Disease In Pelvic Lymph Nodes Research Articles

Prostate Cancer Recurrence: Examining the Role of Salvage Radiotherapy Field and Risk Factors for Regional Disease Recurrence Captured on 18F-DCFPyL PET/CT

PurposeThe role of elective pelvic nodal irradiation in salvage radiotherapy (sRT) remains controversial. Utilizing 18F-DCFPyL PET/CT, this study aimed to investigate differences in disease distribution after whole pelvic (WPRT) or prostate bed (PBRT) radiotherapy and to identify risk factors for pelvic lymph node (LN) relapse. MethodsThis retrospective study included patients with PSA > 0.1 ng/mL post-radical prostatectomy (RP) or post-RP and sRT who underwent 18F-DCFPyL PET/CT. Disease distribution on 18F-DCFPyL PET/CT after sRT was compared using Chi-square tests. Risk factors were tested for association with pelvic LN relapse after RP and salvage PBRT using logistic regression. Results979 18F-DCFPyL PET/CTs performed at our institution between 1/1/2022 – 3/24/2023 were analyzed. There were 246 patients meeting criteria, of which 84 received salvage RT after RP (post-salvage RT group) and 162 received only RP (post-RP group). Salvage PBRT patients (n = 58) had frequent pelvic nodal (53.6%) and nodal-only (42.6%) relapse. Salvage WPRT patients (n = 26) had comparatively lower rates of pelvic nodal (16.7%, p = 0.002) and nodal-only (19.2%, p = 0.04) relapse. The proportion of distant metastases did not differ between the two groups. Multiple patient characteristics, including ISUP grade and seminal vesicle invasion, were associated with pelvic LN disease in the post-RP group. ConclusionAt PSA persistence or progression, salvage WPRT resulted in lower rates of nodal involvement than salvage PBRT, but did not reduce distant metastases. Certain risk factors increase the likelihood of pelvic LN relapse after RP and can help inform salvage RT field selection.

CT diagnosis of ilioinguinal lymph node metastases in melanoma using radiological characteristics beyond size and asymmetry.

BackgroundDiagnosis of lymph node (LN) metastasis in melanoma with non-invasive methods is challenging. The aim of this study was to evaluate the diagnostic accuracy of six LN characteristics on CT in detecting melanoma-positive ilioinguinal LN metastases, and to determine whether inguinal LN characteristics can predict pelvic LN involvement.MethodsThis was a single-centre retrospective study of patients with melanoma LN metastases at a tertiary cancer centre between 2008 and 2016. Patients who had preoperative contrast-enhanced CT assessment and ilioinguinal LN dissection were included. CT scans containing significant artefacts obscuring the pelvis were excluded. CT scans were reanalysed for six LN characteristics (extracapsular spread (ECS), minimum axis (MA), absence of fatty hilum (FH), asymmetrical cortical nodule (CAN), abnormal contrast enhancement (ACE) and rounded morphology (RM)) and compared with postoperative histopathological findings.ResultsA total of 90 patients were included. Median age was 58 (range 23–85) years. Eighty-eight patients (98 per cent) had pathology-positive inguinal disease and, of these, 45 (51 per cent) had concurrent pelvic disease. The most common CT characteristics found in pathology-positive inguinal LNs were MA greater than 10 mm (97 per cent), ACE (80 per cent), ECS (38 per cent) and absence of RM (38 per cent). In multivariable analysis, inguinal LN characteristics on CT indicative of pelvic disease were RM (odds ratio (OR) 3.3, 95 per cent c.i. 1.2 to 8.7) and ECS (OR 4.2, 1.6 to 11.3). Cloquet’s node is known to be a poor predictor of pelvic spread. Pelvic LN disease was present in 50 per cent patients, but only 7 per cent had a pathology-positive Cloquet’s node.ConclusionAdditional CT radiological characteristics, especially ECS and RM, may improve diagnostic accuracy and aid clinical decisions regarding the need for inguinal or ilioinguinal dissection.

Primary resistance in docetaxel and androgen deprivation therapy in metastatic castrate sensitive prostate cancer patients.

342 Background: Docetaxel chemotherapy combined with androgen deprivation therapy (ADT) has become the new standard of care in patients with metastatic castrate sensitive prostate cancer as it has shown significant benefit in terms of overall survival (OS) and response rates (Sweeney 2015, James 2016). However a subgroup of patients still experience early progression. Methods: We searched the hospital database for patients treated with docetaxel in the castrate sensitive setting. Eligible patients included those with newly diagnosed metastatic prostate adenocarcinoma and also patients with relapsed metastatic disease post radical radiotherapy or radical prostatectomy. Patients starting chemotherapy > 12 weeks after commencing ADT were excluded. Results: We identified 72 patients treated with docetaxel and ADT between August 2014 and September 2017. The median age was 66 years (49-84 years). Of the 72 patients, 63 (88%) had bone metastases, 5 (7%) had visceral metastases and 45 (63%) had pelvic lymph node disease. Seven patients (9.7%) had relapsed metastatic disease post radical treatment. All patients had ≤6 cycles of docetaxel. Median time from diagnosis of metastatic disease to commencing castrate resistant treatment was 13 months (2-41 months). Median duration of follow-up was 16 months (5-39 months). Six patients (8%) had biochemical, radiological or clinical progression during, or at completion of docetaxel chemotherapy. One patient terminated treatment before completion of six cycles due to disease progression. The median presenting PSA in this group was 49.5 ug/L (9.04-2290 ug/L) and 2 patients had visceral disease. Of these 6 patients, 2 have died, and the median OS for the group was 11.5 months (8-22 months). Five patients were subsequently treated with enzalutamide and 1 with abiraterone. Conclusions: Despite the improvement in OS and response rates with the use of early docetaxel, a clinically significant number of patients developed disease progression during treatment, and these patients have a particularly poor prognosis. These patients should be the focus of future clinical trials.

Oncologic outcomes in men with metastasis to the prostatic anterior fat pad lymph nodes: a multi-institution international study.

BackgroundThe presence of lymph nodes (LN) within the prostatic anterior fat pad (PAFP) has been reported in several recent reports. These PAFP LNs rarely harbor metastatic disease, and the characteristics of patients with PAFP LN metastasis are not well-described in the literature. Our previous study suggested that metastatic disease to the PAFP LN was associated with less severe oncologic outcomes than those that involve the pelvic lymph node (PLN). Therefore, the objective of this study is to assess the oncologic outcome of prostate cancer (PCa) patients with PAFP LN metastasis in a larger patient population.MethodsData were analyzed on 8800 patients from eleven international centers in three countries. Eighty-eight patients were found to have metastatic disease to the PAFP LNs (PAFP+) and 206 men had isolated metastasis to the pelvic LNs (PLN+). Clinicopathologic features were compared using ANOVA and Chi square tests. The Kaplan-Meier method was used to calculate the time to biochemical recurrence (BCR).ResultsOf the eighty-eight patients with PAFP LN metastasis, sixty-three (71.6 %) were up-staged based on the pathologic analysis of PAFP and eight (9.1 %) had a low-risk disease. Patients with LNs present in the PAFP had a higher incidence of biopsy Gleason score (GS) 8–10, pathologic N1 disease, and positive surgical margin in prostatectomy specimens than those with no LNs detected in the PAFP. Men who were PAFP+ with or without PLN involvement had more aggressive pathologic features than those with PLN disease only. However, there was no significant difference in BCR-free survival regardless of adjuvant therapy. In 300 patients who underwent PAFP LN mapping, 65 LNs were detected. It was also found that 44 out of 65 (67.7 %) nodes were located in the middle portion of the PAFP.ConclusionsThere was no significant difference in the rate of BCR between the PAFP LN+ and PLN+ groups. The PAFP likely represents a landing zone that is different from the PLNs for PCa metastasis. Therefore, the removal and pathologic analysis of PAFP should be adopted as a standard procedure in all patients undergoing radical prostatectomy.Electronic supplementary materialThe online version of this article (doi:10.1186/s12894-015-0070-1) contains supplementary material, which is available to authorized users.

MP53-16 ONCOLOGIC OUTCOMES IN MEN WITH METASTASIS TO THE PROSTATIC ANTERIOR FAT PAD LYMPH NODES: A MULTI-INSTITUTION INTERNATIONAL STUDY

Background: The presence of lymph nodes (LN) within the prostatic anterior fat pad (PAFP) has been reported in several recent reports. These PAFP LNs rarely harbor metastatic disease, and the characteristics of patients with PAFP LN metastasis are not well-described in the literature. Our previous study suggested that metastatic disease to the PAFP LN was associated with less severe oncologic outcomes than those that involve the pelvic lymph node (PLN). Therefore, the objective of this study is to assess the oncologic outcome of prostate cancer (PCa) patients with PAFP LN metastasis in a larger patient population. Methods: Data were analyzed on 8800 patients from eleven international centers in three countries. Eighty-eight patients were found to have metastatic disease to the PAFP LNs (PAFP+) and 206 men had isolated metastasis to the pelvic LNs (PLN+). Clinicopathologic features were compared using ANOVA and Chi square tests. The Kaplan-Meier method was used to calculate the time to biochemical recurrence (BCR). Results: Of the eighty-eight patients with PAFP LN metastasis, sixty-three (71.6 %) were up-staged based on the pathologic analysis of PAFP and eight (9.1 %) had a low-risk disease. Patients with LNs present in the PAFP had a higher incidence of biopsy Gleason score (GS) 8–10, pathologic N1 disease, and positive surgical margin in prostatectomy specimens than those with no LNs detected in the PAFP. Men who were PAFP+ with or without PLN involvement had more aggressive pathologic features than those with PLN disease only. However, there was no significant difference in BCR-free survival regardless of adjuvant therapy. In 300 patients who underwent PAFP LN mapping, 65 LNs were detected. It was also found that 44 out of 65 (67.7 %) nodes were located in the middle portion of the PAFP. Conclusions: There was no significant difference in the rate of BCR between the PAFP LN+ and PLN+ groups. The PAFP likely represents a landing zone that is different from the PLNs for PCa metastasis. Therefore, the removal and pathologic analysis of PAFP should be adopted as a standard procedure in all patients undergoing radical prostatectomy.

11C]Choline Positron Emission Tomography/Computerized Tomography to Restage Prostate Cancer Cases With Biochemical Failure After Radical Prostatectomy and No Disease Evidence on Conventional Imaging

We assessed the value of [11C]choline positron emission tomography/computerized tomography in patients with prostate cancer in whom biochemical failure developed after radical prostatectomy but who showed no disease evidence on conventional imaging. Considered for this study were 2,124 patients treated with radical prostatectomy who underwent [11C]choline positron emission tomography/computerized tomography to restage disease between December 2004 and January 2007. Study inclusion criteria were 1) previous radical prostatectomy and pelvic lymph node dissection, 2) increasing prostate specific antigen beyond 0.2 ng/ml after radical prostatectomy, 3) no lymph node disease at radical prostatectomy, 4) no evidence of metastatic disease on conventional imaging, 5) no androgen deprivation therapy and 6) no adjuvant or salvage radiotherapy. These criteria were satisfied in 109 of the 2,124 patients (5%). Median prostate specific antigen at imaging was 0.81 ng/ml (range 0.22 to 16.76 ml). Imaging suggested local recurrence in 4 patients (4%) and pelvic lymph node disease in 8 (7%). Scans were positive in 5%, 15% and 28% of patients with prostate specific antigen less than 1, between 1 and 2, and greater than 2 ng/ml, respectively (p <0.05). Prostate specific antigen was the only significant predictor of tomography results (p <0.05). Positron emission tomography/computerized tomography detected increased [11C]choline uptake, suggesting recurrent disease in 11% of patients with prostate cancer, increasing prostate specific antigen after radical prostatectomy and no evidence of disease on conventional imaging. This modality may be useful to restage disease but it cannot be used to guide therapy.

Endometrial cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up

Endometrial cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up

Neues TNM/FIGO-Staging-System für das Zervix- und Endometriumkarzinom sowie maligne Müller'sche Mischtumoren (MMMT) des Uterus

Recent studies of endometrial and cervical carcinomas have shown that the FIGO/TNM classification of malignant tumors in these organs must be revised. Molecular data found that malignant mixed Mullerian tumors (MMMT) are, in fact, epithelial in origin. Starting from January 1, 2010, a new FIGO/TNM classification will be used. There will be a new subclassification of carcinomas of the uterine cervix with proximal vaginal infiltration, using the same cut-off for tumor extension as has been used for stage FIGO IB/T1b ( 4 cm), resulting in stage FIGO IIA1/T2a1 and FIGO IIA2/T2a2. In endometrial carcinoma, the previous FIGO IA/pT1a and FIGO IB/pT1b will be merged into FIGO IA/pT1a. The former category FIGO IC/T1c will change to FIGO IB/T1b. The category FIGO IC/pT1c will no longer be used. Additionally, there will be no separate classification for the involvement of the endocervical glands by endometrial carcinoma. This feature will be incorporated in stage FIGO I/T1 disease. The new category FIGO II/T2 will be defined as endocervical stromal involvement. There will be a new category, termed T3c/IIIC, which will include regional lymph node involvement. Stage T3c1/IIIC1 will be defined as pelvic lymph node involvement and stage T3c2/IIIC2 as para-aortal lymph node involvement with or without pelvic lymph node disease. In the TNM system, regional lymph node involvement can alternatively be classified as N1. MMMT will be staged like endometrial carcinoma.

Extracapsular extension of pelvic lymph node metastases is of prognostic value in carcinoma of the cervix uteri

Objectives Pelvic lymph node involvement is a well-recognized prognostic factor in cervical carcinoma (CX). Limited knowledge exists about extranodal extension of the tumor outside the lymph node capsule, i.e. extracapsular spread (ECS). Methods Two hundred fifty-six cases of surgically treated CX (FIGO stage IB1 to IIB) with pelvic lymph node involvement were evaluated regarding the occurrence of extranodal spread of the metastatic deposits outside the lymph node capsule (ECS), determined on standardized handled lymphadenectomy specimens, regarding their impact of recurrent disease and overall survival during a median follow-up time of 62 months (95% CI 51–73 months). Results ECS was seen in 30.9% (79/256) of the cases. The occurrence of ECS showed a significant correlation to advanced stage disease ( p = 0.02), the number of involved nodes ( p < 0.001) and the size of metastatic deposits ( p < 0.01). The 5-year recurrence-free survival rate in patients with ECS was significant lower compared to patients without ECS (59.7% [95% CI: 46.3%–73.2%] versus 67.2% [95% CI: 58.9%–75.5%]; ( p = 0.04). The 5-year overall survival rate was significant lower in patients with ECS (33.5% [95% CI: 20.6%–46.3%] vs. 60.5% [95% CI: 52.3%–68.6%]; p < 0.001). In multivariate analysis, tumor stage, number of involved pelvic nodes, tumor differentiation and ECS were independent prognostic factors. Conclusions The results indicate that extracapsular spread (ECS) of pelvic lymph node metastases is of prognostic impact in cervical carcinomas. A revised FIGO/TNM classification system for pelvic lymph node disease is recommended: ECS 0 = lymph node involvement without extranodal spread of the metastatic deposits and ECS 1 = lymph node involvement with extranodal spread of the metastatic deposits.

Pattern of invasion is of prognostic value in surgically treated cervical cancer patients

Objectives. Different patterns of invasion (representing different grades of tumor cell dissociation) are associated with prognostic outcome in cancer. We evaluated the prognostic value of different patterns of invasion (PI) in cervical carcinomas (CX). Methods. Six hundred eleven surgically treated CX (FIGO IB to IIB) were re-evaluated histologically regarding the PI, using a three-level scoring system. Closed PI was defined as cohesive growth with well-delineated (pushing) borders. In finger-like PI the tumor grows in solid cords/trabecles. Highly dissociative growth in small groups or single cells was defined as spray-like PI. Types of PI were correlated to tumor stage, histo-morphologic factors and prognostic outcome. Results. Sixty percent of the tumors showed a spray-like PI, 30% a finger-like PI and only 7.4% were of the closed type. Spray-like PI showed a significant correlation with advanced stage disease, lymphovascular space involvement, poorly differentiated tumors and pelvic lymph node metastases. Spray-like PI was accompanied by a reduced 5-year overall survival when compared to the finger-like and closed PI (68.7% vs. 80.9% vs. 88.5%; P = 0.0004). The prognostic impact of the PI disappeared in node-positive patients ( P = 0.06) but persisted in patients without pelvic lymph node disease ( P = 0.03). In multivariate analysis, using COX regression model, the PI represented as independent prognostic factor. Conclusions. Spray-like PI (i.e., highest degree of tumor cell dissociation) is associated with advanced tumor stages, increased rate of recurrency and a reduced overall survival. In separate analysis of patients with and without lymph node metastases, the impact of PI persisted only in node-negative cases as a prognostic factor.

Residual pelvic lymph node involvement after concomitant chemoradiation for locally advanced cervical cancer

Objective. Concomitant chemoradiation (and brachytherapy) has become the standard treatment for locally advanced cervical cancers (FIGO stage IB2 to IVA). Adjuvant surgery is optional. The aim of this study was to evaluate the rate of residual positive pelvic lymph nodes after chemoradiation. Methods. From February 1988 to August 2004, 113 patients with locally advanced cervical cancer have been treated by chemoradiation followed by an adjuvant surgery with a pelvic lymphadenectomy performed (study group). A para-aortic lymphadenectomy had also been performed in 85 of them. Results. The mean age of the patients was 48.4 years (27–74). FIGO stage was: IB2 in 17.7% (20/113), II in 44.2% (50/113), III in 21.2% (24/113) and IVA in 16.8% of the patients (19/113). The mean number of removed nodes was 11.5 (median 11) in pelvic, and 7.5 (median 7) in para-aortic basins. A pelvic lymph node involvement was present in 15.9% (18/113) of the patients after chemoradiation. In 11 patients, only one node was positive. 11.7% (10/85) of the patients had a para-aortic lymph node involvement. A residual pelvic lymph node disease has been observed in 6.3% (4/63) of the cases with no residual cervical disease (or microscopic) versus 26.5% (13/49) of the cases with macroscopic residual cervical tumor ( P = 0.003). Conclusions. Our experience shows that a pelvic lymph node involvement persists in about 16% of the patients after chemoradiation. We can make the assumption that performing a pelvic lymphadenectomy along with the removal of the primary tumor after chemoradiation could reduce the rate of latero-pelvic recurrences, whatever the para-aortic lymph node status.

Ganglionar metastization on radical prostatectomy

To analyze retrospectively 19 patients with positive pelvic lymph node disease obtained with a radical prostatectomy. To discuss the actual role of pelvic lymphadenectomy and evaluate the results obtained using one treatment protocol. Between January 1993 and December 2001 450 patients underwent radical prostatectomy for localized prostate cancer. Nineteen patients were identified as having positive ganglionar disease (4.2%). The mean PSA value of the 450 patients was 11.8 ng/ml (ranging 1.9 - 40 ng/ml). We analyzed the survival curves using the method of Kaplan-Meier, based on non recurrence of elevated biochemical total PSA values. The mean follow up time was 37.7 months. The recurrence of disease was defined by two consecutive determinations of PSA values greater than 0.2 ng/ml. the mean age of the nineteen patients was 66 years, varying between 56 and 74. The specific survival curve for these patients shows a survival probability of 60.9%, after 5 years. The survival curve of biochemical free recurrence shows a probability of 37.5%, after 5 years. A progressive decrease in the incidence of patients with ganglionar disease was observed after radical prostatectomy. It is therefore disputable the role of routine lymphadenectomy, its advantages, disadvantages and indications. The scientific analysis have permited great controversy regarding treatment. Our results with a treatment protocol which utilizes preventive adjuvant radiotherapy together with hormone treatment, initially differed and actually systematic, shows a survival rate similar to other studies. The actual indication of lymphadenectomy is maintained in radical retropubic prostatectomy and in patients with a risk of extracapsular disease in perineal prostatectomy or laparoscopy prostatectomy. The monotherapy offers a limited potential of cure. An extensive disease needs an aggressive therapy. A combination of adjuvant radiation therapy and simultaneous hormone treatment is indicated until there exists a randomized study, with an adequate follow up time, to determine which treatment strategy is the best.

Is there a role for pelvic lymph node debulking in advanced cervical cancer?

The purpose of this study is to determine if a survival advantage exists from surgical debulking of enlarged pelvic lymph nodes in advanced cervical cancer. Using information from studies published on the topic of debulking lymph nodes in locally advanced cervical cancer along with baseline control rates of standard treatment and patterns of failure, an estimate of how many patients with bulky pelvic lymph node disease would benefit from this procedure was calculated. The design and feasibility of a randomized trial to test this intervention is also discussed. Based on our calculations 1, 2, and 4% of stage IB, IIB, and IIIB patients, respectively, would benefit from a debulking procedure. Based on our calculations with such small differences in survival along with other inclusion and exclusion criteria, a randomized trial, which would compare chemoradiation to chemoradiation and surgery, would require anywhere from 10,000-30,000 patients per arm. A very small fraction of patients would benefit from a surgical debulking procedure of pelvic nodes. A randomized controlled trial to test this research question is not feasible. A subset population is identified which may benefit from a debulking approach.

Is There a Role for Pelvic Lymph Node Debulking in Advanced Cervical Cancer?

Objective. The purpose of this study is to determine if a survival advantage exists from surgical debulking of enlarged pelvic lymph nodes in advanced cervical cancer. Methods. Using information from studies published on the topic of debulking lymph nodes in locally advanced cervical cancer along with baseline control rates of standard treatment and patterns of failure, an estimate of how many patients with bulky pelvic lymph node disease would benefit from this procedure was calculated. The design and feasibility of a randomized trial to test this intervention is also discussed. Results. Based on our calculations 1, 2, and 4% of stage IB, IIB, and IIIB patients, respectively, would benefit from a debulking procedure. Based on our calculations with such small differences in survival along with other inclusion and exclusion criteria, a randomized trial, which would compare chemoradiation to chemoradiation and surgery, would require anywhere from 10,000–30,000 patients per arm. Conclusions. A very small fraction of patients would benefit from a surgical debulking procedure of pelvic nodes. A randomized controlled trial to test this research question is not feasible. A subset population is identified which may benefit from a debulking approach.

Serum M3/M21 in cervical cancer patients.

Cytokeratins are polypeptides which constitute a subclass of intermediate filaments in epithelial cells. The serum tumour marker M3/M21 is based on monoclonal antibodies against the epitopes M3 and M21 of cytokeratin 18. In the present study, we measured M3/M21 serum levels in 50 patients with FIGO stage IB-IIB cervical cancer and in 50 control subjects using a two-site radiometric immunoassay directed against soluble fragments of cytokeratin 18. Median serum levels of M3/M21 in patients with cervical cancer and in normal controls were 70.6 U/ml (range 0-397.7) and 6.5 U/ml (range 0-205.2), respectively (Mann-Whitney U-test, P = 0.0001). Median serum levels of M3/M21 prior to therapy and 4 weeks after therapy were 104.2 U/ml (range 24.6-397.7) and 39.3 U/ml (range 0-234.7), respectively (Mann-Whitney U-test, P = 0.004). We found a significant correlation between elevated M3/M21 serum levels and metastatic disease in pelvic lymph nodes (Mann-Whitney U-test, P = 0.002). 24 patients relapsed after complete remission. In these patients, elevated M3/M21 serum levels before the detection of relapse by computed tomography was observed in 13 cases. Considering these preliminary results, further studies with an increased number of patients are justified to clarify the prognostic value and the monitoring abilities of M3/M21 in cervical cancer patients.

Pelvic relapse following subtotal lymphoid irradiation in early stage Hodgkin's disease—An analysis of risk, management, and outcome

To evaluate the time of onset, method of identification, management, and outcome of pelvic relapse following subtotal lymphoid irradiation (STLI) alone (mantle and paraaortic/spleen or splenic pedicle fields, excluding the pelvis) in supradiaphragmatic Stage I-II Hodgkin's disease. A retrospective analysis was performed of the initial, relapse, and regular follow-up evaluations of patients with pelvic relapse following STLI alone from 1968 to the present for supradiaphragmatic Stage I-II Hodgkin's disease after pathologic staging (PS-laparotomy staging) and clinical staging (CS-no laparotomy staging). Following staging, which included bipedal lymphangiography, 482 patients (408 PS and 74 CS), were treated with STLI alone for supradiaphragmatic Stage I-II Hodgkin's disease. The actuarial freedom from relapse at 20 years was 75% in PS patients and 81% in CS patients. The actuarial pelvic failure at 20 years was 7% for PS patients and 3% for CS patients. Of the 29 patients with pelvic relapse, 97% (28 of 29) occurred within 5 years of treatment, including 1 patient who progressed during initial treatment. Pelvic relapse was most commonly initially identified by abnormalities involving patient symptoms (62%), physical examination (55%), erythrocyte sedimentation rate (48%), and bipedal lymphangiogram and/or abdominal radiograph (38%). Relapse was limited to previously unirradiated sites in 17 patients (58%). In addition to pelvic lymph node disease, 3 patients (10%) had involvement of bone, and 4 patients (14%) had bone marrow involvement. Following relapse, all patients were treated with chemotherapy (MOP[P], MOP[P]/ABV[D], ABVD, or PAVe) and 19 of 29 patients received involved field consolidative irradiation. Twenty-one of 29 (72%) remained relapse free at the time of last follow-up evaluation, including 15 of 19 (79%) treated with combined therapy. Eight patients experienced a second relapse despite salvage therapy, and all eight expired with recurrent Hodgkin's disease. Two patients died of complications related to prior treatment. Therefore, the actuarial risk of death at 20 years associated with pelvic failure in the entire cohort of 482 patients was 2%. Pelvic relapse occurred in 7% of patients following STLI alone and was effectively diagnosed by regular follow-up, which included a combination of patient history, physical examination, and radiographic laboratory evaluation. Seventy-two percent of patients remained relapse free following salvage treatment, which included chemotherapy, resulting in an overall survival rate associated with pelvic control of 98%. This approach, therefore, spared the majority of patients the long-term risks associated with pelvic irradiation and/or chemotherapy, such as infertility, but maintained an excellent prognosis.

Radiotherapy following radical prostatectomy in patients with adenocarcinoma of the prostate

From 1973 to 1986, 160 patients with adenocarcinoma localized to the prostate were treated with radical prostatectomy and pelvic lymphadenectomy. In 78 (49%) patients more advanced stage of disease was found at surgery and they received local pelvic irradiation (RT). This consisted of 45 Gy for microscopic and 55 Gy for macroscopic residual disease. RT was given at 1.8 Gy a day, using the four-field “box” technique with the 23 MV X ray beam. Pelvic lymph node metastases were found in 28 (36%) patients who, in addition to RT, received systemic therapy: 20 with cyclophosphamide alone, 4 combined with 5-Fluorouracil, and 4 patients received DES. The 5- and 10-year overall actuarial survival was 95 and 77%, respectively, and the 5- and 10-year disease-free survival was 58 and 43%, respectively. Recurrent tumor was found in 34 (44%) patients. Of these 34 patients, 32 (94%) had distant metastatic tumor and 2 (6%) had local recurrence in the pelvis. The presence of metastatic disease in pelvic lymph nodes had clinical significance since it influenced disease-free survival and the incidence of tumor recurrence. The 10-year disease-free survival for the 50 patients with no lymph node metastases was 51%, as compared to 28% for the 28 patients with such metastases, p = 0.001. Similarly, recurrent tumor was found in 28% of the former and 68% of the latter patients, p = 0.002. Other important parameters predicting recurrence were: clinical stage, p = 0.018, histological grade, p = 0.013, and Gleason's grade, p= 0.002. This treatment program was very well tolerated and of low toxicity. There was no surgical mortality. Surgical complications were seen in 10 (13%) patients including: minor in 5 and major in 5. At 1 year, 77% of the patients remained continent, while 10% had mild stress incontinence. Of the remaining 13% only 3 (4%) patients had severe incontinence (5 pads daily). RT toxicity was mild with 38% experiencing diarrhea. Severe toxicity was seen in 2 (3%) patients who, early in the study, developed scrotal and lower extremity edema. Severe chemotherapy complications were seen in 1 (4%) patient who had severe neutropenic sepsis. Postoperative radiotherapy is a well tolerated, safe and effective treatment in patients who have microscopic or macroscopic residual tumor following radical prostatectomy.

The influence of pelvic lymph node disease on survival for stage I and II carcinoma of the cervix

Two hundred and eighteen patients were referred to the Oxford Radiotherapy Department in the 5 years 1973-77 with stages I and II tumours of the uterine cervix. One hundred and eighty-one underwent pre-operative intracavitary radiotherapy followed by Wertheim hysterectomy and pelvic lymphadenectomy. Twenty-three per cent of these patients had metastatic disease in pelvic lymph nodes. Fifty-five per cent of patients with positive pelvic nodes died of carcinoma of the cervix compared with 9% of negative node cases. Prognostic factors are discussed and management of carcinoma of the cervix reviewed.