Leadbetter and Cooper” meticulously applied the rationale of the Wertheim operation for carcinoma of the cervix, which included removal of the external and internal iliac as well as the common iliac lymph nodes along with a total hysterectomy. Jewett and Strong’s observations’ that pelvic nodal metastases occur in the absence of distant disease further supported the rationale for including PLND at the time of radical cystectomy. Long-term survival was observed in patients with small volume nodal metastases,22 and survival data from several contemporary series indicate that up to 53% of patients with small volume nodal disease potentially are curable.”

Rate of relapse following treatment for localized prostate cancer: A critical analysis of retrospective reports

Purpose : Controversy exists over the optimal treatment for patients with clinically localized prostate cancer. Almost all of the treatment results are from non-randomized trials and interseries comparison is difficult since the apparent success of a treatment, as judged by the actuarial freedom from relapse and survival data, depends on patient selection criteria and post-treatment evaluation, in addition to the efficacy of the therapeutic intervention. In this report the calculation of a hazard function is used to estimate and compare the rate of relapse for the different treatments. Methods and Materials : Clinical reports from major surgery and radiation oncology treatment institutions were analyzed. The actuarial recurrence data were used to calculate the annual rate of recurrence within each series. Results : For all but the lowest volume tumors, patients continueto be at rist of relapse for as long as these series have been followed. Despite the heterogeneity of patient populations, the recurrence rates by stage are similar for patients treated with surgery or irradiation. This result is consistent with pathologic data from prostatectomy specimens which indicate that for lesions > 12 cm 3 (approx. 3 cm in diameter) there is high likelihood of extraprostatic disease. Conclusion : Treatment outcome for patients with localized prostate cancer may be more dependent on the inherent tumor biology than the particular type of treatment. Accordingly, the expectation and recommendation of a treatment must take into consideration the continued risk of relapse with either radiation therapy or surgery. There are, as yet, insufficient data regarding the impact of screening and earlier diagnosis on the curability of patients with localized prostate cancer.

Twenty years follow-up of patients with inoperable cancer of the prostate (stage c) treated by radiotherapy: Report of a national cooperative study

Purpose : To evaluate the longevity and curability of patients with inoperable, Stage C, carcinomas of the prostate by means of external pelvic irradiation. Methods and Materials : 372 patients, averaging 61 years of age, with histologically proven adenocarcinoma of the prostate, Stage C, received radiotherapy as part of a National Research Study, from 1967 to 1973. Treatments were administered in accordance with a strict protocol. Portals of entry were optional but it was required that the total dose received at the center of the prostate should be no less than 7000 cGy in no less than 47 days or 7500 cGy in 54 days. Results : 245 of the 372 patients survived 5 years without evidence of recurrence or metastases; 142 were living after l0.years, 64 after 15 years, and 24 after 20 years. A total of 167 patients (44%) survived for years and died from intercurrent diseases without evidence of prostatic cancer. A total of 177 patients (47%) died of prostatic cancer in decreasing proportions in the years after treatment. Mild episodes of hematuria and of rectal bleeding were recorded in a number of patients; urethral and rectal strictured occurred following cystitis and proctitis but no life-threatening complications occurred. Conclusions : Adequately fractionated external pelvic irradiation can eradicate inoperable intrapelvic prostatic cancer. A simple statement of survival would disregard the fact that these elderly patients may be cured of cancer and yet may die of intercurrent diseases proper of their age. Also, it may be expected that a number of patients with Stage C may have unsuspected subclinical bone metastases when first seen and that death from metastases is not necessarily a reflection on the effectiveness of the regional treatment.