Isolated Nodal Recurrences Research Articles

Efficacy of salvage neck dissection for isolated nodal recurrences in early carcinoma of oral tongue with watchful waiting management of initial N0 neck

Recent studies have shown that salvage treatment may be effective for early tongue carcinoma with nodal failures after watchful waiting policy. We wanted to assess the efficacy of salvage neck dissection. We conducted a retrospective review of all patients with pT1 and pT2 oral tongue cancer who underwent partial glossectomy without any neck surgery and determined the survival after salvage neck dissection in this group of patients. Seventy patients with N0 disease underwent partial glossectomy, 20 patients had development of isolated nodal failures after watchful waiting policy. Apart from the initial T classification, which found to have significant difference in 5-year disease specific survival rate (100% vs 46%, p = .023); other parameters including age, sex, tumor thickness, adjuvant radiotherapy and rN classification had shown no significance in affecting survival. Salvage neck dissection may not be effective for controlling isolated nodal recurrence in patients with oral tongue carcinoma with T2 disease.

Incidence of isolated regional recurrence after definitive (chemo-) radiotherapy for head and neck squamous cell carcinoma

To evaluate the incidence and localization of regional recurrences after definitive (chemo-) radiotherapy for head and neck squamous cell carcinoma (HNSCC). From May 1987 to March 2008, 368 patients with advanced HNSCC were irradiated to 66-80.5 Gray in 6-7 weeks, with (37%) or without (63%) concomitant chemotherapy (Cisplatinum 100mg/m(2)) every 3 weeks. No planned neck dissections were performed. Data on clinical outcome were retrospectively reviewed, location of the original nodal disease and the regional recurrence was indicated on imaging and correlated with radiation dose. Mean follow-up was 34 months (range: 50 days-216 months). Three-year overall survival and disease-specific survival were 55% and 62%, respectively. Loco-regional, local and regional controls were 58%, 65%, and 80%, respectively. Forty-one patients (11.1%) relapsed in the neck, but only 11 patients (2.99%) developed a true isolated regional recurrence, 6 of whom could be successfully salvaged by surgery. Only 2 patients (0.54%) developed an isolated recurrence in the electively treated nodal levels. Isolated nodal recurrences are uncommon and recurrences in the electively treated neck are extremely uncommon.

Low Incidence of Isolated Nodal Failures After Involved-Field Radiation Therapy for Non–Small-Cell Lung Cancer: Blinded by the Light?

Low Incidence of Isolated Nodal Failures After Involved-Field Radiation Therapy for Non–Small-Cell Lung Cancer: Blinded by the Light?

Conformal High Dose External Radiation Therapy, 80.5 Gy, Alone for Medically Inoperable Non-small Cell Lung Cancer: A Retrospective Analysis

Retrospective analysis of patients with medically inoperable non-small cell lung cancer treated with continuous high-dose external beam radiation therapy at the Medical University of South Carolina. We identified 35 patients with non-small cell lung cancer treated 1998-2002. None were candidates for resection for reasons including: pulmonary function (n = 23), previous cancer (n = 9), other co-morbidities (n = 2), and refusal of surgery (n = 1). Median percent predicted forced expiratory volume in 1 second was 41.5%. Median age was 71 years. Five patients had more than one primary tumor: three were concurrently treated, two were sequentially treated. Lesion sizes were <3 cm (n = 24); 3-5 cm (n = 12), and >5 cm (n = 5). Nodal stage was as follows: N0 (n = 33) and N1 (n = 2). Radiation therapy was administered once daily: median dose was 80.5 Gy/35 fx/2.3 Gy/fx. The clinical target volume was tumor plus nodes > or =1.0 cm. V20 data were available for 12 patients, with a mean value of 15.7%. Thirty-four patients completed treatment. Median follow-up was 23.0 months. There were 26 deaths: 19 died from non-small cell lung (73%) and seven died from co-morbid illness (27%). Median survival was 24 months (95% CI, 18.0-31.9 months). Four patients were alive with disease, and five were alive disease-free at 10- and 68-month follow-ups. Of 41 lesions, local failure occurred in 15 lesions (37%) of which 3 local failure patients (9%) failed concomitantly in untreated regional lymph nodes. There were no isolated nodal recurrences. Distant progression: 10 patients (29%) of which 6 distant progression without local failure. Two patients who both had prior lobectomies experienced grade 5 toxicities. Continuous high-dose external beam radiation therapy 80.5 Gy administered in 35 fractions was tolerated. Treatment-related death was rare (6%) and isolated to patients with prior lobectomies in an extremely high-risk population. Most mortality was lung cancer-related. The dose of 80.5 Gy in 7 weeks is supported for patients with single lesions and no prior lobectomy. Local failure dominates and higher effective doses should be explored.

Conformal high-dose external radiation therapy (CHERT) alone for medically inoperable non-small cell lung cancer (MILC)

7228 Background: Treatment options are limited for patients with MILC. This is a review of patients with MILC treated with CHERT. Methods: 36 patients with MILC treated between 1998 and 2002. All had a pathologic diagnosis of non-small cell lung cancer (NSCLC); all unresectable [poor pulmonary function (23 patients), prior cancer (10 patients - other lung, 4 lobectomies, 1 wedge, esophageal, and colon cancer), 2 other co-morbidities, 1 refused surgery]. Six had more than one primary tumor; 4 concurrently treated (1 small cell with concurrent chemotherapy). The median age was 69 years. Lesion size was < 3cm, 25; 3 – 5cm, 12 lesions; and > 5cm, 5. All had CT scans of the chest; no mediastinoscopy; staged as N0, 34 and N1,2. Radiation was once daily (6–18MV). Median dose was 80.5 Gy/35 fx/2.3 Gy/fx. Target volume included tumor and nodes measuring 1.0cm or larger; margin was the clinical target within a 90–95% isodose line. The mean treatment volume was 42.7 cm3. Results: Thirty-five completed treatment; median length of follow-up 11.5 months. 17 deaths, 12 patients died of NSCLC (71%), 4 died of co-morbid illness (24%), and 1 died of small cell lung cancer. Median survival 21.9 months (95% CI: 18.0–29.8). Six patients alive with disease; 13 alive disease free with follow up between 3 and 49 months. Of 42 lesions, local failure (LF) occurred in 11 patients (26%); 2 (5%) failed concomittantly in regional lymph nodes. No isolated nodal recurrences. Distant tumor progression 7 patients (20%), of these 5 patients had distant progression without local failure. Three patients (8%) had a significant pulmonary toxicity. Two are grade 5 toxicity (both had prior lobectomies). Conservatively 6% treatment mortality in an extremely high risk population. Conclusions: CHERT to 80.5 Gy in 2.3 Gy fractions was tolerated. Treatment related death was rare, isolated to patients with prior lobectomies. LF in 26% despite inattention to motion. Most mortality was related to lung cancer, notco-morbidity. A dose of 80.5 Gy in 7 weeks is supported with single lesions, conservative volumes, and no prior lobectomy. Local failure dominates and higher effective doses should be explored. No significant financial relationships to disclose.

Conformal high-dose external radiation therapy (CHERT) alone for medically inoperable non-small cell lung cancer (MILC)

7228 Background: Treatment options are limited for patients with MILC. This is a review of patients with MILC treated with CHERT. Methods: 36 patients with MILC treated between 1998 and 2002. All had a pathologic diagnosis of non-small cell lung cancer (NSCLC); all unresectable [poor pulmonary function (23 patients), prior cancer (10 patients - other lung, 4 lobectomies, 1 wedge, esophageal, and colon cancer), 2 other co-morbidities, 1 refused surgery]. Six had more than one primary tumor; 4 concurrently treated (1 small cell with concurrent chemotherapy). The median age was 69 years. Lesion size was < 3cm, 25; 3 – 5cm, 12 lesions; and > 5cm, 5. All had CT scans of the chest; no mediastinoscopy; staged as N0, 34 and N1,2. Radiation was once daily (6–18MV). Median dose was 80.5 Gy/35 fx/2.3 Gy/fx. Target volume included tumor and nodes measuring 1.0cm or larger; margin was the clinical target within a 90–95% isodose line. The mean treatment volume was 42.7 cm3. Results: Thirty-five completed treatment; median length of follow-up 11.5 months. 17 deaths, 12 patients died of NSCLC (71%), 4 died of co-morbid illness (24%), and 1 died of small cell lung cancer. Median survival 21.9 months (95% CI: 18.0–29.8). Six patients alive with disease; 13 alive disease free with follow up between 3 and 49 months. Of 42 lesions, local failure (LF) occurred in 11 patients (26%); 2 (5%) failed concomittantly in regional lymph nodes. No isolated nodal recurrences. Distant tumor progression 7 patients (20%), of these 5 patients had distant progression without local failure. Three patients (8%) had a significant pulmonary toxicity. Two are grade 5 toxicity (both had prior lobectomies). Conservatively 6% treatment mortality in an extremely high risk population. Conclusions: CHERT to 80.5 Gy in 2.3 Gy fractions was tolerated. Treatment related death was rare, isolated to patients with prior lobectomies. LF in 26% despite inattention to motion. Most mortality was related to lung cancer, notco-morbidity. A dose of 80.5 Gy in 7 weeks is supported with single lesions, conservative volumes, and no prior lobectomy. Local failure dominates and higher effective doses should be explored. No significant financial relationships to disclose.

LACK OF RETROPERITONEAL LYMPHADENOPATHY PREDICTS SURVIVAL OF PATIENTS WITH METASTATIC RENAL CELL CARCINOMA

Patients with metastatic renal cell carcinoma have a reported 5-year survival of 0% to 20%. The ability to predict which patients would benefit from nephrectomy and interleukin-2 (IL-2) therapy before any treatment is initiated would be useful for maximizing the advantage of therapy and improving the quality of life. A retrospective analysis of the x-rays and charts of patients treated at the National Institutes of Health Surgery Branch between 1985 and 1996, who presented with metastatic renal cancer beyond the locoregional area and the primary tumor in place, was performed. Preoperative computerized tomography or magnetic resonance imaging, or radiological reports if no scans were available, were used to obtain an estimate of the volume of retroperitoneal lymphadenopathy. Operative notes were used to evaluate whether all lymphadenopathy was resected or disease left in situ, or if any extrarenal resection, including venacavotomy, was performed. Mean survival rate was calculated from the time of nephrectomy to the time of death or last clinical followup. If patients received IL-2 therapy, the response to treatment was recorded. Mean survival and response rate for IL-2 were compared among patients in 3 separate analyses. Patients without preoperatively detected lymphadenopathy were compared with those with at least 1 cm.3 retroperitoneal lymphadenopathy. Also, the patients who had detectable lymphadenopathy were divided into subgroups consisting of all resected, incompletely resected, unresectable and unknown if all disease was resected. Each subgroup was compared with patients without detectable preoperative lymphadenopathy. Patients with less than were compared to those with greater than 50 cm.3 retroperitoneal lymphadenopathy. Patients undergoing extrarenal resection at nephrectomy (complex surgery) due to direct invasion of the tumor into another intra-abdominal organ were compared with those undergoing radical nephrectomy alone, regardless of lymph node status. Statistical analysis was done with the Mantel-Cox test for comparison of survival on Kaplan-Meier curves and with Fisher's exact test for response rates for IL-2. A total of 154 patients with metastatic renal cell carcinoma underwent cytoreductive nephrectomy as preparation for IL-2 based regimens. There were 82 patients with metastatic renal cell carcinoma and no preoperative retroperitoneal lymphadenopathy who survived longer (median 14.7 months) than the 72 with lymphadenopathy (median 8.5, p = 0.0004). Patients with incompletely resected, unresectable or an unknown volume resected had decreased survival compared to those with no retroperitoneal lymphadenopathy. A multivariate analysis of survival was performed evaluating the known prognostic indicators, performance status and tumor burden, as represented by the number of organs involved with metastases, and the new prognostic factor, lymphadenopathy. Lymphadenopathy was more closely associated with survival than performance status, and appeared to be a new prognostic variable. Patients with and without retroperitoneal lymphadenopathy at initial presentation had similar rates for treatment with IL-2 (54% for both groups). Of the 82 patients with no lymphadenopathy 11 (13%) had long-term survival greater than 5 years. Of the 6 complete responses to IL-2, 5 occurred in this group. Only 1 other patient with incompletely resected retroperitoneal lymphadenopathy survived longer than 5 years. No significant difference in survival was seen between patients who did or did not undergo complex surgery. Patients who presented with metastatic renal cancer and retroperitoneal lymphadenopathy had a shorter survival than those with no detectable retroperitoneal lymphadenopathy. It is warranted to continue to perform complex extrarenal resection during nephrectomy since no significant difference in the response rate for IL-2 or mean survival compared with those of patients undergoing nephrectomy alone is currently detectable.