Nodal Control Rates Research Articles

Breast Conservation Therapy Without Axillary Dissection

Patients with early stage breast cancer are being treated with adjuvant systemic therapy with increasing frequency regardless of the pathological status of the axillary lymph nodes. The purpose of this study was to determine the outcome for local regional control in patients treated with radiation therapy to the intact breast and regional lymph nodes without axillary dissection. The patient population for this study consists of 327 patients with clinical stage I or II invasive breast cancer who were treated by lumpectomy alone without axillary dissection followed by radiation therapy to the intact breast and regional lymph nodes. Outcome for local regional control and survival is reported. As of December 1990, with a median follow-up of more than 10 years, the overall 10-year survival rate was 71%. There were a total of eight regional nodal failures resulting in a 5-year actuarial nodal control rate of 97%. Minimal morbidity was associated with this treatment policy. For selected patients undergoing breast preservation therapy, lumpectomy alone without axillary dissection followed by radiation therapy to the intact breast and regional lymph nodes results in a high rate of local regional control. Selected patients in whom the results of the axillary lymph node dissection will not influence decisions regarding systemic therapy are candidates for this approach.

LOCALLY ADVANCED (STAGE III AND IV) HEAD AND NECK CANCER: WESTMEAD HOSPITAL EXPERIENCE

Two hundred and fifty-one patients with stage iii and iv (uicc staging system) squamous cell cancers of the oral cavity, oropharynx, hypopharynx and larynx were assessed between january 1980 and december 1988 at westmead hospital. Of these, 50 patients received palliative treatment or were not treated and the remaining 201 patients received treatment with curative intent by various combinations of radiotherapy, surgery and chemotherapy. Thirty-nine operable cases were entered into a multimodality protocol initiated in april 1985, which consisted of induction chemotherapy (cisplatin 100mg/m2 i.v. day 1, 5-fluorouracil 1000mg/m2 per 24h i.v. days 1–5, q3w × 2) followed by surgery and postoperative radiotherapy. The median follow-up for all 251 patients was 57 months. Actuarial 3-year survival rate for all 201 patients receiving radical treatment was 48% (stage iii 66%. Stage iv 36%p < 0.001). Overall actuarial local and nodal control rates at 3 years were 67% and 69%. Thirty-two of 201 patients (16%) developed distant metastases at a median time of 11 months. Twenty-one patients (10%) had a previous or subsequent second primary cancer. In the group of 39 protocol patients, overall actuarial survival, local and nodal control rates are 68%, 77% and 73% at 3 years. A group of 22 ‘protocol’ patients was compared with a group of 22 patients treated prior to commencement of the protocol, matched as closely as possible on the basis of site, stage, age, sex and ecog status. Utilizing risk ratios, the protocol group was 4.14 times more likely to survive than the matched non-protocol group (p = 0.023). Nineteen patients were eligible for admission to the protocol but were not entered because their tumours were assessed to be of limited extent. This group received less extensive treatment and was analysed for actuarial survival (57%). Local control (66%) and nodal control (77%). Eight patients entered onto the protocol did not undergo surgery on the grounds of achieving a complete response (clinically or histologically) to induction chemotherapy. Local control was 3 of 8 patients (38%) and nodal control 2 of 8 patients (25%). Only two of these eight patients are alive, with a median follow-up of 12 months. Complications of all treatment modalities were acceptable. We conclude that survival rates in locally advanced head and neck cancer patients may be significantly improved by multimodality regimens and that less extensive treatments in patients responding favourably to chemotherapy may give inferior results. However, the limitations of a retrospective analysis based upon small patient numbers require that these findings are confirmed in properly conducted randomized prospective clinical trials. Chemotherapy currently remains an investigational modality in the treatment of locally advanced head and neck cancer.

LOCALLY ADVANCED (STAGE III AND IV) HEAD AND NECK CANCER: WESTMEAD HOSPITAL EXPERIENCE

Two hundred and fifty-one patients with Stage III and IV (UICC staging system) squamous cell cancers of the oral cavity, oropharynx, hypopharynx and larynx were assessed between January 1980 and December 1988 at Westmead Hospital. Of these, 50 patients received palliative treatment or were not treated and the remaining 201 patients received treatment with curative intent by various combinations of radiotherapy, surgery and chemotherapy. Thirty-nine operable cases were entered into a multimodality protocol initiated in April 1985, which consisted of induction chemotherapy (cisplatin 100 mg/m2 i.v. day 1, 5-fluorouracil 1000 mg/m2 per 24 h i.v. days 1-5, q3w x 2) followed by surgery and postoperative radiotherapy. The median follow-up for all 251 patients was 57 months. Actuarial 3-year survival rate for all 201 patients receiving radical treatment was 48% (Stage III 66%, Stage IV 36%; P less than 0.001). Overall actuarial local and nodal control rates at 3 years were 67% and 69%. Thirty-two of 201 patients (16%) developed distant metastases at a median time of 11 months. Twenty-one patients (10%) had a previous or subsequent second primary cancer. In the group of 39 protocol patients, overall actuarial survival, local and nodal control rates are 68%, 77% and 73% at 3 years. A group of 22 'protocol' patients was compared with a group of 22 patients treated prior to commencement of the protocol, matched as closely as possible on the basis of site, stage, age, sex and ECOG status.(ABSTRACT TRUNCATED AT 250 WORDS)

Concomitant boost radiotherapy schedules in the treatment of carcinoma of the oropharynx and nasopharynx

Concomitant boost schedules are characterized by delivering the boost (10–12 fractions) as second daily treatments during rather than following the basic wide field irradiations. This results in shortening the overall time to administer 69–72 Gy from 712−8 weeks to 6 weeks, which we hoped would improve the tumor control rate by reducing the opportunity for tumor clonogens to regenerate during treatment. From August 1985 to August 1988, 79 patients with T2-4 carcinomas of the oropharynx (72 patients) or nasopharynx (7 patients) were treated according to 1 of the 3 variants of the concomitant boost technique. The median age of patients was 60 years (range: 19–84 years) and the male-to-female ratio was 2.6. The overall 2-year actuarial primary and nodal control rates by radiotherapy alone were 74% and 76%, respectively. The ultimate 2-year control rates after surgical salvage were 82% and 84%, respectively. If the boost given during the last 2–21 weeks of basic treatment, a slightly better primary control rate (p = 0.11) resulted than if the boost was delivered during the first 2−212 weeks or twice a week throughout the basic treatment. The 2-year actuarial primary control rate of the 13 patients receiving induction chemotherapy prior to radiotherapy was significantly lower than that of patients treated with radiation only (81% vs 34%, p = 0.01), but this could be partly attributed to a more advanced stage in the chemotherapy group. The acute mucosal reactions were, as expected, more severe than those observed with conventional fractionation. Fifty patients developed confluent mucositis covering more than half of the boost area. Such reactions lasted for more than 6 weeks in seven patients. Late complications, however, so far observed, have been few. Three patients experienced chronic mucosal tenderness, 1 chronic mucosal ulceration, 2 transient bone exposure, and 1 carotid rupture following salvage surgery. The results so far appear to be better than the outcome of conventional radiotherapy. Its real value will be determined in a prospective randomized study.

Regional nodal irradiation in the conservative treatment of breast cancer

At this institution conservative treatment of breast cancer was begun in the 1960's. The following analysis represents our experience through 1984 with specific reference to the management of the regional lymph nodes. A total of 432 patients with clinical stage I and II breast cancer were treated between 1962 and 1984 with lumpectomy and radiation therapy. The breast was treated with tangential fields to a median dose of 4800 cGy and electron conedown to a total tumor bed dose of 6400 cGy. Axillary dissection was not routinely performed, particularly in the earlier years. More recently, axillary dissection has been used with increasing frequency if it was felt that the results of the dissection would influence systemic treatment. One hundred eighty-seven patients (43%) underwent axillary dissection (30% pathologically positive) and routinely received regional nodal irradiation (median dose 4600 cGy) to the internal mammary and supraclavicular lymph nodes. Two hundred forty-five patients (57%) did not undergo axillary dissection and routinely received regional nodal irradiation to the internal mammary, supraclavicular, and entire axillary regions to a total median dose of 4600 cGy. As of May 1989 with a median follow-up of 7.5 years, there have been a total of 12 nodal failures for an actuarial nodal control rate of 97% at 5 years and 96% at 10 years. The actuarial 5-year regional nodal control rate was the same for both the group of patients receiving regional RT alone without axillary dissection and the group of patients receiving axillary dissection and supraclavicular/internal mammary radiation. There has been minimal morbidity associated with this treatment policy. We conclude that regional nodal irradiation as described above, with or without axillary dissection, results in a high rate of regional nodal control and minimal treatment morbidity in patients undergoing conservative treatment of early stage breast cancer.

The effectiveness of treatment of lymph nodes in cancers of the pyriform sinus and supraglottis.

Three hundred and twelve patients with pyriform sinus or supraglottic cancer were reviewed with respect to effectiveness of therapy upon nodal control. All patients had a minimum 3-year follow-up. Combined modality therapy (radiotherapy and surgery) conferred a higher neck control rate for both N0/N1 and N2/N3 nodes than moderate dose (50 to 60 Gy) radiotherapy alone. Neck dissection appeared to be a significant component of therapy for all neck stages. Fixed nodes, a subset of N2/N3 disease with a very poor prognosis, required combined modality therapy for the best nodal control rates. Downstaging to pN0 with preoperative radiotherapy provided superior nodal control and survival rates.