Recommendations For Radiotherapy Research Articles

Low Grade, Indolent Lymphomas of the Head and Neck: Comparative Toxicity of Standard Versus Very Low Dose Radiation Therapy

NCCN guidelines recommend radiation therapy (RT) for the treatment of localized indolent non-Hodgkin lymphomas (NHL). Yet many referring physicians avoid recommending RT to the head and neck (HN) due to fears of RT-related toxicities despite the limited fields and doses currently used. Further, in recent years, very low doses of radiation (4Gy) that effectively produce local control in select patients have gained popularity. We compared early and late toxicity profiles of standard 24-30Gy to very low dose 4Gy in patients with indolent NHL of the HN. We retrospectively analyzed 239 patients with indolent NHL of the HN who received RT from 1994-2017. Baseline patient characteristics, outcomes, and toxicity data were collected from medical records. Early (≤2 months post-RT) and late (>2 months post-RT) toxicities were graded as low grade (1-2) or high grade (3-4) according to CTCAEv4 criteria. Incidence of any toxicity was compared between the 4Gy and >4Gy cohorts, grouped by RT-site treated (orbit, non-orbit head, neck, skin) and by early vs late. Median follow-up was 1.8 years and 5.3 years for 4Gy and >4Gy cohorts, respectively. Median dose for the >4Gy cohort was 30Gy (5.4-50Gy). There was a lower incidence of both early and late toxicities of any grade in the 4Gy cohort compared to >4Gy across all RT-sites (Table 1). There were no early grade 2 toxicities in the 4Gy group, and incidences in the >4Gy group were as follows: orbit, 14%; non-orbit head, 48%; neck, 38%; skin, 0%. One early high grade toxicity occurred in the >4Gy cohort (dry mouth). Late grade 2 toxicities were infrequent among both the 4Gy and >4Gy groups: orbit (10% vs 7%), non-orbit head (6% vs 8%), neck (0% vs 13%), and skin (0% vs 0%). There were 17 late high grade toxicities (cataracts requiring surgery) in the >4Gy group; however, no information was available to differentiate whether these were age- or RT-related cataracts. There were no grade 4 toxicities in either treatment group. Seventy-three percent of patients in the 4Gy cohort, and 89% in the >4Gy cohort, achieved a complete response at the site of RT. There were 5 in-field failures after initial CR in the 4Gy cohort, and 8 in the >4Gy group. RT to the HN region for indolent NHL is associated with minimal short- and long-term toxicity and excellent local disease control among both 4Gy and >4Gy treatment groups. Thus, toxicity should not be cited as a reason to forgo standard dose RT in the treatment of indolent NHLs of the HN. Further, in select patients for whom early or late toxicity is a concern, very low dose RT may be considered.Abstract MO_1_2459; Table 1SiteEarly toxicityLate toxicity4 Gy (n)(%)>4 Gy (n)(%)4 Gy (n)(%)>4 Gy (n)(%)Orbit5 (12)(42)68 (70)(97)2 (10)(20)48 (68)(71)Non-orbit head4 (17)(24)50 (52)(96)1 (17)(6)34 (51)(67)Neck4 (18)(22)76 (81)(94)1 (18)(6)45 (79)(57)Skin5 (16)(31)13 (15)(87)0 (15)(0)6 (13)(46) Open table in a new tab

Radiation Therapy to Sites of Metastatic Disease as Part of Consolidation in High-Risk Neuroblastoma: Can Long-term Control Be Achieved?

As part of consolidative therapy in high-risk neuroblastoma, modern protocols recommend radiation therapy (RT) both to the primary site and to sites of metastatic disease that persist after induction chemotherapy. Although there are abundant data showing excellent local control (LC) with 21Gy directed at the primary site, there are few data describing the feasibility and efficacy of RT directed at metastatic sites of disease as part of consolidation. All patients with neuroblastoma who received RT to metastatic sites of disease as a part of consolidative therapy at a single institution between 2000 and 2015 were reviewed. Among 159 patients, 244 metastases were irradiated. The median follow-up period among surviving patients was 7.4years. Over 85% of the irradiated metastases were treated with 21Gy (range, 10.5-36Gy). Tumor recurrence occurred in 43 of 244 irradiated metastases (18%). The 5-year LC rate of treated metastatic sites was 81%. Metastatic sites that cleared with induction chemotherapy had improved LC compared with sites with persistent uptake on metaiodobenzylguanidine scans (LC rate, 92% vs 67%; P<.0001).LC at irradiated metastatic sites did not differ based on total number of sites irradiated or site of disease irradiated (bone vs soft tissue). Patients with bulky, resistant disease who were treated with 30 to 36Gy had worse LC (P=.02). However, on multivariate analysis, only persistence after induction chemotherapy remained a significant prognostic factor for LC (hazard ratio, 3.7; P<.0001). Patients who had LC at irradiated metastatic sites had improved overall survival compared with those who did not (overall survival rate, 71% vs 50%; P<.0001). Response to chemotherapy is an important prognostic factor for LC at irradiated metastatic sites in neuroblastoma. Overall, consolidative RT appears to be an effective modality of LC. Long-term disease control can be achieved with such an approach.

Specialty bias in treatment recommendations and quality of life among radiation oncologists and urologists for localized prostate cancer

Given the importance of physician attitudes about different treatments and the quality of life (QOL) in prostate cancer, we performed a national survey of specialists to assess treatment recommendations and perceptions of treatment-related survival and QOL. We mailed a self-administered survey instrument to a random sample of 1366 specialists in the U.S. Respondents were asked for treatment recommendations and survival that varied by PSA levels and Gleason scores and estimate QOL outcomes. Pearson's chi-square and multivariable regression models were used to test for differences in each outcome. Response rates were similar for radiation oncologists (52.6%) and urologists (52.3%; P=0.92). Across all risk strata, urologists were more likely to recommend surgery than were radiation oncologists, for conditions ranging from PSA>20 and Gleason score 8-10 (35.2 vs. 0.2%; P<0.001) to PSA 4-10 and Gleason score 7 (87.5 vs. 20.9%; P<0.001). Radiation oncologists were also more likely to recommend radiation therapy relative to urologists (all P<0.001). From low- to high-risk prostate cancer, radiation oncologists and urologists perceived their treatment as being better for improving survival (all P<0.001). Each specialty also viewed their treatment as having less urinary incontinence (all P<0.001). Radiation oncologists and urologists both prefer the treatment modalities they offer, perceive them to be more effective and to lead to a better QOL. Patients may be receiving biased information, and a truly informed consent process with shared decision-making may be possible only if they are evaluated by both specialties before deciding upon a treatment course.

547 A NATIONAL SURVEY OF RADIATION ONCOLOGISTS AND UROLOGISTS ON ACTIVE SURVEILLANCE FOR LOW-RISK PROSTATE CANCER

INTRODUCTION AND OBJECTIVES: While active surveillance (AS) is well recognized as an acceptable treatment strategy for low-risk prostate cancer (PC), the extent to which radiation oncologists and urologists perceive AS as effective and routinely recommend it to patients is unknown. Therefore, we sought to assess the attitudes and treatment recommendations for low-risk PC from a national survey of PC specialists. METHODS: A mail survey was sent to a population-based sample of 1,439 physicians in the U.S. from late 2011 and early 2012. Physicians were queried about their attitudes regarding AS and treatment recommendations for patients diagnosed with low-risk PC (PSA 10 ng/dl; T1c; and Gleason 6). Pearson Chi-square and multivariate logistic regression were used to test for differences in attitudes and treatment recommendations by physician demographics, compensation structure, primary place of employment, and specialty. RESULTS: Overall, 362 radiation oncologists and 360 urologists completed the survey for a 52% response rate. Most physicians reported that AS is effective for low-risk PC (72%) and stated that they were comfortable routinely recommending AS (69%). Urologists were more likely to agree that AS is effective (78% vs. 65%; p 0.001) and were comfortable recommending AS (75% vs. 62%; p 0.001) compared with radiation oncologists. Most physicians recommended radical prostatectomy (44%) or radiation therapy (32%), but fewer endorsed AS (22%) for low-risk disease. After adjusting for physician covariates, radiation oncologists were more likely to recommend radiation therapy (OR: 10.68; p 0.001), while urologists were more likely to recommend surgery (OR: 4.03; p 0.001) and AS (OR: 2.49; p 0.001) for low-risk PC. CONCLUSIONS: Although AS is widely viewed as effective by both radiation oncologists and urologists, most urologists continue to recommend surgery, while most radiation oncologists recommend radiation therapy. Our results may explain in part the relatively low contemporary use of AS in the U.S.

Is excision alone adequate for low-risk DCIS of the breast treated with breast conserving therapy

Ductal carcinoma in situ (DCIS) represents a quarter of newly diagnosed breast neoplasms, with the majority of cases detected on routine screening mammography in asymptomatic women. Currently, most women with newly diagnosed DCIS are eligible for breast conserving therapy (BCT); however, significant controversy exists regarding whether or not to add radiation treatment (RT) after surgical excision in low-risk patients. While four older prospective randomized clinical trials have shown that the addition of RT after lumpectomy reduces the risk of ipsilateral breast tumor recurrence (IBTR) by approximately 50 %, recent studies have continued to attempt to identify a subset of patients with favorable risk DCIS who are at a sufficiently low-risk of IBTR that omitting RT might be reasonable. While a number of smaller studies have shown promising results, recent prospective data have consistently affirmed the increased risk of IBTR with the omission of RT, with no subset of patients consistently identified that can be safely observed without RT. While radiation after lumpectomy remains the “standard of care,” even in these low-risk patients, future directions include improvements in genetic assays to better identify low-risk patients and new RT techniques and schedules that can potentially reduce the duration of therapy and toxicity while improving quality of life for patients. Based on the data available, we continue to recommend radiation therapy for low-risk patients with DCIS as no discernible subset has been identified that does not benefit from radiation therapy.

Effectiveness of First-Line Management Strategies for Stage I Follicular Lymphoma: Analysis of the National LymphoCare Study

The optimal management of stage I follicular lymphoma, according to consensus guidelines, is based on uncontrolled experiences of select institutions. Diverse treatment approaches are used despite guidelines that recommend radiation therapy (XRT). We analyzed outcomes of patients with stage I follicular lymphoma enrolled onto the National LymphoCare database. Of 471 patients with stage I follicular lymphoma, 206 patients underwent rigorous staging as defined by both a bone marrow aspirate and biopsy and an imaging study (a computed tomography [CT] scan of the whole body, a positron emission tomography [PET]/CT scan, or both). Rigorously staged patients had superior progression-free survival (PFS) compared with nonrigorously staged patients (hazard ratio [HR], 0.63). Treatments given to rigorously staged patients were rituximab/chemotherapy (R-chemo; 28%), XRT (27%), observation (17%), systemic therapy + XRT (13%), rituximab monotherapy (12%), and other (3%). With a median follow-up of 57 months for PFS, there were 44 progression events (in 21% of patients) for rigorously staged patients. For these patients, PFS was significantly improved with either R-chemo or systemic therapy + XRT compared with patients receiving XRT alone after adjustment for histology, LDH, and the presence of B symptoms. There were no differences in overall survival. In this largest, prospectively enrolled group of patients with stage I follicular lymphoma, variable treatment approaches resulted in similar excellent outcomes, which challenges the paradigm that XRT should be standard for this presentation.

A national survey of radiation oncologists and urologists on active surveillance for low-risk prostate cancer.

4657 Background: While active surveillance (AS) is well recognized as an acceptable treatment strategy for low-risk prostate cancer (PC), the extent to which radiation oncologists and urologists perceive AS as effective and routinely recommend it to patients is unknown. Therefore, we sought to assess the attitudes and treatment recommendations for low-risk PC from a national survey of PC specialists. Methods: A mail survey was sent to a population-based sample of 1,439 physicians in the U.S. from late 2011 and early 2012. Physicians were queried about their attitudes regarding AS and treatment recommendations for patients diagnosed with low-risk PC (PSA&lt;10 ng/dl; T1c; Gleason 6 in one of twelve cores). Pearson Chi-square and multivariate logistic regression were used to test for differences in attitudes and treatment recommendations by physician demographics, compensation structure, primary place of employment, and specialty. Results: Overall, 321 radiation oncologists and 322 urologists completed the survey for a 45% response rate. Most physicians reported that AS is effective for low-risk PC (71%) and stated that they were comfortable routinely recommending AS (67%). Urologists were more likely to agree that AS is effective (77% vs. 67%; p=0.005) and were comfortable recommending AS (74% vs. 61%; p=0.001) compared with radiation oncologists. Most physicians recommended radical prostatectomy (47%) or radiation therapy (32%), but fewer endorsed AS (21%) for low-risk disease. After adjusting for physician covariates, radiation oncologists were more likely to recommend radiation therapy (OR: 10.97; p&lt;0.001), while urologists were more likely to recommend surgery (OR: 4.69; p&lt;0.001) and AS (OR: 2.18; p=0.001) for low-risk PC. Conclusions: Although AS is widely viewed as effective by both radiation oncologists and urologists, most urologists continue to recommend surgery, while most radiation oncologists recommend radiation therapy. Our results may explain in part the relatively low contemporary use of AS in the U.S.

A User's Guide to Cancer Treatment

Science and the Stimulus “Is my disease curable?” That's the first question patients usually ask after learning they have prostate cancer, says Patrick Walsh, a surgeon and urology professor at Johns Hopkins Medical Institutions in Baltimore, Maryland. “Then they want to know, ‘What are my options for treatment?’” Choose radiation or surgery—and risk severe side effects? Opt for no treatment—and risk having the cancer spread? Often, there isn't a clear answer. Imaging scans may not accurately identify the amount of cancer in the prostate. Experimental data comparing different treatments are nearly nonexistent. “So you lay out the side effects,” Walsh says. “You lay out the fact that you don't know whether surgery or radiation is better. … It's a very humble conversation.” ![Figure][1] Data slog. A review team led by Timothy Wilt (seated, left ) pored over data from more than 700 prostate cancer studies. CREDIT: APRIL EILERS/VA MEDICAL CENTER, MINNEAPOLIS More than 200,000 men in the United States are diagnosed with the illness every year, making treatment options a prime candidate for review, according to William Lawrence, a medical officer at the U.S. Agency for Healthcare Research and Quality (AHRQ). Lawrence oversaw a comparative effectiveness (CE) review on prostate cancer commissioned by AHRQ in 2005, one of 18 the agency has done. Timothy Wilt of the Minneapolis VA Medical Center, the review's lead author, and eight colleagues compared the most popular treatment methods, including surgery, radiation, hormone therapy, and “watchful waiting.” They also looked at a few not-so-common options, such as cryotherapy, which rapidly freezes and thaws cancer cells to destroy them. The study, which cost $500,000, followed a standard course laid out by AHRQ, guided by questions from a group of “stakeholders” representing patients, radiation oncologists, urologists, and primary-care physicians. The nine reviewers slogged through mounds of evidence from more than 700 studies, assessed the strengths of doctors and hospitals, weighed side effects, and evaluated outcomes. Data on outcomes and side effects were culled from patient databases, surveys, and clinical trials. They encountered hurdles along the way: Countless definitions of erectile dysfunction and urinary incontinence made side effects tricky to compare. Randomized, placebo-controlled trials were lacking. The team searched for patterns, which they painstakingly graphed as a massive scatter plot, the size of each dot relative to the size of the study. In February 2008 they delivered their findings: No one treatment is superior. All have adverse effects. Fewer side effects developed among patients treated by surgeons and medical centers that had performed more surgeries. The reviewers also spotted a revealing pattern: Doctors are more likely to recommend the treatment they practice. Wilt says: “Surgeons recommend surgery, radiation oncologists recommend radiation therapy, and very few individuals recommend watchful waiting, even for men with relatively slow-growing tumors, despite the fact that evidence suggests that all three treatment options are quite acceptable. Both patients and providers would be better served by knowing this information and having it displayed and available to them.” ![Figure][1] Strong differences. An analysis of U.S. prostate cancer treatments by region showed that “watchful waiting” was least practiced in New England. CREDIT: APRIL EILERS/VA MEDICAL CENTER, MINNEAPOLIS Opinions of the review are mixed. Some say it provides important guidance to people struggling with complex decisions. AHRQ produced a pair of guides summarizing the review for doctors and patients. More than 15,000 people ordered the guides for the prostate cancer study, according to AHRQ. “Often, what happens when you get diagnosed with something is you're kind of shell-shocked and you want to read up,” says Jean Slutsky, director of AHRQ's Center for Outcomes and Evidence. These guides, she says, help patients organize their thoughts and understand the research. Others say the prostate cancer review illustrates the limitations of CE research. Walsh, who has published his own book, Dr. Patrick Walsh's Guide to Surviving Prostate Cancer , says the AHRQ clinicians' guide provides information that a doctor should already know, and the consumers' guide is full of questions: “They did their best, but I don't find it terribly helpful in the treatment of my patients.” Sean Tunis, director of the Center for Medical Technology Policy in Baltimore and an expert on CE research, agrees that the review fails to address some essential questions. It represents something that occurs commonly in CE research, Tunis says: “A lot of times people mistakenly think that you can do a systematic review of what's known, and you'll come to a conclusion on what's more effective or less effective, more expensive or less expensive. But most come to the conclusions this one did: The studies we'd like to have haven't been done.” Studies to fill research gaps need to be funded faster and tackled more efficiently, Lawrence says: “That's one area where I think you'll see more from us in the future.” [1]: pending:yes

The Elusive Nature of Primary Intraocular Lymphoma

A 58-year-old woman with an initial diagnosis of multiple evanescent white dot syndrome OU experienced deteriorating vision despite corticosteroid treatment. Reevaluation disclosed retinal and subretinal infiltrates and pigmentary alterations, prompting a suspicion of primary intraocular lymphoma (PIOL). Diagnostic vitrectomy yielded inconclusive cytology, but flow cytometry demonstrated small monoclonal B cells less suggestive of PIOL than of small lymphocytic lymphoma originating outside the eye or central nervous system. Brain magnetic resonance imaging, chest/abdomen/pelvis computed tomography, lumbar puncture, and laboratory studies failed to disclose lymphoma elsewhere. There was insufficient evidence to recommend radiation therapy. Vision deteriorated rapidly, prompting a diagnostic retinal biopsy and aspiration of the subretinal infiltrate, revealing unequivocal evidence of PIOL. After 40 Gy orbital x-irradiation, visual function improved dramatically. This case emphasizes the unusual ocular manifestations of PIOL and the difficulty of obtaining a definitive diagnosis by sampling vitreous, particularly after corticosteroid treatment. In such cases, subretinal aspiration or retinal biopsy may be necessary. Timely diagnosis is critical because treatment can reverse visual loss if it is not severe.

Evaluation and management of men whose radical prostatectomies failed: results of an international survey

Objectives. To determine how urologists evaluate and treat men who develop recurrent prostate cancer after radical prostatectomy. Methods. Surveys were mailed to 4467 American Urological Association members comprising 3205 U.S. and 1262 non-U.S. urologists randomly selected from a total membership of approximately 12,000. One thousand four hundred sixteen were returned and 1050 (760 U.S. and 290 non-U.S.) surveys were evaluable. Results. To evaluate men with an elevated or rising prostate-specific antigen (PSA) level more than 1 year after radical prostatectomy, 98% of respondents use digital rectal examination, 68% use bone scan, 54% use transrectal ultrasound with biopsy, 36% use abdominal or pelvic computed tomography scan, 31% use transrectal ultrasound without biopsy, 25% use prostatic acid phosphatase, 11% use monoclonal antibody scan, and 5% use abdominal or pelvic magnetic resonance imaging. Respondents evaluate men with an elevated or rising PSA within 1 year of radical prostatectomy similarly. To treat documented local recurrence, 81% of respondents recommend radiation therapy, 7% recommend orchiectomy or luteinizing hormone-releasing hormone (LHRH) agonists, 6% recommend observation only, and 5% recommend combined androgen ablation. To treat documented distant recurrence, 50% recommend combined androgen ablation, 42% recommend orchiectomy or LHRH agonists, and 7% recommend observation only. To treat PSA-only recurrence, 54% recommend observation only, 16% recommend combined androgen ablation, 15% recommend orchiectomy or LHRH agonists, and 13% recommend radiation therapy. Conclusions. The evaluation of men whose radical prostatectomy failed varies among urologists and does not depend on time of recurrence. Radiation therapy is used by most urologists to treat local recurrence. Hormonal manipulation is used by more than 90% of urologists to treat distant recurrence. More than 50% of urologists recommend observation for men with biochemical-only recurrence.

Current status of radiation therapy and radiosurgery in the treatment of intracranial meningiomas.

Complete surgical removal, including resection of involved bone and dura, is curative of intracranial meningiomas in approximately 90% of cases. However, complete removal may entail unwarranted risk if the tumor involves or is adjacent to critical vascular or neural structures. In addition, it is possible for fragments of tumor to "evade" resection, even with the use of meticulous microsurgical technique. Because of this, clinicians may be faced with the decision of whether to offer or recommend radiation therapy or radiosurgery to a patient with a residual or recurrent meningioma. For many years, it has been recommended that external-beam radiation therapy be considered in the treatment of incompletely resected or malignant meningiomas. More recently, the role of radiosurgery as adjuvant or even primary therapy for meningiomas has attracted considerable attention. This article presents a review of the literature on postoperative radiotherapy of intracranial meningiomas.

Squamous cell carcinoma of the lip: analysis of the Princess Margaret Hospital experience

We reviewed 117 patients with squamous cell carcinoma of the lip who were treated at the Princess Margaret Hospital between 1976 and 1985. Ninety-eight cancers arose from the lower lip, 18 from the upper lip and 1 from the commissure. Two patients had lymph node metastases at presentation. Sixty-one patients were treated with radiation therapy following a biopsy, 28 underwent surgery followed by post-operative radiation, and 28 had surgery alone. With a median follow-up time of 5.4 years, the 5-year actuarial overall and cause-specific survival rates were 81% and 99%, respectively. Local failure developed in 4 patients after radiation treatment, 3 of whom were salvaged by surgery. Six patients developed regional metastases after initial treatment, 4 of whom were salvaged with surgery and/or radiotherapy. Two patients died from lip cancer. After a univariate analysis, the only factor which predicted for nodal failure was T stage of the primary lesion, with a 4% risk of nodal failure for T 1 lesions vs. 20% for T 2 3 lesions ( p = 0.03). No other patient, tumour or treatment variables influenced loco-regional control or survival in a statistically significant manner. Cosmetic and functional outcome were evaluated in 8 patients whose radiation treatments were administered 13 years ago. No patients had compromised lip function, and the majority had minimal cosmetic sequelae from their radiation therapy. Based on the excellent results of this review, we would continue to recommend radiation therapy as an effective treatment modality for patients with lip cancer because of the ease by which the entire tumour can be encompassed whilst maintaining excellent cosmetic and functional outcome.

Large Cell Lymphoma Stage IA/IAE

Fifty-two patients with large cell lymphoma stage IA/IAE were retrospectively reviewed for the purpose of evaluation of treatment methods. All pathology slides were reviewed by one pathologist with a special interest in lymphoma. There were 24 patients at stage IA and 28 at stage IAE. Twenty-six patients were treated with radiation alone (10 IA, 16 IAE) and 26 patients were treated with radiation therapy and chemotherapy (13 IA, 13 IAE). Patients treated with radiation therapy alone and those with combined modality therapy (CMT) have similar survival curves with p values greater than 0.05. Recurrence patterns are similar for either method of treatment. While the majority of the literature recommends CMT for large cell lymphoma, our study of 52 patients reveals no difference in survival or recurrence patterns for these patients by either method of treatment. We recommend radiation therapy alone for stage IA/IAE large cell lymphoma, with chemotherapy held in reserve for failure.

Testicular Seminoma: The M. D. Anderson Experience. An Analysis of Pathological and Patient Characteristics, and Treatment Recommendations

We treated 240 patients with testicular seminoma at our institution between January 1960 and December 1982. The over-all 5-year survival free of disease for these patients regardless of stage was 93.6per cent. The 165 patients (69per cent) with stage I disease had a 95.5per cent 5-year survival free of disease that remained constant at 20 years. Stage II cancer was diagnosed clinically in 62 patients (26per cent), while 13 (5per cent) presented with more advanced (stages III and IV) disease. The 5-year survival rate free of disease for all patients with stage II cancer was 85per cent. There were 14 pathological and patient characteristics analyzed, 4 of which were statistically significant. All but 1 of these factors (spermatic cord invasion) was related to tumor volume (stage, palpable mass and hydronephrosis). Based on the data of this retrospective review, the Canadian experience without prophylactic mediastinal irradiation and the development of effective chemotherapy, we recommend radiation therapy without prophylactic mediastinal irradiation for patients with stage I or IIA disease and chemotherapy for patients with stage IIB, III or IV disease. In an attempt to improve our results in the latter patients we recently instituted adjunctive radiotherapy for those with a persistent radiographic mass. Our current guidelines for the staging evaluation and followup of patients with this neoplasm also are discussed.

Stage II glottic carcinoma: Prognostic factors and management

Three hundred thirty-six patients with squamous cell carcinoma of the glottic larynx treated at the University of Virginia Medical Center from 1960 through 1977 were reviewed. Seventy patients with T2N0M0 disease, grouped according to the criteria of the American Joint Committee on Cancer, 1978, form the basis of this report. The 5-year actuarial survivals, recurrences, salvages, and prognostic factors were examined. Treatment was radiation, surgery, or a combination of radiation and surgery. Impaired vocal cord mobility in Stage II glottic squamous cell carcinoma is the crucial significant prognostic factor in predicting response to therapy, survival, and response to salvage therapy for recurrences. The 90% 5-year recurrence-free rate with freely mobile cords is comparable to that achieved with Stage I lesions. Impaired mobility resulted in a 5-year recurrence-free rate of 73%, which is comparable to that of T3N0 lesions. We support the concept of reclassifying Stage II disease into Stage IIa (mobile cords) and Stage IIb (impaired mobility). Based on this review and those reported in the literature, we recommend radiation therapy for Stage IIa disease. Surgery results in fewer recurrences and in longer survival than irradiation when the vocal cords are not freely mobile (Stage IIb).

Treatment of primary breast cancer. Change without improvement.

The arena wherein is decided the champion of therapy for primary breast carcinoma is filled with gladiators bearing different weapons. This crowd has gathered during the last decade. The old champion, radical mastectomy, is being challenged by advocates of these "newer" and simple approaches: (1) simple mastectomy plus radiation therapy; (2) simple mastectomy plus excision of axillary lymph nodes only when clinically positive; (3) local excision of the mass plus radiation therapy; and (4) local excision only. Surgeons may eventually recommend radiation therapy alone for both the primary lesion and the regional lymph nodes! As each author presents clinical data supporting his particular regimen, he notes that his approach produces survival rates similar to those following radical mastectomy (but never better) and quickly points out its strengths—his treatment "isn't worse" and is "much less mutilating." This latter is an argument seldom utilized by surgeons, except with respect to the female

Treatment of cancer of the anus.

There is a widespread impression that the best results in the treatment of cancer of the anus are obtained by radical surgery, and that radiation has little or no place in the management of this disease. It is the object of this paper to show that, in many cases, radiotherapy is the treatment of choice and that permanent cure, with preservation of the anal sphincter and absence of complications, frequently follows. Cancer of the anus, usually epidermoid in type, is not common. From 1947 to 1954 only 9 new cases were encountered in the Saskatoon Cancer Clinic, representing 4 per cent of 239 new cases of cancer of the rectum seen in that period. This percentage is in accordance with the comparative figures found in large series (4, 6, 8, 16). Most authors advise radical surgery in all types of anal cancer, i. e., abdominoperineal excision (1, 3, 4, 7–10). A few recommend radiation therapy in certain cases (2, 12, 13). Some prefer local excision, usually for small lesions of the anal margin (5, 10, 11). It is generally agreed that the only treatment for involved lymph nodes is surgery. It is useful to classify these tumours according to their site of origin. The first type arises below the dentate line and extends into the peri-anal skin; the second arises in the anal canal, extending up and down; the third, quite rare, infiltrates upward into the rectum and is usually called anorectal cancer. It is also epidermoid in nature. The spread in cancers of the anus of the first type is to the inguinal lymph nodes. Block dissection on the involved side should be carried out only when it is known that secondary involvement has taken place. Though this procedure is often unsuccessful, it is the treatment of choice. It is seldom, if ever, successful when both inguinal regions are involved. Stearns (15) has shown that prophylactic block dissection has no place. Judd and DeTar (7), with commendable candour, arrive at the following conclusions: “⋯ when the nodes were not involved, bilateral dissections were attended by relatively good results. However, when the nodes were involved, none of the patients survived five years, no matter how radical the approach.” The use of local radiation treatment in cancer of the lower anus, therefore, can hardly be claimed to jeopardize the subsequent course, with respect to lymph-node metastases, since the decision as to the performance of block dissection of the groins is in no way affected. The lymphatic spread from cancer of the anal canal is frequently upward to the pararectal, superior rectal, and inferior mesenteric nodes. It must be admitted that only by abdominoperineal resection can the primary tumour and the lymphatic spread be adequately dealt with. In spite of this, some of these cases can be successfully treated with radium implantation.